1Department of Physical Medicine and Rehabilitation, Marmara University Medical Faculty, Istanbul, Türkiye
2Department of Neurology, Marmara University Medical Faculty, Istanbul, Türkiye
Correspondence: Özge Keniş-Coşkun Department of Physical Medicine and Rehabilitation, Marmara University Pendik Research and Training Hospital, Fevzi Cakmak Mah. Muhsin Yazicioglu Cad, Istanbul 34899, Türkiye. Tel: +90-505-8294947 E-mail: ozgekenis@gmail.com
• Received: January 3, 2025 • Revised: October 4, 2025 • Accepted: October 13, 2025
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
To examine the effect of the telerehabilitation program on sleep quality and fatigue level in patients with multiple sclerosis (MS) was aimed in this study. MS is a demyelinating disease defined by various signs and symptoms that affects physical, emotional, social, and cognitive functioning. Fatigue, depression, sleep disturbance and cognitive impairment are the among common symptoms of MS.
Methods
The study implemented an individual exercise program for twice a week for 12 weeks via telerehabilitation. In the home-based video exercise group, the same exercises were given as video recordings and the patients were asked to do the exercises twice a week for 12 weeks. Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), Multiple Sclerosis Quality of Life Scale-54 and Timed 25 Foot Walk Test were used in the evaluation. The trial is registered with the number of NCT04979845 on ClinicalTrials.gov.
Results
PSQI scores changed from 5.6 (2.1) to 3.66 (2.09) in telerehabilitation group (p=0.03) while no significant change were seen in the video exercise group. Similarly FSS scores decreased from 4.37 (1.42) to 3.67 (1.68) in telerehabilitation group (p=0.04) while no significant changes were seen in the video based exercise group.
Conclusion
The telerehabilitation program is thought to be an effective and accessible non-pharmacological application that can be used in the treatment of sleep quality and fatigue in individuals with MS.
Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system characterized by neuronal loss affecting physical, emotional, social and cognitive functioning [1]. MS affects approximately 2.3 million people in the world and is stated to be the most important cause of disability in young adults [2,3].
Fatigue, depression, sleep disturbance and cognitive impairment are the among common symptoms of MS. Physical and mental fatigue affects more than 50% of patients with MS and reduces their quality of life. Sleep disorders are very common in patients with MS and have been reported to be four times higher than in healthy people [4]. Disturbed sleep causes daytime sleepiness, increased fatigue, worsening depression, and a decrease in pain threshold. Previous studies show that significant improvements in MS symptoms and general quality of life by increasing sleep quality [5].
Regular exercise in MS provides benefits such as increased cardiorespiratory vitality, strengthening of muscles and increased endurance, reduction of systemic fatigue, improvement of mood and ease in performing daily life activities. Regular exercise is thought to help manage common MS symptoms and improve healthy living [6]. A study conducted in middle-aged individuals concluded that exercise had a beneficial effect on sleep quality and reduced both sleep latency and sleep medication use [7]. It is stated that exercise can improve fitness and functionality in mild MS patients and helps preserve function in moderate to severe MS patients [8]. There are studies showing that exercise training may be a useful rehabilitation approach for individuals with MS to manage disease symptoms, increase functionality, improve quality of life, reduce fatigue, support fitness, and increase participation in daily living activities [8]. It has been stated that exercise training programs provide clinically significant improvements in walking ability in individuals with MS [9].
Telerehabilitation provides rehabilitation services to patients in the environment where they live, without going to any clinical setting. Telerehabilitation has been used in a variety of treatments, including a variety of physical exercises, educational and behavioral approaches, and interventions to modify the symptoms of the disease. Wide range of technology products such as computers and smartphones are among the tools that can be used in telerehabilitation. It has been shown that telerehabilitation strengthens the patient-physiotherapist connection by facilitating exercise training, determining the target of treatment, creating a treatment protocol and exchanging information [10]. A study concluded that telerehabilitation application facilitates access to treatment in individuals with chronic neurological diagnoses such as MS and has the potential to provide the daily rehabilitation necessary for the targeted clinical benefit. Another advantage of telerehabilitation is that it can be used to provide access to a wider patient population with different levels of disability [11].
