Pilates for Joint Hypermobility, Fibromyalgia, and Arthritis

Amy KingwillSeptember 2014

BASI Comprehensive Course 2014Berkeley, CA

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Abstract Dancing has been the most important thing in my life since I was three. During my twenties and early thirties arthritis, fibromyalgia, and hypermobile joints contributed to states of chronic and acute pain, mostly centered in the hip joint, which made dancing progressively more difficult; taking a toll on my physical and mental health.

Medical diagnostics were useful, treatments less so. Medications numbed the pain temporarily but quickly became ineffective. Finally, in 2013 a Physical Therapist whose treatments were productive recommended Pilates.

This paper discusses my rehabilitation of my arthritic hip and work towards improved joint stability. It omits much of my trial and error and concisely describes the course of action I found successful, leading to a better body and mind than before practicing Pilates regularly.

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Table of Contents

Abstract…………………………………………….2Table of Contents…………………………………3Anatomical Overview……………………………..4Medical Conditions Overview……………………6Case Study………………………………………...7Recommended Conditioning Program………….9Conclusion………………………………………....14Bibliography………………………………………..16

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Anatomical Overview Structure of the Hip SocketThe head of the femur, the central bone of the upper leg, has a ball-like knob which seats in a socket, the acetabulum, formed by the bones of the pelvis, the ilium, ischium and pubis. This powerful ball-and-socket joint is reinforced by ligaments such as the iliofemoral, ischiofemoral and pubofemerol ligaments. The depth of the acetabulum, angle of the head of the femur relative to the shaft of the femur as well as the overall shape of the pelvis will have direct affect on many things, particularly range of motion.

! ! ! ! ! (A)Muscles of the Hip Socket22 muscles cross the hip joint, providing stable and precise articulation. This powerful and complex area is capable of flexion, extension, abduction, adduction, inward and outward rotation, and circumduction. Depending on the action of coordinated engagement, many of the muscles have more than one role, producing movement on different planes and axes. See images (B) and (C).

Iliopsoas GroupThe iliopsoas is composed primarily of the psoas major and iliacus. These powerful muscles are vastly important in hip flexion, and maintaining normal lumbar curve. The iliacus originates at the iliac fossa and crest, and the ala of the sacrum. The psoas major originates from the anterior surfaces and lower borders of the transverse processes of the

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lumbar spine (L1-L5). The iliacus and iliopsoas join together before insertion at the lesser trochanter of the femur. See image (D).

(B)

(C)

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(D)Medical Conditions OverviewArthritis is a term for reoccurring or long-term joint inflammation. While inflammation is a natural and common reaction to injury and disease that can help in healing, the long term affects of ongoing swelling, pain, and stiffness can be damaging. There are many types of arthritis including common ones like Osteoarthritis, Rheumatoid Arthritis and Gout. Fibromyalgia is a disorder characterized by chronic and widespread musculoskeletal pain and allodynia (heightened and painful response to pressure). Other symptoms include but are not limited to fatigue, trouble sleeping, and overall stiffness of the body’s joints. Other indications of the condition such as digestive issues, numbness and/or tingling, cognitive dysfunction, may or may not present in a given individual. Depression and anxiety are often closely associated with the condition, as is posttraumatic stress disorder. Bone Spurs, or osteophytes, are bony projections that develop in and around joints. The body creates bone spurs in response to arthritis or other conditions as a way to increase a joint’s surface area that has experienced damage or loss. While stabilizing the joint they are often painful and can cause limitations in movement.

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Bursitis is an inflammation of the bursae, small sacs of synovial fluid that act as cushions at places where muscles or tendons cross bones. There are approximately 150 bursae in the body. A major bursitis symptom is tenderness in the affected region. Bursitis in the hip region can vary as there are several bursae. Trochanteric Bursitis is the inflammation of the bursa located between the iliotibial (IT) band and the greater trochanter. If tenderness is in the front of the hip it may be an inflammation of the iliopsoas bursa. Another form, called Ischio Bursitis, or Weaver’s Bottom, is located at the ischial tuberosity/sitz bone area. (Clippinger, 2007 / BASI, 2013).

