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© Studio Pilates International 2008 photocopying prohibited

BODY ESSENTIALS 1

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Contents

Culture 4

History of Pilates 5

Principles of Pilates 6

Postural types

Correct posture 10

Flatback 11

Lordosis 12

Kyphosis 13

Swayback 14

Scoliosis 16

Hypermobility 17

Stabilising muscles

Spine, pelvis and abdomen 18

Hip 21

Scapula 23

Neck 24

Postural assessment 25

Compensatory movement patterns 29

Muscle recruitment tests

Scapula control 30

Gluteal function 31

Abdominals 34

Hip flexors 35

Assessment Guidelines 36

Pilates Basics

Neutral/imprinted spine 37

Ribcage position 39

Scapula position 39

Neck position 40

T-zone 42

Oblique lines 43

Breathing 45

General exercise guidelines 47

Learning modalities 49

Cueing 50

Health and Safety 54

Mat class preamble 55

Spinal pain and injuries

Osteoarthritis 57

Instability 58

Postural neck problems 58

Wry neck 59

Muscle strain 59

Disc problems 60

Sciatica 62

SIJ problems 63

Osteoporosis 64

Pregnancy 66

References 70

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Studio Pilates International Culture

At Studio Pilates International we believe that the way in which we act, behave and instruct is just as

important as what exercises we give and how we give them. We are a company built on the passion

for helping people through Pilates. In order for this passion to help people to grow further, to reach

more people and for all to succeed in their role as an instructor, we have defined several points that

when embraced by all, will help to strengthen each other’s reputations and define Studio Pilates

International as the leaders in Pilates worldwide.

The following is from our company’s corporate documents that are viewed every day in our studios

and revised and read regularly.

Our Vision

To inspire and empower one million people a week to do Studio Pilates®

We will do this as instructors by ensuring on a daily basis we embrace the following

I deliver the absolute best service every time

I will ensure my clients have perfect technique with all of their exercises

My attention to detail is always paramount

I care about my clients and ensure their needs and wants are met

I enjoy helping my clients achieve their goals and success

I instruct with zest, confidence, enthusiasm, knowledge and precision

I contribute to the professional, positive, happy and fun atmosphere of the studio I am a part of

What makes a good Studio Pilates International Instructor

The definition of a quality Studio Pilates International instructor can be summed up simply as happy,

upbeat, always smiling, courteous & supportive. They are intelligent in conversation and always put

the client first. At Studio Pilates the instructor always adapts their style to suit each individual client;

they have fun with clients and fellow team members, never complaining. They are respectful, eager to

learn and open to professional and personal development. They are always looking for ways to get

better results for their clients and their studio.

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History of Pilates

German-born fitness guru Joseph Pilates (1881-1967) developed the Pilates exercise system in the

1920s. Joseph Pilates devised a unique sequence of movements that worked the mind and muscle in

harmony.

He fine-tuned his wellness regimen while interned in England during World War I. Working as an

orderly at an infirmary, he engineered a way to rig springs on hospital beds to offer light resistance

exercises to bedridden patients. This was later refined and became known as the reformer.

After the war, Joseph Pilates moved to New York and opened a studio near the New York City Ballet

in 1926. It wasn't long before he attracted a large following of dancers who took to Pilates for its

ability to create long, lean muscles and a strong, streamlined physique.

In 1945, Joseph Pilates published Return to Life Through Contrology, which described his

philosophical approach to exercise. Soon, some of his students began opening studios of their own -

some making subtle adaptations to the method - and word of Pilates started to spread.

By the mid to late 1990s, mind-body fitness methods took off as people started seeking gentler

paths to health and wellness. Pilates became popular amongst top athletes and Hollywood stars.

Even more recently, it has become very popular amongst Physiotherapists as a rehabilitation tool as

more and more research concludes just how important core stability and strength is in injury

management. Joseph Pilates always claimed he was ahead of his time, and his legacy lives on beyond

his wildest expectations. His own fitness is a testament to his method – this is a photo of Joseph

Pilates at the age of 80 teaching a student and performing a stretch.

http://www.amazon.com/exec/obidos/ASIN/0961493798/pilatesinsight-20/102-5774347-4084128?creative=327641&camp=14573&link_code=as1

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Principles of the Pilates Method

1. Concentration

The number one Pilates principle is concentration. A Pilates workout involves complete

concentration on what our bodies are doing and how they are moving. This includes

concentrating on correct posture and body positioning, movement patterns, muscle

activation and breathing. We are trying to retrain the brain and the body to function more

efficiently which takes a huge amount of concentration. Even when these posture and muscle

activation patterns become more automatic, you still need to concentrate on the muscles

which are working to increase the effectiveness of the exercise.

2. Centering

Every Pilates exercises focuses on the activation of the centre of the body or the core of the

body, the abdominal region. Not only does tightening these core muscles improve the

posture and prevent injury, they also provide a stable base for the rest of the body to work

from to produce movement and strength.

3. Breathing

Every Pilates exercise involves a particular breathing pattern which improves the

effectiveness of that exercise. The breathing patterns help to activate the correct muscles

required for the exercise, help supply oxygen to the muscles and remove waste products, and

prevent holding the breath.

4. Control

Maintaining control of every movement is very important. Pilates is not only about

strengthening the muscles but also about controlling the way they contract and the way the

body moves. Uncontrolled, jerky movements not only lead to injury, they don’t effectively

tone and strengthen the correct muscles. To control a movement, usually correct activation

of the smaller stabilising muscles is required, rather than large gross movements of the larger

superficial muscles.

5. Precision

The movements need to be precise, with purpose and direction. For each exercise we will

describe a precise body posture, position, muscle activation and movement that is imperative

to achieving the goals of that particular exercise. For example, if an exercise requires lifting a

leg up in the air it is completely different to lift the leg up in a random fashion than it is to set

the body in a particular posture, activate a certain muscle, take the leg into a precise position

and move it in a precise manner.

6. Flowing movement

Banish the thinking of repetition and start thinking of duration of the exercise and the total

time the muscle is under tension. Movements need to be continuously flowing, so there is no

stopping throughout the exercise and no distinct start and finish between each movement.

Sometimes in a practical environment you may prescribe repetition numbers, but that

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doesn’t mean the movement has to stop each time. The flowing movement means that there

is often more eccentric control involved to control the movement in all directions.

7. Isolation

Concentrate on isolating the particular muscles that are required to perform the movement.

This often means isolating the stabilising muscles from the larger muscles that like to take

over when performing a movement. Or it can also mean isolating the larger muscles you

want to strengthen. Isolation ensures that the correct muscles are stabilising and working to

perform the movement, so the desired outcome of the exercise is achieved.

8. Routine

Regular practice is essential to ensure the brain and muscles don’t forget the new patterns

of movements that are being taught each session, and to ensure gains in strength and

flexibility continue to progress. One session a week does provide some results, but nowhere

near the results that can be achieved if the frequency is increased. Daily practice is best.

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How Pilates works

Increases Core stability

To begin with, the main muscles that are targeted in Pilates are the core stabilising muscles of the

body. In the mat work repertoire this includes the stabilisers of the spine, pelvis and scapula: the

transversus abdominis and pelvic floor, multifidus, gluteal muscles, lower trapezius and serratus

anterior, and the deep neck flexors. The reformers also allow concentration on the stabilisers of the

more peripheral joint stabilisers, such as the rotator cuff for the shoulder and the VMO for the knee.

Once these core stabilising muscles are activated and isolated, we progress these exercises to

become more dynamic and functional, having to maintain stability whilst working the larger more

superficial muscles.

Total body conditioning

Pilates works on strengthening and toning the entire body. It is one of the most effective forms of

exercise to change body shape and tone up because it targets all of the muscles in the body.

Corrects muscle imbalances

In Pilates, we look at muscle imbalances from a whole body perspective. To put it simply, we aim to

strengthen any muscles which may be weak, and stretch any muscles which may be tight. Some

muscles may be tight because they are overactive and used too much to compensate for other

weaknesses; some muscles are tight because they are weak and as soon as they are used at all they

tighten up.

Potential muscle imbalance can occur between:

1. Small deep stabilising muscles and the larger/more superficial muscles eg. weak gluteus medius and minimus, overactive TFL

2. Anterior versus posterior muscles eg. weak hamstrings and tight overactive quads and hip flexors

3. Muscles on the right side versus muscles on the left side eg. weaker in all of the left leg, arm or abdominal muscles than the right

Once we determine any imbalances, we work on correcting them. This may mean working on the

deep stabilisers only until they are stronger, it may mean working on the hamstrings but not the

quadriceps until the hamstrings are stronger, or it may mean doing twice as many exercises on one

side than the other.

Improves posture

Pilates helps to correct posture through strengthening the postural muscles and correcting any

muscle imbalances. It also teaches and emphasises correct posture as this must be maintained

throughout every exercise performed.

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How is the Pilates approach different to traditional weights programs?

Pilates is similar to weights in that is a strength based exercise program, but in Pilates, correct

muscle activation and control is the focus – it is not all about the amount of weight lifted. Pilates

focuses more on the core muscles of the body – these deep muscles contract at a low level intensity

and need to remain activated to stabilise the body throughout an exercise. It is not necessarily a case

of the stronger the better – muscle control and activation are the aim. This is a very different

concept to a weights based strengthening exercise, for example a biceps curl – you are training the

strength of the bicep using a more intense or maximal contraction,

Pilates movements are usually more flowing, and there is an emphasis on correct posture

throughout the movements. With Pilates, the resistance is either body weight resisted or spring

resisted. It works on toning both the larger and smaller and muscle groups of the body including the

stabilising muscles, which are sometimes hard to target through weights. Pilates exercises can

rebalance muscles around the joints and balance strength with flexibility.

How the Pilates approach differs slightly to traditional physiotherapy programs

Pilates definitely follows on from the basic physiotherapy exercises, but it also works on

strengthening the entire body as a whole. For example, if a patient gets a sore lumbar spine when

they lift their baby, as physiotherapists we would normally address posture and core strength to

help this. In Pilates, we also strengthen the arms and the legs so that they don’t use their back as

much in the lifting process. Another example is someone who gets sore and tight upper trapezius

from carrying the groceries. We retrain scapula stability muscle recruitment, but also strengthen the

biceps to hold the groceries rather than hitching up with the upper trapezius. Also, we look at

postural patterns and assess which muscles may need strengthening eg the hamstrings for a

lordosis.

Whilst understanding the pathology of a particular injury is very important, we focus more on

posture, muscles imbalances, muscle recruitment, stability and movement patterns as Pilates

Instructors and the implications these have on the particular injury. One of the huge benefits of

Pilates to physiotherapy patients is not only are they doing specific exercises to correct their

problem, they can also have an all over body workout at the same time. A lot of patients become

globally weak since they can’t do much exercise without hurting themselves, so Pilates can be a safe

method for them. Also, when patients think they are doing Pilates and using the Pilates equipment

they are often more likely to continue on with their strengthening programs than if they are doing

normal physiotherapy exercises.

Observation is the key to being a great Pilates instructor – open your eyes. You should be able to tell

where a client will be tight, strong and weak just by looking at them whilst standing and also moving

through some simple tests and movements. If need be you can physically muscle test each muscle

but this takes time and you should become good enough at your observation skills that you don’t

need to manually test everything. If you are taking a large group mat class, your observations are

especially important as you will be visually assessing each participant’s movements and postures

very quickly as they are performing the exercises. Observation is also imperative to determine

correct technique is maintained throughout the exercises and if an exercise is too difficult or

inappropriate for a person.

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Posture

Correct posture

Correct Posture

In the ideal posture, the normal curves of the spine are present and the pelvis is in a neutral position.

Plumb line – runs through the ear, shoulder, hip joint, knee joint and just anterior to the lateral

malleolus of the ankle.

Posture diagrams taken from Muscles, Testing and Function by Florence Kendall, 1993 Williams and Wilkins

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Flatback (flattened arch in the lower back, bottom tucked under)

Head – slightly forwards

Cervical spine – slightly extended

Thoracic spine – upper thoracic spine has increased kyphosis, then is straight from here down

Lumbar spine – flattened (flexion)

Pelvis – tilted posteriorly

Hip joints – extended

Work on using a neutral spine for all exercises and keeping the tailbone down.

Muscles which are tight/need stretching Muscles which are weak/need strengthening

Hamstrings, rectus abdominus, pectoralis major

Iliacus, quadriceps, T-zone, all of the gluteals

Flatback posture

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Lordosis (increased arch in the lower back)

Pelvis - tilted anteriorly

Lumbar spine - increased lordotic curve (hyperextension)

Hip joints - flexed

May or may not be associated with an increased thoracic kyphosis

Muscles which are tight Muscles which are weak

Quadriceps, TFL, short adductors, psoas, other hip

flexors, lumbar spine erector spinae.

All of the abdominals, all of the buttocks but

particularly the hip stabilisers, hamstrings.

Work on promoting lumbar flexion throughout exercises, and hip extension without lumbar

extension. Focus on t-zone and obliques activation throughout all exercises.

Kyphosis-lordosis

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Kyphosis (increased arch in the upper back, spine hunched over forwards)

Head – forwards position

Cervical spine – hyperextended

Thoracic spine - increased kyphotic curve (hyperflexion).

Shoulder blades - protracted

Work on increasing thoracic and lower cervical extension, opening out the chest and drawing the

shoulder blades into the correct position.

A kyphosis can accompany a lordotic lumbar spine (kyphosis-lordosis as shown on the left), flatback,

scoliosis or swayback posture.


Pectoralis major and minor, lattisimus dorsi,

upper rectus abdominus, sternocleidomastoid.

Thoracic and lower cervical extensors, lower

trapezius and rhomboids, deep neck flexors.

Kyphosis

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Swayback (the pelvis is shifted forwards in front of the shoulders and ankles)

This is a common posture seen amongst people with hypermobility.

Head – forward position

Upper cervical spine - extended

Thoracic spine – long increased kyphosis with the thoracic spine shifted backwards so that it sits

behind the line of the ankle

Scapula – often protracted

Lumbar spine - usually flattened, sometimes with a short sharp lordosis in the last few vertebrae

Pelvis - tilted posteriorly and is shifted forwards so that it is sitting in front of the ankle

Hips - hyperextended

Knees - hyperextended and locked

Feet – pronated or flattened arches

Often have “no bum” – no size or strength in any of the buttock muscles

This posture is a habit and requires constant reminders to unlock the knees, shift the pelvis

backwards and bring the upper trunk forwards during all sitting and standing exercises.


Often not incredibly tight anywhere, but will rest

in this position due to weakness so they can

hang off their ligaments and not to have to use

stability muscles.

May be tight in hamstrings, pectoralis major and

latissimus dorsi.

All of the stabilising muscles in the body: all of

the buttocks, including gluteus maximus, the

obliques and T-zone, iliacus, lower trapezius,

upper thoracic extensors and deep neck flexors.

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Swayback posture

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Scoliosis (lateral curve of the spine)

Scoliosis is a lateral curvature of the spine, and may occur anywhere in the spine. The curves can be

a C shape curve or an S shape curve. The curves may be either fixed or postural. A fixed scoliosis is

due to a bony deformity in the spine, and can’t be corrected with exercise. Exercise however can

help prevent the curve from worsening and also help to reduce any symptoms. A postural scoliosis is

due to poor posture, differences in leg lengths and muscle imbalances. A postural scoliosis can be

helped with specific strengthening and stretching exercises.

An example of a postural scoliosis seen below: a thoracic/lumbar curve convex to the left:


Left latissimus dorsi and quadratus lumborum,

left quadriceps and left adductors

Right latissimus dorsi and quadratus lumborum,

right hip adductors, left gluteus medius , left

scapula stabilisers, transversus abdominus

Treatment would be aimed in this case at stretching down the left side of the torso and

strengthening the right, as well as working on pelvis stability and correcting any other muscle

imbalances that may be present side to side throughout the body.

Scoliosis

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Joint Hypermobility

When we are talking about hypermobility we are referring to a person’s inherent joint ligament

laxity, and the excessive movement that is allowed to occur in the joints.

Ligaments are responsible for stopping excess movement or translation within a particular joint. In

people who are hypermobile, their ligaments are more lax and have decreased tension in them. This

means that their joints become inherently unstable, and are more prone to developing pain and

injury. Often hypermobile patients have not only one but multiple areas of pain and injury

throughout their body.

For people who are hypermobile, the strength and activation of the stabilising muscles surrounding

their joints is very important, as the muscles are needed to help control this excessive range of

motion available at the joint. Pilates is the perfect form of exercise for hypermobile patients as it

works on strengthening all of the stabilising muscles in the body.

Some signs of hypermobility

Knees and elbows straighten beyond 0 degrees – they hyperextend

Flattened arches of the feet

Ability to pull the thumb back to touch the forearm

Elbows that hyperextend

Ability to bend forwards and place the palms of the hands on the floor

Hyperextended knees

Flattened arch

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Review of the stabilising muscles of the pelvis, spine and scapula

Its normal action functions to form a deep internal corset that acts to draw the abdomen in and

stabilize the spine during movement. This pattern of protection is disrupted in patients with low

back pain, and isolated strengthening of these muscles has been proven to reduce back pain.

(Richardson et al 1998)

Pelvic floor

The pelvic floor consists of a group of muscles which together form an internal sling which provides

support to hold the pelvic and abdominal organs in place, and also allows bladder and bowel control.

These muscles are continuous with transversus abdominus muscles, and activation of the pelvic floor

may help with activation of the TA.

www.merck.com

Transversus abdominus

Origin - the lateral third of the inguinal ligament, from the anterior portion of

the iliac crest, from the inner surfaces of the cartilages of the lower six ribs,

connecting with the diaphragm, and from the lumbodorsal fascia

Insertion – the fibres are orientated horizontally, and act like a corset around

the abdomen, inserting into the linea alba, in the middle of the abdomen and

onto the pubic bone. The upper ¾ of the muscle lies behind the rectus

abdominus, the lower ¼ lies in front of the rectus abdominus.

Function – the transversus abdominus is the deepest of the abdominal

muscles and is also a stabilizer of the spine. Support by this muscle is

considered to be the most important of the abdominal muscles and has also

been found to be in a weakened state in those who have chronic back pain or

back problems.

http://en.wikipedia.org/wiki/Inguinal_ligament

http://en.wikipedia.org/wiki/Diaphragm_%28anatomy%29

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Internal obliques

Origin – iliac crest, inguinal ligament and lumbodorsal fascia

Insertion – linea alba, xiphoid process and inferior ribs

Function – flexion and rotation of the spine, stabilising the back,

flattening the back and drawing the ribs down.

unilateral contraction leads to lateral flexion and rotation to that

side, bilateral contraction compresses the abdomen for stability

and breathing.

External obliques

Origin –anterolateral ribs 5-12

Insertion – iliac crest, inguinal ligament

Function – flexion and rotation of the spine, stabilising the back,

flattening the back and drawing the ribs down.

Unilateral contraction leads rotation to the opposite side,

bilateral contraction flexes the spine and draws the ribcage

towards the hips, and compresses the abdomen.

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Multifidus

Origin – sacrum, erector spinae aponeurosis, PSIS, iliac crest

Insertions – spinous processes of vertebrae. Some fibres span over two vertebrae, some over 3 or 4

vertebrae.

Function – controls segmental motion between each of the vertebrae, it is the only muscle that does

this, studies have shown a decreased strength of multifidus is present with back pain hence it is very

important for lower back pain rehabilitation.

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Iliacus

Origin- ilium, sacroiliac and iliolumbar ligaments, lateral sacrum

Insertion-lesser trochanter of femur

The iliacus fascia is continuous with the transversus abdominus fascia

Function of the iliacus – flexes the hip, holds the femur back in the hip socket, stops anterior

translation of the femur, stabilises the hip joint and SIJ at the end of stance phase. If the iliacus is

weak then the more lateral hip flexors will overwork to compensate and will become tight eg

sartorius, TFL and rectus femoris.

Deep hip rotators

Quadratus femoris – external rotation, stabilises the hip (by stabilising the femur in the hip socket)

Superior and inferior gemelli, obturator internus and externus – the “rotator cuff of the hip”, co-

contracts with gluteus minimus and the quadratus femoris to control translation of the femoral head

within the hip socket.

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Gluteus medius

Origin –gluteal surface of the ilium, under gluteus maximus

Insertion – greater trochanter

Function - stabilises the hip and pelvis laterally in single leg stance

Anterior portion – internal rotation, works with the TFL

Middle portion – abduction

Posterior/deep portion – externally rotates and abducts the hip

Gluteus minimus

Origin – gluteal surface of the ilium, under the gluteus medius

Insertion – greater trochanter

Function – deepest hip abductor, internally rotates the hip, prevents superolateral migration and

anterior dislocation of the femoral head (Beck et al 2000)

Gluteus maximus

Origin - gluteal surface of the ilium, lumbar fascia, sacrum

Insertion – gluteal tuberosity of the femur, iliotibial band

Function – upper glut max abducts and externally rotates the hip; lower glut max extends the hip

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Lower trapezius

Origin - spinous processes of vertebrae C7 to T12

Insertion – spine of the scapula

Function – scapula stability, depresses and retracts the scapula

Serratus anterior

Origin – lateral ribs 1-8 or 9.

Insertion – anterior surface of the medial border of the

scapula

Function – protracts and stabilises scapula, assists in scapula

upward rotation through elevation, hold the scapula against

the ribcage and prevents it from winging (see picture below)

Weak serratus anterior/winging (R) scapula

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Deep neck flexors

The deep neck flexor muscle group consists of the rectus capitis, longus capitis and longus coli

muscles.

Origin and insertions - These muscles run anteriorly over the cervical spine with attachments from

the skull to the upper cervical vertebrae, and from the cervical vertebrae to the upper thoracic

vertebrae.

Function – unilateral contraction leads to lateral flexion and rotation, bilateral contraction leads to

neck flexion and flattening of the cervical lordotic curve and works to correct a forwards head

posture in which the chin is poking out.

In many studies it has been demonstrated that weakness in the deep neck flexors is present in

patients with neck pain and headaches (Watson et al 1993, Jull, 2000) and that strengthening these

muscles helps to improve neck pain.

Fundamentals of Anatomy& Physiology, 7th Edition, Frederick Martini

http://upload.wikimedia.org/wikipedia/commons/7/7d/Longus_capitis.png

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Postural Assessment

Front view

Feet Decreased/increased arches Increased pronation/supination

May need orthotics or arch strengthening May need gluteal strengthening

Knees Locked/hyperextended Internally rotated VMO muscle bulk Lateral quad, TFL muscle bulk

Hypermobile, needs postural retraining May need orthotics, arch retraining and gluteal strengthening Weak VMO Will be increased if weak gluts, VMO and iliacus

Pelvis Rotated One hip higher than the other

Will need specific stretch/strengthen muscle round the pelvis May have leg length difference or a scoliosis, may have a tight lat/QL/psoas hitching one hip up

Ribcage Flared Compressed Symmetry

Weak oblique/s, tight lats and pecs Overactive obliques and rectus abdominus

Shoulders One shoulder higher/lower Arms internally rotated

Tight lat, scoliosis, tight upper trapezius, scoliosis Weak rotator cuff and scapula stabilisers, tight pecs and lats

Neck/Head Rotated or tilted to one side Tight neck muscles on one side or joint problems

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Postural Assessment - Back view

Feet Pronated Turned out/leg externally rotated

May need glut and arch strengthening and orthotics Compensation for pronated feet

Calves Muscle bulk/symmetry Large calves could be as a result of weak iliacus and weak glut on that side. Also due to swayback posture.

Hamstrings Increased muscle bulk and tone Weak gluteus maximus, flatback posture

Gluteals Decreased bulk upper glut max Increased bulk upper glut max Decreased bulk lower glut max

Weak gluts generally Compensating for weak deeper gluts Weak, common in swayback and flatback postures

Pelvis One hip higher than the other See above

Spine Scoliosis

Scapulae Winged Elevated Depressed

Tight pec minor, weak serratus anterior Tight upper trapezius Tight lats, ?weak upper traps

Muscle definition between scapula

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Postural Assessment - Side view

Neck Forward head position Weak deep neck flexors, tight upper cervical extensors and SCMs.

Pelvis/spine Anterior tilt/lordosis Posterior tilt/flatback Swayback – pelvis in front of shoulders and lateral malleolus ankle

Tight quads, hip flexors, erector spinae, weak abdominals, gluteals and hamstrings Tight hamstrings and rectus abdominus, weak gluteals and TA Often weak in all stabilisers, including all gluts, TA, iliacus etc

Thoracic kyphosis Tight pecs/lats, weak thoracic extensors and lower trapezius/rhomboids, may be fixed or postural

Scapulae Protracted Winging

Tight pecs, weak lower traps and rhomboids Tight pec minor, weak serratus anterior

Humeral head

Forward in shoulder socket Weak and or tight rotator cuff

Knees Hyperextended/locked Hypermobile, needs postural retraining

Feet Weight distribution over feet not too forwards or backwards

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Supine postural assessment

Sometimes is can be easier to examine certain postural positions when supine lying.

Pelvic position

Determine if there is an anterior or posterior pelvic tilt, lordosis or flatback. If the legs are down

straight does the lordosis increase (tight hip flexors)? Also look at the distance between the belly

button and the ASIS on each side – are they equal? If one ASIS is further out, it will often be more

difficult for the transversus abdominus to contract on this side. Often, this is due to a

tight/overactive TFL and superficial gluteal muscles and if you release these first by massage or

stretching then the TA will function better.

Neutral pelvic and spinal position Anterior pelvic tilt with lordosis

Ribcage position

Are both sides equal? Is the ribcage flared, normal or compressed? What happens to the ribcage

position as the arms are taken overhead? If the ribcage flares and elevates too much, is it because

the pecs and lats too tight, or the abdominals lazy and weak, or both.

The correct postures will become more evident after reading the Basic Pilates Principles section.

Now we have assessed their posture we have a fair idea where they are going to be tight and where

they may be weak. Let’s now look more in depth into muscle recruitment patterns; this will help us

to determine and understand why the client may be tight in certain areas and carry the specific

postures they have.

Good ribcage position

Ribcage “popping”

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Compensatory movement patterns – also seen as cheating patterns in exercises

Weakness Compensating muscles which may become overactive


Overactive/tight psoas and hip flexors, sometimes overactive in the more superficial abdominals to compensate

Gluteus minimus, medius and deep hip rotators

TFL, piriformis, upper glut max, lateral quads, VL and ITB on the same side and QL, lats and psoas on the opposite side

Gluteus maximus Overactive hamstrings, calves and quads, lumbar erector spinae

Serratus anterior Pec minor

Lower trapezius Lats, levator scapulae, upper trapezius

Deep neck flexors Sternocleidomastoid

Iliacus Overusing TFL, Sartorius, rectus femoris and adductor longus

A whole body approach

As you can see, the whole body compensates and is compromised when there is a weakness. A great

example of this is how pelvic instability can affect neck and shoulder problems and vice versa, here is

how:

The left gluteus medius is weak, so the right latissimus dorsi becomes overactive to help stabilise the

pelvis. It becomes very tight and depresses the shoulder and draws the shoulder into an internally

rotated position, causing shoulder problems. You can strengthen the muscles around the shoulder

girdle as much as you like, but unless you address why the lat is so tight you will only get so far. With

this shoulder now depressed, the upper trap and levator scapulae pull at their attachments on the

upper cervical spine and cause neck problems and headaches.

Conversely, shoulder problems can affect the lower back. If a person has weak scapula stabilisers

and tight pectorals and latissimus dorsi, these muscles will “flare” the ribcage, hence making it more

difficult for the abdominals to work, and leading to a sore lower back.

There are many more examples which we won’t go into now, but you can see how important it is to

look at the body as a whole when assessing posture, muscle imbalances and subsequent pain and

injuries.

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Feeling for muscle recruitment

Often it is helpful to feel for muscle recruitment as well as observe it. As some of the major muscles

we are feeling for are the buttocks and lower abdominal area, always take care not to offend people

or upset them, or make them feel uncomfortable at all in any way.

1. Ask them first if it is okay for you to feel their muscle activation and explain why it is

important that you do. Once you have their permission on the first session, they will expect

you to do this again in the future, but even so please tell them each time before you feel

their muscles “I am just going to feel for your buttock activation whilst you do this exercise”

etc.

2. Never feel lightly with your whole hand. Always press firmly, using either just fingertips or

thumb with no other part of your hand touching their body or use the heel of your hand

with no other part of your hand touching their body. Pressing lightly or grazing the surface of

the skin is much more likely to be seen in a more sexual way.

Quick tests for stability and muscle recruitment

Scapular stability/control standing

Have the client standing facing away from you. Get them to take both arms slowly forwards and

overhead up towards the ceiling, and then slowly return them back to the sides. Look and feel for

overactive upper trapezius or levator scapulae (watching for the muscles tightening too much or the

scapula hitching) poor lower trapezius control and poor serratus anterior control (winging).

Note: also watch from the side as the arms go overhead and observe the abdominal control to see if

there is a massive lordosis with the ribcage “popping out”. If this happens, it could be a sign of

abdominal weakness, tight pecs/lats or both.

Good scapula position Hitching scapulae

Losing the abdominals

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Gluteus medius/general hip stability function test

Have the client standing facing away from you. Get them to lift one other foot (bending the knee and

lifting the foot behind the body) whilst you observe and palpate what happens around the pelvis.

Check points:

Is the leg internally rotating, is the foot pronating?

Gluteal activation over TFL activation?

Is the pelvis staying level ie no Trendelenberg?

Even if the pelvis is staying level, this still doesn’t necessarily mean the gluteals are functioning

properly. They could also be cheating by laterally shifting the pelvis and whole body weight over to

that side to wind up the ITB stabilising mechanism. Or they could be using the opposite psoas, QL or

lat to hitch the hip up rather than using their gluteals. To determine these things it is often necessary

to put hands on the muscles to feel for activation as well as observe.

To challenge you may add in some single leg squats and hops. It is important to get them to do

several of these as some clients, particularly athletes, may have good stability for the first few but

poor endurance in these stability muscles which falter as they tire.

Good stability Bad stability-no compensation Compensation-hitch (R) hip

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Side lying gluteus minimus and gluteus medius activation

Lying on the side with the hips flexed to about 20 degrees, knees bent and a pillow between the legs.

Go to lift the leg slightly off the pillow (abduction) and observe/palpate which muscle initiates the

movement and lifts the leg. The correct order should be gluteus minimus, then medius, then as the

leg lifts further the TFL and superior gluteus maximus kick in to help out, but make sure the gluteus

minimus and medius do not switch off and that the TFL and upper gluteus maximus don’t take over.

Palpate just above the greater trochanter and behind the TFL to feel for activation of the gluteus

minimus and medius. If these muscles are not working as they should, then the first step before

strengthening them is learning how to activate them.

Exercise- lying on the above position, get the patient to think about going to lift the leg without

actually lifting it to firstly activate the gluteus minimus. Then progress to actually lifting the leg whilst

maintaining the correct muscle activation patterning.

Side lying quadratus femoris/deep hip external rotators activation

Lying on the side with the knees bent, hips flexed to 70-90 degrees with a pillow between the legs.

Press the top heel into the bottom heel slightly as if you were going to lift the knee. Palpate on the

line between the greater trochanter and the ischium to feel for quadratus femoris activation, it

should activate before the movement occurs and should stay active throughout the movement. In

this position, the quadratus femoris is the main muscle to externally rotate. If the quadratus femoris

activation is poor, then the first step before strengthening it is to learn how to activate it.

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Exercise – lying on the side in the above position, gently press the top heel into the bottom heel

slightly and feel for the activation of quadratus femoris whilst keeping the rest of the buttock

relaxed. Progress to actually lifting the knee whilst maintaining the quadratus femoris activation.

Sit to stand

This tests the gluteus maximus for hip extension and the hip abductors/external rotators for control.

Observe the patient moving from a sit to stand position and back to sitting. If the hips internally

rotate and the knees roll in then there is definite weakness in the external rotators of the hip (deep

stabilising gluteals). If this “rolling in” becomes more pronounced as the hips flex more, then it is the

deeper external rotators that are the weakest. Also watch for gluteus maximus activation to stand

up - a common pattern used is to posteriorly tilt the pelvis and use the hamstrings and quads to

stand up, or arch the lower back and use only the quads to stand up.

Neutral pelvis Posterior tilt Anterior tilt Internal rotation

Prone gluteus maximus into hip extension

This can be assessed by lying on stomach

and extending the leg.

Feel and observe for gluteus maximus

activation, poor patterns would include-

overusing the hamstring to extend the hip,

hyperextending the lumbar spine by

overusing the erector spinae and losing the

abdominal connection.

Note: if the client has very tight hip flexors,

they won’t have enough hip extension

range and the client will get to a certain

point through the movement where they

will have to extend through the lumbar

spine to compensate.

Good spinal position

Losing the abdominals/extending the lumbar spine

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Transversus abdominus and Oblique activation

Specific abdominal patterns

There are 3 distinct abnormal patterns for recruiting the abdominals that you will observe.

1. All of the abdominal muscles weak.

Implications: Start with TA activation, then the obliques then the rectus abdominus.

2. TA weak, obliques weak, overactive rectus abdominus.

Implications: Focus on TA and oblique activation initially without moving into flexion ie no

head lifting.

3. TA weak, overactive obliques and rectus abdominus.

Implications: Abdominal exercises will need to start off very basic focusing on relaxing the

obliques and rectus abdominus whilst achieving TA isolation. Once the TA activation

improves, more difficult abdominal exercises can be added provided the TA is working

throughout the exercise.

Asides from feeling the patient trying to do a transversus abdominus contraction or using a

real-time ultrasound, these are 2 very quick functional tests to assess TA function:

Good TA and oblique activation – pelvis stays still

Abdominal curl

Observe which muscles are working and the relationship between the TA, obliques and rectus

abdominus throughout a half sit up. The TA should be tight to keep the abdominal wall flat,

and the obliques should be contracting to curl the body up, not just using the rectus

abdominus.

Supine lying plus lift a foot

Lying on the back with the knees bent

and lifting one foot slightly - if the hips

rock or move a lot and the TA doesn’t

activate then the function is poor. You

can feel and observe if it is the

transversus abdominus that is letting go

or the obliques or both.

Letting the TA relax/bulging the stomach

Good TA and oblique activation

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Iliacus activation

Tests - lying on the back with the knees bent, flex the hip and see which muscles work to perform

the movement– the iliacus can be palpated just lateral to the femoral pulse and is the most medial

tendon of all the hip flexors. It should activate first and stay activated throughout the movement,

then the other hip flexors should kick in to help the flexion movement.

Throughout hip flexion, if the leg adducts, then the adductor longus is overcompensating; if it

internally rotates the TFL is overcompensating; if it externally rotates then the sartorius and rectus

femoris are compensating.

The test can also be performed sitting on a chair with the feet

resting on the floor, then flexing one hip as high as possible keeping

the body still. This tests more inner range flexion and an inner range

hip flexor weakness usually means a weak iliacus muscle.

Indications that suggest a weak iliacus

weakness detected in the iliacus lying and sitting tests

all hip pathologies

swayback postures

hip flexor cramps throughout tabletop position

a tendency to move into an externally rotated hip position when the legs are in tabletop

position.

clicking of the hip throughout exercises

If the iliacus is weak then basic activation exercises are often needed prior to strengthening.

Exercise – lying on the back with the knees bent, t-zone tight. Think about drawing the thigh bone

back in the hip socket, or imagine that you are about to lift the foot off the floor but don’t. Feel for

the iliacus activation, once it can activate well progress to holding the activation whilst lifting the

foot.

Iliacus activation exercise

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Assessment Guidelines

Questions

1. Do you have any current pain or injuries? If so ask more details about them.

2. Do you have any medical problems?

3. What are your reasons for doing Pilates and what goals do you want to achieve? Ie lose weight,

tone a certain area, strengthen a certain area, help an injury, improve athletic performance, increase

flexibility, improve posture are common responses.

4. What other exercises do you currently do and what have you done in the past? Have you done

Pilates before?

5. How hard do you like to work when you exercise?

Postural assessment

From side on

Front view

Back view

Supine position

Core stability assessment

Single leg stance test

Arms overhead

Half sit up

Lift a foot (for abdominals or iliacus)

Side lying glut tests – clam, clam in 90 degrees and straight leg raise

Prone lying hip extension

Supine position with legs down straight or arms overhead

Range of motion tests

Any area that is a problem test range of motion at the surrounding joints. You may also wish to

examine muscle lengths here eg touch toes to test for hamstring length and lumbar flexion.

Problem list/treatment plan

Formulate a list of weak muscles, tight muscles, postural type and then an exercise plan to address

those issues, taking into account their level of fitness, injury and goals.

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Basic Pilates Principles

Pelvic and spinal position

For each and every exercise, the specific optimal spinal position will be described. We talk about 2

distinct spinal and pelvic positions in Pilates: neutral and imprint. This describes the position of the

pelvis and lumbar spine in the sagittal plane.

Neutral spine

A neutral spine means that the normal curve of the lumbar spine is present. This should not be too

large or forced, or too small and flattened out. Every person’s neutral spine may look a little

different to the next due to different body shapes and sizes. A general rule to determine a neutral

pelvis is that when lying supine, if you draw an imaginary triangle between the pubic symphysis and

the ASIS on both sides, the triangle should be parallel to the floor. That is, the pubic bone should not

be higher or lower than the ASIS when supine. No tension should be felt in the lower back muscles –

if so, then move into an ever so slightly more imprinted position. It is more important to make sure

the abdominals can activate well and there is no tension in the lumbar area than it is to have

absolutely perfect alignment of the ASIS and pubic bone, as this will differ for each person anyway.

Imprinted spine

An imprinted spine refers to an ever so slight posterior pelvic tilt and using the abdominals to draw

the lower back slightly towards the floor. When supine, the pubic bone will sit slightly higher than

the ASIS. This does not mean posteriorly tilting the pelvis so far that the sacrum lifts off the floor –

the sacrum must always maintain contact with the floor, otherwise the transversus abdominus will

not work effectively. Every person’s imprinted spine will look different to the next, the distance

between the lumbar spine and the floor will be different for each person – the spine does not have

to be touching the floor.

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To find the neutral and imprinted positions

If the pubic bone is higher than the ASIS, then the pelvis is in a posteriorly tilted position. If it is

lower, the pelvis is in an anteriorly tilted position. Lying on the back with the knees bent, feet hip

distance apart on the mat. Tilt the pelvis anteriorly and posteriorly to get the feel of tilting the pelvis,

then find the neutral position and imprinted position.

General rules of imprint vs. neutral for exercises

Throughout our daily life, a neutral spine and pelvis is the optimum position to operate in, so it

makes sense to strengthen the muscles and perform the exercises with a neutral spine.

We prescribe either neutral or imprinted spine positions for each exercise specific to each individual,

and what suits their body best. For example, someone who has a large lordosis might be able to

activate their abdominals better in an imprinted position, whereas somebody with a flatback

posture needs to use a neutral spine so as not to over-activate their rectus abdominus. Someone

with a disc bulge will usually use a neutral spine as an imprinted spine requires slight lumbar flexion

which is contra-indicated for disc bulges.

However, as a general rule-

In all exercises performed when one or both feet are placed either on the mat or Pilates equipment in

a closed chain type of exercise, a neutral spine will be used.

In all exercises performed in an open chain situation whereby both feet are elevated off the floor and

unsupported (eg hundreds) an imprinted position can be used to help stabilise the spine. Once

abdominal strength is good enough to stabilise the spine a neutral spine should ideally be used.

In saying that, there are always exceptions to rules – check with each individual which position is

more comfortable, easier to activate their muscles in and causes no pain, and that is the position to

prescribe for the individual for the particular exercise.

Throughout the exercises, we will use the terminology neutral and imprinted spine. This refers to the

anterior/posterior pelvic tilt of the pelvis and the relative lumbar spine position in the sagittal plane.

The spine may be flexing laterally or rotating, but we still want to maintain the neutral or imprinted

spine whilst it is laterally flexing or rotating.

Posterior pelvic tilt

Anterior pelvic tilt

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Ribcage position

The ribcage position is very important in abdominal activation. Often the ribcage will want to “pop

out” – move forwards and open out and upwards, making it very difficult for the obliques to activate

to stabilise the spine. When supine, there should be a sensation of the ribcage resting gently on the

floor. Make sure the ribcage isn’t being pushed into the floor, and also make sure the ribcage isn’t

allowed to lift up away from the floor. Gentle oblique muscle activation is required to maintain

correct ribcage position.

We will discuss rib movement throughout the breathing cycle later on.

Shoulder blade position

The scapula position is also of upmost importance throughout every exercise.

The shoulder blades should drawing down and back and in towards the spine in “V” shape. At the

same time, concentrate on widening the shoulder girdle, laterally rotating the scapula out to the

side. The shoulder blades should sit flat against the ribcage so that the inferior part of the scapula

doesn’t “wing” out from the ribcage.

Good scapula position Squeezing too hard and high Winging scapulae

Good ribcage position

Ribcage popping out/lifting up

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(Note – do not squeeze the shoulder blades together as hard as possible at the back either as this

over-activates the rhomboids and upper trapezius. It should be a gentle activation and movement)

Even when the arms are lifting there should be a sense of the scapula drawing down and in and

rotating laterally, activating the lower trapezius and serratus anterior.

At the start of each exercise, we cue to place the scapula in the correct position with the scapula

stabilisers activated. If this is not done, then throughout the exercise tension in the neck and upper

trapezius area may be felt, causing neck strain. A lot of people have this bad postural habit of tensing

their upper trapezius whenever they are stressed, concentrating or trying hard, even if what they are

doing has nothing to do with the neck. You will sound like a broken down record at times, but

guaranteed this is the most common correction of all you will make throughout every exercise. It is

important to cue this at the start of every exercise, so that they start off the movement with their

shoulders in the correct position.

Neck position

The cervical spine should maintain its natural lordotic curve when lying, sitting or standing. This is

what we call a neutral position. In the neutral position, the head is back in line with the rest of the

body, the chin ever so slightly tucked in. Think of lengthening through the crown of the head and

lengthening the back of the neck.

If the person has an increased curve of the neck or a forward head position, they may require a

pillow under their neck to prevent it from hyperextending.

Throughout the exercises, we want the cervical spine to follow the movement of the thoracic spine.

If the thoracic spine is extending eg during the swan preparation exercise, we don’t want the neck

the overflex or extend either, it should be in a neutral position.

Neutral neck position Hyperextended neck position

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Neutral, overflexed and hyperextended neck positions

Chin Tuck Exercise Chin tuck

The deep neck flexors are responsible for maintaining the correct neck position.

Here is an exercise to practice deep neck flexor activation and correct neck alignment.

Lying on the back, gently tuck the chin in, imagine that you are lengthening through the crown of the

head and elongating the back of the neck. This is a very small movement, and should not be done

with maximal effort. Monitor the more superficial sternocleidomastoid (SCM) and scalenes. If these

fire or tighten, they are using the wrong muscles to flex the neck. Hold this gentle contraction for 15-

30 seconds, and repeat several times per day. This activation of the deep neck supporting muscles

should be carried out before lifting the head whilst performing abdominal exercises to prevent poor

neck postures and strain.

If the thoracic spine is flexing eg

during an abdominal curl, the neck

should gently continue on with the

line of the thoracic spine. We don’t

want the neck to hyperextend or

overflex throughout the movement.

Please note that the eye line is a very

important key to ensure correct neck

position and often a simple cue to

correct the eye line will correct neck

position. For example, when

performing supine abdominal

exercises and lifting the upper body,

look towards the knees rather than

the ceiling or feet to obtain the best

neck position.

A lot of people have a lightly forward

head position with the chin sticking

out. Prior to performing any exercise,

especially those involving lifting the

head up off the floor, it is important

to practice activating the deep neck

flexors.

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T-zone

We call the transversus abdominus and pelvic floor muscles collectively the “T-zone”. We do this

because it is quicker and easier than saying transversus abdominus and pelvic floor.

If you draw an imaginary horizontal line between the ASIS or “hipbones” this is a visualisation for the

TA. If you then draw a line from the centre of this line down to the pubic bone, this is a visualisation

for the pelvic floor muscle. These 2 imaginary lines form a T shape on the front of the pelvis, hence

the name T-zone.

T-zone activation exercise

To activate the T-zone, start lying on the back with the knees bent and a neutral spine. Think firstly

of the pelvic floor. Gently draw up the pelvic floor along the imaginary vertical line as if you were

trying to stop from going to the toilet. You should feel the muscles deep in the pelvic floor tighten

and draw upwards.

For men, another cue may be to think of drawing the testicles up towards the stomach. For women,

another cue may be to tighten the muscles in the vagina and draw them up and in as if to stop the

flow of urine.

Once the pelvic floor is tight, think of flattening the imaginary horizontal line in towards the spine,

and drawing the hipbones across towards each other along the imaginary line.

If you place your fingers just inside the hipbones (ASIS) you should feel the muscles tighten ever so

slightly underneath the fingers. You should feel like the muscles are drawing upwards, across

towards the centre and in towards the spine. Think of the t-zone as a corset for stabilising the torso,

when it tightens it pulls the area in slightly.

The rest of the abdominals should remain relaxed. There should be no holding of the breath. If the

person states that they are finding it hard to breathe, then they are probably using their obliques

The T-zone

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and not isolating the t-zone. The spine should remain neutral. The t-zone does not move or imprint

the spine, so if the spine moves or flattens then the other abdominals are activating also.

It can be difficult with some people to tell if they are activating correctly. You can feel with your

fingers and observe - you can watch to make sure there is no spinal movement or breath holding.

If you are still having difficulty in knowing whether the t-zone is activating or not, you can also use

real-time ultrasound.

Before we perform any movement in Pilates is it vital that the t-zone is activated. It is the basis of

every exercise we do and must be activated prior to commencing each exercise and held

throughout. It is therefore imperative to practice this activation before moving on to any other

exercises.

Different cues work better for different people –some prefer to think of the pelvic floor, others a

corset drawing the abdominals in, others drawing the hipbones towards each other along the

horizontal line. For some people if they can feel your t-zone working they get a better

understanding of how it should feel for them.

Some people find it easier to activate their t-zone in different positions. Some find it easier kneeling

on all fours, lying on their stomach, sitting, side lying, lying with the legs in tabletop position, feet up

on a chair rather than on the floor etc. It is different for every person, so if someone is having

trouble activating the muscles try using different positions. Sometimes their t-zone activates better

once you actually get them to perform a movement or exercise better than when they just lie there

and concentrate on tightening it.

Oblique lines

For those that have difficulty activating their obliques, or can activate one side but not the other, it

can be useful to use the imagery of oblique lines.

These imaginary lines can be from the ribcage straight down to the ASIS to on the same side, or from

the ribcage to the opposite ASIS. Whilst performing the exercises, observe what the ribcage and

pelvis are doing on each side and check for the obliques connections as well as the t-zone.

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eg During leg slides of the right leg, you may need to focus on drawing the right ribcage towards the

right ASIS to prevent the lower back from arching.

eg During single leg circle on the left leg, you may need to focus on the drawing the left ASIS towards

the right ribcage along the oblique line and also the t-zone to prevent the pelvis from rocking.

eg. During oblique curls, you may need to focus on the left ribcage drawing towards the right hip if

the left external oblique is not working enough.

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Breathing

Technique

As you inhale, if you direct all of the breath low down into the abdominal region the abdomen will

then have to expand and the abdominals will not be able to activate as well, leaving the back

unprotected throughout the exercise. If you take a shallow breath and direct the breath into the

upper chest, the neck and shoulder accessory breathing muscles will be working too hard.

As you exhale, concentrate on using the exhalation to increase the abdominal connection. Avoid

exhaling forcefully and quickly, depressing the ribcage too much otherwise this will cause a bearing

down effect and strain on the pelvic floor, and cause the pelvic floor to deactivate.

Correct exhalation pattern

Correct inhalation pattern – bibasal expansion

Incorrect inhalation pattern – abdominal breathing

EXHALE through the mouth

and concentrate on closing

the ribcage and activating the

transversus abdominus and

obliques.

INHALE through the nose,

directing the breath into sides

and back of the ribcage.

Concentrate on really feeling

the sides and back of the

ribcage expand (bibasal

expansion).

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General Breathing Rules

INHALE to prepare and tighten the t-zone

EXHALE as the movement is performed, exertion is needed and the abdominals are required to work

their hardest to stabilise.

Reasons for this rule:

Research has proven that the pelvic floor works better and is easier to activate whilst inhaling. This

also encourages the start of the transverses abdominus and multifidus activation at this time. As you

exhale, the transverses abdominus and obliques contract to increase intra-abdominal pressure and

stabilize the torso. Transversus abdominus seems to be the major contributor in generating

abdominal expiratory pressure during a progressive expiratory effort (Misuri et al 1997). This

breathing pattern helps with the correct order of recruitment of the core stabilising muscles – pelvic

floor, then transversus abdominus first, then obliques.

Also, if you inhale on the effort or hold the breath throughout the effort, this places an increased

strain on the cardiovascular system and can increase the risk of incidents such as heart attack and

stroke in predisposed individuals.

This rule of exhaling when the most effort and stabilisation is required is carried through most of the

exercises, so you should be able to remember the breathing pattern of most exercises by following

this basic rule.

However, there are a few exceptions to this rule, for example when lying prone and lifting the torso.

As you inhale, the ribcage opens up and out and the spine extends slightly. For this reason, some

prone lying exercises which include lifting the torso through a large range of extension use a breath

in to facilitate extension. However, an exhalation may sometimes be used in this position to

maintain abdominal connection to control the spinal extension.

Also, in certain exercises the breathing patterns may be different as there is effort and abdominal

activation being exerted throughout a whole series of complicated movements, so the breathing has

been determined to best fit the particular movement series. The breathing is proven, tried and

tested to improve the abdominal contraction and the ease and effectiveness of each exercise when

performed in the correct manner.

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How pedantic to be about breathing, corrections and progressions – t-zone, imprint and neutral,

neck position and shoulder blades and muscle activation

It is of utmost importance that the posture and muscle recruitment for each exercise be correct to

achieve the desired result from the exercise. This is especially the case when dealing with a client

who has an injury or pain, as incorrect muscle recruitments and postures can make their problem

worse or even hurt them.

Most clients will get very sick of hearing your nagging voice telling them to fix this, they are cheating

with that etc. Sometimes for this reason it is okay to let a few minor imperfections slide. Make sure

you are always correcting the major points that are necessary to achieve the desired outcome of the

exercise, and anything that may cause injury. Correct those first, then choose whether or not to

correct the not so important ones. For example, when doing side lying gluts, it is very important to

correct the pelvis position, and to make sure they are activating the gluteals correctly; not as

important to make sure their neck is in perfect alignment. But if the client has neck problems, then

correcting the neck position is very important. So it is best to use your judgement. If you follow the

cueing formula and explain all of the setup points before you start and keep cueing the important

points as you go, you will not need to make anywhere near the amount of corrections.

You will find though that a lot of clients want to work hard on their first session, even though they

can’t do the basics properly. It is therefore very important to explain why they can’t do anything

more difficult until they master the basics. Give them home exercises to practice the basics so that

on their second session they will progress. It is good however to give them a small taste of a more

difficult exercise that is safe to do they can feel working eg side lying buttock series so that they

realise it won’t just be lying still and just trying to tighten their muscles forever more.

As far as the breathing is concerned, correct breathing patterns are beneficial to achieving the best

result from an exercise. There is a lot to think about throughout the exercises, so if the breathing is

too confusing for them, make sure they get the movement and muscle activation correct first, then

add the breathing in afterwards.

We have written certain prerequisites to achieve before attempting each of the exercises in this

manual. In saying this, it is quite surprising how many times a client can perform a more difficult

exercise better than a supposed easier exercise. It is best to follow these basic manual guidelines,

but remember that each individual will be different and it always best to assess each individual doing

different exercises to determine what works best for them.

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Speed at which exercises are performed

The basic rule is to only perform each exercise at a speed at which the movements are controlled

and correct muscle activation can be maintained.

So initially, whilst learning the exercise/movement, the movement may be very slow. The client may

even need to stop after each repetition to reset their t-zone and posture. A progression from this

would be to increase the number of repetitions before having to stop and reset the body, then also

increase the speed at which the movements are performed.

Eventually, we want the movement patterns and correct muscle activation to become so natural

that they can perform the movements correctly quite quickly and without too much conscious

thought, as this is what needs to be achieved in everyday life.

Carry- over into everyday life

It has been proven that a specific pattern of movement needs to be performed many times before it

becomes automatic, and up until this point conscious thought is needed to perform the correct

movement. This means that the client will need to consciously think about holding their correct

postures, muscle activation and movement patterns for a long time before it becomes automatic.

A common scenario: you are so proud of your client as they have just done a whole hour session

with beautiful posture and muscle activation. Then they walk over to the counter to pay, all slumped

over in a terrible posture. Here lies the biggest challenge: actually making sure what they are doing

and learning in their Pilates sessions they apply to their everyday life. For them, this means always

thinking about their posture, tightening their t-zone, shoulder blade position etc when they are not

at Pilates. You will need to explain this to them and constantly remind them of this, otherwise all the

good work you are doing with them goes to waste. Remember, eventually it will become automatic,

but in the meantime they really have to concentrate on it.

To help the carry-over into everyday life, you can use specific examples such as “see how we tighten

the t-zone before we move, this needs to be done each time before you lift your child” or “this

exercise strengthens your buttocks, remember to use your buttocks when you sit to stand or walk up

steps” or “remember to keep those shoulder blades down whilst you are sitting at your desk”.

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Learning modalities

You can be the most knowledgeable Pilates instructor in the world, but unless you are good at

actually teaching the clients how to perform the exercises then this is of no use to you or them. It

can be very frustrating for both the instructor and client when they can’t understand how to

perform an exercise. When this happens, it is very easy to blame the client for their lack of listening

and observation skills and co-ordination, but really we should be looking at ourselves for not

teaching the exercise well enough to them in a way that they understand.

There are 3 different methods to how people learn – visual, auditory and kinaesthetic. Every person

is different and will respond better to some types of learning than others.

Visual learning - this is the most common type of learning that people respond to. They find it

easiest to watch someone performing the exercise, and then they copy the movements. This is why

demonstration of the exercises is very important. You can use arm and leg gestures without having

to actually perform the whole exercise lying down.

Auditory learning – this is type of learning whereby people will listen to what you are saying, listen

to your descriptions and follow your instructions. For these people, a step by step verbal cueing of

the setup, breathing and movements is very beneficial.

Kinaesthetic learning – this is the type of learning whereby people learn from feeling how it should

be done and actually doing it. These people will need to know what it should feel like, where they

should be feeling it, then actually perform the exercise a few times to know what they are doing.

They may benefit from feeling you perform the movement eg feel you tighten the t-zone. They may

also benefit from having you hold onto their limb/body and place it in the right position or move it

for them the correct way so they can feel how it should be done.

So when teaching an exercise you should cover all learning bases. You should first demonstrate the

exercise, whilst at the same time talking them through the movements and also explain what they

should feel happening and where they should feel it. Then once they are performing the exercise,

continue with the verbal and kinaesthetic cues to obtain the best result. In a mat class setting, this is

the best method to follow. In a studio setting however, if you get the client to stand up off the

reformer after each time they have finished an exercise so that you can demonstrate the next

exercise, they will not get anything done, and will get sick of getting up and down! For the more

advance repertoire, you will usually need to demonstrate the exercise yourself. But for the basic and

intermediate exercises, you can use arm gestures, get the client to watch the client next to them if

they are doing the same exercise, and use excellent verbal and kinaesthetic cues to guide them. If

they still can’t get it, then get them to stand up and demonstrate the exercise yourself.

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There a few reasons therefore why the verbal cueing is so important. One is the above reason,

demonstrating the exercise is not always practical. It does take up time, but also there may be

exercises that you are not strong or flexible enough to demonstrate, so you need to be able to talk

them through it. Also, once the clients are performing the exercises, they are not looking at you

anymore, so you need to be able to talk them through what they are doing. If your verbal cueing is

great, you can correct people’s mistakes without actually going over and touching them. In a studio

setting, you can be across the studio with a client and call out to another client to make corrections

and also to explain what the next exercise is. For this reason, we have developed a verbal cueing

formula to help you deliver the best verbal cueing for your clients.

Cueing Formula

Name of Exercise

What and/or Where it works

The Set up

T- Zone

Breathing & Movement

Permission to Continue

Concentration Points

Corrections/Common Mistakes

The Challenge

Encourage & Inspire

Remind & Recycle

All in demo and first

two reps

Recycle these points

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Name of exercise

An important tool which makes your instructing life easier. If you state the name of the exercise

before you do it each time, eventually you will just be able to say the name of the exercise and they

know what they are doing. This doesn’t mean you get out of cueing though - you can just focus on

the concentration points rather than explaining the whole exercise from scratch.

What and or where it works

For example, “this works the abdominals”. This gives the clients the knowledge of where they should

feel it before they even start so they can concentrate on that area, and also helps them understand

more about their bodies and how each exercise can help them.

The set up

This is absolutely vital to the performance of the exercise. If the setup is not right from the start,

they will never be able to perform the exercise correctly. Even if you are taking a client who knows

what they are doing, still remind them of the key points of the set up eg remember keep a gap

between the waist and the floor.

T-zone

It is very important to cue to activate the t-zone before they start any movements. Otherwise they

will do several repetitions without it on, and it can be difficult to activate once in the middle of an

exercise.

Movement

Try to think step by step the order in which you need to recruit the muscles and move the body, and

systematically verbalise this. In this manual we have written the cues which after taking tens of

thousands of clients we have been found to be the most effective in getting the message across to

help you with your cueing.

Breathing

Make sure you describe the breathing for each movement and continually remind people

throughout the exercise so that they don’t hold their breath or get the breathing patterns mixed up.

The concentration

It is very important to give the clients something to concentrate on. In a class setting this will be

general, such as “focus on the t-zone and drawing the ribs to the hips using the abdominals” or

“focus on using the buttock to lift the leg and not letting the body roll backwards”. In a studio or

smaller group setting the concentrations can be more specific to each individual, such as “Mary

focus on drawing up the pelvic floor more” and “John focus on keeping the hips still and lifting your

leg as high as possible”. Even if a client can perform the exercises correctly without cueing, still give

them a focus point that will make them work harder.

Corrections

Remember, the better you perform the cueing formula up until this point the fewer corrections you

will have to make. The actual corrections you make are very important, but also the way that you say

them is important. Corrections can be made in the form of a concentration point such as “focus on

keeping your tailbone down” or it can be made as a direct correction eg “John your tailbone is lifting,

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keep it down”. Generally, using the concentration point is positive and it sounds much nicer than

continually telling somebody they are doing it wrong, but sometimes you do have to tell them what

their mistake is. When making a correction, you will need to tell them how to make the correction.

So rather than just saying “don’t arch your lower back” it would be better to say “keep your

abdominals tight and only take your leg as low as possible so as not to arch the lower back”. Once a

specific correction has been made, ensure you compliment them on that so they know they have

achieved the desired correction and feel good about it. You should also verbalise the most common

mistakes that happen with each exercise so the client knows what not to do as well as what to do.

This will pre-empt the mistakes and make the client feel better.

Permission to continue

Once you have finished explaining the exercise and the clients are performing it well, all corrections

have been made and all key points said, then you can give them permission to continue so that you

don’t have to keep saying inhale and ...... exhale and ..... for each movement. Often if you don’t give

them permission to continue, as soon as you stop saying inhale and exhale and describing the

movement the clients will stop the exercise. So you could say something like “and continue,

breathing out as you curl up and keep concentrating on tightening your t-zone as you go”. It is best

to leave them thinking about one or more of the concentration points.

The challenge

Give clients the option to make the exercise harder or to push themselves that last 10%. There are 2

ways to increase the challenge of an exercise:

By giving a more difficult modification for the same exercise eg “to make this more

challenging, perform the exercise with the legs straight legs”

By telling them to extend further or higher, stretch further and elongate, or raise up higher

eg “to make this more challenging, lower the legs closer to the floor” or “make the circles as

large as possible keeping the pelvis still”

Remind and recycle

Even though you have verbalised all of the key points once, you can’t assume that the clients will

remember to do them throughout the whole exercise as there is a lot to remember and think about.

Important things to keep reminding them of is where they should be feeling it, their t-zone

activation, and their postural points such as neck and shoulder blade position and pelvis and lower

back position.

Encourage and inspire

The difference between an average class and a great class is the encouragement, enthusiasm,

motivation and inspiration that the instructor provides the participants. Especially for those who

have been coming for awhile, they could do a lot of the exercises at home but choose to do a class

for the above reasons. Encouragement is especially important as a lot of the class we spend “picking

on” their posture and technique, so it is necessary to encourage and compliment when they do a

good job too. Your enthusiasm levels do wear off on the class participants and they will try harder

and be more motivated to do a better job if you are inspiring, and also they will be more likely to

keep coming back for more classes.

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It is important to ask questions and also observe the participants to determine how they are going

with a particular exercise.

Questions to ask – where are you feeling it and how much are you feeling it work or stretch?

Note: When taking a larger group class, you will not be able to ask every person the questions, so

rather than asking the questions, keep reminding the class where they should be feeling it work and

where they shouldn’t.

An example of this would be “You should be feeling it in your abdominals, not your neck. If you are

feeling it in the neck, remember to draw your shoulder blades down and back, relax the head into

the hands, keep your chin tucked in and use the abdominals rather than the neck to draw you up”.

It is important to note that Pilates exercises should never cause or exacerbate any pain or injuries.

Some exercises will feel like they are working and stretching the muscles quite strongly, but there

should never be any pain felt through the back, neck or any other joints.

Observations - look out for signs of fatigue or pain – these include:

losing technique

starting to use cheating/compensatory movements

facial strain

tensing the rest of the body including feet, hands and neck

grunting and groaning

uncontrollable shaking of the muscles.

Note: in a class setting if you notice that someone is losing their neutral spine for example, remind

everyone to keep their abdominals tight to keep their neutral spine, and then say “If you are getting

too tired to maintain your technique then rest for a moment, then join back in”.

Approved words to describe movements

Incorrect Correct

Push Press

Pull Draw

Drop Lower

Kick Extend

Other useful words:

Raise, slide, slowly, control, ceiling, circle, left, right, up, down, place, curl, straighten, bend

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Descriptive sentences

as you.....

eg breath out as you curl the ribs to the hips

or flatten and scoop the abdominals as you curl up

keeping the.....

eg reach the arms forwards, keeping the shoulders down and back

or slide the arms and legs out, keeping the abdominals tight and the spine imprinted

Use the ______ to.....

eg use the side of the waist to raise the legs

or use the t-zone to stop the hips from moving

Do .....(action) to .....(achieve another action)

eg press through the heels to press the carriage away.

or squeeze the buttock to hold the leg up

To put it all together:

Exhale as you curl the ribs to the hips, lifting the head and shoulders, inhale as you return back to

the mat. Exhale and curl up, keeping the t-zone tight, inhale and control it back down. Continue and

really use the abdominals to slide the ribs to the hips, keeping the neck and shoulders relaxed.

Concentrate on the t-zone tight to flatten the abdominals. Shoulder blades draw down and back,

keeping the head relaxed into the hands and the chin tucked in.

Occupational Health and Safety as an instructor

Never demonstrate an exercise that is too difficult for you to perform or is contra-indicated

due to a particular injury you may have and may cause injury to yourself.

Bend from the knees rather than from the back to get down to the mat to check client’s

techniques. Also, if staying in that position for some time, either sit or kneel rather than

bending over.

Make sure you pick up stray materials off the floor that either you or clients could trip over.

Follow the guidelines for exercises prescription and carefully monitor client’s responses to

exercises.

Say the Mat Class Preamble (written below) to your class before each and every mat class

you take, or modify it to suit a small group or individual session.

Never take more than 20 people per mat class (non-injured general exercise class)

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Studio Pilates International® Class Preamble

Get everyone seated on their mat.

Welcome everyone to your Studio Pilates class, my name is _____ and I’m your instructor today. Is

anyone new to the class...? Great, welcome to those that are new and those that have been here

before, we will go over the basics quickly and then get started. If you have any questions, please feel

free to ask along the way or simply ask me at the end of the class.

Please remember that this is a workout class and not an injury rehabilitation class. You must always

work within your limits, some exercises may have different levels and it is important to choose the

level that’s right for you. Level -1 is always the easiest and please remember, you may rest at any

stage throughout the workout if you need to.

You will the feel the muscles working in your class today but you should never feel any pain in the

neck back or any of the joints. If you do experience pain, either choose an easier level, or stop the

exercise and simply wait for the next one.

There will be several exercises with the head and shoulders lifting off the floor. If the neck is

straining then please place a hand behind the head to support the neck or simply keep the head on

the mat.

Pilates is not a competition. Please don’t feel the pressure to perform each and every exercise and

please don’t compare yourself to the person next to you as they may have come 100 times before so

please work at your own pace.

I’ll demonstrate some of the exercises as we go along; please do the exercise with me as I

demonstrate to speed things up.

I’ll give you the breathing patterns for each exercise as we go along, the breathing is in through the

nose - refocusing the breath into the upper chest- and out through the mouth. Please use the

breathing to maximise the effectiveness of each exercise.

We have what’s called a neutral and an imprinted spine position when lying on our back. Neutral

spine refers to keeping the natural curve in the lower back. Most of your exercises however you will

do in the imprinted position especially when lifting the legs into tabletop.

The spinal imprinted position simply refers to each one of the lower backbones drawing as close as

possible towards the mat without lifting the tailbone off the mat, and you’ll hear me refer to these

positions through the class.

Ok, let’s have a practice of the spinal positions. I’ll get you lying on the back with the knees bent. I

want you to place your fingers underneath your kidneys and you should feel a small space between

the floor and your back. I now want you to flatten the lower back slightly, keeping the tailbone on

the floor.....good.

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We also have what’s called the tabletop position....this is simply when the legs are bent up to 90

degrees in a tabletop position. Let’s give this a go...great.

Next is the T-Zone and is short for the transversus abdominus and pelvic floor, deep stomach

muscles that stabilize the lower back and flatten the stomach...so good ones to strengthen.

Imagine you have the letter T drawn on the surface of the stomach. The horizontal line of the T

connects both of the hip bones and the vertical line of the T starts at the pubic bone and comes up

to meet the horizontal to form the letter T. (gesture with your hands)

OK, to activate and feel for the T zone, simply place the fingertips just inside the hip bones and now I

want you to focus on activating the vertical axis of the T by drawing up through the pelvic floor as if

you are stopping from going to the bathroom, hold this, and then focus on the horizontal line of the

T drawing flat and tight towards the mat or the spine. You can also imagine the hip bones drawing

towards each other along that line also.

Repeat and explain 1-2 more times

You may feel some tension under the fingers when the muscles engage and then disappear when

you relax, if you can’t, don’t worry as you’ll gain in strength and the more you practice it the

stronger it will become.

What I don’t want to see is that horizontal line popping outwards or upwards. You must concentrate

on keeping that T Zone flat especially when we’re lifting the head and working our abdominals and

remember to tighten and flatten the T zone each time I remind you as this is one of the most

important parts of your Studio Pilates workout.

Now let’s use these principles for your first exercise:

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Pain and injuries

Chronic vs. acute pain

Acute pain is a short term pain that is a direct result of an injury or trauma to the body, the pain is

often severe initially and the area may be inflamed, then this generally subsides over time as the

inflammation settles and the healing process takes place. The best response to an acute pain is RICE

(rest, ice, compression, elevation) and referral to a doctor or physiotherapist when required. After

the initial inflammation and pain starts to subside, then a gentle program of Pilates exercises will be

beneficial in the rehabilitation of the injury. You may need to liase with and follow the guidance of

the doctor/physiotherapist.

Chronic pain is a longstanding pain that lasts for over several months. Chronic pain may result from a

previous injury which has long since healed. It may have an ongoing cause, such as poor posture,

muscle weakness/tightness, arthritis, cancer, nerve damage.

After an acute injury, there may be muscle inhibition and spasm, and protective postures and

movements may be adopted in response to the initial pain. After the injury has healed, if the

subsequent poor postures and movement patterns, muscle tightness and weaknesses are not also

corrected then a chronic pain cycle may result. Pilates is a great way to target chronic pain as it

corrects the ongoing factors that may be perpetuating the pain.

Common Lower Back and Neck Problems

Osteoarthritis

Osteoarthritis (OA) is one of the most common types of arthritis. It is a degenerative disease that

affects the cartilage in the joints. Cartilage cushions the ends of bones, where the bones meet to

form a joint. Current belief is that OA is caused by changes within the cells of the cartilage. This

results in a loss of elasticity and gradually the cartilage thins and may even breakdown. This leaves

the ends of the bone unprotected, and the joint loses its smooth functioning.

OA most commonly occurs in the fingers and weight-bearing joints, including the knees, feet, hips

and the spine. OA can be detected through an x-ray.

Symptoms include pain and stiffness in the joints, usually this gets better as the body gets warms up

and the day goes on. If severe, the arthritis in the spine may compress the nerves as they exit the

spine and cause sciatica if the lumbar spine is involved or neural symptoms in the arms if the neck is

involved.

OA – Implications for Pilates

Pilates is great for OA as it mobilises the spine and restores movement, whilst strengthening the

muscles which support the joints. If there is nerve involvement ie sciatica, then no spinal extension is

allowed as this will compress the nerves further.

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Pelvic and lumbar spine instability

In patients who are hypermobile, they can be quite unstable in their joints, and their pubic

symphysis, sacroiliac joints (SIJ) and lumbar spine can all be affected. The increased movement

available at each of these joints may cause pain.

The treatment for pelvic instability is to strengthen all of the stabilising muscles of the hips, pelvis

and lower back, correct any postural problems and muscle imbalances from side to side. Instability is

common during and after pregnancy as the ligaments become more lax at this time.

Postural neck pain and headaches

Postural neck problems - Implications for Pilates

Correction of the posture and muscle imbalances over time usually eliminates all symptoms. A whole

body approach is necessary as poor posture starts from lower down in the body. Sitting posture is

very important to correct as people will spend 8 hours a day slumped forward over a computer at

work with their head jutting forwards, creating most of the problems.

Throughout their Pilates sessions, take care to maintain the correct posture of neck and shoulder

blades at all times and that the neck remains relaxed. Limit or avoid lifting the head during

abdominal exercises and use pillows to support the neck

Typical poor sitting posture

A lot of neck pain and headaches originate from

poor posture, namely an increased kyphosis in the

thoracic spine and a forwards head posture

(increased cervical lordosis). This places the neck

joints and muscles under great tension, causing

pain and stiffness in the neck and also causing

headaches.

There is often a weakness in the stabilising muscles

around the neck and shoulders, including the deep

neck flexors, lower trapezius and serratus anterior.

Subsequently there are often tight muscles with

painful trigger points in the other muscles that are

overworking.

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Acute Wry Neck Acute Wry Neck is the sudden onset of severe neck pain accompanied by spasm of the neck muscles, causing the neck to bend or twist away from the painful side. This common deformity, which usually occurs on one side of the neck, is a protective reaction of the body to safeguard the neck. An acute wry neck is usually caused by facet joint dysfunction whereby the facet joints “lock”. It occurs often after moving the neck very quickly or upon waking after sleeping with the neck in an unusual position. Symptoms include:

Sudden onset of sharp unilateral localised neck pain.

Can be severe pain however it doesn’t usually extend below the shoulder.

Fixed neck deformity, usually holding the head bent to the side and turned away from the painful side, this is unable to be corrected due to joint being ‘locked’.

Neck movement triggers the pain.

Tender and tense musculature.

Impaired mobility of the back of the neck. Treatment includes rest, heat and massage to relax the muscle spasm. Usually within a few days the pain and symptoms have subsided, if they haven’t then some treatment in the form of joint mobilisation is helpful. Acute Wry Neck - Implications for Pilates Initially, depending on how bad the symptoms are, it may be difficult for the patient to even move from lying to standing. If symptoms are very bad, then a Pilates session will be too uncomfortable, so wait for a few days then resume Pilates. If the symptoms are not severe, then the patient may be able to do a modified session with absolutely no head lifting and using pillows to support the neck. The neck will be sensitive for some time after this, so caution must be displayed for quite some time. Gentle neck stretches and exercises can resume only as pain allows.

Muscle strain

Most commonly, patients who develop a muscle strain in the neck or back are doing an activity that places them at risk. This may be a sudden forceful movement, lifting a heavy object, or twisting the back in an unusual manner. Most lumbar muscle strains and sprains cause symptoms isolated to the lower back or neck, usually they do not cause problems in the legs or arms like some other more serious spinal conditions. The most common symptoms of strain are:

Pain around the low back and upper buttocks, or the neck and shoulders

Back or neck muscle spasm

Pain associated with activities, and generally relieved with rest

Muscle strain - Implications for Pilates

Allow the area to rest, then start on a gentle program to regain strength and mobility as pain allows.

Education regarding correct posture and lifting techniques is helpful to prevent reoccurrence.

http://orthopedics.about.com/cs/backpain/ht/lift.htm

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Disc problems

Degenerative disc

As we age, our spinal discs break down, or degenerate. These age-related changes include:

The loss of fluid in the discs. This reduces the ability of the discs to act as shock absorbers and makes them less flexible. Loss of fluid also makes the disc thinner and narrows the distance between the vertebrae. As the space between the vertebrae gets smaller, there is less padding between them, and the spine becomes less stable.

Tiny tears or cracks in the outer layer (annulus or capsule) of the disc. The gel like material inside the disc (nucleus) may be forced out through the tears or cracks in the capsule, which causes the disc to bulge, break open (rupture), or break into fragments.

Disc bulge – also known as a disc protrusion, this is when the outer part of the disc remains intact

but the gel like substance of the disc bulges out against the back wall of the disc, and may or may

not press on the spinal nerves

Ruptured disc – also known as prolapsed or herniated disc, this occurs when the outer layer of the

disc ruptures and the inner gel like substance of the disc squeezes out and usually compresses the

spinal nerves.

Disc problems most commonly occur in the lower lumbar spine but can also occur higher up and in

the neck.

Disc problems are usually diagnosed via a CT scan or MRI.

www.patient.co.uk

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Causes

Disc degeneration and ruptures may be as a result of an acute injury, usually involving bending over

and lifting heavy objects, or from repetitive strain on the discs from repeated flexion movements.

Disc bulges and ruptures are more likely to occur from a degenerated disc as it is more likely to

rupture when is has lost some of its elasticity. And conversely, disc degeneration is likely to occur

once a disc has ruptured.

Symptoms

Initially, severe pain, limited movement and muscle spasm are all symptoms of a disc bulge. Pain is

often worse with flexion or prolonged sitting. If the nerves are being compressed then there will also

be sciatic nerve symptoms which include pain into the buttock or leg, altered sensation of the leg,

pins and needles or numbness in the leg, weakness in the leg muscles.

Disc Problems - Implications for Pilates

AVOID FLEXION, FLEXION WITH ROTATION AND PROLONGED PERIODS OF SITTING.

Flexion causes compression of the disc anteriorly, which forces the contents of the disc posteriorly,

causing more pressure on the disc bulge and spinal nerves. Flexion coupled with rotation is the worst

possible position to place the spine in when there is a disc problem.

Sitting causes an increased pressure in the discs, so initially choose exercises that are performed in

lying or standing positions.

Neck disc bulge – no head lifting with abdominals, maintain a slight lordosis in the

neck/neutral spine at all times.

Lower back – no bending forwards, roll ups etc, pelvic curl ups, and maintain a neutral spine

throughout all exercises, do not use an imprinted spine.

Pilates management of a disc bulge includes focusing on improving the stability and strength of the

muscles around the area and correcting any muscle imbalances that may be present. Often the

patient will be under the guidance of an orthopaedic or neurosurgeon, doctor or physiotherapist. A

patient with a disc bulge that is not compressing any nerves can be pain free once their strength and

stability are restored, however if someone has a severe nerve compression then they usually require

surgery to take the pressure off the nerves.

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Sciatica

The sciatic nerve is the largest single nerve in the human body; it originates from each side of the lumbar spine, runs deep through the buttock muscles, down the back of the thigh, and all the way down to foot, connecting the spinal cord with the leg and foot muscles.

Sciatica commonly refers to pain that radiates along the sciatic nerve and is typically felt in the buttock, down the back of the leg and possibly in the foot. Numbness, tingling, and/or a burning or prickling sensation are also common symptoms. If the sciatic nerve is compressed enough, muscle weakness in the foot/leg may also occur.

Sciatica is actually a symptom and not a diagnosis. The term literally means that a patient has pain down the leg resulting from compression of the sciatic nerve. The diagnosis is what is causing the compression.

Sciatica is caused by compression or irritation of the spinal nerves as they exit the spine, and the leg pain often feels much worse than the back pain. Common causes of sciatica include a disc bulge, degenerative disc, osteoarthritis in the lumbar spine, pelvic and lumbar instability and tightness/spasm in the piriformis muscle.

Sciatica - Implications for Pilates Pilates can help sciatica by stabilising the pelvis and lumbar spine. However, as sciatica is often very painful and debilitating, care should be taken not to exacerbate the sciatic symptoms with exercise.

It is important to avoid movements of the spine that may cause further compression to the sciatic nerve. This includes lumbar flexion for disc problems, and lumbar extension for osteoarthritis. Also care must be taken with any exercises which include neural tension positions. This is the position where the sciatic nerve is most on stretch – this occurs when the knees are straight and the leg/s are flexed, and is increased even further if spinal flexion is added.

Avoid neural tension positions for sciatica

http://www.spine-health.com/conditions/sciatica/what-you-need-know-about-sciatica

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Some patients find that a gentle neural mobilisation stretch may help their sciatic symptoms, whilst others find this may flare up their symptoms and make them worse. It is best to try a very gentle stretch to start with and continually monitor throughout.

Other considerations with the sciatic nerve is during buttock exercises – the sciatic nerve pierces through the piriformis muscle and when the nerve is severely irritated, sometimes any activation of this muscle can reproduce symptoms. It is usually important to strengthen the buttocks, but care must be taken to ensure correct buttock activation and try different buttock exercises to determine the best one for the patient.

As with any severe pain or injury, if it is not improving or you suspect a serious problem, refer to a physiotherapist or doctor for further investigation.

Sacro-Iliac Joint (SIJ) Problems

The SIJ can be inflamed for a number of reasons. It is usually due to a torsion of the pelvis (or the pelvis being “out” of alignment) resulting from instability, muscle imbalances, side to side asymmetry and is quite a common problem, particularly in pregnancy.

Symptoms Pain located either to the left or right side of the lower back. The pain can range from an ache to a sharp pain which can restrict movement. The pain may radiate out into the buttocks and lower back and will often radiate to the front into the groin. Occasionally there may be referred pain into the lower limb which can be mistaken for sciatica. Classic symptoms are difficulty turning over in bed, struggling to put on shoes and socks and pain getting your legs in and out of the car. SIJ problems may cause stiffness in the lower back when getting up after sitting for long periods and when getting up from bed in the morning.

SIJ pain - Implications for Pilates

Assess muscle imbalances around the pelvis, spine, hips and legs. Look for asymmetries side to side,

pelvic alignment/position and stability, and prescribe specific exercises to correct these. Usually

stretching or massaging the gluteals, TFL, hip flexors and quadriceps on the affected side will help,

along with improving pelvic stability. Take care with buttock exercises to ensure correct muscle

activation – sometimes certain buttock exercises may be uncomfortable when the SIJ is inflamed,

but you should be able to find some buttock exercises that are comfortable.

Muscles, Testing and Function, 7th Edition, Florence Kendall

http://www.sportsinjuryclinic.net/cybertherapist/back/buttocks/sciatica.htm

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Osteoporosis

Osteoporosis is a condition in which the bones become fragile and brittle, leading to a higher risk of

fractures (breaks or cracks) than in normal bone.

Osteoporosis occurs when bones lose minerals, such as calcium, more quickly than the body can

replace them, leading to a loss of bone thickness (bone mass or density). As a result, bones become

thinner and less dense, so that even a minor bump or accident can cause serious fractures.

Any bone can be affected by osteoporosis, but the most common sites are bones in the hip, spine,

wrist, ribs, pelvis and upper arm. Osteoporosis usually has no symptoms until a fracture occurs.

Fractures due to osteoporosis (osteoporotic fractures) can lead to changes in posture (eg developing

a stoop or Dowager's hump in the thoracic spine, muscle weakness, loss of height and bone

deformity of the spine. Fractures can lead to chronic pain, disability, loss of independence and even

premature death.

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Prevention and Treatment for Osteoporosis is to obtain enough calcium through the diet, along with

other vitamins that help to lay down new bone such as Vitamin K from eating green leafy vegetables

and Vitamin D from sunlight. A diet high in alkalizing foods (lots of vegetables) is important because

when the body is acidic, calcium is lost out of the bones into the blood to buffer the acidity. Doctors

may prescribe medications if necessary, but diet and exercise are the most important things to

address. Exercise helps to build and maintain strong bones, prevent falls and fractures and speed up

rehabilitation.

Weight bearing exercise is essential for strengthening the bones as the stress produced on the bones

facilitates new bone growth. Degenerative changes in the skeleton occur after relatively short

periods of inactivity. Up to 1/3 of bone mass can be lost in just a few weeks without stress. Weight

bearing exercise includes jogging activities, aerobics, dancing, tennis and also weight resisted

exercises such as weights and certain Pilates exercises. However, care will need to be taken in those

with already established significant osteoporosis as to not place too much strain or the bone due to

the high risk of fracture.

Hormones also play an important role in the synthesis of new bone, and maintaining the strength of

bones. The female and male hormones (estrogen and androgens) and also the parathyroid

hormones are important so it is necessary to address any imbalances in these hormones to treat

osteoporosis. In women who are postmenopausal, taking Hormone Replacement Therapy can be of

benefit to maintaining or increasing bone density.

As long as the body conditions are correct (eg hormone balance, not acidic, good calcium absorption

from the intestines), the diet is rich in alkalising foods, all vitamin and mineral needs are being met

and the right exercise is being undertaken bone density will improve.

Osteoporosis – Implications for Pilates

Reformer and other equipment exercises are particularly useful for prevention and treatment of

osteoporosis as the springs provide extra weight bearing resistance. Certain matwork exercises are

also beneficial, especially the buttock exercises as they help to strengthen the hip bones. Any

exercises which improve core stability and balance will also help to prevent falls and risk of fracture.

In somebody with severe osteoporosis or a high risk of a spinal fracture, avoid all exercises which

either flex, extend or rotate the spine.

eg no abdominal curl, swan prep, rolldown stretch, spiral stretch, pendulum and many others. A

neutral spine position must be maintained throughout all exercises.

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Pregnancy

First trimester – weeks 1-12

The mother-to-be may be experiencing morning sickness (or in some cases all day sickness) or

feeling a little tired. This initial stage of pregnancy is where there is the most risk of miscarriage.

Pilates is safe to perform at this stage, but the intensity will need to be slightly lower because if the

body temperature and heart rate elevate too high this can increase the risk of miscarriage. Pilates is

a more gentle type of exercise, so this is usually not a problem. During this early phase start to

decrease the amount of sit up type abdominal exercises, and focus more on the t-zone and pelvic

floor. Doing too much rectus abdominus strengthening can increase the risk of a rectus diastasis (see

over page).

Second trimester – weeks 13-26

The baby continues to grow, and will start to show around this time. Lying on the back can start to

become uncomfortable for some and potentially dangerous. This is because the baby can sit right on

top of the main blood vessels as they exit the spine and cause less blood to pump through. This can

cause dizziness to the mother and shortness of breath, and less oxygen to the baby. So at this time,

limit or avoid any time spent lying on the back, and omit any supine abdominal exercises. Also, lying

on the stomach will not be comfortable anymore as the baby is showing. Side lying oblique muscle

exercises can still be performed.

Third trimester

This is the time when the baby grows the most and the mother’s posture changes dramatically. A

lordosis-kyphosis posture becomes more evident as the baby grows and the breasts increase in size.

No abdominal exercises are to be performed, not even the side muscles, and no lying on the

stomach or back. Mothers can continue with their workouts as long as they feel comfortable, most

women will stop at 36 weeks or so, but if feeling well there is no reason why they can’t continue

right through to 40 weeks.

Pregnancy - Implications for Pilates

Large group mat classes are not suitable during pregnancy, unless they are specific pregnancy

classes. Even still, there are not many matwork exercises that can be performed in the second and

third trimesters. Studio sessions using the equipment are much better for pregnancy than matwork

sessions and can be done right through the entire pregnancy.

Week 1-12: start to decrease rectus abdominus work, ease back on the intensity of the workouts

Week 12-25: no supine lying, no prone lying, no abdominal work except may do double leg lift

Week 25-40: no supine lying, no prone lying, no abdominal work at all.

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During pregnancy, a hormone is released which relaxes the ligaments in the mother in preparation

for childbirth, which makes the mother more hypermobile and prone to injury. Improving the

strength of the stabilising muscles is therefore very important to prevent and help pain and injury.

Due to these ligament changes and also the changes in posture, lower back pain, SIJ and hip pain,

upper back and shoulder and neck pain are quite common.

Muscles to strengthen in pregnancy: Muscles to stretch in pregnancy:

Pelvic floor


Obliques (up until week 25)

Gluteals

Hamstrings (up until week 12)

Lower trapezius/rhomboids

Arms (to prepare for lifting baby)

Pectoralis major

Latissimus dorsi

Gluteals

Quads and hip flexors

Good pregnant posture Poor pregnant posture

The House Clinics Chiropractic and Physiotherapy

68


Post pregnancy

Women can start back with their sessions after giving birth after their 4-6 week check up. If they are

having any problems with their pelvic floor or rectus diastasis (separation of their rectus abdominus

muscles) then they will need to have personalised sessions to check that their t-zone is on and

progress very slowly with the abdominal exercises. Otherwise if they jump back in to doing sit up

type abdominal exercises and letting their t-zone go they will be making it worse (see over page for

more on these problems).

Lower back pain and neck, shoulder and upper back pain are very common as the mother is

performing a lot of carrying and lifting the baby and pram etc, and their abdominal and pelvic

strength have been so affected by the pregnancy. Also breastfeeding creates a rounded shoulder

posture, both from holding the baby and the weight of the breasts.

The muscles to strengthen and stretch are the same as during the pregnancy, the main difference

will be that they are able to start on a specific routine to regain strength in all of the abdominal

muscles, lie on their stomach and back and also start to promote some lumbar flexion mobility.

Pelvic floor problems

The weight of carrying the baby for 9 months along with the trauma caused to the pelvic floor can

lead to weakened pelvic floor muscles, possibly even a prolapse. A prolapse is when the muscles and

ligamentous structures suspending the pelvic floor and pelvic organs become so stretched and weak

that they sag downwards, allowing the organs to prolapse. The bladder, uterus and bowel can all be

affected.

Symptoms include lack of bladder control, stress incontinence, a feeling of a sagging in the pelvic

floor area and weakness through the area. The treatment for both pelvic floor weakness and

prolapsed is to perform pelvic floor exercises, however if the ligamentous damage is so great surgery

also may be required to repair the prolapse.

Pelvic floor problems - Implications for Pilates

Pelvic floor activation +++ start off with very basic t-zone activation exercises and progress as the

pelvic floor strengthens. Cue to use the pelvic floor with every exercise. Take care with abdominal

exercises – a strong abdominal contraction bears down on the pelvic floor, so if it is not strong

enough to contract against this pressure it will be forced downwards, contributing to the problem.

So focus more on the t-zone isolation rather than global abdominal strengthening.

www.merck.com

69


Rectus diastasis

During pregnancy the rectus abdominus (or six pack muscle) needs to stretch to

accommodate the growing baby. Each side of the rectus abdominus muscle meets in the

midline of the abdomen to form a fibrous structure called the linea alba. This is the weakest

point of the abdominal corset. In some cases when the linea alba is placed under too much

pressure, rather than the rectus abdominus muscles stretching, the linea alba overstretches

or in some cases tears. This is known as a diastasis (or separation) of the rectus abdominus.

The rectus diastasis will look like a vertical bulge or separation in the midline of the

abdomen. This bulge is more noticeable when you do certain movements that increase the

pressure within the abdomen and stress this area.

How to test for a rectus diastasis?

Have the client lie flat on their back with their knees bent. Place your fingers across the

midline of the abdomen just above the belly button. Get the client to perform a sit up and

feel for a vertical gap or separation underneath your fingers.

Rectus diastasis - Implications for Pilates

Performing sit up type movements where the rectus abdominus is working without using the t-zone

properly will make the separation worse. Post pregnancy, start with very basic pelvic floor and

transversus abdominus activation, then progress to exercises using the rectus abdominus only as the

t-zone strength allows. Whilst performing any abdominal exercises, be sure to check that their

separation isn’t bulging out or opening further.

The Breasts

70


References

Misuri G, Colagrande S, Gorini M et al (1997): In vivo assessment of respiratory function of abdominal muscles

in normal subjects. European Respiratory Journal 10: 2861–2867.

Beck M, Sledge J, Gautier E, Dora C, and Ganz R (2000): The anatomy and function of the gluteus minumus

muscle. Journal of Bone and Joint Surgery British, 82B(2), 358-363.

Watson DH, Trott PH. Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance. Cephalgia 1993:13;272-284.

G. Jull. Deep cervical flexor muscle dysfunction in whiplash. Journal of Musculoskeletal Pain 2000;8(1/2).

Fundamentals of Anatomy and Physiology, 7th Edition, Frederick H Martini PhD, Pearson Education 2006.

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