Resource for Understanding Benign Paroxysmal Positional Vertigo

In my last blog post Building Blocks for Better Balance I included some exercises to help improve balance skills in older adults. As mentioned in the post, balance is related to seeing (visual system), feeling where you are in space (proprioceptive system) and the inner ear (vestibular system). Sometimes dizziness caused by inner ear issues can affect balance in older adults and should be addressed prior to introducing balance exercises. Debris in the inner ear can cause a condition called Benign Paroxysmal Positional Vertigo (BPPV). Chicago Dizziness and Hearing private medical practice, led by Dr. Timothy Hain and Dr. Marcello Cherchi, affiliated with Northwestern University, has a comprehensive description of BPPV on their website that addresses causes, diagnosis and treatment. If your client is experiencing issues with vertigo, this is an excellent resource for better understanding the condition. The link is provided below.

http://dizziness-and-balance.com/disorders/bppv/bppv.html

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BUILDING BLOCKS FOR BETTER BALANCE

Improving balance in senior populations is important for the prevention of falls and provides individuals the physical skills to perform daily tasks with confidence. Although there are many strategies to address this concern, all methods require consistent practice (i.e., the “use it or lose it” principle). It is not uncommon for an older client to express surprise at the level of difficulty with such skills as balancing on one leg, shifting weight from leg to leg, or walking on a straight line. The good news is that unsteady balance can improve dramatically with consistent practice. Yoga blocks can be used as an excellent tool to practice such balance skills as picking up one’s feet to clear an object, balancing on one foot, transferring weight from one foot to the other, and staying balanced while shifting the center of gravity.

According to the article “From Athletes to the Elderly: The Science of Trips and Falls” the body uses multiple sources for balance information.

“The visual system takes in information from the outside world and transmits it to the brain. The proprioceptive system, which incorporates sensory systems throughout the body, tells us how the body’s parts are oriented relative to each other. And the vestibular system, located in the inner ear, focuses primarily on how the head is moving”

As people age there is often deterioration in one or more of these systems. Improving core strength and regularly challenging oneself by performing balance-related exercises can allow older adults to adapt to unstable surfaces or other unanticipated obstacles to avoid falls.

In addition to preventing falls, steady balance is a quality of life issue for older adults.  Getting dressed is a basic example of this. To put on a pair of pants or to slip into shoes requires standing on one leg.  When older adults lose confidence in their abilities, they will often sit down to perform basic functions.  Fear of injury due to lack of confidence in physical skills will likely lead to moving less and doing less. Many older adults lack the knowledge and training that a physical coach or Pilates instructor can provide.  In the short term, there is often a modification or different strategy available that can be employed to approach a daily task.  In the long-term, strength and flexibility along with coordination and balance training can make a significant difference in the physical well-being of seniors. Providing guidance and strategy to seniors as they navigate the aging process allows them to continue the activities they enjoy.

YOGA BLblocksOCK BALANCE EXERCISES

Place 4 yoga blocks in a square with enough space for a person to stand in the center of them and space available to comfortably step over them.

Firmly hold the hands and wrists of your client for additional support or let your client use hiking or ski poles. Once confidence and skill improves, the exercises can be done without assistance.IMG_1604[1]

Centered Weight Shift

1.  Step the left foot over the front block with equal weight on each leg in a forward lunge position and the spine in a centered vertical position.  Return to the starting position in the center of the blocks. Repeat the step forward on the right leg.

IMG_1607[1]2.  Step the left foot over the left side block with equal weight on each leg in a centered squat position. Return to the starting position in the center of the blocks.  Repeat the step side on the right leg over the right block.

3.  Step the left fooIMG_1609[1]t backward over the block with equal weight on each leg in a back lunge position and the spine in a centered vertical position (not pictured).  Return to the starting position.  Repeat on the right leg (note the picture shows this–right foot is back).

Be aware that your client may try to “cheat” by going around the side of the block, rather than over the block.  This exercise is designed to give your client proprioceptive feedback since they will kick the block if the foot is not picked up sufficiently.

The pattern above and all subsequent ones can be varied by starting on the right leg or doing repetitions of a step (example: 4 sets of left/right over the front block before moving to the side; or stepping the left foot forward and back over the front block 4 times before stepping over the front block with the right foot). Varying the patterns requires your client to pay closer attention and apply the applicable pattern of the day.

Weight Transfer

IMG_1606[1]1.  Step the left foot over the front block landing with a bent left knee and straight right leg.  The majority of the weight is on the front leg and the spine is on a 45 degree angle forward.  Be sure your client’s knee lines up over the ankle (not off center or with the knee over the toe or beyond, which creates too much forward pressure to the quadriceps).   Return to the starting position with a rebound feeling by pressing the front heel into the floor and engaging the left hamstrings. Repeat forward lunge on the right leg over the front block.

Unlike the Centered Weight Shift version above where the core was centered equally between the legs, this version requires more core adjustment by shifting the weight off center and back to center challenging the awareness of the center of gravity.

