Multiple Sclerosis and the Role of Physiotherapy

Multiple sclerosis (MS) is a complex neurological condition that can affect movement, strength, balance, coordination, sensation, vision, cognition and energy levels. Because symptoms can vary significantly from one person to another, rehabilitation needs to be individualised, flexible and regularly reviewed.

Physiotherapy plays an important role in helping people with MS maintain physical function, manage symptoms and remain as active and independent as possible.

Importantly, physiotherapy does not cure MS or stop the underlying disease process. Instead, it focuses on managing the physical consequences of MS and helping people achieve meaningful functional goals.

Research supports this approach. A Cochrane overview of 15 systematic reviews involving more than 10,000 people with MS found that exercise and physical activity programmes can improve functional outcomes such as mobility and muscle strength, reduce some impairments such as fatigue, and improve quality of life. (Cochrane)

What Is Multiple Sclerosis?

Multiple sclerosis is a condition affecting the central nervous system, which consists of the brain and spinal cord.

In MS, the immune system attacks components of the nervous system, including the protective myelin surrounding nerve fibres. This can interfere with the transmission of nerve signals.

The effects can vary considerably between individuals.

Some people may experience relatively mild symptoms, while others can develop significant difficulties with mobility and daily activities.

Common symptoms can include:

• Muscle weakness

• Fatigue

• Balance problems

• Difficulty walking

• Muscle stiffness or spasticity

• Changes in sensation

• Poor coordination

• Visual problems

• Tremor

• Pain

• Reduced endurance

• Difficulty with transfers and everyday activities

Because MS affects people differently, there is no single physiotherapy programme that is suitable for everyone.

What Is the Role of Physiotherapy in MS? 

The primary role of physiotherapy is to help people with MS maintain or improve their physical function and independence. 

Treatment may focus on:

• Strength

• Balance

• Walking

• Mobility

• Cardiovascular fitness

• Fatigue management

• Flexibility

• Coordination

• Transfers

• Falls prevention

• Exercise prescription

• Mobility equipment

• Functional independence

A physiotherapist may also work closely with neurologists, occupational therapists, speech and language therapists, psychologists, nurses and other healthcare professionals.

This multidisciplinary approach is particularly important when MS symptoms affect several aspects of a person’s daily life.

1. Physiotherapy Can Help Improve Strength

Muscle weakness is common in MS and can make everyday activities more difficult.

Simple tasks such as:

• Getting out of a chair

• Climbing stairs

• Walking

• Carrying shopping

• Getting in and out of bed

may become increasingly challenging.

Strength training can help maintain or improve muscle capacity.

A systematic review and meta-analysis published in 2024 included 40 studies involving more than 2,100 participants and found that exercise significantly improved balance, walking ability, walking endurance, fatigue and quality of life in people with MS (2024). (PubMed)

Resistance exercise was particularly effective for improving fatigue in the subgroup analyses.

This supports the use of appropriately prescribed strengthening exercises as part of MS rehabilitation.

2. Physiotherapy Can Improve Balance

Balance problems can be caused by several factors in MS, including:

• Muscle weakness

• Sensory changes

• Visual problems

• Fatigue

• Reduced coordination

• Changes in postural control

Poor balance can increase the risk of falls and may lead people to become less active because they are afraid of falling.

Physiotherapy can incorporate exercises specifically designed to challenge balance and postural control.

A systematic review and dose-response meta-analysis found Level I evidence that balance rehabilitation can improve mobility and balance in people with MS. The authors also found that task-oriented approaches appeared particularly useful for mobility and balance rehabilitation (Corrini et al., 2023). (ScienceDirect)

Exercises might include:

• Standing balance activities

• Weight shifting

• Reaching exercises

• Stepping exercises

• Turning

• Walking over different surfaces

• Functional balance tasks

The exercises should be appropriately challenging while maintaining safety.

3. Physiotherapy Can Help With Walking

Walking difficulties are common in MS.

Someone may experience:

• Reduced walking speed

• Shorter steps

• Poor foot clearance

• Difficulty turning

• Reduced endurance

• Balance problems

• Leg weakness

• Foot drop

• Increased fatigue when walking

Physiotherapy can assess how someone walks and identify factors that may be contributing to mobility difficulties.

Treatment could include:

Strength training → balance exercises → gait training → functional practice

The physiotherapist may also recommend mobility aids where appropriate.

Importantly, using a walking aid isn’t necessarily a sign that someone has “failed” rehabilitation.

A correctly selected aid can improve safety, confidence and independence.

4. Exercise Can Help Manage MS-Related Fatigue

Fatigue is one of the most commonly reported and disabling symptoms of MS.

