Archives For Kelly Starrett

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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Is Pilates Really Enough?

February 5, 2016 — 9 Comments

This is a question that seems to crop up amongst teachers from time to time, with supporters on either side of the argument. Benjamin Degenhardt reminded me last year that what Joseph Pilates was interested in, was promoting, was overall health. He was concerned with a bigger picture than ‘core stability’, or ‘fitness’ in the gym-focused/endurance event sense (“She’s really fit, she’s run a marathon.”) that tends to be the dominant interpretation these days.

So does the regular practice of Pilates provide everything necessary to be considered fit, in a holistic sense? Perhaps the truth is that it depends. We might run into problems with definitions of the word ‘fit’. I’ve written about this before but, to save you reading more, I like: “greater tolerance to shifts in environmental parameters and biologically mediated challenges” (words by Suzanne Scott). I also like to think of fitness in terms of a capacity to express one’s full homo sapien potential – “are you human?”, if you like. Where being human means, to borrow from Kelly Starrett, that you can squat to take a pooh in the woods; and, to borrow from Katy Bowman, you can pull your own weight with your arms, which is to say you can do a pull-up. While they may not be very common, these are normal things for a human to be doing. (Please check in with yourself here – have you started making a list of reasons for not being able to squat/pull-up? or a list of people whom you know who have good reason to not be able to do one or both of these things? If so, why did you do that?)

Some other expressions of being human: walking, running, crawling, climbing, swimming, playing, dancing (the last two perhaps equalling physically engaging with other humans). And, beyond the realm of movement, to do what’s required in order to eat nutrient-dense foods from a variety of sources; to tolerate a range of temperatures (as in the definition of fitness above).

I got started in writing this because I sometimes feel, when working with teachers in training, and running a studio where a number of people teach, that I want those teachers to believe in more than teaching Pilates, or to see that their mission could/should encompass more than knowing the Pilates repertoire inside out, and being able to teach it to others (though this would be a good start).

In an interview last year Kelly Starrett said:

“Squat down, feet together, knees together, heels down. Can you do that? Yes? No? If you can’t do that you’re missing full hip and or ankle range of movement. That’s the mechanism for your hip impingement, for your plantar fasciitis, for your bunions, for your pulled calf. That is the £*@<ing problem, and you should be obsessing about it.”

You. Should. Be. Obsessing. About. It. You should be obsessing about it. Let’s hope you don’t have bunions or any of those others, nevertheless, if you’re not able to express your full range of movement, you should be be obsessing about it. Can’t squat to the floor? Obsessing. Can’t do one pull-up? Obsessing. If anything is less than optimal you should be doing something about it.

I’m sure it’s not to everyone’s taste, but I always enjoy the way Kelly expresses himself. If you have a look at what he’s involved with you will see that Kelly is clearly trying to reach a lot of people, and a ‘black and white’ delivery probably works best for that. I suspect that a lot of Pilates professionals are anxious not to judge, or be judged, which is nice but I don’t believe I’m alone in sometimes needing to be told “what you’re doing is not good enough”. Self-acceptance, as in not hating yourself, is surely to be encouraged; self-acceptance, as in ‘this is as good as it’s going to get’ should surely be discouraged.

I don’t believe that Joseph thought it was enough to do his exercises. After all, he left us with instructions for how to shower properly (I’m not sure that it’s on YouTube but if you look hard enough I’m sure you can find the film). Never mind the biologically mediated challenges – do you have optimal tolerance to shifts in environmental parameters? No? Then Pilates will be a good start, but you’ll need more.

 

PS. Comments are very welcome, but will not be seen by the author on Facebook. If you would like to start a conversation with me please use the blog comments section.

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!

 

hack, noun : trick, shortcut, skill, or novelty method to increase productivity and efficiency

 

I learned about using ‘jump stretch bands’, or ‘pull up bands’ from Kelly Starrett, and have found them useful in a range of applications in the Pilates studio. I hope this will be the first of a few video posts around this subject.

Achieving ‘clean’ hip flexion, not involving some pelvic motion, can often be a challenge – and this is, of course, a movement theme that crops up in a lot of Pilates repertoire, on all of the equipment.

