Effects of Pilates Exercises on Shoulder Range Of

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doi: 10.2522/ptj.20070099Published online January 24, 2008PHYS THER.

Donna L MacIntyreKim S Keays, Susan R Harris, Joseph M Lucyshyn andWomen Living With Breast Cancer: A Pilot Study

inMotion, Pain, Mood, and Upper-Extremity FunctionEffects of Pilates Exercises on Shoulder Range of

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Effects of Pilates Exercises on Shoulder

Range of Motion, Pain, Mood, andUpper-Extremity Function in WomenLiving With Breast Cancer:A Pilot StudyKim S Keays, Susan R Harris, Joseph M Lucyshyn, Donna L MacIntyre

Background and PurposeThe purpose of this study was to examine the effects of Pilates exercises on shoulder

range of motion (ROM), pain, mood, and upper-extremity (UE) function in womenwho had been treated for breast cancer.

ParticipantsThe participants were 4 women who had undergone axillary dissection and radiationtherapy for stage I to IV breast cancer.

MethodsA nonconcurrent, multiple-baseline, single-subject research design was used to ex-amine the effects of Pilates exercises on the 4 outcomes.

Results

Visual analyses of the data suggest a modest effect of the Pilates exercise program inimproving shoulder abduction and external rotation ROM. Statistically significant

improvement in shoulder internal and external rotation in the affected UE was shownfor the one participant with pre-existing metastatic disease. The improving baselinesseen for pain, mood, and UE function data made it impossible to assess the effects ofPilates exercises on those outcomes. No adverse events were experienced.

Discussion and ConclusionPilates exercises may be an effective and safe exercise option for women who arerecovering from breast cancer treatments; however, further research is needed.

KS Keays home address is #202-2475 Bayswater St, Vancouver,British Columbia, Canada V6K4N3. Address all correspondence

to Ms Keays at: [email protected] Harris, PT, PhD, FAPTA, is Pro-fessor, Department of PhysicalTherapy, Faculty of Medicine, Uni-versity of British Columbia, Van-couver, British Columbia, Canada.

JM Lucyshyn, PhD, is AssociateProfessor, Education & Counsel-ling Psychology and Special Edu-cation, Faculty of Education, Uni-versity of British Columbia.

DL MacIntyre, PT, PhD, is Associ-ate Professor, Department of

Physical Therapy, University ofBritish Columbia.

[Keays KS, Harris SR, Lucyshyn JM,MacIntyre DL. Effects of Pilates ex-ercises on shoulder range of mo-tion, pain, mood, and upper-extremity function in womenliving with breast cancer: a pilotstudy. Phys Ther. 2008;88:xxxxxx.]

2008 American Physical TherapyAssociation

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For women who have beentreated for breast cancer, reha-bilitation aims to restore inde-

pendence and self-sufficiency whilefocusing on quality of life (QOL).1

Although conventional forms of ex-ercise or physical therapy29 anddance therapy10 for women withbreast cancer have been studied, thecomplementary exercise known asPilates has not been researched incancer rehabilitation. Complemen-

tary therapies aim to improve QOLby addressing issues of the body,mind, and spirit and symptom man-agement11 and are used by up to80% of women with breast cancer.12

We examined the effects of Pilates

exercises on shoulder range of mo-tion (ROM), pain, mood, and upper-extremity (UE) function in women

who previously had been treated forbreast cancer.

Systematic searches of PubMed,MEDLINE, CANCERLIT, and CINAHL(1983-July 2007) revealed no studiesthat had examined the effects ofPilates exercises on women withbreast cancer. Key words used in

the searches were breast cancer,breast neoplasm, Pilates, radia-tion, axillary dissection, andrehabilitation.

Axillary dissection (AD) for breastcancer staging and application of ra-diation therapy to the breast or axillacan contribute to reduced shoulder

mobility,4,1318 lasting up to 8 yearsafter treatment.14 Postoperative ex-ercise programs can prevent shoul-der stiffness and enhance ROM16

without leading to lymphedema.4,15

Shoulder pain, another side effect ofAD,13,14,1719 can result from radia-tion fibrosis, surgical scarring, or in-tercostobrachial nerve damage18 and

can persist from months to years af-ter surgery,14 negatively influencingmood and QOL.14 Anxiety, depres-sion, anger, and poor body image areother common sequelae19 that cancontinue despite improved physical

function.20 Emotional well-being(mood) is a significant predictor ofQOL,1 with emotional distress asso-

ciated with surgery-related pain.17

Exercise has been shown to de-

crease anxiety5

and improve self-esteem,7vigor,6 and satisfaction withlife.20

Women with long-term survival afterbreast cancer tend to have poorerfunctional status than women who

have not had breast cancer.21 Re-duced shoulder ROM after axillarysurgery and radiation is related toreduced functional ability.18

