Pilates Therapy: Exercises for Spinal Stability

Penelope Latey

LEARNING OBJECTIVES

After reading this chapter, you should be able to understand:

The history of Pilates
The differences between the original Pilates method and modern Pilates
The fundamental principles of modern Pilates
The research supporting and refuting the use of Pilates in treating lower back problems
How to perform the musculoskeletal reeducation involved in modern Pilates
How to practice stage 1, and proceed to stages 2 and 3 Pilates sequences and introduce the use of Pilates equipment

“It is the body that feels, the body that experiences pain and pleasure, and the body that expresses its concerns. This must not be seen as a reversion to the mind-body dualism that has dominated social thought, but rather as a perspective that transcends one-sided, polarized positions to embrace integration and diverse possibilities.

–W. SEYMOUR

Introduction

Pilates taught by an informed teacher can enhance spinal stability and reduce pain. Pilates exercises facilitate dynamic spinal stability with thoughtful control of the “Center,” with coordinated breathing, in functional postural alignment. The movements are specifically tailored to the client’s ability using a range of more than 500 exercises, which may be performed on a mat or using specifically designed Pilates equipment.

Modern Pilates may be used as a stand-alone modality to treat a range of musculoskeletal conditions arising from spinal instability. The modern method can also provide prehabilitation as well as post-acute rehabilitation and as a preliminary intervention for preparation toward more general athletic strength and conditioning programs.

This chapter introduces the Pilates method and describes the development of Pilates from its inception to its current use in rehabilitation and for maintaining well-being with a focus on spinal health. The original and modern Pilates philosophy and principles are described and compared. The application of the modern method and performance skills required are discussed, including differences in functional spinal alignment, from flat back to neutral spine.

Research into Pilates for low back problems is reviewed. The results of the literature search on Pilates are positive, with research into the efficacy of Pilates for low back pain, and other conditions improving in quality, particularly over the last 5 years.

This chapter describes some of the fundamental mat exercises of modern Pilates. The exercise descriptions include breath patterns, movement sequence, aims, limitations, and watch points for each exercise. Progression from stage 1, to stage 2 and stage 3 and the use of Pilates equipment is also described.

Background

The Pilates method, originally called “contrology,” was developed by Joseph Pilates during the early to mid-19th century. The method grew out of his early exercise and fitness training, as well as his later employment as a body builder, gymnast, circus performer, and boxer. His health and fitness regime would have also been influenced by his experiences during World War I. The Pilates method is a mixture of yoga, martial arts, eastern philosophy, and western 19th-century therapeutic gymnastics and fitness regimes.¹

Joseph Pilates wrote two books describing his philosophy, principles and 34 key mat exercises for personal practice.²^,³ Contrology, Pilates original name for his method, was a “balance of mind and body.” Fundamental principles included “concentrating on the purpose of the exercises as you performed them.” Correct breathing underpinned all the exercises and was primarily from the thorax with extreme effort. “Squeeze every atom of air from your lungs until they are almost as free of air as is a vacuum.” Pilates considered good postural alignment as “the spine should be flat like a plumb line.”³ In practice, this meant the adult pelvis was in a strong posterior tilt, to straighten the lumbar spine with the chest thrust out to reduce any thoracic kyphosis, buttocks clenched,¹ and maintaining the abdomen held in with lateral thoracic breathing⁴ (Fig. 32.1).

After the 1990s, some Pilates instructors changed the ideal “flat back” or straight spine alignment of classic or traditional Pilates³ to an idealized “neutral” spine based on the idea of upright spinal alignment. This “neutral” spine is observed when the symphysis pubis and the two anterior iliac spines are parallel and
on the same plane as the floor in crook lie position, which could be called the “flat front” (Fig. 32.2).

Figure 32.1 Flat back with posterior tilt of the pelvis.

The Pilates neutral spine is not to be confused with the neutral zone as determined by Panjabi.⁵ In modern Pilates therapy, neutral spine is understood to be unique to each individual, based on the lumbar spine being minimally loaded and maintained in a state of elastic equilibrium.⁶ The spine trained to hold in an idealized neutral is not functional.⁷ Functional spinal alignment is dynamic and varies depending on the individual’s axial skeletal structure and function, the relationship of the torso to gravity or position in space, as well as limb (load and speed) movement (Fig. 32.3).⁸

What Is Modern Pilates

Modern Pilates utilizes current understanding of musculoskeletal function and good health with modified fundamentals that include the new definitions of the center, functional postural alignment, and appropriate breathing techniques. The fundamental principles are concentration with quiet relaxed awareness encouraging a body mind connection and maintaining functional alignment of body segments. Alert torso breathing from the center of the body is used to promote internal calm and provides an interface between our voluntary and involuntary systems. Movement is initiated with a dynamic stable center from the pelvic floor to the thoracic diaphragm; working with precision of body movements encourages fine motor control; using coordination—the smooth flowing progression of muscle recruitment through the whole body to allow complex balanced movement sequences; lengthening while strengthening muscles for eccentric control and supporting synergistic effort which reduces joint compression and maintaining persistence of practice to improve physical stamina, endurance, and extend mental attention span.⁸ Moving with and being guided by these principles helps create flowing movement with minimal force, activating the correct muscle groups and relaxing or minimizing tension in overactive muscles.

