44 Pilates background Similar to yoga, the Pilates method incorporates both phys- ical and mental elements. The technique focuses on the ‘‘power house’’ or what is known today as the core; in Pilates, this includes the abdominal, gluteal, and paraspinal muscles in particular. Pilates exercises involve progressive multi- planar excursion of the trunk and limbs. Each starts by stabilizing the core musculature and then proceeds through a controlled range of motion (see Figs. 3 and 4). The goals are to increase muscle strength and endurance as well as ﬂexi- bility and to improve posture and balance. The mental element of Pilates is evident in the additional focus on breathing and concentration during the execution of these exercises. Exercises are performed both on the mat as well as on specialized equipment. In the mat class, participants typically sit or lie supine or prone and use gravity to help stabilize the core. Of note, many of these exercises are non- weightbearing and have a strong ﬂexion bias. In addition, Mr. Pilates designed specialized apparatus to train a variety of movement patterns and postures. The Reformer, for example is made of a sliding horizontal platform within a box-like frame upon which a person sits, stands, kneels or reclines; varying resistance to movement is provided via light springs attached to the moving platform and through a simple pulley system. Other commonly used pieces of Pilates equipment include the Barrel, Cadillac, and Wunda Chair. The Pilates literature The Pilates method has been increasingly applied for its therapeutic beneﬁts, however little scientiﬁc evidence supports or rebukes its use as a treatment regimen for musculoskeletal diagnoses including LBP. While most evidence to date is testimonial or in the form of uncon- trolled case series, two randomized controlled studies exist regarding the effect of Pilates on patients with nonspeciﬁc Fig. 3 Pilates exercise—Swimming Curr Rev Musculoskelet Med (2008) 1:39–47 Fig. 4 Pilates exercise—Teaser CLBP. Donzelli et al. published a randomized controlled study in 2006 to evaluate the efﬁcacy of a Pilates method called Pilates CovaTech compared to a Back School intervention for patients with LBP [8]. The CovaTech method is a speciﬁc rehabilitation method utilized in Italy derived from the original Pilates method. Forty-three sub- jects who had nonspeciﬁc LBP for at least 3 months and were receiving treatment for this complaint were enrolled in this study. Participants were then randomly placed into one of the two groups including 21 to the Pilates CovaTech method and 22 to the Back School method. A rehabilitation therapist trained in the particular method taught a one-hour class to a group of up to seven subjects for 10 consecutive days. For the Pilates CovaTech method, the authors stated their protocol comprised several exercise modules includ- ing ‘‘postural education, search for neutral position, sitting exercises, antalgic exercises, stretching exercises, pro- prioceptivity improvement exercises, breathing education, and mobilization of the cervical rachis and the scapula– humeral joint.’’ On the other hand, their Back School protocol included ‘‘postural education exercises, respira- tory education, muscular extension and strengthening exercises of the paravertebral muscles and lower limb, mobilizing exercises for the spinal column, and antalgic postures.’’ Participants in both groups were also encour- aged to practice their respective exercises at home. Outcome measures included disability assessed using the Oswestry Low Back Pain Disability Questionnaire (OLBPDQ) and pain evaluated with the VAS. Assessments were made at baseline and then at 1, 3, and 6-month fol- low-ups. Subjective response to treatment (worse to better), adherence to home practice, level of satisfaction (dissatis- ﬁed to very satisﬁed), and beneﬁt perceived (little beneﬁt to great beneﬁt) were also assessed in both groups, however no statistical analysis was applied to these results. At baseline, demographic and clinical characteristics were similar between groups with a mean age of 50 years