YPMED-04257; No of Pages 11 Preventive Medicine xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed

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Review

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V. Bullo a, M. Bergamin a, S. Gobbo a, J.C. Sieverdes b, M. Zaccaria a, D. Neunhaeuserer a, A. Ermolao a b

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a

Sport and Exercise Medicine Division, Department of Medicine, University of Padova (IT), Italy Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of SC (United States of America), United States

a r t i c l e

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Available online xxxx

a b s t r a c t

This systematic review aims to summarize the effects of Pilates exercise training (PET) in elderly population on physical fitness, balance and fall prevention, and its effects on mood states, quality of life and independence in the daily living activities. Methods. Keyword “Pilates” associated with “elderly”, “aging” and “old subjects” were identified as terms for the literature research in MEDLINE, Embase, PubMed, Scopus, PsycINFO and SPORTDiscus. Only studies published in peer-reviewed journals written in English language were considered. A meta-analysis was performed and effect sizes (ES) calculated. Results. 10 studies were identified (6 RCTs and 4 uncontrolled trials); age ranged from 60 to 80 years. Overall, PET showed large ES to improve muscle strength (ES = 1.23), walking and gait performances (ES = 1.39), activities of daily living, mood states and quality of life (ES = 0.94), moderate to high effect on dynamic balance (ES = 0.77), small effects on static balance (ES = 0.34) and flexibility (ES = 0.31), while a small effect on cardiometabolic outcomes (ES = 0.07). Conclusions. PET should be taken into account as a way to improve quality of life in the elderly, due to the imparted benefits of fall prevention, physical fitness, and mood states. In this context, physicians might include PET as a tool for exercise prescriptions for the elderly. © 2015 Elsevier Inc. All rights reserved.

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Keywords: Elderly Pilates Physical fitness Fall prevention Review

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The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise prescription

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Introduction . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . Study design . . . . . . . . . . . . . . . . . . . Literature search . . . . . . . . . . . . . . . . . . Inclusion and exclusion criteria . . . . . . . . . . . Study quality assessment . . . . . . . . . . . . . . Data extraction and synthesis . . . . . . . . . . . . Data analysis . . . . . . . . . . . . . . . . . . . Studies description and results . . . . . . . . . . . . . . Muscle strength outcomes . . . . . . . . . . . . . Static and dynamic balance . . . . . . . . . . . . . Flexibility . . . . . . . . . . . . . . . . . . . . . Walking and gait measures . . . . . . . . . . . . . Activities of daily living, mood states and quality of life Cardio-metabolic effects . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . Pilates and muscle strength . . . . . . . . . . . . . Pilates and balance . . . . . . . . . . . . . . . . . Pilates and mobility/walking . . . . . . . . . . . . Activities of daily living, mood states and quality of life Pilates and cardio-metabolic effects . . . . . . . . . Limitations . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . .

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Contents

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http://dx.doi.org/10.1016/j.ypmed.2015.03.002 0091-7435/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

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V. Bullo et al. / Preventive Medicine xxx (2015) xxx–xxx

Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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effects on mood states, quality of life and independence in the activities of daily 122 living in the elderly. 123

Study design

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This is a systematic qualitative review of the literature, with the aim to analyze the effects of PET programs on physical fitness, fall prevention as well as its

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Analyses were conducted from November to December 2013. The keyword “Pilates” associated with “elderly”, “aging” and “old subjects” was used for the literature research in MEDLINE, Embase, PubMed, Scopus, PsycINFO and SPORTDiscus. Inclusion and exclusion criteria

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Only studies published in indexed and peer reviewed journals, written in English language, were considered for this review. The studies needed to provide a Pilates-identified exercise training intervention including subjects 60 years old or older. Both males and females from all races and different states of health (i.e. healthy, with stable chronic disease and Parkinson's disease) were included. Furthermore, only original articles were accepted for the analysis. All studies not evaluating outcomes through pre- and post-intervention comparisons, as well as cross-sectional studies and case reports were excluded. Published abstracts, dissertation materials, or conference presentations were not considered for this review.

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Study quality assessment

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Methods

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Literature search

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Over the last several decades, human life expectancy has progressively increased. In 2012, HelpAge International identified 810 million people that were 60 years or older (one out of nine) with estimates that by 2050, it will increase to one out of five (UNFPA, 2012). Agerelated physical decline and corresponding loss of functional capacity are often related to the loss of muscle mass (sarcopenia), decrease of aerobic capacity, reduced mobility, and other determinants of fitness (Nelson et al., 2007). Thus, there is need to develop and promote interventions that improve physical capacities and consequently quality of life in the elderly population. Indeed, physical activity has a positive key-role in preventing age-related physical decline (Keysor, 2003) and it is used in primary and secondary prevention strategies to reduce the risk of chronic diseases (WHO, 2010). Moreover, cardiovascular and all-cause mortality significantly decreases among people that are physically active and who have higher levels of aerobic capacity (Paffenbarger et al., 1986; Sui et al., 2007). Increasing evidence also demonstrates a positive impact of exercise and physical activity on degenerative musculoskeletal conditions such as osteoporosis, arthritis and sarcopenia (Gaught and Carneiro, 2013; Gomez-Cabello et al., 2012; Montero-Fernandez and Serra-Rexach, 2013). Pilates exercise training (PET) is not conventionally classifiable as traditional exercise (e.g. aerobic exercise or resistance training) (Morrow et al., 1999), but it is rather a form of structured physical activity, which has been shown to improve muscle endurance, flexibility, and dynamic balance in young and middle aged population (Cruz-Ferreira et al., 2011), though, its benefits in older populations are less clear. PET was created in New York, USA and matured from the 1920s to 1960s as an adjunct for the training and rehabilitation for dancers in the performing arts. Despite its long history, PET is a relatively new approach for structured physical activity usually given in the form of classes. The practice of Pilates utilizes multiple practical movement patterns from gymnastics, martial arts, yoga and dance (Latey, 2001). PET is different when compared to traditional exercises, which, in turn, tend to isolate the working muscles and have specific training approaches using repetitive motions. Indeed, this training method has a holistic approach where a correct execution of the six fundamental principles (concentration, control, centering, flowing movement, precision and breathing) increases body awareness with less ground impact and joint-stress. It can also be performed at various intensity levels whereby the participant or patient may adjust the difficulty to their own level of conditioning. There have been several recent reviews that focused on the benefits of PET in various populations and centered around specific functional and strength measures, such as core strength (Granacher et al., 2013), though no review has focused on the effects PET has on fitness measures, fall risk, and quality of life in the elderly. Therefore, this review aims to investigate and summarize the benefits of PET, in terms of physical fitness and other outcomes related to the elderly's quality of life. Physicians play a key-role in the beginning and maintenance of exercise behavior among the older population (Schutzer and Graves, 2004), hence, the results of this review would be useful for general practitioners and sports medicine physicians to incorporate PET in the exercise prescription for the elderly.

