Each person has a unique definition of physical fitness that is based on the activities they care to do. Some people want to be able to do back flips and some people want to be able to walk to end of their driveway to get their mail. Regardless of the countless goals imaginable, they all have something in common. Each is based on personal interpretation of meaningful movement. Luckily, these goals are achievable because they can be distilled down into basic principles that are modifiable through exercise. Herein lies the beauty of synthesizing Pilates principles and the clinical physical therapy perspective. You can simultaneously understand the biomechanical, neurological, cardiovascular, and psychosocial implications on the person in front of you while also having access to an endless supply of tools to modify or progress physical training through breath work, imagery, and control. Below is a story of this method in practice.
Susan* first came to me as a private Pilates client about 2 years ago, around the time that I was deep into my first year of my Doctor of Physical Therapy program. She had her right hip replaced a few months before meeting me. She explained that she had osteoporosis and as a result fractured her left femur before that, resulting in a partial hip replacement on the other side. After she had her most recent surgery, she never received physical therapy. When I asked her why she said that it was because her physician told that she could now walk and that meant she was better than she was before. I could tell she didn’t agree. When asked about her goals in Pilates, she stated that she wanted to be able to get up and down from the floor to be able to play with her grandchildren and to be able to ride her bike at the beach.
My PT hat was securely fastened despite this being a Pilates session. From listening to her story, I discerned that she probably had some mobility deficits and balance limitations along with fear of falling. From watching her move around the studio, it was clear that she had adopted some compensatory movement strategies especially with stair climbing and changing body position along with generalized muscular deconditioning. Based on her medical history, I knew that she was at risk for vertebral compression fracture with heavy loading in flexion and could sustain another fracture if she were to fall again. My mind was simultaneously swimming with excitement and concern. How would we address everything in order to get her back to the activities she cared about in an efficient and meaningful way?
The evidence for the use of Pilates with individuals such as Susan is sparse, but resoundingly positive. A very recent randomized control trial published in April 2018 by Curi et al. found that a 16-week Pilates program significantly improved self-rated life satisfaction in elderly women. Another study published in February 2018 by de Oliveira et al. found that Pilates, when practiced 3 times a week for 6 months, increased bone mineral density of the lumbar spine and femur in postmenopausal women. Furthermore, a preliminary study by Levine et al. published in 2009 highlighted the use of Pilates as a practical rehabilitative tool for standardized recovery following total hip replacement.
While I used my physical therapy education and some clinical evidence to lay the groundwork for my understanding of Susan as a client, I relied heavily on my experience as a Pilates teacher to initiate her personal program. As we began working through the traditional reformer series, it became clear that Susan’s body schema had shifted after her surgeries. Her hips felt foreign to her: this was evident in both her language and the way she used her body. It was very difficult for her to move her legs independently of her pelvis. Voluntary muscle contraction was challenging and sometimes frustrating. Her kinesthetic sense in progressively challenging positions became our first mission. We worked on reformer exercises such as footwork, frog, and leg circles in order to cultivate lumbopelvic control. Imagery cues such as “having a paper weight in the sacrum” or “thinking of the femur as a pool cue and the hip joint (acetabulum) as the chalk” helped her to find fluid hip joint motion that is required for these exercises. Recently we have added a slightly deflated stability ball beneath the sacrum for these exercises and decreased her spring resistance thereby adding an element of instability to further challenge her.
The exercises continue to reveal themselves as we make progress with her mobility and control. Roll back with the roll back bar on the Tower or Cadillac allows for controlled fine articulation of the spine while activating the transverse abdominus, a feat that revealed itself to be challenging for Susan along the way. The addition of props such as the low arc promotes thoracic extension thereby cultivating range of motion in which to build spinal strength. Leg press with shoulder bridge on the push through bar further challenges her spinal articulation and simultaneously strengthens her posterior chain including glutes, hamstrings, and plantar flexors. It also gives her a chance to feel the suspension of her pelvis above her head while maintaining length through her spine. This is always a joy since she used to feel like her hips were very heavy.
Eve’s lunge on the reformer is a favorite to open up the front line of the hips and allow for greater hip extension. This is usually followed by the long box series including swan with stability ball placed between the legs in order to recruit adductors and pelvic floor to leverage off the box and recruit her spinal stabilizers. The emphasis on spinal stabilizers is meant to promote strength to protect her from vertebral fractures secondary to osteoporosis.
We work on standing balance in a variety of ways. We have stood in the ledge of the spine corrector for roll downs that places the ankle in deep dorsiflexion, effectively blocking Susan’s ability to use her ankle strategy to balance and instead helps to find the movement of her pelvis on her femurs. We stand on the floor or on a soft surface with a narrow base of support (tandem stance or on toes) in order to challenge her somatosensory system. We always do a trial with eyes closed to remove her visual input and upregulate her vestibular system, as well as to get a good laugh.
We often work on her functional strength toward the end of the session. We complete squats with the use of standing arm springs in order to take advantage of the resistance to get farther into her range of motion as well as recruit her newly activated abdominals and spinal extensors. Standing arm springs also progresses lumbopelvic control in a more challenging, full weight-bearing position as compared to on the reformer. We improvise at the Tower or Cadillac by using a box as a step to do single leg step ups. I wrap a Theraband above her knee and encourage a varus moment during this exercise in order to provide some input at the joint that helps to engage her gluteus medius at the hip for stability. The progression of her session continues to grow and change based on our collaboration.
Susan has made great strides since first starting in Pilates. She is now able to get up and down from the floor with confidence and has been biking at the beach for the past two summers. She regularly walks 2 miles from her home to work without difficulty and gleefully smiles when telling me that she can balance on one foot better than her grandchildren. It is hard for me to remember the person who was once told that she only needed to be able to walk to be functional. Each person is greater than the sum of their (body) parts and should be treated that way when it comes to their personal movement goals. Pilates allows for the client and the teacher to experience the body moving as a symphony rather than as individual instruments, which is extremely beneficial when the goal is to encourage functionally integrated movement. The use of physical therapy principles brings clinical reasoning to an exercise session which is especially beneficial to someone with a multifaceted medical history such as Susan. Ultimately and ideally, when a person feels confident and capable of going about their daily life without limitations, they are thriving. And whether you are a Pilates teacher or a physical therapist or both, this is the best outcome imaginable.
*Client name has been changed for privacy
Curi VS et al. Effects of 16-weeks of Pilates on functional autonomy and life satisfaction among elderly women. J Body Mov Ther. 2018;22(2): 424-429.
de Oliveira LC et al. Effects of Whole-Body Vibration Versus Pilates Exercise on Bone Mineral Density in Postmenopausal Women: A Randomized and Controlled Clinical Trial. J Geriatr Phys Ther. 2018. Published ahead of print.
Levine B et al. Pilates training for use in rehabilitation after total hip and knee arthroplasty: a preliminary report. Clin Orthop Relat Res. 2009;467(6): 1468-1475.
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