Feasibility,safety and outcomes of an online,remotely supervised neuropilates class in a post stroke patient: A case study

Abstract

Neuropilates, that is, the practice of pilates in a patient with a neurological condition, may benefit post stroke patients through improving their strength, postural control, alignment and stability, with previous studies showing significant improvements in balance and gait parameters post pilates interventions. This case study aimed to investigate the feasibility and outcomes of an online, remotely supervised one to one pilates class, once a week for 6 weeks with a post stroke patient. Outcomes measured included gait and balance through the “Timed Up and Go (TUG)” test, the “Five Times Sit to Stand (5TSTS)” test, the “Activities specific Balance Confidence (ABC) scale” and the “Tinetti” balance and gait assessment. Quality of life was also measured by the “Stroke Specific Quality of Life (SSQOL)” Scale and muscle tone was measured through use of the “Modified Ashworth Scale (MAS)”. Feasibility was assessed qualitatively based on information gathered from the client satisfaction questionnaire and the patient’s tolerance of the programme. Results demonstrated that the patient enjoyed and tolerated the programme well with modifications and that he would prefer online exercise training over face to face in the future. The patient improved his TUG score and his SSQOL score beyond the minimal detectable change. Smaller improvements were also seen in the 5TSTS test, the ABC scale and the Tinetti assessment. Mixed results were seen for muscle tone. Typical neuropilates exercise sets for post stroke patients in standing and seated positions are given as well as advice and protocols for ensuring high levels of safety with online exercising.

Keywords

Pilates rehabilitation physiotherapy stroke telehealth

1 Introduction

Approximately 1.1 million people in Europe suffer a stroke each year [1]. Stroke survivors often experience mobility, strength and balance deficits [2], predisposing them to activity intolerance, falls and further strokes [3]. Studies have shown that physical activity levels of community dwelling people with stroke remain lower than their age-matched counterparts [4, 5] and lower than those with other chronic health conditions [6]. Combined with this, outpatient-based rehabilitation post hospital discharge is unavailable in two in five EU member states [7]. This predisposition to a sedentary lifestyle together with a lack of discharge services, particularly in rural regions in Europe [7], may lead to poor outcomes for stroke survivors and a vicious cycle of inactivity. The benefits of physical exercise for post stroke patients on balance, mobility and fitness have been well documented [8 –10] and could put a stop to this vicious cycle if programmes of safe, targeted, tailored exercise were more widelyavailable.

One such programme of exercise which has received little attention in published literature is Pilates. Created by Joseph Pilates in the 1920s, Pilates is a programme of mind-body exercises focussing on strength, core stability, flexibility, muscle control, posture and breathing [11]. The pilates method contains 6 key principles: centreing, concentration, control, precision, flow and breathing [12]. In recent years, pilates has become an important and effective rehabilitation tool, most often employed and studied in those with musculoskeletal and rheumatological conditions for the purposes of reducing pain and disability [13]. However, the use of pilates interventions has more recently spread to the field of neurology. Neuropilates, that is the practice of modified clinical pilates in patients with a neurological condition [14], is theorised by the Australian Physiotherapy and Pilates Institute (APPI®) to have beneficial effects on strength, postural control, alignment, stability, balance, proprioception, coordination and gait in those with deficits due to a neurological condition, through retraining low threshold activity of local muscles and decreasing over-active global muscles [15].

In post stroke patients, only 5 randomised controlled trials have looked at pilates interventions with a combined total of 122 patients [16 –20]. The results of a recent systematic literature review [21] pointed to the safety and usefulness of in-person neuropilates classes as a rehabilitation tool for chronic stroke patients, with significant improvements found in post intervention balance and gait outcomes, when compared to no treatment or conventional physiotherapy, but further evidence and higher quality studies are needed to establish the entirety of the effects of the exercise method, particularly when compared to general exercise.

