Last month, Sarah and I attended the American Physical Therapy Association's 2018 NEXT Conference and Exposition. As a rehabilitative Pilates instructor I was especially interested in the sessions focused on the integration of the movement system for pain management. A holistic approach to care has played a large part in my personal practice and beliefs of the rehabilitation process. A localized musculoskeletal injury is not the only factor that shapes our relationship with pain, so we should be looking at the whole body during treatment. I attended several lectures that offered ideas for how the holistic model can help alleviate pain in a more efficient and effective manner. If we look at the biomechanics, neural, physiological, and behavioral properties of the movement system, we can develop a unique plan of care to improve the problem from its source. So now the question is this: In the realm of my practice with clients, how do we navigate the spectrum of localized care and whole body attention together?
If there is one thing I’ve learned through teaching over the last five years, it is that you do not need to follow conventional wisdom or a traditional course of treatment. Rehabilitation fields can only progress if we are forward thinkers. As Laurita Hack, PT, DPT, PhD, MBA, FAPTA stated in the 49th Mary McMillan Lecture, we can make good, safe decisions with the information in front of us; this doesn’t ensure a positive outcome. There is no single correct or successful path to take with a client. This is why collaboration between practitioners and modalities is imperative. I often see clients while they are also attending weekly physical therapy sessions. I always spend time learning about the other therapist’s treatment plan so that I can design a course of action to compliment their method. The cross-fertilization of ideas and actions offers the client a wide range of tools for long term success.
The collaboration doesn’t end with the rehabilitative professionals. The client or patient must also act as a partner and collaborator in the healing process. It is our job to encourage such participation. The pain they feel is the result of their brain’s opinion of a perceived threat. We are not surgeons or pharmacists so our main goal is to help remove the threat leading to pain. Now what if I said the threat was more than just a musculoskeletal injury? Everybody has physical, mental, and emotional factors that can affect their experience with pain. The individual is also further influenced by their environment and a larger social context. Sleep habits, eating habits, personal relationships, work, stress and anxiety, family, genetic makeup, politics, geography, and fear are all examples of factors that play a role in the way we perceive pain. Our job as Pilates instructors and physical therapists is to help identify possible internal and external factors that may be leading to increased sensation of pain as we treat the musculoskeletal injury. If your client or patient is willing to work with you to make changes for a more balanced lifestyle, there is a full circle of collaborative effort for holistic care.
Now how can we ensure that our clients and patients get better and STAY better? By treating the person rather than the pain or injury, we are educating our clients on long term well-being and giving them tools to balance their lifestyle. We offer the coping skills to manage the brain’s perceived threats and therefore lessen the chance of pain. We also show them how to stay physically active safely and efficiently. We must not tell our clients and patients what to do and we cannot follow them home every day to ensure they are making good choices. However, it is our job to educate and motivate these individuals to make holistic lifestyle changes for themselves. That is the key to long term success.
An Example Case Study:
After the conference, I was particularly excited to integrate my new pain management toolkit into my sessions with Ryan*. Ryan first came to me with chronic pain in the neck, shoulders, and low back. After several years of doctors visits and scans all coming up clear, he had pretty much given up hope on relieving the pain. As I have gotten to know him over the last few months, I have evaluated the physical, mental, and emotional factors that may be leading to Ryan’s chronic pain. The first red flag for me was the language Ryan used when he talked about his pain. He used phrases like “My traps just always hurt,” and “My low back is tight, but what else is new.” Ryan was holding onto the idea that he couldn’t be helped and had a fear that the pain could worsen at any point. I knew the anticipation of feeling pain was likely contributing to the severity of the pain itself. Don’t get me wrong, there are definitely muscular imbalances in the thorax, shoulder girdle, and pelvis. However, the negative self talk in combination with a reservation about Pilates has resulted in slow change. As the instructor, I have been working on introducing phrasing that supports a more positive outlook on pain and taking notice of what feels good!
I have noticed that the pattern of tightness follows a couple specific myofascial meridians. Pilates is great for full body kinetic chain work so we have incorporated closed chain exercises such as scoop back roll back and exercises that can be done in both open or closed chain format like footwork. The scoop back roll back challenges Ryan’s ability to connect the superior and inferior body halves. He is still working to maintain the c-curve in his spine while letting the tactile feedback of his hamstrings on his hands connect him to his deepest abdominal muscles. The scoop back roll back also challenges him to rotate his pelvis around the heads of his femurs which has proven to be challenging in many different exercises. The footwork on the reformer is a closed chain exercise which allows me to recognize poor biomechanics and challenges Ryan to use multiple muscle systems in coordination. This has been a big help with addressing muscular imbalance in the hips. We have recently tried this exercise in an open chain format on the mat. Ryan’s goal for this exercise is to move the legs independently of the pelvis so he is working on abdominal stabilization and pelvic floor function as it relates to breath.
The myofascial network tightness is also something I’ve been working to address through manual therapy. My goal is to help him release the fascia so he can find more mobility with less pain. From there, we can work to address muscular imbalances in his thorax and shoulder girdle. One thing I’ve attempted to navigate is the desire to overuse manual therapy. Although it can decrease fear and diminish the threat of pain, a passive therapy technique doesn’t address the muscular imbalance. As we work on integrating the pain free mobility after manual release, we look into active muscle control with exercises like prone head turn and swan. These both offer activation of the posterior chain with a lengthening of the anterior chain. Ryan is able to activate his scapular stabilization muscles while also stretching his pectorals which routinely pull him forward into poor posture. The anterior stretch also helps lengthen his sternocleidomastoids which often act in restricting his day to day movement.
So far, Ryan has made good progress with pelvic stability and alignment and has managed to greatly decrease his low back pain. As we continue working together, we are hoping to find the same success for pain relief in his shoulders and neck. The use of spinal extension and posterior chain activation seem to be working so far, but the results are slower than Ryan or I would like. I tend to find these postural issues most frustrating to tackle with clients because as soon as they walk out of the studio, most people hop right onto their phone and computer and fall back into poor postural habits. However, Ryan has brought it to my attention that he is much more aware of his body throughout the day and makes a conscious effort to maintain a stacked spine and open collarbone. Ryan and I will continue to work holistically on modifying the biomechanics, neural, physiological, and behavioral inputs of the movement system, so that the output becomes a pain free lifestyle.
*Name changed for confidentiality
Referenced Presentations from the 2018 APTA NEXT Conference and Exposition:
49th Mary Mcmillan Lecture: Wisdom and Courage: Doing the Right Thing
Laurita Hack, PT, DPT, PhD, MBA, FAPTA
Integrating the Movement System Into Practice, Developing Diagnoses, and Movement Analysis
Lois Hedman, PT, DScPT, MS
Patricia Scheets, PT, DPT, MHS, NCS
Eric Schoenberg, PT, MSPT
Theresa Spitznagle, PT, DPT
Pains, Brains, and Strains: The Pain Science and Tendinopathy Gap
Kenneth Kirby, PT, DPT
J.J. Kuczynski, PT, DPT
Don’t Believe Everything You Think: Cognitive Biases in Practice
Timothy Rethorn, SPT
Zachary Rethorn, PT, DPT, Board-Certified Specialist in Orthopedic Physical Therapy
ASK PILATES PT
Having difficulty finding the right position during exercises? Don’t understand a recent medical diagnosis? Want to know how to target a problem area? You have questions, WE have answers! Don’t hesitate to email askpilatespt@gmail.com!
With Love, Scrubs, and Sidekicks,
