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PrintPilates and Physiotherapy
What is Pilates?
Pilates is a unique body conditioning exercise designed to rebalance the body, bringing it, into its correct neutral alignment whilst targeting the deep postural muscles (Transverse abdominals and muscles of the pelvic diaphragm). In essence pilates challenges the core muscles and builds strength from the inside out, helping a person to reshape their body, adding to a leaner and more toned figure. It boasts of a perfect balance between strength and flexibility, whilst relieving unwanted stress and tension. The phenomena of pilates is a popular and growing trend in western countries amongst athletes and celebrities, as well as in the treatment of peripheral and spinal musculoskeletal dysfunction. Today pilates is evolving and is taught worldwide in gyms and hospital, benefiting millions of people. The aim of this article is a brief introduction to pilates and its clinical benefits in physiotherapy.
Background
Pilates was first discovered in Germany in the early 20th century by a keen diver, gymnast and boxer by the name of Joseph Pilates. Joseph Pilates had spent the majority of his childhood fighting rickets, asthma and rheumatic fever and this fuelled his desire to become physically immune to these ailments. Through studying a variety of different disciplines (yoga, Zen) he brought about this new notion of exercise. During the war he practised his theory of exercise, and became involved in the rehabilitation of war victims. Once the war ended, Joseph Pilates relocated to New York and soon went on to open the first pilates studio attracting elite actors, dancers and athletes.
Clinical Pilates vs Pilates
Clinical pilates is used to treat people with musculoskeletal injuries and is conducted by a physiotherapist certified with Clinical pilates certification. If a person experiences an injury or repetitive injuries, they may have joint stiffness, muscle spasms, poor posture or abnormal movement patterns as a cause or a result of the injury. It is therefore important to first treat the above complaints before commencing pilates.
In addition certain pilates exercises may aggravate the symptoms. An example is someone who may experience a back strain, due to too much extension in the lower back. Such individuals may have an exaggerated lordotic postures and therefore extension pilates exercises may not be advisable. This is something that would not be picked up if a person was to attend a routine pilates class, which does a combination of both flexion and extension exercises.
Not only is it important to select the right type of pilates exercise, it is also necessary to ensure that the correct and appropriate level is prescribed. Routine pilates may be too challenging for a person with back pain. This will cause the individual to compensate and utilise stronger global muscles as opposed to the core muscles, therefore negating the benefits of the pilates exercise. As a secondary result, a person may start to experience muscle spasm in the global muscles due to the increased exertion. The physiotherapist having tested your muscle strength and range of movement, will be able to ensure that the exercises are appropriate and although challenging not detrimental to recovery.
The added benefit of clinical pilates to routine pilates is not only is it more individualised to the person and their problem, it can also be more functional. If the person for example is keen to return to an activity or a sport (swimmer, footballer, dancer) the standard exercises can be modified by the physiotherapist to strengthen the core muscles whilst carrying out the aggravating movement. This could mean that the core muscles of a footballer is challenged as he kicks, dribbles a football and not just in static postures.
Peripheral injuries
When dealing with peripheral joint/ muscular injuries e.g. ankle instabilities the ankle is the main focus of the treatment. This makes sense and is always a good place to start to strengthen and rehabilitate local structures. However the research is beginning to move towards looking at the whole picture. Improving an individual dynamic control of their movements, will mean that person is less likely to sustain injuries. There is a growing trend to rehabilitate athletes whilst incorporating Pilates based exercises to teach a person to move more efficiently. Pilates can be used to treat hip, shoulder, knee and ankle injuries.
Spinal Injuries
Pilates in conjunction with manual joint mobilisations and soft tissue release is an effective way to treat back pain.
Time and time again the research has shown that any form of back pain leads to a loss of function of the deep muscles (multifidus) of the spine at that level. Unfortunately these muscles do not have the capacity to turn back on again, once the initial episode of back pain has resolved, and therefore these muscles require specific training to reactivate and stabilise the spine. In the long term these muscles without exercise will continue to waste further and subsequent muscle spasm in the global and more superficial muscles is experienced. This predominately occurs as a mean to stabilise the back in the absence of the deep muscle activity. Such individuals will report recurrent flare ups of back pain in the year due to the ongoing weakness of the spine.
In addition to weakness, back injuries usually occur after an extended period of time, in a bad posture, excessively loading the joint.
Clinical pilates is a form of exercise that both facilitates the strengthening of these deep muscles whilst educating a person where a neutral spine lies. In time a person will feel that there back is stronger, as they become more aware of what sitting or standing in a good posture entails.
