Pilates-Based Therapeutic Exercise: Effect

on Subjects With Nonspecific Chronic Low

Back Pain and Functional Disability: A
Randomized Controlled Trial
Rochenda Rydeard, PT, MSc 1
Andrew Leger, PT, PhD 2
Drew Smith, PhD 3

Study Design: A randomized controlled trial, pretest-posttest design, with a 3-, 6-, and 12-month modified Pilates-based approach was more effi-
follow-up. cacious than usual care in a population with
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Objectives: To investigate the efficacy of a therapeutic exercise approach in a population with chronic, unresolved LBP. J Orthop Sports Phys
chronic low back pain (LBP). Ther 2006;36(7):472-484. doi:10.2519/jospt.
Background: Therapeutic approaches developed from the Pilates method are becoming increas- 2006.2144
ingly popular; however, there have been no reports on their efficacy. Key Words: exercise rehabilitation,
Methods and Measures: Thirty-nine physically active subjects between 20 and 55 years old with
lumbar spine muscle recruitment,
chronic LBP were randomly assigned to 1 of 2 groups. The specific-exercise-training group
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

participated in a 4-week program consisting of training on specialized (Pilates) exercise

stabilization exercises
equipment, while the control group received the usual care, defined as consultation with a
physician and other specialists and healthcare professionals, as necessary. Treatment sessions were

L
designed to train the activation of specific muscles thought to stabilize the lumbar-pelvic region. ow back pain (LBP)
Functional disability outcomes were measured with The Roland Morris Disability Questionnaire represents the most
(RMQ/RMDQ-HK) and average pain intensity using a 101-point numerical rating scale. common cause of dis-
Results: There was a significantly lower level of functional disability (P = .023) and average pain ability in persons un-
intensity (P = .002) in the specific-exercise-training group than in the control group following the der 45 years of age.1
treatment intervention period. The posttest adjusted mean in functional disability level in the Spinal disorders represent at least
Journal of Orthopaedic & Sports Physical Therapy®

specific-exercise-training group was 2.0 (95% CI, 1.3 to 2.7) RMQ/RMDQ-HK points compared to 40% of the compensated disorders
a posttest adjusted mean in the control group of 3.2 (95% CI, 2.5 to 4.0) RMQ/RMDQ-HK points. treated by physiotherapists, and
The posttest adjusted mean in pain intensity in the specific-exercise-training group was 18.3 (95% 70% of these spinal disorders in-
CI, 11.8 to 24.8), as compared to 33.9 (95% CI, 26.9 to 41.0) in the control group. Improved volve the lumbar spine.39
disability scores in the specific-exercise-training group were maintained for up to 12 months The effectiveness of therapeutic
following treatment intervention. exercise in the treatment of
Conclusions: The individuals in the specific-exercise-training group reported a significant decrease chronic LBP is currently under
in LBP and disability, which was maintained over a 12-month follow-up period. Treatment with a
review.22,28,39,43,44 General condi-
tioning programs to train strength
1
Graduate student (at time of study), School of Rehabilitation Therapy, Queen’s University, Kingston, and endurance of the spine mus-
Ontario, Canada.
2
Educational Developer, Centre for Teaching and Learning, Queen’s University, Canada; Assistant
culature have been shown to re-
Professor (at time of study), School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, duce pain intensity and disability28
Canada. and to be useful in the treatment
3
Senior Lecturer, Department of Sport and Exercise Science, The University of Auckland, Auckland, New of nonspecific chronic LBP22,44
Zealand; Assistant Professor (at time of study), Department of Rehabilitation Sciences, The Hong Kong
Polytechnic University, Hung Hom, Hong Kong SAR, China. and ‘‘activity-related spinal disor-
The protocol for this study was approved by The Faculty of Health Science Research Ethics Board, ders.’’39 Much of the literature
Queens University, Canada and Hong Kong Polytechnic University Human Subjects Ethics Subcommittee, examining chronic LBP and exer-
Hong Kong Special Administrative Region.
Address corresondence to A. B. Leger, Centre for Teaching and Learning, Queen’s University, Kingston, cise interventions study a popula-
Ontario K7L 3N6, Canada. E-mail: AL7@[Link] tion whose pain and disability

