PILATES CONDITIONING FOR PATHOLOGY OF THE INTERVETEBRAL DISK Ashlee Tinken August 12, 2017 Comprehensive Apparatus Program Pilates Denver June 2015
ABSTRACT The pathology of the intervertebral disk is classified in the terms herniation, protrusion, prolapse and extrusion, with respective levels of severity. The focus of this paper is the onset of this condition of disk pathology, known as herniation, and how a BASI Pilates conditioning program will aid in decreasing the likelihood of worsening severity and pain without surgical intervention. A disk herniation is characterized by a change in the shape of the annulus of the disk which causes it to bulge beyond its normal perimeter, causing pain that may seem sudden, but is usually the result of a gradual process. Disk herniation, tissue fluid stasis, diskogenic pain, and swelling from inflammation are conditions that may result from prolonged flexion postures, repetitive flexion micro trauma, or traumatic flexion injuries. ( Kisner, Therapuetic Exercise 412) With sustained flexed postures in the spine, the disks, facet joints and ligaments (inert structures) are placed under sustained loading which increases the vulnerability of these structural components to injury and inflammation. The muscles of our spine and trunk work to support these structures to keep harmony and balance within the body. The deeper, intrinsic muscles of the trunk and spine, which have segmental attachments to the vertebra, work to provide dynamic support to individual segments of the spine, and maintain each segment in a stable position so the inert tissues and structures are not stressed. Studies have shown the the deep fibers of the multifidi and transverse abdominis are the first muscles to become active when there is postural disturbance from rapid extremity movements (Kisner 387) Strengthening of these deep intrinsic core stabilizers such as the transverse abdominis, multifidus and deep rotators of the spine as well as the global stabilizers such as the rectus abdominus, internal/ exernal obliques, illiopsoas and erector spinae are the focus of this BASI pilates conditioning program. By strengthening and stabilizing the spine, and balancing the strength and elasticity that cross the joints, we can correct faulty posture and help to prevent injury from undue loading of the spinal segments and maintain the role of shock absorption of the spinal disks. 1
TABLE OF CONTENTS Abstract 1 Anatomical Description 3 Visual Diagrams 4 Etiology of Symptoms 5 Case Study 6 Basi Conditioning Program 7-8 Conclusion 9 Works Cited 10 2
ANATOMICAL DESCRIPTION The intervertebral disk consists of an annulus fibrosus and nucleus pulposus. The annulus fibrosus is the outer portion of the disk and is made up of collagen fibers and fibrocartilage. The annulus encloses the nucleus, providing a mechanism for dissipating compressive forces and provide tensile strength to the disk with respect to motions of the spine. The nucleus pulposus is located in the center of the disk and is a gelatinous mass with a great affinity for water. This fluid provides transport for nutrients and aids to maintain tissue health within the disk. With sustained flexion of the spine, the nucleus of the disk becomes distorted toward the posterolateral corner, which is termed a posterior herniation or posterior protrusion of the nucleus pulposus of the disk which is the most common condition usually seen in the lower lumbar vertebra which sustains the most weight loading of the spine. 3
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ETIOLOGY OF SYMPTOMS Not all disk protrusions are symptomatic, symptoms are variable depending on the extent of pathology and direction of protrusion as well as the spinal level this takes place. Commonly pain and neurological symptoms arise due to inflammation and pressure of a swollen disk and tissues which can affect the spinal cord and or nerve root. Pain may radiate in a corresponding dermatomal pattern, most commonly presented as Sciatica or radiating pain into the hamstrings on one side of the body with associated muscle weakness. This presentation correlates with the subject of the case study, who suffers a L4/L5 posterolateral disk hernation. Pain is described as severe midback pain which spreads across the back and into the left buttocks and posterior thigh. 5
