This thesis dissertation by London College of Osteopathy graduate, Marliese Steyn, examines the role of Osteopathic Manual Therapy in combination with Pilates on the rehabilitation of disc herniation and degeneration.

1. The combined use of Osteopathic manual therapy and Pilates
in the rehabilitation process for disc herniation and disc
degeneration, including the aging spine
Thesis submitted for the Diploma in Osteopathic Manual Practice
London College of Osteopathy and Health Sciences
by
Marliese Steyn
Johannesburg, South Africa
October 2019

2. i
TABLEOF CONTENTS
1 INTRODUCTION..............................................................................................................................................................1
2 ANATOMY OF THE SPINE .............................................................................................................................................2
2.1 VERTEBRAL DISC.............................................................................................................................................................2
3 THE AGING SPINE...........................................................................................................................................................6
4 HERNIATED DISC AND DISC DEGENERATION, INCLUDING CAUSES AND SYMPTOMS....................................7
5 RECENT RESEARCH FINDINGS REGARDING THE TREATMENT OF DISC HERNIATION......................................9
5.1 MICHELLE HAWLEY:DISC HERNIATION OF L5 – S1 ..........................................................................................................9
5.2 AIMEE FISHMAN: MANUAL OSTEOPATHYTREATMENT......................................................................................................9
5.3 HIROSHI YAMAMOTO: LOW BACK PAIN IN ELDERLYPEOPLE............................................................................................10
6 HOW CAN A MANUAL OSTEOPATH BE OF HELP? ................................................................................................12
7 HOW CAN A PILATES TRAINER HELP A PATIENT WITH A HERNIATED DISC? .................................................13
8 EXERCISES FOR A HERNIATED DISC ........................................................................................................................14
8.1 REHABILITATION EXERCISES..........................................................................................................................................14
8.2 HERNIATED DISC:EXERCISES TO STAYCLEAR FROM .......................................................................................................15
8.3 ADVANCED EXERCISES:WHEN THE CLIENT FEELS PHYSICALLYREADY................................................................................15
9 THE AGING SPINE........................................................................................................................................................17
9.1 PILATES AND THEELDERLY:AGENTLEAND EFFECTIVE WAYOF KEEPING THESPINEHEALTHYAND STRONG.........................17
9.2 THEPOSSIBLEPERILS OF PILATES FOR AHERNIATED DISC................................................................................................18
9.3 MODIFIED PILATES EXERCISES FOR THEOLDER ADULT....................................................................................................19
9.4 HOW TO KEEP THE AGING SPINEHEALTHY.....................................................................................................................20
10 CASE STUDIES ..............................................................................................................................................................22
10.1 CASESTUDY 1 ........................................................................................................................................................22
10.2 CASESTUDY 2 ........................................................................................................................................................23
10.3 SPECIFIC PILATES EXERCISES USED IN THETWO CASESTUDIES....................................................................................24
10.4 LEARNING POINTFROMTHECASESTUDIES...............................................................................................................26
11 OSTEOPATHIC TREATMENTS USED IN THE CASE STUDIES.................................................................................27
12 CONCLUSION ...............................................................................................................................................................28
13 BIBLIOGRAPHY ............................................................................................................................................................30

3. ii
TABLE OF FIGURES
FIGURE 1 – ANATOMY OF THE SPINE (STUDENTDOCTOR.NET,2005)................................................................................................2
FIGURE 2 –DIFFERENTSPINAL DERMATOMES (MAYFIELD BRAIN & SPINE,2018) ............................................................................3
FIGURE 3 –DIFFERENTDISC AND LOWER SPINEPROBLEMS (OPTIMAL HEALTH MATTERS, 2019) ......................................................5
FIGURE 4 - JOSEPH PILATES ATAGE 57 AND 82 RESPECTIVELY.(ISAAC,2012)...............................................................................17
FIGURE 5 - TRADITIONAL PILATES REFORMER (MARCA STUDIO,2019) .........................................................................................18

4. 1
1 INTRODUCTION
This thesis aims to illustrate that a combination of osteopathic manual therapy (OMT)
and selective Pilates exercises work well in the rehabilitation process of lumbosacral
(specifically L5/S1) disc herniation and disc degenerative disease, including the aging
spine.
By way of background information, the study begins, in section 2, with a brief
description of the anatomy of the spine. This is followed in section 3 by an overview of
the aging spine. In section 4 the focus is on the herniated disc and disc degeneration
including the causes and symptoms. Section 5 presents recent research findings on the
treatments of these and related conditions. Sections 6 and 7 it will illustrate the role of
an Osteopath and Pilates trainer in the above-mentioned conditions. Section 8 will
elaborate on the different rehabilitation exercises indicated for aherniated disc.Section
9 focuses on the aging spine. In section 10 the author reflects on the case studies used
in this thesis, followed by section 11 describing the Osteopathic treatments that were
used in the case studies. Section 12 is the conclusion of this thesis.

