Rev Bras Med Esporte – Vol. 22, No 6 – Nov/Dez, 2016
THE IMPACT OF PILATES EXERCISES ON THE POSTURAL
ALIGNMENT OF HEALTHY ADULTS
EFEITO DOS EXERCÍCIOS DO MÉTODO PILATES NO ALINHAMENTO POSTURAL DE ADULTOS SAUDÁVEIS
EFECTO DE LOS EJERCICIOS DEL MÉTODO PILATES EN LA ALINEACIÓN POSTURAL DE ADULTOS SANOS
Míriam Raquel Meira Mainenti2
(Educadora Física e Fisioterapeuta)
Antonio Guilherme Fonseca
1. Centro Universitário Augusto
Motta (UNISUAM), Rio de Janeiro,
2. Escola de Educação Física do
Exército (EsEFEx), Rio de Janeiro,
3. Fundação Oswaldo Cruz
(FIOCRUZ), Rio de Janeiro, RJ, Brasil.
Míriam Raquel Meira Mainenti
Av. João Luis Alves, s/n, Urca, Rio de
Janeiro, Brasil. 22291-090.
Introduction: Exercises of Pilates method have been widely used to improve postural alignment. There is
strong evidence favoring their use in improving flexibility and balance, as well as some evidence of improvement
in muscle strength. However, the benefits related to posture are not well established. Objective: To investigate in
healthy adults, the impact of the Pilates method in the postural alignment through some angles in the sagittal
plane and the occurrence of pain before and after an exercise session, and after the completion of a 16-session
program. Methods: This is a quasi-experimental study of pre and post-intervention type. Healthy adults (n = 37)
interested in starting Pilates were evaluated for acute effects on posture after a Pilates session (n = 37) and after a
16-session program, for a period of 10 weeks (n = 13). Using the postural assessment software (SAPO), six angles
were analyzed: head horizontal alignment (HHA), pelvis horizontal alignment (PHA), hip angle (HA), vertical align-
ment of the body (VAB), thoracic kyphosis (TK), and lumbar lordosis (LL). The occurrence of pain was investigated
to control adverse effects. Results: Statistically significant (p<0.05) differences found after one session include
increased HHA (left view), decreased VAB (left view) and TK (both side views). After 16 sessions, we observed an
increase of HHA, and a decrease of TK, LL (both side views) and HA (right view). All the differences point to an
improvement of postural alignment. A significant reduction of prevalence of pain was verified after the first session
(40.5% vs. 13.5%; p=0.004) and after the full program (30.8% vs. 15.3%; p=0.02). Conclusions: Our results suggest
that the Pilates method has a positive impact on postural alignment in healthy adults, besides being a safe exercise.
Keywords: exercise movement techniques; exercise; posture.
Introdução: Os exercícios do método Pilates têm sido amplamente utilizados com a finalidade de melhorar o alinhamento
postural. Existem evidências científicas fortes que favorecem seu uso na melhora da flexibilidade e do equilíbrio, bem
como alguma evidência de melhora da força muscular. Entretanto, os benefícios relacionados à postura não estão bem
estabelecidos. Objetivo: Investigar, em adultos saudáveis, o impacto do método Pilates no alinhamento postural, por meio
de alguns ângulos no plano sagital e da ocorrência de dor antes e após uma sessão de exercícios, e também após o término
de um programa de 16 sessões. Métodos: Este é um estudo quase-experimental do tipo pré e pós-intervenção. Adultos
saudáveis (n = 37) interessados em iniciar Pilates foram avaliados quanto aos efeitos agudos sobre a postura após uma
sessão de Pilates (n = 37) e após um programa de 16 sessões, por um período de 10 semanas (n = 13). Usando o software
para análise postural (SAPO), seis ângulos foram analisados: alinhamento horizontal da cabeça (AHC); alinhamento
horizontal da pelve (AHP), ângulo do quadril (AQ), alinhamento vertical do corpo (AVC), cifose torácica (CT) e lordose
lombar (LL). A ocorrência de dor foi investigada para controlar efeitos adversos. Resultados: Diferenças estatisticamente
significativas (p < 0,05) encontradas após uma sessão incluem aumento do AHC (perfil esquerdo), redução do AVC (perfil
esquerdo) e da CT (ambos os perfis). Depois de 16 sessões, foi observado aumento do AHC e redução da CT, LL (ambos
os perfis) e AQ (perfil direito). Todas as diferenças encontradas apontam para a melhora do alinhamento postural. Uma
redução significativa de prevalência de dor foi verificada após a primeira sessão (40,5% vs. 13,5%; p = 0,004) e após o
programa completo (30,8% vs. 15,3%; p = 0,02). Conclusões: Nossos resultados sugerem que o método Pilates tem impacto
positivo sobre o alinhamento postural de adultos saudáveis, além de ser um exercício físico seguro.
