TheBenefitsofPilatesforMyofascialPain

Syndrome

By:IfigeneiaKontou

26May2018

Dubai,UnitedArabEmirates

CourseYear2017-2018|BASIComprehensiveGlobalProgram

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Acknowledgments

IwasinspiredtotakethiscourseafterIattendedaworkshopinthesummerof2016inAthens

withRaelIsacowitz.IameversogratefulforRaelandBASI’svisionformakingsuchanamazing

courseandforalltheknowledgeandinspirationitgaveme.

Firstofall,Iwouldliketodedicatethispapertomylovinghusbandandmydearestchildren,

notonlyforalltheirsupportbutmostlyfortheirunderstandingforallthetimeItookfrom

themfromtheverybeginningofmytraining.

Secondly,tomymuch-lovedfriendKapi,whokindlyandpatientlybecamemyfirststudent

andshowedherdevotiontomeuntiltoday.

Tomybelovedfaculty instructorsPatriciaandTash.Thankyou,Patricia,forcaringandfor

sharing your knowledge so generously with me. Thank you, Tash, for all your support,

encouragementandboostingmyconfidencewhenIreallyneededit!

I’malsoverygratefultoLucy,whowasbymysidefromdayoneofthisprogramhelpingand

believinginme.Additionally,abigthankyoutoMirkawhospenthourswithmepracticing

andteachingeachother!

Lastbutnot least,tomypreciousfriendandteacherMaryliz,withwhomImadetheBASI

journey,stepbystep,handbyhand,andwhogrewtobecomea“sister”tome!

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Abstract

ThispaperaimstodescribethebenefitsofPilatesforMyofascialPainSyndrome,whichisa

common syndrome occurring nowadays, not only due to spinal alignment deviations and

muscleimbalances,butalsoduetobadhabitsineverydaylife.

My student came tome after the doctor’s recommendation to do Pilates as one of the

treatments forherMyofascialPainSyndrome,mainly located inherupperbackandneck

area. I spent some time understanding her case, and based on the BASI Block System, I

preparedtwoconditioningprogramsoveraneight-weekperiod,whichI’veoutlinedinthis

paper.

We’vestartedour lessonstogetherandthefirstresultsprovedtobeeffective inrelieving

pain and tension. The aim is to continue the conditioning program to achieve overall

improvementsinthespinalalignmentandposture.

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TableofContents

Acknowledgments 2

Abstract 3

AnatomicalDescription 5

TheMyofascial(Muscle+Fascial)System 5

MyofascialPainSyndromeanditsCauses 6

Kyphosis 6

MyofascialPainCycle 8

Symptoms 10

CaseStudy 11

Introduction 11

Body 11

ConditioningProgram 14

Weeks1-4 15

Weeks5-8 17

Conclusion 20

Bibliography 21

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AnatomicalDescription

TheMyofascial(Muscle+Fascial)System

Fasciaisa“web”-aconnectivetissuethatenvelops,connects,supportsandinvestsallofthe

structuresofthebody.(Oscar,E.andBussard,M.,2015).

Figure1:Fasciaisaweb.

Thefascialsystemofthehumanbodyhasbeencalledthe‘OrganofStabilityandMechano-

regulation’(Myers,T.W.2011,citingValeraandFrenk),whichmeansthatitsjobistodojust

that: to provide stability and maintain it by adapting to whatever mechanical forces it

encounters(Oscar,E.andBussard,M.2015).

TheMyofascialSystemreferstotheinterwovenandinseparablenatureofthemusclesand

thefascia;together,themyofascialsystemcreatesstabilityandintegrityinthebodythrough

tensileforces.(Oscar,E.andBussard,M.2015).

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MyofascialPainSyndromeanditsCauses

MyofascialPainSyndrome,whichisaverycommonconditionnowadays, isacollectionof

signsandsymptomsinaparticularareaofthebodythatindicatesmuscletrauma.Ideally,the

fit of the bones is designed to keep the body’s posture upright and moving smoothly;

however,whenthisisnotoccurring,musclestakeoverthejobandeventuallygetfatigued.

Assuch,poorpostureisoneoftheprimarycausesofMyofascialPainSyndrome.Otherfactors

can include serious lackofexerciseandmovement, generalized fatigueand lackof sleep.

