Strength Training with Scoliosis

by Andrea Signor | September 15, 2020

scoliosis image and brace

When he was 9 years old, Patrick Curry’s doctors diagnosed him with scoliosis. At 10, the 20-degree curvature in his thoracic spine required bracing. By 15, his curve progressed to 43 degrees. Doctors fused his spine and placed stainless steel rods to prevent his curvature from progressing.

Years later, as a junior surgical resident, Curry witnessed many cases of spinal trauma, which led him to specialize as an orthopedic spine surgeon. Now he’s a surgeon for the Boulder Centre for Orthopedics and Spine where he specializes in operative and nonoperative management of spine pathology. He also lifts at Starting Strength Denver where he’s squatting 270 pounds, benching 200 pounds, pressing 147.5 pounds, and deadlifting 350 pounds.

“I think supervised weight training with scoliosis is beneficial,” he said. “I would tell my scoliosis patients the same thing I tell my patients with degenerative discs: we can’t change what happens to the bony elements of the spine, but we can change the strength of the muscles that support the spine.”

Scoliosis is the sideways curvature of the spine, and affects between 2 and 3 percent of the American population – between six and nine million people – according to the American Association of Neurological Surgeons. While there are several subcategories of scoliosis (including congenital and De Novo scoliosis), nearly 80 percent of patients are diagnosed with idiopathic scoliosis, where the cause is not known. Typically diagnosed between the ages of 10 and 18, idiopathic scoliosis affects both males and females, although females are seven times more likely to be diagnosed than males. A female’s curve is also 10 times more likely to worsen over time, potentially impacting breathing, gait, and general appearance.

While any doctor can diagnose scoliosis, including chiropractors, in cases of curvatures more than 10 degrees orthopedists are usually consulted. Typical treatments include observation, bracing, and surgery, depending on the severity of the curve. “Bracing is an attempt to slow the progression of the curve,” Curry said, adding that bracing has proven to be the most effective treatment based on medical studies.

Patients are often advised to avoid contact and high-impact sports and, instead, to stick to stabilization exercises, swimming, and yoga. Physical therapists often use stability exercises and self-corrective techniques to help patients improve posture and restore muscular balance. Despite numerous studies focusing on adolescent idiopathic scoliosis, few quality studies about building and strengthening the back muscles exist.

Scoliosis diagnosis in adults

While idiopathic scoliosis may go undiagnosed until adulthood, the odds of the curve being severe enough to warrant surgical intervention is low. A 2005 study of older adults (average age of 70) found that 68 percent of participants had scoliosis, but no correlation of low back pain. “Adults with scoliosis are not typically braced,” Curry said. “There are studies that show bracing in adults weakens their core musculature over time and they do not prevent progression. In kids, the goal of bracing is to prevent progression during growth.”

Curry said that as we age, it’s common for arthritis to appear in the joints, including the spine, which creates asymmetries. “If you think about how the spine supports weight, this makes sense,” he said. “The cervical spine supports the head, which doesn’t weigh much. The thoracic spine supports the weight of the cervical spine and head, as well as some major organs, but it has the support of the rib cage to help carry that weight. The lumbar spine supports the weight of the thoracic and cervical spine, as well as other vital organs, without a rib cage to help. So it’s common to have more degenerative change in the lumbar spine as we age.”

According to the World Health Organization and a Global Burden of Disease Study, low back pain is among “the top ten injuries and diseases that account for the highest number of DALYs (disability-adjusted life year) worldwide”, with a lifetime prevalence of 60 percent to 70 percent.

Curry added that he considers a curve greater than 10 degrees as meeting the definition of scoliosis. Anything less than that is considered “spinal asymmetry.” “There are those that have seen non-surgeons and get a diagnosis of scoliosis or asymmetry in the back and run with it,” he said. “Patients with small curves do not require treatment if they are asymptomatic. For patients with larger curves monitoring for rapid progression can be useful. Patients who have been told they have ‘scoliosis’ or other alignment abnormalities and that they must avoid certain activities should see an orthopedic spine surgeon for an evaluation. In my opinion, activity restriction for subtle asymptomatic curves or other alignment abnormalities is counterproductive.”

