Pilates method and pain in pregnancy: a systematic review and metanalysis

Huliana Mendo Matheus Santos Gomes Jorge About the authors

ABSTRACT

BACKGROUND AND OBJECTIVES:

The bodily changes resulting from pregnancy can culminate in adverse outcomes to maternal health, including pain, which may be related to postural changes, functional disabilities and impaired quality of life of pregnant women. Due to its effects, the Pilates Method can contribute to alleviate these problems, although its benefits are not a consensus in the literature. In this sense, the objective of this study was to systematically review in the literature the implications of the Pilates Method on pain in pregnant women.

CONTENTS:

Systematic review and metanalysis of randomized clinical trials conducted in the databases Embase, Scopus, Cochrane Library, Medline, Web of Science, PEDro, LILACS and SciELO, where the descriptors “Pregnancy” and “Pilates Method” were used. Of the 105 articles found, five met the selection criteria for this study and two were included in the meta-analysis for the outcome pain. The Pilates Method group showed superiority for pain relief compared to the control group (CI95%: -2.24 - -1.13; I2: 12%). Additionally, the Pilates Method produced less progression of abdominal diastasis, decreased fatigue, maintained anthropometric and hemodynamic parameters, increased abdominal and pelvic floor strength, improved hamstring muscle flexibility, lumbar-pelvic stabilization, posture, functional capacity and quality of life of pregnant women.

CONCLUSION:

The Pilates method was superior to the minimum intervention for pain relief in pregnant women, in addition to improving physical conditions.

Keywords:
Exercise movement techniques; Pain; Pregnant women; Physical therapy specialty; Quality of life

RESUMO

JUSTIFICATIVA E OBJETIVOS:

As mudanças corporais oriundas da gestação podem culminar em desfechos adversos à saúde materna, incluindo a dor, que pode estar relacionada às alterações posturais, incapacidades funcionais e comprometimento da qualidade de vida das gestantes. Em virtude dos seus efeitos, o método Pilates pode contribuir para amenizar estes problemas, embora seus benefícios não sejam um consenso na literatura. Neste sentido, o objetivo deste estudo foi revisar sistematicamente na literatura as implicações do método Pilates na gestação.

CONTEÚDO:

Revisão sistemática e metanálise de ensaios clínicos randomizados realizada nas bases de dados Embase, Scopus, Cochrane Library, Medline, Web of Science, PEDro, LILACS e Scielo, em que se utilizou os descritores “Pregnancy” e “Pilates Method”. Dos 105 artigos encontrados, cinco preencheram os critérios de seleção e dois foram incluídos na metanálise para o desfecho dor. O grupo método Pilates apresentou superioridade para alívio da dor em comparação ao grupo controle (IC95%: -2,24 - -1,13; I2: 12%). Adicionalmente, o método Pilates produziu menor progressão da diástase abdominal, diminuição da fadiga, manutenção dos parâmetros antropométricos e hemodinâmicos, aumento da força abdominal e do assoalho pélvico, melhora da flexibilidade dos músculos isquiotibiais, da estabilização lombo-pélvica, da postura, da capacidade funcional e da qualidade de vida das gestantes.

CONCLUSÃO:

O método Pilates foi superior à intervenção mínima para alívio da dor em gestantes, além de produzir melhora das condições físicas.

Descritores:
Dor; Fisioterapia; Gestantes; Qualidade de vida; Técnicas de exercício e de movimento

