Journal of
Clinical Medicine
Review
Pilates Method Improves Cardiorespiratory Fitness:
A Systematic Review and Meta-Analysis
Rubén Fernández-Rodríguez 1,2
, Celia Álvarez-Bueno 2,3,*, Asunción Ferri-Morales 4
,
Ana I. Torres-Costoso 4
, Iván Cavero-Redondo 2 and Vicente Martínez-Vizcaíno 2,5
1
Movi-Fitness S.L, Universidad de Castilla La-Mancha, 16002 Cuenca, Spain; ruben.fernandez12@alu.uclm.es
2
Health and Social Care Center, Universidad de Castilla La-Mancha, 16002 Cuenca, Spain;
Ivan.Cavero@uclm.es (I.C.-R.); Vicente.Martinez@uclm.es (V.M.-V.)
3
Universidad Politécnica y Artística del Paraguay, Asunción 001518, Paraguay
4
Faculty of Physiotherapy and Nursing, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
Asuncion.Ferri@uclm.es (A.F.-M.); AnaIsabel.Torres@uclm.es (A.I.T.-C.)
5
Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca 3460000, Chile
*
Correspondence: celia.alvarezbueno@uclm.es
Received: 1 September 2019; Accepted: 21 October 2019; Published: 23 October 2019


Abstract: Cardiorespiratory ﬁtness has been postulated as an independent predictor of several chronic
diseases. We aimed to estimate the eﬀect of Pilates on improving cardiorespiratory ﬁtness and to
explore whether this eﬀect could be modiﬁed by a participant’s health condition or by baseline VO2
max levels. We searched databases from inception to September 2019. Data were pooled using
a random eﬀects model. The Cochrane risk of bias (RoB 2.0) tool and the Quality Assessment Tool for
Quantitative Studies were performed. The primary outcome was cardiorespiratory ﬁtness measured
by VO2 max. The search identiﬁed 527 potential studies of which 10 studies were included in the
systematic review and 9 in the meta-analysis. The meta-analysis showed that Pilates increased VO2
max, with an eﬀect size (ES) = 0.57 (95% CI: 0.15–1; I2 = 63.5%, p = 0.018) for the Pilates group vs. the
control and ES = 0.51 (95% CI: 0.26–0.76; I2 = 67%, p = 0.002) for Pilates pre-post eﬀect. The estimates
of the pooled ES were similar in both sensitivity and subgroup analyses; however, random-eﬀects
meta-regressions based on baseline VO2 max were signiﬁcant. Pilates improves cardiorespiratory
ﬁtness regardless of the population’s health status. Therefore, it may be an eﬃcacious alternative for
both the healthy population and patients suﬀering from speciﬁc disorders to achieve evidenced-based
results from cardiorespiratory and neuromotor exercises.
Keywords: aerobic capacity; cardiac rehabilitation; mind–body; Pilates; cardiorespiratory ﬁtness;
VO2 max; adults; prescription of exercise; systematic review; meta-analysis
1. Introduction
Strong evidence supports that higher levels of cardiorespiratory ﬁtness (CRF) are associated with
a lower risk of cardiovascular morbidity and mortality as well as all-cause mortality [1–3]. In addition,
CRF decreases the risk of developing some speciﬁc diseases [4], such as chronic obstructive pulmonary
disease (COPD) and lung or colorectal cancer [5,6], most of which are associated with a large burden
of disease [7]. Furthermore, several studies have shown that higher levels of CRF may attenuate
the negative association between CV risk factors and sedentary behaviours independent of physical
activity [8–11]. Thus, CRF emerges as an independent predictor for several chronic diseases [12] and
as a remarkable overall health status measure in diﬀerent populations [12].
To improve CRF, current evidence suggests that physical exercise must reach a minimum
intensity [13,14] of at least 45% oxygen uptake reserve in the general population and 70%–80% in
J. Clin. Med. 2019, 8, 1761; doi:10.3390/jcm8111761
www.mdpi.com/journal/jcm
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athletes [15]. Greater improvements in maximal oxygen uptake (VO2 max) are obtained with vigorous
physical exercises when compared with moderate intensity exercises [3]. Moreover, it has been
suggested that some types of physical exercises that are not traditionally considered as cardiorespiratory
exercises [16,17], such as Pilates, could increase CRF.
Pilates has become popular in recent years as a holistic exercise [16] focused on respiration, body
control and accuracy of movements. Current evidence suggests positive eﬀects of Pilates on respiratory
muscle strength, balance, quality of life and overall physical performance [18–24]. These beneﬁts
are observed not only in the healthy population but also in those with speciﬁc disorders, such as
chronic low back pain [16], multiple sclerosis [25], breast cancer [26] and Parkinson’s disease [27].
The neuromuscular stimulation achieved during Pilates [28] may be of suﬃcient intensity to improve
CRF, providing beneﬁts in VO2 max for individuals with diﬀerent health conditions [29–33]. Thus,
it seems that Pilates exercises include a mind–body component [34] that could have a beneﬁcial impact
in diﬀerent populations.
However, evidence for the comparative beneﬁts of Pilates vs. other physical exercises in terms
of VO2 max remains inconclusive [22,35], and there are no studies that have evaluated oxygen
consumption during Pilates sessions. Therefore, it is diﬃcult to assess whether Pilates exercises reach
the minimum intensity needed to improve CRF. We conducted this systematic review and meta-analysis
to determine the eﬀectiveness of Pilates on CRF as measured through VO2 max. Moreover, we explored
whether the eﬀect of Pilates on CRF could be modiﬁed by the participant’s health condition or baseline
VO2 max level.
2. Materials and Methods
2.1. Search Strategy and Study Selection
The present review and meta-analysis were reported according to the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) [36] and follow the recommendations of the
Cochrane Handbook for Systematic Reviews of Interventions [37]. This study was registered through
PROSPERO with registration number CRD42019124054.
We conducted a systematic literature search in the following databases: MEDLINE (via PubMed),
Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE (via Scopus), Web of Science
and the Physiotherapy Evidence Database (PEDro), from each database’s inception until September
2019 for studies aimed at determining the eﬀectiveness of the Pilates method on CRF as measured
through VO2 max. The search algorithm was conducted using PICO’s strategy (type of studies,
participants, interventions, comparators and outcome assessment) and combined Medical Subject
Headings, free-terms and matching synonyms of the following related words: (1) population: adults,
“middle aged”, “young adult”; (2) intervention: Pilates, mind–body, “exercise movement techniques”;
(3) outcome: “cardiorespiratory ﬁtness”, “aerobic ﬁtness”, “aerobic capacity”, “heart rate”; and (4)
comparator: control conditions or another physical exercise. In addition, we searched the citations
included in the identiﬁed publications deemed eligible for our study. The complete search strategy for
MEDLINE is presented in Table 1.
Table 1. Strategy for MEDLINE.
Population
