Introduction

The intricate relationship between mental and physical health has been extensively documented in medical literature, with postural deformities such as hyperkyphosis (thoracic curvature exceeding 40 degrees) representing a significant public health concern, particularly among middle-aged women. This spinal abnormality, often resulting from sedentary lifestyles, environmental factors, and improper movement patterns, exerts profound negative effects on psychological well-being, social functioning, and physiological health. Contemporary research has demonstrated that hyperkyphosis frequently coexists with depression and chronic pain, creating a complex interplay of symptoms that significantly impair quality of life. The global prevalence of depression among women is notably higher than in men, with postural abnormalities potentially exacerbating psychological distress through both mechanical and psychosocial pathways. In recent years, Pilates has emerged as a promising mind-body intervention, combining physical exercise with mental focus to address both postural alignment and psychological health. This comprehensive study examines the efficacy of a 12-week Pilates program in simultaneously improving depression symptoms, reducing pain intensity, and correcting kyphotic posture among women aged 20-40 in Shahreza, Iran. The investigation builds upon existing literature while addressing critical gaps in holistic, non-pharmacological treatment approaches for this vulnerable population. By integrating psychological and physical health outcomes, this research contributes to the growing body of evidence supporting multimodal interventions for women's health.

Method: This semi-experimental study employed a rigorous pre-test/post-test design with parallel control groups to evaluate the effects of Pilates training. Thirty women meeting strict inclusion criteria (kyphosis angle ≥40°, age 20-40 years, no cardiovascular conditions or recent surgeries, and no current use of psychotropic medications) were randomly assigned to either an experimental group (n=15) or a control group (n=15). The intervention consisted of supervised 60-minute Pilates sessions conducted three times weekly for 12 weeks, with each session carefully structured to include warm-up (10 minutes), core exercises (40 minutes), and cool-down periods (10 minutes). The exercise protocol specifically targeted postural correction through mat-based exercises such as the "Superman," "Dart," and "Star" maneuvers, which engage spinal extensors and scapular stabilizers. Progressive overload was systematically implemented from week 4 onward by increasing repetitions and sets. Comprehensive outcome measurements were collected pre- and post-intervention using validated instruments: depression severity was assessed using the Beck Depression Inventory-II (BDI-II), pain intensity was measured with a 10 cm Visual Analog Scale (VAS), and kyphosis angle was quantified using a flexible kyphometer at vertebral levels T1-T3 and T11-T12. The control group maintained their usual activities without exercise intervention. Data analysis included normality testing (Kolmogorov-Smirnov), homogeneity of variance assessment (Levene's test), and between-group comparisons using univariate ANCOVA with baseline scores as covariates (significance set at p≤0.05). Effect sizes (η²) were calculated to determine the magnitude of intervention effects.

Results: The 12-week Pilates intervention yielded statistically significant improvements across all measured outcomes compared to the control group. Depression scores, as measured by the BDI-II, demonstrated a remarkable 34.6% reduction in the experimental group (from 15.8±8.0 to 10.4±6.4 points) versus only a 16.1% decrease in controls (15.1±8.1 to 12.6±7.5 points), with a large effect size (F=8.76, p=0.006, η²=0.245). Pain intensity showed even more pronounced improvements, with the experimental group reporting a 55.9% reduction on the VAS (3.4±1.2 to 1.5±1.1 cm) compared to a modest 29.4% decrease in controls (2.4±0.8 to 1.8±1.1 cm), supported by strong statistical significance (F=9.08, p=0.002, η²=0.252). Kyphometric measurements revealed a clinically meaningful 9.8% correction in the experimental group (40.6±1.4° to 36.6±2.2°) versus negligible change in controls (40.4±1.1° to 40.2±1.2°; F=7.6, p=0.004, η²=0.142). The calculated effect sizes indicated that approximately 24.5%, 25.2%, and 14.2% of the variance in improvements for depression, pain, and kyphosis respectively could be attributed to the Pilates intervention. Notably, adherence rates exceeded 85%, and no adverse events were reported, supporting the safety and feasibility of the protocol.

Discussion: The current findings substantially expand upon existing knowledge regarding Pilates as a multimodal therapeutic intervention. The observed psychological benefits align with recent neurophysiological research suggesting that Pilates may modulate hypothalamic-pituitary-adrenal axis function, thereby reducing stress hormone secretion and enhancing mood regulation. The significant pain reduction parallels biomechanical studies demonstrating that Pilates strengthens the deep cervical flexors and scapular stabilizers, thereby improving load distribution across the thoracic spine. The kyphosis angle improvements corroborate previous work by Rajabi et al. (2018) while providing novel evidence for postural correction in younger women, a previously understudied population. Particularly noteworthy is the simultaneous improvement across all three outcome domains, supporting the hypothesis that Pilates addresses the biopsychosocial complexity of hyperkyphosis-related dysfunction. The mind-body components of Pilates, including focused breathing and movement precision, likely contributed to both the physical corrections and psychological benefits through enhanced proprioception and body awareness. These results gain additional significance when considering recent meta-analyses (Ju et al., 2024; Li et al., 2024) that have established Pilates as superior to conventional exercise for certain pain and mood disorders. However, the current study extends these findings by demonstrating concurrent benefits across multiple health domains in a specific at-risk population. The moderate effect sizes for kyphosis correction suggest that while Pilates is effective, it may need to be combined with other modalities (e.g., manual therapy) for severe postural deformities. These findings have immediate clinical applicability for physiotherapists and mental health professionals working with women presenting with postural and psychological comorbidities.

Conclusion: This robust 12-week intervention provides compelling evidence that Pilates constitutes an effective, safe, and accessible intervention for simultaneously addressing depression, pain, and postural abnormalities in women with hyperkyphosis. The demonstrated improvements across psychological and physical health domains underscore the value of mind-body approaches in comprehensive patient care. Healthcare providers should consider incorporating Pilates into rehabilitation protocols for women presenting with this cluster of symptoms. Future research directions should include longitudinal studies to assess durability of effects, investigations of optimal dosing parameters, and mechanistic studies examining neuromuscular and endocrine pathways. Additionally, comparative effectiveness research against other mind-body interventions (e.g., yoga, tai chi) would help refine clinical recommendations. This study makes a significant contribution to the growing evidence base supporting integrative, non-pharmacological approaches to women's health management, particularly in resource-limited settings where accessible interventions are paramount. The findings advocate for broader implementation of Pilates programs in community health initiatives, workplace wellness programs, and clinical rehabilitation settings.

Keywords: Pilates exercises, Angle of Kyphosis, Kyofometer, Depression, Pain Intensity.

Ethical Considerations

Compliance with ethical guidelines

The ethical principles observed in the article, such as the informed consent of the participants, the confidentiality of information, the permission of the participants to cancel their participation in the research. Ethical approval was obtained from the Research Ethics Committee of the Payam Noor University.

Funding

This study was extracted from the M.A thesis of third author at Department of Sport Psychology of Payam Noor University.

Authors' contribution

All authors contributed equally to the conceptualization of the article and writing of the original and subsequent drafts.

Conflict of interest

The authors declared no conflict of interest.

Acknowledgements

The authors would like to thank all participants of the present study.