Herniated Disc Injury

This was emailed to us and we thought others might be interested!

Hi,
I wanted to ask about herniated disks. I have a client who has a herniated disk between L4 & L5, she does not currently have pain. Is it correct to not do any kind of lumbar flexion with thorasic rotation(i.e. short box round back with twist or mat obliques roll back), just rotation of thorasic with lumbar in neutral to avoid any further herniation?
Thanks,
Deanna Murray

Response from Leslie Braverman:

Hello Deanna:
Thanks for emailing. When the disc ruptures or herniates, a portion of the spinal disc pushes outside its normal boundary. When a herniated disc bulges out from between the vertebrae, the spinal nerves and/or spinal cord can become compressed. So depending on where this is happening will determine which movements to avoid. Typically, it is recommended that people avoid spinal flexion and rotation, because the disc most frequently herniates posterior-laterally and flexion and rotation would exacerbate the problem and/or create pain. To be perfectly sure which movements are to be avoided, it is best to speak with a physician or physical therapist that has worked with your client and has seen the notes from an MRI and knows exactly where the bulge is occurring. Unfortunately, as a pilates teacher, it is often hard to get this information.

If your client were still having a lot of pain, I would suggest that he/she consult with a doctor and, ideally, work with a physical therapist before doing pilates.

Since your client is no longer having pain it is possible that the disc problem has been resolved and the annulus is no longer irritable and pushing on the nerves. In this case, you can progress your client through all exercises and use her symptoms as a guide. Initially, be cautious of lumbar flexion and rotation. On the other hand, your client may have lost a lot of disc height and have too much segmental mobility and/or  instability where the disc was herniated. Progress slowly and be cautious of too much flexion load on her lumbar spine. Be very conscious of her ability to sit in neutral lumbar position. Most likely,  your client will need to sit on a box or cushion to have a proper position without stressing the lumbar area.

I would recommend that you focus your programming on work that encourages your client to become very stable in neutral positions. Really monitor what is happening at L4-L5. You may need to place your hand on her back to really be sure that she is not flexion or extending, even minutely, at this level. Often people with L4-L5 herniations will not know how to sit properly in neutral position, so really check that her lumbar and sacrum are absolutely correct.

Giving your client lots of exercising that challenge stability in neutral positions will be key to her avoiding future herniations or other deterioration of the spine. Here are some examples. Use these ideas with discretion-depending on the clients level and innate strength at this time- use your professional judgment:

1.) Cat position exercises- all variations to build stability in neutral:
-picking up one hand at a time
-sliding one leg out at at time
-alternating opposite arms and legs (i.e. swimming prep on hands and knees)

2.) Shoulder Bridges- Glut strength is paramount for people that have lower back instability
-advance to picking one leg up at a time
Make sure she is getting Glut medius and deep fibers of Glut Max- not just her deep rotators and hamstrings- watch she doesn’t tuck her sacrum under. Keep your hand on L4-L5 to maintain neutral.

3.) Leg Pull Front Prep

4.) Reformer- Footwork- keep your hand on L4-L5- maintain neutral

5.) Short Box- Straight back
You could do this on the reformer too with the arm straps (like roll back with a straight back) add bicep curls if able

6.) In kneeling positions, make sure that her hips are open enough to get head of femur over the knee so her spine can stay neutral. Her hips may be tight and not allow her to do this.

7.) Extension work is great- my guess is that it was a posterior herniation- if there is any pain avoid it. You can definitely do things like breast stroke that encourage upper back extension. If things like Swan Dive feel good, then do them. As usual, check that she is not hyper-extending at any one spinal level.

8.) Lateral flexion- watch alignment is excellent.

Hopefully, this gives you some good ideas. Challenge her in standing, kneeling and sitting positions- as long as there is no pain. Add upper body and lower body resistances to challenge her ability to stabilize her back against rotational pulls. Side lying work would be great too.

Then, once she is really strong this way, I would begin to introduce more flexion and rotation. Make sure that she is getting movement in all segments of the spine, and she is distributing and translating movement throughout the spine and not giving in at one level.

Some clients will fully recover from disc issues and some will always have a degree of vulnerability. You will have to find out slowly over time and with thoughtful progressions. When in doubt, be open to consult with your clients’ other health advisors and clinicians.

I hope this helps!

Best, Leslie Braverman

Ideas for working with a spinal fusion

This question was emailed to us, and we thought others might be interested!

