Os Efeitos Do Pilates Nos Resultados Relacionados À Saúde em

Applied Physiology, Nutrition, and Metabolism
The Effects of Pilates on Health-related Outcomes in

Individuals with Increased Risk of Fracture: A Systematic
Review
Journal: Applied Physiology, Nutrition, and Metabolism
Manuscript ID apnm-2021-0462.R1
Manuscript Type: Systematic Review
Date Submitted by the

07-Oct-2021
Author:
Complete List of Authors: McLaughlin, Emily; University of Waterloo, Department of Kinesiology

Bartley, Joan; Osteoporosis Canada, Canadian Osteoporosis Patient
Network
Ashe, Maureen; University of British Columbia,
Dr
Butt, Debra; University of Toronto, Department of Family and

Community Medicine
Chilibeck, Philip; University of Saskatchewan,
Wark, John; The University of Melbourne Department of Medicine Royal
aft
Melbourne Hospital, Bone and Mineral Medicine

Thabane, Lehana; McMaster University, Department of Heath Research
Methods, Evidence and Impact
Stapleton, Jackie; University of Waterloo, University of Waterloo Library
Giangregorio, Lora; University of Waterloo, ; Schlegel Research Institute
for Aging,
Pilates, exercise, osteoporosis < bone health, Low bone mass, exercise
Keyword: prescription < exercise, exercise therapy < exercise, fracture, fracture
prevention
Is the invited manuscript for

consideration in a Special Not applicable (regular submission)
Issue? :
© The Author(s) or their Institution(s)

Page 1 of 34 Applied Physiology, Nutrition, and Metabolism
1 The Effects of Pilates on Health-related Outcomes in Individuals with Increased Risk of
2 Fracture: A Systematic Review
4 Emily Claire McLaughlin1, Joan Bartley2, Maureen C. Ashe3, Debra A. Butt4, Philip D.
5 Chilibeck5, John D. Wark6, Lehana Thabane7, Jackie Stapleton8, Lora M. Giangregorio1,9*
7 1Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada, N2L 3G1
8 2Canadian Osteoporosis Patient Network, Osteoporosis Canada
9 3Department of Family Practice, University of British Columbia, Vancouver, BC, Canada V5Z
10 1M0, Canada
11 4Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
Dr
12 M5G 1V7
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13 5College of Kinesiology, University of Saskatchewan, Saskatoon, SK, Canada, S7N 5A2
14 6University of Melbourne Department of Medicine, Bone and Mineral Medicine, Royal
15 Melbourne Hospital, Parkville, Victoria, Australia, 3050
16 7Department of Health Research Methods, Evidence and Impact, McMaster University,
17 Hamilton ON, Canada
18 8University of Waterloo Library, University of Waterloo, Waterloo, ON, Canada, N2L 3G1
19 9Schlegel-University of Waterloo Research Institute for Aging, University of Waterloo, ON, N2J
20 0E2, Canada
21 Email addresses: ECM (ecmclaughlin@uwaterloo.ca), JB (bartleyj65@gmail.com), MA

