EFFECTS OF STOTT’S PILATES VERSUS YOGIC EXERCISE IN FIBROMYALGIA PATIENTS: A PILOT STUDY

Abstract

Background: Fibromyalgia Syndrome (FMS) can be defined as a rheumatological condition characterised by chronic widespread pain, a reduced pain threshold as well as hyperalgesia and allodynia. It is a nonarticular painful condition with generalised tender points.
Purpose: The aim of this randomised study was to compare the effects of Stott’s Pilates versus Yogic exercise on pain, tenderness, pressure threshold, depression & fatigue in Fibromyalgia patients, which is chronic musculoskeletal disorder.
Methodology: Female and male (n=20) who had a diagnosis of fibromyalgia syndrome (FMS) according to the American College of Rheumatology criteria were selected from Dr. D.Y.Patil hospital, Physiotherapy department O.P.D. The participants were randomly assigned into 2 groups. In group A, a Pilates exercise program of 1 hour was given by a certified trainer to 10 participants 6 days a week for 4 weeks. In group B, Yoga program of 1 hour was given by certified instructor to10 participants 6 days a week for 4 weeks. In both groups, pre- (1st day) and post treatment (4th week) evaluation was performed by VAS (Visual Analogue Scale), TPI (Tender Point Index), AS (Algometric Score), BDI (Beck Depression Inventory) and FSS (Fatigue Severity Scale).
Results: Twenty participants completed the study. In Group A significant difference were observed for VAS, TPI, BDI & FSS (statistically p

Full text

Int J Physiother Res 2015;3(5):1250-57. ISSN 2321-1822 1250
Original Article
EFFECTS OF STOTT’S PILATES VERSUS YOGIC EXERCISE IN
FIBROMYALGIA PATIENTS: A PILOT STUDY
Ashika Tanna *1, Soumik Basu 2, Kajal Anadkat 3.
*1 M.P.T. Orthopaedics, YTTC, Assistant Professor, School of Physiotherapy, R.K.University, Tramba,
Gujarat, India.
2 M.P.T. in Sports Sciences, Assistant professor, Department of Physiotherapy, Padmashree Dr.
D.Y.Patil Medical College and Research Institute, Pimpri, Pune, India.
3 M.P.T. Musculoskeletal and Sports Science, Assistant Professor, School of Physiotherapy,
R.K.University, Tramba, Gujarat, India.
Background: Fibromyalgia Syndrome (FMS) can be defined as a rheumatological condition characterised by
chronic widespread pain. A reduced pain threshold as well as hyperalgesia and allodynia. It is a nonarticular
painful condition with generalised tender points.
Purpose: The aim of this randomised study was to compare the effects of Stott’s Pilates versus Yogic exercise on
pain, tenderness, pressure threshold, depression & fatigue in Fibromyalgia patients, which is chronic
musculoskeletal disorder.
Methodology: Female and male (n=20) who had a diagnosis of fibromyalgia syndrome (FMS) according to the
American College of Rheumatology criteria were selected from Dr. D.Y.Patil hospital, Physiotherapy department
O.P.D. The participants were randomly assigned into 2 groups. In group A, a Pilates exercise program of 1 hour
was given by a certified trainer to 10 participants 6 days a week for 4 weeks. In group B, Yoga program of 1 hour
was given by certified instructor to10 participants 6 days a week for 4 weeks. In both groups, pre- (1st day) and
post treatment (4th week) evaluation was performed by VAS (Visual Analogue Scale), TPI (Tender Point Index), AS
(Algometric Score), BDI (Beck Depression Inventory) and FSS (Fatigue Severity Scale).
Results: Twenty participants completed the study. In Group A significant difference were observed for VAS, TPI,
BDI & FSS (statistically p<0.05) and in Group B significant difference were observed for VAS, TPI, AS, BDI & FSS
(statistically p<0.05). But between group comparison result was not supports the within group differences
(statistically p>0.05).
