Aladro Et Al., (2012). Pilates-based Exercise for Persistent, Non-specific Low Back Pain and Associated Functional Disability. a Meta-Analysis With Meta-regression

8/9/2019 Aladro Et Al., (2012). Pilates-based Exercise for Persistent, Non-specific Low Back Pain and Associated Functional Disability. a Meta-Analysis With Meta-regression

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recreation, family and community) and functional disability[FD] (Asghari and Nicholas, 2001 ; Woby et al., 2004 ; Mannionet al., 2001 ). Additionally research has found that perceivedpain scores demonstrated a strong correlation with disabilitymeasures ( Lackner et al., 1996 ; Waddell et al., 1993 ).

Treatment options for LBP can be placed into two cate-gories, activeand passive ( Kirkaldy-Willis and Bernard,1999 ).One increasingly common exercise regimen suggested for patients with LBP is Pilates-based therapeutic exercise,adapted and simplied from the traditional and modernPilates Method, which usually is dened as a comprehensiveminde body conditioning method with the main goals of ef-cient movements, core stability and enhanced performance(Akuthota and Nadler, 2004 ; Muscolino and Cipriani, 2004 ).

Pilates-based therapeutic exercise has been introducedin the physical therapy community in recent years toimprove rehabilitation programs ( Bryan and Hawson, 2003 ).Return to functional activities has also been a primaryobjective since the method encourages movement earlier in the treatment process by providing the necessary assis-tance ( Anderson and Spector, 2000 ).

Several studies have aimed at documenting the benetsof this modied method in decreasing LBP ( Maher, 2004 ;Sorosky et al., 2008 ; La Touche et al., 2008 ). Recently twosystematic reviews proposed that there is some evidencesupporting the effectiveness of Pilates-based exercises inthe management of LBP. Posadzki et al. (2011) useda simple descriptive approach to summarise their results,alerting that no denite conclusions can be drawn. Limet al. (2011) used a meta-analytical approach and addeduseful information about the magnitude of the effect ofPilates on pain relief and disability when compared to other forms of exercise or minimal intervention.

Despite the aforementioned attempts to summarise andintegrate the results of selected trials, up till now,a regression analysis for predictor variables on treatmenteffectiveness has not been applied.

Thus, the objectives of this study were to systematicallyreview and apply regression analysis to the RCTs thatevaluated the effectiveness of Pilates exercise aimed atimproving persistent, non-specic LBP and associated FD,and to provide practical and clinically precise information.

Methods

Data sources and searches

A computerised electronic search was performed to iden-tify relevant articles. The search was conducted on MED-LINE (1950e March 2011); CINAHL (Cumulative Index toNursing and Allied Health Literature) (1982 e March 2011);SPORTDISCUS (1975e March 2011); ProQuest Dissertations &Theses (1980 e March 2011); ScienceDirect (1990 e March2011) and Scholar Google. The terms used were PilatesAND low back pain AND randomised controlled trial ORsystematic review and Pilates AND low back functionaldisability AND randomised controlled trial OR systematicreview. Key words relating to the domains of randomisedcontrolled trials and back pain were used, as recommended

by the Cochrane Back Review Group [CBRG] ( Bombardier et al., 2006 ).

One reviewer (MMD) screened search results for poten-tially eligible studies, and 2 reviewers (MMD, AAG) inde-pendently reviewed articles for eligibility. A thirdindependent reviewer (GAV) resolved any disagreementabout inclusion or exclusion of trials.

Study selection

The reviewers followed a selection protocol, developed prior to the beginning of the review that included a checklist for inclusion and exclusion criterion. Articles were eligible for inclusion if they were a) RCTs comparing Pilates exercisewith a PT, MI or APT; b) studies carried out on individuals ofall age groups and sex with LBP and FD; c) RCTs reportingthat a criterion for entry was persistent non-specic LBP(with or without leg pain) of at least 6 weeks duration (notattributable to any specic disease) or recurrent LBP with atleast 2 painful incidences per year; d) RCTs describing anyrestriction or loss of ability associated with LBP, if they re-ported that a criterion for entry was functional disability; e)RCTs that reported one of the following outcome measures:pain or disability; f) RCTs that reported the mean outcome(e.g., means, standard deviations and sample sizes); and g)studies that were not restricted to any specic language.

Articles were excluded if they were a) studies that werenot RCTs; b) RCTs that did not provide sufcient informa-tion for the calculation of effect size (i.e., means, standarddeviations and sample sizes for the comparison betweengroups); and c) RCTs with inconsistent or internal discrep-ancies in data.

