Physical Therapy

Fascinating Neuro-Concepts You Need To Know As A Pilates Instructor

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Watch the #PilatesHour webinar “Neuro-Concepts in Pilates” with Brent Anderson PT, PhD, OCS, NCPT, and Kate Strozak MSc Applied Neuroscience, LMT, NCPT.

Neuroplasticity

KS: Neuroplasticity is a term that you are probably hearing a lot about. With ample new funding for neuroscience, there has been a lot about the study of neuroplasticity and how to best support its process. 

Neuroplasticity is the nervous system forming, adapting, or reorganizing in terms of its structure and function.  Neuroplasticity describes the actual structural changes that can occur to a brain when it comes to learning and adapting. It also refers to brain function and how we relay and communicate information “out” from the brain.  Neuroplasticity occurs throughout all stages of life however it certainly seems to slow down with age. That’s not to say it doesn’t continue to happen. The process can become a bit slower or require increased thoughtfulness to facilitate.  

Until around the age of 25, humans are very wired to learn. It’s like giving water to a sponge. You can soak things in and you don’t really have to put much thought, attention, and focus on it. Past 25, in the way that our bodies are evolving through age, we benefit from harnessing factors like attention, focus, and sleep. 

Sleep is particularly important in supporting neuroplastic changes in the brain.  

There’s all this excitement about neuroplasticity, “oh we’re going to work on your neuroplasticity today! You are changing your brain by learning all of these things”! But neuroplasticity doesn’t exclusively describe what you might think of as a “positive” process of learning things. Neuroplasticity also includes and encompasses maladaptive processes.  When we develop compensations or when we have traumatic experiences in our life, that’s also neuroplasticity.  It’s good to be aware that there is much more to it than just “learning new things” for fun or for efficiency. 

BA:  This reminds me of our conversation about centralized pain with Adriaan Louw. Not the peripheral pain of a message coming in and the brain protecting, but a centralized pain pattern. This is exactly what you’re talking about Kate.  In this case, it is neuroplasticity in the “negative” way that creates a circuit of pain that gets stimulated by many different things. From emotions, touch, proprioception, and temperature, any of these can facilitate or trigger a response now that it’s been hard-wired.  

As Pilates teachers, our goal is to create positive movement experiences that don’t have pain. And doing this with the intention of rewiring that poorly wired circuit that we refer to as centralized pain.  What are your thoughts on that? What are we able to facilitate as Pilates instructors in terms of neuroplasticity? How do we do this in the one or two hours a week we have with our clients? 

KS:  We will do this by giving new experiences, and very importantly, by challenging people. It cannot work by keeping people in their comfort zone. 

There is of course a time and a place for moving within a comfort zone. Maybe you are trying to establish rapport or get someone comfortable and familiar with the movement. Eventually, you have to take them to that point where they are being challenged and they are exerting. You see this intense focus on their faces and the sweat beads starting to drip! So that’s a really key thing you can start to integrate as a movement professional now. 

Neurogenesis

Neurogenesis is the idea that our brains actually create new neurons.  I grew up believing that once you damage a brain cell or a neuron it’s gone forever, so good luck!  But this is actually not the case.  Evidence is suggesting that neurogenesis does occur throughout life. It’s a process that slows as we get older, which makes a lot of sense if you think of a newborn.

Newborn brains are just incredible in how much neuronal growth they are going through and synaptic connections they are building.  Children go through this until about the age of three when you see this rapid increase of neurons, neuronal size, and connections forming.  Around the age of three, they enter a state of “pruning” or cell death (but pruning sounds much better), where you see those communications simplify and streamline. This makes a lot of sense if you are around, say, three-year-olds and what they are going through behaviorally and developmentally.  

100 Billion Neurons

Even though it most profoundly occurs at that early stage in life, neurogenesis is something that occurs throughout life.  There is a lot of excitement about neuroplasticity, and neurogenesis and this is good news, but it is relatively small.  If we have 100 billion neurons in an adult brain, neurogenesis accounts for about 700 new neurons added per day in the hippocampus part of the brain.  There are similar factors to neuroplasticity that support neurogenesis such as sleep, exercise, learning, nutrition, and play.  The play aspect encompasses the challenge component of neuroplasticity. Attention and focus can also support the process of neurogenesis.  

BA:  When you’re looking at 100 billion neurons, 700 new neurons per day is not a whole lot. The idea of genesis – we have angiogenesis where our arteries and capillaries regenerate as well as peripheral nerve regeneration. We have known this for a long time, and you have to create the demand for the peripheral nerve to regenerate. 

It makes sense that there would be regeneration in the central nervous system.  I think the challenge we have is finding the data to show how that works. Perhaps looking at the difference between something like a central pattern generator in a cat versus in a human. It would be interesting to look at research trying to activate those in people who have had a spinal cord injury. Maybe using stem cells to be able to speed up the neurogenesis inside the brain and the spinal cord.  Either way, if it’s exogenous or endogenous, I think we are going to figure it out. It is an exciting time to be involved in neuroscience.  

KS:  We know IQ can change. It is not a fixed measurement.  We now know that we can grow new neurons.  It is amazing the things we can do as humans. 

Watch #PilatesHour Episode 120 “Neuro-Concepts & Pilates” and Join us Thursdays at 3 PM eastern and participate live with Brent and special guests: #PilatesHour Live!

Do You Really Understand Osteoarthritis?

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Gain insight into osteoarthritis and discover the benefits of Pilates for osteoarthritis prevention in this exclusive conversation with Polestar faculty Brent Anderson PT, PhD, OCS, NCPT, and Beth Kaplanek RN, BSN, NCPT. Watch the #PilatesHour Webinar “Working With Clients With Osteoarthritis” and take your understanding to the next level in our online course “Osteoarthritis of the Hip & Pilates”.

BA:  We’ve been talking about positive movement experiences since the first time we met. How do we create these positive movement experiences? Osteoarthritis (OA) of the lower extremities is the best topic to talk about regarding positive movement experiences. The research all points clearly to this!

