SPINE Volume 41, Number 12, pp 1013–1021
ß 2016 Wolters Kluwer Health, Inc. All rights reserved
COCHRANE COLLABORATION
Pilates for Low Back Pain
Complete Republication of a Cochrane Review
Tiê P. Yamato, MSc, Christopher G. Maher, Bruno T. Saragiotto, MSc, Mark J. Hancock, PhD,y
Raymond W.J.G. Ostelo,z,§ Cristina M.N. Cabral, PhD,{ Luciola C. Menezes Costa, PhD,{
and Leonardo O.P. Costa, PhD ,{
Study Design. Systematic review.
Objective. To determine the effects of the Pilates method for
patients with nonspecific acute, subacute, or chronic low back
pain.
Summary of Background Data. The Pilates method is one of
the most common forms of intervention based on exercise used
for treating patients with low back pain. However, its effective-
ness is not well established.
Methods. We conducted searches on CENTRAL, MEDLINE,
EMBASE, CINAHL, PEDro, and SPORTDiscus up to March 2014.
We included randomized controlled trials examining the effec-
tiveness of Pilates in patients with acute, subacute, or chronic
nonspecific low back pain. The outcomes evaluated were pain,
disability, function, and global impression of recovery. Two
independent reviewers screened for potentially eligible studies,
assessed risk of bias, and extracted the data. We evaluated the
overall quality of evidence using the GRADE approach and
treatment effect sizes were described using mean differences and
95% confidence intervals.
Results. Searches retrieved 126 trials, of which 10 were
included in the review (n ¼ 510 participants). Seven studies were
considered to have low risk of bias, and three were considered at
high risk of bias. When compared to minimal intervention, Pilates
reduces pain at short and intermediate term with low- to
moderate-quality evidence and medium effect sizes. For disability,
From the Musculoskeletal Division, The George Institute for Global Health,
Sydney Medical School, The University of Sydney, Sydney, Australia;
y
Faculty of Medicine and Health Sciences, Macquarie University, Sydney,
Australia; zDepartment of Health Sciences, EMGO Institute for Health and
Care Research, VU University, Amsterdam, Netherlands; §Department of
Epidemiology and biostatistics, VU University medical centre, Amsterdam,
Netherlands; and {Masters and Doctoral Programs in Physical Therapy,
Universidade Cidade de São Paulo, São Paulo, Brazil.
Acknowledgment date: November 6, 2015. First revision date: December 2,
2015. Acceptance date: December 3, 2015.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work.
Relevant financial activities outside the submitted work: grants.
Address correspondence and reprint requests to Tiê P. Yamato, MSc, Level
13, 321 Kent Street/Sydney NSW 2000 Australia;
E-mail: tiparma@gmail.com
DOI: 10.1097/BRS.0000000000001398
Spine
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there is also a significant difference in favor to Pilates with low- to
moderate-quality evidence and small effect size for short term and
medium effect size for intermediate term compared with minimal
intervention. It is unclear whether Pilates is better than other
exercises for short-term pain, but there is low-quality evidence
that Pilates reduces pain at intermediate term. For disability, there
is moderate-quality evidence that there is no significant difference
between Pilates and other exercises in either the short term or the
intermediate term.
Conclusion. There is low- to moderate-quality evidence that
Pilates is more effective than minimal intervention with most of
the effect sizes being considered medium. However, there is no
conclusive evidence that Pilates is superior to other forms of
exercises.
Key words: chronic pain, core, exercise, lower back, motor
control, pain, Pilates, spine, stabilization, stretching.
Level of Evidence: 1
Spine 2016;41:1013–1021
E
xercise therapy is one of the most common treatments
for nonspecific low back pain (LBP), especially for
chronic symptoms, and it is widely recommended in
clinical practice guidelines.1,2 One type of exercise that has
gained increasing popularity among patients with LBP
over the last decade is the Pilates method.3 – 5 Pilates
was developed in the 1920s by Joseph Pilates and consists
of comprehensive body conditioning, which aims to
develop better body awareness and improve posture.4,5
Pilates exercises mainly involve isometric contractions of
the core muscles, responsible for stabilization of the spine,
both while moving or at rest. The reported benefits of
Pilates exercises include improvements in strength, range
of motion, coordination, balance, muscle symmetry, flexi-
bility, proprioception (awareness of posture), body defi-
nition, and general health.6,7
The effectiveness of Pilates has been tested in randomized
controlled trials (RCTs) and systematic reviews.5,7–14 How-
ever, different findings have been reported in these studies
and a well-conducted systematic review is needed to better
inform clinicians, patients, and policy makers about the
effectiveness of this intervention in patients with nonspecific
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 COCHRANE COLLABORATION
LBP. Therefore, the aim of this Cochrane review was to
evaluate the effectiveness of Pilates for patients with LBP.
MATERIAL AND METHODS
Data Sources and Searches
The search was conducted in CENTRAL, MEDLINE,
EMBASE, CINAHL, PEDro, and SPORTDiscus databases
without restrictions on language or date of publication. We
used the search strategies developed by the Cochrane Back
and Neck Review Group. We searched all databases from
the date of their inception to June 2015. We also searched
