Pilates has existed as a form of exercise for over 100 years. Originally popular with dancers, the last 20 years have seen it pushed forwards into the sphere of lower back pain rehabilitation. This blog will focus on the link between Pilates and rehabilitation for lower back pain in particular.
Important research over 25 years ago discovered that the muscles closest to the spine had a role in its stabilisation (Panjabi et al 1989). Dysfunction in these muscles was found in patients with lower back pain and therefore a lack of spinal stability often referred to as ‘core strength’ was identified as an important factor in recurrent back pain (Hodges and Richardson 1996 and 1998). The transversus abdominis muscle, the multifidus muscle, the pelvic floor muscles and the deep gluteal muscles were identified as important. Based on this research, physiotherapists started to develop exercise programmes to address the dysfunction. The problem was thought to be due to altered motor control, that is to say the way in which the muscles are controlled by the brain itself. Retraining focusses initially on very specific activation of these muscle groups with lots of repetitions and then progresses gradually to more integrated exercises. An example of how a physiotherapist might teach you to activate transversus abdominus is given below:
Activation of transversus Abdominis
Breathe in and on the breath out imagine a line that connects the inside of your two pelvic bones (front of hips). Think about connecting, or drawing the muscle, along this line as if closing two book covers. No movement of your hips, pelvis or spine should occur. If you palpate your belly just inside the left and right hip bones, this deep contraction should feel like a light, deep tension under your fingertips, not a contraction that pushes your fingers out. Hold the contraction for 3 – 5 seconds and then release and breathe throughout this exercise.
The focus and the control required for this type of physiotherapy rehabilitation soon lead to an area of cross over with the principles behind traditional Pilates exercises. Pilates quickly developed popularity as an exercise form for people who had experienced lower back pain. Many physiotherapists have now trained in Pilates and have incorporated modified Pilates exercises into their rehabilitation programmes. Below are examples of Pilates exercises often taught by Physiotherapists as part of early lower back rehabilitation.( Terminology from the APPI (the Australian Physiotherapy and Pilates Institute) is used).
1. Setting your centre (hundreds level 1.)
In the Pilates rest position (on your back with your knees bent up), head and neck supported, breathe in to prepare, breath out and slowly and gently draw in your lower abdominal or pelvic floor muscles to engage your centre. Breathe normally for 10 breath cycles, whilst maintaining your centre and neutral spine alignment.
2. One leg stretch (level 1.)
From the Pilates rest position, engage your centre as above, breathe out as you slide one heel forwards to lengthen your leg fully, breathe in as you slide your leg back to the rest position. Repeat on the other side.
3. Shoulder |Bridge (level 1.)
From the Pilates rest position, set your centre, breath in to prepare and as you breathe out peel your spine away from the mat one vertebra at a time until you are resting on your shoulder blades. Breathe in to hold this position and as you breathe out gently replace your spine onto the mat.
Research into Pilates and lower back pain
A recent Cochrane review has started to provide an evidence base for Pilates in the treatment of lower back pain. Whilst it is clear that more studies are needed to fully support the role of Pilates in rehabilitation, the emerging evidence is supportive of its’ role in reducing pain and disability at short term follow up for patients with non specific lower back pain (Yamato et al 2015)
Some of the reasons why it is difficult to standardise Pilates research include:
• A large repertoire of exercises which can be adapted or modified
• Different schools of Pilates which have slight variations in the method e.g. Polestar Pilates, Stott Pilates, Body Balance, APPI.
• A huge variety in the training levels of instructors and therefore in the quality of the exercise instruction given.
Group vs Individual Pilates-how many is too many?
