Pilates Is an Effective Treatment for Low Back Pain
Pilates has been shown again and again to be one of the best therapeutic interventions for the treatment of mechanical low pain (1-4). For years therapists and practitioners have assumed that the reason Pilates was so successful was the concept of strengthening the core. But is it? What would you say if I could show you that the greatest predictor of overcoming mechanical low back pain is in fact linked to creating a series of successful movement experiences and Pilates is the perfect modality?
Behavioral science has shown that psychosocial outcome measures, such as self-efficacy (the belief in one's ability to successfully accomplish specific tasks or goals), are among the strongest predictors of functional outcome in cases of mechanical low back pain (5-11). Individuals with low back pain, who have high self-efficacy scores have an 80% likelihood of improving, while those with low scores have an 80% likelihood of not improving, regardless of the intervention. The original literature showed that even though the psycho-social measures are a strong predictor of getting better, it was not easy to influence the individual’s belief with psychosocial interventions alone. In other words, “diagnose, adios!” These practitioners lacked an appropriate and effective modality.
In the field of rehabilitative medicine, it was believed that physical measures such as strength and range of motion were the best predictors of returning to normal participation and function. However, outcome measures such as core strength, flexibility, coordination, and balance have been found to be poor predictors of return to function with mechanical low back pain (5).
Years ago, we conducted a research study that revealed an intriguing relationship between psychosocial and movement outcome measures as predictors of return to function, which shed light on why Pilates is so successful. Our study had two groups, one did Pilates group Reformer classes and the other had massage. The Pilates group exhibited significant gains in returning to function compared to the massage group. As predicted, the psychosocial outcome measures strongly predicted function, while physical measures like core strength, flexibility, and balance improved but did not correlate with improved function. It's fascinating that the perceived benefits of Pilates, such as a stronger core, increased joint and myofascial tissue mobility, improved balance, and improved coordination, align with legitimate gains from practicing Pilates. However, belief and hope emerged as the strongest predictors of improved outcomes (12-14).
The Pilates environment provides an ideal setting for creating positive movement experiences for clients, as we can modify load, explore movement in foreign environments, and modification of range of motion, support, and lever length. Most importantly, Pilates creates a "Positive Movement Experience without Pain”. One of the primary reasons for failure when addressing back pain is the loss of hope. By fostering consistent positive movement experiences without pain or that exceed the client’s expectations, we begin to restore hope. As we progress these small victories toward functional activities, clients become more motivated to be consistent with home exercises, more regularly attend their movement and therapy sessions, and return to function.
Pilates has an undeniable "stickiness" factor. For instance, our Healthy Spine Reformer group class, initiated for clients recovering from low back pain 20 years ago, still continues with several original participants. Many others graduated from the Heathy Spine class into our other Pilates classes. Enhancing this stickiness factor of Pilates could better serve our communities with what Joe Pilates referred to as "Contrology”. My understanding is that Joe aimed for people to develop an internal sense of awareness or locus of control (15).
The term "Locus of Control", a psychological term, refers to how individuals perceived control over their lives. An internal locus of control implies individuals believe they control their lives, while an external locus of control suggests they believe external factors control their lives.
Clients with mechanical low back pain and other movement-related pain syndromes, especially in chronic cases (lasting over 3 months), often lose hope and adopt an external locus of control ("My back won't let me hike anymore"). This leads to a belief that normal activities are no longer attainable. Our research found that such individuals did not respond to passive interventions like massage but did respond positively to Pilates classes where they were taught how to adjust things like their body position, the springs, and the repetitions. After 12 weeks of graded positive movement experiences, we observed changes in their self-efficacy scores, indicating a shift towards an internal locus of control. They now had ways to control their environment and were no longer perceiving they were at the mercy of the situation. These clients did see improvements in core strength, flexibility, coordination, and balance, but it was the increased number of positive movement experiences that led to greater compliance with exercises, increased daily activity levels, and a stronger sense of internal control.
