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Effects of the Pilates Method on Kinesiophobia Associated with Chronic Non-Specific

Low Back Pain: Systematic Review and Meta-Analysis.

Cíntia Domingues de Freitas, Deborah Araujo Costa, Nelson Carvas Junior, Vinicius
Tassoni Civile

PII: S1360-8592(20)30067-X
DOI: https://doi.org/10.1016/j.jbmt.2020.05.005
Reference: YJBMT 1963

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 17 March 2019

Revised Date: 11 December 2019
Accepted Date: 3 May 2020

Please cite this article as: Domingues de Freitas, C., Costa, D.A., Junior, N.C., Civile, V.T., Effects of
the Pilates Method on Kinesiophobia Associated with Chronic Non-Specific Low Back Pain: Systematic
Review and Meta-Analysis., Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/
j.jbmt.2020.05.005.

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Cíntia Domingues de Freitas: Conceptualization, Supervision, Project

administration, Writing - Review & Editing Vinicius Tassoni Civile:

Methodology, Resources, Formal Analysis,Validation Deborah Araujo Costa

: Investigation, Writing - Original Draft, Nelson Carvas Junior : Resources,

Formal Analysis ,Validation

 TITLE PAGE

Effects of the Pilates Method on Kinesiophobia Associated with Chronic

Non-Specific Low Back Pain: Systematic Review and Meta-Analysis.

Cíntia Domingues de Freitas1, Deborah Araujo Costa2, Nelson Carvas Junior3,

Vinicius Tassoni Civile4

1. Doctor of Science from Universidade de São Paulo (USP); Professor of the

Physiotherapy course at Universidade Paulista (UNIP);

2. Undergraduate of the Physiotherapy course at Universidade Paulista (UNIP).

3. Master of Science from Instituto de Assistência Médica ao Servidor Público

Estadual (IAMSPE) . Professor of the Physiotherapy course at Universidade

Paulista (UNIP)

4. Specialist in Cardiorespiratory Physiotherapy from Universidade Metodista de

São Paulo (UMESP); Professor of the Physiotherapy course at Universidade

Paulista (UNIP).

Corresponding author :Cintiafreitas24@gmail.com

Adress:Universidade Paulista

Amazonas da Silva street, 737 São Paulo SP, Brazil

Phone number 5511985788312

Declaration of interests: none

 ABSTRACT

Background: Patients with chronic low back pain with higher levels of kinesiophobia

have a 41% greater risk of developing a physical disability. The kinesiophobia model

suggests that patients fear movements because of pain, associating movement with

worsening of their state. Studies that apply the Pilates method for chronic low back

pain achieve positive results in reducing pain and disability, and moderate results

regarding kinesiophobia.

Objective: The purpose of this review is to evaluate the effects of the Pilates method

on kinesiophobia associated with chronic non-specific low back pain.

Search Methods: The following databases were searched from August to October

2018: MEDLINE, PEDro, SciELO, LILACS and the Cochrane Database of

Systematic Reviews (CENTRAL), without restriction of language and year of

publication. Selection criteria: Randomized clinical trials assessing the

effectiveness of the Pilates method in the treatment of kinesiophobia in patients with

chronic non-specific low back pain. Data collection and analysis: Two authors

independently selected the studies, assessed the risk of bias and extracted data. A

third author was consulted in case of disagreements. The primary outcome was

kinesiophobia as evaluated by the Tampa scale. Results: Our electronic searches

resulted in 314 studies; 288 studies were excluded and 27 were selected for reading

in full-text. Five articles were included in this review and four in the meta-analysis.

Conclusion: There is a favorable effect of the Pilates method compared to minimal

intervention or no treatment in reducing kinesiophobia associated with chronic non-

specific low back pain, with a moderate quality of evidence.

Descriptors: Low Back Pain, Exercise Movement Techniques, Exercises, Pilates-

Based

TEXT

BACKGROUND

Chronic non-specific low back pain is characterized by the absence of

structural alteration and is not attributed to a specific pathology. About 90% of

patients with chronic low back pain present non-specific origin (Maher et al 2017;

Koes et al 2006).

