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Journal of Back and Musculoskeletal Rehabilitation -1 (2020) 1–8 1

DOI 10.3233/BMR-191810
IOS Press

The effects of clinical pilates exercises on

functional disability, pain, quality of life and
lumbopelvic stabilization in pregnant women
with low back pain: A randomized controlled
study
Emel Sonmezer∗ , Manolya Acar Özköslü and Hayri Baran Yosmaoğlu
Department of Physical Therapy and Rehabilitation, Faculty of Health Sciences, Baskent University, Ankara, Turkey

Received 6 November 2019

Accepted 24 August 2020

Abstract.
BACKGROUND: Although the Pilates method has been reported to be effective in women with low back pain (LBP), the efficacy
of Pilates exercises in pregnant women with LBP has not been evaluated widely.
OBJECTIVE: The purpose of this study was to determine the effects of clinical Pilates exercises on lumbopelvic stabilization,
pain, disability and quality of life in pregnant women with LBP.
METHODS: Fourty pregnant women were randomized into either a Pilates exercise group (n = 20) or control group (n = 20).
Subjects in the Pilates exercise group performed the exercises two times a week for eight weeks. Subjects in the control group
followed regular prenatal care. Lumbopelvic stabilization was assessed with a pressure biofeedback unit, pain with the Visual
Analog Scale, disability with the Oswestry Low Back Pain Questionnaire and quality of life with the Nottingham Health Profile
(NHP).
RESULTS: Pain and disability were significantly improved in the Pilates exercise group after intervention (p = 0.03, p < 0.001,
respectively). There were also significant improvements in sleep, physical mobility sub-parameters of NHP and lumbopelvic
stabilization after Pilates exercises (p = 0.048, p = 0.007, respectively). However, there were no statistically significant changes
in all outcome measures in the control group (p > 0.05).
CONCLUSIONS: Pilates exercises can be recommended as an effective and safe method for increasing lumbopelvic stabilization,
reducing pain and disability, improving physical mobility and sleep problems in pregnant women with LBP.

Keywords: Pilates exercises, disability, pain, quality of life, lumbopelvic stabilization, pregnancy, low back pain

1. Introduction 1

Weight gain, postural changes and hormonal fluctu- 2

ations in pregnancy may lead to musculoskeletal sys- 3

∗ Corresponding author: Emel Sonmezer, Department of Physi- tem problems [1]. Relaxin, a hormone secreted by 4
cal Therapy and Rehabilitation, Faculty of Health Sciences, Baskent
the placenta particularly during late pregnancy relaxes 5
University, Eskisehir Yolu 20, Baglıca, Ankara, Turkey. Tel.:
+90 3122466673; Fax: +90 3122466674; E-mail: emelsonmezer@ pelvic ligaments and ligaments supporting the spine, 6

gmail.com. however, the relaxed ligaments may trigger low back 7

ISSN 1053-8127/20/$35.00 c 2020 – IOS Press and the authors. All rights reserved
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2 E. Sonmezer et al. / The effects of clinical pilates on pain in pregnancy

8 pain (LBP) in pregnant women [2]. LBP is the most Outpatient Clinic of Baskent University Medical Fac- 56

9 common pregnancy-induced musculoskeletal problem. ulty for routine pre-natal care were allocated to this 57

10 Many studies report that about 50% of women suffer study over a period of 18 months. After a thorough 58

11 from LBP during pregnancy [3–11]. This pain usually evaluation of the pregnant women by an obstetrician in 59

12 increases as the pregnancy progresses, and it can affect order to eliminate any systemic or obstetric causes that 60

13 activities of daily life in pregnant women such as weight may mimic the same pain, the women were referred to 61

14 bearing, sitting and walking. It can also cause physi- a physiotherapist. The inclusion criteria for this study 62

15 cal inactivity and insomnia in pregnant women [12]. were: pregnant women in weeks 22–24 with pregnancy- 63

