How Can Pilates Equipment Training Help Improve Pelvis Instability?

Transcription

1 How Can Pilates Equipment Training Help Improve Pelvis Instability? Svenja Hampel September 2018 May - Nov 2018, Dubai Training 1

2 Abstract Throughout my journey teaching and practicing Pilates, I came across a lot of clients who had a hard time understanding neutral pelvic alignment. Furthermore, the majority came to me to seek for help for lumbar sacroiliac pain, nerve pain shooting down one leg or undefined tingling in the leg. Therefore, I choose to write on pelvic lumbar stabilization. First of all: What is pelvis instability? Where is the pelvis region? And what can be instable? The pelvis hip leg connection is a quite solid bone structure and builds a solid connection between upper and lower half of the body. This is what it should do. Unfortunately for a lot of people nowadays the pelvis region gets less movement and less strength training than it should get. As a consequence, it is less stable and it gets more unstable, creating pain while doing normal everyday movements like walking and running, getting on and off bed or a chair. All these moves should not create any discomfort. Sadly, to see, the majority to the population are seated to long either at work behind the desk, driving the car to or from work or relaxing after a long working day at home on the sofa. Only few of them take action and try to work against this sedentary lifestyle, being more active and healthy in their daily living. 2

3 Table of Contents Abstract... 2 Table of Contents... 3 Anatomy... 4 Case Study Conditioning program Conclusion Bibliography

4 Anatomy The pelvis is a symmetrical bony ring structure connecting the vertebrae column and the lower limbs via the hip joint. The vertebrae column function as shock absorption. If each vertebrae are correctly aligned the vertebrae column will absorb the shock to its best, if the alignment of the hole body is incorrect it will have a knockdown effect of the weakest part in the system. The pelvis holds the abdominal organs of the body as bladder, intestine, uterus for woman and prostate in man. The pelvis consists of three strong bones fused together: the ilium, ischium and pubis. They form the acetabulum, the socket joint of the hip which connect to the femur head. The ilium is the largest flat bone on each side of the upper portion of the pelvis girdle, including the iliac crest with the anterior superior iliac spine (ASIS), the hip bone which can be easily felt with palpation. The pubis is the anterior side of the pelvis fused together by the cartilaginous pubis symphysis. The anatomy of the pelvis differs in male and female: the females pelvis is wider and the pubis shorter than male. The pubis symphysis will widen for child birth in woman. The sacrum contains five fused vertebrae S1 to S5 creating a triangular shape at the posterior side of the pelvis girdle. The ilium connects on either side of the sacrum S1 to S5 and builds the sacroiliac joint connected via powerful posterior and anterior ligaments and muscles. The network of ligaments and muscle around the sacroiliac joint limits movement within the joint. 4

5 Sacrum from posterior view The sacroiliac joint has normally only a small range of movement, 2 4 mm in any direction. The sacroiliac ligaments are less stiff in women allowing to prepare for child birth. Cause this segment has less movement, the primary movement in the sacrum occurs relative to the last lumbar vertebrae. Movements at this joint has a profound influence on alignment of the lower back and pelvis, state in Pilates Anatomy. Sacroiliac Joint ( SI ) and Lumbosacral Joint ( S1 to L5 ) At the lower part of the spinal cord numerous nerves of the cauda equine extend from the foramen of the lumbar spine into the sacral canal and exiting the sacrum through the sacral foramina on each side of the canal. Correct body alignment increases the possibility that all nerves work in the most efficient way. 5

6 Sacrum including Nerves roots The pelvic girdle connects the upper and the lower part of the body. The hip joint, a major ball and- socket joint, connect the pelvis to the long bones of the femur. The hip joint allows a wide range of movements of the lower limbs as it is used in running, walking, climbing and bending. The hip joint bears the body weight and is support through large, strong tendons, ligaments and muscle gluteus maximus, medius, minor, iliacus and piriformis. The muscle of the pelvis and hip controlling the legs and upper trunk. Posterior the gluteus complex controlling hip extension as the hamstrings; anterior the deep hip muscle, the Psoas consisting of psoas major and iliacus controlling hip flexion and trunk flexion and trunk lateral flexion. The Psoas is connected in the lowest thoracic vertebrae, 12 th thoracic vertebra to the 5 th lumbar vertebrae, and crosses to the front of the body along the pelvis and attaches to the femur which makes it one of the most important muscles in the body. The Psoas is the only muscle which connects the spine to the lower limbs. Psoas Major and minor Gluteus Maximus and medius The gluteus maximus is the largest muscle of the body, consisting of gluteus minimus and gluteus medius, connecting to the sacrum above the iliac crest. The gluteus maximus controls hip extension as in running and walking. It attaches as well to the ilio-tibial (IT) band, a complex connective fibre. 6

