Massage therapists are increasingly being asked to solve their client’s frank pain problems. Exercise instructors – be they in the yoga, Pilates or the personal training industries have to deal more with clients who have various pain issues.

Why do so many people have ‘injuries’- particularly those who are diligently working at being active and fit? If the exercise is ‘right’ surely we should expect to feel good?

In the technology age we move a lot less – and with a more limited repertoire. Obesity is becoming an increasing problem. We certainly need to be more active. However, how we are active, and the kind of exercise we do is important in ensuring our musculoskeletal fitness and somatic wellbeing – or otherwise.

The research evidence is increasingly clear that people with low back and pelvic pain disorders have altered control of movement. It’s not about strength but rather how they control quite basic movements. In particular they have difficulty recruiting their ‘deep’ myofascial system. They must compensate for this by over using the more superficial large muscles. This is a problem for the spine and pelvis which rely heavily on effective ‘deep system’ activity for proper antigravity postural support and healthy movement control. Now days, lazy ‘deep system’ control is more common than not – and why so many have ‘poor posture’ and breathing pattern disorders.

Poor ‘deep system’ control results in feeling tense, increasingly stiff and tight – and having pain. This imbalanced myofascial activity underlies many ‘injuries’ and chronic pain complaints – tendinopathies; plantar fasciitis; back, groin, hip or knee pain etc. The site of pain is not necessarily the source of pain and compromised axial control is invariably the criminal.

Core matters

These days one hears a lot about ‘the core’. It has become a real selling point promulgated as the panacea for just about everything from helping back pain, enhancing performance, to improving your shape.

‘Core’ isn’t what most people think it is. Unfortunately it’s been dumbed down to mean ‘working your abs’ and ‘pull in your stomach’. This creates lots of problems.

‘The core’ is part of the deep myofascial system. The concept of ‘core stability’ probably emanated from from some Australian research into postural control in both healthy and chronic low back pain populations. They studied the feed-forward anticipatory role played by the intra-abdominal pressure (IAP) mechanism, an important aspect of the antigravity postural control and spinal stabilisation system. They looked at the role of transversus abdominis as a marker of function in a synergy of muscles responsible for generating intra-abdominal pressure (IAP). However, it is important to appreciate that they also looked at function in the rest of the synergy – the diaphragm, the pelvic floor and the deep fibers of lumbar multifidus and the combined role these muscles play in generating appropriate levels of IAP. ‘Core control’ thus involves their simultaneous activity: it’s a ‘stabilisation synergy’.

In healthy populations all elements in the ‘stabilisation synergy’ co-activate prior to the actual movement occurring. Yet, in people with low back and pelvic girdle pain the pre-activation response of all these muscles was variably delayed and/or diminished during movement. Spino-pelvic control suffers.

However, it is apparent that these research findings and their implications have been ignored and/or misinterpreted such that the transversus abdominis muscle has been singled out as ‘the core muscle’. What about the important role of the diaphragm and the rest of the ‘stabilisation synergy’?

Further, this differential function between the deep transversus and the more superficial abdominals is generally overlooked. Instead of specific activation of and building control and endurance in the deep ‘stabilising synergy’, much of the ‘core training’ offered simply becomes ‘strengthening the abs’ as a group – principally in supine into repeated cycles of spinal flexion: ‘tail tucking’, crunches, curls, sit-ups, ‘teasers’ and so on. Research has demonstrated that excessive spinal flexion has adverse consequences on spinal health and wellbeing.

Choosing the ‘right’ exercise

Movement re-education is an art dependent upon a good understanding of healthy spinal control mechanisms and being able to recognise the distinct common patterns of compensated control which drive the development of many pain syndromes. Therapeutic movement re-education needs to be highly specific in order to appropriately address ‘what’s wrong’ – its serious work requiring focus and feedback.

Retraining ‘core control’ involves building basic patterns of control from the inside out.

Clients attending exercise providers are often asked ‘what is their goal’? This can vary from ‘the look good in bed’ seekers – wanting to lose weight; ‘get rid of my tummy’; ‘get toned and fit’ to those wanting real help for their pain. They aren’t necessarily at opposite ends of the spectrum. Many clients while not complaining of pain are certainly at risk in developing it.

In terms of exercise, what clients think they want and what they actually need are often quite different.

The challenge for the teacher is to be able to match the needs and abilities of their client and deliver safe and effective exercise. This is impossible to do with large classes which invariably become little more than a ‘Simon Says’ play group for adults.

Let’s consider the Pilates industry for a moment. Undoubtedly ‘Pilates’ got its launch through the dance community. Dancers are elite athletes who nonetheless get injuries. The Pilates Method has provided useful tools to help dancers refine their control. Many teachers are ex dancers with advanced neuromuscular fitness and well able to cope with ‘advanced’ Pilates moves – but not so for most of their clients.

It is apparent that whether it is in the Pilates, yoga or the fitness industry there is a trend in ‘upping the challenge’ probably to gain market advantage in a crowded field – large floor classes that strive to be ‘upbeat’ and ‘fun’ with more and more ‘new tricks’ to keep their audience interested. Yet many of the participants are missing control of quite fundamental links in the movement chain.

To keep up with the pace and level of demand, those with wobbly function will use whatever they can, further imprinting compensated patterns of control. There is no opportunity for relearning quality control or correcting adverse movement behaviour.

Pain here we come. Just observe how many are constantly using the foam roller in an attempt to iron out their various pain and tightness issues!
So don’t assume that because your clients are exercising that they are necessarily doing what’s ‘right’ and good for them. It could be the reason why they keep coming back with the same old problem – or developing new ones.