5. 2
2 ANATOMY OF THE SPINE
Figure 1 – Anatomy of the spine (Studentdoctor.net, 2005)
2.1 Vertebral disc
The spine consists of the vertebrae (bones), with cartilage discs between them. The
discs consist of a circle of connective tissue called the annulus fibroses. This contains a
central gel-like core, the nucleus pulposus. The combination of bone and discs renders
the spine flexible and at the same time acts as a protective buffer. In the centre of this
column of vertebrae and discs is the spinal canal, which contains the spinal cord
stretching from the brainstem down to the L2 vertebra. At this point it continues as a
bundle of nerve fibres calledthe cauda equina that stretches down towards the sacrum.
Between each vertebra, there is nerve route opening known as the intervertebral
foramina where the nerves exit to the part of the body it supplies. For example, if there
is a nerve entrapment at L5/S1, pain and discomfort may radiate down to the calf and
foot (Espinoza and Morris, 2017).

6. 3
Figure 2 – Different spinal dermatomes (Mayfield Brain & Spine, 2018)
Figure 2 above illustrates how the spinal nerves exit the spinal canal through the
intervertebral foramen below each pedicle and innervate a specific area (striped
pattern) across the body calleddermatomes. Doctors usethis pattern to localizeaspinal
problem based on the area of pain or muscle weakness (Myotomes) (Mayfield Brain &
Spine, 2018).

7. 4
Myotomes: Muscle weakness test
L2 – Hip Flexion (Psoas Major and Minor)
L3 – Knee Extension (Quadriceps Muscles)
L4 – Dorsi Flexion (Tibialis Anterior)
L5 – Great big toe extension (Extensor hallicus longus)
S1 – Plantar Flexion (Plantar Fascia)
S2 – Knee Flexion (Hamstring Muscles)
Vertebral spine
The vertebral spine is made up of 33 vertebrae and divided into the following regions:
 Cervical vertebrae: C1 – C7
 Thoracic vertebrae: T1 – T12
 Lumbar vertebrae: L1 – L5
 Sacrum: S1 – S5
 Coccyx: C1 – C4

8. 5
Figure 3 – Different disc and lower spine problems (Optimal Health Matters, 2019)
Of the 33 vertebrae, only the top 24 are moveable and the bottom 9 are fused (Reese,
2019).

9. 6
3 THE AGING SPINE
If your spine is stiff at 30, you are old. If it is flexible at 60, you are young.
-Joseph Pilates
As people get older, they typically experience an increase in aches, pains and joint
stiffness. With age progression, the body undergoes a series of physiological changes to
muscles, ligaments, bones and joints. When it comes to the spine, people may expect a
decline in function, mobility and flexibility as the bones and intervertebral disks begin
to deteriorate over time. Some of spinal conditions are common in the elderly.
 Disc degeneration
Such degeneration in the elderly is mainly because of wear and tear over the years.
It is a condition in which the fibrous discs between the vertebrae become
deteriorated, brittle and lose their shock absorbing function. The discs also lose their
sponge-like quality due to a decline in moisture as a person age.
The process of disc degeneration may be accelerated by trauma, such as a sports
injury, car accident or fall or from hard labour. It can occur in any part of the cervical,
thoracic or lumbar spine.
 Spinal stenosis
The vertebral foramen that protects the spinal cord can narrow over time, putting
pressure on the cord which results in pain, discomfort and in some cases weakness.
This age-related condition typically affects people over the age of 60 years.
 Compression fractures
This is another age-related condition, especially in people who have osteoporosis.
Such a fracture in the bone will cause the vertebrae to partially collapse.
It has a predilection for the thoracic and lumbar spine. Patients usually present with
a sudden onset of sharp pain and discomfort in the back.

10. 7
4 HERNIATED DISC AND DISC DEGENERATION, INCLUDING CAUSES AND
SYMPTOMS
A herniated disc is when the jelly-like nucleus pulposus bulges through the anulus
fibroses, which is a fibrocartilage tissue. This bulge may push on the spinal cord or on
the nerve roots. Some herniated discs cause no symptoms. When the nerve root is
irritated by the compression however, this results in pain, numbness, tingling or
weakness along the root in the leg. Herniated discs are most common in the lumbar
spine between the ages of 30 and 50 years of age. The main affected areas are L4/L5 or
L5/S1 (Schroeder, Guyre and Vaccaro, 2016).
A herniated disc occurs due to weakness in a certain part of one’s back. Picking up a
heavy object with incorrect posture leads to excessive pressure on the spine leading to
herniation at the weakest link of the spine. Herniated discs most often affect the lower
back and neck and are relatively rare in the thoracic spine. They are also occasionally
seen following trauma such as an injury from a fall or a road traffic accident. (Awad and
Moskovich, 2006) (Ma et al., 2013) (Fishman, 2019) (Institute Spine Health, 2019)
There are several other causes:
 Natural degeneration of the intervertebral disc
 Heavy work
 Poor posture
 Obesity
 Weak back muscles
 Weak core muscles
 Tight back, psoas, gluteus and hamstring muscles.
A combination of above conditions contributes to herniation of the disc.
The typical symptoms of a herniated discs are the following:
 A grating pain mostly on one side of the body (excluding the face)
 Muscle weakness and spasms
 The distress increases with bending and lifting

11. 8
 Numbness, tingling and discomfort along the nerve root down the leg to the foot and
big toe
 Loss of bladder function.

