Though historically people with MS were advised to avoid physical activity to reduce symptoms such as fatigue, they are now encouraged to be active1. Exercise as a form of MS therapy has consistently been associated with benefits for physical performance and quality of life2-5. Exercise has increasingly been recommended for patients with MS to control symptoms – particularly impaired balance and fatigue6 – improve function and quality of life, and enhance participation in daily activities3. Meta-analyses have shown that exercise training had important positive effects on balance in MS patients7,8. Cognitive function has further been shown to be enhanced with moderate-to-vigorous intensity exercise 9,10. 

     According to a recent survey in patients with MS who use wheelchairs, preferred exercise modes were primarily aerobic and strength training, supported by rehabilitation therapies and adapted sports 11. 

     Of note, much of the research on exercise in MS has been conducted between flares. A recent study explored the subjective response to exercise during relapses, and found that while diminished function, general malaise, and self-consciousness limited participation to some extent, physical activity could be individualized to the benefit of the patient, preferably by a professional 12. Enhancement of corticosteroid treatment with exercise (virtual “exergaming” mimicking bowling, jet ski racing, rock climbing, football, tennis, and goal shooting) during an MS flare was associated with safety and benefits – as good as or better than conventional rehabilitation – including improvement in upper extremity and cognitive functions, fatigue, quality of life, balance, and walking ability4.

     An in-depth research analysis compared the effects of yoga, Pilates, aquatic aerobic, virtual reality, whole-body vibration, and resistance exercise on balance function and walking ability in MS. It was concluded that although each type of exercise is useful, yoga, virtual reality, and aerobic training are more effective in improving the balance function, and aquatic, virtual reality, and aerobics are better for walking ability 13. Further, physical activity interventions that develop feelings of competence and independent choice in the patient may be more successful for long-term participation 14.

Aerobics

     Aerobic training refers to physical activity that utilizes large muscle groups that can be maintained continuously, involves use of oxygen by the body, and may be rhythmic in nature, e.g., walking, cycling, long-distance running, and dancing 15. Aerobics was found to be a preferred mode of exercise among MS patients, including those who use a wheelchair for mobility 11.

     MS research has demonstrated benefits of incorporating aerobic activities into one’s lifestyle, 16. Based on this, a suggested approach for MS patients who use wheelchairs is a structured exercise program that incorporates alternative modes of aerobic training that entail use of machines and/or are adapted to a seated position15. 

     In addition to conventional fitness outcomes, sleep was shown to improve for MS patients with aerobic exercises of varying intensities 17, especially moderate-to-vigorous 18.

Aquatics

     Aquatic therapy is defined as “using the properties of water, planned by an appropriately qualified physiotherapist specifically for an individual to improve balance, fatigue, and motor function, carried out by suitably trained personnel in an appropriately heated aquatic therapy pool” 19. Because of the properties of water such as buoyancy, turbulence, hydrostatic pressure, and resistance, exercising in in can benefit patients with MS. Indeed, extensive reviews of studies with MS patients showed balance 17,19 and fatigue 19 to improve with aquatic exercises, with one of the included studies also showing an improvement in overall functional capacity20. In a study of aquatic strength exercises in MS patients, all tested physical capacities were improved significantly after the workout, including six-minute walk time, hand grip strength, getting up, sitting and getting up, walking up and down 15 steps, putting on socks, and severity and impact of fatigue 21.

    Aquatic exercises are usually done in shallow water, with the depth selected according to body position – whether standing or sitting, the water should reach the middle ribcage to chest. The aim of the workout is to improve motor skills, flexibility, balance, strength, and many other functions that support activities of daily living. Many of the exercises executed incorporate resistance training, taking advance of the properties of the water itself, which can help correct muscle weakness as well as improve muscle power and endurance. Aquatic resistance exercise can be enhanced by equipment such as paddles, flotation devices, and bands. It is recommended to engage in aquatics at least twice per week, 8-12 repetitions per exercise, with light-to-moderate loads 22.

     For individuals with more limitations, e.g., lacking range-of-motion or experiencing pain while exercising on land, water offers opportunities for movement and flexibility that might not exist otherwise. The aquatic form of land-based tai chi exercise, called ai chi, is a gentle method that combines slow, fluid rhythmic motions with healing breathing patterns. The benefits of Ai Chi include improving balance strength, weight-shifting, body awareness, postural control and stress management. Other slow-moving aquatic exercises to assist with mobility, strength, balance, and stretching include water-walking, toe and heel lift, knee extension, and movement games 22.

    Overall, it is up to the individual with MS with self-knowledge of the body, aquatic therapist, and/or fitness instructor to establish a sound and effective regimen, under the guidance of a physician who can help prevent injury.

