|Year : 2019 | Volume
| Issue : 2 | Page : 79-88
Comparative effect of mat pilates and egoscue exercises in asymptomatic individuals with lumbar hyperlordosis: A randomized controlled trial
Gayatri S Kudchadkar, Peeyoosha Gurudut, Aarti Welling
Department of Orthopedic Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India
|Date of Submission||20-May-2019|
|Date of Decision||08-Nov-2019|
|Date of Acceptance||10-Nov-2019|
|Date of Web Publication||23-Dec-2019|
Dr. Peeyoosha Gurudut
KAHER Institute of Physiotherapy, Belagavi, Karnataka
Source of Support: None, Conflict of Interest: None
Context: Correcting lumbar hyperlordosis, a main cause of back pain, will reduce the stress on the lumbar spine thereby preventing future problems in back and lower limb. Clinical trials are lacking where mat Pilates, Egoscue exercises and lumbar stabilization exercises are compared for their effect on spinal malalignment.
Aims: This study aims to compare the effectiveness of Pilates, Egoscue, and lumbar stabilization exercises for reducing hyperlordosis angle in asymptomatic individuals with lumbar hyperlordosis.
Settings and Study Design: A randomized controlled trial conducted on volunteer participants from Health Science University of Belagavi.
Materials and Methods: Asymptomatic individuals with lumbar hyperlordosis (n = 51) were randomly allocated to Pilates, Egoscue and Lumbar stabilization groups. Outcomes assessed were index of lumbar lordosis, pelvic tilt, and tolerance to exercise performance which was measured at baseline and after 4 weeks.
Results: There was significant reduction in the hyperlordosis score (P < 0.001) in the three study groups when compared for pre-and post-intervention scores. However, more reduction was seen in the Pilates and Egoscue groups compared to the lumbar stabilization. Pilates and Egoscue groups were equally effective in Lumbar lordosis angle (P = 0.68) and pelvic tilt (P = 0.51). Participants of Pilates group graded the exercises with superior tolerance to performance (P < 0.0006) than Egoscue and Lumbar stabilization.
Conclusion: Pilates group and Egoscue group were equally effective and superior to lumbar stabilization group in correction of hyperlordosis. Further, ease of performance of exercise was rated high for Pilates than the Egoscue exercise. These exercises should be included by the clinicians in preventive or corrective rehabilitation towards spinal posture malalignments.
Keywords: Correction, Exercises, Hyperlordosis, Lumbar spine, Posture
|How to cite this article:|
Kudchadkar GS, Gurudut P, Welling A. Comparative effect of mat pilates and egoscue exercises in asymptomatic individuals with lumbar hyperlordosis: A randomized controlled trial. Indian J Phys Ther Res 2019;1:79-88
|How to cite this URL:|
Kudchadkar GS, Gurudut P, Welling A. Comparative effect of mat pilates and egoscue exercises in asymptomatic individuals with lumbar hyperlordosis: A randomized controlled trial. Indian J Phys Ther Res [serial online] 2019 [cited 2020 Sep 30];1:79-88. Available from: http://www.ijptr.org/text.asp?2019/1/2/79/273724
| Introduction|| |
The prevalence of low back pain (LBP) in India is found to be 6.2% in the general population and 90% in construction workers. It is estimated that 1 out of 25 people will leave their job due to LBP. Studies have shown that approximately 90.5% of people having LBP have alteration in the lumbar spine alignment. A study states that 70% of the population with LBP has postural deviations in spine changing the normal relationships between spine and pelvis.,
Maintenance of normal limits of lumbar lordosis is necessary for obtaining ideal posture. Lumbar hyperlordosis is an acquired disorder having increased concavity posteriorly that may be caused due to poor posture, inactivity, improper shoes, etc., This occurs to compensate the inclination of the sacrum to get back its upward orientation. Lumbar hyperlordosis is characterized by muscle imbalance with the tightness of back and hamstring muscles with weakness of abdominals.,,
According to Kendall's theory, exercises are the commonest method to correct abnormal posture, with stretching of shortened soft tissue structures and strengthening the weak musculature. Pilates exercises aim at promoting good posture by improving the strength and flexibility of the muscles around the lumbar spine. Various studies have shown its effectiveness in the management of lumbar hyperlordosis in the immediate postpartum period, LBP  and chronic mechanical neck pain. Lumbar stabilization exercises are motor control conventional exercises that provide internal stabilization at spine and trunk enhancing the control of the neuromuscular system, strength, and endurance., Literature has shown it to be effective in LBP, and in spinal and the pelvic pain.
A novel form of exercise known as the Egoscue exercises, was developed where focus was to target the musculoskeletal dysfunction with the theory to bring back the postural balance through corrective exercises. It is suggested to be effective in rectifying poor posture., To the best of our knowledge and literature search, only one study has been published to evaluate the efficacy of Egoscue exercises in chronic hip and knee pain and is found to be effective. However, no study has been done to see the effect of these exercises on spinal malalignment.
Further, there was paucity of literature where comparison was done between the Pilates and stabilization exercises on hyperlordosis correction. Hence, the present study was undertaken to compare the effects of the exercises on correction of lumbar lordosis. The aim of the study was to assess and compare the effectiveness of Mat Pilates, Egoscue exercises and Lumbar stabilization, in reduction of lumbar lordosis angle, anterior pelvic tilt and to see the tolerance to exercise performance (TTEP) in asymptomatic individuals with lumbar hyper-lordosis.
| Materials and Methods|| |
Study design and ethical consideration
The study was a parallel design randomized controlled trial conducted on volunteer participants from constituent colleges of Health Science University, Belagavi, Karnataka, India from April 2018 to March 2019. The study was approved by the Institutional Research and Ethics Committee (KIPT/183/14/05/18). The trial is registered with the Clinical Trial Registry-India (CTRI/2018/07/015086). All the individual participants in this study gave written informed consent.
Participants and randomization
All individuals with lumbar hyperlordosis were screened for inclusion and exclusion criteria. Individuals were informed about the aims and procedure of the study and were included if they had positive prone hip extension test, no physical complaints at spine, within the age group of 18–40 years, and anterior pelvic tilt angle of >13°. Individuals were excluded if they had any history of back injury, LBP having localized or radiating pain, undergone treatment for LBP in past 6 months, and practiced any kind of exercise or sports activity during last 6 months.
Sample size calculated was fifty-one (51), based on the previous literature considering effect size with α value 1.96 and β value 0.842. Allocation to the groups was done using lottery method. The subject randomly picked up the chit, with each number corresponding to the group. The individuals were subsequently allocated into three study groups, viz. Pilates, Egoscue, and Lumbar stabilization groups with 17 in each group [Figure 1].
Measurement of treatment outcomes
Degree of lumbar lordosis using index of lumbar lordosis
A 61 cm Surveyor's flexi curve was used. It was molded to the curve of the spine and traced on a paper to calculate the index of lordosis. Maximum width and the total length of the curve were measured. The formula used was θ° = 4 (arc tan [2H/L]), where L = vertical line joining the T12 and S2 vertebrae and H = maximum width that is the deepest part of the curvature [Figure 2]a.
|Figure 2: (a) Calculation of index of lumbar lordosis, (b) Measuring the pelvic tilt with the pelvic inclinometer|
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Percentage of lumbar lordosis using index of lumbar lordosis
Same instrument and procedure as used for the degree of the lumbar lordosis except for the formula used: IL = lumbar width/lumbar length × 100 [Figure 2]a.
Anterior pelvic tilt using pelvic inclinometer
The subject was asked to stand with the feet shoulder-width apart. Even pressure was applied to both the arms of the inclinometer at anterior superior iliac spine and posterior superior iliac spine, with a bubble in the center the reading was then measured in degrees [Figure 2]b.
