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Effects of Pilates exercises on sensory interaction, postural control and fatigue in patients with multiple sclerosis
Multiple Sclerosis and Related Disorders, Volume 7, May 2016, Pages 70–73
Decreased postural control, sensory integration deficits and fatigue are important problems that cause functional impairments in patients with multiple sclerosis (pwMS).
To examine the effect of modified clinical Pilates exercises on sensory interaction and balance, postural control and fatigue in pwMS.
Eleven patients with multiple sclerosis and 12 healthy matched controls were recruited in this study. Limits of stability and postural stability tests were used to evaluate postural control by Biodex Balance System and sensory interaction assessed. Fatigue was assessed by Modified Fatigue Impact Scale. Pilates exercises were applied two times a week for 10 weeks and measurements were repeated to pwMS after exercise training.
Postural control and fatigue (except psychosocial parameter) of pwMS were significantly worser than healthy controls (p<0.05). Significant improvements occurred in sensory interaction (eyes open, foam surface) and total, physical and cognitive scores of fatigue after 10-week modified clinical Pilates training (p<0.05). No significant changes were detected in postural control after the pilates exercises (p>0.05).
Ten-week Pilates training is effective to improve sensory interaction and to decrease fatigue. Pilates exercises can be applied safely in ambulatory pwMS for enhance sensory interaction and balance and combat fatigue. More investigations are needed.
- Poor postural control is linked to sensory deficits in multiple sclerosis (MS).
- Lack of scientific evidence the effectiveness of Pilates exercises in MS.
- Pilates exercises for central integration is effective to improve sensory interaction.
Keywords: Sensory interaction, Postural control, Pilates exercises, Fatigue, Multiple sclerosis.
Multiple sclerosis (MS) is a chronic, autoimmune, demyelinating, degenerative disease of the central nervous system (Trapp and Nave, 2008). Patients with MS (pwMS) are effected by visual, vestibular and somatosensory impairments and frequently experience postural instability, sensory disturbances and fatigue. Poor postural control and fatigue are linked to central integration deficits and suffer some adaptive problems with disability (Cameron and Lord, 2010, Cattaneo and Jonsdottir, 2009, Hebert et al, 2011, Krishnan et al, 2012, and Freal et al, 1984).
Different assessment strategies have been offered for impairments in MS. Clinicians have available clinical tests to quantify postural control such as force plates and postural stabilometries (Gandolfi et al, 2015, Robinson et al, 2015, and Eftekharsadat et al, 2015). However computarized stabilometry has become an important objective tool for assessing sensory integration for balance and postural control, there is no study that evaluate the sensory interaction and postural control in patients with MS by Biodex Balance System after exercise training.
Although the benefits of regular exercise for patients with MS are known, wide variety of exercise types for reduce deficits in mobility, fatigue and balance focus on strengthing, stretching, aerobic, endurance, core exercises and yoga (Motl and Sandroff, 2015 and Gunn et al, 2015). Furthermore Pilates based exercises are popular form of exercise that use stabilising muscles of the body and postural stability but there is lack of scientific evidence to support the effectiveness of Pilates exercises in pwMS (Freeman et al, 2010 and Guclu-Gunduz et al, 2014).
Our hypothesis was a modified clinical Pilates exercises that specifically addresses postural stability and central integration improve sensory interaction, postural control and fatigue. This study has had two aims: first aim was to compare sensory interaction and balance, postural control and fatigue in pwMS and healthy subjects, the second but important one was to determine the effect of modified clinical Pilates exercises on sensory interaction, postural control and fatigue in pwMS.
2. Materials and methods
This was a single blind, experimental before-after cohort, controlled study. Ethical approval has been gained from Dokuz Eylül University Ethics Commitee and written informed consent was obtained from all participants to participate the study.