INTRODUCTION

During pregnancy, hormonal and physiological changes occur, culminating in musculoskeletal complications11 Kesikburun S, Güzelküçük Ü, Fidan U, Demir Y, Ergün A, Tan AK. Musculoskeletal pain and symptoms in pregnancy: a descriptive study. Ther Adv Musculoskelet Dis. 2018;10(12):229-34., which can cause great emotional impact, especially in primiparous women22 Westerneng M, Witteveen AB, Warmelink JC, Spelten E, Honig A, de Cock P. Pregnancy-specific anxiety and its association with background characteristics and health-related behaviors in a low-risk population. Compr Psychiatry. 2017;75(75):6-13.. Among these complications, musculoskeletal pain stands out as one of the main ones33 Casagrande D, Gugala Z, Clark SM, Lindsey RW. Low back pain and pelvic girdle pain in pregnancy. J Am Acad Orthop Surg. 2015;23(9):539-49.,44 Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev. 2015;(9):CD001139., especially affecting the lumbar, pelvic or pubic regions55 Meucci RD, Perceval AH, Lima DR de, Cousin E, Marmitt LP, Pizzato P, et al. Occurrence of combined pain in the lumbar spine, pelvic girdle and pubic symphysis among pregnant women in the extreme south of Brazil. Rev Bras Epidemiol. 2020;23(1):1-12..

Approximately 30% of pregnant women have severe pain symptoms that may interfere in their functional capacity and quality of life (QoL)44 Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev. 2015;(9):CD001139., and several factors, such as postural changes, lumbar hyperlordosis and pelvic ligament loosening may cause pain during pregnancy33 Casagrande D, Gugala Z, Clark SM, Lindsey RW. Low back pain and pelvic girdle pain in pregnancy. J Am Acad Orthop Surg. 2015;23(9):539-49., as well as persist even after this period66 Colla C, Paiva LL, Thomaz RP. Therapeutic exercise for pregnancy low back and pelvic pain: a systematic review. Fisioter Mov. 2017;30(2):399-411.. Contributing to the advancement of the gestational period is the weakness of the stabilizing muscles of the abdominal region and pelvic floor77 Moccellin AS, Rett MT, Driusso P. Existe alteração na função dos músculos do assoalho pélvico e abdominais de primigestas no segundo e terceiro trimestre gestacional? Fisioter Pesqui. 2016;23(2):136-41.. Although evident in most pregnant women, these health problems are little investigated in populations of middle and low income88 Duarte VM, Meucci RD, Cesar JA. Dor lombar intensa em gestantes do extremo Sul do Brasil. Cien Saude Colet. 2018;23(8):2487-94..

Pregnant women benefit from physical therapy when it comes to treating pain, facilitating labor and improving QoL99 Castro AS, Castro AC, Mendonça AC. Physiotherapeutic approach in the pre-partum: proposed protocol and evaluate pain. Fisioter Pesq. 2012;19(3):210-4.. Among the physiotherapeutic interventions for this public, the Pilates Method (PM) is an alternative for pain relief and improvement of the lumbopelvic region, functional capacity and QoL1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8., among other benefits. Nevertheless, the literature points out that the heterogeneity about the practice of PM among pregnant women, as well as the low adherence to the clinical practice guidelines, are factors that drive the need for more grounded research on the subject, especially in cases that present health problems during pregnancy1111 Mazzarino M, Kerr D, Morris ME. Pilates program design and health benefits for pregnant women: A practitioners' survey. J Bodyw Mov Ther. 2018;22(2):411-7..

Therefore, the objective of the present study was to systematically review the literature on the effects of PM during pregnancy.

METHODS

A systematic review and meta-analysis of randomized clinical trials (RCT) following the recommendations proposed by the PRISMA checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), which is specific for reviewing RCT1212 Galvão TF, Pansani TS, Harrad D. Principais itens para relatar revisões sistemáticas e meta-análises: a recomendação PRISMA. Epidemiol Serv Saúde. 2015;24(2):335-42..

The present review included RCT, studies whose intervention included PM, and studies whose samples were composed exclusively of pregnant women. The following were excluded: review studies, guidelines, observational studies, qualitative studies, case studies, editorials, expert opinions or studies of any other nature, studies that investigated the effects of other physical therapy approaches, such as Kegel exercises, kinesiotherapy, hydrotherapy, electrothermophototherapy, etc. (associated or not with PM) and studies that included other types of approaches such as nutritional, pharmacological or surgical intervention.

