Multiple Sclerosis: Fatigue, Mobility, and Therapy

Sources

1. National Institute of Neurological Disorders and Stroke. Multiple sclerosis (MS) (last reviewed December 17, 2025). Checked November 3, 2026.
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   “Multiple sclerosis (MS) is a chronic neurological disorder. It’s an autoimmune disorder”; “MS symptoms usually begin in young adults, between ages 20 and 40”; “Most people with MS have a normal life expectancy”; “In MS, the immune system attacks myelin in the central nervous system”; the scar-like areas “are visible on an MRI (magnetic resonance imaging) scan”; “The symptoms of MS depend on the severity of the attacks as well as the location and size of the plaques”; “Currently, the five courses used to describe MS are”: clinically isolated syndrome, “a single attack (also called "exacerbation" or "relapse") followed by complete or near-complete recovery”; relapsing-remitting MS, “Most people with MS are initially diagnosed with this form”; “Relapsing-remitting MS can gradually evolve into secondary-progressive MS”; primary-progressive MS “is less common and has progressively worsening symptoms from the beginning, with no noticeable acute attacks”; radiologically isolated syndrome, “the rarest course of MS”. “Early MS symptoms often include” vision problems, “Muscle weakness, often in the arms and legs, and muscle stiffness with painful muscle spasms”, “Tingling, numbness, or pain in the arms, legs, trunk, or face”, “Clumsiness, especially difficulty staying balanced when walking”, “Bladder control problems” and “Intermittent or constant dizziness”; other symptoms include “Mental or physical fatigue”, mood changes and cognitive changes; “Muscle weakness, stiffness, and spasms may be severe enough to affect walking or standing”; “Many people with MS find that their symptoms are worse when they have a fever or are exposed to heat or following common infections”; “Women are more likely to get MS than men”. “There’s no single test to diagnose MS”; MRI, lumbar puncture, evoked potential tests and tests of the optic nerves; “In most cases, doctors can diagnose MS by considering someone’s symptoms and identifying characteristic MS signs on an MRI”. “There’s no cure for MS, but there are treatments that can reduce the number and severity of relapses—and delay the long-term progression of the disease”; corticosteroids “make recovery from MS attacks faster, but they don’t alter the long-term outcome of the disease”; disease-modifying therapies “are designed to regulate or suppress the inflammatory reactions of the disease”; ocrelizumab: “It’s currently the only FDA-approved disease-modifying therapy for primary-progressive MS”; “many of the symptoms of MS can usually be treated or managed”; “Neurologists (specialty doctors) with advanced training in the treatment of MS can prescribe specific medicines to treat these problems”; “Vision therapy exercises, special eyeglasses, and resting the eyes may be helpful”; “It’s very important that people with MS stay physically active because physical inactivity can contribute to worsening stiffness, weakness, pain, fatigue, and other symptoms. Stretching and exercising muscles through water therapy, yoga, or physical therapy (PT) can help manage mild spasticity. Medicines can also help reduce spasticity”; “Assistive devices are sometimes helpful for people with tremor”; “Many people with MS have difficulty with balance and walking. The most common walking problem is ataxia”; “People with severe ataxia generally benefit from the use of a cane, walker, or other assistive device. Physical therapy (PT) can also reduce walking problems. Occupational therapy (OT) can help people learn how to walk using an assistive device or in a way that saves physical energy. The FDA has approved the drug dalfampridine to improve walking speed in people with MS”; fatigue “may be both physical (tiredness in the arms or legs) and cognitive (slowed processing speed or mental exhaustion)”; “Daily physical activity programs of mild to moderate intensity can significantly reduce fatigue”; “PT and OT can sometimes help manage fatigue. PT provides personalized treatments, while OT teaches ways to use energy wisely. They also help find the right changes in the person’s environment”; “Depression can intensify symptoms of fatigue, pain, and sexual dysfunction. It is most often treated with cognitive behavioral therapy and selective serotonin reuptake inhibitor (SSRI) antidepressant medicines”; “Cognitive impairment—a decline in the ability to think, learn, and remember—affects up to 75% of people with MS”; “Sometimes, depression causes cognitive impairment in people with MS, and it’s important to rule out depression, first”.
2. National Multiple Sclerosis Society. Symptoms of multiple sclerosis. Checked November 3, 2026.
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   “No two people have exactly the same symptoms, and symptoms can change over time.” “About 8 out of 10 people living with MS have bladder issues.” “Many people with MS report that fatigue impacts them more than any other symptom.” Pain “affects 1 in 2 people living with MS.” “Muscle weakness, spasticity, loss of balance, sensory deficits or fatigue can cause mobility challenges.”
