EMDR Therapy Quarterly

The NICE guideline (2020) for the treatment of non-specific chronic lower back pain (CLBP) –pain lasting for more than twelve weeks, with no identified physical or structural cause – states that clinicians should:

“Consider psychological therapies using a cognitive behavioural approach for managing low back pain with or without sciatica, but only as part of a treatment package including ‘exercise’ (my emphasis) with or without manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage).”

There is growing evidence that EMDR is an effective treatment for chronic pain (Grant, 2018; Gerhardt et al., 2016) and that Pilates may be more effective than other forms of exercise for treating and preventing CLBP (Domingues de Freitas et al., 2020; Wells et al., 2014). I am a personal trainer and Pilates teacher specialising in exercise for CLBP as well as an EMDR therapist specialising in trauma-related chronic pain. I run a recovery programme for people living with CLBP, combining individual EMDR sessions with a weekly online Pilates group focusing on improving core strength and spinal flexibility.

This case report regards ‘Sara,’ a former participant in the programme, and explores the question: Can Pilates and EMDR be an effective combination of psychotherapy and exercise for recovery from CLBP?

Sara and the initial consultation

Sara is 30 years old. Seven years ago, while studying for a master’s degree abroad, she had a sudden attack of back pain at an airport while travelling to the UK for a visit. The pain was excruciating and felt in the L4/L5 area of the spine (between the fourth and fifth lumbar vertebrae, counting from the top of the spine, so at the very bottom of the spine, just above the sacrum). The pain became chronic, and Sara had to give up her course and return home. At assessment, she was living with her parents, still in pain and with limited mobility, seven years after the incident at the airport when the pain began.

Sara described a happy childhood, good relationships with family and no major traumas. I administered the Back Bournemouth Questionnaire (Bolton & Humphreys, 2002), a recognised tool for assessing the physical and psychological impact of CLBP, and Sara scored 34 out of a possible 70, indicating moderate but significant levels of pain, anxiety and depression. She described her pain as a “dull ache” rated at 5 out of 10 on a numerical scale (0 = no pain, 10 = the worst pain imaginable). She could only stand for a few minutes and walk for five minutes at a time before the pain increased and she needed to rest.

I talked Sara through Grant’s (2018, p. 253) ‘pendulation’ exercise (where the therapist asks the client to focus on the area in pain, then another part of the body that is not in pain, and ‘gather up’ that more comfortable experience and take it back to the area in pain, and ‘pour it over’ to feel the relief). She reported a small, positive effect on her pain, making her feel more relaxed. This also indicated a psychological element to the pain, and that finding further ways to help Sara relax could be beneficial. I undertook a postural and movement analysis, in line with best practice, when a client joins a Pilates group to better understand how the back pain impacted on her functionally so the session exercises could be made accessible for her.

Initial formulation

Sara was diagnosed originally with an “annular tear” in the L4/L5 area, which meant there was damage to the external, fibrous ring (annulus fibrosus) of the intervertebral disc between L4 and L5. If pressure were placed on the disc concerned (by sitting for too long or through poor posture, for example), part of the disc would push out through the tear in the fibrous ring meant to hold it in place, pressing onto nerves coming out of the spinal column and thus causing pain. The spinal specialists Sara consulted told her the pain was “excessive,” given the current physical condition of her spine. As Sara had become almost house-bound, creating muscle tone loss in the core and stiffness in the spine, she was less able to use her core to support her spine, making the pain worse. Being less mobile affected her confidence: she talked of low mood and anxiety, which also exacerbate pain (Grant, 2018, pp. 39-40; Lalkhen, 2021, p. 15), and had tried several treatments over the years, none of which had a lasting effect, leading to a sense of hopelessness. In the absence of any identified serious early trauma, I believed the experience of the sudden onset of the pain at the airport and its subsequent impact on her life to be worthy of exploration and processing, as the memories of such experiences may well have prolonged the pain.