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The quality of the studies was assessed applying an adapted nine criteria checklist provided by the Cochrane Collaboration Back review Group (van Tulder et al., 1997). As in previous reviews, the checklist had to be marginally adapted to rate the strength of the evidence (Bergamin et al., 2012; Claessen et al., 2012; Gobbo et al., 2014; Proper et al., 2003). Each study in the review was scored based on the following nine criteria: (1) ‘Was the method of randomization adequate?’; (2) ‘Were the groups similar at baseline regarding the outcome measures?’; (3) ‘Were inclusion and exclusion criteria adequately specified?’; (4) ‘Was the drop-out rate described adequately?’; (5) ‘Were all randomized participants analyzed in the group to which they were allocated?’; (6) ‘Was the compliance reported for all groups?’; (7) ‘Was Intention-to-treat analysis performed?’; (8) ‘Was the timing of the outcome assessment similar in all groups?’; (9) ‘Was a follow-up performed?’. When the study provided a satisfactory description, a positive value was assigned (+). If the criterion description was considered absent, unclear, or lacked the specified content, a negative value was assigned (−). A study was qualitatively judged as high quality if it showed a positive score on 5 to 9 of the criteria; otherwise, it was considered a low quality study (van Tulder et al., 1997).

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Data extraction and synthesis

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All abstracts of the sourced studies from the literature search were examined independently by two researchers. Suitable studies were analyzed in more detail for meeting eligibility criteria. Additional articles were sourced by reviewing the reference sections of the included studies. A final quality check of each study was performed by each researcher. Afterwards, the individual searches were combined, compared, and reviewed for applicability where a consensus was made regarding study inclusion. In case of discrepancies, the review process was repeated and a third researcher was consulted. Quality assessment using the modified Cochrane methodological quality criteria was then independently applied and discussed before final quality scores were assigned (Table 1). Several domains were identified for categorization of the study results. In particular, studies were analyzed in regard to muscle strength outcomes, static and dynamic balance, flexibility, walking and gait measures, independence in the activities of daily living and quality of life, as well as cardio-metabolic evaluation.

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Data analysis

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Meta-analyses were performed using random-effect models, Hedge's g ef- 176 fect sizes (ES) were calculated through Comprehensive Meta-Analysis software 177 (Biostat Inc., Englewood, NJ); the moderator analysis was included in the 178

Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

V. Bullo et al. / Preventive Medicine xxx (2015) xxx–xxx t1:1 t1:2

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Table 1 Quality assessment of the studies shows the results of the quality appraisal of the included PET-studies.

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Citation

Randomization Similarity of Inclusion or Dropouts Blinding Compliance Intention-to-treat Timing of Follow-up Results procedure study groups exclusion criteria analysis outcomes assessment

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Bird and Fell (2013) Mokhtari et al. (2013) Marinda et al. (2013) Johnson et al. (2013) Bird et al. (2012) Newell et al. (2012) Plachy et al. (2012) Irez et al. (2011) Siqueira Rodrigues et al. (2010) Kuo et al. (2009)

− + + − + − + + + −

Studies description and results

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The systematic search resulted in a total of sixty-seven articles. After applying specific inclusion and exclusion criteria, ten articles were

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5/9 2/9 2/9 1/9 7/9 2/9 1/9 6/9 2/9 6/9

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− − − − − − − + − +

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considered eligible for this review. Reasons for studies' exclusions are displayed in Fig. 1. Sample sizes of the studies were rather different ranging from 9 to 60 participants. Exercise programs were varied and included different modalities, frequencies, and durations. The durations of the exercise interventions ranged from 5 to 52 weeks and included sessions that spanned 1–3 times per week. One limitation for most of the papers is the lack of reporting on the level of intensity. Additionally, only 4 studies reported adherence rates, which ranged from 50% to 97.5% (Bird and Fell, 2013; Bird et al., 2012; Irez et al., 2011; Kuo et al., 2009). Characteristics of the studies, including participants' description, type of intervention, frequency and duration are summarized in Table 2. Finally, Table 3 reports all results of the included studies.

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models, calculated by the duration of intervention. The ES is a measure of the effectiveness of a treatment, and it helps to determine whether a statistically significant difference is a difference of practical concern. Interpretation was performed according to guideline by Cohen (1988) where an ES value of 0.20 indicates small effect, ES of 0.50 indicates medium effect, and finally, ES higher than 0.80 indicates large effects. Forest plots for each specific domain were also reported (Derzon and Alford, 2013).

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Fig. 1. Flow chart of the literature search.

Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

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Table 2 Characteristics of the studies summarizes the characteristics of the studies, including participants' description, type of intervention, frequency and duration.

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Author

Subjects

Age

Grouping

Training modality, program and intensity

Frequency

Duration

Compliance rates

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Bird and Fell (2013)

30 (25 F, 5 M)

N60

Intervention group (5 w, 30) Continued Pilates (14) Ceased Pilates (16)

5 weeks: 1 h 2 d/w 2 months: 1 h 1 d/w 10 months: 1 h 2 d/w

5 weeks + 12 months

N50%

t3:5

Mokhtari et al. (2013)

30 F

1 h 3 d/w

12 weeks

Not reported.

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Marinda et al. (2013)

1 h 3 d/w

8 weeks

Not reported.

