‘Pilates for lower back pain’
By Adam Donoghue 16 Roope St, New Town, Hobart Australia May 2014 Maroochydore Course, Australia
ABSTRACT Lower back pain (LBP) is a huge problem in society, it’s estimated that 25% of all physical therapy visits in the U.S. are people with lower back pain*. World-wide there’s an incidence of LBP with 80-90% of people during one’s life*.
There are a number of causes of LBP. This paper is focused specifically on a fairly typical scenario. The case study is of a woman with poor posture (hyperlordosis) and disc bulge, she spends extended periods sitting (shortening hamstrings) and limiting movement in body, and does gardening in her spare time (over doing forward flexion).
It is recommended she start a tailored Pilates conditioning program. The program aims to get balance in body to reduce load on her lower back. It does this by strengthening weak areas (core muscles, hip abductors, upper back stabilizers). And stretching out tight areas (psoas, hamstrings). There is an emphasis throughout the program to improve body awareness and postural correction in the hope that she takes these new skills into her work and play. *Source: Basi Injuries & Pathologies Advanced Education Course Handout (2013)
Table of Contents Page 2
Table of Contents
Anatomical Description and Diagram
Case Study and Conditioning Program
Program Chart with Reasons for selecting & desired results
ANATOMICAL DESCRIPTION AND DIAGRAM
Lumber Spine- There are 5 lumber vertebrae (L1 to L5), 5 fused bones that form the sacrum, and 3 to 5 fused bones that form the tailbone (coccyx). Individual vertebra are made up of several parts. The body of the vertebra is the primary area of weight bearing and provides a resting place for the fibrous discs which separate each of the vertebrae. The lamina covers the spinal canal, the large hole in the center of the vertebra through which the spinal nerves pass. The spinous process is the bone you can feel when running your hands down your back. The paired transverse processes are oriented 90 degrees to the spinous process and provide attachment for back muscles. Spinal Nerves- The spinal cord is made up of nerves that extend from the brain into the spinal canal and then out to various parts of the body. Nerve roots are the points where nerves leave the spine and form nerve branches to parts of the body. Main muscles of the lumber spine- the erector spinae are long muscles are on either side of the spine; these are usually the culprits if there are muscle spasms in the back. Under these are medium length muscles that extend from one vertebrae to the next. At
the front of the body the psoas muscle runs from the front and sides of lower spine across the hip joint and attaches to the femur bone. The front of the body houses the all important abdominal muscles (transverses abdominus, oblique’s, rectus abdominus, multifidus). These muscles are critical to your spines forward movement and provide support for your back.
HOW THE SPINE MOVES There are four facet joints associated with each vertebra. A pair that face upward and another pair that face downward. These interlock with the adjacent vertebrae and provide stability to the spine. The vertebrae are separated by intervertebral discs which act as cushions between the bones. Each disc is made up of two parts. The hard, tough outer layer called the annulus surrounds a mushy, moist center termed the nucleus. The movements of the majority of the spine (except the cervical spine) are limited by the various ligaments that attach the vertebrae to one another and also by the shape of the facets, discs and spinous processes. Movement between ant two vertebrae is quite limited however the total amount of movement in a given region can be considerable.
Lumbar vertebrae are massive for weight bearing and are designed to bear 80% of the weight. The facets have a sagittal orientation allowing little rotation, but a lot of flexion, extension. With spinal discs the nucleus attracts fluid to keep it hydrated to absorb force. The discs reply on regular movements of the spine to assist in the drawing in of fluid to keep them healthy.
CASE STUDY Client: Fiona Smith Occupation: admin work, spends 8 hours + a day sitting Age: 50 Hobbies: gardening (forward bending) Limitations: lower back pain for 10 years + due to poor posture and disc bulge posterior L2/L3 for 3 years Rehabilitation treatments: has tried physio with some relief but keeps getting pain coming back due to posture and muscle imbalance.
CONDITIONING PROGRAM Problem: Poor posture with hyper-lordosis, therefore weak abdominals, tight psoas, weak inner thigh muscles, poor knee alignment (locked in joints), tight hamstrings, shoulders pushed too far back, chin and neck too far forward. Programs General Goals: Get balance in body to reduce load on lower back. Strengthen weak areas (core muscles, hip abductors, upper back stabilizers). Stretch out tight areas (psoas, hamstrings). Improve body awareness and postural correction. General Exercises: Back extension good to squeeze opposite way on lumber discs. Flexibility and strength around the hip flexors and extensors. Strengthen knee extensors. stretch calves. Alignment of core in neutral while doing exercise with arms or legs through full range (eg. footwork, arm work and hipwork). Avoid: avoid loaded flexion, vertical loading of discs and strong rotation.
