Strengthening Core Stability · 2020-04-27 · 1. Normalize the periphery:joint mobility, biomechanics, swelling control 2. Restore muscle imbalance: lengthen the tight antagonistic

Strengthening Core Stability

Presented by: Lori Duncan, DPT, MTC, CPT

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CredentialsLori Duncan, DPT, MTC, CPT

• Doctorate of Physical Therapy ‐ University of St. Augustine for Health Sciences

• Manual Therapy Certification ‐ University of St. Augustine

• Pilates Certification ‐ June Kahn Bodyworks

• Group Fitness Instructor ‐ Life Time Fitness/Schwinn

• Blogger ‐ Duncan Sports Therapy + Wellness

• Lecturer ‐ Fitness, gyms, corporate wellness

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Objectives1. Implement and effectively convey the most important Pilates principles.2. Appraise the patient experience, HEP compliance, and quality of movement

for each client.3. Integrate the concept of "mobility on stability" for all therapeutic exercise.4. Identify the common areas of weakness including the diaphragm, scapula, hip

and ankle complex.5. Develop specific treatment plans for common injuries and post‐op recovery

for all patient populations.6. Utilize all 6 Pilates principles for any exercise to improve function and

decrease fall risk.7. Include evidence‐based research and clinical case studies for optimal rehab

outcomes

“Physical fitness is the first requisite of happiness.” ~Joseph Pilates3

History of Pilates

• Joseph Pilates, 1883‐1967

• Born in Germany

• Greek name

• Sick Child (asthma, rickets, rheumatic fever)

• Influence: yoga, gymnastics, circus, diving, boxing

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History of Pilates

• Lived in England and placed in Internment Camp because of German heritage

• 1918 flu epidemic during WWI

‣ All of his trainees survived the epidemic

• “Pilates” originally called “Contrology”

‣ The mind controls the muscles

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History of Pilates

• 1925, moved to America

• Opened “Contrology” in New York

• Dance community starting taking note of effects

“I’m 50 years ahead of my time.” ~ Joseph Pilates

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Our body was designed for movement

Pilates is a MOVEMENT system

Thus, it is functional and effective for rehabilitation

“[Pilates] develops the body uniformly, corrects wrong postures, restores

physical vitality, invigorates the mind, and elevates the spirit.”

~Joseph Pilates

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Pilates Enhances Rehabilitation~It masters the ability to teach our bodies how to move through space for function and

sport~

• Teaches dissociation of movement

• Stimulates slow motor recruitment > fast motor recruitment

• Strengthens eccentrically

• Increases ROM/flexibility: multi‐planar and multi‐joint

• Emphasizes movement initiated from core

• Increases lung capacity: diaphragmatic breathing

• Increases circulation

• Improves body awareness, coordination and precision of movement

• Establishes balance throughout the body

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Pilates Principles• Centering

‣ powerhouse

‣ secondary powerhouse

‣ centerline

• Concentration

‣ mind/body connection

‣ focus on the task

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Pilates Principles• Control

‣ neuromuscular coordination: harmonious interaction of muscles and CNS

‣ smooth and efficient movement patterns for safety

• Precision

‣ accuracy to accomplish the task

• Flow

‣ lightness of movement

‣ control of acceleration and deceleration (function!)

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Pilates Principles• Breathing

‣ The most important principle

‣ Diaphragm muscle

‣ Inhalation‐ to open

‣ Exhalation‐ to close

‣ Consider rib/thoracic mobility

“Above all, learn how to breathe correctly.” ~ Joseph Pilates

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Pilates Equipment

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Pilates Progression1. Center of Gravity

2. Base of Support

3. Surface Stability

4. Exercise Complexity

5. Rhythm and Tempo (pace)

“[Pilates] is not a fatiguing system of dull, boring, abhorred exercises

repeated daily ‘ad‐nauseam’.” ~ Joseph Pilates

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Rehab Progression1. NWB

2. WB double support (static)

3. WB single support (static)

4. WB double support (dynamic)

5. WB single support (dynamic)

6. WB double support (ballistic)

7. WB single support (ballistic)

8. Sports Specific Training

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Mobility with Stability• Mobility with stability is the KEY to healthy function

‣ FUNCTION: integrated, multi‐planar movement that requires acceleration, deceleration and stabilization.

• Pilates is brilliant at teaching this concept

• Natural progression in childhood

1. mobility: flexibility, ROM

2. stability: neuromuscular control of movement, also termed motor control

3. mobility with stability = function!

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Pain and StabilitySource: Kinetic Control (2011) by Commerford and Mottram

• Pain affects slow motor units more significantly than fast motor units

• Athletes can still generate power and speed

• 90% of sport world records broken by athletes with chronic or recurrent musculoskeletal problems

• In a pain‐free state, the CNS is able to utilize a variety of motor control strategies to perform coordinated and efficient movement patterns

• In pain, subjects employ strategies of muscle recruitment normally reserved for high load function (lifting, pushing, throwing, jumping) and use these for normal low threshold, postural activities (Hodges et al, 2009)

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Pain and Motor Control• Hodges and Tucker (2011) have proposed a new theory for pain adaptation:

1. Redistribution of muscle activity occurs within and between muscles

2. Altered mechanical behavior is present

3. Protection from further pain or injury is the main goal...at any cost

4. Changes occur at multiple levels of the motor system

5. Short‐term benefits may have long‐term consequences

• Take‐away note from research: pain does not have a uniform effect

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7 Pain DiscoveriesSource: Lorimer Moseley, Phd via The Pain Revolution (2017) and Explain Pain (2009)

1.Pain is Real, no matter what is causing it

2.Pain relies on context and cues ‐ how does each person respond to cues?

3.Pain is about protection ‐ the brain will protect tissue from pain

4.Pain and tissue state are poorly related ‐ when the system no longer needs to protect, pain goes down EVEN when the tissue healing will continue

5.We are adaptable, bioplastic (not just the neuro system) learners

6.Movement is KING! ‐movement helps suppress pain and best way to recover

7.Understanding pain and retraining the system does actually work.

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The “Core” Muscles of Pilates

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Thoracolumbar Fascia

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Willard FH, Vlemming A, Schuenk MD, Denneels L, SchleipR. The thoracolumbar fascia: anatomy, function and clinical considerations. J Anat. 2012:221;507‐536.

• Central point of “the girdle:” aponeurotic, fascia and retinaculum of L/S region.

• Helps with posture, load transfer & respiration• Irregular collagen for resist multi‐planar stress• 3 layers: posterior, middle, anterior• High density of sympathetic nerves• Proprioceptive properties ‐ joints only help in large movements• Tensile strength has been measured up to IkN• Deformation (flexion) of TL fascia = strain energy into tissue

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Langevin HM, Fox JR, Koptiuch C, et al. Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskeletal Disorders. 2011:12;203‐215.

• 121 Subjects: 71 LBP, 50 No‐LBP• Prone‐lying motorized articulated table to simulate trunk flexion• TLF has various directions of pull for individual muscles• Dense connective tissue separated by “loose” areolar tissue ‐ dense layers move independently

• Control Group‐ Layers move I and in opposite directions of each other• LBP Group‐ Less motion between layers & 20% less shear strain• Overall less shear strain in males than females

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Abdominal Muscles• Transverse Abdominis

‣ Stabilization

• Internal Abdominal Oblique

‣ Stabilization

‣ Rot/SB

• External Abdominal Oblique

‣ Posterior Pelvic Tilt

‣ Rot/SB

• Rectus Abdominis

‣ Posterior Pelvic Tilt

‣ Trunk flexion

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Glute Muscles• Gluteus Maximus

‣ Hip Ext, Abd, ER

• Gluteus Medius

‣ Hip Abd, Stability

• Gluteus Minimus

‣ Hip Abd, Stability Assistant

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Scapula Muscles

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• Serratus Anterior‣ Stabilizes scapula‣ Protracts scapula

• Latissimus Dorsi‣ Depresses scapula‣ Extends, adducts, IR arm

• Lower trapezius‣ Stabilizes scapula‣ Depresses scapula

• Rhomboids‣ Stabilizes scapula‣ Retracts scapula

• Middle Trapezius‣ Retracts scapula‣ Stabilizes scapula

Other Key Muscles• Lumbar Multifidus‣ Segmental stabilizer of spine

‣ Controls rotation/SB to opposite side, extender

• Diaphragm‣ Expands rib cage, increases intra‐abdominal pressure

‣ Separates lungs from abdomen

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Wilke J, Krause F, Vogt L, Banzer W. What is

evidence-based about myofascial chains: a systematic

review. Arch of Phys Med and Rehab. 2016;97:454-61

• Central Rule for Meridian = 2 direct linear muscle connections

• Spiral, Lateral, Front Functional Back Functional, Superficial Back, Superficial Front

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• Fascia transmits tension/load and has nocioceptive and proprioceptive properties

• Spiral ‐ strong connection between SA/Rhomboids• Spiral ‐ Ext Oblique has aponeurtic extensions to contralateral In Oblique • Lateral ‐ strong connection of IT band to Glute Max/TFL• Back Functional ‐ Lat & Glute Connect to TLF• Front Functional ‐ Pec Major ot contralateral RA, Adductor longus to contralateral rectus sheath

• Back Superficial ‐ Gastroc linked to Semimembranous, Hamstrings linked to Erector

• Front Superficial ‐ No evidence to support

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Pelvic Floor• Comprised of:‣ Muscular Diaphragm ‐ Levator Ani + Coccygeus‣ Piriformis‣ Together, these elevate the pelvic floor

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Local Stabilizers• Rotator Cuff• Deep Neck Flexors ‐ Longus Capitus, Longus Colli• VMO ‐ Vastus Medialis Oblique• Soleus

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Muscle Roles• Local Muscle System: responsible for segmental stiffness and decreasing

excessive intersegmental motion. These maintain activity in the background for all motion. (TA, VMO, multifidus, foot intrinsics)

• Global Muscle System: produces ROM and control of load. These usually have a primary role of either:

1. Stability: external abdominal oblique

2. Mobility: rectus abdominis, hamstrings, rectus femoris

• Multi‐Task Muscles: these muscles act as a local stabilizer, global stabilizer and global mover (gluteus maximus, infraspinatus, subscapularis, internal abdominal oblique)

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“...it is in principle a wrong approach to try to understand impairments of different parts of the motor system separately, without understanding the function of the motor system as a whole.” ‐ Vladimir Janda

The Body as a Whole System

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Vladimir Janda• Czech neurologist and physiatrist

• Influenced by many (Bobath, Kendall, many MD’s)

• CNS is highly important to mediate pain because of neuromuscular imbalance

• Posture muscles ‐ become tight with dysfunction

• Phasic muscles ‐ become weak with dysfunction

• Created Upper Crossed and Lower Crossed Syndromes

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Janda’s Philosophy• Sensorimotor System: the health and tone of the muscle system reflects

the state of the sensorimotor system because it receives input from the muscle system and the CNS

• Tonic and Phasic muscles are based on phylogenic development

‣ Tonic/Flexor muscles usually become TIGHT

‣ Phasic/Extensor muscles usually become WEAK

‐ Those muscles that work eccentrically against gravity and develop later during development.

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The Janda Approach1. Normalize the periphery: joint mobility, biomechanics, swelling

control

2. Restore muscle imbalance: lengthen the tight antagonistic to restore strength in the weak agonist

3. Increase afferent input to facilitate reflexive stabilization: create automatic coordinated movement

4. Increase endurance in coordinated movement patterns: repetition, low intensity, high volume

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Tonic Muscles• Become tight with dysfunction

✴SCM, scalenes

✴Upper trapezius, levator scapulae

✴Pectoralis major/minor

✴Hamstrings, adductors, iliopsoas

✴TFL

✴Piriformis, erector spinae

✴Gastroc

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Phasic Muscles• Become weak with dysfunction

✴Peroneals

✴VMO

✴Glutes

✴Abdominals

✴Deep neck flexors

✴Serratus anterior, lower trapezius

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Upper Crossed Syndrome

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Lower Crossed Syndrome

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“Muscles We Don’t See in the Mirror” Syndrome

• Adults rely on vision for body awareness and proprioception

• Common muscles that require attention in rehab:

‣ Soleus

‣ Scapular muscles

‣ Glutes

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Specific Injuries42

Common Links to Pain and Injury

• Previous Injury

‣ this is the main risk factor for injury, especially within the last 12 months

• Poor dissociation of movement

‣ especially the scapula and hip complex

• Compensation patterns

‣ upper trap, TFL, VL, hip flexors

• “Muscles We Don’t See in the Mirror” Syndrome

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Foot and Ankle• Ankle instability / chronic sprains‣ Hip stability just as important as ankle stability

• Achilles Tendonosis‣ Eccentric training to remodel the tendon from type III collagen to type I

• Plantar fasciitis‣ Restore the windlass mechanism

✴This region requires foot intrinsic and eccentric training

✴EXERCISES:

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Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy‐load eccentric calf muscle training for the treatment of chronic achilles tendinosis. Am J Sports Med. 1998;26: 360‐366.

• Type I collagen‐ strong, resists tension, stretch and arranged orderly, likes to form strong bundles

• Type III collagen‐ delicate, fabric‐like and doesn’t form strong bundles for force production. “Gooey” tendon

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Knee• PFPS‣ Optimal hip mechanics are key

• IT Band Syndrome‣ IT band may be considered tendon of glute max, based on histology

research

‣ VMO to balance glute max

• ACL ‐ pre and post surgical• TKA ‐ pre and post surgical

✴This region requires glute and VMO training

✴EXERCISES:

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Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat 2006; 208:309–316

• IT Band ‐ thickened part of the fascia lata that travels down the leg to insert around the LFE and Gerdy’s tubercle

• Gluteus maximus has a significant insertion into the IT band • This study suggests that the IT band could be considered a tendon of the gluteus maximus

• Histology research supports this theory ‐ the tissue from the hip to the LFE is similar to tendon and the tissue from the LFE to Gerdy’s tubercle is similar to ligament.

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Hip• THA ‐ pre and post surgery

• Hip fractures

• Myofascial Pain ‐ poor dissociation and proprioception of hip complex

✴This region requires core and glute training

✴EXERCISES:

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Back Pain• Low Back Pain

‣ Post surgical: discectomy, laminectomy, fusion

‣ Lumbar multifidi atrophy with chronic LBP

• Scoliosis

• Postural Pain

✴This region requires glute, core and scapular training

✴EXERCISES:

“A man is as young as his spinal column.” ~ Joseph Pilates

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Goubert D, De Pauw R, Meeus M, et al. Lumbar muscle structure and function in chronic versus recurrent low back pain: a cross‐sectional study. Spine J. 2017;17:1285‐1296

• Studied Muscle Structure, Quality & Activation • CSA & Fatty Infiltration of Multifidus, ES• Chronic Pain (31) ‐ Continuous & Non‐Continuous

• Body Mass Index Sig Higher (Cont LBP)• Increased Metabolic Activity of Muscles (both groups)

• Recurrent Pain (24) & Non‐Continuous LBP• Smaller fat infiltration and fat CSA

• A Spectrum of LBP Exists

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Periera I, Quieroz B, Loss J, Amorim C, Sacco I.TrunkMuscle EMG During Intermediate Pilates Mat Exercises in Beginner Healthy and Chronic Low Back Pain Individuals. J Manip Phys Ther. 2017; 40(5):350‐357.

• 32 untrained subjects: 19 healthy, control group (no LBP > 7 days in 6 months) and 13 non‐specific LBP

• EMG of multifidus, ext abdominal oblique, internal abdominal oblique, RA

• Measured activity of dead bug, single leg stretch, criss‐cross (Mat Pilates)

• Criss‐cross‐ highest activation of int/ext obliques compared to RA.

• Multifidus‐ similar activation in both groups. Hypothosized to be from neutral pelvis position.

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Shoulder• Rotator Cuff ‐ surgical and non‐surgical‣ Internal rotation may be more important than external rotation

• Scapular dyskinesia• Shoulder impingement‣ Posture? Rotator cuff laziness? Structural?

• Myofascial Pain ‐ poor dissociation and proprioception of shoulder complex

✴This region requires scapular stabilization and RC training

✴EXERCISES:

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Wickham J, Pizzari T, Balster S, Ganderton C, Watson L. The variable roles of the upper and lower subscapularis during shoulder motion. Clin Biomech. 2014;29:885‐891.

• The subscapularis has lower and upper fibers, each having a distinct nerve supply. They can act independently of each other.

• EMG studies ‐ during flexion, abduction and ER the lower fibers are extremely active

• The lower fibers are important to counter‐balance the tension of the infraspinatus AND resist the shear forces of the deltoid as the arm goes overhead

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Cervical• Cervical pain

• Deep neck flexor training is important

• Cervical fusion ‐ pre and post surgery

• Myofascial Pain ‐ usually associated with scapular myofascial pain

✴This region requires deep neck flexor and scapular training

✴EXERCISES:

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Jull GA, Falla D, Vicenzino B, Hodge PW. The effect of therapeutic exercise on activation of the deep cervical flexor muscle in people with chronic neck pain. Man Ther.2009;14(6):696‐701.

• Training the deep neck flexors, longis capitus and longiscoli, has a direct correlation with decreased neck pain

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Jull GA, Falla D. Does increased superficial neck flexor activity in the craniocervical flexion test reflect reduced deep flexor activity in people with neck pain?. Man Ther.2016;25:43‐7.

• Craniocervical flexion ‐ not a role of SCM/ant scalene

• EMG study‐ surface electrodes of SCM/ant scalene and nasopharyngeal catheter on longus capitus/colli.

• 32 femailes (18‐60) with history of non‐specific chronic neck pain, >6 mos, no UE neurological signs

• Inverse relationship of SCM:Deep Neck Flexors ‐ higher SCM activity, lower deep neck flexor activity. Ant Scalene did not have signficantrelationship.

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Pilates in Research

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Cancelliero‐Gaiad K, Ike D, Pantoni C, Borghi‐Silva A, Costa D. Respiratory pattern of diaphragmatic breathing and pilatesbreathing in COPD subjects. Braz J Phys Ther. 2014;18(4);291‐9.

‣ 15 subjects with history of COPD, current or former smokers, 40‐80 years old

‣ Diaphragmatic Breathing ‐movement of abdominals with diaphragm breathing

‣ Pilates Breathing ‐ contraction of TA and pelvic floor with diaphragm breathing

‣ Diaphragm Breathing ‐ increased lung volume, respiratory motion and decreased respiratory rate for COPD patients

‣ Pilates Breathing ‐ increased lung volume in healthy patients and increased oxygenation in both groups

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Newell D, Shead V, Sloane L. Changes in gait and balance parameters in elderly subjects attending an 8‐week supervised pilates programme. J Bodyw Mov Ther.2012;16(4):549‐554.

• Observational Study, n= 9, 8‐week supervised Pilates program

• Mat exercises with theraband and physioball for core, LE emphasis

• Results: After 8 weeks, subjects had improved walking speed, step cycle, step length and FRI (fall risk index) along with decreased anterior/post trunk sway.

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Natour J, Cazotti L de A, Ribeiro L, Baptista A, Jones A. Pilates improves pain, function, and quality of life in patients with chronic low back pain: a randomized controlled trial. ClinRehabil. 2015;29(1):59‐68.

• n=60 subjects with LBP randomly assigned to two groups:

• Experimental group: NSAID’s and Pilates

• Control group: NSAID’s only

• Data collected at 0, 45, 90 and 180 days

• Pain (VAS), function (Roland Morris), quality of life (SF‐36) were significantly improved with Pilates group and they reported less NSAID use.

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Oksuz S, Unal E. The effect of the clinical pilates exercises on kinesiophobia and other symptoms related to osteoporosis: randomised controlled trial. Comple Ther in Clin Practice.2017;26:68‐72

• 40 females with osteoporosis randomly divided into two groups

• Group 1 ‐ Pilates Exercises 3x/week for 6 weeks. Mat exercises (example: hundred, ab series, clams, saw, spine twist)

• Group 2 ‐ Control Group. No intervention, but they continued their normal function and ADL’s

• Kinesiophobia (avoidance and fear of movement), pain, functional status and quality of life measured after 6 weeks. Signficantimprovement with the Pilates group.

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Kara B, Kucuk F, Poyraz EC, Tomruk MS, Idiman E. Different types of exercise in multiple sclerosis: aerobic exercise or pilates, a single‐blind clinical study. J Back Musculoskelet Rehabil. 2017; 30(3):565‐573.

• Subjects ‐ 26 Aerobic, 9 Pilates, 21 Control Group (healthy)

• Measured fatigue, physical performance, depression, cognition

• Arerobic results: fatigue, cognition and physical performance were signficantly improved within the group

• Pilates results: physical performance improved within the group, all areas signficantly improved compared to CG (except depression), cognition signficantly improved compared to aerobic group.

• Do Both!

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Lim Km, Jung J, Shim S. The effect of bilateral trainings on upper extremities muscle activation on level of motor function in stroke patients. J Phys Ther Sci.2016;28(12):3427‐3431

• 20 Inpatient patients with stroke (12 males, 8 females)• Measured affect of bilateral training• EMG study - hands clasped vs. Pilates Ring‣ Trapezius, anterior deltoid, biceps, triceps

• Group 1 - moderate FMA: scored 9-44‣ co-contraction ratio of affected limb was signficantly decreased

• Group 2 - well FMA: scored 45 and above‣ trap, ant delt, triceps of affected limb and B biceps significantly

higher with Pilates Ring

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Other Areas of Research

• Ankylosing Spondylitis

• Breast Cancer

• Amputees

• Fibromyalgia

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Case Studies

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Chronic LBP‐ 20+ years• 49 year‐old mother with long history of back pain. Was told she had a spondylolisthesis and to never extend, rotate or bend forward.

• CAUSE OF PAIN ‐ poor leg, pelvis, trunk dissociation and PETRIFIED to move

• Started in supine progressed to sidelying, standing, prone

• Exercises: core + heel slides, bridging small ROM, lat overhead, arm circles

• After 1+ year of consitent PT (4x/month to 1x/month progression), able to function, sleep, drive and exercise without back pain and EXCELLENT body awareness

• Continues to come to Pilates 1x/wk for maintenance

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R Hip Pain• 40 year‐old mom, soccer coach and weight lifter with 1‐2 years of R hip pain

• Worsened from July ‐ Sept 2016. 5+/10 constant R hip pain that increased at night, driving and exercising at gym

• MD stated small labral tear on MRI, MRI stated tendenosis

• Positive for R hip FAI

• CAUSE OF PAIN ‐ used RF tendon for all core stabilization!

• Exercises ‐ core + heel slides, NM re‐ed LE, glute lift from block, quad PPT, SL circles

• 11 visits in 3 months and absolutely pain‐free…she finally found her core!

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R‐sided pain with breathing• 35 year old mom, pain with breathing

• Strained R side during Lifting Class 4 weeks prior and pain not improving

• Radiograph stated no rib fracture

• CAUSE OF PAIN ‐ R diaphragm and external abdominal oblique strain

• Exercises ‐ seated criss‐cross, lat overhead, breathing and side stretch

• 2 visits in 4 weeks and pain‐free

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3 Hip Surgeries in 5 Years• 46 year old engineer, mother and recreational athlete

• Had a right hip labral repair 2013 ‐ FAILED

• Had a 2nd right hip labral repair 2015 = FAILED

• Had ant approach R THA in 8/2017 ‐ 10 months later still in pain

• PREVIOUS TX: painful dry needling, painful massage, painful exercises

• CAUSE OF PAIN ‐Myofascial pain, fear, trauma of 5 years, atrophy of RLE

• EXERCISES ‐ core + heel slides, glute lift on side + band + wall, breathing, desensitization

• *** Visits in 5 months and she is back to hiking, Pilates, Lifting, Sleeping and Traveling without right hip pain.

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R Elbow Pain‣ 27 year old soccer player returnign to lifting in gym

‣ R medial elbow pain with biceps curls, pull ups, some row grips

‣ MMT ‐WNL for elbow, shoulder. Positive pain with wrist flexors.

‣ Weak Lat Stability on R

‣ CAUSE OF PAIN ‐Weak Lat to stabilize RUE with lifting.

‣ EXERCISES ‐ Lat OH, lat on side press up, wrist eccentrics, stretch to biciptial area.

‣ 3 Visits in 6 weeks.

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Chronic Headaches

• 44 year old woman, HA almost every day and wanted to drive, workout without neck pain and HA’s.

• PMH: cervical disc herniation (no surgery), R subclavian bloot clot 3 years prior

• CAUSE OF PAIN‐ used upper trap and SCM to stabilize with all function and exercise.

• Exercises ‐ chest exp, row + rotation, RC training, cervical nods, lat overhead, core + heel slides

• Continues to come to Pilates 2x/month for maintenance (no HA’s or neck pain)

• Calls them SPTE’s (Lori’s Stupid PT Exercises), but knows they work!

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Congenital Scoliosis ‐Rod from T2‐T12

• 40 year‐old mom, swimmer, hiker with R‐sided low back pain, plantar fasciitis

• CAUSE OF PAIN ‐ poor leg, pelvic, trunk dissociation, no lumbar mobility, unable to retract or depress scapula. Back felt “numb.”

• Exercises ‐ core + heel slides, SL circles, lat overhead, chest expansion

• Continues to come 1x/wk for maintenance of body balance, mobility and dissociation

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Unexplained Foot Drop•45 year‐old, mom, dental hygienist and yoga instructor

• Sudden onset of foot drop that developed in 2010 (first seen by me in 2014)

• Saw 3 neurologists without any explanation or relief

• PAIN: Significant R hip and back pain and difficulty with walking (no AFO)

• GOAL: to avoid tripping and teach yoga

• Exercises: AFO, SLS practice, clams, side series, SL circles, glute lift, Pilates running, thoracic rotation, chest expansion

• Findings: ‣ DF 2‐/5 with significant gastroc/soleus tightness‣ SLS less than 1 sec‣ Poor glute, core awareness and activation

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Thank you!

Physical Fitness is: “the attainment and maintenance of a uniformly developed body with a sound mind fully capable of naturally, easily and satisfactorily performing out many and varied

daily tasks with spontaneous zest and pleasure.” ~ Joseph Pilates

In 10 Sessions You’ll Feel Different. In 20 Sessions You’ll Look Different.

And In 30 Sessions, You’ll Have A New Body.

~Joseph Pilates, 1941

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Pilates References• www.pilatesanytime.com

• www.pilatescenter.com

• www.peakpilates.com

• www.merrithew.com (Stott Pilates)

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`Lori Duncan, DPT, MTC, CPTEmail: [email protected]

Website & Blog: www.duncansportspt.com

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Duncan Sports Therapy + Wellness

Lori Duncan PT

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Summit Blog Page

https://blog.summit‐education.com/duncan/

•Includes:•Manual •PowerPoint •References•Additional supplements

Pilates ExercisesA few well‐designed movements, properly performed in a balanced sequence, are worth hours

of doing sloppy calisthenics or forced contortion.”

~Joseph Pilates

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Diaphragmatic Breathing• Supine‐ Lay on your back, knees bent and head relaxed‐ Cross your arms and place your hands on the outside

of your ribs‐ Keep the neck relaxed and breathe into your hands to

expand the rib cage‐ Practice 1‐2 minutes.‐ Add core activation when ready

• Sitting‐ Sit tall with your feet on the floor‐ Cross your arms and place your hands on the outside

of your ribs‐ Keep the neck relaxed and breathe into your hands to

expand the rib cage‐ Practice 1‐2 minutes in the mirror‐ Add core activation when ready

• Standing with Offering‐ “Lean into the Wind and Breathe”‐ Stand in Pilates stance, engage your core and lean

slightly forward‐ Breathe in as you move your arms up‐ Breathe out as you lower them down‐ Perform 10‐12 repetitions

Reprinted with permission. Strengthening Core Stability by Lori Duncan, DPT, MTC, CPT 80

Fundamental Cervical Exercises

• Cervical Nod ‐ “Curl your chin to your chest”‐ Lay on your back, knees bent‐ Head is relaxed and neutral‐ Gently curl or nod your chin to your chest

without lifting your head‐ Feel the “throat muscles” working‐ Practice 1‐2 minutes

• Cervical Nod + Lift‐ “Curl your chin to your chest and lift your

head, look at your navel and lengthen through the crown of the head”

‐ Perform a cervical nod‐ Lift your head up and come to rest on the

bottom of your shoulder blades‐ Your head should feel anchored into your

core at the sternum‐ Perform 2‐5 repetitions

Reprinted with permission. Strengthening Core Stability by Lori Duncan, DPT, MTC, CPT

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FundamentalAbdominal Exercises

• Core setting + heel slides‐ “Move your leg from your core”‐ Lay on your back, knees bent in neutral spine‐ Place two fingers on inside of your hip bones and

draw the belly in without moving any bones.‐ Feel muscles “poke” into your fingers.‐ Slide your right heel out and in slowly, feeling the leg

anchored into the core. R Repeat on the left side‐ Perform 5‐10 repetitions, alternating

• Pilates Bridging ‐ “Snake through the spine”‐ Start with deep core setting ‐ Breathe in, then breathe out and use your core

to press your low back into mat/floor‐ Gently peel the spine off vertebrae by vertebrae

and rest on your shoulder blades‐ Breathe in at the top and breathe out as you

paste the spine down vertebrae by vertebrae. The tailbone is the last bone to hit the mat

‐ Perform 5‐8 repetitionsReprinted with permission. Strengthening Core Stability by Lori Duncan, DPT, MTC, CPT 82

Fundamental Abdominal Exercises

• Knee Circles‐ “Move your knees from a stable core”‐ Lay on your back with knees in table top

position ‐ Make very small circles (silver dollar size)‐ Feel the knees anchored from a very deep

core sensation‐ Perform 5‐8x each direction

• Arm Beats‐ “Awaken your core”‐ Lay on your back with knees bent, feet on

floor, arms at your side‐ Scoop the belly in to engage your core‐ Option: Perform a cervical nod and look at

your navel‐ Begin lifting your arms up to your knees, down

to your hips without touching the floor.‐ Perform 10‐15 repetitions


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Fundamental Abdominal Exercises

• Hundred ‐ “Warm up the body with the core”‐ Lay on your back with knees bent,

feet on floor, arms at your side‐ Option: Perform a cervical nod and

look at your navel‐ Begin pumping your arms quickly for

100 counts. Breathe in 5 counts, breathe out 5 counts.

‐ Leg position options‐ Feet on floor (top picture)‐ Legs in table top (bottom left)‐ Legs straight up (not shown)‐ Legs at 45 degrees (bottom right)


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Fundamental Arm Exercises

• Lat Overhead with Rib Stability

‐ “Move your arms from your back”‐ Lay on your back, knees bent, feet on the floor, arms

over your shoulder joints ‐ Turn your palms toward each other and reach overhead

without letting your ribs “pop”‐ Return the arms over your shoulder joints using your

core/lat connection‐ Perform 10‐15 repetitions. Add 3 or 5 lb. weights when

indicated

• Arm Circles‐ “Move your arms from your back”‐ Lay on your back, knees bent, feet on the floor, arms

over your shoulder joints‐ Keep your ribcage tucked in and connected to the mat‐ Move your arms in the socket, feeling the connection

to your back and core‐ Head options: relaxed on the mat or lifted‐ Perform 5‐8 repetitions each way


Fundamental Leg Exercises

• Frogs with Band‐ “Move your legs from your core”‐ Lay on your back with your feet in a frog position,

band wrapped around your arches‐ Ensure your tailbone is on the mat and the core is

engaged‐ Feeling your legs anchored into your core, press

your legs out to 45 degrees and “zip up your legs”‐ Perform 5‐8 repetitions

• Single Leg Circles with Band‐ “Feel the hip move in the socket”‐ Lay on your back with one leg in the band, the other

leg bent or straight‐ Keeping the pelvis stable (do not let it rock and roll),

make leg circles in a controlled motion‐ Perform 5‐6 repetitions each way, both legs


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Fundamental Leg Exercises

• Single Leg NM control‐ “Control the knee from the hip”‐ Lay on your back with one foot in the

band, the other leg bent‐ Bend your knee to 90 degrees and

press the foot through the band to straighten the leg

‐ Keeping the leg straight, slowly raise the leg up and then lower

‐ With control, bend the knee to the starting position

‐ Perform 8‐10 repetitions each leg.

• Single Leg NM control + bridge‐ As above, but in a bridge position‐ Keep the pelvis level during the

exercise‐ Perform 8‐10 repetitions each leg.


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FundamentalFoot Exercises

• Running ‐ Knees Straight‐ “Prance” ‐ Place your feet under your hips or next to eachother and try

to articulate through all 4 layers of your foot‐ Ensure your foot progresses between the 1st and 2nd toe at

the top‐ Perform 10‐12 repetitions

• Running ‐ Knees Bent‐ “Prance” in a mini‐squat‐ Place your feet under your hips or next to eachother, sit into

your glutes and try to articulate through all 4 layers of your foot

‐ Ensure your foot progresses between the 1st and 2nd toe at the top

‐ Perform 10‐12 repetitions

• Tendon Stretch ‐ Eccentrics‐ “The deeper the scoop, the lower the drop”‐ Place your feet hip width apart at the the end of a step‐ Engage your core ‐ Slowly lower on 3 counts and lift on 1 count‐ The deeper you scoop your belly, the lower your heels will

drop‐ Feet in neutral, toes out and toes in‐ Perform 10‐15 repetitions each


Posterior Pelvic Tilt Isolation

• Roll downs‐ “Tuck your tailbone and slowly roll down”‐ Sit with your knees bent, feet relaxed on ground‐ Gently place your finger tips behind your knees‐ Draw your belly in, tuck your tailbone and slowly

paste your spine down while keeping the feet on the floor

‐ Using your core and gentle finger tip touch, return to sitting

‐ Perform 5‐8 repetitions. Pre‐cursor for sit‐ups

• Quadruped PPT isolation‐ “Isolated pelvic tuck, not cat”‐ Position yourself on your hands and knees,

hands under shoulders, knees under hips.‐ Find neutral spine and engage your core‐ Using your core, tuck your pelvis under and

round your low back. ‐ Make sure you’re not rounding your mid‐back‐ Perform 8‐10 repetitions.

Yes: Long C Curve No: Upper Back Only


The Ab SeriesThe Ab Series is performed consecutively.Classically, this is performed with the head liftedoff. However, it can be effective with the headrelaxed on the ground. Lay on your back to start.Perform 5‐10 repetitions each.

• Single Leg Stretch‐ One knee straightens and reaches out of the

hip socket while the other knee pulls in, hands gently on top of knee pulling in

• Double Knee Stretch‐ Both knees hug in, then the legs straighten

out to 45 degrees while the arms extend by the ears


90

The Ab Series

• Scissors‐ Both legs stay straight as they

alternate in a split‐like action, hands gently behind the leg closest to the body

• Double Leg Lower / Lift‐ Keeping the pelvis level, both legs

lower. Hands are by hips or behind head


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The Ab Series ‐ Criss‐Cross• Criss‐Cross‐ “Train the obliques with thoracic rotation”‐ Hands behind head and rotate outer elbow to

outside of mat. ‐ “Keep the wingspan” and extend one knee,

bend the other‐ Do not let pelvis move‐ Perform 5‐10 repetitions

• Criss‐Cross ‐Legs Stable‐ Hands behind head and rotate outer elbow to

outside of mat. ‐ “Keep the wingspan” and keep feet on ground

or at table top‐ Do not let pelvis move‐ Perform 5‐10 repetitions

• Criss‐Cross ‐ Sitting Modification‐ “Keep the wingspan” with knees and feet

together. Squeeze towel or ball if needed.‐ Do not let pelvis move or knees shift.‐ Perform 5‐10 repetitions


Glute Exercises:Clams

• Clams ‐ “Move your leg on a stable body”‐ Lay on your left side and line up your heels, hips

and shoulders to be in one line‐ Bend your knees to 90 degrees and stack your

hips.‐ Engage your core‐ Keeping your heels connected, open the top leg

to activate the glute‐ Perform 15‐20 repetitions on each side‐ Add a theraband at the thighs when indicated

• Clams ‐ feet off‐ Lay on your left side and position yourself for

the clam‐ Keeping the knees on the ground, lift your feet

off‐ Keeping your heels connected, open the top leg

to activate the glute‐ Add a leg extension (straighten the leg) after a

few repetitions‐ Perform 10‐15 repetitions on each side


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Glute Exercises:The Side Series

The side series is performedconsecutively. Lay on your left side withyour hips and shoulders in one line, thelegs are slightly forward at an angle.Perform 5‐15 repetitions of each.

• Up / Down‐ Keep the heel tracking over the heel‐ Flex your foot and lift your leg, point

your foot and lower your leg

• Up / Down‐ Switch‐ Point your foot and lift your leg, flex

your foot and lower your leg


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Glute Exercises:The Side Series

• Circles‐ Point or flex your foot and make plate

size circles around your heel. Increase the circle size when indicated.

• Bicycle‐ Bring your knee into your chest,

extend your leg out and sweep it behind with you from your glute.

‐ Repeat the other direction


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Glute Exercises:Glute Max Training

• Glute Lift‐ “Find your glute, not your hamstring”‐ Position yourself on your elbows and knees.

Elbows under shoulders, knees under hips‐ Kick your glute up with control, concentrating on

the end range motion‐ Perform 12‐15 repetitions

• Glute Lift in Bridging‐ “Lift your pelvis from your glute”‐ Perform a Pilates Bridge and get to the top of

your endrange‐ Keep your core engaged, lower your hips a little

and then lift back up from your glutes.‐ Perform 10‐15 repetitions‐ Finish the exercise by articulating your spine

down (paste your spine)Reprinted with permission. Strengthening Core Stability by Lori Duncan, DPT, MTC, CPT

96

Glute Exercises:Glute Max Training

• Glute Circles‐ “Rotate your hip in the socket”‐ Position yourself on your hands and

knees. Hands under shoulders, knees under hips

‐ Option 1: Rotate a long leg behind you with stable trunk

‐ Option 2: Bend the knee and rotate your hip in the socket, keeping the knee in line with the ankle

‐ Perform 4‐5 repetitions each way


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Pilates Plank• Plank Prep ‐ Hover‐ “Lift knees from core”‐ Position yourself on your hands and knees.

Hands under shoulders, knees under hips‐ From your core, lift your knees off to hover a

few inches off the floor‐ Press through your shoulder blades to feel the

back/core connection‐ Perform 4‐5 repetitions

• Pilates Plank‐ “Engage from head to toe”‐ Using the Pilates Prep, find your plank position‐ Step your feet slightly back‐ Lengthen yourself forward into a plank‐ Stay long, engaged and strong as long as you

can before your feel pain in your back. 15‐90 seconds


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Pilates Side Plank

• Side Plank‐ “Anchor your shoulder down your back and

press up from your obliques and scapula”‐ Sit on your left side, position your elbow

under your shoulder and glide your shoulder blade down your back

‐ Using your core and scapular muscles, breathe in and lift up into a plank.

‐ Perform 2‐5 repetitions, hiold 5‐30 seconds‐ Options: elbow + knees, elbow + feet, hand +

knees, hand + feet


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Scapular + ShoulderExercises

• Chest Expansion‐ “Open your chest with the back”‐ Stand with feet hip width apart, tall posture, ribs

tucked in, core engaged‐ With straight elbows, pull the arms to the sides of

your hip‐ To finish the movement, squeeze your shoulder

blades together and open your chest. The arms will move further back.

‐ Feel the muscles under your armpit engage‐ Perform 10‐15 repetitions

• Row + Rotation‐ “Row and Rotate”‐ Stand with feet hip width apart, tall posture, ribs

tucked in, core engaged, knees bent‐ Bend one elbow and “row” it back, while rotating

the upper spine on a stable lower spine‐ Gaze the eyes over the elbow‐ Return to start and repeat the other side‐ Perform 10‐12 repetitions each side, alternating


100


• Offering‐ “Find your lat to core connection with posture” ‐ Sit in a criss‐cross position, the band placed evenly

under your glutes‐ Lean forward and lift the band at a 45 degree angle

from your trunk up toward your ears to feel your posture, lat and core.


‐ Option: sit on band at the edge of a chair and perform as above.

• Rotator Cuff Training ‐ Pilates‐ “Move the shoulder in the socket”‐ Stand with feet hip width apart, tall posture, ribs

tucked in, core engaged‐ Keeping the wrist neutral, rotate the arm out

without moving your shoulder blade‐ Perform 10‐15 repetitions‐ Turn 180 degrees and repeat for internal rotation


101


• Shave the Head‐ “Lean into the wind and extend your arms”‐ Sit in a criss‐cross position, the band

placed evenly under your glutes‐ Lean forward and place your thumbs and

index fingers together to make a triangle behind your head

‐ With a long, neutral spine, raise your arms up at an angle. Keep your fingers and thumbs connected


‐ Option: sit on band at the edge of a chair and perform as above.


102


• Long Back Stretch‐ “Open your chest + train your back”‐ In standing or on knees grab a towel

and walk hands close together.‐ Squeeze your shoulder blades

together‐ With a long, neutral spine, raise your

arms behind you keeping your core engaged so the ribs don’t pop.



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Posture• Spine Twist at Wall‐ “Move upper spine on lower spine”‐ Place your feet flat against the wall, legs slightly

wider than hips‐ Extend your arms out in front and find your tall spine‐ Breathe in and rotate your right arm back and look

over your middle finger. Breathe out to return.‐ Do not allow the feet to move away from the wall‐ Perform 3‐5 repetitions each way

• Posture at Wall‐ “Sit out of your pelvis and lift your ribs from your

hips”‐ Place your back against a wall with your soles of feet

touching‐ Extend one arm up without any rib movement‐ Extend the other arm up‐ Extend both arms up and try to reach your ribs away

from your hips‐ Practice at least once a day


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