BK: As you know, osteoarthritis is the most under-recognized chronic condition out there. The wear and tear are present in almost all individuals on some level, whether you are exemplifying symptoms or not. 

59.4 million Americans have some sort of arthritis and if we look at it globally it’s much bigger. If you take hip, knee, hand, and spine, we’re talking about the fourth largest global disability. 85% of this osteoarthritis is related to the hip and knee.  

There are many different types of arthritis. We are talking specifically about osteoarthritis which tends to be more about wear and tear. But there are definitely some systemic inflammatory conditions that can cause osteoarthritis besides just wear and tear. 

What is Osteoarthritis?

Osteoarthritis is a breaking down of the articular cartilage. Exposed subchondral bone, underneath the articular cartilage, is supposed to slide and glide and move beautifully. It’s also bathed in synovial fluid. The articular cartilage needs this nourishment to stay healthy.  

When you have irritated synovial fluid, in addition, to wear and tear, the breakdown of cartilage creates an inflammatory contusion. We want to work on the things we can do to create an anti-inflammatory environment. This creates the best environment possible to keep that nourishment going properly for the articular cartilage so we have less breakdown. We want to get to a place where we have a little homeostasis. This will hopefully delay and deter the breakdown of the articular cartilage.  

Osteoarthritis today is not only occurring in older people. There is a major increase of individuals between the age of 40 and 55. It is amazing how many more people are suffering from osteoarthritis these days. When it gets severe, it’s a total joint failure. One in two Americans and two in three obese people will likely get knee osteoarthritis. The knees seem to be the leading joint where osteoarthritis is found. 1 in 4 Americans, or about 25 percent of the population, will develop hip osteoarthritis, and it’s very costly. 

Not just costly for the amount of care you need, but costly to the individual. They lose work and time, and can’t make the money they need which also affects their well-being and quality of life. There’s a lot to it, and the pathogenesis of osteoarthritis can get very deep – the chemistry. What we can do is create a beautiful environment to deter or prevent further breakdown. Pilates is great for this!

BA: Something that comes to mind is the importance of students knowing the leading causes of excessive stress to the knee. Especially since the knee is the primary joint where osteoarthritis occurs. I often challenge them with this question:

Where is a place where you have decreased mobility leading to knee wear and tear? 

The answers are lack of ankle mobility, dorsiflexion, hip extension, and deceleration strength in the hip and pelvis. These are some of the leading causes of excessive stress through the knee leading to the loss of congruency. Because the knee is always load-bearing in humans, because we are bi-pedal animals, it takes a lot of the brunt of that wear and tear. If we work backward, how can we improve alignment, congruency, and distribution of force? These are the fundamental components of prevention.  

BK: Yes, lack of hip extension and dorsiflexion are the two biggies. We can also add a lack of thoracic extension and balance on the lateral line of the body to that list. These are the very things we can target in our Pilates programs.

Looking at a 2017 Study from the Journal of Orthopedic and Sports PT, we can see the highlighted reasons that are causing OA. We see that 25% of knee pain is related to obesity. We also see that high BMI has increased overall in males and females ages 15-49 which contributes to the increase in global osteoarthritis. The five major contributors to osteoarthritis are obesity, traumatic injury to the knee, femoral acetabular impingement (FAI), hip dysplasia, and sports injuries.

We see more young people playing sports and see a lot more ACL injuries early on, along with meniscal tears. Both of these can develop into knee osteoarthritis in a person’s lifetime.

The five major contributors to osteoarthritis are obesity, traumatic injury to the knee, femoral acetabular impingement (FAI), hip dysplasia, and sports injuries.

When we get into the hip we’re talking about femoral acetabulum impingement and hip dysplasia. These can have a 10-fold increase in progressing to end-stage hip osteoarthritis within 5-20 years. 

We also see osteoarthritis develop due to high-impact sports like wrestling, distance running, soccer, and weight lifting – these are definitely players as well. Of course, if you are not recovering, rehabbing correctly, maintaining the congruency in the joint, and doing all of the other anti-inflammatory things you need to do, that causes a progression as well. 

BA: A lot of our students answer running when we ask what the causes might be. I want to make it clear that although there is a stereotype out there that running is bad for the knees, humans are designed to run! I will say that jogging may not be as natural human locomotion as others, but walking, running, and sprinting are.

Jogging seems to put an abnormal amount of stress on the knee. Especially if you run with a heel strike, and more if you don’t have the ankle dorsiflexion that you are meant to have. If you visit countries where they still squat a lot, they do not have the same incidence of knee pathologies as elsewhere. These are areas where they are squatting to go to the bathroom, do work, socialize, and rest specifically with the heels down.

Register for our upcoming #PilatesHour Webinar here. Deepen your understanding of osteoarthritis in our online course “Osteoarthritis of the Hip & Pilates” with Polestar Faculty Beth Kaplanek, RN, BSN, NCPT.

The Expert of Their Pain – Listening to Our Clients’ Stories

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Brent Anderson PT. Ph.D., OCS, NCPT, and Adriaan Louw PT, Ph.D. discuss how to practice presence when listening to our clients’ history and pain. Watch #PilatesHour episode 113 “All Things Pain” here.

Listening To Our Client’s Stories

BA: How do we learn to listen as practitioners? In the interviewing and questioning area, what are some tips for listening? 

AL: You’re throwing some tough ones at me today! There is eye contact and eye level and all of those things, but I think there is more to it.  When it comes to chronic pain, which is the area that we tend to specialize in, there has to truly be a desire to get to know the patient, empathy, and compassion. I know this is a very hard thing to wrap our minds around today. All of us say “I care”, but I don’t know if we do. 

I’m listening to your story today and I’m thinking, I didn’t even know a lot of these things existed in my first 5 years of orthopedic practice. If my patient came in and said “my pain is worse because I’m being punished by a deity” I would say “yeah right, get out of here, I have another patient at 2 o’clock”. We’re all on a journey in our professional lives, and luckily as you get older you get more experience and things come to you. 

