GLUTEUS MAXIMUS RECRUITMENT THROUGH THE BASI PILATES BLOCK SYSTEM

Transcription

1 GLUTEUS MAXIMUS RECRUITMENT THROUGH THE BASI PILATES BLOCK SYSTEM BODY ARTS AND SCIENCE INTERNATIONAL Teresa Dalla Torre BASI CTTC 2018 Ballito, South Africa

2 ABSTRACT People have different reasons for starting Pilates, for some it s to increase their flexibility or to reduce back pain, for most it is to strengthen their core. Pilates trains and recruits the abdominals to provide a strong core which in turn provides pelvic lumbar stabilisation (PLS) around which other exercises, such as arm and leg work challenge the core, much like the movements of daily living where our arms and legs move around a strong core that stabilises our spine against these external limb moments. The gluteus maximus muscle plays an important role in pelvic lumbar stabilisation. Pilates is important for improving core strength and stability. Most of the Pilates exercises demand PLS achieved by the abdominals. Gluteus maximus is also an important muscle for PLS and yet there is no cueing for gluteus maximus specifically in the repertoire of exercises. The purpose of this case study is to cue for gluteus maximus in the BASI Pilates repertoire of exercises, and to ascertain the effects of this recruitment in terms of hip extension activation sequencing and the client s awareness of this muscle with regards to its presence and activation. Tarryn, a 32 year old elite trail runner and Pilates instructor complained of right sided lower back pain. On testing, she showed aberrant hip extension recruitment patterns. A 30-session BASI Pilates Block exercise program was instituted where there was cueing for gluteus maximus activation and recruitment specifically. On completion of the program, Tarryn showed improved hip extension recruitment patterns, awareness of her gluteus maximus and improved PLS with hip extension range of motion with respect to the Gluteals Kneeling exercises. These results suggest that with specific gluteus maximus cueing within the BASI Pilates Block of exercise repertoire, gains may be made with respect to hip extension recruitment patterns as well as improved pelvic lumbar stabilisation and client awareness. 2

3 Table of Contents 1. Introduction Anatomy of the Gluteus Maximus Muscle Functions of the Gluteus Maximus Muscle Verbal and Tactile Cueing for Gluteus Maximus Activation Case Study: Tarryn Lopez The 30-session BASI Program Outcome Conclusion References Table 1: The 30-Session BASI Pilates Program.. 12 Figure 1: Muscles of the Hip and Posterior Thigh - A Posterior View Showing the Gluteus Maximus Muscle...5 Figure 2: Muscles of the Back: Superficial Layers Showing Gluteus Maximus Connection with TLF and the Latissimus Dorsi Muscle. 6 Figure 3: Prone Hip Extension Test.10 3

4 1. Introduction The gluteus maximus is the strongest and largest muscle of the body. The gluteus maximus is not only a powerful hip extensor but also plays an important role in pelvic and spinal stabilisation.the gluteus maximus allows us to maintain an upright position needed for bipedalism. Through evolution the gluteus maximus enlarged in humans as a means to stabilise the trunk while standing and counteract the high impact forces that tend to flex the trunk anteriorly during running and sprinting. Consequently, the gluteus muscles gradually lose tone during our chair-laden lifestyle, or through muscle imbalances that have occurred across the lumbopelvic hip complex, resulting in inhibition and delayed activation. Low back pain has been associated with inhibition of the gluteus maximus. The activation of the gluteus maximus during hip extension is delayed in people with a history of low back pain compared to people with no back pain. In people with low back pain, hip extension is initiated by the hamstrings and erector spinae instead of the gluteus maximus. Even after the episode of low back pain has resolved, the altered firing patterns in the gluteus maximus remains. 2. Anatomy of the Gluteus Maximus Muscle This muscle attaches extensively to the pelvic girdle. It arises from the posterior gluteal line of the innominate, the dorsum of the lower lateral sacrum and coccyx, the aponeurosis of the erector spinae muscle, the sacrotuberous ligament, the superficial laminae of the posterior Thoracolumbar Fascia (TLF) and the fascia covering the gluteus medius muscle. In the pelvis, the gluteus maximus blends with the ipsilateral multifidus through the raphe of the TLF and the contralateral latissimus dorsi through the superficial laminae of the TLF. Less than one-half of this muscle attaches directly to the gluteal tuberosity of the femur. The remainder inserts into the iliotibial tract of the fascia lata. 4

