Preliminary assessment of adolescent idiopathic scoliosis prevalence and physiotherapeutic scoliosis specific exercises workforce needs in accessible areas of conflict-affected Syria

Preliminary assessment of adolescent idiopathic scoliosis prevalence and physiotherapeutic scoliosis specific exercises workforce needs in accessible areas of conflict-affected Syria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Perspective Preliminary assessment of adolescent idiopathic scoliosis prevalence and physiotherapeutic scoliosis specific exercises workforce needs in accessible areas of conflict-affected Syria Mohamad Firas Wahbeh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8541646/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Adolescent idiopathic scoliosis (AIS) constitutes a significant public health challenge that necessitates specialized conservative management. However, in conflict-afflicted regions such as Syria, a profound deficit of epidemiological data exists, obscuring the true prevalence of the condition and the corresponding need for a skilled workforce in Physiotherapeutic Scoliosis-Specific Exercises (PSSE). Objective Despite its severe limitations, this study provides the first local data snapshot of AIS in conflict-affected Syria. Rather than a foundation for direct policy, these findings should serve as a compelling rationale and baseline for urgently needed, methodologically rigorous, and nationally representative epidemiological research. Any planning based on these preliminary estimates must be undertaken with extreme caution and must prioritize robust data collection. Methods A cross-sectional field study was conducted, screening a convenience sample of 2,847 adolescents (mean age 14.0 ± 2.6 years; 59.7% female) across eight accessible governorates in Syria. Initial screening utilized the Adam's forward bend test and a scoliometer. Suspected cases were referred for radiographic confirmation, with a Cobb angle of ≥ 10° defining a positive diagnosis. A preliminary workforce estimation model was subsequently developed, integrating the observed prevalence, national demographic data, and established conservative treatment parameters. Results The point prevalence of scoliosis in this sample was determined to be 2.49% (95% CI: 1.92%–3.07%), with a female-to-male ratio of 3.73:1. Critically, 92.96% of confirmed cases presented with mild to moderate curves (Cobb angle 10–39°), representing the cohort for whom PSSE is the recommended intervention according to SOSORT guidelines. An exploratory workforce model, applied strictly to the demographic profile of the surveyed accessible areas, illustrated a range of hypothetical scenarios. The Base Case scenario (α = 0.55, β = 0.25), reflecting current severe constraints, projects a need for approximately 240 specialists. A Moderately Optimistic scenario (α = 0.70, β = 0.30) projects a need for approximately 350 specialists. This figure serves not as a definitive target, but as a conceptual tool to visualize the potential scale of need and to frame discussions on resource allocation priorities in similar accessible, conflict-affected settings. Conclusion This preliminary investigation, based on a non-representative sample from accessible Syrian regions, provides the first internally generated data on scoliosis prevalence in this context, which is consistent with global estimates. The substantial proportion of cases amenable to conservative care underscores the theoretical demand for PSSE services. While any workforce projection remains speculative, it establishes a crucial initial benchmark and highlights the urgent imperative for methodologically rigorous, population-based epidemiological studies and the development of context-adapted implementation frameworks. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity that typically manifests during the peripubertal growth spurt. While its etiology remains incompletely understood, its potential for progression and long-term morbidity necessitates early detection and structured management [ 1 , 2 ]. The standard of care for mild to moderate curves (10–40°) increasingly incorporates Physiotherapeutic Scoliosis-Specific Exercises (PSSE) as a primary conservative intervention, aimed at halting curve progression, improving cosmetic appearance, and enhancing quality of life [ 3 , 9 , 12 ]. In stable, high-resource settings, the infrastructure for scoliosis screening and management is well-established. Conversely, in regions destabilized by prolonged conflict, such as the Syrian Arab Republic, the public health system faces catastrophic disruption [ 5 ]. Basic health services are fragmented, and specialized care for non-communicable, chronic conditions like AIS is largely non-existent. This creates a critical knowledge gap: the prevalence of AIS and the capacity of the health system to manage it are entirely unknown. Without baseline data, it is impossible to advocate for resources, plan interventions, or train a necessary workforce. This study represents a foundational, albeit preliminary, effort to address this void. It is not intended as a definitive epidemiological survey but rather as a prospective, exploratory analysis designed to generate initial estimates and catalyze a more formal, evidence-based approach to a neglected public health issue. By providing the first internally generated data on scoliosis prevalence and modeling workforce requirements, this paper aims to furnish national and international health stakeholders with a data-driven starting point for dialogue and strategic planning. 2. Methods 2.1. Study Design and Population This investigation was designed as a cross-sectional field study, conducted between January 2022 and June 2023 across eight accessible governorates in Syria. A convenience sample of 2,847 adolescents, aged 10 to 18 years, was recruited from schools and community centers. The mean age of the cohort was 14.0 ± 2.6 years, with a predominance of females 59.9% (1,705) over males 40.1% (1,142). The inherent limitations of convenience sampling, particularly the potential for selection bias and the lack of generalizability to the entire Syrian adolescent population, are explicitly acknowledged. Data collection was conducted in full compliance with humanitarian principles and local ethical standards in accessible regions only. 2.2. Screening Protocol and Diagnostic Confirmation The screening protocol was administered by a team of 20 physiotherapists who underwent a brief, hybrid training program. This included a 4 hour online theoretical module and an 8 hour in-person practical session for 14 of the participants [ 13 ]. It must be emphasized that this training regimen is substantially abbreviated compared to the rigorous certification standards of international bodies like SOSORT, constituting a significant methodological limitation. Screening involved two primary steps. First, visual and instrumental assessment was conducted using the Adam's forward bend test to visually inspect for trunk asymmetry, followed by a quantitative measurement of the angle of trunk rotation (ATR) using a smartphone-based scoliometer application. An ATR of ≥ 5° was considered a positive finding warranting further investigation. Second, radiographic confirmation was obtained when adolescents with a positive screening result were referred to specialist orthopedic clinics for a standing posteroanterior radiograph. A definitive diagnosis of scoliosis was established based on a Cobb angle measurement of ≥ 10°, as per international consensus. All radiographic measurements were supervised by the principal investigator using Surgimap software to ensure consistency. 2.3. Methodological Limitations This study is subject to several profound limitations that must be considered when interpreting the findings. The lack of blinding meant that assessors were not blinded to the initial screening results, introducing a potential for confirmation bias. Non-standardized instrumentation was employed, as the use of smartphone applications for scoliometer, while pragmatic in a low-resource setting, lacks the validated accuracy of dedicated mechanical scoliometer. Limited assessor training was provided, with the brief training of the screening team falling short of international standards for PSSE-qualified practitioners. Sampling bias was inherent to the convenience sample, drawn from accessible urban and semi-urban areas, which likely underrepresents rural, displaced, and out-of-school populations, who may face different health determinants. 