Effect of Pilates Intervention on Physical Function of Children and Youth: A Systematic Review

Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2019;-:-------

REVIEW ARTICLE

Effect of Pilates Intervention on Physical Function of Children and Youth: A Systematic Review Elizabeth Hornsby, BPhty,a,b Leanne M. Johnston, PhDa From the aSchool of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia; and b Kids Care Physiotherapy, Brisbane, Australia.

Abstract Objective: To conduct a systematic review to evaluate the effectiveness of Pilates intervention on physical function in children and youth. Data Sources: Six electronic databases were searched from inception to June 2018 using the term Pilates. Study Selection: Articles were included if they (1) reported original data for a Pilates-only intervention; (2) involved children or youth aged up to 22 years; (3) reported a musculoskeletal, pain, or function study outcome. Searches identified 2565 papers and 11 studies fulfilled the inclusion criteria. Data Extraction: The 2 authors independently screened and assessed all studies and any discrepancies were resolved by consensus. Data Synthesis: Level of evidence was classified using the Oxford Centre for Evidence Based Medicine. Study quality was assessed using the Physiotherapy Evidence Database for randomized controlled trials and Risk of Bias in N-of-1 Trials scale for single case experimental design studies. Four studies were high quality, 3 were fair quality, and 4 were of low quality. Findings showed that Pilates does appear to improve flexibility (nZ6); muscle strength, power and movement speed (nZ3); postural control, orientation and balance (nZ3); metabolic cost (nZ1); functional ability (nZ1) and health related quality of life (nZ1) and reduce pain (nZ2) in children with musculoskeletal pathology, the majority with a large effect size. Pilates content varied from group-based mat classes to individualized programs using specialized equipment. Intervention dose and frequency varied widely. Conclusions: This is the first systematic review of the effect of Pilates intervention for children and youth. Research is in the preliminary stages; however, Pilates does appear to improve flexibility, strength and postural control, and reduce pain in children with musculoskeletal pathology. Further research is warranted to determine the potential effectiveness of Pilates for children and youth for various population groups and to develop comprehensive treatment guidelines. Archives of Physical Medicine and Rehabilitation 2019;-:------ª 2019 by the American Congress of Rehabilitation Medicine

Pilates was devised by Joseph Pilates during World War I as a series of exercise techniques aimed to develop physical and mental conditioning of members of an internment camp and later patients in a rehabilitation hospital.1 This mind-body exercise places emphasis on cognitive concentration to produce slow, controlled, and fluid body movements. In the 1920s, Joseph Pilates set up a studio in New York where he refined his techniques and developed a clientele of mostly dancers who were aiming to develop high level motor control or rehabilitate from injuries.1 However, since the 1980’s participation in Pilates has extended to become a mainstream exercise in many countries as well as a form of rehabilitation offered by health professionals, such as

Disclosures: none.

physiotherapists to improve physical attributes such as flexibility, muscle strength, core stability, and postural control. Accordingly, there has been an escalation in clinical trials and systematic reviews for various populations in the last 2 decades. Now a wide range of research is available describing the benefits of improving flexibility, dynamic balance and muscle endurance in healthy adults,2 postural control for adults with conditions such as low back pain,3 upper limb pain and function following recovery from breast cancer,4 balance dysfunction in the elderly,5 and exercise tolerance in chronic stroke patients.6 However, some of this evidence shows mixed effects and little of this literature focuses on the potential benefits for children and youth. Traditional principles of Pilates exercises include centering, concentration, control, precision, flow, and breathing.7 Pilates exercises can be performed on the floor, commonly known as

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E. Hornsby, L.M. Johnston

mat-based Pilates or they can be performed using uniquely designed Pilates equipment. This equipment allows the instructor to select exercises that gradually increase motor control complexity or challenge, as well as to increase load by using gravity or adjustable resistance with springs. The Pilates approach provides potential benefits for exercise motivation and safety for children. First, Pilates includes a wide variety of exercises that can be used to focus on key areas, or an affected joint. Second, for individuals with chronic conditions, Pilates can provide an interesting full body workout to strengthen and maintain multiple body areas simultaneously over the long term. Third, older children and youth can also benefit from specialized Pilates equipment, such as the reformer, which provides a safe option for growing bodies by using body resistance to increase strength. Fourth, many of the exercises are closed chain exercises that assist with improving joint proprioception and muscle control. Pilates has been reported to have many positive effects in (1) reducing pain; (2) joint stability as well as mobility; (3) balance. Firstly, the positive effect of Pilates for reducing pain has been well illustrated in adult populations, for example, in adults with chronic low back pain.3 Musculoskeletal pain is also a major symptom experienced by children with conditions such as hypermobility spectrum disorders,8 cerebral palsy,9 and juvenile idiopathic arthritis.10 Each of these groups may benefit from practicing Pilates for improved alignment, strength and motor control to properly distribute movement load and decrease adverse load through involved joints. Secondly, Pilates has been reported to improve joint stability in some studies with adults.11,12 This form of intervention may also be beneficial for children. For example, joint hypermobility is a problem experienced by children and youth, causing joint instability, pain, and reduced proprioception.13 This increased joint range is characteristic of individuals with hypermobility spectrum disorders,14 or disorders of connective tissue such as EhlersDanlos syndrome.15 It is also a common condition seen in those who excel at sports, such as dancing or gymnastics, where their increased joint range enables the flexibility to achieve highly desired body positions or techniques. Children with hypotonia often experience poor movement control due to poorly controlled increased joint range, along with poorer muscle control and proprioception.16 Alternatively, children and youth may lack flexibility during periods of rapid growth, such as during the teenage years, leading to muscle imbalance, which places additional strain on joints to maintain correct postural alignment. Children with hypertonia may also experience stiffness and decreased joint range.17 Pilates may be a positive intervention to benefit all these groups. Thirdly, improvements in balance and postural control have been reported in a variety of adult studies including elderly patients5,18 and those with neurologic conditions.19 Improved postural control is highly desirable in youth with a range of abilities, from elite athletes perfecting complex movement patterns20 to populations with neurologic dysfunction21,22 to those

List of abbreviations: HRQoL JIA PEDro PRISMA

health related quality of life juvenile idiopathic arthritis Physiotherapy Evidence Database Preferred Reporting Items for Systematic Reviews and Meta-Analyses SCED single case experimental design

with musculoskeletal problems,23 so this warrants more investigation into the effect on children. Based on the background literature and the positive effects of Pilates in adults, this review has highlighted a number of potential benefits of Pilates for children. The aims of this study therefore, were to systematically review the existing literature to identify studies of Pilates intervention for children and youth aged up to 22 years and to evaluate potential effects on physical function, participation, or quality of life. Effect on physical function in this context may include changes to pain, flexibility, muscle strength, musculoskeletal alignment, or postural control. Effect on participation may include, for example, improved involvement in physical activity.

Methods This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Search strategy A systematic search of published articles from inception to June 2018 using the term “Pilates” was performed using 6 electronic databases: PubMed, Web of Science, Medline, Embase, Cinahl, and Psych Info. Initially, the search term (“Pilates AND children OR adolescent OR young adult”) was used for the type of intervention (Pilates) and the population of interest (children and youth) but this revealed less than 20 studies. The search term was then broadened by removing the terms for children or adolescent or young adult to ensure inclusion of studies that may have included significant numbers of children and youth along with other age groups. Secondary searches included checking reference lists of included papers to identify relevant papers that had not previously been found.

Eligibility criteria Articles were included if they (1) reported original data for a Pilatesonly intervention; (2) involved children or youth, of whom at least 90% were aged <22 years to be consistent with standardized pediatric terminology24; (3) reported at least 1 outcome measure for physical function, participation, or health related quality of life (HRQoL); (4) were published in full text in English in a peer reviewed journal. Articles were excluded if (1) Pilates intervention was performed in combination with other interventions so change could not be solely attributed to Pilates; (2) age of participants was not documented; (3) participants had concomitant diagnoses that may confound outcomes (eg, cancer, pregnancy).

Data extraction Two reviewers independently screened all titles and abstracts, then reviewed full texts as needed to determine if articles met the inclusion criteria. Any uncertainties around content between reviewers were resolved through discussion until consensus was reached.

