pilates exercises in physical therapy utilizing pilates
TRANSCRIPT
PILATES EXERCISES IN PHYSICAL THERAPY
UTILIZING PILATES EXERCISES IN THE PHYSICAL THERAPY MANAGEMENT OF A PATIENT WITH BREAST CANCER-RELATED SHOULDER IMPAIRMENTS
A Case Report
Presented to
The Faculty of the Marieb College of Health and Human Services
Florida Gulf Coast University
In Partial Fulfillment
Of the Requirement for the Degree of
Doctor of Physical Therapy
By
Jose Francisco Sagastume
2019
PILATES EXERCISES IN PHYSICAL THERAPY
APPROVAL SHEET
This case report is submitted in partial fulfillment of
the requirements for the degree of
Doctor of Physical Therapy
___________________________
Jose Francisco Sagastume
Approved: April 2, 2019
___________________________
Dr. Ahmed Elokda, PhD, PT, FAACVPR Committee Chair
___________________________ Dr. Arie J. van Duijn, EdD, PT, OCS
Committee Member
The final copy of this case report has been examined by the signatories, and we find that both
the content and the form meet acceptable presentation standards of scholarly work in the
above-mentioned discipline
PILATES EXERCISES IN PHYSICAL THERAPY
ACKNOWLEDGEMENTS
I would like to thank my family and friends for their support throughout my journey in
the Doctor of Physical Therapy program. I would like to acknowledge Dr. Mary Kaye Rueth, DPT,
owner of THRIVE Physical Therapy & Wellness Solutions, for her generous dedication of time
and effort in order to make the completion of this paper possible. I would also like to thank
Dianne Ambrose, Pilates instructor and owner of Energi Pilates, for her assistance and
contribution of expert knowledge into creating this case report. Finally, I would like to thank my
research committee members Dr. Ahmed Elokda and Dr. Arie van Duijn for their guidance in
completing this paper.
PILATES EXERCISES IN PHYSICAL THERAPY 1
TABLE OF CONTENTS
ABSTRACT ........................................................................................................................................ 2
BACKGROUND AND PURPOSE ........................................................................................................ 4
CASE DESCRIPTION ......................................................................................................................... 8
Patient History and Systems Review ........................................................................................... 8
Clinical Impression #1. ............................................................................................................. 9
Examination ............................................................................................................................... 10
Clinical Impression #2. ........................................................................................................... 12
INTERVENTION .............................................................................................................................. 13
OUTCOMES ................................................................................................................................... 14
DISCUSSION................................................................................................................................... 17
REFERENCES .................................................................................................................................. 19
Appendix A: Videos of Mat Based Pilates Exercises ..................................................................... 23
Appendix B: Pictures of Mat Based Pilates Exercises ................................................................... 24
PILATES EXERCISES IN PHYSICAL THERAPY 2
ABSTRACT
Background and purpose: Cancer is one of the major leading causes of death in the
United States and continues to be a prevalent pathology encountered by physical therapists
today. Patients diagnosed with breast cancer will undergo multiple combinations of treatment
methods that lead to a myriad of side effects involving multiple body systems. This case report
describes the use of mat based Pilates exercises as part of the physical therapy management of
a patient with breast cancer related shoulder impairments. Case description: The patient was a
76-year-old female treated in an outpatient physical therapy setting following the diagnosis of
stage III breast cancer with subsequent bilateral mastectomy, chemotherapy, and radiation
therapy. The patient presented with left upper extremity pain, upper extremity mobility
impairments, and bilateral chest wall pain. Outcomes: Physical therapy treatment consisted of
manual lymph drainage (MLD), manual therapy techniques, modalities for pain relief and
promotion of tissue healing, patient education for independent lymphedema management,
establishment of a home exercise program, and therapeutic exercises comprising of mat based
Pilates. The exercise program was created specifically for the case patient through collaboration
by a physical therapist and a Pilates certified instructor. Studies have shown that performing
Pilates exercises is beneficial to improving the side effects of secondary lymphedema in
addition to improving shoulder range of motion and strength in patients with breast cancer
related deficits. Following physical therapy intervention, the patient demonstrated improved
pain levels on the visual analog scale (VAS) from 4/10 in the right chest/shoulder to 2/10 and
from 7/10 in the left chest/shoulder to 4/10. The patient also improved their overall upper
extremity function as noted by a score increase on the Quick DASH from 52 to 36 and active
PILATES EXERCISES IN PHYSICAL THERAPY 3
range of motion (AROM) improvements with right shoulder flexion, left shoulder flexion, and
left shoulder abduction. Discussion: This case report demonstrates the potential use of mat
based Pilates exercises as a viable exercise method in the multi-modal treatment approach for
patients affected by breast cancer related shoulder deficits. The exercise method has also
shown to be safe and beneficial to a patient who was currently receiving active radiation
therapy as part of their cancer treatment.
