856675

research-article2019
CRE0010.1177/0269215519856675Clinical Rehabilitationde Oliveira et al.

CLINICAL
Original Article REHABILITATION

Clinical Rehabilitation

Pilates method in the treatment 1­–11

© The Author(s) 2019
Article reuse guidelines:
of patients with Chikungunya sagepub.com/journals-permissions
DOI: 10.1177/0269215519856675
https://doi.org/10.1177/0269215519856675

fever: a randomized journals.sagepub.com/home/cre

controlled trial

Bruna Fernanda Alves de Oliveira1,

Paulo Roberto Cavalcanti Carvalho2,
Alessandro Spencer de Souza Holanda2 ,
Rebeca Izis Silva Barbosa dos Santos2,
Filipe Alax Xavier da Silva2,
Gustavo Willames Pimentel Barros2,
Emídio Cavalcanti de Albuquerque3,
Andrea Tavares Dantas4, Nara Gualberto Cavalcanti4,
Aline Ranzolin4, Angela Luzia Branco Pinto Duarte1,4
and Claudia Diniz Lopes Marques1,4

Abstract
Objective: The aim of this study was to evaluate the effects of the Pilates method on the reduction of
pain, improvement of joint function, and quality of life of patients with chronic Chikungunya fever.
Design: This is a randomized, controlled, blind trial for the evaluators.
Setting: The study was conducted at the Advanced Laboratory in Physical Education and Health at
Federal University of Pernambuco, Brazil.
Subjects: A total of 51 patients were allocated randomly and divided into 2 groups: a Pilates group (26
patients) and a control group (25 patients). After 12 weeks, 4 patients in the Pilates group and 5 in the
control group were lost to follow-up.
Intervention: The Pilates group performed 24 Pilates method intervention sessions; the control group
continued to receive standard clinical treatment at the outpatient clinic.

1Programa de Pós-Graduação em Ciências da Saúde, Corresponding author:

Universidade Federal de Pernambuco, Recife, Brasil
2Departamento de Educação Física, Universidade Federal de
Pernambuco, Recife, Brasil
3Instituto de Medicina Integral Professor Fernando Figueira,
Recife, Brasil
4Serviço de Reumatologia—Hospital das Clínicas da
Claudia Diniz Lopes Marques, Programa de Pós-Graduação
em Ciências da Saúde, Universidade Federal de Pernambuco,
Avenida Professor Moraes Rego, s/n Varzea, Recife, PE 50670-
901, Brasil.
Email: claudia.reumatologia@gmail.com

Universidade Federal de Pernambuco, Recife, Brasil

2 Clinical Rehabilitation 00(0)

Main measures: The main measures were as follows: visual analogue scale (VAS) for pain, functional
capacity evaluated by Health Assessment Questionaire (HAQ), quality of life measured by the 12-Item
Short-Form Health Survey (SF-12), and range of joint motion by goniometry.
Results: After 12 weeks, patients in the Pilates group presented lower VAS (P < 0.001), lower HAQ
scores (P < 0.001), and higher quality-of-life scores (P < 0.001) compared with the control group. We
found statistically significant results for the Pilates group in the range of movement for shoulder, knee,
ankle, and lumbar spine (P < 0.001). In the intragroup analysis, there was a significant improvement in all
outcomes evaluated.
Conclusion: In this study, patients undertaking Pilates method for 12 weeks had less pain, better function
and quality of life, and increased range of joint movement.

Keywords
Pilates method, Chikungunya fever, chronic pain, rehabilitation interventions, quality of life

