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Pilates on Call: Core Conditioning PTs

Dawn-Marie Ickes

Allyson CabotGabrielle Shrier

 

 

 

 

 

 
In the third installment of Pilates on Call—our month-long open Q&A with Pilates experts—we’re thrilled to welcome the owners of Core Conditioning in Los Angeles: Dawn-Marie Ickes, MPT (l); Allyson Cabot, PT (m); and Gabrielle Shrier, MPT (r). The three physical therapists/Pilates instructors founded Core Conditioning, a pair of integrated wellness centers, in 2003, where they combine physical therapy with Pilates and Gyrotonic for rehabilitation, as well as offer group classes.

This month, they will be taking your questions on joint injuries and issues—hips, knees, shoulders, feet, spine, neck, etc. Chances are you have encountered clients with problems with all of the above and more. Or perhaps you have a new client with an injury you’ve never dealt with before. Here’s you chance to get the PT-Pilates perspective on how to help them. Post your questions in the comments section below or email editor@pilates-pro.com. Dawn-Marie, Allyson and Gabrielle will get to them as quickly as possible, but might need a day or two to respond.

More About Dawn-Marie, Allyson and Gabrielle
In addition to owning and operating Core Conditioning, the trio has developed and continues to teach educational programs internationally for Pilates instructors and health care professionals, integrating Pilates and rehabilitation. They also teach a comprehensive teacher training program as faculty members for Balanced Body University. All three specialize in women’s health; Dawn-Marie also specializes in pediatrics and sports medicine; Allyson’s specialties include dance medicine, mind-body healthcare and craniosacral therapy; Gabrielle specializes in neurologic disorders and orthopedics.

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Reader Comments (39)

I've condensed and moved some entries to make reading through these Q&As easier. If you'd like to ask a question, leave it at the end of the comments or email editor@pilates-pro.com.

Thanks,
Amy/Editor

June 10, 2009 | Unregistered CommenterAmy Leibrock/Editor

Hi

I have a client with a slipped disc and sciatica in his right leg. This is what I received from his physio: "He has moderate disc protrusion at multiple levels. This has impacted on neural mobility and caused irritation. The most important aspect with the rehab is to re-educate re: neutral spine and make this functional ie standing, sitting, cycling position etc. I would suggest that stabilizer activation is of prime importance and this to be done again in functional postures. The Erector Spinae complex is over-firing and will be the prime mover for all motion - try to inhibit this. I would dissuade flexion movements and particularly flexion/rotation. Hence, the normal mat routine will not be applicable."

My client is used to very active & high impact sports (cycling, running etc), so small movements with small ROM etc are difficult for him to focus on. I would appreciated any ideas on what I can do to keep it slow & sure, but still keep him challenged and motivated. Particularly when work for the core is done in extension (incl Erector Spinae!) if flexion is contra-indicated...

Many thanks.
Kind regards
Anne

Hello Anne,

First and foremost - DO NOT BE DISC-OURAGED - a definite pun intended, there are so many ways to keep the matwork challenging by modifying a few simple things to ensure the maintenance of Neutral and to work towards core stabilization in neutral and extension-based exercises. We have also included other exercise options on the equipment as well should you have access to it.
 
Keep in mind and as you know, the matwork really is the most challenging and will definitely tap into his athletic prowess if done appropriately. Reiterate frequently to your client that the fundamentals of core stability will support his body's spinal integrity and are the foundation of what high-level athletes need to have to be truly effective at whatever endeavor they pursue.
 
Mat
• Neutral (ASIS and pubic symphysis parallel in the frontal plane) & Grounding
• Foam roller – ironing, puppet arms, alternate UE with ironing, arm circles, swan, plank/push-ups
• Quadruped – grounding, airplaning
• Side-bridging
• Kneeling with elbow press on ball (kneeling plank)
• Side-lying leg work
• Scapula push-ups – single leg kick, double leg kick
• Leg pull back – front support
• Prone extension w/arm circles
• Flower on ball or long box
• Leg pull up – back support
• Side-kick kneeling
• Theraband pectoral stretch
• Plank
• Plank with LE extension
 
Reformer
• Quadruped abdominals (facing forward and back)
• Scooter (with UE-sling activator)
• Plank – Long Stretch
• Balance Control Front
• Seated ER / IR (on long box, moon box or seated)
• Rowing (rhomboids)
• Scapula adduction with straight arms (middle trap) (on long box)
• Long box series – pulling straps, triceps, T-press, breaststroke, swan prep
• Knee stretch series
 
Trapeze 
• High-kneeling chest expansion (with squats)
• Boxer
• Hug a tree
• Prone extension w/arm circles
• Scapula draw downs (on moon box)
• Kneeling biceps/triceps with tower bar
• Squat
• Biceps curl into squat with roll down bar-using rolldown bar and arm springs

Wunda Chair
• Triceps press (seated on floor)
• Swan (bilateral and unilateral arm push)
• Swan on floor (proceed with caution)
• Neutral bridge on floor with feet on pedal-add body on foam roller to increase instability/integrate core stabilizers

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 10, 2009 | Unregistered CommenterCore Conditioning

Core Conditioning writes to Anne:
"Reiterate frequently to your client that the fundamentals of core stability will support his body's spinal integrity and are the foundation of what high-level athletes need to have to be truly effective at whatever endeavor they pursue."

