during middle age , women enter a stage of physiological aging , experiencing changes such as 
 decreased muscle strength and mass , with increased body fat1 . following hormonal changes due to aging and menostasia
, problems 
 can occur not only in the cardiovascular and genitourinary systems but also in the 
 musculoskeletal system .
the physical , psychological , and mental factors of middle age 
 directly and indirectly affect the quality of life in old age .
thus , there is a need to develop and promote interventions that 
 improve physical capacity and , consequently , the quality of life in elderly populations3 . pilates appeals to women as a mainstream form of exercise4 for improving physical health ( muscular strength , endurance , core 
 stability , and breathing ) and motor function ( muscle control , dynamic postural control , 
 balance , and coordination)5 , 6 .
currently , the pilates method is widely applied in 
 physiotherapy for flexibility training , stimulation of blood circulation , improvement of 
 postural alignment , and body awareness7 . 
 in particular ,
as pilates focuses on strengthening the abdominal region , the lumbar region , 
 and the thighs so that they are strong enough to sufficiently support the spine , it is known 
 to be appropriate for women past middle age who can not perform difficult exercise8 .
pilates exercise has been introduced in 
 korea , but with the heavy emphasis on its aesthetic aspects , it is commonly believed that 
 pilates is simply an exercise for weight loss , and it is not well known that it can improve 
 physical structures , muscle mobilization , and postural alignment8 .
this study attempted to examine whether pilates is an effective exercise for improving the 
 postural alignment and health of middle - aged women .
the subjects of this study included 20 middle - aged women who were taking pilates classes at 
 the pilates center , located in gyeongju , republic of korea , and a control group of 20 
 middle - aged women with no previous experience with this type of exercise .
the control group 
 did not participate in any specific exercise program in daily life , and those who joined 
 certain exercise programs during the research period were excluded from the sample . however , 
 strolling or stretching in daily life
the subjects were members of a 
 community culture center and either participated in the pilates program or in the general 
 cultural program . the study objectives and procedures
the ethics committee of kangwon national 
 university s institutional review board approved the study ( kwnuirb-2014 - 09 - 004 ) .
those with neurologic or cardiovascular disease or previous experience with pilates were 
 excluded from the sample . based on similar previous studies ,
each group had a standard 
 sample size of 20 , with a total of 23 subjects collected for the experimental group and 20 
 in the control group .
those in the experimental group who did not participate in the 
 exercise sessions more than three times during the total period of 12 weeks were excluded 
 from the results analysis , which resulted in there ultimately being 20 subjects in the 
 experimental group .
participants in the control group who participated in other exercise 
 programs or experienced any significant changes during the research period were excluded , so 
 ultimately 16 control subjects were included in the final results analysis .
for the pilates program , exercises that included warm - up and stretching were performed .
the 
 warm - up exercises were performed for approximately 1015 minutes , the main exercises were 
 done for approximately 2040 minutes depending on the exercises performed , and the wrap - up 
 exercises were done for approximately 1015 minutes .
the 12-week period was divided into the 
 adaptive period ( weeks 13 ) , the development period ( weeks 410 ) , and the maintenance period 
 ( weeks 1112 ) .
the intensity of the pilates exercises was controlled at level 11 on the 
 rating of perceived exertion ( rpe ) scale and at a percentage of maximal heart rate ( % hrmax ) 
 of 40% .
body and balance measurements before and after applying the pilates exercise program were 
 performed with a body composition analyzer ( x - scan plus ii ) and a three - dimensional ( 3d ) 
 scanner .
the body composition analyzer can assess not only weight , bmi , body fat , and muscle 
 mass but also obesity in the abdominal region and muscle development according to body part . 
 for the body composition measurements , the subjects held electrode handles in both hands in 
 a vertical position with their socks off and maintained the correct posture for 
 approximately one minute .
the 3d scanning of the subjects was done using a whole - body 
 scanner ( model wb4 , cyberware , monterey , ca , usa ) . on 3d scanning of the body ,
a scoliosis 
 analysis ( medicube ) , a body mass and surface analysis ( volume and surface 
 report ) , and diverse skeletal muscle angle analyses ( lateral , hip , and knee views ) were 
 performed .
the 3d scanner consists of four vertical axes , each of which have two ccd 
 cameras .
as the cameras move from the head to the toes of the subject , information about the 
 shape of the body is obtained , and the data , such as angles between each part of the body 
 and the surface mass , are computed with rapidform software . during these measurements , the 
 subjects looked straight ahead in a standing position and maintained the correct posture 
 until the scanning was finished .
descriptive statistics were used for the physical characteristics of the groups and the 
 measurement data .
a paired - sample t - test was conducted to examine the difference between 
 before and after the pilates program .
the statistical significance level for the 
 measured values was set at p < 0.05 , and the data were statistically processed using ibm 
 spss statistics version 20.0 .
this study examined the degree to which a pilates exercise program can improve the postural 
 alignment and composion of middle - aged women .
markers were used to measure the body as 
 follows , a is the out ear ; b is the acromion process ; c is the great trochanter , d is the 
 fibula head and d is the lateral malleolus .
postural alignment and body composition changes in an ordinary - routine group and a pilates 
 exercise group were examined and compared ( table 
 1table 1.changes in postural alignment and balance before and after the exercise 
 programordinary - routine grouppilates groupbeforeafterbeforeaftervariablesm  sdm  sdheight ( cm)159.82  4.87 159.81  4.85 157.56  3.77 158.13  3.85**weight ( kg)57.69  6.33 57.71  6.25 57.62  7.13 57.04  7.47 * muscle mass ( kg)37.72  3.12 37.71  3.13 36.50  2.67 36.95  2.74 * * body - fat mass ( kg)16.81  3.59 16.84  3.6217.81  4.55 17.02
 4.76**waist - hip ratio0.87  0.06 0.88  0.05 0.89  0.03 0.88  0.04 * balance left33.05  14.98 33.06  14.95 30.03  4.37 29.12  3.88*balance right27.93  3.52 27.99  3.40 27.60  3.57 27.86  4.20 ab3.37  2.27 3.38  2.28 4.71  2.95 2.53  3.79*bc1.19  1.00 1.19  0.98 1.24  0.62 0.82  0.94 cd1.39  1.08 1.38  1.09 1.82  1.53 0.84  1.00 * * de1.43  1.26 1.44  1.24 1.60  1.14 0.98  0.87 * abc4.38  3.17 4.41  3.11 5.62  3.05 2.54  3.57**bcd2.07  2.07 2.09  2.04 2.51  1.62 1.52  1.24 * * cde3.00  2.75 3.02  2.71 2.99  1.92 1.74  1.85 * * pelvic angle3.17  2.69 3.19  2.67 3.27  1.76 2.22  1.87 * * shoulder tilt0.97  0.75 0.97  0.75 1.66  1.22 1.13  0.89 * * scoliosis1.39  0.82 1.35  0.81 2.47  1.67 1.40  1.12***p<0.05 ; * * p<0.01 .
m  sd : mean  standard deviation ; ab : distance out ear and 
 acromion process ; bc : distance acromion process and great trochanter ; cd : distance 
 great trochanter and fibula head ; de : distance fibula head and lateral malleolus ; 
 abc : angle 
 abc ; bcd : 
 angle bcd ; cde : 
 angle cde ) . in the ordinary - routine group ,
no variables showed statistically significant 
 differences between before and after the study period . in the pilates group ,
all variables 
 showed statistically significant differences during this period , except for right balance 
 and from the acromion process to the great trochanter .
height increased and body fat 
 decreased in the pilates group . with regard to balance
, the bias toward the left side 
 decreased , while the pelvic angle and angle of connecting both shoulder tilt decreased . 

therefore , it can be said that the postural alignment in the sagittal and horizontal planes 
 was enhanced in the pilates exercise group .
m  sd : mean  standard deviation ; ab : distance out ear and 
 acromion process ; bc : distance acromion process and great trochanter ; cd : distance 
 great trochanter and fibula head ; de : distance fibula head and lateral malleolus ; 
 abc : angle 
 abc ; bcd : 
 angle bcd ; cde : 
 angle cde correlations among the variables affecting body composition and postural alignment in the 
 pilates group were also investigated .
the left balance difference showed a positive 
 correlation with the body fat difference ( r=0.54 ) and a negative correlation with the right 
 balance difference ( r=0.79 ) .
this implies that body fat differences decreased and right 
 balance differences increased , with a smaller left balance difference .
the angle abc difference showed a positive correlation with muscle mass ( r=0.52 ) , body fat 
 difference ( r=0.45 ) , waist measurement difference ( r=0.54 ) , and angle difference between the 
 line connecting the internal ear to the acromion and a plumb line ( r=0.89 ) .
the angle bcd difference showed a negative correlation with the skeletal muscle difference 
 ( r=0.51 ) and a positive correlation with the angle difference between the line connecting 
 the acromion to the greater trochanter and aplumb line ( r=0.51 ) .
the the acromion process , 
 great trochanter , fibula head angle difference also showed a positive correlation with the 
 difference between the line connecting the fibular head to the lateral epicondyle and a 
 plumb line ( r=0.47 ) .
the angle cde difference showed a positive correlation with the angle difference between 
 the line connecting the acromion to the greater trochanter and a plumb line ( r=0.49 ) and 
 with the angle difference between the line connecting the fibular head to the lateral 
 epicondyle and a plumb line ( r=0.66 ) .
the difference in shoulder tilt that connects the acromion on both sides showed a negative 
 correlation with skeletal muscle ( r=0.54 ) and a positive correlation with the angle 
 difference between the line connecting the greater trochanter to the fibular head and a 
 plumb line ( r=0.53 ) .
the scoliosis difference showed a positive correlation with the 
 waist - hip ratio difference ( r=0.46 ) .