472 Journal of Orthopaedic & Sports Physical Therapy

 manifest in ‘‘deconditioning syndrome,’’ as described adapted but consistent with traditional Pilates tech-
by Mayer.22 It follows that exercise-training programs niques, focusing on postural symmetry and controlled
directed generally at muscle strength, endurance, and movement. Particular emphasis, however, was placed
reconditioning are appropriate. However, physical on specific muscle activation strategies thought to
deconditioning may not be the limiting factor to stabilize the lumbar-pelvic region.
recovery for many patients seeking treatment for A modified Pilates approach to improve posture
chronic low back disorders; it is now accepted that and control movement can thus be supported within
muscle dysfunction in chronic LBP may not simply be a theoretical context of neuromuscular control and
a problem of muscle strength or endurance. Instead, builds upon the concept of stability about a local
the problem may be one of altered neuromuscular spinal segment. Global stability mechanisms to con-
control mechanisms affecting muscular stability of the trol the lumbar-pelvic region are then incorporated
trunk and movement efficiency.5,15,17,29 Bergmark3 into this background of segmental lumbar control.
classifies spinal stability as being comprised of 2 This may be achieved by incorporating specific activa-
(muscular) mechanisms: local mechanisms, whereby tion of the gluteal muscles to stabilize the lumbar-
deep, local muscles act to control movement at the pelvic region while performing hip extension.34,35
intervertebral segment, and global mechanisms, Stability of the trunk is thereby accomplished by
whereby muscles control movement of the spine using an overlapping of stabilization strategies. Fur-
generally and at multiple segments. Effective control ther, the use of Pilates apparatus to train stabilization
of both mechanisms is necessary for efficient stabiliza- strategies during movement may enhance the effect
tion of the spine and alterations in neuromuscular of a relatively more static mat exercise. This may be
control and the loss of normal patterns of spinal important for retention of treatment effects and
motion will cause pain.26 Further, Edgerton et al5
transfer to everyday movement and functional activi-
suggest that pain and pathology result in changes in
ties.
neural input to motor neuron pools affecting muscle
The function of the hip extensors and the gluteus
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activation. A general reconditioning approach,

through its lack of specificity, may reinforce abnormal maximus is thought to be central to stability and
muscle recruitment and perpetuate compensatory control in the lumbar-pelvic region.14,18 The gluteus
strategies that may have developed as a result of maximus muscle may play an important role in
neuromuscular adaptation over time. lumbar-pelvic mechanics and load transfer from the
Consequently, specifically designed therapeutic ex- lumbar spine to the pelvis and lower extremities.46
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ercise approaches that enhance spinal stability and Altered recruitment of the lumbar-pelvic musculature
modulate neuromuscular control in the presence of and dysfunction of the gluteus maximus muscle is
chronic LBP have been embraced by physiotherapists. reported in LBP conditions.4,24,47 Janda14,15 describes
Techniques evaluated in the literature to date address a characteristic ‘‘pseudoparesis’’ of the gluteus
muscle activation directed at the intervertebral seg- maximus in LBP, characterized by hypotonia and a
ment via the cocontraction of the deep abdominals delay in activation. A concomitant imbalance in the
and the paraspinals, enhancing stabilization at the functional length or recruitment of the hamstrings
lumbar spine segments.25 Recent evidence supports and/or superficial lumbar erector spinae relative to
the effectiveness of such a specific-exercise approach the gluteus maximus has been associated with
Journal of Orthopaedic & Sports Physical Therapy®

in a chronic LBP population with a diagnosis of LBP.2,13-15,24,36 The resultant pull of muscle forces
spondylolysis or spondylolisthesis.25,44 O’Sullivan and may impact adversely on neuromuscular control of
colleagues25 found a significant reduction in pain hip extension and the ability of the trunk to stabilize
RESEARCH REPORT
intensity (P = .0006) and functional disability levels effectively against the demands of loading during
(P = .0001) in a group who received specific exercise activities such as walking.
with maintenance of effect over a 30-month follow- Evidence supporting the effect on pain and disabil-
up. No significant changes were seen in a control ity from specific exercise approaches applied to
group receiving usual care. nonspecific chronic LBP has not been confirmed.
The Pilates Method37 is an exercise method popu- Similarly, no studies to date have examined the
lar for decades in dance training and the dance effects of a specific exercise training approach that
medicine community. The Pilates Method is a unique emphasizes lumbar-pelvic stability and the function of
approach to training in mind-body awareness and the gluteus maximus. As well, no clinical research
control of movement and posture. Specialized appa- activities have been reported to date that elucidate
ratus provides an opportunity to train a variety of the efficacy of an exercise intervention based on the
movement patterns and postures. The neuromuscular Pilates Method in the treatment of chronic LBP.
demands of traditional Pilates methods can be quite Therefore, the objectives of this study were to
high and therefore a modification of this method is investigate the efficacy of a specific-exercise interven-
necessary for application to physiotherapeutic inter- tion based on the Pilates Method and emphasizing
ventions. The technique used in this study was specific-activation strategies of the gluteus maximus

J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006 473

 and the effect on LBP intensity and functional Hong Kong Special Administrative Region, granted
disability in an identified population with nonspecific ethics approval for the study. Subject characteristics
chronic LBP. are reported in Table 1.