Descritores: técnicas de exercício e de movimento; exercício; postura.
Introducción: Los ejercicios del método Pilates se han utilizado ampliamente con el fin de mejorar la alineación
postural. Hay una fuerte evidencia científica que favorece su uso para la mejora de la flexibilidad y el equilibrio, así
como algunos indicios de mejora de la fuerza muscular. Sin embargo, los beneficios relacionados con la postura no
están tan bien establecidos. Objetivo: Investigar en adultos sanos, el impacto del método de Pilates en la alineación
postural a través de algunos ángulos en el plan sagital y en la aparición de dolor antes y después de una sesión de
ejercicios, y también después de un programa de 16 sesiones. Métodos: Se trata de un estudio cuasi-experimental del
tipo antes y después de la intervención. Se evaluaron adultos sanos (n = 37) interesados en iniciar Pilates para efectos
agudos sobre la postura después de una sesión de Pilates (n = 37) y después de un programa de 16 sesiones durante
10 semanas (n = 13). Usando el software para el análisis postural (SAPO), se analizaron seis ángulos: alineación
horizontal de la cabeza (AHC); alineación horizontal de la pelvis (AHP), el ángulo de cadera (AC ), la alineación vertical
Rev Bras Med Esporte – Vol. 22, No 6 – Nov/Dez, 2016
Artigo recebido em 02/09/2015 aprovado em 18/08/2016
del cuerpo (AVC), cifosis torácica (CT) y la lordosis lumbar (LL). La aparición de dolor se investigó para controlar los
efectos adversos. Resultados: Las diferencias estadísticamente significativas (p < 0,05) encontradas después de una
sesión incluyen aumento de AHC (perfil izquierdo), reducción de la AVC (perfil izquierdo) y aumento de la CT (ambos
perfiles). Después de 16 sesiones, se observó un aumento de la AHC y reducción de la CT, LL (ambos perfiles) y AC (perfil
derecho). Todas las diferencias apuntan a la mejora de la alineación postural. Se observó una reducción significativa
en la prevalencia del dolor después de la primera sesión (40,5% vs. 13,5% p = 0,004) y después del programa completo
(30,8% vs. 15,3%, p = 0,02). Conclusiones: Nuestros resultados sugieren que el método Pilates tiene un impacto positivo
sobre la alineación postural en adultos sanos, además de ser un ejercicio seguro.
Descriptores: técnicas de ejercicio con movimientos; ejercicio; postura.
Pilates is a mind-body exercise approach requiring core stability,
strength, flexibility, attention to muscle control, posture control and
breathing. Exercises may be floor-based, but also include use of spe-
cialized equipment1.The method is widely used by physical fitness and
rehabilitation professionals,2 aiming to ensure postural alignment dur-
ing the execution of movements in functional positions3. Exercises also
involve focused breathing and the activation of the central region of the
body, especially the muscles located between the rib cage and the hips
The Pilates method has been applied worldwide but its benefits are
yet to be established for postural alignment, which is critical since one of
the basesof this methods’ theory is the posture control. There is strong
evidence in the literature related to the effect of Pilates increasing flex-
ibility and balance, and moderate evidence concerning the increase of
muscle strength5. However, there are few reliable evidence concerning
the benefits of the method to posture alignment in orthostatic position
A study sought to determine the effect of a Pilates training program
(1h session twice a week for 12 weeks) on arm-trunk posture, strength,
flexibility and biomechanical patterns
. The results indicated that the
Pilates training program was effective in improving abdominal strength
and upper spine posture, as well as in stabilizing core posture when
shoulder flexion movements were performed. In another report
researcher’s recruited 34 adults aged 60 and over to participate in a
study investigating saggital spinal posture after Pilates-based exercises.
