Managing Lumbar Facet Joint Syndrome
through Pilates: A Case Study
Jennifer Anderson-Ehrlich
April 14, 2016
Body Arts and Science International
Comprehensive Teacher Training Program 2015
Synergy, Vail CO
Instructor: Amy de Sa
ABSTRACT:
The purpose of this paper is to examine what Lumbar Facet Joint Syndrome is;
the symptoms and effects it can cause and how the implementation of the BASI Pilates
Block System can help sufferers dealing with facet joint pain. Facet joints are the small joints behind and between each of the vertebrae in the
spine which allow us to bend forward and backward whilst controlling the twisting
motion of the spine. Nerves exit your spinal cord through these joints on their way to the
other parts of your body. Healthy facet joints have cartilage; but daily wear and tear,
arthritis or a single injury can damage these joints. Damage of the joint’s cartilage
prohibits smooth movement against each other, which causes grinding and can
potentially lead to chronic and sometimes debilitating low back pain. When this occurs,
there is literal joint inflammation, changes or osteoarthritis. This arthritic condition is
referred to as “facet joint syndrome”. 1
TABLE OF CONTENTS
Abstract
page 1
Anatomical Description
page 3
Case Study
page 6
Rationale for Selected Conditioning Program
page 8
BASI Block System Conditioning Program
page 9
Conclusion
page 13
Bibliography
page 14
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ANATOMICAL DESCRIPTION
The Vertebral Column
“The spine, or vertebral column, is made up of 33 bones called
vertebrae that are stacked one upon the next to form a long column
like structure” (Isacowitz & Clippinger, 2011, p. 9). The spine is
composed of seven cervical vertebrae, five lumbar vertebrae, five
sacral vertebra and four (occasionally three or five) coccygeal
vertebrae. (See Figure 1.1)“The lumbar, thoracic, and all but the top
two cervical vertebrae are joined to the vertebrae above and below by
a series of joints that greatly influence the ranges of motion that are
possible between consecutive vertebrae” (Isacowitz &
Figure 1.1
Clippinger, 2011, p. 12).
Facet Joints “Between the vertebrae of each spinal segment are two
facet joints. A facet joint is made of small, bony knobs that line up
along the back of the spine. Where these knobs meet, they form
a joint that connects the two vertebrae” (“A Patient’s Guide”, p. 3).
The facet joints in the spinal column are located posterior to the
vertebral body (on the backside).Each vertebra has four facet
joints, one pair that connects to the vertebra above (superior facets)
Figure 1.2
and one pair that connects to the vertebra below. The superior articular facet faces
upward and works like a hinge with the inferior articular facet (below). These joints help
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the spine to bend, twist, and extend in different directions. Although these joints enable
movement, they also restrict excessive movement such as hyperextension and hyper
flexion (see Figure 1.2).
Like other joints in the body, each facet joint
is surrounded by a capsule of connective tissue
that produces synovial fluid to nourish and lubricate
the joint (Figure 1.3) “This capsule, or sack, of
sticky lubricant contains a rich supply of tiny nerve
fibers that provide a warning when irritated”
Figure 1.3
(Ray, 2002, para. 8). The surfaces of these joints are coated with articular cartilage (a
smooth, rubbery material) that helps each joint to move and articulate smoothly;
allowing small gliding movements, enhancing rotation in the thoracic region of the spine
and limiting rotation of the spine in the lumbar region. “Normally, the facet joints fit
together snugly and glide smoothly, without pressure. However, if pressure builds
where the joint meets, the cartilage on the joint surfaces wears off, or erodes” (“A
Patient’s Guide”, p. 4). Causes of Facet Joint Syndrome
“Each segment in the spine has three main points of
movement, the intervertebral disc and the two facet joints”
(A Patient’s Guide” p.4). As we go through life, daily wear
and tear can cause discs in the spine to thin, in turn
causing shrinkage between two spinal Figure 1.4
vertebrae. This shrinkage
may cause facet joints to press together. Not only can disc degeneration put
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additional stress on the surfaces of the facet joints, but also back injuries such as
torn ligaments and fractures that
cause abnormal spinal alignment and movement. If this occurs, the results are an
extra stress being placed upon the facet joints and a narrowing of the space between
each vertebra. This pressure overload can lead to the development of bone spurs. As
these bone spurs form, the joints become enlarged - eventually destroying and wearing
away the articular cartilage. “When facet joints become worn, torn or the cartilage thins
or disappears there may be a reaction to the bone of the joint underneath producing
overgrowth of bone spurs and an enlargement of the joints” (Ray, para. 9 ). This leaves
swollen, inflamed and painful joints, where bone underneath is uncovered and rubbing
bone against bone.