The therapists that really get to know pain and how pain works, that truly start seeing how complex human pain experience is, are more intent on listening. They think “tell me more, I want to know more”. There is a real interest and desire to know.

As we get more of a human pain experience there is almost an innate wanting to know more. And as you see more complex pain patients, things sometimes don’t make sense – how does this work? We’re becoming more aware of the things we don’t know, so we ask more questions. 

Be There And Be Present At The Moment

An interesting thing that we have shown is that outcomes have nothing to do with time. I think this is important because every person listening today is thinking “you have to spend more time with your patient” and the answer is no. There’s no data to prove it. We did a study where patients came in and we measured a bunch of “stuff”. We then sat and interviewed, heard their story, and had a therapist time how long they sat with them and measured this “stuff” and some physical exams as well.

People had 25% better outcomes before we even started treatment. It had nothing to do with time. So what I tell students often is “be there and be present at the moment”.  Other data showed that we trust in less than 1 second. Trust is almost an instantaneous thing, but it’s about being there, being present, and wanting to know this person.

I’m going to very shameful share that when I was an OMT I don’t think I wanted to know people. It was just a joint or muscle that I had to manipulate to get them out and get them better. This is no disrespect to my instructors, they were amazing.  

BA:  It’s how we were trained.

AL: And that’s ok. As I worked my way through, I learned more about pain. The more I learned about the neuroscience of pain and how complex pain is, the less likely I was to cut people short or interrupt them or explain things to them because I don’t know yet. I have to think, “that’s interesting”, I should go learn more. We become vulnerable and remember that the patient is the expert in their pain. “Tell me your story – what brings you here?”.

BA:  I think the keyword is “present”. One of the things we talk a lot about in Pilates, Yoga, Tai Chi, and Feldenkreis, is being present. Be mindful and understand that there’s something important happening right now. Right now I’m fully interested in sharing information with you and learning from you and I’m present, writing notes down!

I see this often with students who are in my class. They are on their cell phones doing things and I know they can’t be present and be on the cell phone at the same time. Or they are present with their cell phone but not present with me.  

I think it’s a great question, and one of the dilemmas we present to students sometimes is that you have to document. So you have your computer there documenting what you’re doing, but the documentation is taking away from the contact you’re talking about. Eye contact, same level, body language, being present, listening, appearing to listen, and building that trusting relationship. 

As we mature in the practice we start to realize that we don’t have all the answers. We end up getting more complex clients, that have more complex issues. More comorbidities, and more psychological and social-emotional issues, are tied to the physical manifestations. What I have learned as well is that the patient knows what’s wrong with them, but they often don’t know how to articulate it. If we can listen and ask the right questions, we can get the information we need to help them walk out the door. 

The Problem Of A Lion

BA: Regarding centralized pain, I want to mention how you talk about the “Lion”. How the lion increases, anxiety, fear, relationships, finances you name it – and can sensitize the interpretation of pain. I think this is so important!

AL: To put it into context, one of the metaphors we use to teach people about pain is a lion metaphor. This story works with people who talk about fatigue or problems sleeping. Let’s first take a half step back. The patient walks in and I say “since you have developed fibromyalgia what’s the biggest thing you struggle with”… “Well I’m always tired, exhausted, and cannot sleep at night”. 

We develop different stories based on problems people face based on their underlying biology. We may explain this and turn to the patient and ask them “has anyone explained to you why you are so tired, or why you can’t fall asleep?”. In 99 percent of the patients, the answer is no, no one has explained this pain to them. 

I ask the patient, “if a lion jumped in his room right now, what would you do?”. Then you stop, you don’t talk. We have a marker and dry erase board in the room and the patient writes down what they would do. They will write things like scream, run, freak out, or whatever they may think of. Then I systematically go through a list of biological processes. “Suzy, if a lion jumped into the room is it time to take a nap? Yes or no”… “Well, no”.

They know the answers! If a lion jumped in, is it time to save energy for the winter or time to use energy? “I need to use it”. 

We go through their system and use big muscles and small muscles working our way down. Then we ask them “what does this have to do with you today?”.  And we know what they are struggling with. They have seen 2 podiatrists, nine PTs, and three orthopedic surgeons. They have bills and co-pays, (and we start writing these on the board), and all the things they are dealing with like stress, anxiety, life, and relationships. All of these are the problem of a lion.

From the moment you wake up, there is a lion in your life, and your system shunts. When a lion jumps in you freak out, and your fight and flight systems begin, the sympathetics. Then when the lion gets pulled out you sink back in the room and think “that’s the third lion attack today, this better stop!”.  Our system is designed to ramp and calm. But for Suzy, this lion has been in her life for 5 years or 7 years. Her system shunts constantly and she never saves energy.

They know we are using a simple analogy, so the questions come about what we can do about it.  “Suzy, how do we make the lion smaller?”. We talk about nutrition, sleep, mindfulness, relaxation and movement. This is all the cool stuff that can make your lion smaller and smaller and when the small lion enters the room we don’t freak out. We go “Awww a little baby lion”. 

I know this sounds silly, but it’s the latest neuroscience, and in a simple way the patient says “this makes so much sense”. We have systematic reviews and meta-analyses to show this really works! 

BA: I love the analogy!  One of the products that you’ve put out is the fibromyalgia workbook and I’ve used that a lot with many of my patients. We go through the lessons and we take one lesson a week if they can handle it. Going through each of the lessons helps them and they go home and think about it and work through it. I use the workbook with anyone with chronic pain. It works great with people with fibromyalgia diagnoses, why is that?

AL:  Fibromyalgia is obviously a complex condition that affects millions of people. We wrote a paper a few years ago, “treat the patient not the label” because their labels change all the time. Between chronic Lyme disease, fibromyalgia, IBS, and chronic fatigue syndrome, the list can go on and on. The underlying biology is absolutely intriguing.