My story

At 12, my doctors diagnosed me with scoliosis. I had a 36-degree curvature in my lumbar spine and a 15-degree curvature in my thoracic spine – a classic “S” curve. For 23-hours per day for five years I wore a plastic back brace that went from my armpits to my hips to help correct the curve. The only time I was allowed out of the brace was to shower or be active in a sport. The doctor’s recommendations for activity: low-impact sports such as swimming and yoga, and physical therapy exercises with a stability ball. I joined the swim team and spent the next four years swimming tens of thousands of yards, thinking I was doing the best I could to keep my back healthy. There was never any talk about building and strengthening the muscles that supported the spine. Instead, the mantra became “be careful with your back” and “you shouldn’t do that with your back.”

andrea signor trains at starting strength denver

After coming out of the brace at 17, my curves “corrected” to 29 degrees and 12 degrees, respectively. It was always known that the curve would eventually slink back to the original curvature, but the hope was that it would be several years before it progressed and reached 40 degrees, which is when most doctors recommend surgical intervention in the form of a spinal fusion and metal rods to support the spine.

Despite being on the swim team and staying active, I had chronic low-back pain. And it wasn’t until I picked up a barbell that that pain subsided.

Strength training with scoliosis and the lack of medical studies

Strength training and building muscle is crucial for scoliotics. Building muscle helps support the spine, potentially preventing the curvature from worsening. The most effective lifts for building that muscle: squats and deadlifts. Strength training also builds bone density – a must for females, who are more likely to be diagnosed with scoliosis, whose spines are compromised during pregnancies, and who are more likely to be diagnosed with osteoporosis after menopause.

Many doctors recommend patients with scoliosis avoid high-impact sports – football, gymnastics, softball – and recommend swimming as a good alternative for protecting the back. However, numerous studies have concluded that females have the most potential for building bone density in their adolescence (when most scoliatics are braced) and many have shown that high-impact sports such as gymnastics and volleyball have the best potential for building bone density, with weightlifting closely behind.

A 2016 study compared bone mineral density in female adolescent swimmers and weightlifters. Researchers used DXA scans to look at the bone density of 25 adolescent female athletes. The study determined that weightlifting improved bone mineralization and bone density while the swimmers’ bone mineral density was “not higher compared to non-athletic counterparts.” The study concluded that swimming was not beneficial for bone health and that “the bone measurements of swimmers were lower by 4-19 percent compared to the athletes in any other sport.”

Yet patients with scoliosis are cautioned not to do the very activities that may improve their bone density and prevent the degeneration of the spine that plagues so many later in life. Instead, physical therapists have patients perform self-corrective exercises and spinal stabilization isometric holds to help improve the appearance of the patient’s scoliosis. Methods such as the “Schroth method” and “Scientific Exercises Approach to Scoliosis” (SEAS) aim to improve the patient’s mind-body awareness by having them perform spinal stabilization self-correction in three planes of motion.

Developed in Germany in 1921, the Schroth method aims to align the pelvis, elongate the spine, and “tense the muscles isometrically in order to strengthen weak muscles and preserve the corrected posture.” Similarly, SEAS exercises “train neuromotor function to stimulate by reflex a self-corrected posture during the activities of daily life.” Although used by doctors worldwide, these self-corrective exercises remain controversial among those in the medical community.

A 2012 review of studies that aimed to reduce the progression of adolescent idiopathic scoliosis with scoliosis-specific exercises (SSEs) concluded that there was low quality evidence that SSEs alone provided any cosmetic improvement. For Dr. Curry, these exercises, along with bracing, may have potential to help strengthen the back, but he hopes more evidence-based studies will show the potential for strength training for scoliotics.

A recent study published in the Journal of Physiotherapy looked at patients with adolescent idiopathic scoliosis and curvatures greater than 45 degree and the impact aerobic and resistance training had on their respiratory function. The study divided patients into two exercise groups – one group performed 60-minutes of aerobic exercises three days per week for 12 weeks while the other combined aerobic and resistance training.

Despite doing only 10 minutes of resistance training per session (with light dumbbells and ankle weights), researchers concluded that “the combined aerobic and resistance training improves functional exercise capacity and several respiratory outcomes more than a similar training regimen with aerobic training only.”

“This is not a perfect study and the resistance training they included is not at all Starting Strength style,” Curry said. “But it did show some benefit.”