PILATES EXERCISES IN PHYSICAL THERAPY 4
BACKGROUND AND PURPOSE
As one of the major leading causes of death in the United States, cancer affects the
majority of today’s society either directly or indirectly.1 In the year 2019, there will be an
estimated 1,762,450 new cases of cancer in the United States.2 Of those cases, breast cancer
will be the most prevalent with an estimated 271,270 new cases.2 Physical therapists will most
likely encounter patients with either a history of or a current diagnosis of breast cancer as it has
the highest incidence rate in females, 124.7 per 100,00.3 These individuals will likely undergo
multiple combinations of treatment methods that can include surgery, radiation therapy, or
systemic therapy (chemotherapy, endocrine therapy and target immunotherapy).4 Although
the methods of treatment are aimed at targeting cancer cells, the patient’s healthy cells and
tissues still receive toxic consequences. This leads to a plethora of complications that can
involve multiple body systems and includes fatigue, fibrosis, edema, muscle weakness, joint
pain, and neuropathies.5 One example of this is radiation therapy, which can lead to
lymphedema and fibrosis.5
Lymphedema is known as an accumulation of protein rich fluid in extracellular space,
which is caused by decreased lymphatic transport capacity and/or increased lymphatic load.6
Lymphedema may be categorized into either primary (idiopathic) or secondary (acquired).
Secondary lymphedema occurs when an otherwise normal lymphatic system becomes
disrupted or damaged from a known cause.6 The incidence of secondary lymphedema greatly
increases as a result of treatment for breast cancer by lymph node removal, radiation therapy,
or a combination of the two. The incidence of secondary lymphedema increases three fold
when local radiation treatment follows surgical procedure to remove cancerous cells.7 There
PILATES EXERCISES IN PHYSICAL THERAPY 5
are an estimated 3 million new cases of secondary lymphedema each year in the United States.
In addition, up to 30% of breast cancer survivors develop secondary lymphedema within their
lifetime.6 Secondary lymphedema has been reported to induce physical discomfort, functional
impairments, increase in anxiety, depression, and emotional distress.8 A study that included
women with breast-cancer related lymphedema found that common symptoms after 6 months
post-diagnosis included tingling, weakness, pain, poor range of motion, numbness, and
stiffness.9
It is well known that radiation therapy can cause significant effects on the connective
tissue. Fibrosis, contraction of tissue, and secondary lymphedema are all known to be common
side effects.10 Aggressive cancer treatments, such as radiation therapy post-surgery, are a risk
factor for women to develop chronic pain.11,12 Chest wall post-mastectomy radiation therapy
increases the risk of grade III/IV contracture formation due to increased myofibroblast
conversion, leading to cosmetic deformity, severe tightness, and pain.13,14 Fibrosis of connective
tissue can result in edema, decreased range of motion, and functional impairment.10 In a study
of 183 patients receiving radiation therapy for breast cancer related treatment, ninety-one
percent of the women presented with some type of arm or shoulder impairment.15 Literature
has also indicated that patients undergoing medical treatment for cancer develop lymphedema
due to tissue fibrosis with subsequent shoulder girdle joint restrictions.16
Through a multidisciplinary approach, breast cancer related deficits can be managed
effectively with proper intervention, patient education, and regular medical follow ups. One of
the most effective and widely used treatments in reducing the effects of lymphedema has been
complete decongestive therapy (CDT). This treatment is comprised of an array of components:
PILATES EXERCISES IN PHYSICAL THERAPY 6
manual lymph drainage, short-stretch compression bandaging, exercise, compression garments,
patient education, compression pumps, and psychological and emotional support.6 Although
CDT encompasses an array of therapeutic interventions, the use of each component of the
treatment varies and is constantly modified to fit the needs of the specific patient. This means
that the impact of each individual intervention is not well defined, as it is integrated as part of a
comprehensive approach.
