Objectives To investigate the effect of Pilates on balance and falls in older adults, and whether programs tested in prior studies met best-practice recommendations for exercise to prevent falls. Data Sources MEDLINE, SPORTDiscus, CINAHL, PubMed, Physiotherapy Evidence Database, and The Cochrane Library were searched from earliest record to July 2014. Study Selection Randomized and controlled clinical trials evaluating the effect of Pilates on balance and/or falls in older adults. Data Extraction Two reviewers independently extracted demographic, intervention, and outcome data. Six studies were included in this review. Data Synthesis High-quality studies in this area are lacking. When compared with nonactive control groups, Pilates was shown to improve balance (standardized mean difference [SMD]=.84; 95 confidence interval [CI],.44-1.23; 6 studies) and reduce the number of falls (SMD=-2.03; 95 CI, -2.66 to -1.40; 1 study). Three studies provided sufficient detail to enable assessment of compliance with the recommendation of exercises providing a moderate or high challenge to balance. In these studies, 2 to 36 of exercises were assessed as providing a moderate or high challenge to balance. All studies provided =2 hours of exercise per week, and 1 study provided >50 hours of exercise during the study period. Conclusions The evidence suggests Pilates can improve balance, an important risk factor for falls in older adults. However, there is limited data on the impact of Pilates on falls. Effects may have been overestimated because of the low methodological quality of studies. Best-practice recommendations were rarely applied in prior studies, indicating greater effects may have been achieved if recommendations were incorporated.