Monthly Archives: June 2009

Help for Sciatic Pain

If your client complains of pain shooting down the back of her leg accompanied by tingling, or numbness, she may be experiencing symptoms of sciatica. Sciatica involves a compression or irritation of the sciatic nerve. The pain can occur for a variety of reasons, including a herniated disc pressing on the nerve roots coming out of the spinal cord into the lumbar region, or a tight piriformis muscle pressing into the sciatic nerve that feeds down into the leg. Although the symptoms may go away over time, there are exercises and stretches available to help alleviate discomfort.

 Pilates exercises that strengthen the core and stabilize the pelvis in neutral placement can decrease the downward pressure on the intervertebral discs. Think about the intervertebral discs like fluffy marshmallows. You can squish them and watch the sides protrude or you can pull your fingers apart to return them to their original shape. Being able to sit tall with muscular support for the low back in a neutral pelvis position gives you better odds at decompressing the irritated nerves if the discs bulge.

 Positions requiring spinal flexion can sometimes increase symptoms. Emphasize core strength in neutral pelvis placement found in sitting, standing, side lying, quadruped, or neutral pelvis supine positions such as footwork on the Reformer. Prolonged standing or sitting can also increase symptoms, so try not to stay in one position too long. Be sure that your client understands how to activate the pelvic floor, transversus abdominis and lumbar multifidi. Most people have never consciously tried to contract these muscles, and need to first find them in order to activate them for pelvic stabilization.

 If your client is not used to sitting up tall, activating postural muscles can cause fatigue. When her back gets tired, make sure she reaches over to grab her ankles and takes a few deep breaths to relieve any tension created in the back to prevent muscle spasms. (See post The Use of Imagery to Help Your Client Find Lift Through the Core.) Sitting in a chair with good back support can also help.

 If sciatica symptoms are present when getting out of the car, you can suggest trying a towel “tootsie roll.” Fold a small bath towel in half lengthwise and roll it up as you would a yoga mat into a tootsie roll shape. Place the towel support at the crease of the car seat to prevent the pelvis from shifting out of neutral into a posterior tilt. This roll can also be placed on a chair for additional support. Be sure that your client understands that the towel tootsie roll is used ONLY at the base of the sacrum (where the crease of the seat and backrest meet) and NOT to be placed at the lumbar spine. The towel’s purpose is to give the pelvis a feeling of rocket boosters at the base of the pelvis shifting the weight slightly forward on the ischial tuberosities, not to force more curve in the low back.

 Tightness in the piriformis muscle can also cause sciatic pain since the pathway from the origin and insertion of the muscle crosses over the sciatic nerve. Improving flexibility through regular stretching may also help relieve sciatic symptoms. The pretzel stretch is useful for stretching the piriformis and can be performed with modifications. 

Directions for the Pretzel Stretch

Lie on your back with bent knees with both feet on the floor. Place your right ankle over the left knee and clasp the back of the left thigh with both hands and pull the left thigh toward the chest. Keeping the left thigh toward the chest, inhale and push the left thigh away from the chest while simultaneously pulling the clasped hands behind the thigh toward you. The leg doesn’t go anywhere, but muscle tension is created. Exhale releasing this muscle tension and pull the left leg closer to the chest. As you do the above, it is very important to keep the sitbones (ischial tuberosities) reaching toward the floor and try to maintain the lumbar curve found in neutral pelvis. This “sitting” toward the floor feeling creates opposition in the stretch providing a better pull. You can also rock the stretch slightly from side to side. Hold the stretch for around one minute and then repeat it to the opposite side. Sitting in a chair can modify this exercise for those unable to stretch on the floor with the emphasis placed on sending the tailbone back and lifting the chest up and forward.

Although some clients will need to see a doctor for their sciatic symptoms, the improved core strength and flexibility provided by Pilates exercises may decrease sciatic discomfort. As we are not stationary beings, understanding how to stabilize the core as we move through space pursuing our daily activities can help prevent aggravation. With the proper knowledge and consistently applied tools, your client can self-correct if she slips into old habits. Although exercise alone may not alleviate sciatic symptoms, the pain experienced by sciatica is often a great motivator for even the most committed couch potato to give it a try.

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Helping your Parkinson’s Client with Frozen Gait

Some clients with Parkinson’s disease (PD)  may experience difficulty moving from one piece of Pilates equipment to another after completing an exercise.  This inability to propel the feet is a symptom of PD and is commonly referred to as “frozen gait.”  With most clients, their unconscious mind gives them the commands necessary for their body to move and perform the next action. With PD, this automatic feature can sometimes be interrupted.

 Fortunately, we often can help our client “reboot” the system with a conscious command originating from another part of the brain.  Once the body makes the first move, another part of the brain takes over for locomotion—like the jumpstart of a car battery getting the engine going again.

