What is Clinical Pilates?

Full disclosure: I teach a clinical Pilates course. I’m also an exercise physiologist.

I read the interview with Craig Phillips in August, and I have to say I disagree strongly with just about everything Craig says in the article. Here is my response:

Is a specific diagnosis useful for people in pain?

My disagreement with Craig is as follows. He implies that a clinical Pilates instructor requires a detailed understanding of pathology in order to correctly diagnose a client and avoid damaging them.

This kind of thinking is simply out of date. The current Australian NHMRC guidelines for treatment of musculoskeletal pain have been around since 2003 (before the first iPhone) and were last updated in 2015. They state:

‘A specific patho-anatomic diagnosis is not necessary for effective management of acute non-specific low back pain’ and ‘The most effective treatments are advice to stay active, heat and behavioural education’
(Brooks et al., 2003, p. 4; quoted in Schug, Palmer, Scott, Halliwell, & Trinca, 2015).

The most recent version of the guidelines go even further:

‘Information should be provided to patients in correct but neutral terms with the avoidance of alarming diagnostic labels to overcome inappropriate expectations, fears or mistaken beliefs’ (emphasis mine)
(Schug et al., 2015, p. xlv)

We have also known for a long time that the vast majority of back pain is not attributable to a specific pathology (Schug et al., 2015). Pain that is not caused by a specific pathology is called non-specific pain.

Non-specific pain accounts for around 95% of all back pain (Schug et al., 2015). Yes, around 5% of people do in fact have a serious medical cause for their pain, so it is important for practitioners to screen clients for red flags (indicators of serious pathology) and refer where required. Just like we screen for terrorists at the airport.

And just like in screening for terrorists, the chance of an adverse event is vanishingly small; you’re actually three hundred and ninety times more likely to die in the cab on the way to the airport than from a terrorist attack inflight (Wilson & Thomson, 2005).

Yet in the case of terrorism, as in so many other areas of life we exaggerate the probability of highly emotive threats, even when in reality they are extremely unlikely to occur (Sunstein, 2003). This is a well-documented phenomenon in psychology called probability neglect.

We’re all afraid of the high-profile risks like terrorists, spider bites and shark attacks when we should really be afraid of obesity, a sedentary lifestyle and motor vehicles.

So it is with red flags in clinical Pilates. You pretty much don’t see a single spinal tumour or cauda equina syndrome from one year to the next, whereas we see people with non-specific low back pain every day. But we exaggerate the risk from serious pathologies, because they are scary.

In reality, almost everyone we work with has non-specific pain. People with non-specific pain are our bread and butter. We should spend most of our time thinking about what we do for people with non-specific pain.

We have already seen that a diagnosis is not helpful for these people. But what about exercise prescription? Do we need to prescribe highly specific rehabilitation exercises to avoid damaging people with non-specific pain, or even people with specific pain, say caused by a disc prolapse, shoulder impingement or a rotator cuff tear?

No, we do not. And there is an impressive amount of evidence to support this (see below).

Should we be giving specific exercise to people in pain?

Craig seems to have developed a specific protocol for his clinical Pilates method. However, this does not define best practice in clinical Pilates or in movement rehabilitation. Rather it defines his particular system. And based on current evidence his system is unlikely to be more effective than any other form of exercise.

There is quite a bit of evidence showing pretty much any form of exercise is equally beneficial for pain. This includes walking, general progressive resistance exercise, Pilates, motor control training and heavy deadlifting – they all work about the same. And not just in lower back pain. In pretty much any area of the body that has been studied. Including people with specific pain from rotator cuff tears, disc bulge and shoulder impingement. There are numerous systematic reviews to this effect (Azevedo et al., 2017; Hayden, Van Tulder, & Tomlinson, 2005; Searle, Spink, Ho, & Chuter, 2015; Shire et al., 2017).

Exercise does help musculoskeletal pain. But apparently just getting moving is the important part. How you move doesn’t really matter.

What is current best practice in working with pain?

Finally, and again from the 2003 Australian national guidelines (reinforced in the current guidelines), the factors that predict progression from acute to chronic pain are all psychosocial (Brooks et al., 2003, p. 4). Psychosocial factors like depression, fear, expectation of poor outcome, low self-efficacy, stress, poor sleep, fear-avoidance and negative pain beliefs are better predictors of outcomes than an MRI finding or structural diagnosis.

Our current guidelines define best practice in working with the 95% of people whose pain is nonspecific (Schug et al., 2015, p. 306).

The most effective interventions are very simple:

• heat
• advice to stay active
• behavioural coaching (to get active)
• most importantly addressing yellow flags such as low physical activity, poor sleep, stress and negative pain beliefs

That’s it. Current best practice in managing musculoskeletal pain. Put a hot water bottle on it, get moving and don’t worry about it. All of this can be easily done by someone with sound basic training and an awareness of current best practice.

Can we damage people by giving them the wrong exercise?

There is no evidence that any form of exercise is potentially dangerous or harmful for people with nonspecific low back pain (or shoulder, neck, knee or hip pain). Quite to the contrary, exercise is good. Even painful exercise is good.

A recent systematic review and meta-analysis found that exercising into pain actually leads to BETTER outcomes, at least in the short-term, with no difference in the long-term between painful and pain-free exercise (Smith et al., 2017).

Injury risk seems to be very poorly related to exercise technique, or exercise choice. The major risk factor for injury is a spike in training load (Gabbett, 2016). So it’s more about how much you do, rather than what you do.

In conclusion

• In the absence of red flags a specific patho-anatomical diagnosis is not useful in treating people with musculoskeletal pain.
• There is a lot of evidence showing very low risk in working with people with nonspecific pain.
• Current guidelines and a large amount of research support the approach of:

– just getting people moving
– reassuring them and
– coaching them to replace their negative beliefs with more positive ones

Oh, and put a hot water bottle on the sore bit.

If the getting them moving part is in the form of Pilates, I would call that clinical Pilates.

Raphael Bender
PAA member, Founder & CEO of Breathe Education

 

(Disclaimer: The PAA invite discussion on many topics and respect the varied views and opinions of our members. However, printing and sharing of such articles should not imply endorsement of any particular point of view.)

References

Azevedo, D. C., Ferreira, P. H., Santos, H. d. O., Oliveira, D. R., de Souza, J. V. L., & Costa, L. O. P. (2017). Movement System Impairment-Based Classification Treatment Versus General Exercises for Chronic Low Back Pain: Randomized Controlled Trial. Physical therapy.

Brooks, P., March, L., Bogduk, N., Bellamy, N., Spearing, N., Fraser, M., . . . Blyth, F. (2003). Evidence-based management of acute musculoskeletal pain: Australian Academic Press.

Gabbett, T. J. (2016). The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med, bjsports-2015-095788.

Hayden, J. A., Van Tulder, M. W., & Tomlinson, G. (2005). Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Annals of Internal Medicine, 142(9), 776-785.

Schug, S. A., Palmer, G. M., Scott, D. A., Halliwell, R., & Trinca, J. (2015). Acute Pain Management: Scientific Evidence (4th edition). Melbourne: ANZCA & FPM.

Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical rehabilitation, 29(12), 1155-1167.

Shire, A. R., Stæhr, T. A., Overby, J. B., Dahl, M. B., Jacobsen, J. S., & Christiansen, D. H. (2017). Specific or general exercise strategy for subacromial impingement syndrome–does it matter? A systematic literature review and meta analysis. BMC Musculoskeletal Disorders, 18(1), 158.

Smith, B. E., Hendrick, P., Smith, T. O., Bateman, M., Moffatt, F., Rathleff, M. S., . . . Logan, P. (2017). Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med, bjsports-2016-097383.

Sunstein, C. R. (2003). Terrorism and probability neglect. Journal of Risk and Uncertainty, 26(2-3), 121-136.

Wilson, N., & Thomson, G. (2005). Deaths from international terrorism compared with road crash deaths in OECD countries. Injury prevention, 11(6), 332-333.