Lower back pain (LBP) is the most prevalent musculoskeletal injury, as approximately 80% of the population will experience LBP in their lifetime (Arab et. al 2010). Transverse abdominus activation is often prescribed for LBP however pelvic floor muscle (PFM) is not always incorporated into treatment. PFM aids in supporting the abdominopelvic organs and there is an abundance of research on the role of the PFM in urinary and fecal incontinence. Nevertheless, it is important to remember the PFM role in lumbar and pelvic stability and intra-abdominal pressure (Mohseni-Bandepi et. al 2011). Research illustrates that the combination of pelvic floor exercise alongside routine treatment can provide significant pain relief in LBP compared to routine treatment alone (Bi et. al, 2013), demonstrating the importance of PFM exercises.

The link between LBP and PFM helps to provide insight into the correlation between LBP and pelvic floor dysfunction (PFD). PFD is an umbrella term to describe weakness, poor endurance and hypertonicity of the PFM which can impact incontinence, prolapses and pelvic pain. Dufour et al. found that 95% of women with LBP had PFD, ‘71% of the participants had pelvic floor muscle tenderness, 66% had pelvic floor weakness and 41% were found to have a pelvic organ prolapse’(Dufour et. al 2018), further highlighting the importance of incorporating PFM in treatment. Arab et al. also examined PFD in women with and without LBP. The results show PFD in participants with LBP compared to those without. This is valuable for health care participants when assessment and treating LBP (Arab et. al 2010). It is also important to recognize PFD in pregnancy-related lower back pain (PLBP). Pool-Goudzwaard et. al discovered ‘52% of PLBP, significantly more than in the healthy control group’ (Pool-Goudzwaard et. al,2005) and promote addressing both LBP and PFD during pregnancy.

There are a variety of methods to help activate, strengthen and relax the pelvic floor in order to aid recovery in PFD.  Kegels or reverse Kegels are often prescribed to promote awareness and strengthen PFM (Torgenu et. Al 2021). Transverse abdominus contraction has also been shown to help activate and strengthen PFM. Sapsford et al. found ‘that abdominals contract in response to a pelvic floor contraction command and that the pelvic floor contracts in response to both a “hollowing” and “bracing” abdominal command’(Mohseni-Bandepi et. al 2011), therefore proving the PFM can be activated by engaging the abdominals. Hypopressive exercises (HE) have also shown to aid recovery from PFD. HEs lowers the intra-abdominal pressure which enables an involuntary contraction of the PFM and transverse abdominus. Navarro-Brazález et. al suggests the combination of HEs and pelvic floor muscle training improves PFM strength and quality of life for patients with PFD (Navarro-Brazález et. al 2020).

Reference List

• Arab, A.M., Behbahani, R.B., Lorestani, L. and Azari, A. (2010). Assessment of pelvic floor muscle function in women with and without low back pain using transabdominal ultrasound. Manual Therapy, 15(3), pp.235–239. doi:https://doi.org/10.1016/j.math.2009.12.005.

• Bi, X., Zhao, J., Zhao, L., Liu, Z., Zhang, J., Sun, D., Song, L. and Xia, Y. (2013). Pelvic floor muscle exercise for chronic low back pain. Journal of International Medical Research, 41(1), pp.146–152. doi:https://doi.org/10.1177/0300060513475383.

• Dufour, S., Vandyken, B., Forget, M.-J. and Vandyken, C. (2018). Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskeletal Science and Practice, 34, pp.47–53. doi:https://doi.org/10.1016/j.msksp.2017.12.001.

• Mohseni-Bandpei, M.A., Rahmani, N., Behtash, H. and Karimloo, M. (2011). The effect of pelvic floor muscle exercise on women with chronic non-specific low back pain. Journal of Bodywork and Movement Therapies, 15(1), pp.75–81. doi:https://doi.org/10.1016/j.jbmt.2009.12.001.

• Navarro-Brazález, B., Prieto-Gómez, V., Prieto-Merino, D., Sánchez-Sánchez, B., McLean, L. and Torres-Lacomba, M. (2020). Effectiveness of Hypopressive Exercises in Women with Pelvic Floor Dysfunction: A Randomised Controlled Trial. Journal of Clinical Medicine, 9(4), p.1149. doi:https://doi.org/10.3390/jcm9041149.

• Pool-Goudzwaard, A.L., Slieker ten Hove, M.C.P.H., Vierhout, M.E., Mulder, Paul.H., Pool, J.J.M., Snijders, C.J. and Stoeckart, R. (2005). Relations between pregnancy-related low back pain, pelvic floor activity and pelvic floor dysfunction. International Urogynecology Journal, [online] 16(6), pp.468–474. doi:https://doi.org/10.1007/s00192-005-1292-7.

• Torgbenu, E.L., Aimakhu, C.O. and Morhe, E.K.S. (2020). Effect of Kegel Exercises on Pelvic Floor Muscle Disorders in Prenatal and Postnatal Women – A Literature Review. Current Women’s Health Reviews, 16. doi:https://doi.org/10.2174/1573404816999200930161059.

Physiotherapy Scoliosis Specific Exercise (PSSE) is the umbrella term and model that encompasses specific education, physiotherapy exercises, psychological support and bracing for scoliosis (Berdishevsky et. al, 2016). PSSE approach has become a more accepted form of conservative treatment due research showing an improvement in cobb angle, posture and breathing function (Seleviciene et. al, 2022). The PSSE model incorporates a multidisciplinary approach and can be used as an adjunct to medical treatment (Berdishevsky et. al, 2016). There are currently 8 scoliosis schools which use PSSE, however the Schroth method, Scientific Exercise Approach to Scoliosis (SEAS) and Barcelona Scoliosis Physical Therapy School approach (BSPTS) are the most researched and shown to be the most effective in reducing Cobb angle and quality of life (Seleviciene et. al, 2022)

Schorth method

The Schorth method is the most studied approach with research demonstrating reduced prevalence of surgery, improved self-image and quality of life. This method uses ‘body blocks’ to help explain the scoliosis and therefore determine the most appropriate treatment. For example, the spine is split into hips, lumbar, thoracic and shoulder blocks to help assess the curvature and rotation of the spine. This provides a clear exercise programme and prioritises the manual therapy techniques. Education is used throughout the various exercises to help teach the patient to elongate the concave areas in order to improve posture. The four most common exercises include:

• 50 X pezziball – The ’50 X pezziball’ involves the patient sitting on a swiss ball in front of a mirror and using a wall bar to self-correct the spine alignment. The patient uses the mind body connection and cues to aid spine elongation and core engagement.

• Prone exercise- This exercise uses shoulder traction and counter traction to aid the thoracic curve while activating the iliopsoas for the lumbar curve.

• Sail exercise- Sail involves stretching and elongating the thoracic cavity.

• Muscle cylinder- This involves side lying on the convex side to engage QL and correct the lumbar curve against gravity. (Berdishevsky et. al, 2016)

SEAS

The SEAS approach focuses on increasing spine stability and is often used alongside wearing corrective braces to maintain range of motion and muscle tone. This approach is more functional by encouraging postural correction in different activities of daily living. Equipment such as balance boards are regularly used to aid muscle endurance and neuromotor function. (Berdishevsky et. al, 2016)

BSPTS

The BSPTS approach is based on the Schroth method and focuses on challenging the trunk with or against gravity. This includes supine exercises which remove gravity and allows the patient to focus more easily on posture corrections, as well as side lying exercises which concentrate on lumbar concavity by working against gravity. The various exercises use corrective pads and cueing to promote elongation, traction/counter traction and muscle activation to improve posture. (Berdishevsky et. al, 2016)

Despite the various research conducted on these approaches, there is still a lack of research (Seleviciene et. al, 2022); therefore, it is important to incorporate each method into clinical practice to aid posture and quality of life (Berdishevsky et. al, 2016).

Reference List

Berdishevsky, H., Lebel, V.A., Bettany-Saltikov, J., Rigo, M., Lebel, A., Hennes, A., Romano, M., Białek, M., M’hango, A., Betts, T., de Mauroy, J.C. and Durmala, J. (2016). Physiotherapy scoliosis-specific exercises – a comprehensive review of seven major schools. Scoliosis and Spinal Disorders, 11(1). doi:https://doi.org/10.1186/s13013-016-0076-9.

Seleviciene, V., Cesnaviciute, A., Strukcinskiene, B., Marcinowicz, L., Strazdiene, N. and Genowska, A. (2022). Physiotherapeutic Scoliosis-Specific Exercise Methodologies Used for Conservative Treatment of Adolescent Idiopathic Scoliosis, and Their Effectiveness: An Extended Literature Review of Current Research and Practice. International Journal of Environmental Research and Public Health, 19(15), p.9240. doi:https://doi.org/10.3390/ijerph19159240.

There are many risk factors that could cause injury when skiing which include equipment, technique, experience, education, awareness and snow related injuries (Hebert-Losier and Holmberg,2016). Research has shown that ski equipment (highly shaped, short and wide skis) has the most impact when preventing injuries (Spörri et. Al, 2017). Nevertheless, it is important to ensure professional and amateur skiers meet the physical demands of skiing to further reduce the risk of injury; this can be achieved through endurance training and strength and conditioning (Hebert-Losier and Holmberg,2016).

Sport specific strength training is key for improving technique and delay in muscle fatigue (Sandbakk, 2018). In order to formulate a ski specific strength programme, it is important to understand the most common injuries caused by skiing.  Spörri et. all established 80% of injuries occur while the skier is turning and 19% when landing. Upper limb injuries are caused by crashes (96%) and knee injuries are the most common in skiing (83%). Hewett et. al used a screening method to assess the valgus loading of the knee to predict the risk of ACL injuries. The athletes who sustained ACL injury had a higher valgus angle compared to the uninjured athletes (Spörri et. al 2017).  In order to reduce the valgus angle in the knee, it is important to focus on strengthening hip abductors, hip external rotators (Dix et. al 2019) and quadriceps to support the knee within the sagittal plane when skiing (Morrissey et. Al 1987). Additionally, recent studies have shown the importance of core strengthening exercises in preventing ACL injuries in alpine skiing. Raschner et. all found athletes with reduced core strength or core strength imbalance had an increased risk for an ACL injury (Spörri et. Al, 2017). Therefore, a strength training programme focusing on core and lower limb strengthening is key to reducing the risk of injury in skiers.

Endurance training for alpine skiing is crucial for performance (Neumayr et. Al 2003) and in reducing the risk of fatigue. The traditional recommendation for cardiovascular endurance training is a minimum of 20 minutes within 70%-80% of maximum heart rate (Morrissey et. Al 1987). However more recent research has shown high intensity interval training (HIIT) is also an effective method of improving endurance for skiers. Sandbakk et. al found aerobic HIIT improves endurance and ‘oxygen uptake at the ventilatory threshold’ (Sandbakk et. al 2013) in junior cross-country skiers. Furthermore, active on-hill recovery within training has shown to ‘optimize blood lactate clearance’(Spörri et. al 2017) and ‘increase run completion rate’ (Spörri et. al 2017) therefore highlighting the importance of endurance training in the prevention of injury.

Neuromuscular training for skiers is key to preventing falls. Jacopo et. al established that including a neuromuscular warm- up programme for skiers had a positive impact on dynamic balance by improving their lower limb awareness and control (Jacobi et. al 2018). However recent studies show neuromuscular training programs reduce the risk of ACL injuries apart from alpine ski racing. This is likely due to ski boots further challenging the athletes’ balance (Spörri et. al 2017).

Reference List

• Dix, J., Marsh, S., Dingenen, B. and Malliaras, P. (2018). The relationship between hip muscle strength and dynamic knee valgus in asymptomatic females: A systematic review. Physical Therapy in Sport, 37. doi:https://doi.org/10.1016/j.ptsp.2018.05.015.

• Hébert-Losier, K. and Holmberg, H.-C. (2013). What are the Exercise-Based Injury Prevention Recommendations for Recreational Alpine Skiing and Snowboarding? Sports Medicine, 43(5), pp.355–366. doi:https://doi.org/10.1007/s40279-013-0032-2.

• Morrissey, M.C., Seto, J.L., Brewster, C.E. and Kerlan, R.K. (1987). Conditioning for Skiing and Ski Injury Prevention. Journal of Orthopaedic & Sports Physical Therapy, 8(9), pp.428–437. doi:https://doi.org/10.2519/jospt.1987.8.9.428.

• Neumayr, G., Hoertnagl, H., Pfister, R., Koller, A., Eibl, G. and Raas, E. (2003). Physical and Physiological Factors Associated with Success in Professional Alpine Skiing. International Journal of Sports Medicine, 24(8), pp.571–575. doi:https://doi.org/10.1055/s-2003-43270.

• Sandbakk, Ø. (2018). PRACTICAL IMPLEMENTATION OF STRENGTH TRAINING TO IMPROVE THE PERFORMANCE OF WORLD-CLASS CROSS-COUNTRY SKIERS. Kinesiology, [online] 50(1), pp.155–162. Available at: https://hrcak.srce.hr/ojs/index.php/kinesiology/article/view/6420 [Accessed 26 Jan. 2024].

• Sandbakk, Ø., Sandbakk, S.B., Ettema, G. and Welde, B. (2013). Effects of Intensity and Duration in Aerobic High-Intensity Interval Training in Highly Trained Junior Cross-Country Skiers. Journal of Strength and Conditioning Research, 27(7), pp.1974–1980. doi:https://doi.org/10.1519/jsc.0b013e3182752f08.

• Spörri, J., Kröll, J., Gilgien, M. and Müller, E. (2016). How to Prevent Injuries in Alpine Ski Racing: What Do We Know and Where Do We Go from Here? Sports Medicine, [online] 47(4), pp.599–614. doi:https://doi.org/10.1007/s40279-016-0601-2.

• Vitale, J.A., La Torre, A., Banfi, G. and Bonato, M. (2018). Effects of an 8-Week Body-Weight Neuromuscular Training on Dynamic Balance and Vertical Jump Performances in Elite Junior Skiing Athletes. Journal of Strength and Conditioning Research, 32(4), pp.911–920. doi:https://doi.org/10.1519/jsc.0000000000002478.

• White, G.E. and Wells, G.D. (2015). The Effect of On-Hill Active Recovery Performed Between Runs on Blood Lactate Concentration and Fatigue in Alpine Ski Racers. Journal of Strength and Conditioning Research, 29(3), pp.800–806. doi:https://doi.org/10.1519/jsc.0000000000000677.

Lower back pain (LBP) is the most common injury for golfers as 34.5 % of all golfing injuries involve the lumbar spine. It is important to understand the golf swing in order to identify the cause of injury and provide optimum treatment. Most injuries occur due to the impact of the golf club and the follow-through phase. Follow-through phase promotes lumber extension and eccentric contraction of abdominals in order to generate force and rotation; this places increased pressure on the spine and intervertebral discs (Finn et. Al 2013). Hosea et. al found that the compressive load during a golf swing was considerably higher in professionals than amateur golfers, with a difference of 7584 N versus 6100 N. The compressive load in a professional golf swing is equivalent to 8 times body weight (Dale and Brumitt, 2015). It is important to compare this to cadaveric studies which have shown disc prolapses to occur at 5,500 N; this highlights that the golf swing (in both amateur and professional golfers) is able to generate enough force to injure the lumbar spine (Lindsay and Vandervoot,2014).

The golf swing is repetitive, asymmetric in nature and dependent on the dominant hand; this can determine the location and severity of LBP. For example, in a right-handed golfer, the right- sided external obliques, paraspinal muscles and abdominals take the most impact and therefore the right lumbar region is most commonly injured. Also, the end position of the golf swing is called reverse C position which promotes lumbar extension and increases the risk of facet irritation. In more severe cases, spondylosis and discogenic back pain can occur from poor technique and severe muscle imbalances. (Finn et. Al 2013)

It is important to focus on muscle imbalances, thoracic and lumbar mobility and technique to prevent and recover from LBP. From analysing the swing mechanics, core stability exercises are essential in LBP rehabilitation (Evans and Oldreive,2013). Horton et al. found a delay in muscle activation in abdominal muscle for golfers with LBP, especially the lead external oblique during back swings; this further highlights the importance of core strength and endurance in protecting lumbar spine. (Horton et. Al 2001). Hip stabilisation and mobility is equally important to aid trunk rotation and lumbar stability. Vad et. al demonstrated that reduced lead hip rotation (internal and external) and lumbar spinae extension were found in golfers with LBP; this may be due to decreased hip rotation in the leading lower limb causing more force to be directed into the spine (Vad et. al 2004). Therefore, ensuring glute strengthening exercises in rehabilitation are key to provide a base of support for trunk rotation. (Finn et. Al 2013)

Reference List

• Dale, R.B. and Brumitt, J. (2016). Spine biomechanics associated with the shortened, modern one-plane golf swing. Sports Biomechanics, 15(2), pp.198–206. doi:https://doi.org/10.1080/14763141.2016.1159723.

• Evans, C. and Oldreive, W. (2000). A Study to Investigate Whether Golfers with a History of Low Back Pain Show a Reduced Endurance of Transversus Abdominis. Journal of Manual & Manipulative Therapy, 8(4), pp.162–174. doi:https://doi.org/10.1179/jmt.2000.8.4.162.

• Finn, C. (2013). Rehabilitation of Low Back Pain in Golfers. Sports Health: A Multidisciplinary Approach, 5(4), pp.313–319. doi:https://doi.org/10.1177/1941738113479893.

• HORTON, J.F., LINDSAY, D.M. and MACINTOSH, B.R. (2001). Abdominal muscle activation of elite male golfers with chronic low back pain. Medicine & Science in Sports & Exercise, 33(10), pp.1647–1654. doi:https://doi.org/10.1097/00005768-200110000-00006.

