Archives For back pain

Or, (very long subtitle) the niggle in your back/shoulder/hip/neck/ankle etc. wasn’t caused by something you did – it was caused by everything that you do.

Or, no-one can fix you, except you.

humancar

It might be tempting to think that my body is a lot like my car – I put fuel in my car and use it to get from A to B, and I put fuel in my body and use it to move from A to B, amongst other things, as well. When a warning light came on in my car recently, I took it to the garage for diagnostics and repair. It turned out that the catalytic converter had reached the end of its life and needed replacing.

Last year a warning light came on in my body, that’s to say, my knee started to hurt and wouldn’t straighten fully. I took it for diagnostics and it turned out that it needed (surgical) repair. Here’s the crucial difference – my knee joint hadn’t reached the end of its life, I’d simply not been using it as well as I might have done. And I don’t know when that happened. I may have been using it poorly for 2 years, or 20 years. I’ve done more sitting in the last few years that we’ve had a studio and I’ve been a manager as well as a teacher, and I used to run relatively high mileage with no understanding of good running technique around 17/18 years ago. Either or both of these things could have contributed but really my knee problem was probably a result of everything I have (and haven’t) done for decades.

I can drive too fast, take speed-bumps too hard, ride the brakes or the clutch and cause components of my car to wear out faster than they should. Then, if I’ve got the money, I can get those parts replaced and carry on as before. There’s no harm done, except to my wallet. I won’t have changed the structure of the chassis, nor altered the way that it processes fuel and oil, there won’t be scars left where parts have been replaced.

My body, however, is an organic, dynamic (on a good day) system. It’s continually responding and adapting to its environment.

en+vi+ron+ment: Ecology. the external surroundings in which a plant or animal lives, which tend to influence its development and behaviour. (We might simplify this to place and time).

Somehow environment isn’t a broad enough term – I like to think of inputs instead/as well.

in+put: Computer technol. a. the data fed into a computer from a peripheral device. b. the devices and operations involved in transferring the data.

In human terms there are some very obvious inputs, like oxygen, water and food. There are visual, auditory, olfactory and thermal inputs. There is the, largely, unfelt input of gravity. There are inputs of light, in addition to visual inputs – daylight, dusk etc. There are the inputs from my emotional response to place or time. And, with a significant nod to Katy Bowman, there are inputs of forces, or loads constantly being applied to our body, whether we are in motion or static. Even asleep, the surface you are sleeping on is a load on your body, and we are constantly adapting to our environment/inputs.

Current pain research also tells us that our memories of past experiences and stories we have heard also act, if not as an input, then as a filter through which certain inputs are passed. So they will influence the way we respond to those inputs. (Am I making the case for our bodies being quite different from cars yet?)

To paraphrase Katy Bowman, “No-one is ‘out of shape’. Everyone is exactly the shape that their inputs have caused their body to adapt to.” We are the product of everything that we do. And to paraphrase Kelly Starrett, “We do not randomly break”. If my knee cartilage wears out, it’s not because I carry the weak knee cartilage gene, its because of how I’ve used (misused) my knee. We could argue that there’s some luck involved, inasmuch as I may not have known I was abusing my knee, but I’m still responsible.

When the catalytic converter was replaced in my car, my car was fixed. End of story. On the other hand, the excellent surgeon, who trimmed my torn meniscus, did not fix my knee. He did the work necessary to allow me to fix my knee (if we can truly say ‘fixed’ in relation to bodies/body parts). Unfortunately, the Western model of health supports the idea that your doctor fixes you, strongly reinforced by the pharmaceutical industry. The chiropractor/osteopath/physiotherapist/Pilates teacher that helps you with your problem does not fix you – they help you to fix yourself. The magic comes from your own body, and your own nervous system. There is no external magic, however good your favourite therapist/teacher may be. THERE IS NO EXTERNAL MAGIC, THE MAGIC HAPPENS INSIDE YOU (perhaps with the guidance of your therapist or teacher).

You cannot take your body to someone else to get it fixed, you have to fix it yourself.

 

 

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Does Posture Really Matter?

October 11, 2015 — 1 Comment

Perhaps this is a heretical question…. the importance of ‘good posture’ to health and well-being is so widely recognised that it is beyond question. Certainly, in the world of Pilates, it would seem to be doctrine. Jillian Hessel tells us that good posture is “essential to a healthy, well functioning body.” The good news is that Pilates apparently has a solution – Pilates For Posture’s website declares: “Evidence has shown Pilates to….improve posture…” (These are two examples out of many, and just happen to be near the top of my search results. See here, and here, for a couple more).

I accepted the importance of posture for years, as well as ‘postural optimisation’ being a reasonable goal for someone’s Pilates practice, and I was a little irritated by, for example, Todd Hargrove questioning links between posture and pain – why ask the question at all when we know that bad posture is bad for you? I started to be curious and question my own orthodoxy on this subject first when I noticed that people I was taking workshops with, in particular with MovNat and with Ido Portal, who were effortlessly wonderful movers, had (to my Pilates teacher, good posture obsessed eye) crappy resting positions. In other words, when they were relaxed, they were really relaxed, and clearly not trying to hold themselves well. To reiterate, when they wanted or needed to move they were graceful, supple and strong. When they didn’t need to move they did not seem to be controlling the form their body took.

thumb3_leopard_relaxing_in_a_tree_after_lunch

Needs some postural training?

More recently someone I was training with said “posture is reflexive”, which really got me thinking. It ties in with ideas of energy efficiency that I gleaned from basic evolutionary biology – as a species we are ‘programmed’ to use as little energy as possible; and with an idea I got from Katy Bowman: no one is ‘out of shape’, we are all in the shape that our brain/body thinks is best for us, based on the environment and inputs (nutrition, movement etc etc) we receive. So ‘posture is reflexive’ means that at any given moment your brain will organise your body according to the best (most energy efficient) strategy that it has available, based on the information it has received. You can consciously organise your posture, until your brain is occupied with something else – if your job is to sit or stand up straight that’s great, but if your life requires you to do anything else then postural organisation will quickly take a back seat. To say that your posture is a determinant of your health is putting the cart before the horse – your posture is a manifestation of your health, and ‘fixing’ your posture, however fleeting that might be, will not fix your health.

