Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2015;96:2231-42

REVIEW ARTICLE

Pilates Method for Womens Health: Systematic

Review of Randomized Controlled Trials
Melissa Mazzarino, MCMid,a Debra Kerr, PhD,a Henry Wajswelner, DPhysio,b
Meg E. Morris, PhDb
From the aCenter for Chronic Disease Prevention and Management, College of Health & Biomedicine, Victoria University, Melbourne; and
b
College of Science, Health and Engineering, Department of Physiotherapy, La Trobe University, Melbourne, Australia.

Abstract
Objective: To critically analyze the benefits of Pilates on health outcomes in women.
Data Sources: CINAHL, MEDLINE, PubMed, Science Direct, SPORTDiscus, Physiotherapy Evidence Database (PEDro), Cochrane Central
Register of Controlled Trials, and Web of Science.
Study Selection: Databases were searched using the terms Pilates and Pilates Method. Published randomized controlled trials (RCTs) were
included if they comprised female participants with a health condition and a health outcome was measured, Pilates needed to be
administered, and the article was published in English in a peer-reviewed journal from 1980 to July 2014.
Data Extraction: Two authors independently applied the inclusion criteria to potential studies. Methodological quality was assessed using the
PEDro scale. A best-evidence grading system was used to determine the strength of the evidence.
Data Synthesis: Thirteen studies met the inclusion criteria. PEDro scale values ranged from 3 to 7 (mean, 4.5; median, 4.0), indicating a
relatively low quality overall. In this sample, Pilates for breast cancer was most often trialed (nZ2). The most frequent health outcomes
investigated were pain (nZ4), quality of life (nZ4), and lower extremity endurance (nZ2), with mixed results. Emerging evidence was found for
reducing pain and improving quality of life and lower extremity endurance.
Conclusions: There is a paucity of evidence on Pilates for improving womens health during pregnancy or for conditions including breast cancer,
obesity, or low back pain. Further high-quality RCTs are warranted to determine the effectiveness of Pilates for improving womens health
outcomes.
Archives of Physical Medicine and Rehabilitation 2015;96:2231-42
2015 by the American Congress of Rehabilitation Medicine

Pilates is a form of exercise based on movement principles

including whole-body movement, breathing, concentration,
centering, precision, and rhythm.1-5 Pilates is a mindful approach
to exercise, stimulating awareness of body structure, muscle
recruitment, and body alignment during movement.1,2 Joseph
Pilates2,3 claimed that this set of corrective exercises promoted
voluntary control over the body and effective posture, stabilizing
core muscles during dynamic movement, and promoted physical
and mental vitality.4,6 Pilates may be practiced on the mat using
ones body weight or using Pilates equipment,7,8 which has
resistant springs to stabilize and strengthen deep muscle groups.2
Internationally, Pilates has appealed to women as a mainstream

Disclosures: none.

form of exercise9 for improving physical health (muscular

strength, endurance, core stability, breathing), psychological
health (mood, motivation, body awareness), and motor functions
(muscle control, dynamic postural control, balance and
coordination).1,4
Recent systematic reviews have investigated the effectiveness
of Pilates on health outcomes related to body composition,10
breast cancer rehabilitation,11 physical fitness and fall prevention
in seniors,12-14 and pelvic floor muscle function.15 AladroGonzalvo et al10 reported on 7 studies and concluded that there
was poor empirical evidence supporting Pilates having a positive
effect on body composition. Alternatively, another review11 of 3
studies that applied Pilates for breast cancer rehabilitation found
trends in enhanced quality of life (QOL), mood, body image, and
aerobic capacity; however, sample sizes were small. Granacher

0003-9993/15/$36 - see front matter 2015 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2015.04.005

2232

M. Mazzarino et al

et al12 reviewed 20 studies and found improvement in trunk

muscle strength, functional performance, and balance in healthy
seniors. A similar review13 of 17 experimental studies found
improvement in static and dynamic balance in elderly people.
Currently, there is limited evidence to support Pilates effectiveness to reduce stress urinary incontinence.15
Most studies examining Pilates have investigated individuals
with chronic low back pain.16-23 La Touche17 and Lim19 and
colleagues found evidence that Pilates reduced pain. A review22 of
5 systematic reviews concluded that there is inconclusive evidence
to support Pilates in reducing pain in people with chronic low back
pain, and cautioned against the use of findings because of concerns about the heterogeneity of pooled studies and scientific rigor.
While several studies have investigated the effectiveness of
Pilates for health conditions (eg, breast cancer,9 postmenopausal
osteoporosis)24 and in promoting health (eg, strengthening pelvic
floor muscles,25 preventing falls),26,27 a synthesis and evaluation
of the evidence has not been conducted in the form of a systematic
review. Although there is emerging evidence that Pilates may
reduce chronic low back pain,18-21,23 these investigations were
from samples of men and women. The specific effects on womens
health are difficult to ascertain in these mixed samples, and the
benefits are not clear. Therefore, the aim of this systematic review
was to evaluate the evidence for the effectiveness of Pilates for
improving health outcomes in women.

