The use of Breath in the Pilates Method

Denise Small PT, DPT

The following series of Pilates blog posts will focus on the principles that define the Pilates method.  Joseph Pilates developed his methodology using eight basic movement principles: whole body movement, breathing, balanced muscle development, concentration, control, centering, precision, and rhythm.  Today’s blog will focus on the principle of Breathing.

pilatesBreathing is a natural phenomenon that is performed thousands of times a day. Our daily intake of oxygen and expulsion of carbon dioxide is needed to cleanse our blood, and maintain the functioning of our body systems.  That being said, there are different ways to manipulate one’s breath to help facilitate certain physiological functions. For example, there have been many BBPT blog posts about diaphragmatic breathing, where one breathes into their abdomen to get a stretch of both the diaphragm and the pelvic floor muscles. Well, Pilates had his own approach to breathing, which was a variation on Diaphragmatic breathing.  Pilates approach to breathing was aimed at getting maximal air intake and release to give the body, what he called, “an internal shower” to rid the body of “toxins”. Pilates focused specifically on lateral expansion of the diaphragm, whereas traditional diaphragmatic breathing focuses on the vertical expansion of the diaphragm. In order to achieve this, Pilates encouraged maintaining the engaged tone of the abdomen, while breathing into the front, sides, and back of the ribcage. See the image below for further explanation.


Pilates- Ribcage/ Chest breathing versus Belly/Diaphragmatic breathing

This is an overly simplified view of the actual mechanics. However, both versions are very important. With the ability to differentiate between ribcage and diaphragmatic breathing you can offer your diaphragm a 3-dimensional stretch and the ability to work on abdominal contraction as well as endurance. If you have any questions you can ask them in the comments section. Or come visit me at Beyond Basics for a Pilates Private session!

Benefits of Pilates with Pain Conditions

By: Amy Stein, PT, DPT & Denise Small, PT, DPT
deniseDenise Small, Physical Therapist and resident Pilates instructor spoke on the differences between Pilates’ practices, and what aspects are important for her patients with chronic pelvic pain. Denise is third generation instructor of Joseph Pilates’ technique. She has also taken supplemental training courses with Eric Frankel and Thomas Myers, both well-known body workers and movement therapy practitioners.

Denise explores movement patterns in her patients that may have caused pain in the past, and are now labeled as something to fear. Patients try to avoid these movements; however, they are necessary for healthy functional mobility. Denise uses the Pilates method to explore these movements, and to make them pain free and more familiar. Denise is guided by Pilates’ 8 movements principles, which are the staples of Joseph Pilates’ methodology.

They are:

1. Whole Body movement- all structures are involved, even if they are not moving.

2. Breathing- Pilates refers to this as an internal shower, or a massage for your internal organs. This also helps coordinate your movement, using breath as your internal rhythm.

3. Balanced muscle development: concentric and eccentric movements happen in synchronicity with the use of the Pilates’ springs.

4. Concentration and focus: Required for all of the above to be performed together

5. Control- Pilates is not about repetitions and muscle bulk. Pilates is about Form and coordination of all the movement principles. If all of the movement principles are being incorporated, one needs only to perform 8-10 repetitions of each exercise for maximum benefit.

6. Centering- Pilates heals the mind and body, by bringing your attention to your core. That is: the abdominal wall, the diaphragm, the pelvic floor, and the deep spinal extensors.

7. Precision- If the movement is specific, there is very little room for error

In addition to being guided by the movement principles, Denise has a few staples of her own, that she uses to frame her sessions. First, Denise believes that you need to have tissue mobility before stability. For example, one needs to be able to move their abdominal muscles before they can begin strengthening their abdominal muscles. If a patient’s abdominal wall is hard, then it is not necessarily strong. A strong abdomen is a part of a strong core. A strong core requires fluid coordination of the diaphragm, pelvic floor, the spinal extensors, and the abdominal wall with movement. This lack of coordination may be observed when a patient is performing an abdominal strengthening exercise. Does the patient hold their breath? Are they tucking in the tailbone and gripping their pelvic floor muscles? Does their abdomen bulge? Many of these compensations can be avoided with the use of breath while performing more subtle core exercises, like marching, before progressing to more advanced exercises.

