Pilates For Back Pain: Avoid Making It Worse

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Pilates is a common choice for those with lower back pain because it is seen as a sensible, and gentle way to help you strengthen your back and recover from severe pain. However, there are two major issues that pilates all too often fails to address, leading people down the wrong path and ultimately worsening their back pain. 

If you’re a fan of pilates or an instructor yourself, the great thing about today’s video is that once you understand these common but serious flaws, you can very quickly modify your pilates instruction and practice. At the end of it all, pilates has many positive goals for ordinary people, from a health and wellbeing point of view. But when we have an injury to the low back, a deeper understanding is necessary to correctly modify practice in order to be helpful and not harmful to recovery. 

Mistake One: Pilates is good for posture and alignment

This is a simple oversight because most pilates instructors are not trained in spinal alignment, but posture, and are unaware of the implications certain movements can have on the spinal alignment, especially in the event that one has a lower lumbar injury as is commonly the case where sciatica is experienced. The last two lumbar segments, L4-L5 and L5-S1 are most commonly the root cause of lower back pain or sciatica, and this frequently involves some degree of damage to the disc which is the “cushion” between the two vertebrae.

Example of where pilates commonly gets posture wrong

The most common example of this comes when we look at the pelvic tilt or tucking movement before exercises such as the dead bug or bridge, or even the pelvic tilt being an exercise to engage the core in its own right. This is a problem because most with long standing lower back pain have a reduced curve in the lower back, meaning it is already too flat. 

Postural examinations are practically useless at gauging whether a person has too much or too little lumbar curve, and 9 times out of 10, the person will be told they have anterior pelvic tilt. We discuss the reasons for this in many other podcast episodes but simply put. Most have little experience with imaging and therefore haven’t had the humbling experience of realising in real time how inaccurate physical examinations of this sort of phenomenon – spine alignment – are.

Repeatedly learning the pelvic tuck with every core exercise is a recipe for disaster as once you have this habit, you repeat it when standing which only serves to further off-balance the person’s spine and is certainly not helpful in the case of lower lumbar issues.

How to engage the core properly without flattening the spine

Resources for further explanation: 

Pelvic tilt podcast episode

Anterior pelvic tilt podcast episode

Mistake two: Pilates is good for strengthening your core

This is a less serious mistake but one that is necessary to understand so that you have a complete pathway forwards for strengthening your core. Your core consists of muscles and a spine, and is built to bear load and move. While pilates exercises can be great to activate the core musculature – once you’ve eliminated mistake one – it is doing nothing to strengthen the “whole core” which includes your spine.

Example of strengthening of the core for long term back resilience

Exercises that might be done on the floor or preferably on a pilates reformer have many benefits which we will discuss later, but if you’re trying to restore the stability in your spine you have to include progressively more load. On the whole this is not included in pilates, instead a simple example of a better core exercise would be the loaded squat or hip hinge movement.

Resource for further explanation:

5 core strengthening exercises you must do

Moving forwards with pilates for your lower back health

There are many benefits to pilates, the gentle approach, the thoughtfulness of the exercise at a slow and controlled pace and the activation of core musculature are all great attributes of the pilates system. However, we can enhance the effectiveness of our pilates if we sensibly integrate this improved anatomical knowledge to make things more appropriate for the individual with a back injury that’s causing either local back pain or sciatica. 

Thankfully the mistakes, while significant, are easily remedied for more effective and safe pilates that will actually help you rebuild your back health for the long term.

Step one: Learn about the neutral spine and support it

The first and most important lesson that must be learned is about the neutral spine. What is this and how do we go about maintaining it? All of us should have a natural arch in the low back which means when we lie down on our back, or stand against the wall, the sacrum or pelvis will touch the floor, the rib cage will touch the floor and our lower back will form an arch and not be in contact with the floor. In essence your fingers should be able to slide into the space between the floor and your low back. 

