Ya-Nan Leng ,Min Zhang ,Yu-Qi Li ,Ting-Ting Liu ,Xiao-Li Pang

1Department of Graduate,Tianjin University of Traditional Chinese Medicine,Tianjin,301617,China;

2Department of Nursing,Tianjin University of Traditional Chinese Medicine,Tianjin,301617,China.

Abstract Objective:To systematically evaluate the effects of Pilates exercise on balance,walking and lower limbs motor function in stroke patients.Methods:The literature databases such as the Cochrane Library,EMbase,PubMed,Web of Science,Chinese Biomedicine Database (CBM),China National Knowledge Infrastructure (CNKI),VIP Database for Chinese Technical Periodicals (VIP) and Wan Fang database (Wan Fang) were retrieved.Randomized controlled trials (RCTs) regarding the effects of Pilates exercise on balance,walking and lower limbs motor function of stroke patients were retrieved.Data were collected and evaluated independently by two researchers.Then,we adopted RevMan 5.3 software to perform a meta-analysis.Results:A total of 5 RCTs were included,including 182 subjects were chosen.The result showed that compared with the routine care group,Pilates exercise can effectively improve the balance of stroke patients when they have trained eight weeks [MD=4.71,95%CI(2.14,7.28),P=0.0003],shorten the time of the Timed Up and Go test (TUG) [MD=-1.63,95%CI (-2.69,-0.56),P=0.003],increase the stride velocity [MD=3.83,95%CI (1.43,6.23),P=0.002].However,the evidence did not support the effectiveness of Pilates exercise on increasing the score of Fugl-Meyer Assessment-Lower Extremity(FMA-LE) of stroke patients [MD=6.70,95%CI (-3.46,16.86),P=0.20].Conclusion:The findings suggest that Pilates could improve the balance and walking speed of stroke patients.However,there still is the lack of the evidence in improving lower limb function.Due to the limitation of the quality of the included studies.highquality studies still should be conducted to investigate the effect of Pilates exercise in stroke patients.

Keywords:Pilates exercise,Stroke,Balance,Walking,Meta-analysis

Introduction

Stroke is a major cause of death in the world [1].According to the guideline published by the American Stroke Association (ASA) in 2019,Approximately 800,000 people in the United States experience a new or recurrent stroke each year.It is estimated that by 2030,there will be 3.4 million stroke patients among adults [2].It is the most common and fatal disease in China,with an incidence of 11.2% [3].Patients often have multiple dysfunctions,especially motor dysfunction.Eighty-five percent of stroke patients had limb dysfunction at the time of onset,and many of them showed defects in walking ability after onset[4,5].Besides,it may include loss of balance and gait[6].In addition to medical treatments,rehabilitation therapy is of great significance for patients to promote the establishment of normal movement patterns of affected limbs,restore walking ability,alleviate disability and improve the quality of life [5,7,8].Pilates has been demonstrated to be an effective physical technique for improving body flexibility,muscle endurance and coordination by stretching and relaxing the body muscles [9].Studies have shown that Pilates exercise has a certain healing effect on diseases such as lumbar disc herniation,ankylosing spondylitis,multiple sclerosis,etc [10,11].

Pilates exercise has been increasingly popular in stroke patients,but the evidence on Pilates exercise in stroke patients has not yet been conclusive.Therefore,this study used the meta-analysis to evaluate the intervention effect of Pilates in stroke patients.

1 Materials and methods

1.1 Inclusion and exclusion criteria

1.1.1 Study Design

Randomized controlled trials were included.

1.1.2 Subjects

Stroke patients with stable vital signs and basically normal cognitive function were included.

1.1.3 Types of interventions

Patients in the control group were given routine nursing care such as the control of blood pressure and blood sugar,nutrition guidance,infection prevention,stroke rehabilitation training,etc.The interventions in the experimental group included the combination of routine rehabilitation nursing and Pilates training or Pilates training alone.Pilates training includes:(1) emphasis on breathing,exhaling from the mouth and inhaling the nose,recognizing the coordination of breathing and exercise training;(2) using props such as balls and magic circles to strengthen the training of core muscle groups under the guidance of a rehabilitation physician.

1.1.4 Outcome

Outcome indicators include balance function,functional mobility,lower limb function and walking speed in stroke patients.The scales used are required to be published and have been tested for reliability and validity such as the Berg Balance Scale (BBS),The Timed Up and Go test (TUG),Fugl-Meyer Assessment-Lower Extremity (FMA-LE).

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1.1.5 Exclusion criteria

Research will be excluded if the following contents are included:(1) The literature quality is extremely poor,and the quality evaluation result is“C”;(2)A literature without a full text but with an abstract,duplicate literature,case report,literature with little information or data that cannot be used;(3) Patients with Pilates exercise in intervention group who contained other interventions.

