PILATESANDADHESIVEARACHNOIDITIS:

SlowRecoveryandStrengtheningExercisesthroughDailyPilates,GentleMovementandanAnti-inflammatoryDiet

BYHOLLYGRUVERSTUDIO27

Bryanston,SouthAfricaSeptember2017

ABSTRACTThispaperaddressesthebenefitsofadailyregimenofBASIPilatestogetherwithananti-inflammatory diet on the long-term reduction of drug dependence for visceral painmanagementduetoneuropathicdisease.After studyingballet, contemporary, jazzdanceandpracticingPilates forover25years inDallas Texas (BFA Honors, Southern Methodist University, Dallas, Texas), New York City(MarthaGrahamSchoolofContemporaryDance),Chicago(viaHubbardStreetJazzDanceandGus Giordano), Minneapolis Minnesota (Ballet Arts MN) and Europe (various EnsemblePerformances and Pineapple Dance Studios), I became Pilates-certified in Johannesburg(separatelythroughTri-FocusandthenlaterandmorecomprehensivelythroughBASI)whileliving in South Africa. Teaching and choreographing dance along with studying bodymechanics andPilates havemore recently occupiedmy timeover thepast several years,whilstraisingandhomeschooling4children.UponcompletionofmysecondcertificationwithBASI,itbecamecleartomethatphysicalfitnessexecutedinacareful,mindful,andcustomizedmannercanreduceneuropathicpain,andimprovestrength,rangeofmotion,andflexibility.Thisapproachalsoaidsinfunctionalmovementpatternsfor life.Evidencedfromresearchandstudy,ananti-inflammatorydietandintentionaldeepbreathingexercisesareessentialtolivingatourbest,mostoptimallevelofhealth. MytraininginthePerformingArts,practiceofPilatesasadancer,studyoftheuniqueprinciplesoftheBASIPilatesblocksystem,andapproachtobreathingandfunctionalmovement, combined with the study of physiology and anatomy, have allowed for aframeworktoaddressandsuccessfullytreatmyhusband’ssevereneuropathicdiseasecalled“AdhesiveArachnoiditis”.Adisorderofthecentralnervoussystem,AdhesiveArachnoiditispresentsverysimilarlytoMS, and often results in muscle atrophy, numbness and debilitating, intractable pain,especially in the legs, feet and hands. It is clear from my study that a carefully, andstrategicallydesignedPilatesregimenisasuperiorchoiceofexerciseforthosesufferingfromAdhesiveArachnoiditis(AA).Thefollowingprotocolwasdesignedinordertosafelyaddressa client with advanced stages of neuropathic pain. The protocol emphasizes supportivestrengthtraining,flexibility,balance,coordination,andfunctionalmovement,combinedwithananti-inflammatorydietandprayer,meditation,andintentionalrest.JosephPilateswasquotedassaying,“Changehappensthroughmovementandmovementheals.”7ThisstatementhasproventobequitetrueoverthepastyearswhiletreatingW Gruver. However, to be specific, I found that not all movement heals. For instance,excessive running, pounding, jarring exercises, cross-fit, rough contact sports, and otheractivitiesthatarecommonlyregardedashealthful,arenotefficaciousforthetreatmentofneuropathicchronicpain.Aregular,disciplined,personalizedPilatesprogramishelpfulinthisregard.It is important that a patient be evaluated individually by a health care provider prior tobeginninganynewconditioningprogram.

TABLEOFCONTENTS

1. Thesis

2. AdhesiveArachnoiditis(AA)–BackgroundonaDebilitatingDisease

3. CaseStudyofPatientwithAA

4. ABASIPilatesConditioningProgramtoAddressPatientwithSevereAA

5. Conclusion,Outlook

6. ReferencesandResources

THESISWhenoneexperiencesdaily,extreme,intractablechronicpain,itcanbedifficulttoevengetoutofbedorhavehopeforthefuture,letaloneregularlyexercise.Thisarticledemonstratesthat even when suffering from debilitating neuropathic pain, a strategically focused anddesignedPilatesregimenthatispracticeddaily,combinedwithamodifieddiet,cangreatlyimprovestrengthandreducesymptomsofdisease.Thisapproachcansignificantly reducepainanddepression,aswellasmedicinedependence.ItcandrasticallyincreasethequalityoflifeinpatientswithneuropathicdiseasessuchasAdhesiveArachnoiditis(“AA”),solongasthepatientlimitsmoretraditionalorpopularphysicalactivities.“Daily,fromsunrisetosunset,theradio,newspapersandmagazinesbroadcasttotheworldhowtomaintainhealth,howtoregainhealth...theconflictinginformation,expressiveofthedifferentopinionsof these varioushealth authorities, hasproved tobenothing less thanconfusion...”--JosephPilates7

