Colleague Questions: Sciatica
February 17, 2013 at 6:14 pm
Shari Berkowitz and Cheryl Sullivan Cole at Pilates on Tour Atlanta, GA 2013
Thank you, as always, for reading and continuing your education here on Shari Berkowitz & The Vertical Workshop’s Pilates Teacher Blog. I’m going to start posting articles in several different topic-groups. One will be “Colleague Questions”. That’s what we have today.
I always ask that if you have questions regarding biomechanics or Pilates, to please reach out to me. I will work to either answer your question or guide you toward an answer…my choice on that is based on my desire for you to learn and continue practicing being a critical thinker. I will always, always give you the help you need…most often I will ask that you work to gain the answer rather than my just giving it to you. That way I am really helping you!
Here is a question from a colleague about a client who is experiencing symptoms of sciatica. I’ve not included any personal information on the teacher or client…just our discourse with some additional information to help flesh out the education. The final part of our interaction is full of information of what to do and what not to do…solid guidelines.
I’ll continue to post some of the interactions I have from wonderful teachers from all over the world. I spend a hearty part of each day doing this via email…might as well share:
Line of pain for sciatica
Client Issue: Sciatica
I have a question, a student asked if I could suggest stretches for Sciatica. I told her I would do some research and get back to her. So here I am asking you what to suggest? Any help would be appreciated.
It’s great hearing from you!
I’m glad you reached out! Here’s what I suggest you do…and I will give you the answer, too:
A-1 IMPORTANT: Is she self-diagnosed? Did she see a doctor? Why does she think this is sciatica? What are her symptoms? How long and how often does she have this?
If the determination is some sort of sciatic or seeming sciatica:
1st: You must study what sciatica is. There are many ailments that present themselves like true sciatica. So…study away! Two that you will clearly encounter and should study up on are actually Sciatica and then Piriformis Syndrome.
2nd: Once you see how the sciatic nerve is affected in both Sciatica and then Piriformis Syndrome you will recognize that no matter how badly your client wants to stretch his/her hamstrings…she must not! She will be overstretching an impinged nerve only causing more damage. So…
1 – No stretching of hamstrings.
2 – Eliminate all hamstring stretch components of exercises. For example: Single Leg Circles, The Spine Stretch Forward and The Saw – do with bent knees and other such exercises. Skip things like Single Straight Leg Stretch/Scissors, Side Kicks, The Tree…these things are just asking for trouble when she is in pain.
3 – Stretch the lower back and back of hips – So I’ll ask you, Janet: Which exercises in Pilates work to stretch the posterior lumbar spine and the glutes and piriformis?
Your turn! Write back to me and let’s go over the stretches that will help!
All the best!
So, client has ongoing issue, waiting to get her report about doctor visit.another instructor told me to avoid stretching and only work on strengthening. Is that right?
I am not sure what to do to help. Do I work to strengthen like Bridge, ab work pelvic tilts, glute chest Lifts, reverse curls, leg slides and leg lifts. I don’t know what to do to stretch with care?
Still need help, she comes to my reformer classes and I don’t want to cause her pain.
Knowing what is really going on will be great! A true diagnosis can tell you what to do and not to do.
With that…As long as it’s not an actively bulging disc that is creating this issue, then you can do 1/2 Roll Down on the Mat and Rolling Back with Roll Back Bar and Push Through on the Cadillac to help stretch her lower back, but if she has a bulging or herniated disc that is actively causing problems…then she cannot do any of those, right now.
Now…bulging discs that don’t cause any pain are not an issue in these exercises…only if someone is having pain that is diagnosed by a doctor as coming from that disc pressing into a nerve do we have trouble. If you had an MRI today, though you are not in that sort of pain, you would likely find that you have bulging discs. Does that make sense? They just don’t always bulge into nerves…so are usually no problem at all.
With that…disc issue or not, she can do stretches of the back of the hip. That is lying on her back, she would cross on ankle/base of shin over the thigh of her other leg. That would put her in a “4” shape. Hold behind her thigh and flex at that hip bringing her thigh closer to her chest. That stretches the back of her hip as long as she keeps her sacrum centered and stable on the mat. in a neutral pelvis. As soon as she tips her “tailbone” up…posterior tilt…she will be skipping the hip focus and now into loaded posterior lumbar spine stretch…which if disc issue is no good. So…keep neutral pelvis and you’re in business!
I hope that helps.
And…no straight legs when there is a possibility of her hamstrings stretching…because that will add to the inflammation of her sciatic nerve, no matter why it is inflamed.
When does she get doctor visit report? Did she have xrays/MRI?
My client saw a doctor and this is what she reports so far:”I have had a few MD appts this week. In My back…have slipped disk L4&5 and inflamation in other discs.
Will have a nuclear stress and additional blood work when we get back.
Docs do not seem concerned’ neither do I.”
She is going away for a 3 weeks, so I have time to plan her return and what I can do with her.
Any further thoughts on this would be welcome!
I’m glad that your client saw a doctor. Most important with a persistent situation like this.
Indeed, a “slipped disk L4&5 and inflamation in other discs”
MayoClinic.com often has wonderful simple definitions for ailments…of the entire body. A great resource.
If the word “slipped” is used, then we’ll consider it herniated where the nucleus is coming out of the crack in the annalus fibrosus. The extruded nucleus and mis-shapen annalus likely creates smaller than normal pathways for the nerves to leave the spinal column…hence pain. Pain is from nerve endings that are being pressed on when they’re not supposed to be.
It’s always good to know which side the disc is protruding towards. She may be able to get that information. Then you can see in your mind’s eye which movements will likely cause more pressure on that nerve and what won’t.
Has the doctor given her any precautions or contraindications for movement?
I suggest going with what I said earlier…since we know it’s a disc issue that is showing itself with symptoms of sciatica, then until she is feeling no pain, eliminate seated exercises. You see, sitting (even with the most lifted and perfect posture) provides 9 times the amount of lumbar loading as lying down. 9 TIMES. So…considering that she has an ailment of the lumbar spine/discs and likely is guarding (muscular gripping to protect the area) which adds to load and that she likely doesn’t have the greatest abdominal and back support, muscular strength and stretch in balance to give the most space to her vertebral joints and her hip socket…then eliminate seated exercises so as not to exacerbate the issue.
Exercises where she is lying supine are great.
Exercises where she is standing with support are great.
Guidelines are just that…”beware” spots. These are not absolutes. Just items to keep in mind so that you can decide what to do and what not to do…
- Only choose exercises that will aide in creating space and support in her spine, keep her body active, but work around the area of pain
- Eliminate Seated Exercises until she is feeling good again and the inflammation has retreated.
- Beware of Twisting Exercises. The lumbar spine has a very limited amount of rotation without sheer forces. With her inflammation and current condition, hold off on twisting.
- Beware of Prone Exercises. In truth, she might do great with prone exercises…a limited range of motion of spinal extension…but…you must know which direction the disc is bulging to feel comfortable with this. If the doctor has suggested prone exercises and that feels great to her, then you’ll have the all clear. Until then…Best to…
- Only do exercises that are lying supine or standing with support
- Reformer: Reduce Spring Load.
Body Position/Exercise Modifications:
- Eliminate Hamstring Stretch Component of Any Exercise: Full extension of the hamstrings can add to the lumbar load. Especially if client has tight hamstrings, then you must bend the knees a little bit (or even a little more than normally) on any exercise where the legs would be outstretched.
- Ex: Spine Stretch Forward – Still sit up on center of sit bones/ischial tuberosity, but bend knees a bit to eliminate the hamstring stretch component
- Single/One Leg Circles – Keep circling leg’s knee bent a little bit to eliminate the hamstring stretch component.
Now…bent knee does not mean “soft” knee. Soft knees are a waste in Pilates and a good topic for another time. The leg can be very active though bent. A strong leg that just happens to be bent.
Eliminate the Hamstring Stretch Component also because this client is experiencing sciatica. While she feels that she just wants to stretch, as I mentioned earlier, the nerve is already inflamed and “over-stretched” because of the impingement. Any additional stretching will increase the pain, though in the moment it might feel good to her. Again…it will only exacerbate the issue.
Apparatus and Exercise Set Ups:
- Make sure getting into an exercise is actually safe.
- Ex: Perhaps you want to get her into Leg Circles/Frogs on the Reformer. Make sure that you are certain that how she is getting into the straps is actually effective for her ailment. I would suggest that you keep her legs into her chest and that you pull the straps (and carriage) to her feet. Please do not let her push on foot on the foot bar and reach a leg into the strap. You will only twist her pelvis with spring load and add to the compression, not to mention you run the risk of twisting her SI joint out which is already going to be strained by her experience.
- Remember that if your client is on any opiate or sincerely strong pain-killers or muscle relaxers, she is in a dangerous condition to exercise. She will not be able to judge what is painful or not…her nervous system will not be able to figure out before damage happens if she should or shouldn’t do a move. In which case…until she is off of strong pain-killers and/or muscle relaxers, she must not do Pilates or any exercise that is not prescribed by the doctor (and shouldn’t “operate heavy machinery”…including a car!)
A Good Rule:
- Please work to keep her out of pain.
- Anticipate what might be painful to her. It’s not OK to do a repetition to see if that causes pain. One repetition with pain is too much. Plan ahead by learning from each of the previous repetitions and exercise.
- Refrain from asking her if every exercise feels OK. Only ask her about pain or no pain in the first few exercises. Tell her something like “Remember the gam3 is “no pain”. If you hurt at all…you must tell me so that I can modify the exercise to make it right for you. I don’t want you to hurt at all.” Then keep an eye on facial expressions, body movements and sounds to know if it’s OK. If you ask over and over again, then you only concern your client. She needs to focus on what’s working rather than what is not working.
Now…you have to study up and see how it all goes!
If you have any other questions about this, please ask. If you ask your client what hurts and what doesn’t, what did the doctor say she could and could not do and then go with care, but no fear…then all is well!
All the best,
****I hope that you could follow our conversation well. I would like to share these sorts of conversations with you from time to time.
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