To the experts:

I am just curious to know if you all believe that the "fundamentals of core stability" of which you speak are universally known and agreed-upon in the pilates professional community; that is, that the underlying assumptions of your approach need not be at least briefly acknowledged first (as Pilates Pro is a public forum)?

I look forward to your insights.
Thanks,
Carole Amend

June 10, 2009 | Unregistered CommenterCarole Amend

[A question submitted via email]

Good Morning - I've recently become a certified instructor & I am working with my 87 year old mother at home. She has worked with an instructor, where we live in Florida - now we are away at our summer home for 4 months.

My challenge is; she has very bad knees & can't kneel on them - she is able to do bridges while lying down on a cadillac w/a bosu resting against the tower... I purchased the 3-d bosu, thinking I could rest it also & she would be able to lie down on a mat ... not realizing she can't get up and down from the floor - she is in great shape - she golfs, she walks 3 days a week - she can balance on the bosu & do squats ... I am wondering what else I can do for her lower body - without getting her down on a mat - I need to rethink my entire workout with her .. I'm stuck!
thanks for any help you can provide.

Robin


Hi Robin,

Here are a few suggestions based on the information you provided. If you would like more specific exercise suggestions it would be helpful to know which pieces of equipment and what "props" you have at home.
 
Cadillac
If the Cadillac is at the summer home, standing leg work would be great--especially for her golf. Try 4-way hip: Stand on moon box with one leg as the stabilizing leg and the other off the side with one long leg spring on foot and do a set of extension, abduction and adduction.
 
Side-lying leg in the strap work would be great for pelvic and hip stability and strengthening activities.
 
Footwork with the tower bar with client facing tower bar vs. underneath the tower.
 
Floor 
Standing on floor in Pilates stance position, utilizing arm springs or a theraband, have client assume a a semi-lunge position and perform unilateral boxer. You can add a rotational component as well to facilitate thoracic rotation and pelvic stability.
 
Try standing footwork with a broomstick held in front of the body for balance (if needed). Do the entire foot work series incorporating the breathing and muscular sequencing just as you would supine on the Reformer.
 
Standing chest expansion and Chariot - with springs if Cadillac is present, with a theraband or elastic tubing if not.  To this you could add a mini squat which would integrate her LE strengthening and her Core with UE stabilization.
 
For golf specifically, you could have her do a 1/4 squat and then take a 1-pound weight or a 6-inch round ball and, starting with her hands reaching straight out in front over her, have her switch the ball from arm to arm, bringing it back into horizontal abduction and then returning to the start position - it is great for the shoulders and thoracic rotation (golf) and integrates the lower body.
 
Wall squats using a physioball behind the back and a small 6-inch ball between the knees to activate adductors and facilitate transversus abdominus and pelvic floor.

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 10, 2009 | Unregistered CommenterCore Conditioning

Hi Carole,
The information in this forum is designed to answer troubleshooting-based questions for Pilates professionals and THEIR understanding of the concepts of Pilates in the most basic form. I will add that the general public may educate themselves on the basic fundamentals of core stability via the internet or professionals in their area.

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 11, 2009 | Unregistered CommenterCore Conditioning

Hi Dawn-Marie, Allyson, Gabrielle,

Yes, I am aware this is for Pilates professionals, but professionals of ALL kinds.
Therefore, I asked about the underlying ASSUMPTIONS of YOUR work. You are all Physical Therapists.

Most pilates teachers are probably not, and I wouldn't want the public to be led to think that this is necessary, nor would I want people to believe that pilates concepts were the same as basic fundamentals of core stability you can find on the internet (although that's also helpful). I believe the two are different. Just my two cents.

Thanks,
Carole

June 11, 2009 | Unregistered CommenterCarole Amend

[Question submitted via email]

My question concerns a forty-year-old client of mine with EDS. She wears leg braces and originally was sure that she would have to keep these braces on, as well as her shoes, while on the Reformer. After several sessions she felt confident enough to remove the braces and shoes and the time on the Reformer/Cadillac is the only time she is out of her braces. She is a very committed client as evidenced by the fact that she has had 120 private sessions with me since November. I am Peak certified, PPS One, with one year of Pilates experience and thirty years as a personal trainer preceding my Peak certification including working for a physical therapy clinic for fifteen years. I have worked my client into doing most of the PPS One Reformer exercises with an emphasis on strengthening the muscles around her hyper lax joints. She cannot kneel due to the scar tissue on her right knee as the result of six knee surgeries. She has had thirty years of physical therapy sessions, off and on, following surgeries and/or injuries.