Research has been compiled to show well-established benefits of exercise for patients
post-cancer in respect to their improvements in function, health, and quality of life.17 Despite
the evidence, patients continue to avoid physical activity and exercise due to the fear and
misconception that it will spread the fluid elsewhere, progress the swelling, and that it will
cause them harm.18 Two studies have debunked this belief and have shown that participation in
an exercise program does not increase the symptoms of secondary lymphedema.19,20 In fact,
exercise has been shown to improve physical function, muscular strength, fatigue, and quality
of life in patients with breast cancer related deficits.21,22 According to the clinical practice
guidelines for breast cancer rehabilitation, it is recommended that patients perform ROM,
stretching, and strengthening exercises to optimize upper extremity rehabilitation.23
One example of a common therapeutic modality used for strengthening and ROM is the
Pilates exercise approach. Research has been conducted regarding the use of Pilates in patients
with fibromyalgia, post-menopausal osteoporosis, and low back pain.24 These studies have
assessed the effectiveness of the Pilates approach in health outcomes related to body
composition, breast cancer rehabilitation, physical fitness and fall prevention in seniors, and
pelvic floor muscle function.24 Developed in the 1930s by German trainer, Joseph Pilates, the
PILATES EXERCISES IN PHYSICAL THERAPY 7
exercise method originally revolved around the principles of proper breathing, proper posture,
stretching the spine, and obtaining a stable “center”. Since then, the method has continued to
develop and progress the original principles, shaping it into modern day strengthening of the
core muscles with improvement in spine flexibility and posture.25 The benefits of exercise can
also be supported by the theory that skeletal muscle contractions facilitate lymph fluid
propulsion by direct compression on the lymphatic vessels.20 This is especially true when you
take into consideration the compression that occurs to the ductus thoracicus when intermittent
external pressure occurs from muscular contraction, in addition to diaphragmatic assistance
with deep breathing.16 Furthermore, deep breathing can improve lymphatic flow via changes in
intrathoracic pressures.20 This results in lymphatic flow stimulation, reducing lymphatic load
and promoting immune system function.16 Due to the fact that Pilates exercises are known to
activate various muscle groups simultaneously, with added breathing exercises, then it would
suggest that this modality would be beneficial for patients with secondary lymphedema. In
addition, there is strong evidence that the foundational Pilates exercises can improve overall
body flexibility, including upper extremity function.26
Four studies were found that observed the effects of Pilates on patients with breast
cancer related deficits. These studies were able to show improvements in aerobic capacity,
quality of life, body image after a mastectomy, shoulder ROM, and shoulder strength.16,27-29
Pilates is a form of exercise that is usually performed using specialized pieces of equipment
such as the reformer, chair, barrel, and the cadillac. However, these pieces of equipment are
typically not readily available to practicing clinicians due to either spacing restrictions or
funding purposes. Mat based Pilates exercise is a methodology that does not require
PILATES EXERCISES IN PHYSICAL THERAPY 8
specialized equipment and still follows the basic principles of centering (tightening the
muscular center of the body), concentration (cognitive attention required to perform the
exercises), control (close management of posture and movement during exercise), precision
(performing the right movements each time), flow (smooth transition of movements), and
breathing (moving air into and out of the lungs in coordination with exercise).30 Therefore, it is
the purpose of this case report to demonstrate the potential benefits which mat based Pilates
exercises may have on the upper extremity function of patients with breast-cancer related
impairments.
