Preventive Medicine 75 (2015) 1–11

Contents lists available at ScienceDirect

Preventive Medicine

journal homepage: www.elsevier.com/locate/ypmed

Review

The effects of Pilates exercise training on physical fitness and wellbeing in

the elderly: A systematic review for future exercise prescription
V. Bullo a, M. Bergamin a,⁎, S. Gobbo a, J.C. Sieverdes b, M. Zaccaria a, D. Neunhaeuserer a, A. Ermolao a
a
Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Padova, Italy
b
Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, United States of America

a r t i c l e i n f o a b s t r a c t

Available online 12 March 2015 This systematic review aims to summarize the effects of Pilates exercise training (PET) in elderly population on
physical fitness, balance and fall prevention, and its effects on mood states, quality of life and independence in the
Keywords: daily living activities.
Elderly Methods. Keyword “Pilates” associated with “elderly”, “aging” and “old subjects” were identified as terms for the
Pilates literature research in MEDLINE, Embase, PubMed, Scopus, PsycINFO and SPORTDiscus. Only studies published in
Physical fitness
peer-reviewed journals written in English language were considered. A meta-analysis was performed and effect
Fall prevention
Review
sizes (ES) calculated.
Results. 10 studies were identified (6 RCTs and 4 uncontrolled trials); age ranged from 60 to 80 years. Overall, PET
showed large ES to improve muscle strength (ES = 1.23), walking and gait performances (ES = 1.39), activities
of daily living, mood states and quality of life (ES = 0.94), moderate to high effect on dynamic balance (ES =
0.77), small effects on static balance (ES = 0.34) and flexibility (ES = 0.31), while a small effect on cardio-
metabolic outcomes (ES = 0.07).
Conclusions. PET should be taken into account as a way to improve quality of life in the elderly, due to the
imparted benefits of fall prevention, physical fitness, and mood states. In this context, physicians might include
PET as a tool for exercise prescriptions for the elderly.
© 2015 Elsevier Inc. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Study design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Literature search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Study quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Data extraction and synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Studies description and results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Muscle strength outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Static and dynamic balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Flexibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Walking and gait measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Activities of daily living, mood states and quality of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Cardio-metabolic effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Pilates and muscle strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Pilates and balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Pilates and mobility/walking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

⁎ Corresponding author.
E-mail address: [email protected] (M. Bergamin).

http://dx.doi.org/10.1016/j.ypmed.2015.03.002
0091-7435/© 2015 Elsevier Inc. All rights reserved.
2 V. Bullo et al. / Preventive Medicine 75 (2015) 1–11

Activities of daily living, mood states and quality of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Pilates and cardio-metabolic effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Methods
Introduction
Study design
Over the last several decades, human life expectancy has progres-
sively increased. In 2012, HelpAge International identified 810 million This is a systematic qualitative review of the literature, with the aim to ana-
people that were 60 years or older (one out of nine) with estimates lyze the effects of PET programs on physical fitness, fall prevention as well as its
that by 2050, it will increase to one out of five (UNFPA, 2012). Age- effects on mood states, quality of life and independence in the activities of daily
related physical decline and corresponding loss of functional capacity living in the elderly.
are often related to the loss of muscle mass (sarcopenia), decrease of
Literature search
aerobic capacity, reduced mobility, and other determinants of fitness
(Nelson et al., 2007). Thus, there is need to develop and promote in-
Analyses were conducted from November to December 2013. The keyword
terventions that improve physical capacities and consequently qual- “Pilates” associated with “elderly”, “aging” and “old subjects” was used for the
ity of life in the elderly population. Indeed, physical activity has a literature research in MEDLINE, Embase, PubMed, Scopus, PsycINFO and
positive key-role in preventing age-related physical decline SPORTDiscus.
(Keysor, 2003) and it is used in primary and secondary prevention
strategies to reduce the risk of chronic diseases (WHO, 2010). More- Inclusion and exclusion criteria
over, cardiovascular and all-cause mortality significantly decreases
among people that are physically active and who have higher levels Only studies published in indexed and peer reviewed journals, written in En-
of aerobic capacity (Paffenbarger et al., 1986; Sui et al., 2007). In- glish language, were considered for this review. The studies needed to provide a
Pilates-identified exercise training intervention including subjects 60 years old
creasing evidence also demonstrates a positive impact of exercise
or older. Both males and females from all races and different states of health (i.e.
and physical activity on degenerative musculoskeletal conditions
healthy, with stable chronic disease and Parkinson's disease) were included. Fur-
such as osteoporosis, arthritis and sarcopenia (Gaught and thermore, only original articles were accepted for the analysis. All studies not eval-
Carneiro, 2013; Gomez-Cabello et al., 2012; Montero-Fernandez uating outcomes through pre- and post-intervention comparisons, as well as cross-
and Serra-Rexach, 2013). sectional studies and case reports were excluded. Published abstracts, dissertation
Pilates exercise training (PET) is not conventionally classifiable as tra- materials, or conference presentations were not considered for this review.
ditional exercise (e.g. aerobic exercise or resistance training) (Morrow
et al., 1999), but it is rather a form of structured physical activity, which Study quality assessment
has been shown to improve muscle endurance, flexibility, and dynamic
balance in young and middle aged population (Cruz-Ferreira et al., The quality of the studies was assessed applying an adapted nine criteria
checklist provided by the Cochrane Collaboration Back review Group (van
2011), though, its benefits in older populations are less clear. PET was cre-
Tulder et al., 1997). As in previous reviews, the checklist had to be marginally
ated in New York, USA and matured from the 1920s to 1960s as an ad-
adapted to rate the strength of the evidence (Bergamin et al., 2012; Claessen
junct for the training and rehabilitation for dancers in the performing et al., 2012; Gobbo et al., 2014; Proper et al., 2003). Each study in the review
arts. Despite its long history, PET is a relatively new approach for struc- was scored based on the following nine criteria: (1) ‘Was the method of ran-
tured physical activity usually given in the form of classes. The practice domization adequate?’; (2) ‘Were the groups similar at baseline regarding the
of Pilates utilizes multiple practical movement patterns from gymnastics, outcome measures?’; (3) ‘Were inclusion and exclusion criteria adequately
martial arts, yoga and dance (Latey, 2001). PET is different when com- specified?’; (4) ‘Was the drop-out rate described adequately?’; (5) ‘Were all
pared to traditional exercises, which, in turn, tend to isolate the working randomized participants analyzed in the group to which they were allocated?’;
muscles and have specific training approaches using repetitive motions. (6) ‘Was the compliance reported for all groups?’; (7) ‘Was Intention-to-treat
Indeed, this training method has a holistic approach where a correct exe- analysis performed?’; (8) ‘Was the timing of the outcome assessment similar
in all groups?’; (9) ‘Was a follow-up performed?’. When the study provided a
cution of the six fundamental principles (concentration, control, center-
satisfactory description, a positive value was assigned (+). If the criterion de-
ing, flowing movement, precision and breathing) increases body
scription was considered absent, unclear, or lacked the specified content, a neg-
awareness with less ground impact and joint-stress. It can also be per- ative value was assigned (−). A study was qualitatively judged as high quality if
formed at various intensity levels whereby the participant or patient it showed a positive score on 5 to 9 of the criteria; otherwise, it was considered a
may adjust the difficulty to their own level of conditioning. low quality study (van Tulder et al., 1997).
There have been several recent reviews that focused on the benefits
of PET in various populations and centered around specific functional Data extraction and synthesis
and strength measures, such as core strength (Granacher et al., 2013),
though no review has focused on the effects PET has on fitness mea- All abstracts of the sourced studies from the literature search were examined
sures, fall risk, and quality of life in the elderly. Therefore, this review independently by two researchers. Suitable studies were analyzed in more detail
for meeting eligibility criteria. Additional articles were sourced by reviewing the
aims to investigate and summarize the benefits of PET, in terms of phys-
reference sections of the included studies. A final quality check of each study was
ical fitness and other outcomes related to the elderly's quality of life.
performed by each researcher. Afterwards, the individual searches were com-
Physicians play a key-role in the beginning and maintenance of exercise bined, compared, and reviewed for applicability where a consensus was made
behavior among the older population (Schutzer and Graves, 2004), regarding study inclusion. In case of discrepancies, the review process was re-
hence, the results of this review would be useful for general practi- peated and a third researcher was consulted. Quality assessment using the mod-
tioners and sports medicine physicians to incorporate PET in the exer- ified Cochrane methodological quality criteria was then independently applied
cise prescription for the elderly. and discussed before final quality scores were assigned (Table 1).
 V. Bullo et al. / Preventive Medicine 75 (2015) 1–11 3

