Journal of Bodywork & Movement Therapies (2015) 19, 636e645

Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/jbmt

RANDOMISED, CONTROLLED TRIAL

Pilates versus general exercise effectiveness

on pain and functionality in non-specific
chronic low back pain subjects
Fernanda Queiroz Ribeiro Cerci Mostagi, PT, MSc a,
Josilainne Marcelino Dias, PT, MSc a,
Ligia Maxwell Pereira, PT, MSc, PhD a, Karen Obara, PT, MSc a,
Bruno Fles Mazuquin, PT, MSc a,b,
Mariana Felipe Silva, PT, MSc a,
Monica Angelica Cardoso Silva, PT, MSc a,
Renata Rosa de Campos, PT, MSc a,
Maria Simone Tavares Barreto, PT, MSc a,
o Lima, PT, MSc c,
ssyca Fernandes Nogueira a, Tarcsio Branda
Je
Rodrigo Luiz Carregaro, PT, MSc, PhD d,
Jefferson Rosa Cardoso, MSc, PT, PhD a,*
a

Laboratory of Biomechanics and Clinical Epidemiology, Universidade Estadual de Londrina, Londrina,

PR, Brazil
b
Allied Health Research Unit, University of Central Lancashire, Preston, United Kingdom
c
Universidade Tirandentes, Aracaju, SE, Brazil
d
Universidade de Brasilia, Brasilia, DF, Brazil
Received 16 May 2014; received in revised form 5 November 2014; accepted 11 November 2014

KEYWORDS
Clinical trial;
Low back pain;
Physical therapy
modalities;
Pilates

Summary Low back pain (LBP) is one of the most common causes of disability, and the Pilates method has been associated with improvements in symptoms. The purpose of this study
was to assess the effectiveness of the Pilates method, when compared to general exercises, on
pain and functionality after eight weeks (16 sessions, 2
/week) and a follow-up of three
months, in subjects with non-specific chronic low back pain (NSCLBP). A randomised controlled
trial composed of 22 subjects was proposed. Subjects were allocated into two groups: the Pilates group (PG) (n Z 11) and the general exercise group (GEG) (n Z 11). The PG protocol was

* Corresponding author. Laboratory of Biomechanics and Clinical Epidemiology, PAIFIT Research Group, Universidade Estadual de Londrina, Londrina, PR, Brazil. Av. Robert Koch, 60, Londrina-PR 86038-440, Brazil. Tel.: 55 43 3371 2649; fax: 55 43 3371 2459.
E-mail address: jeffcar@uel.br (J.R. Cardoso).
http://dx.doi.org/10.1016/j.jbmt.2014.11.009
1360-8592/ 2014 Elsevier Ltd. All rights reserved.

Pilates versus general exercise on pain and functionality in non-specific chronic low back pain subjects

637

based on the Pilates method and the GEG performed exercises to manage NSCLBP. There were
no differences between the groups. When analysed over time, the GEG demonstrated improvements in functionality between baseline and the end of treatment (P Z .02; Cohens d Z 0.34)
and baseline and follow-up (P Z .04; Cohens d Z 0.31). There were no differences between
the Pilates and general exercises with regard to pain and functionality in NSCLBP subjects but
general exercises were better than Pilates for increasing functionality and flexibility.
2014 Elsevier Ltd. All rights reserved.

