Pilates For Promoting Back Health    

Relieving Low Back Pain                                     Lisa Henry-Hamilton 1 January 2015 Sept 2014 – Jan 2015 San Antonio, TX Lianne Gamble  

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Abstract

The purpose of this paper and case study is to explore the benefits of a Pilates practice

as it relates to back health. Back pain is the second most common neurological ailment

in the United States – only headaches are more common. And, after colds/flu, it’s the

second most common reason Americans see their doctors. At some point, almost all of

us will have an episode of severe low back pain (LBP) that will adversely interfere with

our quality of life. It’s believed that LBP costs the US economy $50 to $100 billion

annually. It’s also the most common cause of job-related disability, accounting for more

than 149 million lost workdays per year in the US. Every month in the US, more than 4

million people Google the term “back pain” looking for information on why they hurt and

what they can do about it. Research shows a strong correlation of LBP to extended

periods of sitting. This is cause for concern since the average 8-hour work day for

many is spent at a desk sitting. In addition to proper sitting mechanics, an effective and

consistent Pilates practice may be effective in protecting against LBP occurring.

When sitting, the pelvis is the base of support for the spinal column and eliminates the

supporting role of the legs. Individuals with chronic LBP show a decrease in activation

of certain muscles, mainly the transverse  abdominis (TA), internal obliques, pelvic floor

muscles, multifidus, diaphragm, and deep erector spinae. These muscles comprise

what is referred to as the “core.” Joseph Pilates called it the “powerhouse,” and Rael

Isacowitz calls it the Internal Support System. The deep muscles of the core work as a

protective belt to shield the spinal column from unwanted movement.

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Table of Contents

Title Page

Abstract 2

Anatomical Description and Pictures 4

Introduction 7

Case Study/Conditioning Program 8

Conclusion 12

Bibliography 13

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Pictures of Low Back

Figure 1. Figure 2.

Figure 3.

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Figure 4.

Figures 1 & 2.

The lower back where most back pain occurs includes five vertebrae (referred to as L1-

L5) in the lumbar region, which supports much of the weight of the upper body. They

allow for movement and flexibility in the back and are integral to general mobility in that

area. These five vertebrae are the largest of the spine and together form a reverse “C”

curve in the lower back. With this larger circumference, the nerves are able to move

more freely and thus back pain is more likely to occur.

The spaces between the vertebrae are maintained by round, rubbery pads called

intervertebral discs that act like shock absorbers throughout the spinal column to

cushion the bones as the body moves. Bands of tissue known as ligaments hold the

vertebrae in place, and tendons attach the muscles to the spinal column. Some

common risk factors for developing LBP include: age, fitness level, pregnancy, weight

gain, genetics, and occupational risk factors. Daily life prevention/relief of LBP may

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occur by avoiding movements that jolt or strain the back, maintaining correct posture,

and lifting objects properly, maintaining a healthy weight, and proper sitting.

Figures 3 & 4.

To properly support the back, there needs to be enough strength in the abdominal and

trunk muscles as well as the pelvic floor to create a protective belt. By strengthening

the core muscles, the back is supported, thereby relieving the back pain. The

abdominals are made up of the rectus abdonimis, external oblique, internal oblique, and

transverse abdominis (TA). The TA muscles are the most important of the abdominal

muscles regarding stabilization of the torso. The TA is the deepest of the abdominals

wrapping around the spine and acting like a natural protective weight lifting belt to

protect the spine from unwanted movement. Intra-abdominal pressure is the co-

contraction of the TA and the obliques, which surround and compress the abdomen to

protect the spine from pressure . When these muscles are weak, the spine is left

vulnerable to stress which can lead to injury. The spinal extensors are located on the

back of the trunk and include three muscle groups: erector spinae, semispinalis, and

the deep posterior spinal group. The deep posterior spinal group includes the multifidis

muscles which lie deep along the spinal column and are comparable to the TA in terms

of stabilization. The multifidus and TA work together to co-contract providing support

and stabilization to the trunk helping to provide relief and prevention of back pain.

Actively working the pelvic floor muscles, can influence the position of the sacrum and

can help relieve or prevent LBP. Three other important muscles that support the low

back and spine: psoas major, quadratus lumborum, and lattissimus dorsi.

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Introduction

This research paper will focus on the issue of LBP. It will look at what it is, how/why it

occurs, and anatomy. It will also discuss a case study and provide a Pilates

conditioning program. Pilates has gained recognition in medical and fitness circles as a

beneficial form of exercise to address an array of concerns to include LBP. An effective

Pilates back care program pays careful attention to the muscles of the abdominals, back

extensors and pelvic floor while also considering the body as a whole. The body is an

interconnected chain and compensation or dysfunction in the lumbo pelvic hip complex

will lead to dysfunction in other areas of the body. A complete program will provide

special attention to varying ranges of motion, sufficient intensity, load, correct

mechanics and muscle recruitment, as well as utilizing the core.

