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REVIEW ARTICLE (META-ANALYSIS)
Effect of Pilates Exercise for Improving Balance in
Older Adults: A Systematic Review With Meta-Analysis
Anna Lucia Barker, PhD,
a
Marie-Louise Bird, PhD,
b
Jason Talevski, BHlthSci (Public Health)
a
From the
a
Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University,
Melbourne, Victoria; and
b
Faculty of Health, School of Health Sciences, University of Tasmania, Launceston, Tasmania, Australia.
Abstract
Objectives: To investigate the effect of Pilates on balance and falls in older adults, and whether programs tested in prior studies met best-practice
recommendations for exercise to prevent falls.
Data Sources: MEDLINE, SPORTDiscus, CINAHL, PubMed, Physiotherapy Evidence Database, and The Cochrane Library were searched from
earliest record to July 2014.
Study Selection: Randomized and controlled clinical trials evaluating the effect of Pilates on balance and/or falls in older adults.
Data Extraction: Two reviewers independently extracted demographic, intervention, and outcome data. Six studies were included in this review.
Data Synthesis: High-quality studies in this area are lacking. When compared with nonactive control groups, Pilates was shown to improve
balance (standardized mean difference [SMD]Z.84; 95% confidence interval [CI], .44e1.23; 6 studies) and reduce the number of falls
(SMDZ2.03; 95% CI, 2.66 to 1.40; 1 study). Three studies provided sufficient detail to enable assessment of compliance with the
recommendation of exercises providing a moderate or high challenge to balance. In these studies, 2% to 36% of exercises were assessed as
providing a moderate or high challenge to balance. All studies provided 2 hours of exercise per week, and 1 study provided >50 hours of
exercise during the study period.
Conclusions: The evidence suggests Pilates can improve balance, an important risk factor for falls in older adults. However, there is limited data
on the impact of Pilates on falls. Effects may have been overestimated because of the low methodological quality of studies. Best-practice
recommendations were rarely applied in prior studies, indicating greater effects may have been achieved if recommendations were incorporated.
Archives of Physical Medicine and Rehabilitation 2015;-:-------
ª2015 by the American Congress of Rehabilitation Medicine
Falls in older adults continue to be a major source of disability,
mortality, and health care utilization.
1
In the United States, 1 older
adult dies after a fall every 29 minutes.
2
While falls do occur in
young
3
and middle-aged people,
4
their sequelae are most delete-
rious in older adults. Thirty percent of falls in older adults have
been reported to result in severe injuries, substantially affecting
independence and risk of early death.
5
Balance impairment is a
key modifiable risk factor for falls.
6,7
Therefore, exercises that aim
to improve balance are a key component of fall prevention pro-
grams in both clinical practice and the research literature.
8
Pilates is a mind-body exercise that has been used since early
in the 20th century. It focuses on improving strength, core
stability, flexibility, muscle control, posture, and breathing.
9
Pilates aims to improve coordination and control of the core
muscles of the trunk, which contribute to the optimal lumbar-
pelvic stabilization needed for daily activities and function.
10
Pilates exercises can be categorized into 2 types: (1) mat exer-
cises (which have commonalities with yoga and tai chi), and
(2) equipment exercises (which use springs to achieve muscle
strengthening). Many Pilates exercises are performed in a standing
position, with a narrow base of support without hand support,
challenging trunk muscle stability to maintain upright postures.
An example of this is standing leg pumps on the wunda chair, or
scooter on the reformer (fig 1).
A recent systematic review
11
of 16 studies concluded that
Pilates can improve dynamic balance in healthy populations.
However, this conclusion was based on findings from only 2 of the
Disclosures: none.
0003-9993/14/$36 - see front matter ª2015 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2014.11.021
Archives of Physical Medicine and Rehabilitation
journal homepage: www.archives-pmr.org
Archives of Physical Medicine and Rehabilitation 2015;-:-------
16 included studies. Additionally, only 1 of the 2 studies that re-
ported on dynamic balance was completed in older adults (65y),
therefore limiting the generalizability of this finding to older
adults. The review also reported a significant decrease in number
of falls; however, this result was also concluded from only
1 study.
