Effect of short-term Pilates exercises on bone mineral density and physical performance in older women
Kadriye Sevilay Bayram1, Gülşah Şahin2, Coşkun Zateri3, Ali Coşkun4
1Institute of Postgraduate Studies, Çanakkale Onsekiz Mart University, Çanakkale, Türkiye
2Faculty of Sports Sciences, Çanakkale Onsekiz Mart University, Çanakkale, Türkiye
3Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Türkiye,
4Bayramiç Vocational School, Çanakkale Onsekiz Mart University, Çanakkale, Türkiye
Keywords: Pilates, bone mineral density, physical performance, DEXA, aging
Objective: Although high-stress exercises on the bone have been emphasized in previous research on BMD, high intensity exercises may increase the risk of injury in inexperienced older women. Also, these exercises are not recommended due to risk of injury or other problems in fragile older adults. Due to the fact that it is one of the most preferred methods by postmenopausal women, our study focused on the effects of the Pilates method on bone mineral density. The aim of this study was to determine the effect of short-term Pilates exercise on bone mineral density and physical performance in older women.
Methods: Twenty-three older women were voluntarily involved in this research (Pilates group, n=13, and control group, n=10). The Pilates group participated in Pilates exercise for 12 weeks, two days per week. Bone mineral density and physical performance were evaluated. The prospective case-control, pre- and post-test study was conducted at the Çanakkale University Hospital. All measurements were repeated following three-months. The Mann-Whitney U test was used to compare groups, and the Wilcoxon test was used to assess differences between pre- and post-exercise measurements for each group.
Results: After three-months, there was an increase in physical performance scores in the Pilates group (p=0.013). Although there was an improvement in bone mineral density of older women in the Pilates group, it was not statistically significant (p>0.05).
Conclusion: It is possible to say that "short-term Pilates exercise does not produce a resistance training effect on bone mineral density of postmenopausal women". However, Pilates is effective for improving physical performance in older women.
Bone mineral density (BMD) is one of the important parameters for daily living activities and quality of life in older women. Deteriorations in BMD may cause an increased risk of falling and reduced parameters of physical performance (1,2). Hip, vertebral and non-vertebral fractures include severe complications like chronic pain, disability, low quality of life and early mortality (3). Moreover, the estrogenic response to mechanical loading decreases with age (4). During the postmenopausal period, decreased estrogen levels may cause some harmful changes for health (5).
Regular exercise is considered as an important strategy to prevent and treat age-linked bone weakness (6). Previous studies have shown that it is possible to improve physical fitness, BMD and body composition, to improve balance and to reduce risk of falling via physical training programs (7-12). Resistance exercise is considered as a low cost and safe treatment strategy for the protection of musculoskeletal health and fracture prevention; therefore, numerous studies have focused on the effects of exercise on BMD in post-menopausal women (13). It is known that high-intensity resistance exercises are more effective in maintaining or increasing BMD, especially in the postmenopausal period (14).Despite the advantages of resistance exercise on BMD, strength or resistance exercise may not always be preferred by older adults due to its difficulty. In addition, fear of injury and pain caused by strength training has been reported as a barrier involving in exercise (15).
Contrary to resistance exercise; Pilates, including balance, flexibility, breathing, posture and resistance exercises, is becoming popular in the rehabilitation process of the older adults (16,17). However, there is no clear data on whether Pilates exercise has similar effects on BMD as a resistance exercise in older women. One study determined the effect of the Pilates method on BMD in older women with osteoporosis (18). It is also known that Pilates is motivating and has lower rates of withdrawal and injury (19). This might be crucial especially for older individuals (20). Although high-stress exercise effects on the bone have been emphasized in previous research on BMD, high intensity exercises may increase the risk of injury in inexperienced older women. Also, these exercises are not recommended due to the other problems in fragile older adults. Due to the fact that it is one of the most preferred methods by postmenopausal women (21), our study focused on the possibly positive effects of the Pilates method on bone mineral density.
In our study, to confirm this hypothesis, BMD of postmenopausal older women was measured with radiographic techniques (DEXA) before exercise and after three months. The primary aim of this study was to determine the possibly positive effects of short-term Pilates exercise on BMD of healthy older women. The second aim was to investigate its again possibly favorable effects on BMI, fat %, FFM, waist and hip circumference, and physical performance.
Material and Methods
Participants and procedure
The prospective, case-control, randomized controlled and single-blind study was conducted at the Çanakkale Onsekiz Mart University Health, Research and Practice Hospital in the March 2019- January 2020 period. The first assessment and evaluation was conducted prior to the Pilates program. The second evaluation was performed following three months. The Pilates group participated in 50 min Pilates exercises throughout the 12 weeks.