The current thought process in the neuroscience world, in the condition you and I would label “fibromyalgia”, is that the immune system plays a significant role in sensitizing the peripheral and central nervous system. We understand the mechanisms better, but that doesn’t help the patient. The patient came to me with their fibromyalgia. If I take that label away from them, I might as well cut their body in half. With patients, we validate them by using their labels.  

Pain is an individual human experience and we need to be careful about labeling. Fibromyalgia tells me nothing that is happening under their skin, in their system, in their brain, in their amygdala – but that’s what the patient has chosen to call it and be labeled as. You and I know the underlying mechanisms of all of these are very similar biological processes.  

BA:  I want to go into these stories you created with your team and through the years what I find most important is looking to match a story. Having a story that a client can relate to and understand just like we talked about the lion. 

Understanding Pain

AL:  It started way back when we interviewed a lot of people with chronic pain and what the most common struggles were. There are 6 of them: persistent pain (pain that does not get any better), pain that spreads (pain that moves to different areas of the body), fatigue and sleep issues, odd pain (pain when it’s cold, pain when you are stressed), and a “fog” causing forgetfulness and lack of focus.

We went and studied the underlying biology to know when a patient comes to us. I ask them, “Since your knee replacement, what’s the biggest thing that bothers you?”. They respond “when it’s cold I feel my knee pain”, and I ask if anyone explained this to them and the answer is often “no”.

We can use car sensors as explanations. A car sensor goes “hey you need gas”. Is there something catastrophically wrong with your car? No, you just need gas. There are sensors in our body that tell us how cold it is today, or if we are stressed. They are all balanced and when there’s a cold front coming, the temperature sensors will tell us “hey it’s cold out, make sure you put on long pants”.

These stories are designed to de-threaten the pain experience so the patient understands “oh, that’s what’s going on”.  We have studies to show that fear avoidance and catastrophization positively shift and that then makes your candidate for movement.

People who are not as afraid of their pain anymore are now prime candidates for the most powerful thing to change pain, which is movement.  People in pain are afraid to move. They fear that they will undo their knee or hurt their back and their alarm system is on full alert while the back is healing. Tissues heal, right?  It’s the education model designed to facilitate people to move that is where we really want to get them, that’s where the therapy happens. They are just afraid to move. 

Watch the #PilatesHour episode 113 “All Things Pain” Here. Learn more about Adriaan Louw and Evidence in Motion here.

The Influence Of Imagery On Neurobiology is Powerful

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Watch the full Pilates Hour Episode #108 “Does Ideal Alignment Really Matter” with Brent Anderson PhD, PT, OCS, NCPT, and special guest Eric Franklin, Franklin Method.

Imagery Influencing Neurobiology

BA: What is your gut feeling about imagery influencing neurobiology?

EF:  It must be happening. We know the influence of imagery on a variety of psychological states and obviously, we know its influence on movement. For any of that to happen, you are changing things in your neurobiology, from neurotransmitters to hormone release. But we haven’t looked at it directly yet at the cellular level, which is where we want to go next!

BA: One of the interesting things about the idea of neuroplasticity is how our experiences modify our neural pathways. The synapses change and some of the neuromodulators change because of our experiences. Something I am reading about is the belief that neuroplasticity happens at night time when we are in our sleep. We have these experiences during the day and when we are in deep sleep the nervous system processes them. It actually moves through that neuroplastic part, the hard part of changing biology. 

It is interesting to use that knowledge to see if people in their sleep are in conjunction with their imagery and movement experiences. To see if those who have a good night’s sleep have better neuroplastic, bio cellular, and neuro-cellular change than those with poor sleep and the same interventions.

“the fastest way to change your movement is to change your mind”

Eric Franklin

EF:  I would be pretty sure about that because I always say “the fastest way to change your movement is to change your mind”. That’s because synaptic waiting and synaptic change happen so fast. You change your mind about the movement and the movement changes. That’s a very fast approach. Changing muscles takes longer, and changing the fascia takes even longer.

It doesn’t mean those are things you shouldn’t do. If you want something that works fast then images are a great way to create relatively rapid neuroplasticity. It is not just to brag about imagery and say it’s so cool because it’s also about motivation. 

People get stuck in end goals like “I have to work out and train until I get my six-pack or until this or that releases”. Or “I have to get some more collagen laid down in that area…”. Instead, give them some motivational things. Give them some imagery so they can immediately feel a change. Of course, that is not going to change the fascia immediately. It will need a lot more repetition, but it’s very motivational. 

BA: You are the pioneer on a lot of this, and especially for making it known. Back when I met you 25 years ago at IADMS our thinking was more about “hard-wired”, suggesting everything was structural.  People thought “my plie is limited structurally, I have tight heels”. Then we play the bone rhythm game and all of a sudden they can move into another 10 to 15 degrees of ankle dorsiflexion. Releasing the hips just with the image of the sitting bones widening.

We love your work and have supported it from the beginning, and that was a big breakthrough for us. That experience led to part of my dissertation looking at the idea of creating successful movement experiences for people in chronic pain.  Having that successful movement experience shifted their paradigm and we created that by using imagery they could process.  This is key as a lot of times doctors use imagery that the client can’t process and is thus unsuccessful.

EF: It’s very nice of you to say all these things. To this day, we first look at the kinds of functions that are built into you structurally. Then we add functional exercise on top of that. If you are told that your bone structure won’t allow certain movement, that’s already negative imagery. This alone could be part of why it is difficult. You hear “oh my bone structure doesn’t allow…”, and if you think this, why even bother?

If you are told that your bone structure won’t allow certain movement, that’s already negative imagery. This alone could be part of why it is difficult. You hear “oh my bone structure doesn’t allow…”, and if you think this, why even bother?

BA:  “I’m built this way…”

EF:  If you tell someone “you’re not built to do that very efficiently”, they may think “ok, I won’t even do it in the first place”. 

