Portal de Periódicos da CAPES

Pilates: Ranging beyond neutral

2013; Elsevier BV; Volume: 18; Issue: 1 Linguagem: Inglês

10.1016/j.jbmt.2013.11.012

1532-9283

Warrick McNeill,

Shoulder Injury and Treatment

When Peter O'Sullivan, Professor of Musculo-Skeletal Physiotherapy, Curtin University, Western Australia, was interviewed in London in 2012 (Websource 1Websource 1 http://www.youtube.com/watch?v=YezBG_NdLgs.Google Scholar), he stated that he did not understand the term ‘core-stability’ and that he thought that, ‘the term is not helpful, it leads to the idea that to stiffen your back is better, and that bracing or pre-bracing is healthy. But we know that bracing is compression and this can potentially lead to pain.’ This apparent volte-face, from one of many researchers who has been investigating lumbar instability and has published numerous papers on the subject (Dankaerts et al., 2004Dankaerts W. O'Sullivan P.B. Burnett A.F. Straker L.M. Danneels L.A. Reliability of within-day and between-days EMG measurement for trunk muscles during maximal and sub-maximal voluntary isometric contractions in healthy controls and CLBP patients.J. Electromyogr. Kinesiol. 2004; 14: 333-342Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar, O'Sullivan et al., 2003O'Sullivan P. Burnett A. Floyd A. Gadson K. Logiudice J. Miller D. Quirke H. Lumbar repositioning deficit in a specific low back pain population.Spine. 2003; 28: 1074-1079Crossref PubMed Scopus (184) Google Scholar, O'Sullivan, 2000O'Sullivan P.B. Lumbar segmental instability: clinical presentation and specific exercise management.Man. Ther. 2000; 5: 2-12Abstract Full Text PDF PubMed Scopus (346) Google Scholar), as well as book chapters, such as one entitled, “Lumbar segmental ‘instability’: clinical presentation and specific stabilising exercises,” In a book called ‘Manual Therapy Masterclasses: The Vertebral Column’ (O'Sullivan, 2003O'Sullivan P. Lumbar segmental ‘instability’: clinical presentation and specific stabilising exercises.in: Beeton Karen S. Manual Therapy Masterclasses: the Vertebral Column. Churchill Livingstone, Edinburgh2003: 63-76Google Scholar). Though O'Sullivan may be taking a reactionary line in this argument he is becoming increasingly convinced, as he stated in the London interview, that the non-specific chronic low back pain (NSCLBP) sufferer is being led to believe that the spine is a vulnerable structure, easily damaged and that it requires abnormal focus on tensing certain muscles to protect it. This belief triggers fear avoidance behaviours inhibiting normal movement and escalating pain levels in this group. O'Sullivan, taking the biopsychosocial approach to heart, wants to convey the message to these NSCLBP sufferers that, ‘the spine is a strong, robust structure, that thinking positively and trusting their spine – no matter what an MRI says (as they are not predictive of pain) will help, and that developing normal healthy patterns of movement and lifestyle will benefit them over the long term.’ O'Sullivan suggested further that just generally focusing on stability exercise for low back pain sufferers can increase pain in many instances, and maintaining beliefs that this will work as a strategy means that therapists are not looking at the data and insist on continuing down a path that won't help the patient or the therapist. Interestingly, Zusman, 2011Zusman M. The modernisation of manipulative therapy.Int. J. Clin. Med. 2011; 2: 644-649Crossref Google Scholar, from the same university, goes further in his attempt to modernise the manipulative therapist to move them away from a passive movement model that ‘to date (shows) no convincing evidence for any lasting alteration in tissue length, position, shape or content following passive movement. Nor would any be expected given that the forces delivered by passive movements are said to be too small and too brief to do so, are readily dissipated and in any case, appear to lack accuracy’ towards the more person-centric, multi-factorial, biopsychosocial approach looking at such ‘variables as excessive attention (hyper-vigilance), exaggerated beliefs/fears (catastrophising) and unwarranted avoidance of activity…If the physiotherapy profession wishes to remain a respected provider in the musculoskeletal pain area then it has no choice but to drop the “lip-service” and actually undertake serious philosophical change.’ In fact, O'Sullivan does still advocate exercise in his classification based cognitive functional therapy (CB-CFT) approach to treating NSCLBP has been validated by a Norwegian Randomised Controlled Trial (RCT) he co-authored (Fersum et al., 2013Fersum K. O’Sullivan P. Skouen J. Smith A. Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial.Eur. J. Pain. 2013; 17: 916-928Crossref PubMed Scopus (293) Google Scholar). The classification component of the research sub-grouped the subjects so that aspects of the approach could be highlighted during the CB-CFT intervention, that presented with factors that showed a cognitive biased treatment modality would be more helpful, had the therapist treating the subject attending to those elements. The subjects were taught about their personal vicious cycle of pain, negative beliefs, and fear of movement and were shown how to deal with these factors. Other sub-grouping within the study identified those who would benefit from a more functional approach. The exercise intervention that these sub-groups received was specifically tailored to normalise their maladapted movement behaviours. These subjects were divided into those O'Sullivan reported to have ‘Control Impairments’ and those who have ‘Movement Impairments.’ Subjects with ‘Control Impairments’ when physically assessed are shown to have a full range of spinal movement, and no MRI explanation for their symptoms. O'Sullivan tailors individualised functional exercise for them so they can modify their pain provocative movements and postures aimed at reducing pain while performing functional tasks. Subjects with ‘Movement Impairments’ are identified to have an impairment reducing their movement into the direction of their pain provocation – for example, pain limiting a subjects lumbar flexion. These individuals can have increased muscular tension in their lumbar extensors preventing lumbar flexion, even though they may have already finished the inflammation and repair phase of the injury that caused this issue in the first place. This reluctance to move into their pain direction in the absence of inflammation may be a fear avoidance behaviour. A very thorough assessment was undertaken for all subjects in this study prior to being randomised into the two intervention groups. The full assessment included a comprehensive interview, including the Orebro Musculoskeletal Pain Questionnaire, a look at pain provocative postures, easing postures and other movement behaviours, an assessment of lifestyle and cognitive behaviours, as well as a physical examination analysing the primary functional impairments. Assessment of their body control and awareness was also undertaken. The CB-CFT group of subjects were given graded exposure to their pain provocative directions of movement to re-establish unguarded normal movement into that direction. They were also encouraged to relax and avoid the movement behaviours associated with fear, such as breath holding, and other protective behaviours. All subjects within the CB-CFT group also received other elements of exercise therapy targeting functional integration of the activities they avoided or reported as provocative of pain in their daily life; as well as a normal physical activity program such as walking or cycling. The second intervention group involved in the study received ‘high quality’ manual therapy and a home program of exercise, such as isolated contractions of the deep abdominal muscles or more general ‘physiotherapy led’ exercise. The findings showed improvements in both groups but CB-CFT group did significantly better across all measurements, including patient satisfaction. This RCT indicates that a tailored approach demands appropriate assessment in the management of those already in pain. It indicates too that an analysis of movement is fundamental for those with neuromusculoskeletal issues and that addressing a person and their function is imperative for a positive outcome. Not just the person but their psychology, their social situation and, the beliefs they hold, need to be taken into consideration when individualising an approach with which to manage their issues. Waddell, 2005Waddell G. Editorial: subgroups within “Nonspecific” low back pain.J. Rheumatol. 2005; 32PubMed Google Scholar quoting Koes et al., 2001Koes B.W. van Tulder M.W. Ostelo R. Burton A.K. Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison.Spine. 2001; 26: 2504-2513Crossref PubMed Scopus (558) Google Scholar and Borkan and Cherkin, 1996Borkan J.M. Cherkin D.C. An agenda for primary care research on low back pain.Spine. 1996; 21: 2880-2884Crossref PubMed Scopus (86) Google Scholar suggests that diagnostic triage of acute low back pain reveals that nerve root pain (from discal or stenosis causes) accounts for about 5% of cases, serious spinal pathology (red flags – vertebral fracture, spinal tumour or infection, cauda equina syndrome) accounts for 1–2%. This leaves about 95% of back pain sufferers being placed in a very diverse group with dissimilar signs and symptoms. Waddell describes that the ability to sub-group these individuals into clinically meaningful groups is the holy grail of low back pain research. But low back pain is not the only condition or area that the readers of this Journal endeavour to influence, in fact this section of the journal has as its remit to focus on prevention – which could be interpreted as the management of risk. This suggests that research that looks at factors that may lead to pain is as important as those factors involved in the treatment of those already in pain. Luomajoki, 2010Luomajoki H. Movement Control Impairment as a Sub-group of Non-specific Low Back Pain. Evaluation of Movement Control Test Battery as a Practical Tool in the Diagnosis of