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

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.

Breaking Down the Pilates Hundred

The Hundred (100s) is one of the most widely recognized exercises of the Pilates matwork and also one of the more choreographically complex. It is the first exercise in the matwork series in Joseph Pilates book Return to Life Through Contrology, and its expansive breathing and percussive pumping arms increases oxygen exchange circulating blood and energizing the body for the exercises to follow. The name comes from the hundred pumps achieved through 10 sets of 5 arm pumps during inhalation and 5 arm pumps on exhalation. Breaking down the components of the 100s into individual sections can help students more easily grasp each element as it integrates into the exercise as a whole. This awareness improves mental concentration yielding more fluid and precise movements.

The key elements found in the 100s include quality of breath and its influence on core connection; sequence of abdominal muscle recruitment; and scapular stabilization to power the arms. I have had a few clients who initially expressed a dislike for this exercise, and later changed their minds after integrating the various parts into a more coordinated whole.

BREATHING

The fundamental element in the 100s is breath, and costal (chest) breathing  is necessary to perform the 100s effectively. During a normal breath the diaphragm contracts and descends to make more space available in the chest cavity for the lungs to fill and the belly expands. Although this diaphragmatic breath pattern is oxygen-rich, it is ineffective for the 100s since it does not provide adequate support for the lumbar spine when the legs are in the air. The abdominal muscles must be engaged during the inhalation phase of the breath cycle to counterbalance the weight of the legs. This abdominal cinching action reduces available expansion during inhalation to the chest cavity alone. If your client has only experienced diaphragmatic breathing, it may be difficult to maintain the engagement of the transversus abdominis on the inhalation and she may also feel that she does not get enough air with costal breathing alone. Therefore, proper activation of respiratory muscles must first be explored. Select the exercises most accessible and applicable to your client’s needs.

Exercise 1—Lying in Clay

Have your client lie supine and direct her to imagine she is lying in clay or sand. On the inhalation have her visualize that she squishes the ribcage down and wide making a perfect imprint. The breath should also open the sides of the ribcage so the thought of breathing through gills like a fish can also be useful. Breathe in through the nose for 4 counts and out through the mouth for 8 counts.

Exercise 2—Inner Tube

Note that some people use their facilitating respiratory muscles to do the job of the primary respiratory muscles causing the shoulders to lift and lower during each breath. To prevent this, have her imagine that an inner tube is around the chest and to breathe only in this area. You can wrap a scarf around the ribcage for better feedback. Direct her to pull air through her nose and take as many “sniffing” breaths as possible filling up this inner tube and notice the feeling of the muscles engaging in the chest. The last few sniffs will not yield more air intake, but will feel more like intercostal muscles around the ribcage firing.  After performing this sniffing breath a few times, go back to normal breathing and she should feel that it is easier to expand the chest and fill up the inner tube.

 Exercise 3—One Lung

Have your client imagine that she is breathing only through the right lung. Direct her to feel the breath in the back, front and side of the ribcage. Be sure she feels the expansion of the right ribcage through her focused attention. Then direct her attention to the left side. After feeling each side individually, have her feel the volume available when she breathes into both sides. This exercise demonstrates to your client that she controls muscle activation by thought and that greater attention can lead to an increased reaction.

Exercise 4—Physioball

If your client lacks the proprioceptive awareness of chest expansion, it is helpful to sit next to a physioball and lean into it. The physioball gives better feedback as it “dents in” on the inhalation 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 her body as she breathes.  Use a smaller ball than the one pictured if your client has shoulder issues and cannot raise the arm comfortably.

 Exercise 5—Marble

Although a full breath in the chest includes breathing into the front of the chest, this can hinder lumbar support when lying supine and holding the legs in the air. When people breathe anteriorly, they often lift the chest off the floor diminishing the supported counter-leverage necessary to hold the legs in the air. Have your client visualize squeezing a marble below the xiphoid process and hold it on the exhalation with the narrowing of the ribs. Suggest that your client take an inhalation without losing the marble. This requires the breath go to the back and to the side of the ribs in a saddle shape. The marble image keeps the thoracic vertebrae pressed into the floor maintaining the strength of the posterior pelvic tilt and support for the lumbar region.

Exercise 6—Elevator

The activation of the transversus abdominis or concept of “navel to spine” requires a cumulative response that evolves and deepens on each exhale. Clients will often tighten the abs in a bracing action as if waiting for a punch to the gut. This is a static engagement and works from the outside in. The transversus abdominis should initiate from the inside, as if the organs are inviting the abdominal wall inward. Guide your client to imagine the abdomen as an elevator. Keep the abdominals engaged holding the elevator level to let the people in on the inhalation (using a costal breath). As she exhales lower the elevator from the 3rd floor to the 2nd floor and feel the navel drop toward the spine in a relaxed action as if a soufflé were to sink in. Hold the elevator still on the next intake of air and exhale again to the 1st floor.

The work phase takes place on the inhalation trying to prevent the belly from expanding and the relaxation occurs during the exhalation deepening the scoop. Any cumulative image will work. For example, deep sea diving going lower and looking at fish; scooping ice cream toward the bottom of the container, etc.

Exercise 7—Segmented vs. Nonsegmented Breath

The 100s breathing can be done in either a continuous regular breath or a segmented breath. The regular breath would include 5 arm pumps on the inhalation and 5 arm pumps during the exhalation. There is also an option to make the breath more percussive inhaling for 5 “sniffs” and exhaling for 5 “candle flickers.” The sniff should have a quality smelling something pleasant (not sniffing a nasal spray) and the blowing out the mouth should be like blowing a candle to watch it flicker, but not blow it out entirely. During the inhalation the ribcage should open and expand into the back with each sniff (as in the “Marble” exercise) and the belly should scoop and deepen during the exhalation (as in the “Elevator” exercise). This percussive breathing can contribute to the invigorating characteristic of the 100s preparing the body for further movement, but for some the saturation of too many details can cause confusion. Choose as needed.

ABDOMINALS

The posterior pelvic tilt or “flat back” position in the 100s occurs in an ordered sequence of abdominal muscle recruitment. If the pelvic tilt is taken in steps, instead of in one action, the low back can lengthen while the abdominals shorten in the front. In contrast, if the low back is pressed into the floor without first tractioning the lumbar vertebrae apart, it creates gripping tension and restricts the ability to scoop the navel toward the spine. My clients have expressed that this sequence gives them a deeper core connection.

Inhale

Step One: Inhale

Take a costal breath expanding the ribcage and using the marble image outlined above, while holding the abdominal wall flat.

Exhale

Step Two: Pelvic Floor with Transversus Abdominis

Engage the pelvic floor at the same time as the transversus abdominis pulling the pubic bone toward the throat (sinking the soufflé as in the “Elevator” exercise). If your client has no experience with engaging the pelvic floor, the direction to stop gas and urination without squeezing the gluts can be helpful. This step happens on the beginning of the exhalation and should feel fairly relaxed. The pelvis will begin to shift into the posterior tilt, but only slightly.

Step Three: Lengthen the Spine and Clamp the Obliques

Direct the head and the tailbone to pull apart from each other to traction the lumbar vertebrae while the obliques bilaterally contract. This action takes place during the middle of the exhalation and should have a strong squeezing or cinching feel to shorten and contract the ribs toward the hipbones while lengthening the low back. The pelvis now moves into a full posterior pelvic tilt.

Step Four: Imprint

Once the above is achieved the low back should have full contact with the floor and an imprint of the lumbar spine is explored. This step occurs at the end of the exhalation and a firm connection with the floor can be felt.

Without releasing the pelvic tilt, begin the process over again until as deep a scoop as possible is achieved (see “Elevator” exercise above).

POWERING THE ARMS

All Pilates exercises include initiation from the core prior to powering the limbs. The pumping arms in the 100s must start from the connection into the back, not the hands going up and down. Firing the lower trapezius, posterior rotator cuff and triceps will intensify the striking action of the arm pump. The arms should not feel like they are slapping, but rather they should be pressing isometrically against imagined thick space such as pressing into peanut butter in a rapid motion.

Exercise 1—Depression of Scapula

Have your client lie supine vertically along a foam roller (or on the floor if you don’t have one). Raise the right hand in the air toward the ceiling and be sure your client feels the scapula either hugging the roller or on the floor and the humerus bone is weighted in the glenohumeral joint.  Elevate the scapula and squeeze the shoulder toward the ear staying connected with either the roller or floor. Lower the scapula to a neutral position relaxing the upper trapezius and then further depress the scapula with the intention of activating the lower trapezius. You may need to put your finger on the target so your client feels the inferior angle of the scapula pressing into you. Once your client feels the lower trapezius activate, have her hold the position and isometrically engage it further to increase awareness. Repeat on the left side and then do both at the same time. 

Exercise 2—Posterior Rotator Cuff

Have your client bend her elbows in front of her body to ninety degrees palms up as if holding a large tray. Stand behind your client and place the fingers of your left hand below the inferior angle of the right scapula and your right hand on her right shoulder with the thumb pressing into the infraspinatus and teres minor muscles.   Ask your client to externally rotate the right shoulder while holding the connection at the posterior rotator cuff and lower trapezius. The elbow has a slightly forward scooping feeling, and the ribs should not release. Repeat this exercise on the other side. After completing both sides ask your client to sit with her arms by her sides and hands on the thighs with the palms up. See if she can widen at the clavicles while pleasantly activating the posterior rotator cuff muscles without letting the ribs protrude. Another option is to have your client hold a scarf or piece of fabric around the mid-back doing the exact same exercise above so that the angle of the arm becomes clearer and provides a little resistance at the elbow.

Exercise 3—Triceps in Upside Down 100s

Performing the 100s in a prone position causes the triceps to go against gravity and activate more intensely. The depression of the scapula and firing of the posterior rotator cuff can also be felt more acutely in this position. Instead of pumping the arms toward the floor, your client will now be pumping the arms to the ceiling doing the exact same 100s exercise while lying prone and scooping the belly off the floor instead of imprinting into the floor. If your client does not experience neck problems, she can activate the back extensors to lift her head an inch or two off the floor keeping the gaze down to maintain the neck alignment. When the exercise is flipped back to the normal supine position, the client is able to feel a better core connection with an increase in isometric effort.

Be sure to modify the 100s to accommodate your client’s needs.

Neck Issues

The entire 100s exercise can be done keeping the head on the floor. 

Low Back Pain

One or both feet can keep contact with the floor.

Hip Flexor Discomfort

Keep the feet on the floor or bend the knees in the air keeping them close to the chest.

Rounded Shoulders

The palms can be flipped to face the ceiling on the pump to work more external rotation of the shoulder.

Difficulty Getting to the Floor

 The 100s can be performed standing alternating legs after fifty pumps or performed seated.

Advanced Challenges

If you want to challenge your client, try the 100s while lying vertical on a half or full foam roller. Do the first half of the exercise with one leg in the air and then exchange legs for the second half. A BOSU can also be used to challenge your client’s skills performed in a supine position with the low back on the arc of the dome. 

The Hundred is a Pilates basic, but can be a coordination nightmare for some new students. Make it easier for your clients to integrate the components by breaking it down into simpler more digestible parts. As with any good building project, start with a solid foundation. Practice breath, abdominal acuity and scapular awareness to build a “power house” that is all about the core.

Using Thera-bands® to Stretch the Possibilities

Stretching leg muscles with a Thera-band® improves flexibility in the legs, but also relieves tension in the hips and low back with minimal time and effort. The Thera-band is a resistance exercise band available in a variety of strengths indicated by color (the thicker the band the stronger the resistance). Bands are often used in physical therapy rehabilitation, since patients can maintain a consistent practice working at home and strength development can be easily monitored with the progressive color coding system. They can be purchased individually or in bulk rolls and are sold under a variety of brand names offering latex and latex-free versions. (I prefer black Cando bands.) The 50-yard roll can be cut into individual bands making it economical to provide multiple clients and mat class attendees with equipment. Although there are multiple uses for Thera-bands in an exercises program, leg stretches yield quick results and are easy for most clients to practice.      

As with any stretching program, consistency with a long-term commitment to practice is essential. Using a pain scale of 1-10 with “10” being the most intense is a good guide to check in and keep clients on track. As a general gauge, “7” on this scale means your client will be actively stretching without strain or pain, but individuals vary and some may require less intensity. Microscopic tearing of the muscle fibers is a risk for overstretching and the scar tissue that develops can lead to a decrease in muscle elasticity so “more” is not always better. If your client has strained a muscle, stretching may cause further harm, so be sure no chronic condition exists prior to starting a new routine.      

Stretching after warming the muscles is preferable so a brief warmup such as a short walk can be useful to elasticize the collagen fibers prior to stretching. Stretches should be held for thirty seconds to a minute and should evolve; as the stretch is held, the intensity diminishes requiring the limb to move into a greater range to maintain the “7” on the pain scale. These stretches will always be a bit uncomfortable (they should not be painful). Regular practice will increase range of motion and the discomfort will be experienced similarly in the newer more flexible range.      