Introduction
Low back pain (LBP) is one of the most common causes of
disability and is the most common musculoskeletal condition found in the adult population, with a prevalence of up
to 84%. Back pain may be the leading cause of absenteeism
in North American countries and between 60% and 90% of
the population is at risk of developing this condition during
their life (Dagenais et al., 2010; Delitto et al., 2012;
Philadelphia Panel, 2001; van Middelkoop et al., 2011).
Low back pain has a significant impact on functional capacity, as the pain restricts occupational activities and is a
major cause of absenteeism. Thus, the economic burden of
low back pain is represented directly by the high costs of
health care spending and indirectly by decreased productivity (Dagenais et al., 2010; Philadelphia Panel, 2001). The
use of new technology in diagnosis and intervention contributes to the increased costs (Becker et al., 2011). Recent
estimations show that the economic burden of back pain in
the United States, including both direct and indirect, costs
ranges from 84 to 624 billion dollars per year (Dagenais
et al., 2010; Fairbank et al., 2011; Karayannis et al., 2012).
This condition can be classified as specific, in which the
pain is caused by a specific pathology or condition, or
nonespecific, in which the cause of the pain cannot be
determined (Manek and MacGregor, 2005). Back pain can be
further classified into acute (less than six weeks), subacute
(six to 12 weeks) or chronic (longer than 12 weeks) (Hayden
et al., 2005).
Of the various treatment strategies for non-specific chronic
low back pain (NSCLBP), studies have shown that the most
effective treatments use exercise and cognitive/behavioural
programs (Airaksinen et al., 2006; Bekkering et al., 2003;
Philadelphia Panel, 2001; van Middelkoop et al., 2011). Systematic reviews have shown that exercise-based treatments,
especially motor control exercises, present the best evidence
in the management of NSCLBP and this type of intervention
appears to be effective in reducing pain and improving functional status (Airaksinen et al., 2006; Bekkering et al., 2003;
Delitto et al., 2012; Philadelphia Panel, 2001; van
Middelkoop et al., 2011; van Middelkoop et al., 2010; van
Tulder et al., 2000). This can be explained by the mechanical characteristics of CLBP, lumbo-pelvic instability,
decreased joint mobility and neuromuscular mechanisms
greatly impact trunk stability and movement efficiency
(Mannion et al., 2001; Panjabi, 2003).
The trunk muscles can be divided into two groups: the
global and local system. The muscles of the first group
possess long levers and large moment arms, with emphasis

on speed, power, and larger arcs of multiplanar movement.

The second group consists of short muscles with direct action on the vertebra, which generate power for segmental
stability of the spine (transversus abdominis, multifidus,
internal oblique, medial fibres of external oblique, quadratus lumborum, diaphragm, pelvic floor muscles, iliocostalis and longissimus (lumbar portions)) (Faries and
Greenwood, 2007). Evidence regarding the role of trunk
muscles, especially the transversus abdominis and multifidus, has been discussed in the literature and demonstrates that these muscles are the main providers of lumbopelvic stability (Barker et al., 2006, 2004; Hides et al.,
2011; Hodges et al., 2005, 2003; Hodges and Richardson,
1996). Additionally, there is a consensus that these disorders arise from pain and inactivity associated with muscle
disuse (Smeets et al., 2006).
Thus, Pilates could be an alternative treatment for these
patients because it is based on strength and flexibility exercises, which are not exclusively static, but are also dynamic and focus on the muscles that are responsible for
lumbo-pelvic stability (Gladwell et al., 2006). Pilates is
known as a form of physical and mental conditioning
characterised by a set of exercises performed on a mat or
specific apparatus. It was created by Joseph Humbertus
Pilates in the middle of the last century and is based on six
principles: concentration, control, centring, flow, precision
and breathing (Latey, 2001; Muscolino and Cipriani, 2004).
Several studies, both RCTs and systematic reviews, have
evaluated the Pilates method for low back pain, but their
results are conflicting (Aladro-Gonzalvo et al., 2012;
Anderson, 2005; Cruz-Ferreira et al., 2013; Donzelli et al.,
2006; Gagnon, 2005; La Touche et al., 2008; Lim et al.,
2011; Marshall et al., 2013; Miyamoto et al., 2011; Natour
et al., 2011; Pereira et al., 2012; Posadzki et al., 2011;
Rydeard et al., 2006; Wajswelner and Metcalf, 2012). In
addition, one study evaluated the methodological quality
of systematic reviews on the effectiveness of Pilates to
treat adults with CLBP (Wells et al., 2013). The authors
included five systematic reviews that evaluated the outcomes of pain and functionality and determined that there
was inconclusive evidence as to whether the Pilates method
is effective in reducing pain and improving functionality in
individuals with CLBP (Wells et al., 2013).
Thus, the aim of the present study was to assess the
effectiveness of the Pilates method, when compared to
general exercises (kinesiotherapy), on pain and functionality after 8 weeks intervention and again after a shortterm follow-up period (three months) in subjects with nonspecific chronic low back pain.

