PILATES FOR LUMBO-PELVIC-HIP- MOTOR-CONTROL-DYSFUNCTION (LPHMCD)

Transcription

1 PILATES FOR LUMBO-PELVIC-HIP- MOTOR-CONTROL-DYSFUNCTION (LPHMCD) Name: Carmen Gathmann Date: September 2016 Course Location: Ballito

2 Abstract My chosen topic is LPHMCD or Lumbo-Pelvic-Hip-Motor-Control-Dysfunction in a female athlete. LPHMCD can be defined as instability and loss of motor control in the lumbar spine, pelvis, hips and the sacroiliac joint. This can be due to multiple problems, including malalignment of the body s structural system and underactive muscles. The hip flexors (rectus femoris; iliopsoas) and the lumbar spine erectors are generally prone to tightness in LPHMCD sufferers, which is largely due to underactive gluteals and abdominal muscles. This combination of dysfunctions often leads to an overextended lumbar spine and anteriorly tilted pelvis due to inflexibility and loss of motor control. This commonly observed pattern in athletic populations results in decreased stability and power, stiff and unstable joints, poor neuromuscular control and abnormal multi-segmental movement patterns, hereby potentially decreasing athletic performance. In this particular case study the LPHMCD arose from several horse riding accidents in combination with a rotated, right tibia which had been consistently malaligned during Pilates strengthening. This led to chronic pain and discomfort in the lumbar, sacroiliac and lower limb region due to sacroiliac joint-, as well as hip-motor-control -dysfunction The consequent muscle weaknesses caused injuries, such as a severe tear in the right soleus, chronic peroneal tendon dislocation, trochanter bursitis and ITB syndrome as her body compensated for the imbalances caused. Research has shown the benefits which Pilates has for LPHMCD clients, by restoring sacroiliac and hip joint mobility and stability, retraining integration of local and global systems including functional movement patterns and restoring alignment between segments within the lumbo-pelvic-hip complex. 1

3 Table of Contents 1. An anatomical description of the lumbo-pelvic-hip-complex and sacroiliac joint Introduction Common presentations of LPHMCD How LPHMCD is treated The BASI Programme Warm up Footwork Abdominal work Hip work Spinal articulation Stretches Full Body Integration (1) Arm work Full Body Integration (2) Leg work Lateral flexion/rotation Back extension week programme Conclusion Bibliography

4 1. An anatomical description of lumbo-pelvic-hip-complex and sacroiliac joint 1.1 The Lumbo-Pelvic-Hip -Complex The Lumbo-Pelvic-Hip-Complex consists of the muscles and tissues of the lumbar spine, the pelvic girdle, the abdomen and the hip joint. These structures around the lower girdle must be in alignment, muscle function needs to be appropriate and the mechanical aspects of all of the structures need to work together. 3

5 1.2 The Sacroiliac Joint (SIJ) The SIJ connects the sacrum (triangular bone at the bottom of the spine) with the pelvis (iliac bone that is part of the hip joint) on each side of the lower spine. It transmits all the forces of the upper body to the pelvis and legs. There is usually not a lot of motion in the joint and it should be very strong and stable. 4

6 *Note: The iliotibial band syndrome symptoms which the client was experiencing were caused by a spasmed piriformis in conjunction with an overly tightened gluteus medius which was exerting pressure on the sciatic nerve, as can be seen in the diagram. Due to the high likelihood of another muscle spasm and severity of pain caused by the spasm of the piriformis, all external rotation is to be strictly avoided. 5