Intervention
Outcome
Adults
Pilates
“Cardiorespiratory ﬁtness”
OR
OR
OR
Middle aged
Mind-body
“Aerobic ﬁtness”
OR
OR
OR
Young adult
Exercise Movement Techniques (Mesh)
“Aerobic capacity”
OR
“Heart rate”
OR
Cardiorespiratory ﬁtness (Mesh)
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2.2. Eligibility Criteria
Two initial reviewers (RFR and CAB) independently examined the titles and abstracts of retrieved
articles to identify suitable studies. Those studies in which the title and abstract were related to the
aim of the present review were included for full text request. We included studies that (1) were
conducted as randomised controlled trials (RCTs), non-randomised controlled trials (non-RCTs) or
pre-post studies; (2) included a mean participant age ≥18 years; (3) involved participants in any health
condition; and (4) were based on at least one exercise intervention described as “Pilates” (mat, machine
or both). Studies were excluded if (1) outcome measurements were not reported as VO2 max values, or
(2) they were not written in English, Spanish or Portuguese. A third reviewer (VMV) resolved cases of
initial reviewer disagreement.
Ethical Aspects
The present systematic review and meta-analysis were performed by collecting and analysing
data from previous studies in which informed consent had been obtained by the respective original
investigators. Therefore, this study was exempt from ethics approval.
2.3. Data Extraction and Quality Assessment
Two authors (RFR and CAB) independently extracted the following information from the included
studies: First author’s name and year of publication; study design; characteristics of the participants
included; mean age; sample size and percentage of female subjects; weekly frequency, period and
modality of Pilates intervention; supervision of the intervention by a certiﬁed instructor; use of
a detailed exercise protocol; the reported measurement of VO2 max; the device used to measure VO2
max; and main results. A third reviewer (VMV) resolved cases of author disagreement.
The risk of bias of RCTs was assessed using the Cochrane risk-of-bias tool for randomised trials
(RoB 2.0) [38], in which ﬁve domains were evaluated: Randomization process, deviations from intended
interventions, missing outcome data, measurement of the outcome, and selection of the reported result.
Each domain was assessed for risk of bias. Studies were graded as (1) “low risk of bias” when a low
risk of bias was determined for all domains; (2) “some concerns” if at least one domain was assessed as
raising some concerns, but not to be at high risk of bias for any single domain; or (3) “high risk of bias”
when high risk of bias was reached for at least one domain or the study judgement included some
concerns in multiple domains [38].
For pre-post studies and non-RCTs we used the Quality Assessment Tool for Quantitative
Studies [39], in which seven domains were evaluated: Selection bias, study design, confounders,
blinding, data collection methods, withdrawals and dropouts. Each domain was considered strong,
moderate or weak. Studies were classiﬁed as “low risk of bias” if they presented no weak ratings;
“moderate risk of bias” when there was at least one weak rating; or “high risk of bias” if there were
two or more weak ratings [39].
Risk of bias was independently assessed by two reviewers (RFR and CAB). A third reviewer
(VMV) was consulted in case of disagreement.
2.4. Data Analysis
Primary data extracted from each study included mean VO2 max, standard deviation of pre-post
intervention and sample size. Eﬀect sizes (ES) and related 95% conﬁdence intervals (CIs) were calculated
for each study [40]. The Dersimonian and Laird random eﬀects method [41] was used to compute
pooled ES estimates and respective 95% CIs. We estimated the pooled ES for the eﬀect of Pilates vs. the
control group (CG). The heterogeneity of results across studies was evaluated using the I2 statistic, with
I2 values of 0%–30% considered “not important” heterogeneity; >30%–50% representing moderate
heterogeneity; >50%–80% representing substantial heterogeneity, and >80%–100% representing
considerable heterogeneity. The corresponding p-values and 95%CI for I2 were also considered [42].
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Finally, we conducted two additional analyses: (i) the pre-post ES of Pilates on the intervention group
(Appendix A), and (ii) the mean diﬀerence of Pilates vs. CG (Appendix B).
For all the analyses, when studies reported data on two intervention groups of Pilates, the eﬀects
of both groups were pooled in order to calculate the average eﬀect size. Finally, when studies
reported more than one intervention, we only considered the Pilates intervention for conducting
this meta-analysis.
A sensitivity analysis was conducted by removing each included study to assess the robustness
of the summary estimates. Further, subgroup analysis based on participants’ health status and
random-eﬀects meta-regression by baseline VO2 max values were conducted to determine their
potential eﬀect on the pooled ES estimates. Finally, publication bias was evaluated through visual
inspection of funnel plots and Egger’s regression asymmetry test for the assessment of small-study
eﬀects [43]. Statistical analyses were performed using StataSE software, version 15 (StataCorp, College
Station, TX, USA).
3. Results
3.1. Systematic Review
3.1.1. Study Selection
The search strategy identiﬁed 527 potential studies for inclusion. Of these, 10 studies were
included in the systematic review. Only nine studies were included in the meta-analysis because one
study [44] did not provide the required data to calculate ES (Figure 1).
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For all the analyses, when studies reported data on two intervention groups of Pilates, the effects 
of both groups were pooled in order to calculate the average effect size. Finally, when studies 
reported more than one intervention, we only considered the Pilates intervention for conducting this 
meta-analysis. 
A sensitivity analysis was conducted by removing each included study to assess the robustness 
of the summary estimates. Further, subgroup analysis based on participants’ health status and 
random-effects meta-regression by baseline VO2 max values were conducted to determine their 
potential effect on the pooled ES estimates. Finally, publication bias was evaluated through visual 
inspection of funnel plots and Egger’s regression asymmetry test for the assessment of small-study 
effects [43]. Statistical analyses were performed using StataSE software, version 15 (StataCorp, 
College Station, TX, USA). 
3. Results 
3.1. Systematic Review 
3.1.1. Study Selection 
The search strategy identified 527 potential studies for inclusion. Of these, 10 studies were 
included in the systematic review. Only nine studies were included in the meta-analysis because one 
study [44] did not provide the required data to calculate ES (Figure 1). 
 
