Released: 7-Oct-2014 10:00 AM EDT
Newswise — A basic yoga pose, done for an average of only 1.5 minutes a day, six days a week for two months, reduced idiopathic scoliosis curves for adolescent and adult patients an average of 32% in the first peer-reviewed published clinical trial studying yoga for the reduction of scoliosis curves.* The 25-participant trial was evaluator-blinded, X-ray based and used the standard Cobb method for measuring results. Among nineteen compliant patients who did the yoga more than three times a week, the improvement was 40%. In this group of compliant patients, adolescents improved 49.6% . almost half; adults improved 38.4%. All patients did the Side Plank (Vasisthasana) yoga pose, and all patients did it on one side only – the side of the curve.

We are currently researching a new pose for the thoracic curves.  More on this as results come in from second X-rays.

Protocol for Scoliosis Study:

 

IRB PROTOCOL:

 

Principal Investigator: Loren M. Fishman, M.D., B. Phil.,(oxon.)

Assistant Clinical Professor

Department of Rehabilitation Medicine

Columbia University Medical School

Yoga for Scoliosis

Abstract

 

Scoliosis is frequently first detected by the school nurse or athletics department at about age 12.  Once found, young people and their parents face a dilemma: bracing the curved spine is frequently done, but almost as frequently cited as dubious in the literature, while surgery is usually successful but entails a long and cumbersome period of recuperation.  To the $125,000 to $250,000 cost of surgery we must add the personal cost of young people, very generally young girls being placed in casts at the very time that their bodies are changing, intimate impulses are gathering, and peer groups and other social affiliations are gaining paramount importance in their young lives.  Foregoing the surgery often leads to increasingly severe curvature with increasing age, and may require later surgery to avoid life-threatening respiratory complications.

 

We have found a single yoga pose, done for three – five months, reduces the lumbar and lower thoracic curves in adolescents and older people who have no evident cause for their scoliosis, by an average 36%.  We have averaged the improvement patients have realized from doing this single pose over the past 5 years, and the results are consistent, so long as the patients consistently perform the pose, a yoga pose known as Vasisthasana.  We intend to perform a controlled, double blinded crossover study to document and better quantify the results of using Vasisthasana in both adolescent idiopathic and degenerative scoliosis.

 

A brief summary of our work up to the present is included at the end of this protocol.

 

 

Outline of the Research

 

 

The proposed investigation involves five steps:

 

         First:  Patients with scoliosis will be qualified for the study by submitting scoliosis films within 6 months of their completion, and filling out the induction form that includes age, medication, medical, surgical and parturition history, family history and current activities and accept full responsibility for injury resulting from performing the pose. See the Voluntary Consent form. Risser scores of bone maturity and Cobb measurements of curve(s) will be recorded for all patients.

 

Second:  Qualifying patients will be randomized into yoga and control groups until 50 patients are acquired in each group.

 

Third:  Intervention group patients will be taught the side-angle pose (Vasisthasana) on the convex side of their lumbar curve.  Control group patients will be taught the mountain pose (Tadasana) a simple symmetrical yoga pose.

 

Fourth: Patients will do their pose for as long a period as is practicable every day (intervention patients) or for one minute (control patients) for three months.  A “scorecard” will enable them to record the frequency and duration of their practice on a weekly basis.

 

Fifth:  After three months the patients will repeat their scoliosis films.

Sixth: The control group patients will be taught the intervention group’s pose, the side plank (Vasisthasana) and re-tested after a second three month period. This will not constitute a strict crossover study since our past experience suggests that if intervention group patients discontinue the proper posture too quickly, their curves may revert back to their pre-study levels.  Those patients initially in the intervention group will continue to do the Vasisthasana, and have a third scoliosis film as well, thereby providing a means of judging whether the expected first three-month improvement is sustained or enhanced over a second three-month period.     

 

Standard statistical methods will be applied to the analysis of the data, including t-tests, Wilcoxon and Mann Whitney U tests, and ANCOVA.

 

The study will be published in an appropriate venue.

 

Detailed Description of the Study

 

1. Background:

 

Definition

 

Scoliosis is a disease in which there is a lateral curvature in the vertebral column.  This right-to-left asymmetry is often accompanied by a rotational or front-to-back component.¹

 

Incidence and Prevalence

Scoliosis affects 2-3 percent of the population, or an estimated 6 to 9 million people in the United States. Scoliosis can develop in infancy or early childhood, and 80% of cases are idiopathic. The primary age of onset for scoliosis is 10-15 years old, occurring equally among both genders. Females, however, are eight times more likely to progress to a curve of a magnitude that requires treatment. Every year, scoliosis patients make more than 600,000 visits to private physician offices, an estimated 30,000 children are fitted with a brace, an unstudied number having other conservative therapies, and 38,000 patients undergo surgery.