Problematic postures are only problematic when they indicate poor movement strategies. If someone’s default standing position is a swayback, and they have glute amnesia, the solution will be to teach them to move, not to teach them to stand. If someone’s sitting position appears to be causing them problems with their neck, shoulders, back, digestion, breathing etc. the solution won’t lie in teaching them to be better at sitting (just as a more ‘ergonomic’ chair won’t help), but might lie in helping them to sit less and move more. I understand, too, that someone’s posture can be a product of their emotional state. In this situation teaching posture doesn’t present a solution, and teaching movement actually might.

Assessing someone’s standing posture may be useful in terms of having quick/simple clues as to what kind of movement they have the most urgent need for, and perhaps there’s a movement assessment that will serve the same purpose, or do better. Beyond that, is there any point in teaching someone how to stand, or sit?

 

 

 

 

The Dirty Secret

April 4, 2015 — 12 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!

 

Neutral?

October 18, 2014 — 13 Comments

This subject may have been done to death, but the last post that I wrote garnered reaction from a number of people, specifically in relation to my writing that “I may have uttered the phrase ‘neutral spine’ at some point in my life” (as if that were a bad thing). So, it seems like something worth addressing, and having done some hunting in books and via the internet, there is plenty of (at least) potentially conflicting information available.

Neutral posture is defined as one “where the joints and surrounding soft tissues are in elastic equilibrium and thus at an angle of minimal joint load”.

(sorry, I’ve seen this quoted repeatedly but cannot find the original source).

If you’re going to be lifting weights, whether a barbell or bags loaded with a weekly shop, neutral is a fantastic place for your spine to be. There will be load on your spine, because it is the transmission from your arms (carrying the weight) to your hip joints, which should be moving the weight, but the load will be distributed evenly through the joints. If you are a Pilates teacher, or enthusiast, you probably know what Joseph Pilates believed about spinal flexibility – he wrote, in ‘Return to Life’ “If your spine is inflexibly stiff at 30, you are old. If it is completely flexible at 60, you are young.” In the lifting example though, the facility to maintain stiffness in your spine is very valuable.

One of the foremost proponents of spine stiffness is Prof. Stuart McGill (the link is to an article that he wrote) who has spent years researching spines, and apparently gathered lots of evidence that supports his theories.

I can’t disagree with a lot of what Prof. Mc Gill says in the video (and what right, as a layperson, would I have anyway?), especially in relation to the importance of lifting with the hips and not simply bending your knees. I heard recently of research on dancers showing a strong correlation between poor hip hinging (the ability to hinge the trunk around the hip joints without spinal articulation) and both back and knee pain – back pain especially. There would seem to be a strong case for making sure that the people we teach understand how to hip hinge (to powerfully extend their hips, you might say.)

Are there exercises in Pilates that involve the spine acting as a static transmission of load from one extremity to another? Absolutely. And there are also, of course, plenty that require us to sequentially articulate our spines, or to maintain spinal flexion. I suspect that the work of Prof. McGill has caused some teachers to believe that we should be avoiding lumbar flexion (it seems to be regarded as more sinister than thoracic or cervical flexion, presumably because the majority of disc injuries occur there). If you look you can find video online (try “the Pilates Nun”) of the Rollup being taught with a neutral lumbar spine, so as to keep it safe. If you peruse Professor McGill’s ‘Ultimate Back Fitness and Performance’ book you will see that he particularly advocates exercising with lumbar in neutral for people who have had back injuries or back pain: “Generally, for the injured back, spine flexibility should not be emphasised until the spine has stabilised and has undergone strength and endurance conditioning – and some may never reach this stage!” (page 47). This is not at all the same as never, ever flex your lumbar spine, yet this is what some people have taken from his work.

As a concept, neutral spine seems to be predominantly taught lying supine, which is curious to me because it seems to be the one position where neutral has least value or application. Under what circumstances, when lying down, do you need to maintain a neutral spine? If the only answer is ‘during exercise’, then we have to wonder what the purpose of the exercise is. I’m referring to mat based exercise, Footwork on the Reformer, and similar exercises with straps/springs being an exception, because you are applying force from your hip joint against mechanical resistance – they are mimicking deadlifting and squatting while supine. There is not a single exercise in ‘Return to Life’, beginning from a supine position, that calls for neutral spine, so it would seem reasonable to say that any pre-Pilates exercise (that is truly progressing toward an actual Pilates exercise) would not call for it either.

You might want to encourage a neutral spine in standing, in which case this is entirely dependent on the leg/pelvis relationship. If that is well organised – pelvis neutral – then cues related to axial elongation will surely help to achieve an appropriate spine position. After all, as Shari Berkowitz writes in her blog post ‘Neutral Pelvis and Neutral Spine: What are they and why do we care?‘, neutral spine is not a specific shape but unique to each individual. And, with that reference, ‘neutral pelvis’ rears its head.

Neutral pelvis, defined by Ms Berkowitz in her article as: “ASIS and pubic bone in line with each other in the Coronal Plane”, seems to me a more appropriate thing to be talking about than neutral spine, but do we really need to talk about it at all? Yes, it may well be a helpful cue to some, and my discomfort with the term may be a little irrational. (I’m much happier talking/thinking about organising one’s pelvis on the top/end of one’s legs..) Once again, I have to wonder if the term has a place in Pilates – particularly the matwork?

maxresdefaultMany gymnastic exercises involve the hollow body, or ‘dish’ position, and it seems to be central to gymnastics foundational strength programs (Gymnastic Bodies, for example). Having been introduced to the hollow body position it became apparent to me that this was the basis for a number of Pilates exercises – The Hundred; Single & Double Leg Stretches; and even The Push Up (ask any gymnast – push ups aren’t done in ‘neutral’). In fact, the second picture accompanying The Double Leg Stretch in ‘Return to Life’ is identical to the picture above. According to gymnastics coach, and author Carl Paoli, the hollow body is fundamental to learning to control your lumbar spine against the natural tendency to excessive flexion. It seems entirely natural to me that Joseph Pilates would have adopted this idea from gymnastics, which was particular popular in Germany.

