Clients with Arthritis? Pilates to the Rescue!

By Jeanne Missey Osgood | share As Pilates teachers, most of us have had clients who have had some form of arthritis. In fact, arthritis is the most common chronic condition in the United States affecting 40 million older adults, about half of all people over the age of 65. There are over 100 kinds of arthritis, some that affect children as well, but the most common is osteoarthritis the uneven wearing down of cartilage and other cushioning structures, as well as inflammation in and around the joint that cause pain, stiffness or swelling. Inflammation is sometimes due to the drying around a joint, less moisture, less fluid, less nourishment. It is considered the nations most common cause of disability. The photo below shows the structural change of a joint with arthritis.

Healthy Joint vs. Damaged Arthritic Joint Arthritis Defined Arthritis means, joint inflammation and may affect one or more aspects of a joint. The degree to which joints are affected by arthritis varies considerably among the various rheumatic diseases. Most rheumatic diseases are chronic; however, they can be managed through proper treatment. When a joint is inflamed, it appears red, swollen, warm and tender to the touch. The joint also will lose function. The loss of function may even persist when the inflammation subsides. Many medications can reduce inflammation and pain improving the ability to use the joint. But for the last 20 years, the Arthritis Foundation has recommended movement as the best medicine. If exercise is an important component in the comprehensive health care management program of an individual with arthritis, we need to ask some important questions: What kind of movement will help and not exacerbate an already painful condition? How can Pilates instructors help these clients? Are there specific Pilates exercises that are ideal for these clients? In this article, I will review Pilates components of physical fitness that are beneficial to an individual with arthritis, share some general guidelines from the Arthritis Foundation that address exercise safety and effectiveness as well as share some specific Pilates exercises and tools that I have found useful in the 10 years that I have spent teaching Pilates at a retirement center in Tucson, Arizona. Clients with arthritis are reluctant to engage in physical activity because of pain or fear of pain, fear of worsening symptoms or damaging joints. The problem is that rest and lack of exercise or activity may lead to muscular atrophy and a decrease in joint mobility, which is precisely why exercise is now recommended. It is apparent that there is a lack of information from Pilates and other fitness professionals about how to engage clients to move beyond fear toward better health through optimal movement. It starts with educating your client about why Pilates is different from exercises that may hurt them and why Pilates is good for joint health. The chart below is a reminder to our clients about the answers to the why Pilates? question.

