For many years, Clinical Pilates has been the popular vessel of Physiotherapists to prescribe “core stability” programs for people with low back pain. Historically, these core stability programs have encouraged clients to engage core muscles and maintain this contraction while they perform a series of movements. Recently, there is a growing mass of research showing that this approach is not as beneficial as we once thought.
A recent systematic review of the literature suggested that in people with low back pain, core stability programs are no more effective than general exercise (Smith, Littlewood & May, 2014).
It is even hypothesised that encouraging these heightened contractions and rigid postures can breed unhealthy beliefs around pain and movement, and perpetuate symptoms (Nijs et al., 2013).
Given this shift in thinking, it is imperative that Physiotherapy, and in particular Clinical Pilates evolves.
Thankfully, Clinical Pilates has the capacity to move beyond this stability approach. Clinical Pilates can be used as a platform to explore movement rather than promote rigidity. It can take focus away from isolated contractions and concentrate more on factors science is telling us contribute to pain. I have listed below a few areas in which I believe a modern Pilates approach can be helpful to people with low back pain.
Altered body schema has been observed in people with low back pain (Mosely, 2008). This manifests as a lack of awareness of body position with movement. Performing movements with tools such as mirrors for visual feedback in various positions can help reconnect with movement and improve movement co-ordination.
The experience of pain with a given movement is linked to the perceived level of danger to the body’s tissues with that movement, not the actual state of the tissues (Mosely & Flor, 2012). Meaning, if you subconsciously think a movement will hurt, it probably will, whether there is any damage occurring or not. This also means that performing a similar movement in a different functional context or position can be completely pain free, as there is no perceived threat by the brain in that scenario. Exploring these different positions and progressing back towards the original movement can start to diminish the perceived danger with that task.
Tissue loading with exercise can have an effect on several levels. Firstly, loading muscles, tendons and joints around a painful area can initiate a neurophysiological response, diminishing symptoms for short periods (similar to that of manual therapy). Secondly, mechanical loading can promote tissue repair in muscle, tendon, cartilage and bone through a process called mechanotransduction (Khan & Scott, 2009). Loading tissues appropriately through a variety of targeted mobility and strength based drills can make use of these factors.
In summary, discouraging rigidity and being liberal with movement can contribute to a more modern and evidence based Clinical Pilates approach for low back pain. As always, chatting to your Physiotherapist about the benefits of exercise for your problem is the best place to start.
Khan K. M., & Scott A. (2009). Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine, 43, 247-251.
Mosely G. L. (2008). I can’t find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain, 140, 239-243.
Mosely G. L., & Flor H. (2012). Targeting cortical representation in the treatment of chronic pain: a review. Neurorehabilitation & Neural Repair, 26(6), 646-652.
Nijs J., Roussel N., Paul van Wilgen C., Koke A., & Smeets R. (2013). Thinking beyond muscles and joints: therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Manual Therapy, 18, 96-102.
Smith B. E., Littlewood C., & May S. (2014). An update for stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskeletal Disorders, 15, 416-437.