In regard to LA's post. If a Pilates teacher is educated and works with in a specialized field of movement there is no reason why they should not be able to diagnose or prescribe exercises to fix those particular issues. Those particular issues also share the same anatomical names that are diagnosed by the medical industry.To a doctor it is an SI joint problem, to me it is a postural problem. He treats with physical therapy and medication, I throw them on a reformer and fix their alignment.
I am very clear that my area of expertise is postural alignment and physical strengthening. It is within those parameters that I diagnose and prescribe the proper exercises to fix those particular issues.
I think Pilates teachers have to be clear on how they choose to practice, so as not to overstep their boundaries of education and experience.

Hi Stacy,
Individuals need to be licensed in the majority of states to "diagnose," evaluate or "rehabilitate." We do feel as you state that most well-trained Pilates instructors have the knowledge and tools to facilitate movement, and Pilates is inherently rehabilitative in nature. Assessing postural imbalances is within the scope of practice and an alternative way to describe what well-trained Pilates instructors do to stay in line with the legal and scope of practice guidelines with the use of these terms.

Thanks,
Dawn-Marie, Allyson, Gabrielle

Valerie emailed in with three questions. See the answers below.

1. 75-yr-old male with very arthritic shoulders, very limited range of motion. Anything I can do for him to help alleviate pain? 

Your fitness goals with this gentleman should gear towards maintaining and improving function by encouraging pain free range of motion.  Thoracic mobility/flexibility has a driect relationship with shoulder elevation so postrual exercises and those promoting good thoracic spine motions would benefit him. (ie foam roller, spine corrector and other Pilates exercies focussed on segmental motion)  Be sure that he has no other pre-existing conditions which would be contraindicated for this type of motion.
 
2. 51-yr-old female with neurosarcodosis, wheelchair bound, a lot of spasticity mostly lower body. ANY suggestions! 

First and foremost, this client should have a team of medical professionals who can guide you with indications and contraindications specific to her case. With the variability of prognoses for individuals with neurosarcoidosis it would be difficult to make specific suggestions. The most important factor is maintaining function and mobility. Since she is WC bound UE activities and seated trunk work would be wonderful.  (ie try 100's in sitting, chest expansion, chariot, hug-a-tree)
 
3. My studio is in a gym that also has a PT. Any way we can share these people so that insurance will cover their sessions? I do mostly Feldenkrais with the woman and she has financial problems, but I don’t want to send her away as she is feeling better and more mobile and relaxed! 

The only legal and ethical way for insurance to cover sessions being billed for PT is for them to be provided by a physical therapist. We have seen a few rare cases of insurance companies covering preventative/adjunctive exercise therapies such as Pilates and Feldenkrais, however you would have to obtain authorization directly from them.
 
Thanks,
Dawn-Marie, Allyson, Gabrielle

Hi CC PTs,

Thank you for your very thorough and informative reply to the question presented about golfers and SI Joint Dysfunction. You were indeed correct about this particular case involving "hypermobility" in the joint. Since "hypomobility"was mentioned in your discussion, may I inquire how you might work differently with a client who presents with this form of SI Joint history? Is it possible for the sacrum to be "hypermobile" on one side while "hypomobile" on the other side? I also want to use this opportunity to acknowledge the spirit with which you offer information and share ideas based on your experience and education. I am very confident that my pilates certification and subsequent cec workshops, which recently have more of a "therapeutic base", have prepared me well to work with "special populations". I enjoy and seek a range of ideas and methods for working with clients so thank you for providing that opportunity.

Kathy

Hi Kathy,
It is absolutely possible to have an SIJ hypermobile on one side and hypomobile on the other. For hypomobility of the sacrum, first you need to clear the joints above and below. You need to make sure there is not hypermobility in the lumbar spine. If so, address that first with lumbar stabilization exercises. One great exercise that comes to mind for hypomobility is to put a 6" rubber ball under the sacrum and rest for a minute or two and then you can add in knee folds, bent knee fall outs etc. Any exercises that stretch and mobilize the pelvic region are beneficial keeping in mind the above comments about the lumbar spine.

Thanks,
Dawn-Marie, Allyson and Gabrielle

Hi Ladies, thank you all the hard work you've put into these posts, the amount of detail and specificity shows clearly how dedicated you are to getting information out to the Pilates community. I don't have a question, I really just wanted to comment to those people who have posted regarding scope of practice and the whole "fundamentals of core stability" discussion. This is supposed to be a forum for Pilates professionals who are looking for information about specific body conditions and ways to help clients. I think that there is a basic understanding that we all (should) share, thus allowing the discussion to be at a higher level. The Core ladies did not agree to write a column on "the basics of Pilates." If someone doesn't understand those basics, they should be pursuing their education elsewhere. I think the ladies indicated that very politely, but there was some definite hostility which is very unbecoming in this forum. Likewise, any good Pilates instructor knows that if a client comes in with severe problems, that client should be referred to a medical professional. No one wants to cause injury or exacerbate existing problems. However, within the scope of many of our practices we get clients who have been discharged from physical therapy or referred to pilates by their physicians. We cannot treat them the same as all other clients, therefore we need to expand our understandings of the human body with each new client and condition.
I feel like this month's Pilates on call has included a lot of judgmental postings that don't show appreciation for how intelligent the experts are and how much they are trying to help. I just wanted to let them know how much the rest of us appreciate their contributions.

Jessica,
Thanks for your comments. Scope of practice is an important topic in this industry. If anyone would like to continue a discussion on the theme, I suggest starting a thread in our Community area so we can keep this discussion on track with Q&As about joint injuries and issues.

Thanks!
Amy
Editor

Hello, I have been doing Pilates for almost two years now. However for some reason every now and then my right hip makes poping noises during things like single leg circles, double-leg stretch and scissors. Lately it's been alot worse. However sometimes it does not even pop at all? I find that sometimes specific hip stretchs can lesson the popping a little but the effect is always temporary.

Why would my hip be popping and how can I eradicate this problem?

Thanks!

Hi Sammy,
This is called "snapping hip." It is most likely due to the psoas tendon moving as it goes from a shortened to lengthened position. In general, this is usually not painful. Is yours? We tend to run with the theory of "if it ain't broken, don't fix it." Continue to stretch the hip flexors and lumbo-pelvic muscles in general and make sure you are engaging your core vs. overusing hip flexors in those particular exercises. Keep all range of motion within pain-free ranges.

Thanks,
Dawn-Marie, Allyson, Gabrielle

AS a Pilates instructor, we do see a variety of conditions and should know how to modify for them within the context of knowing and understanding how the Pilates system of exercises is adaptable to the human body and works in a wholistic and simplistic way. Pilates Instructors are like conductors of a symphony and when we teach we should know the instruments we are working with (bones,muscles) and how they work in concert to produce movement. Since many muscles are involved to produce even the smallest movement, it is very difficult to diagnose exactly what muscle is directy responsible unless specific tests are applied or diagnostic equipment is used. Unless there has been a specific acute trauma from a fall or some other outside force, most of the time dysfunctional muscular patters are caused by some muscle doing too much and others not doing enough, which over time results in injury at the joint. The Pilates Method works even by default and if one does nothing but apply the system of exercises keeping in mind the principals of alignment, focus of intention and breath while making accomodation for every individual, those individuals will see marked improvement in coordination of motor skills and movement patterns.

http://aasicontributions.blogspot.com/2009/06/pts-on-ppro-continued.html

see posts from 6-11-09 and 6-25-09.
Carole : )

I have a client when doing chest expansion she can pull back no problem but when she adds the looks of the head she feels pain behind her right shoulder blade. It is the only exercise this happens on. Any suggestions on what is going on here and what I can do to help her? As of now I just have leave the head out of it. Thank you!

Hi PD,
Many of the muscles have attachments to both the scapula and the cervical spine. Most likely one of the muscles she is using (contracting) while retracting her scapula is pulling on her cervical spine, which is then causing a change in how her neck functions. The wise choice is to do what you are doing and leave the neck rotation out of this particular exercise.

If she needs further help, this seems like one of those situations where she needs to be referred out for an evaluation of what might be going on in her neck. Most likely the pain in her scapula is referral pain from her neck (either a facet issue or discogenic). If she has no pain any other time and has no issue with her neck in general, then not being able to do one exercise does not need to be an issue.

Thanks,
Dawn-Marie, Allyson, Gabrielle

Hi! Thanks for this great opportunity!
First, sorry for my English (I'm from Argentina) but I'll do my best.
I have a new student who broke her fibula and sprained his ankle three months ago. She started Pilates but still does her rehabilitation, in fact, she does Pilates for the rest of her body and not only for her feet, but I really like to help her or do something beneficial for her recovery. In fact, in her rehabilitation, she does very strong exercises. What kind of exercise she will try? I know she is in pain yet, but maybe I can introduce her slowly in some exercises like footwork or single leg stretch.
I'm very appreciative your help.

Thank you very much.

Bárbara

Hi Barbara,
Firstly you should have a conversation with her therapist and see what is indicated at this point in her rehabilitation. You certainly can be strengthening her hip musculature in open chain, such as clams, hydrants, kick backs and any side-lying leg work. If she is cleared to work on her ankle, start in closed-chain for LE strengthening. Using the jumpboard, perform bilateral and unilateral footwork with special attention to foot articulation and alignment through the feet, working on heel-toe translation. Any LE work that focuses on unilateral strengthening and facilitates proprioception is good.

