Multiple sclerosis: what exercise achieves – and what it does not – Knowledge

1. Why this article?

Multiple sclerosis is talked about today mainly in one language: the language of medication. That is understandable, because a great deal really has happened with the drugs over the last thirty years. Anyone diagnosed today has a distinctly better outlook than someone diagnosed in 1990.

But there is a second treatment that demonstrably works and is talked about far less often: exercise – guided, regular and matched to your condition. It is not a consolation prize for the time between medical appointments. It works on exactly those things where the drugs achieve little: on the exhaustion, on walking, on balance, on strength, on safety in everyday life.

That is the reason for this article. It answers four questions:

• What actually happens in the body in multiple sclerosis – and why does the disease look different in every person?
• What does physiotherapy achieve, measured against what the studies show – and what does it not achieve?
• Which kind of exercise helps with which problem?
• How much of it is needed, how often, and how do you deal with heat, exhaustion and bad days?

The text is written for those affected and their families, not for professionals. Technical terms do appear, because you will meet them in your medical reports anyway – but each one is explained the first time it comes up. The numbers in square brackets refer to the list of references at the very bottom.

And one note in advance: this article does not replace an examination. Multiple sclerosis takes a different course in every person, and whatever your neurologist decides for your situation takes precedence.

2. What multiple sclerosis is

2.1 An insulating layer that is missing in places

The brain and the spinal cord consist of nerve cells that exchange signals with one another – electrical impulses travelling along long extensions, rather like electricity along a cable. For such a cable to conduct quickly and without interference, it is insulated. This insulating layer is called myelin, and on healthy nerve fibres it is not continuous but applied in segments. As a result the signal jumps from gap to gap and becomes very fast – over a hundred metres per second.

In multiple sclerosis the body's own immune system attacks this insulating layer. That is the core of the disease: it is an autoimmune disease – an immune system that turns against its own body, although its job is to fight pathogens. Inflammation arises at the places attacked, the insulating layer thins or disappears, and scarred tissue is left in its place. Hence the name: «multiple sclerosis» literally means «many scars».

Two consequences of this are decisive for everyday life:

• The signal becomes slower – or it does not arrive at all. At a demyelinated place the impulse crawls instead of jumping. With more severe damage it breaks off entirely. What fails depends solely on where that place lies.
• It is not only the insulation that suffers. With more severe or repeated inflammation the nerve fibre itself is lost as well. That is the part which does not recover – and the reason why complaints can remain even though the inflammation subsided long ago [18].

The nervous system can compensate for a fair amount of this. It routes signals around the damage, it partly rebuilds insulating layer, it recruits neighbouring pathways. It is precisely in this compensation that physiotherapy has its starting point – more on that later.

2.2 Why the disease looks different in everyone

If you place two people with the same diagnosis side by side, one may run marathons and the other use a wheelchair. That is not because one of them has «more» MS. It is because the inflamed places lie in different locations in each of them.

A few examples, to make that concrete:

• A place on the optic nerve causes a painful visual disturbance in one eye – in many people this is the very first sign of all.
• A place in the spinal cord causes a numb or tingling leg, stiffness, bladder problems.
• A place in the cerebellum, the part of the brain that fine-tunes movement, causes unsteadiness when walking and trembling when reaching for things.
• Places in the connecting pathways of the cerebrum cause slowing of thought and that particular exhaustion which gets a chapter of its own further down.

That is why there is no «typical MS programme» that suits everyone. That is why the assessment at the beginning of physiotherapy matters so much – and why comparing yourself with other people who have MS is almost always misleading.

2.3 The forms of the disease course

Medical reports usually contain abbreviations. They describe not how severe the disease is, but by which pattern it changes:

• Relapsing course (technical term: relapsing-remitting, abbreviated RRMS). Relapses occur: complaints that appear anew within hours to days, last at least a day, and afterwards recede completely or partly. Between the relapses things are stable. This is how the disease begins in the great majority of people.
• Secondary progressive course (SPMS). After many years the pattern changes in some of those affected: relapses become rarer, but the complaints increase slowly and steadily – even without anything new flaring up.
• Progressive from the outset (primary progressive, PPMS). In roughly one in eight to one in ten people there are never proper relapses. Instead something slowly deteriorates from the start – most often walking. Onset is on average later in life than with the relapsing course.

This distinction is not a label; it has a very practical reason. The anti-inflammatory drugs work well where inflammation is the driving process – that is, in relapses. In the progressive forms without new inflammatory lesions they can achieve little or nothing; this is undisputed in the professional literature and is described as one of the largest open gaps in MS treatment [18].

It is precisely in this gap that rehabilitation works. That is the most important sentence in this section: the less the drugs can still contribute, the larger the share contributed by exercise and training.

2.4 How common it is, and whom it affects

According to the projection of the Swiss MS Registry, about 18 000 people in Switzerland live with multiple sclerosis (reference year 2021, range 17 400 to 18 700) [21]. That is roughly 20 per cent more than the previous estimate – although part of that increase is because diagnosis today happens earlier and more reliably.

Women are affected considerably more often than men, in a ratio of about 2.7 to 1 [21]. The disease usually begins between the ages of 20 and 40, that is, in the middle of education, career and starting a family. That is one of the reasons it is experienced as such a deep incision: it does not come at the end of a working life but at its beginning.

2.5 What physiotherapy does here – and what it does not

So that expectations are right from the outset, three plain sentences.

Physiotherapy does not influence the inflammation. It replaces not a single drug, and nobody should stop a prescribed treatment on their own account because of a good training programme.

Physiotherapy works on the consequences. Strength, endurance, balance, walking, mobility, exhaustion, independence, quality of life – those are its target measures, and that is where the effect is documented in many studies [1].