the following trial registries: Australian New Zealand
Clinical Trials Registry, National Research Registry, Clin-
icalTrials.gov, metaRegister of Controlled Trials, Brazilian
Registry of Clinical Trials, and the World Health Organiz-
ation International Clinical Trials Registry Platform. We
scanned the reference lists from previous published reviews
on Pilates as well as the reference lists from the eligible
randomized trials. We considered only full-text papers,
written in any language, regardless of the date of
publication.
Study Selection
We only included RCTs in this review and we did not
consider trials that used quasi-random allocation pro-
cedures. We included studies that enrolled adult participants
aged 16 or older with acute, subacute, or chronic non-
specific LBP who were recruited from primary, secondary,
or tertiary care (seeking care for back pain or recruited from
the community). We excluded studies that included patients
with any contraindication to exercise therapy, pregnancy,
serious spinal pathology (i.e., cancer, fracture, cauda equina
syndrome, and inflammatory diseases) and studies that
included more than 5% of participants with evidence of
nerve root compromise. Two pairs of review authors inde-
pendently screened titles and abstracts for potentially
eligible studies. We used full-text papers to determine the
final inclusion in the review. We resolved disagreements
between review authors through discussion or by the arbi-
tration of a third review author when consensus could not
be reached.
We considered any type of exercise therapy that followed
the Pilates method. We judged trials to have evaluated
Pilates if (1) the study explicitly stated that the intervention
was based on the Pilates principles (i.e., centering, concen-
tration, control, precision, flow, breathing, and posture) or
at least three of these elements15 or (2) the therapists who
provided the interventions had previous training in Pilates or
were certified as Pilates instructors. The primary outcomes
were pain intensity, disability, global impression of recov-
ery, and quality of life. The secondary outcomes were return
to work and any adverse effects.
Data Extraction and Quality Assessment
Two independent review authors extracted the bibliometric
data, the study characteristics, the characteristics of the
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Pilates for Low Back Pain  Yamato et al
participants, the description of the interventions, the
duration of follow-up assessments, the outcomes assessed,
the study results, and the time periods for outcome assess-
ment defined as: short term (<3 months after randomiz-
ation), intermediate term (3 months and <12 months after
randomization), and long term (12 months after random-
ization). When there were multiple time points that fell
within the same category we used the one that was closer
to the end of the treatment (short term), 6 months (medium
term), and 12 months (long term).
We assessed the risk of bias in the included studies using
the Cochrane risk of bias assessment tool.16,17 Two review
authors (B.T.S. and T.P.Y.) independently performed the
risk of bias assessment and resolved possible disagreements
between review authors by discussion, or arbitration by a
third review author (C.M.) when consensus could not be
reached. We scored each of the 12 risk of bias items as
‘‘high,’’ ‘‘low,’’ or ‘‘unclear’’ risk. We defined a study with
an overall low risk of bias as having low risk of bias on six or
more of these items.
Data Synthesis and Analysis
For all continuous outcomes, we quantified the treatment
effects with the mean difference (MD). To accommodate the
different scales used for these outcomes, we converted out-
comes to a common 0 to 100 scale. For dichotomous out-
comes, we calculated the risk ratios for experiencing the
positive outcome. We used effect sizes and 95% confidence
intervals (CIs) as a measure of treatment effect. We con-
sidered between-group differences of at least 20% as clin-
ically important.18 For effect sizes, we defined three levels as
small (MD <10% of the scale), medium (MD 10%–20% of
the scale), or large (MD >20% of the scale).19 We used
Review Manager 5 for all analyses.
The assessment of heterogeneity was based on visual
inspections of the forest plots (e.g., overlapping CIs) and
more formally by the x2 test and the I2 statistic.16 We
combined results in a meta-analysis using a random-effects
model if I2 <50%. If substantial heterogeneity was present,
we did not combine the results but instead presented them
as a narrative synthesis. If I2 values were slightly higher
than 50% but we identified no clear heterogeneity by
visual inspection, we combined the results within a
meta-analysis.
We assessed the overall quality of the evidence for each
outcome using the GRADE approach.16 Factors that may
decrease the quality of the evidence are study design and risk
of bias (downgraded if more than 25% of the participants
were from studies with a high risk of bias); inconsistency of
results (downgraded if significant heterogeneity was present
by visual inspection or if the I2 value was greater than 50%);
indirectness (generalizability of the findings; downgraded if
more than 50% of the participants were outside the target
group); imprecision (downgraded if fewer than 400 partici-
pants were included in the comparison for continuous data
and there were fewer than 300 events for dichotomous
data20); and other factors (e.g., reporting bias, publication
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 COCHRANE COLLABORATION Pilates for Low Back Pain  Yamato et al

