Kristopher Bosch, DPT, ATC, works with a patient on the Pilates Reformer.

Around the globe, Pilates is making a mark in the world of rehabilitation and physical therapy. The Pilates principle of core stabilization addresses posture, muscle performance, and motor control—the same concepts that form the basis of most orthopedic rehabilitation and therapy. PTs are using Pilates successfully to treat many common conditions and diseases. Pilates-based therapy is especially fast-growing for treating and preventing injuries to the back.

To better understand how Pilates can help with back injuries, it is important to look at the overall effectiveness and therapeutic value of Pilates.

PILATES AS AN EFFECTIVE REHABILITATION TOOL

One reason that Pilates works so well in physical therapy is due to a one-on-one emphasis with the therapist. In traditional physical therapy, clinicians are often forced by a variety of circumstances to see multiple patients at one time. That can be hard to juggle. While many patients do well in this environment, many require more individualized care, particularly when dealing with chronic pain syndromes.

Patients are frequently started on a modality or given exercises, and are told to continue while the therapist moves on to other patients. Clients start doing the exercise on their own and may not be sure they are doing it correctly. In a Pilates-based program, the therapist educates the patient on the principles of Pilates, one of which is precision. Through attention to these principles and manipulation of the Pilates environment, the therapist works to create a positive movement experience in which the patient learns to move without pain.

PASSIVE VERSUS ACTIVE—BRIDGING THE GAP

The "Pilates environment" refers to the full complement of repertoire and apparatus. This environment lends itself to a wide array of movement possibilities. Traditional therapies often have a difficult time bridging the gap between active and passive movements. Patients may not be able to exercise actively due to pain or weakness, so creating a more assistive environment is valuable. Use of the Pilates apparatus allows us to create this assistance.

The exercises can also be modified to meet the needs of each individual patient. You can start a patient in a movement sequence that does not tax the injured area or cause pain, and then build on that as the patient progresses.

PILATES AND THE BACK: A PERFECT FIT

Pilates stresses correct posture and spinal alignment, making it a perfect fit for back injuries. Many things cause back problems, from trauma to poor movement strategies and sustained faulty postures. It's theorized that Pilates works well for these patients by improving strength and recruitment of core musculature, increasing patients' awareness of their own bodies, and normalizing the forces that distribute through the spine. In particular, the lower lumbar area is where we see the most injuries. This correlates to the fact that most of our mobility comes from the lower segments of the lumbar spine. Part of that is attributed to how we put together our movements in our body.

Pilates teaches clients how to access other spinal segments more easily and then redistribute the load that goes through the spine. This redistribution removes a patient's dependence on one or two segments of the spine, particularly crucial if that is the area of injury. This theory has been posed by Brent Anderson, PhD, PT, OCS, of Polestar Pilates Education. Anderson believes that if we engage more segments to organize movement, then less force will be applied to injured lower segments. This is especially true in a chronic back injury, where multiple compensatory changes take place due to pain, muscle imbalance, and weakness.

Pilates focuses on creating an even musculature, which can correct these muscle weaknesses and re-educate the body as to what muscles should be recruited for a specific movement. Normalizing these patterns will allow the body to heal, instead of repeatedly irritating the site of the injury.

MAT VERSUS EQUIPMENT

Pilates exercises are done on a mat or using various apparatus. When first treating a patient, a therapist should use the apparatus because of the assistance the springs provide. By selecting the appropriate exercises and modifying them as needed, a therapist can make the initial therapy very supportive and assisted. Patients can learn to organize their bodies and put principles of Pilates into play.

For a lumbar injury, we can recruit the core muscles in that area, teach the patient to find and maintain a neutral spine position, and then have the patient work on basic movements that can both increase their strength and eliminate pain. Pilates includes a tremendous number of assistance-based exercises that can be difficult to achieve in the traditional rehabilitation clinic. And that's a big step toward the ultimate goal—creating a positive movement experience where the patient successfully achieves pain-free movement and gains confidence in their movement abilities.

In our facility, we use the full complement of Pilates apparatus: the Trapeze Table (Cadillac), Reformer, Combo Chair, and Ladder Barrel. The Cadillac is great for initial patient evaluations. It is also a good piece of equipment for teaching patients how to attain neutral spine. And again, the springs provide assistance—we can begin with movements like the 90/90 position, which takes the pressure off the hips and low back, and allows the patient to begin combining activation of deep abdominals with small movements in the support of the springs.

In addition to strengthening and stretching, the Reformer is a great diagnostic tool for seeing how a client puts his or her movements together, which we refer to as "organization of movement." We have patients start on the back and do footwork exercises, which gives the clinician an indication of the patient's ability to maintain neutral spine, separate movements at the hip from the pelvis and lumbar spine, and align the lower extremities. We can see where weakness or muscle imbalances exist, and can also begin to promote stability without irritating the spine.

The following is a brief case study to give an example of how patients are managed in this environment.