Figure 32.2 Flat front with elevated lumbar spine.

Figure 32.3 Dynamic neutral with relaxed lumbar spine.

Research Into Pilates for Low Back Problems

For many decades, the Pilates method was considered one of the few ways dancers or gymnasts could rehabilitate after injury and maintain form during injury repair. Research to support this anecdotal opinion was very slow to develop. However as modifications were made to the Pilates method in the early 1990s, which made it more accessible to the general public, physical therapists began investigating dynamic joint stability in the lumbo-pelvic region, and low back problems. Local or core muscle (that directly attach to the lumbar vertebrae) inactivity or delay had been seen as a probable cause of some lower back pain.⁹^,¹⁰^,¹¹ Similar
to working from the Pilates center, core strengthening exercises focus on drawing in and holding the local muscles of the lumbar pelvic region to maintain functional stability.¹² Core strengthening has been promoted as a preventative regimen, as a form of rehabilitation, and as a performance-enhancing program for various lumbar spine and musculoskeletal injuries.¹³ This research was in part embraced by the Pilates community as supporting one of the fundamental tenets of the method—working from the center for dynamic stability.

There is some disagreement in the field of musculoskeletal rehabilitation about the focus on core control and activation of the transversus abdominis. Some research suggests that abdominal hollowing can decrease spinal stability in some situations, and that abdominal “bracing” is the correct way to maintain truncal stability.¹⁴ There are also different opinions on what constitutes the core and how important core control is compared to general exercise programs.¹⁵^,¹⁶ McGill advocates activating all the abdominals and the muscles of the back, particularly the quadratus lumborum, to make the spine stiff, and suggested that the gluteal muscles play a large part in lumbar pelvic stability for rehabilitating the lower back.¹⁷ (see Chapter 19).

Aside from Your Health,² Return to Life With Contrology,² and the Pilates Method of Physical and Mental Conditioning,¹ minimal literature or research into the Pilates method was published until the early 21st century. In contrast, an electronic search of the literature conducted by the author in January 2017 identified 25 systematic reviews on Pilates. Of these, eight were specifically on the efficacy of Pilates for the treatment of low back pain¹⁸^,¹⁹^,²⁰^,²¹^,²²^,²³^,²⁴^,²⁵ or rehabilitation,²⁶ two on exercise interventions, including Pilates¹⁸^,²⁷ and a Cochrane review on Pilates for low back pain.²⁸ The Cochrane review to determine the effects of the Pilates method for patients with nonspecific acute, subacute, or chronic low back pain²⁹ retrieved 126 trials, of which 10 fulfilled the inclusion criteria and were included in the review (a total sample of 510 participants). They reported no conclusive evidence that Pilates is superior to other forms of exercise for treating nonspecific low back pain. However, they found low to moderate quality evidence that Pilates is more effective than minimal intervention in the short and intermediate term, as the benefits were consistent for pain intensity and disability, with most of the effect sizes being considered medium. A systematic review on core stabilization exercise prescription, comparing motor control versus general exercise evaluates core stability exercises that are also basic pre-Pilates exercises. This review of exercise rehabilitation for patients with low back pain found that stabilization exercises help to decrease pain and disability.³⁰ Further to this, a quality evaluation of nine systematic reviews from 2008 to 2014 reports that Pilates exercise provided pain relief and functional improvement in the short term in participants with chronic low back pain.³¹ The report also found evidence of improved flexibility and dynamic balance, and of enhanced muscular endurance in healthy people in the short term.

A systematic review on the effectiveness of Pilates as a rehabilitation tool included studies for low back pain, ankylosing spondylitis, multiple sclerosis, post menopause osteoporosis, nonstructural scoliosis, hypertension, and chronic neck pain, and concluded that the quality of the research into the efficacy of Pilates has improved considerably in the last 5 to 10 years.³² Nineteen of the 23 papers that met the reviews’ inclusion criteria found Pilates to be more effective than control or comparator groups at improving outcomes including pain and disability levels.

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