Abstract
Background
Musculoskeletal disorders that follow a chronic course are associated with many symptoms, the most striking one is chronic pain that gradually worsens. The aim of this randomized controlled and single- center study was to investigate the effect of Reformer Pilates exercises on pain severity, pain coping methods, pain beliefs, fear of movement, fatigue and sleep quality in young adult patients with chronic low back pain and neck pain.
Methods
A total of 54 women aged between 30 and 50 were randomized into two groups. The Reformer Pilates (RP) group received a 6-week exercise program (45 min/twice per week), while the control group (CG) didn’t receive any exercise program. Outcomes measured before and after the interventions were, Brief Pain Questionnaire, Pain Coping Scale, Pain Beliefs Scale, Tampa Kinesiophobia Scale, FACIT Fatigue Scale and Pittsburg Sleep Quality Index.
Results
The groups were homogeneous at baseline. Statistical differences were found in favour of RP with small to large effect size in pain parameters (p < 0.05; Cohen’s d = 0.17–1.45), large effect size in fear of movement, small effect size in fatigue and medium effect size in sleep quality (p < 0.05; Cohen’s d = 0.43–0.86). No statistical difference between the groups was observed only in the pain beliefs organic sub-heading of the Pain Beliefs Scale and in the passive strategies sub-headings of the Pain Coping Scale (p > 0.05).
Discussion
The results of the current study suggest that Reformer Pilates increased active living in patients with chronic low back pain and chronic neck pain engenders a comprehensive enhancement in both physical and mental health, in addition to the capacity of patients to proactively manage their condition.
Trial registration
Registration number: NCT06706037. Date of registration: 11/25/2024.
Supplementary Information
The online version contains supplementary material available at 10.1186/s40359-025-03207-9.
Keywords: Musculoskeletal pain, Pain perception, Pilates-Based exercises, Coping skills, Patient beliefs
Background
Musculoskeletal disorders are a global health problem causing heavy economic burden due to their widespread prevalence and leading to significant health problems [1, 2]. Musculoskeletal disorders that follow a chronic course are associated with many symptoms, the most striking one is chronic pain that gradually worsens [3]. Chronic pain is generally described as ongoing or recurrent pain that continues for more than three months, distinguishing it from acute pain conditions [4]. It often continues even in the absence of peripheral pain stimuli due to synaptic plasticity and neural network restructuring at various levels of the nervous system—a phenomenon known as pain centralization [5].
Epidemiological studies report that approximately one in nine young adults suffers from chronic pain, with prevalence rates ranging from 5 to 30% in this population and more common in the female population [6, 7]. The most prevalent types of musculoskeletal pain include neck pain, osteoarthritis, rheumatoid arthritis, and chronic low back pain [8]. In Turkey, low back, neck, and upper back pain—also the focus of the present study—are reported as the most prevalent forms of musculoskeletal pain [1]. Recent studies have found that chronic musculoskeletal pain is not only physically disabling but is also associated with numerous somatic comorbidities, anxiety, depression, fearful beliefs about the meaning of pain, poor coping skills, catastrophizing, work avoidance behavior, stress, increased use of health services, insomnia, and unemployment [9, 10]. Considering the complex and multifactorial nature of chronic pain, multimodal and biopsychosocial approaches are more recommended in its management [11, 12].
Data from several studies suggest that, resistance exercise training and flexibility exercises performed at least twice a week are recommended in international treatment guidelines for the management of musculoskeletal pain in terms of preservation of functional status, promotion of lifelong physical activity and improvement of general quality of life [2, 13].
Over the past 20 years, Pilates has grown in popularity and recommendation as a form of physical exercise globally, despite the abundance of physical activity programs [14]. Pilates consists of over fifty exercises of varying degrees of difficulty. Exercise programs can therefore be tailored to individuals with varying demands, tastes, ailments, ages, and abilities. Controlled movement patterns and elastic resistance applications improve neuromuscular control, core stability and dynamic balance. These components are often impaired, especially in individuals with chronic back and neck pain [15, 16]. More effective activation and coordination of the trunk muscles contribute to better proprioception and spinal stabilization [16].
Additionally, the benefits of Pilates exercises are noticeable in a short period of time, they motivate people to stick to their training regimens and alter their behavior permanently to lead more active lives [18, 19]. Exercises can be performed on a mat and also using special Cadillac, Reformer and Wundachair equipment [20]. Pilates is a mind–body exercise system grounded in six core principles: concentration, movement control, centering, fluidity, precision, and breath. It is designed to promote physical fitness and mental discipline by fostering harmony between the body and the mind [14, 21]. This allows for reduced stress and anxiety and increased psychological resilience in coping with pain. In these ways, Pilates can also offer psychological benefits similar to mindfulness-based interventions [22, 23].
