Exercise and multiple sclerosis: fatigue, strength, balance

Yes, exercise helps MS. NICE tells clinicians to encourage people with MS to exercise, because regular exercise may benefit their MS and does not harm it [1]. Trials show gains in fatigue, strength, walking and balance [3][4][5]. The most reliable results come from supervised programmes that mix aerobic and resistance work, adjusted to your symptoms, heat sensitivity and energy [1][2].

Does exercise help MS, and how important is it?

For years people with MS were told to rest; the MS Society's 2020 evidence review notes that rest was once "the treatment of choice" [6]. That advice has been reversed.

NICE's 2022 guideline (NG220) says: "Encourage people with MS to exercise. Advise them that regular exercise may have beneficial effects on their MS and does not have any harmful effects on their MS" (1.4.1) [1]. For people with mobility problems or fatigue it asks clinicians to consider supervised programmes of moderate progressive resistance training and aerobic exercise (1.5.20) [1].

A systematic review of 54 studies found that exercise twice a week at moderate intensity increases aerobic capacity and strength in mild to moderate disability [4]. A review in Nature Reviews Neurology adds benefits for walking, "fatigue, gait, balance and quality of life" [5]. It is well tolerated: in supervised studies more than 80% of people completed the programme [6].

How to exercise with MS: how much, and what kind

The most specific guidance comes from an international expert panel published in Multiple Sclerosis Journal in 2020. It recommends at least 150 minutes a week of exercise and/or at least 150 minutes a week of lifestyle physical activity, progressed gradually "based on the person's abilities, preferences, and safety" [2].

For mild to moderate disability the panel's targets are [2]:

• Aerobic: 2 to 3 times a week, 10 to 30 minutes at moderate intensity (40 to 60% of maximum heart rate)
• Strength: 2 to 3 times a week, 1 to 3 sets of 8 to 15 repetitions per exercise
• Flexibility: daily stretching, holding each stretch 30 to 60 seconds

The panel also recommends an early assessment by a physiotherapist, occupational therapist or exercise scientist experienced in MS, and that when mobility is very limited, exercise "should be facilitated by a trained assistant" [2].

Is walking good exercise for MS? Is swimming? The evidence does not single out one type: "it's not clear that any one type of exercise should be recommended for a particular improvement or outcome" [6]. Treadmill walking increases walking speed, and an 8-week aqua aerobics trial (3 sessions a week) improved walking speed, balance and perceived fatigue in women with low disability scores [6]. Seated classes exist for people who cannot stand for long. The MS Society's advice is simple: "some activity is better than none", and do both aerobic and strength work [6].

What's the best exercise for MS fatigue?

Fatigue is the symptom with the strongest exercise evidence. A Cochrane review pooled 45 trials with 2,250 people; across the 36 trials reporting fatigue (1,603 people), exercise produced a moderate reduction compared with no exercise (standardised mean difference −0.53) [3].

Endurance training, mixed training and approaches such as yoga all helped, with mixed aerobic-plus-resistance programmes showing the largest effect [3]. NICE agrees: "aerobic, resistive and balance exercises, including yoga and pilates, may be helpful in treating MS-related fatigue" (1.5.7) [1].

One caveat: the benefit can fade once a programme stops [6], so NICE asks clinicians to help people keep exercising afterwards (1.5.23) [1]. And the MS Trust stresses that it is "not a good idea to 'work through' fatigue" [9].

Can exercise slow MS progression?

Be wary of confident claims here. Exercise clearly improves fitness and function; whether it changes the underlying disease course is not settled.

The 2020 expert panel lists "disease-modifying effects (secondary prevention)" among its rationale [2]. The Nature Reviews Neurology review is more cautious: exercise "is proposed to affect inflammation, neurodegeneration, and CNS structures, but current evidence is limited" [5].

The best direct test so far is a Danish trial of 84 people diagnosed within the previous two years, who did 48 weeks of supervised high-intensity aerobic training alongside their usual disease-modifying drugs. Aerobic fitness rose by 21%, but there was "no difference between the two groups in relapse rate, brain tissue loss or number of lesions" [7].

What exercise does not do is trigger relapses: in the Cochrane review relapse counts were almost identical in the exercise and control groups (25 versus 26) [3]. Treat exercise as a proven way to protect your function, not a substitute for disease-modifying treatment.

Exercise, heat and Uhthoff's phenomenon

Many people with MS find symptoms worsen as their body temperature rises. The MS Trust calls this Uhthoff's phenomenon: "the temporary worsening of MS symptoms in response to an increase in temperature", with exercise a common trigger [8].

The key word is temporary. Symptoms "should improve within a few hours once you cool down", and the worsening "is not usually due to new MS damage" [8]. Heat-sensitive people may simply need cooling strategies [2].

Practical steps the MS Trust recommends [8][9]:

• Exercise in a cool room, near a fan or open window
• Wear loose, lightweight clothing and drink iced water before and during sessions
• Use cooling garments (vests, scarves, wrist bands) or a mister on your wrists and face
• Choose water-based exercise, where the water cools you as you work

Exercise during MS relapse

A relapse is a new or significantly worse symptom lasting at least 24 hours, with no other explanation such as infection or overheating, after at least 30 days of stability [10]. If that describes you, contact your MS team first.

In early recovery the MS Trust advises resting "as much as possible to help with any fatigue". As you improve, "you can slowly build back up to your usual activities and normal routine. This might include some gentle exercise if you're able to do it safely" [10]. Physiotherapy after a relapse can address deconditioning [10].

The evidence here is thin: a City, University of London study notes that "little is known about the safety of exercise during a relapse and when physical activity should be" restarted. Rebuild under supervision rather than guess.

Balance exercise for MS: walking and falls

Balance training has "a small, but statistically significant effect on improving stability and reducing the risk of falls" for people with moderate disability [6]. Mixed aerobic, resistance and balance programmes have significantly improved walking compared with no exercise [6].

NICE recommends vestibular rehabilitation where fatigue or mobility problems are linked to limited standing balance (1.5.19) and, for an EDSS score of 4 or more, supervised aerobic and progressive resistance training with cognitive behavioural techniques (1.5.9) [1]. Balance work should be set up by someone who has assessed your falls risk, not copied from a video.

Can you overdo exercise with MS?

Yes, and the signs differ from the general population. The MS Trust puts it plainly: "The attitude of 'no pain, no gain' does not apply in MS", and a person with MS "should be prepared to stop before their body is telling them they have reached their limit" [9].

People with MS have "a reduced tolerance for strenuous physical activity", and any heat-related worsening "tends to go away soon after finishing exercise" [6]. A short-lived flare after a session is common; a lasting worsening is not, and needs a clinical check.

Who should you see?

MS is a neurological condition, so a physiotherapist with expertise in MS is central; NICE names them for helping people continue to exercise, alongside exercise referral schemes (1.5.21) [1]. Physiotherapists are statutorily regulated by the HCPC and are the right first call for diagnosis, hands-on treatment and post-relapse rehabilitation.

For structured fitness, strength prescription and exercise testing, a Clinical Exercise Physiologist (CEP) is the most specialised exercise professional. NHS Health Careers lists them as healthcare scientists who prescribe evidence-based exercise for long-term conditions, carry out cardiopulmonary exercise testing and tests such as the six-minute walk, and work across neurological conditions including "stroke, dementia, Parkinson's disease and multiple sclerosis" [11]. The route is an accredited master's degree and the AHCS voluntary register; they typically work at NHS band 6 [11]. Their skills overlap with physiotherapists rather than replace them; see our tiers guide and what is a Clinical Exercise Physiologist.

Underneath CEPs sit Level 4 Long-term Neurological Conditions instructors. The Wright Foundation's Level 4 course, developed with Keele University and endorsed by CIMSPA, requires an exercise referral qualification and trains instructors to deliver exercise to referred clients with neurological conditions [12]. They cannot diagnose or act as a regulated clinician, but for someone stable and already assessed they are a lower-cost way to keep exercising in a leisure centre or community class.

	Physiotherapist (neuro)	Clinical Exercise Physiologist	Level 4 LTNC instructor
Regulation	HCPC statutory register	AHCS voluntary register (PSA-accredited)	Ofqual/CIMSPA qualification
Best for	Diagnosis, relapse rehab, hands-on treatment, falls assessment	Exercise testing, structured strength and fitness prescription, complex or changing MS	Supervised classes for stable, assessed people
Setting	NHS and private clinics	NHS services, private practice	Leisure centres, community schemes

Ready to start? Request a match with a verified clinical exercise physiologist through The Health Nav.

