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Cochrane Database of Systematic Reviews

Pilates for low back pain

Information

DOI:
https://doi.org/10.1002/14651858.CD010265.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 02 July 2015see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Back and Neck Group

Copyright:
  1. Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Tiê P Yamato

    Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia

  • Christopher G Maher

    Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia

  • Bruno T Saragiotto

    Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia

  • Mark J Hancock

    Faculty of Human Sciences, Macquarie University, Sydney, Australia

  • Raymond WJG Ostelo

    Department of Health Sciences, EMGO Institute for Health and Care Research, VU University, Amsterdam, Netherlands

  • Cristina MN Cabral

    Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil

  • Luciola C Menezes Costa

    Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil

  • Leonardo OP Costa

    Correspondence to: Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil

    [email protected]

    [email protected]

    Faculty of Medicine, The University of Sydney, Australia, The George Institute for Global Health, Sydney, Australia

Contributions of authors

Conception, design and drafting of the protocol: Leonardo OP Costa, Luciola da Cunha Menezes Costa and Cristina Maria Nunes Cabral.

Critical revision of the protocol for important intellectual content: Chris G Maher, Raymond Ostelo and Mark Hancock.

Final approval of the protocol: all authors.

Collection and assembly of data: Tiê P Yamato, Bruno T Saragiotto.

Analysis and interpretation of the data: Tiê P Yamato, Bruno T Saragiotto and Chris G Maher.

Drafting of the article: Tiê P Yamato, Bruno T Saragiotto and Chris G Maher.

Critical revision of the article for important intellectual content: Leonardo OP Costa, Luciola da Cunha Menezes Costa, Chris G Maher, Raymond Ostelo and Mark Hancock.

Final approval of the article: all authors.

Sources of support

Internal sources

  • None, Other.

External sources

  • None, Other.

Declarations of interest

Tiê P Yamato has no conflict of interest.

Christopher G Maher has no conflict of interest.

Bruno T Saragiotto has no conflict of interest.

Mark J Hancock has no conflict of interest.

Raymond WJG Ostelo has no conflict of interest.

Cristina MN Cabral conducted two randomised controlled trials that use Pilates as an intervention for patients with chronic non‐specific low back pain and she is also author of one of the included trials (Miyamoto 2013).

Luciola da C Menezes Costa has no conflict of interest.

Leonardo OP Costa conducted two randomised controlled trials that use Pilates as an intervention for patients with chronic non‐specific low back pain and he is also author of one of the included trials (Miyamoto 2013).

Acknowledgements

Tiê Parma Yamato is supported by CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior), Brazil. Chris Maher is supported by National Health and Medical Research Council of Australia. Bruno Tirotti Saragiotto is supported by CNPQ (Conselho Nacional de Desenvolvimento Científico e Tecnológico), Brazil.

Version history

Published

Title

Stage

Authors

Version

2015 Jul 02

Pilates for low back pain

Review

Tiê P Yamato, Christopher G Maher, Bruno T Saragiotto, Mark J Hancock, Raymond WJG Ostelo, Cristina MN Cabral, Luciola C Menezes Costa, Leonardo OP Costa

https://doi.org/10.1002/14651858.CD010265.pub2

2012 Dec 12

Pilates for low‐back pain

Protocol

Leonardo OP Costa, Mark Hancock, Christopher G. Maher, Raymond WJG Ostelo, Cristina MN Cabral, Luciola daC Menezes Costa

https://doi.org/10.1002/14651858.CD010265

Differences between protocol and review

There were some differences between the protocol and review in three subsections of Data collection and analysis:

  • In Selection of studies, the screening for potentially eligible studies was conducted by two pairs of review authors instead of two review authors as stated in the protocol.

  • In Measures of treatment effect, we had pre‐specified in our protocol that for different scales we were going to quantify effect using the standardised mean difference (SMD) and the mean difference (MD) for studies using the same scale. However, we decided to quantify the effects of treatments using the MD for all continuous outcomes. If different scales were used we converted the scales to a 0 to 100 point scale.

  • We did not perform a sensitivity analysis by excluding trials where the definition of the intervention was not clear because all definitions of Pilates exercise were consistent with our criteria.

  • We did not perform a subgroup analysis for duration of symptoms as all trials included chronic patients.

  • In Assessment of heterogeneity, we included an acceptable range of the I2 value (< 50%) to combine the results in a meta‐analysis when no clear heterogeneity was identified by visual inspection. We used the 50% cut‐off as I2 values above this value may represent substantial heterogeneity.

  • The approach to GRADE has been clarified further since the protocol with more detail about downgrading.

