Irene is a 50-year-old woman with Scoliosis. Her right shoulder is rotated forward, right rib cage collapsed from the right thoracic curve. She has exercised all her life. Her legs are very tight, likely a result of compensating patterns due to Scoliosis. She has ITB ( Illio- tibial band) syndrome, and lack of flexibility hamstrings. 5 years ago she had surgery for rotator cuff repair, left shoulder.
GENERAL CONSIDERATIONS AND COMMENTS
Scoliosis is defined as a three-dimensional deviation in the axis of a person’s spine.
The diagnosis is confirmed with XRays. Scoliosis is typically classified as either structural in which the curve is fixed or functional in which the underlying spine is normal. Fixed curves tend to occur after adult maturity. The degree of the curve, known as the Cobb angle, measures the severity of the curve. Above 40% is severe, 20-40% is moderate, and below 20% is mild. I would like to know the medical history of Irene’s Scoliosis.
Generally, the prognosis of scoliosis depends on the likelihood of progression. The general rules of progression are that larger curves carry a higher risk of progression than smaller curves, and thoracic and double primary curves carry a higher risk of progression.
There is no information in this case history about whether Irene has ever worn a brace or had surgery, so we will presume that here the answer is no. However, her Thoracic curve and rib cage collapse put her at a much higher risk for further progression. Our general approach will still to offer a balanced (both sides) full-body exercise approach since there is both a convex and concave side to Scoliosis, but I would like to consider at least a couple of exercises which just concentrate on the right side, or extra repetitions and work a bit more intensively on straightening out the curve.
GOALS OF TREATMENT – Our components of treatment for scoliosis includes exercises that strengthen weak core muscles and stretch the tight structures of the trunk. While it has not been proven that exercise alone will prevent or correct the progression of existing scoliosis, exercise — especially core movements — has shown to be beneficial. Pilates, with its attention to alignment and rotational movement patterns, provides the core stability to actively decrease muscular rotation and strengthen the muscles of the trunk.
Asymmetrical repetitive movements and imbalanced habitual patterns such as constantly standing with one hip jutted to the side or always lifting heavy objects with a dominant side, may well have reinforced Irene’s functional scoliosis and produce imbalanced core muscles and collapse of her right thoracic area.
Studies of scoliosis patients have shown that their back muscles are not necessarily weak. Muscle weakness usually occurred in the abdominals, pelvis, hip and leg muscles. Because of these weaknesses, their bodies substitute other muscle groups which, in turn, produces even greater curvature and rotation. With the Pilates emphasis on core alignment and stabilization, asymmetrical realignment, Pilates will balance Irene’s muscles, improve her body awareness and increase her core fitness and function.
Bringing awareness to Irene’s pelvis, abdominals, and back extensors is critical. Connecting throughout her body and calling on muscle groups to co-contract will be very helpful. Her exercise plan is not particularly complicated as even the most fundamental of exercises can make a huge shift in the posture, strength and even balance of muscle use.
EXERCISES TARGETING SCOLIOSIS
Note that with all these exercises, Irene might need a small towel or extra support under her lowered affected right shoulder to bring her spine into alignment and then she can feel how a balanced symmetrical spine should feel.
- Pelvic Clock – Supine. Rolling pelvic area back and forth. Legs bent to loosen the base of the spine while keeping glutes and legs inactive. X 5 reps
- Knee sways- for upper thigh stretch and modest gluteal stretch X 5 reps
- Knee Folds. Supine, knees bent, feet flat. Clasp one leg at a time, moving closer to the chest. Alternate legs. Engage the core but do not move the Pelvis.X 5 reps
- Leg Slides (Supine Hip Extension) Supine, Legs Bent feet on the floor, to lengthen leg out from thigh, and feel hamstring stretch. Stretch out one leg at a time. Add variation of ankle rotation and toes wiggling.X 5 reps
- Stretch Supine, knees bent and feet flat. One leg crossed over the other. Take a knee in the opposite hand, pull stretch over for 3 inhalations/ exhale, outer thighs and gluteal and piriformis stretch. X 5 reps
- Supine One leg/ knee bent. Other Leg straight up vertical in the air for small circles, 5 in each direction (clockwise and counter-clockwise). Loosens the hips and works adductors.X 5 reps
- Spine Twist Supine. Sometimes you might need to prop up Irene’s lowered side with a small towel or cushion. It is important that she feel the alignment on both sides of her back. X 5 reps
REFORMER FOOT EXERCISES
Doing Reformer foot exercises is an essential part of Irene’s program but she will most probably need a small towel under her right shoulder giving additional support on her right side, so she can feel the sensation of correct spinal alignment. Any of these sequences can be repeated, session time permitting. As basic as these exercises are, they are perfect for Irene.
- Footwork parallel Closed Heels, x 8-10 reps
- Footwork – Parallel Closed Toes, x 8-10 reps
- Footwork – V position open Toes, heels touching x 8-10 reps
- Footwork – Open 2nd Position parallel toes and heels x 8-10 reps
- Heel lowers for hamstring stretch x 8-10 reps
- Running in place for hamstring stretch x 8-10 reps
- Single heels or toes. When she gets more advanced, she can do one leg at a time, but not early in treatment. x 8-10 reps
OTHER REFORMER EXERCISES
1. McGill Crunch-This targets the abdominals while still supporting the back. Irene will probably need a small towel to prop her up underneath the shoulder on her right side. X 5 reps and hold for 10.
2. Frog in leg straps – Target adductors (inner thighs), hamstrings and hip flexors. Irene will have difficulty doing this exercise evenly. A small towel lift under her right shoulder will help with correct spinal alignment.X 5 reps
5. Bridging- works on spinal articulation and control. This is difficult for a Scoliosis client to do evenly, so I would manually assist her in the beginning. X 5 reps hold for 10.
6. Small Rollups – only roll up and lift the spine to the bottom of the scapula. Use rollup fixed bar. It allows for concentration on abdominals without scoliosis affecting her work. Use a small towel on one side to keep the spine even. When she is stronger she will find that her obliques strengthen and she can stretch out and rotate out her right side.X 5 reps
7. Leg Supine- done individually which allows for working with each of Irene’s legs differently and building on the muscles to help Irene even out. The legs can be up-down, in circles and in both hip adduction and abduction positions. X 5 reps
8. Lunges. I would add these very cautiously as Irene becomes stronger and is less twisted in the thoracic area. She will undoubtedly need physical assistance and experimentation with variations will be needed to see in what position Irene can keep square to the Reformer and her back in a straight position. But it is good for Irene’s tight hamstrings and glutes. 8-10 reps
9. The Swan- Back extension basic. This is an advanced exercise and not the first exercise we would give Irene but an excellent one for progression. The movement is in the knees under the hips, with an elongated spine and neutral pelvis. The abdominals need to be really strong as the spine lengthens. We will be using arm straps which will float up as Irene hinges back. Exhale as carriage returns.X 5 reps
10. Sitting Arms on the short box, pulldowns at 90 and 45 degrees which allows for chest expansion, biceps, rhomboids, triceps. This is a bit more challenging for Irene as she would have to try very hard to keep spinal lift and back erect. She may need some physical assistance, in order to pull down evenly. Good for both Irene’s Scoliosis and rotator cuff issues. 8-10 reps
11. Squats, firstly version sliding down against a wall, which allows Irene to work on her posture. If there is room to get behind the tower, a more advanced version of the squat could be done with a tension bar. The back extensors, abdominals, and quads are all engaged to bring Irene into a squat position while keeping her spine erect. The springs will assist in keeping her spine stable and aligned. X 5 reps
12. Mermaid- sitting modified. This is a lateral flexion exercise that helps bring space into the outer body, and the act of twisting helps stretch out the tightness of Irene’s back and rib cage. Note she will perform this exercise far better on one side than the other and it will be important to coax her right side into gentle compliance. The Mermaid opens up the right side concave curve of upper thoracic collapse. Focus on obliques and external shoulder rotation as well as shoulder abduction. Spinal mobility, scapular stabilization.X 5 reps
13. Upward and Downward Dog. Since Irene is experienced in exercise, I would give her this more advanced exercise. In a prone plank position with arms stretched out straight, push the hips up and back, hold briefly, and then lower, without pain. However, with Irene’s history of rotator cuff problems, this is an exercise to cautiously add to Irene’s program. 5×10 reps. It can be repeated.
14. Rowing Front. As Irene progresses, I would like to see her do some seated rowing. In this exercise, Irene is sitting straight and tall and will encourage torso stabilization. It will strengthen her abdominals, hip flexors, and stabilize her scapula including the serratus anterior, trapezius and rhomboids as well as Teres minor and major. It will stretch her hamstrings and improve her coordination. It will. Also strengthen her shoulder and rotator cuff muscles including pectoralis major, deltoid and latimus dorsi. So this exercise tackles the multi-faceted nature of Irene’s remedial program. X 8 reps
ONE SIDE EXERCISES
In general, I am in favor of balanced “both side exercises” but I think a few in Irene’s exercise regimen which concentrates solely on her right side to help pull it back into alignment would be a good idea. These are 2 such exercises and can be done at home.
- Step-down and one arm reach. Standing. Irene will have one leg ( left) longer than the other which will have been clear when she lies flat on the Reformer carriage. Standing and using a very small box, use the longer left leg to step up, bend the knee as you come down on the right leg, keeping the right arm extended and raised up as far as possible. 5x 10 reps. It can be repeated. Only do on one side.
- Split Stance with Arm Reach. Standing. Irene should step forward with her longer left leg with an exaggerated stride. Her torso should be as upright as possible. She should shift her weight back and forth in a rocking motion, allowing her forward left leg to bend slightly. As she shifts forward, she should raise her right arm upwards and forwards as far as possible, while the left arm should now extend back as far as possible with palm up( a little difficult to do). This causes the torso and spine to rotate and turn towards the forward leg. Only do on this side. 5-10 Reps can be repeated.
EXERCISES FOR ROTATOR CUFF
Rotator cuff injuries whether impingement/ tendinitis or even post-surgery seem to reoccur with some regularity. The only way to combat this is a system of exercises that can be done both on a Reformer with a teacher, plus at-home exercises.
It is important to note that Irene’s rotator cuff problems were on her left side probably because of overcompensating for weakness on her right thoracic side. This makes her treatment protocol a bit more complex. I would concentrate on Irene’s Scoliosis issues as the priority and work in later more targeted rotator cuff exercises, as we straighten out Irene’s spine as best we can. Luckily, there are exercises, we are already using for Irene’s Scoliosis which will do double duty. The important thing here is as we are working on Irene’s spinal alignment on the Reformer is to keep on emphasizing that she engage the muscles under her arms and back as part of her body awareness. This will, in turn, strengthen the rotator cuff muscles.
HOME EXERCISES FOR ROTATOR CUFF
I particularly like home exercises for the rotator cuff because it will encourage Irene to think about those muscles as she goes about her daily life and they can be done in small increments of time, rather than special work out time needed. I would only have her do them after we had practiced them in session together, so I can see if she can do them effectively by herself, given her right side thoracic collapse.
- Practice “core walking” with core engaged, rotator cuff muscles engaged, for walking anywhere. Irene is going to have to focus on spinal lifting up and opening up her right collapsed thoracic side. Daily.
- Abduction with Theraband. Standing with core and rotator cuff muscles engaged. Hold a Theraband in front of you, then stretch it out, with elbows at 90 degrees, as you raise the band outward and upward. 10-30 reps
- External Rotation with Theraband. Standing. Core and rotator cuff muscles engaged. Place a small folded towel between the waist and upper arm, and keep elbows close to the waist, pull the Theraband wide without dropping the towel. 10-30 reps
- Standing press with light weights. Start with as little as 1 lb (not more than 5). Hold the weight at the shoulder level and raise vertically until arm is straight above the head. I suspect Irene could handle 3 lbs. 10-30 reps. One side at a time.