Our hypothesis for this study is that the patients who received supervised exercise therapy via telerehabilitation would improve more than patients who were on home-exercise regimens in quality of life, sleep quality and functionality aspects.
METHODS
The study was planned as a randomized controlled trial and conducted in Department of Physical Medicine and Rehabilitation of Marmara University Hospital between October 2021 and December 2021. The necessary permission for the study was received from Marmara University Medical Faculty Clinical Research Ethics Committee on 29/09/2021 with protocol number 09.2021.808. The research has been registered to the ClinicalTrials.gov with the number of NCT04979845. The inclusion criteria were the presence of MS diagnosis by a neurologist, an Expanded Disability Status Scale (EDSS) score 6 or below, which was applied in a clinical setting by a physiotherapist after physician guidance, showing moderate disability but independent ambulation were included for our study. Our exclusion criteria were patients who had accompanying neurological problems, patients who would be unable to participate in the exercise program due to the presence of other musculoskeletal, audiovisual or neuropsychiatric issues, patients with an EDSS score above 6 indicating moderate disability but still able to ambulate with or without assistance and patients who did not have access to online video calling programs. All participants have given written and verbal informed consent. The participants were randomized into two groups, the telerehabilitation group and the home-based video group, by a computerized randomization list. The allocation was concealed from the evaluator, since the patients would know what kind of exercise they are participating in. Block randomization or stratification were not applied. The telerehabilitation sessions included in an online home exercise program under the supervision of a physiotherapist for 40 minutes, 2 days a week for 12 weeks. The exercise program is aimed at upper extremity, lower extremity, and trunk muscles; It included range of motion, stretching, strengthening, endurance and relaxation exercises. For the home-based video exercise group, the same exercises were given as pre-recorded videos and the patients were asked to implement this program 2 days a week for 12 weeks. It was confirmed verbally by calling every week that these exercises were performed at home. All patients were evaluated before the program and at the end of the program with the Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), Multiple Sclerosis Quality of Life Scale-54 (MSQoL-54), and Timed 25 Foot Walk Test (T25FW) scales. Pre- and post-treatment evaluations were made by another researcher who was not involved in randomization process and exercise programs to ensure blindness. All evaluations were done face to face in the clinic. Based on a similar previous study that investigated the effect of telerehabilitation on sleep quality the sample size were calculated as a total of 32 patients were recruited with an effect size of 1.08 according to the changes in the PSQI, an alpha error level of 0.05 and a power of 80% [12].
Exercise program
The patients’ exercise program included the following stretching and strengthening program. The patients in telerehabilitation arm did these exercises with the physiotherapist while the patients on the home-exercise arm did them according to a pre-recoded video. The stretching exercises were done as 10 repetitions before and after the strengthening program. All strengthening exercises were done as 10 repetitions per set and for 3 sets.
Stretching exercises included:
• Neck muscle stretching (4 directions)
• Back extensor muscle stretching
• Pectoral muscle stretching
• Hamstring and gastro-soleus muscle stretching
• Hip extensors and lumbar extensor muscle stretching
• Cat-camel exercise
Strengthening exercises included:
• Shoulder flexion (with 1 kg dumbells)
• Shoulder abduction (with 1 kg dumbbells)
• Elbow flexion (with 1 kg dumbbells)
• Elbow extension (with 1 kg dumbbells)
• Wrist flexion (with 1 kg dumbbells)
• Wrist extension (with 1 kg dumbbells)
• Hip flexion (seated, with 1 kg sandbag)
• Hip abduction (side-lying, with 1 kg sandbag)
• Knee extension (seated, with 1 kg sandbag)
• Straight leg raise (supine, with 1 kg sandbag)
• Rising on toes and rocking back onto heels (standing)
• Bridge exercise
• Crunch exercise
• Back extensor strengthening (in prone position)
PSQI
PSQI is a 19-item self-report scale that evaluates sleep quality and disturbance over the past month. Each item of the test is scored equally between 0–3. The scale consists of 7 subscales that evaluate subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disorders, use of sleeping pills, and loss of daytime functionality. By summing the subscales, the total PSQI score ranging from 0 to 21 is obtained. A total PSQI score greater than five indicates that the individual's sleep quality is inadequate, with a sensitivity of 89.6% and a specificity of 86.5%, and indicates that there is serious impairment in at least two of the above-mentioned areas or moderate impairment in three areas [13]. It has been translated and validated in Turkish [14]. The change in sleep quality was established as the primary outcome measurement.
