Comparative effects of pilates-based interventions on functional mobility, balance, fatigue, and quality of life in people with multiple sclerosis: a systematic review and network meta-analysis

PURPOSE: Pilates-based exercise has gained attention as a non-pharmacological rehabilitation strategy for people with multiple sclerosis (MS), yet the comparative effectiveness of different Pilates modalities remains uncertain. This systematic review and network meta-analysis evaluated and ranked Pilates-based interventions for functional mobility, balance, walking performance, fatigue, and health-related quality of life in adults with MS. METHODS: PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were searched from inception to October 24, 2025. Eligible studies were randomized controlled trials of structured Pilates-based interventions lasting at least four weeks in adults with MS. The primary outcome was functional mobility measured by the Timed Up and Go test. Secondary outcomes included balance, walking endurance, fatigue, walking performance, and MS-specific quality of life. A frequentist random-effects network meta-analysis was performed; treatment ranking was summarized using SUCRA, risk of bias using RoB 2, and certainty of evidence using GRADE-NMA through CINeMA. RESULTS: Twenty-two randomized controlled trials involving 901 participants were included. Pilates ranked first for functional mobility and significantly improved Timed Up and Go performance versus control (MD: -5.23 s; 95% CI: -6.39 to -4.06). It also ranked first for balance, with a mean improvement of 8.58 points on the Berg Balance Scale (95% CI: 7.86 to 9.30). Pilates combined with Pilates-based telerehabilitation ranked highest for the 6-Minute Walk Test (MD: 50.81 m; 95% CI: 0.16 to 101.46) and significantly improved Fatigue Severity Scale scores. Home-based Pilates showed the largest reduction in Modified Fatigue Impact Scale scores. No comparison reached high certainty under GRADE-NMA. CONCLUSION: Pilates-based interventions may improve mobility, balance, walking endurance, fatigue, and quality of life in people with MS. Sparse networks, risk of bias, heterogeneity, imprecision, and limited follow-up warrant cautious interpretation. Adequately powered trials with standardized protocols are needed before routine implementation can be recommended.