In the long term they will also have the endurance to sustain these better postures for longer periods, through conducting the exercises.
If a person is new to pilates one- to one sessions with a physiotherapist or very small classes is initially strongly recommended, this is to ensure a person can be taught the correct techniques and the 5 concepts of pilates accurately (breathing, neck, rib pelvis position and stabilizing). Pilates can be a little tricky and can easily be done incorrectly and therefore close supervision is required to prevent faulty patterns learnt.
The benefits of Pilates
• General fitness and body awareness greater strength and muscle tone
• Improved flexibility
• A flatter stomach
• Improved efficiency of the respiratory, lymphatic and circulatory systems
• Better posture and awareness
• Less incidence of back pain
• Increased joint mobility
• Lower stress level
Which clients would benefit from Pilates?
• Males and females
• Pregnant: Pre and post natal
• Athletes and dancers
• Amputee and stroke rehabilitation clients
• Elderly
• Children 12 years-old +
Clinical pilates therefore targets the musculoskeletal injury more specifically. The physiotherapist is able to identify your posture type, establish the mechanism of injury, understand what the peron is aiming to return to and work out which exercises would be of more benefit to the individual. Clinical pilates therefore looks at treating the cause as well as selecting the appropriate repertoire of exercises to strengthen the injured areas and even be done for injury prevention.
If your suffering from recurrent episodes of back pain or peripheral injuries – Clinical Pilates may be just what you need!
Non-golfer with golfer’s elbow
Golfer’s elbow refers to a painful condition of the inner side of the elbow. Cause of the pain is usually overuse of the forearm muscles attached to the elbow. These muscles work to bend the wrist and rotate the forearm. Despite the name, it also afflicts non-golfers.
Any repetitive wrist flexion activity (bending towards the palm side your hand) can lead to the development of Golfer’s elbow; activities such as golf, tennis, badminton, or games that involve repetitive throwing such as cricket and netball.
Symptoms
The main symptom for Golfer’s elbow is pain at the inside of the elbow. In addition,
- The pain is felt either on or around the bony part, and sometimes spreads down the forearm.
- The pain is usually worse with wrist bending or grasping/lifting activities. Sometimes fully straightening the elbow is difficult because of pain.
- There may be tingling sensation, or numbness on the inside of the forearm and the last 2 fingers, and is usually worse with or after activities.
- Over time, grip strength weakens.
Treatment
The management of Golfer’s elbow starts with pain control, followed by soft tissue therapy, and conditioning of the affected muscles and followed by the correction of technical faults.
Pain control & soft tissue therapy
This is the first stage. Before we proceed with the other stages of treatment, the pain needs to be under control. Initial pain and inflammation control is usually achieved by rest, icing, and use of anti-inflammatory medication (see RICER). This happens within the first 1-2 weeks. Physiotherapy treatments such as ultrasound, myofacial release & taping are helpful too.
Conditioning of the affected muscles
When pain and inflammation is under control, the stiff muscles need to be released by heat treatment, massage, and stretching exercises. (pictures) Strengthening exercises should start with pain-free movements. Important movements are gripping, bending of the wrist, and turning of the forearm. Good posture of the body and shoulders is important during exercises. For those who experience tingling or numbness of the forearm and fingers, it is because the nerve passing through the affected muscles is irritated, either by direct compression of the muscles or by the chemicals released from the inflammation of the muscles. In this case, it is necessary to gently mobilize the nerve to assist with better healing (see picture).
Functional Recovery
Technical fault in movements varies depending on the different requirements of the individuals. For example, those who play racquet sports, good wrist control during strokes are crucial to prevent overuse injury. A good technique is one in which the wrist stays neutral (bent neither to the palm nor the opposite) during strokes. Return to sports should be paced to the tolerance of the muscles, and improvement of techniques and fitness.
Jaw pain? Physiotherapy can help.
Although physiotherapists are getting more referrals from dentists, many people are not aware that physiotherapy is capable of treating a wide range of symptoms caused by a dysfunction of the Temporoandibular Joint (TMJ). Common symptoms are local jaw pain, clicking jaw, and muscle tension around the jaw.
Anatomy
The TMJ is a more complex structure compared to our other joints in our body because of the interaction among the disc and a good amount of muscles, ligaments, the jaw and skull bones. Furthermore it is supplied by blood vessels and a large number of nerves, which makes it sensitive to pain.