BA: Or, they might try to do it in a way that can potentially injure tissue. I love this idea of these two areas in particular that you’re focusing on right now. The idea of understanding biology in conjunction with imagery and the behavior, belief, or perception of how we mix the two. This connecting of behavioral science with the physiology and biology of things we’ve suspected for a long time because we see the change.  A lot of times the change is immediate, and when we think about the long-term acquisition of it it’s like you said, the tissue adapts with practice and repetition.

When someone can implement an image that helps them on a regular basis in their movement practice, you will start to see the shift in their motor control. We know the neuromuscular system shifts and is always seeking efficiency with the task, so we will often see that. 

The most exciting part of this is working with fascial gurus to understand the mass of science coming out about the communication system that exists inside of our fascia. In one study they removed fascial tissue from a living animal, put it in a dark room, and it continued emitting light photons for minutes after it was removed from the living organism. Just think about these tubulars that are talking to all the cells. The cells are very dynamic in their synapses, at least we know that –  really, really exciting!

EF: A lot of the research in motor imagery supports that if you rehearse the movement before you do it, afterward it’s better.  That is very interesting, but what about going further back even into the emotional aspect? What about working with the limbic system and how it affects all that movement and working directly at the endocrine and cellular level and doing imagery there.  So instead of just looking at the results and then trying to find explanations, go directly into the tissue with imagery and see if that’s measurable. No one has ever done that, why not?  

Maybe not measuring the amygdala and stress response on the cellular level. Maybe that’s a bit complicated, but there are other things that we’re going to look at -and to go further back, not looking so much at the result, but at the much earlier stage where these results are being created. Look at the imagery – what is it doing there?  That’s the next step.

BA: The neuromodulators can also be measured, like the serotonin type 2a and dopamine. Those things are tied to motivation and satisfaction.  I would find it really interesting to learn how a successful movement experience with imagery that they’ve embedded changes the whole neuro response. Specifically with the serotonin type 2a, which is thought to correspond to contentment or satisfaction, and dopamine, the motivation modulator.

EF:  Dopamine only gets released when you’re planning or thinking about what you want to achieve. As soon as you achieve it, the dopamine is gone. The serotonin for the contentment part, to give one answer – movement is good if it feels comfortable to you. If you enjoy doing the movement, then there must be efficiency on some level. There are several perspectives on efficiency and good movement. The inner perspective is:

“What is your experience of this movement?” and the external perspective is “What is the experience of the beholder?”. 

For example, you go to this incredible ballet performance or Cirque du Solei and they’re doing these incredible things. You say, “That was so amazing, so beautiful”, but meanwhile on the stage they are wrecking their bodies. 

There you have the conflict full on. A lot of things they were doing were dysfunctional, pushing their bodies way beyond what they should be doing. They were hurting badly on every level, but the audience thought it was beautiful and incredible movement.  They are basically ending their career right out there on stage.

Looks Good / Feels Good

BA: That’s a great topic, that “external versus internal”. Where is the feedback coming from? Who is giving the feedback that it was amazing? The observer or the mover? It’s the “looks good versus feels good”. When we teach, we provide external feedback “Move the pelvis in this direction”, “Allow this to happen”, or “Reach there”. The internal feedback is the question “How does that movement feel?”, “What do you observe with that?”, “What happens when you use this imagery versus that imagery?”.

EF: Starting way back, my experience in exercise classes and dance classes was all about positional alignment. You were told about the shoulders and ankles. Shoulder blades down, endless stuff like that, “Lift pelvis”, on and on until I felt immobilized, literally!  Is this correct now? Am I supposed to move from here? Well, I can’t really move because I’m going to wreck this great posture.

I was thinking that it feels very conflicted and it eventually donned on me that you can’t teach movement through a position. They contradict each other. Movement is movement, and a position is a position. We are not a statue on a wall.  That’s where it kind of started for me. If you want to align onto a wall, stacking the body like bricks, I think that works pretty well for a wall… but I’m not made for not moving.

In fact, we are very bad at not moving – that’s basically the crisis we have right now. We are more sedentary than our ancestors.  We are very adapted to a lot of moderate movement for hours daily. That’s what we’re adapted to and that’s why I was wondering about this postural teaching. If you try to move while you try to keep a position, you are going to create conflict and it expresses itself in tension. As we know, tension is the enemy of movement. If the movement from the beholder looks tense, and there are different ways it can be expressed, like discomfort, the suspicion should be high that this movement is not efficient. 

Watch the Full Replay of Pilates Hour Episode #108 “Does Ideal Alignment Really Matter” with Brent Anderson and Eric Franklin. For more on Neuroscience and Pilates check out the blog “Neuro-Concepts and Pilates”.

Do You Really Understand Pelvic Floor Health?

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Watch #PilatesHour episode 110 “Pelvic Talk” with Brent Anderson PhD, PT, OCS, NCPT and Pam Downey PT, DPT, WCS, BCB-PMB.

BA: Do you cue for pelvic floor activation? 

PD: The good and the bad is that there is a lot of buzz around the pelvis, and pelvic floor. Then, like everything else, it gets a little diluted or a little “translated”. I always like to come back to what we really mean by certain things. That’s one aspect of what I’m really trying to put out there now. Let’s all try to have a similar vocabulary and understand really what we are after.  

There are way more people coming via the internet, with more open-mindedness about how women are during the birth experience. For example, people are seeking services after delivery with different health professionals. Most people are coming into the system because of excellent trainers picking up on dysfunctions and referring them appropriately. That’s what I get really excited about. It’s not really a medical model, but it’s out there with educators. 

BA:  It’s such an important aspect, that continuum of care that we’ve always talked about. A lot of times people get very territorial. It’s like, “the pelvic floor is my territory, my profession, my training”. What we don’t realize is it’s a continuum of health just like everything is. At some point, clients are going to be doing at-home exercises, going to the gym, and attending movement classes. The more people are aware of that whole spectrum of pre, during, and post-rehab, the more able we are able to achieve our ultimate goal. To allow people to participate more wholly in life.