The stretch reflex is the body’s protective tool to prevent muscle fibers from overstretching and helps protect the tendon origins and insertions from being over-pulled. When the stretch intensifies, the muscle being stretched contracts to prevent it from being forced beyond normal range. Putting the muscle being stretched in contraction helps to inhibit this reflex and can make the process safer and more comfortable. For example, when stretching the hamstrings with the Thera-band, press the leg slightly toward the floor to engage the hamstrings while pulling the band with the hands bringing the leg closer to the chest.      

Conscientious breathing will allow the body to relax with the stretch. Breathe into the tension of the stretch on the inhalation and let it go on the exhalation. This push/pull quality (pushing the limb and pulling with the band) applies to all of the following stretches and will make them feel more like pushing through peanut butter or working with taffy rather than the slack feeling of hanging in a hammock.     

Although the following descriptions indicate which hand to use to hold the band, this is a personal choice based on comfort and body limitations. For example, if your client has arthritis a two-handed hold might be more comfortable or Thera-band exercise handles  could be used to reduce grip tension.     

BAND STRETCHES   

  • Calf

The objective is to stretch the gastrocnemius and the soleus  muscles. Place the band with its full width across the metatarsals (don’t let it bunch up like a tourniquet) and hold each side of the band in either hand. Make sure you do not have a “death grip” on the band or your fingers will fatigue too quickly. Inhale—plantar flex the ankle moving the metatarsals (or ball of foot) into a demi pointe (half point) while spreading the toes. Exhale—dorsiflex the ankle and keep the toes spread. Repeat this approximately five times making sure to keep the hip of the stretching leg pressing into the floor, so the initiation of the movement starts at the core with the ankle being the end result. Variations of this stretch include ankle inversion, eversion and circles. Be careful on inversion to press from the fifth (pinky) metatarsal straight from the body without “sickleing” (shifting medially). A sickled foot is an instable ankle twist waiting to happen in the future, because it lacks strength. The objective of this exercise is to develop ankle strength and flexibility in the calf. This kind of ankle work is very useful for ballet dancers trying to achieve more articulation in their feet.  

  • Hamstrings 

The objective is to stretch the semimembranosus, semitendinosus and biceps femoris muscles. After working the ankle in the above exercise remain in the dorsiflexed position. Inhale—press the thigh toward the floor slightly to activate the hamstrings while keeping the band pulled toward the chest. Exhale—pull the leg closer to the chest while retaining some tension in the hamstrings as if still trying to lower the leg to the floor. Never “yank” on the leg. This stretch can be performed with a bent or straight knee. Both are useful and stretch either the belly of the muscle or the back of the knee. If the knee is bent, keep energy reaching through the heel toward the ceiling so the stretch remains active. This stretch is like a tug of war with the heel being one team and the ischial tuberosity (sitbone) being the other. Both sides need to actively pull on the rope.  

  • Inner Thigh/Adductors

The objective is to stretch the adductor magnusadductor longusadductor brevisgracilis and the pectineus muscles.  It is sometimes more comfortable to hold the band in the same hand as the working leg—left hand holds the band when opening the left leg so the right shoulder can stay open and relaxed on the floor. Open the leg laterally while externally rotating the hip joint. The opposite side of the pelvis should remain on the floor and the body should not roll toward the open leg. If your client is unable to keep the opposite hip down, bend and externally rotate the knee of the leg on the floor to provide a little more leverage in the counterbalance. Be sure the chest presses into the floor and the abdominal muscles are actively engaged. If the abs are not engaged and the ribs lift off the floor, your client may push the head into the floor for leverage creating a discomfort in the neck and shoulders. Use the same push/pull tension strategy as explained in the previous stretches (inhale while creating tension and exhale as the stretch increases). As the leg moves wider and externally rotates, the foot moves closer to the ipsilateral ear, but the hip should remain anchored and the pelvis square. There is a tendency for people to hike the hip in an effort to achieve greater range of motion. A hiked hip does not stretch the inner thigh more—it is like the tug of war image used before except one team walks forward and the other walks backward as they pull apart. The hip must remain down to get the oppositional energy flow.   

  • Outer Hip/Abductors

The objective of this stretch is to stretch the gluteus mediusgluteus minimus and tensor fasciae latae muscle down into the illiotibial tract. Move the leg medially across the center of the body until the hip slightly lifts off the floor, but not so much that a full twist occurs in the lumbar region. It is not important for the leg to reach across the body very far, the stretch occurs when the hip pulls back into the floor (the foot in the band remains held in space and the hip pulls downward in opposition). Having the band in the opposite hand of the leg that is stretching contributes to this opposition. Inhale—pull on the band slightly and press the leg laterally into the band to create tension. Exhale—keep the foot held in space and drop the hip toward the floor using the internal obliques to rotate the spine. Be sure to also lengthen the waist by pulling the head and tailbone apart.     

