How the Pilates Method Can Influence Sports Performance in Different Modalities

The intense and repetitive training required in high-level sport to achieve better ability, flexibility, muscular strength, and sports performance can lead to injuries and muscular imbalances to athletes. (Ishøi et al., 2020; Pertile et al., 2011)

Training or competition can lead to the appearance of lesions that are directly related to intrinsic and extrinsic predisposing factors, as well as to the absence of preventive programs (Gantus, Assumpção, 2002). Lack of flexibility and poor muscular strength are factors that limit athletic performance, making it necessary to undertake awareness activities with the athletes at both physical and mental levels. (Lima et al., 2019; Bertolla et al., 2007; Aparício, Pérez, 2005; Musculino, Cipriani, 2004)

The Pilates Method is a form of physical and mental conditioning created in Germany by Joseph Hubertus Pilates in the early twentieth century (Latey, 2001). It emphasizes body symmetry, spinal alignments, pelvic and scapular stabilization, flexibility, breath control, and muscle strengthening, employing exercises performed on the ground and using specific equipment. It advocates the use of a set of muscular chains, rather than muscle groups in isolation, integrating the upper and lower extremities with the trunk. Besides these benefits, it develops aspects of motor coordination and body awareness, which are used in the exercises. (Queiroz, 2010; Massey, 2009)

The increasing popularity of the Pilates Method is evidenced by the participation of about five million people in Pilates practice in the United States (Chang, 2000). Latey (2001) suggested that some of the reasons for this growing interest are the broad approach of the method, the differences in the demands of the population for physical activity, and the ability to improve injury prevention.

Unfortunately, the increasing number of clients and professionals of the Pilates Method has not been accompanied by concomitant research efforts to understand its effects. There are few reported studies concerning the effects of the Pilates Method exercises in the various sports modalities. Therefore, in order to enable a better understanding and knowledge of the benefits of applying the Pilates Method, we sought to answer the following question: What are the aspects covered in the scientific literature correlating the Pilates Method to sports?

It was evident that an update of the literature was necessary given the current paucity of information concerning this topic. Hence, the objective of this study was to perform a systematic review, based on the current literature, in order to investigate the effects of the Pilates Method in athletes of different sports modalities, and to use meta-analysis to investigate the effect of the technique on the flexibility of these athletes.

This review was followed the PRISMA recommendations (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). (Moher et al., 2009)

The present study is a systematic review with meta-analysis of experimental studies that sought to identify, select, and critically evaluate the scientific evidence regarding the effectiveness of the Pilates Method in athletes of different sports modalities. The search strategy was based on articles indexed in the electronic databases SciELO, LILACS, PubMed, Web of Science, and SCOPUS. Searches were performed between June 2018 and September 2018, with the last search on September 25th, 2018.

In the survey, the following descriptors were used: “Pilates”, “Pilates Method”, “atletas”, and “athletes”, considering the titles and abstracts of the articles. The expression “AND” was used for combinations. For example, in the PubMed database, the advanced search was selected, using “Pilates OR Pilates Method AND atletas OR athletes”, filtering for the period from 2007 until the current time, with selection of all fields and also only titles/abstracts.

The studies included were original experimental and quasi-experimental clinical type investigations related to the topic and indexed in the selected databases, with abstracts and full online access available. The articles were written in the Portuguese and English languages and were published between 2007 and 2018, a period during which public awareness of the Pilates Method increased, since it is a relatively new resource, compared to other traditional methods of physical activity. Studies excluded were those that did not fit the inclusion criteria, pilot studies, case studies, theses or dissertations, systematic reviews, and others that had a different approach to the proposed theme.

The articles were evaluated and selected independently by two researchers, obeying the eligibility criteria. After the removal of duplicates, the titles and abstracts were checked in order to exclude studies that had no relation to the guiding question. After this pre-selection, the evaluators analyzed the remaining texts in full, considering the pre-defined inclusion and exclusion criteria. Subsequently, the evaluators met in order to agree on the final studies to be included in the review. There was no disagreement between the reviewers. Two other reviewers then performed the search again, in order to confirm the eligibility of the papers selected for this review. There was no need to contact the authors of the articles.

The methodological quality was evaluated using the PEDro Quality Scale, which aims to assist users of the PEDro database regarding the methodological quality of randomized controlled studies. (Shiwa et al., 2011)

The scale is composed of eleven items and classifies the methodological quality (considering internal validity and statistical information) of randomized and almost randomized clinical trials. Each item, except the first, contributes one point to the total score of the scale, which ranges from zero to ten points. Scoring is only made when a criterion is clearly satisfied. There is a possibility that a criterion has not been met if from literal reading of the clinical trial report not receive a score.

Information about the study method (study design, participants, intervention, and outcome measures) and outcomes (number of participants and mean/standard deviation of variables related to flexibility) was extracted by an independent assessor and was checked by a second evaluator.

The variables used for meta-analysis were flexibility parameters. The first variable was the result (given in cm) obtained using the Wells bench Sit-and-Reach test, which was provided in all four selected studies. The second variable, presented in degrees (°), was the result obtained using a flexometer instrument, with only two of the studies providing this information.

The measurements for Pilates and control groups (difference of means and standard deviations) were used, since these values were available in all the studies. Only two studies provided post-intervention measurements, which were excluded from the meta-analysis.

The meta-analysis and evaluation of bias risks based on the results of the articles were performed using Review Manager v. 5.3 software (Cochrane Collaboration), considering an alpha value equal to 5% to be statistically significant (95% confidence interval). Statistical heterogeneity was evaluated using Cochran’s Q test, and the inconsistency was determined by the I2 test, with 0% indicating non-heterogeneity among the studies, close to 25% indicating low heterogeneity, close to 50% indicating moderate heterogeneity, and close to 75% indicating high heterogeneity among the studies.

A total of 87 studies were identified in the database searches. Of these, 11 articles were considered potentially suitable for full analysis of the studies. Four studies met the eligibility criteria for the systematic review and four for meta-analysis. Figure 1 shows a flowchart for the studies included in this review, and Table 1 presents the characteristics of these studies.

Figure 1. Flowchart with the numbers of articles identified, excluded, and included

in the literature review, according to the PRISMA statement (Moher et al., 2009)

Author/ Scale Pedro	Objective	Test/ Instrument	Intervention	Conclusion
Chinnavan, Gopaladhas, & Kaikondan (2015) / 6	Evaluate the association between Pilates training and increased flexibility.	Goniometer (range of motion) and Sit-and-Reach test.	Control (n = 15): ballistic, PNF and static stretching exercises. Pilates (n = 15): low resistance exercises. 5 times a week for 4 weeks, 30 minutes per session.	Pilates improved the flexibility of the hamstrings when compared to static stretching.
Cruz et al. (2014) / 5	Evaluate the effects of a 6-week Pilates program (with device exercises) on body composition and physical fitness in young basketball players.	Sit-and-Reach, Shuttle Run, Vertical Jump, and Wingate tests.	Pilates (n = 8): exercises from the Pilates Method Alliance (PMA). Control (n = 7): conventional training of the basketball team. 2 times a week for 6 weeks.	Six weeks of Pilates was not enough to change physical fitness and body composition in young basketball athletes.
Pertile et al. (2011) / 6	Analyze and compare the effectiveness of muscle strength and flexibility training in young soccer athletes, using the Pilates method on the ground and therapeutic exercises.	Isometric trunk dynamometer, Wells bench, and flexometer.	Pilates (n = 9): Double Leg Stretch, Leg Pull Down, Double Leg Kick, Swimming and Swan Dive Therapeutic exercises (n = 9): five classic kinesiotherapy exercises. 4 consecutive weeks, 3 times a week, 25 minutes each session.	Depending on the aim of those practicing these methods, conventional exercises could, in the short term, be better than the more complex exercises used in the Pilates method on the ground.
Bertolla et al. (2007) / 7	Evaluate the effects on flexibility provided by a Pilates program in a junior-level futsal team.	Wells bench and flexometer.	Pilates (n = 6): Mat Pilates. Control (n = 5): usual team training. 3 times a week for 4 weeks, lasting 25 minutes.	Pilates presented acute effects, represented by a statistically significant increase in post-immediate and chronic flexibility, with a slight decline (without significant difference) in the post-late period.

Table 1 qualitatively characterizes the main methodological information for the selected studies, such as the purpose of the study, the sample, the instrument (or test) used to achieve the objective, the intervention, the conclusion, and the score on the PEDro scale.

All four studies we had analized (Pertile et al., 2011; Bertolla et al., 2007; Cruz et al., 2014; Chinnavan et al. 2015) found in the systematic review had the aim of evaluating the effectiveness of a Pilates training program in athletes. The study reported by Pertile et al.1 compared a Pilates training program with classical kinesiotherapy therapeutic exercises. The results showed that the therapeutic exercises provided better short-term effects, while Pilates provided better long-term effects in terms of flexibility, indicating that selection of the Pilates protocol or therapeutic exercises would depend on whether the objective was to achieve short-term or long-term goals.

Regarding heterogeneity, the four studies that assessed flexibility with the Wells bench Sit-and-Reach test (n = 73) (Figure 3A) found improvement for the Pilates group, although in most cases there was no significant difference, compared to the control group (2.83; 95% CI: -0.73 to 6.38; I2 = 99%), showing the high heterogeneity among the studies.

The meta-analysis comparing the two studies (Pertile et al., 2011; Bertolla et al., 2007) that assessed flexibility using the flexometer (n = 28) (Figure 3B) showed that there was no statistically significant difference between the Pilates and control groups, although the results suggested improvement (-0.78; 95% CI: -1.84 to 0.27; I2 = 0%), indicating non-heterogeneity between the studies.

Figure 2 shows the bias risk graph. All the studies were blinded in terms of their methodologies, but full descriptions of the procedures were not provided, so the risk was characterized as uncertain for all articles. For the rest of the fields, the absence of information or classification as high risk of bias in relation to the aspects of selection, implementation, detection, attrition, and description showed that the studies were compromised in terms of the methodology. In some cases, there was information that could be judged as having low risk of bias, but overall, the studies were considered methodologically flawed.

Figure 2. Graph of bias risk analysis of the selected studies. Source: authors

Figure 3. A: Forest plots: Meta-analysis comparing the Pilates and control groups in relation to flexibility evaluation using the Wells bench Sit-and-Reach test. B: Forest plots: Meta-analysis comparing the Pilates and control groups in relation to flexibility evaluation using the flexometer. Legends: SD: standard deviation; Weight: statistical relevance of the study; IV: inverse variance; CI: confidence interval; I2: heterogeneity index; Z: global effect test; Chi²: chi-square test; Tau²: Tau test of Kendall; df: degrees of freedom; P: p-value. Source: authors. Source: authors.

Although the studies investigated the influence of Pilates training in athletes, the objectives differed. Regarding the type of Pilates protocol, three studies used exercises on mats on the ground, which facilitated their applicability in possible studies, but the exercises were different. The study by Cruz et al. (2014) used equipment specifically developed for the Pilates Method (Cadillac, Reformer, and Wunda Chair), which hindered reproducibility.

According to the meta-analyses (Figure 3), all the articles showed low quality of the methodological processes and poor descriptions of the procedures, prejudicing the final results and leading to poor quality of the evidence.

The aim of this research was to review the literature concerning the role of the Pilates Method in sports. The studies evaluated were those whose outcomes could contribute to the dissemination of useful scientific evidence. The systematic review showed that there is a lack of scientific research concerning use of the Pilates Method in different sports modalities, since only four articles were found that were relevant to the topic.

Bertolla et al (2007) investigated the effect on flexibility provided by a Pilates program in a youth futsal team, performing a protocol with Pilates exercises for four weeks. In contrast to the results of Pertile et al. (2011), the research by Bertolla et al. (2007) and Chinnavan et al. (2015) showed that Pilates had a positive effect in increasing flexibility in soccer players.

The study of Cruz et al (2014) could not be compared to the rest of the studies, because it aimed to determine the effects of a six-week Pilates training program on body composition and physical fitness in young basketball players. The results indicated that the Pilates training program did not change physical fitness or body composition in these individuals. In two of the four articles explored in this study, Pilates provided positive results, in terms of flexibility, when it was added to athlete training, with even a short training period (4 weeks) resulting in improved flexibility. Similarly, Sekendiz et al. (2007) found a significant difference between the results of pre- and post-intervention tests, with increased posterior trunk flexibility in the group submitted to Pilates exercises, while Segal et al. (2004) also found significantly increased flexibility after three months of applying the same method. Valenza et al. (2016) similarly found positive results for flexibility in individuals with chronic low back pain after 8 weeks of Pilates exercise.

Pertile et al (2011) found no increase in strength, while Cruz et al. (2014) reported no differences in physical fitness or body composition after interventions using the Pilates Method. It is possible that the short time periods used (4 and 6 weeks, respectively) were insufficient to cause significant chronic adaptations, with longer duration of training being required in order to detect changes in these variables. An additional important point is that neuromuscular adaptations were already well established in the athletes.

Flexibility was shown to increase after the protocol with the Pilates Method, although the changes were not statistically significant, based on the four studies with poor methodological quality.

The classification of the studies in relation to the methodology was hindered by the fact that for most of the studies, there was no way to classify low or high risk of bias, since the necessary information was not provided. It was evident that the addition of Pilates to the usual training of the sport modality led to improved flexibility of the athletes in terms of the primary outcomes. Flexibility is essential for good musculoskeletal functioning, contributing to maintaining healthy muscles and joints throughout life (Cyrino et al., 2004). Declining levels of flexibility can lead to muscle injuries, resulting in the athlete desisting from the sport, as well as increased expenditure on health issues (Fraser et al., 2020; Krause et al., 2019).

Data for other secondary endpoints, such as the strength of trunk extensor muscles, body composition, and physical fitness, were measured using an isometric dynamometer, measurements of the thickness of skin folds with a Lange caliper, and performance tests (Shuttle Run Test, Vertical Jump Test, and Wingate Test), respectively. In the case of muscle strength, only one of the four studies included in the quality analysis mentioned this variable, with no increase being found. Regarding body composition and physical fitness, the study by Cruz et al. (2014) did not find any significant changes after the Pilates intervention.

Finally, some strengths and weaknesses of this systematic review should be highlighted. Firstly, an important limitation was the low methodological quality of the studies included. In addition, there were differences in the sizes of the samples selected for the studies, divergences in the Pilates protocols used, and a lack of information in some studies about the type employed. In terms of strengths, the four studies compared the results for different sample groups and provided statistical data (expressed as mean ± standard deviation).

It should be stressed that there is the need for randomized and well-controlled clinical trials with patients and blinded assessors, as well as adequate sample sizes, in order to clarify the contribution of the Pilates Method in different sports modalities as a suggestion for future studies. Reliable results generated by conducting clinical trials with high methodological quality, summarized in a systematic review with meta-analysis, will enable determination of whether the Pilates Method is an effective tool for improving sports performance.

This review had as limiting factors the small number of studies, with participants of different age groups, lack of homogeneity of the sample population, as well as the variation in the protocol of experimental intervention; the non-standardization of exercises according to the chosen sports modality, among the studies, the inadequate and non-explicit sample calculation and the absence of patients' blindness, evaluators among the articles. This small number of published articles had direct repercussions on the meta-analysis, since the analyzes were carried out considering few articles. The strengths of this study were that the four studies compared the results between the groups after the application of Pilates, and the PRISMA recommendations were used to base the methodological structure and the quality of the textual presentation.

It is suggested that future studies should be carried out with standardized protocols, according to the selected sport modality, in order to determine how the Pilates Method can be used to improve the performance of athletes.

Firstly, a literature review is important because it is through it that we better understand our work and the existing studies on that subject. Given this and due to the scarcity of studies involving Pilates in healthy athletes, a meta-analysis was performed to better clarify the evidence about the results of the articles found. The article indicates the importance and the need for further studies with healthy athletes, as this modality has been increasingly included and demonstrating efficacy.

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