Pilates Method for Women’s Health

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REVIEW ARTICLE

Pilates Method for Women’s Health: Systematic

Review of Randomized Controlled Trials

Melissa Mazzarino, MCMid,a Debra Kerr, PhD,a Henry Wajswelner, DPhysio,b

Meg E. Morris, PhDb

From the aCenter for Chronic Disease Prevention and Management, College of Health & Biomedicine, Victoria University, Melbourne; and bCollege of Science, Health and Engineering, Department of Physiotherapy, La Trobe University, Melbourne, Australia.

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 women’s 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 women’s health

outcomes.

Archives of Physical Medicine and Rehabilitation 2015;96:2231-42

ª 2015 by the American Congress of Rehabilitation Medicine

Pilates is a form of exercise based on movement principles

including whole-body movement, breathing, concentration,

centering, precision, and rhythm.1-5 Pilates is a mindful approach

to exercise, stimulating awareness of body structure, muscle

recruitment, and body alignment during movement.1,2 Joseph

Pilates2,3 claimed that this set of corrective exercises promoted

voluntary control over the body and effective posture, stabilizing

core muscles during dynamic movement, and promoted physical

and mental vitality.4,6 Pilates may be practiced on the mat using

one’s body weight or using Pilates equipment,7,8 which has

resistant springs to stabilize and strengthen deep muscle groups.2

Internationally, Pilates has appealed to women as a mainstream

form of exercise9 for improving physical health (muscular

strength, endurance, core stability, breathing), psychological

health (mood, motivation, body awareness), and motor functions

(muscle control, dynamic postural control, balance and

coordination).1,4

Recent systematic reviews have investigated the effectiveness

of Pilates on health outcomes related to body composition,10

breast cancer rehabilitation,11 physical fitness and fall prevention

in seniors,12-14 and pelvic floor muscle function.15 Aladro-

Gonzalvo et al10 reported on 7 studies and concluded that there

was poor empirical evidence supporting Pilates having a positive

effect on body composition. Alternatively, another review11 of 3

studies that applied Pilates for breast cancer rehabilitation found

trends in enhanced quality of life (QOL), mood, body image, and

aerobic capacity; however, sample sizes were small. GranacherDisclosures: none.

0003-9993/15/$36 - see front matter ª 2015 by the American Congress of Rehabilitation Medicine

http://dx.doi.org/10.1016/j.apmr.2015.04.005

Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org

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et al12 reviewed 20 studies and found improvement in trunk

muscle strength, functional performance, and balance in healthy

seniors. A similar review13 of 17 experimental studies found

improvement in static and dynamic balance in elderly people.

Currently, there is limited evidence to support Pilates’ effective-

ness to reduce stress urinary incontinence.15

Most studies examining Pilates have investigated individuals

with chronic low back pain.16-23 La Touche17 and Lim19 and

colleagues found evidence that Pilates reduced pain. A review22

of 5 systematic reviews concluded that there is inconclusive evidence

to support Pilates in reducing pain in people with chronic low back

pain, and cautioned against the use of findings because of con-

cerns about the heterogeneity of pooled studies and scienti-

fic rigor.

While several studies have investigated the effectiveness of

Pilates for health conditions (eg, breast cancer,9 postmenopausal

osteoporosis)24 and in promoting health (eg, strengthening pelvic

floor muscles,25 preventing falls),26,27 a synthesis and evaluation

of the evidence has not been conducted in the form of a systematic

review. Although there is emerging evidence that Pilates may

reduce chronic low back pain,18-21,23 these investigations were

from samples of men and women. The specific effects on women’s

health are difficult to ascertain in these mixed samples, and the

benefits are not clear. Therefore, the aim of this systematic review

was to evaluate the evidence for the effectiveness of Pilates for

improving health outcomes in women.