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Johnson et al. (2013)

Small group classes with a maximum of six people consisting of standing and floor mat exercise as well as a circuit style session using Pilates equipment (Reformers, Chairs). 5 weeks: warm up mat exercise + standing exercise to challenge balance. Home program of mat exercise. First 6 weeks: mat Pilates exercises. Second 6 weeks: exercises with bands. The subjects of the control group did their daily activities in the training period. Before the training period, a lesson to explain the basics of mat Pilates (explanation of the neutral position of the spine and the correct breathing technique). All sessions started with breathing, followed by a flowing system from standing, to sitting, to lying down exercises and ended with the rest position. Increasing intensity. Combination of plinth exercises, gym-ball exercises, stepping exercises and exercises on a Pilates reformer. The combination and duration of each exercise depend to participant functional capabilities, strength and degree of flexibility. The difficulty of the exercises was increased progressively, based upon performance and subjective feedback from the participant. The progression involved the addition of movements to increase task complexity, reducing the base of support and increasing the resistance during the reformer exercises Classes were held in small groups of no more than 6 people. Standing and mat exercise followed by a circuit style session of exercises with Pilates reformer, mat-based exercises. Focus included balance and lower-limb strength exercises. Training was progressed in terms of repetitions and load of exercises at the earliest opportunity. Home program of mat exercises to make in 1 other occasion per week. Core stability and spinal mobility were addressed by the use of abdominal bracing and pelvic tilt exercises. Lower limb exercises addressed quadriceps, hamstrings, gastrocnemius, soleus and tibialis anterior. Upper limb exercises included abduction and flexion using weights. A wobble board was used primarily to strengthen the ankle and improve mobility. A swiss ball was used to enhance core stability exercises. For all participants was chosen strength, stretching, range of motion and balance exercises.

1 h 2 d/w

6 weeks

Not reported.

1 h 2 d/w Home exercise: 1 d/w

5 weeks

80%

1 h 1 d/w

8 weeks

Not reported.

Pilates group: 1 h 3 d/w Pilates and aqua-fitness group: 1 h 1 d/w + 1 h 2 d/w 1 h 3 d/w

6 months

Not reported.

12 weeks

92%

1 h 2 d/w

8 weeks

Not reported.

75′ 2 d/w

10 weeks

97.5%

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62–80

Experimental group Control group

50 F

N60

IG — Mat Pilates group (25) CG — non-exercise control group (25)

10 (3 F, 7 M)

N60

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Pilates group (10)

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R

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Bird et al. (2012)

32

N60

Pilates group Non-active group

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Newell et al. (2012)

9 (8 F, 1 M)

60–76

Intervention group (9)

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Plachy et al. (2012)

42 F

N60

Pilates group (15) Pilates + aqua-fitness group (15) Control group (12)

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Irez et al. (2011)

60 F

N65

Experimental group (30) Control group (30)

Pilates-based exercise was divided into three parts:

Session divided into: 10′ global stretching + 40′ general conditioning + 10′ relaxation. The springs used were the same for all the volunteers, with adjustments in order to provide greater of lesser resistance, according to the physical capacity of each subjects. Each exercise was performed for a maximum of ten repetitions. The exercises included strengthening, stretching, range of motion and balance. Exercises were performed on mats and with traditional Pilates equipment and accessories. The difficulty/level of the exercises was modified in according to the participant's progress. Participants were instructed not to perform any exercises at home.

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Siqueira Rodrigues et al. (2010)

52 F

60–78

PG — Pilates group (27) CG — Control group (25)

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Kuo et al. (2009)

34 (24 F, 10 M)

60–75

Intervention group (34)

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- First part (4 weeks), Pilates mat exercises. - Second part (5–8 weeks), Thera-Band elastic resistance exercises. - Third part (9–12 weeks), Pilates ball exercises.

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V. Bullo et al. / Preventive Medicine xxx (2015) xxx–xxx

Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

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V. Bullo et al. / Preventive Medicine xxx (2015) xxx–xxx

t5:3

Table 3 Study results shows the results from a pre- to post comparison of the included PET-studies. Bird and Fell (2013)

Pooled force (kg) p b .05** T1: 71.2 ± 19.0 T2: 74.3 ± 20.3 T3: 67.2 ± 18.0

Mobility and dynamic balance TUG (s) p b .05*, ** T1: 6.0 ± 1.0 T2: 5.3 ± 1.2 T3: 5.4 ± 1.1

Ceased Pilates (16)

Pooled force (kg) T1: 61.8 ± 13.1 T2: 56.2 ± 12.5 T3: 51.6 ± 12.3

Mobility and dynamic balance TUG (s) p b .05* T1: 6.7 ± 1.4 T2: 6.0 ± 1.0 T3: 6.4 ± 1.2

Experimental group

Psychological factors GDS (short form) p b .05** 7.1 ± 1.9 to 5.7 ± 1.3 Psychological factors GDS (short form) 6.5 ± 1.0 to 7.3 ± 1.7 RHR (b/m) 68.8 ± 12.6 to 73.2 ± 11.5 Glucose (mmol/L) p b .05* 5.1 ± 0.5 to 5.8 ± 0.6 RHR (b/m) p b .05* 62.5 ± 9.0 to 74.9 ± 10.0 Glucose (mmol/L) p b .05* 5.2 ± 0.7 to 5.8 ± 0.6 Dynamic balance TUG (s) 10.1 ± 0.6 to 10.2 ± 0.6 Personal ability ADL SES (%) 79 ± 3.8 to 80.0 ± 2.1 Dynamic posturography Reaction time (s) 1.1 ± 0.1 to 1.0 ± 0.1 Velocity (cm/s) 1.5 ± 0.2 to 2.0 ± 0.3 Target overshoot (cm) p b .05* 0.5 ± 0.1 to 0.7 ± 0.1 Static balance ML sway EO (cm) 2.0 ± 1.2 to 1.8 ± 1.1 Static balance ML sway EC (cm) 2.2 ± 1.2 to 1.9 ± 1.2 Ankle strength (kg) 11.8 to 12.3 Static balance ML sway EO (cm) p b .05* 1.8 ± 0.6 to 1.6 ± 0.8 Static balance ML sway EC (cm) 2.2 ± 1.3 to 1.8 ± 0.9 Ankle strength (kg) 11.6 to 11.8 Time on foot (R) 49.3 ± 3.5 to 49.9 ± 0.9 Av. SL (m)(R) p b .05* 0.4 ± 0.1 to 0.5 ± 0.1 Av. WS (m/s) p b .05* 0.5 ± 0.1 to 0.7 ± 0.2 AI p b .05* 77.8 ± 5.7 to 84.3 ± 2.8 Strength Sit-to stand test for 30 s p b .05*, ** 16.6 ± 2.4 to 23.9 ± 2.5 Aerobic capacity

