Consultative, Proactive Physical Therapy in Early Multiple Sclerosis

Scientific evidence and expert opinions support the safety of exercise and suggest that it may be the single most effective nonpharmacological symptomatic treatment for people with multiple sclerosis (MS).^1–6  Physical activity and exercise are associated with improved physical function, walking ability, fatigue, muscular strength and endurance, and quality of life in people with MS.^7–9  Exercise guidelines established for people with MS recommend 2 to 3 days weekly of aerobic exercise for 10 to 30 minutes at a moderate intensity.^10–12  Advanced aerobic exercise recommendations include up to 5 days per week and up to 40 minutes at a moderate to high intensity.^10,11  Resistance training is recommended 2 to 3 days per week; the suggested regimen is 1 to 3 sets of 8 to 15 repetitions of 5 to 10 exercises.^10–12 

Despite strong evidence supporting the benefits and safety of physical activity and exercise participation, people with MS often do not engage in sufficient levels of physical activity to achieve health benefits.¹³  They report barriers to exercise such as a lack of knowledge of the benefits of exercise, lack of time or motivation, increased fatigue at rest and with exercise, low exercise self-efficacy, financial constraints, and a lack of access to fitness resources.^14,15  Physical therapy (PT) may play an important role in facilitating increased physical activity and exercise for people with MS through education on its benefits, helping to initiate or modify an individualized exercise routine, setting exercise goals, and providing resources for local fitness options.^16,17 

The Academy of Neurologic Physical Therapy's Health Promotion and Wellness Task Force proposed a model for PT for people with chronic neurologic conditions, including people with MS, to optimize their exercise routine.¹⁸  This task force emphasizes the importance of changing the current PT model of care from a reactive system where patients are seen after deficits and disabilities have manifested to a proactive system where PT is used to prevent or reduce the negative impact of ongoing illness and to improve function and quality of life as soon as possible to slow functional decline.¹⁹  This proactive PT (PAPT) model utilizes a relatively low number of PT sessions, making it a more approachable and sustainable option for care. Evidence is emerging on the benefits of PAPT specifically for people with MS who are in the early stages of the disease course.²⁰  This program applies diagnosis-specific exercise guidelines within a PT program to bridge the knowledge-to-practice gap and implement research in clinical practice. Using the CARE Case Report Guidelines,²¹  this case series examines the effect of PAPT on 4 people with MS.

We expanded upon an existing PAPT model described in Parkinson disease.^22,23  Briefly, patients are referred to PAPT directly following a diagnosis of MS before symptoms substantially impact mobility. This model is conceptualized as low-dose PT with 1 to 4 sessions within the span of 6 to 12 months.¹⁸ 

Patients signed an informed consent and Health Insurance Portability and Accountability Act privacy document before participation in the case series. Patients attended a 90-minute evaluation, including a full clinical evaluation and an individually tailored goal setting and exercise prescription.²³  At the evaluation, functional strength was measured with the 5 Times Sit-to-Stand Test (5xSTS),²⁴  the 10-Meter Walk Test (10MWT), and a self-selected velocity (SSV) and a fast velocity (FV) test; functional exercise capacity was measured by the 6-Minute Walk Test (6MWT)²⁵ ; dynamic balance was measured with the Functional Gait Assessment (FGA)²⁶ ; higher level mobility was measured with the High-Level Mobility Assessment Tool (HiMAT)²⁷ ; and self-reported fatigue was measured with the Fatigue Severity Scale (FSS).²⁸ 

The 30-minute intervention portion of the evaluation consisted of education and promotion of regular exercise to meet physical activity guidelines for people with MS, including written or electronic handouts with individualized prescriptions for aerobic exercise, resistance training, balance training, and flexibility.^10–12,29  Adherence to the exercise program and long-term exercise engagement were facilitated through a shared decision-making process.³⁰  Barriers to exercise were identified and addressed with education and exercise training. Common MS symptoms that may impact engagement in exercise (eg, fatigue, heat sensitivity) were discussed as needed. To conclude the initial evaluation, a 1-month follow-up email, a 3-month phone call, and a 6-month in-person visit were scheduled.

The 1-month email exchange and 3-month phone call (5-10 minutes long) included updates on current exercise and physical activity, current MS symptoms, barriers to exercise, updated exercise prescription, and quality improvement questions. The 6-month follow-up visit mimicked the initial evaluation, and patients were discharged with a plan to follow up for an evaluation and to review exercise behaviors and goals every 6 to 12 months.

Four patients (P₁, P₂, P₃, P₄) were referred to PAPT, 3 by their neurologist during a standard clinic appointment and 1 by their neurologist for restorative PT. This patient completed restorative PT 2 times per week for 4 weeks and then transitioned to the PAPT model of care due to their recent diagnosis of MS, functional status, and exercise goals. All 4 patients were on disease-modifying therapy and had initial Expanded Disability Status Scale scores of 3.5 or less. TABLE 1 includes patient background information, reported MS symptoms, and reported barriers to exercise.

P₁, P₂, and P₃ received a follow-up email 1 month after evaluation. P₁ reported that he returned to aerobic exercise, 60 to 90 minutes per week on average at a moderate intensity, and continued his regular stretching program of 100 minutes per week. The physical therapist's prescription was for him to increase the frequency and duration of aerobic exercise to achieve 90 to 150 minutes per week at a moderate intensity. P₂ reported regular aerobic exercise for 60 minutes per week at moderate intensity and continued her stretching program of 100 minutes per week. The physical therapist's prescription was for her to increase the frequency and duration of aerobic exercise to achieve 120 minutes per week at a moderate intensity and begin strength training 2 times per week and balance training 1 time per week. P₃ reported no exercise because she was experiencing increased pain and severe fatigue and was awaiting an appointment with her neurologist for an MRI. A plan was made to check in with P₃ at 3 months, unless she needed follow-up sooner. P₄ was participating in restorative PT at this time.