Table 1
Quality assessment of the studies shows the results of the quality appraisal of the included PET-studies.

Citation Randomization Similarity of Inclusion or Dropouts Blinding Compliance Intention-to-treat Timing of Follow-up Results
procedure study groups exclusion criteria analysis outcomes
assessment

Bird and Fell (2014) − − + + − + + − + 5/9

Mokhtari et al. (2013) + − + − − − − − − 2/9
Marinda et al. (2013) + + − − − − − − − 2/9
Johnson et al. (2013) − − + − − − − − − 1/9
Bird et al. (2012) + − + + + + + − + 7/9
Newell et al. (2012) − − + + − − − − − 2/9
Plachy et al. (2012) + − − − − − − − − 1/9
Irez et al. (2011) + + + − + + − + − 6/9
Siqueira Rodrigues et al. (2010) + − + − − − − − − 2/9
Kuo et al. (2009) − − + + + + − + + 6/9

Several domains were identified for categorization of the study results. In par- performed according to guideline by Cohen (1988) where an ES value of 0.20 in-
ticular, studies were analyzed in regard to muscle strength outcomes, static and dicates small effect, ES of 0.50 indicates medium effect, and finally, ES higher
dynamic balance, flexibility, walking and gait measures, independence in the ac- than 0.80 indicates large effects. Forest plots for each specific domain were
tivities of daily living and quality of life, as well as cardio-metabolic evaluation. also reported (Derzon and Alford, 2013).

Data analysis
Studies description and results
Meta-analyses were performed using random-effect models, Hedge's g ef-
fect sizes (ES) were calculated through Comprehensive Meta-Analysis software The systematic search resulted in a total of sixty-seven articles. After
(Biostat Inc., Englewood, NJ); the moderator analysis was included in the applying specific inclusion and exclusion criteria, ten articles were con-
models, calculated by the duration of intervention. The ES is a measure of the ef- sidered eligible for this review. Reasons for studies' exclusions are
fectiveness of a treatment, and it helps to determine whether a statistically sig- displayed in Fig. 1. Sample sizes of the studies were rather different
nificant difference is a difference of practical concern. Interpretation was ranging from 9 to 60 participants. Exercise programs were varied and

Fig. 1. Flow chart of the literature search.

 4
Table 2
Characteristics of the studies summarizes the characteristics of the studies, including participants' description, type of intervention, frequency and duration.

