Effect of Exercise on Fatigue in Multiple Sclerosis: A Network Meta-analysis Comparing Different Types of Exercise

The effects of dual-task training on inflammatory biomarkers, physical performance, fatigue, and quality of life in patients with multiple sclerosis

OBJECTIVE

This study investigates how combined aerobic-cognitive training and aerobic training impact some symptoms of MS.

METHODS

Thirty RRMS patients with EDSS≤ 4 were randomly assigned to three groups: Brythonic training, aerobic training, and control. The training groups participated in ten weeks of home-based online training. The Brythonic group performed aerobic movements while reciting motivational words. The aerobic group performed the same movements without cognitive tasks. Interleukin 17 (IL-17), Interleukin 4 (IL-4), and Interleukin 17 to Interleukin 4 ratio (IL-4/IL-17), Time Up and Go (TUG) and Six-Minute Walk Test (6MWT), Modified Fatigue Impact Scale (MFIS), Multiple Sclerosis Quality of Life-54 Questionnaires (MSQOL-54) were measured before and after the 10-week.

RESULTS

The Interleukin 17 variable significantly decreased in the Brythonic (P < 0.0001). Nevertheless, Interleukin 4 and the Interleukin 17 and 4 ratios did not significantly differ. TUG and 6MWT variables substantially differed in training groups compared to the control. In MFIS, a significant difference was observed between the training and control groups. The MSQOL-54 variable substantially differed in mental health items in the Brythonic compared to the control group and in physical health items a significant difference was observed between the training and the control groups. Notably, in all the variables except the Interleukin 4 variable, the Brythonic significantly improved the results within the group.

CONCLUSION

This study concluded that engaging in any aerobic activity, even with moderate intensity, can improve some symptoms of MS such as fatigue and physical performance. Additionally, incorporating cognitive challenges into aerobic activity can cause a more significant effect, specifically on inflammatory factors.

Meeting Physical Activity Guidelines for Persons With Multiple Sclerosis Reduces Fatigue Severity and Impact: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

Regular physical activity is a recommended behavioral goal for persons with multiple sclerosis. This review aimed to determine the effect of interventions that met physical activity guidelines for persons with multiple sclerosis on fatigue measures and to compare the magnitudes of the effect sizes for meeting these guidelines with the minimal clinically important differences for fatigue measures.

METHODS

The search was conducted in PubMed, Embase, Web of Science, SPORTDiscus, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and PsycINFO from inception to October 2024. Only randomized clinical trials that explicitly met physical activity guidelines and evaluated fatigue were included. Two independent reviewers screened articles for inclusion and evaluated the risk of bias of included trials using the Cochrane risk-of-bias tool for randomized trials. Findings were summarized, and a meta-analysis was conducted. Fatigue measures included the Fatigue Severity Scale, Fatigue Impact Scale, and modified Fatigue Impact Scale. The Grading of Recommendations, Assessment, Development and Evaluation was used to evaluate the quality of the evidence. The review protocol was preregistered in the International Prospective Register of Systematic Reviews (PROSPERO) database (registration number: CRD42023387305).

RESULTS

Twenty-two randomized clinical trials with 920 participants were included in the review; 17 studies were included in the meta-analysis. Findings indicated that interventions meeting physical activity guidelines for at least 4 weeks significantly reduced fatigue severity (standardized mean difference = -1.46; 95% CI = -2.11 to -0.81) and fatigue impact measured with the modified Fatigue Impact Scale (mean difference = -11.88; 95% CI = -20.57 to -3.19) and Fatigue Impact Scale (mean difference = -21.08; 95% CI = -31.01 to -11.15). All findings were clinically relevant, with effect sizes exceeding the established minimal clinically important differences for the fatigue measures. Some methodological concerns were noted, and the evidence level ranged from very low to moderate.

CONCLUSIONS

Evidence suggests that engaging in physical activity for at least 150 minutes per week or 2 sessions of 10 to 30 minutes of moderate-intensity aerobic training plus 2 sessions of resistance training per week results in clinically significant reductions in fatigue severity and impact necessary to improve the quality of life of persons with multiple sclerosis.

IMPACT

Fatigue is a highly prevalent symptom associated with poor outcomes, including falls, activity restrictions, pain, cognitive problems, functional limitations, and mortality risk among persons with multiple sclerosis. Our study suggests that adhering to physical activity guidelines developed for persons with multiple sclerosis clinically reduces the severity and impact of fatigue. This regimen includes engaging in physical activity for at least 150 minutes per week or participating in 2 sessions of 10 to 30 minutes of moderate-intensity aerobic training plus 2 sessions of resistance training per week.

Changes in fatigue after first-ever ischemic stroke and their associations with changes in physical fitness, body composition, and physical activity

OBJECTIVES

The objectives of the present study were 1) to describe changes in fatigue from 3 to 12 months post-stroke and compare different patterns of fatigue changes with respect to concurrent changes in physical fitness, body composition, and activity levels, and 2) to explore whether changes in fatigue are associated with changes in physical fitness, body composition, and physical activity levels in patients recovering from first-ever ischemic stroke.

MATERIALS AND METHODS

In this longitudinal observational study, we assessed 72 patients (mean age 62 years, 36 % females) at 3 and 12 months after first-ever ischemic stroke. Fatigue was measured with the 7-item Fatigue Severity Scale. Physical fitness, body composition and physical activity were assessed using cardiopulmonary exercise testing, physical function tests, Dual-energy X-ray Absorptiometry, and accelerometers.

RESULTS

Fatigue levels was stable between 3 and 12 months post-stroke in 44 (61 %) patients, decreased in 14 (19 %), and increased in another 14 (19 %). Patients with increased fatigue levels showed a greater decrease in cardiorespiratory fitness, as measured directly by peak oxygen uptake, compared to those with decreased fatigue. Robust regression analysis, adjusted for age and sex, indicated that each kilogram of lean body mass gained from 3 to 12 months post-stroke was significantly associated with a 0.3-point reduction in fatigue during the same timeframe (B= -0.32; 95 %CI [-0.51, -0.12]).

CONCLUSION

There was considerable individual variation in changes to fatigue, physical fitness, body composition, and physical activity levels between 3 and 12 months following a first-ever ischemic stroke. Increased fatigue was linked to a greater concurrent decline in cardiorespiratory fitness, while lean body mass was associated with decreases in fatigue.

