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Utilizing Pilates to Improve Respiratory Function in Breast Cancer Survivors
Korean J Sports Med 2024;42:86-98
Published online June 1, 2024;
© 2024 The Korean Society of Sports Medicine.

Sujin Park1, Kyung Eun Nam2, Kyuwan Lee1

1Department of Kinesiology and Sports Studies, Ewha Womans University, Seoul, 2Department of Rehabilitation Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
Correspondence to: Kyuwan Lee
Department of Kinesiology and Sports Studies, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea
Tel: +82-2-3277-2575, Fax: +82-2-3277-2575
Received April 1, 2024; Revised May 10, 2024; Accepted May 20, 2024.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Complications resulting from cancer therapy can significantly influence the health outcomes of breast cancer survivors, particularly regarding their respiratory system. Pilates interventions have been utilized to improve cancer-related complications in clinical settings, but the evidence has not been comprehensively reviewed to prescribe Pilates as an effective rehabilitation option to improve respiratory function in breast cancer survivors. A systematic search strategy was employed to identify relevant literature from PubMed, Scopus, and Web of Science using specific keywords: Pilates, respiratory function, breast cancer. The purpose of this review is to summarize the current evidence on the effects of Pilates on respiratory function in breast cancer survivors providing a thorough overview of the specific benefits associated with Pilates within the context of breast cancer. Further, we address the unique challenges faced by breast cancer survivors when performing Pilates, as well as current knowledge gaps and future directions in the field of rehabilitation science. The primary features of Pilates include an emphasis on specialized breathing techniques in conjunction with core stability, strength, flexibility, and precise control over muscle movements and posture that can be relevant to the health of breast cancer survivors. Our findings suggest that Pilates appears as a promising rehabilitation strategy to counteract the adverse effects of cancer therapies on the respiratory system.
Keywords : Exercise movement techniques, Breast neoplasms, Respiratory muscles, Prescriptions

Despite remarkable advances in breast cancer therapies, anti-cancer therapies such as mastectomy, chemotherapy, and radiotherapy are associated with multiple complications and side effects1. In particular, breast cancer survivors often encounter persistent health challenges such as cardiorespiratory dysfunction following anticancer therapies. Previous studies have predominantly focused on the cardiac diseases and cardiac injuries known as cancer therapy-induced cardiotoxicity, induced by trastuzumab or anthracycline-based chemotherapy2. However, breast cancer survivors may experience health challenges that extend beyond cardiac issues. For example, chest wall constraints resulting from chemotherapy or radiation therapy may lead to diminished respiratory function and breathing capacity emphasizing the need for a comprehensive understanding of their impact on respiratory function to develop appropriate interventional strategies3.

Multiple randomized controlled trials have demonstrated that a conventional aerobic and/or resistance exercise intervention can reduce the risk of cardiovascular disease and physical function in breast cancer survivors4,5. Recently, Pilates has gained scientific attention on improving health outcomes, such as improved physical function, muscular strength, endurance, balance, fatigue, quality of life, and anxiety6,7. This may be due to the characteristics of Pilates associated with enhanced posture, reduced chronic muscle tension, and increased strength and proprioception8. In addition to these physical, physiological, and psychological benefits, Pilates interventions applied to breast cancer survivors hold the potential for further enhancing respiratory capacity, due to the impact of specialized breathing techniques on ribcage, thoracic movement, and the capability of improving respiratory mechanics9,10. Importantly, Pilates interventions have been proven to effectively enhance the alignment, stability, and mobility of both the ribcage and the thoracic region as well as respiratory mechanics7,11.

The impact of Pilates on respiratory function has been studied in numerous clinical settings. However, the evidence has not been comprehensively reviewed to prescribe Pilates as an effective option to improve respiratory function in breast cancer survivors. Therefore, the purpose of this review is (1) to summarize the current evidence on cancer therapy-induced respiratory dysfunction and (2) to provide an overview of the specific benefits associated with Pilates in the context of breast cancer. Lastly, we address the unique challenges faced by breast cancer survivors when performing Pilates, as well as current knowledge gaps and future directions in the field of exercise science.

