Sarah Mottramand Suzanne Scottillustrate how Pilates can be used in retraining to correct stability faults
In SIB 57, the article 'Adding rigour to core stability' discussed the ‘performance matrix’, an assessment system that can help therapists determine the ‘weak links’ (uncontrolled movement) in a client’s stability and performance chain. These weak links were identified in terms of:
i. the site
ii. the direction of musculoskeletal risk
iii. the threshold (low or high) of potential performance failure.
We applied the assessment system to the case of a footballer with recurrent right hamstring ‘strain’, outlining two tests (one low-load and the other high-load) to try and identify his weak links. The tests established that the footballer had two weak links:
* lumbo-pelvic (site)rotation(direction) under low load (threshold)
* lumbar (site)extension (direction)under high load (threshold).
This tool makes it easier for the support professional to design and implement a prescriptive retraining programme to manage symptoms and improve performance. This article will illustrate a retraining programme using Pilates principles and repertoire.
Pilates as a rehab tool
As a system of movement re-education and a method of rehabilitation, Pilates has a long and anecdotally successful history of use among the dance and performance community. Recently it has become more widely adopted within sports therapy and evidence-based clinical practice, as appreciation has grown of the versatility of the spring-tensioned equipment unique to the technique, and the sophistication of the exercise repertoire and handling skills of its practitioners. While short courses exist that are aimed at therapists wishing to add Pilates to their existing clinical expertise, a longer, dedicated training in the method is recommended.
The exercises described below focus on controlling the direction of the uncontrolled movement and give examples of matwork and equipment options (see Table 1 and Table 2 below).
Retraining lumbo-pelvic rotation weak link under low load
To test for uncontrolled movement, the subject is asked actively to control the ‘weak link’ and move independently at the adjacent joint in the direction of testing. This principle of dissociation can be used for retraining, as the following exercises illustrate (control lumbo-pelvic rotation and move the hip into rotation) under low load. The aim is to reverse the dysfunctional recruitment sequence and control movement at the site of the ‘weak link’. Guidelines for retraining control of direction are listed in Table 3 below. The aim is to regain awareness of:
* alignment and postural position
* muscle tension and effort
* the sensation of ‘easy’ low-load holding
* moving one joint independently of another.
This is a process of sensori-motor re-programming to regain kinaesthetic awareness of joint position, muscle activation, movement coordination and motor control.
Pilates matwork:Modified Pilates: Oyster (Side-lying: hip abduction & lateral rotation)
This dissociation exercise is aimed at retraining lumbo-pelvic rotation control under low load.
* Lie on side in lumbo-pelvic neutral, lower leg flexed 90° at the knee and in 15-20° hip flexion (to assist balance and reduce co-contraction of the dominant mobility muscles), with knees and heels together.
* Abduct and laterally rotate femur of top leg to approximately 45° from start position, maintaining alignment of lumbar spine and shoulder girdle.
* Lower leg to start position without loss of control of trunk position.
This is repeated slowly and with control 15 to 30 times on each side, with the aim of repeating the movement without fatigue for 1 to 2 minutes. This will demonstrate efficient low-threshold recruitment. The exer- cise is performed on both sides but the focus is on the right side to retrain the stability dysfunction.
Pilates equipment:Modified Pilates side- lying push through on the Cadillac
This dissociation exercise is aimed at retraining lumbo-pelvic rotation control under low load, using spring-tensioned Pilates equipment.
* Lie on side (in lumbo-pelvic neutral), lower leg extended at the knee and in 15-20° hip flexion; place the foot of the upper leg on the push-through bar (1 light spring from above), maintaining contact with the bar on the metatarsal heads (Pilates ‘high half toe’ position).
* Extend knee of the upper leg, pushing bar away smoothly at the same time, pivoting through the toes so that the femur laterally rotates.
* Control the return of the bar to the start position, reversing the lateral rotation of the femur to end in neutral start position.