Internet-based exercise and physical activity promotion for persons with multiple sclerosis: a randomized controlled trial

BACKGROUND

We evaluated the effects of a 12-week internet-based exercise and physical activity promotion program for persons with multiple sclerosis.

METHODS

We performed a multicenter, randomized, waitlist-controlled study. The intervention group (IG) received the 12-week program, followed by 12 weeks with usual care. The control group (CG) received usual care only. The main components of the 12-week program were: (1) a tailored home-based exercise prescription, (2) e-learning resources, (3) telephone and video meetings with an exercise therapist, (4) the provision of a consumer-based PA monitor. Measurements were taken at baseline, postintervention, and after 24 weeks. The primary outcome was device-measured steps/day. Other outcomes were device-measured moderate-to-vigorous physical activity, subjectively measured leisure-time and transportation physical activity and sport/exercise, physical activity-related health competence, walking ability, quality of life, fatigue, depression, and PA-related self-concordance. We compared changes from baseline to postintervention between groups and analyzed changes in the IG during the follow-up.

RESULTS

Analysis of 56 persons with multiple sclerosis (IG: n = 29, CG: n = 27, age: 45.6 ± 10.9) revealed no significant intervention effect on steps/day. However, significant improvements were observed in moderate-to-vigorous physical activity, sport/exercise, control competence, fatigue, and quality of life (physical). During the follow-up, sport/exercise and quality of life decreased significantly. Leisure-time and transportation physical activity increased significantly.

CONCLUSIONS

Our study provides first evidence that the developed program can increase control competence, aspects of physical activity and health in persons with multiple sclerosis. A trial with a larger sample is recommended to confirm our results and examine intervention mechanisms.

TRIAL REGISTRATION

Registry: Clinicaltrials.gov; registration number: NCT04367389; date of registration: 2020-04-21 (retrospectively registered).

Scoping review: The effects of diet, physical activity and sleep on motor and physical fatigue in people with multiple sclerosis

Physical and motor fatigue are debilitating symptoms common in multiple sclerosis (MS). Lifestyle interventions may be effective in managing MS-related fatigue. This scoping review aims to: (i) identify and summarise lifestyle interventions including those focused on diet, physical activity, and sleep, or multicomponent interventions for physical and motor fatigue management in MS; and (ii) provide recommendations for future research in this area. Database searches of MEDLINE (Ovid), Cochrane (Cochrane Library), Scopus (Elsevier), CINAHL (EBSCOhost), and Embase (Ovid) were conducted. To be included in this scoping review, studies were to be published in a peer reviewed scientific journal, focused on a non-pharmacological lifestyle intervention (physical activity, exercise, sleep, diet, or a combination), and written in English. Forty-one studies were included for analysis. Included participants were predominantly female, living with relapsing-remitting MS, with a median age of 48 years. The design of the studies comprised mainly of randomised control trials and pilot/feasibility studies. All included studies incorporated a physical activity intervention, with most examining aerobic/endurance exercise. Most studies reported an effect on improving physical/motor fatigue and a large proportion incorporated an endurance training program. To build on the current evidence and progress MS-fatigue related recommendations, further studies with larger sample sizes and a more inclusive range of MS types are required. Finally, with a gap of research investigating the role of diet and sleep on motor and physical fatigue in MS, research into this field is critically needed.

Exploring rest advice in fatigue interventions in rehabilitation among adults with long-term conditions: a systematic scoping review of the reporting of rest in randomised controlled trials

OBJECTIVE

To explore how rest is described or included as part of rest advice in fatigue interventions within rehabilitation for adults with Long-term conditions (LTC).

DATA SOURCES

This scoping review identified fatigue interventions through PubMed, the Cumulative Index to Nursing and Allied Health Literature, the Allied and Complementary Medicine Database, and the Physiotherapy Evidence Database, from inception to July 2024.

STUDY SELECTION

Two independent reviewers screened and selected the articles. Studies were included if they: (1) involved adults with LTC, (2) used non-pharmacological fatigue interventions, (3) had fatigue as the primary outcome, and (4) were randomised controlled trials (5). Only randomised controlled trials that include rest advice in the interventions were selected.

DATA EXTRACTION

Extracted data included the first author's name, year of publication, country, type of LTC, intervention category, specific interventions, how rest was reported in all interventions. Furthermore, rest was reported using the FITT principle, focusing on the frequency, intensity, duration, and type of rest in the exercise interventions and key conclusions.

DATA SYNTHESIS

Results were summarised, tabulated, and reported descriptively. Out of 13,645 initial records, 56 studies were included in the review. Of the total interventions analysed, 55.4% (31/56) were classified as physical activity interventions, 14.3% (8/56) as psychological interventions (e.g., cognitive behavioural therapy), 12.5% (7/56) were identified as energy management strategies, 8.9% (5/56) as educational interventions, and 8.9% (5/56) as activity pacing strategies. A disparity was observed in the instruction of rest advice between exercise interventions and daily fatigue management strategies. Specifically, physical activity interventions tended to adopt a more prescriptive approach to rest, whereas rest in daily fatigue management strategies was primarily instructed through education on the importance of rest in daily life. Notably, the level of detail provided in reporting rest parameters was generally limited.

CONCLUSIONS

This review found insufficient reporting of rest, highlighting a significant gap and indicating the need for improved documentation and standardisation of rest in fatigue interventions. Future research is necessary to better understand the role of rest in the rehabilitation of LTC.

Lower Limb Strength Differentiates Between Fallers and Nonfallers With Multiple Sclerosis

OBJECTIVE

To determine whether hip flexion (HF), extension (HE), abduction (HA), knee flexion (KF) and extension (KE), and ankle plantarflexion (APF) and dorsiflexion maximum voluntary contraction (MVC) differentiates between nonfall and fall history in persons with multiple sclerosis (PwMS) after accounting for age, gender, fatigue, disability, and disease duration.

DESIGN

Secondary analysis of a cross-sectional study.

SETTING

Community-based comprehensive MS center.

PARTICIPANTS

A total of 172 PwMS who completed a 1-time visit.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Lower limb (LL) MVC was measured for each muscle group as isometric peak torque (Newton-meter: Nm) of both limbs (Strongest: S; Weakest: W) using a Biodex Dynamometer and normalized by body weight (Nm/kg). Falls in the past 6 months were retrospectively collected and participants were classified as nonfall history (0 falls [nonfallers]; n=78) or fall history (≥1 falls [fallers]; n=94). Fall history was further categorized as occasional (1-2 falls [occasional fallers]; n=51) and recurrent (≥3 falls [recurrent fallers]; n=43).