Conclusion: Hence, we suggest Pilates exercise and Yoga both are equally effective in treating fibromyalgia
patients.
KEY WORDS: Fibromyalgia, Pressure Algometer, Stott’s Pilates, Yoga.
ABSTRACT
INTRODUCTION
Address for correspondence: Dr. Ashika Tanna, M.P.T. Orthopaedics, YTTC, Assistant Professor,
School of Physiotherapy, R.K.University, Tramba, Gujarat, India. Contact No. +91-9978469090
E-Mail: ashika.tanna@rku.ac.in / dr.ashikatanna89@gmail.com
International Journal of Physiotherapy and Research,
Int J Physiother Res 2015, Vol 3(5):1250-57. ISSN 2321-1822
DOI: http://dx.doi.org/10.16965/ijpr.2015.186
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Access this Article online
International Journal of Physiotherapy and Research
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DOI: 10.16965/ijpr.2015.186
Received: 22-09-2015
Peer Review: 22-09-2015
Revised: None
Accepted: 01-10-2015
Published (O): 11-10-2015
Published (P): 11-10-2015
and allodynia. It is an idiopathic, nonarticular
pain syndrome presenting with generalised
tender points. It is a multisystem and
multifactorial disease characterised by sleep
disturbance, fatigue, headache, morning
Fibromyalgia Syndrome (FMS) is a common
rheumatological condition characterised by
chronic widespread musculoskeletal pain and a
reduced pain threshold as well as hyperalgesia

Int J Physiother Res 2015;3(5):1250-57. ISSN 2321-1822 1251
fostering more efficient movement patterns. This
is similar in principle to the dynamic stabilization
exercises widely used in the treatment and
prevention of musculoskeletal low back pain
(LBP), which advocates promoting efficiency of
deep stabilizers and decreasing contraction of
muscles counterproductive to the activity [3].
Stott Pilates is a version of the Pilates method
of physical exercise. It was developed by Lindsay
and Moira Merrithew. The most significant
difference between Stott Pilates and Joseph
Pilates’s (which was original method of the early
1900s) is that, where the original method uses
a straight spine during exercise, Stott Pilates
focuses on maintaining the natural curvature of
the spine.
“Yoga” derives from the Sanskrit word ‘yukti’
meaning “union,” aiming to unify spirit
(consciousness) with super spirit (God). Yoga is
one of the six systems of Indian Vedic philosophy
(Darshan). Maharishi Patanjali, rightly known as
the “Father of Yoga,” compiled and refined
various aspects of yoga systematically in his
“Yoga Sutras” (aphorisms), wherein he
advocated the eight-fold path known as
“Ashtanga Yoga” for an all-around development
of human personality. These include - Yama
[moral codes], Niyama [self-purification and
study], Asana [posture], Pranayama [breath
control], Pratyahara [sense control], Dharana
[concentration], Dhyana [meditation], and
Samadhi [super contemplation]. These are
formulated on the basis of multifarious
psychological understanding of human
personality [4,5].
The strongest evidence in both quality and
quantity suggests yoga has a positive impact
on hormone regulation. Salivary levels of cortisol
have been measured and notably decreased in
FMS patients in numerous reviews and trials [6-
9]. Yoga leads to increased cortisol is associated
with decreasing perceived stress, decreasing
anxiety, increasing feelings of well-being and
improving pain management [10,11] and higher
levels of melatonin to improve immunity and
sleep quality [12,13] are other potential effects
of yoga practice. Although individual asana and
pranayam practices can selectively affect
sympathetic or parasympathetic nervous system,
the overall effect of yoga practice is to bring a
stiffness, paresthesias, anxiety, depression and
some other psychological symptoms [1,2]. In the
most of cases of fibromyalgia, the causes are
unknown. Physical injuries, emotional trauma,
or viral infections may trigger the disorder, but
no one trigger has proven to be a cause of
primary fibromyalgia. The etiology and bio
pathophysiological mechanisms of FMS are not
completely understood still. It is a complex
disorder with considerable variations in clinical
symptoms among patients. Several mechanisms
such as peripheral & central hypersensitivity at
spinal or brainstem level, brain chemical and
hormonal abnormalities, muscle abnormalities,
altered pain perception and somatosensation
have been hypothesised in various studies [3,4].
