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clinical pilates

Clinical pilates: the art and science of Pilates as a rehab approach

In Part 1 of this exploration of Pilates (SIB 42, September 2004), we looked at ‘fitness Pilates’: how the original 1920s artistic exercise form for dancers has evolved since the 1950s to suit the needs and preferences of the fitness industry. We raised some questions of those involved in this vast and organic industry, about their responsibility in assuring the quality and effectiveness of the Pilates discipline. More recently, the scientific community has also taken an interest in Pilates and its applicability for injury rehabilitation, leading to the development of a separate stream called ‘clinical Pilates’. This second evolution is the focus of this article.

Here, we get scientific. We look at how to decide which kind of Pilates an individual should be doing, and we analyse the six Pilates principles from a scientific perspective. Finally, we offer some illustrations as to how athletes can make Pilates work for them.

The birth of clinical Pilates

The fitness Pilates industry is populated by instructors and core stability teachers with varying levels and standards of training. Many of them have little or no advanced education or training in injury process, pathomechanics, movement dysfunction or rehabilitation management.

I suspect that many genuine practitioners of fitness Pilates have a strong sense that they are offering their clients something with incredible potential, yet because they have little understanding of the inner workings of the mechanical body, these well-intentioned teachers suffer some confusion about why certain clients get a great result from their instruction while others break down with injury, despite every effort to teach them correctly and specifically.

This is where clinical Pilates started. In the early 1990s, rehabilitation specialists such as physiotherapists (especially in Australia) began to incorporate Pilates exercises and equipment into their protocols, but found that some aspects of what they were importing did not sit well with the best available evidence from sports therapy and rehabilitation research. By infusing Pilates exercises with well established physiotherapy concepts – and thereby scientific validity – clinical Pilates was born.

Back in the 1920s Joseph Pilates gave us a method that prioritised the building blocks of core stability and rehabilitation. It has only been in the last couple of decades that sports science research has helped us see more clearly why some of his ideas work brilliantly on injured bodies, while others are at odds with current best practice.

Table 1 below summarises the main differences in approach between fitness and clinical Pilates.

Table 1: Characteristics of fitness and clinical Pilates
Fitness Pilates Clinical Pilates
Dance-oriented exercises, used for general conditioning and lifestyle benefit Diagnostic and rehabilitation tool for injury and performance enhancement
Strong bias towards flexion, stretching, end-of-range movements, moderate to high loads and low repetitions Progresses from static stabilisation to dynamic; trains local then global stability systems. Neutral zone stability comes before end-of-range flexibility
No evidence to support its use for rehabilitation of low-back pain Aims to fulfil established evidence based criteria
Non pathology-specific exercises Observes pathology under load and modifies accordingly
Prioritises variety of movements and exercises Prioritises strict adherence to scientific interpretation of the six principles
Source: Adapted from the work of Craig Phillips, Dance Medicine Australia

Which type of Pilates for which people?

The key question is: are you injured or do you have a history of injury? If so, clinical Pilates is essential for your rehabilitation before attempting fitness Pilates with an instructor or in a class environment.

If you are injured…

  • Do you have a history of spinal pain?

If yes, you will probably need some treatment and investigations before undertaking any Pilates. Clinical Pilates can then equip you with the body movement skills that will allow you to exercise without reaggravating the injury. Let’s be clear: there is a vast array of spinal musculoskeletal problems that a fitness Pilates instructor is not equipped to help you with, from segmental instability or pars defect, through ankylosing spondylitis to fibromyalgia or spinal canal stenosis. And many more.

Nothing concerns me as much as well-meaning personal trainers or Pilates instructors trying to help fix someone’s injury, based only on what they have read on the internet about that condition. Legally they are on very shaky ground.

  • Is your pain Pilates-related?

If you are developing new aches and pains over a period of time that seem directly related to doing Pilates (nonmuscular pains will often appear the next day), talk to your Pilates instructor immediately. Ask if they can see any obvious technique issues, try to do modified versions of the class exercises, and if that doesn’t improve things, visit a physiotherapist (or a clinical Pilates specialist), to determine what’s wrong.

Your goal is to discover exactly what your ‘movement dysfunction’ is. With corrective training and time (weeks to months), it should be possible to work out what the problem was and have improved your control and awareness in that area. You can then gradually phase back into the class or studio situation.

