February 2002

Adding to the Athlete's Rehab Arsenal

By Ada M. Wells, MPT

Adding to the Athlete's Rehab Arsenal

Pilates is effectively integrated into a sports rehabilitation program through proper timing, movement, and practice.

Sports rehabilitation comes in many forms. It may involve getting a high-level athlete back on the court or returning Aunt Ethel to her golf game after a total hip replacement. In either case, athletes and rehabilitation practitioners recognize the benefits of rehab programs that incorporate not only strength and flexibility training, but also balance, kinesthetic awareness, and efficient movement patterns. Pilates is one type of exercise that is able to synthesize these components, making it ideal for sports rehabilitation.

Pilates' Rehab Niche
Pilates addresses the athletic patient's needs in all phases of rehab, from the most acute phase to advanced functional reeducation. Assistance or resistance is controlled through variances in the patient's relationship to gravity, alterations of the base of support, and the use of levers, springs, and props. This flexibility allows progression of exercises and a continuum of movement strategies.

Pilates trains patterns of movement rather than isolating single muscle groups. The exercises are used to simplify components of the task, making verbal and tactile cues easy to administer, and ensuring that faulty movement patterns are corrected and carried over to the sport-specific skill. Task-specific exercises are adapted to unload the limbs or spine appropriately as healing occurs, while still allowing muscle reeducation to take place.

Pilates apparatuses provide more flexibility than traditional gym equipment. A large number of exercises can be performed on a diverse patient population. This includes athletes of different levels (amateur to elite), different body types (ice skaters to football players), and different skill sets (golfers to kayakers). Pilates apparatuses include the universal reformer, trapeze table, combo chair, and ladder and step barrels. Props include rotating discs, resistance rings, boxes, and balance boards. Many of the Pilates-inspired exercises are easily adapted into home programs with no props or with a few small pieces of equipment, such as a foam roller or exercise ball.

Donna Burden Flowers, PT, ATC, is a former professional figure skater who works as a therapist and trainer for the US Olympic Figure Skating Team and is also a physical therapist at BaySport Inc in Los Gatos, Calif. She talks about the adaptability of the equipment with her athletic patients, "Pilates can be incredibly sports specific, and many of the skills needed to properly stroke and position on the ice can be done dynamically on the reformer. The [combo] chair allows for great eccentric work on the legs....There is really no limit to what [Pilates] can do."

Incorporation
There have been few direct scientific studies to support the claims of Pilates-based practitioners. However, respected studies of motor learning can be applied to Pilates.^1-3 Anecdotal reports from patients and practitioners indicate that significant improvements in athletic performance following injury have been achieved through the use of Pilates in rehabilitation. Athletes who have used Pilates in their rehab report heightened body awareness, fewer injuries, enhanced coordination, improved flexibility and strength, and a rapid return to their sport.

At BaySport Inc, we have successfully integrated Pilates into sports rehabilitation programs at five clinics associated with athletic clubs in California.⁴ Sheri Betz, PT, also a Los Gatos-based physical therapist for BaySport, states that success with Pilates in a sports rehab program starts with teaching appropriate breathing, muscle facilitation, and spinal alignment while progressing the patient from supported to unsupported positions. "When optimal spinal alignment, stabilization, and breathing are mastered during simple exercises, I progress to more complex exercises-mobilization and dynamic stabilization exercises. I can simulate any sports activity and evaluate the athlete in a moving environment to break down faulty movement patterns and replace them with biomechanically correct and safer movement patterns that avoid further damage to soft tissues."

Guidelines
Pilates-based exercise can be incorporated into any sports rehabilitation program. However, just tossing in a few Pilates exercises without a plan or without proper instruction can have a negative outcome. Therefore, some general guidelines should be followed when integrating Pilates into a sports rehabilitation program.

1. Identify the appropriate phase of rehab and progress accordingly. According to Porterfield and DeRosa, there are three phases of Pilates-based rehabilitation.¹ In phase I, the goals are to avoid further irritation of tissue and decrease pain. Exercises should use the principles of disassociation, stabilization, and initiation of pain-free mobilization. Optimal recruitment of the trunk stabilizers minimizes undesirable guarding from larger muscle groups and allows the desired movement to occur distal or proximal to the lesion.

In Phase II, restoring mobility lost due to injury is the primary goal. Once the patient is able to successfully stabilize the trunk, mobilization can be achieved by using springs for assistance. In this way, the therapist avoids traumatizing injured tissues with premature, aggressive, or inadequate mobilization. Movements are progressed in a continuous fashion, moving from passive to assistive movement, active movement with gravity eliminated to active movement against gravity, and finally to movements with resistance. In Phase III, proprioceptive and kinesthetic training are accomplished via dynamic stabilization. Dynamic stabilization is achieved as assistance is decreased and the challenge increases by incorporating the effects of gravity, base of support, and resistance in multiple planes of motion.

2. Identify and break down faulty movement patterns. Traditional exercise often involves identifying, then training isolated, deconditioned muscles, usually in a single plane of motion. Acknowledging these isolated deficits is important, but realize that many sports skills are complex, multiplanar movements requiring a blend of coordination, balance, and kinesthetic awareness. A Pilates practitioner evaluates the faulty movement pattern and then breaks it down into smaller units that fit nicely into the Pilates repertoire of exercises. Training starts in a less challenging environment where parts of the task can be broken down and the orientation to gravity is changed to disrupt unwanted movement strategies. Verbal and tactile cues are effective in this new orientation where it is difficult to resort to old habits.

The concept of functional reeducation is important to return athletes back to their activity. Research in motor learning has shown that carryover occurs with task-specific movements.³ Therefore, once the activity is mastered in the less challenging environment, it must move back into its familiar environment to be further practiced until an efficient movement strategy is learned.

3. Use cues appropriately to enhance motor learning. Pilates-based exercise allows the athlete to retain and then transfer these coordination patterns to outside of the practice environment into the sports-specific skill. Motor learning has been defined as "a set of processes associated with practice or experience leading to relatively permanent changes in the capability for movement."⁵

Practice is an important aspect of motor learning, but structuring that practice may affect how much learning takes place. Verbal, visual, and tactile cues give better performance after each practice trial, but this does not necessarily mean that the movement is carried over or learned. In fact, excessive feedback can have less effective results when it comes to patients recalling those movements on their own.³ Therefore, it is important to review the exercise or sport-specific task on a regular basis to assess if learning is taking place. It also reinforces the importance of appropriate cueing.

Use short cues so as not to disrupt the normal rhythm of the movement. Teaching imagery and self-talk regimens helps athletes cue themselves when there is not a Pilates practitioner present. In this way, the patient relies more on internal stimuli to learn and perform the movement efficiently.

4. Use principles of movement facilitation. Movements should be facilitated in a manner that does not further irritate the lesion and that optimizes the desired effect. One approach describes six principles of movement facilitation: breathing; axial elongation and core control; efficient organization of head, neck, and shoulder girdle; spine articulation; alignment and posture; and movement integration.¹

Diaphragmatic breathing is used to facilitate both stabilization and mobilization of the spine, which enhances trunk organization. Core control by the deep trunk stabilizers, combined with the concept of axial elongation, gives the body a more optimal position from which to obtain efficient movement. This, in turn, decreases compressive forces. Proper organization of the shoulder girdle assists with effective force transfer between the trunk and upper extremity. Spine articulation is facilitated with breathing and is performed in a controlled manner to decrease potential shear forces around the lesion.¹ Encouraging proper alignment and posture also improves movement efficiency. Through movement integration, the athlete has a heightened level of body awareness during the activity. Use of these principles of movement facilitation assists with efficient movement patterns without irritating the lesion and enhances appropriate movement strategies.

5. Exercise prescription. First, ensure that the appropriate amount of assistance is given to successfully complete the exercise without increasing stress on the tissues. The goal is to challenge, but not discourage the athlete. Second, do not continue with a basic exercise once it has been replaced by a more challenging movement. This keeps the routine fresh and the athlete motivated. Next, the number of repetitions should be based on goals and on the quality of movement. As a general rule, the number of repetitions is usually kept small with the emphasis on quality movements and minimal outside cueing. Finally, educate patients to monitor their progress and set limits. They should be able to recognize variables that could put them at risk for reinjury and know when to stop the activity.

Pilates can be integrated into any sports program as long as the practitioner identifies the appropriate stage of rehabilitation, identifies and breaks down faulty movement patterns, facilitates movement through appropriate cues and assistance, and enables the athlete to practice until the new movement strategy is transferred. As research relating directly to Pilates-based exercise advances, it is expected that Pilates will set a new standard for sports rehabilitation.

References
1. Anderson B, Larkam E. Focus on Pilates-evolved training. Polestar® Education Rehabilitation Laboratory Manual for Continuing Education. Miami: Polestar Education; 2000:1-30.
2. Anderson BD, Spector S. Introduction to pilates-based rehabilitation. Orthopaedic Physical Therapy Clinics of North America. 2000;9(3):395-410.
3. Lange C, Unnithan V, Larkam E, Latta P. Maximizing the benefits of pilates-inspired exercise for learning functional motor skills. Journal of Bodywork and Movement Therapies. 2000;4(2):99-108.
4. BaySport Pilates. Available at: www.baysport.com/pilates.shtml. Accessed January 1, 2002.
5. Schmidt RA. Motor Control and Learning: A Behavioral Emphasis. 2nd ed. Champaign, Ill: Human Kinetics; 1988:346.

Ada M. Wells, MPT, is a certified Pilates rehabilitation practitioner. She is a physical therapist at BaySport Inc at Pacific Athletic Club in Redwood City, Calif. She can be reached via email: ada.wells@baysport.com.

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