multiple sclerosis ( ms ) is an inflammatory , neurodegenerative disease of the central 
 nervous system that results in demyelination and transaction of axons in the brain , spinal 
 cord , and optic nerves1 . due to the 
 changing distribution throughout central nervous system demyelination in ms
, many different 
 symptoms like fatigue , weakness , posture , and movement and cognitive disorders can be seen . 

effects of exercise on function and quality of life have been examined in ms , and previous 
 studies have recorded significant improvements in muscle strength , exercise tolerance and 
 mobility levels in ms patients performing exercise2,3,4 .
the majority of studies in literature were conducted in the area of 
 strengthening and aerobic exercises .
clinical pilates is an exercise model that has become very popular in recent years and it 
 has beneficial effects on both ore stabilization and the whole body .
clinical pilates is 
 different from other exercise programs , as it includes respiratory component . a 
 meta - analysis of clinical pilates performed in healthy individuals revealed that clinical 
 pilates appeared to be effective in improving flexibility ( strong evidence ) , dynamic balance 
 ( strong evidence ) , and muscular endurance ( moderate evidence ) in healthy people2 .
clinical pilates - based exercise 
 incorporates the principles of trunk stability , which is also referred to as core stability 
 or core control3 .
clinical 
 studies in the literature have examined the impact of pilates on physical parameters such as 
 balance , mobility , and strength in patients with ms5,6,7 .
however , there are no studies in the literature that have 
 investigated the effects of clinical pilates on cognitive function and quality of life as 
 well as physical parameters . in this respect
the aim of this study was to analyze the effects of clinical pilates on body control , 
 balance , quality of life , fatigue , and cognition in ms patients .
there were no changes 
 in the medication regimes of the ms patients during the survey period .
the inclusion criteria were as follows : over 18  years of age , diagnosed with ms , an 
 expanded disability status scale ( edss ) score of six or lower , and able to act , or move 
 independently , able to walk alone or with support .
the exclusion criteria were as follows : 
 an ms - related acute attack , cardiovascular diseases , thyroid disorders , gout or orthopedic 
 limitation or irregular attendance .
demographic and clinical characteristics of the participants are shown in table 1table 1.demographic and clinical characteristics of the participantsvariables pilates group ( n=11)control group ( n=9)mean  sdmean  sdage ( years)47.2  9.549.7  8.9body mass index ( bmi ) ( kg / m)23.7  3.224.9  5.2illness duration ( years)14.8  7.414.2  9.5edss3.2  2.22.8  1.4n%n%education levelprimary education 2 18.2 444.4secondary education4 36.4 111.1higher education545.5444.4number of falls * noneonce436.4222.2twice218.2111.13 times or more 5   45.5 6 66.7marital statusmarried555.5654.5single444.5545.4employmentemployed327.3111.1unemployed872.7888.9assistive device using327.3222.2not - using872.7777.8genderfemale763.6666.7male436.4333.3 * in the last 6 months .
thirty - seven ms patients originally agreed to participate in the study , but 
 17 dropped out of the study due to health , transportation , or other problems . among the 20 
 ms patients who completed the study , 65% ( n=13 ) were female and 34% ( n=7 ) were male ( fig .
* in the last 6 months flowchart of the study participants were randomly assigned to two groups , the clinical pilates ( n=11 ) and the 
 control group ( traditional exercise program ; n=9 ) .
patients were given two days of exercise training per week for a 
 total of eight weeks . in order to understand the rate of benefit related to clinical pilates 
 in terms of cognition , disability , balance , coordination , mobility , physical performance , 
 fatigue , depression , and quality of life , relevant measurements were conducted .
the study was approved by the local ethics committee ( date , 16.01.2014 , protocol number , 
 1287-goa and decision number , 2014/03 - 19 ) . written informed consent was obtained from all 
 patients who participated in the study .
the pilates key elements were taught to the patients before the clinical pilates exercise 
 lessons .
these key elements were breathing , focus , and placement of the rib cage , shoulder , 
 head , and neck .
all pilates movements were checked , and necessary corrections were made by a 
 physical therapist during pilates exercise sessions .
the exercises were repeated 810 times . 
