Review of The McGill 2 course: "Reducing pain and enhancing performance: The three hour back assessment."

I attended this course on 4th February at the Anglo-European College of Chiropractic in Bournemouth. I previously attended McGill 1 ('Building the ultimate back: from rehabilitation to performance') in Dublin in 2015.

To see the general description of Professor Stuart McGills courses and his books and publications go here. I assume by reading this blog you already know who he is.

Now, I'm not going to give the detail of the course, if you want that you can pay for the course yourself! But I will compare McGill 1 and 2, give a few insights and suggest whether it is worth you doing the course yourself if you are interested. Also, McGill doesn't let you take pictures of video either, so none of that here.

Anything in quotation marks is a quote from Stuart McGill unless otherwise stated.

McGill 2.

The course is one day, and split in two halves. The morning is lectures covering the theory, movement screening, imaging and examples from various research studies.

The afternoon is the practical going through various tests, movement screens, and practical recommendations in a clinical environment. In this case using Chiropractor plinths - which I must say are bizarre and not very good if you are not doing Chiropractic manipulations! Apparently McGill has presented at AECC on several occasions, so they should have known that the treatment tables they had were not going to be any good for the practical things we were doing.

Movement Screens.

McGill is quick to point out that he is not going to give you a simple system like an FMS to use. There is no simple screen or test with complicated back pain cases.

He covers his research into the FMS - which he also does on McGill 1. He probably spent more time on this in McGill 1.

There is an assumption that people on this course had done McGill 1, but it seemed most people hadn't. Most people on McGill 2 were Chiropractors (surprising eh, being at a Chiro school) whereas I would say at McGill 1 there were more athletic trainers.

In short, even though he has a lot of good things to say about Gray Cook and suggests any new trainer learns the FMS, this is not going to be enough for anyone trying to be a top notch clinician. In essence the FMS is a three chord punk song whereas the McGill assessment is "jazz".

For example, the overhead squat test in the FMS, which requires very good shoulder mobility to score a 3,  but "shoulder mobility is a gift from God!', not necessarily something you can change.

His approach is about "converging on a precise diagnosis".

This is where his scientific background comes in. You formulate your hypothesis, and then test it. For example, pain is coming from disc at L.4. Test it, if your wrong, go again.

You can read his books, get his DVDs and listen to podcasts with him in to garner most of what he covers in his seminars. However, there is that extra quality to seeing him in a real life situation. He has charisma, a wealth of knowledge and despite protestations that he is no clinician - obviously is gifted in this area as well as his ability to relate to people.

He has worked with so many different types of people from professional hockey, NFL, MMA, rugby, powerlifting, as well as every day people with everyday jobs with back pain that has been dismissed or misdiagnosed (or not diagnosed at all). He is normally the last resort, if you are seeing him, you are desperate and have seen 10 other experts; his approach has to work.

He brings all this into the lecture theatre, at his best when going off on tangents, citing a research study, talking about specific patients, answering questions - but genuinely listening and not afraid to give strong opinions and say "I don't know" when he doesn't.

For example, I asked him why people sit into their pain, it seems counter-intuitive that someone who is forward flexion intolerant would adopt that posture. He said he didn't know why people did it, but they do and we don't know why.

Or, a friend of mine who is in his 2nd year at Chiropractor school asked if McGill ever saw acute cases. He doesn't, by the time they reach him they are chronic. He said the acute cases are for the clinicians and manual therapists.

Context.

His approach is all about context. He gives the example of posture, no variability and too much variability in posture will result in injury, there is a "sweet spot" in the middle. However, in the weights room there should be zero variability (not in that everyone should squat or deadlift the same) but when you have found the best technique for you or a client, you should be fastidious with every rep.

He also gives examples of very good winning athletes with so called 'poor movement', are you going to change their posture when they are winning and not in pain? Of course not.

He also covered several studies in the morning session. Including one on firefighters and movement screening, and how some moved better with load and some moved worse with load. And studies on changing hip mobility, stretching,  and trying to change peoples lordotic spine curves.

Stop trying to fit a pentagon shaped peg into a square hole. Everyone is different.

Non specific back pain and imaging.

If  you really want to wind up Prof. McGill mention non specific back pain and general exercise recommendations.

He is dismissive of the medical profession that gives this diagnosis (no one ever had non specific head pain and then was told to have surgery anyway to remove part of the head!) and also some radiologists and their inability to interpret an MRI.

In the morning session of McGill 2 he briefly covers medical imaging and differential diagnosis.

For example, MRI might show a disc bulge at L.2, but if all the symptoms show a problem with L.4, then surgery in L.2 is not going to do anything, even if the MRI shows 'abnormality' there.

In fact, he is very much certain that in 95% of cases that have been told they need surgery you can help them avoid it.

I think one of the other attendees used the phrase "Victim Of Medical Imaging Technology" - VOMIT. Haha. Yes imaging is a fantastic tool but know its limitations.

People giving general exercise recommendations like 'do yoga or pilates' is also lazy. Know the limitations of research where people are diagnosed with 'general back pain' and given 'general exercise'.

In terms of differential diagnosis, McGill interestingly says he has only come across two cases of piriformis syndrome - it is very rare. But, as anyone working in this field knows, people get told all the time they have piriformis syndrome and advised to drive a lacrosse ball into it.

Two interesting things McGill mentioned were spinal shock and neural resonance.

