Anterior Pelvic Tilt (A Paradox, A Question, Some Possible Answers)

In this post I will cover anterior pelvic tilt, back pain, why your tight hamstrings may be trying to save you, why trying to counteract pelvic tilt with strength exercises may not work, open scissor posture and how the diaphragm could be the culprit. But first, the question.

Why do some people have excessive anterior pelvic tilt and lordosis when standing but when then go into 4-point kneeling quadruped they are able to get their spine into neutral, and sometimes when they lay on their back the spine is nearly flat? But when you return to standing they can't tilt their pelvis, they can't achieve a neutral position, they are locked in anterior tilt and hyper-lordosis.

If it was a structural issue they wouldn't be able to tilt their pelvis in 4-point kneeling and the back wouldn't go flat in supine. If it is a 'tight' muscle, why is that muscle not tight when they are on the floor?

I have observed this over and over again. As a background, I deal with a lot of people with lower back pain, but not all the people I have observed this in have back pain, but most do. I also see this mainly in women, again, mainly because I probably see more women with back pain and in classes, but also I just don't see this anterior pelvic tilt in many men.

But first things first.

What is anterior pelvic tilt?

Pelvis rotates down and forward, lower back becomes 'excessively' curved

If we consider a level pelvis to be neutral, then if it tilts down and forward it is no longer neutral, anterior pelvic tilt (APT), if it tilts the other way the pelvis has gone posteriorly and the lower back can end up flat. You can also get a paradoxical lumbar curve without the pelvis moving, the curve goes the wrong way, I have observed this in men, according to Pavel Kolar (prague school, www.rehabps.com, Dynamic Neuromuscular Stablization -DNS) this is caused by hip dysplasia. (I will say no more about this).

A couple of things to consider:

1. If the anterior pelvic tilt isn't accompanied by any back pain or movement restriction is it really a problem?
2. Some people have genetics that pre-dispose them to APT, this is most commonly seen in sprinters, therefore it may have an advantage for certain movements. Also be careful when looking at sprinters and some people, it may look like they have excessive APT or lumbar curve due to the size of their glutes. The glutes give the illusion of a large lumbar curve, but when you look at the lumbar spine in isolation it is  'neutral'.

What causes APT & hyper-lordosis?

As stated above it could genetics. Two other obvious scenarios: if someone is 8 months pregnant or is carrying an extra 2 stone on their gut then the reason for the APT are obvious and no amount of 'corrective' movement or breathing will make a difference.

In the women I mainly observe this in it could due to several reasons

1. Cultural: stick out your bum, push out your chest and suck your abs in to exaggerate your attributes!
2. Lifestyle: women wearing high heels, changes the whole kinetic chain, weight is shifted forward at the foot and everything above compensates. To be fair to the women I have observed this in aren't always big high heel wearers.
3. A compensation or protective mechanism: If flexion is painful then the body compensates by going into extension to spare the spine and avoid the pain. But why does it go so far into extension, if neutral is also pain free?

All these can result in the classic Janda lower crossed syndrome - tight erector spinae, weak abdominals, weak glutes and tight hip flexors. However, why aren't the erector spinae tight when laying down, they can easily do a knee hug stretch, and some clients can even do core work in supine with a neutral spine, but in the plank or press up position they typically drop back into hyper-lordosis.

In standing, the pelvis tilting down can also be accompanied by the ribs going up or flaring. This results in something that the DNS folks call open scissor posture, and the point where the scissors are pivoting and where the most pressure is occurring is typically in the lumbar spine.

Open scissors posture: the front of the scissors is the pelvis and ribs moving away from each other. The pivot point is in the lumbar spine - ouch!

Toe Touches and Hip Hinging

Using the SFMA there are four scenarios, they can touch their toes (multi segmental flexion in the SFMA parlance) and it is either painful or not, they cannot touch their toes and it is painful or not painful.

The painful scenario is most obvious, flexion causes pain, they are forward flexion intolerant and are avoiding flexion because it hurts. I don't actually see the painful scenario that much in the APT clients, more typical is they can't touch their toes and it is not painful or you ask them to touch their toes and they put their hands on the floor - they are mobile...too mobile.

