PilatesforCentralSensitization

fromChronicPain

ElizabethClark

March18,2016

FlowStudios,Chicago,2015

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Abstract

Centralsensitizationisaconditionofheightenedsensitivity,closelyassociatedwith

chronicpain.Inthisstate,thebrainisbeingtoldthatthebodyisinmoredangerthanit

actuallyis,maintaininganongoingstateofstress.Muscleactivity,brainfunctionand

emotionalwellbeingarenegativelyaffected.Individualsexperiencingchronicpainand

centralsensitizationusuallyattempt,unsuccessfully,toeitherpowerthroughtheir

symptomsoravoidpainfulactivitiescompletely.Abetterconditioningmethodhasproven

tobetheslowandsteadyapproach.Thiscasestudyexaminestheeffectsofapersonalized

BASIPilatesprogramonaclientwithchronicpainandasensitizedcentralnervoussystem.

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TableofContents

CentralSensitization....................................................................4

CaseStudy..............................................................................8

ConditioningProgram....................................................................9

Conclusion.............................................................................11

Bibliography............................................................................13

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CentralSensitization

Thecentralnervoussystem(CNS)ismade

upofthebrainandspinalcord.Working

withtheperipheralnervoussystem,itsjob

istosend,receiveandprocessinformation

fromeverypartofthebody.Adamagedor

faultyCNS,onethatdoesn’thandle

informationcorrectly,canleadto

symptomsrangingfromaheadache,to

slurredspeech,toradiatingbackpain,to

numbness,tolossofcoordinationto

numerousothersymptoms.(JohnHopkins

Medicine)ThiscasestudyinvolvestheCNS

disordercalledCentralSensitization.

One formof information theCNSdealswith ispain. Likemost stimuli, pain travels from

peripheralsensoryneuronstothespinalcord,andthenonuptothebrain.Thebrain’sjob

is to interpret the information andmake a variety of short and long-term responses by

sendinginformationbackthroughthespinalcordtothebody.

Ifthespinalcordcontinuallyreceivespainstimulus,theveryadaptablenervoussystem

respondsbygettingbetteratsendingdangersignalstothebrain.Thingsthatusedtohurt

begintohurtmoreandthingsthatpreviouslydidn’thurtstarttocausepain.(Butler,

Fig.1:http://climatereview.net/ChewTheFat/?p=1015

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Moseley73)Thebrainisbeingfedinformationthatnolongerreflectstheactualhealthand

abilityofthetissues.It’sbeingtoldthereismoredangerthantherereallyis.Althoughthe

levelofsensitizationvaries,heightenedsensitivityoftheCNSisalmostalwaysasymptom

ofchronicpainatsomepoint.And,thelongerthepainlasts,thegreaterthechangesinthe

CNSbecome.(Ingraham)

Commoncharacteristicsofcentralsensitizationincludethefollowing:

- Thepainlastsafteraffectedtissueshavehealed.

- Thepainspreadsbecausethebrainisincorrectlybeinginformedthatmoreof

thebodyisindangerthanactuallyis.

- Thepainincreases,sendingamessagesayingtoescapetheperceiveddanger.

- Assensitivityincreases,theamountofmovementrequiredtoignitepain

reduces.Inseverecases,eventhinkingaboutamovementcancausepain.

- Thepainbecomeslesspredictable.

- Thepainlinksmoretothoughts,feelingsandbeliefs,whichinturnstart

contributingtotheproblem.(JohnHopkinsMedicine)

Inresponsetochronicpain(thebrainreads:chronicdanger)plusasensitizednervous

systemmagnifyingtheissue,manyadaptationscanoccur.Oneisalteredmuscleactivity,

specificallyactivationofthelongermovermusclesanddeactivationoftheshorter

stabilizermuscles.Intheshortterm,thisisagoodresponsetodanger.Thebrainis

preppingthebodytofightorflee.Inthelongterm,however,thisstatenegativelyimpacts

postureandmovementpatterns.Theactivatedlongmusclesbecometightandthe

deactivatedshortmusclesbecomeweak.(Butler,Moseley90)

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Anotheradaptation,onethathappensinasectionofthebrain’scortexcalledthe

homunculus,isknownassmudging.Areasofthebrainnormallydevotedtospecificbody

partsbegintooverlaponeanother.Smudgingcanoccurinbothmotorandsensoryareasof

thebrainandisthoughttobeaprotectivestrategy.Motorsmudgingmakesitharderfor

thebraintoaccessbodypartsassociatedwithpainandthereforelimitingtheiractivity.

