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The 9 studies included in this review involved people of different ages, predominantly adolescents but also children and adults. The interventions were all Pilates-based; although the findings they assessed varied, they all highlighted common themes. Pilates is a mind–body exercise that focuses on core stability, flexibility, posture control and breathing [41], and it has recently become a target of interest as a beneficial form of exercise [42]. The findings of this review provide strong evidence that muscle strength and control can be enhanced to correct spinal deformities and improve posture through Pilates training, and that participants’ self-image and social interaction can also be enhanced through Pilates. The study results show that Pilates can be used to benefit a variety of people of different ages, including children, junior high school students, high school students, college students, people with AS and those with upper cross syndrome. The findings of this systematic review have important implications for the development of targeted Pilates training programmes for postural correction, improving spinal deformities, and the promotion of physical health and well-being.
Effects of Pilates on spinal deformity and posture
Recent research and clinical trial results have shown that Pilates has emerged as a promising intervention for correcting spinal deformities and improving posture. This systematic review provides a comprehensive discussion centred on the background and findings of recent relevant studies with the aim of revealing whether Pilates has positive effects on spinal deformity and posture. Exploring the potential mechanisms and clinical treatment outcomes of these effects will inform and provide insights for subsequent relevant research and practice by academics and healthcare professionals.
The diagnosis of scoliosis is based on a standing anteroposterior radiograph with a Cobb angle greater than 10° [43]. In addition to Cobb’s Crossing, the Angle of Trunk Rotation (ATR) is another important indicator of scoliosis. Two studies in the literature included in this systematic review addressed the effect of the Cobb angle and ATR on scoliosis. Rrecaj-Malaj’s [33] study showed that both groups of patients significantly improved in terms of lordosis malformations while wearing and not wearing a brace for the Cobb angle (from 21.97 ± 4.99° to 18.11 ± 6.39°; from 14.19 ± 3.11° to 11.66 ± 2.73°), ATR (from 7.19 ± 1.36° to 5.36 ± 1.66°; from 4.72 ± 1.04° to 3.58 ± 0.94°), chest expansion (from 2.56 ± 0.84 cm to 3.46 ± 0.72 cm; from 2.57 ± 0.87 cm to 3.52 ± 0.72 cm), trunk flexion (from 9.55 ± 1.95 cm to 14.33 ± 2.40 cm; from 9.82 ± 2.61 cm to 13.98 ± 2.18 cm). These results were achieved in 69 patients aged 11–17 years with mild-to-moderate idiopathic scoliosis after 24 weeks of combined Schroth and Pilates exercises. The results of this study are consistent with those of previous related studies [24, 44]. However, Başaran Özden [34] compared the Cobb angle and ATR in the PG and CG groups in their study at baseline and after eight weeks of intervention, finding no significant changes in either parameter in patients with adolescent idiopathic scoliosis after the Pilates intervention. Based on our discussion, it was concluded that the inconsistency between the results of these two studies may have been because Schroth exercises were superior to Pilates exercises in improving the Cobb angle and ATR.
