The Pilates method in the rehabilitation of musculoskeletal disorders: a systematic review

Introduction: Joseph Pilates created an authentic method of physical and mental conditioning, which he called Contrology and defined as the complete coordination of body, mind and spirit. Recent studies indicate that the Pilates Method is a useful tool in rehabilitation can improve overall health, sports performance and help in the prevention and attenuation of injuries and disorders of the musculoskeletal system. Musculoskeletal disorders are prevalent and costly conditions that develop gradually, presenting a chronic course and often remain untreated. Objective: This study aimed to identify the effects of the Pilates Method in the rehabilitation of musculoskeletal disorders through a systematic review. Methods: An active search was performed in the PubMed, PEDro, Scielo and Bireme databases. A total of 24 studies were pre-selected and their methodological quality was evaluated based on the PEDro scale. Of these, 14 fulfilled the selection criteria. Results: The studies analyzed indicate that Pilates can be effective both for the treatment of *JCC: BS, e-mail: josiczfisio@gmail.com RL: MS, e-mail: rafaelametodologia@gmail.com TMFC: MS, e-mail: ticianecruz@gmail.com MIAN: BS, e-mail: inesartaxo@gmail.com


Introduction
Joseph Hubertus Pilates was born in 1880, near Düsseldorf in Germany (1).During childhood, he suffered a multitude of illnesses resulting in muscular weakness.Determined to overcome his weakness, he dedicated his life to become more physically strong (2).During the First World War, while he was interned, his experiences allowed him to develop an authentic method of physical and mental conditioning, which he perfected over the subsequent 50 years, until his death in 1967 (3).
Joseph H Pilates called his method Contrology and defined it as the complete coordination of body, mind and spirit.Contrology was created in order to develop the body uniformly, restore physical vitality, correct wrong postures, invigorate the mind and elevate the spirit (4).Recent studies indicate that Pilates is a useful tool in rehabilitation (5,6,7) and can improve overall health, sports performance, proprioception, the level of pain (8), flexibility (9), the degree of depression, strength and muscular endurance (10), encourage the control of the mobility of the trunk and pelvic segments, as well as help in prevention and mitigation of injuries and dysfunctions of the musculoskeletal system (11).
Musculoskeletal disorders are prevalent and costly conditions for primary healthcare (12).They develop gradually, presenting a chronic course, and often go untreated.Although many symptoms are associated, the most notable is pain, which can worsen gradually and progress to incapacity (13).Repetitive movements and inadequate long-term posture alter the characteristics of the muscle tissue and can cause muscle dysfunction, altered movement pattern, pain and movement disorders (14).To change this condition, strength training can prevent disuse atrophy and additional deconditioning, as well as improve muscle and cardiorespiratory function in people with muscular disease (15).
Advanced musculoskeletal fitness is directly associated with functional independence, mobility, glucose homeostasis, bone health, psychological well-being and overall quality of life and is inversely associated with the risk of falls, disease and premature death.This evidence provides direct support for the recent recommendation for resistance training and flexibility exercises, carried out at least twice a week, to maintain functional status, promote physical activity throughout life and improve the overall quality of life (16).It is also important to mention that a lack of coordination in the core muscles can lead to a loss of movement efficiency and compensatory patterns, causing stress and overuse injuries.Thus, the motor relearning of inhibited muscles may be more important than strength in patients with musculoskeletal injuries (17).In this context, the Pilates method appears to be an interesting alternative for the treatment of musculoskeletal disorders, and for the maintenance of health and quality of life.
The aim of this study was to investigate, through a systematic review, the Pilates method in the rehabilitation of musculoskeletal disorders.