bias). We considered single studies with fewer than 400

participants for continuous or dichotomous outcomes
inconsistent and imprecise, providing ‘‘low-quality evi-
dence,’’ which could be downgraded to ‘‘very low-quality
evidence’’ if there were further limitations on the quality of
evidence.21 We reduced the quality of the evidence for a
specific outcome by a level, according to the performance of
the studies against these five factors and we described them
as follows.

 High-quality evidence: there are consistent findings

among at least 75% of RCTs with low risk of bias,
consistent, direct, and precise data, and no known or
suspected publication biases. Further research is
unlikely to change either the estimate or our confi-
dence in the results.
 Moderate-quality evidence: one of the domains is not
met. Further research is likely to have an important
impact on our confidence in the estimate of effect and
may change the estimate.
 Low-quality evidence: two of the domains are not met.
Further research is very likely to have an important
impact on our confidence in the estimate of effect and
is likely to change the estimate.
 Very low-quality evidence: three of the domains are
not met. We are very uncertain about the results.
 No evidence: no RCTs were identified that addressed
this outcome.

RESULTS
The searches retrieved 126 trials, of which 10 were included
in this review (Figure 1). A total of 510 participants were
enrolled in the included trials, and we included data from
478 participants in the meta-analyses. All participants had
chronic LBP and were middle aged (mean: 38 yr), ranging
from 22 to 50 years of age. The duration of the treatment
programs ranged from 10 to 90 days, and the treatment
frequency varied from one to four sessions per week. The
duration of all sessions was approximately 1 hour for all
included studies, and the mean number of sessions was 15.3,
ranging from six to 30 sessions. The study characteristics are
described in detail in Table 1.
In total, we considered 70% of the studies to have a low
risk of bias, which represents 83.7% of all participants.
More than half of the included trials met the criteria for
allocation concealment,5,11,23 –26 one trial blinded both
participants and assessors,22 one trial blinded only the
participants,23 and seven trials blinded only the asses-
sors.5,7,11,24 –26 A total of eight trials provided adequate
information about missing data and were able to keep losses
below 20% for short- and intermediate-term outcomes, Figure 1. Flowchart of the study.
though none of the trials report long-term follow-
up.5,9,11,13,22 –24,26 Published or registered protocols were ANALYSIS
available for four trials.11,23,24,26 We did not assess publi- We used two comparisons for this review: (i) Pilates versus
cation bias with funnel plots because too few studies were minimal intervention or no intervention5,7,9,11,24,25 and (ii)
included in the meta-analysis. The results from the risk of Pilates versus other types of exercises.13,22,23,27 The sum-
bias assessment are presented in Figure 2. mary of evidence is presented in Table 2.
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 COCHRANE COLLABORATION Pilates for Low Back Pain  Yamato et al