 when the pilates exercises could be done by the patients with maintaining the key elements , 
 the level of exercise was increased .
exercises were started with closed chain exercises , and 
 advanced to open chain exercises . on the other hand , exercises started at level 1 and 
 advanced to level 3 .
each session was comprised of a 10  min warm - up , 
 2545  min of mat exercises , and 10  min cool - down . pilates warm - up exercises consisted of cleopatra , the chest stretch , the toy soldier , upper 
 extremity proprioceptive neuromuscular facilitation patterns , and roll down .
the one leg stretch , hundreds , the double 
 leg stretch , scissors , the shoulder bridge , oblique preparation , and the hip twist were 
 performed in the supine position .
the clare , the side kick , arm openings , the lower lift , 
 leg lifts , and the side bend were performed in the side - lying position .
3 . the swan dive , 
 the one leg kick , swimming , the breast stroke preparations , the breast stroke , and the cobra 
 were performed in the prone position .
4 . the half roll back , oblique roll up were performed 
 in the sitting position .
the pilates 
 cooldown exercises were the spine stretch , saw , mermaid , cleopatra , chest stretch , toy 
 soldier .
traditional exercises including strength , balance and coordination exercises were , applied 
 to the control group .
grading by 
 this instrument was done on a scale of 010 , with the disability rate increasing as the 
 grade increased .
patients were classified into five stages of disability : stage i ( edss = 0 , 
 the patient is not disabled but has been diagnosed of a chronic disease ) , stage ii ( edss = 
 13 , minimally disabled ) , stage iii ( edss = 3.55.5 , rather disabled ) , stage iv ( edss = 67 , 
 patient still capable of walking with aid ) , and stage v ( edss = < 7 , patient is unable to 
 walk at all)4 .
the cognitive impairments of participants were evaluated using the multiple sclerosis 
 functional composite ( msfc ) .
the msfc is a three - part performance scale for evaluating the 
 degree of impairment in ms patients .
it includes assessment of leg function by moving a 
 short walking distance ( timed 25-foot walk ) , assessment of arm function using the nine - hole 
 peg test ( nhpt ) , and assessment of cognitive functions with an attention / concentration test 
 ( paced auditory serial addition test , pasat)7 .
the msfc assesses upper - motor function with the nhpt , lower - motor 
 function with the timed 25-foot walk test , and cognitive functions with the pasat .
the berg balance scale ( bbs ) was used for evaluating static and dynamic balance .
the bbs is 
 a clinical scale that evaluates balance in sitting and standing positions and rates 
 performance from 0 ( can not perform ) to 4 ( normal performance ) .
the scale has fifteen items 
 that explore the ability to sit , stand , lean , turn , and maintain an upright position on one 
 leg .
time to roll from right to left : while lying in a supine position on a mat , the patient 
 was asked to roll to one side and return to the supine position as quickly as possible .
2 . lie / sit test : starting from a back - lying position , the patients were asked to move into 
 their usual sitting position by turning a side their swinging feet .
3 . sit / stand test : patients were asked to sit on a bed set at a standard height from the 
 floor and stand up once .
4 . repeated sit / stand ( on / from a chair ) : the patients were asked to sit on a chair set at a 
 standard height and stand up 3 times .
5 . 50-foot walking test : the patients were timed while they walked 25 feet as fast as 
 possible , turned , and walked rapidly back to the starting point .
the 50-foot walking test 
 was recorded in seconds6 . the timed up and go test ( tug )
the tug test is 
 a commonly used instrument that measures the time taken to rise from a chair , walk 3 meters , 
 turn , walk back , and sit down again .
it is a valid and reliable tool for patients with ms , 
 and one measurement is sufficient . in the present study ,
the trunk impairment scale ( tis ) was used to assess static and dynamic sitting balance and 
 trunk coordination and control in a sitting position .
the static subscale investigates the 
 ability of the subject to maintain the sitting position with the feet supported , while the 
 legs are passively crossed , and when the subject crosses the legs actively .
results were analyzed under three headings , namely static , 
 dynamic , and coordination8 .
the mfis is a 
 21-item scale used to evaluate the impact of fatigue with regard to psychosocial , cognitive , 
 and physical functioning .
