Journal of Bodywork & Movement Therapies (2014) 18, 361e367

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QUASI-EXPERIMENTAL STUDY

The effect of Pilates based exercise on

mobility, postural stability, and balance in
order to decrease fall risk in older adults
Rachel W. Pata, PT, DPT*, Katrina Lord, SPT , Jamie Lamb, SPT

Department of Physical Therapy, Quinnipiac University, United States

Received 7 August 2013; received in revised form 22 October 2013; accepted 31 October 2013

KEYWORDS Summary Falls are a common problem in older adults. Impaired balance, mobility and
Pilates; postural stability are risk factors for falling. Limited research has been performed on Pilates
Fall prevention; exercise and the ability to decrease fall risk.
Balance; In this quasi-experimental study, 35 adults (61e87 years old) participated in an 8-week Pi-
Physical therapy lates based exercise program. Blind examiners conducted the Timed Up and Go (TUG), Forward
Reach Test, and Turn 180 Test before and after the intervention. Number of falls, perception of
Pilates, and fear of falling was also recorded.
Thirty-two (91.4%) participants completed post-test measures. Significant improvements
were seen in the TUG (p <0.001) and Turn 180 Test (p Z 0.002). Improvements were also
demonstrated in the Forward Reach Test (p Z 0.049). A positive perception of the Pilates pro-
gram and decreased fear of falling was shown.
Results suggest a Pilates based exercise program may be effective in improving balance,
mobility and postural stability to decrease fall risk.
ª 2013 Elsevier Ltd. All rights reserved.

Introduction
Falls have been a long-standing problem facing older
adults. In 1999 there were over 647,721 fall related acci-
dents and emergencies in the UK for persons
60 (Scuffham
* Corresponding author. Tel.: þ1 203 582 8321; fax: þ1 203 582
6714.
E-mail address: Rachel.pata@quinnipiac.edu (R.W. Pata).
et al., 2003). The total cost of these falls was £981 million.
In the United States one out of three adults over the age of
65 falls each year; yet less than half of these individuals
discuss their falls with their healthcare provider (Hausdorff
et al., 2001). Falls account for approximately 10% of visits
to the emergency department and 6% of urgent hospitali-
zations of the elderly each year (Sattin, 1992). In 2010, the
overall rate of non-fatal fall injury episodes for which a
health-care professional was contacted was 43 per 1000
population. Rate of falls was 26 per 1000 in persons aged

