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Symptomatic Lumbosacral Dysfunction and the Management & Rehabilitation through Pilates
Özge Gow November 2015
Body Arts and Science International Comprehensive Teacher Training Program 2015
Brisbane, Australia
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Abstract
The purpose of this paper is to explain and identify chronic lower back pain (CLBP)
and related lumbosacral dysfunctions. The paper will focus heavily on congenital
conditions mainly the sacralisation of the lumbar vertebrae. In addition, this paper
will examine the effectiveness of Pilates exercises in the management and
rehabilitation of these conditions.
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Table of Contents
Abstract ......................................................................................................................................2
Table of Contents ...................................................................................................................3
Chronic Lower Back Pain ....................................................................................................4
What is Sacralisation? ...........................................................................................................4
Why Sacralisation Causes Pain? .......................................................................................5
What can Pilates do? .............................................................................................................7
Case Study .................................................................................................................................7
Session Plan ............................................................................................................................10
Conclusion................................................................................................................................12
Bibliography............................................................................................................................13
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Chronic Lower Back Pain
Chronic low back pain affects approximately a quarter of the population.1 This
physiological burden can lead to difficulties in everyday life and if untreated can lead
to irreversible degeneration.
There are many causes for lower back pain that have been put forward. These can be
summarized into five main areas, which Dharati (2012) identifies as;
1. Actual pressure on nerves or nerve trunks.
2. Ligamentous strain.
3. Compression of soft tissue between bony joints.
4. By an actual arthritis if a joint is present.
5. By a bursitis if a bursa is present.2
These disorders make up the majority of lower back pain however Dharati ignored an
often overlooked cause for pain in the lower back which can be caused by a congenital
mechanical dysfunction, mainly that of sacralisation.
What is Sacralisation?
The lumbosacral spine protects the spinal cord and spinal nerves but another
important function of the region is to support and transmits the weight of the body to
the inferior extremity and in doing so plays an important role in posture.3
Sacralisation occurs when the transverse process of fifth lumbar vertebra and the last
lumbar vertebra becomes larger than normal on one or both sides, thus causing fusion
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to the sacrum, or ilium and or both.4 It is believed to occur in about 3.6 % to 18 % of
the population. 4
Why Sacralisation Causes Pain?
Pain is first recognized in the early stages of development due to the improper
formation and union of somites, which cause vertebral abnormalities. 5 This is
amplified by the fact that the lumbar spine experiences more abuse from the everyday
functions than any other part of human body and it explains why, without
intervention, pain increases as a person ages.
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It’s important to note that sacralisation wont always cause pain, often the condition is
asymptomatic. Wazir (2014) explains that pain occurs as a result of disc degeneration,
L4/L5 disc prolapse, lumbar scoliosis and/or lumbar extradural defects.6 According to
Castellvi (1983) the transitional vertebrae has the potential to cause abnormal torque
movements above these anomalous vertebrae, which can be a direct result of disc
degeneration.7
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What can Pilates do?
Sacralisation usually goes undiagnosed because it is difficult to diagnose without the
access to x-‐ray. However, sacralisation itself it is not generally the cause of discomfort
and pain but the chronic failure of lumbar and pelvic biomechanics.
According to Eyo (2001) “to be able to give support to and bear the weight of the body,
the integrity of all the vertebrae in the spine, particularly in the lower back must be
maintained”7 The 2014 Delphi Study examined the affect of Pilates exercises as a
treatment for people with complex lower back pain associated with sacralisation.8 The
study found that Pilates exercises may benefit people with lower back pain by
“increasing their functional ability and their confidence with movement, exercise, and
activities”.9 The research also showed improvements in body awareness, postural
control and movement patterns. 9
Case Study
Özge is a 32-‐year-‐old woman with chronic lower back pain. The pain has existed for
over five years. The origin of the pain is not known but the client did mention that she
slipped on ice during primary school and injured her lower back. The client is not on
any medication however she does take the occasional ibuprofen when the pain
becomes unbearable. The ibuprofen seems to help.
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Postural Assessment and Physical Examination
The client presents hypertension in her lower back, gluteus muscles, hip flexor
muscles as well as in the quadriceps muscles. Secondary concerns show a posterior
tilt in the pelvis, which has caused a minor lordosis affecting muscles throughout the
thoracic and cervical regions, particularly in trapezius muscles. Due to the
hypertension caused the trapezius muscles the client presents cervical pain and
occasional headaches.
Exercise Plan
An exercise plan has been devised for Özge, which consists of movements designed to
strengthen and stretch affected muscles. The main focus was strengthening her
abdominal muscles, her upper thorasic muscles, back extensor muscles, hip flexors as
well as gluteal. Exercises were chosen from the mat, reformer, cadillac, avalon and
wunda chair repertoire.
During the first few sessions she was having trouble keeping the pelvis in a neutral
position while performing supine exercises while actively using hip flexors. The
warm-‐up exercises involved a lot of pelvic tilts as well as pelvic curls. We also did
quite a bit of abdominal work in order to strengthen her core. At the beginning she
was very cautious with her back extensions, so we did a lot of swimming, cat stretch
until she felt stronger through her back and abdominal muscles. The intensity of the
exercise plan I have created can be upgraded or downgraded for different apparatuses
depending on the strengths and weaknesses of the client during the session.
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On the left a normal lumbar X-‐ray, on the right is Özge’s lumbar X-‐ray. As you can see
the image on the right has a much lower L5 vertebrae which is in line with
sacralisation.
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Sessions
BASI Block 1-10 11-20 21-30 Warm Up Pelvic Curl
Spine Twist Supine Chest Lift Chest Lift with Rotation Leg Lifts
Roll up with Rub Spine Twist Supine Mini Roll ups Mini Roll ups with oblique
Pelvic Curl Roll up Spine Twist Supine Double Leg Stretch Single Leg Stretch Criss Cross
Foot Work Reformer: Parallel Heels&Toes V Position Toes Open V Heels&Toes Calf Raises Prances Prehensile Single Leg Heels&Toes
Cadillac and Reformer: Parallel Heels&Toes V Position Toes Open V Heels&Toes Calf Raises Prances Single Leg Heels&Toes
Cadillac, Reformer and Wunda Chair: Parallel Heels&Toes V Position Toes Open V Heels&Toes Calf Raises Prances (except Wunda Chair) Single Leg Heels&Toes
Abdominal Work
Reformer: Hundred Prep Mat: Chest Lift Chest Lift with Rotation Hundred Prep
Reformer: Coordination Short Box Series Mat: Hundred Hamstring Pull 1 Cadillac: Roll up Top Loaded
Reformer: Hundred Cadillac: Roll up Bottom Loaded Avalon: Hundred
Hip Work Reformer: Frog Circles Down-‐Up Openings Cadillac: Frog Circles Down-‐up Walking Bicycle
Reformer: Extended Frog Extended frog reverse Cadillac: -‐Single Leg Series Frog Circles Down-‐up Hip Extension Bicycle
Cadillac: -‐Single Leg Series Frog Circles Down-‐up Hip Extension Bicycle Avalon: Frog Circles Down-‐Up Openings
Spinal Articulation
Pelvic Curl Spine Stretch
Reformer: Short spine Cadillac: Tower Prep Monkey Original
Mat: Roll Over Avalon: Pelvic Curl Wunda Chair: Standing Pike
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Stretches Reformer: Standing lunge
Reformer: Kneeling lunge Avalon: Gluteals Hamstrings Adductors Hip Flexors
Reformer: Side Split Shoulder Stretch
Full Body Integration
(F/I)
Reformer: Scooter Elephant
Reformer: -‐Knee Stretch Group-‐ Round Back Reverse knee stretch
Reformer: Up stretch 1-‐2 Cadillac: Sitting Forward Kneeling Cat Stretch
