Karyn session 4-12

I am very guilty for not being able to record Karyn's progress promptly. So here is what happened in the past 1.5 month.


Since Karyn has completed her study she managed to squeeze out more time to do Pilates twice weekly amidst her super hectic child-caring schedule.


Though her pain was initially relieved by few pilates sessions, her baby boy is growing fast and is making it even more stressful on Karyn's back whenever she carries him. Thus the pain on her left lumbar area originating from her herniated disc continued to come and go over the weeks, and severity varies depending on how much she carries him.


One day she called me to complain about numbness on the lateral side of her right knee, I suspected it might be due to her twice weekly jog or due to her aggravated disc condition, but on the safe side I asked her to consult a doctor.


She consulted a private orthopaedic doctor and, based on verbal description of her symptoms, he concluded (without any physical/ manual/ functional check-up) that Karyn was suffering from ITB symdrome. So she was told to do some ITB stretch and given anti-inflammation cream. To my surprise, she was also told that she could continue her jogging as per normal. Both me and Karyn felt that this particular doctor was not very helpful as he did not really investigate the real cause of the problem, he just wanted to get his patient out of his office asap. With the recommended stretch and medicated cream, the numbness at Karyn's knee did not really go away.


Then she developed numbness at her right toes. She thought it was due to her new running shoes. But I was skeptical and urged her to consult another doctor instead.


An orthopaedic surgeon from Tan Tock Seng Hospital who specialises in spine finally confirmed what I suspected. The numbness at her knee and toes were actually symptoms refered from her herniated disc. He advised against surgery as the herniation is still very much preliminary, and he also discouraged the use of pain killer or analgesic cream as they only masked the symptoms. He ordered Karyn to continue with Pilates as main treatment as it can help correct mechanical problem in the spine. He also advised her to swim regularly.


With few Pilates sessions focusing on core control, lumbar stabilisation and spinal extension, the numbness dissipated gradually. Karyn was all excited and got herself into the pool soon after the consultation. She swam so hard and long that after her swim her back pain turned from bad to worse! Karyn was totally puzzled as swimming was "supposedly" good for back pain but yet it made hers worst instead.

Moral of the story? always get 2nd medical opinion if you feel that the doctor was not detailed or proficient enough to help alleviate your problem. And be easy on your body if you have not done certain exercise for a long time. For Karyn she probably overstrained from the swim as she had not swim for years! Too much good thing is not neccessarily good and moderation is the key :)

Aerial Cartwheel

Ken surprised me that besides being an intelligent PhD student who is active in swimming, water polo, he is also very much into Capoeira and even break dance. That was partly why he is interested in learning Pilates. Ken feels that Pilates can restore muscle flexibility and core strength to improve his break dance stunts.

One of the break dance stunts that he liked very much was the Aerial cartwheel, which is basically a cartwheel performed without the hands touching the floor or the apparatus. It looks like this. Frankly I don’t know much about break dance, so in order to help Ken improve his aerial cartwheel, I had to first find out what exactly it is. I think Just The Skills provides the best illustration of how to do it, even though the site is a little slow.

Some pointers on how to do aerial cartwheel on Tulsa Gymnastics:

1. Start this from a run and hurdle or from standing. If you are hurdling into an aerial, the hurdle should neither be too long nor too high. You need some forward momentum, but you don't want too much.
2. Push off of your take-off leg to get your height.
3. Kick your back leg as hard as you can to get around to get rotation.
4. Swing your arms will help in both rotation and height. Some people do aerials better swinging the arms down by your side, and others do an arm circle into it.
5. Don't try twisting your body into the aerial. This throws your alignment off and makes it harder to rotate.
6. As your land, lift your chest up. Not only will this make it easier, it looks better than having your upper body flopping over when you land.

Ken asked how Pilates can help strengthen the sides of his waist (the quadratus lumborum, QL) as he feels that this area is weakened and thus he can’t do the aerial cartwheel with ease now.

QL is a muscle with many functions. It laterally flexes (side-bends) the trunk, and elevates the hip. It also helps to stabilize the low back (thus usually involved when low back pain is present). After analysing the movements in aerial cartwheel, I think the strength of QL should not be the main focus of concern. Because in an aerial cartwheel, it is the momentum generated from the kicking of “back leg” (in point 3) that brings the legs overhead. QL is more of stabilising the lumbar area than to twist the body over (as in point 6) which will only distort the form.

I would rather focus on the flexibility of QL (especially on the push off side) so that the momentum of the leg swing will not be slowed down by tight QL. Mermaid is fantastic exercise in lengthening the QL.

I would rather focus on improving core control and stability of the lumbar area, strengthen of hip abductor and stretch the hip adductors to facilitate “kicking the back leg”. Good Pilates exercises are Sidekicks, Leg Circles, Star.

Karyn - Session 2 & 3

Session 2 (Feb 2008)
Karyn indicated that her back pain was aggravated in the week after session 1. But she felt that the pain was not entirely caused by the Pilates exercises but possibly due to the intense childcare duties that she did over the week.

In session 2, lateral breathing, pelvic tilt and chest curl were repeated to reinforce their proper execution. However basic bridging was removed to prevent any lumbar flexion since pain was active. Side kicks on elbow were added to strengthen core, arm and shoulder girdle. Karyn has very good body awareness thus was able to disassociate her hips beautifully. Prone press up was highly emphasized and encouraged to practice on her own as it can improve spinal extension through the thoracic spine and improve control to stabilize the lumbar area.

Thorough postural and home ergonomic analysis were done to correct any harmful postures used when Karyn takes care of her children. For example, it was suggested to bathe the baby in a basin on the dinning table instead of on the bathroom floor so that she could stand in proper posture; also Karyn was advised to kneel rather than sit cross-legged on the floor when caring for her baby so that she could maintain neutral spine.

After session 2, Karyn reported that her back pain has gone. I would attribute such improvement to the extension work done during the session.

Session 3 (12 August 2008)
Karyn had to stop training due to her study and could only resume after 6 months. Her back condition has gotten from bad to worse, and her quadratus lumborum area was swollen due to active inflammation. Her left and right side muscle imbalance in upper body also became more severe.

Breathing exercise, dead bug on foam roller, prone press up were performed. Mermaid was done but range of motion was reduced (only reached up instead of “reach up and over”) on the inflicted side to prevent aggravation. I have advised Karyn to consult a physiotherapist who is trained in Pilates to do a spine check so that I could work her in safest and most optimal range in future sessions

Ken - Session 1 & 2

Ken is a healthy 25 y/o PhD student who wants to learn as much Pilates as he can before returning to US for his study, so that he can maintain his fitness by doing Pilates on mat amidst his busy schedule. He has no medical or joint issue, and he played water polo and trained in gym.

Ken scored very well in fitness screening. Overall he has good arm and leg strength and excellent body awareness. He has good shoulder and adductor flexibility, but hamstrings are tight (scoring 1.5 in long sit). His thoracic spine and chest are stiff, thus restricting his lateral breathing and articulation in the thoracic spine. His rib cage flares when lying supine in neutral spine. Core control and dynamic stability can be improved, which will in turn help to reduce over-recruitment of hip flexors. Right dominance and lateral chain of lower extremities are much stronger than the medial.

Main Fitness Goals:

1. Learn to do as many Pilates mat repertoires he can correctly.
2. Reduce tightness in hamstrings, hip flexors, pectorals, thoracic spine.
3. Strengthen core (abs & lumbar spine).
4. Achieve overall muscle balance.

Click here for the summary of exercises done in session 1 & 2.

Case Study - Karyn 1

Background
Karyn, mother of 2, underwent C-section 4 months ago. While caring for her new born she developed moderate lower back pain during recent Chinese New Year. MRI confirmed that she suffered from L4/5 disc herniation. She does not want to take oral pain killer as she is nursing, instead she choose to manage her pain by practicing Pilates.

She has always been active. Prenatally Karyn runs regularly to build stamina and resistant trains to strengthen joints. She then switched to cross-trainer until 7th month pregnant when her weight gain induced knee pain.

She has also tried fundamental Pilates matwork & reformer at a professional Pilates studio in HK.

Medical History

• Hip injury from a fall
• Carpal tunnel symdrome on right wrist, treated with physiotherapy
• Lateral knee pain due to running
• Ankle sprains
  

Body Assessment

• Forward neck posture
• Slight thoracic scoliosis, contributing to unbalanced shoulders and raised, prominent left sacrum & leaning on right ankle
• Moderate knocked knees & foot pronation.

Fitness Assessment
Score = 2.6
Generally she has good flexibility (possibly due to the post-natal oxytocin level in her body) but lack of upper body and core strength. Her prenatal fitness level and Pilates experience may have contribute to her good body awareness.

Exercise for Today

1. Lateral Breathing - to learn efficient breathing pattern thru fully utilise intercostal space intead of purely thru accessory breathing.
   
2. Pelvic Tilt - to find neutral spine
3. Chest Curl - to learn to initiate deep transverse abdominus
4. Basic Bridging - to learn spinal articulation, strengthen hamstring
   

Alvin - Session #3

Session 3 again focused on shoulder movements and strengthening, through the proper use of seated row machine. When using the seated row machine, most people are only concerned with how heavy they manage to row and completing a "set". However the most important thing is actually to row with proper shoulder stabilisation. because without stabilising the shoulder joints, one cannot fully activate and thus strengthen the back muscles, which was what the exercise supposed to achieved. Thus much time was spent to make sure Alvin can row and activate his back muscles properly.

misalignment was also noted in Alvin's lower body, thus I worked on his alignment for both standing and walking. though it is not possible to correct the misalignment within a single session, Alvin will at least be more aware and conscious about the way he should stand and walk which should prevent further perturbation to his posture.

