Rehabilitation Pilates

Pilates Rehabilitation

Pilates, named after its developer, Joseph Pilates, was originally created for the use of rehabilitating wounded soldiers during World War I. Soon after, it was adopted by the dance community and seemed to lose its place in the medical industry. Today, pilates is returning to its roots! Many health conditions can benefit from physical therapy and pilates rehabilitation. Also known as ‘rehab pilates’, it not only promotes good posture, it is used to retrain the stabilizing muscles in the joints to improve function and assist in pain free movement.

At Firehaus Pilates Studio, we use rehab pilates to work with many medical conditions such as lower back pain, Thoracic Outlet Syndrome, joint replacement, Osteoporosis, Degenerative Disk Disease, chronic headaches, and much more. No matter your age, movement restrictions, or health conditions, using rehabilitation pilates, we will develop an individual pilates reformer plan to aid you in your recovery. Talk to your doctor today to find out if pilates physical therapy would be a beneficial addition to your current treatment plan!

Rehab Pilates for TOS

One of Firehaus Pilates’ specialty areas is pain management for Thoracic Outlet Syndrome. Owner, Rachel Algra, was diagnosed with Thoracic Outlet Syndrome in her teens and has been researching the condition and possible treatments ever since. She is dedicated to educating clients and their families about the daily challenges of the condition and creating personalized pilates rehabilitation programs for each individual.

We have seen many positive outcomes from using rehab pilates with clients ranging from newly diagnosed to long-term pain management. We also work with post-operative care. Firehaus Pilates is conveniently located in Denver’s LoHi neighborhood and was voted A-List’s “Best Pilates Studio in Denver” in 2012!

View all our rehab pilates and reformer pilates classes in Denver on our Pilates Schedule.

TOS info …

Below are some topics related to Thoracic Outlet Syndrome (TOS)


Physical examination is most helpful. Common findings are tenderness over the scalene muscles, located about one inch to the side of the wind pipe; pressure on this spot causes pain or tingling down the arm; rotating or tilting the head to one side causes pain in the opposite shoulder or arm; and elevating the arms in the “stick-em-up” position reproduces the symptoms of pain, numbness, and tingling in the arm and hand.

Diagnostic tests, such as EMG’s (electromyography’s) or NCV’s (Nerve Conduction Velocities), may show non-specific abnormalities, but in most people with TOS, these tests are normal. Neck or chest x-rays may show a cervical rib (extra rib). Loss of the pulse at the wrist when elevating the arm or when turning the neck to the side (Adson’s sign), has been thought by some to be an important diagnostic sign. However, it is sometimes unreliable because many normal people also lose their pulse in the same positions, and the majority of people with TOS do not lose their pulse in these positions. Shrinkage of hand muscles (atrophy) occurs in about 1% of people with TOS, and these people will have nerve tests that show a typical pattern of ulnar nerve damage.

To aid in the diagnosis of vascular or arterial TOS, vascular studies may also be recommended by your doctor. The most non-invasive would be a Doppler study, which is an ultra-sound picture of your veins and arteries. An MRA (magnetic resonance angiography) is another option. An MRA is the same as an MRI (magnetic resonance imaging), only a special dye is injected into the veins so they show up during the images. This makes it easier for doctors to see if there is a blockage in the veins. A more invasive test would be a venogram, which requires an IV to be started. Dye is injected into the veins while the images are being taken. This gives doctors a clear picture of the entire vein as it travels through the arm. Venograms are typically a last resort, but are often necessary in the diagnosis and treatment of severe vascular and arterial TOS.