CASE STUDY

Patient Background. Our patient is Kay, a 61-year-old female referred to us for low back pain and lumbar stenosis. She sustained her back injury from a fall that occurred during a tennis clinic 5 months prior. While returning balls from her partner, she fell backward and landed on numerous tennis balls that had accumulated in the backcourt. She had some immediate back pain, which worsened as the day went on. Kay stated that her "muscles tightened and spasmed," and she had "a large pelvic torsion and a lot of pain." She eventually sought help, trying chiropractic, acupuncture, and physical therapy. MRI revealed lumbar stenosis, arthritis changes, and disk pathology at L4-5, L5-S1.

Initial patient history review. Improvement was made with physical therapy, but upon finishing her course of treatment she believed that she was not yet at her preinjury level of function and was still having a marked amount of back pain. As an active athlete, Kay was frustrated by her inability to participate in all of her activities and perform at her previous level of tennis. Her chief complaints at the time of evaluation were LBP and numbness of the feet and LE with prolonged activity. The pain was described as sharp, intermittent, and rated at 6/10 subjectively on a 10-point subjective pain scale. Pain started in the central lumbar spine and radiated down to the R buttock and down the R posterior LE. Symptoms were made worse by lying, sitting, and standing for more than 20 to 30 minutes. Heat and exercise provided some relief, and she stated that movement tended to help prevent symptoms. Her medical history was otherwise unremarkable.

Physical evaluation. Postural evaluation was unremarkable. Assessment of the spine active range of motion (AROM) revealed a decrease in extension and lateral flexion ROM bilaterally (limited to 50% of normal), with pain into extension. Lumbar flexion was also noticeably deficient, with no reversal of lordosis. Flexion movement was achieved primarily by thoracic spine flexion and hip flexion, with very little segmental mobility of the lumbar spine. Strength was intact, with manual muscle-testing grades of 5/5 throughout the LE's bilaterally. Sensation and reflexes were also intact bilaterally, 2+ throughout. Straight-leg raise was negative and 85º bilaterally.

Assessment/plan of care. Kay presented with the following impairments and functional limitations: decreased spine AROM, decreased core strength, decreased spine articulation, and decreased overall movement awareness and control. Functionally, these impairments presented as a decreased tolerance for sitting, standing, or lying for more than 20 to 30 minutes. Our plan of care was to see Kay two times per week for 6 weeks to address these impairments and functional limitations. Treatment was to consist of Pilates rehabilitation exercise and manual therapy. Sessions were one-on-one with a therapist certified in Pilates rehabilitation, using the full complement of Pilates exercises and apparatus. A comprehensive home-exercise program was also used to allow the patient to continue to progress on days she was not being seen for Pilates.

Treatment. Sessions focused on improving her core stability, increasing her segmental mobility and control, improving her hip and thoracic spine mobility, and improving her overall strategies of movement. Our hypothesis is that increasing the ability to disassociate at the hips and improving thoracic spine mobility will allow the patient to access and distribute movement to areas other than the lumbar spine and the lesion site. The initial phase of treatment focused on the ability to find and maintain neutral spine and engage deep abdominals. These components were then coupled with disassociation movements above (shoulders) and below (hips) the lumbar spine to further facilitate deep abdominal recruitment. Exercises were progressed when the patient showed proficiency with previous lower-level movements. Mobility exercises were then introduced to improve spine ROM, segmental movement, and control. Care must be taken at this point, because movement is now occurring through the site of lesion. Dynamic stability and functional exercises are introduced next, and allow for carryover of newly acquired ROM and strategies of movement into daily activities.

Outcome. This patient progressed extremely well and was able to return to all activities without pain or limitation. Kay is back to playing competitive tennis more than 3 days per week, and is very satisfied with the results she has achieved through Pilates rehabilitation.

For more Pilates-related articles, search for "pilates" in our online archives.

It is also important to note that at week 2 of her treatment plan, Kay sustained a significant ankle injury (grade 2 inversion sprain) and was able to successfully rehabilitate both her back and ankle injuries. We believe that success is achieved in these situations through the dynamic, whole-body approach that this Pilates environment provides. The variability of the equipment makes it possible to use an assistive or resistive environment, depending on the patient's stage. Exercises and movements are also variable, and can be modified or progressed as appropriate. With Kay, we were able to focus on exercises that challenged her core stability and allowed us to address her low back injury without perturbing the recent ankle injury. We also incorporated ankle ROM, strengthening, and proprioception exercises, beginning with minimal weight-bearing in an unfamiliar environment (for example, supine footwork on the Reformer) and then progressing to familiar, functional exercises in full weight-bearing (for example, spring-assisted squats, multidirectional lunges).

Overall, Kay was seen for 12 sessions over an 8-week period of time before returning to tennis, and she has not had any problems thus far. She continues to exercise regularly to maintain the gains made in rehabilitation and to continue to improve her overall state of wellness.

Kristopher Bosch, DPT, ATC, is the director of rehabilitation and cofounder of Northstar Pilates Solutions LLC, Buffalo, NY. He is a licensed athletic trainer and PT, and is also a certified Pilates rehabilitation practitioner through Polestar Pilates Education. For more information, contact .