I believed Sara’s CLBP began with the annular tear, which happened for reasons unknown. The injury took time to heal, and over time, her brain’s pain system became overly sensitised to harm signals from the L4/L5 area. This, together with the stress of the initial incident, its impact on her life and career, and the ongoing stress of being virtually housebound for seven years and not recovering, becoming less and less mobile, as described, exacerbated and maintained the pain.

We agreed Sara would begin weekly EMDR sessions to address the psychological aspects of her pain and join my Pilates group in a few weeks, when the next term began, to improve her core strength, mobility and posture – addressing the physical elements of her condition. Sara accepted my suggestion that she begin the class seated in a chair (chair Pilates), given her limited mobility and the fact that she could only stand for a few minutes at a time, as the class is 60 minutes long.

Course of treatment

As Sara reported no early traumas, I began searching for targets by asking her to ‘listen’ to her back pain (Keefe, 2024). I asked her to close her eyes, slow her breathing and focus on the sensations in the painful areas of her lower back. I then asked her to imagine the pain could speak to her and what it would say. After a minute, Sara responded, “It’s saying, ‘Pay attention to me, I need some attention.’” She was surprised by this, as she felt very well connected to family and friends and believed she had all the attention she needed.

I asked Sara to focus on the “pain itself,” notice any related thoughts, emotions or images, and then let her mind drift back to similar moments in her past (Shapiro, 2001, P. 433).

Sara found a memory from six months after the initial episode at the airport, when the pain began. She was still living in the same country and was lying on her bed, unable to move, when an alarm sounded in the street outside. There were two separate alarm sounds: one to indicate a fire in the neighbourhood and the other to warn of an earthquake. The latter alarm sounded, and Sara was terrified.

Sara’s negative cognitions were “I’m stuck here” and “I will never get home”. Her positive cognition was “I can move, and I can leave,” (VOC = 3). Her emotions were fear and panic (SUD = 7). Sara reported a “panicky feeling” in her body, “like you’re in fight or flight.”

We agreed to begin processing by targeting this memory, and Sara noted she was sitting up more already, with less leaning from side to side (Sara would often rock slightly from side to side when sitting down, as sitting in one position for too long exacerbated the pain).

Processing this memory led, over the next few weeks, to a series of memories related to her experience of CLBP, including: lying in her bed in pain, unable to move but trying to write an essay; being in agony at the end of a long flight home – she was in business class, so could lie down for most of the flight, but had to sit up for thirty minutes while the plane was landing and this caused excruciating pain in her lumbar spine; a time when her back was improving, when she bent down to pick up a heavy pot from a low shelf in her kitchen, which made the condition much worse, leading to seven months of increased pain and reduced mobility (I met Sara at the end of this period); and a Christmas dinner when she was in so much pain she had to lie down upstairs, listening to family and friends enjoying themselves downstairs.

 In other sessions, we processed the pain itself in her lumbar spine directly, as when she had a flare-up after several weeks of progress in reducing pain and increasing mobility and an unidentified but chronic stomach pain that Sara linked to her underlying health anxiety. We also processed Sara’s anxiety about an upcoming train trip to London and her fear of collapsing with pain, needing to go to the hospital by ambulance, and the bodily anxiety she felt when thinking about the future in general.

Technically, memories were processed using the standard protocol and Pain-Itself; the actual physical experience of painwas processed using Grant’s (2018, p. 222) EMDR Pain Protocol by asking Sara to focus on the pain and note what images, negative cognitions, emotions and other bodily sensations she noticed, with the pain being rated on a numerical scale of 0 to10 alongside VOC and SUDs. ‘Float backs’ were used when addressing issues in the present or future to identify the source of the present disturbance: the root of the anxiety about the train trip to London, for instance, was found to be the memory of being in agony at the airport, requiring an ambulance to be called and morphine administered. Sara found ‘time travelling’ (rescue interweaves) particularly helpful, as, when I asked what she would say to her younger self if she could travel back in time to a moment of especially intense pain to help, she said, “I would tell her the pain will never be this bad again and that things will improve.” The positive feelings thus invoked were then installed as a resource, using BLS.

Sara’s negative cognitions expressed themes of helplessness (“I can’t do anything without causing pain,” “I can’t look after myself”), disbelief (“Why me? I don’t have bad luck like this”), self-blame (“Why did I do that? I made the pain worse”) and isolation (“No one understands what this is like for me”).

Her positive cognitions, as ever, acted as antidotes (“I can move, and I can leave,” “I can look after myself,” “I can move safely and without pain,” “I can accept that I am well” or “I can cook dinner for my family and enjoy it”). Sara’s VOCs for these PCs would typically move from 1/7 to 7/7, from Phase 3 to Phase 5, showing a growing sense of agency, confidence and optimism, reflected in her reported material between sets. When processing the earthquake memory, Sara moved from the terror of lying on her bed, thinking she couldn’t move while listening to the alarm signalling the start of an earthquake, to getting out of bed and outside her apartment, where she meets a neighbour who helps her onto the street. There, she meets the building caretaker, who tells her it’s a false alarm. She felt the relief flowing through her body; the SUD went from 6/10 to 0, and the VOC from 2 to 7.

 Sara attended her first session of my weekly Pilates for Chronic Lower Back Pain class after the third EMDR session. Pilates is a progressive, “layer-based exercise system. Participants typically take a twelve-week course, beginning with Level 1, or the simplest, most accessible version of each exercise, spending four weeks practising this level while gradually increasing the number of repetitions, before moving onto Level 2 for four weeks and finally Level 3, provided each layer has been accomplished. I also provided Sara with relevant information and explanations, including the nature and role of fascia in CLBP (Lesondak, 2023), the neurology of pain, and the link between trauma, stress and pain.

Sara talked about her progress in Pilates in her therapy sessions, providing a language to express and track her physical progress. After three sessions, she mentioned feeling a bit more mobile and able to walk further. At week seven, she could stand for longer and bend down to pick something up from nearly floor level, which she couldn’t do before. At week eight, she asked for recordings of the early sessions so she could try the exercises she couldn’t do before. By week nine, she could walk for forty minutes (up from five at week one). She was “wiped out” afterwards, but not in pain. In that week’s Pilates class, she got down onto the floor and lay on her back with both legs in the ‘tabletop’ position (knees over hips, shins parallel to the floor, a staple position in Pilates, from which many exercises begin), which she couldn’t do before.

At week 10, she had “a bit of a setback.” The pain at L4/L5 had increased, and she couldn’t do as much in the Pilates class. However, she wasn’t despondent, saying, “I know there’ll be ups and downs in my recovery; I still have to climb mountains.” She noted that although the pain had gone up, she was less bothered by it. She began to recover within a few days, returning to where she had been before, in terms of Pilates, within three weeks.

Outcomes

At the final session (session 16), Sara’s score on the Bournemouth Back Questionnaire was 22/70, down from 34 at assessment. Her pain score had reduced from 5/10 at assessment to 0.5/10 at week 16. Sara says she feels much better. She had made progress before, like when she went to ‘back school’ and had a mixture of education, movement, physio and group therapy, but the progress never lasted after the intervention ended.

The progress she’s made through Pilates has been more sustained and consistent. In September, she could only do housework in small bursts. However, now (in January), she can cook dinner in one go. At the start, she could only sit for a few minutes but can now manage a couple of hours. She can tolerate the pain much better, which has greatly improved her mood. She now has two new goals of having a nine-to-five job and travelling to socialise. She can sit and type for about 10 minutes without any pain and can take a break then, if needed. She feels more comfortable if upright or reclining.

At assessment, Sara had very limited flexion/extension (rolling down and up again) and rotation mobility in her spine, and as she could only stand for a few minutes, she did the first couple of Pilates classes sitting down, using adapted, ‘chair-based’ versions of the exercises, followed by the rest of the class. She could not get onto the floor and back up without the aid of a chair. The Pilates classes built her core, upper and lower body strength, and improved her spinal flexibility, and I encouraged her to walk every day, gradually increasing the distance and hence time spent walking. By the end of the programme, she could do the whole routine of nine exercises either standing or on the mat as appropriate. She could also walk for 40 minutes, up from five minutes at the start of the programme. The progressive nature of the Pilates classes gave Sara a ladder to climb up. Her confidence improved as she could do more and more of the routine, and this complemented and supported the cognitive change (the movement from helplessness and pessimism to agency and optimism about the future described above).