5 Figure 1: Muscles of the Hip and Posterior Thigh - A Posterior View Showing the Gluteus Maximus Muscle 5

6 Figure 2: Muscles of the Back: Superficial Layers Showing Gluteus Maximus Connection with TLF and the Latissimus Dorsi Muscles 6

7 3. Functions of the Gluteus Maximus Muscle The gluteus maximus is the strongest muscle of the body and has a multi-tasking function. This muscle is able to combine a local stabiliser, global stabiliser and global mobiliser role. As a local stabiliser it provides segmental stabilisation: Force closure of the sacroiliac joint: The gluteus maximus provides stability to the sacroiliac joint (SI joint) by bracing and compression. Excess movement at the SI joint would compromise the L5-S1 intervertebral joints and disc and could lead to SI joint dysfunction and low back pain. Control and centralise the femur in the hip socket (acetabulum): Co-contraction with psoas major contributes to lumbo-sacral stabilisation. Segmental stabilisation of the vertebrae by directly tensing the TLF: The gluteus maximus also provides lower back stability through its connection with the erector spinae and TLF. Some of its fibres are continuous with the fibres of the erector spinae. A contraction of the gluteus maximus generates tension in the erector spinae muscle on the same side, providing stiffness to the spinal column. Gluteus maximus contraction also exerts a pull on the lower end of the TLF, which is a thick layer of ligamentous connective tissue. Tightening of this fascia stabilises the vertebrae. Indirectly by triggering the deep lumbar multifidus. As a global stabiliser it provides: Eccentric lengthening or isometric holding to control range of motion i.e. sagittal plane stabilisation of the trunk during walking, running and standing via eccentric control of hip flexion. Control of trunk rotation during gait through the connection with the contralateral latissimus dorsi muscle (Posterior Oblique System). Frontal plane stabilisation of the pelvis during single-leg stance (resisting gravity s hip adduction torque). Control of the stance leg in the frontal (preventing adduction of the thigh) and transverse plane (preventing internal rotation of the thigh). 7

8 As a global mobiliser it produces high force power: Hip extension. External rotation of the hip. Superior fibers: hip abduction. Lower fibers: hip adduction. In summary, the gluteus maximus provides for pelvic lumbar stability, segmental stabilisation of the vertebrae, concentric control of hip extension, eccentric control of hip flexion and single-leg balance. The pelvic lumbar stabilising function and intersegmental motion control of vertebrae through the action of gluteus maximus supports the view that activating and strengthening the gluteus maximus muscle needs to form an important part of the core routine. Inhibition and delayed activation of the gluteus maximus compromises pelvic stability. This can result in compensation by the lower back as well as additional altered muscular firing patterns and function. Likewise, low back pain and lower body injuries result in delayed and reduced glute activation with concurrent hamstring and low back compensation. 4. Verbal and Tactile Cueing for Gluteus Maximus Activation Effective cueing is integral to successful Pilates teaching and as such I primarily used verbal and tactile cueing to assist Tarryn with gluteus maximus activation or engagement. Firstly, I cued for gluteus maximus activation in most exercises where there was opportunity to engage gluteus maximus either in isometric, concentric or eccentric contraction. Secondly, special attention was made to ensure that Tarryn maintained pelvic lumbar stabilisation throughout the activation of gluteus maximus. Lastly, for each exercise, I cued specifically to those aspects specific and unique to that exercise in addition to cueing for gluteus maximus. 8

