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.
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 experiencein 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.
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.
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.
For more on critical reasoning with Brent click here.
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).
How would you describe your presence in the Pilates Studio? Cheerful, affectionate, grounded, powerful, indulgent? How is it that two Pilates teachers can lead the same exercise, using similar cues, yet one of them leaves you feeling great and the other falls flat. This is the nuance that presence brings to a session. As a teacher trainer, one of my biggest goals is to equip students with the tools necessary to teach a safe and thoughtful class as well as to cultivate their presence.
How do we do that? Is this even measurable? Below I offer some tips and suggestions for cultivating presence in your teaching. – Nichole Anderson, NCPT, Director of Curriculum
Practice Teaching a Simple Task Authentically
For new teachers, finding your authentic voice can be a daunting task. You are busy remembering the basics of each exercise, attempting to follow the sequence you planned out. On top of that, trying to keep everyone safe. There is also the added pressure of being seen and having a feeling of performing in front of others.
What is the simplest way to find your voice and style as a teacher? Practice teaching something simple to a friend. The goal is to teach a rote task, one where you don’t have to think about the steps or language involved. For me, it’s teaching someone how to make a peanut butter and jelly sandwich. Because of the simplicity of this, your personality and uniqueness are able to shine through.
Take the time to notice the feeling of teaching this small task. What kind of language comes naturally to you? Do you make jokes? Are you more straight forward? Try recording yourself teaching this task and go with your gut instinct on if it feels authentic to you. Practice bringing this authenticity into your classes.
Gain Perspective: Record yourself teaching
As an expansion from the idea above, record yourself teaching Pilates. This can be as simple as recording your screen when teaching a virtual class. With permission, you could leave your smartphone set up in the studio while you teach a client. During your initial review of the session, practice moving to your own instructions. Notice how your language makes you feel as a mover. Do you feel that the teaching is clear, inspiring, and thoughtful?
Next, watch the video without sound. Your physical presence in the space of the Pilates studio is as important if not more important than the words you say. Notice how you move throughout the space. Do you gravitate to one area of the studio? Are you spending approximately equal time in the space of each of your clients? What does your body language suggest?
Finally, listen to the audio of the recording. Listen to the words you use and the tone and timbre of your voice. Does your voice match the intensity of the movement? Is it supportive? Do you sound interested? This is a practice that can be done indefinitely and will always give you opportunities for growth.
Show Up Early and Grounded
We all know the feeling of being late for an appointment. Even worse is the feeling of being late to teach a Pilates class! When we are under stress our body creates the stress hormone cortisol. This causes our heart rate to increase and our blood pressure to spike. If you want to show up for your clients authentically and be fully present with your calm and centered self – show up early!
When you come prepared to teach your Pilates class early you will have time to ground yourself with a centering practice. This will support you in feeling fully ready to be present with your clients. We all have lives outside of the studio. I find that leaving the stressors of your personal life at the studio door allows you to be fully present with your clients.
Make The Shift To Teaching Mode
It’s always ideal to have ample time to shift into teaching mode. What happens if you end up running late to teach? A brief grounding practice will help you be present in the studio. When you arrive a grounding practice can help you focus on what is happening in the moment. Grounding practices vary greatly, and I encourage you to find something that works for you. Some teachers like washing their hands and others like to tidy up the studio space. Both are calming, organizing, and refreshing.
My favorite way to ground myself before teaching Pilates is to do Pilates! Showing up early to the studio will give you time to jump on a piece of apparatus or the mat. Ground yourself in your body and with your breath in preparation to assist your clients in doing the same!
Create A Routine
Create your own grounding routine and ritual by testing out what practices help you feel calm and centered when you arrive at the studio. Some teachers swear by saying hello to every person they pass on their way to the studio. This can help even if that is only one person at the front desk. The practice allows you to practice engagement, eye contact and using your voice before you begin teaching.All of which are things you will want to do with your clients.
Pre-teaching rituals to support grounding:
Listen to a familiar playlist to get in the mood to teach
Take a class before the class you are leading
Get enough rest, food, and water before teaching
Arrive early to ensure time to shift from your personal life into your professional life
Check-In: Connect with Your Students
What separates a mediocre teacher from an incredible teacher? It’s the ability of the incredible teacher to make everyone in their classes feel seen. How do we do this? Greet your clients! In a group setting, this can sometimes feel awkward. There is nothing worse than a teacher who is on their phone or standing around not making eye contact as the students roll in.
Ask questions before the class to determine how students are feeling. What are their goals for the session? Use this time to acknowledge that you see the students individually. “Hi Kevin, did you end up going skiing this weekend? How did that feel?” Acknowledging the students facilitates connection and camaraderie with you as the teacher as well as with each other. In a virtual setting, this can help them feel connected even if they are not in the same space. This will help develop a rapport which is a good indicator of if a client will return.
Learn your client’s names! When teaching group classes, I try to always greet people by name and ask new students their names so that I can refer to them personally throughout the class. Teach from a standpoint of allowing clients autonomy. Let them know you are supporting them in their exploration of moving their bodies. If you see clients struggling, give options that let you know you see them struggling. You are there to help them move successfully!
Be Yourself!
