By Brent D. Anderson, PT, OCS
Pushing for Pilates Pilates exercise has taken the field of rehabilitation by storm. Even large corporate entities like Healthsouth are publicizing Pilates to create market niches. Currently, there is a high demand for physical therapists around the world that are certified in Pilates. Most physical therapists, athletic trainers, and even physicians are becoming familiar with the word, but still know little about Pilates. Joseph H. Pilates (1880-1967) was a German immigrant to the United States in the early 1900s. Like Feldenkrais, Aston, Alexander, and Laban, Pilates developed his own system based on observed movement, creative exercises, and theories on healthy movement. The system is yoga-based with Germanic overtones of fitness; by today’s standards, it matches with rehabilitation very well. Some of the theories and rationale for the successes that were documented by early Pilates enthusiasts are not supported by current research; however, many studies today support common movement principles found in the Pilates exercises. Unlike Feldenkrais and Laban, Pilates did little writing and no research that discussed the foundations on which his work was built. Most of his work was passed on in an authoritative model—from master to student. Over the past 5 years, Pilates work was primarily used by dancers. Once endorsed by choreographers like George Balanchine and Martha Graham, Pilates became the treatment of choice for the rehabilitation of injured dancers. In the mid 1980s, dance medicine programs began to introduce Pilates into hospitals and clinics to attract dancers back into mainstream medicine. Pilates is best known for its mat work; how- ever, the design of his apparatus that allows properties of assistance, changing the center of gravity, shortening the length of levers, and changing the base of support is ingenious. After his death in 1967, his work was carried on by numerous disciples. Now there are thousands of practitioners around the world who refer to themselves as Pilates or Pilates-based instructors. The trademark ended in November 2000, so now Pilates is generic like yoga or karate. Pilates will therefore need to be more specifically defined by principles rather than purely by repertoire. Physical therapists began discovering Pilates during the mid 1980s. Early presentations on Pilates by physical therapists introduced it as the ultimate stabilization tool, at a time when stabilization was a hot topic in the field. Traditional Pilates trainers are concerned about the implications of limiting the use of Pilates as a stabilization tool only. Traditional applications of Pilates can also have their negative aspects. Often taught without clinical reasoning skills, mismatches of exercises to movement pathologies can slow down the healing process or even be contraindicated. The biggest problem has been the lack of research done on Pilates. Anecdotal claims have included cures for low back pain, musculoskeletal injuries, neurological diseases, and chronic pain. As a PT who uses Pilates and as an instructor for the past 10 years, the curriculum I use is based on the principles of movement common to most rehabilitation professionals, and clinical reasoning skills within the Pilates environment. Such organization has made it easier to understand and integrate the benefits of Pilates for rehabilitation professionals. Each principle contains fundamentals of anatomy, physiology, biomechanics, motor learning, and bioenergetics. This outline allows therapists who have patients and clients with a variety of movement impairments to use a much broader application to implement Pilates. Pilates rehabilitation is no longer limited to just orthopedics but benefits individuals with neurological impairments, cardiopulmonary restrictions, chronic pain, women’s health needs, performance enhancement needs, arthritic impairments, and other movement dysfunctions. The six principles are as follows: Breathing. Breath is one of the key elements of Pilates training. Breath is thought to be a facilitator for stabilization and mobilization of the spine and extremities. Faulty breath patterns can be responsible for common complaints of pain and movement dysfunction. Pilates movements create an environment whereby breath is facilitated to increase the efficiency of breath exchange, increase breath capacity, and facilitate thoracic postural changes thought to be a causative factor in common cervical and lumbar pathologies. The Pilates approach to breathing varies depending on which school of Pilates you graduate from, but one element in common is that breath is an integral part of each exercise. Axial elongation/core control. The principle of stabilization and axial elongation greatly relies on research from Queensland, Australia. Such studies demonstrate that the transversus abdominis, multifidus, diaphragm, and abdominal oblique muscles are key organization muscles of movement in healthy individuals with historical low back pain.1-3 Motor control studies and theories of trunk organization and stabilization show that subthreshold contraction of global stabilization muscles can provide safe movement throughout daily activities.4 Sahrmann relates control of the trunk to a balance of stiffness between muscles, in order to provide efficient control of dynamic posture.5 Axial elongation is thought to organize the spine in its optimal orientation for efficient movement, thus avoiding resting or working at the end of range, which can place undue stresses on the inert and contractile structures of the trunk and extremities. The above organization of spine and extremities also provides optimal potential for performance of sport and leisure activities. With an ever-growing population interested in feeling good and performing daily activities and recreation without the risk of injury, this principle is a high priority and could account for many of the anecdotal spontaneous resolutions of low back pain with Pilates. Pilates exercises have an innate way of facilitating trunk organization at a subconscious level, allowing the individual to explore and assimilate more efficient control of the trunk. These clinical observations warrant scientific investigation. Pilates also provides an environment where the difficulty of the exercise can be modified, thus facilitating successful execution of a desired movement outcome. The use of springs allows assistance, the tables allow the practitioner to lower the center of gravity and increase base of support, and all the exercises can be modified by changing the length of the levers. This formula allows the therapist to facilitate motor changes of the trunk quickly. Efficient organization of head, neck, and shoulder girdle. This principle allows the patient to organize and relax the head, neck, and shoulder girdle in relationship to the thoracic spine. Many restrictions and stress can occur in this area. Increasing awareness of the head, face, neck, and shoulder girdle in relation to the trunk can significantly increase efficiency of movement and diminish unwanted energy expenditures. Correct organization and facilitation of the upper extremity in relationship to the trunk can also prevent potentially harmful forces from causing injury to the shoulder joint and surrounding structures. Spine articulation. The distribution of segmental movement through the spine is a topic researchers are anxious to measure. Does distributing the motion between spinal segments significantly reduce stressful forces from causing micro and macro traumas to the hypermobile segment? Currently, there are no instruments that can measure this accurately. Alignment and posture. Postural organization can significantly improve energy expenditure in daily activities. Looking down at the ground while walking will cause much more expenditure of energy than when looking forward. Pilates not only pays attention to static alignment and posture but also, and more importantly, to dynamic posture and alignment. With a device called the rotating T-bar, a therapist can measure weight-bearing asymmetries while squatting. Using the closed chain foot bar on all reformers can assess asymmetries between hip rotators as they apply to alignment through a squatting range of motion. These diagnostic and treatment applications in the Pilates environment allow rehabilitation practitioners to better assess and treat alignment impairments not only in the lower extremity but also in the upper extremity and trunk. Movement integration. Not only does Pilates affect people physically, but also emotionally. When experiencing movement integration, the patient often feels an emotional release. According to master clinicians, this type of behavior is seen or expressed quite often. However, we usually do not talk about it because it does not fit within our current practice. If movement integration is allowed to be expanded beyond just the musculoskeletal and to incorporate the entire person, including the mind, emotions, subconscious, spirit, and physical body with its digestive, circulatory, respiratory, and reproductive systems, then this is true movement integration of the entire person. Movement systems such as Pilates, tai chi, yoga, Feldenkrais, and Gyrotonic expansion that incorporate the movement of the whole person will continue to receive more and more attention because of the great results. Rehabilitation sciences need to look for other ways of measuring outcomes as they pertain to movement of the whole person. Studies on perception of self through movement, depression scales as they pertain to perception of ability to move or inability to move, and communication of disability through movement patterns are examples of possible directions that movement research might go. Pilates is now being subjected to multi-faceted research and is likely to become commonplace for rehabilitation experts around the world. Many are not waiting for the research, but are quickly integrating Pilates-evolved exercises into their practices and reaping the benefits. Brent D. Anderson, PT, OCS, specializes in education and clinical reasoning of Pilates evolved exercises for rehabilitation and fitness professionals in Coral Gables, Fla. He is currently working on a doctorate in physical therapy at the University of Miami. References 1. Richardson C, Jull G, Hodges P, et al. Local muscle dysfunction in low back pain. In: Therapeutic Exercise for Spinal Segmental Stabilisation in Low Back Pain. London: Churchill Livingstone; 1999:61-68. 2. Richardson C, Jull G, Toppenberg R, et al. Techniques for active lumbar stabilisation for spinal protection: a pilot study. Australian Physiotherapy. 1992;38:105-112. 3. Richardson C, Jull G, Hodges P, et al. Overview of the principles of clinical management of the deep muscle system for segmental stabilization. In: Therapeutic Exercise for Spinal Segmental Stabilisation in Low Back Pain. London: Churchill Livingstone; 1999:93-102. 4. Porterfield JA. Dynamic stabilization of the trunk. J Orthop Sports Phys Ther. 1985;6:271. 5. Sahrman S. Diagnosis and treatment of movement system imbalances associated with musculoskeletal pain. Polestar Education lecture outline; 1996.
