The effectiveness of the therapeutic exercise Clinical Pilates in adult patients with multiple sclerosis: a systematic review

International Journal of Clinical Trials Matsouki E et al. Int J Clin Trials. 2024 Aug;11(3):240-251 http://www.ijclinicaltrials.com pISSN 2349-3240 | eISSN 2349-3259

DOI: https://dx.doi.org/10.18203/2349-3259.ijct20241618

Systematic Review

The effectiveness of the therapeutic exercise Clinical Pilates in adult

patients with multiple sclerosis: a systematic review

Eleni Matsouki1, Georgios Marios Kyriakatis2*

1Department of Physiotherapy, School of Health Rehabilitation Sciences, University of Patras, Rion, Achaia, Greece 2Department of Physiotherapy, School of Health Sciences, University of Thessaly, 3rd km Old National Road Lamia- Athens, Lamia, Greece Received: 07 June 2024 Revised: 12 June 2024 Accepted: 13 June 2024 *Correspondence: Georgios Marios Kyriakatis, E-mail: georgemarioskiriakatis2000@gmail.com Copyright: © the author(s), publisher and licensee Medip Academy. 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.

ABSTRACT Existing literature supports various forms of exercise as appropriate for treating people with multiple sclerosis (MS) with mild or more severe symptoms. In recent years, Pilates is a form of therapeutic exercise used more and more often in rehabilitating people with MS. The purpose of this systematic review is to explore the effectiveness of the clinical Pilates method in adult people with MS. Research was performed in 4 scientific databases (PubMed/MEDLINE, ScienceDirect, PEDro and Scopus) using the following keywords: multiple sclerosis, MS, Pilates and Clinical Pilates. Inclusion criteria were studies randomized controlled, written in English, published in 2012-2022, with adult people with MS and where the intervention should have been only the Pilates method and the results had to be relevant to physiotherapy. The methodological quality of the studies included was assessed by PEDro Scale. From a total of 329 initial records, only 12 studies were included. Results show that Pilates can improve balance, gait, functionality, physical and cognitive capacity, quality of life and body composition in adult people with MS and with mild to moderate disability. Fatigue, anxiety and depression levels did not show clear improvement after the application of the Pilates exercises in comparison with other therapeutic exercises. Pilates is a safe method of exercise for adult people with MS and can improve many symptoms. It is necessary more research to be conducted so that the effectiveness of the Pilates exercises be explored further on different parameters in patients with MS, like fatigue. Keywords: Multiple sclerosis, Pilates, Mat pilates, Exercise method, Physiotherapy

INTRODUCTION

Multiple sclerosis (MS) is an inflammatory autoimmune disease of the central nervous system manifesting various forms of progression. The most common form of MS is the relapsing-remitting form, which is characterized by periods of remissions and relapses of symptoms.1 It is estimated that 2.5 million people worldwide suffer from MS, while 500,000 of them are European citizens.2

Most patients with MS experience numbness and non- physiological muscle tone and weakness, especially in the

lower limbs, resulting in gait difficulties.3 Fatigue and visual problems are also evident in 40% of patients, while smaller proportions of patients have pain, dizziness, bladder and bowel dysfunctions, depression, or varying levels of cognitive disorders.4 All the above deficits result in gradual loss of walking and independence of the patients with MS, which in turn, result in decreased quality of life and participation of people with MS in the community.5

The literature supports a large number of exercise modalities as suitable for treating less or more severe

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symptoms of the patients with MS, but without demonstrating any particular one as the most effective.6 For example, there are studies that suggest that stretching and high-intensity aerobic exercise help relax spasticity and increase aerobic capacity respectively, but various studies conclude that a combination of different types of exercise might be more effective for these patients.3,7-9

A therapeutic exercise method that combines different types of exercises and has been increasingly used in the recent years for people with MS is Pilates method (Clinical Pilates or Therapeutic Pilates).10,11 The Pilates method involves repetitive exercises that aim to increase strength, flexibility and endurance of the muscles. All exercises are followed by certain rules that must be strictly applied in order to achieve the maximum effect of the exercises and avoid injuries.12 Patients with MS who were in a wheelchair seem to have noticed physical, psychological and social benefits, an improvement in their sitting position and a reduction in shoulder and back pain, while home exercise with Pilates improved symptoms of anxiety, depression and fatigue in patients with mild to moderate mobility problems.10,11 Pilates is an exercise method that can be performed individually or in groups, combining exercises to strengthen and stretch the body's contracting structures (muscles, ligaments and fasciae), as well as exercises to mobilise and stabilise the spine and the peripheral joints.13