From March 2015 to June 2015, eleven outpatient with relapsing-remitting MS referred to the local MS society and 12 healthy matched controls were assessed. A neurologist confirmed diagnosis, eligibility criteria and Expanded Disability Status Scale (EDSS) scores. Inclusion criterias were; age between 18 and 65 years,, 2≥EDSS score ≤5, ability to walk independently with or without use of intermittent or constant unilateral assisstance such as walking stick, ability to stand independently without any aid for at least 3 minutes for pwMS. Exclusion criterias were; in MS relapse or relapse in previous three months, presence of paroxysmal vertigo, blurred vision, concurrent neurological or orthopeadic disorders interfering with the standing position, medical conditions that restrict participation in the Pilates, current or recent participation in another exercise programme.
2.3. Exercise procedure
Patients with MS underwent 10-week modified clinical Pilates training designed to improve their ability to integrate multisensory inputs and challenge postural control. Pilates was applied by an Australian Physiotherapy and Pilates Institute (APPI) certified physiotherapist. Activation of transversus abdominus in neutral spinal alignment and basic principles of Pilates was informed in first session. Exercises were performed in front of the mirror and different positions (supine, prone, side lying, sitting and upright position). Exercises were progressed in response to the feedback of the participants. Modified clinical Pilates exercises applied one hour a day, twice a week and every exercise was done with 10 repetitions.
2.4. Test procedure
The demographics of participants were noted before test trials. Each participant was assessed by the blinded examiner. When healthy controls were evaluated for once, pwMS were evaluated before and after exercise training.
The Biodex Balance System (BBS; SD 12.1“Display 115 VAC) was used to assess postural control and clinical test of sensory interaction and balance (CTSIB). Limits of stability (reaction time and overall score) and postural stability tests (overall, mediolateral and anteroposterior score) were used to evaluate postural control in rigit surface and eyes open during a period of 20 s. Participants stood barefoot and were not permitted to touch the handrails during the tests. The platform locked and the patients were asked to control themselves keeping the indicator in the center of target on the screen for postural balance position. Firm and foam surfaces were used and patients were asked to open or close their eyes during dynamic CTSIB test. The foot position was recorded using the platform rail. Three trials with a rest period of 10 s were performed in each condition. Postural tasks were explained to each participant before starting the measurements. Participants were fully briefed on all testing procedures. Not only lower postural stability and CTSIB scores, but also higher limits of stability scores reflect better postural control (Eftekharsadat et al, 2015 and Sherafat et al, 2013).
Fatigue was evaluated with Modified Fatigue Impact Scale (MFIS). The MFIS is a 21-item shortened version of the 40-item Fatigue Impact Scale. It assesses the perceived impact of fatigue on the subscales physical, cognitive and psychosocial functioning during the past 4 weeks. Total score (0−84) and subscales for physical (0−36), cognitive (0−40) and psychosocial functioning (0−8). The 5 item version is scored (0−20). Higher numbers indicate greater fatigue (Larson, 2013).
2.5. Statistical analysis
Descriptive statistics were expressed as median, minimum-maximum and percentage. Mann Whitney U test was used for compare results of pwMS and healthy controls. The treatment effect was tested with Wilcoxon signed-rank test. Significance was set at 0.05 for the analysis. All data were analyzed using the SPSS 20.0 software package.
Median age of MS patients was 52.0 and median EDSS score were 3.5 (Table 1).
|Age (years) Median (IQR)||52 (35–66)|
|EDSS (0–10) Median (IQR)||3.5 (2.0–5.0)|
|Male n(%)||7 (63.6)|
|Female n(%)||4 (36.4)|
|Working n(%)||2 (18.2)|
|Not working n(%)||9 (81.8)|
|Using n(%)||4 (36.4)|
|Not using n(%)||7 (63.6)|
n:number, EDSS: Expanded Disability Status Scale, IQR: minimum-maximum
Age, gender and working status of pwMS and healthy subjects were similar (p>0.05). However postural control scores and fatigue (except psychosocial parameter) of healthy controls were significantly better than pwMS (p<0.05), there was no significantly difference between the groups in CTSIB scores and psychosocial parameter of fatigue (p>0.05, Table 2).