The standard of care indicates surgery for patients with curves above 45 degrees, bracing of patients with curves in the 20 – 45 degree range, and observation of patients with curves less than 20 degrees.

The studies on brace and other conservative therapies’ efficacy are quite controversial and must be regarded as inconclusive at this point.^2-8 Surgeries generally are fusions and/or wiring, generally either Harrington rods, Cotrell-Duboset or Scottish Rite types of procedures.^9-12 The overall efficacy is 58-59% reduction of the curves on which surgery is performed,^10,12 but there is comorbidity in the form of restrictions on spinal mobility, hardware malfunctioning, infection, extra strain on the vertebrae above and below the fusion, and pseudoarthroses.¹³ One study represents the revision rate after surgery as close to 50%.¹⁴ The cost of surgery varies from $125,000 to $250,000.¹⁵(FN) Estimating the average cost at $187,500, the total annual cost for surgery in the United States would be $7,125,000,000.

Causes

Scoliosis can be classified by etiology: idiopathic, congenital, or neuromuscular. Idiopathic scoliosis is the diagnosis when all other causes are excluded, and comprises about 80 percent of all cases. Adolescent idiopathic scoliosis is the most common type of scoliosis and is usually diagnosed during puberty.

Congenital scoliosis results from embryological malformation of one or more vertebrae and may occur in any location of the spine The vertebral abnormalities cause curvature and other deformities of the spine because one region of the spinal column lengthens at a slower rate than the rest. The geometry and location of the abnormalities determine the rate at which the scoliosis progresses in magnitude as the child grows. Because these abnormalities are present at birth, congenital scoliosis is usually detected earlier than idiopathic scoliosis.

Neuromuscular scoliosis encompasses scoliosis that is secondary to neurological or muscular diseases. This includes scoliosis associated with cerebral palsy, osteogenesis imperfect, spinal cord trauma, muscular dystrophy, spinal muscular atrophy, spina bifida, Marfan’s and Chiari syndromes, Sanfilipo mucopolysaccharide abnormality, and even the tetralogy of Fallot).¹⁶ These types of scoliosis generally progress more rapidly than idiopathic scoliosis and often require surgical treatment.  Patients with these conditions will be excluded from our study, though a patient with osteogenesis imperfect has substantially reduced his curve with our method, and others may indeed benefit from conclusions supported by the study.

In our unpublished clinical work, we have used the side-plank, Vasisthasana, a single yoga pose done diligently and daily, with considerable success on patients of all ages with idiopathic and degenerative scoliosis.  We presented the results at a conference one year ago in which we studied ten patients using the single pose for an average of 4.4 months, obtaining before-and-after scoliosis films.  The average improvement in their thoracolumbar curves was 36%.

Theory:  The spine may be seen as a tensegrity structure, a term used by Buckminster Fuller to describe structures that are held together by the tension between their parts.  Radio antennae and tent-poles that are held up by downward-pulling cables are classical examples. According to our view, the human spine is another.

A slightly simplified analysis of how we stand erect involves the symmetrical downward pull of muscles.  Scoliosis, then, is explained by asymmetry in the force these muscles exert on the spine. The spine will bend toward the stronger side, indicating that the convex side is the weaker one.

If this is true, treatment is just equalizing the strength of these muscles’ pull.  That is the point of this investigation, which will strive to strengthen the quadratus lumborum and paraspinal muscles of the convex side.   The control group’s exercise will, if anything, strengthen back muscles symmetrically.

 

 

1. Method:

 

Subjects will be solicited through public advertisements, website and blogging sites, and from our medical practice.  Qualifying patients will be randomly assigned either to the treatment or control groups.  All patients will present scoliosis films, and studies adequate to determine the Risser number and the degree of scoliosis before entering the study.

 

Inclusion criterion:

Lumbar or thoracolumbar scoliotic curve of 10 degrees or more.

Ability to perform the side-plank for at least 10 seconds and Mountain pose for one minute.

 

Exclusion criteria:

1. Previous spinal surgery, fracture, or similar abnormal condition.
2. Neuromuscular or orthopedic conditions that may reasonably contribute to scoliosis, such as Duchennes muscular dystrophy, cerebral palsy or hemiplegia.
3. Pregnancy
4. Inability to perform the required exercise daily, due, e.g., to carpal tunnel syndrome, severe imbalance, intercurrent surgery.

