Pilates for Golfers with Nonspecific Low Back. Pain

Transcription

1 Pilates for Golfers with Nonspecific Low Back Pain Megan Parent June 22, 2014 CTTC 2014 Costa Mesa

2 Abstract: Lower back pain is a common problem that affects many individuals through out their lifetime, especially in golfers. Pilates has been shown to decrease pain for individuals experiencing lower back pain. Amateur golfers are often guilty of being weekend warriors and focusing on golf instead of overall strengthening. This causes them to have significant weakness and decreased flexibility; which can contribute to lower back pain. The goals for golfers can be addressed by Pilates; and therefore is a good tool for decreasing lower back pain for golfers, and allow for strengthening in order to avoid pain in the future.

3 Table of Contents 1. Lower Back Pain and Pilates 4 2. Golf Swing Analysis 6 3. Case Study Conclusion Bibliography 14

4 Lower Back Pain and Pilates Lower back pain affects many people throughout the world; and is a large cause of disability and missed work 1. This leads to a large cost not only due to loss of work, but from medical visits, treatments, and in some cases surgeries. It is estimated that between 60%-80% of adults will experience low back pain in their lives 1. Of those that experience lower back pain; 30%-40% will never completely resolve and will ultimately lead to chronic low back pain 1,2. Low back pain is considered pain that occurs bellow the twelfth rib and above the gluteal folds 3. Non-specific low back pain is defined as lower back pain that does not involve pain that radiates down the leg, no disk involvement, or structural abnormalities, such as spondylolisthesis, stenosis, or other fractures 4. There has been a great increase in the popularity of Pilates as a method of exercise and fitness as well as with use in rehabilitation. As a result, there has been an increasing amount of research investigating the effectiveness of Pilates Method exercises with individuals with lower back pain. Many studies have examined the effect of Pilate s exercises versus minimal interventions or no intervention in individuals with lower back pain. They have found that Pilate s

5 exercises show a significant decrease in pain and perceived disability when prescribed to individuals that have lower back pain compared to those that had no intervention 1,2,3,4,5. One study investigated further to find that individuals who underwent a program that included Pilate s equipment exercises, i.e. Reformer, had improved outcomes compared to individuals that had strictly mat exercises 7. They believed that this could be contributed to the complex nature of some of the mat exercises, as well as equipment exercises possibly providing the patients with more stability and more ability to adjust the difficulty of the exercises 7 ; although both groups showed an overall decrease in lower back pain. This shows us that Pilates is an effective means to help clients decrease their low back pain. Although there are promising studies that showed improvement with Pilate s exercises, some studies indicated that although individuals had decreased back pain with Pilate s there was not a significant difference between standard stabilizing exercises and Pilate s exercises 1,2,3,6. However, there are multiple factors that were discovered in these studies that should be noted. It was found that the time frames that the exercise programs were implemented were typically short, 6-8 weeks. This may not be enough time to see significant difference between the two groups,1,2,3. They also noted that there was poor follow through with the patient s home program once the interventions were stopped 2. A study by Notarnicola et al compared Pilate s exercises to no intervention; however, they extended their intervention for 6 months and found a significant decrease in lower back pain 4. It may be necessary for the length of

6 the intervention to be extended in order to allow significant muscle development and create a difference between standard exercises and Pilate s exercises. The studies also indicated that the same standard exercises were prescribed to all the individuals in both groups 1,2. It might be necessary for instructors to adapt the exercises depending on the level and needs of each client, in order to receive an optimal outcome. This is a standard of practice for BASI Pilates as well as many physical therapy practitioners. Adapting the exercises based on the patient s level and needs is beneficial and necessary to decreasing the individual s lower back pain 4. Adapting patient s exercises and extending the treatment or intervention time maybe necessary in order to determine if there is truly a difference between standard exercise and Pilate s exercises. However, it is clear that Pilates does help decrease lower back pain. Golf Swing Analysis Golf is an extremely popular sport, especially among men here in Southern California. Golf is a sport that requires the close coordination of movements in order to produce an optimal swing that will drive the ball in the direction desired and ultimately put the ball in the hole. The Titleist Performance Institute (TPI) is a leading educational organization that is dedicated to the analysis of the movement of the golf swing, and how the body functions in relation to the golf swing. The goal of this paper is not breakdown the swing into the specific mechanics necessary for an optimal swing, but the gross movements required and the major muscles groups that are recruited.

