Case Study: Older Adult with Multiple Challenges
Case Study: Creating a Pilates program for “Betty” required a solid educational foundation, attention to contraindications and creativity.
When a client who has multiple physical challenges comes to your practice, it can cause you a certain amount of anxiety. Before you even schedule the first session, do a thorough phone interview to gain a strong sense of the client’s issues. Also, be sure to obtain a physician’s release for exercise. If the client has been seeing a physical therapist, speak with this person so that you fully understand the client’s contraindications. I have worked with people who had all kinds of different needs and issues. This article explores my experience with one woman who had multiple challenges and describes how I approached the task of programming her Pilates sessions.
Problems and Goals
Betty (not her real name) was a 76-year-old female who started with me after her daughter, a physician, recommended that she begin doing Pilates as part of her fitness program. In her health and history questionnaire, Betty disclosed that she had the following issues: osteoporosis (diagnosed and being medically treated); macular degeneration; hearing loss; osteoarthritis in the right shoulder; a lumpectomy and node removal (7 years earlier, completely resolved); and a hip replacement (5 years before). During our phone interview, I asked Betty to bring me a medical release from her doctor, which she did. She had received physical therapy for her shoulder and the hip replacement and was not experiencing any issues with either. Her goals were to develop more core and peripheral strength.
My initial considerations were to follow the guidelines regarding contraindications. In regard to Betty’s osteoporosis, I could not program any flexion, rotation or lateral flexion. Contraindications for her hip replacement included no flexion greater than 90 degrees, no medial rotation of the femur and no adduction to the midline of the body. Since Betty had hearing loss and macular degeneration, I knew that balance would be an issue. I also understood that I would need to speak more loudly than usual, stand close to my client and use a lot of visual and tactile cues.
Observations and Solutions
Betty favored an abdominal breath, so I noted that I needed to teach her about the pelvic-floor and transversus abdominis connection. She also tended to contract her upper shoulder muscles when she inhaled. Therefore, I knew that teaching her to breathe into the back and sides of the ribs to decrease firing of the upper shoulder musculature would be very important. I did this by wrapping a STOTT PILATES® Flex-Band® around her back in order to give her proprioceptive feedback on where to “place” her breath. I also asked her to focus on her exhalation so that she would feel her abdominal wall compressing—an action that supported her lower back and pelvis.
With the upper shoulder musculature deactivated, I focused on scapular stabilization, to help with her shoulder osteoarthritis. After she had done some breathing with the Flex-Band around her while standing, I had her raise her arms slightly less than 90 degrees in front of her and perform scapular protraction and retraction. She also did this lying on the bed of the Cadillac, with springs attached from below, to stimulate the mid and lower trapezius, as well as the rhomboids. We used springs from below to work the serratus anterior.
When Betty did footwork on the reformer, I had her place her feet hip distance apart. This placement was functional and appropriate for her hip replacement. I also set the reformer so she could not flex to 90 degrees. Using the STOTT PILATES V2 Max Plus™ Rehab Reformer, I added the extender straps attached to the frame (behind the legs and above the knee) for more hip extensor work.
I always worked Betty on a higher reformer than I would use with less challenged clients. I didn’t want her to flex her hips too much while getting on and off the carriage. Also, when I asked her to lie supine on any surface, I kept her there for a while doing a series of exercises. She performed a midback series for scapular stability and for the shoulder extensors, keeping the straps around her legs for support. This put less stress on her hip flexors and allowed her to focus on her core musculature. At other times she did the midback series on the Cadillac with her feet down for programmatic variation.
Adding Creativity and Variety
Flexion is contraindicated for people with osteoporosis, so I never programmed flexion into Betty’s workout. I did, however, work her back extensors in different ways. One time we used the arc barrel with her pelvis behind the apex. This allowed her to keep tension out of the lumbar extensors and stay focused on the middle and upper-back extensors. Betty started from an unweighted, flexed spinal position and then went to neutral spine. This also allowed me to consider the slight amount of kyphosis she had. I progressed her first to single-leg extensions in that same position and finally to hip extension with a block between her inner thighs over the arc barrel. I also sat her on a reformer box with a platform extender to do back rowing preps, a postural support for kyphosis.
Lateral hip strength was another area of importance. I began with standing side-leg series abduction. First I had Betty stand beside the Cadillac, holding onto the frame for balance on a platform extender. This kept her hips even while she took her leg out to the side. I added resistance with the Flex-Band. I kept the range of motion small and carefully watched her pelvis and hip stability while in neutral. After 3 months I started adding lateral movement with the band around her lower legs in a squat position, focusing on core awareness. I then added step-ups on the BOSU® Balance Trainer, using the push-through bar for balance assistance. The safety chain was attached, and I spotted her closely. This exercise stimulated balance and proprioception. I wouldn’t do this with just any client, and I made sure Betty felt comfortable. I felt it was a safe and appropriate time to add this to her program.
Another challenge presented itself when Betty broke her foot (outside of our Pilates sessions). Following her doctor’s recommendation, she rested. When he released her, I modified her exercise program again to avoid putting any pressure on the foot.
I viewed all the challenges Betty came to my studio with as an opportunity to use my creativity while helping her reach her goals. During our time together, she gained mobility and strength in her hips and developed core awareness and strength. She also told me that our work was having a direct influence on her daily living activities and that she felt much more agile.
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