pilates exercises in physical therapy utilizing pilates

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


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


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


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


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.


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


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:


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


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


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.


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


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


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.


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


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


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


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


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





Numeric Pain Rating (NPR) Right Chest/Shoulder: 4/10 Left Chest/Shoulder: 7/10

Right Chest/Shoulder: 2/10 Left Chest/Shoulder: 4/10


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.


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.


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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


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


Appendix B: Pictures of Mat Based Pilates Exercises (Continued)


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




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




13

Prone on elbows with diaphragmatic breathing, and unilateral/bilateral shoulder

flexion in scaption plane

14 Upright Sitting Diaphragmatic

Breathing

pilates exercises in physical therapy utilizing pilates

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