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Pilates for Falls Prevention and Balance in Older Adults

Original Editor - Shailly Yadav

Top Contributors - Shailly Yadav, Vidya Acharya and Alexandra Stead  

Introduction

Pilates has moved from a niche studio-based practice, into an increasingly researched exercise modality within geriatric rehabilitation, reflected in a growing number of systematic reviews and meta-analyses of balance and fall risk in older adults published in the recent years.[1][2][3][4] This has largely superseded the earlier, smaller reviews on which much of the original clinical interest was built.[5]

Within exercise-based rehabilitation, Pilates sits alongside the Otago Exercise Programme and conventional balance training as a lower-limb and trunk-focused option that can be delivered on a mat or with specialist equipment, in groups or individually, and adapted across a wide range of physical ability.[2][6] [7] Its appeal for clinicians lies in this adaptability and in a growing, evidence-supported rationale for its use.

The epidemiology, multifactorial risk assessment, and general exercise-based management of falls in older adults are covered on Physiopedia's broader falls prevention pages. This page examines the benefits of Pilates, identifies the target populations, and outlines recommendations for its implementation in clinical practice.

Rationale for Pilates in Balance Training

Pilates is a low-impact exercise method, originally developed for rehabilitation, built around controlled, precise movements performed with conscious attention to alignment, breath, and core engagement. It can be practised on a mat or using specialist apparatus (e.g. the reformer), and sessions are typically structured around a defined repertoire of exercises rather than free-form movement.[1][5]

Pilates is built around six foundational principles - centring, concentration, control, precision, flow, and breathing. These principles underpin the exercise selection, cueing, and progression described in this page.[8]

Two features of the method stand out as relevant to postural control, distinguishing it from purely strength-based resistance training:

  • Core and trunk stability directed at postural response: Pilates emphasis on deep trunk stabilisers works alongside anticipatory postural adjustments that control the trunk and pelvis during functional movement, which is directly relevant to recovery from a trip or stumble.[8]
  • Body awareness and proprioceptive training: The method's continuous attention to alignment and conscious control of position targets the sensory component of postural control. A 2024 comparative trial found that Pilates training improved wrist joint position sense alongside gait and balance measures, supporting a genuine proprioceptive training effect rather than a strength effect alone.[9]

Mechanisms Behind Balance Improvement

The balance benefits associated with Pilates are thought to arise from several interacting mechanisms rather than a single pathway.[8][9] These are summarised below, alongside their proposed functional relevance.

Mechanism Proposed effect
Neuromuscular and sensorimotor adaptation Repeated, precise, low-load movement reinforces joint position sense and postural correction strategies. [9]
Core activation and postural control Strengthening deep stabilising trunk muscles is theorised to improve rapid postural adjustment in response to external perturbation.[8]
Lower limb strength and dynamic stability Gains in lower limb strength and functional reach contribute to dynamic stability during gait, transfers and stair negotiation.[2][9]
Functional relevance Sensorimotor/core control supports gait and turning; postural alignment training supports transfers and reaching; strength gains support stair negotiation and sit-to-stand.[2][8]


Clinically, this suggests Pilates is best framed as a sensorimotor and postural-control intervention with a secondary strength component, rather than a strength intervention alone.

Indications

Pilates-based rehabilitation is not indicated uniformly across all older adults with, or at risk of, falls. Indication depends on baseline function, comorbidity, and the specific fall-risk factor being targeted.

Intended Population

Pilates suitability varies by baseline function and the specific fall-risk factor being targeted, rather than applying uniformly across all older adults. The table below summarises the current indication-level evidence by population group.

Population Indication notes
Healthy community-dwelling older adults The bulk of the falls-specific evidence sits here. The largest and most recent reviews support moderate, fairly consistent balance and functional gains. [1][3][4]
Older adults with reduced functional reserve (advanced age, lower baseline mobility) A 2024 comparative trial in adults with a mean age of 78 found meaningful gains in gait speed, functional reach and sit-to-stand performance after only 6 weeks of twice-weekly Pilates, suggesting benefit extends beyond the “healthy, younger-old” population typically studied.[9]
Neurological conditions (Parkinson's disease, stroke, multiple sclerosis) Neuropilates : Reported safe and beneficial for balance in mild-to-moderate Parkinson's disease;[10] balance improvement after stroke is supported by moderate-certainty evidence from a pooled analysis of 5 RCTs;[11] MS-specific balance gains are supported by a 2022 meta-analysis.[12] None of these reviews report fall-incidence data specifically, a gap even in these well-studied populations.
Frailty and reduced mobility Direct trials in frail or institutionalised populations remain scarce and reviews on this group still draw largely on broader multicomponent exercise evidence.[4]
Fear of falling without frank balance impairment One of the more consistently responsive indications for Pilates, reported in healthy older adults and other at-risk groups, with one meta-analysis reporting a large, statistically significant reduction in fear-of-falling scores.[2]