One of the most valuable elements of the hollow body position for me was the understanding that my spine is organised by my glutes. My abdominals can then go to work to help to sustain that organised position but, under load, my glutes (the auto spell check is determined that I use my flutes to organise my spine…) are paramount. In a supine position this has the effect of lengthening my lower back into the ground, rather than jamming it down, and it becomes a much more sustainable position than it used to be for me. I would go as far as to say that my abdominals depend on the efficient functioning of my flutes (see?) to be able to function efficiently themselves. This does not equate to neutral pelvis.

Aside from it not seeming to be what Pilates himself was teaching, the problem with ‘neutral pelvis’ is that, once you take yourself away from either vertical or horizontal, the term has no meaning, except in relation to your spine. So, when a teacher calls for a variety of exercises from the original repertoire to be performed in ‘neutral pelvis’, I suspect that what they are really saying is ‘lumbar neutral’. If that is what’s intended, why stop there? If you flex your thoracic but not your lumbar then one would think that there would necessarily be significant intervertebral compression in the lower thoracic. If it is truly important to keep the lumbar in neutral, then why not the thoracic and the cervical? Where does that take us? Everything neutral in the sagittal plane only allows us to include The Twist, Side Kick Lying and Kneeling, and The Leg Pull (if you’re careful).

Under those circumstances, Pilates, as an exercise method, is dead – killed by the creeping influence of physiotherapy and disc injury and rehabilitation research. If you think that gymnastics may not hold all the answers to sound movement then I’d agree – practiced at an elite level it’s probably not fantastic for your health. That doesn’t mean that the basics haven’t been worked out over a long period of time – at least a century more than Pilates has been around. Gymnastics, like Pilates (I hope) is also very much concerned with having control over one’s body in movement. Can the same thing be said for the advocates of ‘neutral’?

 

 

 

 

 

 

Pilates vs. Evolution

April 16, 2014 — 3 Comments

What should I call it?

What should I call it?

I imagine that the great majority of teachers and/or practitioners of Pilates would agree, that it is alive – that Pilates is a living thing. All living organisms must be able to adapt to changes to their environment (or move to a different environment) to avoid extinction. Thus, I would contend that, Pilates has to be capable of adapting to environmental shifts in order to avoid eventual extinction.
Yes, here we are once again, musing on what Pilates really is/should be etc. It’s a subject that seems ‘to have legs’, very long legs perhaps (and how appropriate).

A recent post on a Pilates related forum invited discussion on “innovation in Pilates”, with fairly predictable results. Some comments endorse the idea of everything that one does informing everything else that one does, others decry the lack of respect shown to the originator, or worry that the public may be confused. The latter idea is particularly fascinating for me, in part because I think that ‘the public’ may not be that interested anyway. If I think of my job as teaching people to position and move themselves as well as possible (on another forum thread Sean Gallagher recently wrote: “…Pilates is a way of living in your body” which feels similar, if not better), then I do not see it as my job to teach people about Joseph Pilates, to make sure that ‘they’ know exactly what was devised by him, and what was not. The subject may well come up, but I’m more interested in honouring the marvellous tool that nature has given us (our moving body) than I am in honouring the man, much as I believe he was a genius.

Back to evolution (apologies to anyone who is troubled by this concept – I believe that its acceptance in the US is particularly limited). There’s no doubt that the environment in which Pilates resides, that’s to say our understanding of biomechanics, neuroscience and so on, has changed substantially in the last 46 years. It may be that you believe that Joseph was indeed 50 years ahead of his time, so still ahead of the evolutionary curve. In which case there may be no reason to look elsewhere for inspiration or more thorough understanding. For some of us, exposure to other modalities, or information that helps to refine our understanding of what’s important, may mean that we begin to incorporate into our teaching things that do not look exactly Pilates, as taught by Joseph. As an example, there have been a couple of instances recently when, within the first few classes, I have taught a deadlift pattern to clients (both of whom had young children, and back problems). This is because I believe that understanding this movement pattern is essential to their well-being, so that they do not have to choose between back pain or picking up their children. I may have mentioned that the deadlift is not strictly a Pilates exercise, I don’t remember. I don’t think it really matters, again, because of how I see my professional responsibility, and because I don’t think my clients are helped by making those differentiations.

I can see that this point of view may not sit well with some teachers, those that we might consider to be devoted to authenticity. They may feel that different disciplines should not be mixed together. As I may have mentioned in an earlier post, I have always been most interested in that area in-between. As an art student I was excited by the blurring of boundaries, between sculpture and furniture, say, or sculpture and architecture. At the moment I believe that it’s appropriate to refer to what I teach as Pilates, because the great majority of it is recognisably Pilates, and because I use the equipment a lot. It’s possible that at some point in the future less of what I’m teaching will be recognisably Pilates, and that may lead me to eventually try to find a different name for what I do. When I was training as a Pilates teacher one of my teachers was known for having his own versions of exercises, and we were encouraged to pin him down about which was original, and which was not of what he was teaching us. His mat classes were called Pilates classes, and whilst the original repertoire was in there, there were flavours of yoga, contemporary dance, and other systems too (and, importantly, in relation to the ‘confusing the public’ issue – they were busy classes, people came and moved, breathed, were challenged, and had fun). That was 12 years ago, and at some point it clearly made sense to give his teaching a new name, so that we now have Garuda. If James were still calling his work Pilates it would probably be totally inappropriate, and the creation of Garuda seems like a natural evolution of his teaching.

