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School of Physical Education and Sports, University of Costa Rica, San Jose, Costa Rica
Medicine Sport Center of Cienfuegos, Cuba
Received 27 March 2012; received in revised form 29 July 2012; accepted 17 August 2012
KEYWORDS
Pilates;
Systematic review;
Exercise therapy;
Complementary
therapy;
Lumbar spine;
Rehabilitation;
Meta-regression
Summary Objective: The purposes of this study were to systematically review and apply
regression analysis to randomised controlled trials [RCTs] that evaluated the effectiveness
of Pilates exercise in improving persistent, non-specific low back pain and functional disability.
Methods: Electronic databases were searched from January 1950 to March 2011. Articles were
eligible for inclusion if they were RCTs comparing Pilates exercise with a placebo treatment
[PT], minimal intervention [MI] or another physiotherapeutic treatment [APT].
Results: Nine trials were included. Pilates was moderately superior to APT (pooled Effect Size
[ES] weighted Z 0.55, 95% confidence interval [CI] Z 0.08 to 1.03) in reducing disability
but not for pain relief. Pilates provided moderate to superior pain relief compared to MI
(pooled ES weighted Z 0.44, 95% CI Z 0.09 to 0.80) and a similar decrease in disability.
The statistical model used did not detect any predictor variable.
Conclusions: Due to the presence of co-interventions and the low methodological quality of
some studies, these conclusions should be interpreted with caution.
Crown Copyright 2012 Published by Elsevier Ltd. All rights reserved.
Introduction
Low back pain [LBP], with or without leg pain, has been one
of the main burdens to public health for years in the
Western industrialised world, with an abundance of records
* Corresponding author. 44th Ave., Number 3720, Cienfuegos, Cuba. Tel.: 53 43523650.
E-mail address: aladro80@fastmail.es (A.R. Aladro-Gonzalvo).
1360-8592/$ - see front matter Crown Copyright 2012 Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbmt.2012.08.003
126
recreation, family and community) and functional disability
[FD] (Asghari and Nicholas, 2001; Woby et al., 2004; Mannion
et al., 2001). Additionally research has found that perceived
pain scores demonstrated a strong correlation with disability
measures (Lackner et al., 1996; Waddell et al., 1993).
Treatment options for LBP can be placed into two categories, active and passive (Kirkaldy-Willis and Bernard, 1999).
One increasingly common exercise regimen suggested for
patients with LBP is Pilates-based therapeutic exercise,
adapted and simplified from the traditional and modern
Pilates Method, which usually is defined as a comprehensive
mindebody conditioning method with the main goals of efficient movements, core stability and enhanced performance
(Akuthota and Nadler, 2004; Muscolino and Cipriani, 2004).
Pilates-based therapeutic exercise has been introduced
in the physical therapy community in recent years to
improve rehabilitation programs (Bryan and Hawson, 2003).
Return to functional activities has also been a primary
objective since the method encourages movement earlier
in the treatment process by providing the necessary assistance (Anderson and Spector, 2000).
Several studies have aimed at documenting the benefits
of this modified method in decreasing LBP (Maher, 2004;
Sorosky et al., 2008; La Touche et al., 2008). Recently two
systematic reviews proposed that there is some evidence
supporting the effectiveness of Pilates-based exercises in
the management of LBP. Posadzki et al. (2011) used
a simple descriptive approach to summarise their results,
alerting that no definite conclusions can be drawn. Lim
et al. (2011) used a meta-analytical approach and added
useful information about the magnitude of the effect of
Pilates on pain relief and disability when compared to other
forms of exercise or minimal intervention.
Despite the aforementioned attempts to summarise and
integrate the results of selected trials, up till now,
a regression analysis for predictor variables on treatment
effectiveness has not been applied.
Thus, the objectives of this study were to systematically
review and apply regression analysis to the RCTs that
evaluated the effectiveness of Pilates exercise aimed at
improving persistent, non-specific LBP and associated FD,
and to provide practical and clinically precise information.
Methods
Data sources and searches
A computerised electronic search was performed to identify relevant articles. The search was conducted on MEDLINE (1950eMarch 2011); CINAHL (Cumulative Index to
Nursing and Allied Health Literature) (1982eMarch 2011);
SPORTDISCUS (1975eMarch 2011); ProQuest Dissertations &
Theses (1980eMarch 2011); ScienceDirect (1990eMarch
2011) and Scholar Google. The terms used were Pilates
AND low back pain AND randomised controlled trial OR
systematic review and Pilates AND low back functional
disability AND randomised controlled trial OR systematic
review. Key words relating to the domains of randomised
controlled trials and back pain were used, as recommended
by the Cochrane Back Review Group [CBRG] (Bombardier
et al., 2006).
