Chronic non-specific low back pain (CNLBP) is a prevalent cause of long-term disability, with nearly 80% of individuals experiencing low back pain (LBP) during their lifetime ^[1,2]. While many recover, a significant proportion develops chronic symptoms without identifiable pathology, hence termed “non-specific” ^[3]. The Global Burden of Disease (2019) ranked LBP as the leading cause of years lived with disability, especially in adults aged 40–69 years ^[4,5], with CNLBP largely influenced by sedentary behavior, poor ergonomics, psychosocial factors, and limited physical activity ^[6,7,8]. In India, prevalence varies across populations ^[9], and 10–20% of acute cases progress to chronic stages ^[10], leading to persistent pain, reduced work productivity, and increased healthcare costs ^[11,12]. CNLBP is a complex condition involving deficits in trunk control, core stability, spinal flexibility, and mobility ^[13,14,15]. Although kinesiotherapy has long been the standard rehabilitation method ^[16,17], growing evidence supports Pilates for its emphasis on controlled movement, alignment, and neuromuscular retraining ^[18,19], Conventional therapy, while beneficial, may not sufficiently target deep core activation, postural re-education, or neuromuscular control, often leading to limited long-term outcomes and reduced adherence ^{[16,20,21,22,23]}. Integrating Pilates with kinesiotherapy offers a more comprehensive approach, addressing motor control, spinal stability, and body awareness ^{[18,24,25,26]}. Studies show that Pilates enhances lumbar stability, trunk endurance, flexibility, and pain modulation, while its structured and progressive design improves patient engagement, making it a valuable addition to conventional rehabilitation ^[27,28]. Therefore, adding Pilates to conventional therapy has the potential to optimize clinical outcomes by addressing both the mechanical and neuromuscular contributors to CNLBP. Although kinesiotherapy and Pilates independently aid in managing CNLBP, their combined impact within rehabilitation programs remains underexplored. Most studies investigate them separately with varied methods, making it difficult to form integrated guidelines. Limited research has also assessed feasibility factors like adherence, safety, and retention. Pilot studies are therefore essential to evaluate the practicality and early benefits of combining Pilates with conventional physiotherapy for CNLBP. The aim of this pilot study is to evaluate the feasibility, safety, and acceptability of integrating Pilates into conventional kinesiotherapy for individuals with CNLBP. Specifically, it seeks to assess recruitment, adherence, and retention rates, while also exploring preliminary clinical outcomes such as pain intensity, functional disability, lumbar mobility, and lumbo-pelvic flexibility. The findings will help refine the intervention model and provide essential data for planning future large-scale trials.

Ethical approval
The study protocol was reviewed and approved by the Institutional Ethics Committee of NIMS University, Jaipur, Rajasthan, India (Approval No: NIMS/PTOT/Ethical/Feb/2025/01). Written informed consent was obtained from all participants before their enrollment in the study.

Study design, setting, and duration
This was a prospective single-group pre-post pilot study conducted to assess the feasibility, safety, and preliminary clinical effects of integrating Pilates exercises into conventional kinesiotherapy for individuals with CNLBP. The study was carried out in the Department of Physiotherapy at Bundelkhand Medical College, Sagar (Madhya Pradesh) over a duration of 6 months.

Participants
A total of 35 individuals were screened for eligibility. Of these, 30 met the inclusion criteria and were enrolled in the study. Eligible participants were adults aged 20–60 years with CNLBP persisting for ≥12 weeks, able to travel independently, and willing to provide informed consent. Exclusion criteria included acute or subacute LBP, neurological involvement, impaired mobility, prior physiotherapy within the past 6 months, pregnancy, major surgery, malignancy, or significant systemic illness. During the intervention, four participants discontinued and were excluded from the final analysis, leaving 26 participants who completed the 8-week program. The flow of participants through the recruitment, enrollment, and retention stages is summarized in Fig. 1.

Figure 1: Flow diagram of participant recruitment, enrollment, allocation, and retention.