  • Circles

The circumduction of the hip joint reviews all the previous stretches. The image of an ice cream cone can be a useful tool to mimic the conical pathway. The emphasis should be to press the hip into the floor where the ice cream would go at the tip, and then draw the lip of the cone either on the ceiling or on the walls if your client has greater range. Keep that feeling of pushing through taffy and guide your client to make sure that each hamstring/adductor/abductor position previously stretched is addressed. The leg must externally rotate each time the leg moves laterally to guide the ball in the socket of the hip joint comfortably. Correct the pathway or limit the range if your client experiences clicking in the hip joint.  Be sure to circle both clockwise and counter-clockwise three to five times each.   

  • Splits

The objective is to energize and lengthen both legs while simultaneously activating the core. The feeling should be like doing splits on the ceiling. Hold the band in both hands with an underhanded grip to encourage the shoulders to stay down. Split the legs apart with the lower leg off the floor and lift the head off the floor as well (if your client has neck discomfort keep the head on the floor). Inhale—press the thigh into the band as in the previous hamstring stretch. Exhale—pull the top leg slightly toward the chest while preventing the hip from hiking and deepen the belly scoop. Draw in the transversus abdominis deeper on each exhalation.  Hold for three to five breath cycles.

The improved range of motion from regular stretching may help decrease injuries by preparing the body for a variety of activities.   Mayo Clinic physical medicine and rehabilitation specialist Edward R. Laskowski, M.D. says,   

 “If your joints are not able to go through their full range of motion because of muscle tightness, sports and exercise activities may put an excessive load on the tissue and contribute to injury. Think of a runner with tight calf muscles and a tight Achilles tendon running up a hill. This activity requires that the ankle bend up to accommodate the slope of the hill. But if it can’t because of tightness, the runner may be at risk of getting Achilles tendon irritation and injury.”    

There is a correlation between leg stretching and improved posture in the spine. Tight hamstrings will encourage a posterior pelvic tilt eliminating the necessary lumbar curve for lifted posture (see article The Use of Imagery to Help Your Client Find Lift Through the Core). The lumbar lift and core stability available in a neutral pelvic placement is diminished with the downward pressure of the tucked pelvis. If your client experiences low back pain, leg stretching with a band may be one component in a program to improve this condition.      

Regular leg stretching with Thera-bands can improve mobilization at the hip and ankle joints better preparing your clients for whatever activities they choose. Bands are portable and require almost no storage space and are great for traveling. The leg stretch series also increases blood flow, which facilitates the body’s ability to heal and repair itself. Have your client notice the energy flow into the stretched leg prior to switching sides. Your client should be able to perceive the asymmetry of the stretched and unstretched leg. Noticing an immediate difference for the effort exerted is a great motivation to keep stretching and will keep your client consistently practicing at home. Better posture, improved range of motion, healthy blood flow…what’s not to love!

Coordination and Balance through Cross-Crawling

The coordination training we received as children through the developmental stage of crawling set the foundation for right and left brain hemisphere communication. Since the right hemisphere of the brain controls the muscles on the left side of the body and visa versa, the oppositional nature of arm and leg coordination during crawling activates the nerves across the corpus callosum connecting the two brain hemispheres. As adults, the continued integration of the two sides can result in better coordination, balance and efficient movement. The nerve networks can be stimulated and developed through cross-crawling exercises that utilize oppositional movement patterns.

Although you could crawl on the floor, the “crawling” in cross-crawling does not mean you have to replicate the movement of babies.  The main intention of every exercise is to use the opposing arm and leg. The exercises can be performed in supine, quadruped, sitting, or standing positions. It is also beneficial to try variations that move the limbs in the sagittal, coronal or transverse planes for better spatial awareness.

The following are some samples, but certainly not all the possible options. Be creative and come up with your own choreography that serves the needs of your clients. Do a few repetitions of each action focusing on the ones that are most difficult for your client to achieve. A more challenging combination is to string several different variations in a row requiring quicker changes, rather than repeating one exercise several times. Even harder is to do a combination of several different variations and then decrease the time it takes to complete the entire set.

If your client has difficulty performing cross-crawl exercises, that is an indication that coordination skills are lacking and the exercises should be added to your client’s daily practice. The senior population is one that can especially benefit by preventing falls (and possible breaks) though improved balance and coordination. In addition, clients with a homolateral gait (monkey walk) where the same arm and leg swing together can also benefit. I started doing these exercises with one of my clients who has Parkinson’s and he found them to be very useful in improving his gait and spatial awareness.

