The article below is a modified version of an article written by Rob & Ash for the PAA, one of the industries bodies in Australasia.

Pilates and Pain - breathe, move, load and celebrate!

There are so many old expressions that spring to mind when we are talking about pain, particularly in relation to exercise. ‘Pain is weakness leaving the body’ is the classic one I grew up with in the rugby sheds of New Zealand. These expressions usually revolve around the fact that being in pain creates the opportunity for us to experience growth and pleasure. Now this may have been true to those who originally made those statements, but if we are talking about pain in relation to the human body and movement, there are a few extra things to consider before pushing through to the glory we've been promised.

At its most basic, what is pain? I’ll reflect on a lecture we recently had at Movementality from Dr Della Buttigieg, an osteopath and pain science specialist: “Pain is a mutually recognisable somatic experience that reflects a person’s apprehension of threat to their bodily or existential integrity”1. This differs from nociception, which is the chemical signaling we experience in relation to a potentially harmful stimulus. So in layman's terms, we are perceiving an array of signals from our brain that something potentially isn’t right. The important word here is ‘potentially’. Pain can signal tissue damage or trauma, but it can also send off these signals way earlier to warn us of potential damage which most likely hasn’t happened yet.

I always find it helpful to remember that pain is the result of pre-programmed and developed reactions in our psychology and physiology that have to be triggered and transmitted via chemical reactions. Why is that important? We already know that the body becomes accustomed to things it experiences and does a lot. So, if your brain is constantly firing off signals that you’re potentially in danger, then it becomes predisposed to expect to be in pain. Similarly if you have injured a particular area in the past, your system’s tolerance for stress to that area drops significantly and so your brain will fire off warning signals to stop long before there is any risk of actual injury. This is what often leads to what many classify as chronic pain. I will add that this can occur at both the physiological and psychological level, both impacting and playing off the other to create a cycle which is often hard to break out of. 

The in’s and out’s of pain are far too complex to pull apart in a single article, and there are a bunch of amazing practitioners out there who have already put together excellent resources around the topic. Specifically, check out the work of Butler and Mosely if this is your first venture into this topic, and their book Explain Pain. Next we’ll touch on how we work with pain at Movementality to give you some tools to work with it in clients of your own.

Relax and Breathe - it will be okay

The first thing you can do to disarm the body against both acute and chronic pain is to create a space for the system to relax and breathe. Now that seems obvious enough, but it’s something we find a lot of people are missing out on. The next step is to breathe and pay attention to your body. We are aiming to move from a fight or flight response to a parasympathetic/relaxed state. Then we want to notice sensation, as opposed to pain, by asking to feel more deeply into your body and reveal more information as to what might be going on for you.

Now that you’re relaxed, it’s time to move!

This is where Pilates apparatus is fabulous. Regardless of whether pain is acute or chronic, the best starting point is to show the person that they have a body that can move pain free. The more positive movement experiences they can have in their body, the more likely they will be able to find pathways out of pain over time. The easiest way to provide these experiences, is to let the equipment do the work for you, taking your joints through passive range of motion. By passive, I mean that they have to be relaxed as much as they feel they can, and then we can start to gently move the focus area either with our hands, or through the use of the apparatus. When pain signals start to fire off, you pause - wait and see what happens. If they can relax, you may be able to go further, or it may be time to back off. But everytime you show their brain that they can move pain free, you’ve proved to them that movement in that area is possible - another battle won.

Apply Load

Once you have experienced pain free movement in a passive way, it’s time to load the area up a little. The best way I find to do this is with isometric holds. Starting in pain free positions, adding a level of load you can maintain for 10-20 seconds without compensating in other areas of the body. Gradually test the range - even by just doing a isometric hold, then moving the joint passively through it’s range again to show the brain that with the load initially stabilising the joint, it’s okay to relax even more as you have more strength than you realise. Then you can start to load up in different ranges - be careful to keep going between safe and testing zones though. If you keep pushing and pushing, you’ll over do it. We find the ‘less is more’ approach often helps organise the body at a deeper level, rather than a ‘push push push’ approach which can create unnecessary compensations you have to then try to undo later down the track. 

Celebrate the wins!

Because pain isn’t just a physiological experience, it’s important to openly celebrate the wins when they come, particularly when working with chronic pain. We will try to highlight what you’ve learnt is not just an exercise or two, but a safe strategy that you can trust. Most importantly, we make sure you acknowledge that you are the person who made it happen - we didn’t fix you, we just facilitated an opportunity for you to make the change. 

Good luck

Don’t beat yourself up, as there will be setbacks, especially initially as you try to navigate what is possible. Use positive reinforcement and language and remind yourself regularly that you can trust your body to look after you by re-highlighting all those times that you did have a win. The rest comes down to considered and clever programming at our end to gradually increase range and load, and build in variety of movement to help build you robustness. Keep the feedback coming as we’ll leverage off it to provide more options around how you can keep building on the safe strategies. Your everyday life will do the fancy stuff for you in terms of building reflexes if you build solid, foundational movement patterns that you can trust such as breathing, crawling, squatting, lunging, twisting and hanging. 

Pain is a tricky beast, and there is no single way to work with it. What we’ve outlined is what’s helped us significantly and consistently, but even within that there have been rogues and non-starters who just don’t improve for any number of reasons. In these cases, the best thing we can hope for is to not aggravate them, and to build in joy during the sessions and eventually they’ll be ready to tackle their pain head on. We’ll just keep the space open and friendly, keep asking the right questions and celebrating the wins where we can. 

References

1. Cohen, Milton; Qunitner, John; van Rysewyk, Simon. Pain Reports: March 05, 2018. Doi: 10.1097/PR9.0000000000000634

Acknowledgements

Dr Della Buttigieg is an Osteopath in her own business, Melbourne Osteopath, a Pain Science lecturer at Victoria University, as well as affiliations with numerous pain science resources. 

Exercise pictured was originally shown to us by Bruce Hilderbrand.