Treatment of Idiopathic Scoliosis During Adolescence: A Qualitative and Quantitative Analysis of Its Long-Term Psychosocial and Functional Impact

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This study aimed to better understand these patients' long-term health status by identifying key factors that had influenced it over time. Methods: A mixed-methods approach was used. Qualitative data included recording, transcription, coding and content analysis of focus groups and semi-structured interviews. For the quantitative analysis, patients completed questionnaires. Results: Fifty-seven patients were recruited. Two focus groups and 44 individual interviews were performed. All of them completed the questionnaires. Quantitative analyses showed significant age-related differences in ODI, SRS22-Function, SRS22-Pain, SRS22-Self Image and trunk deformity perception, with older patients showing poorer results. Trunk deformity perception was the only domain associated with treatment received, with conservative patients scoring worse. Qualitative findings highlighted psychosocial impacts of IS and its treatments during adolescence, particularly related to bracing, which was often associated with discomfort and social stigma. However, these effects generally did not persist into adulthood. In contrast, surgical treatment was generally viewed positively, associated with deformity correction, improved self-image and the elimination of bracing, all contributing to better social integration and overall well-being. Qualitative factors influencing current self-image, self-esteem and overall well-being varied by both age and treatment type. Conclusions: While IS may significantly impact adolescents’ psychosocial health, particularly when it is treated with bracing, the effect tends not to persist into adulthood. In adulthood, age becomes the primary determinant of psychosocial health and general well-being. This mixed-method approach revealed distinct factors influencing each domain studied and offered a deeper understanding of their interconnections, highlighting the complex interplay between social, physical, and psychological factors. These findings underscore the importance of a holistic, patient-centered approach in managing IS, with greater emphasis on psychosocial aspects including self-image, self-esteem, and sexual health, throughout treatment planning and long-term follow-up. Idiopathic Scoliosis mixed-methods long-term treatment surgery bracing Figures Figure 1 Introduction Idiopathic scoliosis (IS) usually develops in otherwise healthy individuals and is often considered "asymptomatic" during adolescence. However, growing evidence indicates that IS can significantly impact Health-Related Quality of Life (HRQoL), particularly in terms of psychosocial well-being [ 1 ]. Adolescence is a critical stage of development, characterized by physiological, emotional, cognitive, and especially social changes that heighten concerns about body image [ 2 ]. In this context, adolescents with IS face a potentially visible deformity at a time when body perception becomes particularly relevant [ 3 ]. This can lead to decreased self-esteem and social confidence, along with increased anxiety and depressive symptoms, especially among female adolescents undergoing brace treatment [ 4 ]. Beyond consolidating a coherent body image, adolescents are also in the process of developing a personal identity, as well as dealing with emerging sexuality and the stress of intimate relationships [ 3 , 5 ]. As a result, the cosmetic impact of IS and its effects on emotional well-being are considered to be among the most affected dimensions of HRQoL during this life stage [ 6 ]. However, as individuals transition into adulthood, the focus of the impact on HRQoL tends to shift toward functional limitations and physical discomfort [ 7 ]. The connection between self-image, self-esteem and sexual health has been studied previously [ 8 ]. The link can be further exacerbated in chronic conditions affecting self-image from an early age, influencing emotional well-being and psychosexual development [ 9 ]. While the short-term outcomes of IS are well-documented, research on its long-term psychosocial and functional impact remains relatively scarce [ 10 – 16 ]. Moreover, most assessments rely on quantitative measures such as radiographic curvature or standardized HRQoL questionnaires. While valuable, these methods may overlook the nuanced, subjective experiences of patients and fail to capture the full scope of their long-term well-being. To address this gap, the present study opted for a mixed-methods approach, enabling a more comprehensive understanding -not only of what is happening (quantitatively) but also how and why it is happening (qualitatively). This design aimed to not only measure outcomes but also to understand the factors influencing the long-term psychosocial and functional status of individuals diagnosed and treated for IS during adolescence. In addition to established domains such as general health, mental health, function, pain, and body image, the study explored underexamined aspects such as self-concept, self-esteem, affect, and sexual health. The ultimate goal was to provide a more comprehensive understanding of long-term outcomes and unravel the complex interplay of factors that shape them. Materials and Methods This study employed a mixed-methods approach, combining a qualitative component (cross-sectional and retrospective) through focus groups and semi-structured individual interviews, with a quantitative component (cross-sectional) based on validated HRQoL instruments completed individually by each participant. The selected questionnaires were chosen to comprehensively address the study’s objectives and included: Tennessee Self Concept Scale (TSCS); Rosenberg Self-Esteem Scale (RSES); Scoliosis Research Society 22 (SRS22); Trunk Appearance Perception Scale (TAPS); Positive and Negative Affect Schedule (PANAS); Short Form-36 Health Survey (SF36); Oswestry Disability Index (ODI); Female Sexual Function Index (FSFI); Female Sexual Distress Scale (FSDS). A summary of the data collection tools is provided in Table 1 . Study Population and Sampling Participants were recruited from a single clinical centre. Inclusion criteria were: female, pre-menopausal, aged ≥25 years, diagnosed with IS and treated during adolescence (either conservatively or surgically via posterior approach, with no revision surgeries), thoracic curve ≥40°, no neurological dysfunction, and informed consent to participate. The potential participants were stratified into six groups based on age and treatment history: Age: Group 1: patients aged 25-39 years Group 2: patients over 40 years Treatment: Groups a: patients treated conservatively during adolescence but operated on in adulthood Groups b: patients operated during adolescence Groups c: patients treated only with conservative methods during adolescence Interview Design and Optimization The initial version of the interview guide was developed by a multidisciplinary team: the questions were initially informed by prior literature and drafted by the spine research unit, then refined with input from a psychologist specializing in sexology (responsible for data collection) and a group specialised in qualitative research (responsible for data analysis). However, since there was no pre-established theoretical framework to specifically evaluate the study's objectives, the guide was piloted based on the grounded theory methodology [17] in two focus groups (subgroups 1a and 2a). Through their dual experience separated in time, they could provide a more comprehensive insight into both the condition and its treatment over time. This iterative, multidisciplinary approach ensured the reliability and validity of the data collection process. The final interview guide (see Supplementary material) and the same HRQoL questionnaires were then used for individual data collection on subgroups 1b, 1c and 2b, 2c. Participants were contacted by phone and scheduled for in-person appointments. The final sample size of each group was determined through theoretical saturation [18]. Sampling was conducted sequentially with the transcription analysed as received. Each subgroup was closed once no new relevant information emerged, indicating that saturation had been achieved (Table 2). Combined Qualitative and Quantitative Analysis The qualitative analysis involved recording, transcription, coding, and co-occurrence content analysis using the Network Text Analysis (NTA) [19]. Codes were classified into families based on conceptual proximity, and the structure and dynamics within and between families were analysed to detect overarching patterns. The meanings and effects (positive, negative, or neutral) of a code could vary depending on the context. For this reason, each relationship was carefully interpreted to identify general patterns, rather than focusing on contradictions. Atlas.ti v7 was used to code and extract the