Do you know someone who has been diagnosed with multiple sclerosis (MS)? Given its increasing prevalence, you probably do—and you may even work with clients who have been diagnosed with this autoimmune disease. Currently, the National Multiple Sclerosis Society estimates that as many as 1 million Americans are living with MS, and it is the most common progressive neurologic disease among young adults in the United States and worldwide.

For those who are unfamiliar with MS, it is an autoimmune disease in which the body’s own immune system attacks the central nervous system and causes damage that slows or stops normal nerve transmission. The symptoms of MS can be varied and highly unpredictable. In fact, each individual has unique symptoms, which can vary in nature and severity over time. Importantly, both the symptoms of MS and the commonly prescribed medications used to treat it can affect the normal response to exercise.

As a health coach or exercise professional, it’s important to understand the unique exercise programming needs of this underserved and vulnerable segment of our population. The purpose of this article is to share nine insights that will help guide your work with individuals with MS, and to provide you with the information you need to create safe and effective programs for this clientele.

9 Key Exercise Programming Considerations for Clients Who Have Multiple Sclerosis

1. Clients who have MS often have been leading sedentary and inactive lifestyles and may have other health concerns.

Common symptoms of MS include fatigue, muscle weakness, poor balance, spasticity (i.e., abnormal increase in muscle tone or stiffness), intolerance to heat and depression. Not surprisingly, these symptoms often contribute to sedentary and physically inactive behaviors. Sedentary behavior is separate from physical inactivity. While sedentary behavior refers to too much sitting, physical inactivity signifies too little exercise. Overall, research has uncovered significant associations between sedentary and physically inactive behaviors and the development of multiple comorbidities. According to a comprehensive systematic review, the most prevalent comorbidities in MS are depression (23.7%), anxiety (21.9%), hypertension (18.6%), high cholesterol levels (10.9%) and chronic lung disease (10%).

Given the strong likelihood that your client will possess multiple chronic conditions, you must be prepared to meet the challenge of developing a suitable comprehensive exercise program that addresses each of the client’s chronic conditions. Here are several considerations:   

  • The complexity of working with clients possessing multiple chronic conditions requires a thorough pre-participation health screening. 
  • A shortcoming to our overall current healthcare model for the management of chronic conditions is that the treatment has historically been approached in a singular fashion. In fact, clients rarely receive guidance from medical providers on prioritizing and managing multiple chronic conditions. As such, you can play a critical role in helping your clients follow a suitable comprehensive exercise program that addresses each of their chronic conditions.
  • Individuals with multiple health concerns may experience issues that fluctuate significantly from day to day in terms of severity. This is especially true with MS. As such, you must be prepared to accommodate an ever-changing chronic condition landscape and constantly adjust sessions to best serve your clients on any given day.
  • One strategy to consider when working with clients with multiple health issues is to focus on the most limiting one first (as opposed to the most serious). This approach can unlock potentials that were not previously accessible. For instance, working on strength and posture can help alleviate back pain, which can open up the ability to finish cardiorespiratory exercise sessions and thus help lower cardiovascular disease risk factors. This progressive approach allows clients to experience real progress, as opposed to only seeing their restrictions.

2. Take the time to learn about common MS medication–exercise responses and how these might affect program design interactions and considerations.

The pathophysiology of MS is complex and unique for each client; thus, the medical management of MS can include a broad range of medications to address both the MS and any other conditions the individual may have, such as high cholesterol or hypertension. Therefore, as a health and exercise professional, it is critical that you understand how certain medications interact with an individual’s response to exercise and how the exercise program might need to be adjusted. For example, some of the most common medications prescribed to Americans include beta blockers, ACE inhibitors, diuretics and lipid-lowering drugs, each of which are accompanied by a wide range of side effects. For example, beta blockers may reduce heart-rate and blood-pressure responses to a given exercise workload, and individuals who take ACE inhibitors and diuretics have both lower resting and exercise blood-pressure values. A primary concern for individuals taking ACE inhibitors and diuretics is that the combination of the reduction in blood pressure from both these categories of medications, combined with a natural-occurring post-exercise hypotension can result in excessive reductions in blood pressure. One way to counteract this affect is to incorporate two to three minutes of cool-down time between each exercise in a workout.  