1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbmt.2013.11.002
362
18e44 and increased incrementally up to 115 per 1000 in
persons aged
75 years (Centers for Disease Control and
Prevention, 2013). Falls often results in long term compli-
cations and participation restrictions in this population.
The National Health Interview Survey indicates that falls
are the leading cause of restricted activities among older
adults, accounting for 18% of total restricted days
(Rubenstein, 2006). By the year 2020, the annual direct and
indirect cost of fall injuries is expected to reach $54.9
billion dollars in the United States (Englander et al., 1996).
Falls are a multifactorial problem with many intrinsic
and extrinsic risk factors that have been identified
(Rubenstein, 2006). Extrinsic risk factors may include un-
safe foot wear or environmental tripping hazards (Tinetti
et al., 1988; Tinetti and Speechley, 1989). Some intrinsic
risk factors for falling include impaired mobility, decreased
postural stability, and impaired balance (Tinetti et al.,
1988; Campbell et al., 1989; Nevitt et al., 1989; Lord
et al., 1991). Additionally, many people, who fall, even if
they are not injured, develop a fear of falling. Due to this
fear, they limit their activities leading to reduced mobility
and loss of physical fitness, which in turn increases their
actual risk of falling (Clark et al., 1993; Brown, 1999).
Vellas et al., reported about one-third of elderly people
developed a fear of falling after an incident fall. Fallers
who were afraid of falling again had significantly more
balance and gait disorders (Vellas et al., 1997).
Many exercise programs have been studied to determine
their effectiveness on improving these risk factors. Aerobic
and resistance activities have been used by many re-
searchers to improve physical functioning and reduce fall
risk (Liu-Ambrose et al., 2004; Providence et al., 1995;
Tromp et al., 1998). Multicomponent exercises programs
have targeted strength and balance for the prevention of
falls and shown improvements in fall rates of up to 34%
(Gillespie et al., 2009). Tai Chi programs with an emphasis
on balance have demonstrated improvements in postural
stability (Wolf et al., 2003; Li et al., 2003). Additionally
when comparing group based exercise to no intervention,
group based exercise has been found to be more effective
in decreasing fall frequency, increasing balance, and
improving quality of life (Martin et al., 2013).
Pilates based exercise is increasing in popularity and has
begun to have an impact in rehabilitation (Di Lorenzo,
2011). The goal of Pilates is to fuse the mind and body so
that the body uses the greatest mechanical advantage to
achieve optimal balance, strength and health (Pilates and
Miller, 1945). The core principles of the Pilate’s method
of exercise include centering, concentration, control,
breath, precision and fluidity (Di Lorenzo, 2011). From a
clinical perspective, Pilates is composed of synergistic
movement patterns that include isometric, eccentric, and
concentric muscle contractions. These movement patterns
are easily translated into functional activities. Pilates em-
phasizes lumbo-pelvic stability, precision of movement,
segmental mobility of the spine, coordination, and balance
(Smith and Smith, 2005). Recent Pilates research has sug-
gested that a Pilates based exercise program may also
reduce risk factors, such as impaired balance and postural
stability associated with falls (Kaesler et al., 2007; Guedes
et al., 2010; Johnson et al., 2007; Newell et al., 2012). This
research is limited however, due to small sample size and
R.W. Pata et al.
the use of the reformer system, which is not feasible for all
to use.
This study investigated the efficacy of a group based
exercise program combining traditional and Pilates-derived
movements. The purpose was to determine if a Pilates-
based program is effective in improving dynamic balance,
mobility, and postural stability in order to decrease the
number of falls in older adults. Based on previous research,
it is hypothesized that the Pilates program will be effective
in improving these risk factors for falls in the older adult
population.
Methods
For this study, a quasi-experimental pre-test, post-test
study design was used. Participants completed pre-testing
one week prior to the beginning of the exercise interven-
tion. Post-testing was completed one week after the
completion of the Pilates based intervention program.
Thirty-five participants were enrolled in the class which ran
through September and October 2012. Prior to
commencement of the study approval was received from
the Quinnipiac University Institutional Review Board (IRB).
Participants
Subjects for the study were recruited in the town of Wall-
ingford, CT through flyers at the Wallingford Senior Center.
Individuals that were interested in participating were
instructed to contact the Wallingford Senior Center Pro-
gram Coordinator. The Program Coordinator then took
down names and telephone numbers of those interested.
Eligibility was then determined by a telephone interview.
Inclusion criteria for participation were: 1) over 60 years
old 2) no history of hospitalization in the past 3 months 3)
residents of Wallingford, CT 4) able to attend at least 80%
of the fitness classes. Exclusion criteria included: 1) the use
of assistance device 2) inability to comprehend instructions
in the English language 3) medical and pharmacologic
contraindications to exercise 4) peripheral neuropathy 5)
vertigo 6) inability to raise the arms to 90 degrees of
shoulder elevation. After being deemed eligible to partici-
pate, each individual signed an informed consent.
Thirty-seven participants were screened and thirty-five
were eligible to participate. Two participants were not
eligible due to an exacerbation of vertigo. See Fig. 1.
Procedures
The pre-testing session was scheduled the week before the
start of class. Each participant completed three standard-
ized testing measures that have been associated with fall
risk. Participants also completed a survey requesting in-
formation about previous falls, perception of Pilates, and
fear of falling. Participants were additionally provided with
a monthly calendar with instructions to indicate any falls
during the month. Post-testing was completed one week
after the completion of the class with identical procedures
to the pre-testing. Three examiners, who were blinded to
participant allocation, conducted the pre-test and post-
test measures. The same examiner performed all pre-test
The effect of Pilates based exercise on reducing risk of falls in older adults
Figure 1 Summary of participants.
and post-test measures for a given outcome to improve
reliability. Each examiner was a student of physical ther-
apy, trained in testing protocol by a licensed physical
therapist. Students demonstrated competence in
completing each standardized test prior to the pre-testing
sessions. Each test was conducted twice and the average of
the results was calculated for analysis.
Outcome measures
The Timed up and Go (TUG) is an indicator of ‘basic
mobility.’ It measures the amount of time required for an
adult to rise from a chair, walk 3 m, turn around and walk
back to the chair, and sit down. A score of greater than 10 s
indicates impaired mobility (Whitney et al., 2005). Walking
is a dynamic activity requiring muscle strength, balance,
and attention (Shubert et al., 2010; Schlicht et al., 2001;
Ringsberg et al., 1999; Sparrow et al 2002). The TUG has
been shown to correlate with the Berg Balance Scale,
Barthel Index of ADL, and gait speed. It has also been shown
to correlate with ability to safely ambulate outside inde-
pendently (Podsiadlo and Richardson, 1991). According to
Shumway-Cook, a TUG score of greater than 14 s signifi-
cantly discriminates between fall and non-fall groups; this
study yielded an 87% specificity and sensitivity for the TUG
(Shumway-Cook et al., 2000).
The Turn-180 Test is an indicator of postural stability and
fall risk. It is designed for use in the older adult population.
The individual is instructed to stand up from a chair, put
their hands on their side, and turn 180 to face the opposite
direction. The number of steps needed to complete the
maneuver is indicative of postural stability (Simpson et al.,
2002). The Turn 180 Test has shown statistically significant
differences between fall and non-fall groups. A score of
greater than 4 steps indicates a limitation in postural sta-
bility and an increased risk of falling. With each additional
step taken in the 180 Turn Test, there is a 22% increase in
the risk of falling within the next year (Simpson et al.,
2002). Measures of relative repeatability of the Turn 180
Test are good, with an interclass correlation coefficient of
0.828 (Fitzpatrick et al., 2005).
The Forward Reach Test is utilized as a measure of bal-
ance and fall risk. Individuals are instructed to place their
363
feet hips width apart, flex their shoulder to 90 and reach
forward as far as possible without stepping. The distance is
then measured in inches. A forward reach less than 10
inches is indicative of impaired balance (Weiner et al.,
1992). In a study of 128 volunteers, ranging from age
21e87, the forward reach test was determined to be pre-
cise (coefficient of variation Z 2.5%) and stable (intraclass
correlation coefficient across days Z 0.81) (Duncan et al.,
1990).
Intervention protocol
The exercise program developed for this intervention was
based on the key Pilate’s principals and was specifically
designed for older adults. Participants were educated in
activation of core musculature and this was emphasized
throughout the program. Fluid transitions of movement,
and breath control were also incorporated. Exercises
included seated and standing chair assisted exercises to
allow for optimal participation in this population. The ex-
ercise program was offered twice weekly, for 8 consecutive
weeks. The duration of each exercise class was 60 min.
Each class was instructed by a doctor of physical therapy
student who is certified in Pilates. Participants were pro-
vided with a chair and a Theraband for resistance. Classes
began with a 10- minute warm-up which focused on
breathing and core stability. After the warm up, the exer-
cise program progressed to 25 min of active and resisted
exercises in the chair. This focused on strengthening of the
extremities and core and improving flexibility of spinal
segments. Then, a 15 min standing exercise program was
completed to focus on lower extremity stability and
strength. Finally, a 10 min cool-down regime was utilized
focusing on breathing and balance. The exercise sheet
outlines key principles of Pilates, See Table 1.
Data analysis
Following all post-data collection, data analysis was con-
ducted using SPSS. Non-parametric testing was conducted
because the data were not normally distributed. A Bon-
ferroni adjustment was completed to protect against type 1
error. Therefore a P-value of 0.017 was used to determine
statistical significance. Intent to treat was utilized for the
three participants who did not complete post-data collec-
tion. The Wilcoxon Sign Rank Test was used to determine p-
values for the TUG, Turn 180, and Forward Reach tests.
Descriptive statistics were used to assess pre and post test
fear of falling with the use of frequency tables.
Results
Of the thirty-five participants, 31 were female and 4 were
male. Age range was 61e87, with an average of 74.4 years.
Compliance with attendance for all participants throughout
all 16 Pilates sessions was 84.3%. There was an average
improvement of 1.39 s in the TUG, 0.27 steps in the Turn
180 Test, and 1.13 inches in the Forward Reach Test. The
Timed Up and Go Test and the Turn 180 test showed sta-
tistically significant improvements, with p-values
of < 0.001 and 0.002, respectively. The forward reach,
364 R.W. Pata et al.