co-occurrence matrices [20]. For each transcription, a symmetric double-entry table was generated, transferred to a spreadsheet for processing and imported into a network visualization software (UCINET for focus groups and Gephi for individual interviews). These network visualizations helped identify discourse patterns at both group and individual levels (Figure 1). Comprehensive reports were generated for each patient and group. Mann-Whitney U tests were used to analyse differences within groups. Relationships between domains were analysed using Spearman correlations with all analyses conducted in SAS v9.4. Results A total of 57 patients participated in the study (Table 2). Focus group analysis yielded 262 codes grouped into 15 thematic families. Individual interviews identified 2,022 codes later organized into 21 families (Table 3). Focus Group Findings and Questionnaire Testing The preliminary findings derived from the analysis of the two focus groups allowed for: The improvement of the interview guide: The structure and wording of the questions were revised based on participants' feedback. Frequently mentioned new concepts were incorporated: psychological support, sports practice, civil status/household composition, and environment (urban/rural setting). Refinement of the code dictionary: A code-cleaning process was conducted, which involved adding new codes and merging those that were synonymous or conveyed the same meaning. Development of a positive-negative index: This index accounted for the contextual nature of codes, recognizing that the same code could reflect a positive, neutral, or negative connotation depending on the discursive context in which it appeared. The HRQoL questionnaires were also piloted during the focus groups and selected for use in the individual interviews. Individual Interviews and Questionnaire Data Patient characteristics and treatment results : Of the 44 patients who participated in the individual interviews (Table 2), 91% expressed either negative (70.5%) or neutral (20.5%) feelings towards the use of the brace (Table 4). Negative experiences were largely psychosocial, impacting self-esteem, body image and interpersonal relationships. Patients also cited physical discomfort, activity limitations, and a perceived lack of treatment effectiveness. Low adherence was often linked to the combination of perceived ineffectiveness and rigid family expectations. In contrast, 87.5% of patients expressed neutral (25%) or positive (62.5%) perceptions of surgical treatment (Table 4). Surgery was often credited with halting curve progression and improving self-image and self-esteem. Concerns about potential worsening if untreated further reinforced this favourable perception. For many, discontinuing brace use post-surgery significantly improved emotional well-being and social engagement. Nevertheless, three patients (1 from group 1b, 2 from 2b) expressed dissatisfaction with surgery, citing stiffness, residual deformity, scar impact, or incomplete correction. Collaborative decision-making involving family and medical teams emerged as a key factor in positive surgical perceptions, although emotional difficulties (particularly in the recovery area) were frequently mentioned, deriving from both physical pain and feelings of isolation. Patients consistently emphasized the value of strong support systems. Family, friends, peer/scoliosis support groups, and psychological counselling were noted as especially beneficial, particularly during conservative treatment phases [1]. General Health, Function and Pain : Age-related differences emerged in physical function and pain: older patients scored significantly worse ODI, SRS22-Function and SRS22-Pain (p<0.05) (Table 5). No statistically significant differences were found between treatments. Mental Health, Anxiety and Depression : No significant effects of age or treatment were found on mental health domains as measured by SF-36 MCS, SRS22-Mental Health, or HAD (Table 5). However, there was a trend indicating that older and surgically treated patients tended to report poorer mental health outcomes. Self-Concept: Although no statistically significant differences were observed across TSCS dimensions (Table 5), many patients scored below the normative threshold on Self-Concept (75). This suggests a possible disconnect between behavioural self-assessment and emotional self-regard. Qualitative data revealed that participants described themselves using personality traits or character-related adjectives. While no clear patterns emerged, self-concept was frequently interwoven with self-esteem and self-image indicating an interrelationship between these constructs. Positive and Negative Affect: The PANAS questionnaire showed no significant differences in Positive Affect (PA) or Negative Affect (NA) by age or treatment. However, descriptively, younger and surgically treated patients reported slightly higher PA, while NA remained relatively stable but was marginally elevated in surgical groups (see Table 5). Qualitative findings, both from current experiences and adolescent memories, revealed a tendency toward social affect linked to feelings of self-isolation or avoidance of physical contact, often driven by insecurity or fear of rejection. Self-Image and Trunk Deformity Perception: Quantitative analysis revealed significant differences (p<0.05) across both age and treatment groups in self-image (SRS22) and trunk appearance (TAPS). Older and non-operated patients reported worse outcomes (Table 5). Qualitatively, 86.4% of participants reported either a neutral (36.4%) or positive (50%) self-image, with many indicating improvements since adolescence. Surgical patients frequently attributed this improvement to the correction and stabilization of their deformity. In contrast, conservative patients reported body image concerns related both to scoliosis-specific features and unrelated factors (i.e. weight), which had even greater impact than deformity features. Brace use during adolescence was widely cited as damaging to self-image, restricting clothing choices and subsequently exacerbating feelings of social exclusion. While most surgical patients had experienced improved self-image post-surgery, three had not. Concerns included scar visibility, persistent deformity, and fear of ongoing progression. Scarring had a more notable emotional impact on younger patients, who often concealed it with hairstyles, clothing, or even tattoos. Older patients tended to accept their scars more readily, even viewing them with pride. Self-Esteem : No significant differences in self-esteem, as measured by RSES, were found between age or treatment groups (Table 5). Qualitative findings showed that most patients experienced low self-esteem during adolescence, primarily due to concerns about self-image and social support. Bracing contributed to discomfort, limited clothing choices and physical activity, and heightened feelings of difference and self-consciousness. Currently, 84.1% of patients reported either neutral (36.6%) or positive (45.5%) self-esteem (Table 6). Although the majority of patients reported their current self-esteem as positive, influencing factors varied by treatment type. Among surgically treated patients, self-image remained a key factor, but instrumentation-related stiffness, particularly in younger individuals, negatively affected self-esteem. Older patients, by contrast, were generally more accepting and able to normalize these limitations. For conservatively treated patients, self-esteem seem to be influenced by a broader array of factors beyond deformity and self-image. Factors such as personal identity, physical activity limitations, pain or the social environment (including family, friends, partners, and work) seemed to play a more prominent role. Sexual Health: Sexual health was analysed using the FSFI, the FSDS and the sex item of ODI. Quantitative analysis showed a significant effect of age (p<0.05) on sexual health, with older patients scoring lower on FSFI (being below the norm) and the sex item of ODI (Table 5). There were no statistically significant differences between treatment groups, but there was a trend for conservative patients to have better sexual function but higher sexual distress than surgical patients (being below the norm). The qualitative analysis revealed better sexual health among younger and surgically treated patients. Overall, 38 out of 44 patients (86.4%) reported either neutral (7; 15.9%, with 4 younger and 3 older patients; 2 surgical, 5 conservative) or positive (31; 70.5%, with 18 younger and 13 older patients; 19 surgical, 12 conservative) sexual health (Table 6). The qualitative analysis also revealed that, for most patients, achieving orgasm was closely linked to positive sexual health and was often seen as a key indicator of it. Sexual health was closely tied to self-esteem, which in turn was affected by self-image and physical limitations, often resulting in frustration, reduced sexual desire, and