Pilates ExercisesOriginally called Contrology, Pi-lates is an exercise approach devel-oped in the early 1900s that is based

on Eastern theories of body-mind-spirit interaction combined with

Western theories of biomechanics,motor learning, and core stabili-ty.22,23 Spirit encompasses emo-tional well-being,24 and mind-bodyexercise incorporates an inwardly di-rected, nonjudgmental focus andspecific attention to breathing and

proprioception.25

During a Pilatesexercise session, mental effort fo-cuses on activating specific musclesin a functional sequence at con-trolled speeds, emphasizing quality,precision, and control of movement.Exercise repetitions rarely exceed10, with resistance usually in theform of body weight or springs. Pro-

ponents of Pilates exercises claimthat regular practice leads to relax-ation and control of the mind, en-hanced body- and self-awareness,improved core stability, better coor-dination, more ideal posture, greater

joint ROM, uniform muscle develop-ment, and decreased stress.23,26

The effects of Pilates exercises ondancers posture, strength (force-generating capacity), and tech-nique,2731 as well as on muscle con-traction,32 body composition, andflexibility in adults who are healthy,33

have been studied. Pilates exercisehas been recommended to preventand rehabilitate overuse injuries in

ballet dancers34 as well as to treatgroin35 and foot and ankle36 injuries.

Despite the increasing popularity ofPilates exercises, their effects havenot been studied in individuals withchronic disease.

Because its proponents claim thatregular Pilates exercise leads to in-

creased joint ROM23,26 (which cantranslate into improved UE func-tion18) and decreased stress,23,26

we chose to examine the effects ofPilates exercises on shoulder ROM,pain, mood, and UE function in

women who had received AD andradiation therapy for stage I to IVbreast cancer37 at least 6 months

prior. We hypothesized that a Pilatesexercise program would increaseshoulder ROM, decrease pain, en-hance mood, and improve UEfunction.

MethodStudy Design

A nonconcurrent, multiple-baseline,

single-subject research design (SSRD)was used.38 Well suited to rehabilita-tion settings,39 SSRD allows isolationof variables directly contributing tochanges in performance.40 System-atic, repeated measurement of a tar-get behavior during both baselineand intervention phases (with eachparticipant serving as his or her own

control)39 allows for comparisonsbefore, during, and after an interven-tion within each participant.

To control for history and matura-tion, 4 participants were randomlyassigned to baselines of 3, 5, 7, or 9sessions of repeated measures.38

Baselines of varying lengths estab-

lished the preintervention rate ofperformance and served as a com-parison after intervention was intro-duced, thus strengthening the evi-dence that intervention effects werenot due to extraneous variables to

Pilates Exercises in Women With Breast Cancer

2 f Physical Therapy Volume 88 Number 4 April 2008



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which participants were exposed.Phase changes were made based onshoulder ROM data, the primary out-come measure. Intervention was

introduced after the preselectedbaseline if the ROM baselines dem-

onstrated stability.38When a baselinefailed to exhibit stability, it was ex-tended until stability was attained oruntil the intervention had to begindue to social validity concerns (ie,the unacceptability of an extendedbaseline to participants). To examine

the effects of the independent vari-able on the dependent variables overtime, follow-up data were collectedapproximately 4 weeks after comple-tion of the intervention.

Participants and SettingParticipants were 4 volunteers whohad undergone AD and completed

radiation therapy for stage I to IVbreast cancer at least 6 months prior

and who had restricted shoulderROM secondary to breast cancertreatments (ie, a limitation of10between the surgical and nonsurgi-

cal shoulders in flexion, abduction,internal rotation [IR], or external ro-

tation [ER]).14 One participant hadprevious experience with Pilates ex-ercise. To recruit participants, an ar-ticle was published in the provincialbreast cancer newsletter, posters ad-

vertising the study were distributedto local cancer support groups and

posted in the provincial cancer cen-ter and community centers aroundthe city, e-mail messages were sentto local breast cancer dragon boatteams, and announcements were

made at local breast cancer forums.Women who were undergoing che-motherapy; had a history of bilateralbreast cancer; were attending regu-

lar physical therapy, chiropractic,massage therapy, or psychological

counseling sessions; or had previousshoulder injuries or other healthproblems were excluded. Partici-pant demographic information is

presented in Tables 1 and 2. Signedinformed consent was acquired from

all participants.

The Pilates exercise and data collec-tion sessions took place at MeridianPilates Studio in Vancouver, BritishColumbia, Canada, typical of manycommunity-based Pilates exercise

studios in existence today. Thehome exercise sessions took place inthe participants homes.

Outcome Measures

Shoulder ROM. We defined shoul-der ROMas the range through whichthe participant could move theshoulder while maintaining a neutral

thorax. Measurements were takenwith a single plastic, 30.48-cm (12-

Table 1.Participant Background Information

Participant

No.

Age (y) Highest

Level of

Education

Completed

Marital

Status

Dominant

Arm/Hand

Other Current

Activities

1 71 University Widowed Right Walking

2 66 University Married Right Walking

3 38 University Married Right Walking/running

4 51 University Divorced Right Walking/running

Table 2.Participant Treatment Information

Participant

No.

