IS IT TIME TO RETHINK PILATES?
This article I wrote was published in the Australian Physiotherapy Association SportsPhysio magazine, Issue 3, 2018, pg 10-12.
Patient have enjoyed Pilates and many clinics have been offering the service since the turn of the century. John Contreras, APA Sports Physiotherapist, investigates why it might be time to reassess the role of Pilates in physiotherapy.
My initial experience with Pilates was not unlike many other physiotherapists in the early 2000s. The clinic I worked at had recently purchased a reformer and a colleague soon returned from a weekend course eager to promote the wonders of this ‘new’ way to exercise. Soon it was all about engaging, activating, contracting, controlling, and aligning patient’s bodies. This suggested our patients were not sufficiently engaging, activating, contracting, controlling, or aligning—but that is a dichotomy to discuss another time.
Overall, patients enjoyed Pilates and more clinics began offering it as a new service. Pilates seemed to work well with the motor control models used during the 2000s. Both clinician and patient were encouraged by Pilates’ low-impact nature, supported postures while exercising, the interesting equipment used, and the assurances from clinicians that their cores were getting the specific workout required.
Wells et al (2012) defined our understanding of Pilates in physiotherapy during those years by summarising Pilates as ‘a mind-body exercise approach requiring core stability, strength, and flexibility, and attention to muscle control, posture, and breathing’.
Fast forward to 2018 and times have changed slightly. Not only am I no longer burning music onto CDs to play during class, more importantly, our understanding and management of various musculoskeletal conditions traditionally referred to Pilates has also advanced. For conditions such as low back pain, the staple diet of any Pilates studio, we now appreciate that the management need extend beyond the motor control model of ‘isometric contractions of the core muscles’ (Yamato et al 2016) previously favoured within Pilates. Considering the long exploited language of core, glutes, stability and alignment, viewed now with our current understanding of pain science, injury prevention, load management, psychological, social, lifestyle and injury risk factors, this Pilates language and perception seems incomplete.
Perhaps it is time for another model to guide our use of Pilates in physiotherapy?
So what is Pilates anyway?
For the purpose of better understanding Pilates and its value to physiotherapy, I believe it is worth looking back to its origins and consider what Pilates was initially intended to achieve. Though I am not one for guru objectification, I do think it is helpful to mention the creator of Pilates, Joseph Pilates (1883-1967).
Instead of writing a Joseph Pilates’ biography, the most interesting point is that initially it was not called Pilates. Pilates himself referred to it as ‘contrology’, defined as an exercise form that enabled ‘complete coordination of body, mind and spirit’ (Pilates and Miller 1945). Furthermore, he added that ‘through Contrology, you first purposefully acquire complete control of your own body and then through proper repetition of its exercises you gradually and progressively acquire that natural rhythm and coordination associated with all your subconscious activities’ (Pilates and Miller 1945).
This definition of Pilates highlights three key points that we as clinicians should reflect on when making a clinician decision to implement its use:
1. Pilates is a ‘whole-person’ form of exercise;
2. It places emphasis on gaining coordination though progressive repetition towards improved task performance; and
3. It is not aimed at targeting individual muscles, muscle groups or a part of the body.
Despite a common misconception, Pilates was never intended to focus on isolated, uniplanar, uniarticular movements, or solitary muscle actions—Pilates considers human movement far from a reductionist viewpoint. There may be cases where the initial phase of a Pilates program will involve exercises synonymous with motor control exercises (Saragiotto et al 2016). However, these ‘beginner level’ exercises should be viewed as an introductory step along a clinical pathway towards a performance goal established by both patient and clinician/s. Pilates should be viewed as a whole-body, intersegmental approach that is consistent with other models that aim to improve performance through experiential learning (Caniero et al 2016).
Owing to the multifaceted and complex nature of most conditions managed with Pilates (eg, low back pain), the aim of Pilates during the early phase of rehabilitation should be to facilitate patients’ confidence with movement and regain control (in the metaphorical sense) of the active part of their rehabilitation. To borrow from low back pain literature, Pilates also provides many—though not all—aspects of a flexible, integrated behavioural approach advocated by O’Sullivan et al (2018).
Pilates is intended to continually challenge and progress an individual’s ability to perform co-ordinated movement. It is this aspect of Pilates that resonates with physiotherapists and lends itself to the rehabilitation process of most musculoskeletal conditions. Using Pilates as a plastic vehicle to guide patients through clinically indicated, graduated movement enables common presentations from lateral ankle sprains to cervical dysfunctions to be managed.
Pilates: from rehabilitation towards athletic development.
All of my patients are athletes these days. For some of my athletic patients their objective is a 40-minute 10 kilometre run, for others, it is returning to competitive sport. I also see athletes whose goals are simply returning to a weekly three kilometre walk along the beach, or playing a social round of golf. Placing a patient within an athletic framework enables the rehabilitation process to progress in a graduated manner towards specific performance goals. It should be no different when using Pilates. Rather than encouraging patients to participate in Pilates in an endless quest to improve their Pilates ability, our goal should be to assist our patients to achieve their performance goals with the assistance of Pilates. However, in most cases this will result in encouraging patients to eventually progress away from Pilates and towards a gym, or sports specific training approach.
When discussing long-term athletic development in youth, Bergeron et al (2015) stated that muscular fitness and effective movement skills form the foundation of achieving both optimal and sustainable athletic performance. Lloyd (2016) describes athleticism as the ‘ability to repeatedly perform a range of movements with precision and confidence in a variety of environments, which require competent levels of motor skills, strength, power, speed, agility, balance, coordination, and endurance’. Both statements resonate with the definitions used by Pilates and Miller (1942) and Wells (2012). So, what role does Pilates play in athletic development?
With a common theme being to improve physical performance, I argue that we can place Pilates as a component of athletic development. Obviously, in order for this to function, clinicians using Pilates need to recognise not only its strength but also the genuine limitations of Pilates when developing athleticism. For example, it would be unachievable to use a reformer, with its maximal resistance, to increase the lower limb strength of an anterior cruciate ligament patient six months post-operative who is now able to perform a single leg press of 150 per cent bodyweight for six repetitions. However, if the aim is to address the same patient’s pliometric performance, the reformer may initially provide a significant advantage in providing an environment of reduced load on landing and reducing the balance demand.
Considering Pilates’ ability to use a variety of postures and progress patients from a considerably low load environment, Pilates should be view as a derivative of neuromuscular training (NMT) and consequently a vital component of athletic development. NMT is based on biomechanical and neuromuscular principles aimed at improving both sensorimotor control and achieving compensatory functional stability (Ageberg et al 2010).
Viewing Pilates as a form of NMT and part of a patient’s athletic development, clinicians can plan a graduated, performance goal orientated rehabilitation program. Uninhibited by the concept of whether an exercise is being done correctly according to a text, or whether a specific muscle is ‘activated’, the Pilates program design can be guided by nothing other than the patient’s current performance level and the proposed performance goal in a similar manner to the gap analysis suggested by Drake (2017).
As an example, a patient who is returning to a jumping sport requires triple extension (extension of the hip, knee, ankle plantarflexion) training. Using Pilates to assist athletic development, the components of a vertical leap can be progressively challenged. This may commence with performing triple extension in progressively less supported postures with increasing emphasis on rate of force development. Therefore, while the strength demand of each exercise may reduce, the coordination and performance demand increases. At a clinically appropriate point, you can introduce and progress exercises such as loaded squats and box jumps. As jumping tasks are being trained, Pilates may be then used to challenge clinically indicated components of coordination, balance and/or mobility as part of their athletic development.
Pilates challenges athleticism. The countless images of dynamic, athletic movements that litter Pilates social media accounts are testament to this. However, has this quest for Pilates specific athleticism lead Pilates in physiotherapy to not see the wood for the trees. As a patient progresses with their Pilates program, it may be common for the original performance goal of running, competitive sport or walking to be lost. Placing the Pilates program within an athletic development model maintains both the clinician and patient’s focus on the performance goal at hand. That performance goal may be a five kilometre fun run, a return to basketball following a lateral ankle sprain, or may even be performing ‘reformer scooter holding a magic circle while standing on a BOSU ball.
The use of Pilates within physiotherapy is only limited by the clinician’s approach. Understanding the patient’s goals and performance requirements, the relevant clinical rehabilitation guidelines and the patient’s current level of performance are a crucial first step in establishing a suitable Pilates program. Subsequently expanding one’s repertoire of Pilates exercises across a range of equipment and levels of athleticism, the clinician can further explore their patient’s coordination. Conducted under the banner of athletic development, the clinician can then determine which aspect of their patient’s progress can be suitably challenged by Pilates, and which may need to be referred to a different form of training, such as gym based or on-field training.
· Pilates can be used as a form of neuromuscular training to challenge coordination under low to moderate loads
· Pilates can facilitate athletic development by employing a neuromuscular approach to the exercise prescription
· Pilates should be used with other exercise forms better suited to addressing certain physical characteristic, for example, gym based training for maximal strength.
John Contreras, APA Sports Physiotherapist, Strength & Conditioning Coach, Pilates Coach B.Physio (Hons) B.Sc M.ExSci (S&C) M.Sports Physio
Ageberg, E., Link, A., & Roos, E. M. (2010). Research article Feasibility of neuromuscular training in patients with severe hip or knee OA: The individualized goal-based NEMEX-TJR training program.
Drake, E. (2017, April 10th) Using strength & conditioning in Physiotherapy [Blog Post]. Retrieved from
Caneiro, J. P., Smith, A., Rabey, M., Moseley, G. L., & O'Sullivan, P. (2017). Process of change in pain-related fear: clinical insights from a single case report of persistent back pain managed with cognitive functional therapy. journal of orthopaedic & sports physical therapy, 47(9), 637-651.
Saragiotto, B. T., Maher, C. G., Yamato, T. P., Costa, L. O., Costa, L. C. M., Ostelo, R. W., & Macedo, L. G. (2016). Motor control exercise for nonspecific low back pain: a Cochrane Review. Spine, 41(16), 1284-1295.
Pilates, J. H., & Miller, W. J. (1945). Return to life through contrology. JJ Augustin.
Yamato, T. P., Maher, C. G., Saragiotto, B. T., Hancock, M. J., Ostelo, R. W., Cabral, C. M., ... & Costa, L. O. (2016). Pilates for low back pain: complete republication of a cochrane review. Spine, 41(12), 1013-1021.
Wells, C., Kolt, G. S., & Bialocerkowski, A. (2012). Defining Pilates exercise: a systematic review. Complementary therapies in medicine, 20(4), 253-262.