All patients completed a phone call check-in at 3 months. P₁ reported that he achieved regular aerobic exercise for 150 minutes per week at moderate intensity and continued with his stretching program for 100 minutes per week. The physical therapist's prescription was to add regular strength training 2 times per week. P₂ reported performing aerobic exercise 90 to 120 minutes per week at moderate intensity, beginning strength training 2 times per week, yoga 20 minutes per week, and the stretching program for 100 minutes per week. The physical therapist's prescription was to increase the frequency of aerobic exercise to achieve 150 minutes per week. P₃ reported that she was starting to work with a trainer at her gym and performing aerobic exercise 45 to 60 minutes per week at moderate intensity and strength training 2 times per week. P₄ reported consistently completing a daily walking routine and strength and balance exercises several times per week. She estimated a total of 240 minutes per week of dedicated exercise. In this communication, patients reported appreciation of exercise education, increased motivation to exercise, and increased confidence with choosing exercise.

P₁ remained stable in all outcome measures at the 6-month follow-up. He reported no issues with heat sensitivity and exercise and no longer identified this as a barrier to participation. He noted occasional tingling in his legs with long-distance or high-intensity ambulation but indicated this was not a barrier to exercise. He reported increasing his aerobic exercise time from 30 minutes per week to 200 minutes per week at moderate intensity, maintaining his stretching program at 100 minutes per week, and beginning a strengthening program 2 times per week.

Both P₂ and P₃ achieved significant functional gains in gait and functional mobility. P₂ increased her fast walking speed by 0.15 meters per second and walking endurance on the 6MWT by 68 meters, both meaningful changes.³¹  Her HiMAT score increased by 15 points. P₃ increased her self-selected walking speed by 0.25 meters per second and her fast walking speed by 0.14 meters per second, both meaningful changes.³¹  Her HiMAT score increased by 10 points. Her score on the FSS decreased from 52 to 9, indicating a significant decrease in fatigue. Both P₂ and P₃ reported being able to complete a regular exercise routine and were meeting or exceeding guidelines for all domains of prescribed exercise (TABLE 2 and TABLE S1).

P₄ was unable to participate in the 6-month follow-up because of complications with her pregnancy. She was discharged from the program via a phone call follow-up after canceling her 6-month visit.

P₁, P₂, and P₃ were discharged after the 6-month visit with a plan to follow up regularly with the physical therapist every 6 to 12 months to evaluate outcomes and review exercise goals. All patients reported success with insurance coverage for PAPT care. All patient outcomes are provided in Table 2, and patient-reported exercise and exercise prescriptions at each time point are provided in Table S1.

This case series supports the feasibility of using PAPT to increase exercise participation and improve functional and patient-reported outcomes for people with MS. PAPT includes aspects of secondary prevention by initiating treatment early in the disease course before the onset of significant symptoms rather than the typical tertiary prevention focused on restoring lost function.¹⁸  Appropriate exercise early after diagnosis with MS has been potentially identified as one of the most promising, possibly disease-modifying treatment strategies.^1,32  When performed appropriately, exercise can significantly improve cardiorespiratory fitness, muscle strength, flexibility, fatigue, cognition, and quality of life in people with MS.³⁰  Although MS progression can be extremely variable, we chose a 6-month follow-up based on the model proposed by Ellis et al who studied PAPT for people with Parkinson disease.³³ 

The 3 patients who completed the PAPT program had excellent maintenance or improvement of their physical function with minimal PT visits in conjunction with their independent engagement in exercise. Using an individually tailored approach rather than a protocolized one, an exercise prescription was provided at each time point to encourage each individual to meet the general or advanced exercise recommendations.³⁴  All 4 patients increased their exercise participation and achieved the recommended levels of exercise. P₄ highlights how this consultative model of care can be applied at many stages of the disease as long as impairment levels are mild.

Although our case series addresses and applies a consultative, proactive model of PT delivery to individuals newly diagnosed with MS, limitations should be considered. Limitations include a small, homogeneous sample of individuals with a history of exercise and good insurer-sponsored health care, long-term follow-up limited to 6 months, and a retention rate of 75%. If patients had limited experience with exercise prior to PAPT or poor insurance coverage, the program may have been less successful. The clinical case series format means that our data sources were limited by clinical notes and we did not have qualitative interviews or objective physical activity data from wearable activity trackers. Future research should include an appropriately powered randomized controlled trial to establish the effectiveness of PAPT in increasing physical activity in inactive people with MS as well as maintenance and/or improvement of functional status. Further research on the sustainability of PAPT for long-term adherence with guidelines and its effect on disease and symptom severity are needed (ie, ≥ 1-year follow-up). Additionally, the facilitators and barriers to implementing PAPT in different clinical settings and identifying implementation strategies for optimizing PAPT implementation should be investigated.

Physical therapists play a pivotal role in promoting physical activity and exercise across the life span, especially for individuals with neurologic conditions such as MS. Individuals living with MS can benefit greatly from interactions with knowledgeable and experienced clinicians. We initiated a PAPT model for patients newly diagnosed with MS and saw success with functional activity monitoring and education. This program has been successfully utilized in persons with Parkinson disease,²³  and we believe it needs to be standardized for people with MS as well. This case series demonstrates how the program implements evidence-based practices in an outpatient clinical setting and can improve functional mobility, health, and wellness for people with MS. More research is needed with larger and more diverse sample sizes, long-term follow-up, and ways to address other patient accessibility and health literacy barriers.

The authors gratefully acknowledge the participants in this case series.