Pilates and Rehabilitation for Disc

Protrusions in the Lower Lumbar Spine

– A Case Study of a Marathon Runner

JENNIFER POWELL

16 October 2018

CTTC FEBRUARY 2018

BODY MECHANIX JOHANNESBURG

FACULTY MEMBER: ASHLEY RITCHIE

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Abstract Chronic lower back pain is very common across the globe and specifically in

South Africa with a lifetime prevalence of 51% to 80% in adults and is noted as

being the leading cause of years lived with disability (Harsha Shanthanna, 2017).

The function of the vertebral disks is to protect the vertebrae of the spine by

absorbing the shocks from daily activities such as running, walking, lifting and

twisting. The causes of prolapse or slipped disk conditions often occur when the

outer supporting ring of the disks between the vertebrae become weak or torn

allowing the inner portion to slip out between two vertebrae. The weakness of the

disks may often occur through overuse or simply the daily physical actions listed

above (Nall, 2016). Patients with lower back pain and prolapse disk conditions are

often considered as candidates for spinal fusion and other invasive procedures by

surgeons, who may also obtain similar results and benefits from an intensive

rehabilitation program through the correct exercises as they would from surgery

(BMJ, 2005).

The case identified is:

• Ryan

• Marathon Runner – high mileage, no other strength or cross training

• Diagnosed with - laterally prolapsed disk between L4 and L5 vertebrae see

Annexure A.

• Choice of treatment – series of epidural cortisone injections, followed by

physiotherapy and pilates strength training program

This case study highlights the benefit of using a specific pilates program and

exercises as a means of rehabilitation for lower lumbar disc injuries.

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Table of Contents

LIST OF FIGURES 4

LIST OF TABLES 4

PROBLEM STATEMENT 5

INTRODUCTION 5

About the Case Study Client 5

ANATOMY OF THE LUMBAR SPINE 7

The Bones 7

The Discs 10

The Muscles 12

RECOMMENDATIONS FOR RYAN 14

SUMMARY OF RYAN’S GOALS THROUGH PILATES 14

MAT REPERTOIRE DESIGN 15

EQUIPMENT REPERTOIRE DESIGN 18

CONCLUSION 22

BIBLIOGRAPHY 24

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ANNEXURE A. 25

ANNEXURE B. 26

List of Figures Figure 1. Two main divisions of the skeleton, taken from IB SEHS NOTES ........ 8

Figure 2. Five regions of the vertebrae, taken from Isacowitz, Rael. Pilates

Anatomy (Kindle Locations 349-353). Human Kinetics. Kindle Edition. ................ 9

Figure 3. Joints of a healthy spine with detail of a intervertebral disc (Isacowitz

& Clippinger, 2011) ............................................................................ 11

Figure 4. MRI and Posterior view of a bulging disc, (Alamy Stock Images online)

.................................................................................................... 11

Figure 5 Diagram of the key core muscles recruited to stablise the spine

(Function 360 images online) ................................................................ 12

Figure 6 Spinal movements: (a) flexion and extension; (b) right lateral flexion

and left lateral flexion; (c) right rotation and left rotation (Isacowitz & Clippinger,

2011) ............................................................................................. 13

List of Tables Table 1 Mat Repertoire designed for Ryan ............................................ 15

Table 2 Equipment Repertoire designed for Ryan ................................... 18

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Problem Statement We operate in a world where instant gratification rules and short-term results

are tempting, but often more invasive and sometimes risky. Can a focussed,

individually tailored pilates programme provide the necessary rehabilitation in

rebuilding the strength, mobility and stability in active individuals with lower

lumbar disc protrusions?

Introduction

About the Case Study Client

Ryan Powell is a director at a conservation and destination management

company, he is a 42-year-old, 1,93m tall – as well as a passionate recreational

marathon and long-distance runner. Ryan’s type of work requires long periods of

time sitting behind a desk, in meetings as well as flying on long haul flights in a

reclined seated position over most months of the year. Despite this, he tried to run

every morning before work even whilst travelling to ensure he kept up with his

running program distance goals in preparation for the marathon distance races.