Author Subjects Age Grouping Training modality, program and intensity Frequency Duration Compliance rates

Bird and Fell (2014) 30 (25 F, 5 M) N60 Intervention group (5 w, 30) Small group classes with a maximum of six people consisting of standing and floor 5 weeks: 1 h 2 d/w 5 weeks + N50%
Continued Pilates (14) mat exercise as well as a circuit style session using Pilates equipment (Reformers, 2 months: 1 h 1 d/w 12 months
Ceased Pilates (16) Chairs). 10 months: 1 h 2 d/w
5 weeks: warm up mat exercise + standing exercise to challenge balance. Home
program of mat exercise.
Mokhtari et al. 30 F 62–80 Experimental group Control First 6 weeks: mat Pilates exercises. 1 h 3 d/w 12 weeks Not reported.
(2013) group Second 6 weeks: exercises with bands.
The subjects of the control group did their daily activities in the training period.
Marinda et al. (2013) 50 F N60 IG — Mat Pilates group (25) Before the training period, a lesson to explain the basics of mat Pilates (explanation of 1 h 3 d/w 8 weeks Not reported.
CG — non-exercise control the neutral position of the spine and the correct breathing technique).
group (25) All sessions started with breathing, followed by a flowing system from standing, to
sitting, to lying down exercises and ended with the rest position.
Increasing intensity.
Johnson et al. (2013) 10 (3 F, 7 M) N60 Pilates group (10) Combination of plinth exercises, gym-ball exercises, stepping exercises and exercises 1 h 2 d/w 6 weeks Not reported.
on a Pilates reformer.
The combination and duration of each exercise depend to participant functional
capabilities, strength and degree of flexibility.
The difficulty of the exercises was increased progressively, based upon performance

V. Bullo et al. / Preventive Medicine 75 (2015) 1–11

and subjective feedback from the participant.
The progression involved the addition of movements to increase task complexity,
reducing the base of support and increasing the resistance during the reformer
exercises
Bird et al. (2012) 32 N60 Pilates group Classes were held in small groups of no more than 6 people. Standing and mat exercise 1 h 2 d/w 5 weeks 80%
Non-active group followed by a circuit style session of exercises with Pilates reformer, mat-based Home exercise: 1 d/w
exercises. Focus included balance and lower-limb strength exercises. Training was
progressed in terms of repetitions and load of exercises at the earliest opportunity.
Home program of mat exercises to make in 1 other occasion per week.
Newell et al. (2012) 9 (8 F, 1 M) 60–76 Intervention group (9) Core stability and spinal mobility were addressed by the use of abdominal bracing and 1 h 1 d/w 8 weeks Not reported.
pelvic tilt exercises.
Lower limb exercises addressed quadriceps, hamstrings, gastrocnemius, soleus and
tibialis anterior.
Upper limb exercises included abduction and flexion using weights.
A wobble board was used primarily to strengthen the ankle and improve mobility.
A swiss ball was used to enhance core stability exercises.
Plachy et al. (2012) 42 F N60 Pilates group (15) For all participants was chosen strength, stretching, range of motion and balance Pilates group: 6 months Not reported.
Pilates + aqua-fitness exercises. 1 h 3 d/w
group (15) Pilates and
Control group (12) aqua-fitness group:
1 h 1 d/w + 1 h 2 d/w
Irez et al. (2011) 60 F N65 Experimental group (30) Pilates-based exercise was divided into three parts: 1 h 3 d/w 12 weeks 92%
Control group (30)
- First part (4 weeks), Pilates mat exercises.
- Second part (5–8 weeks), Thera-Band elastic resistance exercises.
- Third part (9–12 weeks), Pilates ball exercises.

Siqueira Rodrigues 52 F 60–78 PG — Pilates group (27) Session divided into: 10′ global stretching + 40′ general conditioning + 10′ 1 h 2 d/w 8 weeks Not reported.
et al. (2010) CG — Control group (25) relaxation.
The springs used were the same for all the volunteers, with adjustments in order to
provide greater of lesser resistance, according to the physical capacity of each subjects.
Each exercise was performed for a maximum of ten repetitions.
Kuo et al. (2009) 34 (24 F, 10 M) 60–75 Intervention group (34) The exercises included strengthening, stretching, range of motion and balance. 75′ 2 d/w 10 weeks 97.5%
Exercises were performed on mats and with traditional Pilates equipment and
accessories.
The difficulty/level of the exercises was modified in according to the participant's
progress.
Participants were instructed not to perform any exercises at home.
 V. Bullo et al. / Preventive Medicine 75 (2015) 1–11 5

Table 3
Study results shows the results from a pre- to post comparison of the included PET-studies.

Bird and Fell (2014) Continued Pilates (14) Pooled force (kg) p b .05** Mobility and dynamic balance Static balance
T1: 71.2 ± 19.0 TUG (s) p b .05*, ** ML sway EC on foam (cm) p b .05*
T2: 74.3 ± 20.3 T1: 6.0 ± 1.0 T1: 8.0 ± 1.8
T3: 67.2 ± 18.0 T2: 5.3 ± 1.2 T2: 5.8 ± 1.9
T3: 5.4 ± 1.1 T3: 4.5 ± 1.4
Dynamic balance
FSST (s) p b .05*, **
T1: 7.8 ± 1.1
T2: 6.8 ± 1.3
T3: 6.4 ± 1.0
Ceased Pilates (16) Pooled force (kg) Mobility and dynamic balance Static balance
T1: 61.8 ± 13.1 TUG (s) p b .05* ML sway EC on foam (cm) p b .05*
T2: 56.2 ± 12.5 T1: 6.7 ± 1.4 T1: 7.1 ± 2.4
T3: 51.6 ± 12.3 T2: 6.0 ± 1.0 T2: 5.1 ± 1.8
T3: 6.4 ± 1.2 T3: 5.2 ± 1.9
Dynamic balance
FSST (s) p b .05*
T1: 8.5 ± 1.1
T2: 7.0 ± 1.0
T3: 7.3 ± 1.0
Mokhtari et al. (2013) Experimental group Psychological factors Dynamic balance Static balance
GDS (short form) p b .05** TUG (s) p b .05* FRT (cm) p b .05*
7.1 ± 1.9 to 5.7 ± 1.3 13.1 ± 2.4 to 12.2 ± 2.6 18.2 ± 2.7 to 21.2 ± 4.4
Control group Psychological factors Dynamic balance Static balance
GDS (short form) TUG (s) FRT (cm)
6.5 ± 1.0 to 7.3 ± 1.7 13.3 ± 2.0 to 13.8 ± 1.9 18.1 ± 3.7 to 18.9 ± 3.2
Marinda et al. (2013) Mat Pilates group (25) RHR (b/m) Resting SBP (mm Hg) p b .05* TC (mmol/L)
68.8 ± 12.6 to 73.2 ± 11.5 135.9 ± 14.7 to 128.8 ± 16.4 5.4 ± 1.0 to 5.7 ± 1.0
Glucose (mmol/L) p b .05* Resting DBP (mm Hg) TG (mmol/L)
5.1 ± 0.5 to 5.8 ± 0.6 75.6 ± 10.1 to 77.4 ± 9.3 1.8 ± 0.9 to 1.9 ± 0.9
Non-exercising control RHR (b/m) p b .05* Resting SBP (mm Hg) TC (mmol/L)
group (25) 62.5 ± 9.0 to 74.9 ± 10.0 134.5 ± 13.7 to 136.0 ± 17.8 5.3 ± 1.3 to 5.4 ± 1.3
Glucose (mmol/L) p b .05* Resting DBP (mm Hg) TG (mmol/L)
5.2 ± 0.7 to 5.8 ± 0.6 81.4 ± 9.3 to 79.8 ± 9.3 1.6 ± 0.5 to 1.8 ± 0.7
Johnson et al. (2013) Pilates group (10) Dynamic balance TUG cadence (steps/minute) p b .05* Balance
TUG (s) 84.9 ± 3.4 to 78.0 ± 3.8 ABC (%)
10.1 ± 0.6 to 10.2 ± 0.6 Parkinson's disease 71.0 ± 3.4 to 74.7 ± 3.9
Personal ability ADL UPDRS Balance
SES (%) 19.1 ± 3.1 to 18.1 ± 3.4 BBS p b .05*
79 ± 3.8 to 80.0 ± 2.1 Static posturography 47.1 ± 2.0 to 50.4 ± 1.5
Dynamic posturography Static sway area (cm2) Time of walking
Reaction time (s) 2.9 ± 0.7 to 3.3 ± 0.9 5-m walk (s) p b .05*
1.1 ± 0.1 to 1.0 ± 0.1 Sway path length (cm) 6.3 ± 0.4 to 5.5 ± 0.3
Velocity (cm/s) 108.6 ± 10.0 to 108.5 ± 9.3 5-m walk cadence (steps/minute)
1.5 ± 0.2 to 2.0 ± 0.3 97.4 ± 5.2 to 103.7 ± 5.3
Target overshoot (cm) p b .05*
0.5 ± 0.1 to 0.7 ± 0.1
Bird et al. (2012) Pilates group Static balance Static balance Dynamic balance
ML sway EO (cm) ML sway EO on foam (cm) p b .05* TUG (s) p b .05*
2.0 ± 1.2 to 1.8 ± 1.1 4.6 ± 1.8 to 3.8 ± 1.7 6.3 ± 1.2 to 5.9 ± 1.2
Static balance Static balance Dynamic balance
ML sway EC (cm) ML sway EC on foam (cm) p b .05* FSST (s) p b .05*
2.2 ± 1.2 to 1.9 ± 1.2 7.4 ± 2.2 to 5.8 ± 1.9 7.9 ± 1.5 to 7.3 ± 1.0
Ankle strength (kg) Knee strength (kg)
11.8 to 12.3 21.0 to 21.6
Non-active group Static balance Static balance Dynamic balance
ML sway EO (cm) p b .05* ML sway EO on foam (cm) TUG (s)
1.8 ± 0.6 to 1.6 ± 0.8 4.6 ± 1.7 to 4.1 ± 1.5 6.0 ± 1.2 to 5.9 ± 1.2
Static balance Static balance Dynamic balance
ML sway EC (cm) ML sway EC on foam (cm) FSST (s)
2.2 ± 1.3 to 1.8 ± 0.9 7.2 ± 2.6 to 6.1 ± 3.0 7.6 ± 1.3 to 7.2 ± 1.4
Ankle strength (kg) Knee strength (kg)
11.6 to 11.8 21.9 to 21.0
Newell et al. (2012) Intervention group (9) Time on foot (R) Time on foot (L) Ant–Post
49.3 ± 3.5 to 49.9 ± 0.9 50.7 ± 3.5 to 50.1 ± 0.9 5.5 ± 4.1 to 3.2 ± 4.2
Av. SL (m)(R) p b .05* Av. SL (m)(L) p b .05* Med–Lat
0.4 ± 0.1 to 0.5 ± 0.1 0.4 ± 0.1 to 0.5 ± 0.1 0.8 ± 0.4 to 0.9 ± 0.5
Av. WS (m/s) p b .05* Av. SC (m) p b .05* FRI
0.5 ± 0.1 to 0.7 ± 0.2 0.6 ± 0.1 to 0.7 ± 0.0 3.7 ± 3.4 to 1.5 ± 0.8
AI p b .05*
77.8 ± 5.7 to 84.3 ± 2.8
Plachy et al. (2012) Pilates group (15) Strength Shoulder flexion (°) Lumbar flexion (cm) p b .05*, **
Sit-to stand test for 30 s p b .05*, ** 138.0 ± 24.0 to 155.3 ± 6.9 3.7 ± 0.9 to 4.7 ± 0.5
16.6 ± 2.4 to 23.9 ± 2.5 Thoracolumbar flexion (cm) p b .05* Hip flexion (°) p b .05*
Aerobic capacity 4.1 ± 2.2 to 5.8 ± 1.4 90.0 ± 15.0 to 104.5 ± 6.3

(continued on next page)

6 V. Bullo et al. / Preventive Medicine 75 (2015) 1–11

Table 3 (continued)

Plachy et al. (2012) 6′ walk (m) p b .05*, ** Lateral flexion (cm) p b .05*
416.5 ± 80.6 to 528.8 ± 67.7 11.9 ± 3.7 to 14.9 ± 4.2
Pilates + aqua-fitness Strength Shoulder flexion (°)p b .05* Lumbar flexion (cm) p b .05*
group (15) Sit-to stand test for 30 s p b .05* 127.0 ± 16.1 to 150.3 ± 16.2 3.7 ± 1.2 to 5.4 ± 1.0
15.9 ± 4.5 to 20.7 ± 3.5 Thoracolumbar flexion (cm) p b .05 * Hip flexion (°) p b .05*
Aerobic capacity 3.0 ± 1.1 to 4.8 ± 1.8 95.3 ± 11.4 to 112.1 ± 7.6
6′ walk (m) p b .05* Lateral flexion (cm)
418.7 ± 86.9 to 503.3 ± 115.4 p b .05*
11.3 ± 2.5 to 14.3 ± 3.0
Control group Strength Shoulder flexion (°) Lumbar flexion (cm)
Sit-to stand test for 30 s 148.8 ± 24.2 to 150.0 ± 25.7 7.7 ± 4.8 to 7.8 ± 5.0
17.9 ± 5.4 to 19.3 ± 6.3 Thoracolumbar flexion (cm) Hip flexion (°)
Aerobic capacity 6.3 ± 2.8 to 6.3 ± 2.7 102.5 ± 14.1 to 104.6 ± 14.1
6′ walk (m) Lateral flexion (cm)
351.9 ± 56.6 to 399.2 ± 112.5 14.4 ± 4.6 to 14.7 ± 4.9
Irez et al. (2011) Experimental group Muscle manual tester (kg) p b .05*, ** Dynamic balance MED-SP300 (°) p b .05*, Simple RT (ms) p b .05*, **
(30) 23.3 ± 5.7 to 32.7 ± 7.0 ** 0.3 ± 0.1 to 0.3 ± 0.1
Flexibility 11.0 ± 1.5 to 9.0 ± 1.5 Choice RT (ms) p b .05*, **
Sit and reach (cm) Number of falls p b .05*, ** 0.7 ± 0.2 to 0.6 ± 0.1
p b .05*, ** 1.9 ± 1.4 to 0.4 ± 0.5
12.8 ± 4.4 to 15.9 ± 5.1
Control group (30) Muscle manual tester (kg) Dynamic balance MED-SP300 (°) Simple RT (ms)
21.0 ± 8.9 to 20.7 ± 8.6 11.4 ± 1.8 to 11.2 ± 2.1 0.4 ± 0.1 to 0.4 ± 0.1
Flexibility Number of falls Choice RT (ms)
Sit and reach (cm) 1.6 ± 1.2 to 1.3 ± 0.4 0.7 ± 0.2 to 0.7 ± 0.1
10.8 ± 3.8 to 10.4 ± 3.6
Siqueira Rodrigues Pilates groups (27) Static balance (Tinetti) p b .05* Functional autonomy Quality of life
et al. (2010) 23.9 ± 1.5 to 24.9 ± 1.1 C10M p b .05*, ** DOM1 p b .05*
7.6 ± 1.7 to 6.9 ± 1.6 4.2 ± 2.9 to 14.7 ± 2.4
LPS p b .05** DOM2
10.5 ± 2.2 to 9.2 ± 2.3 13.7 ± 2.8 to 14.2 ± 3.2
LPDV p b .05*, ** DOM3 p b .05*
4.2 ± 0.9 to 3.1 ± 0.8 15.7 ± 1.6 to 15.9 ± 2.8
VTC p b .05** DOM4 p b .05**
14.3 ± 3.3 to 12.3 ± 2.6 15.9 ± 1.8 to 16.4 ± 2.2
LCLC p b .05** DOM5
35.0 ± 5.0 to 31.1 ± 6.0 12.9 ± 4.1 to 13.0 ± 3.5
IG p b .05*, ** DOM6 p b .05**
27.2 ± 3.9 to 23.6 ± 4.0 15.2 ± 3.0 to 15.0 ± 3.8
QVG p b .05*
88.2 ± 6.2 to 89.4 ± 9.4
Control group (25) Static balance (Tinetti) Functional autonomy Quality of life
22.0 ± 2.9 to 22.4 ± 2.6 C10M DOM1
7.6 ± 1.1 to 7.6 ± 1.2 13.4 ± 4.3 to 13.2 ± 4.9
LPS DOM2
10.7 ± 2.0 to 10.6 ± 2.2 13.9 ± 2.5 to 13.6 ± 2.8
LPDV DOM3
4.4 ± 1.0 to 4.6 ± 1.1 15.0 ± 2.5 to 15.0 ± 2.4
VTC DOM4
13.0 ± 1.8 to 13.2 ± 1.9 14.5 ± 3.5 to 14.2 ± 3.9
LCLC DOM5
36.7 ± 4.7 to 36.7 ± 4.9 10.8 ± 4.8 to 10.9 ± 4.9
IG DOM6
27.0 ± 3.4 to 27.2 ± 3.6 17.2 ± 2.3 to 17.2 ± 2.5
QVG
84.8 ± 10.6 to 84.2 ± 11.0
Kuo et al. (2009) Pilates group Sagittal angles for the spine in Sagittal angles for the spine in sitting (°)
standing (°) Upper cervical spine
Upper cervical spine Baseline: 0.3
p b .05* Exercise: −0.1
Baseline: 0.2 Follow-up: 1.2
Exercise: 1.7 Lower cervical spine
Follow-up: −0.3 Baseline: −1.4
Lower cervical spine Exercise: 0.2
Baseline: −0.5 Follow-up: −0.5
Exercise: 0.3 Thoracic spine
Follow-up: −1.2 Baseline: −1.2
Thoracic spine p b .05* Exercise: −0.4
Baseline:−0.2 Follow-up:0
Exercise:−2.3 Lumbar spine p b .05*
Follow-up: 0.9 Baseline: −2.8
Lumbar spine p b .05* Exercise: −2.7
Baseline: −1.5 Follow-up: −1.5
Exercise: −1.5
Follow-up: −0.8
 V. Bullo et al. / Preventive Medicine 75 (2015) 1–11 7