With the emergence of the Covid 19 pandemic, vital outpatient services, exercise classes and many support systems for post stroke patients came to an abrupt stop as health professionals all over the world grappled to cope with public health guidelines [22, 23]. The severely reduced capacity of most forms of outpatient services has had far reaching consequences for stroke survivors. Coupled with this, there was a global reduction in activity levels in the general population during times of severe restrictions [24] which was likely mirrored in stroke patients, an already relatively sedentary population, putting them at further risk of cardiovascular events.

In response to the pandemic, there has been a rapid shift to telehealth services to deliver rehabilitation services remotely, with supervised exercise delivered via telehealth becoming an increasingly utilised option [22]. Virtual pulmonary rehabilitation and virtual cardiac rehabilitation have both been researched and preliminary data suggests thesevirtual programmes are safe and viable options for their specific populations [25, 26]. However, less is known about virtual exercise classes in post stroke patients. One scoping review identified a lack of evidence to support or refute the safety and efficacy of interventions involving activities undertaken in weight-bearing or standing positions that are delivered via telehealth in stroke patients [22]. This review did, however, highlight strategies that may inform delivery of a safe, feasible model of telehealth care.

To date, no study has investigated virtual, online, remotely supervised pilates exercise classes in the post stroke population, or any population with neurological deficits or strength, balance or mobility limitations. Basic pilates exercises are generally undertaken on mats on the floor in a group scenario or one-to-one on a plinth in clinics. This makes it a particularly challenging exercise form to instruct virtually, to physically compromised post stroke patients who are often unable to lie on the floor, as exercises have to be adapted to the seated and standing positions. Standing pilates exercises are often challenging to an individual’s balance which adds an extra layer of uncertainty for the instructor when conducting classes virtually. In this case study therefore, we aimed to examine the feasibility, safety and outcomes of an online, remotely supervised neuropilates class delivered via telehealth (henceforth will be referred to as the online neuropilates class) in a post stroke patient. The objectives of the case study were; to investigate the necessary assessments, safety precautions and exercise modifications to ensure safety in exercising remotely; to assess the patient outcomes with regard to gait, balance, spasticity and quality of life and; to gather the patient’s overall thoughts on online neuropilates training.

2 Methods

2.1 Case presentation

The participant was a 68-year-old male who had suffered a left basal ganglia infarct six months previously resulting in right lower limb weakness and impaired coordination of the right upper limb with mildly increased tone. In the acute phase, he had attended a rehabilitation ward for therapies for a period of 6 weeks and was discharged home with the early supported discharge team in stroke for home rehabilitation. He had been discharged from formal rehabilitation before commencing the case study as his progress had plateaued. He could manage his ADLs independently and could transfer independently from lying to sitting and sitting to standing. He was mobile independently with a walking stick at home and a 4 wheeled rollator frame for outdoors, relatively short distances only. He lived with his wife in a bungalow. He possessed a smart phone but was unsure of how to access the internet on it.

2.2 Assessment

The patient was known to the investigating physiotherapist, having treated him during his inpatient stay. Ethical approval for this case study was obtained prior to commencement from both Sligo University Hospital’s and IT Sligo’s Research Ethics Committees. Informed consent was obtained from the patient to partake in this intervention. Assessments were undertaken by an independent physiotherapist and not the treating physiotherapist, to reduce bias. Initial and follow up assessments were completed face-to-face in the exercise laboratory in IT Sligo. The outcome measures chosen for this study are highlighted below.

2.2.1 Five times sit to stand (5TSTS)

The 5TSTS [27] was chosen as a measure of lower limb strength and function. The patient was instructed to stand and sit 5 times from a standard armchair as quickly as possible and his effort was timed. An inability to perform 5 repetitions without assistance or use of the upper limb indicates failure of the test. A cut off score of greater than 15 seconds has predictability value in identifying recurrent fallers [28]. For elderly patients, the minimal detectable change (MDC) is 5.2 seconds [29] and the minimal clinically importance difference (MCID) in post stroke patients is around 3 seconds, depending on their ambulation status [30]. The scale has excellent intra-rater reliability (ICC = 0.97) [31].

