Pilates method on pain in patients with low back pain: systematic review

Cordeiro, André Luiz Lisboa; Oliveira, Ana Paula Silva; Cerqueira, Natale Sena; Santos, Fernanda Aparecida Ferreira; Oliveira, Alberto Manoel Sarkis

doi:10.5935/2595-0118.20220038-en

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REVIEW ARTICLE • BrJP 5 (3) • Jul-Sep 2022 • https://doi.org/10.5935/2595-0118.20220038-en copy

Pilates method on pain in patients with low back pain: systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND AND OBJECTIVES:

The weakness of the trunk extensors is one of the main causes in the development of low back pain in a large part of the population. Low back pain is a disabling condition and due to the pain many people have difficulty performing activities of daily life. Thus, Pilates becomes one of the methods of choice in the treatment of low back pain because it brings muscle strengthening exercises that positively impact the stabilization of the spine. The objective of this study was to review the impact of the Pilates method on pain in patients with low back pain.

METHODS:

This is a systematic review, with search for data in the Scielo, OVID, Lilacs, Pubmed and PEDro databases, which included randomized clinical trials that addressed the Pilates method in patients with low back pain. The following search descriptors were used: low back pain, Pilates method, exercise movement techniques. The Boolean operators were: “and” and “or”.

RESULTS:

Of the 8 selected studies, all obtained positive results in the reduction of low back pain, each using a different protocol associated with physical therapy treatment. Of the eight studies considered eligible, only seven were included. For the study of this comparison, a random model was used (I2=92%, df=6, p=0.01), in which there was a statistically significant diference between the Pilates and control groups (95% CI -1.79, -0.19).

CONCLUSION:

It was possible to conclude that the Pilates method he was effective in the treatment of low back pain.

HIGHLIGHTS

The study reinforces the importance of the Pilates method for patients with low back pain, focusing on pain reduction, but with an impact on functionality and quality of life.
The role of Pilates as an integral part of a care protocol is also reinforced, not as the only tool for physical therapy care.
The application of Pilates method should begin with exercises of mild to moderate difficulty and, with functional gain, progress to high complexity.

Acronym	Description	Definition
P	Patient	Patients with chronic low back pain
I	Intervention	Pilates method
C	Control	Patients who received another type of intervention other than Pilates method, such as electrotherapy, manual instructions through leafets and joint mobilization.
O	Outcome	Pain

	Silva et al.¹³13 PEDro is the Physiotherapy Evidence Database. Escala de PEDro. Acesso em: 16/07/2020. Disponível em: https://www.pedro.org.au/portuguese/downloads/pe-dro-scale/ https://www.pedro.org.au/portuguese/down...	Rydeard, Leger and Smith¹⁴14 Moher D, Liberati A, Tetzlaf J, Altman DG. The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta- Analyses: The PRISMA Statement. PLoS Med. 2009;6(7):e1000097.	Díaz et al.¹⁵15 Silva PH, Silva D F, Oliveira JK, Oliveira FB. The effect of the Pilates method on the treatment of chronic low back pain: a clinical, randomized, controlled study. BrJP. 2018;1(1):21-8.	Cruz-Diaz et al.¹⁶16 Rydeard R, Leger A, Smith D. Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability: a randomized controlled trial. J Orthop Sports Phys Ter. 2006;36(7):472-84.	Valenza et al.¹⁷17 Cruz-Díaz D, Martínez-Amat A, De la Torre-Cruz MJ, Casuso RA, de Guevara NM, Hita-Contreras F. Efects of a six-week Pilates intervention on balance and fear of falling in women aged over 65 with chronic low-back pain: a randomized controlled trial. Maturitas. 2015;82(4):371-6.	Miyamoto et al.¹⁸18 Cruz-Díaz D, Martinez-Amat A, Osuna-Pérez MC, De la Torre-Cruz MJ, Hita-Contreras F. Short- and long-term effects of a six-week clinical Pilates program in addition to physical therapy on postmenopausal women with chronic low back pain: a randomized controlled trial. Disabil Rehabil. 2016;38(13):1300-8.	Bhadauria and Gurudut ¹⁹19 Valenza MC, Rodrigues-Torres J, Cabrera-Martos I, Díaz-Pelegrina A, Agular-Ferrándiz ME, Castellote-Caballero Y. Results of a Pilates exercise program in patients with chronic non-specific low back pain: a randomized controlled trial. Clin Rehabil. 2017;31(6):753-60.	Natour et al.²⁰20 Miyamoto GC, Costa LO, Galvanin T, Cabral CM. Eficacy of the addition of modified pilates exercises to a minimal intervention in patients with chronic low back pain: a randomized controlled trial. Phys Ter. 2013;93(3):310-20.
01 Eligibility criteria have been specifed.
02 Subjects were randomly assigned to groups.	Y	Y	Y	Y	Y	Y	Y	Y
03 Subject allocation was secret.	Y	Y	Y	Y	Y	Y	Y	Y
04 Initially, the groups were similar with respect to the most important prognostic indicators.	Y	Y	Y	Y	Y	Y	Y	Y
05 All subjects participated blindly in the studies.	Y	Y	Y	Y	Y	N	Y	Y
06 All therapists who administered therapy did so blindly.	N	N	Y	Y	Y	N	N	N
07 All evaluators who measured at least one key outcome did so blindly.	N	Y	N	Y	Y	Y	N	N
08 Measurements of at least one key outcome were obtained in more than 85% of subjects initially distributed among groups.	N	Y	N	N	N	Y	N	N
09 All subjects from whom outcome measures were presented received the treatment or control condition according to allocation, or when this was not the case, data analysis was performed for at least one of the key outcomes by “intention of treatment”.	Y	Y	Y	Y	Y	Y	Y	Y
10 The results of the inter-group statistical comparisons were described in at least one key result.	N	Y	N	N	N	Y	Y	N
11 The study presents both precision measures and variability measures for at least one key outcome.	N	N	N	N	N	N	N	Y
Score	6/10	8/10	6/10	7/10	7/10	7/10	6/10	6/10