The search strategy was done in pairs in September 2020 using English terms that were in accordance with the Medical Subject Headings (MeSH). The descriptors ‘’Pregnancy’’ and “Pilates Method’’ were used. The search didn’t restrict the studies by language, period of publication or type of access (free or restrict). The searched databases were Embase, Scopus, Cochrane Library, Medline, Web of Science, Physiotherapy Evidence Database (PEDro), LILACS and Scielo.

The search conducted on Medline (via PubMed) used database-specific filters to make the search more sensitive, crossing terms contained in “#1” and “#2” (Table 1).

Table 1
Filters for search strategy

Initially, studies were identified in the databases and duplicate studies were excluded (Identification Phase). The titles, abstracts, and descriptors/keywords of all articles identified by the search strategy were evaluated by two reviewers. In case of disagreement, a third reviewer was requested in order to reach a consensus and for tie-breaking (Screening Phase). Then, all pre-selected studies were evaluated in their entirety, using the same tie-breaking strategy as in the previous phase (Eligibility Phase). Finally, information was extracted regarding the characteristics of the selected studies regarding: identification, samples, methodological procedures, and outcomes. Of the five included articles, two composed the meta-analysis (Inclusion Phase) (Figure 1).

Figure 1
Articles search and selection strategy flowchart

The methodological quality of the included articles was evaluated using the PEDro scale, with scores from zero to 10, in which the following criteria are evaluated: 1. Eligibility criteria; 2. Random allocation; 3. Concealed allocation; 4. Baseline comparability; 5. Blinded subjects; 6. Blinded therapists; 7. Blinded evaluators; 8. Adequate follow-up; 9. Intention-to-treat analysis; 10. Between-group comparisons; 11. Point estimates and variability. The first criterion is not counted in the total score1313 PEDro. Escala PEDro [Internet]. PEDro. 2020 [cited 2020 Nov 10]. p. 1. Available from: https://pedro.org.au/portuguese/resources/pedro-scale/
https://pedro.org.au/portuguese/resource...
.

Meta-analysis was performed using Review Manager software version 5.4 (Cochrane Collaboration), using the random effects model. Effect measures were obtained by post-intervention values. The studies were analyzed separately according to the pain variable, measured by the Visual Analog Scale (VAS). A value of p≤0.05 and 95% confidence interval (CI) were considered statistically significant. Statistical heterogeneity of treatment effects between studies was assessed by Cochrane’s Q test and inconsistency by the I2 test, where values above 25, 50, and 75% were considered to indicate moderate, substantial, and considerable heterogeneity, respectively.

RESULTS

The studies place of origin varied, with two coming from Turkey1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3., one from Brazil1515 Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84., one from Indonesia1616 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51., and one from Spain1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7.. Four studies were written in English1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1515 Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84.

16 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51.
-1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7. and one in Turkish1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3.. According to the evaluation of the methodological quality of the studies by the PEDro scale, the scores of the articles ranged from three to eight points (Table 2).

Table 2
Characterization of the studies' referential data

The total analyzed data was of 261 pregnant women, whose mean age was 23.06 ± 3.23 years. The data on pregnancy-related information is heterogeneous, with the gestational time ranging from the 14th to 36th week of gestation and most of the samples being primiparous (Table 3).

Table 3
Characterization of studies' samples

Several instruments were used for the assessment, among which were: VAS1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3.,1616 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51., muscle strength test (abdominal muscles)1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3., palpation (abdominal diastasis)1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3., SF-36 Questionnaire (quality of life)1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3., Beck Depression Inventory (psychological state)1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3., Fatigue Severity Scale (fatigue)1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3., manometer (pelvic floor muscle strength)1515 Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84., Oxford Scale (pelvic floor muscle strength, endurance, and repeatability)1515 Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84., anthropometry (height, weight, and body mass index)1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7., blood pressure1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7., hand dynamometry (hand grip strength)1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7., goniometry (hamstring muscle flexibility)1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7. and inclinometer (spinal curvatures)1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7., Oswestry Questionnaire (functional capacity)1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8., Nottingham Health Profile Questionnaire (quality of life)1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8. and biofeedback in the lumbopelvic muscles (lumbopelvic stabilization)1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8. (Table 4).