Figure 1. Flow of the included studies. 
Figure 1. Flow of the included studies.
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3.1.2. Study and Intervention Characteristics
Study and intervention characteristics are summarised in Table 2. Of the 10 included studies,
ﬁve were RCTs [22,29,33,35,45], two were non-RCTs [31,44] and three were pre-post studies [30,32,46].
All the studies were conducted between 2008 and 2019 and included a total of 332 participants,
of which 223 were in Pilates groups (67%) and 109 in control groups (33%).
The age of the
participants ranged between 18 and 66 years; four studies were conducted in women only [22,31,32,46].
Furthermore, seven studies were conducted in a healthy population, including people described
in the primary studies as people without health disorders or speciﬁc pathologies [22,31] (four in
sedentary individuals [30,32,44,46] and one in trained runners [33]) and three studies were conducted
in populations with speciﬁc health disorders, including those described in the primary studies as
suﬀering some diseases or speciﬁc health disorders such as heart failure [35], chronic stroke [29] and
overweight/obesity [45].
In control groups, participants were encouraged to continue with their routine physical activity
or to obtain conventional treatment. Among control groups, two studies did not allow structured
physical exercise [22,45]; one did not describe the control group activity [31]; and one performed the
running conventional program [33] and two studies the conventional rehabilitation programs [29,35].
Concerning the characteristics of the Pilates interventions, the majority of studies consisted of
two or three 40–60 min sessions, three times per week, over 8–16 weeks. The mean attendance at the
Pilates sessions was 88.2% (80%–100%). Among the 10 studies, six described the Pilates intervention as
Pilates mat [22,29,30,33,35,46], three studies combined both modalities (mat and machine) [32,44,45]
and one did not report the Pilates modality [31]. Moreover, six studies were conducted by a certiﬁed
instructor [22,29,30,33,35,45] or with a detailed exercise protocol [29,30,32,34,44,45].
The outcome, VO2 max, was directly measured in nine studies (two with a cycloergometer and
seven with a treadmill) [29–33,35,45–47] and one study [22] used an algorithm based on heart rate to
estimate VO2 max values. The studies assessed participants at the end of the Pilates intervention, an
no study measured VO2 max during the Pilates session.
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Table 2. The included studies.
Author
Design
Participants’
Characteristics
Mean Age
Sample Size (%
Female)
Frequency
Period
Type of
Pilates
Certiﬁed
Instructor
Detailed
Protocol
Outcome Measure
Outcome Results
Wolkodoﬀ 2008
[44]
CT
Sedentary
(healthy)
PG = 23–64
n = 20
PG = 14 (85.7%)
CG = 6 (83.3%)
40′/3.2xwk
8wks
Both
NA
Yes
-Peak VO2 mL/kg/min
(Oxycon Mobile)
CG change = 0.38
PG change = 6.06
17% of change in PG
Guimarães et al.,
2012 [35]
RCPT
Heart failure
PG = 46 ± 12
CRG = 44 ± 11
n = 16
PG = 8 (38%)
CRG = 8 (19%)
60′/2xwk
16wks
Mat
Yes
Yes
-Peak VO2 mLO2/kg/min
(Vmax 229 model, SensorMedics,
Yorba Linda, CA, USA)
PG: improvements in peak
VO2 (p = 0.01)
Comparing both groups, PG
showed greater improvement
on peak VO2 (p = 0.02)
Gildenhuys et al.,
2013 [22]
RCT
Elderly women
(healthy)
PG = 66 ± 5
CG = 65 ± 5
n = 50
PG = 25 (100%)
CG = 25 (100%)
60′/3xwk
8wks
Mat
Yes
NA
-VO2 max mL.kg−1 min−1
(6minWalk; indirect equation)
PG did not signiﬁcantly
improve VO2 max (p = 0.247)
Lim HS et al.,
2016 [29]
RCT
Chronic stroke
PG = 63 ± 8
CG = 62 ± 7
n = 20
PG = 10 (40%)
CG = 10 (50%)
3xwk
8wks
Mat
Yes
Yes
-VO2 max mL/min
-VO2 max per kg
(metabolic analyzer: Quark b2,
COSMED, Italy 2011)
PG: VO2 max and VO2 max
per kg increased signiﬁcantly
CG: VO2 max per kg
diminished signiﬁcantly
Diamantoula et
al., 2016 [46]
Q-E
Sedentary
women
(healthy)
PG = 26 ± 5
AP = 21.3 ± 2
PG land = 20
(100%)
AP = 20 (100%)
2xwk
2years
Mat/aqua
NA
NA
-VO2 max mL/min (Ergometer
cycle (Amila kh803), following
the Astrand-Ryhming test, based
on heart rate in submaximal
eﬀort)
No diﬀerences between
groups, better VO2 max in
total for both groups
Tinoco-
Fernández et al.,
2016 [30]
Q-E
Sedentary
students
(healthy)
PG = 18–35
n = 45
PG = 45
(78%)
60′/3xwk
10wks
Mat
Yes
Yes
-VO2 max L/kg/min
-VO2 max L/min
(MasterScreen CPX apparatus)
Increment in peak VO2 and
VO2 max
Rodrigues et al.,
2016 [32]
Q-E
Sedentary
women
(healthy)
PG = 23 ± 2
PG = 10 (100%)
45′/2xwk
11wks
Both
NA
Yes
-VO2 max mL.kg−1 min−1
portable metabolic system
(VO2000®, MedGraphics®,
St. Paul, MN, USA)
Peak VO2 tended to increase,
but the diﬀerences were not
statistically signiﬁcant
Mikalacki et al.,
2017 [31]
CT
Adult women
(healthy)
PG = 48 ± 7
CG = 47 ± 7
n = 64
PG = 36 (100%)
CG = 28 (100%)
55–60′/2xwk
NA
NA
NA
NA
-Relative VO2 max
-Absolute VO2 max
(Medisoft, model 870c)
PG: signiﬁcant increase on
relative VO2max, absolute
VO2 max
-CG: not signiﬁcant changes
Finatto et al.,
2018 [33]
RCT
Trained
runners
(healthy)
PG = 18 ± 1
CG = 18 ± 1
n = 32
PG = 15–13
NA %
CG = 16–15
60′/1xwk
12wks
Mat
Yes
NA
-VO2 max mL.kg−1.min−1
(VO2000 (Medgraphics, Ann
Arbor, USA)
PG: signiﬁcantly higher
values on VO2 max (p < 0.001)
Rayes et al., 2019
[45]
RCT
Overweight/obesePG = 55.9 ± 6.6
CG = 45.5 ± 9.3
n = 60
NA%
PG = 22
CG = 25/17
60′/3xwk
8wks
Both
Yes
Yes
-VO2 max (mL/kg/min)
(motorized treadmill; Inbrasport,
ATL, Porto Alegre, Brazil)
PG: Signiﬁcant improvement
on VO2 max
CG: not signiﬁcant changes
CT: controlled trial; RCT: randomised controlled trial; RCPT: randomised controlled pilot trial; Q-E: quasi-experimental; PG: Pilates group; CG: control group; AP: Aqua-Pilates group; NA:
not available; wk: week; VO2 max: maximal oxygen uptake.
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3.1.3. Quality Assessment and Risk of Bias
Five RCTs were assessed according to the RoB 2.0 tool [38], of which two were assessed as “low
risk of bias” and three as “some concerns” (Figure 2). The remaining ﬁve studies (non-RCTs and
pre-post studies) were assessed according to the Quality Assessment Tool for Quantitative Studies [39],
of which two were classiﬁed as “low risk of bias”, two as “moderate risk of bias” and one as high risk
of bias (Figure 3).
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3.1.3. Quality Assessment and Risk of Bias 
Five RCTs were assessed according to the RoB 2.0 tool [38], of which two were assessed as “low 
risk of bias” and three as “some concerns” (Figure 2). The remaining five studies (non-RCTs and pre-
post studies) were assessed according to the Quality Assessment Tool for Quantitative Studies [39], 
of which two were classified as “low risk of bias”, two as “moderate risk of bias” and one as high risk 
of bias (Figure 3). 
 
Figure 2. Quality assessment for RCT (RoB 2.0). 
 
Figure 3. Quality assessment for non-RCT. 
 
Figure 2. Quality assessment for RCT (RoB 2.0).
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3.1.3. Quality Assessment and Risk of Bias 
Five RCTs were assessed according to the RoB 2.0 tool [38], of which two were assessed as “low 
risk of bias” and three as “some concerns” (Figure 2). The remaining five studies (non-RCTs and pre-
post studies) were assessed according to the Quality Assessment Tool for Quantitative Studies [39], 
of which two were classified as “low risk of bias”, two as “moderate risk of bias” and one as high risk 
of bias (Figure 3). 
 
Figure 2. Quality assessment for RCT (RoB 2.0). 
 
Figure 3. Quality assessment for non-RCT. 
 
Figure 3. Quality assessment for non-RCT.
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3.2. Data Synthesis
3.2.1. Meta-Analysis
The pooled ES for the eﬀect of Pilates vs. CG on CRF was 0.57 (95% CI: 0.15–1.00; I2 = 63.5%,
p = 0.02) (Figure 4) and for Pilates pre-post ES was 0.51 (95% CI: 0.26–0.76; I2 = 67%, p < 0.01) (Figure A1,
Appendix A). The mean diﬀerence analysis of Pilates vs. CG was 2.77 (95% CI: 1.12–4.42; I2 = 33.4%,
p = 0.19) (Figure A3, Appendix B).
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3.2. Data Synthesis 
3.2.1. Meta-Analysis 
The pooled ES for the effect of Pilates vs. CG on CRF was 0.57 (95% CI: 0.15–1.00; I2 = 63.5%, p = 
0.02) (Figure 4) and for Pilates pre-post ES was 0.51 (95% CI: 0.26–0.76; I2 = 67%, p < 0.01) (Figure A1, 
Appendix A). The mean difference analysis of Pilates vs. CG was 2.77 (95% CI: 1.12–4.42; I2 = 33.4%, 
p = 0.19) (Figure B1, Appendix B). 
 