CASE DESCRIPTION
Patient History and Systems Review
The patient was a 76-year-old female who presented to physical therapy with chief
complaints of left upper extremity pain, decreased mobility, and chest wall pain, tightness, and
edema. She was diagnosed with stage III breast cancer 14 months ago and received
chemotherapy treatment. The patient than had a bilateral mastectomy performed five months
following her initial diagnosis of breast cancer with subsequent radiation therapy. At the time
of initial evaluation, the patient had four treatments of radiation, with plans of completing up
to 24 sessions. The patient had a left chemotherapy upper quarter port in place that was
causing complications and an increased risk of infection. The patient was continuing to receive
radiation therapy treatment and consultations with her oncologist concerning the cancer
treatment. The patient’s goal for physical therapy was to decrease chest wall pain and improve
left shoulder mobility.
PILATES EXERCISES IN PHYSICAL THERAPY 9
Clinical Impression #1. Based on the patient’s history and systems review she would be
a good candidate for the inclusion of Pilates exercises as part of her physical therapy
management due to her medical diagnosis, relevant past medical history, and current chief
complaints. A recent Cohrane review by Furmaniak et al. demonstrated that there are positive
effects from exercise training during ongoing cancer treatment.31 This supports the hypothesis
that the case patient would benefit from physical therapy services despite the opinion of many
patients that they should rest and avoid physical activity while receiving cancer treatments.
That same review of twenty-eight studies concluded that only a very small number of women
were affected by adverse effects from exercise, including complaints of muscle soreness or
discomfort during the exercise. Current research studies looking at the effects of Pilates on
patients with breast cancer have not included patients that were currently undergoing cancer
treatment.27-29 Therefore, the current case patient will provide a contribution to the literature
regarding the potential benefits that Pilates exercises may have while also posing minimal risk
of adverse effects to the patient. In addition, diaphragmatic breathing, a core principle of
Pilates, will assist the patient in combating reduced rib excursion from scarring and fibrosis that
occurs when chest wall irradiation and surgery is performed.10
The examination process focused on determining if the patient was appropriate for
physical therapy services and mat based Pilates exercises. Tests and measures included upper
extremity range of motion, upper extremity strength testing, upper quarter muscular flexibility,
and chest wall skin integrity. In conjunction with the patient’s evaluation of her current
condition, differential diagnosis included acute complications that can occur from radiation
PILATES EXERCISES IN PHYSICAL THERAPY 10
therapy such as nervous system involvement, radiation dermatitis, and connective tissue
involvement.
Examination
At the initial evaluation of the case patient, a standard outcome measure was utilized,
and objective data was obtained. The patient completed the QuickDash self-reported outcome
measure, an abbreviated version of the Disabilities of the Arm, Shoulder and Hand (DASH). The
original 30 item questionnaire that is the DASH, was designed to measure symptoms and
physical functioning in patients with one or multiple musculoskeletal symptoms of the upper
extremity.32 In the attempt to make a more time-efficient, straightforward, and more patient
friendly questionnaire, the Quick DASH was developed.33 The short version was created with
the attempt to select just one question from the key domains of the DASH while still
maintaining the key concepts of being patient centered and demonstrating clinical relevance to
healthcare profressionals.33 The result was an eleven item questionnaire that provides a
summative score on a 100-point scale, with higher scores indicating greater disability. Although
a shorted version may minimize the burden on the respondent, it is important that it keeps its
measurement properties. Studies have demonstrated that the Quick DASH can be utilized as an
alternative to the original DASH, demonstrating excellent test-retest reliability, good construct
validity, and has responsiveness to change in patients with shoulder pain.34,35 Studies have also
reported a minimal important difference (MID) of 13.4 points or 8% relative to baseline and a
smallest detectable change (SDC) of 17.1 points.36,37
The examination process further included measurements of the patient’s active range of
