+ MODEL

Journal of Bodywork & Movement Therapies (2015) xx, 1e9

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LITERATURE REVIEW

Effects of Pilates method in elderly people:

Systematic review of randomized controlled
trials
Cristina de Oliveira Francisco, MS*,
Alessandra de Almeida Fagundes, PhD , Bruna Gorges, BS

Department of Physiotherapy, Universidade Federal de São Carlos (UFSCar), São Carlos, Brazil

Received 18 September 2014; received in revised form 4 December 2014; accepted 24 February 2015

KEYWORDS Summary The Pilates method has been widely used in physical training and rehabilitation.
Pilates training; Evidence regarding the effectiveness of this method in elderly people is limited. Six random-
Rehabilitation; ized controlled trials studies involving the use of the Pilates method for elderly people, pub-
Elderly; lished prior to December 2013, were selected from the databases PubMed, MEDLINE, Embase,
Aged; Cochrane, Scielo and PEDro. Three articles suggested that Pilates produced improvements in
Systematic review balance. Two studies evaluated the adherence to Pilates programs. One study assessed Pilates’
influence on cardio-metabolic parameters and another study evaluated changes in body
composition. Strong evidence was found regarding beneficial effects of Pilates over static
and dynamic balance in women. Nevertheless, evidence of balance improvement in both gen-
ders, changes in body composition in woman and adherence to Pilates programs were limited.
Effects on cardio-metabolic parameters due to Pilates training presented inconclusive results.
Pilates may be a useful tool in rehabilitation and prevention programs but more high quality
studies are necessary to establish all the effects on elderly populations.
ª 2015 Elsevier Ltd. All rights reserved.

Introduction Guimaraes et al., 2012). The participation in exercise pro-

The Pilates method has been widely used in physical
training and rehabilitation (Latey, 2001; Kloubec, 2011;
* Corresponding author. Tel.: þ55 (016) 3351 8705, þ55 (016)
99157 2798.
E-mail address: cristinaft05@gmail.com (C. de Oliveira
Francisco).
grams is a usual recommendation for older adults. These
programs should include strengthening exercises as well as
balance and flexibility training, in order to maintain the
muscle mass and performance (Paterson et al., 2007).
Pilates method is an option to achieve these goals, since it
is composed of a series of exercises that promotes core
stability, muscle strength and flexibility, and attention to
muscle control, posture and breathing (Wells et al., 2012).
Many aspects of Pilates exercises improve body composition