Repeat 15 to 30 times on each side under control with the aim of repeating the movement without fatigue for 1 to 2 minutes. This will demonstrate efficient low-threshold recruitment.
Retraining lumbar extension control under high load
The principle of dissociation can be used for retraining and the following exercises illustrate this (control lumbo-pelvic extension and move the hip into extension) under high load. Strength, as well as motor control, is required to control the load.
Pilates matwork:Modified Pilates leg pull front
* Assume four-point stance with hands in front of shoulders (approx 120° shoulder flexion), spine in neutral ‘mid range’ position.
* Pressing hands into the mat and lifting knees up, take weight on to toes, move smoothly through the shoulder joint, gliding the body forward so that the hips move into extension without losing the alignment of the lumbar spine. The subject has to actively prevent the back from dropping into extension.
* Return to start position and repeat.
To fulfil the criteria of high load, the client should be able to maintain alignment (extend at hips without extending at lumbar spine) for a maximum of 2 minutes’ continuous activity before fatigue sets in. Alternative high-load options include placing the hands or feet on a balance pad or air discs, or increasing the speed of repetitions without observed loss of form.
Pilates equipment exercise:Pilates knee stretch ‘flat back’ on the Reformer
* Assume four-point position, spine in neutral ‘mid-range position’ on Reformer carriage, facing footbar with hands gripping bar, springs tensioned to balance body weight (approximately 2 springs, middle gear) and soles of feet against shoulder rests.
* Press down on to bar and lift knees off carriage, flexing at shoulders and extending at hips to press the carriage out without losing the position of the lumbar spine.
* Return carriage, maintaining alignment of spine, and repeat, keeping knees off carriage throughout.
To fulfil criteria of high-load exercise activity, the subject should reach fatigue within 2 minutes.
Both weak links (lumbo-pelvic rotation and extension) may be simultaneously retrained by the following sequence, using modified Pilates matwork and equipment exercises.
*Assume four-point position, kneeling on the mat with shoulders in 120° flexion and spine in neutral mid-range position.
*Abduct and laterally rotate one leg, allowing the knee to move away from the mat in a smooth arc, pivoting on the toes while gliding the body forward so that both hips move into extension.
* Return to the start position, maintaining alignment in the pelvis and spine, and repeat using the other leg.
The addition of an unstable base and increased load via decreased support of lower limbs converts the exercise to high load. To make this sequence high load, repeat the above exercise with either the hands on a balance pad or air discs, or both knees off the mat (support through toes). Alternate between low- and high-load combinations.
* Kneel on the Reformer carriage facing the footbar, soles of feet against the shoulder rests.
* Grip the bar and, flexing the shoulders and hips, press the carriage out while extending, abducting and laterally rotating the hip, pivoting on the toes so that the knee moves off the carriage in a smooth arc as the leg rotates.
* Return the carriage, controlling the alignment of the spine and pelvis as the knee swings back to the start position and repeat with the other leg.
To make the exercise high load, repeat with both knees hovering off the carriage. Decrease spring tension orlower the footbar and place a balance pad or air discs on the platform extender. Repeat with or without the knees off the carriage.
The retraining programme can be expanded to focus on the stability muscles, which will control the range of the uncontrolled movement. For lumbo-pelvic rotation this will target the oblique abdominals and gluteus medius and for lumbar extension the oblique abdominals and gluteus maximus. These can be adapted for low- and high-load stability. Examples of Pilates repertoire to target this are listed in Table 4.
This article has focused on Pilates in the retraining of the movement faults identified by the assessment. Other movement systems, individual exercises or equipment can successfully be adapted for the retraining process according to the coach or therapist’s particular knowledge or expertise. Pilates repertoire, equipment, key principles (eg integrated breathing) and somatics (eg focus on centre), as referenced in this article, have been found tobe particularly valuable in encouraging compliance because of the exceptional versatility and specificity of the system.