Serial Case Reporting Yoga for Idiopathic and Degenerative Scoliosis

Abstract

Non-surgical techniques for treating scoliosis frequently focus on realigning the spine, typically by muscular relaxation or muscular or ligamentous stretching. However, such treatments, which include physical therapeutic, chiropractic, and bracing techniques, are inconsistently supported by current evidence. In this study, we assess the possible benefits of asymmetrical strengthening of truncal muscles on the convex side of the scoliotic curve through a single yoga pose, the side plank pose, in idiopathic and degenerative scoliosis.
Twenty-five patients with idiopathic or degenerative scoliosis and primary curves measuring 6 to 120 degrees by the Cobb method had spinal radiographs and were then taught the side plank pose. After 1 week performing the pose with convexity downward for 10 to 20 seconds, they were instructed to maintain the posture once daily for as long as possible on that one side only. A second series of spinal radiographs was taken 3 to 22 months later. Pre- and post-yoga Cobb measurements were compared.
The mean self-reported practice of the yoga pose was 1.5 minutes per day, 6.1 days per week, for a mean follow-up period of 6.8 months. Among all patients, a significant improvement in the Cobb angle of the primary scoliotic curve of 32.0% was found. Among 19 compliant patients, the mean improvement rose to 40.9%. Improvements did not differ significantly among adolescent idiopathic and degenerative subtypes (49.6% and 38.4%, respectively).
Asymmetrically strengthening the convex side of the primary curve with daily practice of the side plank pose held for as long as possible for an average of 6.8 months significantly reduced the angle of primary scoliotic curves. These results warrant further testing.

Full text

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Volume 3, Number 5 • September 2014 • www.gahmj.com
GLOBAL ADVANCES IN HEALTH AND MEDICINE
Original Research
ORIGINAL RESEARCH
Serial Case Reporting Yoga for Idiopathic and
Degenerative Scoliosis
系列案例报告瑜伽治疗特发性和退行性脊柱侧弯
Informe de serie de casos sobre el yoga para la escoliosis idiopática y degenerativa
Loren M. Fishman, MD, United States; Erik J. Groessl, PhD, United States; Karen J. Sherman, PhD, MPH, United States
Author Affiliations
Columbia College of
Physicians and Surgeons
New York (Dr Fishman);
University of California
San Diego, VA San
Diego Healthcare
System (Dr Groessl);
Karen J. Sherman, PhD,
MPH, Group Health
Research Institute,
Seattle, Washington.
Correspondence
lorenmartinfishman@
gmail.com
Citation
Global Adv Health Med.
2014;3(5):16-21. DOI:
10.7453/gahmj.2013.064
Key Words
Scoliosis, yoga,
adolescent idiopathic,
degenerative
ABSTRACT
Background: Non-surgical tech-
niques for treating scoliosis fre-
quently focus on realigning the
spine, typically by muscular relax-
ation or muscular or ligamentous
stretching. However, such treat-
ments, which include physical
therapeutic, chiropractic, and brac-
ing techniques, are inconsistently
supported by current evidence. In
this study, we assess the possible
benefits of asymmetrical strength-
ening of truncal muscles on the
convex side of the scoliotic curve
through a single yoga pose, the side
plank pose, in idiopathic and degen-
erative scoliosis.
Methods: Twenty-five patients
with idiopathic or degenerative sco-
liosis and primary curves measuring
6 to 120 degrees by the Cobb meth-
od had spinal radiographs and were
then taught the side plank pose.
Aer 1 week performing the pose
with convexity downward for 10 to
20 seconds, they were instructed to
maintain the posture once daily for
as long as possible on that one side
only. A second series of spinal radio-
graphs was taken 3 to 22 months
later. Pre- and post-yoga Cobb mea-
surements were compared.