Figure 4. Meta-analysis for Pilates Method vs. control group (pooled ES analysis). 
3.2.2. Sensitivity and Meta-Regression Analyses 
After removing studies from the analyses individually, none substantially modified the pooled 
ES estimate in Pilates vs. CG (Table 3), Pilates pre-post effect on intervention (Table A1, Appendix A) 
and mean difference of Pilates vs. CG. (Table B1, Appendix B). The subgroup analyses by 
participants’ health conditions modified the pooled ES estimate for Pilates vs. CG (Table 4) and mean 
difference of Pilates vs. CG (Table B2, Appendix B), but not for Pilates pre-post effect on intervention 
(Table A2, Appendix A). 
Table 3. Sensitivity analyses. 
Pilates Method vs. Control 
Author, Year 
 
ES 
 
LL 
 
UL 
 
I2 
Guimarães et al., 2012 [35] 
0.6 
0.12 
1.08 
70.8 
Gildenhuys et al., 2013 [22] 
0.69 
0.20 
1.18 
64.4 
Lim HS et al., 2016 [29] 
0.62 
0.10 
1.14 
70.7 
Mikalacki et al., 2017 [31] 
0.62 
0.03 
1.22 
70.8 
Finatto et al., 2018 [33] 
0.4 
0.16 
0.64 
0 
Rossell-Rayes et al., 2019 [45] 
0.63 
0.12 
1.15 
70.4 
ES: Effect size; LL: Lower limit; UL: Upper limit. 
 
 
Figure 4. Meta-analysis for Pilates Method vs. control group (pooled ES analysis).
3.2.2. Sensitivity and Meta-Regression Analyses
After removing studies from the analyses individually, none substantially modiﬁed the pooled ES
estimate in Pilates vs. CG (Table 3), Pilates pre-post eﬀect on intervention (Table A1, Appendix A) and
mean diﬀerence of Pilates vs. CG. (Table A5, Appendix B). The subgroup analyses by participants’
health conditions modiﬁed the pooled ES estimate for Pilates vs. CG (Table 4) and mean diﬀerence of
Pilates vs. CG (Table A6, Appendix B), but not for Pilates pre-post eﬀect on intervention (Table A2,
Appendix A).
Table 3. Sensitivity analyses.
Pilates Method vs. Control
Author, Year
ES
LL
UL
I2
Guimarães et al., 2012 [35]
0.6
0.12
1.08
70.8
Gildenhuys et al., 2013 [22]
0.69
0.20
1.18
64.4
Lim HS et al., 2016 [29]
0.62
0.10
1.14
70.7
Mikalacki et al., 2017 [31]
0.62
0.03
1.22
70.8
Finatto et al., 2018 [33]
0.4
0.16
0.64
0
Rossell-Rayes et al., 2019 [45]
0.63
0.12
1.15
70.4
ES: Eﬀect size; LL: Lower limit; UL: Upper limit.
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Table 4. Subgroup analyses by participants’ health status.
Pilates Method vs. Control
ES
LL
UL
I2
Healthy
0.80
−0.05
1.65
85
Unhealthy
0.40
−0.01
0.81
0
ES: Eﬀect size; LL: Lower limit; UL: Upper limit.
The random-eﬀects meta-regression models by VO2 max baseline levels were signiﬁcant for
Pilates vs. CG (p = 0.03) (Table 5) and for Pilates pre-post eﬀect on intervention (p = 0.05) (Table A3,
Appendix A) but not for mean diﬀerence of Pilates vs. CG (p = 0.08) (Table A7, Appendix B).
Table 5. Meta-regression analyses by VO2 max baseline values.
Coeﬃcient
p
Pilates Method vs. control
0.04
0.03 *
VO2 max: Maximal oxygen uptake (mL/kg/min); * Signiﬁcant at p ≤ 0.05.
3.2.3. Publication Bias
A signiﬁcant publication bias was not found in Pilates vs. CG studies, as evidenced by both the
funnel plot (Figure 5) asymmetry and an Egger’s test (p = 0.465) (Table 6), nor in the mean diﬀerence
of Pilates vs. CG by funnel plot asymmetry (Figure A4, Appendix B) and an Egger’s test (p = 0.69)
(Table A8, Appendix B). However, in Pilates pre-post eﬀect studies publication bias was found (p = 0.07)
(Table A4, Appendix A).
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Table 4. Subgroup analyses by participants’ health status. 
Pilates Method vs. Control 
 
 
 
 
 
ES 
LL 
UL 
I2 
Healthy 
0.80 
−0.05 
1.65 
85 
Unhealthy 
0.40 
−0.01 
0.81 
0 
ES: Effect size; LL: Lower limit; UL: Upper limit. 
The random-effects meta-regression models by VO2 max baseline levels were significant for 
Pilates vs. CG (p = 0.03) (Table 5) and for Pilates pre-post effect on intervention (p = 0.05) (Table A3, 
Appendix A) but not for mean difference of Pilates vs. CG (p = 0.08) (Table B3, Appendix B). 
Table 5. Meta-regression analyses by VO2 max baseline values. 
 