12. 9
5 RECENT RESEARCH FINDINGS REGARDING THE TREATMENT OF DISC
HERNIATION
A selection of three sets of research findings relevant to the present thesis will now be
presented in summary form.
5.1 Michelle Hawley: Disc herniation of L5 – S1
Research has demonstrated that non-surgical methods for treating lumbar disc
herniation are just as effective as surgical methods in the long term. Although physical
therapy is effective, a method that focuses on correcting alignment, posture, and
improving the strength and endurance of synergistic muscles is preferred for successful
treatment of a herniation.
Because Pilates addresses this specifically, it was considered an appropriate method to
treat my client with a possible lumbar L5/S1 spine herniation.
Lumbar disc herniation is the result of excessive spine loading, causing fragmentation
of the nucleus pulposus which then extrudes from the disc,compressing the nerve root.
Pilates is a form of exercise that centres around re-educating proper alignment while
strengthening synergisticmuscles,it is the safest and most effective method for treating
a client with a lumbar disc herniation. Pilates has the potential to lessen pain and
improve his alignment (Studentdoctor.net, 2005; Hawley, 2012).
5.2 Aimee Fishman: Manual osteopathy treatment
Due to the fact that the aetiology of disc herniation can vary greatly from patient to
patient, treatment in her study was based on individual osteopathic findings. Structural
techniques, thrusts, visceral and cranio-sacral techniques were employed. Thrust
techniques were used in the thoracic spine and at the thoraco-lumbar junction.
Additionally, correction of the ilio-sacral joints was often necessary (Fishman, 2019).

13. 10
To provide relief of the strain, the patient was placed in a prone position with the
therapist on the side on which the patient reported pain. The technique involves the
therapist fixing the thumb of one hand on the L4 spinous process. The other hand is
then placed on the anterior ilium. The therapist uses this manoeuvre to turn the pelvis
to the contralateral (opposite) side and forms an opening at the facet between L5/S1
on the ipsilateral (same) side.
This results in relief of the load on the intervertebral disc and subsequent pain relief.
Fascial techniques were also applied, specifically, on trigger ligaments of the dorsal
thigh, and gluteal region. With respect to cranio-sacral techniques, quite often
hypermobility of the sacrum was diagnosed and treatments were performed on the C4
vertebrae. Thepatients in the control group were treated with exercises for stabilization
and strengthening of the trunk and the affected spinal segments (Fishman, 2019).
5.3 Hiroshi Yamamoto: Low back pain in elderly people
5.3.1 Abstract:
Low back pain in elderly individuals arises from age-related changes in lumbar spine
structures, and these changes are closely associated with the lifestyle of the patient.
Low back pain is classifiedinto: organic pain associatedwith organic disorders in lumbar
spine structures (spondylolisthesis, spinal stenosis, osteoporotic vertebral fracture,
etc.) and functional pain associatedwith no lesions other than physiologicalage-related
changes. (Kezuka et al., 2012), (Yamamoto, 2003).
5.3.2 Treatment 1: Basics of treatment of lumbar spine disorder in elderly patients
The first choice of treatment for elderly patients with lumbar spine disorder is
conservative therapy. Conservative therapy refers to medication, i.e. oral, transdermal,
suppository or intravenous composites Non-steroidal anti-inflammatory drugs (NSAIDs)
is the mainstay of oral medication for lower back pain. Prolonged bed rest and
prolonged corset use weakens the trunk muscles of patients with degenerative disease
in the lumbar region and is thus not advised.

14. 11
5.3.3 Therapeutic exercise for functional low back pain
The author and his colleagues conducted trunk muscle training in elderly patients with
functional lower back pain. They found that lower back pain improved as the trunk
muscles strengthen. This was observed in particular the lower back muscles.
Therapeutic exercise should be prescribed based on specialist evaluation of the pain
reduction achieved by medication. Paying attention to posture and continuing physical
exercise in daily living can improve the health of the lumbar region (Sato et al., 2014).

