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21
R. bras. Ci. e Mov 2012;20(1):21-33
Contato:
Maria Gabriela Valle Gottlieb - maria.gottlieb@pucrs.br
Artigo Original
Effectiveness of pilates method for the posture
and flexibility of women with hyperkyphosis
Eficácia do método pilates para a postura e flexibilidade em mulheres
com hipercifose
Silvana Junges
1
Maria G. Gottlieb
1
Rafael R. Baptista
1
Carlos B. de Quadros
1
Thais de L. Resende
1
Irênio Gomes
1
1
Pontifícia Universidade Católica
do Rio Grande do Sul
Enviado em: 10/03/2011
Aceito em: 23/07/2012
RESUMO:
O objetivo do estudo foi avaliar a eficácia do método Pilates em melhorar a postura e a
flexibilidade em mulheres com hipercifose. Foi conduzido um ensaio clínico, controlado e randomizado
com 41 mulheres (média de idade= 59 ± 9 anos), divididas aleatoriamente em dois grupos: 22 no grupo de
intervenção e 19 no grupo controle. As participantes passaram por dois conjuntos iguais de mensurações,
antes e depois de um período de treinamento/ controle, que foram compostos por: características
sociodemográficas e clínicas, peso, altura, índice de massa corporal (IMC), percentual de gordura corporal
(três pregas cutâneas), razão quadril-cintura (medidas das circunferências). Além desses, o grau de cifose
foi mensurado pelo ângulo de Cobb através de um exame radiológico (Raio-X) com o paciente em pé, a
flexibilidade foi medida com um flexímetro e a postura analisada através de quatro fotografias (visão
anterior, perfil direito e esquerdo e posterior) com o software Fisimetrix. Todas as medições foram
realizadas pelo mesmo observador, que foi treinado e cegado quanto à alocação dos sujeitos. Os exercícios
foram realizados duas vezes por semana (60 minutos cada aula) durante 30 semanas. Antes do estudo, os
dois grupos não
diferiram estatisticamente em nenhuma das características analisadas. Após o estudo
foram detectadas diferenças significativas entre os dois grupos em termos de: ângulo da cifose torácica
(grupo experimental= -8,0 ± 7,5 graus; grupo controle= -0,6 ± 3,4 graus; p <0,001), flexibilidade de todos
os movimentos da região cervical e do tronco, IMC (p <0,001), percentual de gordura corporal (p <0,001)
e todos os movimentos (p <0,05), com exceção da flexão anterior do tronco. Portanto, o método Pilates é
eficaz em melhorar a postura e flexibilidade em mulheres mais velhas com hipercifose, bem como em
reduzir a gordura corporal.
Palavras-chave: Treinamento; Cifose; Postura; Flexibilidade; Composição Corporal.
JUNGES S, GOTTLIEB
MG, BAPTISTA RR, QUADROS CB, RESENDE TL,
GOMES I. Eficácia do método pilates para a postura e flexibilidade em
mulheres
com hipercifose; R. bras. Ci. e Mov 2012;20(1):21-33.
ABSTRACT:
The aim of the study was to evaluate the effectiveness of the Pilates method in improving
posture and flexibility in women with hyperkyphosis. A randomized controlled trial was performed with
41 women (mean age of 59 ± 9 years) randomized into two groups: 22 in the intervention group and 19 in
the control group. Subjects undertook two equal sets of assessment, before and after a training/ control
period, which comprised of sociodemografic and clinical characteristics, height, weight, body mass index
(BMI), body fat percentage (three skin fold measurement), waist-hip ratio (circumference measurements).
In addition to these, the degree of kyphosis was measured by the Cobb angle on a standing lateral
radiograph, flexibility was measured with a fleximeter and posture assessment was carried out with the
Fisimetrix software through four view photographs (front, right profile, left profile and back). All
measurements were carried out by the same observer, who was trained and blinded with respect to the
subjects’ group allocation. The exercises were carried out twice a week (60-minute class) for 30 weeks.
Before the study, the two groups did not differ statistically in terms of any of the characteristics analyzed.
After the study, statistically significant differences were found between the two groups in terms of:
kyphosis angle (experimental group = -8,0 ± 7,5 degrees; control group = -0,6 ± 3,4 degrees; p <0,001),
flexibility of all cervical region and trunk movements, BMI (p <0,001), body fat percentage (p <0,001) e
all body movements (p <0,05), except for trunk flexion. Therefore, the Pilates method is effective in
improving posture and flexibility in women with hyperkyphosis as well as reducing body fat.
Key Words: Training; Kyphosis; Posture; Pliability; Body Composition.
JUNGES et al.