Discussion

Research literature on the effectiveness of EMDR in the treatment of chronic pain in general and CLBP specifically is growing (Grant, 2018; Gerhardt et al., 2016),and the mechanisms by which this happens are clearly explained (Grant, 2018), therefore, Sara’s progress after 16 sessions of EMDR was to be expected, to some extent. The novel factor in this case study is the Pilates programme Sara undertook alongside EMDR, raising the question of whether the Pilates contributed to the reduction in her pain, and if so, how.

Pilates is a system of exercise developed by Joseph Pilates in the 1920s (Steel, 2020), promoting core and whole-body strength and flexibility. A systematic review by Wells et al (2014) concluded that findings from the studies concerned show Pilates is effective in the treatment of CLBP and more effective than other forms of exercise.  The teaching and practice of Pilates are based on the six principles of breath, concentration, centring, control, precision and smooth, flowing movement, which all contribute to addressing the ‘physical’ causes of CLBP, but two of the principles (smooth, flowing movement and concentration) also address the psychological elements.

In a Pilates session, one is taught to move smoothly, with flow – not to rush but to move with control and precision. Pilates teachers encourage participants to concentrate on the movement, letting go of all other thoughts. Breath sets the rhythm of movement (usually one inhales to prepare, moves on the exhale, and returns on the inhale). This engages the parasympathetic nervous system, as does Yoga (Emerson & Hopper, 2011), calming and relaxing the body. Focusing mindfully on this smooth movement engages interoception, which is the process of the nervous system informing the brain of ‘how’ the body is. (Myers, 2014, p. 281). The brain receives messages that the body is moving smoothly, without impediment. To live with CLBP is to be beset with maladaptive cognitions: “If I move, the pain gets worse ”, “I can’t move without pain.” Pilates counters these thoughts with more adaptive information generated by this combination of focusing on the smoothly moving body, contributing to, and enhancing AIP (Shapiro, 2001, P. 456).

This process counteracts the ‘centralisation’ effect, often a significant factor in the development and maintenance of CLBP. When there is a physical cause for the pain (such as Sara’s annular tear), harm signals are sent from the site of the damage to the pain system in the brain. The brain analyses the signals, decides there is a risk of further damage unless the harm is attended to, and induces the sensation of pain in the relevant area to alert the conscious brain into action. If the damage takes time to heal, the harm signals will continue, and the pain system will become overly sensitive to them, continuing to send out pain signals, even though the harm signals are weakening as the damage slowly heals.

Sometimes the brain continues to send out pain signals even after the damage has healed and the harm signals have ceased – the mechanism through which phantom limb pain can develop (Doidge, 2007, pp. 184-186). Put another way, one part of the brain will be aware that the damage has healed and there is no need to feel pain, while another part still thinks there is harm in the lumbar spine, so it continues to send out pain signals. Ultimately, it is the brain’s decision whether something should hurt. In making the decision, the brain not only considers information received from the body through the nervous system, as discussed, but also how the person feels, including how stressed, depressed, anxious or traumatised they may be (Lalkhen, 2021, pp. 16-18).

Norman Doidge (2007, p. 192) quotes neurologist and expert on phantom limb pain, V. S. Ramachandran: “Pain is an opinion on the organism’s health, rather than a reflexive response to injury.” The more emotionally distressed someone is, the more likely it is their brain will send them pain. Depression and anxiety also lead to a fall in serotonin levels in the blood, which acts both as a painkiller and a mood regulator. (Lalkhen, 2021, p. 15).

Melzack and Wall’s groundbreaking work on the “Gate Control Theory of Pain,” published in 1965 (as cited in Lalkhen, 2021, pp. 153-54), showed that even where there is physical damage, the brain can stop the body feeling pain if this would be unhelpful under the circumstances. For example, if a soldier is wounded in a battle, they may not feel pain until the fighting is over and they have reached safety. If the brain had let them feel pain at the time, they would have stopped fighting and could have been killed. The brain does this by releasing endorphins and other painkillers to close a series of ‘gates’ along the nerves running up and down the spinal column, preventing pain signals from passing through them.

Psycho-education on this process, and the brain’s role in deciding whether the body should feel pain, helps clients understand how Bi-Lateral Stimulation (BLS )can address pain by stimulating AIP, promoting flow of information around the brain, so that the pain centre, which still thinks the body is damaged, can receive updated information about the healing of the injury concerned. However, such interventions need to be delivered sensitively and carefully to avoid the client believing you are telling them that “it’s all in your head” or “you’re making this up,” reminding them of unhelpful encounters with previous clinicians. In some cases, this can repeat patterns from childhood where expressing emotion was discouraged and emotional pain was unconsciously converted into physical pain to make it feel more manageable. This dynamic is recognised as a risk factor for the development of chronic pain in adulthood. (Grant, 2018, pp. 214-215; Keefe, 2024).

The EMDR/AIP approach promotes the flow of information around the brain through BLS, so the news that the original damage has healed can reach the part of the brain that thinks the lumbar spine hasn’t healed yet. Pilates contributes to this process by sending information to the brain (through proprioception and interoception) about the moving spine, which is getting stronger.

Walking (Pocovi et al  2024) is an effective method of reducing and preventing CLBP, and as Sara was keen to walk more, it gave us another metric (alongside pain measurements and progress through the Pilates programme) to measure her progress, i.e., tracking the number of minutes she could walk each day.

Sara’s responses to BLS showed her moving from being a passive recipient of pain at the start, to gaining a sense that she has control over the pain by sessions 15 and 16. This change could be seen within sessions, such as when we processed the memory of the earthquake alarm. At the start she felt terrified and helpless, but she then remembered getting out of her flat to find help. She also remembered more traumatic moments of the story than she was in touch with at assessment, enabling these to be processed too. This takes the view that traumatic memory is sometimes stored in the body as chronic pain, the processing can cause more experience to be converted back into memory, allowing it to be processed.

Education around the role of fascia in spinal health (Lesondak, 2023) aided Sara’s understanding of the condition, again helping her feel less helpless and more in control. This shift helped Sara take a positive approach to the increase in pain she experienced around week 10, regarding it as due to becoming more mobile during her recovery, rather than as a problem. She reached the point where she could distinguish between the pain itself – the actual physical sensation of pain – and the emotional experience of it, and how much she was bothered or disturbed by it. This is an important milestone in the recovery journey. As you become less emotionally disturbed by the pain, feelings of overwhelm reduce and agency returns. The fear that moving will exacerbate the pain decreases, and you become more physically and socially active, more engaged in the world again and less isolated by it. More physical movement and having other things to do and think about, to distract yourself with, all contribute to lower pain (Grant, 2018, p. 246).

Conclusion

Returning to the question asked at the start of this paper: Can Pilates and EMDR be an effective combination of psychotherapy and exercise for recovery from CLBP?

By the end of the combined Pilates and EMDR programme described, Sara’s CLBP had improved considerably. Her pain level had reduced from 5/10 to 0.5/10, she was more mobile and she was able to walk for forty minutes at a time compared to just five minutes as at the start. She could also stand for longer periods, including long enough to cook for herself and her family.

As noted, there is growing evidence that EMDR is an effective treatment for chronic pain; therefore, it is important to question whether this improvement would have happened anyway, without the Pilates or whether the exercise programme contributed to and enhanced the process of recovery. Clearly, there is a need for further research, as this is only a single case study.