Second, Denise always highly recommends rolling out your patient’s feet before doing any mat or reformer work. Studies have shown that the fascia of your feet is directly connected to the fascia of your core, pelvis, and spine. So, if you release your plantar fascia, you can release restrictions all the way through your legs and torso. Once the muscles and fascia of your feet are more pliable one can better align their skeleton, from the domes of their feet to the roof of their mouth.

Lastly, Denise likes to use as few cues as possible to not confuse or overwhelm the patient. In addition, her cues are oriented around the bones. Bones are easier for patients to visualize, and focusing on the bones alleviates the possibility of dysfunctional muscle recruitment; i.e. gripping. For example, for pelvic floor muscle tightness and pain conditions, Denise cues widening the sits bones with squatting and inhalation. The patient/client needs to work on letting go of the muscles and the sits bones, while we work on eccentric control. To learn more about Denise, visit her bio and our Pilates program .  Also see her recently published health tip to get started.

Welcome Denise Small, PT, DPT

deniseWe are very excited to have Denise Small, PT, DPT join our team at Beyond Basics Physical Therapy.

Denise Small, PT, DPT received her doctorate in physical therapy from SUNY Downstate University, with additional pelvic health training from Beyond Basics Physical Therapy and Herman and Wallace Pelvic Rehabilitation Institute. Denise is also a member of the International Pelvic Pain Society.  Before becoming a physical therapist, Denise was a professional Ballet dancer for over 15 years, dancing for the Kansas City Ballet, Pennsylvania Ballet, and the New Chamber Ballet and Metropolitan Opera in New York City. After retiring from performing, Denise earned her Pilates certification through Balanced Body University, with a focus on Pilates for Dancers and Pilates for Rehabilitation.  Along with Pilates, Denise has studied various forms of movement therapy including the Franklin Method, the Feldenkrais Method, The Alexander Technique, and Laban Movements Analysis. Denise combines her knowledge of movement and Dance with traditional Physical Therapy interventions to help her patients approach both functional and sophisticated movements with comfort and ease.

To schedule Pilates or PT with Denise Small, PT, DPT please email Beyond Basics Physical Therapy at

Postcard From: Expert Panel

Compiled By Fiona McMahon DPT


Beyond Basics Physical Therapy recently held its first ever Expert Panel and it was a massive success. We invited some of the City’s/Country’s/ World’s leading clinicians in pelvic health/pain and opened the floor up to our guests to ask questions regarding pelvic pain and its treatment.

Let us first introduce you to the guests on our panel. First up is Dr. David Kaufman (DK), urologist and leading expert on interstitial cystitis, a condition affecting the bladder, which can cause severe pain, urinary urgency, retention and frequency. Our next expert speaker is Dr. Dena Harris (DH), a gynecologist and expert in chronic sexual, vulvar, and pelvic pain. Dr. Allyson Shirkhande (ASMD) is a physiatrist specializing in male and female pelvic pain. Dr. Amy Stein (ASPT) is a physical therapist specializing in pelvic floor dysfunction, the author of Heal Pelvic Pain, and founder of Beyond Basics Physical Therapy.

The floor was opened to our guests to ask our expert panel whatever questions they wanted. Here is a brief synopsis of the questions asked and our experts’ answers.

Question: How can a labral tear [a tear in the the covering of the hip joint] effect pelvic pain and vulvodynia?


DH: A labral tear can be related to pelvic floor dysfunction and starting off with a conservative approach is recommended: PT, injections and anti-inflammatory medication if needed. Earlier detection is better and repair of labral tear can help, especially with generalized vulvodynia  (non-provoked). [Non-provoked vulvodynia means that there are vulvar symptoms without a specific irritant. Provoked vulvodynia means that vulvar pain occurs in response to a specific stimulus].