FSS
It is used to evaluate the fatigue levels of individuals. This scale consists of nine items. Each item is scored between 1 and 7, and as the total score decreases, fatigue decreases. It has been translated and validated in Turkish [15].
MSQoL-54
It is the first MS-specific quality of life scale developed from Short Form 36 (SF-36). This scale, which consists of fifty-four questions, mostly Likert type, was created by adding 18 questions related to MS-specific problems to the SF-36. MSQoL-54 consists of 2 main groups, composite physical and composite mental health, 12 subgroups and 2 independent items. Items taken verbatim from SF-36; emotional well-being, health perception, physical functions, emotional role limitations and physical role limitations. Energy-fatigue, pain, and social function sections were created by changing the items of SF-36. In addition, 4 main items specific to MS were added: cognitive function, health stress, sexual function and overall quality of life. Scores from the scale vary between 0 and 100. A high score indicates good quality of life. It has been translated and validated in Turkish [16].
T25FW
It is a test that measures lower extremity functions. It was developed to record the patient with this test at every examination. The patient is asked to walk within a predetermined range. It is noted how many seconds it takes to leave and come, and the average of both times is taken [17].
Statistical analyses
Data analysis in the study was performed with the SPSS 20.0 (IBM Corp.) Mac OS program. Basic descriptive analyzes were used to calculate frequencies, means, and standard deviations. In categorical data, the McNemar Test was used for intra-group comparisons and the chi-square test was used for inter-group comparisons. The distribution of non-categorical data was examined with the Shapiro–Wilks test and was found normal. Independent samples t-test was used for baseline differences between groups. Two-way mixed ANOVA was used for within- and within-group analyses. For all statistical tests, the significance level was accepted as p<0.05.
RESULTS
A total of 32 patients were included in initial recruitment. 16 patients were allocated to the telerehabilitation group and 16 to the control group. Both groups adhered perfectly to the exercise programs. Due to various reasons, 3 patients did not finished the protocol and therefore 29 patients were included in the final analyses. A per-protocol analysis was applied. Patient flow chart is given in Fig. 1. Mean age of the patients were 37.5±13.0 in the telerehabilitation group and 41.7±10.2 in the home-exercise group (p=0.34). Nine patients (60%) were female in the telerehabilitation group while 11 patients (78%) were female in the home-based exercise group (p=0.28). The mean EDSS score was 2.4±1.7 in the telerehabilitation group and 2.8±1.3 in the home based exercise group (p=0.73). The PSQI, MSQoL-54 and T25FW values at the beginning of the study were not significantly different between groups and are given at Table 1.
PSQI score improved significantly within the telerehabilitation group after treatment (p=0.03), but no statistically significant difference was found in the home-based exercise group (Table 2). According to the established cutoff points of 5 of PSQI, the number of patients with poor sleep quality in the telerehabilitation group was 9 patients before the intervention and 3 patients after the intervention, but this decrease was not statistically significant (p=0.07). In the home-based video exercise group, the number of people with poor sleep quality was 6 people before and after treatment, and no change was observed (p>0.999).
There was a significant improvement in the telerehabilitation group after the intervention (p=0.05), while it was not significant in the home-based video exercise group (p=0.09) in the FSS (Table 3). When the FSS score of the individuals was evaluated, while the fatigue level of 10 individuals in the telerehabilitation group was high before the intervention (FSS≥4 according to the previously established cut off points), the fatigue level of 9 individuals was found to be high after the intervention, and this change was not significant (p>0.999) [18]. In the home-based video exercise group, while the fatigue level of 8 individuals was high before the intervention, the fatigue level of 4 individuals was found to be high after the intervention, and this change was not statistically significant (p=0.45).
While there was an intra-group change in the T25FW in the telerehabilitation group (p=0.01), this difference was not seen in the video-exercise group (p=0.29) (Table 4).
An improvement was observed in the subparameter scores of the quality of life scale in both groups. In the telerehabilitation group, except for the change in health component of the quality of life scale, a significant difference was observed within the group in the composite physical health, composite mental health and satisfaction with sexual function components. Similarly, in the home-based video-exercise group, the change in subparameters other than the sexual function satisfaction component was significant within the group (Table 5).