11
In addition to this review of the effectiveness of Pilates exer-
cise, a systematic review
12
including 54 randomized controlled
trials (RCTs) on all forms of exercise designed to prevent falls has
been completed. This review reported that exercise programs
including balance training achieved the greatest reductions in
falls. Since many Pilates exercises provide a challenge to balance,
Pilates may achieve similar effects on falls as reported by this
review. After this initial review, an updated review
13
was pub-
lished and provided best-practice recommendations to guide the
use of exercise for falls prevention (box 1). The authors recom-
mended that exercises for falls prevention should provide a
moderate or high challenge to balance; be undertaken for 2h/wk;
and provide a total dose of more than 50 hours of exercise over the
study period. Programs with these characteristics achieved a 38%
reduction in the rate of falls (95% confidence interval [CI], 27%e
46%).
13
The primary aim of this systematic review was to evaluate the
evidence for the effect of Pilates on balance and falls in older
adults. A secondary aim was to identify whether Pilates programs
tested in prior studies met the best-practice recommendations for
exercise to prevent falls
13
in terms of program content and dose
of exercise.
Methods
This systematic review was performed according to the criteria of
the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses.
14
Search strategy
A systematic search of literature was conducted in July 2014.
MEDLINE, SPORTDiscus, and CINAHL were searched to find
published research. Supplementary searches were also con-
ducted in PubMed, the Physiotherapy Evidence Database
(PEDro), and The Cochrane Library. Comparative research
studies published up to July 2014 were selected for evaluation. A
sensitive search strategy was developed using the terms Pilates
AND Balance OR Accidental Falls OR Postural Stability,and
was translated for each database as appropriate. The search
strategy was validated by identifying a “validation set” of ref-
erences based on studies obtained from the MEDLINE search
and ensuring that these were also included in searches in each of
the other databases.
Inclusion criteria
Studies were included in this review if they were published in a
peer-reviewed journal; written in the English language; con-
ducted as an RCT or controlled clinical trial in older adults
(mean age of participants 60y); tested an exercise intervention
described as “Pilates” (mat, equipment, or both); included a
comparison group that participated in no exercise (including
nonactive activities such as education); and reported on at least
1 performance-based measure of balance (dynamic or static) or
falls. Studies that recruited people living in the community or
residential aged care, including nursing homes and long-term
care, were included.
Fig 1 Pilates equipment exercises for balance.
List of abbreviations:
CI confidence interval
POMA Performance-Oriented Mobility Assessment
RCT randomized controlled trial
SMD standardized mean difference
2 A.L. Barker et al
www.archives-pmr.org
Study selection
Two reviewers independently screened and excluded studies based
on title and abstract. If it was clear that the intervention tested was
not Pilates, or that measures of balance or falls were not reported,
the study was excluded. Duplicate publications, where there was
overlap of participants across publications, were also excluded.
For studies not excluded by this process, the full text was obtained
and assessed independently by both reviewers against the inclu-
sion criteria. Differences of opinion regarding eligibility of studies
were resolved by a third reviewer.
Data extraction
Two reviewers independently extracted data from the included
studies. Information on population (mean age, sample size),
setting (community or residential aged care), study design,
outcome measures (balance, falls, or both), and intervention
characteristics was recorded. The intervention was described in
terms of who delivered the exercise (Pilates instructor or physical
therapist); the type of Pilates exercises included (mat, equipment
or apparatus); mode (group or individual), frequency (hours per
week), and duration of delivery (length of intervention in weeks);
total dosage of exercise (in hours); and adherence to exercise
sessions. This information was recorded based on information
included in the publication. If this information was not included in
the publication, the study authors were contacted to provide
additional detail.
Quality assessment and risk of bias
Two review authors independently assessed the methodological
quality and risk of bias of included studies. Uncertainty or dis-
agreements were resolved by discussion with a third reviewer.
Study quality was assessed according to 6 criteria described in the
Cochrane Handbook for Systematic Reviews of Interventions
14
:
(1) blinding of provider or patient; (2) concealment of allocation;
(3) blinding of outcome assessment; (4) cointervention avoided,
controlled, or used similarly across comparison groups; (5) loss to
follow-up <20% and equally distributed between comparison
groups; and (6) intention-to-treat analysis performed. Criteria
were assessed as met, unclear, or not met.