Results: The mean self-reported
practice of the yoga pose was 1.5
minutes per day, 6.1 days per week,
for a mean follow-up period of 6.8
months. Among all patients, a sig-
nificant improvement in the Cobb
angle of the primary scoliotic curve
of 32.0% was found. Among 19
compliant patients, the mean
improvement rose to 40.9%.
Improvements did not dier signifi-
cantly among adolescent idiopathic
and degenerative subtypes (49.6%
and 38.4%, respectively).
Conclusions: Asymmetrically
strength ening the convex side of the
primary curve with daily practice of
the side plank pose held for as long as
possible for an average of 6.8 months
significantly reduced the angle of pri-
mary scoliotic curves. These results
warrant further testing.
摘要
背景：治疗脊柱侧弯的非手术方
法常常注重通过肌肉松弛或拉伸
肌肉或韧带而重新调整脊柱的方
面。然而，目前的证据显示，这
些物理治疗、脊柱推拿和支撑术
等方法的效果不稳定。本研究
中，我们在特发性和退行性脊柱
侧弯中，评估侧面平板式的瑜伽
姿势对于非对称加强脊柱侧弯凸
侧躯干肌肉的益处。
方法：25名特发性或退行性脊柱
侧弯经Cobb法测量原发曲度为6度
至120度的患者，进行脊椎X光
片，之后获教授侧面平板式姿
势。姿态保持凸面向下10至20
秒，练习一周，之后指导患者每
日尽可能长时间地仅在一侧脊柱
的保持该姿势。3到22个月以后，
拍摄第二次脊柱X光片系列。对比
做瑜伽姿势前后的Cobb测量值。
结果：患者自我报告做瑜伽姿势
的时间平均为每天1.5分钟、每周
6.1天，患者的平均随访时间为
6.8个月。在所有患者中，发现
32.0％出现脊柱侧弯原发曲度的
Cobb角度值显著改善。在19例有
主诉的患者中，平均改善率上升
为40.9％。 在青少年的特发性和
退行性亚型患者中，改善之间未
见显著差别（分别为49.6％和
38.4％）。
结论：平均6.8个月的每日尽可能
长时间的进行侧面平板式姿势的
不对称增强凸侧面的练习，会显
著减小脊柱侧弯的原发曲度。这
些结果需要进一步的测试。
SINOPSIS
Antecedentes: Las técnicas sin cirugía
para el tratamiento de la escoliosis
normalmente se centran en la realin-
eación de la columna; por lo general,
mediante la relajación muscular o el
estiramiento muscular o de los liga-
mentos. Sin embargo, estos trata-
mientos, que incluyen la terapia físi-
ca, quiropráctica y otras técnicas de
refuerzo, son incompatibles de acu-
erdo con las evidencias actuales. En
este estudio, se evalúan los posibles
beneficios de fortalecer los músculos
del tronco de manera asimétrica en el
lado convexo de la curva escoliótica a
través de una única postura de yoga,
la tabla lateral, para la escoliosis
idiopática y degenerativa.
Métodos: A 25 pacientes con escolio-
sis degenerativa o idiopática y con
curvas escolióticas de 6 hasta 120
grados según el método de Cobb se
les hizo radiografías de la columna y
se les enseñó a practicar la postura de
yoga “tabla lateral”. Después de
haberla practicado durante una
semana con convexidad hacia abajo
durante 10/20 segundos, se les ense-
ñó a mantener la postura una vez al
día durante todo el tiempo que pud-
iesen solo por ese mismo lado. Entre
3 y 22 meses más tarde se volvieron a
hacer radiografías por segunda vez.
Se compararon las medidas con el
método de Cobb antes y después de
haber practicado yoga.
Resultados: La experiencia media de
autoevaluación de la postura de yoga
fue de 1,5 minutos por día, 6,1 días
por semana, durante un periodo de
seguimiento medio de 6,8 meses.