The person who posted about ‘innovation in Pilates’ is at the point of making his own equipment, that looks significantly different from Pilates equipment. I would agree that you can apply the principles of Pilates to other modalities, but would suggest that once you need to manufacture your own equipment to best express your work, it may be time to practice under a different banner. The question for me is where one draws the line, between teaching something that looks substantially like Pilates (as I write this I can picture the Pilates fundamentalists gnashing their teeth – sorry), and something which has strayed far enough from the original material that it no longer qualifies. I suspect that the answer may be (aside from needing to create your own equipment) that if you need to ask if you should still call what you teach Pilates, then you’ve probably strayed over that line.

(Image courtesy of http://www.dailymail.co.uk)

 

 

strongfortbellI’ve used this blog previously to write about what I think Pilates is, or is not, so perhaps I shouldn’t need to ask this question. Then again, what I think Pilates is may not sit so well with some of my colleagues. Some of those teachers may have less experience than me, some that disagree (or would if they read this blog) might be ‘master’ teachers – who knows. There are so many of us in the world that it will always be difficult to find a simple, singular explanation of the job/work – if that’s even an appropriate goal.

I love a bit of simplicity, and often feel that we are inclined to complicate things – to hunt for the trees, or even the moss on the trees, and miss the wood that is trying to slap us in the face. I am increasingly embracing the idea of repetition – of exercises, and fundamentals. A few years back I had a conversation with a martial artist, and traditional Chinese medicine practitioner, who struck a chord with me when he opined that yoga is a martial art, and that Pilates is much the same – a bit like a martial art for Westerners. I firmly believe that teachers of Pilates, yoga, and martial arts (spiritual/meditative elements aside) are doing the same thing – teaching ‘good’ (efficient) movement. His argument was that, traditionally, in the East, children would start to learn these movement practices before they were old enough to question the why’s and how’s, and that by the time they were old enough to question, they knew the answers in their bodies – understanding through repetition. Pilates is a little different because it is designed for adults who may want/need to know why they are doing a particular movement. (How many times have you heard: “What’s this (good) for?”)

Whilst I love to talk to the people that I’m teaching about the why’s and how’s, I think that I need to become more at ease with shutting up and allowing people to just ‘do the reps’. I have succumbed, and am certain I’m not alone, to listening to clients niggling complaints, and trying to engineer a variation of an exercise especially for them. I’m sure that Pilates intended his method to be systematic, and sticking to a system is more likely to produce favourable results than regularly deviating from it. Thus, I’m increasingly inclined to side (are there sides?) with the classicists who devote themselves to ‘the work’, and refuse to deviate from the original Pilates repertoire.

The trouble with this is that, however much I’d like to keep thing simple, the ‘original repertoire’ can be hard to pin down. I remember one workshop presenter who would only teach exercises that he had seen archival footage of Pilates teaching, or that he had himself been taught by a first generation teacher (one who had been taught by Joseph). If you’re going to be strict that seems a pretty good start, but what about the repertoire that Pilates taught to a first generation teacher, who did not pass that particular exercise on to the presenter in question? Is it less ‘original’ because one person didn’t think of it, or didn’t feel it was appropriate for this person? So the mat work exercises are the only really reliable record of ‘proper’ Pilates repertoire, because he wrote them down.

And what IS Pilates? There is a growing movement in the UK to create a hierarchy amongst teachers – to set studio trained teachers above mat work teachers. Only last night I read an article suggesting this, because the studio is true Pilates, is ‘the work’ (matwork, as taken from ‘Return to Life’ was, after all, just homework). I suspect, when I hear or read someone talking about ‘the work’ that they’re talking about repertoire – following a system, perhaps. To know Pilates you have to do the work, to become a good teacher you have to do the work. To stay fresh as a teacher you have to do the work.

The repertoire is what separates Pilates from other movement disciplines, yet I don’t know how many times I’ve told potential clients that Pilates is not just a set of exercises – that the exercises are a vehicle for learning principles and fundamentals. In other words Pilates is not Teasers, Hundreds, Footwork, Long Spinals etc. – Pilates is how to move, how to hold/carry yourself. The repertoire is a well thought system for learning those fundamental skills (with a bit of exotica thrown in for those that like/need a challenge). I think the classical repertoire (what I understand it to be, anyway) represents a wonderful mountain to climb. If you reach the peak of executing all the exercises with grace then it’s highly unlikely that you will not be expressing the fundamentals of good movement. I would love to think that everyone who comes through the door of our studio will develop the goal of accomplishing all of those exercises (but I know it won’t happen).

Instead, I will try to teach everyone I work with to move to the best of their capability, and to overcome any challenges they may have in achieving easy, efficient, graceful, powerful motion. Very often the traditional studio equipment will be the ideal vehicle for delivering this, but sometimes I’ll stray. Just yesterday I was teaching a lady for the first time, who has had a history of back problems and is fearful of common daily tasks, not to mention essentials like picking her child up. This wasn’t the first time that I’ve taught a mother who feels scared or unable to pick up their child, and in this circumstance I feel like all other goals take second place. I will try to explain the fundamentals of midline stabilisation, and transmission of load from extremities to centre (I hope we can agree that these are Pilates fundamentals), and I will more than likely use a kettle bell, or weight of some sort to try to teach her how to (in fact, that she can) safely pick her child up. I cannot think of a ‘proper’ Pilates exercise that teaches this fundamental movement as quickly and simply as I can with a weight but that does’t change my belief that I’m teaching Pilates. Am I wrong?

