Multiple Sclerosis (MS) is a disease of the central nervous system that affects signal conduction. It is caused by a degeneration in the myelin sheath that wraps around the nerves to increase the speed at which messages can be sent to and from the brain. This can result in difficulty with speech, involuntary rapid eye movements, intention tremors, weakness, numbness and fatigue. MS can be treated with various medications to reduce the severity and the frequency of bouts, however it can't be cured.
People with MS can have different presentations depending on the type and stage of the disease. Some people have sudden declines in function called "attacks", others have a steady decline or a mix of the two. This is grouped into 4 different types, as shown below.
The recurring theme is that the level of function a person has can change on a daily, weekly or monthly basis but over time, the disease will progress. This is why it is so drastically vital to train the level of function. Through practice, we can physically improve the baseline of function so that attacks are not as debilitating and the overall decline is slowed.
Exercise can improve:
Symptoms of fatigue
Symptoms of depression
Mobility
Flexibility
Balance
Falls risk
Strength
Coordination IN ADDITION to all the usual benefits of exercise
The clinical goals of exercise in patients with MS are to:
Remain as functional as possible for as long as possible
Manage fatigue
Improve quality of life
Reduce comorbidities
So how can you get started with exercise?
Guidelines
The guidelines for exercise for Multiple Sclerosis mainly follow the usual National Physical Activity guidelines for adults. It's important to note that these are just guidelines and do not take your specific circumstances into account. Use these as a general guide of what to aim for, not as a bible to follow religiously.
Exercise guidelines for adults with mild to moderate MS. Adapted from Kim et al 2020
| Aerobic exercise | Resistance exercise |
How often? | 2-5 days per week | 2-3 days per week |
How much? | Gradually increase to 10-40 minutes per day | 1-3 sets 8-15 repetitions 5-10 exercises |
How hard? | Moderate intensity 5.5-7.5/10 RPE | Pick a resistance that you can finish the final set comfortably |
How to? | Continuous movements such as: walking, riding, swimming or cardio machines | Target large muscle groups using: weight machines, free weights or elastic bands |
Special considerations:
Overall progression should start with either duration or frequency, and finally progress intensity per tolerability of the person.
Rest your muscles for 2–4 minutes between sets and muscle groups.
Rest your muscles for at least one day between strength training sessions.
Aerobic and resistance training can be performed on the same day, depending on tolerability.
MS-specific symptoms (i.e. fatigue and heat sensitivity) should be identified and discussed before exercising.
In addition to the basic aerobic and resistance recommendations, it is also advised to perform balance-specific exercises to reduce risk of falls. Falls risk becomes an increasing concern with MS as function declines due to the negative feedback cycle this creates with exercising, which causes a further decline in function.
Balance-specific exercises could involve a progressively challenging 30 second hold (feet apart --> feet together --> tandem stance --> single leg stance), a movement based exercise such as step taps and a dual tasking exercise such as tandem walking while throwing a ball. This will challenge all aspects of balance in order to reduce risk of falls.
When designing your exercise program there are 3 core principles which your training should follow.
The three P's:
Personalised, purposeful, practice
The training must be meaningful to you, it must be specific to what you want to improve and you must perform it a lot.
There is nothing harder as an allied health professional than trying to motivate someone to do something they don't want to do. Making the training meaningful to you means not just lifting a weight for the sake of lifting a weight. It means taking what you want to do in your life and training for that reason. I could throw a lot of words at you here, but this wordless commercial does a far better job at describing what personalised training is.
Make your training meaningful.
Purposeful training means to make it specific to you. In other words, train what you want to get better at. If getting out of a chair has become a challenge for you, leg press can help build your muscle but you need to practice getting out of a chair to get better at it. Why? You will build your specific motor patterns (switching on the right muscles at the right time), you will train all the assisting muscles (think about stabilisation) and you will also build your confidence with that movement.
Finally, you need to practice. Not much more to say on this. You probably don't want to read a full paragraph on it, but you do need to read it... The more you practice, the easier things get. The body is really good at adapting to new things, but it needs to get the input to do so. With 24 hours in the day, how many of them will you spend practicing the right thing?