ADHESIVEARACHNOIDITIS:ATRULYDEBILITATING,INTRACTABLE,“INCURABLE”DISEASEAdhesive Arachnoiditis (“AA”) is a “chronic, insidious condition that causes debilitating,intractablepainandarangeofotherneurologicalproblems.”7AAisregardedasrarebythemedicalcommunity,butDr.CharlesBurtonreportedasearlyas1978thatAAis"commoninpatientswithseverebackand/orlegpainandfunctionalimpairmentduetothefailedbacksurgery syndrome."AA is the thirdmostcommoncauseofFailedBackSurgerySyndrome(FBSS), after stenosis and recurrent disc problems. AA was previously the second mostcommoncause.Thiswas largelyduetotheadverseeffectsofoil-basedmyelography.Theincidencehasdecreased,but ahighproportionof casesof clinically significantAA isnowfoundtobeduetotheadverseeffectsofthecommonuseofepiduralsteroidssuchasDepo-Medrol(Depo-Medrone).14Thedura(exterior)andthearachnoid(interior)aretwoofthethreemembranesthatcoverand protect the brain, spinal chord and nerve roots. The acute inflammation of thesemembranes issaidto leadtothisdisease.“Thearachnoidcontainsthecerebrospinal fluidwhich circulates from the brain to the sacral area, about every two hours; it filters anyinvasion andusually responds first by inflammation and followswith a chronic stage life-lastingphasecharacterizedbyscarringandfibrosis.”5HowdoesArachnoiditisdifferfromAdhesiveArachnoiditis?ManypeopleknowaboutArachnoiditis,asthisisasomewhatcommonconditionthatcauseslowerbackand legpain.TheAdhesiveelementofArachnoiditis isdescribedasaresultofnerves becoming stuck or adhered together at the point of injury, causing inflammationwithinthespinalcolumnwhichthenprohibitstheflowofneuralmessagingandfullfunctionofnerveroots.Thisnewnervelininginthespine,commoninastage3caseofAA,cancauseneurologicaldeficitsandseverechronicneuropathicpainintheaffectedarea.AAisachronicandprogressivediseasethatpresentsinavarietyofwaysovertime.AdvancedAAsuchasstage3isknowntobeincurableandintractable,andvictimsoftenareforcedtostayimmobileinbed,onlyabletostandforshortperiodsoftime.Mostsufferersexperiencemoderate, temporary relief fromhigh level doses of prescription opiates, depression andneuropathicpainmedications,thoughtheside-effectsareoftennearlyasundesirableasthepainitself.The difference between Arachnoiditis and Adhesive Arachnoiditis (“AA”) is similar to thedifference between a candle and a conflagration. Both a candle and conflagration areessentiallyfire,butthelevelofheat,intensity,anddestructionarequitedifferent.Acandlelitdinner represents fire as a peaceful, manageable friend that can be reasoned with. Aconflagrationrepresentsfireasanenemyandsomethingquiteoutofourcurrentabilitytocontrol.AA,especiallywhenitpresentsasaflairup,islocatedonwhatneurologistsconsiderthefarendoftheArachnoiditisspectrum.AAcancarrythepossibilityofalifetimeofagonywhileArachnoiditistypicallydoesnot.FromDr.CharlesBurton,M.D.,TheBurtonReport:“Conflagrationsareusuallydisastersinreallife. When the natural accommodative processes of the human nervous system fail andAdhesive Arachnoiditis becomes symptomatic it can then be a true disaster for theindividual.Thereasonforthisisthattheagony(worsethanpain)producedisconstantand

unrelenting. Sufferers are not even given the blessing of relief by a shortened lifeexpectancy.”14Today there are thousands of AA sufferers, victims of botched surgeries and epiduralprocedureswhoareoldandfrail.Therearealsomanyvictimswhoshouldbeenjoyingtheprimeoftheiryouth.Thesepeopleexperiencedaily,intractablepainonadifferentleveltothatofmostotherchronicpainsufferersandoftenfeelalone,depressed,misunderstood,andhelpless.Eventhoughthisconditionisrelativelyrare,victimsofseverechronicpainsuchasAAneedsupportandcareandinnovativetherapiesinordertoonedaylivelivesthataremeaningfulandactiveagain.

ThispaperwillnowdiscussapatientwithAAandhowhewassuccessfullytreatedusingtheBasiPilatesblocksystem.

CASESTUDYINADHESIVEARACHNOIDITIS“Patienceandpersistencearevitalqualitiesintheultimatesuccessfulaccomplishmentofanyworthwhileendeavor.”--JosephPilates7InitialInjuryin2011After severalweeksofattendingcross fit classes inDallasTexas,WGruverexperiencedaruptureddiskandprotrusionintohisL4/L5in2011whilstonabusinesstriptoEuropeandAfrica. In the fall of 2011, aftermuch lower back and leg pain, and under the care of aneurologistinDallas,WGruverhadanMRIthatconfirmedthistearandprotrusion.Overthenext3years,WGruverunderwent regular chiropracticandphysio therapy,massage,andbattlefieldacupuncturetotreatmusclespasmsandchronicpaininthelowertailboneareaandrightleg.EmergencySurgeryin2015InMarchof2015,WGruverhadanotherMRIwhich showed that theprotrusionon L4/L5hadcalcifiedandlodgedintotheS1tosuchadegree that theS1wasnotvisibleanymoreontheMRI.Dr.AManarajatFourway’sLifeHospital recommended an immediate,emergency laminectomy and discectomy toremove these 2 disc fragments. Dr. A.M.warnedWGruverthatbyremovalofthesefragments,therewasa“10%risk”thathisdurawouldtearduetotheimbeddedcalcificationsthatoccurredfromwaitingtoolongtoaddresshischronicpain.Indeed,on24April,2015,WGruver’sdurawaspiercedduringsurgeryandacerebrospinalfluidleakwasobserved.ItwasalsoobservedthattheduraneartheL4/L5wasveryweakfrombeingbrokendownbythediskfragments.Priortostitchingtheincisionsitebackup,thepieceswereremovedandgluewasappliedtotheholesleftintheduralining.2MonthsinHospitalFor 30 days the CSF leak persisted, despite 2 separate epidural “blood patches” beingperformed.EachbloodpatchconsistedofWGruver’sbloodbeingdrawnfromhisarm,andthenmixedwithglueandinjecteddirectlythroughanepidurallineintohisspinalchord.Whilepainwasreducedfor5-6dayseachtime,andpressurefromhisCSFleakrestoredtonormaltemporarily,neitherpatchresolvedtheleak.SymptomsofsevereheadacheskeptWGruverin a prostrate position, in bed, without the ability to use a pillow. He was forced to layperfectly flatduetothepressureonhisbrainfromtheCSF leak.As long-termpermanentneurological problems can develop quickly if not treated successfully, W Gruver and hisdoctorsdecidedtotryabovinepericardiumpatchnext.MajorDuraRepairSurgeryOnMay22,2015,DrA.ManarajatFourway’sLifeHospitalperformeda“bovinepericardium”patchprocedure,usingtissuederivedfromsurgicalgradecowheart,glue,andstitches.ThisprocedurewassuccessfulinstoppingtheCSFleak.However,thetraumaandfurtherinjurytoWGruver’snervefibersinhisspinalchord,combinedwith6additionalepiduralcortisolandpainprocedureslikelyresultedinwhathasbecomeanadvanced,debilitatingcaseofAdhesiveArachnoiditis.Thus,aftermanyyearsofbodyimbalance,overuse,weakness,andinjury,thevariousoperationsandrelatedprocedurescausedthedevelopmentofAA.

