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Exercise as it relates to Disease/ Pilates based intervention for Post-Menopausal Women living with Osteoporosis.

This is a critique of the research article: N. Kucukcakir et al. Effects of Pilates exercises on pain, functional status and quality of life in women with Post-Menopausal Osteoporosis. Journal of Bodywork and Movement Therapies (2013) 17, 204-211

The critique was written as assignment in the Unit; Health, Disease and Exercise at University of Canberra, September 2020.

What is the background to this research
The Study's objective is to assess the effects of Pilates Based exercise on pain, functional status and wellbeing in postmenopausal women suffering from Osteoporosis (OP). OP is 'the most common metabolic bone disease' with symptoms causing a significant detrimental effect on patients functionality and quality of life. As OP causes the bones to become weak and brittle, bone fracture is very common and contributes to risk of mortality. The main goal for OP prevention, treatment and management is to increase muscular strength, bone mineral density and balance in the older population, especially post menopausal women as well as education amongst these factors. In doing so, N. Kucukcakir et al. incorporate Pilates, as a measure to improve these outcomes. Although Pilates has been utilised as an important part in sport training, chronic low back pain , musculoskeletal disease and balance and quality of life in the elderly population , it hasn't been studied to specifically target the ever-growing issues of bone health on the ageing population and in particular, post-menopausal women.

Where is the research from?
The authors Lale Altan and Nimet Korkmaz, whom took part in this study, also designed another study alongside Umit Bingol and Berna Gunay, on the 'Effect of Pilates training on people with Fibromyalgia syndrome. The study took place in 2009 and shared a very similar approach to the Pilates training on Osteoporosis Study conducted years later. The article incorporates ideas from its previous studies on Pilates and its effects on Musculoskeletal Disorders and have transferred this knowledge onto its effects on a more targeted population of postmenopausal Women with OP. This supports the positive findings that Atlan found on patients with Musculoskeletal Disorders such as Fibromyalgia and Ankylosing Spondylitis.

What kind of research was this?
The study uses a randomised controlled, single blind study allowing no experimental bias when testing the subjects to take place. The person allocating the groups didn’t participate in any patient evaluation at any stage of the study, adopting a strategic approach to prevent any external factors to dictate the study’s results.

The diagnosis of the condition was measured through DEXA which is known to be a commonly used source. The procedure was well set out, starting with a flow chart detailing the enrolment process of participants. Sub-headings of 'pain, six-minute walk test, sit-to-stand test, quality of life assessment and number of falls', gives details of the tests that took place at baseline and the one-year mark of intervention involvement. The six-minute walk test and sit-to-stand test are objective measures that assess lower body endurance and are reliable in that they are well known to be associated with vertebral fracture development and falls Alongside measuring physical outcomes, the study used quality of life assessments to subjectively evaluate the individuals mental state, as this has been proven to be significantly affected with diagnosis of OP. As functionality decreases and therefore independence with OP, it is important to gauge the participants emotional state and how they rate their quality of life with improvement.

What did the research involve?
Participants were selected based on their age and diagnosis. They had to be aged between 45-65years and diagnosed with postmenopausal Osteoporosis. Subjects meeting the above criteria underwent a DEXA scan and those with a 'Bone Mineral Density score of less than -2.5 in the lumbar or femur region was valid for the study'. Participants were randomly allocated into two groups, either Group 1; Pilates based, or Group 2; Home Exercise based. Prior to the program commencing, all participants undertook baseline testing consisting of Visual Analogue Scale (VAS), to determine pain levels, a six-minute walk test, sit-to-stand test and 2 quality of life questionnaires. The intervention took place over a year. Group 1 took part in supervised sessions, twice a week which included 'postural education, focusing on a neutral position, sitting exercises, stretching exercises and proprioceptive and respiratory training' with the use of exercise balls and bands throughout the sessions. Meanwhile, Group 2 were shown exercises by a physiotherapist such as 'thoracic extension exercises and were required to be performed for 3 sets of 20 reps'. Check ins occurred for the Home-Exercise Group to ensure exercises were being performed and correctly. After the 1 year of program intervention, the same tests at baseline were measured and recorded for improvement and comparison.

The sample group of 70 people is relatively small, with each group having 35 participants. A small group limits the study’s ability to apply its findings to the whole population group of Post-menopausal women with OP. Another limiting factor is that there was no control group to compare the full effects of the intervention to, unlike the Study completed by Oksuz and Unal. As both groups were exercising and it had already been known that exercise had shown beneficial effect, it doesn’t provide context for how much the program had effect. The study doesn’t specify how or where the sample was selected from, but tests were performed to ensure eligibility criteria was met.

What were the basic results?
The results were summarised and for the Pilates group, all parameters showed significant improvements at the completion of one year from baseline (p<0.001). The results exhibited a significant improvement in all evaluation parameters for the Pilates Group at the completion of the one year. All parameters bar the pain, functional and mental health questionnaires, showed a statistically significant improvement for the Home-Based Exercise group also. When both groups were compared to each other, the Pilates circumstance displayed more improvement in all areas of testing (p<0.05). The results were displayed and compared in table format which enabled all mean values to be displayed. Comparison of the 2 groups at pre-treatment, supported the findings in post-treatment, as all results weren’t significant in difference. Table 2 and 3 present the data on ‘differences in post-treatment evaluation parameters in comparison with pre-treatment values after 1 year’ for both Pilates and Home-Based Exercise Groups respectively. Table 4 provides comparison of the percentage of the 2 groups from pre to post-treatment, displaying the difference the intervention has caused amongst the conditions.

What conclusions can we take from this research?
It has been proven in more recent research by S. Oksuz and E. Unal (2016) that clinical pilates improves OP symptoms of kinesiophobia, pain, functional status and quality of life. This similar study incorporated a pilates experimental group and control group over a period of 6 weeks with the pilates group receiving 3 physiotherapist lead sessions per week, however, the control group received no intervention. 14 well-known, reliable tests were used to assess pain, functional state and mental health and wellbeing. All evaluated parameters exhibited significantly greater improvements (p<0.05) in the pilates group compared to the control group in post-intervention results. This supports the findings of N. Kucukcakir et al.’s (2012) study that Pilates post intervention scores also revealed significant improvements compared to the home based exercise study.

Practical advice
Although Pilates has been shown to improve functionality and quality of life for those already diagnosed with OP, little to no research has been provided for Pilates to be used as a preventative measure for predisposed conditions. An outcome of Menopause is its detrimental loss in bone mineral density and therefore already places women aged between 45-65years in a high risk category in developing this condition. As pilates is a low impact form of activity, it is ideal for patients whom are already suffering with low bone mineral density and movement, however, it could be argued that a higher intensity exercise be more beneficial for those with normal functionality about to go through menopause. Therefore, other considerations for study investigation could include assessing the benefits of Pilates prior to menopause or if other high intensity exercise intervention would be of more benefit for this target population. A study by Kannus et al., involving the beneficial effects of sport and physical activity participation on bone mineral density, suggests that 'activity should be carried out prior to and during the post-menopausal stages which is critical for bone mineral density loss'. This is supported by their findings in tennis players with significantly improved bone mineral density in the dominant extremities of their bodies. Considering the population is becoming more sedentary, identifying if pilates, a low intensity activity, is beneficial during this crucial time period, would be important to decrease rates of the disease or at least the severity of the condition.

Further information/resources

 * https://www.osteoporosis.org.au/
 * www.premiersportsmedicine.com.au/virtual-pilates-online/
 * https://www.researchgate.net/effectclinicalpilatesonkinesiophobia_osteoporosis.pdf