Pilates + Physical Therapy

Pilates Physical Therapy San Francisco

Joseph Pilates, a German medic who trained in boxing and gymnastics, developed Pilates as a form of exercise in the early 20th century. As a child, he suffered from various illnesses and though he had no formal training, was fascinated with the study of human movement and dedicated to improving his physical fitness. Pilates believed that postural dysfunction and inefficient breathing techniques contributed to poor health. Originally called “Contrology”, he considered the method a holistic approach to movement, incorporating mind, body and spirit.

Initially conceived as a sequence of bodyweight exercises performed on a mat, Joseph Pilates invented several pieces of equipment (apparatus) over the years. The Reformer and The Cadillac were both developed from his experimentation with springs attached to hospital beds, and The Chair was inspired by…you guessed it, a living room chair! As its popularity grew, The Pilates Method became mainstream, offered in gyms, studios and taught as an adjunct in physical therapy clinics.

The benefits of Pilates may seem clear. The most commonly mentioned reasons people do Pilates is to improve core strength and stability. Less obvious are two important reasons I suggest Pilates to my patients:

Pilates is a method of exercise that emphasizes on breathing with movement. The ability to coordinate respiration during movement is essential for everyone, yet many are challenged by this seemingly simple act. The muscles of respiration contribute to stabilization, so if respiration is altered, spinal stability will be compromised.

Pilates can be modified for various levels of recovery and fitness. While mat-based Pilates exercises might seem easy, sequences can actually be more challenging than those performed on a Pilates apparatus since participants must control their bodies without any external assistance. The various Pilates apparatuses can be used to increase the challenge of an exercise or to provide assistance to complete a movement. Depending on how the springs on an apparatus are set, there may be an increase in resistance for a focus on strength or a decrease in resistance for improved control. Springs may also be used to provide support, making an exercise more accessible to a healing body.

While its popularity has increased, Pilates as a method of exercise has become less defined over the years. Today, virtually any type of movement performed on a Pilates Reformer or mat can be labeled Pilates and, without experience working with a qualified instructor, you may never know the difference. When your doctor recommends the method, a coworker suggests Pilates because, “it worked for me,” or you choose to do Pilates independently with an online video, you are applying a very broad exercise method to a condition that may require a little more specificity and individualization. In fact, many mat or equipment-based Pilates exercises are flexion-based and are not only inappropriate for some patients, but actually contraindicated (e.g. herniated disc, osteoporosis). Exercises that focus on strengthening the back of the body (posterior chain) may exacerbate other conditions (e.g. stenosis, spondylolisthesis).

As a physical therapist who is Board Certified in Orthopedics, I use my Pilates training to enhance my educational foundation in anatomy, kinesiology, and pathology. In the United States, there is a large discrepancy in the training involved to qualify as a Pilates instructor. Some instructors train with Master Instructors and participate in educational programs that include a basic study of anatomy with observation and practice hours. These programs may also involve an overview of specific injuries and provide information on what types of exercises should be avoided. Other instructors, including those at TherapydiaSF, are licensed physical therapists looking to expand their exercise instruction techniques as a complement to their physical therapy education. On the other end of the spectrum are those who take a weekend class or do some training on their own to teach Pilates.

Modern day Pilates varies dramatically from what its creator originally taught. A savvy, educated consumer should know what to look for when choosing the right class or instructor.

If you’re looking for a form of exercise to support your recovery, start with a physical therapist who is trained in Pilates. Your goal may be to return to work with your Pilates instructor, but a thorough assessment with a medical practitioner (e.g. your physical therapist) will help identify potentially harmful exercises and highlight what you should focus on during your Pilates sessions with your trainer. A successful treatment strategy often includes work with both a physical therapist and a Pilates instructor open to collaborating.

If you are healthy, pain-free, and looking for a challenging workout, you have a variety of options. Many clients continue their work with Pilates instructors who are also physical therapists based on our ability to recognize and address potential injury risks. Group classes might also be a consideration for a more affordable option and for a more social experience. Classes vary in style and are less individualized, so if you are looking for more guidance, we recommend one-on-one training.

Pilates should never replace work with a qualified rehabilitation specialist trained to treat injury. Nor should someone with an injury attempt to use self-guided Pilates exercises to treat or manage their injury. If your physician has recommended Pilates, or you need a specialized program, find a physical therapist with training in Pilates. You will receive a thorough examination that will help the therapist develop a treatment plan and determine if you are appropriate to begin work with a Pilates instructor, or if you should start with Pilates-based physical therapy.