TABLE 1. Characteristics of the Included Studies

Study (Year) Country Participants Interventions Dose Outcomes

Brooks, Australia 64 participants with 1. Specific trunk exercise group Exercise classes: 3/week, 8 Disability (ODI), pain
201222 LBP, 18–50 yr (Pilates): it was based on a Pilates weeks. Duration: 50– (VAS)
old, >12 weeks training, which incorporated 60 min, 10 participants in
of symptoms skilled contraction techniques, each class
general trunk focused
strengthening exercise, whole-
body movements, and stretching
of the trunk and hip musculature.
2. General exercise group: it was
indoor stationary cycle training.
Fonseca, Brazil 17 participants with 1. Pilates group. Pilates sessions were performed Pain (VAS)
20099 chronic LBP, 2. No Pilates group: continued with 2/week, 15 sessions.
18–59 yr old, at their normal activities and did Duration: 1 hour. Performed
least 6 months of not undergo any other type of individually
symptoms treatment.
Gladwell, United 49 participants with 1. Pilates group. Pilates sessions were performed Pain (RMVAS), disability
20067 Kingdom nonspecific 2. CG: continued with their normal 1/week, six sessions. (OSWDQ)
chronic LBP, activities and pain relief. Duration: 1 hour. Maximum
18–60 yr old, at class size: 12
least 12 weeks of
symptoms
Marshall, Australia 64 participants with 1. Specific trunk exercise group: Exercise classes: 3/week, 8 Pain (VAS), disability
201323 chronic LBP, performed Pilates exercise. weeks. Duration: 50– (ODI)
18–50 yr old, 2. Stationary cycling exercise group: 60 min, 10 participants in
>12 weeks of style of cycling known as Pilates each class
symptoms pedal (it did not include specific
trunk exercise).
Miyamoto, Brazil 86 participants with 1. Booklet group: the participants Pilates sessions were performed Pain (NRS), disability
201311 chronic LBP, received an educational 2/week, 6 weeks. (RMDQ), global
18–60 yr old, at information about the anatomy Duration: 1 hour. Performed impression of recovery
least 6 months of of the spine and pelvis, low back individually (GPES), function
symptoms pain, and recommendations (PSFS)
regarding posture and
movements involved in activities
of daily living.
2. Pilates group (modified Pilates
exercise þ educational Program):
the participants received the
same educational information,
plus Pilates classes.
Natour, Brazil 60 participants with 1. Experimental group: nonsteroidal Not reported Pain (VAS), function
201424 chronic LBP, anti-inflammatory drug and (RMDQ), quality of life
18–50 yr old, Pilates classes. (SF-36), satisfaction
>12 months of 2. CG: nonsteroidal anti- with treatment (Likert
symptoms inflammatory drug (they did not scale), flexibility (sit
undergo any other intervention). and reach test)
Nonsteroidal anti-
inflammatory drug
intake
Quinn, United 29 participants with 1. Pilates group: modified mat-based Pilates sessions were performed Pain (VAS), disability
201125 Kingdom chronic LBP, Pilates exercises and was based during the 8 weeks. No (RMDQ)
18–60 yr old, on a body control Pilates more information reported
>3 months of exercise program used by a
symptoms previous study.
2. CG: participants in the CG
received no further intervention
for the 8-week period.
Rajpal, India 40 female 1. Pilates group. Each exercise of the Pilates Pain (VAS)
200813 participants with 2. McKenzie group: participants sessions was performed 10/
LBP, 20–30 yr were taught postural correction day, 1 month. Duration: Each
old, at least 3 and re-education. exercise was held by 10 sec.
months of McKenzie sessions were
symptoms performed 3/day, 1 month.
Duration: 15–20 min
Rydeard, Hong Kong 39 participants with 1. SETG: the SETG received a Pilates sessions were performed Pain (NRS-101), disability
20065 chronic LBP, treatment protocol consisting of 3/week, 4 weeks. (RMDQ-HK)
20–55 yr old, training in specialized (Pilates) Duration: 1 hour
>6 weeks of exercise apparatus.
symptoms 2. CG: no specific exercise training
and continued with usual care.