Considerations when exercising with MS:
Fatigue management
Fatigue is the largest consideration for exercising with MS. Because the myelin sheathes are inhibited (remember: those are the things that speed up messages in your body), performing normal daily activities requires more effort than usual. This results in more energy being used and less total capacity to complete daily tasks. Exercise is a fatiguing activity by nature, so it is especially important in this population that we are monitoring activity levels and the body's tolerance to exercise.
In the olden days, fatigued people were told to just rest in bed, not to do any activities that could tire them out. Through the miracles of modern-day science, however, we have discovered that this is probably doing more harm than good. While rest is a good temporary alleviation to fatigue symptoms, the body will make long term adjustments that will decrease your total capacity based on this stimulus. We now know that measured exercise will increase your capacity and actually provide you with more energy in the long term, when performed correctly.
One simple way to measure fatigue is to rate it on a 0-10 scale each day at the same time. This measure will fluctuate day-to-day but will provide a good idea of how much energy you have to be utilised that day. This can also be used to compare weekly averages to provide a long-term baseline and to analyse trends.
Another helpful way to keep track of your fatigue is to use the "Spoon theory"
If you want a more in-depth measurement of fatigue, check out the Modified Fatigue Impact Scale. When explaining your fatigue, it can often be helpful to use the to convey what it's like to have to plan out your energy usage.
When looking to minimise fatigue, one factor to consider is temperature. MS can often impact the temperature control of the body, so ensuring the environment is not too hot or too cold while training will go a long way to making the body use less energy. Along the same vein, fluids should be taken regularly to assist with temperature control.
When progressing exercises, remember the general rule of thumb to not increase total work by more than 20% at a time, for clients with MS this number should be even lower. Try not to overdo things, even if you are feeling good at the time. Use your energy levels the day after a workout to plan your intensity for the next workout, as opposed to during the exercises to avoid a "boom-bust" approach.
Flexibility training and spasticity
Spasticity is an exaggerated reflex response to high speed movements. That means if I try to stretch your arm out quickly, it will catch and resist the stretch. This can lead to less use of the affected limb and eventually, if left untreated, a contracture (which you do NOT want). Spasticity can inhibit activities of daily living such as walking and can decrease quality of life.
It's still not entirely clear why spasticity occurs, but it is very clear that daily stretching will lead to at least maintenance of range of motion. To avoid potentially ending up with a contracture, consider stretching muscles out daily. Start by performing 2 lots of 30 second stretches on any limited muscles. As mobility declines, it is a good idea to gradually aim for 2 hours of a stretched out position (e.g. standing for 2 hours if using a wheelchair to get around all day).
Other considerations
MS can also lead to other unwanted complications such as incontinence and cognitive deficits (e.g. short-term memory loss). It is recommended to be aware of these symptoms when exercising and to have plans in place such as going to the toilet before exercise and writing down exercise plans, to make it the least demanding on the body as possible .
Clinical perspective
After working with multiple MS clients, you tend to pick up a few typical patterns that present themselves. To begin with, this is a population that are really easily overworked. It is a good idea to take things slow, and progress in small increments to make sure that they're not going to end up lying in bed for the next few days. Similarly, some clients may have developed a bit of fear around exercising after going through this boom-bust pattern previously. It is important to educate them that slowly progressing the amount of exercise they complete now is going to help them have a greater pool of energy and function to avoid being bed-bound in the future. Finally, the presentation can change from day-to-day, they might be extra forgetful one day or have less energy than usual due to the weather. That's normal, but keep an eye on the overall pattern. It is important that any relapses are identified early so appropriate measures can be put in place, especially around falls risk as a fall can set a client back significantly in a very short amount of time.
Overall, MS can present differently for each individual and each individual can present differently over time. It is important to keep in mind multiple considerations when exercising. While exercise doesn't directly combat the cause of the disease, exercise does directly improve the symptoms and you can see significant benefits to their life when an exercise program is successfully implemented into these clients' lives.
Multiple Sclerosis is a progressive, debilitating disease, but there is something you can do to improve your function and slow the decline. Exercise is one thing you have control over throughout your journey, so make the most of it. Following the guidelines, following the three P's, managing fatigue, spasticity and other complications can help you to live your life to the best of your ability.
Remember that each individual's journey is different and these guidelines do not replace professional advice. For help finding an exercise professional to assist with your Multiple Sclerosis journey, check out ESSA's find an AEP function.
Stay strong! 💪
Further resources:
Kim et al 2020: Exercise training guidelines for multiple sclerosis
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