15. 12
6 HOW CAN A MANUAL OSTEOPATH BE OF HELP?
“Osteopathy is based on the perfection of Nature’s work. When all parts of
the human body are in line, we have health. When they are not the effect
is disease. When the parts are readjusted disease gives place to health.
The work of the osteopath is to adjust the body from the abnormal to the
normal, then the abnormal conditions give place to the normal and health
is the result of the normal condition.” - Dr. Andrew Taylor Still
Manual osteopathic treatment is a holistic approach. The whole body is taken into
account in the treatment of a specific injury. This helps to hasten the recovery time,
enabling the patient to get back to their daily life pain free. The Osteopath works on
tight muscles around the area to relieve tension and spasms. This leads to increase
blood flow and lymphatic flow and enables toxin clearance and healing. There is a
reduction on the pressure on the root and nerve that is being pinched.
The goal of osteopathic treatment is directed at optimizing the function of the
musculoskeletal system. The musculoskeletal system includes bones, muscles, joints,
ligaments and connective tissues. Osteopathy addresses the body as a whole and not
just the problem area.
Osteopaths are thus in a unique position to help keep their patients healthier, allowing
them to continue with their daily lifestyleroutine as these changes manifest. When pain
sets in it is important to know that painkillers are not the only solution for the aches
and pains. Osteopathy can also help to reduce pain and stiffness. There is thus a
decreased need for medication to treat pain.
Osteopaths usea wide range of gentle techniques with the focus on keeping joints loose
and mobile. Osteopaths use stretching, massage and gentle manipulation of joints to
treat the entire body and address the underlying cause of pain or injury.

16. 13
7 HOW CAN A PILATES TRAINER HELP A PATIENT WITH A HERNIATED DISC?
Pilates aids in strengthening the core muscles (transverse abdominal, internal- and
external obliques, multifidus, quadratus lumborum and back extensor muscles) and
improve over-all posture.
Pilates stretching exercises reduces stress on the lumbar spine and improves flexibility
of the iliopsoas, gluteal, quadriceps and hamstring muscles. Upper body stretching
improves mobility in the thoracic spine, ribs as well as the opening up of the chest area
by improving flexibility in the pectoral muscles. By having your chest area open you’ll
feel like you are in control of your life and that you are ready and positive to take on the
world. Breathing patterns improve and increases the flow of oxygen to the body.

17. 14
8 EXERCISES FOR A HERNIATED DISC
8.1 Rehabilitation exercises
8.1.1 Herniated disc exercise 1: The Cobra Stretch
 Lie in Prone position
 Bend your elbows, forearms stay flat on floor. Lift upper body slightly upwards
 Bending your back slightly back and upwards (arching your back)
 Make sure also to extend your neck for maximum result
 Hold this position for 15 - 30 seconds
 Repeat three times.
8.1.2 Herniated disc exercise 2: Increase lower back stability
 Lie down on your back
 Bend your knees, feet on the floor
 Cross your arms over your chest
 Now lift your pelvis
 Hold this position for 10 seconds.
8.1.3 Herniated disc exercise 3: Lower back muscle training
The third exercise you should perform is designed to increase the strength of your big
back muscles. Perform the exercise like this:
 Lie down on the ground with your face facing the floor
 Place your arms in front of you with your elbows bent
 Now lift both your arms and your upper body and HOLD position for 10 seconds
 Keep your feet on the ground.
(Kielema, 2019)

18. 15
8.2 Herniated disc: exercises to stay clear from
Usually, these exercises include bending forward, lifting heavy weights and lifting heavy
objects with an incorrect posture.
 Crunches
 Chest lifts
 Role ups
 Deadlifts
 Good mornings
 Squats
 Shoulder press
 Straight leg raises
 Leg press
 Twisting exercises
 Controlled sit-ups
 Push ups on the Wunda Chair
 Pull ups on the Wunda Chair
 Pilates Teaser.
8.3 Advanced exercises: when the client feels physically ready
 Mat work:
Teaser 1 to 4
Slow and controlled sit ups.
 Wunda Chair:
Pull Ups
Push Ups – with feet on stepper
Mermaid for obliques

19. 16
 Cadillac:
Leg series: 15 reps and up
Side leg series: 15 reps and up
 Reformer:
Advanced knee series.

20. 17
9 THE AGING SPINE
9.1 Pilates and the elderly: a gentle and effective way of keeping the spine healthy
and strong
Pilates helps fight the effects of old ageon the spine. It improves longevity and a healthy
spine by strengthening core muscles, joints and the rest of the neuromuscular system
as wellas improving the breathing motion. Pilates alsoprovides stress relief.It is difficult
to think about anything else while you are doing Pilates. Intense concentration is
applied, focusing on breathing, drawing in core muscles and keeping the posture correct
and upright. Breathing in Pilates directly address the mechanisms of stress in the body.
Better breathing promotes better blood flow throughout the whole body which in turn
delivers nutrients to joints, bones and muscles.
Figure 4 - Joseph Pilates at age 57 and 82 respectively (Isaac, 2012)
Pilates improves strength in the whole body by focussing on anterior and posterior
muscle groups simultaneously. The entire spine is thus strengthened. For the older