Table 4
Characterization of the evaluation tools, intervention protocols and studies outcomes

Three studies1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1515 Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84.,1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7. applied the MatPilates modality with the help of accessories and two studies1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3.,1616 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51. applied MatPilates exclusively. The frequency varied between one1616 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51. and two1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3.,1515 Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84.,1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7. times weekly, in a period between eight1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1515 Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84.

16 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51.
-1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7. and twenty1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3. weeks, totaling eight1616 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51., 161010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1515 Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84.,1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7. and 401414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3. sessions. The comparison groups presented varied modalities, such as irregular voluntary walking1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3., kinesiotherapy1515 Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84.,1616 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51. and general guidance1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7.. In all studies, PM showed superiority over control interventions in all analyzed outcomes (Table 4).

According to the meta-analysis, the PM group was superior to the CG in improving pain as measured by VAS in postpartum women (CI95%: -2.24 - -1.13; I2: 12%). The level of heterogeneous inconsistency of the statistical analysis was 12%, indicating low inconsistency on results (Table 5).

Table 5
Comparison between the Pilates Method versus Control regarding pain measured by the Visual Analog Scale

DISCUSSION

The main finding of this study was the superiority of the PM group over the control or minimal intervention group for pain relief in pregnant women. In addition, PM produced less progression of abdominal diastasis, decreased fatigue, maintenance of anthropometric and hemodynamic parameters, increased abdominal and pelvic floor strength, improved flexibility of the hamstring muscles, lumbopelvic stabilization, posture, functional capacity, and QoL in pregnant women.

PM is a beneficial strategy for the overall health of women and can improve pain, lower limb strength, QoL1818 Mazzarino M, Kerr D, Wajswelner H, Morris ME. Pilates method for women's health: systematic review of randomized controlled trials. Arch Phys Med Rehabil. 2015;96(12):2231-42., among other physical and psychological aspects, especially in the improvement of the pelvic floor and social well-being. However, there is little information and recommendations about the safe and appropriate instructions of this method for pregnant women, besides divergences regarding its safety in special situations, frequency and dosage1111 Mazzarino M, Kerr D, Morris ME. Pilates program design and health benefits for pregnant women: A practitioners' survey. J Bodyw Mov Ther. 2018;22(2):411-7., which is why the present work investigated this physiotherapeutic intervention in this specific population. The present study observed that PM produced benefits for the health of pregnant women, including the aspect of pain1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3.,1616 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51.. Moreover, there was evidence that most studies point to these benefits when the technique is applied at least twice a week, over a period of eight weeks, totaling 16 sessions.

The main symptoms that pregnant women face are musculoskeletal pain, which may affect the lumbar and pelvic regions, the back, hips, and even wrists11 Kesikburun S, Güzelküçük Ü, Fidan U, Demir Y, Ergün A, Tan AK. Musculoskeletal pain and symptoms in pregnancy: a descriptive study. Ther Adv Musculoskelet Dis. 2018;10(12):229-34.. Moreover, about 30% of pregnant women have severe symptoms that usually compromise their daily activities and QoL, requiring rest and time off work44 Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev. 2015;(9):CD001139.. Thus, PM was presented as a strategy for pain relief1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3.,1616 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51., improved functional capacity1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8. and QoL1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8. in pregnant women.

An experimental study with 10 women with primary dysmenorrhea who underwent 10 PM sessions showed that after the intervention there was a decrease in pain during menstrual periods in these patients1919 Araújo LM, Silva JM, Bastos WT, Ventura PL. Diminuição da dor em mulheres com dismenorreia primária, tratadas pelo método Pilates. Rev Dor. 2012;13(2):119-23.. This corroborates the present review, where three studies1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3.,1616 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51. showed a decrease in pain after PM.

