The Pilates Method of Exercise: Effectiveness ​in the Treatment of Chronic Low Back Pain​ and Intervention Limitations

Objective
      This first review does not introduce one, but several articles on low back pain, revealing limitations often encountered in Pilates research. 
​The goal of this article is to assess the effectiveness of the Pilates method in the treatment of chronic low back pain by reviewing scientific studies in which the Pilates Method was used as treatment. A critical look will be taken at the studies’ limitations and the types of exercises used.
The studies were required to meet scholarly standards, be peer reviewed and are randomized and controlled trials. 

Study inclusion criteria
      A Boolean search for randomized controlled and clinical trials using (Pilates) AND "low back pain" on PubMed (including MEDLINE) returned 24 results.

• 1 study was excluded because it was not available as full text.
• 1 study was only the protocol of a randomized control without results.
• 11 studies were excluded because they were reviews or not randomized controlled or clinical trials or because they showed up in the results without actually incorporating both keywords.
• 11 studies were selected.

The effectiveness of Pilates in the treatment of low back pain
      ​Regardless of the limitations of the selected studies described below, the success of Pilates-based exercise in the rehabilitation of low back pain is undeniable:

      ​Due to the different measurements and intervention ranges, there is no statistical data analysis possible. Following a comparative result list:

• 10 studies demonstrate greater beneficial effects compared to other exercise therapies or the control group.
• 1 study demonstrates similar beneficial effects compared to other exercise therapies or the control group.
• All 10 studies measure pain intensity (among other measures), which decreases post Pilates intervention in all studies.

General limitations in Pilates research
      Pilates exercises are being used by physical therapists to support the rehabilitation programs for various musculoskeletal conditions, sports injuries, and neurological disorders, focusing especially on the spine and its stabilization. The increased use of Pilates-based exercises makes it imperative to understand, among other characteristics, its applications, its contraindications, and how to use it appropriately.
As numerous studies about Pilates and low back pain have been authored, the following limitations were observed:

• Scholarly standards: Some studies don’t meet scholarly standards; the studies are not randomized controlled trials or clinical trials or are not peer reviewed.
• Measurements: Some studies use only subjective data analysis tools (scales and questionnaires) that evaluate parameters such as pain intensity and disability; others also use functional tests, such as balance and flexibility.
• Study methods: While subject numbers are generally >20, which is satisfactory, the most significant factors observed are the differences in intervention length and frequency, with 4 weeks being the shortest intervention time.

      Following are inconsistencies related to movement standards that influence scientific evaluation and are further detailed in subsequent pages:

• Pilates equipment: Most studies use only mat exercises, but some studies also use the original Pilates equipment, which is a different biomechanical approach. A few studies use equipment that is often associated with Pilates, but has its origin in fitness or rehabilitation, such as balls, therabands, and foam rollers.
• Type of Pilates exercises: Even though all studies claim they utilize the Pilates method or Pilates-based exercise, applications vary widely. Most studies use contemporary Pilates, none use the original, classical Pilates. The type of Pilates also determines another important factor, which is the amount of exercises given.
• Addition of non-Pilates-exercises: Some studies incorporate other types of exercises, such as movement protocols from physical therapy or yoga.

Classical Pilates, contemporary Pilates and therapeutic exercise
​(contributor: Heather King Smith)
      Following similarities and differences of classical Pilates, contemporary Pilates and therapeutic exercise protocols:

• Classical Pilates uses Pilates exercise names and adheres to a particular sequence of exercises on the two main pieces of equipment, the mat and the reformer. It uses equipment specifically designed for Pilates by the creator, Joseph Pilates.
• Contemporary Pilates uses Pilates exercise names, but there is no particular set sequence. Contemporary Pilates uses Pilates equipment as well as other equipment from the fitness and rehabilitation fields.
• In therapeutic exercise there are no Pilates names and there is no set sequence.

Additional differences are:

• Repetitions: <10x for classical Pilates, >10x for therapeutic exercise. Contemporary Pilates uses both approaches.
• Focus area: Classical Pilates is whole-body exercise, regardless of injury. In contemporary Pilates, additional exercises from the fitness and rehabilitation fields may be incorporated into a session to enhance optimal muscle recruitment and address weaknesses or injuries. Therapeutic exercise movements are mostly spot-specific and selected to strengthen the area of injury or weakness. The client is often asked to recruit certain muscles groups.
• Flow: In classical Pilates the client moves through the exercise sequence with a maximum of 10 repetitions per exercise. In therapeutic exercise, exercises are repeated until the desired muscle recruitment is achieved and the muscle is fatigued. Contemporary Pilates may combine both approaches.

Limitations: Exercise protocol definition and challenges
      Most of the exercises taught to physical therapists in the United States for  low back pain patients fall into general categories of spinal range of motion and strengthening exercises that may be described as core stability, dynamic stabilization, lumbo-pelvic and spinal stabilization, co-contraction type mat or ball exercises, progressive resistive exercises with weights or elastic bands, and functional activities.
      ​Where is the boundary between such therapeutic exercise protocols and Pilates? A comparison of the 11 selected studies shows that the Pilates protocol used is not always clearly defined and may not even be Pilates. 

      Surprisingly, 2 studies do not provide any information about the exercises used (Cruz-Díaz et al., 2015 & da Fonseca et al., 2009). Da Fonseca et al. only provide brief information about muscle recruitment concepts, which indicate that the protocol is more closely related to therapeutic exercise than to Pilates.
      Rydeard et al. (2006) provide a more detailed description about the exercises used, but the protocol is also about muscle recruitment strategies and doesn’t mention any Pilates exercises, in spite of the title of the study: “Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability”.
      Wajswelner et al. (2012) promise “clinical Pilates” in the study title, but they use therapeutic exercises which are performed on the Pilates equipment. It is questionable if the use of equipment makes the exercises Pilates exercises.
      Lastly, about a third of the mat exercises that Lee at al. (2014) use are yoga based, such as “seated hip stretch” and “knee over knee twist stretch”, not Pilates.

Conclusion
      There is evidence that Pilates-based exercise in the rehabilitation of low back pain is effective. Additional peer-reviewed and randomized, controlled research is needed to produce scientifically reliable meta analyses, preferably utilizing similar measurements, intervention durations, frequencies and equipment.
      ​For further scientific evaluation and in order to achieve reproducible exercise protocols and results, a standardization of contemporary Pilates exercises would be desirable. Classical Pilates has not been scientifically analyzed. 

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References:
      Borges, J., Baptista, A. F., Santana, N., Souza, I., Kruschewsky, R. A., Galvão-Castro, B., & Sá, K. N. (2014). Pilates exercises improve low back pain and quality of life in patients with HTLV-1 virus: A randomized crossover clinical trial. Journal of bodywork and movement therapies, 18(1), 68-74.

      Cruz-Díaz, D., Martínez-Amat, A., Manuel, J., Casuso, R. A., de Guevara, N. M. L., & Hita-Contreras, F. (2015). Effects of a six-week Pilates intervention on balance and fear of falling in women aged over 65 with chronic low-back pain: A randomized controlled trial. Maturitas.

      Cruz-Díaz, D., Martínez-Amat, A., Osuna-Pérez, M. C., De la Torre-Cruz, M. J., & Hita-Contreras, F. (2015). Short- and long-term effects of a six-week clinical Pilates program in addition to physical therapy on postmenopausal women with chronic low back pain: a randomized controlled trial. Disability and rehabilitation, 1-9.

      da Fonseca, J. L., Magini, M., & de Freitas, T. H. (2009). Laboratory gait analysis in patients with low back pain before and after a pilates intervention. Journal of Sport Rehabilitation, 18(2), 269.

      Dagenais, S., Caro, J., & Haldeman, S. (2008). A systematic review of low back pain cost of illness studies in the United States and internationally. The spine journal, 8(1), 8-20.

      da Luz, M. A., Costa, L. O. P., Fuhro, F. F., Manzoni, A. C. T., Oliveira, N. T. B., & Cabral, C. M. N. (2014). Effectiveness of mat Pilates or equipment-based Pilates exercises in patients with chronic nonspecific low back pain: a randomized controlled trial. Physical therapy, 94(5), 623-631.

      Gladwell, V., Head, S., Haggar, M.. & Beneke, R. (2006). Does a Program of Pilates Improve Chronic Non-Specific Low Back Pain? J Sport Rehabil. 2006,15, 338-350

      La Touche, R., Escalante, K., Linares, M. T. (2008). Treating non-specific chronic low back pain through the Pilates Method. J Bodyw Mov Ther. 2008 Oct;12(4):364-70

      Lee, C. W., Hyun, J., & Kim, S. G. (2014). Influence of pilates mat and apparatus exercises on pain and balance of businesswomen with chronic low back pain. Journal of physical therapy science, 26(4), 475.

      Lim, E. C., Poh, R. L., Low, A.Y., Wong, W. P. (2011). Effects of Pilates-based exercises on pain and disability in individuals with persistent nonspecific low back pain: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2011 Feb;41(2):70-80

      ​Van Middelkoop, M., Rubinstein, S. M., Kuijpers, T., Verhagen, A. P., Ostelo, R., Koes, B. W., & van Tulder, M. W. (2011). A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal, 20(1), 19-39.

      Miyamoto, G. C., Pena Costa, L. O., Galvanin, T., Nunes Cabral, C. M. (2013). Efficacy of the Addition of Modified Pilates Exercises to a Minimal Intervention in Patients With Chronic Low Back Pain: A Randomized Controlled Trial. Phys Ther. 2013; 93:310-320

      Natour, J., de Araujo Cazotti, L., Ribeiro, L. H., Baptista, A. S., & Jones, A. (2015). Pilates improves pain, function and quality of life in patients with chronic low back pain: a randomized controlled trial. Clinical rehabilitation, 29(1), 59-68.

        Pereira, L. M., Obara, K., Dias, J. M., Menacho, M. O., Guariglia, D. A., Schiavoni, D., Pereira, H. M., Cardoso, J. R. (2012). Comparing the Pilates method with no exercise or lumbar stabilization for pain and functionality in patients with chronic low back pain: systematic review and meta-analysis. Clin Rehabil. 2012 Jan;26(1):10-20

      Posadzki, P., Lizis, P., Hagner-Derengowska, M. (2011). Pilates for low back pain: a systematic review. Complement Ther Clin Pract. 2011 May;17(2):85-9

      Rydeard, R., Leger, A., Smith, D. (2006). Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability: a randomized controlled trial. J Orthop Sports Phys Ther. 2006 Jul;36(7):472-84
      
      Vibe Fersum, K., O'Sullivan, P., Skouen, J. S., Smith, A., & Kvåle, A. (2013). Efficacy of classification‐based cognitive functional therapy in patients with non‐specific chronic low back pain: A randomized controlled trial. European journal of pain, 17(6), 916-928.

      Wajswelner, H., Metcalf, B., & Bennell, K. (2012). Clinical pilates versus general exercise for chronic low back pain: randomized trial. Medicine and science in sports and exercise, 44(7), 1197-1205.