DISCUSSION
The effects of a telerehabilitation exercise program and a home-based video-exercise program on sleep quality, quality of life, functionality and fatigue in patients diagnosed with MS were compared in our study. We found that telerehabilitation positively affected both sleep efficiency and sleep quality, fatigue and functionality and more favorable when compared to video-based home exercises. Quality of life improved significantly in both groups.
In a study comparing supervised exercise with video home exercise and including thirty individuals with MS, individuals who participated in a moderate-intensity aerobic exercise performed recorded significant improvements in subjective sleep quality reported using PSQI and objective sleep components [19]. In our study, there were improvements in the sleep quality of both groups, but these improvements were not statistically different when the groups were compared. But the lack of a significant change in home exercise group points out that telerehabilitation may be a more effective approach. Although a previous study reported that exercising for at least 20 minutes twice a week supports improvements in sleep quality, this frequency still may not be adequate for a home based exercise regimen according to our results [12]. The fact that the PSQI score was significant within the telerehabilitation group suggests that it may be an alternative to supervised, in-clinic exercises.
Exercise has been previously shown to improve fatigue in patients with MS although the current data can found to be conflicting. In a previous study, 36 individuals with MS were randomized into two groups as a clinical exercise group and a home-based exercise group. When the FSS scores of both groups were compared after exercise, it was reported that there was no significant difference in fatigue scores and there was no difference within the groups. It was concluded that exercises performed at home or in the clinic did not show a significant effect in the treatment of fatigue [20]. In another study, it was stated that 30 individuals with MS were randomized into 2 groups: face-to-face group (15 individuals) and home exercise group (15 individuals). In this study, in which the fatigue score was evaluated as FSS, it was reported that the fatigue score decreased statistically in both groups, and when compared between groups, the FSS score was found to be significant in favor of face-to-face exercise [10]. Our findings were similar in the sense that there is a decrease in the FSS scores of both the telerehabilitation group and the video-based home exercise group. But there are no between group differences in the end of the study. These results supports the assumption that any form of exercise would be helpful in patients with MS in decreasing fatigue, so the clinicans should support any effort that improves exercise habits.
The current data about improvement in quality of life in patients with MS is also contradictory. A larger study included 91 individuals with MS, continued for 6 months, and randomized them into 2 groups: the exercise group (45 people) and the control group [21]. In this study, the subheadings of the 4 main subparameters of the quality of life scale were examined and no significant changes were observed in quality of life parameters. The points that differentiate this study from our study are the longer intervention period, the larger number of participants, and the presence of a control group. When both studies were compared, the satisfaction with sexual function subparameter was significant in favor of the telerehabilitation group in our study, and both of our groups included exercise intervention. It was stated that in a 12-week home-based physical telerehabilitation pilot study in which 12 individuals with MS participated, quality of life was evaluated with the MSQoL-54 scale. It was reported that the composite physical health score, one of the sub-parameters of the scale, increased slightly and the composite mental health score decreased without a statistically significant difference [22]. A previous study that investigated the effect of telerehabilitation on quality of life in patients with MS showed improvements in the quality of life assessed by MSQoL-54 in the telerehabilitation exercise group compared to the control group. Among the 16 subparameters of the scale, and a statistically significant difference was found in favor of telerehabilitation only in the pain and cognitive function subparameters [12]. Different than our study, this study had a larger sample size and included a control group, but the results obtained in our study were similar. In our study, there were improvements in composite physical health, composite mental health, change in health and sexual satisfaction scores in both groups, but when the groups were compared, only a significant difference was seen in favor of telerehabilitation in the sexual function satisfaction subparameter. In a pilot study involving 6 individuals with MS and investigating the effects of exercise and treadmill training on quality of life, it was found that there was a statistically significant difference in the composite physical health and composite mental health scores of MSQoL-54, and sexual intercourse. It was reported that there was no statistically significant difference in satisfaction and health change scores [23]. While the exact relationship between improved sexual quality of life and exercise, it can be hypothesized that decreased fatigue and improved sleep might have contributed to sexual functions, but this assumption is beyond the scope of this study.
