
- About Clinical Pilates
- Our Approach
- Testimonials
- Safety
- Stages of rehabilitation
- Health Fund Rebates
- Info for Therapists
- How to book

"Amazing results"
"Please allow me to recommend Raphael and the Breathe team. Raph has demonstrated amazing results with many patients we have
referred. The patients have immediate improvements of their overall posture, a reduction in pain of the lower back and neck and
general improvements of their wellbeing."
Dr. Shady Botros, Chiropractor |
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"After 10 sessions you will feel better. After 20 sessions you will look better. After 30 sessions you will have a completely new body."
~ Joseph H. Pilates |
About Clinical Pilates
Clinical Pilates is modified Pilates for rehabilitation. At Breathe, we specialise in helping people living or working in Melbourne city CBD, with spinal injuries and conditions including disc bulge, disc herniation, disc prolapse, spondylolisthesis, stenosis, scoliosis, osteoarthritis, vertebral end-plate fractures and pelvic fractures. If you suffer from back, shoulder or neck pain, Breathe Clinical Pilates can help you reduce your pain and increase your ability to function effectively and comfortably. We can help you get back to doing the things you want to do, whether that be sports, running, gardening, riding or just putting on your shoes without pain.
Through Clinical Pilates rehabilitation we will help you learn to move more fluidly and safely, with less strain, less pain and more strength. We'll teach you how to correctly strengthen your core, whilst keeping you safe. We'll help you to improve your flexibility and balance, so that your body works the way it is meant to; easily and well.
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"After 6 weeks ... I can honestly say that I have NO back pain"
"I'm 40 years old, I've played sport at a national level and for long periods of my life I've exercised in excess of 20 hours a week.
Over the last few years I've started experiencing lower back pain, first periodically and for the last year quite consistently... >>>more |

"After my third session I literally danced back home."
"My partner Tim could not believe how energized I was. We both are ecstatic that for the first time in months I had no pain at all. My pain level was 0.
Thank you Raph and Breathe – you have literally made a huge difference in my life and your proof is in the smile on my face and in my neutral spine! I look forward to increasing that core strength and getting back to my early morning run with my training group!"
Rachael Jamieson, 40, Recruitment >>>more |


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The Breathe Approach to rehabilitating spinal injuries
At our Melbourne CBD studio, we use a 3-fold strategy for spinal injury rehabilitation with Clinical Pilates. We will work with you to improve your posture, teach you self muscle-release techniques and develop a program of core strengthening, stability exercises to effectively support your back.
1. Postural improvement
Your posture has a dramatic and profound effect on how your spine is loaded. Spinal injuries almost always benefit from postural fine-tuning, and we'll teach you how to stand and sit with ideal posture, so stress on your injury is minimised. One aspect of ideal posture is correct activation of your postural muscles, and we'll help you with this also, to help you to stand, sit and move in a manner that supports your injury, and spreads load through your system in a balanced, supported and controlled way.
2. Self muscle-release techniques
Living in constant pain, or even constant fear of pain, is not fun! We'll teach you self muscle-release techniques including stretching, Trigger Point release, breathing techniques and visualisation to give you the skills to reduce tenstion and dissolve your pain yourself. Learn to "nip your pain in the bud" and avoid the upward spiral of tension and discomfort. Balance your system by releasing tight areas.
3. Improving motor activation patterns and core strengthening
One thing that is very common with spinal injuries, is poor muscle activation patterns (aka motor activation patterns). When your motor activation is not ideal, your muscles don't switch on in the right sequence, or in the right proportion; so you may have some muscles over-active, and others not active enough, and thus imbalance and increased strain to your system.
We'll design a program of exercises specifically for you to improve your motor activation patterns (You'll learn to use the most effective combination of muscles to perform a given movement, especially the movements that have been causing you pain and aggravation). We'll help you safely strengthen your core and all your stabiliser muscles, and make sure your muscular system is in balance, giving you even support through your spine throughout each movement, and as you sit and stand.
Movements that commonly cause aggravation for people with lower back injuries include:
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Getting out of bed
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Putting on shoes, socks or pantyhose
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Standing or sitting for long periods
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Driving, and getting in and out of the car
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Gardening
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Running
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Cycling
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Sneezing
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Picking even very light things up off the floor
Through improved posture and correct motor activation, we can show you have to do the specific things that are causing you pain, in such a way that there is minimal load on your spine, so you'll feel more comfortable again. We will give you practical, simple and precisely targeted exercises to improve the way your body works, and allow your injury to heal, so you can live like a normal person again! For therapists, and those with a technical bent, you can look over our Clinical Pilates rehabilitation guidelines.
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Testimonials for Breathe Clinical Pilates
"For the first time in months I have no pain at all"
"I first visited Breathe in March 2008 after 20 years of intermittent sciatic lower back pain which was getting progressively worse. It was going to be my last attempt at being pain free. I had tried cortisone injections, chiropractic treatment and remedial massage over the years and whilst they gave me relief for short periods of time, it was reactive not preventative treatment. No one could tell me what was causing the pain, or recommended getting an MRI.
Two years ago I invested in a Personal Trainer who was instrumental in getting me fit and even with periods of back trouble (a pain where it felt like someone was pulling a string in my lower back which shot pain down my left leg and made it numb) I was determined to continue doing the things I enjoyed in life. I began seeing an Osteopath who was also brilliant in making sure I was still able to achieve my goals. I ran a half marathon and completed a mini triathlon until the pain increased to a level that was debilitating and was making an impact to my concentration at work, stopping me from sitting for long periods or training as hard as I wanted to, affecting my sleeping and making me feel like my body was giving up on me.
I was frustrated and so tired of being in pain and having it affect what I wanted to do. I also felt like I was paying off a ‘body mortgage’ with the amount of money that I was spending on short term fixes. I decided to find out for good what was causing all the pain so I had an MRI and was told that I had disc herniation in my L4/5 and L5/S1 discs. I was finally relieved that there was actually something wrong and I wasn’t just making it up.
I was advised to stop running (one of my favourite things to do and the only thing to keep my weight off) and to stop any high impact activity. I was not happy to say the least and with the fantastic support of my osteopath, trainer and my partner, I investigated new options. Through this, I found Breathe.
By this time my pain level was on average a daily 7 out of 10. I had forgotten what it was like to not be experiencing pain and discomfort. At my first session Raph gave me the best news I had heard for a long time – that I would be pain free in 2 months and be able to start running again. A big call I thought but I was prepared to give him the benefit of my doubt! With the use of a fabulous little tennis ball and an explanation of what my spine was actually doing I was sent off to do ‘homework’ for a few days. Being able to ‘self medicate’ with the use of a tennis ball was a revelation and it has become an invaluable friend. I now have multiples of this little yellow ball in my handbag, at work, at home and at my partners!
After my second 1:1 session, my pain level had decreased to a 2-3 out of 10 but the best part was being able to get back to more training, sleep better and get out of bed without it taking 10 minutes! Raph has been re-training me how to sit, stand, bend down, get in and out of a car and bed and increase my inner core strength. Through all of this, he has explained in great detail how each exercise was helping me and has taught me to be incredibly picky about how I was performing each one.
After my third session I literally danced back home. My partner Tim could not believe how energized I was. We both are ecstatic that for the first time in months I had no pain at all. My pain level was 0.
So whilst I am still experiencing some very occasional twinges when I sit for long periods of time, I pull out my little yellow ball and spend 10 minutes doing my exercises and I am once again at pain 0. I am a much happier, less stressed and emotional person at work, at home and at training.
Thank you Raph and Breathe – you have literally made a huge difference in my life and your proof is in the smile on my face and in my neutral spine! I look forward to increasing that core strength and getting back to my early morning run with my training group!"
Rachael Jamieson, 40, Recruitment
"I am forever grateful for the confidence and motivation"
"It is with great pleasure that I provide this testimonial to Raphael and the team at Breathe.
All the testimonials I’ve ever read about Pilates rave about how much benefit can be achieved in terms of pain relief and posture. Pilates has certainly helped me with that, but the biggest thing I am forever grateful for is the confidence and motivation Raph has provided me.
I used to be a philanthropist donating to gyms but not actually attending any of them, honestly two years ago I paid $1200.00 for a gym membership that I never used for a single day. I was so ashamed of how much I let myself go I couldn’t bring myself to get out of the house some days let alone get into gym clothes. I was unmotivated, unfit and just plain unhappy.
Breathe’s beautiful atmosphere and wonderful staff create a healing experience with positiveness, kindness and guidance. Through their warmth and encouragement I’m not only attending the addictive reformer Pilates classes but I’m also living a much healthier and happier life. I whole heartedly recommend Raph and the team at Breathe to anyone and everyone.
I’m not at my perfect weight or fitness yet but at least the journey has begun. And it’s a journey that I’m enjoying and smiling every step of the way (well except for the star preps).I feel truly blessed to have found Breathe."
Risharda Robertson, Team Leader Audits – 26 years old
"I have made more progress in the last few weeks that in the previous 3 years"
"After 3 pretty ordinary years of lower back pain, and a string of people who haven’t made any difference I have finally made more progress in the last few weeks that in the previous 3 years.
I am starting to feel stronger in the core which is translating to every part of my body and especially my outlook on life.
Thanks"
Brad Dunk, 40, Business owner
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"Pilates is the best thing I have done in a long time, it helps me feel a lot better both physically and mentally"
"Getting towards retirement age, this is the time where Body Maintenance is becoming very important. I used to go to a Gym but I wasnt getting much out of it any more. Then Breathe message appeared in my Inbox at work and Yes, I had been looking for something like this, so why not and here I am, six months later and going stronger. The first three months, I didnt notice anything major apart from standing taller and straighter; being tall, even as a child I couldnt do that.......
Suddenly, after Xmas, I suddenly noticed that my energy level was higher - I was even willing to do housework (my pet hate!!!) and stay in a good mood while doing it.
Then I realised that my thought process was getting clearer. In the last few years, because of getting older and having been diagnosed with epilepsy and treated for it, it felt that my brain was always in a fog - this has disappeared to more or less what it was before all this happened. My theory is that Pilates has helped the blood circulation in my brain cells and the result is obvious to me.
My aim was to help with muscle toning, balance and coordination and things are starting to happen there. Various parts of my body are getting shapely again.... upper arms, buttocks, my calfs have got muscle definition again.... and my stomach muscles are starting to get some strength, for the first time in a very long time.
When I am stressed the stress goes to my neck and my shoulders. Plus, I have a bit of a bump in my back and with stress, it gets painful too. As I am standing taller and straighter, this bump is starting to disappear too... I used to have a remedial massage every 2 weeks. The first three months of Pilates, my massage therapist was not available. I thought I wouldnt be able to cope without my fortnightly masssages. Well, I only had one massage during that time. Now that she is back, I still have massages but it is more for relaxation and for a good chat.
As a whole, Pilates is the best thing I have done in a long time, it helps me feel a lot better both physically and mentally.
I had a pretty stressful time at work a few weeks back with employment insecurity - Pilates relaxed me and helped me coping with the situation and looking at it more calmly. My Mondays will never be the same again without my Small Group class - it has become an addiction.
I found that Pilates is helping me accepting getting older and helping with the aging process - it is a fantastic maintenance programme. I recommend it to all Baby Boomers.
And a very important fact is that the staff are ever so nice and helpfull. Thanks to all of you for sorting out the problems with my sessions when I didnt know if I was going away for work or not. I am very gratefull for this. Thanks to Raphael for helping finding a solution to my sugar levels when exercising (merci, mon ami) and to Anne for helping me when I had forgotten my sport drink and a nice cup of sweet tea was needed to make me feel better within a couple of minutes to go back to the class straight away."
Yolaine Dugue - A Baby Boomer from North Melbourne - IT - Business Analyst
"I no longer walk around with Nurofen in my handbag."
"In February 2007 I suffered a severe herniation of my L5/S1 disc. After my injury, pain became every part of my day and I thought I would just have to learn to get used to it. By the end of each day I was in so much pain I could barely sit in my chair, and getting in the car after work was the worst moment of every day. I couldn’t even change the sheets on the bed; couldn’t even sit on the sofa to watch TV. I was really starting to get depressed about it.
I saw all kinds of therapists and doctors. I ended up having an MRI and then seeing a surgeon who recommended me having lower branch block injections and a few other needles into my spine. In all I had 4 trips to day surgery to try and improve my pain, however with little success. The surgeon was great and the last injection of cortisone was helpful but wasn’t a long-term solution. I refused spinal surgery, as I am only 30.
It was then that I started Breathe Pilates! Wow! Who would believe that in my first one-on-one session with Raph I would feel such improvement?
Now, after 2 months at Breathe, I no longer walk around with Nurophen in my handbag. I have a tennis ball instead (you’ll need to ask Raph about that one!!). I can bend over and pick things up without pain, I can sit at my desk for longer, and driving isn’t so bad anymore. I can do housework, which of course makes me more popular at home; I am not so stressed and sore by the end of the day. Even on a bad day at least now I have the techniques to be able to make myself feel better.
The exciting thing is knowing that one day in the future when I have kids, my back will be strong enough to support me. Thanks to the great team of people at Breathe, who are helping me achieve this goal!"
Katrina Meek, 30, Balaclava, Hotel General Manager
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"I look forward to coming here everyday!"
"Together you’ve created a phenomenal space. Synchronicity. I look forward to coming here everyday (if I can!) as do many of your other Breathers. If your ‘philosophy’ (objective) was to create a space where people fell welcome, appreciated & wanted, you’ve succeeded.
Thank you for creating a space that brings space, calmness, peace & harmony"
Sarah Allen, Recruiing Consultant
"I feel great, no sore backs and no headaches."
"After years of a bad back, regular monthly visits to the Osteopath and constant back pain to the point of headaches and feeling like my spine was grinding on itself, I decided, based on a recommendation, to try Pilates.
Initially hesitant about whether Pilates was for "guys" I took some one-on-one classes with Raphael, who soon put me at ease and started me on a program of exercises. After six of these sessions I was starting to feel better and had only been to the Osteopath once in six weeks. I then progressed to small group classes before quickly moving to regular classes two - three times a week.
I have been doing Pilates for seven months now and I feel great, no sore backs and no headaches. With the added benefit of being fitter and stronger, and feeling really alive after each class, my energy levels have lifted and my concentration levels are much higher, plus I haven't seen my Osteo for six months now!
I can't recommend Breathe highly enough, the team are great, the classes are fun & the instructors know everyone and are always giving out tips to help you improve"
Adam Coddington, 38, Project Manager
"After 6 weeks ... I can honestly say that I have NO back pain"
"I'm 40 years old, I've played sport at a national level and for long periods of my life I've exercised in excess of 20 hours a week.
Over the last few years I've started experiencing lower back pain, first periodically and for the last year quite consistently.
My pain has been tolerable but intrusive. Its' been there as background hum (always) but occasionally has peaked for short periods
where I have no choice but to sit down and wait for it to clear. Ongoing treatment with an osteopath has brought short-term relief
but this never lasts more than a week beyond the consultation.
Breathe came recommended and despite my scepticism that Pilates could meet all my needs, this fabulous studio has done so and
more. Just walk into the place and you'll get a sense of warmth and calm focus. The great thing is it's not window dressing; it doesn't
evaporate once you sign up but is consistently carried through every part of the business.
From day one every member of the team has been friendly, inviting and genuinely interested in helping me. The teachers are the
best I've met. The first session to help me set up my program was a thorough review of my structure, posture, history and needs.
It wasn't just a generic response either; it was very specific advice on how I could personally approach my goals.
I decided to really commit to the program and after 6 weeks of 5 sessions a week, I can honestly say I have NO back pain. It is
completely gone. I feel as fit as ever despite cutting down quite a bit on my running. The great thing is, the core strength I've
gained and the principles I've learnt from the team at Breathe have helped my running massively. I'm running quicker and smoother
than I have in years. The weird thing is the Pilates sessions never seem that tiring while I'm doing them but the results I've been
getting belie this.
I thoroughly recommend the team at Breathe...what more could you ask for?"
Mike Wilkinson, 40, CEO
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"Amazing results"
"Please allow me to recommend Raphael and the Breathe team. Raph has demonstrated amazing results with many patients we have
referred. The patients have immediate improvements of their overall posture, a reduction in pain of the lower back and neck and
general improvements of their wellbeing."
Dr. Shady Botros, Chiropractor
"The headaches, neck & shoulder pain and abdominal pains have all but completely vanished"
"Raphael, actually, after my few visits with you, I'm now doing so well it's almost embarrassing! I fear now I may be making others sick with my positively cheery disposition (just kidding). And I feel empowered, because now I can be TRULY responsible for my own good health and wellbeing. Actually, with Trigger Point Therapy I almost feel like my own practitioner... well, I suppose, who better to heal me than me????
Since coming to see you I have 'cured' an 8cm cyst on my left ovary (and I have the before and after ultrasound photos and accompanying sonographer’s letters to prove it) and my Ulcerative Colitis appears to be in complete remission. Furthermore, the headaches, neck & shoulder pain and abdominal pains have all but completely vanished and my energy levels have SIGNIFICANTLY increased. I no longer feel permanently lethargic, malaised and totally incapable of even the smallest tasks.
