Polestar Pilates

Six Tips To Better Cue The Breath in Pilates

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By Polestar UK Mentor Kristin Loeer. If you are interested in learning more about Kristin’s approach to working with the breath in Pilates you may be interested in the upcoming workshop “The Movement of Breathing” which will be hosted by Polestar Pilates UK in November 2022.

I have never met a client who was not confused or insecure about the nature and function of their breathing. In fact, I have never met a client who, when asked about it, did not assume that they are “probably breathing badly”. People are exposed to plenty of breathing cues in Pilates and Yoga classes. Outside of the studio, there is also an abundance of breathing practices and breathing apps.

So why is there such confusion and lack of confidence about breathing? And secondly, I dare ask, do we, as movement professionals who cue breathing all the time, feel all that confident about it ourselves?”

After all, we may have learned that thoracic breathing is the way to go. Or we were told that deep diaphragmatic breathing is important. We may feel compelled to remind people to take deep breaths during movement because we see their tendency to hold their breath. Then again we may wonder about the exhale because if we do not breathe out we can not take in fresh air either. When we add Pilates to the equation and start talking about inhaling and exhaling in relation to movement we can easily overwhelm our clients, if not ourselves.

The Breath as Autonomic and Conscious Process

The reason why the subject of breathing causes never-ending confusion is that breathing is both a very finely tuned autonomic process, as well as under our conscious control. Hence it can be altered, but we may wonder whether it should be. This will always have a very complex impact on the rest of our being. 

Just like digestion or heart rate, breathing is orchestrated largely by our autonomic nervous system. The autonomic nervous system is influenced by our life experiences. It is constantly responding and adapting to external and internal changes. Its main concern at all times is homeostasis and survival.  

The Breath As A Tool

As mentioned, unlike heart rate and digestion, breathing is also under our conscious control. I can choose to lengthen my exhale or to hold my breath. I do not have the same control over my heartbeat or digestive processes. This makes breathing such a powerful tool. We can use it when we want to become calmer or more alert and of course, it gives us the opportunity to optimize movement through breath. 

I am a practitioner, who specializes in somatic trauma work. My belief is that it is important to remember that while we can alter our breathing and create powerful change through it, breathing is a carefully and deliberately orchestrated nervous system process. No matter how inefficient or dysregulated a client’s breathing pattern may seem, in my experience, it is never random. There is no such thing as “lazy breathing”, “wrong breathing” or “I forget to breathe”.

There is nothing the nervous system does without good reason or without its key concern being survival. 

This does not mean that we should not work with our breath. It means that we need to go about it gently and respectfully. We need to be aware that there is a reason for the client’s current breathing pattern, and that if we try to alter it, there may be pushback from the client’s nervous system. We can bring about positive change indeed if the nervous system recognizes that this change in breathing is helpful. On the other hand, if we are not careful we might promote a messy interference with the nervous system’s autonomic process, which does not serve the client well.

Here are my six top tips for how to work with the breath in both private Pilates sessions and group classes:

1. Observe The Breathing Pattern

Particularly in private sessions, we have the opportunity to observe our client’s breathing both in stillness and motion.

Let’s not be too hasty with our wish to help them use their breath better. Let’s be curious about what their body is naturally doing. Also, consider how breath might change automatically as we work with using other cues. It is very possible that your soothing voice or their awareness of their body’s movement against the ground settles their nervous system. This alone might regulate their breathing without you having to address it directly.

2. Make Breathing Cues Relevant To The Client.

As with movement, respond to what you are observing rather than using generic, popular cues.

Some people do indeed breathe shallowly. Others have already been told they do so and are now stuck in compensating patterns of excessive abdominal breathing. Many people inhale more than they exhale, however, there are also a fair few people who stretch their exhales and barely feel the need to inhale. The point is that no one person breathes the same and we need to be careful not to generalise and give people cues that are not useful to them.

3. In Group Classes: Offer Different Breathing Cues To Explore.

In group classes, it is much harder to observe and attend to individuals of course.

We need to be aware that not one breathing cue will work or be right for everyone. Let’s provide different options so that they can explore and be inspired by the cues that feel good to them. You might ask them to become aware of how much they breathe in compared to how much they breathe out. You might suggest they try out opposite options within an exercise to let them decide what feels right for them. Also, give people the option to ignore the breath-related cues altogether. They may simply not be in a place where they feel safe to explore their breathing patterns. 

4. Use Positive And Invitational Language

Whether you work with individuals or a group, when it comes to breathing I strongly recommend using invitational language.

