Pilates, Scoliosis, and Raphael Bender

Episode 27: 

Joining Hannah on the Pilates Exchange podcast is exercise physiologist and Pilates instructor, Raphael Bender. He’s the owner of Breathe Education, a company that specialises in training Pilates instructors to excel in rehabilitation and anatomy, as well as helping them build their businesses; all conducted online.

In today’s episode, we dive into a conversation about scoliosis and Pilates, exploring where these two worlds intersect. Raphael sheds light on the intriguing aspects of scoliosis and discusses the limited availability of high-quality research on effective interventions. We highlight the fundamental importance of getting people moving in any demographic and Raphael emphasises the lack of evidence to show that any form of movement could be potentially harmful to those with scoliosis.

We discuss pain, the difference between people with scoliosis who experience pain and those who don’t, and examine some of the existing literature on scoliosis.

Don’t miss this informative conversation on Pilates, scoliosis, and more, including a profound and powerful reframe that movement professionals should adopt!

Key Points From This Episode:

  • Insight into the fascination that people in Pilates have with scoliosis. 
  • The lack of good-quality research evidence for scoliosis (what helps and doesn’t help).
  • Why it’s important to simply getting people moving.
  • What type of scoliosis Raphael is and isn’t referring to.
  • The lack of evidence showing that any form of exercise makes scoliosis worse. 
  • A quick look at fusion surgery and movement. 
  • Raphael’s thoughts on the default for every movement professional: movement optimism.
  • A look at the biopsychosocial model of pain and Greg Lehman’s cup of resilience.
  • The difference between people with scoliosis who experience pain and those who don’t. 
  • Existing literature on scoliosis; the good, the bad, and the ugly.
  • A profound and powerful reframe we as movement professionals should adopt.
  • Addressing overthinking in the world of Pilates; simply do what you normally do!

EPISODE 27

 

RB: We can improve quality of life, even without changing Cobb Angle. That’s probably because when we’re doing exercises, even though we’re ostensibly trying to change the Cobb Angle and doing three-dimensional expansion and axial elongation and stretching the short side and strengthening the weak side, all of that, what we’re probably doing is helping people feel more empowered, releasing endorphins, helping them sleep better, improving their mental health, all of these other things that basically give them a bigger cup, right? So, that it doesn’t have overflow.”

 

[INTRODUCTION]

 

[0:00:35] HT: Welcome! Stick around if you want to learn about the art and philosophy of beautiful movement, mixed with evidence-based exercise science. We’ll be having tough and inspiring conversations with other coaches, experts, artists, and athletes. Our goal is to challenge myths, explore concepts, and engage in healthy debate as we dive deep with intrigue and curiosity.

 

I’m your host, Hannah Teutscher. I’ve been teaching dance, Pilates, and yoga for over two decades, and what I’ve learned is that movement can be the joy that integrates us all, together. When we can trust and express ourselves through our bodies, we are unlimited in our ability to change ourselves and our communities for the better. We, as movement teachers and coaches, have the power to help people experience this, for themselves. Okay, everyone. Let’s dive in. Exchanging ideas and changing people’s lives one session at a time. This is The Pilates Exchange.

 

[INTERVIEW]

 

[0:01:34] HT: I have to say, I am just so darn excited to be able to speak with you on my podcast because I’m a huge fan of Pilates Elephants and what you’re doing on yours. I think there’s a lot of alignment that’s in there of where maybe we’re looking at is to uncover some myths that are going on in some, maybe industry blind spots that need a little bit of shaking up. I’m happy that you’re here. For those of my listeners that maybe wouldn’t be yet listeners of yours, maybe there are some dancers and stuff, would you mind telling a little bit about yourself to our audience?

 

[0:02:09] RB: Sure. I’m also a, yeah, long-time listener, and first-time caller on your podcast. Yeah, it’s a pleasure to be here with you. A little bit about me. My name’s Raphael Bender. I am an exercise physiologist and Pilates instructor. I have a company, Breathe Education. We train people to be Pilates instructors and we also train Pilates instructors to be more skilled at rehabilitation and anatomy. We also help people build their Pilates businesses, and we do that all online.

 

I had a Pilates studio for a decade here in Melbourne, Australia, where I live. We had a tiny, little education business inside of the studio, training up like four instructors a year, or something, and just, basically, to cream off the best ones and hire them in the studio. Then after running the studio for a decade, I – well, I was at the end of my studio running days. I’d had enough of it. I sold out my interest in the studio. I bought out the education business and that was in 2016 and have been full-time teaching Pilates teachers since then. Yeah, a podcast called Pilates Elephants.

 

Really, I think in my 20s and early 30s, I was a musician. I’d say, I’d put quotes around it, “professional musician.” By which, I mean, it was my soul and primary source of income, but it was a really pitiful amount of income.

 

[0:03:29] HT: Musicians are so notoriously underpaid, it’s crazy.

 

[0:03:32] RB: Yeah. In that time, I really formed my – I think the way that I run my podcast and the way that I do my Instagram is very much just a continuation of the way I recorded music, which is I’m a massive fan of organic recording. I love albums like Nevermind by Nirvana, the Red Hot Chili Peppers; their Blood Sugar Sex Magic Album. I mean, I love the music, but the recording aesthetic, where they literally just get in a room, and record it. There are bloopers and outtakes in the main hits that you can tell. It’s just a bunch of guys in a room having fun and jamming out. It’s like, “Okay, we messed up a line there. Doesn’t matter, because the vibe was good.”