Dear Physio, I Can Take it From Here…

So, when does physical therapy end?

This is just a short piece, a reflective piece, about a value that makes up the very core of what I believe in and what I strive to achieve as a Physiotherapist – empowering my patients with the knowledge and the skills they need to make themselves independent.

These past few weeks have reminded me of a very special part of treating patients – discharging them. For months now I have worked intensely to help the small patient population with whom I have contact. After investing so much time in their development and progress, it is a magical moment when they come to me and say “I am not 100% better but I know what the problem is and I know how to make it better. What I need now is time to follow through on my goals and I can take it from here.”

What a pleasure it is to hear that. I know no one will ever be 100% when it comes to discharge and I am fine with that. First, I don’t set “being 100% pain free” as a goal and secondly, I think we all suffer from pain at some point in time. What I feel is more important is for patients to function normally and in the most ideal way for their lives.

Something patients frequently ask is “How long do I need to keep coming to Physical Therapy?”  Or, “Will I always need to do these exercises?”

The answer to the first – how long does it take you to no longer need Physical Therapy?

The answer to the second – No, you will need them when you need them.

What do I mean by this? Let’s take a look at the ideal stages of recovery involved between initial assessment and discharge.

STEP 1 – LET ME HELP STEER YOU IN THE RIGHT DIRECTION

It all starts at the beginning, when life is altered by pain or injury and when patients seek care because they don’t function in their normal way anymore. Sometimes it can be tough to get the ball rolling, to retrain movement patterns and daily habits, to get pain levels under control, and to motivate patients to begin to drive their own recovery. The first step as Physical Therapist is to understand the problem, the contributing factors, to identify milestones that help patients identify with their own recovery process, and then begin guiding them through rehab until they reach step 2.

STEP 2 – START TO TAKE THE WHEELS

Once pain is no longer driving a willingness to come to therapy, what is?

As I often say to my patients – I will sit beside you on this journey to recovery, but I will not drive you there. So, Step 2 is all about helping patients recognise what other barriers need to be overcome or goals need to be achieved before they can function unrestricted.

STEP 3 –  NOW IT’S YOUR TURN TO DRIVE

Once you are functioning well, do you know how to stay that way?

At this point in time I hope that my patients are developing a sound knowledge about how their bodies present/move/behave when they are both feeling good and feeling not so good. Developing this self awareness is a key step towards understanding their bodies better and identifying how their rehab should progress for them to be 100%.

STEP 4 – I AM NO LONGER A PASSENGER

If you’re staying symptom free and doing what you love – do you still need my help?

It is definitely sad to say goodbye but we have to set our patients free. This past week has been sprinkled with discharge assessments–patients who come in smiling because they only have good news to report. They are playing the sports they love, can use exercises to manage any niggles that may come up, are no longer thinking about their injury or their body part, and can see the end goal in sight. And this is when I ask – do you still need my help to get to the end? And with a smile, they reply, “I can take it from here”.

If you are reading this as a patient I want to to ask yourself:

Are you self-discharging too soon? There is a lot of work that lies between reducing pain and discharge.

Are you holding on too long?

Are you taking the steps along the entire journey to make sure your knowledge is developing and growing to accommodate for the changes in your body at that given time?

At TherapydiaSF we strive to form strong relationships with our patients. Communication is the key to break down what problems exist and create individualised treatments for those problems. We all have our niche areas or injuries we love treating, but at the end of the day, you are the person that will direct the treatment path and we are here to help and facilitate you to reach those goals.

Sian Smale, PT, MPhysio has been part of the TherapydiaSF team since 2016. Originally from Australia, Sian is trained in Musculoskeletal Physiotherapy and Clinical Pilates. When not working as a physiotherapist, you can find Sian cycling the hills of Marin, swimming in the elusive outdoor pools of the Bay Area, and chasing down the best avocado toast.

When should I see a physical therapist?

Many of the patients I treat are extremely active, though few make their living playing sports professionally. They are passionate about their lifestyle and sport of choice, and take their health very seriously.  With many sports and hobbies, aches and pains are likely to occur.  Athletes quickly get used to sore muscles and minor injuries, often considephysical-therapy-san-francisco1ring these a normal part of an active lifestyle.

But should these be treated more seriously?

Many of the patients with whom I work initially ignored what seemed to them to be minor injuries, yet have since become more frequent or more intense.