This systematic review followed the recommendationsof the PRISMA statement ( Moher et al., 2009 ).

Data extraction and quality assessment

The rst analysis was based on the understanding of theinformation provided by the title and abstract. The articlesselected from the rst analysis were studied in depth usingthe full text in the data extraction phase. Two independentreviewers (MMD, AAG) extracted data from each study thatwas included using a standardised extraction form. Meanscores, standard deviations, and sample sizes wereextracted from the trials. When there was insufcientinformation about outcomes to allow data analysis, theauthors of the study were contacted.

The methodological quality of the trials was assessedusing the PEDro scale ( Maher et al., 2003 ) with scoresextracted from the PEDro database. The PEDro Scaleincludes 11 items that, overall, aim to evaluate four fundamental methodological aspects of a study such as therandom process, the blinding technique, group comparison,and the data analysis process. The reliability of this scalewas evaluated with acceptable results in intraclass corre-lation coefcients (ICC) Z 0.56 (95% CI Z 0.47 e 0.65) for ratings by individuals, and ICC for consensus ratings Z 0.68(95% CIZ 0.57 e 0.76) (Maher et al., 2003 ).

Assessment of the quality of trials in the PEDro databasewas performed by 2 trained independent raters, and

disagreements were resolved by a third rater ( Sherringtonet al., 2000 ).

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Data synthesis and analysis

The data were grouped into two treatment contrasts: (1)Pilates-based exercise versus minimal intervention (nointervention, general practitioner care, education), and (2)Pilates-based exercise versus another physiotherapeutictreatment.

The calculation of the effect size was used as an esti-mator of treatment effects ( Hedges, 1981 ). Severaldifferent methods have been proposed for the calculationof effect size. In this analysis, Thomas and Frenchs formulawas used for the calculation of ES ( Thomas and French,1986). This formula is: ES Z [(Postest EG Postest CG)/SDPostest CG ], where EG Z experimental group (i.e., Pilatesgroup), CG Z comparison group, SD Z standard deviation.

Because studies with small samples sizes may havea biased treatment effect, each ES was then multiplied by acorrection factor designed to yield an unbiasedestimate of effect size ( Thomas and French, 1986 ). This

correction factor is: ES correction Z

ES C, whereC Z 1 [3/(4 M 1)], and where M Z nCG 1 (nCG :number of participants in the comparison group).

Supplemental procedures (e.g., formulas for estimatingpooled ES weighted and coding the studies) are describedas attachment material.

Testing homogeneityTo determine whether all ESs of the studies reviewed werehomogeneous, and whether they represented a similar measure of treatment effectiveness, a test for homogeneitywas conducted. The homogeneity statistic ( H ) was used totest the null hypothesis, H 0: ES1 Z ES2 Z . Z ESi. Whenthe null hypothesis was not rejected, all ESs were similar and represented a similar measure of treatment-effectiveness, and the opposite. For this analysis thefollowing formula ( Thomas et al., 2005 ) was used:H Z P Division ES2=Variance P DivisionES=Variance 2=P Variance Reciprocal . Under the null hypothesis, H hasa chi-square distribution with N 1 degrees or freedom,where N equals the number of ESs.

Weighted regressionRegression procedures were conducted to determine thepresence of predictor variables on the treatment effec-tiveness ( Thomas and French, 1986 ). This technique wasrealised for ESs signicantly different from zero. Each ES

was weighted by the reciprocal of its variance in theweighted regression technique. The sum of square total for the regression was equivalent to the homogeneity statistic,H . A non-signicant test of model specication indicatedthat the ESs did not deviate substantially from the regres-sion model, which suggested that several features prior coding did not have any inuence on the treatment effec-tiveness, and the opposite ( Thomas et al., 2005 ).

Accounting for publication biasWe estimated the number of studies sitting around in ledrawers using the following formula: K o Z [(k(d pooled ES d EStrivial ))/ d ES trivial ], where K o is the number of studies needed

to produce a trivial ES, K is the number of studies in themeta-analysis, d pooled ES is the mean of all the ESs in the

meta-analysis, and d ES trivial is the estimate of a trivial ES(e.g., 0.15) ( Hedges and Olkin, 1985 ).

Statistical analysis was performed using SPSS , version15.0.