As the gestational period proceeds, there is a decrease in the electromyographic activity and in the strength of the PFM and abdominal muscles attributed to the increase in the overload that this musculature undergoes during pregnancy77 Moccellin AS, Rett MT, Driusso P. Existe alteração na função dos músculos do assoalho pélvico e abdominais de primigestas no segundo e terceiro trimestre gestacional? Fisioter Pesqui. 2016;23(2):136-41.. The principles of PM include the strengthening of the pelvic floor and the prevention and/or treatment of dysfunctions of this region caused by pregnancy2020 Fernandes KTMS, Santos RN. Os benefícios do Método Pilates no fortalecimento do assoalho pélvico no período gestacional: uma revisão bibliográfica. Rev Cient Escol Estad Saud Publ Cândido Santiago (RESAP). 2016;2(3):152-62.. Such benefits were observed in two included studies1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3.,1515 Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84. in which this intervention was beneficial for increasing muscle strength and resistance in this region. In addition, it’s noteworthy that during static contraction pain decreases muscle activity2121 Falla D, Farina D, Dahl MK, Graven-Nielsen T. Muscle pain induces task-dependent changes in cervical agonist/antagonist activity. J Appl Physiol. 2007;102(2):601-9., resulting in compensation by other muscles to perform the desired movements and, consequently, in increase of pain2222 Ervilha UF, Arendt-Nielsen L, Duarte M, Graven-Nielsen T. Effect of load level and muscle pain intensity on the motor control of elbow-flexion movements. Eur J Appl Physiol. 2004;92(1-2):168-75., resulting in a vicious cycle.

There is a decline in handgrip strength as the gestational period advances2323 Zelazniewicz A, Pawlowski B. Maternal hand grip strength in pregnancy, newborn sex and birth weight. Early Hum Dev. 2018;119(1):51-5., requiring attention to this aspect in these individuals. One of the listed studies1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7. verified that PM was beneficial to the handgrip strength of pregnant women when compared to the usual conducts, corroborating a research that showed that PM twice a week, during 12 weeks, produced better effects for the increase of handgrip strength and abdominal resistance in pregnant women when compared to usual physical activities2424 Santos JCL, Vancini RL, Sarro KJ. Impacto de 12 semanas de prática de Pilates solo na força de preensão manual, resistência abdominal e na flexibilidade avaliada por fotogrametria em mulheres saudáveis. Pensar a Prática. 2017;20(2):1-11..

Gestational static and dynamic musculoskeletal alterations, such as decreased trunk mobility and altered movements, increased mass, and body dimensions2525 Ostgaard HC, Andersson GB, Schultz AB, Miller JA. Influence of some biomechanical factors on low-back pain in pregnancy. Spine. 1993;18(1):61-5. can lead to pain and discomfort, causing limitations in daily life and professional activities2626 Mann L, Kleinpaul JF, Teixeira CS, Konopka CK. Dor lombo-pélvica e exercício físico durante a gestação. Fisioter Mov. 2008;21(2):99-105.. Therefore, PM can be an alternative for these problems, because it involves a synchronous work between body and mind2727 Rodrigues BG, Cader SA, Oliveira EM, Torres NV, Dantas EHM. Avaliação do equilíbrio estático de idosas pós-treinamento com Método Pilates. Rev Bras Ciência Mov. 2009;4(17):25033., providing direct and indirect effects on several aspects, from the prevention of health-related problems to physiological changes2828 Mello NF, Costa DL, Vasconcellos SV, Lensen CMM, Corazza ST. The effect of the Contemporary Pilates method on physical fitness, cognition and promotion of quality of life among the elderly. Rev Bras Geriatr Gerontol. 2018;21(5):597-603., as is the case during the gestational period. In that sense, one of the studies1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8. showed that PM was beneficial to improve the functional capacity of pregnant women.

