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 Table of Contents  
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 96-104

Coupling the effect of mental practice and Pilates on ambulation of individuals with multiple sclerosis: Five case studies

1 Department of Neurorehabilitation, Bihar Neurodiagnostic Centre, Patna, Bihar, India
2 R.V. College of Physiotherapy, Bengaluru, Karnataka, India
3 Statistical Consulting Unit, Bihar Neurodiagnostic Centre, Patna, Bihar, India
4 Department of Neurology, NIMHANS, Bengaluru, Karnataka, India

Date of Web Publication2-Jun-2016

Correspondence Address:
Darshpreet Kaur
Department of Neurorehabilitation, Bihar Neurodiagnostic Centre, Aakashvani Road, Near Passport Office, Khajpura, Patna - 800 014, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4848.183338

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Pilates, a popular form of exercise, greatly emphasizes on the strengthening of the core muscles; however, the efficacy of exercise program can be impaired in patients with cognitive impairments. To bridge this gap, mental practice of a desired task can help to mentally simulate a given action and retain many properties of the corresponding real action. This study tries to gain preliminary understanding on the effectiveness of the combination of mental practice and core-strengthening Pilates exercises. To explore the effectiveness of mental practice and Pilates-based training on core strength, balance and mobility in multiple sclerosis (MS) patients. This study highlights a single center case series describing the outcomes in ambulant patients with MS treated with mental practice and Pilates. Five volunteer ambulant individuals with stable relapsing-remitting MS participated in 20 individualized sessions, spread over 10-week duration. Pilates with mental practice session was delivered by a physiotherapist. Each session comprised 20 min of mental practice followed by 40 min of core-strengthening Pilates exercises. All the included patients were screened with Movement Imagery Questionnaire-Revised Second Version to determine if they are were able to effectively engage in imagery practice. A range of outcomes were measured: Timed up and go, chair stand test, curl-ups, the abdominal angle through leg raises, and the Activities-specific Balance Confidence Scale before and after the intervention. Group data analysis indicated significant improvement between baseline and post-intervention phases for all the tested parameters. This study provides preliminary insight into this novel combination technique to improve balance and mobility in ambulant people with MS. Mental practice played an important role in keeping the patient's compliance, which was analyzed through structured interviews. Variations in response to the intervention are evident.

Keywords: Mental practice coupled Pilates, motor imagery, multiple sclerosisMental practice coupled Pilates, motor imagery, multiple sclerosis

How to cite this article:
Kaur D, Billore N, Kaur K, Kumar G, Singh AK. Coupling the effect of mental practice and Pilates on ambulation of individuals with multiple sclerosis: Five case studies. Arch Med Health Sci 2016;4:96-104

How to cite this URL:
Kaur D, Billore N, Kaur K, Kumar G, Singh AK. Coupling the effect of mental practice and Pilates on ambulation of individuals with multiple sclerosis: Five case studies. Arch Med Health Sci [serial online] 2016 [cited 2022 Oct 2];4:96-104. Available from: https://www.amhsjournal.org/text.asp?2016/4/1/96/183338

  Introduction Top

Multiple sclerosis (MS) is a chronic progressive disease [1] of the central nervous system that affects a wide range of neurologic functions, including balance,[2] coordination, sensations, muscle strength and tone, posture, ambulation, vision, fatigue, depression,[3] and cognitive functions.

People with MS frequently experience balance and mobility impairments leading to higher risks of fall and difficulty in carrying out activities of daily living that has been documented in many studies.[4],[5],[6],[7] One of the primary mechanisms underlying the impaired balance and gait in MS is slowed somatosensory conduction and impaired central integration.[2]

Walking and mobility problems in MS represent a major category, posing significant personal, financial, and social burden to the patients, and their caregivers.[8]

Apart from physical disabilities, people with MS also suffer from a wide array of cognitive impairments. These are now well recognized worldwide, with prevalence ranging from 40% to 60%.[9] Cognitive impairments in MS are dominated by a slowdown in the rate of information processing and functions with attention and working memory.[10] All these functions play an important role in taking up any exercise/therapeutic program and in maintaining compliance throughout the treatment duration.

