  multiple sclerosis ( ms ) is a chronic disease that is associated with demyelination of 
 neurons and affects the myelin sheath of neurons in the central nervous system.the cause of this disease is still unknown , but 
 it seems that activation of immune mechanisms against myelin antigen is involved in this 
 regard .
ms usually occurs at ages 
 20 - 40 and affects women more than men .  
currently , 2 million people worldwide , including 400,000 americans , are afflicted with 
 ms . in iran , 15 - 30 out of
the emergence of this disease is usually coincident with situations such 
 as family formation , career choice , and providing financial security .  
ms threatens a person s independence and ability to effectively participate in society , on 
 the one hand , and its prognosis and 
 unpredictable periods considerably affect quality of life and health , on the other hand .  
ms patients are unable to find an appropriate way to solve problems and achieve approaches 
 to improve their quality of life and health .  
in chronic diseases , quality of life is highly influenced by severity and duration of 
 disease and drugs taken by the patient .
since ms patients are no exception , complications of 
 this disease , in addition to causing physical discomforts , imposes mental , social , and 
 economic pressures on patients and their family .
moreover , this disease leads to a decline 
 in personal and social performance of patients and thereby greatly affects their roles in 
 life , job status , and quality of life ( physical and mental health ) .
studies have shown that ms patients have a 
 significantly lower quality of life compared to healthy people and patients with other 
 chronic diseases such as epilepsy , diabetes , and rheumatoid arthritis .
the findings show that fatigue is one of the 
 most common mental symptoms of ms which negatively affects quality of life , as highest 
 prevalence of fatigue in ms patients is 70 - 90% .
ms patients make complaints 
 of fatigue as the worst and most debilitating symptom of their condition .
in fact , 
 ms - related fatigue is a common abnormal lack of energy which dramatically limits one s 
 physical and mental ability , regardless of the level of neurological disability .
this 
 fatigue affects the cognitive and motor abilities manifested as loss of energy , illness , 
 motor weakness , and difficulty in maintaining the focus .
ms - related fatigue can also 
 negatively affect employment , socialization process , and coping with the disease and thereby 
 reduce the level of daily activities and quality of life of patients .   as reported by previous studies , clinical manifestations of ms play an important role in 
 adaptation of patients to the disease . hence , psychotherapy interventions aimed at these 
 manifestations can help patients to better cope with this disease .
the best treatment for improvement of quality of life and 
 reduction of fatigue is to train patients on self - care and help them adapt to changes in 
 their physical and mental status .
one of 
 the most common treatment for decreasing of anxiety , depression , and stress and improving 
 life quality is mindfulness - based stress reduction program ( mbsr ) that has been presented by 
 kabat - zinn in medical centre of massachusetts university in 1979 .
this is an 8-week program which every session lasts 2 hours 
 and mindfulness skills for coping with life stresses and raising awareness of the present 
 moment are taught and include thought - related meditation , relaxation and hatha yoga . 

mindfulness means paying attention to the present time in a special , targeted , and without 
 judgment way .
one of the main goals of 
 this program is promoting the health and reducing stress .
one of the main concepts of 
 mindfulness training is that to be honest to ourselves and our feelings .  
along with increasing individual s ability to mindfulness , the person can accurately 
 detect what is happening in the body and mind as it is happening in the environment 
 around.it seems that the mbsr and 
 conscious yoga in a group can be useful for ms patients .
it is believed that group therapy 
 can be used effectively for most mental disorders , because group therapy is a process 
 through in which the insight of individuals is improved . in addition
, patients in a group 
 feel more powerful and have a higher level of self - confidence .  
many studies have been conducted on the useful effects of mbsr and mindfulness - based 
 cognitive therapy ( mbct ) on chronic diseases such as low back pain , fibromyalgia , breast 
 cancer , and prostate cancer .
the results of studies conducted by gu et al . , 
 about the effect of mindfulness on ms patients have indicated that mindfulness caused no 
 significant change in the management of symptoms among ms patients .
however , the effect of mbsr and conscious yoga 
 program on ms patients has not been studied in the previous studies . in this program , 
 mindfulness means to pay attention to real objectives and being in the present moment in a 
 purposeful manner and devoid of judgment .
mbsr is basically designed to facilitate the compliance with and 
 adaptation to medical conditions and considered a self - regulatory approach to stress 
 reduction , emotion management , and health promotion .
if ms patients regularly do conscious yoga exercises , they will 
 experience some states of balance , relaxation , and in - depth awareness . since high fatigue and low quality of life are 
 prevalent among ms patients and this disease poses many psychological problems not only for 
 patients but also for their family , the present research aimed to study the effect of group 
 mindfulness - based stress reduction and conscious yoga program on the quality of life and 
 fatigue severity among patients with ms .
  the present research was a quasi - experimental study with pretest - posttest design with 
 control and intervention groups and was conducted by authorising from the honorable 
 management of tehran m.s association .
the statistical population included all male and 
 female ms patients aged 20 - 45 who were a member of ms society of tehran , 24 of whom were 
 selected as the sample based on the convenience sampling method and the inclusion criteria . 