Entre todos los pacientes, se experi-
mentó una mejora significativa de un
32,0 % en el ángulo de Cobb de la
curva escoliótica primaria. Entre 19
pacientes colaboradores, la mejoría

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YOga FOR IDIOPaThIc aND DEgENERaTIVE ScOLIOSIS
INTRODUCTION
Scoliosis is a condition in which there is lateral cur-
vature of the vertebral column. This right-to-left asym-
metry is often accompanied by a rotational and/or
kyphotic component.1
Scoliosis affects 2% to 3% percent of the popula-
tion, or an estimated 6 to 9 million people in the United
States. Medical and preventive advances in tuberculosis
and polio have changed the statistics so that at present
more than 80% of cases are idiopathic.1,2 Currently
most scoliosis develops in infancy or early childhood.
Although it is generally discovered in the age range of
10 to 15 years, it usually begins considerably earlier, and
at the time of its origin, is equally common in males and
females.1-3 Females, however, are eight times more like-
ly to progress to a scoliotic curve of a magnitude that
requires treatment.1-3 Degenerative adult scoliosis
results from a combination of age and deterioration of
the spine, generally with onset after the age of 40 years.
It may be related to osteoporosis.4
TREATMENT OF SCOLIOSIS
When untreated, scoliosis can be painful and can
affect gait, posture, and other areas of physical function-
ing, measurably lowering self-esteem,5-10 negatively
affecting body image in teenagers,9 and progressing to
severely reduced respiratory function in aging popula-
tions.11 Recent studies predict as much as a 7% annual
increase in untreated scoliotic curves.10-14 The standard
of care recommends observation of patients with curves
of less than 25 degrees, bracing of patients with curves in
the 25 to 45–degree range, and surgery for patients with
curves greater than 45 degrees.14
The studies evaluating the efficacy of bracing and
other conservative therapies are inconsistent, and thus
their findings must be regarded as inconclusive.15-28
Several small studies are optimistic about yoga-like
Figure 1 The classical Iyengar side plank pose with the addition of
the ribs raised vertically.
(a) Patients with carpal tunnel syndrome, arthritic wrists, or rotator cuff
syndrome used this adaptation. Convex side downward, ribs are still
elevated as in Figure 1.
(b) This adaptation was used for patients with weakness and imbalance.
(c) An adaptation for patients with knee and ankle pain.
(d) An adaptation for patients with knee pathology, in which the body
weight was supported by the hip.
Figure 2 Four modifications of the side plank pose that were used
when appropriate for patients with various co-morbid conditions.
media alcanzó un 40,9 %. No hubo
diferencias significativas de las
mejorías entre los subtipos adolescen-
tes idiopáticos y degenerativos (un
49,6 % y un 38,4 %, respectivamente).
Conclusiones: Al fortalecer asimétri-
camente el lado convexo de la curva
primaria con la práctica diaria de la
postura “tabla lateral” de yoga
intentando mantenerla el máximo de
tiempo posible durante una media de
6,8 meses se consigue reducir signifi-
cativamente el ángulo de las curvas
escolióticas primarias. Estos resulta-
dos deben seguir investigándose.

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GLOBAL ADVANCES IN HEALTH AND MEDICINE
Original Research
approaches.17,25,26 Typical surgical treatments involve
spinal fusion and/or wiring, with or without rods. Surgery
brings a 44% to 59% reduction of the curves on which it
is performed.29-36 However, there is substantial comor-
bidity, including restriction of spinal mobility, hardware
malfunctioning, extra strain on the vertebrae above and
below the fusion, and pseudoarthroses. A recent study
documented a rate of 50% of revision surgery following
Cotrel-Dubousset surgical intervention.33 The cost of the
surgery, which is performed 38
000 times annually, varies
from $125
000 to $250
000.3 Estimating the average cost at
$187
500, the total annual cost for surgery in the United
States would be $7
125
000
000.1,37
For 3 to 22 months, we evaluated the effectiveness of
regular home practice of a single yoga pose designed to
strengthen the convex side of primary thoracolumbar
curves. We began this study after observing that the side
plank pose, done with the convex side down, had arrested
and begun to reverse the natural progression of idiopath-
ic and degenerative scoliosis in several patients.
