By Bernie Clark,
September 15, 2022
This article is adapted from the book Your Spine, Your Yoga
Asymmetries can occur in many areas of the body and one common occurrence is in the spine creating a condition known as scoliosis, which is the Greek word for “crooked” or “bent.” Often yoga students and yoga teachers are puzzled by what can be and should be done for scoliosis and whether yoga can help, hinder or affect it at all. The short answer is yes, no and maybe.
Few of us have a perfectly symmetric spine, and that is normal, but when the curvature of the spine as seen from behind (in the frontal plane) exceeds 10°, the spine is considered officially scoliotic. The reported rates of scoliosis vary from 1% to as much as 8% of the population;1 if the actual rate were 5%, one person in a yoga class of 20 would have scoliosis. When scoliosis is first noticed in children, typically around age 10–15, it is called adolescent idiopathic scoliosis (or AIS), but it can appear earlier, even in infancy, or later in life. The rate of scoliosis increases with age,2 women have two to eight times the rate of incidence as men,3 and the worst cases tend to occur in women.4
Scoliosis may appear in several ways. The bend can be in the lower spine (lumbar scoliosis), the thoracic spine (thoracic scoliosis) or both areas (thoracolumbar scoliosis), or it may be more complicated, with double or multiple curves. The illustrations in figure 1 show these four possibilities. Not visible, though, is the degree of twisting that also occurs; scoliosis is not simply a side bend to the spine but also a rotation. Figure 2 shows how the ribs on the concave side (the right side in this figure) are rotated anteriorly, while the convex side (left) rotates posteriorly. (In other words, the ribs rotate toward the convex side.) This is very noticeable when the subject with a lot of scoliosis folds forward: a costal hump is formed by the left rotated ribs rising up posteriorly.
FIGURE 1 Scoliosis variations.
FIGURE 2 When someone with significant scoliosis folds forward, the rotation of the ribcage may become more obvious. In this student, the concave side (right) of the thorax rotates forward with flexion, so the left ribcage rotates posteriorly and the ribs arch up, producing a costal hump.5
Some instances of scoliosis are not caused by structural variations in the spine and are termed functional scoliosis. In these cases, the spine exhibits a lateral curve, which is caused by non-spinal structural conditions such as varying leg lengths, muscle spasms and inflammation. (For example, appendicitis can cause functional scoliosis due to the muscles spasms accompanying it.) In these cases, the spine is fine and needs no treatment; it is the underlying causes that need to be addressed. In functional scoliosis, folding forward will often straighten the spine.
CAUSES AND CONSEQUENCES OF SCOLIOSIS
The majority of cases of scoliosis are idiopathic. This Latin word basically means “we are idiots at understanding what causes the pathology”—in other words, “we don’t know why.”6 About 65% of teenage scoliosis cases are AIS. About 15% may be congenital or genetic. Around 10% of AIS is believed to be due to neuromuscular problems or disease.7 Many researchers believe chronically poor posture can cause or contribute to a worsening of scoliosis. Indeed, it may arise due to our uniqueness as a true biped, as scoliosis is unknown in the animal kingdom outside of us humans. Constant posterior shearing stress between the vertebrae has been shown to decrease rotational stability and stiffness in the spine, which may predispose some people to scoliosis.8 (The increased incidence of scoliosis in women may be because their spines are more mobile but less stable than men’s.) When it develops, scoliosis causes one side of the torso to shorten, tighten and strengthen, while the opposite side lengthens and weakens, as shown in figure 3.
TREATMENTS FOR SCOLIOSIS
The treatments recommended for scoliosis vary with the degree of curvature. When the curve is 20–25° or less, the patient is watched, with no interventions offered. For scoliosis of 25–35°, bracing is recommended, but braces are uncomfortable, and not everyone adheres to the prescription. For curvatures over 35°, exercises and postural re-education are offered. Over 45°, surgery rears its head.9 Despite this range of options, the effectiveness of all treatments has been called into question by several long-term studies, and the jury still seems to be out on the best way to proceed.10
There is debate in the medical community over the consequences of scoliosis. On the one hand, there are reports that adolescents who develop scoliosis also are prone to self-esteem issues, varying degrees of disability, pain, limitation in activities and reduced quality of life. The increased curvature has also been known to cause breathing problems and other health risks in adults and elderly populations.11 On the other hand, long-term studies of patients with AIS show that the condition does not have a significant impact on quality of life or significant consequences, with the exception of very severe cases.12 Indeed, young people with AIS who receive no treatment become fully functional and active adults. Of course, everybody is unique, and someone with scoliosis needs to determine his or her own path, but these long-term findings show that undergoing surgery and other intense treatments may not be worth the risk, given the minor rewards available. A watch-and-wait approach may be best, combined with some physical or yoga therapy.13 While there is some uncertainty over various therapies’ benefits, it is nice to know that exercise at least has no reported downsides.14 With that in mind, it is interesting to review the findings of a study into the use of yoga for scoliosis.