Low back pain can be triggered by biological, psychosocial, mechanical,

cognitive and occupational risk factors, which seem to contribute to the development

of the disease chronicity (Thomas & France 2007; Delitto et al 2012).

Those who recognize the pain in a threatening and catastrophic way are more

likely to feel fear and anxiety related to pain and become involved in behaviors of

avoiding movement (Thomas & France 2007). The fear related to pain and

catastrophizing are associated with physical performance and perceived deficiency

(Swinkels-Meewisse et al 2006).

In these cases, the hyperexcitability of the central nervous system,

denominated central sensitization leads to cerebral neuroplasticity. Pain neuromatrix

activity is increased. One key brain area involved in the pain neuromatrix is the

amigdala, often referred to as fear memory center of the brain and this area can be

involved more precisely in memories of painful movements. The brain has acquired a

long-term pain memory, associating some movements with danger or threat

(kinesiophobia or fear of movement) (Nijs et al 2015).

Limiting information and beliefs about low back pain may lead the individual to

fear and avoid movement due to fear of pain or recurrence of injury. This fear leads

2
to two responses: the patient can confront or avoid activity. During confrontation, the

individual makes a movement, which gradually reduces the fear of this movement.

By avoiding, the individual does not make the movement and becomes less and less

active. Chronic low back pain patients with higher levels of kinesiophobia have a

41% greater risk of developing a physical disability (Trocoli & Botelho 2016).

Increasing evidence supports the clinical importance of desensitization in

patients with chronic musculoskeletal pain. Thus, a biopsychosocial approach is

required in addition to exercises, associating pain neuroscience education with motor

control training directed to cognition (Malfliet et al 2018).

The Pilates method is one of the forms of exercise applied in the treatment of

chronic low back pain (Yamato et al 2016; Byrnes et al 2018; Patti et al 2015). Most

studies of chronic low back pain apply the Mat Pilates technique (on the ground). It is

unclear if this method is better than other forms of exercise because there is no

evidence to support this statement (Yamato et al 2016; Byrnes et al 2018; Patti et al

2015).

It is important to investigate whether the Pilates method alone interferes with

the outcome of kinesiophobia, considering that the scientific evidence indicates the

importance of an associated biopsychosocial approach.

The objective of this review is to evaluate the effects of the Pilates method on

kinesiophobia associated with chronic non-specific low back pain.

METHODS

The conduction and elaboration of this systematic review followed the

PRISMA guidelines (Moher et al 2009) and the Cochrane Handbook for Systematic

3
Reviews of Interventions (Higgins & Green 2011). The protocol of this study is

registered on the PROSPERO platform under the registration number:

CRD42018115407.

Eligibility criteria

This review included randomized controlled trials with or without follow-up

extension that applied exercises of the Pilates method, on the ground or with

equipment, in individuals with chronic non-specific low back pain associated with

kinesiophobia. Studies of pathologies diagnosed in the spine, such as osteoporosis,

fibromyalgia, radiculopathies, rheumatic diseases, fractures, tumors and infections,

among others, were excluded. The intervention with the Pilates method could be

compared to no intervention, minimal intervention or other exercise-based treatment

techniques. Studies were eligible regardless of publication status and language.

The studies that met the inclusion criteria were also evaluated according to

the PEDro scale (Sampaio & Mancini 2007) and only the studies with a score above

3 were included.

Type of outcome measure

The studies should mandatorily assess the kinesiophobia outcome through

the Tampa scale (De Souza et al 2008; Siqueira et al 2007).

Description of the outcome measure

4
 The Tampa scale contains 17 items with a score ranging from 17 points

(absence of fear) to 68 points (maximum fear). Each item varies from 1 to 4 points (1

= totally disagree; 2 = partially disagree; 3 = partially agree; 4 = totally agree), and it

is necessary to reverse this score in items 4, 8, 12 and 16. The higher the total score

obtained, the higher the level of kinesiophobia (De Souza et al 2008; Siqueira et al

2007).