 

All study participants will read the Lay Summary and read and sign the Voluntary Consent form and present a scoliosis film completed less than 6 months prior to the date of submission.

Participants will be permitted to continue on all current medications and activities.

 

Subjects will be randomized into intervention or control groups after full entrance requirements are completed.  They will then be taught either the side-plank exercise or the Mountain exercise to the satisfaction of the investigators.  They will perform the exercise they are taught at least once every day, for as long as they safely can hold it (intervention group), or for one minute (control group) for three months. A scorecard will enable all subjects to record how long and how often they perform the exercise they are assigned. Following the initial three month period each patient will have a second scoliosis film.

 

After control group patients have completed their second scoliosis film, they will be taught the intervention group’s side-plank pose, Vasisthasana, and asked to persevere with it for another three months, and record their participation on their scorecard.  We do not anticipate asking the intervention group patients to change over to the control group’s exercise for two reasons:

1. In our clinical experience, the side-plank pose is effective in reducing scoliosis, while the Mountain pose is not.
2. The reduction in scoliosis curves seen in patients performing the side-plank pose may be reversed in patients that discontinue the exercise too soon. Therefore crossover of the treatment group patients may reverse the benefits they have derived from the intervention.

However, intervention group patients will be asked to continue with the Vasisthasana exercise, enabling the research team to estimate the longevity of the benefits of the pose as well as further efficacy in reducing the scolioti curves beyond what was seen in the initial three months.

A third scoliosis film will be completed for each previously control group and previously intervention group patient after the second three month period.  In this way the treatment of each group will be symmetrical, and the actual pose will be given to each volunteer, regardless of initial assignment into treatment or control group.   This is what patients will have agreed to when they sign the voluntary consent form. 

 

Patients and/or their health insurance companies will be responsible for regular fees for physician visits and yoga sessions.  Control group patients will not be charged for the teaching of Vasisthasana after their three months in the control pose.  This will maintain strict financial parity between the two groups.

 

The study administrator will make contact with all intervention and control group members as the scorecard indicates.

 

After all 100 individuals have submitted a second scoliosis film, and all 100 patients have submitted their third scoliosis films, the data will be analyzed for significant differences between the efficacy of the two exercises.  Standard statistical methods will be applied to the analysis of the data, including t-tests, Wilcoxon and Mann Whitney U tests, and ANCOVA.

 

The study will be published in an appropriate venue.

 

 

Analysis of the Exercises

Important note:  These are the exercises the subjects are to do every day.  The more they do them, the sooner they will begin to reduce their curves and approach true symmetry.  It is nearly indispensable to have a yoga therapist, physician or physical therapist to help with positioning and check the subjects at least monthly, to be sure that the correct muscles are actually engaged.

Intervention Group Pose

The yoga poses are presented in four grades, starting with the simplest and least arduous.  Each exercise is effective.

 

Vasisthasana   (4 Stages)

1. Purpose:   To strengthen the paraspinal and other muscles of the convex side of the major (largest) curve
2. Contraindications: Profound weakness, Hill-Sachs deformity, balance disorder, carpal tunnel syndrome at wrist on convex side.
3. Props:  A wall, a yoga mat, a block, a chair.
4. Avoiding pitfalls:  The upper arm and shoulder should be aligned perpendicular to the floor during the posture.  Line the head up with the spine.   Subjects should not be tentative:  rather they should be firm and expansive with their whole bodies.
5. Instructions:
6. Lie on the floor on a yoga mat, with the convex side of the body down.
7. Rest on the forearm, the body lined up head to hips parallel to the wall, and knees bent. Pull the shoulders back until both touch the wall.
8. Let the side ribs sag down toward the floor.

Stage 1:

Inhaling, firm arm and abdominal muscles.  Lift the side ribs up away from the floor.  Let hips and legs remain on the floor.  Press on a block (if needed) with the upper hand.   

4. Hold both side ribs up until your back feels tired on the convex side.
5. Slowly release.

 

Stage 2: 

7. When lifting, as per instruction 5, lift the hips up as well, so that only knees, calves, ankles and feet remain on the floor.