Naturally I have researched EDS but I would really appreciate any information you could share with me with specific emphasis on Pilates as it relates to EDS.

Thank you,
Sincerely,
Beth

Hi Beth,
Firstly, isn't it so great what we are able to do for our clients - every little bit of work they are able to do on the machines vs. in the real world is such a blessing. The thing to realize is there is a huge difference between working the springs vs. body weight, and in a controlled environment.

That being said, ways to progress would be to challenge what you're already doing in varying positions to push the proprioceptive component (eg. do things in supine, prone and side-lying). In addition, use props such as balls, magic circle (for adduction), theraband, magic circle (for abduction), rotating discs on the jumpboard for Footwork etc. for increased co-contraction around the joints. If she is able to just stand still without her braces and someone spotting her - do standing balance work, mini wall squats in her available range of motion, standing arm work on the trapeze so that she is standing statically, but challenging core and balance with UE movement. Even though she can't kneel, you can do some of those exercises (example - chest expansion, hug a tree, statue of liberty, seated rotation, etc.) with her seated up on the long box, so you can still challenge core stability in varying planes of motion.

Best,
Dawn-Marie, Allyson and Gabrielle

June 11, 2009 | Unregistered CommenterCore Conditioning

[Question submitted via email]

I have a client who for the life of me cannot hold her head up into flexion. No injuries to speak of. She cannot curl up seems as though the area around her t-12 is so tight it seems fused? no matter the position of a curl-up, 100, assisted roll-up she wants to tip her head back as she says it feels better? I have tried everything? I am on session 20 with her and it seems to not be getting easier? advise? keep her hands behind her head forever? She also cannot roll down forward and release the crown of her head towards the floor, it is still elevated as if her muscles in her posterior will not lengthen? she is not at all relaxed in a rolled down state. HELP?


Thanks for your help.


Michelle

Hi Michelle,
This is a complex question. It appears that there is something more going on that might be outside of your scope of practice. You should consider referring her out to a physical therapist in your area for a comprehensive evaluation. It doesn't mean you have to stop working with her, just don't do exercises that exacerbate her symptoms until she has been evaluated. There could be a number of things going on here, dural tension, some specific muscle weakness/tightness, joint dysfunction.

Also, what is her hamstring range of motion like? Does she get the same feeling when you do LE streching, leg in strap work, short spine?

In the interim, there are some things you can try (always staying out of her discomfort zone):

1. Curl ups with a towel hammock behind her head: Place towel at inferior border of scapula encompassing entire scapula and head - she reaches up and grabs towel keeping head totally relaxed in the towel and curls up using her lats and abdominals.

2. Roll downs on trapeze with sling: Have client sit with knees bent against side rails - yellow arm springs about 1/3 up on open end and use foot strap with fluffy (from reformer) behind her back around T8. Have her roll back segmentally to open up the lower thoracic and lumbar spine, she will probably only roll down to about T10 and then roll back up. This will help stretch the area you are talking about.

There could potentially be many more things you could do with this client, but until there is a clearer idea of where the problem is coming from, we cannot advise on how to progress. Feel free to contact us again once you have more information.

Thanks,
Dawn-Marie, Allyson and Gabrielle

June 11, 2009 | Unregistered CommenterCore Conditioning

[Question:]
I am not a professional but love pilates and some yoga. I've also had a few rounds of physical therapy in my life. Why are we, the public, seeing more integration of PT exercises with Pilates rather than Yoga? Just curious.

Amy


Hi Amy,

Pilates encompasses the fundamentals of physical therapy of core stabilization. As much as some of the exercises have choreography that can potentially be harmful to some diagnoses, the basic concept of pelvic and scapula stability for distal mobility is inherent in the work. Yoga tends to lean more toward end range movements and stretching (dura mater as well as muscles) - which is also an important aspect for overall health, but is more likely to flare up some of the basic diagnoses we see in the rehabilitation world.

Thanks,
Dawn-Marie, Allyson and Gabrielle

June 11, 2009 | Unregistered CommenterCore Conditioning

Core Conditioning states to Amy:
"Pilates encompasses the fundamentals of physical therapy of core stabilization. As much as some of the exercises have choreography that can potentially be harmful to some diagnoses, the basic concept of pelvic and scapula stability for distal mobility is inherent in the work. Yoga tends to lean more toward end range movements and stretching (dura mater as well as muscles) - which is also an important aspect for overall health, but is more likely to flare up some of the basic diagnoses we see in the rehabilitation world."