Results of their training indicated that immediately after the Pilates-
based exercise program, older adults stood with slightly decreased
thoracic flexion and sat with slightly increased lumbar extension.
Improvements were also presented in a randomized controlled trial
(RCT )with 74 adult women6, both in head sagittal alignment and in
pelvis frontal alignment. No adverse effect was controlled in this RCT
and also no analysis was performed considering thoracic and lumbar
angles in sagittal plane6.
Even though the effects of Pilates method on postural alignment
are not well established, many individuals seek this method to improve
. Souza et al.
observed that most Pilates exercise
practitioners (38.8%) shared the same goal: posture improvement.
Furthermore, the same authors verified that most individuals (73.4%)
who enrolled to an exercise program based on the Pilates method
complained about pain or musculoskeletal discomfort. Since many
individuals seeking Pilates exercises feel some kind of discomfort or
musculoskeletal pain, even being healthy (with no chronic diseases),
pain is an important variable to be controlled. In addition, it is also
important to verify if the exercise is not being harmful to the individual
who practices this type of exercise.
In light of such context, the aim of the present study was to investigate
the impact of the Pilates method in the postural alignment analyzing six
angles in the sagittal plane, before and after one training session, and
after the completion of a 16 session program. In order to control for
possible adverse effects, the occurrence of pain was also investigated.
This is a quasi-experimental study, pre and post-intervention. Adults
who were willing to start up the Pilates exercise method were included.
In a first trial class, the subject was invited to participate in the study. Inclu-
sion criteria were: age between 18 and 59 years (adults); being unfamiliar
with the method, or not having practiced it for at least six months; and
able to perform the proposed session sequence protocol. The exclusion
criteria were: occurrence of any kind of musculoskeletal pain that would
prevent the subject from completing the intervention; pregnant women;
individuals under global postural reeducation treatment, surgery on the
musculoskeletal system in the previous year, neurologic or osteomuscular
disease, abnormal blood pressure and cancer. All subjects had a good
general physical aptitude. Regarding the 16 sessions program, individuals
that missed more than 2 weeks of classes, consecutively, were excluded.
The acute effect was evaluated in 37 individuals: 29 (78.4%) females and
8 (21.6%) males, while 13 individuals finished the 16 sessions program:
11 (84.6%) females and 2 (15.4%) males.
To assess the 16 session program, all individuals that practiced
Pilates twice a week and had not missed the sessions for a period ex-
ceeding 2 consecutive weeks were included. All participants signed
an Informed Consent and the study was approved by the institutional
ethics committee of Augusto Motta University Center - UNISUAM (CAAE:
Evaluations were carried out on three occasions: before and after
the first session, to verify the acute effect of a single session; and after
the subject had completed 16 sessions, to verify the full program effect.
Before the first session, a questionnaire was filled out including
personal information and anthropometric data. Pain/discomfort loca-
tion and its intensity according to the Faces Scale were evaluated for
several body locations12. It was assured that the pain was not related to
the discomfort felt by stretching exercises.
Then, anatomical references were manually palpated and marked
by a single evaluator, properly trained, using styrofoam balls and
double-face adhesive tape. The evaluator was trained in palpatory
anatomy and placement of anatomical markers. In addition, before
the present data was collected, a pilot project was performed. The
following anatomical landmarks were identified: in the anterior view,
bilaterally, tragus, acromion, and anterior superior iliac spine (ASIS);
in the side views bilaterally, the greater trochanter of the femur, knee
joint line, and the lateral malleolus; and in the posterior view: posterior
superior iliac spine (PSIS), bilaterally, and the spinous processes of C7
(seventh cervical vertebra), T12 (twelfth thoracic vertebra) and S1 (first
sacral vertebra). Also, we observed the most convex point of the tho-
racic spine of each individual, and the spinous process was marked13.
Rev Bras Med Esporte – Vol. 22, No 6 – Nov/Dez, 2016
Figure 1. Anatomical points and obtained angles.
1. Head horizontal alignment 2.Pelvis horizontal alignment 3. Hip angle 4. Vertical alignment of the body 5.Thoracic
kyphosis 6.Lumbar lordosis.
