• Cervico thoracic stability

• Chronic pain

• Pelvic floor

This module introduces the trapeze table, adding to the reformer and matwork repertoire:

• Shoulder girdle, upper body and combined stability exercises
• Broadening of reformer exercises and matwork
• Attention to manual handling & teaching cues
• Introduction to small barrel & spring wobble board

Clinical applications and pathology management:

• Hypermobility / instability identification and management
• Direction bias assessment techniques
• Chronic pain and systemic autonomic management
• Simplifying the “complex pain” patient
• Integrating evidence on pelvic floor in males and females
• Using outcome measures with Clinical Pilates
• Recording within subject / within session changes
• Programme development using real time case studies
• Introduction to CPMATE software
• Surgical selection and surgical avoidance criteria
• Strategies to address Health Reform changes

UNIT A.

MODULE 1

The Clinical Pilates approach continues to develop as the literature constantly evolves. These changes have occurred in light of research moving the focus towards impairment based management heralding the introduction of MBCT (Movement Based Classification & Treatment) as the traditional structure based classification model is no longer supported by the literature.

Health reform has also highlighted that chronic problems need a more cost effective treatment framework based on strong outcome prediction. The unique MBCT patient subgrouping tool is introduced in this stage of the course. MBCT allows heterogenous, patient specific exercise treatment programmes to drive more successful management.

Over the last 15 years there has been a growing body of literature rebutting training of isolated muscle activity i.e. transversus/multifidus (Macdonald, 2006, Alison 2008, Morris 2013) with the focus now on function, not isolated muscle. This change in focus is further borne out by current motor control literature which does not support conscious (explicit) muscle training, finding it is not particularly robust, with more support for non conscious, task orientated (implicit) muscle control training (Benjaminse 2011).

The Clinical Pilates programme has long embraced the shift towards function, with clinical outcome prediction rules recently validated by Tulloch et al at Otago University (Tulloch E 2012). The simple clinical tests used in this paper highlighted a new process for identifying a patient’s subgroup & managing functional/proprioceptive changes based on that subgroup. These proprioceptive deficits are often identified as the underlying cause for many structural injuries as seen with recurrent injuries, ACLs, falls etc.

The MBCT predictor algorithm, introduced in this first module has near perfect inter rater reliability,(.87 Kappa) showing robust agreement in a broad cross section of DMA trained clinicians (Tulloch E 2012, Yu K 2015). The key to this predictor algorithm lies in using a process of heuristics & “pattern recognition”, as described by Wainner (2007).

Cardiology literature has used pattern recognition and led the way in simplification of the diagnostic process, proving that clinicians can effectively predict patient treatment outcome based on 4 key points. Heuristic information is more effective than the traditional barrage of tests, which ultimately contradict each other, confusing rather than clarifying the diagnosis (Reilly, Goldman, Chin 2006). Directional exercise treatment application, already proven with the McKenzie approach, completes the components that are taught at this stage of the programme, that make up the subgrouping process.

A Melbourne University, RCT showed a measurable (46% vs 29%, p=0.07) finding that a Clinical Pilates programme was better than a general exercise approach, in a chronic, low back pain population over a relatively short 6 week period. The current approach to patient management now being proposed with Clinical Pilates training now follows 2 pathways :

• In the ACUTE injury phase, a structural micro management approach is applicable for 6 – 12 weeks, during which tissue based, manual therapy and homogenous exercise       is the focus of treatment
• In the CHRONIC phase, the focus moves to a macro-management, impairment based approach, addressing function with heterogeneous exercise programmes that are patient specific and can be measured for efficacy.

Allison GT et al (2008) Feedforward Responses of Transversus Abdominis Are Directionally Specific and Act Asymmetrically: Implications for Core Stability Theories JOSPT, May 2008 vol 38,5
Morris S, Lay B and Allison GT (2011) Corset hypothesis rebutted — Transversus abdominis does not co-contract in unison prior to rapid arm movements http://dx.doi.org/10.1016/j.clinbiomech.2011.09.007
Benjaminse A, Otten E (2011) ACL injury prevention, more effective with a different way of motor learning? Knee Surg Sports Traumato Arthrosc (2011) 19:622–627
Wainner R et al (2007) Regional Interdependence:A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther ;37(11):658-660.
MacDonald D, Moseley L Hodges P (2006) The lumbar multifidus: Does the evidence support clinical beliefs? Manual Therapy 11
Reilly, B, Evans A (2006) Translating Clinical Research into Clinical Practice: Impact of Using Prediction Rules To Make Decisions. Annals of Internal Medicine Vol 144 • No 3 207
Tulloch E, Phillips C, Soles G,Abbott H (2012) DMA Clinical Pilates Directional Bias Assessment: Reliability and Predictive Validity J Orthop Sports Phys Ther :42(8): 676-687
Wajswelner, H, Metcalf B, & Bennell K. (2012) Clinical Pilates versus General Exercise for Chronic Low Back Pain: A Randomized Trial. Med. Sci. Sports Exerc., Vol. 44, No. 7, pp. 1197–1205.