2.2.2 Timed up and go (TUG)

The TUG [32] was used as a measure of basic functional mobility. The patient was instructed to stand from a standard arm chair, walk 3 metres to a specified line, turn, walk back and sit. He was allowed to use his arms and mobility aid as necessary and any modifications were documented. The MDC for this outcome measure in post stroke patients is 2.9 seconds and the “smallest real difference” is quoted as 23% [33]. The scale has excellent intra-rater reliability in post stroke patients (ICC = 0.96) [33].

2.2.3 Tinetti balance and gait assessment

The Tinetti test [34] was chosen as a measure of balance and gait. The test uses a 3-point ordinal scale of 0,1 and 2 points. Gait is scored out of 12 points and balance is scored out of 16 points, totalling 28 points. The lower the score, the higher the risk of falling. The minimal detectable change in post stroke patients is 6 points and the MCID is 7 points [35]. The scale has excellent intra-rater reliability in a mixed elderly group including stroke patients (ICC = 0.84) [36].

2.2.4 The stroke specific quality of life scale (SSQOL)

The SSQOL was used to measure health-related quality of life [37]. It is a self-reported scale containing 49 items in 12 domains: mobility, energy, upper extremity function, work/productivity, mood, self-care, social roles, family roles, vision, language, thinking, and personality. Items are rated on a 5-point Likert scale. Higher scores indicate better functioning. The MDC of the mobility, self-care, and upper extremity (UE) function subscales were 5.9, 4.0, and 5.3 respectively. The MCID ranges for these 3 subscales were 1.5 to 2.4, 1.2 to 1.9, and 1.2 to 1.8 [38]. Intra-rater reliability was shown to be excellent (ICC = 0.92) [39].

2.2.5 The modified ashworth scale (MAS)

The MAS [40] was chosen as it is considered the primary clinical measure of muscle spasticity in patients with neurological conditions. The MAS was applied to the muscle groups of the upper and lower limbs in supine and side lying. The MAS is a scored on a 6-point scale with scores ranging from 0 to 4, where lower scores represent normal muscle tone and higher scores represent spasticity. Adequate intra-rater reliability has been demonstrated [41], with agreement ranging from 57.5% to 87%. The MDC is 1 point [42] and the MCID for the upper extremity muscles were 0.48 and 0.76 and for the lower extremity muscles were 0.45 and 0.73, respectively [43].

2.2.6 The activities specific balance confidence scale (ABC Scale)

The ABC scale [44] is a 16 item self-report measure in which patients rate their balance confidence for performing activities. Scoring is from 0 to 100 with 0 being no confidence and 100 being full confidence. It was chosen for the initial assessment to measure balance confidence, but also to guide the treating therapist in recommending whether or not the patient would need supervision during the exercise sessions. In the Irish guidance document [45] for virtual pulmonary rehabilitation, the authors recommend that if a patient scores less than 67%, they require another person present in the house during the online exercise class. That guidance was used to shape our model of safe exercise recommendations. Intra-rater reliability is excellent in the chronic stroke population (ICC = 0.85) [46]. The MDC is 15% in older adults [47] and the MCID has not been reported in post stroke or general elderly populations yet.

2.2.7 Feasibility

Feasibility of the online neuropilates programme was assessed qualitatively based on whether the patient was able to complete the programme with modifications, whether the patient was able to tolerate the programme without increased pain or fatigue and information was also gathered from the patient’s responses in a client satisfaction questionnaire.

Prior to completion of the face-to-face session, the patient was instructed on a number of items:

Technical instructions were given to the patient on using the tablet device, connecting to the internet and connecting to the Zoom classes.

Based on the patient’s results on the ABC scale, the treating physiotherapist recommended that the patient be supervised by his wife whilst exercising.

