Rheumatoid Arthritis and a Pilates Conditioning Program 1 Nicola Ferguson May 29, 2018 Course Year 2016-2017 Bahrain
Table of Contents Abstract Page 3 Anatomical Description Page 4 Case Study Page 6 Pilates Program Page 8 Conclusion Page 12 Bibliography Page 13 2
Abstract Rheumatoid arthritis (RA) is an autoimmune disease which attacks the body s immune system and causes chronic inflammation of the joints. The immune system normally protects the body s health by fighting various viruses and bacteria but for people with RA it mistakenly attacks the joints and organs and can cause joint pain and damage throughout the body. Diagnosis may take time as there is no single test which can confirm a diagnosis of RA, but early diagnosis is key to managing symptom s and devising a treatment plan which can manage pain and decrease inflammation to prevent further joint damage. Research has shown that people with RA need to move to take pressure off joints and to help mobility. Individuals with RA need to stay active, and Pilates can provide many benefits, like better postural balance, spine stability, flexibility, strength, better breathing and movement control says Gerardo Miranda Comas, Assistant Professor of rehabilitation medicine of the sports medicine fellowship at Mount Sinai Hospital in New York City. 1. When we look to the guiding principles of the Pilates method, as devised by Joseph Pilates including balance, breath and control amongst others it seems that yes Pilates has indeed something to offer and can certainly benefit the general well-being of RA sufferer s. 3
Anatomical description Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. The immune system contains a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies and immune cells in their blood that target their own body tissues, where they can be associated with inflammation. While inflammation of the tissue around the joints and inflammatory arthritis are characteristic features of rheumatoid arthritis, the disease can also cause extra-articular inflammation and injury in other organs in the body 2. As it can also affect so many other organs in the body, RA is often then referred to a systemic illness meaning that it affects the entire body as opposed to a localized area. According to the John Hopkins Medicine Research centre RA now has a worldwide distribution of an estimated 1 to 2% and the incidence and prevalence of RA are two to 3 times greater in women than in men. Whilst the average age of onset for RA is between 30 and 60 it can present in any age and has periods of increased activity called flares and other times when it remains in remission. It is however a chronic disease that unfortunately progresses over time. No one knows for sure why the immune system mistakenly attacks the tissues, but there is evidence that genes, hormones and environmental factors are involved. 4
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Case Study Nadia is a 38 year old mother of 2 who was diagnosed with mild RA, 18 months ago. Suffering with chronic pain which was initially treated with DMARDS, (Disease- modifying antirheumatic drugs) Nadia made the decision to try self- manage her condition with NSAIDs for symptomatic relief once her condition became somewhat manageable. She also understood that while she was in the mild stage, certain lifestyle changes could help improve her condition and delay progression. She wanted to try reducing inflammation in her body through dietary and nutritional support and having spent 14 months with very limited activity, realized that she needed to get some form of regular movement back into her life. Her own research identified Pilates as being a form of movement that she felt could offer her benefit and that is what led her to me. She favored Pilates in theory because she felt impact loading the joints could further aggravate her condition particularly during active flare ups or also joints that may have already being damaged by the disease. Nadia s symptoms largely include generalized morning stiffness over the entire body. Bouts of extreme fatigue Fever during active flares Occasional numbness and tingly in the hands and wrists. Hip, knee and shoulder pain during active flare ups Nadia presented with a very strong mind- body connection so despite having no previous experience of Pilates and a limited range of motion, intuitively she had an understanding of what was required of her during her sessions. She took her health very seriously and was open to trying anything which might improve her day to day overall feeling of well- being. At Nadia s first assessment we spoke in general about her overall health and whether she had any injuries prior to developing RA which fortunately she didn t. We also discussed her goals which really just involved get some form of regular movement back into her life and looked at her current daily physical demands. I used the roll down as a means of assessing her posture. She was unable to roll to any great degree and seemed to hinge more so than roll forward. Nadia s right knee seemed to turn in slightly it was more pronounced when I asked her to bend her knees to try increase her range of motion. When analyzing Nadia s posture from the side or the coronal plane using the plumb line it seemed to me that she had lost to some degree her natural low back curve, which 6
seemed somewhat flat. Her whole body had a slight forward tilt with her head also leaning forward. Ideal posture observed from a posterior (back) and anterior view should take note of correct symmetry in the body, especially in the positioning of the head, shoulders, trunk, pelvis, knees and feet (Isacowitz, 2013: 42) Whether this imbalance was a symptom of her RA or if it was a learned or structural deviation was unclear, however it was definitely something I would need to consider when developing her conditioning program. Along with her symptom s and challenges of RA, flat back often results in lengthened and weak hip flexors and shortened and tight hamstrings and abdominals. Nadia herself felt that her posture had become somewhat misaligned following her pregnancies and more evidently since her diagnosis with RA. 7