MRIimagingimmediatelyafterhisoperations,aswellasa12and18monthrepeatimage,confirmed the presence of the neuropathic disease Adhesive Arachnoiditis, as seen thefollowing photos of Gruver’s lumbar spine. This diagnosis was confirmed by numerousneurosurgeonsinSouthAfricaandtheUSA.

WGruverAAevidenceinLumbarMRIAConclusiveDiagnosisfromtheExpertsintheUSAUponatriptotheUSAformedicaltreatmentandadvice,aRadiologicReviewbyDr.CharesV.Burton,M.D. inNovember2016was received.This reportwas the6thMRIassessmentperformed by a Neurosurgeon since 2011 when the initial injury took place. One of theworld’sforemostexpertsonthiscondition,Dr.Burton’sassessmentwastypicaloftheothers.“AnMRIofthelumbarspinefromFourway’sLifeHospitalinSouthAfricadatedApril12,2016was reviewed with Mr. Gruver and his wife, Holly. This study demonstrates lumbardegenerativediscdiseaseinvolvingthelastthreelumbarlevelswithassociatedlossoflumbarlordosisandmultilevelfacetdisease.TherearepostoperativechangesatL4-5.Thereareverymildscalpedendplatedeformitiesthroughoutthelumbarspine.Thereisnormalcaudaequinaat theupper lumbarareasdemonstratingclumpingofnerverootsandclassic lumbosacralAdhesiveArachnoiditisinthelumbosacralarea.”(MedicalReport,CharlesBurton,November2016)

WGruverMRIAAlocation-TopViewMuchlikeotherswithchronicpain,thepatient’smedicalcaregiversputhimonheavydosesof Lyrica, Celebrex,Oxycotin, depressionmedications, andothers, in order to address hissymptoms.Butduringhisdetailedphysicalreviewin2016,Dr.Burton informedWGruverthat his body’s ability to produce endorphins and his overall health were being slowlydestroyedbyhisdependenceuponpainmedications.Thus,NeurosurgeonsintheUSAwhospecializeinthetreatmentofAAencouragedWGruverto wean himself from the heavy opiates he had been on for over 12 months. Thesemedicationshadoftenlefthiminastateofmaniaandequalamountsofpain,providingverylittlereliefatall.InadditiontoweaningWGruveroffofallpainreliefmedications,WGruveradoptedananti-inflammatory diet, and a full, daily regimen of Pilates using the BASI approach. Thesignificanceofunderstanding thebleakprognosis forWGruver’sconditionunderlines thepositiveimpactthePilatesprotocoldescribedhereinhashadinhealingandeliminatingmanyofthesymptomsofAApreviouslylisted.Infact,thisprotocolwassoeffective,theriskyandcontroversialSpinalChordStimulatorsurgeryisnolongerinpursuitalongwiththeresearchintostemcelltherapyforreliefandpossiblehealing.Is Pilates the new trend? Is Pilates in fact the best means for shaping and toning,strengthening,andtotalbodybalancewhenfacedwithneuropathicchronicpain?Atleastinthe Case Study that follows, the consistent practice of Pilates has effectively served torehabilitateWGruver,making his lifemoremanageable for functional living as originallyintended by Joseph Pilates in 1912. J Pilates, who originally called his methodology“Contrology”,oncewrote, “Pilatesdevelops thebodyuniformly, correctswrongpostures,restores physical vitality, invigorates the mind, and elevates the spirit”. 7 From personalexperience and from significant research, I agree with this philosophy and have foundtremendous,positiveresultsthroughworkinthisfield.

CaseStudySummaryandNextStepsIn summary, after the patient developed a Herniated disc which calcified and becamedisplaced, pinching his L4-L5 nerve in 2011, he underwent a discectomy which wascomplicatedby a postoperative spinal fluid leak in 2015. Thiswas followedby a nearly 2monthstayinaSouthAfricanprivatehospitalduringwhichtwounsuccessfulbloodpatcheswereattempted.Thenasecond,majoroperativeproceduretorepairthedamageddurawassuccessful in stopping the CSF leak. Unfortunately, these surgical interventions andprocedures resulted in a deteriorating and progressively painful and debilitating state ofconstantnervepaindownhisrightleg,24hourperdaymusclespasms,depression,muscleatrophy,andintractablepain.Thenextsectionreviewstheholistic,customizedapproachdevelopedtoaddressWGruver’sspecifichealthcrisis.Inordertocopewiththeongoingandadditionalpainanddiscomfortduringthisweaningperiod,theconditioningprogramthatfollowswasdesignedtoaddressthepatient’s:

• Breathing• FlexibilityandStretching• Anti-inflammatoryDiet• StrengthConditionthroughaBASIPilatesApproach• StaminaandCardiovascularCondition

Itisnotablethatthepatientwas100%teachableandopentodailyaccountabilityandthatotherthantheprogramdescribedbelow,thepatientrestedandwasprostrateonthecouchorinbedmostoftheday,atleastuntilaboutmid-year.Ifhehadtogotoameetingorrunanerrand,thepatienthadadrivermostdaysandlaiddowninthebackseatenroutetoeachappointment.Thisdemonstratesboththelevelofpainheexperiencedandalsohisdedicationtorestandtoadjustinghislifestyleduringhistraining.Aswithothersexperiencingadvancedstagesofneuropathicpain,WGruver’sbodydidnot“want”towork,stretch,move,orevenstand for thatmatter. Eachexerciseneeded tobemodified at first, to accommodate thepatient’sconstraints.In thenext sectionwewill lookatWGruver’sconditionand theuniquebeneficialeffectsPilateshashadrelatedtohelpingtorehabilitatehimandaidhiminthefunctionallivingheisexperiencingtoday.