  • Do you have new injuries?

If you have recently injured yourself at work or sport and are wondering whether Pilates will be a safe form of exercise for you, simply try it and see how you go. If the injury persists, or is being aggravated by Pilates, you’ll need to visit a sports therapist.

If you are not injured…

Most uninjured people will find fitness Pilates fantastic for conditioning their bodies and achieving the various benefits we discussed in Part 1. But fitness Pilates is not the best starting point for everyone.

The 0 to 10 fitness scale

Imagine a scale from 0 to 10 where 0 represents someone with no exercise history, and 10 represents an elite athlete. Now, place yourself somewhere along that scale.

For injury-free exercisers, fitness Pilates is highly recommended for anyone in the range of 2 to 7. Active people, recreational sportspeople and even good athletes (range 4 to 7) will benefit from fitness Pilates. Children, the elderly and pregnant women (provided they are in the first trimester of their pregnancy and have some experience with exercise) can benefit and so can new mothers, provided they are not experiencing any spinal or pelvic pain.

In all cases the rules and cautions outlined in Part 1 apply: if the group is too big, and the instructor is moving too fast for comfort, you are at risk of pushing your body in ways it won’t like. Break the six principles and you may get injured.

People who score 0 to 1 on the fitness scale are always going to be at greater risk of hurting themselves in exercise because they are likely to be unhealthy and/or overweight, have poor body awareness and need a little longer to learn the basics of moving safely. For these people an initial course of clinical Pilates would be ideal, to give them a solid and safe grounding in exercise movement and prepare them for fitness Pilates and/or personal trainer/gym work.

It is my personal opinion (although no research confirms this) that sub-elite to high-level elite athletes (8 to 10 on the fitness scale) would also benefit from an initial course of clinical Pilates to really focus their brains and bodies on the subtleties of how they breathe, stabilise and move during exercise.

Niggling injuries or technique faults can often be ironed out by learning clinical Pilates skills – skills that are then incorporated into sport and strength and conditioning routines, helping to enhance the athlete’s overall performance.

What science says about the six principles

In Part 1 we outlined the six underpinning principles of Pilates. These foundation principles can equally be applied to any form of exercise and the more completely they are followed, the more pure, safe and effective will be the resulting movement.

The six principles are the keys to rehabilitating any overuse injury or movement dysfunction – while fitness Pilates will vary greatly in its adherence to them (often to its detriment), clinical Pilates must strictly follow them or cease to achieve its aims. They describe the fastest way to acquire coordinated movement skills, for example learning a forehand stroke, learning to sprint, or simply lifting safely. Each principle in itself is a ‘micro-skill’ that must be learnt and when they are combined, they form a functional ‘macro-skill’.

Practice of the micro-skills at first ‘soft-wires’ them into the brain (they remain a conscious effort), but gradually ‘hard-wires’ them into the neuromuscular system, so that they become subconscious and automatically deployed.

Most people will battle with one principle more than another, depending on their familial history, sport, personality type and their injury history and status.

1. Centring

To activate tonic holding muscles in a static position requires correct cueing plus good core alignment as follows:

around the pelvis (near centre of gravity):

  • transversus abdominis (with some contribution from internal obliques)
  • pelvic floor (pubococcygeus)
  • deeper multifidus
  • diaphragm

around scapula

  • lower trapezius
  • serratus anterior (upper trapezius stabilises only at full elevation eg handstand)

around occiput (skull)

  • upper neck flexors and deep cervical extensors

around knee/hip

  • gluteus medius and minimus at hip (the latest research is also looking at the role of obturators, quadratus femoris and iliacus muscles in controlling hip stability)
  • vastus medialis (plus possibly popliteus) at the knee

around foot

  • tibialis posterior
  • peroneals
  • soleus.