(Asher,A.2018).

Citing the words of Dr. Sheriff Gamil, Specialist Orthopedic Surgery, “Myofascial Pain

Syndrome”isnotadisease;itisasyndromeoutofwhich50%isa‘muscular’issueandthe

other 50% is ‘psychological’; so, tension, stress and emotional problems (e.g. depression,

anxiety)playavitalrole.Besides, ithasbeensaidthatmusclesareawindowtothebrain

(Butler,D.andMosely,L.2013).Truly,ourthoughts,emotionsandbeliefsarereflectedinour

postureandmovementpatternsandthemechanicaltensionsassociatedwiththem.(Oscar,

E.andBussard,M.2015).

Kyphosis

Beforedescribinghowthe“MyofascialPainCycle”occursandaffectsthepersonandthebody

itwouldbenecessarytotalkalittlebitmoreabouttheprimaryandmostcommoncauseof

thesyndrome,thatof“poorposture”.Forthepurposeofthispaperwewillbereferringto

“poorposture”focusingontheareaoftheupperbackandneck.

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Oneofthemosttypicalalignmentproblemsisan“exaggerationofthecurvatureinagiven

regionofthespine;exaggerationofthecervicalcurveisoftenassociatedwiththealignment

problem called ‘forward head’ inwhich the chin juts forward and the earlobe is forward

relativetotheplumblineandshoulders.Thisincreasedcurveinthethoracicregionistermed

asKyphosis”.(IsacowitzR.andClippinger,K.2011).

In thatpostural syndrome, as theupperback appears curved, the shoulders are rounded

(rolledshoulders)andthescapula(shoulderblades)areprotracted,meaningthattheyare

positionedfurtherawayfromthespine.(SportsInjuryClinic).

(a) (b)

Figure2:(a)Idealstandingalignment,(b)kyphoticposture.

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Thus,thiscervicalpoorpostureismainlycausedbythefollowingimbalancesofmusclesin

theupperbackandneck:

- Thepectoralismajorandminormusclesandthemusclesinthebackoftheneckare

shortenedandtight.

- Themusclesofthebackoftheshouldersandupperback(trapezius,latissimusdorsi

andrhomboids)areweakenedandstretched.

- Inparticularthesternocleidomastoidmuscleistightandshortenedcausingthejawto

beposturedforwards.(SportsInjuryClinic).

Mostofthesemusclesmentionedabove,pectoralisminor,trapezius,rhomboids(ofcourse

alongwiththeserratusanteriorand levatorscapulae)aremainmusclesthattheshoulder

girdledependson.AndthisbringsustowhatRaelIsacowitzandKarrenClippingerpointed

out in their book “Pilates Anatomy, that “movements of the shoulder girdle are very

dependedonmusclesandmuscleimbalancescaneasilyleadtoalignmentproblems”.

MyofascialPainCycle

Whilsttalkingaboutalignmentproblemsandmuscleimbalancesitisworthgivinganexample

fromeverydaylifethatIbelieveanyonecouldrelateto.Whenyousitatyourcomputerall

daylongandyourupperbodybeginstoslumpforwardtoraiseyourheadtoseethescreen,

youuseyouruppertrapeziusmuscle–whichislocatedatthetopofyourshoulders.

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Figure3:Commonposturaldeviations.

The‘uppertrapezius’muscleisnowworkingatsomethingitisnotreallysupposedtodoand

itisdoingsocontinuouslyandforaprolongedperiodoftime.Thereislittleornotimefor

rest and relaxation; instead the continual contractionof the trapezius causesmicroscopic

injurytothismuscle.Thenormalorself-protectiveresponseofaninjuredmuscleistoseize

upor spasm.But in this case, theextra inputof tension into the trapezius intensifies the

situation;theconstrictioninthemusclereducesnourishingbloodflowtothearea,whichin

turncausespain,thepainsignalsthecycletobeginagainwhicheventuallycausesthemuscle

tocreatetriggerpoints,whichmayleadtodisability.

If the spasm-pain-spasm cycle is not interrupted to be treated, it will most likely repeat

endlessly and the problem will become chronic; “Chronic Myofascial Pain Syndrome”.

