Pilates and Neuropathy: Finding Confidence through Movement

Megan Huston

September 2016

Pilates Denver 2016

�1

ABSTRACT

As a lifetime athlete, Opera singer, and new Pilates teacher, I esteem the fabled

adage made by the late Joseph Pilates, “Physical fitness is the first requisite to happi-

ness,” and it gives me the greatest joy to help others achieve this goal. Through the 1

unique principles of the BASI pilates Block system, Pilates teachers have a framework

for most efficiently and safely addressing clientele of varying baseline physicality and

restrictions. In the following case study, I will examine an increasingly common ailment

among our population that is not only physically debilitating, but also emotionally frus-

trating. Peripheral Neuropathy is a disorder of the central nervous system that often

results in weakness, numbness and or pain, especially in the feet and hands. Pilates is 2

a superior choice of exercise for those suffering with Peripheral Neuropathy. I have de-

signed a protocol to safely address a client with lack of feeling in their lower limbs, fo-

cusing on supportive strength training, flexibility, balance, coordination, and nourishing

movement.

Joseph Pilates. Return to Life,1998-20101

“Peripheral Neuropathy.” mayoclinic. Mayo Foundation, 20162

�2

Pilates and Neuropathy: 1ABSTRACT 2Anatomical Description and Diagrams 4Introduction 8Case Study 9Conditioning Program 9Block System 11Conclusion 15Bibliography 17

�3

Anatomical Description and Diagrams 3

Images courtesy of www.peripheralneuropathytreatments.com3

�4

• The Peripheral Nervous System is the

vast communications network that transmits

information from the brain and spinal cord

to every other part of the body, and back to

the brain to transmit information such as,

“the feet are cold, or a finger is burned.”

• Peripheral Neuropathy occurs when dam-

age to the peripheral Nervous system inter-

feres with these vital connections.

The

An-

kle-

Foot

Complex: 4

• The foot is made up of 26 bones (one quarter of the bones in the human body), 33

joints, and more than 100 muscles, tendons, and ligaments.

www.webmd.com4

�5

• There are seven short and irregular Tarsal bones that make up the heel and the back

of the instep.

• There are five longer Metatarsal bones that spread from the back to the front of the

foot, and make up the structure for the Ball of the foot. Each metatarsal connects to

one of the toes

• The Tarsals and Metatarsals provide the structure for the arch of the foot.

• There are fourteen small Phalanges that make up the toe structure.

• Bands of ligaments connect and hold all the bones in place

• There is a thick layer of fatty tissue under the sole that acts to absorb pressure and

shock from everyday movement.

�6

Major movers of the Ankle-Foot complex: 5

• Tibialis anterior- long muscle on the front of the shin, responsible for dorsiflexion of

ankle-foot.

• Extensor digitorum longus- muscle on the lateral anterior part of the leg, works to

move the ankle-foot in dorsiflexion.

• Gastrocnemius- A main muscle of the calf, works to move the Ankle-Foot into plantar

flexion. It runs to the Achilles tendon.

• Soleus- Main muscle that moves from just below the knee to the heel, works to move

the Ankle-Foot into plantar flexion.

• Secondary muscle movers: Extensor hallucis longus, Peroneus tertius, Tibialis poste-

rior, Flexor hallucis longus, Flexor digitorum longus, Peroneus longus, Peroneus bre-

vis.

Rael Isacowitz and Karen Clippinger. Pilates Anatomy p.355

�7

Introduction Experiencing numbness in the lower limbs can be extremely frustrating. Simple

daily activities such as walking, standing, and climbing steps can become cumbersome

and painful. It is estimated that 20 million Americans suffer from some form of Peripheral

Neuropathy, resulting in numbness, tingling and or pain in the extremities. Many factors 6

can induce Neuropathy: inherited genetics, physical trauma, systemic diseases such as

diabetes, kidney disorders, hormonal imbalances, repetitive stress, vitamin deficiencies,

and poor circulation; to name a few.

Those who suffer with Peripheral Neuropathy describe a feeling of lack of control

in their limbs, muscle weakening or wasting, and lack of balance and coordination. The

BASI Block System addresses each of these concerns in a well rounded session that

can easily be modified for the individual. It is important for the Pilates professional to

understand that the equipment is safe relative to the severity of the neuropathy. For ex-

ample, while performing foot work exercises it is advisable to closely monitor the posi-

tioning of the client’s feet, as the numbness and lack of proprioception can cause the

feet to move from the footbar spontaneously.

Proprioception, or the ability of knowing spatially where a moving part is in rela-

tion the rest of the body, can be challenging for the client with Peripheral Neuropathy.