I hope these tips serve as a reminder of the value of presence while teaching. Bring your full self to your teaching practice and remember – being distracted will always come through in your teaching. We have the opportunity as Pilates instructors to help people feel amazing every time they enter our classes. Give them your full attention and notice how your client list grows.
Juan Nieto leads Polestar Pilates Spain and is an educator and co-developer of our new Online “Runity Painless Running Course”. As a Physical Therapist and Pilates Instructor, he thrives in bringing the latest technology and research to the Polestar international body.
This excerpt was taken from Polestar’s Pilates Hour Live: “Updating the Science of Running” with Juan Nieto and Brent Anderson. Register for our upcoming #PilatesHour Webinar here.
What causes running injuries?
JN: At the beginning of all the running research it was very focused on biomechanics; kinetics and kinematics. Then we started talking about shoes and maybe even speed and cadence. We then realized again that We are Humans! Even though there are biomechanical variables we can measure like form and cadence, there are additional things that are also influencing running. What about the psychological and mental aspects including motivation, the passion for running, the training strategy, load management and very importantly, recovery including sleep and nutrition.
We know now that all of these things are important to running. I think collectively people still think it’s all about biomechanics, running form, technique, and stretching. I always take the opportunity to spread the message that “We are humans”. We are complex, and the more we understand our complexity and embrace it, the better therapists, coaches, and runners we are going to become.
BA: That’s right, we are incredibly complex. That’s why movement science is so difficult because it’s not just understanding the biomechanics. It goes far beyond that into understanding human behavior and everything that goes with it.
The Pandemic’s Impact On Running
JN: Every time we go to practice running we are exposing ourselves to a certain risk. In a survey of over 1000 runners, they found the Covid-19 pandemic impacted running behavior. It’s interesting because people increased their running time and mileage but decreased their intensity.
Perhaps the people in this study had more time on their hands or were limited to running as the only way to get out of the house. If you remember during the pandemic, at least where I am from in Spain, we couldn’t even go running outside at the beginning of the pandemic. Eventually, we were allowed to go outside for exercise.
JN: Another thing I find important in this survey is how the motivation for running declined. I believe people changed their minds about running from competition and socialization to fitness and stress relief. Perhaps also simply occupying an increase in free time. Another interesting thing is that the injury risk became 40% higher during the pandemic for overuse injuries. Maybe this lack of motivation or mood, or not understanding how to create a routine with an increase in spare time, caused the number of injuries to increase.
The study also pointed out that 90% of the runners surveyed were using technology to record some type of data of their running. The majority of this was technology to interact with coaches, training plans, and exercise prescriptions. These coaches and therapists utilized technology to keep their clients motivated, send them training plans and create a goal-setting environment. Through this, they could still help to mitigate injury risk, which is exactly what we envisioned when we started my company Runity in 2015.
Passion for Running
JN: There is an important role of the “passion for running” in the relationship between mental recovery and running-related injuries.
There are many runners who are devoted to and are very passionate about their sport. We need to understand that we’re looking at two types of passion. We can see what they refer to in the study as “harmonious passion” as well as “obsessive passion” and it seems in most runners tend to find this obsessive passion.
Harmonious Passioncan be seen as having control over running. It could be seen as a harmony between the runner’s passion for running and other activities in their life. This passion is more about balance and most importantly having adequate mental and physical recovery.
Obsessive Passion can be seen as having very little or lack of control over running. Having a very rigid persistence and sometimes seeing this creating conflicts with other activities in a runner’s life.
What they found in the study is that a combination of harmonious passion for running and mental recovery after running are important predictors of preventing running-related injuries. The flip side is that obsessive passion for running is a mental risk factor for running-related injuries.
What we have been advocating at RUNITY since day one is not needing to be the best runner in the world or being able to run all the running events that exist. We advocate being able to have fun and enjoy running every time you run.
JN: There are a lot of things that can go wrong when you enter a running event. That’s the reason why it’s so important to focus on your Pre-Hab.
Are you ready to run a marathon?
Do you really need to run a marathon to be happy? Are you going to put your body through hell because your friends want you to run with them or because you want to participate or belong to the group?
30% of people that we see in the study were underprepared regarding the prerequisites to running a marathon. As for running coaches and physical therapists, we need to help people understand the work in these prerequisites and help them prepare for the next marathon so they may be adequately conditioned to participate.
Another interesting running study from a survey in Hong Kong in 2018 suggested that the number one injury risk factor of a running-related injury for marathon runners was that the ticket for the marathon was bought by a friend or relative as opposed to the runner themself.
Sometimes obsessive passions are great because they allow you to do amazing things! It’s like the path of the hero. In a way you destroy yourself for the greater good, to transcend, or to get the gold medal. Maybe some people want to, or need to do that.
Other people are looking for longevity, fun, and enjoyment in their activities. Maybe they are looking to get 1% better every day. You have to decide where you are on the spectrum. Are you in the place of the hero, willing to ruin your health and longevity in order to get something very important to you? Maybe you are trying to get a sustainable and longer life as a runner.
This online course will teach any movement coach the essential research, exercises, and techniques to prescribe to their running clients to minimize imbalances and risk of injury and strengthen their body’s natural design to run. Let Runity move you!
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