Fig. 2. Forest plot representing effect sizes of intervention and control groups in strength outcomes.

included different modalities, frequencies, and durations. The durations Functional Reach Test (FRT) and Tinetti Static Balance Scale. On the
of the exercise interventions ranged from 5 to 52 weeks and included whole, PET led to an improvement in static balance (decreases in ML-
sessions that spanned 1–3 times per week. One limitation for most of Sway represents improvements): − 16.9% on ML-Sway with open
the papers is the lack of reporting on the level of intensity. Additionally, eyes and − 22.1% with closed eyes on a compliant surface (Bird et al.,
only 4 studies reported adherence rates, which ranged from 50% to 2012). A longer protocol (12 months) showed higher improvements
97.5% (Bird and Fell, 2014; Bird et al., 2012; Irez et al., 2011; Kuo et al., in ML-Sway (closed eyes) by − 43.7% (Bird and Fell, 2014). Further-
2009). Characteristics of the studies, including participants' description, more, FRT showed an improvement of 16.7% after 12 weeks of training
type of intervention, frequency and duration are summarized in Table 2. (Mokhtari et al., 2013) and Tinetti scale increased by 4.3% after 8 weeks
Finally, Table 3 reports all results of the included studies. (Siqueira Rodrigues et al., 2010).
Four studies were classified as high quality (Bird and Fell, 2014; Bird Dynamic balance was measured with a Timed Up and Go Test (TUG),
et al., 2012; Irez et al., 2011; Kuo et al., 2009), while six as low quality Four Square Step Test (FSST) and the Dynamic Balance platform MED-
studies (Johnson et al., 2013; Marinda et al., 2013; Mokhtari et al., 2013; SP300. TUG improved by 11.7% and 10.5% (after 5 weeks in the two dif-
Newell et al., 2012; Plachy et al., 2012; Siqueira Rodrigues et al., 2010). ferent groups) (Bird and Fell, 2014), by 7.3% (after 12 weeks) (Mokhtari
Moreover, three studies were blinded to the researcher (Bird et al., et al., 2013) and by 6.6% (after 5 weeks) (Bird et al., 2012). Only Johnson
2012; Irez et al., 2011; Kuo et al., 2009) and only two performed an “in- et al. (2013) found no difference in pre-post TUG comparison, however,
tention-to-treat” analysis (Bird and Fell, 2014; Bird et al., 2012). Two stud- a significant increase in TUG cadence was found (8.1%). FSST showed
ies reported the timing of outcomes assessment (Irez et al., 2011; Kuo et al., improvement in both Bird et al. studies (Bird and Fell, 2014; Bird
2009) and three studies performed a follow-up evaluation, specifically after et al., 2012) by 17.7% and 7.25%, respectively after 5 weeks of PET,
a 20 week (Kuo et al., 2009), after a 6 month (Bird et al., 2012), and after a while a longer intervention showed an improvement of 18%. Irez et al.
12 month (Bird and Fell, 2014) intervention-free period. (2011) found a significant improvement in balance (18.1%) measured
by MED-SP300. Finally, Johnson et al. (2013) used the Berg Balance
Muscle strength outcomes Scale (BBS) to demonstrate a significant improvement in static and dy-
namic balance (7%). ES value indicated a small effect about efficacy of
Strength was measured in laboratory (e.g. knee extension) and field set- PET for static balance (ES = 0.33) while a moderate to large effect for
tings (e.g. 30 second sit-to-stand test). Plachy et al. (2012) as well as Irez the dynamic balance (ES = 0.77) (Figs. 3 and 4). Overall, it appears
et al. (2011) demonstrated a significant improvement in muscle strength, that longer period of intervention acts in favor to higher improvement
i.e. +43.8% on 30 second sit-to-stand test and +40.2% on lower limb in both static and dynamic balance outcomes.
strength. Differently from these two previous studies, Bird et al. (2012)
did not find any changes on knee extension strength, after 5-weeks of Flexibility
PET. After a 12-month follow-up, Bird and Fell (2014) described an overall
strength decline, however, the group which continued PET showed a higher Three articles reported measures on mobility and flexibility. Irez et al.
pooled force compared to a group that ceased PET. ES calculation indicated (2011) found an improvement in flexibility of 24.6% (sit and reach test)
a large effect of PET for strength outcomes (ES = 1.23) (Fig. 2). after 12 weeks of PET, while Plachy et al. (2012) evaluated mobility in dif-
ferent body regions and detected general significant improvements
Static and dynamic balance (shoulders flexion: 12.5%, thoracolumbar flexion: 42.5%, lumbar flexion:
28.9%, lateral flexion: 25.2% and hips flexion: 16.1%). Only one investiga-
Six studies examined static and dynamic balance. Static balance was tion measured sagittal spine posture. In this study, Kuo et al. (2009) deter-
measured with a force platform (Medio-Lateral Sway range, ML-Sway), mined changes in the angles of spine for sitting and standing positions.

