BENEFITS OF CLINICAL PILATES

Joseph Pilates wrote in his book ‘Return to Life Through Contrology’ that “The Pilates Method teaches you to be in control of your body and not at its mercy.” His original method was a series of specific exercises performed in a certain order to improve flexibility, build strength and endurance of the whole body.  These exercises were often performed with long levers (arms and legs extended out away from the body) and as such if the individual didn’t have sufficient mobility or strength, were not always performed in a “controlled” fashion.  This is why the original Pilates method has been adapted  by current educational providers, such as the Australian Physiotherapy Pilates Institute (APPI) to be more clinically relevant and applicable to a patient population, with staged progression from closed kinetic chain exercises to open kinetic chain exercises, incorporating spinal mobility and functionally relevant strengthening exercises.

Research in the 1990s and early 2000’s suggested that in order to protect the spine and rehabilitate people with chronic low back pain (CLBP) we must first engage our “core muscles”.  It was thought that the delayed activation of the Transversus Abominis (TrA) muscle in response to chronic pain perpetuated the pain cycle by creating increased forces through the spine (Hodges and Richardson, 1996).  As a result, Physio's and Pilates instructors started to prescribe “core exercises” to all individuals with LBP.  However, logically the idea of creating more stiffness via force closure of the pelvis and lumbar spine is counter-intuitive to dealing with a large proportion of clients with CLBP who present with stiff backs.  Clinically, the vast majority of clients with CLBP that I see present as hypomobile, i.e. stiff.  These individuals need to be encouraged to mobilise their spine, allowing it to move in ALL directions freely without the fear that  movement will cause increased “damage” to the spine.  Unfortunately, some in the medical/health field are still creating fear of movement in clients by telling them they shouldn’t bend or flex the spine with certain presentations such as a disc bulge.  Although I wouldn’t load someone in flexion with an acute disc bulge, many CLBP clients who present were diagnosed with a disc bulge on imaging 10+ years ago and since then have been fearful to flex or rotate their spine.  

As such, when I teach Pilates to clients (and educate other clinicians about the Pilates method), I rarely cue “activate the core” before they do an exercise.  Exceptions always exist, most obviously a post-natal woman whose Pelvic Floor and TrA muscles have been stretched considerably, but for the most part cueing correct movement patterns will enable the core to engage automatically.  And for those that are chronically hypomobile (stiff), exercise prescription focuses on “letting go”,  allowing the body to move, rather than being too finicky about pre-activation of the core.

A recent literature review (Lin et al, 2016) concluded that Pilates was no more beneficial than other forms of exercise (that included waist or torso movement) for CLBP.  I’m not going to say that Pilates is a superior form of exercise however, to the critics  who say that Pilates is a waste of time for CLBP, my argument is that if an individual requires guidance and reassurance to help them start to exercise more, then Pilates is perfect for this.  One of the main barriers that many individuals with CLBP face is a fear of movement and exercise due to the belief that this may further harm their back.  Therefore, I would argue that doing exercise in a safe and encouraging environment with a qualified physiotherapist and Pilates instructor is the perfect way to break this ‘fear of movement’ cycle, allowing the individual to mobilise their spine in all directions and build strength through the upper body and legs.  For many individuals this guidance is what they’re needing in the initial phase to feel confident to do other forms of exercise independently.

In summary, I believe that an individual approach to Clinical Pilates where the client’s goals are addressed and appropriate exercises are prescribed to encourage movement of the spine, awareness of the core muscles, and graduated progression of load towards functional positions can be beneficial to all.  

REFERENCES

Hodges P and Richardson C. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transverus abdominis. Spine 1996; 21: 2640-50.

Lin H et al. Effects of pilates on patients with chronic non-specific low back pain: a systematic review. Journal of Physical Therapy Science 2016; 28: 2961-2969.