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In Part 1 of this exploration of Pilates (SIB 42, September 2004), we looked at ‘fitness Pilates’: how the original 1920s artistic exercise form for dancers has evolved since the 1950s to suit the needs and preferences of the fitness industry. We raised some questions of those involved in this vast and organic industry, about their responsibility in assuring the quality and effectiveness of the Pilates discipline. More recently, the scientific community has also taken an interest in Pilates and its applicability for injury rehabilitation, leading to the development of a separate stream called ‘clinical Pilates’. This second evolution is the focus of this article.
Here, we get scientific. We look at how to decide which kind of Pilates an individual should be doing, and we analyse the six Pilates principles from a scientific perspective. Finally, we offer some illustrations as to how athletes can make Pilates work for them.
The fitness Pilates industry is populated by instructors and core stability teachers with varying levels and standards of training. Many of them have little or no advanced education or training in injury process, pathomechanics, movement dysfunction or rehabilitation management.
I suspect that many genuine practitioners of fitness Pilates have a strong sense that they are offering their clients something with incredible potential, yet because they have little understanding of the inner workings of the mechanical body, these well-intentioned teachers suffer some confusion about why certain clients get a great result from their instruction while others break down with injury, despite every effort to teach them correctly and specifically.
This is where clinical Pilates started. In the early 1990s, rehabilitation specialists such as physiotherapists (especially in Australia) began to incorporate Pilates exercises and equipment into their protocols, but found that some aspects of what they were importing did not sit well with the best available evidence from sports therapy and rehabilitation research. By infusing Pilates exercises with well established physiotherapy concepts – and thereby scientific validity – clinical Pilates was born.
Back in the 1920s Joseph Pilates gave us a method that prioritised the building blocks of core stability and rehabilitation. It has only been in the last couple of decades that sports science research has helped us see more clearly why some of his ideas work brilliantly on injured bodies, while others are at odds with current best practice.
Table 1 below summarises the main differences in approach between fitness and clinical Pilates.
| Fitness Pilates | Clinical Pilates |
|---|---|
| Dance-oriented exercises, used for general conditioning and lifestyle benefit | Diagnostic and rehabilitation tool for injury and performance enhancement |
| Strong bias towards flexion, stretching, end-of-range movements, moderate to high loads and low repetitions | Progresses from static stabilisation to dynamic; trains local then global stability systems. Neutral zone stability comes before end-of-range flexibility |
| No evidence to support its use for rehabilitation of low-back pain | Aims to fulfil established evidence based criteria |
| Non pathology-specific exercises | Observes pathology under load and modifies accordingly |
| Prioritises variety of movements and exercises | Prioritises strict adherence to scientific interpretation of the six principles |
| Source: Adapted from the work of Craig Phillips, Dance Medicine Australia | |
The key question is: are you injured or do you have a history of injury? If so, clinical Pilates is essential for your rehabilitation before attempting fitness Pilates with an instructor or in a class environment.
If yes, you will probably need some treatment and investigations before undertaking any Pilates. Clinical Pilates can then equip you with the body movement skills that will allow you to exercise without reaggravating the injury. Let’s be clear: there is a vast array of spinal musculoskeletal problems that a fitness Pilates instructor is not equipped to help you with, from segmental instability or pars defect, through ankylosing spondylitis to fibromyalgia or spinal canal stenosis. And many more.
Nothing concerns me as much as well-meaning personal trainers or Pilates instructors trying to help fix someone’s injury, based only on what they have read on the internet about that condition. Legally they are on very shaky ground.
If you are developing new aches and pains over a period of time that seem directly related to doing Pilates (nonmuscular pains will often appear the next day), talk to your Pilates instructor immediately. Ask if they can see any obvious technique issues, try to do modified versions of the class exercises, and if that doesn’t improve things, visit a physiotherapist (or a clinical Pilates specialist), to determine what’s wrong.
Your goal is to discover exactly what your ‘movement dysfunction’ is. With corrective training and time (weeks to months), it should be possible to work out what the problem was and have improved your control and awareness in that area. You can then gradually phase back into the class or studio situation.
