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Exercise as a therapeutic intervention in multiple sclerosis

min read

By ECTRIMS Contributing Writer Stefania de Vito

Physical activity is undoubtably a potent medicine [1]. Its value has been appreciated since ancient times. The Olympic games were first held in 776 BC at Olympia, in Greece. The earliest written exercise prescription for a patient can be traced back to Hippocrates, traditionally regarded as the father of medicine. For persons with multiple sclerosis, physical activity is now considered an effective prescription. It holds the potential to contribute to patients’ wellness by mitigating the influence of MS on their lives [2].

Physical activity matters

Physical activity encompasses structured exercises and lifestyle physical activities integrated into daily life, such as household tasks and walking. Historically, persons with MS were discouraged from engaging in exercises due to the concern of possibly exacerbating their symptoms [3]. Moreover, some people living with MS may hesitate to participate in physical activity when they experience fatigue, depressive feelings, concerns about safety, and mobility limitations. However, research is highlighting the benefits of physical activity at various levels of health and fitness and across different medical conditions. Latest results suggest that physical activity represents a very beneficial health behaviour for people with MS and can be safely prescribed in optimal doses [4].

What is the safe amount of physical activity that an individual with MS can do to gain considerable health benefits while minimising risks? The National MS Society published evidence-based guidelines meant to support precise guidance for people with MS at each level of disability. A group of international and interdisciplinary experts elaborated on these recommendations upon an extensive review of the current literature [4]. Healthcare providers are encouraged to promote as early as possible patients’ engagement in exercise and lifestyle physical activity plans, tailored to personal abilities, preferences, and safety.

Tanuja Chitnis, professor of neurology at Harvard Medical School, told us in a recent interview: “I generally advise physical exercise to my patients, depending on the level of disability. Regular physical activity is usually proposed to patients at the lower end of the Expanded Disability Status Scale (EDSS). As disability progresses, I normally recommend guidance and supervision by a trained physiotherapist, who establishes personalised exercise plans for each patient. I also tell patients to wear cooling vests and to work out in air-conditioned spaces. It is important not to heat themselves up too much, to avoid the Uhthoff’s phenomenon. The Uhthoff’s phenomenon would entail a transient exacerbation of symptoms, which usually resolves within 30 minutes after completing the exercise. That said, a safe and reasonable regimen, prescribed by a specialist is very beneficial and can certainly help ameliorate patients’ quality of life.”

People with MS may seek a specialist’s advice to discuss their concerns and determine the appropriate type and amount of activity. Generally, the Canadian Physical Activity Guidelines for Adults with Multiple Sclerosis (PAGs) suggest engaging twice per week in a 30-minute moderate-intensity aerobic activity and twice per week in strength training exercises for major muscle groups. Individuals with MS who follow the PAGs at least 75% of the time over 16 weeks show better aerobic capacity, strength, mobility, quality of life and reduced fatigue [5]. The World Health Organisation (WHO) guidelines on physical activity and sedentary behaviour (2020) proposes also, as a rule of thumb, that doing some physical activity is more beneficial than doing none, for adults with and without MS. Physical activity can then gradually increase to align with one’s current fitness level, health condition, and physical capabilities.

Doing regular physical activity improves many aspects of life quality. It has a positive impact on lowering anxiety and depressive symptoms, and on soliciting the desire of taking part in social activities in patients with MS [6]. Physical functions as well, such as walking endurance, are enhanced in people with MS who are more active [7]. At a cognitive level, Robert Motl and his coauthors observed a positive impact of physical activity on the time required to process information (i.e., cognitive processing speed) in cognitively impaired persons with MS [8]. Robert Motl, professor at the University of Illinois Chicago, commented on these results: “Free-living physical activity (measured as the number of steps per day) is significantly associated with a better performance at cognitive processing speed. In our study, we encouraged people with MS to go out and walk around their neighbourhood, in parks, stores, malls. When moving outside their home, people need to process information. They need to think where to go, what to do, how to move to stay safe. This exercise is physically and mentally stimulating. And perhaps, it is this combination of physical and cognitive load that induces cognitive benefits”.

Strategies to become more active

“We must be realistic,” Motl adds. “Most people do not like exercising. So why do we do it? We must have a very good reason for engaging in exercise behaviour. We encourage our patients to identify a couple of meaningful reasons to become more active. We help them focus on a goal and we propose them strategies to implement and maintain this behaviour over time.”

Brian Sandroff, senior research scientist at the Kessler Foundation, elucidates some of these strategies. “Over the years, we have delivered interventions that are aimed at changing people’s behaviour. We try to give people with MS the tools and the knowledge necessary to include physical activity in their life. We encourage persons with MS to participate in theory-based programs, which are meant to increase the rate of physical exercise.” he says.  “In one of our studies, a behaviour-change coach delivered this programme via internet in one-on-one video-chat sessions with people with MS. The coach shared with them techniques to be more active. He guided our participants on setting realistic outcome expectations and goals, on taking advantage of facilitators, and dealing with obstacles and barriers. As a result, we observed a large increase of physical activity during that period, compared to control condition. Now we have strategies, behavioural interventions, that can be applied on a broad scale for changing people’s behaviour, for maintaining it over time, and consequently improving the quality of their life.”

Current research trends suggest that physical activity has beneficial effects on many MS symptoms [9]. Based on current knowledge, physical activity can safely be prescribed alongside medical treatment as early as possible to persons with MS, given its proven impact on symptom management and improvement of quality of life [10].

Special thanks to Tanuja Chitnis (Harvard Medical School), Robert Motl (University of Illinois Chicago), and Brian Sandroff (Kessler Foundation) for their insights.



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[5] Canning K & Hicks A. Int. J. MS Care. 2020; 22(1): 15-21.
[6] Healy B et al. Mult. Scler. Relat. Disord. 2022; 65: 104006.
[7] Sandroff BM et al. J. Neurol. 2014; 261: 363-372.
[8] Motl RW, Sandroff BM, & Benedict RH. Mult. Scler. Relat. Disord. 2022; 63: 103833.
[9] Proschinger S et al. J. Neurol. 2022; 269(6): 2922-2940.
[10] Dalgas U et al. Curr. Neurol. Neurosci. Rep. 2019; 19: 88.