To the hip hinge, there are three scenarios I see

1. They do the hip hinge, and the APT corrects itself into a normal lordosis, this doesn't happened that often, however much you coach
2. They go into even more hyper-lordosis, with the lordosis extending up into their thoracic spine. Typically see this with the mobile Yoga types
3. As soon as they hinge, their lumbar spine goes into flexion and rounds. They have the hip mobility of a breeze block. Therefore, they need to increase hip mobility, but not in the hip hinge position standing, because they just don't get it in this position. In this case taking them to the floor and doing a rocking squat could be a starting point, with the hips unloaded, and in this position their body doesn't have to worry about the ankle and all the other joints trying to keep them upright.

Glutes

You can try to get the person with APT to squeeze their glutes. I normally demonstrate this, as when I squeeze my glutes my pelvis tilts in quite a big way. Normally 2 things happen when they try to squeeze their glutes

1. Nothing happens, they squeeze but there is no glute contraction. If they have back pain or hip pain the glute may be inhibited, they have glute amnesia (listen to audio lecture with McGill and Liebenson where McGill states they have now proved this in the lab, www.movementlectures.com )
2. The glutes contract but the pelvis doesn't move, the APT is not being caused by the glutes not working.

All the standing glute work in the world trying to strengthen these muscles doesn't work in these cases. RDLs and Good Mornings and all that don't do anything,the glutes don't fire, or they do fire and the APT remains. And the client still has APT, excessive lordosis and is still moving through their lumbar spine.

Take the person into a supine 2 leg bridge, but be careful, at the top of extension you can see their lumbar spine actually going into more lordosis with no glute involvement. And at the start of the movement, watch, their lumbar spine flattens, they have gone into posterior pelvic tilt, but check, the glutes may still not be working. They can get into PPT in supine with no glute activation.

To really isolate the glute action here, try the one leg glute bridge aka cook hip lift. This is humbling for many people, hug one knee in and then bridge up, see how far they get with no lumbar spine help.

There are quite a few videos on youtube showing the cook hip lift, here is one 

Tight Hamstrings?

Typically if the person can't touch their toes they tend to think they have tight hamstrings.

However, in nearly every client I can think of, as soon as you lay them on their back and get them to do a straight leg raise (ASLR in the FMS) they can easily achieve 70 degrees, and most women are getting 90 degrees. And if they have 70 degrees or less, they nearly always get more range of movement with simple passive help. This shows two things, when their hamstrings are unloaded in a supine position they show normal range of movement, and if it can be passively increased immediately could it be something on the front of the thigh that doesn't have the strength to life the leg up.

I find people want to stretch their hamstrings for 4 reasons

1. Someone told them their hamstrings were tight, like a physio
2. They can't touch their toes - see above why in most cases the hamstrings are not short
3. They actually feel tight all the time
4. They want to stretch because they like it, they are good at it, and everyone has always told them more flexibility is a good thing

In the back pain client the tight hamstrings may actually be protecting them. If someone has lower back pain and finds forward flexion painful then

"If the hamstrings are tight and short they effectively prevent pelvic tilting." (Chaitow et al, 2002)

 and

"In this respect, an increase in hamstring tension might well be part of a defensive arthrokinematic reflex mechanism of the body to diminish spinal load." (Vleeming et al, 1997 quoted in Chaitow, 2002)

 So the tight hamstrings are preventing movement that may cause pain. I would personally say that the hamstrings are actually contracting all the time rather than being 'tight'. And if they have normal ROM supine then they definitely aren't tight, your body is doing what it can to protect your spine when you stand up, if it has no other option it uses the hamstrings. These people also typically get hamstring cramping in a glute bridge.

Extension, Centration and The Mind

Normally when I ask a person with APT to lean back in standing (multi segmental extension) they can do it and there is no pain, and all sorts of McKenzie extension positions don't make any difference to pain in those with back pain (pain could stay the same, go away, get worse, or not be a problem on that particular day). On that note, it is surprising the amount of back pain patients who have had facet joint injections when extension doesn't hurt but flexion does.

If we take the person to half kneeling hip flexor stretch position we have taken out any influence from the ankle and knee joint. In this position, it is quite normal to see the hip not extending properly, the glute not firing and the lower back going into more lordosis and increasing APT, as well as the person feeling a big stretch on the front of the thigh. Is the lower back compensating for lack of hip extension?

Also, it is important to note that the person in APT doesn't feel like they are in APT, they feel normal. In the case of forward flexion back pain, has the body gone into extension to avoid pain and over compensated. Even with or without pain, has the body decided this is the default postural position, it believes it is centred. It could be compensating for head forward posture or ankle restriction or a whole host of things in the chain, but it thinks this is normal. To use Weingroff core pendulum analogy, the pendulum had swung into flexion, so the body overreacted and swung the pendulum too far into extension.