Dynamic balance TUG (s) p b .05* 13.1 ± 2.4 to 12.2 ± 2.6 Dynamic balance TUG (s) 13.3 ± 2.0 to 13.8 ± 1.9 Resting SBP (mm Hg) p b .05* 135.9 ± 14.7 to 128.8 ± 16.4 Resting DBP (mm Hg) 75.6 ± 10.1 to 77.4 ± 9.3 Resting SBP (mm Hg) 134.5 ± 13.7 to 136.0 ± 17.8 Resting DBP (mm Hg) 81.4 ± 9.3 to 79.8 ± 9.3 TUG cadence (steps/minute) p b .05* 84.9 ± 3.4 to 78.0 ± 3.8 Parkinson's disease UPDRS 19.1 ± 3.1 to 18.1 ± 3.4 Static posturography Static sway area (cm2) 2.9 ± 0.7 to 3.3 ± 0.9 Sway path length (cm) 108.6 ± 10.0 to 108.5 ± 9.3

t5:7

Control group

Marinda et al. (2013)

t5:8 t5:9

Mat Pilates group (25)

Non-exercising control group (25)

Johnson et al. (2013)

Pilates group (10)

t5:11

Bird et al. (2012)

Pilates group

N C O

R

R

E

C

T

t5:10

t5:12

Non-active group

U

P

t5:6

D

Mokhtari et al. (2013)

E

t5:5

R O

O

t5:4

Continued Pilates (14)

t5:13

Newell et al. (2012)

Intervention group (9)

t5:14

Plachy et al. (2012)

Pilates group (15)

Static balance ML sway EC on foam (cm) p b .05* T1: 8.0 ± 1.8 T2: 5.8 ± 1.9 T3: 4.5 ± 1.4 Dynamic balance FSST (s) p b .05*, ** T1: 7.8 ± 1.1 T2: 6.8 ± 1.3 T3: 6.4 ± 1.0 Static balance ML sway EC on foam (cm) p b .05* T1: 7.1 ± 2.4 T2: 5.1 ± 1.8 T3: 5.2 ± 1.9 Dynamic balance FSST (s) p b .05* T1: 8.5 ± 1.1 T2: 7.0 ± 1.0 T3: 7.3 ± 1.0 Static balance FRT (cm) p b .05* 18.2 ± 2.7 to 21.2 ± 4.4 Static balance FRT (cm) 18.1 ± 3.7 to 18.9 ± 3.2 TC (mmol/L) 5.4 ± 1.0 to 5.7 ± 1.0 TG (mmol/L) 1.8 ± 0.9 to 1.9 ± 0.9 TC (mmol/L) 5.3 ± 1.3 to 5.4 ± 1.3 TG (mmol/L) 1.6 ± 0.5 to 1.8 ± 0.7 Balance ABC (%) 71.0 ± 3.4 to 74.7 ± 3.9 Balance BBS p b .05* 47.1 ± 2.0 to 50.4 ± 1.5 Time of walking 5-m walk (s) p b .05* 6.3 ± 0.4 to 5.5 ± 0.3 5-m walk cadence (steps/minute) 97.4 ± 5.2 to 103.7 ± 5.3

F

t5:1 t5:2

5

Time on foot (L) 50.7 ± 3.5 to 50.1 ± 0.9 Av. SL (m)(L) p b .05* 0.4 ± 0.1 to 0.5 ± 0.1 Av. SC (m) p b .05* 0.6 ± 0.1 to 0.7 ± 0.0

Dynamic balance TUG (s) p b .05* 6.3 ± 1.2 to 5.9 ± 1.2 Dynamic balance FSST (s) p b .05* 7.9 ± 1.5 to 7.3 ± 1.0 Knee strength (kg) 21.0 to 21.6 Dynamic balance TUG (s) 6.0 ± 1.2 to 5.9 ± 1.2 Dynamic balance FSST (s) 7.6 ± 1.3 to 7.2 ± 1.4 Knee strength (kg) 21.9 to 21.0 Ant–Post 5.5 ± 4.1 to 3.2 ± 4.2 Med–Lat 0.8 ± 0.4 to 0.9 ± 0.5 FRI 3.7 ± 3.4 to 1.5 ± 0.8

Shoulder flexion (°) 138.0 ± 24.0 to 155.3 ± 6.9 Thoracolumbar flexion (cm) p b .05* 4.1 ± 2.2 to 5.8 ± 1.4

Lumbar flexion (cm) p b .05*, ** 3.7 ± 0.9 to 4.7 ± 0.5 Hip flexion (°) p b .05* 90.0 ± 15.0 to 104.5 ± 6.3

Static balance ML sway EO on foam (cm) p b .05* 4.6 ± 1.8 to 3.8 ± 1.7 Static balance ML sway EC on foam (cm) p b .05* 7.4 ± 2.2 to 5.8 ± 1.9

Static balance ML sway EO on foam (cm) 4.6 ± 1.7 to 4.1 ± 1.5 Static balance ML sway EC on foam (cm) 7.2 ± 2.6 to 6.1 ± 3.0

(continued on next page)

Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

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Table 3 (continued)

Control group

t5:18

Irez et al. (2011)

t5:19

Control group (30)

Siqueira Rodrigues et al. (2010)

Pilates groups (27)

Shoulder flexion (°) 148.8 ± 24.2 to 150.0 ± 25.7 Thoracolumbar flexion (cm) 6.3 ± 2.8 to 6.3 ± 2.7

