METHODS (n=21 clinical pilates group, n=21 home exercise

METHODSTheinvestigation was randomized controlled trial examining the effects of 8-weekspilates exercises on walking, cognition, fall risk, respiratory and cognitivefunctions in patients with MS. Participants were recruited the study from the MS clinic of Dokuz Eylul University Hospital,from April to December 2017. Ethics approval for thestudy (the registration number: 3183-GOA) was obtained from Ethics Committee ofDokuz Eylul University. Written informed consent was taken from allparticipants who participate the study.

SubjectsParticipantsinvited the study in routine clinical examination and informed about exercise programand benefits. Eligibility was determined by the neurologist, physiotherapistand psychologist. A total of 42 patients with MS recruited the study. Patientswere allocated into two groups with stratified randomisation (n=21 clinicalpilates group, n=21 home exercise program group). Inclusioncriteria were, diagnosis of definite relapsing-remitting (RRMS) orsecondary-progressive MS (SPMS) according to revised McDonald criteria, an ageover than 18 years and willingness to participate in the study(polman 2010 revision makalesi). The exclusion criteria to the study wasdetermined as having any neurological illness except MS, in relapse or havingrelapsed in the previous 3 months, orthopedic disorders that could negativelyaffect gait and balance, cardiopulmonary, cognitive and psychiatric problemsthat affect performing pilates exercises, current and recent (within the last 6months) participation in core stability based exercise program.  Thesample size calculate was based on similar study examining the effect ofpilates exercises on walking thus sample size were determined per group was 18.InterventionClinicalPilates GroupTheexercise program was given one session in a week for 8 weeks plus two days homeexercise program.

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Exercise sessions were performed with a group based. Groupswere determined with two or three participants with similar physical status. Thesessions was instructed by physiotherapist who is certified in matwork pilatesby Australian Physiotherapy&Pilates Institute.Inthe first session abdominal draw in maneuver, basic principles includefocusing, breathing and location of the rib cage, shoulder, head and neck weretaught to the participants. Neutral alignment, activation of  M. Transversus Abdominis and breathingreminded for all exercises and corrections were done by physiotherapist.

Theduration of each session was 55-60 minutes. Following 10 minutes warm upexercises, main body exercises were performed in different posititions(standing, sitting, quadruped, side lying, supine and prone) and incorporatedwith resistance bands (Theraband Elastic Band Hygienic Corporation, Akron,Ohio) and exercise ball. In the final 5-10 minutes cool down exercises whichinclude posture and stretching exercises were performed. Exercises wereprogressively challenge from level 1 to level 3 exercises, changing positionsand reducing the base of support. First 4 weeks red Theraband and the last 4weeks green Theraband was used. Attendanceto each sessions was recorded. HomeExercise GroupParticipantsin the control group were given written exercises that matched the aims of thepilates exercises, 3 times per week for 8 weeks. These exercises reflectroutine clinical practice.

The program consist of warm up, main part and cooldown  periods. Progression wasprovided via increasing the number of repetitions, changing positions and baseof support. Three written brochures was given to participants (first 3 weeks,from 4 to 6 weeks and last 2 weeks) and they reminded by telephone.

They weregiven a diary to record days which they had obeyed the program. Subjects werecalled once a week and compliance was monitored. Participantsin both groups continued their routine medical treatment.  Outcome MeasuresEvaluationswere done at the beginning and at the end of the treatment. Physical parametersand respiratory muscle strength were assessed by physiotherapist, psychologicalassessments were carried out by psychologist, EDSS score was determined byneurologist.  Demographicdata includes gender, age height, weight, bodymass index (BMI), history offalls in the past 3 months, disease duration were recorded.  GaitAssessment Weused Six-Minute Walk Test (6MWT) to evaluate walking endurance. Participants wereinstructed to walk safely but as far as possible for 6 minutes.

Distance wasrecorded in meters.Timed25-Foot Walk Test (T25FWT) is widely used to assess gait speed in MS (Fischer,Rudick, Cutter, & Reingold, 1999). This test was performed in 7.62 meters(25-foot). After two trials average score obtained for analysis.Timed-Upand Go Test (TUG): Participants were asked to rise from a seated position, walkfor 3 meters,  then turn back and sitdown. The stopwatch was started verbal instruction ”go” and was stopped whenthe patient was seated in the chair.

In our study, cognitive and manuel formswas used. In the cognitive form, participants completed the test whilesubtracting by threes from a randomly selected number between 20 and 100.Manuel form was performed while holding a cup filled with water. (Shumway-Cook et al ,2000, Hofheinz andSchusterschitz, 2010).12-Item MS Walking Scale (MSWS-12) is a patient based,disease-spesific scale exploring the effects of MS disease on walkingimpairment that ranges from 12 to 54. BalanceAssessmentBiodexBalance System (Biodex® , Inc., Shirley, NY, USA)  is comprised of balance platform thatprovides 20° surface tilt and monitore that gives feedback to person.

Thissystem is valid and objective tool for assessment balance performance. Limitsof stability (LOS), postural stability and fall risk index tests was used inour study. Tests were performed with barefoot.PerceivedConfidenceFearof falling is a risk factor for falls in MS. Falls Efficacy Scale InternationalFES-I evaluates concern for falls during activities. Original FES-I contains 16items. In our study, short form FES-I was used which includes 7 items. Subjectsanswered how concerned they were about the fear of falling if they had toperform 7 different activities.

It was shown that FES-I 7 items has betterpsychometric properties in people with MS. Scores range from 1 (not allconcerned) to 4 (very concerned)  and ahigh score indicates high concern.ActivitiesSpesific Balance Confidence Scale (ABC) was used for evaluation the level ofperceived balance confidence while maintaining 16 activites in daily life.Rates of confidence from 0 percent to 100 percent. CoreStability AssessmentThecurl-up test is a measure of abdominal muscle endurance via repeated isotoniccontractions.

In this test, patients laid supine, bending the knee in 90° andtheir arms beside body in extension. Participants performed trunk flexion toreach their third fingertrip forward on the 10 cm. Successful curl-ups wererecorded in 60 seconds.  The curl-up testis a valid and reliable test in individuals with MS. RespiratoryMuscle Strength AssessmentMaximuminspiratory (MIP) and ekspiratory pressure (MEP) were used to assessrespiratory muscle strength by manovacuometer (The Pocket-Spiro® MPM100,Belgium).

To assess the inspiratory muscle strength, following maximumexpiration participants performed maximal inspiratory manuevers against theoccluded valve. The maximum expiratory pressure was evaluated with a forcedmaximum expiration from the total lung capacity. Measurements were performed insitting position. The largest of three evaluation was recorded.

CognitiveFunctionsBriefInternational Cognitive Assessment for Multiple Sclerosis (BICAMS) was used toevaluate cognitive status which includes Symbol DigitModalities Test (SDMT), California Verbal Learning Test-II  (CVLT-II) and Brief Visuospatial Memory TestRevised (BVMTR). The Turkish version of BICAMS is a suitable evaluation toassess the cognitive functions.  Statistical AnalysisData were analyzed using the IBM® SPSS® Statistics (ver. 24.0; SPSSInc., Chicago, IL, USA) for Windows software.

For cheching normality distribution,Shapiro-Wilk test was used. Wilcoxon signed rank test wasconducted in order to compare differences in each group before and afterintervention. The changes in the measured data between groups were compared with the Mann-Whitney U test. Statisticalsigni?cance was set at p<0.05.

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