motion (AROM) of the shoulder. Baseline measurements of shoulder flexion, abduction, and
PILATES EXERCISES IN PHYSICAL THERAPY 11
internal rotation were taken using a Baseline Goniometer. The patient’s AROM measurements
are listed in Table 1. The patient’s internal rotation was measured using the vertebral-level
method. This method involves having the patient reach behind their back as the clinician
documents the highest vertebral level reached with the thumb. The method is highly popular,
easy to use and teach, and time efficient. Despite this, the method demonstrates a high
potential of poor construct validity due to the incorporation of shoulder extension, scapular
retraction and downward rotation, elbow flexion, forearm supination, wrist radial deviation,
and thumb extension. For this same reason, several studies have challenged the measurement
properties of the method. Studies have reported that the vertebral level method or hand-
behind-back method has poor interobserver reliability, acceptable intraobserver reliability, and
poor examiner estimates of vertebral level when compared with radiograph.38,39 For purposes
of this case report, the method was utilized to demonstrate shoulder outcomes through a
method that is closely tied to functional activities that are performed by the patient on a daily
basis, including self-hygiene and fastening a bra. Utilizing the Numeric Pain Rating (NPR) scale,
the patient reported a 7/10 at worst in the left chest wall and shoulder as well as a 4/10 at
worst in the right chest wall and shoulder. The patient described the pain as a dull ache with
occasional shooting sensations in the left chest wall. The patient reported a disability score of
52/100 on the upper extremity Quick DASH. Clinician examination reported palpatory
tenderness of the mastectomy scars, observable edema of bilateral chest wall, and moderate
amounts of adhesion and bilateral pectoralis muscle tightness, left greater than right.
PILATES EXERCISES IN PHYSICAL THERAPY 12
Table 1. Evaluation Tests and Measures
Measurement Initial Evaluation (12/17/2018)
Quick DASH 52/100
Shoulder AROM (degrees) Flexion Abduction Internal Rotation
Right: 153° Left: 123° Right: 147° Left: 107°
Right: L1 vertebrae Left: L5 vertebrae
Numeric Pain Rating (NPR) Right Chest/Shoulder: 4/10 Left Chest/Shoulder: 7/10
Clinical Impression #2. From the information gathered at the initial evaluation, the
physical therapist determined that the patient was appropriate for their services with the
addition of using mat Pilates exercises as part of their plan of care. No contraindications to
physical therapy were assessed, the patient’s clinical presentation was evolving with changing
characteristics, the patient had good rehab potential, and their primary functional limitation
was carrying, moving, and handling objects. Normative values for active shoulder complex
range of motion for males and females aged between 60-93 years old was used as a reference
point. Two studies reported mean flexion between 160 and 165, mean abduction between 155
and 157.9.40,41 This signifies that the patient, taking into account her age of 71 years old, was
indeed having bilateral shoulder range of motion deficits. In addition, the observable finding by
the clinician of edema at the chest wall demonstrates that the patient was at high risk of
further developing upper extremity lymphedema. This is further solidified by the fact that the
patient’s medical history involved high-risk factors including chemotherapy, radiation therapy,
and bilateral mastectomy.
It is recommended that patients undergoing radiation therapy perform gentle global
flexibility exercises and AROM for generalized tissue mobility.10 This provides another reason
why the patient would potentially benefit from mat based Pilates exercises, which have been
PILATES EXERCISES IN PHYSICAL THERAPY 13
shown to increase flexibility and AROM.29 To determine the outcomes of the interventions
throughout the patient’s plan of care, the clinician remeasured the patient’s AROM, provided
the Quick DASH, assessed pain levels using the NPR scale, observed variations in edema, and
evaluated for changes in adhesions or muscular tightness.
INTERVENTION
Based on the initial examination findings, the clinician and the patient agreed that she
would benefit from receiving physical therapy services twice a week for eight weeks. The
treatment plan included The Physiological Oncology Rehabilitation Institute (PORI) specific
manual lymph drainage (MLD) techniques, manual therapy techniques to improve shoulder
impairments, modalities for pain relief and promotion of tissue healing, therapeutic exercises,
and instruction on a home exercise program (HEP).