This marked process was filed in the subject’s questionnaire, so that
the same point could be used for the next photos. The most concave
point of the lumbar spine was observed and the spinous process
marked, and also filed in the subject’s questionnaire. For the vertebral
column, 25 mm styrofoam balls were used to better ensure the side
view identification. For the remaining points, 15mm balls were used.
Postural alignment evaluation was carried out in sagittal plane.
Postural analysis in three views (anterior, lateral and posterior), would
generate many angles to be analyzed, which would require a very large
sample to have statistical validity. Thus, we chose to analyze only the
side view, with five angles. Some authors claim that the sagittal plane
is the one that best reflects postural clinical evolution, since, on this
plane, angle values differ from zero14. In addition, it has been reported
that a good understanding of the principles of sagittal balance is vital to
achieve satisfactory results when treating postural disorders. Even when
addressing problems in the coronal plane, awareness of the sagittal
balance is necessary to avoid future complications15.
Table 1 and Figure 1 show the six evaluated measurements and
their full description.
Postural assessment was carried out individually with Cyber Shot
W570 (Sony, São Paulo, Brazil) digital camera, positioned 1m from the
floor, on a tripod, 3m away from the subject. The zoom setting was 1.9x.
Women were instructed to wear tops and shorts, and men, Bermuda
shorts. They were freely positioned on the millimeter paper (30 cm
from a wall). The following verbal command was given: “Please stand
on this paper in a comfortable position". The subject was then asked
to flex his elbows, with the forearm in neutral position, to allow the
visualization of the vertebral column markers. Next, the feet contour
was drawn, to guarantee the same support basis in all photo records
All photos were transferred to the computer and analyzed with the
SAPO software. SAPO is a free and simple software developed by re-
searches in Brazil, in 2006, that is frequently used in this country. A study
designed to estimate the accuracy of SAPO considered the software a
reliable tool for postural assessment. Five blinded raters analyzed 88
pictures, and inter and intra-rater reliabilities were estimated using the
intraclass correlation coefficient. Inter-rater reliability was excellent for
41% of the variables and very good for 35%. Ten percent of the variables
had acceptable reliability, and 14% were defined as non-acceptable.
For intra-rater reliability, 44.8% of the measurements were considered
to be excellent, 23.5% were very good, 12.4% were acceptable and
19.3% were considered non-acceptable. Angular measurements had
a mean error analysis of 0.11°
. Additionally, another study using
SAPO for analysis found excellent interrater agreement (ICC> 0.90)
for 28 variables (84.85%) and good agreement (0.80> ICC> 0.89) for
5 variables (15.15%)18.
For comparisons, reference values for the angles measured in this
study were obtained from a systematic review
that sought articles that
employed SAPO as an evaluation tool on healthy adults.
After the completion of the program, a post-intervention evaluation
was scheduled for up to three days after the last session.
One-hour sessions were run by instructors from a Pilates Studio in
Rio de Janeiro, Brazil, who were professionally trained in the method
to accomplish the proposed session protocol. These instructors have
professional training in the Pilates method by the same company (Meta-
corpus Studio Pilates), and before working at Studio underwent a 15-day
training process. The exercises were mat- and equipment-based (Cadil-
lac, Wall Unit, Combo Chair, Reformer and Ladder Barrel –Metacorpus
Studio Pilates, Rio de Janeiro, Brazil).
Verbal commands and tactile guidelines were employed for
conducting the sessions and correcting the performance of exercises.
Different postures were used according to the subject’s needs and
objectives and to his/her performance throughout the sessions. Postural
alignment, movement quality, the principles of centralization, control,
concentration, precision, breathing and fluidity were always the focus.
One set for each of the exercises with 10 repetitions was performed.
Table 1. Evaluated measurements in the lateral views and their abbreviations.
Angle Description of the assessed angles
Angle formed between the line that links C7 and the tragus
with a horizontal line. It is used to verify the head position
in terms of protraction and retraction. It is always positive;
the higher the angle value, the smaller the head protraction.
Angle formed between the line that links ASIS and
PSIS with a horizontal line. It is used to verify whether
the pelvis is in anteversion (anterior inclination), or in
retroversion (posterior inclination). It is always negative;
the more negative, the larger the pelvic anteversion; the
closer to zero, the greater the pelvic retroversion.
