Review: Systematic Review
Is Pilates an effective rehabilitation tool? A systematic review

https://doi.org/10.1016/j.jbmt.2017.04.008Get rights and content

Abstract

Background

Pilates is a system of exercise focusing upon controlled movement, stretching and breathing. Pilates is popular today not only for physical fitness but also for rehabilitation programs. This paper is a review of the literature on the effectiveness of Pilates as a rehabilitation tool in a wide range of conditions in an adult population.

Methods

A systematic literature review was carried out according to the PRISMA guidelines. Electronic databases were searched for cohort studies or randomised controlled trials (RCTs), and inclusion and exclusion criteria were applied. The final RCTs were assessed using the PEDro and CONSORT 2010 checklists.

Results

Twenty-three studies, published between 2005 and 2016, met the inclusion criteria. These papers assessed the efficacy of Pilates in the rehabilitation of low back pain, ankylosing spondylitis, multiple sclerosis, post-menopausal osteoporosis, non-structural scoliosis, hypertension and chronic neck pain. Nineteen papers found Pilates to be more effective than the control or comparator group at improving outcomes including pain and disability levels. When assessed using the CONSORT and PEDro scales, the quality of the papers varied, with more falling toward the upper end of the scale.

Conclusion

The majority of the clinical trials in the last five years into the use of Pilates as a rehabilitation tool have found it to be effective in achieving desired outcomes, particularly in the area of reducing pain and disability. It indicates the need for further research in these many areas, and especially into the benefits of particular Pilates exercises in the rehabilitation of specific conditions.

Introduction

The American College of Sports Medicine (ACSM) 2011 Position Stand on exercise recommends regular “cardiorespiratory, resistance, flexibility, and neuromotor training” to maintain fitness and health. They cite numerous physical and mental health benefits from a variety of exercise (Garber et al., 2011). The evidence for the benefits of Pilates as a form of exercise in healthy adults, although lacking in rigour, was found to be strong for improving flexibility and dynamic balance, and moderate for enhancing muscular endurance (Cruz-Ferreira et al., 2011a).

Pilates has recently been growing in popularity in rehabilitation programs, due to its perceived benefits in musculoskeletal disorders, as well as other conditions (Gallagher and Kryzanowska, 2000, Anderson, 2010, Dunleavy, 2010, Royer, 2013, Cruz-Ferreira A et al., 2011b). This development has occurred in an unregulated manner, as Pilates itself is not taught as a rehabilitative tool, and experts in rehabilitation are not necessarily Pilates experts.

In spite of these limitations, Pilates as a specific form of rehabilitative exercise may prove to be a useful tool for helping people improve physical function in varying stages of life and varying physical condition (Di Lorenzo, 2011).

Originally called Contrology, Pilates was designed by Joseph Pilates as a form of low-impact exercise suitable for use by anyone, and was particularly popular amongst dancers for many years. Pilates described Contrology as a system which ‘develops the body uniformly, corrects wrong postures, restores physical vitality, invigorates the mind, and elevates the spirit’ (Pilates and Miller, 1998).

More recently, Wells et al. (2012) reported the six major components of Pilates as: centering, concentration, control, precision, flow, and breathing. Pilates has become a mainstream, low impact exercise with many perceived benefits; both physical (such as balance, flexibility, pain reduction, disability reduction) and psychological (improved mindfulness, improved affect) (Pilates and Miller, 1998, Küçükçakır et al., 2013, Nóra Tolnai et al., 2016). Pilates exercise can either be done with specialised equipment or ‘apparatus’, or as a floor-based exercise on a mat. There is an emphasis on control of the torso (Pilates and Miller, 1998), and in more contemporary practice, the development of the ‘neutral spine’ or using the abdominals to create an ‘imprinted spine’ (Wells et al., 2012). With a shift in modern healthcare towards patient centered active management compared to a purely passive care model, there is a greater demand for physical exercises in the healthcare system in order to lower the financial burden of disease (Weiss et al., 2003, Richardson et al., 2010) and due to the evidence of its benefits in outcomes (2016, Kemmler et al., 2010).