Authors	Sample size	Gender	Duration of symptoms	Age	Intervention	Control	Measurements	Results
Silva et al.¹⁵15 Silva PH, Silva D F, Oliveira JK, Oliveira FB. The effect of the Pilates method on the treatment of chronic low back pain: a clinical, randomized, controlled study. BrJP. 2018;1(1):21-8.	16 IG: 8 CG: 8	CG: 7 women and 1 man; IG: 7 women and 1 man.	Greater than 24 months in both groups.	CG: 44.87±11.07 years; IG: 47±8.48 years	Nine postures of the Pilates method.	Conventional stretching and strengthening of the lumbar spine and lower limbs.	Visual analog scale (VAS) and the Oswestry Disability Index Questionnaire (ODI).	ODI questionnaire and pain in the pre and post moments between the groups did not present significant statistical difference.
Rydeard, Leger and Smith¹⁶16 Rydeard R, Leger A, Smith D. Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability: a randomized controlled trial. J Orthop Sports Phys Ter. 2006;36(7):472-84.	39 IG: 18 CG:21	CG: 13 women and 8 men; IG: 12 women and 6 men.	Mean symptoms of 8.2 years.	CG: 34 ± 8 years; IG: 37 ± 9 years.	Pilates on gadgets.	Did not receive specific physical training and continued with the usual care.	The Roland Morris Disability Questionnaire (RMQ/RMDQ-HK) and average pain intensity using a 101-point numerical rating scale.	There was a significantly lower level of functional disability (p=0.023) and average pain intensity (p=0.002) in the specific-exercise-training group than in the control group following the treatment intervention period.
Cruz-Díaz et al.¹⁷17 Cruz-Díaz D, Martínez-Amat A, De la Torre-Cruz MJ, Casuso RA, de Guevara NM, Hita-Contreras F. Efects of a six-week Pilates intervention on balance and fear of falling in women aged over 65 with chronic low-back pain: a randomized controlled trial. Maturitas. 2015;82(4):371-6.	97 CG:47; IG: 50.	CG: 47 women; IG: 50 women.	>6 weeks in both groups.	CG: 71.14 ± 3.30; IG: 71.14 ± 3.30.	In addition to the CG treatment, the sample received two sessions a week of Pilates exercises.	The treatment consisted of the application of Transcutaneous Electrical Stimulation, massage and stretching of the lumbar region.	Fear of falling (FoF), assessed by the Falls Efficacy Scale-international; functional mobility and balance, measured with the Timed up and Go Test; and pain, evaluated using the numeric rating scale.	Only the Pilates group showed improvement in FoF (d=0.68) and functional mobility and balance (d=1.12) after treatment, and had better results in pain (d=1.46) than the physiotherapy-only group.
Cruz-Díaz et al.¹⁸18 Cruz-Díaz D, Martinez-Amat A, Osuna-Pérez MC, De la Torre-Cruz MJ, Hita-Contreras F. Short- and long-term effects of a six-week clinical Pilates program in addition to physical therapy on postmenopausal women with chronic low back pain: a randomized controlled trial. Disabil Rehabil. 2016;38(13):1300-8.	101 CG:48; IG: 53.	CG: 48 women; IG: 53 women.	>6 weeks in both groups.	CG: 72/69 ± 3,532; IG: 69.57 ± 2,188;	Application of traditional Pilates principles with 1 hour sessions for 6 weeks.	Application of analgesics, electrotherapy and joint mobilization.	Pain and disability were measured by VAS and the ODI.	Were significant differences between groups in pain and disability after 6 weeks of treatment, with better results in the PPT group with an effect size of d=3.14 and d=2.33 for pain and disability.