METHODS
Patient Selection
We examined 25 consecutive patients in a retro-
spective study from the records of our private practice
physical medicine and rehabilitation clinic in New York
City, which is located in a neighborhood of affluent and
educated people. We included adults with a document-
ed scoliotic curve of 6 or more degrees, the willingness
to perform the pose at least once daily for the entire
study period, and the commitment to have initial and
terminal scoliosis radiographs. Several of these patients
did not follow the protocol. Among our candidates,
patients with non-idiopathic, non-degenerative scolio-
sis, previous spinal surgery, pregnancy, or concurrent
musculoskeletal or neuromuscular or psychiatric disor-
ders were excluded from the study, as well as any per-
sons we judged unable to perform the requisite exercises
daily. Four patients were self-referred; the other 21
patients were referred by healthcare providers. We
defined a noncompliant patient as one who did the side
plank pose fewer than 4 times weekly.
Intervention
A slight modification of the classical Iyengar side
plank pose was used38 wherein patients were instructed
to elevate their ribs, which is not part of the classical
Iyengar technique (Figure 1). In addition, the pose was
modified for other medical conditions and for weakness
(Figure 2). Complex or “S-shaped” curves were treated by
adding a second contralateral strengthening pose that
consisted of holding the free leg with the free arm, and
bulging that part of the spine, generally the cervicotho-
racic spine, upward (Figure 3).
Study Procedures
Before treatment, the study patients were referred
for scoliosis radiographs. Their local radiologists or ortho-
pedic surgeons were asked to read and record the Cobb
angles and send the radiographs to our clinic. Patients
were then taught the side plank pose and instructed to
perform it for 10 to 20 seconds daily for 1 week, and to
perform it once daily for as long as possible thereafter.
Between 3 to 22 months following their initial radio-
graphs, study patients returned to their radiologists or
orthopedic surgeons for a second set of scoliosis radio-
graphs. The radiologists or orthopedic surgeons read and
recorded Cobb angles and sent the radiographs to us.
Measures
The authors re-measured the Cobb angles and agreed
to consult the original radiologist or orthopedic surgeon
if our measurements differed from theirs by more than 5
degrees. Compliant patients were defined as those who
reported performing the side plank pose at least 4 times
per week for the entire follow-up period.
Statistical Analysis
Using paired sample t-tests, the mean change in
primary and secondary Cobb angles were compared
for all patients. Differences over time between degen-
erative and idiopathic scoliosis were compared using
repeated measures analysis of covariance (ANCOVA).
Differences over time between compliant and non-
compliant patients were also compared using repeat-
ed measures ANCOVA. Age and gender were exam-
ined as covariates.
RESULTS
Our study included 25 patients between the ages of
(a) Complex curves require opposite side strengthening, accomplished in this way.
(b) The double-curve treatment may be adapted for limited shoulder function
Figure 3 Adaptations of the plank pose: (a) for complex curves and
(b) for complex curves and limited shoulder function.

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Original Research
YOga FOR IDIOPaThIc aND DEgENERaTIVE ScOLIOSIS
14 and 85 years (mean age of 52.1 y). The group included
23 white patients, one black patient, and one Asian
American patient. Seven patients had secondary curves.
Twelve primary curves and two secondary curves were
convex to the right. For all patients, our spinal angle
measurements and those made by the patient’s radiolo-
gist or orthopedist were within 3 degrees. At the time of
their second scoliosis radiographs, patients had been
practicing the side plank pose nearly daily (average of
6.1 d per wk; range 5 to 7 d) for an average of 1.5 minutes
(range 50 sec to 4 min).
