Creating Strength and Stability From the Lumbar Through the Scapular Regions, In Order To Prevent Injury During Heavy Lifting In the Work Place

Creating Strength and Stability From the Lumbar Through the Scapular Regions, In Order To Prevent Injury During Heavy Lifting In the Work Place Ellen Kraska July 29, 2012 2012 Flow Studios, Chicago, IL 1

ABSTRACT In order to protect the lower back and shoulders from injury during heavy lifting in the work environment, many aspects of movement must be considered. The position of the body, the speed of movement, and engagement of the correct muscles are all critical to a safe lift. Learning, through Pilates, to engage the abdominals, control the breath, maintain scapular stabilization and strengthen the back and leg muscles will all transition to the work place in order to preserve a healthy back and shoulders while lifting heavy objects. 2

TABLE OF CONTENTS 1. Title Page 2. Abstract 3. Table of Contents 4. Diagrams of Muscles Studied 5. Case Study a. Introduction to Topic of Case Study b. In Depth look at the Muscles Being Targeted and Why c. Introduction to Subject of Case Study d. Mat Program i. Exercises ii. Why the exercises were chosen e. Reformer Program i. Exercises ii. Why the exercises were chosen f. Testimonial g. Posture Before and After Pictures h. Lifting after Pilates Conditioning and Strengthening Pictures i. Conclusion 6. Bibliography 3

When developing a program to strengthen the back while lifting heavy objects I specifically looked at the erector spinae (Diagram A) as well as the abdominals (Diagram C), and then moved sequentially up and down the body to produce stability in the entire region. Moving down from the erector spinae, strengthen the hip flexors, gluteus maximus, quadriceps, and hamstrings (Diagram D) all help to stabilize and strengthen the body creating a strong base to lift from. Moving up from the erector spinae, strengthening the Latissimus dorsi, the Trapezius, and the Deltoids (Diagram B) strengthen the upper body bringing strength to the lift rather than relying on only the lower back muscles to lift the weight. Finally, strengthening the rotator cuff muscles (Diagram E) and pectorals (Diagram F) plays a crucial role in stabilizing the shoulders during heavy lifting. The Movement and power of the lift come from the hip flexors, gluteus maximus, quadriceps, hamstrings (Diagram D) as well as the biceps and triceps (Diagram F). A. B. C. D. E. F. 4

A. (The vertebral column and Spinal Cord, 1997) B. (Are you experiencing Back Muscle Pain?, 2012) C. (Medicalook.com, 2012) D. (Arthur's clip art index, 2010) E. (Center, 2011) F. (Netter Medical Images, 2012) Many work environments call for heavy lifting on a daily basis. Firemen, construction workers, movers, factory workers and emergency medical technicians are asked to lift and carry various heavy objects daily just to name a few. Without the proper body mechanics, lifting these heavy objects bring with them the hazard of causing acute or chronic injury to the back and shoulders with each lift. Acute back injuries are the most common injuries resulting from heavy lifting with pain coming on suddenly and lasting no longer than 6 weeks. (Hand Out on Back Pain, 2012) Acute rotator cuff injuries occur from lifting heavy objects, while chronic tears come from lifting above shoulder height. (Charles Thigpen, 2012) Strengthening and increasing stability in the back, abdomen, legs and shoulders will greatly decrease the likelihood of injuring oneself while lifting in the work environment, and in everyday life. To build a strong back one must have an equal amount of strength, flexibility, and endurance training which can be found in the Pilates repertoire. (Vijay Vad, 2004). The first step to beginning a proper lift is centering ones thoughts and focusing ones breathing which then allows the mental focus and breath to be brought to the muscles being recruited for the lift. Relying on the breath and taking breaks to reset the breath will decrease fatigue throughout the lifting, reducing the chance of injuring the back. (Vijay Vad, 2004) Once breathing and mental focus are established and controlled proper lifting techniques must be looked at. When lifting and carrying a heavy object, lift with your knees and tighten your core muscles. Hold the object close to your body and lift it between your legs. Maintain the natural curve of your back. If an object is too heavy to lift safely, find someone to help you. (Staff, 2011). Lifting with your legs and gluteus muscles provides a solid foundation for your spine. You should always bend your knees when lifting heavy objects so you have a solid foundation for your spine. You should keep your trunk vertical when bending down and lifting something. A horizontal trunk can put pressure on the lower back amounting to hundreds of extra pounds. This pressure can eventually compromise a disc or sprain or strain a back muscle. Get close to what you are lifting. It decreases the pressure on your spine. Try to start with the center of the weight no more than 8 inches from your body, then lift the object with a straight back using your leg and buttock muscles. These are simple principles that will help you minimize injury to your back when lifting. (Lifting Techniques, 2009)When you do lift, remember not to: Twist while lifting, lift with one hand, lift while reaching or stretching, and lift from an uncomfortable posture, fight to recover a dropped object or hold your breath while lifting. (Wise, 2007). When these lifting techniques are known we can then look further into the body mechanics to see which muscles are recruited in stabilizing the back and shoulders and which muscles are recruited to use as the force behind the lift in order to avoid injury. First we must look strengthening the back muscles in order to use them as stabilizers throughout the lift. We will look at the muscles starting from the deepest to the most superficial. The deepest muscles include the intertransverse (stabilizing these prevents side bending), interspinalis, and 5

the transversospinalis which consists of the rotatores, multifidus and semispinalis (stabilizing these muscles ensures the spine stays extended and does not round forward during the lift). The Psoas major (stabilized to straighten the spine), the Quadratus lumborum (stabilized to avoid side bending), the levator ani and coccygeus (both strengthened to stabilize the rotation of the sacrum backward) are also to be considered here. Next we must consider the sacrospinalis muscles or erector spinae. Bending, stretching forward and lifting at the same time will injure these muscles, so strengthening and stabilizing these muscles in preparation for heavy lifting is vital. (Blakey, 2007) This group is made up of the iliocostalis (made up of the iliocostalis cervicis, iliocostalis thoracis, and iliocostalis lumborum), the longissimus (made up of the longissimus capitis, longissimus cervicis, and longissimus thoracis), and the spinalis (made up of semispinalis capitis, spinalis capitis, and spinalis thoracis) which all need to be strengthened to avoid side bending, rotation, and strengthen extension of the spine. Next, the levator scapulae must be strengthened to stabilize the scapula and the serratus must be strengthened to stabilize the ribs and aid in inspiration and expiration during a heavy lift. The Rhomboids must be strengthened to stabilize the vertebrae laterally, the latissimus dorsi is strengthened to stabilize the structure of the trunk, and the trapezius is strengthened to stabilize the neck and shoulders. (Calais-Germain, 2007) Moving to the anterior side of the body, the abdominal muscles must be strengthened and conditioned to stabilize with as much emphasis as the posterior muscles in order to create a balance in the body and one firm trunk to work from rather than an overdeveloped back and underdeveloped core. Here we see the transverse abdominis (strengthened to create a stable core and therefore stable trunk, helps in stabilizing the spine by avoiding trunk flexion when controlled), the internal oblique and external oblique (strengthened to prevent side bending or rotation of the trunk and spine during a lift) and the rectus abdominis (strengthened to avoid trunk flexion and to engage so as to protect the back muscles from being engaged during a lift) (Calais-Germain, 2007) Next we must look at the shoulder region to identify the muscles to strengthen and stabilize the upper girdle during a heavy lift. These muscles can be broken into two groups; the scapulathoracic and the scapula-humeral. The scapula-thoracic shoulder is bones which mobilize the scapula and clavicle in respect to the thorax. These muscles include the subclavius (strengthened to stabilize the clavicle depression), pectoralis minor (strengthened to stabilize the scapula downward and forward), sternocleidomastoid (strengthened to assist in inspiration), levator scapulae (strengthened to stabilize the elevation and downward rotation of the scapula), rhomboids (strengthened to stabilize the adduction and downward rotation of the scapula), trapezius (strengthened to stabilize the scapula as well as the adduction, elevation, depression, and upward rotation of the scapula). The scapula-humeral shoulder is bones which mobilize the humerus in respect to the scapula. The muscles include the coracobrachialis (strengthened to flex and adduct the arm), the biceps brachii (strengthened to flex, abduct and adduct the arm), the triceps brachii (strengthened to adduct arm), the pectoralis major (strengthened to stabilize the arm in adduction and medial rotation), the latissimus dorsi (strengthened to stabilize the 6