Received: 13 December 2018; accepted: 17 May 2019

Introduction
Chikungunya fever is a mosquito-borne infec-
tion caused by an arthritogenic alphavirus, the
Chikungunya virus, responsible for a debilitat-
ing arthritic disease, characterized by fever and
joint pain in the acute phase. The chronic phase,
defined by duration of symptoms over three
months, is characterized mainly by musculoskel-
etal and/or joint pain with limited movement.1
The evolution to the chronic phase can occur in
two distinct patterns: inflammatory joint disease,
similar to rheumatoid arthritis, seen in 5% of
cases; and a non-inflammatory joint involvement
characterized by joint pain and stiffness, seen in
95% of cases,2 often becoming incapacitating,
with significant impacts on daily life quality.2,3
The persistent, often disabling, musculoskeletal
pain is the most prominent feature afflicting peo-
ple with this disorder in the long term, and current
management with common analgesics, weak opi-
oids, and non-steroidal anti-inflammatory drugs is
not satisfactory.4,5
Considering the large number of people infected
during outbreaks3–5 and that about 40% of these
individuals will progress to the chronic phase of the
disease,6 the management of these patients has
become a major public health challenge, especially
when the epidemic reaches countries of continental
dimensions such as Brazil, taking into consideration
the high degree of disability generated by joint
symptoms.
The Pilates method of exercise was created by
Joseph Pilates during the 1920s and has as its
traditional principles centralization, concentra-
tion, control, precision, flow, and breathing.
Exercises are floor-based or involve the use of
specialized equipment that provides adjustable
spring resistance.6 Over the past decade, Pilates
has become popular in the treatment and reha-
bilitation of many chronic musculoskeletal con-
ditions such as osteoarthritis, low back pain, and
fibromyalgia.7–9
There is some evidence that Pilates exercise
programs can reduce pain and disability and
improve strength, joint function, and quality of
life.10–13 Given the clinical manifestations of the
chronic phase of the disease, such as pain, stiff-
ness, and postural changes, there is a rationale
for the hypothesis that the Pilates method can
benefit patients with chronic musculoskeletal
symptoms due to Chikungunya fever. Although
recommended by existing guidelines,3,4 there are
no randomized controlled trials of any rehabili-
tation intervention in the chronic phase of
Chikungunya fever.
The aim of this study was to evaluate the effect of
the Pilates method on improving pain, functional
de Oliveira et al. 3
capacity, and quality of life in the treatment of
chronic musculoskeletal manifestations in patients
with Chikungunya fever.
Methods
This study was conducted between April and
November 2017, at the Advanced Laboratory in
Physical Education and Health and Rheumatology
outpatient clinic at Hospital das Clínicas, Federal
University of Pernambuco (HC-UFPE), Recife/PE,
Brazil, which is responsible for the integrity and
conducting of the study. It was approved by the
Ethics Committee in Research on Human Beings
of the Health Sciences Center of the UFPE (under
no. 1.849.487). The project was registered and
approved by the Brazilian Registry of Clinical
Trials (ReBEC; registration no. RBR-99tdpn) with
no external funding.
This two-arm randomized controlled trial was
conducted with a blinded assessor. For conveni-
ence, the sample was obtained through recruit-
ment and spontaneous demand. We selected
patients of both genders, age 18 years and older,
with confirmed diagnoses of Chikungunya fever,
who were in clinical treatment at the Chikungunya
outpatient clinic, and in the chronic phase of the
disease (symptoms lasting more than three months).
The exclusion criteria were contraindication for
physical exercise according to the treating physi-
cian; a severely limiting cognitive, auditory, vis-
ual, or motor deficit confirmed by a specialist
physician; and a history of inflammatory, rheu-
matic, neurological, or neoplastic disorders. All
participants gave written informed consent prior to
the study.
Permuted block randomization was performed
using the program Random Allocation 2.0® (http://
random-allocation-software.software.informer.
com/2.0/) by an independent researcher who was not
involved in the recruitment of the participants or in
the assessments. After the initial assessment, the
participants were referred to the physical health edu-
cator responsible for implementing the intervention
and were allocated to one of two study groups, the
Pilates intervention group or the control group,
using sealed, opaque, and sequentially numbered
envelopes, with a 1:1 allocation ratio. These enve-
lopes were opened only by the non-blind researcher
who was responsible for applying the intervention.
The other evaluators were blinded in relation to the
group in which the patient was included.
During the 12-week period, the Pilates group
received 24 sessions of the Pilates method, 2 ses-
sions per week of 50 minutes per session, and of
light-to-moderate intensity (increasing the number
of repetitions, starting with 6 and increasing to 12
repetitions). The training was divided into training
A (22 exercises) and training B (18 exercises), per-
formed alternately. The exercises involved coordi-
nation, strength, flexibility, and balance. The
intervention was carried out in groups of up to six
patients per class, respecting the principles of the
Pilates method as concentration, centralization,
control, precision, fluidity, and diaphragmatic
breathing. The exercises were always performed in
the morning at a scheduled time and on alternating
days (Monday and Wednesday or Tuesday and
Thursday). Patients continued to receive follow-up
at the rheumatology outpatient clinic for their rou-
tine treatment consultations for Chikungunya
fever. The exercises were performed in a series of
6–12 repetitions, using a 75-cm Swiss ball and
elastic bands of medium intensity (exercises to
strengthen the upper limb muscles) and strong
intensity (stretching exercises for the lower limb
muscles). The training was conducted following
the same sequence of exercises for all groups and
participants. The intervention was conducted by a