2.4. Workforce Estimation Model An exploratory model was developed to generate a preliminary estimate of the required PSSE specialist workforce [ 15 , 16 ]. To explore the potential implications of our findings beyond the sample, we developed a scenario-based model. For this scenario, we hypothetically extrapolated our observed prevalence to the national adolescent population, acknowledging this as a major source of uncertainty. We then applied a series of adjustment coefficients to illustrate how systemic barriers (β) and clinical prioritization (α) could dramatically reduce the theoretically addressable caseload. The model's output is strictly a scenario analysis for the purpose of sensitivity testing and highlighting key constraints. It is important to clarify here that two distinct coefficients are used in the workforce estimation model: The first is the clinical eligibility coefficient (α-clinical) of 93%, which reflects the proportion of mild to moderate scoliosis cases (Cobb angle 10°–39°) that qualify for PSSE according to clinical guidelines (SOSORT). A separate prioritization coefficient (α-prioritization = 0.60) is introduced to ethically triage high-risk cases... This yields an adjusted clinical coefficient of α-adjusted = 0.93 × 0.60 ≈ 0.55. Additionally, an independent effective service access coefficient (β-access = 0.25) accounts for geographic barriers, security constraints, socioeconomic obstacles in conflict-affected Syria., and gaps in community awareness that reduce the ability of clinically eligible candidates to actually access and adhere to services within the Syrian crisis context. Thus, the 55% figure does not reflect a clinical assessment, but rather a practical estimate of the proportion of clinically eligible cases expected to actually reach and sustain treatment under current conditions. The choice of coefficient values ​​(e.g., β = 0.25) is based on a contextual analysis of humanitarian reports (e.g., WHO reports) indicating that less than 40% of specialized health facilities are fully operational in Syria, and that geographical and economic barriers severely limit the population's access to long-term services such as exercise programs. A full analysis justifying each coefficient, along with a sensitivity analysis, is detailed in the Appendix (Section 2 ). 2.4. Methodological Computational Tool for Workforce Estimation (The PSSE Calculator) High-Level Professional Paragraph To enhance methodological transparency and ensure the replicability of the proposed workforce estimation model, an independent computational tool (The PSSE Therapist Calculator) was developed to embody the modified mathematical algorithm [ 19 ]. This tool, classified as a Progressive Web Application (PWA), serves as a crucial bridge between epidemiological data and pragmatic human resource planning. The Calculator's internal logic executes the core equation derived from the WHO-WISN Framework, integrating the five key variables that influence the final requirement (target population, prevalence, disease burden, Effective Service Access Factor, and Average Annual Income Per Capita). The explicit inclusion of the GDP analysis within the Calculator's logic enables the objective adjustment of the therapist's annual efficiency, ensuring that the resulting estimates accurately reflect the logistical and productivity challenges anticipated in low-income or conflict-affected settings. appendix provides the complete methodological and programmatic documentation for this application. To improve methodological transparency and alignment with the WHO Workload Indicators of Staffing Need (WISN) framework (2nd edition, 2023), the adjustment coefficients have been disaggregated into distinct clinical and operational components. The clinical eligibility coefficient (α-clinical) remains 0.93, reflecting the proportion of mild to moderate cases (Cobb angle 10°–39°) eligible for PSSE according to the 2016 SOSORT guidelines. A separate prioritization coefficient (α-prioritization = 0.60) is introduced to ethically triage high-risk cases in resource-constrained settings, focusing on moderate curves (20°–39°) and mild curves with progression risk factors (e.g., Risser 0–2), while deferring stable low-risk mild cases to observation. This yields an adjusted clinical coefficient of α-adjusted = 0.93 × 0.60 ≈ 0.55. Additionally, an independent effective service access coefficient (β-access = 0.25) accounts for barriers in conflict-affected Syria, based on humanitarian reports indicating limited healthcare access (WHO and UNHCR, 2025). The comprehensive multiplier is thus α-adjusted × β-access ≈ 0.1628, ensuring the model prioritizes feasible, high-impact interventions. 2.5. Derivation of the Clinical Eligibility Coefficient alpha (a): To ensure the ethical and sustainable application of the model within a context facing immense constraints on specialized resources, the raw clinical eligibility factor (0.93) was conservatively adjusted down to alpha = 0.55. This 38% reduction represents a necessary proactive filtering of cases that, while generally suitable for PSSE, are deemed lower priority or less prone to rapid progression according to established SOSORT guidelines. The exclusion of these cases is justified by three key ethical and operational imperatives: Ethical Triage and Highest Risk Focus: Given the scarcity, limited capacity is ethically prioritized for cases falling into the 25 to 39 Cobb (Moderate) range and the 10 to 24 Cobb (Mild) cases with high-risk progression indicators (e.g., Risser 0–2). Stable, low-risk mild curves (Risser 4–5) are categorized as secondary priority that can be managed through less resource-intensive monitoring protocols. Assuring Quality of Care: To allow specialists to dedicate the necessary 24 hours of intensive treatment per patient effectively, the caseload must be reduced. Adopting alpha = 0.55 ensures that the highest-need cases receive full, adequate attention, preventing the inefficient dilution of scarce resources across a broader, less urgent patient base. Operational Sustainability: In challenging work environments, high workload directly correlates with staff burnout and attrition. Consequently, this coefficient serves as a programmatic sustainability factor designed to ensure that the specialized workforce remains viable, effective, and retained over the lifespan of the intervention. Therefore, alpha = 0.55 does not reflect clinical ineligibility; rather, it reflects the ethical prioritization and operational feasibility required for specialized intervention in a disaster context. 3. Results Disclaimer: The following results are derived from a limited, non-representative sample and should be interpreted as preliminary estimates, not as definitive national statistics. 3.1. Prevalence and Case Characteristics Of the 2,847 adolescents screened, 71 were confirmed to have scoliosis, yielding a point prevalence of 2.49% (95% CI: 1.92%–3.07%). The prevalence was significantly higher in females (3.29%) than in males (1.31%), resulting in a female-to-male ratio of 3.73:1. The demographic and clinical characteristics of the confirmed cases are detailed in (Table 1 and Fig. 1 , 2 , 3 ). Characteristic Value Mean Age (years) 14.3 ± 2.1 Female:Male Ratio 56:15 (3.73:1) Mean Cobb Angle (degrees) 21.38°± 11.8 Mild (10–19°) 52 (73.2%) Moderate (20–39°) 14 (19.7%) Severe (≥ 40°) 5 (7.0%) Thoracic 37 (52.1%) Lumbar 20 (28.2%) Thoracolumbar 14 (19.7%) 3.2. Population Suitable for Conservative Management A crucial finding is that the vast majority of detected cases, 93.0% (n = 66), presented with mild or moderate curves (Cobb angle 10–39°). This cohort represents the primary target population for whom PSSE is the recommended conservative treatment modality, as outlined by the 2016 SOSORT guidelines [ 12 ]. This high proportion underscores the theoretical potential for a public health strategy centered on non-operative interventions. 3.3. Exploratory Workforce Requirement Projection To translate our local findings into a plausible scenario for planning, we applied the workforce estimation model exclusively to the population size of the eight surveyed governorates. This exercise generated a range of hypothetical estimates. Applying the Base Case coefficients (α-adjusted = 0.55, β = 0.25) to the surveyed population yields an estimated need for approximately 240 specialists. Applying Moderately Optimistic coefficients (α = 0.70, β = 0.30) yields an estimate of approximately 350 specialists. We emphasize that this output is a modelled illustration, not a prescriptive recommendation. Its purpose is to demonstrate the order of magnitude of potential need and to highlight the critical impact of access (β) and prioritization (α) coefficients. An annual caseload capacity of 52 patients per full-time PSSE-certified specialist was adopted (rather than the 80–100 cases typical in high-resource settings). This conservative, context-adjusted figure accounts for logistical challenges, infrastructure limitations, long travel distances, irregular follow-up, and administrative burdens in the current Syrian operating environment. With this realistic caseload, the projected need of approximately 350 specialists is fully consistent with the clinical eligibility coefficient (α = 0.55) and the effective service access coefficient (β = 0.25). The stepwise derivation, detailed in the Appendix, follows the adapted WHO-WISN logic: from epidemiological burden through clinical and access adjustments to workload allocation. The core clinical requirement is calculated as ≈ 350 full-time equivalents (FTE) based on an accessible caseload of approximately 15,261 cases (TLC ≈ 112,827 × 0.55 × 0.25), requiring ~ 437,736 hours annually (15,261 × 24 hours/case), divided by 1,260 available working hours per specialist (210 days × 6 clinical hours). To ensure operational sustainability in a conflict context, a 4–5% buffer (≈ 12–15 specialists) is added for supervision, training, management, and attrition, yielding the rounded target of 350. (1) epidemiological burden, (2) clinical/prioritization adjustment, (3) access filtering, (4) workload allocation, (5) sustainability buffer aligns with WHO-WISN recommendations for low-resource settings and provides an ethically defensible, achievable first-phase goal. 3.4. Sensitivity Analysis: Baseline (α-adjusted = 0.55, β = 0.25) yields ≈ 240 FTE. Increasing β to 0.30 raises the need to ≈ 346 specialists; decreasing β to 0.20 yields ≈ 160. Varying α-prioritization from 0.48 to 0.72 changes the need from ≈ 160 to ≈ 346.These ranges (230–346) confirm the baseline target of 350 as a balanced, conservative estimate resilient to parameter uncertainty, consistent with WHO-WISN guidance for exploratory models in data-limited settings. 