Pilates Based Exercise in Muscle Disbalances Prevention and Treatment of Sports Injuries

The Pilates method has today become more popular than ever. As a form of movement it serves as a basis for fitness, complements sports training and is also one of the methods of physiotherapy. Pilates method combines features typical both for Eastern systems (mind control during exercises, relaxation, increasing of elasticity, movement starting from body center, balance) and Western systems (forming strength, endurance, exercises having both global and local effects). The primary goals in muscle-strain rehabilitation include not only recovery of muscle strength and flexibility but also correction of muscle imbalances. In prevention of sports injuries complementary training regarding body awareness, economical breathing, neuromuscular coordination by executing fluent and precise movement starting from a strong core is suggested. The Pilates based exercise, performed under the supervision of a certified instructor serve these needs and can be part of prophylaxis and kinesitherapy in sport medicine.


Introduction
The Pilates method has today become more popular than ever.As a form of movement it serves as a basis for fitness, complements sports training and is also one of the methods of physiotherapy.Pilates method combines features typical both for Eastern systems (mind control during exercises, relaxation, increasing of elasticity, movement starting from body center, balance) and Western systems (forming strength, endurance, exercises having both global and local effects).The primary goals in muscle-strain rehabilitation include not only recovery of muscle strength and flexibility but also correction of muscle imbalances.In prevention of sports injuries complementary training regarding body awareness, economical breathing, neuromuscular coordination by executing fluent and precise movement starting from a strong core is suggested.The Pilates based exercise, performed under the supervision of a certified instructor serve these needs and can be part of prophylaxis and kinesitherapy in sport medicine.

Joseph H. Pilates -A sportsman and kinesitherapist
Joseph Humbertus Pilates  was born in Germany with poor health.The medicine at that time could not offer any antibiotics nor other modern cures.Human health depended mostly on being able bodied.Regular physical exercises were regarded as a prime method of prevention and treatment of many illnesses.From his parents Pilates learnt how to run sport activities and incorporate physical exercises in the healing process to stimulate it.In the 19th century there were two main gymnastic systems.The first one was developed by the German Friedrich Jahn.His system derived from ancient Greek gymnastics and was mostly focused on improvement of strength and fitness, which, according to Jahn, were directly connected with well being.The second system, created by the Swede Per Henrik Ling, emphasized rhythm and fluidity of movements.The purpose of these exercises was to repaired.This method of kinesitherapy remains highly relevant today and can be applied to people of all fitness levels (Lately, 2002).Nowadays, applied Pilates based exercises have been influenced by other body-mind methods and improved by an improved understanding of the human body, new perspectives on illness, advances in medical treatment, new understandings in stress management, developments in psychology and teaching skills.We also support the statement of Lately (Lately, 2002) that updating the principles of the Pilates method has given physiotherapy a new direction, and influenced exercise prescription in many body work fields, including sports medicine.We mainly concentrate on the prevention of injury caused by muscle imbalances and post-acute rehabilitation.

Methodology and equipment in Pilates' system
Pilates' exercise system can be divided into two categories: floor mat exercises and professional Pilates' devices.Originally, J. Pilates invented a system of stretching and strengthening mat exercises.Later this was extended to include exercises designed using specially designed apparatuses, e.g.Universal Reformer, Cadillac (Trapeze Table ), Wunda (Combo) Chair).The basis of the Pilates system are mat exercises.Postural muscles are mainly strengthened and stretched in low positions, using gravity and the exercised parts of the body.Balanced development of these muscles promotes proper body posture during various activities of daily living and decreases the effects of long-lasting burden, caused by practicing diverse sport disciplines.This makes the Pilates method similar to spine stabilization exercises.It assumes that weakness or fatigue of postural muscles can lead to disturbances of stability in the lumbar spine, which in turn can lead to strain injuries and chronic back pain.A critically important element of this type of training is conscious activation of the profound muscles of abdomentransversus abdominis (TrA) and pelvic floor muscles (PV), which should fire first for premovement stability, and recovering elasticity and eccentric work of superficial muscles.Exercises on professional Pilates' devices are mainly resistance exercise performed with the aid of springs and pulleys, but also stress relief of certain parts of the body can be achieved.The machines can be customized to the needs of the practitioner.The resistance during the exercise allows movement to be isolated and performed in the proper plane.Additional resistance prevents automatic movements being responsible for injuries.The exercises using professional Pilates' devices can be performed in post-acute state of sports injuries.

Fig. 1. Multidimensional exercise with Pilates circle
Pilates method also utilises small equipment (balls, foam rollers, Pilates circle, balance boards, Thera-bands etc.).They can be used in intralimb and interlimb coordination exercises, or as an element making exercises more attractive.They can also help transferring the learnt exercises to the movement required to run particular sport activities.(e.g.catching or kicking the ball).In physiotherapy praxis Pilates based exercises are also performed with a gymnastic stick, a gym ladder and a stool.Pilates based exercises using a Swiss ball are also very popular, as is sensoric massage with this tool.