Hi Leslie,

I have a client who is 25 and has two metal rods in her back, one on each side of her spine because of terrible scoliosis. She is not very mobile because of the rods, she can manage imprint and neutral but can only do extremely limited flexion and extension. The muscles in her lower back are obviously imbalanced, very strong on her right side and almost non existent on the left. What would you suggest for helping balance out her core strength considering her lack of mobility? Thanks so much!
Erin Whipp

Answer from Leslie Braverman:

Hi Erin:
Nice to hear from you. I hope things are going well!
 
Oooh, I have worked with a few clients that have had metal rods put in their back, and there is a lot you can still do.
 
My suggestion is to continue moving her spine only gently through ranges- mostly keep her neutral, but try to do as many things that challenge her torso strength as you can. Contralateral arm and leg work will be excellent, as well as doing things that challenge weight distribution and proprioceptive awareness. Here are some ideas:
 
1.) Sitting back and front rowing (on a box or platform if necessary to sit in neutral). Do one arm backrowing work preps to get the weaker side stronger. You could even sit her on am unstable surface (ie. a wobble cushion) to build spinal control and learn to control rotation.
 
2.) Side lying work will be excellent. One leg kick, side leg lift series- prop her hip on a small ball to build more strength on an unstable surface as she progresses. Make sure to keep her spine in neutral and avoid rotation or lateral flexion. Do more reps on the side that is weaker.
 
3.) Plank position exercises – push up, leg pull front- add things on a ball.
You can also do plank based exercises against a wall too- standing on a BOSU and/or with two small balls under her hands- again to challenge spinal control and build awareness of body in space. Add contralateral arm or leg work to build strength on one side of the back more than the other.
 
4.) Waiters bow- elephant position- (on or off reformer- use ligher weight) with one arm on the bar instead of two. or just practice going into waiters bow while standing on the floor and reaching one arm up by her ear- standing up with that arm by her ear will work her erectors and deep paraspinals on that one side, as well as challenge rotation and build glut strength.
 
5.) Contralateral prone work without extension- ie. swimming preps
 
6.) Standing on one leg while doing arm work, while high level, will help her build up strenth on one side more than the other.
 
Hope this helps and gives you more ideas. Let me know if you have questions. I can leave out your name if you like too.
 
Thanks Erin! Good luck.

Scoliosis & Winging Scapula

This question was emailed to us from Mila in NYC:

I have long s-shaped thoracolumbar scoliosis. I looked at a post on your website and realized you spoke to someone about a client that had a shoulder blade that tips foward. My left shoulder blade, which has been described as a “winged scapula” is tipped foward to the point where it looks like I am slouching. I have a thoracic scoliosis with convexity to the right.

I often feel “tired” on the left side of my upper body. Do you know of any exercises to help with this or with aesthetic apperance of the scapula? I failed to mention that I am 21 years old.  Also, I know you are not a doctor but I was just wondering if you know whether my condition can worsen with time. I happen to be left-handed. Could that have contributed to scoliosis as well? Also, can an abnormality in the shoulder blade (such as winging or rotation) cause scoliosis?

Jean’s response:

Winging scapulas are not an uncommon occurrence when you have a thoracic scoliosis. If it is feeling tipped forward as well as winged then it would help to strengthen the mid and lower segments of the trapezius muscle as well as serratus anterior. STOTT PILATES has a variety of exercises that can help target those muscles. However, based on the curvature of your spine that scapula may not ever be able to lie perfectly flat on your ribcage. We should be able to decrease the amount of winging and help it to stablize in a more neutral position.
As far as feeling “tired” or less connected to your left side, it might help to focus on breathing into that side more. Most of us have a somewhat assymetrical breathing pattern and a scoliosis increases the odds of that happening. Lying over the spine corrector or an arc barrel or large pillow on your right side will help to open up the ribcage on your left side. Imagine the ribs opening and closing like an accordian to increase the oxygenation to that side. Breathing can create some amazing changes in the body just by bringing awareness and increased blood flow to that area.
I have included some photographs of  winging and tipped scapula as well as a good  exercise to strengthen the scapula stabilzing muscles below.

Melanie’s response:

Thank you for writing to us. Indeed there is alot that you can do to help relieve the fatigue you feel in your spine. Whether or not you can change the appearance of your scapula depends on whether there is a myofascial component causing the winging, or if the scapula position is determined solely by your scoliosis.

There is some great research by Paul Hodges that talks about the differences in muscle type and function on either side of the curve. As Jean wrote, combining breathe and movement is one of the very most effective ways to change scoliosis and optimize function.