APILATESBASEDREHHABILITATION,STRENGTHENING&CONDITIONINGPROGRAM“Amanisasyoungashisspinalcolumn.”--JosephPilates7InJanuaryof2017,WGruvercouldnotdrivemorethan10minutesinthecar,couldnotsleepmore than 30 minutes without waking from severe muscle spasms, was forced to limitstandingorsittingtounder5minutesatatime,andsufferedfromconstantandseverepain.WGruverwasforcedtoworklayingdownandmostofhisdayswerespentintheprostratepositioninordertominimizepainandspasms.His intractablepainwascausingsignificantmuscleatrophy,particularlyinthelegs,specificallytherightgastrocnemius.Noamountofmedicine helped to reduce the pain. The medicines he was taking in 2016 had causedsignificantmemory loss, sexual anddigestivedis-function, temperature sensitivity,weightgain, and extreme lethargy. The USA-based doctorsrecommended cutting these medications out andpreparing for a major SCS implant surgery. Due tofollowingthebelowprotocol,thisSCSsurgeryisnolongerneeded.W Gruver’s primary pain presents as sharp, stabbingneural-paindownhisrightlegfromhissacrumthroughthedistalinsertionofthesoleus.Thisoftengivesthepatientalimp, lazy foot,atrophied legmuscles,andforceshimtolayflatforhoursatatimeduringtheday.IntroductionStrengthandConditioningthroughtheBASIPilatesBlockSystemInanerawhencross-fit,mixedmartialarts,ultra-marathons,multi-daystagedraces,roughcontactsports,aggressivemountainbiking,mountaineering,rockclimbing,andheavyweighttrainingarecommonlyregardedasnotonlyhealthful,butinmanywaystheidealorpinnacleofathleticism, Ihavefoundthistonotnecessarilybethecaseatall.Modernpeoplehavebeencoaxedforthepastfewdecadestogetoffthecouchandengageingrouporindividualfitnessactivities.Formanypeopletheirfitnessplansareinitiatedinordertoaccommodatetheirprocessedandfattyfoodfoodintake,fitintotheirclothingbetter,andavoiddisease.Forothers,theirathleticregimenhasbeeninitiatedinordertoensuretheylivealong,vibrantlife. However, due to lack of education and the vain desire for quick results and self-glorification,manypeoplehaveunknowinglyveeredintoextremeactivitiesthatoftenresultin injuryandchronicpain.Cross-fit forexample,extremelypopularonaglobal level,maystrengthenmusclegroups,butthisisoftenattheexpenseofthespinalchord,knees,hips,andeven thenervous system.Spinalhealth isa concern for thosewhoparticipate inanytimed,competitive,groupfitnessenvironment(likeCross-fit)thatinvolvedheavyweights.Inthese formats,commonto fitnessclubsofanykindandnot justcross fit, therearemanyparticipantsofallagesandconditioningbackgroundsusinganearlyone-size-fits-allapproach–whichinvariablyendsformanyininjury.“Goodform”isoftentalkedaboutalotinthesesettings,butpropertechniqueissomethingthatisextremelydifficulttoregulateorcontrolunlessinaone-on-oneenvironmentorwithaninstructorwhoisveryattentive.JosephPilatesoncewrotethat,“Afewwell-designedmovements,properlyperformedinabalanced sequence, areworth hours of doing sloppy calisthenics or forced contortion.” 7Indeed,ifathleticismandahealthy,vitallifestyleisonethatoptimallypromotesthestrength

ofallsoftandhardtissueswithinthebody,andanyinjuryispresentintheparticipant,thenPilates-based,smallgrouporone-on-oneclassesthatfocusonfunctionalmovement,formandbreath,areeasilythemostadvantageous.Pilatesperformedinthismannerpromotestruehealthfulnessandathleticismthatcangothedistance,generateenergyandvitality,andengenderthepeaceandstaminarequiredtobeproductiveandactiveinourmodernworld.ThoughhewasrelativelyfitandcertainlynostrangertoPilates,WGruverbegandailyPilatespracticeinJanuaryof2017.AllotherexerciseswerereducedandinJune2017eliminated.JosephPilateswrotethat,“Youwillfeelbetterintensessions,lookbetterintwentysessions,andhaveacompletelynewbody in thirtysessions.”7Thiswasdefinitely thecasewithWGruver,thoughthereductionoreliminationofotheractivitiessuchasdriving,sittingforlongperiods, and exercises such as running,weight training, andmountain biking reduced hisflare-ups,andhelpedtosethimonajourneytowardrehabilitationaswell.Thus,thereareseveralthingsthatwebuiltintoWGruver’sfitnessplaninorderaddresstheaboveconditions:ConditioningProgramOverview:

1) Introduction2) FocusedBreathingforOptimalHealth3) HipROMandDynamic,NeuropathicStretching4) Anti-InflammatoryDiet5) PhysicalConditioningProgramInspiredbyBASIPilates

FocusedBreathingforOptimalHealth:“Beforeanyrealbenefitcanbederivedfromphysicalexercises,onemustfirstlearnhowtobreathproperly.Ourverylifedependsonit.”--JosephPilates7WGruverhaslongbeenashallowbreather,fasttalkingman,completelyunawareofhispoorbreathing habits. Constantly yawning due to poor air circulation, W Gruver first beganworkingdeliberatelyonaPilates-inspiredapproachtobreathingandbeganworkingonthisaroundtheclock,evenuponwakingatnight.Wefoundthatproperbreathingissomethingthat must be learned, and goes along with correct posture and is fundamental to painreduction.Thedailypracticeofnasalinhalationandoralexhalationpromotedunderstandingof core engagement as well.We have practicedmany hours of conscious diaphragmaticlateralbreathingwhilemindfullycontractingandreleasingthepelvicfloor.MygoalwastohelpWGruver find the awareness to control all three points of the Pelvic Floor so as tospecificallysupporthismultifidus,actingasa“hug-brace”forhisLumbarspine.InanewstudyfromtopmedicalresearchersatNorthwesternUniversityinChicago,Illinois,breathing in through the nose is shown to enable one to remember an object theyencounteredmuchmoreeffectivelythanwhilebreathingoutorinhalingthroughthemouth.“Oneofthemajorfindingsofthestudyisthatthereisadramaticdifferenceinbrainactivityintheamygdalaandhippocampusduringinhalationcomparedwith exhalation,” said lead author Christina Zelano, assistantprofessor of neurology at Northwestern University FeinbergSchoolofMedicine.“Whenyoubreathein,wediscoveredyouarestimulatingneurons in theolfactorycortex,amygdalaandhippocampus,allacrossthelimbicsystem.”