At what point should you visit a physical therapist?

Read more for quick tips to decide if what you’re feeling needs a closer look.

1. Immediately after a specific injury.

A number of recent studies have shown support for early physical therapy for lower back pain.  The studies show that physical therapy within 2-4 weeks of a lower back injury leads to a decreased risk of surgery and injections, fewer doctor visits, faster recovery, and fewer incidents of chronic pain.

Clinically, I have seen even earlier physical therapy provide excellent results. I am a strong advocate of patients developing a relationship with a physical therapist as a practitioner on their medical team (see post).  I also believe that patients should have email access to their physical therapists in order to communicate updates and ask general questions.  Often, a patient will email or call our office within the first few days of an injury and we will schedule them that day.  Earlier this year, I worked with a triathlete who developed intense back pain after a weekend race.  We saw her the next day and within a week she reported an 80% decrease in her symptoms. The following week she reported a 95% improvement and was able to race again exactly one month later. The sooner we can see a patient post-injury, the faster their recovery from the painful, acute stage.  This allows us to move to more advanced stages of physical therapy earlier, in order to address the root cause of their injury.

2. If an old injury has reappeared or never disappeared!

As I was getting ready to graduate one of my runners from physical therapy the other day, she asked, “but…how will I know if I need to come back?”  It was a great question, yet one without a definitive answer.  Runners, especially, are subject to occasional minor aches and pains.  At what point should they take these more seriously and seek help?

In general, you should reconnect with your physical therapist when:

You feel pain during an activity that gets worse as you continue the activity.  This is a sign that something is not right.

Your pain changes the way you perform the activity.  If you are running down the street with foot pain and you have to limp to avoid it, go home and call your PT.  Remember, the faster the painful symptoms are addressed, the more likely the root cause will be identified and other related injuries are less likely to occur.

You feel pain during three consecutive workouts or activities Often pain will be present at the start of an activity, but will disappear within a few minutes.  Does that mean it should be ignored?  No.  If you are consistently feeling the same or similar symptoms, even if they go away during the activity, schedule an appointment.  Pain is a sign of tissue fatigue or too much stress on a particular part of the body, likely related to an underlying movement dysfunction.  In English?  You’re likely not moving as well as you could, an area of your body is doing more than its fair share of the work, and it needs some help.

3. For an annual check up.

Physical therapists can be, and should be, the medical practitioners of choice for a musculoskeletal wellness/fitness screen, an assessment with a physical therapist to identify risk factors for developing a particular injury.  Much like we visit the dentist on a regular basis, we believe that everyone should schedule an annual preventative visit to their physical therapist to identify and address areas of dysfunction (that tight neck you’ve been complaining about, poor posture, or the shoulder that occasionally hurts in your bootcamp class).  Left undetected, these will likely get worse over time.  We would much rather see you once a year to revise your exercise program and keep you healthy, than have you wind up in our office as our newest patient!

Remember, you shouldn’t try to tough it out or wait until an injury becomes more severe before visiting your physical therapist.  You will wind up suffering needlessly and make our jobs even harder!

If you’re still not sure you should come in for an assessment, feel free to email us:  hello@therapydiasf.com.

In your email, please provide the following:

-where is the location of pain?

-how did the injury occur?

-how long has have you had the pain?

-what makes it hurt?

-what makes it feel better?

We will review the information and advise you on the best option for your injury.  This may include advice for self-management, the need to schedule a physical therapy assessment, or a physician contact, if necessary.

Physical Therapists and Exercise

Why work with a physical therapist for fitness? 

PT’s are trained in movement:

We are healthcare professionals trained in optimal patterns of movement, posture, and form and will provide a safe and effective workout.

PT’s are experts in anatomy:

We will design a full body program to address strength, flexibility, cardiovascular health, and balance.

PT’s understand injury:

We will design a program that takes into consideration current and previous injuries, muscle imbalances, and current goals.

At TherapydiaSF, we offer a full selection of wellness services including:

  • Pilates
  • yoga
  • TRX training
  • general fitness training
  • small group classes
  • Fitness Screen: complete assessment of strength, flexibility, balance and independent program design.
  • RunRx: complete assessment of strength, flexibility, and video of running mechanics

An Open Letter to Well-meaning Physicians and Well-educated Patients: Volume 1, Pilates

pilates“My doctor said I need Pilates.”

“I have a prescription for Pilates.”