Should I be in existential crisis? I like simplicity, and I want to teach with integrity, AND I think that often the most interesting things occur when edges are blurred, on the boundaries between things/practices/methods. Can I have my cake and eat it? Can I teach Pilates with a kettle bell?

courtesy of encyclopaedia.wikia.com

courtesy of encyclopaedia.wikia.com

I recently wrote a post which was in response to a review of “Becoming A Supple Leopard” by Kelly Starrett. The reviewer took issue with both the lack of reference to scientific studies within the book, and Starrett’s failure to refer to current pain science (by looking only at postural/structural/biomechanical causes of pain). The same theme cropped up in an article called “Back Pain Myths: Posture, Core Strength, Bulging Discs” from the website ‘Better Movement‘.

“Back Pain Myths” states that the majority of physical therapy and corrective exercise done in the USA is based on incorrect assumptions, and concludes a consideration of the evidence for each ‘myth’ as follows: “..there is little evidence to support the idea that we can explain pain in reference to posture or that we can cure pain by trying to change posture..”; “…if a large percentage of pain free people have bulging discs, then how likely is it that a bulging disc is the cause of your back pain?”; and “..the current evidence states that there is nothing magic about core strength as means to prevent or reduce back pain…”. It is not surprising that some might take this as an attack on their practice.

There is no doubt that pain is a very complex subject, and that, especially in the case of chronic pain, the sensation of pain may not be caused by an injury, postural fault, or structural defect. It seems to be clear too that there are many people who have a disc bulge (or several disc bulges), without any symptoms at all. If nothing else this would seem to be good grounds not to rush into a surgical procedure if you are diagnosed with a disc problem. I can’t argue that Todd Hargrove (the author at Better Movement) doesn’t make some legitimate points – it is always good to have our beliefs and assumptions challenged – and we shouldn’t fall into the trap of letting popular wisdom become dogma.

A typical example of the ‘Back Pain Myths’ content is reference to various studies that fail to show any link between poor posture and pain (and it is interesting to read that other studies show a stronger correlation between back pain and stress levels, job satisfaction, exercise etc). Hargrove does refer to a study that seems to suggest a link between poor posture and pain, but hastens to remind us that: “it is important to remember the rule that correlation does not equal causation“. I like this mantra and am inclined to repeat it quite often myself. However, it is perhaps also worth mentioning that non-correlation does not equal non-causation – if a study fails to find a link between one thing and another it does not mean that there is none (I think that this idea is more normally expressed as: absence of evidence does not equal evidence of absence).

Again, we’d be foolish to pretend that someone’s pain isn’t an intricate tapestry, but I’m not inclined to feel that the foundation of the way that I work is being critically undermined by articles such as this. Dysfunction, poor movement patterns and stabilising strategies may not cause someone pain now, but they may cause tissue damage that could result in pain at a later date, or have a knock-on effect on a nearby structure that may become the cause of pain. I know, there’s a lot of ‘may’s in that last sentence, and I believe that’s partly because it’s very difficult to conduct meaningful studies on humans. That is to say, it is probably impossible to account for every variable between study subjects (even if we were to be able to treat humans as we treat beagles, chimps etc.), so we cannot expect any studies of pain triggers, or potential treatments to do better than show some correlation – and we know the rule about that.

I believe that the majority of studies that have been conducted would seem to indicate that exercise of nearly any kind (shall we just say ‘movement’?) is helpful for back pain sufferers, and one kind of movement doesn’t seem to be better than another. I don’t think it matters that we cannot prove the efficacy of a movement discipline, if the result is that people increase their awareness of their own bodies and thereby move and position themselves in a ‘better’ way than they were previously able to. Another thing that would be very hard to study is how the sense of empowerment from a movement practice might impact someone emotionally or psychologically, and thereby have an effect on pain sensation. Failure to prove these things does not make us charlatans.

To return to ‘Back Pain Myths’, I have to acknowledge that Hargrove’s article finishes with questions: “why do these approaches seem to work; how can so many people be wrong; and if these aren’t the true sources of pain, then what is?” So, despite the lack of science, he acknowledges that ‘these approaches’ (from the article we must assume that he refers to making postural improvements, surgery, and core stability training) seem to work. Interesting… Reading further, Hargrove turns out to be a fan of Eyal Lederman, who wrote a famous/infamous article entitled “The Myth of Core Stability” which, for me, speaks volumes about his outlook. You can easily find “The Myth of Core Stability” with a search of the internet if you wish (I tried to include a link but each time I tried to open a page I got an automatic download and, trust me, I’ve more copies of this article than I need). Lederman does an, apparently, able job of rubbishing the notion that there is such a thing as core stability, provided you accept that he fails to actually define what ‘core stability’ is, and doesn’t include an explanatory quote from any of the practitioners whose work/theories he questions. (I’m no lover of the term ‘core stability’, and I suspect this is true of most Pilates teachers. At the same time, I can’t fault anyone for trying to understand and explain how our brain controls our muscles and movement. I’m inclined to think that they are engaged in trying to find explanations for things that Joseph Pilates, for example, recognised as being true without the need or equipment to figure out why.) Lederman’s article is full of scholarly references, and he undermines the theories of those he calls ‘CS practitioners’ by means of those references to conflicting evidence. That SCIENCE trump card again. (One of those studies, at least, involved methods of testing trunk stability hilariously far removed from a ‘real-life’ situation).

Hargrove is a Rolfer and Feldenkrais practitioner. Lederman is an Osteopath. I do not wish to disparage any of these practices, but/and I’ve found it very difficult to track down any proof for their efficacy, or superiority to other practices, on PubMed, or any other websites. Yes, pain is undoubtedly a complex subject, and it is a very good idea for anyone working with people in acute or chronic pain to be aware of current theory. We cannot overlook the psychological/emotional component to, particularly, chronic pain. A very recent experience of mine (anecdotal, sorry) seemed to show that helping someone to understand how to effectively stabilise their midline (core, if you wish) had a positive impact on their confidence, and sense of self-worth, which had been seriously undermined by back pain. Yes, it only ‘seemed’ to help – I cannot prove it, and I don’t suppose the person in question would feel the need to have proof.