It can be very different from ordinary tiredness.

A person may feel exhausted after relatively small amounts of physical or mental activity.

This can create a difficult cycle:

Fatigue → less activity → reduced fitness → greater effort required for activity → more fatigue

Appropriately prescribed exercise can help break this cycle.

A 2024 systematic review and meta-analysis found significant improvements in fatigue among people with MS following exercise interventions, with resistance exercise and aerobic exercise showing particularly useful effects in subgroup analyses (2024). (PubMed)

More recent review-level evidence also supports structured exercise for reducing self-reported fatigue, with cardiorespiratory exercise showing particularly consistent evidence, although there remains substantial variation between studies and exercise programmes. (ScienceDirect)

Does Exercise Make MS Fatigue Worse?

This is an important question.

People with MS may worry that exercise will simply make their fatigue worse.

Exercise can certainly be tiring, particularly if the intensity or duration is inappropriate.

But this doesn’t mean that people with MS should avoid exercise.

Instead, physiotherapy can help determine:

• How much exercise is appropriate

• How often to exercise

• When to rest

• How to monitor fatigue

• How to gradually increase activity

• Which exercises are most suitable

The aim is to find the right balance between challenge and recovery.

5. Physiotherapy Can Improve Cardiovascular Fitness

Reduced physical activity can lead to deconditioning.

Over time, this can make everyday activities feel more demanding.

Aerobic exercise — such as:

• Walking

• Cycling

• Swimming

• Recumbent cycling

• Cross-training

may help improve cardiovascular fitness.

Research suggests that aerobic exercise can also contribute to improvements in quality of life in people with MS. In the 2024 meta-analysis mentioned earlier, aerobic exercise was particularly effective for improving quality of life in subgroup analyses. (PubMed)

The appropriate exercise should depend on the person’s mobility, fitness, symptoms and overall health.

6. Physiotherapy Can Help With Muscle Stiffness and Spasticity

Some people with MS experience spasticity, which can cause muscles to feel tight, stiff or difficult to control.

Spasticity can affect:

• Walking

• Transfers

• Sleep

• Personal care

• Positioning

• Comfort

Physiotherapy may incorporate:

• Positioning strategies

• Stretching

• Strengthening

• Functional movement

• Weight-bearing activities

• Mobility training

In some cases, physiotherapy may form part of a broader medical approach to spasticity management.

It’s important to recognise that spasticity management should be individualised because reducing muscle tone isn’t always the only goal. For some people, a certain amount of muscle tone may actually help them stand or transfer.

7. Physiotherapy Can Help Prevent Deconditioning

When movement becomes difficult, it’s understandable to become less active.

However, prolonged inactivity can lead to:

• Muscle weakness

• Reduced cardiovascular fitness

• Reduced mobility

• Loss of confidence

• Increased dependence on others

This can make MS-related disability more difficult to manage.

Physiotherapy can help people remain active within their abilities.

The goal isn’t necessarily to exercise at a high intensity.

It may simply be to maintain the highest possible level of physical activity safely and consistently.

8. Physiotherapy Can Help With Falls Prevention

Falls can have a significant impact on people with MS.

A fall may cause injury, but it can also lead to fear of falling.

That fear can result in reduced activity.

Physiotherapists can assess factors contributing to falls, including:

• Balance

• Strength

• Walking pattern

• Footwear

• Mobility aids

• Environmental hazards

• Fatigue

• Transfers

A rehabilitation programme may then incorporate balance and functional exercises.

A 2024 systematic review of circuit-based rehabilitation found improvements in balance and fatigue in people with MS, although the researchers highlighted limitations in the available evidence and the need for higher-quality studies. (PubMed)

9. Physiotherapy Can Help Maintain Independence

Perhaps one of the most important goals of MS rehabilitation is independence.

Physiotherapy isn’t just about improving clinical measurements.

It’s about helping people do the things that matter to them.

For example:

“I want to be able to walk around the supermarket.”

“I want to get up from the floor independently.”

“I want to play with my children.”

“I want to continue working.”

“I want to walk my dog.”

These goals can be incorporated into rehabilitation.

A Cochrane overview found moderate-quality evidence that physical therapy and exercise can improve functional outcomes such as mobility and muscle strength, while multidisciplinary rehabilitation can produce longer-term improvements in activity and participation. (Cochrane)

10. Physiotherapy for Progressive MS

Physiotherapy can also play an important role for people with progressive forms of MS.

A systematic review specifically examining physiotherapy rehabilitation in progressive MS identified studies involving exercise therapy, multidisciplinary rehabilitation, functional electrical stimulation, inspiratory muscle training, therapeutic standing and body-weight-supported treadmill training, among other approaches (Khan et al., 2015). (PubMed)

Progressive MS can present different rehabilitation challenges.

The focus may shift towards:

• Maintaining current abilities

• Preventing secondary complications

• Preserving mobility

• Managing fatigue

• Improving transfers

• Maintaining strength

• Supporting independence

• Recommending appropriate equipment

• Helping carers

The goal isn’t always to achieve dramatic improvements.

Sometimes maintaining function is a successful rehabilitation outcome.

What Might a Physiotherapy Assessment for MS Include?

Your first appointment may involve an assessment of:

Strength

The physiotherapist may assess muscle strength in your arms and legs.

Balance

This may involve standing, reaching, stepping or walking tasks.

Walking

They may assess walking speed, distance, foot clearance and use of mobility aids.

Mobility

This may include looking at how easily you get in and out of a chair or bed.

Fatigue

The physiotherapist may discuss how fatigue affects your day.

Functional activities

They may ask about activities that are difficult at home, work or in the community.

Goals

Most importantly, they should ask:

“What do you want to be able to do?”

Physiotherapy Should Be Individualised

There is no universal MS exercise programme.

Two people with MS can have completely different symptoms.

For example:

Person A

May have mild weakness but significant fatigue.

Their programme might emphasise energy management, aerobic exercise and strength training.

Person B

May have significant balance difficulties.

Their programme might focus on balance, gait training and falls prevention.

Person C

May have progressive mobility difficulties.

Their rehabilitation may focus on maintaining transfers, mobility, strength and independence.

This is why individual assessment is so important.

Can High-Intensity Exercise Be Safe?

Exercise intensity should be individualised.

Research suggests that higher-intensity training can be feasible for some people with MS.

A systematic review examining high-intensity training found evidence that aerobic, resistance and functional high-intensity training can be safe in people with MS and investigated effects on outcomes including walking, balance and mobility (Kasser et al., 2023). (PubMed)

However, high intensity does not automatically mean better rehabilitation.

The appropriate intensity depends on:

• Your symptoms

• Fitness level

• Disease characteristics

• Mobility

• Fatigue

• Heat sensitivity

• Cardiovascular health

• Goals

A qualified healthcare professional can help determine an appropriate starting point.

What About Heat Sensitivity?

Some people with MS experience worsening of symptoms when their body temperature increases.

This is sometimes called Uhthoff’s phenomenon.

Symptoms can temporarily worsen with:

• Hot weather

• Hot baths

• Exercise

• Fever

This doesn’t necessarily mean that exercise is harmful.

Instead, strategies may include:

• Exercising in a cool environment

• Taking regular breaks

• Using cooling strategies

• Avoiding particularly hot conditions

• Monitoring symptoms

Your physiotherapist can help adapt exercise to your individual tolerance.

How Often Should Someone With MS See a Physiotherapist?

There isn’t one correct answer.

Some people may benefit from regular sessions during a period of changing symptoms or rehabilitation.

Others may need periodic reviews and an independent exercise programme.

The appropriate frequency depends on:

• Disease progression

• Current symptoms

• Functional goals

• Exercise confidence

• Mobility

• Falls risk

• Fatigue

• Access to equipment

• Home environment

The aim should be to provide the right amount of support, rather than automatically scheduling long-term weekly appointments.

Physiotherapy Is Not Just About Exercise

Exercise is a major component of physiotherapy for MS, but it isn’t the whole picture.

A physiotherapist may also provide:

Education

Helping you understand how to manage movement and activity.

Mobility advice

Including appropriate walking aids where necessary.

Falls prevention

Identifying and addressing factors that increase risk.

Energy management

Helping you balance activity and recovery.

Positioning

Particularly when mobility becomes significantly restricted.

Equipment advice

Helping you use appropriate equipment safely.

Functional training

Practising activities that are important in everyday life.

Does Physiotherapy Slow the Progression of MS?

This is an important distinction.

Physiotherapy does not currently cure MS or reliably prevent the underlying disease from progressing.

Its purpose is rehabilitation and symptom management.

However, maintaining strength, cardiovascular fitness, mobility and independence can have significant benefits for quality of life.

Research supports exercise and rehabilitation for improving physical function and participation, even though this should not be confused with modifying the underlying disease process. (Cochrane)

What Does the Research Tell Us Overall?

The evidence base has grown considerably.

A Cochrane overview found moderate-quality evidence supporting exercise and physical activity for improving mobility, muscle strength and aerobic capacity, with benefits also seen in quality of life in some rehabilitation programmes. (Cochrane)

More recent evidence strengthens the case.

