Practicing with Scoliosis
Embracing the Curve: Practicing with Scoliosis
by John Zadroga
I remember it like it was yesterday—being corralled down a corridor to the school nurse’s office in separate boys' and girls' lines. Being instructed to bend forward and then stand back up again. Feeling the nurse palpate up my spinal column, tracing a painfully obvious lateral curve…how could this be? Although seemingly insignificant to many, my primary school scoliosis screening is a memory that has remained with me throughout my life.
Until this point, I figured back pain was a part of everyone’s life, and I asked how he managed his.
In high school, I swam varsity. I recall one very frank locker room conversation with a friend about back pain, and how I felt it was keeping me from performing at my best. Until this point, I figured back pain was a part of everyone’s life, and I asked how he managed his. When he told me he didn’t have any, my jaw practically hit the floor. This sparked an interest in the interrelation between anatomical form and function, and it set the stage for my personal philosophy and career choice.
I now understand that the prevalence of back pain is, in fact, remarkably high in the United States—especially among people with scoliosis. Scoliosis is a condition marked by a lateral deviation of the midspinal line. It can be inherent from birth, or develop during growth periods due to poor posture. Its severity is quantified in degrees by a clinical measurement known as the Cobb angle.
Shortly before college, I (reluctantly) attended my first yoga class, at the insistence of my older sister. The teacher that day delivered a structurally oriented class with liberal prop use and consistent verbal feedback. She made me feel as if I were the only student in the room. Without once rekindling my primary school insecurities, she made me feel that she understood my scoliosis better than I did. Most importantly, she gave me a huge gift that class—a pain-free afternoon. This not only convinced me that I could manage my pain by physical means, but also inspired me to become a yoga teacher.
Yoga is for every body. Modifications can make it work, and it is possible to feel at home in a pain-free body.
As a medical student, I spend a fair amount of my day sitting in lecture halls, attempting to absorb what can occasionally seem like an impossible volume of information. As an osteopathic medical student, I receive additional education on the manual diagnosis and treatment of conditions affecting the musculoskeletal system. This, coupled with my own struggle to “find alignment” in my inherently asymmetrical frame, inspired me to reach out to others and let them know that yoga is for every body. Modifications can make it work, and it is possible to feel at home in a pain-free body. I would be remiss to share this sentiment without providing practical examples of how you can accomplish this, so here goes.
Understand the underlying anatomy of your curve.
This might not seem revolutionary, but don’t count on yoga teachers who have completed a 200-hour training program to understand the fine points of your anatomy. A scoliosis-type curve can really be anywhere in the spine and can sometimes result in a compensatory “counter curve” (i.e., an S-curve). Ask your primary care provider to do a musculoskeletal exam on you and tell you if your curve is more predominant in the thoracic or lumbar region. Understand that scoliosis can cause other physical nuances (one shoulder sitting higher than the other, one hip lower than the other, etc.). Depending on your degree of curvature, some physical therapy might be indicated before beginning an exercise regimen like yoga. In severe cases, surgery is the only intervention indicated. Don’t let even this deter you, as I have a client with Harrington rods (i.e., surgically implanted, spine-straightening devices) who is quite capable in her practice.
Watch yourself in the mirror.
The first time I practiced in a studio with mirrors, my mind was blown. “Do I really look like that?” I asked myself in virtually every posture. Humbling as it was, it was an excellent opportunity to learn self-awareness on a very literal level. Need proof? Take yourself to your mirror now. Come into warrior II. Are your arms level with each other? (Mine rarely are.) A neurological mechanism known as “proprioception” is responsible for this awareness (or lack thereof) of our bodies in three-dimensional space. When you have a curvature of the spine at baseline, visible misalignment might feel entirely natural. Be aware of this, and try to make the effort to internalize visual cues and rely less and less on mirrors as you reset your proprioceptive “normal.”
Take verbal cues seriously…but not too seriously.
I genuinely believe in the power of concise, tactful verbal cues for improving form. However, getting caught up in the excessive verbiage employed by some teachers can be far more harmful than helpful. Listen carefully, but do not obsess.
Avoid teachers who make you feel bad about yourself.
I once took a very challenging class with a teacher at a local studio who made me feel terrible about myself. She pointed me out to the class as someone with “poor form,” when in reality her demonstrated knowledge of anatomy was very shaky. I felt compelled to continue to attend her class because of the physical rigor, but then noticed that I left the class feeling down on myself and far from centered. I decided one day that no amount of physical challenge was worth the borderline emotional abuse, and I found a new class.
