Pilates for Rehabilitation

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 Best Tools to Maximize Your Pilates Assessment

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What information can we gather by watching someone perform the goal post?

When assessing the Goal-Post exercise, the client is asked to do three things:

  • Stand up against the wall with their head against the wall
  • Bring the arms to 90/90
  • Bring the arms into a high “V” position

Before cueing the exercise, the first thing to look for is axial alignment.  Can the client position their head over their thorax and thorax over their pelvis while maintaining natural lumbar and cervical curves?

After looking at axial alignment, we look to see what is happening in the shoulder region?

What are some of the things required to be able to bring the arms into a 90/90 position and into a “V” overhead?

  • Shoulder Flexion
  • Shoulder Rotation
  • General Shoulder Mobility

Question: What else connects with shoulder mobility? 

Answer: Thoracic mobility -This is one of the things to look for first when moving into the goal post as it directly impacts shoulder mobility.  If the thoracic spine doesn’t move into extension, the following might be seen:

  • The head comes away from the wall
  • The shoulder girdle can’t slide down into its 90/90 position
  • The back may come away from the wall

Other tests and measures to use to confirm the possibility of a loss of thoracic mobility depend on how other aspects of the movement are functioning.

  • What can be ruled out? 
  • Could it be a loss of scapular mobility? 
  • Could it be a tight pectoral girdle or a loss of humeral rotation in the shoulder such as a rotator cuff injury? 

During the assessment keep in mind, that it could be any of these things and then begin ruling them out.  

Video of Brent teaching assessment using the goal-post exercise.

Faulty movement patterns that could be present:

  • The shoulders hiking up to perform the movement (bilaterally)
  • The pronation of the shoulders (very common) 

Critical Reasoning: Is the client’s limitation in the thoracic spine or in the shoulder girdle?  What other tests might we perform to distinguish between the two?

Asymmetries during Assessment:

When you see an asymmetry, you must seek to understand what the asymmetry is due to. You may see a client who can move one arm back nicely but not the other. If there is scoliosis or a spine deformity, the client might have an asymmetry where one shoulder is being rotated forward. 

  • If there is no scoliosis or spine abnormality, then what is happening at the shoulder blade?
  • Is there a winging of the shoulder blade or poor organization of the shoulder blade?
  • What is happening at the glenohumeral joint?
  • How is it in relationship to the rest of the shoulder girdle?

Assessment Tip: Circle back to the client’s history.

  • Did they have an injury?  
  • Is there any nerve pain? (A brachial plexus lesion could easily cause a limitation in bringing the arm up to 90/90.)

Critical Reasoning: Inquire about the client’s habitual patterns, as some of these daily patterns can create asymmetries, for example:

  • Someone who is always using the computer mouse with tension the right shoulder.
  • Someone who sleeps on one side causeing the shoulder to collapse forward.

The PT and medical world uses what’s called “upper limb tension testing”, one of which tests is to bring the arm up to 90/90 and then straighten it.  A significant amount of people who have had brachial plexus lesions or a thoracic outlet syndrome lose the ability to bring one side up.

Assessment Tip: When an asymmetry is present in an assessment, remember to put a “red flag” on it. Asymmetry means there could have been an injury or something else going on that is challenging the movement. 

Keep in mind – As we Assess we are always:

  • Ruling out
  • Asking questions
  • Seeking to understand:  “What possibly might be causing this?” 

Get the most out of your Assessment and Earn 24 NPCP CEU’s this Summer!

Join us for our upcoming immersion into Critical Reasoning and Assessment Skills:

Critical Reasoning for Rehabilitation and Post Rehabilitation, held this June in Siler City, NC with Polestar Founder Brent Anderson.

Register Here

Discover The 3 Elements That Make Up Motor Control

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Polestar Pilates Teacher Training not only teaches you how to teach exercise choreography but also to see and evaluate the biomechanics of movement, and understand coordination and motor control. This excerpt is from Pilates Hour, a free webinar series hosted by Dr. Brent Anderson that broadcasts weekly.

