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Clinical Pilates is a branch of Pilates that has evolved from the traditional exercises created by Mr Joseph Pilates in the 1920’s. A German, Mr Joseph Pilates developed his exercises after studying Yoga, Zen meditation and Greek and Roman exercises (Anderson, Sept 2001; Withers & Stanko, 2002). In the past five years, Pilates has developed to be more clinically relevant as integration with pathology and research in spinal and movement dysfunction has occurred (Withers & Stanko, 2002). Clinical Pilates is a dynamic method designed to integrate function with appropriate motor control of the necessary stabilising segments (Massey, 2005), and it’s uses can be varied accordingly from patient to patient. It is the readily adaptable exercises which makes it very user friendly (Anderson, Sept 2001; Blum, 2002) and very popular especially within the dance medicine community (Khan et al., 1995; Stolarsky, 1993).
The method uses a combined approach of activating the deep local spinal muscles via a motor control approach. The muscles are activated and patients are taught to achieve a co-contraction of the stabilising muscles in a neutral spinal position(Hides, Richardson, & Jull, 1996; Maher et al., 2005; Richardson, Jull, Hodges, & Hides, 2000). Panjabi’s model of spinal stability and the neutral zone encourages maintenance of a neutral spine with the active and neural subsystems (Panjabi, 1992). Hides (1996) has demonstrated the loss of cross sectional area of multifidus and a change in the timing of the local muscles in low back pain (LBP) (Hides et al., 1996). The activation of the deep local stabilising muscles forms the basis for improving local muscle dysfunction (Hides, Stokes, Saide, Jull, & Cooper, 1994; O'Sullivan,

Phyty, Twomey, & Allison, 1997). The local stabilising muscles, comprising the tranversus abdominus (TA), multifidus, pelvic floor and diapraghm form a cylinder of stability (Hodges, 1999). This cylinder helps to create an increased abdominal pressure to stabilise the spine (Hodges, 1999; O'Sullivan et al., 1997) and with complex anatomical attachments to the thoracolumbar fascia it helps to create increased tensile stresses around the sacro-iliac joint to increase force closure and affect pelvic stability (Pool-Goudzwaard, Vleeming, Stoeckart, Snijders, & Mens, 1998). The Pilates approach uses a combination of matwork, reformer and various props (magic circle, rotation discs, foam pads etc) for the exercises in anti gravity positions. Pilates is initially performed slowly, in an isolated and specific manner to ensure the correct timing and low threshold tonic contraction of the local stabilising muscles, as taught in clinical books (Richardson et al., 2000). Exercises are then progressed on a stable surface to integrate increased load within the muscular system, by moving the arms or legs to gradually challenge the control (Sahrmann, 2002). This increased challenge to the local stabilising muscles will bring in some of the global stabilisers, (internal oblique and posterior fibres gluteus medius, etc) to control the extra load ensuring the neutral spine. The progression of the exercises then begins challenging the stabilising system with movement of the trunk, to integrate some of the global stabiliser and mobiliser muscles (Comerford & Mottram, 2001a, 2001b).
Clinical Pilates uses a “Pilates reformer”, an apparatus that has a moving carriage and springs to exercise on, that challenges spinal alignment and neutral spinal position. The springs are designed to provide progressive resistance to the movement and allow

gradual loading of the joints and soft tissue structures. The reformer allows exercises to become more functional with emphasis on low threshold contractions of the local stabilising system and incorporating the global stabilisers through movement. It is here that Pilates has fantastic benefits in rehabilitating movement dysfunction as it teaches an awareness of stabilising the segment with “give” and moving the appropriate dysfunctional or “stiff” segments (Comerford & Mottram, 2001a, 2001b). The basic concepts of Pilates are; 1. Breath control – A key element as bibasal breathing will encourage improved activation of the local stabilisation muscles. It helps to facilitate an improved con-contraction of the cylinder of stability pre – activating the diaphragm (Anderson, Sept 2001). Improved TA contraction will also occur with exhalation (Hodges, 1999). 2. Core control and Axial elongation – An awareness of the neutral pelvis allows improved activation of the cylinder of stability. Local low threshold contraction will help to assist in controlling the centre and moving from this stable base. Working with axial elongation encourages relaxed movement without unnecessary compressive forces and shear forces through the spine (Anderson, Sept 2001; Massey, 2005). 3. Efficiency of movement - Low threshold contractions help to retrain the local muscle systems, creating improved timing and efficiency of movement so that unnecessary stress and load is not placed on the system. This helps minimise faulty movement patterns leading to greater dissociation of movement which helps to correct movement dysfunction (Comerford & Mottram, 2001a).

