Pilates for low back pain: a systematic review

Complementary Therapies in Clinical Practice Pilates for low back pain: A systematic review Paul Posadzki ,, Pawel Lizis , Magdalena Hagner-Derengowska a Complementary Medicine, Peninsula Medical School, 25 Victoria Park Road, Exeter, Devon EX2 4NT, UKb Institute of Physiotherapy, Saint Cross Physiotherapy College, Kielce, Polandc Rehabilitation Clinic, Department of Health Sciences, Collegium Medicum, Nicolas Copernicus University, Bydgoszcz, Poland Objective: The aim of this paper is to systematically review all controlled clinical trials of Pilates to treat Data sources: A systematic review of nine databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, Pedro, Rehadat, Rehab Trials) was conducted and the reference lists of all the papers were checked for further relevant publications until May 2010.
Study selection: A first selection was performed by means of title and abstract. A second selection wasmade by means of predefined inclusion criteria: randomized controlled clinical trials testing Pilates inpatients of any age or sex with low back pain.
Data extraction: Data relating to changes in body function, quality of life and pain from the includedstudies were independently extracted by the reviewers on a standardized form. Study quality wasassessed using the Oxford scale.
Data synthesis: Four eligible randomized controlled clinical trials (n ¼ 4) involving Pilates for themanagement of low back pain were included. The methodological quality of the RCTs was relatively low,varying from 1e4 on the Oxford scale. All studies were heterogeneous in terms of population of patients,control groups, inclusion and exclusion criteria, and outcome measures making a meta-analysis notfeasible. Although there is some evidence supporting the effectiveness of Pilates in the management oflow back pain, no definite conclusions can be drawn except that further research is needed with largersamples and using clearer definitions of the standard care and comparable outcome measures.
Conclusions: There is a wide diversity in research investigating the clinical and cost-effectiveness ofPilates in patients with low back pain.
experience inappropriate neuromuscular adaptations to maintainand/or preserve functions such as walking, running, or other activi- Chronic low back pain (LBP) is one of the commonest musculo- ties.Potentially effective therapies for this disorder are appropriate skeletal problems in modern societand is a highly prevalent and education, i.e. Alexander Technique and cognitive-behavioural very expensive health dilemmaThe aetiology of this disability is therapy; other alternative modalities such as hypnosis, biofeedback, complex and multidimensional; however, physical and (partially) relaxation, massage, spinal manipulation and traction treatme psychosocial occupational factors seem to play an important aetio- and spinal stabilization exercises.Some researchers suggest that logical rolLBP is defined as pain localized between the twelfth rib weakened muscles such as the transversus abdominis (TA) and and the inferior gluteal folds, with or without leg pain and in 90% of multifidius (MF) may be responsible for decreased spinal stability and cases is non-specific.Other researchers conclude that is best consequently the onset of LBPThe Pilates method strengthens defined as a low level continuous or essentially continuous lumbar, these muscles and hence may be an effective modality for LBThe sacral or lumbosacral spinal pain that is punctuated by exacerbations Pilates method was originally developed by Joseph Pilates during the of pain, each of which is characterized as ‘acute’. Patients who expe- First World War and since then it has brought new insight to lower rience this disability are limited in their daily living activities and may back rehabilitation methods.Pilates’ initial concept mixed elementsof gymnastics, martial arts, yoga and dance, focusing on the rela-tionship between the body and mental discipline.The goal of Pilatestraining is to improve general body strength and posture, and to coordinate movement with the breath.
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doi: P. Posadzki et al. / Complementary Therapies in Clinical Practice 17 (2011) 85e89 To date, scientific evidence of the effectiveness of the Pilates method further evaluation of which 4, involving 228 patients, were eligible for the treatment of LBP is rather anecdotaand therefore the aim of for inclusion (see diagram). Reasons for exclusion included no this review is to systematically assess evidence of its efficacy in the specific outcome measure, trials including patients with conditions treatment of low back pain from all controlled clinical trials.
