Pilates in a Clinical Framework

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Buddy Mosley
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1 Pilates in a Clinical Framework Sarah Mottram MSc MCSP MMACP Chartered Physiotherapist, Kinetic Control Accredited Tutor, Performance Stability Accredited Tutor Pilates Foundation Teacher GYROTONIC Trainer

2 Pilates has become a very popular rehabilitation tool amongst physiotherapists over recent years. Clinicians have used the key principles in their retraining programmes and adapted the repertoire to suit individual patients. Indeed its is interesting to remember that Joseph Pilates ( ) worked with disabled, sick and bed bound internees during the First World War. There are many therapists promoting Pilates in a clinical framework for example Brent Anderson, Pilates-Based Rehabilitation through Balanced Body UK 1 and Craig Philips - Clinical Pilates 2. This essay aims to present a current concept in stability assessment and retraining (Kinetic Control 3 UK and Performance Stability 4 UK) and discuss how the repertoire (both classical and adapted) and key Pilate s principles can be applied to the retraining of stability dysfunction. Stretching and strengthening has always been a key part of physiotherapy practice but in the last 50 years there have been developments in the assessment and retraining of muscle function. Professor Vladimir Janda (1983) and Professor Shirley Sahrmann (2000) have made significant contribution though the diagnosis and treatment of movement impairment syndromes. One of the main focuses of Sahrmann s work has been identifying the direction susceptible to movement. More recently there has been a wealth of research demonstrating evidence for dysfunction in muscle function and evidence for effect of intervention (Cowan et al. 2003, Falla et al. 2004, Hungerford et al. 2003, O Sullivan et al Richardson et al. 2004, Stuge et al. 2004) Over the last 10 years Kinetic Control has developed a comprehensive stability assessment and retraining package using unique concepts & processes (Comerford et al. 2005). This has been based on original ideas, evaluation of current literature, clinical expertise and analysis of individuals and research groups who have contributed significantly to the body of evidence relating to movement and stability dysfunction and corrective retraining. Additionally analysis of common features shared by alternative therapies is considered and the key Pilates principles for example breathing and focus fit in here. The key features of the Kinetic Control process includes a systematic analysis of movement dysfunction, development of principles of stability retraining including the development of local & global muscle testing and retraining, an integrated local and global motor control stability retraining strategy, application of stability assessment and retraining to the whole body, development of clinical assessment of stability dysfunction (based on low threshold tonic recruitment efficiency) and an integrated core stability model (low and high load function) (Comerford 2005)

3 One of the key principles in the Kinetic Control process is identifying give. Give is described as uncontrolled movement and is labelled in terms of site and direction (Comerford et al. 2005). This is important in clinical terms as it is the most likely site of the source of pathology and symptoms of mechanical origin. For example in the clinic uncontrolled lumbo-pelvic extension is associated with back pain, uncontrolled scapula forward tilt is associated with shoulder impingement type symptoms and uncontrolled patello-femoral glide with knee pain. The give / uncontrolled movement may present as dysfunction of articular motion associated with abnormal translation at a single motion segment e.g. uncontrolled patella translation or glenohumeral translation or as dysfunction in the in the myofascial system in the physiological and functional movements associated with range and direction of movement across one or more motion segments; e.g. uncontrolled scapula forward tilt, uncontrolled lumbar flexion, uncontrolled lumbo-pelvic rotation. It is important for rehab and retraining to identify the give in terms of site and direction and differentiate translational and range give as this will guide the retraining process. The concepts of local and global muscle systems and stabiliser and mobiliser muscles have provided a useful framework to classify muscle function. However alone each model demonstrates some clinical deficiencies. Merging these two concepts has provided useful model of classification and from this functional roles of muscles have been developed (Mottram & Comerford 1999, Comerford et al. 2005). Table 1 describes the functional role of the local stability muscles, global stability muscles and global mobility muscles. Effective active stability mechanisms of the local stability muscle system (to control translation) are dependent on efficient low threshold recruitment and present in the background of functional movements. Inefficiencies in this system will result in uncontrolled translation at a motion segment. Effective active stability mechanisms of the global stability muscle system (to control through range movements) are dependent on efficient low threshold recruitment and optimum length tension efficiency. Inefficiencies in this system will result in uncontrolled range at one or more motion segments. The function of the global mobility muscle system is to produce range of movements, speed and control load. These muscles become dominant if there are insufficiencies in the stability system. This can further contribute to uncontrolled movements. Recent research has identified dysfunction in all three muscle system for example Hungerford (2003) identified recruitment changes in the global stability system in subjects with SIJ pain and dominance of the hamstrings (global mobility muscle system); Falla et al. (2004) has shown that subjects with neck pain demonstrate greater activation of accessory neck muscles during a repetitive upper limb task compared to asymptomatic controls. Additional research has demonstrated that muscle retraining can have an effect on outcomes (Cowan et al. 2003, Jull et al. 2002, O Sullivan et al. 1997, Stuge et al. 2004). In the clinical environment assessment of stability dysfunctions should be matched with symptoms and