Diagnosis Year of

Diagnosis

Stage at

Diagnosis

Affected

Side

No. of

Nodes

Dissected

No. of

Nodes

Involved

Surgery Radiation

1 Invasive ductal

carcinoma

2002 III Left 17 0 Lumpectomy Left breast

2 Invasive ductal

carcinoma

2002 II Right 18 2 Complete right

breast

mastectomy

Right mid-axilla

3 Invasive ductal

carcinoma

2001 IV Left 6 6 Bilateral mastectomy Left chest wall

4 Invasive lobular

carcinoma

2003 I Left 16 0 Bilateral

mastectomy,

reconstruction

(tissue expander,

silicone implants)

Left chest wall





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in) universal goniometer with theparticipant positioned supine on aplinth-like platform, using standard-

ized procedures41 to measure ROM.Range of motion was measured in a

supine position to decrease variabil-ity related to placement of the tho-rax. Active shoulder flexion, abduc-tion, IR, and ER (with the shoulderin 90 of abduction) were measuredbilaterally, using the unaffectedshoulder (measured first) for com-

parison. Three consecutive measure-ments were taken in each plane,

with trials averaged for the finalscore. Because there are no pub-lished data for what constitutes aminimal detectable change for

ROM measurements, we used themeasurement difference for interra-ter agreement in our study, which

was 7 degrees (see Interrater Agree-ment section).

Level of pain. Pain was assessedusing the Brief Pain InventoryShortForm (BPI),42 a 15-item, self-administered tool developed for usein patients with cancer. The BPI pro-

vides information on pain intensity

and the degree to which pain inter-feres with function and QOL. Frontand back views of a human figure on

which the participant shades the ar-eas of pain and 7 pain interferencequestions (eg, How much has yourpain interfered with general activityover the past 24 hours?) comprisethe BPI. Items are rated on an 11-

point scale, with lower scores indi-cating less pain. The test takes about10 minutes to complete and hasshown respectable test-retest itemcorrelations over short intervals.42

Mood state. Mood was assessedusing the Profile of Mood StatesShort Form (POMS),43 which rates a

variety of mood states usinga 30-item adjective checklist rated ona 5-point Likert scale. Total mooddisturbance is calculated by sum-ming the scores of the 6 POMS fac-tors and then subtracting that score

from the vigor subscale score. Alower score indicates less mood dis-turbance. Test-retest reliability esti-

mates (rtt) range from .65 for thevigor subscale to .74 for the depres-

sion subscale.43

Concurrent validity(r.80, P.01) was demonstratedbetween the Tension-Anxiety sec-tion of the POMS and the TaylorManifest Anxiety Scale.43

UE functioning. A 12-item, self-report questionnaire was used toenable each participant to assessthe functional status of the affectedUE. Tasks require a combination ofmovements through a variety ofshoulder ranges, representing typi-

cal daily activities. Items are scoredon a 10-point Likert scale from nodifficulty with the task to com-

pletely unable to do the task. Thequestionnaire was modified fromthat used by Wingate8 and expandedfrom 5 to 10 points to enhance re-sponsiveness.16 Lower scores indi-cate improved UE function. Box etal16 attempted to validate 10 of the12 tasks by examining their associa-tions with shoulder ROM. Significant

associations (P.05) were reportedfor 6 of the 10 tasks with a variety ofdifferent shoulder movements (ie,abduction, flexion, extension, IR,and ER).16

UE circumference. Circumfer-ence measurements of both UEs atrecommended anatomical land-

marks44 were collected weekly as asafety guide for potential lymphed-ema. If a difference of 2 cm hadbeen noted at any landmark, the par-ticipant would have been referred toher oncologist and to a physical ther-apist for in-depth assessments. Re-sults of a previous study of circum-ferential measures of both UEs in

women who had been treated forbreast cancer showed high inter-rater reliability (intraclass correlationcoefficient.99) and test-retest reli-ability (intraclass correlation coeffi-cient.99).45

Intervention and Data CollectionPilates intervention. The samecertified Pilates exercise instructor

conducted most of the sessions,based on exercises described by

Stott Pilates.46

When that instructorwas unavailable, another certifiedinstructor led the exercise programs.Sessions were 1 hour long, 3 timesper week, for 12 weeks (Appendix1). We used a generic, whole-bodyexercise program in this study be-

cause we believed it is most acces-sible (in terms of class offerings at atypical studio or gym, as well ascost per class) to the average womanand may be most commonly offeredat studios and gyms in North Amer-

ica. Participants began with pre-Pilates exercises and individualizedstretches, progressing to beginner-

level exercise and, when appropri-ate, to intermediate-level exercises.Progression was based on assess-ment of the participants workinglevel (ie, the level at which the par-ticipants could be safely in theirbody, making appropriate neuro-muscular connections while still be-ing challenged). Equipment was

manufactured by Peak Pilates.* Par-ticipants also were given a Pilatesexercise program to perform athome, 1 time per week, for 12 weeks(Appendix 2).

Data collection. A trained rater(not blind to study phase or hypoth-esis) collected all baseline and inter-

vention data at the studio where theintervention took place. Measure-ments were collected in the sameorder, at the same time of day, on thesame day of the week. During bothbaseline and intervention phases,shoulder ROM data were collected2 times per week, whereas pain,mood, and UE function data were

collected 1 time per week. Follow-updata were collected on the same dayof the week and time of day as dur-

* Peak Pilates, 5555 Central Ave, Suite 200,Boulder, CO 80301.





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ing the baseline and interventionphases.