7 A big group of deep pelvis muscle controlling movements of the leg are the Piriformis, Obturator internus, Obturator internus, Obturator externus, Gemellus superior and inferior and Quadratus femoris connecting the pelvis girdle to the femur. Furthermore, there are Tensor fasciae latae to stabilise the femoral head into the acetabulum and the knee during extension, Rectus femoris acting as hip flexor belonging to the quadriceps. The Satorius is a thin and the longest human muscle of the inner thigh, originates in the iliac crest, running diagonally down to the knee to insert to the inner tibia assisting in external rotation of the hip. Furthermore, the pelvis girdle includes the muscle of the pelvic floor and the perineum to hold the inner organs. The muscles of the abdomen are connected also to the pelvis girdle. The abdominal muscles can be divided into four parts: the external obliques, originates ilium to linea alba, the internal obliques, originates ilium to linea alba, the transversus abdominal, originates ilium and ribs to pubis and linae alba, and the rectus abdominal, originates pubis to sternum. The deepest muscle in the abdomen, the transversus abdominal, is arranged transversely around the abdomen similar to a belt. This arrangement of the layered muscles of the abdomen allows various movements in all directions of the trunk flexion, extension, lateral flexion and rotation. The abdominal muscles also protect the abdominal organs. Abdominal muscle layering On the posterior side of the body the Quadratus lumborum connects from the iliac crest to the 12 th rib and the lumbar vertebrae L1 L4. The quadratus lumborum is a continuation of the transverse abdominal muscle on the posterior side of the body and the deepest abdominal muscle. The Multifidus spinae muscle, also a muscle on the posterior chain of the body, consists of a number of tendinous fasciculi which fill up the groove on both sides of the spinous processes of the vertebrae. The multifidi originate at the sacrum and iliac crest and inserts at the spinous process. It plays an important role in stabilizing the joints within the spine. 7

8 Quadratus Lumborum Multifidius spinae muscle Rael stated in his book Pilates Anatomy Muscle acting as Force Couples. All these muscle described above connected to the pelvis girdle posterior or anterior acting in some kind on pelvis stability. For example, the abdominal hamstrings force couple is acting on both sides of the pelvis. Contraction of the abdominal can produce a posterior pelvic tilt as desired in a pelvic curl, as the hamstrings at the same time lengthen award to support this movement of posterior tilt. If a neutral spine and pelvis is desired both muscles have to work together to create stability overall. As one muscle is in misalignment other muscle have to take over and it creates an imbalance between muscles which can led into discomfort or further worsen to pain. If the optimum position of the spine and pelvic girdle cannot have been maintained, it causes pelvic instability, which can change the gait of walking and/or running and placing unnecessary pressure on the lower spine. Instability in the pelvic region can place pressure on the sciatic nerve which runs down the length of the body from the lower back to the legs. Pelvic girdle instability can also occur during pregnancy and child birth. Physical therapy is the most common therapy to work against the muscle imbalances targeting strengthening the weakened muscles, most likely the abdominals, stretching and strengthen the hip extensors and strengthen the back extensors to stabilize the pelvic joints and muscles. A strong pelvis girdle is less likely to be unstable. Neutral Pelvis Neutral pelvis refers to the position of the pelvis when the ASIS (anterior superior iliac spine) on each side of the pelvis and the pubis symphysis (PS) are in the same horizontal plane and the two ASIS are in the same transverse plane. The spine will than result in a neutral spine position with its normal cervical and lumbar curve. Training in a neutral spine and pelvis position benefit in a balanced training of all muscle surrounding the pelvis, encouraged balanced muscle development of the pelvis complex and correct muscle recruitment. Working in neutral spine position means teaching ideal posture and alignment, reinforcing functional and positive movement pattern. 8

9 As the pelvis anatomical lies between upper and lower part of the body, it will be influenced by movement in the spine and legs. Correct pelvis alignment will develop balance muscle groups acting on the pelvis complex striving for ideal posture and function. 9