21. 18
population it is hard to get fit and even harder to stay fit. Therefore, exercise should be
an essential part of their daily lives (Ogle, 2019a).
Many turned towards Pilates because its gentle on the body and effective.
Cardiovascular exercise like running is perceived as hard and painful on the joints of the
body. Pilates is considered by many experts as one of the best ways to keep fit inhealthy
in older age groups. It focuses on controlled breathing and quality of movement, not
quantity of repetitions. In the geriatric population Pilates is probably the safest way to
restart exercise regimen in a client that has not been active some time (Endelman,
2018).
Pilates for older adults, particularly on a Reformer (resistance-based equipment with
springs and ropes connected to a sliding padded carriage) is beneficial and has light
resistance as opposed to some gym equipment, where even the lightest weight on the
rack might be too much for them (Ogle, 2019b).
Figure 5 - Traditional Pilates reformer (Marca Studio, 2019)
Another important benefit of Pilates in the elderly is that is teaches control and stability
when they do the exercises. Increased control and stability are crucial in this population
as itassists themwith balancein everyday life,with the focus stabilityof feet and ankles.
9.2 The possible perils of Pilates for a herniated disc
9.2.1 Case 1: Sophie
The Mail Online reports that Sophie, a 38-year-old mother of three, was hoping to get
back into shape after giving birth by taking up Pilates. She heard it was good for

22. 19
strengthening the muscles that support the spine, while getting fit. As a young girl she
was diagnosed with scoliosis, so she was particularly concerned with taking care of her
spine health.
Three months into her new Pilates class, she woke up one morning with numbness in
her leg. Her instructor wasn’t concerned and told her to take it easy, but when her
symptoms worsened, she went to the doctor and received an MRI, which confirmed a
herniated disc.She saidat that point everyone thought she would require spinalsurgery
to remove the disc material pressing on her nerve root. Five years later she has been
managing her pain and inflammation with epidural injections, and physiotherapy (North
American Spine, 2012).
9.2.2 Case 1: Comments
Although Sophie is 38 years of age, the same goes for all ages especially the elderly. If
you’ve got a problematic back it is better to proceed with caution. Pilates exercise are
performed on specialized apparatus, a matt or ball. It is an excellent way to develop
strength in the back. Many of the Pilates exercises place a lot of strain and force on the
spine, which can further damage a pre-existing injury or causea new injury in an already
problematic back. Rehab exercises should be carried out correctly. If not, exercises can
weaken the back further and existing conditions can worsen. The Pilates instructor
needs to have full confidence in training older adults with weak back muscles. Specific
rehab exercises are gentle and adapted towards the needs of the older client. Group
classes need to be avoided. Private Pilates sessions is advised, because the instructor
can better identify if the exercises are performed in the correct way (Endelman, 2018).
9.3 Modified Pilates exercises for the older adult
Pilates is the most gentle and popular type of exercise in the older population. In the
author’s experience one needs to focus on exercises to improve posture; strengthening
and stretching exercises for muscles and joints; and very importantly focus on balance
mechanisms.

23. 20
 Leg changes: Supine, Knees bent, feet on the floor (core exercise)
o Change legs in mid-air
Modified: Change legs when they are fixed to the ground.
 Reformer Leg Series:
o 10 – 15 repetitions on medium to heavy springs
o Modified: Do 5 – 10 repetitions on light to medium springs.
 Reformer Arm Series: Ly Supine with legs in table top
o Modified: Client’s core has to be strong to do this exercise
o Keep to 10 repetitions.
 Ball squats: Ball against wall; body against ball, doing squats
o Modified: Sit on a bench; stand up and sit down without using your hands
o 10 – 15 repetitions.
 Pilates exercises on a Chair works very well for the older adult. It’s fun, gentle and
different.
9.4 How to keep the aging spine healthy
Clients can be given the following advice (Institute Spine Health, 2019):
 Be mindful of your posture at all times, especially on how you sit in front of your
desk. Make the needed adjustments of the height of your chair and computer screen
and make sure you’ve got good lumbar support in your chair.
 Do not lift heavy objects. Get someone else who is strong to do it for you. When you
have to lift any lighter objects, make sure your knees are bent, back is straight and
object is kept close to your body when you have to lift it up.
 Focus on strengthening your core muscles which will support your spine especially
your lower back. Pilates training teaches one how to do this.
 Stretching exercises areadvise keep your body mobile and supple. This alsoincreases
quality of life.

24. 21
 Nutrition is important in keeping your body functioning well. By adapting an anti-
inflammatory diet and ingesting enough minerals (like calcium, magnesium,
potassium, Vit D and very importantly vitamin C) enhances bone and muscle health.
 Lastly,a correct sleeping posture should be adapted. Usea good pillow for your head
to support your neck and a pillow between your legs to support our lumbar spine
and pelvis (SIJ) when you lie on your side. Your mattress needs to be checked
regularly to see if it is still adequate to support your whole body and spine.