“I’ve been doing Pilates for months and I’m not getting any better.”

Well-meaning physicians and motivated, educated patients frequently make this assertion without a full understanding of what Pilates really is.  My hope with this post is to explain a bit more about Pilates and why the method may or may not be the best treatment for you.

1.  Pilates is an exercise method 

Joseph Pilates, a German medic who trained in boxing and gymnastics, developed Pilates as a form of exercise in the early 20th century.  As a child, he suffered from asthma, rickets and rheumatic fever. Though he had no formal training, Pilates was dedicated to improving his physical fitness and fascinated with the study of human movement.  He believed that postural dysfunction and inefficient breathing techniques contributed to poor health. Seems like he was onto something here, right?  (see Breathing and Low Back Pain: Is There a Correlation?)  When he emigrated from Germany in the 1920s, Joseph and his wife Clara developed a following in the dance community in New York City.  As its  popularity grew,  The Pilates Method became mainstream, offered in gyms, studios and often taught as an adjunct in physical therapy clinics.

2.  Pilates is not synonymous with core stabilization

When physicians write “Pilates” on a prescription for physical therapy, it is likely that they are recommending core stabilization for their patient.  However, Pilates is too broad a term to use when making suggestions regarding a patient’s rehabilitation without a full understanding of all of the factors that may contribute to a person’s injury.  Not everyone with back pain has a weak core (GASP!) and not everyone has tight hamstrings…more on this in a future post.

3.  Pilates is not synonymous with rehabilitation  

Several years ago I sat in on a meeting of a group of local Pilates instructors to discuss forming a collective. During the meeting, I was surprised to hear such disagreement between instructors about what they actually do.  One in particular was adamant that she provided rehabilitation for her clients.  Another well-known instructor was equally vocal stating that Pilates instructors teach a method of exercise that may be helpful as clients work to rehabilitate an injury, but they do not, in fact, provide injury rehabilitation.  As a physical therapist who is Board Certified in Orthopedics, I use my Pilates training to enhance my educational foundation in anatomy, kinesiology, and pathology.  In the United States, there is a fairly large discrepancy in the training involved to qualify as a Pilates instructor.  Some instructors train with Master Trainers and participate in educational programs that include a basic study of anatomy with observation and practice hours.  These programs may also involve education about specific injuries and assessment of abnormal movement patterns and provide information on what types of exercises should be avoided.  Many instructors, like myself, are licensed physical therapists looking to expand their exercise instruction techniques.  On the other end of the spectrum are those who take a weekend class, or do some training on their own to teach Pilates. A physical therapist is best trained to perform a full physical examination to determine the most appropriate routine of core stability exercises, or whether stabilization is even the correct treatment for the patient.

4.  Pilates is not appropriate for everyone

Unfortunately, as its popularity has increased, Pilates as a method of exercise has become less defined over the years. Now, virtually any type of movement performed on a Pilates Reformer or mat can be labeled Pilates and without experience working with a qualified instructor, you may never know the difference.  When a physician recommends the method, a coworker suggests Pilates because, “it worked for me,” or you choose to do Pilates independently with a video, you are applying a very broad exercise method to a condition that may require a little more specificity and individualization.  In fact, many Pilates exercises, both mat-based and on the equipment, are flexion-based and not only inappropriate for some patients, but actually contraindicated (e.g. herniated disc, osteoporosis).  Exercises that promote strengthening the back of the body (posterior chain) may exacerbate other conditions (e.g. stenosis, spondylolisthesis).

Take home message:

Pilates is too broad a term to use when making suggestions regarding a patient’s rehabilitation.

Pilates should never replace work with a qualified rehabilitation specialist trained to treat injury.  Nor should someone with an injury attempt to use self-guided Pilates exercises to treat or manage their injury.  A successful treatment strategy often includes work with both a physical therapist and a Pilates instructor open to collaborating in order to best help their client.

If your physician has recommended Pilates, or you need a specialized program, find a physical therapist with training in Pilates.  You will receive a thorough examination that will help the therapist develop a treatment plan and determine if you are appropriate to begin work with a Pilates instructor, or if you should start with Pilates-based physical therapy.  

What is Wellness?

Seems like everyone I know is a Wellness Coach these days.  Sounds great, but what exactly does it mean?  As much a buzzword in the health, fitness, and nutrition industry as local, organic, and artisanal are to the food and beverage industry, the term wellness may need a little more explanation.

