Pilates, Pain and Fear of Movement
When someone has been living with pain for a long time, are we only working with the painful area — or are we also working with the way they feel about movement?
Chronic low-back pain is not always simply a reflection of tissue damage. Over time, pain may influence confidence, expectations and movement behaviour. A person may begin to avoid bending, lifting, rotating or exercising because they believe these movements are dangerous or will make their condition worse.
This is often described as fear-avoidance või kinesiophobia — fear of movement.
And this matters.
When people become afraid of movement, they may move less, avoid certain activities and become increasingly cautious. Reduced activity can then contribute to loss of strength, physical capacity and confidence, potentially reinforcing the cycle.
What does recent research tell us?
A 2025 randomized study compared Pilates and Proprioceptive Neuromuscular Facilitation (PNF) in 60 people with chronic low-back pain.
Participants completed 20 sessions over four weeks. Researchers assessed not only pain, but also fear-avoidance beliefs, body image, core stability and balance.
Both groups experienced reductions in pain and fear-avoidance behaviour and improvements in balance. The Pilates group showed greater improvement in core stability, and improvement in body image was also observed within the Pilates group.
The important point is that the changes were not limited to pain.
Movement was associated with changes in how participants felt about moving as well.
Perhaps the exercise is only part of the story
Earlier research provides another interesting piece of the puzzle.
A 2023 analysis involving 255 people with chronic low-back pain investigated how Pilates may influence pain and physical function.
The researchers found that reductions in kinesiophobia and pain catastrophising partially mediated improvements in pain and physical function. In other words, part of the benefit associated with Pilates appeared to occur alongside changes in the way participants thought and felt about pain and movement.
This does not mean that pain is “in someone’s head.”
It means that pain is complex.
Physical capacity matters. Strength matters. Mobility matters. But beliefs, previous experiences, confidence and expectations can also influence how someone moves and responds to exercise.
What does this mean for us as movement teachers?
It reminds us that how we teach may matter alongside what we teach.
Consider the difference between saying:
“Be careful — don’t move your spine there.”
and:
“Let’s explore that movement gradually and find a range that feels comfortable and controlled.”
Or between:
“Your core isn’t supporting your back.”
and:
“Let’s build your strength and confidence in this movement.”
Both may be intended to help. But the message received by the client can be very different.
If we repeatedly communicate that the spine is fragile, unstable or needs constant protection, we may unintentionally reinforce the idea that movement is dangerous.
This doesn’t mean ignoring pain, forcing movement or telling someone that fear doesn’t matter. Nor does it mean that every movement is appropriate for every person.
It means finding the balance between respecting symptoms and unnecessarily creating fear around movement.
From protection to possibility
Pilates offers something particularly interesting in this context.
We can introduce movement gradually. We can change load, range, support, position and complexity. We can allow someone to experience a movement successfully before asking for more.
For a person who has become afraid to bend, for example, the first goal may not be achieving maximum spinal flexion. It may simply be experiencing a small, comfortable movement without the outcome they feared.
Then perhaps a little more.
Strength and capacity can develop alongside confidence.
And that may be one of the most valuable things movement can give someone living with persistent pain: not simply the ability to perform an exercise, but the confidence to move again.
For teachers to consider
When working with someone in pain, ask yourself:
Am I only modifying the movement — or am I also considering the person’s confidence in that movement?
Does my language create reassurance and possibility, or could it unintentionally reinforce fear?
Am I helping this person build capacity, or teaching them that their body constantly needs protection?
Good teaching is not about promising that movement will eliminate pain.
It is about creating an environment where movement can be explored progressively, appropriately and with confidence.
Viited
Ulusoy M, Iyigun G. Comparison of Proprioceptive Neuromuscular Facilitation and Pilates exercises in patients with chronic low back pain: A randomized study. Journal of Bodywork and Movement Therapies. 2025;42:463–470. DOI: 10.1016/j.jbmt.2025.01.018.
Miyamoto GC, et al. Pain catastrophising and kinesiophobia mediate pain and physical function improvements with Pilates exercise in chronic low back pain: a mediation analysis of a randomised controlled trial. Journal of Physiotherapy. 2023;69(3):168–174. DOI: 10.1016/j.jphys.2023.05.008.