4 disabilities. Specific assessments need to address the site and direction of give, inefficiencies in recruitment of the local stability muscle systems, inefficiencies in recruitment and force generation of the global stability muscle systems and over activity and dominance under low functional loads of the global mobility muscle system. Kinetic Control presents a comprehensive stability assessment and principles of retraining and much of this is based on low load testing. Similarly Performance Stability has developed the Performance Matrix : a system of core stability assessment and retraining identifying weak links in the functional performance chain (Comerford 2005). The specific core stability assessment can identify key injury risk and actual or potential performance deficiencies under both low load and high load. This assessment system can be modified for the Pilates teacher 5 and this may help them with functional integration and help the make prioritising decisions about the choice of exercise (McNeill ). The term core stability can be confusing and it can be used to describe activation of the deepest stability muscles e.g. transversus abdominis or high load through range exercise e.g. fast sit up with arms overhead. All original Pilate s repertoire and modified Pilates can be considered to focus on core stability. At this stage in the understanding of core stability it is useful to be more precise with the definition of the term. The term motor control stability may be an appropriate new label for low threshold stability concepts and is best defined as central nervous system modulation of efficient integration and low threshold recruitment of local and global muscles systems. Core strength training may be more appropriate for high threshold or overload strength training of the global stabiliser muscle system. Symmetrical strength training may be more appropriate for the more traditional high threshold or overload strength training of the global mobiliser muscle system (Comerford 2005). Table 2 highlights the similarities and differences between the different processes. Table 3 highlights the key elements that provide the guidelines to train one process or another. Once the site, direction and threshold (high vs low load) has been established through a systematic analysis assessment system retraining can commence. Traditional and modified Pilate s repertoire is a valuable part of this process. Considering the training guidelines in Table 3 specific exercises / repertoire can be chosen to rehab particular dysfunctions (give / uncontrolled movement). Table 4 7 illustrate specific exercises to target aspects of core stability and control give. The Pilates Method is based on six or so principles. These are integrated with the repertoire and recent literature has demonstrated evidence supporting the value of many of these principles. Table 8 illustrates literature to support some of the principles. Therapists can develop skills in motor control retraining and core 5 Pilates & Performance: assessing movement & adapting repertoire to enhance performance. Performance Stability and Scott Studio, UK 6 McNeill W 2005 Is there a need to develop assessment based Pilates? Pilates Foundation Course Work

5 stability training by understanding and applying the Principles, repertoire and adaptations of Pilates for example: Language is client friendly and facilitatory e.g. tuck your chin in may be less effective than the thought of lengthening through the back of the neck Cues target the auditory, kinaesthetic and visual learner Cues can work on the somatic mind body integration e.g. float, soften, lengthen [These cues encourage the letting go of the global mobility muscles. In the literature these muscles have been shown to be dominant and overactive under low (functional) load (Falla et al 2004, Hungerford et al 2003, Richardson et al 2004)]. These changes can influence posture Eccentric control is emphasised and this is a requirement for good postural control Maintaining centre is the key for controlled movement [Joseph Pilates called it the powerhouse and advocated bracing - this is appropriate for high loads but a modified activation of the abdominals is more appropriate for low load] Maintaining appropriate alignment during movement facilitates appropriate recruitment Focus on breathe control can help retrain dysfunction and encourage slow motor unit recruitment Flowing movements require efficient motor control Repertoire influences the whole body rather than just one segment Concentration encourages the mind-body connection The mind-body connection can influence pain (Moseley 2004) Joseph Pilates promoted the influence of mind, body and spirit / It s the mind that builds the body Motor control learning is mindful exercise - concentration Its popularity may influence compliance. In a clinical setting it is important to correct the dysfunction seen in each patient rather than use protocols. An illustration of a protocol commonly used is the focus on a Transversus Abdominis contraction prior to all movements. Research in the early nineties demonstrated a recruitment dysfunction in Transversus Abdominis in subjects with back pain (Richardson et al 2004). The dysfunction reported in the literature demonstrates inefficiency of low threshold recruitment and changes in anticipatory timing (feed forward mechanism). Retraining protocols need to target these dysfunctions and not loosely activate this muscle. It seems many involved in therapies and the exercise industry target the Transversus Abdominis prior to any manoeuvre and this may not change the dysfunctions identified e.g. recruiting Transversus Abdominis prior to a load manoeuvre will not change the low threshold sensitivity. Many of the cues are not specific to Transversus