extension, adduction, and medial rotation of the arm), the tres major (strengthened to stabilize the extension, adduction, and medial rotation of the arm), and the deltoid (strengthened to stabilize flexion, medial rotation, abduction, and extension of the arm)along with these muscles the rotator cuff muscles of the shoulder joint must be strengthened and stabilized during heavy lifting to avoid tears. These four muscles are the supraspinatus (strengthened to stabilize abduction of the arm and keeps the arm from being dislocated upward), the infraspinatus (strengthened to stabilize lateral rotation and abduction of the arm and keeps the arm from dislocating forward), the tres minor (strengthened to stabilize lateral rotation of the arm and keeps the arm from dislocating forward), and the subscapularis (strengthened to stabilize medial rotation of the arm and keeps the arm from gliding backward) (Calais-Germain, 2007) Finally we must move down from the trunk into the hips and legs. These are very important muscles to strengthen and condition as both stabilizers and as movers and power when performing heavy lifts. The hip muscles are the bridge from the trunk to the legs, making them very important muscles. They must carry the weight of the object being lifted, act as shock absorbers for the back from the pressure of the weight on the spine, and pass the momentum from the legs to the trunk for the lift to occur. These muscles include the piriformis (strengthened to stabilize the lateral rotation, abduction, and flexion of the femur as well as the extension and medial rotation of the pelvis), the quadrratus femoris (strengthened to stabilize the lateral rotation of the thigh and the extension and medial rotation of the pelvis), the obturator internus (strengthened to stabilize the lateral rotation flexion and abduction of the thigh as well as extension and medial flexion/rotation of the pelvis), the obturator externus (strengthened to stabilize the lateral rotation, flexion, and abduction of the femur as well as flexion/medial rotation of the pelvis), the gemellus (strengthened to reinforce the obturator internus), the psoas major (strengthened stabilize flexion, adduction and lateral rotation of the hip), the iliacus (strengthened to stabilize flexion of the hip and pelvis), gluteus minimus (strengthened to stabilize abduction, flexion, and medial rotation of the thigh as well as flexion, lateral flexion/rotation of the pelvis), gluteus mediums ( strengthened to stabilize abduction flexion and extension of the hip as well as flexion and extension of the pelvis). (Calais-Germain, 2007) The power for the lift comes from this final set of muscles which work on the hip and knee. This muscle group includes the quadriceps femoris- made up of the vastus intermedius, the vastus lateralis medialis, and the rectus femoris (these muscles are strengthened, being the strongest muscle in the body, to extend the knee and flex the hip and create power for the lift taking the weight off the back muscles and joints), the Sartorius (strengthened to stabilize lateral rotation and abduction of the femur), the hamstring made up of the semitendinosus, the semimembranosus, and the biceps femoris (strengthened to extend the thigh and flex the knee providing power for the lift), the adductors- made up of the pectineus, the adductor brevis, the adductor longus, the adductor magnus, and the gracilis ( these muscles are strengthened to stabilize adduction of the hip), the tensor fasciae latae (strengthened to stabilize abduction flexion and medial rotation of the thigh as well as flexion and lateral flexion/rotation of the 7

pelvis), gluteus maximus (strengthened to provide power for the lift and stabilize hip extension), the popliteus (strengthened to stabilize flexion of the knee), and the gastrocnemius (strengthened to combined with the hamstring to provide power in extending the knee for the lift). (Calais- Germain, 2007) The individual muscles to recruit and the way in which to recruit them for a heavy lift are only the beginning tools to a safe lift. The next step is to strengthen and condition the muscles which will be needed. I developed a Pilates program for an EMT (emergency medical technician), Ian Spindler, age 29, who was experiencing consistent lower back pain, joint pain, poor posture, and a 10 yr. old reoccurring shoulder blade muscle tear. He was concerned because 1 in 4 EMS workers will suffer a career ending back injury within the first 4 years of service, almost 1 in 2 workers sustain back injury while performing EMS duties, and lifting 450 lbs. patients is now a common daily operation. (Spindler, 2012) Ian had not done any Pilates in the past, was worried about his 25 extra pounds, and I was limited to only the reformer and mat at my gym in town when I put together a program for him. He was eager to learn anything to mitigate injury from lifting at work, and so I created two separate programs for him, both a complete mat program and a complete reformer program. I saw benefits in both programs for him such as the mat work focusing so greatly on back extension, trunk stability and strength while the reformer incorporated stabilizing the shoulders and using the quads and hamstrings and hip flexors more than the mat program allowed for. We started with a mat class twice a week and a reformer class once a week for two weeks, then switched to a mat class once a week and a reformer class twice a week for four weeks. Ellen developed a Pilates workout to strengthen my core while assisting my back and shoulders. We initially started with a mat routine to focus on posture. During my first week with Pilates it was odd and difficult; I associated Pilates with women in 80 s leotards and puffy socks. After years of poor posture I became exhausted just rolling my shoulders back. The only way to describe my flexibility is to say it was nonexistent. We focused on basic core exercises, some minor flexibility, and posture. Starting with a 45 minute routine it was helpful to get my body in shape. I found myself focusing on posture while driving the ambulance and sitting in my office chair. I did not notice the pain in the shoulder or back begin to lessen. Ellen assured me if I was patient and continued to work the pain would slowly go away. Starting in with my gym workouts and continuing with Pilates I noticed the pain would go away slightly at times. My pain would come back after short periods of being pain free. However I was gaining some flexibility, Pilate s positions were coming easier to me, and I thought most importantly I was losing about 2-3 pounds a week. Pilates still was the most exhausting thing for me and extremely difficult to hold abdominal exercises for any period of time. My belly fat was getting in the way of some of the exercises however I enjoyed the focus it gave me at the gym. I was paying more attention to correct form and movement; in turn this would help prevent injury at work. (Spindler, 2012) 8

His mat program was as follows: Warm Up: Pelvic Curl, Supine Twist Supine, Chest Lift, Chest Lift w/ Rotation, Leg Lifts/ Leg Changes, Leg Circles (These exercises were all chosen to warm up the abdomen and spine as well as help to condition the breathing pattern and the engagement of the abdominal muscles needed and build up the ability to sustain this abdominal support throughout a heavy lift and condition the body into pelvic stability) Abdominal Section: Hundred Prep, Roll Up, Hundred, Double Leg Stretch, Single Leg Stretch, Criss Cross (These exercises were chosen to strengthen the abdominals and condition the body into trunk stability. As the legs move the in these exercises the abdominals pelvis and spine are forced to find a way to stabilize the body so no movement occurs in the trunk, this will lead to a better understanding of how to stabilize the trunk before engaging a heavy lift so the abdominals are tight and the back muscles are stable.) Hip Extension- Bridging 1: A Pelvic Curl is then done to reinforce the conditioning of the spinal articulation and brings the benefit of hamstring control with it needed as the driving force in a heavy lift. Supine Spinal Articulation: Rolling like a ball, Sitting Spinal Articulation: Spine Stretch (These two exercises were chosen to strengthen and condition the abdominal and back extensors-in the spine stretch, providing further trunk stabilization condition as well as shoulder stabilization from the rolling like a ball and a hamstring stretch from the spine stretch. All of these will be beneficial when determining ones limits in trying to lift a heavy object. Once again the spinal articulation was reinforced with a Pelvic Curl. Sitting Stretches: Saw, Supine Rotation: Spine Twist, Corkscrew (added in after a few classes), and Lateral Flexion/ Rotation: Side Kick (These exercises were added to focus on control of the body and muscles rather than strength. The Saw and Spine Twist work on back extensor and abdominal oblique control both critical when lifting a heavy object so they are not over extended and pulled. The corkscrew works on abdominal strength and hip flexor control both need to engaged so as to take the pressure off the back muscles and joints. The Side Kick works on trunk stabilization, hip flexor control/stretch and hip extensor control/stretch. This exercise is a powerful one for avoiding injury during heavy lifting! The trunk must be stabilized throughout the movement and the hip flexors and extensors are creating the movement.) Back Extension: Back Extension, Single Leg Kick, Full Body Integration: Cat Stretch, Swimming, (This is a very important group for preventing injury during heavy lifting. These exercises strengthen the back extensor, which will provide a strong, stable back for the lift. Without back extensor strength the heavy weight will pull the back and entire trunk towards it instead of the back staying straight and the legs and arms moving the weight towards it. Swimming is especially important in this group as it strengthens the back extensors, as well as conditions trunk stability and shoulder flexor control and hip extensor control. This is an exercise that conditions the entire lifting muscle region and was included in every one of our sessions.) We ended with rest position to stretch the lumbar spine and a roll down to evaluate the postural progress of the session. The reformer program I made for him was meant to complement the mat program so as the two went hand in hand and filled in any missing gaps the other may have in its repertoire. I was experiencing pain in my shoulders which was a combination of poor lifting technique with certain muscles gaining strength more than the others as well as not warming up properly at the 9