Helping your doctor

There are a number of things you can do to help your doctor with either a diagnosis or treatment. Here are some helpful hints:

  1. 1. Keep a pain diary – It is often hard to remember what may have been different from one day to another when it comes to living with chronic pain. Keep a daily pain diary or journal and list what was better/worse, what may have caused a flare-up, what lessened your symptoms, etc… This will be helpful to you and your doctor.
  2. 2. Be prepared for appointments – Doctors are very busy! Be prepared for your appointments. Make a list of questions you would like answered and go through it with your doctor.
  3. 3. Doctors and mind reading – Doctors cannot read your mind, though I’m sure you wish they could sometimes! Be open with your doctor. Make a list of your symptoms so you don’t forget something important. Try to be as detailed as possible in describing your symptoms. Proper diagnosis and treatment cannot be made unless you TELL YOUR DOCTOR.
  4. 4. Visual Symptoms – Oftentimes with vascular TOS, there is a visual change in the color of the arm(s). Try to find the position that causes these symptoms to occur. If you notice discoloration (Ex. Bluing), stop and look at how you are standing/sitting when the symptom came on. Finding these positions can be of great benefit to your doctors. If you can re-create the symptom for your doctor, it will make diagnostic testing easier and more accurate. *Note: If a certain position creates discoloration, try to avoid it as much as possible unless otherwise specified by your doctor (Ex. During appt.’s or diagnostic testing).
  5. 5. Have a medical history letter on hand – Unfortunately, it is common with TOS to have to search for doctors skilled in this field. Many times, numerous doctors will have to be consulted before finding the one who meets your needs. Keep an updated letter on hand to give to your doctors on first time visits. List the onset of your TOS (or pain if you haven’t been diagnosed yet), what caused it (if known), doctors you have seen, tests performed, medications tried, etc… This will help give your doctor a detailed look at what’s been going on, and will save you from having to repeat your story time and time again!
  6. 6. Get your records – It is very important that you get copies of your test results, surgical reports, doctors notes, etc… They are very helpful when seeing a new doctor or changing doctors. Keep them filed together for easy access.



  • Numbness of arms and hands
  • Tingling of arms and hands
  • Positional weakness
  • Discoloration (ex. pale or white hands)


  • Swelling of fingers and hands
  • Heaviness of the upper extremities
  • Discoloration (ex. blueness)


  • Upper extremity pain
  • Paresthesias of ulnar distribution
  • Weakness of the hands
  • Clumsiness of the hands
  • Coldness of the hands
  • Tiredness, heaviness and parasthesias on elevation of arms

Shoulder and Neck

  • Pain
  • Tightness

Chest Wall

  • Anginal chest pain (heavy or squeezing pain in the midsternal area of the chest)
  • Inter-para scapular pain (pain along the shoulder-blade)


  • Headaches
  • Funny feelings in face and ear

Vertebral Artery

  • Dizziness
  • Lightheadedness

Testing – Nerves

EMG’s/Nerve Conduction StudiesElectromyography (EMG) and Nerve Conduction Tests are ordered to learn more about the health of peripheral nerves. These tests can establish if a nerve is pinched, and give a numeric value to how severely it is pinched and often where it is pinched. The test can last anywhere from a half an hour to an hour. The quality of the results is quite dependent on the skill of the person administering the test.EMG’sThe EMG portion of the test measures the electrical activity in muscles. Muscles normally receive constant electrical signals from healthy nerves, and in return “broadcast” their own healthy electrical signals. During the EMG portion of the test, the doctor places acupuncture like needles into the muscles to record the electrical signal from the various muscles in the arm. If a muscle doesn’t receive adequate signals from a sick nerve, it broadcasts signals, which show the muscle is confused.

Nerve Conduction

During the Nerve Conduction portion of the test, electrodes much like EKG patches are placed along the known course of the nerve. The nerve is stimulated with a tiny electrical current at one point. The nerve must then transmit the signal along its course, and an electrode placed further down the arm captures the signal as it passes it. A healthy nerve will transmit the signal faster and stronger than a sick nerve.

*Discomfort and Risks

Some discomfort may occur as the needle electrodes are inserted. The muscle(s) tested may feel sore after the EMG. The risks are minimal. There may be some minor bleeding and there is a small risk of infection where the needle electrodes are inserted.

Testing – Bones & Tissue

CT SCANS – used to view soft tissue or bony abnormalities

Computed Tomography (CT) imaging is also known as CAT scanning (Computed Axial Tomography). The machine resembles a large square with a ring in the middle. CT has the unique ability to image soft tissues (e.g. blood vessels) and renders more detail of bony structures than MRI (Magnetic Resonance Imaging). CT images reveal the relationships between soft tissue and bone. Some CT examinations require a contrast agent to be injected (or intravenously) into the patient’s bloodstream. A contrast agent serves to enhance a particular body part (e.g. intervertebral discs).

