Pilates vs Exercícios Globais

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RANDOMISED, CONTROLLED TRIAL

Pilates versus general exercise effectivenesson pain and functionality in non-specificchronic low back pain subjects

Fernanda Queiroz Ribeiro Cerci Mostagi, PT, MSc a,Josilainne Marcelino Dias, PT, MSc a,

Ligia Maxwell Pereira, PT, MSc, PhD a, Karen Obara, PT, MSc a,Bruno Fles Mazuquin, PT, MSc a,b,Mariana Felipe Silva, PT, MSc a,Monica Angelica Cardoso Silva, PT, MSc a,Renata Rosa de Campos, PT, MSc a,Maria Simone Tavares Barreto, PT, MSc a,Jéssyca Fernandes Nogueira a, Tarcı́sio Brandão Lima, PT, MSc c,Rodrigo Luiz Carregaro, PT, MSc, PhD d,Jefferson Rosa Cardoso, MSc, PT, PhD a,*

a Laboratory of Biomechanics and Clinical Epidemiology, Universidade Estadual de Londrina, Londrina,

PR, Brazilb Allied Health Research Unit, University of Central Lancashire, Preston, United Kingdomc Universidade Tirandentes, Aracaju, SE, Brazild Universidade de Brasilia, Brasilia, DF, Brazil

Received 16 May 2014; received in revised form 5 November 2014; accepted 11 November 2014

KEYWORDS

Clinical trial;Low back pain;Physical therapymodalities;Pilates

Summary Low back pain (LBP) is one of the most common causes of disability, and the Pi-

lates method has been associated with improvements in symptoms. The purpose of this studywas to assess the effectiveness of the Pilates method, when compared to general exercises, on

pain and functionality after eight weeks (16 sessions, 2/week) and a follow-up of three

months, in subjects with non-specific chronic low back pain (NSCLBP). A randomised controlled

trial composed of 22 subjects was proposed. Subjects were allocated into two groups: the Pi-

lates group (PG) (n Z 11) and the general exercise group (GEG) (n Z 11). The PG protocol was

* Corresponding author. Laboratory of Biomechanics and Clinical Epidemiology, PAIFIT Research Group, Universidade Estadual de Lon-drina, Londrina, PR, Brazil. Av. Robert Koch, 60, Londrina-PR 86038-440, Brazil. Tel.: þ55 43 3371 2649; fax: þ55 43 3371 2459.

E-mail address: [email protected] (J.R. Cardoso).

http://dx.doi.org/10.1016/j.jbmt.2014.11.0091360-8592/ª 2014 Elsevier Ltd. All rights reserved.

Available online at www.sciencedirect.com

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Journal of Bodywork & Movement Therapies (2015) 19, 636e645

mailto:[email protected]://dx.doi.org/10.1016/j.jbmt.2014.11.009http://www.sciencedirect.com/science/journal/13608592http://www.elsevier.com/jbmthttp://dx.doi.org/10.1016/j.jbmt.2014.11.009http://dx.doi.org/10.1016/j.jbmt.2014.11.009http://dx.doi.org/10.1016/j.jbmt.2014.11.009http://dx.doi.org/10.1016/j.jbmt.2014.11.009http://dx.doi.org/10.1016/j.jbmt.2014.11.009http://dx.doi.org/10.1016/j.jbmt.2014.11.009http://www.elsevier.com/jbmthttp://www.sciencedirect.com/science/journal/13608592http://dx.doi.org/10.1016/j.jbmt.2014.11.009http://crossmark.crossref.org/dialog/?doi=10.1016/j.jbmt.2014.11.009&domain=pdfmailto:[email protected]


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based on the Pilates method and the GEG performed exercises to manage NSCLBP. There were

no differences between the groups. When analysed over time, the GEG demonstrated improve-

ments in functionality between baseline and the end of treatment ( P Z .02; Cohen’s d Z 0.34)

and baseline and follow-up (P Z .04; Cohen’s d Z 0.31). There were no differences between

the Pilates and general exercises with regard to pain and functionality in NSCLBP subjects but

general exercises were better than Pilates for increasing functionality and flexibility.

