You will certainly encounter clients with low back pain if you teach Pilates. Today we dive deep into what low back pain is, what factors contribute to low back pain, and how to work confidently with these clients. Tune in!
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ACSM Guidelines for Exercise Testing and Prescription, 11th Edition
Back pain halves in six weeks article: https://www.cmaj.ca/content/184/11/E613.full
Disc bulge occurrence rates in pain-free people: http://www.ajnr.org/content/ajnr/36/4/811.full.pdf
Strengthen the Person, Not Just the Body Part: https://strengthentheperson.com/book-page
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[00:00:00] Welcome to Pilates Teachers' Manual, your guide to becoming a great Pilates teacher. I'm Olivia, and I'll be your host. Join the conversation and the Pilates community on Instagram at @pilatesteachersmanual and visit buymeacoffee.com/OliviaPodcasts to support the show. Today's chapter starts now.
[00:00:56] Hello, hello everybody. Welcome back to the podcast. [00:01:00] Today we're diving into working with clients with low back pain, especially chronic low back. And this is going to be a wild ride from start to finish, because we're going to look at why you want to know about working with people with back pain, sort of some theories about pain that might blow your mind. They definitely blew my mind. Um, some strategies that you can use when you're working with these clients. As always some fun facts about why Pilates is great for everybody, including, uh, people who are experiencing back pain.
[00:01:42] If you have worked with the general population, definitely in the United States, I assume it is similar elsewhere. There will be people who come to your class, who, when you ask them how they're doing what's happening in their body, anything you need to know about. They will say, oh, I've [00:02:00] got some back pain. I've had it for 15 years. I've had it for three years. All it's been like this for six months, something like that. It's a very common, it's actually the most common reason that Americans miss work and go on disability is because of back pain.
[00:02:17] And because it's common, a lot of people are going to doctors and physios and those doctors and physical therapists and chiropractors often recommend that those clients do something low impact, like Pilates, to stay active and sort of get back into moving. Um, but that can be really daunting if you are experiencing, especially severe back pain, it's uncomfortable. It's awful. It's not ideal. It interferes with your life, your work, your hobbies, the things that you like to do, even relaxing can be not relaxing when you're dealing with that pain. So these people are showing up in your studio and you will very likely deal with them a lot, if you haven't [00:03:00] already met several people like this.
[00:03:02] People who are in pain predominantly want to get out of pain and they might say things when about, you know, oh, I want to improve my posture. I want to build my core strength or, you know, things like that that Pilates also says, but if you dig a little deeper, a lot of times, it's, I'm unable to do things that I love doing, whether it's playing with my kids or hiking or even going to work. And I can't do that because I'm in pain. I want to get out of pain.
[00:03:35] These people can also have, as I mentioned, fear about moving, they can be really guarded or have ideas like, oh, well I can't forward bend or I can't back bend because it hurts. You know, they'll have these beliefs about their pain that they might share with you. If you're working with people, one-on-one, it's a little bit easier to dive deeper, but just even if someone comes to your group class, these are just kind of things to have in your mind. [00:04:00]
[00:04:00] A lot of what I'm sharing with you is stuff that I'm learning in the diploma of clinical Pilates at Breathe Education. And it's also coming from the low back pain chapter of the American College of Sports Medicine, 11th edition, Exercise Testing and Prescription manual. So if you are interested in learning more about this, those are two great places to go. Um, also Raphael Bender's book Strengthen the Person, not the Body Part. I will link to that as well because he had talks a lot about pain.
[00:04:33] So let's talk about pain, kind of big picture. A lot of times when we think of pain, and I know the way I thought about pain, was that pain is related directly to an injury. And an example of that would be, if you are flipping through some papers and you get a paper. You are immediately aware of it. It hurts. [00:05:00] You can see that your skin has been cut. You might be bleeding and you are in pain. Right. You look at that and you're like, oh my gosh, that is strictly tissue damage. And it hurts. So that's how we can think about pain and think that there is an injury somewhere and that's what's causing the pain. That's kind of our go-to for a lot of us, that's going to be our clients kind of idea about the pain they're experiencing is there must be something wrong and that's why it hurts.
