Eighty percent of Americans experience back pain at one time or another (Luo et al. 2004). The discomfort can range from mild to severe or debilitating. Men and women are equally affected (Luo et al. 2004), and the pain can be caused by sedentary living, aging or overuse (e.g., repetitive motion during a sport).

Often, people are told to strengthen their abdominal muscles to fix a back problem. However, traditional crunches usually strengthen only the outer layers of the abdominal musculature, specifically the rectus abdominis, while bypassing the deep support structures. This can place the lumbar spine in too much flexion and may even exacerbate back pain, depending on what the original physical problem was. If the deeper stabilizers of the lumbar spine—the transversus abdominis and multifidus—are not properly trained, they cannot alleviate the pain or stabilize the spine.

Current research suggests it is important to facilitate stability of the lumbar spine by strengthening these deep stabilizers (Richardson, Hodges & Hides 2004). It is also important to restore the neutral alignment of the joints that make up the lumbopelvic region. Pain occurs when muscles become imbalanced or dysfunctional, thereby losing their effectiveness as stabilizers. When this occurs, the core muscles cannot support the vertebrae in the spine during everyday movements. Other, more superficial muscles, like the rectus abdominis and external obliques, must take over and try to do their work. Since these large muscles cannot stabilize the small, independent joints of the spine, this often results in compressive forces on the intervertebral disks.

Pilates, with its focus on body awareness and proper alignment, can be beneficial for people recovering from low-back injuries or experiencing low-back pain. For Pilates practitioners, instructors and clients, the method has become an invaluable aid in preventing and managing low-back issues.

How Pilates Can Help

In his time, many considered Joseph Pilates a master of rehabilitation. His method temporarily became known as an elite form of exercise for the rich, famous or highly skilled, but the medical and
rehabilitation communities have now
embraced it. Pilates is a gentle, restorative exercise regime that suits most people in the process of recovering from injury and rebuilding their bodies. The foundational approach focused on core strength, precision and control of movement. Combined with current exercise science, this approach is a recipe for success, for a number of reasons.

Pilates Develops Body Awareness. Clients need this awareness in order to recruit and strengthen the deep stabilizing muscles. Well-trained instructors teach clients to recognize when these muscles are activated and how to control the muscular contractions so as to provide support while maintaining the integrity of the muscular and skeletal structures involved.

As suggested by Motor Learning Theory, most beginning clients are unaware of whether they are using their deep stabilizers or not (Richardson, Hodges & Hides 2004). This leaves them vulnerable to pain. With proper Pilates cuing and instruction, clients learn first that they are not using their stabilizers and then how to recruit them. Finally, they progress to integrating the stabilizers and using them unconsciously during daily activities. This helps in preventing further injury and rehabilitating the spine.

Pilates Promotes Effective Breathing Patterns. Effective breathing patterns alleviate stress, which can be a major source of back pain. Conscious breathing provides inner focus, allowing clients to become more aware of their bodies and enabling recruitment of the deep stabilizing muscles.

Pilates Emphasizes Quality of Movement. Clients are required to perform exercises with precision through each execution. Instead of doing many repetitions of the same movement mindlessly, with little concern for form or accuracy, they do fewer repetitions correctly and with care. This is more beneficial than doing the same moves over and over with a faulty muscular firing pattern. A variety of exercises that recruit the same or similar groups of muscles are performed in sequence, allowing both client and instructor to maintain focus.

Pilates Develops Core Strength. Practitioners learn to engage the deep pelvic floor, which in turn works with the transversus abdominis and affects the positioning of other structures in the lumbopelvic region, providing support for the lower back.

Pilates Addresses Joint Functionality. In many cases, back pain results from either hyper- or hypo-mobility of various joints that affect the back and pelvic girdle. For example, if the thoracic spine or hip joints do not move in a biomechanically efficient way, the more mobile lumbar spine will compensate for the loss of motion. Pilates addresses such issues by looking at the functionality of individual joints and how they can work together with adjacent joints to provide natural, pain-free movement patterns within normal ranges of motion.

Pilates Uses Props and Equipment to Aid Progress. Props and larger equipment provide proprioceptive feedback, encouraging proper form and ensuring optimal muscular recruitment, joint stabilization and range of motion. Modifications of standard exercises lead to progressions that take injured clients from the acute stages of injury through to day-to-day
activity and beyond.

For a short series of exercises that benefit the low back, see the sidebar “Sample Pilates Sequence for Low-Back Pain.”

A Whole-Body Approach

One of the most compelling benefits of Pilates is that it focuses on the entire body and not just the injured area. Often, damage results from faulty muscular firing patterns caused by poor posture, habitual movements or compensations for an earlier injury. Low-back pain, for instance, may stem from misalignment elsewhere in the kinetic chain. As a result, failure to address the whole spine, rather than just the area of concern, may yield little or no relief. No matter how much emphasis is placed on rehabilitating the lumbar region, it will continue to compensate if another area of the body is weak or out of alignment.

For example, after an initial episode of low-back pain, the lumbar multifidus has been shown to atrophy or to become inhibited (Richardson, Hodges & Hides 2004). Learning to recruit this deep local stabilizer will decrease both the current pain and the chance of further painful episodes. Appropriate exercises at this stage include ab prep and breast stroke (see the sidebar “Sample Pilates Sequence for Low-Back Pain”). These exercises integrate local and global stabilizers, making the body more efficient by ensuring that all stabilizing systems are operating properly. Once a client knows how to
activate the multifidus and transversus abdominis, the next step is to introduce more challenging exercises involving
adjacent joints and heavier loads. As the client progresses and becomes better able to maintain support, it is appropriate to challenge the larger global mobilizing muscles, such as the rectus abdominis, erector spinae and obliques. These muscles are the prime movers and are responsible for large, gross movements. Appropriate exercises at this stage include cat stretch and hip rolls (see the sidebar “Sample Pilates Sequence for Low-Back Pain”). These muscles are integral in sport-specific moves as well as commonplace activities like chasing toddlers, turning quickly, or sitting at a desk and reaching for the phone.

In this way, by addressing the entire musculoskeletal system, Pilates makes the whole body more efficient, decreasing the incidence of re-injury.

Sample Pilates Sequence for Low-Back Pain

Following these basic Pilates stability exercises will help recruit the deep core muscles, stabilize the entire spine and help decrease or prevent back pain. Note: These exercises should be performed only with prior permission from a healthcare professional.

Breast Stroke Prep: Targets Upper Back

Starting Position. Lie on stomach on mat, legs together, front of hips flat on mat. Hands are by shoulders, with elbows and nose on mat.


1. Inhale: stabilize shoulder blades on back and contract

2. Exhale: raise upper body off mat, keeping lower ribs and elbows in contact with mat; keep head in line with back.

3. Inhale: hold position.

4. Exhale: return to starting.

Complete 5–8 repetitions.

Ab Prep: Targets Abs

Starting Position. Lie on back on mat, feet on mat, hip
distance apart. Spine is in neutral position, neither arched
nor flattened.


1. Inhale: nod head slightly.

2. Exhale: curl upper body off mat without pressing low
back into mat; raise arms slightly off mat during curl.

3. Inhale: hold position.

4. Exhale: return to starting position.

Complete 5–8 repetitions.

Cat Stretch: Lengthens Spinal Muscles

Starting Position. Kneel with equal weight on hands and knees, knees slightly apart. Hands are directly under shoulders, and knees are directly under hips. Spine is in neutral
position, neither arched nor flattened.

Exercise. To prepare, inhale.

1. Exhale: starting from tailbone, round the spine, allowing head to bend toward mat.

2. Inhale: hold position and tighten abdominal muscles.

3. Exhale: starting from tailbone, return spine to starting
position; bring head up last, but keep eyes looking down.

Complete 3–5 repetitions.

Hip Rolls: Targets Abs, Glutes & Backs of Thighs

Starting Position. Lie on back on mat, feet hip distance apart. Pelvis is in neutral position, neither arched nor flattened.

Exercise. To prepare, inhale.

1. Exhale: Starting from tailbone, slowly peel spine off
mat until hips are lifted and weight is resting between shoulder blades.

2. Inhale: hold position and tighten abdominal muscles.

3. Exhale: Starting from top of spine, slowly return to mat, lowering to starting position.

Complete 5–8 repetitions.

Starting PositionExerciseAb Prep: Targets Abs

Starting PositionExerciseCat Stretch: Lengthens Spinal Muscles

Starting PositionExercise

Hip Rolls: Targets Abs, Glutes & Backs of Thighs

Starting PositionExercise

By addressing the entire musculoskeletal system, Pilates makes the whole body more efficient,
decreasing the incidence of re-injury.