Chronic low back pain—pain that lasts 6 weeks or longer—may cause a myriad of postural and breathing dysfunctions, muscular imbalances, inadequate muscle recruitment or contractibility, and dysfunctional movement patterns in patients. At Sports and Orthopedic Leaders Physical Therapy Inc, Oakland, Calif, we have had great success and overall improvement in these patients who are involved in our Pilates Rehabilitation Program.

The benefits of pain reduction; increased core control; and improved breathing, postural, and movement patterns can be attributed to the teachings of Joseph Pilates. I teach one-on-one hour-long sessions using Pilates techniques and exercises, as well as the skills that come from my 16 years of experience in physical therapy, to reach desired results for each patient. Patients are usually seen two times per week for approximately 3 months and are given home exercises to do on a mat, foam roller, and/or physioball.

Like yoga, Pilates incorporates diaphragmatic breathing with movement patterns. I start our first Pilates session looking at the person’s breathing patterns and emphasizing the Pilates wide breath into the ribs as the abdomen moves out on inhalation, and I couple that with pelvic floor, or kegel-muscle, contractions with transversus abdominus and oblique recruitment on the exhale. Then, I move toward phase 1, lumbo-pelvic neutral stabilization, as the patient executes what I call “6 minute abs” (2 minutes of marching, 2 minutes of heel sliding, and 2 minutes of knee fall-outs). These are mat exercises that the patient can continue to do in their home-exercise program and begin to coordinate muscle activation with their breath to initiate neutral spine lumbo-pelvic stabilization in a safe position.

Each of the three “6-minute abs” exercises challenge the patient to stabilize the lumbar spine while they superimpose movements of the lower extremities in each of the frontal, sagittal, and transverse planes. While practicing these exercises, patients will begin to increase their awareness of these muscles so that they can transition to more functional postures and movements, such as sitting, standing, squatting, and lunging. The patient usually reports a change in their pain pattern once they have developed these new coordinated movements, and they start to increase muscle recruitment and the neuromuscular re-education process. We then look at the muscle imbalances and firing patterns.

Common Muscle Imbalances
Gluteal activation and pelvic stability are often decreased in chronic low back pain suffers.² According to Vladimir Janda,³ muscle imbalances develop between muscles that have a tendency to develop tightness and other muscles that are prone to inhibition. Janda classified these muscles into two groups: postural and phasic. Postural muscles, such as the hip flexor or Psoas muscle, tend to become overactive, hypertonic, weak, and shortened in length. Phasic muscles, such as the hip extensor and the gluteus maximus, tend to become weak and inhibited.

For patients with these imbalances, I would have them stretch the Iliopsoas complex first using Pilates’ Eves Lunge on the Reformer to restore the muscles length, then follow it with the “Butt Blaster” to engage the gluteal and hamstring muscles in a hip-extension pattern with a neutral-spine activated core. For homework, I may have the patient do the “Butt Blaster” in prone over the physioball. These are two great exercises to encourage hip extension and the coordination of the hamstring and gluteal muscle firing to produce the movement while stabilizing the lumbar spine.

The Reformer is a powerful Pilates tool for rehabilitation because it allows patients to exercise in supine starting with hips and knees at 90º while providing the least amount of discal pressure. I usually have patients start the footwork and legwork with only as much resistance as they can tolerate while keeping a neutral Lumbo-pelvic spine. These can be coordinated with the breath and contractions of the pelvic floor and gluteals while getting a nice stretch to the gastroc-soleus complex to prep them for standing functional squats. The footwork and legwork exercises are highly effective for lower-extremity-alignment issues; and for weakness in the foot, ankles, and calves; while providing resistance for patients with low-bone-density issues.

Another great Reformer exercise to do is the static and dynamic bridges,  especially if the Eve’s Lunge is too difficult for the patient to stabilize and execute properly without pain. The bridges allow the patient to activate the hamstring and gluteals while simultaneously lengthening the Iliopsoas complex.

As I remind my patients, it takes 6 to 8 weeks to build muscle strength. It takes awareness and dedication to improve breathing patterns, overall posture, and daily coordinated exercise training for the core, hips, and lower extremities for patients to start feeling changes in their chronic-pain patterns and feel a new sense of strength, stability, and control over their low back, and the hope of returning to their preinjury level.

In addition to the postural and phasic muscle imbalances mentioned by Janda, another common muscle imbalance with chronic low back pain sufferers is the weak gluteus medius muscle.

These are the muscles for hip abduction, as well as supporting the hip and spine from shearing forces to the joint capsules and ligaments that might occur in single-leg stances, such as stair climbing, running, and jumping. When the gluteus medius is weak, you often see substitution from the Tensor Fascia Latae and Quadratus Lumborum.

For this condition, I have patients start standing splits on the reformer for gluteus medius strengthening once they are stable and can hold neutral spine while standing. I will also have them stretch the quadratus lumborum with trunk rotation, stretch the adductors with the butterfly groin stretch, and roll the tensor fascia latae and iliotibial band on foam rollers to decrease the active trigger points.

A likely progression to the standing postures might be the wunda chair single-leg lunges, which continue to activate the gluteus medius with the added challenge of a pelvic asymmetry.

Megan Lewis, PT, ATC, ART, CPI, graduated from Boston University with a bachelor’s degree in physical therapy in 1990. Ten years later, Lewis pursued an interest in Pilates and received her certification from the Physical Mind Institute, New York. She has been treating patients with Pilates in the physical therapy setting for more than 6 years. She currently works for Sports and Orthopedic Leaders Physical Therapy, Oakland, Calif. She can be reached at megan_lewis@sbcglobal.net.