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

O método Pilates na reabilitação de distúrbios musculoesqueléticos: uma revisão sistemática

Abstract

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 conditions such as scoliosis, back pain, ankylosing spondylitis and breast cancer, and for preventing injuries in adults, elderly people and athletes.

Conclusion:  The high methodological variability requires that these studies be viewed with caution. It indicates the need for the performance of new studies with high methodological quality and standardization of evaluation instruments.

Keywords:
Pilates Method; Musculoskeletal Diseases; Rehabilitation

Resumo

Introdução:  Joseph Pilates criou um método autêntico de condicionamento físico e mental, que chamou de Contrologia e o definiu como a completa coordenação de corpo, mente e espírito. Estudos recentes indicam que o Método Pilates é uma ferramenta útil na reabilitação, podendo melhorar a saúde geral, o desempenho esportivo, além de ajudar na prevenção e atenuação de lesões e disfunções do sistema musculoesquelético. As disfunções musculoesqueléticas são condições prevalentes e onerosas, que se desenvolvem gradualmente, apresentando um curso crônico e muitas vezes permanecem sem tratamento.

Objetivo:  Este estudo tem como objetivo identificar os efeitos do Método Pilates na reabilitação de distúrbios musculoesqueléticos através de uma revisão sistemática.

Métodos:  A busca ativa foi realizada nas bases de dados: PubMed, PEDro, Scielo e Bireme. Foram pré-selecionados 24 estudos, que tiveram sua qualidade metodológica avaliada com base na escala PEDro. Destes, 14 se adequaram aos critérios de seleção.

Resultados:  Os estudos analisados indicam que o Pilates pode ser eficaz tanto para o tratamento de afecções como escoliose, lombalgia, espondilite anquilosante e câncer de mama, quanto para a prevenção de lesões em adultos, idosos e atletas.

Conclusão:  A alta variabilidade metodológica exige que esses estudos sejam vistos com cautela. E indica a necessidade de realização de novos estudos com alta qualidade metodológica e padronização dos instrumentos de avaliação.

Palavras-chave:
Método Pilates; Doenças Musculoesqueléticas; Reabilitação

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.

Table 1
PEDro scale of Methodological Classification

• Note: BD = Bone densitometry. HAP = Human Activity Profile questionnaire.

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.

Table 2a
Field studies

Table 2b
Field studies (continuation)

Table 2c
Field studies (continuation)

Table 2d
Field studies (continuation)

Table 2e
Field studies (continuation)

Table 2f
Field studies (continuation)

• Note: BD = Bone densitometry. HAP = Human Activity Profile questionnaire.

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; 40 healthy men and women with a mean age of 31.65 ± 6.21 years 11; 10 healthy subjects with a mean age of 33.1 ± 8.6 years in the Pilates group and 9 healthy individuals with a mean age of 28.6 ± 3.7 years in the Control group 28; 34 healthy adults equally divided into two groups, with a mean age of 27.3 ± 4 years in the control group and 27.5 ± 3.6 years of age in the Pilates group 29; 34 patients with chronic lower back pain and a mean age of 40.6 ± 9.7 years 8; 39 recently hospitalized, elderly patients 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.

The aims of the studies of Table 1, were to evaluate the efficacy of the Pilates Method regarding pain 20^,23^,25^,27^,8, flexibilidade 21^,9^,26^,11, strength 22^,28, balance 22^,9^,24^,29, functionality 22^,23^,24^,25^,27^,8, quality of life 23^,24^,26, muscular resistance, posture 9, fatigue 26, lumbo-pelvic stability 11, to quantify the effects of a Pilates program in the biomechanics of the shoulder and trunk 28, and to measure the participation and adherence to Pilates exercises 30.

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 24, Oswestry scale 25^,8, incapacity sub-scale of the Miami Back Index 25, Roland Morris and Roland Morris Hong Kong questionnaire 27, SF-12 8, and a brief sports functionality questionnaire 8. To evaluate the Quality of Life the following instruments were used: Ankylosing Spondylitis Quality of Life Questionnaire (ASQoL), World Health Organization Quality of Life Questionnaire version for elderly people (WHOQoL-OLD) 24, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ -C30) and the EORTC Questionnaire Specific for Breast Cancer (EORTC QLQ BR23) 26. Muscular resistance and posture were evaluated through: YMCA 1 minute sit-up test 9, leg-lowering test 9, performance of the maximum number of push-ups in accordance with the ACSM protocol of evaluation and grade of 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. The studies of Bertolla et al. 21, Bird et al. 22, Altan et al. 23 and Rydeard et al. 27 presented better methodological quality, scoring 8/10 on the PEDro scale. While the studies of Eyigor et al. 26, Emery et al. 28 and Gladwell et al. 8 presented the worst methodological quality, scoring 4/10.

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.

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Publication Dates

• Publication in this collection
  Jul-Sep 2016

History

• Received
  29 Oct 2013
• Accepted
  03 Sept 2015