Pilates = Joint Health We understand the concept of stabilization as well as various exercises that strength and stretch all muscles around a particular joint will mean that the joint capsule or joint articulations will anatomically fit better and will wear more evenly. We understand that Pilates works subtly from the inside out, starting with deep stabilization muscles that create inner warmth and then moving toward the more superficial and distal muscles with just a few repetitions of many kinds of movements. Many different exercises for one joint help to ensure an equal balance of strength and flexibility from all angles. We know that the more we move and breathe, the better the circulation around the joint which carries nourishment and moisture to the joint for better functioning and healing. Our movements are not quick (i.e., tennis) or high impact (i.e., jumping rope, running). Our movements are smooth and controlled with no impact. Pilates/Fitness Components that Help Promote Joint Health Research from the Arthritis Foundation confirms that the components of physical fitness that help clients with arthritis are: muscular endurance, cardiovascular endurance, range of motion/flexibility work, posture/body mechanics, balance, coordination, body awareness training, breathing techniques, and relaxation techniques. Flexibility exercises relieve stiffness and help restore movement through complete PAIN FREE range of motion, prevent loss of motion and deformity and minimize stiffness. In the photo below on the left, the client is holding a dowel behind her back as an awareness tool for better posture, but holding the dowel in this way is also good for flexibility around the shoulder girdle and upper arms, wrists and hands. The right triceps and left rotator cuff muscles are being stretched. The hand position can work up or down the dowel as flexibility improves. The arm position should be switched to balance the other side of the body. Muscular endurance exercises ensure that the weak muscles around a joint are strengthened. This can be done through isotonic exercises or those that involve resistance (i.e., springs, Tye4, Magic Circle, bands, weights) or isometric work (i.e., stabilization of pelvis or shoulder girdle) that we do so often in Pilates. In the example of the picture below, the client can gently and oppositional pull (isometric contraction) on the dowel to strengthen those muscles in and around the shoulder girdle. Isometric work is ideal when a joint is inflamed. Cardio activities such as bicycling, walking and swimming are also good as long as the individuals with arthritis have guidance on the appropriateness of these exercises and how to proceed safely. This is where we can teach proper form and alignment in gait, swimming (on the barrel or mat) and bicycling (on the Cadillac). Posture and body mechanics training (shown in the photos below) is very important in lying down, sitting, standing, and moving as in gait. Transitioning from any of these positions is equally important. In the right photo below, the clients are transitioning from a seated position on the reformer to a standing position and then back to a seated position. This exercise is a basic squat. It is important that the client keeps a neutral spine throughout (this can be done with or without the wooden dowel, weighted dowels or other weights are not recommended). Narrowing the foot position in squats will challenge Balance training. However if the knee or hip joints are painful, keep a wide secure foot base and move the hips and knees in the best PAIN FREE range of motion. Limit abduction of the hip if there is pain. Coordination activities (e.g., holding the dowel behind the back while standing) are excellent to help teach stabilization of one body part (the body part that is sore and maybe only needs isometric contractions) and mobilization of another part. This also helps develop focus and awareness. Awareness training helps a client get in touch with where the body is in space and in relation to

other body parts. (e.g., flexing one knee and then the other and noticing any differences). Emphasize deep breathing while practicing and performing the exercises. We do this well in Pilates, but now, we are reminded that deep breathing moves oxygen as well as other nutrients to all cells in all joints of the body to aid in nourishment and joint health. Teaching Relaxation Techniques such as progressive relaxation or guided imagery can help the client to manage pain as well. (See articles on Teaching Relaxation Techniques.)

An example of a Pilates exercise with a client who has inflammation in spine, hips. Client holding a dowel for postural awareness while standing/sitting. Pilates Exercises for Specific Arthritic Joints 1. Spine Pelvic Clock and modified articulating bridge for spinal arthritis 2. Shoulders Shoulder rotations, gradually moving to Ribcage Arms, Snow Angel Arms and Arm Circles using no or low resistance. 3. Wrists and ankles Open chain wrist and ankle rotations with no/light resistance (band). 4. Knees Seated knee extension (with band to aid in range of motion), or footwork with light springs. 5. Hips Limit hip abduction. Add adduction by squeezing a ball or Magic Circle between the thighs while lying in Bridge position. Hip abduction can exacerbate hip arthritis. 6. Hands Light pressing of the hand (one at a time), base of the fingers and fingertips on a spiny pod. Keep the base of the hand lifted to keep wrist angle aligned. Let the client do the work. They will know how much pressure. Even a little pressure allows for an isometric contraction. 7. Feet Light pressing of foot (one at a time) on the spiny pod. Tennis balls work also but the spiny pod gives both stability and more proprioception which I believe allows for better circulation. Pilates General Guidelines for Clients with Arthritis 1. 2. 3. 4. Encourage clients with arthritis to exercise their joints daily. Inflamed joints should be moved gently through the range of motion. Always begin with a warm-up of slow exercises (i.e., fundamentals). Keep the room warm. Use warmed towels as props. Heat relaxes joints and muscles and helps relieve pain. 5. Keep the rhythm of the exercises slow and steady. Allow rest time between exercises. 6. Clients should be encouraged to attempt full range of motion, PAIN FREE movements. These exercises may not improve range but further restrictions may be prevented. 7. Breathing in a normal deep rhythmic pattern should be encouraged, especially the classis Pilates breath of in through the nose to warm, moisten and filter the breath and out through the mouth to encourage the deep core stabilizers. 8. Encourage clients to move at their own pace and listen to their bodies. If anything hurts, then stop. 9. Exercises should be done at low resistance with two or three repetitions, working to five or six repetitions. 10.Avoid manual cuing or assisting stretches by manipulating limbs; leave that to a qualified

physical therapist. Pilates Apparatus I have found that the Rehab Reformer (a reformer carriage that is high like a Cadillac table) is ideal for working with clients with arthritis. It is easier for the client to sit, stand and lie down as well as for the instructor to maintain proper body mechanics while acting as a support for the client. If a higher Reformer (carriage) is not available, use the Cadillac more. Especially for clients who have arthritis in the hips and/or knees, it is easier to limit deep flexion that can cause pain. I always tell the client when transitioning from lying to sitting to standing (or the other way around) to stabilize the core by pulling in the abdominal, only bend from the knee and or hip, and use only the powerful leg and hip muscles to move. It becomes increasingly important to repeat these reminders often for those clients with arthritis in the spine. Verbalize biomechanical ideals as a reminder to both client and instructor. Comfort Props Keep plenty of comfort props for clients with arthritis. I have blankets, pillows and bolsters that I use for some of the floor work. I keep a sturdy chair at hand to help clients descend to the floor or rise from the floor. As mentioned earlier, warm towels for props at the neck and under the knees. Certainly warming the carriage on the Reformer or Cadillac Table will help cold joints relax. If there is inflammation in the joints, just help the client by encouraging deep breathing, some gentile stabilization awareness exercises (e.g., hold and release tension in various joints) and talking them through progressive relaxation techniques or guided imagery. Summary In this article, I have included some general guidelines as well as some specific exercises to help Pilates instructors feel more comfortable working with clients who have arthritis. I encourage you to share these guidelines with your clients as well as try some of the specific recommended exercises during the Pilates session. If your clients know that you are working to become more knowledgeable about their conditions, they will feel cared for and safe. They will see that their goals of relieving joint stiffness, restoring or maintaining joint range of motion, maintaining strength, improving posture are being met and they will tell their friends! Good luck with building this new, most important client base. Sources Arthritis Today (2012) Retrieved October 12, 2012, from http://www.arthritis.org. Missey Osgood, J. (2012, August) Progressive Relaxation Techniques. Retrieved August 15, 2012, from http://www.themethodpilates.com. Pilates, J. H., Miller, W. J. (2000). A Pilates Primer: The Millennium Edition. Incline Village, NV: Presentation Dynamics Inc.

Raising the Barre: The Fusion of Pilates & Dance

By Joan Breibart | share

PhysicalMind has always been devoted to serious Pilates. We started the first Generation lineage of Master Teachers, now called Elders, and almost all of the Second Generation have been involved with the Institute since its beginning in 1991. We emphasize the importance of correct Form and Technique, and our continued development of TheMethod Fundamentals is what differentiates our teaching style. And, of course, we still believe Pilates is the best form of body conditioning available. However, times are changing. Youve probably noticed the sudden popularity of dance-based classes popping up in studios and gyms across the country. While competition in the fitness world is not ideal, it is inevitable. But Pilates has its roots in working with dancers, after all, and the popularity of dance classes offers our teachers a chance to adapt and grow. Several of our senior instructors have begun exploring dance-based classes like the Bar Method, and a couple have even become Zumba-certified. TheMethod is developing our own dance/Pilates fusion workout, and we look forward to unveiling some exciting new projects and partnerships in the near future. Meanwhile, we appreciate all your feedback on 80Bites. Many of you noted that our program is important for the environment shedding pounds goes hand in hand with conserving natural resources. This is best summed up by Master Teacher Zoe Stein Pierce of Fort Worth Texas: 80Bites is the real Diet For A Small Planet updated for the 21st century. Plus, I lost 22 pounds on it two years ago and have kept it off since. Wed like to hear from you: have your clients expressed interest in dance-based workouts? Have you incorporated any dance elements in your current workouts?

Pilates Reformer Stability Training to Improve Dancer Torso Alignment

By Mary Love Ward | share

As a professional dancer and Pilates trainer I have worked with many dance students to integrate Pilates as a method of cross training. I am particularly interested in the issue of torso stability and alignment because as a dance educator I have observed this as a consistent problem for most young dancers. I also see it as a rising concern in the dance community. Torso alignment is an important aspect of a dancers ability to prevent injury, move with ease and improve the overall aesthetic quality of their dancing. Therefore, if dancers can improve torso alignment while dancing they will be more likely to meet the increasing demands of the profession. Presently, there seem to be increasing expectations for professional dancers to move at exceptional ranges of motion so additionally there is now, more than ever, the possible risk for dancers to injure themselves due to instability. With the current trends in dance risking dancers health due to instability I thought it was important to focus a study on the specific connection between Pilates reformer training and torso alignment. Fortunately, research has concluded that there are certain key muscle groups that facilitate torso alignment and stability. This research has also concluded that these stabilizing muscles can be trained independent of postural activities, which is of particular importance since many Pilates exercises are done in the prone position (Hodges and Richardson, 1999). Current research also suggests that Pilates training, when done properly, can target the specific trunk stabilizing muscles (Endleman and Critchely, 2008). There are many studies that imply that training these postural or stabilizing muscles also include a specific kind of neurological patterning and that strength training alone is insufficient in improving alignment (Phillips, 2005). Pilates in particular relates to these findings because it incorporates a body mind connection as part of the training in addition to strength and targeted muscular training. There is also research specific to Pilates and its affect on alignment. The results of these studies are varied but they do seem to validate that Pilates training can improve dancer alignment especially in the trunk region (Bernardo and Nagle, 2006). The aim of my research is to observe Pilates impact on dancers torso alignment. Since, many dancers seek to be proficient in both ballet and modern I have assessment of both styles in my study for a more practical approach.

Participants and Settings

The participants in this study were selected from pre-professional dance students in the school of dance at Florida State University. The dancers were selected because they showed potential risk of injury related to torso instability based on the results of the Sarhman Torso Stability test screening, which was performed while the dancers were freshman at the university. At the time of the study the

dancers were juniors, however they had not received any serious training interventions for torso stability until my study. The dancers performed the training intervention in their free time among their regular dance activities in the FSU School of Dance conditioning studio under supervision using two Pilates reformers.

Training Procedure
The dancers training involved Pilates reformer work. Dancers completed a 20-30 min reformer training session once a week with a trainer and twice a week with the other dancer in the study. The exercises in the training session were performed in neutral spine and included: The Hundred, Leg Circles, Long Stretch, Mermaid, Seated Side Twist, and Elephant. The training progressed in resistance and aimed to fatigue dancers, but not compromise their alignment. When dancers were able to complete these exercises and maintain proper torso alignment the reformer trainer added exercises and variations to provide progressive challenges. At the end of each session dancers recorded the details of their workouts including repetitions, resistance, and exercises on a workout log sheet. The training intervention lasted 5 weeks.

Research Design
The design of this project was an intensive case study. This study involved two dancers with a demonstrated lack of trunk stability. Measurements were taken as a pre-test and post-test. Dancers torso alignment was measured with video footage that was converted into photographs. In each photo the perpendicular angle was assessed and then the angle of pelvic/rib tilt was measured using a protractor. Each measurement was taken after dancers had completed their daily technique classes. The training intervention involved Pilates Reformer workouts three times a week. The workouts were supervised by the researcher and modified if necessary. For the additional workouts the research participants were asked to workout together and give each other verbal feedback cues to assist better alignment. Throughout the training period the participants were asked to complete an exercise log sheet after each workout that detailed the exercises, resistance, and repetitions completed to assess if any deviations occurred in the training protocol. The pre-test and post-test differences were compared to determine changes in alignment.

