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Victoria Moran PT, DPT, CST Disclosure: I do not have a relevant financial relationship.

Effective Ways to Integrate Pilates into a Physical Rehabilitation Program

Victoria Moran PT, DPT, CST, PI

Pilates Introduction • Joseph Pilates Creator of Pilates called “Contrology” • Contrology according to Mr. Pilates is the complete coordination of body, mind and spirit. Through Contrology you first purposefully acquire complete control over your own body and then through proper repetition of its exercises you gradually and progressively acquire the natural rhythm and coordination associated with all your mental and subconscious activities.

Pilates History • Joseph Pilates born in 1880 near Dusseldorf Germany suffered from Rickets,asthma and Rheumatic fever • Overcame his physical limitations by developing his own program of bodybuilding and exercise • Joe left Germany 1923 and immigrated to the United States during that time meeting his wife Clara a nurse • NYC Fitness Studio- sharing address with New York City Ballet • 1960”s Joe and Clara’s style of exercise termed Pilates

Pilates Today • Modified versions • Polestar Pilates- founded by president Brent D. Andersen, PhD,PT,OCS and co-founder Elizabeth J. Larkam ,MA, Feldenkrais practitioner • Polestar Pilates method incorporates Pilates, fitness and Rehabilitation • Provides the most comprehensive practice through the latest research in biomechanics, motor learning and communication

3 Guiding Pilates Principles

1. Whole Body Health 2. Whole Body Commitment 3. Breath

3 Structures Force Couple • Diaphragm

• Transverse Abdominus Multifidus

• Pelvic floor

Movement Principles Pilates Method Principles • Whole Body • Breathing • Balanced Muscle development • Concentration • Control • Centering • Precision Rhythm

Polestar Pilates Principles • Breathing • Axial Elongation/ Core control • Spine articulation • Organization of the head, neck and shoulders • Weight bearing and alignment of the extremities • Movement Integration

Breathing Muscles of inspiration • Diaphragm • External Intercostals • Accessory Muscles Sternocleidomastoid Scalenes

Muscles of Expiration • Abdominals • Internal Intercostals Pelvic Floor muscles

CORE • Neurological loop > Transverse Abdominus not working properly othe muscles dysfunctional Unable to stabilize (core/pelvis/hips)> Compensatory patterns> Poor load transfer> overuse> degeneration> Breakdown> Injury Crates Weakness in the Chain= Dysfunction

Principle 1- Breathing • Inhalation- facilitates spine stability when hips move into flexion or shoulders move into extension • Exhalation- facilitates spine stability when hips move into extension or when shoulders move into flexion

Jackrabbit on the reformer

Breath Directional Breath • Anterior inhalation =thoracic extension • Forced exhalation= spine flexion • Unilateral= Lateral flexion • Combination+ rotation, flexion and rotation

Pilates: • It is important to sustain postures →Leads to Core stability → directional breath facilitates movement

Principle 2 –Axial Elongation Core Control • Cervical spine Atlas Axis C3-C7 Thoracic spine –C7 landmark for posture • Lumbar spine Facets Spinous process

• Transverse processbody and disc Annulus and Nucleus

Principle 2- Axial Elongation Core Control • Pelvis Sacrum Coccyx Iliac crest Pubis Symphysis Ischial tuberosities ASIS PSIS Musculature Polestar Pilates principles of movementPolestar Pilates Education 2008

Principle 2- Axial Elongation Core Control

Core control • Force couples- ( TA ( transverse abdominus, pelvic floor (PF) and multifidus Vleeming- Muscular slings: AOS-anterior oblique slings POS-posterior oblique slings DLS- Deep longitudinal Lateral system

Principle 2-Axial Elongation Core Control • Lumbopelvic hip complex functional link in the chain • Local and Global muscles of the articulating spine • Weakens with age

Principle 2- Axial Elongation Core Control • What does this mean??? • Core muscles effect what goes on in upper and lower extremity • Group provides stability for body • Allows us to perform activities

Principle 3- Spine Articulation • • • •

Cervical spine 1-7 Thoracic 1-12 Lumbar 1-5 Sacrum

Sagital plane Flexion/Extension Coronal plane Lateral flexion Abduction/Adduction Transverse plane Rotation Internal/External Rotation

Spine Articulation Local Muscles (2-3

Global Muscles ( 4-5 segments) • Rectus abdominus • External Obliques • Internal Oblique- anterior fibers • Quadratus Lumborum (QL)-lateral fibers • Longissimus thoracicsuperior fibers • Iliocostalis lumborumsuperior fibers

Segments) • Transverse abdominus • Pelvic Floor (PF) • Multifidus • Intertransversarri • Interspinales • QL- medial fibers • Internal Obliques- posterior fibers • Longissimus thoracicinferior fibers • Illiocostalis lumboruminferior fibers

Principle 4- Organization of the Head, Neck and Shoulders • Skeletal anatomy • Muscular connections • Joints of the head, cervical spine 9OA, AA) , shoulders and scapula ( GH, SCT, AC, SC )

Principle 4- Organization of the Head, Neck and Shoulders Force couple of the • RTC shoulders• Rotator cuff muscles • Deltoid- maintain good alignment( not allowing humeral head migrate anterior) of humeral head with Shoulder elevation

Principle 4- Organization of the Head, Neck and Shoulders Forces Couples of the shoulder Posterior oblique sling• Latissimus Dorsi • Thoracolumbar fascia • (contralateral) Gluteus Maximus

Principle 4- Organization of the Head, Neck and Shoulders Scapular RotatorsUpward Rotation • Upper Trapezius • Lower Trapezius • Serratus Anterior Downward Rotation Pectoralis Minor Levator scapula Rhomboids

Principle 4- Organization of the Head, Neck and Shoulders • Force couples of the shoulder girdle • Not working properly →faulty movement patterns →poor posture→Pain/weakn ess→Breakdown→Inj ury

Principle 4- Organization of the Head, Neck and Shoulders • Arm Arcs

• Assisted Roll Up

Principle 5- Alignment of the Weight Bearing of the Extremities Lower extremity • Pelvis • Femur • Tibia • Fibula • Ankle joint • Foot- bones of feet

• • • • • •

Upper extremity Humerus Radius Ulna Wrist Hand-carpals, metacarpals, phalanges

Principle 5- Alignment of the Weight Bearing of the Extremities • Muscles and fascial connections of the upper and lower extremities Humerus Tricep ( posterior) Bicep (anterior) Forearm Wrist extensors Wrist Flexors

Thigh-Anterior ( Quads, Sartorius), Lateral( )Medial (Adductors) Posterior ( Hamstrings) Leg Compartments Anterior ( AT, EDL,EHL) Lateral ( PL,PB) Posterior Deep ( PT, FHL, FDL) Superficial ( Gastrocnemius, Soleus)

Principle 5- Alignment of the Weight Bearing of the Extremities • Ideal alignment Look at the entire kinetic chain Feet to head-Head to feet Standing roll down

Leg pull Front

Principle 6- Movement Integration • Integration of movement of many joints and in multiple planes

Motor control • Task- stable vs unstable • Movement• Environment- lighting, space • IndividualPerception, Cognitive, Action

Principle 6- Movement Integration

• Assistance=Springs Passive Assistive Gravity Eliminated Movement against gravity Resistive Base of support/ Center of Gravity Balance/Proprioception Coordination Range of motion Lever length

Book Opening

Integrating Pilates into Physical Rehabilitation Assessment • FMS- Gray Cook and Lee Burton • Posture- Dr.Vladamir Janda ( upper/ lower cross syndromes) • Plumb line from ear to ankle • Gait Analysis

Integrating Pilates into Physical Rehabilitation • Consider the patient • Do not take a cook book approach • Progress appropriately master the basic exercises first before progressing to more challenging exercises • Sports specific

Integrating Pilates into Physical Rehabilitation Equipment • Springs- 5 reformer different colors • Green= 1 1/2 spring • Red= 1 spring • Blue= 1/2 • Yellow= 1/3 • Chair= 4 springs • Set up/Safety • Contraindications and Precautions to exercise

Pilates Training for use in Rehabilitation after Total Hip and Knee Arthroplasty: A Preliminary Report • Levine B et al • 38 patients • Trained pre-post operatively with a certified Pilates instructor • Follow specific post-op protocol -2-6 wks • 3-4x week for 1-2 hours • Follow up 1 year

Table- 1 TKR Protocol

Hundred ½ roll down Single leg circles Single leg stretch Double leg stretch Single straight leg stretch Double straight leg stretch Criss Cross Spine stretch forward Saw Swan prep Single leg kick Shoulder bridge, modified swimming Aside kick , variations Teaser prep 1 and 2

Clin Orthop Relat Res. 2009;467(6)1468-1475

Levine B et al Postoperative TKR Protocol 6 weeks – 6 months • All prior exercises • Full roll up • Double leg kick • Corkscrew • Neck pull modified • Shoulder bridge • Spine twist • Side kick, variations • Teaser 1 • Swimming • Serratus push up. Modified • Push up, modified

6 months + Previous exercises Rolling like a ball Open leg rocker Swan Neck pull Side kick, variation Teaser 2 Can can , modified Hip circles, modified Serratus push up Mermaid , modified Leg pull up, modified Push up

Pilates Training for use in Rehabilitation after Total Hip and Knee Arthroplasty: A Preliminary Report • Levine B et al conclusion: • Phone follow up postoperative 1 year • Determined only by patients satisfaction with using Pilates • 25 of the patients stated extremely satisfied with outcome following Pilates protocol and 13 stated were satisfied

Table -2 THA Pilates protocol 2-6 weeks Hundred ½ roll down Single leg circles Single leg stretch Double leg stretch Single straight leg stretch Double straight leg stretch Criss Cross Spine stretch forward Saw Swan prep Single leg kick Shoulder bridge, modified swimming Side kick , variations Teaser prep 1 and 2

Levine B et al Postoperative THA Protocol 6 weeks – 6 months • All prior exercises • Full roll up • Rolling like ball • Double leg kick • Corkscrew • Neck pull modified • Shoulder bridge • Spine twist • Side kick, variations • Teaser 1 • Swimming • Can, can Modified • Hip circles ,modified

6 months + Open leg rocker Swan Neck pull Side kick, variations Teaser 2 Can can Hip circles Mermaid , modified Leg pull front, modified Serratus push up, modified or full Push up, modified or full

Cervical/Thoracic Spine Cervical spine Conditions/Diagnosis: • OA • FHP • Thoracic spine Conditions/Diagnosis Scoliosis- Right thoracic Left lumbar Kyphosis

Cervical Spine Exercises • Chest lift- beginner exercise mat exercise • Swan on chairIntermediate exercise • Long Box Series on reformer- Pull straps • Advanced exercise

• Chest Lift

Cervical- Intermediate • Swan on Chair

Long Box Series on Reformer

Thoracic Spine- Beginner • Swan –Beginner exercise mat • Spine corrector – Roll down reach Intermediate exercise on spine corrector using partial range of motion • Swan- Advanced exercise on chair

• Swan on Mat

Thoracic spine-Intermediate • Spine corrector

Thoracic- Advanced • Swan on chair

Limbs- Upper Limbs • Identify Impairments • Most common shoulder issues • 1. Impingement • 2. Tendonitis • 3. Faulty Posture

Limbs- Upper Limbs • Shoulder/ shoulder girdle RTC tear TSR • Elbow Tennis elbow Golfers elbow • Wrist/ Hand Sprain

Shoulder Exercises • Arm Arc- beginner • Arm Arcs mat • Supine arm seriesIntermediate on reformer • Scapular seriesAdvanced exercise on chair

Upper limbs - Intermediate • Supine arm series on reformer

Upper Limbs-Advanced • Scapular series on chair

Limbs- Lower Extremities • HipTHR Tendonitis • Knee TKR/OA PFP • Ankle Sprains

Hip and Knee ExercisesBeginner • Femur arcs- beginner exercise on mat • Double leg pumpIntermediate on chair progress to split pedals • Scooter- Advanced exercise on reformer

• Femur Arcs-Mat

Limbs-Lower extremitiesIntermediate • Double/single leg pumps on chair

Limbs-Lower extremitiesAdvanced • Scooter on Reformer

Ankle Exercises • Seated foot workBeginner exercises on reformer • Frog lying flat and single leg pumpIntermediate on chair • Jumps- Advanced on reformer

Ankle-Intermediate • Frog lying flat and single leg pump on chair

Ankle-Advanced • Jumps on reformer

Spine • Lumbar Disc herniation Post-op Arthritis • Sacrum Dysfunction

Spine Exercises • Roll up-Beginner exercise on mat • 100’s with changing leg positionIntermediate exercise on reformer • Teaser- Advanced exercise on chair

Spine- Intermediate • 100’s on reformer with changing leg height

Spine -Advanced • Teaser on chair

Sport specific Swimming• Mat- swimming exercise • Swan on chair • Spine corrector

Sports- Swan on chair

Sports- Spine corrector

Sport specific Tennis • Kneeling arm series on reformer • John Travolta on reformer • Scapular/ shoulder series on chair

Sports-John Travolta

Sports- scapular/shoulder series on chair

Questions!!!!! Thank you ! Victoria Moran PT, DPT , CST, PI 30 East 60th street Suite 904 NY, NY 10022 [email protected]

References • • •

Polestar Pilates Educational Manual-2008 United States Clin Orthop Relat Res. 2009;467(6)1468-1475 https://pixabay.com