Pilates for Lumbar Spine Herniation

Michelle Hawley
Date: Module 12, 10/21/2012
Course Year: July 2012- October 2012
Location: Chandler, AZ

Abstract

Research has demonstrated that non-surgical methods for treating lumbar disc herniation
are just as effective as surgical methods over the long term. Common ailments and symptoms of
a patient with a lumbar disc herniation are low back pain, radiating pain down the legs, and a
worsening posture including a reduction in the natural lumbar spine curvature, scoliosis, and
unilateral slightly flexed and externally rotated hip and knee joints. Although physical therapy is
effective, a method that focuses on correcting alignment, posture, and improving the strength and
endurance of synergistic muscles is preferred for successful treatment of a herniation. Because
Pilates addresses these specifically, it is the most appropriate method to treat my client who has a
lumbar spine herniation. A timeframe of 10 weeks will be used for this program which will
mainly target the Transverse Abdominals and Multifidus muscles while avoiding contraindicated
movements.

Table of Contents

Title

Page Number

Abstract...................................................................................................................... 2
Anatomical Description & Picture..............................................................................4
Introduction................................................................................................................ 5
Conditioning Program.................................................................................................6
Conclusion..................................................................................................................9
Bibliography...............................................................................................................10

The Human Spine

Pictured above is a normal spine viewed from three perspectives: anterior, lateral, and
posterior (7). Included are pictures that demonstrate a herniated disc compared to a normal disc
and a diagram of the disc itself displaying its main components which are the annulus fibrosus
and the nucleus pulposus (8, 1). Type I and Type II collagen fibers compose the annulus
fibrosus in the shape of a ring, structurally allowing it to contain the nucleus pulposus which has
a jelly-like consistency resulting from its high concentration of proteoglycans (2). In the case of
a herniation, the annulus fibrosus has degenerated either from dehydration, fragmentation, or
excessive loading, causing the nucleus pulposus to also fragment and become exposed to the
outer environment (2). Once this fragmentation occurs, one or more of the nerve roots suffers
compression which ultimately causes pain that may radiate from the low back down into the legs
(3). There have been instances in which a herniated disc has spontaneously healed (2, 3).
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My client, Wes, is a 30 year old male firefighter with a herniated disc between the 4th and
5th lumbar vertebra (L4-L5). He injured himself last year on the job while part of a 4 man team
who carried a 400 pound patient on a cloth stretcher down a flight of stairs. This excessive
overload on his spine resulted in his L4-L5 herniation, which was confirmed by MRI. Upon
diagnosis, an epidural and physical therapy were recommended by his doctor who is a prominent
spine specialist. After two epidurals and twelve physical therapy sessions, neither has offered
long lasting pain reduction, resulting in sleepless nights, decreased mobility in his spine in
movements of lateral flexion and rotation, and muscular tension in the compensating
musculature causing chronic pain in his neck, upper back, and mid back along the spine. Wes is
now searching for a safe and effective program that will help reduce his low back pain while still
providing the benefits of physical activity.
According to current research on lumbar disc herniation, non-surgical methods are just as
effective as surgical methods in the long term when the measurement outcomes are spinal
mobility and pain, yet are much more affordable (2, 3). Herniation in the L4-L5 disc is the most
common and may lead to several mechanical misalignments in the body such as scoliosis as a
result of leaning away from the painful side, a reduction in the natural lumbar curvature, and
slight flexion and external rotation in the hip and knee that are experiencing pain from nerve root
compression (2). A period of 3 to 4 months is required to determine if the non-surgical therapy
is successful and is also the maximum amount of time that can elapse before surgical treatment is
no longer a viable option (2, 6). Although physical therapy has proven to be a favorable nonsurgical method, a form of exercise that allows the patient to be in a supine position and that also
focuses on re-educating correct alignment in addition to strengthening and improving the
endurance of the synergistic muscles in the trunk is preferred (5).
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Pilates is a form of exercise that not only improves muscular strength, endurance,
flexibility, and balance but is also a main proponent of teaching correct alignment with proper
recruitment of agonistic, antagonistic, and synergistic muscles. Rael Isacowitz, the founder of
BASI Pilates, promotes it as a bridge... between rehabilitation and healthy movement... [and] a
solution to those with restricted mobility (4). Therefore, Pilates is the most advantageous
method for my client to help reduce his low back pain and improve his alignment. The
transverse abdominals and the multifidus are the primary muscles in stability and function which
work together to create a cylinder of muscular support in the center of the body and will
appropriately be the center of Wes conditioning program (4).
Wes customized program will emphasize building strength and endurance in his back
extensors and deep abdominal muscles while also ensuring balance in his appendicular muscles.
Specific movements that will be avoided are major spinal flexion, major rotation, spinal flexion
in combination with rotation, deep flexion, and spinal extension with excessive load on the
lumbar spine as these are contraindicated for a client with a herniated disc. Wes will come to the
studio 3 days per week for 10 weeks to allow sufficient neuromuscular adaptation, adequate
overload, and time to reach his goals which include pain reduction and a stronger more stable
core. Thorough assessments of posture and alignment will be conducted at the first visit and
every 3 weeks thereafter to track progress in addition to assessing his pain. Every session will be
based on the BASI block system with a chart to include notes for each exercise to determine
areas of weakness and tightness for appropriate modifications and/or changes to his lesson plan.
The Reformer and the Cadillac will be the apparatus of choice since they require the client to lay
supine for the exercises that are suitable for this program, while the warm up will consist of mat
exercises. The Magic Circle, pole, and leg weights will also be utilized in the appropriate blocks.
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The first 10 sessions will be comprised entirely of fundamental exercises in order to

