Initial Examination

Client Report: The client described a constant “ache” in her low back of 5-6/10 with intermittent tingling down her entire right leg. She stated that she did not have the right lower extremity symptoms before the surgery. She continued to wear the lumbar brace as directed by her physician. She reported that sitting and standing tolerance is limited to less than 10 minutes.

Client Goals: To return to full-time work and a regular exercise program and to be able to travel in a car for 2 to 3 hours so that she can get to her vacation home in the mountains on the weekends

Employment: Personal injury attorney

Recreational Activities: Walking, hiking

General Health: Good

Medications: Percocet, Neurontin

Musculoskeletal: ROM: Trunk not tested because of surgical precautions. Bilateral upper extremities, left lower extremity (LLE)=WNLs throughout. Posture: standing: decreased cervical lordosis and thoracic kyphosis, increased lumbar lordosis, pelvic obliquity with right posterior superior iliac spine (PSIS) lower and anterior superior iliac spine (ASIS) higher, right hip in extreme external rotation as compared with the left; supine: right lower extremity ½ inch shorter than left. Palpation: tenderness at right quadratus lumborum, piriformis belly, sciatic notch; left PSIS, posterior iliac crest border, paraspinals.

Neuromuscular: Force generation: Trunk not tested because of surgical precautions. Transversus abdominis activation in supine=poor. LLE=4/5 throughout; right hip flexors, abductors, extensors, adductors=3/5; right hip internal and external rotators=4/5; right knee extensors=4/5 within available range; right knee flexors=4/5; right ankle=3/5 throughout; great toe extensors=3/5. Neurodynamic tests: right straight-leg raise test was positive at 40 degrees; left was negative to 85 degrees. LLE nonsignificant. Deep tendon reflexes: decreased right Achilles; bilateral knee and left Achilles normal

Function: Pain: low back pain, at rest=4/10; sit-ting and standing 10 minutes=7/10; walking 10 minutes=7/10

Integumentary: Surgical scars healed well. Palpation to anterior and right posterior scar revealed limited soft tissue mobility.

Evaluation

The therapist determined that the client’s examination findings were consistent with her medical diagnosis of lumbar radiculopathy. The therapist believed the client’s symptoms could be managed with specific exercises to address impairments in posture, strength, and movement/mobility, plus soft tissue mobilization and ice to decrease pain and improve mobility.

Plan of Care

Elizabeth’s plan of care included progressive lumbopelvic stabilization exercises, gentle range of motion and stretching, soft tissue mobilization, and ice. Elizabeth walked daily as directed by her physician and was instructed in a home lumbar stabilization exercise program to be done on the days she did not attend therapy.

Reevaluation

After 18 sessions over 6 weeks a reexamination demonstrates an improvement in the client’s lower extremity strength and reduction of pain at rest (3/10), sitting and standing (5/10), and walking after 10 minutes (5/10). Her right straight-leg raise remains positive but improved to 54 degrees; however, she states that the “buzzing” and “tingling” in the right leg persists throughout the day. The client also reports that she “can’t feel” her lower abdominals working during the exercises and that she’s frustrated with “gaining weight and getting flabby.”

Incorporating CAM into the Plan of Care

A 6-week course of physical therapy that included a variety of exercises, soft tissue mobilization, and ice has been helpful in reducing the client’s pain and increasing lower extremity strength, but her radicular symptoms have persisted, and her lumbopelvic region continues to be weak. The therapist, who has been practicing Pilates, knows that Pilates focuses on improving trunk and lumbopelvic strength, correcting faulty movement patterns, and realigning posture. She believes it might be a reasonable adjunctive therapy activity to hasten the client’s recovery. Based on her readings and knowledge about Pilates, the therapist refers the client to a certified Pilates instructor for a one-to-one supervised Pilates program that will be integrated into the client’s current therapy program.

INVESTIGATING THE LITERATURE

The therapist is familiar with the Pilates method of exercise through her own personal exercise program and has begun to hear that physical therapists are starting to incorporate principles of Pilates into rehabilitation programs. Her personal experiences of practicing Pilates do support the claims that Pilates can increase core strength and improve awareness of postural alignment and so she is considering becoming a certified instructor. Before making this commitment, however, the therapist decided to investigate the scientific literature about Pilates to better understand its assumptions and principles and to identify any research studies that may have been conducted to measure or test Pilates’ outcomes in rehabilitation. Knowledge the therapist gained from reading the literature informs her decision to pursue certification as a Pilates instructor and the recommendation that Elizabeth add Pilates to her current therapy program. The process of investigating the literature, which included preliminary background reading, searching databases, and evaluating the literature, is described.