22 (maureen.ashe@ubc.ca), DB (debra.butt@utoronto.ca), PC (phil.chilibeck@usask.ca), JW
23 (jdennisw1@gmail.com), LT (thabanl@mcmaster.ca), JS (jstapleton@uwaterloo.ca), LG
24 (lora.giangregorio@uwaterloo.ca) *Corresponding Author: Lora M. Giangregorio, Department
25 of Kinesiology, University of Waterloo, 200 University Ave W, Waterloo, ON, N2L 3G1.
26 Phone: +1 519-888-4567 ext. 36357
1
Applied Physiology, Nutrition, and Metabolism Page 2 of 34
27 Abstract:
28 This systematic review examined the effect of Pilates on health-related outcomes in
29 individuals with increased fracture risk to inform the 2021 Clinical Practice Guidelines for
30 Management of Osteoporosis and Fracture Prevention in Canada. Seven electronic databases were
31 searched to December 2020. Studies of Pilates in men and postmenopausal women aged ≥ 50
32 years with low BMD, history of fragility fracture, or moderate-high risk of fragility fracture were
33 included. Two reviewers independently screened studies and performed risk of bias assessment.
34 Of 7286 records and 504 full-text articles, five studies were included, encompassing data from 143
35 participants (99% female). Data were insufficient for meta-analyses. There is low-certainty
36 evidence that Pilates improved physical functioning and health-related quality of life. The effect
37 of Pilates on falls and BMD is uncertain. No evidence was available for the effect of Pilates on
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38 mortality, fractures, or adverse events. Overall, Pilates may improve physical functioning and
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39 quality of life. Evidence of benefits relative to harms of Pilates in people with increased fracture
40 risk, particularly males, is limited. PROSPERO registration: CRD42019122685.
41
42 Novelty Bullets:
43  Pilates may improve physical functioning and quality of life in women with osteoporosis.
44  Evidence of the effect of Pilates on BMD, falls, fractures, or adverse events is limited.
45
46 Keywords: Pilates, Exercise, Osteoporosis, Fracture Prevention
47
48
49
2
50 INTRODUCTION
51 Osteoporosis is a common skeletal disorder characterized by compromised bone strength,
52 predisposing a person to an increased risk of fracture(NIH Consensus Development Panel on
53 Osteoporosis Prevention, Diagnosis, and Therapy, and Therapy, NIH Consensus Development
54 Panel on Osteoporosis Prevention and Therapy, 2001). Osteoporotic fragility fractures can cause
55 pain, functional impairment and loss of independence, resulting in activity limitations and reduced
56 quality of life, and can lead to hospitalization and early mortality(Ioannidis et al., 2009; Gajic-
57 Veljanoski et al., 2018). Fragility fractures place an economic burden of $4.6 billion yearly on the
58 Canadian healthcare system(Hopkins et al., 2016).
59 Exercise is an integral component in the prevention and management of osteoporosis. In
60 older adults, there is strong evidence that exercise prevents falls and reduces the risk of
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61 fracture(Sherrington et al., 2019). However, the risks and benefits of exercise for fracture
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62 prevention may vary by individual and by type of exercise. Exercise that involves flexion or
63 rotation of the spine, quick transitions between movements, use of loads when proper spinal
64 alignment is not maintained, or activities that challenge balance without support may require
65 modification or careful progression for individuals at a high risk of fracture(Giangregorio et al.,
66 2015).
67 Exercise programs for individuals with osteoporosis should target the prevention of falls,
68 safe movement with a focus on body mechanics, and maintenance of muscular strength in an effort
69 to slow the rate of bone loss(Giangregorio et al., 2015). Pilates, originally developed by Joseph
70 Pilates in the 1930s (Pilates and Miller, 1945), employs principles of core stability, postural
71 alignment, balance, and muscular strength and endurance. Movements are completed with
72 precision and fluidity, through controlled sequences paired with full, rhythmic breathing(di
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73 Lorenzo, 2011). Pilates emphasizes quality of movement, developing foundational patterning that
74 can be progressed to more difficult exercises. Progressions involve decreasing the base of support
75 and altering the centre of gravity to challenge balance, or reducing the amount of assistance
76 provided to increase muscular challenge, working towards functional movement against gravity
77 that is relevant to everyday life(Anderson et al., 2005). Pilates exercise often includes resistance
78 training against spring-loaded apparatuses or elastic resistance bands in addition to floor-based
79 mat work(di Lorenzo, 2011). Though the principles of Pilates align with the therapeutic goals of
80 exercise for preventing fracture, a synthesis of available evidence on Pilates in people with low
81 bone mass is needed to determine if it is appropriate to recommend in guidelines. The aim of this
82 systematic review is to determine the effects of Pilates exercise (versus no intervention, placebo
83 or attention control) on falls, fractures, and other health-related outcomes in men and
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84 postmenopausal women aged 50 years or older at increased risk of fracture. This systematic review
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85 is part of a series of systematic reviews that will inform the 2021 Clinical Practice Guidelines for
86 Management of Osteoporosis and Fracture Prevention in Canada. Each review focused on a
87 specific type of exercise. Pilates emerged as an area of interest during consultation with
88 patients(Morin et al., 2020), therefore a separate review was performed.
89
90 METHODS
91 This systematic review follows the Preferred Reporting Items for Systematic Review and
92 Meta-Analysis (PRISMA) guidelines(Moher et al., 2009). The protocol was informed by the
93 Cochrane Handbook for Systematic Reviews of Interventions(Higgins and Green, 2011), and
94 designed by a working group of researchers, physiotherapists, physicians, a patient advocate, and
95 graduate students. The protocol was registered via the International Prospective Register of
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96 Systematic Reviews (PROSPERO) at https://www.crd.york.ac.uk/prospero/ (Registration
97 number: CRD42019122685; submitted March 6, 2019).
98
99 Data Sources and Searches
100 A librarian with experience conducting systematic reviews (JS) developed a common
101 literature search and used a deduplication process to identify studies for six different types of
102 exercise interventions to be considered in the guidelines. The search was conducted in MEDLINE
103 (Ovid), EMBASE (Ovid), Cochrane CENTRAL (clinical trials), Cochrane database of systematic
104 reviews (meta-analyses), CINAHL (allied health journal content), Epistemonikos, and Web of
105 Science in August 2018 and updated in December 2020. Search terms consisted of a combination
106 of subject headings (i.e. MeSH) and author keywords related to interventions used in the
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107 prevention and treatment of osteoporosis in older adults. The full search strategy can be found in
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108 Supplement S1. No restrictions were placed on gender, ethnicity, exercise setting, country of
109 origin, or language, however only human studies written in English, Portuguese, Spanish, Italian,
110 or Farsi were included due to language limitations of the working group. Randomized controlled
111 trials (RCTs) and quasi-randomized controlled trials comparing Pilates to placebo, attention
112 control, or non-physical activity interventions, as well as cohort studies, case-control studies,
113 cross-sectional studies and case reports were considered for inclusion in the systematic review to
114 ensure that all available studies of Pilates interventions were captured. We included non-
115 randomized trials because we hypothesized that there would be a limited number of RCTs, and we
116 wanted to capture all available evidence for each outcome. Editorials and opinion pieces were
117 excluded. References were stored and managed using EndNote
118 (https://www.myendnoteweb.com/, Clarivate Analytics, Philadelphia, PA, USA). Titles and
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119 abstracts were imported into Covidence (Veritas Health Innovation, Melbourne, Australia) for
120 screening and data extraction.
121
122 Study selection
123 Two authors (EM and JB) independently assessed study eligibility at each phase: level 1
124 screening (title and abstract review), level 2 screening (full-text review) and level 3 data extraction.
125 Conflicts were resolved by discussion between reviewers or by a third author (LG) when
126 agreement was not reached.
127
128 Data items
129 Population
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130 We included studies of men or postmenopausal women with a mean age of 50 years or
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131 older with either a) low bone mineral density (BMD) at the femoral neck or lumbar spine (T-score
132 ≤ -1.00), measured with dual-energy X-ray absorptiometry (DXA); b) history of ≥1 fragility
133 fracture (i.e., fracture of the spine, hip, wrist, humerus); or c) moderate or high-risk of fragility
134 fracture based on the CAROC(Siminoski et al., 2007), FRAX(Kanis et al., 2009), or
135 GARVAN(Nguyen et al., 2008) calculators. Studies of individuals with secondary osteoporosis,
136 glucocorticoid-induced osteoporosis, or pathological fractures were excluded. Studies of older
137 adults were only included if a subgroup analysis was conducted in individuals with low bone mass,
138 or ≥80% of participants had low bone mass. If it was unclear whether studies met inclusion
139 criteria, authors were contacted.
140
141
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142 Intervention
143 We included studies that defined their intervention as Pilates. Interventions could be home-
144 or centre-based, individual or group-based, and either supervised or unsupervised. Studies
145 combining Pilates with pharmacological or other co-interventions (excluding whole-body
146 vibration) were included unless unevenly administered to the intervention and control groups. We
147 attempted to differentiate between studies of interventions that aligned with accepted definitions
148 of classical or hybrid Pilates, or were Pilates-inspired, but could not find established guidelines on
149 how to categorize a Pilates intervention.
150
151 Comparator
152 Studies were included if at least one comparator group received either no intervention,
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153 placebo, a non-exercise or non-physical therapy intervention (e.g., educational intervention), or an