ª 2014 Elsevier Ltd. All rights reserved.

Introduction

Low back pain (LBP) is one of the most common causes ofdisability and is the most common musculoskeletal condi-tion found in the adult population, with a prevalence of upto 84%. Back pain may be the leading cause of absenteeismin North American countries and between 60% and 90% ofthe population is at risk of developing this condition duringtheir life (Dagenais et al., 2010; Delitto et al., 2012;

Philadelphia Panel, 2001; van Middelkoop et al., 2011).Low back pain has a significant impact on functional ca-pacity, as the pain restricts occupational activities and is amajor cause of absenteeism. Thus, the economic burden oflow back pain is represented directly by the high costs ofhealth care spending and indirectly by decreased produc-tivity (Dagenais et al., 2010; Philadelphia Panel, 2001). Theuse of new technology in diagnosis and intervention con-tributes to the increased costs (Becker et al., 2011). Recentestimations show that the economic burden of back pain inthe United States, including both direct and indirect, costsranges from 84 to 624 billion dollars per year (Dagenaiset al., 2010; Fairbank et al., 2011; Karayannis et al., 2012).

This condition can be classified as specific, in which thepain is caused by a specific pathology or condition, or nonespecific, in which the cause of the pain cannot bedetermined (Manek and MacGregor, 2005). Back pain can befurther classified into acute (less than six weeks), subacute(six to 12 weeks) or chronic (longer than 12 weeks) (Haydenet al., 2005).

Of the various treatment strategies for non-specificchroniclow back pain (NSCLBP), studies have shown that the mosteffective treatments use exercise and cognitive/behaviouralprograms (Airaksinen et al., 2006; Bekkering et al., 2003;Philadelphia Panel, 2001; van Middelkoop et al., 2011). Sys-tematic reviews have shown that exercise-based treatments,especially motor control exercises, present the best evidence

in the management of NSCLBP and this type of interventionappears to be effective in reducing pain and improving func-tional status (Airaksinen et al., 2006; Bekkering et al., 2003;Delitto et al., 2012; Philadelphia Panel, 2001; vanMiddelkoop et al., 2011; van Middelkoop et al., 2010; vanTulder et al., 2000). This can be explained by the mechani-cal characteristics of CLBP, lumbo-pelvic instability,decreased joint mobility and neuromuscular mechanismsgreatly impact trunk stability and movement efficiency(Mannion et al., 2001; Panjabi, 2003).

The trunk muscles can be divided into two groups: theglobal and local system. The muscles of the first grouppossess long levers and large moment arms, with emphasis

on speed, power, and larger arcs of multiplanar movement.The second group consists of short muscles with direct ac-tion on the vertebra, which generate power for segmentalstability of the spine (transversus abdominis, multifidus,internal oblique, medial fibres of external oblique, quad-ratus lumborum, diaphragm, pelvic floor muscles, iliocos-talis and longissimus (lumbar portions)) (Faries andGreenwood, 2007). Evidence regarding the role of trunkmuscles, especially the transversus abdominis and multi-

fidus, has been discussed in the literature and demon-strates that these muscles are the main providers of lumbo-pelvic stability (Barker et al., 2006, 2004; Hides et al.,2011; Hodges et al., 2005, 2003; Hodges and Richardson,1996). Additionally, there is a consensus that these disor-ders arise from pain and inactivity associated with muscledisuse (Smeets et al., 2006).

Thus, Pilates could be an alternative treatment for thesepatients because it is based on strength and flexibility ex-ercises, which are not exclusively static, but are also dy-namic and focus on the muscles that are responsible for lumbo-pelvic stability (Gladwell et al., 2006). Pilates isknown as a form of physical and mental conditioningcharacterised by a set of exercises performed on a mat or

specific apparatus. It was created by Joseph HumbertusPilates in the middle of the last century and is based on sixprinciples: concentration, control, centring, flow, precisionand breathing (Latey, 2001; Muscolino and Cipriani, 2004).