3. National Multiple Sclerosis Society. Fatigue and multiple sclerosis. Checked November 3, 2026.
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   “About 80% of people with multiple sclerosis live with fatigue.” “Fatigue can interfere with your ability to function at home and work.” “You may find that family members, friends, coworkers or employers don’t understand your fatigue.” “This is in part because it is hard to measure fatigue.” “muscle spasms or bladder issues may keep you up at night”; “You may find that daily tasks such as getting dressed and preparing meals take more effort. Depression can also cause fatigue.” MS fatigue, called “lassitude”: “Generally occurs daily”, “May occur in the morning, even after a restful night’s sleep”, “Tends to get worse as the day progresses”, “Tends to increase with heat and humidity”, “Comes on easily and suddenly”, “Is generally more severe than normal fatigue”, “Requires more recovery time”. “MS-related fatigue does not appear to be directly related to either depression or your degree of physical impairment.” “Other medical conditions and vitamin deficiencies, for example, can cause fatigue.” “Consult your healthcare provider if fatigue becomes a problem and discuss a treatment plan. They can complete a comprehensive evaluation to identify factors adding to your fatigue”. Rehabilitation can “help you plan ahead to prevent and reduce the effects of MS-related fatigue. They can teach you energy-saving strategies and help you avoid activities that trigger your fatigue.” “Occupational therapy to simplify tasks at work and home and conserve energy”; “Physical therapy to learn energy-saving ways of walking (with or without assistive devices) and performing other daily tasks”; “Physical therapy to develop a regular exercise program to prevent deconditioning”; “Sleep regulation, which might involve treating other MS symptoms that interfere with sleep (e.g., spasticity, urinary dysfunction)”; “Psychological interventions, such as stress management, relaxation training, membership in a support group, cognitive behavioral therapy or psychotherapy”; “Heat management strategies to avoid overheating and to cool down”. “No medications are specifically made for MS fatigue. But you and your healthcare provider may consider some for off-label use.”
4. Giesser BS. Exercise in the management of persons with multiple sclerosis. Therapeutic Advances in Neurological Disorders. 2015;8(3):123–130. doi:10.1177/1756285615576663 (PMID 25941539).
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   Review: “For decades, persons with multiple sclerosis (MS) were counseled to avoid excessive physical activity and exercise because of concerns about worsening disease activity.” “Recent studies indicate that, not only can those with MS tolerate physical exercise, but that it is helpful in managing symptoms”.
5. Kalb R, Brown TR, Coote S, Costello K, Dalgas U, Garmon E, et al. Exercise and lifestyle physical activity recommendations for people with multiple sclerosis throughout the disease course. Multiple Sclerosis Journal. 2020;26(12):1459–1469. doi:10.1177/1352458520915629 (PMID 32323606).
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   The National MS Society “convened clinical and research experts”; recommendations “Based on current evidence and expert opinion”, “endorsed by the Consortium of Multiple Sclerosis Centers”: “Healthcare providers should endorse and promote the benefits/safety of exercise and lifestyle physical activity for every person with MS.” “Early evaluation by a physical or occupational therapist or exercise or sport scientist, experienced in MS” “is recommended to establish an individualized exercise and/or lifestyle physical activity plan.” “Taking into account comorbidities and symptom fluctuations, healthcare providers should encourage ≥150 min/week of exercise and/or ≥150 min/week of lifestyle physical activity.” “Progress toward these targets should be gradual, based on the person’s abilities, preferences, and safety.” “If disability increases and exercise/physical activity becomes more challenging, referrals to specialists are essential to ensure safe and appropriate prescriptions.” “When physical mobility is very limited, exercise should be facilitated by a trained assistant.” For mild impairment (EDSS 0–4.5), existing guidelines: aerobic “2–3x/week; 10–30 minutes at a moderate exercise intensity”; resistance “2–3x/week”; “Exercise may temporarily worsen symptoms in patients who are heat-sensitive”.
6. Learmonth YC, Herring MP, Russell DI, Pilutti LA, Day S, Marck CH, et al. Safety of exercise training in multiple sclerosis: an updated systematic review and meta-analysis. Multiple Sclerosis Journal. 2023;29(13):1604–1631. doi:10.1177/13524585231204459 (PMID 37880997).
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   Randomized trials published since 2013: “Forty-six interventions from 40 RCTs (N = 1780)”; mean relative risks “for relapse, AE and SAE were 0.95 ((0.61, 1.48), p = 0.82), 1.40 ((0.90, 2.19), p = 0.14) and 1.05 ((0.62, 1.80), p = 0.85), respectively”; “In studies that reported safety outcomes, there was no higher risk of relapse, AE, adverse effects or SAE for exercise training than the comparator. Exercise training may be promoted as safe and beneficial to persons with MS.”
