Cover Story: Inside and Out

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April 2004

By Rich Smith

Christine Romani-Ruby, MPT, ATC

For millions of fitness-conscious Americans, Pilates is a new workout program being offered at the corner gym and hawked like mad on late-night cable TV. However, for hundreds of physical therapists, Pilates is a deep-muscle exercise system amounting to an ideal adjunct in the rehabilitation of traumatic injury patients and those with various function-impairing diseases.

“What’s great about Pilates as therapy is it addresses the entire body working as a single unit, not just specific muscle groups —which, of course, is how other types of therapeutic exercises go about [treatment],” says Shellie Sakash, MS, PT, of Canonsburg, Pa, a certified Pilates instructor. “All at the same time, with one technique, Pilates strengthens the deeper muscles, balances the length of muscles, teaches patients correct body alignment, and increases their body awareness. That makes it a very efficient exercise system. Not to mention fun.

“And I have yet to come across a condition where Pilates is unable to help,” she continues. “In particular, I’ve had really great success with Pilates and scoliosis patients. It alleviates their pain, they experience a decrease in curvatures and leg-length discrepancies. Most important, because of the body awareness aspects of Pilates, patients are given the tools to control and avoid progression of their disease state.”

TEACH FIRST BY DOING
Sakash obtained her Pilates certification through a colleague, California University of Pennsylvania professor Christine Romani-Ruby, MPT, ATC, who has been a Pilates advocate since the early 1990s.

“I like Pilates for a whole number of reasons, not the least of which is it can be performed at different levels—beginner to advanced—which allows you to tailor it to the needs of any population,” says Romani-Ruby, who explains that Pilates originated in pre-World War I Germany and was exported about 10 years later to the United States, where its popularity has somewhat cyclically waxed and waned among therapists in the decades since.

Christine Romani-Ruby, MPT, ATC, assists a client with a position at PowerHouse Pilates.

Romani-Ruby operates a sideline company called PowerHouse Pilates LLC, headquartered in Monongahela, Pa, outside of Pittsburgh. Her business employs a team of Pilates experts who travel the country to certify studios, gyms, and clinics as competent providers of Pilates for purposes of healthful exercise, rehab therapy, or both.

“Currently, we have eight such certifying instructors,” she says. “Some are physical therapists, others exercise physiologists, some dancers. All are independent contractors. They visit facilities requesting certification, and we train the staffs at those locations over the course of several weekends. Not consecutive weekends, though. We train on one weekend, then give the trainees some time to practice what they’ve learned before we come back again to provide further instruction.”

The instruction comes in part from the pages of company-produced training manuals and from supporting materials such as the 80-year-old textbooks authored by inventor Joseph Pilates.

Pilates workouts take either of two forms. The first, for novices, entails use of specially designed exercise machines to strengthen the muscles required to safely and beneficially perform the exacting Pilates movements. The second involves exercises on a floor mat, which are for advanced participants. The PowerHouse Pilates certification process requires facility staffers to demonstrate adeptness in the use of both machines and mats before they can be deemed qualified to instruct.

Says Romani-Ruby: “Our philosophy is that you have to experience Pilates before you can teach it. And you have to experience it for more than just a 1-hour class. That’s inadequate to give you the necessary understanding of Pilates. In that hour, if you’re athletic and strong, you’ll be able to perform the Pilates movements but you won’t feel what you should. It takes about 3 weeks of working at it to correctly coordinate the breathing and the movement.

“One thing we make sure instructors understand about Pilates is the necessity of giving people good cues during a workout so they don’t end up using only their big, dumb muscles instead of the ones down deep. The natural tendency is for people to perform the exercises using hip flexors, rectus abdominis, and whatever other muscles they can draw the most strength from. Then they wonder why they leave the class either feeling like they got nothing from the exercises or, at the opposite extreme, feeling a lot of back and neck aches.”

Although Romani-Ruby sees her mission in part as providing certification, she acknowledges there is not much weight to that process: “The problem is there are not at this time any industry-accepted certification standards. They simply don’t exist. You can ask what standards I had to meet in order to be able to certify, and the answer is none apart from my own standards. Now, I happen to think the standards PowerHouse has established are good, but they are still standards that not everyone can or would agree on.”

NOT A CODE-BREAKER
The other part of Romani-Ruby’s mission is for herself to be a provider of Pilates for physical therapy purposes. Accordingly, PowerHouse, a 1,000-square-foot clinic, is staffed on a part-time basis by Romani-Ruby, her business partner Marci Clark, three personal trainers, two physical therapists (Sakash is one of them), and one physical therapy assistant.

“We’ve got just about every Pilates-oriented piece of equipment you can imagine,” Romani-Ruby says. “It’s like toyland here. We have 13 reformers, three trap tables, four chairs, a ladder barrel spine corrector, a c-shaper, a peda-pole, a Pilates-adapted shuttle, and lots of Pilates rings.”

Missing from the mix are modalities.

“If patients need the kind of intervention that modalities would afford, then they either use ice at home or talk to their doctor about taking an anti-inflammatory,” Romani-Ruby tells.

At one time, Pilates fitness classes were offered until PowerHouse transferred them to a wellness center in a nearby community so that the Monongahela staff could focus on therapeutic Pilates work.

“We still have a few fitness clients in our clinic, but only for one-on-one, private-session personal training,” she says.

Clinic physical therapy caseload currently stands at about 20 patients per 5-day business period. Each patient is seen twice weekly for sessions lasting a full hour apiece. Patients (as well as the relatively few personal-training clients) are given the option of spending their hour in a private or semiprivate session: private-session participation is restricted to just one patient or client and one therapist-instructor; semiprivate participation opens it up to as many as three patients or clients.

“Sometimes exercising in a group motivates the participants to work harder,” says Romani-Ruby. “But other times—especially true with rehab patients—the group environment can hold them back because I can’t focus entirely on any single patient, which makes it hard to discuss what they’re feeling.

“So, if I’m working on a specific problem that might even involve pain, I prefer one-on-one.”

Before patients (and fitness seekers) start a Pilates program, the PowerHouse staff first puts them through an evaluation.

“With patients, the evaluation is a standard physical therapy assessment, although I do utilize a lot of the Pilates movements in that process,” Romani-Ruby says. “I’m looking at Pilates movement, not functional movement, because that way I can more easily see the muscles that are weak or imbalanced. Instead of the traditional bend-over-touch-your-toes or bend-to-the-side movements, I may actually have the patient perform an exercise on the machine, and while that’s happening, I’ll observe the patient’s movement pattern. We don’t take a measurement of range of motion, but we’ll note if there’s a limitation.”

Assessing improvements is a bit tricky with Pilates physical therapy because each exercise’s number of repetitions always remains the same, Romani-Ruby indicates. To get around that difficulty, PowerHouse has developed a special tracking form that lets the therapist grade the patient on the movement quality of each particular exercise.

“The grades run from 0 to 4 and they are subjective, but over time you actually can see where progress is being made and where it’s not,” Romani-Ruby says.

Meanwhile, on the matter of getting paid, PowerHouse’s Pilates physical therapy services are billed to the patient’s insurance under either a therapeutic exercise or neuro-rehabilitation code. Fitness clients pay out-of-pocket.

A PERFECT MATCH
Ribbon-cutting at PowerHouse occurred in 1999, but the company’s beginnings date back a number of years earlier, preceded by Romani-Ruby’s time as an undergraduate student at Indiana University of Pennsylvania.

“In college, I was into fitness and looking for a health profession,” she says. “At the time, my mom was very into aerobic dance and I would go to classes with her. One day, the teacher didn’t show, and somebody suggested I fill in as the substitute. So, I did and found it to be exhilarating.”

The experience helped convince Romani-Ruby to change her major from biology to physical education and athletic training. As a result of that switch, circumstances led her to an encounter with a physical therapist who steered her toward his own field as a career choice.

Thus, Romani-Ruby went on to earn her PT license. But not long after entering physical therapy practice, she decided to take time off to start a family. She soon grew restless at home, so she busied herself by returning to aerobics instructing on a part-time basis.

“It was perfect because I could take my young kids with me to the gym,” she says.

During this period, Romani-Ruby developed a friendship with Clark, who was one of the gym’s personal trainers. Among the things they found in common was a curiosity about Pilates, which was then experiencing one of its periodic booms in public awareness.

“We had heard about Pilates and decided it was something we ought to get trained in,” Romani-Ruby remembers.

After gaining sufficient knowledge about and experience with Pilates, the two began conducting occasional Pilates classes at the gym where they were still employed.

“We both held group exercise classes,” Romani-Ruby says. “I also did specialty classes, such as one for fibromyalgia patients and another for back-injury patients, because of my physical therapy expertise.”

The classes proved so popular that Romani-Ruby and Clark decided to cut a deal with the gym for dedicated space to operate a full-time Pilates studio: they would provide the equipment and would share with the gym a percentage of the revenues generated by the classes.

It was not long, though, before Romani-Ruby and Clark were talking about opening a studio of their own, one that would feature an integrated physical therapy clinic. That is when PowerHouse Pilates took wing. It was successful almost from the beginning and still is, even though the clinic relies almost exclusively on word-of-mouth promotion by clients to generate business.

“This is a referral-based enterprise,” says Romani-Ruby, who allows that about the only paid advertising in which PowerHouse engages is in the form of outreach to other studios and clinics. “We exhibit at Combined Sections, we have a Web site [www.phpilates.com], we’ve written articles and books that get us quite a bit of attention in the industry.”

Because it is a sideline for Romani-Ruby, the clinic will not likely ever become a gigantic enterprise. But this suits her just fine.

“I don’t want to get really busy with it, and one of the reasons for this is I enjoy having a whole hour to spend with each patient for that one-on-one work,” she explains.

If growth must occur, Romani-Ruby would much prefer it be realized by others who are also engaged in this particular physical therapy area, for she sees herself as first and foremost a booster of Pilates exercise.

“I’m thrilled that Pilates is getting to be so popular; I feel strongly that the physical therapy profession needs to get on the Pilates bandwagon,” she says. “We’ve got people out there doing Pilates therapy and getting good results. There are, of course, a lot of Pilates instructors who are not physical therapists, and that’s OK. But they take a shotgun approach to exercising a client. Whereas if you put Pilates in the hands of a physical therapist, they know how to draw a tight bead on the problem area and apply exactly the right exercise to it.”

Rich Smith is a contributing writer for Rehab Management.

PILATES IN PRACTICE: Clinton Physical Therapy Center
One facility to recently complete the training course provided by PowerHouse Pilates is Clinton Physical Therapy Center (CPTC) in Clinton, Tenn.

CPTC is a therapist-owned private practice with a single, semirural location on the periphery of the Knoxville market. It has been in operation 15 years. The specialty-focused staff consists of nine physical therapists, one physical therapy assistant, and one occupational therapist (with certification in hand injury rehabilitation).

“We treat everything there is in physical therapy except neuro-pediatrics,” says co-owner Kelly Lenz, PT.

Operated under the auspices of CPTC is a wellness program with 525 monthly-dues-paying members. It was through the wellness program that Pilates first came to be offered by CPTC.

“We felt that Pilates would be a good addition to our wellness program,” says Lenz. “Most of our therapists had a lot of background over the years in lumbar stabilization techniques; Pilates took that one step further.

“Initially, we thought we’d use Pilates only with our low-back patients. But I learned things about Pilates that opened my eyes to how useful it also is for people with urinary incontinence, shoulder and upper extremity injuries, and more.”

PowerHouse Pilates’ role in this was to make a site visit for an initial 2-day training session in mat work. This was followed 2 months later with another 2-day session to train the staff on use of Pilates machines.

CPTC spent several thousand dollars on Pilates training and again as much on equipment, Lenz indicates, adding, “the cost was worth bearing. And we didn’t hesitate to make this investment because we knew that, even if Pilates turned out to be nothing more than a fad on the fitness side, it would always be an excellent adjunct in the therapy side for patient rehab, and so would pay for itself many times over.”

Response to the Pilates programs has been so positive that CPTC plans to expand its wellness space by 10,000 square feet to include a Pilates-dedicated studio (Pilates offerings at CPTC have been sharing space with the clinic’s yoga program).

CPTC also hopes to integrate Pilates with the athletic training programs it conducts on behalf of local secondary schools.

“We see Pilates not only as a way to enhance practice revenues but also as a means of gaining entree to relationships with community partners—partnerships that might otherwise be very difficult to develop,” Lenz says.
—Rich Smith

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April 2004