Spinal curvature is the criterion for determining thoracic kyphosis and lordosis malformations [45]. From the literature included in this review, seven studies involved spinal curvature. Ahmadi’s [37] study on female students showed that through Pilates exercise intervention, students improved on average by 13.68 degrees of hyperkyphosis and 10.79 degrees of hyperlordosis. Weight, height and body mass index were effective factors in alleviating thoracic or lumbar spine abnormalities. Thus, Pilates practice based on the scientific principles of therapeutic planning can be effective in correcting kyphosis and lordosis malformations in female students. The research data gathered by Karkousha [38] showed that participants in the EG and CG groups pre-treatment had mean ± SD of spinal curvature of 45.9 ± 2.6 and 45.2 ± 2.2 degrees, respectively, while the measurements post-treatment were 42.1 ± 2.7 and 35.1 ± 2.4 degrees, respectively. The result confirmed that the Pilates exercise programme proved better than a traditional physical therapy programme in improving spinal curvature in those with upper cross syndrome. In Gandomi’s [39] study comparing the effects of Aqua Pilates and Aqua Stretch exercises on spinal posture in patients with AS, the results for each group of subjects revealed significant improvements in elevated spinal curvature and spinal ROM. The results of González-Gálvez’s [36] data showed a significant reduction in the thoracic kyphosis angle and lumbar lordosis angle in the relaxed standing position for the PG. The adjusted mean difference found between the groups for the thoracic curve was 5.9°. The results of two other studies by González-Gálvez [40] examined how the Pilates method improved the sagittal spinal curvatures and hamstring extensibility of adolescents. Based on the findings, with prolonged Pilates training, adolescents can effectively alleviate increased thoracic spine curvature in the standing position; avoid a further increase in thoracic spine curvature during active alignment in the standing position; and avoid an increased thoracic spine curvature during the anterior trunk tilt. Furthermore, in Rrecaj-Malaj’s [33] study of adolescents with idiopathic scoliosis, spine curvature was only measured at baseline and not further interpreted. The results of the studies discussed above indicate that Pilates intervention has significant effects in terms of reducing spinal curvature in different populations and different patients.
Posture problems can negatively impact overall health, leading to diseases, pain or functional disorder and thus potentially affecting quality of life in both childhood and adulthood [46]. Spinal deformity is a common postural problem. This systematic review discusses the effects of Pilates on spinal deformities while incidentally understanding its effects on posture. González-Gálvez [40] showed that with prolonged Pilates intervention training, lumbar lordosis and pelvic tilt curvature can be reduced, thereby decreasing the prevalence of anterior pelvic tilt in the adolescent population. Ozturk [35] conducted a 10-week Pilates intervention with 66 preschoolers aged 5–6 years old and assessed their body posture, which included the head, shoulders, back, lower back and legs. The results showed significant effects on rounded shoulders and thoracic kyphosis in the PG relative to the CG group after Pilates training. On the other hand, Cibinello [32] showed that after 12 weeks of mat Pilates training, some postures improved. However, since the subjects were at a stage of rapid skeletal development and body structure growth, it was impossible to determine whether this improvement resulted from the Pilates intervention. The findings of these studies are consistent with previous research showing that Pilates leads to notable improvements in posture. Pilates can be promoted as an effective intervention to improve posture in people of all ages.
Overall, the above studies provide strong, compelling and valuable evidence for the role of Pilates in improving spinal deformity and posture. These recent results have demonstrated that Pilates can be used by people of different ages and with different spinal disorders. Underlying postural problems can also be alleviated through Pilates interventions. These findings again demonstrate the breadth of the Pilates audience and the effectiveness of this type of workout. They also highlight the potential of Pilates as an effective and enjoyable exercise in the field of public health and wellness. Combining these benefits and integrating Pilates into clinical practice and public health campaigns would be a cost-effective strategy for promoting physical activity and preventing postural deformities.
Effects of Pilates on quality of life, pain, function and physical fitness
The evidence from recent studies and research shows not only that Pilates exercises excel in correcting spinal deformities and improving posture, but also that people who participate in Pilates exercises experience positive impacts on their quality of life in terms of pain, functioning and physical fitness. Of the studies included in this systematic review, five articles mentioned the positive effects of Pilates. This part of the discussion comprehensively analyses the impacts of Pilates on quality of life, pain, function and physical fitness. Exploring the potential mechanisms and clinical treatment effects of these effects will inform and provide insights for subsequent relevant research and practice by academics and healthcare professionals.
Three of the studies mentioned the impact of Pilates on quality of life, with such exercises having the capacity to alleviate the distress associated with spinal deformities. Rrecaj-Malaj [33] indicated that real idiopathic scoliosis causes deformity of the spinal column, directly affecting a patient’s quality of life. In this study, the quality of life level of all the subjects was tested using the SRS-22r (Scoliosis Research Society Questionnaire). The results showed that the patients’ self-image and quality of life were enhanced by a combined Schroth and Pilates Exercises intervention. Gandomi [39] used the ASQOF (Ankylosing Spondylitis Quality of Life) questionnaire [47] in their study to assess the effects of Aqua Stretch and Aqua Pilates exercises on the quality of life of people with AS. The results showed that the subjects’ quality of life significantly improved. The effects were greater on the water stretching group than the water Pilates group, as shown by the MDC (Minimal Detectable Change) and MCID (Minimal Clinically Important Difference) values. However, this did not prevent the authors from recommending water exercises as part of a treatment plan for AS patients. However, Başaran Özden [34] conducted eight weeks of Pilates training with adolescent idiopathic scoliosis patients aged 15–30 years. At the end of the intervention, the Scoliosis Research Society-23 (SRS-23) questionnaire was used to survey the quality of life of the subjects, with the results showing that their quality of life had not improved.
Three articles covered the effects of Pilates on pain relief. Pilates was found not to affect quality of life in adolescent idiopathic scoliosis patients, but the intervention effectively reduced their back and lower back pain and significantly improved their posture [34]. Karkousha’s [38] study with the Visual Analogue Scale (VAS) demonstrated the effectiveness of Pilates exercises versus traditional physiotherapy in relieving pain in patients with upper cross syndrome. Both Aqua Stretch and Aqua Pilates can provide significant pain relief for those with AS and have great potential to improve their condition [37]. These studies provide strong evidence that Pilates has great potential to relieve the pain caused by spinal deformities or postural disorders.
In terms of improved functionality, Gandomi [39] evaluated physical function using the Bath Ankylosing Spondylitis Functional Index (BASFI) and the 40-m walking test (40-MWT). Improvements were seen in both the Aqua Stretch and Aqua Pilates groups, with no significant difference between the two groups. The authors explained that the warmth of the water, the use of comfortable and painless exercises, and the hydrostatic pressure in the water reduced the time taken to complete the 40-MWT. Similarly, one study provided preliminary evidence that Pilates was superior to traditional physiotherapy in improving balance function [38].
In a study of 5–6 year-old preschool children, not only were the children’s head, shoulder and spine postures assessed, but they were also tested for physical fitness (using scores from the flamingo balance, sit and reach, standing broad jump, 30-s sit-up, bent arm hang and 20-m shuttle run tests) [35]. The results showed that Pilates exercises both enhance children’s posture and positively impact their physical fitness.
Overall, recent research and clinical trials have provided valuable indications of the ways in which Pilates improves quality of life, relieves pain, improves function and enhances physical fitness. Pilates interventions have shown promise in improving quality of life, relieving pain and improving function. However, in terms of enhancing physical fitness, the paucity of the available evidence is too great to make firm conclusions, and more research is needed to further substantiate this. These findings demonstrate the potential of Pilates to enhance people’s lives and improve their sense of well-being. Incorporating Pilates into public exercise and wellness programmes could provide individual participants with more innovative, fun and enjoyable physical activities, thus enriching their leisure time. Pilates is a potentially valuable sport for improving people’s standard of living and sense of well-being.
Implications for public health
The findings of this systematic review reveal that Pilates can be applied to a wide range of people; that it is effective in correcting spinal deformities, improving posture, enhancing quality of life and relieving pain; and that such exercises have considerable potential in terms of their public health benefits. Pilates is a low-cost, easy and high-reward form of exercise that can positively impact public health in several ways. It could be incorporated into public health exercise programmes as a valuable form of physical activity that promotes good health and improves people’s standard of living.