METHODS Study Design

The study consisted of 2 parts, a pretest-posttest
Subjects control group design in part 1 (the primary study)
Fifty-five subjects were recruited over a 4-month and in part 2 (a follow-up on the exercise interven-
period through notices posted to private and public tion group over a 1-year period). Simple randomiza-
physicians’ and physiotherapists’ offices, notices tion was performed at entry to the trial after
posted to local sports clubs and Universities, and by eligibility was determined. Randomization was admin-
advertisement in an English-language newspaper (Fig- istered by independent office staff. Subjects randomly
ure 1). The subjects were recruited from a popula- pulled a card from a box of concealed premarked
tion of physically active adults between 20 and 55 cards to obtain assignment to either the specific-
years of age, living in Hong Kong, with longstanding, exercise-training group (SETG) or control group
persistent LBP (with or without leg pain) of greater (CG) without specific exercise training (Figure 1).
than 6 weeks duration or recurring LBP (with at least The subjects had no preconceived expectations for
2 painful incidences per year) of sufficient intensity treatment because at the time of the study the Pilates
to restrict functional activity in some manner. ‘‘Physi- method was not commonly known. The subjects were
cally active’’ was defined as participation in a mini- advised that the study was designed to evaluate the
mum of three 30-minute sessions per week of activity effectiveness of this specific-exercise intervention in
requiring a moderate effort in keeping with estab- the treatment of LBP.
lished guidelines for physical fitness.6,42 This criterion
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ensured that findings cannot simply be attributed to Intervention

disuse secondary to deconditioning and low activity
levels. Similarly, this criterion may have helped to Those in the CG group received no specific exer-
eliminate those LBP conditions that might have cise training and continued with usual care, defined
responded to general physical conditioning exercise as consultation with a physician and other specialists
without requiring more specific neuromuscular train- and healthcare professionals as necessary. They were
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ing. Subsequent clinical screening was performed by not restricted from seeking any other treatment if
an independent physiotherapist evaluator to test for they so wished. Subjects were instructed to continue
evidence of neuromuscular dysfunction and fulfill- to do what they were previously doing, including
ment of the following criteria: (a) strength recording regular physical activity. For ethical reasons the CG
of grade 4 or less out of 5 on manual muscle testing had the option to receive, free of charge, the
of the gluteus maximus14,18; (b) altered recruitment specific-exercise-training program 4 weeks later, after
of the gluteus maximus muscle as determined clini- collection of posttreatment intervention outcome
cally by visual and manual inspection during a prone data from the main study. During the main study
leg extension test.13,36,38 period, although subjects were aware they could
Journal of Orthopaedic & Sports Physical Therapy®

Prospective subjects were excluded from the study receive the exercise intervention, they were not
if they were pregnant, had a past history of spinal familiar with the technique or aware of any details of
surgery or spinal fracture, were diagnosed with in- what the treatment entailed.
flammatory joint disease, systemic metabolic disorder, The SETG received a treatment protocol consisting
rheumatic disease, or chronic pain syndrome, showed of training on specialized (Pilates) exercise apparatus
evidence of overt neurological compromise or acute in the clinic for three 1-hour sessions per week, and
inflammatory process, or had difficulty understanding training in a 15-minute home program performed 6
written or spoken English. Thirty-nine subjects met days per week for 4 weeks. Treatment was provided at
the selection criteria for inclusion in the study and 16 no charge to the subjects. The apparatus used in the
subjects were excluded. Testing was performed at the clinic consisted of a floor mat and a Pilates Reformer
Hong Kong Polytechnic University. The clinical inter- with standing platform and jump-board attachments
vention was conducted at a private physiotherapy (Balanced Body, Sacramento, CA). The Pilates Re-
clinic in Hong Kong, which specialized in Pilates- former is made of a sliding horizontal platform
based interventions. All subjects signed informed within a box-like frame, upon which the subject sits,
consent forms upon entry to the trial and the rights stands, kneels, or reclines. Varying resistance to
of the subjects were protected. The Faculty of Health movement is provided via light springs attached to
Science Research Ethics Board, Queens University, the moving platform and through a simple pulley
Kingston, Ontario and the Hong Kong Polytechnic system. The subject moves against the low external
University Human Subjects Ethics Subcommittee, resistance offered by the springs.

