Following diagnosis many patients will have a period of a decade or more when they have regular relapses but little or no disability. They will have a number of needs during this time, which include access to:
• Advice, support, and information on a broad range of issues including employment and insurance
• Self-management options
• Treatment of relapses including disease-modifying agents
• Treatment of other conditions

The main focus should be on self-management, with an emphasis on the concept of wellness incorporating diet, exercise, and a healthy lifestyle. The role of steroids in the treatment of relapses has been discussed in an earlier. A recent study has compared the patients’ preference for treatment with intravenous steroids in the home or hospital setting and has demonstrated that the home setting is considered preferable.
A number of studies have been carried out evaluating the role of aerobic exercise, resistive exercise, and more recently a training programme. The impact of aerobic exercise was evaluated in 46 patients with relatively mild MS. Twenty-one patients were randomly assigned to a 15-week exercise programme, while 25 patients had no exercise during that period. There was a wide range of outcome measures, including aerobic capacity, isometric strength, a quality-of-life measure, the Sickness Impact Profile (SIP), the Fatigue Severity Scales (FSS), and the EDSS. Significant changes from baseline were seen in the exercise group over the 15 weeks in the physiologic measures and the physical component of the SIP. There was little sustained change in the psychosocial domain of the SIP and none in the EDSS or FSS.

Recently, the effects of a short-term exercise programme on aerobic fitness, fatigue, and health perception was evaluated in a group of 26 patients and the results compared to 26 matched healthy controls. Although compliance was low (65 percent), benefits were seen in all areas and the regime did not result in symptom exacerbation. Significant benefit was seen in two domains of the SF-36: vitality and social functioning.

Few studies have looked at therapy intervention in the management of MS, and the only specific modality examined has been physiotherapy. A randomized control trial of inpatient physiotherapy (6.5 hours over 2 weeks) was carried out on 45 patients. Outcome measures included the Rivermead Mobility Index, the Barthel ADL Index, and a visual analogue scale (VAS) of “mobility-related distress.” The only measure to demonstrate a significant benefit in the treated group was the VAS. A second study went a step further and attempted to compare two forms of physiotherapy. This pilot study involved 23 patients, 20 of whom completed the study. Ten patients received what was described as an impairment-based “facilitation approach” (e.g., Bobath), while the other group had a more disability-based task orientated approach (e.g. Carr and Shepherd). Patients received a minimum of 15 sessions over 5 to 7 weeks. The outcome measures were mobility-based and included the 10-meter timed walk and the Rivermead Mobility Index. Not surprisingly, no difference was seen between the two small groups, but both improved from baseline (p<0.05).

A recent randomized, controlled, cross-over study evaluated hospital and home-based physiotherapy in 40 MS patients with mobility problems. A very wide range of outcome measures was used, but physiotherapy resulted in significant benefit, irrespective of location, on the Rivermead Mobility Index, which was supported by other measures of mobility, gait, and balance. There was no difference between treatment at home (the patient’s preference) or in the hospital, although the latter was less expensive.

Finally in this group of minimally affected patients it is important to remember that although the majority of relapses resolve completely, up to 40 percent may leave some residual problems. Therefore while steroids might hasten the role of recovery from a relapse, there is a role for therapy input and possibly involvement of the multidisciplinary team in those with residual deficit. A recent randomized, controlled trial has shown that in patients who have not recovered fully following a relapse, there is a significant benefit from therapy input in addition to steroids when compared to steroids alone. Audit data from a neurorehabilitation service also supports the role of rehabilitation in those who have developed severe disability following a relapse.

A number of systematic reviews of the evidence supporting exercise in MS have been published recently (Table 4.3) and provide a critical overview of the areas that require further investigation.

Another key area at this stage in the condition is maintaining people with MS in employment. There are very limited resources available for vocational rehabilitation even though the few studies that have been carried out demonstrate considerable economic benefit from supporting people in employment.

Conclusion: There is increasing evidence to support the role of a range of therapy inputs at this stage of MS particularly focussing on maintaining the level of participation.