During each treatment session the patient received MLD techniques specific to the PORI
approach. The clinician was certified in oncology rehabilitation through the organizations of
PORI and the Oncology Rehab. The MLD techniques were performed to the patient’s bilateral
chest wall and bilateral upper extremities at the beginning of each session with the intent of
reducing the patient’s chest wall edema and preventing any upper extremity lymphedema. In
addition, the patient was instructed on PORI home exercises for lymphedema prevention in the
upper extremity.
The manual therapy techniques performed during each treatment session consisted of
grade I-III joint mobilizations to the scapulothoracic and glenohumeral joints, scar mobilization
techniques, and soft tissue mobilization techniques to the pectoralis major and minor muscles.
The therapeutic exercises performed during each session consisted of a mat based Pilates
PILATES EXERCISES IN PHYSICAL THERAPY 14
exercise program which was created specifically for the patient through collaboration by the
physical therapist and a Pilates certified instructor. The mat based Pilates exercises were
selected with a focus on improving shoulder girdle flexibility, range of motion, and overall
strength. The treating physical therapist was able to utilize these exercises throughout the
patients plan of care and without the requirement of any Pilates specific equipment. The
patient was provided with a list of fourteen Pilates exercises as part of her home exercise
program. She was instructed to perform them twice a week on the days she did not attend
physical therapy with the parameters of two sets of fifteen repetitions per exercise. Current
research studies looking at the potential health benefits of Pilates exercises for patients with
breast cancer utilized exercise sessions lasting between forty-five minutes to one hour.42 To
adopt evidence-based practice, the exercise dosage for the case patient was prescribed to
ensure that session lasted between forty-five to sixty minutes. The list of mat based Pilates
exercises with links leading to video examples can be found in Appendix A as well as pictures of
the exercises in Appendix B.
OUTCOMES
As a result of the patient receiving radiation therapy concurrent with the physical
therapy plan of care, it was expected that she would experience side effects which would
interfere with her progress towards the established goals. During the fourth visit, the patient
reported experiencing left shoulder pain and discomfort when performing her home exercise
program. At the fifth visit, the clinician reviewed the home exercises with the patient to assure
proficiency and assessed her left shoulder for any change in status. It was noted that overhead
reaching in combination with external rotation provided the most significant pain and prone
PILATES EXERCISES IN PHYSICAL THERAPY 15
shoulder flexion exercises would elicit a pulling sensation. The left shoulder was also noted to
have an overt reduction of AROM when compared to the right side. In addition, a significant
increase in edema of the chest wall was observable on the left when compared to the right. The
empty can special test for rotator cuff impingement was positive for pain and muscular
weakness and the patient reported the most pain when placing the hand behind her back.
Based on patient report of complications from the port in her left chest wall and the effects of
continued radiation therapy, the clinician concluded that scar tissue buildup was contributing to
left shoulder deficits. Despite the patient’s symptoms in her left shoulder, she reported feeling
stronger and more confident when performing the home exercises, particularly with the right
shoulder. In the same visit, the patient was measured to have a two degree increase of right
shoulder flexion, an increase of two vertebral levels for right shoulder internal rotation, and no
change in shoulder abduction. During the 8th visit, the patient reported modifying the Pilates
exercises to her left shoulder by not reaching overhead or behind her back into extension due
to the amount of discomfort and pain that it induced. At the 10th recertification visit, the
patient stated that she had discontinued the Pilates exercises that were performed in the prone
position due to increased discomfort in this position. In the same visit, the clinician noted
increased right chest wall radiation burns, new presence of edema on the lateral portion of her
chest wall, and patient subjective report of feeling that the right shoulder was more limited. It
was concluded that the reasoning behind the new symptoms was secondary to a recent
increased dosage of radiation therapy on the right side. However, objective measures
demonstrated that the patient in fact had shoulder AROM improvements, apart from right
shoulder abduction (see Table 2 for comparison of outcomes). The measurements were also all
PILATES EXERCISES IN PHYSICAL THERAPY 16
above the reported standard error of measurement (SEM), two degrees, for shoulder flexion
and abduction using a universal goniometer.43 Using the NPR scale, pain levels were decreased
by three points in the left shoulder and chest wall and two points in the right shoulder and
chest wall (see Table 2). The reported minimal detectable change (MDC) for the NPR scale is 2.5
while the minimally clinically important difference (MCID) is 1.1.34 This means that the change
in right shoulder pain may have been due to measurement error, however would be considered
a meaningful change to the patient. An improvement of 15.91 points was reported on the
upper extremity Quick DASH since the initial evaluation (see Table 2). The amount of change
reported by the patient does not meet the SDC and therefore it could potentially have been
due to a measurement error. The change does however meet the MIC and would therefore be
perceived as an important or significant change to the patient.36,37 The patient reported that
she continued to perform the Pilates exercises at home as instructed with the modification of
not reaching overhead or behind her back with the left shoulder and discontinuation of the
prone exercises. There was no noted lymphedema in the upper extremities or patient report of
signs and symptoms consistent with secondary lymphedema presenting itself in the
extremities.