We’re dealing with things like incontinence, vulvodynia, weak abdominals, and hernia of the abdominal wall postpartum. These are all things that significantly impact people’s well-being. This is what I love about my relationship with you. When I’m screening someone, I completely understand the impact that pelvic floor pathology can have on intra-abdominal pressure with someone with low back pain, but when I rule out pretty much everything that has to do with the physiology and structure of the spine, I can say “I really think this person needs a pelvic floor consult, can you look and see if there’s something missing.”  

PM:  You touch on something that’s really important in the healthcare model. A lot of our healthcare professionals seeing patients on the front line have just minutes with their clients.

BA: I’d love for you to talk about the latest research out there on dealing with stress incontinence. What are some of the latest research? Do we know what is not working? What are some things you do as an internal therapist to be able to understand that better? 

PD:  From a functional standpoint we still don’t have a lot in the literature that is functionally driven, I’ll put that out as a disclaimer. A lot of this is still in case study format, not random control studies. But what we can talk about is just like anything else. People assume. That’s the big part, the assumption when they are told to do a Kegel (and what does that really mean?).

Arnold Kegal designed a perineometer, a device inserted into the vagina that was flexible. Women that had stress incontinence were given this device. It looks like a blood pressure cuff device, and the needle would go off when you had a good squeeze. So instead of pushing it out, which would not register anything on the device, you would get biofeedback from getting a contraction. Arnold Kegel really focused on strengthening the pelvic floor universally to help with stress urinary incontinence. Usually at the level of the urethra.

On the pelvic floor, there are layer one and layer two muscles. We have the pelvis and these small muscles, and on the other side is collagen that is very strong and not very elastic. When the pelvic floor is strong it can act like a trampoline and rebound with the intra-abdominal pressure that is coming down to meet the bladder and other organs. This is the endpoint the anatomists say. The levators are our main postural muscle; which holds our innards up as we walk around, and gives us continence.

So coming from where he identified squeezing these muscles, which led to improvement in stress urinary incontinence, we’re now fifty-plus years later still talking about Kegels. So I really call them a pelvic floor muscle exercise, because there are a lot more dynamics to it. At Herman and Wallace, where I’ve been teaching for many years, we teach an exam to look at these muscles from the vaginal side and the rectal side. We also gather a bunch of other information regarding diagnoses, moving beyond this simple squeeze and release.  

We know the pelvic floor is mostly slow oxidative fibers, 70-80 percent of it. So if you’re just teaching a quick on and off, even in a cueing situation, you’re not doing the majority of what these fibers do for a living. A squeeze also has a quick component. You have to be quick to get the intra-abdominal pressure. In our practice, I would say I’ve become way more interested in identifying what part of it. It all squeezes together, but with proper tactile and verbal cueing, I can get the person to understand it functionally.

Moving into a little anterior tilt, I can say “sit in neutral, perform the pelvic floor lift, feel where that feels in your body. Is it more rectal? Is it closer to the midsection of the perineum near the sitting bones, or do you feel it up front? Then take a moment and lean back in your chair, almost with a posterior slump and squeeze again. Now, where do you register that portion of the contraction?” Remember, it’s all contracting the same but your sensory awareness is going to be different. Then finally roll forward toward the front. I give a cue like “pick up a blueberry with your vagina”, “lift the clitoris”, or in men, “lift the penis”.

If you’re looking up front, you’re going to feel perhaps the three different areas of the pelvic floor. Stress incontinence could be affecting more upfront so we can give it a more anterior cue. It has nothing to do with breath, it just has to do with the squeeze and the isolation of the squeeze. 

BA: You bring up really important points. The one that’s the biggest is how little we know about our pelvic floor anatomy in general. I’ve read a couple of papers now regarding how many women have no idea what their genitalia look like, and don’t want to know.  It’s sort of like a taboo, and heaven forbid you to say the words clitoris or vagina in mixed company. One thing I would love to have you explain a little bit more is the relationship of the sphincter muscles, both the anal sphincter and urethra sphincter, in comparison to prolapse and a vaginal wall breach.

We are realizing something interesting after looking at hundreds of ultrasounds. It’s not that they don’t have an active contraction of the pelvic floor. It’s that they think the vagina muscle is lifting the pelvic floor. So you might see a little bit of activity in the vaginal wall but you wouldn’t see the pelvic floor lift up. In some of them, we would see the glutes squeeze because they weren’t quite sure where the pelvic floor was or what the muscle was that they were lifting. Others were in their own minds thinking things like stopping the flow of urine.

Thinking of that integration you’re talking about, I would love to have a little more explanation on the relationship of the urethral sphincter to incontinence. What is its relation to the pubococcygeus and pelvic floor? How does it relate in the sense of incontinence, or “continence” if we look at it in a positive way? 

PD: So what we really need to know is that part of the musculature is under autonomic control. This means that our urethral area is on “close” or tightened. That is mediated through loops going up to the brain and when we go to the toilet or decide to squat and pee we tell the brain “ok go ahead and relax”.

Through that complex system, the autonomic releases the intrinsic sphincter and we also release our volitional sphincters. It’s a very coordinated effort. That’s why potty training takes so long for human children and what’s important to know is that the autonomics are working to keep us continent. We don’t think about contracting them all day long. Otherwise, we wouldn’t be able to function.

What we do have control over is the override.  In the volitional set, we can delay urination at any point, or with that cueing I just mentioned, getting more where the urethra is, more to layer two where all of that pouch is. Through this, you can elicit a more direct contraction and really tighten and reinforce around the urethra.

This could be utilized if you’ve had damage from an obstetrical tear, a decade of chronic coughing due to allergies, COPD, pulmonary issues, or bronchitis where you’ve blown out a lot of things over weeks. So you can reinforce the contractions and help what’s already happening in the autonomics by adding to this deeper layer, the volitional muscle set versus the autonomic set.

Watch the #PilatesHour episode 110 “Pelvic Talk” here.

