KYPHOSIS/ DOWAGER S HUMP: A CASE STUDY IN SPONTANEOUS SPINAL CURVATURE Debra Rapoport June 4, 2014 Basi Teacher Training Brooklyn, NY
TABLE OF CONTENTS Abstract...1 Kyphotic Postural Analysis...2 A Case Study...4 Susan s Program...7 Conclusion...10 Bibliography...11 i
ABSTRACT Susan is a 36-year-old stay-at-home mom to three kids. She has been fairly active throughout her life, yet now finds herself in chronic back pain. In childhood, her spine spontaneous fractured in a single thoracic vertebrae. The frontal collapse of these vertebrae caused Susan to acquire a condition known as Kyphosis or Dowager s hump. Kyphosis is a forward head and forward rounding of the upper back posture. This rounding is often called hunchback. Because the condition was most often occurring in older woman, the term Dowager s Hump became a term for Kyphosis. The word Dowager means elderly or older woman. Kyphosis is often age-related due to weakened spinal bones. However, poor postural alignment and genetic or congenital deformities can cause the condition to present in much younger people, such as in Susan s case. As her condition has worsened, she has incorporated Pilates into her lifestyle and this study will reveal the findings of her condition and progress. For Susan s condition, we have developed a short term and long- term plan. Incrementally, assessing her abilities and progress to be sure we are on target. 1
Kyphotic Postural Analysis An intervertebral collapse occurs at the disc and causes a loss of normal height. The collapse in the spine does not always produce symptoms, however, compression on a nerve root or spinal cord, may produce pain. 2
Kyphosis will continue to as the hump begins to worsen with ages. Characteristics of a Kyphotic posture are: head forward, hyperextended cervical spine, abducted (protracted) scapula, increased flexion in thoracic spine. Areas of focus: thoracic extension, lumbar flexion, upper back extensors and scapular stabilization. Areas to strengthen: hamstrings, glutes, obliques and abdominals. Areas in need of stretching, hip flexors, rectus femoris, pecs and lower back. Possible modifications when doing Pilates, pads under head when supine, knees slightly bent during seated work. 3
A Case Study Susan Smith, 36, Kyphosis (Dowager s hump). Susan Smith has a 65 degree curve in her thoracic spinal column. Susan s Kyphosis appeared in early adolescence and was described as spontaneous fracture due to a damaged bone in a single vertebrae. Her spinal column is un-diseased, however she is now suffering from her pain in the upper back and sometimes her lower back. Susan s pain has been exacerbated by pregnancies and daily activities of caring for her three children. Susan s day consists of constant movement and she has a habit of bending from the spine instead of her waist. Susan has not been doing any specific exercises aside from walking the dog. Her kyphosis has become a source of chronic musculoskeletal pain in her thoracic spine, tension headaches and occasionally she experiences shortness of breath. Medical Diagnosis: Susan s Doctor has diagnosed her through x-ray as mildly kyphotic, and has determined that her condition is congenital. Because her condition is mild, Susan s doctor believes that through specific therapeutic exercise and strengthening the muscles of the spine, she will experience greater functionality in her daily activities. Limitations Determining the status of Susan s postural mechanics is essential to prescribe an effective exercise routine. Her limitations and challenges must be taken into account in terms of posture and biomechanics, and structure and balance. 4
Posture and Biomechanics: Susan s gross postural distortion makes it critical for the design of exercise progressions to reflect her limited ability to safely load the musculoskeletal system to minimize negative consequences. During movement, her abnormal posture alters the weight bearing effect. We have designed movements, which balance her restricted spinal mobility. Attention to postural alignment and articulation of the spine are paramount in creating the lengthening. We will achieve this with an emphasis on extension exercises. Structure and Balance In order to improve posture and optimize sagittal balance, we must take into consideration Susan s forward head posture and how it creates a distortion of the torso s ability to bear loads. We can enlist the gravitational pull of the springs. Conditioning Program Susan had done Pilates in a group reformer format in the past. When she came to me, she had made the decision to begin private sessions. She wanted a program designed to target her specific needs and issues with regard to her kyphosis and chronic pain. With her previous experience doing Pilates, a conditioning program will be easier to implement. Our short term goal is to get Susan acclimated to using her spine and controlling her muscles consciously. We will help her to move through flexion and extension. This is an important step in her plan to achieve balance in her body. Our mid-term goals and long-term goals are to have Susan strong in her spine and torso. With consistent workouts and her commitment to achieving these goals, our hope is to maintain a pain free daily existence. We will intensify each exercise when she has 5
reached her personal best. We will assess her plume line after 2 months and analyze her range of motion. This will give us a clear picture of our long term plan. Her program will be formatted to lay the foundation of exercise critical for recovery and rehabilitation. For each exercise in the program, we will utilize the components of the Basi block system, specifically, muscle focus and objectives. Susan must begin to make changes in her movement patterns to develop balance and symmetry in her body. An important conditioning program sequence will be using several Pilates apparatus including reformer, ladder barrel and Wunda chair. The reformer will provide stability, mobility and breath control. The ladder barrel will be an essential apparatus we will use to stretch Susan s spine. The Wunda chair, adds another component to the work, necessary for her trunk stabilization. In addition, range of motion, multi-dimensional and multi-planar exercises will be included with attention to muscle focus and control within each movement. One of the most important tools in teaching Susan in her recovery and conditioning, and a staple in the Basi system, is imagery. Susan must begin to make neuromuscular connections. She will be taught to lengthen her spine and support herself through specific words and phrases. Research strategies have proven as an effective tool for motor learning. Developing the mind-body connection is the key to her success. Susan will do a comprehensive, private, Pilates exercise routine three times a week for 45 minutes. Three separate routines will be developed. Each will include: Basi Block series, groups, and stand alone exercises. 6
SUSAN S PROGRAM Basi Block Warm- up 1: Exercise: Pelvic curl Muscle Focus: Abdominal and hamstring Objective: Spinal articulation, hamstring control, pelvic-lumbar stabilization 2: Exercise: Leg Lift/ Changes Muscle Focus: Abdominal Objective: Hip Disassociation, pelvic-lumbar stabilization Basi Block 1: Exercise: Footwork: Parallel Heels, Parallel Toes, V position Toes, Open V Heels, Open V Toes, Calf raises, Prances, Prehensile, Single leg heel and toes Muscle Focus: Hamstrings and quadriceps Objective: Hip extensor strength, and knee extensor strength 2: Exercise: Abdominal work; Short Box series: Flat back Muscle Focus: Abdominal and back extensors Objective: Abdominal strength, trunk stabilization 3: Exercise: Abdominal work; Short Box series: Tilt Muscle Focus: Abdominal with oblique emphasis Objective: Abdominal oblique control and abdominal oblique stretch 7
4: Exercise: Hip Work - Circles Down, Circles up Muscle Focus: Hip Adductor and Hamstrings Objective: Hip adductor strength, Hip extensor control, Pelvic lumbar stabilization. 5: Exercise: Hip Work Openings Muscle Focus: Hip adductor Objective: Hip Adductor stretch and strength, Pelvic lumbar stabilization. AFTER 2 Months and 10 sessions: 1: Exercise: Spinal Articulation: Bottom Lift with extension Muscle Focus: Abdominals and hamstrings Objective: Spinal articulation and hip extensor control Stretches A: Exercise: Ladder Barrel- Shoulder Stretch 1 Muscle Focus: Shoulder Extensors Objective: Shoulder extensor strength B: Exercise: Ladder Barrel- Hamstrings Muscle Focus: Hamstring Objective: Hamstrings AFTER 2 Months and 10 sessions Exercise: 1: Exercise: Full Body Integration Flat Back (knee stretch series) Muscle Focus: Abdominals and back extensors 8
Objective: Trunk stabilization, Shoulder stabilization, Hip and Knee Extensor control strength (depending on resistance) 2: Exercise: Arms Sitting Series: Chest expansion, Biceps, Rhomboids, Hug-a tree, Salute Muscle Focus: Latissimus dorsi, Pectoral major, biceps, posterior deltoid, triceps Objective: Trunk stabilization is the key to all of these exercises, along with Shoulder extensor, adductor and abductor, elbow extensor and flexor strength, and scapular adductor strength 3: Exercise: Wunda Chair Triceps Prone Muscle Focus: Triceps Objective: Elbow extensor strength, Trunk stabilization, Scapular stabilization 4: Exercise: Wunda Chair Triceps Prone Muscle Focus: Triceps Objective: Elbow extensor strength, Trunk stabilization, Scapular stabilization 9
Conclusion This comprehensive, full-body program designed for improving Susan s form, alignment, balance, and muscle recruitment all of which focused on her specific issues relation to her Kyphosis, aka Dowager s hump. The warm-up was designed to have Susan move through spinal articulation while stretching her hamstrings. The Hip Disassociation allows her to maintain a neutral pelvis and engage her abdominals. These warm-up exercises serve as a bridge between her upper and lower body. During her block work, we focus on Thoracic extension, lumbar flexion, upper back extensors and scapular stabilization. Because she has such a significant postural deviation, we need to focus on creating alignment while strengthening and stretching the upper trunk area. In addition, during hip work we are focused on stretching, lengthening and strengthening the hamstring and hip flexors. The final two stretches provide essential positions for maximum benefit for Susan s two critical areas. All these movement patterns target the areas we need to strengthen and stretch with relation to the Kyphosis. The complexity of this exercise regime will lead to long-term rehabilitation and overall well- being. Susan has already experienced less fatigue and pain since starting this routine two months ago. After the first 10 sessions, Susan progressed from the fundamental level. We have added full body integration, and spinal articulation to our layering of the block system. We expect her progress will continue within our long- term plan. 10
Bibliography BASI Pilates. Study Guide Comprehensive Course, (Body Arts and Science International, 2000-2012). Briggs, Andrew; van Dieen, Jaap H; Wrigley, Tim V; Grieg, Alison M; et al. Thoracic Kyphosis Affects Spinal Loads and Trunk Muscle Force. Physical Therapy 87.5 (May 2007) 595-607. J. Ricker Polsdorfer, MD. Kyphosis The Gale Encyclopedia of Medicine.Ed. Laurie. Fundukian. 4 th Ed. Detroit: Gale, 2011. 6Vol. Ryan SD, Fried LP. The Impact of Kyphosis on Daily Functioning. J AM Geriatric Soc. 1997;45: 1479-1486 http://www.ideafit.com/fitness-library/corrective-exercisescoming-full-circle-new http://www.webmd.com http://www.kyphosis.com http://www.pilatesinteractive.com 11
12