Juan Nieto PT, DO, NCPT is the director of Polestar Spain and a frequent international lecturer specializing in rehabilitation through movement and athletic performance. In 2016, along with Brent Anderson and Blas Chamorro, Juan founded RUNITY, a start-up created with the purpose of transforming the Running industry by providing runners with the tools and knowledge they need to practice “painless running”.
Brent Anderson PT, PhD, OCS, NCPT, Polestar Founder. With over 30 years of experience in rehabilitation and movement science, Brent is passionate about the power positive movement experiences have in changing the world. Early in his career as a Physical Therapist with a specialty in dance medicine, he discovered the power and efficacy of Joseph Pilates’ mind-body work to expedite rehabilitation outcomes. This early testament to the power of the Pilates Method inspired him to create a program that merged the worlds of traditional rehabilitation with the mindful movement that Pilates provides.
JN: The results of our survey match the prominent studies on chronic pain, and we often see the knee having prominence in chronic pain.
BA: Our work together with RUNITY has shown us the most common causes of knee pain in runners, which are lack of dorsi-flection, hip external rotation, and thoracic extension. When we look at society’s sedentary lifestyle, it’s no wonder we see knee pain across the board.
JN: If you look at the load management model where there has to be this balance between the load which you apply to the tissues, and combine this with the idea of movement distribution and segmental movement, it makes a lot of sense. When there is a lack of movement somewhere there has to be excessive movement somewhere else, especially in places like the low back and knee (hinge stable joints).
Is chronic pain a measure of tissue damage? No, pain does not equate to tissue damage, and typically anything over 3 months is considered chronic by definition.
JN: Most of my patients have CLBP for 3 or more years and I see a significant amount of clients for this reason. How can we really get a whole perspective of what is going on with clients with CLBP?
We cannot help everyone. We need to accept that there are some patients that we may not be able to help – we may not know enough, and it may not be a perfect fit. Your interventions will work sometimes and other times not, and we need to be ok with that. We all have our own limitations.
The body will heal, especially in the beginning, as in the first episode of back pain. You will be better in a week and maybe the second one as well. By the 20th episode of back pain, things become more complex and that is when the client is usually referred to a physical therapist.
The best thing you can do is deal with the acute situation or manage the pain well and do not allow it to escalate to a chronic situation.
BA: One of the models in the US I admire most is the military model of dealing with low back pain, in which the first two weeks of early intervention are spent differentiating and managing the symptoms. Many of the people in this situation get better and do not need MRI’s, medical injections, surgery, or pharmaceuticals.
JN: We live in this world in which pain is something we think we need to eliminate. Think about the world “Pain Killers” – as if zero pain is the only valid amount of pain. I think that this is a poor framework.
If you truly want to kill pain and reduce pain to zero, and this is the goal of your therapy – you are going to fail…
This will not be a successful process. However, you must understand that pain is something that your body has in order to tell you that there is a potential threat to your health.
Stop chasing the “magic exercises” and “magic recipe” of what to do with your clients who experience low back pain – it does not exist. People ask me “what is the best exercise for low back pain?” To me, this is like asking me “what is the best food in the world?” – who knows! It is entirely individual and a silly question to ask because it depends on the person and the moment. One exercise can have a beneficial outcome for one person and a negative outcome for another.
Every time you see a thing on the internet like “exercises to fix back pain” – Run Away! Or at least keep scrolling.
This will result in confusion, and can you imagine people attempting to do this magic exercise with their clients without understanding why they are doing it?
BA: So many people write to us asking “what exercises do I do for clients with low back pain?”. Ten people could have the same degenerate disease diagnosis with completely different exercise selections. Like Juan said, there is no magic recipe. But we can help you with things like your critical reasoning skills and asking the right questions.
Critical Reasoning Skills:
- Is this a coordination and awareness problem?
- Is this a behavioral problem? They could change the behavior and the problem goes away.
- Is this a load problem? Perhaps they are not conditioned to handle the load in the lower back for longer than 10 minutes.
- Is this a mobility issue? Perhaps the client only moves from one place and has the strategy of moving from this certain place in their spine.
I have had so many experiences where I do bridging, some pelvic tilts, and breathing exercises to help a client learn to move from one or two more segments in their back and my patient says “wow I feel 50% better”. For more on critical reasoning with Brent click here.
You have to keep in mind that low back pain can be very different for each individual. There are times when two of my clients have the same diagnosis and I know there are differences in the individual’s work, relationships, stress, previous injuries, or beliefs, that interfere with their movement and create different paths to treatment for two clients with the same diagnosis.
JN: You need to have the mindset of “let’s see what happens” when you prescribe exercises to a client. There is no such thing as a certain exercise that will fix a problem with a client. As movement instructors and physical therapists, we must become comfortable with this uncertainty.
In my online course on chronic low back pain, of which I receive terrific feedback from my students, you know what? The course does not have any exercises in it! This was a deliberate decision that I made. I can’t go and throw exercises into an online format course for teachers to attempt to use if they don’t understand back pain and what they are dealing with. Treatment of low back pain needs to be based on the movement principles, assessment, interview, ICF model, and understanding of all of the variables and things that influence a client’s pain.
What is the ICF model? International Classification of Function and Disability model developed by the World Health Organization (WHO).
BA: We use the ICF model a lot at Polestar and it is particularly used by physical therapists and medical practitioners around the world. It is used to classify a person’s physiological, functional, activity, and participation limitations.
At Polestar we put a big emphasis on “participation” in our assessment. We ask the client “what activities do you believe you should be able to participate in?”. Maybe the response is “cycling 50 miles” or “hiking Mt Kilimanjaro”. Then as a movement instructor, I need to go seek, learn and discover what those activities require in my client’s body. Then I can assess my client and look at where they currently are and where they believe they should be. There is no “miracle sequence” you do twice a day, three times per week.