All Patients
At baseline, the average Cobb angle for the primary
curves was 37.2 degrees (range 6 to 120 degrees; SD 28.7)
for the 25 patients. After practicing the plank pose for a
mean of 6.8 months, the mean Cobb angle for the pri-
mary curve decreased to 25.3 degrees (range 3 to 90
degrees; SD 21.0), indicating primary curve improve-
ment of 11.9 degrees or 32.0% (range: –50% to 72.1%;
SD 18.5%). P<.001). At baseline, the mean Cobb angle for
the seven secondary curves was 38.3 degrees (SD 37.7)
while the comparable angle after the yoga intervention
was 29.7 degrees (SD 28.0), a reduction of 8.6 degrees, or
26%; P=.108 (Table 1 and Figure 4).
Effect of Compliance
As shown in Table 2, there were substantial baseline
differences between the Cobb angles of patients who were
deemed compliant vs non-compliant. Compliant patients
had significantly greater improvement in the Cobb angle
of their primary curve (40.9% vs 0.5%; P=.014).
Table 1 Changes in Primary Cobb Angle of All Patients With
Follow-up Data
Pre
Mean
(SD)
Post
Mean
(SD)
Mean
difference
%
change df
t
score
P
value
Primary
Angle
(n=25)
37.2
(28.7)
25.3
(21.0)
11.9 32.0% 21 5.25 <.001
Secondary
Angle
(n =7)
38.3
(37.7)
29.7
(28.0)
8.6 22.5% 6 1.89 .108
Pre-Yoga Post-Yoga
Mean = 37.2
Mean = 25.3
140
120
100
80
60
40
20
0
Figure 4 Improvement in Cobb angles of primary curve over an average of 6.8 months of daily practice of the side plank pose.

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Volume 3, Number 5 • September 2014 • www.gahmj.com
GLOBAL ADVANCES IN HEALTH AND MEDICINE
Original Research
Adolescent Idiopathic Scoliosis and Degenerative
Scoliosis
We limited our analysis of these two scoliosis sub-
types to compliant patients only. Both groups showed
significant improvement in primary curve angles from
baseline to the post-yoga follow-up measurement. As
shown in Table 3, the groups did not differ significantly
in the amount of improvement, with degenerative scolio-
sis patients improving 38.6% and adolescent idiopathic
scoliosis patients improving 49.6%.
Compliant Patients With Adolescent Idiopathic
Scoliosis
At baseline, the mean Cobb angle for the primary
curves in the seven compliant patients with idiopathic
scoliosis was 22.8 degrees (range 6 to 43 degrees; SD 13).
After patients practiced the unilateral side plank pose for
an average of 6.5 months, the mean Cobb angle decreased
to 11.2 degrees (range 3 to 23 degrees; SD 7.2), a primary
curve improvement of 49.2% (range 0% to 72.1%; SD
18.6.) (P<.001 for primary curve reduction, Table 3).
Compliant Patients With Degenerative Scoliosis
Among the 12 compliant patients with degenerative
scoliosis, the average Cobb angle at baseline of the prima-
ry curves was 50.4 degrees (range 10 to 120 degrees; SD
36.3). After an average of 4.9 months of practice, their
mean primary Cobb angle decreased to 33.1 degrees (range
7 to 90 degrees; SD 27.6), indicating mean primary curve
improvement of 38.4% (range 25% to 70%, Table 3).
DISCUSSION
In this case series, we found significant improve-
ments in the Cobb angle of the primary scoliotic curve
among 25 consecutive patients who were prescribed a
single yoga pose. The limited number of patients with
secondary curves showed some additional benefit to the
secondary curve as well. Interestingly, this occurred over
a relatively short time period, with a mean follow-up of
6.8 months and as little as 3 to 6 months in many patients.
Among our 19 compliant patients, 7 had sufficiently
large scoliotic curves that they might be surgical candi-
dates (ie, Cobb angles of ≥45 degrees) and another three
had large curves sufficient enough that bracing would be
appropriate (ie, Cobb angles ≥25 degrees and <45
degrees1-3). Untreated scoliosis is believed to progress to
more severe spinal curvature over time.10-13 It appears
that the improvements of the magnitude that we found
(32% on average) would eliminate the need for surgery or
bracing in most of these patients.
