The use of Pilates equipment has been a common practice among dance instructors and dancers for decades.1 However, it is only recently that the practice of Pilates, as a core strengthening method, found its way into health clubs and rehabilitation facilities.2 Today, Pilates and the Pilates Method are common practice for many fitness trainers and physical therapy practitioners, who pride themselves on their ability to help clients and patients achieve core strength, or what has long been referred to as back stabilization.3
The purpose of this article is to describe a practitioner-developed, Pilates-based, Four-step Core Co-contraction Technique-a four-step core stabilization method that can be easily learned without the use of specialized Pilates equipment.
Background
In 1945, pioneer Joseph Pilates used the term contrology to define a unique method of physical and mental conditioning1 while introducing his comprehensive integration method of body, mind and spirit.4 The term contrology has been used to describe being kinesiologically proper, physiologically sound and psychologically correct. Born in Germany and raised in England, Joseph Pilates was the first individual to develop a series of floor exercise commonly known today as Pilates mat work.
During WWI, Joseph Pilates developed many exercise programs for detainees in Germany who suffered from disease and injury, using an assortment of bedsprings and beer keg rings. Pilates was also a student of Zen Buddhism and other Eastern practices; he therefore believed that recovery needed to focus on not only the body but also the mind and the spirit. In fact, Pilates felt that an integrated method of exercise would not only help the body recover physically but would also serve to nourish the vital organs of the body, clarify the mind and also develop the will.
After the war, Pilates continued to work for the German military for some time but later immigrated to New York City in 1925. There, Pilates established a studio for dancers and choreographers seeking to (a) improve posture, (b) enhance grace, (c) facilitate ease of movement and (d) improve their dance performance.
Although Joseph Pilates passed away in 1967, his students continued to use his techniques and methods. By the late 1980s and mid-1990s, the Pilates Method had found its way to others as well, and became a welcoming presence in fitness clinics as well as rehabilitation facilities across the United States and around the world. 
Four-step Core Co-contraction Technique: The Process
The Core Co-contraction Technique was developed to help patients and clients recruit, or activate four key core muscle groups: (a) the multifidus, (b) the respiratory diaphragm, (c) the pelvic floor and (d) the transverse abdominis (TrA).
Studies conducted by C. Richardson, et al reveal that there is considerable weakness and an inability to recruit these muscle groups in individuals with low-back pain.3 Findings purport that the re-education and recruitment of these core muscles are essential for the reduction of pain as well as the promotion of pain-free, functional movement.
The technique begins supine, in the hook-lying position, with one hand placed on the center of the abdomen and the other on the center of the sternum. Before the four-step process begins, individuals are asked to first notice how they are breathing and where they feel greatest movement. Is it in the abdomen or the sternum/chest region? After awareness is achieved, the practitioner then guides the individual through the following four steps:
Step 1. Activate the multifidus by performing a modified long bridge exercise. Different from a traditional bridge exercise, the feet are placed further from the body and the knees are flexed at only 30 degrees, with the ankles held in dorsiflexion. Individuals are asked to gently push (at effort 2-3/10) their heels into the supporting surface, as if to initiate a bridge but without actually lifting the pelvis into the bridge position. This effort activates the multifidii, or deep spinal stabilizers, which can also be palpated by placing the fingertips just lateral to the vertebral spinous processes.
Step 2. Return to the hook-lying position and activate the diaphragm by expanding the breath upon inhalation, as if filling the abdominal cavity with air; the hand placed on the belly should rise more than the hand placed on the sternum. Feedback can also be achieved by placing the palms of both hands on the outer, mid-ribs area during inhalation.
Step 3. Activate the pelvic floor by pulling up on the pelvic sling.5,6 If you are unaware of whether or not your pelvic floor is working, you can practice pelvic floor contractions by sitting on a Joey Cuff that is pumped up enough to gently push into the pelvic floor. Upon contraction, the needle on the BP cuff indicator should increase 5 to 8 mmHg for 8 to 10 seconds. This is also a great exercise for home and provides wonderful and non-invasive visual feedback.
Step 4. Finally, activate the transverse abdominis (TrA) by drawing the navel in toward the spine on exhalation, which will also draw down or compress the lower angles of the rib cage into the abdominal cavity. Contraction of the TrA can be palpated at a point just medial to the ASIS, on each side.
After completing the four steps, or activating the muscle groups in order, individuals are asked to hold the four muscle groups in a state of contraction for a five-second count before relaxing. The four-step process is then repeated 10 to 15 times. Individuals are also advised to perform this recruitment technique two to three times per day, as part of their HEP. As individuals more easily recruit and activate the muscle groups, they can then participate in a series of exercises (in our clinic these exercises are Pilates and Gyrotonic-based) and other core training activities that correct their particular dysfunctions, while also serving to assist them in achieving any functional goals and objectives.
The Purpose of Breath
Proper breathing is essential during the four-step technique. Proper breathing means to inhale through the nose and exhale through mouth. In keeping with the Pilates Method, individuals are encouraged to exert upon exhalation and create a "haaaa" sound. This exhalation is similar to that which we would do if asked to "fog" a mirror.
Proper breathing (a) activates the respiratory diaphragm, (b) lessens the use of accessory breathing muscles, and (c) enhances the expansion of the middle and lower lobes of the lungs, while simultaneously "drawing down the rib angles," which also activates the transverse abdominis.
Making a Connection
Regular daily practice will help to strengthen these four key core muscles while also improving awareness of the mind-body connection. As proficiency improves, individuals can be challenged to practice the technique while in the prone position, seated position or standing position.
Of course, modifications to the multifidus-activation step must be made as one learns how to perform the technique in other positions. Practicing in various positions, in a mindful way, can serve to build one's abilities to connect to the postural musculature more unconsciously. This mindful connection is also essential for proper core control, as proposed by Joseph Pilates some 70 years ago.
In the realm of developmental rehabilitation, therapists have long sought to achieve distal mobility upon proximal stability with traditional physical therapy exercise.7 The significance of such an achievement is to demonstrate good core control during functional task performance, or movement of the arms and legs independent of a stable torso-this has been no easy task for clinicians.
However, in Pilates, mobility upon stability can be easily achieved and felt, just by the nature of the method. This Four-step, Pilates-based, Core Co-contraction Technique makes this achievement even easier for any trained therapist.
In fact, both patients and clients will effectively achieve core-controlled movements, once they master and integrate the sequence. As mastery progresses, progression can be made by adding adduction knee ball squeezes, an active SLRing, and an array of bilateral and unilateral UE movements, depending on goals and objectives.
In addition, the four-part sequence can also be trained using an array of Pilates equipment. Training may be expanded to include other positions (e.g., prone, sitting, side-lying, quadruped, standing). Challenges to balance may also be incorporated within any posture, depending on goals and objectives, too.
The technique has been used at Core Therapy & Pilates for seven years and with more than 900 patients and clients. It has proven, anecdotally, to be both safe and effective. It has been my clinical experience that patients and clients can easily and effectively understand, demonstrate and carry over this training to tasks or any functional movement with consistent training. If we help patients and clients understand and use this technique, we can help them lessen their risk of future injury or even dysfunction.
References are available at www.advanceweb.com/pt.
Stephen Dunn is co-owner and director of Core Therapy & Pilates in Austin, TX, with his wife Cheryl Dunn. He is a 1998 graduate of LSUMC and a 2003 graduate of the Manual Therapy Certification offered by the Maitland-Australian Physiotherapy Association. In addition, he received a 2002 certification in Pilates from RetroFit Pilates, recognized by the Pilates Method Alliance. In 2009, he received a certification in Gyrotonic®.