7. National Multiple Sclerosis Society. Heat sensitivity with multiple sclerosis. Checked November 3, 2026.
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   “60-80% of people living with MS experience heat intolerance. Fortunately, symptoms usually only worsen temporarily. They should improve after you cool down.” “A higher body temperature makes it harder for nerves damaged by MS to conduct electrical signals. In fact, research shows that raising your body temperature even half a degree can affect how nerve signals work.” “activities such as sunbathing, exercising and taking very hot showers or baths may make your MS symptoms worse”. Symptoms that get worse with heat and humidity include blurred vision, cognitive difficulties such as problems with attention and concentration, fatigue, muscle weakness, numbness, slowed reaction times, spasticity and tremor. “Stay in the air conditioning during periods of extreme heat and humidity.” “Wear lightweight, loose and breathable clothing.” “Drink cold fluids and eat popsicles.” “Exercise in a cool place or pool (under 85 degrees Fahrenheit) and at cooler times of day.” “Try cooling down before and after exercising.” Cooling equipment “can include misters, cooling vests, hats or caps, and wrist, ankle or neck wraps”; “Cooling equipment is usually considered durable medical equipment (DME).” “If cooling equipment helps you do your job”, “it may be covered through vocational rehabilitation”. “Call your insurance company and ask what steps you need to take to get the equipment approved.” “Some people with MS notice that some symptoms, especially spasticity, become worse in cold weather.”
8. National Multiple Sclerosis Society. Rehabilitation and multiple sclerosis. Checked November 3, 2026.
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   “Rehabilitation therapies can help people with multiple sclerosis function better at work, at home and in the community. After diagnosis, rehab specialists can provide education and strategies to promote wellness, improve overall conditioning and reduce fatigue. They can also evaluate and treat speech and swallowing difficulties, as well as thinking and memory issues.” “A rehabilitation physician, physiatrist or neurologist often leads the team.” “Which team members take part in your care will depend on your needs, available resources and insurance coverage.” Physical therapists help with walking and mobility, strength, balance, posture, fatigue and pain; “PT might include an exercise program, gait (walking) training and/or training in the use of mobility aids (poles, canes, crutches, scooters and/or wheelchairs) and other assistive devices”; rehabilitation can help prevent “De-conditioning or decline in overall physical function”, “Muscle weakness from lack of mobility” and “Muscle contractures related to spasticity”; “PT can also include pelvic floor exercises to address urinary/bladder issues.” “Occupational therapists will train you in techniques to save energy and in the use of adaptive tools and devices to simplify your daily tasks. They recommend modifications to your home or workplace to improve accessibility, safety and convenience.” “They may perform driving evaluations. Others evaluate and treat challenges with thinking and memory. The goal of OT is to make you more independent, productive and safe in all activities related to personal care, leisure activities and employment.” “The speech-language pathologist evaluates and treats difficulties with speech and/or swallowing.” “Some SLPs also evaluate and treat challenges with thinking and memory.” “Vocational rehab can help you maintain your current job or find a new one that meets your needs.” State programs offer “job readiness training, coaching, placement assistance, mobility training and assistive technology assessments”. Neuropsychologists, “as well as many OTs and SLPs”, evaluate and treat changes in thinking, reasoning, concentration and memory; “Cognitive rehabilitation can help improve quality of life, relationships, activities and work performance.” “Functional electrical stimulation (FES) is a treatment that involves the use of mild electrical stimuli to muscles to help them move.” “Relatively small, battery-powered devices send low-level electrical impulses to damaged nerves. While these devices are effective for many people with MS, they may not be right for everyone.” Search tools: the American Academy of Clinical Neuropsychology, the American Academy of Physical Medicine and Rehabilitation, the American Physical Therapy Association, the American Speech-Language-Hearing Association and the Society’s Find Doctors & Resources tool.
9. Heine M, van de Port I, Rietberg MB, van Wegen EE, Kwakkel G. Exercise therapy for fatigue in multiple sclerosis. Cochrane Database of Systematic Reviews. 2015;(9):CD009956. doi:10.1002/14651858.CD009956.pub2 (PMID 26358158).
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   Systematic review of randomized trials in adults: “Fatigue is often reported as the most invalidating symptom in people with MS.” “Forty-five trials, studying 69 exercise interventions, were eligible for this review, including 2250 people with MS.” “In general, exercise interventions were studied in mostly participants with the relapsing-remitting MS phenotype, and with an Expanded Disability Status Scale less than 6.0.” “Based on 26 trials that used a non-exercise control, we found a significant effect on fatigue in favour of exercise therapy (standardized mean difference (SMD) -0.53, 95% confidence interval (CI) -0.73 to -0.33; P value < 0.01). However, there was significant heterogeneity between trials”; “The mean methodological quality, as well as the combined body of evidence, was moderate.” Effects were significant for endurance, mixed and “other” training (for example yoga). “Across all studies, one fall was reported.” “exercise does not seem to be associated with a significant risk of a MS relapse”. “Exercise therapy can be prescribed in people with MS without harm.” “Unfortunately, most trials did not explicitly include people who experienced fatigue, did not target the therapy on fatigue specifically, and did not use a validated measure of fatigue as the primary measurement of outcome.”
10. National Multiple Sclerosis Society. Rehabilitation for MS management (for healthcare professionals; reviewed February 2021). Checked November 3, 2026.
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    “people living with MS may experience functional limitations from relapses and disease progression”. “Rehabilitation in MS involves strategies to improve or maintain function, prevent complications and enhance overall quality of life. Rehabilitation may be needed at various points in the disease course”; “MS complications (contractures, disuse atrophy, pressure sores, risk of falls, increased dependence) can be reduced or prevented by rehabilitation interventions.” “Assessment for rehabilitation services should be considered early in the disease when changes may be easier to implement, including individuals who are newly diagnosed and present with any functional limitation.” “Healthcare providers should also consider referring a person for a rehabilitation assessment when there is worsening of function or impairment that impacts mobility, safety and independence.” “Individuals should also be assessed for durable medical equipment needs and occupational and environmental modifications.” The team includes “neuropsychology, driver rehabilitation, vocational rehabilitation and vision rehabilitation”; “Rehabilitation specialists may work closely with a registered dietician if a patient has issues with swallowing or fatigue-related weight-loss.” “Whenever possible, patients should be evaluated and treated by therapists who are familiar with neurological degenerative disorders. In physical therapy, MS treatment by a neurologic certified specialist is preferred over an orthopedic certified specialist.”
11. National Multiple Sclerosis Society. Prevalence of multiple sclerosis. “Almost 1 million people in the United States have received a diagnosis of multiple sclerosis, according to a 2019 prevalence study funded by the National MS Society. This is more than twice the estimate from previous studies.” Checked November 3, 2026.
12. Centers for Medicare & Medicaid Services. Physical therapy services (Medicare.gov). Checked November 3, 2026.
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    Part B helps pay for medically necessary outpatient physical therapy; “You can also get this therapy to help improve or maintain your current function, or slow your rate of decline”; your doctor or other health care provider “must certify that you need it”; “you pay 20% of the Medicare-approved amount”; “There’s no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year”.
13. Centers for Medicare & Medicaid Services. Jimmo settlement (CMS.gov). Checked November 3, 2026.
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    The settlement “clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration”; coverage “does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care”.
14. Centers for Disease Control and Prevention. Signs and symptoms of stroke (reviewed May 19, 2026). Checked November 3, 2026.
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    “Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.” “Sudden confusion, trouble speaking, or difficulty understanding speech.” “Sudden trouble seeing.” “Sudden trouble walking, dizziness, loss of balance, or lack of coordination.” “Sudden severe headache with no known cause.” “Call 9-1-1 right away if you or someone else has any of these symptoms.”
15. National Multiple Sclerosis Society. Managing relapses in multiple sclerosis. Checked November 3, 2026.
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    “In a multiple sclerosis relapse, you have new MS symptoms or old ones worsen.” An episode is a relapse when “It happens at least 30 days after the last relapse.” “It occurs without an infection or other cause.” “It lasts at least 24 hours.” “Some relapses produce only 1 symptom, while others cause several at once.” “Relapses last from a few days to several weeks or even months.” “Some people feel exactly as they did before the relapse. In others, symptoms linger, but with less intensity than during the relapse.” “Severe relapses can cause symptoms such as loss of vision, severe weakness or poor balance. They can interfere with your mobility, safety or overall ability to function.” “But always discuss worsening symptoms with your healthcare provider.” “The goal of a rehabilitation program is to restore or maintain functions that are essential to daily living”; after a relapse it can help with dressing and personal care, fatigue, mobility, overall fitness, role performance at home and work, speech and swallowing, and thinking and memory. “If you think you are having an MS relapse, contact your healthcare provider to find the best treatment plan for you.”
16. National Multiple Sclerosis Society. Swallowing difficulties. Checked November 3, 2026.
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    “Dysphagia is more frequent in advanced MS, but it can occur at any time.” Signs: “Difficulty in managing solids or liquids”, “Frequent throat clearing while eating or drinking”, “The feeling that food is stuck in the throat”, “A coughing or choking sensation when eating or drinking”. “It’s important to recognize swallowing issues early. If they continue or worsen, food or fluids may get into your lungs.” “If you are dealing with swallowing issues, a healthcare provider can help.” “modified barium swallow study”; “SLPs are the professionals who diagnose and treat dysphagia. They can offer strategies for safer eating and swallowing, suggest dietary changes and teach you exercises or provide stimulation to improve swallowing.” “Sit upright while eating.” “Chew slowly.” “Eat in a quiet, relaxed atmosphere.” “Avoid distractions such as talking while eating.”
17. National Multiple Sclerosis Society. Cognitive changes in multiple sclerosis. Checked November 3, 2026.
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    “Among people living with MS, more than half experience some change in cognitive function.” “For most people, the changes are mild and only involve 1 or 2 areas of cognitive functioning.” “Can happen with any disease course but are more common in progressive MS.” “Are unrelated to the degree of physical disability.” “Can lead you to leave the workforce early.” “Are more likely to occur during a relapse.” “These changes can significantly affect your quality of life, relationships, activities and work performance.” Self-assessment questions include “Do I feel like my thinking has gotten slower?”, “Do I struggle to find the right word?”, “Do I forget steps in everyday tasks?” and “Do I have trouble keeping up with conversations?” “If the statements above feel familiar, let your healthcare provider know. The standard neurologic exam detects few cognitive changes in people with MS. Your provider can perform an additional, short screening test.” Evaluated by neuropsychologists, some speech-language pathologists and occupational therapists; the evaluation “helps rule out other possible causes of cognitive problems, such as medications and other conditions”, including thyroid issues, vitamin B12 deficiency, sleep disorders and emotional changes. The Society recommends “Early screening to set a baseline and annual reassessment of cognitive health to identify potential problems”.