Results

The initial electronic database search resulted in a total of19 articles potentially eligible based on their title andabstract; of these, 9 ( Rydeard et al., 2006 ; Donzelli et al.,2006; Anderson, 2005 ; Gagnon, 2005 ; Quinn, 2005;MacIntyre, 2006 ; Limba da Fonseca et al., 2009 ; Gladwellet al., 2006 ; OBrien et al., 2006 ) were considered for inclusion in this review ( Fig. 1). Reasons for exclusion areshown in Fig. 1 for those articles that were excluded in thescreening stage ( Curnow et al., 2009 ; Rodrguez-Fuentes andOtero-Gargamela, 2009 ; Ribeiro-Machado, 2006 ; Ya Li,2005). Only 1 author did not reply to our inquiries ( Curnowet al., 2009 ), two authors contacted ( Rodrguez-Fuentes

and Otero-Gargamela, 2009 ; Donzelli et al., 2006 ) sentinformation to us on a new trial for inclusion or exclusion.

A number of trials that were not included in previoussystematic reviews of Pilates-based exercises wereincluded in this review ( Table 1 ). One new unpublished trial(MacIntyre, 2006 ) and one RCT (Limba da Fonseca et al.,2009) that were not included in any of the previouslypublished reviews were included in this review ( Table 1 ).

Methodological quality

Agreement among the 2 reviewers was almost high(ICC Z 0.89) (Atkinson and Nevill, 1998 ). The methodo-

logical quality assessment using the PEDro scale revealeda mean score of 5.5 (range Z 3e 9). One trial (11.1%) didnot consider a point measurement and measurements ofvariability. The groups were similar at baseline in 88.8% ofthe trials. Blinding of the therapist and blinding of thesubject were not used in any of the trials, as would beexpected for an exercise therapy study. An intention-to-treat analysis was used in 22.2% of the trials, allocationconcealment and dropouts were present in 33.3% and 44.4%of the trials respectively. Eligibility criteria were the onlyaspect reported in 100% of the trials. One of the articles(Donzelli et al., 2006 ) included in the review receiveda score of 3 on the PEDro scale and was the only quasi-randomized controlled trial.

Study characteristics

The 9 RCTs included in this review compared Pilates exer-cise against APT (e.g., therapeutic massage, traditionaldynamic lumbar stabilisation exercises, back school andstandard physiotherapy) or Pilates exercise against MI (e.g.,no intervention, usual care, normal exercise or sportsregimes) ( Table 2 ). No placebo RCT was identied. Seventrials assessed the efcacy of Pilates on both variable ofinterest (i.e., LBP and FD) ( Rydeard et al., 2006 ; Donzelliet al., 2006 ; Anderson, 2005 ; Gagnon, 2005 ; MacIntyre,2006; Gladwell et al., 2006 ; OBrien et al., 2006 ). Two

trials just assessed LBP ( Limba da Fonseca et al., 2009 ) or FD (Quinn, 2005 ) in that order ( Table 1 ).

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Overall the female sample (142 subjects) was twice thesize of the male sample (81 subjects). The age of thesubjects ranged from 30 to 50 y ( Table 1 ).

Pilates regimes were heterogenic in term of frequency(range Z 1e 3 times/wk) and number of sessions(range Z 6e 24). Only in one trial were there 10 consecu-tive sessions ( Donzelli et al., 2006 ). The typical sessionlength was usually similar between trials, predominantly60 min per session, performed on mats (i.e., Pilates mat-work) and studio equipment (i.e., Pilates studio appa-ratus). Rydeard et al. (2006) , Donzelli et al. (2006) andMacIntyre (2006) used specic rehabilitation methods (i.e.,Biokinetik Exercise Technique, Pilates CovaTech and STOTT

Pilates respectively) derived from the original Pilatesmethod and its basic principles ( Table 2 ). The use of

certied therapist for Pilates was unreported, except inone trial ( Anderson, 2005 ).

Four trials used co-interventions (e.g., analgesicintake, physiotherapy treatment, home exercise pro-gramme) in the experimental designs ( Rydeard et al.,2006; Gagnon, 2005 ; MacIntyre, 2006 ; Gladwell et al.,2006). In one trial ( Gladwell et al., 2006 ), Pilates exer-cise was applied as an additional intervention to the drugtreatment ( Table 2 ).

Pilates versus minimal intervention

Of the 6 trials (169 subjects) included in this treatmentcontrast, 5 trials (147 subjects) compared Pilates with MI

Figure 1 Flow chart of systematic review inclusion and exclusion. RCTs Z randomised controlled trials.