Methods

Diseases and Related Health Problems29 to identify health problems or diseases, as well as health conditions for individuals in a
general health situation or human life cycle including pregnancy,
childbirth, and aging. For high-resourced countries, the WHO30
defines an older person as
60 years of age, and the researchers
used this criteria to classify an aging population.
The WHO International Classification of Functioning,
Disability and Health28 was used to define health outcomes. It is a
2-level classification system for (1) body structures and functions,
and (2) activities and participation. It was used as a framework to
categorize health outcome metrics with health conditions. For
example, pelvic floor muscle strength (eg, health outcome metric)
assessment may be used to investigate stress incontinence (eg, the
health condition). The following domains were used: structure
related to movement; neuromuscular and movement functions;
sensory functions and pain; mental functions; digestive, metabolic, and endocrine functions; functions of the cardiovascular
system; and activities and participation.
For the first phase of the article selection process, 2 reviewers
(M.M., H.W.) assessed all retrieved abstracts for possible inclusion. Discrepancies were resolved through discussion between the
2 reviewers. A third reviewer (D.K.) was consulted if consensus
could not be reached.
Full articles were then retrieved for the second phase of the
selection process to assess eligibility for inclusion in the review.
Two reviewers (M.M., H.W.) individually reviewed the articles to
confirm eligibility criteria. Articles that were identified as eligible
for inclusion were reexamined for accuracy and consistency by the
third reviewer (D.K.), who also arbitrated on discrepancies.

Data sources and searches

Rating the quality of articles

A joint search was conducted by 2 authors (M.M., H.W.). Studies

were selected for review up to November 2014 by searching the
following search engines: CINAHL, MEDLINE, PubMed, Science Direct, SPORTDiscus, Physiotherapy Evidence Database
(PEDro), Cochrane Central Register of Controlled Trials, and Web
of Science. The search strategy used the terms Pilates and
Pilates Method.

For each eligible RCT, methodological quality was assessed by 2

reviewers (M.M., H.W.) using the PEDro scale.31 The PEDro
scale, based on the Delphi list,32 is commonly used to assess the
quality of clinical trials in physiotherapy.31 It consists of 10
items: random allocation, concealed allocation, similarity at
baseline, subject blinding, therapist blinding, assessor blinding,
adequate follow-up (>85% follow-up for at least 1 key
outcome), intention-to-treat analysis, between-group comparisons for at least 1 key outcome, point estimates and variability
measures.32 These 10 items are each allocated a score of 1 point
if the criteria satisfy the standardized score. The PEDro score
ranges from 1 to 10, with higher PEDro scores corresponding to
a higher quality in methodology.33 A PEDro score 4 has been
evaluated to be of lower quality.31 The interrater reliability has
been evaluated previously31 and appears to be a valid measure of
methodological quality for clinical physical therapy trials.33,34
Disagreements in PEDro scoring between the 2 reviewers
(M.M., H.W.) were resolved by the third reviewer (D.K.). All
PEDro scores were entered into an individual spreadsheet (table 1).

Study selection
Retrieved studies were reviewed for inclusion if they met the
following criteria: (1) published in a peer-reviewed journal in the
period 1980 to July 2014; (2) written in the English language; and
(3) the methodology included a randomized controlled trial (RCT)
design, Pilates administered as the intervention, female participants with a health condition, and an evaluation that included
measurement of a health outcome. The researchers adopted the
World Health Organization (WHO)28 definition for a health condition, which includes disease (acute or chronic), disorder, injury
or trauma, and other circumstances such as pregnancy, aging,
stress, congenital anomaly, or genetic predisposition. The researchers used the WHO International Statistical Classification of

Data synthesis
List of abbreviations:
BES
PEDro
QOL
RCT
WHO

best-evidence synthesis
Physiotherapy Evidence Database
quality of life
randomized controlled trial
World Health Organization

For articles that met the eligibility criteria, the following data were
extracted and reported in an evidence table (table 2): author/year,
health condition, age, sample size, intervention, health outcome
metrics, and results. Only statistically significant improvements in
health outcomes, evidenced by P<.05, were included. Table entries were checked for accuracy and consistency by a second
www.archives-pmr.org

Results

1
1
1
1
1
1
1
1
1
1
1
1
1
13

1
1
1
1
1
1
1
1
1
1
1
1
1
13

6*
5*
5*
4
6*
,
5* y
4
3y
4
,
6* y
4
3
4y
0
0
0
0
0
0
0
0
0
1
0
0
0
1
1
0
1
0
1
1
1
0
0
1
0
0
0
6