16 Therefore, studies report that pregnancy-induced LBP induced lumbar pain; maternal age 20–35 years; parity 64

17 negatively affects quality of life and leads to functional 6 3; and the absence of pre-pregnancy lumbar pain. 65

18 disability in pregnant women [13,14]. The exclusion criteria for this study were: multiple 66

19 It has been reported that non-pharmacological treat- pregnancies; history of cardiovascular diseases, medi- 67

20 ment methods include ergonomic modifications, fre- cal complications (hemorrhage, preeclampsia, placenta 68

21 quent rest periods, hot and cold compresses, waist previa etc.) and/or cognitive disorders; contraindication 69

22 support belts, massage, acupuncture, yoga, manipu- for physical exercise (eg: having severe other muscu- 70

23 lative practices and pregnancy-specific exercises im- loskeletal disease, high risk pregnancies, balance defi- 71

24 prove pain, disability and sick leave with minor, tran- ciencies); and taking part in other exercises or physio- 72

25 sient adverse effects when compared to regular prenatal therapy programs. 73

26 care [12]. Clinical Pilates is one type of exercise that This study was approved by the Medical Ethics Com- 74

27 is used to relieve LBP. The clinical Pilates method is a mittee (KA18/266). Prior to the study, patients were 75

28 technique that focuses on increasing lumbopelvic sta- given information about the risks and benefits of the 76

29 bilization and improving posture, breathing, flexibility, treatment protocol in order to decide whether or not 77

30 strength and muscle control [15]. The Pilates approach they wish to undergo a treatment. The voluntary sub- 78

31 focuses on actively using body muscles to stabilize the jects provided written informed consent. The Declara- 79

32 lumbopelvic region [16]. There is evidence that Pilates tion of Helsinki was strictly followed throughout the 80

33 is an effective approach to increasing strength of deep study. 81

34 body core muscles [17]. Although the increasingly pop-

35 ular Pilates method has been recently reported to be 2.2. Study design 82

36 more effective than other exercise methods in reducing

37 LBP in women [18], only one study examines the ef- A double blind, randomized controlled trial with 1:1 83

38 fects of Pilates on LBP in pregnant women [19], which allocation was performed to examine the effectiveness 84

39 only focussed on pain in pregnant women and found of Pilates exercise on pregnancy-related LBP. The sub- 85

40 that it was effective in reducing pain. jects were randomized by an independent person into 86

41 No studies were found that show the efficacy of either the Pilates exercise group (n = 20) or control 87

42 clinical Pilates exercises on lumbopelvic stabilization group (n = 20) by using a randomization allocation 88

43 strength, disability and quality of life in patients with software program (GraphPad Software QuicksCalcs, 89

44 pregnancy-related lumbar pain. The aim of this study GraphPad Sotfware Inc., USA) before the baseline mea- 90

45 was therefore to investigate the effectiveness of Pilates surements. All parameters were assessed before and 91

46 exercises on lumbopelvic stabilization, pain, disability after the eight week study period in all groups. See 92

47 and quality of life in the pregnant woman. We hypothe- Fig. 1 for the CONSORT diagram regarding patient flow 93

48 sized that the Pilates exercise would result in a signifi- through the study. The assessor and pregnant women 94

49 cant improvement in pain, disability, quality of life and were blind to the allocation group of the subjects. One 95

50 lumbopelvic stabilization strength in pregnant women physiotherapist assessed the pregnant women without 96

51 with LBP. knowledge of the patients’ grouping, whereas another 97

physiotherapist performed the intervention. 98

Participants in the control group followed regular 99

52 2. Materials and methods prenatal care consisting of routine medical and nursing 100

care and were given education consisting of ergonomic 101

53 2.1. Subjects information about activities that exacerbate LBP dur- 102

ing daily living and optimal lifting techniques, sitting, 103

54 Forty pregnant women with LBP complaints reg- standing and sleeping postures. They were not given 104

55 istered at the Gynecology and Obstetrics Department any exercise prescription. 105
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E. Sonmezer et al. / The effects of clinical pilates on pain in pregnancy 3

Fig. 1. Study flow diagram.

clinical Pilates exercise program between weeks 22–24 111

of their pregnancy and terminated it between weeks 30– 112

32. The pregnant women in the Pilates exercise group 113

performed a program that included a warm-up and a 114

main work out session. The total exercise program con- 115

sisted of 18 different clinical Pilates exercises designed 116

to stretch, strengthen and balance the body and lasted 117

for 60–70 minute each session (Fig. 2). The exercises 118

were taught with appropriate breathing techniques. Sub- 119

jects were given information about adverse events in- 120

cluding dyspnea, dizziness, headache, muscle soreness, 121

weakness, calf pain or swelling. When they had any 122

adverse events, they were asked to stop the exercise. 123

2.3. Outcome measurements 124

Baseline demographic and clinical characteristics 125

was recorded at admission. 126

2.3.1. Primary outcomes 127

Fig. 2. Clinical Pilates exercise program.
Disability 128

The present study used the valid and reliable Turkish 129

106 Women in the Pilates group were additionally given version of the Oswestry Low Back Disability Ques- 130

107 clinical Pilates exercises. Clinical Pilates exercises were tionnaire to determine functional disability due to back 131

108 performed individually two times a week for eight pain [20]. The questionnaire has 10 subgroups and is 132

109 weeks under the supervision of a physical therapist who scored between 0 and 5. Subgroups of this questionnaire 133

110 was a certified Pilates instructor. Women started the address the severity of pain, lifting and carrying, walk- 134
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4 E. Sonmezer et al. / The effects of clinical pilates on pain in pregnancy

Table 1
Baseline characteristics of the subjects
Pilates exercise group (mean ± SD) Control group (mean ± SD) p
Age (years) 29.00 ± 2.75 28.00 ± 2.10 0.289
Height (cm) 162.66 ± 4.28 162.50 ± 4.18 0.860
Current weight (kg) 62.83 ± 7.88 61.40 ± 7.24 0.597
Body mass index (kg/m2 ) 23.80 ± 3.16 23.26 ± 2.59 1.000
Gestational age (week) 22.70 ± 0.73 22.90 ± 0.71 0.363
Gravidity 1.30 ± 0.92 1.10 ± 0.30 0.999
SD: Standard deviation. There were no statistical differences among the groups (p > 0.05) (Mann-Whitney U
test).

135 ing, sitting, standing, sleep, sexual life, traveling and to hold the contraction for 10 seconds monitored by 173

136 social life. The total score of the questionnaire ranges using a digital watch. The change in pressure during 174

137 between 0–50, with higher total scores indicating higher abdominal hollowing was repeated three times and the 175

138 functional disability due to back pain [21]. mean of all the measurements were recorded [24–26]. 176

139 Pain 2.3.3. Statistical analysis 177

140 Pain intensity was measured using the Visual Analog Data was analyzed with the SPSS package (ver- 178

141 Scale (VAS). VAS is a single-item scale comprised of sion 17.0). Mean and standard deviations of the values 179

142 a horizontal line, 10 cm (100 mm) in length, anchored were calculated for each variable. A normal distribu- 180

143 by two verbal descriptors extremes: “no pain at all” tion of data was assessed by means of the Kolmogorov- 181

144 and “my pain is as bad as it could possibly be”. Using Smirnov test, and normal distribution was not detected. 182

145 a ruler, the score was determined by measuring the Baseline features were compared between groups us- 183

146 distance (mm) on the 10 cm line between the “no pain” ing the Mann-Whitney U test. Within-group differences 184

147 anchor and the patient’s mark, providing a range of were assessed with the Wilcoxon test. The statistical 185

148 scores from 0–100. A higher score indicates greater analysis was conducted at a 95% confidence level. A P 186

149 pain intensity [22]. value less than 0.05 was considered statistically signifi- 187

cant. Sample size was calculated according to Oktaviani 188

150 2.3.2. Secondary outcomes et al. and indicated that the difference in the response 189

151 Health-related quality of life of matched pairs is normally distributed with standard 190

152 The transcultural adaptation version of the Notting- deviation 1.64 in pregnant woman with back pain [19]. 191

153 ham Health Profile (NHP) was used to assess health- If the true difference in the mean response of matched 192

154 related quality of life [23]. The NHP is a general qual- pairs is 1.11, 19 subjects need to be studied in order to 193

155 ity of life questionnaire designed to measure perceived be able to reject the null hypothesis that this response 194

156 health problems and the extent to which these problems difference is zero with probability (power) 0.8. The 195

157 affect normal daily activities. The survey has a total Type I error probability associated with this test of this 196

158 of 38 questions consisting of six sub-sections: lack of null hypothesis is 0.05. 197

159 energy (3 items), pain (8 items), emotional reaction (9

160 items), sleep disturbance (5 items), social isolation (5
161 items), and physical mobility (8 items). The questions 3. Results 198

162 are answered as “yes” or “no” and the best score taken
163 in the sub-sections is 0 and the worst score is 100 [23]. This study was reported using CONSORT guide- 199

lines. Fifty-eight pregnant women were screened. Four 200

164 Lumbopelvic stabilization assessment women did not meet the inclusion criteria and four 201

165 Lumbopelvic stabilization was evaluated by a pres- women were declined to participate. In total, 50 sub- 202

166 sure biofeedback unit (Stabilizer Pressure Biofeedback jects (median of maternal age: 23 week) were randomly 203

167 Unit, Chattanooga Group Inc., Hixson, TN, USA). The assigned to one of the two groups. Six women in the 204

168 pregnant women were positioned in crook lying posi- Pilates group and four women in the control group did 205

169 tion and the pressure cell was placed under the lumbar not recieve allocated intervention. Twenty subjects in 206

170 spine and inflated to the baseline pressure of 40 mm the Pilates exercise group and 20 subjects in the con- 207

171 Hg. The women were instructed to perform abdominal trol group participated in the final measurements. There 208

172 hollowing without moving their spine or pelvis, and were no differences in the baseline demographic and 209
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E. Sonmezer et al. / The effects of clinical pilates on pain in pregnancy 5

Table 2
Baseline values of outcome measurements
Pilates exercise group (mean ± SD) Control group (mean ± SD) p ES
Disability
Oswestry LBDQ score 9.20 ± 6.87 11.50 ± 10.80 0.398 0.33
Pain
VAS score (mm) 43.60 ± 13.20 41.80 ± 16.50 0.738 −0.13
Quality of life
Nottingham Health Profile scores
Energy 24.60 ± 34.41 44.80 ± 41.58 0.121 0.58
Pain 21.45 ± 18.27 26.44 ± 26.57 0.862 0.27
Emotional reaction 15.70 ± 14.83 24.39 ± 20.79 0.183 0.58
Sleep 28.46 ± 22.76 28.98 ± 21.99 0.758 0.02
Social isolation 6.41 ± 10.06 5.78 ± 12.23 0.841 −0.062
Physical mobility 21.45 ± 13.53 24.97 ± 15.56 0.640 0.26
Total 109.02 ± 54.07 157.54 ± 83.03 0.086 0.89
Lumbopelvic stabilization
M. Transversus Abdominis (mmHg) 44.50 ± 11.49 40.20 ± 11.54 0.478 −0.37
SD: Standard deviation, ES: Effect Size. There were no statistical differences among the groups (p > 0.05) (Mann-Whitney U test).

