A Thematic Synthesis considering the factors which influence Multiple sclerosis related Fatigue during physical activity.


To identify the fatigue related consequences from exercise or physical activity in patients with Multiple Sclerosis (PwMS) and consider the reasons and the extent that fatigue perception inhibits the will of PwMS to participate in physical activities.

Fatigue related to MS has enormous effects on different domains
including physical, emotional and social well-being.
The current research identified six parameters
which can break the cycle of inactivity and empower PwMS to maintain the highest possible standard of physical activity.


A review using a thematic synthesis methodology situated within a subtle realist paradigm was undertaken. The review was completed in three stages: 1) search of relevant studies; 2) critical appraisal of literature; and 3) thematic synthesis. During the final stage, a model was developed as a line of argument synthesis, typically used within this type of review. The review protocol was registered with PROSPERO (Ref: CRD42018115615).

A pre-planned electronic search was undertaken. The eligibility of each article has been considered with the use of the “SPIDER” tool. Five electronic databases including: MEDLINE, PubMed, CINAHL, SPORTDiscus and PsycInfo were searched from inception until 1st November 2018. Papers' quality was assessed with COREQ critical appraisal tool modified for reviews. The studies were further evaluated to be identified and excluded any “fatally flawed” qualitative paper, according to criteria proposed by the National Health Service National Electronic Library for Health. The purpose of this was to identify papers with methodological quality that was so poor that the results became questionable.

Nineteen studies met the inclusion criteria. Total number of participants involved: 263 of whom 243 were PwMS (159 females, 70 males and 14 unknown). The aggregated mean age was 53.3 years and aggregated mean time living with MS post diagnosis was 11.3 years. Following critical appraisal, no articles were excluded.


Three major themes were synthesised: (1) Fatigue related consequences, (2) Exercise related barriers affecting fatigue, and (3) Factors that make fatigue bearable to MS individuals. The thematic synthesis identified the cycle of activity and inactivity as result of fatigue perception.

Physical activity Inhibition: Fatigue related to MS has enormous effects on different domains including physical, emotional and social well-being. When one domain is affected, our results suggest that this may trigger another domain to be affected and could fuel the vicious cycle of inactivity, that causes reduction of bodily control and cognitive dysfunction, which in turn provoke emotional distress and may lead patients to social disruption.

Physical activity facilitation: The current research identified six parameters which can break the cycle of inactivity and empower PwMS to maintain the highest possible standard of physical activity.


  1. Past positive experiences represent a starting point for engagement in physical activity and are likely supported by positive past social support and environment during the activity.
  2. An appropriate level and type of physical activity enables PwMS to maintain engagement.
  3. Determination to hold an active coping strategy empower PwMS to remain active.
  4. The knowledge of physical activity benefits is a strong motivator for exercising.
  5. Perceived control over fatigue related to exercise encourages PwMS to increase physical activity.
  6. The perception that undertaking physical activity in a successful way, increases energy levels in PwMS


The model of exercise facilitation and inhibition, as presented above, integrates MS patients’ experience from fatigue consequences related to exercise. Strong evidence supported that exercise reduces fatigue to PwMS. The implementation of a suitable individualised exercise programme with appropriate social support minimises the stress of physical activity. Exercising in less stressful conditions with a suitable and enjoyable physical activity will likely minimise fatigue related to exercise. In addition, exercise experience helps individuals to recognise and interpret the initial symptoms of fatigue, reduces the anxiety related to the potential negative effects of exercise, proves the exercise benefits and empowers PwMS to adopt an active coping strategy in order to break the vicious cycle of inactivity and maintain their normality.

Cost and savings

The review was a part of my MSc studies and it has not had any additional cost.

Even though guidelines suggest to PwMS who have a mild to moderate level of disability, to participate in moderate intensity aerobic activity and strength training exercises twice a week in order to reduce fatigue levels, improve mobility and well-being, recent studies revealed that the most of PwMS were not met the recommended guidelines for physical activity. Several factors may prevent PwMS from exercise engagement. However, an online survey with PwMS experienced walking difficulties, revealed that 60% of the participants reported that fatigue affected their ability to participate in physical activities and 54% mentioned a direct impact on their employability.


  • Less active PwMS need great effort to break the cycle of inactivity.
  • Exercise training should not increase PwMS's stress.
  • Exercise experience combined with professional and social support are strong facilitators for engaging in physical activity.
  • Acceptance of MS, determination to remain active and positive exercise experience empower PwMS to adopt a more active strategy.

Top three learning points

When PwMS experienced stress and/or depression, experiences of fatigue related to MS were increased and vice versa.

Less active PwMS have a higher level of difficulty to confront stress related to exercise.

Experience of physical activity is a strong facilitator for participating in exercise and reduces negative consequences from exercising.

Funding acknowledgements

This research received no external funding. 

Additional notes

This work was presented at Physiotherapy UK 2019