Study selection
The reviewers followed a selection protocol, developed prior
to the beginning of the review that included a checklist for
inclusion and exclusion criterion. Articles were eligible for
inclusion if they were a) RCTs comparing Pilates exercise
with a PT, MI or APT; b) studies carried out on individuals of
all age groups and sex with LBP and FD; c) RCTs reporting
that a criterion for entry was persistent non-specific LBP
(with or without leg pain) of at least 6 weeks duration (not
attributable to any specific disease) or recurrent LBP with at
least 2 painful incidences per year; d) RCTs describing any
restriction or loss of ability associated with LBP, if they reported that a criterion for entry was functional disability; e)
RCTs that reported one of the following outcome measures:
pain or disability; f) RCTs that reported the mean outcome
(e.g., means, standard deviations and sample sizes); and g)
studies that were not restricted to any specific language.
Articles were excluded if they were a) studies that were
not RCTs; b) RCTs that did not provide sufficient information for the calculation of effect size (i.e., means, standard
deviations and sample sizes for the comparison between
groups); and c) RCTs with inconsistent or internal discrepancies in data.
This systematic review followed the recommendations
of the PRISMA statement (Moher et al., 2009).
Results
The initial electronic database search resulted in a total of
19 articles potentially eligible based on their title and
abstract; of these, 9 (Rydeard et al., 2006; Donzelli et al.,
2006; Anderson, 2005; Gagnon, 2005; Quinn, 2005;
MacIntyre, 2006; Limba da Fonseca et al., 2009; Gladwell
et al., 2006; OBrien et al., 2006) were considered for
inclusion in this review (Fig. 1). Reasons for exclusion are
shown in Fig. 1 for those articles that were excluded in the
screening stage (Curnow et al., 2009; Rodrguez-Fuentes and
Otero-Gargamela, 2009; Ribeiro-Machado, 2006; Ya Li,
2005). Only 1 author did not reply to our inquiries (Curnow
et al., 2009), two authors contacted (Rodrguez-Fuentes
and Otero-Gargamela, 2009; Donzelli et al., 2006) sent
information to us on a new trial for inclusion or exclusion.
A number of trials that were not included in previous
systematic reviews of Pilates-based exercises were
included in this review (Table 1). One new unpublished trial
(MacIntyre, 2006) and one RCT (Limba da Fonseca et al.,
2009) that were not included in any of the previously
published reviews were included in this review (Table 1).
Methodological quality
Agreement among the 2 reviewers was almost high
(ICC Z 0.89) (Atkinson and Nevill, 1998). The methodological quality assessment using the PEDro scale revealed
a mean score of 5.5 (range Z 3e9). One trial (11.1%) did
not consider a point measurement and measurements of
variability. The groups were similar at baseline in 88.8% of
the trials. Blinding of the therapist and blinding of the
subject were not used in any of the trials, as would be
expected for an exercise therapy study. An intention-totreat analysis was used in 22.2% of the trials, allocation
concealment and dropouts were present in 33.3% and 44.4%
of the trials respectively. Eligibility criteria were the only
aspect reported in 100% of the trials. One of the articles
(Donzelli et al., 2006) included in the review received
a score of 3 on the PEDro scale and was the only quasirandomized controlled trial.
Study characteristics
The 9 RCTs included in this review compared Pilates exercise against APT (e.g., therapeutic massage, traditional
dynamic lumbar stabilisation exercises, back school and
standard physiotherapy) or Pilates exercise against MI (e.g.,
no intervention, usual care, normal exercise or sports
regimes) (Table 2). No placebo RCT was identified. Seven
trials assessed the efficacy of Pilates on both variable of
interest (i.e., LBP and FD) (Rydeard et al., 2006; Donzelli
et al., 2006; Anderson, 2005; Gagnon, 2005; MacIntyre,
2006; Gladwell et al., 2006; OBrien et al., 2006). Two
trials just assessed LBP (Limba da Fonseca et al., 2009) or
FD (Quinn, 2005) in that order (Table 1).
127
128
Figure 1
Flow chart of systematic review inclusion and exclusion. RCTs Z randomised controlled trials.
Article
Pain (VAS)
Disability (ODQ)
Pain (VAS)
Disability (ODQ)
Included in La Touche
et al., 2008 and Lim
et al., 2011
Pain (VAS)
Disability (RMDQ)
Included in Posadzki
et al., 2011 and Lim
et al., 2011
Pain (VAS)
Disability (ODQ)
Included in La Touche
et al., 2008; Posadzki
et al., 2011 and Lim
et al., 2011
Table 1
129
Table 1 (continued )
Article
Limba da
Fonseca
et al., 2009
Pain (VAS)
Rydeard et al.,
2006
MacIntyre,
2006
Quinn, 2005
OBrien et al.,
2006
Pain (NRS-101)
Included in La Touche
Disability (RMDQ-HK) et al., 2008; Posadzki
et al., 2011 and Lim
et al., 2011
Pain (VAS)
Disability (RMDQ)
Disability (ODQ)
Pain (VAS)
Disability (RMDQ)
Included in Posadzki
et al., 2011 and Lim
et al., 2011
Abbreviations: VAS Z visual analog scale, MBI-Pain: Miami Back Index Pain Sub-Scale, NRS-101: 101-point numerical rating scale,
ODQ Z Oswestry Disability Questionnaire, RM Z Roland-Morris Disability Questionnaire, RM-HK Z RolandeMorris Questionnaire Chinese
version.
a
Duration of complaint as inclusion criterion.
