Knowing proper positioning techniques will help prevent further injuries when using Pilates in a patient’s therapy program.

It seems like Pilates became an overnight sensation, especially in the physical therapy community, although it has been practiced for more than 70 years. It has proven to be more than just an exercise fad, however. It is one of the fastest-growing exercise methods in the world, with millions of people practicing it in the United States alone. Although Pilates was originally used to train dancers and acrobats, it is now commonly used in outpatient physical therapy clinics as a means to rehabilitate almost any body part. It is most popular in spine, hip, and knee rehabilitation. However, each part of the body can benefit from the Pilates regimen.

Pilates consists of both mat work and machine exercises performed on equipment such as the Reformer, Cadillac, Barrel, and Wunda Chair. With the growing interest in Pilates, there is concern regarding the injury risk from performing Pilates exercises.

The objective of this article is to help therapy professionals who have minimal to no Pilates training understand the precautions needed in Pilates. Let’s consider the following scenario: Your patient has a history of L5-S1 disc herniation, and after 6 weeks of physical therapy, she is asymptomatic. She says that her gym offers a Pilates mat class and asks you if it would reinjure her. You have never done a Pilates mat class in your life. Would you say, “Go ahead, but don’t do anything that hurts”? Or would you educate her on avoiding certain types of movements and remind her about keeping good form to avoid back strain? Hopefully, you will choose the latter. As a PT, you determine whether or not the patient is ready for Pilates and help educate her about the injury risks.

Safety First
The position of the client on Pilates equipment, such as the Reformer, is very specific—the patient cannot just lie there. He or she must think about where each part of his or her body should be placed. He or she should maintain cervical retraction, with scapulae retracted and depressed. The lumbopelvic region should be in neutral, unless the exercise calls for a flat-back posture. “Neutral spine” posture requires that the person tilt the pelvis until the anterior superior iliac spines are level with the pubic symphysis.

“Neutral” occurs when the large muscle groups, such as the rectus femoris and vastus lateralis, are stabilized and released. “Flat back” is achieved when the pelvis is tilted posteriorly with lifting of the coccyx. In either neutral or flat-back posture, the patient must tighten the transverses abdominus. The patient must also be cued to draw the rib cage downward and inward but while the sternum stays lifted. The wrists and elbows are neutral between flexion and extension.

If the patient is in hooklying, seated, or  quadruped, the ischial tuberosities are aligned with the heels. The ASIS, patella, and second metatarsals are also aligned. Veering away from these positions causes inefficient movement and can potentially strain muscles as a result of compensations.

Most physical therapy patients using Pilates for rehabilitation are suffering from back pain. However, some Pilates exercises can cause further injury to the spine because they place the patient in ranges of flexion, rotation, or extension that are beyond their limits.

For which diagnoses or conditions do you teach neutral or flat back with spine exercises? Emphasize neutral if the person is hypolordotic, but flat back if he or she is hyperlordotic. If the lumbar spine has a normal curvature, train him or her in neutral spine. Understand, however, that some Pilates exercises are designed to be in flat back, while some others are up to the discretion of the therapist. Thus, some exercises should just be avoided while others can be modified.

Exercises that require the legs to be overhead while in supine can aggravate any part of the spine. A patient who has disc herniation or protrusion should avoid flexion-biased exercises such as the “jack knife” or “short-spine massage.” On the other hand, a patient who has osteoarthritis of the spine or spinal stenosis will usually feel better with flexion exercises.

Extension-based patients may benefit more from prone exercises, such as “swimming” (alternating arm and leg extension) or long box pulling straps (shoulder extension). A pillow or two under the abdomen can help minimize a hyperlordotic posture in prone. In addition, if the patient activates the abdominals in prone, and learns to initiate movement from the core muscles, compression in the lumbar spine is lessened.

The most common injuries in Pilates are cervical strain and shoulder impingement. Some exercises on the Reformer and Cadillac involve pushing and pulling straps or bars overhead with resistance. Patients with a history of neck or shoulder problems may be easily aggravated if they perform these exercises with their chin protruded, neck extended, and shoulders elevated.

If the shoulders are hiked and the head is forward, cervical strain can result from overuse of the upper-trapezius muscle. With patients who have tight upper trapezii, the therapist should emphasize working the latissimus dorsi and middle trapezii/rhomboids.