Coefficient 
p 
Pilates Method vs. control 
0.04 
0.03 * 
VO2 max: Maximal oxygen uptake (ml/kg/min); * Significant at p ≤ 0.05. 
3.2.3. Publication Bias 
A significant publication bias was not found in Pilates vs. CG studies, as evidenced by both the 
funnel plot (Figure 5) asymmetry and an Egger’s test (p = 0.465) (Table 6), nor in the mean difference 
of Pilates vs. CG by funnel plot asymmetry (Figure B2, Appendix B) and an Egger’s test (p = 0.69) 
(Table B4, Appendix B). However, in Pilates pre-post effect studies publication bias was found (p = 
0.07) (Table A4, Appendix A). 
Table 6. Publication bias by Egger’s test. 
 
Coefficient 
p-Value 
Pilates method vs. control group 
1.64 
0.47 
 
 
Figure 5. Funnel plot for Pilates vs control group. 
Figure 5. Funnel plot for Pilates vs control group.
Table 6. Publication bias by Egger’s test.
Coeﬃcient
p-Value
Pilates method vs. control group
1.64
0.47
J. Clin. Med. 2019, 8, 1761
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4. Discussion
This systematic review and meta-analysis were performed to determine the eﬀectiveness of Pilates
interventions for improvement of CRF measured through VO2 max. Our ﬁndings highlight that Pilates
is an alternative exercise to improve VO2 max values. Furthermore, our results were substantially
modiﬁed by participants’ health conditions for Pilates vs. control group analyses but not for Pilates
pre-post eﬀect on intervention; otherwise, baseline VO2 max values could inﬂuence CRF improvement.
Although some studies [22,35,45,46] have failed to show signiﬁcant changes in CRF after Pilates
intervention, no study has reported negative eﬀects of Pilates on the CRF levels, and therefore the
positive clinical implications should not be underestimated. Additionally, more signiﬁcant beneﬁts of
Pilates on CRF were achieved when other activities, such as running, were included [33] and this could
be explained through a synergistic relationship between these training methods.
Evidence suggests that people with lower levels of CRF are more sensitive to improvement of
this parameter [47]. Accordingly, in our study estimates of pooled ES were higher in those studies in
which participants had lower baseline CRF levels, such as people with health disorders. Conversely,
our meta-regression analyses suggested that higher levels of VO2 max at baseline are related with
higher ES of the Pilates intervention. These ﬁndings should cautiously be interpreted since they
may indicate that the eﬀect of Pilates in those studies with higher VO2 max levels at baseline were
distortedly overestimated. Probably these biased estimates were a consequence of reporting results in
absolute terms (change in VO2 max in ml) instead of in relative terms (percentage of increase in VO2
max), but could have clinical implications suggesting that Pilates exercise is an eﬀective rehabilitation
strategy for several disorders, including some cardiac pathologies. Moreover, Pilates exercise showed
high compliance levels indicating that it may be better tolerated than the aerobic exercises typically
employed in rehabilitation programs.
Three potential sources of improvement may explain the positive impact of Pilates intervention
on CRF: Strengthening of the lumbopelvic region, increased ﬂexibility of the ribcage and breathing
exercises. First, the strengthening of lumbopelvic and core muscles induced by Pilates may produce
a more eﬃcient movement pattern in upper and lower limbs, as well as greater strength in expiratory
muscles [19,33]. Second, due to the ﬂexibility improvement, a more eﬃcient mobility pattern of the
ribcage may be achieved [30]. Finally, the breathing techniques adopted during Pilates training may
increase lung capacity [29] and functionality of intercostal muscles [17]. On these bases, improved
ventilation eﬃciency would be achieved, resulting in a higher ﬂow of oxygenated blood into muscle
tissues [35], enhanced local circulation [19,30] and muscle oxidative capacity [45], and less energy
waste. Therefore, Pilates could reach the minimum intensity required to improve CRF [13,14] although
no published study has veriﬁed this.
Our systematic review and meta-analysis present some limitations that must be stated. First,
it was not possible to blind Pilates interventions and some of the included studies did not provide
details about the randomisation sequence or allocation concealment. Second, considerable levels of
heterogeneity were observed in the analyses, and we cannot omit this fact. Third, the heterogeneity of
participants’ health conditions and the dose and intensity of the Pilates intervention could potentially
aﬀect our estimates. Fourth, signiﬁcant publication bias was evidenced by Egger’s test and unpublished
results could modify the ﬁndings of the present meta-analysis. Fifth, it should be highlighted the
diﬃculty to comply with a full training program by very busy professionals, thus, this concern should
not be neglected in the implementation of our results. Sixth, rarely it is possible to measure VO2
max directly in clinical settings, thus other more applicable procedures for indirect measurement of
VO2 max should be used. Seventh, although subgroup analyses by participants’ health conditions
modiﬁed the ES estimates, these results should be cautiously considered due to the lack of studies in
each subgroup. Finally, due to the lack of long-term assessments, we could not determine whether the
beneﬁts to CRF measured through VO2 max are preserved over time. Therefore, our results should be
cautiously considered.
J. Clin. Med. 2019, 8, 1761
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5. Conclusions
In summary, our results support Pilates as an eﬀective intervention to improve CRF in both healthy
people and individuals with disorders related to aerobic capacity. Despite this, further studies should
be conducted, including short- and long-term measurements to determine the intensity level reached
by VO2 max during Pilates intervention and whether CRF improvement is preserved over time.
Author Contributions: Conceptualization, R.F.-R. and I.C.-R.; methodology, R.F.-R., C.Á.-B. and I.C.-R.; software,
I.C.-R.; validation, A.I.T.-C. and A.F.-M.; formal analysis, R.F.-R.; investigation, R.F.-R. and A.I.T.-C.; resources,
R.F.-R. and A.F.-M.; data curation, C.Á.-B. and V.M.-V.; writing—original draft preparation, R.F.-R. and C.Á.-B.;
writing—review and editing, V.M.-V.; visualization, A.I.T.-C. and A.F.-M.; supervision, V.M.-V. and C.Á.-B.
Funding: This study was funded by Apadrina la Ciencia.
Acknowledgments: We are grateful to Movi-ﬁtness, FSE and JCCM for the fellowship contract of R.F.-R.
Conﬂicts of Interest: The authors declare no conﬂict of interest.
Appendix A
Analyses for Pilates pre-post eﬀect on intervention (A1–A6: Meta-analysis, sensitivity analysis,
subgroup analysis, meta-regression, publication bias and funnel plot).
Appendix Figure A1. Meta-analysis.
J. Clin. Med. 2019, 8, 1761 
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5. Conclusions 
In summary, our results support Pilates as an effective intervention to improve CRF in both 
healthy people and individuals with disorders related to aerobic capacity. Despite this, further 
studies should be conducted, including short- and long-term measurements to determine the 
intensity level reached by VO2 max during Pilates intervention and whether CRF improvement is 
preserved over time. 
Author Contributions: Conceptualization, R.F.-R. and I.C.-R.; methodology, R.F.-R., C.Á.-B. and I.C.-R.; 
software, I.C.-R.; validation, A.I.T.-C. and A.F.-M.; formal analysis, R.F.-R.; investigation, R.F.-R. and A.I.T.-C.; 
resources, R.F.-R. and A.F.-M.; data curation, C.Á.-B. and V.M.-V.; writing—original draft preparation, R.F.-R. 
and C.Á.-B.; writing—review and editing, V.M.-V.; visualization, A.I.T.-C. and A.F.-M.; supervision, V.M.-V. 
and C.Á.-B. 
Funding: This study was funded by Apadrina la Ciencia.  
Acknowledgments: We are grateful to Movi-fitness, FSE and JCCM for the fellowship contract of R.F.-R. 
Conflicts of Interest: The authors declare no conflict of interest. 
Appendix A 
Analyses for Pilates pre-post effect on intervention (A1–A6: Meta-analysis, sensitivity analysis, subgroup 
analysis, meta-regression, publication bias and funnel plot). 
Appendix Figure A1. Meta-analysis. 
 