A Safe Exercise Checklist was given to the patient and he was instructed how to set up his home environment safely for exercising in sitting and standing. (Appendix 1)

A disclaimer was also discussed with and signed by the patient in which he agreed that he was voluntarily taking part in the exercise class at his own risk and assumed all risk of injuries himself (Appendix 2).

The patient was also taught the pilates “rest” position in sitting and standing, including pelvic tilting, neutral spine acquisition and transversus abdominis activation.

2.3 Intervention

The physiotherapist conducted 6 online neuropilates classes with the patient via the ZOOM platform, instructing him in neuropilates principles and exercises. All exercise sessions were fully supervised on a one-to-one online basis by the treating physiotherapist. The treating physiotherapist was an experienced CORU registered senior Physiotherapist with 8 years’ experience in stroke rehabilitation and was also a qualified pilates instructor certified with the Australian Physiotherapy and Pilates Institute (APPI ®) with over 5 years’ teaching experience. All pilates exercises were conducted in line with APPI ® teaching using visual imagery and real time feedback to promote alignment and correct execution of the exercises. Modifications were made as necessary using the physiotherapist’s clinical reasoning skills to accommodate for increased tone in the right arm and balance deficits. These modifications included verbally cueing; altered stance positions; reduced ranges of motion at the shoulder and; increased upper limb support taking amongst others. Throughout the sessions, emphasis was placed on equal weight distribution and equal muscle activation between the affected limb and the non-affected limb. Normal movement sequences were also practised withadditional focus on neutral postures and “core” activation. Simple warm up and cool down exercises were completed at the beginning and end of each session. All exercises were conducted in sitting and standing to ensure continual remote monitoring of the patient and safety. Examples of exercise sets are presented in Table 1.

Table 1
Examples of Neuropilates Exercise Sets using a combination of APPI ® exercises and physiotherapy led normal movement sequences

Posture exercises in sitting and standing Balance exercises in standing

∘ Pelvic tilting and neutral spine alignment ∘ Weight shifting, “ankle strategy”

∘ Postural setting with imagery for the whole body ∘ Stepping with weight transference

∘ Transversus abdominis activation in neutral spine postures ∘ Calf raises progressing to alternate calf raises

∘ Scapular setting exercises ∘ “Side leg lift” in standing level 1

∘ “One leg circle” in standing level 1

∘ “One leg stretch” in standing level 1

∘ Stride stance with upper limb movements

APPI ® Upper limb exercises and stretches(With / without therabands) Lower limb strengthening:

∘ “Mermaid” ∘ Sit to stand with focus on postural alignment and normal movement patterns progressing to no use of upper limbs

∘ “Arm openings” ∘ Squats, wide squats, stepping into wide squats, sustained squats all with focus on neutral spine alignment and upper body postural cues

∘ “The offering”

∘ “Chest stretch”

∘ “Spine Twist”

∘ “Hundreds” modified to a sitting position with leg lifts as appropriate

Posture exercises in sitting and standing	Balance exercises in standing
∘ Pelvic tilting and neutral spine alignment	∘ Weight shifting, “ankle strategy”
∘ Postural setting with imagery for the whole body	∘ Stepping with weight transference
∘ Transversus abdominis activation in neutral spine postures	∘ Calf raises progressing to alternate calf raises
∘ Scapular setting exercises	∘ “Side leg lift” in standing level 1
	∘ “One leg circle” in standing level 1
	∘ “One leg stretch” in standing level 1
	∘ Stride stance with upper limb movements
APPI ® Upper limb exercises and stretches(With / without therabands)	Lower limb strengthening:
∘ “Mermaid”	∘ Sit to stand with focus on postural alignment and normal movement patterns progressing to no use of upper limbs
∘ “Arm openings”	∘ Squats, wide squats, stepping into wide squats, sustained squats all with focus on neutral spine alignment and upper body postural cues
∘ “The offering”
∘ “Chest stretch”
∘ “Spine Twist”
∘ “Hundreds” modified to a sitting position with leg lifts as appropriate

As the weeks progressed, the patient was instructed to use his upper limbs less for support as able and also, more time was spent in standing in line with the patient’s standing tolerance. The physiotherapist demonstrated any new exercises to the patient instructing him to watch first, before trialling the exercise himself and the patient then practised as the physiotherapist observed or exercised with him and provided feedback.