Several studies, both RCTs and systematic reviews, haveevaluated the Pilates method for low back pain, but their results are conflicting (Aladro-Gonzalvo et al., 2012;Anderson, 2005; Cruz-Ferreira et al., 2013; Donzelli et al.,2006; Gagnon, 2005; La Touche et al., 2008; Lim et al.,2011; Marshall et al., 2013; Miyamoto et al., 2011; Natour et al., 2011; Pereira et al., 2012; Posadzki et al., 2011;Rydeard et al., 2006; Wajswelner and Metcalf, 2012). Inaddition, one study evaluated the methodological quality

of systematic reviews on the effectiveness of Pilates totreat adults with CLBP (Wells et al., 2013). The authorsincluded five systematic reviews that evaluated the out-comes of pain and functionality and determined that therewas inconclusive evidence as to whether the Pilates methodis effective in reducing pain and improving functionality inindividuals with CLBP (Wells et al., 2013).

Thus, the aim of the present study was to assess theeffectiveness of the Pilates method, when compared togeneral exercises (kinesiotherapy), on pain and function-ality after 8 weeks intervention and again after a short-term follow-up period (three months) in subjects with non-specific chronic low back pain.

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Method

Design

A randomised controlled trial (RCT) with a three-monthfollow-up according to the Consort-Statement (Schulz et al.,2010) was conducted at the Laboratory of Biomechanics andClinical Epidemiology and in a private Pilates studio.

A table of random numbers was generated (www.random.org) and used for randomisation. The allocationconcealment was performed using opaque sealed enve-lopes. A researcher who was unaware of the goals or pur-pose of the study performed this procedure. After allocation, the participants were referred for treatment.Data collection and radiological examinations were per-formed by blinded, independent assessors.

Participants, therapists, and centres

Seventy-two subjects were evaluated for study eligibility,recruited from the local community and private health

services. Subjects were considered to be eligible if theywere sedentary and had not undergone physical therapy for at least six months. Moreover, they had to present anexclusive medical diagnosis of non-specific chronic lowback pain over a period of more than 12 weeks and be18e55 years old. Subjects were excluded if they had adiagnosis of protrusion of the intervertebral disc, scoliosis,spondylolisthesis, previous spine surgery, radicular symp-toms, inflammatory disease, rheumatic disease, cancer or pregnancy. To verify that the participants did not havestructural deformities that would justify the pain, an x-rayexamination was performed by an orthopaedic surgeon(Airaksinen et al., 2006).

After evaluation of the inclusion criteria, 50 (69%) pa-tients were excluded. Therefore, 22 participants wererecruited. In total, 11 participants were randomised to thePG group, and 11 participants were randomised to the GEGgroup. More information can be found in Fig. 1. All partic-ipants were notified of the research procedures, re-quirements and benefits and were invited to participate bysigning an informed consent form that was approved by theUniversidade Estadual de Londrina Ethics Committee(#062/2011). The study was registered in the NationalRegistry of Clinical Trials (REBEC:#7yhzym).

Procedures

Theparticipants whomet the eligibilitycriteriawere assessedon three different occasions: at baseline, at the end of thetreatment (8-weeks) and after three months of follow-up.

Participants attended the laboratory for evaluations. Atthe baseline evaluation, the participants signed the con-sent form, and anthropometric data were collected(weight, height and waist circumference) for the purpose ofanthropometrical characterisation of the participants.Following evaluation, the VAS and Quebec Questionnairewere completed, and then the SRT and Sorensen tests wereperformed. After the baseline assessment, participantswere allocated to either the Pilates group (PG) or thegeneral exercises group (GEG).

Intervention

Participants performed a total of sixteen sessions twice per week for eight weeks. For both groups, the interventionscomprised a one-hour individual/private session. The PGreceived a direction-specific exercise program based ontheir history and physical examination. The protocol wasbased exclusively on the Pilates method and some adap-

tations were prescribed following the participant’s maincomplaint (Appendix 1). All exercises were prescribed by alicensed physical therapist with clinical experience inmanaging patients with low back pain.