638

F.Q.R.C. Mostagi et al.

Method

Intervention

Design

Participants performed a total of sixteen sessions twice per

week for eight weeks. For both groups, the interventions
comprised a one-hour individual/private session. The PG
received a direction-specific exercise program based on
their history and physical examination. The protocol was
based exclusively on the Pilates method and some adaptations were prescribed following the participants main
complaint (Appendix 1). All exercises were prescribed by a
licensed physical therapist with clinical experience in
managing patients with low back pain.
In the first session, the basic principles of Pilates were
explained and the participants were familiarised with the
exercises. The fundamental principles were reiterated at
the beginning of every class. Body perception aspects
included postural alignment (neutral spine, positioning of
the scapula and cervical spine) and recruitment of core
muscles. All aspects were performed with controlled
breathing.
The GEG received standardised generic exercises that
are commonly used by physical therapists for the management of CLBP. These exercises included stationary bicycling, trunk and lower limb stretching, spine mobilisation
and trunk muscle strengthening (Appendix 2). The orientation/application was performed by three licensed physical therapists with expertise in exercise prescription and
previous guidelines of exercise-based treatment for CLBP.
None of the physical therapists involved in either program
had access at any time to the assessment results.

A randomised controlled trial (RCT) with a three-month

follow-up according to the Consort-Statement (Schulz et al.,
2010) was conducted at the Laboratory of Biomechanics and
Clinical Epidemiology and in a private Pilates studio.
A table of random numbers was generated (www.
random.org) and used for randomisation. The allocation
concealment was performed using opaque sealed envelopes. A researcher who was unaware of the goals or purpose of the study performed this procedure. After
allocation, the participants were referred for treatment.
Data collection and radiological examinations were performed by blinded, independent assessors.

Participants, therapists, and centres

Seventy-two subjects were evaluated for study eligibility,
recruited from the local community and private health
services. Subjects were considered to be eligible if they
were sedentary and had not undergone physical therapy for
at least six months. Moreover, they had to present an
exclusive medical diagnosis of non-specific chronic low
back pain over a period of more than 12 weeks and be
18e55 years old. Subjects were excluded if they had a
diagnosis of protrusion of the intervertebral disc, scoliosis,
spondylolisthesis, previous spine surgery, radicular symptoms, inflammatory disease, rheumatic disease, cancer or
pregnancy. To verify that the participants did not have
structural deformities that would justify the pain, an x-ray
examination was performed by an orthopaedic surgeon
(Airaksinen et al., 2006).
After evaluation of the inclusion criteria, 50 (69%) patients were excluded. Therefore, 22 participants were
recruited. In total, 11 participants were randomised to the
PG group, and 11 participants were randomised to the GEG
group. More information can be found in Fig. 1. All participants were notified of the research procedures, requirements and benefits and were invited to participate by
signing an informed consent form that was approved by the
Universidade Estadual de Londrina Ethics Committee
(#062/2011). The study was registered in the National
Registry of Clinical Trials (REBEC:#7yhzym).

Procedures
The participants who met the eligibility criteria were assessed
on three different occasions: at baseline, at the end of the
treatment (8-weeks) and after three months of follow-up.
Participants attended the laboratory for evaluations. At
the baseline evaluation, the participants signed the consent form, and anthropometric data were collected
(weight, height and waist circumference) for the purpose of
anthropometrical characterisation of the participants.
Following evaluation, the VAS and Quebec Questionnaire
were completed, and then the SRT and Sorensen tests were
performed. After the baseline assessment, participants
were allocated to either the Pilates group (PG) or the
general exercises group (GEG).