Participants were recruited from the activity center for older adults with an announcement. Thirty women were randomly separated into Pilates (n=15) and Control (n=15) groups. Participants were evaluated at the University HospitalPhysical Medicine and Rehabilitation department by a physician. Following clinical evaluation, participants that were: 1) volunteers, 2) of community-dwelling status, 3) between 65-80 years of age, 4) not under any therapy and exercise intervention, and 5) without any physical or mental illness were included in the study. Exclusion criteria included: 1) any health problems, 2) severe cardiac disease, 3) uncontrolled hypertension, 4) unregulated diabetes mellitus, 5) severe shortness of breath, 6) neuromuscular diseases, 7) inflammatory rheumatic diseases, 8) physical and mental disability, 9) to be unable to walk without support, 10) using drugs affecting the central nervous system, 11) receiving osteoporosis treatment in the last year, 12) receiving calcium and vitamin D supplements, and 13) to have participated in any training program in the last six months.
Participants were informed regarding the exercises and tests. Researchers explained about possible muscular soreness risks due to the Pilates exercise. During the process, some participants withdrew from the study due to moving to another city, thinking they could not continue regularly, experiencing health problems not linked to exercise, not wanting to perform measurements again, and unknown reasons. Therefore, the research was resumed with 23 older women. The flow diagram of the research is presented below (Figure 1). All participants were asked to sign an informed consent form. The study was approved by the Çanakkale Onsekiz Mart University Medical Faculty Clinical Research Ethics Committee (Date: 13.03.2019, Number: 18920478-050.01.04-E.1900042414, Decision no: 2019-06). The research was supported by the Çanakkale Onsekiz Mart University Scientific Research Projects Commission (Project ID: 2925). All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and complying with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Figure 1: Flow diagram of the study process
Bone mineral density measurement: Bone mineral density was measured with dual energy x-ray absorptiometry (DEXA) (Lunar, General Electric) at the proximal femur level on the nondominant side using standard protocols. DEXA measurements yielded BMD, T and Z scores for L1-L4, total hip and femur neck. All scans were performed by the same clinical technician using standard procedures. Women laid flat on the scanning bed, and were positioned in the center aligned with the long axis of the scanner, with arms and legs evenly separated to allow for accurate analysis. The DEXA scanner was calibrated within 24 h prior to every scan.
Physical performance evaluation: The short physical performance battery (SPPB) was used to evaluate physical performance. The assessment was recorded side-by-side with tandem and semi-tandem stances, 4-m walk test, five times sit-stand test, and the duration to complete these tests. Points were given as follows: two-foot side-by-side stance <10s 0 points, >10s 1 point, semi-tandem stance <10s 0 points, >10s 1 point, and tandem stance duration <3s 0 points, 3-9.99s 1 point and >10s 2 points. For the 4-meter walking test, inability to walk 0 points, >8.70s 1 point, 6.21-8.70s 2 points, 4.82-6.20s 3 points and <4.82s 4 points. For the five times sit-stand test, inability to perform the movement 0 points and according to the duration ≤60 sec, points were given between 1 to 4 (22).
Body composition evaluation: Body height was measured without shoes with a stadiometer (SECA, Germany). Body weight was measured without shoes and wearing light clothes only, using a body composition analyzer. Waist and hip circumferences were measured by a non-elastic tape. Body mass index, fat ratio, fat-free mass (FFM) were assessed by bioelectrical impedance analysis (BIA) with a body composition analyzer (TANITA, TBF-310 GS, Tokyo, Japan). Participants were asked to avoid any exercise or physical activity, caffeine consumption or eating for three hours prior to the analyzes.
Pilates mat exercise intervention: The Pilates group performed 50 min of Pilates exercises for 12 weeks (Table 1). Each exercise class was performed two days per week. The elastic band was used for resistance in Pilates exercises. Prior each class, general health status of participants was evaluated through heart rates and blood pressures. During the first four weeks only mat exercises were used, while the last eight weeks elastic band work was added. Participants were permitted to leave the exercise class after their blood pressure and heart rate levels reached resting levels. There were no cases regarding any health problem linked to exercise. The control group were asked to continue their daily activity throughout the study.
|Warm-up||»5 min||Breathing, and movements to increase shoulder and hip joint movement angles||Twice/wk|
|Mat Pilates||40 min||Mat Pilates phase (four weeks)
Abdominal, back, spine, arm, leg and hip movements like the hundred, one leg circle, side kick, swan, swimming, saw, bridge, spine stretch, lower back, spine twist, side-leg stretch exercise.
