I have a client who is 21 years old and is an avid surfer. My client has been diagnosed with type C single curve and type D scoliosis. It is structural, she is not receiving treatment, she does not were a brace, and she has never received staples. She has one leg slightly shorter than the other due to a raised pelvis, and because of this, it is difficult to do certain exercises for legs (i.e., side lunges). Her goals are to gain lean body mass in the legs and upper body and to enhance core stabilization and balance. I have been with the client for one month, and she has made significant gains. I need an intermediate to advanced program for a surfer and specific to the conditions outlined above.
There are several nomenclatures associated with scoliosis along with several causes. Congenital scoliosis is typified by vertebral anomalies that occur by birth. Idiopathic scoliosis (not associated with any other cause) occurs during life (infantile to adult) and includes infantile, juvenile and adolescent idiopathic scoliosis (AIS) sub classifications. While infantile scoliosis has a high rate of resolution, AIS requires more attention. Other types of scoliosis, based on cause, include neuromuscular scoliosis (caused by neuromuscular disease/disorder and/or injury), paralytic scoliosis (secondary to a spinal cord injury) and functional scoliosis (caused by muscle imbalance or leg length). The nature of the spinal curve is often classified as C-shaped (one curve) or S-shaped (two curves).
Next, it should be remembered that for many clients with scoliosis, your training will form part of an overall treatment plan. For example, clients could be receiving physical therapy as well as osteopathic care and undertaking other maintenance training (e.g., spinal exercises/stretches). Therefore, prior to training clients with scoliosis, it is important that you fully appreciate their condition in regards to possible progression of the condition and previous/ongoing treatments (like bracing and stapling). From your email, it sounds like you are well versed in the specifics on her condition.
It is very difficult to prescribe direct exercises for a client without being able to assess her both physically and technically, so with this in mind, I will follow my golden adage (how to think as opposed to what to think) and provide several areas for consideration that should help you form your conditioning program.
As scoliosis deals with the vertebrae, and we will be looking at movement, the nature of coupling needs to be quickly covered. Along the spine, the functional structure of the vertebrae causes two movements to be coupled together. These are lateral flexion with rotation. Therefore, every time the spine is flexed laterally, rotation occurs, and every time rotation occurs, there is reciprocal lateral flexion. The amount and direction of the coupling depends on the vertebrae. Generally, the lower cervical and upper thoracic vertebrae have a strong ipsilateral (same side) couple, whereas the lower thoracic and lumbar vertebrae have a weaker contralateral (other side) couple. This means that with any functional or structural lateral flexion of the spine, rotation can occur. For a client with scoliosis, this could mean that her general posture has a slight rotation along the spine.
General Exercise Considerations
Choosing exercises for clients with scoliosis requires more than just thought into what muscles the exercise trains. Consider, for example, the differences between a lat pulldown and a squat. The lat pulldown (together with chin ups and dips) can have a traction effect on the spine and cause the vertebrae to distraction. A squat on the other hand, with the load on the shoulders, or seated overhead shoulder press could cause a spinal compression. For the average client without any spinal pathology, mixing these exercises is useful in improving spinal health, for the client with scoliosis. However, either one or both can cause pain and discomfort, depending on the nature of their curve.
FOR YOUR PROGRAM: Ensure you take the time to link the overall impact of exercises. If she finds exercise X and Y cause discomfort, but not exercise A, look at factors other than muscle movements that may cause the discomfort to allow more effective programming. This will also be useful in monitoring your client, and if any changes in discomfort are noted, the client should be advised to see her physician. Remember that the nature of the scoliosis can change.
Leg length differences can make other exercises more complicated. While a typical solution to a leg length difference is to move to a unilateral exercise, many trainers forget that even unilateral exercises, like a lunge or side lunge, have a bilateral start and finish, and as such, problems can be caused at end repetitions positions. Furthermore, the discussed rotation of the spine can cause a reciprocal rotation of the pelvis, which impacts on the ability to perform the exercises following traditional exercise postural guidelines.
FOR YOUR PROGRAM: Lower limb, purely unilateral exercises, like a one legged squat or step up (where the other leg does not touch the ground at any stage) can be useful.
Consider the use of counter-functional movements to prevent imbalances. Everyday life leads to excessive use of certain movement patterns, like hip flexion when sitting for long periods. Therefore , the aim is to minimize the impact of these overloading Activities of Daily Life (ADLs) and counteract any restrictive effects.