Search methods for identification of studies

Electronic searches

The searches were performed in the databases MEDLINE, PEDro, SciELO,

LILACS and the Cochrane Central Register of Controlled Trials (CENTRAL).

The search terms and strategies were adjusted for each database and

combined to specific search filters when needed. The searches were conducted from

August 2018 to December 2019.

Two authors (CDF and DAC) independently assessed titles and abstracts of

the studies found through the search strategies to identify studies that potentially met

the eligibility criteria. Two authors (CDF and DAC) independently read the selected

studies in full-text and assessed their eligibility for inclusion. Disagreements

regarding eligibility of the studies were resolved by discussion with a third author

(VTC).

Data collection and analysis

5
 A standard form was used for the data extraction of each included study, as

recommended by the Cochrane Collaboration (Higgins & Green 2011), to assess the

quality of the studies and synthesize the evidence from randomized clinical trials.

The extracted information included: study definition; population, demographic

data and baseline characteristics; details of the intervention (Pilates method) and

control conditions; study methodology; recruitment and completion rates of the

studies; analysis of the kinesiophobia outcome and follow-up periods; indicators of

participants’ acceptability; suggested mechanisms of action of the intervention; and

information for assessment of risk of bias. Two authors (CDF and DAC)

independently extracted data and identified and resolved discrepancies through

discussion (with a third author – VTC – when necessary). Missing data was

requested to the study authors.

Assessment of risk of bias in included studies

Two authors (CDF and DAC) independently assessed the risk of bias of

included studies according to the criteria proposed by the Cochrane Collaboration

(Carvalho et al 2013; Higgins & Green 2011), which is based on the following seven

domains: random sequence generation, allocation concealment, blinding of

participants and personnel, blinding of outcome assessment, incomplete outcome

data, selective reporting and other sources of bias. The risk of bias for each

analyzed domain was judged as: low risk of bias, high risk of bias, or unclear risk of

bias.

6
 Disagreements between the authors regarding risk of bias assessment were

resolved through discussion, with involvement of a third review author (VTC) when

necessary. We contacted the study authors to request missing data.

Summary measures

The mean, standard deviation, median and confidence intervals, plus sample

size of the Pilates and control groups (minimal intervention or no treatment) were

extracted, considering the baseline assessment and the follow-up after 6 weeks of

intervention, which was a common time period in the selected studies.

Synthesis of results

The meta-analysis was performed on the RevMan 5.1 software (Review

Manager 2014). The random-effects model was used for the meta-analysis to

provide a summary effect size that represents the mean of a distribution of effects of

the included studies.

The homogeneity of the studies was measured though the heterogeneity test

using the T2 and I2 statistics. An additional Bayesian fixed-effect meta-analysis with a

vague prior distribution (Lambert et al 2005) and 10000 simulations in two chains

each were performed using the bmeta R package (Tao 2016).

RESULTS

Results of the search

The searches in the mentioned databases resulted in 314 studies. After

reading the titles and abstracts, 288 studies were excluded because they did not

meet the inclusion criteria and 27 studies were selected for full-text reading. After

7
reading the full texts, 22 studies were excluded because of duplicity or absence of

the kinesiophobia outcome. Thus, five studies were included in this review, and four

studies were included in the meta-analysis (see Figure 1).

Figure 1. Flow diagram of the different steps of the systematic review.

