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How Can Pilates Equipment Training Help Improve Pelvis Instability?

SvenjaHampel

September2018

May-Nov2018,DubaiTraining

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Abstract

ThroughoutmyjourneyteachingandpracticingPilates,Icameacrossalotofclientswhohadahardtimeunderstandingneutralpelvicalignment.Furthermore,themajoritycametometoseekforhelpforlumbarsacroiliacpain,nervepainshootingdownonelegorundefinedtinglingintheleg.Therefore,Ichoosetowriteonpelvic–lumbarstabilization.

Firstofall:Whatispelvisinstability?Whereisthepelvisregion?Andwhatcanbeinstable?

Thepelvis–hip–legconnectionisaquitesolidbonestructureandbuildsasolidconnectionbetweenupperandlowerhalfofthebody.Thisiswhatitshoulddo.Unfortunatelyforalotofpeoplenowadaysthepelvisregiongetslessmovementandlessstrengthtrainingthanitshouldget.Asaconsequence,itislessstableanditgetsmoreunstable,creatingpainwhiledoingnormaleverydaymovementslikewalkingandrunning,gettingonandoffbedorachair.Allthesemovesshouldnotcreateanydiscomfort.Sadly,tosee,themajoritytothepopulationareseatedtolongeitheratworkbehindthedesk,drivingthecartoorfromworkorrelaxingafteralongworkingdayathomeonthesofa.

Onlyfewofthemtakeactionandtrytoworkagainstthissedentarylifestyle,beingmoreactiveandhealthyintheirdailyliving.

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TableofContents

Abstract ............................................................................................................................. 2

TableofContents............................................................................................................... 3

Anatomy............................................................................................................................ 4

CaseStudy ....................................................................................................................... 11

Conditioningprogram ...................................................................................................... 13

Conclusion ....................................................................................................................... 15

Bibliography..................................................................................................................... 16

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Anatomy

Thepelvisisasymmetricalbonyringstructureconnectingthevertebraecolumnandthelowerlimbsviathehipjoint.Thevertebraecolumnfunctionasshockabsorption.Ifeachvertebraearecorrectlyalignedthevertebraecolumnwillabsorbtheshocktoitsbest,ifthealignmentoftheholebodyisincorrectitwillhaveaknockdowneffectoftheweakestpartinthesystem.Thepelvisholdstheabdominalorgansofthebodyasbladder,intestine,uterusforwomanandprostateinman.Thepelvisconsistsofthreestrongbonesfusedtogether:theilium,ischiumandpubis.Theyformtheacetabulum,thesocketjointofthehipwhichconnecttothefemurhead.Theiliumisthelargestflatboneoneachsideoftheupperportionofthepelvisgirdle,includingtheiliaccrestwiththeanteriorsuperioriliacspine(ASIS),thehipbonewhichcanbeeasilyfeltwithpalpation.Thepubisistheanteriorsideofthepelvisfusedtogetherbythecartilaginouspubissymphysis.Theanatomyofthepelvisdiffersinmaleandfemale:thefemales’pelvisiswiderandthepubisshorterthanmale.Thepubissymphysiswillwidenforchildbirthinwoman.

ThesacrumcontainsfivefusedvertebraeS1toS5creatingatriangularshapeattheposteriorsideofthepelvisgirdle.TheiliumconnectsoneithersideofthesacrumS1toS5andbuildsthesacroiliacjointconnectedviapowerfulposteriorandanteriorligamentsandmuscles.Thenetworkofligamentsandmusclearoundthesacroiliacjointlimitsmovementwithinthejoint.

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Sacrumfromposteriorview

Thesacroiliacjointhasnormallyonlyasmallrangeofmovement,2–4mminanydirection.Thesacroiliacligamentsarelessstiffinwomenallowingtoprepareforchildbirth.Causethissegmenthaslessmovement,theprimarymovementinthesacrumoccursrelativetothelastlumbarvertebrae.“Movementsatthisjointhasaprofoundinfluenceonalignmentofthelowerbackandpelvis”,statein‘PilatesAnatomy’.

SacroiliacJoint(SI)andLumbosacralJoint(S1toL5)

Atthelowerpartofthespinalcordnumerousnervesofthecaudaequineextendfromtheforamenofthelumbarspineintothesacralcanalandexitingthesacrumthroughthesacralforaminaoneachsideofthecanal.Correctbodyalignmentincreasesthepossibilitythatallnervesworkinthemostefficientway.