BLOCK Warm Up
REASON FOR SELECTING
lying on roller (shoulder Improving awareness and Finding Neutral and core. Getting retract/protract, pelvic alignment of body. Preparing stability around pelvis. hitches and tilts, arm core for exercise. Awareness of floats, balance awareness), centre of gravity. Pelvic curl, chest lift + Massage/release of erector rotation. Single leg lifts. spinae. Roll-like a ball. Footwork on Wunda Chair Improved posture in sitting and Unsupported posture so better to awareness of neutral spine. ensure core in on while doing Knee flexor strength & control. footwork. Also helps to get good Hip flexor strength and control. sitting habits for her work. Stretch calves.
Roll up with roll up bar
Abdominal strength and control. Trunk stability
Hip work series on reformer
Improve knee extensor control Core stability while strengthening and pelvic lumbar stability. legs. Strengthen adductors and hamstrings.
Hamstring and Abdominal strength. Smooth and controlled spinal movement.
Can modify with springs and footbar height to ensure theres good control.
Stretch hamstrings and hip flexors.
Also gets client keeping spinal alignment while stretching these tight areas.
Full Body Integration 1 Scooter
Strengthen abdominals. Strengthen hip & knee extensors. Trunk stability.
Shoulder awareness and scapula stability. Body awareness.
Scapula control, Shoulder Good to reinforce correct standing strength and control, symmetry posture while working arms. left to right. Functional postural awareness.
Arms standing series
Get spine moving with control and support. Can adjust springs to ensure client has good form.
Full Body Integration 1 Down stretch (instead of 2)
Shoulder control and stability. (Not ready for challenging FBI 2). Trunk stability. Getting Abdominals & back extensors working together.
Additional Leg Work
Gluteals kneeling series
Strengthen hip extensors and Focus on pelvic lumber stability and abductors. Improve stability at strengthening the hip area. hip and torso while moving leg.
Side stretch on chair
Strengthen the obliques. Stretch lateral flexors.
Strengthen back extensors and Combines scapula stability with shoulder stabilizers. Open out back extension. lumber discs opposite to bulge disc.
Good to find neutral spine in a diagonal orientation and strengthen core.
CONDITIONING PROGRAM CONCLUSION • Often pain inhibits movement so aim is to keep areas moving pain free to maintain range and restore confidence in body. • Strong focus of program is in postural re-education to improve posture and body awareness in space (ability to correct to a functional position). This is important as pain often changes the default way you use your body. • Restoring balance in body by strengthening weak areas and stretching tight areas with an emphasis on neutral spine while moving. • Frequency of the program is important as we want to create good habits and obviously the more practice the easier it is to break incorrect habits (recommend 2 to 3 sessions per week one on one initially till suitable for a small group). • Encourage client to take the core stability and awareness into their work (sitting at desk posture) and hobbies etc.
• Give client some basic stretches and core awareness exercises to do daily. (STRETCHES: hamstring, hip flexor. CORE: Pelvic curl, chest lift, leg floats, roll like a ball).
BIBLIOGRAPHY Basi Injuries & Pathologies Advanced Education Course Handout (2013) Basi Movement Analysis Workbooks Burn, Dr Loic (2007) Treating your back and neck pain for dummies, John Wiley & Sons, UK. Dru Yoga Teacher Training Notes Fine Judylaine (2000) The Ultimate Back Book, Stoddart Publisher. Highsmith, Jason (2011) The Complete Idiots Guide to Back Pain, Alpha, New York. Jenkins, David (1991) Functional Anatomy of the Limbs And Back, Saunders, Sydney. Lacey Laurie (2012) Yoga for Arthritis Workshop Handout, Hobart Australia. Marcus, Norman (2012) End Back Pain Forever, Atria, New York. McIlwain, Harris (2004) The Pain Free Back, Henry Holt, New York. Robinson, Lynne (2002) The Body Control Pilates Back Book, Pan, London. Siegel, Dr Ronald (2001) Back Sense, Vermilion, London. Vad, Vijay MD (2004) Back Rx, Gotham Books, New York Wharton, Jim & Phil (2004) The Whartons Back Book, Rodale, London.