“One of my favorite studies, also showing a significant increase in all 3 layers of the abdominals, was able to demonstrate a full correction of an 8% muscle imbalance between non-dominant and dominant sides by the end of a 36-week program!”

-Sarah McMahon

If you're one of the many who have heard whispers about the transformative powers of Pilates for rehab, you're in good company. Maybe you've even been told to try it for back pain relief or injury prevention, but like me, you might have had little more than a vague notion of what Pilates truly entails.

It was with this curiosity, and plenty of emails toting the benefits of Pilates, that I became more interested in exploring it. So, I asked (the sender of those emails) my coworker and physical therapist (PT) Sarah McMahon to help demystify this practice.

With careful consideration, Sarah provided great insight into the benefits of pilates, the evidence supporting this practice, and the unique roots that date back to an internment camp. Sarah also debunks common misconceptions and uncovers its profound benefits for rehab, particularly in addressing back pain and preventing injuries.

Let’s dive in.

5 Questions with Sarah McMahon

1. What is Pilates and why did you choose this as such a specific area of focus?

Pilates is an exercise philosophy, method, and movement modality designed to balance, strengthen, and lengthen the body. The specific, often ordered, exercises are coupled with focused breathing patterns and refined motor programs making it a great tool in injury prevention and rehabilitation. 

Joseph Pilates began teaching his mat exercises in the early 1900s and expanded the system by designing and creating patents for 26 pieces of equipment, many still used in Pilates studios today! One thing I love about the system is how you can teach the same exercise multiple ways depending on which apparatus you are using and what modifications/advancements are already built into the original work. Systematically, Joe was incredibly smart with the suggested order of the exercises. When looking deeper at the types of movement, the exercises begin with flexion, progress with a coupling of flexion and rotation, are balanced out by extension, and then work laterally in the frontal plane. Pilates referred to his exercises as "corrective" and having that experience is what brought me further into the practice. 

In my sophomore year at Drexel, dancer majors were offered free Pilates classes as a form of conditioning. Even though I had spent years staring at myself in a dance studio mirror and getting critiqued by countless dance professionals from all over the world, I began to find connections to my breath and muscles in a way I had never felt before. Fast forward to audition season, the director of the dance department sat in the studio apathetically while choreographers assessed the best dancers to cast in their pieces. Between rounds of the audition, she approached me and said we had to talk. I immediately thought I was in trouble until she said, "I can't keep my eyes off of you today. Never stop doing Pilates." In that moment she confirmed that what I was feeling in class had completely changed the mechanics of how I was moving and performing. 

Several months later, I was asked if I was interested in continuing my journey by being in the 1st cohort of students to be certified through their new Pilates Training Program. As you may have guessed, it was an easy YES! The program taught me how to analyze the body, provide an exercise program specific to client needs, and provide appropriate verbal and tactile cues to fine-tune mechanics. In my senior year Injury Prevention course, I realized I could share these skills and my passion for movement with a much larger population if I became a physical therapist like the professor! So off I went 😊

2. What are some of the most common misconceptions you hear about Pilates?

I would be a billionaire if I had a dollar for every time someone said “Pilates is like yoga, right?” While there are many parallels, and I personally enjoy doing both, they are definitely two distinctly different practices. Another misconception I hear, which I can quote from a patient just a few weeks ago, is “Pilates is for fit, middle-aged women.” Don’t worry, he changed his mind! It is ironic that this is a popular perception of Pilates given the history.

Joseph Pilates dedicated his life to the development of these exercises to cure his body of his own childhood illnesses, including asthma, Ricket’s, and rheumatic fever. While working as a professional boxer and self-defense trainer, he found himself in a British internment camp during World War I. Here he refined and began teaching the mat exercises to fellow inmates and injured veterans. It is believed that it was here he first attached spring and pulley systems to the beds of the ill, resulting in the development of the apparatuses. How did we get from injured men to “fit women”?

When Joseph Pilates immigrated to the US and opened his studio in NYC in 1926, he quickly gained popularity training dance legends including Martha Graham and George Balanchine.  However, Pilates has always been for every body and luckily emerging research is starting to bring us back to the roots in rehabilitation.

3. What does the research say about the benefits of Pilates? 

This could be a whole blog post in itself so I will speak generally. The first thing research has shown is that it does in fact target what it was intended for: improving breathing, strengthening the deepest abdominal muscles, and uniformity. Lumbar stabilization exercises as a whole have been shown more effective than traditional abdominal exercises in reducing pain and improving function. When comparing musculature between a Pilates instructor and a resistance trainer, the Pilates instructors have shown significantly greater resistance and control of the transverse abdominals during stabilization exercises. (1) Part of this may be due to the fact that other studies support there is a significant increase in transverse abdominal and internal oblique contraction with trunk flexion when using the Pilates breathing technique vs. natural breathing. (2)

One of my favorite studies, also showing a significant increase in all 3 layers of the abdominals, was able to demonstrate a full correction of an 8% muscle imbalance between non-dominant and dominant sides by the end of a 36-week program! (3) A systematic review in 2015 looking at Pilates in healthy adults showed a large effect size for muscle strength, gait, activities of daily living, quality of life, and mood​. It also showed a moderate to large effect size on dynamic balance, and a small effect size on static balance, flexibility, and cardiometabolic outcomes. (4)

The most common themes I have noticed in the Pilates research show significant improvements in reducing low back pain and reducing the risk of falls, however, research can be found on many specific populations including stroke, Multiple Sclerosis, Parkinson’s, and more. One randomized control trial that really caught my eye was one that determined Pilates services were equally effective to outpatient physical therapy in improving walking speed and step length in patients with MS. (5) While I don’t think Pilates should be replacing physical therapy, this highlights how we can further support our patients with a Pilates-based home exercise program or referral to a Pilates studio when insurance is no longer covering visits. 

In summation, the studies I have read over the years so far are almost always in favor of Pilates, but the research has been limited in terms of sample sizes and the number of studies in a given area. I am hopeful the positive results compel more professionals to explore this area and continue building studies around Pilates as a treatment. If you are interested in reading more Pilates research, the Pilates Method Alliance Research Committee publishes a list of resources every few years. The current list was updated in 2021 and has 22 pages of studies!

4. The patients we see have wide-ranging presentations from spinal cord injuries to strokes to progressive neurological conditions.  How do modify Pilates to meet these patients, and anyone with physical limitations without sacrificing the core aspects of the practice?

I always include pre-Pilates warm-ups, start with the beginner mat exercises, and then have patients see if they can carry it over into whatever functional movement patterns they are currently working on.  When assessing their ability to perform a specific movement I keep my eye on the six Pilates principles- concentration, control, centering, precision, breath, and flowing movement.  If any of them are missing I will simplify the movement further, change verbal and tactile cues, and/or add assistance.

I definitely focus the most on breathing, as the proper timing of an inhale or an exhale can drastically make a difference in someone’s ability to recruit certain muscle groups and decrease their assistance level in Pilates and life! Another great thing about Pilates is most of it is already done lying down or sitting, making it perfect to trial with patients at all levels. While many of the seated exercises are traditionally done in long sit, I often have patients perform these seated at the edge of a mat or their wheelchair to accommodate for any hamstring tightness or balance deficits.

5. For individuals who are new to Pilates, what advice or tips would you offer to help them get started and stay motivated?

Find the right studio and the right instructor!

As mentioned earlier, the movements are made to be specific and, when in a group class, in order. You should be able to follow an intermediate, or level 3, mat class in the US the same as if you went to Germany or Brazil and didn’t understand a word the instructor was saying. Unfortunately, with popularity over the years, came a lot of Pilates spin-offs. Like most movies and TV shows, the spin-offs aren’t as good as the original.

• Look for studios and instructors that even if they deviate from the original approach, still have a full foundation and offer the classics.

• Does the studio only offer reformer or is there access to other pieces of equipment like the tower, chair, and barrels? Studios with a classical approach to Pilates will have equipment made by Gratz (the original manufacturer), Peak, Balanced Body, or Stott.

• If you are at a studio that offers only one subtype of Pilates, what does the instructor’s bio look like? Were they only certified by the brand they are promoting in class? Is their certification in one area (Ex: certified mat level I) or in all of them (a “comprehensive” certification in all levels on all equipment with hundreds of practice hours)?

• Are the instructors able to provide feedback to improve technique and individualize the experience even in a group setting? More in-depth certifications also require an instructor to have a health and fitness background or demonstrate proficiency in anatomy to safely modify or omit the correct exercises. 

Once you find where to start, start with the mat classes or try a private session for equipment to build your foundation. Many Pilates studios offer an introductory private or private series at severely discounted rates to make sure you are safe and ready for a group equipment class.

In terms of motivation, the system does that for you. There are over 600 classical exercises and variations that a good instructor will add to your repertoire over time. Being able to set short and long-term goals within the framework always keeps people coming back for more!

1. Moon, Ji-Hyun, et al. "Comparison of deep and superficial abdominal muscle activity between experienced Pilates and resistance exercise instructors and controls during stabilization exercise." Journal of exercise rehabilitation 11.3 (2015): 161.​

2. Barbosa, Alexandre Wesley Carvalho, et al. "The Pilates breathing technique increases the electromyographic amplitude level of the deep abdominal muscles in untrained people." Journal of bodywork and movement therapies 19.1 (2015): 57-61

3. Dorado, Cecilia, et al. "Marked effects of Pilates on the abdominal muscles: a longitudinal magnetic resonance imaging study." Medicine and science in sports and exercise 44.8 (2012): 1589-1594.​ 

4. Bullo, V., et al. "The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: a systematic review for future exercise prescription." Preventive medicine 75 (2015): 1-11.

5. Kalron A, Rosenblum U, Frid L, Achiron A. Pilates exercise training vs. physical therapy for improving walking and balance in people with multiple sclerosis: a randomized controlled trial. Clin Rehabil. 2017 Mar;31(3):319-328. doi: 10.1177/0269215516637202. Epub 2016 Jul 10. PMID: 26951348.