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Table 1 Details of the included randomised controlled trials.

Article Patient characteristics, sample size, andduration of complaint

Outcomes (measure) Article included inprevious reviews

Pilates versus another therapeutic treatmentAnderson, 2005 Volunteers recruited from local clinicians

which physicians, surgeons and therapies.Age 30e 58 yMain exclusion criterion: Signicant weaknessof the lower extremities, pregnancy, recentabdominal surgery.N Z 21Gender: 10 Female, 11 MaleDuration of LBP: (mean SD): Pilates group,18.1 (27.0) mo; massage group, 58 (103.7) mo

Pain (MBI-Pain)Disability (ODQ)

Included in Lim et al.,2011

Gagnon, 2005 Patients recruited from Sports Medicine Group.Age 18e 45 yMain exclusion criterion: Positive neural signs,any serious pathology preventing exercise,

workers compensation or motor vehicle cases.N Z 12Gender: 9 Female, 3 MaleDuration of LBP: > 3 mo in 5 patients, < 3 mo in1 patients for Pilates group > 3 mo in 4patients, < 3 mo in 2 for lumbar stabilizationexercises.

Pain (VAS)Disability (ODQ)

Included in Lim et al.,2011

Donzelli et al.,2006

Volunteers recruited from outpatientdepartments.Age 20e 65 yMain exclusion criterion: Structuraldeformities, neurological values outside thenormal range, disk hernia, spinal surgery.N Z 40Gender: 26 Female, 14 MaleDuration of LBP: > 3 mo for both groups. a


Included in La Toucheet al., 2008 and Limet al., 2011

OBrien et al.,2006

Patients recruited from medical generalpractitioner clinics.Age 25e 65 yMain exclusion criterion: Nerve rootcompression signs, recent spinal fracture,tumour, or infection; co-morbidities or contraindications to exercise.N Z 28Gender: 9 Female, 19 MaleDuration of LBP: overall, 10.9 (7.7) mo.

Pain (VAS)Disability (RMDQ)

Included in Posadzkiet al., 2011 and Limet al., 2011

Pilates versus minimal interventionGladwell et al.,

2006Patients recruited via posters, letters given inclinics and e-mail information.Age 29e 54 yMain exclusion criterion: Back pain attributedto any specic pathology. Major surgery withinthe past year.N Z 34Gender: 26 Female, 8 MaleDuration of LBP: Pilates group, 115 (101) mo;minimal intervention group, 139 (148) mo.


Included in La Toucheet al., 2008 ; Posadzkiet al., 2011 and Limet al., 2011

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Table 1 (continued )

Article Patient characteristics, sample size, andduration of complaint

Outcomes (measure) Article included inprevious reviews

Limba daFonsecaet al., 2009

Patients recruited from waiting list for physiotherapeutic treatmentAge 21e 47 yMain exclusion criterion: prior back surgery or radiological signs of spinal instability.N Z 14Gender: 12 Female, 5 MaleDuration of LBP 6 moa

Pain (VAS) Not included in previousreviews

Rydeard et al.,2006

Subjects were recruited through notices postedto private and public physicians andphysiotherapists ofces, local sports clubs andUniversities.Age 20e 55 yMain exclusion criterion: prior spinal surgery or spinal fracture, evidence of overt neurological

compromise or acute inammatory process,pregnant.N Z 39Gender: 25 Female, 14 MaleDuration of LBP: (mean [range]): Pilates group,66 [6e 324] mo; minimal intervention, 108 [12e 240] mo.

Pain (NRS-101)Disability (RMDQ-HK)

Included in La Toucheet al., 2008 ; Posadzkiet al., 2011 and Limet al., 2011

MacIntyre,2006

Participant recruited voluntarily from a privatephysiotherapy practice.Age 25e 62 yMain exclusion criterion: Previous or currentparticipation in a Pilates or back class program,spinal surgeryN Z 32Gender: 25 Female, 7 MaleDuration of LBP: Pilates group, 27.0 (22.2) mo;minimal intervention, 20.4 (19.0) mo


Not included in previousreviews

Quinn, 2005 Volunteers recruited from local commercialand community-tness center via yers.Age 27e 53Main exclusion criterion: No speciedN Z 22Gender: No speciedDuration of LBP 6 moa

Disability (ODQ) Included in Lim et al.,2011

OBrien et al.,2006

Patients recruited from medical generalpractitioner (GP) clinics.Age 25e 65 y

Main exclusion criterion: Nerve rootcompression signs, recent spinal fracture,tumour, or infection; co-morbidities or contraindications to exercise.N Z 28Gender: 9 Female, 19 MaleDuration of LBP: overall, 10.9 (7.7) mo.