gym. Ellie started to develop exercises to warm up, cool down, stretch, and strengthen my shoulders. I took 3 weeks to focus on shoulders and back strengthening and stretching. This helped tremendously, along with shortening my movements during heavy lifting, I was able to get back and I felt like my shoulders and back were able to keep up during my lifting. The techniques Ellen was teaching me were becoming a focus while lifting, as well as a large part of my warm up and cool down. I was able to get my shoulders, arms, and back warmed up before strength training. Following training I would cool down with a few more Pilate s exercises as well as work my abdominals with Pilates three days a week. It was the first time I have begun to see definition in my abdominals in 9 years. While watching several members of the gym have asked Ellen about how Pilates can help with their shoulder problems. I have a newfound confidence in Pilates to help prevent injury. (Spindler, 2012) The reformer workout I put together for Ian was basic, because he had never been on a reformer, but it was very effective because he was very willing to learn. Warm Up: Bottom Lift (Pelvic Curl), Spine Twist Supine, Chest Lift, Chest Lift with Rotation (These exercises are all chosen to warm up the abdominals, spine and pelvis while conditioning a breathing pattern and engagement of the abdominals for the extent of the lift.) Foot Work: Parallel Toes, V Position Toes, Open V Heels, Open V Toes, Calf Raises, Prances, Prehensile, Single Leg Heel, and Single Leg Toes (These are all chosen because they work on quads and hamstring in a way the mat cannot work on. They warm up the legs while developing hip extensor strength and ankle plantar strength from the toe positions. This is important in leg strength and stability and well as hip flexor strength in the movement of the lift.) Abdominal Work: Hundred Prep, and Hundred-added once abdominal strength was present. (These are great exercises for preparing for a heavy lift because they work on abdominal strength needed to engage the core before and throughout the lift, pelvic lumbar stabilization so the lower back is stabilized during the lift and shoulder flexor/ extensor control so during the lift the shoulders are controlled and stabilized avoiding tears in the muscles. They also have a set breathing pattern which forces awareness to the breath as is needed during a heavy lift.) Hip Work: Frog, Down Circles, Up Circles (These exercises both work on pelvic lumbar stability hip adductor strength, both important when stabilizing the body before and during the lift. The frog adds knee extensor control work useful for gaining momentum in the lift, while the circles strengthen the hamstrings and hip extensor control both needed to power the lift itself.) Spinal Articulation: Bottom Lift (this exercise condition the movement to initiate from the hamstrings which is needed for the movement of the heavy lifting). Stretches: Standing Lunge (this exercise was chosen to stretch the hip flexors and hamstrings so they do not shorten and over tighten) Arm Work: Extension, Adduction, Triceps, Biceps, and Rhomboids, Hug a Tree (These were all chosen to condition scapular stabilization and improve shoulder strength and trunk stabilization. This will help avoid tears to the shoulder muscles during lifts and protect the shoulder joint. They also work on arm strength which is needed during the lift.) Lateral Flexion/ Rotation: Mermaid (This was chosen to work on scapular stabilization, latissimus dorsi, deltoids, and mobility of the spine. Controlling all these is important during a heavy lift.) Back Extension: We moved to the mat to do Back Extension and Swimming (These were chosen to strengthen the 10

back extensors and once again swimming also conditions trunk stability and shoulder flexor control and hip extensor control.) I ended his program with a roll down to evaluate the progress of his posture. I have become much stronger and have found Pilates to be an invaluable tool to help strengthen and stretch the muscles, joints, and ligaments. Mentally I find myself continuing to focus on core strength and form, how much I lift has become an afterthought. However, my strength has exploded and I attribute Pilates to keeping my shoulders and back strong enough to maintain my progress. My joints are significantly less painful. Focusing on core strength has virtually eliminated my lower back pain. The pain in my shoulder blade is no longer constant and hurts only a few hours each week. I have an increased focus while lifting patients at work and have new tools to assist new EMT hires in showing them lifting techniques. If I am able to continue with Pilates I believe I will be able to stave off typical EMS injuries. On my first year on the job I was told I would have to accept painful joints, a bad back, and bad knees later in life. Hopefully using Pilates along with a proper diet and exercise routine will make me the exception in an EMS career. (Spindler, 2012) Posture Before Posture After Lifting after pilates strengthening and conditioning: 11

The case study I conducted on Ian, the EMT, was very beneficial to both him and me. I gained a deeper understanding of the muscles, their functions, the need to strengthen or simply condition them into the proper behavior pattern for distinct clients, in this case one looking to stabilize and strength to prevent injury during heavy lifting. Combing through the individual exercises and their objectives not only in the short term but for a specific goal greatly helped me to grasp the depth each individual exercise can have and the many different ways it can be applied to everyday life. I was also given the chance to focus on a part of the repertoire gaining a better grasp of it each time I met with him as he gained control over the exercises as well. During the six weeks we met with 18 classes, 8 being mat classes and 10 being reformer classes, Ian s posture improved not only during Pilates but during his everyday life. His joint pains and lower back pain were diminished due to better posture and an improved heavy lifting pattern. He learned to engage his breath, focus mentally, and recruit the proper muscles for movement and stabilization before and during his lifting. AS he progresses in Pilates, his stabilization will improve and his strength will improve lessening the chance of injury more and more. 12

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Wise, A. (2007, Dec). Avoiding Back Injuries at Work. Retrieved from http://voices.yahoo.com/avoiding-back-injuries-work-747427.html 14