7 1.3 Transverse Abdominus and Multifidus 6

8 1.4 The general structural and muscular system of the lower girdle: 7

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10 2. Introduction This research paper will give an overview of a young female athlete suffering from chronic pain in her lumbar spine and in various areas of her right leg which was, over time, incorrectly attributed to iliotibial band syndrome but is in actual fact due to Lumbo-Pelvic-Hip-Motor-Control-Dysfunction. A BASI Pilates program will be utilized to strengthen the muscles which support and stabilize the lumbo-pelvic-hip-complex. BASI Pilates will offer spesialised training of the mind and body according to symmetry, coordination and correct muscle recruitment, with a specific focus on improving the motor control and strengthening of the stabilising muscles around the lumbar spine, pelvis, hips and sacroiliac joint. My case study is Linda. She is 26 years old, and an avid trail runner, horse rider and swimmer. She has suffered from LPHMCD for a considerable amount of time with intensifying pain and discomfort in direct relation to (as diagnosed by a physiotherapist): a lack of control into lumbar extension (need to work on strengthening the gluteals, transverse abdominus, multifidus and obliques) a lack of inner range in hip extension (again, glutes require strengthening) lack of hip control in rotation and abduction (falls into flexion, abduction and external rotation, and therefore has a tendency toward midfoot eversion) (here, the post-tibularis requires strengthening). piriformis spasm which caused the ITB symptoms (hip external rotation to be avoided at all times) 9

11 Severe tear in the right soleus Overstretched psoas, contributing towards the anterior tilt of the pelvis In addition, Linda was diagnosed with a right, externally rotated tibia, something she was born with and which consequently everts her foot by 10 degrees to allow for correct alignment of the knee and femur. This was to be approached with extreme caution in the10-week BASI Pilates strengthening program as correction or rather malalignment of the foot to achieve straightness with disregard of the tracking of the femur and knee, had in the past, caused damage to the knee and resulted in LPHMCD. 10

12 3. Common presentations of LPHMCD SIJ: Pain in the thigh and/or buttock, and possibly pain that radiates down the sciatic nerve, although it rarely radiates into the foot More commonly experienced on one side of the body, but may occur on both sides More commonly found in young or middle age women. Hip Motor Control Dysfunction: Altered motor recruitment patterns which inhibit muscle function and cause motor imbalance Buttock pain Lateral and thigh pain ITB syndromes Recurrent groin pain Hamstring insertion point pain Trochanter bursitis 11

13 4. How is LPHMCD treated When LPHMCD has been identified, treatment is aimed at: Strengthening the transverse abdominus Strengthening the multifidus Achieving transverse abdominus and multifidus co-contraction Strengthening obliques Strengthening the gluteus medius and maximus At times where there is persistent pain and muscle tension, trying additional treatments such as sports massage could be beneficial. Monitoring the volume of activity performed per weekly training sessions Maintaining proper form and technique whilst running, riding and swimming In this specific case: Strengthening the soleus Strengthening posterior tibialis Strengthening of the vastus medialis oblique Avoiding external rotation of the hip at all times Avoiding stretching of the psoas Allowing for 10 degrees of eversion of the right foot 12

14 5. The BASI Programme The programme is a 10 week Programme based on the BASI Block system designed for the client with LPHMCD. Linda attended twice a week sessions where possible, therefore completing up to 20 sessions. This particular use of the Block System is designed for a full body workout in 55minutes. 5.1 Warm up For the first 5 weeks the client will perform a basic, Fundamental Warm Up, hereby ensuring that the principles of BASI Pilates are understood and executed with precision and utmost stability before advancing to a more intermediate Warm Up from Week Assists must be used to support Linda s head and neck during some movements, as she struggles with dizziness and neck flexor spasms due to horse riding accidents. 5.2 Footwork Linda will start on the Wunda Chair for the first three weeks. This was chosen to allow me to extensively monitor her transverse abdominus and multifidus cocontraction in a postural position as well as to ensure the 10degree eversion of her right foot and consequently the correct tracking of the femur and knee specific to her body. External rotation of the hip is to be strictly avoided, therefore V Position Toes is to be excluded, and Open V Heels and Open V Toes are to be executed in a parallel position. After 3 weeks the Reformer and Cadillac footwork are to be integrated into the programme. Calf raise repetitions are to be increased as they are vital to rehabilitate the healed, weak, right soleus. 13