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154 attention control not expected to affect outcomes of interest.
155
156 Outcomes:
157 A list of outcomes deemed critical or important to individuals living with osteoporosis and
158 to exercise professionals was established (Rodrigues, 2019; Morin et al., 2020) The outcomes of
159 interest were: 1) mortality due to any cause, including natural death, disease, or circumstance
160 resulting in fatal injury or death; 2) fracture-related mortality, defined as deaths attributed to a
161 fragility fracture; 3) fragility fractures, either self-reported or X-ray verified fracture of the spine,
162 wrist, humerus or pelvis that occurred from a low-trauma event; 4) hip fractures, either self-
163 reported or X-ray verified fracture of the femoral neck or trochanter; 5) number of fallers, falls,
164 and fall-related injuries; 6) physical functioning and disability, using any validated tool measuring
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165 activities of daily living or performance-based measures of physical functioning (e.g., gait speed,
166 Timed Up-and-Go, Sit-to-Stand test). Measures of strength of individual muscles or muscle
167 groups (e.g., quadriceps strength) were not included; 7) health-related quality of life, using any
168 validated generic or osteoporosis-specific quality of life questionnaire; and 8) serious adverse
169 events, defined as any untoward medical occurrence that at any dose resulted in death, life-
170 threatening injury, inpatient hospitalisation, prolongation of existing hospitalisation, or persistent
171 or significant disability or incapacity, and non-serious adverse events, defined as any reaction
172 related to the intervention such as musculoskeletal injuries (e.g., sprains, strains, joint pain, overuse
173 injuries). Pain and BMD were not voted as critical outcomes for the guidelines but were included
174 in this systematic review. We reported BMD measures determined by DXA at any bone site. BMD
175 was used as an indirect measure of fracture risk when data on fractures was unavailable or of very
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176 low certainty. Pain outcomes reported using any validated questionnaire (e.g., Visual Analogue
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177 Scale) or pain subscale from a generic functional status questionnaire (e.g., SF-36, Nottingham
178 Health Profile) were included.
179
180 Time
181 We included studies with interventions lasting a minimum of four weeks.
182
183 Data Extraction and Quality Assessment:
184 Two independent reviewers (EM and JB) extracted the following information from eligible
185 studies: year of publication, study setting, participant characteristics, details of the intervention
186 and control groups including exercise frequency, intensity and duration, the number of recruited
187 participants at baseline, adherence rates in intervention group(s), drop-out rates, outcomes of
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188 interest, and adverse events. If data were missing, authors were contacted. Data were only reported
189 from subscales when the study did not report total scores. For example, we preferentially reported
190 total quality of life scores compared with scales that individually reported physical or mental health
191 aspects of quality of life. If a study reported multiple study arms, we only extracted data from
192 groups of interest.
193 The same independent reviewers (EM and JB) assessed risk of bias using the Cochrane
194 Risk of Bias Assessment Tool (Sterne et al., 2019). When assessing risk of bias due to “other
195 sources of bias” we considered factors such as between group differences in participant
196 characteristics or health status at baseline, differences in the length of follow-up period,
197 measurement error, and consistency in exercise instruction (e.g., did they provide a familiarization
198 period to ensure all participants were prepared to begin exercise). Conflicts were resolved by
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199 discussion between reviewers, or by a third author (LG) when agreement was not reached. A
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200 rating of low, unclear, or high risk of bias was assigned. Certainty of evidence was determined for
201 each outcome using the Grading of Recommendations, Assessment, Development and Evaluations
202 (GRADE) framework(Zhang et al., 2019).
203
204 Data Synthesis and Analysis:
205 Statistical analysis was performed using Review Manager 5.3 (RevMan 5) (Cochrane
206 Community, London, UK; https://community.cochrane.org/help/tools-and-software/revman-5).
207 Mean difference (MD) with 95% confidence intervals (CI) was calculated for continuous
208 outcomes. Risk ratio (RR) or rate ratio (RaR) with 95% CI was calculated for dichotomous
209 outcomes. Our original protocol dictated that study outcomes would be pooled, and standardized
210 mean difference (SMD) would be calculated when pooling total scores across studies. Due to the
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211 small number of included trials and heterogeneity in duration of follow-up, comparators, and
212 measurement tools used to assess outcomes, we present a narrative synthesis of findings instead.
213
214 RESULTS
215 Description of studies
216 The initial search strategy identified 7286 references. After removing duplicates and
217 reviewing titles and abstracts, 504 full-text articles were assessed for eligibility (Figure 1). Five
218 studies were included, encompassing data from 143 unique participants in two countries (Table
219 1)(Kopitzke, 2007; Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can, 2015; Cabot
220 and Shrier, 2017; Oksuz and Unal, 2017). Three studies were randomized controlled trials