A couple of exercises that you could start with:
Arm scissors and arms overhead: focus on the motion of the left scapula and clavicle. The clavicle must rotate posteriorly to achieve full elevation and to bring the scapula in contact with the rib cage. Keep your posterior rib cage down as you slowly create the proper mechanics at the SC joint and clavicle. You can use your inhale to try to elongate the pectoralis minor which is frequently is a cause of winging.

Mermaid- Do this to both sides but have a different focus for each side: side bending to the right with the left arm in elevation: focus your inhale into the pectoralis minor region and try to get elongation through the lateral muscles of your trunk and scapula. Really focus on reaching up and over as you side bend right. On the side, after side bending to the left, really focus on your return to vertical. Developing the the multifidus and erector spinae should help with the fatigue.

Spinal rotation with scapula isolation: focus on spiraling through the rotation. Usually we will allow the pelvis to move instead of maintaining the initial stacked position due to the scoliosis.

Spine stretch forward with hands on a stability ball- exhale as you roll forward focusing on keeping your scapulae centered and with no gripping; inhale in your flexed position focusing on not gripping around your scapular and neck muscles; then exhale as you re-stack your spine. After having done a couple of repetitions, add an additional challenge to your spine; after stacking up your spine perfectly, maintain your spine and lift both arms off the ball without shifting or rotating.

Start with those and let us know how it goes. Naturally every exercise can be adapted for your scoliosis and scapular issue.

A good example of winging and anteriorly tipped  scapulae.

Shrugging the shoulders up and then sliding them part way down is a good way to find a more neutral alignment.

Once you have your shoulder blades as neutral as possible, (i.e. flat against the ribcage) then try some wall push-ups, trying to maintain the scapula in this stable position while you are bending and straightening the elbows. You should not let the shoulder blades move while you do the push-up.

Keep the body in one straight line as you do the push-ups. The heels can come off the floor as needed.

Pilates and Posture: What is ideal?

Yesterday, one of my new students asked me if I thought Pilates could help their posture, and I told her that over the last ten years, I have seen countless numbers of students radically improve their posture through pilates. So, she asked me to analyze her posture and suggest exercises that would be most beneficial for her to do. Of course, I did this for her, and she was able to leave the lesson with five or six things that she could focus on while working in group classes and on her own.

Later, I realized that this would be a great topic to focus on for our blog. So, here is my first entry about Pilates and Posture. Today, I will talk about what is commonly considered “Ideal Posture.” An ideal posture (or standard posture) is something that we strive for.

In general, ”good posture” is one that promotes overall balance for all the joints and organs and minimizes stress and strain throughout the body. Good posture allows joints to glide and move as they were meant to, minimizing unwanted grinding or sheering. Good posture also is “conducive to good alignment of the abdomen and trunk, so that the chest and upper back are in a position that favors optimal function of the respiratory organs” (Florence Peterson Kendall, PT)

As seen in the profile picture below, the spine has its’ normal curves, the pelvis is level (the two hip bones in the front (ASIS) are on the same plane as the pubic bone), the hip joint is centered in the socket and the thigh bones are stacked directly over the bones of the lower leg (tibia and fibula) and the head sits balanced on the spine so that there is a slight (lordodic) curve in the neck and the chin sits in line with the sternum.

 

The back view of an ideal posture, seen to the right, shows the head balanced (neither tilted or rotated), a straight neck, level shoulders and shoulder blades, a straight spine (right and left sides of the trunk are symmetrical), level pelvis and neutral hip joint and knees. The toes are pointing slightly outward.

 Since there is a direct coorelation between the static alignment of the bones and the balance of the muscles which attach to them, pilates exercise can be used as means to change posture. In order to do this effectively, one’s posture should first be analyzed for deviations that appear different from the standard posture. Then, a qualified instructor should be able to select exercises that help to lengthen or strengthen muscles that contribute to the postural deviation. In addition, the instructor needs to be able to successfully guide the student through the exercises, using props or modifications as needed, in order to ensure that the student is effectively changing their habitual movement pattern and using the correct muscle groups throughout.

Stay tuned for more entries about posture and learn about the three classic postural types and which pilates exercises may be most beneficial to focus on in each case.

 

 

Anatomy of the Pilates Reformer

The pilates reformer is an amazing piece of equipment. The design is simple and, yet, it is extremely versatile, enabling one one to do hundreds of different exercises that strengthen and/or stretch the arms, legs and trunk.

There is a carriage in which one can sit, kneel or stand on and which glides back and forth. On the underneath side of the carriage or wheels which allow it to glide and 5 different springs which create resistance to work against.