During the test, the patient must lie still and may be asked to hold their breath for a several seconds from time to time. The patient may hear the scanner rotating during the study – this noise may be soft or more audible. Depending on the type of study, the CT scanner or table will move slightly as low intensity x-ray beams are rotated at many angles around the patient. A computer collects the data from the scanner, calculates the density of a given cross-sectional slice, and produces the image onto film for study by a radiologist.

*Discomfort and Risks

Without contrast: None

With contrast: There may be some minor bleeding and there is a small risk of infection where the IV is started. There is also a risk of an allergic reaction to the contrast dye.

MRI’s – used to detect soft tissue or bony abnormalities

Magnetic Resonance Imaging (MRI) is a radiation-free, computer-assisted technique used to produce high quality sectional images of the inside of the body. MRI is performed in a hospital, medical center, or an MRI facility. Many facilities utilize ‘open-air’ MRI scanners, beneficial to patients who are claustrophobic. When an open-air scanner is unavailable, patients who feel anxious are given a mild sedative. During the scan, the patient lies comfortably on a motorized table inside the scanner surrounded by huge powerful magnets. The technician observes the patient throughout the exam through large windows in the adjacent control room. The technician converses with the patient by means of an intercom. Typically, the test takes up to an hour to complete.

Unlike MRI, some imaging studies require the patient to change position during the examination. Conversely, an MRI is able to generate images in the sagittal (left/right), coronal (front/back), axial (head/toe), and oblique (slanted) planes without moving the patient. Certain MRI studies utilize a contrast medium to enhance particular body structures.

MRI is able to produce vivid complex images in 256 levels of gray characterizing relationships between vertebrae, intervertebral discs, the spinal cord, and nerve roots. It is a valuable diagnostic and pre-surgical planning tool, and replaces some invasive diagnostic procedures.

*Discomfort and Risks

There may be discomfort if you are claustrophobic. Please tell your doctor if you have trouble in small spaces. Open-sided MRI’s are available in certain areas or sedatives can be prescribed. Patients also need to tell their physician if their body contains any ferromagnetic objects such as shrapnel, a pacemaker, or aneurysm clips. These patients cannot undergo MRI study. Ferromagnetic objects are attracted by the MRI’s magnet.

Testing – Vascular TOS

Testing for Vascular TOS

Adson’s Maneuver

To perform Adson’s maneuver, the practitioner finds the client’s radial pulse at the wrist, then brings the client’s arm back into extension and lateral rotation. The client is instructed to look over his/her shoulder toward the affected side and take in a deep breath. If the intensity of the pulse diminishes, the client is suggested to have entrapment of the brachial plexus and subclavian artery by the anterior and middle scalene muscles — or thoracic outlet syndrome. The problem with this procedure is that a large number of people who do not have any symptoms test positive (diminishing radial pulse) when this test is performed. Thus, this test does not have a high degree of specificity.

*Discomfort and Risks

Weakness and/or tingling in the arm may occur during this test.

Doppler Study

A Doppler Study is simply an ultra-sound image of the veins and arteries. It is a non-invasive and completely pain free procedure used to detect vascular TOS. A liquid jelly is applied to the skin to make close contact between the skin and transducer, eliminating air pockets. This will ensure that the sound waves are freely conducted into and out of the body. The radiologist or technologist presses the transducer firmly to the skin and moves it back and forth to obtain complete images of areas of interest. The entire area of interest will be scanned, obtaining images from different perspectives. The examiner may want to obtain images while you are standing upright or laying down. The radiologist also may ask you health-related questions during the exam and may repeat some images to clarify the findings. When the transducer is over a vein or artery, it will become visible on the ultra-sound screen, showing up in different colors. The entire procedure usually takes about 30 minutes. The images will be evaluated by a radiologist and given to your doctor. A Doppler Study is not always accurate in diagnosing TOS.

