As Pilates teachers, most of us have had clients who have had some form of arthritis. In fact, arthritis is the most common chronic condition in the United States affecting 40 million older adults, about half of all people over the age of 65. There are over 100 kinds of arthritis, some that affect children as well, but the most common is osteoarthritis – the uneven wearing down of cartilage and other cushioning structures, as well as inflammation in and around the joint that cause pain, stiffness or swelling. Inflammation is sometimes due to the drying around a joint, less moisture, less fluid, less nourishment. It is considered the nation’s most common cause of disability. The photo below shows the structural change of a joint with arthritis.
Arthritis means, “joint inflammation” and may affect one or more aspects of a joint. The degree to which joints are affected by arthritis varies considerably among the various rheumatic diseases. Most rheumatic diseases are chronic; however, they can be managed through proper treatment. When a joint is inflamed, it appears red, swollen, warm and tender to the touch. The joint also will lose function. The loss of function may even persist when the inflammation subsides. Many medications can reduce inflammation and pain improving the ability to use the joint. But for the last 20 years, the Arthritis Foundation has recommended ‘movement as the best medicine’.
If exercise is an important component in the comprehensive health care management program of an individual with arthritis, we need to ask some important questions: What kind of movement will help and not exacerbate an already painful condition? How can Pilates instructors help these clients? Are there specific Pilates exercises that are ideal for these clients?
In this article, I will review Pilates components of physical fitness that are beneficial to an individual with arthritis, share some general guidelines from the Arthritis Foundation that address exercise safety and effectiveness as well as share some specific Pilates exercises and tools that I have found useful in the 10 years that I have spent teaching Pilates at a retirement center in Tucson, Arizona.
Clients with arthritis are reluctant to engage in physical activity because of pain or fear of pain, fear of worsening symptoms or damaging joints. The problem is that rest and lack of exercise or activity may lead to muscular atrophy and a decrease in joint mobility, which is precisely why exercise is now recommended. It is apparent that there is a lack of information from Pilates and other fitness professionals about how to engage clients to move beyond fear toward better health through optimal movement. It starts with educating your client about why Pilates is different from exercises that may hurt them and why Pilates is good for joint health. The chart below is a reminder to our clients about the answers to the ‘why Pilates?’ question.
Pilates = Joint Health
We understand the concept of stabilization as well as various exercises that strength and stretch all muscles around a particular joint will mean that the joint capsule or joint articulations will anatomically fit better and will wear more evenly.
We understand that Pilates works subtly from the inside out, starting with deep stabilization muscles that create inner warmth and then moving toward the more superficial and distal muscles with just a few repetitions of many kinds of movements. Many different exercises for one joint help to ensure an equal balance of strength and flexibility from all angles.
We know that the more we move and breathe, the better the circulation around the joint which carries nourishment and moisture to the joint for better functioning and healing.
Our movements are not quick (i.e., tennis) or high impact (i.e., jumping rope, running). Our movements are smooth and controlled with no impact.
Pilates/Fitness Components that Help Promote Joint Health
Research from the Arthritis Foundation confirms that the components of physical fitness that help clients with arthritis are: muscular endurance, cardiovascular endurance, range of motion/flexibility work, posture/body mechanics, balance, coordination, body awareness training, breathing techniques, and relaxation techniques.
Flexibility exercises relieve stiffness and help restore movement through complete PAIN FREE range of motion, prevent loss of motion and deformity and minimize stiffness. In the photo below on the left, the client is holding a dowel behind her back as an awareness tool for better posture, but holding the dowel in this way is also good for flexibility around the shoulder girdle and upper arms, wrists and hands. The right triceps and left rotator cuff muscles are being stretched. The hand position can work up or down the dowel as flexibility improves. The arm position should be switched to balance the other side of the body.
Muscular endurance exercises ensure that the weak muscles around a joint are strengthened. This can be done through isotonic exercises or those that involve resistance (i.e., springs, Tye4, Magic Circle, bands, weights) or isometric work (i.e., stabilization of pelvis or shoulder girdle) that we do so often in Pilates. In the example of the picture below, the client can gently and oppositional pull (isometric contraction) on the dowel to strengthen those muscles in and around the shoulder girdle. Isometric work is ideal when a joint is inflamed.
Cardio activities such as bicycling, walking and swimming are also good as long as the individuals with arthritis have guidance on the appropriateness of these exercises and how to proceed safely. This is where we can teach proper form and alignment in gait, swimming (on the barrel or mat) and bicycling (on the Cadillac).
Posture and body mechanics training (shown in the photos below) is very important in lying down, sitting, standing, and moving as in gait. Transitioning from any of these positions is equally important. In the right photo below, the clients are transitioning from a seated position on the reformer to a standing position and then back to a seated position. This exercise is a basic squat. It is important that the client keeps a neutral spine throughout (this can be done with or without the wooden dowel, weighted dowels or other weights are not recommended).
Narrowing the foot position in squats will challenge Balance training. However if the knee or hip joints are painful, keep a wide secure foot base and move the hips and knees in the best PAIN FREE range of motion. Limit abduction of the hip if there is pain.