McNeill [11] suggested that the “presence of 'uncontrolled movement' within the human neuro-musculoskeletal system can be found, if the movement control system (mind) and muscular system (body) are tested for their combined ability to successfully control low threshold forces, such as those affecting posture and alignment, or high threshold forces, such as those requiring muscular strength to control the movement. Deciding which exercises are the best to 'fix' the uncontrolled movements is a fundamental part of the rehabilitative process.”[11]

One important component to maintain balance is core stability. It is defined as the ability to control the trunk in response to disturbances generated by movement of the limbs, or other perturbations.[12],[13],[14] About 75% of people with MS report balance problems during the course of their disease.[15] However, the cause of impaired balance and mobility is probably multifactorial, and the key mechanisms involved vary from the cerebellum, vestibular, visual and/or cognitive processing.[16] Rationale behind using task-specific rehabilitation is to enhance neural plasticity.[17]

Pilates-based rehabilitation program to restore core stability is being widely used by physical therapists in improving flexibility and dynamic balance.[18] This training is a precise, controlled form of exercise using the stabilizing muscles of the body to strengthen them.[19] This technique is tailored according to the patient's disability levels [20] and if given appropriately can also aid in psychological well-being [21] along with physical disability reduction in MS patients. A couple of researchers have come up with studies showing positive effect of Pilates not only in MS but also as a treatment option for many other conditions.[22],[23],[24]

Freeman et al.[25] have demonstrated improvement across six measures of balance and mobility in ambulatory people with MS following 8 weeks of individualized core stability training. Since people with MS have been found to have weak trunk stabilizers, these muscles, specifically transverse abdominis, play an important role by early activating and creating core stability. Hence, the training program designed by Freeman et al., specifically activated the core muscles along with some of the exercises for leg muscles.

A systematic review of literature on the effects of physiotherapy interventions on balance in MS indicated small, but significant, effects of physiotherapy interventions on balance in people with MS, who have a mild to moderate level of disability.[26] They emphasized on specific balance exercises and found some evidence about progressive resistance and aerobic training, to have positive effects.

Motor imagery (MI) can be defined as mental rehearsal of a motor act in the absence of an overt motor output.[27] Recent studies have shown that MI of the desired motor task can result in similar neural reorganization as actual physical practice.[28] The mental imagination of a motor task is a complex cognitive task, which is self-generated by an individual by using appropriate sensory and perceptual processes. This coupling leads to the reactivation of specific motor actions within working memory.[29] Although the terms “motor imagery practice” and “mental practice” are often used as synonyms, however the former refers to the mental rehearsal of MI with the goal of improving motor performance and the latter refers to a voluntary rehearsal of images.[29] MI can be performed either as visual or kinesthetic MI. However, the combined application of both is more feasible and appropriate. Mental imagery also incorporates the principle of mindfulness. Mindfulness is defined as “…paying attention in a particular way: On purpose, in the present moment, and non-judgementally.”[30] Various pilot studies have shown the usefulness of mindfulness to improve balance [31] and coordination [32] in MS patients. Nevertheless, studies related to the effect of mindfulness [33] and physical exercises remain limited.

To summarize, the aim of this study was to gain preliminary understanding about the effects of a 10-week, twice-weekly individual exercise training program consisting of Pilates with mental practice on balance performance, balance confidence, and abdominal strength in relapsing-remitting MS (RRMS). The specific hypotheses were that the participation would:

  1. Improve the balance and walking abilities, as measured objectively and subjectively in ambulant patients with RRMS and
  2. Result in better adherence to exercise therapy, which will be accounted by a number of dropouts in therapy sessions and through follow-up call to patients.

  Materials and Methods Top

A single center five cases pilot study was undertaken. Such individual-based single case research method is a useful way to explore the effectiveness of a new or lesser known rehabilitation program.[34] The baseline parameters of subjects served as a control.


Five volunteer ambulant individuals with or without the use of a unilateral assistive device such as walking stick or orthotic brace, having definite diagnosis of MS according to McDonald's [35] criteria, aged 18 years or above, who had been referred for outpatient physiotherapy were recruited. Patients in relapse or had a relapse in the previous 3 months or wheelchair bound or with history of psychological or psychiatric problems/severe depression as assessed by Beck Depression Inventory or with history of substance abuse were excluded from the study. Even patients with any comorbid medical or mental condition contraindicating their participation in core stability exercises were excluded from the study. Patients undergoing or having undergone any recent core stability exercises or cognitive rehabilitation program were also excluded.