1.2 Search strategy

We systematically searched RCTs on the Pilates exercise for stroke patients from the Cochrane Library,PubMed,EMBASE,Web of Science,Chinese biomedical literature database (CBM),China National Knowledge Infrastructure (CNKI),Chinese Scientific Journals Database (VIP) and Wan Fang database (Wan Fang).The retrieval time was from the establishment of each database to June 5,2019.At the same time,relevant materials were searched manually.Besides,researchers developed reasonable search strategies based on different database characteristics,the combination of medical subject headings and free words was adopted.Finally,in order to ensure a comprehensive search,the references included in the literature were traced back.The search terms were listed as follows:(“Pilates”O(jiān)R“Pilates-Based Exercises”O(jiān)R“Exercises,Pilates-Based”O(jiān)R“Pilates Training”) AND (“Stroke*”O(jiān)R“ischemic stroke”O(jiān)R“hemorrhagic stroke”O(jiān)R“cerebrovascular disease”O(jiān)R“apoplexy”O(jiān)R“brain infarction”O(jiān)R“intracranial vascular disorder”O(jiān)R“cerebrovascular insufficiency”O(jiān)R“cerebrovascular accident”O(jiān)R“transient ischemic attack”O(jiān)R“intracerebral hemorrhage”O(jiān)R“cerebral infarction”O(jiān)R“CVA”).

1.3 Literature screening and data extraction

The two researchers first used the EndNote X7 literature management software to eliminate the duplicated literatures,read the abstracts and the titles of the remaining literatures,screened the literatures strictly according to the inclusion and exclusion criteria,and read the full text of the preliminary included literatures to determine the final choice of the literatures.If the two researchers had any doubt in the process,they discussed or invited the third-party to intervene in the arbitration.The extracted contents included:authors,publication time,national,sample size,baseline level of relevant subjects,intervention and control measures,assessment time and outcome indicators.

1.4 Methodological quality assessment

Two researchers independently evaluated the quality of included literatures according to the Cochrane Handbook for Systematic Reviews of Interventions[12].Specific items included (1) Random sequence generation;(2) Allocation concealment;(3) Blinding of participants and personnel;(4) Blinding of outcome assessment;(5) Incomplete outcome data;(6) Selective reporting;(7) Other sources of bias.The results of each item are described as“l(fā)ow risk of bias”,“high risk of bias”or“unclear”.If the above standards are fully met,the quality grade of the literature is“A”.If partial satisfied,the“B”grade quality evaluation result is given.If the above standards are all not satisfied,the result of the quality evaluation result is“C”.when the results of the independent evaluation of the two researchers were controversial,a third party was invited to negotiate.

1.5 Data analysis

In this study,meta-analysis was conducted using the RevMan 5.3 software.Different methods are used depending on the type of data.Continuous variables can be represented by weighted mean difference(WMD) or standardized mean difference (SMD) with 95% confidence interval (CI).Heterogeneity across the included results was tested by chi-square test.When P＞0.1 and I2＜50%,the homogeneity was considered.Fixed effect model was used for analysis.When P≤0.1 or I2≥50%,the source of the heterogeneity was considered.If there is only statistical heterogeneity between studies without clinical heterogeneity,random effects model analysis can be used.If the source of heterogeneity cannot be judged,only descriptive analysis can be used.

2 Results

2.1 Study selection

One hundred and nineteen articles have been collected during the initial literature search,finally included 5[13-17]articles.The total sample size was 182,with 91 in Pilates group and 91 in control group.The detailed process of literature screening,such as reasons and number of selection or deletion,were shown in Figure 1.Three articles were from China and two articles come from Iran.The basic characteristics of the included researches was shown in Table 1.

2.2 Methodological quality assessment of included trials

2.3 Meta-analysis results

2.3.1 Effect of Pilates exercise on balance function of stroke patients

Three [13-15]studies,including 142 stroke patients,compared the score of BBS between the Pilates exercise group and control group,which the scale used in the above study is consistent.The heterogeneity test results showed that the heterogeneity was large among the studies (P=0.01,I2=77%).The meta-analysis with the random-effect model showed that the Pilates training group improved the patient's balance function better than the control group,and the difference was statistically significant [MD=4.71,95%CI (2.14,7.28),P=0.0003](Figure 3).

2.3.2 Effect of Pilates Exercise on Functional Mobility of Stroke Patients

Two studies [13,16]reported the situation of TUG test between the Pilates exercise group and control group.Heterogeneity test results show that the homogeneity between the studies is low (P=0.74,I2=0%).The meta-analysis with the fixed-effect model showed that the ability of functional mobility of stroke patients in the Pilates exercise was better than that in the control group,and the difference was statistically significant [MD=-1.63,95%CI (-2.69,-0.56),P=0.003](Figure 4).

Table 1.The basic characteristics of included studies

Table 2.Methodological Quality Assessment

Figure 2.Risk of bias summary and graph

Figure 3.Effect of Pilates and routine nursing on balance function of stroke patients

Figure 5.Effect of Pilates and routine nursing on lower limb function of stroke patients

Figure 6.Effect of Pilates and routine nursing on walking speed of stroke patients

2.3.3 Effect of Pilates exercise on lower limb function of stroke patients

Two [13,15]of the 5 studies,including 106 stroke patients,compared the score of FMA-LE between the Pilates exercise group and control group.The heterogeneity test results showed that the heterogeneity was large among the studies (P＜0.00001,I2=97%).The results of the meta-analysis with the randomeffect model showed that the improvement of lower limb function between two groups was not statistically different [MD=6.70,95%CI (-3.46,16.86),P＝0.20](Figure 5).

2.3.4 Effect of Pilates exercise on walking speed of stroke patients

A total of 2 [13,17]studies were included with 40 in the Pilates exercise and 40 in the control group.Heterogeneity test results show that the homogeneity between the studies is low (P＝0.33,I2=0%).The meta-analysis with the fixed-effect model showed that the walking speed of stroke patients in the Pilates exercise was faster than that in the control group,The difference was statistically significant [MD=3.83,95%CI (1.43,6.23),P＝0.002](Figure 6).

3 Discussion

3.1 Methodological quality analysis included in the study

The quality grade of the five literatures included was B.Because of the Pilates exercise for patients,it is difficult to achieve double blindness for the interveners and patients.Only part of the studies adopted single blindness for the evaluators,such as Liang's study[13].Three studies [13-15]reported the use of a random number table.One study[17]only mentioned randomization,but the specific random method was unclear.All studies did not mention the allocation of hidden implementations.In addition,only Wang's study [14]reported in detail the shedding of the two groups of patients.

3.2 Pilates exercise can improve balance function of stroke patients

Balance refers to the ability to maintain position,adjust and maintain posture and gait when the body is in different states or positions [18].Balance disorder is one of the most common dysfunctions in stroke patients.About 75% of stroke patients will experience balance dysfunction,which is a key issue that hinders patients from returning to family and society [5,13,19].It is characterized by short supporting time and differences between two sides of the body and slow walking speed,which may increase the risk of sports fear and fall,reduce the self-confidence of patients'rehabilitation and seriously affect the quality of life of patients [20,21].This study shows that Pilates exercise can improve the balance ability of stroke patients,which is consistent with the conclusion of Shea [22].Pilates is a targeted training of the patient's core muscles,which can improve the control of the abdomen,back,pelvis and buttocks muscles,strengthen muscle strength and maintain the stability of the body,thus improving patients' imbalance [23].Exercise is a slow and long process.Therefore,medical staff should formulate individualized rehabilitation program for patients,teach them action essentials patiently,pay attention to the strengthening and repetition of patients,so that they can implement and persist in exercise as soon as possible,which can effectively improve the balance function of patients.

3.3 Pilates exercises can enhance the functional mobility and walking speed of stroke patients,but the effect of promoting lower limb function is uncertain

As medical technology advances,there is an increasing need for effective,low-cost programs to reduce deconditioning and improve mobility.Meta-analysis showed that Pilates combined with conventional rehabilitation measures can improve functional mobility and walking speed in stroke patients,similar to the results of Bulguroglu [24]in 38 patients with multiple sclerosis.Pilates rehabilitation exercise can improve the function of the ankle joint-related muscle group in stroke patients,enhance the patient's balance ability,and thus make it stand up,walk better and walk faster [25].In addition,Pilates exercise can improve the heart and lung function and sleep quality of patients,increase the patient's walking endurance and relieve fatigue,which may be help to their mobility and walking speed [24,26,27].Therefore,it is suggested that nurses distribute and explain scientific,pertinent and interesting educational materials to improve the awareness of stroke patients about Pilates exercise in order to encourage them to participate in Pilates exercise voluntarily and actively.Besides,nurses can organize patients to participate in Pilates exercise together.Exchanging with each other can help patients improve their enthusiasm and confidence and strengthen exercise.Standing and walking function of patients is the focus of rehabilitation training,but in this process,we should also focus on assessing whether patients have falls to ensure patient safety.However,the results of this study indicate that Pilates exercise can' t effectively improve the overall function of lower limbs in stroke patients,which may be related to the less included studies and the different time,frequency and intensity of Pilates in each study.In the future,relevant studies should be carried out to further verify the effect of Pilates exercise in stroke patients.

4 Conclusion

The findings suggest that Pilates could improve the balance and walking speed of stroke patients.However,there still is the lack of the evidence in improving lower limb function.Due to the limitation of the quality of the included studies.high-quality studies still should be conducted to investigate the effect of Pilates exercise in stroke patients.

Authors' contributions

Ya-Nan Leng conceived and designed this experiment.Min Zhang and Yu-Qi Li performed the search.Ting-Ting Liu and Min Zhang analyzed the data.Xiao-Li Pang recheck the data and results.Ya-Nan Leng wrote the paper.All authors offer to help when submitting materials.