Lindy Royer had been a PT for more than 20 years before she discovered what she calls the "missing link" to her practice—Pilates.

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. Mention Pilates to many, and the response will likely be that it is predominantly done on a mat, much like yoga. But those familiar with the exercise method know that the majority of Pilates for rehabilitation is primarily done on various types of equipment. The most well-known of these is the Reformer.

The Reformer came about at the outbreak of World War I, when method creator Joseph Pilates was interned in England as an "enemy alien" with other German nationals. During his internment, Pilates rigged springs to hospital beds, enabling bedridden patients to exercise against resistance—an innovation that led to his later equipment design for the Reformer.

A patient performs a squat variation of the standing split series on the reformer.

Today's Reformer provides an effective, low-impact, resistance-based therapy session that is friendly to a client's joints. It consists of a gliding carriage inside a wooden or metal frame connected to a system of springs, pulleys, and ropes/straps. Users sit, kneel, stand, or lie on the carriage, and push and pull the footbar and the ropes. Resistance is provided by the attached springs, and exercises target every part of the body.

Therapists all over the globe are turning to Pilates on a Reformer as a successful and lucrative adjunct to their physical therapy practice. Its focus on movement and breathing brings them new and effective treatment methods. And it's also extremely versatile—the extensive exercise repertoire can be modified on the Reformer to fit the needs of each patient. In addition, it improves strength, flexibility, balance, control, and muscular symmetry. The series of rhythmic exercises promote elongated and toned muscle, and are noted for turning the abdominals, lower back, and hips into the body's power center.

Royer, a PT since 1976 and a certified Pilates instructor since 2001, is the owner and director of Park Meadows Pilates, a Pilates-based therapy center in Lone Tree, Colo. She started her Reformer program in 2005 with very successful results.

Key to her program's success, Royer believes that the essential first step was not an examination of how the Reformer is applied to Pilates, but rather the development of a solid understanding of how Pilates for physical therapy differs from Pilates the fitness method, as well as how it compares to other traditional therapy techniques. She highly recommends taking this approach.

PILATES FOR REHABILITATION VERSUS PILATES FOR EXERCISE

"I think the big difference between Pilates for rehabilitation and Pilates for fitness is that the former focuses on getting an individual to a desired state of functional movement, whereas the latter focuses on general athletic or health goals," Royer says.

Royer points out that PT professionals use the exercise to assess and evaluate an ailment, prescribe a treatment modality, and then reassess to see if it was effective. In addition, critical reasoning with Pilates is key.

"A therapist is not just delivering a recipe of exercises that could be found in a gym setting," Royer says. "He or she is delivering to a patient a set of specific exercises to meet a patient's specific needs and facilitate a positive movement experience. They must also know how to modify the exercises where the standard repertoire may be contraindicated for special populations like osteoporosis—something that may not be addressed in the fitness world."

PILATES VERSUS OTHER REHAB TECHNIQUES

Royer thinks of Pilates as her practice's missing link because it focuses on the entire body, which enhances the more traditional therapeutic methods she uses. "Not that a PT doesn't focus on the entire body, but sometimes we tend to zero in on the pain," she says. "Pilates provides a total solution rather than an isolated one—areas of pain can be identified as the result of body strategies gone wrong in other parts of the body."

Pilates looks at how the systems within the body are organized, effectively integrating the entire body into treatment. Therapists using Pilates discover not only the location of pain faster and more easily, but the true cause of the pain as well.

PILATES ON THE REFORMER

Compared with using a standard mat, the major asset in treating patients on the Reformer is how the equipment assists with gravity. Simply put, Pilates done on a mat requires that a person's own body provides the resistance to gravity. This is contraindicated for clients who cannot tolerate weight-bearing positions. The Reformer, with its myriad of adjustable ropes, pulleys, and springs, helps clients attain positions they would not be able to while using a mat.

The Reformer also changes the therapeutic environment by breaking down a functional movement into separate components. It does this by changing the handling of gravity and by using spring resistance. "The end result is, you are now able to retrain a faulty movement pattern and help a client relearn a functional task that had been difficult when gravity was involved. Basically, they learn to move more efficiently on the Reformer," Royer says.

SPECIAL POPULATIONS ON THE REFORMER

Two patients perform a variation of the knee stretch series, which facilitates core control and shoulder girdle organization.

Because of its versatility and its ability to change the orientation of gravity, the Reformer allows a therapist to expand his or her client base to special populations like older adults or those with neuromuscular disorders.

At Park Meadows, Royer deals with many afflicted multiple sclerosis and Parkinson's disease sufferers: "The Reformer is a very safe way to work with these populations. While supine on the Reformer, they can replicate movements that would not be possible if they were standing."

With clients who are older adults, she finds that many have a hard time recovering from their weight-bearing physical activities—or worse, from injuries sustained by these activities. The Reformer is an optimal tool; with it, clients can maintain their mobility and flexibility because the equipment is assistive and movements are easier on the joints.

PROPS ON THE REFORMER

Props are smaller pieces of equipment (for example, balls and poles) that can make an exercise on the Reformer easier or more challenging. Royer has found that clients enjoy exercises using props. They also make conducting a group class much easier: "In a single group class, we can combine six different populations and achieve a different level of difficulty for each group participant by using a prop. Props help you increase the challenge for some, yet provide more assistance and safety for others of a different fitness level."

BUYING A REFORMER

Several important factors should be considered when purchasing a Reformer: functionality, versatility, durability, and aesthetics.

Functionality and Versatility

These two are somewhat intertwined, since the effectiveness of a Reformer can be dictated by its overall versatility. This is especially true for a therapist working with a wide variety of body types.

"I work with populations of all sizes," Royer says. "Sometimes I'll have a 6-foot-2-inch football player on the Reformer, and other times I'll have a child who is 4 feet 10 inches. The equipment needs to accommodate both sizes, so it is important to examine how the footbar and shoulder rests adjust."

Other questions to ask:

• What is the variability of the straps and loops?
• What is the riser height? (Riser height varies the angle of the straps.)
• How easy is it to change the springs?
• How large is the standing platform at the foot-end of the Reformer? (Important for standing exercises.)
• How smooth and quiet is the carriage ride?
• What features are available so exercises can be easily modified for different condition levels?
• How easy is it to get off and on?

Durability

Your Reformer will see a lot of use with varying body types and sizes. It is important to ask questions about the durability of the equipment, such as:

• What type of wood or metal is used for the frame, and how strong is it?
• What type of upholstery is used?
• What replacement-part policy should I need?
• How long do the springs last?
• What warranties apply?

Aesthetics

The look and feel of your studio and its equipment sets the tone for the type of experience your clients will have. For instance, Royer's studio has a very natural look, so she chose Reformers with wooden frames and an upholstery color that matched the tones of her studio. "Aesthetics are important. Our facility sets a comforting tone for our patients, so we chose equipment to match that tone."

CERTIFIED REFORMER TRAINING

If you want to add Pilates as an adjunct to your practice, your first step should be to investigate becoming certified. How? Royer recommends contacting the Pilates Method Alliance, an organization that can help put you in touch with educators in your area. In addition, several organizations and Pilates equipment manufacturers offer Pilates education/certification for PTs.

Whatever choice you make for your education, Royer—a principal educator for Polestar Pilates, a Pilates-based educational institute for therapists—stresses one critical caveat:

"If you are going to get certified, you need a comprehensive certification. Not just 'Reformer certification' or a 'mat certification,' but a complete certification that includes a critical reasoning component for therapists," Royer says.

REFORMER CASE STUDIES

Royer offers two case studies using Park Meadows clients to illustrate how Pilates on the Reformer can be an effective method of rehabilitation.

Case Study 1)

Client A is 42-year-old man, very active physically and an avid weight trainer. His initial diagnosis from his physician was spondylolisthesis. Client A experienced intense pain and had to modify most of his everyday movements. Client A's physician had recommended a surgical fusion procedure on his vertebrae.

At Park Meadows, he did a series of five 1-hour private trainings centering on core control and neutral spine. Client A also focused on relearning his postural alignment, then using the core control to maintain it. Exercises included footwork, feet and hands in straps, seated box work, and standing and assisted roll-downs. The Reformer helped Royer place the client in a weight-bearing position with no load on his spine.

At the end of his initial five sessions, the pain was gone and surgery is no longer needed. Client A continues to take weekly Reformer classes at Park Meadows.

Case Study 2)

Client B is 55-year-old woman with an initial diagnosis of sacroiliac (SI) joint instability at the junction of the spine and the pelvis. The SI joint is critical to transferring the load of the upper body to the lower body. Client B had experienced severe back pain for 4 to 5 years and had visited several physicians and back specialists with little success. Royer worked with her in four rehabilitation sessions, followed by five private postrehab sessions.

The sessions included exercises on mat and Reformer, with emphasis on maintaining neutral spine and activating the transverse abdominus and pelvic floor control. Royer first focused on hip and shoulder disassociation using footwork, and feet and hands in straps on the Reformer, then moved to quadruped, sitting on the box, kneeling, prone on the box, and standing. Finally, she integrated exercises that focused on spine movement, including bridging, assisted roll-downs, and mermaid.

Client B is now back to playing golf 2 to 3 times per week and is pain-free. She also continues to take classes twice per week with an occasional private session.

As Pilates for rehab continues its worldwide expansion, more and more PTs are not only finding it to be a remarkable form of therapy, but a financial windfall as well. Increasingly, people are taking wellness into their own hands and looking for effective ways to stay healthy. Pilates is the perfect fit.

Says Royer: "We offer rehab, postrehab, and fitness sessions. Once they join our rehab classes, many clients see the benefits and are eager to continue. Some say they 'get addicted!' I estimate that approximately 40% of our clients continue on from rehab into other classes. It's a fantastic source of continuous income."

Daniel Wilson is a contributing writer for Physical Therapy Products. For more information, contact .