 

I’ve always been a big fan – and the Rolling Stones, that sloppy magical chemistry that they have, where you’ve actually really listened to it, it’s like, it’s out of time, but it’s like, it works. Really, really, really works. I just am a big fan of capturing moments, rather than perfectly scripted, choreographed, but more maybe quantised performance as, yeah, I’m just a big like, what you hear is what you get and what you see is what you get.

 

[0:04:39] HT: What instrument did you play?

 

[0:04:40] RB: Bass guitar.

 

[0:04:42] HT: My dad plays bass.

 

[0:04:43] RB: Really?

 

[0:04:44] HT: Yeah. Funny. Well, then, I’m sure you know of him, but Victor Wooten. That’s the music like, oh. Speaking of just being the real magic of whatever happens is there and there’s always genius to that.

 

[0:05:01] RB: Yeah.

 

[0:05:01] HT: I’m in it.

 

[0:05:02] RB: There is genius, absolutely, in people. I mean, there’s a different school of thought that is very meticulous and choreographed, and I can appreciate that as well. I don’t think that’s a worse way of doing things, but just my personal bent is, I like it so sloppy and real and raw.

 

[0:05:19] HT: All right. Well, that’s how we’ll roll. That’s good.

 

[0:05:21] RB: Okay.

 

[0:05:24] HT: I was always a big fan of improvisation. I’m a dancer, that’s my – was a dancer. I’m a recovering dancer, let’s say. My favourite part of dancing was actually, the improvisation. When I had opportunities to express myself in a different way with the movement, or within a choreography, that was where I shined. I enjoyed that. Moving my body is different from using my words. I feel more nervous when I am needing to use my words to express myself, which was a huge deal as I was transitioning more to teaching, especially when I’m doing it in a second language. I have to be very thoughtful about everything that I do and say because it’s not the same type of expertise that I had with my body. No.

 

[0:06:13] RB: Yeah. I mean, I don’t speak anything approximating a second language. I can only stand in admiration of those who can, and only order a cheese sandwich, but actually teach Pilates class in a second language.

 

[0:06:26] HT: Oh, well. It’s creative. Let’s say that. They get it. That’s all it does. I get my people moving. That’s all I need. Raph, when we started talking about perhaps, doing this podcast, we wanted to jump into a subject; that I don’t think needs to be contentious, but somehow, there are a lot of different ideas about scoliosis and I’d love to learn a little bit of more about scoliosis. Where are we in the Pilates world specifically? What myths do you see around here and what we can do some practical steps, maybe helping clients around there, or just learning about it? That’s a lot. You could start wherever you want.

 

[0:07:06] RB: Yeah. All right. I guess, I would say I’m not a specialist in scoliosis. That’s not my lifetime study or anything like that. I read an absolute truckload of research. That’s what I do for fun. I’ve basically created a business for myself where it’s my job to read research and share it with people in simple bite-size chunks. Scoliosis is something that people in Pilates are very, very, I would say, fascinated by. It’s like one of those words if you put it in the title of your podcast, you’re going to get more downloads.

 

[0:07:35] HT: Yes.

 

[0:07:36] RB: I’ve made a particular study of the research on scoliosis. I guess, that’s the background I’m coming from. I guess, I see probably the same thing that I see in many other similar areas in Pilates. When I say similar areas, I mean, things that are – there’s a lot of – I use the word fascination [inaudible 0:07:57], but I think anxiety might be another word that I would use about it. Things like, prenatal, postnatal, diastasis, osteoporosis, older adults, and even sometimes. Disc bulge, spinal alignment, these topics that people, I think, have anxiety about a lot as teachers.

 

I think in common with all of those other areas, I think we, in general, we overcomplicate what we do for people with scoliosis. There’s the level of evidence that we have about what helps or doesn’t help people with scoliosis is extremely low. There are a bunch of studies, and almost all of them are really poor quality. There’s significant publication bias in literature. We can get into what that means later. Basically, there’s no clear evidence that any form of exercise is better than any other form of exercise. I’m talking about adults with scoliosis here, by the way.

 

We do have some, I would say, there’s low-quality evidence that exercise can help, so we should be getting these people moving but, there’s no evidence that any particular exercise is better or worse. It’s like, I just think we way overthink it and way overcomplicate it. We spend hours coming up with these complicated algorithms about what to do for people. Whereas, we could just say, “Okay, let’s just do Pilates.”

 

[0:09:10] HT: My idea all along has just been, if I have someone in front of me that has scoliosis and we’ve talked about, okay, what can I do or not do based on what their doctor has said? Other than that, my love has just been to get them moving and get them feeling good in their bodies and they will communicate, because I teach them how to communicate with me, if something is not feeling good, and then we take it from there.

 

My hope that we’re doing this right is that just based on the amount of minutes of exercise that we need to be getting per week anyway, moving is going to be a better idea than not moving and being terrified of moving the body in front of me. What do you think of that?

 

[0:09:47] RB: Oh, I agree. I think, except for the bit about the doctor and the listening to your body. Maybe, I’ll partially agree.

 

[0:09:54] HT: I’ll take that.

