Pilates guide
After a stroke, Pilates can be a way to keep working on your trunk, balance and strength once you're home. In small trials, mostly months or years after a stroke, it improved balance and some walking tests, and trunk exercises in general improve trunk control and balance.
It is an addition to the rehabilitation your stroke team gives you, never a replacement: it doesn't replace walking practice, arm and hand therapy or fitness training, and your weaker arm needs protecting.
This guide covers what the trials show, why recovery doesn't stop at six months, your trunk and balance, your weaker arm and shoulder, fatigue and blood pressure, which moves to start with and which to leave out, and a 20-minute chair and bed class.
NICE (the National Institute for Health and Care Excellence) asks for physiotherapy for weakness in the trunk, strength training and fitness training started by a physiotherapist, who can pass instructions on to an outside class. The Stroke Association lists Pilates among group classes and suggests talking to the teacher first.
Across 5 small trials (122 people), Pilates improved balance, and possibly walking and quality of life. In later trials of 20 and 30 people, Pilates added to usual therapy improved walking, standing up and balance tests.
Across 22 trials, trunk training improved trunk control, standing balance and mobility. Walking itself didn't clearly improve with core training in the largest review, so practise walking too.
People a median of 18 months after a stroke still made important gains with intensive therapy, and kept improving for 6 months afterwards. The NHS says recovery can take months or years.
Shoulder pain affects 22% to 47% of people after a stroke in studies. Support the arm, never pull it up with your other hand or let it hang, and keep weight off it unless your therapist agrees.
Face weakness, arm weakness or speech problems, even if they stop: call 999.
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NICE asks for physiotherapy for people with "weakness in their trunk or upper or lower limbs, sensory disturbance or balance difficulties that affect their movement", continued until they can keep going on their own or with help from others, including fitness instructors. It suggests strength training such as "sit-to-stand repetitions", and fitness training started by a physiotherapist, who passes on information so an outside programme is safe and suits you. It asks teams to warn people about "common, potential problems, such as shoulder pain".
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Weakness on one side, reduced feeling, balance problems, changes in attention and vision, and fatigue are all common, and each can affect how you exercise.
The muscles of your trunk keep you steady when you sit, reach and walk. Trunk training trials measure trunk control, sitting and standing balance, and getting about.
Pilates offers trunk, hip and balance work you can do lying, sitting and standing, slowly and on both sides. It doesn't replace walking practice, arm and hand rehabilitation or fitness training (our reading).
A 2023 review pooled 5 randomised trials of Pilates after a stroke (122 people). Balance, quality of life and walking all favoured Pilates. The authors judged the evidence moderate for balance and limited for quality of life, fitness and walking, and asked for longer follow-up and comparisons with other exercise.
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In 20 people, adding Pilates to standard physiotherapy 3 times a week for 3 weeks made a timed walking test 2.2 seconds faster, five sit-to-stands 1.7 seconds faster and walking speed 0.15 metres a second faster. Smaller trials found longer strides, faster walking and less sway when standing. All were small, single trials.
In 30 people, a modified Pilates for neurological rehabilitation (called Neuropilates) added to usual therapy for 3 months improved daily functioning and balance. In 24 people, trunk exercise on a reformer improved trunk control, balance and walking more than the same exercise on the floor.
In 20 people, 8 weeks of modified Pilates improved fitness on a treadmill test, and in 40 people, 12 weeks of twice-weekly Pilates improved quality of life more than therapy without exercise.
In a feasibility trial of 12 people, a weekly online class was safe, with no exercise-related problems; the main difficulty was the teacher not seeing whole bodies on screen.
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Our search found no Pilates trial that counted falls or measured shoulder pain after a stroke, and few that compared Pilates with other exercise. The review authors asked for those comparisons, and for longer follow-up.
Across 22 trials (394 people), trunk exercises such as core stability, reaching and weight shifting improved trunk control, standing balance and mobility, with large effects. The programmes added 3 to 36 hours of practice.
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Across 11 trials, adding core exercises to usual physiotherapy improved trunk control, balance on the move and walking speed, at moderate quality, but not a timed walking test.
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In the largest review (29 trials, 1,030 people), core training improved trunk function and balance but not walking. Practise walking itself, as your therapist sets out.
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In 224 people a median of 18 months after a stroke, a 3-week intensive arm programme brought clinically important gains, which "continued during the 6-month follow-up period". Nearly all the Pilates trials were also in people months or years after their stroke.
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A Cochrane review of 267 trials found physical rehabilitation likely improves function and mobility after a stroke, with long-term benefits (low certainty). The NHS says recovery can take months or years, and you should have a review at about 6 months.
When the muscles around the shoulder are weak, "the weight of the arm can pull and stretch the soft tissues", and the top of the arm bone can slip partly out of its socket (subluxation). Shoulder pain affects 22% to 47% of people after a stroke in studies, more often with more weakness, stiffness or reduced feeling.
Correct positioning and support, careful handling, and keeping the arm moving within comfort. NICE asks teams to explain how to prevent shoulder pain, and to assess pain if it happens to find the cause.
Our reading of this advice:
The Stroke Association says "Using your unaffected side too much can sometimes lead to problems with the affected side". Pilates can train your weaker side on purpose, slowly and with attention.
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Fatigue after a stroke "does not seem to get better with rest". The Stroke Association says physical activity can actually help with fatigue: start slowly, build up over time, and build in rests during and after.
Being active can lower blood pressure over time, but if yours is very high, speak to your doctor before starting, and ask your pharmacist if your medicines affect exercise. Breathe out as you work and never hold your breath or strain (our suggestion).
"Unless your doctor tells you otherwise, moving and being active is safe", the Stroke Association says, and it helps lower the risk of another stroke.
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Exercise may lower the rate of falls after a stroke (8 trials, low quality), but hasn't been shown to reduce how many people fall. Falls guidelines suggest individual balance, strength and walking exercise, with more supervision for more impairment.
You can do activities on a chair or a mat. "If you are standing, hold onto a chair back or lean against a wall."
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Our exercise after a stroke guide covers walking practice and arm and hand rehabilitation.
A Cochrane review found resistance training probably makes arm and leg muscles stronger, with little effect on walking speed and a small improvement in balance.
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Aerobic training may increase fitness, walking speed and balance, and combined aerobic and strength training gives small gains, though it's unclear how much difference they make day to day. Neither caused serious problems.
Pilates suits trunk control and balance. Keep up walking practice, the arm exercises your therapist sets, and activity that gets you a little out of breath.
Most trials used 2 or 3 sessions a week for 8 to 12 weeks.
Our editorial starting point:
Your weaker arm rests on a cushion or table. 5 to 8 breaths, 3 to 5 upper-back lifts held 3 to 5 seconds, 2 or 3 side bends each side held 10 to 20 seconds with the stronger arm, 10 slow table slides as your therapist allows, and 1 to 2 minutes of marching are the move pages' doses; 5 turns each side and 8 knee straightenings each leg are our editorial starting point.
3D demoLateral breathing (Pilates breathing)Beginner · No equipment
3D demoSeated upper-back lift (sit tall, shoulders back)Beginner · A bench or box
3D demoThoracic rotationBeginner · No equipment
3D demoSeated overhead side bendBeginner · A bench or box
3D demoTable slide (seated forward reach)Beginner · A bench or box
3D demoSeated marchBeginner · A bench or box
3D demoSeated knee extension (chair)Beginner · A bench or box + Something with weightHold the chair back with your stronger hand. Our editorial starting point, as in our home exercises after a stroke: 5 to 10 sit-to-stands, 1 minute of marching, 3 holds of 10 seconds in semi-tandem and 8 to 10 calf raises.
Weaker leg first, weaker arm on a pillow. 10 heel slides each leg, 10 slow windscreen-wiper passes and 5 to 10 knee folds or fall-outs each side are within the move pages' doses; 6 slow bridges and 8 clams each side are our editorial starting point.
The knee hover, leg pull, push-ups, planks, the bird dog and all-fours moves put weight through the weaker arm: only if your therapist agrees. Otherwise, use the sitting and lying versions.
Reach with your stronger arm. The weaker arm moves only within its pain-free range, without pulling.
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Leave out rolling like a ball, the roll-over, jack knife and teaser: they challenge balance, put your head below your heart and aren't needed for trunk control (our reading).
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Skip long plank holds, especially if your blood pressure is high, and never hold your breath or strain.
Only with a support to hold and someone nearby if your balance is poor.
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Do the 20-minute class two or three times a week, with or without the standing and bed blocks. The home exercises add walking; the seated MS workout is fully seated if you use a wheelchair.
A 20-minute Pilates class after a stroke: trunk and breathing work sitting, legs and balance at a chair, and an optional bed or mat block, weaker arm supported.
20 minBeginner17 movesA bench or box, Something with weightA gentle 20-minute routine for home after a stroke: moves on the bed, in a chair and standing at a chair, then a short walk. Do the parts your team has agreed.