R. bras. Ci. e Mov 2012;20(1):21-33
22
Introduction
In general, human posture undergoes modifications
over the years and several factors may influence the
maintenance and formation of the primary and secondary
curves of the spine. In anatomical terms, thoracic
kyphosis refers to the posterior primary curvature. In
some people, this curvature maintains its mobility, while
in others it becomes rigid and fixed
1
. After menopause,
sedentary women may show a change in this curvature,
increasing the kyphosis level (hyperkyphosis), altering the
axial and pelvic alignment. In more severe cases, it can
interfere with the pulmonary function and lead to an
unbalanced gait, which can decrease daily living
activities
2,3
. Additionally, in elderly people,
hyperkyphosis is associated with difficulties in daily
living activities and a decline in physical condition,
resulting in impaired metabolic functions, which may lead
to an increase in the mortality rate
4
. After the age of 55,
the excessive curvature and forward positioning of the
head causes a height decrease that ranges from 6% to
11%, besides increasing the fracture risk, independent
from the bone mineral density
5,6
.
Some studies show that physically active people
have less chance of developing kyphosis, compared to
sedentary people
2
. Back extension exercises as well as
exercises involving a greater number of muscle groups
may decrease the deformity or delay the deforming
process, helping on the maintenance of good posture
2,7
. In
this context, the Pilates method is said to be a movement
reeducation technique composed of exercises deeply
rooted in the human anatomy, able to restore and increase
flexibility and muscle strength, improve breathing, correct
posture and prevent injuries
1
.
In the Pilates method, the main exercises aim to
develop the strength of the extensor muscles of the back
and abdomen, particularly the abdominal transverse,
which refers to the center of strength and coordinates
breathing and movement
8
. When the center of strength is
weak, without stability and resistance, the movement in
the body’s distal portions is diminished, damaging the
proximal portions and increasing the stress on joints and
ligaments, thereby leading to degeneration. Through the
neuromuscular control technique, there is an increase on
the stability of this region, which leads to improvements
in posture and movement control
1
. One of the most
important elements in the application of this method is the
observation of the correct pelvic alignment, which allows
for the accurate performance of the movements and the
stability of the lumbar region
1
. This stability and
alignment leads to the alignment of the pelvis with the
diaphragm, which further enhances the trunk stability.
This facilitates the action of the abdominal transverse,
oblique and multifidus muscles, which are the back
stabilizers and act as its protectors, allowing freedom of
movement
9,10
. Recent investigations have demonstrated
that specific exercises for strengthening the multifidus
and abdominal transverse may contribute to the reduction
of lumbar back pain and the stability of all the spine
segments
9,10
.
Flexibility is limited by several factors: the shape
of the articular surfaces, adhesions, contracture and scars
on the soft tissues, and contraction components,
ligaments, tendons and fascia
5
. In the Pilates method,
exercises for flexibility are constantly carried out, mainly
in the hip and trunk’s extensor and flexor muscles.
In order to achieve total physical conditioning,
Joseph Pilates conceived his method aiming to purify the
bloodstream through oxygenation. When executing full
inspirations and expirations, there is an increase in the
efficiency of the gas exchange, bringing more energy and
vitalizing the whole system
11
. The breathing technique is
an important element for increasing oxygenation, as well
as aiding the venous return and the action of the lumbar
region stabilizer muscles. The pulmonary alterations
caused by the normal aging process are mainly caused by
the loss of elasticity of the pulmonary tissue and chest
wall
2
.
Despite the knowledge and the utilization of the
Pilates method worldwide, methodologically adequate
clinical trials proving the efficiency of this therapeutic
method are still scarce. This study, therefore, aimed to
evaluate the effectiveness of a physical training program
utilizing the Pilates method in improving posture and
flexibility in women with thoracic hyperkyphosis.
23
R. bras. Ci. e Mov 2012;20(1):21-33
Material and Methods
Study design: randomized Controlled Trial;
Sample: the volunteers were Caucasian women with a
radiological diagnosis of hyperkyphosis. The participants
were recruited from the city of Porto Alegre and its
metropolitan region in the state of Rio Grande do Sul,
Brazil. Recruitment was carried out via radio, newspapers
and internet. This study was conducted from April 2009
to December 2010. The Research Ethics Committee of the
Pontifícia Universidade Católica do Rio Grande do Sul
(PUCRS) approved the study (protocol no. 08/04448) and
individual informed consents were obtained from all
participants previous to their engagement.
Forty-one women over 45 years of age with
hyperkyphosis (Cobb angle > 45º) were included in this
study. The major exclusion criteria were: a body mass
index >30, previous or actual engagement in Pilates’
classes, a kyphosis angle smaller than 45º, and vertebrae
compression fracture or some other spine disease detected
by radiological diagnosis. Other reasons for excluding
from the study were an attendance rate lower than 30% or
engagement in another type of physical activity while in
the research program.