Why “Exercises To Fix Back Pain” is a Headline to Avoid

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Watch the #PilatesHour Episode 105 “Chronic Low Back Pain” with Brent Anderson and Juan Nieto Here.

Juan Nieto PT, DO, NCPT is the director of Polestar Spain and a frequent international lecturer specializing in rehabilitation through movement and athletic performance. In 2016, along with Brent Anderson and Blas Chamorro, Juan founded RUNITY, a start-up created with the purpose of transforming the Running industry by providing runners with the tools and knowledge they need to practice “painless running”.

Brent Anderson PT, PhD, OCS, NCPT, Polestar Founder. With over 30 years of experience in rehabilitation and movement science, Brent is passionate about the power positive movement experiences have in changing the world. Early in his career as a Physical Therapist with a specialty in dance medicine, he discovered the power and efficacy of Joseph Pilates’ mind-body work to expedite rehabilitation outcomes. This early testament to the power of the Pilates Method inspired him to create a program that merged the worlds of traditional rehabilitation with the mindful movement that Pilates provides.

JN: The results of our survey match the prominent studies on chronic pain, and we often see the knee having prominence in chronic pain.

BA: That’s right – our work together with RUNITY has shown us the most common causes of knee pain in runners. These include lack of dorsiflextion, hip external rotation, and thoracic extension.  When we look at society’s sedentary lifestyle, it’s no wonder we see knee pain across the board. 

JN:  If you look at the load management model it makes a lot of sense. There has to be this balance between the load which you apply to the tissues as well as movement distribution and segmental movement. When there is a lack of movement somewhere there has to be excessive movement somewhere else. Especially in places like the low back and knee (hinge stable joints).

Is chronic pain a measure of tissue damage? No, pain does not equate to tissue damage, and typically anything over 3 months is considered chronic by definition.

JN: Most of my patients have had chronic low back pain for 3 or more years and I see a significant amount of clients for this reason. How can we really get a whole perspective of what is going on with clients with CLBP?

We cannot help everyone. It can be hard to accept that there are some patients that we may not be able to help. We may not know enough, and it may not be a perfect fit. Your interventions will work sometimes and other times they won’t. We need to be ok with that.  Every practitioner has limitations. 

The body will heal, especially in the beginning, as in the first episode of back pain.  Each week you may see improvements. By the 20th episode of back pain, things become more complex. This is when the client is usually referred to a physical therapist. 

One of the best things you can do is deal with the acute situation or manage the pain well. The goal is to not allow it to escalate to a chronic situation.

 BA: I really admire the military model of dealing with low back pain. In this, the first two weeks of early intervention are spent differentiating and managing the symptoms. Many of the people following this model get better and do not need MRI’s, medical injections, surgery, or pharmaceuticals. 

JN:  We live in this world in which pain is something we think we need to eliminate. Think about the world “Pain Killers”. As if zero pain is the only valid amount of pain. I think that this is a poor framework. 

If you truly want to kill pain and reduce pain to zero, and this is the goal of your therapy – you are going to fail…

Juan Nieto

However, you must understand that pain is something that your body has in order to tell you that there is a potential threat to your health.

Magic Exercises

Stop chasing the “magic exercises” and “magic recipe” of what to do with your clients who experience low back pain. It does not exist.  People ask me “what is the best exercise for low back pain?”. This is like asking me “what is the best food in the world?”. Who knows! It is entirely individual and a silly question to ask because it depends on the person and the moment.  One exercise can have a beneficial outcome for one person and a negative outcome for another.  

Every time you see a thing on the internet like “exercises to fix back pain” – Run Away! Or at least keep scrolling. 

Juan Nieto

This will result in confusion. Can you imagine people attempting to do this magic exercise with their clients without understanding why they are doing it?  

BA:  So many people write to us asking “what exercises do I do for clients with low back pain?”. Ten people could have the same degenerate disease diagnosis with completely different exercise selections.  Like Juan said, there is no magic recipe.  But we can help you with things like your critical reasoning skills and asking the right questions.  

Critical Reasoning Skills: 

  • Is this a coordination and awareness problem? 
  • Could it be a behavioral problem? They could change the behavior and the problem goes away.
  • Have you considered a load problem? Perhaps they are not conditioned to handle the load in the lower back for longer than 10 minutes.  
  • Is the client presenting a mobility issue? Perhaps the client only moves from one place and has the strategy of moving from this certain place in their spine.  

I have had so many experiences where I have my client do bridging, some pelvic tilts, and breathing exercises. My goal is for them to learn to move from one or two more segments in their back. My patient says “wow I feel 50% better”. 

You have to keep in mind that low back pain can be very different for each individual.  There are times when two of my clients have the same diagnosis. I know there are differences in the individual’s work, relationships, stress, previous injuries, or beliefs, that interfere with their movement. This creates different paths to treatment for two clients with the same diagnosis. 

JN:  We can adopt the mindset of “let’s see what happens” when you prescribe exercises to a client.  There is no such thing as a certain exercise that will fix a problem with a client.  As movement instructors and physical therapists, we must become comfortable with this uncertainty. 

My online course on chronic low back pain, of which I receive terrific feedback from my students does not include any exercises. This was a deliberate decision that I made.  I can’t go and throw exercises into an online format course. Teachers will attempt to use exercises and if they don’t understand back pain and what they are dealing with the results won’t be good.  Treatment of low back pain needs to be based on the movement principles, assessment, interview, ICF model, and understanding of all of the variables and things that influence a client’s pain. 

ICF MODEL

What is the ICF model? International Classification of Function and Disability model developed by the World Health Organization (WHO).

BA: We use the ICF model a lot at Polestar. It is particularly used by physical therapists and medical practitioners around the world.  It is used to classify a person’s physiological, functional, activity, and participation limitations.

At Polestar we put a big emphasis on “participation” in our assessment. We ask the client “what activities do you believe you should be able to participate in?”.  Maybe the response is “cycling 50 miles” or “hiking Mt Kilimanjaro”. Then as a movement instructor, I need to go seek, learn and discover what those activities require in my client’s body. I can then assess my client and look at where they currently are and where they believe they should be.  There is no “miracle sequence” you do twice a day, three times per week. 

