Adolescent Idiopathic Scoliosis

(AIS) with a Postero-Lateral L4/L5

Disc Herniation

Ann van Messel

Sept 14, 2015

CAP 2015 Gig Harbor, WA, USA

Abstract

Sharon Bates presents with numbness in her right leg as well as varying degrees of

numbness in her toes. Additionally Sharon experiences regular low back pain causing

disruptions to sleep and daily activity. Her goal for pilates is to return to a more active life

that had been compromised.

Disc herniation may cause low back discomfort with radiating pain. Adolescent

Idiopathic Scoliosis may cause muscle imbalance and poor body alignment. This paper

will look at how the BASI block system can be successfully adapted to address these

multiple issues.

Through a course of regular targeted pilates (2-3x per week @ 1-1.5 hours/session) a

result of increased mobility and decreased pain will be seen.

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Table of Contents:

Abstract

Anatomical Description

Introduction

Case Study

Conclusion

Bibliography

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Anatomical DescriptionScoliosis is a three-dimensional deviation of the spinal axis.

The most common form of scoliosis that presents in patients between the ages of

10-18 when there is no known cause is termed adolescent idiopathic scoliosis (AIS). Spinal

deviations can be seen fairly easily with routine body alignment observation. Shoulder

height asymmetry (one shoulder higher than the other) is quite a common finding.

Likewise a body shift to one side, or a prominence or hump on the back will be seen as

secondary to rotational aspect and is one of the most visible signs of scoliosis. When

viewed from the side AIS patients appear normal.

It is important to ensure that during the growth phase the curve does not increase.

Females have a risk of curve progression 10x higher than males. AIS may occur with

little to no pain. A number of factors are taken into account to determine a course of

treatment, typically observation, bracing or surgery. Studies have shown that later in life

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physical function is lower for those braced when compared with controls, but better

than those with more severe disease processes.

Disc Herniation, also known as a “slipped disc” is categorized by the direction that the

disc has moved out of its anatomically correct position.

A spinal disc looks much like a doughnut filled with a jelly-like substance. It is the

cushion between the vertebrae of the spine. When a tear occurs in the outer part of the

disc the jelly-like substance begins to protrude out of that tear. The most common tear

is almost always postero-lateral (pushing backwards and to the side) in nature due to

the posterior longitudinal ligament in the spinal column. When this happens the nucleus

pulposus (stuff that comes out of the disc) can put pressure on nerves causing sciatic

pain or radiating pain down one leg.

L4/L5 refers to the area of the spine that the protrusion takes place. In this case it is

the lowest 2 vertebrae of the spine, the lumbar region, just before the sacral region is

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reached where fused vertebrae are seen at the bottom of the spine. The illustration

below is helpful in that the red area of the spine indicates the protrusion of the L4/L5

disc.

Causes of disc herniation can be as simple as the aging of the spine. There are risk

factors that can increase one’s likelihood and they include gender - males 30-50yrs are

most likely to have a herniated disc; improper lifting, !being overweight, repetitive

activities that strain the spine, frequent driving or staying seated for long periods of

time, sedentary lifestyle, and smoking may cause more rapid disc degeneration.

Resulting symptoms include back pain, leg and/or foot pain (sciatica), numbness or

tingling sensation in the leg and/or foot, weakness in the leg and/or foot, loss of

bladder or bowel control (extremely rare). By relieving the pressure on the nerve the

pain can be reduced.

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Case Study:

Sharon Bates is a 45 year old, mother of two with a goal to better manage her chronic

low back pain. She approached pilates after trying many other exercise regimes

including swimming, walking, running, weight training and yoga. Sharon was

diagnosed with AIS at age 12, wore a brace for a year and then was told she had

stopped growing and would go forward with a 15 degree s-curve. At 35 Sharon was

working in the garden when it seemed her back “went out”, she was told then that she

had a L4/L5 disc bulge. This was treated with a steroid injection and bed rest after

which all seemed well. Four years later the pain reoccurred and it was discovered that

by now Sharon had a full L4/L5 posterior lateral disc herniation. It was treated a second

time with a steroid injection that seemed to help temporarily, although she was left with

radiating pain down her right leg and numb toes. Being an active person, movement

had always helped, at least temporarily. Two years post the second steroid injection

Sharon finally decided to give pilates a chance.

Conditioning Program

The program designed for Sharon Bates will focus on proper body mechanics to help

both strengthen and lengthen her lateral curves and create greater stability in her pelvic

- lumbar region. Due to her disc herniation loaded flexion and deep rotation will be

avoided as these are contraindicated movements.

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Warm up: Fundamental Warm Up:

-Pelvic Curl (depending on strength of the day may be modified to reduce spinal

articulation and be performed as hip lifts); Spine Twist Supine; Chest Lift; Chest Lift

with Rotation (depending on the strength of the day a wedge assist may be used to

support the low back and ensure that abdominals fire while supporting the back and

avoiding deep flexion); Leg Changes -- added to warm up to create focus early in each

session around stabilizing the lumbar/pelvic region.

Back Extension -- added to warm up to address overly tight back extensors.