Mentally and emotionally this has all had a wonderful effect on me. Depression is a thing of the past. I now feel 'open' and loving, balanced and safe. I also feel.... stable and well grounded. So, the emotional roller coaster ride has finally finished. All this has had a wonderful effect on my relationship, and Nick and I are experiencing new levels of love that we have not achieved before. Throughout this process - individually, and together, we have grown. This has been a wonderful time of shedding, releasing, embracing, accepting.... and loving, of course!
So, thank you VERY much!!! I still have one pre-paid session unused, but I'm saving it until I feel I really need it (which may be never).... so your not having seen me is actually a good thing. Since coming to you my whole approach to pain has undergone a radical shift and each day I grow 'closer to' myself.
Pain now no longer frightens the living daylights out of me and makes me worry that I may have some sort of serious mysterious chronic terminal untreatable illness. I am more 'in-tune' with my physical body and what it is trying to tell me... I really listen and actively try to decipher the messages it's sending me. (.... And sometimes these messages have nothing to do with the physical body at all). I then objectively acknowledge the pain and thank it for drawing my awareness to an area that needed attention. Through Trigger Point Therapy I then release the pain with love and acceptance using the principles that you have taught me.
It is with great pleasure that I write this testimonial for you. It is one small thing that I give you in return for the very great thing that you have given me... an understanding of how my body works and a practical method for healing it.
Take care, and thank you."
Sebastiana (Nella) Santisi, Mount Waverley Victoria, 27 August 2007
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"It's a fantastic feeling to notice my strength and flexibility increasing with every class"
"After a yoga session at Breathe, I feel energised, calm and centred. It's a fantastic feeling to notice my strength and flexibility increasing with every class.
As well as being highly skilled, all of the instructors bring a warm and sincere energy to each class. It's also a unique and lovely space to practice in. In essence, the sense of wellbeing that I take away from each class makes the time that I devote to it extremely worthwile."
Daphena Renton, 32, Melbourne City
"My Pilates classes are a highlight of my day"
"After living with chronic lower back pain for almost a year, I was introduced to Breathe by a friend. I was made to feel extremely welcome and the improvements in my back began almost immediately. After around two months of classes I am feeling stronger, healthier and the pain in my back has reduced dramatically. More than just a part of my routine, my Pilates classes are a highlight of my day and week. Not only have they become an integral part of my pain/discomfort management, without the use of drugs or creams, but they force me to slow down and take 45 minutes out of day and decompress, refresh and do something for myself. Afterwards, not only do I feel physically stimulated, but mentally refreshed as a great bonus."
Isabelle Oderberg, 28,
News Editor
"I leave every class feeling stronger - physically and mentally"
"After suffering lower back pain for a few years I had developed a fear of exercising as it more than often caused more back issues. My osteopath recommended Raphael at Breathe and since then I haven't looked back. After six months of classes and slowly building up my strength its hard to remember how far we have come. Now I feel fit, walk taller and I am getting that new toned body. Raphael and the team at Breathe are a wonderful in support - they really encouraged me.
Most importantly, I leave every class feeling stronger - physically and mentally. Do your body & mind a favour and give it a try. You won't look back! And if you are anything like me...it may result in that extra confidence encouraging you to make changes to your life. Positive changes."
Nadine Parkington, 36, Advertising
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"My pain is reduced ...the tension and tightness has almost reduced entirely"
"2 years ago I suffered a fractured pelvis in three places and deep tissue injury to my back, following a serious car accident. I spent
4 months on crutches and suffered memory loss. Coming back from my injury I felt nervous; I'd lost a lot of strength and was
fearful of aggravating my injuries or jarring anything. I did things quite gingerly and was guarded and protective of my body.
Within my first session at Breathe I started feeling more aware of my body, after attending Breathe for 6 weeks my pain is reduced
and my lower back is so much better; the tension and tightness has almost reduced entirely. I can accurately identify what is real
pain versus nervousness or tension.
The fear of being restricted by my injury is slowly going as well; I've signed up to do a fun run with some friends from work. I feel
like I will actually get back up to my previous capabilities, where I used to feel that my full fitness would never return.
One of the best things is that I genuinely look forward to the exercises. Even after a long day at the office, even in winter and on a
cold night. The Breathe studios are calming, welcoming and not intimidating. I get a tailored, specific routine making the exercise
rewarding and so beneficial. I can feel my confidence growing. I leave feeling better every time.
For me, the personal focus has been so much a part of embracing a whole new approach to my health, my weight and my fitness.
I'm now in a position to complete the healing and get my body back. I'd recommend Breathe to anyone.
PS: Thanks Raph and the Breathe Team, see what a difference you are making to me!"
Alison Hurburt-Burns, 25, Marketing & Business Development Manager
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"I've only been completely pain free since I took up Pilates"
"A back injury I received as an adolescent has ensured that exercise has always been an important component of my life. I have tried
numerous forms of exercise including boxing, cardio, aerobics, fit ball classes and weights but I've only been completely pain free
since I took up Pilates a couple of years ago. Pilates has strengthened my core, giving my back the support it needs and has also
increased my body awareness resulting in improved posture.
Breathe is different from the other Yoga and Pilates classes I've tried (and over the years I've tried a few).
At Breathe members are treated with friendly courtesy and respect. The teachers are always willing to find one-on-one time to help
sort out any little niggles. I find that regular classes at Breathe give me the time I need to focus on my own needs, and most particularly
give me a reason to leave the office during lunchtime or after work.
I find myself coming up with excuses for going to class, and that I leave each session feeling relaxed, calm and ready to tackle any
challenge.
Breathe has helped me balance and better understand my personal priorities and both my personal relationships and work performance
has improved as a direct result. Even better, the free organic fruit has helped improve my diet!"
Melissa Jordon, 31, Analyst
"Breathe has ...given me movement where previously I had minimal"
"I had practised Pilates at another studio for over a year and was keen to put the team at Breathe through their paces. I was in, what
I thought, full physical health when I arrived, however, within minutes of my first one-on-one assessment, my Breathe teacher had
isolated (to the vertabrae) the cause of my past nerve problems in my hands which my GP had not been able to gain insight into
except "it's stemming from your neck". I have had the issue for the past 2 years. Explanation of the cause and exercises to release the muscles in my neck has given me the movement where I previously had minimal.
Since joining Breathe, I've become more aware of my technique and have become more effective and efficient in my Pilates practice.
Even if I have done the exercises over a hundred times before, I learn something new in every class I attend and can not only feel, but
also see the improvement in my postural alignment and strength. The teachers have been great in helping me re-train and regain
pelvic stability within weeks of an osteopathic assessment and have also given me helpful exercises to do at home to release tension
in my muscles in-between classes. I have learned to Breathe in all aspects of my life - Balance, Restore, Energise, Achieve, Teach, Health,
Equilibrium.
My previous Pilates teacher's departing words of wisdom were, "You know enough about Pilates now to determine if an teacher
is good or not." I know I have found a fabulous teacher (or three) at Breathe."
Tina-Louise Low, 31, Management Consultant
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Safety
When you have a spinal injury, you need to strengthen your core and increase your ability to stabilise the injured joint(s). To do this you need to exercise the muscles that are responsible for stabilising your injured area. In doing this, you need to be extremely careful not to overstrain or damage your already injured and thus weakened system. There is a fine line to traverse between improvement and overdoing things. For this reason it's critical to begin with a diagnosis from a specialist such as a phsyiotherapist, osteopath, chiropractor or orthopaedic surgeon, preferably from an MRI or CT scan.
It's important to use the right exercises for your particular body, and your particular injury. We'll consult with your diagnosing specialist to develop a program of exercises that will safely strengthen your body whilst minimising compression and shearing loads on your spine. You'll have strong abs, alright, but not a sit up in sight! |

"I have made more progress in the last few weeks that in the previous 3 years"
"After 3 pretty ordinary years of lower back pain, and a string of people who haven’t made any difference I have finally made more progress in the last few weeks that in the previous 3 years.
I am starting to feel stronger in the core which is translating to every part of my body and especially my outlook on life.
Thanks"
Brad Dunk, 40, Business owner |

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Stages of Rehabilitation for back injuries
This is a general guide to what you can expect when you're rehabilitating from a back injury. Specifics may vary for each individual. Talk with your Clinical Pilates instructor for a more accurate idea of you individual progression.
Stage 1: Reducing pain and improving stability for everyday tasks.
(Average 5-7 Individual sessions)
We'll assess your posture, your symptoms and your medical history, and consult with your diagnosing physiotherapist, osteopath, chiroprator or orthopaedic surgeon to develop a program that will get you results, safely and quickly.