The increasing demand for Pilates in recent years due in part to the association with celebrity workouts as well as its role in rehabilitation has lead to larger classes in less specific environments. Key principles of any method of Pilates include the following:
• Flowing Movement
• Integrated Isolation
It is easy to see how these principles can be lost in larger groups, where the teacher is unable to monitor individual movement patterns. On a lot of occasions where Pilates has had bad press in back pain rehabilitation it has been because of these differences in group size and supervision. A Pilates class of 20 people given by a gym instructor who has done a weekend course in Pilates would be expected to yield very different results to a 1:1 or 1:3 session with a specifically trained Pilates instructor. Unless your Pilates class is focussing on the principles of Pilates and specifically allows the instructor to monitor the individuals then it does not align with the research into lower back pain and would not necessarily be expected to have a positive effect on your pain levels.
Many people are discouraged by higher prices for smaller group or individual Pilates classes. However it is important to realise that better supervision is much more likely to yield better results, particularly in terms of pain and disability.
Do I need Physiotherapy or Pilates?
If you are in pain then the chances are you need to see a physiotherapist to be assessed. If you are already doing Pilates then your Pilates instructor will probably suggest this. One of the biggest differences between your Pilates instructor and a physiotherapist is that your physiotherapist will give you a diagnosis. Your Pilates instructor can assess you for incorrect movement patterns which will likely be associated and may be a cause of your problem. However your physiotherapist has more background in the physiology of injuries and can help to identify more easily the structure which may be injured or under strain, for example the intervertebral disc in lower back pain. This enables them to advise you on the need for investigations or referrals to other specialists if needed. Your physiotherapist can even refer you directly to a specialist if it is needed depending on your insurance company. Furthermore they will give you a timeframe for your recovery.
Once you have a diagnosis and it is clearer where your pain originated from, it is not usually necessary to stop Pilates completely. If you are in an acute stage of pain you may need to modify your usual workout programme as there may be some exercises which should be avoided and you may need to adapt others until the pain settles. However increasingly research, particularly in back pain, is advising that it is important to continue exercising.
I have been doing Pilates with my Physiotherapist, should I carry on with her or see a Pilates instructor?
As you move out of the acute phase of an injury and your pain becomes more manageable you will need to focus more on the rehabilitation of your muscles. You will require less of the manual therapy skills which a physiotherapist provides initially to ease your symptoms and improve movement restrictions. At this stage your physiotherapist may recommend that you continue your rehabilitation with a Pilates instructor. This is a great way of improving your overall exercise tolerance and fitness and making your body more resistant to re-injury. It also promotes clients to take responsibility themselves for their full rehabilitation.
Whilst building an exercise programme around your specific injury, progressing exercises you have already started with your physiotherapist, Pilates sessions will focus on the body as a whole and include work for your overall alignment and posture. Your Pilates instructor should be specifically trained in imagery and facilitation skills to help you achieve the correct postures and best muscles activation during different exercises.
Joseph Pilates himself initially advised 10 sessions of Pilates to feel a real difference and a further 10 sessions to see visible differences in posture and form. Many clients enjoy their Pilates rehabilitation so much that they continue to attend sessions and their programmes evolve to become a challenging full body work out. At little Venice Pilates our Physiotherapists and Pilates Instructors are always happy to liaise together when necessary to give you the best advice depending on your stage of rehabilitation.
By Nikki Richards MPHTY(Sports), BSC(Hons), MCSP
M Panjabi, K Abumi, J Duranceau, T Oxland (1989) Spinal Stability and Intersegmental Muscle Forces: A Biomechanical Model. journals.lww.com
Hodges PW, Richardson CA (1996) Inefficient muscular stabilisation of the lumbar spine associated with low back pain: A motor control evaluation of transversus abdominis. Spine 1996;21:2640–50.
Hodges PW, Richardson CA Delayed postural contraction of of transversus abdominis associated with movement of the lower limb in people with low back pain. J Spinal Disord 1998;11:46–56.
Yamato TP, Maher CG, Saragiotto BT, Hancock MJ, Ostelo RWJG, Cabral CMN, Menezes Costa LC, Costa LOP. Pilates for low back pain. Cochrane Database of Systematic Reviews (2015), Issue 7. Art. No.: CD010265. DOI: 10.1002/14651858.CD010265.pub2.
E Withers, G Withers (2011) Back to Life with APPI Pilates. APPI Health Group Limited.