Tolerance to exercise performance using Borg's scale
The scale consists of 6–20 scores on which the words are printed as “very very light” at 7 and “very very hard” at 19. In this scale 6 states no exertion and 20 states maximum exertion. This was done to guage the difficulty level of the exercises that were performed in each group and to find which exercises were graded with more ease of performance.
[Table 1] shows exercise and dosage including the progression for 3 study groups.
The common treatment given to the participants of the three study groups consisted of stretching exercises [Table 1]. The passive stretching was given to hamstring, ilipsoas, rectus femoris and tendo-achilles muscles bilaterally., Three stretches were given with each stretch was held for 30 s.
Pilates group (n = 17)
Individuals in this group received Mat Pilates exercises with each week having a different set of exercises [Table 1] and [Figure 3].,, Each exercise was performed for 5 times.
|Figure 3: (a) Pilates week 1 exercises (i) Hip release (ii) Spinal Rotation (iii) Cat stretch (iv) Neutral to imprint (v) Knee to chest (vi) Single knee extension (vii) Leg slides, (b) Pilates week 2 exercises (i) Bridging (ii) Spine twist (iii) Imprint table top position (iv) Imprint table top knee extension (v) Imprint table top touching floor (vi) Ab prep in table top position (vii) Ab prep (c) Pilates week 3 exercises (i) Half roll back (ii) Single leg extension (iii) Single leg stretch (iv) Leg circles (v) Pull up (vi) Pull up with extension (vii) Swimming extension, (d) Pilates week 4 exercises (i) Bridging on ball (ii) Double knee lift (iii) Upward dog (iv) Spine stretch forward (v) Shell stretch|
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Egoscue group (n = 17)
The Egoscue group received a total of 10 exercises which included static back alone and with breathing, abdominal contraction while in the static back position, abductor press, overhead extension, elbow curls on wall, static wall, upper spinal twist, pelvic tilts, supine groin progressive, and air bench exercises [Table 1] and [Figure 4].
|Figure 4: Egoscue exercises (a) Static back (b) Static back with abdominal contraction (c) Abductor press (d) Pelvic tilts (e) Static extension (f) Elbow curls (g) Air bench (h) Static wall (i) Overhead extension (j) Spinal twist (k) Supine groin progression|
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Lumbar stabilization group (n = 17)
The Lumbar stabilization group received stabilization exercises which included crook lying, crook lying with one leg extended and resting down on couch, prone lying with arms at the side and head turned to opposite side, quadruped position with head in neutral, supine lying with one knee flexed resting on couch and other knee flexed to be held without support, supine lying with both the legs extended and one leg raise, sitting on chair erect, plank position, sitting erect on Bobath ball [Table 1] and [Figure 5].
|Figure 5: Lumbar stabilization exercises (a) Crook lying (b) Supine lying with leg raise (c) Crook lying with Ext (d) Prone lying (e) Plank position (f) Quadripod position (g) Supine lying with one knee flexed (h) Sitting on Bobath (i) Sitting on chair|
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Exercises in all the three groups were done on alternate days for 3 times in a week for a period of 4 weeks with stretching prior to the exercises.
Statistical analysis was done using R software version 3.5.1 (2018, Vienna, Australia). Normality distribution was assessed using the Kruskal–Wallis test. Comparison between the groups was done using independent t-test/Mann–Whitney U-test and within the group with Paired t-test/Wilcoxon sign rank test. Comparison of the difference in pre-and post-between the groups is done by ANOVA. P < 0.05 was considered as statistically significant.
| Results|| |
[Table 2] provides details on the demographic profile and the baseline characteristics of participants.
|Table 2: Summary of the demographic data and the baseline characteristics|
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There was a statistically significant reduction in the mean of Index of lumbar lordosis (degree and percentage) and anterior pelvic tilt scores among all the three groups, when compared for pre-and post-intervention scores indicating improvement with all three forms of exercises. For TTEP in Pilates Group, the P value was significant (P < 0.0006); but the P value for Egoscue group and lumbar stabilization groups were 0.1559 and 0.7768, respectively, which was not statistically significant [Table 3].