Whether exercise beyond that slows the course of the disease itself is an open question – an exciting one, being researched intensively. It gets its own chapter further down (section 15), and the honest answer there is: not proven yet.

3. What the disease does to everyday life

From the technical terms back to the living room. What actually restricts people with MS is often not what is visible from outside.

For most, the exhaustion is the biggest problem. Around four in five of those affected know it, and many call it the most burdensome symptom of all – more burdensome than difficulty walking [5]. It has been given a name of its own because it differs from ordinary tiredness: fatigue. More on this in section 7.

Walking changes – slower, less steady, weaker, often with a foot that catches as it swings through. This is the restriction people most often describe as the most important one, and it is also the one that can be measured best.

Balance becomes unreliable. Not necessarily because the legs are weak, but because feedback from the feet and joints arrives in the brain more slowly and less precisely. The body notices too late that it is tipping.

Muscles become stiff – the technical term is spasticity. The muscle is permanently under too much tension and catches when moved quickly. About six to eight in ten of those affected know this in some form [12]. At night it is often cramp in the calves; during the day, a leg that feels as though it were being dragged along.

Sensation in the skin and limbs changes: tingling, numbness, a feeling like a band tightened around the chest, sometimes burning pain in the skin with no visible cause.

The bladder causes difficulties. Sudden urgency that can hardly be postponed, frequent trips at night, involuntary loss of urine. Up to eight in ten of those affected experience this over the course of the disease [20] – and hardly anyone raises it unprompted.

Thinking becomes slower. Not less intelligent – slower. Mainly affected are the speed of processing, attention and working memory. That explains why a busy open-plan office or a noisy restaurant can become so exhausting [16].

And then there is what nobody sees: visual disturbances, dizziness, swallowing problems, low mood, anxiety, disturbed sleep, sexual difficulties. Professionals call these the «invisible symptoms» – invisible because a person with MS can look entirely unremarkable on a station platform and still be right at their limit.

This list is not meant to frighten. It is meant to make two things clear. First: if you have one of these problems, you are not alone with it, and it is not «all in your head». Second – and this is the point here: a large part of this list can be influenced by exercise. Not all of it, but considerably more than was assumed twenty years ago.

4. The long-standing error: «take it easy»

For decades the medical advice in MS amounted to: do not exert yourself, ration your strength, avoid sport. The reasoning behind it was not stupid. It was known that exertion can temporarily worsen the complaints, and the conclusion drawn was that it might harm the disease.

Today we know: the conclusion was wrong, and the advice did harm. It set in motion a cycle that still accompanies many of those affected: less movement → less strength and fitness → everyday journeys become more exhausting → even less movement. At the end of this cycle stands a body that, on top of the disease, is also untrained – and from outside it is barely possible to tell which part of the restriction comes from where.

How long such advice echoes on is shown by a sobering observation: people with MS on average move considerably less than the rest of the population – and that has not changed in twenty-five years, although the evidence for the benefit of exercise has grown steadily denser in that time [2].

Two findings overturned the advice.

First: training is safe. The most thorough compilation to date evaluated 40 randomised trials with 1780 participants – that is, trials in which a draw decided who trained and who did not. Result: those who trained had no more relapses than the comparison groups (risk ratio 0.95) and also no more serious adverse events (1.05). For the milder adverse events – muscle soreness, temporarily increased complaints – the figure was somewhat higher, without the difference being statistically established [4].

These figures should be read carefully: they show no increased risk, not a reduced one. But that was exactly the question that stood in the way for decades. It has been answered.

Second: the temporary worsening is something other than a relapse. When the leg becomes heavier or vision blurs after training, this is as a rule not a new inflammatory lesion but a reaction to the raised body temperature. It passes as soon as the temperature falls – usually within minutes to a few hours. Why this is so is explained in the next section.

Specialists in this field today put it so sharply that exercise should no longer be understood as a pleasant accompaniment but as «medicine» that belongs prescribed early and dosed individually [17]. The evidence is not quite that far yet (see section 15) – but the direction is clear, and «take it easy» is finally off the table as general advice.

5. The heat trap

This section deliberately comes before all the training sections, because it is the most common reason why people with MS abandon a programme again.

5.1 What happens as you warm up

Between six and eight in ten people with MS react sensitively to warmth [19]. If body temperature rises – through exertion, a hot bath, a fever, a summer's day – the existing complaints temporarily worsen. Vision blurs, the leg becomes heavier, the exhaustion greater, thinking more sluggish.

There is an understandable reason for this. On a nerve fibre whose insulating layer is damaged, signal transmission is borderline anyway. Warmth further lowers the reliability of that transmission – beyond a certain point the signal no longer gets through at all [19]. The phenomenon is so old and so well described that it carries a name of its own: Uhthoff's phenomenon, after the ophthalmologist who observed it in 1890 in patients with inflammation of the optic nerve.

The decisive point: it is a loss of function, not damage. No new inflammatory lesion arises, nothing breaks, and everything returns as soon as the temperature falls again. Anyone who does not know this experiences every demanding training session as proof that exercise is harmful – and stops. Anyone who does know it plans for it.

