Pilates On Phusical Functional

American Journal of Physical Medicine & Rehabilitation Articles Ahead of Print
DOI: 10.1097/PHM.0000000000000883
“Effects of Mat Pilates on Physical Functional Performance of Older Adults: a
Meta-analysis of Randomized Controlled Trials.”
Roberta Oliveira Bueno de Souza1, BS
Liliane de Faria Marcon1,2, BS
Alex Sandro Faria de Arruda1, BS,
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Francisco Luciano Pontes Junior1, PhD
Ruth Caldeira de Melo1, PhD.
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1
School of Arts, Sciences and Humanities, University of São Paulo, São Paulo, SP, Brazil.
2
Physiotherapy Department, Anhanguera University, Taubaté, São Paulo, SP, Brazil.
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Correspondence:
Ruth Caldeira de Melo.
School of Arts, Sciences and Humanities, University of São Paulo, São Paulo, SP, Brazil. Av.
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Arlindo Béttio, 1000 - Ermelino Matarazzo - São Paulo - SP - Brazil. ZIP Code: 03828-000.
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e-mail: ruth.melo@usp.br
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Author Disclosures:
The authors declare no conflict of interest. Neither the study nor the authors received financial
support from any source. The study was not presented at a scientific meeting or was considered
for publication in proceedings or similar format.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ABSTRACT.
Objective: The present meta-analysis aimed to examine evidence from randomized controlled
trials in order to determine the effects of mat Pilates on measures of physical functional
performance in the elderly.
Design: A search was conducted in the MEDLINE/PubMed, Scopus, Scielo and PEDro
databases between February and March 2017. Only RCTs that were written in English; included
subjects 60 years-old; utilized mat Pilates exercises; included a comparison (control) group; and
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reported performance-based measures of physical function (balance, flexibility, muscle strength
and cardiorespiratory fitness) were included. The methodological quality of the studies was
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analyzed according to the PEDro scale and the best-evidence synthesis. The meta-analysis was
conducted with the Review Manager 5.3 software.
Results: The search retrieved 518 articles, nine of which fulfilled the inclusion criteria. High
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methodological quality was found in five of these studies. Meta-analysis indicated a large effect
of mat Pilates on dynamic balance (SMD=1.10, 95%CI=0.29-1.90), muscle strength (SMD=1.13,
95%CI=0.30-1.96), flexibility (SMD=1.22, 95%CI=0.39-2.04) and cardiorespiratory fitness
(SMD=1.48, 95%CI=0.42-2.54) of elderly subjects.

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Conclusion: There is evidence that mat Pilates improves dynamic balance, lower limb strength,
hip and lower back flexibility and cardiovascular endurance in elderly individuals. Further high-
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quality studies are necessary to clarify the effects of mat Pilates on other physical functional
measurements among older adults.

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Keywords: Pilates-based exercises, elderly, balance, muscle strength, flexibility and
cardiorespiratory fitness.
The number of older people is expected to nearly triple worldwide by 2050.1 With
population ageing, the number of people with disabilities also increases, overburdening social
security systems, public health, and society.2 Age-related physiological changes in various
physical abilities, such as reductions in postural balance, mobility, muscular strength and
endurance, contribute to disability and dependence at older age.3,4 The relationship between poor
physical functioning and undesired outcomes5 supports the importance of exercise interventions
to maintain and improve physical performance and, consequently, quality of life among the
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elderly.6
The Pilates method has been used since the beginning of the 20th century as a form of
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exercise that was devised to improve strength, flexibility and muscular control, particularly of
the muscles of the lumbar and pelvic regions, which are essential for activities of daily living.7,8
Pilates exercises can be performed in two modalities: mat work and apparatus work. 9 Mat Pilates
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is performed on the floor with or without accessories such as rubber bands and Swiss balls,
whereas Pilates apparatus work is performed using specific equipment that allows for better
adjustment of loads by changing spring tension and by adopting different body positions (i.e.,
lying, seated and standing).7,9 In addition to load adjustments, Pilates with equipment might
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facilitate learning and movement execution, providing a different stimulus and consequently
different results when compared to mat Pilates.10

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Recent meta-analysis articles suggest that Pilates can improve different physical
functional abilities in older individuals.11-13 Bullo et al.,11 for example, analyzed ten randomized
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controlled trials (RCTs) and found there was considerable effect of Pilates training on lower limb
strength, dynamic balance and walking/gait assessments. The results of this study also showed
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some effect of Pilates on static balance and flexibility. In a different meta-analysis, which
included six RCTs and aimed to investigate the effects of Pilates training on balance in older
adults, the authors observed substantial effects of Pilates training on static and dynamic balance.
Despite these positive results, it is important to note that only three studies 14-16 included
moderate to high challenge balance exercises and were in accordance with best-practice
recommendations of exercises for balance improvement and fall prevention.17 Moreover, the
percentage of moderate to high challenge balance exercises in those studies was 2% (mat
protocol),14 20% (Swiss ball and equipment protocol)15 and 36% (mat and equipment protocol),16
showing a discrepancy among the Pilates training programs, which might be partially explained
by the differences between the two Pilates modalities. It is important to emphasize that no
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distinction between Pilates modalities was drawn in the meta-analysis11,12 discussed above and,
consequently, results from both mat and equipment Pilates studies were pooled and analyzed
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together.
Considering that mat Pilates does not involve balance-challenging exercises, trunk
stability is the mechanism through which it might improve balance. Still mat Pilates repertoire
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includes core stability and strength exercises, which seem to be important for balance and for
physical functional performance in old age.7,8,18 According to Hodges and Richardson,19 trunk
muscle activity occurs prior to lower limb movements. Although the relationship between
balance and trunk stability is not fully elucidated, a stable and strong core may contribute to a
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more efficient use of the lower and upper extremities and, consequently, to successful
performance of activities of daily living.20

