Pilates guide
Chronic pain, also called persistent or long-term pain, is pain that lasts or keeps coming back for more than 3 months. Exercise is one of the main treatments the National Institute for Health and Care Excellence (NICE) recommends, and Pilates is one of the best-studied kinds for long-lasting back pain: in trials it eased pain and disability more than doing little. It isn't clearly better than other exercise, and for most other kinds of long-term pain there's much less research.
Pilates sits beside your other care, such as your GP, a physiotherapist or a pain service, not in place of it. This guide explains why pain can carry on when nothing is being damaged, what the trials show for back, neck and widespread pain, how much pain is OK while you exercise, how to pace yourself and get through flare-ups, and which moves to start with, with a gentle 20-minute class and 3D demos. If your pain has a name, such as fibromyalgia or arthritis, start with that guide too.
NICE says to offer a supervised group exercise programme for long-term pain with no clear cause, and names no type. Across 157 reviews of 2,736 trials, exercise eased pain by a moderate amount, and Pilates was one of the types that worked.
In a Cochrane review of 10 trials, Pilates eased back pain by about 14 points out of 100 in the short term, more than doing little. It often ranks near the top of exercise types, but it hasn't been shown to beat other exercise head to head.
For neck pain and fibromyalgia, Pilates helps about as much as other exercise. For headaches, pelvic pain and nerve pain we found one or two small studies at most.
In long-term pain, hurt doesn't necessarily mean harm. Our rule: pain no higher than about 5 out of 10, settling by the next morning. Stop or shrink any move that sends pain, pins and needles or numbness down an arm or leg.
In a trial of 296 people with back pain, Pilates twice a week beat once a week, and three times was no better than twice. People who kept to their programme did better, and the benefits of every treatment for long-term back pain were clearest in the first months.
Do a planned amount on good and bad days, and in a flare do something shorter and gentler rather than nothing. Some back pain signs need 999, and activity that is regularly followed by a delayed crash needs a GP.
NICE defines chronic pain as pain that lasts or keeps coming back for more than 3 months, and says it's also called persistent or long-term pain. Sometimes a condition explains it, such as arthritis; sometimes nothing fully does, as in fibromyalgia, which NICE calls chronic primary pain. The two can happen together.
In UK population studies, about 4 in 10 adults had chronic pain, and between 1 in 10 and 1 in 7 had pain that badly limited them.
The British Pain Society explains that in long-term pain, nerve cells in the spinal cord and brain can "learn" to keep producing pain, so "the body's warning system becomes more sensitive, producing an increased feeling of pain even though there may no longer be any continuing damage to the body". Pain researchers call this central sensitisation, and pain that comes from a sensitised system rather than ongoing damage nociplastic pain. Many people, including many with long-lasting back pain, have a mix of both.
The British Pain Society is clear that pain is never "just in the mind" or "just in the body".
"In long-term pain conditions, hurt does not mean that harm is taking place", says the British Pain Society, and a small rise in pain for a while may be worth it if it helps you get back to things you've lost. The NHS says that if you become more active gradually, it's unlikely you'll cause any damage.
In people without pain, exercise usually dampens pain for a while afterwards. In long-term pain that effect is less reliable, and pain can stay the same or even rise for a while, which is one reason people give up. Start small and use the pain rule below.
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Pilates is slow, controlled exercise for the trunk, hips and spine, done lying, side-lying, sitting or standing, with a focus on breathing. The NHS counts it as muscle-strengthening activity. For long-term pain its useful features are supported positions, small ranges you can adjust, and a set number of repetitions, which suits pacing (our reading).
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If your pain has a name, the guide for that condition has the specific moves and cautions. This page covers what they share.
Most Pilates trials are small and short, and most were in non-specific back pain, neck pain or fibromyalgia, so the size of the benefit is uncertain.
For chronic primary pain, NICE says to "Offer a supervised group exercise programme" that takes your needs and abilities into account. In its review, exercise reduced pain and improved quality of life, short and long term, whatever the type, with "no negative effects demonstrated except for more people discontinuing from exercise programmes". For low back pain, NICE says to consider group exercise that can be biomechanical, aerobic or mind-body.
An umbrella review of 157 reviews, 2,736 trials and 221,279 people found exercise eased pain by a moderate amount, with moderate certainty. Pilates was one of the types that worked, with an effect a little larger than the average in 7 reviews, and lower-intensity programmes of under 12 weeks did best. That review pooled short-term and long-term pain, so it supports exercise in general more than any one condition. An earlier Cochrane overview found mostly mild soreness as the only side effect.
In the Cochrane review of 10 trials with 510 adults, Pilates cut pain by about 14 points out of 100 in the short term (low-certainty evidence) and by about 10.5 points at 3 to 12 months (moderate certainty), against doing little. The NHS has a free 29-minute Pilates class for chronic back pain and says Pilates may help ease back pain. Our Pilates for back pain guide has the programme.
Against other exercise, the Cochrane review found no difference in disability, and its authors concluded there's "no conclusive evidence that it is superior to other forms of exercises". A 2025 review of 57 trials found Pilates, core stability and core strength training all eased back pain, with no significant difference between them.
Several network meta-analyses, which compare exercise types indirectly, rank Pilates at or near the top for back pain, and an umbrella review found 7 of them favoured motor control exercise and Pilates. The certainty was low or very low, the trials small, and the gap between Pilates and other exercise is smaller than the gap between exercising and not.
In 8 trials with 439 people with long-lasting neck pain, Pilates eased pain more than no treatment, by about 1.5 points out of 10 straight after a course (very low certainty) and 2.5 points at follow-up (moderate certainty, 2 trials). Against other exercise it did slightly less well straight after. A larger analysis found no single best type of exercise for neck pain. Our Pilates for neck pain guide has more.
Across 6 trials with 265 people, Pilates eased pain by about 0.7 points out of 10 and the impact of fibromyalgia a little, against usual care. A 2026 review of 7 newer trials (which we read as an abstract only) found no difference between Pilates and other active exercise, with very low to low certainty, and a comparison of exercise types across 50 trials ranked Pilates behind water exercise and aerobic exercise with stretching. The NHS says regular exercise has been shown to help reduce fibromyalgia pain; our Pilates for fibromyalgia guide has more.
In 11 small studies of 444 people with conditions such as knee or shoulder problems, Pilates eased pain and disability against control groups, but the certainty was very low, and whether it beats other exercise is "inconclusive".
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Two small trials from one research group looked at headaches that come from the neck: neck mobilisation by a physiotherapist mattered more than clinical Pilates alone, and adding Pilates to mobilisation eased headache intensity a little more. We found no trial of Pilates for chronic pelvic pain, complex regional pain syndrome or nerve pain.
In 63 women aged 65 or over with long-lasting back pain, mat Pilates for 45 minutes twice a week for 10 weeks eased pain and disability for up to 6 months; balance didn't change.
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Across 551 studies of treatments for long-term back pain, exercise eased pain in the short term, but no treatment's long-term effect was large enough to matter, and most of the evidence was very low certainty. Across 46 trials, people who did most of their exercise programme improved more than those who did little of it.
Only 2 of the 10 Cochrane Pilates trials looked at harms, and found only minor ones such as short-lived shoulder or knee pain. Across exercise trials for back pain, side effects were mostly muscle soreness, no serious ones were reported, and fewer than a third of trials reported harms at all.
In trials of long-lasting back pain, Pilates reduced fear of movement (kinesiophobia) more than minimal or no treatment. Across 17 exercise studies, Pilates was the commonest type tested, and exercise reduced fear of movement, with very low certainty.
In a Pilates trial for back pain, less catastrophising (expecting the worst) and less fear of movement explained between a fifth and a half of how much people improved. Our reading: part of how Pilates helps is showing you that you can move safely.
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A review of exercise for catastrophising in fibromyalgia found no clear effect from Pilates.
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In 54 people with knee osteoarthritis, 3 sessions of pain education before 8 weeks of Pilates didn't ease pain any more, but did reduce catastrophising and fear of movement more than Pilates alone. One small trial.
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Graded exposure, doing the movements you've come to fear in small steps, reduced fear of movement and catastrophising across 8 trials with 554 people; its effect on pain was inconsistent. If you avoid bending or twisting, Pilates can be a controlled way to build those movements back, ideally with a physiotherapist (our reading).
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In 145 people with long-lasting back pain, supervised mat Pilates (50 minutes twice a week for 6 weeks, in small groups) beat a home exercise programme straight after, but by margins its authors judged too small to matter, and pain didn't differ at 6 months. NICE's evidence was mostly supervised group exercise; a home routine between classes is a sensible add-on (our suggestion).
In 87 people with long-lasting back pain, an individual clinical Pilates programme from a physiotherapist did no better than general exercise from a physiotherapist. See a physiotherapist first if you have leg symptoms, recent surgery, or no progress after several weeks; our clinical Pilates guide explains what it involves.
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In 152 people with long-lasting back pain doing Pilates twice a week for 12 weeks, those taught to keep the tummy relaxed and move smoothly improved disability slightly more than those taught to tighten their core. Move smoothly and keep breathing.
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Our Pilates for back pain and reformer guides cover the trials: mat and equipment Pilates eased back pain about equally. A small, well-taught mat class is enough to start (our suggestion).
In 296 people with long-lasting back pain, Pilates for 6 weeks eased pain by about 1.2 points out of 10 at once a week, 2.3 at twice a week and 2.1 at three times a week, against an advice booklet alone. Twice a week beat once a week. One trial, in back pain.
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The trials ran sessions of 45 to 60 minutes, 2 or 3 times a week, for 6 to 12 weeks. Across 239 back pain trials, low to moderate doses helped, and modelling put the best short-term dose for pain at about 3 sessions of 30 minutes a week for 8 weeks, though the doses overlapped too much to name a single best one.
A routine you can keep for months beats a hard start you can't sustain. Benefits fade when people stop.
Our editorial starting point, matching our chronic pain and fibromyalgia guides: in weeks 1 and 2, 15 to 20 minutes of Pilates twice a week, mostly lying down, 1 set of 8 of each move, plus a few minutes of slow breathing, and 5 to 10 minutes of walking or cycling on 2 or 3 other days. Each week without a flare lasting more than a day or two, add a few repetitions or a few minutes; after a flare, go back to the last week that felt manageable. Over 2 to 3 months, build towards 2 sessions of 30 to 50 minutes a week, with the NHS's 150 minutes of moderate activity a week as a long-term goal.
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This is the rule our pain guides use, borrowed from osteoarthritis research:
The rule comes from an exercise programme for severe hip and knee osteoarthritis that counted pain of 0 to 2 out of 10 as safe and up to 5 as acceptable. In 76 people using it, median pain after sessions was 2 out of 10, 94% of sessions stayed acceptable, and nobody stopped because of joint pain. Across 7 trials in long-term musculoskeletal pain, exercise that allowed some pain gave a small short-term benefit over pain-free exercise. It hasn't been tested across all kinds of long-term pain.
Stop or shrink any move that sends pain, pins and needles or numbness down an arm or leg, and get advice. Sharp pain, a joint giving way or new swelling aren't the acceptable kind either (our reading, as on our arthritis and hypermobility guides).
The NHS's Pilates videos say to stop "if you feel any pain or become unwell". That is general safety advice for classes made for most people. With long-term pain, use the pain rule above, and stop at once for sharp, new or spreading pain, chest pain or feeling unwell (our reading).
Setting targets and breaking them "down into small and manageable steps (this is called 'pacing yourself')", says the British Pain Society, because "Carrying on physical activity to the point of unmanageable pain or exhaustion is rarely helpful". NHS pain management programmes teach pacing to avoid flare-ups.
Set the class by time or repetitions, not by how you feel on the day: the same 20 minutes on good and bad days. On a good day, stop while you could do more; on a bad day, do the first half, or just the breathing and lying-down moves (our suggestion).
A 2026 review of 9 studies with 873 people found pacing based on planned amounts gave mixed results, with very low confidence in the evidence. It's sensible expert advice more than a tested treatment.
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If activity is regularly followed, hours or days later, by a crash that is out of proportion to what you did, see a GP. That's post-exertional malaise, a feature of ME/CFS, and NICE says not to offer programmes with fixed increases in activity for ME/CFS. This guide's advice to build up gradually isn't for ME/CFS.
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NICE describes a flare-up as "a sudden, temporary worsening of symptoms", usually more intense pain, sometimes more fatigue or stiffness. Flare-ups can be unpredictable, and a cause may not be found. If a flare brings new symptoms, see your GP.
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Arthritis UK's advice is "slow and gentle movement during a flare up, rather than stopping altogether": swap long walks for short strolls, and cut the load before the number of sets. The British Pain Society says pain may increase when you first try new exercises, and to tell your physiotherapist if a flare is more than mild.
In a flare, do our flare-day set or the first block of a gentle class once or twice a day. Then rebuild over a few days from the last level that felt manageable. Flare plans are expert advice; they haven't been tested in trials (our suggestion).
Slow breathing for 2 minutes at the start of a class (our fibromyalgia class), or at least 5 minutes on its own (the move's page); lateral breathing for 5 to 8 breaths (the move's page).
From our fibromyalgia class: pelvic tilt into bridge, 8; heel slides, 8 each side; knee folds, 8 each side. Dead bug heel taps, 5 each side with your head down (our neck pain class). Start with 1 set of each.
Single-leg circles, 5 small circles each way with the other knee bent, and side kicks, 8 each side with your head on your arm (our fibromyalgia class); clamshells, 10 each side (our sports classes); bird dog one limb at a time, 5 each arm and leg (our neck pain class); swan, 5 small lifts, left out if arching pinches.
Cat-cow, 8 slow waves (the move's page); windshield wipers, 8 slow passes, and open book, 5 each side with your head on a cushion (our fibromyalgia class).
Lie still for 3 to 4 minutes at the end of a class (our fibromyalgia class), or at least 5 minutes on its own (the move's page). Sitting is fine if lying isn't comfortable.
Slow, gentle movement rather than stopping, as Arthritis UK advises: 5 to 10 slow repetitions in a comfortable range, then rest and repeat later in the day (our editorial starting point, as on our chronic pain guide).
3D demoSlow breathing (6 breaths a minute)Beginner · No equipment
3D demoLateral breathing (Pilates breathing)Beginner · No equipment
3D demoSupine heel slideBeginner · No equipment
3D demoHip windshield wipersBeginner · No equipment
3D demoKnee foldBeginner · No equipment
3D demoCorpse pose (Savasana)Beginner · No equipmentLeave out moves that put weight on your neck, such as the roll-over, jack knife, control balance and boomerang, and rest your head down in curl-ups, as our Pilates for neck pain guide says.
With osteoporosis, use head-down versions of curl-ups, swap the roll-up and roll-down for alternatives, and twist only smoothly and comfortably, as the move pages and our Pilates for osteoporosis guide say.
Work in the middle of your range and keep circles small, as the move pages and our Pilates for hypermobility guide say.
Let the direction that eases your pain guide your moves, and stop anything that spreads symptoms down your leg; our Pilates for sciatica guide has more.
Keep the swan small or leave it out, and do bird dogs instead of swimming.
Leave the teaser and other long-lever moves until the basics feel easy (our suggestion). Long-term pain doesn't mean any move is banned; it means building up to it.
Start with our paced 20-minute class: it was built for fibromyalgia, and its stop point and 1 set of 8 of each move suit most long-term pain. The back and neck pain classes suit those areas, the somatic and chair classes suit very sore or tiring days, and the flare-up routine is for bad days.
A gentle 20-minute Pilates class for fibromyalgia, built on the trial programmes: 8 of each move, a stop point for bad days, and rest to finish.
20 minBeginner13 movesNo equipmentA gentle 15-minute Pilates-based routine for ongoing low back pain, built from neutral-spine moves with options for backs that dislike bending or arching.
15 minBeginner10 movesNo equipmentA 20-minute Pilates class for neck pain: head-supported core work, upper-back and shoulder-blade strength, gentle neck movement and slow breathing.
20 minBeginner15 movesA wallA 15-minute routine of the exercises NHS physiotherapy Pilates classes send home: bridge, knee folds, leg slides, clam, side kick and side openings.
15 minBeginner10 movesNo equipmentA slow, 20-minute Pilates class with time to notice your breath and how each move feels. Every move is optional and you can pause or stop at any point.
20 minBeginner12 movesNo equipmentA 15-minute chair Pilates class done entirely sitting down, in a chair or wheelchair: breathing, spine moves, and leg and arm strength with water bottles.
15 minBeginner13 movesA bench or box, Something with weightA slow 15-minute Pilates wind-down for the last hour before bed: slow breathing, small lying moves and a few minutes of stillness, with no effort or holds.
15 minBeginner9 movesFirm cushionA 10-minute routine for a pain flare-up: slow breathing, small gentle moves lying and sitting, a short stroll if you can, then rest. Repeat later in the day.
10 minBeginner10 movesA band, A bench or boxA gentle 25-minute Pilates class for arthritis: lying, side-lying, chair and standing moves, with no kneeling or weight on your hands, and flare-day options.
25 minBeginner16 movesA bench or box, Something with weightA 20-minute Pilates class for hypermobile joints, HSD and hEDS: supported positions first, mid-range control, slow changes and steady breathing.
20 minBeginner17 movesOther / check instructions, A bandFollow the plan at a slower pace than written, repeating a week whenever you need to (our suggestion, as on our chronic pain guide).
These match our back pain and chronic pain guides. In the US, call 911 where this page says 999.
Call 999 or go to A&E: loss of feeling or numbness around the genitals or bottom, new trouble peeing or controlling your bladder or bowels, changes in genital sensation during sex or problems with erections or orgasm, or pain, tingling, weakness or numbness in both legs. These are signs of cauda equina syndrome, which needs treating in hospital urgently. Don't drive yourself.
Call 999 or go to A&E: back pain with chest pain, or back pain that started after a serious accident, such as a car crash.
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Call 999 if:
Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.
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Same day (GP or NHS 111): back pain and you feel hot, cold, shivery or generally unwell, or severe pain that starts suddenly or is getting worse quickly.
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If you are thinking about suicide or can't keep yourself safe, call 999 or go to A&E. For urgent help, call Samaritans free on 116 123, any time, or in England call 111 and select the mental health option. In the US, call or text 988.
Your GP first. In many areas you can refer yourself to NHS physiotherapy without seeing a GP. A GP can refer you to a pain clinic or a pain management programme, which teach pacing among other things.
The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.
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In long-term pain, hurt doesn't necessarily mean harm, and long rest brings stiffness and weakness of its own. NICE recommends exercise because it eased pain and improved quality of life.
Some pain during exercise is expected and usually settles. Keep to about 5 out of 10, back to your usual by the next morning. Sharp, new or spreading pain is different: stop and get advice.
It ranks highly for back pain at low certainty, but it hasn't beaten other exercise head to head, in back pain or fibromyalgia. The best exercise is the one you'll keep doing.
In 152 people with back pain, a relaxed tummy did slightly better for disability than a braced one.
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Pilates, core stability and core strength training gave similar results for back pain, and much of Pilates' effect came through less fear and catastrophising. Long-term pain is about a sensitive warning system as much as muscles.
Clinical Pilates from a physiotherapist did no better than general exercise, and supervised Pilates beat home exercise only by small margins. A well-taught mat class or a home routine is fine; see a physiotherapist first for leg symptoms, recent surgery or no progress.
Expect modest, steady gains that need keeping up. NICE asks doctors to explain that "there can be improvements in quality of life even if the pain remains unchanged".
NICE says a reason for the pain may not be found, and still recommends exercise for chronic primary pain. Get the warning signs checked first.
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It can be, especially for long-lasting low back pain, where trials show it eases pain and disability more than doing little. For neck pain and fibromyalgia it helps about as much as other exercise, and for other kinds of long-term pain there's very little research. NICE recommends exercise for chronic pain without naming a type, so Pilates is one good option.
Not clearly. It often ranks near the top for back pain in studies that compare exercise types indirectly, but with low certainty, and head-to-head trials find it about as good as other exercise. Choose what you enjoy and can keep doing.
In long-term pain the nervous system can become more sensitive, so new movements can hurt without causing damage, and exercise eases pain less reliably than it does in people without pain. Start smaller, keep to about 5 out of 10, settling by the next morning, and build up slowly.
Twice a week is the best-tested dose: in back pain, twice a week beat once a week, and three times was no better. Give it at least 6 weeks. Start with 15 to 20 minutes (our suggestion) and add walking or cycling on other days.
Some pain is fine if it stays at about 5 out of 10 or less and settles by the next morning; if it doesn't, do less next time rather than stopping. Stop and get advice for sharp pain, a joint giving way, or pain, pins and needles or numbness travelling down an arm or leg.
Keep moving gently rather than stopping: a shorter, easier session, or our flare-day moves once or twice a day. Then build back up from the last level that felt manageable. See a GP if a flare brings new symptoms.
It can be, but it isn't necessary. Mat and equipment Pilates eased back pain about equally, and clinical Pilates from a physiotherapist did no better than general exercise. A small beginner class, mat or reformer, is a sensible start.
Yes: in the Cochrane review, Pilates eased pain by about 14 points out of 100 in the short term and about 10 at 3 to 12 months, more than doing little. The NHS has a free Pilates class for chronic back pain, and our Pilates for back pain guide has the full programme.
There's no need. In a trial of 152 people with back pain, those taught to keep the tummy relaxed did slightly better than those taught to tense it. Move smoothly and keep breathing.
We found no trials of Pilates for nerve pain in general. For sciatica, let the direction that eases you guide your moves and stop anything that spreads pain down your leg; our Pilates for sciatica guide covers it. Numbness around the genitals or bottom, bladder or bowel changes, or weakness in both legs needs 999.
This guide's advice to build up gradually isn't for ME/CFS. If activity is regularly followed, hours or days later, by a crash out of proportion to what you did, see a GP. NICE advises against exercise programmes with fixed increases for ME/CFS.
Look for a small beginner or gentle class, or ask your GP or physiotherapist about clinical Pilates or a local exercise programme. Tell the teacher about your pain and ask for easier versions. Any good class should let you work at your own pace.
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.