6 Abdominis but co-activation of the abdominal wall. This is appropriate for loaded exercises but not for retraining the low threshold recruitment dysfunction. In the 1980 s manual therapy methods became very popular with physiotherapists and perhaps there was less of an emphasis of movement disorders and their relationship to signs and symptoms. However through the 1990 s and into the twenty first century most physiotherapists have become aware of the relationship between movement disorders and pain and performance deficits. Much of the literature has focused of identifying movement dysfunction and there has been less emphasis on appropriate retraining. Many physiotherapists have struggled to retrain patients with movement disorders and have embraced the Pilates method as a tool for correcting dysfunction. Classical repertoire tends to focus on higher loads but modified Pilates can be applied in the clinical setting. The focus on the Pilates principles can be a make a significant difference to stability rehab e.g. concentration can assist in retraining of slow motor unit recruitment. Learning the Pilates principles and repertoire is a huge advantage to therapists retraining movement faults in patients with stability disorders. A specific assessment is needed to identify the individuals dysfunction and once established Pilate s principles and repertoire can be used to retrain the movement faults. There is wealth of literature illustrating evidence of dysfunction and effect of intervention. Current research is exploring the sub grouping of patients into specific categories so that further research can determine the most effective management / intervention programme for individual patients. I believe Pilates principles and repertoire will have a huge influence on management / intervention programmes for individual patients.

7 Table 1 Muscle Functional Roles Local Motor Control Role muscle stiffness to control segmental translation no or minimal length change in function movements anticipatory recruitment prior to functional loading provides protective stiffness activity is continuous and independent of the direction of movement (e.g. transversus abdominis, segmental lumbar multifidus, posterior fasciculus of psoas major) Global Stability Role generates force to control / limit range of movement functional ability to (i) shorten through the full inner range of joint motion (ii) isometrically hold position (iii) eccentrically control the return low threshold eccentric deceleration of movement (rotation) high threshold activation under situations of increasing speed and load activity is non-continuous and is direction dependent (e.g. external obliquus abdominis, superficial Multifidus, iliacus) Global Mobility Role generates force to produce range of movement concentric acceleration of movement ( sagittal plane: power) High load shock absorption activity is especially phasic (on:off pattern) and is direction dependent (e.g. rectus abdominis, iliocostalis, rectus femoris, hamstrings) Reproduced by permission of Performance Stability (2005)

8 Table 2: Core Stability Summary Symmetrical Strengthening (Limbs) Core Strengthening (Trunk) Motor Control Stability: Global Motor Control Stability: Local Activation Threshold high high low Low Muscle Emphasis global mobilisers global stabilisers global stabilisers local stabilisers Position / Direction of 1 0 Loading flexion-extension +/- sidebend +/- abd-add (no rot control) neutral position +/- rot resistance +/- rot thru range neutral position & dissociate all 3 planes esp. rot control but incl. flex & ext control neutral position Type of Contraction *isotonic: move limbs and trunk through range (concentric) *symmetrical & bilateral limb movement +/- isometric & isokinetic isometric: resist trunk motion *isotonic: move trunk through rotation (concentric) *isometric: resist trunk motion (dissociation) * isotonic: move limbs through range (isometric hold in shortened range & eccentric lowering) isometric hold in different trunk postures e.g. sit, stand, lying Reproduced by permission of Performance Stability (2005)