Index of lumbar lordosis (degrees and percentage) and pelvic tilt for Pilates group (P < 0.0001) and Egoscue group (P < 0.0001) were significantly different from Lumbar stabilization group [Table 4]. However, there was no significant difference between Pilates group and Egoscue group (P = 0.68) in degrees, (P = 0.9361) for percentage and (P = 0.51) for pelvic tilt. The lumbar lordosis angle (degrees and percentage) and pelvic tilt reduced in all the 3 groups, but more reduction was seen in the Pilates group and Egoscue group when compared to the lumbar stabilization group.
|Table 4: Comparison of between group differences for all the outcome measures|
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For TTEP in Pilates group, the P value was (P < 0.0006) in the Pilates group. But the P value for Egoscue group and lumbar stabilization groups were 0.1559 and 0.7768 respectively which was not statistically significant [Table 3]. Ease of exercise performance was graded during the exercise and the individuals in Pilates group were able to tolerate the exercise better while Egoscue exercise group found the exercises to be difficult to perform whereas in lumbar stabilization group graded the exercises to be constant throughout the exercise time.
| Discussion|| |
The present randomized controlled trial was done to compare the effect of Pilates exercises, Egoscue exercises and lumbar stabilization exercises in individuals with lumbar hyperlordosis.
The result from the statistical analysis showed that the Pilates group and Egoscue group were better in the reduction of lumbar lordosis and anterior pelvic tilt as compared to lumbar stabilization group. Further individuals in the Pilates group reported better TTEP than the other groups.
Lumbar hyperlordosis could have been reduced with Pilates intervention due to the following reasons. Hyperlordosis is characterized by tightness of the lumbar multifidus, thoracolumbar fascia, erector spinae, rectus femoris and iliopsoas along with weakness of abdominal muscles, pelvic floor muscles and asymmetrical tension in lumbo pelvic region. Pilates exercises focus on core and breath control that activates local muscles especially the diaphragm, lumbar multifidus, pelvic floor muscle, transverse abdominal muscle, and the obliques. Another possible reason for the change in lumbar lordosis angle and the anterior pelvic tilt could be that Pilates exercises involve muscle conditioning that focuses on recruiting most abundantly used motor units. Type I fibers are recruited the most in day to day activities which are abundant in mitochondria, oxidative enzymes, and capillaries. Pilates exercise mainly focuses on Type I fibers, thereby improving the strength and endurance of these fibers at the lumbar spine. This improvement will enhance synchronous stimulation of these motor units conditioning the muscles that are responsible for maintaining lumbar lordosis.
A study was conducted by McNellis et al. to check the effectiveness of Pilates exercises on lumbar hyperlordosis. The findings of the study showed improvements in the lumbar hyperlordosis after 4 weeks. Another study was done to show the efficacy of Pilates exercises on lumbar hyperlordosis immediately after the postpartum period and found a significant decrease in lumbar hyperlordosis. Similar improvements in another study were noted after 8 weeks of Pilates exercises on lumbar lordosis correction. The findings of these studies were in accordance with the findings of the present study.
However, literature also shows studies with contradicting results using Pilates as an intervention for lumbar spine posture correction. Yi-lang et al. conducted a study where Pilates exercises were given in older adults. No significant change was seen in lumbar posture which was unexpected finding according to authors. The reason for no change in the lumbar angle was mentioned to be probably because individuals were not encouraged to maintain good posture while doing activities of daily living. However, present study showed positive results in which young participants were included as compared to the above-mentioned study where older adults formed the study population. Another study was done to see the effect of Pilates on spine posture. The change was seen in the thoracic curve and length of the spine while the minimal change was seen in lumbar lordosis and pelvic tilt. This insignificant improvement could be due to the fact that the exercises were performed only once in a week.