Pre-Pilates Screening Criteria

Pre-exercise screening should follow a risk-stratified approach rather than a uniform checklist, per current falls-prevention exercise prescription guidance.[13]

  • Baseline balance assessment (e.g. Berg Balance Scale, Timed Up and Go)
  • Functional mobility and transfer ability
  • Bone health history, particularly vertebral fracture risk in suspected or confirmed osteoporosis[14]
  • Cognitive screening where dual-tasking or multi-step instruction may be a barrier[13]
  • Cardiovascular and orthopaedic contraindications to floor-based or equipment-based exercise, with medical clearance guided by exercise intensity and apparent health status rather than age alone[13]

Clinical Implementation

Pilates Programme Characteristics

Reported Pilates programme characteristics vary considerably across trials, which limits the ability to draw firm dose-response conclusions.[1][5] Based on recurring patterns across the evidence, the following characteristics are recommended when designing a falls-focused Pilates programme:

  • Delivery format: Favour mat-based Pilates, with resistance bands or small equipment as needed. Most trial evidence sits here; reformer/apparatus-based Pilates is comparatively under-researched in older adults and should be used with the same caution as any less-studied modality.[5]
  • Supervision: Deliver via a certified instructor using a detailed, structured protocol rather than an unstructured class, this is associated with more consistent effect sizes.[1]
  • Session duration and frequency: Plan for 40–60 minute sessions, two to three times weekly. Programmes of 5–6 weeks can produce measurable gains even in adults in their late 70s;[9] longer programmes (up to 24 weeks) with standing balance work and a home component have been used where fall-injury outcomes are the target.[2]
  • Progression: Progress difficulty via reduced base of support, added instability (foam, unstable surfaces) and increasing precision demands, rather than simply increasing repetitions.[5]

Programmes that combine supervision, a structured protocol, and balance-specific progression are more likely to produce consistent effects than an unstructured or generic Pilates class.[1][5]

Exercise selection

Exercise choice should be matched to the impairment being targeted rather than applied as a generic Pilates class. The following selections reflect movements used in a published mat-based Pilates programme for community-dwelling seniors targeting core strength and balance:[15]

  • Bridging (pelvic curls): targets posterior chain and pelvic control relevant to sit-to-stand and gait[15]
  • Dead bug (opposite arm/leg lifting): trains anti-rotation trunk control relevant to reaching and turning tasks[15]
  • Side leg series (sidekicks, half clams): targets hip abductor strength, relevant to mediolateral stability[15]
  • Spine mobility work (spinal twist, chest lifts): addresses postural stiffness that shifts centre of mass[15]
  • Standing balance progressions: directly transfers to functional balance tasks[5]
  • Functional transitions (sit-to-stand, floor-to-stand where appropriate): bridges exercise gains to activities of daily living, and can be screened at baseline using tools such as the Sitting-Rising test[15]


[16]
[17]

[18]

Progression principles

Progression should follow recognised balance-training principles rather than Pilates convention alone: reducing base of support, altering visual input (eyes closed/altered gaze), introducing unstable surfaces, layering dual-task demands, and integrating movements into functional sequences.[19] To maximise effect on fall risk, exercise should be progressively challenging and delivered at a sufficient dose.[19] Benefits are not retained indefinitely, effects diminish once a programme is stopped, which has implications for long-term adherence planning.[19]

Safety considerations

Falls-focused Pilates carries specific safety considerations beyond standard exercise screening, particularly around positional transitions and spinal loading.[13][14] These should be addressed before and during programme delivery:

  • Supervision and, where balance is significantly impaired, hands-on spotting or nearby supports during standing or unstable-surface work[13]
  • Avoidance of end-range spinal flexion under load in osteoporosis, particularly with vertebral fracture history[14]
  • Monitoring for dizziness or orthostatic symptoms, particularly during transitions between positions[13]
  • Adapting pace and instruction complexity for frailty or cognitive impairment, and considering one-to-one delivery where group instruction is unsafe; safety strategies should be tailored to the individual's level of vulnerability rather than applied uniformly[13][19]

