CCHOI_CR

C U R T I S H . C H O I  
S A M U E L M E R R I T T U N I V E R S I T Y
D O C T O R O F P H Y S I C A L T H E R A P Y P R O G R A M
A U G U S T 1 3 , 2 0 1 5  
T H E E F F I C A C Y O F P I L AT E S - B A S E D T H E R A P E U T I C E X E R C I S E S I N
C O N J U N C T I O N W I T H C O N V E N T I O N A L P H Y S I C A L T H E R A P Y I N T E R V E N T I O N S
T O I N C R E A S E B O D Y A WA R E N E S S A N D L U M B O P E LV I C C O N T R O L I N A PAT I E N T
W I T H L O W B A C K PA I N A N D L U M B O S A C R A L R A D I C U L O PAT H Y S Y M P T O M S I N
A N O U T PAT I E N T S E T T I N G : A C A S E R E P O R T

B A C K G R O U N D
L O W E R B A C K PA I N ( L B P )
Prevalence1
PrevalencePrevalence
- In United States, Full scale and prevalence is still debatable.
- 2 million new episodes of LBP occurred between 2004-2008. 
 
- Incidence rate = 1.39 per 1,000 people

B A C K G R O U N D
L O W E R B A C K PA I N ( L B P )
Significant risk factors2
Prevalence
Risk
factors
- Lumbar disc degeneration (LDD): 
Individual with advanced LDD had 3.2 higher odds of  
manifesting LBP 
 
- Obesity
http://www.eorthopod.com/sites/default/files/images/lumbar_degeneration_cause01_STILL.jpg
https://thenypost.files.wordpress.com/2013/09/obesity.jpg

B A C K G R O U N D
L O W E R B A C K PA I N ( L B P ) 1 - 3
Medical costs3
Prevalence
Risk
factors
Medical
costs
“Total cost exceeding in United States.”$100 billion

B A C K G R O U N D
P I L AT E S
Origin & Definition4,5,6
Origin &
Definition
- Founded by Joseph H. Pilates in 1920’s7,8
http://www.movementhealth.com.au/wp-content/uploads/2013/04/josephpilates_atwork.jpg
- Exercise method focuses on strength, core stability,
flexibility, muscle control, posture and breathing9

B A C K G R O U N D
P I L AT E S
Branding5,7-12
Origin
Branding
Origin &
Definition
- There has been an increase in popularity of
Pilates in mainstream exercise realm as well as in
rehabilitation settings8,10
- Pilates exercises is often prescribed to LBP
patients because Pilates focuses on activating
stabilizing muscles of the trunk and lower back,
which is often inhibited in people with LBP11-15
http://www.pilates9.com/wp-content/uploads/2013/04/pma_pilates.jpg
https://classic.regonline.com/custImages/240000/243242/PolestarPilatesLogo.png
http://www.pilatestherapeutics.com/images/logo-grn.gif

B A C K G R O U N D
P I L AT E S
Principles13
Origin
Branding
Principles
1 . C O N C E N T R AT I O N 2 . B R E AT H I N G 3 . C E N T E R I N G 4 . C O N T R O L
5 . P R E C I S I O N
6 . F L O W I N G
M O V E M E N T
7 . I N T E G R AT E D
I S O L AT I O N
8 . R O U T I N E
Origin &
Definition

B A C K G R O U N D
P I L AT E S
Breathing13,14
Origin
Branding
Principles
Breathing
Origin &
Definition
- “Breathing is the first act of life, and the last.
Therefore, above all, learn how to breathe
correctly.” - Joseph H. Pilates16
- Transversus Abdominis (TrA) activates earlier in
expiration than in inspiration17
- Re-educating the TrA to activate on correct
timing could diminish pain inhibition of TrA and
ongoing recurrent back pain16
http://40.media.tumblr.com/tumblr_m9iqk9ehvc1ry5naio1_500.jpg

B A C K G R O U N D
C O N V E N T I O N A L
P H Y S I C A L T H E R A P Y
Lumbar stability and strengthening15
Origin
Branding
Principles
Lumbar  
S & S
Breathing
Origin &
Definition
- Trunk stability exercise = great effect on
patients with chronic LBP by deep
abdominal muscle strengthening
http://www.leanitup.com/wp-content/uploads/2013/07/ab-plank-2x3.jpg

B A C K G R O U N D
C O N V E N T I O N A L
P H Y S I C A L T H E R A P Y
Dynamic lumbar exercises16
Origin
Branding
Principles
Lumbar  
S & S
Dynamic
lumbar
exercises
Breathing
Origin &
Definition
http://rockyourbootycamp.com/wp-content/uploads/2013/04/birddog.jpg
- The use of dynamic lumbar exercises on patients
post microdiscectomy procedure has shown to
improve pain, mobility, and faster time to return
to work

G A P S I N T H E L I T E R AT U R E
Lack of research overall for Pilates
Better quality research is needed17,18
Currently no studies comparing the
efficacy of the Pilates-based
therapeutic exercises vs.
conventional physical therapy
exercises
?