The obstacle usually seems to be anterior dominance, leading to a hip joint position that ‘closes’ and restricts that isolated flexion.

More and more, in our studio, we’re using bands to create distraction of the joint, allowing for a better ‘fold’ of the leg into flexion. After a fair amount of experimenting, we finally arrived at a set-up that allows for strong hip distraction without the band slipping off when the athlete is reaching toward hip extension.

imagesFollowing on from a mention in part 1 of this post, I think that a lot of interesting things happen on the boundaries between disciplines. Kelly Starrett, who has influenced my thinking about Pilates a lot in the last few years, talks about the benefits of sports people from different disciplines talking to, and learning from each other (power lifters talking to gymnasts talking to rowers talking to olympic lifters talking to swimmers/runners etc).

The subject of the first post, and the comments that followed (thank you all for your interest and contribution) made me start to think that there is a problem inherent in classification – in trying to define or draw lines between things. Once again, I find myself a little conflicted – I love simplicity, but…

I’ve found the Classical Pilates Inc DVDs to be an invaluable resource, from the point of view of learning to put the correct name to an exercise, or checking choreography. I’ve learned to assume (who knows how/why) that what is usually referred to as ‘classical’ Pilates, is that which was taught by Romana Kryzanowska and her followers. The “Romana’s Pilates” DVD I have in front of me has the tagline “….the true pilates method as taught by Joseph Pilates”. As an enthusiast of simplicity I am drawn to the ‘this is the way it is supposed to be’ kind of presentation. From watching the DVDs, and taking class with Romana trained teachers, I know that Footwork on the Reformer should be done with all the springs attached, as should the Hundred.

And then again, I was watching part of another DVD the other evening (that is still available from Michelle Larson) of Eve Gentry giving a workshop in 1991. My understanding is that Eve worked alongside Joseph Pilates in New York for close to 30 years – longer than anyone of the other first generation teachers. At the beginning of the workshop she talks about what she learned from Pilates: “I learned about not using too many springs….” This is just one example and I’m sure there are plenty of other instances when the Eve Gentry approach to Pilates differs from the Romana Kryzanowska approach. Ironically, courtesy of this blog I now realise that it’s even more complicated than I thought – the classification ‘Classical Pilates’ requires sub-classification!

I’m not at all interested in entering a discussion about which one is better, or closer to Pilates’ original intentions.  I’m curious as to whether being more definitive about classification does more good than not. This gets back to the original question of what it means to call myself a Pilates teacher. I understand the value of being systematic, and holding true to the principles of rhythm and flow, and, ultimately, I believe (as Eve Gentry says) that I’m trying to teach a concept, not a set of exercises. The exercises are a vehicle for delivering/understanding those principles, and can represent a fantastic challenge for someone who is interested in exploring the limits of their physicality (I can see no need for inventing advanced repertoire). I also believe that Pilates himself would adapt/create exercises for individuals, based on his understanding of their specific needs. Whilst I wouldn’t try to compare myself to Pilates (though I not-so-secretly like to think it may be significant that I was born in the year that he died….), I often use other exercises to teach the principles to certain clients – because I think they will be more effective, or represent a more accessible route to understanding the concepts than a ‘classical’ exercise might. I’m back at the ‘Can I teach Pilates with a kettle bell? question from my previous post – can you teach Pilates with exercises that are not Pilates? According to the blog post that I linked to above, I should be acknowledging to whoever I’m teaching a non-Pilates exercise that I’m not actually teaching them Pilates at that moment. But I think Pilates is a concept, not a set of exercises! Isn’t it perplexing?

Here’s another way that I like to think about this – Can you be good at Pilates? If your answer is ‘Yes’, what does that mean? What does it look like to be good at Pilates? I routinely tell people coming to our studio that there’s no value or point to being ‘good at Pilates’. Who cares if you can perform Pilates repertoire beautifully (or however else we might define ‘good at’)? The point, for me, is to use Pilates to help people be good at, or find easy, everything else that they want or need to do. I think that my job is to teach people to move and position themselves as well as possible, and Pilates is the vehicle that helped me on this journey, and what I feel competent to teach to others.

