# Exercise as it relates to Disease/The effect of pilates training on multiple sclerosis

This is a critique of the research article: Whitney R.D. Duff, Justin W. Andrushko, Doug W. Renshaw, Philip D. Chilibeck, Jonathan P. Farthing, Jana Danielson, and Charity D. Evans (2018) Impact of Pilates Exercise in Multiple Sclerosis. International Journal of MS Care: March/April 2018, Vol. 20, No. 2, pp. 92-100.
The critique was written for a wiki assignment for Health, Disease and Exercise (8365) at the University of Canberra, September 2019.

## What is the background to this research?

Before it was suggested that people living with multiple sclerosis (MS) should avoid exercise. However these days, those with MS can tolerate physical exercise, which is helpful in managing symptoms, preventing complications and comorbidities as well as maintaining overall well being.
Pilates training is a series of exercises, based on whole-body movements that focuses on body structure, body alignment and muscle recruitment with an emphasis on stabilizing core muscles during dynamic movements. Pilates may have a beneﬁcial effect because activation of core muscles could combat difﬁculties with mobility and balance in persons with MS. Despite this, a meta-analysis of 12 studies of 2360 patients with MS, cumulative evidence suggested that patients with MS are less physically active than people without the disease.
The purpose of the present study was to see if Pilates specific training on persons with MS, could improve mobility and determine the effect of Pilates in walking performance in people with multiple sclerosis. The importance of this study can help influence different types of training adaptations such as Pilates training in the physical therapy of persons with MS, which could promote further investigation into why this specific type of training is beneficial in the well being of persons with multiple sclerosis.

## Where is the research from?

The Authors of this study, Whitney R.D. Duff (College of Medicine), PhD; Justin W. Andrushko (College of Kinesiology), MSc; Doug W. Renshaw (College of Kinesiology) , MEd; Philip D. Chilibeck (College of Kinesiology), PhD; Jonathan P. Farthing (College of Kinesiology), PhD; Jana Danielson (College of Kinesiology), MBA; Charity D. Evans (College of Pharmacy and Nutrition), all have extensive knowledge in this study, planned and implemented by the Consortium of Multiple Sclerosis Centers in Canada. The assessment was undertaken at the University of Saskatchewan and the intervention at Lead Pilates and Integrative Therapies sites, both located in Saskatoon, Saskatchewan, Canada.

## What kind of research was this?

The study conducted on the Impact of Pilates Exercise in Multiple Sclerosis was a RCT - Randomized Controlled Trial. Which means people are allocated at random to receive one of several clinical interventions. RCT reduces bias and provides a outcomes to examine a cause-effect relationship between an intervention and an outcome. This is because the RCT balances out participants attributes between groups, allowing characteristic differences between the groups, this is not possible with any other design such as observational or meta-analysis.

## What did the research involve?

A total of 30 individuals (15 female, 15 male) were obtained through the local MS Society of Canada office and social media from November 20, 2016, through January 20, 2017. The criteria was kept broad that consisted of a diagnosis of MS, that were not restricted to a wheelchair or scooter.
The 12-week study involved a randomization of the 30 participants where a Pilates and a control group were formed, that included a baseline and post-intervention results. The Pilates group were given an exercise program that included a range of exercises, such as the CoreAlign "hoof" which focused on gait and "angles in the snow", which focused on shoulder mobility. Progression was added over the course of the period, with instructors to observe each participants ability to focus on proper breathing, correct body alignment and core stabilization. The Pilates group also received weekly 1-hour massage therapy session with a registered massage therapist specifically trained in massage for MS.
Participants in the control group received a weekly 1 -hour massage therapy session. The researchers decided to include a massage session because it had the potential to improve health outcomes in persons with MS, such as pain and stress, without minimal effect on walking ability. The control group did not receive a Pilates training program, but were not restricted from performing other exercise during the study period.
The primary outcomes was walking ability which was assessed via the 6-Minute Walk Test (6MWT). Secondary outcomes included Timed Up and Go (TUG) test where studies have shown it as a measure of functional mobility in both clinical and research practice in persons with MS; Sit and reach test for flexability; Fullerton Advanced Balance Scale (FABS) for balance; Dual-Energy X-ray Absorptiometry for body composition; Plank-Hold test for core endurance and Maximum Voluntary Contraction for quadriceps strength. Test for fatigability and voluntary muscle activation were also assessed.