But this is only happening in a loaded position, note that when the spine isn't being loaded by gravity in standing it can go back to neutral. The brain is in control. The person has what Kolar and the DNS guys would call 'body blindness'. In the movement system Feldenkrais they talk about a Homunculus in your mind, a little version of you in space, your body has an image of where you are in space, and it may not match reality, you need to reset the system.

In the standing loaded position.

"internal forces developed by our own muscle are often more detrimental than external forces..external forces are decisive in what way external forces apply on our system." (DNS course notes)

You get told to strengthen your core or back or posterior chain, but strengthen what? In standing we're making the position worse, we need to take the person into unloaded positions or more 'primitive' postures if you will. If we change the function we may be able to change the structure (Lewit, Kolar) with the right exercise.

Its not a strength issue or a muscle issue, its a motor control issue. Having said that, there might be one muscle you need to work on first.

The Diaphragm and a possible answer

  
Breathing is the fitness concept de-jour at the moment, and I will cover it in more detail in another post. However, I think we need to explain exactly why breathing and the diaphragm is so important, especially when it comes to back pain. Firstly the diaphragm actually attaches to the lumbar spine and ribs, as well as many other structures and muscles in the abdomen and thorax (Chaitow, 2002), so it would seem we should train it like the other core muscles. Secondly, "the lower back is stabilised via intra abdominal pressure" (DNS notes). The diaphragm pushing down when you breathe in and helps to stabilise the spine. And in people with lower back pain this may be lost.

Nearly all the people who I have seen with APT and/or lower back pain demonstrate paradoxical breathing, which means their diaphragm and ribs move up when they breath in during normal relaxed breathing. When it should move down when they breathe in.


In a study by Kolar et al (2012, JOSPT) they scanned the diaphragms of people without back pain and compare them with those who had had chronic back pain for 6 months. In the MRI scanner, they did three things, 1) lay down normal breathing 2) then got the person to do isometric flexion of an arm 2) then isometric flexion of a leg.


(I have taken the image below from the paper, before anyone sues me, it is available on the internet for free). On the left is the diaphragm movement during normal breathing of a non painful subject, image B is the movement of the diaphragm in a person with chronic back pain.

Source: Kolar et al, JOSPT, vol 42, no.4, rehabps.com

But the key point is shown in the graph below, when the person is relaxed there isn't much difference between the back pain and non pain people, but as soon as the back pain people have to apply resistance the diaphragm shoots up, it becomes higher in the thorax and the amount it is moving is a lot less than in the non painful subjects.

Source: Kolar et al, 2012, JOSPT, vol 42 no 4. rehabps.com for full article

During strenous activity the breathing pattern in a person with back pain is altered. In a cross sectional view the front and middle of the diaphragm doesn't get recruited but the back part does, this basically pulls the spinal column up and forward causing shear forces which may make back pain worse. Also with the diaphragm higher you can surmise that intra abdominal pressure is lower and the spine is not as stable.

And this may cause the back to be unstable. Of course, there is always the possibility that the back pain caused this dysfunction and not the other way around.

"One possibility is the lack of postural diaphragmatic activation is substituted by excessive activation of the superficial lumbar paraspinal muscles, which may lead to hypertrophy and, eventually, result in lumbar hyperlordosis and/or anterior pelvic tilt. Future research should study this mechanism as possibly contributing to or even underlying the etiology of low back pain symptoms." (Kolar et al 2012:360)

Breathing incorrectly may cause the muscles in the back to become over-developed, until you addres the breathing issue those erector spinae may continue to be rock hard and switched on.

So the first port of call to resolve APT and back pain may well be breathing correctly. See the video below from Evan Osar (though he doesn't mention it all in the video this is essentially the DNS method, he does mention DNS and Kolar a fair amount in his book). This video basically covers what I woudl consider the first thing to do with someone who had APT and back pain. Note the three dimensional nature of the breathing. You will find that many Yoga disciples can easily breathe forward into their abdomen, but they will find it difficult to breathe into their back, which can really help stabilise the spine, relax the lower back and get the area into a more neutral position; all with nothing more than breathing. Simple, but easily missed in our rush to load up with weights.





In Summary

Hopefully this post has raised a few questions and given a few answers.

