It’s Not Just Fatigue: Recognizing MS First

Multiple Sclerosis (MS) is a chronic, immune-mediated disease that targets the central nervous system. Inflammation and demyelination cause plaques to form anywhere in the brain, spinal cord, or optic nerves. This widespread potential for damage is why the symptoms of MS vary so widely from one patient to another¹ .

As physical therapists, we are often in a unique position to detect the early signs of MS. A patient might present for recurrent fatigue, falls, dizziness, or vague sensory complaints, and we could be the first line of care to recognize the bigger picture. Understanding the disease, its red flags, and how it behaves is critical to providing safe, effective, and timely intervention.

MS Looks Different for Every Patient

The location of demyelinating plaques determines the clinical presentation. Some patients present with unilateral vision loss and pain with eye movement (optic neuritis). Others develop balance issues, spasticity, bladder urgency, or sensory changes. Because any tract of the CNS can be affected, MS may present like a vestibular issue, an orthopedic condition, or even as vague fatigue or anxiety¹ .

According to the NICE guidelines, the most common presenting symptoms of MS include:

• Vision loss in one eye with painful eye movements

• Double vision

• Ascending sensory loss or weakness

• Lhermitte’s sign (shock-like sensation with neck flexion)

• Progressive balance and gait dysfunction

• Spasticity

Among the most important symptoms to recognize and manage in physical therapy are fatigue and heat sensitivity. Fatigue in MS is not just tiredness; it is a primary neurological symptom that can affect endurance, balance, and cognitive performance. Heat sensitivity can exacerbate all symptoms, even during mild exertion. If not respected, both can lead to functional decline or pseudo-relapse^1,2 .

These symptoms must shape treatment planning. Strategies include scheduling sessions during cooler times of day, incorporating rest breaks, and choosing moderate intensity exercises that avoid overheating. Educating patients on energy conservation and self-monitoring is essential to supporting long-term participation in therapy.

Patients are typically under age 50, and symptoms often evolve over 24 hours or more, improve partially, and are not associated with fever or infection¹ .

Red Flags Physical Therapists Should Screen For

When a patient presents with unexplained balance loss, fatigue, or falls, physical therapists must think beyond deconditioning or age-related weakness. MS often presents subtly, and early neurologic signs can be missed without a thorough screening.

A scanning exam, cranial nerve testing, coordination assessment, sensation testing, and reflex testing can each reveal neurologic findings that are not consistent with musculoskeletal limitations. Functional tasks such as stair climbing, gait observation, or sit-to-stand transfers may reveal spasticity, ataxia, or abnormal movement patterns, especially if movement appears effortful despite preserved strength¹ .

Do not automatically attribute gait disturbances to weakness alone. If symptoms are disproportionate, progressive, or unresponsive to typical treatment, consider neurologic causes. Prior episodes of transient numbness or blurred vision, Lhermitte’s sign, or heat-sensitive fatigue further raise suspicion for MS. In these cases, referral to neurology may be warranted^1,2 .

Types of MS and Their Clinical Implications

MS is classified by its pattern of progression:

• Relapsing-Remitting MS (RRMS): Clearly defined attacks followed by partial recovery. This is the most common form. Over time, about two-thirds of individuals with RRMS will transition to Secondary Progressive MS (SPMS), usually within 10 to 20 years¹ .

• Secondary Progressive MS (SPMS): Initially relapsing, but becomes steadily progressive over time.

• Primary Progressive MS (PPMS): Steady progression of symptoms from the beginning, with no relapses. Seen in about 10 to 15 percent of cases.

• Progressive Relapsing MS (PRMS): Rare. Progressive from onset, with superimposed relapses¹ .

Understanding the type of MS helps physical therapists decide whether a restorative or compensatory approach is more appropriate. In RRMS, periods of remission may allow for restorative treatment such as aerobic exercise, strengthening, and neuromotor retraining. In contrast, individuals with SPMS or PPMS often benefit more from compensatory strategies that focus on preserving safety and independence. These include assistive technology, mobility aids, energy conservation techniques, and caregiver training.

Treatment plans should be flexible and evolve alongside the patient's functional changes and goals.

Evidence-Based Interventions for MS

Now here is what you all came here to read: how can I help my patient with MS?Effective physical therapy for individuals with MS centers on maximizing function, managing symptoms, and adapting care as the disease progresses. The strongest evidence supports interventions that address mobility, fatigue, strength, balance, and safety. According to the APTA Clinical Practice Guideline and supporting literature, the following approaches offer the most benefit^{2, 3} .

1. Aerobic and Resistance Exercise
Both aerobic and resistance training have been shown to improve fatigue, walking capacity, and overall physical function in people with MS² . Moderate intensity is key. Moderate intensity corresponds to 40 to 70 percent of heart rate reserve, or a Rate of Perceived Exertion (RPE) of 11 to 14 on the Borg scale^{2, 3} . This level supports cardiovascular fitness and strength without risking symptom exacerbation.

Aerobic activity enhances cardiovascular endurance and energy efficiency, which can counteract MS-related fatigue. Resistance training helps maintain or restore muscular strength and power, especially in the lower extremities, which supports transfers and gait. These programs must be individualized and should avoid overheating or overexertion, as both can temporarily worsen symptoms¹ .

