Typically, when we think of physical rehabilitation we think of Physiotherapy. However, with the exceptional rise in the popularity of Pilates over the past ten years, awareness of its rehabilitative effects has increased. Doctors recommend Pilates to their clients with foot, knee, back, shoulder, neck pain and more. Physiotherapists are integrating Pilates equipment and exercises into their practices, and many are trained as Pilates instructors as well.
This interesting and growing relationship between Pilates and Physiotherapy is what we will look at more closely in this article.
Before we get underway, I want to say that there is no intention here to imply that Pilates and physical therapy are the same or interchangeable, but rather to look at the mutually beneficial relationship between the two – for clients, therapists, and instructors – as well as distinctions that need to be made with regard their approaches and limits in addressing health and disease. Also, please note that in this context we are talking about experienced Pilates instructors who are comprehensively educated in Pilates methodology, exercises, and equipment.
To get a clearer look at the differing roles of Pilates instructors and Physiotherapists, how rehabilitation is approached differently between the two, and how they can successfully work together I turned to Dr. Brent Anderson.
Dr. Anderson is the founder, president, and CEO of Polestar Pilates. He is a licensed physical therapist and orthopedic certified specialist with a Ph.D. in physical therapy. Polestar Pilates has for many years been at the forefront of the dialogue between Pilates and physical therapy. I start our interview by asking Dr. Anderson to clarify some key roles and terminology between Pilates and physical therapy.
Defining Rehabilitation and Who Gets to Do It
So often, we have advertising promoting Pilates as good for rehab of this or that — knees, backs, necks, shoulders, etc. But Pilates is a method of fitness; and the scope of practice for a Pilates professional specifically excludes claiming to diagnose, prescribe, treat or rehabilitate any injury or disease (this is true for all non-licensed fitness professionals). So I asked Dr. Anderson, What is the relationship between rehabilitation and physical therapy and what the appropriate use of the term rehabilitation?
Rehabilitation, Dr. Anderson says, is the medical arm of restoring function. “You have to be a licensed professional to say you offer rehabilitation. Physical therapists, chiropractors and speech therapists, for example, are licensed so they can offer rehabilitation. Since they are not licensed, Pilates, yoga, movement instructors in the United States cannot say they offer rehabilitation. To get even more specific, physical therapists are the licensed professionals who can offer rehabilitation through physical therapy and physical therapy is exclusive to them.”
What Pilates teachers can do, Dr. Anderson suggests, is say they provide post-rehabilitation or wellness education.
We are talking now about legalities in the United States because, as Dr. Anderson points out, “these rules have been defined by the states and the professions and all the lobbying that goes on to protect their special interests”. They do not apply in most other countries.
Pilates Has Roots in Rehabilitation
It is quite relevant, Dr. Anderson points out, to look at the history of Pilates in terms of rehab. Rules regarding scope of practice and what can and cannot be called rehabilitation were not in place when Joseph Pilates began to develop his work in WWI as a prisoner on the Isle of Man. Pilates took injured and sick people through exercises with the definite intention of rehabilitating them.
Later, as Pilates’ studio in New York City grew, it was in large part because Joseph and his wife Clara were rehabilitating dancers. Pilates Elders Carola Trier, Ron Fletcher, and Eve Gentry were among many dancers who went to Joe for rehab.
Further, Pilates equipment was designed to address rehabilitation – to take people through ranges of motion they couldn’t do against gravity. Dr. Anderson gives an example: “if you could not hold your arm up against gravity, you could suspend the limb. You could lay on your side with your arm connected to a spring or a chain, and you could move your arm forward and backward without the effect of gravity on it and start re-engaging muscle fibers. That’s the trapeze table. And on the reformer, if you couldn’t stand or squat on your legs, you could set it to a lower spring and still have the closed chain effect of squatting and moving. So Joseph Pilates’ work had an element of rehabilitation built into it.”
Two Views of Pilates in Physical Therapy Today
Today, as Dr. Anderson reports, thousands of physical therapists are utilizing Pilates. Some are fully trained in Pilates and incorporate the entire holistic philosophy into their practice. We’ll talk more about that later. Other physical therapists take what Dr. Anderson calls “a smorgasbord approach”. This, he describes as a therapist using a few Pilates mat exercises or utilizing the equipment on a limited basis — essentially using Pilates in bits and pieces as part of to a more a traditional, allopathic approach to physical therapy. In that approach, the idea is to identify a pathology and rehabilitate it from a localized point of view.