The combination of Pilates and other forms of exercise seems to be more effective on some parameters of MS based on some research. Better results in controlling fatigue is when Pilates is combined with aerobic exercise by regulating the body's neuroimmune parameters since cytokine levels are regulated and the anti-inflammatory action of serotonin is enhanced.14 A randomized controlled trial (RCT) concluded that combined resistance, Pilates, resistance, balance and stretching exercise activates neurotrophin production and release regardless of their disability level and thus the modified exercise may have effects in people with MS and different fitness levels, while the same combination of exercises activated anti-inflammatory processes with the production of substances such as pentraxin and cytokine.15,16

In modern international literature, there is a scientific gap in terms of systematic reviews that include only RCTs and that exclusively evaluate the application of Pilates programs in adult patients with MS and not in combination with other interventions. The present study will attempt to address the need to draw objective conclusions about the effectiveness of Pilates therapy in people with MS on parameters of physical, mental and cognitive function.

Therefore, the purpose of this systematic review was to investigate the effect of the Clinical Pilates therapeutic exercise method on adults with MS.

METHODS

This systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.17

Search strategy and selection process

Search of eligible reports was conducted in four databases: PubMed/MEDLINE, Science Direct, Physiotherapy Evidence Database (PEDro) and Scopus from 2012 and until May 2022. Key terms relevant to multiple sclerosis and Pilates were used. Studies that initially met the inclusion criteria for the systematic review were entered in Mendeley reference manager. After duplicates were deleted, evaluation of the references’ titles and abstracts was performed according to the pre-determined inclusion and exclusion criteria and irrelevant references were deleted. After the full texts of the included in the review studies were retrieved.

Eligibility criteria

The inclusion and exclusion criteria of the review were based on the Population/Patient, Intervention, Comparison, Outcomes (PICO) structure and are presented in Table 1. Only RCTs were meant to be included in this study.

Table 1: Inclusion and exclusion criteria of the

studies.

P=population; I=intervention; C=comparison; O=outcomes, PNF=proprioceptive neuromuscular facilitation.

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Data collection process and data items

Data from studies were extracted by one person and checked by a second person. Τhe data extracted included the characteristics of the participants (age, gender, severity of condition); the type of intervention (Pilates) and its parameters (duration of session, number of sessions and total program duration); the type of intervention of the control group and the outcome measures at post-intervention and if available at follow- up.

Quality assessment of the trials

The quality of the studies was assessed independently using the PEDro scale (Physiotherapy Evidence Database scale) by both the two authors.18 The PEDro scale is a tool for evaluating studies involving physiotherapy interventions and in particular RCTs. It includes a total of 11 criteria with the first criterion relating to the external validity of the study, the second to ninth criteria relating to the internal validity of the study, while the last two criteria assess the statistical evidence so that the results of the study can be interpreted. Each criterion is scored 0 or

1 point, except for the first criterion which is not scored and the total score of a study can range from 0 to 10. Studies with a score 0-3 are rated as of “low methodological quality”, with a score 4-5 as of “moderate methodological quality”, with a score of 6-8 as of “good methodological quality” and with a score 9-10 as of “excellent methodological quality”.19

RESULTS

Study selection

The search of the 4 databases retrieved 329 records and after duplicates were deleted 258 records remained for screening. Of these, 58 records were published before 2012 and, thus, 200 records remained for further screening. After reading the titles and abstracts, 169 studies were discarded, 3 studies were discarded due to lack of access to the full text of the studies, and finally, 12 studies were included to the review according to the inclusion and exclusion criteria. The flowchart of the PRISMA 2020 for the selection process of the studies is presented in Figure 1.

Figure 1: Flowchart of the selection of the studies process. PEDro=Physiotherapy evidence database, RCT=randomized controlled trial.

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Table 2: Characteristics of the studies.

Continued.

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RCT=Randomized Control Trial, n=number of participants, PDDS=Patient-Determined Disease Step Score, STAI=State-Trait Anxiety Inventory, HADS=Hospital Anxiety and Depression Scale, QIDS=Quick Inventory of Depressive Symptomatology, MFIS=Modified Fatigue Impact Scale, EDSS=Expanded Disability Status Scale, m-CTSIB=modified Clinical Test of Sensory Integration of Balance, BESS=Balance Error Scoring System, PST=Postural Stability Test, BBS=Berg’s Balance Scale, TUG test=Time Up and Go test, FRT=Functional Reach Test, 6MWT=Six-Minute Walk Test, T25FW=The Timed 25-Foot Walk, MSWS-12=The 12-item MS Walking Scale, FES-I=Falls Efficacy Scale International, ABC=Activities-Specific Balance Confidence, MIP=Maximum Inspiratory Pressure, MEP=Maximum Expiratory Pressure, BICAMS=Brief International Cognitive Assessment for Multiple Sclerosis, POMS-B=Profile of Mood States – Brief Form, 7d-PAR=Seven-day Physical Activity Recall Scale, GLTEQ=Godin Leisure-Time Exercise Questionnaire, BMI=Body Mass Index, FM=Fat Mass, BD=Body Density, FP=Fat Percentage, 10MWT=Timed 10-Meter Walk Test, FSS=Fatigue Severity Scale, MSQOL-54=Multiple Sclerosis Quality of Life Instrument, 2MWT=Timed 2-Meter Walk Test, FSST=Four Square Step Test, MSWS-12=12-Item Multiple Sclerosis Walking Scale, NRS=Numeric Rating Scale, MSFC=Multiple Sclerosis Functional Composite, TIS=Trunk Impairment Scale, BDI=Beck Depression Inventory, MusiQol=Multiple Sclerosis International Quality of Life Questionnaire, TGUG=Timed Get-Up-and-Go.