Although Reformer Pilates exercises have become increasingly popular in recent years, the findings of existing studies remain inconsistent [17–19, 24]. Therefore, the present study aims to investigate the effects of Reformer Pilates on various dimensions of pain perception—including pain intensity, coping strategies, pain-related beliefs, and fear of movement—as well as on fatigue and sleep quality in young adult women with chronic musculoskeletal pain.
The findings are expected to contribute to the growing body of literature on exercise-based, holistic approaches to chronic pain management.
Methods
The present study, designed to examine the effects of Reformer Pilates on pain intensity, pain coping strategies, pain-related beliefs, kinesiophobia, fatigue, and sleep quality in individuals with chronic musculoskeletal pain, was conducted between March 1 and October 7, 2024.
Ethics statement
The study was accepted by Çankırı Karatekin University Health Sciences Ethics Committee with the verification code (5c93542196214664) on February 9, 2024. All procedures involving human participants were carried out in accordance with the ethical standards of the Declaration of Helsinki. Prior to participation, individuals were thoroughly informed about the purpose, procedures, and voluntary nature of the study. They were also assured of their right to withdraw at any point without penalty. Written informed consent was obtained from all participants before data collection commenced. This study was registered at https://www.clinicaltrials.gov/ (registration number: NCT06706037, Date: 11/25/2024). Study findings were reported based on the 2010 CONSORT Statement [25].
Sample
The randomize controlled trial included 60 patients aged between 30 and 50 years, referred to the physiotherapy and rehabilitation department by a physician and deemed suitable for the Reformer Pilates program. Inclusion criteria included female individuals with a diagnosis of chronic musculoskeletal pain that persisted for at least six months. In terms of having a history of mechanical pain, the inclusion criteria were that the pain was characterized as increasing with physical exertion and decreasing with rest. Other inclusion criteria were that the participants had the cognitive ability to understand the exercise instructions, were able to comply with the intervention protocol and gave informed consent.
Exclusion criteria were a diagnosis of low back or neck pain due to a serious underlying disease such as cancer or radiculopathy, or other causes such as fibromyalgia; spinal surgery within the last six months; a history of emotional problems and psychiatric disorders or known cognitive impairment that interfered with communication; and participation in an exercise or physical therapy program during the last three months.
The control group consisted of patients waiting for treatment without any intervention method. Individuals were assigned to the study (Reformer Pilates) group or the control group by simple randomization.
Study design
The study group (the Reformer Pilates group) underwent a 6-week exercise regimen. The control group was made up of inactive female volunteers who were waiting to begin Reformer Pilates workouts; no exercise regimen was used. Evaluations were conducted both before and after the 6-week exercise program in the research group (Reformer Pilates group) and the control group.
The study’s power analysis was conducted using the G*power 3.1.9.7, with alpha and beta errors set at 5% and 20%, respectively. Based on the study of Natour et al. [26] (effcet size = 0.77), it was determined that 54 samples (27 experimental and 27 control groups) would be sufficient. To account for the possibility of patients dropping out of the study, we added 3 participants to each group and initially evaluated 60 patients.
Randomization
Participants were randomly assigned to the intervention (Reformer Pilates) and control groups using simple randomization with a 1:1 allocation ratio. The randomization sequence was generated in advance by an independent researcher using a computer-assisted randomization tool (www.randomizer.org) to minimize selection bias. Blinding of participants and the treating physiotherapist was not possible given the study’s design. However, to minimize bias, all outcome assessments were performed by an independent physiotherapist blinded to group allocation. Furthermore, data analysis was carried out by a researcher who was not involved in the intervention implementation or outcome assessments.
Reformer pilates exercise training protocol
Reformer Pilates exercises focusing on core strength, spinal mobility, postural control, flexibility, and muscular endurance. Reformer Pilates exercise protocol was determined according to previous clinical studies in the literature [16, 27]. For six weeks, the exercises were done twice a week for 45 to 50 min each time. Firstly, the Reformer machine and its operation were demonstrated to all participants. The individuals were given an explanation of the Pilates method’s core concepts of centering, concentration, breathing, control, flow, and precision. Lateral breathing, neutral spine, and pelvic floor exercises were described and shown. Stretching exercises took up the opening and last five minutes of the sessions. Three to five repetitions of stretching exercises were performed first, followed by six to eight repetitions of strengthening and stabilizing activities. Repetitions were gradually increased to 10–12 on a weekly basis, depending on each participant’s tolerance. The individual exercise tolerance of the participants was determined based on verbal feedback from the participant, such as pain and fatigue, or symptoms observed by the physiotherapist, such as difficulties in performing the movement and compensatory movements. Repetitions were increased when the participant was able to perform the exercise correctly without any unfavorable conditions (e.g., pain, fatigue). Springs were included according on the workouts’ objectives and degree of difficulty. Higher resistance springs were used for strengthening and stabilization exercises, while lighter resistance springs were used for stretching activities. As with increasing the number of repetitions, the use of springs was individually regulated according to the participant’s verbal feedback (such as pain, fatigue or increased pain after the previous session) and the physiotherapist’s observation (such as the participant’s ability to perform the movement correctly and with ease). To ensure that the exercises were performed correctly, each movement was demonstrated and explained individually. For breathing control and centering, verbal cautions were issued. Pilates workouts included posture exercises, standing hip stretching, elephant stretching, long box series, plank, knee stretch, back extensor strengthening, footwork series, supine armwork, and feet in straps (Supplementary Materials). The Reformer Pilates intervention was delivered by an expert physiotherapist with 5 years of clinical experience and certified training in Pilates-based exercise. All Reformer Pilates applications were applied individually. The 6-week Reformer Pilates program was carried out in a controlled and professional clinical environment in the Physical Therapy and Rehabilitation Department of the Private Middle East Hospital. There were no intervention-related adverse events during the study.
Outcome measures
All study participants were asked for demographic data, including age, body mass index (BMI), education level, pain duration and diagnosis.
Brief Pain Inventory (BPI) was developed by Cleeland and Ryan in 1994 [28]. The Brief Pain Inventory consists of eleven items related to the extent of pain intensity and the extent to which pain interferes with activities of daily living. Pain intensity measurements include the most severe, the mildest, the average and the pain at the time of interview in the last 7 days. A numerical pain scale is used to evaluate the level of pain (0 being no pain and 10 being unbearable pain). In the past 7 days, pain has affected the patient’s ability to walk, work, sleep, and enjoy life. It also measures their mood, relations with others, and general activity level. On a numerical pain scale of 0–10, each object is scored (0 being fully unaffected, 10 being completely affected). The Turkish validity and reliability of the BPI was performed by Dicle et al. (2009) in surgical patients [29].
Pain Coping Scale, created by Kraaimaat and Evers [30], measures the frequency with which people with chronic pain employ behavioral and cognitive coping mechanisms. Three active sub-dimensions, such as distraction, pain transformation, and comforting thinking, and three passive sub-dimensions, such as withdrawal, worrying, and rest, are included in the scale’s original version. It is scored between 1 (almost never) and 4 (very often). A high score on the scale means using the strategy in the related subscales more. The scale was adapted to Turkish with 279 chronic pain patients including rheumatic diseases, fibromyalgia, low back pain and non-specific pain categories [31].
Pain Beliefs Scale was developed by Edwards et al. to assess beliefs on the origin and management of pain [32]. The scale consisted of 12 questions and two sub-dimensions as ‘psychological beliefs’ and ‘organic beliefs’. The six-point Likert-type scale was scored from 1: ‘never’ to 6: ‘always’. The organic beliefs dimension showed that the pain was mostly of organic origin, while the psychological beliefs dimension showed that the pain experience was influenced by psychological factors. The highest score that can be obtained from the organic and psychological beliefs sub-dimensions is 6 and the lowest score is 1. Although there is no cut-off score for the scale, an increase in the score indicates that pain beliefs related to that dimension are high [2].
Tampa Kinesiophobia Scale was developed to assess the fear of movement and potential damage. Injury/reinjury and fear-avoidance in work-related activities are two of the scale’s parameters. The 17-item likert scale has four points: 1 for strongly disagreeing and 4 for strongly agreeing. A total score is determined after the fourth, eighth, twelfth, and sixteenth elements are reversed. A high degree of kinesiophobia is indicated by a high score on the scale. In the studies, using the total score is advised. Yılmaz et al. conducted a study on the scale’s reliability and validity in Turkish [33].
Functional Assessment of Chronic Illness Therapy (FACIT) Fatigue Scale is a scale developed to measure the fatigue level of individuals in the last week. The scale consists of 13 items. It is a 4-point Likert-type scale with 1 = not at all and 4 = very much. Total score 0–52. A total score below 30 indicates severe fatigue. The higher the score, the less tired the person is and the better the quality of life. It was developed by Webster et al. in 2003 [34].
Pittsburg Sleep Quality Index (PSQI) is a scale used to assess the quality and disruption of sleep throughout the previous month. The scale has a total of 19 items and 7 sub-items, which include subjective sleep quality, sleep latency, duration, habitual sleep efficiency, sleep disruptions, use of sleep aids, and loss of daily functioning. Each item is scored between 0 and 3. A total PSQI score ranging from 0 to 21 is obtained by summing the subscales [35]. The scale’s validity and reliability in Turkish were investigated by Ağargün et al. [36].