CASE STUDY Subject: DJ, caucasion male, age 37. Occupation: Occupational Therapy Assistant. Symptoms: Pain in midback pain which spreads across the back and into the left buttocks and posterior thigh. Symptoms are aggravated in a sitting position, so standing and supine positions are preferred. Symptoms are slightly alleviated with extension of the spine. Postural Assessment: Postural deviations noted include forward head, rounded shoulders and posterior tuck of the pelvic causing a decrease in the curvature of the lumbar spine. Focus of the BASI Pilates conditioning program focus on correcting these postural deviations by strengthening the transverse abdominis, back extensors and hip flexors as well as stretching the hamstrings and pectoral muscles. Focus of this program is to reduce further flexion of the spine and concentrate on exercises that bias towards extension or flat back positions. 6
BASI CONDITIONING PROGRAM Warm Up -Chest lift on step barrel. In this position, the lumbar vertebra are supported, creating the least load on the spinal disks while strengthening abdominals. -Single leg lifts/ leg changes: strengthening transverse abdominis and hip flexors. -Leg Circles After 10 sessions, warm up is progressed to include: -Hamstring Pull 1, 2 and 3: increases muscular endurance, deep abdominal control, stretches hamstrings and strengthens hip flexors. Foot Work Parallel Heels, Parallel Toes, V position toes, open v heels, open v toes, calf raises, prances, single leg heel, single leg toes. All footwork is beneficial, yet emphasis is placed on footwork on the tower to promote hamstring stretch. Footwork on the wunda chair is avoided to prevent flair up of pain due to increased pain in sitting position. Reformer footwork focuses emphasis on pelvic stability and deep core stabilization. Abdominal Work Hundred prep, Hundred, Coordination, Double leg/ Double leg with rotation, Flat back (from short box series) Hip Work Single leg supine series: Frog, Down Circles, Up Circles, Hip extension, Bicycle/ reverse. This series focuses on strengthening while lengthening hamstrings as well as detecting and correcting imbalances in the body and specifically the pelvic region. Spinal Articulation The Spinal articulation block is avoided due to the contraindication of lumbar flexion in this program and spinal pathology. Stretches Standing Lunge on Reformer: Stretches hamstrings and hip flexors while focusing on strength of back extensors and TrA. Gluteals, Hamstrings, Adductors, Hip flexors on Ladder Barrel. Shoulder stretch 2 on Ladder Barrel: Stretches pectorals 7
Full Body Integration Elephant, Up Stretch 1, Thigh stretch with Roll up Bar, Down stretch. Elephant and Up stretch 1 focus on stretching hamstrings and shoulders while strengthening back extensors, abdominals and scapular stabilizers. Thigh stretch strengthens the abdominals, back extensors and quadriceps. Arm Work Supine Arm series on reformer: Strengthens abdominals and challenges hip flexors while holding legs in table top with dynamic upper extremity movements. Leg Work Gluteal Sidelying Series : Strengthens Gluetus medius to stabilize pelvic/ lumbar region. Lateral Flexion/ Rotation Corkscrew on Step Barrel Side lift on mat Side over prep on ladder barrel Back extension Prone 1 and 2 on tower Swan Basic on Wunda Chair Swan on Floor on Wunda Chair Back extension Single Arm on Wunda Chair Back extension is the block where the most exercises will be performed due to the nature of the pathology and alleviation of symptoms/ correction of postural deviations to reduce further degree of pathology to disk and protrusion. 8
CONCLUSION This program was implemented for 8 weeks, 3 days a week, with an at home exercise program consisting of fundamental mat exercises and stretches to complement the in studio conditioning program. The emphasis of this program was strengthening the deep abdominals, increasing lower back extensor strength and strengthening hip flexors to reduce strain on low back. The subject of this study experienced a noticeable improvement in postural control, hamstring length and reduction of symptoms with this program. 9
WORK CITED Isacowitz, Rael. Study guide: Comprehensive Course. Costa Mesa, California: Body Arts and Science International, 2013. Isacowitz, Rael. Study guide: Reformer. Costa Mesa, California: Body Arts and Science International, 2013. Kisner, Carolyn. Therapuetic Exercise: Foundations and Techniques. 2002. Herniated Disk. Mayo Clinic, Mayo Foundation for Medical Education and Research, 23 Nov. 2016, www.mayoclinic.org/diseases-conditions/herniated-disk/home/ovc-20271246. 10