Cancer Therapy-Induced Respiratory Dysfunction

1. Surgery

The primary choice for treating breast cancer often involves surgery as the first step in the treatment plan to remove cancerous tissues from the breast12. However, surgery such as mastectomy or breast-conserving surgery is frequently associated with various surgical complications, including reduced soft tissue mobility, scar tissue formation, fibrosis, and myofascial dysfunctions, which may result in undesirable biomechanical changes such as restricted upper extremity mobility, lymphedema, and disruptions in coordinated body-arm movement13. In particular, persistent pain after breast cancer surgery is a well-recognized complication of surgical procedures, referred to as postmastectomy pain syndrome14. Post-mastectomy pain syndrome may induce intercostobrachial nerve injury, intercostal neuromas, and phantom breast pain, mainly appearing in the upper arm, shoulder, and chest, exacerbated by shoulder movements (Table 1). Consequently, chest and shoulder blade muscles responsible for overall respiratory capacity can be weakened and individuals may develop shallow breathing patterns and experience inadequate lung expansion, potentially leading to reduced oxygenation levels15. This mechanism is explained by compensatory postural adjustments, characterizing that patients may have to adjust their posture, such as raising their shoulders or adopting a rounded stance, further exacerbating respiratory dysfunction. The compensatory postural adjustments, such as increased surface rotation and lateral deviation in the spine, can affect the muscles surrounding the thorax and spine, which are crucial for respiration16. Changes in spinal alignment may restrict lung expansion and contraction, demanding increased effort for respiration. Thoracic kyphosis can further reduce thoracic cavity volume, potentially hindering full lung expansion during inhalation17. Studies have reported coronal plane abnormalities, impacting lung expansion and breathing efficiency due to thoracic region structural alterations18. These complications including pain and biomechanical changes should be considered in the care and rehabilitation of these individuals.

Table 1 . Summary of study protocols and results

StudyYearStudy populationPurpose of studyMethodsMajor Findings
Koc et al.32200274 Patients treated with adjuvant radiotherapy and tamoxifen and 37 patients treated with radiation therapy onlyTo investigate whether the tamoxifen-induced the development of pulmonary fibrosisComputed tomography performed before initiation of radiotherapy and tamoxifen treatmentMedian time for the development of pulmonary fibrosis was 8 months in tamoxifen-treated patients whereas it was 10 months in non-tamoxifen-treated patients
Krengli et al.29200841 Women who had undergone conservative surgery for breast cancer before and 3 and 9 months after postoperative radiotherapyTo investigate the potential detrimental effects of radiotherapy following conservative surgery for breast cancerPFTs: FVC, FEV1, total lung capacity, maximal expiratory flow at 50% and 25% of vital capacity, and diffusion capacity of carbon monoxidePFTs exhibited a significant decrease at 3 months, with only partial recovery observed at 9 months. Chemotherapy, but not hormonal therapy, was associated with changes in PFTs
Jaén et al.28201243 Patients diagnosed with breast cancer treated with postoperative radiation therapyTo evaluate late pulmonary function changes after incidental pulmonary irradiation for breast cancerPFTs and ventilation/perfusion scans were conducted before radiation therapy and up to 7-year postradiation therapyDiffusing Capacity: Reduction observed for 24 months, partially recovering baseline values at 7 years. Ventilation/Perfusion Scans: Continued reduction for 24 months, with partial recovery at 7 years
Roberts et al.262013A mouse without tumor and a Colon-26 tumor-bearing mouseTo assess the impact of cancer cachexia on diaphragm muscle fiber types, atrophy-related gene expression, contractile properties, and ventilatory parametersDiaphragm muscle fiber types; atrophy-related genes (atrogin-1 and MuRF1); maximum isometric specific force of diaphragm strips; absolute maximal calcium-activated force; and maximal specific calcium-activated force of permeabilized diaphragm fibers; ventilation measurements, including tidal volume and respiratory responsesAll diaphragm muscle fiber types were significantly atrophied in C-26 mice, with atrophy-related genes, atrogin-1 and MuRF1, increased in C-26 mice. Maximum isometric specific force, absolute maximal calcium-activated force, and maximal specific calcium-activated force of diaphragm fibers were significantly decreased in C-26 mice.
C-26 mice had significantly lower tidal volume under basal conditions and an inability to increase breathing frequency, tidal volume, and minute ventilation in response to a respiratory challenge
O’Donnell et al.3201629 Breast cancer survivors and 29 age-matched healthy controlsTo investigate the physiological contributors to reduced peak oxygen uptake in breast cancer survivors, with a specific focus onMeasurement of respiratory and peripheral muscle strength, pulmonary function, and ventilatory responses to symptom-limited incremental treadmill exerciseLower lung diffusing capacity for carbon monoxide, respiratory and limb muscle strength, and ventilatory thresholds compared with controls Inspiratory capacity was lower, and the breathing pattern was more rapid and shallow in breast cancer
Kim and Lee11201728 Healthy female adultsTo investigate the effects of Pilates breathing on trunk muscle activationTrunk muscle activations measured while they performed curl-ups, chest-head lifts, and lifting tasksAll trunk muscles measured in this study had increased activities after Pilates breathing training and Pilates breathing increased activities of the trunk stabilizer muscles
Lorbergs et al.172017193 Women and 82 men in the Framingham Study original cohortTo quantify the impact of kyphosis severity on decline in pulmonary functionKyphosis angle from lateral spine radiographs and FEV1 from spirometryKyphosis severity was associated with greater decline in FEV1 in women but not in men. Adjusted mean change in FEV1 over 16 years was −162, −245, and −261 mL (p for trend=0.02) with increasing tertile of kyphosis angle in women and −372, −297, and −257 mL in men
Suesada et al.31201837 Breast cancer patients treated with radiotherapyTo assess the impact of thoracic radiotherapy on respiratory function in patients with breast cancerHigh-resolution computed tomography, respiratory function tests, respiratory muscle strength, chest wall mobility, and complete PFTThoracic radiotherapy appeared to lead to significant losses in respiratory and exercise capacity, likely attributable to chest wall restriction
Landman et al.22201934 Patients with early breast cancer without preexisting lung diseaseTo investigate the long-term pulmonary and oncological outcomes of these patients as well as the impact of patient and treatment characteristics on diffusing capacity for carbon monoxide recoveryDiffusing capacity for carbon monoxide measured by the PFTSignificant effects of time on diffusing capacity for carbon monoxide and its trend; a significant recovery on the follow-up (75.6% vs. 81.9%), but still significantly lower than the baseline (81.9% vs. 92.0%). Five patients (20%) still showed a >20% relative reduction from baseline
Ding et al.21202020 Patients diagnosed with breast cancerTo evaluate changes in chest X-rays, PFTs and quality of life in female breast cancer patients treated with four cycles of neoadjuvant chemotherapyChest X-ray examinations, PFTs, and the EORTC QLQ-C30 questionnaireSignificant decreases in carbon monoxide diffusing capacity; significant increase in maximal ventilatory volume most patients experienced dyspnea
Fretta et al.7202118 Breast cancer survivors performing mat Pilates and 16 patients in control groupTo analyze the effects of a 16-week mat Pilates intervention on the postural alignment and balance of breast cancer women receiving hormone therapyThe postural alignment was assessed using the Postural Assessment Software (SAPO) and the balanceSignificant difference in the angle between acromion and the anterior-superior iliac spines of the mat Pilates group. The mat Pilates method had an improved horizontal alignment of the anterior-superior iliac spines and vertical alignment of the acromion head on the right side
Kutlu et al.33202338 Female breast cancer survivorsTo investigate the relationship between spinal posture and mobility in breast cancer patients who have completed their treatment and their impact on respiratory muscle strength and pulmonary functionsSpinal curvature, spinal mobility, and spinal inclination with a noninvasive, computer-assisted electromechanical device
PFT and respiratory muscle strength with a portable digital spirometer device
Increased thoracic curvature angle associated with: decreased FEV1 (r=−0.360, p=0.026), decreased subcostal mobility (r=−0.385, p=0.017)
Increased thoracic frontal mobility associated with: decreased PEF (r=−0.342, p=0.036)
Increased lumbar mobility associated with: increased FVC (r=0.324, p=0.047)
Increased total spinal inclination mobility associated with: decreased MIP (r=−0.396, p=0.017), chest wall mobility associated with postural assessments at varying rates (r-value ranged from −0.357 to 0.661, p<0.05)