Intervention protocol
The intervention was conducted over 8 weeks, comprising 24 supervised sessions (3/week, ~60 min each). Each session included a 5–10-min warm-up, a main exercise module, and a 5–7-min cool-down. Abdominal bracing (drawing-in maneuver) was taught to all participants. The program alternated weekly between conventional kinesiotherapeutic exercises and mat-based Pilates to promote varied neuromuscular engagement.
The kinesiotherapy module included pelvic rocking, curl-ups, bridging, trunk extensions, bird-dog, dead bug, planks, cat-cow, and targeted stretches for hamstrings, piriformis, hip flexors, and thoracolumbar fascia. The Pilates module comprised single-leg circle, pelvic curl, hundreds, roll-up, table-top, swimming, swan, child’s pose, side kick, saw, shoulder bridge, and teaser.
Progression was structured as follows: Weeks 1–2 (2 sets × 15 reps), weeks 3–4 (2 sets × 20 reps), weeks 5–6 (3 sets × 15 reps), and weeks 7–8 (3 sets × 20 reps). Stretching was held for 10 s with equal rest, while strengthening involved body weight resistance with a 5-s hold and 2-second relaxation per repetition. All sessions were supervised by a qualified physiotherapist to ensure safety, correct technique, and adherence.

Outcome measures
Feasibility outcomes were assessed through recruitment rate (eligible vs. enrolled), retention rate (completed vs. enrolled), session adherence (attendance records), acceptability (participant feedback and interviews), and safety, determined by monitoring adverse events. Clinical outcomes included pain intensity, evaluated with the Visual Analog Scale (VAS); functional disability, assessed using the Roland-Morris disability questionnaire (RMDQ); lumbar mobility, measured by the Modified-modified Schober’s Test; and lumbo-pelvic flexibility, assessed with the V-sit and Reach Test. All measures were collected at baseline and again after completion of the 8-week intervention.

The intervention demonstrated high feasibility and safety, with recruitment of 85.71%, retention of 86.67%, mean session adherence of 75.64% (SD = 21.72), moderate-to-high acceptability (mean feedback score = 3.77 ± 0.85), and no adverse events (Table 1 and Fig. 2).

Table 1: Feasibility outcome

Figure 2: Feasibility outcomes of the integrated Pilates–kinesiotherapy intervention. The study achieved high recruitment (85.71%) and retention (86.67%) rates, with good adherence (75.64%) and moderate-to-high acceptability (mean feedback score: 3.77). No adverse events were reported, indicating the intervention was safe and well-tolerated.

Clinically and functionally, participants showed significant improvements after the 8-week program: Pain intensity (VAS) and disability (RMDQ) decreased, with mean scores reducing from 7.23 to 3.90 and 14.37 to 7.93, respectively, while lumbar mobility (Modified Schober’s test) and flexibility (V-Sit and reach) increased from 1.80 to 3.23 and –1.40 to 0.60, respectively. All changes were statistically significant (t = 16.70–24.22; P < 0.0001) (Tables 2 and 3).

Table 2: Summary of clinical outcome measures: Pre- and post-intervention analysis

Table 3: Pre-post intervention differences in outcome measures: t-statistics and significance