Thanks,
Dawn-Marie, Allyson, Gabrielle

Thank you for your comments. I was not aware that diagnosing postural imbalances and prescribing corrective exercises were regulated on a state by state basis. I live in PA where there are no regulations pertaining to that type of practice.

Hello,
I have a client who recently (3 weeks ago) started running. She is starting slow (walk/run)doing a program to build up to 2 miles over the course of 2 months. She has recently started to get shin splints on her left shin. Is there any specific I can give her to help her with the pain so she can reach her goal of 2 miles on time? She is about an int/adv level in Pilates and has been doing it 9 years but is new to running.
Thank you so much for all your knowledge and advise this month!

Hi FL Pilates,
Shin splints can be caused by a variety of issues. Sometimes it is due to tight calf muscles such as the gastrocnemius and soleus muscles. When the plantar flexors are tight, the dorsiflexors (tibialis anterior) have to work harder to counteract the tight muscles. In addition to tight calf musculature, there also may be eccentric weakness of the posterior tibialis, therefore eccentric strengthening of that muscle would be beneficial--try heel raises focusing on a slow return back to the floor. This could be performed bilaterally or unilaterally standing or on the jumpboard doing closed-chain footwork.

What is a little concerning, however, is that your client is getting this so quickly in her training with low mileage and while doing a run/walk. Some other things to think about are the route she is training on. Is it flat or are there a lot of hills? What footwear is she using? It is imperative when starting a running program to specifically use shoes that are biomechanically correct for your foot architecture. Does your client pronate or supinate? It may be beneficial for her to go to an athletic shoe store where they analyze your feet and also look at how you move through your feet from heel strike to toe off while running and walking.

If this does not seem to help, it may necessitate a visit to a podiatrist or foot specialist for an orthotic consultation.

The bottom line is to start with good shoes, an even route, and stretch and strengthen the calf musculature and consult an orthotist if need be.

Thanks,
Dawn-Marie, Allyson, Gabrielle

I am a beginning Pilates instructor.I have a new client who is 17 and has a tilted knee which prevented her from her favorite track and field last year as her parent told me. She also has very tight hamstrings, oversupination and very high arches. Any suggestions on what I can do to help her? Any direction? Thank you!
-Tatiana

Hi Tatiana,
Patella tilting can occur in varying positions and degrees, the most common being laterally. it is unclear from your question how the patella is tilting.

Firstly, did your client have formal rehabilitation with a professional? If the patella is tilting laterally, specific strengthening exercise should have been prescribed which target the LE musculature, specifically the quadriceps with an emphasis on VMO (vastus medialis oblique) activation. Using an adductor component with a quadriceps contraction will enhance the contraction of the VMO. Exercises that use a 6" ball between the ankles with footwork, or magic circle with leg in the strap work will help facilitate these muscles. Also hip stabilization exercises are very important and effective in this situation. If she had formal rehabilitation it may be of benefit for you to contact the professional that treated her for specific information since it is difficult with this minimal information to know the specific causes of her dysfuction. In addition, specific taping techniques can be employed to reduce the effects of the tilt and can eliminate some of the negative effects. Usually McConnell taping is utilized. A rehabilitation specialist can teach your client how to do this so that she can advance in exercises more quickly and with less or no discomfort.

Some things you can focus on would be performing LE strengthening exercises in closed chain on the jumpboard focusing on LE alignment--2nd toe to patella to ASIS and pelvis in neutral. Foot articulation on the jumpboard, wall slides with a ball between the knees, single-leg balance activities monitoring alignment, hip abducion and adduction activites all closed chain if possible (standing splits). When performing the exercises, they should always be pain-free and with good alignment.

In terms of the supination, this client may be a candidate for custom orthotics. In terms of hamstring tightness, instruct her in self stretches and choose exercises that lengthen the hamstrings, such as leg in the strap making sure the tailbone remains in contact with the mat surface and getting pure lengthening of the hamstrings from the ischial tuberosities.

Thanks,
Dawn-Marie, Gabrielle and Allyson

Thanks so much to our June Pilates on Call hosts—Dawn-Marie Ickes, Allyson Cabot and Gabrielle Shrier of Core Conditioning—for taking time from their busy schedules all month to respond to our readers' questions. And thanks also to all who participated. We hope these questions and answers will be a continued resource to the Pllates community.

We're looking for suggestions for upcoming Pilates on Call hosts. If there's someone you'd like to hear from, send nominations to editor@pilates-pro.com.