*Discomfort and Risks



Magnetic Resonance Angiography (MRA) is an MRI study of the blood vessels. MRA provides detailed images of blood vessels without using any contrast material, although a special form of contrast is sometimes given to make the MR images more clear. The procedure is painless, and the magnetic field is not known to cause tissue damage of any kind. The patient is placed on a special table and positioned inside the opening of the MRI unit. A typical exam consists of two to six imaging sequences, each taking from 2 to 15 minutes. Depending on the type of exam being done, the total time needed can range from 10 to 60 minutes, not counting the time needed to change clothing and have an IV put in (if contrast is needed). When contrast material is needed, a substance called gadolinium is given by IV injection during one of the imaging sequences. It highlights blood vessels, making them stand out from surrounding tissues.

*Discomfort and Risks

There may be discomfort if you are claustrophobic. Please tell your doctor if you have trouble in small spaces. Open-sided MRI’s are available in certain areas or sedatives can be prescribed. Patients also need to tell their physician if their body contains any ferromagnetic objects such as shrapnel, a pacemaker, or aneurysm clips. These patients cannot undergo MRI study. Ferromagnetic objects are attracted by the MRI’s magnet

With contrast: There may be some minor bleeding and there is a small risk of infection where the IV is started. There is also a risk of an allergic reaction to the contrast dye.


A venogram is a procedure that looks at your blood vessels (veins) by simultaneously injecting x-ray dye and taking x-rays. It is used to determine if/where there is restricted bloodflow in the veins. A venogram is the most accurate way to diagnose vascular TOS.

First, an IV (intravenous catheter) will be started in the limb you are experiencing symptoms in (ex. for TOS, it is usually somewhere between the wrist and elbow). Ultra-sound may be used to help the radiologist locate a vein. Once the IV is started, a small tube is inserted into the vein that needs to be viewed. The tube is then secured and the test will begin.

The radiologist will have you stand/lay in the symptomatic position. X-ray dye will then be injected into the IV tube. You may feel a warm sensation from the dye. X-rays will be taken throughout the procedure. These pictures will be displayed on a TV monitor so the radiologist can clearly see problem areas during the test. You may be asked to change positions several times throughout the test.

After the procedure, saline is usually flushed through the IV to make sure the veins are clear of any x-ray dye. The IV is then removed and if you are free to go home. The radiologist will review the films and contact your doctor with the results.

* Be sure to tell the radiologist of any pain during this procedure. Once the IV is in, there should be a minimal amount of pain during the actual test. Also, if there is a certain position that brings on the vascular symptoms, be sure to tell the radiologist before the test begins. Testing should be done in the symptomatic position!

*Discomfort and Risks

There may be some minor bleeding and there is a small risk of infection where the IV is started. There is also a risk of an allergic reaction to the contrast dye.

Treatment – Physical Therapy

**Please note: All physical therapy should be pain free. If you are experiencing pain during stretching, exercising, etc…please talk to your PT or physician and see if the exercise can be modified.

There are many different therapy options available for TOS and pain relief. It is best to work with a doctor or physical therapist to create the best therapy program for you. Each person is going to need a specialized program. The following is a list of some of the therapies you may want to try:

General Physical Therapy

Working with a therapist to regain your full range-of-motion and building muscle strength. You may also do pain relief techniques such as biofeedback, water therapy, EMS and ENS (described below), or stretching.

Postural Therapy

TOS is aggravated by poor posture. Most general PT’s can work with people on improving their posture to lessen the stress and pressure that is put on the nerves in the brachial plexus (shoulder region). Postural therapy may include techniques like shoulder taping and breathing exercises.

Muscle Strengthening

Start very gently!! Muscle strengthening is very important to give the body better support and stabilization.

Nerve Gliding

TOS can cause severe nerve pain and damage. To keep the nerves moving and free of scarring (especially after surgery), it is crucial to do nerve glide techniques. Nerve gliding should be carefully monitored by a physical therapist or doctor. If done correctly, this technique will help to stretch the nerves and allow them to heal more fully.


Allows the muscles to stay looser and helps to prevent pain or injury throughout the body.


Helps keep muscles loose and may keep pain levels down.