Dynamic balance MED-SP300 (°) p b .05*, ** 11.0 ± 1.5 to 9.0 ± 1.5 Number of falls p b .05*, ** 1.9 ± 1.4 to 0.4 ± 0.5 Dynamic balance MED-SP300 (°) 11.4 ± 1.8 to 11.2 ± 2.1 Number of falls 1.6 ± 1.2 to 1.3 ± 0.4

Simple RT (ms) 0.4 ± 0.1 to 0.4 ± 0.1 Choice RT (ms) 0.7 ± 0.2 to 0.7 ± 0.1

Functional autonomy C10M p b .05*, ** 7.6 ± 1.7 to 6.9 ± 1.6 LPS p b .05** 10.5 ± 2.2 to 9.2 ± 2.3 LPDV p b .05*, ** 4.2 ± 0.9 to 3.1 ± 0.8 VTC p b .05** 14.3 ± 3.3 to 12.3 ± 2.6 LCLC p b .05** 35.0 ± 5.0 to 31.1 ± 6.0 IG p b .05*, ** 27.2 ± 3.9 to 23.6 ± 4.0

Quality of life DOM1 p b .05* 4.2 ± 2.9 to 14.7 ± 2.4 DOM2 13.7 ± 2.8 to 14.2 ± 3.2 DOM3 p b .05* 15.7 ± 1.6 to 15.9 ± 2.8 DOM4 p b .05** 15.9 ± 1.8 to 16.4 ± 2.2 DOM5 12.9 ± 4.1 to 13.0 ± 3.5 DOM6 p b .05** 15.2 ± 3.0 to 15.0 ± 3.8 QVG p b .05* 88.2 ± 6.2 to 89.4 ± 9.4 Quality of life DOM1 13.4 ± 4.3 to 13.2 ± 4.9 DOM2 13.9 ± 2.5 to 13.6 ± 2.8 DOM3 15.0 ± 2.5 to 15.0 ± 2.4 DOM4 14.5 ± 3.5 to 14.2 ± 3.9 DOM5 10.8 ± 4.8 to 10.9 ± 4.9 DOM6 17.2 ± 2.3 to 17.2 ± 2.5 QVG 84.8 ± 10.6 to 84.2 ± 11.0

t5:22

Static balance (Tinetti) 22.0 ± 2.9 to 22.4 ± 2.6

Pilates group

N

Kuo et al. (2009)

U

t5:23

C

O

R

R

E

Control group (25)

C

T

E

D

t5:20 t5:21

Experimental group (30)

Strength Sit-to stand test for 30 s 17.9 ± 5.4 to 19.3 ± 6.3 Aerobic capacity 6′ walk (m) 351.9 ± 56.6 to 399.2 ± 112.5 Muscle manual tester (kg) p b .05*, ** 23.3 ± 5.7 to 32.7 ± 7.0 Flexibility Sit and reach (cm) p b .05*, ** 12.8 ± 4.4 to 15.9 ± 5.1 Muscle manual tester (kg) 21.0 ± 8.9 to 20.7 ± 8.6 Flexibility Sit and reach (cm) 10.8 ± 3.8 to 10.4 ± 3.6 Static balance (Tinetti) p b .05* 23.9 ± 1.5 to 24.9 ± 1.1

Sagittal angles for the spine in standing (°) Upper cervical spine p b .05* Baseline: 0.2 Exercise: 1.7 Follow-up: −0.3 Lower cervical spine Baseline: −0.5 Exercise: 0.3 Follow-up: −1.2 Thoracic spine p b .05* Baseline:−0.2 Exercise:−2.3 Follow-up: 0.9 Lumbar spine p b .05* Baseline: −1.5 Exercise: −1.5 Follow-up: −0.8

Lateral flexion (cm) p b .05* 11.9 ± 3.7 to 14.9 ± 4.2 Lumbar flexion (cm) p b .05* 3.7 ± 1.2 to 5.4 ± 1.0 Hip flexion (°) p b .05* 95.3 ± 11.4 to 112.1 ± 7.6 Lateral flexion (cm) p b .05* 11.3 ± 2.5 to 14.3 ± 3.0 Lumbar flexion (cm) 7.7 ± 4.8 to 7.8 ± 5.0 Hip flexion (°) 102.5 ± 14.1 to 104.6 ± 14.1 Lateral flexion (cm) 14.4 ± 4.6 to 14.7 ± 4.9 Simple RT (ms) p b .05*, ** 0.3 ± 0.1 to 0.3 ± 0.1 Choice RT (ms) p b .05*, ** 0.7 ± 0.2 to 0.6 ± 0.1

F

t5:17

Shoulder flexion (°)p b .05* 127.0 ± 16.1 to 150.3 ± 16.2 Thoracolumbar flexion (cm) p b .05 * 3.0 ± 1.1 to 4.8 ± 1.8

O

Pilates + aqua-fitness group (15)

R O

t5:15 t5:16

6′ walk (m) p b .05*, ** 416.5 ± 80.6 to 528.8 ± 67.7 Strength Sit-to stand test for 30 s p b .05* 15.9 ± 4.5 to 20.7 ± 3.5 Aerobic capacity 6′ walk (m) p b .05* 418.7 ± 86.9 to 503.3 ± 115.4

P

Plachy et al. (2012)

Functional autonomy C10M 7.6 ± 1.1 to 7.6 ± 1.2 LPS 10.7 ± 2.0 to 10.6 ± 2.2 LPDV 4.4 ± 1.0 to 4.6 ± 1.1 VTC 13.0 ± 1.8 to 13.2 ± 1.9 LCLC 36.7 ± 4.7 to 36.7 ± 4.9 IG 27.0 ± 3.4 to 27.2 ± 3.6

Sagittal angles for the spine in sitting (°) Upper cervical spine Baseline: 0.3 Exercise: −0.1 Follow-up: 1.2 Lower cervical spine Baseline: −1.4 Exercise: 0.2 Follow-up: −0.5 Thoracic spine Baseline: −1.2 Exercise: −0.4 Follow-up:0 Lumbar spine p b .05* Baseline: −2.8 Exercise: −2.7 Follow-up: −1.5

Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

V. Bullo et al. / Preventive Medicine xxx (2015) xxx–xxx

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the dynamic balance (ES = 0.77) (Figs. 3 and 4). Overall, it appears 252 that longer period of intervention acts in favor to higher improvement 253 in both static and dynamic balance outcomes. 254

212

Four studies were classified as high quality (Bird and Fell, 2013; Bird et al., 2012; Irez et al., 2011; Kuo et al., 2009), while six as low quality studies (Johnson et al., 2013; Marinda et al., 2013; Mokhtari et al., 2013; Newell et al., 2012; Plachy et al., 2012; Siqueira Rodrigues et al., 2010). Moreover, three studies were blinded to the researcher (Bird et al., 2012; Irez et al., 2011; Kuo et al., 2009) and only two performed an “intention-to-treat” analysis (Bird and Fell, 2013; Bird et al., 2012). Two studies reported the timing of outcomes assessment (Irez et al., 2011; Kuo et al., 2009) and three studies performed a follow-up evaluation, specifically after a 20 week (Kuo et al., 2009), after a 6 month (Bird et al., 2012), and after a 12 month (Bird and Fell, 2013) intervention-free period.

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Muscle strength outcomes

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223 224

Strength was measured in laboratory (e.g. knee extension) and field settings (e.g. 30 second sit-to-stand test). Plachy et al. (2012) as well as Irez et al. (2011) demonstrated a significant improvement in muscle strength, i.e. + 43.8% on 30 second sit-to-stand test and + 40.2% on lower limb strength. Differently from these two previous studies, Bird et al. (2012) did not find any changes on knee extension strength, after 5-weeks of PET. After a 12-month follow-up, Bird and Fell (2013) described an overall strength decline, however, the group which continued PET showed a higher pooled force compared to a group that ceased PET. ES calculation indicated a large effect of PET for strength outcomes (ES = 1.23) (Fig. 2).

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Static and dynamic balance

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250 251

Six studies examined static and dynamic balance. Static balance was measured with a force platform (Medio-Lateral Sway range, ML-Sway), Functional Reach Test (FRT) and Tinetti Static Balance Scale. On the whole, PET led to an improvement in static balance (decreases in MLSway represents improvements): − 16.9% on ML-Sway with open eyes and −22.1% with closed eyes on a compliant surface (Bird et al., 2012). A longer protocol (12 months) showed higher improvements in ML-Sway (closed eyes) by − 43.7% (Bird and Fell, 2013). Furthermore, FRT showed an improvement of 16.7% after 12 weeks of training (Mokhtari et al., 2013) and Tinetti scale increased by 4.3% after 8 weeks (Siqueira Rodrigues et al., 2010). Dynamic balance was measured with a Timed Up and Go Test (TUG), Four Square Step Test (FSST) and the Dynamic Balance platform MEDSP300. TUG improved by 11.7% and 10.5% (after 5 weeks in the two different groups) (Bird and Fell, 2013), by 7.3% (after 12 weeks) (Mokhtari et al., 2013) and by 6.6% (after 5 weeks) (Bird et al., 2012). Only Johnson et al. (2013) found no difference in pre-post TUG comparison, however, a significant increase in TUG cadence was found (8.1%). FSST showed improvement in both Bird et al. studies (Bird and Fell, 2013; Bird et al., 2012) by 17.7% and 7.25%, respectively after 5 weeks of PET, while a longer intervention showed an improvement of 18%. Irez et al. (2011) found a significant improvement in balance (18.1%) measured by MED-SP300. Finally, Johnson et al. (2013) used the Berg Balance Scale (BBS) to demonstrate a significant improvement in static and dynamic balance (7%). ES value indicated a small effect about efficacy of PET for static balance (ES = 0.33) while a moderate to large effect for

t0:1 t0:2 t0:3 t0:4 Q2 t0:5 t0:6 t0:7 t0:8 t0:9 t0:10 t0:11 t0:12

Notes to Table 3: Abbreviations: * within group comparison, ** between group comparison Bird and Fell (2013): T1: baseline, T2: 5-week follow-up, T3: 12-month follow up; ML sway EC: medio-lateral sway eyes closed; FSST: four square step test; TUG: timed up and go; Mokhtari et al. (2013): GDS: geriatric depression scale; and FRT: functional reach test. Marinda et al. (2013): RHR: resting heart rate; SBP: systolic blood pressure; DBP: diastolic blood pressure; TC: total cholesterol; and TG: triglycerides. Johnson et al. (2013): BBS: Berg balance scale; ABC: activities-specific balance confidence scale; ADL: Activity of daily life; SES: Schwab and England scale; and UPDRS: unified Parkinson's disease rating scale. Newell et al. (2012): WS: walking speed; SC: step cycle; SL: step length; R: right; L: left; Ant–Post and Med–Lat: frontal and sagittal plane excursions; FRI: fall risk index; AI: ambulatory index Irez et al. (2011): MED-SP300: Medical Sports Performance 300; RT: Reaction Time Siqueira Rodrigues et al. (2010): C10M: walked of 10 m; LPS: to rise from a seated position; VTC: putting on and to taking off a shirt; LCLC: to rise out of a chair and to move freely through the house; IG: index GDLAM (protocol evaluated the personal autonomy); DOM1: sensorial abilities; DOM2: autonomy; DOM3: past, present and future activities; DOM4: social participation; DOM5: death and dying; DOM6: privacy; and QVG: quality of life index. Kuo et al. (2009): Comparisons for Baseline: pretest 1 (week 1) vs pretest 2 (week 5); exercise: pretest 2 vs posttest 1 (week 15), and follow-up: posttest 1 vs posttest 2 (week 20). Pilates intervention given during weeks 6–15.

227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249

Three articles reported measures on mobility and flexibility. Irez et al. (2011) found an improvement in flexibility of 24.6% (sit and reach test) after 12 weeks of PET, while Plachy et al. (2012) evaluated mobility in different body regions and detected general significant improvements (shoulders flexion: 12.5%, thoracolumbar flexion: 42.5%, lumbar flexion: 28.9%, lateral flexion: 25.2% and hips flexion: 16.1%). Only one investigation measured sagittal spine posture. In this study, Kuo et al. (2009) determined changes in the angles of spine for sitting and standing positions. Immediately after PET, only thoracic spine angle in standing was statistically significantly changed. ES value indicated a small effect about efficacy of PET for flexibility outcome (ES = 0.31) (Fig. 5).

