Increased Strength of The Scapular Stabilizer and Lumbar Muscles After Twelve Weeks of Pilates Training Using The Reformer Machine: A Pilot Study

Abstract

Objective:
The aim of this work was to analyze muscle strength in Pilates novices who used the Reformer equipment during twelve training sessions.

Methods:
Twenty-four healthy young female volunteers, who were non-smokers and did not exercise regularly, were split into a control group (mean age 28 ± 4 years and BMI 24.55 ± 3.21 kg/m(2)) and a training group (mean age 29 ± 4 years and BMI 22.69 ± 2.87 kgm(2)). The data were checked for normality using the Kolmogorov-Smirnov test, and were then analyzed using the t-test (p < 0.05).

Results:
After the training sessions, there were statistically significant differences between the groups for the scapular stabilizer muscles (p = 0.0263) and the lumbar muscles (p = 0.0001). For the scapular stabilizers, the initial/final values were 14.69 ± 2.80/14.79 ± 2.89 (control group) and 15.99 ± 3.54/17.44 ± 2.88 (Pilates group). The corresponding values for the lumbar muscles were 53.83 ± 11.66/53.28 ± 11.14 (control group) and 54.75 ± 10.27/64.80 ± 10.20 (Pilates group).

Conclusion:
After twelve sessions of Pilates with the Reformer equipment, there were improvements in lumbar extensor and scapular stabilizer strength. Several benefits are reported by practitioners of Pilates, but until now, there has been limited scientific evidence of the improvement of strength in the trunk and limbs after application of the technique.

Full text

PILOT STUDY
Increased strength of the scapular stabilizer
and lumbar muscles after twelve weeks of
Pilates training using the Reformer machine:
A pilot study
Nu
´bia Tomain Otoni dos Santos, Master in Physical Education
a
,
Karoline Cipriano Raimundo, Master in Physical Education
b
,
Sheila Aparecida da Silva, Master in Physical Education
b
,
Lara Andrade Souza, Master’s student in the Graduate Program
in Physical education
b
,
Karoline Carregal Ferreira, Physiotherapy bachelor
c
,
Zuleika Ferreira Borges Santo Urbano, Master in Health
Sciences
d
,
Andre
´a Licre Pessina Gasparini, Master in Bioengineering,
School of Medicine and a PhD in Biomechanics, Medicine and
Locomotive Apparatus Rehabilitation
b
,
Dernival Bertoncello, Master and PhD in Physiological Sciences
b,
*
a
Federal University of Triangulo Mineiro (UFTM), Brazil
b
UFTM, Brazil
c
Uberaba University (UNIUBE), Brazil
d
UNIUBE, Brazil
Received 5 December 2015; received in revised form 13 May 2016; accepted 25 May 2016
KEYWORDS
Exercise therapy;
Muscle strength;
Pilates
Summary Objective: The aim of this work was to analyze muscle strength in Pilates novices
who used the Reformer equipment during twelve training sessions.
Methods: Twenty-four healthy young female volunteers, who were non-smokers and did not
exercise regularly, were split into a control group (mean age 28 4yearsandBMI
* Corresponding author. Science Institute of Health, Federal University of Triangulo Mineiro (UFTM), Department of Applied Physiotherapy,
159, Getu
´lio Guarita
´Street, zip code: 38025-440, Uberaba, MG, Brazil. Tel.: þ55 34 3700 6950.
E-mail addresses: sassilva1721@gmail.com (S.A. da Silva), bertoncello@fisioterapia.uftm.edu.br (D. Bertoncello).
http://dx.doi.org/10.1016/j.jbmt.2016.05.005
1360-8592/Published by Elsevier Ltd.
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/jbmt
Journal of Bodywork & Movement Therapies (2017) 21,74e80