Manipulation helps keep the spine in alignment preventing other areas of the body to become overstressed. It also can help maintain or improve proper nerve function.


Can be helpful in relieving pain.


Teaches you to improve your posture and move in ways that are pain free.

Electronic Muscle Stimulation

Used to relax tight or tense muscles.

Electronic Nerve Stimulation

Used to relax and calm irritated or inflamed nerves.


Helps loosen tense muscles and calm irritated nerves.


Ice is used to decrease inflammation of sore or injured muscles. Heat can also aid in relieving sore muscles.


Transcutaneous Electrical Nerve Stimulations (TENS) is a safe non-invasive drug-free method of pain management. It relieves pain by sending small electrical impulses through electrodes placed on the skin to underlying nerve fibers. It is a small device that is usually worn on the belt.

Edgelow Technique

This technique is about listening to your body and deciding what you can do each day. The goal is to NOT get flared up. The goal is to STOP before pain starts. To STOP at the first sign of tension. It involves exercises such as: self traction, breathing for relaxation, rib mobilization, use of Styrofoam cylinders to work on spinal mobilization and stability, and aerobic walking.

Hyperbaric Oxygen Therapy

This is not a new therapy, but is new in the area of pain management. While in a hyperbaric chamber, you breath 100% oxygen. The increased oxygen levels at certain depths, can help to repair damaged nerves, muscles, and tissues at a much greater speed, resulting in a faster recovery time.

Treatment – Injections

There are many different kinds of injections available for pain relief. Here are some examples:

Trigger point injections

Trigger points are hyperirritable bundles of fibers within a muscle, which become “knotted” and inelastic, unable to contract or relax, due to an injury and may cause referred pain. Lidocaine is injected into these points to re- establish a painless, full range of motion.

Botox injections

BOTOX, short for Botulinum Toxin A, works by binding to nerve endings and preventing the release of chemical transmitters that activate muscles. A small amount of Botox is injected into a tight or spastic muscle. The toxin temporarily paralyzes the muscle, forcing it to relax.

Stellate Ganglion Blocks

A needle is injected into the front of the neck and is pushed gently through to just before the spine. Anesthetic is then injected into the ganglion, which is the nerve center for the nerves that feed the face, neck and arm. This numbs the nerves for pain relief. Several treatments may be necessary before the nerves fully respond.

Cortisone injections

Cortisone is injected into a joint, muscle, or tendon for pain relief and to lower inflammation.

Treatment – Other

There are other options that are fairly new in the world of pain relief, but have been found to be helpful in some cases.

Spinal Cord Stimulators/Peripheral Nerve Stimulators

A small neurostimulation system that is surgically placed under the skin to send mild electrical impulses to the spinal cord. The electrical impulses are delivered through a lead (a special medical wire) that is also surgically placed. These electrical impulses block the signal of pain from reaching the brain. Peripheral nerve stimulation works in a similar way, but the lead is placed on the specific nerve that is causing pain rather than near the spinal cord.

Medication Pumps

A pump is surgically implanted under the skin of a person’s abdomen. A catheter is run to the precise location in the spine where the pain is. Medication can than be pumped directly into the spinal fluid, allowing for a much more potent effect on the spinal cord. This drastically cuts down the dose of medication that is needed, and the medication often provides even better pain relief with much fewer side effects.

Nerve Ablation

Burning nerve endings that are transmitting pain signals. This is a very permanent procedure and is often used as a last resort.


A 1st rib resection is usually only done as a last resort, or when there is an obvious vascular obstruction. Another situation that may require surgery would be if the patient has cervical ribs or “extra” ribs that are causing vascular and/or neurological compression in the brachial plexus (shoulder region). This surgery is typically performed one of 2 ways. Through the armpit (trans-axillary approach) or from above the collar-bone (cervical approach).

Trans-axillary approach: First, an incision will be made under your armpit (usually about 2 inches). Then they will tunnel up to the 1st rib, which is located under your collarbone. Once in position, they will cut off the bone at the sternum and proceed to do the same in the back. They also have to cut what scalene muscle is attached to the 1st rib. Some doctors leave the muscle to atrophy and some completely remove it.