Pilates improves people’s physical fitness, which would have an important impact on public health. Pilates emphasises core strength, flexibility and overall body conditioning [48]. Regular and disciplined Pilates practice builds muscular strength, endurance and flexibility, thus helping to reduce the risk of injuries, especially those related to poor posture and muscle imbalance [49]. This systematic review study found that Pilates can improve spinal deformity and poor posture by increasing spinal strength in patients, a result consistent with those of previous studies. Such findings offer a valuable rationale for utilising Pilates to enhance public health and particularly the well-being of patients suffering from spine-like disorders and/or poor posture.
Another advantage of Pilates is that it relieves pain from chronic conditions, especially back and lower back pain. Evidence suggests that many people have relieved their chronic lower back pain and reduced their dependence on painkillers by participating in a Pilates exercise programme [50]. For sedentary, healthy middle-aged women, a Pilates exercise programme can improve the respiratory system, relieve shoulder and lower back pain, as well as enhance parameters such as shoulder girdle, abdominal strength and endurance, and hip and shoulder mobility [51]. The findings of these studies are consistent with those of this review study [34, 38, 39]. When included in a public health exercise programme, Pilates appears to be a physical activity that brings guaranteed benefits for people with chronic pain, as well as a promising therapeutic tool for physical rehabilitators, rehabilitation coaches and healthcare professionals.
Pilates helps to improve the mental health of participants, which in turn improves their social connectedness and sense of community. Pilates improves not only people’s physical health but also their mental health [52]. Regular Pilates practice can reduce stress, anxiety and depression, thus contributing to better overall mental well-being. Therefore, treatment with the Pilates method should be encouraged so that a better quality of life can be achieved [53]. Group Pilates classes build social connections and a sense of community, which can have positive impacts on mental health and overall well-being. Social support is a proven key factor in public health outcomes. Pilates, with its novel teaching style, relaxed workout atmosphere and enjoyable workout process, provides participants with a friendly platform for communication when they are exercising. It also provides opportunities for more community participants to be physically active, which can increase community cohesion and people’s sense of well-being, thus providing opportunities to build a network of social support platforms.
In conclusion, the public health impact of Pilates is considerable. Due to its accessibility, Pilates is a low-intensity exercise that can be used in public health programmes, and the populations in which such activities could be conducted are unlimited. Therefore, there is a strong need to build partnerships with community organisations, physical rehabilitation facilities, healthcare professionals and educational institutions when integrating public health exercise programmes. This would ensure the universality and breadth of the exercise population, maintain the sustainability of Pilates interventions and promote knowledge exchange and innovation. Whilst Pilates exercise can make a positive public health contribution, it should form part of a wider approach to safeguarding the health of the population. Encouraging and facilitating physical activity such as Pilates should be one of many strategies to promote physical health in the general population. Certainly, more pilot studies are needed to provide guidance and explanations for the effectiveness and practice of Pilates in the public health context.
Limitations and future research
There are limitations to this systematic review that must be acknowledged. Firstly, only 9 articles were included in the review. There may have been some flaws in the inclusion criteria and search strategy developed to screen the articles, resulting in the exclusion of some articles that met the requirements. In future review studies, a more comprehensive search strategy and finer-grained inclusion criteria need to be developed to ensure a universal and more authoritative representation of the relevant articles.
Secondly, the sample sizes of the articles included in this review study varied considerably, with the largest being 236 and the smallest 15. This meant the authors were unable to explore potential bias, which could have affected each set of results. Future review studies could focus on research conducted using large sample sizes and standardised intervention trials to provide more precise results and findings.
Thirdly, the studies included in this systematic review used Pilates exercises of varying intensity, which prevented a more precise definition of the parameters by which Pilates affects spinal deformity. Future studies could focus on research with long intervention durations and similar intervention intensities to obtain more precise trial parameters.
Finally, the articles included in this systematic review rarely used hidden allocation and blinded assessment, and they had fewer follow-up studies. In future studies, long experimental designs are necessary and extended follow-up periods are important to determine the effectiveness of the interventions.
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