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Table 3: Assessment of the methodological quality of the studies for adherence to quality criteria and risk of bias based on the PEDro Scale.

#1=eligibility criteria, #2=random allocation, #3=concealed allocation, #4=baseline comparability, #5=participant blinding, #6=therapist blinding, #7=assessor blinding, #8=outcome data > 85%, #9=intention to treat analysis, #10=between-group difference, #11=point estimates and variability.

Table 4: Results of studies.

Continued.

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BBS=Berg’s Balance Scale, TUG test=Time Up and Go test, FRT=Functional Reach Test, BMI=Body Mass Index, NRS=Numeric Rating Scale, MFIS=Modified Fatigue Impact Scale, MSFC=Multiple Sclerosis Functional Composite, TIS=Trunk Impairment Scale, BDI=Beck Depression Inventory, MusiQol=Multiple Sclerosis International Quality of Life Questionnaire, ABC=Activities-Specific Balance Confidence, TGUG=Timed Get-Up-and-Go.

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Study characteristics

All of the studies used in this systematic review are RCTs and one of them is a pilot RCT. Most clinical trials used a small sample size of 18 to 50 people, and only two trials had more than 50 subjects in the sample. In all studies the sample included individuals of both genders, except for two that included only men and one that included only women.20-22 In one study, a separate analysis of the female sample was conducted to assess the effect of gender on trial parameters.11 All study participants were ambulatory with an Expanded Disability Status Scale (EDSS) score of less than 6.5.

All of the studies had a total duration of 8 weeks of Pilates interventions, except for three studies that had a total intervention duration of 12 weeks.21,23,24 The majority of sessions were held twice a week. In three studies, Pilates home exercise instructions were provided alongside the intervention and in two studies DVD- assisted support was provided.11,23-26 The duration of each session was typically 60 minutes, with a range of 45-90 minutes, with the exception of two studies where the session duration was 30 minutes.23,24 Sessions were conducted by Pilates-certified physiotherapists, except for two studies that were conducted by certified Pilates instructors.11,26 Three studies did not report the professional status of the instructors and whether or not they were certified.20-22

Pilates’s sessions were mainly conducted on an individual level, except for three studies where interventions were conducted in groups.25,27,28 Two studies did not specify whether it was an individual or group Pilates class and in three studies whether the class was Mat Pilates or Reformer Pilates.20,22,24,27 In the remaining studies the interventions were Mat Pilates and the use of small equipment such as balls was used, rubber bands and foam rollers.21,23,25,27,29,30

All interventions were preceded by training in the basic principles of Pilates and training in lateral breathing and transverse abdominal activation to achieve better core activation and spinal stabilization. Also all interventions were structured in warm-up, main program and recovery and aimed at the recovery of MS symptoms. For this reason, Pilates programs were all dynamic and gradually increased the volume of exercise, either with more repetitions, or with longer session duration, or by using higher resistance, or by changing positions and reducing the support base.11,21,22,24-30

In addition, 4 studies did not report at all on whether or not there were any adverse events, while the remaining 8 studies did not observe any adverse events in any participant related to the types of interventions used in the clinical trials. In one study, a specific description is given only for the experimental group where there were no adverse outcomes, and in another it is reported that no adverse or harmful outcomes occurred in any of the groups.23,24

The characteristics of the studies used are shown in Table 2.

Quality of studies

The mean qualitative rating of the studies selected for this systematic review is 5.42. One of the studies has low methodological quality with a total score of 3/10, 6 studies have moderate methodological quality (4.5/10±0.5/10) and 5 studies were rated with good methodological quality (6/10±1/10) (Table 3).

Effectiveness of the interventions

The results of each study are presented in Table 4.

