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Episode 363

363. How to keep your clients safe in Pilates according to science

Here's how we know humans are antifragile:

  • Yoga is pretty dang safe here
  • But if you REALLY want a safe sport, take up breakdancing here (no, seriously!)
  • Or Crossfit here
  • Knees going in during a squat or lunge doesn't predict injury here
  • Plus here are my TWO episodes looking at this topic here and here

But what DOES predict injury:

  • Having weak hamstrings here
  • Having a weak barbell squat here
  • Doing too little for too long, followed by too much too soon here and here

And what protects against injury:

  • Strength training is the best injury prevention here and here
  • High consistent workloads protect against injury here

Mentioned in this episode:

Done-for-you client acquisition:



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Transcript
::

Welcome to Pilates Elephants, I'm Raphael Bender. How do we keep our clients safe in Pilates?

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I'm going to have a reasonably in-depth tour of the literature on injury prevention,

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alignment and load and see where that takes us and,

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come up with some strong evidence-based recommendations on how you can run your Pilates classes to,

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keep your clients as safe as possible.

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All right, so the two big questions here that kind of really interlock quite

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a lot are to do with, firstly, alignment.

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So to what extent, if at all, does alignment predispose people to injuries?

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And I'm talking about alignment, not just within a particular move,

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so like whether your knee is pointing in or out when you squat,

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but also just the choice of moves, like is it safe to do backbends or rotations under load?

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And so that's the first area I want to explore, alignment and relationship to injury risk.

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And the reason I want to talk about that is it's very, that's what most people

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think of when they think about injury risk is like, oh, how do I adjust someone's

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alignment to keep them as safe as possible?

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The second thing I want to look at is the relationship of load to injury risk.

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And so these things, the alignment and the load overlap quite a lot.

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And so we need to consider them together.

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So the first thing I want to really,

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I think, and really the number one thing that I want to share with you is the

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concept of anti-fragility and that

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asking the question of how important is alignment, how important is load,

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really both of these questions kind of miss the point,

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that there's not one ideal kind of setting for alignment and load to prevent

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injuries in Pilates or in any area of life.

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Because obviously we want to keep people safe in the Pilates class,

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but we also want to keep them safe the rest of the time when they're outside of the Pilates class.

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And many of us think of Pilates as amazing preparation for doing life.

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And so part of that is reducing chance of injuries or recovering from injuries.

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And so the idea that there's one kind of fixed you know,

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rule of alignment or rule of loading that prevents injuries is is just it misses

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the point and here's why because humans,

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are not fragile we're anti-fragile and anti-fragile is a coin a term coined by um nasim taleb.

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And what he means by that is something that gains by stress.

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So let's think about the three examples that I think illustrate this really

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well that Nassim Taleb uses.

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First, there's something that's fragile. Now, something that's fragile,

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almost any stressor is likely to make it worse.

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So think about your grandma's crystal vase that's been sitting in the cabinet

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it untouched for 20 years because it's too precious to use because you might break it.

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So anything you do to that, if you knock it, if you pick it up,

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if you drop it, if you walk past it and brush past it, it's not going to make it better.

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It's only going to, there's a chance that you're going to damage that with every

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time you knock it, the only possible outcome is it stays the same or it gets worse.

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And the harder you knock it, the more worse it's going to get.

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And when we think of something that's fragile and we think of the opposite of

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fragile, often people think of like resilient or robust.

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And that is something that's very tough and can withstand a lot of stress.

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I think about like one of those, I always think of those tough Tonka toys.

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I'm not sure if there's a brand anyone outside of Australia had,

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but these kind of really tough, rough and tough kind of tip trucks and things

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that I had when I was a kid that, you know, they're made for young kids and you can throw them.

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You can step on them, you can leave them out in the garden for three months

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in the rain, and they're totally fine. They just keep going through it all.

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And so these are very robust, they're very resilient. They can tolerate a lot of abuse.

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But that's not actually the opposite of fragile because fragile things,

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any kind of stress makes them worse.

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Whereas a robust thing, stress doesn't make it worse, but it doesn't make it better.

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So the opposite of something that's fragile is something that stress actually,

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it requires stress to thrive.

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And so that is humans, humans and all organic life.

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For example, if you take a human and you put them in bed and don't let them

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move for six weeks, they do not get stronger. They get weaker and they don't

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get more healthy. They become sicker.

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And so how to make humans more resistant to stress, we actually have to apply stress.

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And that's what we do for a living. We apply stress to the body in the form

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of resistance from the body weight or the springs on the Reformer or the Cadillac

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or whatever, and that stress stimulates the body to become stronger.

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So the stress makes us stronger, the opposite of fragile.

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Now, why is this important?