  • We found three potentially eligible studies in trial registries reported as completed at least two years ago, for which no publicly available report was found. Additionally, we were unable to contact the authors for these trials. Thus, we considered that there was a possibility of publication bias in this review and downgraded all studies regarding publication bias for the analysis of quality of evidence (GRADE). This condition was not mentioned previously in the protocol.

  • Two studies measured quality of life, but the data from the physical and mental components were not available in the text and the authors did not provide this information on request (Natour 2014; Wajswelner 2012), so we were unable to analyse this primary outcome cited in the protocol.

  • We did not find any studies that reported return to work, so we were unable to analyse this secondary outcome cited in the protocol.

Keywords

MeSH

Medical Subject Headings Check Words

Humans;

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 Pilates versus minimal intervention, outcome: 1.1 Pain.
Figures and Tables -
Figure 3

Forest plot of comparison: 1 Pilates versus minimal intervention, outcome: 1.1 Pain.

Forest plot of comparison: 2 Pilates versus other exercises, outcome: 2.2 Disability.
Figures and Tables -
Figure 4

Forest plot of comparison: 2 Pilates versus other exercises, outcome: 2.2 Disability.

Comparison 1 Pilates versus minimal intervention, Outcome 1 Pain.
Figures and Tables -
Analysis 1.1

Comparison 1 Pilates versus minimal intervention, Outcome 1 Pain.

Comparison 1 Pilates versus minimal intervention, Outcome 2 Disability.
Figures and Tables -
Analysis 1.2

Comparison 1 Pilates versus minimal intervention, Outcome 2 Disability.

Comparison 1 Pilates versus minimal intervention, Outcome 3 Function.
Figures and Tables -
Analysis 1.3

Comparison 1 Pilates versus minimal intervention, Outcome 3 Function.

Comparison 1 Pilates versus minimal intervention, Outcome 4 Global impression of recovery.
Figures and Tables -
Analysis 1.4

Comparison 1 Pilates versus minimal intervention, Outcome 4 Global impression of recovery.

Comparison 2 Pilates versus other exercises, Outcome 1 Pain.
Figures and Tables -
Analysis 2.1

Comparison 2 Pilates versus other exercises, Outcome 1 Pain.

Comparison 2 Pilates versus other exercises, Outcome 2 Disability.
Figures and Tables -
Analysis 2.2

Comparison 2 Pilates versus other exercises, Outcome 2 Disability.

Comparison 2 Pilates versus other exercises, Outcome 3 Function.
Figures and Tables -
Analysis 2.3

Comparison 2 Pilates versus other exercises, Outcome 3 Function.

Pilates compared with minimal intervention for low back pain

Patient or population: patients with low back pain

Settings: primary or tertiary care

Intervention: Pilates

Comparison: minimal intervention

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Minimal intervention

Pilates

Pain

NRS: scale from 0 to 100 (worse pain)

Follow‐up: short‐term (less than 3 months from randomisation)

The mean pain at short‐term follow‐up ranged across control groups from

33.9 to 52 points

The mean pain at short‐term follow‐up in the intervention groups was
14.05 lower

(18.9 to 9.2 lower)

Mean difference ‐14.05 (‐18.91 to ‐9.19)

265 participants
(6 studies)

⊕⊕⊝⊝
low1,2

This is a moderate effect that is clinically relevant in this patient group

Pain

NRS: scale from 0 to 100 (worse pain)

Follow‐up: intermediate‐term (more than 3 months and less than 12 months)

The mean pain at intermediate‐term follow‐up ranged across control groups from

53 to 58.3 points

The mean pain at intermediate‐term follow‐up in the intervention group was

10.5 lower

(18.5 to 2.6 lower)

Mean difference ‐10.54 (‐18.46 to ‐2.62)

146 participants

(2 studies)

⊕⊕⊕⊝
moderate1

This is a moderate effect that is clinically relevant in this patient group

Disability

Multiple scales: scale from 0 to 100 (worse disability)

Follow‐up: short‐term (less than 3 months from randomisation)

The mean disability at short‐term follow‐up ranged across control groups from

13.3 to 44.1 points

The mean disability at short‐term follow‐up in the intervention groups was

7.95 lower

(13.2 to 2.7 lower)

Mean difference ‐7.95 (‐13.23 to ‐2.67)

248 participants

(5 studies)

⊕⊕⊝⊝
low1,4

This is a small effect that may be clinically relevant in this patient group

Disability

Multiple scales: scale from 0 to 100 (worse disability)

Follow‐up: intermediate‐term (more than 3 months and less than 12 months)

The mean disability at intermediate‐term follow‐up ranged across control groups from

27.9 to 44.4 points

The mean disability at intermediate‐term follow‐up in the intervention groups was
11.2lower

(18.4 to 3.9 lower)

Mean difference ‐11.17 (‐18.41 to ‐3.92)

146 participants

(2 study)

