Feasibility and outcomes of a classical Pilates program on lower extremity strength, posture, balance, gait, and quality of life in someone with impairments due to a stroke.

+

MODEL

Journal of Bodywork & Movement Therapies (2013) xx, 1e29

Available online at www.sciencedirect.com

ScienceDirect journal homepage: www.elsevier.com/jbmt

PILATES REHABILITATION

Feasibility and outcomes of a classical Pilates program on lower extremity strength, posture, balance, gait, and quality of life in someone with impairments due to a stroke Sarah Shea, PT, DPT, PMA-CPT a,b,*,1, Gabriele Moriello, PT, PhD b,1 a

The Pilates Principle, Latham, NY, USA Doctor of Physical Therapy Program, School of Health Sciences, The Sage Colleges, 65 Ferry Street, Troy, NY 12180, USA

b

Received 3 June 2013; received in revised form 4 November 2013; accepted 18 November 2013

KEYWORDS Pilates; Exercise rehabilitation; Cerebrovascular accident (CVA); Alternative therapies; Feasibility of Pilates

Summary Pilates is a method that can potentially be used for stroke rehabilitation to address impairments in gait, balance, strength, and posture. The purpose of this case report was to document the feasibility of using Pilates and to describe outcomes of a 9-month program on lower extremity strength, balance, posture, gait, and quality of life in an individual with stroke. The participant was taught Pilates exercises up to two times per week for nine months in addition to traditional rehabilitation in the United States. Outcomes were assessed using the Berg Balance Scale (BBS), Stroke Impact Scale (SIS), GAITRite System, 5 repetition sit-to-stand test (STST), and flexicurve. Improvements were found in balance, lower extremity strength, and quality of life. Posture and gait speed remained the same. While these changes cannot be specifically attributed to the intervention, Pilates may have added to his overall rehabilitation program and with some modifications was feasible to use in someone with a stroke. ª 2013 Elsevier Ltd. All rights reserved.

* Corresponding author. 3776 Route 9, Hudson, NY 12534, USA. Tel.:þ1 518 929 0433. E-mail address: [email protected] (S. Shea). 1 Tel.: þ1 518 244 2063. 1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jbmt.2013.11.017

Please cite this article in press as: Shea, S., Moriello, G., Feasibility and outcomes of a classical Pilates program on lower extremity strength, posture, balance, gait, and quality of life in someone with impairments due to a stroke, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.11.017

+

MODEL

2

Introduction Each year there are approximately 750,000 new incidents of stroke in the United States alone, making it the third leading cause of death (Duncan et al., 2005; Kwon et al., 2006), as well as the leading cause of long-term disability (Natarajan et al., 2008). In 2010, national costs due to stroke were in excess of $53.9 billion (Heidenreich et al., 2011). Individuals with stroke often develop limitations in functional mobility, and increase their risk of falls, as a result of impairments in flexibility, muscle strength, somatosensation, coordination, tone, and balance (Yates et al., 2002). These limitations can then affect an individual’s quality of life due to major life changes affecting the ability to work, drive, and/or perform social roles (Pohl and Richards, 2000). Rehabilitation after stroke is aimed at restoring function and limiting disability, and those interventions that are intense produce better outcomes (Langhorne, 1996; Kwakkel et al., 1999). The issue with current therapy across the United States is that once someone is discharged home, therapy is often limited to a few hours per week, not providing the intensity necessary for optimal functioning. Creative ways to provide additional exercise for individuals with stroke, which can improve outcomes, need to be identified. Pilates is a method that has been shown to improve flexibility, somatosensation, muscle strength, and balance, which are areas commonly affected in people who have suffered a stroke. The principles of Pilates, control, concentration, centering, flow, breath, and precision are incorporated each aspect of the workout to achieve complete control of the mind over the body (Pilates and Miller, 1945), which is in essence motor control. Research has shown that Pilates exercises can increase core strength (Emery et al., 2010; Kloubec, 2010), flexibility (Rogers and Gibson, 2009; Cruz-Ferreira et al., 2011; Kloubec, 2010), muscular endurance (Rogers and Gibson, 2009; Lim et al., 2008), and dynamic balance (Cruz-Ferreira et al., 2011; Johnson et al., 2007; Irez et al., 2011; Rodrigues et al., 2010), improve posture (Emery et al., 2010), and have a positive effect on quality of life (Rodrigues et al., 2010) in healthy adults. Individuals affected by stroke often have impairments in these areas, and therefore could likely benefit from Pilates exercises. Improving core strength (Endleman and Critchley, 2008; Cruz-Ferreira et al., 2011) with Pilates exercises may improve mobility and endurance (Sekenddiz et al., 2007) which can potentially impact gait and posture (Emery et al., 2010; Kloubec, 2010). Pilates was shown to increase autonomy, improve static balance and quality of life in elderly females (Rodrigues, 2010). Adding Pilates into stroke rehabilitation may not only help decrease impairments and improve quality of life, but also allow the person to become empowered by gaining some independence. Classical Pilates refers to performing the exercises of Contrology that Joseph Pilates created, in the order that he formulated with a neutral spine. There are many other schools of Pilates that have deviated from Joe’s original work. In this study, classical Pilates refers to a systematic integrative approach, meaning to follow Joseph Pilates’ original system of Contrology, including the principles,

S. Shea, G. Moriello exercises and apparatus. Classical Pilates is performed in a studio that is equipped with Pilates mats and multiple apparatus including the reformer, the cadillac, the wunda chair/high chair, barrels, magic circle, magic square, foot corrector, toe corrector, and sand bag (Kravitz and Shedden, 2006). The apparatus were created to make the mat work more accessible to those who could not perform the exercises due to injuries or weakness and allows each person to work on his or her individual needs within each session (Power Pilates, 2006; Rogers and Gibson, 2009). As a form of supervised exercise, Pilates may be ideal for individuals with stroke who may not have the ability to perform the exercises without some type of assistance. Unfortunately, most of the current literature primarily evaluates the use of Pilates for orthopedic rehabilitation, and most specifically for low back pain (Critchley et al., 2011; Lim et al., 2008; Rydeard et al., 2006; Posadzki et al., 2011). Literature using Pilates for people with neurological diagnoses is limited to a case report describing outcomes following a 7-month mat home exercise program in a middle-aged woman with multiple sclerosis (Hay-Smith and Standring, 2010). There currently is no research evaluating the effect of a Pilates program in those with stroke. The purpose of this case report was to document the feasibility and outcomes of using Pilates on lower extremity strength, balance, posture, gait, and quality of life in an individual with deficits due to stroke.

Methods Case Description The participant was a 67-year old male who experienced a right-sided ischemic stroke eight months prior to the start of this study. Prior to the Pilates intervention, his course of rehabilitation post-stroke included acute and subacute rehabilitation for seven months, which was interrupted by a series of medical complications (acute renal failure, kidney stones, and sepsis resulting in six weeks in critical care). At the beginning of the study he was receiving home physical therapy (24 visits over 3 months) and outpatient occupational therapy twice per week (24 visits over 3 months). Over the next 3 months he received outpatient physical and occupational therapy once per week for an additional 12 visits of each. His therapies included botox injections in his left calf and left arm, myomo, electrical stimulation for shoulder subluxation and muscle re-education of his left ankle dorsiflexors, transfer training, gait training with a Ustep and theratogs, endurance training, balance activities, and stair training. His past medical history included coronary artery bypass graft, aortic valve replacement, myocardial infarction, chronic kidney disease, and hypercholesterolemia. Prior to the stroke he was independent in community ambulation, activities of daily living (ADLs), and independent activities of daily living (IADLs). Human subjects’ approval was obtained from The Sage College’s Institutional Review Board. His goals were to be more independent in ADLs and be able to walk better. He had a strong family support system and was willing and motivated to participate.


+

MODEL

Feasibility and outcomes of a classical Pilates program following stroke

Examination The participant was alert and oriented times three and his communication abilities and memory were intact. He presented with left sided strength and somatosensory deficits. He reported left shoulder pain that ranged from 0/10 to 56/10 and his left shoulder was subluxed. Assessment of his posture using a flexicurve ruler revealed a ½” thoracic curvature and a ¼” lumbar curvature. His Berg Balance Scale (BBS) score was 20/56. He was independent in bed mobility, but required supervision for transfers. He was unable to complete the 5repetition sit-to-stand test (STST) since he could not transfer according to the instructions and keep his arms in his lap. In order to stand, he had to use his right upper extremity to push off from the arm rest. He was able to ambulate 100 feet with contact assistance using a shortbased quad cane indoors, with an average gait speed of 11.6 cm/s. He required total assistance to navigate a wheelchair in the community. With contact assistance, he was able to negotiate 7 stairs using a single handrail and a step to step pattern. His left upper extremity was nonfunctional so he required assistance with dressing and toileting. The participant’s Stroke Impact Scale (SIS) scores at initial evaluation were strength (15.0), emotion (44.4), memory and thinking (54.3), and communication (77.1); the other domains were not reported at initial evaluation.

Outcome Measures The outcome measures chosen for this study were lower extremity strength and function as measured by the 5repetition STST, thoracic and lumbar posture as measured by a flexicurve ruler, balance as measured by the BBS, gait speed and stride length as measured by the GAITRite Portable Walkway System, and quality of life as measured by the SIS. Outcome measures were assessed every three months by a physical therapist with 23 years experience working with this population. The 5-repetition STST (Csuka and McCarty, 1985) was chosen to measure lower extremity strength and function. The participant was instructed to keep his arms on his lap while standing up and sitting down five times as quickly as possible from an armless chair measuring 19 inches from the floor. The test was timed from the moment his back left the back rest of the chair until it returned to the back rest of the chair after five repetitions. For people post-stroke, the minimal detectable change (MDC) value for the 5repitition STST is 3.6 s (Mong, 2010). The flexicurve ruler was utilized to measure thoracic and lumbar curvatures (Milne and Lauder, 1974). The flexicurve is a malleable ruler that can be molded to the contours of a person’s spine to measure the curvatures in the sagittal plane. With the participant standing as straight as possible, the ruler was placed starting at the C7 spinous process and then molded to the spine in a caudal direction (Prince et al., 2007). The ruler was then placed flat on graph paper and its outline was traced. Thoracic and lumbar curvatures were measured in centimeters. The MDC value for the flexicurve ruler is 1.62 cm (Dunleavey et al., 2010).

3

The BBS (Berg et al., 1992) was utilized to measure balance. The scale consists of fourteen common movement-based tasks: sit-to-stand transfer, stand-to-sit transfer, bed-to-chair transfer, sitting unsupported, standing unsupported, standing with eyes closed, standing feet together, tandem stance, single limb stance, reaching, picking up an object from the floor, alternating foot on stool, looking over the shoulders, and turning 360 . Each item is scored using a five point ordinal scale (0e4) and then all items are added for a high score of 56. The higher the score, the better the balance. The cut-off score for safe independent ambulation is 45 (Hayes and Johnson, 2003) and for people post-stroke, the MDC value is six points (Stevenson, 2001). Gait speed and stride length were collected using the GAITRite Portable Walkway System. The GAITRite System is an electronic walkway utilized to measure the temporal and spatial parameters of gait. Stride length was defined as the line of progression between the heel points of one footprint to the next footprint and was expressed in centimeters (cm). The MDC value for stride length in older adults is 7 cm (Youdas, 2010). Gait speed was obtained by dividing the distance traveled by ambulation time and was expressed in centimeters per second (cm/sec). The MDC value for gait speed in people with stroke is 0.2 m/sec (Hiengkaew, 2012) while the minimal clinically importance difference (MCID) value is 0.16 m/sec (Tilson et al., 2012). Quality of life was measured using the SIS Version 3.0 (Duncan, 2003), a 59 item self-report scale designed to measure a person’s perspective of the effect of stroke on quality of life. The SIS assesses eight domains: strength, hand function, ADLs/IADLs, mobility, communication, emotion, memory and thinking, and participation. Each item was rated on a five point ordinal scale where five was “not difficult at all” to one which was “extremely difficult”. Summative scores are generated for each domain and can range from 0 to 100. The MDC value for the overall stroke recovery score of the SIS is 10e15 points while the individual domain MDC values for chronic stroke are strength (24), mobility (47.3), ADLs/IADLs (15.1), and hand function (25.9), while MCID values are strength (9.2), mobility (4.5), ADLs/ IADLs (5.9), and hand function (17.8) (Lin et al., 2010a,b). All of the above outcome measures have been found to be reliable and valid (Mong et al., 2010; Greendale et al., 2011; Blum and Komer-Bitensky, 2008; Kuys et al., 2011; Webster et al., 2005; Duncan et al., 2003; Lin et al., 2010a,b). Feasibility of the program was assessed qualitatively on whether he was able to complete the program with modifications, whether he was able to tolerate the program without undo fatigue or pain, and whether he enjoyed the sessions.

Evaluation/Prognosis The participant was a 67-year old male status post right ischemic stroke with left hemiplegia. He presented with less than normal curvatures of the spine. His score on the BBS indicated that he was at a high risk for falls, and his performance on the 5-repetition STST indicated that he had significant lower extremity weakness since he was unable to complete the test without use of his hands. He required


+

MODEL

4

S. Shea, G. Moriello Hundred by just breathing (See Appendix 1). The Hundred is the first Pilates mat exercise performed to get the body warmed up and the blood flowing. He then progressed to performing The Hundred while holding his head up (and breathing), and then holding a bar while pumping both arms (while keeping his head lifted and breathing). During The Hundred, the position of his legs progressed from being supported on a small barrel on the mat, or the foot bar on the reformer, to table top position. Exercises such as The Hundred, the abdominal series, shoulder bridge, leg springs and magic circle supine were included for core strength. Since the participant had a shoulder subluxation, exercises such as rib cage arms, swan prep, single leg kick, teaser series e arms only, and serratus push ups on the wall were included. For gait, side kicks, the sleeper and pelvic lift were chosen, and for posture spine stretch forward, saw and the wall. In general, the participant needed more closed chain and gravity eliminated positions to start off with once he started working on the apparatus, and was gradually able to progress to more positions challenged by gravity. See Appendix 1 and 2 for examples of exercise modifications. See Tables 1and 2 for a progression of the Pilates program. The continuation of the Pilates program was dependent upon whether he continued to show progress on the outcome measures and whether he wanted to continue the program.

the presence of another person to transfer, walk, and negotiate stairs due to his strength and balance deficits as well as his fear of falling. His initial SIS scores fell on the low end of normative data for those with stroke. The use of Pilates exercises could potentially address these issues since Pilates exercises allow for neuromuscular reeducation by modifying the base of support and impact of gravity in order to provide appropriate challenges and feedback to achieve functional movement. The participant’s prognosis to meet his goals was fair/good.

Plan of Care The intervention for this study was classical Pilates with modifications to accommodate the participant’s ability to perform the exercises. A comprehensive classical approach was used, incorporating all apparatus (mat, reformer, cadillac, wunda chair, magic circle, barrels, and the wall). He was seen up to 2 times per week for nine months under the instruction of a certified Pilates teacher for a total of 58 Pilates sessions. The Pilates teacher was comprehensively certified by Power Pilates and The Pilates Method Alliance with five years of teaching experience, and in her final year of physical therapy school. Initially mat exercises were performed at home, under the supervision of a certified Pilates teacher, for ease of accessibility for the participant. The 55-minute sessions then progressed to the Pilates studio in order to incorporate the apparatus that provide varying spring resistance into his exercise program. The majority of each session was spent either on the reformer or the mat, with the last 10e15 min of the session on the specialized apparatus, concluding with 5 min of walking around the studio and out to his car. Exercises were modified and touch cues and indications in addition to verbal cues were used as needed. For example, initially he completed the exercise The

Table 1

Results Improvements were noted on the 5-repetition STST, the BBS and on certain domains of the SIS. Stride length was close to surpassing the MDC value while posture and gait speed remained relatively unchanged. Initially he was unable to complete the 5-repetition STST without the use of his right arm, and after nine months of

Progression of Pilates mat program. Month 1

Pre-Pilates Abdominal Hollowing Chest Lift Rib Cage Arms Basic Shoulder Bridge Knee Folds Knee Opening to Side Hundred Half Roll Down One Leg Circle Scissors Lower Lift Criss Cross Spine Strech Forward Corkscrew Saw Swan Prep Single Leg Kick Shoulder Bridge Side Kicks

X X X

Month 2

X X X

Month 3

X X X

X X

X X X X X X X

X X

X X X

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

X

X X X X X X X X X

X X X X X X X X X X X X X X X X X X

X X X X

X

X X X X X X

X

X

X

X X X X X X X X X X X X X

X

X

X

X

X X

X X

X X

X X X

X X X X

X

X


+

MODEL

Feasibility and outcomes of a classical Pilates program following stroke Table 2

Progression of Pilates program on apparatus. Month 1

Reformer Footwork Hundred Frogs & Leg Circles The Sleeper Pelvic Lift Snow Plow Cadillac Roll Back Single Leg Springs Leg Springs Teaser Series e Arms Only Magic Circle Seated Inner Thigh Work Supine Inner Thigh Work Wunda Chair Pumping Wall Articulation Arm Circle Roll Down with Arm Circles Squats Serratus Push Ups

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

X

X X

X X

X X

X X

X X

X X

X X X X X X

X X X X X

X X X X X X

X X X X X X

X

X X

X X

X X X

X X

X X X

X X X

X

X

X

X X

X X

X X

X

X

X X X X X

X X

X

X

X X X X X

X X X X X

X

X X

Pilates exercises he was able to complete the test without use of his arms in 20.53 s. This change exceeds the MDC value for this test indicating that the change was beyond measurement error. His score on the BBS increased from 20/56 to 39/56 which also exceeds the MDC value for the BBS. Gait speed decreased slightly from 11.6 cm/s to 10.8 cm/s, and stride length increased from 47.3 cm to 53.5 cm on the left and 47.6 cm to 54.5 cm on the right. Neither exceeded the MDC value though stride length came extremely close. The curvature of his thoracic spine remained the same at 1.3 cm, while his lumbar spinal curvature increased minimally from 0.2 cm to 0.3 cm over the course of the intervention. See Table 3 for values at initial evaluation and at three month increments for the 5repetition STST, posture, BBS, gait speed, and stride length. Following the 9-month intervention the participant was able to ambulate on level surfaces using a short-based quad cane with distant supervision, climb stairs with a single handrail, step-to pattern and contact guard, and all transfers were independent.

Table 3

5

X

X

The change in his total score of the SIS was not beyond measurement error since it did not exceed the MDC value for this test. However, his scores exceeded the MCID values on three of the domains (strength, mobility, ADLs/IADLs) indicating clinically important changes. Scores on the SIS at initial evaluation and at three month increments are shown in Table 4. This case shows it was feasible to complete a Pilates program in conjunction with traditional rehabilitation and that is was possible to modify classical Pilates exercises for someone with a significant stroke. The participant did not report undo fatigue or pain and he reported he enjoyed the program more than his physical therapy sessions. He chose to continue the program after the study was complete.

Discussion The available literature on Pilates is primarily orthopedically based, and more specifically focused on the

Posture, balance, lower extremity strength, gait speed, and stride length at three month intervals.

Measure

Initial evaluation

3 Months

6 Months

9 Months

Thoracic Curvature (cm) Lumbar Curvature (cm) Berg Balance Scale 5 Times Sit-to-Stand Test (sec) Average Gait Speed (cm/sec) Average Stride Length Right (cm) Average Stride Length Left (cm)

1.3 0.2 20 Unable to complete 11.6 47.6 47.3

1.9 0 26 21.63 12.9 60.5 59.1

1.9 0.2 35 19.32 6.4 50.5 50.3

1.3 0.3 39a 20.53a 10.8 54.5b 53.5b

a b

Surpassed minimal detectable change (MDC) value. Approached the MDC value.


+

MODEL

6

S. Shea, G. Moriello Table 4 Stroke Impact Scale Scores at three month intervals. Domains

Initial 3 Months 6 Months 9 Months evaluation

Strength Hand Function Mobility ADLs Emotion Memory and Thinking Communication Social Participation Stroke Recovery Score

15.0 * * * 44.4 54.3

30.0 12.0 31.1 32.0 37.8 71.4

35.0 0.0 48.9 34.0 42.2 77.1

25.0a 12.0 66.7a 44.0a 48.9 77.1

77.1 *

77.1 35.0

80.0 22.5

68.6 35.0

*

40.0

40.0

43.0

*Not completed. a Surpassed the minimal clinically importance difference (MCID) value.

treatment of low back pain. The purpose of this case report was to explore the feasibility of teaching Pilates to someone with severe impairments due to stroke, and to describe outcomes on lower extremity strength, balance, posture, gait, and quality of life. Over the course of the intervention many domains of the SIS improved as did the participant’s lower extremity strength, balance, and possibly stride length, while gait speed and posture remained relatively unchanged. While these changes cannot be specifically attributed to the intervention, we feel that Pilates may have added to the success of his overall rehabilitation program. With some modifications, Pilates was feasible to use with someone with severe impairments due to stroke. Lower extremity strength as measured by the 5repetition STST greatly improved over the course of the 9-month intervention. Initially, the participant could not rise from a chair without the use of his arm, but could do so by the end of the intervention. Several of the exercises performed by the participant on a regular basis, including footwork on the reformer, leg springs on the cadillac, shoulder bridge on the mat, and squats on the wall, all work muscles necessary for sit to stand transfers (Endleman and Critchley, 2008; Critchley et al., 2011). In addition, he was required to transition on and off the Pilates apparatus after each session which provided task specific practice. All Pilates exercises incorporate the principles of concentration, centering, control, flow, breath, and precision. Incorporating these principles consistently may have encouraged the participant to use them outside of his Pilates sessions while completing everyday activities, such as transferring sit-to-stand. The participant’s score on the BBS consistently increased at each three month interval, by increments greater than or equal to the MDC value of 6 points. From initial evaluation to discharge, the score almost doubled, and his score on eleven of the fourteen individual items improved. His initial score was in the range considered

wheelchair bound while his final score put him in the walking with assistance category, and very close to the independent walking range (Blum and Komer-Bitensky, 2008). Reasons for these improvement in balance may include improved strength (Endleman and Critchley, 2008; Critchley et al., 2011), kinesthetic awareness, proprioception, muscular endurance (Cruz-Ferreira et al., 2011; Kloubec, 2010), and improved self-confidence (CruzFerreira et al., 2011) from completing the intervention. With the assistance of the apparatus, Pilates exercises allow functional movements to be deconstructed into components and challenged appropriately with gravity and spring resistance, such as side kicks with the leg spring and the sleeper on the reformer. This reeducation of the neuromuscular system may have allowed for carry over to efficient functional and dynamic balance activities, such as transfers (Anderson and Spector, 2009). Pilates exercises focus on hip flexor stretching (single leg kicks) and strengthening of the core (abdominal series) (Critchley et al., 2011; Cruz-Ferreira et al., 2011) muscles including the gluteals (shoulder bridge, pelvic lift) and hip abductors muscles (side kicks), which are important in walking and could have contributed to improvements in stride length. Also, his balance improved indicating he may have been better able to stabilize himself during the single leg stance phase of gait, allowing him to take larger strides (Johnson, 2007). In addition, the intervention ended with walking practice where he focused on walking with proper biomechanics which provided task oriented training. Of the eight domains that make up the SIS, the participant’s score improved in three of them (strength, mobility, ADLs/IADLs). The changes in these physical domains could be attributed to improvements in muscle strength (Endleman and Critchley, 2008; Critchley et al., 2011) and balance. Improvements in strength can lead to improvements in self-confidence and dynamic balance (Johnson et al., 2007), which may positively affect walking ability and ADLs. Participating in Pilates exercises in a Pilates studio setting also provides an environment of positive reinforcement and encouragement from other clients, teachers, and staff members on a regular basis, which could also be attributed to the changes noted. His score remained the same over the course of the intervention for the hand function and social participation domains of the SIS, while it decreased for the communication domain score. The Pilates exercises practiced by the subject in the intervention did not put great emphasis on use of his hands, nor was he practicing Pilates in a group class to impact the social participation score. Although the participant was able to interact with other clients and teachers in the studio setting, who encouraged his progress, his Pilates sessions were completed individually. Lack of change in posture could be due to the emphasis on supine exercises during the participant’s sessions because it is a more supportive position. This may have led to a lack of carry over to the postural muscles in sitting when gravity is in effect. Gait speed initially increased but then decreased again by the end of the intervention. After the three month evaluation, his goals for walking changed in that he was more interested to intentionally focus on the precision of


+

MODEL

Feasibility and outcomes of a classical Pilates program following stroke his walking instead of his speed, which probably accounts for the lack of overall improvement on this measure. Even though most of the gains were made in the first 3 months, he continued to show progress on the 5-repetition STST, on certain domains of the SIS and especially on the BBS. He also enjoyed participating in the program and wished to continue with the program since he felt he was benefitting from it. The major limitation of this case report is that it cannot be assumed that improvements made in this case were exclusively due to the Pilates intervention. The participant was also undergoing physical therapy and occupational therapy, in addition to the Pilates intervention. Generalizability is also limited with a case report. This case report, however, does show it was feasible to complete a Pilates program with someone with a significant stroke by modifying the exercises to meet his needs and abilities. Hopefully, this case report can provide clinicians with

7

modifications to a Classical Pilates repertoire in order to work with a more diverse client population, such as those with impairments due to a stroke, stroke as well as generate a hypothesis for researchers to test through controlled experiments. In addition to conducting research of higher methodological quality with a larger sample size and control group, future studies should look at the difference between Pilates exercises performed on the mat versus the apparatus, as well as supervised Pilates exercises versus an independent home program or use of a Pilates video at home. It is important to look at the impact of Pilates on people with other neurological diagnosis, in addition to stroke. Research such as this could give people another option in addition to, or after ending, physical therapy to continue progressing toward their personal goals without the regulations of health insurance.

Appendix 1. Modifications of Pilates mat exercises Mat: Pre-Pilates

Mat

Modification

Fig. 1a. Abdominal Hollowing

Breathing (forceful exhalation) used to help activate transverse abdominus

Picture

Fig. 1b. Abdominal Hollowing

(continued on next page) Please cite this article in press as: Shea, S., Moriello, G., Feasibility and outcomes of a classical Pilates program on lower extremity strength, posture, balance, gait, and quality of life in someone with impairments due to a stroke, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.11.017

+

MODEL

8

S. Shea, G. Moriello (continued ) Mat

Modification

Fig. 2a Chest Lift

Arms across chest

Picture

Fig. 2b Chest lift

Fig. 3a Rib Cage Arms

Weighted bar or roll back bar (larger diameter for easier grip)

(continued on next page)


+

MODEL


9

(continued ) Mat

Modification

Picture

Fig. 3b Rib Cage Arms

Fig. 4a Basic Shoulder Bridge

Ball between knees

Fig. 4b Basic Shoulder Bridge



+

MODEL

10

S. Shea, G. Moriello

(continued ) Mat

Modification

Fig. 5 Knee Folds

Assist left hip flexion manually to help break tone

Fig. 6a Knee Opening to Side

Tapping at left hip adductors to help bring leg back to midline

Picture

Fig. 6b Knee Opening to Side



+

MODEL


11

(continued ) Mat

Modification

Fig. 7 Hundred

Feet on small barrel; No pumping of the arms - breathing only; hold on to bar to pump arms - legs in table top

Fig. 8 Half Roll Down

Seated, triad ball between knees, feet under strap

Fig. 9 One Leg Circle

With leg spring

Picture



+

MODEL

12


(continued ) Mat

Modification

Fig. 10 Criss Cross

Upper body only, arms across chest; feet on small barrel

Fig. 11a Spine Stretch Forward

Seated with legs off Cadillac and ball between knees; feet supported on short box; Arms across chest work lifting with breath first, then add in forward bend

Picture



+

MODEL


13

(continued ) Mat

Modification

Picture

Fig. 11b Spine Stretch Forward

Fig. 12 Corkscrew

Legs in diamond shape



+

MODEL

14


(continued ) Mat

Modification

Fig. 13 Saw

Seated with legs off cadillac and ball between knees; feet supported on short box; arms across chest - work lifting with breath first, then twist, then add in twist with forward bend

Fig. 14a Swan Prep

Lift head only and work spinal extension; legs hip distance apart

Picture

Fig. 14b Swan Prep



+

MODEL


15

(continued ) Mat

Modification

Fig. 15a Single Leg Kick

Prone prop of upper body to work lift of chest and hugging midline with arms; touch cues to activate serratus anterior

Picture

Fig. 15b Single Leg Kick

Fig. 16 Shoulder Bridge

With ball between knees; tapping of left glutes for hip extension



+

MODEL

16


(continued ) Mat

Modification

Fig. 17a Side Kicks

Lift/Lower with leg spring; clam shells - focusing on lowering the leg

Picture

Fig. 17b Side Kicks

Appendix 2. Modifications of Pilates apparatus exercises

Reformer

Modifications

Fig. 1a Footwork

Feet hip distance, arches only – > Tendon stretch – > Toes in Pilates stance – > Heels parallel and together; Use jumping board to encourage weight bearing through left heel for all toes, arches, and heels

Picture



+

MODEL


17

(continued ) Reformer

Modifications

Picture

Fig. 1b Footwork

Fig. 1c Footwork on the Jumpboard

Fig. 1d Footwork on the Jumpboard



+

MODEL

18



Modifications

Picture

Fig. 1e Footwork on the Jumpboard

Fig. 1f Footwork on the Jumpboard

Fig. 2 Hundred

Feet on foot bar; no straps; chest lift and breathing only



+

MODEL


19


Modifications

Fig. 3a Frogs & Leg Circles

Support at heels

Picture

Fig. 3b Frogs & Leg Circles

Fig. 4a The Sleeper

Parallel and turn out with heel on corner of foot bar, or flat foot on jumping board



+

MODEL

20



Modifications

Picture

Fig. 4b The Sleeper

Fig. 4c The Sleeper

Fig. 5a Pelvic Lift

No lift; Then parallel hip distance, ball between knees with lift



+

MODEL


21


Modifications

Picture

Fig. 5b Pelvic Lift

Fig. 6a Snow Plow

Can use pillow between knees to work midline of the legs

Fig. 6b Snow Plow


+

MODEL

22


Cadillac

Modification

Fig. 7a Roll Back

Guiding at left side for grip and tone in left leg

Picture

Fig. 7b Roll Back

Fig. 8 Single Leg Springs

Lower/Lift, Out/In, One leg frog, Circles



+

MODEL


23

(continued ) Cadillac

Modification

Fig. 9a Leg Springs

Frog, Lower/Lift: Circles Use eye hooks on trapeze to work hip extension

Picture

Fig. 9b Leg Springs

Fig. 9c Leg Springs



+

MODEL

24


(continued ) Cadillac

Modification

Fig. 10a Teaser Series - Arms Only

No spring on Push Throuh Bar; Serratus prep – > elbow bend/extend

Picture

Fig. 10b Teaser Series - Arms Only

Magic circle

Modification

Fig. 11 Seated Inner Thigh Work

Seated on edge of Cadillac with short box supporting feet; open close, single leg, pulses

Picture



+

MODEL


25

(continued ) Magic circle

Modification

Picture

Fig. 12 Supine Inner Thigh Work

Wunda chair

Modification

Fig. 13 Pumping

Lighter spring with emphasis on lifting pedal; facilitate left ankle foot placement and use moon box to support back against wall

Picture


+

MODEL

26


Wall ending

Modification

Fig. 14 Articulation

Emphasis on equal weight bearing bilaterally and lengthening left side of waist

Fig. 15 Arm Circle

Using non-weighted bar so that unaffected arm can help the affected arm

Picture



+

MODEL


27

(continued ) Wall ending

Modification

Fig. 16 Squats

Small ROM, focus on equal weight bearing; With physioball behind back and cues for weight bearing on left leg

Fig. 17 Serratus Push Ups

On forearms, support left elbow and use stroking/tapping to help facilitate left serratus anterior

References Anderson, B.D., Spector, A., 2009. Introduction to Pilates-based rehabilitation. Orthop. Phys. Ther. Clin. N. Am. 9, 395e411. Berg, K.O., Wood-Dauphinee, S.L., Williams, J.S., Maki, B., 1992. Measuring balance in the elderly: validation of an instrument. Canad. J. Pub. Health 83, S7e11. Blum, L., Korner-Bitensky, N., 2008. Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review. Phys. Ther. 88, 559e566. http://dx.doi.org/10.2522/ptj.20070205.

Picture

Critchley, D.J., Pierson, Z., Battersby, G., 2011. Effects of pilates mat exercises and conventional exercise programmes on transverse abdominis and obliquus internus abdominis activity: pilot randomized trial. Man. Ther. J. 16, 183e189. http: //dx.doi.org/10.1016/j.math.2010.10.007. Cruz-Ferreira, A., Fernandez, J., Laranjo, L., Bernardo, L.M., Silva, A., 2011. A systematic review of the effects of Pilates method of exercise in healthy people. Arch. Phys. Med. Rehabil. 92, 2071e2081. http://dx.doi.org/10.1016/j.apmr.2011. 06.018.


+

MODEL

28 Csuka, M., McCarty, D.J., 1985. Simple method for measurement of lower extremity muscle strength. Am. J. Med. 78, 77e81. http: //dx.doi.org/10.1016/0002-9343(85)90465-6. Duncan, P., Bode, R., Min Lai, S., Perera, S., 2003. Rasch analysis of a new stroke-specific outcome scale: the Stroke Impact Scale. Arch. Phys. Med. Rehabil. 84, 950e963. Duncan, P., Reker, D., Kwon, S., Lai, S., Studenski, S., Perera, S., et al., 2005. Daily functioning and quality of life in a randomized controlled trial of therapeutic exercise for subacute stroke survivors. Stroke 36, 1764e1770. http://dx.doi.org/10.1161/ 01.STR.0000174192.87887.70. Dunleavy, K., Mariano, H., Wiater, T., Goldberg, A., 2010. Reliability and minimal detectable change of spinal length and width measurements using the Flexicurve for usual standing posture in healthy young adults. J. Back Musculoskelet. Rehabil. 23, 209e214. http://dx.doi.org/10.3233/BMR-2010-0269. Emery, K., De Serres, S., McMillan, A., Cote, J., 2010. The effects of a Pilates training program on arm-trunk posture and movement. Clin. Biomech. 25, 124e130. http://dx.doi.org/10.1016/ j.clinbiomech.2009.10.003. Endleman, I., Critchley, D.J., 2008. Transverse abdominis and obilquus internus activity during Pilates exercises: measurement with ultrasound scanning. Arch. Phys. Med. Rehabil. 89, 2205e2212. http://dx.doi.org/10.1016/j.apmr.2008.04.025. Greendale, G.A., Nili, N.S., Huang, M.H., Seeger, L., Karlamangla, A.S., 2011. The reliability and validity of three non-radiological measures of thoracic kyphosis and their relations to the standing radiological cobb angle. Osteoporos. Int. 22, 1897e1905. http://dx.doi.org/10.1007/s00198-010-1422-z. Hay-Smith, J., Standring, D., 2010. Choosing outcome measures that reflect what is important to the patient: a case study of clinical Pilates in a woman with multiple sclerosis. N. Z. J. Physiother. 38, 91e97. Hayes, K.W., Johnson, M.E., 2003. Measures of adult general performance tests. Arthritis Rheum. 49, S28eS42. http: //dx.doi.org/10.1002/art.11411. Heidenreich, P.A., Trogdon, J.G., Khavjou, O.A., Butler, J., Dracup, K., Ezekowitz, M.D., et al., 2011. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 123, 933e944. Hiengkaew, V., Jitaree, K., Chaiyawat, P., 2012. Minimal detectable changes of the Berg Balance Scale, Fugl-Meyer Assessment Scale, Timed “Up & Go” Test, gait speeds, and 2-minute walk test in individuals with chronic stroke with different degrees of ankle plantarflexor tone. Arch. Phys. Med. Rehabil. 93, 1201e1208. http://dx.doi.org/10.1016/j.apmr.2012.01.014. Irez, G.B., Ozdemir, R.A., Evin, R., Irez, S.G., Korkusuz, F., 2011. Integrating Pilates exercise into a program for 65þ year-old women to reduce falls. J. Sports Sci. Med. 10, 105e111. Johnson, E.G., Larsen, A., Ozawa, H., Wilson, C.A., Kennedy, K.L., 2007. The effects of Pilates-based exercise on dynamic balance in healthy adults. J. Bodyw. Movement Ther. 11, 238e242. http: //dx.doi.org/10.1016/j.jbmt.2006.08.008. Kloubec, J., 2010. Pilates for improvement of muscle endurance, flexibility, balance, and posture. J. Strength Cond. Res. 24, 661e667. http://dx.doi.org/10.1519/JSC.0b013e3181c277a6. Kravitz, K., Shedden, M., 2006. Pilates exercise: a research-based review. J. Dance Med. Sci. 10.3, 111e117. Kwakkel, G., Wagenaar, R.C., Twisk, J.W., Lankhorst, G.J., Koetsier, J.C., 1999. Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial. Lancet 354, 191e196. Kwon, S., Duncan, P., Studenski, S., Perera, S., Lai, S.M., Reker, D., 2006. Measuring stroke impact with SIS: construct validity of SIS telephone administration. Qual. Life Res. 15, 367e376. http: //dx.doi.org/10.1007/s11136-005-2292-2.

S. Shea, G. Moriello Kuys, S.S., Brauer, S.G., Ada, L., 2011. Test-retest reliability of the GAITRite system in people with stroke undergoing rehabilitation. Disabil. Rehabil. 33, 1848e1853. http://dx.doi.org/10. 3109/09638288.2010.549895. Langhorne, P., 1996. Physiotherapy after stroke: more is better? Physiother. Res. Int. 1, 75e88. http://dx.doi.org/10. 1002/pri.6120010204. Lim, C., Chen, Y., Lim, H., Quek, M., 2008. A retrospective evaluation of isotonic strengthening with clinical Pilates exercises on patients with chronic low back pain. Physiother. Singap. 11, 5e12. Lin, K.C., Fu, T., et al., 2010a. Psychometric comparisons of the stroke impact scale 3.0 and stroke-specific quality of life scale. Qual. Life Res. 19, 435e443. http://dx.doi.org/10.1007/ s11136-010-9597-5. Lin, K.C., Fu, T., et al., 2010b. Minimal detectable change and clinically important difference of the stroke impact scale in stroke patients. Neurorehabil. Neural Repair 24, 486e492. http: //dx.doi.org/10.1177/1545968309356295. Milne, J.S., Lauder, I.J., 1974. Age effects in kyphosis and lordosis in adults. Ann. Human Biol. 1, 327e337. Mong, Y., Teo, T.W., Ng, S.S., 2010. 5-repetition sit-to-stand test in subjects with chronic stroke: reliability and validity. Arch. Phys. Med. Rehabil. 91, 407e413. http://dx.doi.org/10.1016/ j.apmr.2009.10.030. Natarajan, P., Oelschlager, A., Agah, A., Pohl, P.S., Ahmad, S.O., Liu, W., 2008. Current clinical practices in stroke rehabilitation: regional pilot survey. J. Rehabil. Res. Dev. 456, 841e850. http: //dx.doi.org/10.1682/JRRD.2007.04.0057. Pohl, P., Richards, L., 2000. Decreasing stroke deficits. Interdiscip. J. Rehabil. 13, 32e35. http://dx.doi.org/10.1161/STROKEAHA. 109.567438. Pilates, J.H., Miller, W.J., 1945. Return to Life through Contrology. Joseph H Pilates. Posadzki, P., Lizis, P., Hagner-Derengowska, M., 2011. Pilates for low back pain: a systematic review. Complement. Ther. Clin. Pract. 17, 85e89. http://dx.doi.org/10.1016/j.ctcp.2010.09.005. Power Pilates, 2006. Comprehensive Manual. Power Pilates, Inc, New York NY. Prince, R.L., Devine, A., Dick, I.M., 2007. The clinical utility of measured kyphosis as a predictor of the presence of vertebral deformities. Osteoporos. Int. 18, 621e627. Rodrigues, B., Cader, S., Torres, N., Oliveira, D., Dantas, E., 2010. Pilates method in personal autonomy, static balance and quality of life. J. Bodyw. Movement Ther. 14, 195e202. http: //dx.doi.org/10.1016/j.jbmt.2009.12.005. Rydeard, R., Leger, A., Smith, D., 2006. Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability: a randomized controlled trial. J. Orthop. Sports Phys. Ther. 36, 472e484. http://dx.doi.org/10. 2519/jospt. 2006.2144. Rogers, K., Gibson, A.L., 2009. Eight-week traditional mat Pilates training-program effects on adult fitness characteristics. Res. Q. Exerc. Sport 80, 569e574. Sekenddiz, B., Altun, O., Korkusuz, F., Akin, S., 2007. Effects of Pilates exercise on trunk strength, endurance and flexibility in sedentary adult females. J. Bodyw. Movement Ther. 11, 318e326. http://dx.doi.org/10.1016/j.jbmt.2006.12.002. Stevenson, T.J., 2001. Detecting change in patients with stroke using the Berg Balance Scale. Aust. J. Physiother. 47, 29e38. Tilson, J.K., Sullivan, K.J., Cen, S.Y., Rose, D.K., Koradia, C.H., Azen, S.P., Duncan, P.W., 2012. Meaningful gait speed improvement during the first 60 days poststroke: minimal clinically important difference. Phys. Ther. 90, 196. http: //dx.doi.org/10.2522/ptj.20090079. Webster, K.E., Wittwee, J.E., Feller, J.A., 2005. Validity of GaitRite walkway systems for the measurement of averaged and


+

MODEL

Feasibility and outcomes of a classical Pilates program following stroke individual step parameters of gait. Gait Posture 22, 317e321. http://dx.doi.org/10.1016/j.gaitpost.2004.10.005. Yates, J.S., Lai, S.M., Duncan, P.W., Studenski, S., 2002. Falls in community dwelling stroke survivors: an accumulated impairments model. J. Rehabil. Res. Dev. 39, 385e394.

29

Youdas, J.W., Childs, K.B., McNeil, M.L., Mueller, A.C., Quilter, C.M., Hollman, J.H., 2010. Responsiveness of 2 procedures for measurement of temporal and spatial gait parameters in older adults. P M & R 2, 537e543. http: //dx.doi.org/10.1016/j.pmrj.2010.02.008.


Effects of Pilates on muscle strength, postural balance and quality of life of older adults: a randomized, controlled, clinical trial.

Effects of therapeutic Tai Chi on balance, gait, and quality of life in chronic stroke patients.

The effect of progressive task-oriented training on a supplementary tilt table on lower extremity muscle strength and gait recovery in patients with hemiplegic stroke.

The association between social participation and lower extremity muscle strength, balance, and gait speed in US adults.

Effects of a multifactorial fall prevention program on balance, gait, and fear of falling in post-stroke inpatients.

Effects of an elastic band resistance exercise program on lower extremity muscle strength and gait ability in patients with Alzheimer's disease.

Associations between lower limb strength and gait velocity following stroke: a systematic review.

"Life is at a standstill" Quality of life after lower extremity trauma in Malawi.

Influence of trunk posture on lower extremity energetics during running.

Effects of gait training with horizontal impeding force on gait and balance of stroke patients.

A systematic review of functional and quality of life assessment after major lower extremity amputation.

Does dance-based therapy increase gait speed in older adults with chronic lower extremity pain: a feasibility study.

Objective measurement of lower extremity function and quality of life after surgical revascularization for critical lower extremity ischemia.

Assessment of the relationship between Quality of Life and Upper Extremity Impairment Due to Occupational Injuries.

Effect of forced use of the lower extremity on gait performance and mobility of post-acute stroke patients.

The effects of Pilates exercise training on static and dynamic balance in chronic stroke patients: a randomized controlled trial.

Living Longer Living Stronger™: a community-delivered strength training program improving function and quality of life.

Effects of hippotherapy on recovery of gait and balance ability in patients with stroke.

Effects of a Task-specific Exercise Program on Balance, Mobility, and Muscle Strength in the Elderly.

Effect of neonatal posture on later lower limb rotation and gait in premature infants.

Effects of kinetic chain exercise using EMG-biofeedback on balance and lower extremity muscle activation in stroke patients.

Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders.

The effect of various dual task training methods with gait on the balance and gait of patients with chronic stroke.

Effect of transcranial direct current stimulation on postural stability and lower extremity strength in hemiplegic stroke patients.