Impact of Pilates Program Combined with Paced Breathing on Reducing Back Pain & Pelvic Pain and Enhancing Sleep Quality & Quality of life in Perimenopausal Women

INTRODUCTION

Perimenopause is the transitional phase ends up to menopause, the stage at which menstruation permanently stops. Women in this period commonly experience low back pain, which is a significant concern and is often linked with several other perimenopausal symptoms[Kozinoga M et al.,2015]

Women in the perimenopausal period may experience a wide spectrum of clinical manifestations. These commonly include Musculoskeletsl discomfort; back pain, pelvic pain and peripheral joint pain, hot flashes, night sweats, and persistent fatigue. Psychological such as irritability, anxiety, mood fluctuations, depression, and sleep disturbances are also frequently reported. These changes are largely attributed to the gradual decline in ovarian function and the associated reduction in estrogen levels. In particular, decreasing estrogen and fluctuating progesterone levels can directly affect the brain’s sleep–wake regulation and circadian rhythm, thereby contributing to sleep-related problems[Zeng W et al.,2025].  

Hormonal changes during the perimenopausal period can affect pelvic floor and musculoskeletal tissues, contributing to symptoms such as pelvic and back pain, urinary incontinence, pelvic organ prolapse, and joint discomfort, all of which may reduce quality of life [Australian Physiotherapy Association, 2024].

 back pain is highly prevalent worldwide and is influenced in women by anatomical, hormonal, and biomechanical factors. Fluctuations in estrogen and progesterone across life stages can alter bone integrity, collagen structure, and ligament stability, increasing susceptibility to lumbar instability and exacerbating musculoskeletal symptoms, particularly in women with pre-existing conditions [Rupali Milind Salvi et al., 2025].

Low estrogen levels during the perimenopausal and postmenopausal periods can lead to pelvic floor muscle (PFM) dysfunction and ligament weakening. The PFM, including the levator ani muscles, forms a supportive “hammock” for pelvic organs, aids in continence, sexual function, core stability, and venous return, and works with abdominal and back muscles to stabilize the trunk (Figure No-1.1). Declining estrogen can cause muscle and ligament atrophy, reduced blood supply, and mucosal degeneration, increasing the risk of pelvic organ prolapse and functional impairments [Zhuo Z et al., 2021 & Raizada V et al.,2008].

Figure No-1.1: The pelvic floor muscles form a supportive hammock at the base of pelvis, work in coordination with abdominal, back & diaphragm muscle to stabilize the trunk.

 There is a reciprocal relationship between female reproductive hormones and the circadian rhythm. The suprachiasmatic nucleus (SCN), which functions as the body’s central biological clock, regulates hypothalamic activity involved in the secretion of gonadotropin-releasing hormone. Melatonin also plays an important role, as it has been shown to exert a direct influence on female reproductive and sexual function. Conversely, fluctuations in female sex hormones can modify circadian regulation, further affecting sleep and physiological rhythms[Kyung Mee Park.,2024].

Human sleep is regulated through the interaction between homeostatic mechanisms and the circadian rhythm, which together control the sleep–wake cycle. Many vital physiological and metabolic processes in the body follow circadian regulation and operate with an approximately 24-hour rhythm. The suprachiasmatic nucleus (SCN) acts as the primary circadian pacemaker of the brain and is organized in a hierarchical, multi-oscillator system. The SCN communicates timing signals to peripheral clocks distributed across the cerebral cortex and throughout the body, thereby influencing a wide range of physiological functions and behavioral rhythms.[Reddy S et al.,2023].

A reduction in melatonin secretion and disturbances in circadian rhythm mechanisms can adversely affect sleep regulation.The gonadotropin-releasing hormone (GnRH) system plays a central role in regulating female reproductive hormones. GnRH is released from the hypothalamus and stimulates the anterior pituitary gland to secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which together govern reproductive functions through a signaling pathway that originates in the hypothalamus.This regulatory pathway is influenced by circadian rhythm mechanisms. Within the hypothalamus, specific neuronal populations are essential for integrating GnRH activity, particularly the estrogen-sensitive kisspeptin/neurokinin-B/dynorphin (KNDy) neurons. These neurons not only modulate reproductive hormonal regulation but are also involved in the homeostatic control of body temperature and other key physiological processes[Maki, Pauline M et al., 2024] .