ASPT: Typically we like to see if PT or a more conservative approach can help and in most cases it does! We do a combination of manual [hands-on] work and exercise to take the pressure off of the labrum and to help with proper alignment and body mechanics.

ASMD: There is a relationship with obturator, piriformis and other external rotators of hip and vulvuodynia. Typically we do a course of physical therapy first. We very rarely do surgery right away.

Follow up question: Can you treat it with physical therapy here [Beyond Basics Physical Therapy], if we are already seeing you for another issue?

ASPT: Yes, we are all well trained in treating hip issues, including labral tears. We find that people with premorbid pelvic floor dysfunction present differently than those with just hip pain. Because we have knowledge of the pelvic floor, we can treat your hip without worsening your pelvic floor, which can happen with clinicians who are not well educated in pelvic floor dysfunction. We also treat hip dysfunction with patients that do not have a pelvic floor condition.

Question: I have a lot of pulling in my pelvic floor. I do pilates and yoga and I know the importance of strengthening. I have vulvodynia and neuropathy. I sometimes feel like I’m hurting myself. I sometimes get stabbing pain throughout my leg. I’m tight but not too flexible. What should I do?

DH:  Have you been to physical therapy?

ASPT: It sounds like you have tightness in your pelvic floor muscles and other areas of the body and possibly some nerve irritation.

ASMD: It sounds like you are spasming because you are unstable.

ASPT: We see a lot of foot pain secondary to fascial pulling and nerve irritation. In the brain, [the homunculus: the area that senses what is going on in the body], the feet and the genitals are very close together and the nerves get overflow onto the other nerves. I would tell you to stop Pilates if I saw you and then I think you’d need a very specific type of yoga. I have my patients start from 0 and then slowly work up. I then monitor very careful to detect what is aggravating their symptoms.

Follow up comment: I have neuropathy too.

DH: It may be worth checking it out if you haven’t been to physical therapy in a while. A lot can change [in one’s body over time] and there are constantly advances in medicine and physical therapy.

ASPT: Have you had a nerve block?

Follow up Question: What type of nerve block?

ASMD: That would require an assessment to determine which nerve(s) are irritated. There are a lot of medications to calm it down, injections, medications as well.

DK: I find that if you do things piecemeal it doesn’t work as well. You can do all these individual pieces, but the magic is when you do it all together

Follow up Question: I see a lot of different doctors, it’s so hard to navigate.

DK: That’s why we’re all here, I certainly understand it.

ASPT: A fresh set of eyes may be helpful to see what’s changed in the past five years. I am a huge proponent of home exercise programs and so are the physical therapists here. For your situation I’d have you do more relaxation and breathing exercises. You probably need a lot of soft tissue work and sympathetic nervous system down training.

DH: A lot of doctors are into meditation in ways to desensitize the pain, acupuncture

ASMD: Accupressure as well.

Question: Is there ever a time where it stops? Are you in therapy and the doctor’s office forever? Do you always have to maintain or do a home program?

DH: It depends what’s wrong. Some people get completely better

ASMD: With our physical therapists, we try to instill lifestyle changes. When you’re done with PT you may want to do something like yoga.

DK: You need to find the instigator to find out what’s making the fire that’s making the muscles go nuts. You need to get the fire down. Medicine and physical therapy can help.

Follow Up Question: Say you got a massage and then you feel better, but a few days later your back hurts again, is it like that?

DK: If you haven’t figured out why your back hurt in the first place your back will cramp again.

ASPT: When people are getting ready to be discharged,  I warn them to come back  if they feel their symptoms coming back even the slightest or to increase their home program. Your home program should work for you. It should help to reduce your symptoms and reset the pain cycle. If not, you need to meet with your PT and adjust it accordingly. I have patients that come in for “check ups” but the majority of our patients we do not see again in our office because they get better. We give them the tools to be independent, monitor their symptoms, make adjustments in their daily routine, etc.

Question: What’s the relationship between the gastrointestinal system and vulvodynia?