Figure A1. Meta-analysis for Pilates pre-post effect on intervention. 
Appendix Table A1. Sensitivity analysis. 
Table A1. Sensitivity analyses for Pilates pre-post effect on intervention. 
Pilates Method Intervention 
 
 
 
 
Author, Year 
ES 
LL 
UL 
I2 
Guimarães et al., 2012 [35] 
0.52 
0.25 
0.79 
71.1 
Gildenhuys et al., 2013 [22] 
0.57 
0.29 
0.84 
69.1 
Diamantoula et al., 2016 [46] 
0.53 
0.25 
0.80 
71.1 
Lim HS et al., 2016 [29] 
0.53 
0.24 
0.83 
71 
Figure A1. Meta-analysis for Pilates pre-post eﬀect on intervention.
Appendix Table A1. Sensitivity analysis.
Table A1. Sensitivity analyses for Pilates pre-post eﬀect on intervention.
Pilates Method Intervention
Author, Year
ES
LL
UL
I2
Guimarães et al., 2012 [35]
0.52
0.25
0.79
71.1
Gildenhuys et al., 2013 [22]
0.57
0.29
0.84
69.1
Diamantoula et al., 2016 [46]
0.53
0.25
0.80
71.1
Lim HS et al., 2016 [29]
0.53
0.24
0.83
71
Rodrigues et al., 2016 [32]
0.43
0.20
0.65
60.1
Tinoco-Fernández et al., 2016 [30]
0.56
0.24
0.89
71.1
Mikalacki et al., 2017 [31]
0.57
0.26
0.89
70.5
J. Clin. Med. 2019, 8, 1761
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Table A1. Cont.
Pilates Method Intervention
Author, Year
ES
LL
UL
I2
Finatto et al., 2018 [33]
0.39
0.24
0.54
19.6
Rossell-Rayes et al., 2019 [45]
0.55
0.27
0.83
70.6
ES: Eﬀect Size; LL: Lower Limit; UL: Upper limit.
Appendix Table A2. Subgroup analysis.
Table A2. Subgroup analyses by participants’ health status.
Pilates Method Intervention
ES
LL
UL
I2
Healthy
0.64
0.26
1.02
78.9
Unhealthy
0.39
0.14
0.64
0
ES: Eﬀect Size; LL: Lower Limit; UL: Upper limit.
Appendix Table A3. Random eﬀect meta-regression by baseline VO2 max values.
Table A3. Meta-regression analysis by VO2 max baseline values.
Coeﬃcient
p-Value
Pilates Method intervention
0.05
0.05 *
VO2 max: Maximal oxygen uptake (mL/kg/min); * Signiﬁcant at p ≤ 0.05.
Appendix Table A4. Publication bias (table).
Table A4. Publication bias by Egger’s test.
Coeﬃcient
p-Value
Pilates Method intervention
2.19
0.07 *
* Signiﬁcant at p < 0.1.
Appendix Figure A2. Funnel plot (ﬁgure).
J. Clin. Med. 2019, 8, 1761 
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Rodrigues et al., 2016 [32] 
0.43 
0.20 
0.65 
60.1 
Tinoco-Fernández et al., 2016 [30] 
0.56 
0.24 
0.89 
71.1 
Mikalacki et al., 2017 [31] 
0.57 
0.26 
0.89 
70.5 
Finatto et al., 2018 [33] 
0.39 
0.24 
0.54 
19.6 
Rossell-Rayes et al., 2019 [45] 
0.55 
0.27 
0.83 
70.6 
ES: Effect Size; LL: Lower Limit; UL: Upper limit. 
Appendix Table A2. Subgroup analysis. 
Table A2. Subgroup analyses by participants’ health status. 
Pilates Method Intervention 
 
 
 
 
 
ES 
LL 
UL 
I2 
Healthy 
0.64 
0.26 
1.02 
78.9 
Unhealthy 
0.39 
0.14 
0.64 
0 
ES: Effect Size; LL: Lower Limit; UL: Upper limit. 
Appendix Table A3. Random effect meta-regression by baseline VO2 max values. 
Table A3. Meta-regression analysis by VO2 max baseline values. 
 