20 minBeginner12 movesA bench or box, Something with weightA 25-minute chair yoga class after a stroke: seated breathing, arm and hand moves your therapist has agreed, seated twists and leg work, and optional standing poses.
25 minBeginner16 movesA bench or box, Something with weightA 25-minute workout done sitting, in a chair or wheelchair: seated cardio intervals, light strength work, posture and stretches, with pacing and cooling built in.
25 minBeginner14 movesA bench or box, A dumbbellA 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 weightThe seniors plan builds walking and strength around your Pilates, if your therapist agrees.
Call 999 if you think you're having, or have had, a stroke, or you've had signs of a stroke in the last 24 hours, even if they've stopped. The NHS uses FAST:
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Other signs include weakness or numbness down one side, blurred vision or loss of sight, difficulty speaking or finding words, confusion and memory loss, feeling dizzy or falling over, a severe headache, and feeling or being sick. Don't drive yourself to A&E (accident and emergency).
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Call 999 if:
Call 999 if someone has hit their head and has been knocked out and hasn't woken, can't stay awake, has a fit, has problems with their vision or hearing, has clear fluid from their ears or nose, or has new numbness, weakness or problems walking, balancing or speaking.
Call 999 too if someone has fallen and may have hurt their head, back, neck or hip, or can't get up. Call 111: If you've fallen and may be in pain, hurt or unwell; or you've hit your head and you take medicine that thins your blood (or have a condition that does), or you're being sick or feel dizzy. Don't drive yourself to A&E after a head injury.
You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.
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Sore muscles are common when you start a new exercise, but if it's a sharp pain or you are worried, stop and check with your fitness instructor, GP or therapist. Stop, too, for chest pain, dizziness or unusual breathlessness (our suggestion).
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Stroke Association helpline: 0303 3033 100.
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People a median of 18 months after a stroke made important gains with intensive therapy, and the NHS says recovery can take months or years.
"Sometimes people worry that being active could cause another stroke. But the opposite is true", the Stroke Association says. Check with your doctor first if your blood pressure is very high.
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Core training improved trunk control and balance but not walking in the largest review, and strength training didn't improve walking speed. Walking improves most with walking practice.
Using your unaffected side too much can cause problems with the affected side. Pilates can work your weaker side on purpose.
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The weight of a weak arm can stretch the shoulder's soft tissues; it needs support, careful handling and movement within a pain-free range.
Most stroke trials used mat Pilates; one small reformer trial helped trunk control. A chair and a bed are enough to start.
Small trials suggest so: across 5 trials of 122 people, Pilates improved balance, and later trials found faster walking and standing-up times. Use it alongside your rehabilitation and walking practice, not instead of them.
Once your stroke team has cleared you for exercise. NICE asks for fitness training to be started by a physiotherapist who can tell an outside teacher what's safe for you, so talk to the teacher before your first class.
Pilates and trunk training improve trunk control and balance. Walking improved in some small Pilates trials but not in the largest review of core training, so keep practising walking itself.
No. Nearly every Pilates trial was in people months or years after a stroke, and people a median of 18 months after a stroke still made important gains with intensive rehabilitation.
Rest it on your lap, a cushion or a table, move it only in a pain-free range your therapist has shown you, and don't pull it up, let it hang or lean on it unless your therapist agrees. Ask the teacher not to move it for you, and stop if your shoulder hurts.
Yes. Seated trunk moves, leg work and lying moves on a bed cover most of what Pilates offers, and the Stroke Association says activities can be done on a chair or a mat. Our 20-minute class has sitting, standing and bed blocks.
Gentle, regular exercise can help fatigue, but start slowly, build up and rest during and after. Stop early on tired days rather than pushing through.
Activity usually helps blood pressure over time, but if yours is very high, check with your doctor first. Breathe out as you work and never hold your breath or strain.
That's where it has most support: trunk training improved trunk control and balance across 22 trials, and adding core work to usual physiotherapy helped trunk control and balance on the move. Walking improved less, so keep up your walking practice too.
In a small trial, weekly online classes were safe; the main problem was the teacher not seeing whole bodies on screen. Set your camera so your teacher can see all of you, and keep a chair within reach.
Neither has been compared directly after a stroke. Both can be adapted to a chair; our yoga for stroke guide covers yoga.
Call 999 for face weakness, arm weakness or speech problems, even if they go away, or for chest pain or fainting. See your GP or stroke team about shoulder pain in your weaker arm, frequent falls or new stiffness.
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.