2. Step left foot over the left side block landing with a bent left knee and sIMG_1608[1]traight right leg.  The majority of the weight is on the left side leg and the spine is on a 45 degree angle sideways to the left. Again, look for the lineup of the knee and foot. The step to the side can be done with a parallel leg (toes pointing forward) or with an externally rotated leg (toes point outward). Return to the starting position with a rebound feeling by pressing the left heel into the floor and engaging the left hamstrings. Repeat side lunge on the right leg over the right side block.

3.  Step the left foot backward over the block (not pictured) with the chest over the back leg landing with a bent left knee and straight right leg holding the core to support the low back. Return to the starting position with a rebound feeling by pressing thIMG_1610[1]e back heel into the floor and engaging the left hamstrings. Repeat this back lunge on the right leg (note the picture shows this–right foot is back).  The majority of the weight is on the back leg and the spine is at approximately a 45 degree angle backward with the chest over the back foot.  It is acceptable to slightly rotate the back foot out if needed, but since this tends to also rotate the pelvis, the exercise is more challenging if the back leg is parallel and the hips are “square” to the front.

One Leg Rebounds

This exercise can be done with either the Centered Weight Shift or Weight Transfer version above. The right foot remains in a stationary position while the left leg steps forward over the front yoga block, rebounds and returns center; steps left side over the block, rebounds and returns center; steps left back over the block, rebounds and returns center. Repeat with the right foot stepping the right foot over the front, side and back block. The pace of the exercise is a bit faster so the adjustments need to be made quicker. Vary the pattern by starting with the right leg, repeating positions more than once or starting the exercise to the back.

Stepping Over

This variation of the exercise is useful to do initially in front of a mirror since it requires that the client step backward over the block.  The mirror can be used to see the yoga block and judge the distance and size of the step better. Be sure to assist the client supporting the hands/wrists or use the hiking/ski poles until they are no longer needed.

1.  Step the right foot over the front block followed by the left foot to completely step over the yoga block.  Step the right foot backward over the front block followed by the left foot to return to the starting position in the center off all the blocks. Be sure your client goes over the block, not around it. This requires momentary balance on a single leg and picking up the feet.

2.  Step the right foot over the right side block followed by the left foot to completely step over the yoga block.  Step the left foot sideways over the side block followed by the right foot to return to the starting position in the center off all the blocks.

3.  Step the right foot over the back block followed by the left foot to completely step over the yoga block.  Step the right foot forward over the back block followed by the left foot to return to the starting position in the center off all the blocks.

4.  Repeat the entire pattern above starting with the left leg lead going completely over the front, side and back block to finish in the center of all the blocks.

Again, the patterns can be varied starting with the left leg, mixing front right/left leads before moving into the side or back positions, starting the exercise to the back, etc.

Eyes Closed

This is an advanced exercise to be completed only after the above skills are acquired and your client feels confident.  Be sure to have your client master the skill of balancing on one leg with the eyes closed and taking steps forward, side and back with the eyes closed prior to trying this exercise with the yoga blocks. Be sure to assist your client by supporting the hands/wrists or carefully spotting each step so that your client does not trip over the blocks.   Try any of the above exercises: Centered Weight Shift, Weight Transfer, One Leg Rebounds, or Stepping Over with the eyes closed while carefully assisting to make sure your client does not trip. Advise your client to feel the floor with the toes on the other side of the yoga block prior to transferring the weight.

Standing Balance

blocks verticalMove the front and back yoga blocks a quarter turn so that all of the four blocks line up in the same direction with enough space for a person to stand in the center of them.

1.  Step the right foot forward up onto the front block to balance on the block on the right leg with the left foot suspended off the floor.  Step the left foot back down to return to the starting position. RepIMG_1620eat on the left leg stepping up on the front block (shown in picture). Return to the starting position.

2.  Step the right foot up sideways onto the right side block to balance on the block on the right leg with the left foot suspended off the floor.  Step the left foot back down to return to the starting position. Repeat on the left side using the left side block.

3.  Step the right foot backward up onto the back block to balance on the block on the right leg with the left foot suspended off the floor.  Step the left foot back down to return to the starting position. Repeat on the left foot stepping up on the back block and return to the starting position with the right foot joined by the left.

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All of the above exercises require core strength, leg strength and ankle stability. If you feel that your client is deficient in one of these areas and cannot successfully perform the exercises outlined above, try doing some basic exercises that boost these skills prior to working with the yoga blocks.

Although the yoga blocks are useful tools since they are a good height and size for practice, any obstacle is acceptable.  Envelopes can work well as a target to step over if picking up the feet is too difficult. A client can practice at home stepping over books, shoes or even cracks on a sidewalk. If your client is unstable, assign a preparatory exercise to stand on one leg in a doorway holding the doorframe or holding onto a counter for stability. Make sure your client’s home practice is commensurate to skill.

The loss of balance can feel like a loss of control in the lives of older adults. It is unfortunate that many seniors begin to give up activities simply because they feel unsteady and fear they may fall. The building blocks for better balance are available to everyone, but require a commitment to practice and a systematic plan.  Getting older does not have to mean a wobbly future.  Balance can be relearned and continuously improved. Practice may not always make perfect when it comes to balance in older adults, but the progress is definitely worth the effort—ask anyone who can now put on pants one leg at a time.