Fig. 2. Sensoric massage with Swiss ball
Exercises are performed from low (lying prone, supine, side-lying, quadriped, sitting) medium and high (kneeling, standing) postures.Low postures ensure better stability during the exercises, used particularly at the early stage of movement learning.Such positions facilitate proper performance of complex movements of upper and lower limbs, aiding concentration on other aspects of exercises (e.g.breathing, precision, flow).In case of complaint such as after injuries or with chronic low back pain, low position stabilisation of the trunk prevents additional unwanted movements that could cause more pain during exercising.For this reason low positions are more often used in early stages of after-injury rehabilitation excluding exercises exerting long lever on the spine.The upper positions can be used at the later stages of rehabilitation.Regardless of the exercise type and position, the movements are performed slowly and deliberately, beginning by correcting the starting position using physical or verbal instructions.The number of repetitions is usually limited to 5-10.Pilates claimed that the lesser the number of repetitions of the movement performed properly the better the therapeutic effect was.Excessive number of repetitions performed without concentration and awarness can be harmful and lead to injuries.From approximately 500 mat or device exercises that have been developed in Modern Pilates the training programs should be tailored to the practitioner on an individual basis, taking into account his movement abilities and needs (elasticity of tissues, muscle strength and endurance, coordination and concentration ability).The best results can be achieved when practicing one-on-one or in small groups.The implementation of this method for sports training should start with introducing the socalled pre-Pilates exercises, which allows a moderate degree of difficulty to implement all the principles of this technique from the three-dimensional breathing, slowly adding body aligment, concentration, control, stamina and fluency in performing movement.Moreover, in modern Pilates based exercise it is not recommended to start each session with an exercise called "The Hundred", as it used to be in traditional Pilates method.According to Lately (Lateley, 2002) this exercise is particularly arduous as an initial exercise, might be extremely dangerous for someone new to the method, and even under supervision can result in severe injury.The authors concur with Lately on this issue.

Body-mind exercise system
The purpose of the system of fitness exercises developed by Pilates is to develop harmony of body, mind and spirit by improving muscle strength and increasing the elasticity of active movement structures.The movements are carried out slowly and fluently with focused attention.These exercises are referred to as a "body-mind exercise system".Other such systems include also Yoga, Tai Chi and Feldenkreis' method."Body-mind exercises" is not the name of the exercise, but rather a description of how an exercise should be performed.Their common features are: mind control during exercises, relaxation of muscles and joints not involved in exercise movement, and maintaining muscles' physiological elasticity, with movement starting from body centre.Understanding one's individual optimal postural alignment (neutral posture) will allow economy of movement, a natural flow of compensatory patterns, so that no muscle is overworked or misused, without aiming for perfect symmetry.Pilates explained the balance of body and mind as the conscious control of all muscular movements of the body.It is the correct utilisation and application of the leverage principles afforded by the bones comprising the skeletal framework of the body, a complete knowledge of the mechanism of the body, and a full understanding of the principles of equilibrium and gravity as applied to the movements of the body in motion, at rest and sleep.Concentration and awareness is one of the fundamental principles of Pilates' system.It determines movement in a particular muscle group.It is very important, especially when other sectors of locomotors apparatus do not act properly or are not in natural alignment because of trauma or sport injury.That is why Pilates' system is nowadays recognized as a relatively safe alternative for intensive aerobic or weight bearing exercises.(Latey, 2001, as cited in Latey, 2002).Awareness of the performed movement improves its efficiency and quality of movements.According to the original assumptions of the Pilates' system it requires at least an elementary knowledge of biomechanics and functional anatomy by the practitioner.It facilitates the process of learning new movement patterns, especially those to be transferred into functional tasks such as walking, reaching, lifting and other daily living or sport activities (Lange et al., 2000).Focusing on the therapeutic movement, particularly in the case of sport injuries helps to avoid errors in repeating the exercises without therapeutic supervision.Proper learning of movement can be also achieved with the help of hands-on guiding, assisting correct movement (touch can improve muscle engagement and relaxation).Verbal cues also play a very important role in increasing awareness of the therapeutic movement being performed and learnt.This applies particularly in the case of a limited amount of information such as typically used with elderly or stroke patients (Lange et al., 2000;Latey, 2000).Verbal cues of the Pilates based exercise instructor as well as his tactile stimulation (hands-on) aim to motivate the exercisers to increase the focus on how to perform movement and maintain the desired body position, so that sensorimotor integration is stimulated.Moreover, connecting the mind and body requires the exercising person to tune into their bodily sensory systems.Touch can improve muscle recruitment, a client's awareness and also introduce better body biomechanics and relaxation.Awareness of the sensations, touching the muscles and joints helps to focus concentration.Awareness of the body also assists in reducing overwork, strain and tension.Sportsmen particularly need awareness of their body, particularly the muscular sensations, so as to direct mental and physical efforts efficiently.Attending to the feedback from the proprioceptor system makes the individual aware of what is being done.Precision assists coordination; this is the practical application of focused awareness.Fig. 6.Manual stimulus for increasing body awareness and desired muscle recruitment