Risk of bias was assessed as high, low, or unclear based on the
domains included in the Cochrane Collaboration’s tool for
assessing risk of bias in clinical trials.
15
The tool covers 6 domains
of bias: selection bias, performance bias, detection bias, attrition
bias, reporting bias, and other bias. If insufficient detail was re-
ported in the trial, the judgment resulted in an unclear risk of bias.
Data synthesis
Meta-Analysis
A meta-analysis was conducted to assess intervention effects on
balance and falls, using unadjusted, pooled data and described as
standardized mean differences (SMDs) and 95% CIs. The use of
pooled data is effective for comparing data collected using different
outcome measures and can provide an improved estimate of the
effect of the intervention as a consequence of the larger number of
total participants and reduction in random error resulting from
sampling differences.
14
An SMD <0.2 was considered a small
effect; between 0.2 and 0.8, a moderate effect; and >0.8, a large
effect.
16
A random-effects model was used since it was assumed
that the true effect could vary between studies because of the
heterogeneity of study populations, intervention characteristics,
and measurement of outcomes. For example, the effect size might
be higher if participants were older; if the study used a more
intensive Pilates program or longer duration of the intervention; or
if balance outcomes were measured using a more sensitive
assessment tool. Heterogeneity between studies was assessed using
the I
2
statistic, which shows the proportion of total variance that is
explained by heterogeneity.
17
Statistical heterogeneity was
considered substantial if I
2
was >50%.
14
Scale directions were
aligned by adding negative values where required.
Balance outcomes were categorized as static, dynamic, or both.
Dynamic balance was defined as the ability to maintain equilibrium
while moving through space either with or without moving the feet
(eg, standing up from a chair, walking 3m, turning, and returning to
the chair to sit down, as in the Timed Up and Go test; or reaching
forward while keeping the feet in full contact with the floor, as in
the Functional Reach Test). Static balance was defined as the
ability to hold an upright position while keeping the feet in full
contact with the floor (eg, maintaining an upright stance while the
feet are together). To be included in the meta-analysis, studies must
have reported outcome measures known to be responsive for
measuring change in balance. The outcome measure from each
study was chosen before analysis according to the following order
of priority: timed Up and Go test
18
/8-ft up and go test, Tinetti
Performance-Oriented Mobility Assessment (POMA) test,
19
5
times sit-to-stand test,
20
4-Square Step Test,
21
Functional Reach
Test,
22
and static balance tests (measures of hold times, sway,
stability, and pressure in static stance positions). This list was
determined by tabulating the frequency with which each test was
reported in the included studies. The more frequently reported tests
were prioritized for inclusion in the meta-analysis over the less
frequently reported tests. This was done to decrease the hetero-
geneity of outcome measures used in the meta-analysis. Where a
study reported results for more than 1 of these outcomes, only the
Box 1 Best-Practice Recommendations for Exercise for Falls Prevention
13
1. Exercise must provide a moderate or high challenge to balance.
2. Exercise must be of a sufficient dose to have an effect (2h/wk and >50h over total study period).
3. Ongoing exercise is necessary.
4. Exercise should be targeted at the general community as well as those at high risk of falling.
5. Exercise may be undertaken in a group or home-based setting.
6. Walking training may be included in addition to balance training, but high-risk individuals should not be prescribed brisk walking
programs.
7. Strength training may be included in addition to, but not in place of balance training.
8. Exercise providers should make referrals for other falls risk factors to be addressed.
Pilates to improve balance in older adults 3
www.archives-pmr.org
outcome of the highest priority was used to minimize bias in the
results, and dynamic measures were prioritized over static where
both were reported. Outcome data were excluded from the meta-
analysis if there were significant differences in baseline scores of
the outcome of interest between the 2 groups, to ensure results were
not confounded. A test of subgroup differences was performed to
ensure it was appropriate to combine dynamic and static measures
in the same meta-analysis. The meta-analysis was performed using
Review Manager (RevMan 5.3
a
) software.