the self - reported ratings of each item range from 0 ( never ) to 4 
 ( almost always ) , for a total possible score ranging from 0 to 84 points .
the multiple sclerosis international quality of life questionnaire ( musiqol ) was used for 
 measurement of quality of life .
the musiqol questionnaire comprises 31 questions in 9 
 dimensions ( subscales ) : activities of daily living ( 8 items ) , psychological well - being ( 4 
 items ) , symptoms ( 4 items ) , relationships with friends ( 3 items ) , relationships with family 
 ( 3 items ) , sentimental and sexual life ( 2 items ) , coping ( 2 items ) , rejection ( 2 items ) , and 
 relationships with healthcare system ( 3 items ) .
all 9 dimensions and the index score are linearly transformed and 
 standardized on a 0 to 100 scale , where 0 indicates the worst possible level of quality of 
 life ( qol ) and 100 indicates the best level .
differential item functioning analysis was 
 performed in an initial validation study showing satisfactory results across countries12 .
each patient completed the beck depression inventory ( bdi ) , which is a 4-point likert - type 
 self - rating scale developed by beck .
the validity and reliability of the scale was assessed 
 by hisli ( 1989 ) , and the cronbach s alpha coefficient of the scale was found to be 0.80 . 

assesment of the validity and reliability study of the turkish version of the scale revealed 
 that the cutoff point was 17 .
descriptive statistics were calculated for 
 demographic characteristics , and the wilcoxon test was used to evaluate scores obtained 
 before and after the intervention , while the mann - whitney u test was used for testing the 
 differences between groups .
there were statistically significant 
 differences in the clinical pilates group in terms of bbs , timed performance tests , mfis and 
 pasat step of the mfcs between before and after the intervention ( p<0.05 ) .
on the other hand , in the control group , we also found statistically significant 
 differences in timed performance tests ( except time to left ) , the timed up and go test , and 
 the nhpt step of the mfsc between before and after the intervention ( p<0.05 ) . to test our hypothesis , we conducted a difference analysis between the clinical pilates and 
 control groups .
we found statistically significant differences in pasat ( mfsc ) and musiqol 
 in favor of the clinical pilates group ( p<0.05 ) ( tables 2 , and 3table 2.balance , gross motor coordination , and mobility scores before and after 
 exercisepilates group ( n=11)control group ( n=9)meansdmeansd berg balance testbefore50.64  6.4144.67  10.99after 53.55  4.16 * 47.78  13.89trunk impairment scalestaticbefore6.09  2.075.89  1.36after6.73  0.476.33  0.71dynamicbefore718  2.997.33  3.35after9  1.677.33  3.08corebefore6  0.895.44  1.33after5.91  0.35.56  0.88pyical performance testsrling to rightbefore5  1.225.68  1.58after3.3
 1.21 * 3.65  0.94*rolling to leftbefore4.56  1.135.77  1.96after3.07  0.54 * 3.64  1.15*lie / sit testbefore5.78  4.537.29  3.97after3.56  1.47 * 4.13  2.11*sit / standbefore3.12  1.393.61  1.23after1.98  0.96 * 2.35  1.61*repeated sit / standbefore9.73  2.669.74  3.38after7.52  1.93 * 6.37  2.86 * 50-foot walking before30.2  7.2926.36  10.1after26.45  5.13 * 24.07  9.56*timed up and go testright before9.62  5.6110.44  5.04after10.74  7.519.47 
mann - whitney u test ( difference between independent groups)table 3.fatigue , depression , impairment , and quality of life before and after 
 exercisespilates group ( n=11)control group ( n=9)meansdmeansdmodified fatigue impact scale cognitivebefore8.82  5.498.11  10.73after5.82  5.04 * 7.33  6.60physicalbefore9.73  4.4311.56  9.33after7.18  3.63 * 7.44  5.27socialbefore15.45  12.8817.33
 13.09after7.64  9.60 * 13.11  10.24beck depression inventory before10.18  5.2311.44  6.52after7.91  6.869.78  5.26msfc 
pasatbefore44.91  11.6327  16.91after47.82  11.21 * 27.89  13.17*hpt dominantbefore21.51  6.3929.29  13.33after21.49  5.2426.37  10.93*hpt nondominantbefore24.75 
5.6838.98  35.55after23.5  4.7435.59  35.56 * 25-foot walkingbefore7.41  4.159.76  8.23after7.18  4.749.36  8.05*musiqolbefore28.22  9.0644.44  16.06after23.82  7.5340.05  17.96**statistically significant ( p < 0.05)mann - whitney u test ( difference between independent groups ) ) .