256 257

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O

F

255

258 Q8 259 260 261 262 263 264 265 266 267 268

Walking and gait parameters were evaluated in two investigations; Johnson et al. (2013) assessed time and steps in the 5-m walk test, only finding improvements with timed test duration (12.7%). Newell et al. (2012), however, showed an increase in walking speed (26.9%), step cycle (12.7%) and length (23.8%) after an 8-week PET-intervention on 9 elderly individuals. ES value indicated a large effect for PET about walking measures and gait ability (ES = 1.39) (Fig. 6).

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Activities of daily living, mood states and quality of life

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Four studies evaluated elderly subjects' functional capacity to perform daily living activities and their quality of life. Johnson et al. (2013) evaluated personal abilities in activities of daily life with the Schwab and England Scale (SES) and found no significant changes after PET. Siqueira Rodrigues et al. (2010) evaluated changes in the independence in the activities of daily living using the Latin American Development Group for Elderly (GDLAM) protocol and quality of life with the World Health Organization's quality of life questionnaire for elderly after a PET intervention. In regard to functional autonomy, there were significant improvements in 10-m walks (9.3%), time to stand up (11.8%), time to rise from the prone position (26.0%), time to put on and to take off a shirt (13.9%), and time to walk through a house (11.2%). Also, quality of life improved significantly in the questionnaire domains of “sensorial abilities”, “past, present and future activities”, “social participation”, and “intimacy”, resulting in an overall increase of the quality of life index by 1.3%. The impact of PET on independence, quality of life and mood state was examined by Mokhtaria et al. (2013) who analyzed its effects on depression with Geriatric Depression Scale (GDS) (Cruice et al., 2011). In this study, a significant improvement with a 19.8% decrease of depressive symptoms was found (2013). ES calculation resulted in a large effect of PET for measures concerning activities of daily living, mood states and quality of life (ES = 0.94) (Fig. 7).

278

P

Walking and gait measures

D

221 222

Flexibility

E

220

T

218 219

C

216 217

E

210 211

R

208 209

R

207

N C O

205 206

U

203 204

Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

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Fig. 2. Forest plot representing effect sizes of intervention and control groups in strength outcomes.

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Only one study evaluated the cardio-metabolic effects of PET in the elderly. Marinda et al. (2013) found a significant decrease in systolic blood pressure (5.2%) in apparently healthy and sedentary older women, without any significant alterations of arterial blood pressure, resting heart rate or blood triglycerides. ES calculation indicated a small effect of PET for cardio-metabolic pattern (ES = 0.07) (Fig. 8).

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Discussion

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321

Overall, results reported in this review indicate that PET may be considered beneficial for improving strength, dynamic balance, as well as walking performance in elderly populations. Furthermore, from a clinical perspective, PET might be useful in reducing fall-risk, improving independence, quality of life and mood state. However, due to the low number of studies as well as the heterogeneity of the study outcomes, larger clinical trials should be designed to increase scientific evidence about the potential effectiveness of PET, especially on variables where statistical power calculations were not performed. Even so, PET for elderly individuals seems to incorporate many of the components of the ACSM training recommendations (Chodzko-Zajko et al., 2009) (i.e. strength, flexibility, balance training) and has an encouraging perspective in filling the needs for this population, like other forms of structured exercise.

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Pilates and muscle strength

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PET was demonstrated to have positive effects on lower limb strength (Irez et al., 2011; Plachy et al., 2012); these results are supported by a large ES (1.23). Data by Plachy et al. (2012) are comparable to those reported by Lubans et al. (2013) which investigated on an elastic-resistance-training and lifestyle-activity intervention for sedentary older adults. Although the duration of training intervention was shorter

319 320

324 325 326 327 328

D

E

Pilates and balance Minor changes were found in static balance with an overall small ES (0.34). On the other hand, dynamic balance measures showed a different trend in nearly all PET-intervention studies with a moderate to large ES (0.77). Larger improvements appear to be associated with the length of the training. Interestingly, some improvements were still present after 5 weeks from the end of the intervention. The FRT, used by Mokhtari et al. (2013), showed an improvement in anterior and posterior stability after 12 weeks of PET. Although fall risk remained clustered at a “moderate level” before and after the PET intervention, clinically relevant improvements in FRT scores were observed, suggesting PET for fall prevention strategies in patients with high fall risk. Other improvements in static and dynamic balance assessed by the BBS also suggest a possible reduction in fall-risk in frail elderly (Johnson et al., 2013). Furthermore, participants significantly improved their TUG test scores in several studies after PET, which has been associated with reductions in fall risk (Bird and Fell, 2013; Bird et al., 2012; Mokhtari et al., 2013). However, there are too few studies that make this statement definitive. There is evidence that PET has the potential to prevent falls due to positive effects on physical and mental risk factors. However, only Irez

T

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E

317 318

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R

313 314

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311 312

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309 310

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in Lubans et al., similar improvements in muscle strength were found, assessed by the same method (30-s chair-stand test). Another interesting point can be observed in individuals who might not have access or the ability to perform traditional strength exercise. It was shown that home-based strength exercises tended to have smaller effects in increasing muscular strength than exercising with traditional resistance training equipment or facility-based resistance training (Thiebaud et al., 2014). On the other hand, PET protocol by Irez et al. (2011) appeared comforting since it showed higher improvements compared to the home-based strength training protocol by Thiebaud et al. (2014). Finally, it should be mentioned that 5 weeks of PET (Bird and Fell, 2013; Bird et al., 2012) were probably too short to determine a significant, but also clinically meaningful increase in muscle strength.

R O

Cardio-metabolic effects

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300

Fig. 3. Forest plot representing effect sizes of intervention and control groups in static balance outcomes.

Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

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Participants' mobility was shown to improve in different body regions after a PET-intervention (2011; Plachy et al., 2012). Furthermore, the 5 m-walk test improved, highlighting the potential benefits on dynamic balance, mobility and walking. Moreover, Johnson et al. (2013) investigated PET in Parkinson patients reporting improved 5 m-walk times despite null improvements with the TUG tests. The training effect on Parkinson patients cannot be extended to the general population, however, it stresses the possibility to implement PET exercise prescription with chronically diseased patients.

