We see a lot of physiotherapists and Pilates teachers with low back pain in our clinic. Many of them have turned to Pilates or some other form of stabilisation training in order to address their own back pain, and it initially gave them a sense of control over their situation. However, years later, despite their professional knowledge and background, these people are presenting with ongoing back pain.
Firstly, I must make clear that this is not an anti-Pilates piece. I richly enjoy teaching Pilates teachers, relish the discussions we have, and have a deep respect for their dedication to their clients’ welfare and their own development. No, this piece is about the perception of these highly trained low back pain patients of ours, that control is the goal for their exercise regimen. This impression, which rightly or wrongly is commonly associated with Pilates and some other “stabilisation” approaches, is the issue at hand.
So to the primary question. Is control really the overall aim in a rehabilitation context?
For the injured individual, normalisation is the goal. We ask ourselves:
– Can the individual maintain the integrity of their system under functional and contextual conditions?This is stability, and it requires the integration of multiple factors – it is not merely a matter of muscle activation.
– Can they create and control forces using the least costly and most sustainable strategy to meet their functional needs?
– Are they able to do this with confidence and spontaneity?
– Do they have a functional window large enough to adapt and respond to variety, variability and the unexpected? Has their rehabilitation allowed them to diversify their learning?
The answer in the case of these particular patients is no. They actually have a fear of “uncontrolled motion”, and thus vigilantly control the injured area with various learned “setting” behaviours prior to movement. They are what I call the functional frozen, a group whose underlying anxiety channels them towards an anti-movement approach. These people have lost the overall goal of recovery, and made control their holy grail. To ask them to release their control behavior, even in very supported, low load positions, constitutes a threat – it challenges a learned behavior which they believe is sustaining the safety of their system, and emotionally this is quite traumatic.
Physically in this group, we see a suppression of normal equilibrium responses, a lack of normal spinal response to perturbation or even basic weight transference, altered upper limb mechanics, contrived breathing patterns, and limitations in hip, shoulder and thoracic rotational mobility. This lack of functionality reinforces the individual’s belief that more control is needed, but the stabilising (or more accurately, immobilising) behavior that they use to try to overcome the experience is actually sustaining it. The problem is actually too much control: through constant holding behaviours, these people develop an inability to grade, time and coordinate their muscular, mechanical and neurosensory responses .
So what’s my point?
Well, firstly to be aware that even in trained professionals who know the anatomy and are exposed to the research and discussions, the personal experience of back pain can override rationality.
People seek safety and reassurance when injured, and anything that seems to protect the injured part seems like a good idea. The frightened human inside that professional is ripe for the kind of dialogue around stability that has prevailed for the past twenty years. The use over the past decade of the term “uncontrolled movement” as if it is a pathology is not helpful, but is often well established in the professional psyche. The alternate reality to normal movement presented by certain approaches (any form of setting, trying to lift your arm with your scapula “back and down”, keeping your ribs and pelvis the same distance apart…) has not helped with this. To the injured person, these explanations and instructions seem simple and concrete (reassuring when your head is full of worries) and therefore provide a soothing sense of control, which in turn can make the individual feel better. A reduction in catastrophising has been shown to have more consistent influence on low back pain outcomes than transversus muscle activation (Mannion et al 2012), so all this stabilising activity may have a positive effective early on, but not for the reasons that its practitioners believe. This type of patient hooks onto that early experience, and never transcends it. As Hodges said in his 2009 paper, training to stiffen the spine after injury can offer short term benefits, but may lead to recurrence later due to altered trunk dynamics.
Riding the pendulum to the other extreme by rejecting it all as bunkum as is currently in fashion, is not so helpful either, nor is it particularly informed. Stability itself is not a myth (sorry, Eyal Lederman). It is integral to our overall capacity to meet the force management challenges that are part of our everyday lives. We do need to be able to support the forces we create, and withstand those acting upon us. The ability to do so arises from multiple system integration, and in this is included psychological, emotional and behavioural responses alongside the biomechanical, neuromuscular, sensory, coordinative (and more) factors.
The trouble then with the term “stability” stems from two sources: the first being the commodification of the concept, which involves extreme simplification in order to be packaged and disseminated (sold) successfully. What people recognise as “stability” or “stability training” is usually based on this vastly reduced and usually prescriptive training approach, hence the backlash against the term now.
The second is how we have set about trying to address the control deficits we see. Much of what we see in the current evidence base is highly muscle-centric and one dimensional. Studies offer tiny pieces of the puzzle, each one useful but none holding all the answers, and the dominantly convergent thinking style in our profession fails to integrate them into a bigger picture. It is not by coincidence that neuromuscular type programmes seem to fare better, especially in the field of injury prevention. They offer a mix of high and low threshold exercises, proprioception and balance activities i.e. a balanced diet of sensory, neuromuscular and biomechanical challenges.
So, I don’t think that stability itself is a problematic term, but one that is improperly used to represent an ideology i.e. a belief system, instead of a natural physical phenomenon. If we recognise it accurately, we see it not as an entity trainable by “stability exercises”, but as the result of multisystem interplay, requiring multimodal inputs, and that these inputs will vary and progress based on the functional, physiological and contextual requirements of the patient. Looking more broadly, we also can appreciate that stability is but one feature amongst many in the bigger picture that is movement, yet many in the rehabilitation community have hung their hats on this one pillar, only to be surprised when the clinical outcomes have not supported this approach.
So where does that leave us?
Well, we remember that stability arises from systems, not muscles. This requires variety and variation in our programmes, working our way up to variability in order to foster robustness and a range of solutions to meet the challenges in our work, play and general environment.
We recognise that the emotional landscape of the patient can be the determining factor for the success of our intervention, and we use our language carefully to shape healthy understanding and normalise the patient’s arousal threshold.
We teach that learning to support ourselves is not the same as trying to protect ourselves. If we break a bone in our arm or leg, the body reacts with muscle spasm to immobilise the area, but to regain our use of the limb, those muscles need to relax and learn to work together again, lengthening and shortening, grading and timing. The spine is no different. It also needs to move in beautiful and complex ways. Our job is to intelligently select our rehabilitation start point and progress at a rate which is challenging but not threatening in order to encourage exploration into movement, instead of fear and resistance.
We explain that sustaining a fixed level of muscle activity in a body area affects coordination throughout the whole body. Instead we establish appropriate movement relationships, and progressively manipulate load and skill until the patient’s functional requirements are met. This is as much about developing confidence and self efficacy as it is about strength, endurance, coordination etc.
It could be said that all of this contributes to developing control, and I would agree, other than to say that conceptually, control is often perceived in rehabilitation as stopping unwanted movement, where ultimately we’d like to see our patients understand it as a means to expressing their movement freely and spontaneously.
Control really ain’t the goal.
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