24.55 3.21 kg/m
2
) and a training group (mean age 29 4 years and BMI 22.69 2.87 kgm
2
).
The data were checked for normality using the KolmogoroveSmirnov test, and were then
analyzed using the t-test (p <0.05).
Results: After the training sessions, there were statistically significant differences between
the groups for the scapular stabilizer muscles (pZ0.0263) and the lumbar muscles
(pZ0.0001). For the scapular stabilizers, the initial/final values were 14.69 2.80/
14.79 2.89 (control group) and 15.99 3.54/17.44 2.88 (Pilates group). The corresponding
values for the lumbar muscles were 53.83 11.66/53.28 11.14 (control group) and
54.75 10.27/64.80 10.20 (Pilates group).
Conclusion: After twelve sessions of Pilates with the Reformer equipment, there were im-
provements in lumbar extensor and scapular stabilizer strength. Several benefits are reported
by practitioners of Pilates, but until now, there has been limited scientific evidence of the
improvement of strength in the trunk and limbs after application of the technique.
Published by Elsevier Ltd.
Introduction
Muscle strength can be defined as the tension generated by
the muscles in order to cause contraction, which is classi-
fied as isometric/static or dynamic (Mcardle et al., 2008).
Muscle strength is very important for the performance of
daily activities, since it provides independence, agility, and
safety, maintaining physical fitness and overall health (Valls
et al., 2014). Currently, in Brazil there are no public health
guidelines concerning physical activity as a strategy for
health (Sebastia
˜o et al., 2014). However, the Brazilian
Guidelines on Cardiovascular Prevention state the need to
implement comprehensive strategies to encourage the
practice of sports throughout life, from childhood to old
age (Sima
˜o et al., 2013).
The most common types of strength training are free
weight lifting or the use of devices that offer resistance.
Enhanced strength training requires application of the
principle of overload, increasing the amount of resistance
used over time. Increased muscle strength results from the
muscle being forced to endure relatively high tensions. This
strength training method is called progressive resistance
exercise (Powers and Howley, 2009).
There are various forms and methods of achieving
increased muscle strength. One is Pilates. There have been
several positive reports regarding its benefits (Granacher
et al., 2013; Oliveira et al., 2015), although limited scien-
tific evidence is available (Aladro-Gonzalo et al., 2012). The
Pilates method is a comprehensive body-conditioning
technique that aims at the development of both the body
and the mind of the individual. To this end, Pilates in-
corporates six key principles: centering, concentration,
control, precision, breath, and flow (Latey, 2002). Pilates-
based core stability training is a precise, controlled form
of exercise using the stabilizing muscles of the body (Kilber
et al., 2006). The exercises that make up the method
emphasize isometric contraction of the core muscles. This
strength center consists of the abdominal muscles (the
transversus abdominis), the deep extensors of the spine,
and the pelvic floor muscles (Mare
´s et al., 2012; Silva and
Mannrich, 2009; Key, 2013).
The Reformer is an item of resistance exercise equip-
ment designed by Joseph Pilates. It consists of a platform
that moves back and forth along a carriage. Resistance is
provided by the exerciser’s body weight and by springs
attached to the carriage and platform, and the training
performed with this device complies with the principle of
overload.
The question to be addressed here is whether there are
any changes in the strengths of the lumbar extensor or
scapula stabilizer muscles, after Pilates training sessions
using the Reformer device. The aim of this study was
therefore to analyze the strengths of these muscles in a
control group and in a group of Pilates novices who were
submitted to twelve sessions of Reformer training.
Material and methods
Subjects
This pilot study design was classified as quantitative,
experimental, descriptive, and longitudinal. The work was
approved by the Research Ethics Committee of Uni-
versidade Federal do Tria
ˆngulo Mineiro (protocol number
2406). The volunteers signed informed consent forms after
being advised about the objectives and procedures of the
study.
The participants consisted of 24 healthy young adult
female volunteers, aged between 21 and 34 years, who
were self-reported non-smokers and were not engaged in
any regular mode of exercise. This was a simple random
sample, whose size was chosen according to the literature
(Dias et al., 2008; de Oliveira Menacho et al., 2013). Using
closed envelopes, the participants were randomly allocated
to one of two groups: a training group (TG, n Z12) or a
control group (CG, n Z12).
Experimental design
The TG volunteers were first submitted to a session of
muscle stretching performed on the ground. The aim was to
prepare the muscles for the exercises and help to reduce
the incidence of muscle strains, although the scientific
evidence is mixed concerning the effectiveness of this
practice in preventing lesions (Kisner and Colby, 2005; Simic
Increased strength of the scapular stabilizer and lumbar muscles 75