In early 2017 Ryan decided to undertake a personal and lifelong goal of

completing the major marathons of the world while raising funds to support the

Rhinos Without Borders initiative. This meant completing seven marathons over

seven consecutive months starting in September 2017, including and in order of

occurrence:

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Marathon Date Status Cape Town Marathon 2017

17 September 2017 Completed

Berlin Marathon 2017 24 September 2017 Completed Chicago Marathon 2017

8 October 2017 Completed

New York Marathon 2017

5 November 2017 Completed

Tokyo Marathon 2018 25 February 2018 DNS Boston Marathon 2018

16 April 2018 DNS

London Marathon 2018

22 April 2018 DNS

*DNS – Did not start

Ryan steadily completed the first four marathons successfully, however towards

the last two marathons in 2017 he presented with plantar fasciitis and lower back

pain not long after the New York Marathon in November. While Ryan was able to

rest during the December month before the next three marathons, he was not able

to regain running without pain and acute discomfort. As a result, Ryan went to see

a sports physician in order to assess the situation before embarking on the next

three marathons.

Shortly after his initial assessment with the specialist, on the 9th of January

2018, Ryan was diagnosed with a “right paracentral disc extrusion at the level of

L4/L5 with associated nerve impingement” per DR S Palliam taken from an MRI

Lumbar of the spine (Annexure A refers). The treatment diagnosis and plan

discussed in consultation with Ryan’s sports physician Dr Jon Patricious was to

avoid surgery where possible and to proceed with a first course of treatment

through “epidural and perineural injections, medication, physiotherapy and rest”

(Annexure B refers).

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This meant that Ryan was no longer able to complete the marathon goals and

had to completely stop all running while he went through the treatment with lots

of rest, very little sitting recommended and not much exercise other than the

relevant physio prescribed low impact home exercises.

The most likely reasons for the injury are believed to be due to the overuse

through repetitive motion of the back to back marathons with very little additional

cross training or strengthening of the core and other muscles involved in

supporting the spine.

Once the physio had given the consent to continue with a Pilates strengthening

program, while avoiding deep flexion and rotation, we started working on a plan

for how best to address any weaknesses, imbalances, alignment and mobility

through targeting the supporting structure of the spine.

Anatomy of the Lumbar Spine In order to assist Ryan with his rehabilitation and recovery, it was important to

understand the anatomy of the spine and surrounding muscles so that I could

provide the best possible guidance and program for his recovery.

The Bones

In order to understand how best to improve alignment we need to consider

looking into the structural building blocks of the human skeleton that assist in

determining alignment. The human skeleton has two main divisions being the axial

and appendicular skeleton as referred to in Figure 1. Below. For the purposes of

this case study we will be focusing on the axial skeleton anatomy without

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forgetting the appendicular skeleton as many precautions and compensations

might be related to or have an impact on either division of the skeleton.

Figure 1. Two main divisions of the skeleton, taken from IB SEHS NOTES

If we focus on the spine itself within the axial skeleton we can see that it

consists of 33 bones called the vertebrae, stacked in a column like fashion and

grow in size from the top of the neck to the bottom of the pelvis (Isacowitz &

Clippinger, 2011).

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Per Figure 2. The primary movements of the spine come from the three highlighted

regions of the total five sections shown in the image as they contain the 24

vertebrae responsible for these movements such as flexion, extension and

rotation.

The five divisions of the spine include the cervical vertebrae, thoracic vertebrae,

lumbar vertebrae, sacrum and finally the coccyx as shown in Figure 2 above. The

Cervical spine as shown in the green colour covers the top seven from the head to

the base of the neck and are the smallest and lightest vertebrae responsible for

the movements of the head and neck. The next 12 are the Thoracic vertebrae

Figure 2. Five regions of the vertebrae, taken from Isacowitz, Rael. Pilates

Anatomy (Kindle Locations 349-353). Human Kinetics. Kindle Edition.

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shown in blue and run from just below the next to the last rib and articulate with

the rib cage key in movements in the upper back.

Finally, and for the focus of this case study - the Lumbar vertebrae run from the

last rib to the pelvic girdle and these vertebrae are the stronger and larger of the

vertebrae in the spinal column mostly critical for weight-bearing and load and the

movements of the lower back.