4. Discussion This study, despite its significant limitations, provides a seminal, data-driven glimpse into the potential burden of adolescent idiopathic scoliosis in Syria. The observed prevalence of 2.49% is consistent with the 1–3% range reported in stable, high-income countries [ 1 , 11 ]. However, this congruence should be interpreted with extreme caution. The complex interplay of genetic and environmental factors in a conflict-affected population including chronic stress, nutritional deficiencies (e.g., Vitamin D), and altered physical activity patterns may uniquely influence the epidemiology of AIS in ways that our limited sample could not capture [ 6 , 7 , 8 ]. The primary conclusion of this work is not the specific prevalence figure, but rather the urgent need for more methodologically robust research. A single cross-sectional study based on a convenience sample is insufficient for national health policy formulation. The path forward must involve population-based longitudinal studies to accurately determine incidence, prevalence, and progression rates, and to identify local risk factors. Methodological standardization is essential, with future studies employing stratified random sampling, validated instrumentation (e.g., mechanical scoliometers), and ensuring assessors are rigorously trained and certified according to international standards (e.g., SOSORT). International collaboration with global research bodies (e.g., Scoliosis Research Society) is essential to ensure methodological rigor, data validity, and capacity building. 4.1. From Preliminary Data to a Prospective Framework: Scenario-Based Planning for PSSE Capacity Development Given the explicitly acknowledged methodological limitations and the non-representative nature of our sample, this study cannot and does not propose a definitive national action plan. Instead, we utilize the exploratory workforce model to construct a prospective, scenario-based framework. This framework translates the mathematical sensitivity of our model into a conceptual tool for strategic dialogue, illustrating how capacity needs could evolve under different future conditions in Syria. Core Conceptual Shift: From Fixed Plan to Flexible Scenarios The framework is built on the principle that the primary driver of workforce demand is not the fixed epidemiological burden, but the variable system capacity (represented by coefficient β) and clinical prioritization strategy (coefficient α). The model's high sensitivity to these coefficients (as detailed in the Appendix, Fig. 1 ) means that planning must be inherently adaptive. Illustrative Scenarios Derived from Model Sensitivity Analysis: Scenario A (Constrained Response) : Corresponds to a continued severe operational environment (β ≈ 0.15–0.20) with a necessary focus on the highest-risk cases (α ≈ 0.40–0.50). This scenario, aligned with the Pessimistic model projection, suggests a need for approximately 80–160 specialists. The strategic focus would be ethically constrained to establishing a foundational expert nucleus (20–30 master trainers) and initiating pilot services in the most accessible urban hubs. Scenario B (Consolidated Scale-Up) : Reflects a modest improvement in security and health system functionality (β ≈ 0.25) and an expanded, yet still prioritized, clinical scope (α ≈ 0.55). This aligns with the Base Case model estimate of ≈ 240 specialists. The strategic focus could shift to deliberate regional expansion, formalization of training curricula, and the development of basic clinical governance structures within accessible regions. Scenario C (Enhanced Integration) : Assumes significant improvements in access and stability (β ≈ 0.30) allowing for a broader treatment mandate (α ≈ 0.70). This Moderately Optimistic scenario projects needs of ≈ 350 specialists, enabling strategies aimed at systemic integration, such as embedding PSSE into primary care referral pathways and national health professional curricula. This scenario-based framework underscores that the primary constraint to service delivery in conflict settings is not merely the clinical burden, but the system's capacity for access (β). Consequently, strategic investments should concurrently address system-level barriers while developing the specialized workforce, as improvements in access will exponentially increase the effective demand for trained personnel. 5. Conclusion This study should be viewed not as a definitive epidemiological statement, but as a call to action. It provides a preliminary, data-informed foundation for what has, until now, been a neglected area of public health in Syria. The findings, while tentative, underscore a significant potential burden of disease and a corresponding gap in specialized services. Effectively addressing adolescent idiopathic scoliosis in a post-conflict setting is more than a clinical imperative; it is a long-term investment in the health and well-being of a future generation. Transitioning from this exploratory analysis to tangible, impactful policy requires a clear vision, sustained political commitment, and strategic international partnerships. Declarations Ethics approval and consent to participate This school-based screening project was conducted with full official approval from the Syrian Ministry of Education and the Directorate of Education in Homs Governorate, in close collaboration with the Faculty of Health Sciences at Baath University (Homs). In the Syrian context—particularly in government-controlled and conflict-affected areas—school health initiatives of this nature are governed directly by the relevant ministerial and directorate authorities, which provide the necessary ethical and administrative oversight. No separate institutional review board (IRB) approval was required or pursued, as such studies fall under the direct mandate of the Ministry of Education when implemented through official educational channels. Ethical approval The study was conducted in accordance with the Declaration of Helsinki and local ethical standards in the accessible regions of Syria. Due to the ongoing conflict and the absence of functioning institutional review boards in the study areas, formal ethical approval from an IRB was not required. Consent to participate Oral informed consent to participate in the study was obtained from the parents or legal guardians of all participants (minors under 18 years of age). Consent to publish Not applicable (the manuscript contains no individual person's identifiable data). Author Contribution Author Contributions StatementM.F.W. conceptualized the study, designed the methodology, supervised data collection and radiographic measurements, performed statistical analyses, developed the workforce estimation model, drafted the original manuscript, and revised all subsequent versions. M.F.W. prepared all tables and figures in the Technical Handbook appendix. As the sole author, M.F.W. reviewed and approved the final manuscript and is accountable for all aspects of the work. Acknowledgement Thanks to the Syrian Health Professions Syndicate for their support. Data Availability The datasets generated and/or analyzed during the current study are available on Figshare repository:https://figshare.com/articles/dataset/psse\_data\_base/30979648https://figshare.com/articles/software/SL\_STL\_PWA/30983821 References [1]. Konieczny MR, Senyurt H, Krauspe R. (2013). 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Eur J Phys Rehabil Med, 55(3), 363–371. https://www.minervamedica.it/en/journals/europa-medicophysica/article.php?id=R33Y2019N03A0363 [22]. World Health Organization. (2023). Global Health Observatory data repository. Geneva: WHO Press. https://www.who.int/data/gho [26]. World Health Organization. (2020). Workload indicators of staffing need (WISN): user's manual. Geneva: WHO Press. https://www.who.int/publications/i/item/9789240009543 Additional Declarations No competing interests reported. Supplementary Files Appendix2.docx documentation.docx Appendix.docx SupplementaryFigures.docx architecturejustification.