mann - whitney u test ( difference between independent groups ) * statistically significant ( p < 0.05 ) mann - whitney u test ( difference between independent groups )
in this controlled randomized study , the effects of clinical pilates on body control , 
 balance , qol , fatigue , and cognition were investigated in ms patients .
physical performance tests have been studied in a geriatric group , and these tests 
 represent a measurement system commonly used in physiotherapy evaluations .
parameters such 
 as rotation and moving to a sitting position from a supine position , which are examined in 
 physical performance tests , evaluate activities of daily living .
activities such as 
 rotation , sitting up , and standing up from a sitting position require successful countering 
 of gravity and better use of the trunk muscles .
clinical pilates is an effective form of training for the 
 postural muscles . in this respect , making these measurements is thought to have a great 
 importance in terms of manifest clinical pilates effects .
studied the effects 
 of pilates on the volume of the rectus abdominis , obliques , and transversus abdominis , with 
 the last two considered conjointly with magnetic resonance imaging .
their study revealed the 
 existence of asymmetries in the muscles of the abdominal wall in nonactive healthy women . 

performance of pilates exercises twice a week for nine months elicited hypertrophy of the 
 abdominal wall muscles , particularly of the rectus abdominis , and eliminated preexisting 
 asymmetries of the obliques and transversus abdominis .
they concluded that pilates can be 
 recommended as an effective method to reinforce the muscles of the abdominal wall and to 
 compensate for preexisting asymmetric developments13 .
however , we used physical performance tests requiring body control because 
 of the primarily major muscle groups are body muscles in the activities of daily living 
 ( adl ) . according to the results of our study , clinical pilates
is an effective exercise 
 method in patients with ms for improving the ability to perform adl .
clinical pilates is an exercise program basically affecting the trunk muscles , and it has 
 characteristics similar to daily activities and includes exercises in different positions 
 and with progressive features14 .
clinical 
 pilates primarily affects core stabilization , running posture , and muscles15 . in this regard , we believe that it is 
 important to evaluate different tests of the trunk muscles beyond the physical performance 
 tests and introduce changes . in previous studies ,
the clinical effects of pilates on 
 parameters such as stability were generally investigated16 . in the present study
, we used the tis , which evaluated the control 
 of body muscles other than those mentioned in previous studies .
the tis is a scale that is 
 used in stroke patients , but it can also be used in patients with ms for assessing trunk 
 impairment10 .
clinical pilates is a 
 system focused on the correct use of four core muscles , the diaphragm , transverses 
 abdominis , multifidus , and pelvic floor muscles .
however , there were no meaningful changes 
 in the tis in the patients who participated in this study .
it is thought that this may be 
 related to the training period . in previous studies on clinical pilates ,
the finding 
 can be explained by an insufficient number of cases in studies that had a training period of 
 8 weeks , as in our study .
clinical pilates , is an exercise program based on the trunk muscles that affects the level 
 of proficiency in adl .
the results of our study revealed that clinical pilates has 
 significantly positive effects on qol based on comparison with our control group . in the 
 literature
, there are no studies that have investigated the effect of clinical pilates on 
 qol in ms patients .
the present study is noteworthy because it demonstrated the effect of 
 clinical pilates on qol in ms patients .
the pasat is a measure of cognition and is included 
 in the msfc . in the present study , the possible association between cognition and exercise 
 was examined . in the literature
, there are only a small number of studies that have 
 investigated the effects of exercise and particularly aerobic exercise , on cognition .
there 
 are no studies examining the effects of clinical pilates on cognition . in this respect ,
the 
 current study is the first study to examine such an association . in the literature ,
the effects of exercise on cognition were studied with different groups . 
 in a randomized study by sun et al . ; tai chi exercises were shown to be effective in the 
 cognitive functions on elderly18 .
on the 
 other hand , in a study on cerebral palsy it s shown that there are relationships between 
 physical and cogntitive functions19 .
a 
 study by laitman showed the effect of exercise on cognitive integrity in the aging brain . 

