Efficacy of Pilates intervention for school aged children with Hypermobility Spectrum Disorder.

The Pilates program will be designed and delivered by the chief researcher who is (i) an experienced physiotherapist with over 30 years clinical experience in paediatric physiotherapy and (ii) an accredited Pilates instructor for the past 15 years. The program will be provided on an individualized basis and include a structured combination of Pilates exercises performed on mat or Pilates equipment that is provided at an appropriate level and age for each child. Exercises will focus on basic muscle activation and patterns of movement that are the essential basis of Pilates. As pain is decreased and children improve in strength, body awareness and confidence, they will be progressed to a more challenging level of difficulty. The intervention will be provided for 45 minutes, 2 times per week for 8 weeks with a home program of 45 minutes to be performed on one additional day under parental supervision. This will meet basic guidelines for physical activity and strength training. Each session is divided into sections to focus on specific body areas. Section 1: Warm up (5 minutes) Prepares the body for work and is typically a selection of mat exercises that involve trunk movement. Some examples are 'the roll down' and 'pelvic curl'. Section 2: Regional Muscle training (30 minutes) Includes specific areas of the body to ensure a complete body program: - Foot work -develops the strength of muscles surrounding the knee, ankle and feet eg 'calf raises' in standing or 'prances' on the reformer. - Abdominal work -focuses on specifically developing the abdominal muscles even though the abdominals are engaged throughout the session eg 'chest lift' on the mat or 'hundred prep' on the reformer. - Hip work -works on control of the hip joint an control of the pelvic- lumbar region eg 'leg circle' on the mat and 'hip circle down' with legs in straps on the reformer. - Spinal articulation -works on spinal mobility and developing control of the deeper trunk muscles eg 'rolling like a ball' on the mat or 'bottom lift' on the reformer. - Arm work -works various muscle groups in the arm and shoulder girdle eg 'front support' on the mat or 'triceps' with arms in straps on the reformer. - Leg work -focus on upper leg and hip strength eg 'side leg lift' on the mat or 'skating' on the reformer. - Lateral flexion and rotation -works on symmetry of the rotators and lateral flexors of the trunk eg 'spine twist' on the mat or 'mermaid' on the reformer. - Back extension -exercises of the back extensors eg 'back extension' on the mat or 'breaststroke prep' on the reformer. Section 3: Full body integration -specifically works on full body motion, balance and co- ordination eg 'single leg standing' on the mat or 'scooter' performed on the reformer . Section 4: Stretching and cool down (5 minutes) Specific stretches depending on the need of the individual eg 'hamstring stretch' on the mat or slow full trunk movement in standing such as 'roll down' focusing on slow deep breathing. At each session the Pilates instructor will record which exercises were performed, the number of repetitions, the equipment and amount of resistance used (number and colour of springs used on the reformer denotes whether mild, medium or heavy resistance). The parent will be invited to observe each session and a photograph of the child performing the exercises will be taken to personalize the home program along with a written sheet which will include particular focus exercises that need additional training. The home program will be composed of a number of mat exercises that continue to strengthen many parts of the body. One combination would be 'roll down', 'pelvic curl', 'chest lift', 'leg circles', 'side leg lifts', 'back extension', 'thread a needle', 'front support','single leg standing' and 'cat stretch'. If the child had difficulty with co-ordinating transverse abdominus (deep abdominal muscle) with the pelvic stability then some focus exercises would be to practice isolating transverse abdominus, then progressing to pelvic tilt while maintaining a transverse abdominus contraction before progressing to holding the transverse abdominus contraction with a 'pelvic curl' exercise With the home program the parent will mark down the number of each exercise performed, sign and return it at the next session so adherence to the program can be monitored.