RESULTS

Overall differences between participants with and without a fall history were noted on both limbs, with post-hoc analyses showing that those with a fall history had significantly lower strength (P<.05) on all LL-W and HF-S, HE-S, HA-S, KF-S, and APF-S. When separated out by fall frequency, recurrent fallers had diminished strength on all LL-W and HF-S, HE-S, HA-S, and APF-S, whereas occasional fallers exhibited reductions on HA-W, KE-W, and KF-W compared with nonfallers. Recurrent and occasional fallers differed on HE-W.

CONCLUSION

All LL-W and aspects of LL-S differentiated between fallers and nonfallers, with further differences observed when fall history was separated by frequency. These findings provide the necessary information to clinicians to inform their plans of care to address falls in MS and provide education on the importance of maintaining LL strength.

Effects of Transcranial and Trans-Spinal Direct Current Stimulation Combined with Robot-Assisted Gait Training on Gait and Fatigue in Patients with Multiple Sclerosis: A Double-Blind, Randomized, Sham-Controlled Study

Background/Objectives: Multiple Sclerosis (MS) is a chronic neurological condition that impairs motor and sensory functions, particularly gait. Non-invasive neuromodulation techniques aim to enhance functional recovery and motor-cognitive outcomes, though their effectiveness remains debated. This study compared the effects of transcranial direct current stimulation (tDCS) and trans-spinal direct current stimulation (tsDCS), combined with robotic-assisted gait training (RAGT), on motor function and fatigue in people with MS (pwMS). Methods: This double-blind, randomized, sham-controlled clinical trial included 35 pwMS, who participated in 12 sessions of 20 min anodal tDCS (n = 11), cathodal tsDCS (n = 12), or sham treatment (n = 12), in addition to RAGT. Primary outcomes were assessed using the Timed 25-foot Walk (T25-FW), Timed Up and Go (TUG), walking speed, and Multiple Sclerosis Walking Scale-12 (MSWS-12). Fatigue was assessed with the Fatigue Severity Scale (FSS) and the Fatigue Impact Scale (FIS). ClinicalTrials number: NCT06121635. Results: Significant improvements in gait speed, T25-FW, MSWS-12, TUG scores, and fatigue (FSS) favored tDCS and tsDCS over sham stimulation. While no differences were found between tDCS and tsDCS, the tsDCS group showed a significant improvement in the FIS physical subscale compared to sham, unlike the tDCS group. Conclusions: tDCS and tsDCS, combined with RAGT, improve walking and reduce fatigue in pwMS, highlighting their potential in motor rehabilitation.

Advancements and Challenges in Exercise Training for Multiple Sclerosis: Comprehensive Review and Future Directions for Randomized Controlled Trials

Exercise training represents a health behavior for the treatment and management of the multi-faceted manifestations of multiple sclerosis (MS). This paper provides a comprehensive overview of evidence from randomized controlled trials (RCTs) regarding benefits, safety, participation, and guidelines for exercise training in MS, based on systematic reviews and meta-analyses. The paper then provides our opinions based on extensive experience regarding challenges for improving and expanding future RCTs that will advance our understanding of exercise training in MS. The comprehensive review of evidence from RCTs indicates that exercise training yields substantial improvements in aerobic and muscle fitness, mobility, fatigue and depression, quality of life, and participation outcomes. There is a non-significant increase in the risk of adverse events or serious adverse events with exercise training compared with control conditions or healthy populations. Rates of adherence and compliance with exercise training (i.e., participation) approximate 80% and 70%, respectively. The current prescriptive guidelines suggest 2-3 days per week of aerobic and resistance exercise training as the minimal dose for safely benefiting from exercise training in MS. We propose 10 important topics as avenues for expanding the body of research and improving its scope for evidence-based practice in MS. Overall, the research on exercise training in MS is strong, but it can get stronger. The expansion and advancement of evidence are critical for moving exercise training into the clinical armamentarium of MS disease treatment and management.

Comparison of different exercise modalities on fatigue and muscular fitness in patients with multiple sclerosis: a systematic review with network, and dose-response meta-analyses

Background

Fatigue and muscular fitness are closely related to the quality of life in patients with multiple sclerosis (MS). However, the optimal exercise dosage to improve these outcomes remains unclear.

Objective

We evaluated the effects of different exercise modalities and dosages on fatigue levels and muscular fitness in patients with MS.

Methods

A systematic search was conducted across five electronic databases, including randomized controlled trials involving exercise interventions for patients with MS. The data covered literature from the establishment of each database up to August 2024. Two independent reviewers assessed the quality of the studies. Network and dose-response meta-analyses were performed using a random-effects model to evaluate the impact of exercise.

Results

A total of 84 papers were included, involving 3,786 participants. The network meta-analysis revealed that mind-body exercise (MBE) had the most significant effect on reducing fatigue (SMD = -0.94; 95% CrI: -1.3 to -0.6), followed by resistance training (RT) (SMD = -0.86; 95% CrI: -1.2 to -0.58), combined exercise (COM) (SMD = -0.70; 95% CrI: -1.2 to -0.22), and high-intensity interval training (HIIT) (SMD = -0.50; 95% CrI: -1.1 to 0.14). Additionally, HIIT were found to be the most effective in improving muscular fitness (SMD = -0.86; 95% CrI: -1.5 to -0.27), followed by COM (SMD = -0.81; 95% CrI: -1.2 to -0.41), MBE (SMD = -0.64; 95% CrI: -1.1 to -0.16), and RT (SMD = -0.62; 95% CrI: -0.89 to -0.16). Moreover, a dose as low as 240 METs-min/week was sufficient to improve fatigue, while a dose of 430 METs-min/week was required to enhance muscular fitness. The optimal dose for reducing fatigue was 650 METs-min/week, and the best dose for improving muscular fitness was 530 METs-min/week.

Conclusion

Exercise is an effective method for improving fatigue and muscular fitness in patients with MS. While MBE and COM rank relatively higher compared to other exercise modalities. The optimal exercise dosage for reducing fatigue and improving muscular fitness ranges between approximately 530 to 860 MET-minutes per week.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, CRD42024577643.

