BODY ESSENTIALS 1. Studio Pilates International 2008 photocopying prohibited

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1 1 BODY ESSENTIALS 1

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3 3 Contents Culture 4 History of Pilates 5 Principles of Pilates 6 Postural types Correct posture 10 Flatback 11 Lordosis 12 Kyphosis 13 Swayback 14 Scoliosis 16 Hypermobility 17 Stabilising muscles Spine, pelvis and abdomen 18 Hip 21 Scapula 23 Neck 24 Postural assessment 25 Compensatory movement patterns 29 Muscle recruitment tests Scapula control 30 Gluteal function 31 Abdominals 34 Hip flexors 35 Assessment Guidelines 36 Pilates Basics Neutral/imprinted spine 37 Ribcage position 39 Scapula position 39 Neck position 40 T-zone 42 Oblique lines 43 Breathing 45 General exercise guidelines 47 Learning modalities 49 Cueing 50 Health and Safety 54 Mat class preamble 55 Spinal pain and injuries Osteoarthritis 57 Instability 58 Postural neck problems 58 Wry neck 59 Muscle strain 59 Disc problems 60 Sciatica 62 SIJ problems 63 Osteoporosis 64 Pregnancy 66 References 70

4 4 Studio Pilates International Culture At Studio Pilates International we believe that the way in which we act, behave and instruct is just as important as what exercises we give and how we give them. We are a company built on the passion for helping people through Pilates. In order for this passion to help people to grow further, to reach more people and for all to succeed in their role as an instructor, we have defined several points that when embraced by all, will help to strengthen each other s reputations and define Studio Pilates International as the leaders in Pilates worldwide. The following is from our company s corporate documents that are viewed every day in our studios and revised and read regularly. Our Vision To inspire and empower one million people a week to do Studio Pilates We will do this as instructors by ensuring on a daily basis we embrace the following I deliver the absolute best service every time I will ensure my clients have perfect technique with all of their exercises My attention to detail is always paramount I care about my clients and ensure their needs and wants are met I enjoy helping my clients achieve their goals and success I instruct with zest, confidence, enthusiasm, knowledge and precision I contribute to the professional, positive, happy and fun atmosphere of the studio I am a part of What makes a good Studio Pilates International Instructor The definition of a quality Studio Pilates International instructor can be summed up simply as happy, upbeat, always smiling, courteous & supportive. They are intelligent in conversation and always put the client first. At Studio Pilates the instructor always adapts their style to suit each individual client; they have fun with clients and fellow team members, never complaining. They are respectful, eager to learn and open to professional and personal development. They are always looking for ways to get better results for their clients and their studio.

5 5 History of Pilates German-born fitness guru Joseph Pilates ( ) developed the Pilates exercise system in the 1920s. Joseph Pilates devised a unique sequence of movements that worked the mind and muscle in harmony. He fine-tuned his wellness regimen while interned in England during World War I. Working as an orderly at an infirmary, he engineered a way to rig springs on hospital beds to offer light resistance exercises to bedridden patients. This was later refined and became known as the reformer. After the war, Joseph Pilates moved to New York and opened a studio near the New York City Ballet in It wasn't long before he attracted a large following of dancers who took to Pilates for its ability to create long, lean muscles and a strong, streamlined physique. In 1945, Joseph Pilates published Return to Life Through Contrology, which described his philosophical approach to exercise. Soon, some of his students began opening studios of their own - some making subtle adaptations to the method - and word of Pilates started to spread. By the mid to late 1990s, mind-body fitness methods took off as people started seeking gentler paths to health and wellness. Pilates became popular amongst top athletes and Hollywood stars. Even more recently, it has become very popular amongst Physiotherapists as a rehabilitation tool as more and more research concludes just how important core stability and strength is in injury management. Joseph Pilates always claimed he was ahead of his time, and his legacy lives on beyond his wildest expectations. His own fitness is a testament to his method this is a photo of Joseph Pilates at the age of 80 teaching a student and performing a stretch.

6 6 Principles of the Pilates Method 1. Concentration The number one Pilates principle is concentration. A Pilates workout involves complete concentration on what our bodies are doing and how they are moving. This includes concentrating on correct posture and body positioning, movement patterns, muscle activation and breathing. We are trying to retrain the brain and the body to function more efficiently which takes a huge amount of concentration. Even when these posture and muscle activation patterns become more automatic, you still need to concentrate on the muscles which are working to increase the effectiveness of the exercise. 2. Centering Every Pilates exercises focuses on the activation of the centre of the body or the core of the body, the abdominal region. Not only does tightening these core muscles improve the posture and prevent injury, they also provide a stable base for the rest of the body to work from to produce movement and strength. 3. Breathing Every Pilates exercise involves a particular breathing pattern which improves the effectiveness of that exercise. The breathing patterns help to activate the correct muscles required for the exercise, help supply oxygen to the muscles and remove waste products, and prevent holding the breath. 4. Control Maintaining control of every movement is very important. Pilates is not only about strengthening the muscles but also about controlling the way they contract and the way the body moves. Uncontrolled, jerky movements not only lead to injury, they don t effectively tone and strengthen the correct muscles. To control a movement, usually correct activation of the smaller stabilising muscles is required, rather than large gross movements of the larger superficial muscles. 5. Precision The movements need to be precise, with purpose and direction. For each exercise we will describe a precise body posture, position, muscle activation and movement that is imperative to achieving the goals of that particular exercise. For example, if an exercise requires lifting a leg up in the air it is completely different to lift the leg up in a random fashion than it is to set the body in a particular posture, activate a certain muscle, take the leg into a precise position and move it in a precise manner. 6. Flowing movement Banish the thinking of repetition and start thinking of duration of the exercise and the total time the muscle is under tension. Movements need to be continuously flowing, so there is no stopping throughout the exercise and no distinct start and finish between each movement. Sometimes in a practical environment you may prescribe repetition numbers, but that

7 7 doesn t mean the movement has to stop each time. The flowing movement means that there is often more eccentric control involved to control the movement in all directions. 7. Isolation Concentrate on isolating the particular muscles that are required to perform the movement. This often means isolating the stabilising muscles from the larger muscles that like to take over when performing a movement. Or it can also mean isolating the larger muscles you want to strengthen. Isolation ensures that the correct muscles are stabilising and working to perform the movement, so the desired outcome of the exercise is achieved. 8. Routine Regular practice is essential to ensure the brain and muscles don t forget the new patterns of movements that are being taught each session, and to ensure gains in strength and flexibility continue to progress. One session a week does provide some results, but nowhere near the results that can be achieved if the frequency is increased. Daily practice is best.

8 8 How Pilates works Increases Core stability To begin with, the main muscles that are targeted in Pilates are the core stabilising muscles of the body. In the mat work repertoire this includes the stabilisers of the spine, pelvis and scapula: the transversus abdominis and pelvic floor, multifidus, gluteal muscles, lower trapezius and serratus anterior, and the deep neck flexors. The reformers also allow concentration on the stabilisers of the more peripheral joint stabilisers, such as the rotator cuff for the shoulder and the VMO for the knee. Once these core stabilising muscles are activated and isolated, we progress these exercises to become more dynamic and functional, having to maintain stability whilst working the larger more superficial muscles. Total body conditioning Pilates works on strengthening and toning the entire body. It is one of the most effective forms of exercise to change body shape and tone up because it targets all of the muscles in the body. Corrects muscle imbalances In Pilates, we look at muscle imbalances from a whole body perspective. To put it simply, we aim to strengthen any muscles which may be weak, and stretch any muscles which may be tight. Some muscles may be tight because they are overactive and used too much to compensate for other weaknesses; some muscles are tight because they are weak and as soon as they are used at all they tighten up. Potential muscle imbalance can occur between: 1. Small deep stabilising muscles and the larger/more superficial muscles eg. weak gluteus medius and minimus, overactive TFL 2. Anterior versus posterior muscles eg. weak hamstrings and tight overactive quads and hip flexors 3. Muscles on the right side versus muscles on the left side eg. weaker in all of the left leg, arm or abdominal muscles than the right Once we determine any imbalances, we work on correcting them. This may mean working on the deep stabilisers only until they are stronger, it may mean working on the hamstrings but not the quadriceps until the hamstrings are stronger, or it may mean doing twice as many exercises on one side than the other. Improves posture Pilates helps to correct posture through strengthening the postural muscles and correcting any muscle imbalances. It also teaches and emphasises correct posture as this must be maintained throughout every exercise performed.

9 9 How is the Pilates approach different to traditional weights programs? Pilates is similar to weights in that is a strength based exercise program, but in Pilates, correct muscle activation and control is the focus it is not all about the amount of weight lifted. Pilates focuses more on the core muscles of the body these deep muscles contract at a low level intensity and need to remain activated to stabilise the body throughout an exercise. It is not necessarily a case of the stronger the better muscle control and activation are the aim. This is a very different concept to a weights based strengthening exercise, for example a biceps curl you are training the strength of the bicep using a more intense or maximal contraction, Pilates movements are usually more flowing, and there is an emphasis on correct posture throughout the movements. With Pilates, the resistance is either body weight resisted or spring resisted. It works on toning both the larger and smaller and muscle groups of the body including the stabilising muscles, which are sometimes hard to target through weights. Pilates exercises can rebalance muscles around the joints and balance strength with flexibility. How the Pilates approach differs slightly to traditional physiotherapy programs Pilates definitely follows on from the basic physiotherapy exercises, but it also works on strengthening the entire body as a whole. For example, if a patient gets a sore lumbar spine when they lift their baby, as physiotherapists we would normally address posture and core strength to help this. In Pilates, we also strengthen the arms and the legs so that they don t use their back as much in the lifting process. Another example is someone who gets sore and tight upper trapezius from carrying the groceries. We retrain scapula stability muscle recruitment, but also strengthen the biceps to hold the groceries rather than hitching up with the upper trapezius. Also, we look at postural patterns and assess which muscles may need strengthening eg the hamstrings for a lordosis. Whilst understanding the pathology of a particular injury is very important, we focus more on posture, muscles imbalances, muscle recruitment, stability and movement patterns as Pilates Instructors and the implications these have on the particular injury. One of the huge benefits of Pilates to physiotherapy patients is not only are they doing specific exercises to correct their problem, they can also have an all over body workout at the same time. A lot of patients become globally weak since they can t do much exercise without hurting themselves, so Pilates can be a safe method for them. Also, when patients think they are doing Pilates and using the Pilates equipment they are often more likely to continue on with their strengthening programs than if they are doing normal physiotherapy exercises. Observation is the key to being a great Pilates instructor open your eyes. You should be able to tell where a client will be tight, strong and weak just by looking at them whilst standing and also moving through some simple tests and movements. If need be you can physically muscle test each muscle but this takes time and you should become good enough at your observation skills that you don t need to manually test everything. If you are taking a large group mat class, your observations are especially important as you will be visually assessing each participant s movements and postures very quickly as they are performing the exercises. Observation is also imperative to determine correct technique is maintained throughout the exercises and if an exercise is too difficult or inappropriate for a person.