Study appraisal and quality Levels of evidence of each study was determined using the Oxford Centre for Evidence-Based Medicine25,26 (table 1). Methodological www.archives-pmr.org

Characteristics of target populationsdPilates intervention for children and youth Design, Level of Evidence, Method Quality

Individual or Group Intervention

Alves de Araujo et al27

RCT OCEBM II PEDro 6 of 10

Amorim et al28

Chinnavan et al29

References

Participant Details Mean
SD

Pilates Intervention or Control Description

Group

Pop: Nonstructural scoliosis nZ31 F PGZ20 CGZ11 Age: 18-25 y

Non-RCT OCEBM III PEDro 3 of 10

Group

Pop: Dancers nZ15 (12F, 3M) PGZ7 Age: 15.7
0.8 y CGZ8 Age: 16.3
0.9 y

RCT OCEBM II PEDro 3 of 10

Group

Pop: Football players nZ30 PGZ15 CGZ15 Age: 17-20 y

Type: Mat and Equipment: Reformer, Cadillac, Stepchair, Ladderebarrel Instructor: Not stated Dose: 60 min, 2 x per wk Duration: 3 mo PG program: Warm-up: 8 min walk on treadmill Stretching exercises: 4 (5 min) Specific exercises: 12 x 10 repetitions Relaxation: 5 min CG program: Usual sedentary activity Type: Mat Instructor: Pilates instructor Dose: 60 min, 2 x per wk Duration: 11 wk PG program (þdancing): Warmup: 15 min Exercises: 35 min, 3 sets x 8-12 repetitions Cool-down: 10 min CG program: Dancing (usual activity) Type: Mat Instructor: Not stated Dose: 30 min, 5 x per week Duration: 4 wk PG program: Session detail not stated CG program: Ballistic exercises and static stretching

Outcome Measure

Results

1. Cob angle: radiological 2. Trunk flexibility: goniometer 3. Pain levels: Borg CR10 questionnaire

1. Decrease in Cobb Angle 2. Increase in trunk flexion 3. Decrease in pain

1. Isometric strength: timed maintenance of a dance position 2. Flexibility (measurement of photograph)

1. Increased strength in all positions 2. Increased flexibility in some positions: arabesque right limb and developpe front, side and back

1. Goniometer: supine hip and knee flexion 2. Sit and reach test: long sitting

1. Improved hamstring flexibility

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Table 1

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4

Table 1 (continued ) Design, Level of Evidence, Method Quality

Individual or Group Intervention

Finatto et al

RCT OCEBM II PEDro 8 of 10

Gonzalez-Galvez et al31

Kim et al32

References 30

Pilates Intervention or Control Description

Group

Pop: Male 5 km runners nZ32 PGZ16 CGZ16 (running) Age: 18.42
0.51 y

RCT OCEBM II PEDro 4 of 10

Group

Pop: High school students nZ66 (41 M, 25 F) PGZ39 Age: 14.4
0.6 y CGZ27 Age: 14
0.5 y

RCT OCEBM II PEDro 4 of 10

Group

Pop: Idiopathic scoliosis with Cobb angle >20 degrees nZ24 F PGZ12 Age: 14.5-16.7 y SGZ12 Age: 13.7-16.9 y

Type: Mat Instructor: Not stated Dose: 60 min, 2 x per wk Duration: 12 wk PG program (þrunning): (Californian Manual of Pilates Method Alliance) Initial: fundamentals Specific exercises Final: relaxation Progression: 15-25 exercises CG Program: Running (usual activity) Type: Mat Instructor: Physical education teacher Dose: 55 min, 2 x per wk Duration: 6 wk PG program: Session detail not stated CG program: Usual physical education class Type: not specified Instructor: Not stated Dose: 60 min, 3 x per wk Duration: 12 wk PG program: Preparation - 10 min Specific exercises: 40 min Wrap-up: 5 min SG program: Preparation: 10 min Stretching: 5 min Main exercise: 40 min Wrap-up: 5 min

Outcome Measure

Results

1. Metabolic cost: Secondary ventilatory threshold in maximal effort, - treadmill test with maximal oxygen consumption (V_ O2max) 2. EMG activity of postural muscles trunk 3. Time to complete a 5 km run

1. Improved: higher V_ O2max values and lower metabolic cost 2. Improved: decreased trunk muscle activation: energy minimization and possible neuromuscular economy 3. Improved: shorter 5 km running time

1. Toe-touch test

1. Improved hamstring flexibility F>M

1. Cobb angle - radiological goniometry 2. Body weight distribution (Gait View Pro 1.0)

1. Improved Cobb angle for both groups: SG more so than PG 2. Not improved weight distribution in PG 3. Improved weight distribution in SG

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Participant Details Mean
SD

Design, Level of Evidence, Method Quality

Individual or Group Intervention

Non-RCT OCEBM III PEDro 2 of 10

Mendonc¸a et al10

Park et al34

References McMillan et al

33

Participant Details Mean
SD

Pilates Intervention or Control Description

Individual

Pop: Elite ballet dancers nZ10 PGZ5 CGZ5 Age: 15-19 y

RCT OCEBM II PEDro 8 of 10

Group

Pop: JIA nZ50 PGZ25 CGZ25 Age: 8-18 y

Non-RCT OCEBM III PEDro 3 of 10

Group

Pop: Archers nZ20 PGZ10 CGZ10 Age: 17.3
1.06 y

Type: Mat and Equipment Reformer or rotator discs Instructor: Not stated Dose: PG: 23 h over 14 wkZ1.64 h per wk Duration: 3 mo PG program (þ ballet training 20-25 h per wk): Session detail not stated CG program: ballet training 2025 h per wk (usual activity) Type: Mat and Equipment: Reformer, Stability chair, Cadillac and Ladder barrel Instructor: Physical therapist Dose: 50 min, 2 x per wk Duration: 6 mo PG program: (Canadian Stott ePilates) Warm-up: 12 exercises Workout: 11 exercises x 5-10 repetitions Cool-down: 4 exercises CG program: Conventional exercises Warm-up 12 exercises Workout: 6-10 repetitions Cool-down: 4 stretches: 30 s Type: Mat Instructor: Not stated Dose: 60 min 3 x per wk Duration: 12 wk PG program (þ archery): Session detail not stated CG program: Archery (usual activity)

Outcome Measure

Results

1. Dynamic posture during grand plie

1. Improved dynamic posture of upper body region during grand plie in PG No differences seen in CG

1. HRQoL-Peds QL 4.0 2. Joint pain: VAS 3. Disability: CHAQ 4. Joint status: Pediatric Escola Paulista de Medicina Range of Motion Scale

1. Improved HRQoL 2. Improved: decreased pain score 3. Improved: decreased disability 4. Improved joint status

1. Static balance (Humac Norm Balance System) 2. Dynamic balance (Humac Norm Balance System)

1. No improvement in static balance 2. Improved dynamic balance in up, right, down-right, down, downleft, and up-left postures 3. No improvement in dynamic balance in upright and left postures

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Table 1 (continued )

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5

6

Table 1 (continued ) Design, Level of Evidence, Method Quality

Individual or Group Intervention

Tunar et al

Non-RCT OCEBM III PEDro 4 of 10

Walowska et al36

RCT OCEBM II PEDro 6 of 10

References 35

Participant Details Mean
SD

Pilates Intervention or Control Description

Group

Pop: Type 1 Diabetes Mellitus nZ31 PGZ17 (11 F, 6 M) CGZ14 (5 F, 9 M) Age: 12-17 y

Type: Mat Instructor: Pilates instructor Dose: 45 min, 3 x per wk Duration: 12 wk PG program: Session detail not stated CG program: Usual activity

Group

Pop: Congenital severe hearing impairment nZ80 PGZ41 CGZ39 Age: 13-24 y

Type: Mat Instructor: Not stated Dose: 45 min, 3 x per wk Duration: 6 wk PG program: (modified Pilates but complied with main Pilates principles) Warm-up: 7 exercises Specific exercises: 10 strengthening and balance Cool-down: 6 stretching and relaxation exercises CG program: Usual physical education class

Outcome Measure

Results

1. BMI: Height and Weight 2. Metabolic control: Glycated hemoglobin (HbA1c) spectrophotometry; blood lipid profile - (Beckman Coulter Synchron CX9 auto analyzer) and glucose levels (Accu check go glucose meter) 3. Physical performance Flexibility: sit and reach Height: vertical jump Power: modified Wingate Test (Cycle Ergometer) 1. Body balance control: CoP (International East ALFA AC stabilometric Platform) freestanding and reduced plane of support - eyes open and eyes closed

1. No improvement in BMI 2. No improvement in metabolic control 3. Improved peak and mean power, flexibility, and jump height

1. Improved body balance in relaxed posture and with feet together 2. Greater improvement seen with eyes open with less improvement seen with eyes closed

Abbreviations: BMI, body mass index; CG, control group; CHAQ, Childhood Health Assessment Questionnaire; CoP, center of pressure; EMG, electromyography; F, female; km, kilometer; M, male; OCEMB, Oxford Centre for Evidence-Based Medicine; PG, Pilates group; Pop, population; Peds QL 4.0, Pediatric Quality of Life Inventory version 4.0; PE, physical education teacher; RCT, randomized controlled trial; SG, Schroth group; VAS, visual analog scale; V_ O2max, maximum oxygen consumption.