Outcome measures
Primary outcome
The primary outcome was pain, which was assessed by a
visual analogue scale e VAS. The participants were
instructed to mark a point on a line between zero and
10 cm. Zero represented no pain and 10 represented the
maximum possible pain (Mannion et al., 2007).
Secondary outcome
Patient functionality was evaluated by the Quebec Back
Pain Questionnaire (0 represented no disability and 100
represented maximum disability) (Rodrigues et al., 2009).
Flexibility was measured by the Sit and Reach test (Fig. 2)
(Kawano et al., 2010).The flexibility value was determined
by kinematic analysis measuring the hip joint angle (HJA).
Three repetitions were performed and the lowest hip angle
of the three attempts was included for analysis. The HJA
was measured by the inclination angle of the sacrum and
pelvis, related to the horizontal line, at the point of
maximal forward reach in the SRT (Cardoso et al., 2007).
The endurance of the trunk extensor muscles was assessed
by the Sorensen test (Fig. 3). The duration of the test was
measured in seconds (Latimer et al., 1999).

Data analysis
The variables were analysed for normal distribution using
the ShapiroeWilk test. When the normality assumption was
accepted, the data were presented as means and standard

Pilates versus general exercise on pain and functionality in non-specific chronic low back pain subjects

Figure 1

deviations (SD). Otherwise, the data were presented as

medians and quartiles (25%e75%). The mean differences
(MD) and 95% confidence intervals (CI) are presented.
Additionally, the effect size was calculated to indicate the
magnitude of treatment effect. Cohens d was used to
measure the effect size for both the PG and GEG for power
analysis purposes. The effect size was classified as high,
medium or low (Cohen, 1988).
To determine statistical differences from baseline, a
Student t-test or ManneWhitney U-test was employed
according to the distribution of the data. To identify
within-group differences, a mixed analysis of variance
(mixed ANOVA) for repeated measures was used with
syntax according to the multivariate model. The Boxs M
test was used to verify the equality of covariance
matrices. Repeated measures ANOVA was used to
compare data between groups. Mauchlys test was used to
test the assumption of sphericity. When sphericity was
not assumed, the Greenhouse-Geisser adjustment
applied. When the F value was significant, the Bonferroni
post hoc test was used to identify the differences. The
statistical significance adopted for all tests was 5%. All
statistics were performed according to intention-to-treat
analyses.

Results
Both groups were similar in all the assessed characteristics
at baseline (Table 1). The dropout rate was 9% and the

639

Flow diagram.

adherence to treatment was 100%. No statistical differences were found between groups for any outcome.
The GEG improved over the period of the study, functionality had statistically improved at the end of treatment
compared to baseline (P Z .02; MD Z 17.7 CI 95% [7.5;
27.9]; Cohens d Z 0.34) and at the follow-up compared to
baseline (P Z .04; MD Z 16.9 CI 95% [0.32; 33.4]; Cohens
d Z 0.31) (Table 2). The GEG also had improved flexibility
at follow-up compared to baseline (P Z .01; MD Z 32.5 IC
95% [7.7; 57.3]; Cohens d Z 0.89) (Table 3). However, the
PG displayed no differences over the period of the study.

Discussion
The results of this study indicate that there is no difference
between the Pilates method and general exercises for the
treatment of NSCLBP. However, a difference was found
within the GEG for functionality and flexibility. The RCT of
Miyamoto et al. (2011) (Pilates versus Minimal Intervention)
and Wajswelner and Metcalf (2012) (Pilates versus General
Exercises) evaluated patients with NSCLBP and their results
agree with the results of the present study. However,
studies of Gladwell et al. (2006) (Pilates versus Control
Group) and Marshall et al. (2013) (Pilates versus Stationary
Bike) found statistical improvements in the Pilates group
for functionality, flexibility, proprioception and pain
outcomes.
Furthermore, the reviews of La Touche et al. (2008) and
Posadzki et al. (2011) reported that the results on the

640

F.Q.R.C. Mostagi et al.

