The use of Pilates for pain control in patients with fibromyalgia

Introduction: Although the Pilates method is commonly used to treat fibromyalgia (FM) in clinical practice, research is scarce, and little is known about its real effectiveness in pain management. Objective: Systematically review the literature to determine whether Pilates affects pain control in FM patients. Methods: The PubMed, Science Direct, PEDro and Cochrane databases were searched to identify randomized controlled trials that investigated the effects of Pilates in individuals diagnosed with FM. The descriptors used were: “pilates based exercise” OR “pilates training” OR “pilates exercise” OR “pilates” AND “fibromyalgia.” Independent reviewers performed abstract/full-text screening, data extraction, and methodological quality assessments using the PEDro scale. Results: The search identified 646 potential articles, four of which were used in the analysis. The Pilates method had positive effects on pain control, physical function, quality of life and biopsychosocial factors such as stress and depression in individuals with FM in four studies. However, improvement in these parameters did not differ between intervention groups in three studies. Additionally, the control group showed no significant improvement for the same parameters in one study. The PEDro scale scores of the studies ranged from 6 to 8 points. Conclusion: Evidence suggests that Pilates influences pain control in individuals with FM, and is more effective than no intervention or minimal intervention in the treatment of FM.


Introduction
Fibromyalgia (FM) is a syndrome characterized by diffuse chronic pain, fatigue, anxiety, sleep disorders, cognition and mood. It occurs in 2 to 5% of the general population, particularly in women aged between 50 and 80 years. [1][2][3] The diagnosis is purely clinical and confirmed by the Widespread Pain Index (WPI) and the Symptom Severity Scale (SSS) (score 2A and 2B), including assessment of fatigue, sleep quality, cognitive state and the presence of other associated symptoms. 3 Moreover, the presence of symptoms and absence of other pathologies were assessed for three months. Complementary laboratory and radiographic examinations should be prescribed with the clinical investigation criteria of the patient and FM-associated comorbidities. 1 Its pathology, far from being completely elucidated, has been related to neuroendocrine abnormalities involving the body's main stress modulating system, the hypothalamic-pituitary-adrenal axis (HPA), and deficits in the pain modulation endogenous systems. 4,5 FM symptoms have been directly related to the inability of the HPA axis to modulate acute and chronic stress. 6 Stress causes the hypothalamus to release the corticotrophin-releasing hormone (CRH) which, in turn, stimulates the pituitary gland to secrete the adrenocorticotropic hormone (ACTH). 7 The increase in ACTH plasma concentrations stimulates the adrenal gland to release cortisol. High serum cortisol concentrations seem to exacerbate musculoskeletal pain in patients with FM. 4,6 With respect to changes in endogenous pain modulation systems, low brain serotonin concentrations and high P substance, inhibitory and excitatory neurotransmitter concentrations in the central nervous system (CNS) may be directly related to central sensitization and hyperalgesia in patients with FM. 4,8 In this respect, pain and comorbidities are currently

Methods
The present study complied with PRISMA guidelines for systematic reviews and meta-analyses 17 (PROSPERO:

Results
A total of 646 articles were initially identified, 32 of which were excluded for being duplicates on the databases. After titles/abstracts were analyzed and the articles read in their entirety, four studies met the eligibility criteria and were included in qualitative analysis, as described in Figure 1. Participant characteristics, parameters assessed, and the interventions of each study were summarized and described in Table 1.
The four randomized clinical trials included in this review were conducted in Brazil (n = 2) 16,19 and Turkey (n = 2). 12   Considering pain indicators, the groups that used Pilates as intervention significantly improved pain intensity (VAS) in three studies, 12,16,19 tender points in two, 12,16 algometry in one, 12 and FIQ in four studies after the intervention. 12,16,19,20 Pilates was significantly better in improving pain intensity (VAS), tender points, algometry and FIQ when compared to home-based stretching/relaxation exercises in only one study. 12 When compared to aquatic aerobic exercises, Pilates showed no significant differences in terms of pain intensity in one study. 19 Similarly, the improvement in pain intensity did not differ between the groups that underwent individualized or group-based Pilates sessions. 20 A statistically significant improvement was observed in pain intensity and the number of tender points in the Pilates group in one study, 16 while the control group, which did not receive physiotherapy for FM, showed no significant improvement for the same parameters.
In this case, the intergroup differences pre-and postintervention were not significant. 16

PRCTS.
Both groups improved in terms of pain and function (p < 0.05).
The PMG showed no significant differences in relation to the AAEG for the variables analyzed. Both groups improved significantly in FIQ, SF36 and BETY. Group II improved in the HAQ and BAI (p < 0.05).
Intergroup comparison showed a statistically significant difference in Group II (p < 0.05) for FIQ. However, no statistical differences were found in other results.   16 Medeiros et al. 19 Caglayan et al. 20 1. Eligibility criteria were specified. x x x x 2. Subjects were randomly allocated to groups (in a cross-reference study, subjects were randomly placed in groups, according to the treatment received). x x x -8. Measures of at least one key result were obtained in more than 85% of subjects initially allocated to the groups.
x -x x 9. All the subjects whose results were presented received the treatment or were controls, according to allocation, and when this was not the case, intention-to-treat analysis was used for at least one of the key results.
x x x 10. The results of intergroup statistical comparisons were described for at least one key result.
x x x x 11. The study shows both accuracy and variability measures of at least one key result.
x x x x TOTAL 6 8 8 6 Note: Criterion 1 is not scored on the PEDro scale; -(not scored); x (score).
Pilates training is based on flexibility associated with trunk and limb strengthening exercises, respiratory, postural and motor coordination excercises. 13 Recent studies have shown that Pilates can effectively relieve pain and reduce the degree of patient disability. 14,21 In regard to pain control, several studies have demonstrated that musculoskeletal exercises seem to increase

Discussion
The  and HAQ. 20 Pilates was significantly better in improving function and quality of life in FIQ analysis when compared to stretching/relaxation exercises in only one study. 12 Group-based Pilates also exhibited a significant improvement in the HAQ and FIQ when compared to individual Pilates. 20 Most studies (n = 3) found no statistically significant differences between the Pilates group and the other groups for the other variables analyzed. 16,19,20 In relation to the assessment of methodological quality, the score obtained by the studies on the PEDro Scale varied between 6 and 8 points, with an average of 7 on the 10-point scale. Each article was assigned a score from 0 to 10, according to the criteria described in Table   2. In regard to specification of eligibility criteria and the random allocation of subjects to groups, all the studies scored positively. However, most of the studies obtained a low score in allocation concealment and participant and therapy blinding. In addition, Komatsu et al. 16

Conclusion
The studies selected for this systematic review demonstrate that clinical intervention using the Pilates parasympathetic tonus and decrease the sympathetic response. 10,22,23 Central interactions between the neurovegetative system and the motor cortex