FEV: force expiratory volume, FEV1: forced expiratory volume in 1 second, PFT: pulmonary function test, EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, FVC: forced vital capacity, MuRF1: muscle RING-finger protein-1, MIP: maximum inspiratory pressure, PEF: peak expiratory flow.

2. Chemotherapy

Chemotherapy administered to breast cancer survivors, whether in the neoadjuvant or adjuvant settings involves a range of cytotoxic drugs, including alkylating agents, antimetabolites, tubulin inhibitors, or anthracyclines and taxane-based chemotherapy19. However, a major complication resulting from breast cancer chemotherapy includes a broad range of acute and chronic toxicities, leading to respiratory distress, coughing, dyspnea, fatigue, and pneumonitis20. These issues can result in impaired respiratory function and breathing difficulties21. A significant decline in diffusing capacity of the lung for carbon monoxide (DLCO) has been observed following anthracycline and taxane-based regimens22. The DLCO remained notably lower compared to the baseline (81.9% versus 92.0%, p=0.003). Further, 20% percent of patients still exhibited a reduction in DLCO of more than 20% from the baseline. Importantly, patients who experienced dyspnea or fatigue during subsequent clinical follow-ups had significantly lower DLCO values on their follow-up pulmonary function test compared to those who were asymptomatic (Table 1). Although anthracycline and/or taxane-based chemotherapies significantly improve cancer survival, their clinical use can be limited by their harmful effects on respiratory function, including the diaphragm, caused by mitochondrial reactive oxygen species production23,24. Cancer cachexia, characterized by a continuous loss of skeletal muscle mass leading to profound weakness, is now a well-recognized complication following chemotherapy25. There is currently insufficient clinical evidence to indicate that the diaphragm is under the influence of cancer cachexia. However, if cancer cachexia extends to the diaphragm muscle, it may compromise respiratory function26. Potential mechanisms were investigated in a preclinical model, which revealed significant respiratory muscle atrophy, weakness, and ventilatory dysfunction, underscoring the critical impact of cancer cachexia26. These findings emphasize the importance of addressing respiratory dysfunction and skeletal muscle deconditioning as integral components of a holistic approach to cancer care. Incorporating strategic respiratory training into comprehensive cancer rehabilitation plans is crucial for improving respiratory function and addressing these side effects.

3. Radiation therapy

Radiation therapy plays an important role in the treatment of breast cancer, markedly enhancing cancer survival rates, especially for patients with early-stage disease. This treatment modality utilizes two main approaches: one targets the remaining breast tissue or chest wall, while the other focuses on the axilla and clavicular regions, although the choice of radiation field depends on the stage of the disease and the extent of surgical intervention. One of the adverse events caused by radiation therapy is the development of fibrosis, a condition marked by an increase in collagen deposition, reduced blood flow, and scarring27. Radiation therapy can induce nonspecific inflammatory lesions within the lung tissue, promoting radiation-induced fibrosis. This fibrotic change in the lungs was shown to contribute to compromised respiratory mechanisms including tightening the soft tissues, affecting essential respiratory muscles such as the diaphragm, intercostal muscles, and muscles in the neck, all vital for the expansion and contraction of the ribcage during breathing28. Overall, radiation therapy can successfully improve cancer survival but may lead to significant declines in respiratory muscle strength and chest wall mobility, diminishing respiratory and exercise capacities. The fibrotic changes from radiation may alter respiratory muscle leverage and posture, reducing chest wall mobility29. Additionally, such changes affect chest wall stability and mobility, causing myofascial restrictions that degrade respiratory patterns and function30. This is evidenced by a study showing significant reductions in pulmonary function (i.e. forced vital capacity, expiratory volume in one second, total lung capacity, and inspiratory capacity) and chest wall mobility at the axillary level and at the level of the xiphoid process detected after radiotherapy areas among breast cancer patients3,31. Therefore, understanding the relationship between radiation therapy and respiratory function is critical for developing effective rehabilitation strategies for breast cancer survivors.