Treatment is usually symptomatic because of
lack of understanding of etiology and
pathogenesis. A range of pharmacological and
non-pharmacological management is useful
according to evidence based guidelines and
reviews.
Exercise programs were reported to be helpful
in FMS patients in several studies. Such
exercises includes stretching, strengthening,
flexibility, aerobic exercises, yoga, tai chi etc..
Pilates is a particular exercise approach that
was founded by Joseph Pilates (1880–1967) and
was initially practiced by athletes and dancers.
Pilates training is intended to improve general
body flexibility and health by emphasizing “core”
(truncal) strength, posture, and coordination of
breathing with movement. Pilates exercises are
designed to put participants in a position that
minimizes unnecessary muscle recruitment,
which could potentially lead to early fatigue,
decreased stability, and impaired recovery.
Pilates exercises mainly focusing on back
extensors and the abdominal musculature, in
particular the transversus abdominis, is referred
to as core strengthening. The goal of core
strengthening without straining peripheral joints
is realized through concentrating on (1)
coordinating breathing with movement; (2)
scapular, pelvic, and rib cage stabilization during
abdominal movements; and (3) head and cervical
spine placement to avoid neck strain. As the
participant develops improved strength and
form, the base of support is gradually reduced
to retrain proprioceptive mechanisms while
Ashika Tanna, Soumik Basu, Kajal Anadkat. EFFECTS OF STOTT’S PILATES VERSUS YOGIC EXERCISE IN FIBROMYALGIA PATIENTS: A PILOT STUDY.

Int J Physiother Res 2015;3(5):1250-57. ISSN 2321-1822 1252
state of parasympathetic dominance. Sympathe-
tic activity decreased after yoga based guided
relaxation. Vijayalakshmi et al (2004) studied
that after 4 weeks of supervised yoga training,
there was optimization of sympathetic response
and restoration of autonomic regulatory reflex
mechanisms.
EEG studies show that yoga and meditation
practice lead to increase in alpha rhythm,
inter-hemispheric coherence & homogeneity in
the brain. On the night following yoga, the
percentage of slow wave sleep was significantly
higher, whereas the percentage of rapid
eye-movement sleep and the number of
awakenings per hour were less. Following this,
the self rating of sleep based on visual analog
scales showed an increase in the feeling that
the sleep was refreshing, an increase in feeling
“good” in the morning, an overall increase in
sleep duration [14].
MATERIALS AND METHODS
Participants: A total of 20 subjects who fulfill
the ACR 1990 Criteria, were participated in this
study. Subjects were recruited from Dr. D. Y. Patil
Orthopedic department, Physiotherapy OPD. All
subjects met the following inclusion criteria: (1)
Pain >3months (2) 11 tender points out of
18points over anatomical sites (3) Pressure
threshold <3kg/cm2 (4) Both male and female
patients within the age group of 20-50 years.
Subjects were excluded with following exclusion
criteria: (1) cardiac disease (2) vascular disease
(3) spine pathology (4) joint pathology. All
subjects were required to sign the written
informed consent document approved by the
ethical committee at Dr. D. Y. Patil Vidyapeeth,
Pimpri, Pune, India.
Study Design: This study was an RCT, was
completed in a month period. Recruitment began
on 20th of September 2012, and the study was
completed by 3rd of November 2012. Twenty
subjects were randomly allocated to two groups
by the investigator who was involved in data
collection, treatment implication, and data
analysis. 26 Fibromyalgia subjects were
targeted, out of which 20 were included for the
study purpose. Subjects in group A received
Pilates exercises.
While, subject in group B received Yoga; both
the groups received this protocol for a period of
one month, with a frequency of 6 times in a
week. Baseline assessments were done after
randomization, at the start of the protocol 1st
day and at the end of 4 weeks. For each subject,
all assessment sessions were performed at the
same time of day.
