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Three Part Question

In [patients with chronic lower back pain] does [pilates] help to [improve functional outcome and symptoms?]

Clinical Scenario

A 35 year old fit female presents with several years history of lower back ache/pain. She is otherwise well. Her work requires her to be mobile, flexible and strong enough to assist in the movement of heavy objects while also having a minor desk role. She also enjoys an active sporting/social life. She wishes to know if pilates can help her back pain and prevent any further recurrence.

Search Strategy

An advanced medline search from 1950 to Jan 2007. Using lower back pain with a thesaurus search and pilates without. Also, the Allied and Complementry medicine (AMED) database 1985 to Jan 2007. Also, the CINAHL database 1982 to Dec 2006 using both pilates and lower-back-pain as thesaurus searched terms.
Medline {(pilates) AND (lower back pain OR intervertebral disk displacement OR spinal disease OR pain OR lumbar vertebrae)}
AMED {(pilates) AND (lower back pain OR pain OR back pain OR lumbar vertebrae OR chronic pain)}
CINAHL {(pilates) AND (lower back pain OR pain OR back pain OR lumbar vertebrae OR chronic pain)}

Search Outcome

Medline found 5 papers which 1 was relevant. AMED found 8 papers of which 3 shown some relevance. CINAHL found 17 papers of which 3 were relevant. After removing the duplicates of the relevant papers from the three database, a total of 4 relevant papers were found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Herrington et al Jan 2005 UK	36 asymptomatic females divided equally into a pilates group, a abdominal curl group and a non training group		Transverse abdominis isolation test	83% pass from pilates group, 33% pass from the abdominal curl group and 25% pass from the non training group	Small group size. Could have performed a true RCT if the patients were symptomatic. Not specifically answering the question but related.
			Lumbo-pelvic stability	42% pass from the pilates group with all others failing
Gladwell V, Head S, Haggar M and Beneke R Nov 2006	49 participants with chronic low back pain were randomly allocated to control (n=24) or Pilates group (n=25). 34 subjects completed the study (14 and 20 individuals for control and Pilates group, respectively). Pilates group underwent a 6-week program of pilates. Both groups continued with normal activities throughout the study.	A blinded assessor conducted functional and questionnaire-based assessments pre- and post intervention.	Pilates group	Significant improvement in general health, sports functioning, flexibility, proprioception and a decrease in pain.	Small sample size used and not a double blinded RCT.
			Control group	No significant differences seen in general health, sports functioning, flexibility, proprioception and a decrease in pain.
Rydeard R, Leger A and Smith D Jul 2006 Canada	Thirty-nine physically active subjects between 20 and 55 years old with chronic LBP were randomly assigned to 1 of 2 groups. The specific-exercise-training group participated in a 4-week program consisting of training on specialized (Pilates) exercise equipment, while the control group received the usual care, defined as consultation with a physician and other specialists and healthcare professionals, as necessary.	A randomized controlled trial, pretest-posttest design, with a 3-, 6-, and 12-month follow-up. Objectives of the study is to investigate the efficacy of a therapeutic exercise approach in a population with chronic low back pain (LBP) by measuring Functional disability outcomes with The Roland Morris Disability Questionnaire (RMQ/RMDQ-HK) and average pain intensity using a 101-point numerical rating scale pre and post exercise program.	Pilates group	significantly lower level of functional disability (P = .023) and average pain intensity (P = .002). Improved disability scores in the specific exercise-training group were maintained for up to 12 months following treatment intervention.	Small sample size, single blinded RCT.
			Control group	No significant decrease seen in level of functional disability and average pain intensity
Gagnon LH 2005 USA	Twelve subjects who presented for physical therapy with low back pain (LBP), were randomly assigned to either the traditional lumbar stabilization exercise group (A, n = 6) or the Pilates exercise group (B, n = 6) and completed participation in the study.	The purpose of this research was to investigate the efficacy of Pilates exercises as a therapeutic intervention in treatment of low back pain (LBP). Pilates exercises have been integrated into many rehabilitation programs for those with LBP; however, no clinical research was found that supports its efficacy. Outcome measures used were the Visual Analogue Scale (VAS), the Revised Oswestry Disability Index (ODI), lumbar spine active range of motion (AROM), and measures of core stability on the Stability Platform (LaFayette Instrument Co), taken at pre-treatment, every fourth visit and at discharge from physical therapy.	There were no significant differences in any of the outcome measures between the groups over time.		Extremely small sample size to demonstrate anything significant, if significant findings were found, relevance of such findings would be questionned.

Comment(s)

There is little published evidence to support pilates and improving symptoms of chronic lower back pain. Most studies used very small sample sizes hence despite having significant results, the relevant findings are questionnable. Emerging evidence are showing that pilates is able to improve range of movement in the lower back and increased strength in the core muscles.

Clinical Bottom Line

There is some evidence using small sample sizes to suggest that pilates is more useful than conventional care in treatment of chronic low back pain, possibly due to the increase range of movement and increased strength in core stability muscles. Further larger and double blinded randomised controlled trials are required to fully determine the extent of pilates has on chronic low back pain.

References

1. Herrington L. Davies R. The influence of Pilates training on the ability to contract the transverse abdominis muscles in asymptomatic individuals Journal of Bodywork and Movement Therapies 2005 Jan, vol. 9, no. 1, p 52-7
2. Gladwell V, Head S, Haggar M and Beneke R Does a Program of Pilates Improve Chronic Non-Specific Low Back Pain? Journal of Sport Rehabilitation 2006 Nov;15(4):338-350
3. Rydeard R, Leger A and Smith D Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability: a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy 2006 Jul; 36(7):472-84
4. Gagnon LH Efficacy of Pilates exercises as therapeutic intervention in treating patients with low back pain The University of Tennessee 2005; Ph.D p119