YOGA FOR SCOLIOSIS
Figure 3 shows both a presentation of scoliosis and a theory for fixing it. Since the convex side (the open left side) is too long and too weak, it makes sense to shorten and strengthen this side. Since the concave side (the closed, right side) is too tight and too short, it makes sense to lengthen it but not strengthen it any further. A posture such as Side Plank (Vasisthasana) fits the bill nicely. As shown in figure 4 3.322a, the lower (left) side of the torso is contracting and strengthening. The upper (right) side is lengthening but is not bearing much load, so it is not becoming stronger.
FIGURE 3 Scoliosis causes the concave side of the spine to become tighter and shorter, while the convex side becomes longer and weaker. It is easy to visualize the effect of this on a fishing rod supported by guy wires. The same happens in some people’s spine. The rehabilitation exercise philosophy is to strengthen and shorten the convex side (left) while lengthening the concave (right) side.15
A team led by Loren Fishman, a medical doctor and a senior yoga teacher, tested this idea on 25 scoliosis patients.16 Those who stuck to the practice and worked up over time to holding this one pose for 90 seconds, six days a week for seven months had a 40% reduction in the curvature of their spines.17 That was the average; the range of improvement was 25–75%, significant enough for several of the participants to avoid braces and even surgery.
FIGURE 4 Yoga postures to reduce scoliosis. (a) Side Plank (Vasisthasana); b) Side Plank on elbows for those with wrist or shoulder problems; (c) Side Plank with knees on the floor for those with knee problems; (d) Side Plank with raised leg for double-curve scoliosis.973
Not all participants in the study were able to hold the full Side Plank posture, due to knee, wrist and shoulder problems, so the main posture was adapted to the patient’s needs. For wrist and shoulder issues, the version shown in figure 4b 3.322b was used. For students with knee issues, the knees were flexed and on the floor (c), but the hips were still raised. Notice that for these students, who have a single C-shaped curve, the convex (left) side of the spinal curve is on the bottom. For double-curve scoliosis, a more complicated posture was used, as shown in (d). Here both curves were worked, following the same philosophy of opening the tight side and strengthening and shortening the long side.
NOTE TO TEACHERS: Sometimes it is okay to do only one side of a pose!
For students with an asymmetric spine, it may be a good idea to hold a pose on one side longer than on the other side, or to skip the second side completely and do the first side twice! A student with single-curve scoliosis has one side that is tight and short, while the other side may be long and weak. Rather than work both sides of the spine equally, it may be more beneficial for the student to do two side bends or two twists to the same side and not work the other side at all. For example, the student depicted in figure 2 has a convex curve to the left and his axis is rotated to the left, which is obvious when he folds forward. For him, it may be more beneficial to do the Side Plank Pose (Vasisthasana) twice on the left side and not at all on the right side. Since his ribcage is already rotated to the left, he may only do twisting poses to the right and skip twists to the left.
Although the definition of scoliosis is a curve of the spine of 10° or more, many people have minor curves less than 10°. For these milder conditions, it may be appropriate to work both sides of the spine but for uneven amounts of time. In my own case, I have a slight curve, convex side facing left. This causes me to sit with my head slightly tilted to the right. In my yang yoga practices, I will hold a Side Plank Pose with the right side low for 45 seconds, then do the left side low for 90 seconds. In this way, I can maintain the range of motion of my left side and the strength of my right side while enhancing the range of motion of my right side and the strength of my left side. In my yin yoga practice, I will first hold a twist to the left for three minutes but then hold a twist to the right for six minutes. For my beloved Bananasana poses, I will hold the curve to the left longer than the curve to the right. Awareness of my slight curvature has also led me to change some habitual movement patterns: I remind myself to carry things in my left hand or draped over my left shoulder rather using my more comfortable right side, and to sit straighter with a slight, conscious tilting to the left. These little techniques are helping me to reduce the curvature and prevent it from getting worse. They may help you or your students too.