9 Verbal cueing consisted of squeeze your glutes to elicit gluteus maximus recruitment. For seated exercises, the cueing used was sitting on a hot plate. Exercises that made use of external rotation and extension of the hip, the phrase wrap your thigh outwards to enhance activation of gluteus maximus and take full advantage of the external rotation component of the exercise. Permission was attained from Tarryn before I performed tactile cueing. Tactile cueing entailed placing firm deliberate finger/s on Tarryn s gluteus maximus and feeling for the engagement before or during the exercise. In addition to tactile cueing I also closely observed for gluteus maximus activation. As Tarryn became more aware and proficient at engaging the gluteus maximus, I reduced the tactile cueing. 5. Case Study: Tarryn Lopez Tarryn Lopez is a 32-year old Pilates Instructor and an elite trail runner.tarryn complained of right sided lower back pain, especially felt when she ran longer trail distances. Although Tarryn does not engage in a sedentary lifestyle and is very active, she displayed aberrant hip extension patterns on testing. When testing both legs, Tarryn recruited the erector erector spinae muscle before the gluteus maximus muscle and also showed reduced hip extension range of motion in both hips. Increased lumbar lordosis resulted when asked to extend each leg further. Thus, in addition to abnormal hip extension sequencing, Tarryn exhibited reduced hip extension range of motion as well as compensatory recruitment of the erector spinae muscles. A thirty-session progressive BASI Pilates program was instituted with specific cueing for gluteus maximus activation with the expectation of improved hip extension patterns. Prone Hip Extension measurements were taken before the first, eleventh, twenty-first and thirtieth Pilates exercise sessions. Prone Hip Extension Test This test assesses the pattern of muscle firing and thus muscle imbalances. 9

10 Procedure: The client lies prone with feet hanging off the end of the table to allow for neutral leg rotation. The head is in a neutral position. The client is asked to lift a straight leg toward the ceiling about 6 inches off the table. The ipsilateral gluteus maximus muscle and bilateral lumbar erector spinae muscles are palpated to assess recruitment sequencing. The following normal activation sequence is palpated and observed: Hamstring and gluteus maximus muscles, then Contralateral lumbar erector spinae muscles, and then Ipsilateral lumbar erector spinae muscles. Results A positive result for this test is lumbar erector spinae muscle recruitment before the gluteus maximus muscle. Indications of an abnormal movement pattern would also include trembling during the first 20 degrees of movement, decreased extension range of motion, early hyperlordosis, lateral or rotational deviations of the lumbar spine, recruitment of upper back/cervical musculature, and an inability to maintain extension of the knee. Figure 3: Prone Hip Extension Test 10

11 6. The 30-session BASI Program BLOCK Sessions 1-10 Sessions Sessions WARM UP Roll Down Roll Down Roll Down Pelvic Curl Pelvic Curl Roll Up Spine Twist Supine Spine Twist Supine Spine Twist Supine Chest Lift Chest Lift Double Leg Stretch Chest with Rotation Chest with Rotation Single Leg Stretch FOOT WORK Reformer Cadillac Wunda Chair Parallel Heels Parallel Heels Parallel Heels Parallel Toes Parallel Toes Parallel Toes V-position Toes V-position Toes V-position Toes Open V Heels Open V Heels Open V Heels Open V Toes Open V Toes Open V Toes Calf Raises Calf Raises Calf Raises Prances Prances Single Leg Heel Single Leg Heel Single Leg Heel Single Leg Toes Single Leg Toes Single Leg Toes ABDOMINAL Reformer Cadillac Reformer WORK Hundred Prep Roll Up with Roll Up bar Double Legs Coordination Roll Up Top Loaded Double Legs with Rotation HIP WORK Reformer Cadillac Cadillac Supine Leg Series Basic Supine Leg Series Basic Supine Single Leg Series Frog Frog Frog Down Circles Down Circles Down Circles Up Circles Up Circles Up Circles Openings Walking Hip Extension Bicycle & Reverse Bicycle & Reverse SPINAL Not recommended for the Reformer Wunda Chair ARTICULATION first 10 sessions Bottom Lift Pelvic Curl Bottom Lift & Extensions 11

12 STRETCHES FULL BODY INTEGRATION F/I ARM WORK FULL BODY INTEGRATION A/M LEG WORK LATERAL FLEXION/ ROTATION BACK EXTENSION Ladder Barrel Gluteals Hamstrings Adductors Hip Flexors Ladder Barrel Gluteals Hamstrings Adductors Hip Flexors Ladder Barrel Gluteals Hamstrings Adductors Hip Flexors Not recommended for the Reformer Reformer first 10 sessions Elephant Down Stretch Reformer Wunda Chair Reformer Arms Supine Series Frog Back Arms Sitting Series Extension Chest Expansion Adduction Biceps Up Circles Rhomboids Down Circles Hug-A-Tree Triceps Salute Not recommended for the Not recommended for the Reformer first 10 sessions first 20 sessions Balance Control Back Gluteals Kneeling Series Gluteals Kneeling Series Wunda Chair No weights With 1kg ankle weights Forward Lunge Hip Extension Bent Knee Hip Extension Bent Knee Hip Abduction Bent Knee Hip Abduction Bent Knee Hip Extension Straight Leg Hip Extension Straight Leg Adductor Lift Adductor Lift Wunda Chair Ladder Barrel Cadillac Side Stretch Side Over Prep Side Lift Reformer Avalon Barrel Step Barrel Pulling Straps 2 High Swan Swan Roll Down Roll Down Roll Down Table 1: The 30-Session BASI Pilates Program 12

13 NOTES: I followed the guidelines to the Progressive Layering of the Block System even though Tarryn is an experienced Pilates Instructor. I did this for two reasons, firstly I did not realise I could start including spinal articulation and Full Body Integration from session 1 with Tarryn an experienced Pilates instructor, and secondly, in hindsight, following the progressive system gave me the time and mindfulness to cue for gluteus maximus as effectively as I could. I don t believe that leaving the aforementioned sections out would have had an impact on the results as they were included in subsequent sessions. WARM UP Pelvic Curl: Cued to squeeze your glutes at the up phase of the pelvic curl before the inhale whilst maintaining PLS. Roll UP: Cued to squeeze your glutes or sitting on a hot plate when in the seated roll up position and relax them for the roll down. Double Leg Stretch: Cued to squeeze your glutes on the inhale. FOOT WORK Reformer Foot Series Emphasis placed on keeping a neutral pelvis as well as PLS throughout the movement. Movement initiated from the hamstrings, cued to squeeze your glutes with hip extension and as well as to wrap your thigh outwards with hip extension and external rotation. Cadillac Foot Series Emphasis placed on keeping a neutral pelvis with the sacrum anchored as well as PLS throughout the movement. Movement initiated from the hamstrings, cued to squeeze your glutes at knee extension and as well as to wrap your thigh outwards with knee extension and hip external rotation. Wunda Chair Foot Series Emphasis placed on keeping a neutral pelvis as well as PLS and trunk postural stability throughout the movement. Movement initiated from the hamstrings and then cued sitting on a hot plate. 13

14 ABDOMINAL WORK Hundred Prep: Emphasis placed on keeping a neutral pelvis and PLS throughout the movement and to squeeze your glutes on the exhale. Coordination: Cued the same as Hundred Prep. Roll Up with Roll Up Bar: Cued to squeeze your glutes or sitting on a hot plate when in the seated roll up position and relax them for the roll down. Roll Up Top Loaded: cued the same as Roll Up with Roll Up Bar. Double Leg & Double Leg with Rotation: Cued to squeeze your glutes on the inhale. HIP WORK Focused on hip dissociation with emphasis placed on keeping a neutral pelvis, as well as PLS throughout the hip movements. Frog: Cued to squeeze your glutes at knee extension. Down & Up Circles: Cued to squeeze your glutes and wrap your thigh outwards when the legs where extended and towards hip abduction. For single leg Cadillac work, cued to squeeze your glutes when the leg was lowered as well as towards hip abduction. Openings: Cued to squeeze your glutes towards hip abduction. Walking, Bicycle & Reverse: Did not cue for gluteus maximus here due to the complexity of these exercises whilst also endeavoring to maintain PLS during their execution. Cadillac Supine Single Leg Series: Single leg hip work is beneficial for addressing muscular imbalances between the lower limbs. SPINAL ARTICULATION Bottom Lift and with Extensions: Cued to squeeze your glutes in the up phase of the spinal articulation as well as to keep the pelvis lifted and hips extended as the carriage returns to the stopper. Pelvic Curl: Cued to squeeze your glutes in the up phase of the spinal articulation. 14