therefore , variables indicating trunk postural 
 alignment showed correlations with body fat and muscle mass ( table 2table 2.correlations among variables in the pilates exercise groupabcdefghijklmnopf0.290.270.540.110.211g0.090.140.080.250.230.791h0.520.150.450.440.540.130.261i0.290.080.260.460.450.090.440.651l0.540.150.490.260.400.170.180.890.360.100.371m0.110.510.390.010.190.170.090.290.240.510.470.121n0.030.030.020.130.200.210.310.140.490.350.660.050.321o0.170.540.060.060.060.120.140.320.210.560.140.390.530.191p0.040.120.230.460.310.080.280.250.270.300.300.170.030.180.171*p<0.05 ; * * p<0.01 . a : muscle mass difference ; b : skeletal muscle difference ; 
 c : body fat difference ; d : waist - hip ratio difference ; e : waist measurement 
 difference ; f : left balance difference ; g : right balance difference ; h : angle 
 difference between the line connecting the outer ear to the acromion and plumb line ; 
 i : angle difference between the line connecting the acromion to the greater 
 trochanter and plumb line ; j : angle difference between the line connecting the 
 greater trochanter to the fibular head and plumb line ; k : difference between the 
 line connecting the fibular head to the lateral malleolus and plumb line ; l : 
 abc angle 
 difference ; m : bcd angle difference ; n : cde angle difference ; o : shoulder - tilt angle 
 difference ; p : scoliosis difference ) . * p<0.05 ; * * p<0.01 .
a : muscle mass difference ; b : skeletal muscle difference ; 
 c : body fat difference ; d : waist - hip ratio difference ; e : waist measurement 
 difference ; f : left balance difference ; g : right balance difference ; h : angle 
 difference between the line connecting the outer ear to the acromion and plumb line ; 
 i : angle difference between the line connecting the acromion to the greater 
 trochanter and plumb line ; j : angle difference between the line connecting the 
 greater trochanter to the fibular head and plumb line ; k : difference between the 
 line connecting the fibular head to the lateral malleolus and plumb line ; l : 
 abc angle 
 difference ; m : bcd angle difference ; n : cde angle difference ; o : shoulder - tilt angle 
 difference ; p : scoliosis difference
this study attempted to examine how pilates exercise can improve the postural alignment and 
 body composition of middle - aged women .
pilates makes use of minor muscles that are not 
 frequently used in daily activities , without implementing running or large movements of the 
 body .
it is an exercise that can enhance body function and muscle strength , while addressing 
 incorrect posture , fatigue , muscle pain , low back pain , shoulder and neck pain , and 
 stress9 .
denise et al . argued that 
 pilates enhances the stability of the trunk , as it affects the joint contractions of 
 antagonistic muscles9 . in this study ,
the 
 pilates exercise group showed better postural arrangement on the sagittal and horizontal 
 planes , increased muscle mass , and decreased body fat in the abdominal region .
moreover , the 
 results indicated that problems with trunk postural alignment are closely related to 
 skeletal muscle and body fat . hence , proper muscle mass is one of the important factors for 
 trunk postural alignment .
ju et al.10 
 reported in their study on elderly people that a group that performed pilates showed 
 increased walking speed compared with a group that performed exercises on unstable ground . 

positive effects on chronic low back pain and balance among working women were also 
 confirmed11 . moreover , pilates results 
 in improved muscle strength and balance of the lower limbs , as well as improved quality of 
 life12 .
pilates exercise , which was 
 created by joseph pilates , is a form of exercise that relaxes body tension and strengthens 
 deep muscles by using the body weight of the participant .
this kind of pilates program is 
 known to be useful in enhancing lower limb function in stroke patients13 .
in korea , pilates began to receive attention after a 
 female celebrity released a fitness video using this technique .
however , this has caused 
 pilates to be known in korea as an exercise with aesthetic purposes .
however , as studies on 
 diverse age groups with various purposes continue to be performed , pilates is now becoming 
 known as an effective and moderate from of exercise .
the present study confirms that pilates has a positive impact on trunk postural alignment 
 in middle - aged women , which can be attributed to the fact that pilates exercises are 
 performed symmetrically and strengthen the deep muscles .
moreover , the results showed that 
 muscle mass was correlated with trunk postural alignment , and that the amount of body fat 
 had a negative correlation with balance , indicating that the proper amount of muscle is 
 critical in maintaining trunk postural alignment .
the actions of the muscles should come 
 first in order to maintain the skeletal form and the postural alignment , not only on the 
 left and right , but also at the front and back .
 [ purpose ] this study attempted to examine whether pilates is an effective exercise for 
 improving the postural alignment and health of middle - aged women . [ subjects and methods ] 
 the participants in this study were 36 middle - aged women ( 20 in the experimental group , 16 
 in the control group ) . 
 the experimental group participated in pilates exercise sessions 
 three times a week for 12 weeks . 
 body alignment and composition measurements before and 
 after applying the pilates exercise program were performed with a body composition 
 analyzer and a three - dimensional scanner . 
 [ results ] postural alignment in the sagittal and 
 horizontal planes was enhanced in the pilates exercise group . 
 trunk alignment showed 
 correlations with body fat and muscle mass . 
 [ conclusion ] the pilates exercises are 
 performed symmetrically and strengthen the deep muscles . 
 moreover , the results showed that 
 muscle mass was correlated with trunk postural alignment and that the proper amount of 
 muscle is critical in maintaining trunk postural alignment . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION