Using Pilates to Alleviate Pain

Transcription

1 Mr. Glenn Withers B.Physiotherapy MAPA, MCSP, MAPPI Founding Director Australian Physiotherapy & Pilates Institute Vice Chair ACPET Director London Sports Medicine Director Pilates Art Physiotherapy Using Pilates to Alleviate Pain The Australian Modified Physiotherapy Pilates & Pilates Institute (APPI) Who are we? Founded in 2000 in Melbourne, Australia Trained in traditional/fitness based Pilates Analysed each of the traditional 34 exercises Link to Pain, Pathology and Function Create a program based on sound clinical reasoning The largest supplier of Pilates training to Physiotherapists in the UK and one of the biggest in Europe. The APPI Modified Pilates Pilates Curriculum A foundation Matwork series of 3 modules An equipment program of 4 modules A CPD program of over 10 different courses A series of DVD s aimed at Rehabilitation professionals and patients. Teach the program in over 10 countries Train on average physiotherapists a year

2 Modified problem Pilates The Problem 80-90% incidence of low back pain (LBP) 60-80% recurrence within 3-12 months Troup et al billion spent on LBP treatments in the UK annually 5 billion lost through 11 million days off annually The Times, 2004 The Modified Pilates Method A form of dynamic stabilisation retraining that reconditions the body from the central core to prevent the recurrence of and treat a range of postural, musculo-skeletal and neurological conditions Withers and Stanko, 2006 The APPI Modified Pilates Pilates Philosophy At APPI we believe that to rehabilitate a body, your goal is to recreate normal movement patterns. That begins from a stable central base, but most importantly engages a client in the joy of normal movement once again.

3 What Modified does Pilates Pain do? Pain alters normal movement patterns. Pain alters our perception of normal movement. As clinicians/trainers we treat the causes of that abnormal movement What Modified does Pilates Pain do? In our focus is to regain the normal movement Modified Define Pilates Pain An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. International Association for the Study of Pain An unpleasant sensation and emotional response to that sensation. The American Academy of Pain Medicine

4 Consequences of pain Pain inhibition of deep stabilisers Reflex Inhibition of postural muscles Initial protective global muscle spasm Reduced proprioception Disuse muscle atrophy and altered movement Resulting in reduced local joint protection Recovery is not automatic Limitations of Traditional Pilates and Pain Large focus on the Global Muscle System (GMS) Excessive compressive spinal loading Gardener-Morse and Stokes 1998, Thelen et al 1995 Non specific stabilisation due to lack of spinal attachment Panjabi et al 1989 Unable to control shear intervertebral forces Raschke & Chaffin 1996 Antagonistic global muscle co-activation results in rigidity of the spine Richardson et al 2004 How Works? Re-train the Local Muscle System (LMS) in non-weight bearing. Strengthen the global muscles system (GMS) through slings analysis Incorporate the synergy between the LMS and the GMS into function. Richardson et al 2004

5 The Local Muscle System (LMS) LMS dysfunction due to Pain Delayed activation Hodges & Richardson 1997a; Hodges & Richardson 1997b Direction specific contraction Hodges & Richardson 1996 Phasic postural response Hodges & Richardson 1996 Loss of independent control Hodges & Richardson 1998 Local Changing The vs treatments Global Muscle muscle System Local Muscle System Attach directly to the spine Long lasting, low torque producing Activate early Tonic, continuous activity Control movement Global Muscle System Do not attach directly to the spine Large muscles Delayed activity Phasic Produce movement

6 Local vs Global muscle System Local Muscle System Mutifidus Transversus Abdominis Diaphragm Pelvic Floor Global Muscle System Rectus Abdominis External Oblique Internal Oblique Lat. Dorsi Gluteus Maximus Changing The Current treatments Debate A large debate in the literature on the efficacy of specific stabilisation exercises (SSE) Macedo et.al, 2009; Allison et al, 2008; Hodges 2008; Ferreira et al, 2006; Evidence is conclusive that SSE are more effective than other interventions in mid and long term back pain Ferreira et al, 2006 The debate is around their effectiveness in acute LBP c.f manual therapy intervention Ferreira et al, 2006; Ferreira et al 2003; van Tulder et al 2000a; APPI follows Jull et al, 2002, that the best approach is a combination of manual therapy and exercise therapy. APPI PIlates Changing The Current treatments Debate Acute low back pain Pain and disability associated with acute low back pain is not reduced with SSE s. Van Tulder et al 2002a; Hides et al 1996 Specific manipulation therapy is effective in reducing pain Ferreira et al 2003 SSE s effective in reducing recurrence of low back pain Hides et al 1996 SSE s should be prescribed to acute low back pain patients to reduce recurrent episodes Ferreira 2006

7 Changing The Current treatments Debate Chronic low back pain SSE s more effective than usual care for reducing pain in short and medium term Goldby 2000; O Sullivan et al 1997 Effects of SSE similar to manipulative therapy in reducing pain at short and long term Rasmussen et al 2003;Goldby et al 2000 SSE s as effective as surgery in reducing pain and disability in disc degeneration patients Brox et al 2003 APPI PIlates Changing The Current treatments Debate Pelvic pain SSE s in conjunction with Physiotherapy more effective in reducing pain and disability than Physiotherapy alone. Stuge et al 2004 Improvements maintained at 1 and 2 years Stuge et al 2004 APPI PIlates Changing The Current treatments Debate Neck Pain SSE s effective in reducing pain and disability in short and long term for neck pain and cervicogenic headaches. Jull et al 2002

8 Changing Evidence to Support treatments The APPI Method Pilates-Based Therapeutic Exercise: Effect on Subjects With Non specific Chronic Low Back Pain and Functional Disability: A Randomised Controlled Trial. Rydeard R, Leger A, Smith D Journal of Orthopeadic & Sports Physical Therapy 2006; 36(7): Conclusions: The individuals in the SET group reported a significant decrease in LBP and disability, which was maintained over a 12 month follow-up period. Treatment with a modified Pilates based approach was more effective then usual care in a population with chronic, unresolved LBP. APPI PIlates Course aims The role of the Pelviss Primary load transfer function SIJ must resist vertical and horizontal shear forces that are incurred during extremity motion Pubic symphysis also required to absorb and transmit these forces Modified Form closure Pilates A state of pelvic stability provided by the interlocking SIJ surfaces where no extra forces are required to maintain pelvic stability given that postural load Pool -Goudzwaard et al., 1996 APPI PIlates Pilates

9 Force closure The extra forces produced by ligaments, muscle and fascia that provide compression of the SIJ to maintain pelvic stability when the postural load is increased Pool-Goudzwaard et al., 1996 Primary sling TrA, multifidus, pelvic floor and diaphragm Local muscles Provides segmental stabilisation to spine The centre Posterior oblique sling Latissimus dorsi and contra-lateral gluteus maximus Coupled by posterior layer of the TLF creating a compressive force vector perpendicular to SIJ Mooney et al 2001

10 Anterior oblique sling External oblique and contra-lateral adductors Coupled via anterior abdominal fascia creating compressive force vectors at the pubic symphysis Deep longitudinal sling Longitudinal muscle - tendon fascia sling Erector spinae TLF ST ligament - long dorsal ligament - biceps femoris sling Activation of sling increases tension in TLF and pelvic ligaments Lateral sling Gluteus medius, minimus and tensor fascia latae and contra-lateral adductors Activation of sling provides pelvic stability in the frontal plane Prevention Trandelenburg sign

11 Dysfunction Integration into Practice Restore both Local and Global Muscle system synergy Shoulder Bridge, Swimming Add small equipment to target part of a specific sling Theraband to shoulder bridge works by balancing the Systems Integration of local and global muscle systems required for maintenance of neutral joint position Kiefer et al (1997)

12 The Pilates Journey Joseph Pilates Pilates principles 1) Concentration 2) Breathing 3) Centering 4) Control 5) Precision 6) Flowing movement 7) Integrated isolation 8) Routine Modified Pilates Rehabilitation

13 Traditional Pilates exercises Rocker with open legs Control balance Neck pull Traditional Pilates exercises Designed for fit and healthy people Originally used largely within dance world Little focus on deep inner muscle core Large focus on outer muscle unit Requires very good muscle flexibility Requires end of range joint movements Reliant on good proprioception and body awareness exercises Designed by Physiotherapists specifically for use in the rehabilitation setting Traditional Pilates exercises broken down and modified to be suitable for clinical population Based on segmental spinal stabilisation research and lumbo-pelvic stabilisation theory Suitable for use in orthopaedic, neurological, women s health, sports, paediatric settings

14 Modified Pilates exercises The Clam Breast stroke preps Shoulder bridge Modified Pilates Traditional Imprinted spine Maximal bracing of the outer core muscles Head/neck flexed Modified Neutral spine Most isolated activation of TrA in neutral Sapsford et al 2001 Low threshold contraction Maximal exertion of erector spinae = posterior translation from L1 - L4 but anterior shear at L5/S1 Bogduk et al 1992 Commence neutral Cx for DNF Traditional Strict order of movements in repertoire Strict dosage Ballistic end range movements Modified Movement selection based on clinical reasoning Dosage based on precision of skill and fatigability Focus on control of neutral before increasing ROM

15 Principles of Training Pain relief: Physio, NSAID s, heat, etc Minimise tissue loading with neutral joint postures Sub maximal tonic contractions Progress repetitions and load with care Avoid fatigue Minimise lifestyle factors which may be detrimental to retraining The 5 Stage Rehabilitation Program Stages of segmental Modified Pilates spinal stabilisation training 1. Local segmental control - Centre Assess level of impairment with abdominal drawing-in Retrain independent control of local muscle system Train NWB bearing first Progress into kneeling, sitting and standing postures Provide feedback +++

16 Stages of segmental spinal stabilisation training 2. Closed chain segmental control Limb Dissociation - Maintain TrA contraction and gradually progress load through closed kinetic chain movements static spine - Train initially in NWB positions Stages of segmental The problem spinal stabilisation training 2. Closed chain segmental control Progress towards weight bearing positions and on unstable surfaces slowly Monitor ability to maintain neutral spine and activation of local stability muscles Stages of segmental spinal stabilisation training 3. Open chain segmental control Maintain TrA contraction while load is added with open chain movements of arms and legs Static spine Assess for any loss segmental control during high level open chain tasks Check for compensations

17 Stages of Changing segmental treatments spinal stabilisation training 4. Spinal movement with stabilisation Assess segmental control through movement - ensure you maintain centre Stages of segmental spinal stabilisation training 5. Functional Exercises Progress into a variety of closed and open chain functional tasks Vary speed of movement Maintain and check centre regularly Adapted from Panjabi, 1992 Integration into Practice Rehabilitate a 32 y.o social runner who presents with LBP post running. On assessment you discover that the client has a combined saggital and rotational instability and a lack of isolated hip extension.

18 Integration into Practice Stage 1: Stage 2: Stage 3: Stage 4: Stage 5: To comply with professional boards/associations standards: I declare that I or my family do have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally all Planner s involved do not have any financial relationship. Requirements for successful completion is attendance for the full session along with a completed session evaluation form. Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. Pilates for Rehabilitation Glenn Withers, B.Physio, MAPA, MCSP, MOCPPP, Cert. Pilates, MAPPI Cross Country Education Leading the Way in Professional Development. Modified Pilates Rehabilitation Program Glenn Withers Founding Director The Australian Physiotherapy and Pilates Institute t: e: info@ausphysio.com