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In the literature, there are many studies involving mat Pilates training. 12 The preference
for mat Pilates is probably due to its convenience, since costs related to professional training and
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accessories are lower, and since it makes it possible to have large groups attending each session.
It is important to point out that Pilates exercises can be applied safely in different populations21
although there are few high-quality studies that establish their effects on and indications for the
elderly.11-13 So, the benefits of the Pilates method for older people, especially of mat modality,
are still under discussion. Regarding balance, for example, there are studies that found either
improvement14,22 or no changes23,24 in assessments of community-dwelling older adults after a
mat Pilates training program. For other physical functional abilities, such as flexibility and
cardiorespiratory fitness, the benefits of mat Pilates for the elderly are scarce and remain
unclear.23-25 Therefore, present meta-analysis aimed to examine evidence from randomized
controlled trials in order to determine the effects of mat Pilates on measures of physical
functional performance in the elderly.
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METHOD
Systematic Literature Search
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The meta-analysis was performed according to the PRISMA statement guidelines (see
Checklist, Supplemental Digital Content 1, http://links.lww.com/PHM/A541).26 The search was
conducted up to March 31 2017, considering the literature published in the previous 6 years and
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using the following electronic databases: MEDLINE/PubMed, Scopus, Scielo and PEDro. The
search algorithm was “Pilates” AND “older” OR “aging” OR “elderly” (see Supplementary
Database Query Strategy, Supplemental Digital Content 2, http://links.lww.com/PHM/A542).

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Inclusion and Exclusion Criteria
Studies were included in this review if they 1) were published in a peer-reviewed journal
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between January 2011 and March 2017; 2) were written in English; 3) were conducted as
Randomized Controlled Trials (RCT); 4) included subjects aged 60 and older in good health; 5)
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provided clear information about the modality of Pilates-exercise intervention utilized (only Mat
Pilates with or without accessories); 6) included a comparison group that did not participate in
other exercise training activities; and 7) reported at least one performance-based measure of
physical function (balance, flexibility, muscle strength and cardiorespiratory fitness).
Ethical Aspects
The present meta-analysis is exempt from ethics approval since it was performed by
collecting and analyzing data from previous RCTs in which informed consent had already been
obtained by their respective investigators. Thus, the present study did not include confidential
participant data and interventions.
Data Selection and Extraction
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Two reviewers independently examined and excluded studies based on their title and
abstract. Suitable studies were analyzed in more detail for meeting eligibility criteria. Studies
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that were duplicate, that included older subjects with specific health issues (chronic low back
pain, for example) and those in which the Pilates intervention modality was not explicit (i.e.,
mat), were also excluded. In case of differing opinions regarding eligibility of studies, a third
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researcher was consulted. The following information was extracted from each eligible scientific
study: first author, year of publication, characteristics of subjects (i.e., gender of participants),
total sample size and sample size per group (Pilates, control and others), characteristics of mat
Pilates training (period and frequency), outcomes, baseline and end-point measurements, and
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main results.
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Assessment of Study Quality
The quality of the studies was assessed using the Physiotherapy Evidence Database
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(PEDro) Scale, which is based on a Delphi list27 and assists researchers in identifying RCTs that
may have internal validity and sufficient statistical information.28 The PEDro scale evaluates 11
items: specified eligibility criteria, random allocation, concealed allocation, baseline
comparability, blinded subjects, blinded therapists, blinded assessors, adequate follow-up,
intention-to-treat analysis, between-group comparisons, and point estimates and variability. The
eligibility criteria, related to external validity, is not used to calculate the PEDro score. Thus, the
PEDro total score varies from zero to 10, and the higher the score, the better the methodological
quality of the RCT. In the present review, the alternative cut-off score of 5 was used to classify
the studies as high-quality ( 5) or low-quality (< 5).29 The PEDro scale is a valid28 and
sufficiently reliable30 tool for use in systematic reviews of physical therapy RCTs.
Rating the level of evidence
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In addition to the statistical analysis described below, a best-evidence synthesis (BES)
based on the guidelines for systematic review of the Cochrane Collaboration Back Review
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Group31 was performed. This method summarizes the evidence in five levels: STRONG:
consistent findings among multiple high-quality RCTs; MODERATE: consistent findings among
multiple low-quality RCTs and/or one high-quality RCT; LIMITED: consistent findings in one
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low-quality RCT; CONFLICTING: inconsistent findings among multiple RCTs.
Statistical Analysis
A meta-analysis was conducted to assess the effects of Pilates interventions on static