Individualized and Controlled Exercise Training Improves Fatigue and Exercise Capacity in Patients with Long-COVID

(1) Background: Long-term health effects after SARS-CoV-2 infections can manifest in a plethora of symptoms, significantly impacting the quality of life of affected individuals. (2) Aim: The present paper aimed to assess the effects of an individualized and controlled exercise intervention on fatigue and exercise capacity among Long-COVID (LC) patients in an ambulatory setting. (3) Methods: Forty-one (n = 41) LC patients performed an exercise protocol with an individualized control of the patients' training intensity during the study period based on the individual's ability to achieve the target criteria. The program was carried out two to three times a week, each session lasted 30 min, and the study parameters were recorded at the beginning of the program, as well as after 6 and 12 weeks, respectively. These included both patient-reported (PCFS questionnaire, FACIT-Fatigue questionnaire) and objective (one-minute sit-to-stand test (1MSTST), workload) outcomes. (4) Results: The exercise training intervention resulted in significant improvements in the FACIT-Fatigue (F(2, 80) = 18.08, p < 0.001), 1MSTST (χ2(2) = 19.35, p < 0.001) and workload scores (χ2(2) = 62.27, p < 0.001), while the PCFS scores remained unchanged. Changes in the workload scores were dependent on the frequency of the completed exercise sessions and were higher in the LC patients with a moderate Post COVID Syndrome Score (PCS) compared to a severe PCS. (5) Conclusions: The individualized and controlled training approach demonstrated efficacy in reducing fatigue and enhancing exercise capacity among outpatient LC patients. However, for complete regeneration, a longer, possibly indefinite, treatment is required, which in practice would be feasible within the framework of legislation.

Benefits of self-paced concurrent training on lung function, cardiopulmonary fitness and fatigue perception in patients with multiple sclerosis

Aim: Studying the effects of self-paced concurrent high-intensity interval training and resistance training (HIIT-RT) on respiratory function, cardiopulmonary fitness and fatigue perception in patients with multiple sclerosis (PwMS).Methods: Twenty-three PwMS were randomized into a 12-week training group (three times per week) (TG, n = 11) or a control group (CG, n = 12). Lung function (spirometry), aerobic capacity (graded cardiopulmonary-exercise-testing) and perceived fatigue (Fatigue Severity Scale (FSS)) were evaluated pre- and post-intervention.Results: The forced vital capacity (p = 0.036, Hedges'g (g) = 0.93), forced expiratory time (p = 0.045, g = 0.88), peak expiratory flow (p = 0.043, g = 0.89) increased in TG compared with CG. The TG showed an increase in peak aerobic power (p = 0.004, g = 1.34) and peak oxygen uptake (p < 0.001, g = 2.58) compared with CG. There was a decrease in ventilatory equivalent for carbon dioxide (p = 0.02, g = 1.02) and FSS scores (p < 0.001, g = 1.72) in TG comparatively with CG.Conclusion: 12-week self-paced HIIT-RT enhanced lung function as well as aerobic fitness, and alleviated fatigue perception in PwMS.

Elaborating the knowledge structure and emerging research trends of physical activity for multiple sclerosis: A bibliometric analysis from 1994 to 2023

BACKGROUND

Multiple sclerosis is a common inflammatory neurological disease among young adults and is the tenth leading cause of the global burden of disease. Existing common treatments such as pharmacological and palliative therapies do not control the neurodegenerative process or cure multiple sclerosis. Numerous epidemiological surveys, randomised controlled trials, and systematic reviews with meta-analyses support the effects of physical activity on health-related outcomes among patients with multiple sclerosis. Moreover, bibliometric analysis can provide a broad evidence synthesis beyond systematic reviews and meta-analyses, allowing researchers and other stakeholders to obtain a one-stop overview of this research field. Therefore, this bibliometric analysis aims to provide insight into the knowledge structure of the field of physical activity for multiple sclerosis over the past three decades, and to predict emerging research trends.

METHODS

This study strictly complied with step-by-step guidelines of bibliometric analysis, combining performance analysis and science mapping. Four indexes from the Web of Science Core Collection were selected as data sources, and articles and review articles in the field of physical activity for multiple sclerosis from 1994 to 2023 were included in this analysis. Mircrosoft Excel, RStudio, VOSviewer 1.6.20, and CiteSpace 6.3.R1 (64-bit) Advanced were used to perform performance analysis and science mapping.

RESULTS

Over the past three decades, this field published a total of 1,271 documents, with the scientific output showing a rapid upward trend over the past two decades. Robbert W Motl was the most prolific author in this field, with a total of 300 publications. The USA contributed nearly half of the publications in this field (549 documents), and the University of Illinois System was the institution with the highest number of publications (222 documents). Multiple Sclerosis and Related Disorders was the journal that published the highest number of documents in this field (117 documents), while more than a third of this field's publications were included in the category: Clinical Neurology (438 documents). The Reference co-citation analysis identified three main research trends, including shifts in research methodology, changes in health outcomes in randomised controlled trials, and shifts in different types of physical activity interventions. Combining the results from reference co-citation analysis and citation burst analysis, the combination of behaviour change technique and telerehabilitation may be the emerging research trend.

CONCLUSION

This bibliometric analysis identifies rapid growth in the field of physical activity for multiple sclerosis over the past two decades. Moreover, the combination of performance analysis and science mapping provides insight into knowledge structure in this field and informed future research trends for researchers and the relevant stakeholders.

Exergames and Immersive Virtual Reality as a Novel Therapy Approach in Multiple Sclerosis: Randomised Feasibility Study

Background: Multiple sclerosis is a chronic, inflammatory, neurodegenerative autoimmune disease caused by myelin loss in the central nervous system, which leads to motor and non-motor problems. The main objective of this study was to explore whether an immersive virtual reality (IVR) exercise programme would be feasible as a form of physical therapy for people with MS (pwMS). Methods: 18 participants (13 women; 45.06 years) were assigned to an experimental group (EG, n = 8) and a control group (CG, n = 10). The EG took part in a twice-weekly IVR exergame physical therapy programme-ExeRVIEM programme. A randomised, single-blind clinical trial was conducted and was registered in clinicaltrials (NCT05870254). Results: The intervention was feasible and safe. The participants completed the programme with no adverse effects (no symptoms on the Simulator Sickness Questionnaire), high usability (System Usability Scale 90.31%), and outstandingly positive post-game experiences (Game Experience Questionnaire 3.10/4). In addition, the GE significantly improved several of their functional capacities: increased lower limb strength (Five Times Sit-to-Stand Test p = 0.042), improved functional mobility, and reduced fall risk (Timed Up and Go Test-simple p = 0.009; Timed Up and Go Test-cognitive p = 0.003). There were no statistically significant differences between the groups. Conclusions: The findings support that the use of exergames and IVR as physical therapy in pwMS is feasible and safe. Furthermore, there is the suggestion of possible benefits to participants' functional abilities, all of which position IVR as a promising tool for the rehabilitation of this neurodegenerative pathology affecting young adults.