Multimodal exercises

     A multimodal fitness protocol refers to a combination of physical exercises of different components, such as cardiorespiratory, muscular strength, and flexibility, which may be performed in both real and virtual reality environments. Multimodal exercises were shown in MS patients to improve walking ability, balance, and aerobic fitness 17.

Pilates

Pilates is a form of exercise developed in the 1920s by German physical trainer Joseph Pilates, after whom it was named. It has increasingly become popular in rehabilitation, and may be particularly beneficial in MS. Research has reported that Pilates is useful for people of different ages, body types, and degrees of physical conditioning 23.

      Pilates focuses on stabilizing core muscles during movement, which can address the mobility and balance problems inherent in MS 24. Improvements in walking performance, functional ability, balance, strength, and well-being have been reported in studies with MS patients 23-29, including those who are wheelchair-bound 30.

     Pilates comprises six main components – centering, concentration, control, precision, flow, and breathing – to improve flexibility, strength, core stability, muscle control, endurance31,32, and range-of-motion 31. Unlike traditional strength training focusing on single movements, Pilates training aims to train several muscle groups at once 33

     Regimens vary depending on the specific condition being addressed, and are floor-based and/or involve use of specialized equipment 34 – such as the CoreAlign (by Balanced Body), exercise balls (e.g., Swiss ball by Theragear, with different sizes), and TheraBands (various resistance levels)23 – with exercises performed in standing, sitting, and lying positions35. Mat-based Pilates training has been designed for those who cannot exercise more seriously because of injury or poor health 36. Strength-based exercises can play a role in improving balance abilities and can be implemented to improve postural malalignment 31.

     The following is an example of a successful regimen from a recent research study: extension of thoracic (chest level) spine, abdominal strengthening, core stabilizing exercises for the deep abdominal muscles (transverse and internal oblique), upper and lower limb exercises, and postural correction and stability exercises, with difficulty gradually increasing based on individual ability, and with considerable focus on keeping neutral positions of the spine in different gravity orientations. Training programs are ideally based on ability, with advancement based on improvement 23.

     Studies in MS patients found that Pilates regimens of moderate intensity for 30-60 minutes – with warm up and cool-down stretches – at least 2-3 times per week for 12 weeks are associated with improvements in key parameters such as walking performance, balance, and functional ability 23,25,27,28.

Resistance exercise

     Resistance exercise or training is considered to be an effective tool in MS rehabilitation. It is a type of exercise in which participants exercise muscles against some type of resistance, e.g., weight-lifting, squats, or planks. A 12-week resistance training program improved a key fitness measure known as “knee extension maximal voluntary isometric contraction,” as well as muscle power in MS patients; though 12 weeks of abstaining from training eroded the beneficial effects, some muscle power remained 37. Additional benefits observed for MS patients from resistance training include enhanced sleep and cardiac fitness. Following a 10-week program of resistance training with three training sessions per week, MS patients were observed to have improvements in sleep quality, sleep comfort, and ease of falling sleep, as well as modulate autonomic cardiac control. In this study, each training session consisted of “four lower body exercises, performing 2-4 sets of each exercise, with 8-15 repetitions each set, at an intensity ranging from 60-75% of one-repetition maximum” 38.

     Strength training is a type of resistance exercise generally associated with weight-lifting and adventure-type sports such as climbing. The latter was shown in a study to reduced fatigue and improve voluntary control of muscular movements in MS patients, similarly to yoga 39, but exercises favored by MS patients include low-cost, lightweight options requiring minimal if any assistance and that facilitate full participation, ease, and independence. Another study in MS patients showed strength training matching that description to improve muscle and nerve activity, as well as spasticity. The program consisted of three times per week on alternating days for 10 weeks of a multipronged regimen that included 48-hour rest periods between workouts. Each started with a standardized warm-up protocol that comprising five minutes cycling on a stationary bicycle, five minutes of lower limb exercises (bilateral leg press, unilateral leg extension, unilateral hip extension and bilateral seated calf raise) on conventional weight machines, and five repetitions at 40% of one repetition maximum (1RM) on each machine; this was followed by four more sets of lower-limb exercises, taking care to avoid muscle failure 38.

     Progressive resistance training (PRT) is resistance training whose intensity is progressively increased as one’s strength improves. From studies in MS patients, strong evidence exists regarding the beneficial effect of PRT on muscle strength, with positive results observed for functional capacity, balance, and self-reported fatigue, quality of life, and mood40,41. In a study examining the effects of an eight-week PRT regimen (intensity 40-70% of maximal voluntary contraction) on different strength manifestations, muscle mass, and functionality in moderately impaired MS patients (aged 35-51), isometric strength, muscular endurance, maximal power, muscular hypertrophy of both thighs, and functionality improved significantly without injuries 42. Following a twice-a-week 12-week regimen focusing on lower limbs, a similar group of MS patients demonstrated significant and sustained improvements in isometric muscle strength of knee extensors and functional capacity 43. In a later study, PRT on a bicycle plus balance exercise compared with static lower-limb strengthening and balancing exercise was shown to improve mobility, falls, fatigue, and depression in MS patients 44. Additionally positive effects on underlying mechanisms such as muscle form changes, nerve cell adaptations and cytokines have been shown 41,45,46.