Hip angle HA11, 13,15
Angle formed between the line that links ASIS and the
greater trochanter of the femur with the line that links the
knee joint line to the greater trochanter of the femur. It
is used to verify the position of the hip joint in relation to
the flexion and extension. It is always negative; the more
negative, the greater the hip tendency and extension; the
closer to zero, the greater the tendency to hip flexion.
Vertical alignment of
the body VAB11,13,15,16
Angle formed between the line that links the acromion
and the lateral malleolus with a vertical line, and it reflects
the anteroposterior inclination of the body. It is always
positive; the higher the angle value, the greater the
forward body inclination.
Thoracic Kyphosis TK17,18
Angle formed from the intersection of the lines that
link the spinous processes of C7 and T12 with the most
convex point of the thoracic spine. It is always positive;
the higher the angle value, the smaller the thoracic
Lumbar lordosis LL17
Angle formed from the intersection of the lines that link
the spinous processes of T12 and S1 with the most convex
point of the lumbar spine. It is always positive; the higher
the angle value, the smaller the lumbar lordosis curvature.
Rev Bras Med Esporte – Vol. 22, No 6 – Nov/Dez, 2016
The first session comprised the following sequence:
1. Mobility and initial warm up stretching workouts
a) 1 exercise for spine mobility
b) 2 exercises for posterior chain stretching
2. Lower limbs strengthening
a) 2 exercises for the quadriceps
b) 1 exercise for the triceps surae
c) 1 exercise for the hamstrings and gluteus
d) 1 exercise for the hip adductor muscles
3. Abdominal toning (3 exercises)
4. Strengthening the upper limbs
a) 2 exercises for the great dorsal muscle and biceps
d) 1 exercise for the triceps and for the serratus anterior
c) 1 exercise for the scapular adductors
5. Mobility exercises and final stretching
a) 1 exercise for the spine mobility
b) 2 exercise for stretching the posterior chain
6. Relaxing on the foam roller
The remaining sessions followed the same sequence: mobility and
stretching, strengthening and new mobility and stretching, and final
relaxation. However, according to the specific needs and objectives
planned by the instructor for each individual, the exercises could vary
concerning their amount for each muscle group. As each individual has
different motor experiences, exercise progression during the sessions
may vary, which makes it unfeasible to prescribe the same exercise series
for everyone. According to the Brazilian Society of Sports Medicine, the
emphasis for each individual varies according to their clinical condition
and according to the objectives of each20. The subjects were instructed
to report any musculoskeletal pain complaints when performing the
exercises, which would be interrupted if there were any.
The data were analyzed by the R program for Windows 3.0.121 and
described as median and interquartile range (IQR). For tables, we also
included mean ± standard deviation for a better comprehension of the
data. Two paired analyses were performed: the first one, to evaluate the
effect of a session, and the second, to verify the effect of the 16 sessions
program. In addition, an independent analysis was also carried out with
the purpose of comparing the initial characteristics of the group that
concluded the 16 sessions program (n=13) and the group that failed to
complete the protocol (n=24). The Fisher test (independent analysis)
and the McNemar test (paired analysis) were used for comparing the
frequencies of the categorical variables. The paired Wilcoxon test was
used to compare the pre and post-intervention angular values, and the
non-paired test was used for the independent analysis, considering
the significance level p ≤0. 05. Mixed effect linear models were used
to study the association covariates age and abdominal circumference
with the outcomes studied, since aging
be associated with postural alignment.
The acute effect was evaluated in 37 individuals: 29 (78.4%) females and
8 (21.6%) males (Table 2). Only four (10.8%) were under physical therapy
(electrotherapy techniques) and 18 (48.6%) claimed to practice some other
type of physical exercise regularly. For pain or musculoskeletal discomfort,
35.1% of the subjects (n=13) presented some complaint, with a median
intensity of 3 (IQR=2;4) –moderate pain, according to the Faces scale.
After the first session, there were significant increases of the
HHAangle (left view) and TK angle (both side views). It could be also
observed a reduction of the VAB angle (left view). These results point
to an improvement of postural alignment (Table 3).
Immediately after the first session, only 13.5% of the sub-
jects (n=5) reported pain, compared to 40.5% (n=15) at baseline
(p=0.004; McNemar Test); the median intensity after the first session
(2, IQR=2;2) was also lower compared to baseline (3,IQR=2;4).