5.2 What helps in practice

There is no large trial identifying a single cooling strategy as the best. What there is, is many small studies and a great deal of experience. The following points are the common denominator:

• Cool beforehand, not only afterwards. A cool drink before you start, cold water over the forearms, a cool room. Anyone who cools only once the complaints are there is always behind.
• Drink cold during training. This is the simplest and least demanding measure of all.
• Cooling where it works: palms, forearms, the back of the neck, the face. That is where the blood vessels through which the body gives off heat are located.
• Choose the time of day. In summer, train in the morning, not at four in the afternoon.
• Water as a training room. A pool at 27 to 29 degrees carries the heat away continuously. For people who are very heat-sensitive, hydrotherapy is therefore often the only way to train hard at all. Note: therapy pools are sometimes heated to 32 to 34 degrees – for many of those affected that is too warm.
• Train in blocks rather than in one go. Four blocks of five minutes each with breaks in between lead to less heat build-up than twenty minutes continuously – for a similar amount of work.
• Cooling vests and cuffs help some people a great deal and others hardly at all. It is worth trying such a thing out before buying it.

And a rule of thumb for the mind: if complaints appear during or immediately after exertion and disappear again within hours, it is with high probability the heat. If something appears anew, stays and builds up over days, it belongs in a medical assessment (section 22).

6. What rehabilitation demonstrably achieves

Now for the figures. The broadest overview of the whole field comes from an Australian group who, on behalf of the Cochrane Collaboration, summarised not individual studies but review articles. Cochrane is an international network that evaluates medical studies under particularly strict rules; its reviews are regarded as the most careful there are.

This work summarises 15 Cochrane reviews with 164 randomised trials and 10 396 participants in total [1]. It covers a broad field: exercise therapy, occupational therapy, cognitive and psychological methods, nutrition, vocational reintegration, telerehabilitation, treatment of spasticity and a good deal more.

The result can be summarised in three sentences [1]:

• Exercise therapy and physical activity improve mobility, muscle strength, endurance and quality of life – and they reduce exhaustion. For these statements the certainty of the evidence was moderate; in rehabilitation research that is a good value.
• Programmes involving several professions – whether inpatient or outpatient – bring longer-term improvements at the level of everyday activities and participation.
• For other methods – treatment of spasticity, whole-body vibration, telerehabilitation, neuropsychological methods – there were indications of benefit, but on a weaker basis.

Two limitations belong with this directly, and the authors name them themselves. First, many individual studies are small; groups of 20 to 40 people are the norm. Second, some of the summarised reviews were no longer up to date at the time of the evaluation. The direction of the result is robust, the precision of the individual figures less so.

A third limitation does not come from this work but applies to the whole field: most studies included people with relapsing MS and mild to moderate impairment. Anyone who is severely restricted or has a progressive course is under-represented in the figures. What that means is set out in section 16.

7. Fatigue: the exhaustion that no amount of sleep fixes

7.1 What fatigue is – and what it is not

Fatigue is the most common symptom of multiple sclerosis and for many of those affected the worst [5]. And it is the one least well understood by those around them.

The difference from normal tiredness can be pinned to four points:

• It is out of proportion to the effort. An hour of ironing can be as exhausting as moving house is for others.
• Sleep does not fix it. Being well rested and being exhausted are not mutually exclusive in MS.
• It often arrives suddenly. Many describe it as «the wall» or as «someone pulling the plug» – from one moment to the next nothing works any more.
• It affects the mind as well. Thinking, speaking and listening become just as sluggish as walking. That is why a distinction is made between physical and cognitive fatigue.

Before training against fatigue, it should be investigated – because part of what looks like MS fatigue has other, treatable causes: anaemia, an underactive thyroid, vitamin D or iron deficiency, depression, poor sleep (often because of the bladder or because of cramp at night), side effects of medication. This assessment is not a formality. It is the reason why some people gain more from a blood test than from six months of training.

7.2 Why, of all things, exertion helps against exhaustion

At first this sounds contradictory: someone who is exhausted is supposed to exert themselves. Here, though, the evidence is unusually clear.

The authoritative Cochrane review evaluated 45 trials with 2250 people [5]. In the 26 trials that compared exercise therapy with «no training», exhaustion decreased clearly in favour of those training. In technical language: a standardised mean difference of −0.53. Translated, that means a medium-sized effect – not the difference between ill and healthy, but distinctly more than measurement error. The certainty of the evidence was moderate.

Best documented were endurance training and mixed programmes of endurance and strength [5]. Across all the studies, incidentally, a single fall was reported – that too is a statement about safety.

Why it works is not fully explained. Several things are most likely involved at once: better fitness, so that the same everyday activity uses up a smaller share of the available reserve; more regular sleep; an effect on mood; and the experience of being able to influence one's own condition instead of being at its mercy.

7.3 Which kind of training achieves most

A Spanish group evaluated 58 trials using a method that can compare treatments even when they have never been tested directly against one another [6]. The result:

• Combined training – endurance and strength in the same programme – came out best for physical fatigue.
• Strength training came out best for total fatigue.

Both effects were large. That is useful information, because it contradicts a widespread assumption: many of those affected regard strength training as the thing most likely to «drain» them. According to this evaluation the opposite is closer to the truth.

Nevertheless the usual reservation: such rankings rest on indirect comparisons and are less reliable than a direct comparison. The practical translation is not «do strength training», but: a programme that contains strength is superior to a programme of walks alone.

7.4 The second route: arranging the day differently

Training is one half. The other is called energy management – a structured programme in which those affected learn to distribute their strength across the day and the week: observing and rating activities, setting priorities, planning breaks before exhaustion arrives, adapting routines and workplaces, using aids, handing tasks over.

Such programmes have been used and studied in Swiss rehabilitation for years. A study at the Valens clinic allocated 106 people with MS and fatigue by draw to two three-week programmes: energy management plus high-intensity interval training versus relaxation training plus moderate continuous endurance training [7].

The result is instructive precisely because it is not a success story. On the primary outcome – quality of life after six months – the more intensive combination was not superior. On several other measures it did better at individual time points: on fitness, on physical functioning, on anxiety, and above all on the confidence in being able to manage one's own energy [7].