Let’s remember that the nature of our breathing is closely linked with our sense of survival. It is important to put the client in charge of their breath. Encourage them to be present and curious with their breath. Reassure them that while they may want to try out making changes, their natural breathing is not wrong and they can return to it whenever they want.  

5. There Is No Failure. 

A client may simply not be able to access the shift in breathing we are encouraging them to find.

This may bring about a sense of failure in the client. Let’s remember that the nervous system always has the final say and if it does not deem a change safe it will not allow it. You can communicate this to the client by explaining how their body is “saying no” to this today and how over time it can change its mind”. Encourage the client to explore and “play with this again later.”  

6. Bring Awareness To The Impact

If the client’s breathing does change, allow them time to experience this without adding any further new information or cues.

It can take a few minutes to explore this and to become aware of the holistic impact this change has had. They may feel calmer, stronger, or experience more flow in the movement. This positive shift is really worth exploring! It has the potential to integrate and perhaps become the new normal. They may become emotional, anxious, or irritated and feel their movements ‘disintegrate’. It is important for the client to experience whether this shift is positive for them or not. They can revert back to their previous way of breathing if they need to. 

If you would like to learn more about my approach to working with the breath in Pilates you may be interested in my upcoming workshop “The Movement of Breathing” which I will be running for Polestar Pilates UK in November 2022. For more information please contact me @kristinloeer_movement .

Kristin Loeer

5 Ways Pilates Can Support Your Mental Health

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“If you can relate to overwhelm, anxiety, or perhaps being ‘tired and wired’, then read on for ways in which Pilates as a practice can help you, and support your positive mental health.”

Sarah Edwards is a Doctor of Education and Comprehensive Polestar Graduate of Polestar Pilates UK.

Pilates is often promoted as being great for ‘core strength’ or ‘reducing back pain’, both of which it certainly can do. (I know, as back pain was the main reason I took up Pilates in the first place). Through personal experience and in teaching clients in private and group settings, I now know that Pilates has consistently supported me in managing my own anxiety. The practice can be instrumental in supporting the positive mental health of others.

Prior to teaching with Polestar and while I attended my weekly Pilates class, I was working as a Teaching and learning director in higher education. I completed a Doctorate in Education, raised a family, and I also experienced a number of traumatic experiences regarding my children’s health. Not surprisingly, I was diagnosed with Generalised Anxiety Disorder. 

Thankfully, Pilates really brought me out of that very busy headspace and, at times, my overwhelm. My experiences led me to train with Polestar as a Comprehensive Practitioner. I also trained as a mental health first-aider and, safe to say, I haven’t looked back.

Joseph’s Mind-Body Method

Joseph Pilates advocated a mind-body practice much before his time. In many aspects of holistic health, the context of “typical daily life” has changed in drastic ways. Modern lifestyle habits including chronic sleep deprivation, poor nutrition, and even social media use and ‘doom scrolling’, have fuelled the anxiety epidemic. Mental Health disorders, including anxiety, have also increased as a result of the COVID-19 pandemic. While the context has changed, the practice of Pilates, for the main part, hasn’t.  

How can Pilates specifically help? If you can relate to overwhelm, anxiety, or perhaps being ‘tired and wired’ then read on for ways in which Pilates as a practice can help you, and support your positive mental health.

1. Regular Practice

Pilates as part of your regular schedule will interrupt your overthinking and helps ‘press pause’ on any overwhelm. In our digitized, and always “on call” culture, we need to step away from our devices, and literally and figuratively “switch off”.

2. Break The Cycle

In turn, positive movement experiences can help break the chronic stress cycle. Chronic stress affects the nervous system, and influences related anxiety disorders. Stress can also have profound physiological effects. The long-term stimulation of the fight-or-flight response leads to the constant production and secretion of hormones such as cortisol. Long-term excessive cortisol is associated with a variety of consequences, including diabetes and cardiovascular disease.

3. Connect With The Breath

Pilates focuses on breath (it’s the first Principle of Polestar Pilates). Focusing on the breath, and particularly an extended exhale can help access the parasympathetic nervous system. This sends signals to the brain that all is well. The parasympathetic nervous system is responsible for the “rest and digest” function of the body which is why you can likely hear your digestive system at work once you relax!

4. Practice Embodyment 

A skilled teacher will give you both internal and external cues that allow you to move in a mindful way. When you focus on the internal sense of your body (interoception) you cannot be thinking about your overwhelming to-do list. Teachers who have also embraced an element of psychological fitness training (such as with Polestar) can also help clients come out of their ‘thinking brain’ by stimulating the vagus nerve. This can support reducing stress, anxiety, and even depression.