10 Position of the Pelvis The pelvis is in a posterior tilt (tuck) when the Pubis symphysis is higher than the ASIS. The lower spine is lengthening into the mat and forces the upper back to round more forward, the natural lumbar curve has changed to a flexed lumbar spine position. The pelvis is in an anterior pelvic tilt (arch) when the ASIS is higher than the pubis symphysis. The lower spine is arched of the mat and forces the upper back to flatten more into the mat, creating an extended position of the lower spine. Pelvis instability Pelvis instability can present at any age, but tends to decline with aging, due to stiffening of ligament tissue. It often presents in young females who are involved in sports that requires a high degree of mobility such as dancers, gymnasts and swimmers. These three have also in common a high intensity in training load and within its training an increased amount of back bending. The pelvis is bearing the body weight and distribute it through the hips and legs. If ligaments are injured or overstretched, the pelvis loses its stability and begins to move excessively. Due to excessive range of motion without necessary adequate muscular control structures in spine and pelvis as joint and ligaments can be deformed. Holding the joints in or near their end range of motion stresses and stretches the retaining ligaments which will be noticed in pain symptoms as sacroiliac joint pain, lower lumbar spine pain or pubic pain. 10

11 Case Study Marcy, 16 years old, is an ambitious swimmer. She trains 9 times a week each training session 2 hours, and sometimes twice per day. As cross training she is doing running and weight training in the school gym. She started to swim with the age of 5 and developed over the years a real passion for swimming. Her dream is to become an Olympic swimmer since Grade 3 as she wrote her first assay about Being an Olympic swimmer. She achieved to start twice in the German Junior National Swim Championship 2016 and 2017 qualified for 100 breast and 200 breast. She was as well qualified for the German Junior National Championships in 3 events 100 Breast, 50 free, 200 Breast and she could have qualified for more events. Unfortunately, her back pain increased over the last 1/2 year, correlating with lifting higher weights in the school gym in bad posture. Cause of increased pain in the mid back, lower back near the sacroiliac joint she needed to step back and reduce her training load to try to heal of pain. She has seen several different medical professionals as physiotherapists, osteopaths and orthopaedics. The MRI showed that no bone damaged in the sacral vertebrae occurred, that the ligaments and muscles are working to their normal function. She was than referred to the next physiotherapist. She decided to choose Pilates as her cross training to have a low-impact training which trains her body to be in correct body alignment while working in supine, prone, side lying and Four Point Kneeling position. Training on Pilates equipment will help her to then transfer neutral alignment to perform her favourite sport - swimming. In general, she feels Pilates is boring and she only does it to improve her performance. I started to assess her with the posture plumb line and noticed that her pelvis is anterior tilted. Her overall posture is showing an increased lumbar curve, lumbar Hyper lordosis. This posture is associated with weak abdominals, tight hip flexors and tight lower back extensors. We will focus on working against this findings: strengthen the abdominals, stretching hip flexors and lower back extensors, strengthen the hip extensors and maintaining pelvic lumbar stability in all body positions. We continued with the standing Roll Down. In the standing Roll Down it was quiet obvious that her left mid back muscle were over developed compared to her right mid back muscles. The Pilates conditioning program for Marcy should also include balanced work for both sides of the body - right and left and specially to strengthen the back muscles and abdominals in an equal balanced manner. She started with Pilates twice per week, but she still continued swim training 4 times a week each 2 hours and cross country running 3 times per week each 1,5 hour. The first sessions were fundamental reformer workouts focused on maintaining the pelvis lumbar area in a neutral position. Marcy, as she is over several years an athlete, has a great 11

12 understanding how her body moves in space. She picks up the concept very quick; so we could move on to intermediate work on the Reformer and Cadillac as for example single leg hip work on the Cadillac to challenge her pelvis stability even more. She progressed very quickly with the Pilates work on equipment. We also focused on hip flexors stretch as in the lunge series on Reformer, and worked on strengthening the abdominals in neutral spine as done in abdominal work, hip work and arm supine series on the reformer. She is overall very strong, but needs to focus on details to achieve the best results. Working evenly through both hip joints was quiet challenging. Slide Spinal articulation as in bottom lift, pelvic tilt and back extension as in swan basics on the chair were gradually incorporated. Single leg skating was one of the most challenging exercises for her. As the training load for school cross country and swimming team increased she started to get more pain again, which made her think to reduce her overall training load for a while. She reduced the cross country running for school team, but still continues with swim training for the school team. Her pain is on and off, but has improved as her stability of the trunk and pelvis girdle has improved overall. Her muscle spam on the left erector spinae has reduced but is still not completely healed. We are still trying to improve her muscle memory to work towards a balanced muscle recruitment so that she is able to compete again in swim meets; she will further continue with the program. 12