Statistical analysis
As a result of the assessments given to the study participants, descriptive statistics and analyses were conducted. Frequency and percentage were used as descriptive statistics for categorical variables, or demographic traits. The “Shapiro-Wilk Test” was used to control for the variables’ conformance to a normal distribution. The variables’ descriptive statistics were presented as mean ± standard deviation (X ®±SD) values. Two independent groups having a normal distribution were compared using the “two-sample t-test,” while two independent groups without a normal distribution were compared using the “Mann-Whitney U Test.” Two dependent groups with a normal distribution were compared using the " paired t-test” while two dependent groups without a normal distribution were compared using the “Wilcoxon Signed Rank Test.” Effect sizes were categorized as small (0.20–0.50), medium (0.51–0.80), and large (> 0.80), following Cohen’s guidelines [37]. The minimum significance level was taken as 0.05 for all analyses. Statistical analysis of the data was performed using SPSS v26 (IBM Inc., Chicago, IL, USA) statistical package program.
Results
Three participants in the Reformer Pilates/research group were eliminated from the study due to their irregular attendance and subsequent dropouts, and three participants in the control group were excluded as they refused to continue with the study after it was over and evaluation measurements could not be taken. 54 people participated in the study; 27 of them were women in the Reformer Pilates group and 27 were in the control group (Fig. 1).
Fig. 1.
Participant diagram
A summary of each participant’s demographics is provided in Table 1. The demographic features of the participants in the Reformer Pilates group and the control group (age, BMI, education level, chronic pain area, and duration) were found to be similar, with no statistically significant difference between the two groups.
Table 1.
Demographic characteristics of reformer pilates group and control group
| Reformer Pilates Group (n = 27) | Control Group (n = 27) | |||
|---|---|---|---|---|
X
|
X
|
p | ||
| Age (year) | 34.22±7.08 | 34.81±7.15 | 0.795a | |
| BMI | 22.69±2.76 | 23.84±2.09 | 0.070a | |
| Duration (month) | 11.18±3.22 | 11.40±2.63 | 0.467a | |
| n (%) | n (%) | |||
| Condition | Low back pain | 19 | 18 | 0.770b |
| Neck back pain | 8 | 9 | ||
| Education Status | High School | 2 (7.4%) | 3 (11.2%) | 0.893b |
| University | 19 (70.3%) | 18 (66.6%) | ||
| Master’s Degree/PhD | 6 (22.3%) | 6 (22.2%) | ||
a: Mann-Whitney U Test; b:Chi-Square Test(χ2)
In the pre-treatment evaluations of both the Reformer Pilates group and the control group, the groups were homogenous (p > 0.05).
When pre-treatment and post-treatment scores were compared within groups, a statistically significant improvement was observed in the Reformer Pilates group for all outcomes except the passive coping subscale of the Pain Coping Scale, and the organic subscale of the Pain Beliefs Scale (p < 0.05). The effect sizes for the observed changes ranged from small to large (Cohen’s d = 0.40 to 1.42) (Table 2).
Table 2.
Intra-group comparison of pre- and post-treatment values of pain, kinesiophobia, fatigue, and sleep quality
| 0. week | 6. week | Within-group difference | |||||
|---|---|---|---|---|---|---|---|
| X±SD | X±SD | W | p | Effect size | |||
|
Brief Pain Inventory (pain intensity) |
Pain worst | Reformer | 6.18±2.01 | 3.77±1.98 | -4.316a | < 0.001 | 1.21 |
| Control | 5.25±1.63 | 5.11±1.55 | -1.190a | 0.234 | 0.08 | ||
| Pain least | Reformer | 3.03±1.84 | 1.18±1.07 | -4.143a | < 0.001 | 1.23 | |
| Control | 3.03±1.50 | 3.07±1.51 | -1.000a | 0.317 | 0.02 | ||
| Pain average | Reformer | 4.33±1.64 | 2.37±1.36 | -4.195a | < 0.001 | 1.30 | |
| Control | 3.85±1.97 | 3.70±1.26 | -1.414a | 0.157 | 0.09 | ||
| Pain now | Reformer | 4.29±1.95 | 2.18±1.41 | -4.416a | < 0.001 | 1.24 | |
| Control | 3.11±1.94 | 3.18±1.98 | -1.414a | 0.157 | 0.03 | ||
| Brief Pain Inventory (pain interference) | General activity | Reformer | 4.85±2.08 | 2.18±1.66 | -4.313a | < 0.001 | 1.42 |
| Control | 4.07±2.05 | 3.88±1.88 | -1.633a | 0.102 | 0.09 | ||
| Mood | Reformer | 4.74±2.37 | 2.18±1.84 | -4.223a | < 0.001 | 1.20 | |
| Control | 4.11±2.17 | 4.00±2.07 | -0.966a | 0.334 | 0.05 | ||
| Walking ability | Reformer | 4.07±2.58 | 1.92±1.81 | -4.246a | < 0.001 | 0.96 | |
| Control | 3.29±1.97 | 3.18±1.84 | -1.732a | 0.083 | 0.05 | ||
| Work | Reformer | 2.62±2.13 | 0.96±1.42 | -4.054a | < 0.001 | 0.91 | |
| Control | 2.37±1.98 | 2.25±1.87 | -1.732a | 0.083 | 0.06 | ||
| Relations with others | Reformer | 3.00±2.43 | 1.03±1.42 | -3.848a | < 0.001 | 0.98 | |
| Control | 3.00±1.51 | 3.00±1.51 | 0.000a | 1.000 | 0 | ||
| Sleep | Reformer | 3.59±2.45 | 1.55±1.76 | -4.130a | < 0.001 | 0.95 | |
| Control | 3.29±2.19 | 3.18±2.18 | -1.732a | 0.083 | 0.05 | ||
| Enjoyment of life | Reformer | 4.51±1.86 | 2.03±1.65 | -4.223a | < 0.001 | 1.41 | |
| Control | 4.40±1.71 | 4.40±1.73 | 0.000a | 1.000 | 0 | ||
| Pain Coping Scale (active) | Distraction | Reformer | 6.62±2.00 | 7.70±2.07 | -2.359a | 0.018 | 0.53 |
| Control | 5.88±2.22 | 5.96±2.19 | -1.414a | 0.157 | 0.03 | ||
| Pain transformation | Reformer | 3.55±1.62 | 4.29±2.01 | -3.043a | 0.002 | 0.40 | |
| Control | 2.96±0.93 | 3.22±0.80 | -1.540a | 0.123 | 0.30 | ||
|
Comforting thinking |
Reformer | 6.29±1.79 | 7.29±2.12 | -2.840a | 0.005 | 0.51 | |
| Control | 5.92±2.21 | 5.74±1.89 | -1.508a | 0.132 | 0.08 | ||
| Pain Coping Scale (Passive) | Worrying | Reformer | 7.81±2.49 | 7.77±2.43 | -0.378a | 0.705 | 0.01 |
| Control | 7.00±1.49 | 7.03±1.60 | 0.000a | 1.000 | 0 | ||
| Resting | Reformer | 15.33±4.35 | 15.29±4.30 | -1.000a | 0.317 | 0.01 | |
| Control | 15.59±3.61 | 15.25±4.44 | -1.359a | 0.174 | 0.08 | ||
| Withdrawal | Reformer | 8.18±2.27 | 8.11±2.30 | -0.816 | 0.414 | 0.03 | |
| Control | 7.37±2.28 | 7.14±1.87 | -0.612a | 0.541 | 0.11 | ||
| Pain Belief Scale | Organic Beliefs | Reformer | 3.64±0.44 | 3.58±0.77 | -0.122a | 0.903 | 0.09 |
| Control | 3.71±0.62 | 3.75±0.55 | -1.224a | 0.221 | 0.06 | ||
| Psychological Beliefs | Reformer | 4.75±0.71 | 4.16±0.88 | -3.172a | 0.002 | 0.74 | |
| Control | 4.26±1.05 | 4.32±0.95 | -1.015a | 0.310 | 0.06 | ||
|
Tampa Kinesiophobia Scale |
Reformer | 39.74±4.04 | 36.55±3.95 | -4.451a | < 0.001 | 0.79 | |
| Control | 39.62±3.38 | 39.74±3.42 | -1.732a | 0.083 | 0.03 | ||
| FACIT Fatigue Scale | Reformer | 28.74±7.31 | 34.51±8.07 | -3.312a | 0.001 | 0.75 | |
| Control | 31.25±9.23 | 30.85±8.69 | -1.100a | 0.271 | 0.04 | ||
| Pittsburgh Sleep Quality Index (PSQI) | Reformer | 6.81±2.41 | 4.70±2.74 | -3.616a | < 0.001 | 0.81 | |
| Control | 6.07±2.09 | 6.18±2.09 | -1.732a | 0.083 | 0.05 | ||
U: Mann-Whitney U Test; a: Wilcoxon Signed Rank Test; b: Mann-Whitney U Test; *p < 0.05
However, when post-treatment outcomes in the Reformer Pilates group were evaluated in terms of minimal clinically important difference (MCID), only the improvements in pain intensity and fatigue scales met the threshold for clinical significance [38, 39].
The Reformer Pilates group showed statistically significant improvements in a wide range of pain-related outcomes. Significant reductions were observed in worst pain intensity (Mean difference (MD) = 2.18, 95% CI: 1.52–2.84, p < 0.001), least pain intensity (MD = 1.88, 95% CI: 1.29–2.48, p < 0.001), average pain (MD = 1.81, 95% CI: 1.21–2.42, p < 0.001) and current pain (MD = 2.14, 95% CI: 1.57–2.72, p < 0.001). Functional interference items of the Brief Pain Inventory also showed significant improvements in general activity (MD = 2.52, 95% CI: 1.86–3.17, p < 0.001), mood (MD = 2.62, 95% CI: 2.01–3.24, p < 0.001), walking ability (MD = 2.03, 95% CI: 1. 40-2.67, p < 0.001), work (MD = 1. 55, 95% CI: 1.04–2.06, p < 0.001), relationships with others (MD = 1.96, 95% CI: 1.30–2.61, p < 0.001), sleep (MD = 1.92, 95% CI: 1.24–2.61, p < 0.001) and enjoyment of life (MD = 2.48, 95% CI: 1.71–3.24, p < 0.001). There was also a significant increase in active pain coping strategies (MD = -2.62, 95% CI: -4.01 to -1.24, p < 0.001) and improvement in the psychological subscale of the Pain Beliefs Scale (MD = 0.61, 95% CI: 0.21–1.01, p = 0.001). Improvements were also observed in fear of movement (MD = 3.00, 95% CI: 2.44–3.55, p < 0.001), fatigue (MD = -6.18, 95% CI: -9.48 to -2.88, p < 0.001) and sleep quality (MD = 2.22, 95% CI: 1.26–3.18, p < 0.001). The effect sizes of these changes ranged from small to large (Cohen’s d = 0.17 to 1.45) (Table 3).
Table 3.
Between-group comparison of pain, fear of movement, fatigue, and sleep quality after treatment
| Between- group difference | |||||
|---|---|---|---|---|---|
| RP VS CG (CI 95%) |
U | p | Effect size | ||
|
Brief Pain Inventory (pain intensity) |
Pain worst | 2.18 (1.52–2.84) | -5.263b | < 0.001 | 0.75 |
| Pain least | 1.88 (1.29–2.48) | -5.575b | < 0.001 | 1.45 | |
| Pain average | 1.81 (1.21–2.41) | -5.228b | < 0.001 | 1.01 | |
| Pain now | 2.14 (1.57–2.72) | -6.122b | < 0.001 | 0.58 | |
| Brief Pain Inventory (pain interference) | General activity | 2.51(1.86–3.17) | -5.748b | < 0.001 | 0.96 |
| Mood | 2.62 (2.01–3.24) | -5.932b | < 0.001 | 0.93 | |
| Walking ability | 2.03 (1.40–2.67) | -5.571b | < 0.001 | 0.69 | |
| Work | 1.55 (1.04–2.06) | -5.045b | < 0.001 | 0.77 | |
| Relations with others | 1.96 (1.30–2.61) | -5.210b | < 0.001 | 1.34 | |
| Sleep | 1.92 (1.24–2.61) | -5.059b | < 0.001 | 0.82 | |
| Enjoyment of life | 2.48 (1.71–3.24) | -5.523b | < 0.001 | 1.40 | |
| Pain Coping Scale (active) | Distraction | -2.62 (-4.01- -1.24) | -3.803b | < 0.001 | 0.38 |
| Pain transformation | |||||
|
comforting thinking | |||||
| Pain Coping Scale (Passive) | Worrying | -0.11 (-0.52-0.29) | -0.807b | 0.420 | 0.15 |
| Resting | |||||
| Wthdrawal | |||||
| Pain Belief Scale | Organic Beliefs | 0.17 (-0.12-0.46) | -0.680b | 0.496 | 0.08 |
| Psychological Beliefs | 0.61 (0.21–1.01) | -3.311b | 0.001 | 0.17 | |
|
Tampa Kinesiophobia Scale |
3.00 (2.44–3.55) | -5.987b | < 0.001 | 0.86 | |
| FACIT Fatigue Scale | -6.18 (-9.48- -2.88) | -4.367b | < 0.001 | 0.43 | |
| Pittsburgh Sleep Quality Index (PSQI) | 2.22 (1.26–3.18) | -4.553b | < 0.001 | 0.60 | |
U: Mann-Whitney U Test; a: Wilcoxon Signed Rank Test; b: Mann-Whitney U Test; *p < 0.05
Discussion
The results of this study showed that a six-week program of Reformer Pilates exercises in patients with chronic musculoskeletal pain exerted a favorable influence on perceived pain intensity, pain coping, pain beliefs, fear of movement, fatigue and sleep quality. From a clinical perspective, the most notable outcomes were the improvements in pain intensity and fatigue levels, as these changes reached the threshold for clinical significance.