Two conclusions from this. First: the quieter programme worked too – there is not one single right approach. Second: the most stable gain lay not in fitness but in confidence. In a disease that accompanies you for decades, that is not a side result.

7.5 How to start without overdoing it

The most common mistake at the start is not too little ambition but too much. A good day tempts you to catch up on everything – and costs two bad days. This roller-coaster is the most reliable way to give up a programme after six weeks.

What has proved itself:

• Start from an average day, not from your best one. The programme has to be manageable on a mediocre Wednesday.
• Shorter sessions, but more of them. Three times ten minutes is often more effective in fatigue than once thirty – and far easier to keep up.
• Judge the next morning, not the same evening. The decisive question is not «how exhausted am I now» but «how am I tomorrow morning». Anyone who is distinctly worse off 24 hours later did too much.
• Increase slowly, and only one screw at a time. Either longer or harder or more often – not all at once.
• Fixed appointments beat good intentions. A class you have signed up for, an agreed training partner, a recurring entry in the calendar.

8. Walking

8.1 What changes

After fatigue, walking is what those affected most often name as their most important restriction. Typically several things change at once: speed drops, steps become shorter and wider, endurance over longer distances decreases, and as the leg swings through a foot catches, because the muscles that lift the front of the foot are too weak or too slowly activated.

Usually several causes are at work simultaneously: weaker muscles, increased muscle tension, imprecise feedback from the feet and legs, unsteady balance – and on top of that the exhaustion, which amplifies everything. That is why a programme that works on only one of these often falls short.

8.2 Strength is the most direct route to walking speed

The obvious question is: if I make my legs stronger, will I walk faster? An evaluation of 12 randomised trials with 425 people with MS examined exactly that. Result: strength training for the legs improved walking speed by an average of 0.10 metres per second [10].

What does that mean in everyday life? Someone previously travelling at 1.00 metres per second afterwards walks at 1.10 – and covers around ten per cent more ground in the same time. A pedestrian crossing that was previously tight becomes manageable. For comparison: in rehabilitation research a change of 0.05 to 0.10 metres per second over short walking distances counts as noticeable. So the effect lies at the threshold of everyday relevance – modest, but real.

Two limitations from the same work: the results varied considerably from study to study, and the effect was larger over short test distances than over long ones [10]. Strength training therefore improves speed rather than endurance in walking. Anyone who wants both needs both.

An older compilation of 20 papers found, in people with MS, strength gains of between 4.5 and 36 per cent after strength training, and alongside those improvements in exhaustion, everyday capacity and quality of life [11]. The spread of these figures mainly shows one thing: how much comes out of it depends heavily on how seriously the training is done.

How an effective strength programme is built – sets, repetitions, progression, and why many of the disputed questions make no difference – is set out in detail in our article Strength training. The principles hold in MS as well; what is adapted is mainly the pace of progression, the length of the breaks and the room temperature.

8.3 The robot is no better than the therapist

In some clinics there is a device that guides the legs while walking on a treadmill – a kind of motorised exoskeleton, known by the name Lokomat. It looks impressive, and the question naturally arises whether more comes of it than of ordinary walking training.

This question has been well studied, and the answer is remarkably clear.

A Swiss study allocated 67 people with MS by draw either to robot training or to equally intensive walking training on the ground, both in addition to comprehensive rehabilitation. Participants were on average 56 years old and considerably restricted. Result: robot training was not superior; if anything, walking speed developed somewhat better in the group with ordinary walking training [14].

A later summary of nine randomised trials reached the same conclusion and pursued the obvious follow-up question: perhaps the robot at least benefits those who are more severely restricted? Nothing was found for that either. Neither baseline speed nor degree of disability predicted who would benefit more from the robot [13].

Disclosure: Roger Hilfiker was involved in both of these papers.

What follows from this? Not that such devices are useless. They make walking training possible for people who would otherwise not get onto their feet at all, and they relieve the staff. But they are not better training, only a different route to the same thing. For the great majority of those affected: time is better invested in guided walking, strength and balance than in the search for the right machine.

8.4 Foot drop, sticks, splints

If the foot catches as the leg swings through, there are three routes, and they do not exclude one another:

• Training whatever can still be activated – the foot lifters themselves, plus the hip and trunk, which provide the swing.
• A splint (technical term: ankle-foot orthosis) that mechanically holds the foot in position.
• Electrical stimulation, in which a small device stimulates the nerve to the foot lifters at the right moment of the step.

Which is better in an individual case depends on the cause, on the skin, on sensation and – not least – on what someone actually puts on every day.

A word about the stick and the walking frame, because it is so often hard to accept: an aid is not giving up and is no contradiction to training. It makes journeys possible that would otherwise be dropped – and journeys you actually make are themselves training. Anyone who stays at home out of pride loses twice: the distance and the strength. All that matters is that length and handling are right; a badly adjusted stick creates new problems in the shoulder and back.

9. Balance and falls

9.1 How often falls happen

The figure is higher than most people assume: in a summary of several investigations, around 56 per cent of people with MS fell at least once within three months [8]. And it is not only the severely restricted who are affected. Those who still walk freely are out and about more often – and therefore fall not less often, but sometimes more.

On top of this comes something no statistic captures: the fear of the next fall. It leads to journeys being avoided, invitations declined and activities given up – and each of these avoidances makes balance a little worse. That is why the fear belongs in the treatment and should not be brushed aside.

9.2 What balance training demonstrably changes

A Scandinavian group evaluated 18 randomised trials with 902 people, all of which consisted at least half of balance training. Included were people from barely restricted to severely limited in walking [9]. The results are encouraging and sobering at the same time:

• On tests that examine balance comprehensively, a medium effect in favour of training appeared.
• On tests of everyday mobility the effect was small, but present.
• On walking speed and stepping tests no effect appeared.

