A Pain Informed Approach to Teaching Pilates
Many people are drawn to pilates because they are battling with pain. Research and client testimonials show that pilates can help reduce pain, improve function and increase quality of life. Indeed, many pilates instructors were drawn to teaching because of the positive impact that pilates had on their own pain experiences and a desire to help others access the same benefits.
However, a significant gap exists in many Pilates teacher training programs: a comprehensive understanding of modern pain science. At best this lack of knowledge can limit instructors' ability to effectively support clients in pain and, at worst, means that teaching practices may even inadvertently contribute to or exacerbate pain.
What is Pain?
The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." This definition is crucial because it emphasizes that pain is not simply a direct reflection of tissue damage. While tissue injury can certainly cause pain, the experience of pain is always complex and influenced by a multitude of factors, including neurological, psychological and social factors.
Biological factors that can influence pain include injury, disease, genetics and epigenetic lifestyle factors (such as diet, physical activity and sleep). Psychological factors can include past pain experiences, beliefs, expectations and mood. Social factors that can affect pain can include access to services, social support, work and home environments, as well as cultural beliefs, to name a few, Because someone’s experience of pain will always be shaped by a multitude of factors, pain is best understood as a biopsychosocial phenomenon. If we become too focused on the biological or the biomechanical, we can miss the bigger picture.
Not only do we need to remember that pain is always biopsychosocial, we also need to understand that pain can occur when no tissue damage has occurred. We often think of pain as a ‘tissue damage indicator’ but pain is much better understood as a warning system designed to keep us safe, warning us of the possibility of tissue damage. This distinction is particularly important when considering chronic pain, where the relationship between tissue damage and pain intensity is often less clear.
Acute vs Chronic Pain
Acute pain is typically associated with a specific injury or tissue damage and follows a predictable healing trajectory (this will depend on the injury, but tissue healing times are typically 6 to 12 weeks). In acute pain, pain serves as a protective mechanism, signalling the need to rest and allow the body to recover.
Chronic pain, on the other hand, differs significantly. Chronic pain is defined as pain that lasts more than 3 months, persisting beyond expected tissue healing times. Chronic pain may be related to ongoing disease processes (such as rheumatic arthritis), may develop after an injury (as is the case in Chronic Regional Pain Syndrome – CRPS), or may be more difficult to explain. All chronic pain however, regardless of the origin, involves changes in the nervous system, a phenomenon known as neuroplasticity.
In chronic pain, the nervous system can become sensitized, meaning it becomes more easily triggered and amplifies pain signals. This can lead to pain being experienced even in the absence of ongoing tissue damage. Furthermore, psychological factors like stress, anxiety, and depression can significantly influence the experience of chronic pain.
Pilates instructors are well-positioned to support individuals living with pain, particularly those with chronic pain as we have the unique privilege of getting to spend extended periods of time with our clients. This provides us with the opportunity to educate our clients about pain science, encourage and provide support, and empower them to take an active role in their recovery. To be most effective however, pilates instructors need to adopt a pain informed approach to teaching pilates.
Working with People with Pain
There are many ways to upskill when it comes to working with people with pain. Here are a few suggestions to get you started:
Learn more about modern pain science. Focus on learning and understanding key principles of pain science rather than learning more exercises or specific protocols. Books, podcasts and blogs that talk about the neuroscience of pain or supported self-management can be a good place to start. If you are interested in reading research, look for papers on the biopsychosocial model of pain.
Remember that pain is a complex and individual experience. There is no one-size-fits-all approach or specific protocol of exercises that can cure pain.
Broaden your goals – instead of focusing on pain, consider how pilates can help people move more, improve function, and enhance overall quality of life.
Be thoughtful when it comes to talking about pain with your clients. Are you communicating up to date ideas about pain or are you making your clients nervous about movement?
Think about how you can create supportive and encouraging environments for your clients. Remember pain is always the result of a combination of biological, psychological and social factors.
Seek support – find pain informed healthcare practitioners in your area that you can consult with if you feel uncertain.
Finally, it is important to remember that our role as pilates instructors is not to treat or cure the pain! Our role is to support people and help them move, with the hope that this will bring about more zest and pleasure in everyday life.
References
1 Hayden, J. A., Ellis, J., Ogilvie, R., Stewart, S. A., Bagg, M. K., Stanojevic, S., ... & Saragiotto, B. T. (2021). Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis. Journal of physiotherapy, 67(4), 252-262.
2 Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., ... & Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain, 161(9), 1976-1982.
3 Van Griensven, H., Strong, J., & Unruh, A. (2013). Pain: a textbook for health professionals. Churchill Livingstone.
Julie Anne van Veenendaal is an Occupational Therapist and Pilates Instructor based in Pietermaritzburg, South Africa. She has a particular interest in supporting people living with persistent pain and teaches regularly on the topic. You can find out more about her work at www.returntolife.co.za or connect with her on Instagram @returntolifetherapy.