 

[0:09:55] RB: I definitely agree with getting people moving. I think that should be our default and that should be our number one mandate as movement professionals is like, the more people, the larger number of people move and the more each person moves, the better. Anything that gets people moving is a net good in the world. I think we literally save lives by moving people, because we reduce, or cause mortality, reduce cardiovascular disease, mortality, cancer, strokes and all of that stuff by just moving.

 

I think, yeah, absolutely, I’m with you on that. Yeah, I just want to frame this by saying like, I’m talking about adults with scoliosis. There’s a slightly different literature on adolescents with scoliosis, because they’re scolioly not mature yet, and so, there might be some different factors that play there. I’m not talking about people with severe scoliosis, like a 100-degree, literally bent at right angles, people. I’m talking about a regular Pilates client who might have a 10, 20, or 30-degree curve. It might or might not be noticeable in clothing, but maybe you notice when they do a forward bend, their ribcage is a little bit obliquely angled. Just like the regular average range of people, you would see in the normal Pilates setting.

 

We do have evidence that people with scoliosis, adults with scoliosis, are more likely to have back pain and sciatica than people without. They’re almost double as likely, according to the longest study we’ve got. There’s a 50 follow-up study from Iowa. It’s all relatively low numbers, only a couple hundred people in this study. This is the best study we’ve got. We really don’t know a lot about the natural history of scoliosis, what happens if we leave it untreated? Because most of the studies follow up with people who’ve had surgery, or had bracing or had whatever, so we don’t know. Like, well, what happens if we just leave them alone?

 

It seems to be the case that curves progress at a bit under one degree a year on average for adults. Again, low numbers. One or two studies. We’re looking at with double digits of people in them. How far can you generalise from that? People with scoliosis are more likely to have back pain, but their back pain is not more severe than people without scoliosis. If we get two groups of people, one group with scoliosis, one group without, there’ll be more people in the scoliosis group who have back pain, but the average level of pain out of 10 won’t be higher in the scoliosis group.

 

[0:12:17] HT: Oh, that’s interesting.

 

[0:12:18] RB: Yeah. That’s just the background. I think one part of the background. There is, as far as I’m aware, and I’ve read literally hundreds of studies on scoliosis, exercise, scoliosis, natural history, pain, treatment, etc., there is not a single study that I’m aware of showing that any form of exercise makes scoliosis worse on any measure. There’s literally zero evidence of any harm of any kind from doing exercise that is specific to scoliosis. There’s no documented research showing that any position makes it worse, increases a Cobb Angle, or makes pain worse.

 

I’m sure that on occasion, someone’s hold up sore after a workout or whatever, but we don’t have any research showing that there are any risks of it. I just think like, yeah, don’t worry about the doctors okay? Just get them moving. It’s like, it’s all going to be good.

 

[0:13:12] HT: Yeah, when I meant doctors are okay, I have a couple of people with, what do you call that? I’m only thinking of a German word, rods in their back that are stabilising everything. That’s where I –

 

[0:13:21] RB: Fusion surgery.

 

[0:13:22] HT: Yeah. A fusion surgery. In that, there are a couple of contraindications that I was aware of in these specific clients of loaded flexions and rotations. Other than that, I just let people, if there’s been that, then yes. Other than that, I just move.

 

[0:13:41] RB: Yeah. In fusion surgery, there is some evidence that people are more likely to develop disc degeneration at the level adjacent to the fusion.

 

[0:13:49] HT: Right above or right below, correct.

 

[0:13:50] RB: Yeah. I think that there is a case to be made for bending those people less, or keeping them closer around neutral. I think there’s a case to be made. I don’t think it’s an open and shut case, but I think you could make a rational argument to say, yeah, probably would be better for these people overall if we bend their spine less. You could also say, well, what if we bend their spine, but focus on articulating evenly through all of the segments above and below the fusion? Anyway, I think you could have a rational argument about that. I think, I could see why you might choose not to bend those people, and I probably would endorse that view.

 

[0:14:30] HT: Okay. Oh, good. Back to the layman. At the very beginning, we were talking about, how people are fearful of working with some – specifically in this case, scoliosis. I feel like, it’s been drilled into us through various teacher training programs throughout the world, that make people unsure, make teachers unsure of what they should be doing, because there’s a lot of things like, this is contrary indicated, this is contrary indicated. That level of fear, then when you’re looking at a client, you just don’t know what to do anymore. I think that that’s feeding into a problem, actually, a very major problem, and which is part of what your work is to try to unravel some of that.

 

What we’re talking about now is like, okay, if there are so few really good quality studies and maybe, just maybe those other teacher training programs have not even mentioned these studies with insight stated those within their teacher training manuals that maybe, we just need to all calm down and work with the body that’s in front of us and just get them to move.

 

[0:15:42] RB: Yeah. I pretty much agree with that. I think my default and I think, what I think the default should be for every movement professional is a position of what I call movement optimism, which I got from Greg Lehman, physical therapist and chiropractor, which is basically, the position that the default assumption is exercise is helpful and beneficial for everyone. Any given exercise is helpful and beneficial for anyone, assuming you’re not insane in the – I’m not saying, okay, stand on a stool with a 100-pound weight overhead, juggling a live cat, a chainsaw, and raw egg, or something.

 

We’re talking about things that sane people would do, is the roll-up safe for this person, or is it safe to do footwork for this person, or whatever? It’s like, yeah. The answer should – the default answer should be yes until proven otherwise. I think, even if that person that we’re talking about has scoliosis, or is pregnant, or has diastasis, or has osteoporosis, the default answer should be yes.