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Because if you apply stress to something fragile, you're only going to do it harm.

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Whereas if you apply stress to something anti-fragile, like humans,

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you're going to make them stronger.

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Now, there's a limit to how much stress humans can tolerate,

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and so you have to apply the right amount of stress at the right time.

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But stress is actually what makes us stronger.

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And when we're stronger, we're more resistant to injury.

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Because injury occurs when a body tissue, whether it's a ligament,

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a tendon, a muscle, fascia,

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bone, whatever it might be, is subjected to a load beyond its capacity to tolerate.

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And so if you subject the hamstrings to a load that they can't tolerate you

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get a hamstring tear if you subject a spinal disc to a load it can't tolerate

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you may have a disc injury,

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so how do you prevent injuries well do you avoid loading the hamstrings well

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how would you avoid loading the hamstrings send somebody to bed and don't let

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them move is that going to make them more resistant to injury no it's not it's going to make them.

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More vulnerable to injury. So how do you make somebody less likely to get a

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hamstring injury? You strengthen the hamstrings. How do you strengthen the hamstrings?

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You apply stress to the hamstrings in the form of load.

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So load is what too much load can cause an injury because the tissues can't tolerate it.

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Not enough load can predispose to injury because it causes the tissues to become

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weaker and reduces their load tolerance. So then when you do load it,

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you're more likely to injure it.

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The right amount of load at the right time reduces the likelihood of injury

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quite substantially because it increases the strength and resilience of those

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tissues and their ability to tolerate load.

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So with injury prevention, the question of what is the right load and what is

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load dangerous is not the right question.

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The right question is, how much load is the right amount to apply right now?

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And load is very, very specific. So if you want to prevent hamstring injuries, you should,

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apply load in the positions where the hamstring is vulnerable to injury.

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Now, you need to apply progressively and start with what the tissues can currently tolerate.

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But.

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If you want to make your spine robust to injuries during spinal extension or

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injuries during rotation or injuries during flexion, well, you need to apply load

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in those positions progressively, starting with what the person can currently

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tolerate and then progressively loading over time,

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to build up tolerance in those tissues.

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When I say tolerance, I mean the tissues literally get bigger, thicker, stronger.

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Like we have decent evidence, I mean, everybody understands that muscles get

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bigger when you load them,

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but it's also true that tendons, ligaments, discs, and bones,

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and connective tissue in general, get bigger and thicker and stronger when we,

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load them progressively and repeatedly over time.

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So with load and with alignment there is no one single rule that says you know

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this particular alignment or this particular load is ideal to avoid or prevent injuries,

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really what we want to do is progressively load all positions over time starting

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with the client what the client concurrently tolerate, and then progressively

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adding load to increase tolerance.

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Now I'm going to talk through some examples of this.

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There was a, I'm going to put a bunch of studies in the show notes.

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I'm not going to talk about every particular study in my little monologue here,

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but I'll put a bunch of studies in the show notes.

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So we have quite a few studies showing prospective differences between levels

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of strength predicting future injuries.

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So people with low strength have more injuries later.

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So if we measure a bunch of people's hamstring strength, for example,

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and then follow them for a year and we see who gets a hamstring injury,

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guess what? The people with lower hamstring strength at baseline had more injuries

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subsequently over the year.

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Uh and we see the river we can see the reverse as well um that,

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uh athletes who have a stronger squat so can squat more than 2.2 times body

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weight for males or 1.6 times body weight for females,

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have fewer lower body injuries in football softball and volleyball or put another

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way we could frame that exactly as the opposite,

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athletes who are not strong in their lower body, who are less strong in their

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lower bodies, have more lower body injuries.

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So if you want to predict how likely someone is to get injured in football or

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softball or volleyball, get them to squat and see how much they can squat.

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If they're a female and they can't squat 1.6 times their body weight,

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they're more likely to get injured.

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So by keeping our clients weak, by avoiding squatting maybe because we think

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it's dangerous, we're actually increasing the chance of them becoming injured,

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because humans are anti-fragile,

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and we actually require stress and load in order to thrive and become stronger.

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And we see that with a couple of quite substantial.

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Systematic review and meta-analysis that have come out over the last few years.

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There's one from 2018 by Lauson et al, which found that a 10% increase in strength

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training volume reduced injury risk by 4%.

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So increase it by 20%, reduce injury risk by 8%. Increase strengthening training

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volume by 30%, reduce injury risk by 12%, etc.

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And so this systematic review from 2018 from Lawson,

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Well, the title of the paper is a little bit of a giveaway. It's called Strength

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Training as Superior, Dose-Dependent and Safe Prevention of Acute and Overused

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Sports Injuries, A Systematic Review, Qualitative Analysis and Meta-Analysis.

