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Leslie N Russek,1 Jeannie Di Bon,2 Anthony Herbland,3 Cheyenne Vivlamore Zion Higgins,1 Tiffany R Jandrew,1 Alison M Adams,1 Jane Simmonds4,5 1Physical Therapy Department, Clarkson University, Potsdam, NY, USA; 2The Zebra Club, London, UK; 3University of Hertfordshire, Hatfield, UK; 4Great Ormond Street Institute of Child Health, University College London, London, UK; 5London Hypermobility Network, Central Health Physiotherapy, London, UKCorrespondence: Leslie N Russek, Physical Therapy Department, Clarkson University, Potsdam, NY, 13699, USA, Email Lrussek@clarkson.eduPurpose: This study evaluated whether an independent, online modified Pilates program alters function, interoception (internal body awareness), activity levels, and kinesiophobia (fear of movement) in people with symptomatic joint hypermobility.Patients and Methods: This pragmatic clinical trial included and exercise group that did 8 weeks of modified Pilates and an 8-week waitlist control group. People with symptomatic hypermobility were asked to do an independent, online Pilates program designed specifically for people with hypermobility; each module was about 25 minutes, and participants were asked to do at least 3 days/week. Outcome measures included the Bristol Impact of Hypermobility (BIoH), International Physical Activity Questionnaire (IPAQ), Revised Body Awareness Questionnaire (BARQ), and Tampa Scale of Kinesiophobia (TSK). Clinical Trial &num; NCT07118865.Results: A total of 420 participants completed questionnaires at 8 weeks: 200 completed 8 weeks of Pilates and 220 were on a waitlist. The Pilates group demonstrated statistically significant improvements in BIoH, BARQ, and TSK immediately after the intervention (p< 0.001 for each) and compared to the control group (p< 0.001 for each). Improvements in the Pilates group remained statistically significant at 6 months. IPAQ did not change for any group.Conclusion: This online Pilates program for people with symptomatic hypermobility improved BIoH, BARQ, and TSK, though changes were modest. The exercises did not improve IPAQ. Online exercise may provide a cost-effective way to encourage life-long activity in people with hypermobility. Limitations include the inability to monitor performance of the Pilates, high drop-out rates, and the inability to control for changes in other treatments patients may have received.Plain Language Summary: We evaluated whether 8 weeks of an independently performed, online Pilates exercise program designed for people with symptomatic joint hypermobility could improve hypermobility-related pain, function, body awareness and overall activity level. We had 200 people in the Pilates group, who tried to do one of five 25-minute modified Pilates modules three times a week for eight weeks. We also had 220 people in a waitlist group who were able to start the Pilates after repeating questionnaires after an 8 week delay. Participants reported hypermobility-specific pain and fatigue-related function, body awareness, fear of movement, and overall activity levels. We found that hypermobility-specific pain and fatigue-related function, body awareness, and fear of movement improved in the Pilates group compared to the control group, but activity level did not change. Improvements were maintained at 6 months. Our conclusion is that an independent, on-line Pilates program designed for people with hypermobility may be beneficial and may provide a cost-effective way for people with hypermobility to engage in life-long exercise.Keywords: hypermobile Ehlers-Danlos syndrome, hypermobility spectrum disorders, exercise, pragmatic clinical trial, symptomatic generalized joint hypermobility