2233
author (D.K.). Any disagreements concerning the information
reported in the evidence table were reconciled among the
research team.
The best-evidence synthesis (BES) approach35,36 was used to
measure the strength of the evidence. BES incorporates processes
of the meta-analysis including systematic literature searches and
quantification with a detailed analysis of study characteristics. The
BES approach is an alternative to a meta-analysis when the
number of eligible studies and power is low.35-38 BES provides a
strategy for prioritizing evidence37 and has been used in a previous
review6 on the effects of Pilates in healthy people. The researchers
adopted the method of Cruz-Ferreira et al6 in allocating strength
of evidence to findings as follows: strong evidence allocated to
health outcomes where >1 high-quality (PEDRO score >4) RCT
is available; moderate evidence allocated to health outcomes
where 1 high-quality RCT with >1 low-quality RCT is available;
limited evidence allocated to health outcomes where 1 highquality or >1 low-quality RCT is available; and no evidence
allocated where 1 low-quality RCT or contradictory outcomes
were found between group comparisons.

Assessor
Blinding

1
0
0
0
1
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Study selection

Therapist
Blinding

Intention to
Follow-up Treat

Between
Group

Point
Estimate

Total PEDro
Score

Pilates method for womens health

The initial search located a total of 362 citations. After review of

the title and abstract, 59 full articles were retrieved for further
assessment of eligibility. After article review and identification of
duplicates, 13 RCTs9,24,39-49 were included in the review. Figure 1
illustrates the process for selection of articles.

PEDro scores ranged from 3 to 7 (mean, 4.5; median, 4.0) (see

table 1). Six RCTs24,40-43,46 scored >4 and 7 RCTs9,39,44,45,47-49
scored 4, with the former indicating a higher quality in methodology. The PEDro criteria of random allocation, reporting of
between-group difference, and point estimate variability were
fulfilled in all 13 RCTs. The criterion groups similar at baseline
was fulfilled in 10 RCTs.9,24,39-43,46,47,49 One RCT41 fulfilled the
criteria for concealed allocation and 1 RCT46 for intention to
treat, and no RCTs fulfilled the criteria for participant blinding
and therapist blinding. Adequate follow-up was fulfilled in 6
RCTs,24,40,42-44,46 whereas assessor blinding was fulfilled in
only 2 RCTs.24,40 Group comparisons were performed in 9
RCTs9,24,39-42,44,47,48 (see table 1).

1
1
1
1
1
1
0
0
1
1
1
0
1
10
0
1
0
0
0
0
0
0
0
0
0
0
0
1

0
0
0
0
0
0
0
0
0
0
0
0
0
0

Groups
Similar
Concealed
Allocation

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* High-quality RCT.
y
Group comparison not performed.

Study characteristics
1
Altan et al40 (2009)
Alves de Araujo et al41 (2012) 1
1
Cakmakci42 (2011)
Eyigor et al9 (2010)
1
1
Kucukcakr et al24 (2013)
1
Marinda et al43 (2013)
Martin et al44 (2013)
1
1
Plachy et al45 (2012)
Rodrigues et al39 (2010)
1
1
Fourie et al46 (2013)
Ashrafinia et al47 (2014)
1
Lee et al48 (2014)
1
1
Gildenhuys et al49 (2013)
Total rating no.
13

Random
Allocation
Study

Table 1

PEDro score ratings for eligible studies

Participant
Blinding

Method quality

The delivery of the Pilates intervention ranged from 2 to 5 sessions per week. Duration of treatment ranged from 8 weeks to 1
year; 8 studies delivered the intervention for 8 weeks.9,39,42-44,46-49
Sample sizes were small, ranging from 26 to 80 female subjects
(see table 2). Musculoskeletal conditions that included fibromyalgia,40 nonstructural scoliosis,41 postmenopausal osteoporosis,24
and chronic low back pain48 were the most frequently investigated. Other health conditions included breast cancer9,44 and
obesity,42 and 1 study47 investigated sleep disturbances in postnatal women. Five RCTs39,43,45,46,49 studied health outcomes in
elderly women.

2234

Table 2

Description of eligible studies

Study

Health Condition/
Age of Subjects

Intervention

Control

Health Outcome Metrics

Key Results

Women with
fibromyalgia
syndrome
Pilates: MZ48.2y
Control: MZ50.0y

Total: NZ50
Intervention: nZ25
Control: nZ25

Duration and frequency:

12wk, 3  1h/wk
Pilates: Pilates using props
(balls and resistance
bands)

Home exercise
(relaxation/
stretching)

Algometric score for tender

points
Fibromyalgia impact
Lower extremity endurance
Pain
QOL

Alves de Araujo
et al41 (2012)

Sedentary women with

nonstructural
scoliosis
Range: 18e25y

Total: NZ31
Intervention: nZ20
Control: nZ11

Duration and frequency:

12wk, 2  1h/wk
Pilates: Pilates performed
with Swiss balls, flexball
quarks, and apparatus
(Cadillac, Reformer, Step
chair, and Ladder-barrel)

No intervention

Degree of scoliosis
Pain
Range of motion for trunk
flexion

Cakmakci42
(2011)

Sedentary, obese women

Pilates: MZ36y
Control MZ39y

Total: NZ61
Intervention: nZ34
Control: nZ27

Duration and frequency:

8wk, 4  1h/wk
Pilates: Mat work with balls

No intervention

Basal metabolic rate

BMI
Fat percentage
Flexibility
Lean body mass
Metabolic
Waist circumference
Skinfold thickness (biceps,
iliac, subscapula, triceps)
Waist-hip ratio
Weight

Pilates: Significant improvement in pain,

fibromyalgia impact, tender points,
algometric score, and life quality at
week 12; and fibromyalgia impact at
week 24
Control: Significant improvement in
tender points and algometric score at
weeks 12 and 24
Group comparison: Superior improvement
in pain, fibromyalgia impact, lower
extremity endurance, and QOL at week
12 for Pilates
Pilates: Significant decrease in scoliosis
and pain, significant increase in flexion
Control: No significant difference in
parameters
Group comparison: Superior improvement
in degree of scoliosis, range of motion
for trunk flexion, and pain for Pilates
group
Pilates: Significant decrease in weight,
BMI, waist circumstance, subscapula
and iliac skinfold thickness, lean body
mass, and metabolic. Significant
difference in waist-hip ratio, biceps
and triceps skinfold thickness, fat
percentage, basal metabolic rate, and
flexibility
Control: Significant difference in waisthip ratio, biceps, triceps and
subscapula skinfold thickness, fat
percentage, basal metabolic rate, and
flexibility
Group comparison: Superior improvement
in waist-hip ratio, skinfold thickness
(biceps, subscapula, triceps), fat
percentage, basal metabolic rate, and
flexibility for Pilates group
(continued on next page)

M. Mazzarino et al

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Sample Size

Altan et al40
(2009)

Study

Health Condition/
Age of Subjects

Sample Size

Intervention

Control

Health Outcome Metrics

Key Results

Eyigor et al9
(2010)

Women with breast

cancer
Pilates: MZ49y
Control: MZ50y

Total: NZ52
Intervention: nZ27
Control: nZ25

Pilates: Daily Pilates

exercise (floor) and
walking, 8wk, 3  20
e30min/wk

Home exercise:
Walking, 8wk,
3  20
e30min/wk

Depression
Fatigue
Flexibility
Functional capacity
QOL

Kucukcakr
et al24 (2013)

Women with
postmenopausal
osteoporosis without
history of a fracture
Pilates: MZ57y
Control: MZ56y

Total: NZ70
Intervention: nZ35
Control: nZ35

Duration and frequency:

52wk, 2  1h/wk
Pilates: Pilates exercise
using resistance bands
and balls

Home exercise:
Thoracic
extension
exercises in a
sitting
position

Functional capacity
Lower extremity endurance
Number of falls
Pain
QOL

Marinda et al43
(2013)

Sedentary elderly
women
Pilates: MZ66.1y
Control: MZ65.3y

Total: NZ50
Intervention: nZ25
Control: nZ25

Duration and frequency:

8wk, 3  1h/wk
Pilates: Mat work

No intervention

Martin et al44
(2013)

Women after breast

cancer treatment
Pilates: MZ44.6y
RT: MZ47.8y
Control: MZ49.5y

Total: NZ26
Pilates: nZ8
RT: nZ8
Control: nZ10

Duration and frequency:

8wk, 45min/session*
Pilates: MVe Fitness Chair

RT: Resistance
exercises for
8wky
Control: No
intervention

Glucose
Resting heart rate
Resting systolic blood
pressure
Resting diastolic blood
pressure
Total cholesterol
Triglycerides
Muscular endurance

Pilates: Significant improvements in

functional capacity, depression, and
QOL
Control: Significant decrease in functional
capacity
Group comparison: Superior improvement
in functional capacity for Pilates
Pilates: Significant improvement for pain,
functional capacity, lower extremity
endurance, QOL, and number of falls
Control: Except for QOL subscales
(physical function, physical role
limitation, emotional role limitation),
significant improvement for pain,
functional capacity, lower extremity
endurance, QOL, and number of falls
Group comparison: Superior improvement
for pain, functional capacity, lower
extremity endurance, QOL. Number of
falls comparison not performed
Pilates: Significant decrease in systolic
blood pressure and significant increase
in blood glucose
Control: Significant increase in resting
heart rate and blood glucose
Group comparison: Not performed

Pilates method for womens health

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Table 2 (continued )

Pilates: Significant improvement in

muscular endurance
RT: Significant improvement in muscular
endurance
Control: No significant improvements
Group comparison: Superior improvement
in muscular endurance for Pilates and
RT compared with control group
(continued on next page)

2235

2236

Table 2 (continued )
Health Condition/
Age of Subjects

Sample Size

Intervention

Control

Health Outcome Metrics

Key Results

Plachy et al
(2012)

Elderly women
Pilates: MZ66.2y
Aqua/Pilates: MZ67.1y
Control: MZ68.2y

Total: NZ42
Intervention: nZ15
Aqua/Pilates: nZ15
Control: nZ12

Frequency: 24wk
Pilates: Pilates exercises,
3  1h/wk
Aqua/Pilates: 2  1h/wk
(Aqua) and Pilates 1 
1h/wk

Aqua fitness/
Pilatesy
No intervention

Aerobic endurance
Endurance and low body
strength
Flexion of right shoulder
Flexion of right hip
Lumbar spine flexion
Thoracolumbar spine flexion
Trunk lateral flexion

Rodrigues et al39
(2010)

Elderly women
MZ66yz

Total: NZ52
Intervention: nZ27
Control: nZ25

Duration and frequency:

8wk, 2  1h/wk
Pilates: Pilates exercises
used with Bobath ball,
Cadillac, Wall Unit,
Combo chair, and
Reformer devices

No intervention

Personal autonomy
QOL
Static balance

Fourie et al46
(2013)

Elderly sedentary
women
Pilates: MZ66.1y
Control: MZ65.3y

Total: NZ50
Intervention: nZ25
Control: nZ25

Duration and frequency:

8wk, 3  1h/wk
Pilates: Mat work

No intervention

Body fat
Body mass
BMI
Fat mass
Lean body mass

Pilates: Significant improvement for

flexion of right shoulder, flexion of
right hip, lumbar spine flexion,
thoracolumbar spine flexion, trunk
lateral flexion, aerobic endurance,
endurance, and low body strength
Aqua/Pilates: Significant improvement for
flexion of right shoulder, flexion of
right hip, lumbar spine flexion,
thoracolumbar spine flexion, trunk
lateral flexion, aerobic endurance,
endurance, and low body strength
Control: No significant improvements
Group comparison: Not performed
Pilates: Significant improvement for static
balance, personal autonomy, and QOL
domains (sensory abilities, social
participation, intimacy, putting on and
taking off shirt)
Control: Significant improvement in 1 QOL
domain (intimacy) and 1 personal
autonomy domain (putting on and
taking off shirt)
Group comparison: Superior improvement
in static balance, QOL domains (social
participation, death and dying,
intimacy), and personal autonomy for
Pilates group
Pilates: Significant decrease in body fat
and fat mass and an increase in lean
body mass
Control: No significant improvements
Group comparison: Not performed

Study
45

M. Mazzarino et al

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(continued on next page)

Health Condition/
Age of Subjects

Sample Size

Intervention

Control

Health Outcome Metrics

Key Results

Ashrafinia et al47
(2014)

Postpartum women
Pilates: MZ24.6y
Control: MZ24.4y

Total: NZ80
Intervention: nZ40
Control: nZ40

Duration and frequency:

8wk, 5  30min/wk
Pilates: Pilates performed
on the floor

Postnatal
education

Sleep quality

Lee et al48
(2014)

Businesswomen with
chronic low back pain
Pilates: MZ34.0y
Pilates apparatus
exercise: MZ34.4y

Total: NZ40
Intervention: nZ20
Control: nZ20

Duration and frequency:

8wk, 3  50min/wk
Pilates: Mat work

Pilates apparatus
exercisey

Pain
Sway length
Sway velocity

Gildenhuys
et al49 (2013)

Sedentary elderly
women
Pilates: MZ66.1y
Control: MZ65.3y

Total: NZ50
Intervention: nZ25
Control: nZ25

Duration and frequency:

8wks, 3 (nonconsecutive)
 1h/wk
Pilates: Mat work

No intervention

Agility
Functional mobility
Maximal cardiorespiratory
fitness

Pilates: Significant improvement in

subjective sleep quality, sleep latency,
daytime dysfunction, and global sleep
quality index
Control: No significant improvements
Group comparison: Superior improvement
in sleep quality, sleep latency, daytime
dysfunction, and global score for
Pilates group
Pilates Mat work: Significant decrease in
pain, sway length, and sway velocity
Pilates apparatus exercise: Significant
decrease in pain, sway length, and sway
velocity
Group comparison: Superior improvement
in pain, sway length, and sway velocity
for Pilates group
Pilates: Significant improvements in
agility and 3 domains of functional
mobility (sit-to-stand 1 repetition test,
sit-to-stand 5 repetition test, pick up
weight test)
Control: Significant improvement in
agility and 1 domain of functional
mobility (pick up weight test)
Group comparison: Not performed