Therefore,MyofascialPainSyndromeshowsupas‘activetriggerpoints’inmusclesandifleft

untreated,it’softenexperiencedasarecurring‘cycleofspasm’(restrictioninthesofttissue):

spasm–pain–spasmagain.(Asher,A.2018).

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‘ActiveTriggerpoints’,canbefeltnotonlywheretheyarelocatedbutalsoaspainreferred

tootherareas.Eachmusclehasaparticularreferralpattern;inotherwords,painthatgoes

fromatriggerpointinaspecificmuscletoanotherplaceinthebodywillshowupprettymuch

thesamewayineverypersonwhohastriggerpointsinthatparticularmuscle.

Whenthis‘spasm-pain-spasmcycle’occurs,bloodflowdecreases,anditcausesthemuscle

todevelop‘activetriggerpoints’,whichcausepainthatleadsbacktomorespasms,andthe

cyclerepeatsitself.

Figure4:Triggerpoints.

Symptoms

MyofascialPainSyndromecanaffectyourqualityoflife;youmaynotbeabletoparticipate

inphysicalactivitiesthatyouusedtoenjoy.Itlimitsflexibilityandmusclesbecometight,tense

andtautand joint rangeofmotiondecreases;all thesecausepainanddysfunction in the

musculoskeletalsystemandallthesetogethercouldleadtodepressionandevenisolation.

Generally, myofascial pain can be found in the shoulders and neck but also arms, face,

low/upperback,and/orlegs.(Asher,A.2018andOsborn,C.2017).

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CaseStudy

Introduction

Thewholeproblemfeels likeoneviciouscircle itself;upperbackmuscle imbalances,poor

posture, incorrect scapular movements leading to further muscle imbalances and more

alignmentdeviations,musclesgetfatigued,tensedandtightandifremaineduntreated,they

get traumatized, then range of motion decreases and movement is poorly performed.

Eventually,ifalltheseconditionsremainwithouttreatmentorcorrectionsthiswillleadtoa

“ChronicMyofascialPainSyndrome”.

Itcanoccurinallsectionsofthepopulation.Even,inthesportsworldforexample,cyclists

and baseball catchers are at risk as they have to hold postures for long periods of time.

(Internet,SportsInjuryClinic).

Body

Sophia,my40-yearoldclientwasdiagnosedwithMyofascialPainSyndromethreemonths

ago.Sophiahadbeenverysportyandactiveallherlife;fromballetandcontemporarydance

inheryouth,tovolleyballandtennis.Sincegivingbirthinherearlythirtiesto2children,she

wasfollowinggymfitnessprograms,doingcardioclasses(e.g.stepclass,bodycombat)and

alsolightweightliftingclassesforstrength(bodypump).PilatesMatclasseshavebeenpart

ofherlifeforthelast6yearsalongwiththeotherfitnessprogramsandsherecently(2months

ago)startedprivatesessionsusingthePilatesapparatus.

In the meantime, being a full-time active mom, Sophia got a new part time job which

demandedalotofreading,writingand‘computerwork’whichinvolvedspendingalotoftime

atadesk.

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Coordinatingandkeepingupwithallresponsibilitiesoffamilyandwork,andmaintainingher

veryactiveathleticlife,Sophiastartedfeelingalotoftensionandstress.

WhenIfirstmetSophia,Icouldnotavoidnoticingher‘kyphotic’tendency,whereherupper

backappearedtobecurvedwiththeshouldersroundingforward,herscapulaeprotracted

(positioned away from the spine) and her chin slightly poking forward rather than being

tuckedin.

PuttingallthesedetailsaboutSophiaandherlifestyletogether,itseemsthatshefulfillsall

thepreconditionstodevelopaChronicMyofascialPainSyndromemainlyaffectingthearea

ofherupperback,hershouldergirdleandherneck.Thus,aftervisitingthedoctor,Sophia

waspartially treatedwithoralmedication, includinganalgesics,pain relieversandmuscle

relaxantsfor10days.Accordingtothedoctor,thisalonewouldneversolvetheproblembut

wouldratheronlyrelievethepain.Shewasalsoprescribedwith20sessionsofphysiotherapy.

Duringherphysio-sessionshertherapistusedtherapymessagetoincreasethebloodflowin

theareaandtowarmupthemusclesinordertoreleasemusclestiffness,tensionandpain.