The Discs

There are intervertebral discs which are very strong tissues filled with gel,

connect the front of the spine which allows the spine to move and provides the

necessary support. As seen in Figure 3 below depicting a healthy spine - the discs

are made up of the annulus fibrosus holding the gel substance called the nucleus

pulposus - and when the discs become compressed through overuse or injury the

gel like substance is squeezed and pushed out either laterally, anterior or posterior

to the spinal column often pushing out onto a nerve creating referral pain as seen

with Ryan’s case. This is referred to as a bulging or prolapsed disc of the lumbar

spine, per the image example in Figure 4 below reflecting the MRI scan as well as

the associated pain felt as a result of the bulging disc.

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Figure 3. Joints of a healthy spine with detail of an intervertebral disc (Isacowitz &

Clippinger, 2011)

Figure 4. MRI and Posterior view of a bulging disc, (Alamy Stock Images online)

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The Muscles

With over 30 muscles working to provide stability and movement in the spine,

there are two most important groups namely the abdominals and the spinal

extensors. The abdominals consist of the Rectus Abdominus, External and Internal

obliques and the Transversus Abdominus. The spinal extensors costs of the Erector

spine, semispinalis and deep posterior group. The first muscles believed to fire in

the stabilization of the spine are the transversus abdominus (TA), Multifidi and

pelvic floor muscles per Figure 5 below (Wood, 2018).

When the Transverse Abdominis and Multifidi co-contract, it provides the

essential stability for the lower lumbar spine along with the engaging the pelvic

floor which in turn takes the load off the spine when recruited.

For Ryan’s condition, it was critical to work on strengthening these core

powerhouse muscles in order to provide the necessary support and stability for the

Figure 5 Diagram of the key core muscles recruited to stabilise the spine (Function 360 images online)

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lumbar spine in order to avoid any further herniation of the disc and potentially

alleviate the side effects.

However, it was critical to understand that the affected disc can easily bulge

further under pressure such as compression, flexion and severe rotation. With this

in mind, it was noted that I would not be working with Ryan in his strengthening

program through any flexion or vertical loaded activities such as roll downs, sitting

for too long, roll overs or chest lifts done incorrectly. I also recommended he avoid

any strong spinal rotation such as golf, or related pilates exercise in determining

the repertoire to follow.

Figure 6 Spinal movements: (a) flexion and extension; (b) right lateral flexion and left lateral

flexion; (c) right rotation and left rotation (Isacowitz & Clippinger, 2011)

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Recommendations for Ryan Other than avoiding flexion and strong spinal rotation, the recommendation for

his rehabilitation journey through pilates was to focus on core strengthening with

the goal of unloading the disc and adding in back extension, glute strengthening

and upper torso stabilization. In discussions with Ryan’s physiotherapist, in his

particular case, flexion certainly could aggravate the bulging disc, however due to

Ryan’s disc bulge being posterior too much extension may also aggravate or pinch

of the disc. These precautions had to be considered with the main objective being

Pelvic mobility including the progression of exercises like the pelvic clock into a

pelvic curl provided no pain as a result of these exercises further down the

journey.

With the clearance from Ryan’s physio, two weeks after his last epidural

injection we started his first pilates session on the 27th of May 2018 with a basic

mat repertoire as listed below in Table 1. The rationale for selecting to start with

mat first was to introduce the fundamentals to Ryan first and keeping the

movements small, focused and controlled. I wanted to teach Ryan the importance

of the pilates principles and in particular the breathing and how this can help him

recruit the correct muscles to support him through the strengthening program.

Summary of Ryan’s goals through Pilates • Focus on awareness and working in neutral

• Strengthen back extensors and core including pelvic lumbar region

• Lengthen the spine without load and without flexion

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• Regain slow walking and running by the end of the year provided pain

free

Table 2 refers to the equipment repertoire then designed once Ryan was strong

enough and was able to perform the fundamental movements on the mat with

integrity and focus.

Mat Repertoire Design Table 1 Mat Repertoire designed for Ryan

The repertoire was designed using a combination of Ryan’s physiotherapist

recommended movements along with Sam Wood’s modified exercises on the mat

for disc precautions in the lumbar spine (Wood, 2018).