Mayo Clinic Parkinson Specialist J. Eric Ahlskog, Ph.D., M.D. provides some possible suggestions you may make to your client in The Parkinson’s Disease Treatment Book

  • Swing one leg forward.  Think about swinging the leg rather than walking.  Start with a long leg swing that will place that leg far in front of you (but not so far that you fall).
  • Try goose-stepping. This was the marching gait of German soldiers.  They would stiffly lock their knees and march by taking long stiff steps.  Envision what they looked like and keep this thought as you take your first step.
  • Think about a drum major’s marching step, raising one leg straight up off the ground before placing it forward.  Envision that same movement when you get stuck.
  • Think about a drill sergeant’s marching cadence:  “one-two, one-two, one-two…” You might even count out loud.  This might get you started and help you mentally envision a marching step.
  • Thinking of a certain musical tune may be helpful. For example, a gliding first step may come more easily if you hum “Blue Danube” in your mind and imagine a ballroom dancer gliding in that same way.  A boogie or rock and roll tune that brings a dance step to mind may also work.
  • Find a target on the floor and step on it.  Sometimes people imagine they are stepping on a fly in front of them.  Look for an imaginary fly on the ground and try to crush it; this may get your gait started.
  • A variation on this involves using a laser pointer to create a target to step on. If you point the laser light 1-2 feet in front of you and then think about stepping on that tiny lighted spot that may get you going.  Laser pointers are used by professors and lecturers and may be purchased at bookstores.

 Consult with your client to see what tool works best.  After your client begins moving, it is also common for a PD client to have difficulty maintaining the tempo, or to freeze again upon slowing down or stopping. One of my clients will put his hand on his wife’s shoulder when they are walking together to maintain a sense of rhythm in his gait, which he at times loses on his own. Impressively, he still skis and will count the ski lift towers and sing a song to himself like “one, two, three…and” to get ready to initiate push off from the ski lift and transfer his weight over his legs.  This counting also becomes useful in Pilates exercises, such as with leg circles in the straps on the Reformer, to maintain fluid movement.  If you think that your client is experiencing inconsistent or stilted movement, try leading with your voice “circle down 1,2,3,4, circle up 1,2,3,4” to maintain the rhythmic feel.

Despite all your clever tricks, sometimes nothing works.  When this happens, it is often a medication issue. Your client generally knows from taking medication when “on” and “off” efficacy times occur relative to the dosage and the time the medication was taken.  Schedule your appointments based on medication peak performance to get the most out of a session.

Brent Anderson PhD, PT, OCS of Polestar Pilates has a great recommendation for working with PD clients.  He suggests that you provide a, “successful movement experience that exceeds their expectation.” PD clients may not always have the perfect Pilates form, but acknowledging and praising what they can do will empower them to recognize their own accomplishments and strive for success in the future. 

 A working relationship with a PD client can be challenging for a Pilates instructor, but it is extremely rewarding when your client experiences improved function.  Understanding the common symptoms, such as freezing gait, can help you know what to expect and to work with greater patience.

 

The Use of Imagery to Help Your Client Find Lift Through the Core

Many clients struggle with accessing the muscles necessary for core engagement and postural alignment. The use of imagery or metaphors can help your client find the proper form. Instead of taking a client through the specific steps of muscular activation, try suggesting that your client concentrate on images, such as a diamond, marble or golf ball, for example. You can easily refer to these chosen images later and your meaning will be understood without excessive verbiage.

To begin, have the client sit on a chair in a neutral pelvis position with weight slightly forward on the ischial tuberosities (sitbones) and the weight solidly on the feet. Ask your client to find the feeling of being a chair with its weight distributed equally between the sit bones and the feet as a chair would have four points of equal contact against the floor. Then suggest that your client imagine that an arrow has been shot sideways (coronal plane) through the pelvis and another one from front to back (sagittal plane) about 2-3 inches below the navel (umbillicus). Where those arrows intersect in the center, ask your client to visualize a diamond as if it were cradled and held up between prongs like in a ring. Keep the diamond lifted and suspended from all sides.

Then have the client lift the chest away from the pelvis and notice the space where her ribs meet at the bottom of her breastbone (sternum) at the xiphoid process. Ask her to visualize a marble has been inserted here and to give it a squeeze, pulling it up off the diamond below. Finally, suggest that your client continue to lengthen up the spine to where the bottom of the ears connect to the neck lifting her head as if it were a golf ball suspended on a tee. Tell her to breathe expansively through the chest and continue to lift her diamond, marble, and golf ball away from each other. Ask your client to release any excess tension so that she could hold the lifted position for an extended period of time. Remain in this position several (costal) breath cycles and then have her reach toward the floor to relax the back.

Finding lift through the core can be a challenge for many clients, but using imagery can help your client “see” what should happen and find the proper form.