474 J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

 Journal of Orthopaedic & Sports Physical Therapy®
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Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Figure 1. Subject flow during the study.

J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

475
RESEARCH REPORT
 TABLE 1. Subject characteristics and demographic data for the specific exercise-training group (SETG) and the control group (CG).
Subject Characteristics CG SETG P Value
Gender P = .77*
Male 8 6
Female 13 12
Age (y) 34 (8) 37 (9) P = .34†
Height (cm) 171(10) 169 (8) P = .65†
Mass (kg) 69 (15) 68 (14) P = .92†
Duration of symptoms (y) Median, 9 (range, 1-20) Median, 5.5 (range, 0.5-27.0) P = .25‡
Nature of condition P = .58*
Chronic 16 15
Recurrent 5 3
Area of symptoms P = .27*
Low back pain (LBP) 11 9
LBP and leg pain above knee 3 6
LBP and leg pain below knee 7 3
Previous physiotherapy treatment 19 16 P = .87*
Included exercise therapy 15 14 P = .65*
Functional disability (mean ± SD) 4.2 ± 3.6 3.1 ± 2.5 P = .14†
Pain intensity score (mean ± SD) 30.4 ± 17.6 23.0 ± 17.7 P = .56†
* Chi-Square test.
†
Unpaired t test.
‡
Mann-Whitney U test.

The clinic treatment protocol was provided in an apparatus (Figures 2 and 3) and (2) skill drills in
individualized manner by 1 of 2 experienced physio- which difficult tasks were broken down into move-
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therapists trained in the treatment protocol and ment components and practiced in isolation incorpo-
blinded to the results of testing. The standardized, rating correct abdominal and gluteal control.
progressive treatment protocol addressed targeted Compliance with the home exercise program was
muscle activation strategies throughout a variety of encouraged and was self-monitored on a log sheet.
movement patterns involving hip extension. The The treating physiotherapist kept clinical notes docu-
menting details of the treatment program and the
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

subject was required to consciously recruit specific

muscles—the deep anterolateral abdominals (with subject’s progress.
coactivation of the pelvic floor and lumbar
multifidus), followed by activation of the gluteus Outcome Measure Testing
maximus muscles. Static postures were initially
trained (Figure 2), followed by training a variety of Data collection monitored both pain intensity and
movement patterns to stress the lumbar-pelvic region functional status and included 2 self-report question-
and involving hip extension (Figure 3). The training naires administered by the research assistant, an
was progressed on the Pilates Reformer (Figure 4) independent physiotherapist investigator blinded to
Journal of Orthopaedic & Sports Physical Therapy®

over the 4-week period as tolerated. Initially move- group assignment. In part 1 all subjects were tested
ments were practiced using weight-bearing patterns in on baseline measures at entry to the study (pretest-
supine, with the lumbar spine in the neutral position. ing). Retesting of both groups was done at the end of
Gradually more upright postures and controlled the 4-week treatment intervention period (posttest-
movement of the lumbar-pelvic region out of neutral ing). In part 2, disability measures for retention of
posture were incorporated. Prescribed movements treatment effect were collected from the SETG using
were performed slowly, smoothly, and without pain. a questionnaire mailed to the subjects over a 12-
Individualized facilitation strategies were provided by month follow-up period.
the physiotherapist to correct technique, control Pain Intensity Outcome The NRS-101, a 101-point
speed, assist appropriate muscle activation, or modify numerical rating scale, was used to measure subjec-
the exercise or the progression to suit the subjects’ tive pain intensity.16 The subject rated his or her
needs. Facilitation strategies included mental and perceived pain level between 0 and 100, with 0
visual imagery, manual or verbal cueing, and demon- representing no pain and 100 representing pain as
stration. bad as it could be. The test protocol asked subjects to
The home treatment protocol consisted of 2 parts: verbally state the number that best described the
(1) floor exercises to specifically activate the deep average amount of pain they had experienced in the
anterolateral abdominals and local stability syner- past week. The number noted by the subject was
gists31 and the gluteus maximus muscle by moving recorded on the subject’s record card and used for
the leg in a manner similar to that utilized on the data analysis.

476 J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

 range from 0 to 24, with 0 representing no disability
and a score of 24 indicating severe disability.