P U R P O S E
The purpose of this case report is to demonstrate the effects of
Pilates-based interventions, in conjunction with conventional
physical therapy, for a young female patient with decreased
lumbopelvic control, poor body awareness and low back pain
in an outpatient physical therapy setting.

M U LT I - M O D A L A P P R O A C H
Pilates-based
Therapeutic
Exercises
Conventional  
Physical Therapy  
Exercises

C A S E D E S C R I P T I O N
PAT I E N T P R O F I L E
21 year-old female
CR
Approximately 1-year status post L5/S1 discectomy
Outpatient physical therapy setting
Surgery and post-op physical therapy in Belgium
Medical diagnosis: Lumbosacral radiculopathy
Chief complaint: Lower back and left posterior thigh pain
http://www.periodvitamin.com/images2/back-period-pain.jpg
Prior medical history: L5/S1 disc herniation, frequent
shoulder dislocations

C A S E D E S C R I P T I O N
PAT I E N T P R O F I L E
PLOF
CR
Social/ Environment
Recreational
Patient goal:
Independent in all activities of daily living (ADL) and  
instrumental activities of daily living (iADL)
Lives with a roommate in an apartment (3rd ﬂoor)
Enjoys playing basketball, hiking, running, and weight-lifting 
http://thefightandflightresponse.files.wordpress.com/2011/12/hill-running.jpg
https://upload.wikimedia.org/wikipedia/commons/7/7a/Basketball.png
http://www.retailtrail.com/images/P/BSTVD10_orange_pair-01-01.jpg
Eliminate pain and return to active lifestyle including playing basketball,  
running, hiking, and weight-lifting activities

S Y S T E M S R E V I E W
NM
MS I
C,C,A
L
Cardiovascular & Pulmonary 
System: Not indicated
Musculoskeletal system: 
Further examination indicated
Neuromuscular system: 
Integumentary system:  
Cognition, communication,  
affect: Not indicated
Learning style: 
Verbal explanation and demonstration
CV&P
Occasional numbness and tingling of L LE
Recent history of ground level fall (GLF)
Alert & Oriented x 4
Pain and symptoms in lower back and  
posterior thigh. 
Surgical scar examination

E X A M I N AT I O N
Functional activity analysis
- Independent in all functional activities
- Gait analysis19(p132-133)
:  
* Patient can ambulate independently on an
even surface without requiring any assistive
device (AD) 
* Positive left hip drop, excessive foot
pronation during mid-stance phase bilaterally.
http://www.ironman.today/wp-content/uploads/2015/03/walking-1.jpg

Impairment testing
- Posture observation19
:  
Poor sitting and standing posture. Forward head,
protracted shoulders, excessive anterior pelvic tilt
observed
- Pain20 
4/10 NPRS
- AROM using double inclinometer21 
Lumbar AROM 24°- 0°-60 ° in sagittal plane, 34°-0°-32° in
the frontal plane
http://www.precisionnutrition.com/wordpress/wp-content/uploads/2011/03/Bad-and-good-posture.jpg

Impairment testing
- Manual muscle testing22 
(Refer to Table 1)
- Neurological examination22 
*
Light touch: Normal 
* Lower quarter segmental myotome testing: No  
muscle weakness observed 
* Lower quarter segmental deep tendon reflex (DTR) 
testing: Normal response
- Balance assessment19 (p232-241),23 
*
Normal static and dynamic balance 
* Fullerton advanced balance scale: 40/40
Table 1. Manual muscle testing result on initial visit.