Cervical approach – The procedure is the same, only it is done through an incision above the collarbone.

There are different risks with each approach to the surgery. With the Trans-axillary approach, there may be a greater risk of a punctured lung, although, this is a risk either way. You will also most likely have more pain and a longer recovery time with this approach because the muscles will need to be stretched considerably far, as they tunnel through to the 1st rib. However, the scar will be less visible as it is under your arm. With the cervical approach, there is less muscle and tissue damage, but a greater risk of hitting a vein or artery with the incision made directly above the vein passage. Your surgeon will decide what he/she is most comfortable with and should discuss the risks and benefits of the different approaches with you.

Surgery Tips

  • Learn the pain scale and be prepared to use if after surgery. This will help the doctors and nurses to keep your pain level manageable. (Pain scale is 0-10, 0 being no pain and 10 being the worst imaginable pain.)
  • Try not to take so many drugs after surgery that you are in no pain. If you have little or no pain, it will be easier to do too much and re-injure yourself, setting back your recovery time. Keep the pain at a manageable level but enough so that you have to take it easy! Give your body time to heal.
  • If traveling out of state for surgery, bring lots of pillows. It is important to be able to rest comfortably after surgery. Most hotels are not known for their plush, comfy pillows!
  • Try to keep moving the arm. You will most likely lose a lot of range of motion after surgery, but the sooner you get it moving, the easier it will be to regain full motion. Remember to stay in a pain free range! In the shower is a good time to do these exercises because your muscles are warm.
  • If helpful, use ice or heat to relieve pain and swelling.
  • Keep lotion or vitamin E oil on your scars to help keep them soft and pliable. Vitamin E oil can also help to fade the scar more quickly.
  • When out in public places, wear a sling. It may give your arm more support, but more importantly, it will tell others to stay away! You do not want to get bumped after surgery. People see a sling and will most likely try to avoid bumping you.
  • Because of the loss of scalene muscle attached to the 1st rib, it is quite common for the head to feel very heavy! Try to rest often while the other muscles in the neck learn to take over.
  • Desensitization is a must!!! You need to be touching the surgery area as much as possible. Use your hand, a washcloth, body brush, sponge, blanket…etc. Try to get different textures of things. Gently rub them on the area (or have someone do it for you) as often as possible and for at least 10 minutes at a time. Hand-held massage wands are also very helpful. They are about a foot long and have a ball on the end. Your goal will be to put the ball directly up against your armpit. It will take a long time to get to that point. Until then, put a blanket, towel, etc…in between the massager and your skin. Turn it on low and leave it there for 15 minutes. You should feel it tingling all the way down your arm. You might even have to start with it just vibrating the pillow you are resting your arm on. This is very normal!! The armpit is where all the nerves pass through for your arm, which makes it a great location for this desensitization technique!! If at all possible, wear tighter fitting clothes too. The constant rubbing on the area will desensitize it much faster. These techniques will help to calm the nerve down quickly by getting them used to touch. Try to do these several times a day.
  • Have clothes that are easy to put on. You will most likely not be able to get something over your head, so button-up or zip tops are a must!
  • Chest tubes are very common during a rib resection. Talk to your doctor beforehand to learn about this procedure.
  • Freeze meals ahead of time in microwave safe containers. You won’t feel like cooking for a while. This way, you can have home cooked meals without the hassle!
  • Bags of frozen peas work great as ice bags.
  • Put all necessary phone numbers in one spot so you or your family can find them easily.
  • Try and get your pain prescription before you’re released so family members can have it filled and waiting for you when you get home.
  • Make sure you have someone that can stay with you full time for at least the first 2-3 days – you will need it
  • Bring clothes that are easy to get in and out of to the hospital. You will need to wear something when you go home!! Slip-on shoes are also recommended.
  • Have the house as neat as possible before you have surgery. You won’t be up to cleaning for a while.
  • Have a place set up at home where you can spend your recovery. Make sure that you have easy access to whatever you might need. (Ex. TV, remote, pillows, etc…)
  • Don’t overdo it. This will be a slow recovery. Get plenty of rest and let your body heal!