Protracted scapulae also can contribute to shoulder impingement with overhead motions. Thus, patients with a history of neck or shoulder injuries need to be educated about the correct posture during upper-extension (UE) exercises, whether they are on the Pilates apparatus or on the mat. They should avoid UE flexion or abduction above 90º until they can perform overhead motions without compensating and without pain.

Knees are also commonly strained in Pilates when modifications are not made for patients with a history of degenerative joint disease and patellofemoral syndrome. The patient should avoid knee flexion beyond 90º to 100º on the Reformer, Cadillac, and Wunda Chair. Knee strain can also be prevented by maintaining the alignment of the knees over the ankles and second metatarsals. Excessive pronation subsequently leads to internal tibial rotation and femoral adduction.

Teaching patients to be aware of their position with closed kinetic movements is key to injury rehabilitation, because they promote neuromuscular control. Medial knee strain results especially if “footwork” is done in this position. Footwork is basically like the leg press, which can be modified on the Reformer by adding blocks against the stopper, thereby limiting knee flexion.

On the Cadillac, the person can adjust where he or she is lying in relation to the spring-loaded bar to change the angle of the knee. However, adequate modifications may not be so easily achieved on the Wunda Chair for footwork. Footwork on this box-like apparatus is similar to a deep knee bend and puts more strain on the knees than the Reformer and Cadillac.

An exercise to avoid on the Reformer or Cadillac when one has knee issues is the “thigh stretch,” in which the patient is kneeling with the hips in neutral and leans back without flexing at the hips. This exercise puts tremendous pressure on the patella and menisci.

Beginners’ Basics
It is important to note that patients who have never tried Pilates should not start it in a group format for two reasons: First, it is important that the patient learn basic principles about alignment, posture, breathing, grounding, and correct recruitment of muscles via one-on-training. But, of course, he or she had already learned all of this in physical therapy, right? Well, when people are introduced to new forms of exercise, they forget how to apply previously learned principles in a new context. Your patient may have mastered the dozen home exercises you gave him or her in physical therapy, but remember that there are more than 500 Pilates exercises.

The second reason why a patient should not jump into group Pilates classes is because he or she may overexert himself or herself trying to keep up with the rest of the class. A PT should tell the patient to start with one-on-one Pilates training for four to six sessions before trying the classes, whether they are Reformer, wall unit (half Cadillac), or mat classes. That way, the patient will know what to expect and understand his or her limitations. He or she will also have a better mind-body connection, which is key to injury prevention.

Besides proper alignment, other recommendations should be made to the patient to help prevent injury. Of course, start with a lower workload. Note that decreasing resistance is not the answer, because some exercises become more challenging when there is less spring tension.

Fortunately, there is no need to be concerned about excessive repetitions in Pilates. No exercise is performed for more than 10 repetitions. Constantly changing the exercise keeps the exercises from becoming boring and helps achieve a balance of the total body.

Breathing should be rhythmic and flow appropriately with each part of the movement. As with any exercise, holding the breath upon exertion may increase blood pressure and drive up the demand on the heart.

Lastly, warming up and stretching will help prevent injury when doing Pilates. Although this is a well-known fact, some traditional Pilates trainers insist that stretching is already innate to Pilates. This can be debated. Pilates exercises usually are not held for more than a couple of seconds. Pilates is not like yoga. Stretching the upper trapezii and pectoralis muscles before doing Pilates will help decrease compensatory shoulder elevation and scapular protraction. Stretching the hamstrings, piriformis, and rectus femoris will help decrease strain on the low back and hips.

Pilates teaches the body to move more efficiently by developing control of the “inner unit” of the body, transverse abdominus, multifidi, pelvic floor, and diaphragm. The rhythmic and dynamic nature of the exercises can help the body become more coordinated and balanced. But without proper training, compensations can lead to injury.

If you do not have a background in Pilates, the best advice you can give your patients is to start with individualized training, and teach him or her what motions or positions to avoid. Furthermore, re-emphasizing proper posture and alignment will help prevent injury.

Theresa Egler, MPT, received her bachelor’s degree in exercise physiology from Chapman University, Orange, Calif, in 1996, and her master’s degree in physical therapy from Western University of Health Sciences, Pomona, Calif, in 1999. She has been working in outpatient orthopedics for 7 years. She trained in Pilates with traditional physical therapy exercises at Congress Medical Associates, Pasadena, Calif, for spine rehabilitation.