In the first session, the basic principles of Pilates wereexplained and the participants were familiarised with theexercises. The fundamental principles were reiterated atthe beginning of every class. Body perception aspectsincluded postural alignment (neutral spine, positioning ofthe scapula and cervical spine) and recruitment of “coremuscles”. All aspects were performed with controlledbreathing.

The GEG received standardised generic exercises thatare commonly used by physical therapists for the manage-ment of CLBP. These exercises included stationary bicy-cling, trunk and lower limb stretching, spine mobilisationand trunk muscle strengthening (Appendix 2). The orien-tation/application was performed by three licensed phys-ical therapists with expertise in exercise prescription andprevious guidelines of exercise-based treatment for CLBP.None of the physical therapists involved in either programhad access at any time to the assessment results.

Outcome measures

Primary outcomeThe primary outcome was pain, which was assessed by avisual analogue scale

e VAS. The participants were

instructed to mark a point on a line between zero and10 cm. Zero represented no pain and 10 represented themaximum possible pain (Mannion et al., 2007).

Secondary outcomePatient functionality was evaluated by the Quebec BackPain Questionnaire (0 represented no disability and 100represented maximum disability) (Rodrigues et al., 2009).Flexibility was measured by the Sit and Reach test (Fig. 2)(Kawano et al., 2010).The flexibility value was determinedby kinematic analysis measuring the hip joint angle (HJA).Three repetitions were performed and the lowest hip angle

of the three attempts was included for analysis. The HJAwas measured by the inclination angle of the sacrum andpelvis, related to the horizontal line, at the point ofmaximal forward reach in the SRT (Cardoso et al., 2007).The endurance of the trunk extensor muscles was assessedby the Sorensen test (Fig. 3). The duration of the test wasmeasured in seconds (Latimer et al., 1999).

Data analysis

The variables were analysed for normal distribution usingthe ShapiroeWilk test. When the normality assumption wasaccepted, the data were presented as means and standard

638 F.Q.R.C. Mostagi et al.

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deviations (SD). Otherwise, the data were presented asmedians and quartiles (25%e75%). The mean differences(MD) and 95% confidence intervals (CI) are presented.

Additionally, the effect size was calculated to indicate themagnitude of treatment effect. Cohen’s d was used tomeasure the effect size for both the PG and GEG for power analysis purposes. The effect size was classified as high,medium or low (Cohen, 1988).

To determine statistical differences from baseline, aStudent t-test or ManneWhitney U -test was employedaccording to the distribution of the data. To identifywithin-group differences, a mixed analysis of variance(mixed ANOVA) for repeated measures was used withsyntax according to the multivariate model. The Box’s Mtest was used to verify the equality of covariancematrices. Repeated measures ANOVA was used to

compare data between groups. Mauchly’s test was used totest the assumption of sphericity. When sphericity wasnot assumed, the Greenhouse-Geisser adjustmentapplied. When the F value was significant, the Bonferronipost hoc test was used to identify the differences. Thestatistical significance adopted for all tests was 5%. Allstatistics were performed according to intention-to-treatanalyses.

Results

Both groups were similar in all the assessed characteristicsat baseline (Table 1). The dropout rate was 9% and the

adherence to treatment was 100%. No statistical differ-ences were found between groups for any outcome.

The GEG improved over the period of the study, func-

tionality had statistically improved at the end of treatmentcompared to baseline (P Z .02; MD Z 17.7 CI 95% [7.5;27.9]; Cohen’s d Z 0.34) and at the follow-up compared tobaseline (P Z .04; MD Z 16.9 CI 95% [0.32; 33.4]; Cohen’sd Z 0.31) (Table 2). The GEG also had improved flexibilityat follow-up compared to baseline (P Z .01; MD Z 32.5 IC95% [7.7; 57.3]; Cohen’s d Z 0.89) (Table 3). However, thePG displayed no differences over the period of the study.