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balance, dynamic balance, flexibility, muscular strength and cardiorespiratory fitness, using
unadjusted, pooled data, and describing these as standardized mean differences (SMDs) with
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95% confidence intervals (CIs). For this purpose, the Review Manager 5.3 software
(Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) was used. SMD
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(i.e., effect size) < 0.2, between 0.2 and 0.8, and > 0.8, were considered as small, medium, and
large effects, respectively. Statistical heterogeneity of combined effect size was assessed by the
I2 test. A fixed-effects model was used if the results were homogeneous (I2<25%), and a random-
effects model was used when this assumption was not met. Overall estimates of the treatment
differences are presented in forest plots (Figures 2 to 4 and Figures 1). Where an outcome was
assessed by more than one tool in a trial, only the main outcome measure (i.e., the measure more
frequently reported among the selected RCTs) was included in the meta-analysis. As it was not
possible to pool data from all included studies, a summary of results from individual trials is
outlined and presented in Table 1.
RESULTS
Studies’ description
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Searches from databases sorted out 518 articles. Of these, 492 were excluded after a
review of their title and abstract, as they did not meet the inclusion criteria and/or were duplicate.
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Among the 26 studies selected for full text reading and additional analysis, six studies were
excluded because they applied only Pilates with equipment, three because they did not specify
the Pilates modality utilized (i.e., mat or with equipment), three did not include a control group,
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three did not have performance-based measurements of physical function as outcomes, and two
were not RCTs. Thus, nine RCTs were ultimately included in the review (figure 1).
Quality Assessment
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PEDro scale scores ranged from three to seven (mean: 4.9, SD: 1.3, median: 5), and five
studies were classified as high-quality ( 5) and four as low-quality (< 5) (Table 2). PEDro scale
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items satisfied most often in the RCTs are those related to pretreatment homogeneity, to
comparison between groups and to point and variability measures. Moreover, few studies were
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blinded to the assessor,22,23 had concealed allocation,23,24 and performed an “intention-to-treat”
analysis.32 So, the majority of included studies are biased in their allocation process, subjects’
withdrawal, and blinding (subjects, therapist and data processing). It is important to note that
blinding of subjects and therapists is difficult to accomplish in studies involving physical
activities, which justifies the non-compliance of such items in the included RCTs.
Study Characteristics
The summary of the analyzed studies, including number, recruitment place and mean age
of participants, study’s design (intervention time, frequency and duration of Pilates sessions,
presence of certified Pilates instructor and description of Pilates protocols), outcomes related to
physical function and main results, is presented in table 1.
Sample size of the studies ranged between 45 and 88 subjects (mean: 57.3, SD: 12.5), in
which four (44%) RCTs included both genders23,25,32,33 and five (56%) included only
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women.14,22,24,34,35 The mean age of the participants was 68.5 5.1 years old (excluding one study
that did not provide mean age of the groups).32 In 44% of the studies, participants were
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community dwellers, recruited from centers/services for the elderly (i.e., club for retired people,
church projects and Open University of the Third Age),22-25 or institutionalized, who participated
in the mat Pilates training program in residential home/caring facilities.14,32,34,35 Only one study
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did not mention where the volunteers were recruited from.33 The majority of the RCTs stated that
participants should be in good health to be included in the study, based on a medical certificate
allowing their participation in the study,23,25,35 and on the absence of diseases and/or any other
conditions (for example, orthopedic problems, visual impairment, neurological diseases,

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cardiovascular diseases) that limited and/or contraindicated the execution of exercises.22-24,32-34
Only one study did not include information about health status of participants.14 With regards to
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physical activity levels, three studies included only volunteers that were not considered
physically active (different criteria among studies)24,25,34 and one included only inactive
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volunteers.14 In two studies, physical activity questionnaires were used to better characterize the
sample.22,33 On the other hand, three studies did not include information about the physical
activity status of participants.23,32,35
All studies presented a control group that was not submitted to any type of intervention,
while four studies also included a third intervention group (walking, aquatic exercises,
proprioceptive neuromuscular facilitation and balance training).22,25,32,33
In relation to the Pilates program design, the training period varied too much among the
studies (four to 24 weeks): one22 was considered a short-term (four weeks) program,
seven14,23,24,32-35 of medium-term (eight to 16 weeks), and one25 a long-term (24 weeks) exercise
training program. In six studies,14,23,25,32,34,35 a Pilates training program was offered three times
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per week, while in one22 and two24,33 studies the exercises were performed twice and four-times
per week, respectively. Except for Mesquita et al.,22 in all studies the Pilates sessions lasted 60
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minutes. In the majority of studies,14,22-24,32-35 a certified instructor provided mat Pilates training.
On the other hand, only one study detailed the mat Pilates protocol used.22
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Strength of the Evidence and Meta-analysis
Static Balance
Static balance was evaluated by four RCTs (three high-quality and one low-quality) using
a functional test (i.e., one leg stance test)24 and a force platform (i.e., center of pressure
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oscillation).22,23,33 Although the meta-analysis showed medium effect (SMD= 0.48, 95%CI=
0.11-0.85) of Pilates interventions on static balance (figure 2A), no study found statistical
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increase of measured variables after the training period. Therefore, there´s STRONG evidence of
maintenance of static balance after mat Pilates training (table 3).