Interrater AgreementA physical therapist trained the 2

study raters. A woman who had un-dergone AD and radiation for breastcancer was measured while thephysical therapist guided the ratersthrough standardized shoulder ROMmeasurement procedures.41 The rat-ers repeated the procedure 5 more

times, without the physical thera-pists guidance, with 2 women whohad been treated for breast cancerand a woman who had not beentreated for breast cancer.

Interrater agreement was conductedfor 20% of all ROM data collectionsessions, balanced across study

phases. To account for lack of pri-mary rater blinding, a trained out-side rater, blind to study phase andhypothesis, served as the secondrater for these sessions. Differencesof7 degrees were considered ac-ceptable interrater variability.47 In-terrater agreement was 74%. To pre-

vent observer drift, the rater and co-

investigator periodically reviewedprocedures for ROM measurementand questionnaire administrationover the course of the study.

Treatment IntegrityTo ensure that the Pilates exerciseinstructor was adhering to the studyprotocol, a Pilates exercise instruc-

tor trainer monitored one session foreach participant after being pro-

vided with a sheet outlining the ex-ercises. We required adherence tothe basic choreography and Pilatesexercise principles, with flexibilityfor images and visualizations used

with each participant. In all 4 cases,the trainer confirmed that the Pilates

exercise instructor was adhering tothe protocol. For the intervention tobe complete, participants couldmiss no more than 15% of the super-

vised Pilates exercise sessions. ThePilates exercise instructor standard-

ized and documented the exercisesperformed during each session.

Data AnalysisGraphed data were analyzed visually

using standard rules of evidence forSSRD.40 Levels, trends, and variabil-ity within and across phases wereanalyzed for all repeated measureson all participants, and data paths

were compared across participants.Level represents changes in magni-

tude of the data, conveyed by changesin the mean level for each phase (ie,average rate of performance across 2or more phases).40 Trend is the di-rection of change within a phase. Anaccelerating trend moves in an up-

ward direction, whereas a decelerat-ing trend progresses downward.40

Trends for all data paths were de-

termined using the Microsoft Excel

linear regression option. To aid invisually analyzing trends, baselinetrend lines were extended into inter-

vention and follow-up phases. Thenumber of data points above and be-low the extended trend lines, acrossphases, was compared to determinethe intervention effect.40 Variability

refers to the amount of fluctuation in adata series.40

Statistical analysis was conducted us-ing ITSACORR, an interrupted time-series analysis software program.48

Using an omnibus F test to deter-mine significance of overall changein intercept and slope between base-

line and intervention phases with5data points, ITSACORR controls forautocorrelation. Analyses were per-formed only on ROM data sets in

which all participants had baselinephases of 5 data points. Signifi-cance was set at P.05.

ResultsThroughout the results, unaffectedrefers to the untreated UE and af-fected refers to the surgical or irra-

diated UE. For shoulder ROM, an ac-celerating trend indicates increasingrange, and a decelerating trend indi-

cates decreasing range. Deceleratingtrends for pain, mood state, and UE

functioning suggest improvement. Itis important to note that trends inSSRD do not relate to statistical sig-nificance (or lack thereof) but ratherto the direction of the data paths.

Shoulder ROMUnaffected UE. Based on changesin average level from baseline to in-tervention, all participants improvedin shoulder flexion and ER. Partici-

pants 1 and 3 also showed improvedabduction and IR, and participant 4also showed improved abduction.

No change in level was observed forparticipant 2 in abduction, and dete-rioration occurred for participants2 and 4 in IR (Figs. 1, 2, 3, and 4).Improving trends were seen forparticipant 1 in flexion, abduction,and IR; for participant 2 in IR only;for participant 3 in abduction, IR,and ER; and for participant 4 in ER

only. Participant 2 changed from adeteriorating to a stable trend for ab-duction. Improving baseline trends,followed by an improving or stabletrend during intervention, were seenfor participant 2 for shoulder flexionand for participant 4 for shoulderflexion and abduction.

For participants 1 and 3, most shoul-der flexion intervention data points

were above baseline trend lines(Fig. 5). For participant 2, almost allintervention data points were be-low or on the baseline trend line,

whereas all intervention data pointswere below the baseline trend linefor participant 4. For shoulder ab-

duction, the majority of interventiondata points for participants 1, 2, and3 were above baseline trend lines(Fig. 6); all except one interventiondata point for participant 4 was be-low the baseline trend line.

Microsoft Corp, One Microsoft Way, Red-mond, WA 98052-6399.





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For shoulder IR, the majority of in-tervention data points for all partici-pants were above baseline trend

lines (Fig. 7). For ER, the majority ofintervention data points were above

the baseline trend lines for partici-pants 1, 3, and 4 (Fig. 8) but themajority of intervention data points

were below the baseline trend linefor participant 2.

Based on visual analyses, only 2 par-

ticipants showed change that ex-ceeded the measurement differencefor interrater agreement (7), which

we interpreted as the minimal de-tectable change: Participant 1 in-creased average shoulder ER by 14

degrees, and participant 4 increasedaverage shoulder flexion by 12 de-grees, shoulder abduction by 12 de-

grees, and shoulder ER by 18 degrees.

Affected UE. All participants im-proved in average level of ER frombaseline to intervention. Participants1, 2, and 4 also improved in flexionand abduction. Average levels ofshoulder flexion and abduction de-teriorated slightly for participant 3

(by 1 and 2, respectively ). No par-ticipant improved in average level ofIR from baseline to intervention. Achange in trend, from stable or de-teriorating to improving, was seen inparticipants 1 and 2 for all 4 planesof movement and in participant 3for abduction and IR. An improvingbaseline trend (followed by an im-

proving or stable trend during inter-vention) was seen for participant 4for flexion, abduction, and ER, as

well as for participant 3s ER.

For shoulder flexion, all except oneintervention data point for partici-

4

Figure 1.Shoulder flexion: mean level lines andtrend lines for each phase. Graphs are or-ganized from shortest to longest baseline

for ease of interpretation. UEupperextremity.





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pants 1 and 2 were above baselinetrend lines (Fig. 5). The majority ofintervention data points for partici-

pant 3 and all data points for partic-ipant 4 fell below baseline trend

lines. For shoulder abduction, themajority of intervention data pointsfor participants 1, 2, and 3 were abovethe baseline trend lines (Fig. 6), withall intervention data points for partici-pant 4 below the baseline trend line.

For shoulder IR, the majority of inter-vention data points for participants 1,2, and 3 were above the baseline trendlines (Fig. 7). For ER, the majority ofintervention data points were abovethe baseline trend lines for partici-

pants 1, 2, and 4 (Fig. 8). For partici-pant 3, all intervention data points

were below the baseline trend line.

Based on visual analyses, participant1 showed 2 changes that exceededthe measurement difference for in-terrater agreement (7): averageshoulder flexion increased by 10 de-grees, and average ER increased by18 degrees. For participant 2, aver-age shoulder abduction and ER on

the affected side increased by 18 and12 degrees, respectively. Participant4 showed improvement in averageshoulder flexion (17), abduction(24), and ER (23).

Level of PainDuring the baseline phase, all partic-ipants showed decelerating trends,

indicating decreasing pain (Supple-mental Figs. 1 and 2, available onlineonly at: www.ptjournal.org). Afterintervention, the average level ofpain continued to decrease for par-ticipant 1, whereas data for partici-

3

Figure 2.Shoulder abduction: mean level lines andtrend lines for each phase. Graphs are or-ganized from shortest to longest baseline

for ease of interpretation. UEupperextremity.





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pants 3 and 4 exhibited no trend(average pain score of 0). At the1-month follow-up, participants 1, 3,

and 4 had pain scores of 0.

For participant 2, average level ofpain increased from baseline to inter-vention. Both baseline and interven-tion phases demonstrated decelerat-ing trends (indicating a decreasinglevel of pain), but the slope of theintervention trend line was not as

steep as that of the baseline trendline.

Mood StateParticipants 1, 2, and 4 demonstratedimproving mood (decelerating trends)

during the baseline phase (Supple-mental Fig. 3, available online onlyat: www.ptjournal.org). This improve-

ment continued into the interventionphase, but did not accelerate asquickly (Supplemental Fig. 4, availableonline only at: www.ptjournal.org).For participants 2 and 4, follow-updata points suggested greater mooddisturbance. For participants 1, 2, and4, the majority of intervention datapoints were above the baseline trend

lines, whereas all data points for par-ticipant 3 were below the baselinetrend lines.

UE FunctioningDuring the baseline phase, partici-pants 1, 3, and 4 reported improvingUE functioning (decelerating trends)prior to introducing the Pilates exer-

cise program (Supplemental Fig. 5,available online only at: www.ptjour-nal.org). During intervention, im-provement continued (deceleratingtrends) for participants 1 and 3. Forparticipant 4, the level of function-ing was stable during intervention,

4

Figure 3.Shoulder internal rotation: mean levellines and trend lines for each phase.Graphs are organized from shortest tolongest baseline for ease of interpretation.UEupper extremity.





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showing an average score of 12(range1113).

At follow-up, UE functioning had de-teriorated for participant 1 when

compared with the mean of the last3 data points in the interventionphase (Supplemental Fig. 6, availableonline only at: www.ptjournal.org).For participant 3, the follow-up datapoint (29 points) was 3 points aboveboth the last data point in the inter-

vention phase (26 points) and themean for the intervention phase (26points), suggesting deterioration.For participant 4, the level of func-tioning was the same at follow-up asthat seen during intervention. For

participant 2, baseline data wererelatively stable, with an average UEfunctioning score of 24 (range21

28). During intervention, slightly de-creased function occurred, with anaverage score of 22 (range1926).Function was further decreased atfollow-up (at 30 points).

For participant 1, all except one in-tervention data point was above thebaseline trend line. For participant 2,

almost as many intervention datapoints were above as were belowthe baseline trend line. For partici-pants 3 and 4, all intervention datapoints were above the baseline trendline.

Statistical Analysis of ShoulderROM

Although some of the changes notedin the foregoing sections may havebeen clinically relevant to individ-ual participants, the only analysesthat indicated statistically significantchange were those for participant

3

Figure 4.Shoulder external rotation: mean levellines and trend lines for each phase.Graphs are organized from shortest tolongest baseline for ease of interpretation.UEupper extremity.





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3s affected UE shoulder IR (P.028)and ER (P.049) ranges.

Treatment AdherenceAdherence to the supervised exer-

cise sessions ranged from 86% to94%. To monitor adherence to homeexercise, participants were asked atthe start of each intervention weekhow many of the home program ex-ercises had been completed. Adher-ence to home exercise sessions for

participants 1 to 4 was 100%, 100%,33%, and 92%, respectively.

DiscussionShoulder ROM

When all participants unaffected UE

ranges were considered, 13 of 16comparisons showed improved lev-els, and 8 of 16 comparisons

showed improved trends. Seven of16 comparisons showed improve-ment in both average level and trendfrom baseline to intervention: forparticipant 1 in shoulder flexion, ab-duction, and ER; for participant 3 inabduction, IR, and ER; and for partic-ipant 4 in ER.

For affected UE ranges, 10 of 16comparisons showed improved lev-els from baseline to intervention,and 10 of 16 comparisons showedimproved trends. Overall, 6 of 16comparisons showed improved lev-els and trends (flexion, abduction,and ER for participants 1 and 2),suggesting a modest functional ef-

fect of the Pilates exercise programon improving these ranges in 2participants.

Based on visual analyses, participant1 showed the greatest improvementin shoulder ROM following imple-

4

Figure 5.Shoulder flexion: baseline trend line ex-tended into intervention and follow-up.Graphs are organized from shortest tolongest baseline for ease of interpretation.UEupper extremity.





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mentation of the intervention, butonly 3 of these changes exceededthe accepted measurement differ-

ence for interrater agreement. Worthnoting is that participant 1 was only

6 months following radiation treat-ment when she joined the study. Shealso was the oldest participant (71

years of age); had the highest overallscores for pain, disturbed mood, anddifficulty with UE functional tasks;and showed the most impaired af-

fected shoulder ROM in flexion, ab-duction, and ER when compared

with the other participants, despitebeing the only one who had not hada mastectomy.

One month after completing the in-tervention, participant 2 was diag-nosed with metastases to the patel-

lae and skull, suggesting that she wasliving with metastatic cancer whiletaking part in the Pilates interven-tion. Even with metastatic cancer,participant 2 improved in both leveland trend for shoulder flexion, ab-duction, and ER in the affected UE.

Although participant 3 was the only

one to show statistically significantchange in affected shoulder ROM forIR and ER, visual analysis suggeststhat she may have experienced theleast change of the 4 participantsdue to the Pilates exercise program.That is, her changes in level frombaseline to intervention across allranges were the smallest, and, in 3

planes (flexion, abduction, and IR)in the affected UE, average ROM de-creased from baseline to interven-tion. She did show increases, how-ever, in both level and trend forshoulder abduction, IR, and ER in theunaffected UE.

3

Figure 6.Shoulder abduction: baseline trend lineextended into intervention and follow-up.Graphs are organized from shortest tolongest baseline for ease of interpretation.UEupper extremity.





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Secondary Dependent MeasuresLevel of pain. Except for partici-pant 1, high levels of pain at the

study outset were not reported. Av-erage pain level decreased by 2 to 11

points from baseline to interventionfor participants 1, 3, and 4 but in-creased by 1 point for participant 2,due perhaps to the undiagnosed pa-tellar metastases, as indicated by hermarkings on the body diagram. Thefact that all participants had decreas-

ing pain during the baseline phasemakes it difficult to conclude thatthe Pilates exercise program was re-sponsible for the further decrease inpain over the course of the study.

Mood state. All participantsshowed decreases in mood distur-bance from baseline to intervention.

However, the fact that mood wasimproving for participants 1, 2, and 4during the baseline phase makes itdifficult to conclude that improve-ment during intervention was due tothe Pilates exercises. At the 1-monthfollow-up, participant 4 showed adramatic increase in mood distur-bance, as compared with her mood

level during the last part of the inter-vention phase.

The POMS asked participants to ratetheir mood during the past week,including today and was completedprior to the exercise sessions. Partic-ipants reported feeling very relaxedand calm after the Pilates exercise

sessions, suggesting that the pro-gram may have had a transient effecton mood that the POMS was unableto detect. Participants 1 and 2 com-mented that they believed the POMS

4

Figure 7.Shoulder internal rotation: baseline trendline extended into intervention and

follow-up. Graphs are organized fromshortest to longest baseline for ease ofinterpretation. UEupper extremity.





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to be ineffective and inappropriateas an outcome measure.

UE functioning. While participants1, 2, and 4 improved in average level

of UE functioning from baseline to in-tervention, participants 1 and 4 alsoshowed trends toward improved func-tion during the baseline phase, makingit difficult to be sure that improvementduring intervention was due to the ex-ercises. Participant 3 showed an aver-

age level that deteriorated by 1 pointfrom baseline to intervention due, per-haps, to the fact that, on the day for

which she reported the most difficultywith UE functioning (the first day ofintervention), she was recovering

from a sinus infection and had beenbedridden for several days leading upto the Pilates exercise session. When

her data for day 1 of the interventionphase are ignored, her average level ofperformance for the baseline phase isthe same as for the intervention phase.