 I believe the Pilates programme added several elements to the recovery process that were not provided by EMDR alone. Firstly, to the extent that there was still physical damage to the intervertebral disc with the annular tear, Pilates will have assisted with the physical resolution of the issue by strengthening Sara’s core and improving her posture, enabling her deep core/spinal stabiliser muscles to lengthen her spine, pulling the L4 vertebrae upwards, lessening pressure on the disc that sits below it and above L5. There would therefore be less pressure on the gel-like, inner part of the disc (nucleus pulposus) to push out through the tear in the outer ring and put pressure on spinal nerves, reducing the physical elements of the pain.

Secondly, Pilates is a form of AIP. Sensory data gathered through focusing on the smoothly moving body becomes part of the ‘adaptive information’ that BLS processes, updating the brain’s pain centre regarding the true condition of the lumbar spine.

Thirdly, Pilates provides the participant a ladder to climb up: the layered approach of Pilates, gradually increasing the difficulty of each exercise and the number of repetitions, allows participants to understand that they are making progress and Sara found this very helpful. Each EMDR session would begin with a brief update on how she had found that week’s Pilates session. Sara’s progress, from sitting in a chair to fully participating in classes (standing and lying on the mat), translated into improvements in her activities of daily living (ADLs). This gave her greater confidence and contributed to the shift from negative to positive beliefs noted earlier, which was a key feature of her recovery.

This experience can be used as a resource. As Sara became stronger and more mobile, I was able to ask her to visualise herself performing an exercise such as the Roll Down (see Table 1), to notice her emotions and where she felt them in her body and then use BLS to install the resource. When Sara had the setback at week 10, this knowledge sustained her and helped her view the increase in pain as temporary and probably just caused by increased fatigue, as becoming more active put more strain on her muscles.

TABLE 1 The Roll Down Stand with feet hip distance apart, ankles at right angles, soft knees, pelvis in neutral, core engaged, breathing sideways into the ribs. Shoulders down and stabilised, neck long, head forward and slightly down, as if holding an apple under your chin. Breathe in (nasally) and rock your head back slightly. Breathe out through the mouth and look down your chest, as if at the buttons of your shirt. Slowly bend forward and roll down, vertebrae by vertebrae, sliding your hands down the front of your legs till they get to your knees.  Shift weight slightly onto the balls of your feet. Hold here for an in-breath, an out-breath, another in-breath. On the out-breath, push the floor away with your feet, lift through the belly button, and slowly roll back up, with control, lifting and stacking one vertebra on top of the one below it, like Lego bricks. At the top, inhale and rock the head gently back. Exhale and repeat the downward movement, this time going just beyond the knee. Repeat another two to three times, each time going a little bit further. This exercise increases flexibility through the lumbar spine (flexion and extension) and strengthens the spinal stabiliser and mobiliser muscles.

Finally, offering a Pilates programme alongside therapy and making space in the therapy to reflect on Sara’s experience of Pilates is a powerful way of taking the physical reality of the pain seriously and avoiding the pitfalls of focusing exclusively on the psychological aspects (Keefe, 2024).

The overall effect of the Pilates programme complemented the AIP work of the EMDR sessions themselves in targeting traumatic memories underlying and generating the pain and the pain itself (Grant, 2018). Sara was courageous and determined to recover. Pilates gave her something she could actively do to contribute to her recovery, rather than being a passive recipient of therapy, and this was also a major factor.

Although not all EMDR therapists aspire to become Pilates teachers, increasing awareness of spinal anatomy and how core stability and increasing flexibility in the spine can reduce and prevent CLBP can help therapists to understand why the NICE guideline recommends the combined approach and explain this to clients. The more you understand about what happens in a Pilates session, the more you can understand the progress a client is making, which you can then use in therapy sessions to resource the client. Rather than being an adjunctive therapy, I regard exercise and Pilates as an essential element of the therapy itself, which greatly assists recovery from CLBP.

Statement of consent 

I can confirm that the client who is the subject of this case study has given their full consent: they gave consent for me to begin work on the article and have read this finished version. They are aware that the article is aimed at publication in the EMDR Therapy Quarterly and are content for it to be published.