Assessment: VAS (Visual analogue scale), TPI
(Tender point index), AS (Algometric score), BDI
(Beck depression inventory) and FSS (Fatigue
severity scale) assessed at baseline & at the
end of 4 weeks.
Rehabilitation programme: The rehabilitation
program consisted of 24 sessions, each session
was 1 hour long, 6 times weekly for 4 weeks. All
treatment sessions occurred at the same time
of day on the same 6 days of the week
throughout the study. Intervention was
conducted individually and not in a group format.
The physical therapist was involved in
performing the intervention as well as
conducting the assessments. Pilates exercises
given to group A patients. There were 10 sets of
exercises of which few trial sessions were given
before starting the treatment protocol for core
muscle activation. Subjects were given warm up
(general mobility exercises) for 7-8min, then
pilates exercises were given, each for 5 reps and
then cool down (stretching exercises) were
given for 7-8 min.
Yoga given to group B patients and there were
10 alternating supine, prone and sitting poses
chosen. Subjects were given warm up (general
mobility exercises) for 7-8min, then yoga poses
were given, each for 5 reps and then cool down
(stretching exercises) were given for 7-8 min.
There is evidence in the literature to support
each of the components contained in the
intervention.
Outcome measures:
Visual Analogue Scale (VAS) [15]: Mechanical
version of a VAS (a tool with a 10-cm ruler and a
marker that the patient moves to the point
indicating his or her intensity of pain) used by
patients.
Scoring: 0 = No pain; 10 = Severe pain
Tender Point Index (TPI) [16]: Calculating the
Tender Point Index, Apply 4 kg of pressure to
each tender point, Observe body language,
Ashika Tanna, Soumik Basu, Kajal Anadkat. EFFECTS OF STOTT’S PILATES VERSUS YOGIC EXERCISE IN FIBROMYALGIA PATIENTS: A PILOT STUDY.

Int J Physiother Res 2015;3(5):1250-57. ISSN 2321-1822 1253
GROUP A - STOTT’S PILATES EXERCISE
GROUP B - YOGA
Bilateral leg lift in supine Bridging with swiss ball Neck extension with fore-
arm supp prone Heel slides with swiss ball
Shoulder & trunk roll with
swiss ball Shoulder & trunk flexion
with ball Alternate arm lifting with
swiss ball Knee extension with swiss
ball
Rowing on swiss ball Chest hold & arm lifting in
supine
Paschimottanasana
Yogamudrasana
DandasanaBhujangasanaNaukasana
Dhanurasana
Uttanpadasana
Utthithastha Merudand-
asana
Setubandhasana
Urdhva dhanurasana
Ashika Tanna, Soumik Basu, Kajal Anadkat. EFFECTS OF STOTT’S PILATES VERSUS YOGIC EXERCISE IN FIBROMYALGIA PATIENTS: A PILOT STUDY.

Int J Physiother Res 2015;3(5):1250-57. ISSN 2321-1822 1254
especially face, for response, Use the following
scale to quantify each response:
Not painful = 0
Felt painful, no physical response = 1
Felt painful, wince or withdrawal = 2
Felt painful, exaggerated withdrawal = 3
Area too painful to allow pressure = 4
Add the tenderness severities for all 18 sites:
The sum is the Tender Point Index (TPI)
The expected range for normal controls = 0-5
The expected range for fibromyalgia = 11-72
Algometric Score (AS) [17]: The foot pad of an
algometer is placed vertically on the skin of area
to be tested and consistently at a rate of 1kg/
sec. The subject is advised to say “now” when
the pressure makes the expected transition from
pressure to pain. Immediately the examiner
withdraw the instrument and read from the
gauge the maximum amount of pressure
achieved. Each of anatomical tender points
should then be examined and the sum of values
obtained from the 18 ACR Criteria designated
tender points is divided by 18 to obtain AS.