If people may be being routinely harmed by a practice then there is clear reason to question it. Does this mean that an unproven movement practice should be avoided, or that it is invalid? Er, NO.

Prove it!

December 1, 2013 — 1 Comment

X YI recently came across “Back Pain Myths” via pilatestree.com, from a website called ‘Better Movement’, and a review of Kelly Starrett’s book ‘Becoming a Supple Leopard’ from a website called ‘Exercise Biology’, that both use science, or the absence of it, to question, or indeed attack, the beliefs and practices of many practitioners working within the sphere of exercise and rehabilitation. Somehow it feels as though this is a popular subject at the moment.

To paraphrase outrageously, the thrust of these is that if scientific studies cannot be found to support an idea, the idea must be wrong. “Back Pain Myths: Posture, Core Strength, Bulging Discs” (to give it its full title) sets out to show that anyone who has suggested that poor posture, lack of core strength, or bulging discs are a likely cause of someone’s back pain has not kept up with the science, and is barking up the wrong tree. (More about ‘Back Pain Myths’ in a post to follow). Our man at Exercise Biology levels the same accusation at Starrett: “He is literally taking your hand and walking you back to the dark ages of physical therapy of the 1950’s, when we used to believe pain comes from joint, tissues, bad posture and movement.” (Good thing that the OED had revised the definition of ‘literally’ to include ‘metaphorically’ as one of its meanings). To be fair, the book’s subtitle: ‘The Ultimate Guide to Resolving Pain, Preventing Injury, and Optimizing Athletic Performance’, leaves Starrett open to this kind of critique (if you are deliberately obtuse and overlook the fact that the book is manifestly about all three things combined, and not just resolving pain).

I don’t suppose that it will be news to many of us in the Pilates world that the causes and manifestation of pain are complex areas, and that there is strong evidence that people can have, for example, multiple disc bulges and no pain. Many of us may be familiar with the work of Butler and Moseley, who wrote the excellent ‘Explain Pain‘, and will know that (oversimplified) pain is a sensation produced by our brain, based on information it has received from somewhere in the body, that it has filtered through near enough every sensory input (physical experience, anecdotes heard, films watched etc) it’s ever received. Small wonder that experience of pain seems so highly individualised.

The International Association for the Study of Pain defines pain as: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” So, the role of pain is to alert us to the likely need to change our behaviour, which seems pretty straightforward, and supports the idea that a poor position could indeed trigger a pain response. Of course, it is complicated, especially in the realm of chronic pain, and when someone experiences pain with no identifiable symptoms. Whilst I am familiar with, at least some (Butler/Moseley), current pain theory, I’m not ready to dismiss the possibility that how someone moves and holds themselves may have a bearing on the inputs that their brain receives. According to Anoop Balachandran (Mr Exercsie Biology), who is a fan of the ‘biopsychosocial’ model of pain, the biomechanics (usually termed PSB: postural-structural-biomechanical) model of pain “is now outdated, unscientific and incomplete..” Incomplete it may be, but if someone has pain that is clearly mechanically derived, and resolves the pain by changing their mechanics, that can’t be dismissed. (Nor would it somehow serve to disprove the idea that there is a valid biopsychosocial model of pain).

I don’t want to give into what may be flawed logic, but I’m sure that many of us will have seen the positive outcomes achieved by helping people to understand and change poor posture or movement patterns. I have no studies to fall back on to prove it, and accept the fact that we cannot prove that Pilates, for example, works. A solution that appears simple can still be a solution. Balachandran writes: “I wrote an article back in 2005 about the myth of posture and pain and ended the article saying Now close your eyes, take a deep breath, slowly slump – and savor the freedom of movement”.” He ‘knows’ that this is a sound thing to be saying, because no-one has yet conducted a study that can show conclusively that there is a relationship between posture and pain. I ‘know’ that it’s a ridiculous statement, because I’ve never seen anyone moving well, or freely, from a slumped position. I know that I went from being a chronic pain sufferer, to being pain-free because I learned better movement patterns, and better positioning strategies. I know that my joints fitting together as well as possible, and the surrounding soft tissues being supple and elastic will help me to avoid dysfunction – and I’m positive that, pain or no pain, that’s a good thing. To quote him again: “The more you talk about biomechanics, joints and movements, the more you are raising the threat level in the brain and making the pain chronic. This is exact reason why current pain science involves educational sessions to change people’s belief about the role of their muscles and joint in pain. Just changing the beliefs about pain has been now shown to lower pain, disability score and improve ROM and movement.” It may be that my beliefs about pain were changed during the first year or so that I took Pilates classes, I’ve no way of knowing that. It may be that counselling would have had a similar result, but we cannot prove it either way. A movement practice, and the changes in habit that followed, in my experience, resolved my back problem. I don’t need to prove whether it was a mental or physical change – it’s not provable – and it doesn’t matter. The practice was empowering to me in some way, maybe many ways, and that’s all that matters.

Ironically, Balachandran refers his readers to this interview, which is fascinating, and also includes the affirmation that Balachandran’s beloved BPS (bio-psycho-social) model of pain actually incorporates the PSB model of pain that he derides, as we saw above, as “unscientific” and “outdated”. His scathing review of ‘Becoming a Supple Leopard’ hinges on it being unscientific – given that Starrett doesn’t mention BPS, and that there is “no single scientific reference...” included. Ah, SCIENCE, the trump card. Balachandran makes it clear on his blog that he favours an ‘evidence-based’ approach to fitness. I believe that the only evidence that can be considered to prove anything comes from a randomised, double-blind study. I’m given to wonder what exercise we can undertake whose efficacy has been proven by studying groups of people, chosen at random, some of whom are undertaking the exercise without being aware of it, and supervised by people who don’t know who’s exercising and who isn’t. Thus, if he’s not basing his exercise on anecdote or observation, he is probably not exercising very much.

