Archives For April 2015

The Dirty Secret

April 4, 2015 — 11 Comments

Or, ‘Clinicians, what have you done to Pilates?’100910doctor

“We only hire experienced Physiotherapists trained in Pilates to teach in our Pilates studios: we dig the bloke that started it, but can’t understand how you’d let anyone who can’t relate your pain and pathology to your problem come anywhere near you!” 

(‘Clinical Pilates’, http://www.sixphysio.com)

There seem to be frequent scuffles in the Pilates teaching world (at least in the forums that I see) between ‘classical’ and ‘contemporary’ Pilates teachers. I’ve no interest in pursuing that particular debate here, not least because I think it may not be the right on to be having. Rather, I’m interested in the influence of physiotherapy and ‘clinicians’ on Pilates, and the profession of teaching Pilates.

It seems appropriate that, over the years, different teachers developed what may be termed ‘pre-Pilates’ exercises, to provide a kind of ‘on-ramp’ to the original work for those who may need it, for whatever reason. I guess that this is how some ‘contemporary’ Pilates developed. However, I suspect that ‘contemporary’ Pilates is routinely intermingled with ‘clinical’ Pilates, and the ideas that underpin the various ‘clinical’ Pilates brands (yes, there are lots of them) are increasingly exerting a pernicious influence on much of Pilates teaching.

Why the ‘Dirty Secret’ title? I was recently listening to an interview with Kelly Starrett, a physiotherapist particularly well know in the CrossFit community. In the interview he refers to what he calls the “dirty secret” of physiotherapy – the phrase “within normal limits”. He describes the tenets of physiotherapy training as getting the patient functional -‘can you do your daily activities’, and resolving pain. Clearly these aren’t bad things but, as Kelly says, “within normal limits” does not mean “full function”. So, allowing for the fact that this is a generalisation, and that there are many excellent physios in the world who are committed to their clients high achievement, the fundamental measure of a successful outcome for a physiotherapist might well be ‘can you walk to the shops without pain?’

Joseph Pilates wrote of his method: “You will develop muscular power with corresponding endurance, ability to perform arduous duties, to play strenuous games, to walk, to run or travel long distances without undue body fatigue or mental strain. And this is by no means the end.” His ambitions were a little higher than ‘can you walk to the shops without pain?’

The term ‘evidence based exercise’ seems to be increasingly popular, and probably underpins a lot of the colonisation of Pilates by clinicians. Clinical Pilates™ have a video on YouTube called “What is Clinical Pilates™” which makes reference to “recent research into spinal stability“. The APPI (The Australian Physiotherapy and Pilates Institute) website tells us that “Pilates focuses on building an efficient ‘central core’. In Pilates, ‘central core’ refers to the TrA, multifidus, pelvic floor and diaphragm. In Pilates, abdominal hollowing techniques are utilized to activate this central core.” (About Pilates, http://www.ausphysio.com) The Clinical Pilates™ video goes on to explain that “Some of the original exercises have been cut from the regime, as research cannot support their efficacy. What’s left over is a set of proven, effective exercises, now known as ‘Clinical Pilates’“. (What is Clinical Pilates™, dmaclinical pilates, YouTube). So, research tells us that we can prove the efficacy of certain exercises, but not others. Best practice is therefore to exclude anything that we cannot prove is efficacious. This may be a line of reasoning that appeals, but does it have anything to do with Pilates, or real life, for that matter? I’m in no position to question the merits of research, like Hodges’ & Richardson’s ‘A motor control evaluation of transverses abdominis’ (published in 1996), that concluded “The delayed onset of contraction of transversus abdominis indicates a deficit of motor control and is hypothesized to result in inefficient muscular stabilization of the spine.” In case you are unfamiliar with this, their research found that in healthy subjects – those without back pain – EMG readings showed that their TVA fired in anticipation of movement, whereas the back pain suffering subjects showed delayed TVA firing. I do wonder, though, about it’s application to Pilates.

This happened before my introduction to Pilates, but I imagine that, because Pilates was recognised to help people with back pain, it was then deemed necessary (by whom – who knows?) to incorporate conscious, isolated TVA contraction into Pilates. As APPI told us above, Pilates uses ‘abdominal hollowing techniques’, though I can’t find any reference to it in Pilates’ own writing. I recently had an online conversation of sorts with a former Pilates teacher and studio owner who described herself as a ‘master trainer’. The conversation started because she had blamed Pilates for her ‘weak’ rectus abdominis, and she explained to me that: “The pilates priciple of navel to the spine creates an imbalance in the abdominal muscles.” I have no wish to impugn the integrity or sincerity of this lady, presumably her view is a reflection of what she was taught herself. But where did it come from? I’d be very interested to hear if anyone who was trained by Romana, Kathy, Eve, Ron, Carola or any of the other first generation teachers ever heard a ‘navel to spine’ or abdominal hollowing cue. Again, Pilates himself never mentioned any such thing in ‘Return to Life’. I know from other exchanges that I’ve had on Facebook forums that, amongst plenty of teachers, the importance of cueing transversus, and the correct usage of transversus are, beyond question, fundamental to Pilates.

So, research appearing to indicate that transversus contraction is normally reflexive, we find that it is being cued nearly constantly in Pilates. The truth is that, having had a lumbar disc injury, I probably benefited greatly from some simple spinal stabilisation/hip dissociation exercises when I first started Pilates, but these were in preparation for doing Pilates, not central to it. In other words, these were pre-Pilates exercises that seem to have somehow morphed into what Pilates is perceived to be. Indeed, organisations like APPI and Clinical Pilates™ will teach their students that this is how Pilates should be – “The APPI Pilates Method provides Physiotherapists and equivalent degree therapists with a clinical and user friendly tool for retraining correct activation of the Multifidus, TrA muscles and pelvic floor muscles.“(The APPI Pilates Method, http://www.ausphysio.com) I should say here that, of course, physiotherapists do a very important job of helping people to be pain-free, and I am sure too that there are many great and dedicated teachers trained under these and similar methods. My concern is, to revert to the analogy above, that the on-ramp becomes the freeway, first in the perception of teachers trained in this thinking, and then in the public perception.

I’ve written recently about our willingness to believe that we understand bodies and movement better than Pilates did, and I assume this is the reason that Pilates teachers were apparently so willing to adopt clinical concepts in their teaching. The slightly bizarre thing to me is that at the same time some of those clinicians were busy declaring that physiotherapists are the natural bearers of the Pilates flame – that they are the people best qualified to teach Pilates. It’s an idea that is routinely promoted now -“Pilates instructors may be able to teach Pilates but are they qualified to give rehabilitation to someone who has an injury or medical diagnosis? We would suggest not. Physiotherapists can give full rehabilitation and can be taught to teach Pilates.” (The Benefits of Physiotherapist Led Pilates, http://www.pilatesandtherapy.co.uk) and, of course, in the quote at the top of the page.

Intertwined in this is the notion that actually Pilates is for people who are injured, or in pain. This brings us back to the ‘within normal limits’ outcome, and the idea that repertoire that hasn’t been validated by research should be discarded – “We don’t know for sure that this will help to resolve your pain, or increase the efficacy of your spinal stabilisation strategies, so you shouldn’t do it.” What was devised as a system is reworked (unsystematised, perhaps) and then, weirdly, appears often not to work. I have a strong suspicion that there are plenty of teachers who have arrived at Pilates after pain or injury, followed the unsystem approach and failed to enjoy the outcomes that Pilates intended. They’ve trusted the clinicians instead of the system, and thus find themselves ‘within normal limits’, when Joseph was trying to offer “godlike attributes” – what a compromise!

 

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