MD, PhD, FMedSci, FSB, FRCP, FRCPEd

What is the best treatment for the millions of people who suffer from chronic low back pain (CLBP)? If we are honest, no therapy has yet been proven to be overwhelmingly effective. Whenever something like that happens in medicine, we have a proliferation of interventions which all are promoted as effective but which, in fact, work just marginally. And sure enough, in the case of CLBP, we have a constantly growing list of treatments none of which is really convincing.

One of the latest additions to this list is PILATES.

Pilates? What is this ? One practitioner describes it as follows: In Pilates, we pay a lot of attention to how our body parts are lined up in relation to each other, which is our alignment. We usually think of our alignment as our posture, but good posture is a dynamic process, dependent on the body’s ability to align its parts to respond to varying demands effectively. When alignment is off, uneven stresses on the skeleton, especially the spine, are the result. Pilates exercises, done with attention to alignment, create uniform muscle use and development, allowing movement to flow through the body in a natural way.

For example, one of the most common postural imbalances that people have is the tendency to either tuck or tilt the pelvis. Both positions create weaknesses on one side of the body and overly tight areas on the other. They deny the spine the support of its natural curves and create a domino effect of aches and pains all the way up the spine and into the neck. Doing Pilates increases the awareness of the proper placement of the spine and pelvis, and creates the inner strength to support the natural curves of the spine. This is called having a neutral spine and it has been the key to better backs for many people.

Mumbo-jumbo? Perhaps; in any case, we need evidence! Is there any at all? Surprisingly, the answer is yes. Recently, someone even published a proper systematic review.

This systematic review was aimed at evaluating the effectiveness of Pilates exercise in people with chronic low back pain (CLBP).

A search for RCTs was undertaken in 10 electronic. Two independent reviewers did the selection of evidence and evaluated the quality of the primary studies. To be included, relevant RCTs needed to be published in the English language. From 152 studies, 14 RCTs could be included.

The methodological quality of RCTs ranged from “poor” to “excellent”. A meta-analysis of RCTs was not undertaken due to the heterogeneity of RCTs. Pilates exercise provided statistically significant improvements in pain and functional ability compared to usual care and physical activity between 4 and 15 weeks, but not at 24 weeks. There were no consistent statistically significant differences in improvements in pain and functional ability with Pilates exercise, massage therapy, or other forms of exercise at any time period.

The authors drew the following conclusions: Pilates exercise offers greater improvements in pain and functional ability compared to usual care and physical activity in the short term. Pilates exercise offers equivalent improvements to massage therapy and other forms of exercise. Future research should explore optimal Pilates exercise designs, and whether some people with CLBP may benefit from Pilates exercise more than others.

So, Pilates can be added to the long list of treatments that work for CLBP, albeit not convincingly better than most other therapies on offer. Does that mean these options are all as good or as bad as the next? I don’t think so.

Let’s assume chiropractic/osteopathic manipulations, massage and various forms of exercise are all equally effective. How do we decide which is more commendable than the next? We clearly need to take other important factors into account:

  • cost
  • risks
  • acceptability for patients
  • availability

If we use these criteria, it becomes instantly clear that chiropractic and osteopathy are not favourites in this race for the most commendable CLBP-treatment. They are neither cheap nor free of risks. Massage is virtually risk-free but not cheap. This leaves us with various forms of exercise, including Pilates. But which exercise is better than the next? At present, we do not know, and therefore the last two factors are crucial: if people love doing Pilates and if they easily stick with it, then Pilates is fine.

I am sure chiropractors will (yet again) disagree with me but, to me, this logic could hardly be more straight forward.

14 Responses to Pilates for chronic back pain? Yes, maybe

  • So for the most useful/meaningful research for low back pain, should we disregard the treatment itself and use cost, time and adherence to the treatment as the outcome measures?

    How would i do that? Genuinely, how would i do that? Any advice would be greatly received.

    • no, this is not what I meant; such factors might determine what treatment patients prefer, not what the research agenda should be. the outcome measure for pain is pain.

      • Sorry, my inexperience in expressing my thoughts by text is showing.

        What i meant was that the treatment is irrelevant as they all provide similar results. So the main outcome measure is pain and the most likely way we would influence that is by providing treatment that the patient is most likely to adhere to. What they prefer and what they are consistent with could be totally different.

        So useful research would focus more on the way to create adherence to the treatment rather than the treatment itself? I suppose the question i was trying to ask before was what could be done at a clinical level to investigate how to make people comply. I now understand this is a slightly naive question but thought i would post it anyway.