Acknowledge that you are perfect just the way you are.
I basically consider myself a bonsai tree in the literati style. Pin-straight posture is a beautiful and rare thing, but I embrace the curve handed to me and recognize that some of the most beautiful things in nature are asymmetrical. Although alignment is always a good goal to have in a yoga practice, recognize that concerning yourself too much with perfection is anti-yogic in itself.
I embrace the curve handed to me and recognize that some of the most beautiful things in nature are asymmetrical.
Do what feels right and set small goals, keeping in mind that there is nothing ugly or wrong about your essential physical composition.
Feeling “at home” in my body is a choice I had to make, and my constant postural self-adjustment continues on. However, the corporal awareness yoga has instilled in me has helped not only to address discomfort in the physical sense, but also to correct some misconceptions I had internalized over the years of how one “ought” to stand tall.
developed an interest in the human body and how its form influences its function as an awkward 10-year old at a school-mandated scoliosis screening.
Scoliosis and Yoga: The Do’s and Don’ts
by Amber Burke
Editor's note: The below are intended to be general recommendations for yoga practitioners and teachers. They are not a replacement for the personal advice of a health professional.
Scoliosis is an abnormal curvature of the spine whose most commonsymptoms are lower back pain and stiffness. Nascent research into the effects of yoga on scoliosis has shown that regular practice of a single posture, side plank, can reduce scoliosis curvature. If one pose has that kind of power, some yogis might wonder about the value of a more complete yoga practice for those with scoliosis, as well as how to approach such a practice to make it as safe and beneficial as possible.
Bill Reif, a physical therapist, yogi, and author of The Back Pain Secret: The Real Cause of Women’s Back Pain and How to Treat It, believes that yoga can be a valuable part of the treatment for scoliosis. “Yoga can help foster the self-awareness—and the strength and flexibility—that make it possible to improve the alignment of the spine, which can in turn minimize pain and possibly respiratory issues, too,” Reif says.
But for a yoga practice to be helpful, both students with scoliosis and their teachers need to understand the condition and its implications when choosing and approaching poses.
Unlike kyphosis and lordosis, which refer, respectively, to the outward and inward curvature of the spine, scoliosis refers to the sideways, or lateral, curvature of the spine. While a healthy spine will have some degree of kyphosis and lordosis, ideally there is no lateral curvature at all; viewed from behind, the spine should appear relatively straight from neck to tailbone.
Scoliosis can be categorized into two main types: nonstructural, or functional, scoliosis, which results from a soft tissue asymmetry and is temporary, and structural scoliosis, in which the changes to the curvature of the spine are generally more permanent.
Most cases of structural scoliosis, the focus of this article, are idiopathic; that is, they have no clear cause. Idiopathic scoliosis tends to appear just before puberty and occurs in females more frequently than in males.
Scoliosis has been observed in 10.7 percent of women and 5.6 percent of men between the ages of 25 and 74. In an older population, scoliosis may occur in up to 68 percent of individuals. (The increased prevalence in older adults may be connected with osteoporosis, loss of bone density, which has been observed in many older people with scoliosis.)
Though scoliosis can often be treated nonsurgically (for example, by bracing and physical therapy exercises), in severe cases, the insertion of a titanium rod to straighten the spine may be necessary.
Types Of Curves
The most common curvature pattern in scoliosis is a spinal curve to the right (dextroscoliosis). Usually this occurs in the thoracic spine, with the midspine curving to the right as if to avoid the heart. On the other hand, a leftward curve (levoscoliosis) most often occurs in the lumbar spine.
Both of these spinal curves are examples of a singular C curve—one concave side, which curves inward and is shortened, and one convex side, which is lengthened and rounded laterally.
But in some cases of scoliosis, there are S curves; for example, the right thoracic curve may be accompanied by a left lumbar curve, making an S shape, with two concave sides and two convex sides.
“Some, but not all, S curves may start as C curves,” Reif says. “Compensation over time may cause an S as the body attempts to level itself, but one curve is generally larger—a major curve—and accompanied by more restrictions. That’s the one you’ll want to focus on in your yoga practice: You’ll feel the greatest effects of stretching and strengthening there.”
Symptoms and Symmetry
The relationship between asymmetry and pain is a complex one. “When the spine curves abnormally, spinal cord compression can occur,” Reif says. “Just as in conditions like intervertebral disc disease, when the spinal cord is compressed, pain and neurologic signs will result.”