Resistance can be created for the arms or legs in various positions by either placing the hands or feet on the footbar (the bar at the front) or by putting the hands or feet into the straps. Depending on the exercise, all parts of the body can be used to either move the carriage or to stabilize the body against resistance that is very light or very heavy.

 In this particular exercise, the student is rotating her spine against resistance when she turns to the left, using her obliques, to create the rotation.

 

 The focus of an exercise, muscularly, can change depending on the amount of resistance (number of springs). For example, In this next exercise (pictured below), the student is pushing the carriage in and out with her arms. If the weight is lighter, then it takes more effort to control the position of her back to maintain a plank position, if it is heavier than it becomes more challenging for her upper body.

    This remarkable piece of equipment also allows you to use the straps to work the upper body and legs while, simultaneously, working the abdominals to create length of the spine. Seen here, the arms are working but also the spine is rounding into a deep curve.

The reformer also allows you to build strength and flexiblity by controlling the carriage in a standing postion. Imagine trying to keep the carriage pressed out and bending forward (as seen below) on very light spring weight! This exercise is a great workout for the muscles on the inside of our legs and challenges flexibility of the hamstrings, coordination and balance!

Pilates can condition your body and mind like a dancer’s

I started doing pilates while dancing as a student in New York City at the School of American Ballet during the summer of 1988, and it is still the only kind of cross training I do. I’ve tried yoga, I’ve tried running, I’ve tried weight lifting, but none of them have stuck.

 

Pilates has been used by dancers as a method of improving technique and helping to rehabilitate injuries for decades. In fact, famous clients of Joseph Pilates include Martha Graham and George Balanchine, two of the most influential people in American dance history. Because of this, generations of dancers have studied pilates since the 1940’s.

 

So, what makes Pilates so useful to dancers? And can these concepts be applied to others?

Tracey Carboneau of Bouand DanceCompany

 

When Joseph Pilates worked with students, it is said, that he worked with everyone as an individual and, in fact, he had many of his students that were dancers work in a parallel position versus in a turned-out (externally rotated) position. His logic, likely, was to try to counter the work that dancers normally do (often in an externally rotated position) and provide more balance to the muscles fibers of the legs that get overworked by always being shortened in one way. So, while it may be assumed that the idea of turning out the legs is what makes pilates useful to dancers, on the contrary, it seems it is the idea of balance that is more important.

 

I remember when I first started doing Pilates it felt strange and awkward, to try to keep my legs in a parallel position. In fact, I had to look down at my feet sometimes in order to see if my feet really were in that position. I started to feel new muscles working- my adductors felt sore in a new way, and my quadriceps were really weak in parallel positions, especially when asked to jump or balance in a deep lunge. And strangely, my turn-out improved, and I felt stronger while dancing then ever before! I remember thinking, at the time, how odd it was that my legs would get stronger, be able to go up higher and externally rotate more easily by working on the opposing muscle groups.

 

Today, I find this is true with clients. If I focus on creating balance in their overall movement, they find improvement happens in their other activities. For example, if I work with someone that is a golfer, I try to provide them with a workout that balances their body. In other words, if he or she always hits the ball from one direction, I make sure they do a lot of spinal rotation in the other direction when they do pilates, and, inevitably, their golf swing improves!

 

Another reason, I believe, that pilates is such a useful training system for dancers, is that it asks the dancer to do movement that is efficient and full of ease. Just as with dancing, one must condition him or herself in a way that does not create the look of strain. This is untrue in other training systems, like weight lifting, where, often, the focus is on how much weight can be lifted and power, versus the quality of the movement that is being created. Even a male dancer that has to lift his partner has to be able to do this with ease and grace. This means that the power he has in his body must be gained using technique that is, simultaneously, coordinated, rhythmic and expressive. For a dancer, having power exclusive of these other factors is meaningless.

 

Scott Trumbo and Cate Powers of Bouand DanceCompany

Consider this same concept for other athletes, and the same is true. The greatest basketball players, golfers, skaters, swimmers and runners, all share this same quality. Their movement looks utterly effortless, coordinated and beautiful when done well. Granted Michael Jordan isn’t paying attention to the same kinds of details on the basketball court that Mikhail Baryshnikov is paying attention to in a ballet, but I would bet that the level of concentration, attention to detail and skill is equivalent. If a dancer is unable to execute his or her pirouettes well, he or she is going to think about changing any number of things to correct the problem. Perhaps the way he or she is taking his foot of the floor is effecting the direction of the turn, the dancer will have to consider this change and then work to integrate it into the mechanics of the turn until it becomes natural to do. The same way that a basketball player may need to alter the timing of his throw or how he or she releases the ball from his hands in order to consistently throw the ball in an accurate direction.