YOU’LL “LOVE” USING TENNIS BALLS TO “ACE” THE PELVIC CLOCK

Tennis balls can add a whole new spin on the introductory Pilates Pelvic Clock exercise.  This basic exercise uses the image of a clock at the pelvis to direct the mover to various points in space that represent the numbers of the clock and illustrates basic pelvic placement positions such as neutral (with lumbar curve) and flat back (no curve). Adding tennis balls to this exercise can improve proprioceptive awareness of pelvic placement and release myofascial trigger points in the gluteus maximus and piriformis muscles leading to better activation of core muscles  (see previous article “Addressing Trigger Points to Facilitate Range of Motion.” ) 

PELVIC CLOCK EXERCISE

The Pelvic Clock (also used in the Feldenkrais method) is a perfect beginning exercise since it illustrates how to initiate movement from the core, but can also be enjoyed by advanced students who continue to garner self-awareness from its repeated practice.  To perform the Pelvic Clock exercise, have your client lie supine with knees bent and feet on the floor (or you can prop the client’s legs on the Reformer Short Box).

 Imagine that the pelvis is a clock with the navel as 12 o’clock and the pubic bone as 6 o’clock. Move the pelvis into a posterior pelvic tilt (flat back) for 12 o’clock and then return the pelvis anteriorly to 6 o’clock (neutral pelvis) where the pubic bone and anterior superior iliac spine (ASIS) points are parallel with the floor and a lumbar curve is present. Repeat pelvic shifts 4 times or as many times as needed.

 After returning to neutral pelvic placement, move to 3 o’clock (left lumbar rotation) and 9 o’clock (right lumbar rotation). For example, you could have your client imagine the pelvis as a boat filled with people. Then visualize all the people walking to one side of the boat, so that it dips in the water to one side heavier than the other. Repeat the left and right shifting 4 times.

 The previous practice moves the client’s pelvis in a cross-like shape relative to the clock (up to down 12 o’clock to 6 o’clock, and left to right, 3 o’clock to 9 o’clock). Next explore the “X” shape on the clock going from 10 o’clock (weighted right waist flat back) to 4 o’clock (weighted reaching left buttock in neutral) and 2 o’clock (weighted left waist flat back) to 8 o’clock (weighted reaching right buttock in neutral). Repeat each sequence 4 times.

 Finally, have your client use their fingers to palpate each number on the clock starting and 12 o’clock and explore each number individually clockwise and counter-clockwise taking one to two full breath cycles at each number.  Once each number has clarity, sew them together like a plate would spin clockwise and counter-clockwise making sure the core initiates the motion, not the feet or legs. The continuous moving clock does not correspond with the breath—the client breathes when needed, not timing it to any number on the clock.

 Please note that the description of the Pelvic Clock is in the perspective of the viewer of the clock (navel as 12 o’clock).  Personally, I would prefer the clock be in the perspective of the person exercising (pubic bone as 12 o’clock), but it is not generally taught this way.  So as not to confuse people, I have conformed to standard practices.

 BREATHING FOR PELVIC CLOCK

Be sure that your client integrates breathing into this exercise. I choose to move the pelvis on the exhalation, as it is easier to feel the activation of the pelvic floor and the transversus abdominis to assist with the transition through core initiation. Be aware that there is a tendency for the client to move the pelvis from a distal initiation by pushing on the feet or legs, so cue your client to feel the pelvic floor and engage the transversus abdominis prior to moving. For example, inhale at 6 o’clock and move to 12 o’clock on the exhalation using core muscles. Hold 12 o’clock on the inhalation and then move back to 6 o’clock on the exhalation.  You may choose to slow the exercise down spending more time on each number to further activate and deepen the abdominals with a cumulative dropping of the abdominal wall on each breath.

 PELVIC CLOCK WITH TENNIS BALLS

Place a tennis ball approximately 4-5” below the posterior superior iliac spine points (PSIS) on the right and left sides of the sacrum in the fleshy part of the buttocks. The target for the tennis balls is either the gluteus maximus or piriformis trigger points. Ask your client to place the balls so they are placed symmetrically right to left and hit these tender trigger points. I usually stand up and demonstrate the ball placement visually before lying supine. Although the balls will likely be uncomfortable, discontinue if the discomfort is intolerable. Hitting the right trigger points may require a little fishing, so tell your client that they may move the balls at any time. Since there is more than one trigger point to address, suggest that the balls be moved if the initial trigger point becomes comfortable.

 Perform the Pelvic Clock as per the instructions above. The objective is to keep the gluteus maximum muscles relaxed as the pelvis is moved to each number on the clock. This will require breathing, concentration and core initiation.  Many people tighten the gluts for stabilization, which can lead to tension in the low back and hip flexors.  Pelvic Clock with the tennis balls illustrates quickly if the gluts are being used since they dig into the muscles on each movement. This helps the user to let go of the gluts and focus instead on the deeper core muscles of the pelvic floor, transversus abdominis and multifidus muscles. The tennis balls also inform the user when the legs or feet initiate the movement since there is more tension over the balls.