 

8. Extend the legs straight out.
9. Place one foot on top of the other.
10. Lift the whole body up, from ribs to ankles.

Stage 4: 

Go into the pose from the Downward Facing Dog pose as follows:

1. Place a chair next to a mat in case it is needed for support.
2. Perform Adho Mukha Svanasana, the Dog pose  

 

 

3. From the Dog pose, shift weight onto the outside of the foot on the convex side of the spine.
4. Re-position the convex side’s hand lining it up with the foot, the fingers angled outward slightly.
5. Firm the upper arm and pull the concave side’s shoulder back.
6. Revolve over onto the convex side’s arm and one foot until the back is parallel to the wall.
7. Use the upper hand on the chair for balance if needed. One option here (not pictured) is to place the upper foot at mid-mat for additional aid in balance.  In those that do need to do this, these actions make the pose work better.  Otherwise, stretch the other arm up along the wall.    
8. Raise the ribs and hips enough to make one long diagonal line from head to feet
9. Breathe lightly but fully.
10. Remain until the convex side tires.
11. Return to the Dog pose, followed by the Child’s pose.

 

           Standard Classical Pose                       Pose for Complex Curve

 

The pose on the right may be used for complex S-shaped curves.

 

The control group will be given the pose known as Mountain (Tadasana).  It is not a vigorous pose.

Mountain Pose (starter’s version)

 

Purpose:   To increase symmetry in posture and to promote balance.

Contraindications:   Severe imbalance, weakness or dyscontrol of lower extremities, relevant amputation without prosthesis.

            Props for first variation:  wall and chair

Avoiding pitfalls for first variation:  Even though are depending on a chair for balance, the subject must engage his or her posture fully.

1. Stand with feet hip-width apart and parallel.
2. Balance weight evenly between right and left feet, and between balls of feet and heels on each side.
3. Pull shoulders and head back slightly, advance pubic region forward to align ears, shoulders, hips and ankles in one plane.
4. Look straight ahead.
5. Rebalance weight-bearing between each foot and between ball of foot and heel.
6. Remain in the position for one minute.

 

 

Patients are advised to seek several private lessons with the yoga teacher were yoga ,communicate with the study administrator or with the principal investigators if questions arise.

 

A one to three minute resting period concludes each daily session.

 

Safety Considerations:

Each scoliosis X-ray imparts a minimal radiation to patients, estimated at 140 mSv.¹⁷  Although younger individuals are somewhat more sensitive to radiation, these levels are well below those that would cause even the mildest deterministic effects such as erythema or epilation.^18-19  By way of comparison, a typical abdominal X-ray gives 1000 mSv, barium enema is rated at 3,000 – 7,000 mSv.¹⁷  It has been estimated that children with scoliosis are give 22 scoliosis films over a 3 year period.  This study involves at most three.  The radiologic exposure required in this study is very low risk, as seen in the following estimate of radiation:

 

United States Nuclear Regulatory Commission website, Page Last reviewed/updated Friday, June 28, 2013.

 

 

 

 

 

 

 

 

Previous experience with patients:

 

Over the past 5 years the principal investigators have worked directly with over 700 patients with scoliosis, kyphosis, osteoporosis or osteopenia and other orthopedic, neurological and cardiovascular conditions ranging from herniated lumbar disc and congestive heart failure to multiple sclerosis and rotator cuff syndrome.  Our sessions are generally 1 hour long, and involve Dr. Fishman and two assistants:  one an experienced physical therapist and long-time yoga practitioner, the other an experienced yoga teacher and yoga therapist. None of these patients have sustained injuries of any kind beyond minor aches and pains in the few days following yoga sessions.

 

In a ten patient 4.4 month period, yoga was shown to improve the thoracolumbar or lumbar major curves of patients aging from 12 to 74 a mean 36%, while control patients lost 0.08 and 0.12 points in spine and hip, respectively, over the same using the Cobb method of measuring.  The Risser score and other parameters such as the Lenke classification were not taken into account in this group, but all were judged to be idiopathic or degenerative scoliosis that had never undergone instrumentation of any kind.

 

No patient in the study used a brace during the study period.

 

 

References

 

1. National Scoliosis Foundation: 2007.
2. Czupryna K, Nowotny-Czupryna O, Nowotny J. “Neuropathological aspects of conservative treatment of scoliosis. A theoretical view point.” Gait Posture.2011 May;34(1):13-8.
3. Romano M,Minozzi S, Zaina F, Saltikov JB, Chockalingam N, Kotwicki T, Hennes AM, Negrini S. “Exercises for adolescent idiopathic scoliosis: a Cochrane systematic review.” Spine (Phila Pa 1976). 2013 Jun 15;38(14):E883-93.
4. Weiss HR.“Inclusion criteria for physicaltherapy intervention studies on scoliosis – a review of the literature.” Stud Health Technol Inform. 2012;176:350-3.
5. Weiss HR, Goodall D. “The treatment of adolescent idiopathic scoliosis (AIS) according to present evidence. A systematic review.” Eur J Phys Rehabil Med.2008 Jun;44(2):177-93.
6. Misterska E,Glowacki M, Latuszewska J. “Female patients’ and parents’ assessment of deformity- and brace-related stress in the conservative treatment of adolescent idiopathic scoliosis.? Spine (Phila Pa 1976). 2012 Jun 15;37(14):1218-23. Kinel E, Kotwicki T, Podolska A, Białek M, Stryła W.
7. Quality of life and stress level in adolescents with idiopathic scoliosis subjected to conservative treatment. Stud Health Technol Inform.2012;176:407-10