physical education professional trained in the
Pilates method. The complete treatment protocol is
shown in Supplemental Appendix 1. One week
after the end of the 24 Pilates sessions, the patients
were submitted to the second clinical and metric
evaluation, using the same variables collected in
the first evaluation.
The control group did not perform the Pilates
intervention and continued to receive follow-up at
the Chikungunya outpatient clinic, with standard
clinical care for the treatment of the disease. During
the intervention period, the investigator had no
contact with these patients. When the study ended,
an opportunity to participate in the Pilates method
was offered to all patients in the control group.
4 Clinical Rehabilitation 00(0)
After a period equivalent to 24 Pilates sessions, the
patients in the control group were also submitted to
the second clinical and metric evaluation, using the
same variables collected in the first evaluation.
The assessments were conducted at baseline and
after 24 Pilates sessions (12 weeks) by a blinded
assessor who did not know to which group each
participant had been allocated. It was not possible
to blind the participants and the physical therapist
due to the interventions.
The primary outcome was pain intensity meas-
ured at the end of the intervention period. Pain
intensity was assessed with the visual analogue
scale, a continuous scale comprising a horizontal
line, 10 cm (100 mm) in length, anchored by two
verbal descriptors: “no pain” (score of 0) and “pain
as bad as it could be” or “worst imaginable pain”
(score of 10).14 The secondary outcomes were joint
range of motion, function, and quality of life.
The joint range of motion was assessed by goni-
ometry, using a standard mechanical goniometer
placed across the shoulder, wrist, knee, and ankle
joints, as well as at the cervical and lumbar spine,15
while the patient performed the active movement.
The assessment was taken by the same evaluator
throughout the study.
Functioning was evaluated using the Health
Assessment Questionnaire,16 which includes items
that assess fine-motor movements of the upper
extremities, locomotor activities of the lower
extremities, and activities that involve both the
upper and lower extremities. Scores of 0–1 gener-
ally represent mild-to-moderate difficulty; 1–2 rep-
resent moderate-to-severe disability; and 2 to 3
indicate severe to very severe disability.
The quality of life was measured by the 12-Item
Short-Form Health Survey (SF-12),17 self-adminis-
tered, for which two scores can be measured: the
Physical Component and the Mental Component. In
both, scores range from 0 to 100, with the highest
scores associated with better levels of quality of life.
All scales were cross-culturally adapted and clini-
metrically tested in a Brazilian population.18,19
The analysis was performed considering, for a
positive outcome, a minimal, clinically important
difference for both the primary and the secondary
outcomes, except goniometry: a reduction of 2 points
on the visual analogue scale from baseline,20 at least
0.22 points reduction in the Health Assessment
Questionnary,21 and an increase greater than 3.29
points for the SF-12—Physical Component and 3.77
points SF-12—Mental Component.22 Although the
sample was of convenience, all calculations per-
formed to verify the sample size needed to verify
minimal clinically important difference demon-
strated that the sample size achieved was sufficient to
demonstrate such differences.
Numerical variables were represented by meas-
ures of central tendency (mean) and dispersion
measures (standard deviation or interquartile
range); the association between the categorical
variables was verified through the chi-square test
and Fisher’s exact test. The Kolmogorov–Smirnov
normality test was performed for quantitative vari-
ables (n ⩾ 30) and the Shapiro–Wilk normality test
for quantitative variables (n < 30).
Intragroup outcomes were compared using
Student’s t-test for paired samples (normal distribu-
tion) and Wilcoxon (non-normal distribution); inter-
group outcomes were compared using Student’s t-test
for unpaired samples (normal distribution) and Mann–
Whitney (non-normal distribution). Unadjusted effect
sizes and their 95% confidence intervals (CIs) were
also calculated; the continuous results of the outcomes
were transformed into dichotomous variables, using
the minimal, clinically important difference defined
for each variable (reached outcome/did not reach
outcome), and the relative risk, relative risk reduc-
tion, absolute risk reduction, and number needed to
treat were calculated. The level of significance consid-
ered was 95%.
The data were analyzed using the SPSS Statistics
for Windows version 19 software package (SPSS,
Inc., Chicago, IL) by a blinded statistician who
received the coded data.
Results
A total of 111 patients with Chikungunya fever
were considered potentially eligible for the study,
which took place between April and November
2017, of which 60 did not meet the eligibility crite-
ria (Figure 1). The final sample comprised 42
patients, mostly women (n = 39, 92.9%), with a
de Oliveira et al. 5
Figure 1.  Study flowchart.
mean (SD) age of 56.9 (10.6) years and a mean
(SD) disease duration of 14.6 (1.6) months. At
baseline, the mean (SD) visual analogue scale for
pain was 7.0 (2.4); Health Assessment Questionnary
was 1.6 (0.6); SF-12—Physical Component was
29.2 (7.0); and SF-12—Mental Component was
37.6 (8.3). Table 1 shows the results for the sample
as a whole and divided by groups. The groups were
similar in almost all variables except height, the
mental component of the SF-12, and the use of
analgesics, which was higher in the control group.
Regarding the primary and secondary outcomes,
in the intragroup analysis, a significant improve-
ment was observed in all parameters after 24
Pilates sessions (week 12) in relation to the base-
line (week 0), but the same was not observed in the
control group. People who were lost to follow-up
were excluded from the analysis (Table 2).
Patients in the Pilates group had a significant
increase in range of motion in degrees in the shoul-
der, knee, ankle, and lumbar spine joints compared
to the control group, which was not observed for
6 Clinical Rehabilitation 00(0)

Table 1.  Demographic and clinical characteristics of the grouped data (n = 42), Pilates group (n = 22), and control
group (n = 20) at baseline.

Variables Grouped data PG (n = 22) CG (n = 20) P-value

(n = 42)
Demographic and clinical data
Disease duration in months, mean ± SD 14.6 ± 1.6 14.9 ± 1.5 14.2 ± 1.7 0.136***
Age in years, mean ± SD 56.9 ± 10.6 54.4 ± 10.6 59.6 ± 9.4 0.101***
Women, n (%) 39 (92.9) 19 (86.4) 20 (100.0) 0.233*
Years of study, n (%)
 5 15 (35.7) 6 (27.3) 9 (45.0) 0.412*
 9 12 (28.6) 5 (22.7) 7 (35.0)
 10 3 (7.1) 2 (9.1) 1 (5.0)
 12 7 (16.7) 5 (22.7) 2 (10.0)
 16 5 (11.9) 4 (18.2) 1 (5.0)
Marital status, n (%)
 Single 5 (11.9) 2 (9.1) 3 (15.0) 1.000*
 Married 23 (54.8) 12 (54.6) 11 (55.0)
 Companion 1 (2.4) 1 (4.5) 0 (0.0)
 Widow/widower 8 (19.0) 4 (18.2) 4 (20.0)
 Divorced 5 (11.9) 3 (13.6) 2 (10.0)
Work status, n (%)
 Active 15 (35.7) 8 (36.4) 7 (35.0) 0.927**
 Inactive 27 (64.3) 14 (63.6) 13 (65.0)
Weight (kg), mean ± SD 78.7 ± 15.5 80.1 ± 15.9 77.1 ± 15.3 0.549***
Height (m), mean ± SD 1.6 ± 0.01 1.6 ± 0.1 1.5 ± 0.1 0.002***
Flexibility (cm), mean ± SD 12.2 ± 8.1 11.3 ± 8.6 13.1 ± 7.7 0.467***
BMI, mean ± SD 32.0 ± 5.8 31.0 ± 5.6 33.2 ± 5.9 0.225***
VAS, mean ± SD 7.0 ± 2.4 6.7 ± 2.4 7.4 ± 2.4 0.356***
HAQ, mean ± SD 1.6 ± 0.6 1.6 ± 0.7 1.5 ± 0.6 0.770***
SF-12, mean ± SD
  Physical Component 29.2 ± 7.0 29.7 ± 8.4 28.7 ± 5.3 0.641***
  Mental Component 37.6 ± 8.3 41.7 ± 7.3 33.2 ± 7.1 0.001***
Analgesic use, n (%) 36 ± 85.7 16 ± 72.7 20 ± 100.0 0.02**
Prednisone use, n (%) 5 (11.9) 4 (18.2) 1 (5.0) 0.346*
MTX use, n (%) 5 (11.9) 3 (13.6) 2 (10.0) 0.999*

PG: Pilates group; CG: control group; BMI: body mass index; VAS: visual analogue scale; HAQ: Health Assessment Questionnaire;
SF-12: 12-Item Short-Form Health Survey; MTX: methotrexate.
*Fisher’s exact test; **chi-square test; ***Student’s t-test; CI = 95%.

cervical spine (flexion and extension) and wrist
(flexion and extension) (Table 3). At the end of the
study, all patients were still using the same drug
treatment compared to baseline.
The relative risk of a person having been treated
with Pilates and having decreased pain was 0.48
(95% CI = 0.28–0.82, P < 0.0001), with a number
needed to treat two patients (95% CI = 7–2,
P < 0.0001). The effect sizes calculated for the
endpoints are shown in Table 4.
Discussion
In our study, it was possible to demonstrate the better
outcomes with Pilates method in reducing pain and
improving functional capacity, quality of life, and
de Oliveira et al. 7

Table 2.  Evaluation of pain, functional capacity, and quality of life at baseline (week 0) and after the intervention
(week 12) in the Pilates group and control group.

Outcome PG (N = 22) CG (N = 20)

Week 0 Week 12 P-value Week 0 Week 12 P-value

VAS, mean ± SD 6.7 ± 2.4 4.4 ± 2.4 0.001* 7.4 ± 2.4 7.8 ± 2.4 0.590**
HAQ, mean ± SD 1.7 ± 0.7 0.7 ± 0.5 0.001** 1.5 ± 0.6 1.7 ± 0.6 0.079**
SF-12—PC, mean ± SD 29.7 ± 8.4 39.9 ± 9.0 0.001** 28.7 ± 5.3 28.9 ± 5.0 1.000**
SF-12—MC, mean ± SD 41.7 ± 7.3 47.7 ± 9.7 0.001* 32.2 ± 7.1 33.2 ± 7.2 0.904**

PG: Pilates group; CG: control group; VAS: visual analogue scale; HAQ: Health Assessment Questionnaire; SF-12-PC: 12-Item
Short-Form Health Survey—Physical Component; SF-12-MC: 12-Item Short-Form Health Survey—Mental Component.
*Paired Student’s t-test; **Wilcoxon test.

Table 3.  Analysis of joint range of motion (ROM) using goniometry in grades comparing Pilates and control
groups.

Joint Pilates group Control group P-value Pilates group Control P-value
group

Right side Left side

Shoulder flexion 147.7 ± 21.1 119.8 ± 24.4 0.001* 146.8 ± 18.9 123.5 ± 28.7 0.003*
Shoulder extension 43.4 ± 3.6 36.5 ± 9.0 0.001** 42.5 ± 4.8 34.4 ± 8.5 0.001**
Shoulder adduction 30.6 ± 11.4 18.4 ± 10.5 0.001* 33.5 ± 7.2 19.9 ± 10.9 0.001*
Shoulder abduction 134.1 ± 28.1 108.0 ± 32.9 0.008* 134.5 ± 27.7 115.0 ± 28.6 0.030*
Wrist flexion 78.2 ± 14.4 73.0 ± 13.8 0.164** 75.7 ± 13.5 74.0 ± 12.7 0.593**
Wrist extension 57.3 ± 13.2 50.0 ± 15.9 0.094** 59.3 ± 15.5 56.0 ± 11.9 0.152**
Knee flexion 116.4 ± 12.6 108.5 ± 11.4 0.040* 118.2 ± 11.4 107.0 ± 12.2 0.004*
Ankle extension 11.9 ± 3.8 9.0 ± 4.2 0.015** 12.6 ± 4.9 7.5 ± 6.0 0.005**
Ankle flexion 32 ± 9.5 24.5 ± 8.3 0.009** 28.3 ± 8.2 22.5 ± 8.5 0.015**

Spine Pilates group Control group  

Cervical spine flexion 52.0 ± 9.9 48.0 ± 8.9 0.180* – – –
Cervical spine extension 47.5 ± 6.9 46.3 ± 4.8 0.139** – – –
Lumbar flexion 86.1 ± 7.7 75.5 ± 11.9 0.002 – – –

All results are expressed as mean ± standard deviation.

*Student’s t-test; **Mann–Whitney’s test; CI = 95%.

range of joint motion after 24 training sessions in the
treatment of patients with musculoskeletal manifes-
tations in the chronic phase of Chikungunya fever.
Current evidence for the improvement of chronic
musculoskeletal pain after treatment with the Pilates
method has been related mostly to patients with
mechanical low back pain.23–25 Few studies have
evaluated this method in relation to improving
peripheral joint pain or in chronic inflammatory
joint diseases7,26,27 or even for generalized pain such
as that related to fibromyalgia.28 However, the ben-
eficial role of physical activity in modulating pain is
well established29–31 through various mechanisms,
including opioid, non-opioid, and serotonergic sys-
tems that contribute to changes in pain sensitivity
resulting from exercise.32 In addition, it has been
shown that Pilates exercises improve isokinetic
muscle strength, flexibility, and postural aware-
ness,33 thereby contributing to the reduction of pain
and improvement in functional capacity.34,35
8 Clinical Rehabilitation 00(0)

Another important feature of the Pilates method is

2 (7–2)
1 (2–1)
2 (5–1)
2 (7–2)

NaN: not a number; VAS: visual analog scale; HAQ: Health Assessment Questionnaire; SF-12-PC: 12-Item Short-Form Health Survey—Physical Component; SF-12-MC: 12-
the avoidance of positions that demand unnecessary
NNT

PG: Pilates group; CG: control group; RR: relative risk; RRR: relative risk reduction; ARR: absolute risk reduction; NNT: number needed to treat; CI: confidence interval;
(CI)
muscle recruitment and consequent early fatigue.36
Altan et al.37 evaluated the effect of Pilates on

0.44 (0.15–0.64)
0.90 (0.65–0.97)
0.52 (0.22–0.71)
0.44 (0.14–0.64)
fibromyalgia patients and observed a positive effect
on pain and function that was higher than that
ARR (CI)

observed in relaxation/stretching exercises. However,

this positive effect was observed only immediately
after the exercise program; three months after the
completion of the Pilates program, the difference
0.52 (0.28–0.82)

0.74 (0.34–0.89)
0.54 (0.18–0.75)
Table 4.  Effect size of the Pilates method intervention in chronic musculoskeletal symptoms of Chikungunya fever patients.