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Dynamic Balance
In the analyzed studies, dynamic balance was assessed through force platform; 23
functional tests (Timed Up and Go - TUG, 8 Foot Up and Go - 8FUG, and Functional Reach
Test - FRT);14,22,24,25 and scales (Berg Balance Scale – BBS and Tinetti Assessment Tool –
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TAT).22,23,32 Three studies (one high-quality22 and two low-quality14,25) observed improvement in
TUG/8FUG performance after Pilates training, and one high-quality study22 also showed
improvement in FRT. Only one24 high-quality study did not find changes in mobility (TUG) in
the Pilates group. According to the authors, the absence of changes in TUG could be partly
explained by subjects’ characteristics (they had a good TUG time at baseline), protocol (not long
enough to bring about changes) and test design (not sensitive enough to detect changes). In the
same way, two high-quality studies22,32 found better BBS scores in the Pilates group when
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compared to control, while one high-quality study23 did not observe changes in BBS and TAT.
The authors justified the lack of improvement in such scales as due to a ceiling effect and to the
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relatively high functioning characteristics of subjects. Effect measurements from the pooled
studies described above indicated a large effect (SMD= 1.10, 95%CI= 0.29-1.90) of Pilates on
dynamic balance (figure 2B). According to the best-evidence synthesis, there is MODERATE
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evidence of improvement in dynamic balance after Pilates training (table 3).
Muscle Strength
Muscle strength was measured in five studies of which two (high-quality)24,34 evaluated
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only lower limbs and three (one high-quality32 and two low-quality14,25) evaluated both upper
and lower limbs. Results are more consistent for lower limbs, since all studies found
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improvement in performance on the Sit-to-Stand (STS)14,24,25 test and the Muscle Manual Tester
(MMT).32,34 On the other hand, the effect of Pilates training on muscle strength of upper limbs is
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still unclear. Two low-quality studies observed performance increase in functional tests (total
number of arm curls with a dumbbell for 30 seconds25 and time spent to lift a five kilogram bag
from floor to a table14), while no change of shoulder abduction strength (assessed by MMT) was
found in one high-quality study.32 Results from meta-analysis indicate a large (SMD= 1.13,
95%CI= 0.30-1.96) and a medium (SMD= 0.72, 95%CI= 0.02-1.43) effect of Pilates training on
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muscle strength of lower (figure 3) and upper limbs (figure C1A, see Supplementary Figure,
Supplemental Digital Content 3, http://links.lww.com/PHM/A543), respectively. However, if
best-evidence synthesis is considered, there is STRONG evidence of increase in lower limb
strength after Pilates training, while their effects on upper limbs are CONFLICTING (table 3).
Flexibility
Only three studies (one high-quality and two low-quality) included in the present review
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evaluated flexibility. In two studies (one high-quality34 and one low-quality25), the Pilates
training program increased lower back and hamstring flexibility (Sit and Reach test). In the same
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way, one low-quality study35 showed improvement in hip flexion and shoulder flexion ranges of
motion, while no modification was observed for shoulder extension and knee flexion flexibility
after Pilates training. Another low-quality study25 also failed to demonstrate improvement in
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upper limb flexibility, assessed through the Back Scratch Test in the Pilates group. The meta-
analysis showed a large effect of Pilates training on flexibility for both hip and lower back
(SMD= 1.22, 95%CI = 0.39-2.04, figure 4A) and upper limbs (SMD=1.16, 95%CI = 0.70-1.63,
figure C1B, see Supplementary Figure, Supplemental Digital Content 3,