Alignment – Assists in teaching appropriate connection between the neutral spine and the interconnecting thorax, pelvis, head and neck. Appropriate alignment of the upper and lower limbs is necessary for efficient transference of forces. 5. Movement integration of pelvis, thorax, head and extremities – Motor control and learning a new motor skill will lead to enhanced automatic postural control. Practice of movement patterns will enable appropriate movements to be performed correctly and with minimal energy wasted. Integration of whole body movements challenges the motor control and leads to improved performance with functional tasks. 6. Concentration – Pilates requires learning a new motor skill. Conscious focus on the task enhances the mind body connection and improves the awareness of movement. Encourages isolated movement of the appropriate parts of the body to perform the exercise precisely (Massey, 2005). 7. Spinal articulation and flowing movements – Allows the spine to be mobilised through direction encouraging movement of inhibited or stiff segments. Repetitive, flowing movement allows for the appropriate motor skill and movement pattern to become automatic and engrained within the body. This gives greater postural awareness.
Pilates has found a way into mainstream thoughts and treatment via it’s continued use with success in rehabilitating dancers (Khan et al., 1995). It is extremely useful in its ability to be able to reproduce varied movements and postures that are often hard to mimic in controlled environments. The beauty of Pilates is that the exercises are

extremely versatile which allows adaptability to the person, sport or particular environment. It is for this very reason that dancers use Pilates equipment for training, injury prevention and for treatment (Khan et al., 1995; Phillips, 1999). Training the sporting population for a particular movement with control and precision in a safe environment can lead to enhanced control and activation of the local and global stability muscles. Various cohort and case control studies have shown particular benefits using Pilates with elite gymnasts (Hutchinson, Tremain, Christiansen, & Beitzel, 1998), ballet dancers (Khan et al., 1995) and patients with scoliosis (Blum, 2002). Herrington and Davies (2005) compared Pilates with abdominal curl training and untrained females in their ability to maintain a neutral spinal position and appropriately activate TA. They discovered that the pilates trained individuals were able to maintain a neutral lumbo-pelvic position and better activate their TA. (Herrington & Davies, 2005) Anecdotal evidence suggests that the precision of specific motor control exercises requiring high levels of concentration will also enhance the neuromuscular adaption of muscles. The adaption can then carry over to their specific sports due to the high level of specificity of the exercises ( eg tennis - rotation control on reformer ). Practice of a motor task leads to automatic control of a particular task. Repetition of particular tasks emphasising the local control with global stability through movement can then help to imprint this memory on the brain.

Spinal proprioception and positional sense has been shown to be dysfunctional in chronic LBP (O'Sullivan et al., 2003). Improving spinal proprioception can help to control movement dysfunction and correct muscle imbalances. It has been shown that the neutral joint position will help facilitate an improved TA contraction (Sapsford & Hodges, 2001) and teaching awareness of this through Pilates can improve the functional stability of the local and global systems. Some potential negatives of Pilates that could be considered: Specificity - Movements are performed in controlled environments and many contact sports are uncontrolled. Therefore specificity may be challenged. Therapist dependant - Exercises are therapist and patient dependant. Successful intervention requires in depth therapist knowledge and a certain degree of understanding from patients/athletes. Psychology - Psychological factors (boredom and motivation) can influence patients outcome. Time - Rehabilitation is time consuming and requires motivation and patience from the participant as improvements can be slow. A clinical example of a patient managed with Pilates: Patient A (Pt A)

34 year old ex professional Rugby player
18 month history episodic low back pain and left leg symptoms, dull and throbbing in nature, prominent morning stiffness
Keen tennis player and golfer. Unable to play for 18 months

MRI – small left paracentral disc prolapse L5/S1, disc dehydration L4/5 and L5/S1
Two Epidurals and sets facet infiltrations performed to some effect

Examination revealed:

Muscle spasm – erector spinae, quadratus lumborum and piriformis ( left sided)
Lumbar flexion – provocative movement
PPIVM’s – reduced flexion L4/5 and L5/S1
Poor TA and multifidus activity
Overactivity of rectus abdominus and external oblique
Poor isolated and dis-coordinate lumbo-pelvic movements
Inability to maintain a neutral pelvis through various positions

Pt A had sufficient movement dysfunction and poor local muscle control to indicate he would be a suitable candidate for Pilates. Many authors have advocated the integration of local stability into functional positions (Comerford & Mottram, 2001a; O'Sullivan, Twomey, & Allison, 1998) for resolution and improvement in local muscle dysfunction. It was also important to improve his coordinated patterns of muscle activity and his poor movement dysfunction, so Pilates was initially commenced while addressing some of the muscle spasm and articular dysfunction with manual therapy.
Initially Pt A was taught how to activate his TA in crook lying with appropriate breathing patterns to switch off overactivity through his global system. Having played rugby in the past he had always trained his global system. He was having difficulty

learning to activate his local muscle system without overactivity of his global system. Using the reformer, helped combine his local and global stability by gradually loading the arms and legs progressively to challenge his control. (Comerford & Mottram, 2001a, 2001b; Massey, 2005). It can be a useful method for targeting appropriate muscle groups and teaching patients appropriate TA activation and core control (Herrington & Davies, 2005). For Pt A, Pilates was used to retrain his lumbar stability because it allows easy integration into functional movements and taught him about body awareness and core control. Pilates facilitates improved carry over into functional tasks and daily postural awareness due to the variety of positions that can be used to recreate specific exercises. In this patient, Clinical Pilates was used in favour of traditional floor exercises and swiss ball exercises as the emphasis on overall body position and control is greater through the use of the Pilates principles. Due to the increased neuromuscular input from the joints on a reformer, Pilates has the advantage of being able to assist in spinal proprioception. For Pt A the exercises focussed on incorporating the neutral spinal position with control of the local stabilising system in positions mimicking those of the tennis and golf swing. In summary Pilates can be a very effective way of rehabilitation of an injury during sports physiotherapy and for improvement in performance. However, it is a new clinical skill and needs further research to validate its approach.