Low Back Pain and Pilates: When to flex and when to extend?

– By Karen Clippinger, Professor Emerita CSULB, MSPE, PMA-CPT, ACSM-GEI 

Low back pain is a common condition worldwide and one of the major complaints that bring people to seek medical attention. The old approach to “just stop the activity and rest for extended periods of time” is not considered acceptable to many fit individuals. Furthermore, extended rest has been shown to generally not be effective for long-term back health, as it can produce further core weakness and disrupted movement patterns, making even smaller forces produce low back discomfort. In addition, studies indicate that just having low back pain go away, does not mean that altered activation of key core muscles is corrected, leaving individuals at higher risk for recurrence of low back problems.

With its keen attention to technique and focus on developing core stability, Pilates offers a valuable approach for improving back conditions. And with more clients turning to Pilates it is important for Pilates instructors to better understand common back conditions, since the same exercise can provide one client with relief, yet aggravate another client. One approach commonly used by medical professionals that can also be helpful for Pilates instructors is the division of back conditions into those that tend to be aided by flexion but aggravated by extension, versus those that will tend to be aided by extension but aggravated by flexion. This stratification can provide a logic that will allow for utilization of appropriate positions and exercises so that the necessary strength can be developed and range of motion restored, while initially protecting the area of concern. 

For example, individuals with spinal stenosis have a narrowing of the spinal canal, through which the nerve root runs, or the opening through which the nerve root exits the spine. Studies show that these openings are made markedly smaller with extension, versus markedly larger with flexion. Thus, there is an underlying logic why many individuals with this condition are aggravated when they go beyond a certain degree of extension. In more severe cases, clients may actually sit and stand with the low back rounded (in flexion) to relieve the pain and other symptoms.

With these later clients, emphasizing good technique and applying many of the classic Pilates cues to co-contract the abdominals and distribute the arch throughout the lumbar and thoracic spine are just not sufficient. So, depending on the severity of the condition, the lumbar spine may need to be initially maintained in slight flexion or a neutral position. For example, in the pictured exercise, a sitting position is used because it tends to decrease the low back curve (create relative lumbar flexion) while the abdominals are used to maintain a neutral position of the pelvis as hyperextension is limited to the upper back (thoracic region). When the logic is understood, classic Pilates exercises can be modified and novel exercises designed to develop desired strength, flexibility and muscle activation.

When working with low back conditions it is essential to stay within the scope of practice as Pilates instructors. But, in my experience Pilates can make a valuable contribution when combined with a good diagnosis and restrictions provided by a physical therapist or other qualified medical professionals.  More specifically, Pilates can enhance specific trunk strength and awareness of spine positioning that will help many clients return to full functional movement, rather than becoming victims of restricted activity and recurrent chronic pain.  

My workshop at BASI Headquarters on Jan 14, 2018 Is designed to offer practical information about common low back conditions such as spinal stenosis, spondylolistheses, lumbosacral strain and disc injury to help you become more specific and effective in your teaching. The underlying logic for why these low back conditions tend to fall in flexion or extension-based approaches will be described. Modifications for classical and novel Pilates exercises to improve vital trunk strength and stability will also be provided, with an emphasis on optimal technique, detailed anatomically-based cues, and progressions that can be used as conditions improve. In addition, these exercises and cues can be used with healthy clients in an effort to reduce the risk of future low back pain.