5. Empowerment

The benefits in strength, posture, and mobility you gain from Pilates can help your self-confidence (we call this self-efficacy) and your self-esteem. Any positive movement experience will release endorphins, and hormones that will reduce pain and stress, and improve your mood.

Sarah Edwards @positivepilateswithsarah is a Doctor of Education (with specializations in Teaching and Learning), a Comprehensive Pilates Instructor with Polestar, and a Mental Health First Aider. She is particularly interested in promoting Pilates for mental health and runs one-to-one, and on-demand classes from her recently completed garden studio in England (gardening being another of her passion projects)!

References:

i Vora, E. (2022) The Anatomy of Anxiety. Harper Collins publishing.

ii Mental Health First Aid England, 2020.

iii The Parasympathetic Nervous System (2022) Brittanica Science. Available at : Sciencehttps://www.britannica.com/science/parasympathetic-nervous-system (accessed 8th August 2022).

iv The Counselling Directory. What is the vagus nerve? Available at http://www.counselling-directory.org.uk/member-articles Accessed 24th August 2022.

v As a Mental Health First Aider (1) I am trained to recognize when someone is struggling with an anxiety disorder, depression, or psychotic episode and to signpost them to appropriate help. It is not within my scope to diagnose these conditions.

How To Make Your Movement Look Good And Feel Good With Dynamic Alignment

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BA:  I like the idea of observation, the observer, and the observed. We talk about the quality of movement versus quantity of movement and often I feel we are stuck in the quantity. We feel and see a quality movement, we don’t quite know how to identify it but we try to mimic it sometimes by trying to position correctly what we saw or interpreted rather than what really is happening in the movement.

Were they allowing themselves to move?  The idea of novice to expert moving, the novel mover will always over recruit, not sure where the organization is going to come from. I often think about riding a bike. From week one to week two they are riding very efficiently with no hands. This idea of moving from unconscious incompetent movement, not knowing what they don’t know, into unconsciously competent movement. 

Do We Teach Movement Or Position?

I love the idea that you can teach movement from a position. I think that’s really important for the Pilates teacher and physical therapists because so often everything is assessed in static. Does static alignment really tell us anything about movement? I want to preface this in the sense that most of us in this community work within the spectrum of pathokinesiology or performance kinesiology. We study the science of movement. As a physical therapist, I’m trying to restore movement to a level of function. As a performance practitioner, I’m trying to enhance their movement performance however I can with whatever tools I can use. 

EF: One great question is “what does the person want to achieve”? Obviously, if they come to you in pain, and they have an issue the number one goal is to remove the pain. This will mostly involve improving function and improving efficiency but interestingly, not always. Compensation patterns sometimes are the name of the game. If you have a broken bone or something like that, you have to do a “dance” around it. It might not be the ideal most efficient thing but it brings you out of pain. 

Let’s say you want to improve your performance. It’s one thing if we’re are talking about walking, running and the things were structured for but let’s say it’s dance, Pilates and yoga. Now, I’m going to contradict myself on a level here. You have form and you cannot get away from form. There is form!  If you want to be a dancer or demonstrate a Pilates exercise you have you show good form and this involves a position.

The question is: How can you teach the kind of forms we work with, but still maintain that dynamic alignment? 

Eric Franklin

Say the goal as a dancer is to look good in the mirror. What if it also feels good and is also efficient?  Learning how to create that would be the goal.  I’ve had conversations with people saying “Ballet wrecks your body”, but I disagree. Ballet can be a great exercise but you have to work on achieving those forms with good function and in dialogue with whoever is trying to achieve them. This is especially true if you look a the traditional forms. Dialogue doesn’t exist. You have the expert, the guru, and there is a sense of “this is how it is”. You have to get that form into your body and it doesn’t matter if it breaks. If it breaks? Next in line…So that’s the other extreme and we’re trying to be the nice ones here and say we can achieve that healthily. We need that dialogue and a lot of that world is not used to what we call student-centered teaching

BA: A lot of Juan Nieto’s language lately has been talking about tissue adaptation. We’re excited to see Ido Portal’s work and Mike Fitch’s work in animal flow. These practices are exciting, how they are looking at different ranges of motion and mixed martial arts. The body needs to go into these ranges over time and gradually increase the load in different directions and different planes. This ensures that there is tissue and neurological neuromuscular adaptation.