Statistical Analysis
Statistical analysis was performed using SPSS soft-
ware. Results were considered statistically significant if
the P value was less than .05
Part 1 Subject characteristics, such as height and
body mass, were compared between groups prior to
the treatment intervention using unpaired t tests.
Gender distribution, nature of condition, area of
symptoms, previous physiotherapy treatment, and the
inclusion exercise therapy were compared with a
nonparametric statistics. Duration of symptoms
(years), however, was analyzed with a nonparametric
test, considering the positively skewed nature of the
data. Outcome measures following the 4-week treat-
ment intervention period were compared between
the 2 groups using an analysis of covariance accord-
ing to the general linear model, with group (2 levels:
CG and SETG) as main factor, prestest measurements
as a covariate, and posttest measurements as depen-
dent variable.
Part 2 RMQ/RMDQ-HK data were collected for the
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SETG immediately after and at 3, 6, and 12 months

following the treatment intervention period. As
follow-up information was not available for some
participants, a sensitivity analysis with 4 intention-to-
treat analyses was conducted to evaluate the retention
of treatment effect. First, missing data of all random-
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ized subjects were handled with the ‘‘last observation

carried forward’’ (LOCF) imputation method and
analyzed with a repeated-measures ANOVA on the
different periods that data were collected, followed by
post hoc analyses using Fisher’s least significant
difference test. To verify the robustness of the conclu-
sions of the analysis, 3 intention-to-treat analyses were
conducted with 3 alternative approaches. The
ANOVAs were carried out for the subjects with a
Journal of Orthopaedic & Sports Physical Therapy®

complete data set only, and then the worst-case value

was imputed to the missing data, and finally the RESEARCH REPORT
best-case value. Post hoc analyses were once again
conducted using the Fisher least significant difference
test.
Figure 2. The subject was required to consciously recruit specific
muscles: the deep anterolateral abdominals (with coactivation of the RESULTS
pelvic floor and lumbar multifidus), followed by activation of the
gluteus muscle to control a static posture.
Subjects
Functional Disability Outcome Functional disability was Subjects were recruited over a 4-month period. The
evaluated with the RMQ32,33 and the RMDQ-HK.11 treatment intervention took place over a 4-week
This tool is a self-administered questionnaire listing period from the time of randomization. Analysis
activities that can be compromised by LBP. The RMQ indicated no significant difference between the
(English version)/RMDQ-HK (Chinese version vali- groups regarding baseline characteristics (Table 1).
dated in a Hong Kong Chinese population) is a The study sample represented a population of
self-administered questionnaire consisting of 24 items longstanding LBP conditions with the median dura-
to measure disability secondary to LBP. The scores tion of symptoms in the CG (n = 18) and SETG (n =

J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006 477

 protocol and questionnaire data were collected for
analysis from all subjects in the main study. Response
rate to posttreatment intervention questionnaires in
part 2 was 86% at 3 months, 57% at 6 months, and
62% at 12 months (Figure 1).

Treatment Efficacy (Part 1)

After adjusting for measurements at pretest, there

was a significant reduction in average pain intensity
(P = .002) and in functional disability (P = .023) in
the SETG following the treatment intervention pe-
riod (Table 2). No significant interactions between
pretreatment and group were detected for either test.
The means and adjusted means and standard errors
of the mean for the SETG and CG pretreatment and
posttreatment intervention period are depicted
graphically in Figures 5 and 6. The posttest adjusted
mean in the SETG was 2.0 (95% CI, 1.3 to 2.7)
RMQ/RMDQ-HK points compared to a posttest ad-
justed mean in the CG of 3.2 (95% CI, 2.5 to 4.0)
RMQ/RMDQ-HK points. The posttest adjusted mean
in pain intensity in the SETG was 18.3 (95% CI, 11.8
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to 24.8) NRS points, as compared to 33.9 (95% CI,

26.9 to 41.0) NRS points in the control group.

Retention of Treatment Effect (Part 2)

Retention of treatment effects was examined in the

Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

SETG for RMQ/ RMDQ-HK data collected at 3, 6,

and 12 months following the completion of the main
study (Table 3).
The first intention-to-treat analysis, using LOCF,
revealed significant improvements in RMQ/
RMDQ-HK scores over the 12-month period (P⬍.01)
(Figure 7). Post hoc analysis showed a significant
difference between pretreatment and posttreatment,
Journal of Orthopaedic & Sports Physical Therapy®

and pretreatment and the 3 follow-up periods. Data

for the posttreatment differed from the 3- and
6-month periods, but not from the 12-month period.
However, no differences were found among the 3
follow-up periods. The analysis suggests that treat-
ment effects were not only retained over time but
Figure 3. Static posture training was followed by training the control that the functional disability score decreased further
of a variety of movement patterns involving hip extension.
following the completion of the treatment interven-
21) at 9 years (range, 1-20 years) and 5.5 years tion up until 3 months. From 3 months to 12
(range, 0.5-27 years), respectively. Twenty percent of months, the effects seem to be maintained, although
the entire subject group described their LBP condi- these results should be considered with caution,
tion to be one of a recurring nature and 80% of the knowing the lack of significant difference between
subjects described their condition to be of a chronic, posttreatment results and the 12-month follow-up.
persistent nature. Ninety percent of all subjects had The other 3 intention-to-treat analyses supported,
received previous physiotherapy intervention and for the most part, the results found. Significant
74% of those interventions had included exercise improvements were found for the group of subjects
therapy. with a complete data set (P⬍.01) and for the data set
All subjects in the main study completed the with best-case value imputed to the missing data
4-week treatment intervention according to the study (P⬍.01). Post hoc tests also showed similar results,