The sleep–wake cycle is regulated through the interaction of multiple brain nuclei and neurotransmitter systems. Wakefulness is sustained by ascending arousal networks involving noradrenaline, serotonin, dopamine, histamine, glutamate, acetylcholine, and orexin, which are suppressed by GABAergic neurons during sleep [Haufe A et al., 2022]. Sleep timing is coordinated by the suprachiasmatic nucleus, the central circadian pacemaker [España RA et al., 2011]. Estradiol, a neuroactive estrogen (Figure No-1.2) ; influences sleep regulation both directly, through its actions on sleep-promoting regions and the SCN, and indirectly, by modulating neurotransmitter systems such as serotonergic and dopaminergic pathways [Haufe A et al., 2022].

Figure No-1.2: Mechanism of  the effect of  estradiol on sleep

The preoptic area of the hypothalamus, rich in estrogen receptors, is a major site of estrogen-related modulation of sleep–wake activity. Fluctuations in estrogen during the menopausal transition can affect mood and sleep, and management of sleep disturbances may also improve depressive symptoms [Wegrzynowicz,A.K et al., 2025].

Declining ovarian hormones alter hypothalamic thermoregulation and homeostasis, leading to vasomotor symptoms [Figure No-1.3] such as hot flashes and night sweats reported in up to 80% of women, which frequently disrupt sleep. At the same time, reduced estrogen levels can influence circadian pacemaker activity and disturb the balance between arousal-promoting and sleep-promoting neurotransmitters, with evidence that estrogen acts at multiple thermoregulatory nodes within the hypothalamus to modulate body temperature [Haufe A et al.,2022].

Progesterone acts as a neuroactive steroid with receptors present in major sleep–wake regulatory nuclei including the basal forebrain, dorsal raphe nucleus, locus coeruleus, and the suprachiasmatic nucleus allowing it to directly modulate sleep and circadian rhythms [Dorsey A et al., 2021]   Although progesterone has sleep-promoting effects through GABAergic mechanisms [Figure No-1.4], it also produces thermogenic effects that raise core body temperature, which may impair sleep quality. As a result, progesterone can show mixed or even negative associations with sleep across menstrual and reproductive transitions, depending on its influence on thermoregulation and circadian timing  [España RA et al.,2011].

Figure No-1.3 : Fluctuation in estrogen level during perimenopause or menopause transition can profoundly influence sleep through their effect on  hypothalamic temperature control or  homeostasis, leading to vasomotor symptoms.

Figure No -1.4: Potential Mechanism of the effect of progesterone  on

Study of Women’s Health Across the Nation (SWAN), suggests that 34.3% of perimenopausal women reported sleep disturbances compared with 28.0% of premenopausal women[Figure No-1.5], in their study they tracked 3,045 middle-aged women over eight years [Kyung Mee Park, 2024].

Figure No -1.5: Prevalence Rate  Of  Sleep Disturbances by SWAN

According to Dugan et al. 61% of 2,218 women reported lumbar spine pain. Back pain experienced at least once in the two weeks prior to the study was reported. An association was also observed between higher BMI and increased pain, Which is due to greater mechanical loading of the spine   The Pilates method is increasingly used in rehabilitation and offers multiple health benefits. It emphasizes strength, concentration, stability, breath control, fluidity, and proper body alignment, targeting core muscles as well as the hips and ribcage. Overall, studies indicate that Pilates has positive effects on muscle activation and pelvic floor strengthening compared to no intervention [Gisto L et al., 2023].