Discussion

The results of this study indicate that there is no differencebetween the Pilates method and general exercises for the

treatment of NSCLBP. However, a difference was foundwithin the GEG for functionality and flexibility. The RCT ofMiyamoto et al. (2011) (Pilates versus Minimal Intervention)and Wajswelner and Metcalf (2012) (Pilates versus GeneralExercises) evaluated patients with NSCLBP and their resultsagree with the results of the present study. However,studies of Gladwell et al. (2006) (Pilates versus ControlGroup) and Marshall et al. (2013) (Pilates versus StationaryBike) found statistical improvements in the Pilates groupfor functionality, flexibility, proprioception and painoutcomes.

Furthermore, the reviews of La Touche et al. (2008) andPosadzki et al. (2011) reported that the results on the

Figure 1 Flow diagram.



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subject were inconclusive, while the systematic review of

Lim et al. (2011) found improvements in the Pilates groupwhen compared to the control group in pain and function-ality outcomes. However, the systematic review of Pereiraet al (2012), considered by Welss et al. (2013) to be themost reliable, concludes that there is no difference be-tween Pilates and exercise stabilisation or the controlgroup for patients with NSCLBP. The studies presented herehave methodological differences such as: sample size, typeof subject, different frequency and duration of treatment,among others. These methodological differences mayexplain the differing results.

For pain, no difference was found either between thegroups or within the groups. However, it should be notedthat the mean baseline pain was low: 3 cm for the PG and

2.4 cm for the GEG; there was a decrease for the PG to 0.4and 0.3 cm at the 8 week and follow-up assessments,respectively and for the GEG to 0.5 and 1.1 cm at the 8week and follow-up assessments. Nevertheless, accordingto Ostelo et al. (2008), a statistical improvement does notrepresent a clinically relevant improvement and theopposite phenomenon is also true. In this case,

improvements in pain in the present study can be consid-

ered satisfactory and must not be discarded.It is worth noting that the evaluation of chronic painrequires a clear understanding of its origin and patho-physiology, which is highly complex in NSCLBP. Fears andbeliefs about pain, anxiety, depression and catastrophisingare associated with the perception of the same event(Dagenais et al., 2010; Lewis et al., 2012). Thus, pain in-tensity may vary throughout the day, over long periods or due to physical effort. This subjectivity makes pain difficultto measure and describe and it also imposes a source of bias(Mannion et al., 2007). Moreover, nociceptive factors playan important role; however, the clinical interpretationcannot be based solely on anatomical factors. In this case,the psychosocial dimensions become relevant and have

been identified as possible causes of pain and could affectthe development of and patient prognosis (Airaksinenet al., 2006; Dellito et al., 2012).

For trunk extensor endurance, no differences werefound either between groups or within groups. According toLatimer et al. (1999), asymptomatic individuals performedthe Sorensen test for an average of 132 s and patients with

Figure 2 Sit and reach test.

Figure 3 Sorensen test.



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chronic low back pain performed the test for 94.6 s.Another study (Alaranta et al., 1995) showed that lower values of endurance (less than 58 s) may be associated withrecurrent episodes of low back pain. However, a review(Demoulin et al., 2006) showed that, although widely used,the Sorensen test presents variations in the test descrip-tion, duration, predictive values, differences betweengenders and reasons for ending the test. Furthermore, ac-cording to Ropponen et al. (2005), pain and fear can alsointerfere with performance in this endurance test, whichcould explain our findings.

For flexibility, there was no difference between thegroups. However, the GEG showed an improvement over time and this result was not observed for the PG. ROM isknown to improve after approximately 3e4 weeks ofstretching exercises (Decoster et al., 2005). However, the

type of stretching in the evaluated groups was different.The PG performed dynamic stretches, whereas the GEGperformed static stretches. Another distinguishing factor was the time of realisation of the exercise. In the PG, thisfactor was not controlled and for the GEG, this time wasbetween 30 s and 1 min with progression in the repetitions.Static stretching may be better than dynamic stretching(Bandy et al., 1998; Decoster et al., 2005). The

recommended time to achieve results is between 10 and30 s (Bandy et al., 1997); furthermore, 2 to 4 repetitionshave better results than just one (Garber et al., 2011).

There are some valid comments regarding this outcome.

The SRT was used to assess flexibility and evaluated theflexibility of the hamstrings. However, some studies havereported that this test is a poor indicator of hamstringflexibility because it has several confounding factors (Daviset al., 2008). Nonetheless, the SRT was adopted due to itsfrequent use. Additionally, in the evaluation of this study,the number of centimetres achieved during the test was nottaken into account, and instead, the indirect hip joint angle(HJA) was used for analysis. This test can be measured bythe inclination angle of the sacrum and pelvis in relation tothe horizontal line at the point of maximal forward reachon the SRT. Furthermore this approach reduces the influ-ence of variations in the length of the upper and lower

limbs and the contribution of the lower back. The HJA canbe assessed with high reliability by angular kinematicanalysis (Cardoso et al., 2007).

The GEG had improved functionality. However, therewas no difference between groups or within the PG. Thisoutcome can be influenced by various motor skills,including muscle strength and the characteristics of theinterventions directly influence this skill.

The American College of Sports Medicine recommendsthat novices perform at least one set of 8e12 repetitionswith a load of 60e70% of maximum repetition (MR) for resistance training (Ratamess et al., 2009). This recom-mendation was similar to the procedure followed by theGEG, where training was usually composed of 3 sets of 8

repetitions with progression, while the PG generally per-formed one set of 10 repetitions for each exercise withoutchanges in repetition. Moreover, evaluations of muscle ac-tivity during conventional exercises and Pilates exercisesshowed an activation of 52.4% of the MVIC for the rectusabdominis (RA) during the Straight Curl-up and an activationof 55.9% during the Cross Curl-up (Konrad et al., 2001). Incontrast, the activation was 39% of the MVIC during theHundreds exercise (Souza and Cantergi, 2012), 31.2% of themaximum peak during the Teaser and 23.5% of the maximumpeak during the Longspine (de Oliveira Menacho 2013) for the RA muscle. In other words, the proposed interventionsfor the GEG better suited improvement in muscle strength.

Table 1 Baseline characteristics of participants.

PG (11) GEG (11)

Gender

Male (n; %) 2; 18.2 2; 18.2

Female (n; %) 9; 81.8 9; 81.8

Age (y)

Mean (SD) 36.1 (9) 34.7 (8.1)

BMI (kg/m2)Md (1st;3rd quartile) 25.7 (22; 26.9) 28.2 (26.6; 32.6)

Abdominal circumference (cm)

Mean (SD) 87.4 (8.3) 91 (13.1)

P > .05 for all analyses. PG: Pilates Group; GEG: General Ex-ercise Group; M: male; F: female; y: years; SD: standard devi-ation; BMI: body mass index; Md: median; cm: centimetres;VAS: visual analogue scale; SRT: sit and reach test; s: seconds.Intention-to-treat analyses.

Table 2 Summary of the primary outcome measures.

PG (n Z 11) GEG (n Z 11)

VAS (cm) md (1st; 3rd quartiles)

Baseline 3.0 (0.3; 4.7) 2.3 (1.1; 3.1)8th week 0.4 (0; 3.5) 0.50 (0; 2.1)

Follow up 0.3 (0; 2) 1.1 (0.1; 2.2)

Quebec Scale mean (SD)

Baseline 27 (15.7) 29.4 (17.8)

8th week 15.5 (10.3) 11.7 (9)a

Follow-up 16 (11.7) 12.5 (10.8)b

PG: Pilates Group; GEG: General Exercise Group; VAS: visualanalogue scale; Md: Median; SD: standard deviation; a: P Z .02(Baseline 8th week GEG, Mean Difference Z 17.7 CI 95% [7.5;27.9]); b: P Z .04 (Baseline Follow-up GEG, MeanDifference Z 16.9 CI 95% [0.32; 33.4]). Intention-to-treatanalyses.

Table 3 Summary of the secondary outcome measures.

PG (n Z 11) GEG (n Z 11)

SRT (cm) mean (SD)

Baseline 112.1 (20.8) 112.6 (22.9)

8th week 95.5 (24.3) 103.2 (26.3)

Follow up 97.3 (20.5) 80 (18.3)c

Sorensen Test (s) Md (1st; 3rd

quartiles)

Baseline 44 (34; 68) 39 (19; 85)8th week 68 (56; 78) 58 (22; 66)

Follow-up 67 (51; 80) 40 (20; 63)

PG: Pilates Group; GEG: General Exercise Group; SRT: sit andreach test; cm: centimetres; SD: standard deviation; c: P Z .01(Baseline Follow-up GEG, Mean Difference Z 32.5 cm IC 95%[7.7; 57.3]); s: seconds; Md: Median. Intention-to-treatanalyses.



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However, there are disagreements regarding these results(Esco et al., 2004), because the functionality outcome canbe influenced by several factors, such as improved flexibilitywhich may have interfered in this difference in favour of theGEG.

The treatment of patients with NSCLBP is complex. Someauthors mention that patients with low back pain are hetero-geneous. In other words, subgroups of patients may respond

differently to the same treatment and some patients mayrespond betterto onetype of treatmentthan another (Fersumet al., 2010). Furthermore, according to the biopsychosocialmodel recommended by the guidelines (Airaksinen et al.,2006; Bekkering et al., 2003; Dagenais et al., 2010; Dellitoet al., 2012; Philadelphia Panel, 2001; van Middelkoop et al.,2011), chronic low back pain should be treated with a multi-disciplinary approach and should include not only biologicalfactors but also psychosocial dimensions.

Some limitations of this study should be taken intoconsideration. The small sample size may have caused atype II error, although we have presented the effect-size. Inaddition, Hayden et al. (2005) recommend a minimum of20 h of supervised treatment for patients with NSCLBP. In

this study, patients received 16 h of intervention, whichmay not have been sufficient to enable body adaptations toexercise, especially for patients in the PG as this method isvery different from commonly performed exercises.

Implications for practice

According to the results, general exercises are better thanPilates for improving functionality and flexibility. However,other outcomes, such as pain and endurance, showed nodifferences between the treatments.

For patients with NSCLBP, the following interventions havean effect on flexibility and functionality: aerobic exercises,

strengthening and stretching of the muscles of the trunk,lower limbs and posterior chain and mobility exercises for thespine (flexion, extension, lateral flexion and rotation).

Implications for future research

New RCTs are needed to confirm the effects of Pilates onpatients with NSCLBP. High quality studies that follow therecommendations of the Consort e Statement (Schulzet al., 2010) are required, as well as a standardisation ofoutcomes and interventions to facilitate comparisons be-tween studies. Moreover, the calculation of sample size isrequired to demonstrate the power of each study. In

addition, future studies should also consider cognitive/behavioural treatments for these patients.

Conclusions

The Pilates method was not superior to general exercise inreducing pain and improving functionality in patients withnon-specific chronic low back pain. Functionality (Quebecscale) showed within-group improvements (for the generalexercise group) with a mean difference of 17 points after 8weeks and also 17 points in the follow-up period (whencompared to baseline). In addition, hamstring flexibility(through SRT) showed a within-group improvement (for the

general exercise group) with a mean difference of 32 cm inthe follow-up period (when compared to baseline).

Acknowledgements

The authors would like to thank Ana PRG Cardoso, PT, for her assistance during the preparation of the exercises aswell as the CNPq (Grant #70/2009), Productivity Scholar-ship/2014 to the last author and PPSUS/Fund. Araucaria(Grant # 04/2012).

Appendix 1. Pilates Group Protocol

Week Protocol

1st week Presentation of the method and apparatus

of Pilates.