Block & Exercise Modification Reason Foundation – Warm up:

- Pelvic clock & tilts

- Leg Changes & Leg Lifts

- Chest Lift - modified

- Starting with basic Pelvic Clocks and Tilts before progressing later to a pelvic curl/hinge

- Fundamental mat leg lifts and changes no modification

- Modified Chest lift using a bosu or support behind the thoracic spine

- First teaching Ryan to connect with the deep TA muscles and encouraging mobility of the pelvis

- Basic leg lifts and changes encourages stability of the spine – started with lower reps moving up to 8-10 reps

- Doing a Chest lift from a supported position with a straight spine is far safer and less flexion into lower lumbar – also able to provide a small

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upper thoracic extension

Abdominals:

- Single Leg Stretch modified

- Leg Changes on Foam Roller

- Hundreds Prep modified

- Dead Bug using large ball lying supine

- Single Leg stretch – sliding leg out with the heel on floor progressing to on a ball for challenge on each side

- Lying supine on foam roller for leg changes stabilizing with hands and abdominals

- Hundreds Prep with the head down on the mat and knees bent and feet on the floor – progressing to bent 90 but head stays down – added a ball under one foot for challenge

- Encouraging pelvic stability with no rotation and abdominal work without loading the lumbar

- The foam roller challenges stability and we used this when Ryan was feeling stronger and more stable

- Keeping the head down ensures no deep flexion into lower lumber, and the feet down on the mat first ensures no pressure into lower lumbar – Ryan progressed to then adding legs up in bent 90 and we will move next into challenging using a small ball under one foot

Spinal Articulation:

- Pelvic curl/hinge Stretches:

- Hamstring stretch with TheraBand

- Piriformis Stretch

- Very little spinal articulation to start with other than once Ryan was stronger articulate more thoracic spine than lumbar with pelvic curl/hinge

- Lying supine on a mat using TheraBand over foot to stretch hamstring

- Piriformis Stretch – figure 4 on mat

- After 10 sessions the pelvic curls provided good spinal articulation and progression was noticed as Ryan’s strength improved

- Stretch Hamstrings to release pressure into lower lumbar

- Stretching out the piriformis helped alleviate some referral pain

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per Sam Wood’s exercises

Bridging:

- Front Support on elbows

- Physio ball walk outs and Pike on ball and push ups

Leg Work: - Clam level 1 and

2 and variation with small ball

- Shoulder bridge with adduction

- Gluteal Side Lying Series

- Magic Circles supine and standing series

- None to begin with until Ryan was strong enough to hold lumbar stability and pelvic floor without losing scapula stability or sinking into the lower lumbar.

- Started with modified pushups on the mat and bent on knees – progressing to the ball in next phase

- Clams using the

ball and different positions to target the glutes

- Modified on elbows to ease into movement and hold stable without sinking into lumbar

- Added the walk outs on ball after 20 sessions when stability and strength had improved

- Leg work to encourage glute activation and strengthening as well as to ensure hamstrings and quads are working

Lateral Flexion & Rotation:

- Modified Side Bend

- Side lifts & Side Kicks

None to begin with and very little rotation done with Ryan especially of the lower lumbar due to the disc precautions

- Started with a modified side bend with bent knees hinging up at the waist after 20 sessions

After 10 sessions we did basic standing lateral flexion reaches to each side. We also added in the side lift and side kick after 15 sessions.

- Bent knees on the mat adds less load to the lumbar as the lever to hinge is shorter

Back Extension:

- Basic Back Extension

- Multifidi on ½ foam roll/ rolled up mat

- Bird Dog

- Basic back with focus on upper thoracic extension only

- Adapted exercise to engage multifidi on half foam roll or mat

- Bird Dog for extension and

Focusing just on a small extension into the upper back extensors

- Multifidi focus to engage lower back extensors to strengthen and support lumbar

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adding with TheraBand for additional glute work

Equipment Repertoire Design Table 2 Equipment Repertoire designed for Ryan

The Equipment repertoire was designed using modified exercises as well as

some standard exercises taken from the Comprehensive course work as well as

from Sam Wood’s book on rehabilitation (Wood, 2018).