However, while those with scoliosis do not always have back pain, some studies seem to indicate that adolescents with scoliosis experience more frequent and more severe episodes of back pain than control groups.
According to Reif, “Whether or not scoliosis leads to pain depends in part on the load the asymmetry is asked to bear, and how often it bears that load. For instance, someone with scoliosis who participates in vigorous sports might be more likely to feel pain than someone who doesn’t, since more weight is moving through that asymmetry more repetitively. Pain can also depend on the severity of the asymmetry.”
Further, more severe curves (greater than 40 degrees) tend to correlatewith higher degrees of pain, and problematically, many curves become more severe over time. While smaller curves are less likely to progress, many curves greater than 30 degrees do tend to increase over time. As many as 68 percent of curvatures detected in children will progress even after spinal maturity. Curves may continue to progress with age because of disc degeneration and muscular imbalances.
If the scoliosis progresses to a degree that places pressure on the heart and lungs, it may impair cardiovascular and pulmonary function. In severe cases, scoliosis may even lead to respiratory failure.
Because so many curves progress in magnitude, and because curves of greater magnitude may be linked with greater pain as well as lung and heart problems, Reif believes in being proactive, suggesting that even those with minor curves or without symptoms practice movements and poses designed to minimize asymmetries.
“Even though it is unlikely that you can make dramatic changes to a longstanding scoliosis curve through targeted exercises, what you can do is reduce the negative impact of a large curve—usually breathing difficulty, upper or lower back pain—and prevent further deterioration of the curve over time,” Reif says.
Practicing Yoga With Scoliosis
If you have scoliosis, it’s important to check with a medical professional before embarking on a yoga practice. During your consultation, the more information you can find out about your curve pattern the better. Work with your doctor, physical therapist, or chiropractor to find out which adjustments bring your torso closer to neutral—i.e., what you have to do, and in what order, to even out your hips, shoulders, and head; you can then apply this information to your yoga practice.
If you have had corrective surgery for scoliosis, as long as you have been cleared by your doctors to exercise, you may also benefit from a yoga practice, though your practice may be more limited. As Reif explains, “Your focus will need to be on poses that help to elongate the spine above and below the surgically fixated region.” Since a corrective rod would not allow backbending and forward folding, he recommends that you skip extremes of all motion and instead focus on neutral-spine poses, poses in which your back is in its “mountain pose” alignment.
In addition to speaking with your doctor, it’s a good idea to talk to the teacher before taking a yoga class. While being able to give adjustments and advice tailored to a particular curvature often requires medical training, your teacher might be able to provide or reinforce general advice. At the very least, a conversation with your teacher will ensure that they do not unwittingly make things worse, for example by giving encouragement or hands-on assistance designed to bring you more deeply into a pose than you can safely go.
The following do’s and don’ts for a general yoga practice may be helpful for students with scoliosis and their teachers. If you’d like a yoga practice specifically designed for scoliosis, try this one.
While you’ll notice that very few types of poses are off-limits for many of those with scoliosis, Reif points out, “If your scoliosis is accompanied by another condition, like kyphosis or osteoporosis, you may need a gentler practice that forgoes extreme ranges of movement, especially forward folds.”
1. Do asymmetrical poses a second time on the more challenging side…or stay on that side longer.
“You may notice that your abilities on each side differ,” Reif says. “This difference comes from the scoliosis curvature causing asymmetries in your torso muscles. Often the concave side is tighter, and the convex side is longer and weaker.”
Some recommend that yoga students with scoliosis practice a pose on one side and not the other in order to strengthen the convex side and lengthen the concave side. While Reif understands this advice, he notes that it can be complicated to apply, especially when students have S curves—two concavities or two convexities—and wonders if such methods might lead to other imbalances elsewhere.
Reif instead recommends practicing asymmetrical poses on both sides and then repeating the pose again on the side where the stretch felt more intense or the strengthening work felt more challenging. This way, neither side of the body is entirely neglected. Through this method, any asymmetrical pose in which you notice a difference in how the pose looks or feels on different sides would be practiced a total of three times.
But Reif explains, “The purpose of repeating poses like this is to establish which side of your body is not as mobile or strong in a particular pose.” If you already know which side of a given pose is more challenging, feel free to simply spend more time on that side than you do on the more mobile or stronger side—perhaps another five breaths or so.
2. Using mirrors, practice self-study to create a longer, more neutral spine.
While mirrors are often eschewed in yoga, “a mirror is the best way to learn awareness and provides important feedback when not being observed by a medical practitioner,” according to Reif.