the inclusion criteria were ms diagnosis by a specialist ( neurologist ) , being in the 
 relapse - suppression stage of the disease , independency on wheelchair , a minimum educational 
 attainment of high school diploma , non - use of psychotropic drugs and psychological 
 treatments throughout the study , and being aged 20 - 45 .
the exclusion criteria were absence 
 of patients in yoga and meditation classes before and during the study , affliction with 
 acute or chronic problems like severe depression , psychosis , and so on , not obtaining a 
 written consent for participation in the study , and absence of more than two sessions in the 
 program .
the samples were selected by convenience sampling method and were randomly ( a 
 random sample is drawn from a population by using a probability device .
we put everyone s 
 name on a slip of paper , mix thoroughly , and select the number of names we need .
the use of 
 a probability device to select the subjects allows us to make valid generalizations from the 
 sample to the population) assigned into experimental and control groups .
the adequacy of sample size was examined by basic statistical 
 methods ( krejcie and morgan table , g - power software ) and results of the previous 
 studies , with a confidence level of 
 95% and error of 5% .  
significance level of less than 5% error rate that we are committed to reject the null 
 hypothesis .
then , after obtaining written informed consent from all participant , pre - test 
 evaluations were conducted .
data were collected by following tools .   a : clinical version of the structured clinical interview for axis i disorders in dsm - iv 
 ( scid - i / cv ) ( diagnostic and statistical manual of mental disorders - iv ) : this is a 
 standardized tool for assessment of the major psychiatric disorders based on the definitions 
 and criteria of dsm - iv which has been developed for clinical and research 
 purposes .   implementation of scid - i / cv requires clinical judgment of the interviewer on the 
 interviewee s responses
therefore , the interviewer should have enough knowledge on 
 psychopathology . an acceptable validity and reliability of this tool
for instance , a cohen s 
 kappa coefficient of above 0.7 has been reported in the diagnostic reliability between 
 raters . according to the findings of another study , the validity of this tool
was confirmed 
 by experts and its test - retest reliability , in a week interval , was reported to be 
 0.95 .
this tool has been translated 
 into farsi and its validity and reliability has been confirmed by sharifi et al . , in 
 iran .  
b : fatigue severity scale ( fss ) : fatigue severity scale has been developed by krupp et 
 al .
, for assessing the severity of fatigue in chronic diseases such as multiple sclerosis 
 and lupus .
this scale measures fatigue in 9 items based on 7-point likert scale and higher 
 scores indicate greater fatigue .
cronbach s alpha of this scale for healthy people , ms 
 patients , and lupus patients has been reported to be 0.88 , 0.81 , and 0.89 , 
 respectively .
the internal 
 consistency ( cronbach s alpha ) and test - retest reliability of the farsi version of this 
 scale have been obtained equal to 0.98 and 0.93 , respectively . in the present study , test - retest reliability ( within two 
 months ) and internal consistency ( cronbach s alpha ) of fss
c : multiple sclerosis quality of life- 54 ( msqol-54 ) : this scale has been developed by 
 barbara vickrey for ms patients .
it consists of 54 items , modified by adding 18 items to the 
 36-item short questionnaire , and measures quality of life in 13 areas .
each subscale is scored from 0 to 100 and 
 score of each area is determined by calculating the mean scores .  
two important scores are the score of physical dimensions and score of mental dimensions 
 of quality of life . in a study on ms patients , subscales of quality of life presented a good 
 internal consistency with cronbach s alpha coefficients between 0.75 and 0.96 . to assess the 
 reliability by using the test - retest method , correlation coefficient for subscales was 
 obtained between 0.66 and 0.96 .
the validity of msqol-54 have been assessed and confirmed by 
 faculty member of tarbiat modarres university and medical universities of tehran , iran , and 
 shahid beheshti .
split method was used to examine the reliability of this scale and pearson 
 correlation coefficient was used for determining the correlation level .
the reliability of 
 msqol-54 using internal consistency and cronbach s alpha was obtained 0.86 and 0.88 , 
 respectively in patients with ms .  
after sincere cooperation of tehran ms society with authors , all members of this society 
 were invited to voluntarily attend in a meeting session in summer 2014 . in this meeting , 