Duringthetherapeuticmessages,thetherapistavoidedusingthethumbtoputpressureon

the trigger points as this only aggravated the pain. Instead, it was decided to follow the

method of ‘dry needling’, one of the most effective and quickest methods to inactivate

myofascialtriggerpoints.However,afterallthesetreatments,citingDr.Sherif’swords,“when

medicationisfinishedandphysioisover,thisiswhenPilatescomesin”toassistintargeting

theproblemfromitsroot.

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AndthisismoreorlesshowSophiaandIgottogether.Fromourfirstsessionafterhearingall

the details about her life, I assessed her posture and itwas obvious that her back had a

kyphotic tendency. As I correctly suspected after our first session, most of her arm and

scapularmovementswerebeingperformedinanundesirablemanner.

ItisexactlywhatRaelIsacowitzandKarenKlippingerveryaccuratelyandclearlyexplainedin

theirbook“PilatesAnatomy”:“Oneofthemostcommondysfunctionalmovementsofthe

shouldergirdle,themovementsofthescapula,iswhenthearmrisestothesideortothe

front.Ideally,whenthearmmovesthescapulawouldmoveinacoordinatedmannerthat

wouldallowthehumerustomaintainproperpositioningintheshouldersocket.”However,

inourcase, “as thearmmovesupwards, there isanundesiredexcessiveelevationof the

scapula”, whichmeans that thewrongmuscle has taken over tomake an unnecessary

movement.

(a) (b)

Figure5:(a)Upwardanddownwardrotation,(b)useofscapulardepressorstoavoidexcessiveelevationofeachscapulaasthearmsareraisedoverhead.

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ConditioningProgram

ThemaintargetoftheConditioningProgramdesignedforSophiais,ofcoursetostrengthen

themusclesthatareimportantforhercorrectalignmentandnottoforgethercorestability.

Equallyimportantistomakeherfeelthecorrectalignment;toguideherhowtohonethe

skillsforquicklyachievingthiscorrectalignmentandtopracticewithherhowtoutilizethis

alignment,inbothhersportsandhereverydaylifeactivities.“Researchsuggeststhatwith

repetitiveactivationofthedesiredmusclesintheappropriatemanner,overtimeyourbody

willautomaticallystartutilizingthesemoreoptimalstrategies”.(IsacowitzR.andClippinger,

K.2011).

Moreanatomicallyspeaking,I‘lltrytoeducateSophiaonhowtouseherscapulardepressors

topullthescapulaeslightlydownbeforeliftingthearms,toencourageuseofthesemuscles

asthearmsmove.Wewilltrytobalancetheusebetweentheuppertrapezius,whichelevates

the scapulae and the lower trapezius which depresses the scapulae. (Isacowitz R. and

Clippinger,K.2011).At thesametime,wewillattempt tostrengthenherbackextensors,

‘ErectorSpinaeMuscleGroup”,whicharealsoresponsibleforthepostureaswellasthehead

andarmmovement.Finally,wewillworkonstrengtheningthe“Rhomboid”muscles,right

underneath the trapezius as they bothwork together to adduct (or to bring towards the

middleofthebody)theshoulderblades.(Salyer,J.2017).

ItisnecessarytoclarifyherethatSophia’slevelisintermediateasshehasbeendoingPilates

forquitealongtime.Moreover,dueherprolongedexperiencewithsportssheisalsoquite

awareofherbody.

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Weeks1–4

BASIBlockSystem Exercise ReasonsandPurpose

WARMUP

Basic:• PelvicCurl• SpineTwistSupine• ChestLift• ChestLiftwith

Rotation

Wewanttomakesurethattheclientisabletoperformallthesefundamentalexercises.Weneedtostartmobilizingthespineindifferentdirectionsandstartfocusingontherightalignmentespeciallythatoftheupperback.(E.g.keepingshouldersrelaxedanddownonmatduringspinetwist;orkeepingtheheadinalignmentwiththespineduringchestlift).

FOOTWORK

Wundachair:• ParallelHeels• ParallelToes• VpositionToes• OpenVheels• OpenVtoes• CalfRaises• SingleLegHeel• SingleLegToes

Givingagoodopportunitytoworktheclient’suprightposition,tolearntokeepthetrunkstable,tobeabletofocusonco-contractionofabdominalsandbackextensorsandthroughthedifferentarmpositionstolearntocontrolthemovement(especiallytheunnecessaryelevation)ofthescapula.

ABDOMINAL

StepBarrel:• ChestLift• Reach• OverheadStretch

Itisanextraordinaryandyetsafeway,especiallyforacurvedthoracicspinetostartopeningupandstretching,whileyoustrengthentheabdominals!Atthesametime,youeducatethespine,whilesafelysupportingit,toworkinalldirections;fromanupperbackextension,throughneutral,allthewaytoflexion.Theclientlearnstokeeptheheadinalignmentwithandwithoutsupportsotheneckmusclesarenottensedoroverworked.Anditisawonderfulwaytomobilizeandstretchtheshoulders!

HIPS

StepBarrel:• Openings• Helicopter• Scissors• Bicycle• Bicyclereverse

Itcanhelptheclientgetthefeelingthattheupperbackissupportedbythemat;tolearntoavoidputtingtensionontheneckbutkeeptheweightontheshouldergirdle.Andwhileworkingthehips,shecanfeelperhapsastretchhappeningacrossthechest,controlshouldersfromroundingforwardandworkonhertrunkstabilitywhilelegsaremoving.

SPINALART Stepbarrel:• RollOver

Fromtheretheclientisreadytomoveintoarolloverasshecancontrolnowtoavoidputtingtensionontheneck.Thearticulationofthespinewiththesupportofthebarrelhereallowstheclienttostretchmoreofthelowerbackwhilekeepingshouldergirdleonthemat.

STRECHES

StepBarrel:• ShoulderStretch

LyingSideLadderBarrel:

• ShoulderStretch1• ShoulderStretch2

Whatanincrediblewaytostretchthethoracicspineandthetightshouldersofourclient;toreleaseallhertensionfromherneckmusclesbyallowingherheadtorollbackandforward,naturallyfollowingthepathofthebody.Atthesametime,wearefocusingontheLatissimusdorsiandpectorals,musclesofgreat

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importanceifwewanttocorrectourclientspostureandscapulamovement.Andofcourse,ashoulderextensorandflexorstretchattheLadderBarrel,willencourageespeciallywiththeshouldermobility.

FBI1

Mat:• FrontSupport• BackSupport

KeepingtheflowofthesessionbymovingintotheMat,totargetnotonlyabdominalsbutwecaremoreaboutinourcasestudy,thescapularstabilizers.Strengtheningboth(abdominalsandscapularstabilizerswillsupportourclientinherefforttomanagetokeepherbodyinastraightlinefromheadtotoes!Afterhavingstretchedhershoulderextensors(justinthepreviousblock)nowwewillstrengthenthemwithBackSupport;theclienthere,willalsohavetomaintainco-contractionoftheabdominalsandbackextensorstokeepthatneutralityofthespine,theneutralityofthescapulae,andatthesametimetheshoulderextensorsarestrengthening!

ARMSWundaChair:

• Shrugs• TriceptsPressSit

Shrugs:whatabetterwaythanthisfundamentalexercisetomakesomeoneunderstandandcontrolthescapularmovement.Supportingtheoverworked‘uppertrapezius’toelevatethescapulaewiththehelpofthepedalandthenengaging/strengtheningthe‘middletrapezius’(muscleresponsiblefortheretraction[adduction]ofthescapula’andthenstrengtheningthe‘lowertrapezius’whoisresponsibleforthedepressionofthescapulaeand(alongwiththeuppertrapezius)itwillrotatescapulaetoliftthearmoverhead.It’sawonderfulexerciseforourclienttocontrolandatthesametimesupport,anuprightpositionandthescapulaemovementfromrollingforward.ThenfocusingonstabilizingthescapulaetheclientwillstrengthenTriceptswhilegettingastretchacrossthechest.

FBI2 WundaChair:• TendonStretch

Havingfocusedmostlyonworkingtheupperbacktowardsanextensionandaneutralposition,Ibelieveitwouldbenecessarytoworkonhowtostabilizetheshoulderswhiletheupperbodyisinflexion.Itisalsoimportanttomentionthatwewanttotargettheserratusanteriorhere,themusclewhichisresponsibleforstabilizingscapulaeduringapushuptypemovementandwhichrotatesscapulaefromabductingandraisingarm.(Bandhayoga.com)

LEGSWundaChair:

• FrogFront

Again,herewewanttofocusonmaintainingtrunkstabilization,bykeepingmoreofanuprightpositionwiththeupperbody;wealsofocusonscapulaestabilizationasthelegswork.

LATFLEX/ROTATION

WundaChair:• SideKneeling

Stretch

Focusingoncemoreonmaintainingstablescapulaeinaneutralposition,whilethebodythistimeisworkinglaterallytostrengthenobliqueabdominals.

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BACKEXTENSION

WundaChair:• SwanBasic• Swanonthefloor

Usingthesupportofthepedaltostrengthenbackextensorsisaverysafewaytodoso,especiallywhenthespecificareaofthebodyisalreadyintraumatized.Theclientalsogetsabetterfeelingofwhetherscapulaearebeingstablethroughoutthemovement(fromneutralspinetobackextension).Comingon“Swanonthefloor”wedemandfromtheclientabitmoreofaneffort;toengageherbackextensorsevenmoretoenhancetheirstrengthandalittlebitmoreefforttostabilizeherscapulaeandasnowthepedalisworkinglikeanextrachallengeinhermovement.Also,thisexerciseishelpingtheclienttoincreaseshoulderextensorcontrol!

Weeks5-8

BASIBlockSystem Exercise ReasonsandPurpose

WARMUP

Intermediate:• RollUp• SpineTwistSupine• DoubleLegStretch• SingleLegStretch• CrissCross

Theclienthasbeenreadytomoveintoamoredynamicandintermediatewarmup.Withthe‘rollup’,theclientwilllearnhowtofeelandcontrolthescapulaethroughthearticulationofthespine,fromneutralallthewaytoaCcurve.Thisisalsoaverynicewaytolearnhowtokeeptheheadinalignmentwiththespinethroughoutthemovement,soshestopsputtingexcessivetensioninherneckmuscles.Sheisgettinganicethoracicstretchwith“SpineTwistSupine’.Andfinally,sheworksonthetrunkstabilizationwiththethreeabdominalexercises.Shealsoworksonkeepingtheheadalignedwiththespineinflexionandtofocusontheabdominalengagementratherthanputtingtensionintheneckmuscles.

FOOTWORK

Cadillac:• ParallelHeels• ParallelToes• VPositionToes• OpenVHeels• OpenVToes• CalfRaises• Prances• SingleLegHeel• SingleLegToes• HipOpener

AveryactiveandsportypersonlikeSophianeedsaverygoodstretchinherhamstrings.IbelievefootworkintheCadillacisoneofthemosteffectivewaystodothat.Inaddition,withherbacksupportedontheCadillac,shecanlearntofeelherscapulaewideandflatonthe‘mat’,keepingshouldersformroundingforward,herchestopen,andtheneckmusclesarewithouttension,astheheadisalignedwiththespineandsupportedbytheCadillac.

ABDOMINAL

Reformer:ShortBoxSeries:

• RoundBack• FlatBack

RoundBack:isaveryniceexercisetomaketheclientunderstandhowtheCcurveishappeningbypullingdeeplyintotheabdominalsandtheupperbackisroundingasanaturalresponsetothatdeeplumbarflexionratherthancurvingjustthethorax.

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• Tilt• Twist• RoundAbout• Climb-A-Tree

Then,wegettheopportunityherewiththerestoftheseries,toworkontheabdominalsandthebackextensorsatthesametimebyco-contractingthemequallytomaintainmovementwithaflatback.Also,thisisagreatchancefortheclienttoworkonkeepingtheheadinalignmentwhilesupportingitslightlybygivinghertheoptiontopositionherhandswithinterlacedfingersbehindthehead(likein“Tilt”)untilthe“Roundabout”.Andfinally,agreatbenefitforSophia,isthatbackextensionduring“Climb-A-Tree”asshewillfeelthechestmusclesopeningandstretchingwhilethearmscircleoverhead!

HIPS

Reformer:• Frog• CirclesDown• CirclesUp• Openings

Whiletheclientisstrengtheningandstretchingherhipadductors,theclientcanworkonmaintainingherchestniceandopenkeepingherarmsactiveandlongbyhersidetomaintainslightactivityintheupperbackthere.