Pilates Conditioning Program To start Nadia s training program we agreed to doing 5 Mat based sessions working on Fundamental moves really to increase her body awareness and to have a better understanding of what she could expect on the Reformer.. We focused on concepts such as lateral breathing and how to establish a neutral pelvis and spine in order to work on her stabilization. We started with a modified roll down from the wall to encourage a better sense of posture and then moved to the Mat where we went through fundamental moves, which she would continue to use as part of her warm up for the Machines. We thereafter agreed to meet twice a week focusing initially on the Reformer and then the Cadillac. We would then assess what changes if any had taken place. My intention for this Pilates program was to help increase Nadia s overall range of motion whilst paying attention to her postural misalignment and strengthening her body to support the joints she found affected by her RA namely her hips, knees and shoulders 8
Program Class 1-10 Reformer Warm Up Footwork Assisted roll downs on the wall followed by Fundamental Warm up Series on the Mat Parallel Heels Parallel Toes Small V Large V Heels Large V Toes Calf Raises Prances Prehensile Single leg Heel Single leg Toe Class 11-20 Cadillac Roll Downs Alternating between Fundamental and Intermediate Warm Up on the Mat We started facing the tower for footwork but soon turned around to lie in the correct position. Her head was placed very high on the extension headrest to allow for her to get her tailbone down Full footwork was completed. Notes Initially on the reformer we used very light springs to build strength and also awareness to her hamstrings which were very tight. Used the footwork to observe and focus on alignment, particularly the tracking of her right knee which I had her push constantly into my hand for correction. The single leg work was of huge benefit is supporting her through the correction Abdominal Work Hundred Prep Hundred Bent Knee position Coordination Short Box Series Round Back Flat Back Tilt Twist *Roundabout *Climb a tree Roll up with Roll up Bar Mini Roll Ups Mini Roll Up Oblique Roll Up Top Loaded We started the Reformer Abdominal work with light springs to focus more on engagement and less on arms. I also included the short box series although we omitted the advanced Roundabout and Climb a tree. However the cocontraction of abdominals and back extensors helped strengthen the low back extensors. The Cadillac sequence allowed for a 9
deep TA connection and increased her flexibility in her lumbar spine Hip Work Spinal Articulation Stretches Full Body Integration Arm Work Frog Circles Down Circles Up Openings Later Extended Frog Extended Frog Reverse Bottom Lift Bottom Lift with extension Standing Lunge Kneeling Lunge Upstretch Elephant Arms Supine Series Shoulder Push Double Arm Frog Circles Down/ Up Walking Bicycle Single Leg Frog Single Leg- Circles Down/Up Hip Extension Bicycle Pelvic Curl- Holding PT Bar Tower Prep Monkey Shoulder Stretch Sitting Forward Side Reach Arms Standing Series We worked on Pelvic lumbar stabilization and Hip adductor strength and hip extensor strength. The single Leg work on the Cadillac was particularly useful to focus on hip dissociation and pelvic stabilization. With the reformer we focused on keeping the shoulders on the Mat. Initially Nadia couldn t go to straight legs on the Monkey so we worked towards that by increasing her stretch range for her hamstrings and calf For the standing and kneeling lunge we focused on lifting the upright position of her torso. On the Cadillac her shoulder stretch initially had very little range which gradually increased Worked on encouraging a flat back and keeping stability in shoulders and trunk on the reformer. With the Cadillac we focused on maintaining flexion in the lumbar area when reaching back and pelvic stability The standing Cadillac chest expansion was super to promote external rotation of the 10
Shoulder Push Single Arm shoulder whilst maintaining core activation and trunk stabilization Leg Work Single Leg Skating Squats With squats we worked on keeping the body upright as if moving and down a wall with a slight anterior tilt to keep the hips in line with the pelvis. Lateral Flexion /Rotation Back Extension Cool Down Side overs Modified to just hold the correct position Breaststroke Prep Pulling Strap 1 Rest Position Roll Downs Cadillac as Mat - Side Lifts Prone 1 Prone 2 modified to using single arm with forehead resting on other hand turning head to look at arm extending as elbow reaches back Rest Position Roll Downs Worked on promoting lateral activation, Initially just held position on reformer holding for longer each session We started Breaststroke prep with no springs to encourage stability and control and focused on maintaining back extensor engagement whilst constantly lengthening through back of legs We finish with a roll down allowing Nadia to feel her increased range of motion and flexibility at the end of class. 11
Conclusion Rheumatoid Arthritis is a debilitating condition, but Nadia found that Pilates could assist with increasing her overall quality of life. She enjoyed her sessions hugely and always felt taller and more aligned when she finished. In fact the outstanding comment from her was that after she left our sessions she would have to alter her rear view mirror in her car as she was sitting so much straighter. She felt her strength and flexibility increase and we mindfully worked her through the ROM that was available to her on any given day. She decided to continue with her training and has even added a Group Mat class to her sessions. As RA is a chronic condition, there will always be periods of inactivity during active flare up s so I am really happy that Nadia felt the value in investing in her health and well-being through Pilates. I was satisfied that Nadia had some form of enjoyable movement back in her life and we continue to work towards improving her posture and the alignment of her right knee. 12
Bibliography Isacowitz, Rael: 2013. The Comprehensive Course Study Guide & Workbooks Isacowitz/Clippinger. Pilates Anatomy Isacowitz, Rael: 2006. Pilates. Illinois. Human Kinetics Calais-Germain, Blandine: Anatomy of Movement, revised edition, 1999 Foot notes: 1. Quote from https://www.everydayhealth.com/rheumatoid-arthritis/living-with/how-pilates-can-ease-rasymptoms/ 2. Quote From https://www.medicinenet.com/rheumatoid_arthritis/article.htm#what_are_rheumatoid_arthri tis_causes_and_risk_factors 13
Image 1 from website: https://www.medicinenet.com/rheumatoid_arthritis/article.htm#rheumatoid_arthritis_ra_fact Image 2 from website: https://www.medicinenet.com/rheumatoid_arthritis/article.htm#rheumatoid_arthritis_ra_fact 14