educate proper muscle recruitment and stability. A progression into intermediate exercises,
spinal articulation, and full body integration will then begin at the eleventh session. Wes will
also progress into lateral flexion and supine rotation with a *shortened range of motion. The mat
work bridging block will be added to this program because of its benefits in increasing stability
of the shoulder girdle and the core muscles. The full body integration 2 block will be omitted
from this program as the exercises are not suitable for this client. Sessions 1-10 represent the
fundamental exercises while progressing into intermediate exercises for sessions 11-20 and 2130. The chart below shows which exercises will be incorporated into the repertoire available for
this client after the specified number of sessions so there will be a growing variety of exercises to
combine for each session. This program will cover 30 sessions, a point at which Joe Pilates has
claimed a client will feel like a new person, while also remaining within the surgical decision
timeframe.
Block

Sessions 1-10

Sessions 11-20

Sessions 21-30

Warm Up

Pelvic Curl

*Spine Twist Supine

Double Leg Stretch

Mat

Chest Lift

*Chest Lift with Rotation

Single Leg Stretch

Leg Lifts

*Criss Cross

Leg Changes

Foot Work

Reformer

Cadillac

Cadillac (+ Hip Opener)

Hundred Prep

Coordination

Hundred

Mini Roll-Ups & Mini

Double Leg

Reformer, Cadillac
Abdominal Work
Reformer, Cadillac

*Roll-Ups Obliques

Hip Work

Reformer- basic

Reformer, Cadillac

Ext. Frog, Ext. Frog

Single Leg Supine Series

Reverse
Basic Leg Springs

Spinal Articulation

None

Bottom Lift

Bottom Lift w/ Extensions

Stretches

Standing Lunge

Side Split

Kneeling Lunge

Reformer, Pole

Pole Series (no twist)

Bridging

Front Support

Front Support

Leg Pull Front

Back Support

Leg Pull Back

None

Round Back, Flat Back

Long Stretch

Arm Work

Arms Supine Series

Arms Standing Series

Side Arms Kneeling

Reformer, Cadillac,

M.C. Standing Series

Arms Sitting Series

Series (*slight side bend

Reformer

Mat
Full Body Integration
Reformer

Magic Circle

for triceps)

Additional Leg Work

Gluteals Side Lying Series Gluteals Kneeling Series

Single Leg Skating

Leg Weights

M.C. Prone Series

M.C. Supine Series

Hamstring Pull

Magic Circle

M.C. Adductor Squeeze

None

None

*Side Lifts

Back Extension

Back Extension

Pulling Straps 1

Pulling Straps 2

Mat

Breaststroke Prep

Reformer
Lateral Flexion/
Rotation
Reformer

Breaststroke

Reformer

Conclusion

Lumbar disc herniation is the result of excessive spine loading, causing the fragmentation
of the nucleus pulposus which then extrudes from the disc, compressing the nerve root. Low
back pain, radiating pain down the leg, and mechanical misalignments are the consequences of
herniation, worsening posture and decreasing mobility. Because Pilates is a form of exercise that
centers around reeducating proper alignment while strengthening synergistic muscles, it is the
safest and most effective method for treating a client with a lumbar disc herniation.
Wes, a 30 year old firefighter, has tried non-surgical methods such as physical therapy
and epidurals, but neither has offered long lasting relief of the pain and muscular tension he
experiences as a result of his lumbar disc herniation. Pilates has the potential to lessen his pain
and improve his alignment. Utilizing the Reformer, Cadillac, and other pieces of equipment will
allow Wes to exercise while lying in a supine position which is recommended for someone with
this medical condition. Therefore, a 30 session program lasting 10 weeks and excluding the
contraindicated movements for a client with a herniation is the next step in Wes nonsurgical
journey to treating the symptoms of his herniation.

Bibliography

1. Abitbol, Jean-Jacques, et al. Lumbar Herniated Disc. [image] Retrieved from

http://www.spineuniverse.com/conditions/herniated-disc/lumbar-herniated-disc
2. Awad, J.N. & Moskovich, R. (2006). Lumbar Disc Herniations: Surgical versus Nonsurgical
Treatment. Clinical Orthopaedics and Related Research, 443, 183-197.
3. Ciaccio, E.D., et al. (2012). Herniated Lumbar Disc Treated With Global Postural
Reeducation: A Middle-Term Evaluation. European Review For Medical and
Pharmacological Sciences, 16(8), 1072-1077.
4. Isacowitz, Rael. (2006). Pilates: Your complete guide to mat work and apparatus exercises.
Champaign, IL: Human Kinetics.
5. Iwamoto, J., Sato, Y., Takeda, T., and Matsumoto, H. (2010, December). The Return to
Sports Activity After Conservative or Surgical Treatment in Athletes with Lumbar Disc
Herniation. American Journal of Physical Medicine & Rehabilitation, 89(12), 10301035.
6. Postacchini, F. (1999). Management of Herniation of the Lumbar Disc. The Journal of Bone
& Joint Surgery, 81(4), 567-576.
7. Tumminello, Nick. (2010, May 27). An Inside Look at Spinal Osteoporosis, Scoliosis and
Osteophytosis. [image] Retrieved from http://nicktumminello.com/2010/05/an-insidelook-at-spinal-osteoporosis-scoliosis-and-osteophytosis/
8. WebMD, LLC. (2012, January 24). Slideshow: A Visual Guide to Low Back Pain. [image]
Retrieved from http://www.webmd.com/pain-management/ss/slideshow-low-back-painoverview

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