http://dx.doi.org/10.1016/j.jbmt.2015.03.003
1360-8592/ª 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: de Oliveira Francisco, C., et al., Effects of Pilates method in elderly people: Systematic review of
randomized controlled trials, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.03.003
 + MODEL
2 C. de Oliveira Francisco et al.
(Jago et al., 2006; Fourie et al., 2013), functional capacity
(Guimaraes et al., 2012) and balance (Kloubec, 2010) which
could have a positive impact in elderly people.
The aging process of the world’s population is associated
with several health problems (Faria et al., 2003). The reg-
ular participation on exercise programs improves physical
function, promotes an increase in the quality of life and life
expectancy (Monteiro et al., 2007). Regular exercise pro-
tects against the development and progression of several
chronic diseases (Florindo et al., 2001) and multi-
component exercise programs, such as the Pilates
method, are an important aspect of a healthy lifestyle,
preventing falls and disabilities (Gillespie et al., 2009).
Pilates is considered appropriate for all ages and fitness
status (Latey, 2001; Segal et al., 2004; Kloubec, 2011) and
has been used in multiple conditions, such as aged related
disabilities (Bird and Fell, 2014; Stivala and Hartley, 2014),
low back pain (Miyamoto et al., 2013), rheumatic diseases
(Altan et al., 2009, 2012; Mendonca et al., 2013), cystic
fibrosis (Franco et al., 2014), cerebral palsy (Dos Santos
et al., 2014), stroke (Shea and Moriello, 2014), breast
cancer (Eyigor et al., 2010), heart failure (Guimaraes et al.,
2012), among others. However, there is a lack of studies
with high methodological quality regarding the effects of
Pilates (Kloubec, 2011) especially in older adults (Irez
et al., 2011). Randomized clinical trials (RCT) have been
considered the best among all research designs (Stolberg
et al., 2004) since it reduces the risk of serious imbalance
in known and unknown factors that could influence the
clinical outcome (Stolberg et al., 2004). In addition, a sys-
tematic review provides information about whether the
evidence of an intervention may be generalized to other
populations, settings, and treatment variations or not
(Mulrow, 1994). Systematic reviews regarding Pilates have
been conducted, however, none of them aimed to synthe-
size data regarding the effects of Pilates in elderly people.
Exercise is an important tool to improve quality of life and
increase the life expectancy of elderly people. Further-
more, the expansion of options of evidence based exercise
programs may be beneficial to address elderly people needs
and preferences, which would improve the adherence of
the exercise programs.
Figure 1 Flowchart of article selection process.
Please cite this article in press as: de Oliveira Francisco, C., et al., Effects of Pilates method in elderly people: Systematic review of
randomized controlled trials, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.03.003
The purpose of this systematic review was to verify the
evidence of effectiveness of the Pilates Method in elderly
people as determined by RCT studies.
Methods
Searches were performed in November 2014, and they
included the following databases: PubMed, MEDLINE,
Embase, Cochrane, Scielo and PEDro. The search keywords
used were “Pilates”, “Pilates method” and “Pilates
technique”.
Firstly, the results of the searches were filtered to
eliminate any duplicates. Secondly, two independent re-
viewers (C.O.F and A.A.F) read all the abstracts and, when
necessary, full texts, to select articles that met the
following criteria: RCT study in elderly people (age over 60
years), involving the Pilates method as the study interven-
tion, published up to December 2013; published in full (with
methods and results), in English, in a peer reviewed jour-
nal. Lastly, both reviewers assessed independently the
method quality of each selected RCTs using the Physio-
therapy Evidence Database (PEDro) scale. A third reviewer
(B.G) was consulted when there was disagreement between
the main reviewers.
PEDro scale is based on a Delphi list (Verhagen et al.,
1998), and it identifies the internal validity of a study
and if there is sufficient statistical information to make
its results interpretable. PEDro scale scores range varies
from one to ten points; and higher PEDro scores corre-
spond to higher method quality. The cut-off score used
to rate the method quality was based on the Cruz-
Ferreira study (Cruz-Ferreira et al., 2011) that pro-
posed PEDro scores of less than five points indicate low
quality, and PEDro scores of five points or higher indicate
high quality.
The scientific strength of evidence was graded using the
following criteria: strong evidence, at least 2 high-quality
RCTs (PEDro "5); moderate evidence, 1 high-quality RCT
and one or multiple low-quality RCTs (PEDro < 5); limited
evidence, 1 high quality or multiple low quality RCTs (Cruz-
Ferreira et al., 2011).
 + MODEL
Pilates method in elderly people 3

Results

Pedro
score
In the database searches, we found 169 studies, however

6
7
4
4
5
163 were not included since they did not meet the inclusion

Point estimate
and variability
criteria. Only six studies were RCTs and enrolled elderly
volunteers, and therefore were included in the review

reported
(Fig. 1).
Table 1 presents the quality scores of the included

N
Y

Y
Y

Y
Y
studies. Three studies were considered to be high quality
(PEDro score "5) and three were considered to be low

Between-group
quality (PEDro score <5).

difference
Table 2 summarizes the results of three studies which

reported
investigated the effects of Pilates on balance (Siqueira
Rodrigues et al., 2010; Irez et al., 2011; Bird et al.,
2012). Of these three studies, two enrolled only women

N
Y

Y
Y
Y

Y
(PEDro scores 4 and 6) (Siqueira Rodrigues et al., 2010; Irez

Intention-to-treat
et al., 2011) and one enrolled both genders (PEDro score 7)
(Bird et al., 2012). Based on each study’s PEDro score, we
found ‘moderate’ evidence of the positive effects of Pilates

analysis
on static and dynamic balance in elderly women and
‘limited’ evidence of the Pilates method improving balance
in both genders. In addition, the Pilates intervention in

N
N
N
Y
elderly people had limited evidence of improvements in

dropouts
muscle strength, flexibility, reductions of falls (Irez et al.,

<15%
2011), autonomy and quality of life (Siqueira Rodrigues
et al., 2010).