25. 22
10 CASE STUDIES
10.1 Case study 1
Mr GN (68 years old) suffers from degenerative disc disease and L5/S1 disc herniation.
He has been struggling with this condition for the past 10 – 12 Years. Prior to his
diagnosis he participated in 10 Comrades Marathons (96km running race). His best
result was 11th place. Unfortunately, the running took its toll on his lower back. Pain in
his lumbar spine and referred pain down the left leg started to make life difficult for
him. Mr GN went to see a physician who told him to start doing Pilates to strengthen
his core.
Mr GN has been a client at our Pilates Studio since 2010. I started training him in 2014
when his previous trainer relocated. I also started treating him with deep tissue
massagetherapy since2015. GN and I have been focusing on strengthening his core and
doing stretching exercises for his hip flexors, quads and gluteal muscles. Together with
the massage therapy, I have started applying some osteopathic therapy treatments on
him like myofascial release, soft tissue therapy and strain-counter-strain release with
very positive results.
10.1.1 IMAGING: X-Ray and MRI Scan
The diagnostic radiologist’s reports:
 X-Ray Scan of the lumbar spine
o Mr GN has mild narrowing of the L4/L5 and L5/S1 disc interspace. No instability
noted on the dynamic flexion and extension views. Mild facet joint arthrosis is
noted bilaterally, predominantly at the L5/S1 level. No focal destructive lesion
noted on the available radiograph.
 MRI Scan of the lumbar spine
o Clinical Indication: Lower back pain with radiation to involve the lower limbs.
o Findings: The alignment appears within normal limits in the neutral position.
Intervertebral disc space narrowing noted at the L4/L5 and L5/S1 levels with

26. 23
associated alteration in intervertebral disc signal and at the abovementioned
levels.
o L3/L4: A mild broad-based discbulge noted. No overt foraminal narrowing noted.
Mild facet joint arthrosis noted bilaterally however no significant compression of
thecal sac or bony canal stenosis.
o L4/L5: A mild posterior disc bulge is noted resulting in a mild anterior extradural
impression on thecal sac. There is also a mild foraminal narrowing more overt on
the right-hand side. Mild facet joint arthrosis noted bilaterally however no
significant compression of thecal sac or bony canal stenosis.
o L5/S1: A posterior disc herniation is noted resulting in mild to moderate anterior
extradural impression on thecal sac. There is a mild foraminal narrowing
bilaterally however no overt cut off of exiting nerve roots. There is mild abutment
of the left descending S1 nerve root due to the posterior disc herniation,
described above.
10.2 Case study 2
Mr HZ (65 years old) also has a herniated disc in L5/S1. Being a film and series
producer/director, he is seated for prolonged periods throughout the day. Additionally,
Mr HZ struggles with polymyalgia rheumatica and giant cellarteritis. The treatment plan
advised is: an initial 10 weeks of very basic Pilates /core/isometric exercises to
strengthen his core and lower back, along with stretching exercises to improve his
mobility and flexibility.
10.2.1 X-RAY AND MRI SCAN: 9 MARCH 2019
Report according to the diagnostic radiologist:
 X-RAY LUMBAR SPINE WITH OBLIQUE AND STRESS VIEWS
o Slight scoliotic curve towards the right. Spondylosis and degenerative change,
with osteophyte formation at levels L3/L4, L4/L5 and L5/S1. Disc space narrowing
at levels L4/L5 and L5/S1. The facet joint is intact. No instability with stress views.
Spondylosis of the Lumbar spine in relation to levels L4/L5 and L5/S1, with disc
space narrowing and osteophyte formation.

27. 24
 MRI LUMBAR SPINE, UNCONTRASTED
o No spinal cord pathology and no bone marrow abnormality.
 L4/L5: There is disc desiccation with preservation of disc height. There is an
annulus disc bulge present. There is no left or right sided foraminal narrowing.
There is early ligamentum flavum hypertrophy with paravertebral arthropathy.
 L5/S1: There is decreased disc signal and disc height. There is focal posterio-
central disc protrusion, this results in early spinal canal and lateral recess stenosis.
There is also associated end plate osteophytes projecting with the disc bulge
posterio-centrally. There is a possibility of a left lateral disc bulge at this level.
 Disc pathology at L4/L5 and L5/S1 with stenosis seen at L4/L5 but especially L5/S1,
predominantly affecting the exiting L5 nerve roots bilaterally. Possibility of a left
lateral disc bulge at L5/S1.
10.3 Specific Pilates exercises used in the two case studies
This Pilates programme was aimed to improve spinal mobility and stabilise the lumbar
segments. The focus is on stretching and mobility exercises for the back, abdominal
muscles, hip flexor muscles, quadriceps, hamstrings and calf muscles. Additionally, it
also focuses on doing isometric strengthening exercises for the upper and lower back
muscles as well as stability exercises on the Pilates ball and Pilates apparatus.
10.3.1 Patient: Mr HZ
 In the supine position, knees bent, feet on floor. Slide the heel of on leg slowly out
and back, focusing on keeping core tight. Alternate legs. (Called – Heel slides)
 In the supine position, knees bent, feet on floor. Lift one leg slowly up and down and
alternate. The focus must be on core and keeping pelvis stable when changing legs.
 Entry level: Back extension exercise on the Pilates ball.
o Stand on the knees behind the ball. Stomach lies over the ball with pelvis and legs
tucked tightly into the ball. Inhale, keeping the core tight, slightly extend the back
up.
o Exhale, slowly lower the stomach down on the ball.
 Electric Chair: Standing leg series work on the chair