Compliance with best-practice recommendations for exercise
for falls prevention
This review assessed whether the Pilates programs tested in each
study met the following best-practice recommendations for ex-
ercise to prevent falls
13
: (1) exercises provided a moderate or high
challenge to balance (ie, performed in standing and using a small
base of support while moving the center of mass over that base);
and (2) programs were of sufficient dose (2h/wk and a total of
>50h over the study period). These assessments were performed
independently by 2 physiotherapists experienced in the delivery of
both Pilates exercise and exercises for the prevention of falls.
Results
Study selection
The 13 references from the validation set were identified in the
search results from each database. The electronic search identified
Fig 2 Flow chart of exclusion process.
Table 1 Study and participant characteristics
Study
Study
Design Setting
Sample
Size Age (y)
Women
(%)
Control
Intervention
Outcome Measures
Dynamic
Balance Static Balance Falls
Bird et al
23
RCT Community 32 67.26.6 78 Usual
activity
FSST
TUG test
Center of
pressure/
mediolateral
sway
NA
Gildenhuys
et al
24
RCT Community 50 65.35.0 100 Usual
activity
(asked not
to perform
structured
exercise)
FTSST NA NA
Irez et al
25
RCT Residential
aged care
60 72.86.7 100 Usual
activity
(asked not
to perform
structured
exercise)
NA Rank value
stability
index
(MED-SP300)
Monthly
falls
calendar
Kovach et al
26
RCT Community 54 66.46.2 76 Usual
activity
8-ft up and
go test
NA NA
Mokhtari et al
27
CCT Community 30 NR 100 Usual
activity
FRT
TUG test
NA NA
Siqueira
Rodrigues
et al
28
RCT Community 52 664.0 100 Usual
activity
Tinetti
POMA
test
Tinetti POMA
test
NA
NOTE. Values are n, mean SD, or as otherwise indicated.
Abbreviations: CCT, controlled clinical trial; FRT, Functional Reach Test; FSST, 4-Square Step Test; FTSST, 5 times sit-to-stand test; MED-SP300, Medical
Sports Performance 300; NA, not applicable; NR, not reported; TUG, timed Up and Go.
4 A.L. Barker et al
www.archives-pmr.org
309 potential studies for screening of eligibility. Of these, 285
were excluded after review of title and abstract as not meeting
the inclusion criteria, and the full text was obtained for the
remaining 24 studies. Based on the reviewers’ decisions, 6
studies met the inclusion criteria and were included in the re-
view
23-28
(fig 2).
Study and intervention characteristics
Of the 6 studies included, 5
23-26,28
were conducted as an RCT
and 1
27
as a controlled clinical trial. Four studies
23,24,26,27
reported on dynamic balance outcomes, 2
23,25
on static bal-
ance outcomes, and 1
28
reported on a combined static and
balance outcome. Only 1 study
25
reported data on falls. The
sample sizes in all included studies were small, ranging from
30 to 60 participants, and most of the participants were
women. One study
25
delivered the Pilates intervention in a
residential aged care facility, and the others in community-
dwelling adults (table 1). The programs included various
combinations of mat, equipment, and other apparatus exer-
cises. Two studies
24,26
included only mat exercises, with
others including mat exercises as well as resistance training
(bands or weights), small apparatus, or equipment in combi-
nation. The duration of Pilates interventions ranged from 5 to
24 weeks, and sessions were all delivered in a group setting.
Only2studies
23,26
recorded exercise adherence, and both of
these had participation rates >80% (table 2).
Quality assessment and risk of bias
The methodological quality of the included studies was low.
Common flaws included lack of reporting of allocation
concealment; lack of blinding of participants, persons delivering
the intervention, and those assessing outcomes; inclusion of a
group delivery cointervention for intervention but not control
participants; and no reporting of intention-to-treat analysis.
Studies were assessed as having a high degree of bias, with
common sources of bias being selection bias, performance bias,
detection bias, and attrition bias (table 3).
Data synthesis
Meta-Analysis
There was significant heterogeneity detected for the 6 studies
included in the meta-analysis of balance outcomes (I
2
Z61%).