Brent Recommends Anne Shumway-Cook’s Book “Motor Control”: I always recommend this addition to your movement library especially if you are interested in movement science and motor control. – Brent

Questions:   

How do the principles of coordination relate to the quality of movement versus the quantity of movement?  

Where does “Awareness” fit into movement integration?  

How do alignment, mobility, control, and load relate to understanding coordination and motor control?  

What is the best way to understand coordination to optimize our teaching strategies as Pilates teachers? 

How is movement learned in the best way possible for long-term retention? 

Motor learning has to do with the awareness of internal and external feedback provided both by the Pilates teacher and also from inside the client.  

Movement integration is the principle that synthesizes all the Principles of Movement.  It gives us the tools and understanding for new movement acquisition and learning new strategies to replace older and less efficient ones.  As we better understand coordination and the science of motor control and motor learning, we start to use a different set of tools than what might traditionally be used in the fitness, athletic, and rehabilitation sciences.  

How do we create an environment that allows someone to learn new movements most effectively?  

We often see clients come into the studio with guarded, compensated movement that continues to plague them with an unnecessary expenditure of energy. This can cause a predisposition to things like repetitive strain problems or injuries from those old patterns.   

Think about how you might always cross your leg right over left when you sit – this creates a torsional force in the body and the tissues adapt to this movement or posture from the daily habits we might have.  Improving movement is not necessarily about increasing flexibility, range of motion, or strength, but learning to take a different look at how we in the Pilates environment can really optimize the client’s understanding and learning experience.   

Motor Control is this mixture of the individual, the task, and their environment. When the three of these are working together synergistically, we see movement that has both quality and effectiveness.  (Motor Control: Anne Shumway Cook). 

The Individual: Action, Perception, Cognition 

Action: We define movement in terms of human actions or tasks, whereas we can define motor control as the science that tries to identify how the many degrees of freedom are controlled pertaining to human actions. 

-Anne Shumway-Cook 

Some examples of human action are getting the mail, taking the dog for a walk, and putting on clothing.  You can imagine the almost infinite possibilities in our bodies of the timing of doing simple activities such as these or another example, touching your ear.  The arm can go in many different patterns, perhaps millions, in the attempt to touch the ear.  How does the body navigate that?  

It used to be believed that we were purely reflexive animals. For example, if we step on something sharp and have a reciprocal reflexive response, the leg that is not stepping on something sharp presses down, and the leg that is stepping on something sharp lifts up. It’s the same if you touch something hot.  

Then the science moved to a more hierarchical perspective where individuals think about things with the cortex (brain), have desires to do things, and send commands to the body to do them. For example, if you are thirsty you are going to grab your cup and use a “Motor Plan” to bring the cup to your lips and take a sip of water.   

Consider the act of signing your name on a small piece of paper, which uses a different set of fine motor skills as compared to drinking from a glass.  When I attempt to sign my name on a big chalkboard, I end up using different muscles and different strategies that result in the same signature (hopefully).  What if I tried to sign my name with my foot? 

Perception: The integration of sensory impressions into psychologically meaningful information.  

What is it that we perceive? Where does the sensory information come from? What do we see, hear taste, and smell, what do we feel in our skin and proprioception – where is the body in space? Where are the shoulders and where is the head? 

As Pilates teachers, we are essentially teachers of awareness and perception. That is important! 

My original physical therapy research was looking at perception. Does the client believe they are going to get better?  Clients who believed they would get better had an 80% likelihood that they would indeed show signs of improvement with their low back pain.  Individuals who believed they would not get better also had an 80% correlation that they would indeed not get better.   My challenge was to see if I could shift their perception to one where they were able to move successfully without the pain.  When they had a successful movement experience without the pain and their perspective shifted to one of “I believe I can move without pain”, it made all the difference. 

Cognition: Includes attention, motivation, and emotional aspects of motor control.   

This is something I want – I am afraid of falling and don’t want to – It always hurts when I do this movement… We are constantly problem-solving to get what we want.  