Notes to Table 3:
Abbreviations: * within group comparison, ** between group comparison.
Bird and Fell (2014): T1: baseline, T2: 5-week follow-up, T3: 12-month follow up; ML sway EC: medio-lateral sway eyes closed; FSST: four square step test; TUG: timed up and go;
Mokhtari et al. (2013): GDS: geriatric depression scale; and FRT: functional reach test.
Marinda et al. (2013): RHR: resting heart rate; SBP: systolic blood pressure; DBP: diastolic blood pressure; TC: total cholesterol; and TG: triglycerides.
Johnson et al. (2013): BBS: Berg balance scale; ABC: activities-specific balance confidence scale; ADL: Activity of daily life; SES: Schwab and England scale; and UPDRS: unified Parkinson's
disease rating scale.
Newell et al. (2012): WS: walking speed; SC: step cycle; SL: step length; R: right; L: left; Ant–Post and Med–Lat: frontal and sagittal plane excursions; FRI: fall risk index; AI: ambulatory
index.
Irez et al. (2011): MED-SP300: Medical Sports Performance 300; RT: Reaction Time.
Siqueira Rodrigues et al. (2010): C10M: walked of 10 m; LPS: to rise from a seated position; VTC: putting on and to taking off a shirt; LCLC: to rise out of a chair and to move freely through
the house; IG: index GDLAM (protocol evaluated the personal autonomy); DOM1: sensorial abilities; DOM2: autonomy; DOM3: past, present and future activities; DOM4: social partic-
ipation; DOM5: death and dying; DOM6: privacy; and QVG: quality of life index.
Kuo et al. (2009): Comparisons for Baseline: pretest 1 (week 1) vs pretest 2 (week 5); exercise: pretest 2 vs posttest 1 (week 15), and follow-up: posttest 1 vs posttest 2 (week 20). Pilates
intervention given during weeks 6–15.
8 V. Bullo et al. / Preventive Medicine 75 (2015) 1–11

Fig. 3. Forest plot representing effect sizes of intervention and control groups in static balance outcomes.

Fig. 4. Forest plot representing effect sizes of intervention and control groups in dynamic balance outcomes.

Immediately after PET, only thoracic spine angle in standing was statisti- the Schwab and England Scale (SES) and found no significant chang-
cally significantly changed. ES value indicated a small effect about efficacy es after PET. Siqueira Rodrigues et al. (2010) evaluated changes in
of PET for flexibility outcome (ES = 0.31) (Fig. 5). the independence in the activities of daily living using the Latin
American Development Group for Elderly (GDLAM) protocol and
Walking and gait measures quality of life with the World Health Organization's quality of life
questionnaire for elderly after a PET intervention. In regard to func-
Walking and gait parameters were evaluated in two investigations; tional autonomy, there were significant improvements in 10-m
Johnson et al. (2013) assessed time and steps in the 5-m walk test, walks (9.3%), time to stand up (11.8%), time to rise from the prone
only finding improvements with timed test duration (12.7%). Newell position (26.0%), time to put on and to take off a shirt (13.9%), and
et al. (2012), however, showed an increase in walking speed (26.9%), time to walk through a house (11.2%). Also, quality of life improved
step cycle (12.7%) and length (23.8%) after an 8-week PET-intervention significantly in the questionnaire domains of “sensorial abilities”,
on 9 elderly individuals. “past, present and future activities”, “social participation”, and “inti-
ES value indicated a large effect for PET about walking measures and macy”, resulting in an overall increase of the quality of life index by
gait ability (ES = 1.39). 1.3%. The impact of PET on independence, quality of life and mood
state was examined by Mokhtaria et al. (2013) who analyzed its ef-
Activities of daily living, mood states and quality of life fects on depression with Geriatric Depression Scale (GDS) (Cruice
et al., 2011). In this study, a significant improvement with a 19.8%
Four studies evaluated elderly subjects' functional capacity to decrease of depressive symptoms was found (2013). ES calculation
perform daily living activities and their quality of life. Johnson et al. resulted in a large effect of PET for measures concerning activities
(2013) evaluated personal abilities in activities of daily life with of daily living, mood states and quality of life (ES = 0.94) (Fig. 6).

Fig. 5. Forest plot representing effect sizes of intervention and control groups in flexibility outcomes.
 V. Bullo et al. / Preventive Medicine 75 (2015) 1–11 9

Fig. 6. Forest plot representing effect sizes of intervention and control group in activities of daily living, mood state and quality of life outcomes.