 

What I realize as a pilates teacher is that the idea of training your body to be able to do things with precision and ease is a skill that everyone can use. I believe, human beings were designed to use their body that way. In a pilates class, I ask my students to do the same thing I would ask of myself as a dancer: to pay attention to the quality of the movement, the rhythm, dynamic and genesis of it.

 

With this point of view, an exercise like “Footwork” on the reformer becomes quite demanding. A student not only has to think about the placement of his or her feet, but the timing of the movement, the alignment of the knees while they bend and straighten, the position of their back and the recruitment pattern and quality of the muscles that are at work to either stabilize some parts of the body or create effortless, coordinated movement with others. Finally, can all these things be integrated so that the movement is done as efficiently and easily as possible.

 

Pilates, for me, will always be a remarkable conditioning method, because it conditions me like a dancer. It incorporates all the subtle distinctions of training my body as an artist that must take care with the placement of my hands, feet, eyes and head while incorporating the power and control of an athlete that must jump, turn and have fluid, exquisite control.

 

 

 

 

How do I work with someone with scoliosis?

From Melanie Byford-Young

Hi Jeff,
Great questions about your client.

Osteoporosis & Pilates

This question was sent and responded to through email, but we thought others might be interested!

Hi Pacific Northwest,
This is Christi Tuck from the YMCA in Colorado Springs. I thought I would run this question by your studio since over the years we have had your instructors come out to the Springs to do our CEC’s. Anyways, I have a client that was recently diagnosed with osteoporosis of the spine and osteopenia of the hip. I have done quite a bit of research regarding safe exercises for her, however I am still not sure about backward flexion, e.g. backrowing roll-down on the reformer … I know to avoid all forward flexion and lateral flexion. Her doctor said minimal spinal rotation with no resistance would be okay. Any thoughts on the backward flexion??
Thanks for any information you can provide. Have a great holiday weekend.

Sincerely,

Christi Tuck

Answer from Leslie Braverman:

Hi Christi:

This is a great question!

The conservative approach is to omit all flexion and rotation from a client’s workout. Unfortunately, most normal people have to conduct some flexion and rotation in their daily lives, so, in my opinion, it is a good idea that they know how to do these movements appropriately and without alot of loaded compression. Practically speaking, an individual will have to do these movements but should be educated to know what is appropriate for the overall health of their bones.

The thing I try to do is to make sure that the flexion and rotation is never in a loaded position and is done minimally during a workout (i.e. with lots of exercises that include extension and neutral spine spaced between.) Loaded flexion includes ANY inverted work. I would make certain never to do any roll over, short spine type of exercises. Especially because the thoracic spine can fracture easily, you want to make very sure that you omit these kinds of exercises—easily done. This is, of course, something to keep in mind when working in a group setting, also, when you don’t know all the students or their history very well.

In addition, you may need to be cautious with other types of loaded rotation or flexion that uses alot of spring tension or sends a great amount of loaded compression through the spine (I would be careful with things like stomach massage and elephant in a round back position). Also, exercises that combine flexion and rotation in one should, generally, be omitted (i.e. saw, stomach massage with twist etc.)

Do your best to keep your client working in neutral positions as much as possible. As an important aside, loading the bones in other ways would be great and makes Pilates a safe and effective tool for bone building! (i.e. footwork, jumping on the STOTT PILATES® jumpboard, armwork with the spine in a neutral position) all of these types of exercises are going to help your client to build bone without stressing one particular area of the spine too much. Good for you…. being a smart and inquisitive instructor!

I also hope that Melanie and Jean will put in their two (or three) cents!

I hope you are well…all my best to everyone in Colorado Springs.

Leslie

Reply from Christi:

Hi Leslie,
Thank you so much for your quick reply. Your information was invaluable and it also helped confirm the changes I have made to her workout. We had a private session on Friday with omitting the exercises you have mentioned with a main focus on staying neutral. She attended my reformer class yesterday so I was able to ask her how her body responded with the changes we made and I am pleased to say she felt great. Fortunately, she has been doing pilates for a while so her mind/body focus is wonderful. I am happy to hear that you think the jumpboard is a good option because she enjoys it. Thanks again for all your information.

Sincerely,

Christi Tuck