‘Pilates for lower back pain’

By Adam Donoghue

16 Roope St, New Town, Hobart Australia

May 2014

Maroochydore Course, Australia

ABSTRACT

Lower back pain (LBP) is a huge problem in society, it’s estimated that 25% of all physical

therapy visits in the U.S. are people with lower back pain*. World-wide there’s an

incidence of LBP with 80-90% of people during one’s life*.

There are a number of causes of LBP. This paper is focused specifically on a fairly typical

scenario. The case study is of a woman with poor posture (hyperlordosis) and disc bulge,

she spends extended periods sitting (shortening hamstrings) and limiting movement in

body, and does gardening in her spare time (over doing forward flexion).

It is recommended she start a tailored Pilates conditioning program. The program aims to

get balance in body to reduce load on her lower back. It does this by strengthening weak

areas (core muscles, hip abductors, upper back stabilizers). And stretching out tight areas

(psoas, hamstrings). There is an emphasis throughout the program to improve body

awareness and postural correction in the hope that she takes these new skills into her

work and play.

*Source: Basi Injuries & Pathologies Advanced Education Course Handout (2013)

Table of Contents

Page 2 Abstract Page 3 Table of Contents Page 4 Anatomical Description and Diagram Page 5 Introduction Page 6 Case Study and Conditioning Program Page 7 Program Chart with Reasons for selecting & desired results Page 8 Conclusion

Page 9 Bibliography

ANATOMICAL DESCRIPTION AND DIAGRAM

Lumber Spine- There are 5 lumber vertebrae (L1 to L5), 5 fused bones that form the

sacrum, and 3 to 5 fused bones that form the tailbone (coccyx).

Individual vertebra are made up of several parts. The body of the vertebra is the primary

area of weight bearing and provides a resting place for the fibrous discs which separate

each of the vertebrae. The lamina covers the spinal canal, the large hole in the center of

the vertebra through which the spinal nerves pass. The spinous process is the bone you

can feel when running your hands down your back. The paired transverse processes are

oriented 90 degrees to the spinous process and provide attachment for back muscles.

Spinal Nerves- The spinal cord is made up of nerves that extend from the brain into the

spinal canal and then out to various parts of the body. Nerve roots are the points where

nerves leave the spine and form nerve branches to parts of the body.

Main muscles of the lumber spine- the erector spinae are long muscles are on either

side of the spine; these are usually the culprits if there are muscle spasms in the back.

Under these are medium length muscles that extend from one vertebrae to the next. At

the front of the body the psoas muscle runs from the front and sides of lower spine across

the hip joint and attaches to the femur bone. The front of the body houses the all important

abdominal muscles (transverses abdominus, oblique’s, rectus abdominus, multifidus).

These muscles are critical to your spines forward movement and provide support for your

back.

HOW THE SPINE MOVES There are four facet joints associated with each vertebra. A pair that face upward and

another pair that face downward. These interlock with the adjacent vertebrae and provide

stability to the spine. The vertebrae are separated by intervertebral discs which act as

cushions between the bones. Each disc is made up of two parts. The hard, tough outer

layer called the annulus surrounds a mushy, moist center termed the nucleus.

The movements of the majority of the spine (except the cervical spine) are limited by the

various ligaments that attach the vertebrae to one another and also by the shape of the

facets, discs and spinous processes. Movement between ant two vertebrae is quite

limited however the total amount of movement in a given region can be considerable.

Lumbar vertebrae are massive for weight bearing and are designed to bear 80% of the

weight. The facets have a sagittal orientation allowing little rotation, but a lot of flexion,

extension. With spinal discs the nucleus attracts fluid to keep it hydrated to absorb force.

The discs reply on regular movements of the spine to assist in the drawing in of fluid to

keep them healthy.

CASE STUDY

Client: Fiona Smith

Occupation: admin work, spends 8 hours + a day sitting

Age: 50 Hobbies: gardening (forward bending)

Limitations: lower back pain for 10 years + due to poor posture and disc bulge posterior

L2/L3 for 3 years

Rehabilitation treatments: has tried physio with some relief but keeps getting pain coming

back due to posture and muscle imbalance.

CONDITIONING PROGRAM

Problem: Poor posture with hyper-lordosis, therefore weak abdominals, tight psoas, weak

inner thigh muscles, poor knee alignment (locked in joints), tight hamstrings, shoulders

pushed too far back, chin and neck too far forward.

Programs General Goals: Get balance in body to reduce load on lower back. Strengthen

weak areas (core muscles, hip abductors, upper back stabilizers). Stretch out tight areas

(psoas, hamstrings). Improve body awareness and postural correction.

General Exercises: Back extension good to squeeze opposite way on lumber discs.