What can cause a TMJ problem?
Disorders in this joint rarely occur as single symptom, but more often as multiple problems with overlapping symptoms. Usually, the pain, tension and degeneration are caused by anatomical features. But pain can also occur after a period of teeth grinding, bite problems or even having to open the mouth for a long period of time at the dentist. A history of trauma, such as at hit on the face or head can also have aneffect on the jaw.
How can physiotherapy help?
The TMJ can be affected by several factors – the position of our head, the cervical spine, the hyoid bone and our posture are often responsible for a TMJ dysfunction. A specialized therapist will assess the TMJ together with it's surrounding structures, the cervical spine, the shoulder girdle and will analyze the posture of patient. The tongue, mouth and facial functions will also be assessed to get a clear view of the actual cause of the jaw pain or referred pain.
Depending on the diagnosis a physiotherapist have several treatment options. Treatment options include soft tissue release and trigger point therapy to decrease the tension of the jaw, facial and neck muscles, mobilization techniques to decrease pain and help the TMJ joint to move correctly.
Advice on the right posture and home exercises are essential to strengthening of the weakened muscles and to assist on the right alignment. Most patients will experience an improvement with TMJ physiotherapy. Lasting improvement however will depend on staying in the right posture, and being discplined in doing the home exercises.
Bracing for Scoliosis
How many types of braces are available for scoliosis?
In general, there are 2 main types of braces: hard brace and soft brace.
Hard braces are made of thermoplastic. It has been the main brace prescribed over the last a few decades. Common types of hard braces are Boston’s, Charleston’s, and Milwaukie’s etc.
| Hard Brace | Soft Brace |
Like what its name suggests, it is hard and non-flexible, and wearing which limits movements of the spine. Hence it greatly affects one’s sports participation and causes significant comfort and tolerance issues. Additionally, hard brace is usually bulky and heavy, and shows under the clothes, it is not easily accepted by image-conscious teenage girls. Besides, it also creates much stiffness of the spine, weakness and tightness of the spine muscles.
Soft brace on the other hand, allows movement of the spine when worn. Therefore, the spine is much more mobile during and after the treatment, there is also much less muscle imbalance and joint stiffness of the spine.
Currently the only available soft brace for scoliosis is SpineCor brace. You can get more information on SpineCor brace by following this link: http://www.spinecorporation.com.
How different are the two types of braces? Is one definitely better than the other?
It’s hard to say which brace is definitely better than the other, they work on different principles. Hard braces are designed to hold against spine deformity statically, soft brace on the other hand, is designed to use dynamic force to target on bone deformity and muscle re-training and balancing.
Both hard and soft braces can be effective before the bones of the spine reach maturity, which is usually between 13-15 years old for girls and 15-17 years old for boys. Hard braces can be used for any types of scoliosis such as neuromuscular scoliosis, congenital scoliosis, and idiopathic scoliosis. SpineCor brace is designed for idiopathic scoliosis only.
Both braces need to be worn regularly throughout the day (16 hours per day). Soft braces are lighter and more comfortable to wear; it is more cosmetically acceptable as it can be well hidden under the clothes. It also allows better posture & muscle development, and is able to promote good mobility of the spine while correcting the curve. Hard braces are usually much heavier and hotter to wear and may result in a poorer compliance compared to soft braces.
For people who participate in sports like dancing, gymnast, running or badminton, soft brace is of a much more practical choice. Soft brace is also recommended for individuals who are more prone to skin problems or who are likely to have compliance issues.
Lower Back Lumbar Segmental Instability
Someone with a lower spine that frequently moves through a larger-than-normal range of movement is more susceptible to low back pain. This tendency of moving beyond its normal range is known as lumbar segmental instability.
The normal range of the movement is defined as the neutral zone. A person with lumbar instability tends to move beyond the normal range of movement into the extreme end ranges.
What keeps the spine stable?
In order to understand what causes lumbar segmental instability, we first need to understand what keeps it stable in the first place. The human body holds the spine stable or steady through the help of three basic structures – the passive, active and neural structures.
- Passive structures in the lumbar spine are the vertebrae, the discs, then joints and ligaments. These are structures that do not move.
- Active structures are the global and local muscles. These contract or relax depending on the direction of the force required.
- And finally the neural structures; nerves that control and direct the muscles. This control is also known as motor control.
A stable lumbar spine segment coordinates global and local muscles using the motor control system to supply compressive forces along the spinal passive structures for stability. This coordination helps maintain the spine's normal curvature at a segmental level as we move about.
Active Structures
The global muscles include:
- Rectus abdominis,
- External oblique
- The thoracic part of lumbar illiocostalis (an erectae spinae muscle). ·
These three muscle groups are large torque producing muscles that provide general trunk stability and allow movement to occur.
The local muscles attach directly to the lumbar vertebrae. They are:
- Lumbar multifidus,
- Psoas major,
- Quadratus lumborum,
- Lumbar parts of lumbar illiocostalis and longissimus (more erectae spinae muscles),
- Transverse abdominus,
- The diaphragm and
- Posterior fibres of internal oblique.
- Interspinalis/ Intertransversii
The two lowest spinal segments, L4 and L5 vertebrae, are the most susceptible to segmental instability. This could be due to pathological/ degenerative changes to the passive structures that sometimes show up on x-rays. Instability can also occur if there is a loss of motor control and muscle strength/stamina within the neutral zone.
What does it feel like?
A person with lumbar segmental instability typically has a patient-history something along these lines.
- Back pain may have started after a direct injury to the area, or it may have just developed gradually.
- The pain tends to be recurrent and has more debilitating effects as time goes on.
- That person will try to do as little as possible in an episode of pain. According to a survey (O’Sullivan 1997), people most commonly describe the pain sensation as · catching, · locking, · giving way or · feeling of instability.
Classically, the most painful postures are sitting or standing for long periods of time, or being in bent over postures.
The most painful movements are
- bending forwards,
- moving unexpectedly quickly,
- standing up straight after being bent over, lifting or sneezing.
So basically….
The lumbar spine moves in an uncontrolled manner, causing pain. Because the big muscles and little muscles don’t work together properly and the body is unable to control each segment as the body moves.
How do I get rid of it!?
A physiotherapist will need to perform an assessment to find out what type of segmental instability is present (and the type of control that is lacking due to which structure – passive, active or neural). Based on the findings, an intervention will be planned.
In cases where the passive structures have degenerated, it is often possible to train the active and neural structures to compensate for the lower level of stability provided by the passive structures.
With this sort of condition, the exercises that are required are more ‘brain’ exercises than ‘muscle’ exercises. A new way of moving has to be re-learnt, and it requires a lot of concentration.
Heat or Ice? When to use which?
When should you use heat or ice therapy? The answer is – it depends. In general, heat therapy is for chronic conditions and ice is useful in acute situations.
If you recently sustained an injury or aggravated an old injury, ice should be applied for a period of 15mins each time for the first 3 days. If you feel your muscles are feeling tight and stiff, a hot pack on the muscles will help to relieve the tightness.
This spectrum of acute to chronic looks at the duration since injury. If the injury is sustained within 36 hours, it is considered to be in the acute stage. At this stage the inflammation process is ongoing. Ice will help to bring down the inflammation and swelling so that the injury can heal better. Note that applying heat to this stage will increase the blood circulation, inflammation and hence swelling.
There are 2 common scenarios that cause pain, making you reach for that heat/ice pack. One of them is the acute injury (for example a fall, twisting movement or direct blow that is immediately painful) and the other is the chronic injury (happened over a period of time or from an acute injury that failed to heal). Each scenario requires a different approach to reducing your pain and speeding up your recovery.
Acute Injuries
It might be that you have just sprained your ankle playing soccer, shut your fingers in the car door or fractured your hand. All these are examples of acute injuries and will show the following signs:
- Sharp, severe pain
- Swelling
- Redness
- Increased warmth
- Restricted joint movement
- Unable to put weight through the structure (e.g. leg, ankle, wrist etc).
Flickr: Kyle May
There are many ways of applying ice like using an ice pack; wrapping ice cubes in a wet towel or using a bag of frozen peas (sometimes that is the only thing on hand!). The cold agent should be in contact with the area for up to 20 minutes at a time and re-applied every 2-3 hours for around 3-5 days or until the swelling settles.
How does ice work?
1. Decreasing the pain
There are a few proposed theories regarding how ice decreases pain and it is possible that a combination of some of them can cause pain relief.
- Decreased nerve transmission in pain fibres
- Cold reduces the activity of free nerve endings
- Cold raises the pain threshold
- Cold causes a release in endorphins
- Cold sensations over-ride the pain sensations
2. Reducing swelling
Ice cools the surface of the skin and its underlying tissues, causing narrowing of the blood vessels. This narrowing leads to a decrease in the amount of blood delivered to the area and subsequently reduces the amount of swelling. After a few minutes, the blood vessels re-open allowing blood to return to the area. The narrowing and opening repeat in cycles.
The decrease in swelling also allows more movement in the area and lessens the loss of function associated with the injury. Pain is also reduced as pressure from the swelling lessens. Chemicals that intensify the pain are released into the bloodstream when tissues are injured, thus the narrowing of the vessels help to minimize this release and pain.
3. Decreasing metabolic rate
Ice reduces the metabolic rate and oxygen requirements of the cells. Thus, even with the decreased blood flow and oxygen delivery that comes with narrowing of the vessels, the risk of cell death will be lessened. This prevents further injury.
Sub-acute phase
A few days following an acute injury, the pain and swelling may have decreased so much that there may be no sign of the original injury. However, the tissues are still in the process of recovery and will still benefit from modifying your activities (less vigorous) as well as using both ice and heat alternatively. This means to apply ice for 10 minutes, followed immediately by 10 minutes of heat.
How does this work?
Doing this will cause massive increases in blood flow to the area as the narrowing caused by cooling is reversed when heat is applied, resulting in an influx of blood to the damaged tissues. The increased blood flow to the area provides proteins, nutrients and oxygen for better healing. It also helps remove the products of inflammation and reduce residual swelling.
An important point to note is to ensure that inflammation has stopped before applying this technique. That means that the area should not be red, and should not be warm to touch.
Chronic Injuries
Flickr: Capture Queen
In order to treat these, heat should be used to help relax tight, aching muscles and joints, increase the extensibility of ligaments and tendons and promote blood flow to the area. Heat can also be used before exercise in chronic injuries to warm the muscles and increase flexibility.
Heat can be applied to the area in the form of heat packs, a warm damp towel, hot water bottles or heat rubs. If using a heat pack or hot water bottle, ensure a suitable layer of protection is placed over the skin to prevent burns. The heat should be applied for 15-20 minutes.
How does heat work?
Heat applied on the skin increases the temperature of the skin and the underlying tissues. This in turn opens up the blood vessels like your ateries, allowing more blood to flow into the area. This increase flow helps to remove waste products from cells and deliver more nutrients, relaxing tissues. The increased temperature of the blood also warms up surrounding tissues. Heat also has an effect of increasing flexibility of the soft tissues.
Both heat and ice are cheap, easy to use and effective ways of speeding up recovery when used correctly. Besides managing your injuries with these modalities, it may be a good idea to consult a physiotherapist in helping you rehabilitate and/or prevent the same injuries from occurring.
What to do when your back hurts so much that you can’t get out of bed?
Source: Flickr erikogan
What you NEED to do
- Reduce the inflammation:
- Either take an anti-inflammatory medication (tablet or injection). GP prescription may be required.
- If it is too painful even to go see the GP,
- Apply a COLD press to the sore/painful area.
- Take an over-the-counter anti-inflammatory (e.g. Voltaren Gel / Tablet). This is a weaker form of anti-inflammatory medication than what you will get from your GP.
- Rest to let your body heal and reduce the inflammation naturally.
What NOT to do
- Apply Heat (either through a hot pack or some of heat rub) You will further aggravate the inflammation.
- Massage the sore area.
See your physiotherapist only after it doesn't feel so sore or painful the day after.
Improving Your Chances for a Successful Back Surgery
Spine-Health.com recently listed 5 ways to improve your chances in their article, “5 ways to minimise failed back surgery and continued back pain”1. One of the 5 ways was – “Be Ready to Rehabilitate”. We would like to add one more way to improve your chances – Pre-Habilitation. (more…)
Idiopathic Scoliosis Video
Idiopathic scoliosis is the most common form of scoliosis. This video provides a good visualisation on how a scoliotic spine looks like. It also shows how the forward bending test will reveal scoliosis.
Read on here to know how the SpineCor programme helps in the treatment and management of scoliosis.
Core Concepts is an accredited SpineCor Physiotherapy Centre. The first private centre in Asia, outside of Europe and the Americas
Traction Therapy – No Help in Long Term
Traction Therapy
Many people may have heard stories about their friends having treatment for their spinal pains in hospitals or physiotherapy clinics where they were strapped into a contraption and having their back or neck stretched. This device is called a traction machine. To some the description may sound intimidating or even medieval, but in fact, traction is a very gentle form of treatment and is extremely effective when applied appropriately in specific conditions.