Subjects undertook two equal sets of assessment,
30 weeks apart. All measurements took place at the
PUCRS’s Physical Activity Laboratory and at the
Exercise Research Laboratory of the Universidade
Federal do Rio Grande do Sul. Participants underwent
laboratory tests, physical examination and interviews. The
first set of assessments took place soon after subjects
entered the study. After the first assessment was carried
out subjects were randomly allocated into two groups: the
experimental one (intervention) with 22 women and the
control group with 19 women (no intervention; see Flow
Diagram). No active or placebo intervention was
prescribed for the control group. Controls were asked to
carry on their normal activities for the next 30 weeks. The
exercise group underwent a 30-week Pilates training
period. At the end of the 30-week period, exercisers and
controls underwent the second set of measurements. All
measurements were carried out by the same observer,
who was trained and blinded with respect to the subjects’
group allocation.
Variables analyzed
Before and after the intervention, the following
data were collected from all the participants:
Life style and clinical conditions
Data were gathered on daily consumption of
alcohol, smoking, current engagement in any type of
exercises, if on any kind of a diet, medication intake and
any known disease or dysfunction.
Body mass index (BMI) was calculated by
dividing weight (kg) by the squared height (m2). Body
weight was measured using a scale (G. TEC, Oregon
Scientific) and height was measured using a stadiometer
(Cardiomed Seca).
The body fat percentage was calculated by the
measurement of skin folds – using a scientific plicometer
(Cescorf) and a protocol for functional assessment
(Jackson and Pollock) of three skinfolds (triceps,
suprailiac and thigh). The absolute values of skinfold
thickness used individually or as a sum of skinfolds are
quite useful for determining the results obtained with
training programs.
Waist-hip ratio was determined from the
circumference measurements. A flexible metal tape
(Sanny Medical) was used. The waist circumference was
measured at the midpoint between the last rib and the iliac
crest; the hip circumference was measured at the point of
greatest gluteal protuberance.
Posture assessment was carried out by four view
photographs (front, right profile, left profile and back).
The posture analyses were carried out with the Fisimetrix
software.
Flexibility was measured with a fleximeter
(Fleximeter - Code Research Institute) using a flexibility
protocol. The analysis was carried out using the angles of
the cervical column (flexion, extension, and rotation and
lateral flexion of both sides), hip (flexion, extension,
abduction and adduction of right and left legs), shoulders
Flow Diagram
JUNGES et al.
R. bras. Ci. e Mov 2012;20(1):21-33
24
(flexion, extension, adduction and abduction of right and
left sides) and trunk (flexion, extension and lateral flexion
of the right and left sides).
The degree of kyphosis was measured by the Cobb
angle taken from a standing lateral X-rays.
Training Protocol Study
Training was carried out in twice a week in 60-
minute sessions, for a total of 30 weeks. Basic level
Pilates method exercises were used. The degree of
difficulty of the exercises was gradually increased and
their focus was on keeping a neutral posture in different
gravity orientations. Exercises were carried out in an open
and closed sequence, with variations on the floor and
devices. Training of all participants was provided by the
same instructor.
Planning and periodization - Macro cycle
Three macro cycles were used as shown below.
• 1st Macro cycle - (6 weeks) - Period of neural
adaptation; general exercises at the Pilates basic
level and diaphragmatic deep breathing
exercises.
• 2nd Macro cycle - (20 weeks) - Inclusion of
specific exercises to strengthen and stretch.
Strength: trunk extensors, latissimus dorsi,
serratus anterior, rotator cuff and abdominal
muscles. Stretching: chest, abdominal,
intercostal, iliac-psoas, trapezius and cervical
muscles. Throughout this period the series were
maintained while the training resistance was
increased with the use of springs and variations
of the joint angles and distance.
• 3rd Macro cycle - (4 weeks): Maintenance of
resistance, stretching and relaxation techniques.
This period involved exercises using specific
devices of the method (Cadillac, Reformer, Wunda Chair,
Wall Unit, Spine Corrector, Ladder Bar, Circles fit), as
well as floor exercises without any device. The exercises
applied were: (1) Reformer – scapular movement and
stabilization, mermaid, footwork, running, bend and
stretch, leg circles, frog, single thigh stretch, front rowing,
arms pulling straps, long stretch, elephant, chest
expansion, arm (internal rotation, external rotation,
adduction, abduction), twist, straight forward, bicep curls,
hip rolls
12
; (2) Cadillac and Wall – cat prep, roll-down, lat
press, press down, press down with triceps, breathing, lat
pull, scapula isolation, push-thru on back with roll up,
swan, side arm pull, mermaid, leg press, bicep curls
supine, midback series, back rowing press, font rowing
preps, lower, middle, upper trap strengthener, chest
25
R. bras. Ci. e Mov 2012;20(1):21-33
expansion, bicep curls, tricep press, side arm work, snow
angels, standing pull down, leg circles, walks, abduct top
leg, adduct top leg, side stretch
12
; (3) WundaChair –
footwork, hamstring press hips down, adductor press,
ankle exercise, crossover press, standing leg press,
forward step up, side step up, triceps press sitting, cat
standing front, cat kneeling, cat standing back, horseback,
elephant, swan, swan dive from floor, mermaid, mermaid
kneeling
12
; (4) abdominal exercises were carried out on
the floor, with the utilization of a thread-band and ball.