1.00 (NaN–1.0)

between the two groups was no longer significant,

demonstrating the necessity of an ongoing, uninter-
RRR (CI)

rupted Pilates program in order to sustain significant

improvements gained immediately following the
treatment period.
0.48 (0.28– 0.82)

0.26 (0.10–0.66)
0.46 (0.25–0.82)

Patients in the chronic phase of Chikungunya

0.00 (0.0–NaN)

fever can evolve in two distinct patterns: a chronic

inflammatory joint pattern, which occurs in about
RR (CI)

5% of cases, and a non-inflammatory musculoskel-

etal pattern (diffuse or localized), present in most
patients and characterized by pain, stiffness, and
< 0.0001*

joint limitation, often disabling.3 All these symp-

0.0046*

0.0015*
0.0058*
P-value

toms lead to significant functional impairment, as

observed in the sample of patients in this study,
who at baseline presented with mean HAQ scores
85.00
90.00
70.00
80.00

associated with moderate-to-severe disability

Outcome–

(between 2 and 3).16

Several published works have shown that Pilates
17
18
14
16

is an efficient strategy for improving functional

n

capacity in patients with chronic pain, as demon-

15.00
10.00
30.00
20.00
Outcome+

strated in our study.7,26,38 Mendonça et al.26 demon-

%

strated that patients with juvenile arthritis who

were treated with the Pilates method presented
CG

Item Short-Form Health Survey—Mental Component.

with better results than patients treated with con-

3
2
6
4
n

ventional exercises to reduce pain and improve

40.91

18.18
36.36
0.00
Outcome–

functional capacity. Altan et al.7 conducted a study

%

with 55 ankylosing spondylitis patients randomly

assigned to two groups: the Pilates method or pre-
9
0
4
8
n

vious standard-treatment programs. The patients in

the Pilates group had significant improvement at
59.09
100.0
81.82
63.64

*Chi-square test; CI = 95%.

Outcome+

week 12 (P = 0.031) and week 24 (P = 0.007) in

%

physical capacity, as measured by the Bath

Ankylosing Spondylitis Functional Index (BASFI),
PG

13
22
18
14
n

compared to the control group. A systematic review

to determine the effects of the Pilates method in
SF-12-MC
SF-12-PC

patients with non-specific low back pain concluded

HAQ
VAS

that, although there is no conclusive evidence that

 