Effect of the 16 session program
The effect of the Pilates method after the full 16 session program
was evaluated in 13 individuals: 11 (84.6%) females and 2 (15.4%) males
(Table 2). Among those, only two practiced other exercises regularly. None
of the subjects started practicing any other physical exercise during the
period of intervention. The remaining 24 individuals were excluded from
this analysis due to the fact that they did not complete the program.
It is noteworthy that these individuals did not present characteristics
that statistically differed from the group that completed the protocol
(n=13) (Table 2). The high number of individuals who didn’t complete
the program occurred because of faults in the classes for a period not
exceeding two weeks (personal reasons involving travel, work, vacation,
family problems); individuals that choose to practice only once a week
were also excluded for the analysis after 16 classes. The dropouts did
not affect the validity since there was no difference between groups.
Table 2. Distribution of demographic variables.
Variables All the subjects
Age (years) 35.2 ± 12.9
34.9 ± 14.1
35.4 ± 12.5
Weight (kg) 68.0 ± 12.9
63.9 ± 10.7
70.2 ± 13.7
Height (m) 1.70 ± 0.10
1.60 ± 0.10
1.70 ± 0.10
BMI (kg/m2)24.6 ± 3.2
23.7 ± 2.2
25.1 ± 3.6
Pain 13 (35.1) 4 (30.8) 9 (37.5)
AC (cm) 85.3 ± 9.7
83.3 ± 8.7
86.3 ± 10.2
Values expressed as mean ± standard deviation; and median (1st quartile; 3rd quartile), except for pain: counts
(relative frequency, %); Wilcoxon’s independenttest for continuous variables and Fisher’s exacttest for categorical
variables (occurrence of pain) when comparing subjects who completed the protocol with those who did not
(p>0.05 for all the comparisons); BMI: body mass index; AC: abdominal circumference.
Table 3. Angles (in degrees) observed before and after the first session (n=37).
Angles Before the session After the session
HHA/R (º) 42.60 ± 4.10
43.40 ± 4.70
HHA/L (º) 43.80 ± 4.60
45.90 ± 4.70
PHA/R (º) -9.90 ± 4.40
-10.70 ± 4.70
PHA/L (º) -9.90 ± 4.20
-10.00 ± 4.20
HA/R (º) -4.60 ± 2.8
-5.30 ± 3.90
HA/L (º) -6.80 ± 3.40
-6.90 ± 3.70
VAB/R (º) 2.30 ± 1.20
2.40 ± 1.10
VAB/L (º) 1.90 ± 1.30
1.40 ± 1.10
TK/R (º) 154.10 ± 5.40
155.30 ± 5.20
TK/L (º) 154.00 ± 5.30
155.00 ± 5.20
LL/R (º) 150.70 ± 10.80
151.00 ± 11.70
LL/L (º) 150.50 ± 11.30
151.30 ± 11.60
Values expressed as mean ± standard deviation; and median (1
quartile). R: right; L: left; * p < 0.05;
paired Wilcoxon Test; HHA: head horizontal alignment; PHA: pelvis horizontal alignment; HA: hip angle; VAB: vertical
alignment of the body; TK: thoracic kyphosis; LL: lumbar lordosis.
Rev Bras Med Esporte – Vol. 22, No 6 – Nov/Dez, 2016
Compared to baseline, the 13 individuals who completed the pro-
gram, showed statistically significant differences for the following aspects:
increase of HHA, TK and LL angular values (right and left views); as well
as reduction of the HA angular value (right view)(Table 4). From the
initial assessment of 13 individuals, 11 reported having any factor in his
posture that bother (84.61%) after the program. Only 2 continued refer
ring some uncomfortable posture, indicating that the improvement of
posture alignment had clinical significance in the group.
Musculoskeletal pain/discomfort was reported by 4 (30.8% from de 13
individuals) during initial assessment; and by only 2 (15.4%) after program
completion, which represented a significant decrease (p=0.02). In this
group the median of pain after the program was 2(IQR = 2;2), mild pain.