When designing a program for a client with moderate to severe Neuropathy in their feet,

I held the key principles of Control, Concentration, Center and Precision close to heart.

Then utilizing the Block System, I designed a thorough and effective protocol for ad-

dressing the needs of my client with Peripheral Neuropathy affecting her feet.

www.ninds.nih.gov/disorders/peripheralneuropathy 20166

�8

Case Study

Client: Nedra Age: 67

Occupation / Hobbies: Art gallery owner, travels a lot to auctions, sitting majority of

day. Nedra used to be an avid tennis player, and swimmer.

Limitations: Peripheral Neuropathy resulting in moderate to severe numbness in her

feet, this symptom was a result of complications from the Hepatitis C Virus infection.

She has muscle weakness, and wobbly balance. Nedra has a slightly rigid and fatigue

posture. She has low back pain, and impaired range of movement on Right Rotator cuff

from a tennis injury. Nedra has acid reflux, and had bouts of vertigo and fainting in the

past.

Treatments: Nedra had surgery on her Right Rotator Cuff in 2010, and Right Hip re-

placement surgery in 2015, for which she is undergoing PT. Nedra has been under

close doctor supervision for her complications with HCV and the fainting, and has been

cleared by her physician to practice Pilates. She takes daily medication to help her gain

feeling in her feet, this often results in dry mouth. Water breaks are necessary.

Conditioning Program

• Strength training - Nedra’s muscle weakness needs regular resistance training

�9

• Flexibility - Maintaining flexible muscles is an integral part in maintaining a healthy

body. Nedra often exhibits a tense posture, and she benefits greatly from stretching

for healthy muscle function.

• Balance and coordination - In order for Nedra to feel more confident on her feet in

daily activities, we must practice functional balance in every session.

• Scapular stabilization and mobility - Nedra’s rotator cuff surgery has impeded her

range of motion on the Right side, and she has pain on the Left side. We keep Ne-

dra’s arms below 90 degrees when using resistance to avoid discomfort, and we prac-

tice healthy functional “reaching” (forward as opposed to upward).

• Correcting Fatigue and rigid posture - Because Nedra feels “unsure” on her feet

due to the numbness, she often exhibits a very rigid posture with elevated shoulders

and tight gluteals. Other times Nedra displays fatigue, or swayback posture. Working

on pelvic lumbar stability is key, and strengthening her upper back extensors by ex-

tending her upper back in sitting postures.

• Correcting gait cycle - As part of the addressing Nedra’s balance, I have looked

closely at her gait. Due to the neuropathy and her Hip Replacement, Nedra shows in-

creased supination and transverse motion in the pelvis. She has a slight “limp”. To ad-

dress her gait, we pay particular attention to the foot work block, and we practice

weighting and unweighting the feet in different exercises.

�10

Block System

�11

Block Exercise Reason for selec-tion

Desired Results

Warm Up Lie on roller and do pelvic tilts, “puppet arms”, and single leg lifts. Pelvic Curl Spine Twist Supine Chest Lift and chest lift w/ Rotation (modified with arms at sides for shoulders)

Cadillac roll-up w/ RU Bar

Spinal alignment in a supine position is great for Nedra. The foam roller is a safe stability challenge.

Warm up with stability challenge will center Nedra and focus her concentration. Turn on abdominals and hip extensors.

Foot Work Foot work on the Reformer or Cadillac

Elevating feet slightly and keep spine in a supine, neutral position. Single leg foot work to help balance strength

Elevating feet can help circulation. Pelvic alignment, lumbar stability, and fuller breathing. Strengthen hip extensors and ankle-foot complex, continue warming up

Abdominal Work

Reformer: Hundred Prep Coordination

or

Short Box Series: Round back Flat Back Tilt Twist (arms modified below 90 degrees with gondola pole)

Build abdominal strength, and endurance. Work on proprioception through coordination. Pelvic-lumbar stability and flexibility in spine.

Work on core strength and proprioception will guide Nedra through the session with a sense of precision and focus in her center powerhouse.

�12

Hip Work Hip work Series on Reformer

Or

Basic Leg Springs on Cadillac

(After 20 sessions) Single leg Supine on Cadillac

Work on proprioception, strengthen pelvic lumbar stabilizers

Greater control of Hip movement, gain a greater connection to powerhouse.

Spinal Articulation

Bottom Lift, Bottom lift with “Marching” (Shoulder Bridge prep) or and Bottom Lift with Extensions on Reformer

To work evenly on each foot, to articulate the spine in a safe range

Awareness of pelvic stability, foot-ankle control, spinal mobility

Stretches Standing Lunge with balance (arm reach in lateral flexion)

And

Shoulder Stretch Side Stretch Spine Twist (pole Series on the ball)

Or

Shoulder Stretch 1 and 2 on Ladder Barrel

Flexibility is key to healthy ROM. The stretches refresh Nedra to continue the rest of her session. We also use the stretches to practice balance.