et al., 2012). Six exercises were employed in order to
stretch the musculature of the posterior chain (spine and
lower limbs), as well as the hip flexor, brachial triceps, and
deltoid muscles, prior to the Pilates exercises using the
Reformer machine. The stretching exercises were: single
knee to chest, double knee to chest, prayer stretch, spine
stretch, triceps stretch, and arm across chest stretch
(Kisner and Colby, 2005)(Table 1). These stretches were
performed in three sets, with a rest period of 20 s before
each of twelve sessions with the Reformer. After the
stretches, the volunteers underwent twelve training ses-
sions with the Pilates exercises: Footwork Toes, Leg Series
(One Leg), Hundred, Arms Pulling, Down, Arms Pulling
Straps, and Shoulder Bridge, performed using the Reformer
machine (Table 2).
For cooling down at the end of the session, breathing
exercises were carried out with the volunteers positioned
supine on the ground, in order to decrease the resting heart
rate (Takahashi et al., 2002).
The exercise protocol was performed three times a
week, with each session lasting 50e60 min and including a
series of ten repetitions of each exercise. Twelve sessions
were undertaken. Prior to the first training session, a
practice session was held in order to familiarize the vol-
unteers with the Reformer machine, the exercises to be
performed, and the six principles of the method.
The CG did not attend the training program with the
Pilates exercises and did not practice any other regular
mode of exercise. After completion of the study, those
volunteers in the control group who were interested were
offered the same training protocol designed for the trained
group.
Procedures
The participants were first asked to complete an evaluation
form containing personal data, health history (in which the
volunteer declared any health problems or the continuous
use of any medication), and history of sports practice. The
latter reported for how long no regular physical exercise
had been taken, the type of exercise performed, and for
how long exercise had been practiced on a regular basis.
Both groups were submitted to initial and final assess-
ments of muscle strength. Before the tests, the volunteers
were instructed in the operation of the dynamometer and
Table 1 Stretching exercises.
Single knee to
chest
Begin by lying on the back with both knees
bent. Bring one knee up towards the
chest.
Double knee to
chest
Begin by lying on the back with both knees
bent. Bring two knees up towards the
chest.
Prayer stretch Sit back so the buttocks are resting on the
heels. Reach hands forward to lengthen
the spine
Spine stretch Sitting on the floor with the feet wider
than your hips, nod the head forward and
begin to bend forward by hinging at the
hips.
Triceps stretch Place one hand behind the lower neck and
the other hand on the elbow. Gently push
the elbow backwards so that the hand
moves further down the spine, until
feeling a mild to moderate stretch.
Arm across chest
stretch
With the back and neck straight, gently
take the arm across the body, using the
other arm to take it a little further.
Table 2 Pilates exercises.
Footwork
toes
Supine, this exercise can be carried out with
the feet in parallel or in a Pilates V position
(heels together, toes apart). The toes should
be on the bar and the heels lifted (on
tiptoes). The heels should stay in the highest
possible lifted position as the carriage is
moved in and out, flexing and extending the
knees.
Leg Series
One Leg
Supine, place the feet parallel on the
reformer bar, lift one leg and hold with hip
flexion and knee to 90, and with the leg
extended perform flexion and knee
extension. When finished, perform with the
other leg.
Hundred Lie supine on the carriage with the legs in the
tabletop position (90 of knee and ankle
flexion). Place the hands in the straps, with
the arms perpendicular to the body. Maintain
mild tension in the straps and keep the lower
back in a neutral position. Inhale, and then
exhale lifting the head and chest,
straightening the legs and keeping the feet at
eye level. Simultaneously extend the arms to
the sides of the body. Reach the legs toward
the ceiling, with a slight angle forward to
keep a neutral spine. Lower the legs as far as
possible without the back moving. Exhale and
pump the arms up and down in a rhythmic
motion for 5 counts. Inhale and pulse for 5
counts. Repeat for 10 breath cycles. Here,
this was performed using only one series of
ten repetitions, and was therefore
considered a variation.
Arms Pulling
Down
Supine, keep the legs in 90 of knee and
ankle flexion. Extend the elbows and grasp
the handles in 90 of flexion. Perform
shoulder extension and return to starting
position.
Arms Pulling
Straps
With the box on the reformer, stay prone.
Keep the legs straight and the ankles in
plantar flexion. Grasp the handles with both
hands. Keep the abducted shoulders and
arms straight, and perform adduction of the
arms and elbow extension simultaneously.
Shoulder
Bridge
In the supine position, support the feet in the
reformer bar, with hips and knees flexed at
90. Step hard on the bar and perform hip
extension. Maintain hip extension and
flexion, and perform knee extension.
76 N.T.O. dos Santos et al.