2. Balance and Gait Training
Impaired balance and fall risk are common in MS due to sensory loss, motor incoordination, or spasticity. Balance training should be task-specific and challenging, incorporating static and dynamic exercises, narrow base support tasks, and perturbation-based training. Gait interventions often include cueing strategies, treadmill walking, and adaptive equipment. These help patients regain walking confidence, improve step quality, and reduce fall frequency^{2, 3} .

3. Task-Specific and Functional Training
Neuroplasticity is still possible in MS, especially in earlier stages or during periods of remission. Repetitive practice of meaningful tasks such as stair climbing, sit-to-stand transfers, and reaching can reinforce efficient movement patterns and helps retain functional independence. This type of training also supports motor learning and can promote self-efficacy through skill mastery² .

4. Vestibular and Oculomotor Rehabilitation
Lesions in the brainstem or cerebellum may result in dizziness, vertigo, or visual disturbances. Vestibular rehab improves gaze stability, postural control, and tolerance to head movements. Exercises may include VOR training, habituation tasks, or balance activities with head turns. These are particularly useful for individuals with MS who present with subtle or persistent vestibular symptoms² .

5. Stretching and Spasticity Management
Spasticity is common in MS and can interfere with gait and daily mobility. While stretching is often used, current evidence does not strongly support its effectiveness in reducing spasticity or preventing contractures. A 2020 review concluded that stretching alone shows limited benefit for long-term spasticity management in people with MS⁴ .

In addition to stretching, orthotic devices such as ankle-foot orthoses (AFOs) can be valuable. They help improve gait efficiency, reduce fall risk, and support joint alignment, particularly when spasticity causes abnormal movement patterns or muscle weakness⁵ .

A combined approach using targeted stretching, functional activity, and orthotic compensation provides more benefit than passive stretching alone.

6. Fatigue Management and Pacing Strategies
Energy conservation is more than a home strategy, it should be built into every phase of therapy. This includes planning treatment at optimal times, using interval training formats, and teaching patients how to prioritize meaningful tasks. Incorporating rest breaks and tracking exertion levels can help avoid symptom worsening and improve session tolerance^{1, 3} .

Across all interventions, the focus should be on function, safety, and participation. PTs must regularly reassess fatigue levels, tolerance to activity, and changes in mobility. A flexible, patient-centered approach is essential, as each person’s symptom profile and disease progression will be different.

Medications to Be Aware Of

While PTs do not prescribe medications, understanding pharmacologic effects is essential for safe care¹ :

• Ampyra (dalfampridine): May improve walking speed but increases seizure risk.

• Baclofen, tizanidine: Used to treat spasticity but may cause sedation, weakness, or hypotonia.

• Gabapentin: Often prescribed for pain or spasticity. Can cause fatigue and dizziness.

• Steroids: Used in high doses during relapses. Side effects include mood changes, blood sugar spikes, palpitations and insomnia.

• Disease-modifying therapies (e.g., Tysabri, Ocrevus): Reduce relapse rate and progression but require close monitoring.

Knowing which medications your patient is on helps you interpret performance changes and adjust appropriately. Also, these are just a few of the possible medications a patient may be taking and only some of their respective side effects. If you notice any other inconsistent new signs or symptoms never hesitate to refer back to the patients PCP.

Parting Words

MS presents differently in every patient, and physical therapists play a key role in early recognition and long-term management. Stay alert to signs that suggest something beyond weakness or deconditioning.

Fatigue and heat sensitivity are not minor issues. They directly impact function and recovery, and should guide how you plan and pace each session.

Use interventions that are supported by evidence, but always adapt to the individual. Whether you are restoring function or helping someone compensate, your clinical judgment matters.

Listen closely. The patient will often reveal what the disease does not.

References:

1. National Institute for Health and Care Excellence (NICE). Multiple Sclerosis in Adults: Management (NG220). London: NICE; 2022. Available from: https://www.nice.org.uk/guidance/ng220

2. Platta ME, Ensari I, Motl RW, Pilutti LA. Effect of exercise training on fitness in multiple sclerosis: A meta-analysis. PM R. 2016;8(6):542–552. doi:10.1016/j.pmrj.2015.10.018

3. Hebert JR, Corboy JR, Manago MM, Schenkman M. Effects of vestibular rehabilitation on multiple sclerosis–related fatigue and upright postural control: A randomized controlled trial. Physical Therapy. 2011;91(8):1166–1183. doi:10.2522/ptj.20100372

4. Katalinic OM, Harvey LA, Herbert RD. Stretch for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews. 2010;(9):CD007455. doi:10.1002/14651858.CD007455.pub2

5. Bregman DJJ, Harlaar J, Meskers CGM. Spring-like ankle foot orthoses reduce the energy cost of walking by taking over ankle work in patients with calf muscle weakness. Journal of NeuroEngineering and Rehabilitation. 2019;16:10. doi:10.1186/s12984-019-0482-3

Disclaimer:

I am a current Doctor of Physical Therapy (DPT) student sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While I strive to provide accurate and up-to-date information, my knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.