Idiopathic scoliosis will be noted in 2% to 3% of typically developing athletes. Sports physicals are an opportunity to screen for spinal deformity and to promote healthy involvement in activities. Bracing is effective at limiting further progression if a curve progresses beyond 20°. If spinal fusion is performed, most surgeons allow return to noncontact and contact sports by 6 to 12 months. There are many other conditions associated with scoliosis that require a more nuanced approach and assessment of the entire patient. Patients with Down syndrome should be examined for myelopathy before participation and a lateral radiograph obtained if concerned for instability.
Key points
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Scoliosis defined as lateral curvature of more than 10° is present in 2% to 3% of the population.
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Full participation in sports should be allowed and encouraged in patients with scoliosis undergoing nonoperative treatment including brace wear.
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Patients after spinal fusion can return to sport activities after discussion with their surgeon at an average interval of 6 months postsurgery depending on the activity.
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Athletes with Down syndrome have an increased risk of atlantoaxial instability and should be screened with a neutral upright lateral if they have signs or symptoms of myelopathy or cord compression.
Introduction/history/definitions/background
This article focuses on sports participation among children and adolescents with spinal disorders. Sports among children is common—whether it be pickup, community, travel, school, Special Olympics, or just physical education class, children should be encouraged to remain active. During periods of rapid growth the developing spine may experience alteration in growth patterns, leading to scoliosis or kyphosis. In this chapter the authors begin by discussing screening for spinal disorders and then discuss the treatment of scoliosis including scoliosis-specific exercises, bracing, and posterior spinal fusion and the implications for sports participation. Although adolescent idiopathic scoliosis is the most common form of scoliosis, the authors also discuss sports participation among patients with other origins of scoliosis such as congenital scoliosis and scoliosis stemming from or associated with other conditions. They also touch on the cervical spine in pediatric patients with a special focus on cervical instability in Down syndrome, as it pertains to sports participation.
Adolescent idiopathic scoliosis is defined as a lateral curvature of the spine of greater than 10° measured on a posteroanterior radiograph of the spine with vertebral rotation. Because radiographs are a 2-dimensional image, the rotation of the spine from scoliosis rotates some of the natural curvature of the spine from the sagittal plane to the coronal plane. Only 2% to 3% of patients younger than 16 years will have a curvature of greater than 10° and only 0.3% to 0.5% will have a curve over 20°. At these small curve magnitudes patients usually present as a result of screening or incidental diagnosis not with clinical changes. The likelihood of scoliosis increases with a first-degree relative with scoliosis indicating a genetic underpinning that has not been fully elucidated and may have different sites depending on patient’s ethnic background.
Discussion
Screening for scoliosis takes place in multiple settings: pediatrician or family medicine offices, school screenings, and the “screening” performed by families. There is evidence that the effectiveness of pediatrician screening can be improved with provider-focused interventions. There is a contentious history of school screening for scoliosis with ties to an era of spinal deformity due to tuberculosis or polio bleeding into spinal deformity due to idiopathic scoliosis, which has a more benign natural history. Because of the relatively low incidence of scoliosis and the variable age at onset, school screening does refer some patients with scoliosis but misses some (false negatives) and generates referrals that sometimes result in radiographs but no diagnosis or treatment of scoliosis (false positives). In 1999 Yawn and colleagues reviewed a population of 2242 children screened in Rochester Minnesota and followed them to age 19 years. Screening identified 5 of the 9 children treated for scoliosis but also created referrals for 87 children who were not treated. The incidence of curves of at least 20° was 0.4%, and 448 children needed to be screened to identify one child who received treatment. Karachalios and colleagues highlighted the high false-positive rate of forward bend test alone and advocated for objective data through Moire topography, humpometer, or scoliometer readings with cutoffs. In a meta-analysis in 2010 Fong and colleagues noted that forward bend test alone was not sufficient for screening. In 2015 Fong followed-up with a study highlighting the effectiveness of a school screening program in Hong Kong with sustained effectiveness over 5 years. Altaf and colleagues also discussed that screening is effective at finding scoliosis when using scoliometer or Moire topography but highlight the high referral to radiology rate of 6.6% as a hurdle to overcome.
There are also considerations of cost of school screening with Yawn and Yawn finding costs of $24.66 per child screened, $3386.25 per child with a curve of 20° or more, and $10,836 per child treated. In addition to radiation and cost there is familial and patient anxiety created with a referral for scoliosis. Thomas and colleagues found an increase in curve magnitude of patients presenting with scoliosis after school screening ceased in their area from 20 to 23° on average and a higher rate of patients undergoing brace and surgical treatment on presentation. There were also 48% fewer children seen from the county after school screening was discontinued. As a result of these studies as well as the effectiveness of bracing demonstrated by Danielsson and the BrAIST trial the US Preventative Services Task Force changed the recommendation for school screening from a D in 2004 recommending against school screening to an I or insufficient rating in 2018, highlighting a lack of current evidence to balance the benefits and harms of screening. They highlighted the effectiveness of bracing in limiting curve progression but cited insufficient evidence on the long-term outcomes of adolescents treated with a brace, exercises, or surgery.
Diebo and colleagues highlighted the lack of screening in underserved populations, and Kadhim postulated that screening underserved populations may be the solution to scoliosis school screening, highlighting a lack of referral pathway as a barrier to screening frequently cited. Sports participation physicals may be an alternate avenue for screening this population. The costs of universal screening may not be viable without further evidence to support improved long-term outcomes and the difficulties associated with gathering that data, but the effectiveness of bracing at limiting curve progression should not be understated. The crux of the matter is that the same issues that limit the effectiveness of school screening—variable age at onset and variable progression after onset of scoliosis—will continue to apply. Creating multiple potential touchpoints for screening and increasing the accuracy of screening would help to identify those patients who would potentially benefit from brace wear as in Fig. 1 .
If a patient is noted to have scoliosis this should not be a barrier to participation. There have, historically and among families, been concerns regarding lifestyle and physical activities that lead to scoliosis. Watanabe and colleagues evaluated 2600 Japanese female junior high school students aged 12 to 15 years who were due to undergo a radiographic screening after a positive screening for scoliosis and found that backpacks, time studying, playing a musical instrument, swimming, rhythmic gymnastics, artistic gymnastics, tennis, volleyball, hours of sleep and positioning during sleep, age of mother at delivery, birth weight, and maternal smoking and alcohol use were not predictive of scoliosis defined as a curvature of more than 15°. They did find more frequent and earlier initiation of ballet, a mother with scoliosis, being underweight, and dental braces were associated with increased odds of scoliosis, whereas more frequent basketball participation was protective against a diagnosis of scoliosis. Green and colleagues performed a systematic review in 2009 and found that brace-treated and surgically treated patients with scoliosis can participate in sports, and nonoperative patients are encouraged to participate in sports.
Screening for scoliosis can be seen in an alternate light—rather than emphasizing the limitation of prevention of scoliosis curve progression, it can be used to encourage the normalization of scoliosis and creation of good body habits. In long-term follow-up of brace treatment with a Wilmington brace, Gabos and colleagues found difficulty with functional activities of shopping, sitting, and side lying when compared with controls, and Misterska and colleagues found an increase in back and neck pain in long-term follow-up after brace treatment with a Milwaukee brace. Piantoni and colleagues in 2018 found that 72% of female patients given the Brace questionnaire were psychologically affected in some way by their brace. In long-term follow-up Danielsson comparing 40 patients observed with scoliosis and 37 brace-treated patients found no difference in SRS scores or SF-36 scores at a mean follow-up of 16 years after maturity. Interestingly, in an earlier study out of Sweden with an earlier subset of patients comparing posterior spinal fusion with Harrington rods with brace-treated patients and normal Swedish controls, Danielsson found surgical and braced patients had slightly worse physical function on SF-36 subscales as well as worse Oswestry Disability Index. Overall, the differences were minor and the conclusion was that adolescents treated for scoliosis with surgery or bracing had approximately the same health-related quality of life as controls.
Could these outcomes be improved with an increase in activity and improved back health created through early focus on maintenance of exercise routines and participation in sport? Segreto and colleagues found patients with scoliosis being treated with a brace who participated in noncontact sports had improved functionality, self-image, expectations, and parental perception of deformity when compared with brace-treated patients who did not participate in sport. This requires planning, as the typical brace wear prescription is 16 to 18 hours a day, leaving 6 to 8 hours a day for activities. In an editorial Kakar and colleagues discussed decreased participation in sport after fusion as well as the osteopenia seen in patients with scoliosis, highlighting the need for interventions to maintain activity levels in patients with scoliosis. There are more recent studies that demonstrate patients with scoliosis participating at similar levels with peers. Diarbakerli and colleagues gave patients with scoliosis the international physical activity questionnaire short form and found no differences in percentage of patients who achieved moderate activity level and sports participation compared with controls. In 2012 Negrini and colleagues reviewed 607 patients and found no difference in sport participation before initiation and after 6 months of bracing with both numbers around 50%.
There is also a growing body of evidence with low-level support for scoliosis-specific exercise routines for scoliosis. Thompson and colleagues performed a systematic review of scoliosis-specific exercises compared with other nonsurgical interventions and found very low-quality evidence, indicating scoliosis-specific exercises improved function, pain, and overall health-related quality of life with no effect on self-image and mental health. They also found that bracing was more effective than scoliosis-specific exercises on measures of spinal deformity, but exercises showed greater improvements in function, health-related quality of life, self-image, mental health, and patient satisfaction. A newer study not included in that review found that patients with adolescent idiopathic scoliosis (AIS) curves 12 to 20° enrolled in Schroth therapy had smaller curves than controls on average (16.3 vs 21.6, P = .04) and less curve progression on average (0 vs 5.6°, P = .2), although there was no difference in bracing at 1 year (37% vs 43%). This study highlights the potential for multimodal treatment of scoliosis. Patients with a small curvature of scoliosis often want some control over their outcome, and being “observed” to watch for curve progression may not satisfy that need. Screening and giving children and families a diagnosis with no treatment may also heighten their feeling of a “disease state” of a “dangerous curve” highlighted by Linker earlier. If scoliosis-specific exercises are found to be effective at prevention of progression before bracing this could fill the void. It will also highlight to patients their ability to continue to participate in activities including therapy and perhaps create better coping mechanisms as opposed to a wait and see approach. This does need to be balanced with appropriate expectations of the benefits of exercise programs. Current evidence supports bracing above all other measures for prevention of curve progression. Longer term studies are needed to see what effects, if any, scoliosis-specific exercises have on outcomes.
There are still patients who will present with large curves, likely to progress in adulthood leading to potential pulmonary restriction as well as increased likelihood of pain as an adult. The long-term Iowa studies also highlighted patient statements that they had lived a good life but wished there had been surgery as a choice when they were diagnosed. For these patients the current gold standard is a posterior spinal fusion to limit longer term progression of scoliosis as in Figs. 2 and 3 . Based on the Iowa longitudinal studies a surgical discussion takes place around 50°, especially if there is growth remaining. Fusion levels are chosen to fuse all relevant portions of the scoliotic deformity while limiting distal fusion levels to preserve segments of motion. Another group of adolescents who have not been mentioned yet is those with Scheuermann’s kyphosis. The nonoperative treatment of this group is not published to the extent that patients with scoliosis is, but if they reach a deformity magnitude resulting in spine fusion the postoperative recommendations for sport will apply similarly.