On January 1, 2005 new legislation was passed to allow physical therapists in California to practice “wellness”.  What exactly did that permit us to do?  We could now see clients for “the promotion and maintenance of physical fitness to enhance the bodily movement related to health and wellness of individuals through the use of physical therapy interventions.” It is perplexing that physical therapists, healthcare professionals with extensive training in anatomy, physiology and pathology, had been previously relegated to treating only the injured.  There is no legislation to limit access to personal trainers and massage therapists.  Funny that it took a Senate Bill to allow CA PT’s to work preventatively with healthy adults.

I have always enjoyed my role as Wellness Provider (see definition above).   I believe that physical therapists are best poised to fill this role beyond formal rehabilitation.  Physical therapists have the training and formal education to help you before an injury occurs. You see your doctor and dentist on a regular basis.  Why not schedule an annual exam with an expert in neuromuscular health?

In addition to the Wellness Screen that many clients schedule annually, we offer a range of Wellness Services at TherapydiaSF.  Many clients have continued working with me following rehabilitation for a specific injury because of my training as physical therapist.  For those who wish to schedule Wellness sessions, we offer customized single and partner Pilates or TRX sessions as well as small group classes that are limited in size to provide attention to form. Injured or healthy runners benefit from RunRx, our program to evaluate run form and provide a custom, progressive training plan for improved performance and prevention of injury.

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The label “Wellness Provider” is not exclusive to physical therapists.  Other professions use this term though it’s meaning may be different from industry to industry.   If you are interested in working with someone who calls him or herself a Health or Wellness Coach, ask them what it means.  Do they have specialized training in a particular skill beyond their primary occupation?  How are they unique compared to another massage therapist, personal trainer, nutritionist or life coach?

Don’t be fooled by labels.

Pain IS the perfect excuse…

…to call your physical therapist.  I get it.  I’m the one who cleans the apartment BEFORE the housekeeper comes. But waiting to schedule because you’re in too much pain is like telling your dentist, “my teeth are too dirty”, your personal trainer, “I need to lose weight before I start ” or your therapist, “I’m too down in the dumps to see you today.”  I can understand the fear that a PT may make you move, but being in pain is exactly why you should see a PT who will assess your movement and choose a treatment to alleviate your symptoms.  

Join our Matrix Mashup class!

Led by physical therapist, Master Instructor for TRX and Pilates instructor Sydney James, this 6-week strength & conditioning circuit class incorporates a wide variety of exercises and equipment.  Experience a full-body workout to improve fitness and enhance your current exercise routine. With the class size limited to 10, participants can work at their own pace and will receive individual attention.

Join us Tuesday evenings 6-7 pm June 11-July 16.

Drop-in (based on availability) $35
6 week series: $150

Contact info@therapydiasf.com or call 415-765-1502 to sign up.

One size fits all? Part 2: What makes a good PT? Aren’t all therapists the same?

IMG_3930A good physical therapist…

…invests in continuing education- While the majority of states require continuing education credit for continued licensure, some therapists complete only the minimal requirements while others seem to spend every weekend taking courses!  It is reasonable for a patient to inquire about the therapist’s interest in educational topics.  Chances are the PT will be excited to talk about their latest course.

…considers the whole person.  An injury is very rarely limited to the specific joint or muscle that hurts.  A good therapist treats not only the symptoms, but looks for the cause of the injury and understands how dysfunction in one area of the body may contribute to symptoms in a different location.

…draws from a variety of sources and isn’t afraid to learn from others.  Therapists who are willing to collaborate with other practitioners can learn a lot!  See this post for further comments on this topic: Lessons Learned

…is directly involved in your care.  Some tasks are acceptable to delegate to a physical therapy aide, but only a physical therapist (PT) or physical therapy assistant (PTA) can perform physical therapy.  If you only see your PT for a few minutes at the beginning or end of your appointment and spend most of your time doing exercises with an aide or independently, you are not receiving quality care.  The foundation of my training and education is my ability to observe dysfunctional patterns of movement and to relate those findings to the patient’s primary complaint.  It has taken me a long time to refine my observational skills and the longer I practice, the better I get.  Guiding a patient through their exercises provides yet another window of observation and completes my assessment of that person’s problem and is not something I’m willing to delegate to someone else.

…revises or progresses your treatment.  If you are not seeing changes in your condition, are doing the same exercises, or receiving the same treatment at every appointment from week one to week six, you need to consider finding a new therapist.