Table 2. Comparison of Outcomes
Measurement Initial Evaluation (12/17/2018)
Recertification Visit (01/28/19)
Quick DASH 52/100 36/100
Shoulder AROM (degrees) Flexion Abduction Internal Rotation
Right: 153° Left: 123° Right: 147° Left: 107°
Right: L1 vertebrae Left: L5 vertebrae
Right: 156° Left: 127° Right: 147° Left: 111°
Right: L1 vertebrae Left: L4 vertebrae
Numeric Pain Rating (NPR) Right Chest/Shoulder: 4/10 Left Chest/Shoulder: 7/10
Right Chest/Shoulder: 2/10 Left Chest/Shoulder: 4/10
PILATES EXERCISES IN PHYSICAL THERAPY 17
DISCUSSION
This case report details how mat based Pilates exercises could be incorporated into the
physical therapy management of a patient affected by shoulder impairments due to breast
cancer. The plan of care established by the treating clinician incorporated manual therapy
techniques, MLD techniques, therapeutic exercise, modalities, and a comprehensive HEP. It is
well established in the literature that CDT is an effective treatment for cancer-related
lymphedema, while stretching and range of motion exercises are effective for upper extremity
rehabilitation.23 One of the main strategies to achieving patient adherence and compliance is
through matching the interventions to their interests and lifestyle habits. Pilates in recent years
has gained consideration as a viable exercise model, especially in the field of women’s health.
As breast cancer is highly more prevalent in women, Pilates may be a viable and effective
exercise modality in obtaining desirable health outcomes. Improvements in patient adherence
and subsequent increased patient outcomes can occur if more exercise treatment options were
to be provided to the patient population, such as Pilates exercises. Although Pilates exercises
has been researched to provide positive outcomes in patients with breast cancer related
deficits, the studies did not include patients undergoing active cancer treatment.27-29 Physical
therapy management is further complicated by active cancer treatment as patients decrease
their physical activity and alter their exercise regime due to fear, depression, anxiety, and a
multitude of treatment side effects.31 This report offers a unique case as it utilized a non-
traditional exercise method in the therapy management of a patient undergoing active cancer
treatment.
PILATES EXERCISES IN PHYSICAL THERAPY 18
A limitation of this case report is that a multi-modal treatment approach was used,
inhibiting the ability to attribute specific treatment effects to individual patient outcomes.
Additional research is needed to analyze the distinct outcomes which mat based Pilates
exercises can provide for patients with breast cancer related shoulder impairments. Two recent
studies that looked at the effectiveness of Pilates-based exercises for breast cancer related
shoulder disorders reported that patients can experience shoulder flexion and abduction ROM
improvements by as much as ten to twenty degrees.16,29 When taking into account the current
information provided in the literature, the case patients range of motion improvements did not
meet the initial expectations. However, it should be considered that due to the potential side
effects of radiation therapy, the case patient’s outcomes were presumably diminished. It could
also be said that her participation in the mat based Pilates exercises was counter-acting any
further loss of upper extremity function that would have otherwise occurred if not for her
exercise regimen. The case patient’s improvements in pain level did however coincide with a
recent study that reported a mean VAS score improvement of three points in patients with
breast cancer related deficits who participated in a Pilates exercise program.16 This case report
adds to the literature as it suggests that mat based Pilates exercises may be a safe and effective
method for use in the physical therapy management of breast cancer related shoulder
impairments. In addition, it is a viable Pilates exercise method that does not require specialized
equipment and can therefore be easily implemented in various clinical settings.
