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REVIEW ARTICLE
Abstract
Objective: To critically analyze the benefits of Pilates on health outcomes in women.
Data Sources: CINAHL, MEDLINE, PubMed, Science Direct, SPORTDiscus, Physiotherapy Evidence Database (PEDro), Cochrane Central
Register of Controlled Trials, and Web of Science.
Study Selection: Databases were searched using the terms Pilates and Pilates Method. Published randomized controlled trials (RCTs) were
included if they comprised female participants with a health condition and a health outcome was measured, Pilates needed to be
administered, and the article was published in English in a peer-reviewed journal from 1980 to July 2014.
Data Extraction: Two authors independently applied the inclusion criteria to potential studies. Methodological quality was assessed using the
PEDro scale. A best-evidence grading system was used to determine the strength of the evidence.
Data Synthesis: Thirteen studies met the inclusion criteria. PEDro scale values ranged from 3 to 7 (mean, 4.5; median, 4.0), indicating a
relatively low quality overall. In this sample, Pilates for breast cancer was most often trialed (nZ2). The most frequent health outcomes
investigated were pain (nZ4), quality of life (nZ4), and lower extremity endurance (nZ2), with mixed results. Emerging evidence was found for
reducing pain and improving quality of life and lower extremity endurance.
Conclusions: There is a paucity of evidence on Pilates for improving womens health during pregnancy or for conditions including breast cancer,
obesity, or low back pain. Further high-quality RCTs are warranted to determine the effectiveness of Pilates for improving womens health
outcomes.
Archives of Physical Medicine and Rehabilitation 2015;96:2231-42
2015 by the American Congress of Rehabilitation Medicine
Disclosures: none.
0003-9993/15/$36 - see front matter 2015 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2015.04.005
2232
M. Mazzarino et al
Methods
Diseases and Related Health Problems29 to identify health problems or diseases, as well as health conditions for individuals in a
general health situation or human life cycle including pregnancy,
childbirth, and aging. For high-resourced countries, the WHO30
defines an older person as 60 years of age, and the researchers
used this criteria to classify an aging population.
The WHO International Classification of Functioning,
Disability and Health28 was used to define health outcomes. It is a
2-level classification system for (1) body structures and functions,
and (2) activities and participation. It was used as a framework to
categorize health outcome metrics with health conditions. For
example, pelvic floor muscle strength (eg, health outcome metric)
assessment may be used to investigate stress incontinence (eg, the
health condition). The following domains were used: structure
related to movement; neuromuscular and movement functions;
sensory functions and pain; mental functions; digestive, metabolic, and endocrine functions; functions of the cardiovascular
system; and activities and participation.
For the first phase of the article selection process, 2 reviewers
(M.M., H.W.) assessed all retrieved abstracts for possible inclusion. Discrepancies were resolved through discussion between the
2 reviewers. A third reviewer (D.K.) was consulted if consensus
could not be reached.
Full articles were then retrieved for the second phase of the
selection process to assess eligibility for inclusion in the review.
Two reviewers (M.M., H.W.) individually reviewed the articles to
confirm eligibility criteria. Articles that were identified as eligible
for inclusion were reexamined for accuracy and consistency by the
third reviewer (D.K.), who also arbitrated on discrepancies.
Study selection
Retrieved studies were reviewed for inclusion if they met the
following criteria: (1) published in a peer-reviewed journal in the
period 1980 to July 2014; (2) written in the English language; and
(3) the methodology included a randomized controlled trial (RCT)
design, Pilates administered as the intervention, female participants with a health condition, and an evaluation that included
measurement of a health outcome. The researchers adopted the
World Health Organization (WHO)28 definition for a health condition, which includes disease (acute or chronic), disorder, injury
or trauma, and other circumstances such as pregnancy, aging,
stress, congenital anomaly, or genetic predisposition. The researchers used the WHO International Statistical Classification of
Data synthesis
List of abbreviations:
BES
PEDro
QOL
RCT
WHO
best-evidence synthesis
Physiotherapy Evidence Database
quality of life
randomized controlled trial
World Health Organization
For articles that met the eligibility criteria, the following data were
extracted and reported in an evidence table (table 2): author/year,
health condition, age, sample size, intervention, health outcome
metrics, and results. Only statistically significant improvements in
health outcomes, evidenced by P<.05, were included. Table entries were checked for accuracy and consistency by a second
www.archives-pmr.org
Results
1
1
1
1
1
1
1
1
1
1
1
1
1
13
1
1
1
1
1
1
1
1
1
1
1
1
1
13
6*
5*
5*
4
6*
,
5* y
4
3y
4
,
6* y
4
3
4y
0
0
0
0
0
0
0
0
0
1
0
0
0
1
1
0
1
0
1
1
1
0
0
1
0
0
0
6
2233
author (D.K.). Any disagreements concerning the information
reported in the evidence table were reconciled among the
research team.