10 10 Posture Correct Posture In the ideal posture, the normal curves of the spine are present and the pelvis is in a neutral position. Plumb line runs through the ear, shoulder, hip joint, knee joint and just anterior to the lateral malleolus of the ankle. Correct posture Posture diagrams taken from Muscles, Testing and Function by Florence Kendall, 1993 Williams and Wilkins

11 11 Flatback (flattened arch in the lower back, bottom tucked under) Head slightly forwards Cervical spine slightly extended Thoracic spine upper thoracic spine has increased kyphosis, then is straight from here down Lumbar spine flattened (flexion) Pelvis tilted posteriorly Hip joints extended Muscles which are tight/need stretching Hamstrings, rectus abdominus, pectoralis major Muscles which are weak/need strengthening Iliacus, quadriceps, T-zone, all of the gluteals Work on using a neutral spine for all exercises and keeping the tailbone down. Flatback posture

12 12 Lordosis (increased arch in the lower back) Pelvis - tilted anteriorly Lumbar spine - increased lordotic curve (hyperextension) Hip joints - flexed May or may not be associated with an increased thoracic kyphosis Muscles which are tight Quadriceps, TFL, short adductors, psoas, other hip flexors, lumbar spine erector spinae. Muscles which are weak All of the abdominals, all of the buttocks but particularly the hip stabilisers, hamstrings. Work on promoting lumbar flexion throughout exercises, and hip extension without lumbar extension. Focus on t-zone and obliques activation throughout all exercises. Kyphosis-lordosis

13 13 Kyphosis (increased arch in the upper back, spine hunched over forwards) Head forwards position Cervical spine hyperextended Thoracic spine - increased kyphotic curve (hyperflexion). Shoulder blades - protracted Muscles which are tight/need stretching Pectoralis major and minor, lattisimus dorsi, upper rectus abdominus, sternocleidomastoid. Muscles which are weak/need strengthening Thoracic and lower cervical extensors, lower trapezius and rhomboids, deep neck flexors. Work on increasing thoracic and lower cervical extension, opening out the chest and drawing the shoulder blades into the correct position. A kyphosis can accompany a lordotic lumbar spine (kyphosis-lordosis as shown on the left), flatback, scoliosis or swayback posture. Kyphosis

14 14 Swayback (the pelvis is shifted forwards in front of the shoulders and ankles) This is a common posture seen amongst people with hypermobility. Head forward position Upper cervical spine - extended Thoracic spine long increased kyphosis with the thoracic spine shifted backwards so that it sits behind the line of the ankle Scapula often protracted Lumbar spine - usually flattened, sometimes with a short sharp lordosis in the last few vertebrae Pelvis - tilted posteriorly and is shifted forwards so that it is sitting in front of the ankle Hips - hyperextended Knees - hyperextended and locked Feet pronated or flattened arches Often have no bum no size or strength in any of the buttock muscles Muscles which are tight/need stretching Often not incredibly tight anywhere, but will rest in this position due to weakness so they can hang off their ligaments and not to have to use stability muscles. May be tight in hamstrings, pectoralis major and latissimus dorsi. Muscles which are weak/need strengthening All of the stabilising muscles in the body: all of the buttocks, including gluteus maximus, the obliques and T-zone, iliacus, lower trapezius, upper thoracic extensors and deep neck flexors. This posture is a habit and requires constant reminders to unlock the knees, shift the pelvis backwards and bring the upper trunk forwards during all sitting and standing exercises.

15 15 Swayback posture

16 16 Scoliosis (lateral curve of the spine) Scoliosis is a lateral curvature of the spine, and may occur anywhere in the spine. The curves can be a C shape curve or an S shape curve. The curves may be either fixed or postural. A fixed scoliosis is due to a bony deformity in the spine, and can t be corrected with exercise. Exercise however can help prevent the curve from worsening and also help to reduce any symptoms. A postural scoliosis is due to poor posture, differences in leg lengths and muscle imbalances. A postural scoliosis can be helped with specific strengthening and stretching exercises. An example of a postural scoliosis seen below: a thoracic/lumbar curve convex to the left: Muscles which are tight/need stretching Left latissimus dorsi and quadratus lumborum, left quadriceps and left adductors Muscles which are weak/need strengthening Right latissimus dorsi and quadratus lumborum, right hip adductors, left gluteus medius, left scapula stabilisers, transversus abdominus Treatment would be aimed in this case at stretching down the left side of the torso and strengthening the right, as well as working on pelvis stability and correcting any other muscle imbalances that may be present side to side throughout the body. Scoliosis

17 17 Joint Hypermobility When we are talking about hypermobility we are referring to a person s inherent joint ligament laxity, and the excessive movement that is allowed to occur in the joints. Ligaments are responsible for stopping excess movement or translation within a particular joint. In people who are hypermobile, their ligaments are more lax and have decreased tension in them. This means that their joints become inherently unstable, and are more prone to developing pain and injury. Often hypermobile patients have not only one but multiple areas of pain and injury throughout their body. For people who are hypermobile, the strength and activation of the stabilising muscles surrounding their joints is very important, as the muscles are needed to help control this excessive range of motion available at the joint. Pilates is the perfect form of exercise for hypermobile patients as it works on strengthening all of the stabilising muscles in the body. Some signs of hypermobility Knees and elbows straighten beyond 0 degrees they hyperextend Flattened arches of the feet Ability to pull the thumb back to touch the forearm Elbows that hyperextend Ability to bend forwards and place the palms of the hands on the floor Flattened arch Hyperextended knees

18 18 Review of the stabilising muscles of the pelvis, spine and scapula Transversus abdominus Origin - the lateral third of the inguinal ligament, from the anterior portion of the iliac crest, from the inner surfaces of the cartilages of the lower six ribs, connecting with the diaphragm, and from the lumbodorsal fascia Insertion the fibres are orientated horizontally, and act like a corset around the abdomen, inserting into the linea alba, in the middle of the abdomen and onto the pubic bone. The upper ¾ of the muscle lies behind the rectus abdominus, the lower ¼ lies in front of the rectus abdominus. Function the transversus abdominus is the deepest of the abdominal muscles and is also a stabilizer of the spine. Support by this muscle is considered to be the most important of the abdominal muscles and has also been found to be in a weakened state in those who have chronic back pain or back problems. Its normal action functions to form a deep internal corset that acts to draw the abdomen in and stabilize the spine during movement. This pattern of protection is disrupted in patients with low back pain, and isolated strengthening of these muscles has been proven to reduce back pain. (Richardson et al 1998) Pelvic floor The pelvic floor consists of a group of muscles which together form an internal sling which provides support to hold the pelvic and abdominal organs in place, and also allows bladder and bowel control. These muscles are continuous with transversus abdominus muscles, and activation of the pelvic floor may help with activation of the TA.

19 19 Internal obliques Origin iliac crest, inguinal ligament and lumbodorsal fascia Insertion linea alba, xiphoid process and inferior ribs Function flexion and rotation of the spine, stabilising the back, flattening the back and drawing the ribs down. unilateral contraction leads to lateral flexion and rotation to that side, bilateral contraction compresses the abdomen for stability and breathing. External obliques Origin anterolateral ribs 5-12 Insertion iliac crest, inguinal ligament Function flexion and rotation of the spine, stabilising the back, flattening the back and drawing the ribs down. Unilateral contraction leads rotation to the opposite side, bilateral contraction flexes the spine and draws the ribcage towards the hips, and compresses the abdomen.

20 20 Multifidus Origin sacrum, erector spinae aponeurosis, PSIS, iliac crest Insertions spinous processes of vertebrae. Some fibres span over two vertebrae, some over 3 or 4 vertebrae. Function controls segmental motion between each of the vertebrae, it is the only muscle that does this, studies have shown a decreased strength of multifidus is present with back pain hence it is very important for lower back pain rehabilitation.

21 21 Iliacus Origin- ilium, sacroiliac and iliolumbar ligaments, lateral sacrum Insertion-lesser trochanter of femur The iliacus fascia is continuous with the transversus abdominus fascia Function of the iliacus flexes the hip, holds the femur back in the hip socket, stops anterior translation of the femur, stabilises the hip joint and SIJ at the end of stance phase. If the iliacus is weak then the more lateral hip flexors will overwork to compensate and will become tight eg sartorius, TFL and rectus femoris. Deep hip rotators Quadratus femoris external rotation, stabilises the hip (by stabilising the femur in the hip socket) Superior and inferior gemelli, obturator internus and externus the rotator cuff of the hip, cocontracts with gluteus minimus and the quadratus femoris to control translation of the femoral head within the hip socket.

22 22 Gluteus medius Origin gluteal surface of the ilium, under gluteus maximus Insertion greater trochanter Function - stabilises the hip and pelvis laterally in single leg stance Anterior portion internal rotation, works with the TFL Middle portion abduction Posterior/deep portion externally rotates and abducts the hip Gluteus minimus Origin gluteal surface of the ilium, under the gluteus medius Insertion greater trochanter Function deepest hip abductor, internally rotates the hip, prevents superolateral migration and anterior dislocation of the femoral head (Beck et al 2000) Gluteus maximus Origin - gluteal surface of the ilium, lumbar fascia, sacrum Insertion gluteal tuberosity of the femur, iliotibial band Function upper glut max abducts and externally rotates the hip; lower glut max extends the hip

23 23 Serratus anterior Origin lateral ribs 1-8 or 9. Insertion anterior surface of the medial border of the scapula Function protracts and stabilises scapula, assists in scapula upward rotation through elevation, hold the scapula against the ribcage and prevents it from winging (see picture below) Weak serratus anterior/winging (R) scapula Lower trapezius Origin - spinous processes of vertebrae C7 to T12 Insertion spine of the scapula Function scapula stability, depresses and retracts the scapula

24 24 Deep neck flexors The deep neck flexor muscle group consists of the rectus capitis, longus capitis and longus coli muscles. Origin and insertions - These muscles run anteriorly over the cervical spine with attachments from the skull to the upper cervical vertebrae, and from the cervical vertebrae to the upper thoracic vertebrae. Function unilateral contraction leads to lateral flexion and rotation, bilateral contraction leads to neck flexion and flattening of the cervical lordotic curve and works to correct a forwards head posture in which the chin is poking out. In many studies it has been demonstrated that weakness in the deep neck flexors is present in patients with neck pain and headaches (Watson et al 1993, Jull, 2000) and that strengthening these muscles helps to improve neck pain. Fundamentals of Anatomy& Physiology, 7 th Edition, Frederick Martini

25 25 Postural Assessment Front view Feet Knees Pelvis Ribcage Decreased/increased arches Increased pronation/supination Locked/hyperextended Internally rotated VMO muscle bulk Lateral quad, TFL muscle bulk Rotated One hip higher than the other Flared Compressed Symmetry One shoulder higher/lower Arms internally rotated May need orthotics or arch strengthening May need gluteal strengthening Hypermobile, needs postural retraining May need orthotics, arch retraining and gluteal strengthening Weak VMO Will be increased if weak gluts, VMO and iliacus Will need specific stretch/strengthen muscle round the pelvis May have leg length difference or a scoliosis, may have a tight lat/ql/psoas hitching one hip up Weak oblique/s, tight lats and pecs Overactive obliques and rectus abdominus Shoulders Tight lat, scoliosis, tight upper trapezius, scoliosis Weak rotator cuff and scapula stabilisers, tight pecs and lats Neck/Head Rotated or tilted to one side Tight neck muscles on one side or joint problems

26 26 Postural Assessment - Back view Feet Pronated Turned out/leg externally rotated May need glut and arch strengthening and orthotics Compensation for pronated feet Calves Muscle bulk/symmetry Large calves could be as a result of weak iliacus and weak glut on that side. Also due to swayback posture. Hamstrings Increased muscle bulk and tone Weak gluteus maximus, flatback posture Gluteals Decreased bulk upper glut max Increased bulk upper glut max Decreased bulk lower glut max Weak gluts generally Compensating for weak deeper gluts Weak, common in swayback and flatback postures Pelvis One hip higher than the other See above Spine Scapulae Scoliosis Winged Elevated Depressed Muscle definition between scapula Tight pec minor, weak serratus anterior Tight upper trapezius Tight lats,?weak upper traps

27 27 Postural Assessment - Side view Neck Forward head position Weak deep neck flexors, tight upper cervical extensors and SCMs. Pelvis/spine Anterior tilt/lordosis Posterior tilt/flatback Swayback pelvis in front of shoulders and lateral malleolus ankle Tight quads, hip flexors, erector spinae, weak abdominals, gluteals and hamstrings Tight hamstrings and rectus abdominus, weak gluteals and TA Often weak in all stabilisers, including all gluts, TA, iliacus etc Thoracic kyphosis Tight pecs/lats, weak thoracic extensors and lower trapezius/rhomboids, may be fixed or postural Scapulae Protracted Winging Tight pecs, weak lower traps and rhomboids Tight pec minor, weak serratus anterior Humeral Forward in shoulder socket Weak and or tight rotator cuff head Knees Hyperextended/locked Hypermobile, needs postural retraining Feet Weight distribution over feet not too forwards or backwards

28 28 Supine postural assessment Sometimes is can be easier to examine certain postural positions when supine lying. Pelvic position Determine if there is an anterior or posterior pelvic tilt, lordosis or flatback. If the legs are down straight does the lordosis increase (tight hip flexors)? Also look at the distance between the belly button and the ASIS on each side are they equal? If one ASIS is further out, it will often be more difficult for the transversus abdominus to contract on this side. Often, this is due to a tight/overactive TFL and superficial gluteal muscles and if you release these first by massage or stretching then the TA will function better. Neutral pelvic and spinal position Anterior pelvic tilt with lordosis Ribcage position Are both sides equal? Is the ribcage flared, normal or compressed? What happens to the ribcage position as the arms are taken overhead? If the ribcage flares and elevates too much, is it because the pecs and lats too tight, or the abdominals lazy and weak, or both. Good ribcage position Ribcage popping The correct postures will become more evident after reading the Basic Pilates Principles section. Now we have assessed their posture we have a fair idea where they are going to be tight and where they may be weak. Let s now look more in depth into muscle recruitment patterns; this will help us to determine and understand why the client may be tight in certain areas and carry the specific postures they have.

29 29 Compensatory movement patterns also seen as cheating patterns in exercises Weakness Transversus abdominus Gluteus minimus, medius and deep hip rotators Gluteus maximus Serratus anterior Lower trapezius Deep neck flexors Iliacus Compensating muscles which may become overactive Overactive/tight psoas and hip flexors, sometimes overactive in the more superficial abdominals to compensate TFL, piriformis, upper glut max, lateral quads, VL and ITB on the same side and QL, lats and psoas on the opposite side Overactive hamstrings, calves and quads, lumbar erector spinae Pec minor Lats, levator scapulae, upper trapezius Sternocleidomastoid Overusing TFL, Sartorius, rectus femoris and adductor longus A whole body approach As you can see, the whole body compensates and is compromised when there is a weakness. A great example of this is how pelvic instability can affect neck and shoulder problems and vice versa, here is how: The left gluteus medius is weak, so the right latissimus dorsi becomes overactive to help stabilise the pelvis. It becomes very tight and depresses the shoulder and draws the shoulder into an internally rotated position, causing shoulder problems. You can strengthen the muscles around the shoulder girdle as much as you like, but unless you address why the lat is so tight you will only get so far. With this shoulder now depressed, the upper trap and levator scapulae pull at their attachments on the upper cervical spine and cause neck problems and headaches. Conversely, shoulder problems can affect the lower back. If a person has weak scapula stabilisers and tight pectorals and latissimus dorsi, these muscles will flare the ribcage, hence making it more difficult for the abdominals to work, and leading to a sore lower back. There are many more examples which we won t go into now, but you can see how important it is to look at the body as a whole when assessing posture, muscle imbalances and subsequent pain and injuries.

30 30 Feeling for muscle recruitment Often it is helpful to feel for muscle recruitment as well as observe it. As some of the major muscles we are feeling for are the buttocks and lower abdominal area, always take care not to offend people or upset them, or make them feel uncomfortable at all in any way. 1. Ask them first if it is okay for you to feel their muscle activation and explain why it is important that you do. Once you have their permission on the first session, they will expect you to do this again in the future, but even so please tell them each time before you feel their muscles I am just going to feel for your buttock activation whilst you do this exercise etc. 2. Never feel lightly with your whole hand. Always press firmly, using either just fingertips or thumb with no other part of your hand touching their body or use the heel of your hand with no other part of your hand touching their body. Pressing lightly or grazing the surface of the skin is much more likely to be seen in a more sexual way. Quick tests for stability and muscle recruitment Scapular stability/control standing Have the client standing facing away from you. Get them to take both arms slowly forwards and overhead up towards the ceiling, and then slowly return them back to the sides. Look and feel for overactive upper trapezius or levator scapulae (watching for the muscles tightening too much or the scapula hitching) poor lower trapezius control and poor serratus anterior control (winging). Note: also watch from the side as the arms go overhead and observe the abdominal control to see if there is a massive lordosis with the ribcage popping out. If this happens, it could be a sign of abdominal weakness, tight pecs/lats or both. Good scapula position Hitching scapulae Losing the abdominals

31 31 Gluteus medius/general hip stability function test Have the client standing facing away from you. Get them to lift one other foot (bending the knee and lifting the foot behind the body) whilst you observe and palpate what happens around the pelvis. Check points: Is the leg internally rotating, is the foot pronating? Gluteal activation over TFL activation? Is the pelvis staying level ie no Trendelenberg? Even if the pelvis is staying level, this still doesn t necessarily mean the gluteals are functioning properly. They could also be cheating by laterally shifting the pelvis and whole body weight over to that side to wind up the ITB stabilising mechanism. Or they could be using the opposite psoas, QL or lat to hitch the hip up rather than using their gluteals. To determine these things it is often necessary to put hands on the muscles to feel for activation as well as observe. To challenge you may add in some single leg squats and hops. It is important to get them to do several of these as some clients, particularly athletes, may have good stability for the first few but poor endurance in these stability muscles which falter as they tire. Good stability Bad stability-no compensation Compensation-hitch (R) hip

32 32 Side lying gluteus minimus and gluteus medius activation Lying on the side with the hips flexed to about 20 degrees, knees bent and a pillow between the legs. Go to lift the leg slightly off the pillow (abduction) and observe/palpate which muscle initiates the movement and lifts the leg. The correct order should be gluteus minimus, then medius, then as the leg lifts further the TFL and superior gluteus maximus kick in to help out, but make sure the gluteus minimus and medius do not switch off and that the TFL and upper gluteus maximus don t take over. Palpate just above the greater trochanter and behind the TFL to feel for activation of the gluteus minimus and medius. If these muscles are not working as they should, then the first step before strengthening them is learning how to activate them. Exercise- lying on the above position, get the patient to think about going to lift the leg without actually lifting it to firstly activate the gluteus minimus. Then progress to actually lifting the leg whilst maintaining the correct muscle activation patterning. Side lying quadratus femoris/deep hip external rotators activation Lying on the side with the knees bent, hips flexed to degrees with a pillow between the legs. Press the top heel into the bottom heel slightly as if you were going to lift the knee. Palpate on the line between the greater trochanter and the ischium to feel for quadratus femoris activation, it should activate before the movement occurs and should stay active throughout the movement. In this position, the quadratus femoris is the main muscle to externally rotate. If the quadratus femoris activation is poor, then the first step before strengthening it is to learn how to activate it.

33 33 Exercise lying on the side in the above position, gently press the top heel into the bottom heel slightly and feel for the activation of quadratus femoris whilst keeping the rest of the buttock relaxed. Progress to actually lifting the knee whilst maintaining the quadratus femoris activation. Sit to stand This tests the gluteus maximus for hip extension and the hip abductors/external rotators for control. Observe the patient moving from a sit to stand position and back to sitting. If the hips internally rotate and the knees roll in then there is definite weakness in the external rotators of the hip (deep stabilising gluteals). If this rolling in becomes more pronounced as the hips flex more, then it is the deeper external rotators that are the weakest. Also watch for gluteus maximus activation to stand up - a common pattern used is to posteriorly tilt the pelvis and use the hamstrings and quads to stand up, or arch the lower back and use only the quads to stand up. Neutral pelvis Posterior tilt Anterior tilt Internal rotation Prone gluteus maximus into hip extension This can be assessed by lying on stomach and extending the leg. Feel and observe for gluteus maximus activation, poor patterns would includeoverusing the hamstring to extend the hip, hyperextending the lumbar spine by overusing the erector spinae and losing the abdominal connection. Good spinal position Note: if the client has very tight hip flexors, they won t have enough hip extension range and the client will get to a certain point through the movement where they will have to extend through the lumbar spine to compensate. Losing the abdominals/extending the lumbar spine

34 34 Transversus abdominus and Oblique activation Asides from feeling the patient trying to do a transversus abdominus contraction or using a real-time ultrasound, these are 2 very quick functional tests to assess TA function: Supine lying plus lift a foot Lying on the back with the knees bent and lifting one foot slightly - if the hips rock or move a lot and the TA doesn t activate then the function is poor. You can feel and observe if it is the transversus abdominus that is letting go or the obliques or both. Good TA and oblique activation pelvis stays still Abdominal curl Observe which muscles are working and the relationship between the TA, obliques and rectus abdominus throughout a half sit up. The TA should be tight to keep the abdominal wall flat, and the obliques should be contracting to curl the body up, not just using the rectus abdominus. Good TA and oblique activation Letting the TA relax/bulging the stomach Specific abdominal patterns There are 3 distinct abnormal patterns for recruiting the abdominals that you will observe. 1. All of the abdominal muscles weak. Implications: Start with TA activation, then the obliques then the rectus abdominus. 2. TA weak, obliques weak, overactive rectus abdominus. Implications: Focus on TA and oblique activation initially without moving into flexion ie no head lifting. 3. TA weak, overactive obliques and rectus abdominus. Implications: Abdominal exercises will need to start off very basic focusing on relaxing the obliques and rectus abdominus whilst achieving TA isolation. Once the TA activation improves, more difficult abdominal exercises can be added provided the TA is working throughout the exercise.

35 35 Iliacus activation Tests - lying on the back with the knees bent, flex the hip and see which muscles work to perform the movement the iliacus can be palpated just lateral to the femoral pulse and is the most medial tendon of all the hip flexors. It should activate first and stay activated throughout the movement, then the other hip flexors should kick in to help the flexion movement. Throughout hip flexion, if the leg adducts, then the adductor longus is overcompensating; if it internally rotates the TFL is overcompensating; if it externally rotates then the sartorius and rectus femoris are compensating. The test can also be performed sitting on a chair with the feet resting on the floor, then flexing one hip as high as possible keeping the body still. This tests more inner range flexion and an inner range hip flexor weakness usually means a weak iliacus muscle. Indications that suggest a weak iliacus weakness detected in the iliacus lying and sitting tests all hip pathologies swayback postures hip flexor cramps throughout tabletop position a tendency to move into an externally rotated hip position when the legs are in tabletop position. clicking of the hip throughout exercises If the iliacus is weak then basic activation exercises are often needed prior to strengthening. Exercise lying on the back with the knees bent, t-zone tight. Think about drawing the thigh bone back in the hip socket, or imagine that you are about to lift the foot off the floor but don t. Feel for the iliacus activation, once it can activate well progress to holding the activation whilst lifting the foot. Iliacus activation exercise

36 36 Assessment Guidelines Questions 1. Do you have any current pain or injuries? If so ask more details about them. 2. Do you have any medical problems? 3. What are your reasons for doing Pilates and what goals do you want to achieve? Ie lose weight, tone a certain area, strengthen a certain area, help an injury, improve athletic performance, increase flexibility, improve posture are common responses. 4. What other exercises do you currently do and what have you done in the past? Have you done Pilates before? 5. How hard do you like to work when you exercise? Postural assessment From side on Front view Back view Supine position Core stability assessment Single leg stance test Arms overhead Half sit up Lift a foot (for abdominals or iliacus) Side lying glut tests clam, clam in 90 degrees and straight leg raise Prone lying hip extension Supine position with legs down straight or arms overhead Range of motion tests Any area that is a problem test range of motion at the surrounding joints. You may also wish to examine muscle lengths here eg touch toes to test for hamstring length and lumbar flexion. Problem list/treatment plan Formulate a list of weak muscles, tight muscles, postural type and then an exercise plan to address those issues, taking into account their level of fitness, injury and goals.

37 37 Basic Pilates Principles Pelvic and spinal position For each and every exercise, the specific optimal spinal position will be described. We talk about 2 distinct spinal and pelvic positions in Pilates: neutral and imprint. This describes the position of the pelvis and lumbar spine in the sagittal plane. Neutral spine A neutral spine means that the normal curve of the lumbar spine is present. This should not be too large or forced, or too small and flattened out. Every person s neutral spine may look a little different to the next due to different body shapes and sizes. A general rule to determine a neutral pelvis is that when lying supine, if you draw an imaginary triangle between the pubic symphysis and the ASIS on both sides, the triangle should be parallel to the floor. That is, the pubic bone should not be higher or lower than the ASIS when supine. No tension should be felt in the lower back muscles if so, then move into an ever so slightly more imprinted position. It is more important to make sure the abdominals can activate well and there is no tension in the lumbar area than it is to have absolutely perfect alignment of the ASIS and pubic bone, as this will differ for each person anyway. Imprinted spine An imprinted spine refers to an ever so slight posterior pelvic tilt and using the abdominals to draw the lower back slightly towards the floor. When supine, the pubic bone will sit slightly higher than the ASIS. This does not mean posteriorly tilting the pelvis so far that the sacrum lifts off the floor the sacrum must always maintain contact with the floor, otherwise the transversus abdominus will not work effectively. Every person s imprinted spine will look different to the next, the distance between the lumbar spine and the floor will be different for each person the spine does not have to be touching the floor.

38 38 To find the neutral and imprinted positions If the pubic bone is higher than the ASIS, then the pelvis is in a posteriorly tilted position. If it is lower, the pelvis is in an anteriorly tilted position. Lying on the back with the knees bent, feet hip distance apart on the mat. Tilt the pelvis anteriorly and posteriorly to get the feel of tilting the pelvis, then find the neutral position and imprinted position. Anterior pelvic tilt Posterior pelvic tilt General rules of imprint vs. neutral for exercises Throughout our daily life, a neutral spine and pelvis is the optimum position to operate in, so it makes sense to strengthen the muscles and perform the exercises with a neutral spine. We prescribe either neutral or imprinted spine positions for each exercise specific to each individual, and what suits their body best. For example, someone who has a large lordosis might be able to activate their abdominals better in an imprinted position, whereas somebody with a flatback posture needs to use a neutral spine so as not to over-activate their rectus abdominus. Someone with a disc bulge will usually use a neutral spine as an imprinted spine requires slight lumbar flexion which is contra-indicated for disc bulges. However, as a general rule- In all exercises performed when one or both feet are placed either on the mat or Pilates equipment in a closed chain type of exercise, a neutral spine will be used. In all exercises performed in an open chain situation whereby both feet are elevated off the floor and unsupported (eg hundreds) an imprinted position can be used to help stabilise the spine. Once abdominal strength is good enough to stabilise the spine a neutral spine should ideally be used. In saying that, there are always exceptions to rules check with each individual which position is more comfortable, easier to activate their muscles in and causes no pain, and that is the position to prescribe for the individual for the particular exercise. Throughout the exercises, we will use the terminology neutral and imprinted spine. This refers to the anterior/posterior pelvic tilt of the pelvis and the relative lumbar spine position in the sagittal plane. The spine may be flexing laterally or rotating, but we still want to maintain the neutral or imprinted spine whilst it is laterally flexing or rotating.

39 39 Ribcage position The ribcage position is very important in abdominal activation. Often the ribcage will want to pop out move forwards and open out and upwards, making it very difficult for the obliques to activate to stabilise the spine. When supine, there should be a sensation of the ribcage resting gently on the floor. Make sure the ribcage isn t being pushed into the floor, and also make sure the ribcage isn t allowed to lift up away from the floor. Gentle oblique muscle activation is required to maintain correct ribcage position. Good ribcage position Ribcage popping out/lifting up We will discuss rib movement throughout the breathing cycle later on. Shoulder blade position The scapula position is also of upmost importance throughout every exercise. The shoulder blades should drawing down and back and in towards the spine in V shape. At the same time, concentrate on widening the shoulder girdle, laterally rotating the scapula out to the side. The shoulder blades should sit flat against the ribcage so that the inferior part of the scapula doesn t wing out from the ribcage. Good scapula position Squeezing too hard and high Winging scapulae

40 40 (Note do not squeeze the shoulder blades together as hard as possible at the back either as this over-activates the rhomboids and upper trapezius. It should be a gentle activation and movement) Even when the arms are lifting there should be a sense of the scapula drawing down and in and rotating laterally, activating the lower trapezius and serratus anterior. At the start of each exercise, we cue to place the scapula in the correct position with the scapula stabilisers activated. If this is not done, then throughout the exercise tension in the neck and upper trapezius area may be felt, causing neck strain. A lot of people have this bad postural habit of tensing their upper trapezius whenever they are stressed, concentrating or trying hard, even if what they are doing has nothing to do with the neck. You will sound like a broken down record at times, but guaranteed this is the most common correction of all you will make throughout every exercise. It is important to cue this at the start of every exercise, so that they start off the movement with their shoulders in the correct position. Neck position The cervical spine should maintain its natural lordotic curve when lying, sitting or standing. This is what we call a neutral position. In the neutral position, the head is back in line with the rest of the body, the chin ever so slightly tucked in. Think of lengthening through the crown of the head and lengthening the back of the neck. If the person has an increased curve of the neck or a forward head position, they may require a pillow under their neck to prevent it from hyperextending. Throughout the exercises, we want the cervical spine to follow the movement of the thoracic spine. If the thoracic spine is extending eg during the swan preparation exercise, we don t want the neck the overflex or extend either, it should be in a neutral position. Neutral neck position Hyperextended neck position

41 41 If the thoracic spine is flexing eg during an abdominal curl, the neck should gently continue on with the line of the thoracic spine. We don t want the neck to hyperextend or overflex throughout the movement. Please note that the eye line is a very important key to ensure correct neck position and often a simple cue to correct the eye line will correct neck position. For example, when performing supine abdominal exercises and lifting the upper body, look towards the knees rather than the ceiling or feet to obtain the best neck position. A lot of people have a lightly forward head position with the chin sticking out. Prior to performing any exercise, especially those involving lifting the head up off the floor, it is important to practice activating the deep neck flexors. Neutral, overflexed and hyperextended neck positions Chin Tuck Exercise Chin tuck The deep neck flexors are responsible for maintaining the correct neck position. Here is an exercise to practice deep neck flexor activation and correct neck alignment. Lying on the back, gently tuck the chin in, imagine that you are lengthening through the crown of the head and elongating the back of the neck. This is a very small movement, and should not be done with maximal effort. Monitor the more superficial sternocleidomastoid (SCM) and scalenes. If these fire or tighten, they are using the wrong muscles to flex the neck. Hold this gentle contraction for seconds, and repeat several times per day. This activation of the deep neck supporting muscles should be carried out before lifting the head whilst performing abdominal exercises to prevent poor neck postures and strain.

42 42 T-zone We call the transversus abdominus and pelvic floor muscles collectively the T-zone. We do this because it is quicker and easier than saying transversus abdominus and pelvic floor. If you draw an imaginary horizontal line between the ASIS or hipbones this is a visualisation for the TA. If you then draw a line from the centre of this line down to the pubic bone, this is a visualisation for the pelvic floor muscle. These 2 imaginary lines form a T shape on the front of the pelvis, hence the name T-zone. The T-zone T-zone activation exercise To activate the T-zone, start lying on the back with the knees bent and a neutral spine. Think firstly of the pelvic floor. Gently draw up the pelvic floor along the imaginary vertical line as if you were trying to stop from going to the toilet. You should feel the muscles deep in the pelvic floor tighten and draw upwards. For men, another cue may be to think of drawing the testicles up towards the stomach. For women, another cue may be to tighten the muscles in the vagina and draw them up and in as if to stop the flow of urine. Once the pelvic floor is tight, think of flattening the imaginary horizontal line in towards the spine, and drawing the hipbones across towards each other along the imaginary line. If you place your fingers just inside the hipbones (ASIS) you should feel the muscles tighten ever so slightly underneath the fingers. You should feel like the muscles are drawing upwards, across towards the centre and in towards the spine. Think of the t-zone as a corset for stabilising the torso, when it tightens it pulls the area in slightly. The rest of the abdominals should remain relaxed. There should be no holding of the breath. If the person states that they are finding it hard to breathe, then they are probably using their obliques

43 43 and not isolating the t-zone. The spine should remain neutral. The t-zone does not move or imprint the spine, so if the spine moves or flattens then the other abdominals are activating also. It can be difficult with some people to tell if they are activating correctly. You can feel with your fingers and observe - you can watch to make sure there is no spinal movement or breath holding. If you are still having difficulty in knowing whether the t-zone is activating or not, you can also use real-time ultrasound. Before we perform any movement in Pilates is it vital that the t-zone is activated. It is the basis of every exercise we do and must be activated prior to commencing each exercise and held throughout. It is therefore imperative to practice this activation before moving on to any other exercises. Different cues work better for different people some prefer to think of the pelvic floor, others a corset drawing the abdominals in, others drawing the hipbones towards each other along the horizontal line. For some people if they can feel your t-zone working they get a better understanding of how it should feel for them. Some people find it easier to activate their t-zone in different positions. Some find it easier kneeling on all fours, lying on their stomach, sitting, side lying, lying with the legs in tabletop position, feet up on a chair rather than on the floor etc. It is different for every person, so if someone is having trouble activating the muscles try using different positions. Sometimes their t-zone activates better once you actually get them to perform a movement or exercise better than when they just lie there and concentrate on tightening it. Oblique lines For those that have difficulty activating their obliques, or can activate one side but not the other, it can be useful to use the imagery of oblique lines. These imaginary lines can be from the ribcage straight down to the ASIS to on the same side, or from the ribcage to the opposite ASIS. Whilst performing the exercises, observe what the ribcage and pelvis are doing on each side and check for the obliques connections as well as the t-zone.

44 44 eg During leg slides of the right leg, you may need to focus on drawing the right ribcage towards the right ASIS to prevent the lower back from arching. eg During single leg circle on the left leg, you may need to focus on the drawing the left ASIS towards the right ribcage along the oblique line and also the t-zone to prevent the pelvis from rocking. eg. During oblique curls, you may need to focus on the left ribcage drawing towards the right hip if the left external oblique is not working enough.

45 45 Breathing Technique Correct inhalation pattern bibasal expansion INHALE through the nose, directing the breath into sides and back of the ribcage. Concentrate on really feeling the sides and back of the ribcage expand (bibasal expansion). As you inhale, if you direct all of the breath low down into the abdominal region the abdomen will then have to expand and the abdominals will not be able to activate as well, leaving the back unprotected throughout the exercise. If you take a shallow breath and direct the breath into the upper chest, the neck and shoulder accessory breathing muscles will be working too hard. Incorrect inhalation pattern abdominal breathing EXHALE through the mouth and concentrate on closing the ribcage and activating the transversus abdominus and obliques. Correct exhalation pattern As you exhale, concentrate on using the exhalation to increase the abdominal connection. Avoid exhaling forcefully and quickly, depressing the ribcage too much otherwise this will cause a bearing down effect and strain on the pelvic floor, and cause the pelvic floor to deactivate.

46 46 General Breathing Rules INHALE to prepare and tighten the t-zone EXHALE as the movement is performed, exertion is needed and the abdominals are required to work their hardest to stabilise. Reasons for this rule: Research has proven that the pelvic floor works better and is easier to activate whilst inhaling. This also encourages the start of the transverses abdominus and multifidus activation at this time. As you exhale, the transverses abdominus and obliques contract to increase intra-abdominal pressure and stabilize the torso. Transversus abdominus seems to be the major contributor in generating abdominal expiratory pressure during a progressive expiratory effort (Misuri et al 1997). This breathing pattern helps with the correct order of recruitment of the core stabilising muscles pelvic floor, then transversus abdominus first, then obliques. Also, if you inhale on the effort or hold the breath throughout the effort, this places an increased strain on the cardiovascular system and can increase the risk of incidents such as heart attack and stroke in predisposed individuals. This rule of exhaling when the most effort and stabilisation is required is carried through most of the exercises, so you should be able to remember the breathing pattern of most exercises by following this basic rule. However, there are a few exceptions to this rule, for example when lying prone and lifting the torso. As you inhale, the ribcage opens up and out and the spine extends slightly. For this reason, some prone lying exercises which include lifting the torso through a large range of extension use a breath in to facilitate extension. However, an exhalation may sometimes be used in this position to maintain abdominal connection to control the spinal extension. Also, in certain exercises the breathing patterns may be different as there is effort and abdominal activation being exerted throughout a whole series of complicated movements, so the breathing has been determined to best fit the particular movement series. The breathing is proven, tried and tested to improve the abdominal contraction and the ease and effectiveness of each exercise when performed in the correct manner.

47 47 How pedantic to be about breathing, corrections and progressions t-zone, imprint and neutral, neck position and shoulder blades and muscle activation It is of utmost importance that the posture and muscle recruitment for each exercise be correct to achieve the desired result from the exercise. This is especially the case when dealing with a client who has an injury or pain, as incorrect muscle recruitments and postures can make their problem worse or even hurt them. Most clients will get very sick of hearing your nagging voice telling them to fix this, they are cheating with that etc. Sometimes for this reason it is okay to let a few minor imperfections slide. Make sure you are always correcting the major points that are necessary to achieve the desired outcome of the exercise, and anything that may cause injury. Correct those first, then choose whether or not to correct the not so important ones. For example, when doing side lying gluts, it is very important to correct the pelvis position, and to make sure they are activating the gluteals correctly; not as important to make sure their neck is in perfect alignment. But if the client has neck problems, then correcting the neck position is very important. So it is best to use your judgement. If you follow the cueing formula and explain all of the setup points before you start and keep cueing the important points as you go, you will not need to make anywhere near the amount of corrections. You will find though that a lot of clients want to work hard on their first session, even though they can t do the basics properly. It is therefore very important to explain why they can t do anything more difficult until they master the basics. Give them home exercises to practice the basics so that on their second session they will progress. It is good however to give them a small taste of a more difficult exercise that is safe to do they can feel working eg side lying buttock series so that they realise it won t just be lying still and just trying to tighten their muscles forever more. As far as the breathing is concerned, correct breathing patterns are beneficial to achieving the best result from an exercise. There is a lot to think about throughout the exercises, so if the breathing is too confusing for them, make sure they get the movement and muscle activation correct first, then add the breathing in afterwards. We have written certain prerequisites to achieve before attempting each of the exercises in this manual. In saying this, it is quite surprising how many times a client can perform a more difficult exercise better than a supposed easier exercise. It is best to follow these basic manual guidelines, but remember that each individual will be different and it always best to assess each individual doing different exercises to determine what works best for them.

48 48 Speed at which exercises are performed The basic rule is to only perform each exercise at a speed at which the movements are controlled and correct muscle activation can be maintained. So initially, whilst learning the exercise/movement, the movement may be very slow. The client may even need to stop after each repetition to reset their t-zone and posture. A progression from this would be to increase the number of repetitions before having to stop and reset the body, then also increase the speed at which the movements are performed. Eventually, we want the movement patterns and correct muscle activation to become so natural that they can perform the movements correctly quite quickly and without too much conscious thought, as this is what needs to be achieved in everyday life. Carry- over into everyday life It has been proven that a specific pattern of movement needs to be performed many times before it becomes automatic, and up until this point conscious thought is needed to perform the correct movement. This means that the client will need to consciously think about holding their correct postures, muscle activation and movement patterns for a long time before it becomes automatic. A common scenario: you are so proud of your client as they have just done a whole hour session with beautiful posture and muscle activation. Then they walk over to the counter to pay, all slumped over in a terrible posture. Here lies the biggest challenge: actually making sure what they are doing and learning in their Pilates sessions they apply to their everyday life. For them, this means always thinking about their posture, tightening their t-zone, shoulder blade position etc when they are not at Pilates. You will need to explain this to them and constantly remind them of this, otherwise all the good work you are doing with them goes to waste. Remember, eventually it will become automatic, but in the meantime they really have to concentrate on it. To help the carry-over into everyday life, you can use specific examples such as see how we tighten the t-zone before we move, this needs to be done each time before you lift your child or this exercise strengthens your buttocks, remember to use your buttocks when you sit to stand or walk up steps or remember to keep those shoulder blades down whilst you are sitting at your desk.

49 49 Learning modalities You can be the most knowledgeable Pilates instructor in the world, but unless you are good at actually teaching the clients how to perform the exercises then this is of no use to you or them. It can be very frustrating for both the instructor and client when they can t understand how to perform an exercise. When this happens, it is very easy to blame the client for their lack of listening and observation skills and co-ordination, but really we should be looking at ourselves for not teaching the exercise well enough to them in a way that they understand. There are 3 different methods to how people learn visual, auditory and kinaesthetic. Every person is different and will respond better to some types of learning than others. Visual learning - this is the most common type of learning that people respond to. They find it easiest to watch someone performing the exercise, and then they copy the movements. This is why demonstration of the exercises is very important. You can use arm and leg gestures without having to actually perform the whole exercise lying down. Auditory learning this is type of learning whereby people will listen to what you are saying, listen to your descriptions and follow your instructions. For these people, a step by step verbal cueing of the setup, breathing and movements is very beneficial. Kinaesthetic learning this is the type of learning whereby people learn from feeling how it should be done and actually doing it. These people will need to know what it should feel like, where they should be feeling it, then actually perform the exercise a few times to know what they are doing. They may benefit from feeling you perform the movement eg feel you tighten the t-zone. They may also benefit from having you hold onto their limb/body and place it in the right position or move it for them the correct way so they can feel how it should be done. So when teaching an exercise you should cover all learning bases. You should first demonstrate the exercise, whilst at the same time talking them through the movements and also explain what they should feel happening and where they should feel it. Then once they are performing the exercise, continue with the verbal and kinaesthetic cues to obtain the best result. In a mat class setting, this is the best method to follow. In a studio setting however, if you get the client to stand up off the reformer after each time they have finished an exercise so that you can demonstrate the next exercise, they will not get anything done, and will get sick of getting up and down! For the more advance repertoire, you will usually need to demonstrate the exercise yourself. But for the basic and intermediate exercises, you can use arm gestures, get the client to watch the client next to them if they are doing the same exercise, and use excellent verbal and kinaesthetic cues to guide them. If they still can t get it, then get them to stand up and demonstrate the exercise yourself.

50 50 There a few reasons therefore why the verbal cueing is so important. One is the above reason, demonstrating the exercise is not always practical. It does take up time, but also there may be exercises that you are not strong or flexible enough to demonstrate, so you need to be able to talk them through it. Also, once the clients are performing the exercises, they are not looking at you anymore, so you need to be able to talk them through what they are doing. If your verbal cueing is great, you can correct people s mistakes without actually going over and touching them. In a studio setting, you can be across the studio with a client and call out to another client to make corrections and also to explain what the next exercise is. For this reason, we have developed a verbal cueing formula to help you deliver the best verbal cueing for your clients. Cueing Formula Name of Exercise What and/or Where it works The Set up T- Zone Breathing & Movement All in demo and first two reps Permission to Continue Concentration Points Recycle these points Corrections/Common Mistakes The Challenge Encourage & Inspire Remind & Recycle

51 51 Name of exercise An important tool which makes your instructing life easier. If you state the name of the exercise before you do it each time, eventually you will just be able to say the name of the exercise and they know what they are doing. This doesn t mean you get out of cueing though - you can just focus on the concentration points rather than explaining the whole exercise from scratch. What and or where it works For example, this works the abdominals. This gives the clients the knowledge of where they should feel it before they even start so they can concentrate on that area, and also helps them understand more about their bodies and how each exercise can help them. The set up This is absolutely vital to the performance of the exercise. If the setup is not right from the start, they will never be able to perform the exercise correctly. Even if you are taking a client who knows what they are doing, still remind them of the key points of the set up eg remember keep a gap between the waist and the floor. T-zone It is very important to cue to activate the t-zone before they start any movements. Otherwise they will do several repetitions without it on, and it can be difficult to activate once in the middle of an exercise. Movement Try to think step by step the order in which you need to recruit the muscles and move the body, and systematically verbalise this. In this manual we have written the cues which after taking tens of thousands of clients we have been found to be the most effective in getting the message across to help you with your cueing. Breathing Make sure you describe the breathing for each movement and continually remind people throughout the exercise so that they don t hold their breath or get the breathing patterns mixed up. The concentration It is very important to give the clients something to concentrate on. In a class setting this will be general, such as focus on the t-zone and drawing the ribs to the hips using the abdominals or focus on using the buttock to lift the leg and not letting the body roll backwards. In a studio or smaller group setting the concentrations can be more specific to each individual, such as Mary focus on drawing up the pelvic floor more and John focus on keeping the hips still and lifting your leg as high as possible. Even if a client can perform the exercises correctly without cueing, still give them a focus point that will make them work harder. Corrections Remember, the better you perform the cueing formula up until this point the fewer corrections you will have to make. The actual corrections you make are very important, but also the way that you say them is important. Corrections can be made in the form of a concentration point such as focus on keeping your tailbone down or it can be made as a direct correction eg John your tailbone is lifting,

52 52 keep it down. Generally, using the concentration point is positive and it sounds much nicer than continually telling somebody they are doing it wrong, but sometimes you do have to tell them what their mistake is. When making a correction, you will need to tell them how to make the correction. So rather than just saying don t arch your lower back it would be better to say keep your abdominals tight and only take your leg as low as possible so as not to arch the lower back. Once a specific correction has been made, ensure you compliment them on that so they know they have achieved the desired correction and feel good about it. You should also verbalise the most common mistakes that happen with each exercise so the client knows what not to do as well as what to do. This will pre-empt the mistakes and make the client feel better. Permission to continue Once you have finished explaining the exercise and the clients are performing it well, all corrections have been made and all key points said, then you can give them permission to continue so that you don t have to keep saying inhale and... exhale and... for each movement. Often if you don t give them permission to continue, as soon as you stop saying inhale and exhale and describing the movement the clients will stop the exercise. So you could say something like and continue, breathing out as you curl up and keep concentrating on tightening your t-zone as you go. It is best to leave them thinking about one or more of the concentration points. The challenge Give clients the option to make the exercise harder or to push themselves that last 10%. There are 2 ways to increase the challenge of an exercise: By giving a more difficult modification for the same exercise eg to make this more challenging, perform the exercise with the legs straight legs By telling them to extend further or higher, stretch further and elongate, or raise up higher eg to make this more challenging, lower the legs closer to the floor or make the circles as large as possible keeping the pelvis still Remind and recycle Even though you have verbalised all of the key points once, you can t assume that the clients will remember to do them throughout the whole exercise as there is a lot to remember and think about. Important things to keep reminding them of is where they should be feeling it, their t-zone activation, and their postural points such as neck and shoulder blade position and pelvis and lower back position. Encourage and inspire The difference between an average class and a great class is the encouragement, enthusiasm, motivation and inspiration that the instructor provides the participants. Especially for those who have been coming for awhile, they could do a lot of the exercises at home but choose to do a class for the above reasons. Encouragement is especially important as a lot of the class we spend picking on their posture and technique, so it is necessary to encourage and compliment when they do a good job too. Your enthusiasm levels do wear off on the class participants and they will try harder and be more motivated to do a better job if you are inspiring, and also they will be more likely to keep coming back for more classes.

53 53 It is important to ask questions and also observe the participants to determine how they are going with a particular exercise. Questions to ask where are you feeling it and how much are you feeling it work or stretch? Note: When taking a larger group class, you will not be able to ask every person the questions, so rather than asking the questions, keep reminding the class where they should be feeling it work and where they shouldn t. An example of this would be You should be feeling it in your abdominals, not your neck. If you are feeling it in the neck, remember to draw your shoulder blades down and back, relax the head into the hands, keep your chin tucked in and use the abdominals rather than the neck to draw you up. It is important to note that Pilates exercises should never cause or exacerbate any pain or injuries. Some exercises will feel like they are working and stretching the muscles quite strongly, but there should never be any pain felt through the back, neck or any other joints. Observations - look out for signs of fatigue or pain these include: losing technique starting to use cheating/compensatory movements facial strain tensing the rest of the body including feet, hands and neck grunting and groaning uncontrollable shaking of the muscles. Note: in a class setting if you notice that someone is losing their neutral spine for example, remind everyone to keep their abdominals tight to keep their neutral spine, and then say If you are getting too tired to maintain your technique then rest for a moment, then join back in. Approved words to describe movements Incorrect Push Pull Drop Kick Correct Press Draw Lower Extend Other useful words: Raise, slide, slowly, control, ceiling, circle, left, right, up, down, place, curl, straighten, bend

54 54 Descriptive sentences as you... eg breath out as you curl the ribs to the hips or flatten and scoop the abdominals as you curl up keeping the... eg reach the arms forwards, keeping the shoulders down and back or slide the arms and legs out, keeping the abdominals tight and the spine imprinted Use the to... eg use the side of the waist to raise the legs or use the t-zone to stop the hips from moving Do...(action) to...(achieve another action) eg press through the heels to press the carriage away. or squeeze the buttock to hold the leg up To put it all together: Exhale as you curl the ribs to the hips, lifting the head and shoulders, inhale as you return back to the mat. Exhale and curl up, keeping the t-zone tight, inhale and control it back down. Continue and really use the abdominals to slide the ribs to the hips, keeping the neck and shoulders relaxed. Concentrate on the t-zone tight to flatten the abdominals. Shoulder blades draw down and back, keeping the head relaxed into the hands and the chin tucked in. Occupational Health and Safety as an instructor Never demonstrate an exercise that is too difficult for you to perform or is contra-indicated due to a particular injury you may have and may cause injury to yourself. Bend from the knees rather than from the back to get down to the mat to check client s techniques. Also, if staying in that position for some time, either sit or kneel rather than bending over. Make sure you pick up stray materials off the floor that either you or clients could trip over. Follow the guidelines for exercises prescription and carefully monitor client s responses to exercises. Say the Mat Class Preamble (written below) to your class before each and every mat class you take, or modify it to suit a small group or individual session. Never take more than 20 people per mat class (non-injured general exercise class)

55 55 Studio Pilates International Class Preamble Get everyone seated on their mat. Welcome everyone to your Studio Pilates class, my name is and I m your instructor today. Is anyone new to the class...? Great, welcome to those that are new and those that have been here before, we will go over the basics quickly and then get started. If you have any questions, please feel free to ask along the way or simply ask me at the end of the class. Please remember that this is a workout class and not an injury rehabilitation class. You must always work within your limits, some exercises may have different levels and it is important to choose the level that s right for you. Level -1 is always the easiest and please remember, you may rest at any stage throughout the workout if you need to. You will the feel the muscles working in your class today but you should never feel any pain in the neck back or any of the joints. If you do experience pain, either choose an easier level, or stop the exercise and simply wait for the next one. There will be several exercises with the head and shoulders lifting off the floor. If the neck is straining then please place a hand behind the head to support the neck or simply keep the head on the mat. Pilates is not a competition. Please don t feel the pressure to perform each and every exercise and please don t compare yourself to the person next to you as they may have come 100 times before so please work at your own pace. I ll demonstrate some of the exercises as we go along; please do the exercise with me as I demonstrate to speed things up. I ll give you the breathing patterns for each exercise as we go along, the breathing is in through the nose - refocusing the breath into the upper chest- and out through the mouth. Please use the breathing to maximise the effectiveness of each exercise. We have what s called a neutral and an imprinted spine position when lying on our back. Neutral spine refers to keeping the natural curve in the lower back. Most of your exercises however you will do in the imprinted position especially when lifting the legs into tabletop. The spinal imprinted position simply refers to each one of the lower backbones drawing as close as possible towards the mat without lifting the tailbone off the mat, and you ll hear me refer to these positions through the class. Ok, let s have a practice of the spinal positions. I ll get you lying on the back with the knees bent. I want you to place your fingers underneath your kidneys and you should feel a small space between the floor and your back. I now want you to flatten the lower back slightly, keeping the tailbone on the floor...good.

