Sunday, April 22, 2012

Is Pilates Good For Your Back? Or Will It Make Your Back Pain Worse?

Note: I originally wrote this for the general public, so tried to make it as non technical and clear as possible. In doing this I have not put in any references, as this may interrupt the flow, but as always, everything can be referenced.

Is Pilates Good For My Back?

Pilates popularity does not seem to be waning. In fact it seems to have become the ‘go to’ class for anyone with any type of injury. (Full disclosure: I qualified to teach mat based pilates about 6-7 years ago, so am aware of what the training consists of and why people are told to go and do Pilates). I have noticed more and more people being recommended to do Pilates for a range of conditions. Doctors, Physiotherapists, Osteopaths, Chiropractors and Consultants have all suggested their patients and clients do Pilates to help them with a whole host of injuries and problems. I’ve had people referred for knee injury, hip replacement, whiplash, shoulder problems, chronic fatigue and most commonly lower back pain. Some of these people were unable to get down onto a mat or kneel down or lie flat, but had been recommended to do mat based exercise. One person came to me after sciatica, back surgery and hip surgery and the only exercise advice she had received was 'to do Pilates'. Pilates has become the universal panacea!

The fact that medical and health professionals are recommending anyone to do exercise should be seen as a good thing. It could also be a sign of an over burdened physiotherapy service, where patients are being told to do classes because the one-to-one physiotherapy they need is not available. In my experience, most people recommended to do Pilates due to some type of injury, are following the advice of their GP. Having said that many physiotherapists are now promoting their own back pain classes and are jumping on the Pilates bandwagon, they are advertising the fact that these exercises are specifically based on the Pilates method. Despite no evidence for its benefits. As we shall see, Pilates methodology may not be the wisest choice for those with lower back pain; and as for those with knee pain and neck pain, it's not clear why it's being recommended at all.

It is a positive that physios and osteopaths are trusting fitness professionals and their knowledge, it would also seem curious that they are passing on patients and clients that they could and should be rehabilitating themselves. However, it seems mostly there is a lack of understanding among medical professionals and the general public as to what Pilates actually is.

For those of you who are unfamiliar with the history of Pilates and how it came to be the universal panacea, here is a brief history. Joseph Pilates was born in Germany in late 1800’s, in the early 20th Century he came to England and while interned on the Isle of Man during the first world war was working in a hospital. Around this time he started to develop a series of mat based exercises and novel equipment like the Reformer ( a cable, pulley, sled type machine ) and the Cadillac and other equipment. His choice of exercises and the equipment he developed was very much informed by his gymnastic background and possibly even the circus, where he had performed. It is also likely that many of the exercises would have been influenced by other disciplines and fitness ‘gurus’ at the time. Although, we think of fitness crazes as a modern phenomenon, they are not, and there were a number of fitness ‘gurus’ around at the time and before, like Arthur Saxon, Eugene Sandow and many more who had their own fitness systems and equipment. Joseph Pilates later moved to America where his studio obtained a steady following amongst dancers especially. Joseph Pilates carried on teaching until the 1960’s.


Jospeh Pilates teaching someone on one of his many pieces of apparatus

Pilates stayed more or less as a fitness footnote until ten or fifteen years ago, when various individuals and schools of Pilates started to emerge and expound its virtues, especially in the UK. This also coincided with an explosion in so called ‘functional fitness’, the use of swiss balls and the concept of ‘abdominal hollowing’ (more on this later). This did help the fitness industry out of a rut, which had become stuck using static machines. Suddenly the public and instructors had a whole new range of concepts and exercises to use.

Over recent years Pilates has grown and grown to become more of a brand than a clear cut exercise system. Go to any Pilates class today and it unlikely you will see any instructor doing Joseph Pilates original sequence of mat work exercises, which from a back care point of view may be a good thing. The original exercises can be very challenging and not the gentle exercise for the de-conditioned individual that most people think they are. Pilates has become the class to improve your ‘core’ or ‘posture’ or in Pilates parlance your ‘powerhouse’ and help you get ‘longer muscles' (of course, longer muscles are impossible as the attachments are set). These days, it is very hard to say what Pilates is, even most of the official Pilates courses have modified the original exercises or broken them down into various levels of difficulty. For example, see the pictures below, one of the original ‘swimming’ exercise and the modified 4 point kneeling version, which is a standard rehabilitation exercise called 'Bird Dog'. The original swimming causes massive loads on the lumbar spine, whereas the 4 point kneeling version does not.