For the extension trunk and stabilization of the pelvis, a
half-moon was utilized (spine corrector)
12
. Besides the
strengthening work, stretching exercises were applied for
shortened muscle groups, with the utilization of a tonic-
ball and Franklin ball.
Statistical analysis
Data were collected directly in a database
developed for the study, in Access 2003, and analyzed
using the SPSS program, version 17. The descriptive
analysis was performed by frequencies, medians, means
and standard deviations. Frequencies of the qualitative
variables were compared between the groups using the
chi-square test or Fisher’s exact test (when an expected
value was smaller than 5 it was obtained in the chi-square
test). Student’s t test for paired samples was used for
comparing the means of quantitative variables before and
after the intervention. The comparisons of the means of
variables measured before the intervention and the mean
differences (final values less the initial values) between
the groups were carried out by Student’s t test for
independent samples, taking into consideration the
equality of the variances determined by Levene’s test. P
less than 0.05 was considered significant.
Results
Forty-one women with a mean age of 59 ± 9 years
(range= 45 to 78 years ) were studied. The mean age,
marital status, clinical and lifestyle characteristics were
similar for the two groups (Table 1).
At the beginning of this study, the intervention and
control groups did not differ in terms of height (Table 2).
After the intervention, an increase of 1.1 cm was observed
in the intervention group (P<0.001), which also showed a
significant reduction in the Cobb angle (8 degrees;
P<0.001), as shown in Table 2. No significant change was
observed in the control group. BMI and percentage of
body fat also showed significant differences (P<0.001) in
both groups (Table 2). Nevertheless, these differences
were in the opposite direction; they decreased in the
intervention group and increased in the control group. In
relation to the postural measures (Table 3) there was no
significant difference between the groups before the
training. In the intervention group, a reduction in the
cervical-thoracic distance and an increase in height of the
shoulder and scapula were observed, which was not seen
in the control group (Table 3).
Concerning cervical and trunk flexibility (Table 4),
the two groups were similar before the intervention. In the
control group, a small reduction was found in all means,
but without any statistical significance (P>0.05), except
for neck lateral flexion to the left. The group that
underwent Pilates training showed a significant
improvement in the flexibility of all cervical and trunk
movements. Comparing the means between the groups,
before and after the intervention, significant differences
(P <0.05) were found for all movements except trunk
flexion, which showed only a tendency toward statistical
significance (P=0.066) due to a large standard deviation.
The results of the hip flexibility are presented in
Table 5. In the first evaluation, there was no significant
difference between the two groups in any of the
movements studied. For all movements, a significant
improvement was observed only in the group submitted to
the Pilates training program. The difference in flexibility
change between the groups was significant (P ≤ 0.001) for
all hip movements.
Table 1. Demographic, clinical and lifestyle characteristics of the study population and the comparison between the
intervention (n=22) and control (n=19) groups
JUNGES et al.
R. bras. Ci. e Mov 2012;20(1):21-33
26
Variable Total Population
N(%)
Groups p
Intervention
N (%) Control
N (%)
Age Group (years)
45-49
50-54
55-59
60-64
65 or more
7 (17.1)
11 (26.8)
5 (12.2)
10 (24.4)
8 (19.5)
2 (9.1)
8 (36.4)
3 (13.6)
7 (31.8)
2 (9.1)
5 (26.3)
3 (15.8)
2 (10.5)
3 (15.8)
6 (31.6)
0.127
&
Marital Status
single
married
divorced
widowed
9 (22.0)
28 (68.3)
2 (4.9)
2 (4.9)
4 (18.2)
15 (68.2)
2 (9.1)
1 (4.5)
5 (26.3)
13 (68.4)
0 (0.0)
1 (5.3)
0.563
&
Clinical conditions
Hypertension 9 (22.0) 5 (22.7) 4 (21.1) 1.000
$
Heart disease 3 (7.3) 1 (4.5) 2 (10.5) 0.588
$
Asthma 6 (14.6) 1 (4.5) 5 (26.3) 0.080
$
Thyroid diseases 5 (12.2) 2 (9.1) 3 (15.8) 0,649
$
Diabetes 2 (4.9) 1 (4.5) 1 (5.3) 1.000
$
Osteoporosis 6 (14.6) 4 (18.2) 2 (10.5) 0.668
$
Orthopedic problems 10 (24.4) 4 (18.2) 6 (31.6) 0.469
$
Back pain 26 (63.4) 13 (59.1) 13 (68.4) 0.536
&
Stress 10 (24.4) 6 (27.3) 4 (21.1) 0.727
$
Taking medication 27 (65.9) 13 (59.1) 14 (73.7) 0.326
&
Lifestyle
Daily consumption of alcohol* 11 (30.6) 6 (31.6) 5 (29.4) 0.888
&
Smoker 11 (26.8) 6 (27.3) 5 (26.3) 0.945
&
Currently doing exercises 14 (34.1) 8 (36.4) 6 (31.6) 0.747
&
On some kind of diet 5 (12.2) 3 (13.6) 2 (10.5) 1.000
$
&
p-values calculated by Pearson’s chi-square test.