A 2024 systematic review and meta-analysis of 40 studies found that exercise improved:

• Balance

• Walking ability

• Walking endurance

• Fatigue

• Quality of life

in people with MS. (PubMed)

Meanwhile, a 2023 systematic review found strong evidence supporting balance rehabilitation for improving mobility and balance. (PubMed)

However, researchers continue to highlight limitations such as differences in exercise programmes, participant characteristics, treatment intensity and study quality.

Therefore, research supports exercise and rehabilitation, but it does not mean that one specific exercise programme is suitable for everyone.

When Should Someone With MS Consider Physiotherapy?

Physiotherapy may be particularly useful if MS is affecting:

• Walking

• Balance

• Strength

• Exercise tolerance

• Fatigue

• Transfers

• Coordination

• Mobility

• Confidence

• Independence

• Participation in work or leisure activities

You don’t necessarily need to wait until your symptoms become severe.

Regular assessment can help identify changes in physical function and provide strategies to maintain independence.

Final Thoughts

Multiple sclerosis can affect the body in unpredictable ways, but being diagnosed with MS doesn’t mean that you should stop moving.

In fact, appropriately prescribed physical activity and rehabilitation can play an important role in maintaining physical function and quality of life.

Research supports exercise for improving balance, walking ability, endurance, fatigue and quality of life in people with MS (2024). (PubMed)

Physiotherapy can help turn this evidence into an individualised and achievable rehabilitation programme.

The goal isn’t necessarily to do the hardest exercise possible.

It’s to find the right type and amount of activity for your current abilities, gradually build capacity where possible, manage symptoms and help you remain as independent as possible.

For someone living with MS, successful physiotherapy might mean:

walking further, feeling steadier, managing fatigue better, maintaining strength, reducing falls, or simply continuing to do the activities that matter most to them.

And sometimes, in a progressive condition, maintaining the abilities you have is itself a significant rehabilitation success.

References:

Amatya, B., Khan, F., & Galea, M. P. (2019). Rehabilitation for people with multiple sclerosis: An overview of Cochrane Reviews. Cochrane Database of Systematic Reviews, 2019(1), CD012732. https://doi.org/10.1002/14651858.CD012732.pub2. (Cochrane)

Corrini, C., Gervasoni, E., Perini, G., Cosentino, C., Putzolu, M., Montesano, A., Pelosin, E., Prosperini, L., & Cattaneo, D. (2023). Mobility and balance rehabilitation in multiple sclerosis: A systematic review and dose-response meta-analysis. Multiple Sclerosis and Related Disorders, 69, 104424. https://doi.org/10.1016/j.msard.2022.104424. (PubMed)

Kasser, S. L., et al. (2023). High intensity exercise training on functional outcomes in persons with multiple sclerosis: A systematic review. Multiple Sclerosis and Related Disorders, 74, 104748. https://doi.org/10.1016/j.msard.2023.104748. (PubMed)

Khan, F., Amatya, B., Galea, M. P., Gonzenbach, R., & Kesselring, J. (2015). Rehabilitation for people with progressive multiple sclerosis: A systematic review. Multiple Sclerosis, 21(5), 593–602. (PubMed)

Rietberg, M. B., Brooks, D., Uitdehaag, B. M. J., & Kwakkel, G. (2005). Exercise therapy for multiple sclerosis. Cochrane Database of Systematic Reviews, 2005(1), CD003980. https://doi.org/10.1002/14651858.CD003980.pub2. (Cochrane)

Sedaghati, P., Alghosi, M., & Hosseini, F. (2023). The effect of fatigue on postural control in individuals with multiple sclerosis: A systematic review. BMC Neurology, 23, 409. https://doi.org/10.1186/s12883-023-03464-4. (Springer)

Effects of exercise in people with multiple sclerosis: A systematic review and meta-analysis. (2024). [Journal article indexed in PubMed/PMC]. The review included 40 studies and 2,127 participants and examined balance, walking, endurance, fatigue and quality of life. (PubMed)

Exploring the effectiveness of circuit training rehabilitation on balance, gait, and fatigue in multiple sclerosis: A systematic review and meta-analysis. (2024). Physiotherapy, 125, 101413. https://doi.org/10.1016/j.physio.2024.101413. (PubMed)

Medical disclaimer: This article is for general educational purposes and isn’t a substitute for individual medical advice. Exercise and physiotherapy programmes for people with MS should be tailored to the individual’s symptoms, abilities, disease course and other health considerations. If you have new or worsening neurological symptoms, speak with your MS/neurology healthcare team.