SPINALART Reformer:• Semi-Circle

Thewiderangeofspinemobilityandarticulationofthisexercise,allowstheclienttostretchoncemoretheupperbackandthechestinauniqueway!Again,shecanworkonkeepingallweightonhershouldergirdle,avoidingtensionontheneckmusclesandthebodypositioningwillhelphertokeeparmsstretchedwhilebeingoverhead;pushingintotheshoulderrestscanhelphertocontroltheshouldersfromexcessiveelevating.

STRECHES Cadillac:• ShoulderStretch

Onethebestwaystomobilizeandstretchtheshouldersespeciallywhentheysufferfromtensionandtautness.Thisexercisecouldbeconsideredtherapeuticinourcase.

FBI1

Cadillac:• SideReach• KneelingCat

Stretch

Agreatexerciseformobility,stretchingatthesametimetheshouldersadductors,focusingonopeningthechestandstretchingthebackasthethoracicspinehastoremainisolatedfromthelumbarspine(whichhastoremaininflexion).With“CatstretchKneeling”,whilemobilizingthewholespine,wearestrengtheningthebackextensors,workingonscapularstabilizationandwealsoofferatremendousshoulderstretch!Maintargetsforourclient.

ARMS

Cadillac:• ShoulderAdduction

SingleArm• ShoulderAdduction

DoubleArmOrAlternatively,

• SittingSidePrep• SittingSide

AneffectivewaytomakeourclientunderstandhowtofocusonactivelyengagingtheLatissimusdorsi,withoutlettingthe‘wrongmuscles’totakeoverallthework.It’salsogreatforimprovingtheclient’spostureashershoulders(whichareroundingforward)havetoremainexternallyrotated.Withouralternativeexercise,wecanimprovetheclient’sscapulaadductionandabductioncontrolcreatingatthesametimemorescapularmobility,whichwillfreetheclientfromalotoftensionandperhapssomepain.Itisalsoaniceopportunityfortheclienttounderstandandcontrolscapula

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unnecessaryelevation,whichhasbeenoneofhermostcommondysfunctions.

FBI2 Cadillac:• SittingBack

Wealreadyofferedshoulderstretchesfortheclient(with‘shoulderstretch’,KneelingCatStretch)butwhatismakingthisonemoreintense,andperhapsmoreeffective,isthatinthisexerciseastheshouldersrotateexternallyforthestretchthethoracicspineisflexingquitedeeply.

LEGS Cadillac:• Squats

Whileworkingonthelegstheclientoncemorehastocontrolspinalalignmentandworkonmaintainingthetrunkinanuprightposition.Atthesametime,shewillneedtocontroltheshouldersfromrollingforwardasthesprings’tensionwillbeanextrachallengethereforher.Keepingtheheadinalignmentwiththespinewillbealsooneofourmaintargets.

LATFLEX/ROTATION

Cadillac:• Butterfly

Awonderfulexerciseforourclienttoworkonherabdominalobliqueswhileshewillalsobenefitfromlearninghowtocontroltheunnecessaryelevationoftheuppershoulderduringtherotationofthebodyandwhilethearmsareswingingaround.Thestarting/finishingpositionofthisexerciseuntilthelateralflexion,canencouragetheclienttofeelastrongneutralspinewiththeheadinabsolutealignmentandtheopeninginherthoracicspine(incontrastwithherkyphoticposture).

BACKEXTENSION

Cadillac:• Prone1• Prone2

Nowthebody,iswellpreparedforamorefocusedbackextensorstrengtheningandshoulderstretch!Theclientwilloncemorehavetothinkofscapularstabilization,toachievemaximumstretchintheshouldersandwillstrengthenthebackextensorsbylearningtoarticulatethespineinordertoliftandlowerthetrunk.

It would be naïve for someone to believe that the chosen exercises above for Sophia’s

ConditioningProgram,aretheonlyexercisesthatwillavailheroranybodydealingwiththe

sameproblemof pain. I strongly feel that every single exerciseof thewholeBASI Pilates

repertoire can be a benefit for someone suffering fromMyofascial Pain Syndrome in the

upperbackoranyotherareaofthebody.