Figure 2

Sit and reach test.

subject were inconclusive, while the systematic review of

Lim et al. (2011) found improvements in the Pilates group
when compared to the control group in pain and functionality outcomes. However, the systematic review of Pereira
et al (2012), considered by Welss et al. (2013) to be the
most reliable, concludes that there is no difference between Pilates and exercise stabilisation or the control
group for patients with NSCLBP. The studies presented here
have methodological differences such as: sample size, type
of subject, different frequency and duration of treatment,
among others. These methodological differences may
explain the differing results.
For pain, no difference was found either between the
groups or within the groups. However, it should be noted
that the mean baseline pain was low: 3 cm for the PG and
2.4 cm for the GEG; there was a decrease for the PG to 0.4
and 0.3 cm at the 8 week and follow-up assessments,
respectively and for the GEG to 0.5 and 1.1 cm at the 8
week and follow-up assessments. Nevertheless, according
to Ostelo et al. (2008), a statistical improvement does not
represent a clinically relevant improvement and the
opposite phenomenon is also true. In this case,

Figure 3

improvements in pain in the present study can be considered satisfactory and must not be discarded.
It is worth noting that the evaluation of chronic pain
requires a clear understanding of its origin and pathophysiology, which is highly complex in NSCLBP. Fears and
beliefs about pain, anxiety, depression and catastrophising
are associated with the perception of the same event
(Dagenais et al., 2010; Lewis et al., 2012). Thus, pain intensity may vary throughout the day, over long periods or
due to physical effort. This subjectivity makes pain difficult
to measure and describe and it also imposes a source of bias
(Mannion et al., 2007). Moreover, nociceptive factors play
an important role; however, the clinical interpretation
cannot be based solely on anatomical factors. In this case,
the psychosocial dimensions become relevant and have
been identified as possible causes of pain and could affect
the development of and patient prognosis (Airaksinen
et al., 2006; Dellito et al., 2012).
For trunk extensor endurance, no differences were
found either between groups or within groups. According to
Latimer et al. (1999), asymptomatic individuals performed
the Sorensen test for an average of 132 s and patients with

Sorensen test.

Pilates versus general exercise on pain and functionality in non-specific chronic low back pain subjects
Table 1

Baseline characteristics of participants.

PG (11)

Gender
Male (n; %)
2; 18.2
Female (n; %)
9; 81.8
Age (y)
Mean (SD)
36.1 (9)
BMI (kg/m2)
Md (1st;3rd quartile) 25.7 (22; 26.9)
Abdominal circumference (cm)
Mean (SD)
87.4 (8.3)

2; 18.2
9; 81.8
34.7 (8.1)
28.2 (26.6; 32.6)
91 (13.1)

chronic low back pain performed the test for 94.6 s.

Another study (Alaranta et al., 1995) showed that lower
values of endurance (less than 58 s) may be associated with
recurrent episodes of low back pain. However, a review
(Demoulin et al., 2006) showed that, although widely used,
the Sorensen test presents variations in the test description, duration, predictive values, differences between
genders and reasons for ending the test. Furthermore, according to Ropponen et al. (2005), pain and fear can also
interfere with performance in this endurance test, which
could explain our findings.
For flexibility, there was no difference between the
groups. However, the GEG showed an improvement over
time and this result was not observed for the PG. ROM is
known to improve after approximately 3e4 weeks of
stretching exercises (Decoster et al., 2005). However, the
type of stretching in the evaluated groups was different.
The PG performed dynamic stretches, whereas the GEG
performed static stretches. Another distinguishing factor
was the time of realisation of the exercise. In the PG, this
factor was not controlled and for the GEG, this time was
between 30 s and 1 min with progression in the repetitions.
Static stretching may be better than dynamic stretching
(Bandy et al., 1998; Decoster et al., 2005). The

Summary of the primary outcome measures.

PG (n Z 11)

VAS (cm) md (1st; 3rd quartiles)

Baseline
3.0 (0.3; 4.7)
8th week
0.4 (0; 3.5)
Follow up
0.3 (0; 2)
Quebec Scale mean (SD)
Baseline
27 (15.7)
8th week
15.5 (10.3)
Follow-up
16 (11.7)

Summary of the secondary outcome measures.

