What can we assume?
What must we prove?
How do we prove it?
Since moving to San Francisco I’ve continued to teach Pilates with individuals recovering from injury or struggling with chronic pain. As a Pilates Instructor however, I am now bound by the boundaries of being a fitness professional and I am no longer able to use my Physiotherapy skills to assess and diagnose. Instead clients present to me with a problem and diagnosis and from that I design an exercise program.
Initially I was petrified and kept thinking...
"How do I know their diagnosis is correct?"
"How can I be sure that Pilates is the best approach?"
"How can I assume something is a problem without first proving it with assessment?”
These questions are distilled in my nature, drilled into my methods and clinical reasoning don’t assume something unless you can prove it… don’t implement a treatment without first linking it to an assessment.
Restrained by my new position I have been forced to change my ways. 18 months later and I have a slightly enlightened and more creative perspective about these rules. Why? Because if we don’t adapt, we don’t grow.
Imagine me in a studio with a patient who presents with chronic low back pain and I’m going to take a brief history to determine why they came to pilates and then I am going to essentially design a program based off what I can see and what they tell me. Not what I feel. It’s a hands-off approach of repeatedly asking someone to perform a movement or exercise and watching what they do. It amazes me what you see… when you commit to becoming a people watcher… and these patterns continue to emerge that direct my Pilates programs… but only if you know what you are looking for.
Fortunately for me, my training and my clinical experience and in some part my compulsiveness to never break the rules, has shown me time and time again what patterns emerge when you link assessment to treatment. So now, I skip a large component of the traditional Physiotherapy assessment and carefully observe people as they move through different tasks, asking them questions, changing loads and postures and observing the outcome. Interestingly - they generally have no idea this is all going on in my head.
Do this… try this…. how does it feel?
How heavy are those springs?
Where do you feel that movement is coming from?
Where does the movement-block come from?
In what way does is feel different to the other side?
Can you make it feel the same as the other side?
I have 60 minutes - and for a physiotherapists - that is a lot of time to just observe and scrutinise movements and talk with my clients. Together my clients and I are on a journey, learning together, working together, collaboratively, and at the end of it all I haven’t touched them, palpated their pain or labelled their problem. I have shown them what movements need focussing, which regions of their bodies need strengthening and how, with the right guidance, they can do it all by themselves. Brilliant.
Initially I was scared, but honestly, it is amazing, a relief almost. They aren’t looking for a label and instead I give them a clear set of goals. I show them where their weaknesses and deficits are and they learn how to move better and towards those goals.
Here is a case example:
Meet Lady, who has a history of chronic neck pain and a radiating pain into her left shoulder (a Cloward’s sign). Let me give you the information I gained during our initial interaction.
She used to dance when younger and has learnt to stand up tall with shoulders back to reinforce her posture and poise. Lady also has a large bust and therefore sits up straight all the time to stop her shoulders from rounding. Her profession is a lawyer and Lady spends large parts of her day sitting and looking down while reading reports. She has pain on the medial border of her left scapula. There has been no long-term relief with manual therapy treatments and she always feels she needs to sit up straight. The MRI showed a mild C67 disc budge with no compression of the exiting nerve roots. Lady has taken a break from work as it has been the only way to reduce her pain levels. She asked me if I could help design a Pilates program to improve her core strength, not load her neck, and help get her back to regular exercise.
ON ASSESSMENT, WHAT DO I SEE?
- Scapula position is depressed and downwardly rotated.
- Deltoid bulk is less on the painful (left) side.
- Thoracic kyphosis lost through the upper thoracic spine.
- Movement into cervical and thoracic flexion mainly hinges around the cervicothoracic junction.
- No pain is present on cervical AROM.
- During a sit up there is a tendency towards a poked chin posture rather than lifting the chest.
- Going into table top position with the legs, there is a loss of control of lumbar spine seen by increased lordosis and anterior pelvic tilt and dragging through the back of the neck into neck extension.
- Stretching the scapula depressors in a modified child's pose position helps reduced medial scapula pain.
When I filmed Lady doing cat stretch on the trapeze - I showed her the video and she said “eww that is hideous”. My first question was “Why? What do you see?”
Lady quickly noted that on the way down in the exercise she moved primarily from her cervicothoracic junction. I asked her why she moved that way and her reply was “because the disc in my neck is inflamed and I can’t move normally into flexion” then we watched her return from the bottom and she hadn’t noticed that she moved beautifully on the way back up. First I asked Lady if there was any pain and her reply was 'no'. Then I asked - if you move so well on the way back up - do you think it is your disc making you move badly on the way down or a way you have learnt to move? Instantly Lady realised that her movement pattern was not protective but maladaptive and she immediately started practicing the exercise with more focus and intent. It took three weeks to get her body to relax into the movement and articulate her spine into flexion.
Improving this movement pattern was something I wanted to change. I wanted to improve Lady's perception about how she moves. I wanted to change the segmental control through the cervicothoracic junction because I felt it was abnormal.... but there is one question burning in the back of my mind.... will changing these movement patterns help?
After 2 months we saw this improvement and her pain had resolved. It definitely is not due to just Pilates, in fact, I’d say it is from not spending so much time in cervical flexion. What I can credit to the Pilates trough is her increased strength, increased motivation and confidence to exercise, and reduced time in an over-extended thoracic spine.
What would you treat?
My goals were:
- Restore cervical and thoracic segmental flexion.
- No more ‘back and down’ with your shoulders.
- Bulk up the posterior cuff, rear deltoid and rhomboids.
- Retrain scapula upward rotation and elevation.
- Mobilise latissimus dorsi and scapula depressors.
- Mobilise hamstrings from the perspective that faulty neurodynamics in a straight leg raise has an impact on the neural structures in the thoracic spine.
- Strengthen global abdominal muscles so she can activate her abdominals to do a sit up and not use her neck.
I’d like to emphasise that the case description above is not a validated way to assess and treat chronic neck pain. The reason I wanted to share it with you is to say that what I learnt from this example is that if you have a strong framework for deciphering what you see and then noting that if we change those things, then change pain, those movements are justified and the problem doesn’t need a label. It’s amazing what I can achieve by encouraging people to move better and learn about their bodies without giving the problem a structural label. I hope this blog has encouraged you to take more time to carefully observe others.