9 Table 3 Training Guidelines Symmetrical Strengthening (Limbs) Core Strengthening (Trunk) Motor Control Stability: Global Motor Control Stability: Local Guidelines for Training fatiguing high load exercise +/- speed bilateral or symmetrical limb load no rotation challenge limb or trunk lifting in the flexion-extension plane allow global mobiliser dominance encourage core rigidity fatiguing high load exercise +/- speed unilateral or asymmetrical limb or trunk load high rotation challenge resist rotation force at trunk rotate trunk against resistance discourage global mobiliser dominance non fatiguing low load exercise unilateral or asymmetrical limb or trunk load trunk move out of neutral with control dissociate rotation, flexion & extension emphasise rotation control at trunk and girdles shortened range hold for postural control discourage core rigidity non-fatiguing low load exercise trunk does not move out of neutral allow slight global stabiliser coactivation discourage global dominance discourage core rigidity Reproduced by permission of Performance Stability (2005)

10 Table 8 illustration of supporting literature to the Pilates Principles Concentration Recent research by Moseley (2004) has demonstrated a link between pain cognition and physical performance Breath Alignment Centre / Control A higher sensation of effort (concentration) is required in subjects with proprioceptive deficits for efficient activation of slow motor units (Grimby & Hannerz 1976) O Sullivan (2002) and is co-workers have identifies altered motor control strategies and alteration respiratory function in subjects with sacro-iliac joint pain O Sullivan (2002) demonstrated that the lumbo-pelvic stabilising musculature is active in maintaining optimally aligned erect postures, and these muscle are less active during passive postures (slump sitting and sway standing) Van Dillen (2003) examined the effect on symptoms of altering the patient s habitual movements and alignments of the lumbar spine. There was a significant reduction in symptoms when the lumbar spine is supported in neutral during direction specific tests.

11 References Comerford MJ 2005 Core Stability Training. The Performance Matrix Performance Stability UK Comerford MJ, Mottram SL & Gibbons SGT 2005 Understanding Movement & Function - Concepts Course. Kinetic Control, UK. Cowan SM, Bennell KL, Hodges PW, Crossley KM, McConnell J Simultaneous feedforward recruitment of the vasti in untrained postural tasks can be restored by physical therapy. J Orthop Res 21(3): Falla D, Bilenkij G, Jull G Patients with chronic neck pain demonstrate altered patterns of muscle activation during performance of a functional upper limb task. Spine 29(13): Grimby L, Hannerz J Disturbances in voluntary recruitment order of low and high frequency motor units on blockades of proprioception afferent activity. Acta Physiologica Scandinavica 96: Hungerford B, Gilleard W, Hodges P Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 28(14): Janda V 1983 Muscle Function Testing Ist Ed Butterworth Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 27(17): Moseley G L Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain 8: Mottram S L, Comerford M Stability dysfunction and low back pain. J Orthopaedic Medicine 20(2):13-8. O'Sullivan P B, Twomey L, Allison G Evaluation of specific stabilising exercises in the treatment of chronic low back pain with radiological diagnosis of spondylosis or spondylolisthesis. Spine 22(24): O'Sullivan P B, Beales D J, Beetham J A, Cripps J Altered motor control strategies in subjects with sacroiliac joint pain during the active straight leg raise test. Spine 27(1):E1-E8. O'Sullivan PB, Grahamslaw KM, Kendell M, Lapenskie SC, Moller NE, Richards KV The effect of different standing and sitting postures on trunk muscle activity in a pain-free population. Spine 27(11): Richardson C, Hodges P & Hides J 2004 Therapeutic Exercise for Lumbopelvic Stabilization 2 nd Ed Churchill Livingstone Sahrmann S A Diagnosis & Treatment of Movement Impairment Syndromes. Ist ed. Mosby, USA. Stuge B, Veierod MB, Laerum E, Vollestad N The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a two-year follow-up of a randomized clinical trial. Spine 29(10):E197-E203. Van Dillen L R, Sahrmann S A, Norton B J, Caldwell C A, McDonnell, M K, Bloom N 2003 The Effect of Modifying Patient-Preferred Spinal Movement and Alignment During Symptom Testing in Patients With Low Back Pain: A Preliminary Report. Arch Phys Med Rehabil Vol

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