7 The optimal golf swing requires sequencing of the body segments and ultimately the club in order to produce a fluid movement. TPI breaks down the sequence of the golf swing into the Take Away/Backswing Phase, Forward/Down Swing Phase, Acceleration Phase, Early Follow Through Phase, and Late Follow Through Phase 9. The Take Away/Backswing Phase is defined from the moment the club moves and ends at the top of the back swing. Forward Swing Phase begins from the top of the backswing and ends when the club is horizontal to the ground. The Acceleration Phase begins from the point where the club is horizontal to the ground to the point where the club strikes the ball. The Early Follow Through Phase starts at the point where the club contacts the ball and stops when the club is horizontal to the ground in front. Finally, the Late Follow Through Phase starts when the club is horizontal to the ground and ends when the swing is complete. The Phases of the swings have been further broken down to analyze which muscles are key to each part of the swing 9, A table is attached for further information on which muscles are key for each individual phase. However, the general muscles that are identified as important for the golf swing are the

8 Hamstrings, Quads, Gluteus Medius and Maximus, Obliques, Errector Spinae, Serratus Anterior, Pectoralis Major, and Rotator Cuff Musculature 9. Phase Take/Away Backswing Forward Swing Acceleration Early Follow Through Late Follow Through Key Muscles Subscapularis, Serratus Anterior, Upper & Middle Trapezius, Errector Spinae, Oblques, Semimembranosus, Long Head of the Biceps Femoris Rhomoid, Middle Trapezius, Pectoralis Major, Serratus Anterior, Vastus Lateralis, Adductor Magnus, Gluteus Maximus Pectoralis Major, Levator Scapulae, Serratus Anterior, Obliques, Gluteus Max and Medius, Biceps Femoris, and Vastus Lateralis Pectoralis Major, Infraspinatus, Subscapularis, Obliques, Long Head of the Biceps, Vastus Lateralis, and Gluteus Meds Infraspinatus, Pectoralis Major, Subscapularis, Serratus Anterior, Semimembranosus, Vastus Lateralis, Adductor Magnus, and Glute Medius

9 Along with identifying key muscles in each phase of the swing, The TPI has also identified the importance of both stability and mobility in certain body segments. These segments must work together to provide the optimal swing. Stability is required in order to provide a base for the muscles to move around. Mobility is necessary in order to build enough momentum to drive the ball forward. Although it is often over looked, Strength in the areas of the body that is required for stability is equally as important as strength in the areas that are responsible for the movement in the swing, or the mobile body segments. TPI identified the following parts of the body that are needed for stability during the golf swing, knees, lumbar spine, scapula, elbows, and cervical spine while the corresponding areas are mobile; ankle, hips, thoracic spine, glenohumeral joint, and the wrist. Feet/Ankle Knees Hips Lumbar Spine Thoracic Spine Scapula Glenohumeral Joint Elbow Wrist Cervical Spine Mobile Stable Mobile Stable Mobile Stable Mobile Stable Mobile Stable

10 Lower back pain is a common overuse injury in golf. Commonly, overuse injuries are associated with muscle dysfunction, due to weakness or decreased flexibility 8. This weakness decreases the ability of the muscle to provide shock absorption and protection for the joints. Muscle strengthening is an effective way to improve the functioning of the muscles 8. Pilates focuses on both increasing range of motion and increasing stability. Case Study Bob is a 64-year-old male with chronic lower back pain. He had an exacerbation of symptoms about a year ago, after doing some repairs and lifting around the house. He had significant pain with most all motions causing an inability to perform normal daily activities. He saw a physician at that time, where he had an X-ray and MRI, which indicated no significant abnormalities in the lumbar spine. He, however, did not attend physical therapy, and the symptoms mostly resolved. Currently, there is a significant decrease in pain. He does have occasional stiffness in the lower back with walking greater than minutes and after golfing. He golfs once a week and goes to the driving range 1-2 times a week. He will ride his bike about 1-2 times a week; and admits to not going to the gym or doing any type of strengthening for about 6 months. He would like to increase general strength, especially in the core and lower extremities, in order to decrease these symptoms in the lower back and improve his golf game. Bob has decrease range of motion in the lumbar spine and thoracic spine. He has generalized decreased strength due to de-conditioning, especially the abdominals and lumbar spine extensors. Bob would benefit from an overall

11 strengthening Pilates program; emphasizing abdominal and lumbar spine extensor strengthening, scapular stabilization, quad strengthening, hip mobilization and disassociation, thoracic spine mobility, and glenohumeral joint mobility. These areas are key for optimizing his golf swing, which is one of the goals that Bob has for Pilates. The initial goals for the program for Bob were to increase general strength and flexibility. As his strength and coordination improved, emphasis was placed on strengthening of the core, legs, scapula, and lumbar spine, as well as mobility and flexibility in the hips and thoracic spine. The following program was implemented in order to reach these goals, some exercises were adjusted to provide variety between sessions and adjust to time, but the goals and general progression remained the same, see attached chart. Due to Bob s weakness and general deconditioning, some adaptations and modifications were needed initially in order to allow successful execution of the exercises. Session 1-10 Sessions Sessions 21+ Warm Up Footwork Mat: Roll Down, Pelvic curl, spine twist supine- with swiss ball, chest lift Reformer Footwork, Wunda Chair Footwork Abdominal Work Reformer: Hundred Prep, Short Box Series: Round Back, Flat Back, Mat: Leg Changes, Hundred Prep Mat: Roll Down, Pelvic curl, spine twist supine, chest lift, chest lift with rotation, Reformer Footwork Reformer: Coordination, Short Box Series: Tilt, Twist, Hundred Cadillac: Roll Up with Roll Up Bar, Mini roll up, Mini Roll Up Obliques Mat: Roll Down, Roll up, Spine twist supine, double leg stretch, single leg stretch, criss cross, Reformer Footwork, Cadillac Footwork, Reformer: Hundred, Abdominal Legs in Straps & with Rotations, Short Box Series: Round About Cadillac: Roll Up Top Loaded, Breathing with Push Through

