Clinical Pilates for the Aging Athlete
By Martha Purdy, PT
As printed in the Sport Physiotherapy Canada Momentum Journal , Spring 2009

Clinical Pilates is an ideal form of exercise for the aging athlete. It is an assessment based exercise approach to injury prevention and rehabilitation that focuses on motor control training to correct and treat movement and stability dysfunction. Clinical Pilates is a growing method of rehabilitation for physiotherapists in Australia and the United Kingdom, and has more recently been introduced in Canada.

History of Pilates
Joseph Pilates (1880-1967) originally starting developing his techniques during the First World War to rehabilitate injured soldiers. His method of exercise was called ‘Contrology’ meaning, the art of control. It consisted of 40 original matwork exercises to improve core strength and flexibility, and provide a holistic mind-body workout. It was not until after his death in 1967, that the term Pilates was introduced. Today, the Pilates Method can be classified into three main forms.

1. Classical or Traditional Pilates is strongly based on Joseph Pilates’ original 40 high load matwork exercises. This is still practiced today, and is popular with the dance population.
2. Developed or Modified Pilates incorporates both low and high load exercise, is fitness based, and may include equipment. Modified Pilates programs, such as Stott Pilates, are beginning to incorporate rehab based training programs for health professionals.
3. Clinical Pilates incorporates spinal stability research, taking an evidence based approach to the Pilates method. Founded in 1990 by Craig Phillips, an Australian physiotherapist and former ballet dancer, Clinical Pilates is designed for rehabilitation specialists to use as part of their injury prevention and rehabilitation. Movement and stability dysfunctions are identified during an assessment and exercises are chosen and modified based on findings, as opposed to standard protocols or routines. Kinetic Control is a UK group that has also embraced and developed the concept of Clinical Pilates. Sarah Mottram and Mark Comerford (Kinetic Control, Performance Stability) stress the importance of a formal assessment and have developed a system to evaluate and treat movement and stability dysfunction by testing and retraining local and global muscles and motor control stability (Comerford 2005).
   

Basic Principles of the Pilates Method

1. Concentration
   Focusing on quality of movement helps to facilitate motor control learning and slow motor unit recruitment. For clients with proprioceptive deficits, it appears that a higher sensation of effort is required to activate slow motor units (Grimby &Hannerz, 1976). By increasing awareness of movement we encourage the mind body connection.
   
2. Breathing
   Diaphragmatic breathing is encouraged during exercise. Focusing on the breath can promote relaxation, support slow motor unit activation, and cue the release of unnecessary co-activation and bracing strategies during low load exercises. Diaphragm contraction increases intra-abdominal pressure, thus contributing to core stability.
   
3. Centering / Alignment
   Exercises promote centering of the spine and joints in neutral, and cue activation of low load, slow motor unit muscles, such as transverses abdominus. O’Sullivan (2002) demonstrated that lumbopelvic stabilizing muscles are more active in maintaining neutral alignment, than in passive postures.
   
4. Coordination
   Smooth movement, coordinated with the breath, encourages appropriate muscle pattern and activation levels. Coordination of the local and global stabilizing systems is taught as exercises progress from low load to high load. Exercises flow from one into another, repeating correct movement patterns in various positions.
   
5. Control
   Exercises focus on mid range movement, emphasize both the concentric and eccentric phase, and promote control of neutral. Exercises may be chosen to teach dissociation of limb and spinal movement, correct muscular imbalances, and improve spinal and peripheral joint stability.

"Never do 10 pounds of effort for a 5 pound movement." Joseph Pilates

As physiotherapists, it is important that we observe ‘how’ our athlete is getting to the finish line. Altered motor control can result in movement and stability dysfunction. The majority of athletes perform at high loads, whether they are running, jumping, or swimming. It can be a challenge to convince athletes of the importance of working on low load stability exercises, especially if they have difficulty with activation of the deep stabilizing system (transversus abdominus, multifidus, pelvic floor, diaphragm). Athletes are used to working at a high percentage of maximum voluntary contraction (MVC), and it can be difficult for them to "feel" the low MVC needed for stability and postural control. Aging athletes involved in the same sport for many years, have likely developed muscular and movement imbalances, further challenging their ability to recruit the deep stabilizing system. This may be a functional adaptation that has improved their performance. However, over time this may contribute to overuse syndromes, as well as excess shearing or compression at the joint surfaces, increasing risk of pain and injury.