I’m not seeking to defend Starrett particularly (though I do think that BASL is a very useful resource), but a superficial reading makes it clear that the primary subject is pain that can be related to movement dysfunction, and that the evidence that he bases his work on is the success that it appears to have over his years of practice as a coach and physio. Isn’t it the case, in the realm of fitness (movement), that anecdote and observation are as reliable evidence of the value of a practice as any other kind?

Efforts to increase our understanding of how the human body works must be helpful, and science doubtless has much still to teach us. Particularly if we are working with people who have long-term chronic pain (especially that which doesn’t appear to have any biomechanics cause), it is helpful to have some understanding of the complexities of the biology of pain. That should not equal throwing the baby out with the bath water.

Starrett’s tagline for his work, attached to all the free material that he published to the internet long before the book, is “All human beings should be able to perform basic maintenance on themselves”. Listening to him it’s easy to believe, financial rewards aside, that he is motivated to try to make a positive difference to people’s lives – to make the world a better place. Perhaps those of us in the Pilates teaching profession all share that same desire.

Is the motivation to write a review of this book (which carries an implicit critique of any of us who’s work is often centred on the PSB model of pain) the desire to educate, to advance debate, or the desire to build a reputation?

I seem to have frequent epiphanies these days – or rather the idea that things that I ‘knew’, perhaps in the darker recesses of my mind, suddenly crystallise into sharp and sometimes powerful ideas. Simple things, such as ‘Pilates doesn’t cure back pain, good movement cures back pain.’ Of course, Pilates is an excellent vehicle for teaching good movement, and it certainly ‘fixed’ my chronic low back pain years ago. Now I recognise that it wasn’t that my various Pilates teachers waved their wands and cured me with a dose of magic – they taught me better movement (and positioning) than I was accustomed to practice at that time (God love ’em).

There’s another conversation that can be had later/elsewhere about various methods some Pilates teachers seem to have for appearing to do magic, to be filed under ‘Disempowerment’.

Another closely related epiphany that I had recently (thanks to the wisdom of Kelly Starrett finally sinking in) is that whether we are teachers of Pilates, or yoga, or salsa, or karate, or tai chi, or…almost any other movement discipline, the work is the same – teaching good movement. (Pilates called it ‘right movement’). Some of those disciplines may involve a broader scope than Pilates but, in as much as they are movement disciplines, they should be teaching good movement.

I was leaving a health club today, after teaching, when one of the PTs approached me and asked if I just teach Pilates, or if I teach yoga as well. To my surprise, when I answered “No, I don’t teach yoga.” her immediate reply was “Why?”. My internalised response was something along the lines of: “Because I’ve found a really efficacious method for teaching movement (and spent years trying to do it well), why would I want to train to teach a different method with the same purpose?” I understand that people are drawn to yoga and Pilates in ways that I am not, so no disrespect to the multi-disciplinarians out there. To me, she may as well have said “Why aren’t you a personal trainer?”, given that I think that job should be essentially the same – teaching good movement.

This is what gets me excited at the moment, the idea of helping people in my classes to move, or position themselves well. And Pilates is such a brilliant means to this end. I had another revelation today – that the Hundred is a fantastic assessment tool. It can tell you so much about someone’s awareness and competence – Is their thoracic sufficiently mobile for their head to be well positioned? Can they stabilise their scapula? Are they able to disassociate their arms from their trunk? Can they stabilise their midline under the load of their legs? Can they keep breathing while doing all of the above? And so on. All questions that relate to activities outside the class.

If I can see that someone is struggling with any of those requirements of the Hundred, what are the most effective ways that I have for helping them do better? Obviously there are many ways to skin this particular cat, and I have a question for any teachers that are reading this: Is cueing muscles the best way to help people to move well?

The organisation under which I trained is holding their AGM around the time of writing, and an internationally renowned teacher has been invited to present workshops over the weekend. One of them is apparently titled “Pilates in Clay”*, and offers the chance to sculpt muscles, in clay, onto a pvc skeleton. The description continues: “Once you have made a group of muscles, we will use the Pilates apparatus to understand how they are engaged and in what functional capacity on the reformer.”

Now, it’s probably just me, but isn’t there a significant disconnect between teaching ‘right’ movement and understanding how (which) muscles are engaged and in what functional capacity on the reformer? Perhaps I would discover that my clients left tibialis anterior is over-recruiting during the tendon stretch. Then what? Do I then devise a program of tib ant recruitment timing exercises, along with a stretching program? What would Joseph Pilates have made of this? We might be able to look wise to our clients if we can suggest to them that their serratus anterior is failing to do its job of scapula stabilising correctly, but does that help them to move better? If you know the muscle that’s working/not working, are you a better teacher?

I would argue that this is an illusion. Yes, certainly knowing muscles and their function can aid in understanding movement. And I need to be able to have a conversation with a physiotherapist, osteopath, or surgeon using anatomical language. But when it comes down to the nitty gritty of moving, my brain is simply giving instructions for one body part (or more) to move relative to another, and the muscles are just accessories. Your brain doesn’t actually know that you’ve got muscles. Poor muscle balance is a product of poor movement, not the other way around. Aside from this, focus on muscles when teaching (in addition to appearing clever) can easily disempower the client, and help to reinforce the notion that Pilates is in fact magic, to be performed on you by your teacher. Can’t differentiate between your gastroc and your soleus? Oh dear, this is worse than I thought.

After years of being excited by analysing anatomy, and trying to ‘see’ muscles working/not working in my clients, I’ve been very fortunate to stumble upon the understanding (again, hat off to Kelly Starrett – and Gray Cook, Mike Boyle, Carl Paoli etc.) that Pilates is simple. Brilliant, and simple. The fundamentals of joint positioning for transmission of force, or resistance of load, are the same for Pilates as for any other movement discipline. ‘Force’ and ‘load’ are perhaps not words commonly associated with Pilates, but this is just different written/spoken language to describe the common language of movement.

