Multiple Sclerosis Physiotherapy.
What is multiple sclerosis?
Multiple sclerosis (MS) is a chronic, inflammatory autoimmune disease of the central nervous system in which the immune system attacks the myelin sheath — the protective coating surrounding nerve fibres — causing demyelination and, in progressive disease, axonal damage and loss. MS is an inflammatory immune-mediated disease characterised by demyelination of axons within the CNS that is frequent in young adults and commonly causes a lifelong disability.
MS is the most common neurological condition affecting young adults in Australia, with approximately 33,000 Australians living with the disease. It is significantly more common in women than men (approximately 3:1 ratio) and most commonly diagnosed between the ages of 20 and 40. The cause is not fully understood but involves a complex interaction of genetic susceptibility and environmental triggers, with vitamin D deficiency, Epstein-Barr virus exposure and geographic factors (distance from the equator) all implicated.
Types of multiple sclerosis
Understanding the MS subtype is important for rehabilitation planning as the disease course differs significantly between subtypes.
What are the symptoms of MS?
The symptom profile of MS is highly variable between individuals and across the disease course, reflecting the unpredictable location of demyelinating lesions throughout the central nervous system. Common symptoms include weakness, spasticity, fatigue, balance and coordination impairment, visual disturbances (optic neuritis), sensory disturbances including numbness, tingling and pain, bladder and bowel dysfunction, cognitive difficulties, depression and anxiety.
85% of people with MS are concerned about their gait problems, and 80% have gait problems 10 to 15 years after onset. Gait problems in MS are due to muscle weakness, spasticity, fatigue, ataxia and loss of proprioception.
Fatigue is one of the most prevalent and most disabling MS symptoms — distinct from normal tiredness, MS fatigue is a neurological phenomenon that is not reliably proportional to activity level and does not resolve with rest in the way normal fatigue does. It is one of the primary barriers to exercise participation and must be carefully managed in any rehabilitation program.
The Uhthoff phenomenon — exercise and heat sensitivity
One of the most important clinical considerations for MS exercise programming is the Uhthoff phenomenon — the temporary worsening of MS symptoms with increased body temperature. Many people with MS experience increased weakness, fatigue, vision problems and cognitive fog when their core temperature rises, whether from exercise, hot weather or a hot bath. This does not represent disease progression — it is a temporary, reversible phenomenon caused by the fact that demyelinated nerve fibres conduct poorly at higher temperatures.
The Uhthoff phenomenon does not mean people with MS should avoid exercise — it means that exercise in cool environments, with cooling strategies (cool towels, fans, cool drinks, cooling vests), and at appropriate intensity levels produces the best exercise tolerance and participation. Many people with MS who have stopped exercising because "it makes my symptoms worse" are experiencing Uhthoff and can resume with appropriate environmental management.
Why is exercise so important in MS?
Exercise is essential. Exercise is beneficial at multiple levels and has an important role in delaying negative symptoms of the disease. Ample research evidence suggests that exercise is safe and effective in symptom management and disease modification.
Approximately 78% of people with MS are not involved in regular physical activity — one of the most striking statistics in neurological rehabilitation, reflecting the combination of fatigue, symptom fear, Uhthoff concern and reduced confidence that conspire to make inactivity the default for many people with MS. This inactivity compounds the disability of the disease itself — the deconditioning that accumulates from physical inactivity produces weakness, reduced cardiovascular fitness and increased fatigue that are superimposed on the neurological impairment.
The evidence base for exercise in MS is strong and growing. Resistance training improves muscle strength and reduces fatigue. Aerobic exercise improves cardiovascular fitness, fatigue, mood and quality of life. Balance training reduces fall risk. Aquatic exercise is particularly well tolerated given its cooling properties. The question is not whether people with MS should exercise — they should — but what type, intensity and environment is most appropriate for each individual.
How can physiotherapy help?
Physiotherapy can help in improving mobility through customised exercises and strategies to enhance gait, balance and coordination; muscle spasticity management through techniques to reduce muscle stiffness; pain management using therapies like manual therapy, dry needling or TENS; functional training through tailored strategies to maintain and improve daily activities; and fatigue management through education on energy conservation techniques and developing a balanced routine.
Gait rehabilitation is the most frequently needed physiotherapy intervention in MS. Physiotherapy plays a key role in managing gait impairment in MS through progressive strengthening of the lower limb muscles, balance training, assistive device assessment, and where indicated, foot drop management with ankle-foot orthoses or functional electrical stimulation.
Spasticity management requires a combination of stretching, positioning, splinting and progressive strengthening of the spastic muscles' antagonists. Manual therapy reduces secondary soft tissue changes from prolonged spasticity. Dry needling can assist with localised spastic muscle management and associated pain.
Fatigue management is a distinctive and critical component of MS rehabilitation — pacing strategies, energy conservation techniques, activity monitoring and exercise prescription calibrated to the individual's fatigue profile are all important. The goal is not simply to reduce activity but to optimise activity distribution to avoid the fatigue peaks that most impair function.
Balance rehabilitation addresses the multifactorial balance impairment of MS — combining vestibular, proprioceptive and central contributions — through progressive balance challenges, dual-task training and falls prevention strategies. Real time ultrasound assists in retraining deep stabiliser activation where central motor pathway disruption has impaired normal neuromuscular patterns.
Clinical Pilates is well suited to MS rehabilitation — the emphasis on body awareness, core activation, controlled movement and adaptable load makes it appropriate across a wide range of MS disability levels. Equipment-based Pilates allows supported practice of movements that are too difficult in unsupported positions. The cool studio environment reduces Uhthoff concerns.
Exercise physiology contributes to the cardiovascular conditioning and progressive resistance training components of MS management. Eligible patients can access exercise physiology through a Medicare GPCCMP (previously CDMP or EPC) with GP referral. For NDIS participants, see our NDIS exercise physiology and NDIS physiotherapy pages.
MS Australia — msaustralia.org.au — provides comprehensive patient resources, peer support and research updates for people living with MS in Australia.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Multiple sclerosis (MS) is a chronic, inflammatory autoimmune disease of the central nervous system in which the immune system attacks the myelin sheath — the protective coating surrounding nerve fibres — causing demyelination and, in progressive disease, axonal damage and loss. MS is an inflammatory immune-mediated disease characterised by demyelination of axons within the CNS that is frequent in young adults and commonly causes a lifelong disability.
MS is the most common neurological condition affecting young adults in Australia, with approximately 33,000 Australians living with the disease. It is significantly more common in women than men (approximately 3:1 ratio) and most commonly diagnosed between the ages of 20 and 40. The cause is not fully understood but involves a complex interaction of genetic susceptibility and environmental triggers, with vitamin D deficiency, Epstein-Barr virus exposure and geographic factors (distance from the equator) all implicated.
Types of multiple sclerosis
Understanding the MS subtype is important for rehabilitation planning as the disease course differs significantly between subtypes.
- Relapsing-remitting MS (RRMS) — the most common form of the disease — is characterised by discrete episodes of neurological deterioration (relapses) followed by periods of partial or complete recovery (remissions). Between relapses, the disease does not progress. RRMS accounts for approximately 85% of MS diagnoses and is the form most responsive to disease-modifying therapies.
- Secondary progressive MS (SPMS) develops in many people with RRMS after 10 to 20 years, where the relapsing-remitting pattern gives way to steady neurological progression with or without superimposed relapses.
- Primary progressive MS (PPMS) — affecting approximately 10 to 15% of people with MS — involves steady neurological deterioration from onset without discrete relapses. It typically presents at an older age and has historically been less responsive to disease-modifying therapies, though ocrelizumab has shown meaningful benefit.
What are the symptoms of MS?
The symptom profile of MS is highly variable between individuals and across the disease course, reflecting the unpredictable location of demyelinating lesions throughout the central nervous system. Common symptoms include weakness, spasticity, fatigue, balance and coordination impairment, visual disturbances (optic neuritis), sensory disturbances including numbness, tingling and pain, bladder and bowel dysfunction, cognitive difficulties, depression and anxiety.
85% of people with MS are concerned about their gait problems, and 80% have gait problems 10 to 15 years after onset. Gait problems in MS are due to muscle weakness, spasticity, fatigue, ataxia and loss of proprioception.
Fatigue is one of the most prevalent and most disabling MS symptoms — distinct from normal tiredness, MS fatigue is a neurological phenomenon that is not reliably proportional to activity level and does not resolve with rest in the way normal fatigue does. It is one of the primary barriers to exercise participation and must be carefully managed in any rehabilitation program.
The Uhthoff phenomenon — exercise and heat sensitivity
One of the most important clinical considerations for MS exercise programming is the Uhthoff phenomenon — the temporary worsening of MS symptoms with increased body temperature. Many people with MS experience increased weakness, fatigue, vision problems and cognitive fog when their core temperature rises, whether from exercise, hot weather or a hot bath. This does not represent disease progression — it is a temporary, reversible phenomenon caused by the fact that demyelinated nerve fibres conduct poorly at higher temperatures.
The Uhthoff phenomenon does not mean people with MS should avoid exercise — it means that exercise in cool environments, with cooling strategies (cool towels, fans, cool drinks, cooling vests), and at appropriate intensity levels produces the best exercise tolerance and participation. Many people with MS who have stopped exercising because "it makes my symptoms worse" are experiencing Uhthoff and can resume with appropriate environmental management.
Why is exercise so important in MS?
Exercise is essential. Exercise is beneficial at multiple levels and has an important role in delaying negative symptoms of the disease. Ample research evidence suggests that exercise is safe and effective in symptom management and disease modification.
Approximately 78% of people with MS are not involved in regular physical activity — one of the most striking statistics in neurological rehabilitation, reflecting the combination of fatigue, symptom fear, Uhthoff concern and reduced confidence that conspire to make inactivity the default for many people with MS. This inactivity compounds the disability of the disease itself — the deconditioning that accumulates from physical inactivity produces weakness, reduced cardiovascular fitness and increased fatigue that are superimposed on the neurological impairment.
The evidence base for exercise in MS is strong and growing. Resistance training improves muscle strength and reduces fatigue. Aerobic exercise improves cardiovascular fitness, fatigue, mood and quality of life. Balance training reduces fall risk. Aquatic exercise is particularly well tolerated given its cooling properties. The question is not whether people with MS should exercise — they should — but what type, intensity and environment is most appropriate for each individual.
How can physiotherapy help?
Physiotherapy can help in improving mobility through customised exercises and strategies to enhance gait, balance and coordination; muscle spasticity management through techniques to reduce muscle stiffness; pain management using therapies like manual therapy, dry needling or TENS; functional training through tailored strategies to maintain and improve daily activities; and fatigue management through education on energy conservation techniques and developing a balanced routine.
Gait rehabilitation is the most frequently needed physiotherapy intervention in MS. Physiotherapy plays a key role in managing gait impairment in MS through progressive strengthening of the lower limb muscles, balance training, assistive device assessment, and where indicated, foot drop management with ankle-foot orthoses or functional electrical stimulation.
Spasticity management requires a combination of stretching, positioning, splinting and progressive strengthening of the spastic muscles' antagonists. Manual therapy reduces secondary soft tissue changes from prolonged spasticity. Dry needling can assist with localised spastic muscle management and associated pain.
Fatigue management is a distinctive and critical component of MS rehabilitation — pacing strategies, energy conservation techniques, activity monitoring and exercise prescription calibrated to the individual's fatigue profile are all important. The goal is not simply to reduce activity but to optimise activity distribution to avoid the fatigue peaks that most impair function.
Balance rehabilitation addresses the multifactorial balance impairment of MS — combining vestibular, proprioceptive and central contributions — through progressive balance challenges, dual-task training and falls prevention strategies. Real time ultrasound assists in retraining deep stabiliser activation where central motor pathway disruption has impaired normal neuromuscular patterns.
Clinical Pilates is well suited to MS rehabilitation — the emphasis on body awareness, core activation, controlled movement and adaptable load makes it appropriate across a wide range of MS disability levels. Equipment-based Pilates allows supported practice of movements that are too difficult in unsupported positions. The cool studio environment reduces Uhthoff concerns.
Exercise physiology contributes to the cardiovascular conditioning and progressive resistance training components of MS management. Eligible patients can access exercise physiology through a Medicare GPCCMP (previously CDMP or EPC) with GP referral. For NDIS participants, see our NDIS exercise physiology and NDIS physiotherapy pages.
MS Australia — msaustralia.org.au — provides comprehensive patient resources, peer support and research updates for people living with MS in Australia.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