Included in Posadzkiet al., 2011 and Limet al., 2011

Abbreviations: VAS Z visual analog scale, MBI-Pain: Miami Back Index Pain Sub-Scale, NRS-101: 101-point numerical rating scale,ODQ Z Oswestry Disability Questionnaire, RM Z Roland-Morris Disability Questionnaire, RM-HK Z Roland e Morris Questionnaire Chineseversion.

a Duration of complaint as inclusion criterion.







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Table 2 Details of the interventions and main outcomes in the included randomised controlled trials.

Article Interventions Preintervention Postintervention PEDro score c

Pilates versus another therapeutic treatmentAnderson 2005 Experimental group: Pilates

apparatus.Regime: 50 min., 2 time/wk, 12 sessions.Comparison group:therapeutic massage.Regime: 30 min, 2 time/wk,12 sessions.

Pilates: MBI-pain, 33.5(18.6); ODQ, 16.7 (4.2)Therapeutic massage: MBI-pain, 39.3 (15.6); ODQ, 18.5(5.9)

Pilates: MBI-pain, 24.2(14.7); ODQ, 13.9 (5.7)Therapeutic massage: MBI-pain, 35.0 (18.0); ODQ, 17.9(7.2)

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Gagnon 2005 Experimental group: Pilatesmatwork.Regime: 30 e 45 min., 1.43time/wk, 10.5 sessions andPT.Comparison group:traditional dynamic lumbar

stabilization exercises.Regime: 30 e 45 min., 1.46time/wk, 9.67 sessions andPT.

Pilates: VAS, 2.0 (1.7); ODQ,15.8 (3.7)Lumbar stabilizationexercise: VAS, 3.8 (2.5);ODQ, 17.2 (6.1)

Pilates: VAS, 0.9 (1.7); ODI,7.0 (5.9)Lumbar stabilizationexercise: VAS, 1.5 (1.7);ODQ, 9.1 (7.5)

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Donzelli et al.,2006

Experimental group:bPilates CovaTech matwork.Regime: 60 min., 10.5consecutive sessions.Comparison group: BackSchool.Regime: 60 min., 10.5consecutive sessions.

Pilates CovaTech: VAS, 7.3(2.2); ODQ, 13.6 (7.0)Back School: VAS, 6.8 (3.1);ODQ, 10.0 (6.5)

Pilates CovaTech: VAS, 4.5(2.1); ODQ, 6.9 (3.9)Back School: VAS, 4.3 (3.0);ODQ, 7.7 (6.2)

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OBrien et al.,2006

Experimental group: Pilatesmatwork and apparatus.Regime: 60 min., 2 time/wk, 8 sessionsComparison group: standardphysiotherapy (i.e., manualtherapy, education, corestability exercises,stretches, McKenzie,interferential, orthotics,taping and/or laser).Regime: 30 min., 2 time/wk, 8 sessions

Pilates: VAS, 61.6 (6.5);RMDQ, 10.7 (1.9)Standard physiotherapy:VAS, 54.7 (6.5); RMDQ, 9.5(1.8)

Pilates: VAS, 17.2 (7.7);RMDQ, 1.7 (0.7)Standard physiotherapy:VAS, 17.8 (6.9); RMDQ, 4.2(1.5)

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Pilates versus minimal interventionGladwell et al.,

2006Experimental group: Pilatesmatwork as an additionalintervention.Regime: 60 min, 1 times/wk, 6 sessions.Comparison group: normaldaily activities, drug (i.e.,analgesics) and no exercise.

Pilates: VAS, 2.7 (0.9); ODQ,19.7 (9.8)Control: VAS, 2.4 (0.9);ODQ, 24.1 (13.4)

Pilates: VAS, 2.2 (0.9); ODQ,18.1 (11.2)Control: VAS, 2.4 (0.8);ODQ, 18.1 (13.0)

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Limba daFonsecaet al., 2009

Experimental group: PilatesmatworkRegime: 60 min. 2 times/wk, 15 sessions.Comparison group:maintenance normal daily

activities, non-drugs.

Pilates: VAS, 5.9 (2.0)Control: VAS, 6.1 (1.8)

Pilates: VAS, 3.0 (3.4)Control: VAS, 4.9 (2.5)

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for pain relief ( Rydeard et al., 2006 ; MacIntyre, 2006 ;Limba da Fonseca et al., 2009 ; Gladwell et al., 2006 ;OBrien et al., 2006 ) and 5 trials (155 subjects) for reducing disability ( Rydeard et al., 2006 ; Quinn, 2005;MacIntyre, 2006 ; Gladwell et al., 2006 ; OBrien et al.,2006). The methodological quality of the articles rangedfrom 5 to 8 ( Table 2 ). The pooled results of comparingPilates exercise with MI showed a statistically signicantdifference for pain relief (pooled ES weighted Z 0.44,95% CIZ 0.09 to 0.80) ( Fig. 2). This difference in painscore was moderate according to ES interpretation (i.e.,ES 0.2 poor or weak; between 0.3 and 0.7 moderate; and

0.8 high or strong) ( Thomas et al., 2005 ). When esti-mating the publication bias for this treatment contrast, 9

studies with ES trivial Z 0.15 would have to be present, for the results to be threatened.

There was no evidence that Pilates exercise was effec-tive for improving disability (pooled ES weighted Z 0.28,95% CIZ 0.07 to 0.62) ( Fig. 2).

Pilates versus another physiotherapeutic treatment

Of the 9 studies included in this review, 4 trials (101patients) compared Pilates with APT in both variables ofinterest ( Donzelli et al., 2006 ; Anderson, 2005 ; Gagnon,

2005; OBrien et al., 2006 ). The methodological qualityof the articles ranged from 3 to 7 ( Table 2 ). There was

Table 2 (continued )

Article Interventions Preintervention Postintervention PEDro score c

Rydeard et al.,2006

Experimental group: Pilatesmatwork and apparatus.Regime: 60 min. 3 times/wk, 12 sessions, plus homeexercise program.Regime: 15 min. 6 times/wkComparison group: healthusual care, analgesics, PT asneeded and no exercise.

Pilates: NRS-101, 23.0 (1.7);RMDQ, 3.1 (2.7)Control: NRS-101, 30.4(1.7); RMDQ, 4.2 (3.3)

Pilates: NRS-101, 18.3 (1.4);RMDQ, 2.0 (1.3)Control: NRS-101, 33.9(1.4); RMDQ, 3.2 (1.7)

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MacIntyre,2006

Experimental group: a STOTTPilates matwork.Regime: 60 min.1 time/wk,12 sessions and normalexercise or sports regimes,PT as needed; plus homeexercise program

Regime: 10 min. 3 times/wk, 10 sessions.Comparison group: normalexercise or sports regimesand PT as needed.

Pilates: VAS, 5.1 (2.0);RMDQ, 7.0 (3.1)Control: VAS, 4.8 (1.7);RMDQ, 7.4 (3.4)

Pilates: VAS, 3.4 (2.7);RMDQ, 4.6 (2.3)Control: VAS, 1.8 (3.1);RMDQ, 2.2 (3.6)

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Quinn, 2005 Experimental group: Pilatesmatwork.Regime: 45 e 60 min., 2time/wk, 24 sessions.Comparison group:maintenance normal dailyactivities and no exercise.

Pilates: ODQ, 25.9 (10.7)Control: ODQ, 22.0 (8.7)

Pilates: ODQ, 10.9(10.3)Control: ODQ, 18.0 (12.4)

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OBrien et al.,2006

Experimental group: Pilatesmatwork and apparatus.Regime: 60 min., 2 time/wk, 8 sessionsComparison group: noexercise.

Pilates: VAS, 61.6(6.5);RMDQ, 10.7 (1.9)Control: VAS, 48.7 (6.2);RMDQ, 7.0 (1.9)

Pilates: VAS, 17.2(7.7);RMDQ, 1.7 (0.7)Control: VAS, 52.0 (7.3);RMDQ, 6.2 (1.5)

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Abbreviation: PT Z Physiotherapeutic treatments.a STOTT Pilates is an anatomically-based approach to the original method that emphasizes neutral alignment, core or trunk stability

and peripheral mobility.b Pilates CovaTech is a specic rehabilitation method derived from the original Pilates method in Italy and takes the name from the

therapist who invented it.c Higher scores indicating better methodological qualities of trials.