The first 5 eligible patients in outpatient physiotherapy department were invited to participate and given verbal and written information about the study. The selected patients were referred from a variety of sources, which included a neurologist, other physical therapist, or by self-referral. After obtaining their informed consent, a therapist blinded about the intervention undertook an assessment of their outcome measures.


All the included patients underwent the Movement Imagery Questionnaire-Revised Second version (MIQ-RS) to determine their ability to engage in imagery practice. A range of outcomes were measured: Timed up and go, chair sit-ups, curl-ups, and the abdominal angle through leg raises the Activities-specific Balance Confidence (ABC) Scale.

Based on Freeman's et al.[25] Pilates-based core-strengthening study, the intervention comprised 20 hands on individualized core stability exercise sessions lasting approximately 20 min, delivered twice weekly over 10 weeks, by the same therapist, and additionally an individualized daily 15-min home exercise program consisting of the same exercises. In addition, prior to performing the exercises, these patients were given 10 min of mental imagery session of the exercises to be done that day.

In accordance to the protocol, no intervention other than the core stability training program and mental imagery was undertaken. It was ensured that all the therapists involved in giving therapy sessions to the patients had experience in giving Pilates training to people with MS.

Each subject received intensive practice with mental and core-strengthening exercise program. Eight exercises were selected by our team of specialized physiotherapists with reference to previously published studies [18],[20],[21],[22],[25] and current clinical practice and in lieu with applicability to our participants. Specific and uniform guidelines for the intervention were developed. During the treatment sessions, the therapist stressed on the quality of performance and emphasized on appropriate muscle recruitment.

Stretching was undertaken before or during these exercises to correct any postural malalignments due to muscle tightness. Exercises were progressed in accordance with individualistic performance in each Pilates exercise session. Each participant received video with diagrammatic representation of exercises and instructions describing their individualized home exercise program.

This flexible and individualized approach reflects the normal clinical practice.

Outcome measures

Following a review of the literature, outcome measures according to their ease of administration, clinical relevance, and having published data supporting their reliability and validity in MS populations were selected. Emphasis was laid on using uniform and standardized protocols for each measure by giving prior training sessions to the therapists. This ensured that standardized verbal instructions were used on each test occasion. Blinded assessment was carried out at the start of intervention and at the end of 10-week duration.

Neither the patients nor their treating therapists were shown the scores.

Measures were undertaken in a standardized order and patients were asked to use the same shoes and orthoses/walking aids. Considering all the prime muscles which are activated during walking in MS patients,[36] various outcome measures were selected.

Movement Imagery Questionnaire-Revised Second Version

Mental imagery is more effective in individuals who are able to engage in imagery practice. The MIQ-RS requires movements of both the upper and lower limbs, thus assessing the ability to imagine one's gross motor movements.[37] It consists of 14 tasks. It has high test-retest reliability with a visual score of 0.83 and kinesthetic score 0.73.

Timed get up and go

This single test for assessing muscle function and moving around is undertaken at a self-selected speed, following one practice attempt. This has been shown to be a clinically relevant test in MS patients.[38] This is one of the core-recommended outcome measures for exercise studies in MS.[39]

Activities-specific Balance Confidence Scale

This self-reported scale measures the perceived level of confidence in performing 16 daily activities, generating a total score ranging from 15 to 150.[40],[41] This scale is one of the reliable tools for assessing balance in MS patients.[41]

Chair stand test

This test assesses the leg strength and endurance. This test is also related to balance performance in MS patients.[42] Møller et al. suggested that a change of more than 25% in this test value postintervention can be considered statistically significant.[42]


This test measures abdominal strength and endurance, which are important for back support and core stability. In this test, the feet are not anchored [43] and the partner sits behind the subject and cups the subject's head in their hands. For starting position, the arms fully extended with fingers resting on the legs and pointing toward the knees. The subject curls-up slowly, sliding the fingers along the legs until the fingertips touch the knees, then back down again, until the head touches the partner's hands. This is timed for 1 min. This is also one of the core-recommended outcome measures for exercise studies in MS.[39]

