- •All three clinical guidelines emphasize the importance of physical activity (especially exercise) for persons with MS
- •Guidelines show moderate to high methodological quality
- •Guidelines hold remarkably diverse physical activity-related content
- •Future guideline development should also include details regarding dose-response relationships, risk and harms, prerequisites for starting moderate to vigorous physical activities, exercise vs. lifestyle physical activity for health, and include recommendations surrounding sedentary behavior.
This paper aims to evaluate the quality of clinical guidelines (CGs) for MS and to critically appraise physical activity-related recommendations.
Medical databases (MEDLINE, TRIP), clearinghouses, and guideline developers. An expert was asked to confirm if the list of CGs was complete.
Evidence-based CGs specific to MS with recommendations including aspects of rehabilitation or physical activity were included.
Two reviewers independently first assessed the methodological quality of the CGs based on the 23 items of the Appraisal of Guidelines for Research and Evaluation Instrument version two (AGREE II) and second evaluated the physical activity-related content quality using an instrument containing 14 items that was used for the development of the National Recommendations for Physical Activity in Germany.
For the AGREE II domains and the criteria for content quality, standardized domain scores were calculated.
Three CGs were included. The average scores for the methodological quality of the domains were: scope and purpose (91%), stakeholder involvement (81%), rigor of development (78%), clarity of presentation (93%), applicability (53%), and editorial independence (83%). The mean scores for physical activity-related content quality did not exceed 56% for any criteria.
Overall, this critical review shows that the methodological quality of CGs were moderate to good but physical activity-related content quality was heterogeneous and low. Results emphasize the need for more specific physical activity recommendations that incorporate multiple aspects of physical activity prescription.
Abbreviations:ANN (American Academy of Neurology), AGREE (appraisal of guidelines for research and evaluation), CG (clinical guideline), CSEP (Canadian society for exercise physiology), MS (multiple sclerosis), NICE (National Institute for Health and Care Excellence), pwMS (persons with multiple sclerosis)
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Multiple Sclerosis and Related Disorders
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Summary of systematic review for patients and their families: rehabilitation in multiple sclerosis.Am. Acad. Neurol. 2015; (Accessed January 29, 2018)
- Multiple sclerosis and brief moderate exercise. A randomised study.Mult. Scler. 2007; 13: 776-782https://doi.org/10.1177/1352458506073780
- Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.Phys. Ther. 2011; 91: 843-861https://doi.org/10.2522/ptj.20100104
- Development of the AGREE II, part 1: performance, usefulness and areas for improvement.CMAJ. 2010; 182: 1045-1052https://doi.org/10.1503/cmaj.091714
- Development of the AGREE II, part 2: assessment of validity of items and tools to support application.CMAJ. 2010; 182: E472-E478https://doi.org/10.1503/cmaj.091716
- AGREE II: advancing guideline development, reporting and evaluation in health care.CMAJ. 2010; 182: 42https://doi.org/10.1503/cmaj.090449
- Objective physical activity levels in people with multiple sclerosis: meta-analysis.Scand. J. Med. Sci. Sports. 2018; https://doi.org/10.1111/sms.13214
- Physical activity and disability outcomes in multiple sclerosis: a systematic review (2011–2016).Mult. Scler. Relat. Disord. 2018; 20: 169-177https://doi.org/10.1016/j.msard.2018.01.021
- Physical activity/exercise and diabetes: a position statement of the American Diabetes Association.Diabetes Care. 2016; 39: 2065-2079https://doi.org/10.2337/dc16-1728
- Acute recovery from exercise in people with multiple sclerosis: an exploratory study on the effect of exercise intensities.Disabil. Rehabil. 2017; 39: 551-558https://doi.org/10.3109/09638288.2016.1152604
- Effect of exercising at minimum recommendations of the multiple sclerosis exercise guideline combined with structured education or attention control education - secondary results of the step it up randomised controlled trial.BMC Neurol. 2017; 17: 119https://doi.org/10.1186/s12883-017-0898-y
- Exercise and disease progression in multiple sclerosis: can exercise slow down the progression of multiple sclerosis.Ther. Adv. Neurol. Disord. 2012; 5: 81-95https://doi.org/10.1177/1756285611430719
- Multiple sclerosis and physical exercise: recommendations for the application of resistance-, endurance- and combined training.Mult. Scler. 2008; 14: 35-53https://doi.org/10.1177/1352458507079445
- The effect of exercise on depressive symptoms in multiple sclerosis based on a meta-analysis and critical review of the literature.Eur. J. Neurol. 2015; 22: 443https://doi.org/10.1111/ene.12576
