Adolescent Idiopathic Scoliosis and Sport: Evidence Update

By Rosemary Marchese, Physiotherapist

Is it okay for adolescents with idiopathic scoliosis (AIS) to participate in sport? And, if so, is sport a viable ‘treatment’ approach for these growing children? There are so many questions relating to sport and its appropriateness for these adolescents. AIS is already a complex three-dimensional condition where parents and patients are often left frustrated by the ‘wait and see’ approach (1). Sport, even without scoliosis, has so many potential health benefits and so it’s imperative to be well equipped to know the answers to the likely questions.

Are unilateral sports harmful for AIS?

Tennis is the most practiced unilateral sport (2) and thus it might be natural to assume a correlation between tennis and scoliosis. Tennis has been postulated as one of the types of sport that could increase the risk of spinal deformity progression. There is no evidence to support this theory and the data from a cross-sectional study does not show any correlation between tennis and scoliosis (3).

What about gymnastics?

Gymnastics is another typical sport that is mentioned in scoliosis. Gymnasts tend to be super flexible and it would be reasonable to assume a correlation between this sport and AIS. What we do know is that the incidence of scoliosis was found to be 10-fold higher in a study of 100 rhythmic gymnasts compared to their normal counterparts (4). The authors noted substantial physical loading, accompanied by repeated asymmetric stresses on the spine in these athletes. The author suggested that the results indicate a potential aetiological role of a ‘dangerous triad’ including:

– generalized joint laxity
– delayed maturity, and
– asymmetric spinal loading

This combination of features potentially being linked to AIS is particularly interesting in light of the evidence so far showing a lack of correlation between AIS and the asymmetric spinal loading that occurs in tennis. The potential role of joint laxity has continued to be a point of interest in scoliosis research.

Another study has pointed out that in a group of 201 teenagers with idiopathic scoliosis the incidence of idiopathic scoliosis was higher than in a control group (5). What is even more interesting is that the sport of gymnastics was chosen before scoliosis was diagnosed. This led to the authors raising the question of whether or not the joint laxity that exists in some children makes them more drawn to sports like gymnastics (5). In other words, they choose gymnastics because their bodies are suited to the sport. Whether or not they develop scoliosis as a result of this decision is not proven. It is still possible to consider, based on the data to date, that they would have developed scoliosis no matter which sport they had chosen.

It is likely that hypermobile children choose sports like gymnastics because their body is suited to it and not that the sport causes AIS.

Ballet and AIS

Ballet dancers also often have high levels of joint laxity. Longworth et al (2014) also demonstrated that thirty percent of dancers in their cohort tested positive for scoliosis compared to non-dancers (6). Odds ratio calculations suggest that dancers are 12.4 times more likely to have scoliosis than dancers of the same age. They also noted the higher rate of hypermobility (70%) compared to non-dancers. They concluded that adolescent dancers are at significantly higher risk of developing scoliosis than non-dancers. However, similar to the data provided above regarding gymnastics, it is likely that these children gravitate towards the practice of ballet because of genetic suitability to the sport, rather than the sport causing the actual scoliosis. Further research is required, but for now, vigilant screening of these children is appropriate.

Ballet dancers may be prone to scoliosis, but more so because of their genetic makeup rather than ballet causing the scoliosis. More research is needed in this area!

Should swimming be used as a treatment for scoliosis?

This is a big question that still often pops up in online searches and in clinic settings. Despite swimming being advocated by many health care professionals as a treatment of choice for AIS, the opposite appears to be true – swimming is not effective in the conservative treatment of scoliosis (7, 8). Data from a cross-sectional study showed that swimming seems to be associated with an increased risk of trunk asymmetries and hyperkyphosis. The authors concluded that any indication to use swimming as a treatment for scoliosis is unfounded, and in fact, they showed a higher prevalence of lower back pain in females who practiced swimming (7).

Swimming is NOT a treatment of choice for AIS.

Sport – a treatment or adjunct to scoliosis treatment?

To date, there is no evidence to support that any particular sport is a useful conservative treatment approach to scoliosis. AIS should be treated with the human in mind, and conservative treatment approaches should involve careful consideration of the use of scoliosis-specific exercises, combined in some cases with bracing (9). Sport has many potential benefits to all adolescents, and as clinicians we don´t want these children to miss out on the many benefits of adding sport to their conservative treatment options (10). We need to treat more than just the Cobb angle – we need to treat the whole person (11). Sport is therefore a useful adjunct to treatment, but it should not be used in place of a scoliosis-specific rehabilitation program (11).

Sport is a potential adjunct to scoliosis conservative treatment.

 

References:

(1) Berdishevsky H, Lebel VA, Bettany-Saltikov J, et al.: Physiotherapy scoliosis-specific exercises—a comprehensive review of seven major schools. Scoliosis Spinal Disord, 2016, 4: 1.

(2) 0. I numeri dello sport—a cura del Centro Studi. In: Com Olimp Naz Ital. http://www.coni.it/it/coni/i-numeri-dello-sport.html.

(3) Zaina, F., Donzelli, S., Lusini, M., Fusco, C., Minnella S. and Negrini, S. (2016). Tennis is not dangerous for the spine during growth: results of a cross-sectional study. Euro Spine Journal. 25:2938–2944 DOI 10.1007/s00586-016-4452-1

(4) Tanchev, PI., Dzherov, AD., Parushev, A., Dikov, DM., and Todorov, MB. (2000). Scoliosis in Rhythmic Gymnastics. Spine, 25(11): 1367- 1372.

(5) Meyer, C., Cammarata, E., Haumont, T., Deviterne, D., Gauchard, GC., Leheup, B., Lascombes, P. and Perrin, P. (2006). Why do idiopathic scoliosis patients participate in more gymnastics? Scand J Med Sci Sports. 16: 231-236.

(6) Longworth, B., Fary, R., Hopper, D. (2014). Prevalence and predictors of adolescent idiopathic scoliosis in adolescent ballet dancers. Archives of Physical Medicine and Rehabilitation. 95: 1725-1730.

(7) Zaina, F., Donzelli, S., Lusini, M., Minnella, S., and Negrini, S. (2015). Swimming and spinal deformities: A cross-sectional study. The Journal of Pediatrics, 166(1): 163-167.

(8) Gonen Aydin C, Oner A, Hekim HH, Arslan AS, Oztas D, Akman YE. (2020) The prevalence of scoliosis in adolescent swimmers and the effect of swimming on adolescent idiopathic scoliosis. Turk J Sports Med.;55(3):200-6.

(9) Negrini, S., Donzelli, S., Aulisa, A.G. et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis 13, 3 (2018). https://doi.org/10.1186/s13013-017-0145-8

(10) Sports, in association with specific exercises, can help to achieve better results in controlling the evolution of scoliosis. Oral Presentation. 9th International Conference on Conservative management of Spinal Deformities – SOSORT 2012 Annual Meeting. Milan, Italy 10-12 May 2012. (2013). Scoliosis Spine Journal. 8(Supple 1: O19. http://www.scoliosisjournal.com/content/8/S1/O19

(11) Negrini, S., Grivas, T.B., Kotwicki, T. et al. (2006) Why do we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients. SOSORT 2005 Consensus paper. Scoliosis 1, 4. https://doi.org/10.1186/1748-7161-1-4

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