3 Results

There were no adverse events recorded during the course of this intervention. Constant online supervision was provided to the patient throughout these one-to-one classes. The patient reported no pain or additional fatigue as a result of partaking in this intervention. This case study shows that it was feasible to complete a modified neuropilates programme online with a post stroke patient on a one-to-one basis.

Results from the patient satisfaction survey indicated that this intervention and the mode of delivery were suitable and acceptable to this patient. The patient commented positively on the content and pace of the course and found the exercises were suitably adapted to meet his needs. The patient commented that the sound quality of the virtual class was “good” and the video quality “very good”. The patient enjoyed the classes and commented that he felt “more fit and stronger” after completing the 6 classes. He also reported that he would not have preferred to attend a face-to-face class and if he were offered face-to-face or online classes in the future, he would pick online due to ease of accessibility.

Post intervention results indicated improvements across most outcome measures (see Table 2). The patient’s walking speed improved by 8.5 seconds as measured by the TUG. Other outcome measures also showed post intervention improvements in the areas of quality of life (13.8% improvement) and balance confidence (9% improvement). Positive changes were also seen in terms of balance and gait pattern as measured by the Tinetti assessment, with an increase of 3 points. On initial assessment, the patient failed the 5 times sit to stand test as he was unable to stand without use of the upper limbs. After the intervention, the patient managed 3 stands without upper limb support but still failed the test as he needed the support of one upper limb for the final 2 stands. Mixed results were seen for muscle tone as can be seen in Table 2, with 50% of the muscle groups remaining unchanged, 33.3% indicating improvements in tone and 16.6% disimproving.

Table 2
Results of pre and post intervention outcome measures

Outcome Measure Pre Intervention Post Intervention

Timed up and Go (seconds) Patient used 4 wheeled walker for both tests 32.5 24

5 Times Sit to Stand Unable to stand at all without upper limb support –test failed Able to do 3 x stands with no upper limb support

Stroke Specific Quality of Life (points) 202 236

The Activities Specific Balance Confidence Scale (% confidence) 57% 66%

Modified Ashworth Scale (points) Shoulder: 2 Shoulder: 0

Elbow: 1 Elbow: 2

Wrist: 0 Wrist: 0

Hip: 1 Hip: 1

Knee: 0 Knee: 0

Ankle: 2 Ankle: 1+

Tinetti Balance and Gait Ax (points) Balance Score: 13/16 Balance: 14/16

Gait Score: 7 / 12 Gait Score: 9/12

Total Score: 20 / 28 Total Score: 23/28

Outcome Measure	Pre Intervention	Post Intervention
Timed up and Go (seconds) Patient used 4 wheeled walker for both tests	32.5	24
5 Times Sit to Stand	Unable to stand at all without upper limb support –test failed	Able to do 3 x stands with no upper limb support
Stroke Specific Quality of Life (points)	202	236
The Activities Specific Balance Confidence Scale (% confidence)	57%	66%
Modified Ashworth Scale (points)	Shoulder: 2	Shoulder: 0
	Elbow: 1	Elbow: 2
	Wrist: 0	Wrist: 0
	Hip: 1	Hip: 1
	Knee: 0	Knee: 0
	Ankle: 2	Ankle: 1+
Tinetti Balance and Gait Ax (points)	Balance Score: 13/16	Balance: 14/16
	Gait Score: 7 / 12	Gait Score: 9/12
	Total Score: 20 / 28	Total Score: 23/28