Classic Pilates Swimming exercise - causes massive amounts of compression in the lumbar spine. Say goodbye to your facet joints, you'll miss them when they explode. And your cervical spine (neck) wont like you to much either
Modified Pilates Swimming exercise aka The Bird Dog aka quadruped contralateral arm & leg lift aka your facet joints wont explode


And herein, lies the problem with Pilates as an exercise for lower back pain. You may have lower back pain and have been told to do some Pilates because it will help. You may go to one class which is staying true to the original exercises and do an exercise which is possibly going to make your back worse and you may go to another which is using any of the modified exercises and it is going to possibly help your back. And in another class, an instructor may be throwing in some of the original exercises, some modified ones, and then some general core and toning exercise they’ve picked up along the way because after all that’s why most people come to the class, to tone up and if you do have a lower back problem all that abdominal work is going to help, right? Wrong!

One person may go to Pilates and it helps with their back pain, for another person it may make no difference or make it worse. This doesn’t only apply to Pilates, but Yoga and many other general fitness classes. This also applies to a whole host of injuries, your shoulder/ hip/knee injury may get better but then again it might not, you are not doing a set of exercises specifically designed to help. The problem is Pilates is not specifically designed for lower back pain, and the person teaching it may have no background in it. You may go to a class and be able to do 90% of the exercises, but 10% of the exercises may actually make your back pain worse. You may not have access to a specific lower back class or rehabilitation program where you live and this leaves you with a conundrum - should I do the class or not? Of course, your first port of call is the physiotherapist, though I’m sad to say you may end up with nothing more than advice to do some Pilates and an exercise sheet consisting of knee hug stretches and knee side to side mobility. On the other hand you may get a first class rehabilitation program that is specific to your needs, evidence based and progressive. However, the lack of consistency in this area, means you may need to educate yourself.

With this in mind, here are some ways to modify and avoid certain things that may make your back pain worse. These are all evidence based strategies and proven to work. In each example, I will show the most common way an exercise is taught and how you can modify to help spare your spine and strengthen the muscles.

The Spinal Roll
Modified Spinal Roll in Pilates - may not be the best idea if you have lower back pain

The spinal roll is almost universal in Pilates as a warm up exercise and a way to get down to the mat. However, look at the position of the spine, it is fully flexed, it is in a rounded, bent position. Now, evidence shows that repeated spinal flexion can lead to a disc prolapse or injury. The load is not important, it is the amount of times you do it, and the amount of times you do it before it causes injury is purely individual. Imagine a credit card, if you keep bending it back and forward, eventually it will snap in the middle. Also holding a spinal roll position can cause the muscles in the back to switch off and the back is hanging on the ligaments between the vertebrae in the back.

In adults aged 20-50 years old nearly all back pain is forward flexion intolerant and discogenic. In other words, round the back and bending over makes it worse!

Avoid any exercise that may round the lower back and especially if it is rounded under load. So in Pilates terms this also means you need to avoid the Roll Up and Rolling Like a Ball (see below for pictures and video and to be fair on the Pilates course I attended, they did say to avoid rolling like a ball if you have scoliosis).

Pilates Roll Up - avoid if you have lower back pain and also promotes poor posture

An alternative to the spinal roll is the hip hinge. See my article here, for a full explanation of the hip hinge. In this movement you will keep your back in a neutral position and hinge from the hip by pushing the hips back as you fold forward. This movement spares the spine, works the muscles either side of the spine and gets the muscles around the hip working as they are supposed to.

Abdominal Hollowing

This has become almost universal advice in all classes, in the gym and in Pilates. Joseph Pilates original work was also very much about pulling in the stomach muscles, hollowing, engaging the internal corset. Of course, doing this can immediately make your waist look smaller and more sleek. The explosion in popularity of Pilates also coincided with some Australian research that showed people with lower back pain weren’t firing off their transversus muscles (the internal corset). However, this study only measured the transversus, it didn’t measure any of the other core muscles, and it only measured it on one side when people were told to lift their arm over head. With lower back pain we need to get the whole core working to protect the back. Not just focus on one muscle.

Other muscles around the core are just as important, the obliques, quadratus lumborum and rectus abdominis. These are best engaged by bracing the abdominals. Hollowing actually causes the lower back to be less stable. Imagine the difference between a tent where all the guide lines are taught and spread out, and one where the guide lines are loose and close in, which one is going to stand up?

Brace wherever possible, this engages all the core muscles. Brace as if you are going to punched. It is important to not try to pull in or push out your abdominals, keep the circumference the same.

Lateral Breathing

In Pilates you are instructed to breathe laterally or thoracically. This probably stems from a couple of factors. Firstly, Joseph Pilates came from an era when those involved in Physical Culture pulled their stomachs in and puffed out there chests, it is almost a classic Westernised idea of what good posture should look like. The guys and strongmen especially wanted to make their chests look bigger and their waist look smaller. As do women as well I guess!
Joseph Pilates - note, the abs are being pulled in, the ribs are flaring, the diaphragm can't do its job. And I have no idea what that machine is!


Secondly, if you are practicing abdominal hollowing you can't breathe using the diaphragm because you can't push your abdomen out. In fact, Pilates states that abdominal breathing is wrong. However, if you look at breathing anatomy, to breathe properly your diaphragm must push down to let the lungs fill and that will push the abdomen out and also give you a more stable core.

If you breathe laterally, you should breathe laterally using the diaphragm, which means you should feel the area between your lower ribs and hips (your obliques) expanding sideways. But you should also fell the front of your abdominals and lower back pushing out and expanding as you breathe, like a cylinder.
The diaphragm pushes down when you breathe in
This type of abdominal breathing is practiced in yoga, meditation and most Eastern martial arts. They were onto something.

Spine Twists

This is an exercise where the details matter. A lot of classes will finish by lying on your back and rotating the knees from side to side in a windscreen wiper fashion, this exercise is still given out as a rehab exercise for the back. However, the lumbar spine isn’t designed to rotate that much, your back is designed to rotate through the thoracic (middle back) and hips, therefore sparing the spine. Many people with lower back problems think they need to stretch out their lower back and improve the flexibility in this area. In reality, many of these peoples lower backs are already too mobile and unstable, they need to work on having a ‘stiffer’ core and getting mobility in the middle back.

The modified Pilates spine twist is ideal for doing this. In the video below the modified Pilates spine twist is shown, as well as a tall kneeling version. I use this modified spine twist all the time with people; there are elements of Pilates which work well for back pain, it is just knowing which ones.
The classic Pilates spine twist is much harder, as the arms are out straight to the side and the legs are straight to the front. The modified one fixes the head and rotates with a neutral spine, the classic version can end up being flexion and rotation.



Also, there is a Pilates exercise called The Saw which is flexing and twisting to do a toe touch - one of the worst things for those with back pain. We know one of the worst actions for the back and tearing up the discs is the action of bending and twisting. So we can see how one version of this exercise is beneficial whereas another version is not.

The Saw - most people are going to end up twisting and bending through their lower back.


Crunches and back flattening

There are very few crunching movements in Pilates, to its credit much of the time you are trying to keep a neutral spine. In some exercises though, the back is flattened or rounded into the floor or mat. In Pilates this is called 'imprinting' the spine or back. This is just really forward flexion again but with your body on the floor, same as the standing versions. Repeated crunches or imprinting/ flattening of the back can damage the lower back tissue and are not that effective at activating the muscles in the core and can result in poor upper body posture. Try not to flatten or over extend the back, keep it in a neutral position with a natural curve. Your lower back is strongest when it has a natural curve in it, not flat or excessively curved but neutral. This is where the grey area of what is Pilates comes in. Pilates itself doesn’t have many crunching movements, but instructors may be adding these in.

Classic exercise Neck Pull. Doesn't really get done anymore in classes, but if you think crunches are somehow safer or better then think again
Curl Up - flipped onto its side. Some Pilates courses teach the curl-up. Even if imprinting and flattening the lower back didn't cause problems look at the posture this promotes - head forward, shoulders rounded, hips flexed. Most people spend all day in this posture anyway, they don't need to practice it

Stretches

As mentioned earlier, people with lower back pain often feel the need to stretch out their lower back or are advised to do a knee hug stretch. This is not a Pilates exercises but is often done, as is rolling like a ball, which is one of the original exercises. Stretching the lower back muscles can be detrimental to the spine, as it makes the lower back less stable.  The muscles may have become permanently switched on and in ‘spasm’ but there are other ways of switching these off and helping them to relax that don’t involve stretching. This doesn’t mean stretching in general is bad, other tight muscles in the body may benefit from stretching.

Pilates originally attracted quite a few dancers, this group is naturally very flexible and in many cases way too flexible and unstable. An exercise that may be easy for them may impossible for you. Plus their incidence of back pain is the same as everyone elses, they just end up with different types of back pain.

In summary

Hopefully, this article has cleared up some of the issues surrounding back pain and Pilates. The term Pilates has become so general that really there is no set definition anymore. This article shouldn’t discourage you from taking part in classes, nor does it mean Pilates wont help. Following the guidelines above should help. Remember, this article is aimed at people with lower back pain,

  • Avoid forward bending with a rounded back, you should hinge from the hips
  • Abdominal bracing is superior to hollowing to strengthen the core
  • Avoid lateral or thoracic breathing, breathe using the diaphragm, this will activate your core and  protect your back
  • Try to avoid rotating through the lower back, you should rotate through the middle back and hips
  • Keep a neutral spine and avoid pressing your back flat or doing traditional crunches
  • Avoid stretches like the knee hug stretch, but other muscles like the gluteals & hip flexors may be tight and need stretching.

You may think, that if you do all these things, then you are no longer doing Pilates. The truth is you probably weren't doing classic Pilates in the first place, but a hodge podge of things mixed together. If however, you go to a class, it makes your back feel better and you enjoy it, does it really matter what it was called?

Lastly. Ideally try to attend a specific class for chronic lower back pain or have an individualised program. If you have other injuries like hips and knees, again a specific individualised program specific to your needs will be more beneficial than attending a class where possibly only one or even none of the exercises are going to help you.

*I originally wrote this article over 2 years ago, but never got around to taking the photos for it or publishing it. I have had added a few extra bits, but this is pretty much how I wrote it 2 years ago, the principles in it all hold true. I wasn't going to publish it, as I thought all this information was out there and quite well known. Turns out I was wrong, last weekend I was on a course with Physios, Osteos and Chiros, when the issue of abdominal hollowing and back pain came up it was a revelation to the majority of the people in the room - about 30 - many of whom had been referring patients to Pilates for back pain, as one of the physios/osteos asked at the time 'does this mean Pilates is wrong?' In this case, I'm afraid it is. The mantle of back pain & injury cure-all got projected onto Pilates, and turned it into something it never initially claimed to be. For lower back pain, the evidence is clear and despite over a decade of research showing that many of the Pilates concepts should at least be modified or reversed or in some cases completely replaced, they continue to be taught.

23 comments:

  1. Excellent article. Have been teaching Pilates for over 12 years, teaching exercise classes for 25+ years. The fact is that anyone with health issues of any kind simply should not be in a group class. In a well balanced class aimed at people without known health issues and modified to take into account students physical limitations, classical matwork is a great workout, improving flexibility, mobility, strength - core and whole body. Just had a call from someone with back problem who doesn't want to pay for one to ones and this is where the problem lies: they are advised to do Pilates so pitch up at a class and end up making the problem worse.

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    1. Thanks for the comment Josie. I agree, people don't want to pay for a 1-2-1, so they end up doing a general class, hoping that it will rehab them.

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    2. I've been taking 1-2-1 (aka private session) classes for about 5yrs now. The price of 1-2-1 classes has drastically increased over the years, now $75 a session. I'm a healthcare worker, making a somewhat good income...for me, that price is even too steep. It's a catch 22, which is why people choose the classes. I'd love to only pay for classes. Due to my history of having a microdiscectomy of my L5-s1, I do not have that option. Maybe these studio's should consider lower the prices, at least until insurance companies start recognizing pilates as a rehab route and help cover the cost.

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  2. Consequently, the key steps should be to consume any clean up, nutritious diet and include cardio exercise routines to be able to burn up unhealthy calories in order to shed in which stratum of unwelcome extra fat that is maintaining the abs exercise coming from popcorn out.

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  3. Thank you, many things of what you said above correspond to my intuition and direct impressions from exercises - I am a person with very problematic lower back (MRI showed a lot of damage, and I have scoliosis all my life) and I'm an active person, training a lot, doing body-weight exercises, kettlebells, clubbells, ultra-running, rock climbing...

    By the way, slightly off-topic: are you familiar with Kettlebell Therapy?

    Related G+ post, where Dr. Ben Fung responded.

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    1. Thanks for reading. I'm familiar with kettlebells & using them for corrective exercise but not kettlebell therapy

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  4. Informative post. Thanks for sharing. I was asked about yoga/pilates just the other day. This article has me asking additional questions which is good to see. I look forward to reading more articles in the future.

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    1. Cheers, thanks for reading and the comment

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  5. A great an informative article. You really know your stuff. Thanks. There is a lot of rubbish out there.

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  6. An interesting and informative article and I do agree with many of your points. However, as someone who has been involved in teaching bodywork for the past 30 years and clinical Pilates for 15 years I feel your article assumes that most Pilates classes are teaching exercises from the Joseph Pilates 'menu' of yesteryear. There are many excellent classes out there run by people who are very well trained and who consider the client as an individual and therefore modify movements to suit. I also would like to make a comment about your 'take' on imprint; Imprinting performed correctly does not flatten the lumbar spine into the mat; Also you show spine twist in sitting ( your model in poor alignment) ...... more load on the spine as opposed to spine twist correctly performed in supine? Overall though your article does draw attention to the need for correct exercise precription and moving the body as it is naturally designed.

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  7. I'm not quite certain what you mean by moves that hinge at the hip. Do you mean the forward fold? Are there any versions of the roll up or crunches that are in your opinion ok?

    I started doing Pilates two years ago, but recently my lower back has been getting worse, seizing up just walking the dog. I have been suspicious of Pilates as the source of the pain. We do roll-up, neck-pull, criss-cross crunch, rolling like a ball, lying torso twist, saw, forward fold, sitting torso twist, superman, swim, jet, and rocking horse, just to recall a few...

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    1. The hip hinge is different to the forward fold - type 'hip hinge' into youtube and there are some good videos. Something like McGill curl up will spare the spine while engaging the core - again type 'McGill' curl up into youtube, things like 'deadbugs' will do a similar thing

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  8. I was just telling another chiro today that it takes a village to raise an endurance athlete and having a chiro is the start.

    We get all kinds of pinches and pains and need them taken care of. Just the slightest loose screw in your cleats can f you up because your foot now leans inward instead of straight and you use a muscle differently.
    Mid Back Spasms

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  9. Thank you for this most informative article. I suffer from lower back pain - have done for longer than I can remember. Doctors, chiropractor, nothing can help. I have derived a set of exercises that I do at home, and your article has added two more to my repertoire. And given me basic, very sensible, advice on what I must avoid. But I won't give up on my leg hugs which I find helps to loosen me up. I cycle a lot, play bowls (lots of bending using one leg only), and sit at a computer a lot of the time. But then I am 66 now, so expect aches and pains. Exercising in this way definitely helps get rid of these pains first thing.

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  10. Thank you for this informative article. I have lumbar degenerative disc disease and have spent the last nine months in a Pilates class that has benefited my back hugely, I now have much stronger core muscles and can now walk without pain. My instructor was great in sorting out some modifiers for me when I started to avoid injury. However she's just back from a training course and yesterday she introduced the classic swimmers exercise. I'm so used to just following along that I started doing it, I think I've been coping so well with classes that my back injury has sort of faded from both her and my memory. I did stop part way through when a little warning bell reminded me about compression here but this morning my back is feeling horrible and stiff, I turned to the web for info and here I am. I won't be doing that one again!

    Have to say though that I find most of the spinal roll and spinal twist exercises very good for unkinking my back and I love curling up and rolling my back out on the mat, best thing ever for my aches and pains. Which just goes to prove your point, we're all different and what suits one person doesn't suit another. Thank you!

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  11. Excellent article ever I read about Clinical Pilates.You have provided an uniform and descriptive pilates exercises along with video.

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  12. Pilates can really strengthen the deep muscles in your abdomen providing the core stability to alleviate back pain.

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  13. Hi, on the back of a Pilates consultation, which made my low back pain extremely painful, an online search led me to this page. I have tried contacting you on Twitter for an email address I can contact you on but have not had any response? I cannot find a contact email on this blog and would like to talk to you about my current circumstances in the hope that you may be able to help me?

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    1. You can contact me via private message on twitter

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  14. Excellent Article! The information provided in the article about to lower back pain is very useful. I will follow all the suggestions provided here to avoid my back pain.

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  15. You say you can provide references for all this? Could you please post these?

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    1. Please note I wrote this 5 years ago. A good place to start is the research & books of Stuart McGill.

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