Sensorysmudgingallowsthesensitivityofapainfulareatospreadtoneighboringareasin

ordertoincreasethedangersignalbeingsenttothebrain.(Butler)

Individualswithchronicpain,includingthosewithcentralsensitization,typicallytakeone

oftwoapproachestodealingwithpain:avoidthepainortrytobeatit.Thosewhotakethe

avoidanceroutestopany

activityassoonasthepain

kicksin.Overtime,the

amountofactivitynecessary

totriggerpainbecomesless

andless,leadingtoan

increasinglysedentary

lifestyleandoften

depression.Thosewhotryto

beatthepainattemptto

“pushthrough”andignorealarmsignals.Atsomepoint,thepainbecomestoomuchtotake

andthepersonisforcedtoseverelyreducetheiractivity.Asshownintheabovegraphs,

bothapproachesendwithaverylowactivitylimit.(Butler,Moseley107)

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Abettermethodistousepacingandgradedexposure.Thisrequiresabalancebetween

testingthelimitsofpainandlettingpainbethemaster.Itisimportanttoplanoutaslow,

measuredprogressionandtrytosticktoit,ratherthanrushingaheadorcontinually

allowingthepaintomakedecisions.And,whenthereseemtobesetbacksorpainfuldays,

itisveryimportantnottogiveuporbetoohardononeself.(Butler,Moseley113-117)

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CaseStudy

Anneisa27-year-oldfemale,5’4”tallandweighingabout115pounds.Shehasbeen

experiencingchronicpainandinflammationinherlowerbodyforabout4years.Thepain

beganinAnne’sfeetandkneesandslowlyspreadtoincludemostofherlegsandlower

back.Doctorshavebeenunabletogiveacleardiagnosis,thoughtheyconjecturethatitisa

systemicissue.WhatAnneandherdoctorshavedeterminedisthatovertime,theongoing

painhasledtosensitizationofthecentralnervoussystemandsomecompensatory

behaviors.

AnnebeganattendinggroupPilatesmatclassesinanefforttostayinshapewhilebeing

forcedtogiveuptheformsofexerciseshehadpreviouslyenjoyed(running,biking,

volleyball)duetotheiraggravatingeffectsonherpainlevels.Morethanjusthelpingto

buildstrengthand“stayfit”,Annefoundthatshealsoexperiencedreducedpainfollowing

mostclasses.Theimprovementwouldlastforanywherefrom2-24hours.

Givenhopebythis,AnnedecidedtotakeprivatePilatessessionswiththegoalofsoothing

hersensitizedcentralnervoussystem,continuingtobuildstrength,andimprovingher

qualityoflife.Anneisatalow-intermediatelevelandrequiresextrawarm-upexercisesas

wellasaverygradualprogressioninintensity,toavoidtriggeringpain.Sheisnewtoallthe

Pilatesapparatusbesidesthemat.Fromherassessmentsession,Ialsonotedaneedfor

greatercontrolandstabilization,morecoreenduranceandbetterco-contractionof

musclesduringmanyexercises.UtilizingtheBASI(BodyArtsandScienceInternational)

BlockSystem,Ihavedesignedaconditioningprogramwiththefollowingfeatures:

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1. Amplewarm-upexercisesandpreparatorymovements,concentratingAnne’smind

onherwholebodyratherthanjustthepainfulparts.

2. Agradualbutconsistentincreaseofintensity,toavoidtriggeringpainflare-ups

whilenotallowingthepaincycletoinhibitprogress.

3. Emphasisonstabilizationandmusclecontrolratherthanjustmovermuscle

strength.

4. Functionalworkinallplanes,translatingtopropermusclerecruitmentduringdaily

activities,especiallyinthecoronalandtransverseplanes.

5. Encouragementandpositivity!Peoplewithcentralsensitizationoftenhave

protectivemovement-relatedpainmemoriesthatinhibitexercise,socreatingan

environmentofphysicalandemotionalsafetyisimportant.(VlaeyenandLinton)

Conditioning Program for Client with Central Sensitization

Block Sessions 1-5 Sessions 6-10 Notes

Preparation* Before all sessions: Cue client to focus on breath and move their attention throughout the whole body. Pelvic rocking, scapular protraction/retraction, point

and flex feet, circle ankles.

Warm-up Fundamental Warm-up Series on Mat

Intermediate Warm-Up Series on Mat

Start with modified versions or less repetitions, if necessary, and gradually increase. Focus on control and stability.

Footwork Reformer: Parallel Heels, Parallel Toes, V-position Toes, Wide-V Heels, Wide-V Toes, Calf Raises, Prances, Prehensile and Single Leg Heel or Toes

Cadillac: Parallel Heels, Parallel Toes, V-position Toes, Wide-V Heels, Wide-V Toes, Calf Raises, Prances and Single Leg Heel or Toes

The Reformer offers an easy hip angle and the carriage supports spine and pelvis. Start on lower spring settings and work up. Focus on spinal/pelvic body stability (without unnecessary stress) and hamstring strength. Progress to the Cadillac, with a more challenging hip angle but where the client can view their leg and foot alignment easily.

Abdominal Work

Reformer: Hundred Prep and Hundred

Cadillac: Roll-Up Top Loaded, Mini Roll-Up, Mini Roll-up Oblique, Teaser 1

The hundred prep and hundred build abdominal endurance and control. The Roll-Ups and Teaser 1 increase the strength and control challenge. Teaser 1 will be an attainable goal to work towards.

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Hip Work Reformer: Frog, Circles Down, Circles Up, Openings

Cadillac: Basic Leg Springs Series

Emphasize stabilizing the spine and pelvis. The Basic Leg Springs series adds the additional challenge of separately sprung legs.