Dr. Anderson offers the example of the sequence of events a traditional physical therapist might use with a client who has shoulder pain: “We start looking at the shoulder and if there is shoulder pain, we look at the rotator cuff to see if there is a rotator cuff injury. If we think there is, we treat the rotator cuff. If it doesn’t respond, we go on to injections or, heaven forbid, surgery.” He goes on to contrast the “start with pathology and pain” scenario with the holistic approach a Pilates teacher or physical therapist who integrates the Pilates holistic philosophy into their practice might take, which is to start by looking at overall movement patterns and compensations.
Though Pilates does have rehabilitative effects where we point to benefits to one part of the body or another, many of us bristle at the smorgasbord approach within Pilates itself. I ask Dr. Anderson if it makes any sense at all to say “Pilates for this or that…” Pilates for back pain, for example.
Dr. Anderson’s view is that as a general rule, a holistic, comprehensive Pilates class is going to make a significant difference in a clients’ quality of life. Where it makes sense in Pilates to talk about the uniqueness of a specialty population is in terms of precautions and contraindications. If you have a special population, perhaps someone pregnant or healing an injury, Dr. Anderson says: “There are certain things you are going to avoid or modify in your holistic, comprehensive Pilates class. So if you’re telling them things that are especially good for them, and a few things to take precaution with, then by all means that is appropriate. To use Pilates to isolate body parts, for example, to use Pilates to only do knee exercises, is a little ridiculous because it defeats the whole purpose of the philosophy.”
Pilates and Physical Therapy as a Continuum of Healing
There is a scale of strategic healing Dr. Anderson says is used in Polestar training that shows us how Pilates and physical therapy are different, but also where they can meet on a continuum of healing for the client. “Restriction of any kind”, he says, “psychological or physical, leads to compensation patterns. Those compensations lead to malalignment or deformation. Then, people manifest pathologies that lead to pain.” And here is where Dr. Anderson makes an important distinction between traditional physical therapy and Pilates: “Traditional medical professionals are going to address pathologies and pain. A Pilates teacher is not looking at pathology. A Pilates teacher is looking at overall alignment, at articulation and mobility, at control, at balance and fluidity”.
This is not to suggest that physical therapy is wrong or coming from an outdated point of view. Dr. Anderson also affirms that there are structural problems that need manipulation, or surgery, or some kind of structural fix. The opportunity is to see Pilates and physical therapy in terms of a strategy of healing that starts with overall movement patterns and compensations, which is in the realm of Pilates. If that is not working or there is clearly a structural issue, the client needs to move into physical therapy. After physical therapy, Pilates can provide cost effective post-rehab benefits.
Next, Pilates Instructors and Physiotherapists Working Together
Ideally, the dialogue between Pilates instructors and physical therapists is organized around the needs of the client and benefits each professional as well. Dr. Anderson looks at the potential flow of clients between physical therapists and Pilates instructors this way: “There is no physical therapist in their right mind that would suggest hanging on to a patient forever to keep working with them. And there should be no Pilates teacher that thinks they’re the end all, that there is no structural problem that they can’t fix, because there is and they need the physical therapist and the doctor, chiropractor and osteopath to be able to help them in delivering care to the most important person which is our client.”
What we need, of course, is communication between Pilates instructor and physical therapist. I ask Dr. Anderson whether that kind of give and take actually happening. His answer is a definite yes. “We have physical therapists who have good comprehensive Pilates skills and they can work fairly independently but they tend to refer to the Pilates teacher to transition their patients out of the physical therapy spectrum because they know the client needs something more affordable. They need movement classes and they [the P.T.s] want [the client] to take them with someone trained in post-rehabilitation. So we see that relationship strengthening, he says.
Dr. Anderson also suggests that physical therapists and Pilates instructors enhance their own work, gain confidence about referrals, and be more informed on behalf of their clients by observing and experiencing each other’s work. Basically, don’t be shy. A Pilates instructor can call the physical therapist and ask about movement agendas and contraindications. They can go observe their client in a physical therapy session. Similarly, the physical therapist should experience Pilates before deciding whether or not Pilates is good for their client.
As extra encouragement for the Pilates teacher who might be intimidated by contacting a physical therapist, Dr. Anderson reminds us not to assume that all therapists are created equally: “Somebody who doesn’t want you to come observe their treatment is probably not giving very good treatment or is incredibly insecure. It’s like heaven to me to have a teacher take the time to come see me.”