“Breathing is not just for oxygen; it’s now linked to

brain function and behavior.” -

Northwestern University, Chicago Illinois USA

Anotherpotentialinsightoftheresearchisonthebasicmechanismsofmeditationorfocusedbreathing.“Whenyouinhale,youareinasensesynchronizingbrainoscillationsacrossthelimbicnetwork,”theauthorsnoted.

As W Gruver repeated proper inhalation andexhalation techniques, not only did he enlist morecorestabilitybuthealsoexperiencedfocusedbrainactivityawayfrompain.StretchingandHipMovementthroughFullROM“Repertoire that utilizes a full range ofmotion canpotentiallyenhanceflexibility.”19Ithasbeenimportanttounderstandthenuancesofeffective stretching to help W Gruver with musclespasms, advanced muscular clumping, and severeneural pain. Stretching has been the most helpful

exercise and the improved ROMofWGruver’s hamstrings and calfmuscles through thisapproachhasbeensignificant.ItisimportanttonotethatthepositiveeffectofPNFstretchingalongwithdynamichamstringstretchinghasbeenappliedandadvantageousonlyafterthepracticeofmarching,squatting,calfraisesandotherchosenmovementstocreateheatinthemusclespriortostretching.

PNF stretchingdefinedas, ProprioceptiveMuscular Facilitation, is anextremelybeneficialformofflexibilitytrainingifonewishestoincreaserangeofmotion(ROM).

AccordingtotheInternationalPNFAssociation,PNFstretchingwasdevelopedbyDr.HermanKabatinthe1940sasameanstotreatneuromuscularconditionsincludingpolioandmultiplesclerosis. PNF techniques have since gained popularitywith physical therapists and otherfitnessprofessionals.It’seasytounderstandwhy.AccordingtoresearchfromtheUniversityofQueensland,PNFstretchingmaybethemosteffectivestretchingtechniqueforincreasingrangeofmotion.

PNFtechniquescanbebothpassive(noassociatedmuscularcontraction)oractive(voluntarymusclecontraction).WhilethereareseveralvariationsofPNFstretching,theyallhaveonething incommon- they facilitatemuscular inhibition. It isbelievedthat this iswhyPNF issuperiortootherformsofflexibilitytraining.

Usingthesetechniquesof'contracting','holding'andpassivestretching(oftenreferredtoas'relax')resultsinthreePNFstretchingtechniques.Eachtechnique,althoughslightlydifferent,involvesstartingwithapassivestretchheldforabout10seconds.

ForWGruver,webegantoworkonflexibilityandincreasingROMinthehamstringwhichhadbecometightandofteninspasm.Lyingonhisback,faceupinasupinepositionheplacedonelegextended,flatonthefloor,whiletheotherlegextendedintheairasclosetoarightangle alignment to the body as possible. From this point we engaged one of the threetechniquesknownasHold-Relax.

Hold-RelaxwithOpposingMuscleContraction

§ Afterabriefwarmupfocusedonlooseningandwarmingmuscles,mindfulbreathing,anddynamicmovements,theinstructormovestheclient’sextendedlegtoapointofmilddiscomfort.Thispassivestretchisheldfor10seconds.

§ On instruction, the athlete isometrically contracts the hamstrings by pushing theirextendedlegagainsttheirpartner'shand.Thepartnershouldapplyjustenoughforceso that the legremainsstatic.This is the 'hold'phaseand lasts for6seconds.Thisinitiatesautogenicinhibition.

§ Thepartner completes a secondpassive stretchheld for30 seconds,however theathleteisinstructedtoflexthehip(i.e.pulltheleginthesamedirectionasitisbeingpushed).Thisinitiatesreciprocalinhibitionallowingthefinalstretchtobegreater.

Leaving42hoursbetweenPNFstretching routines,andattemptingat least20minutesoffocused stretching each day, preferably when muscles were warmed up from Pilatesconditioning,wasourgoal.20

UnderstandingtheconnectionofthehamstringmusclegroupintotheHipwasadvantageoustowarddecreasingpain.Webelievethatasthehipincreaseditsrangeofmotion,therotatorsanddeepmuscleslikethepiriformisandgluteusminimus,aswellashipextensors,namelythe biceps femoris, hamstring group and gluteus maximus,increased in strength and flexibility which decreasedinflammationagainstthenervecolumn.Theaforementionedmusclesconnectproximally intothe ischial tuberositywhichthenconnectsintothesacro-spinousortuberousligamentandtouches the pudendal nerve (see photo).21 The client hasexperiencedpainreliefinhisrightlegfromtheactivationandstretching of these hamstring and hip muscles, therebydecreasinginflammationoftherelatednerves.

PudendalNerve

Anti-InflammatoryDietTheobjectiveherewastochangeWGruver’sdiettodecreaseinflammationaroundthespine,withinthenervecolumnandarachnoidspace:Adiet rich inomega-3 fatty acids, vitaminC,B12, andgreen leafy vegetableshasbeenacriticalcomponentofWGruver’sprogression.YoucanreadmoreabouthisdietobjectivesandplansintheReferencesandResourcessectionattheendofthispaper.11,12,13Achievablegoalswereset inaneffort toeliminate inflammatory foodsandbeverages5-6daysaweek.Thisresultedinalifestyleofselectinghealthyanti-inflammatoryfoodsathomeandoutatrestaurantswhichincludedlotsofSlowMag,Omega3,6,9,variousherbalteas,minimalredmeatsandalcohol.

PhysicalConditioningProgramInspiredbyBASIPilates:General Client Physical Evaluation at Beginning of Pilates Training:W Gruver presentstowardaflatbackposturallinewithweakglutealmuscles.Hepresentsroundedshoulders,over-developed pectoralis major muscles, as well as under developed posterior deltoids,shoulder,andlatissimusdorsimuscles,WGruverhastightuppertrapeziusandweakermiddletrapezius.HehasweakgastrocnemiusandhamstringmuscleswithlimitedROMandevidentatrophy in R calf. Supination of the feet. W Gruver demonstrated weak adductors andunawarenessofpelvicfloormuscleengagementalongwithshallowbreathing.AhighstressindividualasabusinessownerandEntrepreneur,WGruvershowedmuchdeterminationanddrivetoimproveandworkhard.HehasbeenanearperfectPilatesstudentwhodeterminedtogetbetter!Thoughhesuffersgreatly,hecontinuestoshowaninspiringpositiveattitude.WarmUpandInitialMovementObjectives:

1) Elevatebodytemperatureinefforttoeventuallystretchthespine,hamstrings,etc.2) Createspacebetweenvertebraethroughspinalarticulation3) Stretch and strengthen the hamstring and gastrocnemius,which have evidence of

constantclumpingandmusclespasm,atrophyandsevereweakness.4) Seektorecruitcorrectmusclesinhips,abdominalsandback.5) WorktoincreaseflexibilitythroughPNFstretchingonlyafterwarmup.

