Pilates and Low Back Pain: Moving Beyond the Traditional Core Stability Model

From Core Stability to Movement Adaptability

Key Ideas:

If you are living with chronic non-specific low back pain, here are some important points to know:

• Your spine is designed to move.
  Age‑related changes on scans are common and do not automatically mean your back is damaged beyond repair.
• You do not need a perfect core or constant bracing to be safe.
  For most everyday movements, your body organises support automatically.
• Core exercises can be useful, especially as part of a broader programme.
  But they are not the only route to improvement, and they work best when tailored to you.
• Pilates can help by giving you structured, graded ways to move, build strength and flexibility, and regain trust in your back.
  You and your teacher can adjust exercises according to your symptoms, confidence and goals.

For example, someone who has avoided bending for months might start with gentle, supported movements on the mat, then progress over time to everyday tasks like loading a washing machine or picking up a grandchild.

The aim is not a quick fix, but a gradual return to confidence in movement and physical capability.

The Beliefs Behind the Core Stability Model

As a Level 4 Pilates teacher, an Exercise Referral Practitioner, and a Back4Good practitioner, I work with people with a variety of conditions, including chronic non-specific low back pain (i.e. pain not attributable to an underlying cause which has last for more than 3 months). For simplicity, I will refer to this as low back pain throughout the article.

During the first session, when I ask clients about their goals for starting Pilates, the most common response is that they want a “stronger core”. This goal is often influenced by the concept of core stability. Many people have been told by healthcare professionals, the fitness industry, media, or well-meaning friends and family that a stronger core will better support the spine, reduce pain, and help prevent injury.

Lederman (2010) identified several assumptions underlying the traditional core stability model, including:

• Certain muscles, particularly the transversus abdominis, are uniquely important for spinal stabilisation
• Weak abdominal muscles lead to back pain
• Strengthening abdominal muscles reduces back pain
• A distinct group of “core” muscles works independently from the rest of the trunk musculature
• A strong core prevents injury
• There is a direct relationship between stability and back pain

Over time, these assumptions have helped shape many of the beliefs people hold about back pain and the core. These beliefs are important and should not be dismissed, as they often influence how a person engages with movement. When designing and progressing an exercise programme, however, they should be considered within the context of the practitioner’s up-to-date professional knowledge and the best available evidence.

Before examining whether these beliefs are supported by evidence, it is worth stepping back and asking two more fundamental questions: what do we mean by the “core”, and is the spine a vulnerable structure that requires special protection?

The Core and the Idea of a Vulnerable Spine

Although many people think of the core as the abdominal muscles, in rehabilitation and movement contexts it is often described as a functional system involving the abdominal muscles, back muscles, diaphragm, pelvic floor, and surrounding connective tissues.

Together, these structures contribute to breathing, postural control, and the management of loads during movement. However, the amount of trunk muscle activation required for everyday spinal control and load management is relatively low (Lederman, 2010). This challenges the common assumption that a “weak” core causes the spine to become unstable or vulnerable.

Indeed, the spine is not a fragile structure waiting to be protected. It is a strong, adaptable biological system designed to move, absorb loads, and respond to changing demands (Galbusera & Bassani, 2019). It is made up of vertebrae and discs and functions within an integrated system of muscles, ligaments, fascia, and connective tissues. It is designed to bend, rotate, and extend in response to the demands of everyday life. Like any complex biological system, the spine requires coordinated neuromuscular control to manage changing demands, but this does not mean that it is inherently fragile or dependent on constant conscious stabilisation.

When a painful back is described as “unstable”, it may unintentionally reinforce the belief that movement is dangerous and that the spine requires ongoing bracing to remain protected (Wand et al., 2024). However, most people with low back pain do not have a spine that is structurally failing. Changes such as disc degeneration and other age-related spinal findings are common in people without pain (Brinjikji et al., 2015), suggesting that these findings alone cannot explain why someone hurts.

So, Where Did the Core Stability Concept Come From?

One of the most influential ideas in back pain rehabilitation emerged from research by Hodges and Richardson in the 1990s. Their early work suggested that some people with low back pain switched on the transversus abdominis slightly later than people without back pain during rapid limb movements.

Importantly, as Lederman (2010) points out, the original findings concerned differences in timing, measured in milliseconds—not muscle strength.

Over time, however, this observation was simplified. A delay in muscle activation became interpreted as a sign of “poor” spinal stability. A laboratory finding became a clinical assumption. And a timing difference became something to be “fixed”.

Is Delayed TrA Activation Really a Dysfunction?

Although Hodges and Richardson’s studies identified delayed anticipatory transversus abdominis activation in some individuals with low back pain, the clinical significance of this finding remains debated (Mehta et al., 2017). In the presence of pain, altered muscle activation may represent a protective adaptation rather than a dysfunction (Lederman, 2010; van Dieën et al., 2019b).

Delayed transversus abdominis activation is therefore better understood as one possible motor-control response rather than a universal feature or a problem that must always be corrected. Trunk muscle activation patterns vary between individuals and according to context, and changes in transversus abdominis and multifidus function do not consistently explain improvements in pain or disability following treatment (Cervera-Cano et al., 2023; Wong et al., 2014; van Dieën et al., 2019a,b).

The Problem with Stabilising Before Moving

The idea of “activating the core” or “bracing” before moving assumes that the spine should first be consciously stabilised before movement begins.

However, even in people with low back pain, movement does not depend on consciously stabilising the spine before every task. Although the trunk muscles do contribute to anticipatory postural adjustments, these responses are largely automatic and context-dependent, not something that needs to be consciously controlled before each movement.

Spinal stability is therefore a dynamic process. It reflects the ability of the nervous system to continuously adapt muscle activity and movement strategies to changing demands placed on the body, rather than relying on a fixed pattern of muscle activation (Mehta et al., 2017; van Dieën et al., 2019b; Wand et al., 2024).

For people with low back pain, encouraging conscious stabilisation before every movement may promote unnecessary stiffness, reduce movement variability, or reinforce the belief that movement is only safe when carefully controlled.

Does That Mean Abdominal Training Is Useless?

Not at all.

Like any other skeletal muscle, the abdominal muscles can adapt to exercise. Progressive resistance training can improve muscle strength. However, improvements in strength depend not only on muscular adaptations, but also on neural adaptations, coordination, and the specific task being performed (Škarabot et al., 2021).

For this reason, becoming stronger in core exercises does not automatically translate into improved performance during everyday activities or reduced low back pain (Lederman, 2010). Developing abdominal muscle capacity can be a valuable component of an exercise programme, but its benefits are unlikely to come simply from creating a more stable or “protected” spine. Instead, they are more likely to reflect greater tolerance to movement and loading, and improved movement confidence.

Beyond Core Stability

One of the limitations of the traditional core stability model is its tendency to reduce low back pain to altered core function. Pain, however, is a personal protective experience that arises from a complex interaction between biological factors, central nervous system processing, beliefs, emotions, previous experiences, and social context (Wand et al., 2024; Moseley et al., 2003).

Our beliefs about pain matter. Our previous experiences matter. Our confidence in our bodies matters (Wand et al., 2024).

Current evidence suggests Pilates, and exercise more broadly, as effective approaches for managing low back pain (Li et al., 2023; Asik et al., 2025). The question, then, is not whether Pilates works, but why it works. A randomised trial found that consciously relaxing rather than continuously contracting the abdominal muscles during Pilates produced similar—and in some respects slightly better—outcomes in people with chronic low back pain (Lunkes et al., 2026).

Rather than simply correcting a supposedly dysfunctional core, Pilates may help through repeated opportunities to explore varied movements in a supportive environment. These experiences provide the nervous system with new sensory and contextual information, supporting adaptation and influencing how a person perceives their back and ability to move (Wand et al., 2024). Movement may also influence pain through physiological mechanisms, including exercise-induced hypoalgesia and modulation of pain sensitivity (Wewege et al., 2021).

Core-focused exercises can still be useful for some people, particularly when they provide reassurance and a gradual return to movement.

However, the goal is not perfect control, but adaptability.

From Core Stability to Movement Adaptability

The idea that low back pain is caused by an unstable spine due to a weak core has been highly influential in rehabilitation and fitness. Yet the original research did not demonstrate that weak abdominal muscles cause back pain; it identified differences in muscle timing during specific laboratory tasks.

Current evidence suggests a more nuanced perspective. Altered muscle activation patterns may represent adaptations rather than dysfunction, and there does not appear to be a single optimal way for the trunk muscles to behave. Spinal stability is a dynamic process, with the nervous system continuously adapting movement strategies according to the task, the individual, and the environment.

Moving beyond a single core stability model does not mean rejecting strength training or core-focused exercise. Rather, it means recognising that recovery is supported by developing physical capacity, confidence in movement, and the ability to adapt to changing demands. This process requires patience and exploration. Some days are easier, others more challenging, and both are a normal part of recovery.

The aim is not a quick fix, but a gradual return to confidence in movement and physical capability.

References

Asik, H. K., & Sahbaz, T. (2025). Preventing chronic low back pain: Investigating the role of Pilates in subacute management—a randomized controlled trial. Irish Journal of Medical Science, 194(3), 949–956. https://doi.org/10.1007/s11845-025-03939-y

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811–816.

Cervera-Cano, M., López-González, L., Valcárcel-Linares, D., Fernández-Carnero, S., Achalandabaso-Ochoa, A., Andrés-Sanz, V., & Pecos-Martín, D. (2023). Core synergies measured with ultrasound in subjects with chronic non-specific low back pain and healthy subjects: A systematic review. Journal of Clinical Medicine, 12(9), 3190. https://doi.org/10.3390/jcm12093190

Galbusera, F., & Bassani, T. (2019). The spine: A strong, stable, and flexible structure with biomimetics potential. Biomimetics, 4(3), 60. https://doi.org/10.3390/biomimetics4030060

Hodges, P. W., & Richardson, C. A. (1996). Inefficient muscular stabilization of the lumbar spine associated with low back pain: A motor control evaluation of transversus abdominis. Spine, 21(22), 2640–2650.

Lederman, E. (2010). The myth of core stability. Journal of Bodywork and Movement Therapies, 14(1), 84–98. https://doi.org/10.1016/j.jbmt.2009.08.001

Li, Y., Yan, L., Hou, L., Zhang, X., Zhao, H., Yan, C., Li, X., Li, Y., Chen, X., & Ding, X. (2023). Exercise intervention for patients with chronic low back pain: A systematic review and network meta-analysis. Frontiers in Public Health, 11, 1155225. https://doi.org/10.3389/fpubh.2023.1155225

Lunkes, L. C., Dias Neto, M. A., Barra, L. F., de Castro, L. R., de Sá Ferreira, A., & Meziat-Filho, N. (2026). Keeping the abdomen relaxed versus contracted during Pilates improves disability slightly and may improve other outcomes in chronic non-specific low back pain: A randomised trial. Journal of Physiotherapy, 72(2), 116–121. https://doi.org/10.1016/j.jphys.2026.03.007

Mehta, R., Cannella, M., Henry, S. M., Smith, S., Giszter, S., & Silfies, S. P. (2017). Trunk postural muscle timing is not compromised in low back pain patients clinically diagnosed with movement coordination impairments. Motor Control, 21(2), 133–157. https://doi.org/10.1123/mc.2015-0049

Moseley, G. L., Brhyn, L., Ilowiecki, M., Solstad, K., & Hodges, P. W. (2003). The threat of predictable and unpredictable pain: Differential effects on central nervous system processing? Australian Journal of Physiotherapy, 49(4), 263–267. https://doi.org/10.1016/S0004-9514(14)60142-2

Škarabot, J., Brownstein, C. G., Casolo, A., Del Vecchio, A., & Ansdell, P. (2021). The knowns and unknowns of neural adaptations to resistance training. European Journal of Applied Physiology, 121(3), 675–685. https://doi.org/10.1007/s00421-020-04567-3

van Dieën, J. H., Reeves, N. P., Kawchuk, G., van Dillen, L. R., & Hodges, P. W. (2019a). Analysis of motor control in patients with low back pain: A key to personalized care? Journal of Orthopaedic & Sports Physical Therapy, 49(6), 380–388. https://doi.org/10.2519/jospt.2019.7916

van Dieën, J. H., Reeves, N. P., Kawchuk, G., van Dillen, L. R., & Hodges, P. W. (2019b). Motor control changes in low back pain: Divergence in presentations and mechanisms. Journal of Orthopaedic & Sports Physical Therapy, 49(6), 370–379. https://doi.org/10.2519/jospt.2019.7917

Wand, B. M., Cashin, A. G., McAuley, J. H., Bagg, M. K., Orange, G. M., & Moseley, G. L. (2024). The Fit-for-Purpose Model: Conceptualizing and managing chronic nonspecific low back pain as an information problem. Journal of Orthopaedic & Sports Physical Therapy, 54(5), 1–13. https://doi.org/10.2519/jospt.2024.12251

Wewege, M. A., & Jones, M. D. (2021). Exercise-induced hypoalgesia in healthy individuals and people with chronic musculoskeletal pain: A systematic review and meta-analysis. Journal of Pain, 22(1), 21–31. https://doi.org/10.1016/j.jpain.2020.04.003

Wong, A. Y. L., Parent, E. C., Funabashi, M., & Kawchuk, G. N. (2014). Do changes in transversus abdominis and lumbar multifidus during conservative treatment explain changes in clinical outcomes related to nonspecific low back pain? A systematic review. Journal of Pain, 15(4), 377.e1–377.e35. https://doi.org/10.1016/j.jpain.2013.10.008

Further resources

Moseley GL. Why Things Hurt [Internet]. TEDxAdelaide; 2011 Nov 21 [cited 2026 Jul 9]. Available from: https://www.youtube.com/watch?v=gwd-wLdIHjs

Pain Revolution. Essential Pain Facts [Internet]. Adelaide (AU): Pain Revolution; [cited 2026 Jul 9]. Available from: https://www.painrevolution.org/painfacts

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