Hip flexor and hamstring lengthening, and greater control in balance.

Shoulder stretching while balancing on a ball will increase stability and confidence. Shoulder stretching is great for Nedra’s ROM

Full Body Integration 1

Scooter Down Stretch

Scooter: Unilateral work Down Stretch: BACK EXTENSION

Working on imbalances, scapular stability, and abdominal control, knee extensor control. Strengthen upper back extensors and lengthen quadriceps.

�13

Arm Work Arms Supine on Reformer

Or

Ped-A-Pull arm series

Scapula Glide (push through series)

Working in supine neutral position, or standing neutral position. Scapula mobility in a safe ROM

Stronger upper body, connection to lats and powerhouse. Stability in pelvic-lumbar.

Full Body Integration 1 (not 2)

Stomach Massage Round back Flat Back (modify arms) Reaching

Or

Sitting Forward (Push Through series) Side Reach

Focus on breathing is beneficial for Nedra, tendon stretching, and ability to see feet in position.

Back extensor control, and length.

Greater abdominal control, trunk stability and Coordination. Ankle-plantar flexor strength, knee extensor strength.

Pelvic lumbar stability and a taller spine, better posture.

Leg Work Leg Press Standing on Wunda Chair

Or

Gluteals Side lying

Gluteals Kneeling series

Forward Lunge “prep” with the crutches on the chair for support

(after 20 sessions) Squats on Cadillac

Balance and hip extensor control and strength with the addition on pelvic lumbar stability.

Strengthen hip AB and AD-ductors with resistance.

Knee extensor strength

Balance!

Better balance and coordination, stronger bone density.

Stronger lower body and muscle development.

Lateral Flexion/ Rotation

Side Stretch Wunda Chair Lateral flexor stretching, oblique strengthening

Trunk stability and postural correction. Keeping spine in Neutral.

�14

*Finish with rest position, and some calf stretching using the wall. And Ladder Barrel

stretches, deeply breathing. Check balance and roll down.

Conclusion

It is the challenge of the Pilates professional to tailor a safe and effective protocol

that address the needs of a client with lack of feeling in their extremities due to Periph-

eral Neuropathy; and more importantly to create a pleasant experience that the client

will want to continue pursuing. Certain complications are unique to this condition- lack of

feeling on feet and or hands, medication side effects, and wobbly balance.

In following the BASI Block system, I was able to address Nedra’s specific needs

in a safe and efficient manner. It is important to keep the client, as well as oneself, safe

while using the pilates apparatus. I find that spotting Nedra during all balance chal-

lenges is crucial for her self-esteem and success. The Block system is designed to ad-

dress the body as a whole of parts that work together with proper biomechanics. When

following the Blocks, the client is warmed up and focused in on their Core, which then

Back Extension

Cat Stretch on Mat - with balance arm and leg extensions

Or

Back Extension on Mat

(after 10 sessions) Swan Basic on Wunda Chair

Back extension single arm

These extension exercises maintain Nedra’s shoulders below 90 degrees.

Challenge Nedra with resistance.

Stronger mid and upper back extensors. Better pelvic- lumbar- thoracic control.

�15

translates to greater flow, concentration, and precision in the following, more challeng-

ing exercises.

Throughout my time working with Nedra, I have had the express pleasure of wit-

nessing her gain so much more confidence in her strength and functional daily activities.

She says that she feels stronger and taller after each session!

�16

Bibliography

Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body Arts and Science International, 2014.

Isacowitz, Rael and Karen Klippinger. Pilates Anatomy. Human Kinetics, 2011.

Jauregui-Renaud, Katherine. “Postural Balance and Peripheral Neuropathy.” www.intechopen.com/books/peripheral-neuropathy-a-new-insight-into-the- mechanism-evaluation-and-management-of-a-complex-disorder/postural- balance-and-peripheral-neuropathy. 2013

Pilates, Joseph and William John Miller. PILATES’ Return to Life Through Contrology. Presentation Dynamics, 1998-2010.

“Peripheral Neuropathy.” www.mayoclinic.org/diseases-conditions/peripheral- neuropathy , 2016

“Peripheral Neuropathy Fact Sheet.” www.ninds.nih.gov/disorders/peripheralneuropathy 2016

Images courtesy of www.peripheralneuropathytreatments.com and www.webmd.com/pain-management/picture-of-the-feet

�17