After applying mixed effect linear models, used to control the ef-
fect for other covariates, age and abdominal circumference remained
in the final model. We observed - regarding acute effect - that the
significant alterations in the angles HHA (left view), VAB (left view), TK
(right view) were maintained. As for the 16 sessions program, after this
same control, maintenance of the alterations to HHA, TK and LL (both
side views) could also be observed. Thus, it could be noted that the
most robust results were the benefits provided to the head position,
vertical alignment of the body and to the spinal alignment.
Our results have pointed that the Pilates method has a positive impact
on postural alignment of healthy adults, after one session, and after a
program of 16 sessions, which means that analyzed angles showed values
closer to what is considered as neutral postural alignment19. Since many
individuals seek the Pilates method in order to improve posture11, it was
important to study whether this exercise brings postural benefits. When
the study sample was asked, if there was something that bothered in
their posture, 28 (75.7%) said yes, showing the relevance of this question.
Also, some studies suggests a relationship between the presence of some
postural abnormalities, that can be present in healthy subjects, and the
incidence of pain, so it’s important to see if the Pilates method is able to
Subjects that did not complete the program were excluded because
they missed two or more weeks of classes, consecutively, or because they
practiced once a week, and not because they were feeling pain. The instruc-
tors were trained to ask their clients, every class, about pain or discomfort,
and this has not been reported as a cause of failure or interruption of classes.
In the acute effect analysis, an increase of the angular value for the
horizontal alignment of the head to the left side (HHA/L) was observed,
indicating a reduced forward head posture
immediately after the session,
to the left lateral view. The unilateral improvement may have occurred
due to a certain level of head rotation, in the coronal plane; however, this
plane was not investigated. After the 16 sessions, a significant increase
of the angular value of the right and left HHA could be observed. Such
increases reflect values closer to those considered as reference for this
angle, which has a mean value of 51.42°(ranging from 43.80°and 54°)
Positive results regarding head alignment in the sagittal plane have also
been observed by Nunes Junior et al.
, who evaluated the posture of
individuals aged between 50 and 66 years old, who took part in a 36 session
Pilates program, three times a week. Four of the five evaluated par ticipants
showed reduced forward head posture. Forward head position has been
linked to musculoskeletal dysfunction and pain including craniofacial pain,
headache, neckache, and shoulder pain26.
In the analysis of VAB (left view), a significant acute reduction
was observed. Reference values for this angle vary from 0.98°to
, and the higher the angle value, the more the
body tilts forward. It can be inferred that there was an improvement
of the vertical alignment of the body, in left side view, after the first
Pilates session. The finding observed only for the left side may have
occurred because of a greater protrusion of the shoulder to the right
side; however, such analysis has not been included in this study.
There was a significant increase in the angular value of the TK (both
side views) after a single Pilates session, which reflects a reduction in
thoracic kyphosis. Kuo et al.8 investigated the postural alterations of the
spine, in the sagittal plane, in 34 healthy elderly individuals in standing
and sitting positions, after a 10 week program of the Pilates method.
The TK angle decreased, on average, 2.3°(p =0.002), immediately after
the exercise program, when the subjects were evaluated in standing
position. Such TK reduction immediately after the Pilates session is in
accordance with our results regarding the acute effect.
In the same study, such alteration changed during the follow-up
period, one week after the program had been completed. The TK angle
had an increase of 0.9°, losing significance (p=0.119). In our study, the
subjects were evaluated up to 3 days after the end of the 16 sessions
program, at which point we observed a significant decrease of the TK.
Benefits of the Pilates method regarding the decrease of TK have also
been reported by Emery et al.
, who observed the sitting posture of
healthy individuals, after a 12 week Pilates program.
We have found an increase in the LL angular value (both side views)
after the 16 sessions, which reflects a decrease of lumbar lordosis. Kuo
et al.8, nevertheless, did not observe any significant difference of LL in
elderly individuals after a Pilates training period.
The positive effects for postural alignment can be attributed to the
movements performed within the principles of the Pilates method, which
implies body awareness improvement. Besides, there is the emphasis on
the maintenance of postural alignment, seeking axial growth during all
exercises. The improvement of postural alignment was still significant,
even after controlling for potential confounders through mixed effect
linear models. When the control was done by abdominal circumference
and age, it was observed that there were postural benefits in the head
Table 4. Angles (in degrees) and abdominal circumference (in centimeters) observed:
prior to the first session and after the 16 sessions (n=13).