221 (n=141)(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can, 2015; Oksuz and Unal,
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222 2017) and two were case reports of individuals (n=2)(Kopitzke, 2007; Cabot and Shrier, 2017).
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223 Reasons for exclusion are listed in Figure 1. References for excluded studies can be found in
224 Supplement S2.
225
226 Participant characteristics
227 All 141 participants in the RCTs were postmenopausal women diagnosed with
228 osteoporosis (T-score ≤ -2.5 SD)(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can,
229 2015; Oksuz and Unal, 2017). Two studies required this diagnosis be confirmed by
230 DXA(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can, 2015). The average age of
231 participants ranged from 57 to 64 years(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden
232 and Can, 2015; Oksuz and Unal, 2017). Participants with a history of fracture were excluded
233 from all RCTs, as were those with mobility or communication limitations(Angin, Erden and Can,
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234 2015; Oksuz and Unal, 2017), or diseases or systemic conditions that may preclude them from
235 exercise(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can, 2015; Oksuz and Unal,
236 2017). Küçükçakir (2013) excluded individuals with secondary osteoporosis or those taking
237 medications that may lead to it. Both Küçükçakir (2013) and Oksuz (2017) also excluded
238 individuals unwilling to participate in an exercise program. Angin (2015) excluded individuals
239 who had regularly exercised in the preceding 6 months. For the two case reports, one subject
240 was male, aged 52 years (Cabot and Shrier, 2017), and the other subject was female, aged 67
241 years(Kopitzke, 2007). Both had a T-score ≤ -2.5 SD, with no reported fractures. Demographic
242 information including place of residence, race, occupation, religion, education, socio-economic
243 status and social capital (a concept referring to social networks, civic participation and
244 interpersonal trust)(O’Neill et al., 2014), was not reported in any of the included studies.
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245
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246 Setting and supervision:
247 Studies were conducted in two countries: Turkey (3 RCTs)(Küçükçakir, Altan and
248 Korkmaz, 2013; Angin, Erden and Can, 2015; Oksuz and Unal, 2017) and the United States (2
249 case-reports)(Kopitzke, 2007; Cabot and Shrier, 2017). Pilates interventions were instructed and
250 supervised by a physiotherapist, either one-to-one(Kopitzke, 2007; Cabot and Shrier, 2017) or in
251 a small group(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can, 2015; Oksuz and
252 Unal, 2017). It was not reported whether physiotherapists had additional qualification or training
253 for Pilates instruction or osteoporosis. Four interventions took place at a physical therapy and
254 rehabilitation centre(Kopitzke, 2007; Angin, Erden and Can, 2015; Cabot and Shrier, 2017;
255 Oksuz and Unal, 2017); one did not report the setting (Küçükçakir, Altan and Korkmaz, 2013).
256
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257
258 Frequency, intensity and duration of the exercise intervention:
259 The experimental interventions consisted of a one-hour exercise session performed two to
260 three times weekly. Sessions included mat-based and standing exercises, resistance bands and
261 balls, and a warm-up and cool-down period(Küçükçakir, Altan and Korkmaz, 2013; Angin,
262 Erden and Can, 2015; Oksuz and Unal, 2017). Progressions were used to advance intervention
263 difficulty over time. A single training session familiarized participants with basic Pilates
264 principles prior to beginning the intervention in two studies(Angin, Erden and Can, 2015; Oksuz
265 and Unal, 2017). Interventions described in the case studies were not consistent with the
266 randomized trials. Cabot (2017) used the Pilates Reformer and Wunda chair, but did not provide
267 details of the exercises performed(Cabot and Shrier, 2017). We included the case study by
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268 Kopitzke (2007) because the author defined the intervention as Pilates, however there was no
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269 description of a Pilates program beyond single-leg heel raises (Kopitzke, 2007). Further details
270 of intervention are provided in Table 1 and Supplement S3.
271
272 Comparator:
273 Angin (2015) compared Pilates to no intervention. Oksuz (2017) instructed participants to
274 continue a normal daily routine, refraining from exercise. Küçükçakir (2013) used an attention
275 control, where participants in the control group were instructed to complete 3 sets of 20
276 repetitions of seated thoracic extensions at home, and received monthly telephone follow-up.
277
278 Adherence and dropouts:
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279 Adherence to Pilates exercise sessions was not reported(Kopitzke, 2007; Küçükçakir,
280 Altan and Korkmaz, 2013; Angin, Erden and Can, 2015; Cabot and Shrier, 2017; Oksuz and
281 Unal, 2017). Angin (2015) reported that 100% of participants in the intervention group
282 completed the study, while 3 of 22 participants (13.64%) in the control group did not.
283 Küçükçakir (2013) reported 14.3% attrition (5 of 35 participants) in intervention and control
284 groups, respectively. Oksuz (2017) reported no attrition.
285
286 Outcomes
287 There were no studies that examined the effect of Pilates on mortality, hip fractures,
288 fragility fractures or adverse events.
289
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290 Bone Mineral Density as an Indirect Measure of Fracture Risk

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291 There is very low certainty evidence from one RCT and two case studies that Pilates may
292 improve BMD (Table 2). Angin (2015) reported an improvement in lumbar spine BMD
293 following a 6-month Pilates intervention compared with no intervention (MD 0.06, 95% CI 0.01
294 to 0.11; n=44). Kopitzke (2007) noted an improvement in T-score at the lumbar spine and the
295 femoral neck in one case after 12 months of Pilates; no BMD values were reported. Cabot
296 (2017) reported an improvement in BMD from 0.815 to 0.893 g/cm2 after 48 weeks of Pilates in
297 one case, but the site of measurement and method of ascertainment of BMD was not disclosed.
298
299 Falls and Fall-related Injuries
300 There is inadequate evidence to make inferences about Pilates and falls. Küçükçakir
301 (2013) reported that two participants experienced one fall each in the Pilates group while one
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302 participant experienced one fall and two participants experienced two falls each in the home
303 exercise group. Between group differences were not evaluated due to the low number of falls.
304 Evidence is of very low certainty (Table 2).
305
306 Physical Functioning and Disability
307 There is low certainty evidence from three RCTs and one case study that Pilates may
308 improve physical functioning (Table 2)(Kopitzke, 2007; Küçükçakir, Altan and Korkmaz, 2013;
309 Angin, Erden and Can, 2015; Oksuz and Unal, 2017) .
310
311 Six-Minute Walk Test
312 Two RCTs, including a total of 101 participants, examined the effect of Pilates on the
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313 Six-Minute Walk Test (6MWT)(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can,
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314 2015). Angin (2015) reported a non-significant improvement in distance travelled during the
315 6MWT following a 6-month Pilates intervention compared with no intervention (MD=53.40
316 metres, 95% CI -3.81 to 110.61; n=41). Küçükçakir (2013) reported a significant improvement
317 in distance travelled during the 6MWT following a year-long Pilates intervention compared with
318 an attention control (MD=91.80 metres, 95% CI 54.12 to 129.48; n=60).
319
320 Seated to Standing Tests
321 Küçükçakir (2013) reported significant improvements in 1-minute sit-to-stand test score
322 after one year of Pilates compared to control (MD 9.50 repetitions, 95% CI 7.32 to 11.68; n=60),
323 while Oksuz (2017) reported improvements in 30-second chair stand test score following the 6-
324 week Pilates intervention compared to control (MD 2.90 repetitions, 95% CI 2.05 to 3.75; n=40).
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325 Oksuz (2017) also noted significant improvements in Timed-Up-and-Go score (MD -1.44
326 seconds, 95% CI -2.04 to -0.84; n=40) following Pilates intervention compared to control.
327
328 Balance tests
329 Oksuz (2017) reported significant improvements in the Berg Balance Test following 6-
330 weeks of Pilates compared with no intervention (MD 1.70, 95% CI 1.14 to 2.26; n=40). An
331 improvement in single leg standing time following one year of Pilates was noted in one case
332 study(Kopitzke, 2007).
333
334 Health-related quality of life
335 There is low certainty evidence from three RCTs that Pilates improved health-related
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336 quality of life(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can, 2015; Oksuz and
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337 Unal, 2017). Küçükçakir (2013) and Oksuz (2017) reported QUALEFFO-41 total score
338 demonstrating relative improvements (lower score is better) in quality of life in the Pilates group
339 compared to control (MD -20.20, 95% CI -23.71 to -16.69) and (MD -7.59, 95% CI -9.35 to -
340 5.83), respectively. For presentation using GRADE methodology, these values were pooled
341 (Table 2). Angin et. al (2015) reported QUALEFFO-41 subscales only, also demonstrating
342 relative improvements in each quality of life domain in the Pilates group compared with
343 control(Angin, Erden and Can, 2015). Additionally, Küçükçakir (2013) reported all subscales of
344 the RAND 36-item Short Form Survey (SF-36), demonstrating relative improvements in the
345 Pilates intervention group compared with the control group (Küçükçakir, Altan and Korkmaz,
346 2013). Oksuz (2017) reported the Hospital Anxiety and Depression scale (HADS), the Health
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347 Assessment Questionnaire (HAQ), and the Satisfaction with Life Scale (SLS), demonstrating
348 relative improvements in the Pilates group compared with the control (Oksuz and Unal, 2017).
349
350 Adverse Events
351 No studies examined the effect of Pilates on serious or minor adverse events. One study
352 reported that no participants withdrew due to complications from the exercise program, and no
353 adverse events were reported in the remaining study population (Küçükçakir, Altan and
354 Korkmaz, 2013), however they did not describe any methods for ascertaining possible adverse
355 events.
356
357 Pain
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358 All three RCTs evaluated pain using a visual analogue scale(Küçükçakir, Altan and
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359 Korkmaz, 2013; Angin, Erden and Can, 2015; Oksuz and Unal, 2017), and reported that
360 participation in Pilates significantly reduced pain compared with control (very low certainty
361 evidence).
362
363 Visual Analogue Scale for pain at rest
364 Angin (2015) reported a significant reduction in pain at rest following the Pilates
365 intervention compared with no intervention (MD= -2.98, 95% CI -4.12 to -1.84; n=41). Oksuz
366 (2017) also demonstrated a significant reduction in pain at rest (MD= -2.57, 95% CI -3.61 to -
367 1.53; n=40) as well as a significant reduction in morning pain in the Pilates group compared with
368 no intervention (MD -2.10, 95% CI -2.84 to -1.36; n=40). Küçükçakir (2013) reported a
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369 significant reduction in pain at rest, following the Pilates intervention compared with the
370 attention control (MD= -2.70, 95% CI -3.20 to -2.20; n=60).
371
372 Visual Analogue Scale for pain with movement or during intervention
373 Angin (2015) and Oksuz (2017) both reported a significant reduction in pain with
374 movement in the Pilates group compared with no intervention (MD= -4.94, 95% CI -5.83 to -
375 4.05; n=41)(Angin, Erden and Can, 2015) and (MD= -1.70 95% CI -2.43 to -0.97; n=40)
376 respectively(Oksuz and Unal, 2017).
377
378 Other pain measurements
379 Oksuz (2017) reported pain using the short form McGill questionnaire and subscales, the
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380 Pain Disability Index (PDI) and the Oswestry Low Back Pain Disability Scale (ODI). In all pain
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381 measures completed by Oksuz (2017), Pilates exercise significantly reduced reports of pain
382 compared with no intervention (Oksuz and Unal, 2017).
383
384 Risk of Bias Assessment
385 The three included RCTs were determined to have a high risk of bias using the Cochrane
386 Risk of Bias Assessment tool (Figure 2). Case reports were automatically considered high risk of
387 bias and were not assessed. Randomization techniques were not described by two of three
388 RCTs, and all studies employed inadequate allocation concealment. Due to the nature of the
389 exercise intervention, blinding of participants and personnel administering the intervention was
390 not possible(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can, 2015; Oksuz and
391 Unal, 2017). Angin (2017) reported that outcome assessment was performed by the same
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392 physiotherapist who administered treatment (high risk). Blinding of outcome assessors was not
393 described in the study by Oksuz (2017) (unclear risk). Intention-to-treat analysis was not
394 conducted in any of the studies(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can,
395 2015; Oksuz and Unal, 2017) despite missing data due to participants dropping out prior to the
396 end of the study period. Küçükçakir (2013) reported equal rates of attrition in both study arms,
397 and stated reasons for drop-outs. Angin (2015) provided no explanation of dropouts. While the
398 published article by Oksuz (2017) reported that all 40 participants completed the study, the
399 registered protocol, identified following a search of clinicaltrials.gov (Identifier: NCT02716855),
400 reported that 47 participants were randomized, and 7 participants did not complete the study.
401 Details of group allocation and reason for drop-out were not disclosed(Oksuz and Unal, 2017).
402 Clinical trial registrations were not reported in any of the published papers, and were not