Myhopewastoachievemovementfromstabilizationwhilstapplyinglearnedbreathing.Ourstrategywastoproduceandincreaseendorphinreleaseandoxygenintakeinefforttocombatpain.GroundRules:Noinitialjumpingorimpactofanykindwasutilized.Infact,forthefirst3monthstheclientcouldnotrolldownorstretchinanywayduetopain.Clientcouldnotperformstandingworkformore than 15minutes, but needed to domostwork supine due to the reduced painrealizedinthesaidposition.Furthermore,itshouldbenotedthatWGruverbeganeachsessioninextremediscomfortandpainduetohiscondition.Overtimewefoundthattheinitialpaindecreasedduringthefirst5minutesofdynamicmovement,solongasbreathingandformweremaintained.ThePainScaleIestablishedforclientsfunctionallivingwasbasedupona3pointsystem.A“1”beinglow/nopainand3beingextremepain:1=mild,2=bearable,3=mustliedown.During the initial phases of our Strength and Condition Program, the patient was in aweakenedstateandeachsessionbeganwithveryshortstandingwork forweight-bearinggastrocnemiusandhamstringactivation,thensupineonthematinordertominimizepainwhilewarmingupthemuscles.Itcannotbeover-emphasizedhowcriticalitistotakethingsslowly when client has chronic neuropathic pain, especially as the patient begins to feelstrongerandwantstopushtheirworkoutlimits.Simplejumpingjacksforinstancecancauserelapseifnotdoneundersupervisionandatthepropertimeandstageofprogress.

WeakenedStateProgram:WeakenedstateProgramJan-Feb

SupineMatwork:Allworkexecutedslowlywithdiaphragmaticlateralbreathing.

5-10minstandingCalfraisesroutine-endhold1minriseMarchx20

Standinglunge-8eachside

Breathingsupinew/breathingfeedbackbelt15min

Spinetwistsupinex8-10alternateRL

ChestLiftx10AddRot.8

Add½PelviccurlimprintingintoLumbarspinex102fullpelviccurls

Legliftsx10Changesx10

STRETCHAFTERWARMUPThroughROM

Kneesintochest-1-2min

Supinehamstringstretch-onekneebent–PNF(*seePNFSection)

ForwardlungehipflexorstretchR/LHold1min+breath-pikehamstringstretch.Hold30sec.

Lieproneoverball1min(Createspaceinspine)Rockingtowardheadandbacktofeet-bendingknees

RestpositionLowbackmassageoversurgerysite

RestPositionHold1minwithintentionalbreathing

PoleSeriesseatedonLargeBall-liftingoutofhipsactivatingglutes.

StandingLleg,pressRlegintowallactivatingglutealmuscles.

LungeforwardStretchlateralreachingarmoverheadRLx5

Massagefootintoball1mineachside

Note:InW.Gruver’sweakened,earlystagestate,heneededtoactivatehishamstringsandglutealmusclesaswellasgastrocnemiuspriortoperformingsupinematwork.Thisallowedmuscles tocontractandrelease inan isometricand isotonicprogram,heatingup forsafemovingandstretchingduringPilates.Mytheoryisthatwhilethesemuscleswereusedinastanding position, gravity and muscle tension decreased inflammation along the neuralpathwaythroughthepudendalnerveintotheArachnoidspacemovingdowntherightleg.Despiteasetbackandflare-upinMarch,whichsenttheclientbacktothestartingline,thefollowingStrongStatewarmuphelpedadvanceWGruver’sprogressioneventually.

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Mat SpineTwist CalfRaises Marching Lunges Supine ChestLift PelvicCurl LegLifts

PainvsWellBeingDuringWeakStateWorkouts

PainLevel HeartRate Breathing WellBeing

TheWeakStateWarmupbeganagaininAprilcontinuingthroughMayandthenmovedintotheStrongerStateWarmupbyJulyandAugustwithoutanyevidenceofflare-ups.StrongerStateProgram:StrongerstateMarch&June-Sept

Roll-DownCarefultodrawnaveltospinex4

10-15minStandingfootwork:flatfootsquatsX10heelraisedsquatsX10holdonrise10seclateraltwistonrise-4X

Breathingoverballproneorsupineonfloor-5minLightmassagebackandoverL4-L5.

Seriesofsinglelegsquat-lunges

Advancedto-lateralRlegreachstephold.(likelateraljumpsw/outjump.)alternatingsides10X

*Fundamentalmatwarmup

*IntermediatematwarmupincludingRollUpinitiallywiththera-bandandthenFullRollupwithoutassistance

PNFStretchHamstrings*seePNFstretching

March1minute

ExplanationofsomewarmupandPilatesexercisesusingtheBASIblocksystem.Month1-2January,FebruaryPleasenotethatmonthswerespenttryingtoachievemindfulmovementthattheBASIPilatesmethodpromotes.Formandslow,deliberatemovementswereemphasizedasfirstpriority.

• Breathingcycle–UsedimagerytoengageTAandpelvicfloor,aswellasfeedbackbelt.• Rolledoutsolesoffeedwithspikyballseverysession,• Marchinginplacefor2minutes• ½RollDownswithbentkneesorbeginningonbackwithbreathing,• 50CalfRaises(50),• SingleLegCalfRaises(15eachside),

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Mat SpineTwist CalfRaises Marching Lunges Supine ChestLift PelvicCurl LegLifts

PainvsWellBeingDuringStrongStateWorkouts

PainLevel HeartRate Breathing WellBeing

• Squatsmakingsurepatientmaintainsproperalignment,promoteendorphinrelease,andengageglobalmusclesfirstandthenmoveintostabilizers(15),

• Squatfromraisedcalfposition(8),imaginingawallagainstspineasliftandloweringmotionoccurredthroughevenlypacedinhalationandexhalationtimedwithupanddownmovement.