[00:05:30] But I want to complicate that idea a bit by imagining, and perhaps this is an experience you've had, where you are getting ready for bed at the end of the day, you're putting on your pajamas and you find a bruise on your shin. And you're like, how did I get that? I don't remember that happening. You know, it doesn't hurt even, maybe it hurts when I touch it, but like, I don't remember that happening.
[00:05:53] If we were to apply that paper cut example, when we have that tissue damage, because a bruise is also tissue damage, we've [00:06:00] popped blood vessels. The blood is pooling there like it does in a bruise. We should have felt it. We should have been immediately aware that there was tissue damage because you know, tissue damage equals pain. But we know from that, that tissue damage doesn't always equal pain. Tissue damage equals tissue damage, but whether or not we perceive it as pain is a bit more complex.
[00:06:25] So instead of the, A plus B equals C idea that where C is pain, and tissue damage plus you equals pain, we can complicate it a bit and we can think of pain as, uh, our body's response as an overflowing of many different things, one of which might be tissue damage.
[00:06:50] There's this idea of a cup of resilience that we all have this cup and into our cup, we put our daily stressors. It could [00:07:00] be your work stress, your relationship stress, how much sleep you're getting, the food you're eating, your mental health. If you're feeling depressed, that's a stress. Are you exercising? Are you having inflammation? Is there also some injury or some tissue damage? Right? And all of these things get poured into our cup of resilience. And if it's so much stress that that cup overflows, then we experience pain. And it's this multifactorial model that the tissue damage alone did not cause pain and that you could have pain without having tissue damage.
[00:07:41] I'm going to say that again because it's taken me several weeks to wrap my head around it. But there's the idea, the theory that you can have pain without having tissue damage is one reality. And for our friends with chronic back pain who do not have an injury, it [00:08:00] could be their reality. And you can also have an injury and not have pain.
[00:08:07] That's wild that you can have an injury and not have pain, but here's a little factoid about that. There's a study where they took pain-free people at multiple ages and did scans of their back to see if they had anything going on. Any disc bulge, disc herniation, things like that. And what they found that people in their twenties, 30% of them had a disc bulge and no pain. And then people in their thirties, 40% of them had a disc bulge and no pain. And in their fifties, or in their forties, rather, 50% of them had a disc bulge and no pain. And that fact, and I'll link to the study that, that shares that information, that you can have something that I know that originally in my teacher training, I was taught, you know, oh, if you have a disc bulge, there's [00:09:00] all these exercises you can't do. And this is what you should do instead.
[00:09:03] But your body doesn't recognize a disc bulge necessarily as cause for pain. And you may have one and not even know that you have one and go about your life at doing whatever you do forward fold, side bends, twisties, and you know, backbends all of this and not even know that you have a disc bulge because there's no pain associated with.
[00:09:26] Unfortunately, that idea does get a bit more complicated than even that, because we do know that people who have back pain are more likely to have a disc bulge. And at first I was like, oh my gosh, scratching my head. Like, I just realized that like, you can have, you know, no pain with some sort of injury, but now we know that people who do have pain are more likely to have this disc bulge.
[00:09:52] But if you look at that cup of resilience model where the inflammation and the tissue [00:10:00] damage also go into that cup, then you can see, yeah, I can see where that might start to overflow. And then that person might experience pain.
[00:10:11] That was a lot in a short amount of time coming up after the break, we're going to talk about the actual strategies of what you do in a class when a person comes and they say they have back pain. Also really good news for Pilates teachers, uh, definitely was good news for me. So that's coming up next.
[00:10:34] Hi there. I hope you're enjoying today's chapter so far. There's great stuff coming up after the break too. Be sure to subscribe wherever you're listening and visit buymeacoffee.com/OliviaPodcasts to support the show. There you can make a one-time donation or become a member for as little as $5 a month.
