Multiple sclerosis (MS) is a chronic, degenerative, autoimmune disease of the central nervous system, affecting over 2 million people worldwide, and is the leading non-traumatic cause of disability in young adults.1 Spain is considered a country with moderate-high MS prevalence, with 80–180 cases/100 000 population.2 MS can cause a broad range of neurological signs and symptoms, resulting in an increase in physical and cognitive disability over time.3

There is a consistent body of evidence that patients with MS are less physically active and present greater levels of sedentary behaviour than the general population in the same age range.4 Sedentary lifestyles are associated with higher levels of disability and the appearance of comorbidities and secondary complications that exacerbate the primary symptoms of the disease.5 It has recently been suggested that lack of physical fitness may contribute to increased motor disability.6

Physical rehabilitation is a key part of the comprehensive management of MS, seeking to maintain or improve physical fitness and levels of activity and participation.7 Tailored exercise interventions have been shown to be beneficial and highly valuable in maintaining good health and preventing complications associated with inactivity; they also reduce mortality rates.8

The COVID-19 outbreak was officially declared a pandemic by the World Health Organisation on 11 March 2020, and had severe repercussions on all areas of the Spanish healthcare system, including neurorehabilitation.9 The lack of specific therapeutic or preventive interventions during the first year of the pandemic, together with the high transmission rate of the virus, led governments to take measures to restrict mobility and enforce physical distancing; this particularly impacted elderly people and people with chronic diseases, including MS.10

These restrictions resulted in the closure of in-person neurorehabilitation departments for the multidisciplinary treatment of MS, including those of Fundació Esclerosi Múltiple (FEM) and the Multiple Sclerosis Association of Biscay (ADEMBI, for its Spanish initials). In response, electronic care protocols were put in place to minimise the impact on patient care.11

The implementation of electronic rehabilitation programmes became a generalised trend. Adherence to these programmes was low, although some studies reported better outcomes in programmes combining in-person physiotherapy sessions with home exercise programmes. This was attributed to the lack of support and supervision during sessions, the lack of immediate relief of symptoms, and doubts about the treatment. Social support appears to be a key factor in adherence to these programmes.12,13

The Special Interest Group in Mobility of the European Network for the Best Practice and Research in Multiple Sclerosis (RIMS) developed a research project at the European level to analyse the initial impact of the COVID-19 pandemic on physical rehabilitation in MS from the patient perspective, comparing the findings against the pre-pandemic situation. This article presents the results from Spain.

The objectives of the study were to understand the impact of the COVID-19 pandemic on participation in physical activity among patients with MS, and to establish patients' opinions on the use of electronic tools in response to the early lockdown measures implemented in Spain.

All phases of the project were developed in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).14

This article reports the results obtained in the Spanish population as part of an international study on changes in physical activity habits among patients with MS as a result of the COVID-19 pandemic, with data gathered through an online survey. The main conclusion from the overall data from all participating countries was that the percentage of patients who were physically active significantly decreased, from 83% to 75%.18 Our data show a practically identical decrease, which was also statistically significant.

In terms of the effectiveness of exercise, the time and the type of physical exercise needed to obtain benefits are important. Published guidelines based on the scientific evidence and expert opinion recommend that the general population of patients with MS perform at least 150 min of physical activity per week, including both aerobic exercise and strength training.19,20 With regard to intensity, although patients with MS typically practise low- or moderate-intensity physical activity, Campbell et al21 report that high-intensity interval training is safe, well-tolerated, and effective in improving physical fitness in patients with MS and mild disability. Joisten et al22 found that 3 weeks of high-intensity interval training reduces levels of cellular markers of inflammation in patients with MS; therefore, this type of training may have benefits for disease progression.

In the analysis of the overall data from the full sample, Pedullà et al23 report a general reduction in the time dedicated to physical activity each week, particularly among patients with milder disability.23 The Spanish data also showed a greater decrease (67.5 min) among patients with lower PDDS scores. This may be due to the fact that survey completion coincided with the strictest lockdown measures. However, other authors report lower levels of physical activity in patients with MS and minimal motor involvement than among the healthy population of the same age range. Gervassoni et al24 observed lower levels of high-intensity physical activity and a higher percentage of individuals who performed no physical activity among patients with minimal disability; this finding was associated with higher levels of self-reported fatigue.24 Huynh et al25 also observed a correlation between insufficient physical activity and such symptoms as walking limitations, depression, fatigue, and cognitive involvement.

Patients who were motivated to continue physical activity used their personal resources to try to maintain it. Koopmans et al26 used semi-structured interviews to examine facilitators and barriers to physical activity during the pandemic. Their conclusions note that through creativity and adaptation, participants were able to continue performing physical activity at home, with online classes, or outdoors, where the risk of infection was minimised by limiting social contact. Among individuals in our sample whose physical activity increased, one of the main reasons cited was awareness of the physical and mental benefits of physical activity; family support was another of the most important facilitators.

The type of physical activity showing the greatest growth was walking. There seems to be a window of opportunity to use walking to increase physical activity among patients with MS, although few studies have addressed walking in training programmes seeking to increase physical activity.20,27 Addressing this point, a recent publication by our study group underscored the benefits of Nordic walking training for patients with MS, particularly in those with restricted capacity to walk due to motor or balance problems, as the poles facilitate more upright, stable gait.28 Nordic walking was associated with improvement in gait parameters, mood, and quality of life.28

However, the pandemic saw a decrease in physical activity levels in a community that was already more sedentary than the general population of the same age, or other populations with neurological disorders29; therefore, we must analyse the barriers leading to this decrease. Koopman et al27 point to the fear of infection and the fact that remote physical activity interventions offer less opportunity for social interaction, which was exacerbated by physical distancing policies during lockdown.27 Salmani et al30 identified lack of knowledge about self-care among this patient group, limited access to resources, and greater physical and cognitive disability as barriers to physical activity. The greatest barrier observed in our survey was the closure of sports facilities and rehabilitation centres. At the time the survey was conducted, home exercise was not an option considered for patients with MS as a collective in Spain; this would also explain the decrease in physical activity levels among those with more severe disease.

Regarding technology use, Malliaras et al31 identified facilitators and barriers to telerehabilitation, concluding that the loss of the therapist–patient relationship, environmental barriers, physical distance, and patients' lack of practise all contributed to telerehabilitation being less-effective and less-valued. As facilitators, they noted the savings in travel time and waiting time. Ellis et al32 highlight the initial technical difficulties with the Internet and various virtual meeting platforms.32 Although users expressed surprise at the benefits of telerehabilitation, despite their initial expectations, it is unclear whether the intervention would be as broadly accepted outside the context of the pandemic. Our results show that use of technology was a facilitator for self-management of physical health, although it also constituted a barrier due to some families' limited Internet access, difficulty finding an appropriate space at home, and the fact that physical activity was performed individually and often without professional supervision.

Finally, it should be noted that this healthcare crisis led to the implementation of a broad range of actions in healthcare systems, accelerating the creation of audiovisual and virtual rehabilitation resources in order to reach affected communities. In the case of patients with MS, telerehabilitation may enable the provision of therapy with a broad reach in terms of geographical area, number of users, and duration; this approach to maintenance treatment may improve adherence and ensure long-term neurorehabilitation therapy. Despite this, and as noted by Hale et al,33 it is important for any intervention of this type to be proven to be effective, and to meet the needs and preferences of patients with MS, the end users of this resource.

During the COVID-19 pandemic, physical activity levels decreased among patients with MS, and particularly among those with mild–moderate disability and for moderate–high intensity physical activity. The main reasons for this decrease were difficulty accessing sports and healthcare facilities, and fear of SARS-CoV-2 infection. Among patients who remained physically active, walking was the most frequent form of exercise. Technology use was a facilitator for some respondents and a barrier for others.

Although COVID-19 has now entered an endemic phase, this experience should boost the development and application of interventions to facilitate physical activity among patients with MS. This would encourage self-care and self-management of physical health with a view to future crises; this is of particular relevance to patients with such chronic diseases as MS, who require continuous multidisciplinary care but whose access to healthcare services, and particularly neurorehabilitation, is limited by the finite capacity of the healthcare system.

This project received no funding of any kind from any public or private organisation.

The authors obtained informed consent from the patients and/or subjects described in the article. The informed consent documents are held by the corresponding author.

The authors declare that the procedures followed comply with the ethical standards of the relevant committee on human experimentation, the World Medical Association, and the Declaration of Helsinki. The authors observed their centre's protocols for the publication of patient data.