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Serial Case Reporting Yoga for Idiopathic and Degenerative Scoliosis
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Informe de serie de casos sobre el yoga para la escoliosis idiopбtica y degenerativa
Erik J. Groessl, PhD, and Karen J. Sherman, PhD, MPHLoren M. Fishman
Columbia College of Physicians and Surgeons New York (Dr Fishman), United States
Erik J. Groessl
University of California San Diego, VA San Diego Healthcare System (Dr Groessl), United States
Karen J. Sherman
Karen J. Sherman, PhD, MPH, Group Health Research Institute, Seattle, Washington, United States
Abstract
Background:
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.
Methods:
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.
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 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).
Conclusions:
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.
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SINOPSIS
Antecedentes:
Las tйcnicas sin cirugнa para el tratamiento de la escoliosis normalmente se centran en la realineaciуn de la columna; por lo general, mediante la relajaciуn muscular o el estiramiento muscular o de los ligamentos. Sin embargo, estos tratamientos, que incluyen la terapia fнsica, quiroprбctica y otras tйcnicas de refuerzo, son incompatibles de acuerdo con las evidencias actuales. En este estudio, se evalъan los posibles beneficios de fortalecer los mъsculos del tronco de manera asimйtrica en el lado convexo de la curva escoliуtica a travйs de una ъnica postura de yoga, la tabla lateral, para la escoliosis idiopбtica y degenerativa.
Mйtodos:
A 25 pacientes con escoliosis degenerativa o idiopбtica y con curvas escoliуticas de 6 hasta 120 grados segъn el mйtodo de Cobb se les hizo radiografнas de la columna y se les enseсу a practicar la postura de yoga “tabla lateral”. Despuйs de haberla practicado durante una semana con convexidad hacia abajo durante 10/20 segundos, se les enseсу a mantener la postura una vez al dнa durante todo el tiempo que pudiesen solo por ese mismo lado. Entre 3 y 22 meses mбs tarde se volvieron a hacer radiografнas por segunda vez. Se compararon las medidas con el mйtodo de Cobb antes y despuйs de haber practicado yoga.
Resultados:
La experiencia media de autoevaluaciуn de la postura de yoga fue de 1,5 minutos por dнa, 6,1 dнas por semana, durante un periodo de seguimiento medio de 6,8 meses. Entre todos los pacientes, se experimentу una mejora significativa de un 32,0 % en el бngulo de Cobb de la curva escoliуtica primaria. Entre 19 pacientes colaboradores, la mejorнa media alcanzу un 40,9 %. No hubo diferencias significativas de las mejorнas entre los subtipos adolescentes idiopбticos y degenerativos (un 49,6 % y un 38,4 %, respectivamente).
Conclusiones:
Al fortalecer asimйtricamente el lado convexo de la curva primaria con la prбctica diaria de la postura “tabla lateral” de yoga intentando mantenerla el mбximo de tiempo posible durante una media de 6,8 meses se consigue reducir significativamente el бngulo de las curvas escoliуticas primarias. Estos resultados deben seguir investigбndose.
INTRODUCTION
Scoliosis is a condition in which there is lateral curvature of the vertebral column. This right-to-left asymmetry is often accompanied by a rotational and/or kyphotic component.1
Scoliosis affects 2% to 3% percent of the population, 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 likely 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 functioning, measurably lowering self-esteem,5–10 negatively affecting body image in teenagers,9 and progressing to severely reduced respiratory function in aging populations.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 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 comorbidity, 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 idiopathic and degenerative scoliosis in several patients.
METHODS
Patient Selection
We examined 25 consecutive patients in a retrospective 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 documented 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 scoliosis, previous spinal surgery, pregnancy, or concurrent musculoskeletal or neuromuscular or psychiatric disorders were excluded from the study, as well as any persons 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 cervicothoracic spine, upward (Figure 3).
The classical Iyengar side plank pose with the addition of the ribs raised vertically.
Four modifications of the side plank pose that were used when appropriate for patients with various co-morbid conditions.
Adaptations of the plank pose: (a) for complex curves and (b) for complex curves and limited shoulder function.
Study Procedures
Before treatment, the study patients were referred for scoliosis radiographs. Their local radiologists or orthopedic 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 radiographs, study patients returned to their radiologists or orthopedic surgeons for a second set of scoliosis radiographs. 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 degenerative 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 repeated measures ANCOVA. Age and gender were examined as covariates.
RESULTS
Our study included 25 patients between the ages of 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 radiologist 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 primary curve decreased to 25.3 degrees (range 3 to 90 degrees; SD 21.0), indicating primary curve improvement 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).
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 |
Improvement in Cobb angles of primary curve over an average of 6.8 months of daily practice of the side plank pose.
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 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) | 1 | 7.26 | .014 |
| Did not do pose (n=5) | 27.0 (17.6) | 25.1 (11.4) | 1.9 | 0.46% (18.5) |