Hi Dawn-Marie, Allyson and Gabrielle,

And therein you state the underlying assumptions with respect to pilates from your vantage point as physical therapists. Thank you answering my question and thanks to Amy, too, for posing the question in a better way.

Best wishes and thank you for your work!

Carole :)

June 12, 2009 | Unregistered CommenterCarole Amend

[QUESTION SUBMITTED VIA EMAIL]

Here is a question for you...

I am wondering if there has been any success with birth injury named Erb's palsy, an injury to the Brachial Plexus nerve. Injured at birth and now 15, [my client] has seen doctors, PT's, Chiropractors with no improvement. He can't straighten his right arm completely and does not have full supination at the wrist when trying to straighten, however has full supination when arm is bent at elbow. He can't do a pull up hanging from a bar, but is very strong otherwise. Thinking maybe the Latissimus Dorsi is not firing in the pull up and the Biceps brachii or brachialis?? He does not have a severe case and has been told to basically live with it...Very frustrating for him...he also has never had any limitations for sports and plays football.

Suggestions??

Thank you!

Gwen


Hi Gwen
This is a bit of a challenge given that it sounds as if he has had a variety of different opinions, and with this type of birth injury, in addition to the direct trauma experienced, as the body grows, adaptations will occur as a result of compensatory patterns of use. It is also unclear as to the precise levels affected so let's start by looking at the movement he cannot do and dissect it from there.

For the pull up I have indicated the muscles required and their corresponding nerve innervation which may shed some light on his difficulty if he is aware of what level his trauma occurred at.

Primary muscle: Latissimus dorsi (C6 C7 C8)

Synergists: Biceps (C5, C6), Levator Scapulae (C3, C4, C5), Pec major - sternal (C7, C8, T1), pec minor (C8, T1), rhomboids (C4, C5), teres major (C6, C7) and lower trapezius

Stabilizers: Long head of triceps (C7, C8)

Most commonly Erb's palsy involves the C5–6 and sometimes the C7 nerve roots and/or upper-middle trunks of the plexus resulting in motor impairment, weakness, atrophy, and secondary joint contracture, typically the elbow. There may also be sensory impairment: Dermatomal or peripheral nerve distribution and/or functional and cosmetic impairment, limb length discrepancy, chronic pain.

• C5 root impairment will result in weakness of arm elevation to the front and side (flexion and abduction, from deltoid and supraspinatus impairment).
C6 root compromise causes weakness of external rotation of the arm at the shoulder (infraspinatus), elbow flexion (mainly biceps), and partial supination (supinator) weakness.
• If the lesion is at the C5, C6 root level or very proximal to the upper trunk, then winging of the scapula (serratus anterior) occurs. The biceps and brachioradialis deep tendon reflexes (DTRs) are depressed or absent.
C7 root alone forms the middle trunk of the plexus and is largely responsible for weakness in extension of the elbow (triceps), wrist (extensor carpi ulnaris) and fingers (extensor digitorum) and of wrist flexion (flexor carpi radialis).
C8 and T1 roots form the lower trunk of the plexus and innervate the intrinsic hand muscles responsible for grip and thumb opposition/abduction.

There is also a lower plexus lesion, such as Klumpke palsy (C8, T1):
• Elbow flexion, supination of the forearm, wrist and finger extension, and an odd cupped-hand position
• Triceps jerk is often absent.
• Sensation may be impaired in the C8-T1 dermatomes.
• An ipsilateral Horner sign (ptosis and miosis of the eye) indicates T1 involvement

I do have a client who is 74-year-old man with Erb's palsy from a birth injury and has been doing Pilates for 8 years now. He came in originally for his back and we never "treated" his arm. He remarked about 2 years into his Pilates training that although his elbow does not straighten all the way, his arm function had improved in general, which he felt was a direct result of some of the exercises. In particular, Chest Expansion, Chariot, Arm Circles, Hundreds and Down Stretch.

We hope this helps a little. Investigating may shed some new light on his challenges and give you some new things to try.

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 12, 2009 | Unregistered CommenterCore Conditioning

I am just a keen Pilates goer but having difficulty with my hip when I try to put on my shoes or socks at the moment ie, when trying to put my foot over on my opposite thigh my hip feels as if it cannot laterally rotate very far. Any suggestions on what I could do?

Felicity

Hi Felicity,
Has your hip always been this way? Some people are born with a decreased amount of lateral rotation. There is an actual test you can do to determine your genetically predisposed hip rotation. Stretching into this position as long as it is not painful is the way to go - slow and steady wins the race. Do NOT push into pain though. Also doing exercises that stabilize the pelvis and work the strength of hip rotators (pure hip rotation which is why you want the pelvis stabilized) - such as clams, hip circles and side-lying hip opening on the trapeze table will help.