GEG (11)

P > .05 for all analyses. PG: Pilates Group; GEG: General Exercise Group; M: male; F: female; y: years; SD: standard deviation; BMI: body mass index; Md: median; cm: centimetres;
VAS: visual analogue scale; SRT: sit and reach test; s: seconds.
Intention-to-treat analyses.

Table 2

Table 3

GEG (n Z 11)
2.3 (1.1; 3.1)
0.50 (0; 2.1)
1.1 (0.1; 2.2)
29.4 (17.8)
11.7 (9)a
12.5 (10.8)b

PG: Pilates Group; GEG: General Exercise Group; VAS: visual

analogue scale; Md: Median; SD: standard deviation; a: P Z .02
(Baseline
8th week GEG, Mean Difference Z 17.7 CI 95% [7.5;
27.9]); b: P Z .04 (Baseline
Follow-up GEG, Mean
Difference Z 16.9 CI 95% [0.32; 33.4]). Intention-to-treat
analyses.

641

SRT (cm) mean (SD)

Baseline
8th week
Follow up
Sorensen Test (s) Md
Baseline
8th week
Follow-up

PG (n Z 11)

GEG (n Z 11)

112.1 (20.8)
95.5 (24.3)
97.3 (20.5)

112.6 (22.9)
103.2 (26.3)
80 (18.3)c

rd
st
;(13 quartiles)

44 (34; 68)
68 (56; 78)
67 (51; 80)

39 (19; 85)
58 (22; 66)
40 (20; 63)

PG: Pilates Group; GEG: General Exercise Group; SRT: sit and
reach test; cm: centimetres; SD: standard deviation; c: P Z .01
(Baseline
Follow-up GEG, Mean Difference Z 32.5 cm IC 95%
[7.7; 57.3]); s: seconds; Md: Median. Intention-to-treat
analyses.

recommended time to achieve results is between 10 and

30 s (Bandy et al., 1997); furthermore, 2 to 4 repetitions
have better results than just one (Garber et al., 2011).
There are some valid comments regarding this outcome.
The SRT was used to assess flexibility and evaluated the
flexibility of the hamstrings. However, some studies have
reported that this test is a poor indicator of hamstring
flexibility because it has several confounding factors (Davis
et al., 2008). Nonetheless, the SRT was adopted due to its
frequent use. Additionally, in the evaluation of this study,
the number of centimetres achieved during the test was not
taken into account, and instead, the indirect hip joint angle
(HJA) was used for analysis. This test can be measured by
the inclination angle of the sacrum and pelvis in relation to
the horizontal line at the point of maximal forward reach
on the SRT. Furthermore this approach reduces the influence of variations in the length of the upper and lower
limbs and the contribution of the lower back. The HJA can
be assessed with high reliability by angular kinematic
analysis (Cardoso et al., 2007).
The GEG had improved functionality. However, there
was no difference between groups or within the PG. This
outcome can be influenced by various motor skills,
including muscle strength and the characteristics of the
interventions directly influence this skill.
The American College of Sports Medicine recommends
that novices perform at least one set of 8e12 repetitions
with a load of 60e70% of maximum repetition (MR) for
resistance training (Ratamess et al., 2009). This recommendation was similar to the procedure followed by the
GEG, where training was usually composed of 3 sets of 8
repetitions with progression, while the PG generally performed one set of 10 repetitions for each exercise without
changes in repetition. Moreover, evaluations of muscle activity during conventional exercises and Pilates exercises
showed an activation of 52.4% of the MVIC for the rectus
abdominis (RA) during the Straight Curl-up and an activation
of 55.9% during the Cross Curl-up (Konrad et al., 2001). In
contrast, the activation was 39% of the MVIC during the
Hundreds exercise (Souza and Cantergi, 2012), 31.2% of the
maximum peak during the Teaser and 23.5% of the maximum
peak during the Longspine (de Oliveira Menacho 2013) for
the RA muscle. In other words, the proposed interventions
for the GEG better suited improvement in muscle strength.