Current Research

Balance outcomes: Recent meta-analyses consistently report moderate improvements in balance following Pilates training, most reliably for dynamic and mediolateral balance rather than static or anteroposterior control.[1][3][4] Reported effect sizes(ES) are not straightforward to compare across reviews. Fernández-Rodríguez et al. report a moderate pooled effect on balance (SMD 0.36), distinct from their much larger effect size for fall risk specifically (0.90).[1] de Campos Júnior et al. and Sampaio et al. describe balance gains only in qualitative terms as small to moderate-or-large, depending on the balance domain, rather than a single pooled figure.[3][4] da Silva et al. report raw mean differences rather than a standardised ES.[2] Outcome measures also vary considerably across trials (Berg Balance Scale, Functional Reach Test, Timed Up and Go, force-platform sway, single-leg stance), further limiting direct comparison.[1][2][3][4]

Fear of falling: A 2021 systematic review specific to healthy older adults reported a significant reduction in fear of falling following Pilates, alongside improvements in mediolateral balance and mobility, when compared with control groups.[2]

Actual fall reduction: This is the area of clearest divergence in the evidence. An earlier, smaller meta-analysis reported a large effect on fall risk (ES 0.90), but rated this low-to-moderate certainty.[1] The largest and most recent review (39 studies, n=1,770) found no significant effect on the number of falls or fear of falling, despite confirming balance gains.[4]

Clinical Evidence Summary

Study Population Pilates programme Comparator Main outcomes Clinical message
Fernández-Rodríguez et al. 2021[1] Adults ≥60 years (39 RCTs) Mixed mat/equipment, varied dose Habitual activity/non-exercise Moderate effect on balance, strength, flexibility, functionality; large effect on falls (low-to-moderate certainty) Consistent multi-domain benefit; fall-reduction effect size large but low certainty
da Silva et al. 2021[2] Healthy older adults (12 RCTs, n=702) Various mat-based protocols Control and other exercise groups Improved mediolateral balance, functional reach, fear of falling; no significant gain in dynamic gait index or anteroposterior sway Benefits most consistent for mediolateral balance and fear of falling; not a uniform effect across all balance parameters
Sampaio et al. 2023[3] Older adults 15 analysed interventions Control/comparator groups ~53% of interventions improved static/dynamic balance significantly Robust but inconsistent effect across individual studies
de Campos Júnior et al. 2024[4] Older adults (39 studies, n=1,770) Heterogeneous protocols Various Moderate-to-large balance gains; no significant effect on falls or fear of falling The most recent and largest evidence to date: balance improvement does not necessarily translate into fewer falls
Patti et al. 2021[20] Older adults (n=41) Pilates vs general physical activity programme General, non-specific physical activity Pilates group showed significantly greater improvement on Berg Balance Scale and posturography Structured, balance-specific Pilates may outperform generic exercise for balance-specific outcomes
Yoon & Yim 2024[9] Older adults (n=45, mean age 78) 6 weeks, 2x/week, 40-50 min, mat Pilates ± vibration adjunct Regular Pilates (active comparator) Improved gait velocity, cadence, functional reach, sit-to-stand, grip strength, wrist proprioception Demonstrates Pilates remains feasible and effective in an older, less robust population over a short protocol
Barker et al. 2015[5] Older adults (6 RCTs, pooled) Variable; mat and equipment-based Non-active control Improved balance (SMD 0.84); fall-incidence data drawn from a single trial The original foundational review; now superseded in scope by the larger analyses above and should be read as historical context rather than current-tier evidence


Clinically, the evidence for Pilates improving balance as a fall-risk factor is more consistent than the evidence for Pilates reducing actual fall events; clinicians should not conflate the two when counselling patients or writing referral justifications.

Pilates Compared with Other Exercise Approaches

Approach Balance evidence Fall-incidence evidence Notes
Pilates Moderate, fairly consistent, particularly dynamic and mediolateral balance Mixed; earlier estimates suggested a large effect, but the larger, more recent evidence found no significant effect Strong sensorimotor/core focus; equipment flexible; may outperform unstructured general exercise for balance-specific outcomes..[1][2][3][4][20]
Tai Chi Consistent improvements in Timed Up and Go, functional reach and other balance measures A 2023 meta-analysis of 24 RCTs found Tai Chi reduced fall risk (RR 0.76) and fall frequency, with effectiveness increasing with duration and frequency of practice Larger and more consistent fall-incidence evidence base than Pilates currently has.[21]
Conventional balance/multicomponent exercise Strong, well-established Strong, well-established; a Cochrane review of 108 RCTs found exercise reduces falls by around 23% Remains first-line where fall-incidence reduction is the primary treatment goal.[19]

Direct head-to-head trials comparing Pilates with Tai Chi and Otago in older adults are limited in number and generally small.[21] Where comparisons exist, Pilates tends to perform similarly to, rather than better than, other established exercise modalities, and reviewers have specifically cautioned against over-stating any superiority of Pilates given the current evidence base.[2][11] Pilates is more reasonably positioned as one option among several effective approaches, best selected on grounds of patient preference, adherence and access rather than assumed superior efficacy. See Physiopedia's dedicated [Exercise Programme|Otago Exercise Programme] page for full protocol detail, and [and Falls Prevention in Older Adults|Falls and Falls Prevention in Older Adults] for the broader multifactorial assessment and management context this page assumes.