Thanks,
Dawn-Marie, Allyson and Gabrielle

June 12, 2009 | Unregistered CommenterCore Conditioning

I am interested on your thoughts about hip flexors in the Pilates context. Many a client has overative hip flexors in core work, and through my own practice and research I have success cueing or modifying clients out of this habit. I have tended to include psoas in this group but Liz Koch (The Psoas Book) has suggested to not think of the psoas as a hip flexor. How do you view the role of psoas from a Pilates perspective?

Thanks.
Melissa Turnock

Melissa,

The psoas is an incredibly interesting muscle and gets a lot of heat!! The posterior fibers of the psoas attach to the lumbar vertebrae and actually work as part of the "inner unit" (Diane Lee), so we don't want to shut it off completely and in this sense it is not only a hip flexor. However, overusing the anterior part of the psoas (which many clients do) is definitely not what you want, and it sounds like you are doing a great job controlling this. Remember that a tight muscle does not work at it's optimum- so if the hip flexors are tight, make sure you are stretching them and addressing that in the workout. Ideally, you would also then want to find a way to strengthen them (preferably in the lengthened position such as Thigh Stretch).

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 12, 2009 | Unregistered CommenterCore Conditioning

[Question submitted via email]

Hi - it's been very helpful to follow the Pilates on Call discussion on the website, I teach Pilates and would love to ask the PTs about how best to use Pilates exercises for clients with hamstring strains and injuries, but that doesn't really fit with this month's focus on joints. Could you let me know if there might be a discussion with PTs in the future which will focus on leg muscles or on injuries of muscles and tendons?

Thank you so much!
Aya


Hi Aya,
This does not really seem to far off topic to me and I think addresses an important question for us to consider as instructors. When clients have a strained muscle/tendon - it usually tightens up. This is the body's healthy response to heal. Yes, we need to stretch it, but very gently so as not to continue to aggravate any micro-tears. Also, there are some who believe that a "strained muscle" or "tendonitis" should just rest until it heals, but then it continues to weaken. The muscle does need continued strengthening - but in PAIN FREE ranges. It may start as small as gentle isometric exercises. Progress the workout/exercises as the muscle heals and is able to tolerate more (but only at the pace that the muscle allows).  You also need to look at the joints around it - in this case hip and knee - and target other muscles in the area with focus on pelvic stabilization and balance/proprioception work.

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 12, 2009 | Unregistered CommenterCore Conditioning

Good Morning.
I have questions on Hip Replacement. I have a client with both hips replaced. One is 24 months the other is at 14 weeks. When is it appropriate to do internal rotation on the new hip? I have just taken over the care of this client from the PT. She actually did very well because of the work that we did mostly on the reformer before the hip replacement. She is on the reformer doing footwork now but is still very tender over the TFL and IT Band. She is doing squats with the ball. She walks with a limp and feels like she has no strength in both legs. She is 72 and in very good health. I would like some "do's" and don'ts. She feels like she is getting stronger and has a good deal of body awareness.

Sally

Hi Sally,
Was the surgery an anterior or posterior approach? The newer surgeries are different and have different contra-indications.
Thanks,
Dawn-Marie, Allyson, Gabrielle


It was a posterior surgery and she is limping. I don't like her gait at all. Her left leg actually folds and moves at the hip joint, the Rt leg, the latest surgery, does not. It has been 16 weeks, she has had PT and I suggested she ask her doctor if she needs more PT or if she will always walk this way. She is very sore over the scar and down to the greater trochanter. Her left leg is hurting in the adductors and where her Psoas starts to go down to the lesser trochanter. She is great on the reformer and when she rolls up the pain begins in the adductor. I am always checking to gripping and is she using her belly. She is a lovely woman.
Thank you
Sally


Hi Sally,
With a posterior approach, you will actually always need to be careful of the IR. It is fine to work the adductors isometrically (with magic circle) and also adduction toward midline (side-lying leg work on trapeze and standing adduction on reformer if appropriate for her) - just don't cross midline. Also, hip flexion beyond 90 degrees is a restriction and may be why she is still having difficulty with pelvic/hip differentiation. Continue to work this concept (pelvic/hip differentiation) in all planes of movement staying below 90 degrees of hip flexion and not crossing midline for IR and adduction. Her gait is probably poor secondary to weak hip stabilizers, so target gluteus medius with single leg standing work, clams/ hydrants, abduction and ER strengthening and hip extension strengthening. The reality is, even for a healthy 72-year-old, 16 weeks is still early in the recovery. Hang in there with the above guidelines and I'm sure you will see improvement.