Clients with MS are likely to be taking medications to control other aspects of the disease. For example, an estimated 80% of people with this disease struggle with something called elimination dysfunction, which includes issues related to bladder or bowel urgency, frequency and incontinence. These issues can cause anxiety for MS clients, so it’s an important consideration when thinking about scheduling the time of day of the exercise session, along with providing periodic and regular breaks during the exercise session. For example, one of our clients who had MS typically needed to use the restroom immediately upon arriving at our fitness center. We placed hand weights and resistance bands outside the restroom so they could immediately begin their resistance training after finishing in the restroom. This helped create a positive atmosphere and reduced the client’s anxiety.

The intent of this section is not to be exhaustive in its scope. Rather, it’s to highlight the concept of medication–exercise responses and reinforce the importance of making appropriate program-design adjustments that better serve your clients who have MS. It’s also critical to collaborate with the multidisciplinary team of medical providers who help your client manage their MS and familiarize yourself with other relevant medications and considerations for overall exercise programming.

3. Familiarize yourself with the stages of MS disease severity.

Physicians use the Expanded Disability Status Scale (EDSS) to classify an individual’s clinical status. The EDSS quantifies the degree of disability in eight functional systems: pyramidal (muscle weakness, difficulty moving limbs), cerebellar (ataxia, tremor, loss of balance or coordination), brainstem (problems with speechswallowing and nystagmus), sensory (numbness or loss of sensations), bowel and bladder, visual (problems with sight), cerebral (problems with thinking and memory) and other. The functional systems on the scale range from 0 (normal function) to 5 to 6 (inability to perform normal functions) to 8 to 9 (restriction to bed) to 10 (death). A simplified version of this scale is shown in Table 1.

Table 1. Simplified EDSS (adapted from White & Dressendorfer)




Normal neurological exam


Minimal disability


Moderate disability


Ambulation without aid for 12 hours


Disability impairs activity (e.g., walk without aid for 300 meters)


Intermittent or unilateral constant assistance


Unable to walk 5 meters without aid


More or less restricted to bed


Full-time restriction to bed


Mortality due to MS


4. Recognize the importance of assessments for safe and effective exercise programming.

As a health and exercise professional, you perform assessments to establish training goals and guide program progressions. As noted earlier, clients with MS generally lead sedentary lifestyles, possess comorbidities and typically don’t engage in much physical activity. For these reasons, it is critical that you screen these clients for cardiovascular risk factors. Exaggerated heart-rate and blood-pressure responses are hallmark autonomic dysfunction features of MS. Thus, assessing their heart rate and blood pressure at rest, along with postural changes and submaximal exercise, are important for creating safe and effective programming. Additionally, muscle weakness and spastic paresis are common in clients who have MS. As such, assessing balance and flexibility is also warranted to guide overall exercise programming.  

5. Avoid activities and environmental conditions that increase a client’s body core temperature.

Individuals who have MS are often heat sensitive and susceptible to overheating more easily while exercising in warm environmental conditions. Overheating also can lead to excessive fatigue, which is especially problematic given that fatigue is already a prevalent and debilitating symptom for individuals with MS. Be particularly mindful of this environmental challenge for your clients and avoid outdoor activity if temperature and humidity combinations are too high. Additional considerations to limit overheating are described in further detail later in the article.   