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[1] See O.D. Carter and S.G. Haynes, “Prevalence Rates for Scoliosis in US Adults: Results from the first National Health and Nutrition Examination Survey,” International Journal of Epidemiology 16.4 (1987): 537–44.
[2] One study found an occurrence rate of only 2% in people under 45 but 15% for people over 65; see D. Pérennou, C. Marcelli, C. Hérisson, and L. Simon, “Adult Lumbar Scolio-sis: Epidemiologic Aspects in a Low-Back Pain Population,” Spine 19.2 (1994): 123–8.
[3] See Jack C. Cheng et al., “Adolescent Idiopathic Scolio- sis,” Nature Reviews. Disease Primers 1 (2015), doi:10.1038/ nrdp.2015.30.
[4] See Carter and Haynes, “Prevalence Rates.”
[5] See Hans-Rudolf Weiss et al., “Postural Rehabilitation for Adolescent Idiopathic Scoliosis During Growth,” Asian Spine Journal 10.3 (2016): 570–81.
[6] Okay, not strictly true: “idio” is from the Greek and means “one’s own,” so the word refers to one’s own problem or pathology, but the modern usage of the word “idiopathic” implies an unknown cause.
[7] See Sandra Nicht, “Incorporating Yoga Therapy into Standard Treatments for Scoliosis,” MUIH Yoga Therapy Program, Yoga 635 Class Project at www.researchgate.net/ publication/281102614_scoliosis_635_project, accessed April 11, 2018.
[8] See T.P. Schlösser et al. “Differences in Early Sagittal Plane Alignment Between Thoracic and Lumbar Adolescent Idiopathic Scoliosis,” The Spine Journal 14 (2014): 282–90.
[9] See Weiss et al., “Postural Rehabilitation”; L.G. Lenke, “Commentary: Continuing the Quest for Identifying Specific Criteria for the Progression of Adolescent Idiopathic Scoliosis,” The Spine Journal 12.11 (2012): 996–7.
[10] A Cochrane report on surgery versus other modalities concluded that there was no evidence showing surgery was better or worse than nonsurgical interventions. No conclusions were reached regarding the benefits of these treatments; see J. Bettany-Saltikov et al., “Surgical Versus Non-surgical Interventions in People With Adolescent Idiopathic Scoliosis,” Cochrane Database of Systematic Reviews 4 (2015): Art. No. CD010663, doi:10.1002/14651858.CD010663.pub2.
[11] See M. Romano et al., “Exercises for Adolescent Idiopathic Scoliosis,” Cochrane Database of Systematic Reviews 8 (2012): Art. No. CD007837, doi:10.1002/14651858.CD007837. pub2.
[12] See Weiss et al., “Postural Rehabilitation.”
[13] See Cheng et al., “Adolescent Idiopathic Scoliosis.”
[14] See Romano et al., “Exercises for Adolescent Idiopathic Scoliosis.”
[15] The photo of a woman with scoliosis is by Dmitry Lobanov, courtesy of Shutterstock, photo ID: 113335180. The drawing is inspired by Loren Fishman, Karen Sherman, and Eric Groessl, “Serial Case Reporting for Idiopathic and Degenerative Scoliosis,” Global Advances in Health and Medicine 3.5 (2014): 16–21.
[16] The researchers admit that their study of yoga postures for scoliosis was small and lacked a control group. Compliance with the protocol was also an issue, but since there were no side effects from the practice (outside of mild soreness in some wrists and shoulders) and the results were so impressive, the use of these exercises as a treatment warrants further investigation. While the patients in this study only did this posture for a minute or so each day, it would be easy to incorporate this pose and its philosophy into a full yoga practice.
[17] See Loren Fishman, Karen Sherman, and Eric Groessl, “Serial Case Reporting for Idiopathic and Degenerative Scoliosis,” Global Advances in Health and Medicine 3.5 (2014): 16–21.