FundamentalWarmUp – used soft ball to help to think of narrowing hips and engagingtransverse.

• PelvicCurl–InitialCurlwentthroughtheLumbarcurltoholdandthenprogressedtominimalfullpelviccurl.Alwaysimaginingmagneticattractionofadductorstowardthemidline(10),

• SpineTwistSupine-witharmsinTpositionandinitialmodificationoffeetonfloor.Alsooccasionallyassistedwithballinbetweenfeetorkneesforcorrectengagementthroughadductorline–enlistingpelvicfloor(6),

• ChestLiftinimprintduetoweakTAandthenworkingtowardneutralusingapadforfeedbackunderthoracicregion(6).

Abdominal

• HundredsPrep(6)-workedinimprintandgraduallytowardneutralspinalalignment,• Alwaysworkedtoachievewidecollarbonealignment,• Hundreds(50)-modifiedwithbentlegs,• DoublelegStretch–splitin2parts:kneesinTableTop,armsfirst(8),then;• Legsaloneslightlystraighteningbutnotcompletelywhileupperbodyremainsinchest

lift(8).Bridging

• Four-pointkneelingalignment-executeextendedarmand legoppositeeachotherholding10secondsalternatesides(6)VerydifficultforGruverbuthealwaysfeltgreatafter,

• Large ball spine twist supine (5) each side – legs over ball with knees and anklestogether,

• FullPlank–heldfrontsupport30seconds,• ActiverestwhileinRestposition,practiceddeepbreathing(20seconds),• FrontSupport(4)oneachsidewithbentknees,then;• AvoidedShoulderbridgeprepatthispoint.

SpinalArticulation

• PelvicCurlwithballbetweenkneesforadductorandPelvicFloorActivation(6).LateralFlexion

• SideLiftonlyonaside(6).BackExtension

• Mild small movement Cat stretch initiating with Lumbar curl upon inhalation andexhalation(4).

10minutesofneural,PNF,anddynamicstretchingHamstrings,GlutealandGastrocnemius

• Restposition–backmassageoverincisionpointatL4-L5,pressureonsacrumwhileaimingforincreasedlengththroughspine(10minutes).

Month3(March)

• 15minutesofmindfulbreathingcycles.ImprintingSpine,findingneutral,• RollDownAdded½andthenFulllastweek(4),• WarmUp–refertowarmupdiagramprevious*,• FullPelvicCurlwithBallinbetweenknees(10),• Chestliftwithballinbetweenknees–hold,extendarmsliftinghigher,returntostart(6),• AddedChestliftwithRotation(6).

AbdominalBlock-(Neveractivatedbotharmsandlegsinlongleverposition,wealwayschoseoneshortleverandonelonglever.)

• HundredsPrep(8),• Hundreds(50),• SingleLegStretch(8),• DoubleLegStretchbentlegs(6).

Bridging

• ShoulderbridgePreptotal-strongattentiontoactivatingbacklineofstabilizingsideandextremelyslow(6)

• FrontSupport-4pt.kneelinghold–plankholds(20seconds)SpinalArticulation

• RollUpwithassistanceandwithbentknees(6).LateralFlexion

• SideliftswithSideplankholdkeepingneutralspinealignment(6).BackExtension

• SlightCatStretch(6),• Basicbackextension(6),• RollDowntopushup(6),• ArmworkwithBands(6),• Poleseries(6),• PNFStretchingRoutineevery3-4days.

NOTE:WGruverexperiencedamajorFLAREUPatthisstagewhichwasquitediscouraging.Patient had experienced rapid improvement and was beginning to feel stronger andexperienced more hours of less pain. He decided to visit the gym and attempted somekneelingarmworkonthereformerinanefforttoworkonchestexpansion,surferrowing,etc. It is believed that because his Core and Trunk Stabilization was not yet establishedenoughtoexecutetheseexercisessafelyinabalancedway,andasitwasagroupPilatesclasswherehisformwasn’tmonitoredcloselyenough,theclientwentintoasevereflare-upandregressed3months.Hewasforcedtolieflatonhisbackfornearlyaweek,andwasonlyabletobeupforafewhoursbeforeseverepainsetin.Hereturnedtoaverydiscouragedstate,

howeverrealizedthatstayingwiththePilatesroutinewasessentialforhishealthandwell-being.RestartinApril:WebeganagainwiththesameplanweinitiatedinJanuaryandcontinuedtobuildupwithin4month’stime.Wewerecarefultoresearchandfollowamoredeliberateanti-inflammatorydiet,andaskedforlotsofprayer.ApplyingallthebreathingtechniquesofPilates,workingtomovefromstabilization,webeganagain.ByJulyWGruver’sPilatesplanlookedasfollows:Months4,5,6(April-May-June)WarmUp:FundamentalorIntermediatePilatesWarmUpSeewarmup–firstWeakerStateChart,thenStrongerStateChartabove.We followed the same Pilates exercises regimen building up slowly working in the fullintermediate mat work by June and then adding in advanced work along with mild andcontrolledcardiothroughstationarybikingandsoft landjumpsonasprungfloorneartheendofJune.Month7,8,9(July,AugustandSeptember)ResultsandPilatesroutinelaunchesGruverinto80%betterstate!StrongerstateWarmUpaboveincludingRollDownsX5.Allexercisesperformedbetween6-8repetitions.

• AbdominalBlock:Allexercisesexcludingteaser1,2,3,andneckpull,• SpinalArticulation–AllexercisesexcludingBoomerangandOpenLegRocker,• Bridging–AllexercisesexcludingBackSupportlegpullduetorecurringlegcramping

andScissorsandBicycle.• LateralFlexion-AllexercisesexcludingHipCirclesprepandHipCircles• BackExtension-AllexercisesexcludingSwanDiveandRocking

WeoftenusedasmallballforfeedbacktoactivatecoreandTA-PelvicFloormuscles.Additionally,weaddedintheGlutealSideLyingseriesandGlutealkneelingseries,Magiccircleworkaswellaslowkghandweightsworkingtowardstrengtheninglats,shoulders,andpecsallthewhilemaintainingpropercoreengagement,movingfromstabilization.Routines also included light cardio work by September and were consistentlymonitoredundercarefulsupervisiontoactivatecorestabilityformovement.Allroutineswereexecutedonasprungfloor.