Research in support:

  • To recruit the low-threshold tonic fibres needed for stabilisation, muscle activation must be in the range of <30% of maximum voluntary contraction for sustained periods (eg 10 x 10 sec holds).
  • Fine-wire EMG and Ultrasound studies show that the tonic fibres of the deep multifidus and transversus abdominis muscles remain activated during various trunk movements, regardless of movement direction. By contrast, the more superficial global stabilisers (eg external obliques, thoracic extensors, superficial lumbar erector spinae muscles) switch on and off, depending on the direction of movement.
  • Perturbation (sudden unexpected movement) studies have shown that in an uninjured person, transversus abdominis is recruited before the body moves, via a feed-forward loop activated by increased intraabdominal pressure (when breathing in, for instance). So in any movement of the body that needs stability, transversus abdominis is the first muscle to switch on.
  • In people with low-back pain, the superficial/global stabilisers change over time to behave like deep, local stabilisers. But these muscles are not anatomically designed for the role of segmental stabilisation and they fatigue.
  • Ultrasound is an established practice in specialist physiotherapy clinics for helping to assess and educate clients’ activation of transversus and multifidus.
  • Current research is validating the use of the ‘Galileo’ machine (a highfrequency vibration platform on which the patient stands) for the purpose of creating short-term high levels of activity in the deep stability musculature. Watch this space … !

2. Conscious breathing

Conscious and correct inspiration (breathing in) allows the diaphragm to help stabilise the trunk, inhibits the use of the external obliques as stabilisers and helps maintain the thorax in a tall position. Rehab and sports therapy greatly underrate the importance of correct breathing: getting it right is critical for stability!

The preferred method of breathing – diaphragmatic – involves increasing the lateral expansion of the rib cage and some upper abdominal lifting, without lifting the shoulders, or excessive billowing of the whole abdomen.

If a client struggles with this, they can practice inspiring against rubber tubing held around their thorax. Expiration should not be forced: the normal elastic recoil of the lungs and rib cage allow for sufficient expulsion of air. Forcing expiration will make the external obliques overwork and pull the thorax into flexion.

The preferred timing of breathing is to breathe in with the initial movement, or the one that requires the initiation of stability mechanisms. Rise up onto your toes as you breathe in; then try it while you breathe out and feel the difference in your ability to balance.

Research in support:

  • Inspiration seems to be the more important mechanism for stability, as the tensioning of the diaphragm increases intra-abdominal pressure, which immediately activates the transversus abdominis.
  • Erector spinae, rectus abdominis, external and internal obliques are not affected by respiration, but the transversus abdominis muscle modulates with respiration.
  • Isolated diaphragm muscle contraction with fine-wire electrode stimulation of the phrenic nerve can produce spinal extension – thereby further enhancing the tall posture that is required for good core alignment.

3. Core alignment

Neutral rotation positions are maintained around the joints of the body, with a focus (at least in clinical Pilates) on any impaired body-part. The body parts and the relevant movements are:

Body part Movement
occiput (back of the head) chin protraction/ retraction
scapula upward/ downward rotation
lumbar spine/ pelvis anterior/posterior tilt
hip/knee internal/external rotation
subtalar joint pronation/supination

Research in support:

  • The terms ‘neutral spine’, ‘stability’, ‘transversus abdominis’ and ‘motor control’ were incorporated into the Pilates language and repertoire as late as the 1990s from physiotherapy research.
  • Poor core alignment decreases the biomechanical efficiency of the tonic stabilisers supporting a joint; eg loaded excessive posterior tilt inhibits the deep multifidus muscle and will lead to disc problems.
  • Clients should not be taught to ‘flatten’ their lumbar spines into the floor, as this position does not maintain neutral pelvic tilt. A recent study showed that anterior pelvic rotation to neutral, maintained by multifidus, produced a significant increase in load-bearing capacity of the passive thoraco-lumbar spine. Multifidus activity is crucial to maintaining neutral lumber spine yet is often ignored in the quest for a ‘flat tummy’.

4. Control

Clients should be taught to limit movement to the mid-range, ie the ‘playing field’ where none of the core alignments are compromised. The more the walls around the playing field are disrespected, the greater the likelihood of compensation from superficial musculature, tissue breakdown and pain from injury.

All exercisers, whatever their sport or discipline, must learn to recognise ‘out of control’ signs in their bodies, such as jerkiness, shaking, tightening or outright pain if injury is acute. They must teach themselves to be patient and stay within the boundaries while the edges of the playing field gradually expand.

This progressive improvement in movement control never happens as quickly as one would like and the greatest challenge is to not rush the process, or load the body too heavily (forcing it to revert to bad old stability activation patterns).