 The Pelvic Clock exercise will likely be slowed down when using the tennis balls since it takes time to relax the tension in the piriformis and gluteal muscles. Have your client imagine the buttocks are like honey melting over the tennis balls. The focus is on the journey from clock number to number feeling the tennis balls almost being absorbed into the gluts.  For example, if an ant were walking across the ball, it would take a lot of steps and every bit of the ball surface would be noticed. That should be the feeling experienced when using the tennis balls with Pelvic Clock.

 Point out to your student that the abdominal muscles play a bigger role in a posterior pelvic tilt (12 o’clock) and the lumbar extensors initiate the movement back toward neutral (6 o’clock). Many people have never isolated and observed these muscles in action. Also cue your client to be aware that the low back should feel a stretch when shifting to 12 o’clock where the tailbone feels as if it is reaching toward the back of the calves.  Often people will just push the low back toward the floor with tension and miss out on the experience of the simultaneous contraction in the front waist and lengthening of the back.

 For a group Pilates mat class, the tennis balls are an inexpensive teaching tool that can multi-task. They release the myofascial trigger points that can often interfere with proper core initiation, and provide improved proprioceptive awareness to the user. Always give the option to students to do the Pelvic Clock exercise without the tennis balls, but my feedback from students has been that the addition of the tennis balls is beneficial.  After doing the Pelvic Clock exercise with the tennis balls, remove the balls and your students will be amazed at how comfortable and easy it is to feel neutral pelvis placement. 

 Once you have taught your students the Pelvic Clock, you can reference the clock numbers for instruction in the Pilates matwork.  For example, during a right Single Leg Circle, you can instruct your students to focus on 3 o’clock to stabilize the pelvis and counterbalance the weight of the right leg.  In Double Leg Stretch you might suggest that the students keep a lengthened 12 o’clock imprint.

 The Pelvic Clock exercise is an effective tool for teaching your students pelvic placement, core initiation and integrating breath with movement.  The use of tennis balls takes the exercise to another level adding myofascial release of gluteal muscles and improved proprioceptive awareness of the pelvic region. Many people are unaware on the tension in the superficial gluteus maximus when deeper core muscles are engaged to shift the pelvis placement. The tennis balls alert the user to unwanted gluteal tension prompting relaxation and proper deep core activation of the pelvic floor and transversus abdominis. Once the gluteal tension is released, the subtle shifts in pelvic motions can be observed and the deeper core muscles identified.  Tennis anyone?

Sing a Song to Enhance Breathing with Your Parkinson’s Client

Parkinson’s clients can benefit immensely from the Pilates method’s focus on breath. Breath is a basic characteristic integrated into all of the Pilates equipment and matwork exercises, and provides oxygen to the cells promoting better health. The same dynamic that creates difficulty with repetitive movement in people with Parkinson’s Disease can also negatively affect respiration, causing shortness of breath or dyspnea.  Breathing exercises providing proprioceptive feedback can “wake up” the muscles of respiration for a deeper breath, but singing can also be a useful and fun tool to incorporate in a Pilates session.

Mayo Clinic Parkinson Specialist J. Eric Ahlskog, Ph.D., M.D. suggests, in The Parkinson’s Disease Treatment Book on page 299, that after other medical conditions are ruled out, Parkinson’s Disease (“PD”) could contribute to dyspnea.

“Consider what happens when we breathe. We repetitively contract and then relax our breathing muscles. Back and forth, the muscles of the diaphragm and rib cage contract to expel air and then relax to expand the lung cavity. (The diaphragm is the large breathing muscle underneath the lungs.) These repetitive movements by the breathing muscles move air in and out of the lungs, and PD occasionally affects these unconscious repetitive breathing movements.”

Most people are not in touch with their shallow breathing until it is brought to their conscious attention. In Parkinson’s clients, since muscular awareness can be diminished, it is often necessary for the instructor to touch the muscles in the ribcage for the person to feel the area expand and contract or have the individual feel it with his/her own hands during the breath.

Since the type and timing of medication will affect muscular coordination, be sure that your client does his/her best to perfect the timing and dosage of medication to be in an optimal physical state for exercise. In the following exercise a Physioball is used as the proprioceptive tool to increase awareness of the chest expansion and contraction.

Physioball Breath Exercise

Have your client sit next to a physioball and lean into it. The physioball “dents in” on the inhalation if the muscles contract sufficiently for a deep breath and “pops back” into the ribs on the exhalation. Assist your client to experience breath in the sideways, dorsal and ventral positions by holding the ball pressed toward the body. Use a smaller ball than the one pictured if your client has shoulder issues and cannot raise the arm comfortably. (Physioball exercise also featured in “Breaking Down the Pilates Hundred.”)

This exercise can “jumpstart” the respiratory muscles  and give your client the ability to direct the deeper breath. The expansive breath will facilitate the oxygen exchange when progressing to exercises using the Pilates equipment. Practicing deep belly breaths or diaphragmatic breaths can be useful to start the process, but ultimately the breath needs to derive from the expansion and contraction of the ribcage (without the shoulders rising and lowering), not the belly. Most of the Pilates exercises require costal breathing, since the abdominal muscles are utilized for core stabilization and support.

