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Options for integrating Pilates training in treatment and rehabilitation will be presented in this chapter, using examples of symptomatic patterns, typical of those encountered in our treatment centers. The effectiveness of the Pilates method, and its intelligent application through a structured process, will be illustrated, along with the benefits for those experiencing health issues.

9.1 Orthopedic (Chronic/Acute)

9.1.1 Chronic Lumbar Syndrome

9.1.1 Patient Example

9.1.1 Case History

Mr. M. complains of persistent back pain, dating back over a period of 4 years. He is a 52-year-old chemist and takes part in some sport (soccer or swimming weekly). His symptoms are not triggered by overloading, but started slowly and become worse with prolonged standing and sitting. Mr. M. has suffered recurring episodes of “low back pain”, which have increased in frequency during the last 12 months.

9.1.1 Findings

  • In standing, presents with an overall flat back and slight posterior pelvic tilt. Knees are hyper-extended, feet and legs are externally rotated.

  • During forward bending, weight shifts strongly over the heels, middle and lower lumbar spine move into strong flexion. Mr. M. complains of a slight pulling pain in the lower back. Distance from fingers to floor is 3 cm.

  • The Safety Test (Laségue – straight leg raise test, for nerve irritation) shows no involvement of the disc or other severe pathology.

  • Muscle testing and the Pilates screening reveal weak abdominal muscles, strong contractures in the hip and pelvic area, and poor segmental segmental stability of the lumbar spine.

9.1.1 Therapeutic Pilates Program

Mr. M. is currently in the subacute phase (phase II), ready to move into the rehabilitation phase (phase III). The Pilates exercises selected should therefore be active/assistive, with a focus on mobilization of the lumbar spine incorporating axial elongation, and dissociation, to relieve stress on the lumbar area. In addition, freedom of movement in the hip/pelvic area should be increased, and trunk strength improved, particularly in areas of segmental instability.

Exercises

1. Reformer:

  • Footwork in all positions (particularly spiraling movements – i to improve mobility in the hip/pelvic area)

  • Abdominals supine

  • Feet in Straps: parallel and closed

  • Quadruped

  • Standing Hip Stretch

2. Chair:

  • Swan

  • Hamstring I

3. Cadillac:

  • Roll Down Series

  • Breathing

4. Mat exercises:

  • Hundred

  • Single Leg Stretch

  • Bridging

  • Dart

  • Assisted Roll Up

9.1.1 Results

The Pilates program above was performed twice a week, for a period of 6 weeks. Afterwards, Mr. M. continued his mat exercises with appropriate progressions at home, and joined a Pilates group session once a week. Due to gains in segmental articulation and dynamic stability, and alterations in posture and everyday movements, Mr. M. no longer suffers from back pain.

9.1.2 Impingement Syndrome

9.1.2 Patient Example

9.1.2 Case History

Mr. S. is 42 years old, runs an insurance firm. He has complained for several months of pain in the right shoulder, which is aggravated by lying on the side for long periods, and by overhead movements. Mr. S. jogs twice a week and plays tennis occasionally.

Previous Therapy: Mr. S’s doctor has diagnosed a subacromial impingement, and slight inflammation of the supraspinatus tendon. He was given a cortisone injection, and anti-inflammatory drugs to be taken if needed.

9.1.2 Findings

  • Mr. S. has an excessive thoracic kyphosis when standing, and is slightly overweight.

  • An examination of active movement reveals a painful arc between 80° and 120° of flexion. The shoulder is raised, the end of movement range is 170°. Both shoulders are protracted.

9.1.2 Therapeutic Pilates Program

The thoracic spine provides the foundation for the shoulder. The organization of this area plays a key role and influences the mechanical function of the glenohumeral joint. Sufficient thoracic extension is essential during bilateral elevation of the arms, and unilateral rotation during single arm movements, in order for the joint surfaces to be aligned correctly in the plane of movement. Balanced strength relationships within the shoulder girdle muscle system are crucial. Breathing, and the motions associated with breathing, can have a strong influence on the shoulder region.

The Therapeutic Pilates Program focuses on mobilization of the thoracic spine and stabilizing exercises for the shoulder joint, taking these functional relationships (and the parameters of the subacute stage (Phase II) of rehabilitation) into account. Following successful dynamic stabilization over smaller ranges of motion, increasingly complex exercises can be added.