Table 3
The disability level, quality of life and lumbopelvic stabilization scores between the groups
Outcome measures Pilates exercise group Control group Pβ
Baseline 8 weeks Baseline 8 weeks
Pα Pα
(mean ± SD) (mean ± SD) (mean ± SD) (Mean ± SD)
Disability
Oswestry LBDQ score 9.20 ± 6.87 5.40 ± 4.70 0.003∗ 11.50 ± 10.80 12.00 ± 10.39 0.266 0.004∗
Pain
VAS score (mm) 43.60 ± 13.20 17.20 ± 10.80 < 0.001∗ 41.80 ± 16.50 38.40 ± 17.50 0.166 < 0.001∗
Quality of life
Nottingham Health Profile scores
Energy 24.60 ± 34.41 19.40 ± 22.22 0.557 44.80 ± 41.58 44.16 ± 41.81 0.317 0.108
Pain 21.45 ± 18.27 15.36 ± 13.95 0.077 26.44 ± 26.57 26.66 ± 26.69 0.686 0.327
Emotional reaction 15.70 ± 14.83 21.03 ± 12.55 0.072 24.39 ± 20.79 23.92 ± 21.02 0.317 0.957
Sleep 28.46 ± 22.76 15.79 ± 14.18 0.048∗ 28.98 ± 21.99 28.70 ± 21.77 0.655 0.018∗
Social isolation 6.41 ± 10.06 8.01 ± 10.19 0.157 5.78 ± 12.23 5.87 ± 12.30 0.999 0.423
Physical mobility 21.45 ± 13.53 15.18 ± 16.10 0.007∗ 24.97 ± 15.56 24.80 ± 15.47 0.414 0.040∗
Total 109.02 ± 54.07 117.43 ± 63.89 0.371 157.54 ± 83.03 157.60 ± 84.01 0.999 0.279
Lumbopelvic stabilization
M. Transversus Abdominis (mmHg) 44.50 ± 11.49 50.35 ± 14.55 0.010∗ 40.20 ± 11.54 39.50 ± 11.54 0.257 0.022∗
LBDQ: Low Back Disability Questionnaire, VAS: Visual Analog Scale. SD: Standard deviation, p < 0.05 P α:
differences between baseline and
after 8 weeks. P β : post-treatment differences between the group, a: Wilcoxon test β: Mann-Whitney U test, significant difference from baseline,
∗ p < 0.05.

210 clinical characteristics (Table 1). Outcome measures Pain 223

211 were also similar between the groups at baseline (Ta- The VAS score was significantly improved in the 224

212 ble 2). Pilates exercises group at the end of the training period 225

(p < 0.001) relative to baseline scores. There was no 226

213 3.1. Primary outcomes significant change in the control group over the eight 227

week exercise program (p > 0.05). When comparing 228

214 Disability post-treatment values, the improvement in the pain level 229
215 The Oswestry Low Back Disability Questionnaire was significantly higher than the control group (p < 230
216 scores were significantly improved in the Pilates exer- 0.001) (Table 3). 231
217 cise groups after the eight week training period (p =
218 0.003). None of these improvements were observed in 3.2. Secondary outcomes 232
219 the control group over the same period (p > 0.05). Af-
220 ter the eight week intervention, disability levels signif- Quality of life 233

221 icantly differed between the two groups (p = 0.004) Based on the quality of life measures using the NHP, 234

222 (Table 3). sleep (p = 0.048) and physical mobility (p = 0.007) 235
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6 E. Sonmezer et al. / The effects of clinical pilates on pain in pregnancy

236 sub-parameters were significantly improved in the Pi- pharmacological interventions such as use of exercise 284

237 lates exercises group. However, there were no statisti- methods, ergonomic modifications and manual ther- 285

238 cally significant changes in any NHP sub-parameters apy methods due to the limited use of pharmacologi- 286

239 in the control group over the study period (p > 0.05). cal agents in pregnancy [12]. Oktaviani et al. reported 287

240 When comparing post-treatment values, the improve- that Pilates is effective in reducing LBP in pregnant 288

241 ment in sleep and physical mobility sub-parameters of women [19]. Similarly, the present study also showed 289

242 the NHP was significantly higher than the control group that an eight week clinical Pilates exercise program 290