Included studies

Most of the included studies had similar populations regarding age (18-60

years) and only one (18 – 80 years). The studies had similar low back pain

characteristics (see Table 1). The intervention period varied from six (da Luz et al

2014; Miyamoto et al 2013; Miyamoto et al 2018) to 12 weeks (Cruz Díaz et al 2017;

Cruz Díaz et al 2018). The data of the six-week follow-up was extracted for the meta-

analysis. Regarding the intervention, two studies evaluated only Mat Pilates

(Miyamoto et al 2013; Cruz Díaz et al 2018) and the other three studies evaluated

Mat and equipment exercises (da Luz et al 2014; Cruz Díaz et al 2017; Miyamoto et

al 2018). However, there was great variety in the quantity and types of exercises

selected from the Pilates method. One study only compared Mat Pilates to

equipment Pilates (da Luz et al 2014). Thus, this study was excluded from the meta-

analysis which considered only studies that compared Pilates exercises to a control

group with or without minimal intervention (Miyamoto et al 2013; Cruz Díaz et al

2017; Cruz Díaz et al 2018; Miyamoto et al 2018). All studies assessed

kinesiophobia through the Tampa scale. Only one study did not achieve a significant

result regarding kinesiophobia (Miyamoto et al 2013), whilst the others reported

moderate clinical effects (da Luz et al 2014; Cruz Díaz et al 2017; Cruz Díaz et al

2018; Miyamoto et al 2018).

8
 The studies met the inclusion criteria of a score higher than 3 in the PEDro

scale.

Risk of bias in included studies

Regarding risk of bias (see Figure 2 and Figure 3), most studies were

classified at low risk of bias. Only one study which did not state the randomization

procedure (Cruz – Díaz et al 2018) was classified at unclear risk of random

sequence generation bias. The study authors did not reply to our contact requesting

this information. There was a low risk of allocation concealment bias because the

allocation was concealed through sequentially numbered, opaque and sealed

envelopes in all studies. The studies were rated at high risk of participants and

personnel blinding bias because it is not possible to achieve blinding in this type of

intervention. The outcome assessment blinding was performed for all outcomes at

baseline and at the follow-up after treatment in the five included studies,

representing low risk of bias for this domain. One study (Cruz – Díaz et al 2018) was

classified at high risk of incomplete outcome data due to data loss in the control

group at the 6-week follow-up (no intention-to-treat analysis). All studies reported

and assessed the outcomes as proposed, representing low risk of selective reporting

bias.

Figure 2. Risk of bias results.

Figure 3. Risk of bias summary: review authors’ judgements about each risk of bias item for each

included study.

Meta-analysis

9
 The meta-analysis only included data of the Pilates intervention at the six-

week follow-up, because this information was common in the four studies that

compared the intervention with a control group (no intervention or minimal

intervention).

As seen in Figure 4, the Pilates intervention has a favorable effect towards the

decrease of kinesiophobia compared to the control group (diamond positioned to the

left). Three studies demonstrated that the Pilates effect is favorable whilst one study

found no difference compared to the control group.

Figure 4. Meta-analysis of the comparison between the Pilates exercises and control for the outcome

kinesiophobia associated with chronic non-specific low back pain

The mean difference between groups indicates a small decrease of 3.72

points in the kinesiophobia scale, ranging from less 5.69 to less 1.76 points, in a

scale that ranges from 17 (absence of fear) to 68 points (maximum fear). The quality

of the evidence was moderate (see table 2).

A high heterogeneity between studies is also observed (I2 = 71%).

The Bayesian meta-analysis resulted in a similar estimate of effect size

difference: -3.88 (95% ICr,-4.93 to -2.86; see Figure 5).

Figure 5. Posterior distribution plot of pooled effect. Based on 10000 simulations.

DISCUSSION

10
 Kinesiophobia can increase the development of functional disabilities by more

than 41%, and it seems to be more related to chronicity and disability than the pain

intensity itself (Trocoli & Botelho 2016).

This is the first systematic review investigating the effects of the Pilates

method specifically on kinesiophobia associated with chronic low back pain.

This review found a favorable effect of the Pilates exercises compared to

minimal intervention (educational book) or no treatment in reducing kinesiophobia

associated with chronic non-specific low back pain after six weeks of treatment (see

Figure 4).

Although the included studies were classified at low risk of bias for most

analyzed characteristics (see Figure 2 and Figure 3), the meta-analysis had high

heterogeneity (see Figure 4). Possible reasons for the high heterogeneity include: no

information of the randomization method in one study; follow-up data loss and no

intention-to-treat analysis in one study.