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SacrumincludingNervesroots

Thepelvicgirdleconnectstheupperandthelowerpartofthebody.Thehipjoint,amajorball–and-socketjoint,connectthepelvistothelongbonesofthefemur.Thehipjointallowsawiderangeofmovementsofthelowerlimbsasitisusedinrunning,walking,climbingandbending.Thehipjointbearsthebodyweightandissupportthroughlarge,strongtendons,ligamentsandmuscle–gluteusmaximus,medius,minor,iliacusandpiriformis.

Themuscleofthepelvisandhipcontrollingthelegsanduppertrunk.Posteriorthegluteuscomplexcontrollinghipextensionasthehamstrings;anteriorthedeephipmuscle,thePsoasconsistingofpsoasmajorandiliacuscontrollinghipflexionandtrunkflexionandtrunklateralflexion.ThePsoasisconnectedinthelowestthoracicvertebrae,12ththoracicvertebratothe5thlumbarvertebrae,andcrossestothefrontofthebodyalongthepelvisandattachestothefemurwhichmakesitoneofthemostimportantmusclesinthebody.ThePsoasistheonlymusclewhichconnectsthespinetothelowerlimbs. ‍

PsoasMajorandminorGluteusMaximusandmedius

Thegluteusmaximus is the largestmuscleof thebody, consistingofgluteusminimusandgluteus medius, connecting to the sacrum above the iliac crest. The gluteus maximuscontrols hip extension as in running and walking. It attaches as well to the ilio-tibial (IT)band,acomplexconnectivefibre.

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A big group of deep pelvis muscle controlling movements of the leg are the Piriformis,Obturatorinternus,Obturatorinternus,Obturatorexternus,GemellussuperiorandinferiorandQuadratus femoris connecting the pelvis girdle to the femur. Furthermore, there areTensorfasciaelataetostabilisethefemoralheadintotheacetabulumandthekneeduringextension,Rectusfemorisactingashipflexorbelongingtothequadriceps.TheSatoriusisathinandthe longesthumanmuscleofthe innerthigh,originates inthe iliaccrest, runningdiagonallydowntothekneetoinserttotheinnertibiaassistinginexternalrotationofthehip.Furthermore,thepelvisgirdleincludesthemuscleofthepelvicfloorandtheperineumtoholdtheinnerorgans.

Themusclesoftheabdomenareconnectedalsotothepelvisgirdle.Theabdominalmusclescanbedividedintofourparts:theexternalobliques,originatesiliumtolineaalba,theinternalobliques,originatesiliumtolineaalba,thetransversusabdominal,originatesiliumandribstopubisandlinaealba,andtherectusabdominal,originatespubistosternum.Thedeepestmuscleintheabdomen,thetransversusabdominal,isarrangedtransverselyaroundtheabdomensimilartoabelt.Thisarrangementofthelayeredmusclesoftheabdomenallowsvariousmovementsinalldirectionsofthetrunk–flexion,extension,lateralflexionandrotation.Theabdominalmusclesalsoprotecttheabdominalorgans.

Abdominalmusclelayering

OntheposteriorsideofthebodytheQuadratuslumborumconnectsfromtheiliaccresttothe12thribandthelumbarvertebraeL1–L4.Thequadratuslumborumisacontinuationofthetransverseabdominalmuscleontheposteriorsideofthebodyandthedeepestabdominalmuscle.

TheMultifidusspinaemuscle,alsoamuscleontheposteriorchainofthebody,consistsofanumberoftendinousfasciculiwhichfillupthegrooveonbothsidesofthespinousprocessesofthevertebrae.Themultifidioriginateatthesacrumandiliaccrestandinsertsatthespinousprocess.Itplaysanimportantroleinstabilizingthejointswithinthespine.