Cardio-metabolic effects Pilates and balance

Only one study evaluated the cardio-metabolic effects of PET in the Minor changes were found in static balance with an overall
elderly. Marinda et al. (2013) found a significant decrease in systolic small ES (0.34). On the other hand, dynamic balance measures
blood pressure (5.2%) in apparently healthy and sedentary older showed a different trend in nearly all PET-intervention studies
women, without any significant alterations of arterial blood pressure, with a moderate to large ES (0.77). Larger improvements appear
resting heart rate or blood triglycerides. ES calculation indicated a to be associated with the length of the training. Interestingly,
small effect of PET for cardio-metabolic pattern (ES = 0.07). some improvements were still present after 5 weeks from the
end of the intervention. The FRT, used by Mokhtari et al. (2013),
showed an improvement in anterior and posterior stability after
Discussion 12 weeks of PET. Although fall risk remained clustered at a “mod-
erate level” before and after the PET intervention, clinically rele-
Overall, results reported in this review indicate that PET may be con- vant improvements in FRT scores were observed, suggesting PET
sidered beneficial for improving strength, dynamic balance, as well as for fall prevention strategies in patients with high fall risk. Other
walking performance in elderly populations. Furthermore, from a clini- improvements in static and dynamic balance assessed by the BBS
cal perspective, PET might be useful in reducing fall-risk, improving in- also suggest a possible reduction in fall risk in frail elderly
dependence, quality of life and mood state. However, due to the low (Johnson et al., 2013). Furthermore, participants significantly im-
number of studies as well as the heterogeneity of the study outcomes, proved their TUG test scores in several studies after PET, which
larger clinical trials should be designed to increase scientific evidence has been associated with reductions in fall risk (Bird and Fell,
about the potential effectiveness of PET, especially on variables where 2014; Bird et al., 2012; Mokhtari et al., 2013). However, there
statistical power calculations were not performed. Even so, PET for are too few studies that make this statement definitive.
elderly individuals seems to incorporate many of the components of There is evidence that PET has the potential to prevent falls due to
the ACSM training recommendations (Chodzko-Zajko et al., 2009) positive effects on physical and mental risk factors. However, only Irez
(i.e. strength, flexibility, balance training) and has an encouraging per- et al. (2011) evaluated fall risk directly. This high quality study showed
spective in filling the needs for this population, like other forms of struc- fewer numbers of falls (80.2%) after 12 weeks of PET, which were relat-
tured exercise. ed to reduction in simple reaction time (23.5%) and choice reaction time
(20.3%). Moreover, Johnson et al. (2013) did not observe any falls
among elderly Parkinson patients performing regular PET. Only
Pilates and muscle strength Newell et al. (2012) found no significant decrease in fall risk which
can be explained by the short duration of their protocol, along with
PET was demonstrated to have positive effects on lower limb the low number of the weekly training session. Furthermore, as previ-
strength (Irez et al., 2011; Plachy et al., 2012); these results are support- ously described in Granacher et al. review (2013) which was strongly
ed by a large ES (1.23). Data by Plachy et al. (2012) are comparable to focused on core strength training, PET could be used as an adjunct or
those reported by Lubans et al. (2013) which investigated on an elas- even alternative to traditional balance and/or resistance training pro-
tic-resistance-training and lifestyle-activity intervention for sedentary grams for older adults. Hence, PET might be proposed as purposeful
older adults. Although the duration of training intervention was shorter training modality to prevent falls due to improvements in dynamic
in Lubans et al., similar improvements in muscle strength were found, balance.
assessed by the same method (30-s chair-stand test).
Another interesting point can be observed in individuals who
might not have access or the ability to perform traditional strength Pilates and mobility/walking
exercise. It was shown that home-based strength exercises tended
to have smaller effects in increasing muscular strength than exercis- Participants' mobility was shown to improve in different body re-
ing with traditional resistance training equipment or facility-based gions after a PET-intervention (Plachy et al., 2012). Furthermore, the
resistance training (Thiebaud et al., 2014). On the other hand, PET 5 m-walk test improved, highlighting the potential benefits on dynamic
protocol by Irez et al. (2011) appeared comforting since it showed balance, mobility and walking. Moreover, Johnson et al. (2013) investi-
higher improvements compared to the home-based strength train- gated PET in Parkinson patients reporting improved 5 m-walk times de-
ing protocol by Thiebaud et al. (2014). Finally, it should be men- spite null improvements with the TUG tests. The training effect on
tioned that 5 weeks of PET (Bird and Fell, 2014; Bird et al., 2012) Parkinson patients cannot be extended to the general population, how-
were probably too short to determine a significant, but also clinically ever, it stresses the possibility to implement PET exercise prescription
meaningful increase in muscle strength. with chronically diseased patients.
10 V. Bullo et al. / Preventive Medicine 75 (2015) 1–11

Activities of daily living, mood states and quality of life Conclusions

Studies demonstrated that physical exercise training improved de- Results from this review showed that PET might be considered an
pressive disorders and anxiety in older people (Zanuso et al., 2012). exercise intervention that is capable to increase muscle strength as
Mokhtari et al. (2013) showed that a 12-week PET program was able well as to improve static and dynamic balance in elderly populations.
to reduce depressive symptoms in elderly. In a similar study, Hassan Furthermore, functional capacity to perform daily living activities and
(2011) found a reduction in depressive disorders (−33.68%) in young quality of life can be generally improved if elderly engage in PET.
women after a 12-week PET intervention. PET seems to be a safe type of exercise. In fact, none of the included
Besides depression, the physical decline of the elderly negatively af- studies reported side-effects during its practice. Although further re-
fects their personal autonomy and quality of life. Physical activity is a search is needed, our results indicate that clinicians who consider PET
way to slow down this decline and maintain or even increase personal for exercise prescription are suggested to recommend PET at least
autonomy and quality of life (Pernambuco et al., 2012). For instance, twice per week, at moderate to vigorous rate of perceived exertion de-
study results show that PET can improve functional autonomy and qual- pending on current conditioning, and to add supplemental aerobic exer-
ity of life in the elderly (Siqueira Rodrigues et al., 2010). Although a large cises. Besides, exercise prescription could incorporate PET for the
ES was determined (0.94), more evidence is needed to definitely state elderly which present impaired balance conditions since PET has
this impact, but as other physical activities, PET seems to produce simi- showed to be effective in increasing static and dynamic balance and in
lar benefits and can be recommended in elderly patients with depres- prevention of falls.
sive disorders.
Conflict of interest statement
Pilates and cardio-metabolic effects The authors declare that there are no conflicts of interest.

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