He suggests that while sitting or standing at the beginning of your yoga practice, you move your spine as close to neutral as you can. For those with scoliosis, creating a more neutral spine will entail some degree of side bending and/or twisting “First, create length by imagining a marionette string pulling you up,” says Reif. “Once you’ve created that length, look in the mirror. Side bend and rotate your spine as needed in order to make the spine more neutral and to level out your hips and shoulders.”
If you have an S curve and know which curve is primary (often the thoracic curve), make adjustments there first and then adjust the area surrounding the secondary curve (often the lumbar curve), so that you are not treating the compensatory effect rather than its root cause.
Don’t expect to instantly achieve a neutral spine. Reif acknowledges: “This realignment can be very confusing, especially if there is a double curve. Only a professional—like a physical therapist, doctor, or chiropractor—can tell you with assurance which way you need to move, though over time you might get better at making these changes on your own.”
Having moved closer to neutral, maintain an awareness of that alignment. “Throughout your practice, look in the mirror to observe the levelness of head, shoulders, and hips,” Reif recommends.
3. Strengthen core- and back-stabilizing muscles by holding neutral in increasingly challenging positions.
For those with scoliosis, some sections of the multifidus and erector spinae, supportive muscles running along the spine, will need strengthening (particularly on the side that’s convex) in order to hold this new, more neutral alignment. The best way to strengthen the muscles that stabilize the spine, in Reif’s view, is simply to hold a near-neutral spine for longer periods and in more challenging positions.
For example, once a student can create a neutral spine in mountain pose or while seated, they can then try to hold that alignment when moving from sitting in a chair to standing or when practicing poses like chair, bird dog, plank, and side plank.
4. Practice pranayama.
Though holding the alignment described above will require some degree of “tensing the torso,” as Reif puts it, the effort you apply should never be so great that you can’t breathe comfortably.
“With scoliosis, often one of the primary losses involves your capacity to inhale and exhale,” Reif says. “Your energy level in turn is affected by this lung capacity. Through stretching and pranayama [breathwork], your vital lung capacity may increase, which in turn increases your energy levels. If your lungs are more efficient, you will be slower to fatigue.”
Deergha swasam (three-part breath), which aims to increase lung capacity, may benefit those with scoliosis. It encourages slow and deep diaphragmatic breathing: The lungs are filled and emptied in three steps each.
Toward the beginning of practice, experiment with this pranayama either sitting or standing while holding the neutral spine you’ve created. Breathe into this alignment, imagining filling your lungs from bottom to top on the inhale, first by expanding the belly, then the lower and middle ribs and lungs, and finally the upper lungs. On the exhale, visualize the breath emptying in reverse, from top to bottom. Draw your belly in slightly at the end of the exhale.
Reif says that you can give yourself additional feedback by placing one hand on your belly and one hand on your chest throughout deergha swasam. Ideally, on your inhale, you will feel your belly expand first, and then your chest will lift. On the exhale, your chest will drop slightly, then your belly will draw in gently. Once this begins to feel natural to you, you can begin to expand your awareness: work to inhale into, and exhale from, your right and left sides as evenly as possible.
“Notice any limitations,” Reif advises. “Does one side of your rib cage have more difficulty expanding—likely the concave side of the curve in the thoracic region, where the ribs are close together? You want to facilitate more expansion in the area that feels restricted on the inhale, and try not to let the restricted space collapse when you exhale.”
5. Emphasize poses that lengthen the muscles between the ribs, like side bends and side glides.
The concave, or shorter, side of the torso can be stretched through side bends and poses called side glides. Reif describes the difference between a side bend and a side glide this way:
“When side bending, you intentionally lengthen one side of the torso and lift one shoulder higher than the other—as you reach back for reverse warrior, for example. But in side gliding, the goal is to try to keep the shoulders—and head—level as you shift the rib cage or the hips to the right and left.”
You can practice such glides standing: Initiating the movement from the middle of the rib cage, encourage your rib cage to move side to side, and then your hips to shift from side to side, without disturbing your shoulders and head. Hold each glide for several breaths.
“Where we will feel the stretch when side bending or side gliding is where the concavity is, and that’s what we want to lengthen,” Reif explains. “So you’ll want to spend more time bending, or gliding, to the side opposite the concave side of the curve.”
6. Practice slowly, holding each pose for at least five breaths.
Instead of practicing at a fast clip, in which it may be possible to forget about alignment and breath, Reif suggests that you hold each pose for several breaths: “Take the time to make sure you are elongating your spine as much as you can in a pose and breathing diaphragmatically.”