Basic principles: concentration, control,

centring, flow, precision and breathing.Fundamental movements: breathing, pelvic

bowl, knee sway, spinal bridge, twist, flight

and cat (10 reps)

2nd week Fundamental movements: breathing, pelvic

bowl, knee sway, spinal bridge, twist, flight

and cat (10 reps)

Spine stretch (10 reps)

Saw (10 reps)

Hundred/dynamic with Swiss ball (10 reps)

3rd week Breathing (10 reps)

Pelvic bowl (10 reps)


Saw (10 reps)Hundred/dynamic with Swiss ball (10 reps)

Spinal bridge with flex ring (10 reps)

Rolling back (Cadillac/10 reps)

4th week Breathing (10 reps)



Saw (10 reps)

Hundred/dynamic with Swiss ball (10 reps)

Spinal bridge with flex ring (10 reps)


Side arm sit (chair/10 reps)

Hamstring (chair/10 reps)

5th/6th week Breathing (10 reps)

Pelvic bowl (10 reps)Spine stretch (10 reps)

Saw (10 reps)

Leg series (reformer/8 reps)

Hundred (reformer/8 reps)

Front split (reformer/8 reps)


Teaser (Cadillac/8 reps)

Bridge (Cadillac/8 reps)

Side arm sit (chair/8 reps)

Swan front (chair/8 reps)




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Appendix 2. General Exercise Group Protocol

References

Airaksinen, O., Brox, J.I., et al., 2006. European guidelines for themanagement of chronic nonspecific low back pain. Eur. Spine J.15 (Suppl. 2:S), 192e300.

Aladro-Gonzalvo, A.R., Machado-Diaz, M., et al., 2012. The effectof Pilates exercises on body composition: a systematic review.J. Bodyw. Mov. Ther. 16 (1), 109e114.

Alaranta, H., Luoto, S., et al., 1995. Static back endurance and therisk of low-back pain. Clin. Biomech. 10 (6), 323e324.

Anderson, B.D., 2005. Randomized Clinical Trial Comparing Activeversus Passive Approaches to the Treatment of Recurrent andChronic Low Back Pain (dissertation). University of Miami,Florida, USA.

Bandy, W.D., Irion, J.M., et al., 1997. The effect of time and fre-quency of static stretching on flexibility of the hamstring mus-cles. Phys. Ther. 77 (10), 1090e1096.

Week Protocol

1st week Stationary bike (10 min)

Lower limb and trunk muscles stretching

(30 s)

Spinal mobility in the seated position and on

all fours (8 reps)

Bipedal bridge (8 reps)

Rectus abdominis strengthening (3 8 reps)

Active stretching of the posterior chain

(1 1 min)

2nd week Stationary bike (10 min)


(30 s)


all fours (10 reps)


Rectus abdominis strengthening (3 10

reps)


(2 1 min)

3rd week Stationary bike (10 min)


(30 s)

Spinal mobility in the seated position and onall fours (10 reps)



reps)

Williams series exercises


(2 1 min)

4th week Stationary bike (10 min)


(30 s)


(continued )

Week Protocol

7th/8th week Breathing (10 reps)



Saw (10 reps)

Swimming (10 reps)

Leg series (reformer/10 reps)Hundred (reformer/10 reps)

Front split (reformer/10 reps)

Pulling straps (reformer/10 reps)

Mermaid (reformer/10 reps)


Teaser (Cadillac/10 reps)

Bridge (Cadillac/10 reps)

Swan front (chair/10 reps)


(continued )

Week Protocol

all fours (10 reps)

Lateral flexion with bat (10 reps)

Trunk rotation standing with bat (10 reps)



reps)Active stretching of the posterior chain

(2 1 min)

Williams series exercises

5th/6th week Stationary bike (10 min)


(30 s)


all fours (10 reps)



Bipedal bridge with hip adduction with a

ball (10 reps)

Rectus abdominis strengthening (3 15reps)

Oblique muscles strengthening (3 15 reps)

Trunk muscles strengthening on all fours

(3 15 reps)


(3 1 min)

7th/8th week Stationary bike (15 min)


(30 s)


all fours (10 reps)



Bipedal bridge with hip adduction with aball (3 15 reps)


reps)

Oblique muscles strengthening (3 15 reps)

Trunk muscles strengthening on all fours

with halter and ankle weight (3 15 reps)


(3 1 min)


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