By Suzanne Martin, PT, DPT
Scoliosis is a chronic spinal condition, not particularly a disease. It’s a hot topic in the Pilates world, and in the hands of a skilled instructor, Pilates can excel in the long-term training needed to help change the many factors involved in the distorted spine and unbalanced musculature associated with scoliosis. In this article, I’ll introduce you to scoliosis and provide some guidelines and Pilates exercises for working with these clients.
Pilates clients are often shocked to learn that scoliosis is not necessarily considered a diagnosis worthy of insurance reimbursement. It tends to be seen as a typical “individual difference” since everyone has some musculoskeletal asymmetry due to the asymmetry of the internal organs and the laterality from right or left-handedness. Plus some people can live quite asymtomatically although they show significant deformities.
Public health standards in the United States traditionally mandate a screening conducted at each child’s school for children at age 10, at the beginning of the second growth spurt, a time when scoliosis usually begins to show its telltale hump in a forward-bend position. Those with positive screen findings are referred into the medical system. Physicians, either a pediatricians or orthopaedists, make a true medical diagnosis of scoliosis using a radiological determination, called a Cobb angle, drawn on the Xray. The skeleton seen from the side shows four spinal curves, making an ‘S’ curve, which is normally where we see our postural preferences such as sway back, posterior or flat pelvis, rounded shoulders and forward head, which may be learned or inherited. From the back, a normal skeleton should not have much of a lateral deviation. The Cobb angle measures the apices of the most lateral curves seen from the back, and must be greater than 30 degrees to be determined clinically significant. However, even people with “minor” scoliosis can be affected by spasms and general rib, low-back and neck pain that often accompanies an altered biomechanical chain.
One major complication is that even though scoliosis is often thought of as a mere sideways shift in the frontal plane (plane cutting the body from front to back), the reality is that it’s quite 3-dimensional, causing essentially a corkscrewing of the vertebrae, due to the bony constraints of the typical shapes of the vertebrae. Add to that the chicken and egg relationship of the weighty head and the heavy legs to a spiraling spine, and you have a catch-22 of ricocheting forces reinforcing, and camouflaging, the original defect that started the whole problem. Plus, the term scoliosis is really a garbage can term, scooping up many spinal issues into one big container. Adolescent scoliosis is obviously more plastic, and intervention here may possibly change a whole life of a skeleton. Yet mature skeletons (over age 22), are still plastic with some capability for change.
Do No Harm
Have heart. The good news is that Pilates can be a very safe, and ultimately very effective modality for most individuals grappling with the scoliosis dilemma, with one major caveat. Remember: First, do no harm. The hallmarks of scoliosis are trunk weakness and what is called a non-neutral spine. [Fred Mitchell, Jr, DO, defines scoliosis as a Type 1 spinal dysfunction, where groups of vertebrae are distorted laterally, giving some force onto “neutral” spinal segments that typically do not have pressure, hence “non-neutral.”] It pays to be conservative when dealing with a spine that is non-neutral to begin with. Performing exercises “within the frame of the body,” and helping someone to find and re-calibrate a closer postural neutral can be effective and meaningful to someone who is out of line. Don’t underestimate the power of neutral.
What Can Pilates Change About Scoliosis?
One major help is just identifying, and then educating the client about, their particular posture type and working on that. Beware the tunnel vision of only seeing the scoliosis curves and then embarking on a mission to overpower the curves. You likely can’t win, and if you do, did you spasm or throw someone into blinding pain? While it’s true scoliosis may not have a cure, you sure can manage it if you’re smart. One of the best things Pilates instructors can do is give some control back to people by teaching them internal control. Being able to hold your spine from the inside is one huge relief to those of us with soft spines.
Change happens in small increments; this is not a quick fix. I start my clients with a manual therapy treatment that usually can lessen their discomfort quickly and loosen up the fascia so they can begin to set new movement patterns. Finding a manual therapist to be a part of the treatment team is a real plus in the rehabilitation scheme. Acupuncture is also a useful adjunct to alleviate pain and promote better nerve conduction.
When dealing with the non-mature skeleton of the adolescent, less is more. The soft skeleton is very plastic and does not have full development of bony prominences that guard joints from coming out of socket. Children and adolescents often cannot bear medications prescribed for adults due to immature organ systems, and so the same is true with exercise.
PILATES EXERCISES FOR SCOLIOSIS
The exercises below are not meant for more complex conditions where osteoporosis, spondylolistheis (slipping vertebrae) or herniated or degenerated discs are involved. Remember that anybody over 30 probably has some spinal degeneration starting. Note that you are ultimately responsible for the risks you take with each client.
Avoid the tendency to think larger is better; working in flexion and extension works well. You should expect that rotation and side-bending will always be limited in one direction. Two rules of thumb are to always do both sides when doing asymmetrical work, and secondly, to first go into the direction of least resistance and then go the other way. Hypermobility can be another contributor to scoliosis, and I’ll address this in a future article.
The best place to start with a scoliosis client is with the pelvic foundation: the pelvic floor and inner unit.
Purpose: Turning the electricity on, starting to balance each side of the pelvis and trunk equally.
Lie on your back with the legs absolutely together, shins in table-top position. Imprint the whole spine into the mat. Lift the groin muscles toward the head. Make “dimples” in the gluteals by squeezing the sitz bones together. Then exhale and begin straightening the legs, feet moving toward the ceiling for 4 slow counts, but stop just short of straightening all the way. Then squeeze more as the knees bend back to table top in 4 slow counts. Repeat 2 more times without releasing the whole time. Do only 3 sets per day; do not strain.
Pelvic Floor Exercise
Purpose: To learn coordination of the inner pelvic muscles with some of the larger muscles as well as balancing the inner thighs, the second spine.
Lie on your back and imprint the whole spine into the mat. Lift the legs one at a time into the table-top position and open the thighs past hip width, being sure to keep the legs in parallel, not external rotation.
Place the hands inside the knees, palms open. Lift the anal muscles toward the head. Squeeze the sitz bones together. Make “dimples” in the gluteals (tense them). Hollow the spine. Press the hands against the legs and the legs against the hands. Go easy. Meet them, don’t beat them. Then in 4 counts slowly press the legs toward each other until they’re about 4 inches apart. Stay and hold, intensifying the contraction, if you can, for 4 breaths. Then release, shake the legs and do 2 more sets. Do this only once per day. Don’t strain.
Hold a resistance band by each end vertically. If you bring the top end toward the bottom end, you’ll see the band buckle. The same is true with the spine; elongating it will give some straightening to what aspect of the spine can be straightened.
Purpose: This exercise teaches segmental elongation and is a great help and reliever for people who sit all day. It increases sitting endurance and can be done inconspicuously to renew postural muscle engagement. It’s also a great exercise to do while sitting in at a red light. Don’t confuse this exercise with simple “bracing” where one increases intra-abdominal pressure; it’s a posture alignment exercise.
Ask the client to slump in a sitting position with the feet dangling off the edge of the Cadillac. Press gently down on the client’s head with the palm of your hand. Give the command to inhale, then exhale and slowly start squeezing the sitz bones together, feeling an imaginary hand lift up the skin of the low back.
Elongation in Supine (Trap Table)
Purpose: To engage the outer units with the inner unit; to disengage the legs from the torso; to find neutral lumbar spine coordinated with thoracic spine.
Place two light springs with foot loops on the sliding bar on the uprights about 3 feet from the mat. Have the client lie on her back and hold onto the uprights. Place the foot loops on the feet, and place the legs in table-top position. Cue the client to inhale, then exhale and press the hands against the uprights as she simultaneously presses the feet out to straighten the legs into the standing position, with the backs of the thighs against the mat. Inhale, break at the hips, keep the lumbar spine neutral and bend the legs to table-top. Exhale, lengthen out, inhale, break and bend. Do this 5 times. Then stay in the lengthened “stand” position for 4 breaths, then bend and come out of the position.
Break Up Laterality
Purpose: To bring the center of gravity more evenly between the feet, to even out pelvic obliquity, to wean a standing pattern away from standing on one preferred leg.
Test which leg a client prefers to stand on and which way they prefer to sway by gently pressing against one side of the pelvis, then the other. Which way is easier? Then take a magic circle and place it on the top of the thigh (greater trochanter) of the side of the direction they prefer, lined up sideways in relation to the wall. Ask the client to step into the ring a bit to make it taut to the wall. Her feet should be parallel, about 4 inches apart. Arms are folded with elbows away from the body in genie position. Then the client presses the ring laterally from the pelvis toward the wall in small pulses. Do about 20 on each side.
BREAK UP LEG LENGTHS
Pointer Dog (Scooter Variation)
Purpose: To balance the psoas and improve the motion of the pelvic bones.
Stand with one leg on the side of the Reformer past the bolt of the gears toward the pulleys about 6 inches. Place the ball of the other foot on the shoulder pad. Make sure the forward leg is not touching the side of the reformer. Place the hand on the same side as the foot on the shoulder pad on the shortened foot bar. Round and flex the spine and place the free hand next to the gluteals. Exhale and lengthen out the Reformer leg, straightening the knee off of the carriage mat, as you simultaneously straighten out the free arm in front of you as a result of reaching the spine into a flat, neutral spine. (Hence the pointer-dog look.) Then hold the hand on the Reformer bar against the straightened leg/foot firm as you rainbow the free hand up and back following with your face. Exhale as you round the spine back into the starting position. Do each side 6 times, ending with the long leg on the floor next to the Reformer in relative posterior rotation to counteract the anterior rotation associated with a long leg.
BREATH AND RIBS
Purpose: To stretch the internal fascial compartments of the thoracic cavity and the abdominal cavity, to mobilize the vertebrae and restore normal breathing motion of the spine.
Lie on the mat with the knees bent, or place the legs up on the side of the long box. Let the spine lie easily against the mat; don’t force any position for this exercise. Let the pelvic floor be easy, with no particular instructions. Place one hand on the abdomen, elbow on the mat, and the other hand on the rib cage, elbow on the mat. Inhale as you puff the chest out, letting the stretch reach up into the base of the skull, while simultaneously pulling the abdomen into a hollowed position. Then reverse the action, exhaling, puffing the abdomen out, letting the stretch reach all the way to the tail bone while simultaneously compressing the chest, squeezing the air out of the chest. After 5 or 6 repetitions, try to change the breath pattern, exhaling on the chest expansion and inhaling on the abdominal expansion. The spine should stay flat against the mat throughout the whole exercise.
TRACTION THE SPINE
Purpose: To open the ribs and the vertebra, especially where the scoliosis curves change, to strengthen the isolated flexion and extension of the spinal elements.
Place the long box on the Trap Table just in front of the fuzzy loops. Have the client hold onto the top rails, and walk their feet up onto the box and help them slip their feet into the fuzzy loops, dorsiflexing at the ankles to keep the feet firmly in the loops. Check to see that they feel they can hold their body weight up beforehand by just holding onto the top rails and bending their knees. Use rubber shelf liner if their hands are sweaty. If they prove able, let them go up into the fuzzy loops and alternately arch and curl through a spinal roll. Check for dizziness and be ready to help them out of the loops. I recommend not more than 2-3 repetitions. Less is more, unless they’re very athletic.
ONE LAST WORD
Scoliosis presents in many different ways; sometimes you have to help a person where they are. They may not understand what the problem is if they are not in pain. Also, if someone has minor, non-symptomatic scoliosis, not ringing the alarm bell may work just fine if you concentrate on the posture type weaknesses. Most people think Pilates is just a simple group of exercises. Some of the more subtle, somatic-oriented exercises that we consider as fundamentals may be lost on those new to Pilates, or to otherwise seemingly healthy adolescents with short attention spans and who view themselves as invincible. When in doubt, refer them, or guide them into a general Pilates classic mat program. They usually can see quite quickly where their deficits are in exercises, such as the Side Hip Lifts.
Suzanne Martin, PT, DPT, is a doctor of physical therapy and a gold-certified Pilates expert, as well as an award-winning author and DVD producer. She has 25 years of experience in the health and movement fields, blending art and science into her instruction. She is a Master ACE and ASCM trainer (with a specialty in exercise for cancer rehabilitation), and maintains a private Pilates/physical therapy practice, Total Body Development in Alameda, Calif. As a performing arts specialist, she conducts nutrition seminars for the School of the San Francisco Ballet and is the lead physical therapist for Smuin Ballet in San Francisco. Through Pilates Therapeutics®, she provides instructional DVDs (available for CE credit) and courses in the therapeutic application of the Pilates Method and nutrition. For more information, visit pilatestherapeutics.com.
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