Impairment testing
- Advanced functional strength tests22(p378-391) 
* Supine bridging: Able to perform for 2-
minutes. (Poor quality) 
* Supine single-legged bridging: Could not
perform
- Central PAIVM24-27 
* Central PAIVM lumbar spine in prone position:
Hypermobile without pain though L1-L3 with
boggy end-feel, L4-S1 assessment limited by
pain
http://media.tumblr.com/025ca150aaada47f16f653cdd60f4224/tumblr_inline_mx3eoermPs1rdu2za.png

Patient-report outcome measure
- Oswestry disability index26-29 
*
Scored 34% 
* Moderate disability 
* MDC = 12.81 
* MCID = 12.8
http://img.docstoccdn.com/thumb/orig/59722121.png

P H Y S I C A L T H E R A P Y D I A G N O S I S
The patient is a 21-year-old female status post L5-S1 discectomy, presenting with limited
ability to perform functional activities including sitting greater than one hour and lifting
objects secondary to increased radiating pain from lower back to left posterior thigh
consistent with medical diagnosis of lumbosacral radiculopathy. The patient presented with
the following impairments: unilateral left hip and lower extremity (LE) muscle weakness via
manual muscle testing (MMT), poor posture including excessive lumbar lordosis, and
positive left hip-drop during gait. The participation limitations included playing basketball,
running and weight-lifting activities since the onset due to increased pain and symptoms.
Patient is also limited participation in hiking activity and other recreational sports such as
skiing and wakeboarding. Factors affecting her recovery include decreased body awareness
and poor movement patterns adapted post surgery (substitution motor pattern).

P H Y S I C A L T H E R A P Y D I A G N O S I S : I C F M O D E L
Health Condition 
Symptoms of LBP,  
radiating posterior thigh pain
Impairments 
Unilateral left hip and abdominal weakness 
Poor posture 
(+) Left hip drop during gait 
4/10 pain (NPRS)
Activity Limitations
Sitting (> 1-hour) 
Lifting objects
Participation Restrictions
Basketball, Hiking,  
Weight-lifting 
Wakeboarding, Skiing
Personal
Motivated 
High PLOF 
Poor body awareness
Environment
Working environment

P R O G N O S I S
The prognosis for achievement of increased functional strength and movement patterns in
order to return to her PLOF was good within 6 weeks
Postive Factor Negative Factor
Young age
High motivation
No learning barriers
High PLOF
Decreased body awareness
No relief of symptoms from  
previous physical therapy
Working environment = aggravating factor
Poor posture habit

P L A N O F C A R E
Frequency/Duration: 1-hour session, 2-times/week x 6 weeks = Total of 12 visits
Anticipated Goals (3-weeks)
1. Maximum pain of 3/10 on NPRS
2. Lumbopelvic control with biofeedback
(minimum of 3 reps)
3. Neutral pelvic positioning on command
Expected Outcomes (6-weeks)
1. Maximum pain of 1/10 on NPRS while
sitting >1-hour
2. Single-legged bridging (more than 60
seconds) with neutral spine
3. Patient will decrease the total score of
ODI by at least 12.8 points
4. CR will perform lower quarter MMT and
score 5/5 on all movements bilaterally
within 12 visits

I N T E R V E N T I O N
Stages of rehabilitation32
- Stage 1: Pain control/Stabilization 
 
- Stage 2: Mobilization 
 
- Stage 3: Dynamic stabilization
S1: Pain control
S2: Mobilization
S3: Dynamic
stabilization
* Avoid further irritation 
* Decrease pain 
* Restore pain-free ROM
* Restoring ROM that has been lost secondary to injury 
* Incorporation of assistance
* Challenge newly acquired ROM against gravity, resistance, and in movements 
requiring proprioception and balance 
* Prepares patient to return to function

12 O’Clock Neutral 6 O’Clock
Pilates-based therapeutic exercises32
- Mat Exercises 
1. Pelvic clock in sagittal plane 
* Photos used with permission from Polestar Pilates education

Pilates-based therapeutic exercises
- Mat Exercises 
1. Pelvic clock 
2. Chest lift 

- Mat Exercises 
1. Pelvic clock 
2. Chest lift 
3. Bridging 

- Mat exercises 
1. Pelvic clock 
2. Chest lift 
3. Bridging
- Exo chair exercise 
1.Modified standing leg-press with 
external rotation
https://www.sissel.de/images/de/products/split2_4327.jpg

- Mat exercises 
1. Pelvic clock 
2. Chest lift 
3. Bridging
external rotation
- Reformer exercises 
1. Leg-press 
http://www.pilatesstyle.com/wp-content/uploads/2013/07/Ariel-photo-11.jpg

Start Finish
Circles
- Mat exercises 
1. Pelvic clock 
2. Chest lift 
3. Bridging
external rotation
1. Leg-press 
2. Feet in straps 