Mat Pilates and elastic band phase (eight weeks)
Similar exercises as above with an elastic band.
|Cool-down||»5 min||Stretching and heart rate check|
Descriptive data were presented as mean, SD, confidence interval and range. The verification of data normality was performed through the Shapiro-Wilk test; and the Levene test was used to evaluate the equality of variances. To verify differences between the groups with regard to baseline physical characteristics (age, weight, height and BMI) and BMD, body composition and physical function scores at the pre-exercise, the Mann-Whitney U test was used. The Wilcoxon test was used to compare within group differences. The confidence interval permitted in all tests was 95% (p≤0.05). Data were analyzed with the SPSS 26.0 (SPSS Corp., Chicago, IL, USA) program.
Table 2 presents the physical characteristics and ages of older women in the Pilates and control groups at the baseline. There was no significant difference for the parameters between the groups at the baseline (p> 0.05).
|Group||Pilates group(n=13)||Control group (n=10)|
|Body weight (kg)||71.1±10.2||54.5-89.4||72.2±10.4||54.9-88.3||-0.031||0.975|
|Figures as mean ± SD|
At the baseline, there was no significant difference between the groups for BMI, fat ratio, FFM, waist circumference, hip circumference, balance, 4 m walk test score, sit to stand test score, L1-L4 T score, L1-L4 Z score, L1-L4 BMD, femur neck T score, femur neck Z score, femur neck BMD, total T score, total Z score, and total BMD (p>0.05) (Table 3).
|Pilates group (n=13)||Control group(n=10)|
|Baseline test||Mean (95% CI)||Range||Mean(95% CI)||Range||p|
|BMI (kg.m-2)||30.6 (27.4-33.8)||21.3-36.8||29.6 (26.7-32.5)||24.5-37.7||0.975|
|Fat ratio (%)||39.1 (35.9-42.7)||24.4-46.3||37.2 (31.7-42.6)||18.4-45.7||0.385|
|FFM (kg)||42.7 (40.9-44.6)||37.5-48.5||44.7 (42.8-46.6)||40.1-47.9||0.620|
|WC (cm)||87.0 (81.4-92.6)||69.0-98.0||93.6 (88.8-98.4)||85.0-102.0||0.128|
|HC (cm)||108.4 (103.0-113.7)||92.0-127.0||109.5 (102.6-116.4)||95.0-124.0||0.136|
|Balance||3.54 (3.22-3.85)||3.00-4.00||3.80 (3.49-4.10)||3.00-4.00||0.202|
|4 m walk||3.77 (3.50-4.03)||3.00-4.00||3.10 (2.47-3.72)||2.00-4.00||0.077|
|Sit-to-stand||3.76 (3.50-4.03)||3.00-4.00||3.00 (2.10-3.89)||1.00-6.00||0.106|
|Total score||11.1 (10.6-11.5)||10.0-12.0||9.90 (8.49-11.3)||6.00-12.0||0.153|
|L1-L4 T score||-0.63 (-1.38-0.12)||-2.20-1.60||-1.05 (-1.87 to -0.22)||-2.90 to -0.40||0.709|
|L1-L4 Z score||0.71 (0.06-1.34)||-0.90-2.80||0.30 (-0.40-1.00)||-1.50-2.00||0.351|
|L1-L4 BMD||1.07 (0.97-1.16)||0.87-1.34||1.02 (0.91-1.12)||0.78-1.19||0.804|
|Femur neck T sco.||-1.11 (-1.49 to -0.71)||-2.20-0.10||-1.35 (-1.93 to -0.76)||-2.40-0.00||0.336|
|Femur neck Z sco.||0.39 (0.10-0.67)||-0.30-1.20||0.19 (-0.42-0.80)||-0.90-2.10||0.367|
|Femur neck BMD||0.83 (0.78-0.87)||0.70-0.95||0.80 (0.73-0.87)||0.68-1.02||0.352|
|Total T score||-0.82 (-1.29-0.34)||-2.70-0.00||-1.11 (-1.72 to -0.49)||-2.10-0.80||0.172|
|Total Z score||0.30 (-0.06-0.66)||-1.00-1.50||0.00 (-0.65-0.65)||-1.40-2.00||0.113|
|Total BMD||0.90 (0.84-0.95)||0.68-1.00||0.86 (0.79-0.93)||0.75-1.23||0.172|
|Figures as means (95% CI). CI: confidence interval; BMI: body mass index, FFM: fat free mass, HC: hip circumference, WC: waist circumference, BMD: bone mineral density, SPPB: short physical performance battery|
Table 4 displays the comparison for all tests between the Pilates group (PG) and the control group (CG). The PG group demonstrated significant improvement (p<0.05) for the waist circumference, and 4m walk, sit to stand and total physical performances. However, there was no significant change in BMD in the Pilates group. Pilates did not significantly improve BMD in older women when compared with the control group (p>0.05).