 
de Oliveira et al. 9
Pilates is superior to other forms of exercise, it
could be more effective than minimal intervention
or non-intervention for pain and disability.38
Patients with Chikungunya fever presented
with reduced health-related quality-of-life scores
not only during the acute phase of the illness but
also for several months after clinical recovery.39,40
Since the disease has a high attack rate and about
one-third of patients progress to the chronic phase,
its implications for public health are serious. The
evaluation of intervention programs that could
improve the impact of the disease on the health of
individuals is extremely important in post-out-
break periods.
The results of our study demonstrate improve-
ment in the quality of life of patients with
Chikungunya fever in the chronic phase who par-
ticipated in the Pilates method, in both the Physical
and the Mental Components of the SF-12. Our
results are similar to those of other studies in which
patients who performed Pilates exercises experi-
enced improvement in quality of life and reduction
in some chronic pain conditions such as low back
pain11 and pain related to fibromyalgia,37 juvenile
arthritis,26 and ankylosing spondylitis.7
Although they were not part of the outcomes
defined for the study, several observations made by
patients at the end of the intervention with regard
to improved disposition, resumption of daily activ-
ities at home and at work, and better mobility dur-
ing treatment demonstrated individual satisfaction
with the treatment. None of the participants with-
drew from the training program due to adverse
effects related to Pilates exercises, corroborating
the belief that Pilates is a safe program.
Several limitations of our study should be
considered. Non-blinding is a limiting factor
since patients and the professional responsible
for conducting the intervention could not be
blinded due to the characteristics inherent in the
method. We also could not control the possible
beneficial effect of the attention and interest
given to the control group. Even though patients
have remained in drug treatment, it was moni-
tored during the protocol, and no differences
were observed at the end of the study, comparing
to baseline. Although a sufficient sample was
obtained to demonstrate the clinically important
difference, the number of patients evaluated is
small and other studies must be performed to
prove these results.
Although positive results have been observed
in this group of patients, these should be evalu-
ated with caution and randomized controlled tri-
als with a larger number of patients, with some
form of control for attention and long-term fol-
low-up, should be performed before this method
is incorporated into clinical practice. In addition,
it is important to note that other modalities of
physical activity besides the Pilates method can
lead to a beneficial effect in the treatment of
chronic musculoskeletal pain of Chikungunya
fever, and this should not be considered as the
only form of treatment.
Since the recommendations for non-pharmaco-
logical treatment in the chronic phase of Chikungunya
fever aim to reduce pain, maintain joint function, and
improve physical conditioning and posture, objec-
tives similar to those identified by Joseph Pilates
when he developed his method and associated with
the results obtained by the patients in our study, we
can suggest Pilates as an effective and safe therapeu-
tic intervention in the treatment of patients in the
chronic phase of Chikungunya fever.
In conclusion, in this study, patients undertaking
Pilates method for 12 weeks had less pain, better
function and quality of life, and increased range of
joint movement. Therefore, Pilates can be consid-
ered a strategy in the non-pharmacological treat-
ment of the disease. It is important to conduct
additional research with larger samples and longer
follow-up time, focusing on non-pharmacological
treatments in order to identify the most cost-effec-
tive strategies for patients.
Clinical messages
•• Patients in the chronic phase of
Chikungunya fever with continuing
symptoms and disability who participate
in Pilates training have reduced pain,
improved functional capacity and qual-
ity of life without any adverse effects
arising.
10 Clinical Rehabilitation 00(0)
Authors’ Note
All the underlying research materials related to the paper
are available as supplementary data.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
Supplemental material
Supplemental material for this article is available online.
ORCID iDs
Alessandro Spencer de Souza Holanda https://orcid.
org/0000-0003-2652-3830
Claudia Diniz Lopes Marques https://orcid.
org/0000-0002-3333-2621
References
1. Suhrbier A, Jaffar-Bandjee MC and Gasque P.
Arthritogenic alphaviruses—an overview. Nat Rev
Rheumatol 2012; 8(7): 420–429.
2. Simon F, Javelle E, Cabie A, et al. French guidelines for
the management of Chikungunya (acute and persistent
presentations). Med Mal Infect 2015; 45(7): 243–263.
3. Javelle E, Ribera A, Degasne I, et al. Specific management
of post-Chikungunya rheumatic disorders: a retrospective
study of 159 cases in Reunion Island from 2006–2012.
PLoS Negl Trop Dis 2015; 9(3): e0003603.
4. Sissoko D, Malvy D, Ezzedine K, et al. Post-epidemic
Chikungunya disease on Reunion Island: course of
rheumatic manifestations and associated factors over a
15-month period. PLoS Negl Trop Dis 2009; 3(3): e389.
5. Schilte C, Staikowsky F, Couderc T, et al. Chikungunya
virus-associated long-term arthralgia: a 36-month pro-
spective longitudinal study. PLoS Negl Trop Dis 2013;
7(3): e2137.
6. Wells C, Kolt GS and Bialocerkowski A. Defining Pilates
exercise: a systematic review. Complement Ther Med
2012; 20(4): 253–262.
7. Altan L, Korkmaz N, Dizdar M, et al. Effect of Pilates
training on people with ankylosing spondylitis. Rheumatol
Int 2012; 32(7): 2093–2099.
8. Miyamoto GC, Costa LO and Cabral CM. Efficacy of the
Pilates method for pain and disability in patients with
chronic nonspecific low back pain: a systematic review with
meta-analysis. Braz J Phys Ther 2013; 17(6): 517–532.
9. Gaskell L and Williams AE. A qualitative study of the