- Mat exercises 
1. Pelvic clock 
2. Chest lift 
3. Bridging
external rotation
1. Leg-press 
2. Feet in straps 
3. Standing hip-stretch

Conventional physical therapy exercises33
Stretching
Hamstring stretching in supine
Piriformis stretching in supine
Towel gastrocnemius stretching
Quadriceps stretching in prone with a strap
Resistance band
exercises
Sidelying clams
Sidelying hip abduction with full knee extension
Foam roller
exercisees
Dying bug in supine on foam roller
Marching in supine on foam roller
Lumbopelvic
control with
biofeedback
Neutral spine hold for 10-seconds per rep

O U T C O M E S
Anticipated Goals Status
1. Maximum pain of 3/10 on NPRS Met
2. Lumbopelvic control with biofeedback
(minimum of 3 reps)
Met (5 repetitions)
3. Neutral pelvic positioning on command Met

O U T C O M E S
Expected Outcomes Status
1. Maximum pain of 1/10 on NPRS while
sitting >1-hour Met
2. Single-legged bridging (more than 60
seconds) with neutral spine
Not met;  
Able to perform10-second hold repetition x 2
3. Patient will decrease the total score of
ODI by at least 12.8 points
Met (14% reduction meets MCID of 12.8)
4. CR will perform lower quarter MMT and
score 5/5 on all movements bilaterally
within 12-weeks
Not Met;  
All left hip muscle strength improved
except for hip IR, but not 5/5

C R I T I C A L S E L F - R E F L E C T I O N
http://www.logware.com/wp-content/uploads/2015/06/mirror-2.jpg
Include other functional strength testing such as single-leg hopping 
tests in order to meet the patient’s goal of returning to basketball and  
jumping activities
Pilates apparatus availability is rare and a therapist  
should consider exploring more mat exercises and  
prescribe them as home exercise program (HEP)
Use other devices for muscle testing such as  
Hand held dynamometry (HDD)

L I M I TAT I O N S
n = 1
Patient was not seen for full 12 sessions (10 out of 12 only)
You cannot isolate and prove the effects of 
Pilates-based therapeutic exercises vs. Conventional physical therapy
http://seriable.com/wp-content/uploads/2012/01/mad-men5.jpg

F U T U R E R E S E A R C H
Randomized controlled trial studies on lumbopelvic control with 
Pilates-based therapeutic exercises group vs. conventional core  
stabilization and strengthening group.
Validation studies on Pilates-based therapeutic exercises on 
different population (Different Med. Dx) https://gigaom.com/wp-content/uploads/sites/1/2011/10/
futurewomanscreenistock_000012491259xsmall.jpg?quality=80&strip=all

C O N C L U S I O N
The patient population with LBP and status post lumbar discectomy may benefit from 
the addition of Pilates-based therapeutic exercises with conventional physical therapy  
in the outpatient physical therapy settings.
The breathing technique used in Pilates-based therapeutic exercises may help reactivate 
and re-educate stabilizing muscles of the trunk and lower back.