Strengths and Limitationsof the StudyThis was the first study to demon-strate an experimental effect of Pi-

lates exercises on shoulder ROM.Safety of Pilates exercises for womentreated for breast cancer, when un-der the direction of a certified in-structor, was shown as well as mod-est effects of Pilates exercises onmultiple outcome measures. Ourstudy demonstrated the feasibility ofusing an SSRD in a clinical setting

and adds to the limited literature onexercise for patients with metastaticcancer (ie, participant 3 had under-gone surgery and radiation for me-tastases to the brain 1.5 years priorto the study, and participant 2 was

3

Figure 8.Shoulder external rotation: baseline trendline extended into intervention and

follow-up. Graphs are organized fromshortest to longest baseline for ease ofinterpretation. UEupper extremity.





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diagnosed with metastases in thepatellae and skull 1 month aftercompleting the intervention). Both

women successfully completed theintervention and reported benefits

from it. Additionally, Pilates exerciseis increasingly being sought as a formof post-rehabilitation exercise for

which there is little scientific sup-port. This study adds to the limiteddata on Pilates exercises and patientpopulations.

The modest results seen in thisstudy may be due to the Pilates ex-ercises selected and the interven-tions length. The 3-month interven-tion was based on the conceptual

framework outlined originally by Pi-lates.26 Because our participants

were from a patient population, 3

participants were over age 50 years,and 2 participants had metastaticdisease, the exercises outlined inPilates book26 would have been in-appropriate. It also is possible thatthe participants might have neededmore than a 3-month intervention toshow dramatic change in ROM. Theprogram we used included several

exercises that required movementinto shoulder abduction and ER,

which might explain why thesewere the ranges that improved most.Only one exercise required notableIR, which may explain why the IRrange appeared to have been lessaffected by the program, based on

visual analyses. Additionally, the

Pilates exercise program was a ge-neric whole-body program. An indi-

vidualized, UE-specific program mighthave resulted in greater shoulderROM gains. It also is possible that theintensity of the exercise program wastoo low to elicit significant changesin shoulder ROM. Lastly, the cancermetastases diagnosed in participant 2

one month after completing the inter-vention may explain the lack of im-provement in her pain and UE func-tioning scores over the course of theintervention.

Testing effects may have threatenedinternal validity. Improving ROM,pain, mood, or function during the

baseline phase made it difficult toaccurately assess the intervention ef-

fects. Based on these pilot data, itappears that 3 baseline data pointsare not sufficient to establish stableshoulder ROM data. The need to ex-tend the baseline phases for 2 partic-ipants (participants 1 and 4) wasproblematic, as they were anxious to

begin the intervention. The lack ofreliability information for the UEfunction measure is another limita-tion, making it impossible to know

whether the changes in UE functionwere true changes or were due to

measurement error.

Because the primary rater worked at

the studio where the interventiontook place, it was impossible to blindher to the study hypothesis or phase.To account for this, we used a blindoutside rater for interrater agree-ment sessions. No standards exist for

what constitutes acceptable interra-ter agreement for shoulder ROM in

women treated for breast cancer.

Our interrater agreement was some-what below the usual standard of80%, despite a standardized measure-ment protocol and trained raters,suggesting that shoulder ROM maybe more variable in this population.

A study of patients with other typesof shoulder dysfunction47 supportsour findings. Hayes and colleagues47

investigated interrater reliability forshoulder flexion, abduction, and ERin patients with rotator cuff repair, ad-hesive capsulitis, or scapulothoracicfusion. Interrater correlation coeffi-cients (rs) ranged from .64 to .69, sug-gesting fair to good reliability.

Although a concurrent multiple-

baseline design would have beenstronger, we selected a nonconcur-rent design because it was notknown whether the intervention

would have an effect on shoulderROM. If ROM had improved after in-

troducing the intervention, it was ex-pected to be gradual, meaning thatparticipants would have had to re-

main in the baseline phase for longperiods of time. A longer follow-up

period would have allowed us to de-termine how long the improvedROM (where applicable) would lastin the absence of a thrice-weekly,supervised Pilates exercise program.

Although this was intended to be a

pilot study, the small number of par-ticipants limits the generalizability ofthe findings. Furthermore, the exer-cise dose may have differed slightlyacross participants, participants en-ergy levels differed, actual time

spent exercising per session mayhave varied (eg, participant 3 oftenstarted late and had to leave early),

and adherence to the home exerciseprogram differed. For participants

who improved in shoulder ROM, itwas impossible to sort out whetherthe improvement was due to theoverall Pilates exercise program or tospecific exercises.

Clinical Implications

None of the participants experi-enced adverse events in the study,suggesting that community-basedPilates exercise programs may besafe for women living with breastcancer. However, the effects of Pi-lates exercises on improving shoul-der ROM were limited and exceededmeasurement error only in 3 planes

(flexion, abduction, and ER) for 2 par-ticipants (participants 1 and 4) in theunaffected UE and in 3 planes (flex-ion, abduction, and ER) for 3 partici-pants (participants 1, 2, and 4) in theaffected UE.

Physical therapists should encour-age interested clients to seek out

trained Pilates exercise instructorswho have knowledge of breast can-cer and related cautions. Ideally,

women with breast cancer could be-gin with individual Pilates exercisesessions to ensure safe performance





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of exercises and proceed to groupclasses. Because of its low intensityand focus on neuromuscular repat-

terning, Pilates exercise would be asensible starting point from which

women could gradually return totheir regular activities after breastcancer treatments.

