Clinical Question

Are Pilates exercises effective for patients with low back pain?

Evidence-Based Answer

There is low- to moderate-quality evidence that Pilates exercises taught by certified instructors improve pain and reduce disability in patients with chronic low back pain. It is unclear whether a Pilates regimen is superior to other exercise plans for the treatment of low back pain. Adverse effects are uncommon. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Up to 40% of patients with acute low back pain will not have resolution of pain in the first three months, and more than one-half of these patients will have residual pain after one year.¹ No systematic review has concluded which, if any, of the commonly suggested exercise regimens—including yoga, tai chi, and McKenzie method regimens—is best for treating patients with chronic low back pain. Once known as “centrology,” the Pilates method was originally developed in the 1920s by Joseph Pilates. It is based on the principles of centering (i.e., toning the core trunk muscles), concentration (i.e., being attentive to movements), control (i.e., maintaining posture), precision (i.e., being accurate in techniques), flow (i.e., making a smooth transition between movements), and coordinated breathing. The authors of this review sought to determine whether this intervention is effective in treating patients with nonspecific low back pain.

This Cochrane review included 10 randomized controlled trials and 478 patients, all 16 years or older. Treatments were supervised by trained or certified Pilates instructors and were carried out from once a day to once a week. All training sessions were approximately one hour long, and treatment programs lasted from 10 to 90 days. Six trials compared Pilates with minimal or no intervention, using a zero (no pain) to 100 rating scale to determine benefit. All of the included trials focused on patients with chronic back pain. Adverse effects were rarely reported; when they occurred, they were mostly mild muscle pain that did not cause patients to discontinue treatment. No trials reported outcomes beyond 12 months from the onset of treatment.

Meta-analysis of low- and moderate-quality evidence demonstrated that Pilates therapy provided pain relief during the first three months (mean difference [MD] = −14.05; 95% confidence interval [CI], −18.91 to −9.19) as well as up to one year after treatment began (MD = −10.54; 95% CI, −18.46 to −2.62) when compared with minimal or no intervention. These improvements are based on a 100-point scale, and this would be considered a clinically significant or noticeable benefit. Each of the individual trials had outcomes favoring Pilates. With regard to reducing disability, meta-analysis found that Pilates was superior in the short term (MD = −7.95; 95% CI, −13.23 to −2.67) and the intermediate term (MD = −11.17; 95% CI, −18.41 to −3.92). These differences are of marginal clinical significance. Only one trial with 86 participants reported on the outcomes of improved function and global impression of recovery. Although it demonstrated statistically significant improvements over the short term, longer-term outcomes were not considered statistically or clinically significant.

Four trials compared Pilates with other exercise regimens, although only three of the trials could be included in the meta-analysis. The comparisons were general exercise or a stationary bicycling program. The evidence was considered low quality, and the outcomes in the studies were not consistent in determining whether Pilates is superior at improving pain. With regard to improving disability, there was moderate-quality evidence that Pilates is no better than other exercise regimens.

The conclusion that Pilates is beneficial in the short and intermediate term for relief of pain and disability is consistent with the findings of other recent systematic reviews.^2,3 Although they do not specify one type of exercise regimen over another, current guidelines suggest that all patients with chronic pain participate in some form of exercise therapy to improve function and fitness.⁴ Patients can find Pilates instruction from many resources, including free introductory videos available online. One such source is https://www.youtube.com/watch?v=cuv3kOp2wLI.