I do understand the need to honour our heritage, and the original work of Joseph Pilates, and I’m grateful to those teachers and organisations who commit themselves to that. I also agree that a familiarity with the apparatus adds to one’s understanding of Pilates. Somewhat unconsciously, I provoked a bit of a comprehensive vs. mat teachers discussion, with the previous post that I wrote. I have no interest at all in supporting or defending diploma courses in Pilates that require very little actual practice of the method, or that offer certification in a short time. I remain uneasy about attempts to make a strong distinction between mat teachers and comprehensive teachers, because I think our job is to teach people to move well. We will, all of us, bring our unique life experiences to the teaching party and whilst many comprehensive teachers may enjoy an ‘edge’ from their experience of the Reformer’s resistance (and I think you’re a fool if you’re a teacher and you haven’t made an effort to experience the apparatus), I do not believe that we are all inherently better teachers of movement than teachers who are not certified in teaching on the equipment.

As an example, I learned more about working my upper back extensors when trying to squat while holding a weight overhead than I did in years of Pilates repertoire both in the studio and on a mat. That doesn’t mean that I give up on using Pilates to teach people back extension, it means that I’ve got something else up my sleeve AND that someone who has done overhead squats (my CrossFit coach, for example) may be at least as good as me at teaching someone to use their upper back extensors. That may be true of a Pilates teacher ‘only’ trained in the mat work.

So is my claim that my job, as a Pilates teacher, is to teach good movement legitimate?

 

Or, don’t have your feet on the ground

I admit to owning some MBTs once, so I understand the seductive power of shoes that are said to improve your posture (there’s a number of things about my past that I’m not especially proud of…). More recently I’ve used this blog to question the use of technology to ‘fake’ a natural situation in pursuit of a solution, rather than accepting the naturally available solution. Of course, there’s often money to be earned from this kind of virtual reality. In the case of shoes, the rationale seems to be: “There’s a problem with your body – your muscles don’t work like they should, because (unlike a Masai warrior) you’ve been disconnected from the ground. Don’t worry, we’ve come up with a way to make your body work better – by tricking it into action.” (For only X amount of £s/$s)

I think I was more eloquent last time I touched on this, so apologies. I was motivated to revisit the subject by someone that came to one of my classes today. She was wearing some brightly coloured Reebok shoes, that served to highlight the degree to which her feet pointed outwards (“Walking like a duck” in Kelly Starrett-speak). When I spoke to her, as a new participant in the class, she told me that she has knee pain. Unfortunately for her, not surprising at all – we’ve probably all seen similar: thighs rotated in, shins rotated out, and arches collapsed. Easy to imagine that she has lower back pain too. Perhaps that’s why she bought the Reeboks, that I discovered were ‘EasyTone’ (“our EasyTone Essential walking shoe features built-in balance pods that transfer air in response to your stride and create micro-instability with every step.”) There’s a great scenario – someone who is putting excessive rotational force through the soft tissue of her knee joint with every step, because of her leg alignment, wears shoes to increase the instability for her already collapsed feet.

Clearly there are many people wearing MBTs, Fitflops, Shape-Ups and Easytones (there are probably other brands too) who do not have the same structural/alignment challenges, yet the logic still escapes me. Why did I ever think that interfering with the interface between my body and the ground was a good idea? Why did I think that elevating my feet further from the ground would be better for my proprioception and muscle activation?

Just as Michael Jordan asserts in the video clip above, it’s not the shoes! The ‘secret’ is to get your feet on the ground – your hip muscles will work better (and give support to your spine) if your feet work better – It’s not the shoes!

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?

71064I have heard Kelly Starrett describing functional movement as ‘a wave of contraction from core to extremity’. This seems to fit very well with the theory of local and global muscles. The idea that we need to stabilise our spine prior to loading/moving is embedded in Pilates. It is easy, too, to find ‘scholarly articles’ on the internet (Paul Hodges, to name one author) exploring this idea, and correlating poor stabilisation in anticipation of movement with lumbar disfunction and injury.

It all seems very logical, but could it be flawed? Things seen in a lab may not have a strong relationship to ‘real life’. The fact that turmeric added to cancer cells in a Petri dish has a measurable negative effect on those cells, does not equate to consumption of turmeric ‘killing’ cancer cells in a living body. Similarly, the research that supports the concept of an anticipatory, local muscle stabilisation strategy may struggle to replicate real life situations, simply because it’s hard to measure a lot of human activity whilst accounting for variables. I imagine it’s really hard to wire someone up to any kind of measuring device and gain significant data if they’re engaged in anything other than fairly pedestrian activity. One of the challenges to the straightforward ‘centre-to-periphery’ concept that I’ve had is its failure to take into account the influence of part of our body coming into contact with the ground, or some other surface. That contact will send feedback to our brains, perhaps triggering further stabilisation strategies, for further anticipated movement or force through the joints. Therefore, the periphery is triggering the action at the centre. Where does that leave our ‘wave of contraction’? Is it blown out of the water, or can it be salvaged?

In the last couple of weeks I met two people who, separately, caused me to start to ruminate on this. One was explaining that her strategy for getting from sitting on the floor to standing was the way it was (alarming, I thought) because she had issues with both her foot and her knee. She was endeavouring to find stability in her foot, and then her knee – working from periphery to centre – on the basis that she needed to have a stable foundation of foot-to-ground before she could stabilise more proximally. It kind of makes sense – you can’t stand a vase on a wobble-board. The other instance was someone who, to my eyes, clearly had habitually internally rotated femurs and matching externally rotated tibias, and was talking about the orthotics that her podiatrist had recommended/prescribed. The podiatrist was apparently relatively disinterested in what was going on at this person’s pelvis (i.e. hip joints) because the thing that needed dealing with was her point of contact with the ground. It felt like a mini-epidemic of periphery to centre thinking. And again, there is a certain logic to this – the lady in question had knee pain. Every time she planted her foot on the ground her inability to stabilise her foot caused an inappropriate load at her knee joint, ergo: stabilise the foot with orthotics.

I should perhaps acknowledge at this point that I’m not at all a fan of orthotics. I can see that they may be a stepping stone toward getting someone’s joints into better positions, but they aren’t a substitute for actually sorting out alignment and strength issues that can have a lasting effect. I’ve worked with too many people who have orthotics for life (i.e.. someone in their 60s who’s had orthotics since their 40s). It seems akin, to me, to putting someone in a neck brace as a long term solution for poor control of their head position.

So, do we have compelling evidence to support an argument that stability actually works from the periphery to the centre (and then back out again)? I don’t think so. In both cases the idea is that a stable point of load, or contact with the ground, is more significant than a stable trunk. I can only assume that the idea is that in that case the trunk will take care of itself. I’ve used the workshop “Pilates Made Simple” to explore the idea that there are three basic demands of any Pilates exercise (that, of course, relate directly to real life) – these are: Stabilising your spine/trunk while moving your extremities; sequentially articulating your spine; and transferring load from your extremities to your centre. The latter is the one that I’m most interested in here – it seems to me to be fundamental to what we teach in Pilates, to functional movement, joint health, longevity etc.

In order to transfer load from your foot to your centre (core, if you like) you need to have control over all the joints in between. If there is a ‘break’ in that chain of force transfer then the load gets absorbed by the more distal joints. This is easy to see in people doing all fours exercises who are not able to effectively stabilise their shoulder blades against their ribcage and consequently feel the load most in their wrists and elbows. (When training I learned that, if a client was injured, Pilates always worked away from the problem – Kelly Starrett talks about “upstream” and “downstream” implications of poor positioning/control. I think the ‘fix’ for an elbow problem will more often than not be found at the shoulder than the wrist – proximal, not distal.) In the medially rotated femur/laterally rotated tibia/orthotic scenario, the orthotics may wedge the foot into a better shape but this won’t transfer into improved hippo control. However, working on laterally rotating at the hip joint whilst maintaining a straight foot (please try this yourself) will have a significant effect on foot activity. This is (for me, at least) very challenging to achieve in open chain exercises, but working on closed chain exercises on Pilates apparatus and standing work in mat classes, seem to really help to manage knee/ankle/foot alignment in open chain exercises.