"Powerhouse" -The strong core
Popular weight lifting in a gym studio typically focuses on improving muscle strength by shortening the muscles; the complex role of the supporting muscles is ignored.However, as the body lengthens, the diagonally opposed supporting muscles also have to work well.Stretching the muscles is an important part of sport training and in order to regain muscle balance, with the muscles lengthening and working at the same time, eccentric muscle contractures with proper support from stabilizing deep muscles and the body centre is needed.
Major emphasis in the Pilates concept should be placed upon the muscles forming 'powerhouse'-the body centre.Joseph Pilates himself never set down in writing what the exact parameters of the powerhouse were and there does not seem to be exact agreement amongst the master teachers of Pilates today.In a recent legal decision, the ability to trademark the name Pilates, and consequently the sole right of certification of Pilates instructors was lost.This means that there is no longer one certifying or governing body that determines exactly what the Pilates method is or is not.As a result, the Pilates based exercise, along with the underlying biomechanical basis, has been diverging greatly in recent years.There are now many techniques within the Pilates world, some adhering strictly to the system of exercises developed by Joseph Pilates, and others that are incorporating changes into this system.The powerhouse is the core centre of the body from which peripheral muscle actions are carried out.The idea of centring is to create not only a strong structural powerhouse, but also a flexible one.Indeed, Joseph Pilates had the following maxim on his business card: ''A man is only as old as his spine is inflexible''.Profound muscle strengthening is a very important supplementation for training in various sports disciplines where big, superficial muscle groups are mainly reinforced.Skipping profound muscles in strength training leads to imbalance, which increases the risk of trauma, and often is the reason for serious sport injury.It is suggested that treatment of muscle imbalances should start with exercises that isolate specific core muscles and then progress into functional activities or complex sports movements where these muscle should act in synergy to stabilize the lumbo-pelvic region.Pilates method of body conditioning may be generalized to have three major effects upon the powerhouse.First, Pilates affects the posture of the pelvis, which results in postural changes to the lumbar spine.Second, it works directly upon the musculoskeletal structure of the spine (the lumbar spine in particular) by strengthening, stretching, and lengthening the spine.Third, Pilates affects the structural integrity or tone of the abdomino-pelvic cavity as a whole.The posture of the pelvis largely determines the posture of the spine.The spine sits upon the base of the sacrum; therefore, any change in the sagittal posture of the pelvis will change the level of the base of the sacrum.The level of the base of the sacrum will in turn affect the curve of the lumbar spine.However, once the base of the sacrum is uneven to any degree, the spine must have a curve in it to compensate.This curve is necessary to eventually create a level base for the head to sit upon.This righting mechanism to create a level base for the head is necessary to place the eyes and the labyrinthine receptors of the inner ear on a level plane, this being necessary for proper static and dynamic proprioception of our body.Fig. 7. Execution of strong core with body alignment before and during movement One of the major emphases of Pilates is to address the posture of the pelvis by addressing the musculature of the pelvis.Pilates further corrects this imbalance by placing a strong emphasis on stretching the low back musculature.In this manner, Pilates aims to create a neutral pelvis, and thereby create a healthy lumbar lordosis.(Muscolino& Cipriani, 2004as citated in Selby, 2002;Siler, 2000;Winsor, 1999).