Regarding clinical heterogeneity, the studies reported judicious criteria to

include patients, whose average age profile was similar, and determined absence of

pregnancy or pathologies of the spine besides no previous experience with Pilates or

physiotherapy a few months before interventions. Regarding the intervention, there

was a considerable variation between the quantity and types of exercises used in

each study.

The Pilates method was applied alone, without a specific biopsychosocial

approach for kinesiophobia. All studies evaluated the kinesiophobia outcome through

the Tampa scale, which varies from 17 to 68 points and considers that the higher the

score, the greater the level of kinesiophobia. The kinesiophobia improvement was

observed after six weeks of treatment in four studies (da Luz et al 2014; Cruz Díaz et

11
al 2017; Cruz Díaz et al 2018; Miyamoto et al 2018), with moderate clinical effects,

and one study found no significant improvement (Miyamoto et al 2013). Considering

that the scale ranges from 17 to 68 points, a decrease from 5.69 to 1.76 points as

indicated in the meta-analysis may not represent a clinical significance. There is no

clinically important minimal difference established for this scale.

LIMITATIONS

Regarding the limitations of the studies, there was no post-intervention follow-

up in two studies (Cruz Díaz et al 2017; Cruz Díaz et al 2018) to verify if the

improvement effects on kinesiophobia were maintained in the medium and long

term. Besides that, the studies did not associate a specific biopsychosocial approach

with the intervention and applied different exercise protocols, especially regarding

quantity and types of exercise, which could justify the high heterogeneity between

studies. There was also no pain education approach nor a specific selection of a

gradual exercise exposure considering the pattern of movement involved in

kinesiophobia, which may explain the moderate clinical effect for this outcome in the

studies included in this review.

PERSPECTIVE

Clinical practice guidelines and systematic reviews about the treatment of

chronic non-specific low back pain recommend identifying the psychosocial risk

factors in this population, including kinesiophobia. When risk factors are present,

pain education and cognitive exercises with gradual exposure are recommended

12
(Nijs et al 2015; Malfliet et al 2018). Future research should consider how the Pilates

method could be associated with pain education and adapt the exercises in order to

gradually promote the movement pattern that the patient is afraid of and has pain,

following the principles of gradual exposure.

Kinesiophobia is an important outcome in patients with chronic non-specific

low back pain because of its relation to disability and perpetuation of symptoms.

Lack of activity due to fear of movement may induce chronicity of symptoms.

CONCLUSIONS

This review presents moderate evidence of a favorable effect with the Pilates

exercises compared to minimal intervention or no treatment in reducing

kinesiophobia associated with chronic non-specific low back pain.

Future studies should investigate the Pilates exercises associated to a

biopsychosocial approach.

CLINICAL RELEVANCE

• Pilates method is effective in improving kinesiophobia in patients with chronic

non- specific low back pain.

• Pilates may be an accessible treatment for kinesiophobia associated with

chronic non- specific low back pain.

• Pilates method may decrease kinesiophobia by an average of 7,29% (3,45%

to 11,15%) compared to no treatment or minimal intervention.

13
 SEARCH STRATEGY

Main search strategy performed on MEDLINE:

"Low Back Pain"[Mesh] OR "Back Pain, Low" OR "Back Pains, Low" OR "Low Back

Pains" OR "Pain, Low Back" OR "Pains, Low Back" OR "Lumbago" OR "Lower Back

Pain" OR "Back Pain, Lower" OR "Back Pains, Lower" OR "Lower Back Pains" OR

"Pain, Lower Back" OR "Pains, Lower Back" OR "Low Back Ache" OR "Ache, Low

Back" OR "Aches, Low Back" OR "Back Ache, Low" OR "Back Aches, Low" OR

"Low Back Aches" OR "Low Backache" OR "Backache, Low" OR "Backaches, Low"

OR "Low Backaches" OR "Low Back Pain, Postural" OR "Postural Low Back Pain"

