Pilates for Chronic Low Back Pain Julianne Bettencourt March 23, 2015 Course Year: 2014 Integrated Fitness, Visalia, CA
Abstract Low back pain is an injury that affects thousands of people every day and has a significant impact on our daily lives and ability to function. It often leads to chronic pain resulting in further injuries to other parts of the body due to compensation. It is extremely important to strengthen our trunks in order to stabilize our spine for more efficient movement of our extremities. With the incorporation of a Pilates program into a persons weekly routine it is possible to significantly decrease pain, improve strength and stability, as well as, improve a persons quality of life. 2
Table of Contents: Anatomical Description...4 Introduction...6 Case Study...7 Conditioning Program...8 Conclusion...10 Works Cited...12 3
Anatomical Description: The lower back region is medically referred to as the lumbar spine and is located below the ribcage immediately after the thoracic spine. It is comprised of 5 large lumbar vertebrae and 5 intervertebral discs. At each level of the spine there is a spinal nerve root that corresponds to that spinal level and exits the foraminal space bilaterally. These nerves branch off to supply each of our lower extremities with sensory and motor capabilities. The low back ends where the lumbar spine meets the sacrum, which is a part of our pelvis. It is very common for people to refer to low back pain as a general area and often includes both the lumbar region as well as the sacrum/sacroiliac region. The sacroiliac region can often cause dysfunction that mimics lumbar pain due to the close relationship of the two. In addition, to the boney structure the lower back is also comprised of several ligaments and muscles that contribute to the stability of the spine and our ability to function as humans in an upright posture. The anterior trunk musculature consists of the transverse abdominus, internal 4
obliques, external obliques, rectus abdominis and to some extent the psoas can also play a role in spinal stability due to its origin on the lumbar spine. The posterior trunk musculature primarily consists of the multifidus, quadratus lumborum, and the collective group of erector spinae. However, the latissimus dorsi, glutes and pelvic floor also contribute to the stabilization of the lumbar spine and pelvis. Therefore, it is important to also consider these muscles key when training. 5
Introduction: The lower back is one of the most commonly injured regions of the body. "Low back pain represents the most common cause of disability in persons under 45 years of age" (Rydeard). It is also estimated that 60-80% of adults will be affected by low back pain at some point in their lifetime (Lim). The back is essentially the powerhouse of our bodies that enables us to function upright and perform our daily routines. When referencing low back pain, many people refer to a weakness of the "core" that contributes to the injury. Often individuals become injured at the vertebrae and disc level resulting in instability of the spine and/or neurological impairments. We then must rely on our musculature to maintain the integrity of our spines. We can break down our trunk into three layers the deep layer, middle layer and outer layer. The deep layer consists of the vertebrae, discs and ligaments responsible for relaying information to our nervous system so we know where our joints are in space. The middle layer has four key muscles the mulifidus, quadratus lumborum, transversus abdominis and psoas and provides the majority of the stability to our lower backs and are key to all daily activities in order to reduce risk of injury. The outer layer is made up of the erector spinae, external obliques, internal obliques and rectus abdominis and these provide us the ability to move and perform our dynamic activities such as bending, lifting, sports, etc (Jemmett). Often chronic low back injuries occur due to poor body mechanics and muscle imbalances that have been ongoing for several years. Research has shown that pain also inhibits muscle recruitment, which can then result in altered neuromuscular control. With the high incidence of low back pain in our society there is constant research being done to determine how to best treat these individuals because it ultimately has an effect on how they are able to function in their daily lives. 6
Unlike when somebody injuries their knee, foot, hand, etc they are still able to function fairly well with their normal routine, but when a person has injured their back it makes it increasingly more difficult to maintain static positions against gravity such as sitting or standing. Studies have shown various physical therapy modalities, techniques and therapeutic exercises have a positive impact on resolving low back pain. However, until recently few research studies have been done on the effects of Pilates in treating low back pain. With reports showing that between 30-40% of individuals never recover from acute low back pain and develop chronic pain it is becoming more important to find a way for these individuals to strengthen their bodies in a way that they can continue with for their lifetime despite their age (Lim). Pilates is a great tool and program due to the versatility there is to adapt and modify exercises to fit individual needs of people. The equipment also allows for decreasing the stresses on joints if needed and has been shown for years to be practiced by people of all ages young to old. The focus Pilates places on awareness, balance, breath, concentration, center, control and precision are key elements that most people forget about and quit doing during their adolescent years as they grow and adapt to their bodies leading to the weaknesses and impairments they develop from years of poor control and imbalances from not being aware of how they are moving. It is also important to take a look at how these individuals move above and below the source of pain and address those areas as well because the low back pain could also be due to compensation. Case Study: Client is a 29 year old female named *Aubrey (name has been changed due to client request). She is a fairly active individual, but recently has not been working out very often 7
and has had increased low back pain. She has had chronic low back pain for several years that seems to become worse when she is not consistently working out. Aubrey has had prior short stints with Pilates and noticed improvement in her back pain. Currently, she has been having increased low back pain with prolonged standing, repetitive bending and prolonged sitting without good lumbar support. She states that she has always had very tight hamstrings with inability to touch her toes for the majority of her teenage/adult years. Within the last 2-3 years she has also noticed increased hip tightness limiting her ability to sit Indian style. She has had 2-3 rehabilitation treatments from her physical therapist to mobilize her hip with active stretches to perform at home. Her primary goal is to increase her trunk stability and increase hip mobility. The following conditioning program was selected based on the availability of equipment and the client's goals with the purpose of improving hip and pelvis disassociation with good lumbar spine stability while also increasing hip mobility and hamstring length. Conditioning program: Started with a Roll Down to get the body moving and as the instructor get a feel for how the client moves. Client has slight difficulty maintaining a lengthened spine due to over recruitment of lumbar paraspinals. Also, limited mobility due to very tight hamstrings. I utilized the reformer, chair and step barrel for the remainder of the program due to availability of equipment within my studio. Warm up: Chest lift, chest lift with rotation, pelvic curl and supine spine twist. Excellent way to warm up the abdominals and loosen up the joints in preparation for the remainder of the visit. 8
Footwork: Done on the reformer to work on abdominal control, pelvic stability and hip/pelvis disassociation. Completed parallel heels, parallel toes, V- position toes, open V- position heels, open V- position toes and prances. Abdominal work: Hundred prep, hundred and coordination done on the reformer to further engage abdominals and stabilize lumbar spine while moving the extremities. Hip work: Supine leg series on reformer. Frog to work the hip external rotators and aid in increasing rotation ROM. Hip circles down and up to further work on hip rotator work, pelvic stability and also allows for a nice hamstring stretch. Openings also are great for hip mobility and strengthening to stabilize the lumbar spine. I did not incorporate extended frog or extended frog reverse at this point due to clients limitations with hip mobility. Spinal articulation: Utilized the chair for pelvic curls to further challenge the hip extensors and to mobilize the spine with good abdominal control. As clients spinal mobility and hamstring length improve I would change this exercise out for the short spine on the reformer to increase the challenge. Leg work: (Moved this block to flow better during the session) Hip opener on the chair again focuses on improving hip mobility and strength while maintaining good pelvic stability. Stretches: Shoulder stretch side lying on step barrel to mobilize the T/S and decrease strain on lower back. Lateral flexion and rotation: (Moved this block to flow better during the session since already on the step barrel) Side lift on the step barrel allows for excellent abdominal oblique work. 9
Full Body Integration: Up stretch 1, 2 and long stretch on the reformer. Excellent for working on hip/pelvis disassociation and allows for a wonderful hamstring stretch. Initially need to start client with slightly flexed knees in order to perform exercise with good form and without increased stress placed on lumbar spine. As the hamstrings stretch out can work on extending knees a little bit more each time until in full knee extension. Arm Work: Kneeling arms series on the reformer, chest expansion, up circles, down circles, triceps and biceps. Provides increased challenge for trunk stability in an upright position against gravity. In addition, it allows for an active hip flexor stretch with engagement of hip extensors in order to better maintain good upright stability. Back extension: Pulling straps 1 & 2 on the reformer in order to allow client to better engage abdominals in a lengthened position against gravity while majority of trunk is still stabilized. Also challenges hip extensor strength and control and allows hip flexors to be in a lengthened position. Conclusion: Aubrey has demonstrated significant gains in only a few sessions along with home hip stretches and supplemental mat exercises in order to continue and gain hamstring length, abdominal strength and control, as well as, spinal mobility. She has great abdominal control and awareness, which has contributed to decreased back pain. However, her pain and symptoms have been her best as she has slowly increased her hamstring length and hip mobility. She notices a significant difference when she is more consistent with her home hip stretches. An unexpected result the client has also noticed is that she has improved ankle stability and no longer has back pain when wearing 2-3 inch heels, which client attributes to footwork on the reformer. Overall, incorporating Pilates into her weekly 10
routine has benefited her and reduced her lower back pain. Client is to continue and supplement her Pilates sessions with daily hip stretches at home and a few mat work exercises she can do on her own to further improve her strength, stability and endurance for the future. Pilates sessions will be progressed to include more chair and Cadillac work in order to further challenge clients ability to stabilize spine against gravity and not just in supported positions. 11
Works Cited: Jemmett R. (2007). Spinal Stabilization: The new science of back pain. Canada: Libris Hubris Publishing. Lim EC, Poh RL, 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. J Orthop Sports Phys Ther. 2011 Feb:41(2):70-80. 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 trial. J Orthop Sports Phys Ther. 2006 Jul;36(7):472-84. Photos http://www.precisionhealth.com.au/services/pain- management/conditions- treated/spinal- conditions/sciatica http://www.pro- tecathletics.com/59057/back- Pain.html http://pixgood.com/lower- back- muscles- diagram- pain.html http://imgbuddy.com/trunk- muscles.asp http://www.elc- jedu.com/knowing- deeper- about- lumbar- spine- anatomy- 2/ 12