These were interesting, and I will have to think about them more from a neuroscience point of view. The neural resonance effect is when someone has a shuddering in a 8-10 Hz range before being able to do a movement like stand up. This appears to be coming from the Motor Cortex itself. This is easier to demonstrate than explain.

At this point he mentioned visualization and trying to lay down myelination and form new engrams (the software in the brain needs updating, the hardware is fine) of movement. This very much chimes with what I've  been reading recently in neuroscience, neuroplasticity and long term synaptic potentiation.

The assessment.

I think what he is trying to get across is how complete the assessment of the person in front of you has to be. From observing how they get out of their car, walk up the stairs, open the door, the look on their face, their complete history, how they sleep, how long they sleep, are they a type A or B personality and on and on.

He doesn't have a set assessment form. Every person is different.

You need to see how they move when fresh, when under stress, when under fatigue - 'break them down' and see what their movement does.

"What matters most to that person" is what you need to focus on.

Is it getting down on the floor and playing with their kids or returning to the NFL or running 10k? There is not one route.

When you have tested the hypothesis, and have a plan you then need to "coach movement not corrective exercise"

You should then "know the goal of the training programme and every single exercise."

The practical.

In the afternoon McGill then goes through the various practical assessments such as heel drop test, seated compression and things like neural flossing. All looking to identify if there is a stability problem, what are the triggers etc. Too many to mention here, with too many pearls of clinical wisdom.

But, I think if you hadn't read his books or watched his DVDs this section could be overwhelming. I would recommend familiarizing yourself with these before attending the course.

Yeah I'm the fan boy who bought the books when they originally came out over 10 years ago. I would read these or watch his assessment DVDs before attending the course. These are my books from 2002 and 2004, the latest editions contain  more recent research.

His assistant Joel (website for his facility here) covered the hip assessment, I believe he is an S&C coach.

By 6pm everyone was flagging and there was information overload. And left me with a couple of final thoughts on how to integrate all this information.

Three hour assessment.

In reality I don't think anyone in that room apart from McGill is going to go away and start doing three hour back assessments. However, I think everyone can take something away and make their approach more rigorous. We all get stuck in patterns, become a  bit lazy and default to certain ways of thinking , or diagnosis (if that's what you do).

Courses like this re-energise you.

McGill 1 or 2?

McGill 1 covered the research for the exercises more in depth and had a big practical element going through cat camels, bird dogs, side bridges, curl ups, glute exercises and more. Afterall McGill 1 is 2 days long.

If you are an athletic trainer, McGill 1 is the course to do. If don't have access to a therapy couch or your job doesn't allow hands on testing and assessment then there is not much you can practically take away from McGill 2.

From a clinician/ therapist point of view, McGill 2 is going to give you more assessment tools and some treatment options that can be done in a clinical setting and help the client can move better. But if you don't know the big 3 exercises, what a hip hinge is, and more, then it doesn't give you much to give your client to take away and do. For example, McGill mentioned the side bridge on the course and some peoples obsession with making it harder, but said that lifting a leg in a side bridge can double the spine load. If you don't know how to do the side bridge in the first place, this information may not be of use.

McGill 1 cover more things you can do with athletes as well. He covers deadlifting technique, squat technique, neural drive and more. In McGill 2 he only briefly mentions the spate of end plate fractures from people deadlifting and broken pelvic rings from people going too heavy on unilateral leg work.

In someways, it might be better to have the courses the other way round.

We had more time on McGill 1, McGill 2 seemed like we were rushing through the tests and assessments in the afternoon. And these are subtle things, with nuance that take time to learn. In some ways trying to cram too much in can cause confusion and lack of clarity.

On McGill 1 we were given a pdf of all the lectures. On this course there was no pdf or printed copy of the slides provided. This would have been useful to have.

Questions.

Some of these questions have only occurred to me after the course, some I had on the day.

McGill 2 doesn't give you an exercise pathway as such. For example, someone has a underhook at L.3, does this change the way you do the cat camel or bird dog? Aren't you going to do the big three exercises regardless of outcome?

Why do some people sit into their pain?

Why do some people have "reversed perception" and constantly self manipulate, how can you stop them?

Does any professional team or facility have a robust screening/assessment process that has been shown to reduce injury and improve performance by individualizing programmes?

Would it be possible to see neural resonance traces on an EEG or fMRI?

As always courses like this always throw up more questions and more to learn.

As McGill says "It depends" and "We are playing Jazz here". Treat or train the person in front of you, adapt and freestyle as needed, but use science and logic as your guide.

Closing thoughts.

You could learn nearly all that is covered on the course from McGills books, DVDs and research publications.

But by going on the course, you learn something more. It gives you an insight into how to interact with clients and patients. You see the man in action and his thought process.

He has just retired and is winding down, so if this is your thing now is probably the time.

I believe AECC billed this as a more intimate course than McGill 1 but it seems there were as many people as McGill 1, with 50+ other people in the room.

But even if you only take away 1 or 2 new bits of information or a way of phrasing something or carrying yourself in front of client then it was worth it.

I preferred McGill 1 as a course, and from McGill 2 I enjoyed the morning lectures session the most. It has given me a list of research to follow up. But maybe that's just my bias of wanting to know more about the research and not being so clinic based.

Take home message - be better, know more.

Now should I do McGill 3?

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.