those willing to participate in 
 the study were invited to an interview . after interview and screening , 24 ms patients were 
 selected as the sample considering the inclusion and exclusion criteria . after filling out 
 the questionnaire as the pretest , subjects were assigned into experimental and control 
 groups .
it should be noted that 3 subjects in the experimental group showed a decline 
 withdrawal . in the experimental group ,
a group mbsr program and conscious yoga were 
 performed in 8 two - hour sessions .
the content of each session are as follow : first session : 
 the introduction of automatic guidance system / knowing how to use present moment awareness of 
 bodily sensation , thoughts and emotions in reducing stress / practicing eating raisins ( object 
 attention training ) , giving feedback and discussion about the practice / three - minute 
 breathing , giving assignment for next week and distributing leaflets of the first session 
 and cds of meditation .
second session : re - examining body workout/ giving feedback and 
 discussion about examining body workout/ practicing breathing mindfulness meditation/ yoga 
 stretching exercise / distributing leaflets of the second session and cds of meditation .
third 
 session : having conscious sitting with awareness of breathing(the sitting 
 meditation)/practicing yoga exercises(in the hospital chapel)/ practicing three -minute 
 breathing /distributing leaflets of the third session and video tape of yoga practices . 

fourth session : re - examining body workout /practicing exercises related to conscious yoga(in 
 the hospital chapel)/5-minute practicing of  seeing or hearing/ re - practicing conscious 
 session with awareness of breathing and body/ distributing leaflets of fourth session and 
 cds of meditation .
fifth session : practicing breathing /re - practicing conscious 
 session(awareness of breathing , body , sounds and thoughts)/explaining the stress and 
 identifying participants reactions to stress / examining awareness of pleasant and unpleasant 
 events on feeling , thoughts and bodily sensations / practicing conscious yoga 
 exercises / practicing 3-minute breathing /distributing leaflets .
sixth session : practicing 
 conscious yoga / practicing sitting meditation ( mindfulness of sounds and 
 thoughts)/distributing leaflets of the sixth session and number 4 video tape to 
 participants .
seventh session : practicing mountain meditation / sleep hygiene/ repeating 
 exercises of the previous session / making a list of enjoyable activities / distributing 
 leaflets of the seventh session .
eighth session : examining body workout /overview of 
 program / examining and discussing programs /practicing stone , beads and marbles 
 meditation .   at the end of all therapy sessions
in addition , due to ethical considerations , subjects in the control group were 
 explained that the implementation of this treatment is will be done for them for a certain 
 period of time ( two months ) .
however , they were put in the waiting list and will be invited 
 for treatment after this period . in order to calculate the mean and standard deviation , 