|Pilates group (n=13)||Control group (n=10)|
|Final test||Mean (95% CI)||Range||pPG||Mean (95% CI)||Range||pCG||p|
|BMI (kg.m-2)||30.3 (27.3-33.3)||21.4-36.3||0.09||29.7 (26.8-32.6)||24.5-37.5||0.66||0.76|
|Fat ratio(%)||38.2 (34.7-41.7)||24.5-45.0||0.01||37.3 (31.8-42.9)||18.4-46.4||0.18||0.62|
|FFM (kg)||42.8(41.0-44.6)||37.4-48.5||0.01||44.6 (32.8-46.5)||40.1-47.9||0.66||0.19|
|WC (cm)||85.5 (80.3-80.6)||69.0-95.0||0.01||93.8 (88.9-98.7)||85.0-102.0||0.32||0.04|
|HC (cm)||106.8 (101.4-112.2)||92.0-123.0||0.03||109.4 (102.8-116.0)||96.0-123.0||0.56||0.58|
|Balance||4.00 (4.00-4.00)||4.00-4.00||0.02||3.90 (3.67-4.12)||3.00-4.00||0.32||0.25|
|4 m walk||4.00 (4.00-4.00)||4.00-4.00||0.08||2.20 (1.09-3.30)||0.00-4.00||0.05||0.05|
|Sit-to-stand||3.77 (3.50-4.03)||3.00-4.00||1.00||2.50 (1.47-3.52)||0.00-4.00||0.03||0.02|
|Total score||11.8(11.5-12.0)||11.0-12.0||0.02||8.60 (6.74-10.4)||4.00-12.0||0.04||0.01|
|L1-L4 Tscore||-0.57 (-1.36-0.22)||-2.20-2.10||0.61||-1.08 (-1.85 to -0.30)||-2.80-0.40||0.52||0.51|
|L1-L4 Zscore||0.80 (0.12-1.47)||-1.10-2.60||0.29||-0.01 (-1.07-1.05)||-3.40-2.00||0.62||0.14|
|L1-L4 BMD||1.12 (0.96-1.27)||0.87-1.79||0.27||1.08 (0.85-1.31)||0.80-1.93||0.77||0.54|
|Femur n. Tsco.||-1.20 (-1.50 to -0.89)||-2.00 to -0.10||0.31||-1.07 (-1.99 to -0.14)||-2.40-1.80||0.55||0.69|
|Femur n. Zsco.||0.32 (0.02-0.62)||-0.30-1.20||0.30||0.12 (-0.49-0.73)||-0.90-2.00||0.17||0.37|
|Femur n. BMD||0.82 (0.78-0.85)||0.72-0.95||0.28||0.79 (-8.56-25.0)||0.68-1.01||0.16||0.29|
|Total Tscore||-1.02 (-1.64 to -0.38)||-3.30 to -0.10||0.84||-0.68 (-1.67-0.31)||-2.20-1.90||0.68||0.88|
|Total Zscore||0.31 (-0.08-0.69)||-1.20-1.30||0.79||0.52 (-0.36-1.40)||-0.90-2.60||0.93||0.69|
|Total BMD||0.91 (0.84-0.96)||0.66-0.99||0.89||0.90 (0.80-1.04)||0.75-1.23||0.65||0.54|
|Figures as means (95% CI). CI: confidence interval; BMI: body mass index; FFM: fat free mass; HC: hip circumference; WC: waist circumference; BMD: bone mineral density; SPPB: short physical performance battery. pPG: difference within Pilates group; pCG: difference within control group; p: difference between groups after the exercise period.|
The Pilates group improved significantly in terms of fat ratio (p=0.005), FFM (p=0.008), WC (p=0.007), HC (p=0.028), balance (p=0.014) and in the SPPB total score (p=0.013, p<0.05). In the control group, there were significant decreases in 4m walk test performance (p=0.041), sit to stand test score (p=0.025), and total physical performance score (p=0.039, p<0.05).