Research in support:

  • It is the one-joint stabilisers (tonic muscles) that give joint control, acting like the background static on a radio channel. Two- or multi-joint muscles are responsible for movement and power. Contrast the role of subscapularis and pectoralis major in the throwing action: the former holds the head of humerus in the glenoid socket, while the latter produces movement and power. Both must work synergistically together.
  • The mechanisms that lead to poor motor control are the same for injured joints as for joints that are deloaded (ie in space, in water, or with extended rest).

5. Concentration

The above skills cannot be achieved without intentional and informed brain focus on the body part. The brain’s connection to the injured part is then slowly re-established (many clients with chronic pain report a wonderful sense of being reconnected to their bodies with massage and exercise therapy).

‘Proprioception’ is the normal sense of where a joint is in time and space and it is the key to understanding why injuries recur time and time again. A proprioceptive deficit from injury impairs your ability to ‘feel’ that area (slowing of afferent feed-forward and feedback loops to the area and altered joint position sense).

Clients who struggle with concentration can be encouraged to do certain exercises with their eyes closed, or with eye patches on, or even in a darkened room, to decrease visual distraction and maximise proprioceptive input.

Research in support:

  • studies in space have shown that proprioceptive information is reduced in anti-gravity situations (which would include extended bed-rest). In effect the brain gets lazy about information it doesn’t need. Astronauts, however, experience high incidences of low-back, hip and knee pain on return to normal gravity.
  • Runners returning from injury must often be shown that they are continuing to protect their formerly injured side out of habit, and are therefore not fully weight-bearing on that side. They must relearn this basic skill by concentrating on it.
  • Use visualisation – a study has shown that there is significant improvement in squat technique after a period of focusing on doing it properly. Elite athletes have for a long time relied on mental imagery and visualisation to perfect their techniques.

6. Coordination

This principle is hard to quantify except to say it is the result of combining all of the above skills, with the net effect of a feeling of ease during a movement that one is learning. For a right-handed person it is the difference between throwing with your left arm as opposed to with the right one. The arm feels ‘gumby’ (an Australianism), or almost totally incapable of doing it!

When we say that a person is uncoordinated, we are saying they lack many or all of the above skills, or they lack the ability to put them all together effectively into a ‘macro-skill’, such as the freestyle stroke.

Whether there is a genetic component to this is arguable, but what is certain is that there is often a strong familial/environmental component.

If slouching about with poor posture and body awareness is what our parents taught us, then that’s what our challenge will be.

The key to good coordination is not to try too hard, because you cannot force yourself to be coordinated. Instead slowly repeat and repeat, break the action into smaller components, approach the movement from as many angles as possible; remember you are training your brain and you cannot rush it.

So there we have it: the six ‘C’s’, and perhaps we could add in a critical seventh ‘C’ – commitment; the strength of character to stick at a process until the results are evident.

Clinical Pilates for athletes

If an athlete carries with them a ‘bad habit’ of movement, it will take the strict and pure approach of clinical Pilates to diagnose it, undo it and teach the correct movement pattern that is going to improve the athlete’s technique and performance. They will usually require the feedback tools of coaches and sports physiotherapists (video, EMG, pressure biofeedback, taping, etc) to make the transition from artificial drills in the studio to technique changes on the track.

Sports specificity

Different sport skills will require different emphases from the six principles. Sports such as rowing or swimming may focus on conscious breathing, whereas gymnastics or diving need higher levels of coordination; and weight lifting and shooting perhaps demand greater concentration and control.

This is where Pilates equipment comes into its own, allowing the therapist to tailor a programme to the mechanical positions and requirements of the specific sport.

Sport-specific examples

  • A golfer kneels facing the side of the Pilates Reformer, assumes the semi-squat position and pulls strap across the body to rotate the trunk.
  • A water-polo player is suspended upside down on the Thoracic Barrel doing egg-beater stroke (treading water), while an ultrasound head monitors their transversus activation (see below).

  • A tennis player or cricket bowler half-kneels facing the springs on the Reformer and goes through serving/ bowling motion, learning to stabilise their trunk in the process (see below).