For individuals who find that they cannot progress, classic resistance training – e.g., via eccentric strength-enhanced training (EST) – can still provide considerable benefit. For example, following a 12-week training program in MS patients, EST was shown to lead to improvements in strength and functional tests similar to those from PRT, but with better promotion of strength adaptations to the functional tests, which are closer to daily-living activities47. EST exercises are slow, lengthening muscle contractions that are for a specific muscle.

     No less important to note, resistance training is highly relevant to wheelchair users as well. In a small study in 10 MS patients using wheelchairs for mobility (Expanded Disability Status Scale score 6.5-8.5), functional electrical stimulation (FES) cycling regimens matched to ability level comprising 6-8 sessions were associated with modest improvement in outcome measures. Half of the participants were able to cycle for 30 minutes and completed interval training protocols requiring increasing difficulty 48. FES is a treatment that applies small electrical charges to a muscle that has become paralyzed or weakened.

Tai chi (t’ai chi ch’üan)

     After many years of exercise being discouraged in MS patients, it was indicated that certain types of mind-body exercises could be practiced by MS patients for health benefits, and tai chi specifically was recommended 49.

     Tai chi, also known as “shadowboxing,” is a form of movement that incorporates meditation and deep breathing. Each session comprises a series of gentle exercises intended to create harmony between the mind and body and facilitate the flow of internal energy (“qi”). Specific regimens are selected according to one’s needs.

    Research studies have shown that tai chi can significantly improve aerobic capacity, muscular strength, balance, health-related quality of life, and psychological well-being, and that it is safe and effective for individuals with neurological disease such as MS 50. In MS patients specifically, findings demonstrate improved functional balance and quality of life 51. In one study evaluating Yang style tai chi exercise sessions twice a week for 12 weeks, MS patients experienced improved balance 52. In another evaluating a regimen of two weekly tai chi sessions of 90 minutes each for six months, participants demonstrated significant, consistent improvements in balance, coordination, and depression relative to MS patients receiving only standard therapy 53.

     There are many different styles of tai chi, with the major styles recognized in China and internationally being Yang, Chen, Sun, and Wu. The Yang style is the most popular and widely practiced in the world, considered feasible for people of all ages and physical abilities. It evolved from the more martial arts-like Chen style, and emphasizes the slow, even, fluid, and expansive movements considered characteristic of tai chi in general. The “24-posture” form of the Yang style is considered to be relatively easy and fast to learn, comprising the following steps that progress from warm-up to principle moves to cool-down:

1. C ommencing Form (Qǐshì, 起势)

2. Part the Wild Horse’s Mane (Zuǒyòu Yěmǎ Fēnzōng, 左右野马分鬃)

3. White Crane Spreads Its Wings (Báihè Lìangchì, 白鹤亮翅)

4. Brush Knee (Zuǒyòu Lōuxī Àobù, 左右搂膝拗步)

5. Playing the Lute (Shǒuhūi Pípā, 手挥琵琶)

6. Repulsing the Monkey (Dǎo niǎn hóu 倒攆猴)

7. Grasping the Bird’s Tail on the Right (Zuǒ Lǎn Què Wěi, 左揽雀尾) 

8. Grasping the Bird’s Tail on the Left (Yòu Lǎn què wěi, 右揽雀尾)

9. Single Whip (Dān biān, 单鞭)

10. Cloud Hands (Yúnshǒu, 云手)

11. Single Whip (Dān biān, 单鞭)

12. High Pat on Horse (Gāo tàn mǎ, 高探马)

13. Kick Out with the Right Heel (Yòu dēng jiǎo, 右蹬脚)

14. Double Punch (Shuāng fēng guàn ěr, 双峰贯耳)

15. 9 9333Turn, Kic Out with the Left Heel (Zhuǎnshēn zuǒ dēngjiǎo, 转身左蹬脚)

16. Serpent in the Grass on the Right, Golden Cockerel Stands on its Left Leg (Zuǒ Xià shì dúlì, 左下势独立)

17. Serpent in the Grass on the Left, Golden Cockerel Stands on its Right Leg (Yòu Xià shì dúlì, 右下势独立)

18. Maiden Working the Shuttles (Yòuzuǒ yùnǚ chuānsuō, 右左玉女穿梭)

19. Needle at Bottom of the Sea (Hǎidǐ zhēn, 海底针)

20. Flash Arms Like a Fan (Shǎn tōng bì, 闪通臂)

21. Turn, Deflect, Parry, and Punch (Zhuǎnshēn Bānlánchuí, 转身搬拦捶)

22. Apparent Closing and Push (Rúfēng shìbì, 如封似闭)

23. Cross Hands (Shízìshǒu, 十字手)

24. Closing Form (Shōushì, 收势)

Demonstrations of these movements can be viewed here.