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a moderate and signicant difference between treat-ment groups in disability score (pooled ESweighted Z 0.55, 95% CIZ 0.08 to 1.03) ( Fig. 3). For this treatment contrast, 10 studies would have to beunpublished with ES trivial Z 0.15, for the outcome to bethreatened.

The pooled results of the comparison between Pilatesexercise and APT did not show statistically signicantdifferences for pain relief (pooled ES weighted Z 0.14,95% CIZ 0.27 to 0.56).

Results for testing homogeneity and weightedregression

The test for homogeneity showed that treatment contrastfor pain relief: Pilates against MI [ H Z 125.29 >0.95 X 2 Z 9.48 with 4 degrees or freedom] and treatmentcontrast for disability: Pilates against ATT[H Z 101.95 > 0.95 X 2 Z 7.81 with 3 degrees of freedom] didnot represent a similar measure of treatment effectiveness.

When the effects of particular features prior coding(e.g., quality of the trials, duration of complaint, regime ofPilates, performed on mats as opposed to studio equip-ment, age of the patients, BMI, use of certied therapist)on treatment contrast that were statistically signicant,

were evaluated, the statistics model used did not detectany predictor variable ( Table 3 ).

Discussion

This systematic review provides evidence that Pilates-basedexercise is moderately superior to minimal intervention for pain relief in subjects with persistent, non-specic LBP(Fig. 2). However, the presence of co-interventions (e.g.,analgesic intake, physiotherapy treatment as needed) in thePilates exercise groups of 2 trials ( MacIntyre, 2006 ; Gladwellet al., 2006 ) was an aspect that could have raised the effectmagnitude, contributing to the increased pain relief. Thismethodological issue compromised internal validity; there-fore, when assessing the impact of the co-interventions onthis treatment contrast, a sensitivity analysis with exclusionof trials with co-interventions ( MacIntyre, 2006 ; Gladwellet al., 2006 ) was performed. When the trials with co-interventions were deleted, the effect size unexpectedlyincreased considerably (i.e., pooled ES weighted Z 1.12,95% CIZ 0.60 to 1.64) for pain relief. Nevertheless, thiswas the nding of 3 trials, and more research is needed toconrm the results.

The pooled results showed Pilates-based exercise ismoderately superior to another physiotherapy treatment inreducing disability. Interestingly, this nding was based onpooled datafrom4 different trials (i.e., therapeutic massage,traditional dynamic lumbar stabilisation exercises, backschool and standard physiotherapy) where Pilates was not

superior to these particularly prescribed treatments ( Table 2 ).On the other hand, these pooled results were biased by the

Figure 2 Forest plot of the results of trials comparing Pilates-based exercises with minimal interventions for LBP and FD. Valuespresented are effect size (with correction factor) and 95% condence interval. The pooled effect sizes were calculated usinga weighting by variance reciprocal.







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used of co-intervention in 1 trial ( Gagnon, 2005 ), but, whenthis study was deleted, the effect size unexpectedlyincreased slightly (i.e., pooled ES weighted Z 0.62, 95%CI Z 0.10 to 1.14) for the disability score.

This systematic review did not nd evidence thatPilates was superior to minimal intervention in reducingdisability, nor superior to another physiotherapytreatment for pain relief, because the pooled results didnot show statistically signicant differences ( Figs. 2and 3).

When looking at the quality of the trials included in thisreview, a mean score of 6 can be considered a moderatescore because these trials were exercise trials where it isimpossible to blind the treatment provider and subjects,and, therefore, the maximum PEDro score that can beachieved is 8. Trials that associated Pilates against minimalintervention scored > 6. However, trials associating Pilatesagainst another physiotherapy treatment were of lower methodological quality (mean score Z 5), and according toCBRG (Furlan et al., 2009 ) potentially presented biasedestimates of treatment effectiveness. The implicationsassociated with the poor methodological quality of thestudies reviewed affecting the observed effects were well-

described in previous systematic reviews ( Lim et al., 2011 ;Pereira et al., 2011 ).

On the other hand, the test for homogeneity showedthere was some source of additional variation that couldbe related to the effect of moderator variables. Anintriguing nding was that the effect sizes did not deviatesubstantially from the weighted regression model. Thisoutcome suggests that the small number of trialsincluded in the study limits the potential merits ofa meta-regression approach. It is also possible thatseveral features not coded a priori that could haveinuenced the treatment effectiveness, were linked topsychological impairments (e.g., pain perception, fear-avoidance behaviour, neurological feedback from thedeep muscles of the trunk, low self-efcacy and cata-strophizing), physical impairments (e.g., weakness,endurance and structural integrity), characteristics oftreatment implementation (e.g., the experience of thePilates instructor in the management of the specialcharacteristic of the subjects, progression), pain copingstrategies (e.g., behavioural and cognitive approach,behavioural and cognitive avoidance), environmental andsocial factors.