- The effect of exercise training in adults with multiple sclerosis with severe mobility disability: a systematic review and future research directions.Mult. Scler. Relat. Disord. 2017; 16: 31-39https://doi.org/10.1016/j.msard.2017.06.003
- The Design and Analysis of Clinical Experiments.John Wiley & Sons, Inc, Hoboken, NJ, USA1986
- Hintergrund und methodisches Vorgehen bei der Entwicklung von nationalen Empfehlungen für Bewegung.Gesundheitswesen. 2017; 79: S4-S10https://doi.org/10.1055/s-0042-123703
- Systematic Review: the effectiveness of interventions to reduce falls and improve balance in adults with multiple sclerosis.Arch. Phys. Med. Rehabil. 2015; 96: 1898-1912https://doi.org/10.1016/j.apmr.2015.05.018
- Summary of comprehensive sytematic review: rehabilitation in multiple sclerosis. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology.Neurology. 2015; 85: 1896-1903https://doi.org/10.1212/WNL.0000000000002146
- Bed rest and ACTH in the treatment of exacerbations in multiple sclerosis patients.Acta Neurol. Scand. 1987; 76: 346-350
- The effects of clinical interventions on health-related quality of life in multiple sclerosis: a meta-analysis.Mult. Scler. 2012; 18: 1686-1704https://doi.org/10.1177/1352458512445201
- Development of evidence-informed physical activity guidelines for adults with multiple sclerosis.Arch. Phys. Med. Rehabil. 2013; 94: 1829https://doi.org/10.1016/j.apmr.2013.05.015
- Effects of exercise training on fitness, mobility, fatigue, and health-related quality of life among adults with multiple sclerosis: a systematic review to inform guideline development.Arch. Phys. Med. Rehabil. 2013; 94: 1800https://doi.org/10.1016/j.apmr.2013.04.020
- Physical activity and cognitive function in adults with multiple sclerosis: an integrative review.Disabil. Rehabil. 2017; 39: 1909-1920https://doi.org/10.1080/09638288.2016.1213900
- Worsening of symptoms is associated with lower physical activity levels in individuals with multiple sclerosis.Mult. Scler. 2008; 14: 140-142https://doi.org/10.1177/1352458507079126
- Top 10 research questions related to physical activity and multiple sclerosis.Res. Q. Exerc. Sport. 2015; 86: 117-129https://doi.org/10.1080/02701367.2015.1023099
- Physical activity and multiple sclerosis: a meta-analysis.Mult. Scler. 2005; 11: 459-463https://doi.org/10.1191/1352458505ms1188oa
- Exercise in patients with multiple sclerosis.Lancet Neurol. 2017; 16: 848-856https://doi.org/10.1016/S1474-4422(17)30281-8
- Lifestyle physical activity in persons with multiple sclerosis: the new kid on the MS block.Mult. Scler. 2014; 20: 1025-1029https://doi.org/10.1177/1352458514525873
- Canadian physical activity guidelines for adults with multiple sclerosis.(Accessed April 17)Accessed April 17)
- Multiple sclerosis management of multiple sclerosis in primary and secondary care: clinical guideline 186.(2014:1-611Accessed December 18)http://www.ncbi.nlm.nih.gov/pubmed/?term=Management+of+multiple+sclerosis+in+primary+and+secondary+care.+NICE(Accessed December 18)Date: 2015
- Exercise as a therapy for improvement of walking ability in adults with multiple sclerosis: a meta-analysis.Arch. Phys. Med. Rehabil. 2015; 96: 1339-1348https://doi.org/10.1016/j.apmr.2015.02.011
- Randomized controlled trial of a behavioral intervention targeting symptoms and physical activity in multiple sclerosis.Mult. Scler. 2014; 20: 594-601https://doi.org/10.1177/1352458513503391
- The safety of exercise training in multiple sclerosis: a systematic review.J. Neurol. Sci. 2014; 343: 3-7https://doi.org/10.1016/j.jns.2014.05.016
- Sedentary behavior and health outcomes: an overview of systematic reviews.PLoS One. 2014; 9e105620https://doi.org/10.1371/journal.pone.0105620
- Evidence-based risk assessment and recommendations for physical activity clearance: Diabetes mellitus and related comorbidities.Appl. Physiol. Nutr. Metab. 2011; 36: 154-189https://doi.org/10.1139/H11-063
- Systematic, evidence-based review of exercise, physical activity, and physical fitness effects on cognition in persons with multiple sclerosis.Neuropsychol. Rev. 2016; 26: 271-294https://doi.org/10.1007/s11065-016-9324-2
- Evaluation of the quality of clinical guidelines for cardiac rehabilitation: a critical review.J. Cardiopulm. Rehabil. Prev. 2015; 35: 1-12https://doi.org/10.1097/HCR.0000000000000075
- Symptom change with exercise is a temporary phenomenon for people with multiple sclerosis.Arch. Phys. Med. Rehabil. 2006; 87: 723-727https://doi.org/10.1016/j.apmr.2006.01.015
- Multiple Sklerose und körperliche Aktivität: Eine historische Betrachtung.Nervenarzt. 2013; 84: 1238-1244https://doi.org/10.1007/s00115-013-3838-0
- Performance-focussed sport – an avenue to gold-medal clinical outcomes for people with neurological impairments?.Brain Impairment. 2016; 17: 99-110https://doi.org/10.1017/BrImp.2016.5
- Global action plan on physical activity 2018-2013.More active people for a healtier world. 2018; (Accessed June 13)
- Global Recommendations on Physical Activity for Health. Switzerland)Accessed February 6, 2018) (
Published online: August 03, 2018
Accepted: July 20, 2018
Received in revised form: July 4, 2018
Received: April 17, 2018
© 2018 Elsevier B.V. All rights reserved.