|MS patients||Healthy controls||p|
|Median (IQR)||Median (IQR)|
|Age (years)||52 (35–66)||50 (38–65)||0.805|
|Gender (n, %)|
|(female, male)||7 (63.6), 4 (36,4)||7 (58.3), 5 (41.7)||0.833|
|Working status (n, %)|
|(working, not working)||2 (18.2), 9 (81.8)||1 (8.3), 11 (91.7)||0.493|
|Overall||0.60 (0.30–1.50)||0.05 (0.00–0.30)||0.001⁎|
|Anteroposterior||0.40 (0.10–0.90)||0.00 (0.00–0.20)||0.001⁎|
|Mediolateral||0.20 (0.10–1.10)||0.00 (0.00–0.10)||0.001⁎|
|Limits of stability|
|Reaction time (min.)||0.38 (0.3–2.47)||0.53 (0.36–1.11)||0.124|
|Overall||53 (13–80)||34 (10–59)||0.045⁎|
|Eyes open firm surface||1.03 (0.45–2.24)||0.90 (0.30–1.06)||0.139|
|Eyes closed firm surface||1.27 (0.46–2.25)||1.00 (0.50–1.10)||0.065|
|Eyes open foam surface||1.08 (0.54–2.05)||0.99 (0.33–1.15)||0.207|
|Eyes closed foam surface||1.10 (0.40–1.99)||1.01 (0.55–1.12)||0.538|
|Total||25 (12–69)||12 (4–16)||0.001⁎|
|Physical||12 (7–29)||2 (0–5)||0.001⁎|
|Cognitive||11 (2–37)||3.5 (1–7)||0.004⁎|
|Psychosocial||3 (0–6)||4 (2–9)||0.126|
n: number, min: minutes, CTSIB: Clinical test for sensory interaction and balance, IQR: minimum-maximum,
Significant improvements occurred in CTSIB (eyes open, foam surface) and total, physical and cognitive scores of fatigue after 10-week modified clinical Pilates training (p<0.05). No significant changes were detected in postural control after the pilates exercises compared to baseline (p>0.05, Table 3).
|Before exercise||After exercise||p|
|Median (IQR)||Median (IQR)|
|Overall||0.60 (0.30–1.50)||0.40 (0.20–1.10)||0.280|
|Anteroposterior||0.40 (0.10–0.90)||0.50 (0.20–0.80)||0.861|
|Mediolateral||0.20 (0.10–1.10)||0.20 (0.10–0.80)||0.161|
|Limits of stability|
|Reaction time (min.)||0.38 (0.30–2.47)||0.44 (0.22–1.39)||0.153|
|Overall||53 (13–80)||55 (30–91)||0.721|
|Eyes open firm surface||1.03 (0.45–2.24)||0.89 (0.39–1.87)||0.929|
|Eyes closed firm surface||1.27 (0.46–2.25)||1.62 (0.87–2.44)||0.110|
|Eyes open foam surface||1.08 (0.54–2.05)||0.77 (0.38–1.61)||0.016⁎|
|Eyes closed foam surface||1.10 (0.40–1.99)||1.16 (0.80–2.67)||0.965|
|Total||25 (12–69)||23 (11–69)||0.033⁎|
|Physical||12 (7–29)||8 (7–29)||0.011⁎|
|Cognitive||11 (2–37)||9 (2–37)||0.039⁎|
|Psychosocial||3 (0–6)||3 (0–8)||0.785|
min: minutes, CTSIB: Clinical test for sensory interaction and balance, IQR: minimum-maximum,
Postural control and fatigue (except psychosocial parameter) were better in healthy individuals when compared with pwMS. Sensory interaction and balance was similar.
