Use a Pilates Map to Stay on Track.

Have you ever had the feeling of being lost when you’re with a patient in a rehab session? Ever felt not quite sure what to do next with them? Yep, it’s not a great feeling and one I definitely haven’t enjoyed experiencing in the past. However; there is a way to reduce the risk of getting lost when travelling through Rehab County – use a Rehab Map, well in this case a Pilates Map.

One thing us Physios are good at doing is travelling. I don’t know why for sure, perhaps after the sartorial shame inflicted on us as students wearing our horrible clinical uniforms we need the cathartic experience of heading overseas to where no one can point at us and say ‘isn’t that the guy who used to wear green trousers* on the ward?’. Anyway, I diverge. My point is that by tackling our patient’s rehabilitation like travelling I think we can make life easier for ourselves. Stick with me on this.

One challenge for Physiotherapists and clinicians using Pilates in rehabilitation is planning the ‘next step’ in our patient’s management.

First step – know where you want to go.

A typical scenario is one where we find ourselves feeling confident with the patient’s starting point. We simply introduce our patient to a range of new movements with a diverse library of variations to play around with. Low back patients get some gluteal based exercises, shoulder patients are shown some scapular work. It then takes our patient a few weeks to learn and perform the movements efficiently, which can give the impression that they are improving. However, we are then thrown off course and feel lost with our project when a patient reports minimal change to their presenting complaint. I’ve found that this can make our next step in our rehab journey difficult to clearly and concisely plan. Upon reflection, by placing an emphasis on developing a patient’s ability to perform Pilates rather than addressing their performance goals, I ended up losing the forest for the trees. I had forgotten that the first step in planning any journey is being clear on where you want to go.

One common example of losing the wood for the trees is when using reformer based exercises to address anterior knee pain. This can happen when there is an emphasis on teaching the Pilates based exercises rather than using the exercise as part of a comprehensive management plan. For example, though the patient may end up being able to perform scooter based movements comfortably and efficiently, various key factors in their management such as eccentric loading, landing control and / or hip-pelvic coordination in the frontal plane may fail to be adequately addressed.

So the second step is checking to see where you are on the Pilates (rehab) map. Namely keep assessing to see where your patient is relative to the goals establish in step one. By having a battery of tests, baseline outcome measures and performance goals, you can then lay out these milestones or reference points that you can measure you patient up against to see if you are on track towards your goals or not. These milestones can also become markers on the path that your patient is ready to progress.

Step three in using the map is to then build your program. Using a map helps plan out your patient’s athletic development towards their goals. You’ve established where you want to go (performance goals), then assessed where you currently are on the map (assessment)- now you mark the path you’ll take by building a series of exercises (program design) that guide your patient towards their performance goals.

The video below shows a brief example of how the performance goal of loaded walking lunges can be ‘reversed engineered’ to Reformer Scooter type exercises.

Reformer Scooter to Walking Lunge

1. Supported isometric loading on the stance leg
2. Supported loading through range
3. Unsupported loading through range
4. Increased deceleration/eccentric loading
5. Propulsion

So here are a few key steps to keep you on track.

Know where you want to go:

• What does your patient want to be able to do? i.e. return to sport, comfortable ADLs, walking holiday coming up?
• Establish the later stage performance goal(s) i.e. walking 5km, squatting 150% bodyweight, walking lunges with 5kg comfortably, symmetrical hop for distance
• Consider the performance characteristics that they need to train towards i.e. speed, change of direction, power

Assess where is your patient compared to the goal:

• Using a battery of appropriate tests assess their current level of performance
• Use some appropriate outcome measures to establish your patient’s baseline i.e sit to stand test, single leg squat test, decline board single leg squat test, knee extension strength
• This also includes referring to your musculoskeletal assessment findings i.e. reduced hip or ankle ROM
• Discuss these with your patient and explain how these are the key goals the rehabilitation program is aiming to address

Create some hurdle requirements or milestones to reach:

• Based on your assessment establish some milestones that your patient should reach before progressing ie. number of calf raises or bridges, establish a consistent ROM i.e. knee to wall distance, hop symptoms free
• This can include Pilates equipment based milestones such as scooter x 15 reps with a specific resistance
• Milestones should address the various performance characteristic pertinent to the patient i.e balance, mobility, endurance, power, change of direction

Build the program:

• Select a group of exercises that can be systematically progressed towards the patient’s performance milestones
• Have the program address a number of appropriate performance characteristics i.e. endurance, balance, mobility
• If unsure then ask a colleague with more (or different) experience
• If you find you have too many/few exercises for the time allocated then simply edit the program. The truth is most programs evolve over a period of time rather than being set in stone from day one
• Start the training process with clear instructions on dosage, frequency, symptoms ceiling i.e. VAS < 3/10

Keep looking at the Pilates map:

• Continually remind your patient (and yourself) what the performance milestones are and assess (as needed) where your patient is at compared to the plan
• Once the milestone(s) has been reached firstly congratulate your patient (and yourself) and then go back to step one to plan the next phase

In Summary:

1. Know where you and your patient want to go
2. Work out where on the map your patient currently is
3. Highlight the milestones you need to pass on the way to your destination
4. Build the exercise program that leads you to the milestones
5. Keep checking the map to make sure you’re still on course
6. Celebrate when you get to your destination
7. Go back to step 1

*I can only assume that the University of Melbourne School of Physiotherapy head honchos in the late 1990’s believed that the collective anxiety experienced by students on placement would be soothed by the calming effects of wearing emerald green trousers.