Exercise as it relates to Disease/Does Pilates improve walking and balance in people with Multiple Sclerosis?

This is a critique of the article:Kalron,A.,Rosenblum,U.,Frid,L.,&Achiron,A.(2017).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.

What is the background to this research?
Multiple Sclerosis (MS) occurs when one's own immune system attacks myelin. Myelin being the fatty material that protects and insulates nerves, allowing electrical messages to travel quickly and efficiently around the body .Through the process of demyelination, patches of the nerve become exposed and scarred which impacts the ability to communicate messages. This break down of communication may lead to symptoms such as loss of motor function, resulting in impairments of walking, memory, vision and sensation.

Individuals with MS commonly experience gait dysfunction and imbalances .Gait dysfunction occurs due to the reduction in gait speed, impaired walking balance and a reduction of walking related physical activity. Balance dysfunction occurs due to inability to maintain position, delays in responses to postural displacements or disturbances in motion and the slowed ability to move the centre of gravity into positions within the limits of stability.

Interventions such as strength training, robot assisted gait training, Tai chi and so fourth have be implemented as rehabilitation methods to improve balance and walking in people with MS. Pilates is a form of low impact exercise that involves a series of movements that incorporate core stability, breathing, strength, flexibility and proper posture .Research suggests that Pilates if an effective method to increasing balance and flexibility in elderly, however little research has been conducted in individuals with neurological conditions such as MS. The following article further investigates the effectiveness of Pilates compared to regular physical therapy interventions in people with MS.

Where is the research from?
Alon Karlon the lead researcher he has a PhD in physical therapy. He has worked as a senior lecturer across universities such as Sackler faculty of Medicine and The Sagol School of Neuroscience. Karlon was head of department in the Physical Rehabilitation Research Unit, The Center of Multiple Sclerosis, Sheba Medical Center, Israel. Karlon has close to 100 published articles, his main research focus being on physical activity, cognition, balance and gait. He has taken a particular interest in the neurological population, including those with MS. No conflict of interest was declared in relation to the research.

What kind of research was this?
The study is a randomised control trial (RCT), assessors were blinded, the research included a parallel group design. RCT are considered the gold standard for effective research. The process of randomisation reduces potential bias and examines the cause and effect relationships between the intervention and outcome measure. In addition, the design of the study ensured the blinding of assessor to which further limits bias and other external factors.

What did the research involve?
Prior to the intervention participants were screened for eligibility. 50 participants were then divided into two groups; Pilates group and standard physical therapy group. The intervention took place for 12 consecutive weeks, the program was as follows:

Standardised Physical Therapy Group:

- 1 x 30 minute physical therapy session (weekly)

- 15 minute individualised home program (daily)

Pilates Group (intervention):

- 1 x 30 minute Pilates session (weekly)

- 15 minute individualised home program (daily)

The Pilates program started with stretching followed by exercises that challenged trunk control through gradually increase limb load by reducing base of support. The physical therapy program was developed according to the Bobath concept. Exercises targeted improvement of trunk and pelvic stability, lower limb muscle strength, balance and control of movement. Limitations exist within the methodology, the home based exercises were not monitored and therefore it cannot be determined whether they were being done correctly or consistently. In addition, some participants my of practiced exercises more than other which may impact results for either groups. Furthermore, the “Pilates instructors” were trained physical therapist with expertise in neuro-rehabilitation. It was speculated that corrections and adjustments to walking and postural control were made. This may impact the ability to apply this intervention to a real life scenario with special considerations needed when making decisions where a individual with MS can go to receive treatment/exercise advice.

What were the basic results?
The research provided evidence to support improvement in mobility function. However, these results did not differ from the group who participated in standard physical therapy. In relation to posturography measures the researchers found reductions in centre of pressure path length and sway rate to which the researchers interpreted as improved static balance control. Findings suggested both groups increased walking speed, mean step length and single support phase. Both groups decreased mean step time and time both legs made contact with the floor. No changes in cadence and stride width were found.

Improvements were seen in gait and clinical balance tests across both groups (as seen in figure 1.1). However, no main effect was found in the Pilates group. The researchers suggested that these results may lead to multiple conclusions:

"Pilates had no advantages over physical therapy in improving gait and balance".

"Pilates exercises are equally effective as physical therapy in improving gait and balance".

What conclusions can we take from this research?
The research provided evidence to support that Pilates exercise can be effective at increasing balance and walking in individuals with MS, demonstrating improvements in both postural control, scores in gait, balance measure and questionnaires. However, no significant difference was found between the two groups.This therefore may suggest that the mode of exercise is less important but rather an increased emphasis on including exercises that are targeted towards improving balance and walking. This is evident in other research that have found significant improvements in balance and gait in people with MS using interventions such as home-based active video games or yoga based therapy. It is also important to consider the long term effect of using Pilates or any other mode of exercise as potential treatment, the research didn't include any follow measures and therefore it would be worthwhile investigating if whether improvements are maintained over time.

Practical advice
The intervention provides individuals with MS with an alternative form of exercise. Pilates training allows for potential improvements in gait and balance. The research suggests there is no added advantage between Pilates and physical therapy. However, Individuals may find Pilates more enjoyable which may increase compliance and motivation which may in turn see long term improvements. It is important that individuals with MS consult a GP or health care professional prior to commencement of exercise to discuss risk factors, it may also be beneficial to seek guidance from a Exercise Physiologist or Physiotherapist.

Further information/resources
MS Australia: fact sheet on balance and walking for individuals with MS can be found here, providing appropriate information and support for symptom management.

National Multiple Sclerosis society: benefits of non-cardio activities for individuals with MS can be found here