642
However, there are disagreements regarding these results
(Esco et al., 2004), because the functionality outcome can
be influenced by several factors, such as improved flexibility
which may have interfered in this difference in favour of the
GEG.
The treatment of patients with NSCLBP is complex. Some
authors mention that patients with low back pain are heterogeneous. In other words, subgroups of patients may respond
differently to the same treatment and some patients may
respond better to one type of treatment than another (Fersum
et al., 2010). Furthermore, according to the biopsychosocial
model recommended by the guidelines (Airaksinen et al.,
2006; Bekkering et al., 2003; Dagenais et al., 2010; Dellito
et al., 2012; Philadelphia Panel, 2001; van Middelkoop et al.,
2011), chronic low back pain should be treated with a multidisciplinary approach and should include not only biological
factors but also psychosocial dimensions.
Some limitations of this study should be taken into
consideration. The small sample size may have caused a
type II error, although we have presented the effect-size. In
addition, Hayden et al. (2005) recommend a minimum of
20 h of supervised treatment for patients with NSCLBP. In
this study, patients received 16 h of intervention, which
may not have been sufficient to enable body adaptations to
exercise, especially for patients in the PG as this method is
very different from commonly performed exercises.

Implications for practice

According to the results, general exercises are better than
Pilates for improving functionality and flexibility. However,
other outcomes, such as pain and endurance, showed no
differences between the treatments.
For patients with NSCLBP, the following interventions have
an effect on flexibility and functionality: aerobic exercises,
strengthening and stretching of the muscles of the trunk,
lower limbs and posterior chain and mobility exercises for the
spine (flexion, extension, lateral flexion and rotation).

Implications for future research

New RCTs are needed to confirm the effects of Pilates on
patients with NSCLBP. High quality studies that follow the
recommendations of the Consort e Statement (Schulz
et al., 2010) are required, as well as a standardisation of
outcomes and interventions to facilitate comparisons between studies. Moreover, the calculation of sample size is
required to demonstrate the power of each study. In
addition, future studies should also consider cognitive/
behavioural treatments for these patients.

Conclusions
The Pilates method was not superior to general exercise in
reducing pain and improving functionality in patients with
non-specific chronic low back pain. Functionality (Quebec
scale) showed within-group improvements (for the general
exercise group) with a mean difference of 17 points after 8
weeks and also 17 points in the follow-up period (when
compared to baseline). In addition, hamstring flexibility
(through SRT) showed a within-group improvement (for the

F.Q.R.C. Mostagi et al.

general exercise group) with a mean difference of 32 cm in
the follow-up period (when compared to baseline).

Acknowledgements
The authors would like to thank Ana PRG Cardoso, PT, for
her assistance during the preparation of the exercises as
well as the CNPq (Grant #70/2009), Productivity Scholarship/2014 to the last author and PPSUS/Fund. Araucaria
(Grant # 04/2012).

Appendix 1. Pilates Group Protocol

Week
1st week

Protocol

Presentation of the method and apparatus

of Pilates.
Basic principles: concentration, control,
centring, flow, precision and breathing.
Fundamental movements: breathing, pelvic
bowl, knee sway, spinal bridge, twist, flight
and cat (10 reps)
2nd week
Fundamental movements: breathing, pelvic
bowl, knee sway, spinal bridge, twist, flight
and cat (10 reps)
Spine stretch (10 reps)
Saw (10 reps)
Hundred/dynamic with Swiss ball (10 reps)
3rd week
Breathing (10 reps)
Pelvic bowl (10 reps)
Spine stretch (10 reps)
Saw (10 reps)
Hundred/dynamic with Swiss ball (10 reps)
Spinal bridge with flex ring (10 reps)
Rolling back (Cadillac/10 reps)
4th week
Breathing (10 reps)
Pelvic bowl (10 reps)
Spine stretch (10 reps)
Saw (10 reps)
Hundred/dynamic with Swiss ball (10 reps)
Spinal bridge with flex ring (10 reps)
Rolling back (Cadillac/10 reps)
Side arm sit (chair/10 reps)
Hamstring (chair/10 reps)
5th/6th week Breathing (10 reps)
Pelvic bowl (10 reps)
Spine stretch (10 reps)
Saw (10 reps)
Leg series (reformer/8 reps)
Hundred (reformer/8 reps)
Front split (reformer/8 reps)
Rolling back (Cadillac/8 reps)
Teaser (Cadillac/8 reps)
Bridge (Cadillac/8 reps)
Side arm sit (chair/8 reps)
Swan front (chair/8 reps)
Hamstring (chair/8 reps)

