How we treat multiple sclerosis

Aerobic and strength work is set at a defined intensity and progressed from measurement rather than from how the session felt. In a condition where fatigue distorts perception, "work to how you feel" is not a prescription.

The hardest work is scheduled early in the day, when capacity is highest, and the day tapers rather than building.

Aquatic sessions do two things at once: the water is cooler than the air, which limits the rise in core temperature that triggers Uhthoff's phenomenon, and it unloads the joints so that more work can be done before fatigue stops the session.

On land, sessions are kept shorter, the environment is kept cool, and cooling is used before and between bouts where heat sensitivity is significant.

Energy conservation is taught as a skill: how to sequence a day, which tasks to delegate or reorganise, when to rest before rather than after. Patients often describe this as the most useful thing they take home.

At the same time fatigue is treated directly, because aerobic and aquatic exercise reduce it — one of the few interventions that improves the symptom itself.

Weakness, spasticity, poor balance and reduced foot sensation each produce a different walking problem and each needs different treatment. Balance and gait analysis separate them so the training targets the actual cause.

Robotic gait work is used where the goal is walking volume that fatigue would otherwise cut short. It is a means of achieving dose, not a treatment in itself.