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403 available for two of the studies. Outcomes listed in the available protocol were consistant with
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404 the published paper(Oksuz and Unal, 2017).
405
406 Discussion
407 Our review identified low-certainty evidence that Pilates improved health-related quality
408 of life and physical functioning, and reduced pain in postmenopausal women with osteoporosis.
409 Very-low certainty evidence suggested that Pilates improved BMD. There was no available
410 evidence for several outcomes including mortality, hip fractures and fragility fractures, and serious
411 and non-serious adverse events. Results were consistent between included studies, however the
412 limited number of studies, very small sample size, and heterogeneity in duration of follow-up,
413 comparators, and measurement tools used for each outcome prevented meaningful pooling of
414 results. There were limited data on the safety of Pilates for individuals at risk of osteoporotic
18
415 fracture. Therefore, it is difficult to make inferences about the benefits relative to harms when
416 considering Pilates practice in individuals at risk of fracture. When creating guidelines or
417 developing therapeutic programs for individuals with osteoporosis, researchers, clinicians, and
418 fitness professionals should balance the available evidence related to benefits and harms of Pilates,
419 the values and preferences of the patient, the qualifications of the Pilates instructor, and whether
420 stronger evidence may exist for other types of exercise (Kistler-Fischbacher et al., 2021). (Table
421 3).
422 Evidence on the effects of Pilates on health outcomes in individuals with low bone mass
423 may be augmented by indirect evidence from other populations. Systematic reviews and meta-
424 analyses of Pilates interventions in adults 60 years of age and older that were not selected for low
425 bone mass have previously reported improvements in physical functioning using performance-
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426 based measures including variations of the sit-to-stand test, the Timed-Up-and-Go test and the
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427 Berg Balance Scale(Barker, Bird and Talevski, 2015; Bueno De Souza et al., 2018; Moreno-
428 Segura et al., 2018). Pilates also improved measures of static and dynamic balance, flexibility,
429 and functional cardiovascular endurance (e.g. 6MWT) in adults 60 years of age and older(Barker,
430 Bird and Talevski, 2015; de Oliveira Francisco, de Almeida Fagundes and Gorges, 2015; Bueno
431 De Souza et al., 2018). Existing systematic reviews of Pilates in older adults without low bone
432 mass also range in quality of reporting and included evidence, and include very few primary studies
433 with small sample sizes(Barker, Bird and Talevski, 2015; de Oliveira Francisco, de Almeida
434 Fagundes and Gorges, 2015; Bueno De Souza et al., 2018; Moreno-Segura et al., 2018). Higher
435 quality research into the effects of Pilates on physical functioning is needed, particularly among
436 individuals with osteoporosis.
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437 While the determined benefits of Pilates may be promising, the risks associated with
438 participation in Pilates remain unknown. In studies of Pilates in people at risk of fracture, fragility
439 fractures have not been measured. Adverse events were not systematically monitored or reported
440 in any study(Küçükçakir, Altan and Korkmaz, 2013; Angin, Erden and Can, 2015; Oksuz and
441 Unal, 2017). Falls were reported in one study(Küçükçakir, Altan and Korkmaz, 2013), however
442 falls were not defined as an outcome a priori, validated methods of falls ascertainment were not
443 used, and sample sizes were small. Some understanding of the risks associated with Pilates may
444 be drawn from populations not selected for low bone mass, however similar limitations persist. In
445 a previous systematic review of Pilates interventions in healthy community-dwelling adults 60
446 years of age and older(Moreno-Segura et al., 2018), two included RCTs reported that a 12-week
447 Pilates program reduced the rate of falls compared with no intervention (Rate Ratio [RaR] 0.28,
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448 95% CI 0.15 to 0.55; 1 RCT, n=60)(Irez et al., 2011) or twenty minutes of daily home exercise
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449 (RaR 1.17, 95% CI 0.43 to 3.19; 1 RCT, n=44)(Barker et al., 2016). One adverse event (hip pain)
450 was reported in the Pilates group (n=44)(Barker et al., 2016). Future research should examine the
451 effects of Pilates on falls, fractures and adverse events.
452 BMD was used as a surrogate measure of bone strength as data were unavailable for the
453 effect of Pilates on hip fractures or fragility fractures. Studies examining the effect of Pilates on
454 BMD have limitations related to sample size, short study duration (6 months) and risk of bias that
455 limited our ability to make inferences about efficacy. While moderate-high intensity resistance
456 and impact exercise may maintain or improve BMD in people with low bone mass(Watson et al.,
457 2018) improvements have not been consistently demonstrated across exercise types and were not
458 observed in a Pilates-inspired intervention which emphasized low-intensity resistance and impact
459 exercise(Kistler-Fischbacher et al., 2021). Further confirmational studies to determine if the
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460 resistance training component of Pilates is sufficient to stimulate maintenance of BMD at fracture-
461 prone sites would be valuable (Howe et al., 2011).
462 There remains an overall need to improve reporting of clinical trials of non-
463 pharmacological interventions(Boutron et al., 2017), particularly the factors that influence efficacy
464 of the intervention. Adherence to the Pilates intervention was not adequately reported in any of the
465 studies, making it challenging to assess the acceptability or feasibility of the program to
466 participants. All studies in this review described clinical Pilates interventions that were conducted
467 under the supervision of a physiotherapist. It is unclear how these results would generalize to a
468 community-based setting where classes may not have a therapeutic focus or be taught by a health
469 care professional. Future studies of Pilates should state the qualifications or Pilates training
470 credentials of the instructor, and individuals with osteoporosis who wish to participate in Pilates
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471 should consider formal instruction by qualified instructors with expertise in osteoporosis. When
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472 considering spaces in which individuals may practice Pilates, the group component of the Pilates
473 classes in the randomized studies offered more social interaction than the control group, which
474 may have influenced health outcomes. Pilates is not a trademarked term and therefore Pilates
475 exercise programs are not standardized. Variability in the duration, intensity or types of exercises
476 included in Pilates interventions can contribute to heterogeneity, therefore specifics relating to
477 dosage, supervision, and delivery method should be clearly reported in future trials.
478
479 Limitations
480 There are limitations in both the quantity and quality of studies examining Pilates in men
481 and post-menopausal women at risk of fracture. Evidence was unavailable for several critical
482 outcomes. Few eligible studies, high risk of bias, and small sample sizes limited the certainty of
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483 evidence presented. The inclusion of case studies and non-randomized studies limits the quality
484 of available evidence. Results of our systematic review may not be generalizable to all people
485 with osteoporosis as the studies included in our review excluded people with a history of fracture,
486 co-morbid health conditions, or risk of secondary osteoporosis. Other than one included case study
487 (Cabot and Shrier, 2017), there are no studies of Pilates in males with low bone mass.
488 The lack of a formal definition for Pilates is a limitation of this study. Pilates is not a
489 trademarked exercise, and there is no single accreditation which standardizes Pilates exercises.
490 Therefore, to reflect the current state of evidence as well as the broad range of Pilates exercise
491 programs that may be available to the public, we included all studies that referred to themselves
492 as Pilates and screened other exercise studies for interventions that may have been more similar to
493 Pilates. As such, we may have represented studies that deviate from original Pilates methodology
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494 and may be better described as Pilates-inspired or Pilates-hybrid interventions.