4 Discussion

This study was undertaken to assess the feasibility, safety and efficacy of an online, remotely supervised neuropilates class in a post-stroke patient, something which has not been investigated in the literature before. The vast majority of literature regarding pilates has been conducted to investigate effects on pain, specifically low back pain [48], However, more recently, literature reviews have found pilates method exercises to be safe, feasible and led to improvements in balance in elderly patients [49], exercise tolerance and strength in patients with non-communicable diseases [50] and physical functioning in patients with multiple sclerosis [51]. A small number of previous studies have investigated in-person group pilates classes in post-stroke patients [16 –20] and one to one pilates training in a case study of a post stroke patient [52]. In all of these stroke-related group and one-to-one pilates classes, the majority of exercises were undertaken in supine, prone and/or side-lying on the mat. Also, most of these studies only included the higher functioning patients that were mobile without an assistive device [17 –19]. The only study, published very recently, that has examined the feasibility and effects of online pilates training [53] employed young, healthy individuals as participants (aged 18–25) and although they concluded that online pilates exercises were feasible and safe and resulted in positive effects on trunk proprioception and core muscle endurance, these results cannot be extrapolated to any clinical population.

There are two major differences between our case study and all of the previous literature in this field; 1) The patient was unable to get on and off the floor unassisted so all pilates exercises would have to be modified to the seated and standing positions. 2) The online nature of the neuropilates class in a clinical population is a novel concept in the literature.

4.1 Feasibility

This case study found that it is feasible for a post stroke patient with balance and mobility deficits to partake in an online 6 week neuropilates class. The patient selected for this case study was not computer literate. During the initial face-to-face assessment, he was provided with a tablet device on loan by the treating physiotherapist and was given a demonstration and written instructions on how to use the tablet, how to connect to his mobile phone as a hotspot and how to log onto the Zoom platform and access the class. This initial in-person session was deemed necessary in order for the class to be feasible. On a few occasions, there were some connectivity issues or sound issues which were usually resolved with the assistance of family members but occasionally resulted in a delay in starting the class. The patient reported having no issues or difficulties connecting to the classes in his feedback questionnaire.

It is important to note for future studies that patients that are not computer literate or do not own a smart phone or tablet can also partake in online exercise classes if provided with the hardware to do so. Initial in-person demonstration of the equipment and technical support from instructors and/or family members at home may also be necessary. This is comparable with findings in the research conducted into online pulmonary rehabilitation, where the authors found that IT issues could be overcome by “providing personalised equipment and one-to-one technical support in patient homes” [54]. In a similar manner to our case study, a scoping review into supervised telehealth interventions involving activities in standing positions for people post stroke [22], also recommended in-person education or demonstration of the telehealth system to optimise feasibility.

The exercises in this case study were only undertaken in sitting and standing to ensure feasibility for the patient who could transition between these positions with no assistance. This was based on initial assessment of function. This required significant modification of many pilates exercises and teaching in line with APPI’s® standing pilates exercise programme. Visibility of the patient on screen was somewhat impacted when the patient stood up, but the treating physiotherapist overcame this by regularly checking in with the patient when he was standing to ensure even weight distribution and correct posture. Asking the patient to adjust his tablet or move further away from the screen every time he stood up would have been difficult for the patient to execute, as he was using his 4 wheeled walker for support in standing and needed regular sitting breaks during the class. It was more feasible for the patient to have the environment and tablet set up on the table in front of him and not to adjust it during the entirety of the class.

4.2 Safety

This case study was conducted based on the safety guidelines in the Irish guidelines for virtual pulmonary rehabilitation (VPR) which have been published [45]. The use of the ABC scale to determine the need for supervision during exercising, together with “safe exercising at home” tips sheet (Appendix 1), use of a disclaimer (Appendix 2) and in-person assessment and demonstration all ensured a high standard of safety protocols in our case study. The set-up of the environment was crucial, particularly when carrying out neuropilates exercises that purposefully challenge a patient’s balance. At all times during the case study, the patient had a support near-by to hold onto if he felt unsteady. This support was either his 4 wheeled rollator in front of him or a bar attached to the wall of his sitting room beside him. Protocols were also in place in the event that an adverse event occurred during the class (Appendix 3). This study has shown that once these safety guidelines are followed and the environment is set up correctly, remotely supervising a post stroke patient online on a one-to-one basis carrying out neuropilates exercises at home is safe. Further research would be needed to assess if online neuropilates would be safe in a group setting where supervision levels would be considerably less.