Movement Control Impairment and Treatment of this Dysfunction. University of Eastern Finland, 2010Google Scholar in his Doctoral thesis identified that there is a clear and significant difference between patients with LBP compared to healthy controls in their movement control. In one section of his study he analysed 6 movement control tests of the lumbar spine and identified that it was normal for a healthy subject to be unable to perform one out of the six tests correctly, but two or more positive tests was an indicator of back pain. This does not identify whether the movement control impairment is just an effect of low back pain or indeed a cause. Sarah Mottram co-author of a recent book, ‘Kinetic Control: The management of uncontrolled movement’ (Comerford and Mottram, 2012Comerford M. Mottram S. Kinetic Control: the Management of Uncontrolled Movement. Churchill Livingstone, 2012Google Scholar), suggests that there is a causal link between a movement impairment and pain and draws attention to research on dancers (Roussel et al., 2009Roussel N.A. Nijs J. Mottram S. Van Moorsel A. Truijen S. Stassijns G. Altered lumbopelvic movement control but not generalized joint hypermobility is associated with increased injury in dancers.Man. Ther. 2009; 14: 630-635Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar) that shows that two motor control tests – a flat back hip flexion in standing and a crook lying hip and knee flexion may be useful for the identification of dancers at risk of developing musculoskeletal injuries in the lower extremities; and a study on athletes that showed that decreased neuromusculoskeletal control of the athletes's core increases risk of knee injury in that person (Zazulak et al., 2007Zazulak B. Hewett T.E. Reeves N.P. Goldberg B. Cholewicki J. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study.Am. J. Sports Med. 2007; 35: 1123-1131Crossref PubMed Scopus (565) Google Scholar). ‘Not only should there be interest in whether there is a causal link between movement control and risk but research proving that exercise can alter impaired movement control is equally important,’ says Mottram, when interviewed for this editorial. A research team she was part of has shown that a ten week motor control intervention for shoulder impingement increased function and reduced pain. The intervention used specific motor control exercises to retrain the subjects scapula orientation (Worsley et al., 2013Worsley P. Warner M. Mottram S. Gadola S. Veeger H. Hermens H. Morrissey D. Little P. Cooper C. Carr A. Stokes M. Motor control retraining exercises for shoulder impingement: effects on function, muscle activation, and biomechanics in young adults.J. Shoulder Elbow Surg. 2013; 22: 11-19Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar). ‘The application of specific exercises for specific movement control problems, and compliance to the exercise plan, are factors that future research should concentrate on’, says Mottram. Placing the correct emphasis of client/patient management on relevant biopsychosocial factors, still leaves a need to manage the physical aspects of an individuals presentation. Current thinking suggests a ‘movement assessment’ should be used to provide the information for the decision making process required to provide the greatest return in the least time. This suggests that ‘specific exercises’ are required to directly attend to the specific problems identified by such a movement assessment. Comerford and Mottram have developed two systems of movement assessment to answer the needs of the two distinct groups that they have identified. Those whose presentation of movement impairments involves pain and those whose presentation of movement impairments reduce performance and function, and increase their risk of developing pain. They call the management of pain ‘Kinetic Control’ (Comerford and Mottram, 2012Comerford M. Mottram S. Kinetic Control: the Management of Uncontrolled Movement. Churchill Livingstone, 2012Google Scholar) and the management of performance and risk the ‘Performance Matrix.’ (Websource 2Websource 2 http://www.theperformancematrix.com.Google Scholar). Both these assessment processes are designed to identify movement impairments that they call ‘uncontrolled movement’ (UCM). An UCM is identified (Comerford and Mottram, 2012Comerford M. Mottram S. Kinetic Control: the Management of Uncontrolled Movement. Churchill Livingstone, 2012Google Scholar) as a movement occurring at a joint or region that the individual is not able to recruit their musculature to exhibit control over. An UCM is identified by ‘site’ – a joint or region – say the hip or lumbar spine, and a ‘direction’ such as flexion, abduction or translation. For a movement to be shown to be uncontrolled it has to be tested. There has to be a cognitive element to the test as the individual needs to know at what site and in what direction they should be exhibiting the control over. The movement being tested has a start position and a benchmark position to reach before the test can be shown to have been passed or