Methods

Data sources and searches

A joint search was conducted by 2 authors (M.M., H.W.). Studies

were selected for review up to November 2014 by searching the

following search engines: CINAHL, MEDLINE, PubMed, Sci-

ence Direct, SPORTDiscus, Physiotherapy Evidence Database(PEDro), Cochrane Central Register of Controlled Trials, and Web

of Science. The search strategy used the terms Pilates and

Pilates Method .

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 partici-

pants with a health condition, and an evaluation that included

measurement of a health outcome. The researchers adopted theWorld Health Organization (WHO)28 definition for a health con-

dition, which includes disease (acute or chronic), disorder, injury

or trauma, and other circumstances such as pregnancy, aging,

stress, congenital anomaly, or genetic predisposition. The re-

searchers used the WHO International Statistical Classification of

Diseases and Related Health Problems29 to identify health prob-

lems 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, meta-

bolic, 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 inclu-

sion. 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.

Rating the quality of articles

For each eligible RCT, methodological quality was assessed by 2

reviewers (M.M., H.W.) using the PEDro scale.31 The PEDro

scale, based on the Delphi list,32 is commonly used to assess the

quality of clinical trials in physiotherapy.31 It consists of 10

items: random allocation, concealed allocation, similarity at

baseline, subject blinding, therapist blinding, assessor blinding,

adequate follow-up (>85% follow-up for at least 1 key

outcome), intention-to-treat analysis, between-group compari-

sons for at least 1 key outcome, point estimates and variability

measures.32 These 10 items are each allocated a score of 1 point

if the criteria satisfy the standardized score. The PEDro score

ranges from 1 to 10, with higher PEDro scores corresponding to

a higher quality in methodology.33 A PEDro score 4 has been

evaluated to be of lower quality.31 The interrater reliability has

been evaluated previously31 and appears to be a valid measure of

methodological quality for clinical physical therapy trials.33,34

Disagreements in PEDro scoring between the 2 reviewers(M.M., H.W.) were resolved by the third reviewer (D.K.). All

PEDro scores were entered into an individual spread-

sheet (table 1).

Data synthesis

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 en-

tries were checked for accuracy and consistency by a second

List of abbreviations:

BES best-evidence synthesis

PEDro Physiotherapy Evidence Database

QOL quality of life

RCT randomized controlled trial

WHO World Health Organization

2232 M. Mazzarino et al

www.archives-pmr.org





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 astrategy 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 high-

quality or >1 low-quality RCT is available; and no evidence

allocated where 1 low-quality RCT or contradictory outcomes

were found between group comparisons.

Results

Study selection

The initial search located a total of 362 citations. After review of

the title and abstract, 59 full articles were retrieved for further

assessment of eligibility. After article review and identification of

duplicates, 13 RCTs9,24,39-49 were included in the review. Figure 1

illustrates the process for selection of articles.

Method quality

PEDro scores ranged from 3 to 7 (mean, 4.5; median, 4.0) (see

table 1). Six RCTs24,40-43,46 scored >4 and 7 RCTs9,39,44,45,47-49

scored 4, with the former indicating a higher quality in meth-

odology. The PEDro criteria of “random allocation,” “reporting of

between-group difference,” and “point estimate variability” were

fulfilled in all 13 RCTs. The criterion “groups similar at baseline”

was fulfilled in 10 RCTs.9,24,39-43,46,47,49 One RCT41 fulfilled the

criteria for “concealed allocation” and 1 RCT46 for “intention to

treat,” and no RCTs fulfilled the criteria for “participant blinding”

and “therapist blinding.” “Adequate follow-up” was fulfilled in 6

RCTs,24,40,42-44,46 whereas “assessor blinding” was fulfilled in

only 2 RCTs.24,40 Group comparisons were performed in 9

RCTs9,24,39-42,44,47,48 (see table 1).