In a recent German study examining live online exercise programmes, including balance training components, in 162 older adults, no safety concerns were reported [55]. Classes in this study had a ratio of 1 supervisor to 8 –15 participants. The authors did state that a professional camera and microphone system was used in order for participants to see the instructor clearly and a 160” screen was used for the instructor to see each participant. This may be an important strategy to optimise safety when supervision levels are lowered. Some other strategies to optimise safety were found in a recent scoping review of supervised telehealth interventions, both individual and group training, involving activities in standing positions for people post stroke [22]. The strategies employed included; in-person initial exercise prescription, non-health professional in-person supervision or assistance when required, physiological monitoring pre, during and post session, and exclusion of those with one or more co-morbidities. One adverse event related to the intervention was reported in one study in this scoping review, namely a fall during a supervised exercise session requiring medical intervention. Overall, the dearth of literature in this field prevents firm conclusions being made about safety of group online exercise training in stroke patients, but future studies examining this should consider employing some or all the above strategies to maximise safety. From a staffing point of view, efficiency would be maximised if online group exercise classes were deemed safe and feasible even with two supervisors going forward.

Another important safety consideration is the level and experience of the treating physiotherapist and/or pilates instructor. Modifications in response to patient need were frequently made during the online classes using the physiotherapist’s clinical judgement and expertise. These included cueing the patient to adjust his posture, to hold the support, to take more weight through the affected limb, to adopt normal movement patterns, to modify the stance position and to modify the range of shoulder movement if causing pain, amongst others. In a literature review examining in-person pilates classes in post stroke patients [21], no major modifications were reported as being made to suit the specific needs of the post stroke patient. However, this could have been a reflection of the higher functioning post stroke patients that were most often selected for inclusion in previous studies and pilates exercises completed mostly on mats and not in more functional positions. In an RCT [56] which compared pilates to physical therapy intervention in people with multiple sclerosis, the authors speculated that the pilates instructors who were also physiotherapists unconsciously took advantage of their skills in neuro-rehabilitation and appropriately adjusted the intensity and difficulty of the pilates exercises as required and questioned whether the results would have been different if the pilates intervention was taught by pilates instructors with no experience in rehabilitation. Based upon the results of this case study, safety is optimised when a clinically experienced physiotherapist who is also a trained pilates instructor carries out the remote supervision and instruction of the pilates exercises online.

4.3 Outcomes

Results of this study are comparable with results of a previous literature review that examined neuropilates training in post stroke patients [21] which found that there was moderate evidence to suggest that pilates may have positive effects on balance in post stroke patients and limited but significant findings on improvements in quality of life and gait parameters in post stroke patients. Our patient experienced improvements in the Tinetti Balance and Gait assessment, TUG and ABC scale, all of which are various measures of gait and balance. The patient’s improvement of 8.5 seconds on the TUG was more than double the minimal detectable change (MDC) for this outcome measure [33], but other improvements fell short of the MDC. Balance is an intricate process with integration of the senses, the vestibular system, the musculoskeletal system and the nervous system. Theories as to why balance may have improved with neuropilates training in our post stroke patient are; a potential improvement in postural stability through strengthening of stabilising trunk, pelvic and lower limb muscles, an improvement in kinaesthetic awareness and a focus on “centreing”, a key principle of pilates which involves a consistent and repetitive focus on neutral postures and alignment. All of these theoretically may have improved balance and minimised compensatory patterns leading to improved verticality perception and normal movement patterns. However, the links made here are only theoretical. Other reviews have found that pilates exercises with a strong focus on core strength training, could be used as an adjunct or even alternative to traditional balance and/or resistance training programmes for older adults [57]. Our patient also improved his gait speed by 26.2% most likely due to improved transfer ability and swiftness, improved confidence in movement (as measured by the ABC scale) causing less hesitancy and possibly due to improved patterning during gait through re-training of equal weight acceptance on both limbs during neuropilates training. This latter inference is made based on previous research demonstrating that weight shifting training in particular in chronic stroke patients when added to a conventional exercise programme, improved trunk control, balance and TUG scores significantly compared to controls [58].