 

*This may well be a brilliant and highly instructive workshop, it’s just that the description made me feel like chewing my fingers off.

I just tried an internet search for “pilates low back pain” and Google returned 1, 380, 000 results. Google scholar also offers hundreds of ‘scholarly articles’ that touch on the subject. Amazon offers several DVDs of Pilates for low back pain, but their offerings are dwarfed by the hundreds of YouTube videos on the same subject. Another Google search for the same terms but in the News section suggests that in the last month English language newspapers and magazines have also had hundreds of articles on this subject. Coupled with my own experience of Pilates ‘fixing’ my low back pain, is it any wonder that I’ve spent years believing that Pilates offered the best solution for anyone suffering from this nearly ubiquitous affliction?

The Dummies.com website has a page, attributed to Ellie Herman on: ‘Easing Your Back Pain with Pilates‘ in which she explains that the causes of back pain are “faulty posture” and “sedentary lifestyle”. While we might like to suggest some other possible causes, I don’t suppose that many Pilates teachers would disagree with her – it seems like pretty basic stuff: you sit and/or stand badly, your postural muscles get lazy, you ability to stabilise your spine is compromised, and from there you’ll be very lucky if you don’t wind up in pain.

So, why is Pilates so good at helping relieve low back pain? Well, of course, it targets your ‘core’, deep postural muscles that give your lower back its stability. The less uncontrolled movement that you have in your lower back, the less likely it is that you will have pain. As your stability improves Pilates can help to develop efficient movement of the whole of your spine, encouraging good posture during a variety of activities. In addition, helping areas of relative stiffness to become more supple, and areas of relative ‘looseness’ to become more  stiff (stable) can help to bring more balance to our structure, and integrate our limbs into our trunk.

I was lucky enough to receive a pretty high level of training as a Pilates teacher (certainly by UK standards), and to work with some truly brilliant teachers from the UK and the US. I hope that I can reasonably consider myself to be well steeped in the principles of Pilates, and how to apply them when faced with clients with chronic pain and/or injury. I know about ‘working away from the pain’, and I’ve particularly enjoyed Ron Fletcher’s anecdote on that subject in his conversation with Kathy Grant (I referred to this DVD in a previous post) – Fletcher (a dancer at the time) explains that he went to see Pilates for help with a knee injury. Every time he went to Pilates’ studio he would be given exercises to do that had nothing to do, and Pilates would ignore Fletcher’s protestations that it was his knee that was the problem. After a few sessions Fletcher discovered that his knee was better.

So, I think my training has equipped me to help clients deal with back pain fairly well. I also believe that I understand a lot of the potential causes of back pain, as well as the importance of posture in maintaining a healthily functioning spine. I’ve been fixated (in my teaching) with hip mobility for years, and ‘get’ its importance relative to spinal stability and functional movement. I know, too, that most of us could do with working on upper back extension (and probably rotation and side-flexion too), and that the consequence of that will be less pressure on our necks. The list could go on, and that’s not really the point. In short, I felt that I had the basic understanding that I needed to do my job well, and that Pilates taught well was the ideal solution for all manner of problems. I certainly didn’t imagine that the world of strength and conditioning would have much more to offer in that regard.

More recently my perspective has been challenged. First of all by learning some of Mike Boyle‘s ideas (if you follow the link you’ll see just the kind of website that fit my prejudice completely – all it’s missing is advertising for protein powder) from his book ‘Advances in Functional Training’. (Actually this info is second-hand since it was my wife who bought the book and then explained it to me – I am nothing without her.) Boyle explains the body from the ground up as a series of joints that require, alternately, mobility then stability: ankle joint needs mobility, knee needs stability, hip needs mobility, lumbar/pelvic joints need stability, thoracic spine needs mobility, cervical spine (neck) needs mobility. Genius!

Being peripherally involved in a Pilates teacher training programme I understand how tricky anatomy and physiology can be to get to grips with, not least because it rarely seems to be straightforward, and how often students crave some dependable, simple answers. I’ve suffered the frustration, and seen it in many students too, of different books giving different answers for muscle functions. I know now that anatomy is an evolving subject, not a science in which all the answers have been found and set in stone. Thus, an explanation of what we need from our joints, expressed as simply as Boyle does, feels like a wonderful breath of fresh air. Mobility: stability: mobility: stability….It also seems to fit perfectly with ‘working away from the pain’ – you leave the problem area alone, and look for the adjacent compensations/weaknesses/stiffnesses. I think I had learned the same thing previously, but perhaps in a way that meant I didn’t see the wood for the trees – I knew it in pieces, and had never heard it said so succinctly. Lots of bits of information fell into place as I mused on this idea, and it’s become a constant reference point when I’m teaching.

Following that I was listening to a podcast recently in which the two hosts (one a strength and conditioning coach and the other an olympic weightlifting coach) were answering a question about exercising with a herniated lumbar disc. In discussing the question they came up with an equation something like: “If your hip joints are mobile, and your thoracic spine is mobile, you probably won’t have low back problems. If your hip joints aren’t mobile, and your thoracic spine isn’t mobile, you probably will have problems with your lower back at some point”. More genius! 

It’s just like Mike Boyle said! (Mobility, stability, mobility, stability….) Again, I knew already what they were saying, in fact I’ve probably been saying the same thing to clients for years, just not in such a clear and straightforward way. Perhaps I’ve just been lagging behind all these years, thinking I knew more than I did – certainly I need to view other disciplines with a little more humility than I have in the past. In any case, when trying to learn more about what I do for a living, casting my net wider has definitely been rewarded.

To return to the Ellie Herman piece on http://www.dummies.com, posture may well be a part of the picture, but there’s more to it, and you may be able to make a significant difference to your risk, or management of back pain, by going beyond her advice to:  “sit and stand up tall, keep your belly pulled in, and keep your shoulder blades pulling down your back”. Maybe even by listening to the advice of weightlifters.