MODULE 2

Module 2 develops on the treatment prediction algorithm taught in module 1 to cover 3 main topics:

• The use of the directional model in assessment
• Identifying and managing “complex” chronic pain/central sensitization / dysautonomia
• Implicit motor control training of pelvic floor in females and males – beyond the “bowel and bladder”

Many musculoskeletal assessments aimed at a structural diagnosis are found to be not structurally specific. (Cook 2010) Added to this, many tests are carried out in a position or direction that may lead to a false finding, e.g. a positive hamstring sign with patient in supine that is absent in prone, despite the same muscle being tested, or a positive hip quadrant that eases when the patient is tested in elbow prop, a position of potentially greater impingement. Directional assessment tools may be a better process of testing “structure” as a differential diagnosis (Hughes 2008).

The chronic patient population is causing significant concern in the current health models and “central sensitization” appears to be a major contributor to this problem (Janig 1996). The relationship between hypermobility and dysautonomia (disturbance in autonomic function) is a common finding in the “chronic/sensitized group” and a strong body of evidence exists that highlights the link to hypermobility, mechanical spinal cord pressure and cervico thoracic trauma. These patients are often classified under a wide range of diagnoses such as Chronic Fatigue Syndrome/Fibromyalgia/ME/IBS and the like. Ironically the symptoms are all very similar (Gazit 2003).

While exercise is strongly promoted with the chronic pain population, a directional subgrouping model, is paramount to minimize symptoms directly related to spinal cord compression (Karlsson 2006). A checklist of symptoms including nausea, dizziness, postural tachycardia syndrome, postural orthostatic intolerance, low blood pressure and gut disturbance can highlight this potential co-morbidity, which often seems to underlie chronic conditions.

Pelvic floor literature is also addressed in this stage of the course, looking at the effect of inappropriate “core stability” strength training on pelvic floor muscle (PFM) function in both males & females. Traditional “bowel and bladder” questions for cauda equina, a presentation very rarely seen, can highlight a strong connection with dysautonomia. Excessive cueing of pelvic floor activity can be detrimental in the absence of any dysfunction and equally ineffective when there  is frank dysfunction (Thompson 2006). Implicit motor training processes, incorporating inspiratory breathing control, provide a more efficient method of PFM training, which is highlighted using real time ultrasound.

This module builds on the module1 knowledge to incorporate the systematic use of outcome predictors with outcome questionnaires to measure the efficacy of the clinicians decision making process and treatment selection.

Hughes PC, Taylor NF, Green RA (2008) Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Australian Journal of Physiotherapy 54: 159–170
Gazit, Y., Nahir, A. M., Grahame, R., & Jacob, G. (2003). Dysautonomia in the joint hypermobility syndrome. The American Journal of Medicine, 115(1), 33-40.
Karlsson A (2006) Autonomic dysfunction in spinal cord injury: clinical presentation of symptoms and signs. Progress in Brain Research, Vol. 152
Janig W, Levine JD and Michaelis M (1996): Interaction of sympathetic and primary afferent neurones following nerve injury and tissue trauma. Progress in Brain Research 113: 
Thompson, J. A., O’Sullivan, P. B., Briffa, N. K., & Neumann, P. (2006). Altered muscle activation patterns in symptomatic women during pelvic floor muscle contraction and Valsalva manouevre. Neurourology & Urodynamics, 25(3), 268-276.

• Programme based management

• Health reform 

Module 4 links the Clinical Pilates program to the current health reform strategies being implemented by government. Consolidates all levels to update the knowledge base, while further extending the exercise repertoire.

Clinical applications and pathology management:

• Advanced clinically relevant exercises
• Developing suitability for surgery / prehab programmes
• Solving problems not just treating symptoms
• Complex case studies for advanced clinical reasoning
• Developing clinical pathways
• Using outcome measures to quantify efficacy
• Costing programmes for better financial returns
• Clinical Pilates cost reduction role in the current health
• Reform and primary care models
• How to integrate tele-medicine into patient care
• Updates on the Clinical Pilates research faculty projects
• Preparation for Clinical Pilates certification process

UNIT B

Module 3

Progressing patients requires a broader repertoire of techniques. As patients improve they will find exercises and movement strategies easier. Using “load” to progress will lead to a strengthening/muscle hypertrophy process that can compromise rather than enhance motor control. Instead, Clinical Pilates exercises are progressed on a co-ordination/proprioception model that increases motor challenge and feed forward planning (Hurd 2008).

The “stability” of a patient’s pathology can be tested by progressing from their specific subgroup into a multidirectional programme. If there is no degradation of their functional tests or outcome measures then the clinician can be confident of further improvement and a change in threshold of provocation. Proprioceptive
deficits are more indicative predictors of injury than strength (Hurd 2008).

Patients will all differ on their ability to tolerate programme changes, as progression is not suitable for everyone. A heterogenous/patient specific approach is still key and the decision to, or not to, progress is based on the response to outcome measures & validated tests of function (Tulloch 2012). Outcome measurements will also be extended to incorporate a greater repertoire of measures of function. Progression to self-management can also be determined by the effect of measured treatment breaks.

The potential of co-morbidities requiring a more complex approach is also covered in this stage of the programme. A patient may have co–existing pathologies, such as a disc protrusion and a spondylolisthesis, which will require a multi directional approach, biased 80%–20% between primary & secondary problems
(e.g. in this case disc as primary, spondylolisthesis the secondary problem).

Neurological patients are also showing strong preference to a directional exercise approach, further strengthening the indication there is a strong sub cortical process in proprioceptive training & function. Pilot studies on Traumatic Brain Injury & Hemiplegia are showing positive results. This has implications in both the neuro population and the ageing population, where there is a growing need for developing further approaches managing this growingly complex & expensive group (Benjaminse 2011).

Similarly, the sporting population often lacks the higher levels co-ordination/proprioception to improve performance & prevent injury. Strength & conditioning training has a threshold of effect and proprioceptive deficits are often more to blame for injury than lack of strength (ACL injuries etc.).

Case studies looked at in this stage will further expand participants ability to develop individualized programmes for challenging presentations, using a simple clinical reasoning basis.

Hurd,WJ ,Axe,M, Snyder-Mackler,L (2008) A 10-Year Prospective Trial of a Patient Management Algorithm and Screening Examination for Highly Active Individuals With Anterior Cruciate Ligament Injury Pt 1 Am J Sports Med 2008 36: 40
Long, A; Donelson, R; Fung,T (2004) Does it Matter Which Exercise?: A Randomized Control Trial of Exercise for Low Back Pain. Spine. 29(23):2593-2602, December
Benjaminse A, Otten E (2011) ACL injury prevention, more effective with a different way of motor learning? Knee Surg Sports Traumatol Arthrosc 19:622–6

MODULE 4

This final stage in the Clinical Pilates programme updates the knowledge base of previous levels with the most recent relevant literature. The treatment exercise repertoire is also further extended.

With the current focus on global health reform and cost vs outcome, the aim is to be able to provide a cost effective service that can be measured for both cost efficacy and positive outcomes. Advanced clinical reasoning is heightened, with the focus moving to using the Clinical Pilates approach within the current health reform models being established globally. As focus moves to hospital substitution and simplification of processes to minimize and prevent surgery, there is significant scope for cost effective programme based management.

In the UK, the NHS reform model has highlighted the need for “get it right first time” management and a move toward primary care and hospital substitution. The focus on outcome measurement has sharpened to ensure better treatment models. In Australia the mood is similar, with the shift towards Primary Health Networks and hospital substitution further opening the door for physiotherapy, which is comparatively cost effective  and relatively cheap. Introduction of physiotherapists in extended scope programmes has shown significant savings and this can be carried into the private system where costs of surgical interventions are rising at
unsustainable rates (www.phiac.gov.au).

The current private health insurance “death spiral“ (Grattan Report 2019) is increasing the load on our already overstretched public system. While discussions of novel funding models to address the heavy skew towards surgery & hospitalization, the scene is set for implementation of primary sector programs that can reduce surgery and hospital admissions, particularly in the ageing population. COVID has further highlighted the over reliance on hospitalisation & surgery and lack of funding to wards the primary sector.

Pre-surgery physiotherapy programmes have the ability to reduce surgical costs and need for interventions,  screening for patients that will respond to conservative management rather than surgical approaches. Development of partnerships with private & public funding bodies by providing a licensed programme model, with trained and certified clinicians delivering Clinical Pilates treatment programmes, has the potential to fulfill the needs of government policy. The cost of an ageing population and the need to keep an active approach to management is fundamental. There now exists an approach that is more patient specific than general exercise and can take into account the effect of structural degradation on neurological & physical function.

Fritz J (2009) Clinical Prediction Rules in Physical Therapy: Coming of Age? J Orthop Sports Phys Ther 2009;39(3):159-161
Feldman, A (2008). Does Academic Culture Support Translational Research? CTS: Clinical and Translational Science;1(2):87-88
Goldblatt EM, Lee WH. (2010) From bench to bedside: the growing use of translational research in cancer medicine. Am J Transl Res;2(1):1-18
NHS ( 2011) www.dh.gov.uk/health/tag/white-paper/
Grattan Report (2015) http://grattan.edu.au/report/questionable-care-avoiding-ineffective-treatment/
Nicholson C (2012) The Evolution of a Primary Health Care System in Australia S25 JABFM March–April 2012 Vol. 25 Supplement
Grattan Report (2019) https://grattan.edu.au/report/the-history-of-private-health-insurance/
Grattan Report (2019) https://grattan.edu.au/a-blueprint-to-rein-in-doctors-bills-reduce-hospital-costs-and-cut-private-health-insurance

On Completion of UNIT B you will be eligible to enter the CLINICAL PILATES CERTIFICATION process.