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 COCHRANE COLLABORATION Pilates for Low Back Pain  Yamato et al

TABLE 1 (Continued)
Study (Year) Country Participants Interventions Dose Outcomes
Wajswelner, Australia 87 participants with 1. Pilates group. 2. General exercise Exercise classes: 2/week, 6 Pain (NRS), disability
201126 chronic LBP, group: standardized generic set weeks. Duration: 60 min. (Quebec), quality of
18–70 yr old, of exercises traditionally used for Maximum class size: four life (SF-36)
>3 months of the management of CLBP. The
symptoms exercises included stationary
bike, leg stretches, upper body
weights, theraband, Swiss ball
and floor exercises that were
multidirectional and nonspecific
in nature.
CG indicates control group; CLBP: Chronic Low Back Pain; GPES: Global Perceived Effect Scale; NRS: Numerical Rating Scale; ODI: Oswestry Disability
Index; PSFS: Patient Specific Functional Scale; RMDQ-HK: Roland Morris Disability Questionnaire Hong Kong Version; RMVAS: Roland Morris Visual
Analogue Scale; SF-36: Short Form Health Survey; VAS: Visual Analogue Scale.

Effect of Pilates Versus Minimal Intervention medium effect size (MD 14.05, 95% CI 18.91 to
There is low-quality evidence (downgraded due to 9.19; P < 0.001, n ¼ 265, six trials),5,7,9,11,24,25 and
imprecision and risk of bias) that Pilates is better than moderate-quality evidence (downgraded due to impreci-
minimal intervention for pain at short term with a sion) for intermediate term, with a medium effect size

Figure 2. ‘‘Risk of bias’’ summary: review

author’s judgments about each risk of bias item
for each included study.

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 COCHRANE COLLABORATION Pilates for Low Back Pain  Yamato et al

TABLE 2. Summary of Findings and Quality of Evidence for All Outcomes Included in This Review
Total Sample Size Quality of
Outcome (n of Studies) Effect Size (95% CI) Evidence
Pilates vs. minimal intervention
Pain
Short term 265 (six studies) 14.05 (18.91 to 9.19) Low
Intermediate term 146 (two studies) 10.54 (18.46 to 2.62) Moderate
Disability
Short term 248 (five studies) 7.95 (13.23 to 2.67) Low
Intermediate term 146 (two studies) 11.17 (18.41 to 3.92) Moderate
Function
Short term 43 (one study) 1.10 (0.23 to 1.97) Low
Intermediate term 43 (one study) 0.80 (0.00 to 1.60) Low
Global impression of recovery
Short term 43 (one study) 1.50 (0.70 to 2.30) Low
Intermediate term 43 (one study) 0.70 (0.11 to 1.51) Low
Pilates vs. other exercises
Pain
Short term 93 (three studies) Not estimatedy Not estimatedy
Intermediate term 76 (two studies) Not estimatedy Not estimatedy
Disability
Short term 149 (two studies) 3.29 (6.82 to 0.24) Moderate
Intermediate term 151 (two studies) 0.91 (5.02 to 3.20) Moderate
Function
Short term 44 (one study) 0.10 (2.44 to 2.64) Low
Intermediate term 44 (one study) 3.60 (7.00 to 0.20) Low
For ‘‘pain’’ and ‘‘disability’’ outcomes, a negative effect size value represents an effect in favor of Pilates. For ‘‘function’’ and ‘‘global impression of recovery’’
outcomes, a positive effect size value represents an effect in favor of Pilates.