The effect of exercise on functional outcomes in patients with MS has been previously positive. In a study investigating the effectiveness of an internet-based home tele-management application reported that there was no significant worsening or improvement in the T25FW score after the intervention [24]. In our study, there were decreases in T25FW times in both groups, but there was no significant difference between the groups. This may be because both groups included exercise intervention and both groups were highly functioning in the beginning of the study. Similar to our findings, in an internet-based home exercise study, it was reported that walking speed, assessed by the T25FW score, increased in the internet-based home exercise group compared to the control group, but this increase was not statistically significant [25]. The intervention period and number of participants were also the same as our study. What was different about our study was that it had a control group. In this study, it was stated that the T25FW times of the intervention group increased, but in our study, a decrease was observed in the T25FW times in both groups. As a result, it can be said that exercise is helpful in improving walking function in patients with MS.
The limitations of our study can be summarized as the limited patient population, which included only highly functional individuals with MS. In MS, lower functionality might hinder the application of the exercises, but a similar design can also be tried to for feasibility and effectiveness. This limited patient population also hindered our ability to perform block randomization in the patient recruitment process, risking heterogeneity in the initial patient population. Second, our study did not look into long-term results, so we cannot say how long does the positive effects of exercise therapies last in this population. Lastly, the home exercise group was only monitored by the weekly phone calls, and their report of adherence relied on their own , which clouds the reliability of the data.
Conclusion
Telerehabilitation based exercises seem more beneficial in improving sleep quality, fatigue and functionality, while both telerehabilitation and home-based video exercises improve quality of life in patients with MS.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING INFORMATION
None.
AUTHOR CONTRIBUTION
Conceptualization: Kaya A, Karadag-Saygi E. Methodology: Kaya A, Keniş-Coşkun Ö. Formal analysis: Kaya A, Keniş-Coşkun Ö. Project administration: Kaya A, Karadag Saygı E, Kucukosmanoglu Z, Ağan Yıldırım K. Visualization: Kaya A, Karadag Saygı E, Kucukosmanoglu Z, Ağan Yıldırım K. Writing – original draft: Kaya A, Keniş-Coşkun Ö, Karadag-Saygı E, Kucukosmanoglu Z, Ağan Yıldırım K. Writing – review and editing: Kaya A, Karadag-Saygı E, Kucukosmanoglu Z, Ağan Yıldırım K. Approval of final manuscript: all authors.
Fig. 1.
Patient flowchart.
Table 1.
Pre-intervention values of the scales used
Telerehabilitation group (n=15)
Home based video exercise group (n=14)
p-value (95% confidence interval)
PSQI score
5.6 (2.1)
5.28 (3.68)
0.78 (-1.97 to 2.59)
Poor sleep quality with PSQI
9 (60%)
7 (50%)
0.71
FSS
4.37 (1.42)
4.31 (1.86)
0.91 (-1.19 to 1.32)
High fatigue with FSS
10 (67%)
8 (57%)
Composite physical health
62.57 (22.93)
66.61 (23.48)
0.64 (-21.73 to 13.64)
Composite mental health
58.84 (21.71)
66.94 (21.91)
0.32 (-24.72 to 8.53)
Overall quality of life
46.66 (28.13)
51.78 (22.92)
0.60 (-24.75 to 14.52)
Sexual satisfaction
80.00 (23.52)
73.21 (84.47)
0.51 (-14.39 to 27.96)
T25FW (s)
5.67 (0.97)
5.87 (1.51)
0.68 (-1.15 to 0.77)
Values are presented as mean (standard deviation).
Values are presented as mean (standard deviation).
MSQoL-54, Multiple Sclerosis Quality of Life Scale-54; CI, confidence interval.
*p-value below 0.05 and
**p-value below 0.01.
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FATIGUE IN MULTIPLE SCLEROSIS – MECHANISMS, DIAGNOSIS, AND TREATMENT OPTIONS Kornelia Kaźmierkiewicz-Makanga, Weronika Spychalska, Emilia Piotrowicz, Filip Witowicz, Julia Glińska, Aleksandra Krawczyk, Wiktoria Waldon, Paulina Sumlet, Maria Gofron, Michał Duliński International Journal of Innovative Technologies in Social Science.2025;[Epub] CrossRef
, Evrim Karadağ-Saygı, MD1
