Low back pain (LBP) is very common and results in many days of ‘sickness’ absence from work in the UK. In fact, back, neck and muscle pain are more likely to cause sickness absence than any other minor illness including cold and flu. The Health and Safety Executive state that back pain can be caused by particular workplace activities, such as heavy lifting and long periods of seated activity like driving or being sat at a computer.

The most common type of back pain is termed non-specific, meaning that no medical reason has been found to explain the discomfort. The best advice in these situations is to keep moving, do daily activities, and to exercise. However, pain is a barrier to exercise, especially when vigorous in nature, as people may believe that this will aggravate their back problem.

Since it’s origins in the early 20th century, Pilates has been used to help those with anatomical problems, including the inventor himself, Joseph Pilates. Alongside it’s now mainstream popularity, many people are now aware of the benefits Pilates possesses, making it a popular exercise choice for those dealing with low back pain.

The National Institute for Health and Care Excellence (NICE) recommend LBP exercise programmes that include the following elements: stretching, postural control, muscle strengthening and aerobic activity. With the exception of aerobic training, Pilates effectively achieves all of these goals.

That said, there are particular Pilates exercises that should be prioritised when working with those with low back pain. These include mobilising the spine; strengthening the back extensors and deep abdominals; and stretching the back extensors, hip flexors and hamstrings.

Pilates exercises that target these elements may require no further modification for those with non-specific LBP, however, others may require additional tailoring options to ensure comfort and adherence to the programme. The recommended Pilates exercises below are therefore grouped according to the target element. As well as this, the exercises have a range of tailoring solutions for specific challenges faced by those performing Pilates exercises with low back pain.

Spine Mobility

Effective exercise choices are ones that mobilise the spine into rotation, such as seated or standing trunk twists.

Focus on keeping the hips facing forwards if standing. With seated exercises, those with poor back extensor strength or poor hamstring flexibility (both common in people with low back pain) may find it difficult to sit tall with a natural curve in the lumbar back, thus their spine position is compromised and this may cause back discomfort.

Try using a block or two under their bottom, checking that the spine is not flexed. If it is, opt for a standing trunk rotation, or a more passive alternative such as supine knee drops; both knees rolling to one side simultaneously and the arms moving in opposition.

The side-lying open book exercise is another potential exercise for rotating the spine. However, as the lower body remains still for the duration of the movement, those with pain associated with the pelvis and/or sciatica may experience discomfort because of the angle created at the top hip. A pillow or folded towel between the knees can effectively remedy this.

Strengthening the Back Extensors

Lying back extensor work is ideal as the position of the body relative to gravity’s pull ensures that the back extensors are sufficiently challenged. The breaststroke exercise is an obvious choice; however, those with LBP may find that lying on their tummy allows a lumbar back curve that is greater than is comfortable.

Placing a folded towel directly under the client’s anterior superior iliac crest (the bony protrusions at the front of the pelvis) tips the pelvis into a more anterior tilt (bottom more tucked under) so that the lumbar curve is reduced and the lumber back extensors are more lengthened. The client should then be able to perform the breaststroke exercise as normal.

Bear in mind that those with low back pain often have weak back extensors, therefore performing fewer reps initially might also be advisable.

Strengthening Transverse Abdominis

Strengthening of the transverse abdominis (TA), which is the deepest of the abdominal muscles, is a primary goal of any Pilates session. Considering this, you can select from several common exercises including knee drops and arm pullovers.

As with the back extensors, the TA is often very deconditioned and weak in those with LBP, so starting with less intense activities is wise. One important caution with TA exercises is associated with those that are more intense and also involve hip flexor work, such as double foot drops. Be mindful of the fact that the hip flexor group is made up of three muscles and that two of these – psoas major and psoas minor – are attached to the lumbar spine.

Therefore, in a double foot drop from tabletop position, the abdominal muscles must contract to maintain a natural curve in the lower back against the weight of the legs, which are attached via psoas major and psoas minor directly onto the lumbar vertebrae. When the weight of the legs is too great for the strength of the abdominals, the low back will be pulled in to an exaggerated curve with the tummy doming up towards the ceiling.

This can exacerbate back pain, so careful observation is required. As well as this, remember that the fascia of TA also attaches into the lumbar back, so challenging the TA (even without using the hip flexors) can cause a ‘pulling’ sensation in the low back that clients may perceive as undesirable. If you get the chance, some education can go a long way to helping clients adhere to their programme.

Stretching the Back Extensors

This can be achieved in several positions, so experiment with your clients and find the one(s) that are most comfortable on an individual basis.

The shell stretch is highly effective, but gravity may ‘push’ the client beyond their capability and lower back comfort. If discomfort is reported, opt for lying on the back instead, hugging the knees to the chest, or even better, drawing the knees towards the armpits. The head can remain down on the floor, thus reducing the active use of the abdominal muscles, or the head can be raised – bringing the forehead towards the knees – which will increase the stretch for the thoracic back extensors.

Stretching the Hip Flexors

Hip flexors are often tight in those with LBP and unfortunately having shortened hip flexors can add to the discomfort. This is because two of the three hip flexors are attached to the lumbar vertebrae. A ‘gently does it’ approach should be adopted, opting for a supine position with one leg bent at the knee and hugged towards the chest.

The other leg can then be slowly straightened, ensuring that the weight remains resting on the sacrum. If this proves to be ineffective, the client can press the lower back towards the floor.

Stretching the Hamstrings

The hamstrings are another group of muscles that should be targeted for improved flexibility with this population. As with the hip flexors, they are often short, thus pulling the pelvis into a posterior tilt.

A classic supine hamstring stretch – with the ‘resting’ leg bent and the foot flat on the floor – should be attempted, but you may find that the client is unable to comfortably reach the extended leg.

This can be remedied with a webbing band around the ankle which the client pulls to draw their leg towards their chest. It is essential to coach this stretch with a natural lumbar curve and not with the lumbar back in ‘imprint’ (pressed into the floor). You can perhaps suggest that they try sliding their hand into the gap between their low back and the floor.

If their flexibility is so poor that the angle between trunk and leg is greater than ninety degrees and the leg tends to shake because the hip flexors are consequently so active, try this stretch seated on the edge of a chair instead. If this is within a group Pilates session, and you are concerned about getting the client up from the floor when everyone else is still mat-based, you could give it to them as a home exercise instead.

Correct Lifting

People with LBP are commonly advised to protect their backs when lifting by using correct lifting technique – holding the load close to the trunk, driving up using the legs, etc.

However, it can be difficult to get the knack of this, and frequently people with back pain resort to either avoiding lifting altogether or adopting a lop-sided manoeuvre involving lateral flexion of the trunk.

The monkey squat is a great exercise to help people achieve safer lifting technique. Plus, if performed correctly, with the hips pressing backwards and the knees remaining above the feet, it strengthens the back extensors; an important goal of exercise for those with low back pain.

In summary, becoming sedentary due to low back pain is rarely helpful and keeping moving is a priority. Pilates already contains all of the necessary ingredients for a sound exercise programme for those with chronic, non-specific LBP. A few simple tweaks to the exercises, along with plenty of reassurance that the right exercises can indeed be beneficial, may dramatically improve the quality of life of those suffering with low back pain.

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