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[00:11:31] Okay. Brilliant. So we've established just from our own bodies, also working with other people, that you can have pain when you have an injury, but you can also have no pain when you have an injury. You can also have pain without an injury. And where we hope to be also is that we have no injury and no pain.
[00:11:53] Right. So when we're looking at chronic low back pain and the way that we kind of [00:12:00] classify back pain or if you're corresponding with a physical therapist or a physio, the way they may describe the back pain is that there's acute back pain. That is from zero to six weeks. That's considered the acute stage. It's recent. We've got subacute from six to 12 weeks. It's kind of the interim. And then if you have pain that persists for 12 weeks or longer, that is considered chronic or persistent back pain.
[00:12:28] Now the majority of back pain is what we call nonspecific back pain, which is not a great thing, I would say, to tell your client because to the client, it's very specific. It hurts right here. And, um, it hurts at like a six or something. It's very painful. So it's specific to them, but non-specific, and that there isn't a cause. There isn't a trauma or an injury that your body is healing from that is causing the pain.
[00:12:58] So I think [00:13:00] when someone comes into your studio and they say, Hey, I've got some really bad back pain today, in addition to welcoming them to the studio, as you would anyone else, you might ask them, Hey, you know, I'm sorry to hear that. You know, how did that back pain happen? And they might say something like, oh, you know, it's been, nothing really caused it, but it's been on and off for six years or so. So the question, how did it happen? And also when did it happen, are good questions to ask that person, because if you say, how did it happen?
[00:13:32] And they say, I was in a car accident and you say, oh, well, when did that happen? And if they say yesterday, you probably want to recommend them to go see a doctor, because that is an obvious trauma. You know, if they say, oh, I slipped in the shower and fell last week. And you say, have you seen anyone about that? They say, no. Well, if that back pain is still there, that might be, you know, worth getting them cleared [00:14:00] from a medical professional.
[00:14:01] As a Pilates teacher, it is not your job to diagnose anyone with any ailment. You know, if that, but if that person is definitely within a tissue healing time and they've had a traumatic onset to that back pain then they want to get cleared for, for exercise. And that is, uh, something for a medical professional and not for you as a Pilates teacher.
[00:14:26] But when your client comes and that experience that they've had is way outside of tissue healing times. Even if you, they say, oh, I was in a car accident, it was 10 years ago. Then you say, you know, even if you had broken a bone, even if you had pulled a muscle or torn something, in 10 years, it's definitely healed, you know, our bones heal way faster than that. Our muscles heal way faster than that. They're outside of tissue healing times and they're, you know, they're still experiencing pain, but that pain is not injury-related.
[00:14:58] It is important to know as [00:15:00] a Pilates teacher, that you are not going to injure someone with chronic back pain. That Pilates is low impact. It is low, load. Load is the biggest indicator of injury. They are not going to hurt themselves doing Pilates. If anything, staying active is amazing for a plethora of reasons. You're not going to injure your client with back pain.
[00:15:24] You can be really empathetic and compassionate to them and work to their pain tolerance. So you might be talking with this client and they say something along the lines of, well forward bending really aggravates my back. And whether that is a belief that they have, that you know, forward bending is what hurts my back. It can also be their experience forward bending has hurt my back. You can be, you know, compassionate to that and not say, okay, well, we're going to do a thousand forward folds right now.
[00:15:56] Like obviously not, you know, you want them to work within a place that they're [00:16:00] comfortable and it's most important that they feel comfortable working with you and trying things. And maybe in the future, as they get stronger, you can open the door to them doing things that perhaps they thought that they couldn't. Because you can sort of start to challenge people's beliefs, but that happens further down the line.