18. Wallin MT, Culpepper WJ, Campbell JD, Nelson LM, Langer-Gould A, Marrie RA, et al. The prevalence of MS in the United States: a population-based estimate using health claims data. Neurology. 2019;92(10):e1029–e1040. doi:10.1212/WNL.0000000000007035 (PMID 30770430).
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    A validated algorithm applied to private, military and public health claims: “The estimated 2010 prevalence of MS in the US adult population cumulated over 10 years was 309.2 per 100,000 (95% confidence interval [CI] 308.1-310.1), representing 727,344 cases”; “450.1 per 100,000 (95% CI 448.1-451.6) for women and 159.7 (95% CI 158.7-160.6) for men (female:male ratio 2.8)”; “The estimated 2010 prevalence of MS was highest in the 55- to 64-year age group”; the authors “extrapolated our estimate to 2017”.
19. National Multiple Sclerosis Society. Relapsing-remitting multiple sclerosis. Checked November 3, 2026.
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    “Approximately 85% of people with MS are initially diagnosed with RRMS.” “Most people with RRMS are diagnosed in their 20s and 30s (although it can occur in childhood or later adulthood) while PPMS is typically diagnosed during the 40s or 50s.” To make a diagnosis the doctor must “Find evidence of damage (lesions) in different areas of the central nervous system” and “Rule out all other possible diagnoses”. “The Food and Drug Administration (FDA) has approved more than 20 medications” for relapsing forms of MS; “Research has shown that all the MS medications can”: “Reduce the number of relapses”, “Limit new MS activity” and “Slow disease worsening (progression)”; “Years of research suggest that starting one of these medications soon after your MS diagnosis is the most effective way to manage the MS disease process.” “Starting a DMT or switching to a different DMT are decisions best made by you and your MS healthcare provider.” “Disease activity and worsening should be evaluated at regular intervals with a neurologic examination and magnetic resonance imaging (MRI).” “Rehabilitation specialists have an important role from the time of diagnosis”.
20. National Multiple Sclerosis Society. Pediatric-onset multiple sclerosis (for healthcare professionals). “Pediatric-onset multiple sclerosis (POMS) occurs when MS is diagnosed before 18 years of age. Approximately 3%-5% of all individuals with MS experience disease onset before age 16”. Checked November 3, 2026.
21. Montalban X, Lebrun-Frénay C, Oh J, Arrambide G, Moccia M, Pia Amato M, et al. Diagnosis of multiple sclerosis: 2024 revisions of the McDonald criteria. Lancet Neurology. 2025;24(10):850–865. doi:10.1016/S1474-4422(25)00270-4 (PMID 40975101).
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    Review: “The new 2024 McDonald criteria provide a unified approach for diagnosing multiple sclerosis in individuals with relapsing or progressive courses throughout the lifespan (ie, from paediatric to late-life presentations).” “The optic nerve can now serve as a fifth anatomical location within the CNS for diagnosis.”
22. National Multiple Sclerosis Society. The MS rehabilitation process (for healthcare professionals; reviewed February 2021). Checked November 3, 2026.
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    “The frequency, intensity and setting of the rehab intervention must be based on individual needs, and goals should be established early and revised as needed.” “Periodic reevaluation and outcomes assessment allow for comparison of function over time and determining if the intervention used was effective.” “The initial evaluation should include a baseline assessment of symptoms currently affecting the individual’s performance as well as their current and prior level of function.” “Early intervention, in conjunction with disease-modifying therapies, can help people maintain or improve their level of function, perform activities of daily living efficiently and prevent premature workforce retirement.” “Restoration of function may or may not occur following an exacerbation. If restoration is not possible, teach effective ways to compensate for impairments”. “PTs and OTs may treat the same problem, though in general, PT focuses on impairments involving gross motor skills, balance and endurance, while OT focuses on impairments involving fine motor skills, fatigue, functional cognition, functional vision and adaptive equipment.” Which specialist sees a person depends on “the person’s insurance plan, which may not cover all specialties”, “the background and training of the OT, PT and SP at a facility” and “the availability of rehabilitation specialists in a facility or geographic area”. “Recent relapses, disease progression or other factors may influence goal setting at any point in time.” “Unrealistic goal setting: The client wishes to walk unassisted to the library, which is something they have not done in five years.” “Realistic goal setting: The client will walk with a walker independently to and from the library to attend story hour with her daughter.” “Their care partner needs to be educated when the patient needs assistance and when they do not. The care partner is instructed on proper body mechanics, necessary equipment and techniques for assisting in transfers, activities of daily living, etc.” “Use shared decision-making when developing goals”; the therapist may “break down the goal into more manageable steps”.
