Rev Bras Fisiol Exerc. 2024;23:e235437

doi: 10.33233/rbfex.v23i1.5437

REVIEW

Impact of Pilates on the quality of life of patients with chronic kidney disease: a systematic review

Impacto do Pilates na qualidade de vida de pacientes com doença renal crônica: uma revisão sistemática

Lucas Oliveira Soares^1,2, Wasly Santana Silva³, Beatriz Rodrigues Mortari², Adriana Malavasi Falleiros², André Luis Lisboa Cordeiro¹

¹Centro Universitário Nobre, Feira de Santana, BA, Brazil

²Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

³Hospital Universitário da Universidade Federal de Sergipe, Aracaju, SE, Brasil

Received: August 19, 2023; Accepted: September 19, 2023.

Correspondence: Lucas Oliveira Soares, lucassoaresft@gmail.com

How to cite

Soares LO, Silva WS, Mortari BR, Falleiros AM, Cordeiro ALL. Impact of Pilates on the quality of life of patients with chronic kidney disease: a systematic review. Rev Bras Fisiol Exerc 2024;23:e235437. doi: 10.33233/rbfex.v23i1.5437

Abstract

Introduction: The evolution of Chronic Kidney Disease (CKD) is silent and asymptomatic, which makes diagnosis and treatment difficult in the initial phase. Patients with CKD present loss of muscle mass, decreased functional capacity, and quality of life (QoL). Objective: To review the effects of the Pilates Method on the QoL of patients with CKD. Methods: This is a systematic review carried out according to PRISMA. The search was carried out in December 2022 in the following databases: Google Scholar, Scielo, Lilacs, CINAHL, Pubmed, PEDro, Web of Science, and the Cochrane Central Register of Systematic Review. To carry out the literary search, the PICOT strategy was used, and the studied population was patients with CKD, the intervention was training with the Pilates method, compared with patients who did not undergo training or any other intervention, the evaluated outcome was QoL and we included only randomized controlled clinical trials. Results: 3,287 articles were found, of which 3 were considered eligible for our systematic review. Due to methodological heterogeneity, it was not possible to perform a meta-analysis. All studies included showed significant benefits of Pilates practice in the QoL of patients with CKD. Conclusion: Our results indicate that the practice of physical exercise with the Pilates method can favor the improvement of QoL in individuals with CKD.

Keywords: renal insufficiency, chronic; Pilates; quality of life

Resumo

Introdução: A evolução da Doença Renal Crônica (DRC) é silenciosa e assintomática, o que dificulta o diagnóstico e tratamento na fase inicial. Pacientes com DRC apresentam perda de massa muscular, diminuição da capacidade funcional e qualidade de vida (QV). Objetivo: Revisar os efeitos do Método Pilates na QV de pacientes com DRC. Métodos: Trata-se de uma revisão sistemática realizada de acordo com o PRISMA. A busca foi realizada em dezembro de 2022 nas seguintes bases de dados Google Acadêmico, Scielo, Lilacs, CINAHL, Pubmed, PEDro, Web of science e o Cochrane Central Register of Systematic Review. Para execução da busca literária foi utilizada a estratégia PICOT, e a população estudada foi paciente com DRC, a intervenção foi o treinamento com o método Pilates, comparado com pacientes que não realizaram o treinamento ou qualquer outra intervenção, o desfecho avaliado foi QV e incluímos apenas ensaios clínicos controlados e randomizados. Resultados: Foram encontrados 3.287 artigos, dos quais 3 foram considerados elegíveis para a nossa revisão sistemática. Devido a heterogeneidade metodológica, não foi possível realizar meta-análise. Todos os trabalhos incluídos mostraram benefícios significativos da prática do Pilates na QV de pacientes com DRC. Conclusão: Nossos resultados apontam que a prática de exercício físico com o método Pilates pode favorecer a melhora da QV em indivíduos com DRC.

Palavras-chave: doença renal crônica; Pilates; qualidade de vida.