[00:16:19] Pilates is so adaptable and so flexible. You can meet that client where they are. So if they are, you know, really weak because they haven't exercised in a really long time, because this back pain has really disrupted everything that they do in their life. You start with something like footwork and you can make the springs lighter for them. You know, you can meet them where they are in terms of their strength and flexibility, the same way you would meet anyone without back pain in terms of strength and flexibility.
[00:16:48] If you're working with them, one-on-one you might be able to establish a directional preference. If they have one, if there's one way of moving, that makes their [00:17:00] back feel better if they say, oh my gosh, you know, whenever I side bend to the right, it just feels better, that my pain goes down. There are, you know, directional preference kind of I'd say test, but it's not a test. You just establish what their base pain level is. And then have them do a bunch of side bends to one side and then say, okay, how's your pain? Did it get better? Do the pain centralize, you know, something like that. And that's the way you can establish what their directional preference.
[00:17:26] But even if you're working with them in a group class, you're going to move their spine in all directions. So they're very likely going to feel better at the end of class because they've moved to their spine in all directions. And you've definitely, if they have a directional preference, which not everyone does, you'll be able to tick that box for them as well.
[00:17:46] The reasons that Pilates are great, or doing Pilates is great for people who are experiencing back pain is because two things can happen often at the same time, sometimes one of the two, but two things can [00:18:00] happen. One is you can help them build a bigger cup of resilience, the cup that's holding all of those stressors. You can help them build a bigger one by improving their overall resilience, that they will be able to tolerate more stressors. They'll feel more self-efficacy. And so that cup that they are having the same amount of stress in, with or without tissue damage. Tissue damage is just one potential factor. In addition with, you know, their sleep and everything, all of those psychosocial factors, as well as the biological what's happening in their tissues factors, you can help them build a bigger cup through exercise.
[00:18:42] You can also reduce some of the stressors through exercise, by helping them sleep better, by reducing inflammation, by building up their image of themselves as being able to change their outcome. That they'll have a [00:19:00] more positive outcome because they believe that they're able to do that. And, you know, we know that that's a huge factor in it as well. So you can just tell them, you know, that yeah, I can definitely help you.
[00:19:12] And one last thing that I just want to throw in here is the natural history of back pain. If someone's coming in with like really fresh back pain that you've established is not traumatic onset and there's no red flags that they need to see a medical profession. That the natural history of low back pain, which is if they were to keep doing whatever they were doing and not change anything, that in six weeks, the pain halves. So if they were at a six in six weeks, their pain is going to be a three as the research shows .In six months, it'll halve again, it'll be down to 1.5. And within a year 95% of back pain is eliminated.
[00:19:53] You know, so Pilates is excellent because it can, you know, help them build a bigger cup of resilience. It can help minimize the [00:20:00] stressors that they're dealing with, but the body also deals with stuff, you know, and it's likely that it will resolve itself on its own. Pilates can help, their body and their natural, you know, regression to the mean, sort of returning to their baseline self is also happening.
[00:20:23] So I hope that that empowers you as a Pilates teacher to, you know, work with these people with back pain really confidently. And you can just be such a force for good in people's lives by encouraging them, by listening to them, by supporting them, and cheering for them as they sort of explore what movement is like in their body. And as they work through this really tough episode of back pain, potentially, they are so lucky to have you working with them.
[00:20:52] Huge thank you to all my supporters on Buy Me a Coffee. It has been such a treat to hang out with you and coffee chat. What an [00:21:00] absolute party. It's June. So those new coffee chats will be opening up soon.
[00:21:03] Stay tuned for that. Thanks so much for tuning in. I hope you have a great couple of weeks and I'll talk to you again soon.
[00:21:18] Thanks for listening to this week's chapter of Pilates Teachers' Manual, your guide to becoming a great Pilates teacher. Check out the podcast Instagram at @pilatesteachersmanual, and be sure to subscribe wherever you listen. For more Pilates goodness, check out my other podcast, Pilates Students' Manual, available everywhere you listen to podcasts.
[00:21:41] The adventure continues. Until next time.