The systematic review indicates that Pilates can help individuals with low back pain improve core muscle strength in the trunk, pelvis, and abdomen. Its effectiveness is comparable to other exercise programs or physical activities of similar or different intensities[Franks J et al.,2023].                                                                                             

                      The systemic review suggests that  physiotherapy interventions such as exercise, yoga, walking, reflexology, massage, and aromatherapy can improve sleep quality and reduce depression in menopausal women, though more research is needed on Pilates, footbaths, acupressure, and combined approaches [Lialy, H.E. et al., 2023].

The conclusion of the experimental study suggests that deep breathing and aerobic exercises improve perimenopausal symptoms: deep breathing mainly enhances mood and reduces anxiety and depression, while aerobic exercise benefits sexual function [Raabia AK et al., 2022]

Overall the meta-analysis suggests that mind-body exercise such as Pilates, yoga, or other structured exercise programs is an effective, non-pharmacological intervention to improve both physical and psychological health during the menopausal transition and leads to measurable improvements in sleep patterns, such as longer sleep duration, reduced sleep latency and improve quality of life [Xu H et al.,2024].s

1.2:1 AIMS  & OBJECTIVES

This study aim was to evaluate the impact of  Pilates Program: Pelvic Floor & Core Muscles Exercises (Mat Pilates Program) Combined with paced breathing on  reducing back & pelvic pain and  enhancing sleep quality  & quality of life in Perimenopausal women

1.2:2 Objectives

l  To evaluate the effectiveness of a Pilates-based pelvic floor and core muscle strengthening program in improving pelvic floor and core muscle strength and in reducing back pain and pelvic pain among perimenopausal women.

l  To evaluate the effectiveness of paced breathing in enhancing sleep quality among perimenopausal women.

l  To evaluate the combined effects of a Pilates-based pelvic floor and core muscle strengthening program and paced breathing on pelvic floor and core muscle strength, reduction of back pain and pelvic pain, enhancement of sleep quality, and improvement in quality of life among perimenopausal women.

2.1 :Ethical consideration Ethical approval for the study was obtained from the Institutional Ethical Committee (SGRR/IEC/03/24). The study was registered with the Clinical Trial Registry of India (CTRI/2025/06/089873) and the Copyright Office, Government of India (Registration No. LD-27299/2015). Written informed consent was obtained from all participants prior to enrollment. The study was conducted at Shri Mahant Indiresh Hospital, Patel Nagar, Dehradun, with approval from 2.2: Research Design and settings

This was an experimental pilot study  involving 22 female subjects. Study  conducted in the Out Patient Door (OPD) Department of Physiotherapy and simultaneously referred from Obs & Gynaecology Units at the Shri Mahant Indiresh Hospital (SMIH) Patel Nsagar, Dehradun

2.3: Eligibility Criteria: Inclusion Criteria:[Table No-2.3.1]

Table No - 2.3.1:  Inclusion Criteria (symptoms / conditions suitable for exercise intervention)

Exclusion Criteria :[Table No-2.3.2]

Table No - 2.3.2: Exclusion Criteria (Not Suitable for Exercise / Needs Medical Referral)

2.4: Materials Used : A measuring tape , pen and paper for recording assessment findings and outcome scores, and Mat for Pilates Program to facilitate the performance of the intervention exercises in a safe and comfortable environment.

2.5: Treatment duration:  24 weeks (6 month), 45min-1 hr ,3 days alternatively in a week.

2.6: Outcome Measures : The study evaluated the  perimenopausal symptoms, pelvic floor muscles weakness , pelvic pain & back pain, Sleep quality and quality of life in these subjects before and after physiotherapy intervention using: [Table No-2.6.1]

Table No - 2.6.1: Outcome Measures

2.7:Intervention: Pilates Program: The intervention consisted of Pilates based (Mat Pilates) exercises program for Pelvic Floor & Core Muscles Strengthening along with Paced Breathing intervention.The program was implemented over 24 weeks with gradual progression in exercise intensity  to improve muscle strength, endurance, and coordination, as outlined in  [Table No-2.7.1],[Table No-2.7.2] & [Table No-2.7.3]

Table No - 2.7.1: Pilates Based Exercise Program For Pelvic Floor Muscles Strengthening

Table No - 2.7.2: Pilates Based Exercise Program For Core Muscles Strengthening   

Table No-2.7.3: Gradual progression in exercise intensity

Paced Breathing :The patient was instructed to sit or lie comfortably and relax the body. They were guided to inhale gently through the nose for 3–5 seconds, allowing the abdomen to rise, and then exhale slowly for 6–7 seconds in a smooth, controlled manner [Table No-2.7.1]:

Table No-2.7.4: Gradual progression in intensity

The present study demonstrates that a 24-week Pilates based (Mat Pilates) exercises program for Pelvic Floor & Core Muscles Strengthening combined  with Paced Breathing intervention significantly improved multiple health outcomes among perimenopausal women, including perimenopausal symptoms, pelvic floor muscle function, pain reduction, sleep quality, and overall quality of life.

Primary Outcome Measures:

The Menopause Rating Scale (MRS) showed a marked reduction in symptom severity, with median scores decreasing from 12.0 at baseline to 3.0 at 24 weeks. This aligns with evidence from meta-analyses indicating that mind-body exercises, including Pilates and yoga, effectively reduce vasomotor, psychological, and somatic menopausal complaints while improving overall well-being [Xu H et al., 2024; Raabia AK et al., 2022].

Pelvic floor muscle strength, as assessed by the Modified Oxford Grading Scale, improved from a median of 2.0 to 5.0. Strengthened pelvic floor musculature contributes not only to continence and pelvic support but may also alleviate musculoskeletal discomfort. This finding is consistent with previous studies reporting that Pilates enhances core and pelvic floor muscle activation, comparable to other structured exercise programs [Gisto L et al., 2023; Franks J et al., 2023].

Pain reduction, measured by the Visual Analogue Scale (VAS) for low back pain (LBP) and pelvic pain (PP), was significant. Median LBP scores decreased from 6.0 to 1.0, and PP scores declined from 4.0 to 0.5, with narrowing interquartile ranges indicating consistent improvement among participants. These results reflect the known benefits of Pilates and core strengthening in reducing lumbar spine and pelvic discomfort, which is especially relevant given the high prevalence of low back pain in midlife women and its association with factors such as increased BMI [Dugan SA et al., 2006].

Secondary Outcome Measures:

Sleep quality improved substantially, as indicated by a reduction in PSQI scores from 14.0 to 4.0. This supports findings from systematic reviews suggesting that physiotherapy interventions, exercise, and mind-body practices can enhance sleep and reduce depressive symptoms in menopausal women [Lialy H.E. et al., 2023].

Overall quality of life, assessed using WHOQOL, increased markedly from 17.75 to 48.25. This indicates that the intervention not only addressed physical symptoms but also positively influenced psychological and social well-being, consistent with prior evidence that structured mind-body exercises improve both physical and mental health outcomes during the menopausal transition [Xu H et al., 2024; Raabia AK et al., 2022].

5.LIMITATIONS

Age-related Constraints: Women over 50 years of age may face difficulty performing some Pilates-based exercises due to reduced flexibility, joint mobility, or pre-existing musculoskeletal conditions, which may limit the generalizability of the findings to older perimenopausal or postmenopausal populations.

Exercise Intensity and Compliance: Some participants may have found certain Pilates movements or paced breathing exercises challenging to perform correctly, potentially affecting adherence and the uniformity of intervention delivery.

Short-term Follow-up: The study assessed outcomes up to 24 weeks. Long-term sustainability of improvements in pelvic floor strength, pain reduction, and quality of life was not evaluated

The 24-week Pilates-based pelvic floor and core muscles strengthening program, combined with paced breathing, resulted in significant improvements in perimenopausal symptoms, pelvic floor muscle strength, back pain & pelvic pain reduction, sleep quality, and overall quality of life among perimenopausal women. The intervention demonstrated consistent and meaningful benefits across both physical and psychological domains, highlighting its potential as a safe, non-pharmacological strategy for managing perimenopausal challenges. These findings support the incorporation of structured mind-body exercise programs into routine care for perimenopausal women to enhance functional well-being and overall quality of life.

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