Methods
A systematic review was used as the methodology, which identifies, selects and critically evaluates studies considered relevant, to give theoretical and practical support for the classification and analysis of the bibliographic study (18).
A review of articles was performed with national [07] and international studies [17] and dissertations [03], for the years 2003 to 2012.The databases searched were: U.S. National Library of Medicine (PubMed), Physiotherapy Evidence Database (PEDro), Scientific Electronic Library Online (SciELO) and Virtual Health Library (BIREME).The descriptors used in the search for the articles were: Pilates, musculoskeletal disorders, lumbar spine, cervical spine, chronic pain, rehabilitation, and occupational diseases.
After detailed reading of the studies (n = 24) selected, those that had no protocols (volume and intensity) reported in the article (n = 0), evaluated only qualitative measures (n = 1), were literature reviews (n = 1) or quasi-experimental studies (n=1), had low methodological quality (n = 2) or did not have a control group compared to the Pilates (n = 4) were excluded.The methodological quality of studies was assessed based on the PEDro scale (19) (Table 1).The inclusion criteria of the articles were: randomized clinical trials that evaluated the efficacy of the Pilates method for prevention or treatment of musculoskeletal disorders, that obtained a score greater than 3 on the PEDro scale and that were published in journals with rating greater than or equal to B1 in the webqualis of CAPES.
The studies potentially appropriate for inclusion in the review (n = 14) consisted of 1 doctoral dissertation of the University of Miami and 13 articles found in the following journals: Motriz [1]; Revista Brasileira de Medicina do Esporte [1]; Archives of Physical Medicine and Rehabilitation [1]; Rheumatology International [1]; Journal of Strength and Conditioning Research [1]; Journal of Bodywork & Movement Therapies [2]; European Journal of Physical and Rehabilitation Medicine [1]; Journal of Orthopaedic & Sports Physical Therapy [1]; Asian Journal of Sports Medicine [1]; Clinical Biomechanics [1]; Journal of Sport Rehabilitation [1]; and BMC Geriatrics [1].

Results
The results of studies investigating the Pilates method in the rehabilitation of musculoskeletal disorders are described below and summarized in Table 2.
All the studies analyzed in table 1 were classified as randomized and controlled.The 14 studies included the following populations and samples: 31 university students of 22 ± 2 years of age (20); 11 athletes aged between 17 and 20 years, mean 18.1 ± 0.83 anos (21); 27 elderly people living in the community, aged 67.3 ± 6.5 years (22); 55 volunteers aged between 28 and 69 years, mean 45.23 ± 10.73 (23); 44 volunteers aged between 25 and 65 years (9); 52 elderly people between 60 and 78 years of age (mean 66 ± 4 years) (24); 21 volunteers aged between 25 and 62 years (25); 60 patients with breast cancer aged between 18 and 75 years (26); 39 physically active adults with a mean age of 34 ± 8 years for the control group and 37 ± 9 years for the exercise group (27) (30).In the study of Gladwell et al. (8), there were significant differences between the Pilates and Control groups in terms of age, however, not for the initial measures.
Of the 14 studies analyzed, 4 evaluated pain, 5 evaluated flexibility, 3 strength, 4 balance, 6 functionality, 3 quality of life, 1 posture, 1 fatigue, 1 lumbo-pelvic stability, 1 the biomechanics of shoulder and trunk and 1 evaluated participation and adherence.The following instruments were used to evaluate pain: Borg CR10 scale (20), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (23), Oswestry Low Back Pain Disability Questionnaire (25), pain sub-scale of the Miami Back Index (25), pain sub-scale of the SF-36 (25) Numerical Rating Scale of 101 points (NRS-101) (27), and Roland Morris pain rating visual-analog scale (8).Flexibility was evaluated through: flexibility test on the Wells bench (21,9,11), fleximeter (21), supine hamstring flexion test (9), and modified sit and reach test (26).Muscular strength of knee extensors was measured in a sitting position with hips and knees at 90° through the maximum extension effort against an elastic resistance in a device capable of recording this effort in kilograms.Dorsiflexor muscular strength was also measured in kilograms with the maximum effort against an elastic resistance.With the foot stabilized on a mobile platform and a strap secured around the metatarsal heads, participants were instructed to raise the front of the foot keeping the heel resting on the plate (22).The strength of the lower abdominals was evaluated with the aid of a goniometer, used to measure the smallest angle in which volunteers could keep the legs suspended isometrically for 3 seconds (28).The following methods were used to evaluate balance: Four Square Step Test (FSST) (22), Timed Up and Go (TUG) test (22), mediolateral sway range (22), modified balance board (9), Tinetti test (24), and functional reach test (29).Functionality was evaluated through: Timed Up and Go (TUG) test (22), Bath Ankylosing Spondylitis Functional Index (BASFI) (23), GDLAM Protocol (Latin-American Development Group for Maturity) for Assessment of Functional Autonomy postural analysis (9).Fatigue was evaluated using the Brief Fatigue Inventory (BFI) (26).Lumbo-pelvic stability was evaluated with the aid of a biofeedback device.The evaluation of shoulder and trunk biomechanics was performed with the aid of an electronic dynamometer and goniometer system for the evaluation of the passive RoM of the shoulder (28).The participation and adherence to a Pilates exercise program was evaluated through the total number of sessions concluded (30).

Discussion
Musculoskeletal disorders are present in a wide variety of health problems.In the studies analyzed, Pilates was used to treat these disorders in patients with Non-structural Scoliosis, Ankylosing Spondylitis, low back pain and breast cancer, as well as for the prevention of injuries in adults, elderly people and athletes.
Scoliosis is a postural change (31) characterized by alterations of the spine in all three planes of movement, with lateral deviation in the frontal plane, lordosis in the sagittal plane and vertebral rotation in the axial plane (32).There are many known causes of scoliosis, which may be congenital or acquired, result from disease or injury as well as from changes in bone structure or neuromuscular problems.However, the majority of cases are of unknown origin and are therefore called idiopathic (33).Recent evidence indicates that physical exercises are able to treat Juvenile Idiopathic Scoliosis, reducing the Cobb angle and producing secondary effects such as improved strength, balance and mobility (34).In relation to the Pilates, despite the positive results indicating improvement in pain and function, the evidence is still limited (35,36,6).Ankylosing Spondylitis (AS) is a chronic disease characterized by rheumatic inflammation (37) of the axial skeleton and sacroiliac joints (38), which affects men more than women (37).Its main clinical manifestations include back pain and stiffness for more than three months, which improves with exercise, but is not relieved by rest (37).Involvement of peripheral joints is reported in approximately one third of patients, most often in the hip, shoulder and knee (38).Its etiology is unknown and there is still no cure, therefore treatment is aimed at relieving and preventing the symptoms (39).The commonly used therapies consist of the administration of drugs and physical exercise.Physical activity and exercise are increasingly considered an important part of the treatment program (38).Hydrotherapy and exercises based on overall postural reeducation seem to offer a valid and promising alternative for these patients (39).Recent studies indicate that Pilates can be promising in the rehabilitation and quality of life of patients with AS, especially for those in the early stages of the disease (40,41,42).
Low back pain with or without pain in the lower limbs is the most common chronic pain disorder, with a significant impact on health, economy and society.It is a multifactorial disorder with many possible causes.Intervertebral discs, joints, ligaments, fasciae, muscles and nerve roots were identified as tissues capable of transmitting low back pain (43).Therapeutic exercise is currently the first-line treatment recommended in clinical guidelines for non-specific chronic low back pain (44).Evidence indicates that Pilates based exercises are superior to minimum interventions for reducing non-specific low back pain, although they are no more effective than other forms of pain reduction exercise (45).Nor are they more efficient than the minimum intervention or other exercises to reduce disability related to chronic low back pain (45).
Breast cancer is the most common cancer among women (46).It is a heterogeneous (47) disease with multiple clinical, pathological and molecular forms (48).The most important risk factors for the disease include gender, age and ethnicity (46).Its incidence and mortality rates generally increase with age, so that women over 45 present greater risk (46).However, in young women it is more often associated with a positive family history and genetic mutations than in older women (49).Current treatment strategies for breast cancer rely on the characterization of the level of protein expression of estrogen and progesterone receptors [estrogen receptor (ER)/ progesterone receptor (PR)], and more recently, the protein expression or gene amplification of human epidermal growth factor (HER2) (48).Breast tumors that cannot express ER/PR and HER2 (triple-negative breast cancer) account for 10% to 17% of all breast cancers (48).The experience of each woman with breast cancer is unique, however, they share common perspectives related to the physical and functional side effects of the breast cancer treatment (50).Limitation of activity, reduced range of motion of the upper limbs, lymphedema, fatigue, pain and chemotherapy-induced peripheral neuropathy are well documented concerns of breast cancer survivors (50).Rehabilitation and exercises are effective in preventing and treating many of these side effects (50).Exercises that cover both physical and psychological needs, such as Pilates, have shown beneficial effects, such as improving the quality of life (QoL) and functionality, reducing fatigue and depression.However, research in relation to Pilates is still scarce and involves studies with small samples (51).