Singing Breath Exercise

When your Parkinson’s client has a more difficult time directing a deep breath, singing can improve breathing capacity. I will often use the “e” sound with a single tone found in vocal warm-ups to give my client a focus. If the “e” sound gets repetitive, mix it up and use another vowel sound or combination thereof. You can also do scales using the same vowel sound.

You will need a watch or clock with a second hand. First have your client sing “e” in a comfortable tone and see how many seconds the note is held. Inform your client how long the note was held and set a goal for the next breath. Keep going until the client improves and reaches full capacity. Be sure to let your client take a “catch up breath” when needed between singing breaths to avoid getting light-headed. Ten seconds is a good final target for holding the note, but make an individual goal since ten seconds might be too challenging for some people when breathing is difficult.

If the client is able to multi-task, I match the singing warm-up with movement. Sitting or standing exercises are better for this since it is easier to take a deep breath—for example, Standing Chest Expansion with light springs off the end of the Cadillac. Have your client sing the “e” sound in a comfortable tone for the target amount of seconds while pulling the springs, and focus on a deep inhalation through the nose during the return phase of the spring recoil.

I also use well-known songs that the client can sing when performing the exercise, which help with the breath and regulate timing. Most people know “row, row, row your boat” so I often pick that one, but let your client suggest songs too. For example, with parallel heel pushes sitting on the Wunda Chair, I would have my client sing “row, row, row your boat” and indicate that the bar should go fully up and down 3 times (or whatever timing you have in mind) before the phrase finishes.

Client’s with Parkinson’s Disease can often improve the depth of breath with a simple verbal or tactile reminder, but may experience difficulty with this task when medication is improperly timed. Singing is a fun and easy option to facilitate breath in the Pilates exercises and help your client feel more successful. In the words of The Carpenters “don’t worry that it’s not good enough for anyone else to hear, just sing, sing a song.”

SENTIENT SITTING STARTS WITH THE PELVIS

Cognitive awareness of the subtle shifts of weight on the pelvis can make a difference between being able to sit upright or collapsing into twisted slumping. Implementing this proper pelvic alignment in a seated position requires each individual to consciously recognize where the weight shifts on each of the ischial tuberosities or sit bones If your client can experience the various options of front/back, side/side, and right/left of the pelvis movement repertoire, then choosing “center” becomes a relative position and easier to replicate. These learned proprioceptive skills can correct dysfunctional patterns, reduce back pain and create body symmetry with improved muscular balance.

SHIFTING WEIGHT ON THE ISCHIAL TUBEROSITIES
Although the following exercises are basic movements of the lumbar spine, I came to understand them better through the Arch and Curl Series in GYROKINESIS® and GYROTONIC®. (Learn more about GYROTONIC® under my blog “Spice Up Your Pilates Palate with GYROTONIC®.” ) The Reformer, rotator disc and dowel are used in the following exercises for improved awareness and feedback. If you do not have these tools, only a firm chair or short stool is needed and hands can be placed on the hips. It is important to sit on the edge of the seat with the knees at approximately a 90-degree angle and the feet and pelvis sharing weight

Yoga blocks needed for shorter legs on Reformer.

Unhook all of the springs on the Reformer and instruct your client to sit on the edge of the carriage on a medium-sized 12″ rotator disc facing the footbar holding a medium-size dowel across the sacrum. Advise your client to be careful when sitting down since the carriage has the potential to slide away without the springs. If your client is too short, you may require the use of yoga blocks or some other prop to bring the legs to a 90-degree angle.

FRONT TO BACK: MOVING ON THE SAGITTAL PLANE
 Eric Franklin instructs how the sacrum moves when shifting the pelvis forward and back in his book Conditioning for Dance (page 92) with helpful tactile cues.

“1. Place a hand on the sacrum, and detect the bumps on the back of the bone. These bumps are the spinous processes of its five fused vertebrae. To feel the movement of the sacrum, it is easier to touch the adjoining bones that are easy to feel under the skin, the tailbone and the lumbar spine.

2. Place the middle finger of one hand on the tip of the tailbone, and place the middle finger of the other hand on the spinous process  of the fourth or fifth lumbar vertebra.

3. Tilt the pelvis forward, and notice how the lumbar spinous processes move forward and the tail moves back. The sacrum is doing a forward rotation movement called nutation (deriving from the Latin for nodding.) At this point the sacrum is only doing the first half of a nod…

4. Tilt the pelvis backward, and notice how the sacrum moves back and up. This movement is called counternutation, the second half of the nod…

5. Tilt the pelvis forward again and notice that nutation is linked with the spreading of the sit bones.

6. Tilt the pelvis backward, and notice that counternutation is linked to the converging of the sit bones.

7. Notice that nutation causes the lumbar spine to extend (the feeling is hollowed spine), while counternutation causes the lumbar spine to flex (the feeling is rounded spine).”