Study characteristics

The delivery of the Pilates intervention ranged from 2 to 5 ses-

sions 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 fibromy-

algia,40 nonstructural scoliosis,41 postmenopausal osteoporosis,24

and chronic low back pain48 were the most frequently investi-

gated. Other health conditions included breast cancer9,44 and

obesity,42 and 1 study47 investigated sleep disturbances in post-

natal women. Five RCTs39,43,45,46,49 studied health outcomes in

elderly women. T a b l e

1

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Pilates method for women’s health 2233






Table 2 Description of eligible studies

Study

Health Condition/

Age of Subjects Sample Size Intervention Control Health Outcome Metrics

Altan et al 40

(2009)

Women with

fibromyalgia

syndrome

Pilates: MZ48.2y

Control: MZ

50.0y

Total: NZ50

Intervention: nZ25

Control: nZ25

Duration and frequency:

12wk, 3 1h/wk

Pilates: Pilates using props

(balls and resistance

bands)

Home exercise

(relaxation/

stretching)

Algometric score for tende

points

Fibromyalgia impact

Lower extremity endurance

PainQOL

Alves de Araujo

et al 41 (2012)

Sedentary women with

nonstructural

scoliosis

Range: 18e25y

Total: NZ31

Intervention: nZ20

Control: nZ11


12wk, 2 1h/wk

Pilates: Pilates performed

with Swiss balls, flexball

quarks, and apparatus

(Cadillac, Reformer, Step

chair, and Ladder-barrel)

No intervention Degree of scoliosis

Pain

Range of motion for trunk

flexion

Cakmakci42

(2011)

Sedentary, obese women

Pilates: MZ36y

Control MZ39y

Total: NZ61

Intervention: nZ34

Control: nZ27


8wk, 4 1h/wk

Pilates: Mat work with balls

No intervention Basal metabolic rate

BMI

Fat percentage

Flexibility

Lean body mass

Metabolic

Waist circumference

Skinfold thickness (biceps,

iliac, subscapula, triceps

Waist-hip ratio

Weight

w w w . a r c h i v

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Table 2 (continued )

Study

Health Condition/


Eyigor et al 9

(2010)

Women with breast

cancer

Pilates: MZ49y

Control: MZ50y

Total: NZ52

Intervention: nZ27

Control: nZ25

Pilates: Daily Pilates

exercise (floor) and

walking, 8wk, 3 20

e30min/wk

Home exercise:

Walking, 8wk,

3 20

e30min/wk

Depression

Fatigue

Flexibility

Functional capacity

QOL

Ku cukcakır

et al 24 (2013)

Women with

postmenopausal

osteoporosis without

history of a fracture

Pilates: MZ57y

Control: MZ56y

Total: NZ70

Intervention: nZ35

Control: nZ35


52wk, 2 1h/wk

Pilates: Pilates exercise

using resistance bands

and balls

Home exercise:

Thoracic

extension

exercises in a

sitting

position

Functional capacity

Lower extremity endurance

Number of falls

Pain

QOL

Marinda et al 43

(2013)

Sedentary elderly

women

Pilates: MZ66.1y

Control: MZ65.3y

Total: NZ50

Intervention: nZ25

Control: nZ25


8wk, 3 1h/wk

Pilates: Mat work

No intervention Glucose

Resting heart rate

Resting systolic blood

pressure

Resting diastolic blood

pressure

Total cholesterol

Triglycerides

Martin et al 44

(2013)

Women after breast

cancer treatment

Pilates: MZ44.6y

RT: MZ47.8y

Control: MZ49.5y

Total: NZ26

Pilates: nZ8

RT: nZ8

Control: nZ10


8wk, 45min/session*

Pilates: MVe Fitness Chair

RT: Resistance

exercises for

8wky

Control: No

intervention

Muscular endurance

w w w . a r c h i v

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Study

Health Condition/


Plachy et al 45

(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 hipLumbar spine flexion

Thoracolumbar spine flexion

Trunk lateral flexion

Rodrigues et al 39

(2010)

