It’s not immediately obvious that glaucoma, a very common degenerative eye condition, is something you need to consider when programming and teaching Pilates. But anything that compromises eyesight affects movement capacity and, given glaucoma is mostly symptomatic in older people, it amplifies the impact of other age-related limitations. It also has some specific characteristics you might want to know about.
First a disclaimer: I am writing this article as a Pilates teacher who has glaucoma herself. I am not an ophthalmologist or orthoptist. It is not medical advice, but (hopefully) practical suggestions for other teachers.
What glaucoma is
The term glaucoma refers to a characteristic pattern of damage to the optic nerve (the nerve that enters the back of the eye and carries the visual signal to the brain) along with corresponding visual field loss which is progressive. Specialists often refer to “glaucomas” as a group of conditions involving excessive loss of retinal ganglion cells, usually degenerative (but not always, as there are childhood conditions). You will come across it mostly with people over 50, it is estimated that 2% of the population are affected and it is predominantly genetic.
One of the main risk factors for the development of glaucoma is elevated intraocular pressure – IOP – (the pressure within the eyeball). About 2/3 of cases have abnormally high IOP but many do not (I myself have “normal tension glaucoma”). Pretty much all treatments (eye drops, medication and surgery) target reducing the IOP even when IOP is “normal”.
How glaucoma affects people
Most glaucoma is initially symptom free and usually discovered as part of normal eye tests. The degree of visual field loss can vary hugely depending on how early it is detected, the effectiveness of various treatments and other (not all known) factors. But once someone knows they have glaucoma and is undergoing treatment or experiencing degenerating vision, this is what they might notice:
- Certain spatial blind spots. Typically peripheral vision goes first, but it is quite individual and could be any angle of vision. Most of us know where our loss of vision is most pronounced as the visual field tests show this, so your client should be able to find out if they don’t know. But, like the optic disk blind spot we all have, our brain fills in the gap, so not everyone knows they can’t see what they can’t see.
- Many other vision impairments may be present, some significant:
- difficulty adapting to changes in lighting
- trouble seeing in dim or dark environments
- blurred vision
- difficulties with glare
- reduced contrast sensitivity
- Using the eye drops can cause or exacerbate “dry eye”, which can be uncomfortable and distracting (and contribute to the “blurred vision”)
- Increased anxiety – the powerful fear of going blind. For example, a 2016 study from researchers at the Wilmer Eye Institute at Johns Hopkins University School of Medicine found that most subjects regard loss of eyesight as the worst ailment that could happen to them, surpassing such conditions as loss of limb, memory, hearing or speech, or having H.I.V./AIDS.
- General lack of confidence about movement – balance, tripping “falling”, collisions, dropping and breaking things.
Pilates can certainly help with the last two issues: reducing anxiety and, of course, increasing the confidence to move. But we can also help build our client’s armoury of adaptations for vision loss:
- improving their proprioception and body awareness
- work on non-visual elements of vestibular balance
- maintaining movement patterns to compensate for visual field loss: eye mobility, neck mobility and down the chain.
Pilates with glaucoma awareness
There is not yet irrefutable evidence that there are specific exercise contraindications for people with glaucoma, but there are two areas of research that are worth considering.
A number of studies suggest potential adverse effects on IOP from two common elements of exercise that are relevant to Pilates; prolonged inversion and weightlifting.
Prolonged inversion:
A 2015 study found that IOP increased significantly during 4 inverted yoga poses (downward dog, plough, forward bend and supine with straight legs elevated) for both people with and without glaucoma. Their IOP recovered quickly after stopping and there is no evidence that yoga participants, in general, exacerbate their glaucoma. It’s also worth noting that these poses were held for 2 minutes, as is often the case in yoga practice, but less common in Pilates.
Most glaucoma patients receive a vague suggestion from their specialist that it’s probably not a good idea to be inverted for “prolonged periods” (and certainly headstands are vehemently discouraged). On pressing some of Australia’s leading glaucoma specialists on what “prolonged” means (“bending down to do their shoelaces? Tinkering under the car?” etc – all of which they think are OK) it is clear there is no evidence-based official position on this. This Pilates teacher takes the following approach to minimise the risk – noting that other contraindications may rule out many of these anyway:
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- Standing rolldowns: single breath cycle only, not hanging in forward flexion
- Rollovers (short spine etc): same principle – single breath cycle, keep it moving.
