Maintaining function, stability and well-being in clients with

Maintaining function, stability and well-being in clients with facioscapulohumeral muscular dystrophy (FSHD)

Laura-May Baldwin 10th December 2016 Wimbledon, The Pilates clinic - 2016

Abstract

Pilates is a well-stablished and long-standing exercise program renowned for it’s holistic benefits. Joseph Pilates addressed not only physical strength and mobility but also believed that through striving for physical excellence we achieve general well-being. The focus is not just on the physical, but also the ability to be in total control of the body and it’s movements through a true mind-body connection. With this in mind it is easy to see why Pilates is so complimentary for individuals where movement is part of their career for example the dance community and professional athletes. It is also incredibly successful in aiding recovery in injuries and assisting those with physical imbalance and disability. This case report covers a comprehensive programme utilising the BASI block system to assist those with FSHD, with particular attention to scapular stabilisation and long term maintenance of muscular balance.

2

Contents

Abstract………………………………………………………………………..…………………………..P2 Contents…………………………………………………………………..……………………………….P3 Anatomical description/focus………………………………………………..………………… P4-5 Introduction…………………………………………………………………….……………………… P6 Case study……………………………………………………………………………..………………….P7-8 Programme……………………………………………………………………..……..………………..P9-12 Conclusion………………………………………………………………………….….…………..……P13 Bibliography…………………………………………………………………………….......………..P14

3

Anatomical focus

This case report discusses the use of Pilates to stabilise the use of the scapula. The scapula has no direct bony attachment; instead it relies on muscular attachment to the axial skeleton. It lies posterior to the thorax roughly from T2-T8. The muscles enable a large degree of mobility which in turn allows for shoulder/arm mobility. The primary muscles of scapula stabilisation are as follows:The Trapezius is a large triangular-shaped muscle divided into upper, mid and lower sections as the fibres of this muscle run in different directions, thus these differing sections are responsible for different scapulothoracic movements. It originates in the occipital bone of the skull, attaching to the clavicular and scapula spinal processes. The upper trapezius is responsible for elevation and upward rotation of the scapula. The mid trapezius is responsible for retraction of the scapula. The mid and lower trapezius is responsible for depression of the scapula. The Rhomboids (major and minor) are deep to the trapezius with diagonal running fibres attaching the mid spinal process to the vertebral border of the scapula. The rhomboids are responsible for retraction of the scapula and downward rotation and to some degree scapula elevation. 4

The Levator scapulae attach the cervical vertebrae C1-C4 to the upper vertebral border of the scapula and aids elevation. The Serratus anterior is a fan-shaped muscle attaching the medial border of the scapula to lateral surface of the ribs 1-8. Serratus anterior is assisted by Pectoralis minor to produce scapula protraction. Serratusus also works with the upper trapezius to create upward rotation. The lower fibres of serratus also aid scapular depression.

5

Introduction

Facioscapulohumeral muscular dystrophy (FSHD) is a genetic, neuromuscular disease. It is marked by slowly progressing skeletal muscle weakness and death of muscle cells and tissues. FSHD primarily affects the back muscles that stabilise the scapula; the upper arm muscle and shoulder girdle and often affecting the pelvic girdle and leg muscles as the disease progresses. Muscle fatigue and pain is widely reported in patients with this condition. Muscle groups tend to deteriorate asymmetrically with one side being affected more than the other. There is little research surrounding the effects of Pilates or any exercise on FSHD as it is difficult to create a controlled test. This is because as a rare genetic disease it manifests in different ways and people’s experiences differ. However with a condition that is so unique to the individual, it seems appropriate to utilise the BASI block system. Creating a programme for a client with FSHD where, alongside focused muscle strengthening, balance is always addressed, which is a key concern for all people especially those with FSHD.

6

Case study

Laura is a 32 year old woman with excellent fitness. She partakes in daily exercise including running, high intensity bodyweight interval training and Pilates. She has two children aged 5 and 7, born naturally with no medical intervention. Laura was diagnosed with late onset FSHD in November 2014. Attributed to this condition is a reduced strength and stabilisation of the left shoulder. Winging of the left scapula is visible and this is exacerbated by certain exercises. Laura has had multiple incidences of severe shoulder and neck pain due to over-active upper trapezius compensating for weaker lower/mid trapezius muscles and surrounding stabilising muscles. For this she has been seen regularly by a specialist (MD) physiotherapist and her osteopath but reports improvement in her left shoulder stability since committing more time to Pilates. She experiences some left hip pain that may be associated with FSHD or poor biomechanics during running. On examination Laura has good posture but has a tendency to allow her shoulders to round forward. She has hammer toes and is conscious of correcting her ankle alignment. After examination and discussion the objectives for the client are to: 

Continue to improve shoulder stabilisation



Improve muscular balance between left and right side back and shoulder muscles. 7



Improve muscular balance between hip flexors and adductors



Feel positive about the future!

