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Effects of Pilates Exercises in Low Back Pain: A Systematic Review Ballard, Beth; Carey, Tina; Clayton, Gillian; Lenz, Angela; Mayall, Erika; Wall, Mike; Dean, Elizabeth; Westby, Marie 2007-07-30

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Effects of Pilates on Low Back Pain: A systematic review Elizabeth Ballard Tina Carey Gillian Clayton Angela Lenz Erika Mayall Michael Wall Outline { Introduction { Methods { Results { Discussion { Limitations { Conclusion { Future Research { Clinical Message Definition { Low Back Pain z Pain in the area between the inferior-most aspect of the scapula and gluteal folds, with or without radiation to the lower extremities (Van Tulder, 2004) Low Back Pain { Contributors z sedentary lifestyle z poor posture z age z excessive body weight z strength of abdominal and back muscles z history of smoking z anxiety z depression z occupational factors z psychosocial factors z trauma z pathological Low Back Pain { Prevalence z 4 out of 5 North Americans experience LBP at least once in their lifetime (Luo et al, 2004) { Recurrence of LBP (Woolf and Pfleger, 2003) z 20-44% within one year z 85% during lifetime { Cost z Total cost $8.1 billion annually in Canada z total direct health care costs represent 1% of the Gross National Product of Canada (Woolf and Pfleger, 2003) Joseph H. Pilates { Inventor of Pilates Method (WW1) { Introduced to dancers and actors What is Pilates? { Approximately 500 exercises that are performed on mats or specialized apparatus { Available through videos, books, and gym classes Definitions { Core z The inner unit is comprised of the muscles of the pelvic floor, transversus abdominis (TA), multifidus, the diaphragm and the posterior fibers of psoas. z The outer unit is comprised of several slings or systems of muscles (global stabilizers and mobilizers) (Gibbons and Comerford, 2001) { ‘Powerhouse’ z The connection between the upper torso and the pelvis.  In a motor control model, this includes the relationship between the TA, internal and external abdominal obliques, diaphragm, and pelvic floor muscles (Anderson, 2005) Goals of Pilates Exercise { To stabilize the ‘powerhouse’ by strengthening the abdominal, lower spine and pelvic floor muscles { To train the active and neural local spinal musculature, incorporating breathing patterns, while inhibiting the global musculature { xXyuLc0 Pilates Industry { In 2003, Pilates exercise was the fastest growing fitness activity in North America { Stott Pilates increased their sales by 1147% between 1997 and 2002 { In 2000, the Pilates trademark ended which may have resulted in the boom in the industry Pilates and Physiotherapy { Pilates exercise training has now become common practice for many physiotherapists in the treatment of many conditions including LBP Research { Joseph H. Pilates did little research to support the effectiveness of his programs in rehabilitation { The usage of Pilates exercise in physiotherapy rehabilitation continues to increase { Is there research to support Pilates exercise use in physiotherapy? Review Question To determine if Pilates exercise has an effect on pain and/or function in individuals with LBP compared with no treatment or other treatments. Methods Paper Identification { Conducted between July 2006 and June 2007 { Selected databases { Grey literature search z Google z Google Scholar z Pilates Exercise Magazines { Experts in the field { Hand search from identified studies Databases { MEDLINE (1966-present) { EMBASE (1980- present) { CINAHL (1982-present) { SPORTDiscus (1830-present) { ProQuest (1980-present) { PEDro { Academic Search Premier { Cochrane Central Register of Controlled Trials { Cochrane Database of Systematic Reviews Search Strategy { Title screen { Abstract screen { Full text screen z Screening tools were developed z Two independent reviewers screened at each level z Inconsistency was resolved through discussion Key Terms { Population z low back pain, back pain, back ache { Intervention z pilates, pilates-based, pilates exercise, lumbo- pelvic, core (strength, strengthening, stability, stabilization), trunk (stabilization, stability, strength), lumbar (strength, stabilization), muscle (strength, strengthening, function), spine stabilization, lumbar spine muscle recruitment, stabilization exercises, stability, and kinesiotherapy. Inclusion Criteria { Low back pain as defined earlier { Any duration (acute, subacute, chronic, recurrent) { Any type { No discrimination based on funding { Adults over 18 years of age { Pilates method intervention { Outcome measures of pain and/or function Exclusion Criteria { Non-English { Pregnancy related pain Outcomes { Pain z An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) z Measured by any valid and reliable pain scale Outcomes { Function z A complex interaction between the health condition of the individual and the contextual factors of the environment as well as personal factors (Stucki, Cieza, & Melvin, 2007). z Measured by any subjective or objective scale validated for the LBP population Quality Assessment { RCTs were assessed using the modified van Tulder scale { Case study was assessed using the Case Study Methodological Quality Assessment Tool { Levels of evidence assigned using guidelines developed by Phillips (2001) Data Extraction & Analysis { Data were extracted from the selected studies using the Data Extraction Form { Two independent reviewers extracted relevant data { In situations where results were inconsistent, the two reviewers