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Am Fam Physician. 2022;105(5):534-539

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Key Clinical Issue

What are the benefits of physical activity in patients with multiple sclerosis (MS), cerebral palsy, and spinal cord injury who use or are at risk of using wheelchairs?

Evidence-Based Answer

Physical activity improves aerobic capacity, balance (i.e., reducing risk of falls), walking ability, depression, sleep, female sexual function, global function, and activities of daily living, depending on the population and activity being considered.1 (Strength of Recommendation [SOR]: B, inconsistent or limited-quality patient-oriented evidence.)

InterventionStrength of evidence (direction of finding)

Multiple sclerosisCerebral palsySpinal cord injury
Aerobic exercise
Dance (one randomized controlled trial in multiple sclerosis and cerebral palsy)● ○ ○
(function improvement)
● ○ ○
(function improvement)
○ ○ ○
Aerobics● ○ ○
(sleep improvement)
○ ○ ○○ ○ ○
Aquatics● ○ ○
(balance, activities of daily living, female sexual function improvement)
○ ○ ○○ ○ ○
Cycling● ○ ○
(no clear benefit on walking)
● ○ ○
(function improvement)
○ ○ ○
Robot-assisted gait training● ○ ○
(balance improvement, no clear benefit on function)
○ ○ ○● ○ ○
(activities of daily living improvement, no clear benefit on function)
Treadmill● ○ ○
(walking, function, and balance improvement)
● ○ ○
(function improvement)
○ ○ ○
Postural control
Balance exercises● ● ○
(balance improvement)
○ ○ ○○ ○ ○
● ○ ○
(fall risk improvement)
○ ○ ○○ ○ ○
● ○ ○
(function improvement)
○ ○ ○○ ○ ○
Hippotherapy○ ○ ○● ○ ○
(balance and function improvement)
○ ○ ○
Tai chi○ ○ ○○ ○ ○○ ○ ○
Motion gaming● ○ ○
(function, balance improvement)
○ ○ ○
(balance improvement)
○ ○ ○
Whole body vibration○ ○ ○○ ○ ○○ ○ ○
Yoga● ○ ○
(no clear benefit on function)
○ ○ ○○ ○ ○
Strength interventions
Muscle strength exercise● ○ ○
(no clear benefit on walking, function, balance, quality of life, spasticity)
● ○ ○
(no clear benefit on walking and function)
○ ○ ○
Multimodal exercise
Progressive resistance or strength plus aerobic and/or balance exercise● ○ ○
(walking, balance, VO2 improvement)
● ○ ○
(no clear benefit on function, quality of life)
○ ○ ○
All types of exercise● ● ●
(walking improvement)
● ○ ○
(function improvement)
● ○ ○
(function improvement)
● ● ○
(balance, depression improvement; no clear benefit on function)
● ○ ○
(VO2 improvement)
● ○ ○
(VO2 improvement, increased episodes of autonomic dysreflexia, no clear benefit on depression)

Practice Pointers

Purposeful physical activity in the general population reduces the risk of cardiovascular disease, diabetes mellitus, mental illness, cancer, and all-cause mortality.2 Although intentional physical activity, including aerobic exercise with strength and balance training, is recommended for those with physical disabilities,3 data for this population are lacking, especially for those who use, or are at risk of using, wheelchairs as their primary mode of ambulation.

The Agency for Healthcare Research and Quality (AHRQ) review was conducted to assess whether patients with MS, cerebral palsy, and spinal cord injury who use a wheelchair, or might benefit from wheelchair use in the future, derive benefits (e.g., improvements in cardiovascular outcomes, activities of daily living, mental health, walking ability, balance) from physical activity. The review included 168 studies, 146 of which were randomized controlled trials. Of the 7,511 patients who were included, 44% had MS, 38% had cerebral palsy, and 18% had spinal cord injury. Studies included many types of purposeful physical activity such as treadmill training, aquatic exercises, cycling, robot-assisted gait training, balance exercises, hippotherapy, tai chi, yoga, muscle strength building, and combinations of modalities.

No studies evaluated cardiovascular outcomes such as myocardial infarction or stroke. Studies evaluating cardiovascular health found no benefit from physical activity in those using a wheelchair or who may benefit from future use of a wheelchair, based on intermediate outcomes such as the development of hypertension or obesity. Of note, studies of these outcomes ranged from two to 24 weeks, potentially missing benefits of longer periods of exercise.1

In patients with MS, physical activity (e.g., using a tread-mill, cycling, aquatic exercise, Pilates, resistance exercise, gaming-assisted activity, yoga, multimodal combinations) compared with no physical activity or usual care improved walking ability (19 studies, n = 933; 43 additional meters on a six-minute walking test; 95% CI, 28 to 57; nine studies, n = 471; 1.4 seconds faster on a 10-meter walking test; 95% CI, 0.1 to 2.7); balance as measured by the Berg Balance Scale (17 studies, n = 879; 3.6-point improvement on a 14-point scale; 95% CI, 2.5 to 4.6); female sexual function (one study, n = 62; women in the aquatic exercise group scored 52.1 on the Sexual Function Index vs. 42.8 for those in the control group; P < .01); and depression (11 studies, n = 522; clinically significant 0.29 standard mean decrease in depression score; 95% CI, 0.03 to 0.50). There were also improvements in sleep, activities of daily living, and maximal oxygen consumption. In patients with cerebral palsy, physical activity improved balance, function, and peak oxygen consumption. In patients with spinal cord injury, physical activity improved activities of daily living, general function, and maximal oxygen consumption. Conclusions were limited by small sample sizes, short study durations, lack of clarity on activity intensity in the intervention groups, lack of specificity of activities in the control group, and a paucity of studies with a low risk of bias.

For adults, the American Heart Association recommends moderate- to high-intensity muscle-strengthening activity at least two days a week in addition to 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity per week.4 The Centers for Disease Control and Prevention recommends the same activity levels for those with disabilities who are able to achieve them. When patients with disabilities are unable to engage in the recommended levels of activity, physicians should help patients find an activity level and type of exercise that are appropriate for them.5 Physicians should continue to recommend physical activity to patients of all abilities.

Editor's Note: American Family Physician SOR ratings are different from the AHRQ Strength of Evidence ratings. Dr. Saguil is a contributing editor for AFP.

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