• Firstly, trying to correct posture in standing with standard strength exercises may never work. You need to unload the system and reset it. And ask yourself why you are correcting it in the first place

• The muscles just do what the brain tells them to do. The movements don't have to be complicated, they should be simple and slow to begin with, and can be quite high repetitions (15-20 reps, re-learn the motor pattern) This could be the DNS approach or a movement system like Feldenkrais or whatever exercises you find work best for you.

• Start with breathing, the diaphragm influences spine position and stability
• Free up muscles that are over- working, for example, 6-10 repetitions of the cat camel are proven to reduce viscosity of the muscles either side of the spine. Then progress to endurance and strength exercises like the bird dog.
• You could then move onto more strength type moves, but stay in these more primitive positions to begin with, could be kneeling rocking squats, then cook hip lifts as well.
• Half kneeling hip flexor stretch with core braced and back in neutral may be appropriate if your movement assessment highlights an issue.
• The hamstrings are probably not tight and don't need stretching, they need to switch off, but they will only do that once other muscles are doing the job for them
• The details matter
• Breathing exercises can even be done in between sets of strength exercises, integrate into the training program
• If somethings worth doing, do it everyday, I think Dan John said that.

The End at last

References

Chaitow L et al (2002) Multidisciplinary Approaches to Breathing Pattern Disorders. Churchill Livingstone
Kolar et at (2012) Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. Journal of Orthopaedic and Sports Physical Therapy. Vol 42, no 4
McGill & Liebenson From the Lab to the Trenches www.movementlectures.com
www.rehabps.com

Is Pilates Good For Your Back? Or Will It Make Your Back Pain Worse?

Note: I originally wrote this for the general public, so tried to make it as non technical and clear as possible. In doing this I have not put in any references, as this may interrupt the flow, but as always, everything can be referenced.

Is Pilates Good For My Back?

Pilates popularity does not seem to be waning. In fact it seems to have become the �go to� class for anyone with any type of injury. (Full disclosure: I qualified to teach mat based pilates about 6-7 years ago, so am aware of what the training consists of and why people are told to go and do Pilates). I have noticed more and more people being recommended to do Pilates for a range of conditions. Doctors, Physiotherapists, Osteopaths, Chiropractors and Consultants have all suggested their patients and clients do Pilates to help them with a whole host of injuries and problems. I�ve had people referred for knee injury, hip replacement, whiplash, shoulder problems, chronic fatigue and most commonly lower back pain. Some of these people were unable to get down onto a mat or kneel down or lie flat, but had been recommended to do mat based exercise. One person came to me after sciatica, back surgery and hip surgery and the only exercise advice she had received was 'to do Pilates'. Pilates has become the universal panacea!

The fact that medical and health professionals are recommending anyone to do exercise should be seen as a good thing. It could also be a sign of an over burdened physiotherapy service, where patients are being told to do classes because the one-to-one physiotherapy they need is not available. In my experience, most people recommended to do Pilates due to some type of injury, are following the advice of their GP. Having said that many physiotherapists are now promoting their own back pain classes and are jumping on the Pilates bandwagon, they are advertising the fact that these exercises are specifically based on the Pilates method. Despite no evidence for its benefits. As we shall see, Pilates methodology may not be the wisest choice for those with lower back pain; and as for those with knee pain and neck pain, it's not clear why it's being recommended at all.

It is a positive that physios and osteopaths are trusting fitness professionals and their knowledge, it would also seem curious that they are passing on patients and clients that they could and should be rehabilitating themselves. However, it seems mostly there is a lack of understanding among medical professionals and the general public as to what Pilates actually is.

For those of you who are unfamiliar with the history of Pilates and how it came to be the universal panacea, here is a brief history. Joseph Pilates was born in Germany in late 1800�s, in the early 20th Century he came to England and while interned on the Isle of Man during the first world war was working in a hospital. Around this time he started to develop a series of mat based exercises and novel equipment like the Reformer ( a cable, pulley, sled type machine ) and the Cadillac and other equipment. His choice of exercises and the equipment he developed was very much informed by his gymnastic background and possibly even the circus, where he had performed. It is also likely that many of the exercises would have been influenced by other disciplines and fitness �gurus� at the time. Although, we think of fitness crazes as a modern phenomenon, they are not, and there were a number of fitness �gurus� around at the time and before, like Arthur Saxon, Eugene Sandow and many more who had their own fitness systems and equipment. Joseph Pilates later moved to America where his studio obtained a steady following amongst dancers especially. Joseph Pilates carried on teaching until the 1960�s.

