Multiple sclerosis (MS) is a neurological disorder that affects physical and cognitive functions. Typically, the demyelination of the neurons' axons caused by the disease leads to a chronic and increasing level of symptoms and disability (1, 2). To manage the main symptoms of the disease -like fatigue, gait impairment, and depression- researchers recommend engaging in physical activity, i.e., any bodily movement produced by skeletal muscle contraction that results in energy expenditure (3), as a complementary therapy (4, 5). In particular, solid evidence suggests that persons with MS (pwMS) who engage in exercise, defined as a planned activity usually performed repeatedly over time with a specific improvement aim (3), can increase walking autonomy, aerobic capacity, and strength (6–10).

Despite these benefits, recent data showed that most pwMS did not follow the recommendations and persist in sedentary behavior (11, 12). In healthy adults, the reasons for physical inactivity range from personal to environmental factors, but the most common limit is the lack of time due to family and work commitments (13). Conversely, for pwMS, factors preventing exercise are usually related to disease symptoms and disability level (14). However, the disease symptoms and disability greatly vary from person to person, hence the reason for inactivity is frequently a combination of general and disease-related factors, without certainty about which of these has the greatest impact.

Along with rehabilitation, exercise is usually prescribed to pwMS by their specialists. Still, it is often limited in time (commonly, two sessions a week for 6–8 weeks) and circumscribed to a clinical setting. Instead, performing regular activities during leisure-time over an extended period of time in a familiar and stimulating environment could enhance motivation, adherence, and continuity of training. Sports may play a crucial role since they pertain to any form of competitive physical activity aiming at using, maintaining, or improving physical ability and skills while providing enjoyment to participants.

In this context, the role of the general practitioner (GP) could be relevant in order to identify a tailored and effective exercise-promoting strategy. GP is the medical interface that takes care of pwMS after the diagnosis and management at the reference MS Center, when this occurs in age ranges where MS can present, if correctly treated, a slower disability progression (15). Indeed, both pediatric (< 16 years) and late (>40 years) MS onset seem to be associated with a higher risk of unfavorable MS prognosis (16, 17) and are usually directly followed by specialists (most likely, neurologists). The GP can also assist patients in managing comorbidity, which has been associated with delayed diagnosis of MS, progression of disability, lower health-related quality of life, increased MS burden on magnetic resonance imaging, and increased mortality due to MS (18–21).

Concerning physical activity, the GP's support might be crucial to maintain or begin a sports activity in order to enhance spontaneous and continuous exercise training during leisure time. Previous studies found that GP is crucial to stimulate healthy lifestyles in his/her patients, including physical activity, exercise, and sports (22, 23). In the present study, we focused on spontaneous exercise habits (i.e., sports and fitness practice) with the aim to determine the main barriers and the relevance of GP advice in pwMS.

The survey was completed by 741 pwMS (disease duration: 19.7 ± 11.8 years.; mean EDSS 3.6 ± 2.2, median EDSS 3, IQR 2-6), 253 were males and 488 females and the mean age was 55.6 ± 12.5 years (age range: 24–89). The most common disease phenotype was relapsing-remitting (RRMS) (496; 161 males, 335 females; disease duration: 17.1 ± 10.2 years; EDSS 2.6 ± 1.7), followed by secondary progressive (SPMS) (192; 71 males, 121 females; disease duration: 27.8 ± 11.9 years; EDSS 5.9 ± 1.6) and primary progressive (PPMS) (53; 21 males, 32 females; disease duration: 16.3 ± 11.8 years; EDSS 4.8 ± 1.8).

The majority of pwMS (75.3%) did not practice any exercise at the time of the survey, with a higher frequency for SPMS (91.7%) (Table 1). PwMS stated that physical issues related to the disease, and work/study duties, as well as family commitments, were the main reasons to withdraw from previous exercise activities. However, work/study and family commitments were relevant only for lower levels of EDSS (0–3.5), whereas physical issues were the principal reason for abandoning previous activities for higher levels of disability (EDSS ≥ 4; Figure 1).

Participants reported fatigue, travel/mobility issues, and lack of time, as the most common barriers to attending and/or starting a new exercise program. Secondary barriers were identified as a lack of self-confidence, economic issues, and a lack of specialized facilities (Figure 1).

Among participants, 189 out of 741 (25.5%) received GP advice to practice exercise and 89 of them (47.1%) actually practiced exercise. Conversely, only 94 out of 552 (17.0%) practiced exercise without having received any advice from the GP (Table 2). Moreover, among those who did not practice exercise but received the advice from GP, 69 out of 99 (69.7%) were motivated to start a new exercise program (Table 2). Interestingly, among pwMS who practiced exercise (183, 24.7%), only 28 (15.3%) were supervised by an exercise specialist.

Table 3 reports crude and adjusted ORs for the practice of exercise. In the multivariate analysis, people who received GP advice showed about three times higher likelihood of exercise practice (OR 2.96; 95% CI 2–4.4; p < 0.001), while increasing disability was associated with about a 20% lower chance of practice (OR 0.78, 95% CI 0.7–0.9; p < 0.001), controlling for sex, age, disease duration, and MS course.

Exercise is an important non-pharmacological strategy to improve the quality of life of pwMS, through the increase of physical capacities and autonomy (5, 9, 10). It should be spontaneously and continuously performed by pwMS, according to their possibilities and disability levels, e.g., by practicing tailored sports activities. However, previous studies showed that most pwMS have a sedentary lifestyle and avoid exercise with a negative effect on their health (12, 25, 26). The aims of the present study were to gather information on the current exercise behavior in terms of sports and fitness practice and identify the main barriers to exercise among pwMS. In addition, we investigated if the role of the general practitioner was relevant to motivate pwMS to maintain or begin training programs.

Participants identified disease-related physical issues, work/study duties, and family commitments as the main reasons to have abandoned their previous exercise activities. The “physical issues” were the prevalent reason to abandon exercise for all levels of disability, however, we noticed that for the 0–3.5 EDSS range the work/study duties are also significant. Work/study duties were listed as limiting factors mostly by people with a low level of disability (EDSS < 3.5), and only for a minority of people with high disability levels, that are often prevented from maintaining their professional careers for several issues directly related to MS.

Regarding the reasons for not attending an exercise program at the time of the interview, pwMS declared that the major barrier was fatigue -the most common symptom in MS (27)—followed by travel and/or moving issues, and lack of time. Probably, travel and/or moving issues were not the main cause for abandoning past activities, contrarily to lack of time due to family and work duties, but became more important over time, limiting the practice of new activities.

As we expected most of the sample did not practice any exercise (75.3%), with no GP's advice as a significant predictor. This finding reflects the results of previous studies that showed sedentary behaviors of pwMS, especially in men (25, 28), probably a result of being more physically affected by the disease. Noteworthy, almost all people with SP form (91.7%) stated that they did not attend any physical activity or exercise program. Even though SP is characterized by a progressively increasing disability accrual, studies have shown that exercise is feasible and effective to reduce symptoms and improve fitness and cognition, so it is strongly recommended also in this form (29, 30). Possible reasons for the low rate of pwMS practicing any kind of physical activity are various, applicable to all the disease phenotypes but clearly more pronounced in SP forms, or in pwMS with moderate-to-high disability levels. First, pwMS may have physical issues limiting their ability to drive or use public transportation, rendering them dependent on caregivers to access gyms or structures where physical activities are practiced. Furthermore, these structures might be geographically distant from patients' houses and difficult to reach. In this regard, patients often refer to the onset of symptoms such as spasticity and fatigue associated with the need to maintain a seated position for prolonged periods of time, such as when spending time in a car to reach their destination. This aspect needs to be considered when planning physical exercise, as a gym located at a long distance might represent an issue counteracting the beneficial effect of a physical activity session. Very often fatigue and depression coexist and become more pronounced over time and are related to disability accrual (31), preventing pwMS from performing physical activity on a regular basis. A higher level of disability further limits the possibility to exercise regularly as requires a professional intervention from physiotherapists, in the context of neuromotor rehabilitation.

According to our findings, pwMS receiving GP advice to practice exercise are more likely to attend an exercise program. Similarly, pwMS not practicing exercise but receiving advice were more motivated to start an exercise program. These results confirm the positive role of the GP in promoting exercise in pwMS, as previously demonstrated in older adults (23). Moreover, as stated in a study by Canning et al., people that were directly referred to an exercise program by the GP were more likely to adhere to the Canadian Physical Activity Guidelines for Adults with Multiple Sclerosis (PAGs) (22).

Considering these results, the GPs could have a fundamental role to reduce the physical inactivity of their patients. Fatigue is known to be the most limiting factor to practicing exercise but was also shown that regular exercise is effective to reduce fatigue and other related physical symptoms. Our results underline the key role of GP in promoting a positive lifestyle in their patients, including recommendations on physical activity, exercise, and sports. Finally, only 28 pwMS practicing exercises (15.3%) were supervised by a specialist. The lack of supervision by an expert trainer could be dangerous for pwMS due to incorrect management of exercise intensity. Similarly, in this case, general practitioners can recommend pwMS not to self-administer exercise, in order to reduce injury risks and maximize exercise benefits.

Although the findings of this study are consistent with the literature, some limitations are noteworthy. The cross-sectional design does not allow comparing exercise barriers before and after the onset of the disease. The answers were self-reported, and we did not record the amount of physical activity or exercise. Similarly, we have no information about the advice of the general practitioner, such as the number and timing of the advice, the exact words, and/or messages delivered to patients.

For these reasons, more studies are needed to understand the underlying mechanisms limiting pwMS to spontaneously practice regular exercise. The role of sports should also be further investigated, focusing on the type and modality of the most commonly practiced and ceased activities in order to help clinicians, e.g., general practitioners, to suggest tailored and effective exercise-promoting strategies. Our findings confirm that fatigue and lack of time due to work/family commitments are the main barriers and new exercise strategies -for example, tele-exercise- need to be considered. Finally, we observed that the role of GP is crucial to persuade pwMS to practice exercise and sports. Therefore, the general practitioners are encouraged to suggest an exercise program for pwMS who are not currently exercising.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The present study was reviewed and approved by IRB Fondazione IRCSS San Matteo. The patients/participants provided their written informed consent to participate in this study.

LC, LM, GB, MB, MP, and RB: conceived and designed the study. LM, LP, GM, GB, MB, and MP: performed the study. CM, MM, PB, and LC: analyzed the data. LC, LM, ET, LP, and GM: wrote the manuscript. RB, CM, GB, and MB: reviewed the manuscript. All authors contributed to the article and approved the submitted version.

This study was supported by FISM Grant 2017/R/4 for the Reasearch Project Costs of comorbidity in multiple sclerosis people.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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