56 56 We also have what s called the tabletop position...this is simply when the legs are bent up to 90 degrees in a tabletop position. Let s give this a go...great. Next is the T-Zone and is short for the transversus abdominus and pelvic floor, deep stomach muscles that stabilize the lower back and flatten the stomach...so good ones to strengthen. Imagine you have the letter T drawn on the surface of the stomach. The horizontal line of the T connects both of the hip bones and the vertical line of the T starts at the pubic bone and comes up to meet the horizontal to form the letter T. (gesture with your hands) OK, to activate and feel for the T zone, simply place the fingertips just inside the hip bones and now I want you to focus on activating the vertical axis of the T by drawing up through the pelvic floor as if you are stopping from going to the bathroom, hold this, and then focus on the horizontal line of the T drawing flat and tight towards the mat or the spine. You can also imagine the hip bones drawing towards each other along that line also. Repeat and explain 1-2 more times You may feel some tension under the fingers when the muscles engage and then disappear when you relax, if you can t, don t worry as you ll gain in strength and the more you practice it the stronger it will become. What I don t want to see is that horizontal line popping outwards or upwards. You must concentrate on keeping that T Zone flat especially when we re lifting the head and working our abdominals and remember to tighten and flatten the T zone each time I remind you as this is one of the most important parts of your Studio Pilates workout. Now let s use these principles for your first exercise:

57 57 Pain and injuries Chronic vs. acute pain Acute pain is a short term pain that is a direct result of an injury or trauma to the body, the pain is often severe initially and the area may be inflamed, then this generally subsides over time as the inflammation settles and the healing process takes place. The best response to an acute pain is RICE (rest, ice, compression, elevation) and referral to a doctor or physiotherapist when required. After the initial inflammation and pain starts to subside, then a gentle program of Pilates exercises will be beneficial in the rehabilitation of the injury. You may need to liase with and follow the guidance of the doctor/physiotherapist. Chronic pain is a longstanding pain that lasts for over several months. Chronic pain may result from a previous injury which has long since healed. It may have an ongoing cause, such as poor posture, muscle weakness/tightness, arthritis, cancer, nerve damage. After an acute injury, there may be muscle inhibition and spasm, and protective postures and movements may be adopted in response to the initial pain. After the injury has healed, if the subsequent poor postures and movement patterns, muscle tightness and weaknesses are not also corrected then a chronic pain cycle may result. Pilates is a great way to target chronic pain as it corrects the ongoing factors that may be perpetuating the pain. Common Lower Back and Neck Problems Osteoarthritis Osteoarthritis (OA) is one of the most common types of arthritis. It is a degenerative disease that affects the cartilage in the joints. Cartilage cushions the ends of bones, where the bones meet to form a joint. Current belief is that OA is caused by changes within the cells of the cartilage. This results in a loss of elasticity and gradually the cartilage thins and may even breakdown. This leaves the ends of the bone unprotected, and the joint loses its smooth functioning. OA most commonly occurs in the fingers and weight-bearing joints, including the knees, feet, hips and the spine. OA can be detected through an x-ray. Symptoms include pain and stiffness in the joints, usually this gets better as the body gets warms up and the day goes on. If severe, the arthritis in the spine may compress the nerves as they exit the spine and cause sciatica if the lumbar spine is involved or neural symptoms in the arms if the neck is involved. OA Implications for Pilates Pilates is great for OA as it mobilises the spine and restores movement, whilst strengthening the muscles which support the joints. If there is nerve involvement ie sciatica, then no spinal extension is allowed as this will compress the nerves further.

58 58 Pelvic and lumbar spine instability In patients who are hypermobile, they can be quite unstable in their joints, and their pubic symphysis, sacroiliac joints (SIJ) and lumbar spine can all be affected. The increased movement available at each of these joints may cause pain. The treatment for pelvic instability is to strengthen all of the stabilising muscles of the hips, pelvis and lower back, correct any postural problems and muscle imbalances from side to side. Instability is common during and after pregnancy as the ligaments become more lax at this time. Postural neck pain and headaches A lot of neck pain and headaches originate from poor posture, namely an increased kyphosis in the thoracic spine and a forwards head posture (increased cervical lordosis). This places the neck joints and muscles under great tension, causing pain and stiffness in the neck and also causing headaches. There is often a weakness in the stabilising muscles around the neck and shoulders, including the deep neck flexors, lower trapezius and serratus anterior. Subsequently there are often tight muscles with painful trigger points in the other muscles that are overworking. Postural neck problems - Implications for Pilates Typical poor sitting posture Correction of the posture and muscle imbalances over time usually eliminates all symptoms. A whole body approach is necessary as poor posture starts from lower down in the body. Sitting posture is very important to correct as people will spend 8 hours a day slumped forward over a computer at work with their head jutting forwards, creating most of the problems. Throughout their Pilates sessions, take care to maintain the correct posture of neck and shoulder blades at all times and that the neck remains relaxed. Limit or avoid lifting the head during abdominal exercises and use pillows to support the neck

59 59 Acute Wry Neck Acute Wry Neck is the sudden onset of severe neck pain accompanied by spasm of the neck muscles, causing the neck to bend or twist away from the painful side. This common deformity, which usually occurs on one side of the neck, is a protective reaction of the body to safeguard the neck. An acute wry neck is usually caused by facet joint dysfunction whereby the facet joints lock. It occurs often after moving the neck very quickly or upon waking after sleeping with the neck in an unusual position. Symptoms include: Sudden onset of sharp unilateral localised neck pain. Can be severe pain however it doesn t usually extend below the shoulder. Fixed neck deformity, usually holding the head bent to the side and turned away from the painful side, this is unable to be corrected due to joint being locked. Neck movement triggers the pain. Tender and tense musculature. Impaired mobility of the back of the neck. Treatment includes rest, heat and massage to relax the muscle spasm. Usually within a few days the pain and symptoms have subsided, if they haven t then some treatment in the form of joint mobilisation is helpful. Acute Wry Neck - Implications for Pilates Initially, depending on how bad the symptoms are, it may be difficult for the patient to even move from lying to standing. If symptoms are very bad, then a Pilates session will be too uncomfortable, so wait for a few days then resume Pilates. If the symptoms are not severe, then the patient may be able to do a modified session with absolutely no head lifting and using pillows to support the neck. The neck will be sensitive for some time after this, so caution must be displayed for quite some time. Gentle neck stretches and exercises can resume only as pain allows. Muscle strain Most commonly, patients who develop a muscle strain in the neck or back are doing an activity that places them at risk. This may be a sudden forceful movement, lifting a heavy object, or twisting the back in an unusual manner. Most lumbar muscle strains and sprains cause symptoms isolated to the lower back or neck, usually they do not cause problems in the legs or arms like some other more serious spinal conditions. The most common symptoms of strain are: Pain around the low back and upper buttocks, or the neck and shoulders Back or neck muscle spasm Pain associated with activities, and generally relieved with rest Muscle strain - Implications for Pilates Allow the area to rest, then start on a gentle program to regain strength and mobility as pain allows. Education regarding correct posture and lifting techniques is helpful to prevent reoccurrence.

60 60 Disc problems Degenerative disc As we age, our spinal discs break down, or degenerate. These age-related changes include: The loss of fluid in the discs. This reduces the ability of the discs to act as shock absorbers and makes them less flexible. Loss of fluid also makes the disc thinner and narrows the distance between the vertebrae. As the space between the vertebrae gets smaller, there is less padding between them, and the spine becomes less stable. Tiny tears or cracks in the outer layer (annulus or capsule) of the disc. The gel like material inside the disc (nucleus) may be forced out through the tears or cracks in the capsule, which causes the disc to bulge, break open (rupture), or break into fragments. Disc bulge also known as a disc protrusion, this is when the outer part of the disc remains intact but the gel like substance of the disc bulges out against the back wall of the disc, and may or may not press on the spinal nerves Ruptured disc also known as prolapsed or herniated disc, this occurs when the outer layer of the disc ruptures and the inner gel like substance of the disc squeezes out and usually compresses the spinal nerves. Disc problems most commonly occur in the lower lumbar spine but can also occur higher up and in the neck. Disc problems are usually diagnosed via a CT scan or MRI.

61 61 Causes Disc degeneration and ruptures may be as a result of an acute injury, usually involving bending over and lifting heavy objects, or from repetitive strain on the discs from repeated flexion movements. Disc bulges and ruptures are more likely to occur from a degenerated disc as it is more likely to rupture when is has lost some of its elasticity. And conversely, disc degeneration is likely to occur once a disc has ruptured. Symptoms Initially, severe pain, limited movement and muscle spasm are all symptoms of a disc bulge. Pain is often worse with flexion or prolonged sitting. If the nerves are being compressed then there will also be sciatic nerve symptoms which include pain into the buttock or leg, altered sensation of the leg, pins and needles or numbness in the leg, weakness in the leg muscles. Disc Problems - Implications for Pilates AVOID FLEXION, FLEXION WITH ROTATION AND PROLONGED PERIODS OF SITTING. Flexion causes compression of the disc anteriorly, which forces the contents of the disc posteriorly, causing more pressure on the disc bulge and spinal nerves. Flexion coupled with rotation is the worst possible position to place the spine in when there is a disc problem. Sitting causes an increased pressure in the discs, so initially choose exercises that are performed in lying or standing positions. Neck disc bulge no head lifting with abdominals, maintain a slight lordosis in the neck/neutral spine at all times. Lower back no bending forwards, roll ups etc, pelvic curl ups, and maintain a neutral spine throughout all exercises, do not use an imprinted spine. Pilates management of a disc bulge includes focusing on improving the stability and strength of the muscles around the area and correcting any muscle imbalances that may be present. Often the patient will be under the guidance of an orthopaedic or neurosurgeon, doctor or physiotherapist. A patient with a disc bulge that is not compressing any nerves can be pain free once their strength and stability are restored, however if someone has a severe nerve compression then they usually require surgery to take the pressure off the nerves.

62 62 Sciatica The sciatic nerve is the largest single nerve in the human body; it originates from each side of the lumbar spine, runs deep through the buttock muscles, down the back of the thigh, and all the way down to foot, connecting the spinal cord with the leg and foot muscles. Sciatica commonly refers to pain that radiates along the sciatic nerve and is typically felt in the buttock, down the back of the leg and possibly in the foot. Numbness, tingling, and/or a burning or prickling sensation are also common symptoms. If the sciatic nerve is compressed enough, muscle weakness in the foot/leg may also occur. Sciatica is actually a symptom and not a diagnosis. The term literally means that a patient has pain down the leg resulting from compression of the sciatic nerve. The diagnosis is what is causing the compression. Sciatica is caused by compression or irritation of the spinal nerves as they exit the spine, and the leg pain often feels much worse than the back pain. Common causes of sciatica include a disc bulge, degenerative disc, osteoarthritis in the lumbar spine, pelvic and lumbar instability and tightness/spasm in the piriformis muscle. Sciatica - Implications for Pilates Pilates can help sciatica by stabilising the pelvis and lumbar spine. However, as sciatica is often very painful and debilitating, care should be taken not to exacerbate the sciatic symptoms with exercise. It is important to avoid movements of the spine that may cause further compression to the sciatic nerve. This includes lumbar flexion for disc problems, and lumbar extension for osteoarthritis. Also care must be taken with any exercises which include neural tension positions. This is the position where the sciatic nerve is most on stretch this occurs when the knees are straight and the leg/s are flexed, and is increased even further if spinal flexion is added. Avoid neural tension positions for sciatica