23. Nilsagård Y, Gunn H, Freeman J, Hoang P, Lord S, Mazumder R, et al. Falls in people with MS: an individual data meta-analysis from studies from Australia, Sweden, United Kingdom and the United States. Multiple Sclerosis Journal. 2015;21(1):92–100. doi:10.1177/1352458514538884 (PMID 24948687).
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    “Individual data from studies in four countries that prospectively measured falls for three months were analyzed.” “A total of 537 participants reported 1721 falls: 56% were fallers and 37% frequent fallers. Most falls occurred indoors (65%)”; “Primary progressive MS was associated with significantly increased odds of being a faller”; “Fall risk peaked at EDSS levels of 4.0 and 6.0”.
24. National Multiple Sclerosis Society. Spasticity and multiple sclerosis. Checked November 3, 2026.
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    “It is one of the more common MS symptoms. Spasticity refers to muscle stiffness and spasms.” “Spasticity can range from mild muscle tightness to painful spasms that you cannot control. Although spasticity can occur in the arms, it is most common in the legs.” “Some degree of spasticity can be beneficial, particularly for people who experience significant leg weakness.” Triggers: sudden movements or position changes, extreme temperatures, humidity, infections and tight clothing. “In these cases, spasticity gives legs some rigidity, making it easier to stand, transfer or walk. The treatment goal for these individuals is to relieve the spasticity enough to ensure comfort and prevent complications while leaving the rigidity needed to function.” “Spasticity and muscle tightness are commonly treated with medications as well as physical and occupational therapy. Because spasticity varies so much from person to person, an individual treatment plan is best.” “Left untreated, spasticity can lead to serious complications, including pressure sores and contractures or frozen or immobilized joints.”
25. Amatya B, Khan F, Galea M. Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. 2019;(1):CD012732. doi:10.1002/14651858.CD012732.pub2 (PMID 30637728).
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    Overview of Cochrane Reviews searched to December 2017: “we included 15 reviews published in the Cochrane Library, comprising 164 randomised controlled trials (RCTs) and four controlled clinical trials, with a total of 10,396 participants”; “Moderate-quality evidence suggested that physical therapeutic modalities (exercise and physical activities) improved functional outcomes (mobility, muscular strength), reduced impairment (fatigue), and improved participation (quality of life). Moderate-quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation, and interventions that provided information improved patient knowledge.” “neuropsychological interventions, symptom-management programmes (spasticity), whole body vibration, and telerehabilitation improved some patient outcomes” on low-quality evidence; “Evidence for other rehabilitation modalities was inconclusive, due to lack of robust studies.” “the majority of included reviews did not include data from current studies”
26. Blikman LJ, Huisstede BM, Kooijmans H, Stam HJ, Bussmann JB, van Meeteren J. Effectiveness of energy conservation treatment in reducing fatigue in multiple sclerosis: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation. 2013;94(7):1360–1376. doi:10.1016/j.apmr.2013.01.025 (PMID 23399455).
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    “The searches identified 532 studies, 6 of which were included.” “Meta-analyses (2 RCTs, N=350) showed that ECM treatment was more effective than no treatment” on the cognitive, physical and psychosocial subscales of the Fatigue Impact Scale and on three quality-of-life scales; “None of the studies reported long-term results.” “in the short-term, ECM treatment can be more effective than no treatment (waiting controls) in reducing the impact of fatigue and in improving 3 QoL scales-role physical, social function, and mental health-in fatigued patients with MS”
27. Blikman LJ, van Meeteren J, Twisk JW, de Laat FA, de Groot V, Beckerman H, et al. Effectiveness of energy conservation management on fatigue and participation in multiple sclerosis: a randomized controlled trial. Multiple Sclerosis Journal. 2017;23(11):1527–1541. doi:10.1177/1352458517702751 (PMID 28528565).
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    “A total of 86 severely fatigued and ambulatory adults with a definite diagnosis of MS were randomized” to energy conservation management or an information-only control; “Modified intention-to-treat analysis was based on 76 randomized patients”; “No significant ECM effects were found for fatigue” or “for four out of five IPA domains”; “An overall unfavourable effect was found in the ECM group for the IPA domain social relations”; “The individual ECM format used in this study did not reduce MS-related fatigue and restrictions in participation more than an information-only control condition.”
28. National Multiple Sclerosis Society. Exercising with multiple sclerosis. Checked November 3, 2026.
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    “One study showed that even just 2½ hours per week of physical activity improves the mental and physical health of people with MS.” “Physical activity can mean exercise, but it also includes everyday activities like walking the dog and gardening.” “Adaptive tai chi, water exercise and yoga are just a few examples.” “Chair exercises can be done by people of all fitness levels, including people with limited mobility.” “Studies of aerobic exercise for people living with MS show the perks of staying active. Benefits include improved” bladder and bowel function, bone density, cardiovascular fitness, cognitive function, energy levels, flexibility, mood and strength. Tips: “Consult a medical professional before starting a new exercise routine.” “Exercise in a cool room and, if outside, exercise at cooler times during the day.” “Go slow.” “Remember to stretch afterward.” “Cold water will help keep your body temperature low.”