If you have recently injured yourself at work or sport and are wondering whether Pilates will be a safe form of exercise for you, simply try it and see how you go. If the injury persists, or is being aggravated by Pilates, you’ll need to visit a sports therapist.
Most uninjured people will find fitness Pilates fantastic for conditioning their bodies and achieving the various benefits we discussed in Part 1. But fitness Pilates is not the best starting point for everyone.
Imagine a scale from 0 to 10 where 0 represents someone with no exercise history, and 10 represents an elite athlete. Now, place yourself somewhere along that scale.
For injury-free exercisers, fitness Pilates is highly recommended for anyone in the range of 2 to 7. Active people, recreational sportspeople and even good athletes (range 4 to 7) will benefit from fitness Pilates. Children, the elderly and pregnant women (provided they are in the first trimester of their pregnancy and have some experience with exercise) can benefit and so can new mothers, provided they are not experiencing any spinal or pelvic pain.
In all cases the rules and cautions outlined in Part 1 apply: if the group is too big, and the instructor is moving too fast for comfort, you are at risk of pushing your body in ways it won’t like. Break the six principles and you may get injured.
People who score 0 to 1 on the fitness scale are always going to be at greater risk of hurting themselves in exercise because they are likely to be unhealthy and/or overweight, have poor body awareness and need a little longer to learn the basics of moving safely. For these people an initial course of clinical Pilates would be ideal, to give them a solid and safe grounding in exercise movement and prepare them for fitness Pilates and/or personal trainer/gym work.
It is my personal opinion (although no research confirms this) that sub-elite to high-level elite athletes (8 to 10 on the fitness scale) would also benefit from an initial course of clinical Pilates to really focus their brains and bodies on the subtleties of how they breathe, stabilise and move during exercise.
Niggling injuries or technique faults can often be ironed out by learning clinical Pilates skills – skills that are then incorporated into sport and strength and conditioning routines, helping to enhance the athlete’s overall performance.
In Part 1 we outlined the six underpinning principles of Pilates. These foundation principles can equally be applied to any form of exercise and the more completely they are followed, the more pure, safe and effective will be the resulting movement.
The six principles are the keys to rehabilitating any overuse injury or movement dysfunction – while fitness Pilates will vary greatly in its adherence to them (often to its detriment), clinical Pilates must strictly follow them or cease to achieve its aims. They describe the fastest way to acquire coordinated movement skills, for example learning a forehand stroke, learning to sprint, or simply lifting safely. Each principle in itself is a ‘micro-skill’ that must be learnt and when they are combined, they form a functional ‘macro-skill’.
Practice of the micro-skills at first ‘soft-wires’ them into the brain (they remain a conscious effort), but gradually ‘hard-wires’ them into the neuromuscular system, so that they become subconscious and automatically deployed.
Most people will battle with one principle more than another, depending on their familial history, sport, personality type and their injury history and status.
To activate tonic holding muscles in a static position requires correct cueing plus good core alignment as follows:
around the pelvis (near centre of gravity):
around scapula
around occiput (skull)
around knee/hip
around foot
Research in support:
Conscious and correct inspiration (breathing in) allows the diaphragm to help stabilise the trunk, inhibits the use of the external obliques as stabilisers and helps maintain the thorax in a tall position. Rehab and sports therapy greatly underrate the importance of correct breathing: getting it right is critical for stability!
The preferred method of breathing – diaphragmatic – involves increasing the lateral expansion of the rib cage and some upper abdominal lifting, without lifting the shoulders, or excessive billowing of the whole abdomen.
If a client struggles with this, they can practice inspiring against rubber tubing held around their thorax. Expiration should not be forced: the normal elastic recoil of the lungs and rib cage allow for sufficient expulsion of air. Forcing expiration will make the external obliques overwork and pull the thorax into flexion.
The preferred timing of breathing is to breathe in with the initial movement, or the one that requires the initiation of stability mechanisms. Rise up onto your toes as you breathe in; then try it while you breathe out and feel the difference in your ability to balance.