4. Hormone therapy

Hormone therapy is a treatment that suppresses hormone production or that interferes with hormone receptor signaling to prevent tumor growth and is prescribed to hormone-positive breast cancer survivors for up to 10 years following diagnosis. Few studies have reported the influence of hormone therapy alone on the respiratory system in breast cancer survivors. It is currently evidenced that tamoxifen therapy when combined with radiation therapy may increase the risk of pulmonary fibrosis, while aromatase inhibitors did not indicate a similar risk32. Clinical evidence is not sufficient to suggest that hormone therapy alone can significantly induce respiratory dysfunction in breast cancer survivors.

Pilates and Improved Respiratory Function

Given the complications resulting from breast cancer therapies, the significance of exercise interventions in mitigating respiratory dysfunction is evident. Pilates has been recognized for its ability to improve core stability, strength, flexibility, and precise control over muscle movements and posture, particularly relevant to breast cancer survivors with marked alterations in body posture and the asymmetry of the trunk and shoulder girdle33. Notably, Pilates breathing techniques emphasize expanding the thorax lateral diameter during inhalation while minimizing the expansion of the abdominal region, which facilitates pulmonary expansion34. This method not only supports oxygen exchange but also promotes body stability, exercise efficiency, and muscle tension regulation, enhancing movement and alignment. Additionally, Pilates breathing encourages a posterior lateral breathing pattern, described as the lateral expansion of the rib cage while maintaining an inward pull of the deep abdominal muscles. This technique is crucial for preventing shallow upper chest breathing, thereby reducing tension in the neck and shoulder muscle35,36. These breathing techniques also generate intra-abdominal pressure that significantly influences spinal stability, creating an extensor moment that supports both the pelvic floor and the diaphragm. This coordinated approach can engage various respiratory muscle groups and facilitate the active participation of the transverse abdominis and pelvic floor muscles, leading to improved posture, reduced chronic muscle tension, and increased strength, supporting the recovery process for breast cancer survivors33. Incorporating systematic Pilates into the treatment plans for breast cancer survivors is crucial for addressing the multifaceted issues arising from cancer therapies. Pilates should be considered in the holistic care of breast cancer survivors as it can promote physical function recovery and improve respiratory function by addressing issues arising from cancer therapies.

Specific Pilates Prescription Utilized in Breast Cancer Survivors

In general, prescribing an exercise program to clinical populations typically considers the FITT principles: frequency, intensity, time, and type of specific exercise. Although the typical recommendation for Pilates interventions aligns with other conventional exercises (i.e. aerobic and resistance exercise), prescribing intensity and type of Pilates appears complicated.

1. Frequency

According to a recent systematic review and meta-analysis in breast cancer survivors, Pilates interventions typically involved three sessions a week which lasted from 3 to 12 weeks9. Similarly, Pilates interventions specifically targeting respiratory function in breast cancer survivors were administered at the same frequency (i.e., three sessions per week); two studies extended over a longer duration, spanning up to 48 weeks37-40. The total duration of Pilates interventions targeting respiratory function ranged from 10 to 12 weeks of the intervention is consistent with other studies focusing on the general benefits of Pilates in breast cancer survivors (Table 2). The total duration and frequency of Pilates interventions were also consistent with studies in elderly women41. Overall, engaging in Pilates sessions 3 times per week interventions appears the most commonly adopted frequency for Pilates interventions in breast cancer survivors.