Working with the 3-fold approach outlined above, you'll learn how to reduce your own pain quickly and safely with targeted micro-stretches, trigger-point self-release, visualisation and breathing exercises. You'll begin to improve your posture, so that your structure is supported more effectively and easily, thus reducing the strain on your injury. You'll begin to safely strengthen your core and stabilise your spine with an individualised, tailored program of exercises targeted to your specific needs. We'll train you to be extremely precise with your technique, and to know exactly where your limits are. Your sessions will be fun, focussed and frank. Ask us why you'll even enjoy doing your homework!
By the end of Stage 1 of the Breathe Clinical Pilates program most people are able to do their everyday activities, such as cooking, walking, sitting, gardening etc pain-free.
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Stage 2: Increasing strength, stability and resilience to allow healing.
( Average 12-15 weekly Studio Pilates sessions)
During Stage 2 of the Breathe Clinical Pilates program, you'll transition from individual sessions to a small group Studio Pilates class, sharing your instructor with up to 3 other people. You'll continue to work on you individualised program of tailored exercises, as you gradually consolidate and increase your early gains, avoiding aggravation and allowing your underlying injury to continue to heal.
During Stage 2 you'll notice your resilience increase, so that you'll be able to tolerate longer periods of sitting, gardening etc, and you'll notice that you're starting to feel stronger and more stable. We'll also begin to work towards any specific goal you may have such as returning to cycling, running, skiing etc.
By the end of Stage 2 of the Breathe Clinical Pilates program you can expect to be ready to begin gradually reintegrating things like running, cycling, bushwalking, salsa dancing etc back into your life.
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Stage 3: Toning & flexibility for ongoing health and wellbeing
(Ongoing weekly Studio Pilates supplemented by group Mat & Reformer Pilates classes)
After completing Stage 2 you'll be ready to start working towards your non-injury related goals, like toning your abs, getting back into martial arts, taking up sky-diving, trekking the himalayas or whatever you're working towards. We'll help you ensure you do these things happily, healthily and pain-free by checking in with you during your weekly Studio Pilates session, and tailoring your strengthening and flexibility exercises to meet your goals. You can safely use the group Mat Pilates and Reformer Pilates classes to fast-track your progress at this stage.
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"I no longer walk around with Nurofen in my handbag."
"In February 2007 I suffered a severe herniation of my L5/S1 disc. After my injury, pain became every part of my day and I thought I would just have to learn to get used to it. By the end of each day I was in so much pain I could barely sit in my chair, and getting in the car after work was the worst moment of every day. I couldn’t even change the sheets on the bed; couldn’t even sit on the sofa to watch TV. I was really starting to get depressed about it.
Who would believe that in my first one-on-one session with Raph I would feel such improvement?
Now, after 2 months at Breathe, I no longer walk around with Nurofen in my handbag. I have a tennis ball instead (you’ll need to ask Raph about that one!!). I can bend over and pick things up without pain, I can sit at my desk for longer, and driving isn’t so bad anymore. I can do housework, which of course makes me more popular at home; I am not so stressed and sore by the end of the day. Even on a bad day at least now I have the techniques to be able to make myself feel better."
Katrina Meek, 30, Balaclava, Hotel General Manager >>>more |
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Health Fund Rebates for Clinical Pilates
Health fund rebates may be applicable for individual Clinical Pilates sessions. Health funds which currently offer a rebate for Pilates include:
- MBF
- Medibank Private
- Australian Unity
- AHM (Australian Health Management)
- Australian Teachers Federation Health
- SGIO
- NRMA
- GU Health
Your health fund may require that you have a referral from a Health professional such as a GP, physiotherapist, chriopractor, osteopath or orhopaedic surgeon.
If you plan to claim a rebate for your Clinical Pilates sessions at Breathe from your private health fund, please let us know when you book your sessions so that we can give you an appropriate receipt. |
Rehabilitating Spinal Injuries with Clinical Pilates
A Guide for Clinical Pilates practitioners and rehabilitation professionals
By Raphael Bender
STOTT PILATES level 2 certified instructor
APMA Level 3 certified instructor
Click here to listen to Raphael discussing this clinical approach with musculoskeletal physiotherapist Antony Lo.
This is the method that I use successfully in my everyday work with spine-injured and unstable clients at Breathe Yoga & Pilates in Melbourne city CBD. I work with clients suffereing from a variety of injuries and spinal dysfunctions including disc bulge, disc herniation, disc prolapse, spondolisthesis, stenosis, sacroiliac strains, pelvic fractures, vertebral end-plate fractures and scoliosis. I hope you find it useful in your work with clients, and in your own practice. If you have questions or comments I'd love to hear from you; please feel free to email me
Background to this approach
This is an evidence-based approach to lumbar spinal rehabilitation, using various traditional Pilates techniques as well as other techniques drawn from various sources including Kit Laughlin’s “Posture and Flexibility” approach to stretching and pain relief; the work of Travell and Simons on Trigger Points, and Clair Davies’ excellent follow up. Probably the biggest influence to my understanding of lumbar spine anatomy, biomechanics and pathology has been from Dr. Stuart McGill, (Professor of Spinal Biomechanics at the University of Waterloo, Canada) through his seminal works “Lumbar Spine Pathology; Evidence Based Prevention and Rehabilitation” and “Ultimate Back Fitness and Performance”. I've also been influenced by the work of my friend Antony Lo, who is a leading Sydney-based physiotherapist, specialising in pelvic and spinal dysfunction. There are doubtless other influences to come, as this document, I suspect, will always be a work in progress, and I welcome any feedback you as a reader would care to contribute.
All techniques have been chosen purely based on their scientifically proven efficacy, regardless of their origin. The approach, techniques and guidelines presented here have all been tested by randomised, controlled studies and are the most effective currently known treatment for clients with lumbar spine pathology. References are at the end of this document.
Goals of rehabilitation
The goals of rehab are to decrease or eliminate pain, and to increase function. In this context, to increase function means to increase the client’s ability to perform their daily tasks easily, efficiently and pain-free. (Note that the goal of increasing function is distinct from the goal of increasing range of motion of the spinal joints. The goal of rehabilitation is to strengthen, and in fact to stiffen the spine. Evidence shows a correlation between increased range of motion of spinal joints, and increased risk of injury.)
Stretches are introduced at the end of this document, specifically to relieve pain caused by muscle spasm or excessive activation. The goal of stretching in this context is not to increase the range of motion (ROM) at the spinal joints, but rather to release excess tension and re-balance the muscles that support the spine.
Methodology
To best achieve these goals for clients with lumbar spinal injury, we need to increase the client’s ability to stabilise both the affected joint(s) and their whole structure. Studies have shown that greater stability is associated with decreased pain, increased function and lesser risk of re-injury.
A note on mobility
Spinal mobility is not a primary goal of rehabilitation. Increased spinal mobility is associated with increased risk of injury, and re-injury of the lumbar spine. To withstand the forces from daily activities, lifting and sports, the injured spine needs increased stiffness, not increased mobility. During rehabilitation it can sometimes be useful to increase the range of motion of the peripheral joints, to allow the spine to function more easily in neutral in particular movements, (for example increasing the ROM of the hip joint can allow for more efficient squatting and lunging movements). As mentioned above, stretching can play a major role in relieving pain from excess muscle tension. Some stretches are provided at the end of this document; for a comprehensive guide to therapeutic stretching methods, see Kit Laughlin’s books “Overcome Neck and Back Pain”, and “Stretching and Flexibility”. Both are highly recommended and were sources for this material.
Why neutral spine is critically important in rehabilitation
The human spine itself is not inherently a stable structure. Cholewicki & McGill (1991) showed that as little as 9kg of force can cause failure of the spinal structure, unsupported by muscles. Stability in the lumbar spinal joints comes predominantly from the muscles of the lower thorax co-contracting to create an effect not unlike guy ropes stabilising a tent pole. In this analogy, should the tent pole deviate from vertical the structure becomes inherently unstable. So too, as the human lumbar spine deviates from the neutral alignment, the structural instability (and therefore the risk of injury) increases dramatically.
In lifting (and in supine open kinetic chain work), there is an anterior shear loading on the lumbar spine (in lifting this force comes from the hand-held weight; in supine, open chain work it comes from the action of the psoas). Because the force (either of gravity or the action of the psoas) is anterior to the spine, there is the tendency to shear the vertebra anteriorly.
In a neutral alignment this anterior shear force is balanced by an equal and opposite posterior shear force exerted by the spinal extensors (just like in the tent pole analogy). The strongest extensors of the lumbar spine are the thoracic fibres of iliocostalis and longissimus thoracis via tendons to their insertion on the sacrum. These are the major extensors of the lumbar spine, due to their superior moment arm relative to the local lumbar musculature.