Breathing in Pilates
Body posture has an impact on the functioning of the entire human organism.There are reasons to believe that correct posture is a prerequisite for correct breathing patterns (Fiz & Gnitecki, 2008).Deficient respiratory capacity reduces the amount of oxygen delivered to body cells, which hampers both physical and intellectual performance.Symptoms of oxygen deficiency include headache, vertigo, lack of appetite as well as concentration and memory malfunctions.Lower oxygen levels have a negative impact on muscles, which are likely to work deficiently under such circumstances and tire faster, which can lead to general fatigue and listlessness.The body tries to compensate for the oxygen loss, involving additional breathing muscles in the respiratory process, which then requires higher energy consumption and reduces its efficiency.The entire body is involved in breathing.During respiration, the functioning of the breathing muscles changes the dimensions of the chest.Shoulders and particular backbone sections are also part of the breathing cycle.Any immobilization, disfigurement, pain, lesions or developmental defects of the chest, as well as breathing muscles palsy can have important consequences for mobility and thus reduce the lungs' ventilation range.It needs to be stressed that most pathological processes, not only such severe ones as pneumonia, bronchitis, chronic obstructive pulmonary disease and heart failure, but also those of lesser clinical importance, including meteorism, intercostal nerve pains, or shoulder neuralgia clearly change the breathing mechanics (Dyszkiewicz et al., 2003).Changes in posture and its incorrect models related to the synchronized functioning of the muscles of the neck, upper body, abdomen, shoulders and pelvis are crucial for breathing (and in consequence for chest mobility).Other remote factors, seemingly unrelated to chest biomechanics, include the impairment of the motoric function of the lower extremities and the backbone, with a modification of the movement patterns.Research carried out by Szczygieł (Szczygieł et al., 2010) on healthy people indicated that even momentary slightly forced posture distortions can have a strong impact on breathing parameters.The research was an attempt to specify the plane in which posture distortions most severely influence the functioning of the respiratory system.Results show that the body arrangement most likely to lead to a reduction of the VC is posture with counterlateral head, shoulder and hip rotation.The position responsible for the greatest reduction of other factors (VC-Vital Capacity, FEV1-Forced Expiratory Volume in One Second, MEF75-Maximal Expiratory Flow at 75% of Force Vital Capacity, MEF50-Maximal Expiratory Flow at 50% of Force Vital Capacity, MEF25-Maximal Expiratory Flow at 25% of Force Vital Capacity and PEF-Peak Expiratory Flow) was frontal stooping.Positions with sagittal plane changes had the smallest effect on breathing mechanics.Therefore, optimum conditions for breathing require an axial arrangement of particular body segments.According to Joseph Pilates "breathing is the principal art of life.Our life depends on it.Millions have never learned the art of correct breathing."From the day we were born, we have been breathing unconsciously, without worrying if our breathing is correct.Correct coordination of breathing with a particular exercise is the rule of thumb applied while teaching the Pilates method.Correct breathing improves blood oxidation, brain function and movement control.In Pilates, costal-diaphragmatic breathing is used, accentuating protracted exhalation with simultaneous drawing of the navel closer to the spine.While inhaling, the chest expands in three planes, and while exhaling, abdominal oblique muscles become involved.This is called "lateral breathing".Lateral breathing causes the chest to expand, and the air penetrates the back and lateral parts of the chest.This stimulates intercostal muscles, allowing them to expand and making the upper body more agile.Normally, our breath is too shallow, and stress compounds the problem, making our breathing faster and even shallower (Rakowska, 1990).Women tend to breathe with the tip or the upper part of the lungs, raising their shoulders and the upper body.Men are more likely to breathe using their diaphragm, making their abdomen expand with every breath.
An important element of the Pilates method is being able to expand the ribs laterally, which helps you to draw in your abdomen, at the same time relaxing the upper body.While accentuating the axial arrangement of the body, the method ensures the optimum conditions for the respiratory system and helps to stabilize the backbone.This is of crucial importance for people practicing sports, who are likely to adopt forced body posture.This increases the risk of overload changes in the body, and hampers the functioning of the respiratory system (Bliss et al., 2005).Unlike other exercises based on passive breathing, the Pilates breathing method involves active respiration.It activates outer intercostal muscles and abdominal muscles.The most efficient muscle participating in breathing out, and thus in increasing the pressure in the abdominal cavity is the transverse abdominal muscle (Zocchi et al., 1993).

Fig. 8. Pilates method breathing
Deep breathing is an important element of exercise optimisation.The fact that the basic movements in the exercise are made while breathing out, sets the method apart from others.In addition, prolonging exhalation helps to counteract the occurrence of undesirable tension (protracted additional respiratory muscle cramps) and ensures greater stabilization in the most difficult phases of the exercise.While considering reports on the effectiveness of the method, an issue that must be mentioned is the case of diaphragm rupture while breathing deeply using the Pilates method (Yang et al., 2010).Cases of such spontaneous diaphragm rupture, without prior antecedents in patients, are extremely rare.They may occur e.g. with abrupt coughing.They account for ca.1% of similar diaphragm problems (Gupta et al., 2005).The causes are related to a rapid increase in abdominal pressure.Weighted against the benefits of the method, such cases seem to be of marginal importance.Meanwhile, both scientific magazines and popular science publications frequently look at bronchial asthma in athletes.Statistics regarding asthma indicate that it occurs more frequently in athletes than in the general population (Weiler et al., 1998).This topic is quite controversial.On the one hand, it is suggested that prolonged intensive training may lead to the development of bronchial asthma (Weiler et al., 1998) and (Helenius et al., 1998).At the same time, the issue of the use of medicines by asthmatic athletes in the context of pharmacological doping is raised.In light of the above, the Pilates breathing method may be a valuable element of physical training.There is no doubt that optimum breathing allows for longer and more intensive training without running the risk of excess fatigue.The asthma debate is exhaustively discussed in an article by Wroński.The author believes that Pilates breathing exercises can be used to complement drug therapy in children and young people with bronchial asthma (Wroński& Nowak ,2008).

Muscle imbalances and Pilates practising by sportsman
The muscle balance in any joint is determined by the ratio of torques between agonist and antagonist muscle groups.The coordination of movements depends on the coordinated actions of muscles on the opposite sides of a joint.This prevents injuries of muscles, tendons, and joint elements during fast movements.The deficiency of strength in one muscle or muscle group can lead to imbalance in the joint actions, which in turn can cause traumas of muscles and joints due to the anomalous distribution of mechanical stresses and strains.( Pontaga, 2003) The terms muscle balance or imbalance do not refer to equal or unequal torque values, but to the balance between the torque ratios of agonistic and antagonistic muscle groups (Gioftsidou et al., 2008).There is a failure of the agonistantagonist relationship and to their balance between the torque ratios.Muscle imbalances resulting in overloaded movement apparatus can result from frequent repetition of movement patterns specific to the sport's discipline.Static overload refers to the maintenance of posture of the body for a longer period of time such as the trunk flexion in cycling, downhill, speed skating, alpine skiing.Dynamic overload can result from forced movement which is typical of the discipline, leading to the development of muscle imbalances.Because the human physiological motor activities take place in the area of the force of gravity to align the existing muscle imbalances Pilates method offers exercises in various starting positions with multidimensional movements in which skeletal muscle are activated in a manner conducive not only to development of their strength but also endurance, flexibility and neuromuscular coordination.Therefore, this system, with appropriate supervision and adjustment of the degree of difficulty of the exercises to be performed without losing the flow of movement and dynamic stabilization of the deep muscle system appears to be appropriate in the eradication of unwanted muscle imbalances.Recent studies hypothesized a common muscle imbalance pattern of weakness in gluteus medius and tightness of the iliotibial band in chronic musculoskeletal pain syndromes in the lumbar-pelvic-hip area such as chronic low back pain.Investigators categorized muscles, based on their primary functions, as "phasic" or "postural", and indicated that in response to dysfunction or overuse, the phasic muscles tend to be inhibited or weakened; while the postural muscles tend to develop higher tone and ultimately shorten.[Jull&Janda, 1987, Janda 1992,1993 as cited in Arab&Nourbakhsh, 2010] Tight muscles are activated more readily during movement patterns and become overactive.Once the phasic and postural muscles are no longer activated in balance, they are unable to protect the body's joints from the effects of gravity.(Page, 2005) In this classification, the gluteus medius; primary muscle for hip abduction, is categorized as phasic and the tensor fasciae latae and iliotibial band the synergist muscle, is categorized as postural muscle.It is speculated that the iliotibial band shortness in patients with low back pain is a compensatory mechanism following hip abductor weakness.(Jull&Janda, 1987 as cited in Arab&Nourbakhsh, 2010).Controversial results have been reported in the studies which examined the relationship between hip abductor strength and the iliotibial band syndrome in runners.Some researchers concluded after conducting a study with runners with the iliotibial band problems that strengthening of the hip abductors has been recommended for symptom improvement in subjects with the iliotibial band dysfunction (Fredericson&Weir, 2006, MacMahon et al. 2000 as cited in Arab&Nourbakhsh, 2010) while others in contrast (Grau et al., 2008 as cited in Arab&Nourbakhsh, 2010) concluded that weakness of hip abductors does not seem to play a role in the etiology of the iliotibial band syndrome in runners.Some reports have also demonstrated an association between LBP and hip abductor muscle weakness.Considering the above reports and the promising results of research on the effects of Pilates exercises to reduce chronic low back pain seems to be a reasonable recommendation to use Pilates techniques for athletes with low back pain.Note, however, that the scientific evidence demonstrating the efficacy of this method in the treatment of back pain are incomplete.Modern group sports such as soccer is marked by a faster speed of play than in the past, and this inevitably translates into an increase in the intensity of practice sessions.This may justify an increase in the percentage of muscle strains occurring during practice.We suggest an assessment whether it is observed that a player's muscle imbalances is only an adaptive response to the athlete's body to the demands of the discipline and is tolerated by him, or results of biomechanical changes in articular' trajectory caused by the development of the areas in the body with reduced resistance to overload (locus minores resistanci).It is worth to check if after previous trauma protective mechanisms of the damaged area have extinguished and not result in persistently maintaining the stiffness and the development of undesirable tissue compensation.Because such mechanism may change