The intervention protocol demonstrated strong feasibility, evidenced by high recruitment (85.7%) and retention (86.7%), indicating the target population was engaged and well-matched. Session adherence averaged 75.6%, reflecting good commitment despite the program’s intensity. Participants reported moderate-to-high acceptability (3.77/5), and no adverse events were observed, highlighting safety and tolerability. Overall, the findings indicate that the protocol was manageable, acceptable, and suitable for future clinical or research implementation. Despite the intervention’s overall feasibility, several challenges were noted. Session adherence averaged 75.6% but varied widely, with some participants attending less than half of sessions due to personal, transportation, or health-related issues, potentially affecting intervention consistency. Recruitment was ultimately successful (85.7%) but initially hindered by eligibility screening and participant time constraints. Sustaining engagement required ongoing communication, and early withdrawals (4 of 30) highlighted the need for strategies to boost motivation and reduce attrition, which is crucial for scaling future interventions. Preliminary results from this pilot study indicate that integrating Pilates with kinesiotherapy may positively impact chronic LBP (CLBP). All outcomes – pain, functional disability, lumbar mobility, and flexibility – showed significant improvements. Pain (VAS) decreased from 7.23 to 3.90 and functional disability (RMDQ) from 14.37 to 7.93, suggesting enhanced core stability and daily functioning. Physical performance also improved, with lumbar mobility (Modified Schober’s Test) rising from 1.80 cm to 3.23 cm and flexibility (V-sit and reach) from -1.40 cm to +0.60 cm. These findings highlight potential benefits of the combined intervention, though they are preliminary due to the small sample and pilot design. The findings of this pilot study are consistent with previous research supporting the use of Pilates and kinesiotherapy in the management of CLBP. Mostagi et al. found Pilates to be more effective than general exercise in reducing pain and disability, which aligns with the significant improvements observed in both VAS and RMDQ scores in the present study ^[29]. Similarly, Llewellyn et al. reported substantial reductions in perceived pain and functional disability following a structured Pilates program, emphasizing the role of movement control and body awareness principles that likely contributed to the observed benefits ^[30]. Popli further highlighted the clinical value of integrating Pilates within broader rehabilitation protocols, suggesting that combining it with conventional kinesiotherapy may enhance functional outcomes, as seen in this trial ^[31]. Supporting this integrated approach, Faria et al. demonstrated improved pain and mobility outcomes through the combined use of Pilates and kinesiotherapy in pregnant women with LBP, reinforcing its applicability across diverse populations ^[32]. Collectively, these studies bolster the preliminary evidence from the present investigation, suggesting that Pilates combined with kinesiotherapy may produce synergistic benefits for individuals with CNLBP. The 8-week intervention duration employed in this study aligns with previous research on Pilates for CLBP, where programs of similar length have demonstrated significant improvements in pain, functional disability, and lumbo-pelvic stability ^[28,29]. While these results are consistent with prior research supporting the effectiveness of Pilates and kinesiotherapy in managing CLBP, certain methodological limitations of the current study should be noted. This pilot study assessed only physical outcomes pain, functional disability, lumbar mobility, and lumbo-pelvic flexibility alongside feasibility parameters, including recruitment, retention, adherence, acceptability, and safety. These measures were selected to provide objective indicators of short-term therapeutic responsiveness and to evaluate the practicality and tolerability of the intervention protocol. Psychosocial outcomes, such as fear-avoidance beliefs, anxiety, and quality of life, were beyond the scope of this initial study but will be incorporated in future randomized controlled trials to comprehensively assess the multidimensional impact of the combined intervention. As a pilot investigation, the modest sample size was intentionally chosen to assess feasibility, safety, and preliminary therapeutic outcomes before progressing to a larger randomized controlled trial. The absence of a control group reflects the exploratory nature of the study, emphasizing procedural refinement, participant adherence, and intervention acceptability rather than establishing definitive causal relationships. Despite these constraints, the findings provide a valuable foundation for future controlled investigations designed to validate the clinical efficacy of this integrative approach. Furthermore, this pilot study was conducted at a single institution with purposive recruitment to evaluate the feasibility, safety, and preliminary effects of the intervention. While this design limits generalizability to broader populations and varied clinical settings, it provides essential data to refine the intervention protocol and inform future multicenter randomized controlled trials.

Limitations

This pilot study has several limitations. The small sample size, single-center design, and absence of a control group limit the generalizability and causal interpretation of the findings. The short intervention period and lack of long-term follow-up restrict evaluation of sustained effects. Moreover, only physical outcomes – pain, disability, mobility, and flexibility – were assessed, while psychosocial factors such as fear-avoidance beliefs, anxiety, and quality of life were not included. Despite these constraints, the study provides valuable preliminary data to refine the intervention and guide future multicenter randomized controlled trials.

Future research directions

This pilot study demonstrates preliminary benefits of integrating Pilates with conventional kinesiotherapy for CLBP, including improvements in pain, functional disability, lumbar mobility, and flexibility. Future multicenter randomized controlled trials with larger, diverse samples, appropriate control groups, extended interventions, and long-term follow-up are needed to confirm effectiveness and sustainability. Inclusion of psychosocial outcomes such as fear-avoidance beliefs, anxiety, and quality of life will enable a more comprehensive assessment of the intervention’s multidimensional impact.

This pilot study demonstrates that an integrated Pilates and kinesiotherapy program is a feasible intervention for individuals with CNLBP, evidenced by favorable recruitment, retention, adherence, acceptability, and safety outcomes. Preliminary results indicate significant improvements in pain, functional disability, mobility, and flexibility, suggesting the potential effectiveness of this combined approach. These encouraging findings support the need for larger, well-designed randomized controlled trials to further evaluate the efficacy and long-term benefits of Pilates-integrated interventions in managing CNLBP.

This pilot study suggests that combining Pilates with conventional kinesiotherapy may enhance clinical outcomes in chronic non-specific low back pain and can be safely incorporated into physiotherapy programs.