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Case Study

John is a 50 year old male who works in a job sitting at a desk for most of the time

during a 40 hour work week. A couple of his hobbies involve sitting as well; playing

video games and watching TV. His exercise includes walking a couple times a week

and coaching softball 3-4 times a week. John has had low back pain off and on for 15

years. Pain relief medication is how he has dealt with this recurring issue.

He’s motivated to try Pilates to improve his body structure and quality of life. The

following conditioning program is laid out into three sessions of 10, progressing on each

previous program. The objective of the conditioning program is to take in the Pilates

principles in order to establish realistic goals consisting of recruiting muscles correctly,

developing core strength, building the appropriate muscle strength and stretching the

tight muscles, improving flexibility, and building through the progression of exercises.

John has poor posture from slouching/hunching and sitting a lot. He has weak

abdominals, tight psoas, hip flexors, and hamstrings. General goals for John include:

1) balance in the body to reduce load on the lower back, 2) strengthening weak areas

(core muscles, hip abductors, upper back stabilizers for example), 3) stretching tight

areas (psoas, hamstrings, hip flexors for example), and 4) improving body awareness

and postural correction. General exercises will include back extension to bring

awareness to and help correct posture. We’ll also work on flexibility and strength

around the hip flexors and extensors and alignment of core while doing exercises with

arms, legs and hips through full range of motion.

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Sessions 1-10

Block/Equipment   Exercise   Purpose/Desired  Results  

Warm-Up/Mat

Roll  Down  Pelvic  Curl  Spine  Twist  Supine  Chest  Lift  Chest  Lift  with  Rotation  

Assessment  Tool  SA,  hamstring  control,  pelvic  lumbar  stability  Ab  Obliq,  spinal  rotation,  pelvic  lumbar  stab  Abdominal  strength,  pelvic  stability  Abdominal  oblique  strength,  pelvic  stability  

Footwork/Reformer Parallel  Heels  Parallel  Toes  V-­‐position  Toes  Open  V  Heels  Open  V  Toes  Calf  Raises  Prances  

Hip/Knee  extensor  strength,  hamstrings,  quads  Hip/Knee  extensor  strength,  hamstrings,  quads  Hip/Knee  extensor  strength,  hamstrings,  quads  Hip/Knee  extensor  strength,  hamstrings,  quads  Hip/Knee  extensor  strength,  hamstrings,  quads  Ankle  plantar  strength  Ankle  plantar  strength  

Abdominal Work/Reformer

100  Prep  Coordination  

Abdominal  strength,  shoulder  extensor  control  Ab  strength,  shoulder  extensor  control  

Hip Work Supine  Leg  Series  -­‐ Frog  -­‐ Circles  Down/Up  -­‐ Openings  

 Hip  adductor  strength,  knee  extensor  control  Hip  adductor  strength  &  extensor  control  Hip  adductor  stretch  &  strength  

Spinal Articulation (SA) None    Stretches/Reformer Standing  Lunge   Hip  flexor  &  hamstring  stretch  Full Body Integration I (FBI)

None    

Arm Work/Magic Circle Arms  Series  -­‐ Arms  Bent  -­‐ Arms  Straight  -­‐ Arms  Overhead  -­‐ Single  Side  Press  -­‐ Single  Arm  Bicep  

 Shoulder  adductor  strength,  pectorals  Shoulder  adductor  strength,  pectorals  Shoulder  flexor  strength,  deltoids  Shoulder  adductor  strength,  scapula  stability  Elbow  flexor  strength,  biceps,  scapula  stability  

FBI II None    Leg Work/Magic Circle Supine  Series  

-­‐ Knees  -­‐ Ankles  

 Hip  adductor  strength,  pelvic  lumbar  stability  Hip  adductor  strength,  pelvic  lumbar  stability  

Lat Flex & Rot/Step Barrel

Spine  Twist  Supine  Side  Lift  

Spinal  rotation,  abdominal  oblique  control  Lateral  flexor  stretch,  abdominal  oblique  control  

Bk Extension/Step Barrel Swan  Prep   Back  extensor  strength,  trunk  stability    Gain familiarity with foundation of BASI Pilates. Most of the practice is on the mat with some Reformer and Step Barrel. Goals include: teaching awareness, movements, proper alignment and focusing on specific muscle groups. Always starting and ending with roll-up and a few extra stretches at the end.