Technology-assisted

According to an extensive review 17, studies in MS patients identified improvements with technology-assisted exercise regimens. Walking ability was observed to be improved with treadmill training; function with treadmill and motion gaming (described below); and balance with robot-assisted gait training and motion gaming.

In a study on young (aged nearly 37 years) women, a treadmill workout regimen of eight weeks, three times weekly, was shown to improve balance, walking, depression, and anxiety 54.

Also known as “exergaming,” “gamercise,” and “motion gaming,” exercising with a virtual reality set-up has been found to improve clinical and motor symptoms and quality of life in patients with MS. This is especially true when performed in an unstable platform, taking care to not risk falls and injury. A rate of one hour a day five days per week was shown to be beneficial, with effects observed after five weeks 55.

To support adherence to physical activity in moderate-to-severe MS, a web-based, individualized exercise program was shown to provide benefits similar to those from in-person training 56.

Yoga

Yoga is an ancient Eastern Indian practice involving movement, meditation, and breathing techniques to promote mental and physical well-being. There are various different types, some of which can be used as a form of anaerobic exercise to promote endurance, muscle strength, and flexibility; reduce stress, anxiety, depression, and chronic pain; as well as improve breathing, heart health, sleep, and overall well-being and quality of life.

An extensive review of 50 studies in patients with neurological disorders – including MS – revealed that group or individual therapy yoga sessions lasting 60-75 minutes one to three times per week for 8-12 consecutive weeks were associated with improved physical, cognitive, and psychosocial outcomes 57.

A shorter five-week holistic biopsychosocial medical therapeutic yoga program demonstrated increased self-efficacy, and emotional quality of life in individuals diagnosed with MS 58.

Personalized yoga sessions were found to be particularly beneficial in MS. A lifestyle change that included a three-month regimen of 12 one-hour private sessions in addition to three group sessions was associated with significantly improved quality of life and health status, as well as trends toward improved pain and sleep quality 59.

There are six branches of yoga, each with a different focus and character. The hatha branch can be harnessed for fitness in MS, as it aims to prime both the body and mind. The modern approach focuses on strength and agility, highly relevant to managing the disease.

There are many styles of yoga, and a choice should be made based on goals, ability, and tolerance.

• Ashtanga. Poses and sequences that rapidly link every movement to breath

• Bikram. Also known as hot yoga, it is practiced in heated rooms at a temperature of nearly 105°F/40°C with 40% humidity. It consists of 26 poses and a sequence of two breathing exercises.

• Hatha. Generic term for any type of yoga that teaches basic, physical poses.

• Iyengar. Focuses on finding the correct alignment in each pose with the help of a range of props, such as blocks, blankets, straps, chairs, and bolsters.

• Kripalu. Teaches the user to know, accept, and learn from the body, to find one’s own level of practice by looking inward. It generally begins with breathing exercises and gentle stretches, followed by a series of individual poses and final relaxation.

• Kundalini. A system of meditation that aims to release pent-up energy. It usually begins with chanting and ends with singing; in between, it features physical poses (known as “asana”), focused breathing (“pranayama”), and meditation that aim to create a specific outcome.

• Power. An active and athletic type of yoga based on the traditional ashtanga system.

• Sivananda. Based on a five-point philosophy maintaining that proper breathing, relaxation, diet, exercise, and positive thinking work together to create a healthy yogic lifestyle. It features 12 basic asanas, which they precede with an introductory set of poses (known as “sun salutations”) and follow with a final resting pose (known as “savasana”). The traditional sun salutations include the following:

  • Prayer pose (pranamasana)

  • Upward salute (hastauttanasana)

  • Standing forward bend (hasta padasana)

  • Low lunge (ashwa sanchalanasana)

  • Plank (phalakasana)

  • Knees-chest-chin (ashtanga namaskara)

  • Cobra (bhujangasana)

  • Downward facing dog (adho mukha savasana)

• Viniyoga. Focuses on form over function, breath and adaptation, repetition and holding, and the art and science of sequencing

• Yin. Focuses on holding passive poses for long periods of time, targeting deep tissues, ligaments, joints, bones, and fascia

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