Tai Chi and Square-Stepping Exercises in Women With Multiple Sclerosis

Multiple Sclerosis (MS) is a chronic and demyelinating disease of the central nervous system observed in young adults. As the disease progresses, impairments occur in motor and sensory functions. Somatosensory inputs, such as knee joint position sense, which is particularly critical for balance and postural control, are frequently affected. In addition to these impairments, a decrease in lower extremity muscle strength and fatigue affecting the vast majority of patients restrict participation in activities of daily living.

Within the scope of this study, women diagnosed with MS will be randomized into one of three different intervention arms: a Tai Chi group incorporating postural stability exercises based on the Yang style; a Square Stepping Exercise (SSE) group consisting of coordinated step patterns aimed at improving sensorimotor integration; or a control group in which Frenkel exercises, representing traditional coordination approaches, are applied. Exercise interventions in all groups were planned for 8 weeks, twice a week.

The study aims to comparatively demonstrate the effects of Tai Chi and Square Stepping Exercises on knee joint position sense, lower extremity muscle strength, and fatigue levels, and to develop evidence-based strategies for these parameters in MS rehabilitation

• Tai Chi (Behavioral): Tai Chi will be delivered for 8 weeks, 2 days per week, 1 session per day (total 16 sessions). Each session will last approximately 45-60 minutes and will include warm-up stretching, main Tai Chi practice, and cool-down stretching plus controlled breathing techniques.
• Square Stepping Exercise (SSE) (Behavioral): SSE will be delivered for 8 weeks, 2 days per week, 1 session per day (total 16 sessions). Each session will be completed in approximately 45-60 minutes, including warm-up and cool-down periods.
• Home-based Frenkel Coordination Exercises (Behavioral): Frenkel Coordination Exercises will be delivered as a home program for 8 weeks, 2 days per week, 1 session per day (total 16 sessions). Each session will last 15-30 minutes, excluding rest periods.

Primary outcomes

• Knee joint position sense [Baseline (pre-intervention) and immediately post-intervention (Week 8).]: Knee joint position sense will be assessed using an electrogoniometer. For standardization, participants will be evaluated in a seated position with back support, with the hip and knee at 90° flexion. A target angle of 30° knee extension (relative to the start position) will be used. When the participant reaches the target angle, she will be asked to hold the position for 5 seconds to learn the angle. The knee will then be returned to the neutral position and the participant will be asked to reproduce the target angle. Measurements will be repeated three times, the mean value will be calculated, and the absolute error (in degrees) will be recorded. Assessments will be conducted in a quiet room with eyes closed, with the joint exposed and barefoot.

Secondary outcomes

• Five-Repetition Sit-to-Stand Test (5STS) [Baseline (pre-intervention) and immediately post-intervention (Week 8).]: Lower-extremity functional strength will be assessed using the Five-Repetition Sit-to-Stand Test (5STS). Participants will sit on a standard chair and fold their arms across the chest. They will be instructed (with verbal explanation and practice before testing) to stand up and sit down five times as quickly as possible. Timing starts from the seated position and ends when the participant returns to the seated position after the 5th repetition. The result will be recorded in seconds; lower times indicate better performance.
• Fatigue Impact Scale (FIS) [Baseline (pre-intervention) and immediately post-intervention (Week 8).]: Fatigue will be assessed using the Fatigue Impact Scale (FIS), which evaluates how fatigued the participant has felt over the past month including the day of assessment. The scale includes three domains: cognitive (10 items), physical (10 items), and social (20 items). Each item is rated from 0 to 4 (0 = no problem; 4 = very big problem). Domain scores are calculated by summing item scores within each domain, and the total score is calculated by summing all domain scores.

Sex: Female, ages: 20 Years to 45 Years

Inclusion Criteria:

* Willing to participate and provide informed consent.
* Diagnosed with multiple sclerosis (MS) according to the McDonald diagnostic criteria.
* Relapsing-remitting MS (RRMS) phenotype.
* EDSS score < 3.5.
* Female, 20-45 years of age.
* No MS relapse within the past 1 month.
* No lower-extremity spasticity according to the Modified Ashworth Scale (MAS).

Exclusion Criteria:

* Any neurological disease other than MS.
* Experiencing an MS relapse during the study period.
* History of orthopedic surgery that may affect balance.
* Cognitive or psychiatric impairment that may interfere with study participation.
* Cardiovascular or pulmonary history that may prevent participation.
* Use of medications that may affect clinical assessment (e.g., antipsychotic use; continuous corticosteroid or immunosuppressive use within the past 1 month).
* Participation in any other exercise program

• Müge İçelli Güneş, PhD, Principal investigator, Pamukkale University Denizli Health Services Vocational School of Higher Education