The pain sensation experienced in chronic musculoskeletal disorders varies from person to person, emphasizing the necessity for objective measurement of pain using a common language [40]. This is crucial for enhancing convenience in diagnosis and treatment. Therefore, the most important step in the management of painful conditions is the multidimensional assessment of pain [41]. The Brief Pain Inventory was used to assess pain in this study. The Brief Pain Inventory is a questionnaire that assesses pain in a multidimensional way by assessing the impact of pain on functioning in daily life (e.g., general activity, mood, sleep) as opposed to scales that only measure the severity of pain [28]. This provides a more comprehensive understanding of how Reformer Pilates affects both sensory and functional dimensions of pain in individuals with chronic musculoskeletal pain. The study revealed a substantial decline in pain intensity and its impact on daily functioning among the Reformer Pilates group, both in the pre-treatment and post-treatment in-group evaluations and in comparison, with the control group. In particular, the decrease in pain intensity met the threshold of clinical significance, indicating that the change was meaningful for the patient. In a study conducted on this subject, although the effectiveness of most exercise interventions in the management of chronic low back pain was emphasized, it was stated that the most beneficial program was Pilates or strength training, which includes mind-body exercises that are applied for 1–2 sessions per week, lasting less than 60 min and lasting 3–9 weeks [42]. Similar to the results of the present study, Şahiner et al. reported that Reformer Pilates was effective and reliable in reducing pain in patients with chronic neck pain. They attributed the pain reduction to improvements in impaired proprioception, suggesting that Reformer Pilates enhances postural awareness and concentration during movement. This, in turn, increases the efficiency of neural inputs transmitted from skin and joint mechanoreceptors to the central nervous system [16].
Pain is a multidimensional experience that encompasses not only physical but also psychological and social components. This complexity explains why the severity of pain is not always directly related to the extent of tissue damage. Especially in the case of chronic pain, it can become a significant source of stress that negatively affects a person’s quality of life. The individual develops cognitive and behavioral responses to this stressor. These efforts, which directly affect the intensity of pain, psychological adjustment and the level of pain-related disability are called coping strategies [4, 30, 31]. In general, passive coping categories (e.g., withdrawal, rest, worry-disasterization) are associated with worse outcomes, such as decreased physical functioning and increased psychological distress, whereas active coping strategies (e.g., continuing activities despite pain, ignoring pain) are more positive, although there is no consensus on this issue [30, 31]. In a separate study by Kaygısız et al. with individuals experiencing chronic musculoskeletal pain, it was observed that young women exhibited a greater tendency to employ active coping strategies in managing their pain [43]. To our knowledge, no previous research has specifically examined the effects of Reformer Pilates on pain coping strategies. According to the results of the current study, regular Reformer Pilates exercises enabled patients with chronic musculoskeletal conditions to adopt more active coping strategies. In fact, considering that the patients who participated in this study were young adults and people who were active in daily life, it is seen that the results are compatible with the literature. In addition, although the difference was not statistically significant, a reduction was also observed in the passive coping strategy of worrying. This is thought to be explained by the fact that deep breathing control and rhythmic and goal-oriented movements in Pilates exercises increase endorphin levels and have a regulatory effect on the central nervous system; thus reducing anxiety, anxiety and depression symptoms by providing relaxation in the body and mind [44]. Interestingly, despite the lack of statistically significant results, a decrease was observed in the passive coping strategies—specifically in the subcategories of resting and withdrawal—among participants in the control group. This suggests that, even without receiving any intervention, simply being included in the study, the information provided about the study, and the initial assessments may have prompted them to reflect on their pain perception and coping strategies.
Beliefs about pain play a strong role in behavioral and emotional responses to musculoskeletal pain. This is because a person’s beliefs about musculoskeletal pain can influence how they respond to pain, how disabled they are likely to be due to pain and how chronic the pain becomes. More importantly, beliefs can be changed and are therefore considered an important goal for pain management. It has been reported that changing pain beliefs has both a positive effect on treatment satisfaction and reduces pain and disability [32, 41]. Pain beliefs are classified as psychological and organic beliefs. Psychological beliefs are related with the belief that psychological factors such as depression and anxiety have an effect on pain. In psychological beliefs, the person thinks that they have control over their own health and well-being. Organic beliefs are that organic factors are effective in the experience of pain. It is the belief that pain is caused by injuries and damages in the individual’s body and that managing pain is under the control of others. Psychological effects and the benefits of relaxation are not accepted [32, 45, 46]. Molazem et al. concluded that relaxation techniques changed the pain beliefs of hemophilia patients [47]. When the results of the study are examined, it is seen that the beliefs of patients with chronic musculoskeletal pain that their pain is mostly caused by psychological effects increased after 6 weeks of regular exercise. The findings of this study are consistent with previous literature indicating that pain-related beliefs are modifiable through targeted interventions [32, 41, 47]. In particular, the results suggest that an exercise-based approach may be effective in promoting this change. Moreover, fostering psychological pain beliefs appears to encourage individuals to adopt a more active and self-efficacious role in managing their pain.
In the development of pain-related fear, overstimulation of the amygdala is said to cause suppression of the medial prefrontal cortex, thus leading to chronic pain. In their study, Senba and Kami mentioned that patients with chronic pain are maladaptive to situations because their limbic system is functionally impaired, they cannot engage in goal-oriented behaviors and they are easily caught in fear-avoidance thinking. In their study, they also stated that the key to getting out of the chronic pain state depends on the activation of the positive neurons of the basal nucleus of the amygdala and that exercise encourages reward behavior and provides relief from the fear response to pain [7]. In the study, it was observed that the decrease in the patients’ fear of movement after 6 weeks of regular exercise training developed in parallel with the literature.