One finding of the same work is especially important for practice: the larger the training volume, the larger the effect [9]. Balance responds to quantity. Twice five minutes a week will achieve nothing.

And one more thing: balance is the ability that declines fastest when you stop. With strength it takes weeks before the loss becomes noticeable; with balance it goes faster. An eight-week course is therefore a beginning, not a conclusion.

9.3 Why the fall figures are weaker than one would hope

Now comes the uncomfortable part, and it belongs in an honest article.

That training improves balance has been shown. That it thereby leads to fewer falls is not securely established in MS. The Cochrane review on this evaluated 13 trials with 839 people. The fall rate was indeed lower in the training groups – a rate ratio of 0.68, that is, arithmetically about a third fewer falls – but the confidence interval ran from 0.43 to 1.06 and therefore also included «no difference». The certainty of the evidence was rated very low [8].

The same review did, however, find an established improvement in balance and in self-reported mobility [8]. So the picture is: the ability improves measurably; whether that results in fewer falls could not be clarified by the studies so far.

Why is that? Above all because falls are hard to study. You need many participants and a long observation period to be able to show a difference at all; the existing studies are simply too small for this question. On top of that comes a known side effect: someone who regains confidence goes out more – and someone who is out more has more opportunities to fall.

What follows practically? Not that you should stop balance training. Rather that it should not stand alone: the trip hazards in the home belong to it just as much as the lighting in the hallway, checking your eyesight, the question of medication that makes you tired or dizzy, and a look at the bladder – the night-time trip to the toilet is one of the most common fall situations of all. What is known about preventing falls in general is set out in our article Fall prevention.

9.4 Two things at once

One detail from the balance evaluation deserves attention of its own: programmes that specifically practised coping with movement and a thinking task at the same time showed the largest effect on everyday mobility in the subgroup analysis [9].

That makes sense once you know how walking works in MS. What used to run automatically now needs attention. And attention is limited. That is why gait becomes less steady as soon as someone simultaneously talks, calculates, searches or carries a tray – and why many falls happen not on the difficult forest path but mid-conversation on a flat pavement.

This is practised by deliberately coupling the two: walking and counting backwards, walking and holding a conversation, walking and carrying a glass, solving a task while standing. Always with a safeguard – a wall, a rail, a person within reach. And for tricky situations in real life the other half of the advice applies: there, deliberately do only one thing at a time. Stopping in order to answer is not a weakness but a strategy.

10. Strength

Strength training long had a bad reputation in MS – too exhausting, too risky, possibly increasing spasticity. None of that has been confirmed.

What strength training achieves in MS has already come up at several points in this article: it improves walking speed [10], it comes out best for fatigue [6], and it improves strength, everyday capacity and quality of life [11]. That makes it the component with the broadest effect – and the one most often missing.

For putting it into practice in MS, four points matter:

• The weaker side gets more. In MS the difference between left and right is often large. A programme that treats both sides equally cements the imbalance.
• Slow movements under full control rather than swinging repetitions. Where activation is imprecise, momentum is the easiest way to work around the target muscle.
• Longer breaks between sets. Two to three minutes are not dawdling in MS but the reason why the next set still succeeds cleanly.
• A cool room and a cold drink – see section 5.

Everything else – how many sets, how many repetitions, how to progress, how little actually suffices – is set out in our article Strength training.

11. Endurance

Endurance training is the best-studied component in MS – above all because it reduces fatigue [5] and because it improves fitness. The latter sounds banal but is not: better fitness means that the same everyday distance uses up a smaller share of the available strength. That is precisely where the everyday gain lies.

How much? The recommendations of the American MS Society, drawn up by an international expert group for all levels of impairment, name as a target at least 150 minutes of exercise per week and/or at least 150 minutes of lifestyle physical activity per week [3]. The two additions stated there explicitly matter: the way there should be gradual, matched to abilities, preferences and safety – and anyone who is more severely restricted should bring in a specialist early rather than waiting until nothing works any more.

On intensity, an observation from research: high intensities are feasible in MS. In a Danish study with 86 participants, fitness improved distinctly under 24 weeks of demanding endurance training – by 3.5 millilitres of oxygen per kilogram per minute, which corresponds to a clearly noticeable gain [15]. And the safety data do not argue against it [4].

«Demanding» does not mean «until you drop». A usable yardstick is the talk test: at moderate intensity you can speak in full sentences but not sing. At high intensity you can only get single words out – and this intensity belongs, if at all, in short blocks with breaks in between. For people who are very heat-sensitive, exactly this division into intervals is often the key: the same work, less heat build-up.

Which form? The one you actually do. Bicycles and exercise bikes are popular because you cannot fall while seated and the load can be dosed finely. Hydrotherapy has the advantage with heat sensitivity. Nordic walking combines endurance with balance. An arm ergometer is an option when the legs no longer deliver enough – and one that is offered too rarely.

12. Spasticity

Spasticity is an increased resting tension in the muscle that additionally catches on rapid stretch. It is not the same as strength: a spastic leg can be stiff and weak at the same time. And it is not merely a nuisance – it disturbs sleep, causes pain and makes movement uneconomical.

One important point first: a certain amount of spasticity can be useful. Some people stand and walk only because the increased tension carries the leg. If it is lowered too far – by medication or otherwise – standing can become worse. That is why the goal is not «as little tension as possible» but «as much as is useful, as little as is necessary».