The best-evidence synthesis (BES) approach35,36 was used to
measure the strength of the evidence. BES incorporates processes
of the meta-analysis including systematic literature searches and
quantification with a detailed analysis of study characteristics. The
BES approach is an alternative to a meta-analysis when the
number of eligible studies and power is low.35-38 BES provides a
strategy for prioritizing evidence37 and has been used in a previous
review6 on the effects of Pilates in healthy people. The researchers
adopted the method of Cruz-Ferreira et al6 in allocating strength
of evidence to findings as follows: strong evidence allocated to
health outcomes where >1 high-quality (PEDRO score >4) RCT
is available; moderate evidence allocated to health outcomes
where 1 high-quality RCT with >1 low-quality RCT is available;
limited evidence allocated to health outcomes where 1 highquality or >1 low-quality RCT is available; and no evidence
allocated where 1 low-quality RCT or contradictory outcomes
were found between group comparisons.
Assessor
Blinding
1
0
0
0
1
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Study selection
Therapist
Blinding
Intention to
Follow-up Treat
Between
Group
Point
Estimate
Total PEDro
Score
1
1
1
1
1
1
0
0
1
1
1
0
1
10
0
1
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Groups
Similar
Concealed
Allocation
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* High-quality RCT.
y
Group comparison not performed.
Study characteristics
1
Altan et al40 (2009)
Alves de Araujo et al41 (2012) 1
1
Cakmakci42 (2011)
Eyigor et al9 (2010)
1
1
Kucukcakr et al24 (2013)
1
Marinda et al43 (2013)
Martin et al44 (2013)
1
1
Plachy et al45 (2012)
Rodrigues et al39 (2010)
1
1
Fourie et al46 (2013)
Ashrafinia et al47 (2014)
1
Lee et al48 (2014)
1
1
Gildenhuys et al49 (2013)
Total rating no.
13
Random
Allocation
Study
Table 1
Participant
Blinding
Method quality
The delivery of the Pilates intervention ranged from 2 to 5 sessions per week. Duration of treatment ranged from 8 weeks to 1
year; 8 studies delivered the intervention for 8 weeks.9,39,42-44,46-49
Sample sizes were small, ranging from 26 to 80 female subjects
(see table 2). Musculoskeletal conditions that included fibromyalgia,40 nonstructural scoliosis,41 postmenopausal osteoporosis,24
and chronic low back pain48 were the most frequently investigated. Other health conditions included breast cancer9,44 and
obesity,42 and 1 study47 investigated sleep disturbances in postnatal women. Five RCTs39,43,45,46,49 studied health outcomes in
elderly women.
2234
Table 2
Study
Health Condition/
Age of Subjects
Intervention
Control
Key Results
Women with
fibromyalgia
syndrome
Pilates: MZ48.2y
Control: MZ50.0y
Total: NZ50
Intervention: nZ25
Control: nZ25
Home exercise
(relaxation/
stretching)
Alves de Araujo
et al41 (2012)
Total: NZ31
Intervention: nZ20
Control: nZ11
No intervention
Degree of scoliosis
Pain
Range of motion for trunk
flexion
Cakmakci42
(2011)
Total: NZ61
Intervention: nZ34
Control: nZ27
No intervention
M. Mazzarino et al
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Sample Size
Altan et al40
(2009)
Study
Health Condition/
Age of Subjects
Sample Size
Intervention
Control
Key Results
Eyigor et al9
(2010)
Total: NZ52
Intervention: nZ27
Control: nZ25
Home exercise:
Walking, 8wk,
3 20
e30min/wk
Depression
Fatigue
Flexibility
Functional capacity
QOL
Kucukcakr
et al24 (2013)
Women with
postmenopausal
osteoporosis without
history of a fracture
Pilates: MZ57y
Control: MZ56y
Total: NZ70
Intervention: nZ35
Control: nZ35
Home exercise:
Thoracic
extension
exercises in a
sitting
position
Functional capacity
Lower extremity endurance
Number of falls
Pain
QOL
Marinda et al43
(2013)
Sedentary elderly
women
Pilates: MZ66.1y
Control: MZ65.3y
Total: NZ50
Intervention: nZ25
Control: nZ25
No intervention
Martin et al44
(2013)
Total: NZ26
Pilates: nZ8
RT: nZ8
Control: nZ10
RT: Resistance
exercises for
8wky
Control: No
intervention
Glucose
Resting heart rate
Resting systolic blood
pressure
Resting diastolic blood
pressure
Total cholesterol
Triglycerides
Muscular endurance
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Table 2 (continued )
2235
2236
Table 2 (continued )
Health Condition/
Age of Subjects
Sample Size
Intervention
Control
Key Results
Plachy et al
(2012)
Elderly women
Pilates: MZ66.2y
Aqua/Pilates: MZ67.1y
Control: MZ68.2y
Total: NZ42
Intervention: nZ15
Aqua/Pilates: nZ15
Control: nZ12
Frequency: 24wk
Pilates: Pilates exercises,
3 1h/wk
Aqua/Pilates: 2 1h/wk
(Aqua) and Pilates 1
1h/wk
Aqua fitness/
Pilatesy
No intervention