The short version of all of the above: Yes, feedback from our periphery is instrumental in establishing positions, but we cannot effectively create stability and control from the periphery to the centre, it HAS to work the other way.

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Image courtesy of hdwpapers.com

I would generally be the first to agree that the world looks in bad shape at the moment. In spite of this, and Matt Ridley’s ‘The Rational Optimist’ it seems evident (certainly from the perspective of non-human populations) that there are too many humans on the planet. Social injustice, the tsunami of obesity, environmental catastrophes…the list could go on for a while, and lead us to conclude that the outlook is very bleak.

And yet we are living in an era of unprecedented access to information – to the extent that I can hardly believe what’s available to me at little to no cost. Of course, we have to exercise some discretion, as some of the free information that’s available may be less than entirely reliable. Perhaps it’s safer/more accurate to say that we have unprecedented access to expert opinion, and the beauty is that it appears that applies to almost any subject one can imagine. For instance, my particular bent is for information in and around the spheres of primal lifestyle, ancestral health, functional medicine, paleo nutrition, optimising human performance, exercise physiology, weight-lifting etc. If, however, your interest is in antiquarian books, veganism, numismatism, natural history, chemical engineering…. I’m sure that your interests are being equally well served. 

The torrent of interesting material is sometimes overwhelming, and I’m rapidly coming to the conclusion that downtime in front of the television will have to go in order for me to keep up with all the reading – not to mention all the ‘watch later’ YouTube videos. TED talks are one of the best examples of our easy access to expert opinion. Some of my favourites are: The real reason for brains; Why things hurt; Why bodybuilding aged 93 is a great idea; Minding your mitochondria (or, how I cured my MS). Most of these talks were not found through my own searching, but through social media which, despite all it’s flaws, I have to concede is a phenomenal tool. In the main, I use it to ‘follow’ various people whose work and opinions I’m interested in, many of whom will regularly post (aside from their own writing) links to videos, details of scientific papers, links to other interesting websites, and so on. (This is also how the volume of stuff to try to keep up with spirals beyond my reach).

The other aspect of social media that’s especially exciting is that we can get instant feedback on ideas. For example, for convoluted reasons, I was reading an issue of ‘Power‘ magazine recently (yes, there’s an article by Kelly Starrett in there) and one of the powerlifters being interviewed was talking about the value of Facebook in developing a new training system. He can post training ideas and get feedback quickly and directly from the people who are trying out his ideas – it’s like simultaneous market and scientific research, in a way that would have been impossible 10 years ago.

Podcasts are another source of joy for me, particularly on long car journeys. There are probably some that you have to pay for, but the ones I’ve wanted to hear have been free. I have learned about nutrition, biochemistry, business management, teaching/coaching, evolutionary biology, neurology, and on and on – all by listening to episodes of not more than 6 different podcasts. On top of this, listening to various people talking on these podcasts has led me to authors whose books would otherwise not popped up on my radar: John Yudkin, Atul Gawande, Nassim Taleb, Tim Ferris, Weston Price, Dan John. I’ve not included links to all of these because you can easily look these people up if you’re curious. The point is that there is quite possibly information about subjects that you’re excited by freely available if you go looking for it.

It’s also easier than ever to ‘self-quantify’, to measure significant markers of lifestyle – tracking exercise, food, sleep etc. It’s quite possible that some people use the gadgets, and do very little with the data that they’re collecting (which might be considered a waste of money) but you could certainly use the data to conduct your own experiments into what changes in your lifestyle have positive or negative effects on you sense of wellbeing. In the UK we are behind the US a little, but hopefully it won’t be too long before we will have access to something like WellnessFX, that allows you, at relatively low cost, to get very detailed information about your own health markers, well beyond the readings from a conventional health check.

The short message: access to information to help you become amazing, to fulfil your genetic potential has never been so accessible. Do the right thing.