failed. The ability to control movement should also be tested at loads that control posture and alignment, or loads utilising strength or speed, as these stress the ability of the neuromusculoskeletal system to control either of these forces. Mottram says, ‘It is possible to have strength and control higher forces but an individual may exhibit poor recruitment under postural loads and vice versa’. This component of the testing identifies the threshold at which an UCM occurs, low and/or high. Simply put, low threshold testing biases the NEUROmusculoskeletal system and at higher thresholds, the neuroMUSCULOskeletal system. An UCM may be identified and linked to a clients pain, though an UCM can present only as a risk for potential pain or injury in the future, hence the two systems of assessment Comerford and Mottram advocate. This blurs the distinction as to which disciplines should deal with uncontrolled movement. If pain is present then the management should lie with a therapist, though if no pain is present the UCM could equally be managed by an exercise professional such as a Pilates Teacher or Personal Trainer, as it is only the management of movement risk that is undertaken in the retraining. This fits firmly in the remit of well trained exercise instructors. ‘Managing pain is a key aim of physiotherapy but this ties a treatment strategy – such as specific exercise, to a medical or rehab model, but specific exercise is not just taught by those managing pain. Specific exercise solutions cross the boundary between the rehab model and the health or wellness model which means that specific exercise that addresses movement control issues can be undertaken within either model. It is very probable that disciplines like Pilates, with its attention to detail in teaching the execution of an exercise to a high standard, prevents movement faults from becoming actual injuries.’ Mottram believes that it is only when correct and precise analysis or assessment of movement is undertaken that the correct specific exercise can be selected. She continues, ‘When pain is not a factor it does not matter if the movement retraining is undertaken by a Physiotherapist, a Pilates Teacher or a Personal Trainer, so long as the exercise is specific to the fault assessed, taught well, re-checked at intervals and client compliance is obtained.’ Once an UCM is found it shows that the individual is susceptible to injury, or has already been injured at that joint, and in that direction. This identifies specific problems that require specific exercises to manage. Comerford and Mottram recommend two key groups of exercises for fixing movement impairment faults. These are ‘Direction Control’ and ‘Range Control’ exercises. They both retrain aspects of ‘uncontrolled movement’ (UCM). Controlling the direction fault is a priority and can be achieved with a ‘Direction Control’ exercise using muscular action. This is usually gained by encouraging a synergistic contraction of the antagonist musculature. For example, to control a lumbar extension UCM, the muscles that prevent lumbar extension – rectus abdominis and the obliques – need to be adequately recruited to prevent that motion. Principles of rehabilitation will often suggest that a client with an injury keeps that area in neutral when beginning an exercise strategy to manage the issue (Frank et al., 2013Frank C. Kobesova A. Kolar P. Dynamic neuromuscular stabilization & sports rehabilitation.Int. J. Sports Phys. Ther. 2013; 8: 62-73PubMed Google Scholar, Wallden, 2009Wallden M. The neutral spine principle.J. Bodywor. Mov. Therapies. 2009; 13: 350-361Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar). Preservation of the neutral position, therefore, is a goal of a Direction Control exercise, but how is this achieved? Mottram suggests that, ‘recruitment of the stability muscles in the area should be encouraged using whatever feedback mechanisms required that are effective for that client. Mirrors, tactile or verbal cueing can all be utilised to keep the affected joint controlled. Then movement is encouraged at the joint above or below, especially into the direction that challenges the identified control issue. A thoracic flexion movement can easily encourage an uncontrolled lumbar flexion movement at the same time. A dissociation of these two movements needs to be taught to the client. This skill is fundamental to the process as it helps develop just enough recruitment of the stabilising musculature to keep the uncontrolled movement stable without over recruiting and generating too much stiffness.’ Mottram points out that the range of the movement of the adjacent joint should only be as much as the individual can achieve without moving at the affected joint. ‘The client may report that the effort they are using to maintain the neutral position of the affected joint is very high, but this may only be a high apparent ‘sensation of effort’ due to the CNS's inefficiency at planning and effecting the muscular control required at this stage of rehabilitation. In fact, as this ‘sensation of effort’ reduces over the retraining phase, this can be a sign that the uncontrolled movement is now becoming controlled.’ Mottram suggests, ‘the exercise movements should be repeated slowly over 1–2 min, perhaps 15–30 times as long as there is no undue fatigue or a change in the muscular recruitment strategy which suggests an undesirable muscular substitution strategy is taking over. This alters the quality of the movement often creating a detectable stiffness in the movement.’ Mottram points out that Direction Control exercises are mainly practiced at low threshold – posture and alignment controlling – loads, as this is the zone in which a client can effect change and develop strategies which are eventually hoped to become automatic. Strength and speed can be built up to for UCM's found in high threshold testing. Direction Control (or dissociation) exercises are not O'Sullivan's ‘functional exercise’ or ‘Pilates exercises’, but they can be viewed as building blocks towards them. If O'Sullivan identifies that he wants his control impaired client to change the way that they sit, he may have identified that they flex their lumbar spine excessively during the functional act of sitting down. To change this he may teach them to maintain a neutral lumbar spine while flexing the hips during a sitting movement. The control of the lumbar spine while flexing the hip is a Direction Control exercise but just in a whole body context. If a Pilates Teacher aims to keep the lumbar spine in neutral while the legs, in a long lever, exerts an extending force on the lumbar spine in a ‘hundreds’ exercise; then this is a high threshold Direction Control exercise of the lumbar spine with a hip extension challenge, again, in a whole body context. By isolating a Direction Control exercise to a specific UCM, it allows a specificity of exercise, reducing the variables that need to be controlled and focusses the individuals attention on the most important elements of their retraining tasks, improving efficiency during a whole body exercise. Direction Control (or dissociation) exercises are only one piece of the puzzle of how to fix UCM's. There are other exercises required for optimal movement health. In a rehabilitation process there is a need to move beyond neutral. Comerford and Mottram have clear views as to the importance of ‘Range Control’ exercises. These exercises are important due to the fact that they manage the changes to the muscles that have adapted physiologically to Sahrmann, 2002Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, 2002Google Scholar identification that ‘sustained postures and repeated movements’ are a cause of deviations of joint movement due to structural change in contractile and non-contractile tissues. Muscles are also adapted by a ‘dysfunction loop’ created by the fact that pain affects proprioception thereby creating inhibition of the slow motor unit (SMU) altering movement strategies and creating dysfunctions in movement patterns. Examples include stabiliser muscle inefficiencies and mobiliser muscle substitutions and restrictions (Comerford and Mottram, 2012Comerford M. Mottram S. Kinetic Control: the Management of Uncontrolled Movement. Churchill Livingstone, 2012Google Scholar). The adaptations result in mobiliser muscles (two joint, superficial muscles that are predominantly used to accelerate or decelerate movement) becoming shortened, and stabiliser muscles (one joint, deep muscles, and that often have a role in rotation control) becoming lengthened. These length changes present most obviously as joint restrictions created by the shortened mobilisers. The restrictions force the movement system to push movement that would ideally be occurring at one joint to another joint further up or down the kinetic chain, Sahrmann's concept of ‘Relative Flexibility’ (2002). This means that stabilising muscles on the other side of the restricted joint become unused to, then eventually are unable to shorten to their ideal length forcing them to adapt by growing longer – actually adding sarcomeres in series (though the drive may occur in the other direction, and the lengthening stabiliser muscle may stimulate the mobiliser to shorten). An individual affected by these changes will exhibit difficulty with an affected stabiliser muscle being unable to shorten fully into its ideal inner range. Mottram describes a test to prove the point. ‘In an ideal situation the active inner range of a joint should match its passive range. A client can be asked to flex a joint as far as they can using the correct stabiliser muscle, making sure that the mobiliser musculature is not substituting for the stabiliser.’ Here she uses hip flexion in sitting as an example. ‘The stabiliser to be tested in this position is iliacus. To reduce the chances that the superficial mobilisers such as rectus femoris, the tensor fascia lata, or sartorius, don't substitute in this action – the client is instructed to gently shorten the femur into the acetabulum to bias iliacus, and lift the flexed knee as high as they can without “gripping” the anterior hip superficial musculature. At the point in range that it appears that the movement will create excessive activity in the mobilising muscles the tester takes over the hold of the clients leg and passively flexes the hip further without posteriorly rotating the pelvis or flexing the lumbar spine. If more hip flexion is available than can be created actively by the client – then the active range is shown not to match passive range – indicating that the stabiliser has been lengthened and requires specific “Range Control” exercises to improve its ability to shorten to the ideal inner range.’ Comerford and Mottram advocate ‘inner range holds’ (Comerford and Mottram, 2001Comerford M. Mottram S. Functional stability re-training: principles and strategies for managing mechanical dysfunction.Man. Ther. 2001; 6: 3-14Abstract Full Text PDF PubMed Scopus (149) Google Scholar) at the point in range that the specific muscle being addressed – the lengthened stabiliser – is actually able to flex to without substitutions taking over. It may not be very far in to the inner range but over time the repeated exercise should result in the muscle being able to achieve greater distance into inner range. Again, this work is best started under lighter postural loads to aid the clients ability to exhibit control and use feedback to improve their ability. If the UCM being managed only appears under loads that challenge strength or speed then the aim is to move the exercise to the appropriate high threshold training loads once control has begun to improve. Inner Range training is not just confined to concentrically shortening the muscle, it also needs to become more efficient at statically holding the inner range position with an ‘inner range hold’ with 10× ten second holds as a tool used to improve this (Jull et al., 2008Jull G.A. O'Leary S.P. Falla D.L. Clinical assessment of the deep cervical flexor muscles: the Craniocervical Flexion Test.J. Manipulative Physiol. Ther. 2008; : 525-533Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar, Jull et al., 2009Jull G.A. Falla D.L. Vicenzino B. Hodges P.W. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain.Man. Ther. 2009; 14: 696-701Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar). The muscle needs also to smoothly eccentrically lengthen, under load, to its outer range and even display deceleration capabilities. The muscle also needs to be efficient in controlling rotation – as this is a key task of a stabilising muscle. Placing focus on a single muscle still needs to be addressed in context with the antagonist coactivation of the trunk stabilisers during exercise. The inner range training exercise should also be part of the correct synergy maintaining good form of the whole body. In an exercise physiology study on Pilates movement by Rossi et al., published in this Prevention and Rehabilitation section, the findings suggest that rotation issues of the trunk during exercise need to be controlled as they highlight the differences in the bilateral recruitment of the trunk stabilisers that their study revealed. There is a case for hands on release based therapies such as trigger point release, or lengthening techniques for the antagonist shortened mobiliser to assist the lengthened stabiliser to get to its inner range – especially in the early stages of the process, but perhaps the primary focus should be on the recruitment pattern retraining (McNeill, 2012McNeill W. Editorial. Pilates: release or recruit?.J. Bodywor. Mov. Ther. 2012; 16: 101-108Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar). Mottram agrees there is similarity in the approach she and Comerford advocate with Pilates. ‘When we analyse what Pilates Teachers are doing we find that a lot of the Pilates process often intuitively uses techniques that we believe help to fix the faults found in the assessment process. When I work with a patient I use a Pilates Reformer and a Cadillac, as well as other pieces of small equipment, as the flexibility of these pieces of equipment allow me to generate the right exercises for the problems I have identified.’ Direction Control exercises which are primarily about controlling neutral, perhaps don't sit as naturally well in the repertoire of normal Pilates classes, especially group classes, but have a better fit within the one to one Pilates format in a rehab Pilates environment. Range Control exercises, however fit neatly into the teaching of Pilates as Pilates exercise is fundamentally about movement. The flow of the repeated movements of Pilates exercise reflect the smooth concentric to eccentric repetitions required by Comerford and Mottram's Range Control exercises which aim to efficiently move the range available, both to improve inner range distance while lengthening the antagonist muscles on the other side of the joint. Improving alignment and rotation control, as well as improving altered recruitment strategies that have adapted because of sustained postures, repeated movements, pain or injury, is fundamental to both Pilates, and the exercises advocated by Comerford and Mottram.