Movement and Multiple Sclerosis: Fatigue, Balance and the Limits of the Current Work

No dance or movement effect size for multiple sclerosis is locked in this site’s source document, so none appears on this page, and the reason is worth more to a reader than a borrowed number would be: this is one of the hardest places in the whole field to produce a trustworthy result. Three features of the condition make it so, and understanding them tells you how to read anything else you find on the subject.

I want to be straightforward about my own position. I have no practice with people with MS. My work is singing sessions in two care homes and on a stroke rehabilitation unit, and MS has never been the reason anybody was in the room in front of me. Everything below is about the shape of the research and the practicalities of running a session, not about anything I have observed. Where I do have something, it is second hand and I will label it as such: a dance artist I share a hall with told me she stopped running her summer term in the room we both use because it faces south and gets warm, after a participant with MS had to leave twice. That was a practical adjustment made by somebody with no research behind her, and it turns out to line up with a well described feature of the condition.

Where a claim about effect appears below it carries a tier (Tier 1 supported, Tier 2 promising but limited, Tier 3 practice and anecdote), explained on reading arts in health research.

The three things that make this research hard

Each one on its own would weaken a study. Together they explain why the literature looks the way it does.

The condition fluctuates on its own. Relapsing and remitting courses are exactly what the name says: symptoms worsen, then improve, without anybody doing anything. People enrol in a programme at a bad point, because a bad point is what prompts somebody to look for help, and bad points are often followed by better ones. A study that measures a group before a ten week course and again at the end will record improvement that owes a great deal to the natural course of the condition and nothing to the course.

The main outcome is self reported. Fatigue is the symptom people with MS most often name as the one that shapes their life, and there is no blood test for it. It is measured by asking, on validated scales, which is the best available method and still leaves the score exposed to everything the participant knows about their own situation. Somebody who has spent ten weeks in a class knows they were in a class. So does whoever is asking them.

Heat changes the symptoms during the intervention itself. A temporary worsening of symptoms with a rise in body temperature is a well described feature of MS, and it reverses as temperature returns to normal. That is not a research problem in the abstract; it is a research problem because the intervention raises body temperature. A vigorous session in a warm room can make somebody’s symptoms visibly worse for an hour or two afterwards, and a measurement taken at the wrong moment reads as harm when nothing lasting has happened.

Put those three together and you have a condition where the untreated course moves, the outcome is a self report, and the intervention itself perturbs the thing being measured. That is a hard trial to design and an expensive one to run, and community arts organisations have neither the money nor the research infrastructure for it.

Why an uncontrolled evaluation is nearly useless here

Because the comparison group that does not exist would also have improved.

This is the general problem with before and after designs, stated in a population where it bites hardest. The field produces a great many such evaluations: the 2024 systematic review of arts on prescription screened 7,805 records, included 25, and found no randomised controlled trials at all, with all 8 of the quantitative studies using uncontrolled before and after designs¹. That review’s pooled wellbeing finding rests entirely on those designs, which is why this site grades it Tier 3.

In a stable long term condition, a before and after evaluation is weak. In a relapsing and remitting one, it is close to uninterpretable, because regression to the mean is not a small correction but potentially the whole of the observed effect. A control group is not a methodological nicety here. It is the difference between a result and a description.

Why no figure appears on this page

Because none is locked, and the alternative is forwarding a number rather than checking it.

The site’s rule is that a figure is printed only after the study or review it came from has been opened and its design, sample size, outcome measure, effect size, interval, certainty rating and year recorded. That work has not been done for dance or movement in MS here, so the gap is named. It makes for a less satisfying page and a defensible one.

What would change it: an adequately powered randomised controlled trial, or a systematic review of several, with a named outcome such as a validated fatigue scale or a balance measure, reporting an effect size, a confidence interval, a certainty rating, a sample size and a date. An active comparator would matter more here than almost anywhere, because a trial of dance against nothing in a fluctuating condition tells you very little. Blinded outcome assessment is achievable for physical measures even when the participants cannot be blinded, and its absence is one of the commonest reasons certainty ratings in this field stay low.

Two calibration points. Volume of studies does not substitute for quality: the 2021 Cochrane review of music interventions in cancer care pooled 81 trials and 5,576 participants and still rated its findings very low certainty², which is Tier 2. And the one dance review traced to source on this site, on depression, reports 3 studies, 147 participants, SMD -0.67 (95% CI -1.40 to 0.05), very low quality, with its authors declining to draw firm conclusions³. See dance for depression.

For contrast, the one movement claim in this field that reaches Tier 1 is rhythmic auditory stimulation after stroke, at 11.34 m/min of gait velocity (95% CI 8.40 to 14.28), from 9 trials and 268 participants at moderate quality⁴. It is a different condition and a different intervention, and it is on this page only to show what the bar looks like. See rhythmic auditory stimulation.

What a class should do differently

These are practical adaptations that experienced practitioners make, and they are worth listing because they are cheap and they decide whether somebody can attend at all.

• Keep the room cool and allow cold drinks throughout. A south facing hall in June is a genuine obstacle rather than a minor discomfort.
• Build in real rests, not a token pause, and pace the session so that intensity comes in bursts with recovery between them.
• Offer a seated version of everything. Standing tolerance varies week to week in the same person, so this cannot be settled once at enrolment.
• Make arriving late and leaving early unremarkable. Fatigue and bladder urgency both make that necessary, and a class culture that treats it as rudeness excludes people.
• Expect irregular attendance, and count it accordingly. A person who comes to six of ten sessions has not dropped out, and a funder’s attendance target that assumes otherwise will distort the provision.
• Do not treat a bad week as a failure of the programme. In a relapsing condition it very often is not.

None of that is unique to dance and all of it applies equally to a singing group, a craft session or any other regular activity. Seated and chair based dance covers the adapted formats in more detail, and finding a dance for health class covers what to ask before joining one.

Community class or clinical therapy

Two different things, arranged differently, and only one of them has anything resembling a clinical apparatus.

Dance movement psychotherapy is a psychological therapy with movement as its medium, with assessment, agreed goals, notes, clinical supervision and a planned ending. In the UK the title is not protected in law, and the Association for Dance Movement Psychotherapy UK runs its own accredited register instead⁵, which is where to check somebody rather than in a directory. There are correspondingly few NHS posts, so most access is private, charitable or through a school: see dance movement psychotherapy.

A community dance class is led by a dance artist, is open ended, and is there for the movement and the company. In practice this is what most movement provision for people with MS actually is, along with physiotherapy led exercise groups, which are a third thing again and are clinical. The reason this site keeps insisting on the distinction is that evidence about one gets quoted in support of another constantly: dance and health sets out the three way split.

What is reasonable to expect, and what is not

Reasonable: movement, music, company, a weekly reason to be somewhere, and an activity that can be adapted around a fluctuating condition. Those are worth having and none of them requires a trial to justify.

Not reasonable: a promise about fatigue, about relapse rate, about disability progression, or about anything the MS team is responsible for. A Tier 3 label on this site is not a verdict that movement does not help, and this particular Tier 3 is an empty file rather than a null result. It means nobody has answered the question properly, and the reasons for that are structural rather than suspicious.

If new symptoms appear, if existing ones worsen and stay worse, or if something changes suddenly, that belongs with the MS nurse or the neurologist and not with a class leader. Anything involving somebody who cannot give informed consent runs into a separate set of constraints, set out on consent and safeguarding in arts in health. Nothing on this page is a reason to alter, delay or decline any part of anybody’s treatment, and no arts activity substitutes for one.