Introduction

The evolution of Chronic Kidney Disease (CKD) is silent and asymptomatic, which makes the diagnosis difficult in the initial phase, or even late when the disease is already advanced, making it an important public health problem [1]. Patients with CKD have significant physical inactivity [2,3], loss of muscle mass [4], and decreased functional capacity [5], these systemic changes intrinsic to CKD cause deleterious effects, significantly affecting quality of life (QoL).

Several factors such as myalgia, fatigue, sleep disorders, and sexual dysfunction contribute significantly to the decrease in QoL [6]. In Brazil, Jesus et al. [7] demonstrated that patients with CKD have a significant impairment of QoL, especially those on dialysis because they are dependent on daily or intermittent hemodialysis (HD). In Iran, Ghiasi et al. [8] performed a systematic review with meta-analysis to summarize the effects of CKD on QoL. The authors evaluated data from more than 17,000 patients and found that scores on the Short Form 36 (SF-36), Health-related Quality of Life (HRQOL), and Kidney Disease Quality of Life-Short Form (KDQOL-SF) questionnaires were lower on different dimensions compared to other populations [8].

Physical exercise is suggested as the main strategy to increase muscle strength, preventing or delaying functional decline and QoL, a result already demonstrated by the study by Cheema [9]. In this scenario, Pilates appears, as an exercise modality whose principles are breathing control, precision in execution, flexibility, activation of trunk stabilizing muscles, and main focus on the central muscles, diaphragm, and pelvic floor [10,11]. Pilates has already shown that it can be effective in improving the QoL of other populations [12,13], in addition, it possibly has better adherence compared to other exercise programs [14]. Therefore, our work aims to review the effects of the Pilates Method on the QoL of patients with CKD.

Methods

Protocol and registration

This systematic review was completed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [15]. It is registered in the International Prospective Register of Systematics (PROSPERO) with the number CRD42022369587.

Eligibility criteria

To carry out the literary search, the PICOT strategy [16] was used, the population studied was patients with CKD, the intervention was training with the Pilates method, compared with patients who did not undergo training or any other intervention, the evaluated outcome was QoL and we only included controlled and randomized clinical trials.

Articles with patients aged 18 years or older with dialytic and non-dialytic CKD who performed physical exercise with the Pilates method and specified which movements were performed were included. As exclusion criteria, we defined that studies that combined Pilates with another exercise (aerobic, neuromuscular, inspiratory muscle training, bodybuilding, or hydrogymnastics) and those in which patients had pathophysiological conditions that reduce performance during exercise (neuromuscular diseases, amputations, dementia).

The complete strategy is shown in Chart 1. Randomized and controlled clinical trials were used, without language and year restriction. The descriptors used were based on DecS/Mesh: Renal Insufficiency, Chronic, Pilates, and Quality of Life and their synonyms.

Chart 1 - PICOT strategy [16]

Database

We conducted a survey based on the following databases: Google Scholar, Scielo, Lilacs, Accumulated Index of Literature for Nurses and Other Health Professionals (CINAHL), Pubmed, PEDro (Physiotherapy Evidence Database), Web of Science, and the Cochrane Central Register of Systematic Review. The survey was carried out between December 5 and January 4, 2023.

Below we demonstrate the search strategy of the main platforms we used to carry out the Pubmed and Central review (Chart 2). The research was based on the PICO strategy [16] previously described and Boolean operators AND and OR.

Chart 2 - Search strategy in the main databases

Data items

The following data were extracted from the included studies: (1) aspects of the study population, such as number of patients, diagnosis; (2) aspects of the intervention performed (sample size, type of Pilates movements, intensity, frequency, duration of training and duration of each session); (3) follow-up; (4) outcome measures; and (5) presented results.

Risk of bias in individual studies

Methodological quality was assessed according to the criteria of the PEDro scale [17], which scores 11 items, namely: 1- Eligibility criteria, 2 - Random allocation, 3 - Blind allocation, 4 - Baseline comparison, 5 - Blind individuals, 6 - Therapists blinded, 7 - Raters blinded, 8 - Appropriate follow-up, 9 - Intent-to-treat analysis, 10 - Between-group comparisons, 11 - Point estimates and variability. Items are scored as present (1) or absent (0), generating a maximum sum of 10 points, the first item being disregarded.