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Sessions  11-­20    

Block/Equipment   Exercise   Purpose/Desired  Results  

Warm-­Up   Same  as  Sessions  1-­‐10   Same  as  Sessions  1-­‐10  Footwork/Cadillac   Parallel  Heels  

Parallel  Toes  V-­‐Position  Toes  Open  V-­‐Position  Heels  Open  V  Position  Toes  Calf  Raises  Prances  Single  Leg  Heels  Single  Leg  Toes  

Hip  &  knee  extensor  strength,  hamstrings  Hip  &  knee  extensor  strength,  hamstrings  Hip  &  knee  extensor  strength,  hamstrings  Hip  &  knee  extensor  strength,  hamstrings  Hip  &  knee  extensor  strength,  hamstrings  Foot  plantar  flexor  strength,  foot  stabilizers  Foot  plantar  flexor  strength,  foot  stabilizers  Hip  &  knee  extensor  strength,  hamstrings  Hip  &  knee  extensor  strength,  hamstrings  

Abdominal  Work/Cadillac   Warm-­‐Up  Series  -­‐Roll-­‐up  with  RUBar  Mini  roll-­‐up  Mini  roll-­‐up  oblique  Roll-­‐up  Top  Loaded  

 Abdominal  control,  trunk  stabilization  Abdominal  strength,  pelvic  lumbar  stability  Abdominal  oblique  strength,  neutral  pelvis  Abdominal  strength,  shoulder  stretch  

Hip  Work   Supine  Single  Leg  Series  -­‐ Frog  -­‐ Circles  Down/Up  -­‐ Hip  Extension  -­‐ Bicycle  

 Hip/Knee  extensor  control,  hamstrings  Adductor  &  Hip  extensor  control,  hamstrings  Hip  extensor  strength,  hamstrings  Hip  extensor  control,  hamstrings,  coordination  

SA/Reformer   Bottom  Lift  Bottom  Lift  With  Extensions  

SA,  abs,  hamstrings,  hip  extensor  control  SA,  abs,  hamstrings,  hip  extensor  control  

Stretches/Reformer   Standing  Lunge   Hip  flexor  &  hamstring  stretch  FBI  I/Reformer   Scooter  

Elephant  Trunk/Shoulder  stability,  hip/knee  extensor  Trunk/Shoulder  stability,  ham/shoulder  stretch  

Arm  Work/Ped-­A-­Pul   Arms  Standing  Series  -­‐ Extension  -­‐ Adduction  -­‐ Circles  Up/Down  -­‐ Triceps  

 Shoulder  extensor  strength,  latissimus  dorsi  Shoulder  adductor  strength,  latissimus  dorsi  Shoulder  extensor/adductor  strength,  lat  dorsi  Elbow  extensor  strength,  triceps  

FBI  II   None    Leg  Work/Leg  Weights  With  Short  Box  

Gluteals  Kneeling  Series  -­‐ Hip  Ext  Bent  Knee  -­‐ Hip  Abduct  Bent  Knee  -­‐ Hip  Ext  Straight  Leg  

 Hip  extensor  strength,  pelvic  lumbar  stability  Hip  abductor  strength,  pelvic  lumbar  stability  Hip  extensor  strength,  pelvic  lumbar  stability  

Lat  &  Rot/  Wunda  Chair   Side  Stretch  Side  Kneeling  Stretch  

Lateral  flexor  stretch,  abdominal  oblique  Abdominal  oblique  stretch/control  

Back  Extension/  WC   Swan  on  Floor   Ab  control,  scapular  stability,  back  ext  strength  

Start to bring more awareness to muscle areas. Trunk stabilization, co-contracting abdominals and back muscles. Strengthen shoulder extensors. Introduce more apparatus: Cadillac, Ped-a-Pul, leg weights, and Wunda Chair. Add on to first 10 sessions, yet still at a mostly fundamental level. It takes time to strengthen back and abdominals, and to stretch chronically tight hip flexors and hamstrings, for example.

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Sessions 21-30

Block/Equipment   Exercise   Purpose/Desired  Results  

Warm-­Up/Mat   Roll-­‐Up  Spine  Twist  Supine  Double  Leg  Stretch  Single  Leg  Stretch  Criss/Cross  

Assessment  Tool  Spinal  rotation/abdominal  obliques  Abdominal  strength,  trunk  stabilization  Abdominal  strength,  trunk  stabilization  Abdominal  obliques,  trunk  stabilization  

Footwork/Wunda  Chair   Parallel  Heels  Parallel  Toes  V-­‐Position  Toes  Open  V-­‐Position  Heels  Open  V-­‐Position  Toes  Calf  Raises  

Trunk  stability,  hip  ext  control,  hams,  quads    Trunk  stability,  foot/ankle  control,  hams,  quads  Trunk  stability,  foot/ankle  control,  hams,  quads  Trunk  stability,  hip  ext  control,  hams,  quads  Trunk  stability,  foot/ankle  control,  hams,  quads  Ankle  plantar  flexor  strength/stretch  