## What were the basic results?

The results showed that the intervention group improved walking distance by a mean of 52.4m compare with 15.0m in the control group with the 6MWT. Results for the TUG functional ability test showed an improvement in the left turn compared to the right turn, with the mean decrease of 1.5 seconds in the intervention group compared to an increase of 0.3 seconds for the control group. There were no major differences between group for secondary outcomes, for balance and flexibility presented in the data below.
| Parameter | Pilates group (n=15) | Control group (n=15) | P value |
| 6MWT (m) | 52.4 | 15.0 | .01 |
| FABS score | 2.3 | 2.2 | .96 |
| Sit and Reach (cm) | 2.0 | 1.9 | .98 |
| TUG test with left turn (sec) | -1.5 | 0.3 | .03 |
| TUG test with right turn (sec) | -1.1 | 0.3 | .06 |

## What conclusions can we take from this research?

The conclusion we can take from this study design can be the fact that any type of exercise whether it be walking or functional training can be beneficial for persons with MS.
The study design covered certain aspects of the research and came to a sound conclusion that 'Pilates is a safe and effective exercise option for improving mobility in individuals with MS'. The researchers have also expressed the need for future studies in comparing Pilates training with other training therapies and evaluate and compare outcomes in MS. The have also mentioned limitations to their study.
A primary focus of the study plan focused on mobility, which is a limitation of the fact that mobility is not a symptom for all individuals with MS. Other limitations include tests which were not specific to MS, such as the Fullterton Advances Balance Scale which was developed to identify balance in older adults.

## Practical advice

* As shown in recent studies, the benefits for physical activity far out whey the negatives, and when coupled with a specific training program, can improve quality of life, increase mobility, strength, cardiovascular fitness and even better cognition based speed of information processing.
* Given the value of physical activity for health outcomes, Pilates is a safe and effective exercise option for individuals with MS which can correlate into improved healthy parameters, or a bridge between more intense and other forms of physical activity.

## Further information/resources

Information related material
What is multiple sclerosis
Multiple Sclerosis Australia
Brain foundation: Multiple Sclerosis information and support
Exercise and Activity
Maintaining a healthy lifestyle
Pilates training: positive change
CoreAlign Hoof exercise
CoreAlign Angels in the Snow

## References

* 1 2 3 4 5 6 Whitney R.D. Duff, Justin W. Andrushko, Doug W. Renshaw, Philip D. Chilibeck, Jonathan P. Farthing, Jana Danielson, and Charity D. Evans (2018) Impact of Pilates Exercise in Multiple Sclerosis. International Journal of MS Care: March/April 2018, Vol. 20, No. 2, pp. 92-100.
* ↑ Giesser B. S. (2015). Exercise in the management of persons with multiple sclerosis. Therapeutic advances in neurological disorders, 8(3), 123–130. doi:10.1177/1756285615576663
* ↑ Kalron, A., Rosenblum, U., Frid, L., & Achiron, A. (2016). Pilates exercise training vs. physical therapy for improving walking and balance in people with multiple sclerosis: a randomized controlled trial. Clinical Rehabilitation, 31(3), 319-328. doi: 10.1177/0269215516637202
* ↑ Heleen Beckerman, Vincent de Groot, Maarten A. Scholten, Jiska C.E. Kempen, Gustaaf J. Lankhorst, Physical Activity Behavior of People With Multiple Sclerosis: Understanding How They Can Become More Physically Active, Physical Therapy, Volume 90, Issue 7, 1 July 2010, Pages 1001–1013
* ↑ Motl, R., & Pilutti, L. (2012). The benefits of exercise training in multiple sclerosis. Nature Reviews Neurology, 8(9), 487-497. doi: 10.1038/nrneurol.2012.136
* ↑ Hariton, E., & Locascio, J. J. (2018). Randomised controlled trials - the gold standard for effectiveness research: Study design: randomised controlled trials. BJOG : an international journal of obstetrics and gynaecology, 125(13), 1716. doi:10.1111/1471-0528.15199
* ↑ Finch P, Bessonnette S. A pragmatic investigation into the effects of massage therapy on the self efficacy of multiple sclerosis clients. J Bodyw Mov Ther. 2014; 18: 11– 16.
* ↑ Sebastião, E., Sandroff, B., Learmonth, Y., & Motl, R. (2016). Validity of the Timed Up and Go Test as a Measure of Functional Mobility in Persons With Multiple Sclerosis. Archives Of Physical Medicine And Rehabilitation, 97(7), 1072-1077. doi: 10.1016/j.apmr.2015.12.031
* ↑ Rose DJ, Lucchese N, Wiersma LD. Development of a multidimensional balance scale for use with functionally independent older adults. Arch Phys Med Rehabil. 2006; 87: 1478– 1485
* ↑ Brunt, A., Albines, D., & Hopkins-Rosseel, D. (2019). The Effectiveness of Exercise on Cognitive Performance in Individuals with Known Vascular Disease: A Systematic Review. Journal of clinical medicine, 8(3), 294. doi:10.3390/jcm8030294