In the present study Pilates exercises also showed improvement in an anterior pelvic tilt. This could be due to the fact that Pilates exercises focus on posterior pelvic tilt. Posterior pelvic tilt has been promoted to cause co-contraction of the local stabilization musculature. This will recruit abdominal muscles thereby preventing excessive anterior pelvic tilt which will reduce the lumbar hyperlordosis. Habibi et al. stated that the weakness of anterior pelvic muscle causes an increase in lumbar lordosis. Secondly, hamstring muscle is connected to the pelvic bone. Changing the length of hamstring can change the position of pelvis thereby correcting and changing the spinal curvatures.
The main motive of the Egoscue Method is to apply corrective exercises to get the whole body or the spine closer to “ideal” posture which will help in reducing the pain. In the present study, the exercises selected were mainly focused on the lumbar and pelvic region. This might have corrected the posture at the lumbar spine and the pelvis in turn reducing the curvature of the lumbar spine and pelvic tilt. The exercises included have caused more of the posterior tilting at the pelvis than the anterior tilting. Egoscue exercises have stretched and strengthened the muscles effectively in order to correct the spine and the pelvis posture. They are majorly corrective exercises and the main focus of these exercises is that it corrects the whole body posture.
Literature suggests corrective exercises to improve posture positively and since Egoscue exercises are similar to corrective exercises it has also shown beneficial effect. A study was conducted by Yazidi et al. to see the effectiveness of corrective exercises on thoracic kyphosis and lumbar lordosis which showed significant improvements after 8 weeks. These results were similar to the present study as the corrective exercises focuses on the strengthening, endurance, and flexibility of the muscle which will accelerate the posture correction.
Till date, only one study has been published on Egoscue exercises. A study was conducted to see the effect of Egoscue exercises in hip and knee pain conducted for 2 weeks. Significant improvements in pain and function were seen. This change was due to the correction of the malaligned posture which will reduce the overuse or increases the activity of underused skeletal muscle to correct the muscle imbalance. Similar effect might have occurred in the present study as there was a change in lumbar spine posture.
Lumbar stabilization exercises are said to reduce the load on the spine and reduce the stress on the spinal structures. Stabilization exercises have been planned to improve the neuromuscular control system and perfect the dysfunction. Lumbar stabilization exercises help in enhancing motor units which are regulated by a large unit muscle system as well as the local muscular system. This helps in building up the postural control of the muscles of the trunk and abdominal.
In literature review done so far on the efficacy of lumbar stabilization exercises on the lumbar spinal curve shows contradictory results. A study was conducted to see the effect of abdominal strengthening on lumbar lordosis and pelvic tilt which did not show any change in lumbar lordosis angle, the reason could be that the protocol used mainly focused on abdominal muscle rather than focusing on trunk extensors and hip muscles to correct the imbalance. Another study was done to see the effectiveness of lumbar stabilization, Pilates exercises and dynamic strengthening exercises in LBP. The findings showed that lumbar stabilization was superior then Pilates and Dynamic strengthening exercise group. This indifference could be due to the fact that the outcome measures used were different in both the studies and the study population included was patients with LBP.
In one of the study, the authors have concluded that Pilates-based exercise program was feasible for the elder population. In present study Pilates exercises were progressed from simple form to advanced form across 4 weeks. Individuals in Egoscue exercise group found the exercises to be difficult to perform with more soreness due to longer and static hold time, however lumbar stabilization group graded the exercises to be constant throughout the exercise time, although the exercises were given in a progressive manner by increasing the number of repetitions.
This study had limitations like the follow up was not done to better understand the carryover effect and recurrence rate. Standard outcome measures like X-ray could have been used to measure the angle of lordosis. Other curvatures of the spine could have been assessed as change in one spinal curvature will change the curvature at the other spinal levels.
More studies using Egoscue exercises can be conducted on the different patient population. Electromyography can be used to study the muscle activity of abdominal and the trunk extensor muscles during the Egoscue exercise. Comparative study between older and younger individuals can be done for LBP or posture corrections using the same exercises.
| Conclusion|| |
Pilates exercises, Egoscue exercises, and Lumbar stabilization exercises for 4 weeks were all effective in reducing the lumbar hyperlordosis angle and anterior pelvic tilt. However, Pilates group and Egoscue group were found to be equally effective and superior to lumbar stabilization group. Further, ease of performance of exercise was rated highest for Pilates followed by lumbar stabilization which was followed by the Egoscue exercise.
Pilates and Egoscue exercises proved to be effective for lumbar hyperlordosis correction but Pilates was with lesser discomfort as compared to Egoscue. Hence, these exercises should be included by the clinicians or exercise therapist in preventive rehabilitation or corrective rehabilitation towards spinal posture malalignments.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We are grateful to the head of the institution for granting us permission to conduct the study and use the research related infrastructure. Our heartfelt thanks to the Health minds team for statistical analysis and helping us in writing the manuscript. We are thankful to all the individuals for participating in the study, without whom the study would not have been possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta S, Azhar M. LBA as an increasing health problem in India. Jk Sci 2016;18:172-5.
Guimond S, Massrieh W. Intricate correlation between body posture, personality trait and incidence of body pain: A cross-referential study report. PLoS One 2012;7:e37450.
Candotti CT, Noll M, Marchetti BV, Rosa BN, Medeiros MD, Vieira A, Loss JF. Prevalence of back pain, functional disability, and spinal postural changes. Fisioterapiaem Movimento 2015;28:711-22.
Kroll PG, Arnofsky S, Leeds S, Peckham D, Rabinowitz A. The relationship between lumbar lordosis and pelvic tilt angle. J Back Musculoskelet Rehabil 2000;14:21-5.
Song MY, Chung WS, Kim SS, Shin HD. Correlation between obesity and lumbar lordosis in obese pre-menupausal Korean females. J Korean Orient Med 2004;25:43-50.
Serola Richard J. Device and method for reducing lumbar lordosis while supine and supporting the lumbar curve when seated. Honolulu, HI: United States Patent US; 1993. p. 5201761.
Samira MS, Laleh B. The impact of 8-week selected Pilates exercises on lordosis correction and BMI in female teens aged 15-18. Biol Forum Int Joint 2015;7:1267-71.
Yazidi AG, Mohammadi M. The effect of corrective exercises on the thoracic kyphosis and lumbar lordosis of boy students. Turkish J Sport Exerc 2017;19:177-81.
Mahdavinejad R, Rezaei SS. Pilate's selected exercises effects on women's lumbar hyperlordosis in immediate post-partum period. Asian J Multidiscip Stud 2014;2:48-53.
Levine D, Walker JR, Tillman LJ. The effect of abdominal muscle strengthening on pelvic tilt and lumbar lordosis. Phys Ther Pract 1997;13:217-26.
Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles: Testing and Function, with Posture and Pain (Kendall, Muscles). Philadelphia: Lippincott Williams and Wilkins; 2005.
Muscolino JE, Cipriani S. Pilates and the powerhouse–I. J Bodyw Mov Ther 2004;8:15-24.
Stolze LR, Allison SC, Childs JD. Derivation of a preliminary clinical prediction rule for identifying a subgroup of patients with low back pain likely to benefit from Pilates-based exercise. J Orthop Sports Phys Ther 2012;42:425-36.
de Araujo Cazotti L, Jones A, Roger-Silva D, Ribeiro LHC, Natour J. Effectiveness of the Pilates Method in the Treatment of Chronic Mechanical Neck Pain: A randomized controlled trial. Arch Phys Med Rehabil 2018;99:1740-6.
Cynn HS, Oh JS, Kwon OY, Yi CH. Effects of lumbar stabilization using a pressure biofeedback unit on muscle activity and lateral pelvic tilt during hip abduction in sidelying. Arch Phys Med Rehabil 2006;87:1454-8.