Think of the language we use with clients: be careful, don’t fall down, don’t let your legs go too low, and don’t spill the milk. This kind of language doesn’t tell them what you would like them to do, nor how to do it.  And think of the language we use to communicate with ourselves.  

We sometimes use language that creates a negative perception or concept that then impacts the clients cognitively and eventually impacts their actions.  And this is why at Polestar we are so fanatical about avoiding the “negativity” in our teaching language. We practice the skill of being able to tell clients what we want them to do or to see in their movement and asking them “What do you notice?” rather than telling them “Your pelvis is out of alignment”.  And if they are out of alignment and don’t notice it, we can give them more useful information like “lengthen your right waist” to help them gain better alignment and eventually an internal awareness.  

How do we manipulate the environment or the task at hand to be able to impact the individual’s perception, belief, and cognition of movement? 

Improving awareness is going to be one of our most powerful tools. We speak about this in the rehabilitation world, mainly in the neurological rehabilitation field however, I feel this should be a key focus of language and strategies for anyone teaching or facilitating movement. Our job is to help our clients turn external feedback cues and information into internal awareness so they can become more efficient and more unconsciously competent.  

The Task 

One of the first questions I ask my clients is “What do you believe you should be participating in that you believe you are not able to participate in?”.  

In the International Classification of Function Model “ICF”, we ask them “What do you want to participate in”? If they wish to participate in golf at 90 years old, I have to be thinking “what does this individual’s body require to be able to play golf at 90 years old? 

And we need to be mindful of the “gap”.  Where are they today, where do they see themselves, where they want to be, and how do we help them develop that task that is part of their ability to function and reach their goals.  

Mobility vs Stability 

What is the mobility and stability required for the task? 

If you are on a flat ground performing a movement it will have a different motor program than if you perform the same movement on an uneven surface while someone is throwing things to you.  

We often make tasks too basic and unstimulating and don’t progress the activity or change the environment. The more complex and more variables involved with the movement, the better they learn in the long run. These factors influence how an individual learns to move. It needs to be appropriately challenging from the start.  

When we stop babying our clients and create an environment that may be a little more challenging, they gain independence and begin to do something that they believed they couldn’t do.    

The Environment 

How does the Environment affect movement performance? 

Consider the weight of an object such as the weight of a backpack. Hiking with a 30lb pack will potentially shorten the distance someone can hike compared to hiking without a pack.   Or consider lighting – when it gets dark, movement can become more challenging for some individuals.  When the darkness of the environment takes away the sense of eyesight, they are relying on their vestibular and proprioceptive systems which may be deficient.   

We need to take into consideration: 

  • The weight of different props or devices  
  • Different textures of surfaces (playing basketball on a rubber court verses wooden or cement court) 
  • Practicing Pilates in a dimly lit studio 
  • Air quality or wearing a face mask 
  • Exercising outside or inside with different temperatures 
  • Uneven surfaces 

The surface has a lot to do with the environment and so does the temperature.  Temperatures can impair the way that we move.  If it is very hot and humid or too cold the body can have a difficult time moving.  

The Takeaway 

All three aspects of motor control, the individual, the task, and the environment are all important to us as movement teachers and analysts. 

Is there a right and a wrong way to move? No, there are an infinite number of ways to perform a task or movement.  The question we should be asking is how do we as movement teachers assess our client’s needs, create the optimal environment for learning, and support them in accomplishing any task they may throw our way? 

We need to use tools of interviewing, informative cueing, assistance, props, manipulating load, tempo changing the environment, and challenging clients with choreography.  If we do this, we and our clients stay engaged and energized and clients accomplish not only their original goals but new goals they didn’t even know they had.   

Brent Anderson PhD, PT, OCS, NCPT is a Physical Therapist, Pilates Educator and Founder of Polestar Pilates. Brent received his degree in Physical Therapy at the University of California, San Francisco in 1989 and his PhD. in Physical Therapy at the University of Miami in 2005. His doctoral thesis explored the impact of Pilates rehabilitation on chronic low back pain using psycho-emotional wellness and quality of life measures. He is currently Assistant Professor faculty at the University of Saint Augustine, College of Rehabilitative Sciences.