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PilatesforCentralSensitization
fromChronicPain
ElizabethClark
March18,2016
FlowStudios,Chicago,2015
2
Abstract
Centralsensitizationisaconditionofheightenedsensitivity,closelyassociatedwith
chronicpain.Inthisstate,thebrainisbeingtoldthatthebodyisinmoredangerthanit
actuallyis,maintaininganongoingstateofstress.Muscleactivity,brainfunctionand
emotionalwellbeingarenegativelyaffected.Individualsexperiencingchronicpainand
centralsensitizationusuallyattempt,unsuccessfully,toeitherpowerthroughtheir
symptomsoravoidpainfulactivitiescompletely.Abetterconditioningmethodhasproven
tobetheslowandsteadyapproach.Thiscasestudyexaminestheeffectsofapersonalized
BASIPilatesprogramonaclientwithchronicpainandasensitizedcentralnervoussystem.
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TableofContents
CentralSensitization....................................................................4
CaseStudy..............................................................................8
ConditioningProgram....................................................................9
Conclusion.............................................................................11
Bibliography............................................................................13
4
CentralSensitization
Thecentralnervoussystem(CNS)ismade
upofthebrainandspinalcord.Working
withtheperipheralnervoussystem,itsjob
istosend,receiveandprocessinformation
fromeverypartofthebody.Adamagedor
faultyCNS,onethatdoesn’thandle
informationcorrectly,canleadto
symptomsrangingfromaheadache,to
slurredspeech,toradiatingbackpain,to
numbness,tolossofcoordinationto
numerousothersymptoms.(JohnHopkins
Medicine)ThiscasestudyinvolvestheCNS
disordercalledCentralSensitization.
One formof information theCNSdealswith ispain. Likemost stimuli, pain travels from
peripheralsensoryneuronstothespinalcord,andthenonuptothebrain.Thebrain’sjob
is to interpret the information andmake a variety of short and long-term responses by
sendinginformationbackthroughthespinalcordtothebody.
Ifthespinalcordcontinuallyreceivespainstimulus,theveryadaptablenervoussystem
respondsbygettingbetteratsendingdangersignalstothebrain.Thingsthatusedtohurt
begintohurtmoreandthingsthatpreviouslydidn’thurtstarttocausepain.(Butler,
Fig.1:http://climatereview.net/ChewTheFat/?p=1015
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Moseley73)Thebrainisbeingfedinformationthatnolongerreflectstheactualhealthand
abilityofthetissues.It’sbeingtoldthereismoredangerthantherereallyis.Althoughthe
levelofsensitizationvaries,heightenedsensitivityoftheCNSisalmostalwaysasymptom
ofchronicpainatsomepoint.And,thelongerthepainlasts,thegreaterthechangesinthe
CNSbecome.(Ingraham)
Commoncharacteristicsofcentralsensitizationincludethefollowing:
- Thepainlastsafteraffectedtissueshavehealed.
- Thepainspreadsbecausethebrainisincorrectlybeinginformedthatmoreof
thebodyisindangerthanactuallyis.
- Thepainincreases,sendingamessagesayingtoescapetheperceiveddanger.
- Assensitivityincreases,theamountofmovementrequiredtoignitepain
reduces.Inseverecases,eventhinkingaboutamovementcancausepain.
- Thepainbecomeslesspredictable.
- Thepainlinksmoretothoughts,feelingsandbeliefs,whichinturnstart
contributingtotheproblem.(JohnHopkinsMedicine)
Inresponsetochronicpain(thebrainreads:chronicdanger)plusasensitizednervous
systemmagnifyingtheissue,manyadaptationscanoccur.Oneisalteredmuscleactivity,
specificallyactivationofthelongermovermusclesanddeactivationoftheshorter
stabilizermuscles.Intheshortterm,thisisagoodresponsetodanger.Thebrainis
preppingthebodytofightorflee.Inthelongterm,however,thisstatenegativelyimpacts
postureandmovementpatterns.Theactivatedlongmusclesbecometightandthe
deactivatedshortmusclesbecomeweak.(Butler,Moseley90)
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Anotheradaptation,onethathappensinasectionofthebrain’scortexcalledthe
homunculus,isknownassmudging.Areasofthebrainnormallydevotedtospecificbody
partsbegintooverlaponeanother.Smudgingcanoccurinbothmotorandsensoryareasof
thebrainandisthoughttobeaprotectivestrategy.Motorsmudgingmakesitharderfor
thebraintoaccessbodypartsassociatedwithpainandthereforelimitingtheiractivity.
Sensorysmudgingallowsthesensitivityofapainfulareatospreadtoneighboringareasin
ordertoincreasethedangersignalbeingsenttothebrain.(Butler)
Individualswithchronicpain,includingthosewithcentralsensitization,typicallytakeone
oftwoapproachestodealingwithpain:avoidthepainortrytobeatit.Thosewhotakethe
avoidanceroutestopany
activityassoonasthepain
kicksin.Overtime,the
amountofactivitynecessary
totriggerpainbecomesless
andless,leadingtoan
increasinglysedentary
lifestyleandoften
depression.Thosewhotryto
beatthepainattemptto
“pushthrough”andignorealarmsignals.Atsomepoint,thepainbecomestoomuchtotake
andthepersonisforcedtoseverelyreducetheiractivity.Asshownintheabovegraphs,
bothapproachesendwithaverylowactivitylimit.(Butler,Moseley107)
7
Abettermethodistousepacingandgradedexposure.Thisrequiresabalancebetween
testingthelimitsofpainandlettingpainbethemaster.Itisimportanttoplanoutaslow,
measuredprogressionandtrytosticktoit,ratherthanrushingaheadorcontinually
allowingthepaintomakedecisions.And,whenthereseemtobesetbacksorpainfuldays,
itisveryimportantnottogiveuporbetoohardononeself.(Butler,Moseley113-117)
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CaseStudy
Anneisa27-year-oldfemale,5’4”tallandweighingabout115pounds.Shehasbeen
experiencingchronicpainandinflammationinherlowerbodyforabout4years.Thepain
beganinAnne’sfeetandkneesandslowlyspreadtoincludemostofherlegsandlower
back.Doctorshavebeenunabletogiveacleardiagnosis,thoughtheyconjecturethatitisa
systemicissue.WhatAnneandherdoctorshavedeterminedisthatovertime,theongoing
painhasledtosensitizationofthecentralnervoussystemandsomecompensatory
behaviors.
AnnebeganattendinggroupPilatesmatclassesinanefforttostayinshapewhilebeing
forcedtogiveuptheformsofexerciseshehadpreviouslyenjoyed(running,biking,
volleyball)duetotheiraggravatingeffectsonherpainlevels.Morethanjusthelpingto
buildstrengthand“stayfit”,Annefoundthatshealsoexperiencedreducedpainfollowing
mostclasses.Theimprovementwouldlastforanywherefrom2-24hours.
Givenhopebythis,AnnedecidedtotakeprivatePilatessessionswiththegoalofsoothing
hersensitizedcentralnervoussystem,continuingtobuildstrength,andimprovingher
qualityoflife.Anneisatalow-intermediatelevelandrequiresextrawarm-upexercisesas
wellasaverygradualprogressioninintensity,toavoidtriggeringpain.Sheisnewtoallthe
Pilatesapparatusbesidesthemat.Fromherassessmentsession,Ialsonotedaneedfor
greatercontrolandstabilization,morecoreenduranceandbetterco-contractionof
musclesduringmanyexercises.UtilizingtheBASI(BodyArtsandScienceInternational)
BlockSystem,Ihavedesignedaconditioningprogramwiththefollowingfeatures:
9
1. Amplewarm-upexercisesandpreparatorymovements,concentratingAnne’smind
onherwholebodyratherthanjustthepainfulparts.
2. Agradualbutconsistentincreaseofintensity,toavoidtriggeringpainflare-ups
whilenotallowingthepaincycletoinhibitprogress.
3. Emphasisonstabilizationandmusclecontrolratherthanjustmovermuscle
strength.
4. Functionalworkinallplanes,translatingtopropermusclerecruitmentduringdaily
activities,especiallyinthecoronalandtransverseplanes.
5. Encouragementandpositivity!Peoplewithcentralsensitizationoftenhave
protectivemovement-relatedpainmemoriesthatinhibitexercise,socreatingan
environmentofphysicalandemotionalsafetyisimportant.(VlaeyenandLinton)
Conditioning Program for Client with Central Sensitization
Block Sessions 1-5 Sessions 6-10 Notes
Preparation* Before all sessions: Cue client to focus on breath and move their attention throughout the whole body. Pelvic rocking, scapular protraction/retraction, point
and flex feet, circle ankles.
Warm-up Fundamental Warm-up Series on Mat
Intermediate Warm-Up Series on Mat
Start with modified versions or less repetitions, if necessary, and gradually increase. Focus on control and stability.
Footwork Reformer: Parallel Heels, Parallel Toes, V-position Toes, Wide-V Heels, Wide-V Toes, Calf Raises, Prances, Prehensile and Single Leg Heel or Toes
Cadillac: Parallel Heels, Parallel Toes, V-position Toes, Wide-V Heels, Wide-V Toes, Calf Raises, Prances and Single Leg Heel or Toes
The Reformer offers an easy hip angle and the carriage supports spine and pelvis. Start on lower spring settings and work up. Focus on spinal/pelvic body stability (without unnecessary stress) and hamstring strength. Progress to the Cadillac, with a more challenging hip angle but where the client can view their leg and foot alignment easily.
Abdominal Work
Reformer: Hundred Prep and Hundred
Cadillac: Roll-Up Top Loaded, Mini Roll-Up, Mini Roll-up Oblique, Teaser 1
The hundred prep and hundred build abdominal endurance and control. The Roll-Ups and Teaser 1 increase the strength and control challenge. Teaser 1 will be an attainable goal to work towards.
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Hip Work Reformer: Frog, Circles Down, Circles Up, Openings
Cadillac: Basic Leg Springs Series
Emphasize stabilizing the spine and pelvis. The Basic Leg Springs series adds the additional challenge of separately sprung legs.
Spinal Articulation
Reformer: Short Spine
Reformer: Long Spine
Once proper muscle recruitment and good spinal articulation are achieved in Short Spine, apply the concepts to Long Spine, with added challenge hip extensor control and more difficult stabilization.
Stretches Reformer: Standing Lunge
Reformer: Full Lunge
Additional stretches may be added based on how the client’s body feels day-to-day. Focus on breathing and checking in with the body.
Full Body Integration
Cadillac: Sitting Forward, Side Reach, Cat Stretch Kneeling
Reformer: Elephant, Up Stretch 1, 2, 3, Down stretch
Focus on coordination, scapular stabilization and proper muscle recruitment, first in more stable positions on the Cadillac, and then in the load-bearing front support positions of the Reformer.
Arm Work Avalon Armchair: Seated Arm Work
Reformer: Arms Kneeling Series
Emphasize trunk stabilization while doing seated arm work on the Avalon and then increase the stability challenge, kneeling upright on the reformer.
Leg Work Mat:Side Lying Gluteal Series w/weights Wunda Chair: Hamstring Curl
Wunda Chair: Leg Press Standing, Backward Step Down
Focus on gluteal and hamstring strength in easier side-lying and supine positions and then add stabilizer muscles and balance challenge in standing Wunda Chair Leg Work.
Lateral Flexion/Rotation
Wunda Chair: Side Stretch
Ladder Barrel: Side Over Prep Reformer: Mermaid
Achieve oblique strengthening and stretch, plus build awareness of where the body is in space. Increase the load and take away pedal support by advancing to Side Over Prep on the Ladder Barrel. Add Mermaid on the reformer for rotation and scapular stabilization.
Back Extension
Wunda Chair: Swan Basic
Reformer: Pulling Straps 1 and 2
Start on the Wunda Chair, with the option to leave feet on the floor at first. Once proper muscle recruitment is achieved, progress to Pulling Straps 1 (and later, 2) coordinating arm work with the back work.
* Preparation is, of course, not an actual Block. See features of conditioning program listed
above for the purpose of beginning this way.
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Conclusion
Annerespondedwelltothisconditioningprogram.Althoughweemphasizeddifferent
blocksandgoalseachday,wegenerallykepttotheoutlineabove.Mentalandemotional
resultsbecameapparentevenbeforethephysicalones.Annereportedfinallyfeelingsome
senseofcontroloverherphysicalwellbeing,whichhadseemedtobeunderthecontrolof
painforsolong.Shealsosaidthatherpainlevelshavespikedlessoftensincethebeginning
ofourprogramandthatheremotionalresponsetowhentheydorisehasbeenless
dramatic.
Anne’sphysicalprogressionhasnotbeenespeciallyfast.Centralsensitizationandchronic
painhaverequiredustoadvanceataverygradualbutsteadypace.Thankfully,wewere
abletoholdatleasttwosessionsaweekandresultsdidslowlybecomeapparent.After
focusingontheimportanceofcontrolandstabilizationinmanyoftheexercises,Anne
begantopracticewithastrongerandmorecontinuousdeepcoreconnection.Workingon
thevariousPilatesapparatus,wewereabletosafelytargetunder-usedmuscles,suchas
thehamstringsandbackextensors.
ThemostnotableresultisthechangeinwhereAnneexperienceshersymptoms.Forthe
pastfewyears,shehurtthroughoutmostofherlowerbody.Recently,withtheexceptionof
duringacuteflare-ups,thepainandinflammationaremostlyrestrictedtoherfeet,knees
andlowerback.AsAnnedescribesit,thepain“shrunkbackclosertothesizeofwhenit
firststarted.”
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AnneiscontinuingtotakeprivatePilatessessionsandalsoattendsgroupequipmentand
matclasses.OverthecourseofstartinggroupPilatesathergymandthentakingprivate
sessions,shehasbeenshehasalsobeenabletocarefullyreturntosomeoftheactivities
shegaveupwhenherpainbegan,suchasbiking,swimming,andhiking.
13
Bibliography
1.Butler,David."ExplainingBrainSmudging."YouTube.NeuroOrthopaedicInstitute,4Dec.2014.Web.4Mar.2016.<https://www.youtube.com/watch?v=3QVAY5stO3U>.2.Butler,David,andLorimerMoseley.ExplainPain.Adelaide:NoigroupPublications,2003.Print.3.Follett,James."TheNervousSystem."ChewTheFat.22Nov.2011.Web.17Mar.2016.4.Ingraham,Paul."CentralSensitizationinChronicPain."PainScience.com.Painscience.com,29Jan.2016.Web.10Mar.2016.5."OverviewofNervousSystemDisorders."JohnHopkinsMedicine.TheJohnsHopkinsUniversity,TheJohnsHopkinsHospital,andJohnsHopkinsHealthSystem.Web.15Feb.2016.6.Vlaeyen,JohanW.S.,andStevenJ.Linton."Fear-avoidanceandItsConsequencesinChronicMusculoskeletalPain:AStateoftheArt."InternationalAssociationfortheStudyofPain,9Sept.1999.Web.15Mar.2016.