 

Now, in some of these situations, like in osteoporosis, there are specific things that are contraindicated, like loaded flexion. It’s not always the case that everything always is safe for everyone, but I think our default should be everything is safe until proven otherwise. Sometimes it is proven otherwise. I think in Pilates, we default the other way and we say, okay, our default is we should avoid everything and be really worried. Then find out what the specific things we need to do with this person.

 

The reality is for most of these conditions, disc, bulged scoliosis, diastasis, pregnancy, osteoporosis, arthritis, being old, or it’s like, the sorts of exercise that benefit these people are the same sorts of exercise that benefit anyone. Just strengthening, stretching, moving, all of that stuff.

 

[0:17:26] HT: I think, I hope all of the listeners are taking a deep breath in, “That feels good to hear.” It’s almost like, we need some more permission just to do that.

 

[0:17:36] RB: Well, if you need permission and if you consider me somebody who’s capable of giving you permission, you have my permission.

 

[0:17:45] HT: Everyone out there, listen to that. Take it. I’m giving you permission as well. Let’s touch on pain. Now, I’ve done a couple of podcasts working with Colleen Jorgensen, who’s fantastic, talking about pain. I know that you have also talked about pain. Something that I know for sure is that when we’re working through movement on just the resiliency, stress resiliency, of just feeling, I don’t know what the right words are right now. It’s late at night, my time. Feeling good, feeling safe, and feeling able to make good decisions about our own bodies in that time that helps a lot with managing pain altogether. Yeah, just wanted to throw that out there. Knowing that people with scoliosis, what we were just talking about of back pain and scoliosis pain in general, right? We don’t have to do anything different than we would treat any other person with pain, other than be mindful of all the good things that we want to support them.

 

[0:18:46] RB: Right. I would say, broadly speaking, I mean, pain is a – we’ve changed our conception of pain. When I say we, I mean, like science, what science understands by pain. We’ve changed that over the last 30, 40 years from what used to be called, or is called the biomedical model, or biomechanical model of pain, to what we now use the biopsychosocial model of pain. It’s still not perfect. We don’t understand it perfectly at all. It’s the least worst of all of the models we have for how pain works.

 

The biomechanical model, or biomedical model says that pain, basically, pain is an infallible indicator of tissue damage. If you’ve got pain somewhere, that means there’s something wrong physically in the tissues. Issues in the tissues. It’s really based on the 19th and early 20th century conception of the body as this mechanical engineering device with cogs and levers and the nervous system as electrical wires transmitting signals. But that doesn’t really fit the facts at all.

 

I mean, we’ve all had the experience of getting undressed at the end of the day and then noticing you’ve got a bruise somewhere on your body, you think, “Huh. How did I get that?” It’s like, well, that’s an injury, a bruise is an injury, broken blood vessels under the skin, but there’s no pain, right? You can have an injury with no pain. Pain and injury are not the same thing.

 

We’ve all had the experience of having pain, but they’re not having an injury. Sometimes you just wake up with a weird pain in your shin, or your neck, or your whatever. Then you’d have a coffee and it goes away. We can have pain without an injury. We can have an injury without pain. We can have pain and injury together. But they often go together, but they’re not the same thing. The biopsychosocial model really views pain as an emergent property or emergent phenomenon of the central nervous system. It doesn’t have a single cause.

 

Again, from Greg Lehmann — he’s got this fantastic metaphor called the cup of resilience, which we teach in our clinical certification, which is a – I think, a very accurate and useful metaphor that models the physiology of the stress response, which basically says that each of us has a cup of resilience, which basically represents how much we can tolerate on stressors. We pour stressors into the cup and a stressor might be like, inflammation in a certain tissue, or some damage to a certain tissue.

 

It might be lack of sleep. It might be financial worries. It might be low physical activity. There’s lots of things. Poor nutrition, etc. Lots of stressors that we might be subject to. If you pour enough stressors into the cup, the cup overflows, and the overflow can be pain. In this metaphor, when – and it does actually hold up when we think about, in more detail about the physiology of stress. I won’t go into it now. But if we think of the overflow as pain, it’s like, well, none of those things that we pour into the cup paused the pain, because we could have poured a smaller number of things into the cup and not had pain. Or we could have put all the same things into the cup, but just less of them and not had pain.

 

It’s not the case that the disc degeneration caused the pain, although it contributed to it. It was one of the things we poured into the cup. It’s not the case that the scoliosis caused the pain, because there are other things we poured into the cup that also contributed to it overflowing. That does really fit with what we see, which is that although people with scoliosis more commonly have pain than people without, a lot of people with scoliosis have no pain.

 

It’s like, well, if you can have scoliosis with no pain, scoliosis does not mean you must have pain. There must be other factors involved. Yeah, scoliosis increases the likelihood. It’s one of the things we pour into the cup. All other things being equal, yeah, you’re more likely to have pain. But if you manage your stress and your sleep and your physical activity and all of these other factors –

 

[0:22:19] HT: Nutrition. Yeah.

 

[0:22:21] RB: Right. All of just the things that promote human flourishing, time in nature, meaning, time with loved ones.

 

[0:22:26] HT: Social connections. Yeah.