Coordination activities (e.g., holding the dowel behind the back while standing) are excellent to help teach stabilization of one body part (the body part that is sore and maybe only needs isometric contractions) and mobilization of another part. This also helps develop focus and awareness.
Awareness training helps a client get in touch with where the body is in space and in relation to other body parts. (e.g., flexing one knee and then the other and noticing any differences).
Emphasize deep breathing while practicing and performing the exercises. We do this well in Pilates, but now, we are reminded that deep breathing moves oxygen as well as other nutrients to all cells in all joints of the body to aid in nourishment and joint health.
Teaching Relaxation Techniques such as progressive relaxation or guided imagery can help the client to manage pain as well. (See articles on Teaching Relaxation Techniques.)
An example of a Pilates exercise with a client who has inflammation in spine, hips.
Client holding a dowel for postural awareness while standing/sitting.
Pilates Exercises for Specific Arthritic Joints
- Spine – Pelvic Clock and modified articulating bridge for spinal arthritis
- Shoulders – Shoulder rotations, gradually moving to Ribcage Arms, Snow Angel Arms and Arm Circles using no or low resistance.
- Wrists and ankles – Open chain wrist and ankle rotations with no/light resistance (band).
- Knees – Seated knee extension (with band to aid in range of motion), or footwork with light springs.
- Hips – Limit hip abduction. Add adduction by squeezing a ball or Magic Circle between the thighs while lying in Bridge position. Hip abduction can exacerbate hip arthritis.
- Hands – Light pressing of the hand (one at a time), base of the fingers and fingertips on a ‘spiny pod’. Keep the base of the hand lifted to keep wrist angle aligned. Let the client do the work. They will know how much pressure. Even a little pressure allows for an isometric contraction.
- Feet – Light pressing of foot (one at a time) on the ‘spiny pod’. Tennis balls work also but the ‘spiny pod’ gives both stability and more proprioception which I believe allows for better circulation.
Pilates General Guidelines for Clients with Arthritis
- Encourage clients with arthritis to exercise their joints daily.
- Inflamed joints should be moved gently through the range of motion.
- Always begin with a warm-up of slow exercises (i.e., fundamentals).
- Keep the room warm. Use warmed towels as props. Heat relaxes joints and muscles and helps relieve pain.
- Keep the rhythm of the exercises slow and steady. Allow rest time between exercises.
- Clients should be encouraged to attempt full range of motion, PAIN FREE movements. These exercises may not improve range but further restrictions may be prevented.
- Breathing in a normal deep rhythmic pattern should be encouraged, especially the classis Pilates breath of in through the nose to warm, moisten and filter the breath and out through the mouth to encourage the deep core stabilizers.
- Encourage clients to move at their own pace and listen to their bodies. If anything hurts, then stop.
- Exercises should be done at low resistance with two or three repetitions, working to five or six repetitions.
- Avoid manual cuing or assisting stretches by manipulating limbs; leave that to a qualified physical therapist.
I have found that the Rehab Reformer (a reformer carriage that is high like a Cadillac table) is ideal for working with clients with arthritis. It is easier for the client to sit, stand and lie down as well as for the instructor to maintain proper body mechanics while acting as a support for the client. If a higher Reformer (carriage) is not available, use the Cadillac more. Especially for clients who have arthritis in the hips and/or knees, it is easier to limit deep flexion that can cause pain. I always tell the client when transitioning from lying to sitting to standing (or the other way around) to stabilize the core by pulling in the abdominal, only bend from the knee and or hip, and use only the “powerful leg and hip muscles” to move. It becomes increasingly important to repeat these reminders often for those clients with arthritis in the spine. Verbalize biomechanical ideals as a reminder to both client and instructor.
Keep plenty of “comfort props” for clients with arthritis. I have blankets, pillows and bolsters that I use for some of the floor work. I keep a sturdy chair at hand to help clients descend to the floor or rise from the floor. As mentioned earlier, warm towels for props at the neck and under the knees. Certainly warming the carriage on the Reformer or Cadillac Table will help cold joints relax. If there is inflammation in the joints, just help the client by encouraging deep breathing, some gentile stabilization awareness exercises (e.g., hold and release tension in various joints) and talking them through progressive relaxation techniques or guided imagery.
In this article, I have included some general guidelines as well as some specific exercises to help Pilates instructors feel more comfortable working with clients who have arthritis. I encourage you to share these guidelines with your clients as well as try some of the specific recommended exercises during the Pilates session. If your clients know that you are working to become more knowledgeable about their conditions, they will feel cared for and safe. They will see that their goals of relieving joint stiffness, restoring or maintaining joint range of motion, maintaining strength, improving posture are being met and they will tell their friends! Good luck with building this new, most important client base.
Arthritis Today (2012) Retrieved October 12, 2012, from http://www.arthritis.org.
Missey Osgood, J. (2012, August) Progressive Relaxation Techniques. Retrieved August 15, 2012, from http://www.themethodpilates.com.
Pilates, J. H., Miller, W. J. (2000). A Pilates’ Primer: The Millennium Edition. Incline Village, NV: Presentation Dynamics Inc.