  • Simple bending and stretching exercises every morning can go a long way to fending off lower back aches and pains. Also, proper posture and good seating. In all, many people could very likely save themselves from a lot of back trouble with not a whole lot of time spent doing such things. It is nothing short of hilarious to hear some chiropractors talk as if exercise was a medical approach that they came up with! Come on, now.

  • Pilates originally was based around expensive machines like the Reformer. In the last 25 years (in order to compete with Yoga) equipment-free mat Pilates was developed.

    http://life.gaiam.com/article/should-you-do-pilates-mat-or-reformer

    Many of the exercises shown in the Pilates link in your article are similar, if not identical, to Yoga postures and dozens of other movements from the myriad of equipment-free calisthenics programs developed in the last 100 years. Most commercialized exercise regimes are inbred and derivative – nothing more than variations on a theme, with the Pilates mat work claim to fame as focused primarily on the core.

    In the Wikipedia article on Pilates, Joseph Pilates intent was to develop a system that united “Physical and Mental Conditioning” not unlike the “Yoke” as the metaphor of yoga as a unifying force for believers in the dualist model of mind and body.

    The conclusion is that all of the mat-based exercise programs have similar overlapping movements or postures and can thus all claim themselves as an effective form of CLBP relief.

    Keep up the great work. We in the trenches appreciate your efforts.

    • Pilates mat exercises were developed prior to the equipment, and obviously during Joseph Pilates’ lifetime (1883-1967). They were NOT developed in the last 25 years “in order to compete with yoga”. This is very basic knowledge for anyone slightly interested in expressing an opinion regarding Pilates.

  • Edzard, I couldn’t disagree with you more on this one – I happily recommend Pilates to my patients as a means of helping them stay out of the treatment room. Not a good business model for me, but one that helps me sleep at night.

    • @Rogue Chiro

      What is it in EE’s post you do not agree with. It seems to me you both recommend Pilates as a better alternative than chiropractic?

  • In my experience Pilates can make your spine much more flexible: after a year of it my pelvis in sitting has rolled back by around 5 degrees (less lordosis) and my kyphosis is also going. Progress sped up when I added one-to-one tuition, first as matwork and now in an equipment studio. My intuition is that my spine is working better.

    Contrast this with a colleague who recently took some time off work with CLBP. He had a workstation assessment by a nurse who recommended a fancy chair and several massage sessions from a physio. I do not think the underlying problem has been solved, but this does fit what I call the car-mechanic view some patients adopt: “Doctor, my back isn’t working: please fix it”. For a brain tumour, it’s a sensible mental model: for back pain, less so.

    • Well, a very popular chiropractor only made his bank balance better, not my back. I had never been so slow recovering from a bad lumbago and I was really not improving any despite repeat visits for months. My back has been fine however since I increased my walking, hiking and exercising and fixed a few minor ergonomic factors in my environment. I earnestly did believe the purported evidence for chiropractic for acute and chronic LBP at the time. Now I know better.

      The worst thing is recalling how the man insisted on manipulating my neck briskly at every visit even if that was not problematic at all. I get shivers down my spine thinking of the small but real possibility of vertebral artery damage.

  • Look at Peter O Sullivans (probably the worlds leading academic researcher for low back pain) views on pilates.Basically its not good if you have back pain.Why tighten an overly tight and reactive group of “core” muscles.You are just throwing petrol on the fire.On top of that you get a pretty low grade CV workout.If you don’t have back pain and enjoy it well go ahead.

  • Oh and by the way stretching doesn’t lengthen muscle nor does it reduce injury-go to the evidence.On a similar note ice,heat benefits are not known and ice probably slows down the healing process.
    But my favourite -early MRI for low back pain gives far worse outcomes(you get pathologised and play up to a diagnosis that most people in the pain free population have i.e disc bulges and arthritis etc.)

  • “Mumbo-jumbo?”

    The theory of Pilates (and the concept of core stability in general) is based on some very doubtful ideas. Is it really important if multifidus activation is delayed by several microseconds?

    On the other hand a Pilates class with an instructor provides a reassuring environment in which to regain confidence in movement. For people who fear bending forward because they think it will cause disc damage (some people have been taught this by therapists) the benefits of exposing your nervous system to safe, progressive movement are huge.

    Personally I think that the psychological benefits are more significant than the effects of strengthening transversus abdominus.

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