 

[0:22:28] RB: Right, all of that stuff. Yeah. I think that’s a much better, more accurate, more useful model of pain. Because research really hasn’t shown that we can make any meaningful difference to Cobb Angle, which is the angle of the scoliosis in adults. It’s the Cobb Angle, C-O-B-B, is the sum of all curves. If I’ve got one curve, or two curves, or three curves, or whatever, it’s like, add them all together, that’s the Cobb Angle.

 

Research has not really convincingly shown that we can do much, or anything about Cobb Angle in adults, but we can improve pain. We can improve quality of life, even without changing Cobb Angle. That’s probably because when we’re doing exercises, even though we’re ostensibly trying to change the Cobb Angle and doing three-dimensional expansion and axial elongation and stretching the short side and strengthening the weak side, all of that, what we’re probably doing is helping people feel more empowered, releasing endorphins, helping them sleep better, improving their mental health, all of these other things that basically, give them a bigger cup, so that it doesn’t overflow.

 

[0:23:33] HT: Thank you for that. That makes sense to me. That’s how I have felt it, but you articulated so beautifully. That’s great.

 

[0:23:41] RB: It’s from Greg Lehman. I can’t take credit.

 

[MESSAGE]

 

[0:23:44] HT: When I started teaching, I felt underprepared and overwhelmed. I needed to learn how to plan my training so that it made sense, but I wasn’t sure what was working and what wasn’t. 

 

So many teacher training programs leave out the actual art and business of teaching. This is why we created Train the Trainers. Train the Trainers is designed to give you the tools you need to create a powerful learning environment for your students. Gain access to the vault of our collected knowledge where you can learn everything we have to teach you, whether you are a freelance teacher or a studio owner. Get constructive feedback on your teaching with actionable tools you can apply immediately. 

 

We can’t wait to be part of your teaching journey and to help you grow in your business. Welcome to Train the Trainers.

 

[INTERVIEW CONTINUED]

 

[0:24:31] HT: Do you have any inclination, why scoliosis is relatively common? Are we at 3% of the population? 4%? I don’t know.

 

[0:24:40] RB: I don’t know the exact figure, but it’s low single digits. It’s like the old 1% to 3%, or 4%, something like that.

 

[0:24:45] HT: Right. If we’re looking at the world population, that’s a lot of people. It’s very surprising to me how few good studies there’s been. Medical studies about exercise, or just in general.

 

[0:24:56] RB: Yeah. It is interesting, because there are actually a lot of studies. They’re all very poor quality.

 

[0:25:01] HT: That’s a better way of saying it. Yes.

 

[0:25:03] RB: Yeah. Every time I’ve said there’s no studies, I haven’t said there’s no studies. I’ve said, there’s no good studies.

 

[0:25:08] HT: No good – That’s right. You did say that. No good studies. Yeah.

 

[0:25:11] RB: Typically, well, sorry, just to go back to the pain thing for a second, we have research looking at what does – so, we look at people with scoliosis with and without pain, for example. Then we say, okay, what’s different between the people with pain and without pain? One of the things we say is different is Cobb Angle, right? If you have a bigger scoliosis, all other things being equal, you’re more likely to have pain than if you have a small scoliosis.

 

Interestingly, Cobb Angle doesn’t correlate with pain severity, right? A bigger Cobb Angle doesn’t necessarily mean that you’re going to have more intense pain, but it means you’re more likely to have some pain. There are other things that also correlate with whether you’re not, you have pain, catastrophising, tending to, which is the tendency to represent or view a situation as worse than it actually is. It has chicken, little disguise falling syndrome. Self-rated mental health correlates with the absence or presence of pain. Also, increased pelvic asymmetry.

 

There are physical factors and there are psychological, or psychosocial factors. Kinesiophobia, anxiety, and family history of non-specific back pain. There are genetic factors involved. This is a complex mix of things that we can’t really disentangle at this point. We know that the spinal angle is part of that mix, but it’s certainly not all of it, and it might not even be the biggest part of it. I think we have to address these psychosocial thoughts, feelings, behaviours, emotions, physical activity, and all of that stuff.

 

Yeah, so just to go back, now to get onto your question about the literature, I don’t know. I just think there’s – my read is that there’s, basically, motivated reasoning going on. Typically, in good research, if you think about somebody trying to research a cure for cancer or something like that, they’ll look at all of the research that’s available and think, scratch their heads, and go, “What do we know about the mechanisms of cancer and what works and what doesn’t work based on what we already know?” Then they’ll think, “Okay. Well, how might I add value to this? Where could work we explore that might be useful?”

 

Then they try some stuff and sometimes it works and sometimes it doesn’t. Science precedes an inch at a time. But in the scoliosis literature, we start from okay, I’ve got this special method. Okay, let’s do a study to see if this is the best way to fix scoliosis. We start with the conclusion and work backward from there. Typically, we have very, very – because of this, we have quite significant problems with study quality.

 

For example, you’ll have an intervention that measures – like this one study, got it here somewhere, which looks at – was the Schroth method. Now, it’s not to pick on the Schroth method, like all of the research is low quality, right? All the strengthening literatures, physiotherapy exercises, it’s all low quality. There’s this one study from 2016 called the efficacy of three-dimensional Schroth exercises in adolescent idiopathic scoliosis, or randomised controlled trial.