In this study, it was observed that the fatigue levels of the patients in the Reformer Pilates group decreased after exercise training. A possible explanation for this might be breathing, which is one of the basic principles in the application of Pilates exercises. Because breathing during exercise increases general well-being by providing respiratory control in individuals and activating the parasympathetic nervous system, and also has a positive effect on physical and mental fatigue [48].
Pilates exercises are being utilized more and more to enhance the quality of sleep, but the effects are inconsistent. More extensive research is required, Chen et al. noted in their study that Pilates had no discernible impact on sleep quality in postmenopausal and healthy women over 40 [49]. However, after a 12-week exercise regimen, Pilates was found to improve sleep quality in a different trial including young people who were sedentary [50]. It is evident from our study’s analysis of the impact of Reformer Pilates on sleep quality that exercise enhances sleep quality.
Limitations
The major limitation of this study is the absence of follow-up assessments, which could have provided important insights into the long-term effects of the Reformer Pilates exercise program on pain-related outcomes such as pain severity and pain perception. Additionally, the study included only female participants, which limits the ability to generalize the findings to male populations or to explore potential gender-based differences in treatment response. Another limitation is the reliance on self-reported outcome measures. The dropout of six participants may have resulted in attrition bias and somewhat reduced the generalizability of the findings. Furthermore, the study sample included both chronic low back pain (CLBP) and chronic neck pain (CNP) patients. Although these conditions share certain pathophysiological and psychosocial mechanisms, they also differ in anatomical and clinical characteristics. The inclusion of two distinct pain regions may have introduced heterogeneity that limits condition-specific interpretations.
Future perspectives
Further research might use some objective evaluations, imaging techniques, and involvement in a long-term Reformer Pilates exercise program in order to provide more accurate and dependable indications of changes in pain-related parameters. It is also recommended to investigate long-term effects and benefits in different patient groups in the future.
Clinical implications
According to the results of the study, Reformer Pilates can be considered as an effective treatment option to alleviate pain and improve psychological well-being (such as fatigue) in patients with chronic musculoskeletal pain (especially those with low back and neck pain). Clinicians and therapists can incorporate Reformer Pilates into multidisciplinary pain management program. Appropriate supervision and individualized exercise prescriptions can be implemented to maximize benefits and minimize risks. The results of this study support the clinical application of Reformer Pilates as part of a holistic approach to pain management.
Conclusion
This study was designed to examine how Reformer Pilates exercises change pain-related perceptions such as pain intensity, pain coping skills, pain beliefs and how it has an effect on fear of movement, fatigue and insomnia caused by pain in individuals with chronic musculoskeletal disorders. According to the results of the study, Reformer Pilates exercises reduce pain perception and help patients with chronic musculoskeletal pain to cope with pain by providing body and mind unity. While previous studies have predominantly focused on the physical benefits of Pilates, the present study extends the scope by evaluating the neurophysiological and cognitive effects of Reformer Pilates, particularly in relation to pain beliefs and coping strategies. In this regard, it is believed to make a meaningful contribution to the existing gap in the literature.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
This research paper was composed with the assistance of Academic Assistant Pro, an AI-based writing tool, as none of the researchers are native English speakers. The use of this tool ensured that the language of the paper is fluent and meets academic standards. The researchers thoroughly reviewed all content in detail, and the design of the writing is solely attributed to the authors.
Abbreviations
- CONSORT
Consolidated Standards of Randomized Trials
- SPSS
Statistical Package for Social Sciences
- BPI
Brief Pain Inventory
- FACIT
Functional Assessment of Chronic Illness Therapy Fatigue Scale
- PSQI
Pittsburg Sleep Quality Index
Author contributions
NŞ, NU, and AÖ designed the research protocol, NU and AÖ conducted data collection, and NŞ analyzed and interpreted the data. All of the authors research the literature, write the manuscript, and perform a critical review.
Funding
Financial support was not received.
Data availability
The datasets used and/or analyzed during the current study are avail-able from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The present study received approval from Çankırı Karatekin University Health Sciences Ethics Committee with the verification code dated 09.02.2024 and numbered 5c93542196214664. This study was registered at https://www.clinicaltrials.gov/ (registration number: NCT06706037, Date: 11/25/2024). The research was carried out in compliance with the principles outlined in the Declaration of Helsinki. All the experimental protocols for involving humans were based on national/institutional guidelines in the manuscript. All patients gave a written informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Nilay Şahan, Email: nilaysahan@karatekin.edu.tr.
Naime Uluğ, Email: naime.ulug@atilim.edu.tr.
Ayşenur Özeren, Email: aysenurozeren89@gmail.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are avail-able from the corresponding author on reasonable request.