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Activities of daily living, mood states and quality of life

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388 389

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C

E

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380 381

R

373 374

N C O

371 372

Pilates and cardio-metabolic effects

404

O

378 379

369 370

R O

Pilates and mobility/walking

367 368

394 395

P

377

365 366

Besides depression, the physical decline of the elderly negatively affects their personal autonomy and quality of life. Physical activity is a way to slow down this decline and maintain or even increase personal autonomy and quality of life (Pernambuco et al., 2012). For instance, study results show that PET can improve functional autonomy and quality of life in the elderly (Siqueira Rodrigues et al., 2010). Although a large ES was determined (0.94), more evidence is needed to definitely state this impact, but as other physical activities, PET seems to produce similar benefits and can be recommended in elderly patients with depressive disorders.

398 399 400 401 402 403

405 406

Limitations

417

There are some limitations that should be considered in the application of our findings. First, due to the low number of studies with small sample size, as well as the heterogeneity of the analyzed outcomes, future high quality investigations are strongly needed. The scientific evidence of PET would benefit from studies incorporating a dose response element or better measures of training intensity to lend credibility to the amount of exposure needed to show an effect on the outcomes mentioned in this review. Additionally, gold standard techniques to measure

418 419

U

Studies demonstrated that physical exercise training improved depressive disorders and anxiety in older people (Zanuso et al., 2012). 390 Q11 Mokhtari et al. (2013) showed that a 12-week PET program was able 391 to reduce depressive symptoms in elderly. In a similar study, Hassan 392 (2011) found a reduction in depressive disorders (−33.68%) in young 393 women after a 12-week PET intervention.

396 397

A small ES (0.07) together with a lack of high quality studies examining the effects of PET on cardio-metabolic parameters in the elderly emphasize the need of RCTs investigating the efficacy of PET for these important parameters. Furthermore, Segal et al. (2004) did not find significant changes in body composition in physically active adults after 6 months of PET, which was concluded in the review by AladroGonzalvo et al. (2013). A possible explanation could be that PET may not impart a strong cardiovascular workload, and thus may be more appropriate for moderate muscle strengthening and to improve attributes of balance. Due to the poor evidence for cardio-metabolic effects in elderly subjects engaging in PET, other supplemental aerobic exercises should be prescribed in addition to PET.

E

375 376

et al. (2011) evaluated fall risk directly. This high quality study showed fewer numbers of falls (80.2%) after 12 weeks of PET, which were related to reduction in simple reaction time (23.5%) and choice reaction time (20.3%). Moreover, Johnson et al. (2013) did not observe any falls among elderly Parkinson patients performing regular PET. Only Newell et al. (2012) found no significant decrease in fall risk which can be explained by the short duration of their protocol, along with the low number of the weekly training session. Furthermore, as previously described in Granacher et al. review (2013) which was strongly focused on core strength training, PET could be used as an adjunct or even alternative to traditional balance and/or resistance training programs for older adults. Hence, PET might be proposed as purposeful training modality to prevent falls due to improvements in dynamic balance.

D

363 364

F

Fig. 4. Forest plot representing effect sizes of intervention and control groups in dynamic balance outcomes.

Fig. 5. Forest plot representing effect sizes of intervention and control groups in flexibility outcomes.

Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

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Conflict of interest statement

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The authors declare that there are no conflicts of interest.

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References

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Aladro-Gonzalvo, A.R., Araya-Vargas, G.A., Machado-Diaz, M., Salazar-Rojas, W., 2013. Pilates-based exercise for persistent, non-specific low back pain and associated functional disability: a meta-analysis with meta-regression. J. Bodyw. Mov. Ther. 17, 125–136. Bergamin, M., Zanuso, S., Alvar, B.A., Ermolao, A., Zaccaria, M., 2012. Is water-based exercise training sufficient to improve physical fitness in the elderly? Eur. Rev. Aging Phys. Act. 9, 129–141.

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Results from this review showed that PET might be considered an exercise intervention that is capable to increase muscle strength as well as to improve static and dynamic balance in elderly populations. Furthermore, functional capacity to perform daily living activities and quality of life can be generally improved if elderly engage in PET. PET seems to be a safe type of exercise. In fact, none of the included studies reported side-effects during its practice. Although further research is needed, our results indicate that clinicians who consider PET for exercise prescription are suggested to recommend PET at least twice per week, at moderate to vigorous rate of perceived exertion depending on current conditioning, and to add supplemental aerobic exercises. Besides, exercise prescription could incorporate PET for the elderly which present impaired balance conditions since PET has showed to be effective in increasing static and dynamic balance and in prevention of falls.

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some physical function parameters, especially for muscle strength, are needed to draw clear conclusions and to permit the comparison among studies. Another key-point to be examined is the core muscle control, even if it is one of the principles of the Pilates method, none of the included studies had analyzed this outcome and its possible correlation with static and dynamic balance. With progressive aging of the population, the prevalence of cardiovascular risk factors as well as subsequent chronic and osteoarticular diseases will increase. This review analyzed PET in healthy subjects and in patients with stable chronic diseases, though future research needs to analyze the effects of PET trying to improve its evidence on single pathologies and in multiple chronic conditions. Another important point concerns the higher prevalence of women recruited in the studies. To evaluate the effectiveness of PET in the elderly, future studies will have to recruit gender-balanced samples and specify the compliance and dropout ratio of the male and female practitioners. Finally, future studies should also identify intensity and progression targets of the training, to record the incidence of injuries reported during PET, and investigate the potential to incorporate PET with other exercise modalities to promote overall wellness in elderly populations. Moreover, future investigations where PET is performed should better describe each single part of exercise.

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Fig. 6. Forest plot representing effect sizes of intervention and control group in activities of daily living, mood state and quality of life outcomes.

Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

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Please cite this article as: Bullo, V., et al., The effects of Pilates exercise training on physical fitness and wellbeing in the elderly: A systematic review for future exercise, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.03.002

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