Future Research Directions

  • Long-term follow-up beyond the immediate post-intervention period.[1][4]
  • Trials using actual fall incidence as a primary, adequately powered outcome.[5][4]
  • Standardised, replicable Pilates protocols to allow meaningful pooling across trials.[5][1]
  • Dose-response studies to clarify minimum effective frequency, intensity and duration.[5][2]
  • Adequately powered trials in frail, cognitively impaired, and institutionalised populations.[1][4]

Clinical Takeaways

  • Pilates shows the most consistent evidence for improving dynamic and mediolateral balance, with less consistent effects on static and anteroposterior balance.[2][3][4]
  • Benefits appear greatest when programmes are supervised, structured, and appropriately progressed in balance difficulty rather than simply repeated.[1]
  • Improvements in balance test scores do not reliably translate into a measured reduction in fall incidence; the largest and most recent review found no significant effect on falls despite confirming balance gains.[4]
  • Fear of falling is one of the more consistently responsive outcomes to Pilates across populations.[2]
  • Short, well-structured programmes (as few as 5-6 weeks, twice weekly) can produce measurable gains, including in older adults with reduced functional reserve.[9]
  • Pilates should be positioned as a complement to, not a replacement for, established multifactorial falls prevention strategies such as the Otago Exercise Programme.[19]
  • Evidence in frailty, cognitive impairment and advanced osteoporosis remains limited; extrapolate cautiously from healthy-older-adult data.[4]

Summary

Pilates has a growing evidence base supporting moderate improvements in balance, functional mobility, and fear of falling in older adults, underpinned by plausible sensorimotor, core-stability, and postural-control mechanisms.[1][2][3][4][8][9] As summarised in the Clinical Takeaways above, these gains are most consistent for dynamic and mediolateral balance, do not reliably translate into a measured reduction in fall incidence, and are best delivered as one option within a broader, multifactorial falls prevention strategy- selected on the basis of patient suitability, preference, and access, rather than as a stand-alone or superior alternative to established programmes such as the Otago Exercise Programme.[4][19] Further high-quality trials with fall incidence as a primary outcome are needed before stronger recommendations can be made.[4][5]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 Fernández-Rodríguez R, Álvarez-Bueno C, Ferri-Morales A, Torres-Costoso A, Pozuelo-Carrascosa DP, Martínez-Vizcaíno V. Pilates improves physical performance and decreases risk of falls in older adults: a systematic review and meta-analysis. Physiotherapy. 2021;112:163-177. doi:10.1016/j.physio.2021.05.008.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 Donatoni da Silva L, Shiel A, McIntosh C. Pilates reducing falls risk factors in healthy older adults: a systematic review and meta-analysis. Front Med (Lausanne). 2021;8:708883.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Sampaio T, Encarnação S, Santos O, Narciso D, Oliveira JP, Teixeira JE, Forte P, Morais JE, Vasques C, Monteiro AM. The Effectiveness of Pilates Training Interventions on Older Adults' Balance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Healthcare (Basel, Switzerland). 2023 Dec 1;11(23):3083. doi: 10.3390/healthcare11233083. PMID: 38063651; PMCID: PMC10706653.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 de Campos Júnior JF, de Oliveira LC, Dos Reis AL, de Almeida LIM, Branco LV, de Oliveira RG. Effects of Pilates exercises on postural balance and reduced risk of falls in older adults: A systematic review and meta-analysis. Complementary therapies in clinical practice. 2024 Nov;57:101888. doi: 10.1016/j.ctcp.2024.101888. Epub 2024 Jul 25. PMID: 39068875.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 Barker AL, Bird ML, Talevski J. Effect of pilates exercise for improving balance in older adults: a systematic review with meta-analysis - PubMed. Archives of physical medicine and rehabilitation. 2015 Apr;96(4):715-23. doi: 10.1016/j.apmr.2014.11.021. Epub 2014 Dec 12. PMID: 25511371.
  6. ↑ Kp N, D A, Nawed A, Nuhmani S, Khan M, Alghadir AH. Comparison of effects of Otago exercise program vs gaze stability exercise on balance and fear of fall in older adults: A randomized trial. Medicine (Baltimore). 2024 Jun 7;103(23):e38345. doi: 10.1097/MD.0000000000038345. PMID: 38847714; PMCID: PMC11155577.
  7. ↑ Moreno-Segura N, Igual-Camacho C, Ballester-Gil Y, Blasco-Igual MC, Blasco JM. The Effects of the Pilates Training Method on Balance and Falls of Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Journal of Aging and Physical Activity. 2018 Apr;26(2):327-344. DOI: 10.1123/japa.2017-0078. PMID: 28771109.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Geremia S, Sampaio J, Boppre G, Carvalho J, Pizarro A. Pilates in digital age: improving balance, core stability, and functional fitness in older adults. Journal of Bodywork and Movement Therapies,Volume 45,2025,Pages 529-535,ISSN 1360-8592,https://doi.org/10.1016/j.jbmt.2025.09.002.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 Yoon DY, Yim JE. Enhancing Balance and Strength in Older Adults: The Impact of Pilates and Vibro-Swing Exercises. Medical science monitor : international medical journal of experimental and clinical research. 2024;30:e945212.
  10. ↑ Çoban F, Belgen Kaygısız B, Selcuk F. Effect of clinical Pilates training on balance and postural control in patients with Parkinson's disease: a randomized controlled trial. Journal of Comparative Effectiveness Research. 2021 Dec;10(18):1373-1383. doi: 10.2217/cer-2021-0091. Epub 2021 Nov 2. PMID: 34726472.
  11. ↑ 11.0 11.1 Cronin E, Broderick P, Clark H, Monaghan K. What are the effects of pilates in the post stroke population? A systematic literature review & meta-analysis of randomised controlled trials. Journal of bodywork and movement therapies. 2023 Jan;33:223-232. doi: 10.1016/j.jbmt.2022.09.028. Epub 2022 Sep 29. PMID: 36775522.
  12. ↑ Arik MI, Kiloatar H, Saracoglu I. Do Pilates exercises improve balance in patients with multiple sclerosis? A systematic review and meta-analysis. Multiple sclerosis and related disorders. 2022;57:103410. 0
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Anne Tiedemann, Daina L. Sturnieks, Elissa Burton, Jeannette M. Thom, Stephen R. Lord, Stacey Scott, Catherine Sherrington, Exercise and Sports Science Australia updated position statement on exercise for preventing falls in older people living in the community,Journal of Science and Medicine in Sport,Volume 28, Issue 2,2025,Pages 87-94,ISSN 1440-2440,https://doi.org/10.1016/j.jsams.2024.09.003.
  14. ↑ 14.0 14.1 14.2 Oksuz S, Ünal E. The effect of the clinical Pilates exercises on kinesiophobia and other symptoms related to osteoporosis: randomised controlled trial. Complementary Therapies in Clinical Practice. 2017;26:68-72. doi:10.1016/j.ctcp.2016.12.001.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 Gonzales L, Ngo K, Kraus P, Zander Y, Hatch MN. Feasibility of a mat-based Pilates program for community dwelling seniors to improve balance and core strength. PM R. 2025;17(8):905-916. doi:10.1002/pmrj.13358.
  16. ↑ Rehab My Patient. Pilates Shoulder bridge Spine curls. Available from: https://www.youtube.com/watch?v=R1qxWNjcleU [last accessed 24/7/2026]
  17. ↑ Complete Pilates. How to do physio led Pilates exercises: Dead Bug. Available from:https://www.youtube.com/watch?v=qxY_0Wrkxw8 [last accessed 24/7/2026]
  18. ↑ The Girl With The Pilates Mat. Standing Pilates for Seniors- Warm-Up and Stretch. Available from: https://www.youtube.com/watch?v=fnQIe_hgleQ [last accessed 24/7/2026]
  19. ↑ 19.0 19.1 19.2 19.3 19.4 19.5 19.6 Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb SE. Exercise for preventing falls in older people living in the community. The Cochrane database of systematic reviews. 2019;1:CD012424.
  20. ↑ 20.0 20.1 Patti A, Bianco A, Karsten B, et al. Physical exercise and prevention of falls. Effects of a Pilates training method compared with a general physical activity program: A randomized controlled trial. Medicine (Baltimore). 2021;100(13):e25289.doi: 10.1097/MD.0000000000025289. PMID: 33787615; PMCID: PMC8021317.
  21. ↑ 21.0 21.1 Chen W, Li M, Li H, Lin Y, Feng Z. Tai Chi for fall prevention and balance improvement in older adults: a systematic review and meta-analysis of randomized controlled trials. Front Public Health. 2023;11:1236050.
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