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 14, 2009 | Unregistered CommenterCore Conditioning

[Question submitted via email]

I am interested in getting information about working with a client who has Multiple Sclerosis. How can I be most helpful to her? What should I be looking for and what should I avoid?

Thanks,
Deborah


Hi Deborah,
I, too am currently seeing someone with MS. Because the diagnosis can vary so much, it is hard to tell you exactly what do with her. There is so much variablility with symptoms and functional limitations for different individuals, but this is why Pilates is such a great method for this group.
  
The important things to consider
1.  Be careful of overheating her and working too hard. Some MS clients can only handle a 30-minute session. Build up the session length incrementally.

2.  Trust yourself and everything you know, and challenge her as long as she is able to accomplish the exercise. Be careful of pain, however, working slowly through stiffness is appropriate.

3.  Think about core stability first - the basic concept of core stability to help distal mobility is key. It can help strengthen, stabilize and decrease tone and spasticity in the extrmeties. Tempo is also important if spacticy is present - slower and controlled.
 
There are some good videos put out by the MS Awareness Foundation, their president in Nancy Yeager.  They offer soem helpful guidleines and modifications for Yoga and Pilates. 

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 15, 2009 | Unregistered CommenterCore Conditioning

Wow! The three of you have a big job for the next month! Thank you for committing your time to our questions. I have a quick and simple question... What book or subscription do you find the most beneficial for your line of work? Reading is a great way to stay educated, especially when it is difficult to attend conferences or CEC courses.

Thank you!
Courtney


Hi Courtney,

We would recommend the new Balanced Body podcasts, Pilates-Pro.com (of course), IDEA fitness journals, and newsletters from studios where you have taken workshops and can identify with their work. There really isn't a ton out there by the way, but if you look you might be surprised by what you find.  :)

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 15, 2009 | Unregistered CommenterCore Conditioning

Hi There,
Thank you so much for having this available to us and for taking the time to answer all these questions. I have a two part question, adding on to melissas question - what are good pilates exercises that can release the psoas especially if your client is having pain in this area, and what pilates exercises would you recommend to release the QL - specific stretches and repetoire.
Hope this finds you well,
Rose


Hi Rose,
If you're trying to find exercises to release a specific muscle, you should always think of working the antagonist. This works because of the concept of reciprocal inhibition (which means when you strengthen the opposite side of the body part, the antagonist, there is a relaxation that occurs in the agonist) - so hip extension strengthening in general would be good. 

As far as repertoire, some examples would be:
Bridging (all variations)
Reformer - scooter, Eve's lunge, Russian splits, front splis, thigh-stretch, semi-circle. 
Trapeze - magician/airplane, breathing
 
As far as the QL, the same concept applies, and some great exercises would include side-bending and rotation to the contra-lateral side - saw, side-bridging on opposite side, side-overs to stretch (especially on spine corrector and barrel), push-through, swan with rotation and mermaid on various pieces of equipment.

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 15, 2009 | Unregistered CommenterCore Conditioning

Hi 3 pt's from Core Conditioning,

I have FAI in my right hip, cam impingement, and torn labrum confirmed by x-ray and MRI. Now have FAI in my left hip. Running is now out (thought I would run forever). Arthroscopic surgery is not an option for me because of age (68) and I have read too many unsuccessful stories.

I go to pilates 3 times per week. Is main thing to strengthen muscles around hip and glutes? Cannot do deep hip flexion. When on elliptical, have problems with SI joint rotating back on left side. Head of femur just doesn't sit correctly in socket any more because of FAI.

Goodness, I am now a mess.
Thanks,
Fern


Hi Fern,
Femoroacetabular impingement or FAI, which I am sure you are extremely versed in (this is for readers) is a condition of too much friction in the hip joint. Basically, the ball (femoral head) and socket (acetabulum) rub abnormally creating damage to the hip joint. The damage can occur to the particular cartilage (smooth white surface of the ball or socket) or the labral cartilage (soft tissue bumper of the socket). 
 
In your case, all of the above and then some has occurred and it does not sound like surgery is an option. It is great that you are consistent with Pilates, and you are correct - the emphasis should be on strengthening the muscles around the hips and the gluteals. You would also wan to focus on your adductors and internal rotators and be sure that you are not overworking your gluteals as this can aggravate the condition if you tend to grip them for your pelvic stability.
 
In addition, you mentioned the left side's SIJ dysfunction so I will add that a particular emphasis on proprioceptive, or body awareness, training for your left hip in single leg standing would be a great addition to your Pilates program and a good follow-up exercise to do at home daily. You instructor can come up with a variety of single leg activities on the Reformer, Wunda chair and Trap table during your workouts so she can cue your pelvic alignment and positioning, and then I would suggest, once your teacher has cleared you to find the position on your own, practice single leg standing with your pelvis completely level 5 times on each leg daily. 

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 16, 2009 | Unregistered CommenterCore Conditioning

Hello,

I am a Pilates Instructor. I have a broken pubic bone and was wondering if you could give me some direction on which exercises are best for me right now.

June 16, 2009 | Unregistered CommenterTasha Holmstrom

Hi Tasha,
With a broken pelvic bone, first be sure that you have clearance form your doctor to begin exercises. The primary goal as you move forward is to ensure stability of the hip and pelvic musculature while being mindful of strengthening this region without producing any shear forces or torsion of the pelvic bones. Begin by working proximally and then progress distally one exercise at a time. Isometric exercises at first will also help reinforce your connection to the muscles of your pelvic girdle. You will also start by strengthening both hips bilaterally versus unilaterally when using resistance to reduce any shear or torsion. 
 
Begin by establishing a connection to the anterior and posterior portions of the pelvic floor muscles equally. The basic Kegel is a great way to do this, check to be sure you feel the entire bottom portion of your pelvis drawing up and that you are not clenching your gluteal or muscles between the sitz bones too much. Then work proximally with isometric hip abduction and adduction (avoiding any pain). Progress by utilizing a theraband (for abduction) or magic circle (for adduction) as long as there is no pain. Exercises such as footwork, bridging, standing splits are all appropriate exercise selections as long as there is no pain. Wall slides, 1/4 squats with a stability ball behind your back are also good. Then work into side lying clams, hydrants and kick backs utilizing own body resistance first to see how it feels (since this is unilateral work and more challenging). Progress this with resistance by performing side lying on the Mat with a therabnad wrapped around your thighs and on the Reformer with the leg strap at the thigh. As you progress and become stronger with the ability to do these exercises pain free, you will want to start working unilaterally with resistance, such as unilateral footwork on the Reformer, single leg standing balance, Wunda chair single leg press/VMO press, side lying leg work on the Trapeze, to name a few.
 
Exercises such as front splits, Russian splits, scooter on the Reformer and step up/down on the Wunda Chair should be avoided as they are unilateral and can create torsion. Once you are able to perform single leg work in supine, side lying and standing balance without pain you could start to initiate some of the more challenging unilateral LE work such as those listed above. Again, avoid pain and torsion and be mindful to not push too hard, too soon. Issues of the pelvis have a huge impact on the rest of the body as it is responsible for providing the stabilizing force during standing and gait/walking, which you must do all day everyday in your line of work so you want to ensure proper rehabilitation of the region.

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 18, 2009 | Unregistered CommenterCore Conditioning

I would appreciate any thoughts you could offer about working with golfers who have "SI Joint Dysfunction". Especially important would be "dos and don'ts" and any guidance regarding appropriate exercise prescription. Matwork + props (including arc) and reformer w/tower are available. Thank you so much! You are a much appreciated resource.

June 19, 2009 | Unregistered CommenterKathy

While the questions posed are valid the fact remains that unless a Pilates instructor has a degree in Physical Therapy, we do not prescribe exercise, we do not and should never diagnose an injury, we do not and should not consider ourselves anything other than instructors of a specialized exercise system and not get into the dangerous territory of thinking that just becasue we read PT Journals or text books, we can "treat injuries". We should know anatomy and know how to adapt the exercises for those who are post rehap, but I really think that it's crossing a dangerous line into territory that we should leave for the experts.

Hi LA,
We completely agree with your comments. Pilates instructors have a vast knowlege of body alignment and mechanics of movement. By utilizing this information instructors can have profound effects on those with current and/or a history of injuries. Situations do exist which are beyond the scope of practice for Pilates instructors, and in those instances they should be referred out to appropriate practitioners. We have recommended this course of action for those inquiries where we felt this was deemed necessary thus far.

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 20, 2009 | Unregistered CommenterLA

Hi Kathy,

There are a variety of different causes for Sacroiliac joint pain and dysfunction, and the particular type of dysfunction may dictate slightly different approaches to working with it. Pregnancy, abnormal alignment, leg length discrepancy and a car accident with one foot firmly placed on the brake are the most common. Pain may exist in the low back and hips and often in the groin and thighs. It is typically worse with standing and walking (bridging) and better when lying down. Inflammation and arthritis in the SI joint can cause “stiffness” or a “burning” sensation in the pelvis.

Corrective exercises such as Pilates, used properly, can be very helpful, but in order to know what is best for the body in front of you, it is imperative to determine if it is a HYPER or HYPO mobility problem, i.e. determining whether there is too much motion or not enough motion in the joint. The SIJ is a sensitive dysfunction and unless the diagnosis is clear with what the specific treatment plan should be, this may be a situation to refer out and find out the true cause of the problem so the exercises are chosen appropriately.