Balance

In all studies Pilates seemed to improve some of the balance parameters after the intervention compared to the initial measurements. The Pilates groups had statistically significant improvements in balance compared to usual care (p<0.05) and compared to those who followed the same lifestyle (p<0.05).21,22 Pilates was statistically significantly more effective than trampoline exercise in improving static balance after completing the intervention at 8 weeks (p<0.01).20

Gait

Statistically significant improvement in walking speed in the Pilates group compared to the lifestyle group (p=0.000).22 Other studies found no statistically significant differences between the Pilates groups and the other compared interventions.23-25

Fatigue

According to all studies evaluating fatigue, Pilates has a positive effect after implementation in people with MS. Pilates is more effective after 8 weeks of intervention compared to wait-listing (p<0.001).11 Pilates at home statistically significantly reduced overall fatigue compared to waitlist after 8 weeks (p≤0.02).26 No statistically significant differences found between Pilates and physical therapy groups after 12 weeks (p>0.05).24

Functionality and physical ability

Functionality and physical fitness include the parameters of strength, endurance, physical and aerobic capacity. All studies had positive results on these parameters using Pilates. More specifically, endurance, strength and core physical capacity increased more in the group that did Pilates with supervision compared to those that did an individual home program (p<0.001).29 Statistically significant increase in trunk flexion strength in the Reformer Pilates group compared to the Mat Pilates group at the end of the interventions (p<0.05).30 Respiratory muscle strength was assessed by peak inspiratory and expiratory pressures and was found to be

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significantly increased in the group doing Clinical Pilates compared to the group doing other types of home exercises (p<0.05).25

Cognitive function & quality of life

Pilates statistically significantly improved the quality of life and cognitive function of study participants compared to before the interventions. The cognitive level was significantly higher in the Clinical Pilates group compared to the group doing other types of home exercises after 8 weeks (p<0.05) and the cognitive function and quality of life improved statistically significantly in the Clinical Pilates group more than in the control group following a usual treatment (p<0.05).25,28

Anxiety & depression

Pilates implementation was statistically more effective on depression and anxiety than waiting list after 8 weeks (p<0.001), whereas there were no statistically significant differences between the compared groups in terms of anxiety symptoms after 8 weeks (p≥0.053).11,27

Body composition

Pilates had no statistically significant difference in body composition change in women with MS after 8 weeks compared to those who maintained the same lifestyle (p>0.05), and only BMI decreased statistically significantly in Pilates group after the intervention (p≤0.05).22

Comparison of different forms of Pilates

Comparing Mat Pilates with Reformer Pilates found no statistically significant differences in any of the parameters measured, except core strength, at the end of the interventions (p>0.05).30 More specifically, trunk flexion test improved statistically significantly more in the Reformer Pilates group than the Mat Pilates group after 8 weeks (p=0.044).30 Individual Pilates classes with and without supervision at home and found that endurance, strength and core physical capacity increased more in the group doing Pilates with supervision compared to those doing an unsupervised program (p<0.001), while no statistically significant difference was observed between the two groups in fatigue (p>0.001).29

DISCUSSION

The purpose of this systematic review was to investigate whether there is an effect of Pilates on the symptomatology of adults with MS. The results suggest that the question was answered and filled a gap in the literature. There are other contemporary systematic reviews in the scientific databases that address similar questions to this paper. However, authors in previous systematic reviews not only included RCTs but also other lower quality research designs, while some other authors

included interventions combining Pilates with another form of exercise e.g. swimming or with physiotherapy interventions e.g. massage or medication, whereas this systematic review investigated Pilates programs exclusively.31-34 Furthermore, the results of this review are partially consistent with the results of other contemporary systematic reviews and meta-analyses that have been conducted.

Pilates can be considered as an alternative method of training and improving balance in patients with MS, but was not found to be superior to other interventions and the authors noted that more research is needed to investigate its effectiveness.35 More specifically, they found that Pilates had a statistically significant difference compared to controls on the BBS (p=0.041) and TUG (p=0.045) balance tests and the ABC scale (p=0.024), but not on the FRT (p=0.06). In the present systematic review only two studies give advantages of Pilates exercise over usual care after 12 weeks [BBS (p=0.001), TUG (p=0.003), FRT (p=0.002)] and the maintenance of the same lifestyle after 8 weeks (p=0.003).21,22

Pilates can also be considered a rehabilitation tool in a wider group of pathologies such as low back pain, ankylosing spondylitis, MS, post-menopausal osteoporosis, non-structural scoliosis, hypertension and neck pain.36 The results were related to pain reduction and improved functionality and are consistent with the findings of the present review on the effect of Pilates on functionality and physical performance in adult subjects with MS (Table 4). The review by Byrnes et al includes only two studies related to MS, whereas the results in the present review are supported by the findings of more clinical trials.24,25,27-30,36