Results
Pelvic and Rib Tilt for Dancer 1 Phrase Plie Pre-Test Pelvic 0 Rib -.25 Jumps Post-Test Pelvic 0 Rib -.25

Pelvic .67 Pelvic .33 Rib -2 Rib -2 Pelvic .25

Tendu

Pelvic 0

Rib -.25 Limon Pelvic 0 Rib -.5

Rib -.25 Pelvic 0 Rib 0

Data shows averages from all measured photos of each separate dance phrase. A 0 indicates perfect alignment, + integer indicates anterior tilt, and integer indicates posterior tilt Pelvic and Rib Tilt for Dancer 2 Phrase Plie Pre-Test Post-Test Pelvic .25 Pelvic .25 Rib 0 Jumps Rib 0

Pelvic .67 Pelvic .33 Rib -1.33 Rib -1

Tendu

Pelvic .25 Pelvic .25 Rib -.5 Rib 0

Limon

Pelvic .25 Pelvic .25 Rib -.25 Rib -.25

Data shows averages from all measured photos. A 0 indicates perfect alignment, + integer indicates anterior tilt, and integer indicates posterior tilt

Difference in Alignment from Pre to Post-Test

Exercises Difference for Dancer 1 in degrees Difference for Dancer 2 in degrees

plies

No No change change
Pelvic .34 Rib no change Pelvic .34 Rib .33 Pelvic no change

jumps

tendus

Pelvic .25

Rib no change Limon Pelvic no change Rib .5

Rib .5

No change

+ integer indicates an improvement, indicates a worsening of alignment

Implications
The differences between the pre and post-test measurements revealed a small improvement in alignment in at least half the dance phrases for each dancer with consistent improvement in alignment in jumps for both dancers. This fact is actually inconsistent with a previous study, which revealed that Pilates training in a supine position does not affect alignment in jumps (Bernardo and Nagle, 2006). Although it appears to have had a positive impact, it would be hard to say that these differences can be attributed to the Pilates training due to the limited nature of this study. More intensive research needs to be done to validate these results. Another notable finding from this study was the perception of improvement. Both dancers expressed to the researcher that they felt that their alignment had improved and that they were more aware of it during their regular classes. They also noted that two of their instructors, a ballet and a modern teacher, had noticed and commented on their improved alignment during classes. This gives rise to the dynamic nature of assessing alignment. It seems that strength is one element of it, however there is also the element of the perceptions of the dancer and his/her colleagues. I think it is important to begin to consider these elements along with physiological ones in the development of future measurement protocols. Overall, this study showed a positive affect of the Pilates training which was revealed in the measurement protocol as well as in the feedback from the dancers regarding their own perceptions and that of their instructors. This fact might encourage dancers or teachers with students who have problems in torso stability and alignment to seek out Pilates reformer trainings as a possible method to improve their torso alignment. To validate the findings of this case study a standardized method of measurement based in advanced technologies as well as input regarding dancer perceptions would be a great step forward in assessing improvement in dynamic torso alignment.

References
Bernardo, L. and Nagle, E. (2006). Does Pilates Training Benefit Dancers? Journal of Dance Medicine and Science. Volume #10, 46-50. Endleman, I. and Critchley, D. (2008). Transversus Abdominis and Obliquus Internus Activity During Pilates Exercises: Measurement with Ultrasound Scanning. Arch PhysMed Rehabil. Volume # 89, 2205-2212.

Hodges, P. and Richardson, C. (1999). Transversus Abdominis and the Superficial Abdominal Muscles Controlled Independently in a Postural Task. Neuroscience Letters. Volume #265, 91-94. Phillips, C. (2005). Stability in Dance Training. Journal of Dance Medicine and Science. Volume #9, 24-28. Mary Love Ward is a professional dancer and dance educator. She currently lives in central Florida and teaches dance at Valencia College and Midway Elementary School of the Arts. She holds an MFA in dance from Florida State University and a BS in Biology from Winthrop University.