 

What they did was they had three groups with scoliosis. One group got the Schroth method, an hour a week with a physiotherapist in the clinic. One group got the same exercises, but just given as a home program, with only one session at the start of the trial, and they just left their own devices. The other group got no treatment. We’re comparing. What they concluded was the Schroth method can help. That what they actually measured, what they didn’t measure, the Schroth method compared to – well, what they measured was the Schroth method given by a physical therapist compared to the Schroth method not given by a physical therapist compared to nothing.

 

What they actually found was the presence of a physical therapist was helpful, regardless of whether they were given Schroth exercises or not. Being given nothing is not helpful. A better study design would have been, okay, the Schroth method given by a physical therapist one hour a week in the clinic compared to just general stretching and strengthening, given by a physical therapist one hour a week in the clinic. Because all of these other intangible things surround that therapeutic encounter with the physical therapist. There’s therapeutic alliance, there’s optimism, there’s social support, there’s just getting moving, there’s socialisation with the other patients at the clinic, there’s getting out of the house, there’s an expectation that it will help, there’s the human touch, there’s all of this stuff that could contribute to the outcome.

 

What we should do when we create these studies is measure general exercise, just regular strengthening and stretching compared to specific exercise methods A, B, or C. But we should equate all of the other factors as much as possible. Same amount of time with the clinicians, same number of exercise sessions, same total duration. All of the other things are same. The only difference is, did they get this special exercise, or did they get just general exercise, right?

 

To my knowledge, there’s no studies like that. All of the scoliosis studies compare to control, which is usually like, waiting list, or advice to sit up straight, or something that’s – it’s very, very – We did a special exercise and it helped. Yeah, but did it help more than just getting moving? We don’t know.

 

[0:30:29] HT: Yeah. It’s fascinating to me how little has been done. How it’s really important also when we are looking, we’re trying to glean information, that we’re actually looking, not just that there’s a study out there, but the quality of the study that we are referencing. Because you can – looks like, you can pretty much justify anything, depending on what that study is, how the study has been done, if you are leading with your conclusion as you’re going in, instead of a hypothesis that’s very, very different than the information that you’re looking for.

 

[0:31:01] RB: Right. There’s also something – and that’s why it’s better to look at things called systematic reviews and meta-analyses, which are really an overview of the whole literature. So, we’re not just looking at one study, because one study might be biased in one way and a different study might be biased in a different way, right? If you look at all of the literature, the bias will tend to – the theories, the bias will tend to average out and you’ll see more of a true indication of what works and what doesn’t.

 

There was a systematic review in 2023 called ‘The Effect of an Exercise Intervention on adolescent idiopathic scoliosis and network meta-analysis’. This is adolescent scoliosis, but they found that there was a significant publication bias in the literature. What that means is that when somebody does a study and they find, okay, we did a physiotherapy intervention for scoliosis and we found it helped and these people had less pain and they stood straighter and everything was great, well, that’s more likely to get published than if they did that exact same study and found that there was no effect. It’s like, well, that’s boring. No one’s going to read that, or pay money to download it from the journal site, so the journal’s less likely to publish it.

 

We do 100 studies. 50 of them show it works. 50 of them show it doesn’t work. All 50 of the ones that showed it work are published and the other ones didn’t get published. Then when we look at all of the literature, we see like, oh, every study finds this thing works, but it’s like, yeah, what about all the ones that didn’t find it work and just didn’t get published? There are so many layers of bias in the literature, within individual studies themselves, and also, just within what gets published.

 

When I say bias, I don’t necessarily mean people are malevolently manipulating this. It’s just like, we all have biases, I’ve got biases, you’ve got biases. Mostly, we’re not even aware of our biases. It shows up in the literature, which basically, there’s another study, another systematic review from 2022, corrective exercise-based therapy for adolescent, idiopathic scoliosis, systematic review of meta-analysis that found, “corrective exercise-based therapy was better than no intervention, but similar to other interventions.”

 

It’s like, yeah, exercise does seem to help, even though the research is terrible quality. But it’s like, we don’t have any evidence that any particular form of exercise is better, or worse than any other. You might as well just do whatever you like, or whatever the client wants, or whatever you know how to do. If that is stretching the short side and strengthening the weak side, well, nothing wrong with that. If that is three-dimensional breathing, that’s fine. If that’s just planks and lunges, that’s fine, too.

 

[0:33:30] HT: Yeah. Goes back to better moving than not moving, in this case, definitely.

 

[0:33:36] RB: Yeah. I just think like, we just really overall, if you read systematic reviews on this and there are probably half a dozen systematic reviews that have come out in the last couple of years on the scoliosis literature. There was a 2017 systematic review, effective stabilisation exercises on own disability and quality of life in adults with scoliosis, a systematic review. They systematically reviewed the literature, and there was only one study that they found that was eligible to be included. One study. It had not many participants in it.

 

[0:34:06] HT: Wow.

 

[0:34:07] RB: Yeah. It’s crazy.

 

[0:34:09] HT: That’s really crazy. That’s just bonkers altogether. But on the other side, we also want to be careful to say like, you and I are still big believers in science, evidence-based and science. We’re not saying, throw it all away. We’re saying, it’s always good to be looking at the meta-analysis if we can, pushing for more studies that are happening and also, that the evidence, when it’s done well quality is still where we should be leading from science.

 

[0:34:37] RB: Right. Well, absolutely. All of the information I’ve shared is from systematic reviews or meta-analysis.

 

[0:34:44] HT: Yeah, absolutely.

 

[0:34:44] RB: This isn’t just me going, I reckon the literature’s poor quality. If you read all of the systematic reviews, all of them start by saying, the literature’s poor quality and biased. It’s actually science that is showing that the science on this topic is not very good. That’s the great thing about science is it’s a self-correcting mechanism, right? The antidote to poor quality science is better science. That’s how the scientific method proceeds. We’re pretty ignorant about this now, but we’ll become less ignorant over time.

 

[0:35:11] HT: Yeah. That’s the great thing is that it is something that we can trust in, because it keeps on going back and say, “Okay. Well, that’s not right. Let’s do it again. Let’s figure out a better way, or more, yeah, to bring us down that path.” I guess, that’s what my point was that we can still trust science because it will highlight where it’s going wrong.

 

[0:35:31] RB: Right. Well, let’s say that we should trust the scientific method, because it’s the best method that humanity’s discovered so far of discovering true facts about how the universe works. Things discovered by science are not always correct. Even when they’re correct, they’re not always entirely correct. Sometimes they miss parts of the puzzle. Then later we discover, oh, there was a bit missing from what we knew was correct, but it wasn’t the whole truth. Now, there were bits missing from that, which we get more and more precise and accurate with our understanding as time goes on and more studies come to light.

 

Sometimes we take a backward step where we thought we were pretty good, and then we realise, “Oh, no. There’s a massive publication bias in this literature.” What we thought was established pretty thoroughly turns out to be no, it’s actually, all the studies that showed it didn’t work just didn’t get published. It wasn’t that like, “science was wrong.” It’s like, no. There were just a glitch in the system, and science has self-corrected that now. Now we go from thinking like, okay, we really know how this works like, oh, actually, we’re not quite sure how this works. We thought we knew how it worked, but back to square one.

 

[0:36:36] HT: That’s the beautiful thing, is that there’s not really an emotional component to that, right? We’re just saying, if we learn something new, we adapt and we go on with the new information. Too soon, I’m a little bit getting to is that sometimes in our Pilates world, or the movement world is that we’ve been taught something and we hold on to that, and it becomes like a dogma that we want to hold on. Well, I was taught this, so it’s got to be like this.

 

Where science is saying, okay, we got it like this. Oops, we got it wrong. Let’s go back. Let’s correct it. There’s no emotional component to that. We see that new information. We correct it and we go on with it.

 

[0:37:16] RB: Yeah. What you just articulated is, I think, the most profound and powerful reframe we as movement professionals can do for ourselves, is which is to detach from our identity from being I am someone who does XYZ modality to being, I do what works best for my clients as currently known by current guidelines and etc. I’m agnostic as to what that thing will be. It’s like, well, if somebody’s in front of me and they’ve got back pain, rather than me thinking like, okay, I’ve got my pet modality that I’m going to use and applied the same tool for all jobs. If my question is not like, well, how can I apply XYZ modality to fix this? If my question is like, okay, well, what’s the best thing that would help this person? Of all the things we could do, what would be the most likely to help them? Let’s do that.

 

[0:38:08] HT: Yeah. Hopefully, it’s as simple as that. It’d be great.

 

[0:38:15] RB: It’s wonderfully liberating, because, I mean, I used to be very attached to my professional identity as – I mean, I used to teach posture analysis and muscle testing and queuing transverse abdominis, and a lot of things which I now don’t do. My identity was tied up in this. I was very skilled and proud of my skill at teaching people how to do the Thomas test for hip flexor length or teaching people how to queue multifidus. I could teach people how to activate their left L45 multifidus at 25% of maximum voluntary contraction. I could feel it swelling into my finger when I placed my finger on their paraspinal muscles. I was very proud of that.

 

I taught literally hundreds of students how to do that. Then I read a few systematic reviews that said, it’s actually no more effective than just going for a walk, or doing any form of exercise. When I realized, that gave me a lot of anxiety for a while. Crap, I’ve been teaching this thing that doesn’t – it’s not actually the magical solution that I thought it was. That made me feel very anxious. Then I realized like, well, if I just changed my mind, I can be on the winning side.

 

It’s like, if your team, if your sports team is losing, it’s like, well, in this metaphor, you can just go for a different team, go for the winning team. Just switch to the winning team. Then your team’s winning. If you’re wrong, you can just change your mind and then you can be right.

 

[0:39:35] HT: Yeah. I mean, I do think it’s that – it is that easy. I think you touched on something that’s really important, is that all of us, what all of us as teachers, we are passionate about what we do. This passion becomes our identity. We want to give this to other people. We’re helpers. That’s why we’re in this industry. When we have to, not necessarily backtrack, but course correct, because something new has – we’ve been given new information, we’ve discovered something new, that it might – this thing that I have been doing for 10 years, or whatever is maybe not the right way of doing it. That moment of change is liberating. Scary. Scary as hell sometimes, but it is a liberating thing, because that’s where all the growth happens.

 

That’s where actually, we’re doing an even better job as a teacher because we’re saying, “Hey, guys. I know I said this, but this new information, we’re going to try it like this, because I think this might be better for us.” Having the courage to do that, because our interest is in the health, and well-being of the person in front of us, not of our own ego.

 

[0:40:43] RB: I think it would be so wonderful if we could just normalise that in the Pilates world. If you go to a surgeon and you’re contemplating having some joint surgery and the surgeon says, “Okay. Well, we used to use the XYZ technique a couple of years ago, but now we know this new information. Actually, I’m going to use this different technique for you, because it’s more effective.” It’s like, you won’t think, “Oh, you idiot. You’ve changed your mind. You were wrong.” It’s like, no. You think, “Thank God, you’re going to give me the most up-to-date treatment, right?”

