Behavioral Interventions in Multiple Sclerosis

A Biopsychosocial Perspective

C Heesen; S Köpke; J Kasper; J Poettgen; A Tallner; DC Mohr; SM Gold


Expert Rev Neurother. 2012;12(9):1089-1100. 

In This Article

Abstract and Introduction


Managing uncertainty is a major challenge associated with the diagnosis of multiple sclerosis (MS). In addition to physical symptoms, neuropsychiatric symptoms are highly prevalent in this disease. Depression in particular is more common in MS than in other chronic diseases. While substantial achievements have been made in the therapy of MS and an increasing number of immunomodulatory treatments are now available, the long-term benefits of these are still a matter of debate. Importantly, while the approved therapies show good efficacy on inflammatory lesions and relapse rate, and may slow certain aspects of disease progression, improvements in function have rarely been reported. On the other hand, behavioral interventions have recently been shown to significantly improve fatigue and depression as well as motor function. In addition, recent evidence suggests that group education or face-to-face behavioral interventions may decrease inflammatory disease activity (such as relapse rate or lesion formation measured by MRI). Therefore, behavioral interventions not only ameliorate symptoms but may have the potential to modify the disease process itself.


Multiple sclerosis (MS) is the most common disabling disease in young adults. Uncertainty is a predominant feature of MS, which prompted J Kesselring, one of the fathers of MS rehabilitation, to argue that the disease should be named 'malignant uncertainty' (MU) instead of MS.[1] Uncertainty in MS begins with disease onset and encompasses the uncertainty of diagnosis[2] as well as the largely unpredictable course and progression of disease. Being diagnosed with MS for some patients could mean living in a nursing home 5 years after diagnosis, while other patients experience a benign disease course that enables them to continue a highly active life 30 years later.

During the last 15 years, uncertainty regarding the effectiveness of medical treatments has been added to the mix as well as very recently the uncertainty of possibly severe, even lethal, side effects of treatments.[3,4] Coping with uncertainty is one of the major challenges in adapting to a disease,[5] which highlights the importance of psychological factors in MS. In addition, neuropsychiatric symptoms such as depression, anxiety, fatigue and cognitive impairments show a high prevalence in MS and can have a major influence on activities and participation in daily life. Importantly, there is increasing evidence that some of these symptoms may not simply be a psychological reaction to a disabling disease, but could be biologically mediated.[6]

The present review will provide an update on psychological risk factors linked to the pathogenesis or progression of MS and summarize recent developments regarding the potential of behavioral interventions (BI) in this patient population. We define BI as any educative or interactive approach that aims to alter health behaviors. These may range from interaction in decision-making processes to engaging in exercise programs as well as other interventional approaches such as stress management or meditation. Therefore, we will cover evidence-based patient information programs, psychological interventions as well as exercise. We will highlight studies in each section based on their methodological rigor or novelty of approach. By summarizing the evidence for these interventions in each domain, we will comment not only on symptom outcomes but also on the potential impact of such interventions on disease processes and brain function. Finally, we will outline the goals and objectives for future research in this area.