Common concerns of scoliotics

When a patient is diagnosed with scoliosis and bracing or surgery are part of the treatment, they are forever placed in the category of “fragile” and “compromised.” The mentality that they cannot do certain activities often follows.

I frequently get messages and emails from fellow scoliotics asking if it’s safe to lift, ii their asymmetry is a concern for squatting, and if they will they further damage their spine by lifting. Of course every person with scoliosis will have different mobilities that require different cues (as any client will), but the main reassurance scoliotics need is that scoliosis is a structural deformity, not a muscular one. And with barbell strength training, they are primarily loading the muscle, not just the spine.

While there aren’t a lot of quality medical or scientific studies on strength training with scoliosis, there is anecdotal evidence that strength training greatly benefits those with scoliosis. Consider the case of Lamar Gant, world-famous powerlifter from the 1970s/1980s who set world records with a curvature between 74 and 80 degrees.

In an interview with Sports Illustrated about Gant’s lifting with scoliosis, Dr. Robert E. Kappler stated:

“I must say I’ve seen nothing in the literature at all like this, in which a person with such an advanced degree of curvature – so advanced that he’d be four to six inches taller without it – is nevertheless a world-class athlete. Most scoliotics are weaker than an average person of the same age. My guess – and it’s only a guess – is that Lamar’s heavy lifting and extraordinary musculature have helped him to be more stable then he otherwise would be. By that I don’t mean to say that I would recommend heavy deadlifts as a treatment for teenagers with scoliosis, just that my hunch is that Lamar’s instinct to keep training was a sound one.

Coaching the scoliotic

Tom DiStasio got his scoliosis diagnosis as a teenager. “I’m not sideways, but I’m definitely not straight,” he said, adding that he never knew the degree at which his spine curves. Despite an MRI that revealed disc herniations, DiStasio kept lifting and playing sports through college, eventually becoming a Starting Strength Coach who has trained several clients with scoliosis.

“There are so many confounding variables [with coaching scoliotics],” he said. “Coaches have to have creativity and ingenuity to move the model for that trainee forward. Some may have limitations and asymmetries that result in an ugly squat - the bar may sit crooked on their back or their feet may need to be staggered. You have to think, ‘How do we create postures that we can create stability in the intervertebral joints (specifically in the L4 and L5 joints) and load them. It’s harder to parse out than with someone with a straight spine.”

Distasio said that his guiding principle when coaching clients with scoliosis is to stabilize the spine and introduce incremental loads to strengthen the spine. “I don’t want to crunch the spine down with vertical compressive forces,” he said. “I want to make the things around that bent spine stronger instead of forcing it down into the joints.” DiStasio said that this is why he prefers the low-bar position for the squat as opposed to high-bar or front squats. He focuses on the alignment of the hip to the foot, and getting the knees out.

One of his biggest challenges with scoliotics is getting them to create tension in the back, due to asymmetric muscle development and the concavity on one (or both) side(s) of the spine. “Getting them to understand what that lumbar extension and tension feels like is much different for someone with scoliosis,” he said. “I tell them you’ve got to get your back to bite down so that you can establish postural control and hold that posture where extension is crucial.”

DiStasio said that he will use remedial and isometric exercises to help clients feel the proper muscles engage and tactile cues – tapping and even smacking a client’s back – to help the client develop tension. “At the end of the day, it’s not that different from coaching someone with a knee problem. You learn what will exacerbate symptoms and do what you can to strengthen the muscles.”

He agrees with the notion: you can have scoliosis with a strong back or scoliosis with a weak back. “Just because it’s not anatomically designed perfectly doesn’t mean it’s wrong.”

Why this matters

Last year I had a follow-up on my back. Since coming out of the brace 18 years ago and having two full-term babies, my curve has crept back to 32 degrees. But the x-rays showed no signs of disc degeneration. My doctor was shocked and asked what I was doing. When I told her about my lifting, she told me to keep doing whatever I was doing because it was working.

Unfortunately, stories like mine are regarded as “merely anecdotal.” But anecdotal data is still data. More quality research and studies are obviously needed to show the potential benefits of strength training with scoliosis. But we know that barbell strength training works for people with scoliosis. And more quality coaches are needed to properly train these clients. Until then, more young people with scoliosis will continue to sit on the sidelines and resign to a life of chronic pain and looming surgeries.


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