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Pilates intervention in children quality was then examined. Group-based studies were examined using the Physiotherapy Evidence Database (PEDro) scale (table 2), which is based on the Delphi list37 and includes 11 items to assess the internal and external validity of randomized controlled trials. Criteria 2-9 rate internal validity and Criteria 10-11 rate whether there is sufficient statistical information to interpret results. Criterion 1 rates external validity but is not included in total PEDro score, which is out of 10. Commonly the PEDro is interpreted with 3 categories with a total score or 6-10 considered high quality, 4-5 as fair quality, and 0-3 as low quality.38 Single case experimental design (SCED) studies were examined using the Risk of Bias in Nof-1 Trials scale,39 which includes 15 items with a total score out of 30. Further meta-analysis was considered, however; on review of the available outcome measure data it was determined that no 2 studies had used identical outcome measures either within or between populations, therefore; a meta-analysis was not performed.

Results Search results The initial search retrieved 2565 papers and after 1308 duplicates were removed, there were 1257 articles remaining. The titles and abstracts of these articles were screened with 270 full text articles retrieved as potential articles and after examination, only 11 of these fulfilled the inclusion criteria. The secondary searches did not reveal any additional papers. The PRISMA diagram displaying the flow of studies and reasons for exclusion in the full text stage can be seen in figure 1.

Population characteristics Table 1 is a summary of the 11 included papers in alphabetical order. Three studies involved young athletes in the high performance sports of football,29 archery,34 and middle distance running.30 These studies focused on improving flexibility, strength, speed, balance, metabolic cost, postural, and motor control. Two further studies involved elite dancers28,33 and these studies focused on improving flexibility, strength, and postural control. Three studies involved children with musculoskeletal issues, including idiopathic scoliosis,32 nonstructural postural scoliosis,27 and tight hamstrings in high school students.31 These studies focused on decreasing pain, improving flexibility, and musculoskeletal alignment. The final 3 studies involved children with medical conditions. The first study was associated with the medical condition juvenile idiopathic arthritis (JIA)10 and focused on reducing musculoskeletal pain and increasing joint range, stability, and function to improve HRQoL. Another study involved children with diabetes mellitus,35 which aimed to improve body composition, metabolism, and physical performance. The third study involved children with congenital hearing loss, which focused on improving balance.36 The majority of participants were of secondary school age (nZ5) with 1 study involving primary and secondary school aged children,10 another study involving both secondary school aged children and youth in the early postschool period,36 and 4 studies involving postschool aged youth. Female participants were included in 5 of 6 studies (54%) and male participants were involved in 4 of 6 studies (46%). In 5 studies, it was not specified if participants were female or male.

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Pilates intervention description There was wide variation in the structure and dose of Pilates interventions in included studies. All were group-based except 1 study involving elite dancers,33 which involved individual instruction. One of the studies was led by a physiotherapist, 2 by a Pilates instructor, 1 by a physical education teacher, and 7 were not specified. In terms of equipment, interventions involved either body-weight resisted exercise performed on the floor (mat exercises) or exercises performed on specialized Pilates equipment with graded springs used to add resistance (equipment exercises). Seven of the 11 studies used mat exercises alone, 3 included both mat and equipment exercises, and 1 was not specified although it is likely it involved mat exercises. If used, Pilates equipment always included the Reformer (nZ3) with some studies also using the Cadillac (nZ2), Ladder barrel (nZ2), and Stability Chair and Step Chair (nZ2). In terms of the number of exercises, 6 studies detailed the number of exercises, ranging from 15 to 27 with the repetitions ranging from 5 to 10, and 7 studies did not specify the number of exercises. The reported dose varied widely. Session duration ranged from 30 to 60 minutes. Session number ranged from 2 to 5 per week, or between 10 to 43 hours over the course of the intervention. Intervention duration ranged from between 1 to 6 months. Studies used a range of comparisons between groups, including usual sporting activities (nZ6, 3 Level II, and 3 Level III), usual clinical care (nZ2, Level II, and Level III), or alternative treatments (nZ3, all Level II). No studies utilized a placebo comparison. No follow-up of participants following conclusion of intervention was reported in any of the studies.

Methodological quality The methodological quality of these studies was evaluated in 2 steps according to their design. The first step was to assess the level of evidence according to the Oxford Centre for Evidence-Based Medicine, which is summarized in table 1. The next step was to measure the methodological quality used in the trial. Eleven studies were evaluated with the PEDro scale, which is summarized in table 2. Total scores ranged from 2 to 8 out of a total possible score of 10. Four of these studies had a higher score of 6, 3 had a fair score of 4, and 4 had a low score of 3. In this style of study, the blinding of participants and practitioner criteria is difficult to meet with no study scoring the 1 point awarded to blinding the participant and only 1 study able to blind the therapist providing the intervention and scoring 1 point here. Other areas of low scoring were concealed allocation (3 of 11 studies), blinded assessor (2 of 11 studies), and the number of subjects initially allocated to the group and from whom the outcome measures were obtained (2 of 11 studies). The areas that studies scored consistently higher in were description of the source of subjects (11 of 11 studies), between-group statistical comparison (11 of 11 studies), a point measure of the size of the treatment effect (11 of 11 studies), a measure of the severity of the condition and a key outcome measure (8 of 11 studies), random allocation (7 of 11 studies), and an intention to treat analysis (6 of 11 studies). One study was reported as a SCED design.40 However, it included only an A-B design comprising a baseline phase (Phase A) followed by a treatment phase (Phase B) without a withdrawal period, so no further analysis of this study is included in this review.

Outcome measures and results The 8 outcomes in response to Pilates intervention were categorized according to World Health Organization International

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E. Hornsby, L.M. Johnston

Classification of Functioning, Disability and Health Criteria domains41,42 in table 3. Some aspects of body functions and structures were measured in all 12 studies with a variety of measurement tools and included (1) flexibility; (2) muscle strength, power and movement speed; (3) postural orientation and balance; (4) musculoskeletal alignment; (5) pain; (6) anthropometric measurements and metabolic control or metabolic cost. For activity, participation and contextual factors, only 1 study measured function and HRQoL. Flexibility Flexibility was measured in 6 studies. Improvement was shown using goniometry,27,29 the Pediatric Escola Paulista de Medicina Range of Motion scale,10 postural photographs,28 the sit and reach test,29,35 and the toe-touch test.31 Most studies reported a significant increase in flexibility with a large effect size (see table 3). Muscle strength, power, and movement speed Muscle strength, power, and movement speed were measured in 3 studies. Improvement was shown using timed maintenance of a dance position,28 vertical jump height,35 the Modified Wingate Anaerobic Test,35 double leg lowering,40 and running speed.30 Most studies reported an increase in muscle strength and movement speed with a large effect size (see table 3). Postural orientation and balance Postural orientation and balance were measured in 3 studies. Improvements were shown in dynamic postural control during dance movements using kinematics,33 limits of stability in archers using the Humac Norm Balance System,34 and in body balance control in children with hearing impairment with the International East Stabilometric Platform36 but not seen in static postural control using center of pressure in archers.34 Electromyography studies in runners demonstrated improved muscle activation of postural muscles.30 Musculoskeletal alignment Musculoskeletal alignment was examined in 2 studies. Improvement in spinal alignment in scoliosis was shown using radiological

Table 2

Cobb angle27,32 but not body weight distribution using the Gait View Pro 1.0.32 Pain Pain was examined in 2 studies. These included children with JIA and nonstructural scoliosis. The level of perceived pain was measured using either the Borg CR10 questionnaire27 (nZ1) or the Pediatric Quality of Life Inventory version 4.0 visual analog scale10 (nZ1). In both studies participants reported a significant decrease in the level of pain experienced. Anthropometric measurements and metabolic control or metabolic cost Anthropometric measurements and metabolic control or metabolic cost were collected in 2 studies. Some improvements were seen in runners in oxygen consumption and metabolic cost (12km/h treadmill test)30; however, no improvement was seen in diabetic patients for body mass index or metabolic control.35 Function and HRQoL Function and HRQoL was measured in 1 study. Improvement was seen in Child Health Assessment Questionnaire and Pediatric Quality of Life Inventory version 4.0 scores in children with JIA.10 This study reported a significant improvement in function and HRQoL with a large effect size (see table 3).