28. 25
o This will improve correct posture and also strengthen gluteal, quads and
hamstring muscles and back extensor muscles.
 Pelvic raises.
 Pelvic raises and hold.
 Stretching exercises on the horse barrel, reformer.
 Stretching of calf muscles.
10.3.2 Patient: Mr GN
 Cadillac
o Leg spring series: not more than 10 reps each
o Slight stretches with the push through bar (only helps for Mr GM)
o Arm spring series: 30 – 40 degree of leaning forward.
 Electric Chair
o Seated posture series: 10 reps each; standing posture series: 10 reps each.
 Reformer
o Leg series: 10 reps each
o Arm series: 10 reps each
o Abs work series: 5 – 10 reps each
o Knee series: 5 – 10 reps each.
 Mat work
o Abs core series: 10 each with rest in between exercises
o Side lying leg/hip series: 10 – 15 reps each
o Opposite arm and leg raise: Super Man (only 10 reps/5 on a side).

29. 26
10.4 Learning point: from the case studies:
 Both Mr HZ and Mr GN have L5/S1 Herniated disc injuries.
 Mr HZ’s herniation is at the middle-posterior side of the vertebrae.
 Mr GN’s herniation is also at the posterior aspect of vertebrae but more to the left
side.
 They are on different Pilates programmes.
 Mr HZ can’t do flexion exercises like chest lifts, role ups, most of the Pilates mat work
ab-series and leg press series on reformer.
 Mr GN can do all of the above-mentioned exercises except the Cobra back extension
stretch and exercise, all exercises with the arching of the spine.
 The Cobra stretch/exercise works well for Mr HZ.
 What works for one person does not always work for another person with a similar
problem.

30. 27
11 OSTEOPATHIC TREATMENTS USED IN THE CASE STUDIES
11.1.1 Mr GN and Mr HZ
 Soft Tissue Therapy
o Effleurage, Petrissage
o Parallel traction
o Prone pressure, Prone traction
o Bilateral thumb pressure
 Myofascial Release
o Soft tissue sacrum in prone position 1 and 2
o Myofascial release prone
o Sacral release
o Myofascial trigger point release
 Strain-Counter-Strain Therapy
o Posterior lumbar counter-strain technique on and around PSIS.
11.1.2 Mr HZ
 With Mr HZ’s, I focused on treating his lower back to keep the lumbar spine muscles
and fascia relaxed.
 He also has giant cell arthritis. This is associated with debilitating post orbital
pressure headaches associated with visual disturbances on a daily basis.
 Treatment therapy focused on the upper back and neck. This relieves headaches and
according to him improves his eye sight for the rest of the day.
 I am humbled by the improvement reported by the client.
 His ophthalmologist confirmed that massage therapy is good for treatment for the
blinding retro-orbital headaches.
11.1.3 Mr GN
 My primary focus is on his lumbar sacrum area, especially the left side.
 Additional treatment of the thoracic spine, shoulders and cervical also relaxes the
lower back.

31. 28
12 Conclusion
Pilates as a treatment and lifestyle assists with the management of disc herniations. It
provides strength, flexibility,balanceand improved overall movement. Pilates improves
the range of motion and general quality of life.
Osteopathic approaches assist with loosening up tight areas and Pilates enables the
maintenance of the balance between flexibility and strength.
Ideally treatment should be conservative, with surgery as a last option. Manual
osteopathic therapy, chiropractic treatment and physiotherapy treatment should be
implemented as first-line therapy. SpecificPilates and core exercises arevery important
for rehabilitation and strengthening of the core muscles of the patient.
The core is strengthened by Pilates exercise. The deep abdominal muscles and para-
spinal muscles are considered core muscles. Pilates exercises train several muscle
groups at once with continuous, slow and controlled movements. Posture improves
with adaptation of the proper technique, with benefits for daily living and work.
Pilates implements low impact and partial weight bearing exercise performed in
reclining or sitting positions. It is also considered a “safe” exercise to use in physio-
therapy facilities to rehabilitate injuries.
The feedback from my clients with lumbosacral disc disease is positive and rewarding.
They report how they apply what they do in the Pilates studio to their everyday
activities. Their intelligent bodies have relearned how to move efficiently. Osteopathy
sees the body as an essentially self-regulating mechanism but sometimes trauma or
wear and tear can create barriers.
Pain and dysfunction can be the result of this trauma. Osteopathy and Pilates work well
together due to shared values at the heart of each method. Both systems focus on
whole body health and supporting the various systems in the body, as opposed to
merely treating the supposed source of injury or pain.
I have seen this in practice where osteopathy principles allow me to open- and loosen
up joints and the rib cage of the client. This in turn gives a better understanding of how

32. 29
their bodies work and what type of Pilates exercises will work for them. I personally
believe that by combining Osteopathy treatment and Pilates exercises you can keep
your body and especially your spine mobile, flexible, healthy and happy.
It would be ideal if one can see an osteopath once or twice a month and additionally
attend Pilates classes twice a week as a maintenance guide to keep your body in shape.
Both of these fields of practice are rewarding. Osteopathy and Pilates complement and
balance each other.
Osteopaths useseveral treatment tools to reduce pain and inflammation. These include
manipulation, soft tissuemassage,myofascialrelease and strain-counter-strain to name
but a few. Physicians may also recommend a course of non-steroidal anti-inflammatory
drugs such as ibuprofen. As the pain and inflammation settle, osteopaths will turn their
attention to muscle length, muscle strength and endurance. They can then commence
on a lower abdominal and core stability program to facilitate important muscles that
dynamically control and stabilise the spine especially where the disc bulge and
herniation are. The Pilates trainer in turn assists with rehabilitation exercises.
This synergistic relationship of Pilates and Osteopathy aids in a holistic approach to the
path of recovery.

