Introduction to Pilates-Based Rehabilitation
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Originally published by Orthopaedic Physical Therapy Fall 2005
Clinics of North America
Introduction to Pilates-Based
Rehabilitation
Brent D. Anderson, PT, OCS and Aaron Spector, MSPT
Brent D. Anderson
resulting in a long recovery period
fig. 1 and an inability for peak performance.
Unique at the time, Pilates’ method
allowed and encouraged movement fig. 3
early in the rehabilitation process, by
providing needed assistance. It was difficult as a result of the relationship
found that reintroducing movement of gravity on the body (fig 3). On
with nondestructive forces early in the the apparatus, springs and gravity are
rehabilitation process hastened the used to assist an injured individual to
healing process. As a result, it was not be able to complete movements suc-
long before the dance community at cessfully, aiding in a safe recovery (fig
large adopted Pilates’ work. 4). Ultimately, by altering the spring
More than 70 years later, Pilates’ tension or increasing the challenge
techniques began to gain popularity in of gravity, an individual may be pro-
the rehabilitation setting. In the 1990s, gressed toward achieving functional
Origins of Pilates-based work in many rehabilitation practitioners were movement.
rehabilitation using the method in multiple fields
of rehabilitation, including general
As a child, German-born Joseph H.
orthopaedic, geriatric, chronic pain,
Pilates (fig1) suffered from a multi-
neurologic rehabilitation, and more.
tude of illnesses resulting in muscular
Within the rehabilitation setting,
weakness. Determined to overcome
most Pilates exercises are performed
his frailties, he dedicated his life to be- fig. 4
on several types of apparatus (fig 2).
coming physically stronger. He stud-
The apparatus work evolved from
ied yoga, martial arts, Zen Meditation,
Pilates’ original mat work, which was Today, despite an increased number
and Greek and Roman exercises. He
worked with medical professionals, in- of health care practitioners using the
cluding physicians and his wife Clara, Pilates-based approach in rehabilita-
a nurse. His experiences led to the tion, there is still a lack of supportive
development of his unique method literature examining the phenomena
of physical and mental condition- associated with Pilates-based tech-
ing, which he brought to the United niques within the field of rehabilita-
States in 1923. In the early 1930s tion. This article discusses theoretic
and 1940s, popular dance instructors foundations of the results experienced
and choreographers, such as Martha by Pilates-based practitioners in the
Graham, George Balanchine, and field of rehabilitation. Current scien-
Jerome Robbins, embraced Pilates’ tific theories in motor learning and
exercise method. As elite performers, biomechanics are examined to explain
fig. 2 the principles of this old method of
dancers often suffered from injuries
movement reeducation.Motor learning and trunk control to facilitate controlled movement.
associated with the Pilates-based en- Such a phenomenon is at the root
vironment of Pilates-based work. It was Pilates’
The Pilates-based environment belief that core control was the essence
is conductive to designing task-ori- of controlling human movement (12).
ented interventions. Within this Richardson and Hodges (14, 16) also
environment, a faulty movement can identified the transversus abdominus
fig. 5
be broken down into components us- muscle as being a primary postural
ing springs and changing the bodies control muscle. It is hypothesized that
orientation to gravity. By successfully the transversus abdominus is activated
evaluating a patient’s needs and access- at a subconscious and submaximal
ing the desired movement outcome, contraction, as part of the motor
be it jumping, sitting, reaching, rotat- plan, to provide trunk stiffness during
ing, or walking, one can easily design dynamic movement. This approach
a similar movement but with the to core control supports the theory
appropriate level of load to the limb of movement advocated by Pilates- and range of a movement often suf-
or trunk to support it while it heals. evolved practitioners, more so than fer. The Pilates-evolved environment
Adapting environmental constraints, traditional methods. Pilates-evolved allows the therapist to decrease the
such as gravity and base of support, is a term used to differentiate practi- proprioceptive challenge by increas-
reduces the degrees of freedom that tioners who are continuing to define ing the base of support and providing
must be controlled by the nervous and expand on Pilates’ work from the adequate assistance and feedback for
system (5). The manipulation of the traditional Pilates practitioners. an optimal motor learning environ-
environment can hasten the reeduca- The goal of achieving efficient ment. The movement sequence can
tion process. As the movements are movement and returning to functional then be progressed by decreasing the
successfully completed, the patient movement and enhanced performance assistance and amount of support,