Chronological aging, or senescence, is associated with increased risk of chronic diseases, such as cognitive dysfunction, cardiovascular disease, and metabolic syndrome.Due to the extended life expectancy, age-related diseases have increased at an alarming rate in recent decades (52).Frailty is an increasingly recognized geriatric syndrome, in which the individual enters a state of vulnerability caused by the functional reduction of multiple systems (53).Furthermore, it is an independent predictor of mortality, morbidity and institutionalization after surgery (54).Evidence indicates that physical exercise can be used in the treatment of fragility (53) and depression (55), as well as in the prevention of age-related cognitive decline and neurodegenerative diseases (52).The Pilates method appears to have positive effects on neuromotor ability, especially regarding the static and dynamic balance.However, compared to other components of physical fitness (cardiorespiratory endurance, muscle strength, body composition and flexibility), the results are still inconclusive, requiring more studies with high quality methodology (56,57).
All 14 studies showed positive and negative aspects for health, such as: reduction of pain, increased flexibility and improved functional capacity.The effect of Pilates was positive, proving to be efficient to reduce pain, increase flexibility, improve balance, increase abdominal and lower limb strength, and improve spinal mobility, chest expansion and disease activity in patients with ankylosing spondylitis.In addition, it increased the strength of the abdominal muscles and lower limbs, improved lumbo-pelvic stability, posture, proprioception, shoulder kinematics functional autonomy, sports function and quality of life.Regarding balance, there was an improvement that was maintained 6 weeks after intervention (22), however, in the study of Bird et al. (22) there was no significant difference between the control and Pilates groups and in the study of Kloubec (9) there was no significant improvement in balance with Pilates.Despite other studies that found improved functionality with Pilates, in the study by Anderson (25) there was improvement in functionality with massage but not with Pilates and in the study Gladwell et al. (8) the improvement of the Control group was greater than the Pilates group.In the study of Mallery et al. (30) the hospitalized elderly patents were able to perform the Pilates program.

Conclusion
Field studies with samples of various characteristics, which favors the generalization of the data, were analyzed.The studies analyzed indicate that Pilates can be effective both for treating conditions such as scoliosis, low back pain, ankylosing spondylitis and breast cancer, and for the prevention of injuries in adults, elderly people and athletes.
However, due to the high methodological variability, these studies should be viewed with caution.This indicates the need for new studies with high methodological quality and standardization of evaluation instruments.

Table 1 -
PEDro scale of Methodological Classification Measurement of at least one key outcome in 85% of the initial subjectsYes/No 1/0 All subjects received treatment or control condition as allocated, otherwise, the data for at least one key outcome was analyzed by "intention to treat"

Table 1 -
PEDro scale of Methodological Classification

Table 1 -
PEDro scale of Methodological Classification

Table 1 -
PEDro scale of Methodological Classification

Table 1 -
PEDro scale of Methodological Classification

Table 1 -
PEDro scale of Methodological Classification

Table 1 -
PEDro scale of Methodological Classification