Discussion This is the first systematic review to study the effects of Pilates intervention in children and youth with musculoskeletal disorders. Eleven studies were identified that met the inclusion criteria. Interventions varied in terms of population of interest and intervention structure with dose and outcome measures used to measure effectiveness. Nevertheless, results showed that Pilates does appear to be an effective intervention for children, with improvements noted in flexibility, muscle strength, postural orientation and balance, musculoskeletal alignment, pain levels, function, and HRQoL. Analysis of the results provides guidance

PEDro score Criteria

Author 27

Alves de Araujo et al Amorim et al28 Chinnavan et al29 Finatto et al30 Gonzales-Galvez et al31 Kim et al32 McMillan et al33 Mendonc¸a et al10 Tunar et al35 Park et al34 Walowska et al36

1

2

3

4

5

6

7

8

9

10

11

Total Score Items 2-11 /10

1 1 1 1 1 1 1 1 1 1 1

1 0 1 1 1 1 0 1 0 0 1

1 0 0 1 0 0 0 1 0 0 0

1 1 0 1 0 1 0 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 1 0 0 0 1 0 0 0

0 0 0 1 0 0 0 0 0 0 1

1 0 0 1 1 0 0 1 1 0 1

1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1

6 3 3 8 4 4 2 8 4 3 6

NOTE. Item score: 1, Meets criteria; 0, Does not meet criteria; Criteria 1, External validity; Criteria 2-9, Internal validity; Criteria 10-11, Sufficient statistics to interpret results.

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Fig 1

PRISMA flow diagram.

for target populations, nature of intervention, and ability of outcome measures to detect change.

Outcomes of Pilates intervention Several studies included in this review reported positive outcomes for flexibility, muscle function, postural orientation and balance, and pain levels, which is consistent with outcomes reported in the broader adult literature. Six pediatric studies reported improved flexibility with 14 of 17 outcomes showing large effect sizes (see table 3). This included 4 Level II studies involving children during growth phases,31 high-level football players,29 or managing health conditions such as JIA,10 or with scoliosis27 and 2 Level III studies in elite baller dancers28 or children with diabetes mellitus.35 Improved flexibility was also reported in adult studies including with healthy adults,43 those with chronic musculoskeletal conditions (eg, low back pain, scoliosis, ankylosing spondylosis),2 postcancer recovery,4 or neurologic conditions (eg multiple sclerosis).19 Three pediatric studies reported improved muscle function in attributes such as strength, with 15 of 19 outcomes showing a large effect size (see table 3). These included 1 Level II study in elite middle-distance runners30 and 2 Level III studies in elite dancers28 or patients with diabetes.35 Improved muscle function was also reported in adult studies, for example, improved

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endurance of trunk muscles with healthy adults43 or those with noncommunicable cardiovascular disease or diabetes.6 Three pediatric studies reported improved postural control (orientation or balance) with 8 of 13 outcomes (able to be calculated) showing large effect sizes (see table 3). These included 1 Level II study in children with balance issues associated with congenital hearing loss36 and 2 Level III studies in elite dancers,33 and archers.34 Improved postural control was also reported in adult studies especially in falls prevention in elderly populations,5 as well as in healthy adults.43 Two pediatric studies focused on reducing pain, with both outcomes showing a large effect size (see table 3). The studies, both at Level II, involved youth with JIA10 or nonstructural scoliosis.27 Many adult studies have reported that Pilates can reduce pain, for example, in musculoskeletal conditions such as chronic low back or neck pain,2,3,44,45 musculoskeletal pain in pregnancy46 or postcancer recovery.47 Given the importance of pain reduction, further research may be warranted for relevant populations of children. One Level II study showed improvements in HRQoL in children with JIA, with a large effect size (see table 3).10 However, there is an emerging body of research with positive outcomes for adults with chronic health problems (eg, cardiovascular disease, respiratory diseases, diabetes,6 and cancer survivors, eg, breast cancer4). Again, this may be an area of research worth attention in treating children.

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Table 3

Study results of outcome measures assessing change in response to Pilates intervention

Study Author, Year; Population Group

Outcome Measurement Description

ICF Category: Body Functions and Structures: Flexibility ROM (degrees) with Alves de Araujo et al27 Sedentary university goniometer: trunk students: flexion (seated with nonstructural legs outstretched) scoliosis ROM (degrees) with Chinnavan et al29 Football (soccer) players goniometer: knee flexion (in hip or knee flexion)

Mendonc¸a et al10 Children with JIA

Amorim et al28 Ballet dancers

ROM (points) with pEPM-ROM: Scale of 9 joints (lower score indicates improved ROM) ROM (degrees) with digitized photograph: Hip motion in ballet positions: Arabesque R Leg Arabesque L Leg

Developpe Front R Leg

Improved P<.001 Pre 9.5
5.9 Post 17.6
9.6 Pilates, nZ20 Improved P<.001 Pre 120.9
4.2 Post 134.2
2.1 Pilates, nZ15

Control Group/Other Exercise Group, Mean
SD

No change P>.371 Pre 8.2
5.2 Post 7.8
5.5 Control, nZ11 No change PZ.18 Pre 124.0
5.0 Post 126.1
3.2 Hamstring exercise group, nZ15 No change No P value stated Pre 0.2
0.2 Post 0.2
0.2 CEG, nZ25 No change No P value stated Pre 96.4
4.2 Post 97.0
4.7 CEG, nZ8 No change No P value stated Pre 93.4
6.5 Post 95.0
4.5

Improved P<.01 Pre 0.5
0.3 Post 0.1
0.1 Pilates, nZ25 Improved No P value stated Pre 99.3
8.9 Post 109.2
12.7 Pilates, nZ7 Improved but not significant No P value stated Pre 102.2
12.1 Post 109.5
11.0 Improved No P value stated Pre 102.3
12.7) Post 112.0
13.1)

No change No P value stated Pre 102.4
10.2 Post 101.5
8.7

Improved No P value stated Pre 102.2
13.5 Post 110.3
13.3

No change No P value stated Pre 95.5
5.3 Post 96.2
5.7

Between Group P Value

Effect Size: Hedges g (95% CI)

Pilates>Control PZ.004

1.13 (0.35, 1.92)

Large, favors Pilates

Pilates>Hamstring exercise P<.05

2.91 (1.88, 3.94)

Large, favors Pilates

Pilates >CEG PZ.002

4.36 (3.34, 5.38)

Large, favors Pilates

Pilates>CEG Group x Time: PZ.002 Time: PZ.001 Group: PZ.085

1.24 (0.13, 2.34)

Large, favors Pilates

No difference Group x Time: PZ0.086 Time: PZ.012 Group: PZ.021 Pilates>CEG Group x Time: PZ.007 Time: PZ.017 Group: PZ.364 Pilates>CEG Group x Time: PZ.002 Time: P<.001 Group PZ.062

1.67 (0.49, 2.85)

Large, favors Pilates

0.90 (-0.16, 1.97)

Large, favors Pilates

1.33 (0.21, 2.45)

Large, favors Pilates

Effect Size Category

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E. Hornsby, L.M. Johnston

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Developpe Front L Leg

Pilates Exercise Group Mean
SD

Study Author, Year; Population Group

Chinnavan et al29 Football (soccer) players

Outcome Measurement Description

Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

Developpe Side R Leg

Improved No P value stated Pre 115.7
21.9 Post 125.7
18.7

No change No P value stated Pre 110.1
13.4 Post 110.7
12.5

Developpe Side L Leg

Improved No P value noted Pre 113.9
88.1 Post 121.5
18.0

No change No P value stated Pre 108.8
14.4 Post 109.7
12.9

Developpe Back R Leg

Improved No P value noted Pre 112.2
10.1 Post 119.8
12.9

No change No P value stated Pre 103.8
6.9 Post 102.2
5.8

Developpe Back L Leg

Improved No P value noted Pre 113.8
13.1 Post 117.3
12.9

No change No P value stated Pre 102.6
4.2 Post 102.2
4.4

Cambre Backward R Leg

Improved No P value stated Pre 91.9
24.1 Post 88.0
23.3

No change No P value stated Pre: 88.1
14.0 Post: 87.6
15.9

Cambre Backward L Leg

Improved No P value stated Pre 95.2
20.4 Post 88.9
20.4

No change No P value stated Pre: 93.9
17.7 Post: 92.4
15.8

Hamstring flexibility: Sit and Reach Test: long sitting, measure finger reach past edge of table (cm)

Improved P<.001 Pre 33.5
1.6 Post 40.7
1.9 Pilates, nZ15

No change PZ0.45 Pre 34.0
2.3 Post 34.6
2.3 Hamstring exercise Group, nZ15

Between Group P Value

Effect Size: Hedges g (95% CI)

Effect Size Category

Pilates>CEG Group x Time PZ.002 Time: PZ.001 Group: PZ.250 Pilates>CEG Group x Time PZ.001 Time: P<.001 Group: PZ.325 Pilates>CEG Group x Time PZ.011 Time: PZ.076 Group: PZ.013 Pilates>CEG Group x Time PZ.020 Time: PZ.055 Group: PZ.017 No difference Group x Time PZ.330 Time: PZ.196 Group: PZ.833 No difference Group x Time PZ.177 Time: PZ.040 Group: PZ.913 Pilates>Hamstring P<.05

0.90 (-0.16, 1.97)

Large, favors Pilates

0.72 (-0.33, 1.76)

Medium, favors Pilates

1.70 (0.52, 2.88)

Large, favors Pilates

1.52 (0.37, 2.67)

Large. favors Pilates

0.02 (-1.00, 1.03)

Small, favors Pilates

-0.18 (-1.20, 0.83)

Unable to calculate

2.81 (1.8, 3.82)

Large, favors Pilates

Pilates intervention in children

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Table 3 (continued )

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11

12

Table 3 (continued ) Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

Tunar et al Sedentary children with Type 1 Diabetes Mellitus

Trunk forward flexion flexibility: Sit and Reach Test (cm)

Gonzalez-Galvez et al31 High school students

Hamstring flexibility: Toe-touch Test (cm) (standing box)

Improved P<.05 Pre 0.4
5.2 cm Post 8.4
5.2 cm Pilates, nZ17 Improved women P<.01 Pre 4.6
9.9 Post 8.5
8.4 Pilates, nZ13

No change No P value stated Pre 1.5
6.3 Post 2.9
6.5 No intervention, nZ14 No change women No P value stated Pre 1.00
5.66 Post 1.13
7.29 CEG, nZ12

Improved men: P<.01 Pre -2.2
8.5 Post 1.2
8.1 Pilates, nZ26

No change men No P value stated Pre -8.9
5.8 Post -8.9
5.8 CEG, nZ155

Improved No P value stated Pre 25.1
11.3 Post 47.6
22.3 Pilates, nZ7 Improved No P value stated Pre 35.1
13.4 Post 49.4
17.8

No change No P value stated Pre 24.9
4.3 Post 26.8
3.2 CEG, nZ8 No change No P value stated Pre 24.5
8.1 Post 24.4
7.7

Developpe Front R Leg

Improved No P value stated Pre 12.9
5.1 Post 19.9
6.2

No change No P value stated Pre 14.8
4.1 Post 14.3
4.2

Developpe Front L Leg

Improved No P value stated Pre 17.7
7.1 Post 23.9
8.2

No change No P value stated Pre 12.3
2.7 Post 12.4
3.1

35

Muscle Strength / Power / Speed Muscle strength: timed Amorim et al28 Elite dancers maintenance of dance position (s): Penche R Leg Penche L Leg

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Between Group P Value

Effect Size: Hedges g (95% CI)

Effect Size Category

Pilates>Control P<.001

0.92 (0.18, 1.66)

Large, favors Pilates

Pilates>CEG P<.01 Women > men P<.01

0.90 (women) (0.08, 1.73)

Large, favors Pilates

1.33 (men) (0.60, 2.06)

Large, favors Pilates

1.28 (0.16, 2.39)

Large, favors Pilates

1.76 (0.57, 2.96)

Large, favors Pilates

1.01 (-0.07, 2.09)

Large, favors Pilates

1.80 (0.60, 3.00)

Large, favors Pilates

Pilates>CEG Group x Time PZ.002 Time: PZ.001 Group: PZ.091 Pilates>CEG Group x Time PZ.002 Time: PZ.002 Group: P<.001 Pilates>CEG Group x Time PZ.006 Time: PZ.014 Group: PZ.425 Pilates>CEG Group x Time PZ.001: Time: P<.001: Group: P<.001

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E. Hornsby, L.M. Johnston

Outcome Measurement Description

Study Author, Year; Population Group

Study Author, Year; Population Group

Finnato et al30 Trained young adult distance runners

Outcome Measurement Description

Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

Developpe Side R Leg

Improved No P value noted Pre 15.0
4.0 Post 22.9
11.0

No change No P value noted Pre 14.0
4.2 Post 14.1
4.6

Developpe Side L Leg

Improved No P value noted Pre 16.6
8.9 Post 24.7
6.5

No change No P value noted Pre 12.5
2.9 Post 12.8
2.4

Developpe Back R Leg

Improved No P value noted Pre 29.3
11.9 Post 49.0
14.9

No change No P value noted Pre 24.9
7.4 Post 25.0
6.0

Developpe Back L Leg

Improved No P value stated Pre 40.9
9.2 Post 52.7
12.6

No change No P value stated Pre 26.9
4.8 Post 26.9
5.7

Maximal isometric activation postural muscles: (EMG) (mV): Obliquus externus abdominis Obliquus internus abdominis

Improved PZ.005 Pre 249.9
22.1 Post 317.0
26.7 Pilates, nZ16 Improved PZ.03 Pre 550.7
60.9 Post 685.5
73.5 Improved PZ.012 Pre 299.4
21.3 Post 371.22
21.49 Improved PZ.032 Pre 432.4
40.8 Post 561.9
46.1 Improved

No change No P value stated Pre 233.0
28.4 Post 229.4
41.8 CEG (runners), nZ16 No change No P value stated Pre 527.1
60.5 Post 510.5
71.2 No change No P value stated Pre 284.3
17.5 Post 285.79
15.25 Improved P<.05 Pre 425.5
26.8 Post 483.2
36.7 Improved

Longissimus

Vastus lateralis

Biceps femoris

Between Group P Value

Effect Size: Hedges g (95% CI)

Pilates > CEG Group x Time PZ.008 Time: PZ.007 Group: PZ.133 Pilates > CEG Group x Time PZ.001 Time: PZ.001 Group: PZ.013 Pilates > CEG Group x Time PZ.001 Time: PZ.001 Group: PZ.010 Pilates > CEG Group x Time PZ.012 Time: PZ.012 Group: P<.001 Pilates > CEG PZ.048

1.01 (-0.07, 2.09)

Large, favors Pilates

2.36 (1.04, 3.67)

Large, favors Pilates

2.05 (0.79, 3.30)

Large, favors Pilates

2.55 (1.18, 3.91)

Large, favors Pilates

2.43 (1.52,3.35)

Large favors Pilates

Pilates > CEG PZ.037

2.36 (1.46, 3.26)

Large, favors Pilates

Pilates > CEG PZ.027

4.47 (3.17, 5.77)

Large, favors Pilates

No difference PZ.193

1.84 (1.01, 2.67)

Large, favors Pilates

No difference

1.71 (0.90, 2.52)

Effect Size Category

Pilates intervention in children

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Table 3 (continued )

Large, favors

13

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14

Table 3 (continued ) Study Author, Year; Population Group

Outcome Measurement Description

Gluteus medius

Latissimus dorsi

Tunar et al35 Sedentary adolescents: Type 1 diabetes mellitus

Power: Vertical jump height (cm)

Tunar et al35 Sedentary adolescents: Type 1 diabetes mellitus

Power: Modified Wingate Anaerobic Test (W) Peak power Mean power

Finnato et al30 Trained young adult distance runners

Speed: Timed 5 km run (minutes; lower time indicates improvement)

Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

P<.001 Pre 370.5
30.6 Post 510.2
27.6 Improved PZ.006 Pre 450.1
33.6 Post 587.7
45.6 No change PZ0.502 Pre 376.1
32.9 Post 385.8
48.0 Improved P<.01 Pre 35.7
10.2 Post 39.2
10 Pilates, nZ17 Improved P<.05 Pre 491.2
236.5 Post 509.6
226.8 Pilates, nZ17 Improved P<.001 Pre 362.2
177.8 Post 386.5
180.7 Improved P<.001 Pre 25.65
0.44 Post 23.23
0.40 Pilates, nZ16

P<.05 Pre 379.4
29.5 Post 452.8
37.1 No change No P value stated Pre 471.2
39.5 Post 529.0
53.1 No change No P value stated Pre 348.1
28.0 Post 376.2
32.6 No change No P value stated Pre 42.1
8.0 Post 43.9
7.4 No intervention, nZ14 No change No P value stated Pre 549.2
161.4 Post 519.3
133.2 No intervention, nZ14 Improved No P value stated Pre 401
104.0 Post 407.5
114.1 No change No P value stated Pre 25.33
0.58 Post 24.61
0.52 CEG, nZ16

Between Group P Value

Effect Size: Hedges g (95% CI)

PZ.559

Effect Size Category Pilates

Pilates > CEG PZ.007

1.16 (0.41, 1.90)

Large, favors Pilates

No difference PZ.660

0.23 (-0.47, 0.92)

Small, favors Pilates

Pilates > Control PZ.003

-0.51 (-1.23, 0.21)

Medium, favors Pilates

Pilates > Control PZ.02

-0.05 (-0.76, 0.66)

Unable to calculate

Pilates > Control P<.001

-0.13 (-0.84, 0.58)

Unable to calculate

No difference PZ.441

-2.90 (-3.89, -1.91)

Large, favors Pilates

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Study Author, Year; Population Group

Outcome Measurement Description

Postural control / Orientation / Balance McMillan et al33 Distance (mm) marker Elite ballet dancers displaced from vertical axis during grand plie: Watsmart: Waterloo spatial motion analysis recording technique (less variability in trunk vertical alignment shows improved dynamic postural stability): ASIS: ear: Greater trochanter: ear

Park et al34 Experienced high school archers

Static and dynamic balance: Humac Norm Balance System: (CoP) Static balance: Up part: Down part:

Left part:

Right part

Dynamic balance: Overall

Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

Improved P<.05 Pre 3.1
0.3 Post 2.7
0.5 Pilates, nZ5

Improved but not significant P>.05 Pre 3.1
0.5 Post 2.9
0.4 No change No P value stated Pre 51.1
1.2 Post 50.8
0.9 Pilates, nZ10 No change No P value stated Pre 48.9
1.2 Post 49.2
0.9 Improved P<.05 Pre 51.1
1.7 Post 50.2
0.4 Improved P<.05 Pre 48.9
1.7 Post 49.8
0.4 Improved P<.001

Between Group P Value

Effect Size: Hedges g (95% CI)

No change No P value stated Pre 2.8
0.5 Post 3.1
0.4 CEG, nZ5

Pilates > CEG P<.05

-0.80 (-2.09, 0.49)

Large, favors Pilates

No change No P value stated Pre 3.0
0.3 Post 3.2
0.4

Pilates > CEG but not significant

-0.68 (-1.95, 0.60)

Medium, favors Pilates

No change No P value stated Pre 51.0
1.9 Post 50.6
1.4 No intervention, nZ10 No change No P value stated Pre 49.0
1.9 Post 49.4
1.4 No change No P value stated Pre 51.60
2.4 Post 51.70
1.6 No change No P value stated Pre 48.4
2.4 Post 48.3
1.6 No change No P value stated

Static balance: Pilates > Control in left part and right part P<.05

0.16 (Up part) (-0.72, 1.04)

Unable to calculate

No difference in up or down part

-0.16 (-1.04, 0.72)

Unable to calculate

-1.23 (2.19, -0.28)

Large, favors Pilates

1.23 (0.28, 2.19)

Large, favors Pilates

1.09 (0.15, 2.03)

Large, favors Pilates

Dynamic balance: Pilates > Control in

Effect Size Category

15

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Pilates intervention in children

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Table 3 (continued )

16

Table 3 (continued ) Study Author, Year; Population Group

Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

Pre 38.6
7.4 Post 47.5
9.3

Pre 38.30
7.1 Post 39.20
4.5

Up part

Improved P<.01 Pre 40.7
8.3 Post 46.9
7.6

No change No P value stated Pre 40.3
13.5 Post 39.4
08.3

Up right part

No change No P value stated Pre 42.6
8.8 Post 46.5
7.4 Improved P<.05 Pre 38.5
14.8 Post 50.4
08.4 Improved P<.001 Pre 31.9
7.8 Post 42.2
7.7 Improved P<.01 Pre 42.0
15.1 Post 48.7
14.2

Down left part

Outcome Measurement Description

Between Group P Value overall, in up part, up right part and down right part, P<.05 No difference in right part, down part, down left part, left part and up left part PZ.05 No P value stated

Effect Size: Hedges g (95% CI)

Effect Size Category

Large, favors Pilates

No change No P value stated Pre 40.6
8.7 Post 39.4
3.0 No change No P value stated Pre 44.7
16.9 Post 43.6
10.4 No change No P value stated Pre 26.2
9.5 Post 30.9
5.3 No change No P value stated Pre 37.2
12.7 Post 38.4
8.5

1.20 (0.25, 2.16)

Large, favors Pilates

0.69 (-0.21, 1.59)

Medium, favors Pilates

1.64 (0.62, 2.65)

Large, favors Pilates

0.84 (-0.07, 1.76)

Large, favors Pilates

Improved P<.05 Pre 29.6
15.5 Post 40.2
12.0

No change No P value stated Pre 28.7
15.1 Post 32.4
10.1

0.67 (-0.23, 1.57)

Medium, favors Pilates

Left part

No change No P value stated Pre 41.5
18.7 Post 49.6
14.2

No change No P value stated Pre 43.2
14.7 Post 43.0
13.1

0.46 (-0.43, 1.35)

Small, favors Pilates

Up left part

Improved P<.05 Pre 43.3
13.5 Post 52.5
12.7

No change No P value stated Pre 48.6
15.6 Post 47.4
11.7

0.40 (-0.49, 1.29)

Small, favors Pilates

Right part

Down right part

Down part

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E. Hornsby, L.M. Johnston

0.90 (-0.02, 1.82)

Study Author, Year; Population Group 36

Walowska et al Adolescents and young adults with hearing impairment

Outcome Measurement Description

Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

Body balance control: International East Stabilometric Platform: (CoP): path length (cm), surface area (cm2), speed (cm/s) Path length in relaxed standing posture with eyes open Path length in relaxed standing posture with eyes closed

Improved P<.00001 Pre 21.3 Post 13.3 Pilates, nZ41

Between Group P Value

Effect Size: Hedges g (95% CI)

Effect Size Category

Improved PZ.00057 Pre 26.7 Post 23.4 CEG, nZ39

Pilates > CEG P<.001

Unable to calculate

Unable to calculate

Improved P<.001 Pre 28.8 Post 19.1

Improved P<.001 Pre 33.6 Post 30.8

Pilates > CEG P<.001

Unable to calculate

Unable to calculate

For path length with feet together with eyes open

Improved P<.001 Pre 35.0 Post 26.7

Improved P<.001 Pre 38.1 Post 33.4

Pilates > CEG P<.002

Unable to calculate

Unable to calculate

For path length with feet together with eyes closed

Improved PZ.006 Pre 47.1 Post 34.1

Improved P<.001 Pre 50.8 Post 42.6

Pilates > CEG P<.006

Unable to calculate

Unable to calculate

Surface area in relaxed standing posture with eyes open

Improved P<.001 Pre 2.9 Post 1.7

No change PZ0.103 Pre 3.4 Post 3.3

Pilates > CEG PZ.002

Unable to calculate

Unable to calculate

Surface area in relaxed standing posture with eyes closed

Improved P<.001 Pre 3.9 Post 2.3

No change PZ.08866 Pre 4.5 Post 3.8

No difference PZ.131

Unable to calculate

Unable to calculate

Surface area with feet together with eyes open

Improved P<.001 Pre 4.6 Post 3.5

Improved P<.001 Pre 5.1 Post 3.9

No difference PZ.658

Unable to calculate

Unable to calculate

17

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Table 3 (continued )

18

Table 3 (continued ) Study Author, Year; Population Group

Outcome Measurement Description

Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

Surface area with feet together with eyes closed

Improved P<.001 Pre 7.1 Post 4.7

Speed in the frontal plane in relaxed standing posture with eyes open

Effect Size: Hedges g (95% CI)

Effect Size Category

Improved PZ.001 Pre 6.6 Post 4.9

No difference PZ.154

Unable to calculate

Unable to calculate

Improved P<.001 Pre 0.5 Post 0.3

Improved P<.001 Pre 0.6 Post 0.5

Pilates > CEG P<.001

Unable to calculate

Unable to calculate

Speed in the frontal plane in relaxed standing with eyes closed

Improved P<.001 Pre 0.6 Post 0.4

Improved PZ.001 Pre 0.8 Post 0.7

Pilates > CEG P<.001

Unable to calculate

Unable to calculate

Speed in the frontal plane with feet together with eyes open

Improved P<.001 Pre 0.8 Post 0.6

Improved P<.001 Pre 0.9 Post 0.8

Pilates > CEG PZ.003

Unable to calculate

Unable to calculate

Speed in the frontal plane with feet together with eyes closed

Improved P<.001 Pre 1.0 Post 0.8

Improved P<.001 Pre 1.2 Post 1.0

Pilates > CEG PZ.012

Unable to calculate

Unable to calculate

Speed in the sagittal plane in relaxed standing posture with eyes open

Improved P<.001 Pre 0.5 Post 0.3

Improved PZ.002 Pre 0.6 Post 0.5

Pilates > CEG P<.001

Unable to calculate

Unable to calculate

Speed in the sagittal plane in relaxed standing posture with eyes closed

Improved P<.001 Pre 0.6 Post 0.4

Improved PZ.004 Pre 0.7 Post 0.7

Pilates > CEG P<.001

Unable to calculate

Unable to calculate

Speed in the sagittal plane with feet together with eyes open

Improved P<.001 Pre 0.8 Post 0.6

Improved P<.001 Pre 0.9 Post 0.8

Pilates > CEG PZ.002

Unable to calculate

Unable to calculate

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E. Hornsby, L.M. Johnston

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Between Group P Value

Study Author, Year; Population Group

Outcome Measurement Description

Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

Speed in the sagittal plane with feet together with eyes closed

Improved P<.001 Pre 1.1 Post 0.8

Range of deflection in the sagittal plane in relaxed standing posture with eyes open Range of deflection in the sagittal plane in relaxed standing posture with eyes closed Range of deflection in the sagittal plane with feet together with eyes open

Between Group P Value

Effect Size: Hedges g (95% CI)

Effect Size Category

Improved P<.001 Pre 1.1 Post 0.9

Pilates > CEG PZ.006

Unable to calculate

Unable to calculate

No change PZ.330 Pre 1.5 Post 1.2

No change PZ.364 Pre 1.4 Post 1.2

No difference PZ.464

Unable to calculate

Unable to calculate

No change PZ.168 Pre 1.4 Post 1.2

No change PZ.665 Pre 1.4 Post 1.2

No difference PZ.260

Unable to calculate

Unable to calculate

Improved PZ.002 Pre 1.7 Post 1.3

No change PZ.521 Pre 1.4 Post 1.5

Pilates > CEG PZ.009

Unable to calculate

Unable to calculate

Range of deflection in the sagittal plane with feet together with eyes closed

Improved PZ.045 Pre 1.6 Post 1.3

No change PZ.791 Pre 1.4 Post 1.4

No difference PZ.065

Unable to calculate

Unable to calculate

Range of deflection in the frontal plane in relaxed standing posture with eyes open Range of deflection in the frontal plane in relaxed standing posture with eyes closed Range of deflection in the frontal plane with feet together with eyes open

No change PZ.712 Pre 0.8 Post 0.8

No change PZ.944 Pre 0.7 Post 0.7

No difference PZ.658

Unable to calculate

Unable to calculate

No change PZ.974 Pre 0.8 Post 0.8

No change PZ.944 Pre 0.7 Post 0.7

No difference PZ.946

Unable to calculate

Unable to calculate

No change PZ.328 Pre 1.0 Post 0.7

No change PZ.336 Pre 0.9 Post 0.8

No difference PZ.923

Unable to calculate

Unable to calculate

19

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Table 3 (continued )

20

Table 3 (continued ) Study Author, Year; Population Group

Musculoskeletal Alignment Alves de Araujo et al27 Sedentary university students with nonstructural scoliosis Kim et al32 Adolescents with Idiopathic Scoliosis

Kim et al32 Adolescents with idiopathic scoliosis

Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

Range of deflection in the frontal plane with feet together with eyes closed

No change PZ.573 Pre 1.0 Post 0.8

Radiological: Cobb Angle (degrees; smaller angle indicates improvement) Radiological: CR 85-X Cobb Angle: (degrees; smaller angle indicates improvement) Body weight distribution between sides spine: Gait View Pro 1.0 (percentage) Convex

Between Group P Value

Effect Size: Hedges g (95% CI)

Effect Size Category

No change PZ.125 Pre 0.9 Post 0.9

No difference PZ.597

Unable to calculate

Unable to calculate

Improved P<.001 Pre 7.6
3.5 Post 4.8
2.0 Pilates, nZ20 Improved P<.05 Pre 24.0
2.6 Post 16.0
6.9 Pilates, nZ12 No change P>.05 Pre 55.3
2.3 Post 54.7
1.7 Pilates, n Z12

No change PZ.676 Pre 7.1
2.8 Post 6.9
3.1 No intervention, nZ11 Improved P<.05 Pre 23.6
1.5 Post 12.0
4.7 Schroth Ex, nZ12 Improved P<.05 Pre 56.7
2.5 Post 52.7
1.7 Schroth Ex, nZ12

Pilates > Control PZ.028

-0.84 (-1.6, -0.07)

Large, favors Pilates

Schroth > Pilates P<.05

0.65 (-0.17, 1.48)

Medium, favors Schroth

Schroth > Pilates P<.05

1.14 (0.27, 2.00)

Large, favors Schroth

Concave

No change P>.05 Pre 44.6
2.7 Post 45.3
2.1

No change P>.05 Pre 43.2
3.5 Post 47.2
1.6

Schroth > Pilates P<.05

-0.98 (-1.83, -0.14)

Large, favors Schroth

Pain levels: Borg CR10 questionnaire (decreased levels indicate improvement) Pain levels: VAS: decreased joint pain levels indicate improvement

Improved P<.001 Pre 5.3
1.5 Post 1.8
1.9 Pilates, nZ20 Improved P<.001 Pre 2.30
1.8 Post 0.00
0.0 Pilates, nZ25

No change PZ.391 Pre 4.4
2.3 Post 3.8
2.7 No intervention, nZ11 No change PZ.09 Pre 2.9
2.4 Post 3.1
2.2 CEG, nZ25

Pilates > Control PZ.019

-0.88 (-1.65, -0.11)

Large, favors Pilates

Pilates > CEG P<.001

-1.96 (-2.64, -1.29)

Large, favors Pilates

(continued on next page)

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Pain Alves de Araujo et al27 Sedentary university students with nonstructural scoliosis Mendonc¸a et al10 Children with JIA

Outcome Measurement Description

Study Author, Year; Population Group

Outcome Measurement Description

Anthropometric measurements Tunar et al35 BMI SDS (kg per m2) Height: Harpenden Sedentary adolescents stadiometer with Type 1 Diabetes Weight: nearest 100 g Mellitus Metabolic measurements Tunar et al35 Sedentary adolescents: Type 1 diabetes mellitus

Metabolic control In blood glucose levels (HbA1c) (%)

In daily insulin dose (u per kg)

In high density lipoprotein level (mg per dl) In low density lipoprotein level (mg per dl) In cholesterol (mg per dl)

In triglyceride (mg per dl)

Finatto et al30 Trained young adult distance runners

Metabolic cost: Medigraphics gas analyzer: VO2000 oxygen consumption on treadmill (VO2max) (mL$kg-1$min1)

Pilates Exercise Group Mean
SD

Control Group/Other Exercise Group, Mean
SD

No pre, post or P values stated Pilates, nZ17

No change No P value stated Pre 8.9
1.6 Post 8.8
1.5 Pilates, nZ17 No change No P value stated Pre 1.1
0.3 Post 1.0
0.2 No change No P value stated Pre 53.9
11.5 Post 56.9
09.6 No change No P value stated Pre 87.4
18.1 Post 85.3
14.6 No change No P value stated Pre 167.4
23.4 Post 167.5
25.8 No change No P value stated Pre 85.9
40.2 Post 89.9
46.8 Improved P<.001 Pre 51.8
1.7 Post 58.5
1.6 Pilates, nZ16

Between Group P Value

Effect Size: Hedges g (95% CI)

Effect Size Category

No pre, post or P values stated No intervention, nZ14

No difference between group BMI SDS score: Pilates 0.04 (1.20) Control 0.18 (1.22) No P value stated

Unable to calculate

Unable to calculate

No change No P value stated Pre 9.2
2.1 Post 8.7
1.8 No intervention, nZ14 No change No P value stated Pre 1.0
0.2 Post 1.0
0.2 Improved P<.05 Pre 58
12.8 Post 64
17.1 No change P<.05 Pre 94.8
25.9 Post 99.1
32.8 No change No P value stated Pre 195.6
62.3 Post 196.1
62.1 No change No P value stated Pre 104.1
80.2 Post 95.1
57.5 Improved P<.001 Pre 51.3
1.2 Post 53.7
1.6 CEG, nZ16

No difference No P value stated

0.06 (-0.65, 0.77)

Medium, favors Pilates

No difference No P value stated

0.00 (-0.71, 0.71)

Unable to calculate

Improved Control > Pilates PZ.046

-0.51 (-1.23, 0.21)

Medium, favors Pilates

No difference No P value stated

-0.55 (-1.27, 0.17)

Medium, favors Pilates

No difference No P value stated

-0.61 (-1.33, 0.11)

Medium, favors Pilates

No difference No P value stated

-0.10 (-0.81, 0.61)

Unable to calculate

No Difference PZ.204

2.92 (1.93, 3.92)

Large, favors Pilates

21

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Pilates intervention in children

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Table 3 (continued )

22

Table 3 (continued ) Study Author, Year; Population Group

Outcome Measurement Description Metabolic cost at 10 km per h (Cmet10) (J$kg1$m1)

Pilates Exercise Group Mean
SD

Improved P<.001 Pre 4.3
0.1 Post 3.8
0.1 Improved Metabolic cost: P<.001 at 12 km per h (Cmet12) Pre 5.0
0.1 (J$kg1$m1) Post 4.3
0.1 Other ICF Categories: Activity, Participation, and Contextual Factors: Function Functional ability: CHAQ Improved Mendonc¸a et al10 Children with JIA (Decreased scores No P value stated indicate Pre 0.9
0.5 improvement) Post 0.1
0.1 Pilates, nZ25 HRQoL HRQoL: Peds QL Improved Mendonc¸a et al10 Children with JIA 4.0 Questionnaire P<.0001 Pre 47.4
12.3 Post 82.2
12.6 Pilates, nZ25

Control Group/Other Exercise Group, Mean
SD

Between Group P Value

Effect Size: Hedges g (95% CI)

No Difference PZ.868

-0.97 (1.71, -0.24)

Large, favors Pilates

Pilates > CEG PZ.014

-3.90 (-5.08, -2.72)

Large, favors Pilates

No change No P value stated Pre 0.9
0.6 Post 0.9
0.5 CEG, nZ25

Pilates > CEG P<.001

-2.18 (-2.88, -1.48)

Large, favors Pilates

No change No P value stated Pre 51.7
17.6 Post 46.9
12.6 CEG, nZ25

Pilates > CEG P<.001

2.76 (1.98, 3.53)

Large, favors Pilates

Improved P<.001 Pre 4.3
0.1 Post 3.9
0.1 Improved P<.001 Pre 5.2
0.9 Post 4.7
0.1

Effect Size Category

NOTE. Large effect size (0.8); Medium effect size (0.5); Small effect size (0.2). Abbreviations: ASIS, anterior superior iliac spine; BMI SDS, body mass index standard deviation score; CEG, conventional exercise group; CHAQ, Childhood Health Assessment Questionnaire; CI, confidence interval; EMG, electromyography; ICF, International Classification Function, Disability and Health; L, left; Peds QL 4.0, Pediatric Quality of Life Inventory version 4.0 Questionnaire; pERM-ROM, Pediatric Escola Paulista de Medicina Range of Motion; ROM, range of motion; R, right; VAS, visual analog scale; V_O2max, maximum oxygen consumption.

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Pilates intervention in children There were a few intervention studies with mixed outcomes in pediatric and adult studies. Two pediatric studies reported improved spinal alignment in children with scoliosis (both Level II).27,32 This was not a focus of adult studies.48 Since there is only very weak evidence in the scoliosis literature that exercises of any kind will alter the progression of spinal deformity, further research is required before recommending this as an aim of Pilates intervention.49,50 Two pediatric studies showed mixed results in improving anthropometric measurements such as oxygen consumption or metabolic cost in runners (Level II)30 and body mass index or metabolic control in Type 1 diabetes mellitus (Level III).35 There are also limited studies and mixed results for these outcomes in adults, suggesting Pilates may not be the treatment of choice for these outcomes. To date, there has been limited Pilates research in neurologic and respiratory populations in children and adults. No pediatric studies met criteria for this review. However, 1 recent case study of a 9-year-old child with hemiplegic cerebral palsy showed that Pilates intervention could improve postural control and muscle strength in both the affected and unaffected limbs.51 This may suggest further research is warranted in neurologic populations. A few studies with respiratory populations across broad age ranges (eg, cystic fibrosis patients aged 7-33y) suggest that Pilates may improve respiratory muscle strength.52 This emerging positive evidence indicates that further research with children with respiratory conditions may be of benefit.

Methodology This review highlighted several methodological differences between Pilates interventions for children. A key difference was the intervention provider, which included professionals with health (eg, physiotherapists) or education (eg, physical education teachers) backgrounds with Pilates training, compared to Pilates instructors with no other formal qualifications. This finding is consistent with the adult literature.53 Since most studies with children reported improvements and no studies reported adverse side effects, it appears that healthy children could participate safely and effectively with education and dance oriented instructors. However, children with clinical conditions associated with pain or motor control difficulties, may be more suited to a health practitioner with Pilates training who can integrate exercise prescription whilst monitoring medical signs and symptoms of the child’s condition. Another difference was the choice of either mat-based or equipment-based intervention elements. Of the 11 studies, 7 utilized mat-based exercises (4 Level II and 3 Level III), with results favoring Pilates with predominantly large effect sizes. Three studies utilized both mat and equipment exercises (2 Level II and 1 Level III), again favoring Pilates with predominantly large effect sizes. One study did not specify mat vs equipment use (Level II). No included studies compared mat- vs equipment-based approaches. However, 2 adult studies have compared these approaches, with 1 study favoring each approach. This suggests that use of equipment can be varied to meet the needs of settings and participants providing the principles of Pilates are followed.54,55 Further research investigating outcomes specifically for children is needed.

Level of evidence Varying levels of evidence should be considered when selecting Pilates for different populations of children. In our included studies, design varied from Level II to Level III, with higher levels www.archives-pmr.org

23 tending to correspond to studies involving clinical populations (eg, JIA or scoliosis) and lower level studies tending to involve populations of athletes (eg, dancers or archers). Quality of groupbased trials varied from 2 of 10 to 8 of 10, again with higher scores mostly attributed to studies involving clinical populations (eg, JIAd8 of 10; nonstructural scoliosis 6 of 10) and lower scores more frequently seen with populations of athletes (eg, dancersd3 of 10 and 2 of 10). The clinical study by Mendonc¸a et al10 in 2013, for example, involving physiotherapy-led Pilates for children 8-18 years with JIA, had good design (Level II) and quality (PEDro 8 of 10), so it gives good insight into the clinical requirements and expected outcomes in pain and HRQoL for children with JIA. However, this study involved intervention twice per week for 50 minutes for nearly 6 months, so further research is warranted to determine a minimally effective dose. Another high-quality sports-focused study by Finatto et al30 in 2018 (Level II, Quality 8 of 10) with middle distance runners showed Pilates could improve metabolic cost, postural and motor control for running and ultimately running speed. Since the majority of studies used a pre-post design, it is difficult to determine how long it takes for Pilates to be effective. One reported SCED by English in 2007 with baseball pitchers scored moderately for quality on the Risk of Bias in N-of-1 Trials scale (18 of 30),39 and repeated measures suggested improvement may occur in some participants in some measures after 6 sessions. It would be beneficial for future research to monitor performance regularly during intervention and during maintenance phases to improve understanding of the minimal dose required for effective outcomes.

Study limitations A few limitations have been noted in this review. First, although positive outcomes were seen for children in all included studies, generally poor methodological and reporting quality was evident in the body of literature, which needs to be addressed in future research. Second, there is an absence of follow-up in the studies investigating sustainability of benefit. Third, while the study has provided Level II evidence with large effect sizes supporting Pilates compared to some alternative interventions for some physical attributes, in some population groups, there is room for future research to confirm effects for these and other populations and outcomes, and to compare effect in comparison with other alternative treatments. Future studies could focus on ascertaining the minimum effective dose and intervention frequency and duration required for specific populations and outcomes. Finally, intervention selection and practitioner qualifications and training varied between studies. Future research could compare practitioner training and exercise selection to determine which is the most effective approach for particular populations and specific physical function or participation outcomes.

Conclusions The primary objectives of this systematic review were to identify studies of Pilates intervention for children and youth and to evaluate effectiveness of these interventions for improving physical function. Overall, results show that research for children and youth is in the preliminary stages, with 11 studies identified. Of these, 7 studies were of Level II evidence, and 5 of these showed large effect sizes to improve physical attributes such as flexibility,

24 muscle strength, postural control, or pain. In comparison, Pilates does not appear to consistently affect attributes such as metabolic function or anthropometric measures. Methodological quality was variable across studies, highlighting a need for further research with well-designed clinical trials to confirm effectiveness for specific population groups and to ascertain ideal frequency, duration, and model of treatment. This information is needed to underpin treatment guidelines for children with elite sporting goals, or musculoskeletal, respiratory, or neurologic pathologies associated with issues of pain, poor flexibility, strength, or postural control. This in turn may assist children to improve their physical activity participation and quality of life.

Keywords Children; Pain; Rehabilitation

Corresponding author Elizabeth Hornsby, BPhty, C/- Division of Physiotherapy, Building 84a, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, 4072, Australia. E-mail address: [email protected].

Acknowledgments We thank the Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Australia, who supported this study.

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