Bhadauria EA, Gurudut P. Comparative effectiveness of lumbar stabilization, dynamic strengthening, and Pilates on chronic low back pain: Randomized clinical trial. J Exerc Rehabil 2017;13:477-85.
Stanford ME. Effectiveness of specific lumbar stabilization exercises: A single case study. J Man Manipulative Ther 2002;10:40-6.
Ferreira PH, Ferreira ML, Maher CG, Herbert RD, Refshauge K. Specific stabilisation exercise for spinal and pelvic pain: A systematic review. Aust J Physiother 2006;52:79-88.
Egoscue P, Gittines R. Pain Free: A Revolutionary Method for Stopping Chronic Pain. Bantam; 2000. p. 90-105.
Egoscue P, Gittines R. The Egoscue Method of Health Through Motion. William Morrow Paperbacks; 1993.
Zachary V. “The Effect of Egoscue Corrective Exercises on Chronic Knee and Hip Pain”. Brigham Young University - Provo. All Theses and Dissertations 2014:5280.
Murphy DR, Byfield D, McCarthy P, Humphreys K, Gregory AA, Rochon R. Interexaminer reliability of the hip extension test for suspected impaired motor control of the lumbar spine. J Manipulative Physiol Ther 2006;29:374-7.
Preece SJ, Willan P, Nester CJ, Graham-Smith P, Herrington L, Bowker P. Variation in pelvic morphology may prevent the identification of anterior pelvic tilt. J Man Manip Ther 2008;16:113-7.
Seidi F, Rajabi R, Ebrahimi TI, Tavanai AR, Moussavi SJ. The Iranian flexible ruler reliability and validity in lumbar lordosis measurements. World J Sport Sci 2009;2:95-9.
Hinman MR. Interrater reliability of flexicurve postural measures among novice users. J Back Musculoskeletal Rehabil 2004;17:33-6.
Alviso DJ, Dong GT, Lentell GL. Intertester reliability for measuring pelvic tilt in standing. Phys Ther 1988;68:1347-51.
Ritchie C. Rating of perceived exertion (RPE). J Physiother 2012;58:62.
Covert CA, Alexander MP, Petronis JJ, Davis DS. Comparison of ballistic and static stretching on hamstring muscle length using an equal stretching dose. J Strength Cond Res 2010;24:3008-14.
Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques: Stretching for Impaired Mobility. 6th
ed. Phildelphia: F.A. Davis Company; 2012. p. 108-12.
McNellis JL. The Effect of the Pilates Training Program as a Therapeutic Intervention for Lumbar Hyperlordosis in Asymptomatic men and Women. Southern Connecticut state university: Proquest, Umi Dissertation Publishing; 2013.
Kuo YL, Tully EA, Galea MP. Sagittal spinal posture after Pilates-based exercise in healthy older adults. Spine (Phila Pa 1976) 2009;34:1046-51.
Schroeder J, Grenz K, Schaar H, Liebig M, Braumann KM. Pilates can affect sagittal spinal alignment: An observational study. J Spine 2014;3:1-5.
El-Hamalawy FA. A newly developed exercise program for treatment of mechanical low back pain associated with accentuated lumbar lordosis. J Am Sci 2011;7:58-70.
Manshouri M, Rahnama N. Effects of swimming technique backstroke on lumbar lordosis and BMI in females. Int J Sports Sci 2014;4:115-20.
Wells C, Kolt GS, Marshall P, Bialocerkowski A. Indications, benefits, and risks of Pilates exercise for people with chronic low back pain: A Delphi survey of Pilates-trained physical therapists. Phys Ther 2014;94:806-17.
Cho I, Jeon C, Lee S, Lee D, Hwangbo G. Effects of lumbar stabilization exercise on functional disability and lumbar lordosis angle in patients with chronic low back pain. J Phys Ther Sci 2015;27:1983-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]