can be progressed by decreasing the is the foundation of Pilates-evolved ensuring that the quality of the move-
assistance or changing the orientation work. Pilates-evolved exercises are ment does not suffer. A therapist could
to gravity until the desired outcome thought to facilitate such movement then continue the progression toward
is achieved. Commonly, trunk control behavior by allowing the patient to be a more functional task and familiar
is a desired outcome for functional in a position that minimizes unwanted orientation with gravity. Traditional
movement and requires successful muscle activity, often responsible motor learning theory would teach
integration of all its components to for inefficient movement patterns that a cognitive level of learning take
maintain a normal orientation to and early fatigue, which can lead to place first with internal and external
gravity. injury. When a desired movement is feedback. Once association takes place
Research has looked at the im- challenged by a decrease in proprio- and the patient continues to practice,
portance of trunk control, led by ception, individuals often overrecruit the new movement sequence may
Richardson and Hodges in Australia muscles in an attempt to stabilize. become automatic. It is this automatic
(14, 16, 21). Their research focused Although it has not been proved, it execution of new movements that re-
on defining the activity of trunk remains plausible that overstabiliza- duces the risk of reinjury and increases
musculature among healthy subjects tion or faulty stabilization inhibits efficiency.
and subjects experiencing chronic efficiency and often acts as a hindrance Another important factor for attain-
low back pain during upper extrem- to efficient movement. For example, ing automatic movement is neurologic
ity movement. The results support a patient may be able to demonstrate feedback from the deep muscles of the
the importance of core stiffening of a 90-degree straight leg passively, but trunk, or the multifidi. The multifidi
the trunk muscles in preparation for when asked to lay on his or her side, muscles have six times the number of
movement of the extremities. For with a decreased base of support, the muscle spindles of any other muscle
the purpose of this article, the word available range of motion on the hip in the trunk (9-11). This great source
core is synonymous with trunk. Core drastically decreases (fig 5). When of kinetic feedback plays a large role in
stiffening is not thought to restrict the base of support and balance are trunk awareness. Richardson et al (14)
movement of the spine but instead challenged, the degree of efficiencyshowed that patients with chronic low other, providing greater variety in the sired movement of the extremity (fig
back pain recruited their multifidi precision of the therapist’s modifica- 6)). Disassociation combined with
with different timing and magnitude tion of selected movements. stabilization provides a favorable
of contraction compared with normal environment for protecting further
subjects. The healthy subjects showed Polestar Education trauma to spine lesions. The large
symmetric recruitment bilaterally of Another example of an optimal muscles that are often guilty of the
the multifidi muscles, whereas the environment for motor learning is unwanted splinting (i.e. quadratus
subjects experiencing low back pain found in Polestar Education, a Pilates- lumborum, gluteus maximus, and su-
showed asymmetry of the multifidi on evolved education company focusing perficial erector spinae) can be taught
the affected side. Another study using on rehabilitation (1). Polestar Educa- to lengthen eccentrically, allowing the
ultrasonography showed a discrepancy tion has defined the process of motor hip to absorb and distribute efficiently
at segmental levels in multifidus girth, reeducation to the spine by breaking potentially harmful flexion forces to
correlating to the site of the lum- it down into three phases. the spine.
bar lesion (14). Theoretically, if the Phase I: Assistive movement
multifidi and other deep paraspinal Stabilization
Assisting movement with the use In the early phase, the interest is
muscles are inhibited secondary to
of springs can allow for a decrease of in recruitment of deep stabilizers (i.e.
pain and pain inhibition, one could
unwanted muscle activity or guarding transversus abdominus, internal and
hypothesize that the same process
often associated with pain or weak- external abdominal obliques, and
would inhibit the proprioceptive
ness. Phase I, according to Polestar, multifidi muscles). The stabilizers
feedback mechanism of that muscle
can be broken down into three stages. consist largely of type I fibers and are
(i.e., muscle spindle fiber). The loss
These three stages can exist simultane- thought to contract at a submaximal
of proprioceptive feedback leads to
ously. level, which is less than 30% to 40%
a decrease in trunk awareness and
control. Inhibition of core proprio- Disassociation of a maximal voluntary contraction.