PILATES EXERCISES IN PHYSICAL THERAPY 19
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Appendix A: Videos of Mat Based Pilates Exercises
Exercise Number Exercise Video Link
1 Chest Ball Press https://youtu.be/s1IDrezQbaA
2 Single Arm and Double Arm Ball
Roll-outs https://youtu.be/XOQGH56sdLo
3 Supine Bilateral Arm Rollouts https://youtu.be/6-c5vRhgdyQ
4 Supine Scapular
Protraction/Retraction https://youtu.be/6-c5vRhgdyQ
5 Supine Single Leg Bent Knee
Fallout https://youtu.be/7IDwflztQqs
6 Side Lying Hand on Forehead
with Upper Extremity and Spinal Rotations
https://youtu.be/VrB0kn65FDM
7
Side Lying Straight Arm Upper Extremity and Spinal Rotations
with Scapular Protraction/Retraction
https://youtu.be/VrB0kn65FDM
8
Upright Sitting Active Assisted Arm Flexion with Scapular
Upward Rotation using wand/stick
https://youtu.be/cAzihfpmqAU
9 Upright Sitting Active Assisted
Arm Internal Rotation and Trunk Side-bending using wand/stick
https://youtu.be/cAzihfpmqAU
10 Active Assisted Trunk and Arm
Circles using wand/stick https://youtu.be/cAzihfpmqAU https://youtu.be/RclpdoeSqvM
11 Active Assisted Scapular
Protraction/Retraction using wand/stick
https://youtu.be/RclpdoeSqvM
12 Prone on Elbows Scapular Protractions/retractions
https://youtu.be/XivSL3ARryw
13
Prone on Elbows with diaphragmatic breathing, and unilateral/bilateral shoulder
flexion in scaption plane
https://youtu.be/2F4bbr9zIxI
14 Upright Sitting Diaphragmatic
Breathing https://youtu.be/7RflnQeuQ14
PILATES EXERCISES IN PHYSICAL THERAPY 24
Appendix B: Pictures of Mat Based Pilates Exercises
Exercise Number Exercise Pictures
1 Chest Ball Press
2 Single Arm and Double Arm Ball
Roll-outs
3 Supine Bilateral Arm Rollouts
4 Supine Scapular
Protraction/Retraction
PILATES EXERCISES IN PHYSICAL THERAPY 25
Appendix B: Pictures of Mat Based Pilates Exercises (Continued)
Exercise Number Exercise Pictures
5 Supine Single Leg Bent Knee
Fallout
6 Side Lying Hand on Forehead
with Upper Extremity and Spinal Rotations
7
Side Lying Straight Arm Upper Extremity and Spinal Rotations
with Scapular Protraction/Retraction
8
Upright Sitting Active Assisted Arm Flexion with Scapular
Upward Rotation using wand/stick
PILATES EXERCISES IN PHYSICAL THERAPY 26
Appendix B: Pictures of Mat Based Pilates Exercises (Continued)
Exercise Number Exercise Pictures
9 Upright Sitting Active Assisted
Arm Internal Rotation and Trunk Side-bending using wand/stick
10 Active Assisted Trunk and Arm
Circles using wand/stick
11 Active Assisted Scapular
Protraction/Retraction using wand/stick
12 Prone on Elbows Scapular Protractions/retractions
PILATES EXERCISES IN PHYSICAL THERAPY 27
Appendix B: Pictures of Mat Based Pilates Exercises (Continued)
Exercise Number Exercise Pictures
13
Prone on elbows with diaphragmatic breathing, and unilateral/bilateral shoulder
flexion in scaption plane
14 Upright Sitting Diaphragmatic
Breathing