13 Conditioning program Session Basi block Warm Up Footwork Abdominals Hip Work Spinal Articulation Stretches Pelvic Curl Spine Twist supine Chest lift Chest Lift with rotation Reformer: Parallel Heels & Toes, Small V, Wide V heels & toes, Calf raises, Prances, Single leg heel & toes Reformer: Hundred Prep, Coordination Refromer: Frog Circles Down/Up Opening none Reformer: Standing Lunge Pelvic Curl Spine Twist supine Chest lift Chest Lift with rotation Reformer: Parallel Heels & Toes, Small V, Wide V heels & toes, Calf raises, Prances, Single leg heel & toes Reformer: Hundred Prep, Hundred, Coordination, Cadillac: Basic Leg springs Reformer: bottom lift Or Cadillac: Bottom Lift with Roll Up Bar Reformer: Kneeling Lunge Full Body none Reverse knee Stretch, Scooter, Roll up Spine twist supine Double leg stretch Single leg stretch Criss cross Reformer or Chair: Parallel Heels & Toes, Small V, Wide V heels & toes, Calf raises, Single leg heel & toes Cadillac: Roll-Up with Roll up Bar, Mini Roll Ups, Mini Roll Ups Obliques, Roll Up Top Loaded, Cadillac: Basic leg springs or Single leg supine, or Reformer: extended frog, extended frog reverse Reformer: Bottom lift, Bottom lift with extension Cadillac: Thigh Stretch with Roll up Bar, Ladder Barrel: Gluteal, hamstrings, abductor, hip flexors Cadillac: sitting forward or side 13

14 Arms Reformer: arm supine series Down Stretch Reformer: Sitting arm series or Cadillac: Standing arm series reach or reformer: Down stretch Reformer: Arm Kneeling Series or Side kneeling Arm Series Full Body none none Reformer; Up Stretch , Long stretch or Down Stretch Legs Lateral Flexion Rotation Back Extension Reformer: Single leg skating Reformer: Side over box Reformer: Back extension or basic back extension mat Reformer: Single Leg skating, Wunda Chair: Leg press standing Ladder barrel: side over prep, or Wunda chair: Side stretch Reformer: Breaststroke prep, Pulling Strap Wunda Chair: Leg press standing, Forward Lunge or Frog Front Ladder barrel: side over, or Wunda chair: Side stretch Cadillac: Prone one Wunda Chair: Swan basic or Back extension single Arm 14

15 Conclusion Marcy included Pilates equipment work into her weekly training program concluding in improvement in her pelvis stability and body awareness over time. This conditioning program for Marcy is designed to improve her pelvic-lumbar area stability, focusing on the following: 1. Strengthening the abdominal muscle, as transvers abdominals and oblique muscles to increase pelvic-lumbar stability; 2. Strengthen and stretch hip flexor; 3. Strengthen the hip extensors, hamstrings and glutes; 4. Strengthen the spinal extensors; 5. Mobilise the pelvis lumbar region 6. Create awareness of good body posture Marcy became aware of her overall body and was grateful to move more freely with less pain. She noticed that misalignment will result in either over correction or over compensation from other muscle groups and may trigger other muscle to go into spasm. She learned a lot about her body, even as she is not completely pain free but more aware of herself. Rael stated in Study Guide Comprehensive Course that studies have shown that a tight erector spinae muscle will be active during its reverse action trunk flexion and this will inhibit its action of its antagonist, the abdominals. If Marcy s muscle imbalance on her mid back is caused in the first place by a training overload and painful stimuli as the movement continued repetitive the further treatment should be re-educating movement pattern and preventing undesirable over-activation and substitution pattern. Quality and precise movement pattern are more important than quantity or intensity. Hopefully this will help Marcy long term. 15

16 Bibliography Isacowitz, Rael and Clippinger, Karen: Pilates Anatomy, Human Kinetic 2011 Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body Arts and Science International, Miller, J. Physio Works. Web