Block & Exercise Modification Reason Warm Up:

- Mat warm up per the above in mat repertoire

- Pelvic clock & tilts

- Leg Changes & Leg Lifts

- Chest Lift - modified

- Starting with basic Pelvic Clocks and Tilts before progressing later to a pelvic curl/hinge

- Fundamental mat leg lifts and changes no modification

- Modified Chest lift using a bosu or support behind the thoracic spine

- First teaching Ryan to connect with the deep TA muscles and encouraging mobility of the pelvis

- Basic leg lifts and changes encourages stability of the spine – started with lower reps moving up to 8-10 reps

Doing a Chest lift from a supported position with a straight spine is far safer and less flexion into lower lumbar – also able to provide a small upper thoracic extension

Foot Work:

- Reformer Footwork series modified

- Full reformer foot work series modified using a pole in the hands with palms facing

- The pole and palms facing up encourages some external rotation of the shoulders and to open up the

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up – working in neutral

upper thoracic area

- Focus on hamstrings and quad strength

Abdominals

- Reformer Hundreds prep with head down

- Reformer Single Arm co-ordination

- Legs in straps modified

- Keeping the head down with hundreds prep ensures no lumbar flexion

- Per Sam Wood’s exercises on Reformer

- Modified legs in straps and head supported by a towel no or very little lumbar flexion

- Keeping the head down or small supported movement up to ensure little lumbar flexion and pressure – lying supine on the reformer takes the load and compression off the lumbar spine and discs

Hip Work:

- Hip Series Reformer and modified Hip Stretches (Adductors, Hamstrings and sciatic Nerve)

- Reformer Supine Hip Work Series – staying in neutral

- The Additional Reformer hip stretches can be a stretch block or Hip Work block – Sam Wood’s exercises

- Lying supine is a good position for Ryan and opening up the hip flexors and encourage mobility in the pelvis and hip flexors

Spinal Articulation Upper thoracic Cat

Stretch or modified on long box on reformer

- Small thoracic spinal articulation only

Stretches:

- Reformer Kneeling lunge stretch and add extension

- Hamstring with TheraBand

- Sitting Forward Cadi – modified

- Piriformis stretch on wunda chair

- Ensure the spine is in a flat back position always and add small amount of upper thoracic extension

- Standard hamstring stretches on mat

- Modified Cadi Sitting Forward from Sam’s repertoire only

- Keeping a flat back in all the stretches ensures no forward flexion into the lumbar spine and still provides a good stretch for the hamstrings and hip flexors

- Stretching out the upper thoracic can

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extending upper thoracic and reaching up with no forward flexion

- Piriformis stretch on wunda chair but with a flat back and not folded into flexion

also provide some relief for Ryan

- Piriformis Stretching always provides Ryan with some referral pain relief and encourage mobility in the pelvis area

Full Body Integration 1:

- Quadruped Abs on reformer – modified Knee Stretch

- Up Stretch 3

- Modified exercise from Sam’s repertoire – facing back of reformer hands on base, light spring using abs eccentrically to pull carriage in and out keeping a stable flat back

- Doing the Knee Stretch with a flat back per Sam’s modification – a nice challenge for Ryan once he had shown improved strength

- Up Stretch 3 with a flat back

- Front support positions encourage Ryan’s shoulder stability and scapula stability while still working the abdominals too

- Keeping a flat back and strong core encourages lumbar pelvic stability and doesn’t add too much pressure to the lumbar spine

Arm Work:

- Supine Arm Series on Reformer – ball

- Single arm co-ordination variation

- Modified Rows on long box

- Bilateral external rotation

- Chest Expansion wide

- Lat pull down reformer

- Chair – triceps press sit and reverse shrugs

- Adding a small soft ball between the knees encourages more adduction

- Bilateral external rotation of the shoulders to work the rhomboids in a seated position – but don’t keep seated for too long due to the load on the spine

- Chair work was added later on for shorter periods of time seated

- Lying supine on the reformer is a nice position for Ryan to still get some good upper body strengthening done

- Single Arm push-ups on the chair from Sam’s repertoire four-point kneeling added a nice challenge for Ryan’s upper body without loading the spine – keeping

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- Single Arm push up progression on chair

position in the workout

- Single Arm push-ups on the chair from Sam’s repertoire four-point kneeling

from sinking into the lower lumbar

Full Body Integration 2:

- Scooter - Modified Scooter

with a flat back - Knee Stretch

Group with a flat back

- Again, the flat back position ensures no flexion into lower lumber

- Full body 2 is more advanced and was only added in the last month once Ryan showed significant improvement in his core strength and stability

Leg Work:

- Chair - Modified Standing Leg press forward and side

- Squats on cadi - Backward step

down on Chair - The Runner on

Reformer - Hamstring Curl

seated on short box (Sam’s)

- Side Split and skating on Reformer

- Adding in the side leg press on the Chair from Sam’s repertoire

- The Runner on the Reformer is from Sam’s repertoire

- Side Split and Skating on Reformer keeping a neutral spine and smaller movement after 20 sessions only

- The Runner on reformer is an excellent way to help Ryan add in the running movement pattern without loading the spine as there is no jarring movement

- Ryan needed to ensure his glutes were firing as they are key to pelvic stability and overall athletic performance

Lateral Flexion & Rotation:

- Star prep kneeling (avoid any rotations)

- Reformer star prep kneeling avoiding all rotation and simply hinging up and down using obliques and shoulder stability

- Rotation of the lumbar spine to be avoided with disc conditions

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Back Extension: - Chair – Modified

swan on floor - Reformer

Breastroke prep - Basic Back

Extension on Mat

- Standard Repertoire but ensuring lower lumbar not in too much extension – pure upper thoracic extension

- Extension of the thoracic spine so critical for Ryan and all clients – but focused with smaller range and upper thoracic only

Conclusion After working with Ryan for 5 months, there has been a marked improvement

against his goals with far less pain and stiffness felt especially when consistently

performing pilates program 3 – 4 times a week. Ryan was also able to manage the

progression of the exercises showing an improved strength in his core muscles and

pelvic floor stability. He also enjoys more range of motion through the upper torso

including improved stability and strength.

• Repetitions increased from 4 to 8 repetitions within 8 weeks

• Mobility and flexibility improved to Ryan being able to tie his own shoe

laces after 6 weeks of consistent pilates sessions

• Ryan experiences far more pain-free days and less referral pain with

almost no pain at all for more than 4 consecutive days while doing

consistent pilates sessions and not travelling on long flights

Therefore, in response to the original problem statement set out, a robust

pilates strengthening program specifically designed to work with lumbar disc

protrusions considering all necessary precautions, was successful in delivering a

stronger support for the spine and increased mobility. The targeting of the spinal

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extensors in particular the multifidi, as well as the transverse abdominals and the

pelvic floor provided Ryan with a far stronger and stable powerhouse in support of

the lower lumbar spine. This in turn improved Ryan’s movement, relieved referral

pain considerably and allowed Ryan to start walking and jogging pain-free after 5

months of consistent pilates exercises.

“The last 5 months have been both frustrating and exceptionally satisfying –

frustrating as the initial progress was slow, but satisfying in that now I am able to

start running again and have experienced the benefit of the pilates program in

overall cross-training and strengthening. Looking forward to continuing and

advancing with the exercises in the pilates program as I am certain this will assist

my running goals in the longer term and prevent me from any further injury.” –

Ryan Powell, 16 October 2018

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Bibliography Harsha Shanthanna, I. G. (2017, August 15). benefits-safety-gabapentinoids-

chronic-low-back-pain. Retrieved from https://painsa.org.za:

https://doi.org/10.1371/journal.pmed.1002369

BMJ. (2005, May 26). Research Papers. Retrieved from www.bmj.com:

https://www.bmj.com/content/330/7502/1233

Nall, R. (2016, May 9). Health. Retrieved from Health Line:

https://www.healthline.com/health/herniated-disk

Isacowitz, R., & Clippinger, K. (2011). Pilate Anatomy.

Wood, S. (2018). Pilates for Rehabilitation. Human Kinetics.

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Annexure A.

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Annexure B.

11January2018

ToWhomItMayConcern:

MrRyanPowell

MrPowellpresented tomeon9 January complainingof intractable right

leg pain that was preventing him from doing any running and also

impacting significantly on daily activities to the extent that he could not

sleep.

AfterexamininghimIsuggested that thepainmost likelyemanated from

nerverootirritationinhislowerbackandrequestedanMRIscan.Thescan

confirmed the clinical impression of a severe prolapsed disc causing

significantnerve root impingementand referredpain.This conditionwill

be treated with epidural and perineural injections, medication,

physiotherapyandrest.Importantly,MrPowellwillbeunabletorunforat

least3months.

Yourssincerely

DrJonPatricios