Case StudyI am 34 years old, female, with a 29 year history of dance training. Pain has plagued my career and life since an early age, due in part to hereditary ailments, in part to accidents and injuries I have sustained. Among my physical challenges, I suffer from Fibromyalgia (FM) and joint instability; the combination of the two often leaves me in a state of pain in at least one area of my body at all times. After attaining a BFA in Modern Dance, I performed professionally for several years before ongoing pain and injuries caused me to stop.

Injuries are extremely common in dancers. We often train and perform while injured. In fact, injury is the most common medical problem for a dancer, with up to 90% having sustained musculoskeletal injuries at some time (Toledo et all S75). Moreover, an estimated 30% of injuries are often unreported (Hincapié, Morton, Cassidy 1824); dancers often try to work through the pain or rehab themselves. Regardless, injuries often eventually lead to the end of a career at an early age for a dancer, similar to that of professional athletes.

My FM diagnosis was made early in life; my mother has a severe form of it that she recognized in me as a child. Doctors said to me later that mine has been mild because I have been so active through dance, and that I should try to stay active as much and as long as possible. My condition, as with many who have FM, is most aggravated when I take more than a few days off from athletic activity. Flare-ups are also likely if I am under a lot of stress or if I push my body too hard in training.

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In addition, I have hypermobile joints; while my muscles tend to be tight for a dancer, my ligaments and tendons are loose and I have difficulty keeping my joints from popping out of place. My time at chiropractors and in various braces for wrist, neck, ankles, etc., has been long and tiresome. Medical professionals have been of little help; medications only numb the pain for so long and then cease to be effective. What does seem to help is regular exercise including stretching and low-resistance strength training, which leads us to Pilates.

I found that I had quite a bit of work to do with regards to the health and healing of my body when I decided to try to come back to a more active lifestyle and dance again at the age of 29. I have been slowly coming back to dancing for the last several years while working in a sedentary job, which had its own effect on my body. Since 2012 I was experiencing steadily increasing pain in and around my right hip joint. Normal techniques I had previously learned did little if anything to help, and by mid 2013 the pain led my doctor to a diagnosis of arthritis in my left hip. X-rays showed signs of degeneration and bursitis, and small bone spurs were also present; the doctor referred me to a Physical Therapist (PT).

There we investigated ways to help decrease the pain. The PT pointed out that I had marked weakness in my outward rotators, hamstrings, adductors and abductors. My hip flexors, particularly the rectus femoris, were over-engaged, and firing even when not needed. We also discovered that the head of my femur does not sit well within the acetabulum (which is notably shallow), and pain decreased when the femur was manually pressed down and into the joint while supine. I noticed many of the exercises the PT gave me were similar to those done in Pilates; the PT recommended I look into it. Later, using the springs while doing foot and hip work on the Cadillac/Tower would result in some of my most noticeable pain-reducing exercises and became the inspiration for this paper.

The BASI study guide states that musculoskeletal conditions frequently show patterns of muscular imbalance. I learned that muscular imbalances like these can have a huge affect on joint stability and subsequent pain associated with inefficient movement patterns. It was a huge insight for me to realize just

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how out of balance I was, and that to a degree I could correct it. In addition to general muscle imbalance, it seems my hip pain has been partially a product of handedess, particularly while dancing, and poor habitual posture, particularly at the computer. The body should be able to function with more of a balance between the muscles that stabilize and the muscles that do the primary work of motion.

Many of the goals of treating muscular imbalance outlined in our coursework are the same goals I needed myself. For any condition like these we as Pilates instructors and students need to guide efficient, safe movement that works within the restrictions outlined by doctors and Physical Therapists. For a condition like mine, focus should be on reeducation of the hip’s movement patterns: Going slowly, focusing on precise movement with careful attention paid to the most efficient muscle groups for the given exercise.