the procedures involved in the measurement protocol.
Three maximal voluntary isometric contractions were car-
ried out using the equipment, with intervals of 2 min be-
tween them, and the average value was calculated.
The measurement of force using a dynamometer is
simple, practical, and inexpensive. Hydraulic dynamome-
ters have two parallel straps, one fixed and the other
movable, and a closed hydraulic system that measures the
amount of force produced by an isometric contraction
applied to the straps (Turner et al., 2009). Dynamometers
have been validated and are widely used as instruments to
measure isometric force (Amaral et al., 2012; Cavazzotto
et al., 2012; Celik et al., 2012; Clerke and Clerke, 2001;
Gray et al., 2013; Pertile et al., 2011).
The extensor muscles of the lumbar spine were assessed
using a lumbar hydraulic dynamometer (Crown brand) with
a capacity of 200 kgf and divisions of 1000 gf. To perform
the test, the volunteer was placed in a standing position on
the platform, with the knees and elbows fully extended and
the trunk semi-inflected (at 45) until the hands were able
to hold the bar of the device. A maximal voluntary iso-
metric contraction was then performed to extend the
trunk, such that the force was exerted by the lumbar region
(Heyward, 2004; Thacker et al., 2004).
Maximal voluntary isometric contraction of the shoulder
girdle muscles was assessed using a scapular hydraulic
dynamometer (Crown brand) with capacity of 50 kgf and
divisions of 500 gf. This test was performed with the
volunteer in a standing position with feet apart, torso up-
right, head directed forward (Frankfurt plane), and shoul-
ders abducted 90, holding the dynamometer with both
hands at the same time and using all the fingers, including
the thumb (Heyward, 2004; Cavazzotto et al., 2012; Beseler
et al., 2014). These tests are commonly used to assess the
strength of the trunk muscles in healthy or ill individuals
(Yahia, 2011; Seitz, 2015).
Statistical analysis
The data were analyzed using the mean and standard de-
viation for each variable. The KolmogoroveSmirnov test for
normality was applied, followed by use of the paired t-test
for intra-group analysis and the unpaired t-test with Welch
correction for inter-group analysis. In the case of non-
normality, the non-parametric ManneWhitney test was
used. The significance level considered was p <0.05.
Results
The participants in this study were 24 randomly selected
sedentary female volunteers who had not attended regular
exercise sessions for more than 150 min a week during at
least one year. Each woman completed a health history
questionnaire. None of the participants reported that they
experienced periodic low back pain. Informed consent
forms that included information on the study and possible
side effects were signed by the participants prior to starting
the trial. The subjects were randomly assigned to the
groups (control and trained), whose average age and initial
anthropometric data are shown in Table 3. There were no
significant differences between the groups for any of these
variables.
In the case of the trained group, there were significant
differences between the strength values for the lumbar and
scapula stabilizers obtained at the beginning and end of the
training. Statistically significant differences were also
observed between the final values obtained for the two
groups (Table 4).
Discussion
In the work of Shahtahmassebi et al. (2014), approximately
half of the 29 studies cited reported an increase in lower
trunk muscle size following participation in an exercise
program. The positive trials included studies involving
motor control exercises combined with non-machine-based
resistance exercises, as well as machine-based resistance
exercises.
Isolated Lumbar Extension (ILE) resistance training pro-
duces significant and meaningful improvements in
perceived pain, disability, and global perceived outcomes
(GPOs), as part of a multiple intervention or using a stand-
alone approach (Franc¸a et al., 2010;Dreisinger, 2014;
Steele et al., 2015). Strength training should focus on
multi-joint free weight exercises, rather than core-specific
exercises, to ensure adequate training of the core muscles
in athletes and others (Martuscello et al., 2013). Regardless
of therapeutic activity, the principle of progressive over-
load governs the ability to increase the capacity to perform
the activities of daily life. Applying greater resistance
during progressive sessions results in increased lean muscle
mass, decreased body fat, and increased work capacity
(Dreisinger, 2014). Stabilization exercise programs are
effective for reducing the recurrence of low back pain.
These exercises, together with muscular endurance exer-
cises, are most important for initial use with patients
suffering low back pain (Rackwitz et al., 2006;Chilibeck
et al., 2011).
Hip flexor strength training is valuable for relatively
untrained individuals. Long-term participation in an aerobic
dance and fitness program was found to increase core
muscle strength, as measured by the Sorensen test and 1-
min sit-up challenge, as well as to improve submaximal
running performance during an incremental 400 m endur-
ance test. It was also found that use of a Swiss ball resulted
in significant increases in core muscle strength in trained
high school athletes (Reed et al., 2012). The findings of
Hides et al. (2006) demonstrated the effectiveness of the
stabilization technique as a non-invasive, inexpensive, and
easy to use alternative treatment of imbalance and weak-
ness of stabilizer muscles in patients with herniated lumbar
discs. The Pilates method advocates the use of muscle
control mechanisms when performing stabilization exer-
cises (Volpato et al., 2012).
Table 3 Baseline age groups (mean SD).
Group Age (years)
Control 28 4
Trained 29 4
Increased strength of the scapular stabilizer and lumbar muscles 77