This may or may not have been what Joseph H. Pilates envisioned with Contrology, but science strongly supports how the Pilates Method improves outcomes. So, knowing then how important an individual’s mental state is in determining physical outcomes, the question posed in this article is: How can Pilates teachers sharpen their skills to create more Positive Movement Experiences for their clients?
To answer this question, we can turn to the book "Principles of Movement" (16) . Some of the greatest tools for Pilates instructors lie within the environment and philosophy:
1. Whole Body Approach to Health and Wellness: Joe's original principles emphasize the incorporation of body, mind, and spirit into achieving whole-body health. Improving one’s perception of their ability becomes a belief. And such a belief becomes empowering for the individual to own their health (15).
2. Breath: Breathing exercises and increasing the capacity of breath directly influence pain management, energy control, and mental calmness during movement. By bringing greater attention to existing breath patterns and improving the client’s knowledge of how breathing can enhance efficiency of movement, improve distribution of movement, especially in the spine and decrease the anxiety that often accompanies low back pain, we can create the paradigm shift that movement can be comfortable instead of painful.
3. Mindful Mobility: Enhancing mobility improves movement strategies for daily activities, distributes force throughout the body and reduces strain on the lower lumbar region. In Polestar we coined the phrase “Distribution of Movement Equals Distribution of Force”. This distribution can immediately change the unwanted stresses causing the pain in the first place. I am sure you have noticed on numerous occasions how even one Pilates session greatly reduced your client’s low back pain. Restore mobility in the thoracic spine, hips and ankles and you will observe a great reduction in mechanical low back pain.
4. Modification of Load: The ability to modify load using the Pilates equipment allows for tailored exercises and a gradual increase or decrease in intensity based on individual tolerance. Ensure that the load progressions simulate the desired functional activities identified by the client. This will build confidence in returning to their daily activities, work, and recreation.
5. Dynamic Alignment: Observing and facilitating efficient movement patterns can lead to more positive movement experiences. Dynamic alignment, combined with increased mobility, improved strategies and modifiable load can quickly create a more efficient neuromuscular and fascial organization in the body that is holistic, spontaneous, and efficient.
6. Movement Integration: Considering the whole person, including beliefs and experiences, contributes to creating positive movement experiences during recovery. The understanding of how humans acquire task-based movement and always focusing on the desired movement task will greatly enhance the client’s desire to be compliant and ability to see the benefits of practicing Pilates. Be sure to use external feedback to facilitate the client’s internal awareness which will result in a quicker acquisition of an Internal Locus of Control.
Effective communication skills are also crucial, and we should strive to avoid language that reinforces negative or unhelpful beliefs. This language is often heard from novice practitioners and sometimes stems from the instructors’ need for the client to ‘need’ them and their services. We can start with the assumption that everyone can benefit from what we offer in the Pilates environment with our intention to facilitate internal awareness and independence. Language can also be used to help the client better communicate what they want and need, as well as what they think is limiting them. It is our responsibility to use their beliefs to create a meaningful program for them. Focusing on clients' goals and activities fosters a sense of control and progress.
By understanding and implementing these principles, Pilates teachers can enhance the effectiveness of their intervention, teach within their scope of practice, provide meaningful movement experiences, and successfully work with clients with mechanical low back pain.
With over 30 years of experience in rehabilitation and movement science, Brent Anderson, PT, PhD, OCS, NCPT is Founder and CEO of Polestar Pilates Education and Polestar Pilates Center. He is also an Assistant Professor at the University of St. Augustine for Health Sciences in the DPT department in Miami, FL. He teaches as an adjunct professor in the Physical Therapy departments at the University of Miami, University of Southern California, and New York University. Brent is passionate about the power of positive movement experiences and is dedicated to sharing Pilates with the world. and He is an active consultant for hospitals, universities, and wellness organisations internationally.
Brent’s book Principles of Movement is also available to be purchased here.
References:
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