Guiding Principles for Teaching Movers with Chronic Pain

I was recently asked to speak to two different communities of movement educators about You’re Meant to Move and my general approach to working with clients in pain. Typically I spend my time talking with aspiring movers. So, it was a uniquely rewarding and thought-provoking experience to see my book through the eyes of teachers and teachers of teachers. 

In response to the discussions we had, I put together a list of guiding principles for instructors looking to create a successful movement experience for chronic pain sufferers. In my opinion, this represents a solid foundation for getting started with clients on a movement-through-pain journey. However, this work is so individualized that our approaches must be nimble and responsive according to the specific challenges, learned thought patterns and distinct desires of each client. If you are interested in talking through a particular situation in detail, I invite you to schedule a Pilates Teacher Mentoring Session with me.

Before the session: Gather the background, but make it easy.

As with other clients, you will want to offer a vehicle for learning about the client’s movement needs, experiences and goals before they arrive. This gives you a chance to gather whatever additional clinical insight or research you need to build trust and confidence with the new client. 

You may use something like an intake form, or an initial assessment session, or both. Keep in mind that people with chronic conditions of any kind have to repeat their medical histories over and over again every time they see someone new, and it can become exhausting. Try to simplify their efforts with clear guidance on which aspects you want to know. Consider using things like checkboxes or drop-down menus to streamline the response process. 

As a movement educator, you don’t need to know the ins and outs of each person’s clinical history in order to be effective. But the client is not going to necessarily know what is most useful for you. Make things simple by honing in exactly on the information you need (e.g. Have you been cleared for exercise? Are there specific limitations/considerations we need to keep in mind when moving together?). This is difficult to do in a standardized form so I do recommend complimenting with a conversation to get a clear narrative.

In early sessions: Get the weight stigma conversation out of the way. 

So many clients will come in carrying the insufferable burden of shame that comes from the belief that being in a larger body is the root cause of chronic pain. Some of this stems from our own judgment and social pressures and some gets perpetuated by well-meaning but ill-informed members of the medical community. Either way, it is important for clients to understand that losing weight is not a pathway to pain reduction. 

Since self-criticism and people-pleasing behaviours ARE predictors of chronic pain, it is unsurprising that many clients start their movement journeys already apologizing for something or blaming themselves. So we need to try and get to the root of this habit at the onset and encourage clients to see their bodies as a partner rather than an adversary. It helps to have research in hand to prove this point, and You’re Meant to Move has lots you can reference.

In early sessions: Commit to what you are certain of and nothing more. 

You are in this business because you care about people. I know you want to be a part of helping others feel their best. But so often I see movement educators promising that they can get people out of pain, when this is simply not something we can guarantee. Do most of my clients experience some kind of relief from their symptoms after working together? Yes. But persistent pain occurs for a wide range of reasons that are difficult to isolate and we cannot and should not promise our clients that by working with us they will find pain relief. 

What we can guarantee is that with regular practice, client mobility, strength and overall confidence in movement will increase. We have the education and tools to guide them through that process with success. But we are not healers. And creating a false expectation that movement cures pain also sets that client up to feel like a failure if pain re-occurs, which it is likely to do. 

Throughout the movement journey: Help clients put pain in perspective.

Pain comes and goes. Pain is a part of the human experience. Pain is the result of a well-functioning nervous system. We cannot prevent it. Our role instead is to overcome pain as an obstacle to high quality movement. One of the ways we do that is by helping our clients see pain as just one of many experiences in a kaleidoscope of sensations. Doing this in practice means that we encourage our movers to take note of various feelings that arise in their bodies as they move, without overwhelming them. 

This is a balancing act. Swing the pendulum too far and the client will become hypervigilant about every single sensation that arises, resulting in an inability to be present and likely undermining any hopes of conquering the fear of pain in movement at all. So you have to be a gentle guide, remaining open and responsive to the individual in front of you. You know you’re doing well when a client remarks that they are learning to discern between pain that is just a mild discomfort that needn’t get in the way and pain that is a sign they should stop doing something.

In-between sessions: Hold clients accountable.

Most people with chronic pain have a difficult time showing up for themselves; giving ample attention to their own needs. Rather than being a consequence of chronic pain, it’s likely that this character trait contributed to the development of a chronic condition to begin with. So you have an important role to play in gently reminding your clients to prioritize their movement goals. You do this by supplying homework assignments and following up on completion. And encouraging consistency as well as patience.

I don’t just assume my help is wanted – I always ask my clients how much accountability they want from me. Most of the time they agree that they need a partner to hold them to their goals. Again, there is balance required here as it can be easy for accountability check-ins to start to feel like another source of guilt. Remind clients that every day is a new day and it doesn’t matter what they did or didn’t do yesterday. Each moment is a chance to make a new choice. You can have a huge impact by supporting clients’ positive self-care habits in a way that is sustainable and nurturing.

In-between sessions: Build an evidence base. 

With the experience of persistent pain often comes a negativity bias where clients struggle to acknowledge their bodies’ positive attributes or identify progress as it's happening. It is crucial that you both bring attention to achievements as they happen and also cultivate a discipline of objective self-evaluation among clients. As an example, many clients fear that a pain flare-up will happen in response to exercise–maybe not that day but even one or more days later. Depending on the nature of any underlying condition associated with that person’s pain, it may very well be that symptoms tend to increase after a session. However, I find that it is difficult for clients to separate the reality of pain from feelings about or fear of the pain. 

One thing I suggest is a simple daily tracker with both a pain score and a list of any activities that the client felt they could not complete as a result of their pain. Over time, this will help you make evidence-based assessments in partnership with your client and also to identify any patterns of exacerbating symptoms that can be addressed. What I usually find is that when clients start this practice they are surprised to realize that whatever discomfort they experience after movement sessions was not actually as disruptive as they imagined; and definitely not as disruptive as complete movement avoidance would have been.