Wherever possible, PEDro scores were drawn from the PEDro database itself. When articles were not found in this database, two independent and trained reviewers evaluated the article with the PEDro scale. Studies were considered high quality if they scored 6 or more. Studies with scores lower than 6 were considered low quality.

Results

Selection and characteristics of the studies

After analyzing the articles found in the search strategy, we realized that some databases delivered generic results, thus increasing the number of articles that were excluded for not addressing the topic. At the end of the careful analysis, we included 3 studies (Figure 1), totaling a sample of 170 individuals.

Figure 1 - Selection process for studies included in the analysis

Methodological quality

To assess the methodological quality, the PEDro scale [17] was used. Scores from two articles were already available in the PEDro database, except for Kheirkhah [24] which was evaluated by 2 independent researchers (LO and WS). The scores ranged from 4 to 6 points on a scale of 1 to 10 points (Chart 3). All studies lost points on items related to patient and therapist blinding.

Chart 3 - Methodological quality of eligible studies (n = 3), PEDro scale

Characterization and results of the studies

Chart 4 presents the sociodemographic characteristics, and sample distribution in the control group and intervention group.

Chart 4 - Características gerais de cada estudo, objetivo, população, grupo intervenção e controle

IG = intervention group; CG = group control; GFR = glomerular filtration rate

Chart 5 shows the evaluation and intervention protocols of each study followed by the pre- and post-intervention evaluation.

Chart 5 - Prescription and study protocols: prescription and movements performed

IG = intervention group; CG = group control; GFR = glomerular filtration rate; QoL = quality of life; U = Mann-Whitney test

Exercise protocols and progression

In the protocol by Kheirhah et al. [18] all 13 movements were repeated four times per session and continued until the end of the program without changing the number of repetitions and training duration. Rahimimoghadam et al. [19], describe very well how the progression of the exercises was performed. In the first week, all 13 movements were repeated 4 times per session, and each week, two more repetitions were added to all movements, so in the 4th week, all movements were performed 10 times, continuing until the end of the program.

Corroborating with the previously mentioned studies, Rahimimoghadam et al. [20] describe that the progression of the exercises was based on the increase of the repetitions and the duration of the training time. The time progressed according to the sessions, the first two sessions lasted 45 minutes, and from the third session, it was increased until it reached 70 minutes. In the first and second sessions, the number of exercises started with 10 repetitions and 45 minutes duration. In subsequent sessions, stretching exercises of about 5 minutes were added, Pilates exercises of 50 minutes and relaxation movements, of about 5 minutes. In these sessions (sessions 3-12), the number of exercises reached 70 to 80 repetitions with 70 minutes duration.

Pilates and quality of life

Of the articles included in this systematic review [18,19,20], all showed a significant increase in QoL in patients with CKD submitted to exercise using the Pilates method compared to the control group. The amount of movements performed was similar between the studies, all performed warm-up exercises prior to the start of training and relaxation exercises at the end [18,19,20].

Discussion

This systematic review of the literature identified, in all analyzed studies, an increase in QoL related to the practice of Pilates in individuals with CKD. The results were obtained through questionnaires that assessed QoL through the dimensions of physical health, mental health, and CKD components. None of the studies analyzed direct variables, such as functional capacity or metabolic response in functional tests. The quality analysis of the papers showed moderate to low methodological quality, which implies a reduction in their inference power.

The Pilates method has diversified over time, with the extension of its use in different contexts and, currently, in different clinical conditions. Improvements in functionality and QoL in individuals undergoing Pilates have been described, from elderly people with chronic musculoskeletal disorders [21] to women with breast cancer [22]. In individuals with CKD, as far as we know, this was the first systematic review of the literature to assess its effects on QoL. We identified that the practice of Pilates improved self-reported functionality in terms of physical, instrumental activities of daily living, and mental, possibly acting in an inverse way to the pathophysiology of CKD.

Among patients with CKD, the literature has already well described a high prevalence of frailty and morbidity, causing functional dependence or disability [23]. The main consequence of this is the decrease in QoL, which is directly proportional to the increase in age and the reduction in GFR, with an even more important drop in those undergoing HD29. A cohort [24] of 5,888 people from the community assessed functional disability among its participants. The presence of limitation in ADLs was almost twice as high in participants with CKD. In another study, Odden et al. [25], a cohort of 1,024 participants with a mean age of 65 years, with stable coronary disease, found that the chances of low functional capacity were six times greater for participants with GFR less than 60 ml/min/1.73 m². Other consequences include a decrease in flexibility, strength, and muscle tropism, with an impact on low capacity in instrumental activities of daily living [23].

Continuing with the previous thought, we suggest that the main physical benefits arising from the practice of Pilates in CKD are related to increased muscle strength and flexibility, as reported in other studies [26,27], however, the evidence is conflicting to argue improvement of cardiovascular conditioning and functional capacity [28]. Some observational studies point to this improvement after 6 to 8 weeks of training, but this evidence cannot impute causality, mainly because they associated the Pilates program with aerobic activities [29,30]. In contrast, Sarmento et al. [31] verified in a study with patients hospitalized with CKD, a greater advantage of Pilates concerning a conventional physiotherapy protocol in the outcomes of functionality and functional capacity measured by an incremental step test, in an intragroup analysis. However, when an extra group analysis was performed, there was no significant difference between Pilates and conventional physical therapy. It is important to highlight that, in the study by Sarmento, due to its nosocomial nature, the interventions lasted 10 consecutive days or less, invariably insufficient time to evaluate the main muscular and systemic adaptations to training with physical exercise.

Another important point to highlight is the mental and cognitive impacts caused by CKD. Studies demonstrate a dependent and independent association between cognitive dysfunction and CKD severity, as measured by GFR. Seliger et al. [32] demonstrated that the prevalence of dementia in these individuals was 37%, in a 6-year follow-up. In addition, in another study [33] it was observed that elderly people with GFR lower than 60 ml/min/1.73 m² presented a faster decline in cognition, especially in memory domains. Our findings lead to the understanding that the benefits of Pilates permeate physical function, also collaborating to improve mental and cognitive aspects in CKD. Similar results were found in an extensive review of reviews with a sample of 128,119 individuals [34]. In this study, the practice of physical activity, in different modalities, was able to reduce mild to moderate symptoms of depression, anxiety and psychological distress compared to usual care in all populations and specifically in greater magnitude in those with CKD and other chronic diseases [34].

In this systematic review of the literature, we identified that the practice of Pilates can act directly on the physical dysfunctions of CKD, thus contributing to the improvement of QoL. However, it is important to take into account the specificity of the results presented here to define the need to associate Pilates with other interventions, according to the individuality of the patient.

Limitations

The small number of works and the heterogeneity in the QoL assessment methods are the main limitations of this systematic review. These factors made it impossible to carry out the meta-analysis, which does not allow us to establish a causal reaction in our work. Moreover, the methodological quality of the analyzed works also limits our power of inferences. The increment of objective evaluation such as functional tests, and the type and location of vascular access for hemodialysis in future studies are necessary to establish the association between QoL and functional capacity and safety in performing Pilates.

Conclusion

Our results point out that the practice of physical exercise with the Pilates method can favor the improvement of the quality of life in individuals with chronic kidney disease. More studies, with standardization of quality of life assessment and association with functional and clinical parameters, are needed to better elucidate these findings in the future.

Funding source

Nothing to declare.

Conflict of interest

We declare that we have no conflicts of interest.

Authors' contribution

Research conception and design: Soares LO; Obtaining data: Soares LO, Silva WS, Mortari BR; Data analysis and interpretation: Soares LO, Silva WS, Mortari BR; Statistical analysis: Soares LO, Silva WS; Writing of the manuscript: Soares LO, Silva WS, Mortari BR, Cordeiro ALL; Critical review of the manuscript for important intellectual content: Soares LO, Silva WS, Mortari BR, Falleiros AM, Cordeiro ALL.

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