R E F E R E N C E S
1. Waterman BR, Belmont PJ, Schoenfeld AJ. Low back pain in the United States: incidence and risk factors for presentation in the emergency setting. Spine J. 2012; 12(1): 63-70.
2. Livshits G, Popham M, Malkin I, et al. Lumbar disc degeneration and genetic factors are the main risk factors for low back pain in women: the UK Twin Spine Study. Ann Rheum Dis. 2011; 70(10): 1740-1745.
3. Crow WT, Willis DR. Estimating cost of care for patients with acute low back pain: a retrospective review of patient records. J Am Osteopath Assoc. 2009; 109(4): 229-233.
4. Friedman P, Eisen G. The Pilates method of physical and mental conditioning. 10th edn. London: Penguin Books; 2005.
5. Latey P. The Pilates method: history and philosophy. J Bodyw Mov Ther. 2001; 5:275-282.
6. Wells C, Kolt GS, Bialocerkowski A. Defining Pilates exercise: a systematic review. Complement Ther Med. 2012; 20(4): 253-262.
7. Bryan M, Hawson S. The benefits of Pilates exercise in orthopaedic rehabilitation. Tech Orthop. 2003;18: 126-129.
8. Ferreira PH, Ferreira ML, Maher CG, Refshauge K, Herbert R, Hodges PW. Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain. Br J Sports Med. 2010;44: 1166-1172.
9. Hides J, Stokes M, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 1994; 19: 165-172.
10. Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. Spine 1996; 21: 2640-2650.
11. Wallwork T, Stanton W, Freke M, Hides J. The effect of chronic low back pain on size and contraction of the lumbar multifidus muscle. Man Ther. 2009; 14: 496-500.
12. O’Sullivan P, Twomey L, Allison G, Sinclair J, Miller K. Altered patterns of abdominal muscle activation in patients with chronic back pain. Aust J Physiother. 1997; 43:91-98.
13. Withers G. The evidence of Pilates is there. Mygroupfit.com. Accessed May 18, 2015.
14. Barbosa AW, Guedes CA, Bonifácio DN, De Fátima Silva A, Martins FL, Almeida-Barbosa MC. The Pilates breathing technique increases the electromyographic amplitude level of the deep abdominal muscles in untrained people. J Bodyw Mov Ther. 2015; 19(1): 57-61.
15. Gak H, Lee CW, Kim SG, Kim HS. The effects of trunk stability exercise and a combined exercise program on pain, flexibility, and static balance in chronic low back pain patients. J Phys Ther Sci. 2015; 27(4): 1153-1155.
16.
Demir
S,
Dulgeroglu
D,
Cakci
A.
Effects
of
dynamic
lumbar
stabilization
exercises
following
lumbar
microdiscectomy
on
pain,
mobility
and
return
to
work.
Randomized
controlled
trial.
Eur
J
Phys
Rehabil
Med.
2014;
50(6):
627-‐40.
17. Aladro-gonzalvo AR, Machado-díaz M, Moncada-jiménez J, Hernández-elizondo J, Araya-vargas G. The effect of Pilates exercises on body composition: a systematic review. J Bodyw Mov Ther. 2012;16(1):109-14.
18.
Ozkara
GO,
Ozgen
M,
Ozkara
E,
Armagan
O,
Arslantas
A,
Atasoy
MA.
Effectiveness
of
physical
therapy
and
rehabilitation
programs
starting
immediately
after
lumbar
disc
surgery.
Turk
Neurosurg.
2015;
25(3):
372-‐379.
19. O’Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation. 6th ed. Philadelphia, PA: F.A. Davis Company; 2014.
20. Magee, DJ. Orthopedic physical assessment. 5th ed. St. Louis, MO: Elsevier; 2008.
21. Norkin CC, White DJ. Measurement of Joint Motion, A Guide to Goniometry. 4th ed. Philadelphia, PA: F.A. Davis Company. 2009.
22. Reese, N. Muscle and Sensory Testing. 3rd ed. St.Louis, MO: Elsevier, Ltd.; 2012.
23. Hernandez D, Rose DJ. Predicting which older adults will or will not fall using the Fullerton Advanced Balance scale. Arch Phys Med Rehabil. 2008; 89(12): 2309-2315.
24. Kulig K, Landel RF, Powers CM. Assessment of lumbar spine kinematics using dynamic MRI: a proposed mechanism of sagittal plane motion induced by manual posterior-to anterior mobilization. J Orthop Sports Phys Ther. 2004; 34(2): 57-64.
25. Viner A, Lee M, Adams R. Posterioranterior stiffness in the lumbosacral spine: the correlation between adjacent vertebral levels. Spine. 1997; 22(23): 2724-2729.
26. Chansirinukor W, Lee M, Latimer J. Contribution of ribcage movement to thoracolumbar posteroanterior stiffness. J Manipulative Physiol Ther. 2003; 26(3): 176-183.
27. Manipulation Education Manual for Physical Therapist Professional Degree Programs (MEM). Manipulation Education Committee, APTA Manipulation Task Force. Education and Orthopaedic Sections. American Physical Therapy Association. 2004.
28. Copay, A. G., Glassman, S. D. et al. Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J. 2008; 8(6): 968-974.
29. Fairbank JC, Pynsent PB, The Oswestry Disability Index. Spine. 2000; 25(22): 2940-2952
30. Fairbank JC, Couper J, Davies JB. The Oswestry low back pain questionnaire. Physiotherapy. 1980; 66: 271-273.
31. Miekisiak, G., Kollataj, M., et al. (2013). "Validation and cross-cultural adaptation of the Polish version of the Oswestry Disability Index." Spine. 1976; 38(4): 237-243.
32. Anderson BD. Polestar Pilates Education Principles of Movement Course Manual. Miami, FL. 2012.
33. Kisner C, Colby LA. Therapeutic Exercise, Foundations and Techniques. F A Davis Company; 2012.

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