63 63 Some patients find that a gentle neural mobilisation stretch may help their sciatic symptoms, whilst others find this may flare up their symptoms and make them worse. It is best to try a very gentle stretch to start with and continually monitor throughout. Other considerations with the sciatic nerve is during buttock exercises the sciatic nerve pierces through the piriformis muscle and when the nerve is severely irritated, sometimes any activation of this muscle can reproduce symptoms. It is usually important to strengthen the buttocks, but care must be taken to ensure correct buttock activation and try different buttock exercises to determine the best one for the patient. As with any severe pain or injury, if it is not improving or you suspect a serious problem, refer to a physiotherapist or doctor for further investigation. Sacro-Iliac Joint (SIJ) Problems The SIJ can be inflamed for a number of reasons. It is usually due to a torsion of the pelvis (or the pelvis being out of alignment) resulting from instability, muscle imbalances, side to side asymmetry and is quite a common problem, particularly in pregnancy. Symptoms Pain located either to the left or right side of the lower back. The pain can range from an ache to a sharp pain which can restrict movement. The pain may radiate out into the buttocks and lower back and will often radiate to the front into the groin. Occasionally there may be referred pain into the lower limb which can be mistaken for sciatica. Classic symptoms are difficulty turning over in bed, struggling to put on shoes and socks and pain getting your legs in and out of the car. SIJ problems may cause stiffness in the lower back when getting up after sitting for long periods and when getting up from bed in the morning. SIJ pain - Implications for Pilates Assess muscle imbalances around the pelvis, spine, hips and legs. Look for asymmetries side to side, pelvic alignment/position and stability, and prescribe specific exercises to correct these. Usually stretching or massaging the gluteals, TFL, hip flexors and quadriceps on the affected side will help, along with improving pelvic stability. Take care with buttock exercises to ensure correct muscle activation sometimes certain buttock exercises may be uncomfortable when the SIJ is inflamed, but you should be able to find some buttock exercises that are comfortable. Muscles, Testing and Function, 7 th Edition, Florence Kendall

64 64 Osteoporosis Osteoporosis is a condition in which the bones become fragile and brittle, leading to a higher risk of fractures (breaks or cracks) than in normal bone. Osteoporosis occurs when bones lose minerals, such as calcium, more quickly than the body can replace them, leading to a loss of bone thickness (bone mass or density). As a result, bones become thinner and less dense, so that even a minor bump or accident can cause serious fractures. Any bone can be affected by osteoporosis, but the most common sites are bones in the hip, spine, wrist, ribs, pelvis and upper arm. Osteoporosis usually has no symptoms until a fracture occurs. Fractures due to osteoporosis (osteoporotic fractures) can lead to changes in posture (eg developing a stoop or Dowager's hump in the thoracic spine, muscle weakness, loss of height and bone deformity of the spine. Fractures can lead to chronic pain, disability, loss of independence and even premature death.

65 65 Prevention and Treatment for Osteoporosis is to obtain enough calcium through the diet, along with other vitamins that help to lay down new bone such as Vitamin K from eating green leafy vegetables and Vitamin D from sunlight. A diet high in alkalizing foods (lots of vegetables) is important because when the body is acidic, calcium is lost out of the bones into the blood to buffer the acidity. Doctors may prescribe medications if necessary, but diet and exercise are the most important things to address. Exercise helps to build and maintain strong bones, prevent falls and fractures and speed up rehabilitation. Weight bearing exercise is essential for strengthening the bones as the stress produced on the bones facilitates new bone growth. Degenerative changes in the skeleton occur after relatively short periods of inactivity. Up to 1/3 of bone mass can be lost in just a few weeks without stress. Weight bearing exercise includes jogging activities, aerobics, dancing, tennis and also weight resisted exercises such as weights and certain Pilates exercises. However, care will need to be taken in those with already established significant osteoporosis as to not place too much strain or the bone due to the high risk of fracture. Hormones also play an important role in the synthesis of new bone, and maintaining the strength of bones. The female and male hormones (estrogen and androgens) and also the parathyroid hormones are important so it is necessary to address any imbalances in these hormones to treat osteoporosis. In women who are postmenopausal, taking Hormone Replacement Therapy can be of benefit to maintaining or increasing bone density. As long as the body conditions are correct (eg hormone balance, not acidic, good calcium absorption from the intestines), the diet is rich in alkalising foods, all vitamin and mineral needs are being met and the right exercise is being undertaken bone density will improve. Osteoporosis Implications for Pilates Reformer and other equipment exercises are particularly useful for prevention and treatment of osteoporosis as the springs provide extra weight bearing resistance. Certain matwork exercises are also beneficial, especially the buttock exercises as they help to strengthen the hip bones. Any exercises which improve core stability and balance will also help to prevent falls and risk of fracture. In somebody with severe osteoporosis or a high risk of a spinal fracture, avoid all exercises which either flex, extend or rotate the spine. eg no abdominal curl, swan prep, rolldown stretch, spiral stretch, pendulum and many others. A neutral spine position must be maintained throughout all exercises.

66 66 Pregnancy First trimester weeks 1-12 The mother-to-be may be experiencing morning sickness (or in some cases all day sickness) or feeling a little tired. This initial stage of pregnancy is where there is the most risk of miscarriage. Pilates is safe to perform at this stage, but the intensity will need to be slightly lower because if the body temperature and heart rate elevate too high this can increase the risk of miscarriage. Pilates is a more gentle type of exercise, so this is usually not a problem. During this early phase start to decrease the amount of sit up type abdominal exercises, and focus more on the t-zone and pelvic floor. Doing too much rectus abdominus strengthening can increase the risk of a rectus diastasis (see over page). Second trimester weeks The baby continues to grow, and will start to show around this time. Lying on the back can start to become uncomfortable for some and potentially dangerous. This is because the baby can sit right on top of the main blood vessels as they exit the spine and cause less blood to pump through. This can cause dizziness to the mother and shortness of breath, and less oxygen to the baby. So at this time, limit or avoid any time spent lying on the back, and omit any supine abdominal exercises. Also, lying on the stomach will not be comfortable anymore as the baby is showing. Side lying oblique muscle exercises can still be performed. Third trimester This is the time when the baby grows the most and the mother s posture changes dramatically. A lordosis-kyphosis posture becomes more evident as the baby grows and the breasts increase in size. No abdominal exercises are to be performed, not even the side muscles, and no lying on the stomach or back. Mothers can continue with their workouts as long as they feel comfortable, most women will stop at 36 weeks or so, but if feeling well there is no reason why they can t continue right through to 40 weeks. Pregnancy - Implications for Pilates Large group mat classes are not suitable during pregnancy, unless they are specific pregnancy classes. Even still, there are not many matwork exercises that can be performed in the second and third trimesters. Studio sessions using the equipment are much better for pregnancy than matwork sessions and can be done right through the entire pregnancy. Week 1-12: start to decrease rectus abdominus work, ease back on the intensity of the workouts Week 12-25: no supine lying, no prone lying, no abdominal work except may do double leg lift Week 25-40: no supine lying, no prone lying, no abdominal work at all.

67 67 During pregnancy, a hormone is released which relaxes the ligaments in the mother in preparation for childbirth, which makes the mother more hypermobile and prone to injury. Improving the strength of the stabilising muscles is therefore very important to prevent and help pain and injury. Due to these ligament changes and also the changes in posture, lower back pain, SIJ and hip pain, upper back and shoulder and neck pain are quite common. Muscles to strengthen in pregnancy: Pelvic floor Transversus abdominus Obliques (up until week 25) Gluteals Hamstrings (up until week 12) Lower trapezius/rhomboids Arms (to prepare for lifting baby) Muscles to stretch in pregnancy: Pectoralis major Latissimus dorsi Gluteals Quads and hip flexors Good pregnant posture Poor pregnant posture The House Clinics Chiropractic and Physiotherapy

68 68 Post pregnancy Women can start back with their sessions after giving birth after their 4-6 week check up. If they are having any problems with their pelvic floor or rectus diastasis (separation of their rectus abdominus muscles) then they will need to have personalised sessions to check that their t-zone is on and progress very slowly with the abdominal exercises. Otherwise if they jump back in to doing sit up type abdominal exercises and letting their t-zone go they will be making it worse (see over page for more on these problems). Lower back pain and neck, shoulder and upper back pain are very common as the mother is performing a lot of carrying and lifting the baby and pram etc, and their abdominal and pelvic strength have been so affected by the pregnancy. Also breastfeeding creates a rounded shoulder posture, both from holding the baby and the weight of the breasts. The muscles to strengthen and stretch are the same as during the pregnancy, the main difference will be that they are able to start on a specific routine to regain strength in all of the abdominal muscles, lie on their stomach and back and also start to promote some lumbar flexion mobility. Pelvic floor problems The weight of carrying the baby for 9 months along with the trauma caused to the pelvic floor can lead to weakened pelvic floor muscles, possibly even a prolapse. A prolapse is when the muscles and ligamentous structures suspending the pelvic floor and pelvic organs become so stretched and weak that they sag downwards, allowing the organs to prolapse. The bladder, uterus and bowel can all be affected. Symptoms include lack of bladder control, stress incontinence, a feeling of a sagging in the pelvic floor area and weakness through the area. The treatment for both pelvic floor weakness and prolapsed is to perform pelvic floor exercises, however if the ligamentous damage is so great surgery also may be required to repair the prolapse. Pelvic floor problems - Implications for Pilates Pelvic floor activation +++ start off with very basic t-zone activation exercises and progress as the pelvic floor strengthens. Cue to use the pelvic floor with every exercise. Take care with abdominal exercises a strong abdominal contraction bears down on the pelvic floor, so if it is not strong enough to contract against this pressure it will be forced downwards, contributing to the problem. So focus more on the t-zone isolation rather than global abdominal strengthening.

69 69 Rectus diastasis During pregnancy the rectus abdominus (or six pack muscle) needs to stretch to accommodate the growing baby. Each side of the rectus abdominus muscle meets in the midline of the abdomen to form a fibrous structure called the linea alba. This is the weakest point of the abdominal corset. In some cases when the linea alba is placed under too much pressure, rather than the rectus abdominus muscles stretching, the linea alba overstretches or in some cases tears. This is known as a diastasis (or separation) of the rectus abdominus. The rectus diastasis will look like a vertical bulge or separation in the midline of the abdomen. This bulge is more noticeable when you do certain movements that increase the pressure within the abdomen and stress this area. The Breasts How to test for a rectus diastasis? Have the client lie flat on their back with their knees bent. Place your fingers across the midline of the abdomen just above the belly button. Get the client to perform a sit up and feel for a vertical gap or separation underneath your fingers. Rectus diastasis - Implications for Pilates Performing sit up type movements where the rectus abdominus is working without using the t-zone properly will make the separation worse. Post pregnancy, start with very basic pelvic floor and transversus abdominus activation, then progress to exercises using the rectus abdominus only as the t-zone strength allows. Whilst performing any abdominal exercises, be sure to check that their separation isn t bulging out or opening further.