Scapular stabilization is extremely important in shoulder
movements (Jang et al., 2015). In a study involving musi-
cians, disturbances of the scapular stabilizers were noted in
females (Steinmetz et al., 2010). Cricchio and Frazer (2011)
highlighted the importance of isometric exercises for
scapulohumeral and scapulothoracic stability.
This study examined the effect of twelve Pilates training
sessions using the Reformer device on the strength of the
extensor muscles of the lumbar spine and the shoulder girdle
musculature. The hypothesis was thatthere would be a change
in the strengths of the scapular stabilizer and lumbar muscles.
According to the statistical methodology employed, the
hypothesis of the study was confirmed, with increased
muscle strength after completion of the training protocol.
The number of sessions employed in this work was in line
with typical recommendations made by clinicians in health
improvement programs (Sekendiz et al., 2007; Garcı
´
a-
Soida
´n et al., 2014; Kao et al., 2015).
The results obtained during the study indicated that
there was a greater gain in strength of the lumbar extensor
muscles (p <0.0001), compared to the other musculatures
tested. As the Pilates method places an emphasis on core
strength and stability, for which contraction of the deep
extensor muscles of the spine is required, these muscles
probably participated in all the exercises (Mare
´s et al.,
2012). The greater requirement for these muscles there-
fore led to a marked improvement in their performance.
The exercises that comprise the Pilates method
emphasize isometric contraction of the core muscles. Other
studies of the muscles responsible for core stabilization
have reported similar improvements in performance after
training with similar populations under similar conditions
(Emery et al., 2010; Kao et al., 2015).
The muscles of the shoulder girdle also showed
increased strength after training. The gain in scapular sta-
bilizers strength was less marked, which could have been
because greater emphasis was given to the pelvic girdle
exercises. It could be argued that use of the lower back
muscles was required throughout the training, in order to
promote stabilization of the lumbopelvic region, known as
the power center (Bertolla et al., 2007). These were the
results found in this sample, but the outcomes may differ
depending on the sample population and the types of
Pilates exercises performed using the Reformer (Menacho
et al., 2010; Merolla et al., 2010a,b; Emery et al., 2010;
Kao et al., 2015).
This study employed a protocol involving a sequence of
six exercises that aimed to include muscle actions of the
upper limbs, lower limbs, abdomen, and spine. This pro-
tocol was performed three times a week, with each session
lasting 50e60 min, as in previous studies of Pilates practice
(Keays et al., 2008; Merolla et al., 2010a,b). Due to the
duration of the training (twelve sessions over four weeks),
the exercise program could be defined as a short-term
intervention.
In the present work, the exercises were performed using
the Reformer machine. Among the various devices created
by Joseph Pilates, the Reformer, Cadillac, and Chair
equipment play important roles in the practice. Around 100
different exercises can be performed with the Reformer
device, stimulating several different muscle groups at the
same time (Powers and Howley, 2009). This diversity of
exercises, together with the ease of manual adjustments to
adapt the device to the physical characteristics of each
individual, were the basis for selection of the Reformer
machine for use in this research, as well as in other studies
(Cadore et al., 2012; Queiroz et al., 2010; Stolze et al.,
2012).
Conclusions
The data obtained for the two groups evaluated showed
that twelve Pilates sessions using the Reformer machine
resulted in improvements in the strengths of the scapular
stabilizer and lumbar muscles in the trained group.
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