A working group compiled the evidence from 29 studies covering exercise therapy, electrical stimulation, shock wave therapy, vibration and standing training [12]. The results:

• The best evidence was for exercise therapy: for guided gait training on self-perceived spasticity and for outpatient training programmes on measured muscle tone.
• The methods were safe – spasticity was not increased by training. That too answers a widespread fear.
• Positive results were also found in people with a progressive course and in those who could no longer walk [12]. That is remarkable, because these groups otherwise hardly appear in studies.
• For spasticity as a whole no firm conclusion could be drawn – the studies were too different and their reporting too imprecise.

In everyday practice a combination has proved itself: slow, long stretching of the affected muscles, daily mobility work, standing in a standing frame with more severe restriction, strength for the opposing muscles – and the removal of stimuli that fan spasticity. Because this is often overlooked: a full bladder, a sore spot, an ingrown toenail, a pinching shoe or an infection can noticeably increase the tension. If spasticity increases for no apparent reason, this search is worth making before any adjustment of the therapy.

13. Bladder and pelvic floor

Up to eight in ten people with MS develop bladder problems over the course of the disease [20]: sudden urgency, frequent urination, getting up at night, involuntary loss. It is the topic least often spoken about – and the one that most reliably prevents outings, concerts and travel.

That pelvic floor training helps here has been studied. One trial allocated 48 people with relapsing MS and urinary leakage by draw to two versions of the same twelve-week pelvic floor programme: with or without guidance by a physiotherapist [20]. Both groups lost distinctly less urine after twelve weeks than at the start. On counting the leakages alone, the groups did not differ. In the guided group, the severity of the complaints, quality of life and bladder symptoms overall improved in addition – in women as in men [20].

The translation for practice: the pelvic floor can be trained in MS too, and the practice is worth it. The guidance mainly adds something where more is at stake than the bare number of accidents. That is plausible as well: anyone who cannot feel their own pelvic floor – and sensation is often altered in MS – easily trains the wrong thing without feedback.

Part of this is what is not training but works just as well: a drinking pattern spread across the day and reduced in the evening (not: drinking less – that makes it worse); going to the toilet by plan rather than by urge; an easily reachable toilet and a lit route to it. And: recurring bladder infections belong in a medical assessment, as does the feeling of not emptying the bladder completely. Both are treatable, and both worsen the MS symptoms for as long as they persist.

14. Thinking, memory, speed

A considerable proportion of people with MS have measurable restrictions in thinking – in the Danish study described below it was 43 per cent of the participants [16]. Most often affected is processing speed – how fast information is taken in and connected. It is not knowledge that is lost, but pace. Anyone who does not know this takes themselves for inattentive or «getting old».

The obvious hope is: if endurance training is good for the brain, perhaps it also improves thinking. This hope has been properly tested – and it was not confirmed in the group as a whole.

In the same Danish study as above, 43 people completed 24 weeks of demanding endurance training while another 43 waited. On tests of processing speed, learning, memory and word finding, no difference appeared in the group as a whole. Only in the subgroup of those who had measurable restrictions at the start did a possible improvement in processing speed emerge; even that was not certain [16].

This is an important result precisely because it is uncomfortable. Endurance training is not memory training. Anyone who needs help with cognitive complaints needs other approaches: a neuropsychological assessment, targeted cognitive training, but above all strategies and adjustments – tasks one after another instead of simultaneously, a quiet environment for demanding work, notes and a calendar without a bad conscience, and putting the demanding things into the time of day when your head works best.

You should train nevertheless – just not with this reasoning.

15. Does exercise slow the disease?

This is the question everyone affected asks. It deserves an honest answer, and that answer has two halves.

There are good grounds to suspect it. In animal experiments exercise demonstrably influences the course of the disease. In humans there are associations between fitness and brain structure, and there is a series of observations pointing in the same direction. An influential review derived from this the demand that exercise in MS should in future be understood not only as treatment of symptoms but as a possible intervention in the course itself [17].

The most thorough attempt so far to test this directly has failed. In the Danish study already mentioned, it was measured in 86 people whether the loss of brain volume – a well-measurable indicator of the progression of the disease – changes through 24 weeks of demanding endurance training. It did not change (difference between the groups +0.12 per cent, not statistically meaningful) [15].

The same study did, however, find two things that make one sit up: fitness improved distinctly, and the relapse rate extrapolated to one year was zero in the training group and 0.45 in the comparison group [15]. The authors themselves stress that this was an exploratory secondary analysis – not the question the study was designed for, and based on a small number of events. As proof it will not serve. As a reason for further studies it will.

So the position in August 2026 is: that exercise makes life with MS better is established. That it slows the disease is not established – it is a well-founded hope.

And practically it makes hardly any difference. The reasons that are documented today – less exhaustion, better walking, better balance, more strength, better quality of life – are entirely sufficient on their own. Anyone hoping for more on top is not hoping unreasonably.

16. Progressive course and greater disability

This section concerns those who are worst represented in the studies – and for whom rehabilitation matters most.

The reason for the second half of that sentence was named above: in the progressive forms without active inflammation the available drugs can achieve little [18]. What remains is the preservation of function – and that is exactly the task of physiotherapy.

What changes in this situation:

• The goal shifts from «getting better» to «keeping». If a measurement is unchanged after a year of training, that is a success in a progressive disease – but you only notice it if you have measured.
• The exercises move into a different starting position. What no longer works standing works sitting; what no longer works sitting works lying down. Strength can be trained in any position, endurance with the arms, mobility with assistance.
• Preventing becomes more important than improving. Maintaining mobility so that joints do not stiffen into one position. Relieving the skin where much sitting happens. Training breathing, because a strong cough protects against pneumonia.
• Aids and home adaptations come earlier. Not when there is no other way, but while they still free up strength for other things.
• Family members are instructed – how to help with transfers without ruining your own back, and how to support without taking over what someone can still do themselves.

What matters is what does not apply: training has not become pointless. The evaluation of spasticity also found positive results in people with a progressive course and in those who could no longer walk [12]. And the international recommendations explicitly cover the whole range up to the most severe impairment; for the case that mobility is very greatly restricted, they provide for exercise to take place with the support of a trained assistant – not for it to be dropped [3].

17. Relapse, recovery, rehabilitation

A relapse is something other than a bad day. Professionals speak of one when new complaints appear or existing ones increase distinctly, this lasts at least 24 hours, and no infection and no heat explain it. The last point is why a fever or a bladder infection is treated first: a temporary worsening caused by an infection is not a relapse and needs no relapse treatment.

For training during this time a simple order has proved itself in practice:

• During an acute relapse medical treatment comes first. Training is scaled back – not cancelled. Maintain mobility, positioning, gentle movement, as much independence as possible.
• In the recovery phase, when the complaints begin to recede, you build back up. Experience shows this is the phase in which most can be regained – and the one in which physiotherapy is most often prescribed too late.
• Afterwards it is checked whether anything has been left behind, and the programme is adjusted accordingly. A relapse that leaves traces changes the goals.

On the cortisone treatment often used in relapses, one practical note: in the days afterwards it can lead to muscle weakness, disturbed sleep and mood swings. This is temporary. In that phase heavy weights and demanding balance exercises are out of place – gentle, frequent movement, on the other hand, is exactly right.

18. How much, how often, how long?

The most concrete answer comes from the international expert group that drew up the recommendations of the American MS Society [3]. Their key points:

• Target: at least 150 minutes of exercise per week and/or at least 150 minutes of lifestyle physical activity per week. The «and/or» is deliberate: even someone who does no training but moves in everyday life is doing something effective.
• Gradually towards it. Someone at twenty minutes a week starts with thirty – not with a hundred and fifty.
• Bring in a specialist early who knows about MS, in order to draw up a personal plan – not only once problems have arisen.
• All levels of impairment are meant, including those who depend on assistance.

For the individual components the following orders of magnitude have proved themselves in the studies: endurance two to three times a week, 20 to 40 minutes each (in blocks if you are heat-sensitive); strength twice a week with few but seriously loaded exercises; balance two to three times a week, but with sufficient volume – because there the quantity is demonstrably decisive [9].

And the third question, which is rarely asked: how long? There is no good study answer to that, because hardly any investigation runs longer than six to twelve months. What is known is banal and unrelenting: the effect lasts as long as the training does, and it recedes when you stop. In a disease that lasts decades, the decisive quantity is therefore not the refinement of the programme but whether you are still training in five years.

From this follows a practical recommendation that helps most people more than any selection of exercises: find something you enjoy and that carries on without physiotherapy. A group, a class, a fixed arrangement, a club. The theoretically best exercise that nobody checks on loses out to the second-best one you turn up for at half past six on Thursdays.

19. What a programme looks like

19.1 The assessment

At the beginning there is no exercise sheet but an assessment. That includes the conversation – what matters to you, what is falling away, what are you afraid of – the examination of strength, mobility, muscle tone, sensation and coordination, and a few measurements that can be repeated.

These figures are not an end in themselves. They are the only way to recognise in six months whether something has changed – or whether you merely wish it had. And in a progressive disease they are the only thing that makes «unchanged» visible as a success.

19.2 The components

A complete programme usually consists of five parts. Not every one is necessary for everybody – the selection follows from the assessment:

That sounds like a lot. It can be combined: an aqua fitness class covers endurance, strength and mobility at the same time and solves the heat problem along the way. Nordic walking covers endurance and balance. Tai chi covers balance, mobility and dual tasks. That is why group offerings in MS are not the budget version but often the wiser solution – the social side comes free, and groups are kept up longer than exercise sheets.

19.3 The home programme

For a home programme to work, three things are needed:

• Short and firmly anchored. Ten minutes coupled to an existing habit – after breakfast, after brushing your teeth – get done. Forty minutes «sometime during the day» do not.
• In the right place and at the right time. The unsteadiness happens in your hallway, not in the exercise room. And anyone who can achieve nothing in the afternoon practises in the morning.
• Written down. A sheet with few exercises, printed large, in a visible place. And a cross for each completed day – that is not surveillance, it is what makes the difference.

19.4 How to measure for yourself whether it is working

Take a few values that you can repeat at home:

• Walking speed over a measured distance – for example eight metres, at your usual pace, with a stopwatch.
• Standing up from a chair five times without using your hands, timed. The most practical strength test for the legs.
• Stand up and walk: get up from a chair, walk three metres, turn round, come back, sit down – in seconds.
• Standing on one leg with eyes open, until you put the foot down – only with something to hold on to within reach.
• A fall calendar. A cross for every fall and every near-fall.
• An exhaustion diary for two weeks, a number from 0 to 10 three times a day. It reveals patterns nobody remembers in hindsight – and it shows which activity really was the trigger.

Two notes on this. Always measure at the same time of day – otherwise you are measuring your daily form and not your training state. And measure twice at the start, on two different days. The difference between those two values is your personal range of variation; a later change is worth something only when it is distinctly larger. After that, every three months is enough.

20. For family members

Family members are in a particularly difficult position in MS, because the most important part is invisible. Four things help most, in our experience:

Believe the exhaustion. The sentence «but you look fine» is well meant and still lands badly. Fatigue cannot be seen, and it is different in the morning from in the evening. What helps is not encouragement but planning: what matters today, and what can wait?

Expect fluctuation. That someone goes hiking on Saturday and cannot manage the shopping on Tuesday is not a contradiction and not a question of willpower. It is the disease.

Do not take over what someone can still do. This is the hardest rule, because helping feels right and is faster. But every activity that is taken over is partly lost. Ask: «Shall I, or will you?» – and go by the answer.

Look after yourself. Anyone accompanying someone over years needs their own breaks, their own appointments and their own people. That is not disloyalty but the precondition for it lasting. And if you help with transfers: have it shown to you. Back pain in family members is a common and entirely avoidable collateral damage.

21. Eight widespread misunderstandings

«With MS you should take it easy.»
That was the advice for decades and it is outdated. Across 40 randomised trials with 1780 participants, those who trained had no more relapses and no more serious events than the comparison groups [4]. Taking it easy, by contrast, has a certain price: less strength, less fitness, more exhaustion.

«If I feel worse after training, it is harming me.»
Usually that is the heat. A temporary worsening with raised body temperature is a loss of function, not damage, and it disappears with the temperature [19]. The difference from a relapse lies in the timing: heat-related worsening recedes within hours; a relapse builds up over days and stays.

«Strength training increases spasticity.»
There is no evidence for that. The evaluation of 29 studies on spasticity found the methods safe and their effect rather favourable [12]. Strength training also came out best for exhaustion [6] – of all things, in the very place where many believe it does harm.

«Exercise does not really help in MS, it is just something to do.»
The Cochrane overview of 15 reviews with 164 randomised trials concludes the opposite: exercise therapy improves mobility, strength, endurance and quality of life and reduces exhaustion [1].

«Against fatigue only rest helps.»
Rest helps in the moment and changes nothing about the cause. Across 45 trials with 2250 people, exercise therapy reduced exhaustion with a medium-sized effect [5]. What helps in addition is not more rest but a better division of your energy [7].

«I need the machine from the clinic, otherwise it is no use.»
For robot training for walking this has been tested: it was not superior to ordinary walking training – not even in those more severely affected [13][14]. What you need is a plan and somebody who checks in.

«With a stick I am finished.»
The other way round. An aid lengthens the distances you actually walk – and those distances are themselves training. Anyone who stays at home out of pride loses the distance and the strength.

«If I train enough, I will slow the disease.»
That is not how it may be turned. The most thorough attempt so far to show this found no influence on the loss of brain volume [15]. There are pointers that make one curious – nothing is proven. And exercise replaces not a single MS medication.

22. When you should get in touch

Have assessed medically without delay:

• New complaints that last longer than 24 hours and are not explained by heat or an infection – the suspicion of a relapse.
• A new or sudden visual disturbance, especially with pain on moving the eye.
• Burning on passing water, cloudy or smelly urine, fever – a bladder infection worsens the MS symptoms and is readily treatable.
• The feeling of not being able to empty the bladder completely, or recurring bladder infections.
• Frequent choking, especially on liquids, or repeated pneumonia.
• A fall with injury – or several falls within a few weeks.
• Exhaustion that is new or has increased distinctly: it can have other, readily treatable causes (section 7.1).
• Persistent low mood. Depression is common in MS, is often regarded as «understandable» and is therefore not treated – although it responds well to treatment.

Raise in physiotherapy:

• You avoid routes, places or activities out of fear of falling.
• Your foot catches, you stumble more often, or you have become less steady.
• Your walking distance has shortened without your being able to say when that started.
• You do not know how much exertion is right for you – and therefore prefer not to train at all.
• You feel bad after every training session and do not know how to set it up differently.
• You have been doing the same thing for months without it having become harder.
• You have pain that nobody has looked at because «that is the MS».
• You do not know how to carry on after the last prescribed treatment.

What to expect in our practice: an assessment with measurements – walking speed, standing up, balance, strength compared side to side, exhaustion, history of falls – and from that a programme with clear goals and a plan for dealing with heat and bad days, a short home programme for in between, instruction for family members if you would like that, and repeat measurements at fixed intervals. And, because this belongs to a long illness: the consideration of how things go on without us – which group, which offering, which rhythm.

23. In summary

Multiple sclerosis is an inflammation of the insulating layer in the brain and spinal cord. Because the inflamed places lie somewhere different in every person, the disease looks different in everyone. And because the drugs act above all against the inflammation, rehabilitation is responsible for everything that comes after it – particularly in the progressive forms [18].

Exercise is safe. Across 40 randomised trials with 1780 participants, those who trained had no more relapses and no more serious events [4]. The old advice to take it easy has been refuted.

Exercise works. It improves mobility, strength, endurance and quality of life and reduces exhaustion [1][5]. Strength training additionally improves walking speed [10], balance training improves balance [9], pelvic floor training improves bladder symptoms [20].

What is not established, we say as well: that fewer falls occur [8], that thinking improves [16], that the loss of brain tissue is slowed [15]. For all three there are indications and open questions – but no proof.

What makes the difference can be said in five points:

• at least 150 minutes of movement a week, built up gradually [3];
• a programme that contains strength, not just walks [6][10];
• balance training with enough volume, not as an afterthought [9];
• a plan for the heat before it becomes a problem [19];
• and a division of your energy that survives a mediocre Wednesday [7].

And what you do not need: the expensive machine, the one right sport, a gym – or the certainty that exercise slows the disease. That certainty does not yet exist. What does exist is firm evidence that exercise makes life with the disease better.

In a disease that lasts decades, the decisive quantity is not the refinement of the programme. It is the question of whether you are still training in five years. Everything in this article – the group instead of the exercise sheet, the living room instead of the clinic, the class you enjoy instead of the theoretically best selection of exercises – serves that one question.

References

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