Coefficient 
p-Value 
Pilates Method intervention 
0.05 
0.05 * 
VO2 max: Maximal oxygen uptake (ml/kg/min); * Significant at p ≤ 0.05. 
Appendix Table A4. Publication bias (table). 
Table A4. Publication bias by Egger’s test. 
 
Coefficient 
p-Value 
Pilates Method intervention 
2.19 
0.07 * 
* Significant at p < 0.1. 
Appendix Figure A2. Funnel plot (figure). 
 
Figure A2. Funnel plot for Pilates pre-post effect on intervention. 
Figure A2. Funnel plot for Pilates pre-post eﬀect on intervention.
J. Clin. Med. 2019, 8, 1761
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Appendix B. Mean Diﬀerence Analyses for Pilates vs. CG (B1–B6: Meta-Analysis, Sensitivity
Analysis, Subgroup Analysis, Meta-Regression, Publication Bias and Funnel Plot)
Appendix Figure A3. Meta-analysis.
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Appendix B. Mean difference analyses for Pilates vs. CG (B1–B6: Meta-analysis, sensitivity analysis, subgroup 
analysis, meta-regression, publication bias and funnel plot).  
Appendix Figure B1. Meta-analysis. 
 
Figure B1. Meta-analysis for Pilates vs. control group (mean difference). 
Appendix Table B1. Sensitivity analysis. 
Table B1. Sensitivity analyses for Pilates vs. control group. 
Pilates vs. Control Group 
 
 
 
Author, Year 
MD 
95% CI 
I2 
Guimarães et al., 2012 [35] 
2.24 
0.89, 4.58 
46.7 
Gildenhuys et al., 2013 [22] 
3.88 
2.53, 5.24 
0.0 
Lim HS et al., 2016 [29] 
2.77 
0.85, 4.69 
46.5 
Mikalacki et al., 2017 [31] 
2.59 
0.48, 4.69 
46.2 
Finatto et al., 2018 [33] 
1.71 
0.09, 3.33 
0.0 
Rossell-Rayes et al., 2019 [45] 
2.25 
0.82, 4.67 
46.7 
MD: Mean difference; CI: Confidence interval. 
Appendix Table B2. Subgroup analysis. 
Table B2. Subgroup analyses by participants’ health status. 
Pilates vs. Control Group 
MD 
95% CI 
Healthy 
2.77 
1.12, 4.42 
Unhealthy 
2.67 
−0.61, 5.95 
MD: Mean difference; CI: Confidence interval. 
Appendix Table B3. Random effect meta-regression by baseline VO2 max values. 
Figure A3. Meta-analysis for Pilates vs. control group (mean diﬀerence).
Appendix Table A5. Sensitivity analysis.
Table A5. Sensitivity analyses for Pilates vs. control group.
Pilates vs. Control Group
Author, Year
MD
95% CI
I2
Guimarães et al., 2012 [35]
2.24
0.89, 4.58
46.7
Gildenhuys et al., 2013 [22]
3.88
2.53, 5.24
0.0
Lim HS et al., 2016 [29]
2.77
0.85, 4.69
46.5
Mikalacki et al., 2017 [31]
2.59
0.48, 4.69
46.2
Finatto et al., 2018 [33]
1.71
0.09, 3.33
0.0
Rossell-Rayes et al., 2019 [45]
2.25
0.82, 4.67
46.7
MD: Mean diﬀerence; CI: Conﬁdence interval.
Appendix Table A6. Subgroup analysis.
Table A6. Subgroup analyses by participants’ health status.
Pilates vs. Control Group
MD
95% CI
Healthy
2.77
1.12, 4.42
Unhealthy
2.67
−0.61, 5.95
MD: Mean diﬀerence; CI: Conﬁdence interval.
Appendix Table A7. Random eﬀect meta-regression by baseline VO2 max values.
J. Clin. Med. 2019, 8, 1761
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Table A7. Meta-regression analysis by VO2 max baseline values.
Coeﬃcient
p-Value
Pilates vs. control group
0.09
0.08
VO2 max: Maximal oxygen uptake (mL/kg/min).
Appendix Table A8. Publication bias (table).
Table A8. Publication bias by Egger’s test.
Coeﬃcient
p-Value
Pilates vs. control group
−0.50
0.69
Appendix Figure A4. Funnel plot (ﬁgure).
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Table B3. Meta-regression analysis by VO2 max baseline values. 
 
Coefficient 
p-Value 
Pilates vs. control group 
0.09 
0.08 
VO2 max: Maximal oxygen uptake (mL/kg/min). 
Appendix Table B4. Publication bias (table). 
Table B4. Publication bias by Egger’s test. 
 
Coefficient 
p-Value 
Pilates vs. control group 
−0.50 
0.69 
Appendix Figure B2. Funnel plot (figure). 
 
Figure B2. Funnel plot for Pilates vs. control group (mean difference). 
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Pilates Method Improves Cardiorespiratory Fitness: A Systematic Review and Meta-Analysis.
Fernández-Rodríguez, Rubén,Álvarez-Bueno, Celia,Ferri-Morales, Asunción,Torres-Costoso, Ana I,Cavero-Redondo, Iván,Martínez-Vizcaíno, Vicente