⊕⊕⊕⊝
moderate1

This is a moderate effect that is clinically relevant in this patient group

Function

Patient Specific Functional Scale: used in a 11‐point scale from 0 to 10 (greater functional ability)

Follow‐up: short‐term (less than 3 months from randomisation)

The mean function at short‐term follow‐up in the control group was

6.4 points

The mean function at short‐term follow‐up in the intervention group was

1.1 higher

(0.2 to 2.0 higher)

Mean difference 1.10 (0.23 to 1.97)

86 participants

(1 study)

⊕⊕⊝⊝
low1,3

This is a small effect that may be clinically relevant in this patient group (results from 1 single study)

Function

Patient Specific Functional Scale: used in a 11‐point scale from 0 to 10 (greater functional ability)

Follow‐up: intermediate‐term (more than 3 months and less than 12 months)

The mean function at intermediate‐term follow‐up in the control group was

6.1 points

The mean function at intermediate‐term follow‐up in the intervention group was

0.8 higher

(0.0 lower to 1.6 higher)

Mean difference 0.80 (‐0.00 to 1.60)

86 participants

(1 study)

⊕⊕⊝⊝
low1,3

The difference is not statistically or clinically significant (results from 1 single study)

Global impression of recovery

Global Perceived Effect Scale: scale from ‐5 to +5 (greater recovery)

Follow‐up: short‐term (less than 3 months from randomisation)

The mean global impression of recovery at short‐term follow‐up in the control group was

1.7 points

The mean global impression of recovery at short‐term follow‐up in the intervention group was

1.5 higher

(0.7 to 2.3 higher)

Mean difference 1.50 (0.70 to 2.30)

86 participants

(1 study)

⊕⊕⊝⊝
low1,3

This is a small effect that may be clinically relevant in this patient group (results from 1 single study)

Global impression of recovery

Global Perceived Effect Scale: scale from ‐5 to +5 (greater recovery)

Follow‐up: intermediate‐term (more than 3 months and less than 12 months)

The mean global impression of recovery at intermediate‐term follow‐up in the control group was

1.7 points

The mean global impression of recovery at intermediate‐term follow‐up in the intervention group was

0.7 higher

(0.1 lower to 1.5 higher)

Mean difference 0.70 (‐0.11 to 1.51)

86 participants

(1 study)

⊕⊕⊝⊝
low1,3

The difference is not statistically or clinically significant (results from 1 single study)

Adverse events

See comment

See comment

Not estimable

See comment

Only 1 included trial assessed adverse events and none were reported

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Downgraded one level due to imprecision (fewer than 400 participants, total).

2 Downgraded one level due to risk of bias (> 25% of the participants were from studies with a high risk of bias).

3Downgraded one level due to clear inconsistency of results.

4Downgraded one level due to inconsistency (I² > 50%).

Figures and Tables -

Pilates compared with other exercises for low back pain

Patient or population: participants with low back pain

Settings: primary and tertiary care

Intervention: Pilates

Comparison: other exercises

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Other exercises

Pilates

Pain

NRS: scale from 0 to 100 (worse pain)

Follow‐up: short‐term (less than 3 months from randomisation)

Not estimated

Not estimated

Not estimated

181 participants

(3 studies)

⊕⊕⊝⊝
low1,2

Pooled results not estimated due to high heterogeneity

Pain

NRS: scale from 0 to 100 (worse pain)

Follow‐up: intermediate‐term (more than 3 months and less than 12 months)

Not estimated

Not estimated

Not estimated

151 participants

(2 studies)

⊕⊕⊝⊝
low1,2

Pooled results not estimated due to high heterogeneity

Disability

Multiple scales: scale from 0 to 100 (worse disability)

Follow‐up: short‐term (less than 3 months from randomisation)

The mean disability at short‐term follow‐up ranged across control groups from

17.1 to 20 points

The mean disability at short‐term follow‐up in the intervention groups was
3.3 lower

(6.8 lower to 0.2 higher)

Mean difference ‐3.29 (‐6.82 to 0.24)

149 participants

(2 studies)

⊕⊕⊕⊝
moderate1

The difference is not statistically or clinically significant

Disability

Multiple scales: scale from 0 to 100 (worse disability)

Follow‐up: intermediate‐term (more than 3 months and less than 12 months)

The mean disability at intermediate‐term follow‐up ranged across control groups from

13 to 18.1 points

The mean disability at intermediate‐term follow‐up in the intervention groups was
0.9 lower

(5.0 lower to 3.2 higher)

Mean difference ‐0.91 (‐5.02 to 3.20)

151 participants

(2 studies)

⊕⊕⊕⊝
moderate1

The difference is not statistically or clinically significant

Function

Patient Specific Functional Scale: scale from 0 to 30 (greater functional ability)