15 5.3 Abdominal work The abdominal work will begin on a fundamental level on the Mat to ensure correct set up and execution, with specific focus on the transverse abdominus and multifidus co-contraction necessary to stabilise Linda s lower girdle, specifically the sacroiliac - and hip- joints. For example, Chest Lift, Chest Lift with Rotation, Hundred Prep, Hundreds, Double Leg Stretch, Single Leg Stretch. After 5 weeks progression, inclusion of the Reformer and Cadillac will be necessary. As in the warm up, assists must be utilised for neck support. 5.4 Hip work The hip work will be executed on the Cadillac, exclusively the Supine Single Leg Series. This was chosen as it is crucial to focus on unilateral work as part of Linda s strengthening programme, as her right leg has markable muscle and stability strength deficits and therefore requires strengthening completely on its own. External rotation of the hip is to be strictly avoided. For example, Frog is to be executed in parallel. The range of motion must be monitored closely with attention to pelvic stability. The crossbar is to be adjusted to modify the exercise specific to the client. 5.5 Spinal articulation Linda will begin spinal articulation in movements on the Mat such as the Pelvic Curl, Spine Stretch and Rolling-Like- A-Ball. After 5 weeks the equipment spinal articulation such as the Reformer Bottom Lift, Bottom lift with Extension, Wunda Chair Pelvic Curl are to be incorporated. Care is to be taken not to overload the lumbar spine and sacroiliac joints. 14

16 . 5.6 Stretches Due to Linda having a tight musculature, we will start with more gentle stretches for the first 2 weeks on the Ladder Barrel with Barrel Gluteals, Hamstrings, Adductors and Hip Flexors. Hereafter, she will progress to the Reformer Standing Lunge, Kneeling Lunge, Full Lunge as well as the Split Group Side Split to encourage the gluteus medius stabilisation function. It is important to limit the range of hip extension to avoid stretching of the psoas. The Ladder Barrel Shoulder Stretches were also integrated to facilitate shoulder flexibility due to tightness caused by swim training. 5.7 Full Body Integration (Fundamental/Intermediate) The FBI (1) exercises will comprise of Mat exercises such as the Front Support and Leg Pull Front for the first 5 weeks, due to the instability and lack of motor control present in LPHMCD. After this time more challenging movements are to be introduced such as the Reformer Round Back, Flat Back, Elephant, Up Stretch 1 (to be modified by bending the knees slightly due to tight hamstrings and lumbar flexors to allow for full extension along the length of the spine and correct execution). The Wunda Chair Full Pike as well as the Cadillac Thigh Stretch with the RUB will also be incorporated. 15

17 5.8 Arm work Arm work is to be chosen with postural support requirements in mind, meaning it must challenge Linda s stability, within reason, to encourage postural control whilst mobilising the upper limbs. Care must be taken to gradually load the spine and pelvic-hip complex, as this should train her body to stabilise during functional movements whilst trail running, horse riding and swimming. The Avalon Arms Sitting Series, Wunda Chair Triceps Press Sit and Triceps Prone is to be introduced first as it requires mild postural support and load, building up towards the Cadillac Arms Standing Series over the first 3 weeks. Hereafter, moving on to the Reformer Arms Supine-, as well as the Arms Sitting- and eventually Arms Kneeling- Series. 5.9 Full Body Integration (Advanced/Master) Due to the nature of Linda s LPHMCD, this block cannot be safely incorporated into the 10-week programme Leg work Leg work will consist of specific rehabilitation exercises from the physiotherapist, in order to strengthen the gluteus- maximus and -medius, posterior tibialis, soleus and vastus medialis oblique (VMO), as Linda s body is not as yet able to stabilise in more dynamic movements.. These are named Small knee bend, Step Up, Step Down for the gluteus maximus, the Thousands for the gluteus medius, Squat Heel Lift for the posterior tibialis, the Bridge Heel Lift for the strengthening of the soleus, and the VMO Wall Squat and VMO Leg Extension. In addition, the ankle stabilisers must be strengthened with the use of a Foamblock on which Linda will stand unilaterally for a minute a side. 16