By contrast, in lumbar flexion the changed moment-arm of these extensor muscles, via their long tendons, causes the force vector to move anterior to the spine, and thus instead of a posterior shear force balancing the anterior load, there is an additional anterior shear loading to the lumbar spine This adds to the loading imposed by gravity (or the psoas), and also increases the risk of injury including disc herniation. Evidence confirms that disc herniation can only occur under conditions of full flexion. (See Adams & Hutton, 1982)
Studies have also shown that, due to the altered moment-arm of the spinal extensors in flexion, the lumbar spine experiences greater anterior shearing loads in a flexed position. Gunning, Callaghan and McGill (2001) showed that a fully flexed lumbar spine is 20-40% weaker than if it were in neutral. It is thus recommended that neutral spine alignment is maintained by all clients with lumbar spine pathology, and that loaded spinal flexion be avoided at all times. This recommendation seems only common sense; when asked to list activities that aggravate their injury, clients invariably come up with such things as extended sitting, getting out of bed, driving, doing up shoe laces, picking things up off the floor, cycling etc, all of which involve lumbar flexion. Clients who cannot support a stable neutral in open kinetic-chain exercises (i.e. with legs in table top position) should be taught to work in a closed-chain configuration (i.e. legs supported) in neutral and that all clients reporting discogenic symptoms or with a diagnosis of disc herniation maintain a neutral spine when under load.
For some discogenic clients, slight lumbar extension may be a more comfortable and less painful position than true neutral – it is suggested that these clients be trained to work in slight lumbar extension (i.e. the position of least pain), and that this alignment be defined as their neutral.
Why abdominal bracing gives maximum core stability
To continue the analogy of the tent pole; all the guy ropes are equally important in creating a stable structure. Having some guy ropes tighter than others will have a destabilising effect on the whole structure. In the same way, the strongest bracing for the lumbar spine is achieved by activating ALL the abdominal muscles, as opposed to just activating Transversus Abdominis or multifidus in isolation. (Abdominal bracing includes T.A. and multifidus activation). Because the fibres of obliques, rectus abdominis and T.A. all run in different directions, and because they share a common fascial sheath, a superior, crosshatched stiffness is achieved with universal activation. With isometric abdominal bracing, the total stiffness is greater than the sum of each muscle’s contribution.
Teach your client to brace all their abdominal muscles isometrically (without sucking in, or pushing out of the abdominal wall). The greatest stability and stiffness will be achieved with an isometric contraction. Avoid “hollowing” or “sucking in” of the abdominal wall as this inhibits activation of obliques and rectus, and also decreases the moment arm of all the abdominal muscles, thus decreasing the stability they are able to impart to the spine.
Stages of rehabilitation
1. Assessment and diagnosis
2. Teach neutral spine & re-sensitise to pain signals (zeroing the scales)
3. Re-groove basic motor patterns/movement templates
4. Increase endurance
5. Increase strength
6. Increase specificity – re-pattern specific movements
Stage 1. Assessment and diagnosis
It’s most useful to have a medical diagnosis (from a doctor, osteopath, chiropractor or physiotherapist), preferably from MRI or CT scanning. X-ray has been shown to be insufficiently sensitive to pick up some disc pathologies, and will also miss many passive tissue injuries such as ligament strains. Don't necessarliy rely on your client's verbal report of their diagnosis. I have too many clients tell me they've got a "disc herniation at L7" to trust the accuracy of verbal reports. Ask for a written diagnosis.
Ideally your diagnosis will include the location, severity (and direction for disc herniation) as well as the medical recommendations and contraindications. At Breathe we use a form which we distribute to local therapists, which you can download here. The form asks all the right questions, so you get the infomation you need from your client's diagnosing therapist. Feel free to copy our form (without the logo of course!).
On taking initial history, it is useful to ask the client which activities or movements aggravate the injury and to ascertain the particular spinal conditions (force vectors, alignment, muscle activation) during each of these movements (such as loaded flexion etc). You can use this information both now (include this in your contraindications list) and further through the rehabilitation process. (To train your client to perform these specific movements with greater biomechanical efficiency).
Stage 2. Teaching neutral spine and re-sensitising to pain signals (zeroing the scales)
I call this stage zeroing the scales, because the higher order goal in the first session or two is generally to give the client an experience of pain-free existance. The reason for this is that many clients I see, have already been to several other practitioners of various modalities, without success. They're often a bit cynical about the outcome, until they have an experience of physical comfort. Once you show them the light, they'll do anything you ask, including their exercises at home (usually!). Zeroing the scales gives the client a "why" so that they'll trust you on the "how".
Zeroing the scales is also critical because it reduces the "background noise" and enables your client to distinguish pain caused by poor posture or motor control errors. They can thus start to use pain as useful feedback, rather than ignoring it.
Pre-Framing
Before I started pre-framing clients I used to lose them after a couple of sessions, before I could help them properly stabilise their injury. Getting people out of pain quickly is not usefu for them if they immediately stop coming to the sessions or doing their exercises! An annular tear will take 12-18 months of non-aggravation to heal, and a ligament injury around the same amount of time. It's important that your client understands (before you take their pain away) that even when you help them relieve their pain through muscle release and postural improvements, they'll still have an injury and they need to complete the course of treatment. A good analogy is finishing a course of antibiotics - you don't stop taking them when your symptoms go away, you need to finish the course of treatment for it to work properly.
Self Muscle-Release
I usually teach these self-massage techniques to clients on their first session. They're really safe because there's no range of motion, and the spine and pelvis stays neutral throughout, so generally even acute clients with severe injuries can use them for relief. Stretching is a more advanced activity that requires your client to be able to maintain neutral aligment, so I generally leave that for later, once the client is able to sustain stable neutral through the various basic movements outlined above.
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Maintaining a perfectly neutral spine, start with the tennis ball (or oversized tennis ball for clients in severe pain) on the muscle, leaning gently against the wall. The client can control the level of pressure by leaning harder or more lightly. Roll in a circular motion over the muscle, and teach your client to explore and discover the particular spots within the muscle that offer the most relief. 12-15 strokes per trigger point are all that is needed. This therapy can be repeated as often as required for acute pain relief, and often makes a major difference to people’s back pain, and general quality of life. Some clients can find it useful to apply the tennis ball to:
- Tensor Fascia Latte/ITB
- Quadratus Lumborum
- Rectus Abdominis, Transversus Abdominis and obliques
- Lumbar multifidus
- Quadriceps
- Hamstrings (sitting on a bench or 2 stacked reformer boxes works well)
We also use larger tennis balls (available from most sports shops) for clients who find the regular tennis ball too strong. You can of course use a foam roller for quadriceps, ITB and Gluteus Medius, but many clients find it too strong initially. One implement we use that I thoroughly recommend is the Theracane, which you can buy online or from Breathe reception. It gets into places the tennis ball can't reach, and it's a lot more precise than a tennis ball, so your client can be more specific with the exact right amount of pressure. |
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2.1 Teach neutral spine
Start by teaching the client to find neutral spine standing, kneeling and supine. If the client is not comfortable in anatomical neutral they may prefer to work in very slight extension; if this is the case, you can define this (slightly extended position) as their neutral (i.e. the alignment which gives them the least pain). Explain and illustrate (literally, using a diagram) the critical importance of maintaining neutral spine vis-à-vis the shearing forces applied to the lumbar spine in loaded flexion.
2.2 Re-sensitising to pain signals
It is essential that your client is able to use the pain signals they receive from their body to help them maintain their neutral spine throughout all exercises. Generally clients will feel the least pain when they are in a perfectly neutral position. As they move, if they experience pain at a particular point in the movement, that is a very good indication that they have lost their neutral spine at that point. This is a novel concept to many clients, and you may need to spend a while communicating with your client to make sure they understand that pain is useful feedback. Helping your client re-sensitise to their pain will help you to hone in on specific points within a movement that need improvement and practice. The aim for each exercise is to maintain a perfect neutral, and to move through the entire exercise with no additional pain (i.e. the same pain level as standing still in neutral spine).
Pain free and neutral spine, are usually interchangeable terms for clients with discogenic lumbar spine pathology.
To achieve success you will need to train your client to listen to and respond to pain signals in a useful way. Many people who have suffered chronic pain will be able to ignore pain, and will in fact often deny that they are in pain, even when asked directly. (Sportspeople and high-powered business people are notorious in this regard!) An attitude of “no pain, no gain” or “I’ll just push through the pain so I can improve more quickly” is counter-productive to the recovery process. Pain is useful feedback!
Stage 3. Re-grooving basic motor patterns.
Transitioning to Stage 4 (increasing endurance), & then Stage 5 (increasing strength)
Until your client can eliminate all the activities that aggravate (i.e. re-injure) their back, their progress is likely to be unsatisfactory. The essence of stage 3 is to retrain your client to perform the movements, which previously aggravated their injury, with optimum biomechanical efficiency, so that they can be performed without pain or re-injury.