Research in support:
Neutral rotation positions are maintained around the joints of the body, with a focus (at least in clinical Pilates) on any impaired body-part. The body parts and the relevant movements are:
| Body part | Movement |
|---|---|
| occiput (back of the head) | chin protraction/ retraction |
| scapula | upward/ downward rotation |
| lumbar spine/ pelvis | anterior/posterior tilt |
| hip/knee | internal/external rotation |
| subtalar joint | pronation/supination |
Research in support:
Clients should be taught to limit movement to the mid-range, ie the ‘playing field’ where none of the core alignments are compromised. The more the walls around the playing field are disrespected, the greater the likelihood of compensation from superficial musculature, tissue breakdown and pain from injury.
All exercisers, whatever their sport or discipline, must learn to recognise ‘out of control’ signs in their bodies, such as jerkiness, shaking, tightening or outright pain if injury is acute. They must teach themselves to be patient and stay within the boundaries while the edges of the playing field gradually expand.
This progressive improvement in movement control never happens as quickly as one would like and the greatest challenge is to not rush the process, or load the body too heavily (forcing it to revert to bad old stability activation patterns).
Research in support:
The above skills cannot be achieved without intentional and informed brain focus on the body part. The brain’s connection to the injured part is then slowly re-established (many clients with chronic pain report a wonderful sense of being reconnected to their bodies with massage and exercise therapy).
‘Proprioception’ is the normal sense of where a joint is in time and space and it is the key to understanding why injuries recur time and time again. A proprioceptive deficit from injury impairs your ability to ‘feel’ that area (slowing of afferent feed-forward and feedback loops to the area and altered joint position sense).
Clients who struggle with concentration can be encouraged to do certain exercises with their eyes closed, or with eye patches on, or even in a darkened room, to decrease visual distraction and maximise proprioceptive input.
Research in support:
This principle is hard to quantify except to say it is the result of combining all of the above skills, with the net effect of a feeling of ease during a movement that one is learning. For a right-handed person it is the difference between throwing with your left arm as opposed to with the right one. The arm feels ‘gumby’ (an Australianism), or almost totally incapable of doing it!
When we say that a person is uncoordinated, we are saying they lack many or all of the above skills, or they lack the ability to put them all together effectively into a ‘macro-skill’, such as the freestyle stroke.
Whether there is a genetic component to this is arguable, but what is certain is that there is often a strong familial/environmental component.
If slouching about with poor posture and body awareness is what our parents taught us, then that’s what our challenge will be.
The key to good coordination is not to try too hard, because you cannot force yourself to be coordinated. Instead slowly repeat and repeat, break the action into smaller components, approach the movement from as many angles as possible; remember you are training your brain and you cannot rush it.
So there we have it: the six ‘C’s’, and perhaps we could add in a critical seventh ‘C’ – commitment; the strength of character to stick at a process until the results are evident.
If an athlete carries with them a ‘bad habit’ of movement, it will take the strict and pure approach of clinical Pilates to diagnose it, undo it and teach the correct movement pattern that is going to improve the athlete’s technique and performance. They will usually require the feedback tools of coaches and sports physiotherapists (video, EMG, pressure biofeedback, taping, etc) to make the transition from artificial drills in the studio to technique changes on the track.
Different sport skills will require different emphases from the six principles. Sports such as rowing or swimming may focus on conscious breathing, whereas gymnastics or diving need higher levels of coordination; and weight lifting and shooting perhaps demand greater concentration and control.
This is where Pilates equipment comes into its own, allowing the therapist to tailor a programme to the mechanical positions and requirements of the specific sport.
Once the ‘rules of good movement’ are well learnt, there is room for athletes to bend them. The welltrained body will tolerate exceptions to the rules when fatigue sets in, under higher pressures, or with unforeseen circumstances – up to a point. As long as accuracy has been enforced from the beginning and the body has matured into good movement patterns, elite athletes will be able to bend the rules to meet the highest-level demands of their sport (eg a cyclist in a very posteriorly tilted position, or a tennis player with open forehand), without sacrificing performance or risking injury.
The future of general conditioning, injury rehabilitation and athletic performance enhancement is, I believe, in the hands of those who teach and practice high-quality Pilates, yet this powerful and hugely important discipline will only thrive if it continuously returns to the deep, foundational musculoskeletal truths that underpin it. And it must be willing to evolve as further research informs it. This interweaving of the art and science will, I am confident, guarantee the future of Pilates.
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