AS will be inversely proportional to the TPI.
Beck Depression Inventory (BDI) [18]: It is a
widely utilized 21-item self-report scale in both
clinical and research studies (Beck et al.,1996).
Interpretation of BDI:
1-10 - These ups and down are considered
normal
11-16 - mild mood depression
17-20 - borderline clinical depression
21-30 - moderate depression
31-40 - severe depression
>40 - extreme depression
Fatigue Severity Scale (FSS) [19]: There are 9
questions in FSS. Patients are instructed to
choose a number from 1 to 7 that indicates their
degree of agreement with each statement where
1 indicates strongly disagree and 7, strongly
agree. [Krupp et al, Arch Neurol 1989] The
scoring is done by calculating the average
response to the questions (adding up all the
answers and dividing by nine).
Statistical Analysis: Differences in data were
analysed by using Primer software under the
supervision of biostatistician staff. For within
group improvement in Visual Analogue Scale
(VAS), Tender Point Index (TPI), Algometric Score
(AS), Beck Depression Inventory (BDI) & Fatigue
Severity Scale (FSS), Paired t-test was used.
Between group improvement in Visual Analogue
Scale(VAS), Tender Point Index (TPI), Algometric
Score (AS), Beck Depression Inventory (BDI) &
Fatigue Severity Scale (FSS), Unpaired t-test was
used.
RESULTS AND TABLES
The finding of present study clinically supports
our alternative hypothesis which was Stott's
Pilates exercises(Group A) is more effective than
Yoga (Group B) in fibromyalgia patients. Our
result reveal significant improvements in VAS,
TPI, AS, BDI & FSS in both groups. No significant
differences between groups were found in VAS,
TPI, AS, BDI & FSS. The within group analysis
did not support the between group difference.
Table 1: Pre-treatment data for both groups.
Group A Group B
Mean SD Mean SD
VAS 7.5 0.849 6.9 0.948
TPI 34.7 8.994 29.5 4.483
AS 20.04 2.223 17.37 5.633
BDI 10.4 2.066 12.3 0.7379
FSS 4.718 0.6749 4.14 0.4904
Table 2: Post treatment data for both groups.
Group A Group B
Mean SD p Mean SD p
VAS 4.6 2.011 0.001 4.3 0.948 0.000
TPI 18.5 5.148 0.000 16.1 4.483 0.000
AS 24.88 6.179 0.058 22.36 5.633 0.000
BDI 6.9 1.197 0.000 6.1 0.7379 0.000
FSS 3.272 0.6158 0.000 2.862 0.4904 0.000
Graphs representing distribution of between
group comparison of VAS, TPI, AS, BDI and FSS
score respectively.
Graph 1: Pre and Post treatment comparison of VAS in
Group A and B.
Ashika Tanna, Soumik Basu, Kajal Anadkat. EFFECTS OF STOTT’S PILATES VERSUS YOGIC EXERCISE IN FIBROMYALGIA PATIENTS: A PILOT STUDY.

Int J Physiother Res 2015;3(5):1250-57. ISSN 2321-1822 1255
Graph 2: Pre and post treatment mean difference
comparison of VAS in both groups.
Graph 3: Pre and Post treatment comparison of TPI in
Group A and B.
Graph 4: Pre And Post Treatment Mean Difference
Comparison Of TPI In Both Groups.
Graph 5: Pre and Post treatment comparison of AS in
Group A and B.
Graph 6: Pre and post treatment mean difference
comparison of AS in both groups.
Graph 7: Pre and Post treatment comparison of BDI in
Group A and B
Graph 8: Pre and post treatment mean difference
comparison of BDI in both groups.
Graph 9: Pre and Post treatment comparison of FSS in
Group A and B.
Graph 10: Pre and post treatment mean difference
comparison of FSS in both groups.
DISCUSSION
Our study shows that both the treatment had
effect on improving VAS, TPI, AS, BDI & FSS but
statistically there was no difference existed
between both the groups at the end of 4 weeks.