Flexibility and strength around the hip flexors and extensors. Strengthen knee extensors.

stretch calves. Alignment of core in neutral while doing exercise with arms or legs through

full range (eg. footwork, arm work and hipwork).

Avoid: avoid loaded flexion, vertical loading of discs and strong rotation.

BLOCK   EXERCISE   DESIRED  RESULTS   REASON  FOR  SELECTING  Warm Up lying on roller (shoulder

retract/protract, pelvic hitches and tilts, arm floats, balance awareness), Pelvic curl, chest lift + rotation. Single leg lifts. Roll-like a ball.

Improving awareness and alignment of body. Preparing core for exercise. Awareness of centre of gravity. Massage/release of erector spinae.

Finding Neutral and core. Getting stability around pelvis.

Foot Work Footwork on Wunda Chair Improved posture in sitting and awareness of neutral spine. Knee flexor strength & control. Hip flexor strength and control. Stretch calves.

Unsupported posture so better to ensure core in on while doing footwork. Also helps to get good sitting habits for her work.

Abdominal Work Roll up with roll up bar Abdominal strength and control. Trunk stability

Get spine moving with control and support. Can adjust springs to ensure client has good form.

Hip Work Hip work series on reformer

Improve knee extensor control and pelvic lumbar stability. Strengthen adductors and hamstrings.

Core stability while strengthening legs.

Spinal Articulation Bottom Lift Hamstring and Abdominal strength. Smooth and controlled spinal movement.

Can modify with springs and footbar height to ensure theres good control.

Stretches Standing Lunge Stretch hamstrings and hip flexors.

Also gets client keeping spinal alignment while stretching these tight areas.

Full Body Integration 1 Scooter

Strengthen abdominals. Strengthen hip & knee extensors. Trunk stability.

Shoulder awareness and scapula stability. Body awareness.

Arm Work Arms standing series Scapula control, Shoulder strength and control, symmetry left to right. Functional postural awareness.

Good to reinforce correct standing posture while working arms.

Full Body Integration 1 (instead of 2)

Down stretch Shoulder control and stability. Trunk stability.

(Not ready for challenging FBI 2). Getting Abdominals & back extensors working together.

Additional Leg Work Gluteals kneeling series Strengthen hip extensors and abductors. Improve stability at hip and torso while moving leg.

Focus on pelvic lumber stability and strengthening the hip area.

Lateral Flexion/Rotation

Side stretch on chair Strengthen the obliques. Stretch lateral flexors.

Good to find neutral spine in a diagonal orientation and strengthen core.

Back Extension Breaststroke prep Strengthen back extensors and shoulder stabilizers. Open out lumber discs opposite to bulge disc.

Combines scapula stability with back extension.

CONDITIONING PROGRAM

CONCLUSION

• Often pain inhibits movement so aim is to keep areas moving pain free to maintain range

and restore confidence in body.

• Strong focus of program is in postural re-education to improve posture and body

awareness in space (ability to correct to a functional position). This is important as pain

often changes the default way you use your body.

• Restoring balance in body by strengthening weak areas and stretching tight areas with

an emphasis on neutral spine while moving.

• Frequency of the program is important as we want to create good habits and obviously

the more practice the easier it is to break incorrect habits (recommend 2 to 3 sessions

per week one on one initially till suitable for a small group).

• Encourage client to take the core stability and awareness into their work (sitting at desk

posture) and hobbies etc.

• Give client some basic stretches and core awareness exercises to do daily.

(STRETCHES: hamstring, hip flexor. CORE: Pelvic curl, chest lift, leg floats, roll like a

ball).

BIBLIOGRAPHY

Basi Injuries & Pathologies Advanced Education Course Handout (2013) Basi Movement Analysis Workbooks Burn, Dr Loic (2007) Treating your back and neck pain for dummies, John Wiley & Sons, UK. Dru Yoga Teacher Training Notes Fine Judylaine (2000) The Ultimate Back Book, Stoddart Publisher. Highsmith, Jason (2011) The Complete Idiots Guide to Back Pain, Alpha, New York. Jenkins, David (1991) Functional Anatomy of the Limbs And Back, Saunders, Sydney. Lacey Laurie (2012) Yoga for Arthritis Workshop Handout, Hobart Australia. Marcus, Norman (2012) End Back Pain Forever, Atria, New York. McIlwain, Harris (2004) The Pain Free Back, Henry Holt, New York. Robinson, Lynne (2002) The Body Control Pilates Back Book, Pan, London. Siegel, Dr Ronald (2001) Back Sense, Vermilion, London. Vad, Vijay MD (2004) Back Rx, Gotham Books, New York Wharton, Jim & Phil (2004) The Whartons Back Book, Rodale, London.