  • A rower perches on the Wunda Chair with two feet on the bar and holds the tall position through hip/ knee flexion and extension – synergy of transversus and multifidus (see above).
  • A cyclist lunges next to the Reformer and holds their lumbar spine in neutral while pushing back with their foot – great for pure activation of gluteus maximus.
  • A runner stands on a block side-on to the Wunda Chair with their other foot on the spring-loaded bar and learns to maintain good lower-limb alignment and a stable pelvis through glute and transversus control.
  • A swimmer lies prone on a box facing away from the bar on the Reformer and practises their ‘catch’ and pull through with the strap in hand, enhancing their scapular stability.

Exceptions to the six principles

Once the ‘rules of good movement’ are well learnt, there is room for athletes to bend them. The welltrained body will tolerate exceptions to the rules when fatigue sets in, under higher pressures, or with unforeseen circumstances – up to a point. As long as accuracy has been enforced from the beginning and the body has matured into good movement patterns, elite athletes will be able to bend the rules to meet the highest-level demands of their sport (eg a cyclist in a very posteriorly tilted position, or a tennis player with open forehand), without sacrificing performance or risking injury.

The future of general conditioning, injury rehabilitation and athletic performance enhancement is, I believe, in the hands of those who teach and practice high-quality Pilates, yet this powerful and hugely important discipline will only thrive if it continuously returns to the deep, foundational musculoskeletal truths that underpin it. And it must be willing to evolve as further research informs it. This interweaving of the art and science will, I am confident, guarantee the future of Pilates.

Fitness and clinical Pilates: further reading

  • Allison, GT, et al ‘The role of the diaphragm during abdominal hollowing exercises’ Australian Journal of Physiotherapy, Vol 44: 95-102 (1998)
  • Cresswell, AG, et al ‘The influence of sudden perturbations on trunk muscle activity and intraabdominal pressure while standing’ Exp Brain Res Vol 98: 336-341 (1994)
  • Goldman, JM, et al ‘An electomyographic study of the abdominal muscles during postural and respiratory manoeuvres’ J Neurol Neurosurg Psychiatry Vol 50:866-869 (1987)
  • Hides, JA et al ‘Long term effects of specific stabilising exercises for first episode low back pain’ Spine, Vol 26: 243-248 (2001)
  • Hodges, P, ‘Feedforward activity of the pelvic floor muscles precedes rapid upper limb movements’ International Physiotherapy Congress Vol 11 (2002)
  • Hodges, PW, Gandevia, SC, ‘Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm’ Journal Applied Physiology" Vol 89 (3): 967-976 (2000)
  • Hodges PW, Richardson CA ‘Inefficient muscular stabilisation of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis.’ Spine, Vol 21: 2640- 2650 (1996)
  • Keifer, A, et al ‘Stability of the human spine in neutral postures’ European Spine Journal Vol 7: 471-479 (1998)
  • Lackner, JR, Dizio, P, ‘Gravitoinertial force level affects the appreciation of limb position during muscle vibration’ Brain research Vol 592: 175-180 (1992)
  • Leanderson, R, et al ‘Role of diaphragmatic activity during singing: a study of transdiaphragmatic pressures’ J appl Physiol Vol 62 (1): 259-270 (1987)
  • Money, KE, Cheung, BS, ‘Alterations of the proprioceptive functions in the weightless environment’ Journal of Clinical Pharmacology Vol 31:1007-1009 (1991)
  • Panjabi, M ‘Stabilising system of the spine, part 2. Neutral zone and instability hypothesis’ Journal of spinal disorders, Vol 5: 390-397 (1992)
  • Roll J, et al ‘Sensory motor and perceptual function of muscle proprioception in microgravity’ Journal of Vestibular Research, Vol 3: 259-273 (1993)
  • Roll R, et al ‘Proprioceptive information processing in weightlessness’ Experimental Brain Research, Vol 122: 393-402 (1998)
  • Williams, M, et al, ‘Multifidus spasms elicited by prolonged lumbar flexion’ Spine Vol 25: 2916- 2924 (2000)
  • Wedin, S, et al ‘The effect of voluntary diaphragmatic activation on back lifting’ Scandinavian Journal of Rehabilitation Medicine Vol 20: 129-132 (1988)
  • Yoshihara, K, ‘Histological changes in the multifidus muscle in patients with lumbar intervertebral disc herniation’ Spine Vol 26 (6): 622-626 (2001)

clinical pilates