• Lindsay, D. and A. Vandervoort, A. (2014). Golf-Related Low Back Pain: A Review of Causative Factors and Prevention Strategies. Asian Journal of Sports Medicine, 5(4). doi:https://doi.org/10.5812/asjsm.24289.

• Vad, V.B., Bhat, A.L., Basrai, D., Gebeh, A., Aspergren, D.D. and Andrews, J.R. (2004). Low Back Pain in Professional Golfers. The American Journal of Sports Medicine, 32(2), pp.494–497. doi:https://doi.org/10.1177/0363546503261729.

Pilates is a form of resistance training that focuses on improving muscular strength, mobility, posture retraining and balance. Pilates incorporates more of a dynamic approach to exercise and can be adapted using various equipment. The mind-body connection is the foundation of Pilates which promotes isolated muscle activation and joint mobility.

Pilates has been modified to be used as an adjunct to physiotherapy, especially to aid women’s health and chronic lower back pain (CLBP) due to its focus on transverse abdominus, multifidus, diaphragmatic breathing and lumbo-pelvic control (Wells et. Al 2014). Pilates also incorporates a holistic approach to strength training, which is achieved by mind-body connection and breathing. Focusing on a muscle, breath or movement helps to redirect thoughts away from stress and create a meditative practice (Memmedove,2015).

There are various types of Pilates equipment which include reformer, chair, cadillac and mat. The equipment enables the exercises to be modified to the patient’s needs; for example, the springs and ropes on the reformer can provide more stability compared to a mat based Pilates exercise. Luz Jr et. Al found that equipment based Pilates reduced patient specific disability and kinesiophobia  (Luz Jr et. al,2014) and therefore aids recovery from injury.

Pilates exercises can be adapted for all age groups and can promote independence for elderly patients. The combination of strength and balance training enables an increase of activities of daily living (ADLs) and prevention of falls (Ferandez-Rodriguez et.al 2021). In addition to preventing injury, more recent studies have shown Pilates to lower the severity of temporomandibular dysfunction, fasting blood glucose and HbA1c level in type 2 diabetes in women (Parveen et. al 2023).

Pilates has been proven to progress both physiological and psychosocial aspects of patients’ well-being. However, there is evidence to suggest that there is no difference between Pilates and other forms of strength training in improving “dynamic strength, isometric strength, resistance strength, balance and flexibility” (Pinto et. Al 2022). It is crucial to understand that there is no optimum form of rehabilitation, and this highlights the importance of patient specific care.

Reference List

da Luz, M.A., Costa, L.O.P., Fuhro, F.F., Manzoni, A.C.T., Oliveira, N.T.B. and Cabral, C.M.N. (2014). Effectiveness of Mat Pilates or Equipment-Based Pilates Exercises in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial. Physical Therapy, 94(5), pp.623–631. doi:https://doi.org/10.2522/ptj.20130277.

Fernández-Rodríguez, R., Álvarez-Bueno, C., Ferri-Morales, A., Torres-Costoso, A., Pozuelo-Carrascosa, D.P. and Martínez-Vizcaíno, V. (2021). Pilates improves physical performance and decreases risk of falls in older adults: a systematic review and meta-analysis. Physiotherapy. doi:https://doi.org/10.1016/j.physio.2021.05.008.

Memmedova, K. (2015). Impact of Pilates on Anxiety Attention, Motivation, Cognitive function and Achievement of Students: Structural Modeling. Procedia – Social and Behavioral Sciences, 186, pp.544–548. doi:https://doi.org/10.1016/j.sbspro.2015.04.009.

Parveen, A., Kalra, S. and Jain, S. (2023). Effects of Pilates on health and well-being of women: a systematic review. Bulletin of Faculty of Physical Therapy volume , 28(1). doi:https://doi.org/10.1186/s43161-023-00128-9.

Pinto, J.R., Santos, C.S., Souza Soares, W.J., Silveira Ramos, A.P., Scoz, R.D., Teixeira de Júdice, A.F., Alves Ferreira, L.M., Baltazar Mendes, J.J. and Amorim, C.F. (2022). Is pilates better than other exercises at increasing muscle strength? A systematic review. Heliyon, [online] 8(11), p.e11564. doi:https://doi.org/10.1016/j.heliyon.2022.e11564.

Wells, C., Kolt, G.S., Marshall, P., Hill, B. and Bialocerkowski, A. (2014). The Effectiveness of Pilates Exercise in People with Chronic Low Back Pain: A Systematic Review. PLoS ONE, 9(7), p.e100402. doi:https://doi.org/10.1371/journal.pone.0100402.