When a random-effects analysis was applied, a large signifi-
cant effect was observed for Pilates on balance (SMDZ.84;
95% CI, .44e1.23). Effects were consistent across dynamic
(SMDZ.62; 95% CI, .15e1.08), static (SMDZ1.21; 95% CI,
.66e1.77), and combined static and dynamic (SMDZ1.25;
95% CI, .66e1.85) balance outcomes (test for subgroup dif-
ferences, PZ.15) (fig 3).
Falls
Only 1 study
25
included in this review reported data on falls. This
RCT observed a significant reduction in the number of falls in the
Pilates intervention participants (preintervention, 1.87; post-
intervention, .37) compared to the control group participants
(preintervention, 1.63; postintervention, 1.30) during the
12-week follow-up period (SMDZ2.03; 95% CI, 2.66 to
1.40) (fig 4). Data on falls were collected during the 12-week
study period using monthly calendars.
Table 2 Pilates exercise intervention characteristics
Study
Pilates Exercise Type
Delivered by
Delivery
Mode
Duration
(wk)
No. of Sessions/
wk Duration of
Session (min)
Guideline Recomendations
13
Exercise
Adherence
(%)Mat Theraband Ball Reformer Trapeze
Wunda
Chair
Challenge
Balance
(%)
2h/
wk
(h)
>50h
Total
(h)
Bird et al
23
UUUPilates instructor Group 5 3 60 36 Y (2) N (10) >80
Gildenhuys et al
24
UPilates instructor Group 8 3 60 2 Y (3) N (24) NR
Irez et al
25
UU U Pilates-trained
PT
Group 12 3 60 UTA Y (3) N (36) NR
Kovach et al
26
UNR Group 24 3 60 UTA Y (3) Y (72) >80
Mokhtari et al
27
UU Pilates instructor Group 12 3 60 UTA Y (3) N (36) NR
Siqueira
Rodrigues
et al
28
UU U U Pilates-trained
PT
Group 8 2 60 20 Y (2) N (16) NR
Abbreviations: N, no; NR, not reported; PT, physical therapist; UTA, unable to assess; Y, yes.
Pilates to improve balance in older adults 5
www.archives-pmr.org
Compliance with best-practice recommendations for
exercises for falls prevention
All 6 studies provided 2 hours of exercise per week over
the study period. However, only 1 study
26
provided >50
hours of exercise during the study period. Three
studies
23,24,28
provided sufficient detail on the Pilates exer-
cises to enable assessment of compliance with the best-
practice recommendation of providing a moderate or high
challenge to balance. Of these 3 studies, the percentages of
exercises that were assessed as providing a moderate to high
challenge to balance were 2%,
24
20%,
28
and 36%
23
(see
table 2). Examples of exercises assessed as providing a
moderate or high level of challenge to balance included
scooter and standing leg side series on the reformer; assisted
squats and standing arm series on the trapeze; arm arcs and
leg side series in standing on the mat; and hamstring series I
on the wunda chair.
Discussion
The focus of this review was to examine the effect of Pilates
on balance and falls in older adults. Until now, no pooled
estimates have been available on the effect of Pilates on
these outcomes. The meta-analysis identified that Pilates can
have a positive effect on balance in older adults. This finding
appeared to be consistent across most of the studies
included. The number of falls was also shown to be lower
after a Pilates intervention; however, this was concluded
from only 1 RCT.
25
The best-practice recommendations for
exercise to prevent falls
13
were rarely applied in prior studies
in terms of program content and dose of exercise, although 3
of the included studies
24,26,27
were completed before these
recommendations were published. Based on these findings,
Pilates can be considered an effective form of exercise to
improve balance in older adults, which is known to decrease
the risk of falling. Greater effects may be achieved if best-
practice recommendations for exercise to prevent falls are
incorporated.
Several exercises in the Pilates repertoire can provide a
moderate or high challenge to balance as recommended by
the best-practice guideline recommendations for exercise to
prevent falls.