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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06:48:26","extension":"html","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":86884,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/a410cff901b3e8e2d7527f63.html"},{"id":101206629,"identity":"4948d903-c6c4-44fe-b772-607cf7015241","added_by":"auto","created_at":"2026-01-27 09:56:34","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":88686,"visible":true,"origin":"","legend":"\u003cp\u003erepresents the interface of a Progressive Web Application (PWA) developed as part of this study to implement a workforce estimation model. The calculator uses a modified WHO-WISN framework (Workload Indicators of Staffing Need) to calculate the number of scoliosis physiotherapists (PSSEs) required based on multiple variables, including population size and projected prevalence of the disease, disease burden and clinical need, access and actual service coefficients, and GDP and its impact on productivity. The calculator allows for sensitivity analysis through multiple scenarios (best-case, average-case, worst-case, and custom), reflecting the uncertainty and flexibility required in health planning in resource-constrained contexts. This tool provides a viable and reproducible model that can be used by policymakers and health planners to estimate workforce needs in similar contexts.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/50ff565bd1144ac2ab218c34.jpg"},{"id":101188971,"identity":"7b4430d7-8b7f-43fc-91c5-717b77edd3ee","added_by":"auto","created_at":"2026-01-27 06:48:25","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":72470,"visible":true,"origin":"","legend":"\u003cp\u003eHeat chart showing the distribution of adolescent idiopathic scoliosis (n=71) by age group and curvature severity (Cobb angle). The first heat chart provides a comprehensive visual representation of the distribution of 71 detected scoliosis cases across four age groups (10–12, 13–14, 15–16, 17–18 years) and three severity categories (mild 10–19°, moderate 20–39°, severe ≥40°). The chart uses a color gradient from light yellow (low number of cases) to dark red (high number of cases), facilitating immediate visual differentiation between areas of high and low concentration.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/03bd814e6688374f15100fe3.jpg"},{"id":101188972,"identity":"072890b2-2437-4d0c-b45f-8b67c62697b9","added_by":"auto","created_at":"2026-01-27 06:48:25","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":60738,"visible":true,"origin":"","legend":"\u003cp\u003eHeat chart showing the percentage distribution of scoliosis severity by sex (females n=56, males n=15). The second heat chart provides a comparative analysis of the sex differences in the distribution of scoliosis severity. The chart uses a color gradient from dark green (low percentages) to orange (high percentages), allowing for easy comparison between the sexes.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/e11c3d9458372ece9a537fb8.jpg"},{"id":101188976,"identity":"6571cbfe-8355-44b3-a69e-5db6365275a3","added_by":"auto","created_at":"2026-01-27 06:48:25","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":127518,"visible":true,"origin":"","legend":"\u003cp\u003eComprehensive Analysis of Confirmed Idiopathic Scoliosis Cases (n=71) This figure presents a comprehensive visual analysis of all demographic and clinical characteristics of the 71 confirmed scoliosis cases. The data show that the vast majority of cases (73.2%) fall within the mild scoliosis category (Cobb angle 10–19°), with a clear variation in distribution by sex (female:male ratio 3.7:1) and geographic region. The Risser Sign distribution indicates that 59.2% of cases (42) exhibit active skeletal growth (Risser 0–2), suggesting the need for early intervention and periodic monitoring. Crucially, 91.5% of cases (65 of 71) qualify for conservative treatment according to the SOSORT 2016 criteria, justifying the urgent need to develop specialized physiotherapy services in the Syrian context.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/71783ea6c5805a4ebab25367.jpg"},{"id":101206936,"identity":"287adb56-a7fa-42ea-b326-9417ea2f1d48","added_by":"auto","created_at":"2026-01-27 09:57:00","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":155653,"visible":true,"origin":"","legend":"\u003cp\u003eSensitivity Analysis of the Workforce Needs Estimation Model This figure illustrates the sensitivity of the estimation model to changes in the underlying mathematical parameters. It is evident that the actual access coefficient (β) and the clinical eligibility coefficient (α) have an equally significant impact on workforce needs, each causing a ±52% change from baseline. Under the baseline scenario (α=0.55, β=0.25), the required number of specialists is approximately 240. However, the overall range varies between 160 and 346 specialists depending on the assumptions used. The proposed target (350 specialists) reflects a conservative approach that acknowledges the inherent uncertainty in exploratory models and provides sufficient margin of safety to account for potential improvements in conditions. This analysis underscores the need for continuous monitoring and data updates as the epidemiological and economic situation in Syria improves.\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/4ae29a98eedc758d55976ac5.jpg"},{"id":106043885,"identity":"2036ce40-41a1-4acd-9cb2-fffd61e7942b","added_by":"auto","created_at":"2026-04-02 18:39:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1344131,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/c9b3fe03-7985-498a-88ff-e84263741b13.pdf"},{"id":101206452,"identity":"c0f168e9-cea5-4773-924f-c970d3d7cfad","added_by":"auto","created_at":"2026-01-27 09:56:15","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":19775,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/2989517a3f21bd767deefe9c.docx"},{"id":101188985,"identity":"51eef543-f01d-4898-9653-c14a591c6435","added_by":"auto","created_at":"2026-01-27 06:48:26","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":91266,"visible":true,"origin":"","legend":"","description":"","filename":"documentation.docx","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/64f8333ad1f24ff6556978f2.docx"},{"id":101206495,"identity":"5aa36513-3e7b-4485-9922-bab47176add7","added_by":"auto","created_at":"2026-01-27 09:56:23","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":170976,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/f33a2c1a2251b41da0d33bfd.docx"},{"id":101188982,"identity":"e89cfb4e-b4a8-4e07-97c8-061683770a1c","added_by":"auto","created_at":"2026-01-27 06:48:26","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":1084354,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigures.docx","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/2063896655f6fa5c91f92981.docx"},{"id":101188978,"identity":"27cc23eb-a432-4f0a-9592-7841292b395d","added_by":"auto","created_at":"2026-01-27 06:48:26","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":18065,"visible":true,"origin":"","legend":"","description":"","filename":"architecturejustification.docx","url":"https://assets-eu.researchsquare.com/files/rs-8541646/v1/0e45c8d25d72fbd4acb70ebc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Preliminary assessment of adolescent idiopathic scoliosis prevalence and physiotherapeutic scoliosis specific exercises workforce needs in accessible areas of conflict-affected Syria","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAdolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity that typically manifests during the peripubertal growth spurt. While its etiology remains incompletely understood, its potential for progression and long-term morbidity necessitates early detection and structured management [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The standard of care for mild to moderate curves (10\u0026ndash;40\u0026deg;) increasingly incorporates Physiotherapeutic Scoliosis-Specific Exercises (PSSE) as a primary conservative intervention, aimed at halting curve progression, improving cosmetic appearance, and enhancing quality of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn stable, high-resource settings, the infrastructure for scoliosis screening and management is well-established. Conversely, in regions destabilized by prolonged conflict, such as the Syrian Arab Republic, the public health system faces catastrophic disruption [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Basic health services are fragmented, and specialized care for non-communicable, chronic conditions like AIS is largely non-existent. This creates a critical knowledge gap: the prevalence of AIS and the capacity of the health system to manage it are entirely unknown. Without baseline data, it is impossible to advocate for resources, plan interventions, or train a necessary workforce.\u003c/p\u003e \u003cp\u003eThis study represents a foundational, albeit preliminary, effort to address this void. It is not intended as a definitive epidemiological survey but rather as a prospective, exploratory analysis designed to generate initial estimates and catalyze a more formal, evidence-based approach to a neglected public health issue. By providing the first internally generated data on scoliosis prevalence and modeling workforce requirements, this paper aims to furnish national and international health stakeholders with a data-driven starting point for dialogue and strategic planning.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design and Population\u003c/h2\u003e \u003cp\u003eThis investigation was designed as a cross-sectional field study, conducted between January 2022 and June 2023 across eight accessible governorates in Syria. A convenience sample of 2,847 adolescents, aged 10 to 18 years, was recruited from schools and community centers. The mean age of the cohort was 14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 years, with a predominance of females 59.9% (1,705) over males 40.1% (1,142). The inherent limitations of convenience sampling, particularly the potential for selection bias and the lack of generalizability to the entire Syrian adolescent population, are explicitly acknowledged.\u003c/p\u003e \u003cp\u003e Data collection was conducted in full compliance with humanitarian principles and local ethical standards in accessible regions only.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Screening Protocol and Diagnostic Confirmation\u003c/h2\u003e \u003cp\u003eThe screening protocol was administered by a team of 20 physiotherapists who underwent a brief, hybrid training program. This included a 4 hour online theoretical module and an 8 hour in-person practical session for 14 of the participants [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It must be emphasized that this training regimen is substantially abbreviated compared to the rigorous certification standards of international bodies like SOSORT, constituting a significant methodological limitation.\u003c/p\u003e \u003cp\u003eScreening involved two primary steps. First, visual and instrumental assessment was conducted using the Adam's forward bend test to visually inspect for trunk asymmetry, followed by a quantitative measurement of the angle of trunk rotation (ATR) using a smartphone-based scoliometer application. An ATR of \u0026ge;\u0026thinsp;5\u0026deg; was considered a positive finding warranting further investigation. Second, radiographic confirmation was obtained when adolescents with a positive screening result were referred to specialist orthopedic clinics for a standing posteroanterior radiograph. A definitive diagnosis of scoliosis was established based on a Cobb angle measurement of \u0026ge;\u0026thinsp;10\u0026deg;, as per international consensus. All radiographic measurements were supervised by the principal investigator using Surgimap software to ensure consistency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Methodological Limitations\u003c/h2\u003e \u003cp\u003eThis study is subject to several profound limitations that must be considered when interpreting the findings. The lack of blinding meant that assessors were not blinded to the initial screening results, introducing a potential for confirmation bias. Non-standardized instrumentation was employed, as the use of smartphone applications for scoliometer, while pragmatic in a low-resource setting, lacks the validated accuracy of dedicated mechanical scoliometer. Limited assessor training was provided, with the brief training of the screening team falling short of international standards for PSSE-qualified practitioners. Sampling bias was inherent to the convenience sample, drawn from accessible urban and semi-urban areas, which likely underrepresents rural, displaced, and out-of-school populations, who may face different health determinants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Workforce Estimation Model\u003c/h2\u003e \u003cp\u003eAn exploratory model was developed to generate a preliminary estimate of the required PSSE specialist workforce [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. To explore the potential implications of our findings beyond the sample, we developed a scenario-based model. For this scenario, we hypothetically extrapolated our observed prevalence to the national adolescent population, acknowledging this as a major source of uncertainty. We then applied a series of adjustment coefficients to illustrate how systemic barriers (β) and clinical prioritization (α) could dramatically reduce the theoretically addressable caseload. The model's output is strictly a scenario analysis for the purpose of sensitivity testing and highlighting key constraints.\u003c/p\u003e \u003cp\u003e It is important to clarify here that two distinct coefficients are used in the workforce estimation model: The first is the clinical eligibility coefficient (α-clinical) of 93%, which reflects the proportion of mild to moderate scoliosis cases (Cobb angle 10\u0026deg;\u0026ndash;39\u0026deg;) that qualify for PSSE according to clinical guidelines (SOSORT). A separate prioritization coefficient (α-prioritization\u0026thinsp;=\u0026thinsp;0.60) is introduced to ethically triage high-risk cases... This yields an adjusted clinical coefficient of α-adjusted\u0026thinsp;=\u0026thinsp;0.93 \u0026times; 0.60\u0026thinsp;\u0026asymp;\u0026thinsp;0.55. Additionally, an independent effective service access coefficient (β-access\u0026thinsp;=\u0026thinsp;0.25) accounts for geographic barriers, security constraints, socioeconomic obstacles in conflict-affected Syria., and gaps in community awareness that reduce the ability of clinically eligible candidates to actually access and adhere to services within the Syrian crisis context. Thus, the 55% figure does not reflect a clinical assessment, but rather a practical estimate of the proportion of clinically eligible cases expected to actually reach and sustain treatment under current conditions.\u003c/p\u003e \u003cp\u003eThe choice of coefficient values ​​(e.g., β\u0026thinsp;=\u0026thinsp;0.25) is based on a contextual analysis of humanitarian reports (e.g., WHO reports) indicating that less than 40% of specialized health facilities are fully operational in Syria, and that geographical and economic barriers severely limit the population's access to long-term services such as exercise programs. A full analysis justifying each coefficient, along with a sensitivity analysis, is detailed in the Appendix (Section \u003cspan refid=\"Sec2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Methodological Computational Tool for Workforce Estimation (The PSSE Calculator)\u003c/h2\u003e \u003cp\u003e \u003cb\u003eHigh-Level Professional Paragraph\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTo enhance methodological transparency and ensure the replicability of the proposed workforce estimation model, an independent computational tool (The PSSE Therapist Calculator) was developed to embody the modified mathematical algorithm [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This tool, classified as a Progressive Web Application (PWA), serves as a crucial bridge between epidemiological data and pragmatic human resource planning. The Calculator's internal logic executes the core equation derived from the WHO-WISN Framework, integrating the five key variables that influence the final requirement (target population, prevalence, disease burden, Effective Service Access Factor, and Average Annual Income Per Capita). The explicit inclusion of the GDP analysis within the Calculator's logic enables the objective adjustment of the therapist's annual efficiency, ensuring that the resulting estimates accurately reflect the logistical and productivity challenges anticipated in low-income or conflict-affected settings. appendix provides the complete methodological and programmatic documentation for this application.\u003c/p\u003e \u003cp\u003eTo improve methodological transparency and alignment with the WHO Workload Indicators of Staffing Need (WISN) framework (2nd edition, 2023), the adjustment coefficients have been disaggregated into distinct clinical and operational components. The clinical eligibility coefficient (α-clinical) remains 0.93, reflecting the proportion of mild to moderate cases (Cobb angle 10\u0026deg;\u0026ndash;39\u0026deg;) eligible for PSSE according to the 2016 SOSORT guidelines. A separate prioritization coefficient (α-prioritization\u0026thinsp;=\u0026thinsp;0.60) is introduced to ethically triage high-risk cases in resource-constrained settings, focusing on moderate curves (20\u0026deg;\u0026ndash;39\u0026deg;) and mild curves with progression risk factors (e.g., Risser 0\u0026ndash;2), while deferring stable low-risk mild cases to observation. This yields an adjusted clinical coefficient of α-adjusted\u0026thinsp;=\u0026thinsp;0.93 \u0026times; 0.60\u0026thinsp;\u0026asymp;\u0026thinsp;0.55. Additionally, an independent effective service access coefficient (β-access\u0026thinsp;=\u0026thinsp;0.25) accounts for barriers in conflict-affected Syria, based on humanitarian reports indicating limited healthcare access (WHO and UNHCR, 2025). The comprehensive multiplier is thus α-adjusted\u0026thinsp;\u0026times;\u0026thinsp;β-access\u0026thinsp;\u0026asymp;\u0026thinsp;0.1628, ensuring the model prioritizes feasible, high-impact interventions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Derivation of the Clinical Eligibility Coefficient alpha (a):\u003c/h2\u003e \u003cp\u003eTo ensure the ethical and sustainable application of the model within a context facing immense constraints on specialized resources, the raw clinical eligibility factor (0.93) was conservatively adjusted down to alpha\u0026thinsp;=\u0026thinsp;0.55. This 38% reduction represents a necessary proactive filtering of cases that, while generally suitable for PSSE, are deemed lower priority or less prone to rapid progression according to established SOSORT guidelines. The exclusion of these cases is justified by three key ethical and operational imperatives:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEthical Triage and Highest Risk Focus: Given the scarcity, limited capacity is ethically prioritized for cases falling into the 25 to 39 Cobb (Moderate) range and the 10 to 24 Cobb (Mild) cases with high-risk progression indicators (e.g., Risser 0\u0026ndash;2). Stable, low-risk mild curves (Risser 4\u0026ndash;5) are categorized as secondary priority that can be managed through less resource-intensive monitoring protocols.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAssuring Quality of Care: To allow specialists to dedicate the necessary 24 hours of intensive treatment per patient effectively, the caseload must be reduced. Adopting alpha\u0026thinsp;=\u0026thinsp;0.55 ensures that the highest-need cases receive full, adequate attention, preventing the inefficient dilution of scarce resources across a broader, less urgent patient base.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOperational Sustainability: In challenging work environments, high workload directly correlates with staff burnout and attrition. Consequently, this coefficient serves as a programmatic sustainability factor designed to ensure that the specialized workforce remains viable, effective, and retained over the lifespan of the intervention.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e Therefore, alpha\u0026thinsp;=\u0026thinsp;0.55 does not reflect clinical ineligibility; rather, it reflects the ethical prioritization and operational feasibility required for specialized intervention in a disaster context.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e \u003cb\u003eDisclaimer: The following results are derived from a limited, non-representative sample and should be interpreted as preliminary estimates, not as definitive national statistics.\u003c/b\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Prevalence and Case Characteristics\u003c/h2\u003e \u003cp\u003eOf the 2,847 adolescents screened, 71 were confirmed to have scoliosis, yielding a point prevalence of 2.49% (95% CI: 1.92%\u0026ndash;3.07%). The prevalence was significantly higher in females (3.29%) than in males (1.31%), resulting in a female-to-male ratio of 3.73:1. The demographic and clinical characteristics of the confirmed cases are detailed in (Table\u0026nbsp;1 and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale:Male Ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56:15 (3.73:1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Cobb Angle (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.38\u0026deg;\u0026plusmn; 11.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild (10\u0026ndash;19\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (73.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate (20\u0026ndash;39\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (19.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere (\u0026ge;\u0026thinsp;40\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (7.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (52.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracolumbar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (19.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Population Suitable for Conservative Management\u003c/h2\u003e \u003cp\u003eA crucial finding is that the vast majority of detected cases, 93.0% (n\u0026thinsp;=\u0026thinsp;66), presented with mild or moderate curves (Cobb angle 10\u0026ndash;39\u0026deg;). This cohort represents the primary target population for whom PSSE is the recommended conservative treatment modality, as outlined by the 2016 SOSORT guidelines [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This high proportion underscores the theoretical potential for a public health strategy centered on non-operative interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Exploratory Workforce Requirement Projection\u003c/h2\u003e \u003cp\u003eTo translate our local findings into a plausible scenario for planning, we applied the workforce estimation model exclusively to the population size of the eight surveyed governorates. This exercise generated a range of hypothetical estimates. Applying the Base Case coefficients (α-adjusted\u0026thinsp;=\u0026thinsp;0.55, β\u0026thinsp;=\u0026thinsp;0.25) to the surveyed population yields an estimated need for approximately 240 specialists. Applying Moderately Optimistic coefficients (α\u0026thinsp;=\u0026thinsp;0.70, β\u0026thinsp;=\u0026thinsp;0.30) yields an estimate of approximately 350 specialists. We emphasize that this output is a modelled illustration, not a prescriptive recommendation. Its purpose is to demonstrate the order of magnitude of potential need and to highlight the critical impact of access (β) and prioritization (α) coefficients. An annual caseload capacity of 52 patients per full-time PSSE-certified specialist was adopted (rather than the 80\u0026ndash;100 cases typical in high-resource settings). This conservative, context-adjusted figure accounts for logistical challenges, infrastructure limitations, long travel distances, irregular follow-up, and administrative burdens in the current Syrian operating environment. With this realistic caseload, the projected need of approximately 350 specialists is fully consistent with the clinical eligibility coefficient (α\u0026thinsp;=\u0026thinsp;0.55) and the effective service access coefficient (β\u0026thinsp;=\u0026thinsp;0.25).\u003c/p\u003e \u003cp\u003eThe stepwise derivation, detailed in the Appendix, follows the adapted WHO-WISN logic: from epidemiological burden through clinical and access adjustments to workload allocation. The core clinical requirement is calculated as \u0026asymp;\u0026thinsp;350 full-time equivalents (FTE) based on an accessible caseload of approximately 15,261 cases (TLC\u0026thinsp;\u0026asymp;\u0026thinsp;112,827 \u0026times; 0.55 \u0026times; 0.25), requiring\u0026thinsp;~\u0026thinsp;437,736 hours annually (15,261 \u0026times; 24 hours/case), divided by 1,260 available working hours per specialist (210 days \u0026times; 6 clinical hours). To ensure operational sustainability in a conflict context, a 4\u0026ndash;5% buffer (\u0026asymp;\u0026thinsp;12\u0026ndash;15 specialists) is added for supervision, training, management, and attrition, yielding the rounded target of 350.\u003c/p\u003e \u003cp\u003e(1) epidemiological burden,\u003c/p\u003e \u003cp\u003e(2) clinical/prioritization adjustment,\u003c/p\u003e \u003cp\u003e(3) access filtering,\u003c/p\u003e \u003cp\u003e(4) workload allocation,\u003c/p\u003e \u003cp\u003e(5) sustainability buffer aligns with WHO-WISN recommendations for low-resource settings and provides an ethically defensible, achievable first-phase goal.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Sensitivity Analysis:\u003c/h2\u003e \u003cp\u003eBaseline (α-adjusted\u0026thinsp;=\u0026thinsp;0.55, β\u0026thinsp;=\u0026thinsp;0.25) yields\u0026thinsp;\u0026asymp;\u0026thinsp;240 FTE. Increasing β to 0.30 raises the need to \u0026asymp;\u0026thinsp;346 specialists; decreasing β to 0.20 yields\u0026thinsp;\u0026asymp;\u0026thinsp;160. Varying α-prioritization from 0.48 to 0.72 changes the need from \u0026asymp;\u0026thinsp;160 to \u0026asymp;\u0026thinsp;346.These ranges (230\u0026ndash;346) confirm the baseline target of 350 as a balanced, conservative estimate resilient to parameter uncertainty, consistent with WHO-WISN guidance for exploratory models in data-limited settings.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study, despite its significant limitations, provides a seminal, data-driven glimpse into the potential burden of adolescent idiopathic scoliosis in Syria. The observed prevalence of 2.49% is consistent with the 1\u0026ndash;3% range reported in stable, high-income countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, this congruence should be interpreted with extreme caution. The complex interplay of genetic and environmental factors in a conflict-affected population including chronic stress, nutritional deficiencies (e.g., Vitamin D), and altered physical activity patterns may uniquely influence the epidemiology of AIS in ways that our limited sample could not capture [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary conclusion of this work is not the specific prevalence figure, but rather the urgent need for more methodologically robust research. A single cross-sectional study based on a convenience sample is insufficient for national health policy formulation. The path forward must involve population-based longitudinal studies to accurately determine incidence, prevalence, and progression rates, and to identify local risk factors. Methodological standardization is essential, with future studies employing stratified random sampling, validated instrumentation (e.g., mechanical scoliometers), and ensuring assessors are rigorously trained and certified according to international standards (e.g., SOSORT). International collaboration with global research bodies (e.g., Scoliosis Research Society) is essential to ensure methodological rigor, data validity, and capacity building.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.1. From Preliminary Data to a Prospective Framework: Scenario-Based Planning for PSSE Capacity Development\u003c/h2\u003e \u003cp\u003eGiven the explicitly acknowledged methodological limitations and the non-representative nature of our sample, this study cannot and does not propose a definitive national action plan. Instead, we utilize the exploratory workforce model to construct a prospective, scenario-based framework. This framework translates the mathematical sensitivity of our model into a conceptual tool for strategic dialogue, illustrating \u003cem\u003ehow\u003c/em\u003e capacity needs could evolve under different future conditions in Syria.\u003c/p\u003e \u003cp\u003eCore Conceptual Shift: From Fixed Plan to Flexible Scenarios\u003c/p\u003e \u003cp\u003eThe framework is built on the principle that the primary driver of workforce demand is not the fixed epidemiological burden, but the variable system capacity (represented by coefficient β) and clinical prioritization strategy (coefficient α). The model's high sensitivity to these coefficients (as detailed in the Appendix, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) means that planning must be inherently adaptive.\u003c/p\u003e \u003cp\u003eIllustrative Scenarios Derived from Model Sensitivity Analysis:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eScenario A (Constrained Response)\u003c/b\u003e: Corresponds to a continued severe operational environment (β\u0026thinsp;\u0026asymp;\u0026thinsp;0.15\u0026ndash;0.20) with a necessary focus on the highest-risk cases (α\u0026thinsp;\u0026asymp;\u0026thinsp;0.40\u0026ndash;0.50). This scenario, aligned with the Pessimistic model projection, suggests a need for approximately 80\u0026ndash;160 specialists. The strategic focus would be ethically constrained to establishing a foundational expert nucleus (20\u0026ndash;30 master trainers) and initiating pilot services in the most accessible urban hubs.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eScenario B (Consolidated Scale-Up)\u003c/b\u003e: Reflects a modest improvement in security and health system functionality (β\u0026thinsp;\u0026asymp;\u0026thinsp;0.25) and an expanded, yet still prioritized, clinical scope (α\u0026thinsp;\u0026asymp;\u0026thinsp;0.55). This aligns with the Base Case model estimate of \u0026asymp;\u0026thinsp;240 specialists. The strategic focus could shift to deliberate regional expansion, formalization of training curricula, and the development of basic clinical governance structures within accessible regions.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eScenario C (Enhanced Integration)\u003c/b\u003e: Assumes significant improvements in access and stability (β\u0026thinsp;\u0026asymp;\u0026thinsp;0.30) allowing for a broader treatment mandate (α\u0026thinsp;\u0026asymp;\u0026thinsp;0.70). This Moderately Optimistic scenario projects needs of \u0026asymp;\u0026thinsp;350 specialists, enabling strategies aimed at systemic integration, such as embedding PSSE into primary care referral pathways and national health professional curricula.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThis scenario-based framework underscores that the primary constraint to service delivery in conflict settings is not merely the clinical burden, but the system's capacity for access (β). Consequently, strategic investments should concurrently address system-level barriers while developing the specialized workforce, as improvements in access will exponentially increase the effective demand for trained personnel.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study should be viewed not as a definitive epidemiological statement, but as a call to action. It provides a preliminary, data-informed foundation for what has, until now, been a neglected area of public health in Syria. The findings, while tentative, underscore a significant potential burden of disease and a corresponding gap in specialized services. Effectively addressing adolescent idiopathic scoliosis in a post-conflict setting is more than a clinical imperative; it is a long-term investment in the health and well-being of a future generation. Transitioning from this exploratory analysis to tangible, impactful policy requires a clear vision, sustained political commitment, and strategic international partnerships.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate This school-based screening project was conducted with full official approval from the Syrian Ministry of Education and the Directorate of Education in Homs Governorate, in close collaboration with the Faculty of Health Sciences at Baath University (Homs). In the Syrian context—particularly in government-controlled and conflict-affected areas—school health initiatives of this nature are governed directly by the relevant ministerial and directorate authorities, which provide the necessary ethical and administrative oversight. No separate institutional review board (IRB) approval was required or pursued, as such studies fall under the direct mandate of the Ministry of Education when implemented through official educational channels.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki and local ethical standards in the accessible regions of Syria. Due to the ongoing conflict and the absence of functioning institutional review boards in the study areas, formal ethical approval from an IRB was not required.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003e Oral informed consent to participate in the study was obtained from the parents or legal guardians of all participants (minors under 18 years of age).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish\u003c/strong\u003e \u003cp\u003eNot applicable (the manuscript contains no individual person's identifiable data).\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor Contributions StatementM.F.W. conceptualized the study, designed the methodology, supervised data collection and radiographic measurements, performed statistical analyses, developed the workforce estimation model, drafted the original manuscript, and revised all subsequent versions. M.F.W. prepared all tables and figures in the Technical Handbook appendix. As the sole author, M.F.W. reviewed and approved the final manuscript and is accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThanks to the Syrian Health Professions Syndicate for their support.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are available on Figshare repository:https://figshare.com/articles/dataset/psse\\_data\\_base/30979648https://figshare.com/articles/software/SL\\_STL\\_PWA/30983821\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e[1]. Konieczny MR, Senyurt H, Krauspe R. (2013). Epidemiology of adolescent idiopathic scoliosis. J Child Orthop, 7(1), 3\u0026ndash;9. https://doi.org/10.1007/s11832-012-0457-4\u003c/p\u003e\n\u003cp\u003e[2]. Altaf F, Gibson A, Dannawi Z, Noordeen H. (2013). Adolescent idiopathic scoliosis. BMJ, 346, f2508. https://doi.org/10.1136/bmj.f2508\u003c/p\u003e\n\u003cp\u003e[3]. Cheng JC, Castelein RM, Chu WC, Danielsson AJ, Dobbs MB, Grivas TB, et al. (2015). Adolescent idiopathic scoliosis. Nat Rev Dis Primers, 1, 15030. https://doi.org/10.1038/nrdp.2015.30\u003c/p\u003e\n\u003cp\u003e[4]. Weinstein SL, Dolan LA, Wright JG, Dobbs MB. (2013). Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med, 369(16), 1512\u0026ndash;1521. https://doi.org/10.1056/NEJMoa1307037\u003c/p\u003e\n\u003cp\u003e[5]. Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, et al. (2018). 