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http://links.lww.com/PHM/A543). Considering the best-evidence synthesis, there is
MODERATE evidence that Pilates training improves hip and lower back flexibility, while
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evidence of its benefits on upper limb flexibility are CONFLICTING (table 3).
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Cardiorespiratory Fitness
Measures of cardiorespiratory fitness were reported by three studies (one high-quality24
and two low-quality14,25) included in the present review. The distance walked in the six-minute
walking test improved both after 12 weeks (~30 meters)24 and after 24 weeks (~130 meters)25 of
Pilates training. The aerobic capacity, assessed by maximal oxygen uptake, remained unchanged
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after intervention in one low-quality study.14 The SMD suggests a large effect (SMD = 1.48,
95%CI = 0.42-2.54) of Pilates training on cardiorespiratory fitness of older adults (figure 4B).
Based on the studies cited above, there is MODERATE evidence of improvement in
cardiorespiratory fitness, evaluated through 6MWT performance, after Pilates training. However,
evidence of alterations in maximal oxygen uptake are LIMITED (table 3).
Discussion
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The Pilates method is an exercise and physical movement system that has become
popular all over the world and has been used in both rehabilitation and fitness.7,21,34 Its practice
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includes movements/exercises that combine muscular strengthening and stretching, integrating
different parts of the body with specific respiratory patterns, optimizing neuromotor control of
the trunk, mainly through the work of its deeper muscles (transverse abdomen, lumbar
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multifidus, diaphragm and pelvic floor).7 The results of the present meta-analysis suggest that
mat Pilates has positive effects on dynamic balance, muscle strength (lower limbs), flexibility
(hip and lower back) and cardiovascular endurance of elderly individuals. The scientific
evidence found in the present study is discussed below, considering age-related changes on
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physical functional performance.
The ability to maintain balance depends on the interaction among visual, vestibular,
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sensory and motor systems. The aging process leads to physiological changes in these systems,
compromising postural stability and, consequently, performance in activities of daily living. 36,37
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In the literature, there is a variety of clinical and functional tests that dichotomously assess and
score specific static and/or dynamic balance conditions.38 Considering that activities of daily
living involve both static and dynamic balance, which are quite difficult to be assessed in
everyday life situations, it is important to choose tests that cover those two aspects of postural
control in the elderly.38 Static balance, defined as the ability to maintain postural control and to
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keep the center of gravity within the limits of the base of support in static conditions, is
frequently assessed through posturography, which provides detailed information about postural
sway.39 Even though daily activities involve static balance, it is important to note that static
balance assessments could underestimate real deficits and might have a limited ability to predict
individuals’ performance outside of clinical environments. Many well-known and widely used
tests have psychometric limitations and do not cover all balance components, thus contributing to
ceiling effects, low sensitivity to change and ineffective interventions.40
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In this way, scientific evidence of age-related changes in static balance is controversial.
Although some authors have noted an increase in postural sway while standing with aging,41,42
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others were not able to find differences in postural sway between young and older adults during
quiet standing.43-45 In general, healthy elderly people develop compensatory strategies to
maintain postural stability in static positions, even if one of the systems involved in balance
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control is compromised.38,46 Based on the studies included in the present meta-analysis, there is
evidence that static balance does not change with mat Pilates training programs. Three factors
may have contributed to the maintenance of static balance after Pilates training: 1) the static
balance seems to be unaffected in healthy older people,43-45 2) mat Pilates programs do not seem
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to be the most suitable for challenging postural stability and, consequently, for improving it, 6,17,18
and 3) ceiling effect and low sensitivity of the applied tests failed to detect changes in static
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balance, especially considering the characteristics of participants (probably high-functioning
older adults).38,46 According to ACSM,6 exercise programs designed to improve balance must
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include activities that 1) progressively and gradually reduce the base of support (e.g., one leg
stance), 2) shift the center of gravity (e.g., tandem walk), 3) stress postural muscle groups (e.g.,
toe stands), or 4) reduce sensory input (e.g., standing with eyes closed). In addition, if the
program is designed to improve balance and prevent falls, it should involve balancing exercises
of moderate to high intensity, performed 2x/week and totaling more than 50 hours of training.17
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It is important to note that none of the 34 mat exercises originally proposed by Joseph Pilates 18 is
performed in a standing position, which can be itself a limiting factor for improving postural
stability. From a critical point of view, the recurring use of static balance tests might lead to
consolidation of the erroneous concept that such type of assessment can be widely applied. As
balance training is highly task-specific and has low transferring effect, a careful selection of the
tests is essential to follow up on improvements over time.47 Therefore, generic balance tasks
(e.g., one leg stance) may be of little value as a measure of overall balance or when the efficacy
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of balance training programs is evaluated.48
On the other hand, aging-associated changes in dynamic balance (i.e., ability to exert
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ongoing control of the center of mass when the base of support is changing) are more clearly
observed, especially when the elderly are submitted to conditions of instability and reduction of
sensory inputs.49,50 Dynamic balance can be assessed by a wide range of clinical tests, 51 which
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cover different components required for postural control.52 Pardasaney et al.40 showed that the
majority of balance measures used in high-functioning older adults are deficient in incorporating
important task and environmental variation, underrepresenting postural control demands in daily-
life situations. Even considering the limitations of clinical balance tests discussed above, most of
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the studies that measured dynamic balance included in the present meta-analysis, regardless of
the method used in the evaluation, observed an improvement in the Pilates group when compared
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to the control group.14,22,25,32,34 The present review suggests there is strong evidence of
improvement in dynamic balance, mainly assessed by functional tests (TUG / 8FUG and FRT),
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among elderly subjects undergoing Pilates training.
Considering the main components involved in postural control proposed by the Systems
Framework for Postural Control,52,53 both the Balance Berg Scale and the TUG/8FUG tests
evaluate biomechanical factors (range of motion, stability and muscle strength), movement
strategies (in particular, anticipatory postural control) and dynamic stability (ability to maintain
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control of the center of mass during changes in the base of support).52 Therefore, even
considering the small amount of exercises that challenge one’s balance in mat Pilates protocols,
improved dynamic balance might be explained by the improvement of other associated factors,
such as the increase in muscle strength of the trunk12,20,54 and lower limbs.25,32,34,55,56 As
mentioned above, stability and strength of the trunk are important in performing activities of
daily living, as they promote a more efficient use of the upper and lower limbs and,
consequently, better balance and functional performance among the elderly.20 Although the
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effects of Pilates on stability and strength of the trunk in elderly individuals are not clear in the
literature,57 positive results have already been demonstrated in young and sedentary women.58
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The cause-effect relationship between muscle function and balance is still controversial.59
However, scientific evidence suggests that the maintenance of muscle strength, especially of the
lower limbs, is essential for performing activities of daily living and, thus, for the independence
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of the elderly.55,60-63 Additionally, reduction in muscle strength of lower limbs is considered an
independent predictor of future falls.64,65 In the present review, strong evidence was found for
improvement of lower limb strength in older adults submitted to mat Pilates training. Since the
progression of mat Pilates exercises depends on the relationship between body and gravity,
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improvement on muscle strength might be potentiated by the use of accessories (i.e., elastic
bands and Pilates ring). Among the studies included in this review, four24,32-34 used the elastic
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band in the training. Conversely, Kovach et al.25 and Gildenhuyns et al.14 conducted mat Pilates
exercises without resistance and observed an improvement in the performance of the elderly
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subjects in general strength tests.
In older age, it is also important to maintain upper limb performance, which involves
motor coordination, manual dexterity, muscle strength and sensibility.66,67 In the present meta-
analysis, only upper limb strength was assessed though different tests (i.e., arm curl, pick-up-
weight and muscular manual tests).14,25,32 The studies that used non-specific tests (i.e., PUWT14
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and ACT25) found improvement in upper limb performance after Pilates training, whereas the
study32 in which upper limb strength was assessed through a specific test (i.e., hand-held
dynamometer) failed to demonstrate positive effects. Therefore, evidence of improvement in
upper limb strength after mat Pilates training is conflicting. In consonance with the above-
mentioned discussions on static balance tests , the use of general and non-specific tests to assess
upper limb strength is a critical point of the present meta-analysis. Furthermore, the repertoire of
mat Pilates includes global exercises for upper limbs (e.g., range of motion and scapula
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stabilization exercises), but muscle resistance/strength is rarely included in this Pilates modality.
Considering all these points, it is not surprising that mat Pilates training had no observable
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effects on upper limb strength.
In addition to muscle strength, flexibility plays an important role in moving during
activities of daily living.68 Studies suggest that there is a reduction in the number of sarcomeres
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in series with aging, resulting in shorter muscle fibers, reduced mobility and, consequently, gait
pattern changes.69,70 In this meta-analysis, moderate evidence was found for improvement in hip
and lower back flexibility, evaluated through functional tests (SRT and CSRT)25,34 and a
flexometer.35 Considering that few exercises originally proposed by Joseph Pilates include
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muscle stretching, Fourie et al.35 suggest that improvement in hip range of motion, for example,
might occur due to the static stretching of the hamstring muscles promoted by the inclusion of
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specific stretching exercises in the experimental protocols. Thus, it is essential to describe the
protocols used in the studies so that the physiological mechanisms involved can be elucidated.
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There is a consensus in the literature that aerobic exercises performed at moderate
intensity (i.e., ≥ 60% of maximal oxygen uptake, ≥ 3 times/week, for a period longer than 16
weeks) can improve the aerobic capacity of the elderly.6 Considering the characteristics of the
Pilates method, it is likely that the type of exercise performed might not provide enough stimuli
to bring about changes in cardiorespiratory fitness. Spilde et al.,71 for example, evaluated the
17
oxygen uptake of young adults during two sessions of Pilates exercises with different intensity
levels (i.e., beginner and intermediate). During the higher intensity session (intermediate level),
the average oxygen uptake was equivalent to 43% of the maximum. In the present review,
limited evidence was found for changes in maximal oxygen uptake14 of elderly submitted to mat
Pilates. Evidence for improved cardiovascular endurance (assessed by performance in 6MWT),
however, was considered moderate. Although 6MWT is widely used to evaluate the
cardiorespiratory fitness of the elderly, mainly due to its practicality and low cost, its results are
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influenced by several factors (gender, height, body mass index, presence of diseases, muscular
strength, etc.).72 In older adults with mobility problems, Suzuki et al.73 showed that strength and
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power of the lower limbs are predictive of performance in the 6MWT. In addition, Holviala et
al.74 observed that strength training, associated or not with aerobic training, can increase not only
lower limb muscle strength and power, but also walking speed. Therefore, it is possible that
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improvement in the distance walked measured by the 6MWT after mat Pilates training, reported
in two studies included in the present review,24,25 might be indirectly related to improvement in
the strength of subjects’ lower limbs.

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Study limitations
The scarcity of high quality studies is a limiting factor for a more thorough analysis of the
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effects of mat Pilates training in the elderly. In this review, only five studies were classified as
high-quality and most of the included studies did not use gold standard measurements to evaluate
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physical functional performance. In addition, most of them might be biased in terms of allocation
process, subjects’ withdrawal and blinding, thereby making the results questionable. Another
limiting factor is related to the description of Pilates training protocols. Since the mat Pilates
exercises and their progression were not detailed in the studies, the analyses of the results as well
as their discussion are limited. Considering that mat Pilates originally comprises 34 different
18
exercises, lack of information about protocols used in the studies also limits a more assertive use
of this method in clinical and rehabilitation practices. Moreover, it was not possible to indicate
the most suitable mat Pilates protocol for the elderly in terms of frequency and training period,
due to the great variability of training protocols in the analyzed RCTs. The influence of low
sensitivity and ceiling effect of the applied physical functional tests, as well as of the
participation of apparently high-functioning subjects on the present results could not be
neglected. Finally, the influence of the small number of studies and the high heterogeneity of the
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data on the meta-analysis results cannot be ruled out.
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Conclusion
Data analysis from the present review suggests that there is evidence in the literature that
mat Pilates can improve lower limb strength in the elderly. In addition, mat Pilates seems to exert
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a positive influence on dynamic balance, hip and lower back flexibility and cardiovascular
endurance of elderly practitioners. However, evidence points to lack of improvement in static
balance. Further high-quality studies, including “gold standard” measurements and detailed
description of the proposed exercises, are necessary to clarify the effects of mat Pilates on other
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variables related to physical functional performance of the elderly.

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A
19
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Figure 1. Flowchart of the selection of studies.
Figure 2. The effects of mat Pilates in static (A) and dynamic (B) balance. OLS: one leg stance;
TUG: timed-up and go; 8FUG: 8 foot up and go; BBS: Berg balance scale; SD: standard
deviation; Std Mean Difference: Standardized Mean Difference (effect size); IV: inverse
variance; Random: random-effects model; CI: confidence intervals.
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Figure 3. The effects of mat Pilates in muscle strength of lower limb. STS: sit to stand test;
MMT: manual muscle tester; SD: standard deviation; Std Mean Difference: Standardized Mean
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Difference (effect size); IV: inverse variance; Random: random-effects model; CI: confidence
intervals.
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Figure 4. The effects of mat Pilates in flexibility of hip and lower back (A) and cardiovascular
fitness (B). SRT: sit-and-reach test; CSRT: chair sit and reach test; 6MWT: six-minute walking
test. SD: standard deviation; Std Mean Difference: Standardized Mean Difference (effect size);
IV: inverse variance; Random: random-effects model; CI: confidence intervals.

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A
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C
A
33
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A
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36
Table 1. Summary of selected studies
Certifi Detail
Subje Group Frequ Peri ed ed
Study Measurements Results
cts s ency od Instru Proto
ctor col
CG: no
- Dynamic
CG: difference.
balance (force
60
n=30, platform) PG:  strength,
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women
73
- Strength  flexibility
Irez et 6.7yrs 3x/wk (hamstrings and
from 12 (MMT)
al., Yes No lower back), 
reside 60 min wks
2011 PG: - Flexibility dynamic
ntial
TE
n=30, (SRT) balance, 
home
78 reaction time e
- Reaction time
5.7yrs  number of
- Falls
falls.
CG: no
difference.
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PG:  strength
(lower and
- Dynamic
balance (8FUG) upper body), 
CG: flexibility (lower
n=15, - Strength limbs), 
65 (STST, ACT) dynamic
±6.2yrs
54 - Flexibility balance, 
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both (BST, CSRT) aerobic

AG:
Kovác gender
n=17, 3x/wk 24 endurance, 
h et al, s from No No - Aerobic quality of life
68 60 min wks endurance
2013 a club (sensory
±6.9yrs (6MWT)
for
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abilities and
retired - Quality of life autonomy)
PG:
n=22, (WHOQOL- AG: same
67 OLD) results of PG.
A
±5.5yrs - Body Mass Additional

Index results: 
flexibility (upper
limbs) and and
quality of life
(sociability).
Gilden 50 CG:  dynamic

CG: 3x/wk - Dynamic
huys et women 8
Yes No balance (8FUG) balance and 
al., n=25, wks strength (upper
from 60min
2013 65 - Strength limb).
caring
37
facilitie ±5.0yrs (STST e PUWT) PG:  dynamic
s balance,
- Aerobic
PG: strength (lower
capacity
n=25, limb and upper
(VO2max)
66 limb).
±4.8yrs
CG:
n=25,
50
65 CG:  shoulder
women - Flexibility
Fourie ±5.0yrs extension
from 3x/wk 8 (flexometer)
et al., Yes No PG:  shoulder
caring 60 min wks - Body Mass
2013 PG: extension and 
facilitie Index
n=25, hip flexion.
s
66
D
±4.8yrs
- Dynamic CG: no
CG: balance (BBS)
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difference.
n=15,
45 - Strength PG:  dynamic
>65yrs*
both (MMT) balance,  hip
gender
WG: 3x/wk - Flexibility (not strength, 
Irez, s from 14
n=15, Yes No specified) flexibility,
2014 a 60 min wks
reside
>65yrs*
- Balance balance
ntial confidence confidence, and
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PG: fall risk.
home (ABC scale)
n=15,
>65yrs* - Falls risk WG:  flexibility
(Downton index) (p<0.05)
CG:
n=18,
71
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±6.2yrs CG: no
- Static balance difference.
58
Mesqu PNFG:
women 4x/wk
(force platform) PNFG:  static
ita et n=20, 4
from a Yes Yes and  dynamic
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al., 68 wks - Dynamic

church 50 min balance vs. CG.
2015 ±5.4yrs balance (BBS,
project TUG, FRT) PG:  dynamic
PG: balance vs. CG.
A
n=20
67
±4.9yrs
CG: - Static balance

88 n=44, (force platform) CG: no
both 70
Gabizo 3x/wk difference.
gender ±3.8yrs 12 - Dynamic
n et al., Yes No
s from 60 min wks balance (BBS, PG: SF-36
2016
comm PG: Tinetti) (mental health).
unity n=34, - SF-36
72
38
±4.6yrs
CG: - Static balance

n=15, (force platform)
59
69 CG: no
both - Dynamic
±6.1yrs difference.
gender balance (Y
s Balance testing PG: no
PG:
Donat (place 2x/wk kit, Perturbed difference.
n=17, 8
h et al, of Yes No kneeling)
71 60 min wks BAL:  Y-
2016 recruit
±6.5yrs - Strength balance-score,
ment
(flexor- trunk extension,
not
BAL: crunches, single leg
specifi
n=16, isometric trunk stance vs. CG.
ed)
D
69 extension and
±5.8yrs flexion)
52 - Static balance
CG: (OLS)
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women
n=19, CG: no
from - Dynamic
63 ± difference.
an balance (TUG)
Vieira 0.9yrs 2x/wk
et al.,
Open 12
Yes No PG:  strength
Univer wks - Strength
2017 PG: 60 min
(STST) (lower limb), 
sity for aerobic
n=21,
the - Aerobic endurance.
66
Third endurance
EP
±1.3yrs
Age (6MWT)
CG: control group, PG: Pilates group, AG: aqua group, PNFG: proprioceptive neuromuscular facilitation
group, WG: walking group, BAL: balance training group, SRT: sit-and-reach test, TUG: timed-up and go
test, MMT: manual muscle testing, STST: sit-to-stand test ACT: arm curl test, FRT: functional reach test,
BST: back scratch test, CSRT: chair sit and reach test, 8FUG: 8 foot up and go, 6MWT: six-minute walk
test, WHOQOL: the World Health Organization quality of life, PUWT: Pick-up-weight test, BBS: Berg
balance scale ABC: Activities-specific Balance Confidence Scale, Tinetti: Tinetti performance assessment
C
of mobility (balance subscale), OLS: One-Leg Stance.*mean age for each group was not included.
C
A
39
Table 2. Classification of studies according PEDro scale.
D Mesquita et al.,
Irez et al., 2011
Gabizon et al.,
Gildenhuys et
Kovách et al.,
Donath et al.,
Fourie et al.,
Vieira et al,
Irez, 2014
al, 2013
2013
2013
2015
2016
2016
2017
PEDro scale itens
TE
1. Eligibility criteria* + + - - + + - + +
2. Randomized/randomly selection + + + + + + + + +
3. Concealed allocation - - - - - - - + +
EP
4. Pretreatment homogeneity + + + + + + + + +
5. Blind subjects - - - - - - - - -
6. Blind therapists - - - - - - - - -
7. Blind assessors C + - - - - + - + -
8. Appropriate monitoring + - + - - + - + -
9. Intention to treat - - - - + - - - -
10. Comparison between-groups + + - - + + + + +
C
11. Point and variability measures + + + + + + + + +
RESULTS 6 4 4 3 5 6 4 7 5
A
*
eligibility criteria is not considered in total score.
40
Table 3. Best-evidence synthesis of the randomized clinical studies.
Measurements Method/Tests Scientific Evidence Overall Results
D
MODERATE evidence of maintenance in
One Leg Stance (OLS) functional test STRONG evidence for
Static Balance MAINTENANCE of static
Force Platform MODERATE evidence of maintenance of COP balance
TE
oscillation
Timed Up and Go (TUG) MODERATE evidence of improvement in