What The Client Wants

You said something earlier I love, “what the client wants”.  One of the things we use a lot at Polestar is the ICF model. What does the client want to participate in? How are their beliefs connected to this? Do they believe they should be participating in activities that they are not comfortable participating in right now? What activities does that involve? Is the demand on the body to participate in those activities where it needs to be?  So many questions!

For example, here are some things you need to be able to do to be a semi-professional ballet dancer. The body needs to be able to do these things, and this is where you are today. Perhaps there is there a big gap between where you are today and where you want to be as a semi-professional dancer. Oftentimes we keep thinking there is some kind of recipe that takes you from one point to another point. This is where anthropometrics come into play. There are many types and shapes and conditions of bodies. Longer or shorter torso, arms, and legs. How do you look at this idea in particular from a teacher’s perspective of receiving these different bodies and goals?  Can we progress safely but also take them to where they want to participate?  They want to do MMA or Cirque du Soleil, how do we help them get there?

Creating a Motivational Climate

EF: It definitely depends on what kind of martial arts. If it’s going to be acrobatics, gymnastics, or dance they could come in and you can say “sorry – not enough hip mobility, thoracic spine too stiff, you shouldn’t do this”. What you often end up seeing is someone doing ballet, and they have the “perfect” body but their movement is not interesting to look at because they are like a machine.  They “have it all” but there’s no sense of rhythm or space and no musicality. These are the important factors! 

There’s a sense of moving your body in space with a certain rhythm and grace.  Often you have to reteach people in that field why they even started to do Pilates. And why did they start to dance? Because they liked doing it! What has it turned into now? All those factors come into play.  It’s tricky also with different body types. 

If someone doesn’t seem to have the body type for an activity, I would still say “go for it!”. Who knows, they might have some other amazing quality which they will bring out in that form and blow us all away. 

BA:  We’ve seen this over and over again. Tenacity even in sports far exceeds the natural ability in people who achieve high levels of performance. I think especially in dance it’s their emotion and motivation and their passion. That’s why I always ask, what do you believe you should be able to participate in? What do you believe is not allowing you to do this?  I love to know what they think.  What’s their belief on why they can’t?  Do they believe their body doesn’t let them?  Is that a pre-conceived belief that controls the actual movement of their body? I happen to believe belief can do this in a lot of ways. How do we recreate an environment in which they can optimize their ability?  We may not know what that will look like, but we can give it a shot.  

EF: This is one of the biggies – creating a motivational climate! Creating a climate within which the student can excel.  Lean into that and forget about teaching technique and the efficiency and all that. Just create an environment in which they feel they can do their best. This is a completely different factor not related to “this joint” or “that fascia”. 

We say in Franklin Method “You don’t get what you want, you get what you believe”. 

Eric Franklin

You want to be able to do these exercises or dance steps really well but you don’t believe that you can do it.  We can examine what the client really believes in and then be careful with the information. We have simple ways in Franklin Method where we do a small movement like an arm gesture while you say “I love moving my arms – It’s really healthy because it really gets my scapula moving – it’s fantastic”. You say this as you do the movement and then you ask the question “how much did you actually believe in that?”.  And a lot of people say 80%, 50%, or no I don’t really love moving.

Watch #PilatesHour Episode 108 “Dynamic Alignment” With Brent Anderson and Eric Franklin. Learn more about the Franklin Method here.

How To Maximize Neuroplastic Processes: Keep Your Clients Focused!

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Watch #PilatesHour Episode 120 “Neuro-Concepts And Pilates” with Brent Anderson and special guest Kate Strozak MSc Applied Neuroscience, LMT, NCPT. New to Neuro-Concepts? Check out the blog “Fascinating Neuro-Concepts You Need To Know As A Pilates Instructor”.

BA:  As Pilates teachers, how do we make what we do in one or two hours a week potentially influence a positive neuroplastic change? We know that one or two hours a week may not be enough to influence this. What else needs to happen, and what needs to be influenced in that one or two hours a week? 

KS:  Giving people good appropriate challenges is really important for this process.  Also, I try to stimulate them in multiple ways.  The use of imagery is incredibly impactful and profound for people to help them embody these new experiences. Imagery helps them build different relationships between a movement and their perception of that movement or their relationship to that movement.

Many of these things are built into the Polestar curriculum actually!  Utilizing imagery, utilizing tactile cueing in order to tie in sensory nerves and proprioception thus integrating the brain on another level.