Exercise in general has been shown to be beneficial in rehabilitation. Not only does tailored exercise potentially improve each component of physical fitness (cardiorespiratory fitness, muscular strength and endurance, body composition, flexibility, and neuromotor fitness) (Garber et al., 2011), research suggests that pain and functional activity can be improved by exercise in patients with disability, in the short to medium term and depending on the exercise (Bertozzi et al., 2013, Ibai Lopez-de-Uralde-Villanueva et al., 2016, Brown CK et al., 2016, Ferreira G et al., 2015, Landmark et al., 2011, Smith and Grimmer-Somers, 2010, Roddy EZ and Doherty, 2005, Slater JKMS et al., 2016).

Bertozzi et al. (2013), for example, conducted a systematic review and meta-analysis on the benefits of therapeutic exercise for subjects with nonspecific neck pain. They found a significant acute and medium term overall effect size for reducing pain, and a medium term but not significant overall effect size in reducing disability. Smith and Grimmer-Somers (Smith and Grimmer-Somers, 2010) reviewed the evidence in the literature for the effectiveness of physiotherapy exercise programs on chronic low back pain (CLBP) and found that exercise programs are effective in reducing pain and reoccurrence rates for CLBP for up to 6 months after the end of treatment.

The benefits of exercise in preventing chronic pain are well documented, with many theories as to how these benefits may occur. Such benefits were well presented in a paper by Landmark et al. (2011). In a study on 46 533 subjects, they found a consistent association between the duration, intensity and frequency of recreational exercise and the prevalence of chronic pain in the general population. They suggest exercise has positive effects on both pain relief and psychological status or mood, and that there may be a common pathway operating. A study done in 2014 by Jones et al. (2014) indicated that beyond the exercise induced hypoalgesia that occurs during exercise, exercise can also alter the long-term tolerance to pain. They were able to show that exercise does not alter the pain threshold but rather the tolerance to pain and that the effect was a systemic one in that although the exercise primarily targeted the legs, the pain tolerance was tested in the arm using a blood pressure cuff. Exercise has also been found to reduce neuropathic pain by reducing inflammatory chemicals that trigger pain (Chen Y-W et al., 2012, Leung et al., 2016, Merriwether E et al., 2016). Leung et al. (2016) found that in mice, regular exercise for 8 weeks increased the prevalence of regulatory macrophages in the muscle, leading to a greater release of anti-inflammatory cytokines and a decreased release of proinflammatory cytokines. A commonly proposed mechanism of hypoalgesia is via the release of endocannabinoids and endogenous opioids following exercise, though research indicates that this is not the only mechanism operating (Hoeger Bement MK, 2005, Hoeger Bement MK et al., 2009, Hoffman MD et al., 2004, Sparling PBG et al., 2003, Koltyn KF et al., 2014). There has been research into the role of conditioned pain modulation as a secondary mechanism of hypoalgesia, whereby exercise acts as a conditioning pain stimulus, and activates the descending inhibitory pathways which causes a decreased response to further pain stimuli (Lemley KJ and Hoeger Bement, 2014, Geva N, 2013, Ellingston L, 2011). These studies suggest that exercise, regardless of its nature, may be beneficial in decreasing the intensity of pain across a variety of conditions by a number of mechanisms.

Existing literature reviews on the topic of the effectiveness of Pilates include the Natural Therapies Overview Report (Baggoley, 2015) and the updated Cochrane Review (Yamato TP et al., 2015). The former (Baggoley, 2015) was a review of previous systematic reviews and were therefore limited to the papers and specific conditions included in those reviews. The authors found the evidence for Pilates to be inconclusive, with varying results and quality across the included studies. The report reviewed systematic literature reviews published between 2008 and 2013. The authors made comment of the number of conditions for which Pilates had been investigated but for which there was no systematic review. The updated Cochrane Review (Yamato TP et al., 2015) was a systematic review of randomised controlled trials published up to March 2014, with an update to include papers published up to June 2015. The Cochrane Review investigated only the effects of Pilates on low back pain.

It is the aim of this study to find the various conditions where Pilates has been studied as a rehabilitative tool and whether it has been beneficial. This research aims to provide an updated review of the literature across a wider range of conditions, thus giving an indication of where Pilates may be most effective in rehabilitation as well as areas for future research.

Section snippets

Methodology

A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009). The following online databases were searched: PubMed, Scopus, Embase, Mantis, CINAHL, and PEDro. An example of the search strategy used in PubMed is displayed in Table 1. The search was carried out from the 13th of March to the 18th of April 2016.

Forward and reverse citation tracking was carried out from January 9 to January

Results

The search terms were entered into the following databases: PubMed (returned 70 results), Scopus (returned 6 results), Embase (returned 76 results), Mantis (returned 28 results), CINAHL (returned 88 results), and PEDro (returned 52 results). This search yielded a total of 320 results. Papers were then screened according to the PRISMA flowchart (see Fig. 1).

One hundred and twelve duplicates were manually removed from the library leaving 208 records. A further 164 records were removed, based on a

Discussion

From the limited data available, it would seem from the statistically and clinically significant findings that Pilates has demonstrated efficacy as a tool for the rehabilitation of a wide range of conditions. Common improvements across the different conditions were in pain, disability, and balance or functional movement outcomes. However, aside from LBP, there were too few studies to draw conclusions as to the usefulness of Pilates for relieving symptoms for specific conditions. Heterogeneity

Limitations

The main limitation found was the small number of conditions represented in the literature, and very few studies into conditions other than LBP. Across all conditions there was a lack of uniformity in study quality, controls or comparators used, Pilates exercises prescribed and study methodology. This made it difficult to compare the studies, perform a meta-analysis and analyse their significance.

A limitation across all included papers was short study periods and limited follow up data. Most

Conclusion

The majority of the clinical trials in the last five years into the use of Pilates as a rehabilitation tool have found it to be effective in achieving desired outcomes, particularly in the area of reducing pain and disability. This latest research has also rated reasonably well in terms of quality, using the PEDro scale and CONSORT method of appraisal. This study updates the systematic reviews of the literature done earlier, and uniquely shows the improvement in the research in the last 5–10

Acknowledgements and Conflict of interest

The authors report no conflict of interest in this research. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References (62)

  • A. Anand et al.

    A study to analyse the efficacy of modified Pilates based exercises and therapeutic exercises in individuals with chronic non specific low back pain: a randomized controlled trial

    Int. J. Physiother. Res.

    (2014)
  • B. Anderson

    Fitting pilates into a rehabilitation practice: pilates could be the perfect fitness program ot add to your PT practice

    Rehabil. Manag. Interdiscip. J. Rehabil.

    (2010)
  • E. Angın et al.

    The effects of clinical pilates exercises on bone mineral density, physical performance and quality of life of women with postmenopausal osteoporosis

    J. Back Musculoskelet. Rehabil.

    (2015)
  • Australian New Zealand Clinical Trials Registry [Online]. Available:...
  • C. Baggoley

    Review of the Australian government rebate on natural Therapies for private health insurance

  • L. Bertozzi et al.

    Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials

    Phys. Ther.

    (2013)
  • S.D. Brown CK et al.

    The effectiveness of exercise on recovery and clinical outcomes in patients with soft tissue injuries of the hip, thigh, or knee: a systematic review by the ontario protocol for traffic injury management

    J. Manip. Physiol. Ther.

    (2016)
  • L.Y.-T. Chen Y-W et al.

    Exercise training attenuates neuropathic pain and cytokine expression after chronic constriction injury of rat sciatic nerve

    Anesth. Analg.

    (2012)
  • F.J. Cruz-Ferreira A et al.

    A systematic review of the effects of Pilates method of exercise in healthy people

    Arch. Phys. Med. Rehabil.

    (2011)
  • M.A. da Luz et al.

    Effectiveness of mat Pilates or equipment-based Pilates exercises in patients with chronic nonspecific low back pain: a randomized controlled trial

    Phys. Ther.

    (2014)
  • C.E. Di Lorenzo

    Pilates: what is It? Should it Be used in rehabilitation?

    Sports Health

    (2011)
  • S. Donzelli et al.

    Two different techniques in the rehabilitation treatment of low back pain: a randomized controlled trial

    Europa Medicophysica

    (2006)
  • K. Dunleavy

    Pilates fitness continuum: post-rehabilitation and prevention pilates fitness programs

    Rehabil. Manag. Interdiscip. J. Rehabil.

    (2010)
  • C.D. Ellingston L

    Exercise induces hypoalgesia through conditioned pain modulation

    J. Pain

    (2011)
  • P.P. Fairbank JC

    The Oswestry disability index

    Spine

    (2000)
  • R.C. Ferreira G et al.

    The effect of exercise therapy on knee adduction moment in individuals with knee osteoarthritis: a systematic review

    Clin. Biomech.

    (2015)
  • L. Gagnon

    Efficacy of Pilates Exercises as Therapeutic Intervention in Treating Patients with Low Back Pain

    (2005)
  • S. Gallagher et al.

    The Joseph H. Pilates Archive Collection

    (2000)
  • C. Garber et al.

    Quantity and quality of exercise for developing and maintaining cardiorespiratory, mscloskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise

    Med. Sci. Sports Exerc.

    (2011)
  • D.R. Geva N

    Enhanced pain modulation among triathletes: a possible explanation for their exceptional capabilities

    Pain

    (2013)
  • V. Gladwell et al.

    Does a program of Pilates improve chronic non-specific low back pain?

    J. Sport Rehabil.

    (2006)
  • Cited by (61)

    • What are the effects of pilates in the post stroke population? A systematic literature review & meta-analysis of randomised controlled trials

      2023, Journal of Bodywork and Movement Therapies
      Citation Excerpt :

      In a systematic review examining pilates exercises in elderly participants, Bullo et al. 2015 found that pilates exercises with a strong focus on core strength training, could be used as an adjunct or even alternative to traditional balance training programmes for older adults. Secondly, pilates, in theory, can assist in improving kinaesthetic awareness (Osar and Bussard, 2016) which could help to improve balance due to the fact that balance limitations can involve deficits in the proprioceptive system, with altered movement patterns (Casonatto and Yamacita, 2020). Thirdly, the balance improvements may have been in part due to “centreing”, a key principle of pilates which involves a consistent and repetitive focus on neutral postures, centreing and alignment.

    • The effects of clinical pilates training on disease-specific indices, core stability, and balance in patients with ankylosing spondylitis

      2023, Journal of Bodywork and Movement Therapies
      Citation Excerpt :

      Pilates is a popular mind–body exercise method developed by Joseph H. Pilates in the early of the 20th century (Latey, 2001). Since the late 1980s, the Pilates method has become more popular in exercise science as the studies pointed out the beneficial results of programs in musculoskeletal problems and other disorders (Byrnes et al., 2018). This method is based on six fundamental principles: concentration, control, centering, flowing movement, precision, and breathing (Latey, 2001).

    • Effects of mat Pilates on older adult women with knee osteoarthritis: A randomized controlled trial

      2023, Journal of Bodywork and Movement Therapies
      Citation Excerpt :

      No participant reported adverse effects to treatment (such as pain or musculoskeletal discomfort), including the periods between sessions. This study intends to fill a gap in the literature as pointed in two systematic reviews (Mazzarino et al., 2015; Byrnes et al., 2018), which indicate the need for further research to assess the benefits of Pilates exercises in the rehabilitation of specific conditions, with programs and protocols described in detail following methodological rigor. Moreover this is a pioneering study which evaluates the effects of Mat Pilates in the rehabilitation of older adult with KOA.

    View all citing articles on Scopus
    View full text