To halt disease progression rehabilitation in MS should start early: Yes

Multiple sclerosis (MS) is a progressive, inflammatory and neurodegenerative disease, emerging as a leading cause of disability in young adults. Starting already early in the disease, persons with MS (PwMS) encounter a spectrum of problems, including fatigue, motor, cognitive and psychosocial challenges. These problems, influenced by personal and environmental aspects, lead to distinctive limitations in daily functioning. The exacerbation of these challenges is a notable feature as the disease advances. ¹ Although not always considered, early rehabilitation can be instrumental in reducing or preventing disease burden and the ensuing limitations in functioning.

Recently, the World Health Organization (WHO) has adopted a resolution that declared functioning as the third health outcome indicator, which underlines the importance of rehabilitation. ² Functioning can be described by using the International Classification of Functioning, Disability and Health (ICF). ³ In brief, MS can impact various aspects of the ICF domains, including the disease process, body functions, and activity and participation. Rehabilitation for MS is designed to address these domains through diverse modalities like physical activity and exercise, ⁴ and uses a comprehensive approach guided by four key principles aimed at facilitating individuals’ recovery and enhancing their overall functioning and well-being: prevention, restoration, compensation and adaptation.

Rehabilitation and the disease process

The disease process in MS is characterized by inflammation, demyelination, axonal loss and gliosis. ¹ In relapsing-remitting MS (RRMS), multiple potent disease-modifying therapies (DMTs) are available to reduce inflammation and alter the disease course. However, options are limited for progressive MS (PMS). A substantial body of evidence shows that exercise is associated with reducing the number of relapses in PwMS. ⁵ In addition, studies show that better cardiorespiratory fitness predicts cortical plasticity and is associated with improved grey matter volume, deep grey matter structures and white matter integrity. ⁵ Once disease progression has already elicited demyelination and axonal loss, rehabilitation can be used to restore part of what is lost. PwMS with progressive disease who undergo progressive aerobic training, combined exercise (i.e. aerobic training and resistance training) and balance exercises are found to have an improved viscoelasticity, functional connectivity and white matter plasticity, respectively, ⁵ indicating the potential of reversing damage. Because of these favourable effects on the disease process, we argue that physical activity and exercise should be a core component of rehabilitation, starting already early in the disease.

Promoting physical activity and exercise early in the disease may also reduce the development of comorbidities. It has been shown that PwMS are significantly less active than healthy controls, resulting in an increased risk of comorbidities. ⁶ Therefore, early rehabilitation may also contribute to mitigating these comorbidities, again promoting overall well-being and enhancing quality of life.

Rehabilitation and body functions

Body functions concern impairments such as motor weakness, spasticity, sensory dysfunction, fatigue, pain, incontinence and cognitive deficits. Building reserve, both physical and cognitive, can limit the burden of these impairments or even prevent them from occurring. The concept of reserve concerns the idea that certain individuals can endure the effects of MS disease with less (or even no) decline in functioning. PwMS have a reduced risk of cognitive and physical decline if they had larger brain growth during development. ⁷ Next to developmental brain growth and premorbid intelligence, cognitive reserve can possibly be influenced by cardiovascular health, diet and sleep. ⁷ In addition, it is hypothesized that people who are more active before disease onset will experience less physical decline, as people with RRMS who have a higher premorbid physical activity experience a reduced disability progression. ⁸

Once building reserve and prevention is no longer an option, and symptoms start to become noticeable, impairments like disrupted balance, gait and cognition may cause limitations in daily functioning. Studies show that various types of rehabilitation (balance and gait training, cognitive training and occupational therapy) can be used in an attempt to restore these functions. ⁶ It is therefore important to implement early rehabilitation as it might help to build a reserve in cognitive and physical domains, facilitating prolonged utilization of body functions. Consequently, adverse effects due to disease progression are less debilitating and may only become noticeable at a later stage, if at all. This, in turn, serves to defer the onset of permanent impairments.

Rehabilitation and activity and participation

In the progression of MS, the development of irreversible impairments gives rise to activity and participation restrictions, impacting mobility, self-care, social activities and employment. Notably, motor and cognitive impairments are prominent contributors to occupational challenges in PwMS. ⁹ When complete restoration proves challenging, prompt adoption of compensation strategies becomes essential for effectively managing impairments and optimizing activity and participation. Compensatory measures addressing cognitive dysfunction, such as time management, schedules and medication reminders, have been proven beneficial. In more advanced disease stages, when compensatory measures may lose efficacy, the timely implementation of environmental adaptations becomes essential. Given the range of impairments that may manifest in MS, varying strongly between individuals, and the highly personalized nature of personal and environmental factors, the impact of MS on activity and participation levels is distinctly individual. Consequently, rehabilitation with goals targeting activity and participation domains becomes more complex, requiring a patient-tailored and often multidisciplinary approach that incorporates compensatory and adaptive measures. ¹⁰

The personalized, early and timely introduction of comprehensive rehabilitation is an indispensable requirement in the care pathways for PwMS. This rehabilitation should address all ICF domains and be grounded in the principles of prevention, restoration, compensation and adaptation. It should commence early and be consistently available throughout the entire disease course, addressing new issues as they arise. This approach positively influences disease progression by enhancing and preserving body functions through building reserves, prevention of loss, and restoring, compensating for and adapting to lost functions. Equally crucial is the fact that personalized, early and timely rehabilitation empowers PwMS to sustain or optimize their participation, address challenges more effectively and foster a sustained sense of independence and well-being. It offers PwMS the chance to an active and participatory lifestyle.