N
Y

Y
Y
Y
Table 3 summarizes the studies with outcomes other

Assessor
blinding
than balance (adherence, body composition, and car-
diometabolic parameters, respectively). One study (Mallery

N
N
N
Y
Y
et al., 2003) evaluated the adherence of a four week Pilates
program compared with passive exercise in hospitalized
Therapist
blinding
older adults (Table 3). The authors (Mallery et al., 2003)
concluded that this Pilates program had lower adherence
(63%) than passive exercise (95%), however the study had
N

N
N
N
N
N
low methodological quality (PEDro score 4). Thus, the
Participant

adherence to the Pilates method had inconclusive results.

blinding

Two of the studies presented in the Table 3 assessed

elderly women after an eight week Pilates intervention
N

N
N
N
N
(Fourie et al., 2013; Marinda et al., 2013). Fourie et al. N
(2013) analyzed the body composition after a Pilates pro-
Groups similar

gram without apparatus (mat Pilates), which showed im-

at baseline

provements in the body fat percentage, fat mass and lean

body mass, however, the study had low methodological
PEDro scores of included studies (n Z 6).

quality (PEDro score 4). Marinda et al. (2013) assessed

Y

Y
Y
Y
Y
Y

cardio-metabolic parameters changes (blood pressure,

Concealed

heart rate, fasting blood glucose, total cholesterol and

allocation

triglycerides) after a Pilates program or a control condition

(without exercise). Although the study had a high meth-
odological quality (PEDro score of 5), the authors consid-
N

N
N
N
Y

ered the results inconclusive regarding the effects on

allocation

cardio-metabolic variables because both groups showed

Random

differences in the outcomes intra-group comparison

(Table 3).
Y

Y
Y
Y
Y
Y
Marinda et al., 2013
Mallery et al., 2003
Fourie et al., 2013
Siqueira Rodrigues

Discussion
Bird et al., 2012
Irez et al., 2011
et al., 2010

Pilates method may be applied safely to elderly people

(Latey, 2001) although there are too few high quality
Table 1

studies to establish the effects and indications of Pilates

Study

intervention in this population. The analysis of the included

RCT studies regarding Pilates method demonstrated a

Please cite this article in press as: de Oliveira Francisco, C., et al., Effects of Pilates method in elderly people: Systematic review of
randomized controlled trials, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.03.003

randomized controlled trials, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.03.003
Please cite this article in press as: de Oliveira Francisco, C., et al., Effects of Pilates method in elderly people: Systematic review of
Table 2 Description of selected studies evaluating balance (n Z 3).
Study Design Subjects
Siqueira Rodrigues et al., Pre-post test Elderly females over 60
2010 years
N Z 52; mean age 66 $ 4
Pilates group: n Z 27
Control group: n Z 25
Irez et al., 2011 Pre-post test Sedentary females living in
a residential house over 65
years of age
N Z 60
Pilates group: n Z 30;
mean age, 72.8 $ 6.7
Control group: n Z 30;
mean age, 75.0 $ 5.7
Intervention Primary outcome
Duration and frequency: Functional autonomy
8 wk, 2 # 600 per week. (general index of Latin
American Development
Group for Elderly protocol
(GDLAM)), static balance
(Tinetti) and quality of life
(WHOQOL-OLD)
Pilates group: supervised
pilates sessions on
apparatus
Control group: no exercise
Duration and frequency: Dynamic balance (dynamic
12 wk, 3 # 600 per week stability measurement
platformplataform),
muscle strength (muscle
manual tester), flexibility
(sit and reach test) and
fall number.
Pilates group: supervised
pilates sessions on mat
Control group: habitual
activity
4
Key outcomes results
Pilates group: improved
personal autonomy (index
of GDLAM from
27.21 $ 3.85 to
23.58 $ 3.96, p Z 0.035),
static balance (score of
Tinetti test from
23.85 $ 1.49 to
24.88 $ 1.07, p Z 0.009)
and quality of life (index
of WHOQOL-OLD from
88.23 $ 6.19 to
89.35 $ 9.38, p Z 0.010)
+
Control group: no
MODEL
differences
Pilates group: improved
dynamic balance (from
10.98 $ 1.5 to 8.99 $ 1.5%
degrees, p < 0.05),
flexibility (from
12.75 $ 4.40 to 15.88 to
5.10 cm, p < 0.05), muscle
strength (from
23.34 $ 5.70 to
32.71 $ 7.00 kg, p < 0.05),
decreased falls number
(1.87 $ 1.4 to 0.37 $ 0.50
C. de Oliveira Francisco et al.
falls, p < 0.05) and had
92% of participation rate.
Control group: no
differences
 Pilates method in elderly people
randomized controlled trials, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.03.003
Please cite this article in press as: de Oliveira Francisco, C., et al., Effects of Pilates method in elderly people: Systematic review of