When to be cautious / talk to your doctor first

Speak to your MS team or GP before starting or changing an exercise programme if:

• You think you are having a relapse (new or worse symptoms for more than 24 hours) [10]
• Symptoms worsen with exercise and do not settle within a few hours of cooling down [8]
• You have had falls, or your standing balance is limited [1]
• Your mobility is very limited and you would need help to exercise safely [2]
• You are struggling with depression or fatigue [9]

Related guides: exercise referral schemes and exercise and Parkinson's, which shares the same Level 4 specialism.

Getting matched with a specialist

Tell us about your MS and where you are, and we match you with a verified clinical exercise physiologist who works with long-term neurological conditions. If you are newly diagnosed or recovering from a relapse, bring your MS team's advice to the first session.

Request a match with a verified exercise specialist through The Health Nav.

This article is general information and does not replace advice from your own healthcare team.

References

1. National Institute for Health and Care Excellence. Multiple sclerosis in adults: management. NICE guideline NG220. 22 June 2022. https://www.nice.org.uk/guidance/ng220 (accessed 15 Sep 2026)
2. Kalb R, Brown TR, Coote S, Costello K, Dalgas U, Garmon E, Giesser B, Halper J, Karpatkin H, Keller J, Ng AV, Pilutti LA, Rohrig A, Van Asch P, Zackowski K, Motl RW. Exercise and lifestyle physical activity recommendations for people with multiple sclerosis throughout the disease course. Multiple Sclerosis Journal. 2020;26(12):1459-1469. https://doi.org/10.1177/1352458520915629
3. Heine M, van de Port I, Rietberg MB, van Wegen EEH, Kwakkel G. Exercise therapy for fatigue in multiple sclerosis. Cochrane Database of Systematic Reviews. 2015;(9):CD009956. https://doi.org/10.1002/14651858.CD009956.pub2
4. Latimer-Cheung AE, Pilutti LA, Hicks AL, Martin Ginis KA, Fenuta AM, MacKibbon KA, Motl RW. Effects of exercise training on fitness, mobility, fatigue, and health-related quality of life among adults with multiple sclerosis: a systematic review to inform guideline development. Archives of Physical Medicine and Rehabilitation. 2013;94(9):1800-1828.e3. https://doi.org/10.1016/j.apmr.2013.04.020
5. Motl RW, Pilutti LA. The benefits of exercise training in multiple sclerosis. Nature Reviews Neurology. 2012;8(9):487-497. https://doi.org/10.1038/nrneurol.2012.136
6. MS Society. Physical activity and managing MS: review of the evidence on physical activity for people with MS. December 2020. https://www.mssociety.org.uk/sites/default/files/2021-01/Physical%20activity%20evidence%20review_2020.pdf (accessed 15 Sep 2026)
7. MS Trust. Can exercise therapy started soon after diagnosis affect the course of multiple sclerosis? 20 April 2022. https://mstrust.org.uk/research/research-updates/220421-exercise-therapy-soon-after-diagnosis (accessed 15 Sep 2026)
8. MS Trust. Heat sensitivity and MS (Uhthoff's phenomenon). https://mstrust.org.uk/a-z/uhthoffs-phenomenon (accessed 15 Sep 2026)
9. MS Trust. Starting to exercise with MS. https://mstrust.org.uk/information-support/exercise-ms/starting-exercise (accessed 15 Sep 2026)
10. MS Trust. MS relapses and their management. https://mstrust.org.uk/information-support/ms-symptoms-diagnosis/managing-ms-relapses (accessed 15 Sep 2026)
11. NHS Health Careers. Clinical exercise physiologist. https://www.healthcareers.nhs.uk/explore-roles/healthcare-science/roles-healthcare-science/physiological-sciences/clinical-exercise-physiologist (accessed 15 Sep 2026)
12. WRIGHT Foundation CIC. Exercise for Long Term Neurological Conditions (Level 4). https://www.wrightfoundation.com/course/exercise-for-long-term-neurological-conditions-15-10-24/ (accessed 15 Sep 2026)