Core Training in Low Back Disorders: Role of the Pilates Method Andrew A. Joyce, MD and Dana H. Kotler, MD Abstract The Pilates method is a system of exercises developed by Joseph Pilates, which emphasizes recruitment and strengthening of the core muscles, flexibility, and breathing, to promote stability and control of movement. Its focus bears similarity to current evidence-based exercise programs for low back disorders. Spinal stability is a function of three interdependent systems, osseoligamentous, muscular, and neural control; exercise ad- dresses both the muscular and neural function. The ‘‘core’’ typically refers to the muscular control required to maintain functional stability. Prior re- search has highlighted the importance of muscular strength and recruit- ment, with debate over the importance of individual muscles in the wider context of core control. Though developed long before the current evi- dence, the Pilates method is relevant in this setting and clearly relates to current evidence-based exercise interventions. Current literature supports the Pilates method as a treatment for low back disorders, but its benefit when compared with other exercise is less clear. Introduction Low back pain is a common condition which affects most people during their lives. Recent estimates indicate that the point prevalence ranges from 1% to 58.1% (median, 15.0%) and 1 yr prevalence from 0.8% to 82.5% (median, 37.4%) (20). To further characterize this impact, the Global Burden of Disease study in 2010 demonstrated that low back pain not only had a global point prevalence of 9.4% but also was the number one cause of disability in the world (21). Despite its high prevalence, treatment of low back pain can be challenging because there are multiple poten- tial pain generators which are often difficult to distinguish clinically. Given the vast global impact, a great deal of re- search has been developed to evaluate various treatments for low back pain. While interventional approaches have gained popularity in the treatment of low back pain, exer- cise and physical therapy make up the foundation for most nonpharmacologic treatments. Therapeutic exercises have several advantages over other treat- ments, which make them appealing for the treatment for low back pain; most are relatively inexpensive, noninvasive, have few side effects, and are beneficial for the general health of an individual. Pilates Method The Pilates method is a system of exercises which focuses on awareness, recruitment, and strengthening of the stabilizing muscles of the body, to pro- mote control of movement, as well as flexibility and improved posture. Joseph Pilates (1883Y1967) created his method of body conditioning in the early part of the 20th century, re- portedly based on his own weaknesses as well as his experi- ences working with soldiers at a British internment camp during World War I (13). In its early years, the method was practiced primarily by elite athletes and dancers who often suf- fered injuries, as it encouraged movement throughout the reha- bilitation process; exercises incorporated springs, pulleys, and gravitational advantage to provide needed assistance. It has recently gained a much wider audience because the Pilates method can be used to develop general fitness, core strength, improved function, or reduced pain. The Pilates method, commonly referred to as just ‘‘Pilates,’’ is traditionally taught in a private or small group session with multiple pieces of apparatus, though there are larger group classes which focus on mat exercises. Pilates method instructors complete a training and certification program of at least 450 h of lecture self-study, and assisted teaching hours, during which they learn the extensive exercises, as well as modifications for specific injuries and conditions. The Pilates Method Alliance established a third-party certification exam for the title of PMA Certified Pilates Teacher (PMA A -CPT). This organization has established standards for Pilates method instruction, after the term ‘‘Pilates’’ was ruled to be generic by a U.S. federal court, allowing for unrestricted use (42). TRAINING ,PREVENTION , AND REHABILITATION 156 Volume 16 & Number 3 & May/June 2017 Core Training, Pilates Method, and the Spine Department of Physical Medicine and Rehabilitation, Spaulding Rehabili- tation Hospital, Harvard Medical School, Boston, MA Address for correspondence: Dana H. Kotler, MD, Harvard Medical School, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Newton-Wellesley Hospital, Spaulding Outpatient Center-Wellesley, 65 Walnut Street, Suite 250, Wellesley, MA 02481; E-mail: dkotler@partners.org. 1537-890X/1603/156Y161 Current Sports Medicine Reports Copyright * 2017 by the American College of Sports Medicine Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.