Anterior pelvic tilt.

Posterior pelvic tilt.

To give my clients the feeling of the pelvis as a whole, I describe an anterior pelvic tilt (sacral nutation) as a “Christmas tree” with a wider base at the sit bones and narrower feeling at the top of the pelvis (ilium) and a posterior pelvic tilt (sacral counternutation) as a “funnel” with a narrower base and a wider feeling at the top of the pelvis.

The benefit of being on the Reformer without springs is that the carriage should move slightly backward in the anterior pelvic tilt and forward toward the calves in the posterior pelvic tilt. If the carriage does not move front and back, then the initiation of the movement is incorrectly occurring at the rib cage instead of being driven by the pelvis. The dowel also assists in helping your client observe and feel the shifting pelvis. Notice if your client tends to put more weight on one sit bone or the other when moving, but do not mention it yet.

After moving a few times between the front and back positions have your client find neutral pelvis (in between the practiced positions) with the weight slightly forward on the sit bones (ischial tuberosities) and the feet weighted on the floor. In the neutral pelvis position, there is a equal activation of the transversus abdominis in the front of the waist and the lumbar multifidus in the low back to create an equal supported lift much like squeezing toothpaste from both sides on the bottom produces the lift out the top. This abdomen/low back gentle lifted squeezing can also be felt at the sides of the pelvis. This comfortable lifted synching feeling (much like pulling the string to tighten a duffel bag) is important to hold and maintain the neutral pelvis position once it is located and experienced.

Ask your client to be in this neutral position with the least amount of effort. If there is excessive muscular tension held in the body, then proper placement cannot be maintained over time. Help your client find the relaxed supported placement that can be held habitually. (See “The Use of Imagery to help Your Client Find Lift Through the Core.” for ideas about helping your client feel core engagement through imagery.)

Repeat the exercise again and have your client notice the weight on each sit bone while rocking front to back. Have your client put more weight on the right side, then the left, followed by weight equal in the center. The hard rotator disc makes this easier for your client to feel shifts of weight. If you previously noticed your client shifting more weight to one sit bone in the exercise, ask him/her if one side or another is more comfortable and see if it correlates to your previous observation.

If your client tends to sit toward one side, suggest that he/she check in throughout the day to see if this is a habit. Your client is best equipped to make this correction and develop the new habit through conscious attention and a commitment to change.

SIDE TO SIDE: MOVING ON THE CORONAL/FRONTAL PLANE
Next ask your client to rock from side to side feeling each sit bone (the carriage will be stationary). Have your client push off of the right sit bone to sit up taller moving the head toward the ceiling as if making space for the kidney and notice the activation of the right lumbar multifidus muscles. Raising the arms overhead can sometimes make the firing of the low back muscles easier feel. Repeat it to the left.

Both sit bones weighted with lateral rib shift.

After about 5 sets, have your client now try to lift the ribcage laterally to the right while sitting up tall, keeping weight on BOTH sit bones. Have your client observe now that both sides of the lumbar multifidi are activated—it is like having two “rocket boosters” (one on each sit bone) to lift the ribcage off the pelvis instead of one. This equal activation creates a more powered balanced lift.

It may be difficult for your client to keep both sit bones weighted in the lateral ribcage shift. Suggest that the bones of the pelvis are like a boat weighted in the water. Keep the boat heavy while the muscles and flesh lift upward into the lateral shift much like the vertical mast. You may see a crossover from the previous exercise. For example, if you client felt more comfortable with the weight on the right sit bone moving front to back, he/she may tend to lift the left sit bone as the ribcage moves sideways to the right since it is not used to bearing weight.

ROTATE RIGHT TO LEFT: MOVING ON THE TRANSVERSE PLANE
 

Right lumbar and thoracic rotation.

The client is sitting on a moving rotator disc so that lumbar rotation of the pelvis is proprioceptively accentuated. Driving the disc is somewhat like moving the wheel of a car: pulling down on the wheel to make a right hand turn would cause the left side of the wheel to move upward, much like moving the right sit bone backward to rotate the disc clockwise would move the left sit bone forward to further rotate the disc clockwise. Have your client rotate the disc to the right while keeping both knees still and holding the Reformer carriage in place. Most people will shift to one sit bone on rotation so instruct your client to drop the lifted sit bone (“sit the boat in the water”). Be sure to initially isolate pure lumbar rotation by keeping the chest facing forward in place. Repeat to the other side. Watch to be sure your client keeps weight on both feet as there is a tendency to roll one knee inward during the exercise.

After your client experiences moving the disc in rotation, add the thought of siting tall during this twist and to engage the transversus abdominis (lower abs) and lumbar multifidus (low back muscles) so that there is a feeling of lifting upward through the spine. Just as it is necessary to bend the knees and go into the floor prior to jumping, the pelvis must first be weighted on the disc in opposition to the lifted ribcage. Both “rocket boosters” (ischial tuberosities) should be connected in a centered pelvis giving more power to the lift since both sides of the back will be active.

Incorrect lateral rib shift with one sit bone weighted.