Obesity can affect up to 60% of pregnant women with a history of overweight, which can lead to adverse health outcomes, such as diabetes mellitus, cardiovascular diseases, endocrine changes, among other comorbidities2929 Moll U, Olsson H, Landin-Olsson M. Impact of pregestational weight and weight gain during pregnancy on long-term risk for diseases. PLoS One. 2017;12(1):e0168543.. Such complications are not restricted to the mother, and may be extended to newborns, predisposing them to the risk of being born with a higher percentage of body fat and obesity in childhood3030 Catalano PM, Shankar K. Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child. BMJ. 2017;1(1):1-16.. Therefore, PM can have effects on the mother’s body composition aiming to minimize these possible future adverse outcomes. Although some studies1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7. observed that PM was not able to prevent the increase in body weight and BMI of pregnant women, it proved to be superior to the usual conducts because the individuals in the conventional treatment showed a significantly higher increase in these variables when compared to the individuals in the PG.

One of the main disorders that occur during pregnancy is hypertension, which can affect up to 10% of cases, being closely related to adverse health outcomes such as pre-eclampsia, premature placental abruption, premature delivery, fetal growth restriction, stillbirths, the development of cardiometabolic diseases, and secondary maternal death. Thus, it’s necessary that blood pressure control is rigidly performed during this period3131 American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-31.,3232 Magee LA, Singer J, von Dadelszen P. CHIPS Study Group. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(24):2367-8., and one of the strategies is physical exercise.

Systemic arterial hypertension is the main chronic disease most prevalent in the general population, and its management involves, besides lifestyle changes, the performance of aerobic and resistance exercises. Thus, PM uses exercises similar to conventional treatment and has the potential to reduce blood pressure in individuals with hypertension3333 Gonzáles AI, Nery T, Fragnani SG, Pereira F, Lemos RR, Bezerra PP, et al. Pilates exercise for hypertensive patients: a review of the literature. Altern Ther Heal Med. 2016;5(22):38-43., including during pregnancy, as observed in one of the included studies1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7..

Low back pain is one of the conditions with the highest impact all over the world, and the greatest restriction occurs in lateral trunk flexion, as well as in the range of motion of the hamstring muscles3434 Sadler SG, Spink MJ, Ho A, De Jonge XJ, Chuter VH. Restriction in lateral bending range of motion, lumbar lordosis, and hamstring flexibility predicts the development of low back pain: a systematic review of prospective cohort studies. BMC Musculoskelet Disord. 2017;18(1):179.. Thus, a study conducted with 47 healthy college women showed that PM was effective in improving the hamstring muscles flexibility, abdominal muscle endurance, and abdominal and lumbar muscle activity3535 Kibar S, Yardimci FÖ, Deniz Evcik SA, Alhan A, Manço M, Ergin ES. Can a pilates exercise program be effective on balance, flexibility and muscle endurance? A randomized controlled trial. J Sports Med Phys Fitness. 2016;56(10):1139-46., which is in agreement with the findings of the present review, since the studies included pointed to the improvement of the hamstring muscles flexibility1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7. and increased abdominal muscle strength1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3..

The adequate alignment is a prerequisite for efficiently performing a movement, especially the pelvic alignment, which has great influence and can impair the performance of some movements when altered. Thus, PM performed during 14 weeks with two weekly sessions becomes an effective strategy to improve body biomechanics3636 Ahearn EL, Greene A, Lasner A. Some Effects of supplemental pilates training on the posture, strength, and flexibility of dancers 17 to 22 years of age. J Danc Med Sci. 2018;22(4):192-202., as observed in one of the selected studies1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7..

During pregnancy, body modifications, such as the anteriorized gravity center, the increase in lumbar curvature, and the installation of a compensatory mechanism, most of the time produce musculoskeletal pain, especially in the spine, negatively impacting the pregnant woman’s QoL. In this sense, PM can benefit these patients, mainly by alleviating low back pain, improving physical performance and biomechanical alignment, as well as health, general psychic and social well-being , and preparation for childbirth3737 Silva JKS, Nascimento LGC do, Borges AMA, Dantas SS, Barbosa JGA, Vidal GP. Benefícios do Método Pilates aplicado em gestantes: um foco nas alterações posturais. Temas em Saúde. 2019;19(2):242-58.. This was pointed out in the present review, which observed that PM was able to reduce pain1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3.,1616 Oktaviani I. Pilates workouts can reduce pain in pregnant women. Complement Ther Clin Pract. 2018;31(1):349-51. (even more than the minimal intervention1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3.), promoting the improvement of posture and pelvic alignment1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1717 Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7., functional capacity1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8. and QoL1010 Sonmezer E, Özköslü MA, Yosmaoglu HB. The effects of clinical pilates exercises on functional disability, pain, quality of life and lumbopelvic stabilization in pregnant women with low back pain: a randomized controlled study. J Back Musculoskelet Rehabil. 2020;1(1):1-8.,1414 Canarslan B, Akbayrak T. Assessing the effects of clinical pilates exercises on the strength of abdominal muscles and diastasis recti abdominis in pregnant women. Fiz Rehabil. 2017;28(2):42-3. of pregnant women.

Reinforcing previous considerations, the literature shows that PM can be capable of promoting, besides pain relief, improvement in flexibility and muscle strength, functional capacity3838 Miyamoto GC, Franco KFM, van Dongen JM, Franco YRDS, de Oliveira NTB, Amaral DDV, et al. Different doses of Pilates-based exercise therapy for chronic low back pain: a randomised controlled trial with economic evaluation. Br J Sports Med. 2018;52(13):859-68. and spinal alignment, effects that can be maintained in the long term3939 González-Gálvez N, Vaquero-Cristóbal R, Marcos-Pardo PJ. Effect of Pilates Method on muscular trunk endurance and hamstring extensibility in adolescents during twelve weeks training and detraining. J Bodyw Mov Ther. 2020;24(2):11-7.. Thus, PM is an approach that, producing benefits on the pain of pregnant women, consequently improves other physical parameters.

A limitation of this study was the fact that sensitivity or meta-regression analysis was not performed, even when inconsistency in the outcome of the statistical analysis was observed. Nevertheless, this does not prevent the generation and dissemination of the present findings on the effects of PM in pregnant women.

CONCLUSION

The PM, when applied in a frequency of two weekly sessions over a period of eight weeks, is superior to the minimal intervention for pain relief in pregnant women. Furthermore, this approach produces improvement in the physical conditions of this population, such as less progression of abdominal diastasis, decreased fatigue, maintenance of anthropometric and hemodynamic parameters, abdominal and pelvic floor strength increase, improvement in hamstring muscles flexibility, of lumbopelvic stabilization, posture, functional capacity, and QoL.

  • Sponsoring sources: none.

REFERENCES

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    Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn. 2018;37(1):379-84.
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    Rodríguez-Díaz L, Ruiz-Frutos C, Vázquez-Lara JM, Ramírez-Rodrigo J, Villaverde-Gutiérrez C, Torres-Luque G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm Clín. 2017;27(5):271-7.
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    Fernandes KTMS, Santos RN. Os benefícios do Método Pilates no fortalecimento do assoalho pélvico no período gestacional: uma revisão bibliográfica. Rev Cient Escol Estad Saud Publ Cândido Santiago (RESAP). 2016;2(3):152-62.
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    Falla D, Farina D, Dahl MK, Graven-Nielsen T. Muscle pain induces task-dependent changes in cervical agonist/antagonist activity. J Appl Physiol. 2007;102(2):601-9.
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    Ervilha UF, Arendt-Nielsen L, Duarte M, Graven-Nielsen T. Effect of load level and muscle pain intensity on the motor control of elbow-flexion movements. Eur J Appl Physiol. 2004;92(1-2):168-75.
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    Zelazniewicz A, Pawlowski B. Maternal hand grip strength in pregnancy, newborn sex and birth weight. Early Hum Dev. 2018;119(1):51-5.
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    Santos JCL, Vancini RL, Sarro KJ. Impacto de 12 semanas de prática de Pilates solo na força de preensão manual, resistência abdominal e na flexibilidade avaliada por fotogrametria em mulheres saudáveis. Pensar a Prática. 2017;20(2):1-11.
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    Ostgaard HC, Andersson GB, Schultz AB, Miller JA. Influence of some biomechanical factors on low-back pain in pregnancy. Spine. 1993;18(1):61-5.
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    Mann L, Kleinpaul JF, Teixeira CS, Konopka CK. Dor lombo-pélvica e exercício físico durante a gestação. Fisioter Mov. 2008;21(2):99-105.
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    Rodrigues BG, Cader SA, Oliveira EM, Torres NV, Dantas EHM. Avaliação do equilíbrio estático de idosas pós-treinamento com Método Pilates. Rev Bras Ciência Mov. 2009;4(17):25033.
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    Mello NF, Costa DL, Vasconcellos SV, Lensen CMM, Corazza ST. The effect of the Contemporary Pilates method on physical fitness, cognition and promotion of quality of life among the elderly. Rev Bras Geriatr Gerontol. 2018;21(5):597-603.
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    Moll U, Olsson H, Landin-Olsson M. Impact of pregestational weight and weight gain during pregnancy on long-term risk for diseases. PLoS One. 2017;12(1):e0168543.
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    Magee LA, Singer J, von Dadelszen P. CHIPS Study Group. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(24):2367-8.
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    Gonzáles AI, Nery T, Fragnani SG, Pereira F, Lemos RR, Bezerra PP, et al. Pilates exercise for hypertensive patients: a review of the literature. Altern Ther Heal Med. 2016;5(22):38-43.
  • 34
    Sadler SG, Spink MJ, Ho A, De Jonge XJ, Chuter VH. Restriction in lateral bending range of motion, lumbar lordosis, and hamstring flexibility predicts the development of low back pain: a systematic review of prospective cohort studies. BMC Musculoskelet Disord. 2017;18(1):179.
  • 35
    Kibar S, Yardimci FÖ, Deniz Evcik SA, Alhan A, Manço M, Ergin ES. Can a pilates exercise program be effective on balance, flexibility and muscle endurance? A randomized controlled trial. J Sports Med Phys Fitness. 2016;56(10):1139-46.
  • 36
    Ahearn EL, Greene A, Lasner A. Some Effects of supplemental pilates training on the posture, strength, and flexibility of dancers 17 to 22 years of age. J Danc Med Sci. 2018;22(4):192-202.
  • 37
    Silva JKS, Nascimento LGC do, Borges AMA, Dantas SS, Barbosa JGA, Vidal GP. Benefícios do Método Pilates aplicado em gestantes: um foco nas alterações posturais. Temas em Saúde. 2019;19(2):242-58.
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    Miyamoto GC, Franco KFM, van Dongen JM, Franco YRDS, de Oliveira NTB, Amaral DDV, et al. Different doses of Pilates-based exercise therapy for chronic low back pain: a randomised controlled trial with economic evaluation. Br J Sports Med. 2018;52(13):859-68.
  • 39
    González-Gálvez N, Vaquero-Cristóbal R, Marcos-Pardo PJ. Effect of Pilates Method on muscular trunk endurance and hamstring extensibility in adolescents during twelve weeks training and detraining. J Bodyw Mov Ther. 2020;24(2):11-7.

Publication Dates

  • Publication in this collection
    08 Oct 2021
  • Date of issue
    Jul-Sep 2021

History

  • Received
    02 Dec 2020
  • Accepted
    16 July 2021
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