13 Aug Pilates: Rehab or Risk?
Pilates has become a popular exercise method. According to an article in the March 15, 2005 Wall Street Journal, the Sporting Goods Manufacturing Association estimated that some 9.5 million people participated in Pilates in 2003. The popularity of Pilates is partially due to a reputed but unproven effectiveness for treating back pain. Some of the classic Pilates exercises are dangerous, even when taught by a qualified instructor; the danger is compounded by hastily but poorly trained instructors attempting to take advantage of the method’s popularity.
In contrast, the July/August 2005 issue of Pilates Style magazine published an article advocating Pilates for various medical conditions: “back pain, torn ligaments, carpal tunnel syndrome, joint problems, scoliosis, multiple sclerosis or cancer recovery”. It quoted medical professionals and carried positive anecdotes, but ultimately admitted “a lack of research” verifying the alleged benefits of Pilates.
As evidence-based medical practitioners, we must make judgments based on the best available research. Regarding spine rehabilitation specifically, research would argue against Pilates as an appropriate method.
Pilates is a flexion-based from of exercise (see illustrations of the Hundred and Saw). While there is little question regarding the necessity of strong abdominal muscles to support the spine, there is evidence that excessive flexion can damage it. The most accepted research has used a relatively neutral spine position for core strengthening.
Repeated flexion actually reduces spine stability via decreased activation of trunk extensors and increased laxity through micro-damage of connective tissues. Ironically, the single muscular deficit most correlated with, and predictive of, low back pain is a lack of lumbar extensor endurance, yet there is little in the Pilates system that emphasizes this critical component of spine health.
Discs may be particularly compromised by Pilates exercise. The annular layers which form the outer wall of the disc are thinner posteriorly and fewer in number postero-laterally. Thus, these portions of the disc are highly vulnerable in flexion, especially if combined with rotation. Such exercises as the Saw would appear designed to damage discs.
Disc pathology may be quite insidious. An injury to a disc, such as a micro-tear, may not be painful at the time of actual injury. However, once sustained, alterations in mechanics lead to further degeneration, and nerve endings (including those specialized for pain transmission) will migrate into areas that formerly lacked them. Performing gravity-loaded, flexion-based exercise on a regular basis may actually train a disc to be a pain-generating structure.
The clinicians at OPTM incorporate some Pilates concepts, exercises, and equipment into our comprehensive treatment of movement dysfunction, just as we integrate other forms of exercise and movement training in accordance with the latest research. But there is a vast difference between simply instructing a rote series of exercises with little genuine understanding of them and carefully constructing a program for an individual based on specific needs and real evidence. The research indicates that Pilates is not suitable for spine rehabilitation; rather, it may be a good way to end up needing spine rehab.