Foot work: Chair: Foot Work

- Heels, Toes, Pilates V, Wide Heels, Wide Toes, Calf Raises -- Single Heels, Single Toes

- - the chair footwork offers the added benefit of core stability work without the need to

round.

Depending on the strength of the day (if torso stability is lacking or Sharon is just not

feeling strong) Foot Work may take place on the reformer adding in prehensile and

dropping out single leg work.

Abdominals: Reformer: Short Box Series (without round back to start):

- Flat Back, Tilt, Twist, Round About and Climb a Tree

NOTE: Round Back is left off until Sharon has better abdominal control to ensure that

she stays out of her low back. Any unsupported forward flexion could cause the pain to

fire so it will be avoided until both control and better body awareness are observed.

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Hip Work: Cadillac: Supine Leg Series:

- Frog; Circles Down; Circles Up; Walking; Bicycle

Spinal Articulation: Reformer: Bottom Lift with Extensions

- gentle lumbar articulation with pelvic stability - able to modify easily if too much

articulation to partial articulation or even simple hip lifts while still building pelvic

lumbar stability.

The mat Cat Stretch is also used at times with very conscious rounding of the spine. The

focus is more on the thoracic extension, allowing for variation of limited spinal

articulation.

Stretches: Reformer: Standing Lunge and/or Split series

-- chosen to build up Sharon’s adductor strength

The Pole Series is also used often in order to focus on thoracic extension and gain more

safe spinal movement.

Full Body Integration 1: Reformer: Up Stretch Series (partial)

- Up Stretch 1; Elephant;

-- working toward adding Up Stretch 2, once upper body strength improved

-- chosen to keep the spine neutral while emphasizing abdominal contraction.

Arm Work: Reformer: Arms Sitting Series:

- Chest Expansion; Biceps; Rhomboids; Hug a Tree; Salute

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Depending on the strength of the day this is alternated with the Arms Supine Series

(Extension, Adduction, up/down circles, triceps) to ensure pelvic-lumbar stabilization

is maintained throughout.

Full Body Integration 2 - Omitted

Leg Work: Gluteal Side Lying Series:

- Side Leg Lift; Forward and Lift; Forward with Drops

- - added to strengthen Sharon’s gluteus medius for a more stable base with which to

support her pelvis.

Lateral Flexion/Rotation: Reformer: Mermaid -- to open up laterally especially the right

side where Sharon’s curvature has led to compression.

Back Extension: Chair: Swan on floor -- since the herniated disc is protruded

posteriorly all extension will help the disc back off the nerves it is otherwise reaching.

Alternated with Pulling Straps I and II for variety.

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Conclusion

Sharon has seen a great improvement in the management of her pain. As she continues

to strengthen her core and stabilizers she has also seen a rise in her energy levels. She

must be careful not to exceed her abilities now that her pain is better controlled and

have patience in her abilities both in her pilates practice and all her endeavors. Sharon

has expressed that having the knowledge to know what movements will help bring her

out of pain, as it occurs, allows her a greater sense of control and well being.

Pilates is a malleable training method that can be easily adapted to multiple presenting

issues while strengthening and advancing a person’s capabilities. No matter a client’s

restrictions, programs can be built to fit the immediate changing needs of that client

from one session to the next all while continually building both their strength and

flexibility. The icing on the cake is that the client experiences the immediate relief of

suffering through safe movement and correct alignment and in doing so keeps coming

back for more -- because it simply feels good.

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Bibliography

Books:

Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California:

Body Arts and Science International, 2014.

Isacowitz, Rael. Movement Analysis Workbooks. Costa Mesa, California:

Body Arts and Science International, 2014.

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international.de 10 Dec 2010; 107(49): 875-84; 6 July, 2015. <http://www.aerzteblatt.de/

int/archive/article?id=79572>

“Adolescent Idiopathic Scoliosis” Scoliosis Research Society 2015, 6 July 2015. ,http://

www.srs.org/patient_and_family/scoliosis/idiopathic/adolescents/>

“Scoliosis” Wikipedia 3 July, 2015; 6 July, 2015 <https://en.wikipedia.org/wiki/

Scoliosis>

Asher, Marc A. & Burton, Douglas C. “Adolescent idiopathic scoliosis: natural history

and long term treatment effects” Scoliosis Journal 31 March, 2006; 12 July, 2015 <http://

www.scoliosisjournal.com/content/1/1/2>

University of Maryland Medical Center “Adolescent Scoliosis” 17 june 2013; 12 July

2015 <http://umm.edu/programs/spine/health/guides/adolescent-scoliosis>

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Perry, M “Posterolateral Disc Protrusion” Laser Spine Institute 2015, 6 July, 2015

<https://www.laserspineinstitute.com/back_problems/disc_protrusion/

posterolateral/>

Spine-Health “Lumbar Herniated Disc” 13 July, 2015 <http://www.spine-health.com/

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www.orthoinfo.aaos.org/topic.cfm?topic=A00534>

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Images:

Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/

2014.010. ISSN 20018762. - Own work

Weiss HR - Weiss HR. Scoliosis 2007, 2:19. PMID: 18163917. doi:10.1186/1748-7161-2-19.

Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/

2014.010. ISSN 20018762. - Own work

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