Study

Pilates method for womens health

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Table 2 (continued )

Abbreviations: BMI, body mass index; M, mean age; RT, resistance training.
* Number of sessions per week not stated.
y
Second experimental group.
z
Mean years of age per experimental group not stated.

2237

2238

M. Mazzarino et al
and sport science clinician (Pilates certification not reported)
(nZ2).44,47 No studies described the style of Pilates or origin of
Pilates exercises.

Best-evidence synthesis: strength of evidence

Fig 1 Flow diagram to summarize stages of systematic review.

Abbreviation: MA, meta-analysis.

Different approaches for Pilates were used as the intervention.

In 6 RCTs,9,43,46-49 Pilates was performed on a mat or floor, and in
some studies assistive equipment (ie, Pilates balls, resistance
bands) was also used.24,40,42 Three RCTs39,41,44 used at least 1
apparatus (ie, Cadillac, Reformer, Step chair, Ladder-barrel,
Combo chair, MVe Fitness Chair). The form of Pilates was not
specified for 1 study.45 In 1 RCT,9 the Pilates intervention was
delivered in addition to home exercises and walking exercise.
For 8 RCTs,39,41-46,49 the control condition did not include any
specific exercise. In 3 RCTs, the control group performed home
exercises that included relaxation and stretching exercises,40
walking,9 and thoracic extension exercise,24 and in 1 RCT47
women were provided with postnatal care education.
Ten studies9,24,39-43,46,47,49 had 1 intervention group and 1
control group as part of the methodology. Two studies44,45 had 2
intervention groups and a control group. The study by Martin
et al44 had 1 intervention group that performed Pilates on the MVe
Fitness Chair, and the other intervention group received resistance
training. The study by Plachy et al45 included a Pilates intervention group and an aqua fitness/Pilates class intervention group.
Lee et al48 included 2 experimental Pilates groups only (mat
Pilates group and an apparatus Pilates group). In the study by
Altan et al40 there were 25 participants in a single large group,
whereas the other studies did not clarify group size. The primary
discipline
of
the
instructor
was
reported
in
8
studies9,39,41,42,44,46,47,49: Pilates instructor certified (nZ3),42,46,49
physiotherapist certified in Pilates instruction (nZ2),9,39 physiotherapist (Pilates certification not reported) (nZ1),41 and exercise

Health outcomes are presented in table 3. With the application of

BES, strong evidence was found for Pilates in improving health
outcomes for pain,24,40,41,48 lower extremity endurance,24,40 and
QOL.24,39,40 Reduction in pain was demonstrated in 3 high-quality
RCTs investigating fibromyalgia syndrome,40 nonstructural
scoliosis,41 and postmenopausal osteoporosis,24 and 1 low-quality
RCT48 investigating low back pain. Strong evidence for lower
extremity endurance was provided by 2 high-quality RCTs24,40
investigating postmenopausal osteoporosis24 and fibromyalgia
syndrome.40 Strong evidence for improvement in QOL was provided by 2 high-quality RCTs24,40 investigating postmenopausal
osteoporosis24 and fibromyalgia syndrome,40 and 1 low-quality
RCT39 of elderly women. In a study of female breast cancer patients by Eyigor et al,9 no improvement was found for QOL.
Limited evidence was found for improving the degree of
scoliosis,41 impact of fibromyalgia,40 number of falls,24 range of
motion in trunk flexion,41 functional capacity,9,24 waist-hip ratio,42
skinfold thickness (biceps, triceps, subscapular),42 fat percentage,42 and basal metabolic rate.42 No evidence was found for
improving muscular endurance,44 static balance,39 sway length
and velocity,48 tender points,40 depression,9 sleep quality,47 fatigue,9 personal autonomy,39 weight,42 body mass index,42 waist
circumference,42 lean body mass,42 metabolic rate,42 and iliac
skinfold thickness.42 Contradictory results were found for flexibility, in which improvement was found in obese women,42 but no
effect was found in female breast cancer patients.9