OR "Low Back Pain, Posterior Compartment" OR "Low Back Pain, Recurrent" OR

"Recurrent Low Back Pain" OR "Low Back Pain, Mechanical" OR "Mechanical Low

Back Pain" OR "Kinesiophobia" AND "Exercise Movement Techniques"[Mesh] OR

"Movement Techniques, Exercise" OR "Exercise Movement Technics" OR "Pilates-

Based Exercises" OR "Exercises, Pilates-Based" OR "Pilates Based Exercises" OR

"Pilates Training" OR " Training, Pilates"

14
 ACKNOWLEDGEMENTS

This research did not receive any specific grant from funding agencies in the

public, commercial, or not-for-profit sectors.

15
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 TABLES

Table 1. Results of the studies included in the review.

Authors Methodological Participants Comparison Intervention Outcome Results

Year design groups protocol

Cruz-Diaz Randomized 64 Control Mat Pilates Kinesiophobia Pilates resulted in a

et al. clinical trial (18-50 years group 12 weeks (Tampa scale) significant improvement in

2018 old) (guidance Twice a kinesiophobia

book on week Results of kinesiophobia at

chronic low 50 minutes baseline, after 6 weeks and

back pain) after 12 weeks, respectively:

Pilates group: 34.5 (33.6–

35.7); 27.5 (26.3–28.6); 27.5

(26.3–28.6)

Control group: 34 (32.6–

35.1); 33 (31.7 - 33.1); 32.5

(32.1 - 34.3)

Cruz Diaz Randomized 102 Control Mat Pilates Kinesiophobia Pilates resulted in a

et al. clinical trial (18-50 years group (no group and (Tampa scale) significant improvement in

2017 old) treatment) Equipment kinesiophobia

Pilates Results of kinesiophobia at

group baseline, after 6 weeks and

12 weeks after 12 weeks, respectively:

Twice a Mat Pilates group: 34,5 (4.1);

week 32,2 (3.0); 31,7 (3.2)

50 minutes Equipment Pilates group:

36,5 (3.9); 34,0 (4.1); 32,0

(3.5)

Control group: 33,9 (4.2);

34,2 (3.9); 34,1 (4.0)

21
Miyamoto Randomized 86 Control Mat Pilates Kinesiophobia Pilates had no effect in

et al. clinical trial (18-60 years group 6 weeks (Tampa scale) kinesiophobia

2013 old) (educational Twice a Results of kinesiophobia at

book) week baseline, after 6 weeks of

1 hour intervention and at week 12

(follow-up after treatment),

respectively:

Control group: 39.5 (7.1);

38.1 (8.3); 38.9 (7.3)

Pilates group: 39.4 (6.1);

36.3 (7.4); 38.1 (7.2)

Da luz et Randomized 86 Equipment Mat Pilates Kinesiophobia Equipment Pilates may be

al. clinical trial (18-60 years Pilates 6 weeks (Tampa scale) more effective than Mat

2014 old) Twice a Pilates for kinesiophobia in

week the long term

1 hour Results of kinesiophobia at

baseline, after 6 weeks of

intervention and at month 6

(follow-up after treatment),

respectively:

Mat Pilates: 39.7 (8.1); 35.3

(6.6); 40.0 (9.9)

Equipment Pilates: 39.6

(8.0); 34.1 (7.8); 34.9 (7.9)

Miyamoto Randomized (18-80 years Control Mat and Kinesiophobia Pilates exercises were more

et al., clinical trial old) group apparatus (Tampa scale) effective than minimal

2018 (educational Pilates intervention for

22
booklet) exercises kinesiophobia. after 6 weeks

6 weeks of intervention at all weekly

Once, frequencies.

twice and Results of kinesiophobia at

three baseline, after 6 weeks of

times a intervention and at 6 –

week month and 12 – month

1 hour follow-ups after treatment),

respectively:

Control group: 40.7(9.1);

41.6 (8.4); 40.4(9.3); 38.0

(9.9)

Pilates group 1:

39.7(7.5);37.1(7.4);

38.3(8.4); 37.6 (8.1)

Pilates group 2:

40.8(7.5);37.4(8.7);

37.9(8.6);36.4(8.1)

Pilates group 3:38.3

(7.2);35.4(8.0); 37.2 (8.3);

37.5(9.0)

23
Table 2. GRADE analysis

Pilates exercises compared to no treatment or minimal intervention for chronic non-specific low back
pain
Patient or population: Chronic non-specific low back pain

Setting: Ambulatory care

Intervention: Pilates exercises

Comparison: No treatment or minimal intervention

Anticipated absolute effects*

(95% CI)
№ of Certainty of the
Relative effect
Outcomes Risk with no Risk with participants evidence Comments
(95% CI)
treatment or Pilates (studies) (GRADE)
minimal exercises
intervention

Kinesiophobia MD 3.72 points

assessed with: The mean lower
Tampa scale kinesiophobia (5.69 lower to
-
507 ⨁⨁⨁◯ Pilates exercises likely reduces
Scale from: 17 ranged from 33 1.76 lower) (4 RCTs) MODERATE a kinesiophobia slightly.
(absence of fear) to 41.6 points
to 68 (maximum
fear)

*The risk in the intervention group (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; MD: Mean difference

GRADE Working Group grades of evidence

High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a
possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Explanations
a. Downgraded one level for inconsistency. We identified substantial heterogeneity (I2 = 71%) that was not possible to explain due to small number of
studies.

24
 CAPTIONS TO ILLUSTRATIONS

Figure 1. Flow diagram of the different steps of the systematic review.

IDENTIFICATION

RESULT OF THE SEARCH ON LILACS RESULT OF THE SEARCH ON

MEDLINE N=228
N=86

TOTAL OF STUDIES N= 314

SELECTION

EXCLUDED RECORDS
SELECTED RECORDS N=27
N=288

EXCLUDED ARTICLES
ELIGIBILITY

BECAUSE OF DUPLICATION
FULL-TEXT READING TO OR LACK OF THE OUTCOME
ASSESS EIGIBILITY KINESIOPHOBIA
N=27 N=22
INCLUSION

STUDIES INCLUDED IN THE

SYNTHESIS AND QUALITY
ASSESSMENT

N=5

25
Figure 2. Risk of bias results.

Figure 3. Risk of bias summary: review authors’ judgements about each risk of bias item for each

included study.

26
Figure 4. Meta-analysis of the comparison between the Pilates exercises and control for the outcome

kinesiophobia associated with chronic non-specific low back pain

Figure 5. Posterior distribution plot of pooled effect. Based on 10000 simulations.

27
Table 2. GRADE analysis

Pilates exercises compared to no treatment or minimal intervention for chronic non-specific low
back pain
Patient or population: Chronic non-specific low back pain

Setting: Ambulatory care

Intervention: Pilates exercises

Comparison: No treatment or minimal intervention

Anticipated absolute effects*

(95% CI)
№ of Certainty of the
Relative effect
Outcomes Risk with no Risk with participants evidence Comments
(95% CI)
treatment or Pilates (studies) (GRADE)
minimal exercises
intervention

Kinesiophobia The mean MD 3.72 points

assessed with: lower
kinesiophobia
Tampa scale
ranged from (5.69 lower to
-
507 ⨁⨁⨁◯ Pilates exercises likely reduces
Scale from: 17 1.76 lower) (4 RCTs) MODERATE a kinesiophobia slightly.
(absence of 33 to 41.6
fear) to 68 points
(maximum fear)

*The risk in the intervention group (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; MD: Mean difference

GRADE Working Group grades of evidence

High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there
is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of
effect
Table 1. Results of the studies included in the review.

Authors Methodological Participants Comparison Intervention Outcome Results

Year design groups protocol

Cruz-Diaz Randomized 64 Control Mat Pilates Kinesiophobia Pilates resulted in a

et al. clinical trial (18-50 years group 12 weeks (Tampa scale) significant improvement in

2018 old) (guidance Twice a kinesiophobia

book on week Results of kinesiophobia at

chronic low 50 minutes baseline, after 6 weeks and

back pain) after 12 weeks, respectively:

Pilates group: 34.5 (33.6–

35.7); 27.5 (26.3–28.6); 27.5

(26.3–28.6)

Control group: 34 (32.6–

35.1); 33 (31.7 - 33.1); 32.5

(32.1 - 34.3)

Cruz Diaz Randomized 102 Control Mat Pilates Kinesiophobia Pilates resulted in a

et al. clinical trial (18-50 years group (no group and (Tampa scale) significant improvement in

2017 old) treatment) Equipment kinesiophobia

Pilates Results of kinesiophobia at

group baseline, after 6 weeks and

12 weeks after 12 weeks, respectively:

Twice a Mat Pilates group: 34,5 (4.1);

week 32,2 (3.0); 31,7 (3.2)

50 minutes Equipment Pilates group:

36,5 (3.9); 34,0 (4.1); 32,0

(3.5)

Control group: 33,9 (4.2);

34,2 (3.9); 34,1 (4.0)

Miyamoto Randomized 86 Control Mat Pilates Kinesiophobia Pilates had no effect in

et al. clinical trial (18-60 years group 6 weeks (Tampa scale) kinesiophobia

2013 old) (educational Twice a Results of kinesiophobia at

book) week baseline, after 6 weeks of

1 hour intervention and at week 12

(follow-up after treatment),

respectively:

Control group: 39.5 (7.1);

38.1 (8.3); 38.9 (7.3)

Pilates group: 39.4 (6.1);

36.3 (7.4); 38.1 (7.2)

Da luz et Randomized 86 Equipment Mat Pilates Kinesiophobia Equipment Pilates may be

al. clinical trial (18-60 years Pilates 6 weeks (Tampa scale) more effective than Mat

2014 old) Twice a Pilates for kinesiophobia in

week the long term

1 hour Results of kinesiophobia at

baseline, after 6 weeks of

intervention and at month 6

(follow-up after treatment),

respectively:

Mat Pilates: 39.7 (8.1); 35.3

(6.6); 40.0 (9.9)

Equipment Pilates: 39.6

(8.0); 34.1 (7.8); 34.9 (7.9)

Miyamoto Randomized (18-80 years Control Mat and Kinesiophobia Pilates exercises were more

et al., clinical trial old) group apparatus (Tampa scale) effective than minimal

2018 (educational Pilates intervention for

booklet) exercises kinesiophobia. after 6 weeks

6 weeks of intervention at all weekly

Once, frequencies.

twice and Results of kinesiophobia at

three baseline, after 6 weeks of

times a intervention and at 6 –

week month and 12 – month

1 hour follow-ups after treatment),

respectively:

Control group: 40.7(9.1);

41.6 (8.4); 40.4(9.3); 38.0

(9.9)

Pilates group 1:

39.7(7.5);37.1(7.4);

38.3(8.4); 37.6 (8.1)

Pilates group 2:

40.8(7.5);37.4(8.7);

37.9(8.6);36.4(8.1)

Pilates group 3:38.3

(7.2);35.4(8.0); 37.2 (8.3);

37.5(9.0)
 DECLARATION OF CONFLICT OF INTERESTS

To the Scientific Editor of Journal of Bodywork & Movement Therapies

Cíntia Domingues de Freitas, Déborah Araújo Costa, Nelson Carvas Junior and Vinícius
Tassoni Civile, authors of the manuscript: “Effects of the Pilates Method on Kinesiophobia
Associated with Chronic Non-Specific Low Back Pain: Systematic Review and Meta-
Analysis”, declare that there is no conflict of interest with the topic addressed.

We do not have conflict of interest of order: financial, commercial, political, academic and
personal.

It is stated that no links or financing agreements have been omitted from authors or companies
that may be interested in the publication of this article.

March 17, 2019

Authors: