Table 3.

Lifestyle physical activity recommendations and key messages for EDSS 0–9.0.

EDSS 0–4.5 (mild impairments)
Key messages • Lifestyle physical activity can be accumulated as part of work, household, and leisure, activities • Cooling strategies may be useful for those with heat intolerance	Recommended lifestyle physical activity strategies • Options are: selected rather than prescribed, planned or unplanned/spontaneous, and accumulated in one long bout or multiple, short bouts throughout the day6,45 • Physical activity is facilitated through behavior change strategies/techniques (e.g. self-monitoring) and environmental stimuli/prompts (e.g. alarms or calendar notes)46 • Physical activity levels can be tracked through self-report (journal) or devices (accelerometry)47,48 • Options include: 150 minutes per week or 30 minutes 5 days per week;6,45,49 7,500 steps per day (0.5 standard deviation above the expected for the MS population and a clinically meaningful change);50 increasing daily steps by 800 per day (smallest MCID);51 or increasing daily steps by 15% per day (smallest MCID); Godin Leisure-Time Exercise Questionnaire health contribution scores of either 24+ or 14–23 units based on starting point of 14–23 or <14 units, respectively52 • Participation options ○ In-person behavioral education/coaching in groups or individually53,54 ○ Remote physical activity behavioral education/coaching in groups or individually50,55,56 ■ Lifestyle physical activity is sustained after support interventions are no longer present50 ○ Active gaming57 ○ Environmental stimuli/prompts (alarms/alerts)46
Expert Opinion: • Evidence that most individuals with MS and in the general population do not meet recommended levels of physical activity has prompted a shift from exercise training for fitness toward lifestyle physical activity for health and wellness6,45 • Options include walking, gardening, road cycling, hiking with poles, individual and team sports, and dancing • Approaches for changing lifestyle physical activity can be delivered in person or through indirect channels (Internet, phone calls, or newsletters)58 • Motion sensors can help monitor activity and serve as motivation59
EDSS 5.0–6.5 (increasing mobility impairments)
Key messages Same as above, plus • Using the appropriate mobility aid can promote physical activity and safety • Adapted leisure activities can increase physical activity levels • Specialists can facilitate greater physical activity levels	Recommended lifestyle physical activity strategies Same as above Participation options Same as above
Expert Opinion/Clinical Considerations: Same as above, plus • Inconsistencies may exist when recording step count for people using mobility aids • Decline in the amount of physical activity often parallels the person’s reluctance to use a more progressive mobility device • Adherence improves with enjoyable activities and ability to demonstrate progress toward goals
EDSS 7.0–7.5 (diminished ability to perform ADLs—non-ambulatory)
Key messages • At this level of disability, all recommendations are expert opinion except where noted, due to lack of published evidence • Daily physical activity is essential • Functional movement of any kind, including ADLs, counts as physical activity • Wheelchair sports/adapted physical activity programs may be appropriate and beneficial • Rehabilitation professionals can help persons integrate more physical activity into the day	Recommended lifestyle physical activity strategies 150 minutes weekly, as tolerated • Walking, as able • Manual wheelchair propulsion60,61 • Power-assist cycling • Swimming • Water therapy with skilled provider • Adaptive sports of all kinds • Seated dancing, yoga, boxing • Active weight shifting62 • Pressure relief (front/lateral press-ups)
EDSS 8.0–8.5 (increasing difficulty performing ADLs—confined to wheelchair)
Key messages Same as above	Recommended lifestyle physical activity strategies 150 minutes weekly, as tolerated • Active participation in ADLs as able, with assistance when necessary • Water activity with skilled provider • Bed mobility with assistance when necessary • Pressure relief (front/lateral press-ups)
EDSS 9.0 (inability to perform most ADLs—confined to bed or chair)
Key messages Same as above	Recommended lifestyle physical activity strategies • As much physical activity as possible • Bed mobility with assistance • ADLs with assistance (e.g. dental hygiene) • Standing in a pool or in a standing frame may be possible with skilled support • Passive pressure relief

EDSS: Expanded Disability Status Scale; MS: multiple sclerosis; MCID: minimal clinically important difference; ADLs: activities of daily living.