Sagittal Spinal Posture After Pilates-Based
Exercise in Healthy Older Adults

Ye-Liang Kuo, et. al
Spine, 2009; 34:1046-1051

This study was designed to determine changes in sagittal spinal posture in older adults during standing and sitting after a Pilates-based exercise program.  They noted that Pilates exercises were purported to improve posture. However, few peer reviewed articles were available to provide scientific support.  They studied 34 healthy older adults, over age 60, who volunteered for this study.  The baseline measures of standing and sitting postures remained unchanged, except for the lumbar spine angle in sitting.  Immediately after an exercise program, older adults stood with slightly decreased thoracic flexion and sat with slightly increased lumbar extension.  No significant differences were found during the follow-up.  The authors concluded that individually designed Pilates-based exercise programs are feasible for healthy older adults, and the high attendance rates support the suitability of the exercise program over a long period.  Considering the variability of the baseline measures, small improvement was only observed in the thoracic kyphosis during standing.  The long-term effects of Pilates exercises require further investigation.  The authors noted that any deviation from the ideal posture may cause excess stress and injury and pain in the musculoskeletal system.  They further note that aging is associated with postural changes such as thoracic kyphosis, especially in women after menopause. Age-related increase in thoracic kyphosis could lead to adverse health conditions such as impaired pulmonary function, reduced physical function, and increased body sway and/or falls.  Forward head deviation, which is defined as the head position forward relative to the trunk, tends to increase with age.  This may be associated with head and neck pain. There is also evidence to show age-related reduction in lumbar lordosis. 

The authors state that in cases of perceived postural deviation, postural education and corrective exercises are often recommended. The authors state that although there appears to be a surge of interest in Pilates programs, with many of the participants being elderly, no studies have evaluated the effects of Pilates exercises in older adults, thus the effects of Pilates exercises on spinal posture of this group is unknown. They do point out that the Pilates program includes strengthening and stretching exercises to help strength and weaken and lengthen muscles and stretch strong and tight muscles, thereby addressing changes resulting from an adaptation of postural deviation.  They concluded that there was small improvement only observed in thoracic kyphosis on standing immediately after an exercise program.  They also conclude that there is probably a slow decline in posture associated with aging over time and the long-term effects of Pilates of maintaining sagittal spine posture requires further investigation. 

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The Benefits of Progressive Resistance Exercise
in a Cervical Patient
Thomas E. Dreisinger, PhD
US Spine & Sport Foundation, San Diego, California

A 68 year old man with chronic neck pain presented to the clinic.  This pain had been going on intermittently for several years.  There was no specific trauma, but the symptoms had progressed increasingly to his right shoulder, arm and to his right hand.  Some days, the symptoms were better and some days they were worse.  Typically, they would be better in the morning when he arose, but as the day progressed they became worse.  On a good day, his symptoms were 3/10 and on a bad day they were 8-9/10.   Aggravating activities were related to his head remaining in a flexed position for extended periods of time.

Personal History: The patient was retired, but had developed a skill in repairing small electric train engines.  These were sent to him from around the country and provided as much work as he liked.  Working on these engines had become progressively worse because he had to bend his neck while working on them.  He would take breaks, but it had gotten to the point where he was unable to work longer than a few minutes.  He was also a swimmer and had stopped because of his neck pain.  Earlier in his life he had been a body builder and for a period of time had taken anabolic steroids, which by his admission had created significant muscle hypertrophy as well as aggressive personality changes.  He had stopped it for several decades and it seemed to have no effect on his current status.

Past Medical History:
Patient reported no prior neck problems before this episode. The patient denied any history of cardiopulmonary disease and no long-term use of mediations.

Red Flags:
There were no red flags and the patient was a non-smoker.

Treatment:
The patient was placed in an aggressive cervical strengthening program.  The program involved cervical stretches (repeated flexions (lateral and saggital), extensions and retractions).  The exercise regimen involved strengthening on resistance exercise machines.  In addition to strengthening the neck in flexion, extension and lateral flexion, strengthening of upper extremity postural muscles also occurred (i.e. lattisimus dorsi, deltoids and rhomboids).   The principle of progressive overload was used to gradually increase resistance to the exercising muscles.   The patient was treated twice a week for 12 weeks as part of a capitated HMO protocol.  At the end of treatment, the patient was pain free and able to work on electric train engines with no difficulty.  He was looking forward to getting back into the pool.

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Rehabilitating Psoas Tendonitis:  A Case Report
Jaime Edelstein, PT, MSPT, CSCS
HSSJ (2009 5:78-82)

This is a case presentation describing the examination and physical therapy intervention for an adult female with anterior hip pain whose medical diagnosis following MRI was bilateral labral tears and psoas tendonitis.  Her physical therapy evaluation revealed findings consistent with psoas tendonitis.  Utilizing theories of neuromuscular patterning and knowledge of normal muscle function, the patient was successfully treated in physical therapy following six physical therapy sessions, once a week for six weeks.  The patient was found to have an over active psoas muscle, as indicated by hip flexion being the primary mover inner movement patterns, and dysfunctional abdominal and pelvic floor muscles.  Functionally based therapeutic exercise and electrical stimulation were used to re-educate the muscles in the abdomen, pelvic floor, and hips in order to regain muscular balance and correct muscle dysfunction. 

The authored noted that there had been prior history of back pain, and a different mechanical or neuromuscular explanation was sought for her hip labral tears and current hip pain.  The thought was that this condition may have been generated by the prior back history, and yielding unilateral symptoms as a result of psoas inhibition and muscle imbalance from the initial injury.  The author notes that where lumbar spine pathology is present, it has been observed that the psoas muscle changes dysfunction.   As a result of the muscle imbalance, the relationship of the lumbar spine and hip becomes dysfunctional.  Over time with resolution of symptoms, the psoas may have begun to function, but in an abnormal manner.  The result would therefore be improper neuromuscular function of the psoas and possible mechanical dysfunction modification of forces to the hip increasing the potential for hip pathology. 

In this case, the patient responded to therapy, which initially aimed to inhibit the psoas muscle essentially removing the abnormal adaptive function followed by a program of re-education to restore normal muscle function and strength.  It appears that in this case that although the primary diagnosis was a hip labral tear, the actual pain generator was a hypersensitive psoas.  Therefore, by treating the soft tissue imbalances through neuromuscular re-education and therapeutic exercise of the abdominals, pelvic floor, and hip musculature, the patient’s pain completely resolved.  The patient states that she still intermittently has clicking in the hips but it does not cause pain. 

The author points out that the success of physical therapy with this patient exemplifies how the body must be examined in its truest form, as a kinetic chain.  In order for this to be accomplished, full subjective history and a clinical systems scan must be completed prior to the performing an objective exam is that the localized region of injury.  The etiology behind the pathology must be identified. 

The second relevant factor in the treatment in this type of patient is a recognition that muscles can be inhibited and re-educated as well as stretched and strengthened.   The ability of a physical therapist to recognize the factors of malfunction and imbalance of muscles and the origin of the malfunction enables them to treat efficiently and thoroughly.  Then, in the manner in which the muscle has maladapted must be explored.  An overreactive muscle in this case must first be inhibited and then functionally strengthened. 

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Different Parts of Erector Spinae Muscle Fatigability
in Subjects With and Without Low Back Pain 
Paul T. Sung, PT, Ph.D., DHSc, Andrew L. Lammers, Ph.D. et al
Department of Physical Therapy Korea University
Seoul Republic of Korea
The Spine Journal (January 9, 2009 115-120)

The authors reported the result of their studies that subjects with low back pain demonstrated higher fatigability of the erector spinae muscles at the thoracic portion than in the lumbar portion of the spine.  The increased fatigability of the thoracic portion needs to be emphasized in rehabilitation strategies for subjects with low back pain.  In addition, as age increase, the median frequency of the lumbar part of the erector spinae muscles significantly decrease.  Understanding the anatomical and biomechanical characteristics of the erector spinae muscles may enhance clinical outcomes and rehabilitation strategies for subjects with low back pain.  The fatigue measurements were evaluated assessing both the thoracic and lumbar portions of the erector spinae muscles and utilizing surface EMG.  They found no clinically relevant differences observed between genders, and they found it important to consider the anatomical and biomechanical characteristics of the different regions of the erector spinae muscles. 
They opined that these results should be considered when developing a comprehensive back muscle endurance rehabilitation strategy while targeting the erector spinae muscles.  The authors note that the erector spinae muscles of the lumbar spine consist of the iliocostalis lumborum and longissimus thoracis.  These muscles can both be further divided into a thoracic and lumbar portion.  The thoracic portions have their rostral attachments at the thoracic level and the lumbar portions at the lumbar level. 

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Physical Therapy for Acute Low Back Pain
Fritz, Coeland, et al.
Spine volume 23 #16 2008, 1800-1805

The authors examined association between adherence to evidence based recommendations for active physical therapy care and clinical outcomes along with subsequent healthcare utilization and charges for one year after completion of physical therapy.  They concluded that adherence to recommendations to active care is associated with better clinical outcomes and decreased subsequent use of prescription medication, MRI and injections. Improving adherence to this recommendation may present an opportunity to improve the cost effectiveness and care for acute low back pain.