other than LBP such as fibromyalgia syndrome, and trials thatincluded healthy individuals only. For example, Culligan et al.and Sekendiz et al’studies were excluded because they did notinclude LBP patients; Kloubec’research was excluded as it Literature searches were performed to identify all controlled considered healthy individuals only; Merrithew’s was clinical trials of Pilates as treatment for LBP. The following excluded as it was not a randomized controlled trial; Da Fonseca et databases were used: Cochrane Central Register of Controlled al’sstudy was excluded because pain was not the primary Trials, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, Pedro, outcome measure; and Cairns et and Hides et were Rehadat, Rehab Trials and web pages such as excluded as their work was concerned with core stability exercises using the search terms ‘low back pain’, ‘chronic’, ‘discogenic low back pain’, ‘non-specific low back pain’, ‘Pilates’, ‘rehabilitation’and ‘physiotherapy’ to identify all relevant published articles onthe subject. The reference lists of the papers initially identified were scanned for further relevant literature. No language barrierswere imposed.
Four studies meeting the criteria mentioned above were included.They originated from the UK,the and Canada.Pilates was used in all four studies. LBP patient pop-ulations were heterogeneous, and the descriptions of pain included All retrieved data including uncontrolled trials, case studies, chronic pain, discogenic pain and non-specific back pain. Control pre-clinical and observational studies were reviewed for safety groups were standard or usual Back School,drug therapy information. However, only randomized controlled clinical trials testing Pilates in patients of any age or sex with low back pain were Gladwell et al. conducted an RCT to evaluate the effect of included. Studies in any language published in peer-reviewed modified Pilates on 49 active individuals with chronic LBP.Study scientific journals between 1980 and 2010 were considered eligible.
participants were randomly allocated to a control or a Pilates group.
Main outcome measures included (1) the visual analogue scale 3.1. Methodological quality of the studies (VAS), (2) subjective improvement of symptoms, (3) an assessmentof back-specific functional status. They report that Pilates was The quality of the studies was assessed using the five-point found to be superior to the controls and improvements were seen Oxford which has good inter-examiner reliabilityThis in this group’s general health, sports functioning, flexibility and scale assesses methodological quality such as randomization and proprioception, and they experienced less pain. There are some blinding procedures, descriptions of withdrawal and dropout rates, limitations to this study: firstly, the randomization is not clearly using a scale from 0 (poorest) to 5 (highest). Points were awarded as described; secondly, it is single-blinded trial only; thirdly, no follows: study described as randomized, 1 point; appropriate intention to treat analysis was performed; and fourthly, the sample randomization method, 1 additional point; inappropriate random- was rather heterogeneous. The strengths of this trial include the ization method, deduct 1 point; patient blinded to intervention good-quality statistical methods used and the adequate description (patient blinding was assumed where the control intervention was of loss to follow-up rate. We gave this study a score of 3.
indistinguishable from the treatment group), 1 point; evaluator Donzelli et al. conducted a randomized controlled trial with 53 blinded to intervention, 1 point; description of withdrawals and patients with non-specific LBPPatients entered either a Pilates dropouts,1 point. Clinical trials scoring 4 or 5 points were considered therapy or a Back School treatment group. They used the Oswestry Low Back Pain Disability Scale (OLBPDQ) and VAS and at six monthsno significant differences were found between the groups. None- 3.2. Data extraction and quality assessment theless, the Pilates method group showed better compliance andsubjective response to treatment. Although this study is described as Initial screening of the abstracts of the studies was performed by randomized, there is no specification at all of how the randomization two authors (PP, PL) independently. If it was not clear from the and allocation to groups was performed. The blinding procedure is abstract whether or not the study should be included in the review, not adequately described, neither does the study elaborate on the full text of the article was assessed. All articles included were whether the statistical analysis was masked. Intention to treat read in full. Data relating to sample size, diagnosis, gender of analysis is not mentioned either. Another possible limitation of this patients in the samples used, their previous incidences of LBP, study is the lack of statistical analysis between the intervention and therapeutic intervention and control, treatment time, primary (and control groups, with frequency tables and distribution of variables secondary) outcome measures and results were extracted by the presented only. This study was given a score of 1; however, the first author and validated by the second. The third reviewer (MHD) dropout (loss to follow-up) rate and eligibility criteria were suffi- further validated data using a predefined standardized form. The ciently described and the group was relatively homogeneous.
authors met to come to a consensus and discrepancies were solved Rydeard et conducted a randomized controlled trial to investigate the efficacy of the Pilates approach with 39 chronic lowback pain (LBP) patients. Patients were randomly assigned to the Pilates group while the control group received ‘the usual care’. Theyused Roland-Morris Disability Questionnaire (RMDQ) and NRS-101, The search strategy generated a total of 199 references, of which a 101-point numerical rating scale assessing pain intensity. There 51 were considered potentially relevant. We did not locate any was a significantly lower level of functional disability and average unpublished trials, nor relevant papers published in any language pain intensity in the specific exercise training group than in the other than English. A total of 11 clinical trials were retrieved for control group following the treatment intervention period.
P. Posadzki et al. / Complementary Therapies in Clinical Practice 17 (2011) 85e89 Obejctive: To systematically review the literature on efficacy of Pilates in LBP. Study selection: - RCTs and CCTs published between 1980 and 2010 - All LBP patients - Pilates therapy; any task improving physical recovery Two reviewers performed the independent search Data Sources:Computer search -Clinicaltrials.gov -Cochrane Register of Controlled Trials- Medline -CINAHL - PsycINFO - EMBASE -AMED - Pedro - Rehadat - RehabTrials - Reference check Included I Class Articles:Outcome: 4 articles Two independent reviewers rated the selected studies with the JADAD score This is a relatively well-designed trial with the randomization and wore a lumbar cryobrace for 15 min before going to bed at night clearly specified. The inclusion and exclusion criteria were pre- while the control group received drugs and a lumbar cryobrace only.
determined and the group was homogeneous. The loss to follow-up Outcome measures included RMDQ, numeric pain rating score, ratio is adequately established. Reasonably strong statistical patient satisfaction score, measured forward flexion, use of drugs, procedures were used and intention to treat analyses was con- time off work and rate of symptom recurrence. The authors report ducted. However, this study is partially blinded as only the phys- that at the 12-month follow-up 70% of the therapeutic group reported iotherapists were blinded to the results of testing and the relatively over 50% pain reduction and good or better patient satisfaction low response rate of 57% at 6 months may confound the strength of compared to 33% in the controls (P ¼.001). We gave this study a score the findings. We gave this study a score of 4.
of 2 for several reasons. Firstly, it lacks explicit description of the Vad et alconducted a prospective randomized study on 87 randomization process. The statistics used are mainly descriptive. No patients with discogenic LBP to determine the efficacy of the Back Rx intention to treat analysis was performed, nor are dropouts suffi- programme, which comprises elements of physical therapy, rehabil- ciently described. The study also lacks blinding procedures: neither itation, yoga and Pilates. The treatment group also received drugs, therapists nor assessors were blinded to the intervention and analysis namely celecoxib and hydrocodone with acetaminophen as needed, respectively. Although the authors define a successful outcome as P. Posadzki et al. / Complementary Therapies in Clinical Practice 17 (2011) 85e89 Table 1Summary of clinical trials of Pilates for Low Back Pain.
Visual Analogue Scale (VAS) and subjective flexibility, proprioception,and a decrease in pain Patient satisfaction score Forward flexiontest Use of drugs Time off workSymptom recurrence ‘greater than 50% pain reduction with good or better patient satis- maximus muscle using the Lovett test and by visual observation of faction’, there is no reference for this claim. The study does have some this muscle maximizes the risk of bias in recruitment to the study.
methodological strengths such as clearly specified inclusion and There is considerable inconsistency across the studies regarding exclusion criteria that may compensate for possible biases.
assessment of LBP at the baseline, with Donzelli et alusing the Generally, the populations of patients with chronic non-specific Lasegue test, which is known for its limited diagnostic accuracy LBP were well defiOnly Vad et define patients as and low specificityThis may have resulted in an increased ‘discogenic with LBP’. Similarly, homogeneous outcome measures number of false positives in recruitment to their study. Ideally were applied. For instance, all the studies measured pain and func- there should be one standardized assessment to determine tional disability, two using and two using inclusion and exclusion criteria in future research. Van der Windt Additional measurements across the studies included the use of et al. suggest that a combination of SLR and imaging can increase drugs, symptom recurrence, time off worand quality of life and specificity and sensitivity in LBP diagnosis in primary health care physiological indicators such as the Stork test and the Sit-and-Reach settings.There is wide variation in terms of the onset and test, both for physical fitness, in Gladwell et al’s trial.On the other duration of LBP in the samples. Gladwell et alconsider chronic hand, several inconsistencies were noticed. First of all, with respect LBP patients to be those who have had symptoms for more than to intervention there is no uniform physical/functional assessment twelve weeks; Donzelli et althree months; Rydeard et al.six nor eligibility criteria at the baseline of all the studies. For example, weeks and Vad et al.,‘at least three months. The authors also to assess and confirm the existence of LBP, patients in the Vad et al.