descriptive statistics were used and data analysis was done using the univariate analysis of 
 covariance . considering the normal distribution of data and homogeneity of variances , the 
 univariate analysis of covariance was used for analysis .
data were analyzed by spss ver.13 
 software .   before participating patients in the study ,
the necessary information on the objects , the 
 duration of study , and how to cooperate during the study was given to the patient and 
 his / her attendant then after receipting them through the written informed consent as written 
 form , they were selected as a research unit .
the research units were assured the collected 
 information and results of all patients will remain confidential and they may canceled if 
 they do nt want to go on . it was provided a necessary call to contact with researcher if 
 necessary .
there was no significant difference between control and experimental groups in 
 terms of mean of demographic characteristics such as sex , age , education , and marital ( p < 
 0.05 ) .  
the mean age of the patients in the 
 intervention and control groups was 32.50 ( 5.14 ) and 32.13 ( 5.04 ) years , respectively .   according to table 2
, the results of the 
 multivariate analysis of covariance showed that there was a significant difference between 
 subjects in the experimental and control groups in terms of mean score of some subscales of 
 quality of life including physical health ( p=0.001 ) , role limitations due to physical and 
 emotional problems , energy , emotional well - being , health distress , health perception , 
 satisfaction with sexual function , overall quality of life ( p<0.05 ) , and fatigue severity 
 ( p<0.001 ) . but about 3 subscales of pain ( p=0.10 ) , social performance ( p=0.08 ) and health 
 change ( p=0.66 )
therefore , it can be stated that mbsr 
 and conscious yoga caused improvement of the above - mentioned subscales of quality of life 
 and reduction of fatigue severity in subjects of the experimental group compared to those in 
 the control group . 

univariate analysis of covariance , statistically 
 significant   the present study was approved by regional ethics committee at behavioral sciences 
 research center , shahid beheshti university of medical sciences ( ethics code : 1287 ) .
  the present research aimed to study the effect of group mbsr and conscious yoga program on 
 the quality of life and fatigue severity among patients with ms .
the study findings revealed 
 that group mbsr and conscious yoga program have significantly improved the physical and 
 mental quality of life in ms patients .
shapiro et al . , concluded that mbsr not only causes a reduction in 
 anxiety and depression symptoms in ms patients but also enhances the quality of life and 
 well - being of individuals .
. senders et al . , showed that , conventionally 
 mind - body therapies ( mindfulness ) can be safe and helpful for treating common ms symptoms 
 and especially non - pharmacological options , but for treating specific ms symptoms , it is 
 needed more rigorously designed trials of mind - body interventions to increase our 
 understanding and awareness on it.as an 
 explanation to these findings , it can be acknowledged that group mbsr and conscious yoga 
 program , through meditation and mindfulness techniques , can increase self - acceptance and 
 self - awareness abilities and thereby improve the quality of life .
mindfulness ( focus and 
 automatic exercises ) and relaxation training ( body scan , relaxation and hatha yoga ) , as 
 stress management skills , should be regularly and permanently used in patients everyday 
 life .
studies have shown that mindfulness has been effective in improvement of mental and 
 physical well - being and reduction of physical symptoms . in another explanation , it can be noted that mindfulness is a balanced 
 and non - judgmental feeling of awareness which helps the clarification and acceptance of 
 physical and emotional phenomena .  
therefore , mindfulness training in patients with ms , who suffer from physical and mental 
 problems , leads to the acceptance of physical and emotional symptoms and this acceptance 
 reduces their excessive sensitivity to their problems . in this regard ,
the results 
 show that emotional inhibition is considered a negative strategy for regulation of the 
 emotion causing chronic diseases such as ms and cognitive - emotional assessment is regarded a 
 positive strategy for regulation of the emotion leading to the improved mental and physical 
 quality of life and reduction of physical symptoms of specific diseases such as ms .  
in contrast , our results are not consistent with the results of dodd et al . , and rampelo et al . ,
have shown that quality of life after exercise training 
 program changes as well , but no significant changes . in the present study ,
mbsr program has 
 not caused significant difference in some of quality of life subscales including pain , 
 social performance and health change . because it seems that low number of research 
 participants is the reason for 
 achieving different results in few quality of life subscales .
lack of significant difference 
 in social functioning subscale between experimental and control group can be affected by 
 different factors such as family relationships , culture , attitude and economic condition in 
 individuals . like our study , henderson et al .
, carletto et al . , and 
 ulrichsen et al . , showed that the 
 treatment of mbsr highly affected on the quality of life , well - being , and hope in traumatic 
 brain injury and ms samples and significantly in reducing subscales of depression , anxiety , 
 and hostility .  
as the study findings show , group mbsr and conscious yoga program significantly reduced 
 scores of fatigue severity in ms patients .
in addition , the results of arch and krask showed that the participants 
 who had 15 minutes of focused breathing ( as a common exercise in mbsr ) reported to suffer 
 from less mental fatigue . yet , fatigue severity causes loss of physical strength and 
 reduction of physical functions on the one hand and reduces the psychological aspects 
 related to quality of life in patients on the other hand .
, showed that fatigue and depression can 
 significantly impact ms patients ' quality of life .
furthermore , for improving quality of 
 life in ms patients ; effective interventions may help , as target fatigue and 
 depression .
in addition , the results 
 of a study conducted by flegal et al . , indicated that yoga improves the quality of life and 
 reduce fatigue in these individuals .  
as an explanation to the findings , it can be stated that mindfulness training means 
 focusing one s awareness on the present moment , while calmly acknowledging and accepting 
 one s feelings , thoughts , and bodily sensations . in the presence of mind
, one learns to be 
 aware of his / her own mental state at any moment and focus on a certain issue .
participants 
 continuously focus on different parts of their body and feelings related to any area of the 
 body are carefully observed .
then , in a relaxed and wide awake state with eyes closed , they 
 focus on breathing senses .
individuals are encouraged to pay attention to their inner experiences at any moment , such 
 as physical sensations , thoughts , and feelings . in addition , focusing on environmental 
 aspects such as sights and sounds are encouraged .
mindfulness should create the attitude in 
 individuals that have a non - judgmental acceptance in the face of affairs and issues . 

participants also apply mindfulness and focus during everyday activities such as walking , 
 standing , and eating , be aware of their moods at any moment , and observe without judgment 
 whenever emotions , feelings , and cognitions are processed . when participants find that the 
 mind is wandering in thoughts , memories or speculations , they direct their attention to the 
 present moment without regard to the content and nature of them .
therefore , participants are 
 taught to pay attention to their thoughts and feelings but do not stick with their content . 

one of the outcomes of mindfulness exercises is that individual find that most of 
 feelings , thoughts and emotions are fluctuating or fleeting . on the other hand , these 
 exercises of mindfulness in the present time
reduce fatigue severity , because individuals 
 lose energy in the process of past and future thoughts and continuously repeat it during 
 daily activities .
one of the limitation of this research was the lack of treatment follow - up due to time 
 limitations .
therefore , it is recommended that the results of treatment to be followed up in 
 future studies .
  in this research the group mindfulness - based stress reduction program and consciousness 
 yoga improved the mental and physical aspects of quality of life and reduced the fatigue in 
 patients with ms .
  we thanks all ms society staff in tehran and patients who has participated in this study 
 is appreciated .
 
 introduction : the chronic nature of multiple sclerosis ( ms ) , 
 have can leave devastating effects on quality of life and fatigue . the present research 
 aimed to study the effect of group mindfulness - based stress reduction ( mbsr ) and conscious 
 yoga program on the quality of life and fatigue severity among patients with ms . 
 
 methods : this study was quasi - experimental with intervention 
 and control groups . 
 the statistical population included all members to ms society of 
 tehran province , 24 of whom diagnosed with ms were selected as the sample based on the 
 inclusion criteria . 
 the subjects were randomly assigned into the test group ( 12 patients ) 
 and the control group ( 12 patients ) . 
 ms quality of life-54 ( msqol-54 ) and fatigue severity 
 scale ( fss ) were used for data collection . 
 subjects in the test group underwent a mbsr and 
 conscious yoga program in 8 two - hour sessions . 
 the data were analyzed using the spss 
 ver.13 software . 
  
 results : the study findings showed that there was a 
 significant difference between subjects in the experimental and control groups in terms of 
 mean score of some subscales of quality of life including physical health , role 
 limitations due to physical and emotional problems , energy , emotional well - being , health 
 distress , health perception , and satisfaction with sexual function , overall quality of 
 life , and fatigue severity . 
 
 conclusion : the results show that the program is effective 
 in reduction of fatigue severity and improving some subscales of quality of life in ms 
 patients . 
 hence , this supportive method can be used as an effective way for improving 
 quality of life and relieving fatigue in ms patients . 
Introduction
Materials and methods
Results
Discussion
Conclusion
Acknowledgments
Ethical issues
Conflict of interest