15 STRETCHES I thought it beneficial for Tarryn to stretch her gluteals, hamstrings, adductors and hip flexors. My reasoning for stretching these muscles were as follow: Gluteals: gently stretching the muscle I am cueing for and training, i.e. gluteus maximus. Hamstrings: the hamstring muscle is a postural muscle and therefore prone to tightness and overactivity. The propensity of hamstring muscles to develop tightness and hyperactivity is associated with a corresponding tendency for the gluteus maximus to become lax and inhibited. Adductors: Because the adductor magnus muscle shares a common function with the hamstring muscle (hip extension), adductors are also stretched. Hip flexors: If a postural muscle such as iliopsoas becomes shortened from overuse, it will mechanically limit the range of motion of the gluteus maximus, its antagonist, and will neurologically inhibit its action. FULL BODY INTEGRATION F/I Elephant: took advantage of the hamstring stretch. Down Stretch: Cued to squeeze your glutes while exhaling keeping a bias towards a posterior pelvis to protect the lumbar spine. ARM WORK Arms Supine Series: Cued to squeeze your glutes on the exhale, all the time keeping a neutral pelvis. Frog Back: Cued to squeeze your glutes on the exhale, taking advantage of the external rotation of the hip. Arms Sitting Series: Cued sitting on a hot plate on the exhale. FULL BODY INTEGRATION A/M Balance Control Back: Cued to squeeze your glutes in preparation of the exhale and continue all the way to the diagonal position. 15

16 LEG WORK Gluteals Kneeling Series (with or without weights): For the first 10 sessions no weights were used in this series in order to make sure Tarryn recruited gluteus maximus via tactile cueing and palpation and that PLS was held and maintained for the whole movement. Cued to squeeze your glutes on the exhale and to hold the eccentric contraction on the inhale. Ankle weights (1kg) were added to each leg from session 11 20, this had the effect of providing resistance and thus increasing gluteus maximus strength. Forward Lunge: This exercise mimics one of gluteus maximus functions, i.e. climbing upstairs, however with added proprioceptive challenge in the single leg stance. Cued to squeeze your glutes in preparation of the exhale and to continue the contraction to foot lifting off the pedal, to relax the contraction momentarily, and to continue the eccentric contraction on the inhale going down with the unsupported leg. LATERAL FLEXION/ROTATION Cued to squeeze your glutes on the exhale of the exercise. BACK EXTENSION Pulling Straps 2: Good exercise as it also engages the latissimus dorsi, an important muscle that acts with gluteus maximus to stabilise the pelvis across the sacroiliac joint. Cued to squeeze your glutes on adduction of the shoulders after the trunk lifted. Observed for pelvic lumbar stability. High Swan and Swan: Beneficial exercises for the back and hip extensor muscles. 7. Outcome The Prone Hip Extension Test measurements were taken before the 1 st, 11 th, 21 st and 30 th session to assess whether activating or engaging the gluteus maximus throughout the repertoire of BASI Pilates Block exercises would result in improved hip extension muscle recruitment patterns. The following results were recorded: 1 st session: lumbar erector spinae contracted first in both legs. 16