29. National Multiple Sclerosis Society. Free From Falls. Checked November 3, 2026.
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    “This 8-module program can help you optimize your mobility with MS and prepare you in the case of a fall.” “Engage in and develop a home fitness plan addressing balance, endurance, and strength, aimed at reducing your fall risk.” Modules: “What Causes and Risks Are Associated With Falls?”, “When Fears Fall Away”, “Optimizing Mobility”, “Managing Energy”, “Staying Safe at Home”, “Staying Safe in the Community”.
30. National Multiple Sclerosis Society. Speech dysfunction. Checked November 3, 2026.
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    “About 2-4 of every 10 people living with MS experience changes to their speech and difficulties in being understood.” “Fatigue, one of the most common symptoms of MS, can make speech issues worse. Many people with speech dysfunction also have dysphagia (difficulty swallowing).” Dysarthria: “Your speech may sound slurred, harsh and uncoordinated.” “Speech clarity changes to some degree in up to 70% of people with MS.” Dysphonia: “You may run out of air while talking. This happens with changes in airflow from the lungs or an abnormal throat structure near the vocal cords.” “You may create abnormally long pauses between words or syllables.” Nasal speech; “Diaphragm weakness can make it hard for you to speak loud enough to be heard.” “Speech therapy and assistive devices can improve speech in most cases.” “your SLP may offer exercises to strengthen and improve the function of the muscles involved in breathing and speaking”; “These can include slowing your speech down, exaggerating sounds and pausing between shorter units of language.” “Smart phone apps can help with communication. Other devices, such as those to amplify your voice, may also be helpful.” “augmentative and alternative communication (AAC) may replace speech or supplement it”.
31. Mirmosayyeb O, Ebrahimi N, Shekarian A, Afshari-Safavi A, Shaygannejad V, Barzegar M, et al. Prevalence of dysphagia in patients with multiple sclerosis: a systematic review and meta-analysis. Journal of Clinical Neuroscience. 2023;108:84–94. doi:10.1016/j.jocn.2023.01.006 (PMID 36630841). Studies using self-report screening were excluded.
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    “A total of 11,266 MS cases and 5047 MS patients with dysphagia were included in the meta-analysis. The overall prevalence of dysphagia across all 54 studies was 44.8 % (95 % CI: [40.4 %-49.2 %]), with a high level of heterogeneity between countries”
32. Moore JL, Potter K, Blankshain K, Kaplan SL, O’Dwyer LC, Sullivan JE. A core set of outcome measures for adults with neurologic conditions undergoing rehabilitation: a clinical practice guideline. Journal of Neurologic Physical Therapy. 2018;42(3):174–220. doi:10.1097/NPT.0000000000000229 (PMID 29901487).
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    “Strong, level I evidence supports the use of the Berg Balance Scale” and “the Activities-specific Balance Confidence Scale”; “Strong to moderate evidence supports the use of the Functional Gait Assessment”, “the 10 meter Walk Test to assess changes in gait speed, and the 6-Minute Walk Test to assess changes in walking distance”; “Best practice evidence supports the use of the 5 Times Sit-to-Stand” (“Based on the GDG clinical expertise, informed by related evidence and the results of the clinician survey”); “Evidence was insufficient to support use of a specific OM to assess patient-stated goals across adult neurologic conditions. Physical therapists should discuss the OM results with patients and collaboratively decide how the results should inform the plan of care.”
33. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15 (Rev. 13889, issued July 30, 2026), sections 220.1.2, 220.2 and 220.3. Checked November 3, 2026.
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    “The plan of care shall contain, at minimum, the following information”: diagnoses, “Long term treatment goals” and “Type, amount, duration and frequency of therapy services”. “Improvement is evidenced by successive objective measurements whenever possible”. “The minimum progress report period shall be at least once every 10 treatment days.” The progress report includes “Assessment of improvement, extent of progress (or lack thereof) toward each goal”.
34. Levack WM, Weatherall M, Hay-Smith EJC, Dean SG, McPherson K, Siegert RJ. Goal setting and strategies to enhance goal pursuit for adults with acquired disability participating in rehabilitation. Cochrane Database of Systematic Reviews. 2015;(7):CD009727. doi:10.1002/14651858.CD009727.pub2 (PMID 26189709).
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    “We included 39 studies (27 RCTs, 6 cluster-RCTs, and 6 quasi-RCTs) involving 2846 participants in total.” “The most common health conditions included musculoskeletal disorders, brain injury, chronic pain, mental health conditions, and cardiovascular disease.” “There is some very low quality evidence that goal setting may improve some outcomes for adults receiving rehabilitation for acquired disability. The best of this evidence appears to favour positive effects for psychosocial outcomes (i.e. health-related quality of life, emotional status, and self-efficacy) rather than physical ones.”
35. U.S. Equal Employment Opportunity Commission. Facts about the Americans with Disabilities Act. Checked November 3, 2026.
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    “The ADA covers employers with 15 or more employees, including state and local governments.” “An employer is required to make a reasonable accommodation to the known disability of a qualified applicant or employee” unless it would impose an undue hardship; “An employer generally does not have to provide a reasonable accommodation unless an individual with a disability has asked for one.”