Elderly women

MZ66yzTotal: NZ52

Intervention: nZ27

Control: nZ25


8wk, 2 1h/wk

Pilates: Pilates exercises

used with Bobath ball,

Cadillac, Wall Unit,

Combo chair, and

Reformer devices

No intervention Personal autonomy

QOL

Static balance

Fourie et al 46

(2013)

Elderly sedentary

women

Pilates: MZ66.1y

Control: MZ65.3y

Total: NZ50

Intervention: nZ25

Control: nZ25


8wk, 3 1h/wk

Pilates: Mat work

No intervention Body fat

Body mass

BMI

Fat massLean body mass

w w w . a r c h i v

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pmr

. or

g

























Study

Health Condition/


Ashrafinia et al 47

(2014)

Postpartum women

Pilates: MZ24.6y

Control: MZ24.4y

Total: NZ80

Intervention: nZ40

Control: nZ40


8wk, 5 30min/wk

Pilates: Pilates performed

on the floor

Postnatal

education

Sleep quality

Lee et al 48

(2014)

Businesswomen with

chronic low back pain

Pilates: MZ34.0y

Pilates apparatus

exercise: MZ34.4y

Total: NZ40

Intervention: nZ20

Control: nZ20


8wk, 3 50min/wk

Pilates: Mat work

Pilates apparatus

exerciseyPain

Sway length

Sway velocity

Gildenhuys

et al 49

(2013)

Sedentary elderly

womenPilates: MZ66.1y

Control: MZ65.3y

Total: NZ50

Intervention: nZ

25Control: nZ25


8wks, 3 (nonconsecutive) 1h/wk

Pilates: Mat work

No intervention Agility

Functional mobilityMaximal cardiorespiratory

fitness

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.

w w w . a r c h i v

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Different approaches for Pilates were used as the intervention.

In 6 RCTs,9,43,46-49

Pilates was performed on a mat or floor, and insome studies assistive equipment (ie, Pilates balls, resistance

bands) was also used.24,40,42 Three RCTs39,41,44 used at least 1

apparatus (ie, Cadillac, Reformer, Step chair, Ladder-barrel,

Combo chair, MVe Fitness Chair). The form of Pilates was not

specified for 1 study.45 In 1 RCT,9 the Pilates intervention was

delivered in addition to home exercises and walking exercise.

For 8 RCTs,39,41-46,49 the control condition did not include any

specific exercise. In 3 RCTs, the control group performed ho me

exercises that included relaxation and stretching exercises,40

walking,9 and thoracic extension exercise,24 and in 1 RCT47

women were provided with postnatal care education.

Ten studies9,24,39-43,46,47,49 had 1 intervention group and 1

control group as part of the methodology. Two studies44,45 had 2

intervention groups and a control group. The study by Martin

et al44 had 1 intervention group that performed Pilates on the MVe

Fitness Chair, and the other intervention group received resistance

training. The study by Plachy et al45 included a Pilates interven-

tion group and an aqua fitness/Pilates class intervention group.

Lee et al48 included 2 experimental Pilates groups only (mat

Pilates group and an apparatus Pilates group). In the study by

Altan et al40 there were 25 participants in a single large group,

whereas the other studies did not clarify group size. The primary

discipline of the instructor was reported in 8

studies9,39,41,42,44,46,47,49: Pilates instructor certified (nZ3),42,46,49

physiotherapist certified in Pilates instruction (nZ2),9,39 physio-

therapist (Pilates certification not reported) (nZ1),41 and exercise

and sport science clinician (Pilates certification not reported)

(nZ2).44,47 No studies described the style of Pilates or origin of

Pilates exercises.

Best-evidence synthesis: strength of evidence

Health outcomes are presented in table 3. With the application of

BES, strong evidence was f ound for Pilates in improving health

outcomes for pain,24,40,41,48 lower extremity endurance,24,40 andQOL.24,39,40 Reduction in pain was demonstrated in 3 high-quality

RCTs investigating fibromyalgia syndrome,40 nonstructural

scoliosis,41 and postmenopausal osteoporosis,24 and 1 low-quality

RCT48 investigating low back pain. Strong evidence for lower

extremity endurance was provided by 2 high-quality RCTs24,40

investigating postmenopausal osteoporosis24 and fibromyalgia

syndrome.40 Strong evidence for improvement in QOL was pro-

vided by 2 high-quality RCTs24,40 investigating postmenopausal

osteoporosis24 and fibromyalgia syndrome,40 and 1 low-quality

RCT39 of elderly women. In a study of female breast cancer pa-

tients by Eyigor et al,9 no improvement was found for QOL.

Limited evidence was found f or improving the degree of

scoliosis,41 impact of fibromyalgia,40 number of falls,24 range of

motion in trunk flexion,41 functional capacity,9,24 waist-hip ratio,42

skinfold thickness (biceps, triceps, subscapular),42 fat percent-

age,42 and basal metabolic rate.42 No evidence was found for

improving muscular endurance,44 static balance,39 sway length

and velocity,48 tender points,40 depression,9 sleep quality,47 fa-

tigue,9 personal autonomy,39 weight,42 body mass index,42 waist

circumference,42 lean body mass,42 metabolic rate,42 and iliac

skinfold thickness.42 Contradictory results were found for flexi-

bility, in which improvement was found in obese women,42 but no

effect was found in female breast cancer patients.9

Discussion

This systematic review of Pilates for women’s 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 women’s health outcomes.

This review found a reduction in pain based on studies

investigating fibromyalgia,40 nonstructural scoliosis,41 post-

menopausal osteoporosis,24 and low back pain.48 For these

studies, the Pilates intervention was compared with control con-

ditions 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 fi-

bromyalgia syndrome40 and postmenopausal osteoporosis,24 and

in a study of elderly women.39 It is unclear from the current re-

view whether participating in a therapeutic ritual provided a pla-

cebo effect,50 and whether the acuity of a health condition

influences QOL in women.

Emerging evidence was found f or lower extremity endurance

in RCTs investigating fibromyalgia40 and postmenopausal osteo-

porosis.24 Weakened low extremity strength and endurance sec-

ondary to physiological changes associated with aging are

Fig 1 Flow diagram to summarize stages of systematic review.

Abbreviation: MA, meta-analysis.







considered a risk factor for falls in the elderly.51 Previous

studies52,53 investigating the efficacy of Pilates on lower extremity

endurance in elderly women have provided contradictory results.

Significant improvements in lower extremity strength and endur-

ance for women participating in aqua fitness were found in a

study52 of 25 elderly women. However, these improvements were

not observed for women who participated in Pilates classes. In

contrast, Fourie et al53 found significant improvement in lower

extremity endurance for sedentary women who participated in mat

Pilates compared with women who maintained their normal ac-

tivity routine. These disparate findings possibly reflect the

different methods used in these studies to measure lower extremity

Table 3 Levels of evidence in health outcomes in WHO ICF categories

WHO ICF Category Health Outcome Study and Direction of Effect* Level of Evidencey

Structure related to movement

Degree of scoliosis (nonstructural) Alves de Araujo et al 41 (þ) Limited evidence

Neuromuscular and movement-related

functions

Flexibility Eyigor, et al 9 (o)

Cakmakci42

(þ) No evidenceFibromyalgia impact Altan et al 40 (þ) Limited evidence

Lower extremity endurance Kucukcakır et al 24 (þ)

Altan et al 40 (þ) Strong evidence

Muscular endurance Martin et al 44 (þ) No evidence

Number of falls Kucukcakır et al 24 (þ) Limited evidence

Range of motion for trunk flexion Alves de Araujo et al 41 (þ) Limited evidence

Static balance Rodrigues et al 39 (þ) No evidence

Sway length and velocity Lee et al 48 (þ) No evidence

Sensory functions and pain

Pain Kucukcakır et al 24 (þ)

Altan et al 40 (þ)