Human movements can be separated into several different broad categories: bilateral movements (i.e. squatting, lifting, getting up from a seated position, tying shoe laces,); unilateral movements (i.e. kicking a football, reaching for something on a shelf); reciprocal movements (i.e. cycling),; contralateral movements (i.e. walking, running) ; multi-planar movements (i.e. rolling over and getting out of bed) or a combination of these (i.e. sports, dance, martial arts).
Check with your client as to what activities aggravate their injury. If necessary get them to give you a (gentle) demonstration of the activity. Categorise these activities into the types of movements listed above. You’ll notice that there are patterns with most clients. There may be several activities which aggravate their injury, and usually most, if not all of these will fall into a single movement category. You will need to retrain this particular movement category most diligently, so that your client can learn to perform all these movements with perfect biomechanical efficiency (i.e. safely).
Start with generic movements listed below, and charge your client with adapting each template to the specific movements and activities which aggravate their injury.
The best way to retrain your client to perfect form in the exercises, is to start with a perfectly neutral spine, and to make very small, very slow movements initially, with the emphasis on using proprioception and pain feedback to maintain absolutely flawless form throughout the movement. You can of course also provide external feedback to help your client learn to propriocept accurately. Using a foam roller on your client’s back can help them to propriocept more easily.
When your client can perform the basic movement very small and very slowly, and with perfect form throughout, you can progress them to Stage 4 as they develop greater endurance, and then challenge strength by increasing the size of the movement, and/or adding resistance or lability (unstable surfaces or loads) as appropriate (Stage 5). The final stage of rehabilitation is to groove and practice specific movement patterns (such as sport-specific movements).
The most useful progression for re-grooving motor patterns is generally to introduce the exercises in the order presented below, that is starting with bilateral movements, progressing to contralateral and then unilateral and reciprocal movements, and finally to combination movements with asymmetrical load or instability. Ensure your client has mastered each movement before you introduce additional challenge.
Once these generic movement templates have been re-grooved, you can adapt them in combination to re-groove specific movements, which, will be useful for your client to perform efficiently (i.e. the specific movements which aggravate their injury).
Recommended lumbar-stability exercises for spine-injured clients
These exercises not only re-groove motor patterns for your client; they simultaneously increase the ability of the trunk muscles to stabilise the spine. In electro-myograph and MRI studies, the exercises described below have been shown to facilitate high levels of activation (Up to 25% Maximum Voluntary Contraction or MVC) of multifidus, transverse abdominis, obliques, erector spinae, longissimus and iliocostalis, whilst keeping compression and shearing stresses on the lumbar spine within safe limits, (safe even for most injured clients). All exercises should be performed with neutral lumbar spine.
The most important principle with injured or unstable clients is when engaging in strengthening exercise, to always work them in neutral spine. Gentle stretching (i.e. supported back bend on bolster) or non-loaded flexion/extension (i.e. Cat/4-point kneeling) are fine for most clients, as long as the movements are pain-free.
3.1 Potty Squat (spinal stability with bilateral leg movement)
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Teach the potty squat movement (double legged squat maintaining a perfectly neutral spine). This movement grooves the basic motor patterns used in sitting, in picking things up off the floor, getting out of bed, in and out of the car, and in lifting, (movements that commonly cause aggravation and pain for clients with disc injury or stenosis). Practice sitting into and rising from a chair until the client is able to perform this action consistently with no additional pain. Emphasis is on strictly maintaining a perfectly neutral spine throughout the movement, and learning to become aware of the pain signals that let the client know instantly when they lose their neutral spine. Stage 4: Work up to 2 minutes total for the exercise, or until perfect form is lost due to fatigue (whichever occurs first). It may be the case that calf, adductor or hamstring flexibility will need to be increased in order to perform this movement efficiently (i.e. pain free). Teach your client to use this technique in their everyday activities wherever it will be useful. Stage 5: Add instability such as standing on rotational disks, a foam roller or a skateboard etc. or asymmetry such as holding a spring/dumbbell/theraband in one hand (do both sides!). |
3.2 four-point kneeling swimming prep (spinal stability with contralateral arm/leg movement)
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Using 4-point kneeling with simultaneous opposite arm/leg activation. This grooves the basic motor patterns used in walking and running (which often causes aggravation for clients with lower lumbar disc injury and sacroiliac joint injury or instability). Emphasis is on maintaining a perfectly neutral spine (i.e. pain-free throughout). To achieve this, arm and leg movements may need to be reduced to almost nothing. Some clients will initially need to keep their limbs completely motionless whilst simply activating the arm/leg extensors. Strict adherence to perfect technique is critical, as this is a motor-patterning exercise. It can be useful to use a foam roller on your client’s back to help them propriocept when they are in a perfect neutral. Hold each side for 5 seconds. Stage 4: Work up to 2 minutes total for the exercise. Stage 5: Once your client can do 2 minutes, you can start to progress them gradually to increased range of motion with the arm and leg. Eventually your client can progress to extending their arm and leg somewhat laterally to increase the load on their spinal stabilisers. |
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Using a foam roller can help clients to propriocept neutral spine when kneeling
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Extending the arm and leg laterally increases the challenge to stabilisers for advanced clients |
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Adding instability increases the challenge further for very advanced clients. One spring on STOTT reformer pictured.
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More challenging variation on the floor with foam roller
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3.3 Abdominal curls (thoracic flexion only)
This exercise is mainly aimed at increasing endurance and strength in rectus abdominis, although it is useful for many clients to be able to engage thoracic flexion whilst maintaining neutral lumbar spine (this can help in things like tying shoes). Keeping lumbar spine neutral during this exercise also reduces compression loading on the spine. Closed kinetic chain (i.e. feet supported) is recommended for injured or unstable clients. These types of exercises (i.e. thoracic flexion under load) activate mainly rectus abdominis. For beginning clients it can be useful to have them keep their fingertips under their lumbar spine to help them more easily maintain a neutral lumbar curve.
Due to the action of gravity, the resistance decreases as the client curls further in this exercise. It’s recommended to curl only very slightly off the mat, for maximum rectus activation. Hold the raised position for up to 5 seconds. Stage 4: Work up to 2 minutes total for the exercise (increase endurance first). Stage 5: At this point you can introduce extra resistance to increase strength (arm springs etc). Asymmetrical arm resistance (one heavy spring, one light spring) works well for advanced clients (do both sides!).
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Increasing the challenge of abdominal curls in stage 5 of rehabilitation by adding resistance |
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3.4 Rolling on the wall aka side/front plank (stability with changing resistance/orientation to gravity)
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Start your client leaning sideways against the wall in a perfect neutral spine. Have them rotate their body as a unit to a front plank, and then through to the other side. This movement grooves your client’s ability to keep neutral spine as their body moves through space, with different angles to gravity, such as in rolling over and getting out of bed, or many of the complex movements found in sports and daily life. Strict emphasis is on maintaining perfectly neutral spine (i.e. pain free) throughout the movement, with the ribs locked to the pelvis.
Some clients will be unable to find or hold their neutral spine through this movement. For these clients it can be useful to begin with separate front plank and side plank exercises, (at a level of intensity that the client can tolerate with no pain), whilst maintaining a perfectly neutral spine. Once endurance, strength and proprioception increase, your client can progress to rolling on the wall again. |
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Hold each position for 5 seconds, and transition very slowly and smoothly in between positions. Stage 4: Work up to 2 minutes total for the exercise. Stage 5: Once your client can sustain 2 minutes with perfect stability (i.e. pain free), you can progress them from the wall to the ladder barrel (with feet on the floor), then to the Cadillac (with feet on the floor) then on a reformer box, then with their hands on the floor. |
Some modifications of the basic side/front plank, suitable for clients with different needs:

No rolling
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Slightly more resistance
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A lot more resistance
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For clients with shoulder instability
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3.5 Single leg squat (stability with unilateral leg movement) a.k.a. Irish dancing
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This is an advanced movement, and should only be taught once your client is comfortable and stable in all the above exercises. Especial care should be taken with clients who have sacroiliac joint injury. For these clients especially, strict maintenance of a perfectly neutral spine (i.e. pain free) throughout the exercise is critical.
Start upright in neutral spine. Keeping the torso perfectly upright and neutral, squat down very slightly on one leg, whilst extending the other (gesture) leg forwards and touching the toes lightly on the floor. |
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Repeat, with the gesture leg extending backwards (with bent knee) |
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And then sideways (more difficult for most clients). Stage 4: Work up to 2 minutes per side (increase endurance). |


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Stage 5: You can begin to increase the depth of the squat (increase strength). This movement template can eventually progress to lunging; squatting with reciprocal knee raises and/or asymmetrical arm resistance, or any other more specific movement pattern, which will be useful for your client. |
3.6 aeroplane (spinal stability with multi-planar movement)
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Starting upright in neutral,
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Hinge forward on one leg whilst maintaining a perfect neutral. Next rotate medially on the grounded leg (bring the hip of the raised leg towards the thigh of the grounded leg) |
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And then laterally rotate. This is an excellent glute max exercise. Emphasis is on strict maintenance of form throughout. It can be useful to teach your client the hinge first, then pivot, and finally to add both movements together to create a multi-planar movement. This is an advanced exercise and should only be taught to clients who possess a high level of stability and body awareness.
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3.7 Power Walking
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Standing upright with neutral spine, reciprocal or unilateral arm movement with shoulder joint flexion, and elbow joint flexion then extension (keep the amplitude of the movement to a range which enables useful shoulder mechanics). Stage 4: Work up to 2 minutes. Stage 5: Increase the resistance by standing on one leg (do each leg!)
Of course you could use arm springs on the Cadillac (punching, biceps curls, etc) or side arm preps kneeling on reformer etc, to the same effect. |
3.8 Wall exercise
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Wall exercise was designed by Sydney physiotherapist Francine St. George, and is great for all the posterior muscles of the thoracic and shoulder girdle. Stand with back to the wall, with neutral lumbar spine and thoracic and cervical spines flattened towards the wall. Straighten arms whilst keeping spine still. Check thoracic placement, to ensure the ribcage is flattened towards the wall, engaging the upper thoracic extensors and anterior abdominals. Stage 4: Work up to 2 minutes. Stage 5: Move feet closer to wall in increase challenge.
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Contraindicated exercises for clients with lumbar disc injury or instability
Evidence suggests that the following types of exercises are highly likely to cause further injury to clients with lumbar or pelvic instability:
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Lumbar flexion under load i.e. all open chain supine exercises in imprint such as roll-up, single leg stretch, double leg stretch, criss-cross, mid-back series on reformer in imprint, hip rolls/pelvic curls, roll down from standing, any exercise in teaser position etc
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Lateral flexion under load i.e. mermaids on ladder barrel, box or carriage, side bends Cadillac/arm springs
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Rotation under load i.e. torso rotations on reformer, roll-back with obliques etc
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Extension under load i.e. down stretch & semicircle on reformer, breast stroke (including preps), swimming, Swan dive, cat on Cadillac/push through bar etc can be beneficial for some clients but should be introduced cautiously. Definitely contraindicated for clients with spondylolisthesis.
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For clients with sacroiliac joint injury, be wary of single/reciprocal leg exercises i.e. single thigh stretch on reformer, ronde de jambe on Cadillac/leg springs; also lunges, bicycling supine on mat or reformer, single legwork on reformer or stability chair, side leg lift series on mat etc. Once the client is able to easily stabilize neutral pelvis and spine with controlled R.O.M. single leg squats and 4-point kneeling swimming prep, they may in time progress to more complicated/larger single/reciprocal leg movements
Pain reduction techniques
These techniques can be used from the first session, so that your client can always leave the session feeling better than when they arrived. You can teach your client how to self-administer these techniques, so they are empowered to control their own pain levels during everyday activities.
1. Tennis ball on gluteus medius, gluteus maximus and piriformis
I usually teach these self-massage techniques to clients on their first session. They're really safe because there's no range of motion, and the spine and pelvis stays neutral throughout. Stretching is a more advanced activity that requires your client to be able to maintain neutral aligment, so I generally leave that for later, once the client is able to sustain stable neutral through the various basic movements outlined above.
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Maintaining a perfectly neutral spine, start with the tennis ball (or oversized tennis ball for clients in severe pain) on the muscle, leaning gently against the wall. The client can control the level of pressure by leaning harder or more lightly. Roll in a circular motion over the muscle, and teach your client to explore and discover the particular spots within the muscle that offer the most relief. 12-15 strokes per trigger point are all that is needed. This therapy can be repeated as often as required for acute pain relief, and often makes a major difference to people’s back pain, and general quality of life. Some clients can find it useful to apply the tennis ball to:
- Tensor Fascia Latte/ITB
- Quadratus Lumborum
- Rectus Abdominis, Transversus Abdominis and obliques
- Lumbar multifidus
- Quadriceps
- Hamstrings (sitting on a bench or 2 stacked reformer boxes works well)
We also use larger tennis balls (available from most sports shops) for clients who find the regular tennis ball too strong. You can of course use a foam roller for quadriceps, ITB and Gluteus Medius, but many clients find it too strong initially. One implement we use that I thoroughly recommend is the Theracane, which you can buy online or from Breathe reception. It gets into places the tennis ball can't reach, and it's a lot more precise than a tennis ball, so your client can be more specific with the exact right amount of pressure. |
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2. Piriformis stretch

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Start sitting upright with a perfectly neutral spine. If your client cannot achieve a neutral spine in the starting position, you can teach them to start with the bottom leg hanging over the side of the Cadillac or chair. Use a gentle PNF stretch (isometric contraction of piriformis on inhalation/relaxation or piriformis on exhalation) and hold the end position for 30 seconds. The stretch should be comfortable and gentle throughout. Don’t allow your client to “push through the pain” as this will usually cause them more pain the next day. Insist that your client maintain a perfectly neutral spine throughout the exercise. It’s most useful to do this stretch AFTER piriformis trigger point release with a tennis ball. |

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3. Obliques/Q.L./Lat stretch

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Stretch only the side of the disc protrusion. (i.e. if there is a RHS disc bulge, stretch RHS lats, QL and obliques). Some clients find this stretch gives them immediate and dramatic relief, whilst other clients cannot tolerate this stretch; go gently. Starting seated, with a blanket under the knee as pictured, and using a strap if required, gently laterally flex torso to a gentle stretch position. You can use a gentle PNF stretch here, with the inhalation coinciding with activation of the QL, obliques and lat in an effort to sit back up. On exhalation, use the leverage between the elbow and knee to rotate the top shoulder a little more open, if comfortable. Hold the end position for 30 seconds. |
4. Lying twist stretch

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Great for releasing tension-pain from Q.L., piriformis or lumbar extensors. Use this stretch only with stable clients. It’s great to provide a bolster for your client to rest their leg on. Work opposite shoulder towards the mat, and use a gentle PNF stretch (activating wherever feels tight) and hold the end position for 30 seconds. |
Help your client to identify & remove the causes of their back pain
You can work with your client from the first session to help them identify and change the way they do the things, which aggravate their back pain. When you eliminate the cause/aggravating activities, your client will progress significantly faster.
With inefficient biomechanics, the lower back can experience high stresses even with light activities like sitting, or bending over to pick up something small off the floor. Here are some tips on how to use good biomechanics to reduce load on the lumbar spine. The more aggravating activities you can remove or improve biomechanically, the less pain your client will experience.
Keep neutral spine (bend your hips & knees, keep your back straight)
Multiple studies have shown that keeping neutral spine is the most important and effective single thing you can do to reduce back pain. It may be that your client will notice a significant reduction in their pain, just by keeping their lumbar spine neutral in the following situations:
- Whilst sitting (and especially as they sit down and stand up from sitting).
- Whilst they stand (keeping their weight even on both feet, and their hips level
- Whilst they bend over (such as to pick something up off the floor)
- Whilst they do the gardening
- Whilst they reach to get something from across the table
- Keep the spine neutral within the first hour after getting out of bed. (So no forward bending, spine stretching or heavy lifting first thing in the morning). Various studies support this including Adams, Dolan and Hutton (1987) who estimated that disc-bending stresses are increased by 300% and ligament stresses are increased by 80% in the morning compared to the evening. Snook and colleagues (1988) demonstrated that simply avoiding full lumbar flexion in the morning reduced back pain symptoms.

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The “golfers lift” is a useful technique which enables clients to maintain their neutral spine whilst picking up light objects from the floor. It can also be useful for some clients in getting in and out of bed.
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Lift with neutral spine
- Keep the spine neutral when lifting anything, even light things (bend at the hips and knees – potty squat)
- Lightly brace all the abdominals, even with light tasks like picking up a pencil from the floor, or getting in and out of the car, or sitting down in an office chair
- When lifting something heavy, keep the load close to the body
- Apply the force vector through the lower back or hips, rather than the upper body (for example when opening a door, pull the handle towards the pelvis rather than towards the chest or beside the body: When vacuuming, draw the vacuum directly towards the belly button rather than obliquely past the hip.)
- Keep straight whilst lifting (avoid twisting). Twisting under load is the weakest action for the spine
- After sitting or stooping for a while, stand straight for at least 2 minutes before you do anything strenuous
Move in a number of different ways every day
Here are some other things; little things, which once your client has been doing them for a little while, you may be surprised at how much of a difference they report to you. Advise your client to:
- Use a variety of sitting positions – change around every 10 minutes or so (keeping neutral where possible)
- Stand up to talk on the phone; this will break up sitting time
- Set up their office so that they need to get up regularly (put the printer, or the phone across the room)
- Every 10-15 minutes, stand up and take a deep breath in as they reach their hands straight up. This stretches the spine gently into extension and allows the muscles to re-oxygenate, keeping them fresh
Once your client has been doing some of these things for a little while, they may be surprised and delighted at how quickly they’ll notice changes in the way they feel. Happy days!

Raphael Bender
STOTT PILATES level 2 certified instructor
APMA Level 3 certified instructor
References
Adams, M.A., Dolan, P. and Hutton, W.C. (1987) Diurnal variations in the stresses on the lumbar spine. Spine, 12 (2): 130
Adam, M.A and Hutton, W.C. (1982) Prolapsed intervertebral disc: a hyperflexion injury. Spine, 7:184
Adam, M.A and Hutton, W.C. (1985) Gradual disc prolapse. Spine, 10: 524
Biering-Sorenson, F. (1984) Physical measurement as risk indicators for low back trouble over a one-year period. Spine, 9: 106-109
Bloomfeld, J., Ackland, T.R., and Elliot, B.C. (1994) Applied anatomy and biomechanics in sport. Blackwell Scientific publications, Melbourne
Callaghan, J.P. & McGill, S.M. (2001) Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clinical Biomechanics, 16 (1): 28-37
Bogduk, N. & Twomey, L. (1991) Clinical anatomy of the lumbar spine (2nd Ed) New York: Churchill & Livingstone
Cholewicki, J. McGill, S.M. (1991) Mechanical stability of the in-vivo lumbar spine: Implications for injury and chronic low back pain. Clinical Biomechanics. 11(1): 1-15
Cripton, P., Berlman, U., Visarino, H., Begeman, P.C., Nolte, L.P. and Prasad, P. (1995) Response of the lumbar spine due to shear loading. Injury Prevention Through Biomechanics (p.111) Detroit: Wayne State University
Davies, C., and Davies, A. (2004) The Trigger Point Therapy Workbook. New Harbinger, Oakland CA
Hides, J.A. Jull, G.A. and Richardson, C.A. (2001) Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine, 26: E243-248
Juker, D., McGill, S.M., Kropf, P. and Steffen, T. (1998) Quantitative intramuscular myoelectric activity of lumbar portions of psoas and the abdominal wall during a wide variety of tasks. Med Sci Sports Exerc, 30 (2): 301-310
King, A.I. (1993) Injury to the thoraco-lumbar spine and pelvis. Nahum & Melvin (Eds), Accidental Injury, Biomechanics and Prevention. New York: Springer
Koes, B.W., Bouterm L.M., Beckerman, H, et al. (1991) Physiotherapy exercises and back pain: A blinded review. Br Med J, 302: 1572-1576
Laughlin, K. (2006) Overcome Neck & Back Pain, Fourth Edition. Simon & Schuster, Sydney, Australia.
McGill, S.M. Low Back Disorders: Evidence based prevention and rehabilitation – Backfitpro Inc., Ontario, Canada.
McGill, S.M. (2006) Ultimate Back Fitness and Performance, Third Edition. Backfitpro Inc, Ontario, Canada.
McGill, S.M. (1991a) Electromyographic activity of the abdominal and low back musculature during the generation of isometric and dynamic axial trunk torque. Implications for lumbar mechanics. Journal of Orthopaedic Research, 9:91
McGill, S.M. (1997) Invited paper: Biomechanics of low back injury; implications on current practice and the clinic. Journal of Biomechanics 30 (5): 465-475
McGill, S.M. and Norman, R.W. (1992) Low back biomechanics in industry – The prevention of injury. In: Grabiner, M.D. (Ed.) Current issues of biomechanics. Champaign, IL: Human Kinetics
Nachemson, A. (1966) The load on lumbar discs in different positions of the body. Clin Rel Res 45:107
Marras, W.S., Jorgensen, M.J., Granata, K.P. and Waind, B. (2001) Female and male trunk geometry: Size and prediction of the spine loading trunk muscles derived from MRI. Clinical Biomechanics. 16: 38-46
Scannell, J.P. and McGill, S.M. (2003) Lumbar posture – should, and can it be modified? A study of passive tissue stiffness and lumbar position in activities of daily living. Physical Therapy, 83(10): 907-917
Siff, M., (2002) Supertraining, Sixth edition. Supertraining Institute, Denver
Suggested reading
All of these books contributed greatly to my understanding of how backs work, and they’re all available in the Breathe library!
Low Back Disorders: Evidence based prevention and rehabilitation – Dr Stuart McGill
An excellent resource, which, as you read it, will clarify and perhaps change your understanding of the anatomy, pathology and rehabilitation of the lumbar spine. Stuart McGill holds a PhD in spinal biomechanics.
Ultimate Back Fitness & Performance – Dr Stuart McGill
Evidence based guidelines for exercise design and prescription for all stages of back rehabilitation from acute injury to elite athletic level
Spinal Stabilization: The New Science of Back Pain – Rick Jemmet.
An evidence-based approach to lumbar stabilization and rehabilitation, by a group of Australian physiotherapists.
Overcome Neck and Back Pain – Kit Laughlin
Learn the science of stretching. Explanations of different methods of stretching and more than 101 stretches (all illustrated, with clear instructions) to release everything from Q.L to masseter. All stretches here came from Kit’s books.
The Trigger Point Therapy Workbook – Clare Davies & Amber Davies
Simple, easy to understand and practical. A self-treatment guide on manual release for over 200 muscles. Ideal for clients who are not stable enough to stretch yet. Based on the work of Travell and Simons.
Stretching Scientifically – Thomas Kurz
Anatomy and physiology of stretching; Explanation and instructions on evidence-based stretching techniques including dynamic stretching and PNF stretching.
Relax Into Stretch – Pavel Tatsouline
Detailed, evidence based stretching manual, concentrating on several different methods of PNF stretching. Super effective!
Spinal Manipulation Made Simple: A Manual of Soft Tissue Techniques - Jeffrey Maitland
Teach your clients self-release of muscle spasm and joint fixations with these wonderfully gentle, passive techniques.
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How to book your Clinical Pilates individual sessions
Part of the benefit of individual Pilates sessions is the increased flexibility of times and days for your sessions. Your individual sessions can be scheduled at a time that suits you on a session-by-session basis, or alternatively you can do all your sessions at the same regular time; depending on what works best for you. To book your sessions, just call reception. You'll need to pay for each session in order to reserve your place for each session, as times tend to fill up some way in advance, and you're eligable for discounted packages when you purchase 10 or 20 sessions together. You can check out prices for individula Clinical Pilates sessions on our Times and Prices page (under 1-on-1 Pilates sessions). You can call us on 9662 1500 and book over the phone, or you can book your Clinical Pilates assessment session online, by clicking on the link below.

Rescheduling individual sessions
We do ask for 24 hours notice for cancellation if you can't make it to your session. This allows us to make the session available for someone else.
How to book your Studio Pilates (Small group) sessions
Studio Pilates sessions are available on the Committed Pilates-ite fortnightly direct debit; you can book your Studio Pilates sessions online, up to 12 months in advance (Group Reformer/Mat/Yoga classes can be booked 14 days in advance). Your weekly session can be at the same time every week, or you can take advantage of the flexibility of online booking to chop and change as much as you like. Your spot is reserved for you, so you’ll never ever miss out. When you start your Committed Pilates-ite direct debit, we'll book you in for your first 2 sessions, and then it's up to you to book online yourself.
Supplementing your Studio Pilates sessions with extra Mat & Reformer classes
You can supplement your weekly Studio Pilates session with up to 3 extra Reformer, Mat Pilates or Yoga classes at no extra cost, for ultimate toning, strength and flexibility. So whenever you're in Melbourne CBD you can feel free to drop in for a Pilates class. If you’re injured or pregnant, please see your teacher before you join in any group classes.
Benefits of Clinical and Studio Pilates
- A spot is reserved for you in your chosen session, so you can diarise your class and you’ll never ever miss out
- You’ll be part of a small, stable group
- You’ll be working from an individually tailored program of Pilates exercises, designed specifically for you
- You’ll benefit from vastly more personal attention than in a larger group class
- Your program will be updated and adjusted every session
- You’ll get to play on the Big Toys (Cadillac, Reformer, Ladder Barrel and Stability Chair, as well as the Small But Really Fun toys such as Bosu, rotational discs, stability ball etc.).
- As part of your Committed Pilates-ite direct debit you can do up to 3 extra Reformer, Mat Pilates or Yoga classes each week. If you're injured or pregnant, please check with your Studio Pilates instructor before joining in any group classes.
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