Fatigue was significantly decreased after ten weeks modified clinical Pilates exercise. Patients performed significantly better sensory interaction test in eyes open foam surface after the pilates exercises compared to baseline. There was no significant difference in postural control.
Spesific balance training may induce positive effects as reduced fatigue and improvement in the central integration of sensory input process in pwMS. Different exercises were studied to improve postural control including strengthing, weight bearing, vestibular stimulation, sensory integration training. Gandolfi et al. (2015) shown that sensory integration was related to the fatigue in MS. According to their results central sensory integration that tested with ‘Sensory organization balance test’ improved postural control and decreased fatigue. In a study of Brichetto et al. (2015) tailored interventions (visual, proprioceptive and vestibular) was found crucial to improve postural control but not fatigue in pwMS those were assessed with computarized dynamic posturography and MFIS.
Robinson et al. (2015) investigated the effects of exergaming on balance in pwMS. They used force platform for assessment and exercises with Nintendo Wii. Their findings supported that the use of Wii is effective in balance and motivation of patients. In another study that aimed to investigate the effect of virtual reality based balance training in pwMS, Eftekharsadat et al. (2015) performed postural stability training for balance training used the BBS. After 24 session of virtual reality training with BBS overall postural stability results of the patients were significantly improved. Parallel to this study we evaluate our participants with BBS (not only postural control but also CTSIB) but in our study modified clinical pilates exercises were performed to patients. CTSIB (eyes open foam surface) was significantly improved but postural control was did not. This result evidenced that pilates exercises improved sensory interaction in foam surface.
There are limited studies that explored the effect of Pilates exercises on postural control and fatigue in MS. This type of exercises include core components and improves cognitive and sensory retraining strategies and decreases fatigue (Eftekharsadat et al., 2015). Freeman et al. (2010) stated that core stability exercises were important for pwMS however there was a lack of scientific evidence to support its effectiveness. They evaluated timed get up and go, 10 m timed walk and single leg stance in ambulatory patients. Their study provided evidence of the effectiveness of an 8-week core stability training in improving balance and mobility. In one study that aimed to effect of pilates exercises and aquatic exercises on dynamic balance, Marandi et al. (2013) reported that dynamic balance has significantly increased after 12 weeks Pilates exercise and aquatic exercises. Guclu-Gunduz et al. (2014) showed that 8-week Pilates based core stability program improved balance, mobility and strength in pwMS.
None of the discussed studies investigated the effect of Pilates exercises on postural control, CTSIB and fatigue and compare them with healthy controls. In terms of the design of the study and the level of the disability of the patients, there are certain differences between these studies and ours. In our study, we focused on CTSIB, postural control and fatigue. Other studies emphasized that the development of balance, mobility and muscle strength only with traditional and some sensory integrated exercises. However, to our knowledge our study is the first study that evaluated CTSIB, postural control and fatigue after the pilates exercises in MS.
Assessment tool (Biodex Balance System) gave us objective results for postural control after exercise training. This was the strength of our study, however our population was too small. Disability status were 2.0–.0$12therefore, we can generalize our result just for ambulatory patients. The results could be compared in different group of disability levels if we could be able to enroll more patients to our study. On the other hand randomization was one of our limitations, there was no other exercise group. Further studies with larger sample sizes and different levels of disability are needed.
Ten-week Pilates exercise training that specifically addresses postural control and central integration is effective to improve sensory interaction and to decrease fatigue. Pilates exercises can be applied safely in ambulatory pwMS for enhance sensory interaction and balance and combat fatigue.
Conflict of interest
The authors declare that they have no conflict of interest.
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a School of Physical Therapy and Rehabilitation, Dokuz Eylül University, 35340 İnciraltı, İzmir, Turkey
b Health Services Vocational School, İzmir Katip Çelebi University, 35340 İnciraltı, İzmir, Turkey
c Faculty of Medicine, Department of Neurology, Dokuz Eylül University, 35340 İnciraltı, İzmir, Turkey
⁎ Corresponding author.
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