33. 30
13 Bibliography
Awad, J. N. and Moskovich, R. (2006) ‘Lumbar disc herniations: Surgical versus
nonsurgical treatment’, in Clinical Orthopaedics and Related Research. Lippincott
Williams and Wilkins, pp. 183–197. doi: 10.1097/01.blo.0000198724.54891.3a.
Endelman, K. (2018) Pilates and Older Adults | Balanced Body. Available at:
https://www.pilates.com/pilates/library/articles/pilates-for-older-adults (Accessed: 17
September 2019).
Fishman, A. (2019) The Effectiveness of Manual Osteopathy Treatment for Individuals
with Lumbar Disc Herniation. Available at:
http://numss.com/Thesis/Fishman,Aimee.pdf (Accessed: 17 September 2019).
Härtl, R. (2016) No Title. Available at: https://www.spine-
health.com/conditions/herniated-disc/lumbar-herniated-disc-causes-and-risk-factors
(Accessed: 25 September 2019).
Hawley, M. (2012) Pilates for Lumbar Spine Herniation. Available at:
https://www.basipilates.com/media/paper/pilates-for-herniation-.pdf (Accessed: 17
September 2019).
Institute Spine Health (2019) How to Keep Your Spine Healthy As You Age. Available at:
http://www.thespinehealthinstitute.com/NEWS-ROOM/HEALTH-BLOG/HOW-TO-
KEEP-YOUR-SPINE-HEALTHY-AS-YOU-AGE (Accessed: 17 September 2019).
Isaac, J. (2012) Joseph Pilates: the man behind the movement - Azulfit. Available at:
https://www.azulfit.com/about-joseph-pilates/ (Accessed: 17 September 2019).
Kielema, M. (2019) Herniated disc treatment L5-S1 with 3 exercises to avoid surgery.
Available at: https://www.alwaysfysio.nl/en/herniated-disc-treatment/ (Accessed: 17
September 2019).
Ma, D. et al. (2013) ‘Trend of the incidence of lumbar disc herniation: Decreasing with
aging in the elderly’, Clinical Interventions in Aging, 8, pp. 1047–1050. doi:

34. 31
10.2147/CIA.S49698.
Marca Studio (2019) Mercadolibre. Available at:
https://articulo.mercadolibre.com.ar/MLA-783185879-cama-pilates-reformer-marca-
studio-modena-directo-de-fabrica-_JM?quantity=1&variation=35809696495
(Accessed: 17 September 2019).
Mayfield Brain & Spine (2018) Spine Anatomy. Available at:
https://mayfieldclinic.com/pe-anatspine.htm (Accessed: 18 September 2019).
North American Spine (2012) Pilates Poses Peril to Herniated Disc, Nobilis Health.
Available at: https://northamericanspine.com/blog/pilates-poses-peril-to-herniated-
disc/ (Accessed: 17 September 2019).
Ogle, M. (2019a) Is Pilates Good Exercise for Seniors? Available at:
https://www.verywellfit.com/is-pilates-good-exercise-for-seniors-2704632 (Accessed:
17 September 2019).
Ogle, M. (2019b) Overview of a Classical Pilates Reformer. Available at:
https://www.verywellfit.com/the-anatomy-of-a-pilates-reformer-2704445 (Accessed:
17 September 2019).
Optimal Health Matters (2019) Optimal Health Matters - Chiropractor in Highlands
Ranch, CO US - Optimal Health Matters: Low Back Pain. Available at:
https://www.optimalhealthmatters.com/conditions-treated/low-back-pain.html
(Accessed: 18 September 2019).
Reese, C. (2019) Treatment of Chronic Health Problems. Available at:
https://www.drcraigreese.com/ (Accessed: 17 September 2019).
Schroeder, G. D., Guyre, C. A. and Vaccaro, A. R. (2016) ‘The epidemiology and
pathophysiology of lumbar disc herniations’, Seminars in Spine Surgery. Elsevier, 28(1),
pp. 2–7. doi: 10.1053/j.semss.2015.08.003.
Spine Anatomy | Mayfield Brain & Spine, Cincinnati (no date). Available at:
https://mayfieldclinic.com/pe-anatspine.htm (Accessed: 17 September 2019).
Studentdoctor.net (2005) OMTGURU.

35. 32
Yamamoto, H. (2003) ‘Low Back Pain Due to Degenerative Disease in Elderly Patients’,
Japan Medical Association Journal, 128(12), pp. 433–438.