Aerobic endurance
Endurance and low body
strength
Flexion of right shoulder
Flexion of right hip
Lumbar spine flexion
Thoracolumbar spine flexion
Trunk lateral flexion
Rodrigues et al39
(2010)
Elderly women
MZ66yz
Total: NZ52
Intervention: nZ27
Control: nZ25
No intervention
Personal autonomy
QOL
Static balance
Fourie et al46
(2013)
Elderly sedentary
women
Pilates: MZ66.1y
Control: MZ65.3y
Total: NZ50
Intervention: nZ25
Control: nZ25
No intervention
Body fat
Body mass
BMI
Fat mass
Lean body mass
Study
45
M. Mazzarino et al
www.archives-pmr.org
Health Condition/
Age of Subjects
Sample Size
Intervention
Control
Key Results
Ashrafinia et al47
(2014)
Postpartum women
Pilates: MZ24.6y
Control: MZ24.4y
Total: NZ80
Intervention: nZ40
Control: nZ40
Postnatal
education
Sleep quality
Lee et al48
(2014)
Businesswomen with
chronic low back pain
Pilates: MZ34.0y
Pilates apparatus
exercise: MZ34.4y
Total: NZ40
Intervention: nZ20
Control: nZ20
Pilates apparatus
exercisey
Pain
Sway length
Sway velocity
Gildenhuys
et al49 (2013)
Sedentary elderly
women
Pilates: MZ66.1y
Control: MZ65.3y
Total: NZ50
Intervention: nZ25
Control: nZ25
No intervention
Agility
Functional mobility
Maximal cardiorespiratory
fitness
Study
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Table 2 (continued )
Abbreviations: BMI, body mass index; M, mean age; RT, resistance training.
* Number of sessions per week not stated.
y
Second experimental group.
z
Mean years of age per experimental group not stated.
2237
2238
M. Mazzarino et al
and sport science clinician (Pilates certification not reported)
(nZ2).44,47 No studies described the style of Pilates or origin of
Pilates exercises.
Discussion
This systematic review of Pilates for womens health found
emerging evidence for reducing pain and improving QOL and
lower extremity endurance. However, overall, the methodological
quality of eligible RCTs was relatively low (mean score, 4.5).
There was a lack of high-quality trials investigating the benefits of
Pilates for improving womens health outcomes.
This review found a reduction in pain based on studies
investigating fibromyalgia,40 nonstructural scoliosis,41 postmenopausal osteoporosis,24 and low back pain.48 For these
studies, the Pilates intervention was compared with control conditions including home exercise relaxation and stretching,40 no
intervention,41 and thoracic extension exercises,24 and in 1 study48
mat-based Pilates was compared with Pilates apparatus exercise.
This demonstrates that there is a paucity of evidence as to whether
other treatment regimens or forms of exercise are more or less
effective in reducing pain.16,19,20,23
Improvement in QOL was found in studies investigating fibromyalgia syndrome40 and postmenopausal osteoporosis,24 and
in a study of elderly women.39 It is unclear from the current review whether participating in a therapeutic ritual provided a placebo effect,50 and whether the acuity of a health condition
influences QOL in women.
Emerging evidence was found for lower extremity endurance
in RCTs investigating fibromyalgia40 and postmenopausal osteoporosis.24 Weakened low extremity strength and endurance secondary to physiological changes associated with aging are
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2239
Health Outcome
Level of Evidencey
Limited evidence
Flexibility
Strong evidence
No evidence
Limited evidence
Limited evidence
No evidence
No evidence
Kucukcakr et al24 ()
Altan et al40 ()
Alves de Araujo et al41 ()
Lee et al48 ()
Altan et al40 (o)
Strong evidence
No evidence
Depression
Sleep quality
No evidence
No evidence
Fatigue
Functional capacity
No evidence
Cakmakci42 ()
Cakmakci42 ()
Limited evidence
Limited evidence
Cakmakci42
Cakmakci42
Cakmakci42
Cakmakci42
Cakmakci42
Cakmakci42
Cakmakci42
Cakmakci42
Limited evidence
Limited evidence
No evidence
No evidence
No evidence
No evidence
No evidence
No evidence
Fibromyalgia impact
Lower extremity endurance
Muscular endurance
Number of falls
Range of motion for trunk flexion
Static balance
Sway length and velocity
No evidence
Limited evidence
Mental functions
Limited evidence
()
()
(o)
(o)
(o)
(o)
(o)
(o)
Rodrigues et al39 ()
Eyigor et al9 (o)
Kucukcakr et al24 ()
Rodrigues et al39 ()
Altan et al40 ()
No evidence
Strong evidence
2240
endurance (time to walk up stairs test,52 squat till fatigue test53) as
well as the varied control conditions. Future studies require congruency in the methodological approach to measuring lower extremity endurance in elderly women, and for specific health
conditions such as fibromyalgia and osteoporosis.