While many times facet joint arthritis develops slowly over time as spinal
deterioration occurs; “rapid movements, heavy twisting or backward motions in the low
back can injure a facet joint, leading to immediate symptoms” (A Patient’s Guide, p. 4).
Facet joint disorders can be the root cause of disabling low back pain and cause serious
symptoms and disability.
Figure 1.1: http://www.coloradospineinstitute.com/subject.php?pn=anatomy-spinalregions14
Figure 1.2 http://www.mayfieldclinic.com/PE-AnatSpine.htm
Figure 1.3: http://www.spine-health.com/image-gallery/images/facet-joint-anatomy
Figure 1.4: http://www.houstonmethodist.org/orthopedics/where-does-it-hurt/lower-back/lumbar-facetjoint-arthritis/
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CASE STUDY:
The subject of this case study is a 50 year old tax attorney named Laird. Laird
has a chronic history of low back pain and suffers from facet arthropathy and chronic
low back pain. Currently, Laird is more active than one year ago, but sits for long
periods of time for work, often hunched over a computer. He tries to play tennis at least
two times a week and is attempting to walk and stretch more and has committed to a
minimum of one weekly hour long private Pilates session (and an additional class when
possible). Other than Laird’s facet joint pain, he also suffers from neural tension and
nerve compression, which causes intermittent (non-traveling) numbness and tingling in
his left buttock and occasional tingling in the heel of his left foot. When he experiences
his nerve compression, the bone spur seems to be rubbing against a nerve root,
causing inflammation and irritation. Furthermore, he has mild to moderate disc
herniations in his L4, L5 and S1 lumbar spinal region sustained in his mid-30s that have
since healed over. Last but not least, he suffers from lumbar lordosis with an anterior
pelvic tilt and incredibly tight hip flexors. Laird finds he feels worse with prolonged
standing or sitting (riding or driving for long periods magnifies his symptoms) and feels
better with movement, stretching and tennis. Occasionally, Laird suffers from point tenderness overlying the inflamed facet
joints and some degree of loss in the spinal muscle flexibility (called guarding). He
experiences more discomfort with spinal extension as opposed to spinal flexion
(although his natural posture is lordotic with a “sway back” stance. While the
sciatica/neural tension he experiences is present in his upper left buttock and left heel of
the foot, it tends to remain local and non-radiating. 6
In the past, Laird tried spinal injections, but they did not seem to help, instead
aggravating his neural tension. In 2014, he received a series of 3 injections to help
manage his pain – in the L4 and L5 facet joints (both above and below) as well as his
left sacroiliac joint. Disappointingly, these injections did not offer much relief and soon
after his physician talked about a possible facet rhizotomy. “A rhizotomy describes a
surgical procedure in which a nerve is purposely cut or destroyed” (Houston Methodist,
p. 6). In an effort to avoid this procedure, Laird instead turned to the Pilates Method
with the goals of increasing his flexibility (particularly his hip flexors), improving his
posture (less hyperlordosis) and activating and strengthening his gluteus medius and
transverse abdominas. 7
RATIONALE The following conditioning program and and exercises were selected to focus on a total,
balanced workout while addressing the goals and desired results outlined below:
● Strengthening abdominals and stretching hip flexors to decrease hyperlordosis