Additionally, according to Reif, applying a milder version of deergha swasam to every pose—filling both the right and left lungs from bottom to top, then emptying them from top to bottom—will enable you to discover, and eventually release, tight areas.
7. Add yin or restorative classes to your yoga regimen.
“In these floor-based, slow practices, the extra time spent in each asana and the support of blocks, bolsters, and the ground in gentle poses will allow gradual lengthening of shortened structures,” Reif says.
While relaxing, Reif recommends that you facilitate deep muscular release by imagining your breath moving into restricted areas.
8. Take a side-lying savasana.
For some students with scoliosis, the pressure of the floor beneath their backs may cause them to be acutely aware of asymmetries, and they might find themselves actively trying to fix them—for instance, working to press one side of the middle back toward the floor—even during time set aside for relaxation.
Reif suggests that you lie on the side that is more convex as you relax. In addition to placing a pillow or blanket under your head, “try placing a bolster or other support under the part of your rib cage that’s rounded outward the most—that way you are still encouraging an adjustment, but passively this time.”
If you have two curves, after several minutes of lying on the larger curve, you could roll over to rest on your other side, placing a rolled-up blanket or towel under the second (smaller) curve.
A yoga practice for scoliosis aims to create length in the concavities (as illustrated here).
1. Don’t practice inversions without support if your scoliosis is severe or you are experiencing pain.
Though Reif is a fan of inversion tables, and a cautious supporter of many yoga inversions when they are practiced against a wall, he has concerns about the pressure an unsupported inversion could place on a scoliotic spine. “Be careful doing any inversion. Inversions allow the spine to compress—the opposite of the elongation that those with scoliosis need to prioritize,” Reif explains. “Use a wall to take some of the load off the spine when doing poses like headstand, handstand, and shoulderstand.”
2. Don’t expect asymmetrical poses to look (or feel) exactly the same on both sides.
In any kind of asymmetrical pose you may find it harder to lengthen, twist, or bend on one side. While, over time, practicing poses on that more challenging side twice or for longer periods, as suggested above, may help create more evenness from side to side, forcing one side of your body to do exactly what the other side is doing may cause strain. In your quest for evenness, “never push yourself to the point that you experience pain,” Reif says.
3. Don’t become overly stressed by the degree of your curvature as you practice, or how much or little your yoga practice is changing your curvature.
While certainly moving toward increased symmetry is important, Reif suggests balancing that focus on evenness with a degree of equanimity. “Don’t obsess or fret,” he says. “Your goal is not to become perfectly neutral, but rather to prevent any further increase in your scoliosis, and perhaps improve your alignment gradually—finding a little more length in the concavity, a little more strength in the convexity—so that you can move without pain and breathe a little easier.”
In Daily Life
Outside of yoga class, those with scoliosis can benefit from continuing to focus on lengthening the spine. “Keep upright, striving to be as tall as you can be,” Reif recommends. “Throughout your day, visualize a marionette string pulling you up by the crown of your head. Slumping will cause further distortion of the spine.”
He suggests that while sitting, you support your lumbar curve and perhaps one arm: “Many of those with scoliosis have one shoulder that is lower than the other. The head tips in that direction, too. To level your shoulders and your head, try placing the arm of the shoulder that’s lower on an armrest or even a bolster to raise it.”
When you stand for a long period, Reif recommends propping one foot on a block or footstool to level your hips, shoulders, and head. If you are not sure which foot to bring to the block to create greater evennness, experiment, looking in a mirror to assess the effects.
Throughout your day, avoid lifting heavy weights or other objects, especially if your scoliosis is severe and/or you are experiencing pain. “Lifting heavy loads will place greater stress on the concave side of your curve, which may lead to further tightness on the muscles within the concavity, causing or exacerbating back pain,” Reif explains. He also recommends that those with scoliosis who weight train counter the downward pressure of the weights by following their routine with some time on an inversion table or with gentle backbends over a large therapeutic ball.
At night, try sleeping on the side that is convex, just as you did in savasana, with some light support—like a pillow—under the convexity, or sleep on your back, if that is comfortable for you. Reif advises against sleeping on your stomach, “which can compress the neck.”
Through a regular yoga practice and this continued awareness, yoga students with scoliosis might find that it gradually becomes natural for them to stand taller, and perhaps even notice that they are breathing easier and moving with less pain.