Research has demonstrated evidence supporting muscle dysfunction and the benefit of retraining stability. Musculo-skeletal failure can be related to poor recruitment of the low load, slow motor unit, overactive recruitment of the high load, fast motor unit, and the faulty integration between these systems. (Comerford and Mottram, 2001). Hides, Jull and Richardson revealed inhibition of the multifidus muscle post back pain, and found its recovery not automatic (1996). It has been demonstrated that feedforward activation of the transversus abdominus (TrA) occurs in healthy individuals during postural perturbations, yet is consistently delayed in people with low back pain (Hodges and Richardson, 1996, 1997). Pain may lead to changes in muscle recruitment (Hungerford, 2003) and activation levels (Falla et al, 2004). Specific activation of the TrA has been shown to prevent reoccurrence of low back pain at one-year followup (Hides, 2001). Tsao and Hodges demonstrated that training isolated voluntary activation of the TrA leads to changes in feedforward postural strategies, and is dependent on the specificity and quality of motor training (2007).

Clinical Pilates is essentially motor control training, or as Joseph Pilates called it, ‘Contrology’. Clinical Pilates incorporates current concepts and research on spinal stability, motor control and muscle balance into the assessment and rehabilitation of movement and stability dysfunction. It helps to identify faulty movement patterns, muscular imbalance, and stability dysfunction. Exercises are chosen and modified to fit the functional needs of the client, incorporating low load stability work with sport specific higher load tasks. One on one instruction with verbal, visual, and hands on cueing promotes correct muscle recruitment, activation and coordination of stabilizing systems. Clinical Pilates is ideal for the aging athlete who presents with movement and stability dysfunction, secondary to years of ‘sprains and strains’.

References

Comerford MJ, 2005 Core Stability Training. The Performance Matrix Performance Stability UK

Comerford M J, Mottram S L 2001. Functional stability retraining: Principles and strategies for managing mechanical dysfunction. Manual Therapy 6(1): 3-14

Falla D, Bilenki G, Jull G 2004. Patients with chronic neck pain demonstrate altered patterns of muscle activation during performance of a functional upper limb task. Spine 29(13): 1436-1440.

Hides JA, Richardson CA and Jull GA 1996. Multifidus recovery is not automatic after resolution of acute, first-episode low back pain. Spine 21(23), 2763-2769.

Hides JA, Jull GA and Richardson CA 2001. Long-term effect of specific stabilizing exercises for first-episode low back pain. Spine 26(11), 243-248.

Hodges PW, Richardson CA (1996) Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine 21: 2640-2650.

Hodges PW, Richardon CA (1997). Feedforward contraction of transversus abdominis is not influenced by the direction of arm movement. Exp Brain Res 114:362-370.

Hungerford B, Gilleard W, Hodges P 2003. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 28(14): 1593-1600.

O’Sullivan PB, Grahamslaw KM, Kendell M, Lapenskie SC, Moller NE, Richards KV 2002. The effect of different standing and sitting postures on trunk muscle activity in a pain-free population. Spine 27(11): 1238-1244.

Pilates, J., Miller W. J. Return to life through Contrology, Christopher Publishing House, Boston, 1945.

Teyhen DS, Gill NW, Whittaker JL, Henry SM. Ultrasound imaging of the abdominal muscles. J Orthop Sports Phys Ther. 2007; 37:450-466.

Martha Purdy is a physiotherapist trained in the pilates method from Halifax, Nova Scotia. She has spent 5 years travelling and working with Cirque du Soleil performers as a physiotherapist and Performance Medicine Supervisor. She now practices physiotherapy and clinical pilates in Nova Scotia at the Halifax Osteopathic Health Centre and KD Physical Therapies. In her practice of pilates, Martha focuses on matwork using minimal equipment, so that exercises can be incorporated into a home program, encouraging independence and self management. If you have any questions or comments please contact her at physio_pilates@hotmail.com.

Ab Prep
The ab prep is performed with a neutral lumbar spine, emphasizing activation of the transversus abdominus (TrA) and internal obliques (IO). A chin tuck position is cued, along with flattening, drawing in, or hollowing of the lower abdominals. The abdominal drawing in preferentially activates the TrA muscle (Teyhen, 2007), and can be performed before movement begins, thus emphasizing feedforward activation.



Bridge
The bridge is performed with a neutral lumbar spine, emphasizing activation of the lumbopelvic stabilizers and hip extensors. A single leg lift can be added to challenge rotational stability and core strength. Dissociation of hip extension from lumbar and pelvic movement challenges motor control and promotes muscle balance

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