The mechanisms responsible for the analgesic
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Int J Physiother Res 2015;3(5):1250-57. ISSN 2321-1822 1256
We believe that further research with more
participants and longer follow up periods could
help to assess the therapeutic value of these
exercises. The frequency, duration of exercises
in both the groups can be alter to check the
effectiveness of treatment. Other outcome
measure can be added to see the effect on ADL,
strength and endurance.
effect of exercise are not clearly understood
[20]. Although it is a widely accepted hypothesis
that activation of the endogenous opioid system
during exercise plays a key role in the analgesic
response mechanism, several researchers have
also suggested a multiple analgesic system
including non opioid mechanisms mediated by
other substances such as growth hormone and
corticotrophin [20,21]. Analgesic effect of
exercise may also help to break the vicious cycle
of pain-immobility-pain by encouraging the
patients to participate in the exercise programs.
Exercise may also increase the well-being of
patients by preventing muscular hypoxia which
is commonly seen in FMS patients [22].
Study has shown that FMS patients have
muscular asymmetry and antalgic postural
problems (Jones, et al) showed that FMS may
affect peripheral and/or central mechanisms of
postural control leading to significantly impaired
balance. The efficacy of Pilates exercise on
fibromyalgia in this study can explain by, Pilates
involves close kinetic chain exercises, which
provide the compressive and decompressive
forces necessary to foster nutrition to the joints
and cartilage to reduce risk of degenerative
changes and also helps to reduce chronic axial
musculoskeletal pain [23].
Several Scientific studies on yoga demonstrate
that yoga improves dexterity, strength and
musculoskeletal coordination of the
practitioners. Postures assumed during yoga
practice are mainly isometric exercises which
provide optimally maintained stretch to the
muscles. Series of asanas involve assumption
of the pose followed by counterpose i.e. it
involves co-ordinated action of synergistic and
antagonistic muscles which brings increased
steadiness, strength, stamina, flexibility,
endurance, anaerobic power, better neuro-
muscular coordination and improved orthostatic
tolerance [14].
Study limitation was that it was conducted with
small size of Fibromyalgia patients, hence there
is limited generalizability of findings to
population of people with Fibromyalgia
Syndrome as a whole. Instead of receiving bout
of exercises and yoga for a shorter period, they
may need to continue the programme for several
more months for better improvement.
CONCLUSION
Here, it can showed that Stott's Pilates exercises
and Yoga both are equally effective in treating
Fibromyalgia patients statistically but, clinically
Stott's Pilates exercises (Group A) showing bet-
ter improvement than Yoga (Group B).
ABBREVIATIONS
FMS - Fibromyalgia Syndrome
VAS - Visual Analogue Scale
AS - Algometric Score
TPI - Tender point Index
FSS - Fatigue Severity Scale
BDI - Beck Depression Inventory
ACKNOWLEDGEMENT
I would like to thank Principal Dr. Tushar Palekar and
my guide Dr. Senthil K. & all staff of Department of
Physiotherapy, Padmashree Dr. D. Y. Patil Vidyapeeth
(Pimpri-Pune), subjects of Fibromyalgia for support,
suggestions, co-operation, keeping spirits high and
successful attempt throughout the study.
There was no funding provided by any institute or
companies to purchase pressure algometer, for data
analysis as well as to do various instructor course for
the same study.
Ashika Tanna, Soumik Basu, Kajal Anadkat. EFFECTS OF STOTT’S PILATES VERSUS YOGIC EXERCISE IN FIBROMYALGIA PATIENTS: A PILOT STUDY.
Conflicts of interest: None
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How to cite this article:
Ashika Tanna, Soumik Basu, Kajal Anadkat. EFFECTS OF STOTT’S PILATES
VERSUS YOGIC EXERCISE IN FIBROMYALGIA PATIENTS: A PILOT STUDY. Int
J Physiother Res 2015;3(5):1250-1257. DOI: 10.16965/ijpr.2015.186