Be careful though as for some with more or less fat or muscle in the buttocks or lower back can skew this “measure” making the illusion that you have more or less curvature there. Unless you have objective measures on load bearing imaging, there is no need to try to change anything.

This position is therefore “neutral” and what you should focus on maintaining. So instead of doing a pelvic tuck, for example, before doing a dead bug exercise, you should simply brace your core and initiate the movement. 

A word of warning on neutral spine core engagement

Please be warned, this way of doing the deadbug can often be quite humbling as it is much more difficult! But do not despair, there are strategies you can take to make this easier without doing pelvic tucks or tilts! We break this down in a deep-dive deadbug for back pain tutorial which you can check out if you struggle keeping a neutral spine when doing the dead bug.

By learning to engage your core to protect your neutral spine, you’re learning a skill which is transferable from the pilates mat or reformer, to your everyday life. No more will you be doing the incorrect pelvic tucks to brace, but simply engaging your core around a neutral spine!

Although it might take a little time to unlearn, it will be time well spent!

Step two: Remove other exercises that imitate the pelvic tilt

The reason the pelvic tilt is problematic is that it flattens the lumbar spine, which is not good for load bearing and certainly not helpful in the recovery process if you have lower back pain. Unfortunately there could be many other movements that imitate this same flattening of the lumbar spine. These should be rooted out from your routine. Movements such as the child’s pose or knee hugs are examples that might be found in the “stretching component” of your pilates class. These again have little place in the development of a healthy lumbar spine post injury.

Pilates does a great job of developing control and balance, but it must be done with goals in mind, so use your pilates classes to help optimise your ability to control a neutral, static lumbar spine when doing the various movements. Especially in the early days of recovery, while your spine is not good at bearing significant load.

Step three: Introduce load to the spine carefully

This is one of the four steps that might not be taking place within the pilates studio or class, but is vital if you are to succeed for the long term. The spine requires that you reintroduce load to it in order to rebuild strength and resilience, otherwise, you’ll be left with good abdominal muscles, but an absence of strength in them and a weak spine. This is all too often the outcome we see for people who’ve relied solely on pilates.

Life has load, and whether it’s your own children or grandchildren, the shopping, the holiday suitcase or something else, your back will be exposed to load again, likely in a far from ideal way. Therefore it is your duty to expose your spine safely to load in a controlled environment. Learning simple movements such as the squat or hip hinge are a great way you can master a bodyweight movement and then add resistance through bands or weights over time to actually build a strong core, in the most complete sense. 

Examples of the squat and hip hinge movements

Step four: Focus on trunk stability and limb mobility in the hips

The final step for your back health within the context of pilates is to focus on building your strength and ability to maintain trunk stability, or in other words maintaining a neutral spine. This stability can be built in the early days through some of the familiar pilates exercises for your core that have been modified to adhere to the “neutral spine principle” as we mentioned in step three, you’ll have to spend some time working with “load bearing exercises to build strength beyond this, likely outside the pilates studio. But as your legs and back gets stronger, your pilates exercises can come back into their own to help you continue to build flexibility to your now strong hips.

Choose to work through pilates movements that involve the hips whilst modifying them to maintain a neutral spine as far as is possible. This modification to your long term pilates strategy will ensure you are using pilates as an effective tool for improving your lower back health in a targeted way, whilst leaning on other strategies where appropriate to complete the rehabilitation process outside the pilates studio.

Example of the hip hinge with progressive resistance

Final thoughts on pilates for low back pain

In conclusion, pilates can be a great healthy practice for many reasons, but when we have lower back injuries, we need to operate from a set of principles, and this means modifying exercises where those principles are violated. Pilates core exercises can be a great gentle way to learn to activate the core musculature, especially for the beginner who’s not had much exercise, but it must be done adhering to these principles we discussed. We cover these in great detail on the weekly podcasts and videos that we release on the Back In Shape Youtube channel, and within the Back In Shape Program. And if you’re a pilates instructor yourself, we hope this has been insightful and of interest in helping you better guide your students who struggle with low back pain!

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