Valenza et al.¹⁹19 Valenza MC, Rodrigues-Torres J, Cabrera-Martos I, Díaz-Pelegrina A, Agular-Ferrándiz ME, Castellote-Caballero Y. Results of a Pilates exercise program in patients with chronic non-specific low back pain: a randomized controlled trial. Clin Rehabil. 2017;31(6):753-60.	54 CG: 27; IG: 27.	CG: 22 men and 5 women; IG: 25 men and 2 women.	CG: 15.1 ± 6.5 months; IG: 13.9 ± 4.4 months.	CG:38±12; IG:40±16	Floor exercises using a 55 cm ball on a rubber mat with 45-minute sessions for 8 consecutive weeks.	Usual activities and received advice in the form of a leaflet.	RMDQ and ODI, current, average and pain at its least and at its worst (Visual Analogue Scales), lumbar mobility (modified Shober test), flexibility (finger-to-floor test) and balance (single limb stance test).	RMDQ (mean change ± standard deviation of 5.31 ±3.37 and 2.40±6.78 respectively and between-groups mean difference of 3.2±4.12, p=0.003) and the ODI p<0.001), current pain (p=0.002) and pain at its least (p=0.033), flexibility (0.032) and balance (0.043).
Miyamoto et al.²⁰20 Miyamoto GC, Costa LO, Galvanin T, Cabral CM. Eficacy of the addition of modified pilates exercises to a minimal intervention in patients with chronic low back pain: a randomized controlled trial. Phys Ter. 2013;93(3):310-20.	86 CG:43; IG: 43.	CG: 34 women and 9 men; IG: 36 women and 7 men	Duration of symptoms greater than or equal to 7 months.	CG: 38 ± 11.4; IG:41 ± 12	Intervention of exercises in the Pilates method of flexibility and strengthening.	Re-education follow-up with books and non-practice physiotherapeutic explanations. They had meetings with the physiotherapist twice a week to clarify doubts.	Pain intensity and disability.	Improvements were observed in pain (mean difference=2.2 points, 95% confidence interval [Cl]=1.1 to 3.2), disability (mean difference=2.7 points, 95% Cl=1.0 to 4.4)
Bhadauria and Gurudut²¹21 Bhadauria EA, Gurudut P. Comparative effectiveness of lumbar stabilization, dynamic strengthening, and Pilates on chronic low back pain: randomized clinical trial. J Exerc Rehabil. 2017;13(4):477-85.	44 CG: 22; IG: 22.	CG: 18 women and 4 men; IG: 22 women	Duration of symptoms >3 months.	CG: 32.75 ± 11.73; IG:21.78± 2.87	Performed lumbar stabilization and strengthening exercises.	A Pilates exercise protocol was used, encompassing strengthening, stretching, flexibility and treatment with electrostimulation.	Pain was assessed by visual analog scale, functional affection by modified ODI.	Pain was found to be significantly reduced in the lumbar stabilization group with p-value of 0.0001 compared to dynamic strengthening exercise.
Natour et al.²²22 Natour J, Cazotti LA, Ribeiro L, Baptista AS, Jones A. Pilates improves pain, function and quality of life in patients with chronic low back pain: a randomized controlled trial. Clin Rehabil. 2015;29(1):59-68.	60 CG: 30; IG: 30.	CG: 18 women and 12 men; IG: 23 women and 7 men	Duration of symptoms <10 months.	CG: 44.83 ± 17.40; IG: 37.54 ± 13.80	Patients using antisteroid drugs without exercise intervention.	50-minute classes being held twice a week working on strengthening, stretching, flexibility and isometric exercises.	Pain and function (Roland Morris questionnaire).	Statistical differences favoring the EG were found with regard to pain (p<0.001), function (p<0.001)