Follow‐up: short‐term (less than 3 months from randomisation)

The mean function at short‐term follow‐up in the control group was

18.9 points

The mean function at short‐term follow‐up in the intervention group was

0.1 lower

(2.4 lower to 2.6 higher)

Mean difference 0.10 (‐2.44 to 2.64)

87 participants

(1 study)

⊕⊕⊝⊝
low1,3

The difference is not statistically or clinically significant (results from 1 single study)

Function

Patient Specific Functional Scale: scale from 0 to 30 (greater functional ability)

Follow‐up: intermediate‐term (more than 3 months and less than 12 months)

The mean function at intermediate‐term follow‐up in the control group was

22.8 points

The mean function at intermediate‐term follow‐up in the intervention group was

3.6 lower

(7 to 0.2 lower)

Mean difference ‐3.60 (‐7.00 to ‐0.20)

87 participants

(1 study)

⊕⊕⊝⊝
low1,3

This is a small effect that may be clinically relevant in this patient group (results from 1 single study)

Adverse events

See comment

See comment

Not estimable

See comment

1 trial assessed adverse events and reported minor events

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Downgraded one level due to imprecision (fewer than 400 participants, total).

2Downgraded one level due to inconsistency (I² > 50%).

3Downgraded one level due to clear inconsistency of results.

Figures and Tables -
Table 1. Clinical Relevance Assessment for Each Study

Studies/criteria

Are the patients described in detail so that you can decide whether they are comparable to those that you see in your practice?

Are the interventions and treatment settings described well enough so that you can provide the same for your patients?

Were all clinically relevant outcomes measured and reported?

Is the size of the effect clinically important?*

Are the likely treatment benefits worth the potential harms?

Brooks 2012

Yes

Yes

Yes

No

Yes

Fonseca 2009

Yes

Yes

No

No

Yes

Gladwell 2006

Yes

Yes

Yes

No

Yes

Marshall 2013

Yes

Yes

Yes

No

Yes

Miyamoto 2013

Yes

Yes

Yes

Yes1

Yes

Natour 2014

Yes

Yes

Yes

Yes1

Yes

Quinn 2011

Yes

Yes

Yes

Yes2

Yes

Rajpal 2008

No

Yes

No

No

Yes

Rydeard 2006

Yes

Yes

Yes

No

Yes

Wajswelner 2012

Yes

Yes

Yes

No

Yes

*Clinical importance: consider 30% on VAS/NRS for pain intensity as clinically significant, and 2 to 3 points (or 8% to 12%) on the Roland‐Morris Disability Questionnaire for disability.

1Disability (short and intermediate‐term).

2Disability (short‐term).

Figures and Tables -
Table 1. Clinical Relevance Assessment for Each Study
Comparison 1. Pilates versus minimal intervention

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Show forest plot

6

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Short‐term (< 3/12 months from randomisation)

6

265

Mean Difference (IV, Random, 95% CI)

‐14.05 [‐18.91, ‐9.19]

1.2 Intermediate‐term (more than 3/12 months, less than 12/12 months)

2

146

Mean Difference (IV, Random, 95% CI)

‐10.54 [‐18.46, ‐2.62]

2 Disability Show forest plot

5

Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 Short‐term (< 3/12 months from randomisation)

5

248

Mean Difference (IV, Random, 95% CI)

‐7.95 [‐13.23, ‐2.67]

2.2 Intermediate‐term (more than 3/12 months, less than 12/12 months)

2

146

Mean Difference (IV, Random, 95% CI)

‐11.17 [‐18.41, ‐3.92]

3 Function Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

3.1 Short‐term (< 3/12 months from randomisation)

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3.2 Intermediate‐term (more than 3/12 months, less than 12/12 months)

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4 Global impression of recovery Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 Short‐term (< 3/12 months from randomisation)

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4.2 Intermediate‐term (more than 3/12, less than 12/12 months)

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 1. Pilates versus minimal intervention
Comparison 2. Pilates versus other exercises

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Show forest plot

4

Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Short‐term (< 3/12 months from randomisation)

3

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

1.2 Intermediate‐term (more than 3/12, less than 12/12 months)

2

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Disability Show forest plot

3

Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 Short‐term (< 3/12 months from randomisation)

2

149

Mean Difference (IV, Random, 95% CI)

‐3.29 [‐6.82, 0.24]

2.2 Intermediate‐term (more than 3/12, less than 12/12 months)

2

151

Mean Difference (IV, Random, 95% CI)

‐0.91 [‐5.02, 3.20]

3 Function Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

3.1 Short‐term (< 3/12 months from randomisation)

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3.2 Intermediate‐term (more than 3/12, less than 12/12 months)

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 2. Pilates versus other exercises