Discussion
This systematic review of Pilates for womens health found
emerging evidence for reducing pain and improving QOL and
lower extremity endurance. However, overall, the methodological
quality of eligible RCTs was relatively low (mean score, 4.5).
There was a lack of high-quality trials investigating the benefits of
Pilates for improving womens health outcomes.
This review found a reduction in pain based on studies
investigating fibromyalgia,40 nonstructural scoliosis,41 postmenopausal osteoporosis,24 and low back pain.48 For these
studies, the Pilates intervention was compared with control conditions including home exercise relaxation and stretching,40 no
intervention,41 and thoracic extension exercises,24 and in 1 study48
mat-based Pilates was compared with Pilates apparatus exercise.
This demonstrates that there is a paucity of evidence as to whether
other treatment regimens or forms of exercise are more or less
effective in reducing pain.16,19,20,23
Improvement in QOL was found in studies investigating fibromyalgia syndrome40 and postmenopausal osteoporosis,24 and
in a study of elderly women.39 It is unclear from the current review whether participating in a therapeutic ritual provided a placebo effect,50 and whether the acuity of a health condition
influences QOL in women.
Emerging evidence was found for lower extremity endurance
in RCTs investigating fibromyalgia40 and postmenopausal osteoporosis.24 Weakened low extremity strength and endurance secondary to physiological changes associated with aging are
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Pilates method for womens health

Table 3

2239

Levels of evidence in health outcomes in WHO ICF categories

WHO ICF Category

Health Outcome

Study and Direction of Effect*

Level of Evidencey

Degree of scoliosis (nonstructural)

Alves de Araujo et al41 ()

Limited evidence

Flexibility

Eyigor, et al9 (o)

Cakmakci42 ()
Altan et al40 ()
Kucukcakr et al24 ()
Altan et al40 ()
Martin et al44 ()
Kucukcakr et al24 ()
Alves de Araujo et al41 ()
Rodrigues et al39 ()
Lee et al48 ()

Strong evidence
No evidence
Limited evidence
Limited evidence
No evidence
No evidence

Tender points and algometric score

Kucukcakr et al24 ()
Altan et al40 ()
Alves de Araujo et al41 ()
Lee et al48 ()
Altan et al40 (o)

Strong evidence
No evidence

Depression
Sleep quality

Eyigor et al9 (o)

Ashrafinia et al47 ()

No evidence
No evidence

Fatigue
Functional capacity

Eyigor et al9 (o)

Eyigor et al9 ()
Kucukcakr et al24 ()

No evidence

Cakmakci42 ()
Cakmakci42 ()

Limited evidence
Limited evidence

Cakmakci42
Cakmakci42
Cakmakci42
Cakmakci42
Cakmakci42
Cakmakci42
Cakmakci42
Cakmakci42

Limited evidence
Limited evidence
No evidence
No evidence
No evidence
No evidence
No evidence
No evidence

Structure related to movement

Neuromuscular and movement-related
functions

Fibromyalgia impact
Lower extremity endurance
Muscular endurance
Number of falls
Range of motion for trunk flexion
Static balance
Sway length and velocity

No evidence
Limited evidence

Sensory functions and pain

Pain

Mental functions

Functions of cardiovascular system

Limited evidence

Functions of digestive, metabolic, and

endocrine systems
Waist-hip ratio
Skinfold thickness (biceps, triceps,
subscapula)
Fat percentage
Basal metabolic rate
Weight
Body mass index
Waist circumference
Lean body mass
Metabolic
Skinfold thickness (iliac)

()
()
(o)
(o)
(o)
(o)
(o)
(o)

Activities and participation

Personal autonomy
QOL

Rodrigues et al39 ()
Eyigor et al9 (o)
Kucukcakr et al24 ()
Rodrigues et al39 ()
Altan et al40 ()

No evidence

Strong evidence

Abbreviation: ICF, International Classification of Functioning, Disability and Health.

* Direction of effect: (), positive effect on health outcome; (o), no effect on health outcome.
y
Strong evidence, >1 high-quality RCT; moderate evidence, 1 high-quality RCT with >1 low-quality RCT; limited evidence, 1 high-quality or >1 lowquality RCT; no evidence, 1 low-quality RCT or contradictory outcomes.

considered a risk factor for falls in the elderly.51 Previous

studies52,53 investigating the efficacy of Pilates on lower extremity
endurance in elderly women have provided contradictory results.
Significant improvements in lower extremity strength and endurance for women participating in aqua fitness were found in a
study52 of 25 elderly women. However, these improvements were
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not observed for women who participated in Pilates classes. In

contrast, Fourie et al53 found significant improvement in lower
extremity endurance for sedentary women who participated in mat
Pilates compared with women who maintained their normal activity routine. These disparate findings possibly reflect the
different methods used in these studies to measure lower extremity