three. Ten participants were identified as having impaired

Table 1 Pilates exercise program
postural stability at pre-testing based on completing the
Sitting 1. The roll over Turn 180 Test with more than 4 steps. At post-testing, only
in a chair 2. Diaphragmatic breathing one individual still needed more than 4 steps to complete
3. Inhale/exhale and pull the test. Twenty participants completed the TUG in greater
up pelvic floor and tighten than 10 s at pre-testing, demonstrating decreased mobility.
abdominals At post-testing, seven participants needed more than 10 s
4. Shoulder rolls/lifts to complete the test, but all participants’ demonstrated
5. Scapular protraction/retraction improvements. Fifteen participants reached less than 10
with arms flexed to 90 inches at pre-testing in the Forward Reach Testing, indi-
6. Arm exercises: inhale reach cating impaired balance. At the completion of the study,
up arms up to ceiling, exhale seven of the fifteen participants improved their Forward
back to ground. Reach to a score no longer considered to be a fall risk.
7. Neck stretches and nodding Before the Pilates program began, 4 participants reported
8. Heel and ankle pumps 1e3 falls in the 6 months prior. In September, after 4 weeks
9. The hundred in the program, 88.5% of participants returned their cal-
10. Abduction and adduction endars, with one fall reported. In October, after 8 weeks in
of the legs with legs hovered the program, 77.1% of participants returned their calen-
11. Roll up dars, with no falls reported.
12. One leg circles The results of a survey, using a Likert scale, showed
13. Spine stretch forward improved confidence related to fear of falling after the
14. Bicycle Pilates program. Participants rated their level of confi-
15. Spinal twist and then add lifting foot dence as no confidence, low confidence, fair confidence,
16. Saw good confidence and complete confidence. For analysis,
17. Swan individuals who answered good or complete confidence
18. Neck pull were grouped together as a favorable outcome. Individuals
19. Swimming: with the arms holding who answered no, low or fair confidence were grouped
the core bringing arms up and down together as an unfavorable outcome. On the pre-test sur-
20. Mermaid: stretching out one leg vey, 10 patients reported having no, low, or fair confidence
and reaching away from it in their balance and their ability to not fall. At the post-
21. Heal raises on edge of the chair, test, this number decreased to 3 participants. See Tables 3
turned out, then just one leg and 4. Additionally, perception of Pilates was very positive.
Standing 1. Side leg series The majority stated they would be likely to continue with a
2. Toe raises in all positions: feet Pilates based program in the future. At post-testing,
together, feet apart and Pilates twenty-seven participants indicated that they were
position “completely” likely to continue with a Pilates based pro-
3. Calf stretches gram if provided with the opportunity. Tables 3 and 4.
4. Roll forward: stretching out back Of the thirty-five participants that were enrolled at the
and hamstrings beginning of the exercise intervention, thirty-two partici-
Theraband 1. Rows pants were post-tested. One participant dropped out of the
exercises 2. Bicep curls exercise program due to conflicts at work. Two participants
3. Triceps were unable to attend post-testing due to weather in-
4. Gastrocnemius flictions. Intent to treat was used for all three subjects and
5. Shoulder presses overhead pre-test scores were used for post-test measures.
6. The hundred

although not statistically significant, did show improvement
with a p-value of 0.049. See Table 2.
Many participants presented at increased risk for falls at
the pre-testing by presenting with decreased mobility,
postural stability, balance, or some combination of the
Discussion
Determining effective strategies to reduce falls is an inte-
gral part of reducing growing healthcare costs. National,
state, and local partners are coming together across the
United States to address the growing public health issue
through evidence-based interventions that promote

Table 2 Quantitative outcome measures.

Test Pre-test Post-test Mean difference P-value
average  SD Average  SD
TUG (seconds) 10.47(2.54) 9.08(1.94) 1.39 <0.001
Turn-180 test (steps) 3.75(0.63) 3.48(0.50) 0.27 0.002
Forward Reach test (inches) 10.71(3.01) 11.83(3.49) 1.12 0.049
The effect of Pilates based exercise on reducing risk of falls in older adults
Table 3 Pre fear of falling.
Frequency Percent Cumulative
percent
Unfavorable 10 28.6 28.6
(fair or less)
Favorable 25 71.4 100.0
(good or better)
Total 35 100.0
collaboration between public health, healthcare, and aging
service providers (Beattie, 2013). Falls account for the
spending of billions of dollars each year. Additionally
community falls are a strong predictor of placement in a
skilled-nursing facility; interventions that prevent falls and
their sequelae may therefore delay or reduce frequency of
nursing home admissions and thus healthcare cost (Tinetti
and Williams, 1997).
The major finding of this study was that a Pilates based
exercise intervention program improved balance, postural
stability and mobility, which are risk factors associated with
falls in the older adult population. Improvements were
demonstrated in all outcome measures. These results sug-
gest that twice weekly participation in a community-based
Pilates program over an 8-week period may decrease fall
risk in older adults.
Pilates emphasizes core stabilization of the trunk,
including the abdominals and back musculature as well as
the shoulder and pelvic girdle. Recent studies have
demonstrated activation of the transverse abdominus, in-
ternal obliques and multifidi during Pilates exercise
(Endleman and Critchley, 2008; Hides et al., 2006; Barnett
and Gilleard, 2005). Improvement in core strength allows
for increased proximal stability and thus greater distal
mobility. During this program participants learned to
engage their core musculature and then to integrate upper
and lower extremity strengthening with control and preci-
sion. These whole body exercises can easily be translated
into functional activities. Pilates also emphasizes neutral
alignment of the pelvis, scapulae, and spine and has been
shown in recent studies to improve postural alignment
(Crus-Ferreira et al., 2013; Emery et al., 2010). Improved
postural alignment can further contribute to improved
balance and stability (Sinaki et al., 2005; Horak et al., 1989;
Overstall et al., 1977).
This study further supports the results of previous
studies looking and Pilates-based intervention and risk
factors for falling (Kaesler et al., 2007; Guedes et al., 2010;
Johnson et al. 2007; Newell et al., 2012). Improvement in
the TUG from pre-test to post-test averaged 14%. In a pilot
study by Kaesler et al., 7 older adults participated in a
Table 4 Post fear of falling.
Frequency Percent Cumulative
percent
Unfavorable (fair or less) 3 8.6 8.6
Favorable (good or better) 32 91.4 100.0
Total 35 100.0
365
Pilates-inspired intervention program, TUG scores improved
by 7%. These results demonstrate that a Pilates-inspired
program may be beneficial in improving mobility. The
Kaesler study also demonstrated an 8e27% improvement in
postural stability by assessing postural sway. The current
study utilized the Turn-180 test to measure postural sta-
bility, and there was 7% overall improvement in all partic-
ipants. There was a 14% improvement in participants who
took greater than 4 steps to complete the test at baseline,
placing them at risk for falls.
A 2007 study by Johnson et al. looked at dynamic bal-
ance in 17 healthy adults. The functional reach test was
used to measure dynamic balance after 10 sessions of a
Pilates exercise program. The results of the study showed
significant improvements in the functional reach test after
the exercise program, however, the mean age of the par-
ticipants was 27.3 years. In the current study, there was an
overall 10% improvement in the forward reach test. In those
older adults that were identified as having impaired bal-
ance at pre-testing, there was a 21% improvement.
Significant differences exist between the Pilates-derived
program used in this study and the previous studies. In the
Kaesler and Johnson studies, participants utilized a
reformer system throughout the exercise regime. This is
expensive equipment that takes up a large amount of room
and may be daunting for older adults to use. Sample size
was also small in these previous studies, requiring addi-
tional research to verify the findings.
There are some note-worthy limitations in this study.
The quasi-experimental design did not allow for a control
group to make comparisons to the experimental group at
baseline and at post-testing measurements. Additionally, a
potential ceiling effect should be considered. The Wall-
ingford Senior Center is available to adults’ over the age of
60, and in an effort to increase sample size the class was
therefore open to adults 60 þ years of age. Although a wide
age range was present, many adults were still very active
resulting in high scores at pre-test measurements. Subjects
were also allowed to continue any exercise routines that
they were currently participating in throughout the dura-
tion of the study. It is therefore difficult to determine the
effects that those programs could have had on the outcome
measures.
Recommendations for further research includes con-
ducting a Pilates Exercise program for a longer duration of
time to see if further gains are made. In addition, outcome
measurements should be taken at different intervals
throughout the program, to see when initial gains are seen,
and several months after the completion of the study to
provide insight as to whether or not the results are long-
lasting. Further, conducting a research study with a larger
number of participants across multiple communities is rec-
ommended to strengthen the results. It may also be bene-
ficial to look at different frequencies of Pilates sessions.
Lastly, a Pilates based intervention should be compared to
other evidence-based fall prevention programs.
Conclusion
Falls have been a long-standing and very costly problem.
Interventions used to decrease the number of falls can not
366
only reduce the strain on the healthcare system, but also
improve the quality of life of elderly individuals. Pilates-
based exercise may improve mobility, postural stability,
and balance in order to reduce falls in the elderly.
Improved core strength, alignment and fluidity of move-
ment are all factors that may contribute to these im-
provements. This study also demonstrated the impact of a
community Pilates based program on confidence and fear of
falling. Pilates based exercises can be effectively inte-
grated into; fitness classes for the older adult as well as
rehabilitation programs. Physical therapists should
encourage patients to partake in exercise classes to
improve functional status and decrease fall risk. Addition-
ally these exercises and the principals of Pilates may be
incorporated into a rehabilitation treatment plan with the
goal of improving balance and stability and reducing fall
risk. In summary, the results of this study suggest that a
short-term Pilates based program focused on strengthening
and core stability may improve balance, mobility, and
postural stability in order to reduce falls in the older adult
population.
Acknowledgments
Thank you to Denise Cameron for her assistance with data
analysis. Thank you to Megan Hastie, Sarah Kaye, Ashley
Kenyon, Corey Lewis for their assistance with the collection
of outcome measures.
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