Spinal Articulation

Reformer: Short Spine

Reformer: Long Spine

Once proper muscle recruitment and good spinal articulation are achieved in Short Spine, apply the concepts to Long Spine, with added challenge hip extensor control and more difficult stabilization.

Stretches Reformer: Standing Lunge

Reformer: Full Lunge

Additional stretches may be added based on how the client’s body feels day-to-day. Focus on breathing and checking in with the body.

Full Body Integration

Cadillac: Sitting Forward, Side Reach, Cat Stretch Kneeling

Reformer: Elephant, Up Stretch 1, 2, 3, Down stretch

Focus on coordination, scapular stabilization and proper muscle recruitment, first in more stable positions on the Cadillac, and then in the load-bearing front support positions of the Reformer.

Arm Work Avalon Armchair: Seated Arm Work

Reformer: Arms Kneeling Series

Emphasize trunk stabilization while doing seated arm work on the Avalon and then increase the stability challenge, kneeling upright on the reformer.

Leg Work Mat:Side Lying Gluteal Series w/weights Wunda Chair: Hamstring Curl

Wunda Chair: Leg Press Standing, Backward Step Down

Focus on gluteal and hamstring strength in easier side-lying and supine positions and then add stabilizer muscles and balance challenge in standing Wunda Chair Leg Work.

Lateral Flexion/Rotation

Wunda Chair: Side Stretch

Ladder Barrel: Side Over Prep Reformer: Mermaid

Achieve oblique strengthening and stretch, plus build awareness of where the body is in space. Increase the load and take away pedal support by advancing to Side Over Prep on the Ladder Barrel. Add Mermaid on the reformer for rotation and scapular stabilization.

Back Extension

Wunda Chair: Swan Basic

Reformer: Pulling Straps 1 and 2

Start on the Wunda Chair, with the option to leave feet on the floor at first. Once proper muscle recruitment is achieved, progress to Pulling Straps 1 (and later, 2) coordinating arm work with the back work.

* Preparation is, of course, not an actual Block. See features of conditioning program listed

above for the purpose of beginning this way.

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Conclusion

Annerespondedwelltothisconditioningprogram.Althoughweemphasizeddifferent

blocksandgoalseachday,wegenerallykepttotheoutlineabove.Mentalandemotional

resultsbecameapparentevenbeforethephysicalones.Annereportedfinallyfeelingsome

senseofcontroloverherphysicalwellbeing,whichhadseemedtobeunderthecontrolof

painforsolong.Shealsosaidthatherpainlevelshavespikedlessoftensincethebeginning

ofourprogramandthatheremotionalresponsetowhentheydorisehasbeenless

dramatic.

Anne’sphysicalprogressionhasnotbeenespeciallyfast.Centralsensitizationandchronic

painhaverequiredustoadvanceataverygradualbutsteadypace.Thankfully,wewere

abletoholdatleasttwosessionsaweekandresultsdidslowlybecomeapparent.After

focusingontheimportanceofcontrolandstabilizationinmanyoftheexercises,Anne

begantopracticewithastrongerandmorecontinuousdeepcoreconnection.Workingon

thevariousPilatesapparatus,wewereabletosafelytargetunder-usedmuscles,suchas

thehamstringsandbackextensors.

ThemostnotableresultisthechangeinwhereAnneexperienceshersymptoms.Forthe

pastfewyears,shehurtthroughoutmostofherlowerbody.Recently,withtheexceptionof

duringacuteflare-ups,thepainandinflammationaremostlyrestrictedtoherfeet,knees

andlowerback.AsAnnedescribesit,thepain“shrunkbackclosertothesizeofwhenit

firststarted.”

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AnneiscontinuingtotakeprivatePilatessessionsandalsoattendsgroupequipmentand

matclasses.OverthecourseofstartinggroupPilatesathergymandthentakingprivate

sessions,shehasbeenshehasalsobeenabletocarefullyreturntosomeoftheactivities

shegaveupwhenherpainbegan,suchasbiking,swimming,andhiking.

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Bibliography

1.Butler,David."ExplainingBrainSmudging."YouTube.NeuroOrthopaedicInstitute,4Dec.2014.Web.4Mar.2016.<https://www.youtube.com/watch?v=3QVAY5stO3U>.2.Butler,David,andLorimerMoseley.ExplainPain.Adelaide:NoigroupPublications,2003.Print.3.Follett,James."TheNervousSystem."ChewTheFat.22Nov.2011.Web.17Mar.2016.4.Ingraham,Paul."CentralSensitizationinChronicPain."PainScience.com.Painscience.com,29Jan.2016.Web.10Mar.2016.5."OverviewofNervousSystemDisorders."JohnHopkinsMedicine.TheJohnsHopkinsUniversity,TheJohnsHopkinsHospital,andJohnsHopkinsHealthSystem.Web.15Feb.2016.6.Vlaeyen,JohanW.S.,andStevenJ.Linton."Fear-avoidanceandItsConsequencesinChronicMusculoskeletalPain:AStateoftheArt."InternationalAssociationfortheStudyofPain,9Sept.1999.Web.15Mar.2016.