Rehabilitation is unlikely to have animpact if the intervention is not impor-tant, viable, and acceptable to con-

sumers. Study participants stated thatthey would recommend the Pilates ex-ercise program to other women living

with breast cancer, suggesting thatthey found the program acceptable.Pilates exercise may benefit women

with breast cancer in ways not exam-ined in our study. Although the par-ticipants in this study found the inter-

vention acceptable, it is unlikely thatmany women could afford to attendindividualized Pilates exercise sessions3 times a week for 3 months, as in ourstudy.

Suggestions for Future ResearchStudies with larger samples comparingPilates exercises with more typical

physical therapy exercise programswould be worthwhile, as wouldlonger interventions with more re-sponsive outcome measures. Random-ized controlled trials comparing dif-ferent exercise interventions (eg, stan-dard physical therapy, yoga, tai chi)

with Pilates exercise clearly areneeded. Individualized Pilates exercise

programs could be compared with thegeneric program provided in thisstudy, including cost-benefit analysesof the 2 approaches. Because thereare no standard definitions of re-duced shoulder mobility or accept-able shoulder ROM reliability afterbreast cancer, research to developsuch definitions would enable more

accurate comparisons across studies.

ConclusionNot every woman treated for breastcancer will develop impaired shoul-der ROM, but appropriate interven-

tions are necessary for those who dodevelop impaired shoulder ROM. Al-though more people are engaging in

Pilates exercise as a form of post-rehabilitation exercise therapy, few

patient-based studies have been con-ducted. Although further study isneeded, our preliminary data suggestthat Pilates exercise appears to havea modest effect on improving shoul-der abduction and ER.

Ms Keays, Dr Harris, and Dr Lucyshyn pro-vided concept/idea/research design andwriting. Ms Keays provided data collectionand facilities/equipment. Ms Keays and DrLucyshyn provided data analysis. Ms Keaysand Dr Harris provided project manage-

ment, fund procurement, and participants.Dr Harris provided institutional liaisons. DrHarris, Dr Lucyshyn, and Dr MacIntyre pro-vided consultation (including review ofmanuscript before submission).

This study was approved by the ClinicalResearch Ethics Board at the University ofBritish Columbia.

The study was undertaken in partial fulfill-ment of the requirements of Ms Keays de-gree of Master of Science in RehabilitationSciences.

This research was presented at the Canadian

Breast Cancer Research Alliance Conference(poster presentation); May 68, 2006; Mon-treal, Quebec, Canada, and at the Universityof British Columbia Womens Health Sympo-sium; October 2021, 2006; Vancouver,British Columbia, Canada.

Funding was provided by the CanadianBreast Cancer Research Alliance and NovartisPharmaceuticals.

This article was received March 28, 2007, and

was accepted December 10, 2007.

DOI: 10.2522/ptj.20070099

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Appendix 2.Pilates Home Programa

First month

Seated breathing

Anterior pelvic floor and transverse

abdominals isolation

Knee folds

Barbie arms

Spinal rotation/rib opener

Shell stretch

Hip rolls

Wall roll down

Second month

Change Barbie arms to arm circles

Change spinal rotation to around the

clock

Add:

Small weight and arm circles to wall roll

own

Spine twist seated

Mid-back Thera-Bandb pull

Third month

Add:

Abdominal preparation/100

Seated shoulder external rotation with

Thera-Band

Baby swan

a

For more information on the Pilates exercises,consult the Stott Pilates matwork manual (avail-able from Stott Pilates, 2200 Yonge St, Suite 500,Toronto, Ontario, Canada M4S 2C6;www.stottpilates.com).b The Hygenic Corp, 1245 Home Ave, Akron, OH44310-2575.

Appendix 1.Pilates Studio Programa

Exercise Progression/Notes

Barrels

Pectoral muscle stretch

over 2 arc barrels

Over12 foam roll, then full foam roll

Spine corrector side

stretch

With instructor assist

Cadillac

Roll down Arms crossed on bar

La ti ss imus dor si pull Si ngle a rm pul l

Reformer

Footwork

Abdominal preparation/

100

On mat first

Mid-back series Or on cadillac

Bend and stretch Or on cadillacBack rowing preparation Start sitting on long box, progress to without box once

able to sit comfortably

Front rowing preparation Straight arm pull

Short box Round back, straight back

Knee stretches Round back, straight back

Running

Mat

Swan Preparation

Thera-Bandb

Mid-back pull Seated

Shoulder externalrotation Seated, elbow at 90

a For more information on the Pilates exercises, consult the Stott Pilates Reformer and Cadillacmanuals (available from Stott Pilates, 2200 Yonge St, Suite 500, Toronto, Ontario, CanadaM4S 2C6; www.stottpilates.com).b The Hygenic Corp, 1245 Home Ave, Akron, OH 44310-2575.





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doi: 10.2522/ptj.20070099Published online January 24, 2008PHYS THER.

Donna L MacIntyreKim S Keays, Susan R Harris, Joseph M Lucyshyn andWomen Living With Breast Cancer: A Pilot Study

inMotion, Pain, Mood, and Upper-Extremity FunctionEffects of Pilates Exercises on Shoulder Range of

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