CONCLUSIONTOPAPER“Toachievethehighestaccomplishmentswithinthescopeofourcapabilitiesinallwalksoflifewemustconstantlystrivetoacquirestrong,healthybodiesanddevelopourmindstothelimitsofourability.”--JosephPilates7AdhesiveArachnoiditisisararemedicalcondition.Ithasadebilitatingeffectonthequalityoflifeofthepersonsufferingfromit.Itismainlyduetothepresenceofsevereintractablepainwhich is unbearable and couldmany times be traumatic enough that a person becomessuicidal.Sinceitisuncommon,hencenotmuchresearchisdonetounderstandhowtotacklethisproblem.Thedoctorstoohavelimitedknowledgeofdrugs,whichcanproviderelieffromthesevereunbearablepain.Thus,thefutureofAdhesiveArachnoiditisisnotveryclear.

JosephPilateswrotethat,“Contrology isnotasystemofhaphazardexercisesdesignedtoproduceonlybulgingmuscles. ...NordoesContrologyerreitherbyover-developingafewmusclesattheexpenseofallotherswithresultinglossofgraceandsuppleness,orasacrificeoftheheartorlungs.Rather,itwasconceivedtolimberandstretchmusclesandligamentssothatyourbodywillbeassuppleasthatofacatandnotmuscularlikethatofthebodyofabrewery-truckhorse,orthemuscle-boundbodyoftheprofessionalweightlifteryousomuchadmireatthecircus.”7Itismybelief,andJosephseemedtoagree,thatPilateswasatleast50yearsaheadofhistime. Joseph Pilate’s point was that true health and fitness isn’t achieved through thedevelopmentofjustthebiceps,pectoralsandlatissimusdorsi–andcan’tbepurchasedoracquired through an over-focus on bulking up like a “circus performer”. In Pilates, truephysicalfitnessandsustainablehealthmustincludeafocusonspinalnourishment,fullrangeflexibility,andcorestrength.

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Jan Feb Mar Apr May June July Aug Sept

2017WGruverKeyPerformanceIndicators

PainLevel MuscleSpasm Flexibility Strength

FrommyworkwithWGruverandresearchonthesubjectofPilatesastreatmentforsevereneuropathicpain,thereissignificantreasonforhopeinthisformoftherapyasaremedyforpainrelief,andphysicalandneurologicalsupport.

By mid September, the daily practice of Pilates combined with healthy diet, prayer andawareness developed toward breath and pace of life, Gruver is 80-90% better. He hasregainedfullrangeofmotioninhishipsandhamstringmusclegroups.Heoccasionallymusttakeamildanti-inflammatoryifhehastositlongperiodsforworkandlife,buthehasbeenabletoresumemanyoftheactivitieshecouldn’tbareearlier.Afteryearsofsufferingandlimited interactionsdue topain, the client is nowonceagainable to sit througha familydinner,listenattentivelytoachildtellabouttheirdaywithoutthedistractionofpain,engagewithclients,andisabletodrivehimselfplaces.HeissignificantlyimpactedifhemissesPilatesforoneday,howeverevenifhisscheduledoesnotallowforthepracticeheisbetteroffthanwhen he began his Pilates journey beginning in 2017. The transformationW Gruver hasexperiencedseemsnothingshortofamiracleforheandhis friendsandentirefamily.Hissleep has improved with the elimination of constant muscle spasm and he even enjoyswalking, hiking and golfing again. While still an “incurable, intractable disease”, it is myopinionthatAAsuffererscanfindhopeintheworldofcarefullyexecutedPilates.YetIbelievethatthereisstillmuchmoreresearchtobedoneinthisfield.WGruvercontinueswiththepracticeofPilatesundercarefulsupervisionandisstrongerandmoreawareofthegiftofabodythatcanmoveeachday.

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Jan Feb Mar Apr May June July Aug Sept

Pain+SpasmsvsFlexibility+Strengthover90MinutesPilatesSession

PainLevel MuscleSpasm Flexibility Strength

REFERENCESANDRESOURCES

1. http://www.burtonreport.com/infspine/adhesarachfaqs.htm

2. http://arachnoiditis.co.uk/index.php/information/medical-papers-2/124-the-arachnoiditis-syndrome-dr-sarah-smith

3. http://onlinelibrary.wiley.com/doi/10.1111/anae.12017/full

4. https://www.epainassist.com/back-pain/adhesive-arachnoiditis

5. http://www.spinal-foundation.org/conditions/arachnoiditis

6. http://www.cofwa.org/arachnoiditis.htm

7. Joseph Hubertus Pilates; William John Miller (1960). Return to Life Through Contrology.

ChristopherPub.House.

8. http://www.cofwa.org/aasyndrome-10-03.pdf

9. https://www.spineuniverse.com/conditions/spinal-disorders/arachnoiditis

10. https://www.practicalpainmanagement.com/treatments/complementary/anti-inflammatory-diet-pain-patients

11. https://www.foundationforpn.org/living-well/lifestyle/nutrition/

12. https://www.loseweightbyeating.com/nerve-pain-relief-with-food/

13. Chinese–anti-inflammatorydietwebsite

14. MedicalReport,CharlesBurton,November2016

15. CharlesV.Burton,M.D.,F.A.C.S.

SentinelMedicalAssociates,PAGalleryTowerOfficeBuilding514St.PeterStreet,Suite220St.Paul,Minnesota55102

16. Northwestern University. “Rhythm of Breathing Affects Memory and Fear.”

NeuroscienceNews. NeuroscienceNews, 6 December 2016. By Heidi Jiang, Guangyu Zhou,NikitaArora,Dr.StephanSchueleandDr.JoshuaRosenow

17. http://neurosciencenews.com/memory-fear-breathing-5699/

18. http://KenHub.com“LearnHumanAnatomy

19. StudyGuide,BodyArtsandScienceInternational,2013.California

20. http://Healthline.com“AHow-to-GuidetoPNFstretching”

21. http://PundendalHope.info