The Pilates method 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).

Pilates matwork exercises

While there are dozens of matwork exercises, the rollback is basic and typical. Because it strengthens the spin and facilitates motor control, it is essential before beginning other exercises. "It is a key movement in the Pilates system because it addresses the core musculature of the powerhouse in detail. This exercise gives an opportunity for an instructor to observe the body's symmetry. It allows them to cue a client to move straight through the spine, correcting the body's inefficient

" (Coleman-Brown and Haley-Kanigel, 2003).

Below are Coleman-Brown and Haley-Kanigel's instructions:

1. Sit on a mat with knees bent, heels together, and knees in line with the shoulders. Place hands behind thighs and make sure shoulders are over hips. Pull the powerhouse in and up, hollowing out the abdomen. Eyes gaze toward navel (photo 2,-page 28).

2. Roll back one vertebra at a time, starting from the base of the spine, until the elbows are straight or only as far back as you can control segmentally. The arms act to assist the abdominals as necessary. Then reverse the move (photo 3,-page 28).

3. Repeat five times, or as many as can be performed precisely.

Kloubec and Banks offer a basic Pilates routine that addresses virtually all the issues involved in hip and knee rehabilitation. They are:

Ab Prep. In a supine position, curl up with your hands by your sides, knees bent and feet on the floor. Stabilize the neck, scapula, and ribs, pull in and flatten the transverse abdominus, exhale to initiate movement, hold for one inhale, release and return on exhale.

Breaststroke. In a prone position, raise your arms overhead and sweep them to the side as the torso lifts from the mat. Holding your arms at the side, the torso "hovers." Then sweep your arms back overhead. Keep your neck long and the scapula retracted.

Half Roll Back. Sit upright with legs bent and feet flat on the floor. Roll half way back down to the floor, hold for one breath (inhale), exhale, and return to a seated position.

Spine Twist. Sitting upright, with legs extended in front slightly farther apart than hip width, and arms horizontally extended from the shoulders, twist the torso to the right on three exhaled breaths. On the inhale, return to center. Repeat on left side. Maximally rotate on the first exhale, then lengthen and increase the motion of rotation with the next two breaths.

Swan Dive Prep. In a prone position with arms extended overhead, press your torso into limited hyperextension. As the torso returns to the mat, extend and lift your legs (rocking on the pelvis).

Rolling Like a Ball. Lift your legs up to the chest, balance on the sitz bones, roll backward, and return to a seated, balanced position. Repeat. Concentrate on staying in full flexion (C-curve) throughout the movement. Use abdominals to initiate and control the movement.

Leg Pull Front Prep. In a prone position, extend your arms to assume a push-up position, lift one leg, extend the back and flex forward on the toes. Then repeat with the other leg. Keep your neck in line with the spine, with the scapula retracted and the transverse abdominals tightened throughout" (Kloubec and Banks, 2004, p. 34+).

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.