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495
496 Conclusion
497 Physiotherapist-supervised Pilates interventions may improve quality of life and physical
498 functioning and may reduce reported pain in postmenopausal women with low bone mass.
499 Evidence to support the benefits of Pilates in individuals with low bone mass is limited and of very
500 low quality, particularly for men. There is no information on the effects of Pilates on fracture risk,
501 falls or potential harms. We cannot make recommendations about participation in Pilates in
502 settings outside of supervised classes in physical therapy clinics, or among individuals at high risk
503 of fracture. Adequately powered studies examining the effects of Pilates on outcomes important
504 to patients with low bone mass are needed.
505
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506 Conflict of Interest Statement
507 Funding: This research was supported by Osteoporosis Canada. Dr. Lora Giangregorio holds a
508 Schlegel-UW Research Institute for Aging Research Chair in Mobility and Aging. Dr. John D.
509 Wark has received grants-in-aid from Amgen & Actavis Australia/Allergan for a project separate
510 from work on this systematic review. The remaining authors have no competing interests to
511 disclose.
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Figure 1: PRISMA Flow Chart of the Study Selection Process
Records identified through database search Duplicates removed

(n = 7286) (n = 3043)
Records screened Records excluded

(n = 4243) (n = 3739)
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Full-text articles excluded, with
Full-text articles assessed for eligibility reasons
(n = 504) (n = 499)
n=160 Wrong patient population
n=148 Wrong intervention
n=106 Wrong study design
n=35 Wrong outcome
n=22 Wrong comparator
Full studies included n=11 Unable to retrieve full text
(n=5) n=9 Language other than English,
Portuguese, Spanish or Italian
n=8 Duplicate
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Table 1: Characteristics of Included Studies
Study Participants Main Inclusion/Exclusion Criteria Outcomes Details of Intervention and Control
Angin, 2015 N=41 Inclusion:  Physical functioning: 6MWT I: Clinical Pilates: 5 Pilates elements using mat
(RCT) Mean age Menopausal women aged >40 years with (metres) work, resistance bands and balls. One 1:1 session,
Turkey (years): osteoporosis, on Fosamax  Pain: VAS (rest and with plus group exercise supervised by physiotherapist.
I: 58.23 Exclusion: movement) 1 hour session, 3 times /week for 24 weeks.
C: 55.95 History of fracture, endoprosthesis or joint  BMD g/cm2 (lumbar spine) C: No intervention
fixation; chronic health condition; visual, hearing  QoL: QUALEFO-41 (subscales
or communication problems; exercising regularly only)
for 6 months
Küçükçakir, N=60 Inclusion:  Physical functioning: 6MWT I: Clinical Pilates: postural education on neutral
2013 Mean age Post-menopausal women aged 45-60 years with (metres), 1-minute sit to stand position, sitting, antalgic and stretching exercises,
(RCT) (years): osteoporosis  QoL: QUALEFFO-41 (total score proprioceptive and respiratory training. Exercise
Turkey I: 56.6, Exclusion: and subscales), SF-36 (subscales) bands and balls (26-inch diameter) were used.
C: 56.3 History of fracture, secondary osteoporosis or  Pain: VAS 1 hour session, 2 times/week for 1 year.
medications that may lead to it; systemic disease C: Thoracic extensions (3 sets of 20 repetitions) in
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limiting ability to exercise; not willing to exercise seated position at home, monthly phone call
Oksuz, 2017 N=40 Inclusion:  Physical functioning: TUG, BBT, I: Clinical Pilates: Participants attended special
(RCT) Mean age Women aged 50-75 years with osteoporosis, session to learn 5 main areas of Pilates, then
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30-second CST
Turkey (years): Physical activity > 3 times/week  QoL: QUALEFFO-41 (total score qualified for group exercise supervised by
I: 63.6 Exclusion: and subscales), HADS, HAQ, SLS1 physiotherapist. Progression from closed to open-
C: 61 History of fracture, joint replacement or fixation;  Tampa Kinesiophobia Scale chain kinetic exercises, increased endurance and
secondary disease causing decreased functional  Pain: VAS (rest, performance, movement capacity in final 3 weeks.
status; mental, visual, hearing or communication movement), SF-McGill, PDI, ODI 1 hour session, 3 times/week for 6 weeks.
problems. C: Continue normal daily routine.
Cabot, 2017 N=1; Age= N/A  BMD g/cm2 (location unknown) I: Exercises using the Pilates Reformer and Wunda
(Case Report) 52 years,  T-score chair with 1:1 supervision. Exercises included
USA male footwork, jumping on jump board, supine arm
circles, hundred preps with neutral pelvis, kneeling
abdominals, kneeling arm series, legs in straps
series, and standing leg (VMO) press.
3 times/week for 48 weeks
Kopitzke, N=1; N/A  Physical functioning: SLS2 I: Pilates with 1:1 supervision under the care of a
2007 Age=67  T-score (lumbar spine and femoral physiotherapist. Exercises involved single heel
(Case Report) years; neck) raises. 3 times/week for 1 year
USA female.
Abbreviations: I: Intervention; C: Control; 6MWT, Six-minute Walk Test; VAS, Visual Analogue Scale; QoL, Quality of Life; QUALEFFO-41, Quality of Life questionnaire in patients with vertebral fractures; BMD, bone
mineral density; TUG, Timed Up-and-Go; BBT, Berg Balance Test; 30-s CST, 30-second Chair Stand Test; BST, Back Scratch Test; HADS, Hospital Anxiety and Disability Scale; HAQ, Health Assessment Questionnaire;
SLS1, Satisfaction with Life Survey; SF-McGill, Short-Form McGill Pain Questionnaire; PDI, Pain Disability Index; ODI, Oswestry Low Back Pain Disability Scale; SLS2, Single-leg stance;
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Figure 2: Risk of Bias summary: review author’s judgements about each risk of bias item for each included study
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Table 2: Summary of Findings Table using GRADE Methodology
Outcome Anticipated Absolute Effects* (95% CI) Relative Number of Certainty

Risk with no Intervention Risk with Pilates Effect participants of
(95% CI) (studies) Evidence
Health Related Quality of Life The mean Health Related MD 13.8 units lower (26.16 - 100 (2 RCTs) Lowa,b,c,d
Assessed with: QUALEFFO-41; Scale from 0- Quality of Life score was 33.6 lower to 1.44 lower)
100 units
Follow-up range: 6 weeks to 12 months
Physical Functioning The mean Physical MD 1.44 seconds lower - 40 (1 RCT) Lowa,b,d
Assessed with: Timed Up-and-Go (TUG) Functioning score ranged (2.04 lower to 0.84 lower)
Follow up: 6 weeks from 7 to 12 seconds
Physical Functioning The mean Physical MD 1.23 seconds lower - 144 (4 RCTs) Lowd,e,h
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(Systematic Review) Functioning score (2.3 lower to 0.15 lower)
Assessed with: Timed Up-and-Go (TUG) (Systematic Review) ranged
Follow up: 4 weeks to 12 weeks from 7-12 seconds
Falls
Assessed with: Self-reported number of people
who fall
Follow up: 12 months
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2 people who fell in the Pilates group (n=30) versus 3
people who fell in the control group (n=30)
- 60 (1 RCT) Very Lowa,d
Lumbar spine BMD (surrogate for fragility The mean Lumbar Spine MD 0.06 g/cm2 higher (0.01 - 41 (1 RCT) Very
fracture) BMD (surrogate for fragility higher to 0.11 higher) Lowa,b,d,f,g
Follow up: 6 months fracture) was 0.653 g/cm2
Abbreviations: CI: Confidence interval; MD: Mean difference. Note: Hip Fractures (or Hip/Femoral Neck BMD), Adverse Events, and Mortality were not reported.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
GRADE Working Group grades of evidence:

High certainty: We are very confident that the true effect lies close to that of the estimate of effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence is the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
Explanations:
a. “Intention-to-treat” analysis was not used which could result in overestimation or underestimation of effect.
b. Allocation of groups is not adequately concealed
c. There is substantial heterogeneity which likely can be explained by differences in length of intervention
d. Small sample size
e. Heterogeneity is substantial to considerable: I2=76%
f. Outcome assessors not adequately blinded to experimental groups
g. BMD is a surrogate measure of fragility fracture
h. Indirect evidence from population not selected for low bone mass
33
Table 3: Research-to-practice Summary and Tips for Pilates Instruction and Practice
Evidence summary: Pilates in Individuals at Risk of Fracture:

 Pilates may improve physical functioning, quality of life, and reduce pain.
 There are very few studies of Pilates conducted in people with osteoporosis, and there is very little
information about its effect on bone mineral density, falls, fractures or adverse events.
Recommendations for Pilates Instruction and Practice:

 Emphasize control of movement over intensity.
 Coach safe transitions between movements.
 Pilates movements that include rapid, repetitive, weighted, sustained or end-range flexion or twisting of
the spine may be risky and should be modified or avoided in individuals with osteoporosis (e.g.,
abdominal prep, roll-up/down and roll-over, jack-knife, criss cross, spinal twist).
Dr
 Example movements in a Pilates class modified for osteoporosis may include Pilates breath, head nod,
imprint and release, shoulder/scapula isolation, shoulder bridge, breast stroke prep, side leg series,
aft
plank, or shell stretch modified with hip hinge.
 Individuals may choose to wear socks with rubber grips (e.g., yoga socks) for better traction.
 Fitness professionals are encouraged to seek additional training on exercise for individuals with
osteoporosis and apply the principles to Pilates instruction.
 When possible, clients should look for Pilates instructors who know how to modify practice for
individuals with osteoporosis, and they should inform the instructor that they have osteoporosis.
Note: Tips for Pilates practice were developed in consultation with a patient advocate from the Canadian Osteoporosis
patient network who has experience with Merrithew Stott PilatesⓇ, and align with previous expert recommendations
(Giangregorio et al., 2015)
34

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Applied Physiology, Nutrition, and Metabolism

The Effects of Pilates on Health-related Outcomes in

Journal: Applied Physiology, Nutrition, and Metabolism

Manuscript Type: Systematic Review

Date Submitted by the

Complete List of Authors: McLaughlin, Emily; University of Waterloo, Department of Kinesiology

Butt, Debra; University of Toronto, Department of Family and

Melbourne Hospital, Bone and Mineral Medicine

Is the invited manuscript for

© The Author(s) or their Institution(s)

1 The Effects of Pilates on Health-related Outcomes in Individuals with Increased Risk of

2 Fracture: A Systematic Review

5 Chilibeck5, John D. Wark6, Lehana Thabane7, Jackie Stapleton8, Lora M. Giangregorio1,9*

7 1Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada, N2L 3G1

8 2Canadian Osteoporosis Patient Network, Osteoporosis Canada

13 5College of Kinesiology, University of Saskatchewan, Saskatoon, SK, Canada, S7N 5A2

14 6University of Melbourne Department of Medicine, Bone and Mineral Medicine, Royal

15 Melbourne Hospital, Parkville, Victoria, Australia, 3050

16 7Department of Health Research Methods, Evidence and Impact, McMaster University,

17 Hamilton ON, Canada

21 Email addresses: ECM (ecmclaughlin@uwaterloo.ca), JB (bartleyj65@gmail.com), MA

28 This systematic review examined the effect of Pilates on health-related outcomes in

40 risk, particularly males, is limited. PROSPERO registration: CRD42019122685.

46 Keywords: Pilates, Exercise, Osteoporosis, Fracture Prevention

51 Osteoporosis is a common skeletal disorder characterized by compromised bone strength,

52 predisposing a person to an increased risk of fracture(NIH Consensus Development Panel on

58 Canadian healthcare system(Hopkins et al., 2016).

59 Exercise is an integral component in the prevention and management of osteoporosis. In

65 modification or careful progression for individuals at a high risk of fracture(Giangregorio et al.,

78 training against spring-loaded apparatuses or elastic resistance bands in addition to floor-based

86 Management of Osteoporosis and Fracture Prevention in Canada. Each review focused on a

88 patients(Morin et al., 2020), therefore a separate review was performed.

94 designed by a working group of researchers, physiotherapists, physicians, a patient advocate, and

96 Systematic Reviews (PROSPERO) at https://www.crd.york.ac.uk/prospero/ (Registration

97 number: CRD42019122685; submitted March 6, 2019).

99 Data Sources and Searches

117 excluded. References were stored and managed using EndNote

118 (https://www.myendnoteweb.com/, Clarivate Analytics, Philadelphia, PA, USA). Titles and

120 screening and data extraction.

122 Study selection

126 agreement was not reached.

128 Data items

136 glucocorticoid-induced osteoporosis, or pathological fractures were excluded. Studies of older

139 criteria, authors were contacted.

144 or centre-based, individual or group-based, and either supervised or unsupervised. Studies

145 combining Pilates with pharmacological or other co-interventions (excluding whole-body

149 how to categorize a Pilates intervention.

153 placebo, a non-exercise or non-physical therapy intervention (e.g., educational intervention), or an

154 attention control not expected to affect outcomes of interest.

170 threatening injury, inpatient hospitalisation, prolongation of existing hospitalisation, or persistent

178 Health Profile) were included.

181 We included studies with interventions lasting a minimum of four weeks.

183 Data Extraction and Quality Assessment:

192 groups of interest.

202 (GRADE) framework(Zhang et al., 2019).

204 Data Synthesis and Analysis:

206 Community, London, UK; https://community.cochrane.org/help/tools-and-software/revman-5).

215 Description of studies

224 Supplement S2.

226 Participant characteristics

246 Setting and supervision:

258 Frequency, intensity and duration of the exercise intervention:

270 of intervention are provided in Table 1 and Supplement S3.