Pilates method principles for hip and knee rehabilitation

¶ … Pilates Method of Mental and Physical Conditioning, as an aid to Hip and Knee Rehabilitation

Pilates, invented at the turn of the 20th century, was not popularized outside specialized dance and athletic worlds until about the past 15 years. However, it seems to be a perfect format for regaining function in a variety of knee and hip conditions. "An important aspect of the Body Control Pilates programme is that it is non-competitive, being geared to an individual's needs and degree of commitment. It balances muscular strength and flexibility asymmetries while working at the client's own pace. This means that it is as appropriate for the elite athlete as it is for a first-time exerciser' (Robinson and Thomson, 2002, Positive Health Web site). That would also make it useful for rehabilitation after knee and hip injuries or hip replacement. Robinson and Thomson note that it is particularly good for sufferers of repetitive strain injuries, and for anyone wanting to prevent the onset of osteoporosis (2002, Positive Health Web site).

Principles of Pilates

There are eight foundation principles of Pilates. According to the Danceanddrama Web site, they are:

Concentration

Breath

Control

Precision

Flowing Movement

Isolation

Routine

This is not "mindless exercise" but rather requires someone -- in the case of rehabilitation, the therapist -- to put some thought into the proper exercises and the proper order of exercises to accomplish the rehabilitation sought. Importantly, Pilates recognizes, in several of its principles, the fact that the torso ultimately controls actions of the extremities; therefore, the Pilates concentration on torso control and improvement cannot help but improve the use and function of muscles of the hip and knee in rehabilitation.

In addition, while most people think of hard, fast movements as being needed for building strength, Pilates movements are slow and methodical but through them, Robinson and Thomson note, strength is regained (2002, Positive Health Web site), a prime intention in almost any rehabilitation program

Because precision is also a prime directive in properly performed Pilates, the rehabilitation therapist has a built-in reason to be very particular with each patient and, after being taught the reasoning behind Pilates, the rehab patient will have no excuse not to comply. At the same time, Pilates movements are continuous movement, and therefore assist in limbering all muscles, not just those that are the targets of the isolation. Robinson and Thomson note that Pilates exercises "challenge each person differently as with different body types and different training programs, we all have different strengths and weaknesses" and the same is true, in even greater magnitude, when it comes to hip and knee rehabilitation. Robinson and Thomson's final statement regarding the eight principles is, however, the most cogent for knee and hip rehabilitation therapists. "As with any principal repetition and frequency leads to the skill level rising. The technique is not meant to be a replacement for any other activity but an addition, to strengthen your body for whatever activity you need it for" (2002, Positive Health Web site).

Knee and Hip conditions

When it comes to knees, the most important thing is to realize there are four ligaments holding it in place: one is at each side keeping the bones from sliding sideways and two cross over it in the middle to stop the bones from sliding forward and backwards. The two in the middle are called the cruciate ligaments: if they are damaged, they may cause knee pain (Sportsinjury clinic Web site, undated).

This figure shows a partial rupture of the anterior cruciate ligament of a left knee.

Source: Sportsinjuryclinic Web site, undated

Cruciate ligament

Injury to the cruciate ligaments ordinarily happens when the knee is twisted or by an impact to the side of the knee, most often the outside. Indications of injury include pain at the time of impact that decreases later; swelling, instability of the joint when the swelling has receded; pain upon bending the leg (Sportsinjury Web site, undated).

Experts advise beginning rehabilitation from the time of injury, not necessarily from the time of surgery if surgery is the option. Mobility exercises are consider important; Pilates is appropriate, as it is for strengthening and for proprioception (Sportsinjuryclinic Web site, undated).

Osteoarthritis

Osteoarthritis is also called degenerative joint disease and most commonly affects older people (NIAMS, 2002, Web site).

The disease affects cartilage, a slipper tissue covering the ends of bones within the joint, allowing bones to glide across one another and absorbing physical shock as long as the cartilage is healthy. In osteoarthritis, this layer breaks down and wears away, allowing bones to rub together and cause pain, swelling and restricted movement of the joint.

Eventually, the joint may become misshapen, and bone spurs may grow at the edges of the joint; some may even break off causing more pain and further limiting movement (NIAMS, 2002, Web site).

Rheumatoid arthritis

Rheumatoid arthritis, unlike osteoarthritis, affects more than joints, but internal organs as well. "It begins at a younger age than osteoarthritis, causes swelling and redness in joints, and may make people feel sick, tired, and (uncommonly) feverish" (NIAMS, 2002, Web site).

Miniscal damage

Also called miniscus can be injured by changing direction rapidly slowing down suddenly when running, landing after jumping, a direct event such as a football tackle. (Dr. Girard Web site, undated). Often, such tears require surgical reconstruction. Even lesser tears call for significant rehabilitation. "If you injure your miniscus, you may not feel any pain immediately. However, you might hear a popping noise and feel your knee give out from under you" and If you walk or run on an injured miniscus, you can damage the cushioning cartilage in the knee" (Dr. Girard Web site, undated). As noted earlier, rehabilitation should begin with injuries even before any needed surgery is scheduled. Pilates, according to the parameters above, seems to be the perfect modality. In fact, although he advocates the use of a brace to provide stability, Dr. Girard recommends a treatment program of muscle strengthening; another indication that Pilates exercise would be beneficial.

Dr. Girard notes that most such rehabilitation plans will include:

Passive range-of-motion exercises designed to restore flexibility.

Braces to control joint movement.

Exercises to strengthen the quadriceps muscles in the front of the thigh. (Muscle strength is needed to provide the knee joint with as much support and stability as possible when weight is placed on it.)

Although arthritis is part of the name, rheumatoid arthritis is actually an autoimmune disease in which the body attacks its own tissues; antibodies in the blood, in targeting the supposedly 'foreign' tissues, can b associated with inflammation (Shiel, Medicinet Web site, 2005). Although at times, those with rheumatoid arthritis can go for years without symptoms, typically, it is a progressive illness with " the potential to cause joint destruction and functional disability" (Shiel, Medicinet Web site, 2005).

Knee replacement

Total knee replacement can be done surgically, with the injured or damaged parts replaced with artificial parts. The knee capsule, a tough, gristle-like collection of tissues, is opened to expose the joint, where the femur and tibia are removed as well as, often, the underside of the kneecap, or patella. The artificial parts are cemented into place. Those parts include a metal shell on the end of the femur, a metal plate and plastic trough at the end of the tibia and, when the patella is involved, a plastic button in the kneecap (University of Iowa, 2005).

The muscles will become weak after such surgery (as after hip replacement, discussed below) and exercise will be needed. While the University of Iowa Web site describes standard exercises, Pilates -- because there is little weight bearing involved -- would work well to strengthen the knee and surrounding tissues after surgery. Below is a photo of a typical knee replacement arrangement.

Source: University of Iowa Web site

Hip replacement

When it has been injured, like the knee, the hip can be replaced.

Usually, the hip is damaged by arthritis, or sometime fracture or some other conditions.

First performed in 1960, more than 172,221 total hip replacements are performed each year in the United States. Similar surgical procedures are performed on other joints, including the knee, shoulder, and elbow (Shiel, Medicinet Web site, 2005).

Like the knee, the hip is a weight-bearing joint. Also like the knee, it consists of two main parts. In this case, the ball at the end of the femur fits into a rounded socket in the pelvis, connected -- like the knee, with bands of tissue to provide stability in the joint. It, like the knee, has a smooth surface of durable cartilage to enable the ends of bones to glide smoothly; when this is damaged, as by osteoarthritis, rheumatoid arthritis or injury, gliding is restricted and there is pain.

When either the knee or hip joint is affected by arthritis or injury, the ability to hold the body erect is compromised and the gait is also compromised. When this happens, other muscles and joints may compensate, in an attempt to achieve equilibrium, and also suffer damage (American Academy of Orthopaedic Surgeons Web site).

Exercises using the Swiss Ball

Designed in many cases to be useful for prevention of low back pain, exercises with a Swiss ball or physio ball are also common to Pilates and have implications for rehabilitation of the hip and knee because they are non-weight-bearing, but do offer strengthening and muscle control rehabilitation (Spine-Health Web site, 2005).

With the exercise ball, an element of instability is introduced to the exercise that one would not normally get in a floor exercise. The body responds naturally and automatically to this instability to keep balanced on the exercise ball. Over time, the muscles used to keep in balance on the Swiss ball become stronger. In essence, individuals build strength in important back muscles and abdominal muscles without knowing it" (Spine-Health Web site, 2005), and this assists in creating a foundation for knee and hip rehabilitation exercises.

In addition, "it is theorized that the type of spinal movement induced by using the exercise ball (small range, adjustment of balance) may help reduce pain by stimulating the body to produce increased amounts of natural pain inhibitors" (Spine-Health Web site, 2005).

Case studies

Following are two case studies involving Pilates,

Female 'C', age 26, Interior Designer.

C' had injured her knee in a skiing accident. She was diagnosed as having a subluxation in the extension of both patellae due to rotary abnormality of the knee. After six weeks of physiotherapy she was still limping and in pain.

C' attended the Body Control Studio in South Kensington where she used the special Pilates machines. She was given remedial exercises to strengthen her leg muscles and was also encouraged to work the rest of her body, with due attention to safeguarding her knee. After just six weeks she had made a complete recovery.

C' writes:

had a very bad knee from skiing and could not walk. I knew that if I did not do something, I would not be able to ski again. I have been to gyms and 'pumped iron', but with Pilates I feel relaxed and understand what I am doing'." (Robinson and Thomson, Positive Health Web site, 2002)

Female 'J', age 38, administrator.

Referred by her GP for osteopathy with Piers Chandler, having complained of upper back and shoulder pain for approximately two years. She had been involved in a road traffic accident three years earlier. Physiotherapy had made no difference. 'J' has a scoliosis's shape with a high left shoulder and high right hip. Chandler's treatment helped, but he felt she needed to try 'whole body exercise' for scoliosis and, therefore, advised Pilates.

J' joined a group matwork Pilates class. The sessions included exercises to improve body awareness, alignment, relaxation, breathing, core stability, strength and flexibility. The overall postural programme has helped with her scoliosis. In addition, 'J' was given remedial exercises for stretching and mobilising her upper body and shoulders. She then concentrated working to stabilise her scapulae, strengthening the Lower Trapezius, not just with specialised exercises but as part of all her movements. She uses light weights to help build her strength.

Two years on, her level of fitness has improved dramatically and she is now able to do the advanced work without strain.

J' writes:

feel stronger and more flexible, with much improved abdominal strength and a greater range of movement. My osteopath told me that my improved posture had made me taller, and that my back was broader. It has been easy to fit Pilates into my way of life, the classes are enjoyable and relaxing and I have been able to follow the routine easily at home. My ability to do the more advanced exercises has crept up on me steadily. The combination of osteopathic treatment and Pilates has been very beneficial and I have only needed to visit the osteopath once in the last eighteen months'." (Robinson and Thomson, Positive Health Web site, 2002).