The Mind-Body connection can also be utilized while studying Pilates, and has tremendous power. My nervous system requires attention, certainly; through Pilates I found a way to quiet my anxiety and fears through tapping into the mind and using visualization to navigate through the pain to a place of peace and harmony within myself.!

Considering my options and seeing a difficult path ahead, I chose to quit my job in last quarter 2013 and focus on regaining the health of my body and mind with the help of Pilates. My first sessions were difficult, as I was still in a great deal of pain and had trouble using the correct muscles for many of the exercises due to habitual movement patterns and hip injury. In the midst of learning the repertoire, I was torn between learning all that I could and realizing that my body truly needed me to take a step back and focus on reeducation. For the purposes of this paper, I’ll provide what I would now recommended to a client that presents with the same issues.

Recommended Conditioning ProgramAssessment: At the start of the session, the roll down shows tension and imbalance in several areas. The cervical spine has little curvature; many years of ballet have elongated and destabilized this area. Noticeable tension exists in the

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rhomboids and tightness in the pecs together pull the upper body out of alignment. While flexible in forward bend, the articulation in forward flexion of the mid-thoracic and lumbar spine is limited. Coming back up to standing, a right rotation, small left lateral tilt, and general anterior tilt of the pelvis is visually obvious. Abdominals are weak and quadratus lumborum muscles are over-developed, particularly on the right side. There is clear indication of unilateral iliopsoas imbalance, and presumably weakness. Objectives: Core strength, overall joint stability, and decreased pain. Muscle(s) to Focus: Abdominals across the board, hip abd/adductors, hamstrings, outward and inward hip rotators, and deep hip flexors.

Sessions 1-5 Fundamentals !The primary focus is on the fundamentals to source correct muscle recruitment. Even if the student is a trained movement professional, we need to establish a solid, efficient foundation and reeducate the body and mind to work in harmony. We will stay solely within the Mat Block System for the first five sessions (one exception to this is the addition of the Leg Work from the Comprehensive Block System, however this work will be done solely on the Mat). Be careful not to over- tax the hip flexors in these beginning stages; the focus here is on decreasing the overuse of these muscles and on waking up the other muscles that surround the hip (which is why the additional block is added).

We will have two sessions a week for two weeks, then three sessions for the remaining three weeks and beyond. The student will also be encouraged to do the foundation exercises on their own 2-3 additional days a week, or as can be done comfortably. Assists are added where needed, but only at the beginning until correct muscles are engaged.

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BASI Block Equipment Exercises NotesFoundation Mat (Roll Down)

Pelvic Curl, Spine Twist Supine, Chest Lift, Chest Lift with Rotation, Leg Lifts/Changes

Start small, with precise initiation to establish efficient, clear execution of the repertoire. Use a deflated ball as needed between the inner thighs to wake up weak inner thighs! Absolute care should be taken to source the powerhouse and visualize the illopsoas for leg movement and not the outer hip flexors like the rectus femoris! Leg L/C can be introduced but more as an idea that the leg can move independently of the hip (keep reps low for the first few sessions – do not trigger pain).

Abdominal Work

Mat Hundred Prep, Leg Circles (modified), Roll Up

Place feet on box if hip flexors become too activated. Use strap or band for leg circles (to feel hip disassociation, then remove) and/or bend the supporting leg. For RU, use weight held between the feet for the initial few reps of the roll up to engage the deep abs and gain confidence, then remove and do remaining reps without weight.

Spinal Articulation

Mat Roll-Like-A-Ball, Spine Stretch

Encourage using the abdominals and relaxing the hips.

Bridging Mat Back Support Wakes up the hamstrings! Introduced during session 4 for a few sessions if time permits and student is able.

Lateral Flexion/ Rotation + Leg Work

Mat Side Lifts, Gluteals Side Lying Series (Side Leg Lift, Forward and Lift, Forward with Drops), Sitting Series

Side Lifts will be done for all sessions, GSLS and Sitting Series alternated so to continue to work the leg muscles but without over taxing the hip so it seizes up.