Now move the pelvis, chest and head in succession during the rotation. It should feel like a spiral staircase moving upward. Notice if the ribcage moves laterally off the pelvis during rotation and indicate the necessary correction to bring the ribcage centered over the pelvis—if the ribcage is shifted, odds are that one sit bone will also be lifted. Just as in stacking blocks, the lumbar and thoracic sections of the spine are structurally solid on top of each other, rather than precariously stacking on the counterbalanced edges.

Conscious and attentive self-awareness of pelvic placement in a seated position can improve overall posture. Just as a building needs a good foundation, the spine’s structural integrity is dependent upon a solid base. Your client can create new sitting habits, but must first have the knowledge and experience of how to find center. The best way to experience center is through its contrast of shifting weight off-center. Once the relative position of center is understood, and the weight over the ischial tuberosities felt, your client can consciously maintain balanced alignment through daily practice.

Pucker Up the Pelvic Floor

Many people think of their abdominal muscles when asked to engage the core muscles, but, unless someone has gone through pregnancy or incontinence issues, the pelvic floor muscles are a relatively unfamiliar yet critical component of core activation. Exercises that strengthen these pelvic floor muscles through isometric contractions are commonly referred to as Kegel exercises named after gynecologist Dr. Arnold Kegel. The basic premise is to “contract and release” the pelvic floor muscles, and includes variations that increase the number or duration of contractions. Using imagery and guided instructions can help your client find the core’s foundation.

The following verbal instruction series can be taught individually or in a group environment.

DIAMOND IMAGE: Describe the pelvic floor as a diamond shape consisting of points at the pubic bone  in the front, sit bones or ischial tuberosities forming the sides of the diamond, and the tail bone or coccyx at the back.

STACKING TRIANGLES: Divide the image of the bottom and top half of the diamond into two separate triangles cutting on the coronal plane and approach each section individually.

Back Triangle (both sit bones and tail bone): Instruct your student(s) to engage the anal sphincter without squeezing the cheeks of the buttocks as if stopping gas from escaping and then release. Once the area is isolated, contract with a small intensity, then medium, then large intensity contraction consecutively without release and then let go of the large contraction to start again. Do this twice through.

After this is achieved, try doing the small, medium, large intensity contraction followed by a small release with a “catch” of the contraction three times to create what feels like a small, medium, and large release of the contraction. A conscious effort must be made to reestablish the contraction each time or the release will feel like one action instead of three.

The purpose of the small, medium and large intensity contractions is to make the exercise more precise and challenging. This will make a plain isometric contraction feel like less work and easier to maintain.  Note that if you are teaching this individually, you can hold your client’s hand and mimic the intensity squeeze of the small, medium and large contraction for guidance.

Front Triangle (both sit bones and pubic bone): Instruct your student(s) to engage the urethral sphincter as if stopping urine flow without squeezing the anal sphincter or cheeks of the buttocks and then release. Once the area is isolated, contract with a small intensity, then medium, then large intensity contraction consecutively without release and then let go of the large contraction to start again. Do this twice through. After this is achieved, try doing the small, medium, large contraction followed by the small, medium and large release as done above with the back triangle of the diamond.

SIDE TRIANGLES: Now divide the diamond into right and left triangles cutting on the sagittal plane.

Left Triangle (pubic bone, left sit bone and tailbone): Instruct your student(s) to engage the left side of the pelvic floor without squeezing the cheeks of the buttocks and then release. Once the area is isolated, contract with a small then medium then large contraction consecutively without release and then let go of the large contraction to start again. Do this twice through. After this is achieved, try doing the small, medium, large contraction followed by the small, medium and large release as done above.    

Right Triangle (pubic bone, right sit bone and tailbone): Instruct your student(s) to engage the right side of the pelvic floor without squeezing the cheeks of the buttocks and then release. Once the area is isolated, contract with a small then medium then large contraction consecutively without release and then let go of the large contraction to start again. Do this twice through. After this is achieved, try doing the small, medium, large contraction followed by the small, medium and large release as done above.

FIGURE 8 IMAGE:  Now relate the front and the back to engage the entire pelvic floor in the initial diamond image (pubic bone, both sit bones, tailbone). A figure 8 or infinity sign could be drawn around the anal sphincter and urethral sphincter. Squeeze each opening individually as you would pucker the mouth to kiss or as if tightening the cord on a duffel bag and cinch them together while drawing them upward toward the internal organs as if sucking on a straw. Once the feeling of this is established, try the small medium and large contraction pattern as established on the previous preparatory sections.

Understanding the contraction of the pelvic floor is the gateway to engaging the rest of the core muscles and facilitates the engagement of the deeper transversus abdominnis muscle.  A study entitled “Instructing pelvic floor contraction facilitates transversus abdominis thickness increase during low-abdominal hollowing,” on the U.S. National Library of Medicine National Institutes of Health website concludes that “Instructing healthy subjects to co-contract pelvic floor muscles results in greater increase in transversus abdominis thickness during low abdominal hollowing in four-point kneeling.”