The main limitations of this meta-analysis were in thereview process (e.g., only a few studies assessing the most

important outcomes of interest) and generalizability (e.g.,limited data for persistent LBP and the review was not able

Figure 3 Forest plot of the results of trials comparing Pilates-based exercises with another physiotherapeutic treatment for LBP

and FD. Values presented are effect size (with correction factor) and 95% condence interval. The pooled effect sizes werecalculated using a weighting by variance reciprocal.







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to offer dosage parameters). The authors did not limit theset for the quality assessment score of the RCTs, because itwould restrict the possibility of accomplishing meta-regression. Limitations between studies were the smallsample sizes, the large variation in intervention protocols(e.g., Pilates regimes: frequency and progression, andPilates type: performed on mats as opposed to studioequipment), the absence of placebo controlled trials, theshort-term follow-up and the absence of assessment oftreatment adherence.

When comparing the strengths of this review in relationto other studies, the authors limited the set for studydesign (e.g., RCT), and detected that there is a source ofadditional variation that can affect the independentmanner the effectiveness of the treatment, and measuredhow many studies were involved in the le drawersproblem. The results found in this systematic review weresimilar to those presented by Lim et al. (2011) . In addition,this review included 2 new trials ( MacIntyre, 2006 ; Limbada Fonseca et al., 2009 ) that were not included by Limet al. (2011) , accounting for the addition of 49 subjects.However, the results found in this systematic review weredifferent to those presented by Pereira et al. (2011) .Basically, the difference was determined by the inclusionin this review, of studies with serious methodologicalaws.

In the authors opinion, future trials could also consider

the preventive actions of Pilates-based exercise to reduceepisodes of LBP and associated functional disability.

Conclusions

The results of this systematic review suggest that Pilates-based therapeutic exercise is moderately superior to minimalintervention for pain relief and confers similar benets whencompared with pooled scores to another physiotherapeutictreatment. Although co-interventions with Pilates, mightenhance treatment effectiveness for pain relief; thisconclusion should be interpreted with caution.

Pilates is moderately better than another physiother-apeutic treatment in reducing disability, and providescomparable benets to minimal intervention. The lowmethodological quality of the studies reviewed, and the

heterogeneity of the physiotherapy treatment showedestimate bias of the treatment effectiveness for reducingdisability; thus, it is recommended that Pilates should becarefully considered for patients with functional disabilityassociated to LBP.

The optimal implementation of Pilates exercise atpresent is unclear. Future studies should incorporateplacebo controlled trial, larger sample sizes, interventionprotocols that are comparable, assessment of the severalfeatures not coded in this review and longer term follow-up.

Conict of interest

None.

Table 3 Summary of the regression model for sizes effect signicantly different of zero.

Particular variables Pilates versus minimal interventions

Pain

R2 F -value P -value k

Age 0.033 0.102 0.771 5BMI 0.046 0.097 0.785 4Duration of complaint 0.074 0.240 0.657 5Quality of the study 0.044 0.137 0.736 5Number of session of Pilates 0.003 0.008 0.935 5Frequency of the session (time/wk) 0.210 0.797 0.438 5Duration of the session (in min) B e e e eType of Pilates class 0.310 1.347 0.330 5Certied instructors 0.757 9.337 0.055 5

Particular variables Pilates versus another therapeutic treatment

Disability

R2 F -value P -value k

Age 0.0393 1.294 0.373 4BMI5 e e e eDuration of complaint 0.393 1.315 0.370 4Quality of the study 0.702 4.713 0.162 4Number of session of Pilates 0.011 0.022 0.896 4Frequency of the session (time/wk) 0.363 1.139 0.398 4Duration of the session (in min) B 0.051 0.108 0.773 4Type of Pilates class 0.007 0.014 0.915 4Certied instructors 0.586 2.836 0.234 4

Abbreviations: k Z number of trials; BMI Z Body mass index; B Constant variable for the trials reviewed; 5 Not reported on the trialsreviewed.







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Appendix A. Supplementary material

Supplementary material associated with this article can befound, in the online version, at http://dx.doi.org/10.1016/j.jbmt.2012.08.003 .

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