Benefits of Individualized Training in Fatigued Patients with Multiple Sclerosis

INTRODUCTION

Chronic fatigue is the most common and debilitating symptom in people with multiple sclerosis (PwMS). Recently, exercise has been proven to alleviate chronic fatigue and improve physical functions. Tailoring the training intervention to the potential fatigue causes could optimize the beneficial effects of training on fatigue. The objective of this study was to compare the effectiveness of an individualized (IND) versus a traditional (TRAD) exercise intervention in reducing chronic fatigue.

METHODS

Twenty-nine PwMS with high chronic fatigue were randomly assigned to 12 wk of either a TRAD or IND exercise intervention. TRAD comprised aerobic and resistance exercises according to the guidelines for PwMS. IND specifically addressed identified individual weaknesses. Participants visited the laboratory before and after training for the following assessments: patient-reported outcomes (fatigue, quality of life, depression questionnaires), incremental cycling test (peak oxygen uptake (V̇O 2peak )), and cycling fatigue test (maximal voluntary contraction, rating of perceived exertion).

RESULTS

Similar improvements in fatigue, depression, and quality of life were observed between groups ( P > 0.05). Compared with TRAD, IND induced a significant greater increase in V̇O 2peak (+21.0% ± 13.9% vs 6.8% ± 11.5%, P < 0.05) and a greater reduction in rating of perceived exertion at a given submaximal intensity (-30.3% ± 18.9% vs -12.1% ± 20.4%, P < 0.001), whereas maximal voluntary contraction increased similarly in both groups ( P > 0.05).

CONCLUSIONS

Although tailored exercise improved similarly fatigue and other subjective parameters (depression, quality of life, sleep quality) compared with than traditional exercise intervention, prescribing an individualized intervention led to greater improvement in V̇O 2peak (but not maximal strength) and perception of effort. This may have positive functional consequences for patients.

Individualized activity recommendation based on a physical fitness assessment increases short- and long-term regular physical activity in people with multiple sclerosis in a retrospective cohort study

Background

Despite the evidence of beneficial effects of physical activity (PA), people with multiple sclerosis (pwMS) are less physically active than the general population. To increase PA in pwMS, we developed a structured individually tailored PA promotion program which is conducted within clinical practice in a university-based outpatient clinic since 2016. This study serves as retrospective quality control of this program.

Objective

In a retrospective cohort study, we assessed the physical fitness of pwMS and the impact of the program on short- and long-term PA changes and behavioral determinants.

Methods

The program consisted of four appointments each 2-4 weeks apart. Spiroergometric test results of female pwMS were compared to female non-MS controls who underwent a voluntary physical fitness analysis. The short version of the Freiburger questionnaire, self-developed questions and the modified Physical activity screening questionnaire (PASQ) were sent to all participants assessing the PA levels before the program, 3 months after the program (short-term), and at the time of the survey (long-term). Additionally, established questionnaires assessed behavioral determinants before the program and long-term.

Results

A total of 166 participants [mean age 38.32 (± 10.61 SD), mean EDSS 2.30 (±1.29 SD)] and mostly females (63.3%, n = 105) were included in the study and started the program. A total of 136 participants completed the program. Out of these 63.9% (n = 87) answered the questionnaires in 12.38 (±11.34 SD) months after finishing the program. At baseline female pwMS (n = 100) showed a lower physical fitness in comparison to non-MS controls (n = 26) (maximal workload (Watts): 138.86 ± 37.85 vs. 191.73 ± 45.25, p < 0.001; peak oxygen consumption (ml min-1 kg-1): 26.40 ± 7.23 vs. 31.56 ± 10.10, p = 0.020). pwMS were more regularly active in short- (62.1%) and long-term (55.2%) compared to baseline (24.2%, p < 0.001). Among the activated participants, we observed improved internal motivation (p = 0.002) and decreased perception of barriers (p = 0.006) compared to baseline.

Conclusion

PwMS showed a lower physical fitness in comparison to non-MS controls. An individually tailored PA promotion program might improve behavioral determinants and thereby increase short- and long-term PA levels of pwMS.

Electroneuromyography comparison between pre-elderly adult females with and without MS; the potential role of a mind-body therapy in improving neurophysiological profile of MS during pandemic

INTRODUCTION

Imaginary exercises seem to be useful therapeutic approaches to modulate neuromuscular functions due to two main reasons: first, this training would not greatly increase body temperature, and secondly, it can positively affect brain-muscle pathways-which are both primary factors should be considered in rehabilitation programs for patients with multiple sclerosis (MS).

METHOD

32 pre-elderly adult females with relapsing-remitting MS (n = 16 - age M (SD): 56.75 (5.07)) and without MS (n = 16 - age M (SD): 56.56 (4.35)) voluntarily recruited. First, they were assigned into two groups: MS patients and healthy controls, to investigate baseline between-group comparison. Then, MS patients were randomly divided into two groups of eight each, designated as experimental and control groups. Recording the nerve conduction velocity (NCV) of tibial nerve and integrated electromyographic muscle activation (IEMG) of gastrocnemius muscle was conducted twice, before and after a six-week mind-body exercise therapy to evaluate its effectiveness on improving neuromuscular function.

RESULTS

The results showed significant difference in both tibial NCV (P < 0.001) and IEMG (P = 0.001) variables between non-MS group and MS group. Furthermore, there was a significant main effect of intervention (P = 0.05) and time (P < 0.001) on IEMG in the MS group, while there was no significant effect of intervention (P = 0.18) and time (P = 0.23) on NCV (p = 0.89).

CONCLUSION

Neuromuscular dysfunction were apparent in MS patients, and a mind-body therapy of imagery isometric training was found to be useful on improving the neurological deficit in women with MS.

TRIAL REGISTRATION NUMBER

UMIN000046935.

Nordic Walking as a Non-Pharmacological Intervention for Chronic Pain and Fatigue: Systematic Review

OBJECTIVE

We aimed to analyze and summarize the available scientific evidence on the benefits of Nordic walking for people with chronic pain and fatigue.