Since Alvin would like to, besides correcting his posture, put on some bulk, I have requested him to give me a complete food diary (which should record down everything he ingests) for 2 typical weekdays and 2 weekend days. this will then allow me to understand his eating habits and from there to develop diet modifications to help him increase calorie intake.

Alvin - Session #2

This session summary came a little late, as I was overseas for training. There was limited internet access and frankly I didn't even have time to sleep... so sadly I couldn't update my blog as much as I wished.

2nd session with Alvin focused a lot on instilling proper movement patterns in the shoulder joint. Instead of giving Alvin a quick fix by just telling him how to stand properly (he could have easily find an answer by himself through the www), I aimed to solve the root cause of his postural problem. Afterall, Alvin's poor posture was not formed over-night. It was rather created by repeated bad movement habits over a long period of time. Since Alvin is unable to stabilise his shoulders, especially during shoulder flexion and abduction, his upper trapezius is often overly recruited and tension start to build up around his neck area. Therefore my first step was to ensure Alvin moves his shoulders properly before moving on to correct his posture in the lower body. This is just like making sure a chemisty student to learn how to balance a chemical equation before teaching them the mole concept.

Exercises:
1. Review of #1's exercises
2. Shoulder Roll (moving shoulders front, centre, back, centre) - Shoulder Isolation exercise to enhancing neuromuscular awareness to control and stabilise shoulders
3. Side Kick: learn to stabilist shoulders (shoulders away from ears) in lateral position (while lying sideway). This is a great exercise to strengthen the stabilising muscles (lower trapezius and latissimus dorsi) for the shoulder joint and educate the body to isolate upper body and keep it stabilised while moving the lower body.
4. Prone Press-up: Fantastic strengthening for the upper back/postural muscles; soften and stretch chest muscles; reinforce shoulder stabilisation while in extension (bending the body backwards).

Case Study - Postural Correction

I decided to start documenting some of my Pilates classes, so that I can share my experience with other instructors, while this kind of written record will also be useful for my clients as reference. *Note: Names used are fictional.

Case Study - Alvin

Background:

Alvin is a 27y/o school teacher who is concerned about his own posture. Initial assessment reveals that he has exaggerated lordotic curves in cervical and lumbar area while too much kyphosis is observed in thoracic spine (hunch-back). He has never been medically diagnosed with any abnormality in the spine before. He is right handed and the right side of his body was generally stronger but also tighter than the left. His right shoulder is higher than the left. He used to play badminton and presently goes to gym regularly, mainly to run on threadmill and perform resistant training on stacked-weight machines (such as Chest-press, Lats Pull Down & Seated Row), after which he did not perform stretching as he was not sure what to stretch. Alvin went through 10-sessions of personal training but had no apparent result in terms of postural correction and weight gain. Movement analysis of upper limbs reveals lack of control and stability in the shoulder joint.

In conclusion, his posture is mainly due to weakness in postural muscles, such as serratus anterior, rhomboids and latissimus dorsi (back muscles), tightness in chest (pectorial major), back of neck (sternocleinomastoid & levator scapulae) and the thigh muscles (hamstrings and hip flexors). Instability & lack of control in shoulder movements (as shown in his pushing and pulling movement patterns) further reinforce the faulty posture.

Session #1 (focusing mainly on upper body):

Education of "correct posture", body awareness and proper neck alignment:

• The spine has two natural curves called the 'double C' or 'S' curves, these are the curves found from the base of head to shoulders and the curve from the upper back to the base of the spine. When standing straight up, weight should be evenly distributed on both feet.
• Using a mirror, align ears, shoulder, and hips. Proper alignment places the ears loosely above the shoulders, above the hips. Again, these points make a straight line, but the spine itself curves in a slight 'S'.
• Hold head in a balanced manner over the trunk in a sitting or standing position. The chin should be horizontal and parallel to the floor, drawn back slightly and centered. Try to stand, walk and sit "tall" at all times.

Reduce tightness and improve flexibility in cervical area.

• Tilt (stretch) head in all four directions over shoulders (forward, back, left, right). Avoid rolling in a circle, as it may cause further strain.

Education of proper movements over the shoulder joint & Improve strength of thoracic postural muscles.

• At quadriped position (on all four, with hips directly above knees and shoulders directly above wrists), find the neutral position by repeatedly curling the back upwards, like a cat, and then the opposite
• Lie facing up on a mat, 1. arms straighten pointing up to ceiling, "peel" shoulders off the mat and return, keeping shoulders away from ears throughout; 2. Arms straighten on the mat overhead, slide them along the mat, drawing shoulders towards ears then away from ears)
• Seated row and Lats Pull down, focusing mainly on engaging shoulders instead of the pulling motion.

By end of Session #1: Alvin's neck is a lot "straighter" (reduced lordosis) and Alvin is supposed to do his "homework" by practicing all the exercises above!