Kate Strozak

Now more than ever I talk to my clients about their sleep habits. I remind them it’s out of the scope of my practice, and that I am not a professional sleep consultant. I encourage them if they feel like their sleep could be better quality than it is right now to reach out to a sleep professional and get some help in that arena. It’s when we are in our deep states of sleep that a lot of these neuroplastic changes occur in our brain.  

Being “Chatty” With Clients

Another important thing is mindfulness. Prior to studying neuroscience, I was inclined to be chit chatty and casual with my clients. In part, thanks to Alexander Bohlander and my experience with him in his meditation workshop at the Polestar experience I dove deep into studying mindfulness and meditation. It’s fascinating the effects of these on the brain and profound in terms of stress reduction and sleep quality.  If you are doing something that supports the quality of your sleep you are, therefore, hopefully then supporting the process of neuroplasticity.  So it’s a very long-winded answer to say there is a lot!

BA: That is excellent Kate!  I just learned this year from an Andrew Huberman podcast about the idea of neuroplasticity occurring typically when we’re sleeping.  We challenge the body and challenge the nervous system during the day, challenging ourselves to learn.  I’ve been using this with the students at the university as well. Especially the ones who are struggling with retaining information or integrating and synthesizing information.  It’s so interesting that it’s the sleep that is going to allow you to synthesize this information.  This leads into the “interleaved” learning where we’re stressing you a little bit to recall information to make it challenging and difficult.  At first, you can’t remember what it is, but when you go back and look at it again after the stress of trying to remember it (and a good night’s sleep), it is amazing the amount of synthesis that happens on the following day or two of processing that information.  

Creating Demand And “Struggle”

The same thing is true with movement of course and some of the things you mentioned.  If I could get my client to remember what we did last week, “do you remember where your body was when we had that really good experience? “Can you show that to me again?”, and maybe they fail, that’s ok.  They are trying to figure it out and recall it, but that’s the internal feedback and the mindfulness that we’re talking about that allows information to be synthesized.  They need this demand and the struggle of the recall. And don’t just give it to them and show them, let them struggle with it, we don’t want to make it so easy.  We want them to understand that struggle is good, that failure is good, and that these are learning processes that will help them in the long run. If we don’t challenge them with that struggle we don’t challenge the nervous system to change.  

KS: Absolutely, there is no incentive to change if you are not being challenged or having that moment where you have those slight releases of cortisol and adrenaline. Your palms start sweating and we have to have those moments, it’s part of the human experience.  

I don’t know about all of you but I was very prone to just having casual conversations with my clients. When the client has done footwork a million times with me, which in and of itself presents another problem, but if I’m talking with them about something, I’m taking them out of their experience and out of their body, so I limit that.  I’m not cold or stoic and not available to them but I really get them to focus on what they’re doing and to really be present and attentive to their movement. 

If I’m talking with them about what they are doing this weekend, they start thinking about it and they are not aware of what their body is doing at the present moment in time. 

Kate Strozak

BA: I really appreciate you saying that.  Our friend Polestar Educator Juan Nieto calls it “being the butler”, and I call it “gum holding”. The point is that we get into a chatty, chummy kind of relationship with them and were really not challenging the nervous system. We become a “paid friend” in that situation.  If they are doing the same thing they always do with you, you are not challenging any improvement or any change other than maybe being a listening ear.  Even worse when we bring our own problems to our clients.  

Supporting Neuroplastic Processes

In group classes when there is flow and purpose, there is more internal reflection going on and feedback that is more likely to create change than in a chatty one-on-one session.  We can create incredible challenges and demands on the nervous system when we’re working with a group of ten people.  If we’re not having that same intensity with our clients one-on-one they are not going to have the same neuroplastic challenges.  

KS: And if you’re not supporting these neuroplastic processes then what are you doing? The neuroplastic process is just a really fancy way of saying that you’re helping to create a repatterning, working on movement efficiency, or working on a tissue adaptation.  If you’re not really supporting those processes you’re not really supporting the longevity of the Pilates work you are doing with them.  So maybe Brent, you, and I are suggesting to everyone that our challenge to you is to try to support more quiet and focus in your pilates sessions.  If your client` is really keen on talking and carrying on a conversation, you might not be challenging them enough!  There is a time and place for all of it as you know!  

BA:  Let’s see how chatty they are when it’s time for jackknife…time for hip circles!

KS: Yes! Can you juggle while doing feet in straps?  

Watch #PilatesHour Episode 120 “Neuro-Concepts And Pilates” with Brent Anderson and special guest Kate Strozak.

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!

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.