As well as improving core stability, strengthening the pelvic floor muscles can help with urinary incontinence, but should be practiced with an empty bladder. According to the Mayo Clinc website “Doing Kegel exercises with a full bladder or while emptying your bladder can actually weaken the muscles, as well as lead to incomplete emptying of the bladder — which increases the risk of a urinary tract infection.”

Guided instructions using imagery can help your students isolate and contract the muscles of the pelvic floor. Once you have established the muscle memory from the above exercises you can use the imagery in cueing. For example, “cinch your figure 8” or “suck the pelvic straw.” The mind is better able to direct the body when the target is clearly understood. Strengthening the pelvic floor builds the foundation on which the other core muscles can be explored.

Opening the Chest with Towels and Rest

Slumped posture and rounded shoulders are the result of our sedentary lifestyle with hours spent looking at computer screens. Although there are many components to correcting this multi-faceted dysfunction, passive stretching of the upper thoracic spine can be useful for addressing the pain that occurs mid-back between the shoulder blades. Gravity can do the work for your client along with towels, pillows and supports to open up the thoracic region. After your client experiences the pleasant and relaxing result of lying supine using this prop arrangement, your client will have a powerful tool to address future discomfort through home care.

A slightly posterior thoracic curve is part of a regular healthy spine, but when this curve becomes exaggerated and rounded, called kyphosis, it compresses the chest toward the pelvis reducing space for the organs and can cause back pain, difficulty breathing and nerve irritation. This rounding can occur through consistently slumped posture over time or may be a result of more serious degenerative issues, such as bone fracturing found in osteoporosis. Severe kyphosis may require the use of back braces or even surgery. The following towel technique is only for mild rounding and should be discontinued if any pain occurs.

Items Needed:

  • Extra large thick bath towel
  • Hand towel
  • Reformer Long Box or equivalent
  • Small 1″ or 2″ pillow

Optional Items:

  • Small heating pad
  • Microwavable neck wrap
  • Eye cover

I usually set up the client on the Cadillac, but a mat on the floor will also work. Fold the extra large bath towel in half lengthwise and then roll up opposite ends (like 2 tootsie rolls) until one rolls in about 1/3 of the way in and the other side rolls in about 2/3. The rounded ends should meet rolled in together with one side larger creating an evenly sloped angle, rather than two distinct steps of differing heights. This is going to be the main support under the upper thoracic spine, and your client should lie on this towel corresponding approximately to thoracic segments 3-6 with the lower side toward the neck. A good check is to look at the base of the sternum and make sure the towel is situated above the xiphoid process.  It is important to place this towel correctly to open the area of sternal concavity found in rounded back posture and to avoid overextension of the lumbar region. I use a small heating pad over this towel to help relax the back muscles.

A pillow should be placed under your client’s head to ensure that the neck is in proper alignment and that the cervical spine does not overextend with the lifting of the chest. The size of the pillow will be determined by the severity of back rounding—the greater the rounding, the bigger the head lift. Any pillow should work, but I like the Balanced Body vinyl head cushions since they come in incremental sizes.  The pillow addresses the head height, but does not provide enough cervical support. Fold the hand towel in half lengthwise and then roll it up completely to make a tootsie roll shape. Place this towel under the neck. Be sure you see a gradual descent from the lifted chest to the crown with mild extension of the upper chest to minimize the intensity of holding the position. I sometimes also use a heated microwavable neck wrap going from the back of the neck around the shoulders, but the alignment of the chest, neck and head must be maintained. A lavender-scented eye cover is also nice if your client does not suffer from allergies or claustrophobia.

It is important to elevate your client’s legs to prevent low back pain that could occur from the pressure on the lumbar region in this position. The Reformer Long Box works great for this and should be placed widthwise under your client’s legs comfortably meeting the crease behind the knees. Ask your client what furniture at home might replicate the size of the box (an ottoman, stool, low table or pillows).

Make sure your client is comfortable in this position and make any necessary adjustments—use larger or smaller towels, move towel placement, adjust neck support, etc. Advise your client that if the position becomes uncomfortable to inform you as soon as possible. This open supported position is meant to feel good. Ask your client to breathe deeply creating a little tension in the back muscles and then relax with each exhalation. When the back starts to relax, normal breathing is resumed.

After completing the five-minute period of relaxation, have your client draw both knees into the chest to stretch the low back. When he/she gets up from the table, demonstrate the setup you used, and give any specific instructions related to what you observed to allow your client to replicate the experience at home. Start at home with the same five-minute session and incrementally increase to about 15 minutes provided all goes well. One of my long-time clients uses this towel setup after doing a lot of gardening and housework and says it prevents the muscle tension she used to get after her activities. Between regular private sessions and self-care, she no longer has a pronounced rounded upper back.

Although a Pilates session for a client with poor posture would include exercises to strengthen the core and back extensors, many clients enjoy spending the last five minutes of a session in a recuperative state. I will often use the towel setup along with guided meditation or playing Tibetan Singing Bowls (see “Reward Your Client with Tibetan Singing Bowls“), but peaceful relaxing music works well too. Consistent practice of restful thoracic extension using towels can counteract slumping posture and make it easier for your client to once again straighten up and sit right.