Many books have been written about Pilates and are useful resources for learning about its history as an approach to fitness and health.¹^–¹⁰ Joseph Hubertus Pilates was born in Germany in 1880. As a child, he suffered from asthma and many other illnesses, which resulted in fragility and weakness.^1,² Determined to overcome his ailments, Pilates became passionate about physical exercise and fitness. He studied many forms of exercise including yoga and martial arts during his young adulthood and began to develop his own philosophy and method of training and fitness. While interned in a prison camp for German nationals during World War I, Pilates taught his exercises to inmates and began developing equipment that could be used to rehabilitate clients who were restricted to their hospital beds.^1,^2,^4,⁸ In 1923 Pilates left Germany and emigrated to the United States. On the crossing, he fell in love with a woman named Clara, who became his wife. Together, they opened an exercise studio in New York City. Within a few years, Pilates’ unique method of physical and mental conditioning caught the attention of professional dancers and choreographers who sought to maintain or regain strength and flexibility as they recovered from a variety of performance-related injuries. Dance artists such as ballet master George Balanchine and modern dance notable Martha Graham supported Pilates’ method of body conditioning and exercise and studied with him for many years.^1,^4,⁹

Pilates’ original program consisted of a series of mat exercises designed to build abdominal strength and develop control of the body. Then he designed and built several pieces of equipment to enhance the exercises and substitute for the manual assistance he was providing for his clients. Pilates also trained the first generation of teachers in his New York studio, including Romana Kryzanowska, Kathy Grant, Ron Fletcher, and several others. Although many of the original teachers have branched out to different areas of the country and have incorporated their own experiences and style into the Pilates method of exercise, the original principles of Pilates have been maintained and continue to be passed down through several generations of Pilates instructors.¹

Contrology

Perhaps the best way to learn about Pilates’ philosophy of fitness and approach to exercise is to read a book written by Pilates entitled Return to Life Through Contrology, which originally was published in 1945. In this text, Pilates explains that, “Physical fitness is the first requisite of happiness …(and that) physical fitness is the attainment and maintenance of a uniformly developed body with a sound mind fully capable of naturally, easily, and satisfactorily performing our many and varied daily tasks with spontaneous zest and pleasure” (p. 6).¹⁰ Contrology, the term Pilates used to describe his method of exercise, was designed to develop coordination of the mind, body, and spirit through purposeful and repetitive exercises. These exercises, according to Pilates,¹⁰ would strengthen muscles and correct abnormal postures while encouraging flexibility and graceful movement. By mindfully attending to the breath and the body’s posture and movement of each repetition of every exercise, the exercises of Contrology were proposed to “correct wrong postures, restore physical vitality, invigorate the mind and elevate the spirit” (p. 9).¹⁰ Central to the Pilates method of body conditioning and exercise is the “powerhouse,” located between the bottom of the rib cage and the hips. Here muscles, including the rectus abdominis, transversus abdominis (TA), obliques, multifidus, erector spinae, gluteals, and quadratus lumborum, support the spine and trunk. When strong, the powerhouse improves alignment and posture and provides a base from which all movements can be generated.¹ Most of the more than 500 exercises described by Pilates focus on strengthening the powerhouse or what some exercise and rehabilitation professionals now call the core, while training the mind and the body to work together. Proponents of Pilates suggest that the Pilates method of body conditioning and exercise can improve strength, endurance, balance, and coordination³ and address respiratory problems and chronic pain.² Other claims include improved sexual enjoyment, better sleep, and the elimination of “love handles.”^1,⁹

Principles

Most contemporary teachers of the Pilates method of exercise and conditioning ascribe to the principles or concepts outlined by Pilates in his writings. Although the terminology used to name these principles may vary from instructor to instructor (Table 23-1), their explanations of the underlying concepts as originally described by Pilates are consistent. The terms most commonly used to identify Pilates’ principles and concepts are provided below.

Table 23-1 Principles of the Pilates Method of Body Conditioning and Exercise

Control

Pilates’ method of exercise requires control of every movement. Strength is developed by moving slowing against and with gravity, avoiding momentum as a means to complete a movement. Each exercise is executed with breath, concentration, and control.

Breath

Every exercise described in Pilates’ text ¹⁰ includes instructions for a specific breathing pattern of when to inhale and when to exhale. According to Pilates, correct breathing requires a full inhalation and complete exhalation so that the blood can receive “vitally necessary life-giving oxygen” and the muscles can be stimulated into greater activity (p. 13).¹⁰

Probably the most accessible form of Pilates is a group of floor exercises often referred to as the mat program. This collection of exercises is the focus of most books written about Pilates ¹^–¹⁰ and for which clear descriptions and illustrations or photographs are available. Exercisers are encouraged to perform an abdominal scoop and achieve and maintain a neutral spine while performing the exercises. Adherence to these positions helps ensure the building of strength and length of the powerhouse musculature and helps guard against injury.¹⁰ A sample of three mat exercises can be seen in Figures 23-1 to 23-3.