● Stretching and loosening up lower back muscles (specifically his quadratus
lumborum)
● Strengthening buttock muscles, particularly the gluteus medius
● Paying careful attention to excessive spinal extension which increases neural
tension and irritation
● Neuromuscular retraining the abdominals and stabilizers (namely, the transverse
abdominis and multifidus) to fire correctly and work in harmony for daily
“functional” activities and playing tennis - allowing the back muscles to relax and
not always “take over” for the abdominals
***Please note, not all exercises from the below conditioning program were always
performed, but this is an example of options selected per session as Laird advanced
through the repertoire. ***
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BASI BLOCK SYSTEM CONDITIONING PROGRAM
Block
Sessions 1-10
Sessions 11-20
Sessions 21 and Beyond
Warm-Up
Mat (Fundamental)
Pelvic Curl
Supine Spine Twist
Chest Lift
Chest Lift with Rotation Mat (Fundamental)
Pelvic Curl
Supine Spine Twist
Chest Lift
Chest Lift with Rotation
Cadillac
Pelvic Curl
Supine Spine Twist
Roll-Up with the Roll Up Bar
Mini Roll-Ups
Mini Roll-Ups Oblique Roll-Up Top Loaded
OR
Mat (Fundamental)
Pelvic Curl
Supine Spine Twist
Chest Lift
Chest Lift with Rotation
Footwork
Reformer
Parallel Heels
Parallel Toes
V Position Toes
Open V Heels
Open V Toes
Calf Raises
Prances
Single Leg Heel
Single Leg Toes
Reformer/Cadillac
Parallel Heels
Parallel Toes
V Position Toes
Open V Heels
Open V Toes
Calf Raises
Prances
Single Leg Heel
Single Leg Toes
Reformer/Cadillac/Wunda
Chair
Parallel Heels
Parallel Toes
V Position Toes
Open V Heels
Open V Toes Calf Raises Prances (not on the Wunda
Chair)
Single Leg Heel
Single Leg Toes Abdominal
Work
*Pick*
Mat
Hundred Prep
Single Leg Lifts/Leg
Changes
Roll-Up
Reformer:
Hundred Prep
Wunda Chair
Standing Pike
Standing Pike Reverse *Pick*
Reformer
Short Box Series
Round Back
Flat Back
Tilt
Twist
Round About
Step Barrel
*modifying to control
extension of the spine with
a slo-mo ball behind the
head*
Chest Lift
Overhead Stretch
*Pick*
Reformer:
Hundred Prep
Hundred
Coordination
Cadillac
Roll Up Bottom Loaded
Teaser
Wunda Chair
Sitting Pike Full Pike 9
Teaser Prep
Hipwork
Spinal
Articulation
Stretches
Full Body
Integration I
Reformer
Frog Circles Down
Circles Up
Openings
*Pick One Series*
Reformer
Frog Circles Down
Circles Up
Openings
Cadillac
Frog
Circles Up
Circles Down
Walking Bicycles
*Pick One Series*
Reformer
Circles Down
Circles Up
Extended Frog
Extended Frog Reverse
Cadillac
Single Leg Supine Frog
Circles Down
Circles Up
Hip Extension Bicycle
Reformer
Bottom Lift
*may add 3-5 reps of
Bottom Lift with Extension
*Pick One*
Reformer
Short Spine
Cadillac
Monkey Original
Reformer
Standing Lunge
Step Barrel
Shoulder Stretch Lying
Side
*Pick*
Reformer
Standing Lunge OR
Kneeling Lunge
Ladder Barrel
Gluteals
Hamstrings
Adductors
Hip Flexors Reformer
Kneeling Lunge Side Split
Ladder Barrel
Shoulder Stretch 1
Shoulder Stretch 2
Reformer
Knee Stretch Group
Scooter
Up Stretch Group Elephant *Pick*
Reformer
Knee Stretch Group
Round Back
Flat Back
OR
Upstretch Group
Upstretch 1
Upstretch 2
Reverse Knee Stretch
Cadillac
Kneeling Cat Stretch
*Pick*
Reformer
Stomach Massage Series
*Pick One*
Cadillac Tower Prep OR Tower
Wunda Chair
Pelvic Curl
Stomach Massage Round Back
Stomach Massage Flat Back
Stomach Massage Reaching
Cadillac
Push Through Group
Sitting Forward
Side Reach
10
Arm Work
Reformer
Arms Supine Series
Extension
Adduction Up Circles
Down Circles
Triceps
Full Body
N/A
Integration II
Leg Work
Ankle Weights
Gluteals Side Lying Series
Side Leg Lift
Forward and Lift
Forward with Drops
*Pick One Series*
Reformer
Arms Sitting Series
Chest Expansion
Biceps
Rhomboids
Hug-A-Tree Salute
Cadillac
Arms Standing Series
Chest Expansion
Hug-A-Tree
Circles Up
Circles Down
Punches
Biceps
*Pick One Series*
Reformer
Arms Kneeling Series
Chest Expansion
Up Circles
Down Circles
Triceps Biceps
Cadillac
Arms Standing Series
Chest Expansion
Hug-A-Tree
Circles Up
Circles Down
Punches Biceps
Wunda Chair
Shrugs
Tricep Press Sit Frog Back
Side Kneeling Arm N/A
Reformer
Balance Control Front
Tendon Stretch
Cadillac
Push Through Group
Sitting Back
Saw *Pick One*
Reformer
Single Leg Skating Cadillac
Squats
Ankle Weights
Gluteals Side Lying Series
Side Leg Lift
Forward and Lift
Forward with Drops
*Pick One*
Cadillac
Single Leg Side Series
Changes
Scissors Circles Forward
Circles Back
Squats
Wunda Chair
Forward Lunge
Backward Step Down
Frog Front
11
Lateral
Flexion/
Rotation
*Pick One*
Mat
Side Lifts
Step Barrel
Side Lift
Wunda Chair
Side Stretch
*Pick One*
Mat Side Lifts
Reformer
Short Box Group
Side Over on Box
Or
Mermaid
Cadillac
Butterfly
Ladder Barrel
Side Over Prep
*Pick One*
Cadillac
Butterfly Arms
Wunda Chair
Side Pike
Ladder Barrel
Side Overs
Back
Extension
*Pick One*
Mat
Cat Stretch
*Pick One*
Reformer
Long Box Group
Breast Stroke Prep (no
lifting of the trunk as the
arms straighten)
OR
Step Barrel
Swan Prep (Glutes MUST
be engaged and active.
Head reaching long out
from the spine.
*Pick One*
Reformer Long Box Group
Breast Stroke Prep (no lifting
of the trunk as the arms
straighten). Ladder Barrel
Basic Back Extension (no
excessive lifting of the head think reaching LONG)
*Focus is on
the reach,
being overly
aware of
activating the
correct
muscles to
avoid neural
aggravation.
OR
Ladder Barrel
Basic Back Extension (no
excessive lifting of the
head - think reaching
LONG)
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CONCLUSION
In closing, facet joint syndrome will be something that Laird will deal with for the
rest of his life. Nevertheless, after working with Lard in conjunction with a physical
therapist for 8 months (eight 60 minute weekly private Pilates sessions per one hour
session of physical therapy), he made significant strides in decreasing low-back pain,
increasing flexibility and strength, while improving his posture. Laird has been able to
resume normal activities with guidance on what is safe for him and Pilates has become
part of an ongoing lifestyle change that allows Laird to remain and live (mostly) pain
free. He feels better completing his day-to-day activities, better manages his chronic
low back tightness, neural tension and pain. He also found adapting his sleep position
to be helpful (curled up to sleep on his left side with a pillow between his knees or lying
back with his knees bent and supported) and awakens feeling less “tight and creaky”.
Fortunately, Laird found by utilizing the Pilates Method in conjunction with Physical
Therapy is attaining a healthier and more active lifestyle! 13
BIBLIOGRAPHY
Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body
Arts and Science International, 2013.
Isacowitz, Rael, & Clippinger, Karen. Pilates Anatomy. Champaign, Illinois: Human
Kinetics, 2011
Spine Anatomy, Anatomy of the Human Spine. (n.d.). Retrieved April 14, 2016, from
http://www.mayfieldclinic.com/PE-AnatSpine.htm
Ray, Charles D. "Facet Joint Disorders and Back Pain." N.p., 10 Dec. 2002. Web. 16
Apr. 2016.
Ray, Charles D. “Symptoms and Diagnosis of Facet Joint Problems.” N.p., 20 Dec.
2002. Web. 19 Apr. 2016
“A Patient’s Guide to Lumbar Facet Joint Arthritis.” PDF Booklet - EOrthopod.com.
Eorthopod.com, 2003. Web. 30 June 2016.
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