Colleague Questions: Sciatica

February 17, 2013 at 6:14 pm 18 comments

Shari Berkowitz and Cheryl Sullivan Cole at Pilates on Tour Atlanta, GA 2013

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:

Colleague: Janet

Image

Line of pain for sciatica

Client Issue:  Sciatica

Conversation:

JANET:

Hello Shari,

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.
Best,
Janet

SHARI:

Hi, Janet,

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!
– Shari
JANET:
Hi Shari,
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.
Thank you,
Janet
SHARI:
Hi, Janet,
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?
– Shari
JANET:
Shari,
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!
Best,

Janet
Sciatic Nerve Exiting the Spinal Canal in Lumbar Spine
Herniated/Slipped/Ruptured Disc impinging nerve and spinal canal
SHARI:
Janet,
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”
To understand with a simple definition:  http://www.mayoclinic.com/health/herniated-disk/DS00893
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:
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…
 
Exercise Choices:  
  • 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
 
Apparatus Modifications:
  • 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.
 
Medications:
  • 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, 
– Shari
****I hope that you could follow our conversation well.  I would like to share these sorts of conversations with you from time to time.
With that…

Ask questions when they arise!  Please drop your questions and thoughts here in the comments so that all can benefit from both your question (as many will have the same one) and the answer as well as your shared experiences from your thoughts!

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18 Comments Add your own

  • 1. Jodie  |  February 17, 2013 at 9:49 pm

    Thank you so much for this. Really appreciate this and I appreciate you.

    Reply
  • 2. Pippa  |  February 18, 2013 at 3:05 am

    Thank you for this clear and understandable information. Very helpful to have the question and answer aspect, I will have my own question coming your way very soon!

    Reply
  • 3. Jill Allen  |  February 18, 2013 at 3:29 am

    Thank you Shari, that cleared up so many doubts I have about what can and cannot be done with sciatic symptoms. You did not go on to develop the conversation about what the precautions would have been had the client had sciatica due to PIriformis syndrome. If you have time, I would be interested in your views. Thanks.

    Reply
  • 4. Fernanda Millions Dutra  |  February 18, 2013 at 5:47 am

    Thank you to share all your knowlegde !
    Thank you to encourage us to think for our own,, helping with so values informations…..

    Reply
  • 5. Rita Matraia  |  February 18, 2013 at 6:47 am

    That’s great Shari. Looking forward to this. When you get a chance can you email me the official description of Cueing and Hip and Leg workshops? I want to get this up on my site so people can start purchasing. Thanks so much! Rita Matraia http://www.thecoreconnection.com

    Reply
    • 6. theverticalworkshop  |  February 18, 2013 at 8:17 am

      My apologies, Rita, I had planned on doing this this very weekend…and clearly couldn’t get to it. I will send this to you this evening!

      Thank you!!
      – Shari

      Reply
  • 7. Sara  |  February 26, 2013 at 4:39 pm

    To add to Shari’s excellent response: I am a Pilates teacher and have been practicing Pilates for nearly 20 years. Two years ago I was diagnosed with a posterior and fairly central L5/S1 herniated disc. It presents as sciatica in my hamstrings. As prescribed, I went to physical therapy for a number of weeks. I was given exercises to strengthen my hamstrings because the “pain” I had in hamstrings caused them to lose strength. I was also given the plank and side plank to hold for 3 sets of 20 seconds. I was told by a Pilates teacher who is also a physical therapist that the plank is a very effective core stabilizer that also increases core stamina. Another core stabilizing exercises that I was given was lying supine on the length of a 1/2 foam roller, holding a small weighted ball above my chest while “marching” similar to Ellie Herman’s “tiny steps” exercise, p.49, in her Pilates Props Workbook. It’s a great simple yet challenging stabilizer, Pilates or not. As for spine stretch forward, the client can sit on top of a moon box, bent knees and reach forward from the waist up (keeping the long and lifted low back, of course; and it’s not for everyone).

    I have found that using my powerhouse while moving through life is very helpful and reduces any pain I might feel (not often now, thank goodness!) rather quickly. So if I feel my hamstrings “acting up,” I pull my abdominals in and up and the pain dissipates. I also use “my Pilates” to pick up the laundry basket, to load and unload the dishwasher, to shovel snow from the driveway, walking down the street, and driving my car. I told my doctor this and he was very pleased. Most patients don’t figure it out – ever. Furthermore, while driving it helps significantly to increase the angle of the seat back in relation to the thighs. While being partially reclined is not ideal for driving, if the seat back can be tilted back even a little and if the seat itself can be angled down, all the better. Pulling the abdominals in and up, lengthening the spine, and pressing contact points (head, shoulders, back of the hips) into the seat back as if lying down on the reformer yet maintaining the natural curves in my spine helps on long car trips. I also make a conscious effort to steer from my lats as there is a tendency is to drive from the shoulders, rounded forward. The reclined position spreads the load throughout the body so that it’s not concentrated on the lumbar spine. I told my doctor what I was thinking and he said I was spot on. He had actually worked on a study that sought the ideal angle while seated, if I remember correctly, is 110 degrees. I still get hamstring pain when I drive longer than an hour but when I follow my own “rules,” the pain goes away.

    As my clients leave the studio, I tell them all, “Take your Pilates with you.”

    Reply
  • 8. James Crane  |  March 12, 2013 at 2:09 pm

    Wise words, one repetition of pain is too much. When I’m unsure if an exercise will cause pain or not, I remind myself that there are plenty of other exercises to do.

    Nice to hear about sciatica. Is an inflamed coccyx a related issue? I have a client who complains her tailbone hurts and her doctor told her it was nerve related and said she should have an injection of some kind to relieve it.

    Reply
    • 9. James Crane  |  March 15, 2013 at 8:50 pm

      Not an inflamed coccyx but the tissue around it. Anyway, today she told me that her doctor does not think it’s a nerve issue but thinks that her tailbone is “too curled under”. For today’s session and in the future (she’s had about 20 so far), I am making sure her tailbone is lengthened when laying down, with pelvis in a good steady position, making sure she sits up tall without tucking under when, and always paying special attention to keeping a long tailbone so that the muscles start working to keep it that way.

      Reply
      • 10. theverticalworkshop  |  March 19, 2013 at 6:21 pm

        Hello, James,

        Thank you for reading this article…and considering how it applies to your work, etc.

        It seems like this has already been checked (sort of), but some people have a nerve that can wrap around the tailbone. It’s not “supposed to”, but does. It is not harmful, just painful. Really painful. Those people may be able to do weight-bearing exercises in a posterior tilt once they develop good abdominal and back support (really working to lift their back bones/create the most space between their vertebrae when in forward flexion of the spine and posterior tilt of the pelvis).

        Now, of course, there is no such thing as lengthening your tailbone. Your tailbone curls one way or the other. I know you’ve been taught this cue as many have…but to me it is not good enough and doesn’t have clients connect into the correct muscles. It is cueing the glutes rather than the abdominals. It’s much more appropriate to say “with your pubic bone facing the ceiling, keep back of your pelvis, your sacrum, floating on the mat…your sit bones forward, your admirals and low back back.” That immediately puts them into internal obliques to shift the pelvis into “neutral” whilst lying down.

        Does that resonate?

        Now…it’s unlikely that her coccyx is too curved in if she is experiencing pain whilst sitting upright and then rolling into posterior tilt of the pelvis. It’s more likely that her coccyx has a reverse curve. With that, a little bit of extra pad under her pelvis in these exercises, along with the lift mentioned earlier, will assist greatly.

        Has she had children with natural childbirth? It’s always likely that the baby broke her coccyx during birth.

        How has it been going since your comment on 3/15?

        – Shari

  • 11. James Crane  |  March 21, 2013 at 1:51 pm

    Hi Shari,

    Thank you for writing, for the info and taking the time to help. I last saw her 3/15 and will only see her every other week now because I will be alternating with other teachers. With your info, I will be able to ask her more specific questions to try to narrow down what the problem might be, and I’ll speak to the other teachers. Her conflicting doctor reports are a little confusing. I think it bothers her more outside the studio than in, she said the only place she feels it is teaser. If it’s a nerve wrapped around her coccyx, would this be something she would have felt her whole life?

    I will work hard to lift her back and develop abdominal and back support. She’s actually relatively strong and in good shape, it’s just that her tailbone tends to curl forward. Anything specific you think might be helpful?

    Yes, your cues resonate. “More space between the bones” is most direct and actually I’ve been using this since I heard it from you. But is it odd that I feel uncomfortable saying “pubic bone” to my clients? Is there another way to describe this? What about “front of the pelvis”? Too vague?

    Thank you again.
    James

    Reply
    • 12. theverticalworkshop  |  April 7, 2013 at 10:08 pm

      Oh, James…I meant to write back to you promptly. My apologies that I clearly did not!

      As for saying “pubic bone”…I understand, but it’s only because of the puritanically hypocritical culture in The USA when it comes to the human body that it would ever feel awkward to say “pubic bone”. It is simply a body part like arm or leg. If you say “tailbone”, then you can say “pubic bone”. It’s always about your intention. If your well-intended when you talk of “pubic bone”, then all good. If you are not well-intended…then no good. It’s always about your intention.

      With that…DO NOT hands-on cue the pubic bone. Do not touch a client’s pubic bone. Just cue it directionally.
      “Hip points and pubic bone facing straight forward, your sit bones facing the floor.”
      “Rotate your pubic bone upwards aiming your sit bones forward; lift your abdominals and low back bones.”
      Things like that.

      Let me know your thoughts.
      – Shari

      Reply
      • 13. James Crane  |  April 18, 2013 at 12:04 pm

        Yes, I’ll have to work on not feeling awkward. When people say it to me, it doesn’t bother me. I’ll work on it. And, I wouldn’t think of touching there!

        Thanks for your help, Shari

  • 14. Ruth Alpert  |  May 22, 2013 at 12:31 am

    love your answers/discussions! Wish I had more time to read each blog. You write so well, and know so much!

    Reply
    • 15. theverticalworkshop  |  May 27, 2013 at 8:12 pm

      Ruth,
      Thank you so very much! Your words are very kind!
      – Shari

      Reply
  • 16. Margaret  |  November 2, 2014 at 1:26 pm

    No wonder my sciatica isn’t getting better. . .straight leg stretches, scissors. . .all Pilates moves. I’ve had sciatica since my 40’s. Didn’t realize all the exercise I do is actually exasperating the situation. . .my Pilates instructor forwarded me this link and I thank her for that. What bothers me is that I have a different instructor on Tuesday . . .why didn’t she advise not to do some of these exercises knowing I had sciatica. Oh well. I sure hope walking is OK and some Pilates.

    Reply
    • 17. theverticalworkshop  |  November 3, 2014 at 10:38 am

      Hello, Margaret,

      I’m very glad that you were directed to this article of mine. I”m glad it makes sense. With that, it would be wonderful if all instructors had a great education on how the human body really works…but that is not the case. Most instructors are extremely well-meaning but have an odd education that is really in-bread in the Pilates world. Well-meaning is essential to see, though! With that, you are going to have to command your session in this regard…with kindness. You will need to make sure that you do not do anything that will aggravate your imbalance (what ever is causing your sciatica) and eliminate or modify as suggested in that article and such. it’s just that most people don’t know how to care for the human body…even though they mean well. It’s a shame. However, it’s my quest to educate both teachers and clients so that this is less prevalent.

      Walking…great…supportive shoes: no high heels, no flip flops, no backless shoes
      Pilates…great…with the correct modifications and omissions.

      Please reach out with any questions…ever. And direct any instructor who questions what to do about sciatica to me and I will gladly educate! My email: info@TheVerticalWorkshop.com

      All the very best!
      – Shari

      Reply
  • 18. Marta Maroni  |  July 20, 2017 at 9:22 am

    hi Shari,
    i have a question.I always thought that with herniated disc, bulging disc you have to avoid any forward flexion, rotation, side flexion, hyper back extension. At work where i teach Pilates they told me that if the disc bulge to the side you are still able to flex forward? i am not a physiotherapist but i thought that the anatomical movements must be avoided anyway does it matter where the disc bulge?what do you think?or they told me that if The bulging of the disc is very old and the client has very strong abdominal he/she can go back to those contraindicated exercises.
    thank you
    Marta

    Reply

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