Journal of Bodywork & Movement Therapies (2014) 18, 124e129
Available online at www.sciencedirect.com
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PREVENTION & REHABILITATION: PRACTICAL EXERCISE SEQUENCE
PREVENTION & REHABILITATION: PRACTICAL EXERCISE SEQUENCE
Pilates: Ranging beyond neutral e A practical discussion Warrick McNeill, Dip. Phyty. (NZ) MCSP* Physioworks, 4 Mandeville Place, London W1U 2BG, UK Received 6 November 2013; accepted 6 November 2013
KEYWORDS Pilates; Uncontrolled movement; Specific exercise; Direction control; Range control
Abstract The presence of ‘uncontrolled movement’ within the human neuromusculoskeletal system can be found if the movement control system (mind) and muscular system (body) is tested for their combined ability to successfully control low threshold forces, such as those affecting posture and alignment, or, high threshold forces, such as those requiring muscular strength to control. Deciding which exercises are the best to ‘fix’ the uncontrolled movements found is a fundamental part of the rehabilitative process. It has been suggested that specific exercises are best suited to fix specific faults. Direction Control and Range Control exercises are postulated as two key types of specific exercises that should be used when specific uncontrolled movements are found. In this paper, examples of the application of these two types of exercises are discussed, as is the fact that the ‘mind and body’ focused Pilates method already uses these two key exercise types as elements within its own system of exercise. ª 2013 Elsevier Ltd. All rights reserved.
The Pilates method of exercise may be used as a form of exercise that is regarded primarily connecting the mind and body e with an ‘emphasis on understanding the body and improving awareness while connecting breathing’ (Latey, 2001). What Latey calls ‘Modern Pilates’ involves tailored exercises particular to the clients needs, body type, strengths and weaknesses. It is the application of the principles of pilates to the needs of the clients which helps determine exercise choice, and, perhaps it is this that indicates the true skill of a Pilates Teacher.
* Tel.: þ44 7973 122996. E-mail address: [email protected].
In the preceding Editorial Comerford and Mottram (2012, 2001) are reported as proposing two key types of specific exercise to be used in response to finding uncontrolled movement on testing an individuals movement system. These are ‘Direction Control’ and ‘Range Control’ exercises. Direction Control exercises can be called ‘dissociation’ exercises e that is; fundamentally keeping a joint or region in a protective neutral position, and controlling it while moving the region directly superior or inferior to it. This type of exercise aims to improve the Central Nervous System (CNS) and muscular control of the region. Until this has been attained the uncontrolled movement has not been adequately managed.
1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jbmt.2013.11.013
There also needs to be a control of the movement through a joints normal ideal range, this is called Range Control. Comerford and Mottram highlight the need for Range Control exercises to improve the ability of stabilising muscles to be able to reach their ideal inner range, as well as smoothly eccentrically control their movement to outer range, control the possibility of rotation in that region and decelerate forces throughout the body as well. What follows is a discussion of a few examples of Direction Control and Range Control exercises so the reader can ascertain how a pattern of similar exercises could be applied to other regions of the body. The last section contains a possible interpretation of an analysis of Pilates movement. This shows the similarities between the key exercises as described by Comerford and Mottram and Pilates. If Comerford and Mottram are correct in their approach, it may suggest a reason why Pilates has anecdotally been perceived to be effective at managing movement control problems.
Direction control exercise examples If, on testing, an individual is shown to have uncontrolled movement in the lumbar spine into the direction of extension, it suggests that the muscles of the anterior abdominal wall are failing to be recruited appropriately or lack the strength to prevent forces from extending the lumbar region during movements of the body being tested. Direction Control exercises are therefore indicated to assist the individual to retrain this control. These Direction Control exercises challenge the individual to keep the area affected, in this case the Lumbar spine, still and in neutral, while adding a challenge to the lumbar spine by moving the region above or below the site in a direction that results in the individual having to focus on recruiting the synergistic muscles in the area to prevent the affected region moving. Choosing the correct exercise for the individual is made using trial and error methods. It is important that the individual is actually achieving the task so may need assistance in the form of cueing, handling or the use of mirrors to help them succeed in exhibiting the desired control. These are ‘dissociation’ exercises, as the individual is learning not to link or ‘associate’ hip extension with lumbar extension, in a ‘dissociation below’ exercise, or thoracic extension with lumbar extension in a ‘dissociation above’ exercise. Image 1 shows a well supported, long lever hip extension while the individual is using the bed for support and her hand on the lumbar spine for external feedback. She has been instructed to keep her lumbar spine in neutral and maintain her breathing to avoid using a bracing pattern to keep the lumbar spine still. She has also been instructed to recruit her anterior abdominal wall without making any one muscle the dominant player, though this may mean that she is given cues that may bias her concentration on to the obliques. A correct pattern for the movement of the hip will be encouraged with the focus being given to the gluteus maximus to be the main driver of the hip extension though the hamstrings will obviously be recruited in this long lever movement. The decision to use a long lever as opposed to a short lever (flexing the knee of the moving limb) is based on
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Image 1 Direction control exercise. Site: lumbar spine, Direction: lumbar extension, Threshold: low. Description: lumbar extension dissociation, below. Supported prone hip extension with proprioceptive assistance. Reset hip to flexed position smoothly to repeat. Duration: Up 2 min, based on quality of execution.