Jospeh Pilates teaching someone on one of his many pieces of apparatus

Pilates stayed more or less as a fitness footnote until ten or fifteen years ago, when various individuals and schools of Pilates started to emerge and expound its virtues, especially in the UK. This also coincided with an explosion in so called �functional fitness�, the use of swiss balls and the concept of �abdominal hollowing� (more on this later). This did help the fitness industry out of a rut, which had become stuck using static machines. Suddenly the public and instructors had a whole new range of concepts and exercises to use.

Over recent years Pilates has grown and grown to become more of a brand than a clear cut exercise system. Go to any Pilates class today and it unlikely you will see any instructor doing Joseph Pilates original sequence of mat work exercises, which from a back care point of view may be a good thing. The original exercises can be very challenging and not the gentle exercise for the de-conditioned individual that most people think they are. Pilates has become the class to improve your �core� or �posture� or in Pilates parlance your �powerhouse� and help you get �longer muscles' (of course, longer muscles are impossible as the attachments are set). These days, it is very hard to say what Pilates is, even most of the official Pilates courses have modified the original exercises or broken them down into various levels of difficulty. For example, see the pictures below, one of the original �swimming� exercise and the modified 4 point kneeling version, which is a standard rehabilitation exercise called 'Bird Dog'. The original swimming causes massive loads on the lumbar spine, whereas the 4 point kneeling version does not.

Classic Pilates Swimming exercise - causes massive amounts of compression in the lumbar spine. Say goodbye to your facet joints, you'll miss them when they explode. And your cervical spine (neck) wont like you to much either

Modified Pilates Swimming exercise aka The Bird Dog aka quadruped contralateral arm & leg lift aka your facet joints wont explode

And herein, lies the problem with Pilates as an exercise for lower back pain. You may have lower back pain and have been told to do some Pilates because it will help. You may go to one class which is staying true to the original exercises and do an exercise which is possibly going to make your back worse and you may go to another which is using any of the modified exercises and it is going to possibly help your back. And in another class, an instructor may be throwing in some of the original exercises, some modified ones, and then some general core and toning exercise they�ve picked up along the way because after all that�s why most people come to the class, to tone up and if you do have a lower back problem all that abdominal work is going to help, right? Wrong!

One person may go to Pilates and it helps with their back pain, for another person it may make no difference or make it worse. This doesn�t only apply to Pilates, but Yoga and many other general fitness classes. This also applies to a whole host of injuries, your shoulder/ hip/knee injury may get better but then again it might not, you are not doing a set of exercises specifically designed to help. The problem is Pilates is not specifically designed for lower back pain, and the person teaching it may have no background in it. You may go to a class and be able to do 90% of the exercises, but 10% of the exercises may actually make your back pain worse. You may not have access to a specific lower back class or rehabilitation program where you live and this leaves you with a conundrum - should I do the class or not? Of course, your first port of call is the physiotherapist, though I�m sad to say you may end up with nothing more than advice to do some Pilates and an exercise sheet consisting of knee hug stretches and knee side to side mobility. On the other hand you may get a first class rehabilitation program that is specific to your needs, evidence based and progressive. However, the lack of consistency in this area, means you may need to educate yourself.

With this in mind, here are some ways to modify and avoid certain things that may make your back pain worse. These are all evidence based strategies and proven to work. In each example, I will show the most common way an exercise is taught and how you can modify to help spare your spine and strengthen the muscles.

The Spinal Roll

Modified Spinal Roll in Pilates - may not be the best idea if you have lower back pain

The spinal roll is almost universal in Pilates as a warm up exercise and a way to get down to the mat. However, look at the position of the spine, it is fully flexed, it is in a rounded, bent position. Now, evidence shows that repeated spinal flexion can lead to a disc prolapse or injury. The load is not important, it is the amount of times you do it, and the amount of times you do it before it causes injury is purely individual. Imagine a credit card, if you keep bending it back and forward, eventually it will snap in the middle. Also holding a spinal roll position can cause the muscles in the back to switch off and the back is hanging on the ligaments between the vertebrae in the back.

In adults aged 20-50 years old nearly all back pain is forward flexion intolerant and discogenic. In other words, round the back and bending over makes it worse!

Avoid any exercise that may round the lower back and especially if it is rounded under load. So in Pilates terms this also means you need to avoid the Roll Up and Rolling Like a Ball (see below for pictures and video and to be fair on the Pilates course I attended, they did say to avoid rolling like a ball if you have scoliosis).

Pilates Roll Up - avoid if you have lower back pain and also promotes poor posture

Also, there is a Pilates exercise called The Saw which is flexing and twisting to do a toe touch - one of the worst things for those with back pain. We know one of the worst actions for the back and tearing up the discs is the action of bending and twisting. So we can see how one version of this exercise is beneficial whereas another version is not.

The Saw - most people are going to end up twisting and bending through their lower back.

Crunches and back flattening

There are very few crunching movements in Pilates, to its credit much of the time you are trying to keep a neutral spine. In some exercises though, the back is flattened or rounded into the floor or mat. In Pilates this is called 'imprinting' the spine or back. This is just really forward flexion again but with your body on the floor, same as the standing versions. Repeated crunches or imprinting/ flattening of the back can damage the lower back tissue and are not that effective at activating the muscles in the core and can result in poor upper body posture. Try not to flatten or over extend the back, keep it in a neutral position with a natural curve. Your lower back is strongest when it has a natural curve in it, not flat or excessively curved but neutral. This is where the grey area of what is Pilates comes in. Pilates itself doesn�t have many crunching movements, but instructors may be adding these in.

Classic exercise Neck Pull. Doesn't really get done anymore in classes, but if you think crunches are somehow safer or better then think again

Curl Up - flipped onto its side. Some Pilates courses teach the curl-up. Even if imprinting and flattening the lower back didn't cause problems look at the posture this promotes - head forward, shoulders rounded, hips flexed. Most people spend all day in this posture anyway, they don't need to practice it

Stretches

As mentioned earlier, people with lower back pain often feel the need to stretch out their lower back or are advised to do a knee hug stretch. This is not a Pilates exercises but is often done, as is rolling like a ball, which is one of the original exercises. Stretching the lower back muscles can be detrimental to the spine, as it makes the lower back less stable.  The muscles may have become permanently switched on and in �spasm� but there are other ways of switching these off and helping them to relax that don�t involve stretching. This doesn�t mean stretching in general is bad, other tight muscles in the body may benefit from stretching.

Pilates originally attracted quite a few dancers, this group is naturally very flexible and in many cases way too flexible and unstable. An exercise that may be easy for them may impossible for you. Plus their incidence of back pain is the same as everyone elses, they just end up with different types of back pain.

In summary

Hopefully, this article has cleared up some of the issues surrounding back pain and Pilates. The term Pilates has become so general that really there is no set definition anymore. This article shouldn�t discourage you from taking part in classes, nor does it mean Pilates wont help. Following the guidelines above should help. Remember, this article is aimed at people with lower back pain,

• Avoid forward bending with a rounded back, you should hinge from the hips
• Abdominal bracing is superior to hollowing to strengthen the core
• Avoid lateral or thoracic breathing, breathe using the diaphragm, this will activate your core and  protect your back
• Try to avoid rotating through the lower back, you should rotate through the middle back and hips
• Keep a neutral spine and avoid pressing your back flat or doing traditional crunches
• Avoid stretches like the knee hug stretch, but other muscles like the gluteals & hip flexors may be tight and need stretching.

You may think, that if you do all these things, then you are no longer doing Pilates. The truth is you probably weren't doing classic Pilates in the first place, but a hodge podge of things mixed together. If however, you go to a class, it makes your back feel better and you enjoy it, does it really matter what it was called?

Lastly. Ideally try to attend a specific class for chronic lower back pain or have an individualised program. If you have other injuries like hips and knees, again a specific individualised program specific to your needs will be more beneficial than attending a class where possibly only one or even none of the exercises are going to help you.

*I originally wrote this article over 2 years ago, but never got around to taking the photos for it or publishing it. I have had added a few extra bits, but this is pretty much how I wrote it 2 years ago, the principles in it all hold true. I wasn't going to publish it, as I thought all this information was out there and quite well known. Turns out I was wrong, last weekend I was on a course with Physios, Osteos and Chiros, when the issue of abdominal hollowing and back pain came up it was a revelation to the majority of the people in the room - about 30 - many of whom had been referring patients to Pilates for back pain, as one of the physios/osteos asked at the time 'does this mean Pilates is wrong?' In this case, I'm afraid it is. The mantle of back pain & injury cure-all got projected onto Pilates, and turned it into something it never initially claimed to be. For lower back pain, the evidence is clear and despite over a decade of research showing that many of the Pilates concepts should at least be modified or reversed or in some cases completely replaced, they continue to be taught.