478 J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

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Journal of Orthopaedic & Sports Physical Therapy®

RESEARCH REPORT

Figure 4. Training progressed on the Pilates Reformer initially involving weight-bearing movements in a lumbar-pelvic neutral position. If
tolerated, more non–weight-bearing movements and control of postures out of neutral were introduced.

with the exception that the best-case method did not DISCUSSION
find a difference between the posttreatment and the
12-month period. When the worst-case value was The main finding of this study was that a program
imputed to the missing data, the results from the of specific exercise directed at retraining
analysis did not show a difference between the neuromuscular control, provided by a physiotherapist,
periods (P = .12). and based on the Pilates method was more effica-

J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006 479

 TABLE 2. Pretest means (SEM) and adjusted posttest means for functional disability and pain intensity for the specific-exercise-training
group and the control group.
Specific-Exercise-Training
Control Group (n = 18) group (n = 21)
Outcome Measures Pretreatment Posttreatment Pretreatment Posttreatment P Value*
Functional disability 4.2 (0.8) 3.2 (0.4) 3.1 (0.6) 2.0 (0.3) .023
Pain intensity score 30.4 (4.2) 33.9 (3.5) 23.0 (3.9) 18.3 (3.2) .002
* Comparison of posttest scores using pretest scores as covariate.

cious in reducing pain intensity and functional dis- been shown to be important for local stabiliza-
ability levels when compared to usual care. In this tion.7,8,10,12 Specific activation of the gluteal muscles
study there were significant improvements in mean was emphasized in this study to assist with global
average pain intensity and in functional disability stability of the lumbar-pelvis-hip region during move-
levels in the SETG following treatment that were not ment. The Pilates Reformer was used to train a
apparent in the CG. Both groups completed the variety of functional movement patterns involving hip
study and compliance was high, with 100% atten- extension.
dance at scheduled clinic appointments. Although In the current study it is not known whether the
compliance with the home protocol was not mea- treatment effect found was due to training the local
sured, it was monitored on a log, and a verbal report stability system or from training more general stabili-
from the treating physiotherapist reported good com- zation strategies. Similarly, it is impossible to disassoci-
pliance in general. The ability to exercise without ate the effect of the clinic intervention from the
pain, the opportunity to practice at home, and the effects of the home intervention.
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quick changes in pain and carryover to function The subjects in the study reflected a chronic LBP
relative to previous chronic condition were reported population with a mean duration of symptoms of 8.2
as important motivating factors for compliance. years. Despite chronic symptoms, this group was able
The results of this study are in agreement with the to participate in some form of physical activity at a
conclusion of a systematic review of the literature45 frequency of 3 times per week. Mean initial RMQ/
and the findings by O’Sullivan et al25 and Lindgren RMDQ-HK scores for both groups fell within the
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

et al.20 These investigators found that a training lowest strata (0-9) identified by Stratford et al,40
approach that followed the principles of segmental suggesting a relatively low level of reported disability.
stabilization and neuromuscular control was effective Despite the apparently low disability and moderate
in reducing pain20,25 and disability25 in a group of activity levels, all subjects continued to report func-
individuals with chronic LBP related specifically to tional restrictions not resolved with previous interven-
radiological instability. The current study demon- tions. It is speculated that this functional limitation
strates that an exercise training approach similarly was the motivation to continue to seek treatment. All
addressing neuromuscular control mechanisms is ef- subjects had received treatment in the past and 90%
fective in decreasing pain and improving function in had received previous physiotherapy treatment(s),
Journal of Orthopaedic & Sports Physical Therapy®

