Guidelines for Home-Based Physical Activities during COVID-19 Quarantine for People with Multiple Sclerosis: A Narrative Review

Abstract

Background: COVID-19 seems to have a major impact on physical activity behaviors, especially for people with Multiple Sclerosis (MS) who have health
conditions.
Methods: This study was a narrative review. Six databases, namely PubMed, ISI Web of Knowledge, Scopus, Google Scholar, Science Direct, and ProQuest, were searched for relevant published studies.
Results: Healthcare providers and organizations advise people to stay at home, but this does not mean that they should be inactive. Self-isolation has an adverse effect on behavior activities and mental health in people with MS. Physical activity can act as medicine for people with MS, as it helps reduce stress, anxiety, and fatigue while improving balance, muscle strength, flexibility, and quality of life.
Conclusion: People with MS are recommended to perform activities such as whole-body chair exercises with moderate intensity at least 150 minutes per week according to the level of the individual’s ability.

Full text

JRSR 8 (2021) 158-163
Guidelines for Home-Based Physical Activities during COVID-19
Quarantine for People with Multiple Sclerosis: A Narrative Review
Hamid Mahdavi Mohtasham
1
*, MSc; Shahnaz Shahrbanian
2
, PhD; Majid Mahdavi Mohtasham
3
, MSc
1Department of Sports Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2Depart ment of Sport Science, Faculty of Humanities, Tarbiat Modares University, Tehran, Iran
3Depart ment of Computer Sc ience, Isla mic Azad University Kermanshah Branch, Kerman shah, I ran
ARTICLE INFO
Review Article
Article History:
Received: 19/12/2020
Revised: 29/05/2021
Acce pted: 29/0 9/2021
Keywords:
Disability
COVID-19
Home-based exercise
Mulple sclerosis
Physical acvity
ABSTRACT
Background: COVID-19 seems to have a major impact on physical activity
behaviors, especially for people with Multiple Sclerosis (MS) who have health
conditions.
Methods: is study was a narrative review. Six databases, namely PubMed, ISI
Web of Knowledge, Scopus, Google Scholar, Science Direct, and ProQuest, were
search for relevant published studies.
Results: Healthcare providers and organizations advise people to stay at home,
but this does not mean that they should be inactive. Self-isolation has an adverse
eect on behavior activities and mental health in people with MS. Physical
activity can act as medicine for people with MS, as it helps reduce stress, anxiety,
and fatigue while improving balance, muscle strength, exibility, and quality of
life.
Conclusion: People with MS are recommended to perform activities such as
whole-body chair exercises with moderate intensity at least 150 minutes per
week according to the level of the individual’s ability.
2021© e Authors. Published by JRSR. All rights reserved.
Journal of Rehabilitation Sciences and Research
Journal Home Page: jrsr.sums.ac.ir
Please cite this article a s:
Mahdavi Mohta sham H, Shahrbanian
S, Mahdavi Mohtasham M.
Guidelines for Home-Based Physical
Activities during COVID-19
Quarantine for People with Multiple
Sclerosis: A Narrative Rev iew. JRSR.
202 1;8 (4):158-163.
Introduction
The novel coronavirus disease 2019 (COVID-19),
identied in December 2019 in Wuhan, China, is an
infectious disease which leads to mild to moderate
respiratory illness. According to the World Health
Organization (WHO), COVID-19 is a pandemic. To
protect against contracting the virus, people should stay
at home and isolate themselves, but such practices could
adversely affect people’s physical activity behaviors [1].
Multiple sclerosis (MS) is an autoimmune disease of the
central nervous system (CNS) which leads to physical or
cognitive disabilities [2]. The exact cause behind MS is
still unknown, but there is increasing evidence suggesting
that a combination of genetic and environmental factors
may increase the risk of developing this disease [3].
Genetic factors include genetics, smoking, and obesity,
and environmental factors include climate, certain
autoimmune diseases such as type 1 diabetes, certain
infections such as coronavirus and human herpesvirus
6 (HHV-6), age, and gender [2, 3]. MS is common in
women, and onset can vary from childhood to adult life;
around an age of 20-40 is most frequently seen [4]. MS
symptoms comprise muscle stiffness, spasms, weakness,
fatigue, walking and balance dysfunction, depression
and anxiety, and problems with mobility [3]. Because
of these disabilities, people with MS are less active than
healthy adults [5], which can affect their quality of life
(QOL) [2].
People with MS are a vulnerable group during
COVID-19 pandemic [6]. To reduce the risk of catching
COVID-19, the authorities have recommended that
people with MS should self-isolate as much as possible
[6]. However, studies have shown that isolation can
reduce health‐related quality of life (HRQOL) in up to
*Corresponding author:
Hamid M ahdav i Mohtas ham, M Sc; Depa rt ment
of Sports Medic ine, School of Medic ine, Sh ahid Behesht i Univer sity of
Medica l Sciences, Yaman st, Shah id Chamran H ighway, P.O. Box: 19857-
17443, Tehran, I ran . Tel : +98 21 22605090
Email: hamid mahdavi@ sbmu.ac.ir

Exercise guidelines for MS during COVID-19
JRSR. 2021;8(4) 159
70% of MS sufferers [7]. COVID-19 has adverse effects
such as anxiety on the mental health of healthy adults [8],
and its effects could be much worse for people with MS.
The WHO state that physical activity is important for
health and well-being during self-quarantine [9]. There
is no original study or clinical trial on how exercise can
protect people with MS against COVID-19, but there are
plenty of studies on the effects of exercise on respiratory
illness [10, 11] and how exercise improves immune
system function [12].
Upper respiratory tract infection (URTI) is caused by
various pathogens such as coronavirus and inuenza,
which involves the nose, sinuses, pharynx, or larynx
[13]. It is believed that moderate-intensity exercise such
as aerobic activity can help the immune system deal with
pathogens to reduce the risk of the infection severity (32-
41%), frequency (43-46%), and symptomatology (34-
41%) [11].
It is acknowledged that reducing stress levels, getting
adequate sleep, and eating a balanced diet strengthen the
immune system. Studies have also shown that exercise
makes the body resistant to diseases such as colds and
u [10, 11]. The J-shape model describes the relationship
between exercise intensity and the risk of catching URTI.
The model showed that moderate-intensity exercise may
lower the risk of URTI, while high-intensity exercise
may increase the risk [14]. Hence, moderate-intensity
exercise could enhance immune function, decreasing the
risk of respiratory infections.
T helper (Th) cells play a signicant role in the initiation
and progression of MS. Th-2 cells reduce inammation
by specic cytokines such as interleukin (IL)-4 and IL-
13, while Th-1 and Th-17 cells promote inammation by
a large number of cytokines such as interferon-gamma
(IFN-γ), IL-17, IL-21, IL-22, and IL-26 [3]. One study
indicated that IL-4, IL-10, c-reactive protein (CRP),
and IFN-g are signicantly reduced after progressive
resistance training [15]. In addition, a most recent study
indicated that 8 weeks of combined exercise (aerobic
and resistance training) in people with MS may decrease
plasma and peripheral blood mononuclear cell (PBMC)
IL-17 and IFN-γ production [16].
During the COVID-19 pandemic, gyms and healthcare-
related centers have been closed, and people with MS
cannot benet from exercise, but they can perform
physical activity and exercises at home. Therefore, this
study purposed to determine a strategy for protecting
people with MS against the COVID-19 pandemic and to
propose a home-based exercise activity for people with
MS during the COVID-19 quarantine period.
Methods
This narrative review of studies on the effects of exercise
in people with MS was conducted to propose a guideline
for people with MS during COVID‐19 quarantine.
The databases of PubMed, ISI Web of Knowledge,
Scopus, Google Scholar, Science Direct, and ProQuest
were searched for the key words people with MS, multiple
sclerosis, immune system, COVID-19, coronavirus,
exercise, home-based exercise, and physical activity.
After eliminating all unrelated and repetitive articles,
those articles that met the inclusion criteria and were
written in English were selected (Figure 1).
Results
Various studies have been conducted on the different
activities of people with MS, such as aerobic [17],
resistance [17], yoga [18], and Pilates [19] exercises.
MRI studies have shown that physical activity may
have neuroprotective effects by increasing the cortical
thickness in people with MS, which can, in turn, impact
the progression of the disease [20]. According to meta-
Figure 1: Search strategy diagram

Mahdavi Mohtasham H et al.
JRSR. 2021;8(4)
160
analyses and systematic reviews of randomized controlled
trials, exercise and physical activity can improve QOL
[21] and impact overall immune function [22] in people
with MS and serve as “medicine” [2]. Moreover, exercise
can improve the mental health of people with MS [23].
Home-Based Physical Activity
Although gyms are closed due to the pandemic, people
with MS can benet from performing physical activities
at home. Every exercise can be performed at home except
those that need particular equipment, such as weights. MS
sufferers can also benet from home equipment workouts
such as TRX, resistance bands, ankle weights, etc. Sosnoff
et al. studied adults with MS who performed 12 weeks of
a group of exercises (stretching, core muscle strength,
balance, and lower limb muscle strength); each session
lasted 45-60 minutes, and each exercise was performed in
sets of 8-10 repetitions [24]. Their results showed that that
home-based exercises are safe, feasible, and effective for
reducing physiological fall risk in older adults with MS [24].
Resistance Training. Studies have found that resistance
training can improve muscle strength in people with
MS [25]. Furthermore, resistance training can improve
functional capacities such as gait, stair climbing, and
chair transfer [25-27] and decrease fatigue [25] in
people with MS. Most studies have focused on the lower
extremities [25, 27], because strength decit is more
frequently experienced in the lower extremities than in
the upper extremities by people with MS [28]. DeBolt
et al. showed that home-based resistance exercise can
improve leg extensor power in people with MS. Their
patients performed lower-extremity resistance training
accompanied by a DVD 3 times per week for 8 weeks.
The sessions consisted of 5-10 minutes warm-up, 25-
30 minutes strengthening exercises, and 5-10 minutes
whole-body stretching. The patients performed 3 sets of
8-12 repetitions of chair raises, forward lunges, step-ups,
heel-toe raises, and leg curls. To increase the intensity, a
vest, ankle weights, and a step were used [27].
Some studies conducted on upper extremity showed
improvement in the upper extremity muscle strength
(elbow exors and extensors, shoulder abductors and
adductors) [26].
Endurance Training. Many studies have investigated
different kinds of endurance training, such as bicycle
ergometry and treadmill walking [29-34]. Endurance
training can be done at home on a chair in the sitting
position such as seated knee lifts (Figure 2). The results
of previous studies have indicated that endurance
training with low to moderate intensity can improve the
activities of daily living in people with MS with EDSS
scores below 7. Studies have also shown that long-
term endurance training can improve maximal aerobic
capacity (Vo2max) [30].
Figure 2: 5-minute whole-body workout on chair. Adapted from MS-UK (Multiple Sclerosis-United Kingdom) with permission. Reps: Repetitions

Exercise guidelines for MS during COVID-19
JRSR. 2021;8(4) 161
Virtual reality-based treadmill training (VR-TT) can be
benecial for people with MS. People with MS with mild
to moderate disabilities received VR-TT three times per
week for six weeks, and each session lasted 45 minutes.
The results showed signicant improvements in walking
endurance and speed, cadence and stride length, lower
limb joint ranges of motion, powers, and balance [35].
Core exercise. People with MS suffer from walking
impairments, and trunk control is a prerequisite for
walking. One study indicated that core and balance
exercises, called Group Core DIST, performed for 60
minutes three times per week for 6 weeks could improve
walking [36].
Pilates. Marques et al. reported the safety and eciency
of Pilates training as a method to improve QOL,
cognition, physical performance, strength, balance,
walking, and posture parameters in people with MS. The
exercise group performed home-based training (chair
raises, forward lunges, step-ups, heel-toe raises, and leg
curls) 3 times per week for 8 weeks [19].
Yoga. Hasanpour-Dehkordi et al. indicated that yoga
can increase lower extremity strength and balance. It can
also decrease fatigue and pain in people with MS [37]. In
their study, MS sufferers performed yoga exercises three
sessions per week for 12 weeks, and each session lasted
60-70 minutes. Hatha yoga was performed in the study,
which included postures, breathing, and meditation
components. Each pose was held between 10-30 seconds,
and the rest interval between poses was 30-60 seconds
[37]. Yoga can help MS patients control their anxiety and
stress, and it promotes social functioning. Hasanpour-
Dehkordi and Jivad found that yoga may improve QOL
in people with MS. The study compared the effects of
regular aerobic and yoga on QOL in people with MS.
The patients performed yoga 3 sessions per week for 12
weeks [34].
Recommendations for Physical Activity
People with MS should perform physical activities at
least 150 minutes per week (2-3 days per week) [38].
There are examples of exercises which they can do for
different goals, such as balance exercises (standing and
straight-line walking with as little assistance as possible),
lower limb muscle strength exercises (squats and leg
abductions with an exercise band), stretching exercises
(ankle rotations, hamstring stretch, and inner groin
stretch), and core muscle strength exercises (abdominal
crunch and seated twist), or they can adapt the exercises
to their own needs at the online source (Table 1) .
People with MS can begin with one set of 8 repetitions
per each task and progress to three sets of 8 repetitions.
According to their ability, they can later change the
exercise progression through lying, kneeling, sitting, or
standing positions. Figure 2 presents a 5-minute whole-
body workout on the chair proposed by MS-UK.
To have a successful workout, people with MS should
remember to do a warm-up before and a cool-down after
the workout. Moreover, they should not push their bodies
hard. If they need to rest, they should do so without
hesitation. In addition, people with MS should keep
their body temperature low by staying hydrated-cold or
exercising in a cool room.
Table 1: Guideline for home-based activities for patients with multiple sclerosis (MS) during COVID‐19 quarantine
Mode of Exercise Guideline General Goals Example
Physical Activity ● Daily
● 30 min in total
● Improve daily activity
● Increase energy expenditure
● Cooking
● Gardening
● Household chores
Aerobic exercise ● 2–3x/week
● 10–30 min (40%–60% MHR) (or 3 sets,
10 min)
● Increase cardiovascular function
● Improve endurance capacity
● Reduce risk for coronary artery
disease
● Stationary bike
● Chair aerobics
● Water aerobics
● Walking
● Dancing
Resistance Training ● 2–3x/week
● 1–3 sets for each exercise,
● 8–15 repetitions
(or 10 sets, 3 repetitions)
● 5–10 exercises
● Increase muscle strength and
endurance
● Reduce fatigue
● Reduce spasticity
● Equalize agonist/antagonist
● Bodyweight
● Resistance Band
● Free weight
● Weight Machines
● Ball
● Pilates
Flexibility (Stretching) ● Daily
● 2–3 sets of each stretch
● Hold 30–60 sec●
● Increase join ROM
● Reduce spasticity
● Improve balance
● Yoga
● Tai Chi
● Passive ROM
● Active ROM
Neuromotor ● 3–6x/week
● 20–60 minutes
● Prevent falls
● Improve balance
● Improve coordination
● Improve cognitive
● Tai Chi
● Virtual reality
● Yoga
Core ● 2x/day
● 4–5 repetitions
● Holding each repetition 10–15 seconds
● Prevent falls
● Improve balance
● Dead bug
● Hollow hold
● McGill curl-up
● Side bridge
● Bird dog
Postural ● Every 1–2 hours
● Hold for 10–15 seconds
● Improve gait
● Prevent falls
● Improve balance stability
● Improve coordination
● Reduce fatigue
● Active weight shifting
● Posture exercises such as Chin
tuck and Pull shoulder blades
back.
Breathing ● Every second day
● 3 sets
● 10 repetitions
● Improve lung function
● Reduce stress
● Reduce anxiety
● Square breathing (inhale, hold,
exhale, and hold for 2 sec)

Mahdavi Mohtasham H et al.
JRSR. 2021;8(4)
162
Discussion
It has been found that MS as an autoimmune disease
could be affected by environmental factors such as
COVID-19, which could further lead to an increased risk
of developing it. According to the WHO, self-isolation
is one of the protective measures against COVID-19 [1].
However, people with MS are less active than healthy
adults, and self-isolation could affect their health [7].
Various studies have reported that exercise and physical
activity play important roles in people with MS lives [2,
21, 23]. Therefore, people with MS should be active,
especially during the pandemic, but the problem is that
gyms are closed during COVID-19 quarantine.
People with MS can benet from exercising at home.
Studies have indicated that home-based exercise can
improve physical and mental health in people with MS
[24, 35, 36, 39]. People with MS can perform many types
of physical activity at home, such as resistance training,
aerobic exercise, Pilates, stretching, and virtual exercise,
based on their ability.
Because of a lack of activity during the quarantine and
safety concerns, resistance exercise may not be a good
rst choice for people with MS; after a couple weeks of
performing other home-based physical activity, however,
it might be good.
Aerobic exercise is fun, simple, and helps improve
activities of daily living and preserve energy during the
day in people with MS. Therefore, it might be a good
choice for people with MS wanting to start exercising.
Some studies have investigated the eciency of
yoga in people with MS, but methodologically sound
evidence was not found on the subject, and according to
a systematic review and meta-analysis, it requires further
study [18]. Researchers have stated, however, that
people with MS who are not adherent to recommended
exercise regimens might perform yoga as an alternative
option [18].
Pilates is a type of exercise which can be performed
at home and does not require special equipment. It
can also improve physical function [19, 24, 36]. In
addition to improving physical performance, Pilates
also can improve mental health [40]. Pilates’ breathing
principles reduce sympathetic nerve activity and lead
to improvement in serotonin system regulation [39].
The study results showed that two weekly sessions for
eight weeks of home-based Pilates by DVD at home
can improve the management of several mental health
symptoms, such as anxiety, depression, and fatigue,
among people with MS [39].
Conclusion
Although self-isolation has an adverse effect on
behavior activities and mental health in people with MS,
home-based activities provide an opportunity for them to
stay healthy during the pandemic. People with MS should
perform physical activities or exercises with moderate
intensity at least 150 minutes per week. Furthermore,
they should choose a favorable activity according to their
ability level.
Acknowledgment
The gures used in this study were produced by MS-
UK, and permission for use was granted subject to an
appropriate acknowledgement given to MS-UK. For
further exercises suitable for people living with MS, visit
the MS-UK website.
Conict of Interest: None declared.
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