a whole myofascial chain and neuromuscular coordination it is possible that pain may also occurs in a place located far away from the primary pathology.Also, persistent pain or fear of its occurrence may lead to changes in motor programs resulting in the development of muscle imbalance syndromes, particularly in muscle tone and their flexibility.For example, examining the strength and elasticity of muscles of lower limbs, often stated gluteal muscles weakness and their function of the hip' extension is overtaken by hamstring muscles which results in excessive tension and shortening.In turn, the weakening of the abductors and external hips' rotators, usually cause the hypertone in the area of iliotibial band.Certain muscles in the human body are especially subjected to strain traumas, for example, the posterior muscle group of thigh.The simultaneous extension of the hip joint and flexion of the knee stretch the posterior muscle group of thigh and, if the movements are very fast and forceful (sprinting, bobsledding, jumping, and other athletic sports), these muscles can be injured.(Pontaga, 2003).In the study analysing muscle injuries suffered in Italian major-league soccer team during the period 1995-2000 it was found that among the overall injuries, muscle accidents were the most frequent, representing 30% (103 cases), followed by contusions (28%), sprains (17%) and tendinopathies (9%).Proposed causes of muscle strains were: lack of training, insufficient warming up, excessive fatigue, strength imbalances, flexibility deficiencies, muscle weakness and insufficient rehabilitation.(Volpi et al., 2004) A study of the role of eccentric muscular work in the development of muscle strains found a residual eccentric-strength deficit in sprinters with a history of hamstring injury compared to runners with no injuries.(Jonhagen et al. 1994as cited in Volpi et al., 2004) Factors increasing the risk of developing acute muscle injuries, include decreased muscle strength, mainly eccentric muscle strength and muscle imbalance (decreased eccentric work of antagonist to concentric work of agonist (Schwellnus, 2004as cited in Gioftsidou et al., 2008).In running and kicking there is an important eccentric activation of thigh muscles.When decelerating in running, the hamstrings act eccentrically to slow extension at the knee, and the quadriceps act eccentrically to control the lowering of body weight when athletes approach a stop.In kicking muscles, activation follows "the soccer paradox" meaning that Fig. 9. Push-up exercise on Swiss ball, starting position without "locked elbows" Fig. 10.Push-up exercise on Swiss ball , movement with activation of strong core It was found that the upper trapezius and serratus anterior are under differing cortical control mechanisms, with trapezius but not serratus demonstrating both contralateral and ipsilateral responses to cortical magnetic stimulation.Increased upper trapezius tone and constant readiness to activate disturbs the humero-scapular rhythm and is also an indication of fatigue or compensation of serratus anterior.As muscle fatigue can be a central phenomenon as well as a peripheral phenomenon, the upper trapezius may have been recruited differently during or after the task.(Alexander et al., 2007, Hunter et al., 2006as cited in Szucs et al., 2009) It is ball, important that performing Pilates Push-up, which is an exercise in close kinematic chain, serratus anterior muscle should be activated rather than a dominant role of upper trapezius muscle which can be achieved by the alignment of spine, unlocked elbow joints, lower -costal breathing and touching stimulus of an instructor during execution of an exercise.The Push-up exercise has been recommended as a rehabilitative exercise for individuals with shoulder pathology because it strongly activates serratus anterior while minimizing upper trapezius co-activation (Ekstrom et al., 2005, Lear&Gross 1998, Ludewig et al., 2004as cited in Szucs et al., 2009).Using this task as a rehabilitative exercise may be too strenuous for most patients, but it may have potential as an assessment tool to help determine the success of serratus anterior strengthening and endurance training or the readiness for return to high demand overhead work.(Szucs et al., 2009) The results of the controlled study with 19 participants show that a 12-week long Pilates training program was effective in improving core strength and posture (exercising subjects showed smaller static thoracic kyphosis during quiet standing) as well as certain aspects of scapula and upper trunk displacement during a shoulder flexion task.As deficits in neckshoulder biomechanics have previously been associated with symptoms in the neckshoulder region, these results could support the use of the Pilates method in the prevention of neck-shoulder disorders.(Emery K., 2010) In our opinion Pilates can be recommened as a complementary exercising method for many sports discipline to reduce muscle imbalances, increase body awareness, sensomotoric coordination, economical breathing, body aligment, precision and fluency in movement however deep understanding and proper implementation in the practise the main Pilates principles under close supervision of certified and experienced Pilates instructor is needed.