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QuadratusLumborumMultifidiusspinaemuscle

Raelstatedinhisbook‘PilatesAnatomy’“MuscleactingasForceCouples”.Allthesemuscledescribedaboveconnectedtothepelvisgirdleposteriororanterioractinginsomekindonpelvisstability.Forexample,theabdominal–hamstringsforcecoupleisactingonbothsidesofthepelvis.Contractionoftheabdominalcanproduceaposteriorpelvictiltasdesiredinapelviccurl,asthehamstringsatthesametimelengthenawardtosupportthismovementofposteriortilt.Ifaneutralspineandpelvisisdesiredbothmuscleshavetoworktogethertocreatestabilityoverall.Asonemuscleisinmisalignmentothermusclehavetotakeoveranditcreatesanimbalancebetweenmuscleswhichcanledintodiscomfortorfurtherworsentopain.Iftheoptimumpositionofthespineandpelvicgirdlecannothavebeenmaintained,itcausespelvicinstability,whichcanchangethegaitofwalkingand/orrunningandplacingunnecessarypressureonthelowerspine.Instabilityinthepelvicregioncanplacepressureonthesciaticnervewhichrunsdownthelengthofthebodyfromthelowerbacktothelegs.Pelvicgirdleinstabilitycanalsooccurduringpregnancyandchildbirth.Physicaltherapyisthemostcommontherapytoworkagainstthemuscleimbalancestargetingstrengtheningtheweakenedmuscles,mostlikelytheabdominals,stretchingandstrengthenthehipextensorsandstrengthenthebackextensorstostabilizethepelvicjointsandmuscles.Astrongpelvisgirdleislesslikelytobeunstable.

NeutralPelvis

NeutralpelvisreferstothepositionofthepelviswhentheASIS(anteriorsuperioriliacspine)oneachsideofthepelvisandthepubissymphysis(PS)areinthesamehorizontalplaneandthetwoASISareinthesametransverseplane.Thespinewillthanresultinaneutralspinepositionwithitsnormalcervicalandlumbarcurve.Traininginaneutralspineandpelvispositionbenefitinabalancedtrainingofallmusclesurroundingthepelvis,encouragedbalancedmuscledevelopmentofthepelviscomplexandcorrectmusclerecruitment.Workinginneutralspinepositionmeansteachingidealpostureandalignment,reinforcingfunctionalandpositivemovementpattern.

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Asthepelvisanatomicalliesbetweenupperandlowerpartofthebody,itwillbeinfluencedbymovementinthespineandlegs.Correctpelvisalignmentwilldevelopbalancemusclegroupsactingonthepelviscomplexstrivingforidealpostureandfunction.

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PositionofthePelvis

Thepelvisisinaposteriortilt(tuck)whenthePubissymphysisishigherthantheASIS.Thelowerspineislengtheningintothematandforcestheupperbacktoroundmoreforward,thenaturallumbarcurvehaschangedtoaflexedlumbarspineposition.

Thepelvisisinananteriorpelvictilt(arch)whentheASISishigherthanthepubissymphysis.Thelowerspineisarchedofthematandforcestheupperbacktoflattenmoreintothemat,creatinganextendedpositionofthelowerspine.

Pelvisinstability

Pelvisinstabilitycanpresentatanyage,buttendstodeclinewithaging,duetostiffeningofligamenttissue.Itoftenpresentsinyoungfemaleswhoareinvolvedinsportsthatrequiresahighdegreeofmobilitysuchasdancers,gymnastsandswimmers.Thesethreehavealsoincommonahighintensityintrainingloadandwithinitstraininganincreasedamountofbackbending.

Thepelvisisbearingthebodyweightanddistributeitthroughthehipsandlegs.Ifligamentsareinjuredoroverstretched,thepelvislosesitsstabilityandbeginstomoveexcessively.Duetoexcessiverangeofmotionwithoutnecessaryadequatemuscularcontrolstructuresinspineandpelvisasjointandligamentscanbedeformed.Holdingthejointsinorneartheirendrangeofmotionstressesandstretchestheretainingligamentswhichwillbenoticedinpainsymptomsassacroiliacjointpain,lowerlumbarspinepainorpubicpain.

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CaseStudy

Marcy,16yearsold,isanambitiousswimmer.Shetrains9timesaweekeachtrainingsession2hours,andsometimestwiceperday.Ascrosstrainingsheisdoingrunningandweighttrainingintheschoolgym.Shestartedtoswimwiththeageof5anddevelopedovertheyearsarealpassionforswimming.HerdreamistobecomeanOlympicswimmersinceGrade3asshewroteherfirstassayabout“BeinganOlympicswimmer”.

SheachievedtostarttwiceintheGermanJuniorNationalSwimChampionship2016and2017qualifiedfor100breastand200breast.ShewasaswellqualifiedfortheGermanJuniorNationalChampionshipsin3events–100Breast,50free,200Breastandshecouldhavequalifiedformoreevents.

Unfortunately,herbackpainincreasedoverthelast1/2year,correlatingwithliftinghigherweightsintheschoolgyminbadposture.Causeofincreasedpaininthemidback,lowerbacknearthesacroiliacjointsheneededtostepbackandreducehertrainingloadtotrytohealofpain.Shehasseenseveraldifferentmedicalprofessionalsasphysiotherapists,osteopathsandorthopaedics.TheMRIshowedthatnobonedamagedinthesacralvertebraeoccurred,thattheligamentsandmusclesareworkingtotheirnormalfunction.Shewasthanreferredtothenextphysiotherapist.

ShedecidedtochoosePilatesashercrosstrainingtohavealow-impacttrainingwhichtrainsherbodytobeincorrectbodyalignmentwhileworkinginsupine,prone,sidelyingandFourPointKneelingposition.TrainingonPilatesequipmentwillhelphertothentransferneutralalignmenttoperformherfavouritesport-swimming.Ingeneral,shefeelsPilatesisboringandsheonlydoesittoimproveherperformance.

Istartedtoassessherwiththepostureplumblineandnoticedthatherpelvisisanteriortilted.Heroverallpostureisshowinganincreasedlumbarcurve,lumbarHyperlordosis.Thispostureisassociatedwithweakabdominals,tighthipflexorsandtightlowerbackextensors.Wewillfocusonworkingagainstthisfindings:strengthentheabdominals,stretchinghipflexorsandlowerbackextensors,strengthenthehipextensorsandmaintainingpelviclumbarstabilityinallbodypositions.

WecontinuedwiththestandingRollDown.InthestandingRollDownitwasquietobviousthatherleftmidbackmusclewereoverdevelopedcomparedtoherrightmidbackmuscles.ThePilatesconditioningprogramforMarcyshouldalsoincludebalancedworkforbothsidesofthebody-rightandleft–andspeciallytostrengthenthebackmusclesandabdominalsinanequalbalancedmanner.

ShestartedwithPilatestwiceperweek,butshestillcontinuedswimtraining4timesaweekeach2hoursandcrosscountryrunning3timesperweekeach1,5hour.

Thefirstsessionswerefundamentalreformerworkoutsfocusedonmaintainingthepelvislumbarareainaneutralposition.Marcy,assheisoverseveralyearsanathlete,hasagreat

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understandinghowherbodymovesinspace.Shepicksuptheconceptveryquick;sowecouldmoveontointermediateworkontheReformerandCadillacasforexamplesingleleghipworkontheCadillactochallengeherpelvisstabilityevenmore.SheprogressedveryquicklywiththePilatesworkonequipment.

WealsofocusedonhipflexorsstretchasinthelungeseriesonReformer,andworkedonstrengtheningtheabdominalsinneutralspineasdoneinabdominalwork,hipworkandarmsupineseriesonthereformer.Sheisoverallverystrong,butneedstofocusondetailstoachievethebestresults.Workingevenlythroughbothhipjointswasquietchallenging.

SlideSpinalarticulationasinbottomlift,pelvictiltandbackextensionasinswanbasicsonthechairweregraduallyincorporated.

Singlelegskatingwasoneofthemostchallengingexercisesforher.

Asthetrainingloadforschoolcrosscountryandswimmingteamincreasedshestartedtogetmorepainagain,whichmadeherthinktoreduceheroveralltrainingloadforawhile.Shereducedthecrosscountryrunningforschoolteam,butstillcontinueswithswimtrainingfortheschoolteam.Herpainisonandoff,buthasimprovedasherstabilityofthetrunkandpelvisgirdlehasimprovedoverall.Hermusclespamonthelefterectorspinaehasreducedbutisstillnotcompletelyhealed.

Wearestilltryingtoimprovehermusclememorytoworktowardsabalancedmusclerecruitmentsothatsheisabletocompeteagaininswimmeets;shewillfurthercontinuewiththeprogram.