Abdominal angle

This test is performed to estimate the degree of abdominal strength by using double leg lowering method. Abdominal muscles play a vital role in maintaining trunk stability during various functional activities.[44] In this test, the subject lays supine on the floor next to the abdominal strength test board. The hip joint should be aligned to the intersection of the scale. The arms are held across the chest and the head rested on the floor. The tester places their fingertips underneath the subject's lower back. Both legs are raised to a 90° angle (vertically) while keeping the upper body flat on the floor. The subject may bend their knees first to move to the starting position, before straightening the knee joint. The subject aims to sustain the pressure on the tester's fingers under the lower back by contracting the abdominals as the legs are lowered. The subject slowly lowers both legs until the pressure on the hand behind the back disappears. The lowest angle observed as the pressure is taken off is the measurement of their abdominal strength.[45]

Statistical analysis

The mean age, MS duration and values for Extended Disability Status Scale (EDSS) and MIQ-RS were computed before administering the intervention. The data were analyzed for individuals and at group level. For individual subjects, the two standard deviation (2 SD) band method was used to quantify the findings.[46] At group level data, repeated measure analysis of variance (ANOVA) within the subjects was done.[25]

  Results Top

The demographic and clinical characteristics of the subjects are given in [Table 1]. The mean age was 36.6 ± 4.98 years (range: 30-44 years) and the mean MS duration since onset was 7 ± 3.08 years (range: 4-11 years). Participants and other clinical characters are displayed in [Table 2]. No relapses were reported, and no changes to medications occurred for any participant during the study timeframe.
Table 1: Demographic and clinical characteristics of subjects

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Table 2: Mean of demographic and clinical characteristics of the patients

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All baseline and outcome variables were retrieved from the five subjects. The compliance rate of the intervention was 100% and the attendance was 100%.

All patients showed varying improvement on different parameters postintervention [Figure 1]. This difference in preintervention and postintervention scores was measured as percentage change in values for each outcome measure [Table 3] and [Figure 2]. The observed percentage change was graphically plotted as a histogram. Maximum variability was observed on the ABC Scale while changes in the abdomen angle showed minimum variation.
Figure 1: Pre- and post-value for each patient on different parameters

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Table 3: Percentage change in variables postintervention

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Figure 2: Percentage change in values for each variable in subjects

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Individual subject analyses

There was variability in the individual's response to core stability training. Visual analyses of the trend, level, and slope between baseline and intervention phases were undertaken in accordance with previously published study.[25] The analysis showed improvement in the five measures for the majority of subjects. This was confirmed by the 2 SD band statistical analyses for six measures [Table 4] and [Figure 3].
Table 4: Change in mobility and balance measures as determined by the two standard deviation method

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Figure 3: Scatter plot to show two standard deviation band statistical analysis for different measures

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Group results

[Table 5] details the range, means, and SDs for all measures. We attempted to attain a homogenous sample by using specific entry criteria (1.0-4.0 on the EDSS). Hence, the range and SDs are not large.
Table 5: Descriptive statistics of various measurements

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Results from the repeated measures ANOVA test provide evidence of a significant time effect for all the four measures which were objectively rated by the therapist. Bonferroni-corrected pair-wise comparisons indicate a significant improvement between baseline and intervention phases F(1,4) = 45.182, P = 0.03. There was a significant difference across all the objective measures between the subjects, F(3,2) = 80.66; P = 0.012. There was a significant interaction between pre- and post-measures with the outcome parameters between the subjects, F(3,2) = 120.67; P = 0.008. However, the mean score for abdominal angle did not change significantly.

  Discussion Top

This pilot study tried to explore the effect of mental practice-based core strength training on balance and mobility in ambulant individuals with stable RRMS. To the best of our knowledge, this is the first study to evaluate the effects of mental practice with Pilates on balance and mobility in MS patients.