8

Programme

Before writing the programme I was able to discuss with the client’s physiotherapist the safety aspects of performing certain exercises for clients suffering with FSHD. The main caution was for Laura to stop on sudden fatigue and to be conscious of not over working weaker muscles. Also it was important to assess on a session by session basis what exercises were appropriate. This would be the case for any client. Sessions

1-10

Warm up

    

Foot work

11-20 Roll down Pelvic curl Spine twist supine Chest lift Chest lift with rotation (MAT)

Reformer/Cadillac  Parallel heels  parallel toes  V position toes  Open V heels  Open V toes  Calf raises  Prances  prehensile (reformer only)  Single leg heels 

Single leg toes

    

21+ Roll up Spine twist supine Double leg stretch Single leg stretch Criss cross (MAT)

Reformer/Cadillac  Parallel heels  parallel toes  V position toes  Open V heels  Open V toes  Calf raises  Prances  prehensile (reformer only)  Single leg heels  single leg toes  Hip opener (Cadillac only)

9

    

Roll up with roll up bar Spine twist supine Mini Roll-Ups Mini Roll-Ups Oblique Roll-Up Top Loaded (CADILLAC)

Reformer/Cadillac/Wunda chair  Parallel heels  parallel toes  V position toes  Open V heels  Open V toes  Calf raises  Prances  prehensile (reformer only)  Single leg heels  single leg toes  Hip opener (Cadillac only)

Abdominal work



Hip work    

Reformer hundred prep

Reformer Frog Circles Down/up Openings Extended Frog/reverse

Reformer  Hundred  Coordination

       

Spinal articulation

Omitted

Reformer Frog Circles Down/up Openings Extended Frog/reverse Cadillac Frog Circles Down/up Walking Bicycles

Reformer Bottom lift Cadillac  Tower prep Reformer  Kneeling lunge 

Stretches 

Pole Pole series

Reformer  Short box series  Teaser prep Cadillac  Roll-Up Top Loaded  Breathing with Push through Bar Wunda Chair  Standing Pike reverse  Pike sitting Reformer  Frog  Circles Down/up  Openings  Extended Frog/reverse Cadillac  Frog  Circles Down/up  Walking  Bicycles Single leg work on Cadillac    

Full body integration

Omitted

Reformer  Scooter  Elephant

     

10

Reformer Short spine Cadillac Monkey original Reformer Full lunge Cadillac Shoulder stretch Reformer Flat back Down stretch Up stretch Cadillac Sitting forward Side reach Kneeling cat stretch

Arm work

Reformer  Arms supine series Wunda Chair  Shrugs

Reformer  Arms supine series

     

Full body integration Leg work

Omitted

  

Lateral flexion

Omitted

 

Back  extension 

Wunda chair Leg press standing Magic circle Adductor squeeze Mat Side lift Wunda chair Side stretch Mat Back extension Wunda chair Swan Basic

Wunda Chair  Single leg press Reformer  Single leg skating Wunda chair Side stretch



    

Wunda chair Swan basic Reformer Breast stroke prep

 

  

Reformer Arms sitting series Cadillac Arms standing series Wunda Chair Shrugs Triceps press sit Frog back Side kneeling Arm Reformer Long stretch Wunda chair Single leg press Reformer Single leg skating Side splits Wunda chair Side kneeling stretch Reformer Mermaid Wunda chair Swan on floor Reformer Breast stroke prep Breast stroke

The exercises chosen for this program are those primarily involving scapular stabilisation. It was necessary to ensure, where possible, that proprioceptive feedback was available to focus the client’s awareness to the stabilising muscle groups. For example the “Arm Series Prone” on the reformer aids stabilisation as well as allowing the client to appreciate the feeling of correct shoulder mechanics against the reformer bed. It is important to note that although Laura has had previous Pilates experience the programme has initially been “back to basics”.

11

Readdressing foundation level work enables the instructor to ensure technique is precise and therefore the client gets the full benefits of a comprehensive programme as well ensuring that they are safe to progress to more challenging exercises. The programme has also been complimentary to Laura’s hobby of running, with many exercises working to balance hip adductors/abductors and hip flexors/extensors. The aim of the these exercises would be to alleviate the left hip pain she has experienced.

12

Conclusion

The client progressed through the programme well and improvements in stabilisation have become apparent specifically in purposeful activation of the serratus anterior which has significantly reduced scapula winging on the left-hand side. As FSHD is a slow progressing condition and deterioration is difficult to monitor, one can only speculate on maintenance but it is my belief that if the client continues to build on her mind body connection that functional movement will be longer lasting. Most importantly Laura has expressed her enjoyment of her self-development through Pilates. She reports to feeling stronger and that she is happy to be doing something to counteract FSHD. This has given her a sense of control over her condition and a belief in her body!

13

Bibliography

Books 

Isacowitz, Rael. Pilates second edition, 2014



Isacowitz, Rael and Clippnger Karen. Pilates Anatomy, 2011



Pilates, H Joseph. Return to life, 1945



Kapt and Elson. The Anatomy colouring in book 3rd edition 2002



Isacowitz, Rael. Study Guide Comprehensive Course, Body Arts & Science International 200-2014

Website 

“About FSHD” , fshsociety.org

14