Bird et al., 2012 Crossover design Pre, post Ambulatory older adults Duration and frequency: Static and dynamic Pilates group: there were
and 6-week follow-up test (over 60 years of age) 5 wk, 3 # 600 per week balance (mediolateral no significant differences
sway range, four square between Pilates and
step test, timed up and go controls groups from pre-
test) and leg strength to post- intervention.
(spring- based There were significant
measurementmeasument improvements post-
system) intervention in all
dependent static and
dynamic variables over the
entire duration of the
study (p,0.001) except leg
strength (numerical data
not presented in the
article). The variables did
not return to baseline
after 6 week wash-out
phase.
N Z 27; mean age,
67.3 $ 6.5
Pilates group: supervised

+
pilates sessions on mat

MODEL
and apparatus 2 # per
week and unsupervised
mat pilates 1 # per week.
Control group: habitual
activity

5

randomized controlled trials, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.03.003
Please cite this article in press as: de Oliveira Francisco, C., et al., Effects of Pilates method in elderly people: Systematic review of
Table 3 Description of selected studies with outcomes other than balance (n Z 3).
Study Design Subjects
Mallery et al., 2003 Pre-post test Hospitalized subjects over
70 years
N Z 39; mean age 82 $ 7.3
Pilates group: n Z 19;
mean age, 82.7 $ 8.5
Range Motion Group:
n Z 20; mean age,
81.4 $ 6.1
Fourie et al., 2013 Pre-post test Females over 60 years of
age
N Z 50
Pilates group: n Z 25;
mean age, 66.12 $ 4.77
Control group: n Z 25;
mean age, 65.32 $ 5.01
Marinda et al., 2013 Pre-post test Females over 60 years of
age
6
Intervention Primary outcome Key outcomes results
Duration and frequency: Participation (total Pilates group had lower
4 wk, 3 # per week. number of exercise participation and
sessions completed) and adherence compared with
adherence (proportion of Range Motion Group (71%
subjects with participation vs 96%, p Z 0.004 and 63%
rates exceeding 75%) vs 95%, p Z 0.020)
respectively
Pilates group: six
supervised pilates
exercises using weights,
rubber tube or springs
Range Motion Group: six
passive range of motion
exercise for lower limbs
Duration and frequency: Body mass, body mass Pilates group: decreased
8 wk, 3 # 600 per week index (BMI), body fat body fat percentage (from
+
percentage, fat mass and 33.85 $ 6.67 to
MODEL
lean body mass 32.23 $ 5.82, p Z 0.016)
and fat mass (from
25.03 $ 9.53 to
23.69 $ 8.06 kg,
p Z 0.038) and increase
lean body mass (from
46.67 $ 6.33 to
48.04 $ 7.52 kg,
p Z 0.006)
Pilates group: supervised
pilates sessions on mat
Control group: no exercise Control group: no
C. de Oliveira Francisco et al.
differences
Duration and frequency: Blood pressure, heart Pilates group: decreased
8 wk, 3 # 600 per week rate, fasting blood systolic blood pressure
glucose, total cholesterol (from 135.84 $ 14.66 to
and triglycerides 128.80 $ 16.36 mmHg,
p Z 0.04) and increased
blood glucose (from
5.07 $ 0.46 to
5.83 $ 0.57 mmol/L,
p Z 0.000)
 + MODEL
Pilates method in elderly people 7

strong evidence supporting the effects of this intervention

on static and dynamic balance in elderly women. These
Control group: increased

74.92 $ 9.96 beats/min,

resting heart rate (from

p Z 0.000) and glucose

studies also demonstrated limited evidence to support the

5.75 $ 0.59 mmol/L,

(from 5.24 $ 0.71 to
effects of Pilates on balance in elderly men and on muscle
strength, flexibility, falls reduction, autonomy and quality
62.48 $ 8.98 to of life for both genders (see Table 2).
Bird et al. (2012) verified that 15 sessions of Pilates in

p Z 0.001)
five weeks was enough to clinically show improvements in
static and dynamic balance but not for lower-limb strength,
probably due to neuromuscular adaptations. This study had
high methodological quality (PEDro Score Z 7), although
used a crossover design, where all subjects participated in
both groups. A six week washout time was performed
before the second intervention group but the authors
recognized that it is possible that longer duration training
may have affected the results.
Siqueira Rodrigues et al. (2010) applied Pilates three
times per week for eight weeks and observed positive re-
sults in static and dynamic balance and functional capacity.
They considered that the results occurred because of im-
provements in flexibility and muscle strength. This hy-
pothesis was confirmed by Irez et al. (2011) that showed
better dynamic balance, flexibility, reaction time and
muscle strength in the Pilates group after three times per
Control group: no exercise

week for 12 weeks. These studies included only women in

Pilates group: supervised

their sample, which prevent us to expand the results to

pilates sessions on mat

both genders. The necessary frequency and period of the

intervention to achieve positive effects are not clear
because each study used different parameters and only
assessed pre and post intervention. On the other hand, five
weeks of intervention was enough to improve the balance
in elderly people (Bird et al., 2012). More studies should be
developed to verify the minimum period of training to
achieve differences in each outcome.
Only one study verified the effects of Pilates on car-
diometabolic parameters (Marinda et al., 2013), which
found reduced systolic blood pressure in the Pilates group,
mean age, 66.12 $ 4.77

mean age, 65.32 $ 5.01

Control group: n Z 25;
Pilates group: n Z 25;

increased heart rate in the control group and increased

fasting blood glucose in both groups. The authors consider
these results to be inconclusive due to their contradictory
nature. It is not possible, at this point, to establish any level
of evidence suggesting that Pilates can affect cardio-
metabolic parameters in elderly people.
N Z 50

One study (Fourie et al., 2013) assessed the effects of

Pilates on body composition in elderly woman. This study
showed a decrease in body fat percentage and body mass
and an increase in lean body mass (Table 3). The authors
conclude that these changes could reduce the morbidity
and mortality, due to the association between aging and
obesity. However, there is limited evidence regarding the
Pilates effect on body composition in women.
Mallery et al. (2003) assessed the adherence to a Pilates
program. The Pilates group had a low adherence to the
method, but the study included only older hospitalized
adults. There are inconclusive results about adherence to
the Pilates program. Studies including men and women with
different health status are necessary to verify the adher-
ence to the method.
Regarding the methodological quality, the PEDro scale is
a quantitative tool, and its application requires considering
as inexistent the criterion when that information was not
mentioned in the text.

Please cite this article in press as: de Oliveira Francisco, C., et al., Effects of Pilates method in elderly people: Systematic review of
randomized controlled trials, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.03.003
 + MODEL
8 C. de Oliveira Francisco et al.
Two criteria of PEDro scale are impossible to be satisfied
in interventional studies with exercise-based therapy (see
Table 1): blinding all subjects and the therapists who
administered the therapy. However, blinding the assessors
who measure the key outcomes is possible and may mini-
mize the research bias. Two of the high quality methodo-
logical studies conducted a blind assessment (Irez et al.,
2011; Bird et al., 2012). The concealed allocation is
another important criterion and only the study of Bird et al.
(2012) mentioned sufficient information to consider this
criterion satisfied. The item “dropouts under 15%” was not
cited in two of the studies (Siqueira Rodrigues et al., 2010;
Bird et al., 2012) and measures of variability were not
presented in the Mallery et al. (2003) study.
This review has some limitations. We excluded studies
that were not RCTs. The criteria to grade the scientific
strength of evidence considered only the methodological
quality. However, the sample size is an important variable
not included in this method. In addition, the clinical het-
erogeneity of measures did not allow a meta-analysis of the
selected RCTs. Nevertheless, although the method used to
grade the scientific strength of evidence is not the most
robust, it does provide some interesting conclusions.
Conclusion
There are few RCT studies which assessed Pilates inter-
vention in elderly people. The effects of Pilates method
verified on the RCT studies demonstrated a strong evidence
level in improvements of static and dynamic balance in
elderly women and limited evidence in the improvements in
balance in elderly men. These studies also showed limited
evidence of improvements in muscle strength, flexibility,
falls reduction, autonomy and quality of life in men and
women. Additionally, there is limited evidence about
adherence to a Pilates program and there were inconclusive
results about the effects on cardio-metabolic parameters.
Pilates could be a useful tool in rehabilitation and preven-
tion programs but more high quality studies are necessary
to establish the full extent of the effects associated with
the use of this method in the elderly population.
Conflicts of interest
None declared.
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Please cite this article in press as: de Oliveira Francisco, C., et al., Effects of Pilates method in elderly people: Systematic review of
randomized controlled trials, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.03.003