ception may be responsible for faulty This submaximal contraction happens
Disassociation entails isolating
compensatory patterns that can result simultaneously while disassociating
movement at the hip or shoulder
in destructive forces that prolong the the extremities or segments above or
girdle, independent of pelvis or spine
healing process. Working to overcome below the lesion. As the extremity
movement. This isolation can begin
faulty compensatory movement pat- disassociates from the trunk and the
by creating an environment with a
terns is a fundamental goal in the pelvis remains in neutral, the deep
large base of support (i.e. in supine
Pilates-evolved method. Treatment stabilizers work efficiently to maintain
and offering assistance into the de-
and intervention goals are to improve
the proprioception of the trunk and
to minimize the destructive forces as
described by Porterfield and DeRosa
(13) in their phase II of rehabilitation
biomechanical counseling. Once the
patient has shown successful move-
ment without pain, the exercise is
progressed by decreasing the assistance
and challenging the base of sup-
port. This process is consistent with
Porterfield and DeRosa’s phase III
dynamic stabilization (13). The ability
to challenge proprioception through
a movement phase in the Pilates-
evolved environment is endless. The
three variables-base of support, length
of levers, and degree of assistance-can fig. 6
be manipulated independent of eachcontrol (fig 7). This efficient use of Phase II: Dynamic Stabilization Phase III: Functional Reeducation
the deep stabilizers and the decreased Dynamic stabilization involves Specificity training and functional
guarding is consistent with Porterfield challenging the newly acquired mobil- reeducation are popular concepts
and DeRosa’s phase I of rehabilitation, ity or stability in a more functional and in the field of rehabilitation. The
to control pain and to encourage bio- gravity dependent environment. This Polestar approach divides functional
mechanical counseling. phase is a continuation of disassocia- reeducation into two stages: (1) for-
tion, stabilization, and mobilization is eign environment and (2) familiar
phase I. By decreasing the assistance environment.
and base of support or increasing the
length of the levers, a movement or Foreign environment
exercise difficulty increases. Once the Task Specificity is a major focus
desired movement is restored, the of attention for those researching
newly acquired movement can be motor learning. Most research shows
fig. 7 challenged at a level appropriate for that neuromusculature reeducation
goals and expected outcomes. Elite has carryover only from task-specific
movers often require greater chal- movements. To teach a patient how
Mobilization to jump off one leg, practice should
lenges against gravity and resistance
Mobilization is the restoration than a more sedentary patient (fig consist of jumping off of one leg. It
of mobility to affected joints and 9). Efficiency of movement is the has been experienced clinically, how-
muscles. A therapist can contribute ever, that putting a patient back in
to the pathology if mobilization is too fig. 9 familiar environments too soon can
aggressive or premature. Conversely a lead to the patient seeking the path
lesion may be traumatized further if of least resistance, returning to old
mobility is not restored. This is why habits. To continue with the example,
the use of assistance is so crucial to if the patient does not tolerate jump-
restore the desired movement prop- ing against gravity, the patient can
erly. The Pilates-evolved environment be placed supine and asked to jump
allows the therapist to use appropriate with gravity eliminated (fig 10). In
feedback and assistance to facilitate a foreign environment, the desired
successful movement. As the therapist movement can be replicated with less
restores mobility to a target joint and proprioceptive challenges and destruc-
surrounding joints, the force can be tive forces, while providing necessary
distributed equally, minimizing de- verbal and tactile clues, facilitating the
structive forces (fig 8). motor learning process and allowing
the patient to perform the movement
goal. By incorporating breathing and correctly.
movement principles early in phase fig. 10
I activities, the ability of the patient
to recruit secondary stabilizers (i.e.,
erector spinae, external and internal
fig. 8
abdominal obliques, latissimus dorsi,
and deep pelvis musculature) im-
proves. The rectus abdominus should
be trained for more ballistic move- Familiar environment
ments because it is primarily a type II In the familiar environment stage,
fiber muscle (fast twitch). The focus the patient is returned to the specific
in this phase is still control. task in their day- to-day environment.
The movement task learned within the
foreign environment is progressed to
a familiar environment with a normalorientation to gravity. The patient is addressed motor learning principles Pilates-evolved approach in rehabilita-
then challenged and encouraged to and current research that helps sup- tion. Current research associated with
build adequate endurance and ef- port Pilates-evolved work as a viable connective and neurologic tissue and
ficiency of movement in the familiar mechanism of neuromuscular inter- the muscoskeletal system is considered
environment. Tactile and verbal clues vention for rehabilitation. in this section. Anthropometry is also
used in the foreign environment are Biological and Physiologic Prin- discussed as a contributing factor to-
repeated to help associate each cor- ciples Associated With the Pilates- ward seeking efficient interventions.
rect movement with the desired task Based Approach
(fig 11). The final goal is to become Connective tissue
Pilates-evolved work identifies vari-
autonomous with the movement. In Connective tissues provide sup-
ous biomechanical and physiologic
summary of motor learning applica- port, transmit forces, and maintain
properties that can help support the
tions to trunk control, this section has the integrity structurally. All connec-
tive tissue is made up of cells and ex-
tracellular matrix composed of fibers
and ground substance. The elasticity
of the connective tissue is based largely
on the ratio of collagen fibers to elastic
fibers found in the tissue (7, 19). A
large portion of connective tissue is
avascular or hypovascular. This lack
if vasculature would imply that nu-
trients are received through changes
in pressure gradients, osmosis, and
chemical and electric concentration
(7). The Pilates-based exercises pro-
vide a closed-chain environment that
facilitates compressive and decom-
pressive forces on the connective tis-
sues. It can be hypothesized, based on
animal research, that the degeneration
often experienced by immobilization
or lack of compressive and decom-
pressive sources can be as destructive
to cartilage as overuse to the cartilage
(6). Many connective tissue lesions,
such as osteoarthritis, osteoporosis,
degenerative disk disease, chronic sys-
tem arthritis, fascial pain syndromes,
and cartilage and ligamentous tears
and repairs, can benefit from closed-
chain movement when the load is
modified.
Nervous tissue
Malfunctions of the peripheral and
central nervous system continue to be
investigated as a source of orthopaedic
pathologies (2). The nervous system
can be temporarily compromised;
fig. 11
become ischemic; and provoke symp-toms of pain, paresthesia, weakness, not the most efficacious way to teach sequencing can be applied to a vari-
and decreased motor control (17). a patient movement or to facilitate ety of body types. The adaptability
Often these signs and symptoms take postural changes. Pilates-evolved of the clinical reformer allows the
on the appearance of a traditional or- practitioners have experienced that practitioner to consider variations of
thopaedic diagnosis but symptoms do movement performance and efficiency an individuals weight and height. A
not respond to traditional treatments, are facilitated best by using imagery good example is an exercise referred
such as injections, transverse tissue and feedback mechanisms instead of to as the hamstring arcs on the clinical
massage, ice, and muscle stretching. eliciting maximal voluntary contrac- reformer (fig 4). The objective of the
Practitioners often experience suc- tions or isolated muscle contractions movement sequence is to teach the
cess in decreasing symptoms through for gross strength. The movement patient to disassociate movement at
mobilization of the nervous system sequences on various Pilates apparatus the hip, while maintaining the pelvis
and its connective tissue. It might be allow the practitioner to modify the and lumbar spine quiet or neutral.
hypothesized, as described by Butler load to facilitate efficient movement The foot straps, as an extension of
(3), that the cases that fail the more accurately. This approach can be sup- the ropes, are attached to the feet.
traditional pathways (i.e., joint and ported with other basic principles of The springs are set so as to hold the
soft tissue mobilization, static rest, biomechanics and muscle physiology, legs effortlessly at approximately 45
bracing or stabilization exercises) such as muscle-length-tension curve degrees flexion. If the legs are long,
would do well with movement, or and velocity training. The variation of the ropes can be lengthened to provide
better stated, mobilization of the strength and mechanics of the joints the same level of assistance as can be
nervous system and its connective and levers through an arc of motion done for a person with much shorter
tissues. Pilates-based exercise can can be explained by the muscle-length- limbs. If the limb is heavy because of
serve sd s technique to mobilize the tension curve and movement velocity. muscle mass or fat, the springs can be
nervous system and its surrounding For example, the greatest assistance increased to balance out the weight
connective tissues, as described by the can be applied at the beginning and of the lower limbs can move with
practitioner. end of the arc, where the strength is control through space without losing
least, and the least assistance can be control of the pelvis and spine. The
Skeletal muscle applied through the middle of the flexibility of this environment can take
Skeletal muscle can be influenced arc, where the strength is greatest. into account multiple anthropometric
greatly by Pilates-evolved exercises. In the case of dynamic stabilization, configurations.
In contrast to traditional modes of the greatest resistance is applied in
muscle conditioning that seek maxi- the middle of the arc of movement, Conclusion
mal voluntary contractions, Pilates- where available torque is greatest. This In comprehending current mo-
evolved muscle conditioning focuses is also the range that is least vulner- tor learning theories, biomechanical
on recruitment of the most effective able to insult. Changing the velocity principles, neuromusculoskeletal
motor units. This form of recruitment can also vary the muscle physiologic physiology, and anthropometry, the
allows for an emphasis to be placed responses, allowing custom tailoring Pilates-evolved work can be perceived
on energy efficiency and quality of of the movement sequence to mir- as a viable and effective method of
performance. Physiologically, most ror the desired functional task of the movement reeducation. It is now
muscle recruitment during day-to-day patient (8, 9). necessary to subject this method to
activities occurs in postural muscles, the rigors of research to investigate
which contain predominately type I Anthropometry its validity as a cost-effective and ef-
fibers. By facilitating postural muscles Anthropometry deals with the ficient intervention for rehabilitation,
in the right sequence, a therapist measure of size, mass, shape, and in- postrehabilitation, and fitness. The
can assist a patient in improving the ternal properties of the human body use of Pilates-evolved methods in the
efficiency of static and dynamic pos- (4). In the Pilates-evolved environ- various fields of rehabilitation, includ-
ture and decreasing significantly the ment, the equipment adapts to many ing neurologically involved, chronic
likelihood of self-induced destructive human body variations. For example, pain, orthopaedic, performance based,
forces. Richardson et al (15) found the springs, ropes, and footbar of the and pediatric rehabilitation, merits
that the traditional method of eliciting clinical reformer can be adjusted such investigation.
an isolated volitional contraction is that similar properties of movementReferences 8 Nordin M, Frankel VH: tal stabilization. In: Thera-
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and ligaments. In: Basic Hodges P, et al: Overview Fig. 1 Joseph H. Pilates
Biomechanics of the Mus- of the principles of clinical
coskeletal System. Philadel- Fig. 2 Pilates-based rehabilitation
management of the deep
phia, Lea & Febiger, 1989 muscle system for segmen- Fig. 3 The Hundred mat exercisedemonstrates a movement Fig. 11 Jumping in a familiar en-
that is difficult because of vironment with a normal
the body’s relationship with orientation to gravity.
gravity.
Fig. 4 Hamstring Arcs on the Clini-
cal Reformer demonstrates
an assistive environment for
hip flexion and disassociation
at the hip joint.
Fig. 5 A, Straight leg raise test
demonstrating 90 degrees of
hip flexion. B, the Sidekick
mat exercise demonstrating
approximately 60 degrees of
available active hip flexion.
Fig. 6 The 90/90 exercise on the
Trapeze Table, demonstrat-
ing disassociation of the hip
joint in an assistive environ-
ment with a large base of
support.
Fig. 7 The Quadruped exercise
on the Clinical Reformer,
demonstrating stabilization
of the spine and pelvis with
disassociation at the shoulder
joint.
Fig. 8 The Roll Down exercise on
the Trapeze Table (A) and the
Spring-Assisted Spine Exten-
sion on the Combo Chair
(B), demonstrating spine
mobilization with spring as-
sistance.
Fig. 9 The Lateral Box Work ex-
ercise (A) and the Inverted
V Series exercise (B) on the
Clinical Reformer, demon-
strating advanced abdominal
work and dynamic stabiliza-
tion.
Fig. 10 Jumping on the Clinical
Reformer, demonstrating an
exercise in a foreign environ-
ment.You can also read