FOR YOUR PROGRAM: A leg length difference can often lead to a tight quadratus lumborum. Performing a single leg step up with a leg off the side of the bench can provide a traction/relaxation effect for the suspended leg as gravity pulls down on the leg. Just make sure your client does not cheat by dropping the hip towards the suspended leg.
For the upper body and trunk in particular, cables are very useful as they allow many degrees of freedom in a given movement and allow the client to adjust her movement curve to circumvent any structural “blocks” along her movement path.
FOR YOUR PROGRAM: Try cable/band exercises and progress to employ as many movement patterns as possible. The more muscle groups used, the more neural energy is used, and the better the overall workout effect. For surfers, as discussed below, there is an increase in synergy, and for the client wanting to increase lean body mass, there is an increase in energy expenditure and calorie consumption.
Finally, I would recommend that part of your program, most notably the cool down, incorporate spinal mobility exercises/stretches like those endorsed by numerous scoliosis organizations around the world. (An example of some of these exercises can be found on the Scoliosis Association of Australia website at http://www.scoliosis.org.au/article/2/1)
Surfing Exercise Considerations
Choosing exercises for surfers can be challenging as many surfers are very fit, with good core control and general muscle endurance, thanks to the nature of this very dynamic activity. However, this is not to suggest that there are not ways to add some specificity to training for surfing. Again, this requires an approach beyond just thinking of the exercises. The nature of surfing must be understood.
Surfing requires a high level of muscle synergistic coordination with limbs moving independently. With this in mind, exercises like a bench press would have very little value as there is very little synergy required when compared to a push up, compared to a push up with one foot in the air, the other on a basketball and one hand on a mat.
FOR YOUR PROGRAM: Avoid exercises with excessive support (e.g., bench, incline bench, etc) and select those that allow for more freedom of movement (again cables/bands/medicine balls, etc will be useful). These exercises can merge well with the exercises for your specific client. Just ensure the concept of ability before load is applied.
Next comes the balance requirements. Unlike many sports, surfers are on an unpredictable free moving surface, and as such, surfers require a strong focus on both balance and counter-balance. Balance involves maintaining your own center of gravity within your base of support countering an internal force (internal perturbation) while counter-balance requires adjusting your center of gravity to return to your base of support following an external force (external perturbations). Maintaining your balance while standing requires balance. Maintaining your balance while standing in a bus going around corners and stopping/starting requires counterbalance. Furthermore, as the water is not as solid as land, there is less force return (Newton's third law of motion, which states that for every action there is an equal and opposite reaction). As such, loss of balance is more difficult to recover from (try standing on a mat on the gym floor and then try standing on the same mat in a swimming pool).
FOR YOUR PROGRAM: Add balance and counterbalance training. For example, exercises can be performed on a fitball or dura disc. Allowing your client to balance develops balance. Making your client balance while you gently push down on different parts of the dura disc or fitball or gently push them requires counterbalance.
NOTE: Also consider the shape of the surfboard your client uses. While some boards have a flat deck, others have a camber from the center down to the rails.
Finally, a look at the nature of the skills your client is developing. Surfing is an “open” skill sport whereby there are many external stimuli bombarding the surfer. Consider the difference between playing a game of soccer in a gymnasium where the lighting, breeze, flooring all stay the same as opposed to the same game outside where the breeze changes, noise changes, light changes, the pitch changes. A key impacting factor on “open” and “closed” skills is the concept of dual and multi tasking. The brain has a finite processing ability, and this ability must be divided up to control a variety of incoming and outgoing signals. Time yourself standing up from a chair and walking 10 paces while holding a full cup of water. Time yourself again, but this time count back from 93 by six while walking. You will find your pace has dropped noticeably as your brain must dual task.
FOR YOUR PROGRAM: Ensure you progress the skill requirements. Rather than looking at a wall or only looking in the mirror (once techniques have been established), turn the client to face distractions, like people walking past. Have some fun by placing a gym fan in front of her and turning it on to rotate so that the breeze comes on and off. Talk to her or throw a ball for her to catch.
Training Load Considerations
I have found it safer to place my key manipulations on volume as opposed to intensity for clients with musculoskeletal and neurological conditions. Rather than increasing loads (intensity), which when in excess can lead to an acute injury, manipulate volume. While excessive volume can lead to overload injury, careful monitoring of the client and variety to avoid pattern overloads can be used to minimize the chance of over use injury. Manipulating volume does not mean increasing sets only. Change recovery times (30 seconds to two minutes) and repetitions speeds (2-2-2-2 to 2-3-4-1).
I hope I have covered all your points. Keep up the great work.