heightened sexual distress. Correlations between domains: We found significant correlations (r>0.50, p<0.05) between self-image (SRS22) and general health (SF36-PCS, ODI), mental health (SF36-MCS, HAD), and sexual distress (FSDS) in both treatment groups. In the surgical group, additional significant correlations were observed: between mental health (SF36-MCS, HAD) and both self-esteem (RSES) and sexual distress (FSDS); between sexual distress (FSDS) and self-esteem (RSES); and between self-esteem (RSES) and self-image (SRS22) (Table 7). Discussion This study highlights the need to address not only the physical and functional aspects of IS but also the psychosocial challenges that arise throughout the treatment journey. By analyzing six well-defined groups of patients (classified by age and treatment modality) we examined the interplay between treatment type, age, and various psychosocial and functional dimensions. Treatment modality had a surprisingly limited impact on most measured domains, with one notable exception: patients treated conservatively reported significantly worse Trunk Deformity Perception. In contrast, surgical patients generally expressed satisfaction with their physical outcomes, although some voiced concerns regarding scarring, often reflecting inadequate preoperative counselling and unmet expectations about the appearance of postoperative scars. Age, however, emerged as a more powerful differentiating factor. Older patients tended to report poorer psychosocial and functional health. Yet, with age also came a greater sense of acceptance. Many older individuals demonstrated a more mature, reconciled view of their scars and their overall condition, suggesting a complex, evolving relationship between physical change and self-concept over time. This study underscores the importance of addressing not only physical and functional aspects of IS, but also psychosocial factors during the treatment process. Psychological distress, particularly during adolescence, was a consistent theme throughout the narratives. This period of identity formation and heightened sensitivity to body image made patients especially vulnerable to emotional challenges. Support systems—including family, peers, and access to professional mental health services—were cited as critical to coping successfully with the demands of treatment. These findings reinforce earlier research that underscores the importance of psychological support in mitigating distress and improving long-term outcomes [ 1 ]. In our study, the psychosocial distress associated with bracing during adolescence was a significant concern, with many patients recalling feelings of discomfort, social isolation, and body image issues. These results align with previous studies that highlight the negative emotional and social consequences of bracing in adolescent patients with IS​ [ 4 ]. Surgery, on the other hand, was generally seen as more liberating. For most patients, surgical correction and the removal of the brace led to significant improvements in self-image and self-esteem. Nevertheless, surgical scarring remained a source of dissatisfaction for some, especially younger individuals who had not fully anticipated the cosmetic impact. These findings underscore the importance of thorough, honest preoperative discussions, including aesthetic outcomes and long-term appearance. Sexual health, often overlooked in scoliosis literature, is a fundamental component of overall well-being. Given its strong associations with self-esteem, self-image, and sexual behavior, particularly among women, it should be recognized as a key determinant of HRQoL [ 8 ]. This is especially relevant in conditions like scoliosis that directly impact body image, underscoring the need for clinicians to address sexual health more openly and routinely during treatment discussions. Collaborative decision-making stood out as another key factor in shaping positive patient experiences. Patients who felt more involved in the decision-making process (especially surgical candidates), reported better coping strategies and a more favorable overall treatment experience. These findings reinforce the value of a patient-centered approach that emphasizes shared decision-making, transparency, and empathy throughout the care process. Previous research on IS using mixed or exclusively qualitative methods is limited and involves predominantly short-term outcomes often focusing on cross-sectional patient experiences [ 21 – 30 ]. Only one qualitative-only study has examined the long-term health status of patients who underwent surgery during adolescence, and its results align with ours [ 16 ]. Mixed-methods are increasingly valued for their ability to provide a comprehensive understanding of complex topics by combining broad statistical trends with individual lived experiences. However, such studies also face inherent challenges due to epistemological differences in sampling, data collection, and result interpretation [ 31 ]. Quantitative research prioritizes objectivity, statistical significance, and generalizability, while qualitative research offers rich, contextual insights through purposive sampling [ 32 ]. A primary limitation of this study lies in these epistemological differences. Our sample size, determined based on qualitative requirements, may have limited our statistical power to detect significant differences across certain quantitative variables. Additionally, recall bias must be acknowledged, as participants’ reflections on adolescent experiences were likely influenced by their current psychological state and coping mechanisms. Their memories may represent reinterpretations shaped by time and perspective, rather than precise accounts of past events. Conclusion This is the first mixed-methods study of the long-term status of individuals with IS. Our results suggest that while the psychosocial challenges associated with treatment—particularly bracing—can be profound during adolescence, their long-term impact appears limited in adulthood. Instead, current psychosocial and functional well-being is more strongly influenced by age, underscoring the evolving nature of self-perception and adaptation over time. This mixed-methods approach, grounded in first-person experiences, proved essential in capturing the multifaceted impact of IS. It enabled a deeper exploration of the interconnections between self-concept, self-esteem, self-image, and sexual health—domains often overlooked in traditional scoliosis research. These insights reveal how psychological and social dimensions are inextricably linked with physical health and should not be treated as secondary considerations. Our results reinforce the importance of a holistic, patient-centered approach to IS management, one that considers structural correction but also the emotional, psychological, and social well-being of patients. This includes proactive and open discussions around sensitive topic such image, scarring, sexual health, and collaborative decision-making, all of which can meaningfully shape the patient experience and long-term satisfaction. Future research should continue to explore the long-term psychosocial effects of IS and investigate targeted interventions that can better support individuals across their lifespan. Declarations Author Contribution AVC wrote the proposal awarded with the Pilot Study Grant 2017, coordinated the project's execution, and wrote the manuscript.JMV and FP were the PhD directors overseeing the project and ensuring its proper conduct. They also reviewed the manuscript.CFSR was responsible for data collection, including focus groups, interviews, and HRQoL questionnaires.OA and EG conducted the qualitative data analysis.XV conducted the quantitative data analysis.SN and AFM contributed to the proposal writing and reviewed the manuscript.JP reviewed the manuscript. Acknowledgement This article is part of a doctoral thesis (http://hdl.handle.net/10803/674528) that was partially funded through a research grant awarded by Eurospine (Pilot Study Grant 2017) for the project The long-term psychological and functional status of female patients after surgical or non-surgical treatment for Idiopathic Scoliosis: A qualitative and quantitative analysis, IRB approval PR(ATR)90/2016. 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Supplementary Files SuplementaryMaterialESJ.docx TablesESJ.docx Cite Share Download PDF Status: Published Journal Publication published 12 Feb, 2026 Read the published version in European Spine Journal → Version 1 posted Editorial decision: Revision requested 02 Dec, 2025 Reviews received at journal 02 Jul, 2025 Reviews received at journal 01 Jul, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers invited by journal 25 Jun, 2025 Editor assigned by journal 20 May, 2025 Submission checks completed at journal 19 May, 2025 First submitted to journal 16 May, 2025 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6682518","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477205967,"identity":"6fed4c3f-2ffc-40bb-b6e2-5b818ae3f335","order_by":0,"name":"Alba Vila-Casademunt","email":"data:image/png;base64,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","orcid":"","institution":"Vall d'Hebron Institut de Recerca","correspondingAuthor":true,"prefix":"","firstName":"Alba","middleName":"","lastName":"Vila-Casademunt","suffix":""},{"id":477205968,"identity":"b5a6e07d-ce31-4c05-9be5-853ced5f2f08","order_by":1,"name":"Joan Miquel Verd","email":"","orcid":"","institution":"Autonomous University of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Joan","middleName":"Miquel","lastName":"Verd","suffix":""},{"id":477205970,"identity":"72b25e0f-68c0-4479-86ac-e9809caa814e","order_by":2,"name":"Clara Figueras","email":"","orcid":"","institution":"Vall d'Hebron Institut de Recerca","correspondingAuthor":false,"prefix":"","firstName":"Clara","middleName":"","lastName":"Figueras","suffix":""},{"id":477205971,"identity":"d2425f84-c1c5-4d5b-ba92-b2095f73023d","order_by":3,"name":"Oriol Alonso","email":"","orcid":"","institution":"Autonomous University of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Oriol","middleName":"","lastName":"Alonso","suffix":""},{"id":477205973,"identity":"4ba00758-b396-40d7-8077-58374081ed94","order_by":4,"name":"Eva Gea","email":"","orcid":"","institution":"Autonomous University of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Eva","middleName":"","lastName":"Gea","suffix":""},{"id":477205977,"identity":"e2a133a6-1f2f-4350-9138-036369298df2","order_by":5,"name":"Xavier Vidal","email":"","orcid":"","institution":"Vall d'Hebron Hospital Universitari","correspondingAuthor":false,"prefix":"","firstName":"Xavier","middleName":"","lastName":"Vidal","suffix":""},{"id":477205978,"identity":"5d974d38-6850-448f-8572-11f45967250e","order_by":6,"name":"Susana Núñez","email":"","orcid":"","institution":"Vall d'Hebron Hospital Universitari","correspondingAuthor":false,"prefix":"","firstName":"Susana","middleName":"","lastName":"Núñez","suffix":""},{"id":477205982,"identity":"576640d7-ff7e-43b4-9ce3-58900d83279e","order_by":7,"name":"Sleiman Haddad","email":"","orcid":"","institution":"Vall d'Hebron Hospital Universitari","correspondingAuthor":false,"prefix":"","firstName":"Sleiman","middleName":"","lastName":"Haddad","suffix":""},{"id":477205983,"identity":"be4f311c-4e0f-4ea5-a5d1-53875de6bd0a","order_by":8,"name":"Javier Pizones","email":"","orcid":"","institution":"Hospital Universitario La Paz","correspondingAuthor":false,"prefix":"","firstName":"Javier","middleName":"","lastName":"Pizones","suffix":""},{"id":477205985,"identity":"68deedb5-e299-4f4a-8475-b5f230b30bdc","order_by":9,"name":"Anne F. Mannion","email":"","orcid":"","institution":"Schulthess-Klinik","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"F.","lastName":"Mannion","suffix":""},{"id":477205986,"identity":"6408a911-eb65-4ba2-8c75-c74433843d83","order_by":10,"name":"Ferran Pellisé","email":"","orcid":"","institution":"Vall d'Hebron Hospital Universitari","correspondingAuthor":false,"prefix":"","firstName":"Ferran","middleName":"","lastName":"Pellisé","suffix":""}],"badges":[],"createdAt":"2025-05-16 16:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6682518/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6682518/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00586-026-09809-0","type":"published","date":"2026-02-12T15:57:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85745855,"identity":"dd757c27-fbce-46e6-9327-d5adad85fd43","added_by":"auto","created_at":"2025-07-01 09:23:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":245630,"visible":true,"origin":"","legend":"\u003cp\u003eExample of a visual co-occurrence network resulting from one individual interview\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6682518/v1/77df799f50e9bbeb984a7b9c.png"},{"id":102785198,"identity":"c0b20a9d-feda-4513-bf10-92fa8bf2a3c5","added_by":"auto","created_at":"2026-02-16 16:02:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":662771,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6682518/v1/20a7674e-1ee9-4e29-bd8d-96336123ff23.pdf"},{"id":85744253,"identity":"4e15d647-23d1-4e2b-ae6b-89db184732d4","added_by":"auto","created_at":"2025-07-01 09:15:59","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17569,"visible":true,"origin":"","legend":"","description":"","filename":"SuplementaryMaterialESJ.docx","url":"https://assets-eu.researchsquare.com/files/rs-6682518/v1/197e85b2e55083cfe5b74d50.docx"},{"id":85745854,"identity":"9ab98cde-97d1-4ecd-ae44-106e1fc765a1","added_by":"auto","created_at":"2025-07-01 09:23:59","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":65069,"visible":true,"origin":"","legend":"","description":"","filename":"TablesESJ.docx","url":"https://assets-eu.researchsquare.com/files/rs-6682518/v1/438c899403012f4966b86d00.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Treatment of Idiopathic Scoliosis During Adolescence: A Qualitative and Quantitative Analysis of Its Long-Term Psychosocial and Functional Impact","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIdiopathic scoliosis (IS) usually develops in otherwise healthy individuals and is often considered \"asymptomatic\" during adolescence. However, growing evidence indicates that IS can significantly impact Health-Related Quality of Life (HRQoL), particularly in terms of psychosocial well-being [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdolescence is a critical stage of development, characterized by physiological, emotional, cognitive, and especially social changes that heighten concerns about body image [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In this context, adolescents with IS face a potentially visible deformity at a time when body perception becomes particularly relevant [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This can lead to decreased self-esteem and social confidence, along with increased anxiety and depressive symptoms, especially among female adolescents undergoing brace treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBeyond consolidating a coherent body image, adolescents are also in the process of developing a personal identity, as well as dealing with emerging sexuality and the stress of intimate relationships [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. As a result, the cosmetic impact of IS and its effects on emotional well-being are considered to be among the most affected dimensions of HRQoL during this life stage [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, as individuals transition into adulthood, the focus of the impact on HRQoL tends to shift toward functional limitations and physical discomfort [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe connection between self-image, self-esteem and sexual health has been studied previously [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The link can be further exacerbated in chronic conditions affecting self-image from an early age, influencing emotional well-being and psychosexual development [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile the short-term outcomes of IS are well-documented, research on its long-term psychosocial and functional impact remains relatively scarce [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Moreover, most assessments rely on quantitative measures such as radiographic curvature or standardized HRQoL questionnaires. While valuable, these methods may overlook the nuanced, subjective experiences of patients and fail to capture the full scope of their long-term well-being.\u003c/p\u003e \u003cp\u003eTo address this gap, the present study opted for a mixed-methods approach, enabling a more comprehensive understanding -not only of \u003cem\u003ewhat\u003c/em\u003e is happening (quantitatively) but also \u003cem\u003ehow and why\u003c/em\u003e it is happening (qualitatively). This design aimed to not only measure outcomes but also to understand the factors influencing the long-term psychosocial and functional status of individuals diagnosed and treated for IS during adolescence.\u003c/p\u003e \u003cp\u003eIn addition to established domains such as general health, mental health, function, pain, and body image, the study explored underexamined aspects such as self-concept, self-esteem, affect, and sexual health. The ultimate goal was to provide a more comprehensive understanding of long-term outcomes and unravel the complex interplay of factors that shape them.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study employed a mixed-methods approach, combining a qualitative component (cross-sectional and retrospective) through focus groups and semi-structured individual interviews, with a quantitative component (cross-sectional) based on validated HRQoL instruments completed individually by each participant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe selected questionnaires were chosen to comprehensively address the study\u0026rsquo;s objectives and included: Tennessee Self Concept Scale (TSCS); Rosenberg Self-Esteem Scale (RSES); Scoliosis Research Society 22 (SRS22); Trunk Appearance Perception Scale (TAPS); Positive and Negative Affect Schedule (PANAS); Short Form-36 Health Survey (SF36); Oswestry Disability Index (ODI); Female Sexual Function Index (FSFI); Female Sexual Distress Scale (FSDS). A summary of the data collection tools is provided in Table 1\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy Population and Sampling\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were recruited from a single clinical centre. Inclusion criteria were: female, pre-menopausal, aged \u0026ge;25 years, diagnosed with IS and treated during adolescence (either conservatively or surgically via posterior approach, with no revision surgeries), thoracic curve \u0026ge;40\u0026deg;, no neurological dysfunction, and informed consent to participate.\u003c/p\u003e\n\u003cp\u003eThe potential participants were stratified into six groups based on age and treatment history:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAge:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eGroup 1:\u003c/u\u003e patients aged 25-39 years\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eGroup 2:\u003c/u\u003e patients over 40 years\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eGroups a:\u0026nbsp;\u003c/u\u003epatients treated conservatively during adolescence but operated on in adulthood\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eGroups b:\u003c/u\u003e patients operated during adolescence\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eGroups c:\u003c/u\u003e patients treated only with conservative methods during adolescence\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eInterview Design and Optimization\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe initial version of the interview guide was developed by a multidisciplinary team: the questions were initially informed by prior literature and drafted by the spine research unit, then refined with input from a psychologist specializing in sexology (responsible for data collection) and a group specialised in qualitative research (responsible for data analysis). However, since there was no pre-established theoretical framework to specifically evaluate the study\u0026apos;s objectives, the guide was piloted based on the grounded theory methodology [17] in two focus groups (subgroups 1a and 2a). Through their dual experience separated in time, they could provide a more comprehensive insight into both the condition and its treatment over time.\u003c/p\u003e\n\u003cp\u003eThis iterative, multidisciplinary approach ensured the reliability and validity of the data collection process. The final interview guide (see Supplementary material) and the same HRQoL questionnaires were then used for individual data collection on subgroups 1b, 1c and 2b, 2c. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants were contacted by phone and scheduled for in-person appointments. The final sample size of each group was determined through theoretical saturation [18]. Sampling was conducted sequentially with the transcription analysed as received. Each subgroup was closed once no new relevant information emerged, indicating that saturation had been achieved (Table 2).\u003cstrong\u003e\u003cu\u003e\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCombined Qualitative and Quantitative Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative analysis involved recording, transcription, coding, and co-occurrence content analysis using the Network Text Analysis (NTA) [19]. Codes were classified into families based on conceptual proximity, and the structure and dynamics within and between families were analysed to detect overarching patterns. The meanings and effects (positive, negative, or neutral) of a code could vary depending on the context. For this reason, each relationship was carefully interpreted to identify general patterns, rather than focusing on contradictions.\u003c/p\u003e\n\u003cp\u003eAtlas.ti v7 was used to code and extract the co-occurrence matrices [20]. For each transcription, a symmetric double-entry table was generated, transferred to a spreadsheet for processing and imported into a network visualization software (UCINET for focus groups and Gephi for individual interviews). These network visualizations helped identify discourse patterns at both group and individual levels (Figure 1). Comprehensive reports were generated for each patient and group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMann-Whitney U tests were used to analyse differences within groups. Relationships between domains were analysed using Spearman correlations with all analyses conducted in SAS v9.4.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 57 patients participated in the study (Table 2). Focus group analysis yielded 262 codes grouped into 15 thematic families. Individual interviews identified 2,022 codes later organized into 21 families (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFocus Group Findings and Questionnaire Testing\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe preliminary findings derived from the analysis of the two focus groups allowed for:\u0026nbsp;\u003c/p\u003e\n\u003col style=\"list-style-type: lower-alpha;\"\u003e\n \u003cli\u003eThe improvement of the interview guide:\u0026nbsp;\u003cul\u003e\n \u003cli\u003eThe structure and wording of the questions were revised based on participants\u0026apos; feedback.\u003c/li\u003e\n \u003cli\u003eFrequently mentioned new concepts were incorporated: psychological support, sports practice, civil status/household composition, and environment (urban/rural setting).\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eRefinement of the code dictionary:\u003cul\u003e\n \u003cli\u003eA code-cleaning process was conducted, which involved adding new codes and merging those that were synonymous or conveyed the same meaning.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eDevelopment of a positive-negative index:\u003cul\u003e\n \u003cli\u003eThis index accounted for the contextual nature of codes, recognizing that the same code could reflect a positive, neutral, or negative connotation depending on the discursive context in which it appeared.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe HRQoL questionnaires were also piloted during the focus groups and selected for use in the individual interviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIndividual Interviews and Questionnaire Data\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePatient characteristics and treatment results\u003c/u\u003e: Of the 44 patients who participated in the individual interviews (Table 2), 91% expressed either negative (70.5%) or neutral (20.5%) feelings towards the use of the brace (Table 4). Negative experiences were largely psychosocial, impacting self-esteem, body image and interpersonal relationships. Patients also cited physical discomfort, activity limitations, and a perceived lack of treatment effectiveness. Low adherence was often linked to the combination of perceived ineffectiveness and rigid family expectations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn contrast, 87.5% of patients expressed neutral (25%) or positive (62.5%) perceptions of surgical treatment (Table 4). Surgery was often credited with halting curve progression and improving self-image and self-esteem. Concerns about potential worsening if untreated further reinforced this favourable perception. For many, discontinuing brace use post-surgery significantly improved emotional well-being and social engagement. Nevertheless, three patients (1 from group 1b, 2 from 2b) expressed dissatisfaction with surgery, citing stiffness, residual deformity, scar impact, or incomplete correction.\u003c/p\u003e\n\u003cp\u003eCollaborative decision-making involving family and medical teams emerged as a key factor in positive surgical perceptions, although emotional difficulties (particularly in the recovery area) were frequently mentioned, deriving from both physical pain and feelings of isolation.\u003c/p\u003e\n\u003cp\u003ePatients consistently emphasized the value of strong support systems. Family, friends, peer/scoliosis support groups, and psychological counselling were noted as especially beneficial, particularly during conservative treatment phases [1].\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eGeneral Health, Function and Pain\u003c/u\u003e: Age-related differences emerged in physical function and pain: older patients scored significantly worse ODI, SRS22-Function and SRS22-Pain (p\u0026lt;0.05) (Table 5). No statistically significant differences were found between treatments.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMental Health, Anxiety and Depression\u003c/u\u003e: No significant effects of age or treatment were found on mental health domains as measured by SF-36 MCS, SRS22-Mental Health, or HAD (Table 5). However, there was a trend indicating that older and surgically treated patients tended to report poorer mental health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSelf-Concept:\u003c/u\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAlthough no statistically significant differences were observed across TSCS dimensions (Table 5), many patients scored below the normative threshold on Self-Concept (\u0026lt;160) while scoring above average in Self-Behaviour (\u0026gt;75). This suggests a possible disconnect between behavioural self-assessment and emotional self-regard.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitative data revealed that participants described themselves using personality traits or character-related adjectives. While no clear patterns emerged, self-concept was frequently interwoven with self-esteem and self-image indicating an interrelationship between these constructs.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePositive and Negative Affect:\u003c/u\u003e The PANAS questionnaire showed no significant differences in Positive Affect (PA) or Negative Affect (NA) by age or treatment. However, descriptively, younger and surgically treated patients reported slightly higher PA, while NA remained relatively stable but was marginally elevated in surgical groups (see Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitative findings, both from current experiences and adolescent memories, revealed a tendency toward social affect linked to feelings of self-isolation or avoidance of physical contact, often driven by insecurity or fear of rejection.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSelf-Image and Trunk Deformity Perception:\u003c/u\u003e Quantitative analysis revealed significant differences (p\u0026lt;0.05) across both age and treatment groups in self-image (SRS22) and trunk appearance (TAPS). Older and non-operated patients reported worse outcomes (Table 5).\u003c/p\u003e\n\u003cp\u003eQualitatively, 86.4% of participants reported either a neutral (36.4%) or positive (50%) self-image, with many indicating improvements since adolescence. Surgical patients frequently attributed this improvement to the correction and stabilization of their deformity. In contrast, conservative patients reported body image concerns related both to scoliosis-specific features and unrelated factors (i.e. weight), which had even greater impact than deformity features.\u003c/p\u003e\n\u003cp\u003eBrace use during adolescence was widely cited as damaging to self-image, restricting clothing choices and subsequently exacerbating feelings of social exclusion. While most surgical patients had experienced improved self-image post-surgery, three had not. Concerns included scar visibility, persistent deformity, and fear of ongoing progression. Scarring had a more notable emotional impact on younger patients, who often concealed it with hairstyles, clothing, or even tattoos. Older patients tended to accept their scars more readily, even viewing them with pride.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSelf-Esteem\u003c/u\u003e\u003cu\u003e:\u003c/u\u003e No significant differences in self-esteem, as measured by RSES, were found between age or treatment groups (Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitative findings showed that most patients experienced low self-esteem during adolescence, primarily due to concerns about self-image and social support. Bracing contributed to discomfort, limited clothing choices and physical activity, and heightened feelings of difference and self-consciousness.\u003c/p\u003e\n\u003cp\u003eCurrently, 84.1% of patients reported either neutral (36.6%) or positive (45.5%) self-esteem (Table 6). Although the majority of patients reported their current self-esteem as positive, influencing factors varied by treatment type. Among surgically treated patients, self-image remained a key factor, but instrumentation-related stiffness, particularly in younger individuals, negatively affected self-esteem. Older patients, by contrast, were generally more accepting and able to normalize these limitations.\u003c/p\u003e\n\u003cp\u003eFor conservatively treated patients, self-esteem seem to be influenced by a broader array of factors beyond deformity and self-image. Factors such as personal identity, physical activity limitations, pain or the social environment (including family, friends, partners, and work) seemed to play a more prominent role.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSexual Health:\u003c/u\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSexual health was analysed using the FSFI, the FSDS and the sex item of ODI. Quantitative analysis showed a significant effect of age (p\u0026lt;0.05) on sexual health, with older patients scoring lower on FSFI (being below the norm) and the sex item of ODI (Table 5). There were no statistically significant differences between treatment groups, but there was a trend for conservative patients to have better sexual function but higher sexual distress than surgical patients (being below the norm).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe qualitative analysis revealed better sexual health among younger and surgically treated patients. Overall, 38 out of 44 patients (86.4%) reported either neutral (7; 15.9%, with 4 younger and 3 older patients; 2 surgical, 5 conservative) or positive (31; 70.5%, with 18 younger and 13 older patients; 19 surgical, 12 conservative) sexual health (Table 6).\u003c/p\u003e\n\u003cp\u003eThe qualitative analysis also revealed that, for most patients, achieving orgasm was closely linked to positive sexual health and was often seen as a key indicator of it. Sexual health was closely tied to self-esteem, which in turn was affected by self-image and physical limitations, often resulting in frustration, reduced sexual desire, and heightened sexual distress.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCorrelations between domains:\u003c/u\u003e We found significant correlations (r\u0026gt;0.50, p\u0026lt;0.05) between self-image (SRS22) and general health (SF36-PCS, ODI), mental health (SF36-MCS, HAD), and sexual distress (FSDS) in both treatment groups. In the surgical group, additional significant correlations were observed: between mental health (SF36-MCS, HAD) and both self-esteem (RSES) and sexual distress (FSDS); between sexual distress (FSDS) and self-esteem (RSES); and between self-esteem (RSES) and self-image (SRS22) (Table 7).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights the need to address not only the physical and functional aspects of IS but also the psychosocial challenges that arise throughout the treatment journey. By analyzing six well-defined groups of patients (classified by age and treatment modality) we examined the interplay between treatment type, age, and various psychosocial and functional dimensions.\u003c/p\u003e \u003cp\u003eTreatment modality had a surprisingly limited impact on most measured domains, with one notable exception: patients treated conservatively reported significantly worse Trunk Deformity Perception. In contrast, surgical patients generally expressed satisfaction with their physical outcomes, although some voiced concerns regarding scarring, often reflecting inadequate preoperative counselling and unmet expectations about the appearance of postoperative scars.\u003c/p\u003e \u003cp\u003eAge, however, emerged as a more powerful differentiating factor. Older patients tended to report poorer psychosocial and functional health. Yet, with age also came a greater sense of acceptance. Many older individuals demonstrated a more mature, reconciled view of their scars and their overall condition, suggesting a complex, evolving relationship between physical change and self-concept over time.\u003c/p\u003e \u003cp\u003eThis study underscores the importance of addressing not only physical and functional aspects of IS, but also psychosocial factors during the treatment process. Psychological distress, particularly during adolescence, was a consistent theme throughout the narratives. This period of identity formation and heightened sensitivity to body image made patients especially vulnerable to emotional challenges. Support systems\u0026mdash;including family, peers, and access to professional mental health services\u0026mdash;were cited as critical to coping successfully with the demands of treatment. These findings reinforce earlier research that underscores the importance of psychological support in mitigating distress and improving long-term outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, the psychosocial distress associated with bracing during adolescence was a significant concern, with many patients recalling feelings of discomfort, social isolation, and body image issues. These results align with previous studies that highlight the negative emotional and social consequences of bracing in adolescent patients with IS​ [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Surgery, on the other hand, was generally seen as more liberating. For most patients, surgical correction and the removal of the brace led to significant improvements in self-image and self-esteem. Nevertheless, surgical scarring remained a source of dissatisfaction for some, especially younger individuals who had not fully anticipated the cosmetic impact. These findings underscore the importance of thorough, honest preoperative discussions, including aesthetic outcomes and long-term appearance.\u003c/p\u003e \u003cp\u003eSexual health, often overlooked in scoliosis literature, is a fundamental component of overall well-being. Given its strong associations with self-esteem, self-image, and sexual behavior, particularly among women, it should be recognized as a key determinant of HRQoL [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This is especially relevant in conditions like scoliosis that directly impact body image, underscoring the need for clinicians to address sexual health more openly and routinely during treatment discussions.\u003c/p\u003e \u003cp\u003eCollaborative decision-making stood out as another key factor in shaping positive patient experiences. Patients who felt more involved in the decision-making process (especially surgical candidates), reported better coping strategies and a more favorable overall treatment experience. These findings reinforce the value of a patient-centered approach that emphasizes shared decision-making, transparency, and empathy throughout the care process.\u003c/p\u003e \u003cp\u003ePrevious research on IS using mixed or exclusively qualitative methods is limited and involves predominantly short-term outcomes often focusing on cross-sectional patient experiences [\u003cspan additionalcitationids=\"CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Only one qualitative-only study has examined the long-term health status of patients who underwent surgery during adolescence, and its results align with ours [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMixed-methods are increasingly valued for their ability to provide a comprehensive understanding of complex topics by combining broad statistical trends with individual lived experiences. However, such studies also face inherent challenges due to epistemological differences in sampling, data collection, and result interpretation [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Quantitative research prioritizes objectivity, statistical significance, and generalizability, while qualitative research offers rich, contextual insights through purposive sampling [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA primary limitation of this study lies in these epistemological differences. Our sample size, determined based on qualitative requirements, may have limited our statistical power to detect significant differences across certain quantitative variables. Additionally, recall bias must be acknowledged, as participants\u0026rsquo; reflections on adolescent experiences were likely influenced by their current psychological state and coping mechanisms. Their memories may represent reinterpretations shaped by time and perspective, rather than precise accounts of past events.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis is the first mixed-methods study of the long-term status of individuals with IS. Our results suggest that while the psychosocial challenges associated with treatment\u0026mdash;particularly bracing\u0026mdash;can be profound during adolescence, their long-term impact appears limited in adulthood. Instead, current psychosocial and functional well-being is more strongly influenced by age, underscoring the evolving nature of self-perception and adaptation over time.\u003c/p\u003e \u003cp\u003eThis mixed-methods approach, grounded in first-person experiences, proved essential in capturing the multifaceted impact of IS. It enabled a deeper exploration of the interconnections between self-concept, self-esteem, self-image, and sexual health\u0026mdash;domains often overlooked in traditional scoliosis research. These insights reveal how psychological and social dimensions are inextricably linked with physical health and should not be treated as secondary considerations.\u003c/p\u003e \u003cp\u003eOur results reinforce the importance of a holistic, patient-centered approach to IS management, one that considers structural correction but also the emotional, psychological, and social well-being of patients. This includes proactive and open discussions around sensitive topic such image, scarring, sexual health, and collaborative decision-making, all of which can meaningfully shape the patient experience and long-term satisfaction.\u003c/p\u003e \u003cp\u003eFuture research should continue to explore the long-term psychosocial effects of IS and investigate targeted interventions that can better support individuals across their lifespan.\u003c/p\u003e"},{"header":"Declarations","content":" \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAVC wrote the proposal awarded with the Pilot Study Grant 2017, coordinated the project's execution, and wrote the manuscript.JMV and FP were the PhD directors overseeing the project and ensuring its proper conduct. They also reviewed the manuscript.CFSR was responsible for data collection, including focus groups, interviews, and HRQoL questionnaires.OA and EG conducted the qualitative data analysis.XV conducted the quantitative data analysis.SN and AFM contributed to the proposal writing and reviewed the manuscript.JP reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis article is part of a doctoral thesis (http://hdl.handle.net/10803/674528) that was partially funded through a research grant awarded by Eurospine (Pilot Study Grant 2017) for the project The long-term psychological and functional status of female patients after surgical or non-surgical treatment for Idiopathic Scoliosis: A qualitative and quantitative analysis, IRB approval PR(ATR)90/2016.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTones M, Moss N, Polly DW Jr. A review of quality of life and psychosocial issues in scoliosis. Spine. 2006;31:3027\u0026ndash;38. \u003c/li\u003e\n\u003cli\u003eNational Academies of Sciences E, Division H and M, Education D of B and SS and, Board on Children Y, Applications C on the N and SS of AD and I, Backes EP, et al. Adolescent Development. Promise Adolesc Realiz Oppor Youth [Internet]. National Academies Press (US); 2019 [cited 2025 Apr 11]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545476/\u003c/li\u003e\n\u003cli\u003eClayson D, Luz-Alterman S, Cataletto MM, Levine DB. Long-term psychological sequelae of surgically versus nonsurgically treated scoliosis. Spine. 1987;12:983\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003ePezham H, Babaee T, Bagheripour B, Asgari M, Jiryaei Z, Vahab Kashani R, et al. Stress level and quality of life of adolescents with idiopathic scoliosis during brace treatment. Turk J Phys Med Rehabil. 2022;68:231\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eWoertman L, van den Brink F. Body image and female sexual functioning and behavior: a review. J Sex Res. 2012;49:184\u0026ndash;211. \u003c/li\u003e\n\u003cli\u003eNegrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018;13:3. \u003c/li\u003e\n\u003cli\u003eBaldus C, Bridwell KH, Harrast J, Edwards C, Glassman S, Horton W, et al. Age-gender matched comparison of SRS instrument scores between adult deformity and normal adults: are all SRS domains disease specific? Spine. 2008;33:2214\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eAckard DM, Kearney-Cooke A, Peterson CB. Effect of body image and self-image on women\u0026rsquo;s sexual behaviors. Int J Eat Disord. 2000;28:422\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eLock J. Psychosexual development in adolescents with chronic medical illnesses. Psychosomatics. 1998;39:340\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eNoonan KJ, Dolan LA, Jacobson WC, Weinstein SL. Long-term psychosocial characteristics of patients treated for idiopathic scoliosis. J Pediatr Orthop. 1997;17:712\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eGoldberg MS, Mayo NE, Poitras B, Scott S, Hanley J. The Ste-Justine Adolescent Idiopathic Scoliosis Cohort Study. Part II: Perception of health, self and body image, and participation in physical activities. Spine. 1994;19:1562\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eWeinstein SL, Zavala DC, Ponseti IV. Idiopathic scoliosis: long-term follow-up and prognosis in untreated patients. J Bone Joint Surg Am. 1981;63:702\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eEdgar MA, Mehta MH. Long-term follow-up of fused and unfused idiopathic scoliosis. J Bone Joint Surg Br. 1988;70:712\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eF\u0026auml;llstr\u0026ouml;m K, Cochran T, Nachemson A. Long-term effects on personality development in patients with adolescent idiopathic scoliosis. Influence of type of treatment. Spine. 1986;11:756\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eDanielsson AJ, Wiklund I, Pehrsson K, Nachemson AL. Health-related quality of life in patients with adolescent idiopathic scoliosis: a matched follow-up at least 20 years after treatment with brace or surgery. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2001;10:278\u0026ndash;88. \u003c/li\u003e\n\u003cli\u003eP\u0026eacute;rez-Grueso FJS, Moreno-Manzanaro L, Pizones J. The reunion with my patients: their journey and experience 30 years after their intervention for adolescent idiopathic scoliosis via CD instrumentation. Spine Deform. 2024;12:671\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eChapman AL, Hadfield M, Chapman CJ. Qualitative research in healthcare: an introduction to grounded theory using thematic analysis. J R Coll Physicians Edinb. 2015;45:201\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eMorse JM. The Significance of Saturation. Qual Health Res. 1995;5:147\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eCarley, K. M. (1997). Network text analysis: The network position of concepts. In Roberts, Carl W.: Text analysis for the social sciences (pp. 79-100). Routledge. \u003c/li\u003e\n\u003cli\u003eSoratto J, Pires DEP de, Friese S. Thematic content analysis using ATLAS.ti software: Potentialities for researchs in health. Rev Bras Enferm. 2020;73:e20190250. \u003c/li\u003e\n\u003cli\u003eSapountzi-Krepia D, Psychogiou M, Peterson D, Zafiri V, Iordanopoulou E, Michailidou F, et al. The experience of brace treatment in children/adolescents with scoliosis. Scoliosis. 2006;1:8. \u003c/li\u003e\n\u003cli\u003eRullander A-C, Jonsson H, Lundstr\u0026ouml;m M, Lindh V. Young people\u0026rsquo;s experiences with scoliosis surgery: a survey of pain, nausea, and global satisfaction. Orthop Nurs. 2013;32:327\u0026ndash;33; quiz 334\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eNavarrete-Zampa\u0026ntilde;a MD, Fern\u0026aacute;ndez-Baillo N, Pizones J, S\u0026aacute;nchez-M\u0026aacute;rquez JM, Sell\u0026aacute;n-Soto MC. The post-surgical transition in adolescents who have idiopathic scoliosis. A qualitative study. Enfermeria Clin Engl Ed. 2023;33:361\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eMacculloch R, Donaldson S, Nicholas D, Nyhof-Young J, Hetherington R, Lupea D, et al. Towards an understanding of the information and support needs of surgical adolescent idiopathic scoliosis patients: a qualitative analysis. Scoliosis. 2009;4:12. \u003c/li\u003e\n\u003cli\u003eRullander A-C, Lundstr\u0026ouml;m M, \u0026Ouml;stlund U, Lindh V. Adolescents\u0026rsquo; Experiences of Scoliosis Surgery and the Trajectory of Self-Reported Pain: A Mixed-Methods Study. Orthop Nurs. 2017;36:414\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eRullander A-C, Isberg S, Karling M, Jonsson H, Lindh V. Adolescents\u0026rsquo; experience with scoliosis surgery: a qualitative study. Pain Manag Nurs Off J Am Soc Pain Manag Nurses. 2013;14:50\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eHoneyman C, Davison J. Patients\u0026rsquo; experience of adolescent idiopathic scoliosis surgery: a phenomenological analysis. Nurs Child Young People. 2016;28:29\u0026ndash;36. \u003c/li\u003e\n\u003cli\u003eBull J, Grogan S. Children having spinal surgery to correct scoliosis: a qualitative study of parents\u0026rsquo; experiences. J Health Psychol. 2010;15:299\u0026ndash;309. \u003c/li\u003e\n\u003cli\u003eMacculloch R, Nyhof-Young J, Nicholas D, Donaldson S, Wright JG. Development of an online information and support resource for adolescent idiopathic scoliosis patients considering surgery: perspectives of health care providers. Scoliosis. 2010;5:13. \u003c/li\u003e\n\u003cli\u003eLi J, Chan EA, Li M, Lam YP, Wong AYL, Cheung JPY, et al. \u0026lsquo;Am I different?\u0026rsquo; Coping and mental health among teenagers with adolescent idiopathic scoliosis: A qualitative study. J Pediatr Nurs. 2024;75:e135\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eBryman A. Barriers to Integrating Quantitative and Qualitative Research. J Mix Methods Res. 2007;1:8\u0026ndash;22. \u003c/li\u003e\n\u003cli\u003ePalinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health. 2015;42:533\u0026ndash;44. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 7 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Idiopathic Scoliosis, mixed-methods, long-term, treatment, surgery, bracing","lastPublishedDoi":"10.21203/rs.3.rs-6682518/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6682518/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e \u003c/strong\u003e\u0026nbsp;No prior study could be identified that combined qualitative and quantitative methods to analyse the long-term psychosocial and functional state of Idiopathic Scoliosis (IS) patients treated during adolescence. This study aimed to better understand these patients' long-term health status by identifying key factors that had influenced it over time.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eMethods: \u003c/strong\u003e\u003c/u\u003eA mixed-methods approach was used. Qualitative data included recording, transcription, coding and content analysis of focus groups and semi-structured interviews. For the quantitative analysis, patients completed questionnaires.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u003c/u\u003eFifty-seven patients were recruited. Two focus groups and 44 individual interviews were performed. All of them completed the questionnaires. Quantitative analyses showed significant age-related differences in ODI, SRS22-Function, SRS22-Pain, SRS22-Self Image and trunk deformity perception, with older patients showing poorer results. Trunk deformity perception was the only domain associated with treatment received, with conservative patients scoring worse.\u003c/p\u003e\n\u003cp\u003eQualitative findings highlighted psychosocial impacts of IS and its treatments during adolescence, particularly related to bracing, which was often associated with discomfort and social stigma. However, these effects generally did not persist into adulthood. In contrast, surgical treatment was generally viewed positively, associated with deformity correction, improved self-image and the elimination of bracing, all contributing to better social integration and overall well-being. Qualitative factors influencing current self-image, self-esteem and overall well-being varied by both age and treatment type.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/u\u003e While IS may significantly impact adolescents’ psychosocial health, particularly when it is treated with bracing, the effect tends not to persist into adulthood. In adulthood, age becomes the primary determinant of psychosocial health and general well-being. This mixed-method approach revealed distinct factors influencing each domain studied and offered a deeper understanding of their interconnections, highlighting the complex interplay between social, physical, and psychological factors. These findings underscore the importance of a holistic, patient-centered approach in managing IS, with greater emphasis on psychosocial aspects including self-image, self-esteem, and sexual health, throughout treatment planning and long-term follow-up.\u003c/p\u003e","manuscriptTitle":"Treatment of Idiopathic Scoliosis During Adolescence: A Qualitative and Quantitative Analysis of Its Long-Term Psychosocial and Functional Impact","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 09:15:54","doi":"10.21203/rs.3.rs-6682518/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-02T12:37:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-02T21:52:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T09:26:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66703011576804793440920240373647845552","date":"2025-06-27T06:29:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126614937571513108311895387560274912369","date":"2025-06-25T19:41:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-25T15:17:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-20T15:54:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-19T12:52:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2025-05-16T16:44:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a5eea9ec-fd5d-4c59-b65b-6b0c6716a3f9","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:00:37+00:00","versionOfRecord":{"articleIdentity":"rs-6682518","link":"https://doi.org/10.1007/s00586-026-09809-0","journal":{"identity":"european-spine-journal","isVorOnly":false,"title":"European Spine Journal"},"publishedOn":"2026-02-12 15:57:51","publishedOnDateReadable":"February 12th, 2026"},"versionCreatedAt":"2025-07-01 09:15:54","video":"","vorDoi":"10.1007/s00586-026-09809-0","vorDoiUrl":"https://doi.org/10.1007/s00586-026-09809-0","workflowStages":[]},"version":"v1","identity":"rs-6682518","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6682518","identity":"rs-6682518","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}