Exercises

1. Cadillac:

  • Shoulders with Tower Bar

  • Breathing

  • Push Through, Sitting in Front of Cadillac

2. Reformer:

  • Arm Work

  • Abdominals Supine

  • Standing Hip Stretch

3. Chair:

  • Reverse Swan

  • Side Arm Twist

4. Mat exercises:

  • Book Opening

  • Dart

  • Swimming

9.1.2 Result

After 8 weeks, during which time he also received manual therapy for the shoulder as well as functional taping for support, Mr. S. was able to move the unweighted arm without pain. A further 6 weeks were necessary before he was able to move the arm while remaining virtually free of pain during sports. He added occasional Pilates sessions to his other sporting activities, and regularly performed corrective stretches using the Pilates foam roller.

9.2 Neurology (Peripheral/Central)

9.2.1 Condition Following Discectomy with Partial Paralysis

9.2.1 Patient Example

9.2.1 Case History

A sequestrum was removed from Mrs. P.’s L4 area using microsurgery 5 weeks ago; this had been causing partial paralysis of the right calf muscle for a number of weeks. She is a business consultant, 46 years of age, enjoys intense sports and currently has light pain in the back under stress. However, she is unable to climb stairs easily or walk rapidly, due to the partial paralysis.

Previous Therapy: Postoperative physical therapy focused on isometric stabilizing exercises. She also received muscle-stimulating electrotherapy.

9.2.1 Findings

  • Mrs. P. presents a sway-back posture when standing.

  • She unloads her right side.

  • She is unable to perform a Heel Raise standing on her right foot.

  • The Lasègue Test is negative. Other, potentially stressful tests have been avoided.

  • Medical guidelines recommend active rehabilitation for up to 3 months following surgery. Mrs. P. should avoid sitting for longer than 15 minutes, and avoid active flexion for the first 3 postoperative months.

Mrs. P. would like to complete her rehabilitation in our Therapy Center, and include Pilates training in her program.

9.2.1 Therapeutic Pilates Program

Mrs. P. is in the subacute phase (Phase II). Following medical recommendations, training focuses on stability of the back, and strengthening of the right leg. Mobilizing exercises at the site of the operation must be avoided, but adjoining vertebral segments are mobilized, to avoid movement deficits in the thoracic spine as a result of lumbar spine issues.

Exercises

1. Reformer:

  • Footwork: double leg for stabilization, single leg (right) for strengthening

  • Arm Work

  • Quadruped

2. Cadillac:

  • Shoulders With Tower Bar

3. Chair:

  • Swan (only thoracic spine)

  • Leg Pump, standing

4. Mat exercises:

  • Dead Bug

  • Side-lying

  • Dart

  • Leg Pull Front

9.2.1 Result

The program was followed 2 or 3 times per week, with gradual modifications and increased challenge. The strength of Mrs. P’s right leg was restored to 80 % after 3 months, and she was feeling increasingly robust. Her intention was to begin swimming training, and continue to practice Pilates once a week, in private sessions or in group reformer classes.

9.2.2 Multiple Sclerosis

9.2.2 Patient Example

9.2.2 Case History

Mrs. W. is 51 years old, and was diagnosed with multiple sclerosis 4 years ago. The disease has an insidious pattern of progression. Mrs. W. complains of disturbed gait, feeling unstable when climbing stairs, and weakness throughout the body but particularly on her left side.

Previous therapy: So far, Mrs. W. has taken part in an inpatient rehabilitation program. She attends physiotherapy (PNF / Vojta) once a week, and is treated by a neurologist and a doctor specializing in holistic treatment.

9.2.2 Findings

  • A slightly reduced level of tone can be observed on the left side of the trunk and shoulder when standing, and she also favors that side.

  • When taking a step forwards from standing, her weight shifts strongly to the left in the standing phase of gait.

  • Her gait is unsteady, and the length of step is asymmetric.

  • A modified fitness test identifies decreased strength on the left side of the body, particularly the hamstrings.

  • Trunk stability is noticeably reduced.

9.2.2 Therapeutic Pilates Program

Using Pilates exercise to support those suffering from neurological diseases, requires specialized knowledge and experience. As Multiple Sclerosis is caused by damage to the central nervous system, and only minimally affected by classical training principles, the therapeutic focus emphasizes those parts of the body as yet unaffected by the disease. Causing additional fatigue, exhaustion, disappointment or frustration during Pilates training must be avoided.

The trunk muscles and connections to the extremities must to be stimulated and stabilized, with particular emphasis on the functional muscle chains; the closed kinetic chain commonly provides the most appropriate starting point for this.

Warning

Avoid fatigue/exhaustion and frustration when working with patients suffering from multiple sclerosis!

Exercises

1. Reformer:

  • Footwork (double leg) using light springs (avoid hyper-extending the knees!)

  • Bridging with heavy springs

  • Combined Arm and Footwork

2. Cadillac:

  • Push Through, Sitting in Front of Cadillac

  • Breathing

3. Chair:

  • Leg Pumps: Sitting, followed by Standing Leg Pumps

4. Mat exercises:

  • Chest Lift

  • Bridging

  • Side-lying

  • Dart

  • Possibly Roll Down

  • Standing into Push Up

9.2.2 Result

Expectations must be modified from the start, due to the prognosis of the disease. The preservation of function, and both psychological and physical stabilization, are most important. Mrs. W continues with Pilates on a weekly basis, and has been delighted by the physical achievements which have been possible, due to the unique nature of this training method.

9.3 Other Medical Conditions

9.3.1 Oncological Issues

Pilates training can play an important role in supporting cancer patients, particularly if a positive perception of the body can be reinforced through movement. The underlying philosophy of the Pilates method emphasizes the development of both internal (“mind”) and external (“body”) facets of health. A number of projects corroborate the beneficial effects of exercise and sport in general (Dr. Freerk Baumann, Sporthochschule Köln, http://innere1.uk-koeln.de/forschung/ag-sportonkologie). This applies particularly to Pilates training, which specifically emphasizes the whole body and the whole person throughout the training process.

Although positive findings and experiences have been associated primarily with training on an individual basis up to now, group training concepts have recently been developed in consultation with oncologists, with the goal of assisting those suffering from oncological diseases to stabilize their bodies and health.

9.3.2 Rheumatoid Arthritis

This chronic disease has a systemic nature, with two forms of progression.

Episodic Progression

In this form of the disease, periodic episodes of inflammation alternate with periods of relatively little irritation. Periods of inflammation are characterized by the exaggerated response of the local mucous membrane, which may cause damage to parts of the joint. This may result in functional limitation, and partial destruction of joint structures causing loss of passive stability.

Warning

Pilates training is not advised during inflammatory phases, due to the generalized nature of the inflammation.

Once acute episodes have abated, Pilates sessions can emphasize gentle, active training within a stable and secure range. The objectives of training are dynamic and static stability of all joints, pain-free mobility and everyday functional stability.

Slow Progressive Development

In these cases the inflammatory processes are insidious, gradually resulting in continuous pain and permanent damage.

Pilates sessions focus on gentle, active training. While fatigue should be avoided, a lack of challenge is not helpful. Both individual and group training are options, with an emphasis on maintaining strength, correcting misalignments, and functional training of all structures (▶ Chap. 4, ◘ Table 4.2, Functional Training Stimuli).

9.3.3 Fibromyalgia

Sometimes referred to as soft tissue rheumatism, Fibromyalgia is characterized by multiple trigger points in the musculoskeletal system, and painful irritation in other connective tissues of the body. A psychological component can sometimes be identified, with similarities to depression.

Depending on subjective symptoms, Pilates training emphasizes pain-free movement. It can improve the general circulation, help to balance the autonomic nervous system, and develop strength and dynamic stability.

9.3.4 Burn Out/Vegetative Dystonia

Burnout syndrome is a disease of modern civilization. Also known as exhaustion syndrome, the physical symptoms may include neck and shoulder pain, ringing in the ears, and indigestion. Similarly, Fatigue syndrome refers to the phenomenon of exhaustion and weakness which are not improved by recreation, rest and sleep. Instead, weakness is persistent and in severe cases, may lead to physical and mental breakdown.

Pilates training provides an opportunity to improve self-awareness through calm, steady exercise, thereby establishing a more stable relationship between external demands and internal resources. As an accompaniment to therapeutic intervention, Pilates training focuses on enjoyable exercises that encourage mindfulness and awareness.

9.4 Surgery

9.4.1 Condition Following Hip or Knee TEP (Total Endoprosthesis)

Following hip or knee joint replacement, Pilates training can be introduced, to develop physical capability, and alter and improve pathophysiological patterns of movement that preceded surgery. Conditions such as atrophy and movement inhibition, which may result from surgery, should be addressed in accordance with medical recommendations, and with reference to the appropriate phase of rehabilitation.

9.4.2 Ligament or Tendon Surgery

Following surgery (for example, suture of the supraspinatus tendon or replacement of the cruciate ligaments of the knee) the affected tendon or ligament represents the limiting structure. While following postoperative guidelines, these structures can be subjected to early functional stimuli through Pilates training (although usually only with use of the Pilates equipment). The surrounding structures can safely be reorganized and strengthened.

9.5 Summary

◘ Table 9.1 summarizes clinical disorders and respective therapeutic Pilates programs.

Table 9.1. Overview: disorders and therapeutic programs
Full size table

9.6 Low-Risk High-Risk Model and “Novice to Expert”

The judgment of the therapist or trainer plays a decisive role when planning therapy, with the professional background and experience of the therapist/trainer providing important parameters for this evaluation.

In a win-win situation, the knowledge, expertise and experience of the therapist/trainer will match the issue the patient is dealing with. A situation where skills and knowledge of the condition at hand are insufficient may result in the therapist/trainer becoming overwhelmed.

Legal guidelines exist in the medical field, and must be observed when working with those suffering from medical conditions:

  • Therapists, sports teachers and trainers are not qualified to provide diagnoses, and should therefore avoid defining the causes of a disease. They are dependent on the diagnosis provided by a physician, and must determine their therapeutic approach based on this diagnosis.

  • Prevention means avoiding the development of symptoms. Preventative classes are not suitable for those suffering from medical conditions, as they may prove inappropriately challenging in the given circumstances. Individual instruction following consultation with the supervising doctor may be more appropriate.

  • Specialized symptoms require specialized knowledge. There is an obligation to only work with those conditions for which sufficient knowledge and experience have been acquired.

In view of the above, the Low-Risk/High-Risk model can be used to clarify the appropriate level at which one can apply ones professional skills.

9.6.1 Low-Risk High-Risk Model

9.6.1 Low-Risk Patients/Clients

9.6.1 Stage 1

The majority of clients taking part in preventative Pilates are not currently receiving medical or therapeutic treatment, or experiencing acute symptoms. In the absence of limitations due to pre-existing conditions, a client can begin training at an appropriate level, after determining current physical capabilities (for example, using a Pilates fitness screening).

A qualified Pilates trainer who has completed a professional Pilates education can work successfully with clients at this stage, even with relatively little experience.

9.6.1 Stage 2

If there are no current, acute symptoms, but there is a fundamental, physical issue, certain movements may be prohibited and individual modifications necessary. This level of challenge for the trainer is increased.

Example

Conditions

  • Chronic spinal disorders

  • Temporary knee, hip and shoulder disorders

  • Slightly decreased bone density (up to 10 %, age-compared)

In order to fulfill the needs of the client, the Pilates trainer requires specialized knowledge of, and experience in dealing with, the specific condition. He must also be prepared to adapt his teaching both didactically and methodically, particularly when teaching a group. It is important to avoid either overloading or underchallenging participants.

If the trainer is not sufficiently qualified, he may consult with a therapist or a qualified trainer for an analysis and training program.

9.6.1 High-Risk Patients/Clients

9.6.1 Stage 3

If clients who are currently experiencing acute or subacute symptoms (▶ Chap. 7) approach a trainer for support, professional knowledge and experience are vital. Decisions about the content, duration and form of Pilates training must be clearly documented, allowing any positive or negative effects to be observed, as conditions can vary greatly according to the individual.

Example

Conditions

  • Acute and subacute spinal disorders

  • Subacute tendonitis (shoulder, elbow, knee)

  • Oncological patients, not currently undergoing therapy

Group classes can only be recommended for these clients under special circumstances; for example, a Pilates back care group led by a qualified physiotherapist or sport teacher.

9.6.1 Stage 4

Stage 4 demands extensive experience, coupled with an appropriate depth of professional knowledge. Only in this way can critical situations be detected and thus avoided. The training program must constantly be reassessed, revised and restructured.

Example

Conditions

  • Patients with unstable circulation

  • Acute symptoms

  • Oncological patients, who are currently undergoing therapy

Training programs in stage 4 should only be planned and conducted by qualified therapists.

Warning

Group training is precluded in stage 4!

9.6.2 “Novice To Expert”

The competence of therapists and trainers is dependent on the following factors:

  • Basic vocational qualification

  • Personal physical and cognitive competence

  • The quality of their Pilates certification

  • Experience in the work environment

  • Continuing education and development

  • Application and evaluation

Every therapist/trainer is required to demonstrate that he/she can meet the challenges presented by the working environment, through completion of continuing education and specialized courses. This is particularly important when working with patients, in the medical field. In the absence of a basic professional qualification, one has a responsibility to patients, to act within the boundaries of one’s knowledge.