$
p-values calculated by Fisher’s exact test.
* Only 36 women responded to this issue (19 of the intervention group and 17 of the control group)
Table 2. General comparison of anthropometric measurements and kyphosis angle measured in X-ray between the
intervention (n=22) and control (n=19) groups, before and after the intervention period
Variable Group p
Intervention
m ±
±±
± sd Control
m ±
±±
± sd
Body weight (Kg)
Before 64.54 ± 9.16 63.21 ± 12 0.693
After 63.28 ± 10.19 64.05 ± 11.01 ---
p 0.090 0.064 ---
Difference -1.26 ± 3.33 0.84 ± 1.79 0.693
Height (m)
Before 1.61 ± 0.07 1.60 ± 0.06 0.389
After 1.62 ± 0.07 1.59 ± 0.07 ---
p <0,001 0.110 ---
Difference 0.01 ± 0.01 0.00 ± 0.01 <0.001
Body mass index (kg/m²)
Before 24.83 ± 3.4 24.79 ± 4.17 0.978
After 23.95 ± 3.41 25.29 ± 3.94 ---
27
R. bras. Ci. e Mov 2012;20(1):21-33
p 0.009 0.007 ---
Difference -0.88 ± 1.42 0.49 ± 0.68 0.001
Fat percentage (%)
Before 28.37 ± 4.50 28.83 ± 4.66 0.897
After 25.62 ± 4.93 28.61 ± 4.77 ---
p <0.001 0.663 ---
Difference -2.75 ± 2.44 -0.22 ± 2.08 0.001
Waist-hip ratio
Before 0.85 ± 0.07 0.86 ± 0.05 0.715
After 0.81 ± 0.05 0.85 ± 0.05 ---
p 0.001 0.501 ---
Difference -0.04 ± 0.05 -0.01 ± 0.06 0.075
Kyphosis angle (Cobb)
Before 63.50 ± 9.78 58.83 ± 8.73 0.124
After 55.50 ± 11.97 58.22 ± 8.59 ---
p <0.001 0.454 ---
Difference -8.00 ± 7.50 -0.61 ± 3.38 <0.001
p-values calculated by Student’s t test for independent sample comparisons between groups and for paired comparisons between
before and after the intervention period.
Table 3. Comparison of the patients’ postural measurements (four view photographs) between the intervention (n=22)
and control (n=19) groups, before and after the intervention period
Variable Group p
Intervention
m ±
±±
± sd Control
m ±
±±
± sd
Cervical-thoracic distance – right profile
Before 9.81 ± 1.45 9.40 ± 1.80 0.427
After 7.53 ± 1.35 9.65 ± 1.76 ---
p <0.001 0.228 ---
Difference -2.28 ± 1.43 0.25 ± 0.83 <0.001
Cervical-thoracic distance – left profile
Before 8.73 ± 1.35 8.80 ± 2.20 0.910
After 7.19 ± 1.38 9.10 ± 2.04 ---
p <0.001 0.439 ---
Difference -1.55 ± 1.67 0.30 ± 1.61 0.001
Height of right shoulder– back
Before 130.27 ± 6.23 129.61 ± 6.00 0.736
After 132.64 ± 6.08 130.17 ± 5.89 ---
p <0.001 0.243 ---
Difference 2.36 ± 2.52 0.56 ± 1.95 0.017
Height of left shoulder – back
Before 131.82 ± 6.38 130.22 ± 6.13 0.428
After 133.64 ± 5.74 130.39 ± 6.00 ---
p 0.002 0.729 ---
Difference 1.82 ± 2.38 0.17 ± 2.01 0.025
Height of right scapula – back
Before 117.86 ± 6.30 117.78 ± 6.12 0.966
After 121.59 ± 5.84 117.33 ± 7.30 ---
p 0.001 0.594 ---
Difference 3.73 ± 4.58 -0.44 ± 3.47 0.003
Height of left scapula – back
Before 118.36 ± 6.30 118.22 ± 5.80 0.942
After 122.00 ± 5.83 118.00 ± 7.05 ---
p <0.001 0.760 ---
Difference 3.64 ± 3.97 -0.22 ± 3.04 0.002
p-values calculated by the Student’s t test for independent samples in comparisons between the groups, and for paired samples in comparisons
between the groups, before and after the intervention period.
JUNGES et al.
R. bras. Ci. e Mov 2012;20(1):21-33
28
Table 4. Comparison of cervical and trunk flexibility measurements between the intervention (n=22) and control (n=19)
groups, before and after the intervention period
Variable Group p
Intervention
m ±
±±
± sd Control
m ±
±±
± sd
Cervical extension
Before 49.45 ± 13.07 49.44 ± 17.76 0.998
After 58.05 ± 11.12 47.44 ± 13.35 ---
p 0.013 0.560 ---
Difference 8.59 ± 14.9 -2 ± 14.27 0.028
Cervical flexion
Before 43.64 ± 13.8 49.83 ± 17.22 0.214
After 60.86 ± 10.51 44.78 ± 12.06 ---
p <0.001 0.340 ---
Difference 17.23 ± 14.02 -5.06 ± 21.83 <0.001
Cervical rotation to the right
Before 58.45 ± 12.04 56.00 ± 12.50 0.532
After 71.14 ± 7.77 52.78 ± 9.43 ---
p 0.000 0.288 ---
Difference 12.68 ± 9.63 -3.22 ± 12.47 <0.001
Cervical rotation to the left
Before 58.18 ± 11.61 57.72 ± 13.03 0.907
After 71.50 ± 8.11 55.22 ± 9.88 ---
p <0.001 0.341 ---
Difference 13.32 ± 13.16 -2.5 ± 10.82 <0.001
Cervical lateral flexion to the right
Before 36.05 ± 10.66 33.06 ± 9.71 0.364
After 41.73 ± 8.00 30.11 ± 8.28 ---
p 0.020 0.138 ---
Difference 5.68 ± 10.58 -2.94 ± 8.03 0.007
Cervical lateral flexion to the left
Before 33.27 ± 9.61 38.61 ± 8.27 0.071
After 42.86 ± 8.44 33.22 ± 8.39 ---
p 0.001 0.014 ---
Difference 9.59 ± 11.23 -5.39 ± 8.32 <0.001
Trunk flexion
Before 111.86 ± 28.35 115.56 ± 31.18 0.697
After 127.59 ± 12.97 114.67 ± 18.16 ---
p 0.007 0.904 ---
Difference 15.73 ± 24.57 -0.89 ± 30.88 0.066
Trunk extension
Before 20.73 ± 9.05 21.33 ± 7.14 0.818
After 24.59 ± 7.37 18.22 ± 5.53 ---
p 0.079 0.052 ---
Difference 3.86 ± 9.80 -3.11 ± 6.32 0.013
Trunk lateral flexion to the right
Before 31.36 ± 11.84 34.94 ± 14.25 0.391
After 37.23 ± 8.44 29.17 ± 8.39 ---
p 0.035 0.146 ---
Difference 5.86 ± 12.19 -5.78 ± 16.10 0.013
Trunk lateral flexion to the left
Before 31.77 ± 11.87 33.17 ± 11.45 0.709
After 38.64 ± 7.73 28.89 ± 8.37 ---
p 0.030 0.139 ---
Difference 6.86 ± 13.82 -4.28 ± 11.70 0.010
p-values calculated by Student’s t test for independent samples in comparisons between the groups, and for paired samples in comparisons
between the groups, before and after the intervention period
Table 5. Comparison of the hip flexibility measurements between the intervention (n=22) and control (n=19) groups,
before and after the intervention period
Variable Group p
29
R. bras. Ci. e Mov 2012;20(1):21-33
Intervention
m ±
±±
± sd
Control
m ±
±±
± sd
Flexion of the right hip
Before 57.32 ± 20.86 69.61 ± 35.47 0.180
After 79.50 ± 13.16 62.67 ± 15.89 ---
p <0.001 0.261 ---
Difference 22.18 ± 19.72 -6.94 ± 25.33 <0.001
Extension of the right hip
Before 17.95 ± 9.84 23.94 ± 11.5 0.084
After 43.41 ± 12.74 22.89 ± 5.33 ---
p <0.001 0.657 ---
Difference 25.45 ± 15.39 -1.06 ± 9.9 <0.001
Abduction of the right hip
Before 50.45 ± 16.32 48.17 ± 17.29 0.670
After 68.5 ± 13.23 47.17 ± 14.47 ---
p <0.001 0.714 ---
Difference 18.05 ± 15.28 -1 ± 11.37 <0.001
Adduction of the right hip
Before 23.23 ± 9.14 22.94 ± 14.71 0.941
After 31.14 ± 7.14 21.44 ± 15.14 ---
p 0.002 0.369 ---
Difference 7.91 ± 10.28 -1.5 ± 6.9 0.001
Flexion of left hip
Before 58.82 ± 19.81 69.17 ± 32.69 0.224
After 82.86 ± 10.28 61.17 ± 11.88 ---
p <0.001 0.245 ---
Difference 24.05 ± 15.82 -8 ± 28.19 <0.001
Extension of the left hip
Before 22.23 ± 11.22 23.72 ± 12.15 0.688
After 42.73 ± 13.47 22.39 ± 8.25 ---
p <0.001 0.454 ---
Difference 20.5 ± 14.14 -1.33 ± 7.39 <0.001
Abduction of left hip
Before 49.05 ± 13.56 50.56 ± 15.62 0.745
After 64.91 ± 12.87 50.61 ± 13.55 ---
p <0.001 0.981 ---
Difference 15.86 ± 15.7 0.06 ± 9.52 <0.001
Adduction of left hip
Before 24.91 ± 11.77 25.39 ± 12.36 0.901
After 31.86 ± 7.25 21.56 ± 10.66 ---
p 0.001 0.094 ---
JUNGES et al.
R. bras. Ci. e Mov 2012;20(1):21-33
30
Difference 6.95 ± 8.92 -3.83 ± 9.16 0.001
p-values calculated by Student’s t test for independent samples in comparisons between the groups, and for paired samples in comparisons
between the groups, before and after the intervention period
Discussion
The Pilates method is believed to improve posture
and flexibility. Nevertheless, few studies are available to
provide scientific support for this belief. Most previous
studies were conducted in young subjects, and the effect
of Pilates exercise on spinal posture and flexibility in
older women remained unclear. We found few studies in
the literature about the Pilates method and kyphosis in
women, and only one on back posture and flexibility in
older women
7
.
In relation to posture, in our study a significant
benefit with the utilization of Pilates method was
observed, with a reduction in the kyphosis angle
measured by X-rays, and the cervical-thoracic distance
(observed in the profile photographs), beyond the
elevation of the scapula and shoulders, also resulting in a
small height gain. Thus, it evidences that the engagement
in an exercise program with emphasis on strengthening
the trunk extensor muscles aids the vertebral column
realignment and may prevent the development of diseases
or dysfunctions related to an impaired posture. These
results are confirmed by those obtained from a
longitudinal study of women in the menopause, for whom
Pilates exercises were used to strengthen the back
extensors and resulted in a 2.8º reduction in the kyphosis
of some participants after a period of two years
13
.
In another study, with the same age group
population, a three month intervention with Pilates
training produced results without statistical or clinical
significance
7
. Considered as a method that involves a
whole educational and physiological process, such as
body perception, neural adaptation and movement control,
this process may be slow regardless of age because of its
complexity. According to the literature, the period of
neural adaptation takes from four to eight weeks. Only
after this period, the muscles are prepared for
conditioning, with the application of exercises with
greater intensity
8,9,14
. It is likely, therefore, that the 10
week training period adopted by Kuo et al.
7
was
insufficient to produce the results shown by the two-year
training used by Eiji and Mehesheed
13
and by our 30
week training. Another reason for the difference between
the findings our study and those from Kuo et al.
7
may lie
in the fact that all of our participants had kyphosis and
theirs did not.
Flexibility is also a theme that has been
approached in many studies on the Pilates method. It is
said that, despite the fact that the aging process brings
about various changes that result in limited flexibility,
with the Pilates method an increase in joint range of
motion can be observed, regardless of age. This was
observed in our results obtained with older women, which
demonstrate a significant improvement in cervical
flexibility of the trunk and hip with Pilates training. In a
study performed by La Touche et al.
15
,
it was suggested
that these changes contributed to the promotion of posture
and relief of pain and discomfort in the neck and lumbar
areas. The authors reported that with the increasing
mobility and mastery of these segments’ motions, the
movements become harmonious, precise and more secure.
Our study also corroborates the findings of Emery
et al.
16
, who performed a randomized clinical trial to
determine the effect of a Pilates training program on arm-
trunk posture, strength, flexibility and biomechanical
patterns during a functional shoulder flexion task in 19
younger subjects (9 controls: 5 men; mean age = 28.6 ±
3.7 years; 10 experimental: 5 men, mean age = 33.1 ± 8.6
years). Their subjects were assessed twice, before and
after a 12 week period, during which the experimental
group was submitted to a Pilates training program (two 1-
h sessions per week). After training, the subjects showed
smaller static thoracic kyphosis during quiet sitting and
greater abdominal strength. The experimental group also
showed reduced posterior and mediolateral scapular
displacements, greater upper thoracic extension and
lumbar lateral flexion, as well as higher activity of the
ipsilateral cervical spine erector, contralateral rhomboid
31
R. bras. Ci. e Mov 2012;20(1):21-33
muscles and lower activity of the ipsilateral lumbar spine
erector during the shoulder flexion task. Regardless of the
methodological differences between the two studies, such
as the fact that in ours the Pilates training was performed
only by women who were on average 30 years older than
their subjects, who trained for a period of time almost
three times longer than theirs, our subjects also improved
on the results expected from the period of neural
adaptation, reaching greater resistance gains and also
maintenance of the lengthening of the skeletal muscle
architecture resulting from their training program. So,
even with an older sample, the Pilates method has proven
effective in women decreasing their kyphosis and
increasing their flexibility.
After the intervention, we found significant
differences in BMI and fat percentage between the older
women who performed the Pilates exercises and their
controls. The plausible biological explanation is that
aging may produce changes in the distribution of slow-
twitch and fast-twitch muscle fibers, mainly because it is
associated with increased fat mass due to an imbalance
between fat deposition and fat mobilization, which
ultimately results from an imbalance between energy
intake and energy expenditure
17
. Thus, there is a
decreased ability to mobilize fat
18
.
To lose fat, moderate
strength and endurance training is more effective than
Pilates, although the Pilates method is considered more
complex
19
. Notwithstanding, the group that underwent the
intervention probably had a higher energy expenditure
with the basic exercises. Going along with this reasoning,
they also presented a significant reduction in the waist/hip
ratio which, according to the literature, is highly
predictive of chronic metabolic disease risk
19
. Most of the
studies to evaluate the effect of Pilates exercise on BMI or
body composition have been conducted in young subjects
or in subjects that were already engaged in some physical
activity, even so they have shown that Pilates holds
promise as a means of reducing obesity
20
. In this case, the
elderly population can also benefit from regular Pilates
exercise, as shown by the results of the present study.
In the comparison of the skinfold measurements,
there was a significant reduction in almost all
measurements in the experimental group, in addition to
the waist and hip circumferences. This suggests that
changes in posture through exercises aimed chiefly at
strengthening the muscle groups responsible for trunk
stability, mainly the abdominals, which are constantly
used in forced expiration and almost all body movements,
are the ones that contributed to the changes in these
measurements. It is suggested that the posture correction
results in a better adipose tissue distribution
21
.
Segal et al.
6
suggest that effects of Pilates training
on body composition, health status, and posture are more
limited and may be difficult to establish. They carried out
an observational study to evaluate the effects of Pilates
training on flexibility and body composition and showed
that median fingertip-to-floor distance improved
significantly from baseline, but no statistically significant
changes were observed in trunk lean body mass, height,
weight, or other body composition parameters
6
.
Nonetheless, in the present study all of these
measurements showed statistically significant
improvements. The answer to these contradictory findings
may lie in the quality of the training program, which in
our case was tailored to the group of enrolled subjects and
planned accordingly. This results show that
multidimensional exercises, aimed at strengthening weak
muscles and lengthening shortened ones, resulted in a
neuromuscular balance and, consequently, in an increase
in mobility of the vertebral column, resulting in harmonic
and balanced action between agonist and antagonist
muscles. The changes that occur with the application of
the exercises and principles of the Pilates method
stimulate body consciousness, the gravity center,
movement control and the respiratory system
6,11
.
Study Limitations
It is important to discuss some aspects related to
our methodological design. We conducted a clinical trial
that was not placebo-controlled, which can lead to bias in
the implementation of the intervention, monitoring and
final diagnosis. However, we tried to minimize these
effects through blinding the examinations before and after
the intervention with Pilates (lateral standing X-rays and
JUNGES et al.
R. bras. Ci. e Mov 2012;20(1):21-33
32
photograph analysis with a specific software), which were
carried out by the same observer, who was trained to do
so and did not know to whom the measurements belonged
to. In addition, the training of the women with kyphosis
was performed by the same individual, who did not deal
with either measurements taking, data registering or
analysis. Furthermore, data were analyzed by a statistician
blinded to the subjects’ randomization. In an effort to
minimize confounding variables, we studied subjects of
similar age, physical activity engagement, diet and
clinical characteristics. Despite the study's limitations, it
opens perspectives for future research on the benefit of
the Pilates method in musculoskeletal rehabilitation.
Conclusions
The results of this study demonstrate the
effectiveness of Pilates in reducing the degree of kyphosis
in women, reflected in the improved posture and
flexibility. Moreover, the exercise method is also
effective in reducing BMI and percentage of fat, which
can have a major impact on cardiovascular disease
prevention. In this sense, it seems that the Pilates method
can have an important role in the prevention of or
rehabilitation for musculoskeletal problems, as well as
prevention of cardiovascular risk factors such as
abdominal fat, which is highly prevalent in the elderly. In
future investigations it would be important to assess the
role of nutrition and usual exercise practice with Pilates
training, as well as the role of this training method in the
modulation of the hormonal biomarkers related to the
accumulation of fat and muscle strength and performance.
Acknowledgments
We thank the volunteers of our study and the
Coordination for the Improvement of Higher Education
Personnel/Post doctoral National Program
(CAPES/PNPD) for the scholarship (2785/09-9).
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