experiences and perceptions of adults with chronic muscu-
loskeletal conditions following a 12-week Pilates exercise
programme. Musculoskeletal Care 2019; 17(1): 54–62.
10. Lim EC, Poh RL, Low AY, et al. Effects of Pilates-based
exercises on pain and disability in individuals with persistent
nonspecific low back pain: a systematic review with meta-
analysis. J Orthop Sports Phys Ther 2011; 41(2): 70–80.
11. Natour J, CazottiLde A, Ribeiro LH, et al. Pilates improves
pain, function and quality of life in patients with chronic
low back pain: a randomized controlled trial. Clin Rehabil
2015; 29(1): 59–68.
12. Campos RR, Dias JM, Pereira LM, et al. Effect of the
Pilates method on physical conditioning of healthy sub-
jects: a systematic review and meta-analysis. J Sports Med
Phys Fitness 2016; 56(7–8): 864–873.
13. Vieira ND, Testa D, Ruas PC, et al. The effects of 12
weeks Pilates-inspired exercise training on functional per-
formance in older women: a randomized clinical trial. J
Bodyw Mov Ther 2017; 21(2): 251–258.
14. Hawker GA, Mian S, Kendzerska T, et al. Measures of
adult pain: Visual Analog Scale for Pain (VAS Pain),
Numeric Rating Scale for Pain (NRS Pain), McGill
Pain Questionnaire (MPQ), Short-Form McGill Pain
Questionnaire (SF-MPQ), Chronic Pain Grade Scale
(CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS),
and Measure of Intermittent and Constant Osteoarthritis
Pain (ICOAP). Arthritis Care Res (Hoboken) 2011;
63(suppl. 11): S240–S252.
15. Boone DC, Azen SP, Lin CM, et al. Reliability of gonio-
metric measurements. Phys Ther 1978; 58(11): 1355–1360.
16. Bruce B and Fries JF. The Health Assessment
Questionnaire (HAQ). Clin Exp Rheumatol 2005; 23(5
suppl. 39): S14–S18.
17. Ware J Jr, Kosinski M and Keller SD. A 12-Item Short-
Form Health Survey: construction of scales and prelimi-
nary tests of reliability and validity. Med Care 1996;
34(3): 220–233.
18. Shinjo SK, Goncalves R, Kowalski S, et al. Brazilian-
Portuguese version of the Health Assessment
Questionnaire for Spondyloarthropathies (HAQ-S) in
patients with ankylosing spondylitis: a translation, cross-
cultural adaptation, and validation. Clin Rheumatol 2007;
26(8): 1254–1258.
19. Silveira MF, Almeida JC, Freire RS, et al. Psychometric
properties of the quality of life assessment instrument:
12-item health survey (SF-12). Cien Saude Colet 2013;
18(7): 1923–1931.
20. Farrar JT, Young JP Jr, LaMoreaux L, et al. Clinical
importance of changes in chronic pain intensity measured
on an 11-point numerical pain rating scale. Pain 2001;
94(2): 149–158.
21. Van den Bosch F, Ostor AJK, Wassenberg S, et al. Impact
of participation in the adalimumab (Humira) patient sup-
port program on rheumatoid arthritis treatment course:
results from the PASSION study. Rheumatol Ther 2017;
4(1): 85–96.
de Oliveira et al. 11
22. Diaz-Arribas MJ, Fernandez-Serrano M, Royuela A, et al.
Minimal clinically important difference in quality of life
for patients with low back pain. Spine (Phila Pa 1976)
2017; 42(24): 1908–1916.
23. Wells C, Kolt GS, Marshall P, et al. The effectiveness of
Pilates exercise in people with chronic low back pain: a
systematic review. PLoS ONE 2014; 9(7): e100402.
24. Patti A, Bianco A, Paoli A, et al. Effects of Pilates exer-
cise programs in people with chronic low back pain: a sys-
tematic review. Medicine (Baltimore) 2015; 94(4): e383.
25. Yamato TP, Saragiotto BT and Maher C. Therapeutic exer-
cise for chronic non-specific neck pain: PEDro systematic
review update. Br J Sports Med 2015; 49(20): 1350.
26. Mendonça TM, Terreri MT, Silva CH, et al. Effects of
Pilates exercises on health-related quality of life in indi-
viduals with juvenile idiopathic arthritis. Arch Phys Med
Rehabil 2013; 94(11): 2093–2102.
27. Mazloum V, Rabiei P, Rahnama N, et al. The comparison
of the effectiveness of conventional therapeutic exercises
and Pilates on pain and function in patients with knee osteo-
arthritis. Complement Ther Clin Pract 2018; 31: 343–348.
28. Ekici G, Unal E, Akbayrak T, et al. Effects of active/pas-
sive interventions on pain, anxiety, and quality of life in
women with fibromyalgia: randomized controlled pilot
trial. Women Health 2017; 57(1): 88–107.
29. O’Connor PJ and Cook DB. Exercise and pain: the neu-
robiology, measurement, and laboratory study of pain in
relation to exercise in humans. Exerc Sport Sci Rev 1999;
27: 119–166.
30. Koltyn KF. Analgesia following exercise: a review. Sports
Med 2000; 29(2): 85–98.
31. Koltyn KF. Exercise-induced hypoalgesia and intensity of
exercise. Sports Med 2002; 32(8): 477–487.
32. Brito RG, Rasmussen LA and Sluka KA. Regular physi-
cal activity prevents development of chronic muscle pain
through modulation of supraspinal opioid and serotoner-
gic mechanisms. Pain Rep 2017; 2(5): e618.
33. Campos de, Oliveira L, Goncalves de, Oliveira R and
Pires-Oliveira DA. Effects of Pilates on muscle strength,
postural balance and quality of life of older adults: a ran-
domized, controlled, clinical trial. J Phys Ther Sci 2015;
27(3): 871–876.
34. Eyigor S, Karapolat H, Yesil H, et al. Effects of Pilates
exercises on functional capacity, flexibility, fatigue,
depression and quality of life in female breast cancer
patients: a randomized controlled study. Eur J Phys
Rehabil Med 2010; 46(4): 481–487.
35. Coudeyre E, Jegu AG, Giustanini M, et al. Isokinetic
muscle strengthening for knee osteoarthritis: a systematic
review of randomized controlled trials with meta-analysis.
Ann Phys Rehabil Med 2016; 59(3): 207–215.
36. Muscolino JE and Cipriani S. Pilates and the
“powerhouse”—I. J Bodyw Mov Ther 2004; 11: 238–242.
37. Altan L, Korkmaz N, Bingol U, et al. Effect of Pilates
training on people with fibromyalgia syndrome: a pilot
study. Arch Phys Med Rehabil 2009; 90(12): 1983–1988.
38. Yamato TP, Maher CG, Saragiotto BT, et al. Pilates for
low back pain. Cochrane Database Syst Rev 2015; 7:
CD010265.
39. Couturier E, Guillemin F, Mura M, et al. Impaired qual-
ity of life after Chikungunya virus infection: a 2-year
follow-up study. Rheumatology (Oxford) 2012; 51(7):
1315–1322.
40. Ramachandran V, Malaisamy M, Ponnaiah M, et al.
Impact of Chikungunya on health related quality of life
Chennai, South India. PLoS ONE 2012; 7(12): e51519.