Angles Before the session After the 16 sessions
HHA/R (º) 42.70 ± 4.00
44.60 ± 4.10
HHA/L (º) 43.10 ± 4.30
46.70 ± 3.40
PHA/R (º) -8.90 ± 4.90
-10.00 ± 4.00
PHA/L (º) -7.90 ± 5.10
-9.70 ± 4.60
HA/R (º) -4.40 ± 2.90
-6.00 ± 2.60
HA/L (º) -6.60 ± 3.50
-6.80 ± 2.80
VAB/R (º) 2.00 ± 1.30
1.60 ± 1.20
VAB/L (º) 1.80 ± 1.30
1.50 ± 1.00
TK/R (º) 154.00 ± 5.10
157.40 ± 4.90
TK/L (º) 153.70 ± 4.60
157.20 ± 5.30
LL/R (º) 151.60 ± 11.10
154.50 ± 9.10
LL/L (º) 151.90 ± 11.20
154.50 ± 10.20
AC (cm) 83.30 ± 8.70
80.10 ± 8.00
Values expressed as median (1st quartile; 3rd quartile); Paired Wilcoxon Test. * p< 0.05 when compared before the
session and after 16 sessions; HHA: head horizontal alignment; PHA: pelvis horizontal alignment; HA: hip angle; VAB:
vertical alignment of the body; TK: thoracic kyphosis; LL: lumbar lordosis; R: right; L=left; AC: abdominal circumference.
Rev Bras Med Esporte – Vol. 22, No 6 – Nov/Dez, 2016
position, in the vertical alignment of the body and in the spinal alignment.
These results are applicable to healthy subjects, so, further studies are
required to check if the Pilates method is effective in improving posture
in different populations and age groups.
Regarding pain, there was a significant reduction immediately after the
first session, which suggests that the practice of Pilates is a safe procedure.
Such results are in accordance with a study in which adult individuals
submitted to a Pilates program did not report any serious side effects
resulting from the exercises, and the rate of adverse events was ver y low27.
It can be suggested that pain intensity was reduced immediately after the
session. However, as it was not assessed a few hours after the session had
finished, we cannot claim that this was a sustained effect.
The significant reduction in pain levels after 16 sessions suggests a
possible beneficial effect of the technique in relation to reduction of mus-
culoskeletal pain, as corroborate by a recent systematic review on chronic
nonspecific low back pain28. Pilates method avoid positions that demand
unnecessary muscle recruitment, which could cause early fatigue, reduction
of stability and a damaged recovery period4, which may explain why Pilates
method is a kind of exercise that don’t causes pain when well executed.
Despite the originality of the present study, one important limitation
was that the effect of the Pilates method after the full 16 session program
was evaluated in only 13 individual, a small sample size. In further studies we
shouldhave a control group and larger samples. Besides, while the instructors
selected exercises for each individual’s posture, this study could not be
replicated. Nevertheless, the instructors were trained to use the exercises
of the method, thinking about individual’s goals should achieve. The same
muscle group can be worked in different ways, in the mat or equipment.
The study points that the Pilates method has a positive impact in the
postural alignment of healthy adults, as measured either acutely after a
single session or after a 16 session program. It is relevant to assess posture
as it is a variable that individuals who seek the method want to improve.
It also seems to be a safe method, as it did not lead to the occurrence or
increase of musculoskeletal pain or discomfort. Even though more studies
are necessary to confirm these results, specially randomized controlled
trials, we believe that Pilates is a safe method and should be recommended
for healthy individuals seeking posture improvement.
This studywaspartiallysupportedby Fundação Carlos Chagas Filho de
Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ) and Conselho
Nacional de Desenvolvimento Científico e Tecnológico (CNPq).
The authors declare that there is any potential conflict of interests
regarding this article.
CONTRIBUIÇÕES DOS AUTORES: Each author contributed individually and signicantly to the achievement of the manuscript. BK (0000-0002-8490-4802) *, was responsible
for writing the manuscript, data collection and intervention. MRMM (0000-0002-2562-9142) * and AGFP (0000-0003-3095-1774) * developed the work and performed
the data analysis. All authors reviewed the manuscript, design, discussed the results, dened and evaluated the study. * ORCID (Open Researcher and Contributor ID).
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