Arm Work Reformer: -‐Arm Supine Series-‐ Extension Adductors Circles up Circles down Triceps
Reformer: -‐Arm Sitting Series-‐ Chest exp Biceps Rhomboids Hug a tree Salute
Cadillac: -‐Arm Standing Series-‐ Chest Expansion Hug a tree Circles Up-‐down Punches Biceps
Full Body Integration (A/M)
None None Cadillac: Saw
Leg Work Mat: -‐Supine Series-‐ Knees Ankles
Reformer: Single Leg Skating Mat: Side Leg Lift Forward and Lift Forward with drops Adductor Squeeze
Cadillac: Squats Avalon: Leg Press Standing
Lateral Flexion/ Rotation
Mat: Side Lifts Ladder Barrel: Side Over Prep
Reformer: Mermaid Mat: Spine Twist Saw
Reformer: -‐Short Box Series-‐ Side over on box
Back Extension Mat: Back Extension Cat Stretch Swimming
Mat: Swimming Reformer: Breaststroke Prep
Cadillac: Prone 1 Wunda Chair: Swan Basic
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Conclusion
After following the conditioning program for five months, Ozge gained strength in her
abdominal muscles, upper back muscles, gluteus and hip flexor muscles and gained
length to her lower back muscles. Her tight trapezius muscles released as well. The
program gave her better control over her pelvic function, which improved her posture
and corrected her lordosis. The results showed that completion of a BASI Block
System program can help improving conditions associated with chronic low back
pain.
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Bibliography
Referenced:
1 -‐ Balague ́ F, Mannion AF, Pellise ́ F, Cedras-‐ chi C. Non-specific low back pain. Lancet. 2012;379:482– 491. 2 -‐ Dharati, K et al, ‘A study of sacralisation of fifth lumber vertebra in Gujarat’, National Journal of Medical Research, volume 2, issue 2 Apr – June 2012. p213) 3 -‐ Dharati, K et al, ‘A study of sacralisation of fifth lumber vertebra in Gujarat’, National Journal of Medical Research, volume 2, issue 2 Apr – June 2012. p211) 4 -‐ Dharati, K et al, ‘A study of sacralisation of fifth lumber vertebra in Gujarat’, National Journal of Medical Research, volume 2, issue 2 Apr – June 2012. p211) 5 – Wazir, S. ‘Sacralisation of Lumbar Vertebrae’ International Journal of Anatomy and Research. 2014, Vol 2(2): (p.387) 6 - Castellvi AE, Goldstein LA, Chan DPK, ‘Lumbosacral transitional vertebra and their relationship with lumbar extadural defects’. Spine, 1983; 9:493–495. 7. Williams, PC. ‘The lumbosacral spine, emphasizing conservative management’. New York, McGraw-‐Hill Book Company 1965,27-‐32. 8-‐ Eyo MU , Olofin A, Noronha C, Okanlawon A: ‘Incidence of Lumbosacral Transitional Vertebrae in Low Back Pains’, Patients West African Journal of Radiology , April 2001: 8(1).1-6. 9 - Wells, Cherie et al "Indications, Benefits, and Risks of Pilates Exercise for People With Chronic Low Back Pain: A Delphi Survey of Pilates-Trained Physical Therapists." Physical Therapy 94.6 (2014): P.811. Web.20 Feb. 2016. 10 -‐ Wells, Cherie et al "Indications, Benefits, and Risks of Pilates Exercise for People With Chronic Low Back Pain: A Delphi Survey of Pilates-Trained Physical Therapists." Physical Therapy 94.6 (2014): P.801. Web.20 Feb. 2016. Sighted: -‐Isacowitz, R.(2015).Reformer Movement Analysis Workbook. Costa Mesa CA: Body Arts and Science International -‐ Isacowitz, R.(2015).Mat Movement Analysis Workbook. Costa Mesa CA: Body Arts and Science International -‐ Isacowitz, R.(2015).Cadillac Movement Analysis Workbook. Costa Mesa CA: Body Arts and Science International -‐ Isacowitz, R.(2015).Wunda Chair, Ladder Barrel Movement Analysis Workbook. Costa Mesa CA: Body Arts and Science International -‐ Isacowitz, R.(2015).Study Guide Comprehensive Course. Costa Mesa CA: Body Arts and Science International