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord, 13, 3. https://doi.org/10.1186/s13013-017-0145-8\u003c/p\u003e\n\u003cp\u003e[6]. Romano M, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Kotwicki T, et al. (2012). Exercises for adolescent idiopathic scoliosis. Cochrane Database Syst Rev, (8), CD007837. https://doi.org/10.1002/14651858.CD007837.pub2\u003c/p\u003e\n\u003cp\u003e[7]. Schreiber S, Parent EC, Moez EK, Hedden DM, Hill D, Moreau MJ, et al. (2015). The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis: an assessor and statistician blinded randomized controlled trial. Scoliosis, 10, 24. https://doi.org/10.1186/s13013-015-0048-5\u003c/p\u003e\n\u003cp\u003e[8]. Monticone M, Ambrosini E, Cazzaniga D, Rocca B, Ferrante S. (2014). Active self-correction and task-oriented exercises reduce spinal deformity and improve quality of life in subjects with mild adolescent idiopathic scoliosis: results of a randomised controlled trial. Eur Spine J, 23(6), 1204\u0026ndash;1214. https://doi.org/10.1007/s00586-014-3201-z\u003c/p\u003e\n\u003cp\u003e[9]. Ma K, Wang C, Huang Y, Wang Y, Li D, He G. (2023). The effects of physiotherapeutic scoliosis-specific exercise on idiopathic scoliosis in children and adolescents: a systematic review and meta-analysis. Physiotherapy, 119, 1\u0026ndash;12. https://doi.org/10.1016/j.physio.2023.01.001\u003c/p\u003e\n\u003cp\u003e[10]. You MJ, Lu ZY, Xu QY, Chen PB, Li B, Jiang SD, et al. (2024). Effectiveness of Physiotherapeutic Scoliosis-Specific Exercises on 3-Dimensional spinal deformities in patients with adolescent idiopathic scoliosis: a systematic review and Meta-analysis. Arch Phys Med Rehabil, 105(5), 982\u0026ndash;993. https://doi.org/10.1016/j.apmr.2024.05.003\u003c/p\u003e\n\u003cp\u003e[11]. Hresko MT. (2013). Idiopathic Scoliosis in Adolescents. N Engl J Med, 368(9), 834\u0026ndash;841. https://doi.org/10.1056/NEJMcp1209063\u003c/p\u003e\n\u003cp\u003e[12]. Negrini S, Grivas TB, Kotwicki T, Maruyama T, Rigo M, Zaina F. (2011). Why do we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients. SOSORT 2005 Consensus paper. Scoliosis, 6, 2. https://doi.org/10.1186/1748-7161-6-2\u003c/p\u003e\n\u003cp\u003e[13]. World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice. Geneva: WHO Press. https://www.who.int/publications/i/item/framework-for-action-on-interprofessional-education-collaborative-practice\u003c/p\u003e\n\u003cp\u003e[14]. World Health Organization. (2016). Global strategy on human resources for health: Workforce 2030. Geneva: WHO Press. https://www.who.int/publications/i/item/9789241511131\u003c/p\u003e\n\u003cp\u003e[15]. Scheffler RM, Liu JX, Kinfu Y, Dal Poz MR. (2008). Forecasting the global shortage of physicians: an economic- and needs-based approach. Bull World Health Organ, 86(7), 516\u0026ndash;523. https://doi.org/10.2471/blt.07.046474\u003c/p\u003e\n\u003cp\u003e[16]. World Health Organization. (2017). National health workforce accounts: a handbook. Geneva: WHO Press. https://www.who.int/publications/i/item/9789241513111\u003c/p\u003e\n\u003cp\u003e[17]. Campbell J, Buchan J, Cometto G, David B, Dussault G, Fogstad H, et al. (2013). Human resources for health and universal health coverage: fostering synergies. Bull World Health Organ, 91(12), 853\u0026ndash;863. https://doi.org/10.2471/BLT.13.118723\u003c/p\u003e\n\u003cp\u003e[18]. Rahman MM, Rahman MA, Islam MS, Rahman MS. (2022). Machine learning approaches for healthcare workforce planning: a systematic review. Health Informatics J, 28(4), 14604582221142788. https://doi.org/10.1177/14604582221142788\u003c/p\u003e\n\u003cp\u003e[19]. United Nations, Department of Economic and Social Affairs, Population Division. (2022). World Population Prospects 2022: Summary of Results. New York: United Nations. https://population.un.org/wpp/Publications/Files/WPP2022_Summary_of_Results.pdf\u003c/p\u003e\n\u003cp\u003e[20]. World Bank. (2023). World Development Indicators. Washington, DC: World Bank. https://databank.worldbank.org/source/world-development-indicators\u003c/p\u003e\n\u003cp\u003e[21]. Negrini S, Donzelli S, Lusini M, Zaina F, Minnella S, Romano M. (2019). The effectiveness of exercises in adolescent idiopathic scoliosis: a systematic review and meta-analysis. Eur J Phys Rehabil Med, 55(3), 363\u0026ndash;371. https://www.minervamedica.it/en/journals/europa-medicophysica/article.php?id=R33Y2019N03A0363\u003c/p\u003e\n\u003cp\u003e[22]. World Health Organization. (2023). Global Health Observatory data repository. Geneva: WHO Press. https://www.who.int/data/gho\u003c/p\u003e\n\u003cp\u003e[26]. World Health Organization. (2020). Workload indicators of staffing need (WISN): user\u0026apos;s manual. Geneva: WHO Press. \u003cu\u003ehttps://www.who.int/publications/i/item/9789240009543\u003c/u\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8541646/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8541646/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAdolescent idiopathic scoliosis (AIS) constitutes a significant public health challenge that necessitates specialized conservative management. However, in conflict-afflicted regions such as Syria, a profound deficit of epidemiological data exists, obscuring the true prevalence of the condition and the corresponding need for a skilled workforce in Physiotherapeutic Scoliosis-Specific Exercises (PSSE).\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eDespite its severe limitations, this study provides the first local data snapshot of AIS in conflict-affected Syria. Rather than a foundation for direct policy, these findings should serve as a compelling rationale and baseline for urgently needed, methodologically rigorous, and nationally representative epidemiological research. Any planning based on these preliminary estimates must be undertaken with extreme caution and must prioritize robust data collection.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional field study was conducted, screening a convenience sample of 2,847 adolescents (mean age 14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 years; 59.7% female) across eight accessible governorates in Syria. Initial screening utilized the Adam's forward bend test and a scoliometer. Suspected cases were referred for radiographic confirmation, with a Cobb angle of \u0026ge;\u0026thinsp;10\u0026deg; defining a positive diagnosis. A preliminary workforce estimation model was subsequently developed, integrating the observed prevalence, national demographic data, and established conservative treatment parameters.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe point prevalence of scoliosis in this sample was determined to be 2.49% (95% CI: 1.92%\u0026ndash;3.07%), with a female-to-male ratio of 3.73:1. Critically, 92.96% of confirmed cases presented with mild to moderate curves (Cobb angle 10\u0026ndash;39\u0026deg;), representing the cohort for whom PSSE is the recommended intervention according to SOSORT guidelines. An exploratory workforce model, applied strictly to the demographic profile of the surveyed accessible areas, illustrated a range of hypothetical scenarios. The Base Case scenario (α\u0026thinsp;=\u0026thinsp;0.55, β\u0026thinsp;=\u0026thinsp;0.25), reflecting current severe constraints, projects a need for approximately 240 specialists. A Moderately Optimistic scenario (α\u0026thinsp;=\u0026thinsp;0.70, β\u0026thinsp;=\u0026thinsp;0.30) projects a need for approximately 350 specialists. This figure serves not as a definitive target, but as a conceptual tool to visualize the potential scale of need and to frame discussions on resource allocation priorities in similar accessible, conflict-affected settings.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis preliminary investigation, based on a non-representative sample from accessible Syrian regions, provides the first internally generated data on scoliosis prevalence in this context, which is consistent with global estimates. The substantial proportion of cases amenable to conservative care underscores the theoretical demand for PSSE services. While any workforce projection remains speculative, it establishes a crucial initial benchmark and highlights the urgent imperative for methodologically rigorous, population-based epidemiological studies and the development of context-adapted implementation frameworks.\u003c/p\u003e","manuscriptTitle":"Preliminary assessment of adolescent idiopathic scoliosis prevalence and physiotherapeutic scoliosis specific exercises workforce needs in accessible areas of conflict-affected Syria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 06:48:16","doi":"10.21203/rs.3.rs-8541646/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc64be2c-49e3-4c40-9dfa-5265c3a0926f","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-02T18:39:08+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-27 06:48:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8541646","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8541646","identity":"rs-8541646","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}