LITERATURE SURVEY

This systematic review adhered to PRISMA guidelines and conducted a comprehensive search across five databases using the PICO strategy.

METHODOLOGY

Inclusion criteria encompassed randomized trials evaluating Nordic walking for pain and fatigue. Two authors independently screened studies, extracted data, and assessed methodological quality using the PEDro scale.

SYNTHESIS

A total of 14 studies were included, with sample sizes ranging from 20 to 136 participants. The methodological quality of the included studies varied from fair (five studies) to good (nine studies). The interventions consisted of supervised Nordic walking sessions lasting 6 to 24 weeks, with a frequency of 2 to 4 days per week and duration of 25 to 75 min. The results of this review suggest that Nordic walking had beneficial effects in six of the eight studies that analyzed participant fatigue. However, Nordic walking did not show greater beneficial effects on fatigue than walking (two studies) or than not performing physical activity (one study). Additionally, six of the nine studies that examined the effects of Nordic walking on participants' perceptions of pain showed beneficial results. However, five studies that compared Nordic walking with control groups did not find any significant inter-group differences on pain.

CONCLUSIONS

Based on our findings, Nordic walking exercise programs provide a potentially efficient method for alleviating pain and fatigue in people with chronic conditions. Its straightforwardness and ease of learning make it accessible to a broad spectrum of participants, which can result in higher adherence rates and lasting positive effects.

Be Cool: A Holistic and Innovative Approach to Rehabilitation in Multiple Sclerosis: Study Protocol for a Randomized Controlled Trial

(1) Background: Individuals with multiple sclerosis (MS) have to deal with numerous symptoms that adversely impact their quality of life. While pharmaceutical treatments offer some relief, they often fall short of addressing the full spectrum of MS symptoms. To bridge this gap, we introduce the Be Cool rehabilitation program, a comprehensive protocol designed to enhance the well-being and life quality of MS individuals. (2) Methods: The Be Cool program is a multifaceted approach that combines exercise training, nutritional guidance, psychological support, and cooling strategies. Adapted to meet the unique needs of MS individuals, this program aims to mitigate symptoms, promote physical and mental health, and improve overall quality of life. The integration of these strategies addresses the complex challenges faced by MS individuals, offering a holistic solution beyond conventional medication. (3) Conclusions: The Be Cool rehabilitation protocol is designed to offer individuals with MS a comprehensive approach to symptom management, fostering improvements in their quality of life. By addressing the multifaceted nature of MS through an integrated strategy, the program holds promise for more effective management of the condition.

Effects of exercise in people with multiple sclerosis: a systematic review and meta-analysis

Background

A growing body of studies have examined the effect of exercise in people with multiple sclerosis (MS), while findings of available studies were conflicting. This meta-analysis aimed to explore the effects of exercise on balance, walking ability, walking endurance, fatigue, and quality of life in people with MS.

Methods

We searched PubMed, Web of Science, Scopus, and Cochrane databases, through March 1, 2024. Inclusion criteria were: (1) RCTs; (2) included an intervention and control group; (3) had people with MS as study subjects; (4) had balance, walking ability, walking endurance, fatigue, or quality of life as the outcome measures. Exclusion criteria were: (1) non-English publications; (2) animal model publications; (3) review articles; and (4) conference articles. A meta-analysis was conducted to calculate weighted mean difference (WMD) and 95% confidence interval (CI). Cochrane risk assessment tool and Physiotherapy Evidence Database (PEDro) scale were used to evaluate the methodological quality of the included studies.

Results

Forty studies with a total of 56 exercise groups (n = 1,300) and 40 control groups (n = 827) were eligible for meta-analysis. Exercise significantly improved BBS (WMD, 3.77; 95% CI, 3.01 to 4.53, P < 0.00001), TUG (WMD, -1.33; 95% CI, -1.57 to -1.08, P < 0.00001), MSWS-12 (WMD, -2.57; 95% CI, -3.99 to -1.15, P = 0.0004), 6MWT (WMD, 25.56; 95% CI, 16.34 to 34.79, P < 0.00001), fatigue (WMD, -4.34; 95% CI, -5.83 to -2.84, P < 0.00001), and MSQOL-54 in people with MS (WMD, 11.80; 95% CI, 5.70 to 17.90, P = 0.0002) in people with MS. Subgroup analyses showed that aerobic exercise, resistance exercise, and multicomponent training were all effective in improving fatigue in people with MS, with resistance exercise being the most effective intervention type. In addition, a younger age was associated with a larger improvement in fatigue. Furthermore, aerobic exercise and multicomponent training were all effective in improving quality of life in people with MS, with aerobic exercise being the most effective intervention type.

Conclusion

Exercise had beneficial effects in improving balance, walking ability, walking endurance, fatigue, and quality of life in people with MS. Resistance exercise and aerobic exercise are the most effective interventions for improving fatigue and quality of life in people with MS, respectively. The effect of exercise on improving fatigue was associated with the age of the participants, with the younger age of the participants, the greater the improvement in fatigue.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=371056, identifier: CRD42022371056.

Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review

Multiple Sclerosis (MS) management in individuals aged 55 and above presents unique challenges due to the complex interaction between aging, comorbidities, immunosenescence, and MS pathophysiology. This comprehensive review explores the evolving landscape of MS in older adults, including the increased incidence and prevalence of MS in this age group, the shift in disease phenotypes from relapsing-remitting to progressive forms, and the presence of multimorbidity and polypharmacy. We aim to provide an updated review of the available evidence of disease-modifying treatments (DMTs) in older patients, including the efficacy and safety of existing therapies, emerging treatments such as Bruton tyrosine kinase (BTKs) inhibitors and those targeting remyelination and neuroprotection, and the critical decisions surrounding the initiation, de-escalation, and discontinuation of DMTs. Non-pharmacologic approaches, including physical therapy, neuromodulation therapies, cognitive rehabilitation, and psychotherapy, are also examined for their role in holistic care. The importance of MS Care Units and advance care planning are explored as a cornerstone in providing patient-centric care, ensuring alignment with patient preferences in the disease trajectory. Finally, the review emphasizes the need for personalized management and continuous monitoring of MS patients, alongside advocating for inclusive study designs in clinical research to improve the management of this growing patient demographic.