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And so what they found was in the title that a very robust relationship between

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strength training and injury risk. Now, most of these studies were on actual hamstring injuries.

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So we we can't draw conclusions necessarily to every single possible injury

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but we have a bunch of other studies supporting this with some of which i'll

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cite today um there's a second meta-analysis by i'm not going to well i'm going to attempt,

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the the uh the name it's by klub bachowski et al uh,

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and from may 2026 so just a month ago at the time of recording this is called

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exercise-based strategies from warm-up to training, a systematic review of performance

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enhancement and injury prevention.

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What they found was that two forms of exercise, both neuromuscular warm-ups

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and strength training, were the most effective injury prevention.

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But when they look at the actual neuromuscular warm-ups they use,

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they were basically the FIFA 11+, which is the soccer warm-up,

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which has a lot of strengthening.

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There are all kinds of side bridges and adductor bridges and,

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you know, things like that in there and sprints and things like that.

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So it's pretty high load that neuromuscular warmup, I would call it a high load,

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or a strength-based neuromuscular warmup. So basically.

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The best quality and most recent research we have strongly supports this notion

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of anti-fragility and that's strengthening people's tissues and,

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protects those tissues that are strengthened against subsequent injury.

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And the idea of antifragility is also supported by the training on overuse injuries,

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by the research on overuse injuries in athletes.

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And so this is from the literature looking at typically ball,

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like grass team ball sports like football, et cetera, rugby,

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where they look at, they can do these, they can track exercise volume very easily

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because people like the players wear GPS trackers and they know how many miles

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they run each week, like when they're playing and training.

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And so what they found, what this literature consistently shows is that too

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little for too long followed by too much too soon is what causes injury.

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So in other words, big increases in training volume and or intensity increase

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the risk of injury. So if you apply an unaccustomed load that somebody's not

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able to tolerate, that increases the risk of injury. But-

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Athletes with consistent high workload suffer fewer injuries.

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So people who are conditioned to tolerate high loads because they habitually

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subject their tissues to high loads actually have fewer injuries.

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So the notion of overuse injuries is mostly, I think, I would say misapplied.

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So of course it's possible to get an overuse injury. I mean,

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if you did like 10,000 deadlifts in 24 hours, you would have almost 100% chance of getting an injury.

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So there is such a thing as overuse injuries, obviously.

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But I think we set the bar way too low for what the body can tolerate and in

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fact, what the body requires to thrive and become stronger.

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So I think in general,

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in Pilates as well as in exercise science and physiotherapy,

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we're way too conservative in what we prescribe for our clients in terms of

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exercise because we want to avoid overuse injuries.

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Actually high habitual training volumes, even like in elite athletes,

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like these people are running ridiculous amounts of distance and training ridiculously

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hard, predisposed to fewer injuries.

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So it's only high big spikes in training volume that are more associated with injuries.

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And then we have a bunch of literature on alignment that says that activities

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that have extreme positions in them like yoga, like breakdancing,

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like CrossFit, like,

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actually have relatively low injury rates. So yoga has lower rates of injuries

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compared to like just other general physical activities.

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Breakdancing, which is people just contort themselves into incredible positions.

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Just go to YouTube and type in like breakdancing competition.

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There's just some incredible work that they do.

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It's safer than badminton, safer than cycling, safer than sailing.

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And CrossFit, where people are, you know, flinging themselves through keeping

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pull-ups and doing, you know, tyre flips and handstand push-ups and all kinds of weird positions.

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Have very similar injury rates to Olympic lifting, where people use very,

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very precise technique under very controlled conditions.

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Um in fact crossfit have way fewer injuries than running soccer and even cricket,

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which is a pretty pedestrian sport um according to most people um,

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the there's not a really good relationship between running biomechanics and

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running injuries in fact it's just mileage that predicts injury risk in running.

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And even with, you know, just things with technique within the activity,

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like I mentioned right at the top, knees going in during a squat,

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that there's actually not really any good evidence that that causes injuries.

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In fact, if you just, again, do a YouTube

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search for powerlifting squat championships or something like that.

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You'll see a large number of elite strength athletes when they squat, their knees go in.

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And so that's probably not bad technique. In fact, I did a whole episode a while

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back, which I'll link to in the show notes, can't remember which one it was,

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talking about the biomechanics and the literature on why the knees going in

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the squat might actually be

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something that increases strength and reduces injury risk during a squat.

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And there's a 2020 systematic review of meta-analysis that,

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looked at this question specifically and concluded that knees going in during

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a squat doesn't increase injury risk. We have got no evidence that it does.

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So besides that, we've got multiple large meta-analyses that have shown that

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spinal flexion does not predict back injury.

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In fact, people with more back pain tend to lift with a straighter back.