As a main finding, the improvement in BMI and BMD was not statistically significant. However, fat ratio, fat-free mass, waist and hip circumference, balance and total physical performance improved significantly in the Pilates group when compared with baseline. Walking test performance, sit-stand test score and total physical performance score declined in the CG.
If the bone is under sufficient mechanical stress, remodeling is promoted (23). However, different results may be obtained in older adults due to individual differences in bone remodeling. Pilates exercise did not change T-, Z- and BMD- scores of postmenopausal elderly women who participated in the study. However, BMD average scores were higher than before. Although no supplements were taken, BMD increased on average. Our findings are consistent with some studies reporting that the effect of exercise on BMD is not significant (24,25). This finding may indicate that, short-term Pilates does not produce a resistance exercise effect on the BMD of postmenopausal women.
Angin et al. reported that Pilates exercises significantly increased BMD. It is thought that the different finding in their study may be due to the fact that they included younger women with osteoporosis (40-69 years), and that it was a six month long study (18). According to a newly published meta-analysis, the effect of Pilates exercises on BMD in postmenopausal women is unclear. However, the small number of studies included in the review and the low methodological quality of the majority of the studies do not currently allow reliable estimation of results. More robust randomized controlled studies with high methodological quality are needed to confirm the results of this meta-analysis (21)
One-third of all adults over the age of 64 is faced with a risk of falling every year (26). When older adults experience concerns about falling, physical activity levels decrease and cause limited daily activities. Exercise improves muscle strength of core and postural stability to prevent falls (27). Keasler et al. found that Pilates and balance exercises may improve postural stability in older adults (28). According to another study, reformer exercises significantly improvefunctional movement, static and dynamic balance (29). Some of the studies supported that Pilates exercise and dance provide an improvement in balance of older adults (30,31). In our study, the PG group demonstrated a significant improvement (p<0.05) for balance. Therefore, it can be emphasized that the result obtained from our study supports the expected effect from Pilates.
According to the secondary findings, the PG group demonstrated a significant improvement (p<0.05) for waist circumference, walking speed (4m walk), leg strength (sit to stand), and total physical performance in older women when compared with the control group (p>0.05, Table 4). Thus, it is possible to state that a hypothesis of the research is confirmed, and Pilates is effective on physical performance. Interestingly, it’s important to emphasize that there was a significant decrease in the CG (p<0.05). Phrompaet et al., who examined the effects of Pilates exercises on flexibility and lumbo-pelvic movement control reported that the flexibility of the Pilates group increased significantly compared with the control group (32).
Pilates improved significantly fat ratio, FFM, WC, HC (p<0.05), but there was no effect on BMI. (p>0.05, Table 4). In the control group, no significant difference in body composition variables was present after the program (p>0.05). Fourie et al. (33), and Sekendiz et al., (34) found insignificant changes in BMI. Older adults who have sedentary lifestyles lose fat-free mass faster than people who have regular exercise routine (35). Accordingly, it was similar to the findings of Ruiz-Montero et al., with improved basic muscle mass and decreased FM values with aerobic and Pilates exercises (36), and of Lomba Vasconcelos et al. on waist and hip measurements in older women (37).
There are some limitations in our study. First is the number of participants. The reason for this is the limited number of participants who can regularly take part in an exercise program, and adherence to exercise in terms of health in this age group. Second, we did not investigate the effects of the frequency and intensity of exercise on BMD. We assessed BMD again after three months of exercise.
Pilates exercise have effects on body composition and physical performance of older women. BMD did not significantly increase; however, the mean values were higher in the Pilates group. It is possible to say that short-term Pilates exercise does not produce a resistance training effect on bone mineral density of postmenopausal women.
Cite this article as: Bayram KS, Sahin G, Zateri C, Coskun A. Effect of short-term Pilates exercises on bone mineral density and physical performance in older women. Turk J Sports Med. 2023 58(2):88-93; https://doi.org/10.47447/tjsm.0744
The study was approved by the Ethics Committee of Çanakkale Onsekiz Mart University (Date: 013.03.2019, Decision no: 2019-06).
oncept:KSB,GŞ; Design: GŞ,CZ; Supervision: GŞ,CZ; Materials: KSB,GŞ; Data Collection and/or Processing: GŞ,AC; Analysis and Interpretation: KSB,GŞ,AC; Literature Review: KSB,GŞ; Writing Manuscript: GŞ,CZ; Critical Reviews: GŞ,CZ.
The authors declared no conflicts of interest with respect to authorship and/or publication of the article.
The research was supported by the Çanakkale Onsekiz Mart University Scientific Research Projects Commission (Project ID: 2925).
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