an identified group with nonspecific chronic LBP 74% of which had included exercise therapy. Most of
when compared to a control group. The subjects in the subjects had seen more than 1 medical specialist
the O’Sullivan et al25 study were trained in stabiliza- over the years and were continuing to seek treatment.
tion exercises designed to enhance local muscular There were no differences between the 2 groups in
stability of the intervertebral segment. Although the any of these characteristics. This population may
theoretical rationale of training muscle activation and represent a significant subgroup of patients with
control was similar in both studies, the training chronic LBP who seek ongoing treatment in the
approach in the current study necessarily differed clinic setting and it may be argued that the needs of
and addressed different components of this group are not adequately met by traditional
neuromuscular dysfunction. The subjects in the cur- interventions, identifying a gap in physical medicine
rent study did not demonstrate a primary segmental service delivery.
instability but clinically appeared to display problems It may be argued that a more useful indicator of
in control of the muscles thought to stabilize the outcome may be the clinical significance of changes
lumbar-pelvis region during hip extension and load- in disability that are identified in a population with
ing.14,38,46 Therefore, in both the home and the low initial RMQ/RMDQ-HK scores. The minimal
clinic protocol, both local and global stabilization clinically important difference (MCID) represents the
strategies were employed. The transversely oriented change in function that is important to an individual
abdominal muscles, the lumbar multifidi, the dia- patient,4 and it is a function of the initial RMQ
phragm, and the muscles of the pelvic floor have all scores. Stratford and colleagues40 have determined

480 J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

 RMQ scores fall within the lowest strata. These results
60 may reflect clinically important changes in functional
disability in the group who received specific exercise
training in contrast to the group who did not. This
50
Ave rage Pain Intensit y (0 to 100 NRS points)

lends further support that treatment with specific

CG
SETG
Pilates-based exercise was more effective than usual
(0 = no pai n, 100 = severe pain)

care in attaining clinically meaningful changes in

40
functional capacity in our group of subjects. Further-
more, although the changes in functional disability
30 are small when examining a group whose pretreat-
ment and posttreatment scores fall within the lowest
strata, it may also be important that no subjects
20 reported an increase in disability throughout the
* study period.
The subjects in this study fall under the broad
10 classification of nonspecific LBP, although the inclu-
sion criteria were strictly controlled. Classification
into more homogenous groups of LBP diagnosis with
0
an intervention tailored according to the needs of
Pre Pos t
the particular group is thought likely to enhance
treatment efficacy.19 Roland and Morris32,33 suggest
Figure 5. Average pain intensity scores for specific-exercise-training that if an intervention is applied indiscriminately to
group (SETG) (n = 21) and control group (CG) (n = 18) previous to all patients with LBP, it is unlikely that any major
(pre) and immediately following (post) the treatment intervention
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effect from treatment will be discerned. Due to the

period. Values are means (pre) and adjusted means (post) and
natural history of LBP it was felt necessary to control
standard error of the means. *Significant difference of post scores,
using pre scores as covariate. for some of its variability and the tight inclusion
criteria attempted to facilitate homogeneity. All sub-
jects reported unresolved chronic LBP, were physi-
9
cally active, and showed evidence on clinical
tests13,18,38 of altered performance in the muscles
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

8
about the lumbar-pelvic region, including the gluteus
Functional Disability (0 to 24 RMQ/RMDQ-HK points)

maximus muscle. It was felt that subjects meeting the

7 criteria would be more likely to respond to this
(0 = no disabilty, 24 = severe disability)

treatment approach. Therefore it follows that a limita-

6 CG tion of this study may be that results cannot be
SETG extrapolated with confidence to chronic LBP condi-
5 tions outside of the selection criteria for this study,
and especially individuals with acute or more dis-
4 abling LBP. The high percentage of subjects receiving
Journal of Orthopaedic & Sports Physical Therapy®

recent care from a health professional, the extent of

3 past physical treatments, and the prior level of RESEARCH REPORT
exposure to physiotherapy and exercise interventions
2 * suggest a response to the intervention itself as op-
posed to a placebo effect. Additionally, given the
1 chronic nature of the subjects’ conditions, it is not
likely that the results in the SETG are due to the
0 passage of time.
Pre Post
Similarly, the results in the SETG cannot simply be
explained by the introduction of physical training, as
Figure 6. Functional disability scores for specific-exercise-training only physically active subjects were selected for the
group (SETG) (n = 21) and control group (CG) (n = 18) previous to study. Subjects in both groups continued with general
(pre) and immediately following (post) the treatment intervention physical training or advice as prescribed by the
period. Values are means (pre) and adjusted means (post) and
independent evaluator and their attending practi-
standard error of the means. *Significant difference of post scores,
using pre scores as covariate. tioner throughout the duration of the study.
Finally, all of the subjects in the CG were instructed
that a change of 1 to 2 RMQ points is reflective of that they would have the opportunity to receive
clinically important changes in subjects whose initial treatment after a 4-week period.

J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006 481

 TABLE 3. Retention of treatment effects for functional disability for the specific-exercise-training group previous to (prettreatment), im-
mediately following (posttreatment), 3, 6, and 12 months after the treatment intervention for the data collected and with the last obser-
vation carried forward intention-to-treat analysis. Values are in means (SEM).
Pretreatment Posttreatment 3 Months 6 Months 12 Months
Data collected 3.1 (0.6) 1.7 (0.4) 0.9 (0.4) 0. 4 (0.2) 0.9 (0.6)
n 21 21 18 12 13
Last observation carried forward 3.1 (0.6) 1.7 (0.4) 1.0 (0.4) 1.0 (0.4) 1.1 (0.4)
n 21 21 21 21 21
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Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

Figure 7. Functional disability scores for specific-exercise-training group (SETG) previous to (pre) and immediately following (post) the
treatment intervention and at 3-, 6-, and 12-month follow-up, using the last observation carried forward intention-to-treat analysis. Values
are means and standard error of the means (n = 21).

To measure for retention of treatment effect, To evaluate the robustness of these results, the
disability measures were collected from the SETG by analysis was conducted again but with 3 different
questionnaire over a 12-month period following methods of handling the missing data. Results were
completion of the treatment. Due to the noncompli- the same with the sample of subjects with a complete
ance of some subjects, the data were analyzed using a data set as well as with the best-case value as imputing
sensitivity analysis contrasting 4 intention-to-treat method. Results did not show a significant difference,
analyses. First the missing data were replaced by the however, when using the worst-case value. Consider-
LOCF value. Analysis of these data indicated lower ing this last analysis and the substantial loss of data,
mean functional disability levels were relatively well the conclusions drawn from the results should be
maintained over the 12-month follow-up period. The considered with caution.
biggest changes occurred from the pretreatment to The lower response rates of 57% for the 6-month
the 3-month follow-up. The disability levels in the and 62% for the 12-month follow-ups may confound
treatment group were negligible by the 6-month the strength of any findings beyond the 3-month
period and any further changes may not have been of follow-up, depending on the reason for dropout from
clinical importance. this part of the study. Three subjects were lost

482 J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

 following posttesting and 1 subject was lost at the provide a useful and cost effective treatment modality
12-month follow-up. Some of the subjects who did in the management of such conditions and merits
not respond at 6 months did at 12 months and vice further study.
versa. An analysis of the group of subjects who did
not respond to either or both of the 6- and 12-month CONCLUSIONS
follow-ups were shown to have responded similarly to
the program on all outcomes compared to the group The results of the study support the hypothesis that
who provided all follow-up data. These findings an exercise therapy approach based on the Pilates
would suggest that factors other than a difference in method and directed at neuromuscular control
status or treatment response acted to influence par- mechanisms was efficacious in the treatment of a
ticipation throughout the follow-up period in this group of individuals with nonspecific chronic LBP. A
group. 4-week treatment intervention was more efficacious
than usual care in reducing average pain intensity
Ability and concomitant disability are relative to
and functional disability levels, changes were main-
individual expectations of function. Also important
tained over a 12-month period.
were unsolicited comments on the questionnaires
returned from subjects whose RMQ/RMDQ-HK
scores throughout the follow-up period were 0 out of ACKNOWLEDGMENTS
24. These subjects described a progressive ability to The authors would like to thank Professor Lo Sing
return to activities that had been previously stopped Kai, Deakin University and Karine Charpentier,
secondary to low back problems that could not be Queen’s University, for statistical advice.
reflected in the RMQ/RMDQ-HK scores. The RMQ/
RMDQ-HK may not be sensitive enough to pick up
these changes in ability despite the significance for
normal function in this population. An alternative, REFERENCES
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36. Sung-Tae Kim, Joon-Hee Lee. 2017. The effects of Pilates breathing trainings on trunk muscle activation in healthy female subjects: a
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60. Gabriela Bueno Silva, Mirele Minussi Morgan, Wellington Roberto Gomes de Carvalho, Elisangela Silva, Wagner Zeferino de Freitas,
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77. Tae-lim Yoon, Ki-song Kim, Heon-seock Cynn. 2014. Slow expiration reduces sternocleidomastoid activity and increases transversus
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78. Chae-Woo Lee, Ju Hyun, Seong Gil Kim. 2014. Influence of Pilates Mat and Apparatus Exercises on Pain and Balance of Businesswomen
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 98. Daniela L. Stan, Nerissa M. Collins, Molly M. Olsen, Ivana Croghan, Sandhya Pruthi. 2012. The Evolution of Mindfulness-Based Physical
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Journal of Orthopaedic & Sports Physical Therapy®