Science of Sport: Pilates injuries - the power of Pilates – and the dangers of its burgeoning popularity

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In the world of working out, Pilates is high fashion. Who in Hollywood doesn’t do Pilates? It seems you can’t flip through a magazine or turn on the TV without coming across someone famous who credits Pilates exercise for their sleek physique.

Once the best-kept secret of the dance community, Pilates has been discovered and embraced by singers, models, athletes and actors. But what exactly is Pilates – and does it really work?

There are two categories of Pilates: the version practised by the mass populace in gyms and studios, which I will call ‘fitness Pilates’, and a growing international movement among allied health professionals (especially physiotherapists), called ‘clinical Pilates’.

Almost anyone who has been exposed to Pilates through a video or gym class has been doing some kind of fitness Pilates. Even within the fitness industry, few people are aware that there exists a separate stream of Pilates with some radically different technical and philosophical aspects, a stream that has developed in Australia in various guises since the early 1990s.

In this two-part SIB analysis we will look at both streams. In Part II we will unpack clinical Pilates and look at exactly what makes it such a valuable tool in the kit of athletes, coaches, and those practising any form of sports medicine.

First, though, we consider in depth fitness Pilates, very much from a consumer viewpoint. I also raise some important questions for those involved in the industry, because the bottom line is that there are greatly varying levels of quality, accuracy and effectiveness in the Pilates world, as indeed is the case in any fitness discipline that is both evolving and holding out big promises to a vast spectrum of people.

Pilates in a nutshell

Fitness Pilates is a method of exercise and physical movement designed primarily to stabilise the trunk (the ‘core’), producing more effective stretching, strengthening and balancing of the body. Through the systematic practice of specific exercises coupled with focused breathing patterns, Pilates has proven itself invaluable as a fitness endeavour and an important adjunct to professional sports training and physical rehabilitation.

It was developed in the 1920s by the German boxer, circus performer and exercise innovator Joseph Pilates, and began to gain a following when dancers he was working with discovered it could create long, lean muscles and a strong, streamlined physique. Pilates’ system didn’t really hit the big time, however, until the 1990s.

After years of high-impact, feel-the- burn fitness workouts, there was great appeal in a slower, safer approach to health and wellness. Fitness Pilates can condition the body from head to toe with a no-to-low-impact approach suitable for all ages and abilities. It requires patience, attention to detail with your body and consistent practice, but results are guaranteed to follow if one sticks at it and does it right.

The kinds of results and benefits you can expect from an accurate, educated and well designed Pilates programme include:

• improving strength, flexibility and balance
• toning and building long, lean muscles without bulk
• challenging deep abdominal muscles to support the core
• engaging the mind and enhancing body awareness
• reducing stress, relieving tension, and boosting energy through deep stretching
• restoring postural alignment
• creating a stronger, more flexible spine
• promoting recovery from strain or injury
• increasing joint range of motion
• improving circulation
• enhancing mobility, agility and stamina
• improving the way your body looks and feels.

Behind each of these benefits there are physiological and technical justifications. However, success depends entirely on understanding the basic principles and practices of Pilates and doing it right.

Pilates is such a versatile exercise system that it is beneficial for a wide variety of conditions. Some fitness facilities target a particular kind of clientele or rehabilitative issue, such as pregnancy, back care, seniors, the unfit and so on.

Pilates is also appealing because it can be practised in different contexts: at home in front of a video, as part of a class in a gym/health club, or in a studio setting. Exercises can be done on mats, with swiss balls, with elastic tubing or rings, or on some weird and wonderful contraptions unique to Pilates called Reformer, Trap Table, Wonder Chair and Thoracic Barrel.

Ideally fitness Pilates is practised in a studio under the careful supervision of a certified instructor, either one-on-one or in small group sessions. A well trained specialist knows how to tailor a Pilates regime to meet individual needs and abilities, monitoring movements to ensure correct form for optimum results.

The emphasis of a good Pilates session is on quality (rather than quantity) of movement, not on how much you can sweat and lift but on how well you can stay true to the principles it espouses. Only certain types of yoga can deliver similar improvements, hence the new fashion of ‘Yogalates’.

Several other fitness trends and gurus have also attempted to link their names with Pilates. The important thing to watch for when assessing these options is how well they subscribe to the basic practice and principles of Pilates. More hype, celebrity testimonials and equipment don’t necessarily equate to better results.

Stability, flexibility, durability

The foundation stone of the Pilates movement is the concept of core stability. A stable trunk, or midsection, is the best platform from which to develop whole-body muscular strength and endurance (durability), balance and flexibility. Having a stable ‘centre’ allows one to move in a way that reduces energy wastage (poor technique and fatigue), tissue overload (injury), and muscle confusion (poor alignment/ imbalance). The balanced approach of Pilates ensures that no muscle group is overworked; the body operates as an efficient, holistic system in sport and daily activity.

In any context the body must have some degree of stability before it can function, whether it be sprinting (who has noticed the awesome stability of Michael Johnson in slow motion?) or gardening. The greater an athlete’s initial levels of stability, the easier it is for their body to acquire the specific requirements of their sport. On the other hand, poor core stability will short-circuit any attempts to improve deficiencies in flexibility or durability.

Nowhere is this more true than with athletes hell-bent on pushing their bodies to the limit: without a stable trunk, they will endlessly battle with injury, poor technical or actual performance, and certainly will never reach their full potential.

Hence, muscle and joint stability is the key prerequisite for the efficient development of muscle flexibility and durability. And the principles and equipment of fitness Pilates help to achieve this better than most, if not all, other exercise systems.

The six Cs

There are several variations of Pilates principles, ranging from those pioneered by Joseph Pilates to contemporary adaptations incorporating modern understandings of fitness, anatomy and biomechanics.

Some forms offer five basic principles to describe what it is all about, while others stress nine. The six principles that I believe define Pilates best are:

• Concentration – That all-important mind-body connection. Conscious focus on movement enhances body awareness. Focusing the brain on the body part enhances proprioception.
• Control – It’s not about intensity, rather it’s about the empowerment of being able to have a definite and positive impact on a body part through the activation of critical stability muscles. Ideal technique brings safe, effective results.
• Centring – A focus on the specific muscles that stabilise the pelvis and the scapula underlies the development of a strong core and enables the rest of the body to function efficiently. The correct muscles must be taught to hold for extended periods of time at a low level. Consequently all action starts from a stable core.
• Conscious breathing – Deep, conscious diaphragmatic patterns of inhaling initiate any movement, help activate deep stabilising muscles and keep you focused.
• Core alignment – Maintaining a ‘neutral’ position (joints held in mid-position by deep tonic stabilising muscles) is the key to proper alignment, and this leads to good posture. You’ll be aware of the position of your head and neck on the spine and pelvis, right down through the legs and toes.
• Coordination – Flowing movement results from brain and body working perfectly in synergy; the aim is smooth, continuous motion, rather than jarring repetitions. Pilates has a grace and elegance to its movement that comes from working ‘smarter’, not ‘harder’. Repetition is used to ‘cement’ good movement into your brain.

These principles are quite different from other forms of exercise such as an aerobics class, running, or a weights session. However, Pilates can greatly enhance the benefits of other types of exercise. For example, when you have learnt how to use your abdominals properly to stabilise your trunk, even cardiovascular exercise such as running becomes an avenue to further train your abs.

Having a stable ‘centre’ also allows one to more effectively stretch one’s limbs. Flexibility problems seen in the physiotherapy clinic often have an instability component that must be resolved in order to stay more flexible and functional in the long term.

So there you have the basics. But they only tell us part of the story, in the same way that listening to the hum of an engine tells us only something of what is going on within it. If we are really going to understand the Pilates concept and what makes it work, we need to look at it with the critical eye of science.

Has fitness Pilates lost the plot?

Certainly some of what fitness Pilates purports to offer taps deeply into the fundamentals of how humans can improve, restore and maintain safe and efficient movement patterns. I believe the ramifications for the medical and fitness industries in the future are vast and varied – if the Pilates industry continues to expose itself to the refining process of critical evaluation by the allied health and medical fraternities.

However, it appears to me that in its fervent attempt to grow rapidly as an industry, fitness Pilates is in danger of becoming its own worst enemy. By forgetting its basic practices and principles, it loses all of its power to transform, and thus creates disillusionment, and at worst, injury.

I speak from experience: working as a physiotherapist in the sports and fitness industry, I hear weekly about the injuries created in Pilates classes by well-meaning instructors with upwards of 30 people in their care. The most common complaint is flexion-related low-back pain. An example of this is an inflamed disc that creates pain and prevents full forward flexibility. Sitting becomes painful, and bending over or lifting can be even worse.

Classes are not the only source of potential disappointment. I saw ‘Vanessa’, for example, for the first time recently: after three years of Pilates one-on-one with an instructor using specialised equipment, she is still carrying a chronic low back ache of a purely mechanical nature – that is, she has no internal damage to her discs, bones or ligaments. How is it possible that she is no better after such a length of time if Pilates was doing what it claims to do?

Yet as I have outlined above, the list of potential benefits of Pilates is extensive – and I truly believe that, given some simple keys, many people can (and do) unlock the door to those rewards. The keys they need are accuracy and specificity.

Key 1: accuracy

Accuracy relates to how fitness Pilates is taught: the method, the environment, the context. The success of the system relies heavily on the careful education and monitoring of a client by a correctly trained teacher. The question must be asked: does the advantage of teaching 30 clients in a class outweigh the disadvantages of 50% to 90% of them getting it wrong?

From experience, I know that it can often take up to 30 minutes of one-on-one attention and direction from me before a patient learns to isolate and activate the correct muscles for even one new movement pattern.

And then they have to practise it! When working with a motivated client, I find that their body takes what it has learnt in our Pilates session and may do things differently for a day or two, until old, bad habits (eg sitting stooped at a desk for eight hours, or standing ‘lazily’ with a child draped across a hip) undo the good we achieved.

I believe one-on-one training must remain the basic initial learning tool for the Pilates method. Is it a luxury we simply must afford to safeguard the industry?