Limited evidence was found for 4 health outcomes related to
body composition: waist-hip ratio,42 skinfold thickness,42 fat
percentage,42 and basal metabolic rate.42 These findings are
consistent with those of Aladro-Gonzalvo,10 who found poor
empirical evidence supporting Pilates having a positive effect on
body composition. Change in body composition health outcome
metrics may be mediated by factors such as life stage (pregnancy,
menopause), health conditions (ie, bulimia, obesity), preintervention fitness level (ie, athletic vs sedentary), and energy
intake (ie, diet),10,54 and these variables require further
consideration.
Contradictory results were found for flexibility. Improvement
was found in obese women,42 but no effect was found in female
breast cancer patients.9 These studies, however, had significant
methodological differences. The method of measuring flexibility
was not stated in 1 study,9 and the sit and reach test42 was used in
the other. Both studies implemented the intervention over 8
weeks; however, the frequency and duration of Pilates were 4
sessions per week, 60 minutes per session for obese woman,42 and
3 sessions per week, 20 to 30 minutes per session for female breast
cancer patients.9 In a review6 of healthy adults, strong evidence
was found for improvement in flexibility in sedentary adult females,55 healthy adults,56 healthy middle-aged adults,57 and
elderly women,26 with flexibility measured in the following body
areas: trunk,55 lower back,26,56 hamstrings,26,56,57 and upper
body.56 For these studies, the duration of the Pilates intervention
was 60 minutes, and the frequency of sessions was 257 or 326,55,56
times per week for a period of 5 weeks,55 8 weeks,56 and 12
weeks.26,57 Factors underpinning exercise prescription, including
body area of focus, type of exercise, number of repetitions, and
frequency of sessions, may influence health outcomes such as
flexibility6 and should be considered in future research.
Pilates is advocated for alleviating discomforts of pregnancy58,59 and assisting in strength and endurance for labor and
birth60; however, this review found that evidence is absent for
improving perinatal outcomes in these situations. The American
College of Obstetricians and Gynecologists and the Centers for
Disease Control and Prevention61-63 recommended that in the
absence of medical or obstetric complications, women should
moderately exercise for 30 minutes daily. Evidence is needed to
verify the benefits of Pilates as a form of exercise for pregnancy
and birthing outcomes.
Study limitations
Limiting the eligibility criteria to women may have omitted evidence on health outcomes previously found in mixed samples. For
example, a large body of evidence on mixed samples of men and
women shows that Pilates may reduce pain and disability in individuals with chronic low back pain.23 Those studies do not
discern differences in outcomes for men and women. The BES
focused on 3 high-quality24,40,41 and 2 low-quality9,48 studies,
which limits the generalizability of findings. Another limitation
was that only RCTs were included; observational and qualitative
studies may provide additional findings in improving health outcomes for women.6 In addition, the search was limited to Englishlanguage journals, and studies using other languages were not
M. Mazzarino et al
considered. This review focused on findings that were statistically
significant. Overall, the studies were small (n<80), and this may
have affected the strength of findings. Larger, well-designed RCTs
are needed. A lack of homogeneity, range of conditions, and
variation in the Pilates intervention inhibited the synthesis of
findings. Also, the extent to which the placebo effect associated
with the therapeutic intervention influences the reduction in pain
and improves QOL in women requires further investigation.
Conclusions
Pilates is a popular form of exercise for women who strive to
improve their physical and psychological health. However, there is
a paucity of evidence that Pilates improves womens health. We
found emerging evidence to show that Pilates may reduce pain and
may improve QOL and lower extremity endurance. Whether
Pilates improves womens health during pregnancy or optimizes
health outcomes for breast cancer, obesity, and chronic low back
pain is yet to be confirmed.
Keywords
Pilates-based exercises; Rehabilitation; Review; Womens health
Corresponding author
Melissa Mazzarino, MCMid, Victoria University, McKechnie St,
Melbourne, Victoria, Australia 3021. E-mail address: melissa.
mazzarino@vu.edu.au.
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