243 (p = 0.018, p = 0.040 respectively) (Table 3). is more effective than regular prenatal care with er- 291

gonomic education in reducing LBP and disability in 292

244 Change in lumbopelvic stabilization pregnant women. Previous studies showed that weak 293
245 The change in pressure during abdominal hollowing muscle function in the lumbar and pelvic region is asso- 294
246 increased significantly in the Pilates exercises group ciated with severe pain and disability in pregnancy [30]. 295
247 after the eight week experimental period (p = 0.013). Therefore, Pilates exercises may ensure biomechanical 296
248 Conversely, in the control group the pressure did not healing resulting from increased lumbopelvic stabiliza- 297
249 significantly change after the eight week experimental tion. 298
250 period (p > 0.05). After the eight week intervention pe- Although the use of Pilates-based stabilization ex- 299
251 riod, lumbopelvic stabilization values were significantly ercises for reducing lumbar-pelvic pain has become 300
252 higher in the Pilates exercise group when compared to widespread, no study was found that investigated the 301
253 the control group (p = 0.022) (Table 3). effects of this program on pregnancy-induced pain and 302

quality of life in pregnant women. The present study 303

examined the effects of an eight week Pilates exer- 304

254 4. Discussion
cise program on the quality of life in pregnant women. 305

Study findings show that the program improved sub- 306

255 The present study results demonstrated that clinical
parameters of quality of life such as physical mobil- 307
256 Pilates exercises are effective in reducing pain and func-
ity and sleep pattern in the experimental group, but 308
257 tional disability, improving lumbopelvic stabilization
258 strength and increasing the quality of life in pregnant did not generate similar results in the control group. 309

259 women with LBP. To the best of our knowledge, this is Progression of pregnancy leads to significant limita- 310

260 the first study that shows the effectiveness of clinical tions in physical activity. However, these activities 311

261 Pilates exercise on disability, quality of life and lum- can be limited pathologically in pregnant women with 312

262 bopelvic stabilization in women with pregnancy-related LBP [31,32]. Pregnant women often avoid doing these 313

263 LBP. activities or develop abnormal movement patterns to 314

264 Postural changes and hormonal fluctuations in preg- relieve or prevent the pain. Both decrease in physical 315

265 nancy negatively affect muscle activation and strength activity and abnormal movement patterns result in a 316

266 by inducing biomechanical changes in the muscles that vicious cycle leading to muscle dysfunction causing 317

267 provide lumbopelvic stability. Previous studies demon- more pain and disability [33]. An increase in motor 318

268 strated that subjects with LBP have an impaired ability control achieved by increasing the stability of the lum- 319

269 to sustain the lumbopelvic stabilisation [26–28]. There- bopelvic region eliminates this cycle by reducing mus- 320

270 fore the accurate assesment of lumbopelvic stabiliza- cle dysfunction [26]. The present study results indicate 321

271 tion is important not only to detect the vulnaribility to an improvement in physical mobility via Pilates exer- 322

272 lumbar pain but also to select the appropriate exercise cises and suggests that Pilates exercises reduce pain and 323

273 programme. disability, increasing mobility and decreasing activity 324

274 It has been reported that Pilates exercises increase the limitations. 325

275 activation of transversus abdominis, diaphragm, mul- Studies report that pain particularly during the later 326

276 tifidus and pelvic floor muscles that affect the local weeks of pregnancy usually increases overnight and 327

277 stability system, thus reducing joint laxity [17,19,29]. causes sleep problems [12]. The present study shows 328

278 Similarly, the present study results also shows that clin- that Pilates exercises with ergonomic education per- 329

279 ical Pilates exercises specific to pregnancy increase formed by pregnant women with pregnancy-induced 330

280 the strength of lumbopelvic stabilization in pregnant LBP is more effective than regular prenatal care with 331

281 women when compared to regular care. ergonomic training, on the sleep sub-parameter of the 332

282 Disability due to LBP is a major problem in preg- quality of life. Altough, according to the statistical anal- 333

283 nancy and can be treated through controversial non- ysis, the p value of the sleep sub-parameter of NHP is 334
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E. Sonmezer et al. / The effects of clinical pilates on pain in pregnancy 7

335 just under 0.05, this result can be accepted as a promis- [5] Mantle MJ, Greenwood RM, Currey HL. Backache in preg- 379

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