Statistically significant difference (P < 0.05).
y
These comparisons were not included in the meta-analysis due to high heterogeneity.
CI indicates confidence interval.

(MD 10.54, 95% CI 18.54 to 2.62, n ¼ 146, two
trials)11,24 (Figure 3).
There is low-quality evidence (downgraded due to impreci-
sion and inconsistency) that Pilates improves disability at short-
term follow-up compared with minimal intervention, with a
small effect size (MD 7.95, 95% CI 13.23 to 2.67;
P ¼ 0.003, n ¼ 248, five trials),5,7,11,24,25 and moderate-quality
evidence for an effect at intermediate term, with medium effect
size (MD 11.17, 95% CI 18.41 to 3.92, n ¼ 146, two
trials).11,24
For global impression of recovery, there is low-quality
evidence (downgraded due to imprecision and inconsis-
tency) of a significant short-term effect in favor of Pilates,
with a small effect size (MD 1.50, 95% CI 0.70–2.30,

Figure 3. Forest plot of comparison between Pilates and minimal intervention for the outcome pain. CI indicates confidence interval; IV:
Inverse Variance; SD, standard deviation.
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 COCHRANE COLLABORATION
Figure 4. Forest plot of comparison between Pilates and other exercises for the outcome disability. CI indicates confidence interval; IV: Inverse
Variance; ODI: Oswestry Disability Index; SD, standard deviation.
n ¼ 86, one trial),11 but not for intermediate-term follow-
up.11 For function, there is low-quality evidence (down-
graded due to imprecision and inconsistency) that there is a
significant short-term effect, with a small effect size (MD
1.10, 95% CI 0.23–1.97, n ¼ 86, one trial),11 but no differ-
ences were found for intermediate term.11
Only one trial24 evaluated quality of life but the estimates
for the physical and mental components were not available
in the publication and the authors did not provide this
information on request. One trial assessed adverse events,
but none were reported.11 None of the trials reported return
to work outcomes.
Effect of Pilates Versus Other Exercises
We did not combine the results for pain at short-term and
intermediate-term follow-up in a meta-analysis due to the
high level of heterogeneity, but reported results descrip-
tively. Based on low-quality evidence (downgraded due to
imprecision and inconsistency), at short-term follow-up,
two trials (n ¼ 94) reported a significant effect in favor of
Pilates,13,22 but one trial (n ¼ 87) did not find significant
differences between groups.27 At intermediate-term follow-
up, based on low-quality evidence (downgraded due to
imprecision and inconsistency), one trial (n ¼ 64) reported
a significant effect in favor of Pilates,23 and one trial (n ¼ 87)
reported a nonsignificant difference in pain intensity.27
For disability, there is moderate-quality evidence (down-
graded due to imprecision) that there is no significant
difference between Pilates and other exercises at short-
term (MD 3.29, 95% CI 6.82 to 0.24, n ¼ 149, two
trials)26,27 or intermediate-term follow-ups (MD 0.91,
95% CI 5.02 to 3.20, n ¼ 151, two trials).23,27 Only one
trial27 evaluated quality of life but the estimates for the
physical and mental components were not available in
the publication and the authors did not provide this
information on request. None of the trials reported
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Pilates for Low Back Pain  Yamato et al
adverse events or return to work for this comparison
(Figure 4).
For function, no differences were found for short term
based on one study (n ¼ 87),27 but there is low-quality
evidence (downgraded due to imprecision and inconsis-
tency) that there is a significant intermediate-term effect,
with a small effect size (MD 3.60, 95% CI 7.00 to
0.20, n ¼ 87, one trial).27
DISCUSSION
Of the 10 studies included in this systematic review, six
(n ¼ 265 participants) compared Pilates to minimal inter-
vention and four (n ¼ 245 participants) compared Pilates to
other exercises. For the short-term follow-up, Pilates was
more effective than minimal intervention for improving
pain, disability, function, and global impression of recovery,
and at intermediate-term follow-up Pilates led to better pain
intensity and disability outcomes, but was not superior to
minimal intervention in terms of function and global
impression of recovery. The effect sizes varied from small
to medium for this comparison. On the other hand, Pilates
appears not to be more effective than other exercises for pain
intensity and disability. For function, one study found a
small significant effect at intermediate-term, but not at
short-term follow-up.