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Conclusion

Inconclusion,IwouldlikeoncemoretorefertoIsacowitz,R.andKlippingerK.(2011)and

emphasizethatthegoaloftheconditioningprogram,“isnottoovercorrectandremovethe

naturalcurvesofthespine”;“thegoalisnottoholdthescapulaeexcessivelydownwardorin

placebutrathertohelpestablishaneutralpositionofthescapulaeastheynaturallyrotate

upward”.AsRaelstated,“it’sjustlikewefindneutralpositionofthepelvisweneedtofind

neutralpositionofthescapula;thescapulaislikethepelvisoftheupperbody,isthepower

houseoftheuppergirdleandweaddressthescapulathesamewayweaddressthepelvis;

weneedtofindneutralpositionofthescapula”.(https://youtu.be/IcZ6jKhwzqA).

Hopefully, in this way we can probably assure that the right muscles will work for the

appropriatemovement.Themovementcanthenbeperformedmoreaccurately,toprovide

a more balanced work on the muscles. This will make it possible for almost any spinal

alignmentdeviationtobecorrected,avoidingmusclefatigueandtraumaandthustreating

MyofascialPainSyndrome!

I can happily note down that Sophia has already felt a significant relief of pain and her

scapulaearemoremobileandherbodyfeelsstrongerandlesstensed.However,herbiggest

achievementandmybiggestsatisfactionisthatSophiahasdeeplyunderstoodhowherpoor

postureaffectsherbodyandshehasnowrealizedwhat/whenandhowtocorrectitbyherself

inhersportsactivitiesbuthereverydaylife! Icanfeelhermorecontent,trouble-freeand

moreconfident,fullofenergytokeepgoingon!

21

Bibliography

Books

Isacowitz,R.andClippinger,K.2011.PilatesAnatomy,IllustratedGuidetoMatWorkandCore

StabilityandBalance.

Butler,D.andMosely,L.2013.ExplainPain.

Oscar,E.andBussaed,M.2015.FunctionalAnatomyofthePilatesCore.

Online

Asher, A.Myofascial pain syndrome and spasm cycle. Verywell health, January 21, 2018.

(https://www.verywellhealth.com/what-is-myofascial-pain-syndrome-296534).

Myers,T.W.Facial fitness: training in theneuromyofascialweb. IDEA fitness journalApril.

2011.(www.ideafit.com).

Osborn, C.What isMyofacial Pain Syndrome?Medically Reviewed byMorrison,W.MD,

August22,2017.(www.healthline.com/health/myofascial-pain#home-remedies).

Salyer,J.Howto`WorkyourUpperBacktoIncreaseDefinition,Livestrong.com,September

11, 2017. (https://www.livestrong.com/article/557405-how-to-work-out-your-upper-back-

to-get-the-muscle-line/)

Sports InjuryClinic:Kyphosis. (http://www.sportsinjuryclinic.net/sport-injuries/upper-back-

neck/kyphosis).

22

Consultation

Dr.SherifGamil,SpecialistOrthopedicSurgery,SymbiosisMedicalCenterDubai,2018.

Videos

BASI Pilates Mat Exercises | Shoulders, the Second Powerhouse, by Isacowitz, R.

(https://youtu.be/IcZ6jKhwzqA)

Figures/Images

Figure1:Fasciaisaweb:www.laurachancelmt.blogspot.com

Figure 2: Figure 2: (a) Ideal standing alignment, (b) kyphotic posture: Isacowitz, R. and

Clippinger,K.2011.PilatesAnatomy,IllustratedGuidetoMatWorkandCoreStabilityand

Balance,page22.

Figure3:Commonposturaldeviations:Marshal,J.4Simpledesk-basedstretchesforeffective

lower back pain relief. (https://www.lifehack.org/492069/4-simple-desk-based-stretches-

for-effective-lower-back-pain-relief).

Figure 4: Trigger points: Prakasa. J. 2012. Myofasical Pain Syndrome, Pain Sensation

(www.painsensation.blog.ae).

Figure5:(a)Upwardanddownwardrotation,(b)useofscapulardepressorstoavoidexcessive

elevationofeachscapulaasthearmsareraisedoverhead: Isacowitz,R.andClippinger,K.

2011.PilatesAnatomy,IllustratedGuidetoMatWorkandCoreStabilityandBalance,page

24.