Pilates versus general exercise on pain and functionality in non-specific chronic low back pain subjects
(continued )

Week

(continued )

Protocol

7th/8th week Breathing (10 reps)

Pelvic bowl (10 reps)
Spine stretch (10 reps)
Saw (10 reps)
Swimming (10 reps)
Leg series (reformer/10 reps)
Hundred (reformer/10 reps)
Front split (reformer/10 reps)
Pulling straps (reformer/10 reps)
Mermaid (reformer/10 reps)
Rolling back (Cadillac/10 reps)
Teaser (Cadillac/10 reps)
Bridge (Cadillac/10 reps)
Swan front (chair/10 reps)
Hamstring (chair/10 reps)

Appendix 2. General Exercise Group Protocol

Week

Protocol

1st week

Stationary bike (10 min)

Lower limb and trunk muscles stretching
(30 s)
Spinal mobility in the seated position and on
all fours (8 reps)
Bipedal bridge (8 reps)
Rectus abdominis strengthening (3
8 reps)
Active stretching of the posterior chain
(1
1 min)
Stationary bike (10 min)
Lower limb and trunk muscles stretching
(30 s)
Spinal mobility in the seated position and on
all fours (10 reps)
Bipedal bridge (10 reps)
Rectus abdominis strengthening (3
10
reps)
Active stretching of the posterior chain
(2
1 min)
Stationary bike (10 min)
Lower limb and trunk muscles stretching
(30 s)
Spinal mobility in the seated position and on
all fours (10 reps)
Bipedal bridge (10 reps)
Rectus abdominis strengthening (3
10
reps)
Williams series exercises
Active stretching of the posterior chain
(2
1 min)
Stationary bike (10 min)
Lower limb and trunk muscles stretching
(30 s)
Spinal mobility in the seated position and on

2nd week

3rd week

4th week

643

Week

Protocol

all fours (10 reps)

Lateral flexion with bat (10 reps)
Trunk rotation standing with bat (10 reps)
Bipedal bridge (10 reps)
Rectus abdominis strengthening (3
15
reps)
Active stretching of the posterior chain
(2
1 min)
Williams series exercises
5th/6th week Stationary bike (10 min)
Lower limb and trunk muscles stretching
(30 s)
Spinal mobility in the seated position and on
all fours (10 reps)
Lateral flexion with bat (10 reps)
Trunk rotation standing with bat (10 reps)
Bipedal bridge with hip adduction with a
ball (10 reps)
Rectus abdominis strengthening (3
15
reps)
Oblique muscles strengthening (3
15 reps)
Trunk muscles strengthening on all fours
(3
15 reps)
Active stretching of the posterior chain
(3
1 min)
7th/8th week Stationary bike (15 min)
Lower limb and trunk muscles stretching
(30 s)
Spinal mobility in the seated position and on
all fours (10 reps)
Lateral flexion with bat (10 reps)
Trunk rotation standing with bat (10 reps)
Bipedal bridge with hip adduction with a
ball (3
15 reps)
Rectus abdominis strengthening (3
15
reps)
Oblique muscles strengthening (3
15 reps)
Trunk muscles strengthening on all fours
with halter and ankle weight (3
15 reps)
Active stretching of the posterior chain
(3
1 min)

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