Comparative Efficacy of Neuromodulation Technologies for Overactive Bladder in Adults: A Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The aim of this study was to investigate the comparative efficacy of neuromodulation technologies for overactive bladder (OAB) syndrome in adults.

DATA SOURCES

A computerized search was conducted of Cochrane Library, EMBASE, MEDLINE (via PubMed), Web of Science, CNKI, Wan Fang Data, and ClinicalTrials.gov up to April 21, 2022.

STUDY SELECTION

The search selected clinical trials with random allocation to percutaneous tibial nerve stimulation (PTNS), transcutaneous tibial nerve stimulation (TTNS), vaginal electrical stimulation (VES), sacral neuromodulation (SNM), parasacral stimulation (PS), pudendal neuromodulation, or placebo.

DATA EXTRACTION

The main outcomes were the voiding diary, OAB-related quality of life, and positive response rate. The Cochrane Risk of Bias tool (RoB 2.0) was used to assess the risk of bias of each included study, and the Grading of Recommendations Assessment, Development, and Evaluation tool was used to evaluate the overall evidence quality of key outcomes.

DATA SYNTHESIS

The study included 21 randomized controlled trials involving 1433 participants, and all trials were used for the meta-analysis. In the network meta-analyses, five of six neuromodulation technologies, including PTNS, TTNS, VES, SNM, and PS, were related to higher efficacy than the placebo. Ranking probability showed that SNM was the most efficacious therapy for improving OAB-related quality of life, urinary episodes, and urinary frequency. For urgency incontinence episodes and the number of pads, PTNS and TTNS were the most efficacious modalities, respectively.

CONCLUSION

Neuromodulation technologies, including PTNS, TTNS, VES, SNM, and PS, may be effective and safe solutions for OAB syndrome in adults. Moreover, SNM is the most efficacious regimen for OAB-related quality of life, urinary episodes, and urinary frequency. PTNS and TTNS are the most efficacious modalities for reducing urgency incontinence episodes and the number of pads, respectively. Future studies should pay more attention to the quality of study design and report, patients who may benefit the most from neuromodulation, and the long-term effect, cost-effectiveness, and satisfaction of neuromodulation.

An Overview of Physical Exercise Program Protocols and Effects on the Physical Function in Multiple Sclerosis: An Umbrella Review

Multiple sclerosis is a disease that concerns a growing number of people, especially females. There are different interventions proposed for this population, and physical activity is one of them. A proper and well-structured physical activity program can be a cheap, feasible, and practical instrument to help this population improve their quality of life. Consequently, the present study aimed to analyze, through an umbrella review, published articles to evaluate the protocols and the effect of intervention on different types of multiple sclerosis and eventually to propose a standardized intervention for this population. Systematic reviews and meta-analyses of randomized controlled trials on multiple sclerosis and physical activity effects were searched for on the electronic databases PubMed, Web of Science, and Scopus up to 22 December 2022. The quality of the studies included was determined and the results were narratively analyzed. The included studies present heterogeneity in the population, in the study design and protocols, and in the outcomes evaluated. Most of the studies detected positive outcomes on the physical function of people with multiple sclerosis. This study highlights the necessity of future studies on a population with similar characteristics, adopting similar protocols to evaluate their feasibility and validity to make physical intervention prescribed as a medicine.

Effect of different types of exercise on fitness in people with multiple sclerosis: A network meta-analysis

BACKGROUND

It is assumed that people with multiple sclerosis (MS) who participate in programs of physical exercise improve their physical fitness.

OBJECTIVE

The aim of this network meta-analysis (NMA) was to analyze the effect of different types of exercise on muscular fitness and cardiorespiratory fitness (CRF) among people with MS and to determine the best type of exercise according to disease severity.

METHODS

MEDLINE, the Physiotherapy Evidence Database, the Cochrane Library, SPORTDiscus, Scopus, and Web of Science were searched from inception to April 2022 to identify randomized controlled trials (RCTs) concerning the effect of physical exercise on fitness in people with MS. We ranked the types of physical exercise by calculating the surface under the cumulative ranking (SUCRA).

RESULTS

We included 72 RCTs involving 2543 MS patients in this NMA. A ranking of five types of physical exercise (aerobic, resistance, combined [aerobic and resistance], sensorimotor training, and mind-body exercises) was achieved. Combined and resistance training had the highest effect sizes (0.94, 95% CI 0.47, 1.41, and 0.93, 95% CI 0.57, 1.29, respectively) and the highest SUCRA (86.2% and 87.0%, respectively) for muscular fitness. The highest effect size (0.66, 95% CI 0.34, 0.99) and SUCRA (86.9%) for CRF was for aerobic exercise.

CONCLUSIONS

Combined and resistance training seem to be the most effective exercises to improve muscular fitness and aerobic exercise for CRF in people with MS.

Effect of Vitamin D Supplementation on Fatigue in Multiple Sclerosis: A Systematic Review and Meta-Analysis

Vitamin D supplementation has been considered a possible treatment to reduce the risk of disease activity and progression in people with multiple sclerosis (MS). However, its effect on disease symptoms remains unclear. The aim of this meta-analysis was to conduct a systematic review to assess the effect of vitamin D on fatigue in this population. The systematic review was conducted using the MEDLINE, Cochrane Library, Embase and Web of Science databases from inception to May 2023. Randomized controlled trials (RCTs) reporting pre-post changes in fatigue after vitamin D supplementation were included. Pooled effect sizes and 95% confidence intervals (95% CIs) were calculated by applying a random effects model with Stata/SE (Version 16.0; StataCorp., College Station, TX, USA). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A total of five studies with 345 individuals (271 females; age range: 25.4-41.1 years) were included. A significant reduction in fatigue was perceived when vitamin D supplementation was compared with a control group: -0.18 (95% CI: -0.36 to -0.01; I² = 0%). Thus, our findings show that the therapeutic use of vitamin D on fatigue in people with MS could be considered. Nevertheless, due to the lack of agreement on the dose to be applied, it is recommended to use it under medical prescription.

Physical Exercise Interventions on Quality of Life in Parkinson Disease: A Network Meta-analysis

BACKGROUND AND PURPOSE

Physical exercise is considered an effective intervention for maintaining or improving quality of life (QoL) in patients with Parkinson disease (PD), but there is no evidence showing which type of physical exercise intervention has more positive effects. This systematic review and meta-analysis aimed to synthesize the evidence regarding the effectiveness of exercise interventions on improving QoL in patients with PD, comparing different types of exercise interventions.

METHODS

A literature search was conducted through January 2022. The methodological quality of the trials was assessed using the Cochrane risk of bias tool RoB2. For the meta-analysis, physical exercise interventions were classified into 5 training categories: resistance, endurance, alternative exercises, dance, and sensorimotor interventions. A standard meta-analysis and network meta-analysis were carried out to evaluate the efficacy of the different types of physical exercise interventions.

RESULTS

The search retrieved 2451 studies, 48 of which were included in this network meta-analysis with a total of 2977 patients with PD. The indirect effects of the network meta-analysis showed positive results for alternative exercises (-0.46; 95% confidence interval [CI]: -0.76, -0.16), dance (-0.63; 95% CI: -1.08, -0.17), and sensorimotor interventions (-0.23; 95% CI: -0.40, -0.07) versus control comparisons.

DISCUSSION AND CONCLUSIONS

More research is needed to determine the types of physical exercise interventions that are most beneficial and for which conditions of the disease they have the most positive effects.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A398 ).

Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group, Heine M, Rietberg MB, Amaral Gomes E, Evenhuis E, Beckerman H, de Port I, Groot V, Kwakkel G, Wegen EEH. Exercise therapy for fatigue in multiple sclerosis

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

The pathophysiology of motor fatigue and fatigability in multiple sclerosis

Multiple Sclerosis (MS) is a heterogeneous immune mediated disease of the central nervous system (CNS). Fatigue is one of the most common and disabling symptom of MS. It interferes with daily activities on the level of cognition and motor endurance. Motor fatigue can either result from lesions in cortical networks or motor pathways (“primary fatigue”) or it may be a consequence of detraining with subsequent adaptions of muscle and autonomic function. Programmed exercise interventions are used frequently to increase physical fitness in MS-patients. Studies investigating the effects of training on aerobic capacity, objective endurance and perceived fatigability have yielded heterogenous results, most likely due to the heterogeneity of interventions and patients, but probably also due to the non-uniform pathophysiology of fatigability among MS-patients. The aim of this review is to summarize the current knowledge on the pathophysiology of motor fatigability with special reference to the basic exercise physiology that underlies our understanding of both pathogenesis and treatment interventions.

Effects of Different Exercise Therapies on Balance Function and Functional Walking Ability in Multiple Sclerosis Disease Patients-A Network Meta-Analysis of Randomized Controlled Trials

The objective of this research is to assess the effects of seven different exercise therapies (aquatic exercise, aerobic exercise, yoga, Pilates, virtual reality exercise, whole-body vibration exercise, and resistance exercise) on the balance function and functional walking ability of multiple sclerosis disease patients.

MATERIALS AND METHODS

The effects of different exercise interventions on the balance function and functional walking ability in people with multiple sclerosis were assessed by searching five databases: PubMed, Embase, Cochrane Library, Web of Science, and CNKI; only randomized controlled trials were included. The included studies were assessed for risk of bias using the Cochrane assessment tool.

RESULTS

The RCTs were collected between the initial date of the electronic databases' creation and May 2022. We included 31 RCTs with 904 patients. The results of the collected data analysis showed that yoga can significantly improve patients' BBS scores (SUCRA = 79.7%) and that aquatic exercise can significantly decrease patients' TUG scores (SUCRA = 78.8%).

CONCLUSION

Based on the network meta-analysis, we suggest that although each type of exercise is useful, yoga, virtual reality training, and aerobic training are more effective in improving the balance function of people with MS; aquatic exercise, virtual reality training, and aerobic training are more effective in improving the functional walking ability of people with MS.

The Effect of Chronic Exercise on Energy and Fatigue States: A Systematic Review and Meta-Analysis of Randomized Trials

In this meta-analysis, we synthesized the results of randomized controlled trials of different exercise training interventions on participants' feelings of fatigue, energy, and vitality. The search of studies was conducted using six databases as well as several other supplementary search strategies available before December 2021. The initial search generated over 3,600 articles with 81 studies (7,050 participants) and 172 effects meeting the inclusion criteria. We analyzed the effects from the studies using a meta-analytic multivariate model and considered the potential moderating effect of multiple variables. Our analysis revealed exercise to decrease the feelings of fatigue by a small effect size (g = -0.374; 95% CI [-0.521, -0.227]), increase energy by a small-to-moderate effect size (g = 0.415; 95% CI [0.252, 0.578]), and to increase the feeling of vitality by a moderate effect size (g = 0.537; 95% CI [0.404, 0.671]). All main results remained robust after several sensitivity analyses using different statistical estimators, and consideration of outlier and influential studies. Moreover, moderator analyses revealed significant effects of exercise intensity and intervention duration on fatigue, exercise intensity, and modality on energy, and participant health, exercise intensity modality, and exercise training location on vitality. We conclude that when groups adopt a moderate intensity exercise training program while participating in a randomized trial, compared to controls, this typically results in small-to-moderate average improvements in feelings of fatigue, energy, and vitality.

Exercise Training for Multiple Sclerosis: A Narrative Review of History, Benefits, Safety, Guidelines, and Promotion

Background: There have been significant advances in the medical treatment and management of multiple sclerosis pathogenesis, relapse and disease progression over the past 30 years. There have been advancements in the symptomatic treatment of multiple sclerosis, including management of secondary multiple sclerosis expressions such as walking, cognitive dysfunction, fatigue and depression. Scientific evidence and expert opinion suggest that exercise may be the single most effective non-pharmacological symptomatic treatment for multiple sclerosis. This article presents the historical context of exercise training within the multidisciplinary management of multiple sclerosis. We guide neurologists and healthcare providers on the recommended prescription of exercise and practical, theoretical methods to overcome barriers to exercise. Method: We undertook a critical search of the historical and current literature regarding exercise and multiple sclerosis from the viewpoint of exercise promotion by neurologists and the multidisciplinary care team. Results: We highlight the ever-strengthening body of research indicating that exercise is safe and effective for improving symptoms of multiple sclerosis. Further, exercise training may be necessary for reducing disease progression. Conclusion: We seek to encourage neurologists and specialists in multidisciplinary healthcare teams to prescribe and promote exercise at diagnosis and across all stages of the disease trajectory using prescriptive guidelines as part of comprehensive MS care. Available tools include clinical education to dispel any historical myths related to exercise in multiple sclerosis, clinical exercise guidelines and behaviour change theory to overcome patients barriers to exercise.