Authors	Sample	Before treatment	After treatment	Six months after randomization	Comparative results
Silva et al.¹⁵15 Silva PH, Silva D F, Oliveira JK, Oliveira FB. The effect of the Pilates method on the treatment of chronic low back pain: a clinical, randomized, controlled study. BrJP. 2018;1(1):21-8.	CG: 8	CG: Pain VAS: 5,75±2,81	CG: Pain VAS: 3,25±3,37	---	Statistically significant improvement in pain (p<0.0031)
	PG: 8	PG: Pain VAS: 5,00±2,00	PG: Pain VAS: 2,00±2,56	---	Statistically significant improvement in pain (p<0.0031)
Rydeard, Leger and Smith¹⁶16 Rydeard R, Leger A, Smith D. Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability: a randomized controlled trial. J Orthop Sports Phys Ter. 2006;36(7):472-84.	CG: 18	CG: Pain NRS: 30.4 (4.2)	CG: Pain NRS: 33.9 (3.5)	---	Statistically significant improvement in pain (p< 002)
	PG: 21	PG: Pain NRS: 23.0 (3.9)	PG: Pain NRS: 18.3 (3.2)	---	Statistically significant improvement in pain (p< 002)
Cruz-Díaz et al.¹⁷17 Cruz-Díaz D, Martínez-Amat A, De la Torre-Cruz MJ, Casuso RA, de Guevara NM, Hita-Contreras F. Efects of a six-week Pilates intervention on balance and fear of falling in women aged over 65 with chronic low-back pain: a randomized controlled trial. Maturitas. 2015;82(4):371-6.	CG: 47	Absent	Absent	---	Statistically significant improvement in pain (p<005)
	PG: 50			---	Statistically significant improvement in pain (p<005)
Cruz-Díaz et al.¹⁸18 Cruz-Díaz D, Martinez-Amat A, Osuna-Pérez MC, De la Torre-Cruz MJ, Hita-Contreras F. Short- and long-term effects of a six-week clinical Pilates program in addition to physical therapy on postmenopausal women with chronic low back pain: a randomized controlled trial. Disabil Rehabil. 2016;38(13):1300-8.	CG: 48	CG: Pain NRS: 6.48 ± 1.28	CG: Pain NRS: 5.69 ± 1.63	---	Statistically significant improvement in pain (p<0.001).
	PG: 53	PG: Pain NRS: 6.80 ± 0.59	PG: Pain NRS: 3.81 ± 1.21	---	Statistically significant improvement in pain (p<0.001).
Valenza et al.¹⁹19 Valenza MC, Rodrigues-Torres J, Cabrera-Martos I, Díaz-Pelegrina A, Agular-Ferrándiz ME, Castellote-Caballero Y. Results of a Pilates exercise program in patients with chronic non-specific low back pain: a randomized controlled trial. Clin Rehabil. 2017;31(6):753-60.	CG: 27	CG: Pain VAS: 5.2 ± 1.9.	CG: Pain VAS: 0.9 ± 2.8 (-0.7 to 2.4)	---	Statistically significant improvement in pain (p< 0.002)
	PG: 27	PG: Pain VAS: 5.2 ± 1.9.	PG: Pain VAS: 2.3 ± 1.9 (1.6 to 3.1)	---	Statistically significant improvement in pain (p< 0.002)
Miyamoto et al.²⁰20 Miyamoto GC, Costa LO, Galvanin T, Cabral CM. Eficacy of the addition of modified pilates exercises to a minimal intervention in patients with chronic low back pain: a randomized controlled trial. Phys Ter. 2013;93(3):310-20.	CG: 43	CG: Pain NRS: 5.2(2.3).	CG: Pain NRS: 2.2(1.1).	---	Statistically significant improvement in pain (p<.001)
	PG: 43	PG: Pain NRS: 3.1(2.3).	PG: Pain NRS: 0.9(0.1)	---	Statistically significant improvement in pain (p<.001)
Bhadauria et al.²¹21 Bhadauria EA, Gurudut P. Comparative effectiveness of lumbar stabilization, dynamic strengthening, and Pilates on chronic low back pain: randomized clinical trial. J Exerc Rehabil. 2017;13(4):477-85.	CG: 22	CG: Pain NRS: 21.78±2.87	CG: Pain NRS: 0.31± 0.42	---	Statistically significant improvement in pain (p=0.0001)
	PG: 22	PG: Pain NRS: 24.71±4.55	PG: Pain NRS: 0.58± 0.54	---	Statistically significant improvement in pain (p=0.0001)
Natour et al.²²22 Natour J, Cazotti LA, Ribeiro L, Baptista AS, Jones A. Pilates improves pain, function and quality of life in patients with chronic low back pain: a randomized controlled trial. Clin Rehabil. 2015;29(1):59-68.	CG: 30	CG: Pain NRS: 22.44±4.56	CG: Pain NRS: 5.79±2.06.	---	Statistically significant improvement in pain (p<0.001)
	PG: 30	PG: Pain NRS: 22.22±4.74	PG: Pain NRS: 5.50±1.25.	---	Statistically significant improvement in pain (p<0.001)

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[1] Correspondence to: André Luiz Lisboa Cordeiro E-mail andrelisboacordeiro@gmail.com