Hypomobility, or decreased movement, can result from a variety of osseous changes within the body which result in increased rigidity of the SI joint and thus inappropriate attenuation (or transfer) of forces on the body through those joints. Mild to moderate hypermobility is more common in individuals with a longstanding history of physical or athletic endeavors and pregnant/post partum women. Severe hypermobility is usually a result of traumatic car or motorcycle accident. SI belts are useful for pregnant and postpartum clients with hypermobile joints. Prolotherapy has also shown to be effective.

We have seen the most success with a very specific and well-documented functional approach addressing the entire abdominal-lumbo-pelvic-sacral-hip relationship. The transverse abdominis has been shown to be the key muscle to functional retraining of the core. We have seen that there are direct and observable benefits of focusing on the transverses abdominis, as studies from Richardson et al have shown, that when it fires properly there is significantly reduced laxity in the SI joint. Correction of leg length discrepancies, poor flexibility, somatic dysfunction and dysfunctional posture is key.

It is also important to appreciate the relationship of the hamstrings to this dysfunction as well. The biceps femoris portion of the hamstring group plays an important role in the intrinsic stability of the SI joint. Recent studies have shown that it is frequently found to be shortened on the painful side in low back pain, and is believed to be the direct result of a compensatory mechanism of stabilization of the SI joint. Normalization of the rhythm in the lumbopelvic muscles (hamstrings, hip flexors, adductors, abductors and deep rotators) is an essential component to corrective exercises for SIJ Dysfunction.

As far as the exercises go,

Begin by establishing awareness of what neutral pelvic alignment feels like in very safe and stable positions and progress accordingly. Supine with the knees bent, table top, seated and quadruped. Then establish the appropriate firing of the transverse abdominis, back extensors and pelvic floor while in neutral and work on increasing the endurance and ability to maintain this contraction without the position changing. Be sure to emphasize the importance that they are connecting to the anterior and posterior portions of the pelvic floor muscles equally. The basic Kegel is a great way to do this, check to be sure you feel the entire bottom portion of your pelvis drawing up and that you are not clenching your gluteal or muscles between the sitz bones too much. Then work proximally with isometric hip abduction, adduction (avoiding any pain). Progress by utilizing a theraband (for abduction) or magic circle (for adduction) as long as there is no pain. Exercises such as footwork, leg in the strap - starting with small boxes and then progressing to circles, and quadruped abdominals are all appropriate exercise selections as long as there is no pain. Wall slides/1/4 squats with a stability ball behind your back are also good.

Bilateral work is the starting point and you will work towards unilateral work as the body demonstrates improved stabilization with the work. Then work into side-lying clams, hydrants and kick backs utilizing body resistance first to see how it feels (since this is unilateral work and more challenging). Progress this with resistance by performing side lying on the Mat with a theraband wrapped around your thighs and on the Reformer with the leg strap at the thigh. As you progress and become stronger with the ability to do these exercises pain-free, you will want to start working unilaterally with resistance, such as unilateral footwork on the Reformer, single-leg standing balance, Wunda chair single-leg press/VMO press and side-lying leg work on the Trapeze, to name a few.

Exercises such as front splits, Russian splits, scooter on the Reformer and step up/down on the Wunda Chair should be avoided as they are unilateral and can create torsion. Once you are able to perform single-leg work in supine, side-lying and standing balance without pain you could start to initiate some of the more challenging unilateral LE work such as those listed above.

Again, avoid pain and torsion and be mindful to not push too hard, too soon. Issues of the pelvis have a huge impact on the rest of the body. It is responsible for providing the stabilizing force during standing and gait/walking so you want to ensure proper rehabilitation of the region.

Thanks,
Dawn-Marie, Allyson and Gabrielle

June 22, 2009 | Unregistered CommenterCore Conditioning

Thank you Pilates Core for your advise,

I say this from the viewpoint of someone who had been in the fitness industy for 30 years and a certified Pilates Instructor since 2000,
My response to any Pilates instructor who is working with clients who have issues like the ones' we have seen in these posts are: If you working with clients who have injuries or dysfunctions and don't know what to do, or you have to ask how to modify the exercises in the Pilates repetoire, it might be that your training in Pilates is insificient to deal with this client and you should refer them to someone else.

Hi LA
We have just sent a reply to a similar inquiry regarding scope of practice. However, we do feel that in the spirit of creativity and trouble shooting within one's appropriate scope of practice, increasing one's knowledge base of information as it relates to working with a growing population of individuals with "body histories" can create a positive experience for anyone wishing to participate in Pilates.

Thanks,
Dawn-Marie, Allyson, Gabrielle

June 23, 2009 | Unregistered CommenterLA
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