Behavioral Bias

JN:  There is another huge group of questions we receive on low back pain. These are regarding the influence of posture, biomechanics, muscle firing, and recruitment patterns on low back pain. You may see some people with “bad” posture with pain and others with the same posture who don’t have any pain.  This is a good reminder that there is really no such thing as good or bad posture for everybody.  There will be certain movements, positions, and patterns that modulate and alleviate pain for some. The same movement can also irritate and create flare-ups for others.  

The wrong exercises for one person could be the right ones for another.  We need to really “move with them” side by side, and together.  Being together, learning together about their experience, and attempting to offer the little amount of movement that their system is able to accommodate.  If you are able to do this, the compounding effect of 1% over and over can lead to very positive results. 

So often people go to the physical therapist to be “fixed” and this is over the expectations of what the reality is. 

They need to get a little new way to deal with their pathology. Just change the trend slightly by 1%, this is the start. Chronic pain is a marathon and this is going to take time.  Some people come into my clinic who have been experiencing pain for 10 years. They have been building this pain for 20 years. They expect to see results in 25 minutes. This is entirely unrealistic. 

What we can do is provide a new way of dealing with it. A more active plan based on what they can do. We can show them the changes they can make in their lifestyle to make little improvements. Maybe we change the pain by 5%, but their perception of quality of life improves by 70%. Just that little bit of relief of disability makes a huge difference in their life. It’s like night and day.  These small changes can give them hope and something to work on which is great.  

BA:  I refer to some of this as behavioral bias. Sometimes we keep looking for a mechanical, physiological, or structural bias. Often times it is a behavioral bias.  They doen’t realize when they are sitting that they are starting to hurt. After 30 minutes of sitting they start to hurt. The goal is to change their behavior to know that the pain is an indicator to get up and move around. They need to catch the warning signs that they need to alleviate that pain that is starting to manifest. It is that first warning sign they often miss.  

JN:  You cannot learn if there is no attention. When you are in pain your attention goes to the painful experience. Your brain gets hijacked and your perception of pain is magnified.  You need the behavioral and cognitive knowledge to examine “what is causing this to happen?”.  Perhaps it’s a long time of sitting.  Your body is telling you that something is not working well for it. You learn to think “what can I do to change this?”.  

Our best Tools – Our Clients

BA:  Our best tools as movement practitioners are in the information the clients give us. Not what we give them.  I ask them “How do you feel when you are in this position? What happens if you move your pelvis this way or another? How do you feel? Does it feel better or worse?”.  

We need to move away from the sedentary world, get on the ground to play. To listen to what the body tells us, and really respect that.  When we’re sitting on the ground we’re changing positions every five seconds. This is because our body tissues are telling us we’ve been in a position too long.  A big step is to heighten our clients’ awareness in of their own bodies. Then they start managing their own symptoms.  Their awareness often turns on at the stage of pain, and by this point, it may be too late. 

If they can learn to identify something that is pre-pain, they start to take responsibility and they have awareness of what is going on in their own body. The more they have these positive experiences, the more their brain will adapt to this to reinforce the new behavior.  We all have our biases.  Our experience influences us, but education can counter a lot of bias.  Clients come in saying “this position is killing me, there is so much pain”. I ask them if they believe there is tissue damage happening right now? Is something tearing, is something breaking?  Usually, their response is “I don’t think so” and I agree with them. If there is no new tissue damage then what do we need to be aware of?  The brain is telling them that they need to be aware of their body and what is happening.  

This “awareness education” is one of our superpowers as Pilates instructors.

Brent Anderson

If we’re telling our clients everything to do and what exercises are going to make them better, then we’re not really helping them as much as we could. I am always amazed at how well people move when they have to govern themselves in their own exercise regime. 

Joseph’s Pilates 

JN: This is of course implicit in Pilates.  In order to do a proper Pilates practice you have to align body, mind, and spirit. This is what Joseph said!  When we are teaching Pilates we have a source and philosophy and we need to be aligned with the method.  

You let the people move like Joseph did, and trust in the process (something I tell my clients often). In the beginning when you start doing exercises you are simply investing. You may not really be able to see any immediate benefit from it for two or three weeks. After that you look back and have gained many benefits.  In the beginning, especially if you are in pain, you are going to be putting forth a lot of effort and time to take care of yourself. During this time noticeable improvement can seem very small.  You have to remember you are investing and in a few weeks, you will see the accumulation of your efforts.

When you allow your clients to move they tend to self-regulate and move well.  When you teach in the style you mentioned, asking your clients questions in order to raise awareness in specific parts of the body…this is huge and an accelerated version of this. 

Are you instructing your clients all the time on how they need to move, what they need to feel, how they need to breathe, and how many repetitions they need to do? I don’t think this has the same effect.  Of course, they may be moving and are probably getting stronger. I don’t think they will be improving their movement skills or communication within their body. 

It’s about letting your clients have the opportunity to be the protagonist of the situation while you guide them. 

Juan Nieto

BA: When you look at motor learning and movement acquisition, there is a balance of external and internal feedback.  In the beginning, it’s going to be a little heavier on the external feedback. This is us as Pilates instructors. As your clients progress into more procedural learning it’s going to be more internal feedback.  What we see sometimes is this “cueing vomit” from new Pilates instructors which can just be too much information for your clients.  We can do so much better! Think of that long-term plan and developing body awareness and mindfulness of their movement. Try to work on taking one step at a time. Just for today let’s start to get an idea of where your head is in space. That internal awareness creates long-lasting change.  When Joseph pilates talked about practicing Contrology every day, he didn’t mean going to a Pilates teacher every day – he meant something else.  

Juan’s Online Course is Live! This self-paced workshop presents the most up-to-date and evidence-based intervention tools for the management of clients with a history of Chronic Low Back Pain (CLBP).
Online Course: Chronic Low Back Pain