- All the leg pull, pull ups, upstretch, elephant, twist–loaded upper body exercise family – in small doses (if otherwise appropriate)
- Quadruped – not maintaining for excessive periods and being attentive to head position
Weightlifting:
There is also research finding increased IOP during weightlifting/resistance training (and glaucoma patients are sometimes advised to “avoid weights”). It is also inconclusive, but the most useful finding is that the potential increased risk seems to be associated with employing a Valsalva Manoeuvre (VM) or partial VM – basically holding your breath.
In case you needed one, this is one more reason to encourage people to breathe properly while doing Pilates, especially during effortful exercises. It could also be interpreted as suggesting steady expiration during the resistance phase creates less risk of increasing IOP.
So, breathing correctly and avoiding prolonged inversions – what else is there to consider?
Inevitably, the majority of people we encounter in the Pilates studio with glaucoma will also have other issues related to ageing and, fortuitously, most of the things we can do/should do are of general benefit anyway.
You’re probably including many of these elements in your programs already, but you might want to tweak the balance to emphasise the following:
- Focus on Feet. All dimensions of foot (and ankle) function: mobility and stability, sensory awareness and motor control. Healthy, alert, responsive feet are key to proprioception, balance, gait – well everything involved in bipedal existence – and can partially compensate for sight loss and improve confidence.
- Vestibular balance work involving head movement, including rapid head and eye movement. Safety first, of course, but it’s also a good way to mix up even a simple basic exercise program. For example, seated footwork on the Wunda Chair with head and eye movements.
- Cervical and thoracic rotation capacity. Everything that can help compensate for the eye’s reduced ability to scan the scene. This is particularly valuable for continuing to drive safely, which is often top of mind for glaucoma patients.
- Anything that builds confidence generally, as you surely do already.
It seems reasonable to apply some deductive reasoning to the limited findings in adjacent areas to conclude that Pilates is largely safe for clients with glaucoma, with more modifications if they are going to be doing more intermediate/advanced repertoire.
What else you can do in the studio to help
Studio lighting is even more important given the sensitivity to glare coupled with difficulty seeing in dim light:
- Avoid positioning them facing the window if there is a lot of glare from daylight
- Good artificial lighting needs to be directed appropriately, avoiding direct beams, and as even as possible.
- Avoid clutter and trip hazards. This is hard for any studio – but keeping it tidy is a good start. As a glaucoma affected teacher I am perpetually covered in bruises and minor lower limb damage from bumping into stray Pilates equipment.
My motivation for writing this article was that very few specialists seem to know what is really involved in a Pilates session so the advice they tend to give their patients is often unhelpful.
There is clearly a lot we can offer people with glaucoma, given the choices we have in the Pilates canon and the care and attention we offer.
Meredith Brooks, PAA Treasurer
References:
Adrienne W Scott 1, Neil M Bressler 2, Suzanne Ffolkes 3, John S Wittenborn 4, James Jorkasky 5
Public Attitudes About Eye and Vision Health
https://pubmed.ncbi.nlm.nih.gov/27490785/
Jessica V. Jasien, Jost B. Jonas, C. Gustavo de Moraes, Robert Ritch
Intraocular Pressure Rise in Subjects with and without Glaucoma during Four Common Yoga Positions
Published: December 23, 2015 PLOSOne https://doi.org/10.1371/journal.pone.0144505
Vaghefi E, Shon C, Reading S, et al.
Intraocular pressure fluctuation during resistance exercise.
BMJ Open Ophthalmology 2021;6:e000723. doi:10.1136/bmjophth-2021-000723
Charles William McMonnies
Intraocular pressure and glaucoma: Is physical exercise beneficial or a risk?
School of Optometry and Vision Science, University of New South Wales, Kensington 2052, Australia Journal of Optometry 12 January 2016
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