- A variation of #4 is a standing press with a stick, where Irene would grasp both ends of a stick horizontally and raise it above her head and then lower. Core and rotator cuff muscles engaged.10-30 reps
- Standing press-ups looking into a corner of a room. Lean into the corner and then back into the upright standing position.10-30 reps
- Supine scapular strengthening using a weight. This is a more advanced exercise as it requires more muscle control in the scapula area. Irene will lie on her back while holding a light weight straight up into the air (1-2 lbs to start) using the affected arm. Keeping the elbow locked, Irene can raise one shoulder off the mat and reach towards the ceiling. Then gently lower to starting position. 10-30 reps
REFORMER EXERCISES FOR ROTATOR CUFF
Note that many of the exercises outlined above for Irene’s Scoliosis remediation in Pre-Mat, Mat and Reformer footwork, as well as other Reformer exercises, are all very useful for strengthening Irene’s Rotator cuff, so will not be repeated here.
However, I would also add some supine and seated arm exercises
- Arms in straps. Supine. The advantage of arms in straps is we can focus on each side a little differently. One side, we would be especially alert for rotator cuff strengthening, while on the other we would be paying more attention to straightening out Irene’s spine. From Irene’s arms in straps position, she can do extension raises, circles, extension side lifts. These all help focus on shoulder adductor/extensor strength while focusing on the lats, anterior/posterior deltoids, biceps, triceps, rhomboids, & pectorals. 8-10 Reps
- Sitting Arms on the short box, pulldowns at 90 and 45 degrees which allows for chest expansion, biceps, rhomboids, triceps. This is a bit more challenging for Irene as she would have to try very hard to focus on spinal lift and keeping her back erect. She may need some physical assistance on her back, in order to pull down the bar evenly. 8-10 Reps
EXERCISES TARGETING ITB and HAMSTRINGS
IT Band syndrome is an injury to the long flat connective tissue that spans from your lateral pelvis to below your lateral knee. Inflammation and friction can cause pain near where it inserts at or below laterally on the knee; this is in addition to pain at the hip, ITB band and tight hamstrings This will make descending stairs for Irene and squatting painful. This is an injury that has been caused by Irene’s compensatory pattern to her Scoliosis. I have no information as to whether this pattern is both sided, but I suspect it might just be on her stronger side. Note that our Reformer footwork series will also be tackling Irene’s ITB and hamstring issues. However, there are two additional stretches that can be helpful.
1.Periformis Stretch ( my favorite stretch).Sit on the Reformer carriage or mat with legs out straight. Bend the knee of the involved leg and cross that leg over your straightened opposite leg, placing your foot flat on the mat or still bent higher up ( variations) Take the opposite hand to leg and gently breathe and pull the knee over. Irene will feel the IT band stretch as well as the piriformis. Breath and deepen the stretch at inhalation, 3 breaths. X2 on each side
2. Laying on the back with legs long and arms out to the sides in a “T” position. Irene might need a small towel under one shoulder to balance her spine. Wrapping a Theraband band around one leg and then extend that involved leg up toward the ceiling giving it a little bit of tension with her arms. Pull that leg ACROSS her body toward the floor on her opposite side. Keeping her upper body firmly on the mat, shoulders heavy, then Irene should rotate from the waist. She should feel the IT band stretch more as the leg comes closer to the floor. Hold for 10 – 30 seconds easing in to the stretch a little more as she repeats for 3-5 times. Each side but one side will be easier for her. She can modify this hip stretch by bending the affected leg at the knee as she brings it across the body.
I put in a version of #2 stretch with a Theraband so it can be part of Irene’s home program and am aware that individual leg exercises in straps can achieve the same objective, but I think these kinds of stretches need to be done daily.
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