Pilates Safety Concerns for Older Adults
Inner IDEA: Top-notch Pilates professionals speak out about keeping seniors injury-free.
The Graying of America is a reality. The U.S. Census projects that nearly 1 in 5 of the nation’s residents will be 65 or older by 2030 (AOA 2011). As the senior population grows, interest in maintaining and improving older adults’ quality of life with physical activity is rapidly expanding. For many, however, aging comes with increasing physical limitations and health issues.
Pilates is a powerful tool for countering the aging process, but it must be taught and practiced safely. Here, three Pilates experts and educators share their recommendations on how to work with mature clients: Lisa Graham owns Agile Monkey in Santa Cruz, California, and is a Balanced Body® faculty member; Rael Isacowitz, MA, is the founder and owner of Basi Pilates®, headquartered in Costa Mesa, California; and PJ O’Clair owns clubXcel and Northeast Pilates, a STOTT PILATES® Licensed Training Center, in Manchester-by-the-Sea, Massachusetts.
In addition to basic knowledge of anatomy, the most important requirements for teaching seniors include a solid understanding of biomechanics and physiology, says O’Clair. “If you are working with a mature client, it is important to know what happens during the aging process and how that can compromise the way the body moves and how the joints function. As people age, they lose mobility owing to physiological changes.”
“There are tremendous variables when teaching the mature population: age, fitness level, lifestyle, body awareness,” to name a few, adds O’Clair. Instructors should start by evaluating a client’s needs and goals, she says. When working with a physically challenged client, she usually begins with simple exercises to mobilize the joints—such as shoulder shrugs and wrist circles—and then works to stabilize and strengthen the client. “Part of the process is to evaluate joint mobility. Can they turn their head, for example? Are they moving in all planes of motion? You can’t begin to strengthen or stabilize something that doesn’t move.”
According to Graham, “Biomechanics is about positioning the body and its orientation to gravity to allow for beneficial movement patterns and efficiency, with the least amount of stress, while also stabilizing the client’s range of motion.” Attempting abrupt changes can harm rather than benefit a client, she warns. “Our goal is to observe our clients while they are moving, to address their movement patterns and to be able to observe and correct alignment in a positive way. We want to make slow and appropriate changes for optimal biomechanics.”
Graham, who uses the mantra “Do no harm” when training clients, says older adults have often had bad postural habits for many years. “It takes longer to unwind them [compared with younger clients]. You can’t reverse 30 years of bad posture in one day. Trying to do that would be unsafe and inappropriate.” On the other hand, Graham notes, many of the seniors she teaches are fit, healthy and vibrant—and ready for a challenge. “Pilates offers a method of communicating to people about their bodies, what they can do, what they should do and how to keep looking forward to the next challenge in a safe and appropriate way.”
Isacowitz, co-author of Pilates Anatomy (Human Kinetics 2011) with educator Karen Clippinger, MA, says instructors need to know a “triangle of information” about “the science of human movement, the person you are working with and the Pilates repertoire [which you need to know in depth].” He says familiarity with the nuances of each exercise and any inherent dangers are especially crucial when teaching seniors. “Lying supine doing footwork I would regard as a safe exercise.” However, he says, chest expansion on the reformer can be difficult if a client is unfamiliar with the exercise and lacks good control. In this exercise, “your center of gravity is high, you face the back of the reformer, and if a client releases the spring too quickly, the carriage can fly back, creating instability. The person can fall into the pit behind the carriage. It is like a carpet being swept from under you.”
All three Pilates experts agree that using equipment and props that are appropriate for the mature population is essential. O’Clair often uses the cadillac with older adults. Compared with a standard-size reformer, “it is more comfortable for them to get on and off because it is higher. The cadillac doesn’t move underneath them—and movement can distract a client’s proprioception.”
The Pilates chair is another of O’Clair’s favorite pieces of equipment. “I put it against the wall because then the person feels more secure knowing that the wall is there for stability. When someone becomes uncomfortable, there’s fear, and when there’s fear, there is dysfunction in the body,” she says.
Isacowitz emphasizes that a teacher must provide a comfortable way for the client to exercise safely. “Sometimes that means using a handle rather than the strap for arm work, or it may mean using a softer strap for the feet.” The choice of spring resistance is also important, he says, because certain exercises can be unstable for seniors. He advises caution with hip work, such as leg circles and the frog. “If you work too light, the person may not have control. If you work too heavy, it may be loading the joints too much. If a person is not properly prepared to do leg circles, the legs may fly out into a circle that is too big, which can hurt or destabilize the client. If the spring is too heavy, it can actually pull the client off the reformer,” he says. Knowing the potential contraindications of exercises is also an integral part of teaching Pilates safely, adds Isacowitz.
Graham believes that one of the key protocols any instructor should follow with seniors is limiting any type of loaded flexion unless the teacher is absolutely certain that the client does not suffer from a condition such as osteoporosis, osteopenia or disk dysfunction.
“Pilates has a great deal of flexion. It can be wonderful because the emphasis on teaching proper spinal flexion includes that sense of actual elongation, to have a sense of lift and decompression in the movement. But for many clients, the emphasis on spinal flexion might not be appropriate, so we concentrate more on torso stabilization and full-body function focusing on the core, and from there we radiate outward.”
The great thing about the Pilates method, Graham says, is that many of the concepts you learn in one position repeat in other positions. “You can practice biomechanically simple movements in a supine position, take them into a prone position, then into a seated position and, eventually, into a standing position.” She says this kind of progression is a great way to integrate all the principles that instructors teach clients in supine work and “translate them into standing work that people can take with them into their everyday lives.”
Cuing is another important element in teaching seniors. O’Clair says all types of cues (tactile, verbal, visual) are important but “not overcuing is something I stress quite heavily with an older population. If you give people too many things to think about at one time, they can get confused. Tell them the simplest steps to take, and you’ll have more success. Of course, this actually works with anyone you teach.”
In many cases, says O’Clair, tactile cuing is extremely effective. “If an older person has lost a spouse or is alone and friends have passed away, he or she is not touched very often and doesn’t have much nurturing contact, so gentle tactile cuing can be supportive and helpful.”
Isacowitz feels that cuing choices are less about age and more about gender. “I don’t find teaching a mature population and young people that different. There is a greater divide between men and women. I find that divide a big one when I am cuing. It really comes down to the individual and how that individual thinks.”
Isacowitz believes that knowledge, practice, experience, intuition, compassion and understanding are all integral to good cuing . . .“and good cuing and modifications are simply fundamental to teaching Pilates” (Isacowitz 2006).
All three experts make the point that Pilates can be one of the most effective and functional modalities for helping mature adults maintain or regain their health and wellness. However, Pilates must be practiced in a safe and appropriate environment and taught by certified, well-educated instructors.
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- Maintain good communication with your client. This is key.
- Conduct a thorough intake interview. On the assessment form ask if the client suffers from orthopedic/joint problems, osteoporosis/osteopenia, disk dysfunction, arthritis, spinal stenosis, peripheral neuropathy/nerve issues or scoliosis.
- Identify appropriate start positions for the client (neutral, supported neutral, imprinted) and know what ranges of motion to avoid, based on physical issues.
- Assess the client’s posture, and work to slowly improve it. Gradual and steady changes are the most beneficial for all clients.
- Teach proper techniques for getting on and off equipment. Make sure the equipment is the appropriate height for your client.
- Start lumbopelvic stabilization challenges with one leg at a time, to offer more support and reduce load on the low back, pelvis and hips.
- Focus on balance and posture (and eventually gait, if you have the necessary experience as an instructor). Be sure to translate supine and prone work to seated and standing exercises.
- Predict the challenges of a particular exercise and give the client something to hold onto for balance challenges. Build confidence as well as muscles.
- Know your scope of practice and refer the client to a more experienced instructor or medical professional when appropriate.
1. Know your client’s restrictions, limitations and medical history.
2. Be familiar with each exercise, down to the finest detail, including possible contraindications.
3. Be aware of the inherent dangers of all the Pilates apparatus.
4. Provide assistance when the client is getting on and off the equipment or using the straps (particularly when the legs are in the straps).
5. Always attach the safety strap when the springs are bottom-loaded on the cadillac.
6. Use particular caution when the push-through bar is top-loaded on the cadillac.
7. Do not “unload” all the springs while the client is on the reformer.
8. Place the headrest in the “down” position during all exercises that place pressure on the cervical spine (short spine, long spine, jackknife, etc.)
9. Protect your own body by cuing and assisting from a safe position in which you can support your client’s weight, if needed.
10. Service the apparatus regularly and check the condition of the springs (replace them at the first sign of deterioration).
This list is not a comprehensive list of all safety concerns and considerations. Please attend a reputable teacher-training course in the study of Pilates before teaching.
- Assess the client’s energy level, state of mind and general well-being.
- Give directions clearly: The client should know what to expect so he or she can prepare both mentally and physically for the workout.
- Explain how to get on and off the equipment safely.
- Provide appropriate props to give proper support (pads under the head, pillows, soft foot bar, foam grip handles instead of straps).
- Keep a constant dialogue going about how the client is feeling throughout the session.
- Be careful with transitions: Don’t move too quickly.
- Ask in advance if the client is comfortable in various body positions, such as supine or side-lying.
- Speak clearly and be aware if the client is hearing impaired. Don’t confuse a lack of response with thinking the client isn’t listening.
- Utilize all types of cues. Tactile, sensory stimuli usually work best.
- Provide opportunities to rest throughout the workout.
- Keep it simple and fun.
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