Although Pilates form of exercise therapy is currently being widely advocated, however its efficacy in patients susceptible to cognitive deficits is still under explored. The objective of this study was to gain preliminary understanding whether or not motor/mental imagery with Pilates training can serve as a potent rehabilitation therapy for improving mobility, balance, and exercise compliance in patients of RRMS. At present, there is not one recognized method addressing the collective management of cognitive and physical disability to improve overall functioning in MS patients. Therefore, this study had to develop its own treatment methodology based on supporting evidence for core-strengthening and mental practice in various patients group.

Some interesting patterns have emerged from this pilot study which deserves replication. Individually, we found clear improvements in balance and mobility in all the five participants. The average percentage increase in test scores varied from 29% to 63% depending on the test in question. For all the five individuals, we found clear improvements in balance and mobility, with significant differences in at least three of the five measures after 10 weeks of training. In the group analysis, the scores significantly improved between baseline and postintervention. Considering the significant improvement or trending toward improvement pattern, the observations may be attributable to the core stability training program. These findings are similar to ones reported by Freeman et al.[25]

Maximum variability was observed on the ABC Scale whereas changes in the abdomen angle showed minimum variation. Since ABC Scale is a patient-rated measure, results indicate that this new protocol of coupling motor imaginary with core strengthening infused lot of confidence in these patients to take up their daily tasks. Although this change in ABC score did not materialize into the same degree in abdominal muscle strength, a definite improvement was observed in this measure postintervention. These findings not only indicate toward improvement in abdominal muscle strength in 10 weeks but also highlight the difficulty in strengthening these muscles group. The measures used in this study had sufficient evidence to support their validity and reliability in ambulant MS patients. All these measures detected a significant change in at least three patients using the 2 SD band method.

Mental practice proved useful to the patients in a couple of ways. First, the patients attended all the proposed sessions for 10 weeks. Second, 6 months after the completion of the study, over a telephonic follow-up with the patients and their attendants when inquired separately, both reported performing Pilates exercises at home, at least thrice a week.

For the groups, all the measures showed significant improvement between baseline and intervention. The occurrence of an overall improving pattern in all the measures in 10 weeks, makes it reasonable to suggest that the improvements observed may be attributable to the coupling effect of mental imagery and core stability training program.

Hence it becomes imperative to define clinical predictors for getting positive response from MI and core-strengthening protocol, for example, the ambulatory status of the patients. Our study included patients with mild to moderate difficulties in their functionality as measured by EDSS. This can help recognize prospective subjects at an early stage and timely intervention can hence improve the quality of life in MS patients.

In our earlier study using Tai-Chi coupled with mental practice versus Tai-Chi only in MS patients, although not significant differences in balance and mobility improvements were found in both the groups. However, the former group participants showed better comprehension of Tai-Chi forms and higher retention rate.[47]

This Pilates and mental practice-based pilot study appear to show improvements in some specific areas, thus pointing toward the need for replication with more number of MS participants, their matched controls, and extensive follow-up. Neuroimaging and neuropsychological assessment-based research on larger cohort can highlight the potential mechanisms underlying the improvements observed through MI. While trying to recreate these results in clinical practice, a sound knowledge in core stability training is advisable. In our study, the treating physiotherapists were specialists in core training. However, all were neurological specialists physiotherapists experienced in the application of core stability exercises, and this should be considered when applying these results to clinical practice.

Although the sample size of five patients limits the study's statistical power, its results have sufficient clinical significance for bringing this pattern of treatment into practice.

It is noteworthy that these results need to be treated with caution. First, there was no control group, which plays an important role in minimizing bias and maximizing validity in a research.[48] Second, there was a lack of formal random assignment to the therapy session, as the classes were undertaken according to patient's days preference. This was done to ensure maximum patients participate in all the sessions for 10 weeks.

In summary, this study, albeit preliminary, suggests a kind of therapeutic intervention, which is aimed at ameliorating balance deficits associated with people with mild MS. This kind of intervention is multimodal, thereby including sensory, motor, strength, and functional activities to manage balance deficits.


We thank all our participants for accepting to be a part of this study. Their willingness was an important driving force for our team to go ahead with this novel technique. This work was presented as poster at the 6th Congress of The Pan-Asian Committee for Treatment and Research in MS (PACTRIMS).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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