DH: Sometimes the trigger is gluten, constipation, ulcerative colitis, Crohn’s, IBS [irritable bowel syndrome]. Sometimes the treatment for IBS helps with vulvodynia.

DK: Sometimes a spastic pelvic floor and abdominal wall can cause constipation and IBS-type symptoms.

Follow up Question: What about food?

DK: It’s interesting with people that think they have bladder problems because their symptoms are flared with certain types of food. I look at the bladder it’s fine. Sometimes the food is actually exacerbating pelvic floor muscles.

Question: If you have pelvic floor dysfunction and nothing else, [no other diagnosis], is there anything else that  could cause it?

DK: If you go back in time there is usually something. Like history of infection, a fall on the tailbone or sacrum as a kid.

ASPT: Lots of things, alignment.

Follow up question: What about scoliosis?

All: Definitely.

Follow up question: How often is the cause emotional?

DK: There is always a component of emotion. It’s devastating. I never think emotions cause the problem. Anxiety can make it worse but not the cause.

ASPT: There’s usually trigger like a urinary tract infection but you have to address the emotional component to bring down the activity of the pelvic floor muscles.

There are some great mindfulness/mediation options on iTunes. It’s not for everyone. Sometimes people respond better to yoga.

Q: I have interstitial cystitis which is well managed, however the interstitial cystitis keeps coming back secondary to bacterial vaginosis. I’m  taking meds and suppositories why does it keep coming back?

DH: Ureaplasma, it can cause recurrent pain. There may be some underlying infections that aren’t being detected. You need a really good lab to pick up some of the other types of yeast. There’s certain candidiasis [yeast] that doesn’t respond to typical drugs.

DK: I think it’s great that she’s figuring out what the fire is. Just a little bit of bacteria can send someone to the moon. Sex can move a lot of bacteria to the urethra and set off interstitial cystitis. These are the things I recommend that my patients do:

1.) Pee after sex- a little tinkle after sex isn’t going to cut it. If you pee before sex you don’t have enough urine to really flush out the bacteria from the urethra. It needs to be like a water hose!

2.) Bidet- really wash out the vulva- you really need to irrigate it with water before sex: put it on strong. Get a moveable shower head, spread apart the lips of the vulva to get it really clean.

Q: What percentage of you patients are male?

DK: There is a whole category of men that no one thinks of as pelvic floor dysfunction. It actually is the most common diagnosis in my office. It’s common knowledge that pelvic floor dysfunction can come from untreated prostatitis. 95% of prostatitis is nonbacterial, and the cause, pelvic floor myalgia/spasm.

PT In-Service: Alignment and Core Exercises

By Amy Stein

Our famous Dania Kafka, who is an amazing physical therapist and Pilates instructor, recently discussed alignment, posture and core exercises correctly at our latest PT In-Service. She helped us with proper cueing because we don’t want pelvic pain patients to utilize the pelvic floor muscles, or limit their use, with any core stabilization exercises. We went over how to gently engage the transverse abdominus, which is one of the core muscles and helps with pelvic and trunk stability. If this muscle is weak and the patient is overusing their pelvic floor, they can end up with pelvic pain. Core and trunk muscle imbalances can be one of many reasons a patient ends up with pelvic pain and/or pelvic weakness. Therefore, it is important to have a strong and balanced core. Dania proceeded to lead us through a series of transverse abdominus exercises that were adapted by Shirley Sahrmann, PT, and we incorporated diaphragmatic breathing with each exercise. We practiced neutral spine versus posterior pelvic tilt to compare the difference, and discussed with which populations we would use which position.

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With any pain condition, if there are active trigger points, tightened and/or shortened tissue, you need to address these impairments prior to strengthening these muscles. Otherwise you can exacerbate trigger points and continue to shorten tissues. It is essential to make sure these conditions are resolved prior to starting a core exercise to that specific area.

