PILATE-DYNAMIC STRETCHING TECHNIQUE

BY

OGUNDARE MOSES TOSIN

(130704019)

A TERM PAPER ASSIGNMENT SUBMITTED TO

ORTHOPADIC UNIT, DEPARTMENT OF
PHYSIOTHERAPY, SCHOOL OF POST GRADUATE
STUDIES, UNIVERSITY OF LAGOS.

APRIL 2024
 INTRODUCTION
Pilates is a system of exercises using special apparatus, designed to improve physical strength,
flexibility, posture and enhance mental awareness. Stretching exercises are widely used in
training routines, typically preceding or following main exercise practice, whether the objective
is related to rehabilitation (Oxford, 2013) or physical conditioning (Owsley, 2015), also aiming
at improving performance in subsequent exercises involving musculoskeletal fitness (Latey,
2010).

In addition, stretching is considered the main exercise to gain flexibility (Mishigura, 2013),
although resistance training alone can promote increased flexibility (Wells et al, 2013).
However, the performance of stretching exercises, preceding muscle strengthening exercises, has
been questioned in the literature over the last few years (Powers and Stefanie, 2015), which
evidently can generate doubts in the definition of intervention protocols for the most diverse
objectives.

Unlike traditional dynamic stretching, in Pilates stretching exercises, the performer holds the
final position of maximum joint amplitude for a few seconds, time necessary to inhale again,
before returning to the initial position, performing exhalation. That is, the performer inhales
whenever he is in the extremities (initial position and position of maximum amplitude) and
exhales whenever he is in motion. This specific technique adopted by Pilates, in comparison with
other forms of stretching, needs to be better explored in the literature. A study that compared
Pilates exercises vs. static stretching identified after 12 weeks that the interventions did not differ
for the following ranges of motion: trunk flexion, hip flexion, plantar flexion and dorsiflexion.
However, Pilates exercises were superior for trunk range of motion in extension and for muscle
strength of knee extensors and flexors (Cakmakçi, 2013). Oliveria et al, (2016) compared static
stretching and the Pilates method on the flexibility of older women, and the study showed that
Pilates exercises are more effective for some body segments. The study set up two randomized
groups (Static stretching or Pilates) to perform exercises of 60min, twice a week, for three
months. Evaluations were done on trunk flexion movement (TFM), trunk extension movement
(TEM), hip flexion movement (HFM), plantar flexion movement (PFM) and dorsiflexion
movement of the ankle (DFM) before and after using a flexi meter (Oliveira, Oliveira, & Pires-
Oliveira, 2016). For the static stretching group, twenty static stretching exercises were
conducted, as recommended by the American College of Sports medicine for cervical and upper
limbs and trunk and lower limbs.

For the Pilates group, twenty Pilates exercises were conducted by a certified Pilates professional
starting with an initial stretching on the Cadillac Trapeze (Spine Stretch, Mermaid, Stretching
Knee); then strengthening of the lower limbs on the Chair and Cadillac Trapeze, followed by
strengthening of the flexor and extensor muscles of the trunk on the Cadillac Trapeze. Finally,
strengthening of the upper limbs on the Universal Reformer and an ending stretch on the
Universal Reformer and the Ladder Barrel

The Pilates group showed a significant improvement across all analyzed variables (TFM, TEM,
HFM, PFM and DFM) while the static group showed significant improvement only for TFM and
HFM. Trunk Extension Movement (TEM) also showed significant difference in favour of the
Pilates group. It is common in Pilates protocols for stretching exercises to be performed at the
beginning of the session, preceding muscle strengthening exercises (Notarnicola et al, 2013).
However, how this impacts a possible harm or benefit in the development of variables such as
strength, power and muscular endurance is unknown. Pilates is a technique used both in cases of
rehabilitation and for physical conditioning, involving stretching exercises and muscle
strengthening.

DESCRIPTION OF PILATE

A systematic review of Pilates in 2012 examined its literature to form a consensus description of
it, and found it could be described as "a mind-body exercise that requires core stability, strength,
and flexibility, and attention to muscle control, posture, and breathing" as seen in figure (1)
below (Wells et al, 2012).
Figure 1; Pilates teacher using verbal and tactile feedback to ensure proper form (Lange et al,
2020).
According to The New York Times, pilates "can be tailored to a spectrum of fitness goals, ages
and abilities". Pilates is not a cardiovascular workout, but rather a strength and flexibility
workout (Friedman, 2023). There are various elements that contribute to distinguishing Pilates
from other forms of resistance training. For example, Pilates places a heavy emphasis on
breathwork and creating a mind-body connection. Joseph Pilates even states "Above all, learn
how to breathe correctly. Participants consciously use the core and breath for all forms of
movement (Friedman, 2023). In his book Return to Life through Contrology (Pilates, 1998)
Joseph Pilates presented his method as the art of controlled movements, which should look and
feel like a workout (not a therapy) when properly done. If practiced consistently, Pilates
improves flexibility, builds strength, and develops control and endurance in the entire body
(Mayo clinic, 2012). It puts emphasis on alignment, breathing, developing a strong core, and
improving coordination and balance. The core, consisting of the muscles of the abdomen, low
back and hips, is often called the "powerhouse" and is thought to be the key to a person's stability
(Houglum, 2016). Pilates' system allows for exercises to be modified in difficulty, from beginner
to advanced or any other level, and to accommodate the instructor's and practitioner's goals
and/or limitations. Their intensity can be increased as the body adapts itself to the exercises
(Mayo clinic, 2012).

A number of versions of Pilates are taught today; most are based on up to nine
principles(stability) (Houglum, 2016).

PILATES METHODS
Pilates, as a method and an exercise movement, yields numerous benefits (Mishigura, 2013).
Its systematic practice leads to increased lung capacity and circulation. It also improves
joint health and bone density. When exercising Pilates, it is important to remember that
every movement should be done slowly and include each of the 6 basic principles.

Concentration - Pay attention to starting position, slow and smooth movements, as well as
each part of the body. Stay focused and do not let yourself be distracted (Wells et al, 2013).

Breathing - Oxygen inhalation refreshes brain and body. Deep breaths clear the lungs, bring
on relaxation, and give a better focus. Coordinate breathing with movement to understand
body work.

Control - Exercises need to be done with a full control of muscle work.

Centering - All movements start from centering – engaging core muscles (deep muscles
such as diaphragm, lumbar multifudus, transversus abdominis, pelvic floor muscles and
their assistants: erector spinae, latissimus dorsi, gluteus medius, oblique abdominis, rectus
abdominis). Centering helps to improve balance and posture. In-other words it is called
powerhouse of the body. One of the primary goals of Pilates is to strengthen the
'powerhouse' or core-stabilization (Muscolino et al, 2012).

Precision - Focus attention on each exercise. They need to be done properly to benefit from
them (Powers and Stefanie, 2015).

Movement - Every movement should start from a strong center and flow gently and slowly.
PILATES IN PHYSIOTHERAPY

The interest and popularity of Pilates is increasing worldwide. In addition to being used in fitness
programs, it is being used in some rehabilitation programs (Di Lorenzo, 2012). There is a
significant amount of research and clinical evidence supporting the benefits of Pilates exercises.

Pilates also incorporates set breathing patterns. Set breathing patterns are when inhalation occurs
during one phase of a specific movement/ exercise, and exhalation during another phase of the
movement. Active breathing is also proven to increase respiratory muscle strength and
performance (Giacomini, 2016).

People with Multiple Sclerosis (MS) frequently experience balance and mobility impairments,
including reduced trunk stability. Pilates-based core stability training, which is aimed at
improving control of the body's stabilizing muscles, is popular as a form of exercise with people
with MS and therapists(Notarnicola, 2021) MS symptoms such as fatigue sensation can be
reduced, and physical performance can be improved in MS patients by Pilates exercises.(Sanchez
et al, 2019)

Studies have shown the effectiveness of a few weekly Pilates sessions as helping to reduce lower
back pain. Improvements in pain, disability, physical and psychological perception of health in
individuals who completed daily sessions of Pilates have been found (Notarnicola, 2021).

Modern Pilates mat and ball exercises were effective in reducing obesity, body composition
parameters and flexibility in sedentary obese women (Cakmakçi, 2013).The use of Pilates was
found to improve ongoing Low Back Pain (LBP) in patients who received conventional
physiotherapy treatment, the improvement was most obvious in the female population group
(Quinn et al, 2021).

PILATES AND LOW BACK PAIN

Pilates as a rehabilitation programme is used in treatment of chronic low back pain (CLBP) and
its results could be compared to exercise program results (Wajswelner et al, 2021).A Cochrane
Review shows that there is a low to moderate quality evidence that support the effectiveness of
Pilates programme on pain and disability in cases of low back pain (LBP)(Yamato et al, 2016).

However, recent studies shows that Pilates training program for 3-9 weeks, including 1 -2
sessions per week, which consist of core and strength exercises or mind-body exercises, found to
be the most advantageous coping with pain and disabilities resulting chronic LBP(Fernández-
Rodríguez et al, 2022). Most of Pilates programmes for LBP depend on improving or activating
the core muscle group or 'powerhouse' (Miyamoto et al, 2018). Mainly it consists of isometric
contraction of the deep abdominal muscles, pelvic floor muscles, gluteus maximus and
multifidus) (Yamato et al, 2016).

Exercises consisted of 5 min of warm-up (breathing and mobility exercises), 50 min of Pilates
exercises (stretching and strengthening exercises for muscles of the trunk and lower and upper
limbs) and 5 min of cool down (relaxation exercises and massage with ball). Exercises were
performed with concentric and eccentric contraction of trunk, spine, upper and lower limb
muscles in all planes of movement. Each exercise was done with a single series, with a 2 min
interval between exercises, and the number of repetitions varied from 8 to 12, corresponding to
approximately 60% to 70% of one maximum repetition as assessed with the Borg scale.

The exercises were performed at three levels of difficulty: basic, intermediate and advanced. The
basic exercises were adapted to the conditions of each patient by reducing or increasing
resistance (e.g, the roll-up exercise using the tower bar on the Cadillac can be performed with the
spring in the high position to make the movement easier or in the low position to make the
movement more difficult) (Yamato et al, 2016; Miyamoto et al, 2018).
A study explored the effectiveness of Pilates exercise for treating people with chronic low back
pain (CLBP) is yet to be found out. 30 Australian physical therapists experienced in the use of
Pilates exercise were surveyed in 3 questionnaires. Participants were agreed that people who
have poor body awareness and mal-adaptive movement patterns may benefit from Pilates
exercises, and they also agreed that Pilates exercise may improve functional ability, movement
confidence, body awareness, posture and movement control (Wells et al, 2014).

Another randomized controlled study was conducted to find out the effect of Pilates on postural
alignment for adult women. The results have shown that the Pilates-based exercise enhanced
some aspects of the postural alignments measured by frontal alignment of the shoulder and
sagittal alignment of the head and pelvis. (Cruz-Ferreira et al, 2013).

PILATES DURING PREGNANCY

Pregnancy is a specific stage in women’s life, a time when they face physiological and
biomechanical changes that, without proper monitoring, lead to the emergence of
musculoskeletal discomforts. Most of these issues are associated with postural changes, balance,
ligament laxity, body weight increase and cardiorespiratory disorders. The Pilates method
provides several benefits such as increased respiratory capacity, improved muscle strength and
the strengthening of torso-stabilizing muscles, flexibility, spine mobility, postural alignment,
coordination, proprioception, balance and motor control. Given the specific condition of
pregnant women and the variations derived from such condition, Pilates may positively
contribute to these women's health within their physical and psychological limitations. Pregnant
women are known for the several physiological changes they go through; thus, Pilates can make
important contributions to their health, such as the promotion of quality of life and well-being to
improve their adaptation to each gestational week (Martin et al, 2017; Fernández-Rodríguez et
al, 2022).

A study conducted to address the importance of Pilates, clinical guidelines and physical activities
practiced in the main pregnancy periods (trimesters) through a bibliographical analysis
concluded that the knowledge about the physiological and psychological changes affecting
pregnant women, in association with the training in Pilate’s techniques, may promote and
contribute to a gestational period with no complications and to reduce the risk of low-back pain
and osteoarticular discomforts.

Stabilization, strengthening and stretching exercises should be performed, but the gestational
week and the patient's physical and emotional limitations must be respected. It is possible seeing
that physical activity is beneficial to pregnant women. Thus, such practice should be encouraged
by health professionals (Martin et al, 2017).

PILATES FOR PELVIC HEALTH

Pilates exercise programs have been assessed for the potential to have a positive effect on pelvic
health in women. Modified Pilates (MP) for Urinary Incontinence have been assessed by Lausen
et al, (2018). This study aimed to assess the effectiveness of a 6-week course of MP classes as an
adjunct to standard physiotherapy care for urinary incontinence through a randomized control
trial. Women who attended the modified Pilates classes and who had lower symptom severity at
baseline showed: improved self-esteem, decreased social embarrassment and lower impact on
normal daily activities. Alternatively, women with higher symptom severity showed
improvement in their personal relationships (Lausen et al, 2018) However, when measuring the
improvement in continence in the ICIQ-SF, Yoga exercises activating the pelvic floor and core
muscles were found to be more beneficial than Pilates exercises (Kannan et al, 2022).

Additionally, Pilates has also been found to be beneficial in males post-prostatectomy dealing
with urinary incontinence, and the results showed that ten sessions of Pilates can increase muscle
strength, accelerate the return to continence, and improve quality of life(Gomez et al, 2018).
Another study examined the effect of a Pilates exercise program and a pelvic floor muscle-
training (PFMT) program on improvements in pelvic muscle strength in women, and the authors
found improvements in both groups, with no significant difference between them.(Culligan et al,
2010). These findings are not consistent and require further research, as some studies have found
no difference between groups completing Pilates training compared with those remaining
sedentary (Ferla et al, 2016 ) It has been shown that it may be necessary to incorporate exercises
into the Pilates program to evoke voluntary pelvic floor muscle contractions in order to see a
positive impact on the strength of the pelvic floor muscles.(Torelli et al, 2016).
PILATES DECREASES FEAR OF FALLING FOR ELDERLY
Pata et al, (2014) found in their 8-week study that older elderly had decreased fear of falling after
Pilates program as well as significant improvement in flexibility measures (Pata et al,
2014). Half of participants who are deemed to have fall risk improved their flexibility (Forward
Reach test) to a score no longer considered to be a fall risk, Numbers of actual falls also
decreased in subsequent two months post Pilates program. A Pilates based exercise intervention
program improved balance, postural stability and mobility, which are risk factors associated with
falls in the vulnerable or older adult population. Pilates stabilizes and strengthens core muscles
with precision and emphasizes neutral postural alignment (Barker et al, 2016), thus allowing for
greater distal mobility and balance control. This translates to improved execution of daily
functional activities and decreased falls.

How does Pilates improve flexibility?

Pilates method is a combination of static and dynamic stretching exercises which are safe to
provide an increasing flexibility. Phrompaet et al, (2021) postulated that there is
neurophysiological properties to stretching exercises. When Pilates position is applied, soft
stretch to tissues and muscles activates Golgi tendon organ, which results in lengthening of
sarcomeres (basic unit of muscles tissues) (McArdle et al, 2016). Repetitive stress will increase
the plastic deformation of tissues in the elastic range, allowing a gradual rearrangement of the
collagen fibres (Liemohn, 2017).

In conclusion, flexibility or stretching exercises is critical to functional quality of life,

performance improvement and injury and pain reduction. Pilates is a proven and safe method for
improving flexibility, which is increasingly important as we advance in age (McArdle et al,
2016).
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