Possible Mechanism
To understand why this yoga pose may help in sco-
liosis, it is important to conceptualize the physics
involved in creating scoliotic curves. A simplified analy-
sis of how humans stand erect involves the symmetrical
downward pull of the dorsal, abdominal, intercostal, and
paraspinal muscles. Scoliosis, then, could be explained by
asymmetry in the force these muscles exert on the spine.
The spine will bend toward the stronger side, and thus,
the muscles of the convex side may be weaker than their
smaller-appearing counterparts on the concave side
(Figure 5). We speculate that the side plank pose is useful
for strengthening the convex side’s quadratus lumborum,
iliopsoas, transverses abdominus, oblique, intercostal,
and paraspinal musculature, which, in turn, might
straighten the spine (Figure 5).
Limitations
Drawing firm conclusions from a small case series is
challenging. In this study, we lacked both a control group
and detailed notes on adherence to the treatment.
However, it is notable that the reductions in the Cobb
angle observed in these patients are superior to those from
Figure 5 Conceptualization of scoliosis and mechanism of correction.
Table 2 Changes in Primary Cobb Angle of Patients by Self-
reported Compliance
Pre
Mean (SD)
Post
Mean (SD)
Mean
difference
%
change df
F
score
P
value
Did the
pose
(n=20)
40.5
(31.1)
25.4
(23.5)
15.1 40.9%
(14.8)
17.26 .014
Did not
do pose
(n =5)
27.0
(17.6)
25.1
(11.4)
1.9 0.46%
(18.5)
Table 3 Changes in Primary Cobb Angle by Type of Scoliosis
Among Compliant Patients
Pre
Mean
(SD)
Post
Mean
(SD)
Mean
difference
%
change df
F
score
P
value
Degenerative
(n=12)
50.4
(36.3)
33.1
(27.6)
17.3 38.4% 10.447 .511
Idiopathic
(n =7)
22.8
(13)
11.2
(7.2)
11.6 49.6%
(18.6)

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YOga FOR IDIOPaThIc aND DEgENERaTIVE ScOLIOSIS
all the therapeutic studies of conservative treatments we
identified and all but one therapeutic study of bracing.19
There may be added value for adolescents because the
daily home practice of these poses is unlikely to raise the
same psychological and self-esteem issues that occur with
bracing as a treatment. Yoga involves no encumbrance or
restriction of movement in daily life and no visible mark-
ers of practice. While the best surgical studies show 59%
improvement for patients, our study could not determine
how much total improvement would be seen if the side
plank pose were carried out for a longer period of time.
The relative ease and low cost of practice might prompt
some parents and children to begin treatment earlier. As a
result, some scoliotic curves might never advance to the
degree that requires surgical correction. In addition, use of
the side plank pose has no notable side effects apart from
occasional and mild wrist and shoulder discomfort. We
therefore believe that future studies of this intervention
are warranted to determine the factors that promote suc-
cess of the procedure and its longevity.
Future Studies
Future studies of yoga as a treatment for scoliosis
would benefit from inclusion of Lehnke classification,
which is used to determine surgical suitability by mea-
suring the primary (largest) curve. In addition, future
randomized studies in adolescent idiopathic scoliosis
should include Risser sign, a measure of hip socket and
iliac bone growth that serves as a proxy for full skeletal
maturity. Use of these measures will help make these
studies comparable to surgical studies. In addition, stud-
ies with longer follow-up periods are needed to clarify the
relationship between duration of treatment to the length
of improvement and the possible side effects of prolonged
treatment. Because past investigations found that both
bracing and surgery impacted quality of life,5-10 including
quality-of-life measures would further facilitate compara-
bility to more traditional studies and may help patients
and if applicable, their parents, with decision making
about the most appropriate treatments.
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