With regard to pelvic floor weakness, including incontinence and post surgical weakness (prostatectomy, prolapse, etc.), it is important to strengthen the pelvic floor muscles correctly and the transverse abdominus correctly, as well as the rest of the core muscles.

Monitoring each patient with each exercise, is essential for their recovery, in order not to worsen any condition. Starting slow and in a controlled environment is key.

If you have any questions with regard to Pilates and core exercises and when to introduce them for pelvic pain, or pelvic weakness, feel free to call us and ask for any of our PTs. Or, attend our upcoming Pelvic Health 101 this spring!

Pilates: The Inner Lane

In our last few blogs, we focused on movement in the hip joint.  As a bonus to increasing our range of motion, we also increased the tone in our abdomen and in our gluteal muscles.  In addition, we did it all without gripping or squeezing our muscles, and by coordinating the movement with our breath.

Now, to balance out our legs and relate the abdominal tone to our inner thighs and pelvic floor, we will do a new set of exercises lying on our back.

To begin, lie on your back, preferably on a firm surface.  If possible, lay on a mat or towel on the floor and put a pillow under your head.  If you use a towel, place your feet on the floor, to prevent any possible sliding.

Next, place a small pillow or ball between your knees.  Preferably, the object should be soft to discourage any tension in your legs.

As usual, we will begin the movement by focusing on our breath.  Place your hands on your abdomen and breathe naturally.  In your mind’s eye, see your diaphragm floating up and down in your abdominal cavity, like a parachute blowing in the wind.  When I do this exercise, I always think about when we used to play with a large parachute in my elementary school gym class.

On your next inhale, feel your abdomen expand in your hands as you envision your diaphragm floating down into your pelvis. As you exhale, feel your abdominals contract as you envision your diaphragm floating up into your ribcage.

This breath coordination can be difficult to envision at first, but keep practicing.  The diaphragm moves this way naturally in relation to the abdominals.  If you attempt this exercise by envisioning what is happening, rather than forcing the movement, your body will fall into its natural rhythm.

When you feel you have mastered this concept, begin to add a light squeeze to the pillow, or object between your knees.  This slight contraction will add to the tone of your pelvic floor muscles and abdominals, as well as increase the length of your breath.  As you inhale, see your diaphragm descend and release the squeeze of the ball.  As you exhale, squeeze the ball as your contract your abdominals and float your diaphragm into your ribcage.

Repeat this exercise five to ten times.  If you are feeling any discomfort, stop the exercise.  Remember to contact your doctor or PT before continue with any painful movement.




Pilates: Foot Review

In honor of summer, and the fabulous Riva Preil, we will use this blog to echo Riva’s advice on summer footwear.  We all know that flip-flops are, in theory, the perfect summer shoe.  They are light, they are airy, and they are very inexpensive.  However, flip-flops provide absolutely no support for our feet.

In an earlier blog, I mentioned the importance of having tone in the muscles of our feet.  If the muscles of our feet have good tone, the bones of our feet can maintain the proper structure they need to balance our legs, pelvis, and spine.  However, if you absolutely need to wear your flip-flops, do the following exercise daily to maintain proper muscle tone in your feet.

You can do this exercise either sitting or standing.  In addition, you will need a small ball, preferably the size of a tennis ball.

Place the ball of your foot on the ball and anchor your heel to the floor (photo 1).  Lift your toes off the ball, and then lower them again attempting to wrap your toes around the ball.  Repeat ten times. With each repetition, the ball of your foot should spread wider and extend further over the ball.

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After ten repetitions, maintain your toes wrapped around the ball.  From here, begin to rotate your foot from right to left (photo 2).  Attempt to keep this motion in your ankle, rather than your knee or your hip.  Do this action ten times.


Next, roll the ball forward and backward under your foot while you point and flex your foot (photo 3).  This will help you maintain the proper heel striking rhythm that Riva mentions in her blog.  Repeat this action ten 10 times.

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When you have finished with one foot, stand on both feet and observe the difference between each.  Hopefully, the foot your exercised feels more grounded, yet, light and supported.