Back ExtensionMat Back Extension, Cat Stretch

Cue to find length; think of rubber band. Cat Stretch is great for creating more mobility in their more restricted areas, waking up the abdominals while articulating the spine.

Rest/ RecoveryMat Rest Position, +, (Roll Down)

+if time, include stretching hip outward rotators and hamstrings (Ladder Barrel, if available)

Sessions 6-10 Fundamentals continue to be the focus of the training. Here we will add the apparatus, introducing more resistance to the hips and challenging the core muscles. The Cadillac/Tower is used often from here forward, as the orientation of the springs to the hips is fantastic for stabilizing the hips and encouraging hip disassociation.

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BASI Block Equipment Exercises NotesWarm Up Mat (Roll down) Pelvic

Curl, Spine Twist Supine, Chest Lift, Chest Lift with Rotation, Leg Lifts/Changes

For added challenge, lengthen top leg at the twist in the STS, add extra lift to chest lift, and simultaneously switch legs for leg lifts/changes

Footwork Cad/T, Reformer Parallel heels/toes (H/T), V Toes, Open V H/T, Calf Raises, Prances, Single Leg H/T

Introducing Reformer work for sessions 6-8, then Cad/T for 9-10

Abdominal Work

Mat, Reformer, Cad/T

Mat: Leg Circles, Double Leg Stretch, Single Leg StretchReformer: Hundred Prep, Coordination

Mat work for sessions 6-8, then add reformer ab work moving forward. May chose to tag on the mat ab work to warm up portion.Reformer in sessions 8-10.

Hip Work Reformer Frog, Circles Up/Down, Openings

Keep things simple, and small. Do not allow full range of motion.

Spinal Articulation

Mat, Reformer, Cat/T

Roll Over (M), Long Spine (R), Monkey Original, Tower Prep (Cad/T)

Roll over practiced 6-8, Long Spine 7-8, Monkey and Tower 9-10

Stretches Reformer, Cad/T Standing Lunge, Shoulder Stretch

Carefully guide them! Standing Lunge 6-10, Shoulder Stretch introduced 9-10

Full Body Integration (FBI) 1

Reformer Scooter

Arm Work Mat, Reformer Standing Series, Arms Supine Series

Use of the magic circle can really take off here. Alternate between this and arm work on Reformer

FBI 2 N/ALeg Work Mat (Magic

Circle/Box)ALL Mix it up! Emphasize the adductor and

abductor workLateral Flexion/Rotation

Mat, Reformer Side Kick, Mermaid

Back Extension +

Mat Double Leg Kick, Rocking Prep (Roll Down)

Sessions 11 forwardWhile my hip and overall pain in my body has greatly decreased, it has become clear that it will remain important to continue a consistent, regular practice but not push my body too far, and trigger a flare up. I enjoy a good challenge and get bored of the same routine, so continuing to learn new exercises is key to keeping my interest in continued training. However as more advanced exercises and other apparatus are introduced, I make sure to continue to pursue a deeper and deeper understanding of the fundamental and beginning exercises.

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BASI Block Equipment Exercises NotesWarm Up Mat, Cat/T, (Roll down),

Mat Warm Up, Warm Up Series (Roll Up w/RUB, Mini RU, Mini RU Obl, Roll Up Top Loaded)

Revisit the Mat warm up to check in.

Footwork Cad/T, Wunda, Reformer

All footwork Alternate Reformer and Cad/T work initially. Introduce Wunda after 20 sessions, then alternate among all three.

Abdominal Work

Cad/T, Wunda, Step Barrel

Roll Up Bottom Loaded, Breathing w/ PT Bar, Bottom Lift w/RUB, Standing Pike/R (W), Teaser Prep (SB)

Wunda and Step Barrel introduced after 20 sessions

Hip Work Cad/T, Avalon Supine Leg Series, Supine Single Leg Series, Hip Extension (Av)

Primarily work on Cad/T; Avalon introduced after 20 sessions as teaser to keep learning more (and to really engage the hamstrings)!