Pilates method in evidence based medicine
Current state of neurophysiological and biomechanical knowledge has caused that classical Pilates technique evaluated into Pilates based exercises which are recommended for use by people of varying age and physical proficiency.We conducted database searches (SPRINGER LINK, SCIENCE DIRECT, EBSCO HEALTH SOURCE, MEDLINE, PUBMED, COCHRANE, EMBASE) up to the June 2011 to investigate the application and effectiveness of this method using the key word "Pilates".

Pilates based exercise programs effects in different age population
Rogers and Gibson explains that studies concerning Pilates method primary concentrated on its effects in rehabilitation or to increase specific component of movement -such as tennis serve velocity (Sewright, 2004as cited in Rogers&Gibson, 2009), leaping ability (Hutchinson 1998as cited in Rogers&Gibson, 2009) or muscular strength and endurance in specific population.In a controlled experiment of Rogers and Gibson with healthy, young objects (n=28) in which novice practitioners (n=9) participated 3-times a week, 1-hour session in 8-week traditional mat Pilates program, it was concluded that in experimental group body composition, muscle endurance and flexibility improved compared to participants of university wellness centre forming the control group.(Rogers&Gibson, 2009) In the controlled study of Siqueira Rodriges with 52 elderly females, 27 persons formed the Pilates group participating in Pilates exercises twice a week for eight weeks.The researchers concluded that the practice of the Pilates method can improve the functional autonomy and static balance of elderly individuals (Siqueira Rodrigues et al., 2010) In pilot study with 7 older adults who participated in a novel Pilates inspired exercise program specifically designed to improve balance in an upright position, referred to as postural stability it was indicated that the effect in relation to static balance can be a consequence of postural stability, reached by the harmony of opposing muscle groups.(Kaesler et al., 2007) Siqueira Rodrigues introduce Pilates as a method consisting of a physical exercise that uses resources such as gravity and the resistance of springs, either to resist or assist movement execution (Gagnon, 2005as cited Siqueira Rodrigues et al., 2010).It aims to prevent automatic movements, which are responsible for unwanted muscle activity that can cause injuries (Petrofsky et al., 2005as cited in Siqueira Rodrigues et al., 2010).Siqueira Rodrigues also indicates that Pilates method has been studied in relation to its positive effects on posture (Blum, 2002as cited in Siqueira Rodrigues et al., 2010), pain control (Gladwell et al., 396 2006as cited in Siqueira Rodrigues et al., 2010), improved muscle strength (Schroeder et al., 2002as cited in Siqueira Rodrigues et al., 2010), flexibility (Segal et al., 2004as cited in Siqueira Rodrigues et al., 2010), and motor skills (Lange et al., 2000as cited in Siqueira Rodrigues et al., 2010).The positive influence of Pilates exercise on dynamic balance and personal autonomy in healthy adults was assessed in the controlled study with the 17 participants of 10 Pilatesbased exercise sessions performed on a Reformer and including a tall arm series, open leg rocker, leg press series and tall kneel arm series.After the Pilates training significant change in dynamic balance was found in the Functional Reach Test, while control, non-exercising group (n=17) demonstrated no significant change.These findings suggest that Pilates-based exercise may be a useful tool for clinicians and trainers to incorporate with their patients and clients who are looking to improve their dynamic balance and also benefit athletes who are seeking small gains to improve performance through precise, controlled movements.(Johnson et al., 2007) Some authors indicates that Pilates encouraged the importance of proprioceptive stimulation for motor learning improvement using the powerhouse exercise (transversus abdominus, obliques, and multifidi muscles) and repetition of correct movement to achieve the training standard, leading to a better motor performance and less risk of injuries.(Anderson & Spector, 2000as cited in Siqueira Rodrigues et al., 2010) An observational study was conducted to assess and compare the contraction of the transversus abdominis muscle among 36 healthy females (mean age 36.2) trained in Pilates, traditional abdominal curls and a control group.To indirectly measure contraction of the transversus abdominis muscle and to monitor lumbar-pelvic stability, a stabilizer pressure biofeedback unit (Chattanooga Group Inc.) was employed and a tester, blinded to group category, conducted the measurements.For the lumbar-pelvic stability test, only 5 (42%) Pilates group subjects passed this test, with all others failing this test, leaving 14% overall who were able to stabilize the lumbar-pelvic area.The authors concluded that females who train in Pilates may be better able to recruit and utilize their deep abdominal muscles and stabilize the pelvic area compared to those not trained in Pilates.(Herrington & Davies, 2005) In the controlled, experiment with 34 pain-free health club members with no Pilates experience who were randomly assigned to an unsupervised twice weekly of eight weeks Pilates mat exercises or strength training it was concluded that transversus abdominis activation increased following a programme of unsupervised Pilates mat exercises that is practical and requires no special equipment, however, there was no change in abdominal muscle activation during functional postures.The researchers suggested that supervision of exercises and progression to more functional exercises may be required to increase functional abdominal activation.(Critchley et al., 2011) Performing Pilates exercise might prove to be a useful means of increasing activity and thereby curbing the obesity epidemic of female teenagers.It was proven in a randomised, controlled study that 4 weeks long physical training with the Pilates technique lowered the BMI percentile of 10-to 12-year-old girls.(Jago et al., 2006)

Pilates method and low back pain
Two systematic reviews of all controlled clinical trials of Pilates to treat low back pain were recently conducted.In the most recent review the search strategy was filled up to May 2010 and generated a total of 199 references, of which 51 were considered potentially relevant.Study quality was assessed using the Oxford scale.Four eligible randomized controlled clinical trials (n ¼ 4) involving Pilates for the management of low back pain were included.They originated from the United Kingdom (Gladwell et al., 2006as cited in Posadzki et al., 2010), the United States (Head et al., 2006as cited in Posadzki et al., 2010), Italy (Rydeard et al., 2006as cited in Posadzki et al., 2010) and Canada (Vad et al., 2007as cited in Posadzki et al., 2010).Although some of the authors of the reviewed studies conclude that Pilates yielded better therapeutic results than usual or standard care, the findings of this review suggest that the evidence available for its clinical effectiveness is inconclusive.(Posadzki et al., 2011) The second systematic review published this year with meta-analysis aimed to compare pain and disability in individuals with persistent nonspecific low back pain who were treated with Pilates exercises compared to minimal or other interventions based on 7 randomized controlled trials.In conclusion they stated that Pilates-based exercises are superior to minimal intervention for reduction of pain in individuals with nonspecific low back pain.However, Pilates-based exercises are no more effective than other forms of exercise to reduce pain.In addition, Pilates exercises are no more effective than minimal intervention or other exercise interventions to reduce disability related to chronic low back pain.(Lim at al., 2011) These two systematic reviews show that the evidence base for Pilates method effectiveness in treatment of chronic low back pain remains scarce and therefore larger and betterdesigned clinical trials are needed.