Table 2 . Summary of evidence to improve respiratory function with pilates in breast cancer survivors

StudyYearResearch designFrequencyIntensityTypeTimeOutcomes
Odynets et al.392018Randomized controlled trial of 115 breast cancer survivors and 50 healthy women3 Sessions per week for 48 weeksIntensity of exercises was individualized based on each patient’s health status, ranging from 40% to 60% of heart rate reserve; 40% to 60% of heart rate reserveMat Pilates (50%), Power Pilates (20%), Pilates ball (20%), Pilates stretch (10%)10-minute warm-up, 40-minute aerobic and resistance training, and 10-minute cool-downFollowing 48 weeks, VC, FEV1, PEF, MEF, MEF 50, expiratory reserve volume, maximal voluntary ventilation
Odynets et al.402019Randomized controlled trial of 68 breast cancer survivors, randomized into two groups of 34 each for water and Pilates programs3 sessions per week for 12 weeksNot availableStatic and dynamic breathing exercises, Hundreds,
Spine stretch, Roll Down, scissors, Chester stretch, shoulder bridge, Dumb Waiter, Swan Dive, One-leg stretch exercises
Not availableFEV1 increased by 300 mL, indication of expiratory respiratory muscles and bronchial patency enhancement.
Odinets et al.372019Randomized controlled trial of 50 women with breast cancer, aged 50-60, who had undergone mastectomy, with normal body mass index3 sessions per week for 48 weeksIntensity of exercises was individualized based on each patient’s health status, ranging from 40% to 60% of heart rate reserveMat Pilates exercises (50%), Power Pilates (20%), Pilates ball (20%), Pilates stretch (10%)10-minute warm-up, 40-minute aerobic exercise, resistance training, and stretching, and was concluded with a 10-minute cool-downFollowing the first 6 months improvements in FEV1, PEF, MEF25 improved by 0.60 l/s; During the second half of the year, VC increased significantly, and those of FVC
Odynets et al.382022Randomized controlled trial of 95 women completed the interventions and were included in the final analysis3 sessions per week for 12 weeksNot availableNot available60 minutes for each sessionImprovements in FEV and MEF50

FEV1: forced expiratory volume in 1 second, PEF: peak expiratory flow, MEF: maximum expiratory flow, MEF50: MEF at 50% of vital capacity, MEF25: MEF at 25% of vital capacity, VC: vital capacity, FVC: forced vital capacity.

2. Intensity

Pilates offers a versatile approach to fitness, with the potential for tailored intensity levels based on equipment selection and utilization. A Pilates intervention in breast cancer survivors typically incorporates exercises utilizing mats, Reformers, Cadillacs, Chairs, or Barrels, the inclusion of accessories such as resistance bands, toning balls, magic circles, weights, dumbbells, and Swiss balls allows for a dynamic range of exercise intensities9. The various equipment options are available to ensure that Pilates interventions can be effectively tailored to meet the diverse needs and preferences of breast cancer survivors. In a study investigating the effects of Pilates in women during hormone therapy for breast cancer, Pilates sessions were designed to increase the frequency of repetitions every 8 weeks, allowing for a gradual progression in exercise intensity tailored to the participants’ capabilities42. This variation emphasizes the need for progressive difficulty and adaptability in the program design. Despite efforts to standardize Pilates intensity, the method used to determine or quantify Pilates intensity remains unspecified. This ambiguity is common in literature on Pilates for breast cancer survivors, where intensity is often customized to the individual, complicating the standardization of exercise specifics. Alternatively, the Borg Scale was used to objectively evaluate the level of fatigue or discomfort experienced by breast cancer survivors43. The Borg Scale (6–20), ranging from “very light” to “moderate” (approximately 9 to 13), provides evidence for assessing exercise intensity and ensuring safe and sustainable exercise participation. However, without specifying the standardized intensity levels, it is difficult to ascertain the intensity at which Pilates exercises were conducted. Particularly, adjustments in exercise intensity may also be necessary based on the degree of lymphedema. For instance, individuals with first and second degrees of lymphedema can perform exercises in various positions, including standing, lying on the back or side, and sitting on a ball. Women with third-degree lymphedema may perform exercises in lying positions without special equipment. This approach underscores the importance of tailoring exercise regimens to address specific patient needs and limitations. Lastly, during active treatment, adherence to prescribed exercise intensity can be challenging due to various factors such as side effects, self-efficacy, and treatment barriers44, as well as psychological hurdles and safety concerns, especially for patients with lymphedema45.

3. Type

Pilates interventions for breast cancer survivors in previous studies have incorporated mat-based exercises with equipment such as the Reformer, Cadillac, Chair, and Barrel, aiming to address their specific rehabilitation needs4,9. With the variety of equipment options, Pilates can be tailored to breast cancer survivors, which include preparatory exercises, fundamental Pilates movements, stretching routines, and a cool-down phase37-40. Pilates can also incorporate proprioception training focusing on flexibility in both the upper and lower limbs, enhancing upper extremity mobility, and strengthening both extremities, shoulder girdle core muscles. Specifically, movements aimed at addressing the physical difficulties and impairments encountered by breast cancer survivors include exercises such as ‘Arms opening’ targeting the shoulder area46, cool-down activities that involve stretching the shoulder and chest muscles, as well as ‘Mid-back pull’ and ‘Shoulder external rotation’ exercises utilizing Thera-Bands47. However, studies often lacked structured Pilates types tailored to individual range of motion and clear guidelines on precautions and potential adverse effects.

While Pilates interventions for breast cancer survivors incorporate various starting positions, some studies emphasize Pilates performed in the supine position to prioritize limb mobility and minimize joint impact. Despite the significance of customizing starting positions based on individual circumstances (e.g., exercise capacity, flexibility, and pain levels) detailed guidelines or additional standardized individualization for starting positions are not currently available. In particular, the specific type of coordinated breathing techniques, such as breathing & hollowing and breathing with powerhouse activation are formally evaluated. Despite these breathing principles crucial for enhancing movement control and the development of respiratory muscles, research on Pilates in breast cancer survivors lacks a focus on integrating the type of Pilates breathing techniques. Lastly, Pilates can be implemented as an aerobic exercise, predominantly utilizing an oxidative phosphorylation energy system. A previous study on respiratory function in postmastectomy syndrome patients included aerobic exercise sessions but lacked specific on how to prescribe Pilates aerobic exercises48. Future studies are needed to investigate the specific utilization of Pilates regarding the starting position, breathing techniques, and aerobic type of Pilates in breast cancer survivors.

4. Time

According to a recent systematic review and meta-analysis of breast cancer survivors9, the time allocated to perform a Pilates session in breast cancer survivors is 40 to 60 minutes. Similarly, each Pilates session tailored to enhance respiratory function in breast cancer survivors required a consistent time of 60 minutes37-40. One study did not specifically report the time of each session, possibly because the primary emphasis is on completing the prescribed movements rather than adhering to a specific timeframe. One study has reported that engaging approximately 40 to 60 minutes of Pilates has been deemed feasible to improve upper extremity disorder and no side effects occurred in breast cancer survivors10. Importantly, 100% of study participants showed full compliance with all 40 to 45 minutes of Pilates sessions throughout the entire 8-week intervention period, suggesting that engaging in Pilates 40 to 45 minutes is a feasible approach to improve respiratory function in breast cancer survivors.

Potential Side Effects of Pilates and Safety Considerations

Pilates intervention can offer benefits for breast cancer survivors but it is essential to consider several factors to ensure the safety and effectiveness of Pilates interventions in this population. One of the most prevalent side effects experienced not only in Pilates but also in many forms of exercise would be delayed onset muscle soreness (DOMS)49. Although DOMS typically disappears within a few days, breast cancer survivors may initially experience unfamiliar discomfort, leading to concerns about the sensation. Pilates equipment may potentially cause injuries such as falls from Reformer, Cadillac, Barrell, and Chair. Inadequate grip on handles or foot straps can increase the risk of slipping or tripping during Pilates sessions50. Specific to breast cancer survivors experiencing bone metastasis of breast cancer, weight-bearing Pilates postures such as bridge and plank or single-leg balance posture may induce bone pain if the loaded weight is on the ribs, spine, and pelvis. These individuals with bone metastasis may need to modify their Pilates session to avoid exacerbating pain. Lastly, due to the characteristics of Pilates certain Pilates movements involving dynamic movement or challenging positions may increase the tightness of shoulder muscles in some individuals if not practicing proper breathing techniques. To prevent these potential side effects of Pilates and improve the safety of Pilates sessions, a certified Pilates instructor can serve as supportive guidance on the personalized sessions and help breast cancer survivors achieve their health outcomes while ensuring safety and effectiveness.

Current Knowledge Gaps and Future Directions

Based on the previous studies examining the effects of Pilates on respiratory function and static respiratory pressures, there is evidence to suggest that Pilates is an alternative exercise option for breast cancer survivors. However, the majority of studies have focused on the general physical function induced by Pilates, such as improved flexibility, and core strength, without specifically addressing outcomes related to respiratory function. Further, the predominance of pilot studies with small sample sizes underlines the urgent need for more adequately powered randomized controlled trials to determine the effectiveness of Pilates in improving respiratory function in conjunction with physical function among breast cancer survivors. Methodologically, spirometry is a commonly used tool for assessing respiratory function by measuring the capacity and flow rate of air inhalation and exhalation, proving useful in detecting respiratory function decline post-breast cancer surgery. However, it focuses primarily on the lung surface functions and does not directly assess deeper tissue or muscle impairment, such as postsurgical muscle weakness or nerve damage, nor does it provide comprehensive insights into dynamic respiratory function changes or the efficiency of respiratory muscles. The weakening of the muscles involved in breathing such as the diaphragm and intercostal muscles, referred to as respiratory sarcopenia, can reduce respiratory depth and efficiency, leading to fatigue even with minimal activity. To comprehensively evaluate respiratory function, it is essential to incorporate inspiratory and expiratory muscle strength measurements. This approach allows for the assessment of postsurgical weakening of respiratory muscles. Additionally, employing Electromyography and nerve conduction studies to measure the electrical activity of respiratory muscles can provide insights into muscle weakness or nerve damage. Together, these methods offer a comprehensive evaluation of respiratory function, aiding in a deeper understanding of the decline in respiratory function post-breast cancer surgery.

With regard to cancer treatment and respiratory function, the focus of previous studies has primarily been on the recovery phase after cancer treatment, with little exploration of Pilates during active cancer treatment phases. This gap limits understanding of Pilates in supporting physical functions related to breathing and recovery across the cancer care continuum. Studies including survivors of various ages, surgical types, and cancer stages, evaluating the long-term effects of exercise programs, and comprehensively assessing discomfort during exercise are needed. Importantly, the absence of specific Pilates guidelines complicates the prescription of effective Pilates regimens. Steps may include the development of evidence-based guidelines that account for various treatment and recovery stages and the incorporation of physical functions related to breathing as a fundamental aspect of Pilates interventions. Future directions should aim at developing a tailored Pilates guideline that integrates physical functions in conjunction with respiratory function into Pilates routines for breast cancer survivors. This should involve large-scale randomized controlled trials to establish best practices in exercise selection, intensity, and progression with a focus on physical functions related to breathing.

In conclusion, Pilates interventions have been proven to improve multiple health-related outcomes in breast cancer survivors. However, there is still a lack of clinical evidence regarding the impact of Pilates on respiratory function in breast cancer survivors. Furthermore, the absence of clear Pilates guidelines for breast cancer survivors makes it difficult to prescribe appropriate Pilates regimens. More rigorous scientific efforts are needed to enable the provision of more effective and personalized Pilates guidelines for improving respiratory function in breast cancer survivors.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.


This work was supported by the Ewha Womans University Research Grant of 2023.

Author Contributions

Conceptualization, Methodology: SP, KL. Funding acquisition, Resources: KL. Writing–original draft: all authors. Writing–review & editing: KE, KL.

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