By Mr Ahmed-Ramadan Sadek, Neurosurgeon · Last reviewed October 2026 · 6 min read

What Pilates actually is

Pilates is a form of exercise built around controlled movement, breathing and the endurance of the trunk muscles. A typical session works through slow, precise exercises lying, kneeling, sitting and standing, with plenty of attention to posture and how the spine moves.

There are two broad styles. Mat Pilates uses your own body weight, sometimes with small props such as bands or a soft ball. Reformer Pilates uses a sliding carriage attached to springs, with straps and a foot bar. The springs can make a movement easier (by supporting you) or harder (by adding resistance), which is why reformer classes are often marketed as more adaptable. Studios sometimes call this “equipment-based” or “apparatus” Pilates.

You will also see “clinical Pilates”, which usually means classes run or designed by a physiotherapist for people with a health problem. The name is not regulated, so it is worth asking what training sits behind it.

What the research says

The main Cochrane review of Pilates for low back pain pooled 10 randomised trials with 510 participants.^[1] Compared with minimal intervention (for example, an education leaflet or no treatment), Pilates reduced pain by a medium amount in the short term: about 14 points on a 0 to 100 scale. Disability also improved. The certainty of that evidence was rated low to moderate, and none of it was high quality.

The more useful question for most people is whether Pilates is better than other exercise. Here the same review found no conclusive evidence that it is. Its authors concluded that the choice could reasonably come down to personal preference and cost.^[1]

A later network meta-analysis, which compares many types of exercise at once, included 118 trials and 9,710 adults with chronic low back pain.^[2] Almost every form of exercise helped compared with no exercise, apart from stretching on its own. Pilates came out with the highest ranking for reducing both pain and disability, with strength and core-based programmes close behind. Rankings like this are interesting, but they rest on indirect comparisons between small studies, so we would not read them as proof that Pilates is the single best option.

The wider picture matters too. A large Cochrane review of 249 trials found moderate-certainty evidence that exercise in general reduces pain in chronic low back pain compared with no treatment, usual care or placebo.^[3] Most side effects reported were minor, such as muscle soreness. Pilates is one good way of doing that exercise, not a separate category of treatment.

Mat or reformer?

Only a handful of trials have compared the two directly. In a Brazilian study, 86 people with chronic low back pain had 12 sessions over 6 weeks of either mat or equipment-based Pilates.^[4] At 6 months, the equipment group had slightly better scores for disability and for fear of movement, but pain was no different between the groups. A Spanish trial of 98 patients found that both styles improved pain, function and fear of movement over 12 weeks, with the equipment group improving faster.^[5]

These are small studies, so the honest summary is that both work and the reformer may have a modest edge for some people. Against that, reformer classes cost more and are harder to find. A well-taught mat class you attend every week is likely to do more good than a reformer class you can only afford once a month.

	Mat Pilates	Reformer Pilates
Equipment	Mat and small props	Spring-loaded sliding carriage
Cost and access	Cheaper, widely available, easy to do at home	Usually pricier, studio only
Support	Relies on your own control	Springs can assist or add load
Evidence for back pain	Helps compared with minimal treatment	Small trials suggest similar or slightly better results

Where Pilates fits in UK guidance

NICE guidance on low back pain and sciatica (NG59) does not single out Pilates. It recommends considering a group exercise programme, which may be biomechanical, aerobic, mind-body or a mix, and says the type should reflect the person’s needs, preferences and abilities.^[6] Pilates sits comfortably within that. The World Health Organization’s 2023 guideline on chronic low back pain makes a similar point: a structured exercise programme may be offered, as a conditional recommendation based on low-certainty evidence.^[7]

Choosing a class and an instructor

• Ask about training. A recognised teaching qualification is the minimum. If you have a back problem, an instructor who is also a physiotherapist, or who works closely with one, is a sensible choice.
• Tell the instructor about your back, any surgery and any other conditions before the first class, not halfway through it.
• Start small. Smaller classes or a few one-to-one sessions let the teacher adapt exercises for you.
• Expect some modification. A good instructor will happily swap an exercise that aggravates your symptoms.
• Give it time. Most trials ran classes once or twice a week for 6 to 12 weeks. Judge it after that, not after one session.
• Mild muscle soreness for a day or two is normal. Sharp pain, pain that spreads down a leg, or symptoms that keep building over several days are not, and you should stop and get advice.

Who should be careful

Pilates is low impact, and serious harm is very unusual. Even so, some people should get individual advice first.

• After recent spinal surgery. Restrictions vary with the operation, so follow your surgeon’s and physiotherapist’s plan. Many people do well returning to Pilates, but usually in a graded way and not straight into a busy reformer class.
• Active sciatica or a recent disc problem. Some positions may aggravate nerve pain. See our guides to sciatica and slipped disc.
• Osteoporosis or a previous fragility fracture. Ask your doctor or physiotherapist which movements are suitable for you before joining a general class.
• Pregnancy. Use classes designed for pregnancy and tell the instructor how far along you are.
• Spinal stenosis. Some people find bending forwards eases symptoms and arching backwards worsens them. See lumbar spinal stenosis.

References

1. Yamato TP, Maher CG, Saragiotto BT, et al. Pilates for low back pain. Cochrane Database Syst Rev. 2015;(7):CD010265. Link
2. Fernández-Rodríguez R, Álvarez-Bueno C, Cavero-Redondo I, et al. Best exercise options for reducing pain and disability in adults with chronic low back pain: Pilates, strength, core-based, and mind-body. A network meta-analysis. J Orthop Sports Phys Ther. 2022;52(8):505-521. Link
3. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9(9):CD009790. Link
4. da Luz MA Jr, Costa LO, Fuhro FF, et al. Effectiveness of mat Pilates or equipment-based Pilates exercises in patients with chronic nonspecific low back pain: a randomized controlled trial. Phys Ther. 2014;94(5):623-631. Link
5. Cruz-Díaz D, Bergamin M, Gobbo S, Martínez-Amat A, Hita-Contreras F. Comparative effects of 12 weeks of equipment based and mat Pilates in patients with chronic low back pain on pain, function and transversus abdominis activation. A randomized controlled trial. Complement Ther Med. 2017;33:72-77. Link
6. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59). 2016, last updated 2026. Link
7. World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: WHO; 2023. Link

This guide is general information and is not a substitute for advice about your own situation. Please speak to your GP, physiotherapist or specialist before starting a new treatment.