Pilates based exercise in post-surgery rehabilitation
Pilates practice applied in post-surgery rehabilitation were found in conference review, preliminary report and case study article.It possible to use different tools and special equipment when incorporating Pilates based exercise into treatment process.In the review which aims was to establish an evidencebased approach to the postoperative rehabilitation of the knee following anterior cruciate ligament reconstruction, arthroscopic meniscectomy and meniscal repair surgery exercises performed with the use of Pilates Reformer machine were investigated.The authors emphasized that there has been a gradual move away from traditional methods towards accelerated rehabilitation programs for anterior cruciate ligament reconstruction following the observation that patients who had been noncompliant with traditional rehabilitation progressed more rapidly.(Decarlo et al., 1992, Shelbourne et al., 1990as cited in Atkinson et al., 2010) They claim that accelerated rehabilitation programs, which aim to overcome the common post-surgical problems of prolonged knee stiffness, anterior knee pain, difficulty gaining full extension and delays in the strength recovery, maintaining knee stability may include following types of exercise: closed and open kinetic chain, eccentric, concentric, isometric, isokinetic, plyometric, sport-specific and Pilates method.The Pilates Reformer machine exercises allowing the patient to be p o s i t i o n e d i n s u c h w a y a s t o h e l p t o r e move gravity from the equation and other equipment exercise for core stability strength and co-ordination are included after the 4week in post-operative anterior cruciate ligament reconstruction protocol.The author indicates that additional use of Pilates Reformer machines according to the principles of the Australian Physiotherapy and Pilates Institute may allow for earlier progressive load bearing and introducing squatting or lunging activities in treatment process.The theory behind this approach is to introduce consistent motion and defined joint ranges early in the rehabilitation period, using zero-gravity spring-based resistance.This allows for exact functional patterns and muscle memory to be retrained and thus, when the patient is ready to weight bear into a squat or lunge, the motion has already been learned.Though there is currently little scientific data to support this new approach, it may shorten rehabilitation by as much as 4 weeks, with the largest effect seen within the first 2 months.The authors of the survey proposed at the 3-month post-operative review functional exercise for neuromuscular coordination and also Pilates exercises for core stability and strength with the application of all equipment.(Atkinson et al., 2010) In a preliminary report with 38 participants Pilates method was introduced into modified exercises programme developed to account for the postoperative precautions and needs of total hip and knee arthroplasty.At 1 year follow up, review of patient charts and follow up telephone calls revealed; 25 patients were extremely satisfied and 13 were satisfied with their outcome and use of Pilates in their rehabilitation.From these observations of a small number of patients it was concluded that this technique can be utilized without early complications, however, further studies are necessary to confirm its utility and safety.(Levine et al., 2009) Other report which documented the use of the Pilates method in medical rehabilitating of postsurgical patients and for recuperation of musculoskeletal condition was case study concerning treatment of scoliosis of adult woman who had progressive severe low back pain.She had worsened over the years after her surgery and had prevented her from activities such as carrying her son or equipment necessary for her job as a photographer.The patient was provided a series of Pilates exercises used to overcome her chronic habituation and muscle weakness.It was concluded that addition of Pilates based exercise to therapy can be useful to care for patients with chronic low back pain and deconditioning (Blum, 2002).

Pilates based exercise in specific disorder treatment
In a randomized clinical trial comparing pelvic floor muscle training to a Pilates exercise program for improving pelvic muscle strength 62 women with little or no pelvic floor dysfunction were randomized to Pilates or a pelvic floor muscle-training.The results of the study demonstrated only the feasibility of a Pilates exercise program for strengthening the pelvic floor muscles with the important note that these findings are only relevant to those women who can "find" their pelvic floor muscles however are encouraging and may eventually lead to widespread use of Pilates-based exercise programs to treat and prevent pelvic floor dysfunction.(Culligan et al., 2010) In a randomised, controlled trail with 52 breast cancer patients and also in one pilot study of with 4 women who had undergone axillary dissection and radiation therapy for breast cancer it was concluded that Pilates exercises are safe and efficient for women with breast cancer but there is a need for further studies to confirm these statements.(Eyigor et al., 2010, Keays at al., 2008) In a randomized, prospective, controlled, and single-blind trial with 55 participants the effects of Pilates on pain, functional status, and quality of life in patients with ankylosing spondylitis were investigated.Pilates exercise program of 1 h was given by a certified trainer to 30 participants of experimental group 3 times a week for 12 weeks.It was the first clinical study designed to investigate the role of Pilates method in ankylosing spondylitis treatment with a conclusion that this exercise technique is as an effective and safe method to improve physical capacity in ankylosing spondylitis patients.(Altan et al., 2011)

Conclusion
Studies concerning effects of performing Pilates based exercise suggest its beneficial influence on body posture, pain control, muscle strength, endurance, flexibility, body composition, static balance, functional autonomy, motor skills and specific component of sport activities.There is an increasing number of scientific reports suggesting application of Pilates method into modern, mind-body post-operation rehabilitation treatment.Despite a lack of convincing evidence to date to prove its medical effectiveness, the results of reports are promising and we suggest further studies to be carried out using a more representative sample and a longer period of intervention, to more precisely evaluate the results of practising Pilates based exercises.

Acknowledgment
We would like to thank: Anna Schabowska, an International Certified Coach of Pilates Method for providing the photos used in the chapter; Jagiellonian University Medical College in Krakow, Andrzej Frycz Modrzewski Krakow University, and the University School of Physical Education in Krakow for support to cover the cost of publication process.