Article
Details of the interventions and main outcomes in the included randomised controlled trials.
Interventions
Preintervention
Postintervention
PEDro scorec
Table 2
131
Table 2 (continued )
Article
Interventions
Preintervention
Postintervention
PEDro scorec
Rydeard et al.,
2006
MacIntyre,
2006
Quinn, 2005
OBrien et al.,
2006
Figure 2 Forest plot of the results of trials comparing Pilates-based exercises with minimal interventions for LBP and FD. Values
presented are effect size (with correction factor) and 95% confidence interval. The pooled effect sizes were calculated using
a weighting by variance reciprocal.
Discussion
This systematic review provides evidence that Pilates-based
exercise is moderately superior to minimal intervention for
pain relief in subjects with persistent, non-specific LBP
(Fig. 2). However, the presence of co-interventions (e.g.,
analgesic intake, physiotherapy treatment as needed) in the
Pilates exercise groups of 2 trials (MacIntyre, 2006; Gladwell
et al., 2006) was an aspect that could have raised the effect
magnitude, contributing to the increased pain relief. This
methodological issue compromised internal validity; therefore, when assessing the impact of the co-interventions on
this treatment contrast, a sensitivity analysis with exclusion
of trials with co-interventions (MacIntyre, 2006; Gladwell
et al., 2006) was performed. When the trials with cointerventions were deleted, the effect size unexpectedly
increased considerably (i.e., pooled ES weighted Z 1.12,
95% CI Z 0.60 to 1.64) for pain relief. Nevertheless, this
was the finding of 3 trials, and more research is needed to
confirm the results.
The pooled results showed Pilates-based exercise is
moderately superior to another physiotherapy treatment in
reducing disability. Interestingly, this finding was based on
pooled data from 4 different trials (i.e., therapeutic massage,
traditional dynamic lumbar stabilisation exercises, back
school and standard physiotherapy) where Pilates was not
superior to these particularly prescribed treatments (Table 2).
On the other hand, these pooled results were biased by the
134
Figure 3 Forest plot of the results of trials comparing Pilates-based exercises with another physiotherapeutic treatment for LBP
and FD. Values presented are effect size (with correction factor) and 95% confidence interval. The pooled effect sizes were
calculated using a weighting by variance reciprocal.
135
Summary of the regression model for sizes effect significantly different of zero.
Particular variables
F-value
P-value
Age
BMI
Duration of complaint
Quality of the study
Number of session of Pilates
Frequency of the session (time/wk)
Duration of the session (in min)B
Type of Pilates class
Certified instructors
0.033
0.046
0.074
0.044
0.003
0.210
e
0.310
0.757
0.102
0.097
0.240
0.137
0.008
0.797
e
1.347
9.337
0.771
0.785
0.657
0.736
0.935
0.438
e
0.330
0.055
5
4
5
5
5
5
e
5
5
Particular variables
Age
BMI5
Duration of complaint
Quality of the study
Number of session of Pilates
Frequency of the session (time/wk)
Duration of the session (in min)B
Type of Pilates class
Certified instructors
R2
F-value
P-value
0.0393
e
0.393
0.702
0.011
0.363
0.051
0.007
0.586
1.294
e
1.315
4.713
0.022
1.139
0.108
0.014
2.836
0.373
e
0.370
0.162
0.896
0.398
0.773
0.915
0.234
4
e
4
4
4
4
4
4
4
Conclusions
The results of this systematic review suggest that Pilatesbased therapeutic exercise is moderately superior to minimal
intervention for pain relief and confers similar benefits when
compared with pooled scores to another physiotherapeutic
treatment. Although co-interventions with Pilates, might
enhance treatment effectiveness for pain relief; this
conclusion should be interpreted with caution.
Pilates is moderately better than another physiotherapeutic treatment in reducing disability, and provides
comparable benefits to minimal intervention. The low
methodological quality of the studies reviewed, and the
heterogeneity of the physiotherapy treatment showed
estimate bias of the treatment effectiveness for reducing
disability; thus, it is recommended that Pilates should be
carefully considered for patients with functional disability
associated to LBP.
The optimal implementation of Pilates exercise at
present is unclear. Future studies should incorporate
placebo controlled trial, larger sample sizes, intervention
protocols that are comparable, assessment of the several
features not coded in this review and longer term follow-up.
Conflict of interest
None.
Pain
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