2240
endurance (time to walk up stairs test,52 squat till fatigue test53) as
well as the varied control conditions. Future studies require congruency in the methodological approach to measuring lower extremity endurance in elderly women, and for specific health
conditions such as fibromyalgia and osteoporosis.
Limited evidence was found for 4 health outcomes related to
body composition: waist-hip ratio,42 skinfold thickness,42 fat
percentage,42 and basal metabolic rate.42 These findings are
consistent with those of Aladro-Gonzalvo,10 who found poor
empirical evidence supporting Pilates having a positive effect on
body composition. Change in body composition health outcome
metrics may be mediated by factors such as life stage (pregnancy,
menopause), health conditions (ie, bulimia, obesity), preintervention fitness level (ie, athletic vs sedentary), and energy
intake (ie, diet),10,54 and these variables require further
consideration.
Contradictory results were found for flexibility. Improvement
was found in obese women,42 but no effect was found in female
breast cancer patients.9 These studies, however, had significant
methodological differences. The method of measuring flexibility
was not stated in 1 study,9 and the sit and reach test42 was used in
the other. Both studies implemented the intervention over 8
weeks; however, the frequency and duration of Pilates were 4
sessions per week, 60 minutes per session for obese woman,42 and
3 sessions per week, 20 to 30 minutes per session for female breast
cancer patients.9 In a review6 of healthy adults, strong evidence
was found for improvement in flexibility in sedentary adult females,55 healthy adults,56 healthy middle-aged adults,57 and
elderly women,26 with flexibility measured in the following body
areas: trunk,55 lower back,26,56 hamstrings,26,56,57 and upper
body.56 For these studies, the duration of the Pilates intervention
was 60 minutes, and the frequency of sessions was 257 or 326,55,56
times per week for a period of 5 weeks,55 8 weeks,56 and 12
weeks.26,57 Factors underpinning exercise prescription, including
body area of focus, type of exercise, number of repetitions, and
frequency of sessions, may influence health outcomes such as
flexibility6 and should be considered in future research.
Pilates is advocated for alleviating discomforts of pregnancy58,59 and assisting in strength and endurance for labor and
birth60; however, this review found that evidence is absent for
improving perinatal outcomes in these situations. The American
College of Obstetricians and Gynecologists and the Centers for
Disease Control and Prevention61-63 recommended that in the
absence of medical or obstetric complications, women should
moderately exercise for
30 minutes daily. Evidence is needed to
verify the benefits of Pilates as a form of exercise for pregnancy
and birthing outcomes.

Study limitations
Limiting the eligibility criteria to women may have omitted evidence on health outcomes previously found in mixed samples. For
example, a large body of evidence on mixed samples of men and
women shows that Pilates may reduce pain and disability in individuals with chronic low back pain.23 Those studies do not
discern differences in outcomes for men and women. The BES
focused on 3 high-quality24,40,41 and 2 low-quality9,48 studies,
which limits the generalizability of findings. Another limitation
was that only RCTs were included; observational and qualitative
studies may provide additional findings in improving health outcomes for women.6 In addition, the search was limited to Englishlanguage journals, and studies using other languages were not

M. Mazzarino et al
considered. This review focused on findings that were statistically
significant. Overall, the studies were small (n<80), and this may
have affected the strength of findings. Larger, well-designed RCTs
are needed. A lack of homogeneity, range of conditions, and
variation in the Pilates intervention inhibited the synthesis of
findings. Also, the extent to which the placebo effect associated
with the therapeutic intervention influences the reduction in pain
and improves QOL in women requires further investigation.

Future research recommendations

Future RCTs could be strengthened by incorporating concealed
allocation, intention-to treat analysis, and blinding. Congruency in
the methodological approach for smaller studies should be
considered, including the type of Pilates intervention, exact exercise prescription, duration and frequency of exercise, and measurement tools. The nonspecific effects or contextual benefits
associated with participating in a mindful approach to exercise
such as the participantePilates instructor relationship may
contribute to a placebo effect and needs verification.50 The
effectiveness of Pilates for improving health for specific conditions such as breast cancer, obesity, and chronic low back pain is
yet to be determined. Given the popularity of Pilates for pregnant
women,60 evidence is needed to support claims of antenatal and
birthing benefits.

Conclusions
Pilates is a popular form of exercise for women who strive to
improve their physical and psychological health. However, there is
a paucity of evidence that Pilates improves womens health. We
found emerging evidence to show that Pilates may reduce pain and
may improve QOL and lower extremity endurance. Whether
Pilates improves womens health during pregnancy or optimizes
health outcomes for breast cancer, obesity, and chronic low back
pain is yet to be confirmed.

Keywords
Pilates-based exercises; Rehabilitation; Review; Womens health

Corresponding author
Melissa Mazzarino, MCMid, Victoria University, McKechnie St,
Melbourne, Victoria, Australia 3021. E-mail address: melissa.
mazzarino@vu.edu.au.

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