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Conditioningprogram Session

Basiblock 1–10 11-20 21-30

WarmUp

PelvicCurlSpineTwistsupineChestliftChestLiftwithrotation

PelvicCurlSpineTwistsupineChestliftChestLiftwithrotation

RollupSpinetwistsupineDoublelegstretchSinglelegstretchCrisscross

Footwork Reformer:ParallelHeels&Toes,SmallV,WideVheels&toes,Calfraises,Prances,Singlelegheel&toes

Reformer:ParallelHeels&Toes,SmallV,WideVheels&toes,Calfraises,Prances,Singlelegheel&toes

ReformerorChair:ParallelHeels&Toes,SmallV,WideVheels&toes,Calfraises,Singlelegheel&toes

Abdominals Reformer:HundredPrep,Coordination

Reformer:HundredPrep,Hundred,Coordination,

Cadillac:Roll-UpwithRollupBar,MiniRollUps,MiniRollUpsObliques,RollUpTopLoaded,

HipWork Refromer:FrogCirclesDown/UpOpening

Cadillac:BasicLegsprings

Cadillac:BasiclegspringsorSinglelegsupine,orReformer:extendedfrog,extendedfrogreverse

SpinalArticulation

none Reformer:bottomliftOrCadillac:BottomLiftwithRollUpBar

Reformer:Bottomlift,Bottomliftwithextension

Stretches Reformer:StandingLunge

Reformer:KneelingLunge

Cadillac:ThighStretchwithRollupBar,LadderBarrel:Gluteal,hamstrings,abductor,hipflexors

FullBody none ReversekneeStretch,Scooter,

Cadillac:sittingforwardorside

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DownStretch reachorreformer:Downstretch

Arms Reformer:armsupineseries

Reformer:SittingarmseriesorCadillac:Standingarmseries

Reformer:ArmKneelingSeriesorSidekneelingArmSeries

FullBody none none Reformer;UpStretch1+2+3,LongstretchorDownStretch

Legs Reformer:Singlelegskating

Reformer:SingleLegskating,WundaChair:Legpressstanding

WundaChair:Legpressstanding,ForwardLungeorFrogFront

LateralFlexionRotation

Reformer:Sideoverbox Ladderbarrel:sideoverprep,orWundachair:Sidestretch

Ladderbarrel:sideover,orWundachair:Sidestretch

BackExtension Reformer:Backextensionorbasicbackextensionmat

Reformer:Breaststrokeprep,PullingStrap1+2

Cadillac:ProneoneWundaChair:SwanbasicorBackextensionsingleArm

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ConclusionMarcyincludedPilatesequipmentworkintoherweeklytrainingprogramconcludinginimprovementinherpelvisstabilityandbodyawarenessovertime.ThisconditioningprogramforMarcyisdesignedtoimproveherpelvic-lumbarareastability,focusingonthefollowing:

1. Strengtheningtheabdominalmuscle,astransversabdominalsandobliquemusclestoincreasepelvic-lumbarstability;

2. Strengthenandstretchhipflexor;3. Strengthenthehipextensors,hamstringsandglutes;4. Strengthenthespinalextensors;5. Mobilisethepelvislumbarregion6. Createawarenessofgoodbodyposture

Marcybecameawareofheroverallbodyandwasgratefultomovemorefreelywithlesspain.Shenoticedthatmisalignmentwillresultineitherovercorrectionorovercompensationfromothermusclegroupsandmaytriggerothermuscletogointospasm.Shelearnedalotaboutherbody,evenassheisnotcompletelypainfreebutmoreawareofherself.Raelstatedin‘StudyGuide–ComprehensiveCourse’thatstudieshaveshownthatatighterectorspinaemusclewillbeactiveduringitsreverseaction–trunkflexion–andthiswillinhibititsactionofitsantagonist,theabdominals.IfMarcy’smuscleimbalanceonhermidbackiscausedinthefirstplacebyatrainingoverloadandpainfulstimuliasthemovementcontinuedrepetitivethefurthertreatmentshouldbere-educatingmovementpatternandpreventingundesirableover-activationandsubstitutionpattern.Qualityandprecisemovementpatternaremoreimportantthanquantityorintensity.HopefullythiswillhelpMarcylongterm.

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Bibliography• Isacowitz, Rael and Clippinger, Karen: Pilates Anatomy, Human Kinetic 2011 • Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body

Arts and Science International, 2013. • Miller, J. Physio Works. Web. https://physioworks.com.au/injuries • http://anatomy.lexmedicus.com.au/pathologies/pelvis-hip • https://fadavispt.mhmedical.com/content.aspx?bookid=1899&sectionid=141191031