18 5.11 Lateral flexion and rotation Lateral flexion and rotation will begin with Mat exercises, such as the Side Lifts progressing to the Side bend (which is to be initially modified by lifting off bent knees),wunda Chair Side Stretch and Side Kneeling Stretch as well as Reformer Mermaid. Towards the end of the10-week programme the Ladder Barrel Side Over Prep, can be introduced Back extension Back extension is to be executed with transverse abdominus and multifidus cocontraction and complete lumbar stability. The Mat Back Extension will be used, with emphasis on building endurance capacity of the lumbar extensors. Repetitions must be built up to 40 repetitions over the course of the 10-week programme as prescribed by the chiropractor. In addition, an exercise which the physiotherapist prescribed, named the Prone Leg Lift is to be integrated into every session. 17

19 Week Programme 18

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22 6. Conclusion As seen from the 10 week Programme, BASI Pilates will assists in addressing muscle imbalances that the client might have due to Lumbo-Pelvic-Hip-Motor- Control-Dysfunction (LPHMCD). By following the BASI Pilates Block System in every session, Linda will receive a full body workout, whilst focusing on the specific areas that need to be strengthened. The mind-body connection will assist Linda to become more aware of her body s imbalances, as well as her strengths and what her body s capabilities and limitations are throughout any activities. Being a high energy individual who mainly partakes in global muscle movement in terms of physical activity, Linda found it challenging to focus on a mind-body connection in order to stabilise, through the use of the deeper layers of muscle needed to stabilise her lumbar-pelvic-hip-complex and sacroiliac joints, rather than mobilise her body during sessions. She did, however, find it immensely beneficial in terms of mental focus, concentration and being aware of her body during her routine training sessions, as well as experiencing an overall reduction in pain and an increase in stability and strength in all the required areas, which has improved her quality of life and the quality of her training sessions as a whole. Joseph Pilates said that No man no machine can correct or create vitality, power or health for you; everything comes from within, you have to unfold it. This has been proven throughout history, as well as in my personal journey with Pilates, first as a client and then as a BASI Pilates student. The significance of unfolding or rather, developing the mind-body connection lies at the core of understanding, performing and ultimately gaining the most benefit from the practice of BASI Pilates. 21

23 7. Bibliography BASI Movement Analysis Workbooks BASI Comprehensive Study Guide, Module 9, The Shoulder Region. Pilates Interactive Google Images rary_developments.pdf?awsaccesskeyid=akiaj56tqjrtwsmtnpea&expires= &Signature=Fq0F4RhD6Kb3O1K%2BYD%2BdJvq3iqM%3D&response-contentdisposition=inline%3B%20filename%3DMovement_and_stability_dysfunction_conte.pdf &bih=585&tbm=isch&imgil=jlE7OTgl1qRa6M%253A%253BLJuLWJy zuwqdgm%253bhttp%25253a%25252f%25252fapmspineandsports.co m%25252fdiagnosis%25252fsacroiliac-jointdysfunction%25252f&source=iu&pf=m&fir=jle7otgl1qra6m%253a%252 CLJuLWJyzuWqDGM%252C_&usg= 8e-c6kZF93Tisq- F1wXV7ix1r4I%3D&ved=0ahUKEwiwm- TC3oTPAhXBCMAKHXlQDDsQyjcINw&ei=KfTTV_DiCcGRgAb5oLHYAw #imgrc=ggvpmyk4pqp0tm%3a 22

24 A298&dq=hip+motor+control+symptoms&source=bl&ots=mMTK2kWwWU &sig=9hbr6r7wtlyah0wtmotew0cjwqu&hl=en&sa=x&ved=0ahukewj kkpl-54tpahvpccakhvumboq6aeiltad#v=onepage&q=hip%20motor%20control%20symptoms&f=f alse Alison Stephenson BscPhysio (Wits) 23