Our participant also improved his quality-of-life score on the SSQOL by 34 points, which is higher than the MDC value for this scale [38]. Other studies investigating pilates training in clinical populations have also found it significantly improves participants’ quality of life scores compared to controls, in post stroke patients [16, 17], in older women [59] and in people with multiple sclerosis [60] others. Theoretically, the actual physical component of the exercise could have positively influenced mood, confidence and overall satisfaction which may have accounted for the improved score. However, pilates exercises in particular, with a focus on greater inner balance and mind body connections may have greater influences on quality of life than general exercise in post stroke patients. This theory is supported by findings from a meta-analysis on controlled trials investigating the effects of pilates on mental health outcomes where the authors found that the magnitude of the mean effect for overall health related quality of life with pilates exercises was larger than previously reported meta-analytic findings for general exercise effects on quality of life among adults with a chronic illness [61]. However, further investigation is warranted before true comparisons can be drawn.

Mixed results were seen with regard to muscle tone with the shoulder and ankle dorsiflexors showing some decreases in tone, the elbow flexors showing minor increases and all other areas remaining unchanged. Breath awareness is another key principle of pilates which could theoretically have effects on muscle tone in post stroke patients through teaching patients how to breathe appropriately and control their movements with maximum efficiency, but this has not yet been studied in the literature, only observed clinically and is another area for future research.

5 Limitations and conclusion

The major limitation of this or any case study is that it provides little basis for generalisation of the results to the wider post stroke population. And although an attempt at minimising researcher bias was made by having a separate physiotherapist carry out the assessments, bias could not be eliminated fully as the assessor was aware of some intervention having taken place during the case study. It can be assumed that some of the findings may have been due to placebo and hawthorne effects also. However, this case study does highlight the feasibility of a neuropilates intervention remotely supervised online in a post stroke patient and highlights some useful safety considerations. It establishes the fact that the patient reported preferring the online format which is interesting for the future development of remote physiotherapy models. Further investigation would be warranted to now assess the feasibility and safety of group online neuropilates training in this population in a randomised controlled trial to rigorously assess outcomes. Comparison with general exercise would be interesting to assess for the potential superiority of pilates in this population. It would also be interesting to include a cost analysis between traditional pilates therapy and remote therapy.

Conflict of interest

The authors have no conflict of interest to report.

Footnotes

APPENDIX I: Safe Exercise Checklist

APPENDIX II: DISCLAIMER

Disclaimer:

I agree and consent to the following:

I am voluntarily participating in a 6-week Virtual Home-Based Exercise Programme as part of a clinical trial investigating the feasibility and effectiveness of these classes, being conducted by IT Sligo.

I understand that this is a novel intervention and the background and benefits of the programme have been explained to me.

I understand that when participating in any exercise there is a potential risk of injury.

I am taking part at my own risk and assume all risk of injury to myself.

IT Sligo and the physiotherapist on this programme accept no liability.

I have read and will adhere to the Safe Home Exercise Checklist.

Signed:_________________________

Print Name:_____________________________

Date:___________________________________

APPENDIX III: Protocol in Case of Emergency

In the case of an emergency event during the class, the following protocol is adhered to:

The class is stopped

All patients except for the unwell patient exit the platform.

The person in the house with the patient is advised on how to deal with the patient OR the patient’s emergency contact person is notified by the class instructor

The class instructor will have all eircodes of the participants readily available in case they need to contact an ambulance.

The class instructor will remain in contact with the patient via videolink until they are stable and/or have received medical attention

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