Our findings are in accordance with the clinical practice
guidelines1 and previous reviews of exercise for low back
pain,28 which recommend exercise therapy for patients with
chronic LBP, but with no clear difference in effectiveness
among the various forms of exercise. In a recent review
of Pilates for LBP, the authors reported a statistically sig-
nificant short-term effect for pain and disability compared
to usual care and physical activity, but for the comparison
with other exercises reported the evidence was conflicting.14
Miyamoto et al11 found a small short-term effect on pain
intensity and disability when comparing Pilates to minimal
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 COCHRANE COLLABORATION
intervention but did not report an effect when compared to
other types of exercises.11 These findings are consistent with
our review although we found some medium effect sizes for
the comparison with minimal intervention and we con-
sidered the results for pain intensity compared to other
exercises too heterogeneous to be combined in a meta-
analysis. The review by Lim et al10 found a small significant
effect on pain intensity in the short term compared to
minimal intervention but not on disability.10 This previous
review did not find any significant effect for the comparison
with other exercises; however, the authors included only one
trial29 and one thesis30 in this comparison. Finally, another
systematic review concluded that no definite conclusions
can be drawn except that further better quality research is
needed.12 In this review, the authors only included four
trials, each one with a different control group, making any
comparison or conclusions difficult.
The strengths of this review include the use of the high-
quality methods of the Cochrane Collaboration. We also
used the GRADE system to assess the quality of evidence.
The main limitation of this review is the low number of trials
and small sample sizes per comparison, outcome, and fol-
low-up period, which also prevented us from conducting a
sensitivity analysis. An additional limitation is the potential
for publication bias in the trials included. Although it was
not possible to assess publication bias using funnel plots, as
too few studies were included, we found one completed trial
(from 2011) that was not yet published, which may indicate
potential publication bias. Moreover, the source of funding
should be considered due to potential financial conflicts
from industry-sponsored research.31,32 One trial received
funding from a Pilates clinic to conduct the study.26 The
remaining trials were not funded.
Pilates appears to be an effective treatment compared to
minimal intervention, but when compared to other types of
exercises the effect sizes tend to be smaller or no difference
in effectiveness is observed. The evidence on the effective-
ness of Pilates for LBP is of low to moderate quality and
limited to patients with chronic LBP. There is an urgent
need for large, high-quality trials evaluating Pilates for LBP.
Most trials included fewer than 40 participants in
total,5,7,9,13,25 or were unregistered,5,7,9,13,22,25 and none
of the trials included long-term follow-up. Additionally,
future trials should include an economic evaluation of the
Pilates method to guide clinical choices between competing
treatment options.
CONCLUSION
No definite conclusions or recommendations can be made as
we did not find any high-quality evidence for any of the
treatment comparisons, outcomes, or follow-up periods
investigated. However, there is low- to moderate-quality
evidence that Pilates is more effective than minimal inter-
vention in the short and intermediate term as the benefits
were consistent for pain intensity and disability, with most
of the effect sizes being considered medium. It was less clear
whether Pilates was more effective than other exercises for
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Pilates for Low Back Pain  Yamato et al
pain intensity, disability, and function as the results across
outcomes were contradictory. However, a small effect
favoring other exercises was found for function at inter-
mediate-term follow-up. The decision to use Pilates for
chronic low back pain may be based on the patient’s or
care provider’s preferences and costs.
Key Points
There is low- to moderate-quality evidence that
Pilates prov ides better outcomes than
minimal intervention.
There is no conclusive evidence that Pilates is
superior to other forms of exercises.
Further large, high-quality trials evaluating Pilates
for low back pain are needed.
References
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