notably , the study further linked the protective effects of chronic exercise on cognition to 
 neurovascular integrity during aging20
neuropsychological assessments are 
 important in ms to predict prognosis and cognitive outcome in treatment trials . in 
 particular
, cognitive impairment may lead to a reduced qol , loss of work , and problems with 
 the social environment .
today , there are three avenues for treatment : disease modifying 
 therapies , symptomatic treatments , and cognitive rehabilitation21 .
our results revealed that clinical pilates leads to 
 positive changes in cognition within ms therapy ; this effect of clinical pilates was 
 demonstrated for the first time in this study .
according to the results of this study , clinical pilates can be used as an effective 
 treatment method in ms due to its positive effects on physical parameters , such as balance , 
 performance , and fatigue ; cognitive problems ; and qol .
the literature includes studies on 
 balance and fatigue . a study by gl - gndz et al .
investigated the effects of clinical 
 pilates training on balance , mobility , and strength in ms patients .
the authors found that 
 clinical pilates training may develop balance , mobility , and muscle strength in ms 
 patients3 .
freeman and his friends conducted a multicenter , double blind , block randomized , controlled 
 trial . similar to our study , they used clinical pilates based core stability training in one 
 group and standardized physiotherapy exercise in their other group22 . in a study by marandi and co - researchers23 ,
pilates interventions can significantly increase the dynamic balance of the 
 examinees in the post - experiment stage24 . 

the results of our study seem to be consistent with these findings . in a single blind randomized study by tarak et al .
, it was concluded that group exercise had positive effects on 
 balance , functional status , spasticity , fatigue , and qol25 . in our study , the exercise programs in the clinical pilates and 
 control groups were applied in a group format .
however , although both exercise programs were 
 applied as group exercise , different effects on balance , fatigue , and qol were found .
the 
 significant differences found in the clinical pilates group were thought to derive from 
 clinical pilates rather than group exercises .
clinical pilates led to significant changes in 
 the pasat , musiqol , physical performance tests , and balance parameters , so it can be used 
 for ms patients reliably .
furthermore , the results obtained from our study were the results 
 of an 8-week exercise program .
the effects of longer periods of clinical pilates are of 
 interest , and we plan to investigate this in the future .
it was also the first study 
 investigating the effects of exercise on cognitive functions in people with ms .
we started the study with 35 
 people , but not all could complete the study .
 [ purpose ] the aim of this study was to determine the effects of clinical pilates in 
 multiple sclerosis patients . [ subjects and methods ] twenty multiple sclerosis patients 
 were enrolled in this study . 
 the participants were divided into two groups as the clinical 
 pilates and control groups . 
 cognition ( multiple sclerosis functional composite ) , balance 
 ( berg balance scale ) , physical performance ( timed performance tests , timed up and go 
 test ) , tiredness ( modified fatigue impact scale ) , depression ( beck depression inventory ) , 
 and quality of life ( multiple sclerosis international quality of life questionnaire ) were 
 measured before and after treatment in all participants . 
 [ results ] there were 
 statistically significant differences in balance , timed performance , tiredness and 
 multiple sclerosis functional composite tests between before and after treatment in the 
 clinical pilates group . 
 we also found significant differences in timed performance tests , 
 the timed up and go test and the multiple sclerosis functional composite between before 
 and after treatment in the control group . according to the difference analyses 
 , there were 
 significant differences in multiple sclerosis functional composite and multiple sclerosis 
 international quality of life questionnaire scores between the two groups in favor of the 
 clinical pilates group . 
 there were statistically significant clinical differences in favor 
 of the clinical pilates group in comparison of measurements between the groups . 
 clinical 
 pilates improved cognitive functions and quality of life compared with traditional 
 exercise . 
 [ conclusion ] in multiple sclerosis treatment , clinical pilates should be used as 
 a holistic approach by physical therapists . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION