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

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.

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.

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 ).

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.