# \"Scoliosis 3D\"-A Virtual-Reality-Based Methodology Aiming to Examine AIS Females' Body Image
## 4 Discussion  
As far as the authors are aware at this time, the proposed methodological project would be the first study concerning the application of biometric avatars in VR to investigate changes within body representation in AIS. It was developed in response to the fact that scoliosis patients following surgical treatment might further overestimate body deformities, e.g., the magnitude of rib hump, scapular and rib prominence, uneven shoulders or asymmetric waistline, and at the same time, experience bod- image disturbances in the long term. In addition, the project was created in the view of challenges related to the need for objective measurement of body representation. The results of the application of AIS avatars may have important implications for the development of standards of body-image-disturbance (BID) treatments in AIS. Promising evidence suggests that implicit interventions aimed at correcting maladaptive automatic processes may be effective at improving body image in other clinical samples [22; 23]. Spina- fusion surgery with instrumentation often successfully reduces severe curves and minimizes the risk of curve progression [1]. However, even though surgery is technically successful and despite the physical benefits of spinal-fusion surgery, which include the preservation of pulmonary function and the prevention of osteoarthritis [24; 25], AIS patients' satisfaction with surgical outcomes can be lower than may be expected, as it is often based on the perception of postoperative cosmesis of the back and shoulders [26]. Considering the issue of body representation in AIS, it has long since been conceptualized as a hierarchical construct with different components [27]. As there is no clear evidence for any such distinction, a dimensional model has recently been developed [28; 29]. In this model, body representation is a conglomerate of multiple body representations that can be characterized in terms of how explicit v. implicit they are, and the extent to which they are perceptual v. conceptual. The body representations are informed by different senses and modalities, such as vision, proprioception or even social comparison, and can be integrated into higher-level representations [13]. Not much is known about changes in AIS patients' body representation over a longer time frame. [PERSON] et al. have shown a more negative body image that may persist for several years in surgical AIS patients [30]. In addition, they found that the perception of self-image might also deteriorate with time. Interestingly, [PERSON] et al. indicated that patients with scoliosis who reported neutrality with the postoperative cosmesis, experienced multiple coping problems and a more critical, negative view of themselves. They also continued to perceive themselves as less attractive than their peers [31]. Several studies concerning BID in clinical samples, e.g., patients treated due to anorexia nervosa (AN), observed that those patients overestimate their body size in different visual-size-estimation tasks [32; 33; 34] as well as in non-visual measures [35]. Researchers also indicated that women with BID neither see their own body nor other weight-matched persons differently than controls, but they evaluate them differently in terms of what weight is desirable [13]. In the current project it is assumed that a similar phenomenon, regarding body-shape estimation, might occur within the AIS population. It should be underlined that results concerning the issue of body-shape evaluation seem contradictory. On the one hand, it was revealed that body dissatisfaction is related to the altered (disfigured) shape and the weight of the individual, but, on the other hand, improvement in body shape and weight loss does not necessarily modify (decrease) body dissatisfaction [36]. This contradiction might be explained by the allocentric-lock hypothesis (ALH) [37].