 

[0:41:10] HT: Right. Exactly. I had a hip replacement, and I chose my doctor because he said, “Well, this is the newest thing. This is what we’ve done. This is what we see.” Sign me up. That’s what I want. I want the newest information. He was great. He actually said, “Okay, this is what I used to do. This is when I changed my mind. This is all the stuff we’ve done in the future.” Or not in the future, since that point. I was like, “Okay. You’re my guy. You’re my doctor. Sign me up.”

 

[0:41:40] RB: Right. I mean, you don’t want the doctors like, “I’ve been doing this way for 40 years and I’m not going to change.”

 

[0:41:45] HT: No. Please don’t. Great analogy. Thank you.

 

[0:41:52] RB: Yeah. I think most of us, imagine, pretty much everyone would want that, the doctor who’s up with the latest developments and using the most effective prosthesis and the most effective surgical techniques and whatever. That’s like, yeah, we should. I think, I hope we can start to normalise that within the Pilates world. I think it doesn’t have to be a scary thing to let go of those beliefs and practices.

 

It doesn’t mean you’re less of a person, less of a practitioner, less of a professional. If anything, it means you’re more of all of the above, because admitting when you don’t know something, or admitting when you learned something new that you can update your practice. I think that’s an admirable thing. It actually will result in better quality care for your clients. Yeah, I don’t see how there’s any negative.

 

I think the negative only comes in our own minds when we think, like you said, we have that anxiety and that fear about making that change, or what will my clients think if I’ve been telling you this thing for years and I’ll tell you this other thing. It’s like, well, my experience is I’m an educator. I’ve been teaching my students to do this thing and then I change it. It’s like, I just recently made a post. We’ve been teaching external queuing for five, or six years now because the science told us that was the best thing.

 

Recently a meta-analysis came out just a few months ago that said, no, there’s significant publication bias in the external queuing literature. We can’t trust the published literature, because it omits all of the unpublished literature that maybe didn’t show that it’s better, right? Now, we’ve gone from external queuing is definitely better. You’re like, yeah, we don’t really know if it’s better or not. We don’t have enough evidence to know. I just put out a little post on that. I got 100% positive comments. “Huh, you taught me how to do it that way. Now, we’re doing it this way. This is great. I’m updating my beliefs.”

 

It’s like, yeah, you don’t have to fear changing your mind publicly. I think if we normalise it, it becomes a good thing. It’s like, when you see a study that says, or a news article, it’s this new treatment that comes out for XYZ disease. It’s like, that’s a good thing, right?

 

[0:43:53] HT: Yes. Yes. It’s funny how some – for it’s such a jump in some people’s minds of normalising that. It feels so big and scary in the Pilates world, where in so many other places, it’s just new information, new medicine. Great. Perfect. Let’s do it this way. All right. Let’s do it. I don’t know why it’s so scary in the Pilates world. Yoga world does the same.

 

[0:44:17] RB: Yeah. I mean, it’s possible to go too far the other way as well.

 

[0:44:20] HT: Of course.

 

[0:44:20] RB: I don’t think everything new is by definition, better.

 

[0:44:23] HT: Of course. Yeah.

 

[0:44:25] RB: Yeah, I’m not sure what it is in the Pilates world. I’ve thought about this a lot, but haven’t come up with any, very clever answers, I’m afraid.

 

[0:44:31] HT: Me neither. I’m still working on it. If I have a good theory, I’ll let you know.

 

[0:44:35] RB: I think that just the overall in general, like I said, I think we tend to overcomplicate things in Pilates. We tend to overthink things when it comes to injuries and conditions like this. Into that, if you’re listening to this and wondering, “Okay. If I have a claim with scoliosis, come into my studio tomorrow, what do I do with them?” It’s like, well, just do literally what you would do with anyone who didn’t have scoliosis. Literally do the exact same things you would do. Whatever you normally do with the client, just do that, right? Just ignore the fact that they have scoliosis. If they’re a bit tight somewhere, stretch that. If they’re a bit weak somewhere, strengthen that. Just what you would normally do, right?

 

If that happens to end up that you stretch one side and strengthen the other side because that’s where they’re weak and that’s where they’re tight, well, fine. No problem. There is no special source there, apart from the special source that’s already baked into Pilates. It’s like, just do what you normally do and it’ll take care of itself.

 

[0:45:33] HT: That is great advice and probably, where we’re going to end that great advice because it’s so – it is the permission, I think, that people needed to hear.

 

[0:45:43] RB: Well, thanks for inviting me on. I hope someone in the audience finds this useful.

 

[0:45:49] HT: Oh, I’m sure they will. I’m sure they’re going to contact both of us, I hope.

 

[0:45:53] RB: Thanks, Hannah.

 

[0:45:54] HT: Thank you.

 

[END OF INTERVIEW]

 

[0:45:57] HT: Thank you so much for joining us today. I hope you enjoyed the conversation. A great cost-free way of supporting us and the podcast would be to give us a five-star rating. You could also look down into the show notes and grab any one of the free resources for teachers. I hope to see you next week on The Pilates Exchange. Happy teaching, everyone.

 

[END]

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