17 11 th, 21 st and 30 th sessions: Right hip extension: normal activation sequence. Left hip extension: hamstring and contralateral erector spinae contracted at the same time. The results indicate that Tarryn showed improvement with respect to the hip extension sequencing after the 10 th session but plateau after that, showing no further improvement but holding the improvement gained. The right hip showed normal hip extension sequencing, however the left hip, although an improvement was noted, showed that the left hip extensors did not recruit accordingly. Reasons for this could be tight left hip flexors which could mechanically and neurologically inhibit gluteus maximus function. Another reason could be in conjunction with tight hip flexor muscles, Tarryn s left gluteus maximus may have been inhibited and poorly activated during the movement, leading to overactivity of the stabilisers in the lumbar spine, the erector spinae muscles. One finding that I observed was that Tarryn was able to extend both hips especially the right hip with greater range of motion, as well as maintain good pelvic lumbar stabilisation during the Gluteals Kneeling Series. I started noticing this at about the 17 th session and decided to test for it at the end of the 30 th session, and found similar results. This improvement can perhaps be explained from the continual activation of the gluteus maximus throughout the repertoire of the BASI Pilates Block exercises. Tarryn mentioned that she started feeling and becoming more aware of her glutes during her trail runs, whereas previously she hadn t felt them. This can perhaps be explained by the fact that through the continual verbal and tactile cueing as well as the continual activation or engagement of the gluteus maximus, Tarryn gained heightened awareness of this muscle. Finally, Tarryn s right sided lower back pain also subsided. 17

18 8. Conclusion The literature shows that single-limb squat and single-limb deadlift exercises are the most effective at recruiting gluteus maximus. The purpose of this case study was not to necessarily increase gluteus maximus strength but rather to recruit gluteus maximus within a Pilates setting, using the BASI Pilates Block System to ascertain the effects of this recruitment in terms of hip extension activation sequencing and Tarryn s awareness of this muscle. Tarryn showed improved hip extension recruitment patterns as well as improved hip extension range of motion and pelvic lumbar stability during the Gluteals Kneeling Box work. Tarryn also became aware of her gluteus maximus muscle while trail running which she hadn t felt before the Pilates instruction, as well as an improvement with respect to her lower back pain. Improved pelvic lumbar stability during the Gluteals Kneeling Hip Extension work indicates that Tarryn did not call on the back extensors to assist the gluteus maximus and hamstring muscles in performing hip extension. This fact together with the other results stated above, suggests that activating gluteus maximus with specific cueing within the Pilates setting, using the repertoire of exercises can have positive effects such as abatement of lower back pain, improved hip extension recruitment patterns required for upright posture, walking and running, as well as improved pelvic lumbar stabilisation, an important and key principle within the Pilates profession. 18

19 9. References BASI Pilates South Africa, Teaching Tip 1 Tone of Voice, BASI Comprehensive Study Guide, Module 3, Anatomy Overview Part 2. p36. Bram Swinnen, Re-activating and Strengthening the Gluteal Muscles, Functional Resistance Training, Jull GA and Janda V (1987). Muscles and Motor Control in Low Back Pain: Assessment and Management.IN Physical Therapy of the Low Back (Eds. Twomey L T and Taylor J R) Churchill Livingstone: NewYork. p 258. Lee D (2000). The Pelvic Girdle. 2 nd Edition. (Ed. Lee D) Churchill Livingstone: New York. p 36. Liebenson C (1996). Rehabilitation of the Spine. Williams & Wilkins: Baltimore. pp 30 and 31. Lumbar Spine Assessment, Prone Hip Extension Test, Netter F K (1989). Atlas of Human Anatomy. CIBA-GEIGY Corporation. Basle. Switzerland. Plate 160 and 465. Sarah L Hundermark (2017). No Ifs. Just Butts workshop. BASI Pilates. Stude D E (1999). Spinal Rehabilitation. Appleton & Lange: Connecticut. p

20 Travell J G and Simons D G (1999). Myofascial Pain and Dysfunction. The Trigger Point Manual. 2 nd Edition. Volume 2.Williams & Wilkins: Baltimore. p 323. University of Western States. College of Chiropractic (2013). Key Movement Patterns: Assessment & Management. p 6. file:///c:/users/administrator/downloads/key_movement_patterns%20(4).pdf 20