CROSS-CRAWL EXERCISES

Supine:

1) Lie of the floor with knees bent and feet flat of the floor. Cross the right elbow to touch the left knee. Return to the starting position. Repeat on the opposite side touching the left elbow to the right knee.

2) Lie flat on the floor with straight legs together and straight arms by your sides. Slide open the right arm along the floor and left leg away from the midline along the floor at the same time and return them back to the center starting position (similar to the action of making a snow angel). Repeat on the other side sliding the left arm and right leg away and back.

Quadruped:

1) Start on all fours with hands below the shoulders and your face looking toward the floor. Simultaneously reach the left arm parallel to the floor by your ear and right leg off the floor in the opposite direction behind you parallel to the floor. Return them at the same time and repeat the opposite side using the right arm and left leg.

2) Try the above exercise with variations. Reach the left arm to the side (rather than overhead) parallel to the floor and take the right leg either back or sideways off the floor to the opposite side like airplane wings (leg side off the floor is more challenging to core strength). Repeat the opposite side using the right arm and left leg.

Sitting:

1) Sit in a chair with feet flat on the floor and arms down by your sides. Step the left foot forward on the floor and reach the right arm out in front of you parallel to the floor. Return to the starting position and then reach the right foot and left arm. This exercise could also be performed with the left foot stepping to the side and the right arm reaching laterally to the opposite side or the left arm reaching back while tucking the right leg under the chair (reaching behind would not be recommended for someone with shoulder issues).

2) Sit in a chair with feet flat on the floor and arms down by your side. Simultaneously step the left foot over the right foot onto the floor, take the right hand and place it on the left hip, and touch the left index finger to the nose. Return to the starting neutral position. Repeat to the other side moving the right foot across the left foot, left hand to right hip and right index finger on your nose.

Standing:

1) Stand with legs hip distance apart and arms by your sides. Raise the right arm reaching toward the ceiling while simultaneously bending the left knee and raising the knee off the floor in a marching position. Return to the starting position. Do the opposite side raising the left arm and right knee.

2) Stand with legs hip distance apart and arms by your sides. Touch the right elbow to the left knee while simultaneously touching the back of your head with the palm of your left hand. Return to the starting position. Do the opposite side touching the left elbow to the right knee while simultaneously touching the back of your head with the palm of your right hand.

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Balance can be improved in the senior population not only with cross-crawling exercises, but also exercises that cross the midline to transfer weight from one leg to another. One of my clients was going to quit her line dancing class because she was frustrated with her poor balance negatively affecting the quick transitions required by the choreography. After about a month and a half of practicing her exercises daily at home, the transition was remarkable! She no longer had problems with her balance and was able to perform more complicated steps. She would have missed out on something fun that provided exercise and social contact had she not made a commitment to practicing.

CROSSING THE MIDLINE

The “jazz square” is useful for practicing weight transfer from one leg to the other crossing the midline. Some people teach the jazz square starting with a forward step, but crossing the midline first may be more useful to practice weight transference.

Jazz Square:

Start standing with legs together. Cross the right leg over the left and transfer the weight to the right foot. Pick up the left back leg and step backward. Shift your weight right to step sideways onto the right leg. Step the left leg forward. The weight will be on the left leg (instead of on two feet as in the beginning) and the step begins again with the right leg crossing over the left to transfer the weight to the right foot. Repeat to the same side several times. Try it on the other side starting with the left crossing over the right, step back with the right, shift side with the left foot and step forward with the right foot.

Switching sides can add a level of challenge. When changing sides the last move in the step is dropped. There are a total of four moves in the step (cross, back, side, front). Perform the jazz square three times with the right foot crossing first over the left foot first. On the fourth set only do the first three moves (cross, back, side). This will put the weight on the right foot. Start the jazz square using the left foot crossing over the right for three sets. On the fourth set only do the first three moves (cross, back, side). This will put the weight on the left foot and the pattern can begin again.

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Coordination and balance are learned skills that begin in our earliest developmental stages. These abilities are perfected through movement challenges and practice. The body in its effort to be efficient will provide less wiring for these activities if they are no longer being used. As we age our activities must reflect a movement vocabulary commensurate with the quality of life we wish to maintain. Cross-crawling exercises that integrate brain function can improve coordination and balance making us more alert and aware. Once again the old adage of “use if or lose it” rings true.