8.    Aulisa AG, Guzzanti V, Perisano C, Marzetti E, Falciglia F, Aulisa L.  “Treatment of lumbar curves in scoliotic adolescent females with progressive action short brace: a case series based on the Scoliosis Research Society Committee Criteria.” Spine (Phila Pa 1976). 2012 Jun 1;37(13):E786-91.

9.    Basu S, Rathinavelu S, Baid P. “Posterior scoliosis correction for adolescent idiopathic scoliosis using side-opening pedicle screw-rod system utilizing the axial translation technique.” Indian J Orthop. 2010 Jan;44(1):42-9.

10. Kelly DM, McCarthy RE, McCullough FL, Kelly HR.“Long-term outcomes of anterior spinal fusion with instrumentation for thoracolumbar and lumbar curves in adolescent idiopathic scoliosis.” Spine (Phila Pa 1976). 2010 Jan 15;35(2):194-8.

11. Good CR, Lenke LG, Bridwell KH, O’Leary PT, Pichelmann MA, Keeler KA, Baldus CR, Koester LA.“Can posterior-only surgery provide similar radiographic and clinical results as combined anterior (thoracotomy/thoracoabdominal)/posterior approaches for adult scoliosis?” Spine (Phila Pa 1976). 2010 Jan 15;35(2):210-8.

12. Xie J, Wang Y, Zhao Z, Zhang Y, Si Y, Li T, Yang Z, Liu L. “Posterior vertebral column resection for correction of rigid spinal deformity curves greater than 100°.”  J Neurosurg Spine. 2012 Oct 12.

13. Hummel JM, Boomkamp IS, Steuten LM, Verkerke BG, Ijzerman MJ.“Predicting the health economic performance of new non-fusion surgery in adolescent idiopathic scoliosis.” J Orthop Res. 2012 Sep;30(9):1453-8.

14. Bachy M, Bouyer B, Vialle R.“Infections after spinal correction and fusion for spinal deformities in childhood and adolescence.” Int Orthop. 2012 Feb;36(2):465-9.

15. Kepler CK, Wilkinson SM, Radcliff KE, Vaccaro AR, Anderson DG, Hilibrand AS, Albert TJ, Rihn JA.“Cost-utility analysis in spine care: a systematic review.” Spine J. 2012 Aug;12(8):676-90.

16. Saifi C, Matsumoto H, Vitale MG, Roye DP Jr, Hyman JE.“The incidence of congenital scoliosis in infants with tetralogy of Fallot based on chest radiographs.” J Pediatr Orthop B.2012 Jul;21(4):313-6.
17. Chamberlain CC, Huda W, Hojnowski LS, Perkins A, Scaramuzzino A. “Radiation doses to patients undergoing scoliosis Radiography.” The British Journal of Radiology, 73 (2000), 847-853.
18. National Council on Radiation Protection and Measurements. Induction of thyroid cancer by ionizing radiation, Report No. 80. Bethesda, MD: National Council on Radiation Protection and Measurements, 1985.
19. International Commission on Radiological Protection. 1990 recommendations of the International Commission on Radiological Protection, Publication 60. Ann ICRP 1991;21:1-201.

 

 

 

 

 

 

 

 

Scorecard

 

Name_______________________________________________________

 

Start Date ___________________

 

Side Angle Pose    Mountain Pose (circle one)

 

Week            Done Days/Week               Average Time in Pose         Other Exercise

 

1_________________________________________________________________

 

2_________________________________________________________________

 

3_________________________________________________________________

 

4_________________________________________________________________

 

5_________________________________________________________________

 

6_________________________________________________________________

 

7_________________________________________________________________

 

8_________________________________________________________________

 

9_________________________________________________________________

 

10________________________________________________________________

 

11________________________________________________________________

 

12________________________________________________________________

 

13________________________________________________________________

 

Problems, questions and suggestions should be referred to Dr. Fishman, (212) 472-0077, or emailed to Nimmi@sciatica.org.