Abdominal  Work/WC   Standing  Pike  Cat  Stretch  Kneeling  

Lower  back  stretch,  abdominal  control  Abdominal  control,  back  extensors  

Hip  Work/Reformer  (Ref)   Extended  Frog  Extended  Frog  Reverse  

Hip  adductor  stretch/strength    Hip  adductor  stretch/strength  

Spinal  Articulation/Ref   Short  Spine  Long  Spine  

SA,  abdominals,  hamstring  stretch  SA,  abdominals,  hamstrings,  hip  ext  control  

Stretches/Reformer   Kneeling  Lunge  Side  Split  

Hip  flexor  &  hamstring  stretch  Hip  adductor  stretch/strength  

FBI  I/Reformer   Stomach  Massage  Series  -­‐ Round  Back  -­‐ Flat  Back  -­‐ Reaching  

 Trunk  stability,  knee  extensor  strength,  abs  Trunk  stability,  knee  extensor  strength,  bk  ext  Trunk  stability,  knee  extensor  strength,  abs  

Arm  Work/Reformer   Arms  Kneeling  Series  -­‐ Chest  Expansion  -­‐ Circles  Up/Down  -­‐ Triceps  -­‐ Biceps  

 Shoulder/elbow  extensor  strength,  lat  dorsi  Shoulder  flexor  strength,  anterior  deltoid,  pecs  Elbow  extensor  strength,  triceps  Elbow  extensor  strength,  biceps  

FBI  II/Reformer   Down  Stretch   Trunk  stability,  shoulder  ext  control,  abs  Leg  Work/Wunda  Chair   Frog  Front  

Backward  Step  Down  Trunk  stability,  knee  ext/hip  external  rotation  Knee  extensor  strength,  glutes,  quads,  hams    

Lateral  &  Rot/Step  Barrel   Side  Lift  Corkscrew  

Lateral  flexor  stretch,  abdominal  obliques  Hip  flexor  control/stretch,  abdominal  obliques  

Back  Ext/Step  Barrel   Swan  Prep  Swan  

Trunk  stability,  back  extensor  strength  Back  extensor  strength,  hip  extensor  control  

Sessions 21-30 Some intermediate exercises are added. John finds Pilates challenging, interesting, and motivating as he notices the progress/benefits he is making. This builds his confidence and continues with the program to a healthier and happier quality of life.

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Conclusion

Back pain is something that most people will experience at some point in their life. John

has made very nice progress in starting and advancing his Pilates sessions and has

noticed the benefits. He feels stronger and knows what muscles to use to co-contract to

maintain proper alignment. He is restoring balance in body by strengthening weak

areas and stretching tight areas with an emphasis on neutral spine while moving. He

plans to continue taking 2-3 sessions weekly and to start small group apparatus

classes. He wants to keep the “good” postural habits he has learned and is aware of

continuing to take them out into his daily life both at work and elsewhere. Lastly,

several strengthening and stretching mat exercises were written out for him to do as

“homework” at his leisure.

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Bibliography

1. Aaronson, Naomi, and Turo, Ann Marie, Pilates For Breast Cancer Survivors: A

Guide to Recovery, Healing, and Wellness, Demos Health New York, 2014.

2. Isacowitz, Rael, BASI Study Guide, Comprehensive Course. Costa Mesa, CA,

2000-2014.

3. Isacowitz, Rael, BASI Movement Analysis Workbooks: Mat, Reformer, Cadillac,

Wunda Chair, Auxiliary, Costa Mesa, CA, 2000-2012.

4. Isacowitz, Rael, Pilates, 2nd Edition, Human Kinetics, 2014.

5. Isacowitz and Clippinger, Pilates Anatomy, Human Kinetics, 2011.

6. Levin-Gervasi, Stephanie, The Back Pain Sourcebook, Lowell House, Los

Angeles, CA, 1995.

7. Stern, Jack, Ending Back Pain: 5 Powerful Steps, Weill Cornell Medical College,

2014.

8. Vijay, Vad, and Hinzmann, Hilary, Back RX: A 15-Minute-a-Day Yoga - &

Pilates-Based Program to End Low Back Pain. Gotham Books NY, 2004.

9. www.mayoclinic.com, “Back Pain” Sept 2012.

10. www.NIH.com, “Low Back Pain Fact Sheet.”

11. www.orthoinfo.com, “Low Back Pain” 2013.

12. www.patient.co.uk, “Nonspecific Lower Back Pain In Adults.”

13. www.spine-health.com, “Lumbar Spine Anatomy and Pain” by Davis, Eben, DC,

Jan 2013.

14. www.spine-health.com, “Pilates Exercise System To Promote Back Health” by

Glosten, Beth, MD, Mar 2003.

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15. Figure 1: www.mayfieldclinic.com, back pain image.

16. Figure 2: www.backnation.com, image.

17. Figure 3: www.denverpost.com, image.

18. Figure 4: www.crossfitresurgence.com, image.