36. National Multiple Sclerosis Society. Work accommodations for MS. Checked November 3, 2026.
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    “One of the key non-discrimination requirements of Title I of the ADA is the obligation to provide reasonable accommodation for employees with disabilities.” “An employer does not need to provide an accommodation that would cause an undue hardship.” “The accommodation process is supposed to be an interactive process between the employee and employer. The employee is responsible for requesting the accommodation and seeing the process through.” Examples include “parking spot closer to the door”, “moving your office closer to the restroom”, “Flexible scheduling”, “Going part-time from full-time work”, “Telecommuting”, “Time off for medical appointments or sick leave” and “Assistive technology including voice recognition software”; the Family and Medical Leave Act “provides unpaid, job-protected leave. Leave may be taken all at once, or may be taken intermittently as the medical condition requires.”
37. U.S. Department of Labor, Wage and Hour Division. Family and Medical Leave Act. Checked November 3, 2026.
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    “The FMLA entitles eligible employees of covered employers to take unpaid, job-protected leave for qualifying family and medical reasons”; “up to 12 workweeks of leave in a 12-month period”; “Eligible employees may use FMLA leave intermittently or on a reduced schedule when medically necessary”. Covered employers include “Private-sector employers who employ 50 or more employees in 20 or more workweeks in either the current calendar year or the previous calendar year” and “Public agencies (including federal, state, and local government employers), regardless of the number of employees”. Employees are eligible if they “Work for a covered employer for at least 12 months”, “Have at least 1,250 hours of service with the employer during the 12 months before their FMLA leave starts” and “Work at a location where the employer has at least 50 employees within 75 miles”.
38. National Multiple Sclerosis Society. Caring for someone with MS. Checked November 3, 2026.
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    “you may find yourself neglecting your own health and well-being”. “Carepartners should do things for themselves and ask others for relief.” “The people who can help will appreciate it if you tell them exactly what you need them to do and how to do it.” “With professional respite care, you hire someone to care for your loved one so you can have a break.”
39. Centers for Medicare & Medicaid Services. Occupational therapy services (Medicare.gov). “Therapy to help you perform activities of daily living (like dressing or bathing). You can get this therapy to help improve or maintain your current capabilities, or slow your rate of decline”; a doctor or other health care provider “must certify you need this care”. Checked November 3, 2026.
40. Centers for Medicare & Medicaid Services. Speech-language pathology services (Medicare.gov). Evaluation and treatment “to regain and strengthen speech and language skills. This includes cognitive and swallowing skills, or therapy to improve or maintain current function or slow decline”; “There’s no limit on how much Medicare pays”. Checked November 3, 2026.
41. Centers for Medicare & Medicaid Services. Costs (Medicare.gov), “What you pay in 2026”. Part B deductible: “$283 before Original Medicare starts to pay”; coinsurance: “Usually 20% of the cost for each Medicare-covered service or item after you’ve paid your deductible”. Checked November 3, 2026.
42. Centers for Medicare & Medicaid Services. Therapy services (CMS.gov, page last modified March 10, 2026). Checked November 3, 2026.
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    The law “preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record”; “Claims for services over the KX modifier threshold amounts without the KX modifier are denied. For CY 2026 this KX modifier threshold amount is: $2,480 for PT and SLP services combined, and $2,480 for OT services”; “the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services”; “not all claims exceeding the MR threshold amount are subject to review”; section 6209 of the Consolidated Appropriations Act, 2026 “extended the ability of PTs, OTs, and SLPs to furnish Telehealth Services” “through December 31, 2027”.
43. Centers for Medicare & Medicaid Services. Compare Original Medicare & Medicare Advantage (Medicare.gov). Checked November 3, 2026.
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    Medicare Advantage: “Plans must cover all medically necessary services that Original Medicare covers”; “You may need to use doctors and other providers who are in the plan’s network”; “You may need to get a referral to see a specialist”; “You may need to get approval (prior authorization) from your plan before it covers certain services or supplies”; “Plans may have different out-of-pocket costs for certain services”; “Plans have a yearly limit on what you pay for covered Medicare services”.
44. Centers for Medicare & Medicaid Services. Home health services (Medicare.gov). Checked November 3, 2026.
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    Covered services include “Physical therapy, occupational therapy, and speech-language pathology services”; “You must need part-time or intermittent skilled services and you’re” homebound; home health can help you “maintain your current condition or level of function, or slow your rate of decline”; “You pay nothing for covered services”.
45. Centers for Medicare & Medicaid Services. Telehealth (Medicare.gov). “Through December 31, 2027, Medicare covers telehealth services that you can get from anywhere in the U.S., including your home.” The examples listed include speech therapy. Checked November 3, 2026.
46. HealthCare.gov. What Marketplace health insurance plans cover. Checked November 3, 2026.
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    “All plans offered in the Marketplace cover these 10 essential health benefits”, including “Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)”; “Specific services covered in each broad benefit category can vary based on your state’s requirements”.

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