mobility tests performance. MODERATE evidence
Dynamic Balance 8 foot up and go (8FUG) for IMPROVEMENT of
CONFLICTING evidence of improvement in dynamic balance
Berg Balance Scale (BBS) BBS score.
EP
Manual Muscle Tester (MMT) STRONG evidence of improvement of lower
Sit-to-Stand Test (SST) limb strength. STRONG evidence for
Strength IMPROVEMENT of
Arm Curl Test (CTT) CONFLICTING evidence of improvement of strength (lower limbs)
Pick-up-weight test (PUWT) upper limb strength.
Sit and Reach Test (SRT) MODERATE evidence of improvement of hip

Chair Sit and Reach Test (CSRT) and lower back flexibility. MODERATE evidence
Flexibility
C
Back Scratch Test (BST) CONFLICTING evidence of changes in upper
limb flexibility.
for IMPROVEMENT of
lower body flexibility
Flexometer
C
MODERATE evidence of improvement in
Ergoespirometer (VO2max) aerobic endurance. MODERATE evidence
Cardiorespiratory fitness for MPROVEMENT of
Six-minute Walk Test (6MWT) LIMITED evidence of changes in aerobic cardiovascular fitness
capacity.
A
COP: center of pressure, VO2max: maximal oxygen uptake.
41

Pilates On Phusical Functional

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American Journal of Physical Medicine & Rehabilitation Articles Ahead of Print

“Effects of Mat Pilates on Physical Functional Performance of Older Adults: a

Meta-analysis of Randomized Controlled Trials.”

Roberta Oliveira Bueno de Souza1, BS

Liliane de Faria Marcon1,2, BS

Alex Sandro Faria de Arruda1, BS,

Ruth Caldeira de Melo1, PhD.

Ruth Caldeira de Melo.

for publication in proceedings or similar format.

performance in the elderly.

conducted with the Review Manager 5.3 software.

of mat Pilates on dynamic balance (SMD=1.10, 95%CI=0.29-1.90), muscle strength (SMD=1.13,

95%CI=0.30-1.96), flexibility (SMD=1.22, 95%CI=0.39-2.04) and cardiorespiratory fitness

(SMD=1.48, 95%CI=0.42-2.54) of elderly subjects.

measurements among older adults.

Keywords: Pilates-based exercises, elderly, balance, muscle strength, flexibility and

different results when compared to mat Pilates.10

performance of activities of daily living.20

unclear.23-25 Therefore, present meta-analysis aimed to examine evidence from randomized

functional performance in the elderly.

Systematic Literature Search

Checklist, Supplemental Digital Content 1, http://links.lww.com/PHM/A541).26 The search was

Database Query Strategy, Supplemental Digital Content 2, http://links.lww.com/PHM/A542).

Inclusion and Exclusion Criteria

physical function (balance, flexibility, muscle strength and cardiorespiratory fitness).

participant data and interventions.

Data Selection and Extraction

Assessment of Study Quality

items: specified eligibility criteria, random allocation, concealed allocation, baseline

comparability, blinded subjects, blinded therapists, blinded assessors, adequate follow-up,

Rating the level of evidence

A meta-analysis was conducted to assess the effects of Pilates interventions on static

outlined and presented in Table 1.

blinded to the assessor,22,23 had concealed allocation,23,24 and performed an “intention-to-treat”

blinding of subjects and therapists is difficult to accomplish in studies involving physical

physical function and main results, is presented in table 1.

conditions (for example, orthopedic problems, visual impairment, neurological diseases,

cardiovascular diseases) that limited and/or contraindicated the execution of exercises.22-24,32-34

activity status of participants.23,32,35

proprioceptive neuromuscular facilitation and balance training).22,25,32,33

maintenance of static balance after mat Pilates training (table 3).

Supplemental Digital Content 3, http://links.lww.com/PHM/A543), respectively. However, if

best-evidence synthesis is considered, there is STRONG evidence of increase in lower limb

figure C1B, see Supplementary Figure, Supplemental Digital Content 3,

http://links.lww.com/PHM/A543). Considering the best-evidence synthesis, there is

Measures of cardiorespiratory fitness were reported by three studies (one high-quality24

Based on the studies cited above, there is MODERATE evidence of improvement in

evidence of alterations in maximal oxygen uptake are LIMITED (table 3).

physical functional performance.

ceiling effects, low sensitivity to change and ineffective interventions.40

quiet standing.43-45 In general, healthy elderly people develop compensatory strategies to

balance, especially considering the characteristics of participants (probably high-functioning

among elderly subjects undergoing Pilates training.

subjects in general strength tests.

dynamometer) failed to demonstrate positive effects. Therefore, evidence of improvement in

In addition to muscle strength, flexibility plays an important role in moving during

There is a consensus in the literature that aerobic exercises performed at moderate

Pilates. Evidence for improved cardiovascular endurance (assessed by performance in 6MWT),

the strength of subjects’ lower limbs.

participation of apparently high-functioning subjects on the present results could not be

endurance of elderly practitioners. However, evidence points to lack of improvement in static

variables related to physical functional performance of the elderly.

Manage J 2014;57:929-935. doi:10.5465/amj.2014.4004.