whether the client is able to successfully keep the lumbar spine still, especially during the hip extension phase of the exercise. The moving limb is then reset smoothly into hip flexion e which is more likely to encourage the clients lumbar spine to move into flexion e which may not be difficult for her e as it was lumbar extension that had been the identified as the uncontrolled movement. As this exercise is using just limb load it is regarded as a low threshold or low load exercise that challenges postural or alignment loads and the anterior abdominal wall synergy should be a slow motor unit dominant activity. To maintain this bias the exercise must be repeated slowly. Comerford and Mottram suggest the exercise should be maintained for approximately 2 min as long as the quality of the control remains good. Two minutes is a time frame that will show if a fatiguing strength type strategy was employed instead of the postural load as the client would fatigue out e perhaps indicated by changing their strategy of support to be a braced breath holding pattern. Though in a Direction Control exercise it is about controlling the direction of the affected region, so if a high threshold strategy was the only method that could control the lumbar extension that would be acceptable initially though the therapist/instructor would be encouraging the client to use a more correct strategy for the exercise over time. The second example Image 2A and B, is a similar Direction Control exercise using ‘dissociation above.’ This means that the challenge comes from above the lumbar spine. This exercise involving a swiss ball uses arm extension e combined with thoracic extension, in standing, to apply the extension challenge to the lumbar spine controllers of extension. If it was just gleno-humeral extension the dissociation challenge would apply to the entire spine but the aim here is to narrow the focus to the lumbar spine only. It is still a posture and alignment load, a low threshold load, though more of a challenge as the clients base of support is small as it is performed in standing. Proprioceptive feed back could be enhanced by allowing the client to view their image in a mirror. The exercise instruction to the client is to lift the ball and extend the thoracic spine while preventing the lumbar spine from extending. An
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Image 3 A & B. Direction control exercise. Site: lumbar Spine, Direction: lumbar extension, Threshold: high. Description: lumbar extension dissociation, below. Unstable base unsupported single hip extension from bilateral hip/knee 90/90 position. Reset hip to flexed position smoothly to repeat. Duration: approximately 1 min, based on fatigue.
Image 2 A & B. Direction control exercise. Site: lumbar Spine, Direction: lumbar extension, Threshold: low. Description: lumbar extension dissociation, above. Standing thoracic and shoulder extension using a swiss ball as load. Reset thoracic spine and shoulders to start position smoothly to repeat. Duration: Up 2 min, based on quality of execution.
anterior abdominal wall synergy is recruited. The range of movement of the thoracic spine must be kept in as small a range as necessary to prevent any movement spilling and creating lumbar extension. The duration of time allocated for the exercise is up to 2 min depending on the quality of movement and the instructor may use verbal cueing through out to keep the pattern of control correct to avoid breath holding or bracing. To make either of these exercises a greater load challenge to bias the synergy of control from slow motor unit dominance to fast motor unit dominance the application of greater loads or speed can be applied. Speeding up the rate of the movements would work in both these examples or adding weight - such as an ankle weight for the hip extension or changing the swiss ball for a theraband resistance, or even using both increased speed and increased load. An unstable base or smaller base of support can add to the challenge of the exercise. The object of the exercise, no matter its speed, load or challenge is to maintain the quality of the movement control exhibited by the client. Image 3 shows a higher load Direction Control exercise dissociating lumbar extension from hip extension, so it is a ‘high threshold dissociation below exercise’. This particular example may actually be a low threshold exercise for a well trained, strong individual, though for an under-trained
weaker one the load could be sufficient to require fast motor unit recruitment in the anterior abdominal wall. To push the exercise to being more cleanly a high threshold exercise, the instruction to the client could be to speed up the movements, or add a weight to the ankles. The unstable base may be enough to make the exercise a higher threshold. This single leg hip extension provides a lumbar extension control requirement for the lumbar spine. It uses eccentric hip flexor muscle work on the outward journey and concentric on the return. The exercise adds a rotary challenge to the exercise, which may also require cueing for the client to successfully exhibit control over e though this should not confuse the issue that this exercise in this situation is being used to retrain the lumbar extension uncontrolled movement. Image 4 shows an example of a Direction Control exercise e a high threshold dissociation exercise for lumbar extension with the loading coming from above the lumbar spine. Despite the paddling movement of the arms it is the extension of the thoracic spine that makes this dissociation exercise work, the long lever of the arms with weights in the hands ramps up the loading so the anterior abdominal wall has to work using strength to prevent the lumbar spine from extending. With the movement of the arms being reciprocal in this exercise and ideally being quick, the loading is further enhanced. The unstable base provided by the bosu also adds to the loading effect on the anterior abdominal wall. The exercise should result in the client fatiguing out in their abdominals in around a minute or so if the exercise is targeted at the right loading, as this is the time frame that a muscle fibre starts to deplete its glycogen store if the exercise is fast motor unit dominant. Adding time or load to continue the over-loading element to the
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Image 4 Direction control exercise. Site: lumbar Spine, Direction: lumbar extension, Threshold: high. Description: lumbar extension dissociation, above. Unstable base thoracic extension with reciprocally paddling arms with hand weights. Reset thoracic spine to a flexed position smoothly to repeat. Duration: approximately 1 min, based on fatigue.
exercise over subsequent sessions is important as the aim is to increase the strength of the anterior abdominal wall. Other muscles will also be gaining strength as a positive side effect but again the aim here is to retrain the ability of the anterior abdominal wall to control a high threshold challenge of lumbar extension. The principals of the Direction Control exercises can easily be applied to other uncontrolled movements at different sites and directions through out the body.
Range Control exercise examples To demonstrate Range Control exercises the muscles being recruited become less a synergistic pattern and more a specific muscle exercise, though under increased loads a synergy may become necessary to execute the exercise. In a Range Control exercise the aim is to improve the ability of a muscle, usually a stabilising muscle, to get to its inner range, or even, over time, to improve previously lost inner range. In this example the muscle in question is the Iliacus, a primary one joint hip flexor. In a movement impaired individual their Iliacus muscle may lose its ability to get into its inner range because of a lumbar flexion uncontrolled movement, as the individual may have historically associated lumbar flexion/posterior pelvic tilt with hip flexion. This associated movement can maintain the Iliacus in a lengthened position and over time ‘setting’ the length of the Iliacus into a non ideal longer length. This stabiliser muscle does need to be able to drive hip flexion to its full range, not least to keep its antagonist musculature and non-contractile tissues on the posterior side of the hip joint long. Comerford and Mottram advocate the use of inner range holds of the affected muscle after a concentric action moving the joint to the desired range (Comerford and Mottram, 2001). After an isometric hold of 10 s the muscle is allowed to concentrically lengthen. Depending on the start position of the exercise the eccentric movement can aim to achieve its full outer range. Ideally this specific muscle exercise should also control any rotary forces acting with out the substitution of other muscles inappropriately trying to assist. The exercise is repeated so that 10 10 s holds (Jull et al., 2008, 2009) in the best inner range possible is attained, using a high quality execution of the exercise.
Image 5 Range Control exercise. Specific muscle: Iliacus. Associated uncontrolled movement e Site: lumbar spine, Direction: lumbar flexion/posterior pelvic tilt, Threshold: low. Description: inner range hold for the Iliacus muscle e including concentric flexion to get to inner range and eccentric control back to the start position. Client flexes hip from sitting to maximum inner range attainable without substitution of the superficial hip flexors. Duration: approximately 10 by 10 s holds, based on fatigue and/or movement quality.
The Authors of, ‘The management of uncontrolled movement,’ also suggest that it may be easier to teach the specific elements of the exercise under lighter postural loads as there is a chance for the client to use feedback to alter the exercise once it is under way, however, a low threshold uncontrolled movement might need a higher load to facilitate the correct execution of the exercise by increasing the feedback. Image 5 shows an unsupported sitting version of an iliacus Range Control exercise with the key focus being on the inner range hold, though, the movement of the exercise also includes the concentric hip flexion up to the inner range as well as the eccentric control on its return. The aim of the exercise, to improve the inner range, must not be impeded by faults in execution such as bracing (including breath holding), or substitution. Substitution can be detected by the client themselves, or the instructor gently placing their finger tips inferior to the inguinal line on the lifting leg in the area of the superficial hip flexors. If a ‘gripping’ sensation ensues this is likely to be the substitution of the superficial hip flexors trying to vie with the Iliacus for dominance in the movement pattern. If this is detected the exercise is stopped and started again only getting to a height that the iliacus can actually, cleanly flex to. The full 10 repetitions should only be used if fatigue or an absence of substitution allows the client to get to that number of repetitions with high quality movement. Image 6 by adding resistance tubing to an iliacus dominant hip flexion, and reducing the base of support to a single foot, the loading dominance of the exercise becomes high threshold. Keeping the dominance of the exercise to
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Similarities between direction and Range Control exercises and Pilates Range Control exercises are clearly different from Direction Control but they are an important next step in the rehabilitation of movement control. Moving away from just controlling neutral is important. Therapists may fixate on neutral to protect their client, however controlling the range of movements has been the norm in Pilates exercise since Joseph Pilates started to develop his ideas in the early part of the 20th Century. The similarity between current Pilates work and the exercises described by Comerford and Mottram is apparent (Websource 1), and the following description of a possible work flow a Pilates Teacher may use, highlights the amount of work undertaken in Pilates that conforms to the requirements of the concepts of Direction Control, and even more so, Range Control. If a Pilates Teacher steps out of their environment and observes their workflow with an enquiring mind they may find that applying ‘specific exercise’ concepts to correct a single named fault that they have identified, and, if they work specifically to fix that one fault as opposed to many faults at a time, it is possible, that the increased attention to detail may more efficiently resolve the identified movement fault.
An analysis of Pilates movement Image 6 Range Control exercise. Specific muscle: Iliacus. Associated uncontrolled movement e Site: lumbar spine, Direction: lumbar flexion/posterior pelvic tilt, Threshold: high. Description: Inner range hold for the Iliacus muscle e including concentric flexion to get to inner range and eccentric control back to the start position. Client flexes hip from standing to maximum inner range attainable without substitution of the superficial hip flexors. Duration: approximately 10 by 10 s holds, based on fatigue and/or movement quality
Iliacus with out the superficial hip flexors substituting for it may become more difficult. This is because there will be increasing load on the entire movement meaning that more muscle action is required to successfully flex the hip. It becomes a question of assessing dominance - is the movement being undertaken by the specific muscle being targeted or other muscles? Usually it will be stronger, short, two joint mobilising muscles trying to take over from under recruited, longer stabilising muscles. Determining how much work a mobiliser is ‘allowed’ to do before it is dominant may take time for a novice instructor to develop assessing skills, but little ‘tells’ such as cramping in the substituting musculature can be helpful. Good finger tip palpation can be useful. A key practical tip is if the instructor is unsure if there is dominance of the substitution musculature, they should stop the exercise and start again. If the apparent dominance continues, it may mean the Iliacus has fatigued and needs to rest and recover, and the exercise should be continued at a later time. In this exercise the range of the iliacus can extend to full outer range if the leg is allowed to move to full extension while keeping the foot clear of the floor.
When the movement vernacular of Pilates is assessed some key points about the movement becomes obvious e in a well executed Pilates exercise there is precision throughout its movements, it looks flowing, smooth. This is related, of course, to the central principles of Pilates. Pilates aims to attain balance between the stabilising muscles anchoring one body region (Direction Control) while the muscles moving an adjacent joint or region, work efficiently to move from one extreme of range (sometimes hyper-mobile) to the other and back again (Range Control). The concentric and eccentric phases should smoothly transition, without judder and without an altered path from the movements ideal. The full range of ideal movement may be achieved, perhaps concentrically to inner range and eccentrically to outer. The muscles should be able to appropriately vary their handling of load from light postural loads, or perhaps gravity eliminated loads, but also be able to ramp up to take loads equivalent to many times body weight, or loads that must be managed at speed. Pilates is about the body working efficiently to the edges of its design parameters. When observing a poorly executed exercise, precision appears to be sacrificed. The exercise is no longer smooth. The stabilising muscles meant to be anchoring are over powered by the load and the no longer anchored body part shifts to make the work easier, advantaging stronger, inappropriate muscles or synergies. The muscles involved in creating the exercises movement may not be able to achieve the full range in one or both directions. A shake may be observed in a concentric phase and perhaps the eccentric return develops a judder as the muscle fails to lengthen smoothly. Other compensations like breath holding or
Pilates: Ranging beyond neutral
Invariably proximal stability is focused on first, with a neutral lumbo-pelvic region being prioritised. (Direction Control) Short lever limb movements are used to create loads across the centre, and these are performed slowly to enable the client to enhance feedback mechanisms to allow self correction of the lumbo-pelvic region in a variety of increasingly difficult start positions from stable to more unstable. (Direction Control) Over time, improvements in the efficiency of the motor planning areas of the CNS (central nervous system) map correct patterns of stability recruitment, improving predictions of where muscular activity will need to be undertaken and under how much effort. The muscles themselves adapt physiologically to the workload. After the client can appropriately recruit the stabilising muscles, and can reduce compensatory movements, then it is the turn of the mobilising musculature to be the focus. The limbs or the spine itself are moved through range with the Pilates Teacher making sure correct skeletal alignment and pathways of movement are obtained (Range Control) e while still keeping one eye on the stabilising components making sure they continue to adequately support during increasing loads. (Direction Control e high threshold). Muscles are concentrically worked to get to their full available inner range, unilaterally or bilaterally. (Range Control) Muscles, and other soft tissues, that have shortened through over use or poor postural positioning, require stretching techniques to be interspersed through the exercise sessions to lengthen them. The stretching of an antagonist can allow the agonist on the other side of the joint to concentrically shorten further, shifting the available inner range more towards its ideal inner range. (Range Control)
Mobilising muscles are also worked eccentrically to decelerate or control all parts of the eccentric range from inner to the full outer range. (Range Control) Flowing full range alternating concentric and eccentric movements can be attempted with variable loads or speed depending on whether the client needs to strengthen or gain postural control. (Range Control e low and high threshold).
Application Pilates Teachers already work in detail but focusing down an exercise to achieve a single goal - correcting an identified movement fault e while still other ‘good things’ are happening at the same time can mean that true specificity is achieved and that the blurring of goals does not happen. A possible watering down of effectiveness of therapeutic intervention may be avoided. It is not necessary for all Pilates Teachers to consider the way they work in the light of the management of uncontrolled movement. But for those who work closely with therapists, creating a common understanding of how the Pilates method might work in rehabilitation environments is useful for Therapists, Pilates Teachers and most importantly their shared clients.
Acknowledgements All photo’s kindly supplied by the copyright holders Movement Performance Solutions from their website www. theperformancematrix.com
References Comerford, M., Mottram, S., 2012. Kinetic Control: the Management of Uncontrolled Movement. Churchill Livingstone, Elsevier. Comerford, M., Mottram, S., 2001. Functional stability re-training: principles and strategies for managing mechanical dysfunction. Man. Ther. 6 (1), 3e14. Jull, G.A., O’Leary, S.P., Falla, D.L., 2008. Clinical assessment of the deep cervical flexor muscles: the Craniocervical Flexion Test. J. Manipulative Physiol. Ther., 525e533. Jull, G.A., Falla, D.L., Vicenzino, B., Hodges, P.W., 2009. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Man. Ther. 14, 696e701. Latey, P., 2001. The Pilates method: history and philosophy. J. Bodyw. Mov. Ther. 5 (4), 275e282. Websource 1 www.theperformancematrix.com.
PREVENTION & REHABILITATION: PRACTICAL EXERCISE SEQUENCE
bracing may become obvious with co-contraction rigidity. The loads may all appear to be high. Limb movements may appear to deviate into rotation, off the intended line, and the exercise could appear rushed at points of peak loading. It is the task of the Pilates Teacher to prioritise what observed fault should be worked on first, there is no exact recipe but a variety of choices can be made to improve the performance of the individual. A typical work flow may include the following points which cover technique or the mechanism the Teacher may be utilising to gain improvements in the body of the client. The order may be rearranged as per requirement:
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
PREVENTION & REHABILITATION: PRACTICAL EXERCISE SEQUENCE
PREVENTION & REHABILITATION: PRACTICAL EXERCISE SEQUENCE
Pilates: Ranging beyond neutral e A practical discussion Warrick McNeill, Dip. Phyty. (NZ) MCSP* Physioworks, 4 Mandeville Place, London W1U 2BG, UK Received 6 November 2013; accepted 6 November 2013
KEYWORDS Pilates; Uncontrolled movement; Specific exercise; Direction control; Range control
Abstract The presence of ‘uncontrolled movement’ within the human neuromusculoskeletal system can be found if the movement control system (mind) and muscular system (body) is tested for their combined ability to successfully control low threshold forces, such as those affecting posture and alignment, or, high threshold forces, such as those requiring muscular strength to control. Deciding which exercises are the best to ‘fix’ the uncontrolled movements found is a fundamental part of the rehabilitative process. It has been suggested that specific exercises are best suited to fix specific faults. Direction Control and Range Control exercises are postulated as two key types of specific exercises that should be used when specific uncontrolled movements are found. In this paper, examples of the application of these two types of exercises are discussed, as is the fact that the ‘mind and body’ focused Pilates method already uses these two key exercise types as elements within its own system of exercise. ª 2013 Elsevier Ltd. All rights reserved.
The Pilates method of exercise may be used as a form of exercise that is regarded primarily connecting the mind and body e with an ‘emphasis on understanding the body and improving awareness while connecting breathing’ (Latey, 2001). What Latey calls ‘Modern Pilates’ involves tailored exercises particular to the clients needs, body type, strengths and weaknesses. It is the application of the principles of pilates to the needs of the clients which helps determine exercise choice, and, perhaps it is this that indicates the true skill of a Pilates Teacher.
* Tel.: þ44 7973 122996. E-mail address: [email protected].
In the preceding Editorial Comerford and Mottram (2012, 2001) are reported as proposing two key types of specific exercise to be used in response to finding uncontrolled movement on testing an individuals movement system. These are ‘Direction Control’ and ‘Range Control’ exercises. Direction Control exercises can be called ‘dissociation’ exercises e that is; fundamentally keeping a joint or region in a protective neutral position, and controlling it while moving the region directly superior or inferior to it. This type of exercise aims to improve the Central Nervous System (CNS) and muscular control of the region. Until this has been attained the uncontrolled movement has not been adequately managed.
1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jbmt.2013.11.013
There also needs to be a control of the movement through a joints normal ideal range, this is called Range Control. Comerford and Mottram highlight the need for Range Control exercises to improve the ability of stabilising muscles to be able to reach their ideal inner range, as well as smoothly eccentrically control their movement to outer range, control the possibility of rotation in that region and decelerate forces throughout the body as well. What follows is a discussion of a few examples of Direction Control and Range Control exercises so the reader can ascertain how a pattern of similar exercises could be applied to other regions of the body. The last section contains a possible interpretation of an analysis of Pilates movement. This shows the similarities between the key exercises as described by Comerford and Mottram and Pilates. If Comerford and Mottram are correct in their approach, it may suggest a reason why Pilates has anecdotally been perceived to be effective at managing movement control problems.
Direction control exercise examples If, on testing, an individual is shown to have uncontrolled movement in the lumbar spine into the direction of extension, it suggests that the muscles of the anterior abdominal wall are failing to be recruited appropriately or lack the strength to prevent forces from extending the lumbar region during movements of the body being tested. Direction Control exercises are therefore indicated to assist the individual to retrain this control. These Direction Control exercises challenge the individual to keep the area affected, in this case the Lumbar spine, still and in neutral, while adding a challenge to the lumbar spine by moving the region above or below the site in a direction that results in the individual having to focus on recruiting the synergistic muscles in the area to prevent the affected region moving. Choosing the correct exercise for the individual is made using trial and error methods. It is important that the individual is actually achieving the task so may need assistance in the form of cueing, handling or the use of mirrors to help them succeed in exhibiting the desired control. These are ‘dissociation’ exercises, as the individual is learning not to link or ‘associate’ hip extension with lumbar extension, in a ‘dissociation below’ exercise, or thoracic extension with lumbar extension in a ‘dissociation above’ exercise. Image 1 shows a well supported, long lever hip extension while the individual is using the bed for support and her hand on the lumbar spine for external feedback. She has been instructed to keep her lumbar spine in neutral and maintain her breathing to avoid using a bracing pattern to keep the lumbar spine still. She has also been instructed to recruit her anterior abdominal wall without making any one muscle the dominant player, though this may mean that she is given cues that may bias her concentration on to the obliques. A correct pattern for the movement of the hip will be encouraged with the focus being given to the gluteus maximus to be the main driver of the hip extension though the hamstrings will obviously be recruited in this long lever movement. The decision to use a long lever as opposed to a short lever (flexing the knee of the moving limb) is based on
125
Image 1 Direction control exercise. Site: lumbar spine, Direction: lumbar extension, Threshold: low. Description: lumbar extension dissociation, below. Supported prone hip extension with proprioceptive assistance. Reset hip to flexed position smoothly to repeat. Duration: Up 2 min, based on quality of execution.
whether the client is able to successfully keep the lumbar spine still, especially during the hip extension phase of the exercise. The moving limb is then reset smoothly into hip flexion e which is more likely to encourage the clients lumbar spine to move into flexion e which may not be difficult for her e as it was lumbar extension that had been the identified as the uncontrolled movement. As this exercise is using just limb load it is regarded as a low threshold or low load exercise that challenges postural or alignment loads and the anterior abdominal wall synergy should be a slow motor unit dominant activity. To maintain this bias the exercise must be repeated slowly. Comerford and Mottram suggest the exercise should be maintained for approximately 2 min as long as the quality of the control remains good. Two minutes is a time frame that will show if a fatiguing strength type strategy was employed instead of the postural load as the client would fatigue out e perhaps indicated by changing their strategy of support to be a braced breath holding pattern. Though in a Direction Control exercise it is about controlling the direction of the affected region, so if a high threshold strategy was the only method that could control the lumbar extension that would be acceptable initially though the therapist/instructor would be encouraging the client to use a more correct strategy for the exercise over time. The second example Image 2A and B, is a similar Direction Control exercise using ‘dissociation above.’ This means that the challenge comes from above the lumbar spine. This exercise involving a swiss ball uses arm extension e combined with thoracic extension, in standing, to apply the extension challenge to the lumbar spine controllers of extension. If it was just gleno-humeral extension the dissociation challenge would apply to the entire spine but the aim here is to narrow the focus to the lumbar spine only. It is still a posture and alignment load, a low threshold load, though more of a challenge as the clients base of support is small as it is performed in standing. Proprioceptive feed back could be enhanced by allowing the client to view their image in a mirror. The exercise instruction to the client is to lift the ball and extend the thoracic spine while preventing the lumbar spine from extending. An
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Image 3 A & B. Direction control exercise. Site: lumbar Spine, Direction: lumbar extension, Threshold: high. Description: lumbar extension dissociation, below. Unstable base unsupported single hip extension from bilateral hip/knee 90/90 position. Reset hip to flexed position smoothly to repeat. Duration: approximately 1 min, based on fatigue.
Image 2 A & B. Direction control exercise. Site: lumbar Spine, Direction: lumbar extension, Threshold: low. Description: lumbar extension dissociation, above. Standing thoracic and shoulder extension using a swiss ball as load. Reset thoracic spine and shoulders to start position smoothly to repeat. Duration: Up 2 min, based on quality of execution.
anterior abdominal wall synergy is recruited. The range of movement of the thoracic spine must be kept in as small a range as necessary to prevent any movement spilling and creating lumbar extension. The duration of time allocated for the exercise is up to 2 min depending on the quality of movement and the instructor may use verbal cueing through out to keep the pattern of control correct to avoid breath holding or bracing. To make either of these exercises a greater load challenge to bias the synergy of control from slow motor unit dominance to fast motor unit dominance the application of greater loads or speed can be applied. Speeding up the rate of the movements would work in both these examples or adding weight - such as an ankle weight for the hip extension or changing the swiss ball for a theraband resistance, or even using both increased speed and increased load. An unstable base or smaller base of support can add to the challenge of the exercise. The object of the exercise, no matter its speed, load or challenge is to maintain the quality of the movement control exhibited by the client. Image 3 shows a higher load Direction Control exercise dissociating lumbar extension from hip extension, so it is a ‘high threshold dissociation below exercise’. This particular example may actually be a low threshold exercise for a well trained, strong individual, though for an under-trained
weaker one the load could be sufficient to require fast motor unit recruitment in the anterior abdominal wall. To push the exercise to being more cleanly a high threshold exercise, the instruction to the client could be to speed up the movements, or add a weight to the ankles. The unstable base may be enough to make the exercise a higher threshold. This single leg hip extension provides a lumbar extension control requirement for the lumbar spine. It uses eccentric hip flexor muscle work on the outward journey and concentric on the return. The exercise adds a rotary challenge to the exercise, which may also require cueing for the client to successfully exhibit control over e though this should not confuse the issue that this exercise in this situation is being used to retrain the lumbar extension uncontrolled movement. Image 4 shows an example of a Direction Control exercise e a high threshold dissociation exercise for lumbar extension with the loading coming from above the lumbar spine. Despite the paddling movement of the arms it is the extension of the thoracic spine that makes this dissociation exercise work, the long lever of the arms with weights in the hands ramps up the loading so the anterior abdominal wall has to work using strength to prevent the lumbar spine from extending. With the movement of the arms being reciprocal in this exercise and ideally being quick, the loading is further enhanced. The unstable base provided by the bosu also adds to the loading effect on the anterior abdominal wall. The exercise should result in the client fatiguing out in their abdominals in around a minute or so if the exercise is targeted at the right loading, as this is the time frame that a muscle fibre starts to deplete its glycogen store if the exercise is fast motor unit dominant. Adding time or load to continue the over-loading element to the
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Image 4 Direction control exercise. Site: lumbar Spine, Direction: lumbar extension, Threshold: high. Description: lumbar extension dissociation, above. Unstable base thoracic extension with reciprocally paddling arms with hand weights. Reset thoracic spine to a flexed position smoothly to repeat. Duration: approximately 1 min, based on fatigue.
exercise over subsequent sessions is important as the aim is to increase the strength of the anterior abdominal wall. Other muscles will also be gaining strength as a positive side effect but again the aim here is to retrain the ability of the anterior abdominal wall to control a high threshold challenge of lumbar extension. The principals of the Direction Control exercises can easily be applied to other uncontrolled movements at different sites and directions through out the body.
Range Control exercise examples To demonstrate Range Control exercises the muscles being recruited become less a synergistic pattern and more a specific muscle exercise, though under increased loads a synergy may become necessary to execute the exercise. In a Range Control exercise the aim is to improve the ability of a muscle, usually a stabilising muscle, to get to its inner range, or even, over time, to improve previously lost inner range. In this example the muscle in question is the Iliacus, a primary one joint hip flexor. In a movement impaired individual their Iliacus muscle may lose its ability to get into its inner range because of a lumbar flexion uncontrolled movement, as the individual may have historically associated lumbar flexion/posterior pelvic tilt with hip flexion. This associated movement can maintain the Iliacus in a lengthened position and over time ‘setting’ the length of the Iliacus into a non ideal longer length. This stabiliser muscle does need to be able to drive hip flexion to its full range, not least to keep its antagonist musculature and non-contractile tissues on the posterior side of the hip joint long. Comerford and Mottram advocate the use of inner range holds of the affected muscle after a concentric action moving the joint to the desired range (Comerford and Mottram, 2001). After an isometric hold of 10 s the muscle is allowed to concentrically lengthen. Depending on the start position of the exercise the eccentric movement can aim to achieve its full outer range. Ideally this specific muscle exercise should also control any rotary forces acting with out the substitution of other muscles inappropriately trying to assist. The exercise is repeated so that 10 10 s holds (Jull et al., 2008, 2009) in the best inner range possible is attained, using a high quality execution of the exercise.
Image 5 Range Control exercise. Specific muscle: Iliacus. Associated uncontrolled movement e Site: lumbar spine, Direction: lumbar flexion/posterior pelvic tilt, Threshold: low. Description: inner range hold for the Iliacus muscle e including concentric flexion to get to inner range and eccentric control back to the start position. Client flexes hip from sitting to maximum inner range attainable without substitution of the superficial hip flexors. Duration: approximately 10 by 10 s holds, based on fatigue and/or movement quality.
The Authors of, ‘The management of uncontrolled movement,’ also suggest that it may be easier to teach the specific elements of the exercise under lighter postural loads as there is a chance for the client to use feedback to alter the exercise once it is under way, however, a low threshold uncontrolled movement might need a higher load to facilitate the correct execution of the exercise by increasing the feedback. Image 5 shows an unsupported sitting version of an iliacus Range Control exercise with the key focus being on the inner range hold, though, the movement of the exercise also includes the concentric hip flexion up to the inner range as well as the eccentric control on its return. The aim of the exercise, to improve the inner range, must not be impeded by faults in execution such as bracing (including breath holding), or substitution. Substitution can be detected by the client themselves, or the instructor gently placing their finger tips inferior to the inguinal line on the lifting leg in the area of the superficial hip flexors. If a ‘gripping’ sensation ensues this is likely to be the substitution of the superficial hip flexors trying to vie with the Iliacus for dominance in the movement pattern. If this is detected the exercise is stopped and started again only getting to a height that the iliacus can actually, cleanly flex to. The full 10 repetitions should only be used if fatigue or an absence of substitution allows the client to get to that number of repetitions with high quality movement. Image 6 by adding resistance tubing to an iliacus dominant hip flexion, and reducing the base of support to a single foot, the loading dominance of the exercise becomes high threshold. Keeping the dominance of the exercise to
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Pilates: Ranging beyond neutral
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PREVENTION & REHABILITATION: PRACTICAL EXERCISE SEQUENCE
Similarities between direction and Range Control exercises and Pilates Range Control exercises are clearly different from Direction Control but they are an important next step in the rehabilitation of movement control. Moving away from just controlling neutral is important. Therapists may fixate on neutral to protect their client, however controlling the range of movements has been the norm in Pilates exercise since Joseph Pilates started to develop his ideas in the early part of the 20th Century. The similarity between current Pilates work and the exercises described by Comerford and Mottram is apparent (Websource 1), and the following description of a possible work flow a Pilates Teacher may use, highlights the amount of work undertaken in Pilates that conforms to the requirements of the concepts of Direction Control, and even more so, Range Control. If a Pilates Teacher steps out of their environment and observes their workflow with an enquiring mind they may find that applying ‘specific exercise’ concepts to correct a single named fault that they have identified, and, if they work specifically to fix that one fault as opposed to many faults at a time, it is possible, that the increased attention to detail may more efficiently resolve the identified movement fault.
An analysis of Pilates movement Image 6 Range Control exercise. Specific muscle: Iliacus. Associated uncontrolled movement e Site: lumbar spine, Direction: lumbar flexion/posterior pelvic tilt, Threshold: high. Description: Inner range hold for the Iliacus muscle e including concentric flexion to get to inner range and eccentric control back to the start position. Client flexes hip from standing to maximum inner range attainable without substitution of the superficial hip flexors. Duration: approximately 10 by 10 s holds, based on fatigue and/or movement quality
Iliacus with out the superficial hip flexors substituting for it may become more difficult. This is because there will be increasing load on the entire movement meaning that more muscle action is required to successfully flex the hip. It becomes a question of assessing dominance - is the movement being undertaken by the specific muscle being targeted or other muscles? Usually it will be stronger, short, two joint mobilising muscles trying to take over from under recruited, longer stabilising muscles. Determining how much work a mobiliser is ‘allowed’ to do before it is dominant may take time for a novice instructor to develop assessing skills, but little ‘tells’ such as cramping in the substituting musculature can be helpful. Good finger tip palpation can be useful. A key practical tip is if the instructor is unsure if there is dominance of the substitution musculature, they should stop the exercise and start again. If the apparent dominance continues, it may mean the Iliacus has fatigued and needs to rest and recover, and the exercise should be continued at a later time. In this exercise the range of the iliacus can extend to full outer range if the leg is allowed to move to full extension while keeping the foot clear of the floor.
When the movement vernacular of Pilates is assessed some key points about the movement becomes obvious e in a well executed Pilates exercise there is precision throughout its movements, it looks flowing, smooth. This is related, of course, to the central principles of Pilates. Pilates aims to attain balance between the stabilising muscles anchoring one body region (Direction Control) while the muscles moving an adjacent joint or region, work efficiently to move from one extreme of range (sometimes hyper-mobile) to the other and back again (Range Control). The concentric and eccentric phases should smoothly transition, without judder and without an altered path from the movements ideal. The full range of ideal movement may be achieved, perhaps concentrically to inner range and eccentrically to outer. The muscles should be able to appropriately vary their handling of load from light postural loads, or perhaps gravity eliminated loads, but also be able to ramp up to take loads equivalent to many times body weight, or loads that must be managed at speed. Pilates is about the body working efficiently to the edges of its design parameters. When observing a poorly executed exercise, precision appears to be sacrificed. The exercise is no longer smooth. The stabilising muscles meant to be anchoring are over powered by the load and the no longer anchored body part shifts to make the work easier, advantaging stronger, inappropriate muscles or synergies. The muscles involved in creating the exercises movement may not be able to achieve the full range in one or both directions. A shake may be observed in a concentric phase and perhaps the eccentric return develops a judder as the muscle fails to lengthen smoothly. Other compensations like breath holding or
Pilates: Ranging beyond neutral
Invariably proximal stability is focused on first, with a neutral lumbo-pelvic region being prioritised. (Direction Control) Short lever limb movements are used to create loads across the centre, and these are performed slowly to enable the client to enhance feedback mechanisms to allow self correction of the lumbo-pelvic region in a variety of increasingly difficult start positions from stable to more unstable. (Direction Control) Over time, improvements in the efficiency of the motor planning areas of the CNS (central nervous system) map correct patterns of stability recruitment, improving predictions of where muscular activity will need to be undertaken and under how much effort. The muscles themselves adapt physiologically to the workload. After the client can appropriately recruit the stabilising muscles, and can reduce compensatory movements, then it is the turn of the mobilising musculature to be the focus. The limbs or the spine itself are moved through range with the Pilates Teacher making sure correct skeletal alignment and pathways of movement are obtained (Range Control) e while still keeping one eye on the stabilising components making sure they continue to adequately support during increasing loads. (Direction Control e high threshold). Muscles are concentrically worked to get to their full available inner range, unilaterally or bilaterally. (Range Control) Muscles, and other soft tissues, that have shortened through over use or poor postural positioning, require stretching techniques to be interspersed through the exercise sessions to lengthen them. The stretching of an antagonist can allow the agonist on the other side of the joint to concentrically shorten further, shifting the available inner range more towards its ideal inner range. (Range Control)
Mobilising muscles are also worked eccentrically to decelerate or control all parts of the eccentric range from inner to the full outer range. (Range Control) Flowing full range alternating concentric and eccentric movements can be attempted with variable loads or speed depending on whether the client needs to strengthen or gain postural control. (Range Control e low and high threshold).
Application Pilates Teachers already work in detail but focusing down an exercise to achieve a single goal - correcting an identified movement fault e while still other ‘good things’ are happening at the same time can mean that true specificity is achieved and that the blurring of goals does not happen. A possible watering down of effectiveness of therapeutic intervention may be avoided. It is not necessary for all Pilates Teachers to consider the way they work in the light of the management of uncontrolled movement. But for those who work closely with therapists, creating a common understanding of how the Pilates method might work in rehabilitation environments is useful for Therapists, Pilates Teachers and most importantly their shared clients.
Acknowledgements All photo’s kindly supplied by the copyright holders Movement Performance Solutions from their website www. theperformancematrix.com
References Comerford, M., Mottram, S., 2012. Kinetic Control: the Management of Uncontrolled Movement. Churchill Livingstone, Elsevier. Comerford, M., Mottram, S., 2001. Functional stability re-training: principles and strategies for managing mechanical dysfunction. Man. Ther. 6 (1), 3e14. Jull, G.A., O’Leary, S.P., Falla, D.L., 2008. Clinical assessment of the deep cervical flexor muscles: the Craniocervical Flexion Test. J. Manipulative Physiol. Ther., 525e533. Jull, G.A., Falla, D.L., Vicenzino, B., Hodges, P.W., 2009. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Man. Ther. 14, 696e701. Latey, P., 2001. The Pilates method: history and philosophy. J. Bodyw. Mov. Ther. 5 (4), 275e282. Websource 1 www.theperformancematrix.com.
PREVENTION & REHABILITATION: PRACTICAL EXERCISE SEQUENCE
bracing may become obvious with co-contraction rigidity. The loads may all appear to be high. Limb movements may appear to deviate into rotation, off the intended line, and the exercise could appear rushed at points of peak loading. It is the task of the Pilates Teacher to prioritise what observed fault should be worked on first, there is no exact recipe but a variety of choices can be made to improve the performance of the individual. A typical work flow may include the following points which cover technique or the mechanism the Teacher may be utilising to gain improvements in the body of the client. The order may be rearranged as per requirement:
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