Alves de Araujo et al 41 (þ)

Lee et al 48 (þ) Strong evidence

Tender points and algometric score Altan et al 40 (o) No evidence

Mental functions

Depression Eyigor et al 9 (o) No evidence

Sleep quality Ashrafinia et al 47 (þ) No evidence

Functions of cardiovascular system

Fatigue Eyigor et al 9 (o) No evidence

Functional capacity Eyigor et al 9 (þ)

Kucukcakır et al 24 (þ) Limited evidence

Functions of digestive, metabolic, and

endocrine systems

Waist-hip ratio Cakmakci42 (þ) Limited evidence

Skinfold thickness (biceps, triceps,

subscapula)

Cakmakci42 (þ) Limited evidence

Fat percentage Cakmakci42

(þ) Limited evidenceBasal metabolic rate Cakmakci42 (þ) Limited evidence

Weight Cakmakci42 (o) No evidence

Body mass index Cakmakci42 (o) No evidence

Waist circumference Cakmakci42 (o) No evidence

Lean body mass Cakmakci42 (o) No evidence

Metabolic Cakmakci42 (o) No evidence

Skinfold thickness (iliac) Cakmakci42 (o) No evidence

Activities and participation

Personal autonomy Rodrigues et al 39 (þ) No evidence

QOL Eyigor et al 9 (o)

Kucukcakır et al 24 (þ)

Rodrigues et al 39 (þ)

Altan et al 40 (þ) Strong evidence

Abbreviation: ICF, International Classification of Functioning, Disability and Health.

* Direction of effect: (þ), positive effect on health outcome; (o), no effect on health outcome.y Strong evidence, >1 high-quality RCT; moderate evidence, 1 high-quality RCT with >1 low-quality RCT; limited evidence, 1 high-quality or >1 low-

quality RCT; no evidence, 1 low-quality RCT or contradictory outcomes.







endurance (time to walk up stairs test,52 squat till fatigue test53) as

well as the varied control conditions. Future studies require con-

gruency in the methodological approach to measuring lower ex-

tremity 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 sk infold thickness,42 fat

percentage,42 and basal metabolic rate.42 These findings are

consistent with those of Aladro-Gonzalvo,10

who found poorempirical 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), pre-

intervention 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 f ound for improvement in flexibility in sedentary adult fe-

males,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 asflexibility6 and should be considered in future research.

Pilates is advocated for alleviating discomforts of preg-

nancy58,59 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 limitationsLimiting the eligibility criteria to women may have omitted evi-

dence 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 in-

dividuals 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 out-

comes for women.6 In addition, the search was limited to English-

language journals, and studies using other languages were not

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.

Future research recommendations

Future RCTs could be strengthened by incorporating concealed

allocation, intention-to treat analysis, and blinding. Congruency in

the methodological approach for smaller studies should be

considered, including the type of Pilates intervention, exact ex-

ercise prescription, duration and frequency of exercise, and mea-

surement tools. The nonspecific effects or contextual benefits

associated with participating in a mindful approach to exercise

such as the participantePilates instructor relationship may

contribute to a placebo effect and needs verification.50 The

effectiveness of Pilates for improving health for specific condi-

tions such as breast cancer, obesity, and chronic low back pain isyet to be determined. Given the popularity of Pilates for pregnant

women,60 evidence is needed to support claims of antenatal and

birthing benefits.

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 women’s health. We

found emerging evidence to show that Pilates may reduce pain and

may improve QOL and lower extremity endurance. Whether

Pilates improves women’s health during pregnancy or optimizeshealth outcomes for breast cancer, obesity, and chronic low back

pain is yet to be confirmed.

Keywords

Pilates-based exercises; Rehabilitation; Review; Women’s health

Corresponding author

Melissa Mazzarino, MCMid, Victoria University, McKechnie St,

Melbourne, Victoria, Australia 3021. E-mail address: melissa.

[email protected].

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Pilates Method for Women’s Health