JN: There is another huge group of questions we receive (on low back pain) regarding the influence of posture, biomechanics, muscle firing, recruitment patterns and timing, habits, and activities on low back pain. You may see some people with “bad” posture with pain and others with the same posture who don’t have any pain. This is a good reminder that there is really no such thing as good or bad posture for everybody. There will be certain movements, positions, and patterns that modulate and alleviate pain for some people that will also irritate and create flare-ups for others.
The wrong exercises for one person could be the right ones for another. We need to really “move with them” side by side, and together. Being together, learning together about their experience, and attempting to offer the little amount of movement that their system is able to accommodate. If you are able to do this, the compounding effect of 1% over and over can lead to very positive results.
So often people go to the physical therapist to be “fixed” and this is over the expectations of what the reality is.
They need to get a little new way to deal with their pathology to just change the trend slightly by 1%, this is the start. Chronic pain is a marathon and this is going to take time. Some people come into my clinic who have been experiencing pain for 10 years, and building this pain for 20 years and expect to see results in 25 minutes – which is entirely unrealistic.
What we can do is provide a new way of dealing with it, a more active plan based on what they can do, and what changes they can make in their lifestyle to make little improvements and change the tendency. Maybe we change the pain by 5%, but their perception of quality of life improves by 70% because just that little bit of relief or activity or the reduction of disability or their perception of disability makes a huge difference in their life – it’s like night and day. These small changes can give them hope and something to work on which is great.
BA: I refer to some of this as behavioral bias. Sometimes we keep looking for a mechanical, physiological, or structural bias, and often times it is a behavioral bias. So often a patient doesn’t realize when they are sitting that they are starting to hurt – after 30 minutes of sitting they need to change their behavior to know that it is an indicator to get up and move around and alleviate that pain that is starting to manifest – but it is that first warning sign they often miss.
JN: You cannot learn if there is no attention – when you are in pain your attention goes to the painful experience, your brain gets hijacked and your perception of pain is magnified. You need the behavioral and cognitive knowledge to examine “what is causing this to happen?”. Perhaps it’s a long time of sitting. Your body is telling you that something is not working well for it – you learn to think “what can I do to change this?”.
BA: Our best tools as movement practitioners are in the information the clients give us, not what we give them. I ask them “how do you feel when you are in this position and what have you observed in your body? What happens if you move your pelvis this way or another? What do you feel? Does it feel better or worse?
We need to move away from the sedentary world, get on the ground to play, listen to what the body tells us, and really respect that. When we’re sitting on the ground we’re changing positions every five seconds because our body tissues are telling us we’ve been in a position too long. A big step is to heighten the awareness in our clients of their own bodies – then they start managing their own symptoms. Their awareness often turns on at the stage of pain, and by this point, it may be too late.
If they can learn to identify something that is pre-pain, which they have tools to manage, they start to take responsibility and they have awareness of what is going on in their own body. The more they have these positive experiences, the more their brain will adapt to this to reinforce the new behavior. We all have our biases. Our experience influences us, but education can counter a lot of bias. Clients come in saying “this position is killing me, there is so much pain” and I ask them “Do you believe there is tissue damage or new tissue damage happening right now? Is something tearing, is something breaking?”. Usually, their response is “I don’t think so”, and I agree with them. If there is no new tissue damage then what do we need to be aware of? The brain is telling them that they need to be aware of their body and what is happening.
This “awareness education” is one of our superpowers as Pilates instructors.
If we’re telling our clients everything to do and what exercises are going to make them better, then we’re not really helping them as much as we could. I am always amazed at how well people move when they have to govern themselves in their own exercise regime.
JN: This is of course implicit in Pilates. In order to do a proper Pilates practice you have to align body, mind, and spirit – this is what Joseph said. When we are teaching Pilates we have a source and philosophy and we need to be aligned with the method.
You let the people move like Joseph did, and trust in the process (something I tell my clients often) – In the beginning when you start doing exercises you are simply investing. You may not really be able to see any immediate benefit from it for two or three weeks upon which after you gain a lot of benefits. In the beginning, especially if you are in pain, you are going to be putting forth a lot of effort and time to take care of yourself and noticeable improvement can seem very small. You have to remember you are investing and in a few weeks, you will see the accumulation of your efforts.
When you let the people move they tend to self-regulate and move well. When you teach in the style you mentioned, asking your clients questions in order to raise awareness in specific parts of the body, this is huge and an accelerated version of this.
If you are instructing all the time how your clients need to move, what they need to feel, how they need to breathe, and how many repetitions they need to do – I don’t think you have the same effect. Of course, they are moving and probably getting stronger but I don’t think they will be improving their movement skills or communication within their body.
It’s about letting your clients have the opportunity to be the protagonist of the situation while you guide them.
BA: When you look at motor learning and movement acquisition, there is a balance of external and internal feedback. In the beginning, it’s going to be a little heavier on the external feedback which is us as Pilates instructors, and as your clients progress into more of the procedural learning it’s going to be more internal feedback. What we see sometimes is this “cueing vomit” from new Pilates instructors which can just be too much information for your clients. We can do so much better when we think of that long-term plan and developing body awareness and mindfulness of their movement and being able to take one step at a time – “Just for today let’s start to get an idea of where your head is in space”. Through the different exercises, “where is the head?”. That internal awareness creates long-lasting change. When Joseph pilates talked about practicing Contrology every day, he didn’t mean going to a Pilates teacher every day – he meant something else.
Every Time You See “Exercises to fix back pain”…Run Away! is written by Polestar Pilates for blog.polestarpilates.com