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And in fact, the belief that moving wrong is dangerous correlates with more pain.

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So in summary, now, I mean, there's many more of these studies.

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So, you know, for example, poor scapular mechanics, you know,

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in quotes, don't predict shoulder injuries and I'll link to most or all of these

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studies depending on how sick I get of copying and pasting them into the show notes.

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But so in summary, Sorry.

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Load, too much load applied to tissues that can't tolerate that load causes injuries.

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Not enough load causes the tissues to become weak and vulnerable to injury.

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So load is both the poison and the medicine because load applied progressively

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over time strengthens the tissues and increases their load tolerance and resistance to injury.

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So it protects against injuries. So too much load, too soon,

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after too little for too long, causes injury.

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Load applied progressively over time reduces the chance of injury or protects

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against injury because humans are anti-fragile.

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And so should we be careful of loading people in extreme positions?

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Yes, if they're not conditioned to tolerate those positions.

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But we should be careful of loading people in any position they're not conditioned to tolerate.

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We should start with a load that they can tolerate and progressively build that load over time.

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And I would argue that it's perfectly safe and in fact probably a lot safer,

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to progressively load someone in extreme spinal positions like flexion,

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rotation, extension, whatever.

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And because that will build up top progressive tolerance to that,

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those positions in their spinal tissues, not just the disc, but the bones,

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the ligaments, the tendons, the muscles, all of the above.

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And just anecdotally, I mean, I do that with my spine.

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I do full range extension, like full backbend as far as I can bend down to full

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flexion as far as I can flex with as much load as I can do for six or seven reps.

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And I think I'm currently doing on my weight stack 125.

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Kilos, something like that. And my back's never felt better and I'm 55 years old.

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And I've been doing that for quite a while. So I know that's an N of one,

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but don't worry, I'll front load all of the scientific papers in the show notes.

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So dear listener, how do we keep our clients safe? Well, I think the answer

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to that is teach them Pilates through full range.

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Don't fear any positions. There are no dangerous positions. There are no wrong positions.

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There are only positions we're unaccustomed to. And so when introducing a new

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position that someone is unaccustomed to, be, I would say.

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I want to choose the right word here.

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Begin with something that you're confident they can tolerate.

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Wait and see how they pull up a couple of days later. If they tolerate it,

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add 10% next time and go again. And just keep going until they reach a point

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where they're like, oh, this is really freaking hard.

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And then just give them adequate recovery in between sessions,

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a couple of days recovery in between sessions. and you can build up load as

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they're able to tolerate it.

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And so that is, I think, in my opinion, the way to maximize the safety of the

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client both in and out of the Pilates class.

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Because even if we avoid certain positions in Pilates, like if we took it to

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the extreme and never rotated our spine under load or never extended our spine

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under load during Pilates,

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Well, that person is going to do both of those things in their real life.

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Okay, when you pick up a kid out of the back seat of a car or you get out of a chair.

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Pulling the washing out of the machine, there are constant situations multiple

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times every day where pretty much every single one of us rotates,

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flexes, and extends our spine under load.

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So just avoiding it during the Pilates class isn't going to prevent injury if

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rotating your spine under load is going to cause injury.

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The much better strategy is to actually build up a tolerance to those positions

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so that when they do inevitably occur in life, they're not a problem.

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And so that's what we would do for any other body part.

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If you're rehabbing an ACL in the knee and you want to prevent that from re-injuring, what do you do?

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You build up a tolerance to the previously injurious stimuli.

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So you have to eventually be able to do direction change in weird angles and

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positions and rotation of the knee.

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Under load at speed. Because if people want to get back to playing sport,

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that's going to occur on the field and they have to be able to tolerate it.

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And how do you get them to tolerate it? Well, you have to start with a low amount

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of load at a slow controlled speed and gradually, gradually over time,

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build up the load and the stimulus and the stress in those positions and build up the tolerance.

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And that, I mean, that's Rehab 101 and Rehab and Injury Prevention are the same

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thing because they're both about building up tissue tolerance to a potentially injurious stimulus.

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And rehab is just where there already has been an injury.

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So we want to build up a tolerance to the same exact stimulus that caused the

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injury so that in future, that same stimulus won't cause another injury.

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Whereas in injury prevention, it just hasn't happened yet.

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So we want to build up a tolerance to that potentially injurious stimulus before it causes an injury.

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But the process is exactly the same. You just gradually build up tolerance to

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the thing that you're worried about causing an injury.

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The poison is the medicine with injury prevention and with rehab, it's the same thing.

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All right, dear listener, keep safe, bend your spine, under load progressively,

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start with what you can do, keep progressing it, keep getting stronger,

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keep getting more awesome and I'll see you in the next one.

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