6. Consider adherence and social support as KEY program outcomes.

Several strategies can help enhance exercise adherence and provide much needed social support for your clients with MS. One way to promote adherence is to encourage clients to participate in activities that help improve their quality of life by attenuating some of the negative effects of MS. For example, to encourage adherence among your older clients with MS, recommend activities such as resistance training focused on functionality of movement, aquatic exercise (which might be easier to perform when muscle weakness is a concern) and balance/fall-prevention group exercise classes. Having an awareness of the natural progression of MS can help you establish realistic program goals that focus on maintenance and delayed MS progression. Additionally, social support can greatly benefit clients with MS by limiting the severity of depression. In other words, the social support that is achieved through exercise participation often carries over to other aspects of clients' lives and benefits them in meaningful ways outside the gym, as well.

7. Follow the ACE Integrated Fitness Training® (ACE IFT®) Model guidelines for cardiorespiratory and muscular training, but keep in mind programming considerations specific to clients with MS.

In general, you should follow the ACE Integrated Fitness Training (ACE IFT) Model guidelines for cardiorespiratory and muscular training with clients who have MS. However, there are a number of special considerations to keep in mind: 

  • Low-volume and intermittent aerobic exercise reduce the risk of excessive metabolic heat being generated, which is helpful for heat-sensitive clients.
  • Resistance training is an appealing exercise modality, as it is less likely to elicit overheating relative to aerobic exercise. It also enhances immune system function, which is highly beneficial for individuals with MS.
  • Aquatic exercise in moderately cool water (i.e., 80 to 85° F or 27 to 29° C) is an excellent option because any body heat generated is more easily dissipated in water, which has a thermal conductivity 25 times greater than that of air.
  • When spasticity is a concern, choosing activities that pose less of a fall or balance risk is important for overall safety:
    • Walking on an indoor track is generally safer than walking on a treadmill.
    • Chair aerobics are a good option when balance is an issue.
    • Avoid having your client perform squats.
    • Instead of using free weights, opt for machine weights because they offer built-in correction for form and the risk of dropping weight is eliminated. 
  • Fatigue can be an issue for clients with MS, so be sure to carefully monitor your clients' energy levels and provide ample recovery between exercises and workout sessions.

8. Incorporate regular flexibility training.

Individuals who have MS frequently have muscle contractures (i.e., fixed tightening of muscle), spasticity and reduced range of motion. For this reason, encourage your clients to participate in daily, 10- to 15-minute flexibility training sessions. The general frequency, intensity, time and type (FITT) approach to exercise programming used for cardiorespiratory and muscular training program design can also be applied to flexibility exercise programming. Here are some additional considerations for flexibility exercise to keep in mind:

  • Flexibility exercises should be gentle and prolonged but not painful.
  • Stretching durations for each flexibility exercise should be 20 to 60 seconds.
  • Flexibility exercises should target muscle groups used during cardiorespiratory and resistance training.
  • Flexibility exercise should be performed before and after cardiorespiratory and resistance training.

9. During exercise sessions, closely monitor your clients to help keep them safe.

The wide-ranging symptoms of MS mean your clients require careful supervision during their exercise sessions. For instance, heat intolerance, decreased gait and balance, and cognitive impairments are all factors that can increase the risks associated with exercise. Here are some specific supervision considerations to keep in mind: 

Research shows that a majority of individuals with MS (50 to 70%) experience at least one fall over a six-month period, and 30 to 50% of those who fall experience recurrent falls. Therefore, balance training and fall prevention must be emphasized for all clients with MS. However, because of the high incidence of falls amongst MS clients, it is important to be more conservative with balance-training exercises and progressions, and to provide more supervision and spotting.

Because individuals with MS are often intolerant of heat, helping them avoid overheating is critical, particularly as some clients may experience vision impairments with only slight increases in core body temperature. As such, careful supervision is required to prevent this from occurring.

Additional Resources

National Multiple Sclerosis Society

Multiple Sclerosis Association of America

A difficult reality with many neurological diseases, including MS, is the decline in cognitive function. Additional supervision is warranted to ensure various exercises and the overall exercise program are being performed correctly.  


Working with clients who have specific health challenges such as MS can be highly rewarding. Frequently, they may not have many treatment options, but exercise can help them retain or regain their autonomy, manage symptoms and improve their overall quality of life.