include vague and undefined categories such as ‘regular physical studyshould have documented evidence of disk pathology (e.g.
activity’ (Gladwell et al.and ‘sufficient intensity to restrict protrusion) as indicated by magnetic resonance imaging. Rydeard functional activity in some manner’ when recruiting LBP patients et al.measured the relative strength of the gluteus maximus muscle (Rydeard et alThere is little homogeneity in terms of control using the Lovett test and by visual observation to confirm the group intervention, varying between ‘routine’ or ‘standard inter- presence of LBP. Donzelli et al.established inclusion criteria for vention’ (Rydeard et al.)the Back School Program (Donzelli patients with a negative Laseque sign for a straight leg raise, and studier a; no intervention (Gladwell et al.and drug therapy Wasserman tests. Interestingly, Gladwell and colleagues looked at (Vad et Clearer definitions of ‘usual’ or ‘standard’ care are the use of drugs and pain in the lower back at the baseline.Similar needed. Rydeard et al. define usual care as ‘consultation with discrepancies were observed in terms of the intervention itself: a physician and other specialists and health care professionals as Gladwell et al.describe modified Pilates; Vad et al.the Back Rx necessary’,but standard care may also include analgesics, program (which includes Pilates), Donzelli, Pilates Cova Techand leaflets,or electrotherapy and general exercise.It is impor- Rydeard et al. mention specialized Pilates exercise equipment tant to emphasize that standard care for LBP patients needs to be manufactured by Pilates Reformer, Balance Body Sacramento CA.
redefined if included in future research.
Overall, all four studies lack formal power and sample size calculation and employed relatively small samples and therefore alllack generalizability, meaning that results cannot be extrapolated This review explores the clinical effectiveness of Pilates in LPB to the wider LBP population. Furthermore, the limited sample sizes patients. Very few studies have been identified that investigate in these trials did not allow us to perform a meta-analysis.
the effectiveness of the Pilates method for the treatment of LBP The potential limitation of this review is that the authors did not patients. There was one good study (Rydeard et al., 2006in include such key words as pelvic floor, core stability, core strength, which the risk of bias was relatively low. Reasonably high transversus abdominis and multifidius in their search strategy, since homogeneity is observed across all studies in terms of outcome strengthening core stability and the above-mentioned muscles is one measures. All the reviewed papers focus on functional disability of the purposes of the Pilates method. However, if the authors had and pain. Nevertheless, this review indicates that there is included these key words this approach could be criticized for limiting heterogeneity at various levels including methodology, physical the Pilates method to strengthening the pelvic floor muscles only.
examination, population, the intervention itself and the outcome Also, from the methodological standpoint comparing and contrasting measures. For instance, the duration of the interventions ranged Pilates as an intervention with trials that focus on core stability per se from six weeks (Gladwell et al. stud) to twelve months (Vad only was not feasible, as Pilates focuses on a more global approach et alDespite the fact that Rydeard et al.conducted the including coordination, endurance, flexibility, cognitive processes and highest-quality clinical trial of those included in this review, the self-awareness. Some researchers have written that the important subjectivity inherent in measuring the strength of the gluteus elements of improving back pain, including biological, educational, P. Posadzki et al. / Complementary Therapies in Clinical Practice 17 (2011) 85e89 and psychological aspects, are encompassed within the principles of 15. Latey P. Updating the principles of the Pilates method. J Bodyw Mov Ther Pilates training and that therefore this method should be regarded as 16. Sekendiz B, Altun O, Korkusuz F, Akın S. Effects of Pilates exercise on trunk strength, endurance and flexibility in sedentary adult females. J Bodyw MovTher; 2007; Nov;(4):318e26.
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