13
Balance-challenging exercises include those
that are multisensory (eg, performed on different surfaces
such as mats, wobble boards, and discs, or on moving sur-
faces such as a wunda chair foot pedal or reformer carriage);
are performed in a standing position; use a foot position that
achieves a narrow base of support (eg, standing on 1 leg
such as in a scooter or standing leg pump exercise; see fig
1); and do not involve the use of hands for support. Many
of the exercises tested in studies included in this review
were performed in a seated or lying position, and therefore
are likely to have only provided a minimal challenge to
balance. The impact of improving trunk muscle strength for
postural stability is not known, but may be 1 mechanism by
which positive effects on balance were achieved by studies
with exercises performed predominately in seated or lying
positions. While the programs tested in studies included in
this review achieved positive improvements in balance,
greater effects may have been achieved if programs included
more exercises in a standing position with a narrow base of
support or an unstable surface, and were given at a
higher dosage.
Table 3 Summary of quality assessment and risk of bias assessment
Study
Quality Assessment Risk of Bias Assessment
Patient/
Therapist
Blinding
Allocation
Concealed
Outcome
Assessor
Blinding
Cointervention
Avoided
Loss To
Follow-
Up
ITT
Analysis
Selection
Bias
Performance
Bias
Detection
Bias
Attrition
Bias
Reporting
Bias
Other
Bias
Bird et al
23
Not met Met Met Not met Met Met Low High Low High Low High
Gildenhuys et al
24
Not met Not met Not met Not met Unclear Not met High High High High Low Low
Irez et al
25
Not met Not met Met Not met Met Not met High High Low Low Low Low
Kovach et al
26
Not met Not met Not met Not met Unclear Not met High High High High Low Low
Mokhtari et al
27
Not met Unclear Not met Not met Unclear Not met High High High High High Low
Siqueira-
Rodrigues
et al
28
Not met Not met Not met Not met Met Not met High High High High High Low
Abbreviation: ITT, intention to treat.
6 A.L. Barker et al
www.archives-pmr.org
The large positive effects on balance reported in the meta-
analysis were consistent across 5 of the 6 included studies. The 1
study where a positive effect was not reported was the randomized
crossover study
23
by Bird et al. The authors of this study reported
that the washout period of 6 weeks used in the crossover design
was unlikely to have been long enough to allow balance to return
to preintervention levels. People who received the intervention
may have gained balance confidence, which meant that in the
subsequent washout period, they may have been more active and
continued to challenge their balance in everyday activities. This
could have maintained benefits achieved.
23
No observable differ-
ences in balance were identified between studies that included
more balance-challenging exercises or that applied a higher
dosage of exercise. It is likely that there were too few studies to
enable an accurate assessment of the impact of these program
characteristics on balance, and because of the high risk of bias in
several of the included studies, differences observed may be
attributable to differences in study quality rather than program
characteristics.
Results from this review should be interpreted with a degree of
caution. The methodological quality of the studies included was
low, and a high risk of bias was present across most of the studies.
High-quality RCTs, with concealed allocation and blinded
outcome assessment, that control for cointerventions such as a
group delivery mode, in conjunction with intention-to-treat
analysis would advance the quality of work in this field.
Importantly, the study with the lowest risk of bias
25
reported a
large positive effect on balance, and also a reduction in the
number of falls, strengthening the conclusion that Pilates has an
effect on both of these outcomes. In all the included studies, the
Pilates interventions were delivered in a group session, while
control participants were asked to continue with their usual ac-
tivity, rather than attending any placebo group activity. As such,
there is a risk that the group delivery mode of the Pilates classes
formed a cointervention and may have influenced the results. To
ensure that the cointervention of the delivery mode is controlled,
future studies should provide a placebo intervention for control
participants by way of group delivery to match the delivery mode
of the Pilates intervention.
The inconsistency in balance outcome measures used in
prior studies limited the ability to meaningfully compare re-
sults from different studies. The different outcome measures
chosen measured different facets of balance control. The Sys-
tems Framework for Postural Control describes 6 major com-
ponents of postural control: (1) constraints on the
biomechanical system (degrees of freedom, strength, limits of
stability); (2) movement strategies (reactive, anticipatory,
voluntary); (3) sensory strategies (integration, reweighting); (4)
Fig 3 Meta-analysis of balance outcomes. Abbreviations: FTSST, 5 times sit-to-stand test; 8FUG, 8-ft up and go; IV, inverse variance; RVSI, rank
value stability index; Std., standard; Total, number of participants in the study group; TUG, timed Up and Go.
Fig 4 Meta-analysis of fall outcomes. Abbreviations: IV, inverse variance; Std., standard; Total, number of participants in the study group.
Pilates to improve balance in older adults 7
www.archives-pmr.org
orientation in space (perception of gravity, verticality); (5)
dynamic control (gait, proactive); and (6) cognitive processing
(attention, learning).
29
The meta-analysis included 4 different
balance outcome measures: (1) the timed Up and Go (8-ft up
and go); (2) 5 times sit-to-stand test; (3) POMA developed by
Tinetti; and (4) the rank value stability index (where a person
maintains an upright standing position on an unstable surface
similar to the foam condition of the clinical test of sensory
interaction in balance). These outcome measures evaluate
different components of balance included in the Systems
Framework for Postural Control as summarized in a recent
review.
30
All 4 of the outcome measures included in the meta-
analysis evaluated strength and sensory integration, and 3
measures (5 times sit-to-stand test, timed Up and Go, POMA)
evaluated anticipatory control and dynamic stability. This
suggests that while there was variability in the outcome mea-
sures included in the meta-analysis, there was sufficient com-
monality in the underlying constructs of balance being
measured to warrant inclusion in a single meta-analysis. In
addition, the POMA and the rank value stability index evalu-
ated static stability, and only the POMA evaluated functional
stability limits and reactive postural control. Future studies
should aim to include a suite of balance outcome measures that
ensures each of 6 components of balance are evaluated, to
enable an increased understanding of which components of
balance Pilates affects.
Most of the studies included in this review did not report data
on falls. Although 1 study
25
reported a greater reduction in the
number of falls in the intervention compared to the control group,
the authors did not provide sufficient detail on the period for
which fall data were collected in the preintervention period,
making a meaningful comparison with the postintervention fall
data problematic. Additionally, 12 weeks is a short follow-up time
to see a change in falls and should be interpreted with caution.
Therefore, we cannot confidently conclude that Pilates exercise
affects falls. Future research focusing on the impact of Pilates on
falls in older people should be completed.
The level of adherence to the intervention was not well re-
ported in the included studies, with only 2 studies
23,26
including
this information. Adherence is a critical measure of effectiveness,
as it represents the acceptability of an intervention. Even if an
intervention is effective, if it is not accepted by the target popu-
lation it is of little benefit. Because of this, it is unknown whether
the effectiveness of the Pilates programs tested was limited by
poor adherence to the programs.
Study limitations
Our study has several limitations; most notably, the available evi-
dence is limited in quality and quantity. There is a risk that effects
may have been overestimated because of methodological weak-
nesses of the studies included. The content of the exercise programs
was highly variable across studies, and many contained exercises
that would not be considered specifically Pilates in origin (eg, squats
with weights). The outcome measures used were also variable. None
of the balance measures included in the meta-analysis evaluated the
verticality or cognitive influence components of balance. Further-
more, functional stability limits and reactive postural control com-
ponents were only evaluated in 1 study. As such, this review only
considers a subset of components that constitute balance. Only
studies published in English were included. Inclusion of studies
published in all languages may have given a different result.
Conclusions
Current literature suggests that Pilates is effective for improving
balance in older adults, which may reduce their risk of falling. In
both research and practice, Pilates programs should apply the best-
practice recommendations for exercise to prevent falls, to ensure
maximum benefit. Further high-quality studies are needed that
include more balance outcomes, and fall and adherence outcomes
measured over longer periods.
Supplier
a. Review Manager (RevMan5.3); Cochrane Informatics &
Knowledge Management Department. Available at: http://tech.
cochrane.org/revman.
Keywords
Accidental falls; Aged; Exercise movement techniques; Postural
balance; Rehabilitation
Corresponding author
Anna Lucia Barker, PhD, Monash University, Department of
Epidemiology and Preventive Medicine, The Alfred Centre, Level
6, 99 Commercial Rd, Melbourne VIC 3004, Australia. E-mail
address: anna.barker@monash.edu.
Acknowledgments
We thank Meghan Ambrens, BCom, and research assistants in the
Falls and Bone Health team at Monash University for their
assistance with activities associated with this review, including the
reviewing of the literature in each database.
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