referred to the study to come to a consensus { Best evidence synthesis was performed Results Search Strategy Flow Diagram Study Design and Quality Author, year Study Design Quality Assessment Level of Evidence Anderson, 2005 RCT 5/10 Level 2b Gagnon, 2005 RCT 5/10 Level 2b Hawson, 2002 Case series 5/7 Level 4 Quinn, 2005 RCT 3/10 Level 2b Rydeard et al, 2006 RCT 8/10 Level 1b Population Author, year Sample Size (male:female) Mean Age (yrs) Duration of LBP Anderson, 2005 n= 10 I n= 11 C (11:10) I= 42.4 C= 44 >3 months Gagnon, 2005 n= 6 I (1:5) n= 6 C  (1:3) I= 36 C= 30.33 >3 months Hawson, 2002 n= 5 (2:3) 36 (range19-48) >3 months Quinn, 2005 n= 15 I n= 7 C I= 46.3 C= 34.7 >6 months Rydeard et al, 2006 n= 21 I(8:13) n= 18 C(1:2) I= 34 C= 37 >6 weeks Intervention Author, year Description Frequency Duration (session, total) Anderson, 2005 I=Pilates, Pilates instructor, Allegro Reformer C=Massage, Massage Therapist, gluteal folds to head 2x/week 50 minutes 6 weeks 30-45 min 7.3 weeks Range 2.5 – 5 weeks 45-60 min 12 weeks 1 hour – clinic 15 min – hour 4 weeks Gagnon, 2005 I=Pilates, Stott Pilates instructor, mat Pilates C=Traditional physio, AT/Ex Phys/PT, mat exercises ~1.5x/week Hawson, 2002 I=Traditional physio & Pilates, Pilates instructor, reformer/wall unit/combo chair 6 treatments Quinn, 2005 I=Pilates, certified instructor, mat exercises C=no exercise, normal daily activities 2x/week Rydeard et al, 2006 I=Pilates, clinic & home, PT, mat/reformer/video C=No exercise, treatment from health care professionals as needed 3x/week – clinic 6x/week – home Intervention Author, year Compliance Drop out rate Anderson, 2005 N/A 32% 43% 44.4% 31.3% 0% Gagnon, 2005 n=1 non compliant Hawson, 2002 N/A Quinn, 2005 Attendance 87.5% Rydeard et al, 2006 100% Outcomes Author, year Pain Intervention Pain Control Function Intervention MBI Pain   ↓ 35.1% (0.54) SF-36 Pain ↑ 7.9% (0.32) ODQ   ↓ 18.1% (0.35) MBI-D ↓ 32.4% (0.39) RODI   ↓ 55.8% (1.09) ODQ   ↓ 38.9% (N/A) ODQ   ↓ 57.9% (2.15) RMQ/RMDQ-HK ↓ 35% (1.57) VAS     ↓ 51.2% (1.07) VAS     ↓ 39.2% (N/A) N/A NRS-101   ↓ 20.4% (1.83) Function Control Anderson, 2005 MBI Pain ↓ 8.7% (0.26) SF-36 Pain  ↓ 2.0% (0.04) ODQ ↓ 2.9% (0.64) MBI-D ↓ 26.1% (0.42) Gagnon, 2005 VAS     ↓ 60.2% (0.60) RODI  ↓ 46.6% (1.79) Hawson, 2002 N/A N/A Quinn, 2005 N/A ODQ    ↓ 18.2% (0.65) Rydeard et al, 2006 NRS-101 ↑ 11.5% (4.67) RMQ/RMDQ-HK ↓ 23.8% (3.43) Summary Author, year Summary Statement Anderson, 2005 Not statistically significant, but PE subjects showed greater improvement on all pain outcomes (MBI Pain & SF-36) and disability outcomes (MBI Disability & ODQ) Gagnon, 2005 PE group improved in measures of pain and function equal to traditional physiotherapy (VAS & RODI) Hawson, 2002 4/5 subjects reported a decrease in pain intensity (VAS) Quinn, 2005 Significant change in pre-post ODQ scores within PE group. No statistical significance in ODQ between PE and control groups. Rydeard et al, 2006 PE significantly reduces LBP intensity and functional disability levels in comparison to usual care. (NRS- 101, RMQ/RMDQ-HK) Discussion Study Quality { Strengths z Groups similar at baseline for prognostic indicators z Randomization and timing of outcome assessment adequate z 3/4 had treatment allocation concealment { Concerns z Lack of blinding z Level of adherence z Drop out rate z Presence of co-interventions z Lack of intention-to-treat analysis { Peer-reviewed article higher quality Population { Male:female subjects consistent with gender distribution of LBP in population { Mean age of studies was lower than LBP population reported { Subjects were no longer in acute stage of healing, but in the repair or remodeling stage { Sample sizes were small { All subjects were volunteers with relatively mild LBP Intervention { Pilates exercise protocols varied z Type, frequency, duration, certification of instructor, progression { Intensity of intervention { Presence of co-interventions { Lack of long-term follow-up { Adverse effects and safety Comparisons { Variability of control groups z Massage and lumbar stabilization z No active treatment { Lack of details of control group parameters Outcomes { No single outcome measure was used in all studies { Some overlap of outcome measures used between studies { Outcome measures validated in the LBP population { Sensitive enough to show change in less severely effected subjects? Limitations { Broad selection criteria { No limits set for study design { No limits set for quality assessment score { Heterogeneity of included studies { Bias in quality assessment tool modifications { Limited outcomes investigated { Effect size calculator Conclusion { There is limited evidence to support the efficacy of a Pilates exercise intervention in the management of LBP when compared to no treatment { There is no evidence that Pilates exercise is superior to lumbar stabilization exercises or massage therapy in the treatment of LBP Future Research { Higher quality studies should incorporate: z Thorough study design z Larger sample sizes z Variation in intervention protocols z Variation in control groups z Use of a standardized outcome measure to facilitate comparison z Long term follow-up Clinical Message { Pilates exercise may be an effective therapeutic intervention for the chronic LBP population when provided by a Pilates certified physiotherapist Acknowledgements We would like to say a BIG “Thank You” to: z Marie Westby z Dr. Elizabeth Dean z Dr. Susan Harris z Dr. Angela Busch z Charlotte Beck Questions? 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