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Teaching Pilates Clients with Sciatica

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By Elaine Ewing

Pilates for clients with SciaticaHave you ever had a Pilates client who seemed to be advancing nicely, then sciatica strikes? This condition—which is an irritation or pinching of the sciatic nerve—often includes pain radiating from the lower back down the back of the leg, tingling in the toes or feet and numbness along the track of the nerve. Sciatica is a symptom of another problem in the body, such as a herniated disk, lumbar spinal stenosis, disc degeneration, pelvic instabilities or Piriformis Syndrome. It is important to remember that, while Pilates work can increase sciatica symptoms, it is not a cause of the condition.  

Luckily, the practice can be modified to make irritation of the sciatic nerve less likely. In working with clients, and in my own battle with the condition, I’ve found that certain positions, practices and cues can actually cause an increase in irritation, but a few subtle changes can help deter flare-ups. Below I’ve listed some easy-to-avoid situations that can contribute to discomfort in sciatica sufferers. Usually, when one of these root causes is found and eliminated early, the sciatica will decrease or disappear.

CAUSE: Squeezing the Sitz Bones
Among my clients, this is the most common irritant of sciatica. It’s also one of the most challenging areas to release because students usually don’t realize how much tension they’re holding.

As soon as a client comes in complaining of sciatica, I have them lay on their back, knees bent and feet flat. I begin with some pelvic tilting and watch how they release the pelvis back to the mat after each tilt. You may see that they are not releasing the sitz bones all the way—instead they’re probably using their glutes to gently “hold onto” the sitz bones the whole time.  

After the last pelvic tilt, when they should be resting in neutral pelvis, instruct your client to “drop the sitz bones.” You should be able to see the sitz bones fall toward the mat. It may take a few minutes of practice for the sitz bones to drop.

The student most likely will feel like they did nothing—the tension is so subtle that they won’t feel the difference between squeezing and relaxing. Focus on continuously telling them to drop the sitz bones throughout the remainder of the session. Some cues I use are “pretend you have a wide butt,” “widen the backs of the thighs” and “give weight to the sitz bones.” Also, check the wrinkles on the back of their pants for a visual cue: these wrinkles will flatten as the bones drop.

CAUSE: Spring Tension
If leg springs on the tower are too heavy, it could cause the student to brace against the tension by pushing down with the low back or tightening the neck and shoulders, thereby creating muscle tension around the sciatic nerve. I want the abdominals to work during leg springs, so I encourage neutral pelvis, particularly for students complaining of sciatica.
When you notice this tensing of the torso and upper body, change to lighter springs and remind your client that the goal is to lengthen the spine and connect to the abs at the same time. If your client is unable to “drop the sitz bones,” the springs are too heavy. Try using lighter springs or teach the exercise without springs.

CAUSE: Extreme External Rotation
As instructors, we know to leave about a fist-width of space between the big toes when externally rotating the legs. If the client is too rotated I’ve noticed they often pull tension into the low back and piriformis muscles, as if the front body is very open and the back body is tightened. All of this squeezing around the sciatic nerve will irritate sciatica.

If you notice extreme external rotation, have your client imagine just a “fist’s width” between the big toes. Use kind and2044814-1510224-thumbnail.jpg
From Henry Gray’s “Anatomy of the Human Body”
gentle images of swirls, such as “imagine candy cane stripes swirling around your legs and meeting in the back.”

CAUSE: Lost Abdominal Connection
Notice if your client is able to maintain neutral pelvis throughout most of the exercises. If, when working in neutral pelvis,  for example, they start to push the low back down during the Stomach Series on the mat or Back Stroke on the Reformer, that is a sign that they’re allowing too much pressure into the sciatic nerve region.

If you generally teach these exercises in a flat back position, keep in mind that this position may not be suitable for some bodies. Since sciatica is often a symptom of a pre-existing condition in the low back, a flat back position for some exercises may irritate the sciatic nerve. Try slowly teaching a client with sciatica to lengthen the spine into neutral during these exercises.

To lengthen the low back and abdominals in a neutral spine position, focus cueing around the pubic bone. Ask the student to “drop the pubic bone through the inner thighs.”  This will rock the pelvis slightly forward, lengthen the spine and engage the abs without creating tension in the low back. It can also help students “drop the sitz bones.” The goal is essentially the same, but here you are approaching the position from the anterior rather than the posterior.

CAUSE: Pushing the Hips and Thighs Forward
When the front hip bones and thighs are thrust forward, the low back is shortened in a forward direction and the sciatic nerve region is tightened and stressed. Muscularly, this is a similar problem as holding onto the sitz bones, and the effect on the nerve is just the same.

Not surprisingly, this is most common and easiest to observe when the client is standing or kneeling. To help retrain the body, ask clients to “bring the hips inside the body” or “draw the hips back below the shoulders.”

If this doesn’t work, have them begin to drop the head forward and start rolling down over the legs. Stop them just after the head and first few vertebrae have rolled forward. At this point, their hips and legs have probably adjusted to the proper place. Tell them to leave the hips right where they are and roll back up.

CAUSE: Specific Pilates Exercises
Sometimes certain exercises just don’t work for people with sciatica. You can try modifications or take the exercise over to another piece of equipment. However, in most cases leaving out the exercise in question is the best way to know they will not be in pain the next day, or the next moment.

These exercises might be contraindicated for those with sciatica:

1. Climb a Tree
2. Side Sit-Ups, specifically on the Short Box
3. Teaser
4. Hamstring Stretches
5. Tower
6. Monkey
7. Stomach Massage
8. Side Kicks

When you and your client discover which habits are contributing to their sciatica, it’s important that you discuss the fact that they are probably following this same movement pattern all day long, not just in Pilates. Pilates does not cause sciatica, it only reveals what is already there. Talk to your clients about moving mindfully throughout the day. You can help them learn how to change their habits, but it’s up to them to actually do the work, inside and outside of the studio, so they can live pain-free and healthfully!

Elaine Ewing is a certified Pilates instructor and owner of Rhinebeck Pilates, located in Rhinebeck, NY.  For more articles about pilates and sciatica, and pilates in general, check out her website, headsuponyourbody.com.
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Posted on Monday, April 21, 2008 at 11:36AM by Registered CommenterJessica Cassity in , | Comments3 Comments | References1 Reference

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Reader Comments (3)

After a recent relapse with sciatica after nine years without (thanks to pilates) I found that leaving out all forward flexion exercises and concentrating on the side lying, plank and extension exercises on the mat has helped keep my back strong while in the recovery stage. The extension exercises such as breast stroke prep, swan and modified swimming are great for relieving sciatica pain and strengthening the supporting muscles along the spine. As always, the exercises should be performed to the range allowed without feeling pain.

April 30, 2008 | Unregistered CommenterJoanne Roberson

This is where a good PT or the like would be important. Spinal extension exercises actually narrow the neural foramina where the nerve roots exit the spine and therefore should be avoided or done with moderation/conservatively. Flexion exercises open the foramina... So if the sciatica is occurring at L4/L5 then this course of action will probably make the situation worse in the long run. A good PT would not give spinal extension exercises to someone with a true sciatica. If the sciatic nerve impingement/irritation is coming from a peripheral impingement (piriformis syndrome) the effect of the exercises will be different. Avoiding flexion exercises helps to ease the anterior tilt of the pelvis (which places a lot of strain on the piriformis muscles in the back of the pelvis which are partly responsible for keeping the pelvis/spine balanced and counter-acting the anterior draw of the pelvis).

Knowing the true nature/cause of the sciatic nerve impingement is very important before taking such action. One persons sciatica can be caused for different reasons than the next persons. And a restriction/impingement of the nerve isn't going to be resolved by adding muscular 'stability', but instead by releasing the compression.

It is important to realize that although pilates may not be the cause of sciatica in some cases (disc buldge, protrusion, herniation, stenosis, spondylosis, etc.) it can make it worse if one of these conditions is present. Spinal extensions, for example, will create more pressure on the posterior side of the disc, and if there is a herniation present on the posterior/lateral aspect, it will amplify it and make it worse. And as I mentioned before, extension of the spine narrows the opening where the nerve exits and thus if there is a foraminal stenosis present it will only make it worse. In some cases pilates can in fact cause/induce sciatic through impingement of the nerve as it passes by the piriformis muscle(s). Since pilates often involves a lot of bracing of the piriformis, and lateral turn-out of the legs (even slightly will engage them) it is very possible that it can cause an impingement of the peripheral branch of the nerve. This is actually quite common in folks that do pilates.

I think it's important to be careful in generalizing about any condition. Unfortunately, these conditions are not within the scope of practice for pilates teachers. I would strongly suggest to leave the management and assessment up to professionals who are qualified.

May 3, 2008 | Unregistered CommenterJust Wondering

I agree that pilates instructors should never try to diagnose any problem a client may have. That should be left up to medical professionals for a multitude of reasons.

The purpose of my article was to help teachers look more carefully at the little, habitual things a client may be doing that could contribute to sciatic pain. Sometimes, if caught early enough, sciatic pain can be minimized or eleviated by proper form during exericise.

I also agree that both spinal extension and flexion do not help sciatica for most people. However, for the first commentor, Joanne, extension did seem to help. This is the nature of sciatica- no two cases are exactly alike. In general, spinal extension should be avoided so not to close off the low back. At the same time, pilates is a balanced, "full-body" workout, so to leave out all back strengthening exercises is a mistake.

Like I said, I agree that instructors should not diagnose problems, and the true cause of sciatica should be determined by a doctor (though it is commonly undetermined, even by doctors). Again, this is why the focus of my article was only on pilates exercises and movements, not diagnosis.

July 4, 2008 | Unregistered CommenterElaine Ewing

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