Spinal Articulation

Cad/T, Reformer Tower (Cad), Short Spine

Stretches Reformer, Cad/T Kneeling Lunge, Shoulder Stretch Prone

FBI 1 Reformer Up Stretch Group (pick from)

Up Stretch 1 and Elephant will be the best initially

Arm Work Cad/T Arms Standing Series

Arms on the Cad/T will work well to encourage appropriate muscles

FBI 2 N/ALeg Work Cad/T Single Leg Side

Series (Changes, Scissors, Circles (fwd/bk)

Work with lighter springs and encourage correct muscle recruitment.

Lateral Flexion/Rotation

Reformer, Wunda Side Over on Box, Side Stretch, Side Kneeling Stretch

Keep the length and source the obliques, back extensors

Back Extension +

Reformer, Wunda Long Box Group (Breastroke Prep, Breastroke, Pulling Straps I/II), Swan Basic (W), (Roll Down)

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Conclusion While Fibromyalgia and arthritis are considered incurable, there are many practices that can be helpful in easing the symptoms that come with the conditions, particularly Pilates.

At the time I stopped dancing, my body felt used up and broken; at 34 I still feel achy, but I am stronger that I have ever been, and I am able to do movements with more efficiency than I could fifteen years ago.

By building my strength and re-educating my body to recruit appropriate muscles for the specific movement, the pain in my hip has significantly decreased. Little more than a year ago I could barely walk and was at rock bottom. Today I know myself to be in significantly better mental and physical health through Pilates. There are days I have minor flare ups, but I view them as simple reminders as to how far I have come; reminders to pay close attention to keeping my body in top physical health and strength so that I never have to feel the kind of hopelessness I felt back when I was not as committed to taking care of myself.

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Bibliography

“Arthritis.” Def. Web MD and Wikipedia. Online. 14 Sept. 2014. http://www.webmd.com/osteoarthritis/guide/arthritis-basics and http://en.wikipedia.org/wiki/Arthritis

Body Arts and Science International. Study Guide and Movement Analysis Workbooks, Comprehensive Course. 2000-2013. Print.

Calais-Germain, Blandine. Anatomy of Movement. Seattle, WA: Eastland Press, 1993. Print.

Clippinger, Karen S. Dance Anatomy and Kinesiology. Champaign, IL: Human Kinetics, 2007. Print

“Fibromyalgia.” Def. Mayo Clinic. Online. 14 Sept. 2014. http://www.mayoclinic.org/diseases-conditions/fibromyalgia/basics/definition/CON-20019243

Hincapié, Cesar A., Emily J. Morton, J. David Cassidy. “Musculoskeletal Injuries and Pain in Dancers: A Systematic Review”. Review Article. PubMed/Medline. Vol 89. September, 2008. 14 Sept. 2014. Online.

Isacowitz, Rael, and Karen S. Clippinger. Pilates Anatomy. Champaign, IL: Human Kinetics, 2011. Print.

Muscle System Pro III iPhone edition. 3D4Medical.com in collaboration with Stanford University School of Medicine, October 2013.

Toledo MD, Santiago D et all. “Sports and Performing Arts Medicine. 6 Issues Relating to Dancers”. Review Article. PubMed/Medline. Vol 85. March 2004. 14 Sept. 2014. Online.

Images: (A) Hip Joint. Digital image. N.p., n.d.Web. 14 Sept. 2014.  <http://www.nvasi.com/hips-joints/>.

(B) The Structures Surrounding the Right Hip Joint. Digital image. N.p., n.d.Web. 14 Sept. 2014.  <http-//www.clinicalanatomy.ca/images/LL/cheney_LLhip.jpg>.

(C) Leg Muscles. Digital image. N.p., n.d.Web. 14 Sept. 2014. 

<http://www.trilliumfit.com/wp-content/uploads/2013/02/leg-muscles1.gif>.

(D) Illiopsoas. Digital image. N.p., n.d.Web. 14 Sept. 2014. 

<https://yogantoinesophie.wordpress.com/category/anatomie/>.

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