12 Hip Work Spinal Articulation Stretches Full Body Integration F/I Arm Work Full Body Integration A/M Leg Work Lateral Flexion/Rotation Reformer: Frog, Up/Down Circles, Openings Reformer: Standing Lunge Reformer: Supine Arm Series, Wunda Chair: Shrugs, Triceps Press Sit Wunda Chair: Hamstring Curl, Leg Press Standing Reformer: Mermaid, Mat: Side Lifts Mat: Roll Up, Leg Circles, Single Leg Stretch, Double Leg Stretch, shoulder bridge prep Reformer: Extended Frog Cadillac: Basic Leg Springs Double Leg Reformer: Bottom Lift Cadillac: Wunda Chair: Pelvic Curl Mat: Spine Stretch Reformer: Side Splint Reformer: Knee Stretch Series, Scooter, Up Stretch 1, Elephant Reformer: Seated Arm Series, Shoulder Press Wunda Chair: Triceps Prone Reformer: Hamstring Curl, Single Leg Skating Wunda Chair: Hip Opener Reformer: Mermaid, Wunda Chair: Side Stretch Mat: Side Kick, Bar Mat: Hundred, hip circles, shoulder bridge, front support, back support Reformer: Supine Hip work All Cadillac: Single Leg Springs Reformer: Bottom lift with extension, short spine Cadillac: Monkey Original Mat: Rolling Reformer: Kneeling Lunge Reformer: Knee Stretch Series, Round Back, Flat Back, Up Stretch 2, Long Stretch, Up Stretch 3 Cadillac: Thigh Stretch with Roll up Bar, Kneeling Cat Stretch Reformer: Kneeling Arm Series, Side Kneeling Series Cadillac: Standing Arm Series Reformer: Balance Control Front, Balance Control Back Prep Reformer: Jumping Series Wunda Chair: Forward Lunge, Backwards Step Down, Frog Front Reformer: Side overs on box Cadillac: Side Lift Wunda Chair: Side Stretch Kneeling Mat: Side Kick Kneeling, Saw

13 Back Extension Reformer: Breaststroke Prep Wunda Chair: Swan Basic Mat: Back Extension Reformer: Pulling Straps 1&2, Mat: Single Leg Kick, Reformer: Breaststroke Mat: Double Leg Kick, Leg Pull Front Bob progressed well through his exercises; however, the exercise was not progressed until the previous exercise had been executed correctly. He had some difficulty with hip disassociation and generalized weakness, especially in the abdominals and back extensors. Conclusion Lower back pain is one of the most common injuries in society, as well as for golfers. It is often associated with poor mechanics during the swing for amateur golfers. This can be caused by both weakness of muscles and decreased range of motion. Pilates has been shown to be an effective way to increase muscle strength and improved mobility. Many studies have shown that it is also effective for decreasing lower back pain. Therefore, Pilates is an effective tool for golfer s to utilize in order to increase their strength and decrease their lower back pain and prevent it from returning in the future, and optimizing their structural mechanics for their golf swing.

14 Bibliography 1. Lim ECW; Poh, RLC; Low AY; Wong WP. Effects of Pilates-Based Exercises on Pain and Disability in Individuals With Persistent Nonspecific Low Back Pain: A Systematic Review With Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2001; 41(2): Miyamoto GC; Costa LOP; Cabral CMN; Efficacy of the Pilates method for pain and disability in patients with chronic nonspecific low back pain: a systematic review with meta-analysis. Brazilian Journal of Physical Therapy; 2013; 17(6): Posadzki P, Lizis P, Hagner-Derengowska M, Pilates for low back pain: A systematic review. Complementary Therapies in Clinical Practice. 2011; 17: Notarnicola A, Fischetti F, Maccagnano G, Comes R, Tafuri S, Moretti B. Daily Pilates exercise or inactivity for patients with low back pain: a clinical prospective observational study. European Journal of Physical and Rehabilitation Medicine. 2014; 50: Rydeard R, Leger A, Smith D. Pilates-Based Therapeutic Exercise: Effect on Subjects With Nonspecific Chronic Low Back Pain and Functional Disability: A Randomized Controlled Trail. Journal of Orthopaedic & Sports Physical Therpay. 2006; 36(7): Wajswelner H, Metcalf B, Bennel K. Clinical Pilates Versus General Exercise for Chronic Low Back Pain: Randomized Trial. Medicine & Science in Sports & Exercise. 2012; 44(7): da Luz Jr AM, Costa LOP, Fuhro FF, Manzoni ACT, Oliveira NTB, Cabral CMN. Effectiveness of Mat Pilates or Equipment- Based Pilates Exercises in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial. Physical Therapy 2014; 94(5): Donatelli, Robert and Dimond, Donn. Muscle Imbalances and Common Overuse Injuries in Golf Titleist Performance Institute- TPI Certified Golf Fitness Instructor Course Manual. Images: 1. Back Pain: 2. Golf Swing Figures: 3. Anatomical Figures: