Seeking Stability

PTs and PTAs use Pilates to improve stability post-stroke

As a popular way to build strength and endurance, Pilates has many fans. Yet beyond the musculoskeletal implications, it also correlates to neurological rehabilitation. Some physical therapists have found it to be an effective additional tool when treating patients who have experienced a stroke.

"Pilates is really unique because it uses developmental positioning," said Alison Lichy, PT, DPT, NCS, owner, NeuroPT and Evolution Pilates, Falls Church, Va. That uniqueness translates into the ability to tailor a Pilates-based therapy regimen for each stroke survivor.

Like all physical therapy, much of Pilates depends on the buy-in of the patient. There is a decided advantage with this style of rehabilitation, though. As Erma Pacheco, PT, owner, Colorado Center for Physical Therapy, Littleton, Colo., explained, "One thing that separates it from so many other things is that it's fun."

Pilates can have a positive impact, whether in the immediate acute phase, or years later with chronic patients. "It goes the whole gamut," observed Lichy of the different functional levels the physical therapists at NeuroPT and Evolution Pilates treat. She asked, "What can we do to make this more functional and address these limitations?"

With any physical therapy, "The sooner the better, because plasticity and the ability to adapt are better," explained Pacheco. She and her colleagues do see a whole range of patients, as Pilates maximizes function over the long term. As Lichy puts it, "Stroke is a chronic disorder. They will have to maintain physical fitness for the rest of their lives."

Patient-Specific Rehab

While patients can perform Pilates at home or at a clinic, one advantage physical therapy offices and gyms may have is the presence of equipment. "We use the Reformer because it gives consistent pressure," Pacheco said. Indeed, the Reformer, one of the most popular pieces of Pilates equipment, focuses on stability and has significant use for patients who suffered a stroke. At Colorado Center for Physical Therapy, however, physical therapists teach patients to isolate their core muscles before putting them on the Reformer. Depending on where a given patient is in the recovery process, they can learn the same exercise on equipment or the floor.

Once patients are ready for equipment, it has some advantages over mat work. Machines are helpful to the therapists as they give feedback, assistance, or resistance. Pilates machines can show physical therapists where their patients are lacking and identify imbalances in the body. Lichy explained, "The beauty of the equipment is that it can help with alignment."

The spring system on the Reformer provides more assistance in performing movements than going against gravity with an exercise band, empowering the patient to complete more exercises. By building up the core, exercises on the Reformer decrease patients' fall risk. "It puts them in a fixed position where they can focus," observed Jill Dietmeyer, PT, DPT, LMT, Rehabilitation Hospital of the Pacific, Honolulu, Hawaii.

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The Reformer can stabilize the trunk while moving the arms and legs, helping with isolation and dissociated movements. "We use the Reformer because it gives varying pressure for resistance and/or assistance," Pacheco explained. It gives patients the freedom to complete smaller, specific movement patterns. Patients can use the Reformer very early in the rehab process, when they might have difficulty standing for prolonged periods. Later, when they have improved balance and strength, the Reformer can challenge them even further.

Other equipment can progress post-stroke rehab too. At Rehabilitation Hospital of the Pacific, physical therapists have a full Pilates gym at their disposal, including a Cadillac, Pilates Chair, Ladder Barrel, and Core Align, among others. The Pilates Chair isolates specific muscles. It has a smaller base of support than the Reformer, so it challenges patients more.

The curved shape of the Ladder Barrel adds an additional level of core strengthening and balance improvement, as it's even more difficult to balance on. At Colorado Center for Physical Therapy, PTs use the Cadillac for patients who need extra stability when isolating scapular movements.

Strength, Balance and Flexibility

Two specific side effects of stroke that physical therapists have found Pilates helps with are hemiplegia and post-stroke fatigue. "One of the benefits of using Pilates is that you can isolate the smallest movements," said Pacheco. It's important to understand the center line of symmetry as much as possible when addressing one-sided weakness. Dietmeyer explained, "I want to strengthen both sides but I have to help them manage the affected side. The equipment is almost like an extra set of hands."

With fatigue, the benefits are more tangential, but still present. Patients think, "I can do this because I have this stable core to work from." They activate the transverse abdominals to create core stability - muscles that many of them have never consciously targeted before, said Dietmeyer. Initial exercises are performed while patients are supine, as it's easier on patients' bodies. With Pilates, by performing short sets of repetitions and quickly moving on to the next area of focus, patients can complete full-body workouts. The smooth, controlled, rhythmic motions of Pilates improve strength, balance and flexibility.

Linking breath to movement is a core Pilates principle, and one that helps patients refocus their energy. "Breathing is very important," explained Dietmeyer. "Every Pilates exercise has a breathing component that goes along with it." Physical therapists and Pilates teachers are tuned into what's happening with the body.

Once they become comfortable with Pilates, patients will push themselves into other activities. "They report to me they have better stamina," Dietmeyer said. Lichy concurred, noting that Pilates improves endurance. As Dietmeyer noted, "It's not the equipment, it's the Pilates method that helps.

Bringing it All Together

Pilates does not operate in a bubble, and skilled physical therapists know it's just one tool in their toolbox for rehabbing patients who have experienced a stroke. "There's so much overlap," Lichy explained. With someone who recently had a stroke, a physical therapist may focus on improving their pelvic stability, with exercises that are similar to basic Pilates mat wok.

Patients will sometimes go into the pool for aquatic therapy or use the anti-gravity treadmill at Rehabilitation Hospital of the Pacific. On average, stroke patients will attend physical therapy twice a week for two or three months - therapy that's a combination of Pilates-inspired exercises and traditional gait training and strength training.

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As both patients and physical therapists know, though, the effects of a stroke can linger for years. Pilates, which can be done either as a home-based program or in a class setting after official physical therapy ends, helps patients maintain their activity levels and stave off deconditioning. Physical therapists perform a lot of work with foam rollers and inexpensive therapy bands, as patients can easily transition into using them at home. "It's a good way to add wellness down the road," noted Lichy. After discharge, patients from NeuroPT and Evolution Pilates can join Pilates groups, where they interact with other stroke survivors.

Some former patients at Colorado Center for Physical Therapy will attend group Pilates classes at their in-house studio, where quality of progress can continue to be measured after discharge. "Our end goal is to get them to be more active in the community," said Christine Drummond, PTA, who works at the center. At the Rehabilitation Hospital of the Pacific, some stroke survivors come in on their own for individual Pilates-based treatment, paying out-of-pocket because their insurance ran out.

Long-Range Benefits

"Long-term patients often develop compensation," Dietmeyer commented. Stroke survivors will develop overuse injuries on the unaffected side.

Pilates is about taking basic therapeutic exercises and focusing on alignment. Physical therapists must learn whether patients are compensating or whether they are getting true movement. Muscle imbalances create orthopedic problems down the road, such as chronic knee, hip and back pain. Pilates exercises can strengthen the unaffected side, making it more functional.

Yet before discharge from monitored physical therapy, PTs must ask, are patients doing the exercise correctly? Can they do it on their own? And more importantly, are the prescribed exercises appropriate for each patient's individual goals?

The strength-building aspects of Pilates also help with fall prevention by creating improved posture. In turn, patients get a better sense of control over their bodies, boosting their self-esteem.

Some PTs think traditional physical therapy is more effective in activating muscles in the acute stage of post-stroke rehab. However, as Pacheco observed, "All the goals are the same using Pilates or traditional PT - optimizing function."

"It's amazing how much they can improve years later," added Dietmeyer. 

Danielle Bullen is on staff at ADVANCE. Contact: dbullen@advanceweb.com


"It goes the whole gamut."

Wow. What a rousing endorsement.

Victor CharlonmondFebruary 20, 2014
Dillon, SC


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