Effect of Nordic Walking Training on Walking Capacity and Quality of Life for People With Multiple Sclerosis Carme Santoyo-Medina, MSc, PT; Montserrat Janer Cabo, PT; Dolors Fàbregas Xaudaró, PT; Gaizka Loyola Sanmillan, PT; Samuel Sanchez Pous, PT; Ingrid Galan Cartaña, MD; Edwin Roger Meza Murillo, MD, MBA; Jaume Sastre-Garriga, PhD, MD; and Xavier Montalban, PhD, MD ABSTRACT M ultiple sclerosis (MS) is a chronic inflammatory dis- Downloaded from http://meridian.allenpress.com/ijmsc/article-pdf/25/3/118/3218331/i1537-2073-25-3-118.pdf by guest on 31 May 2023 ease of the central nervous system resulting from an BACKGROUND: Although there is emerging evidence that abnormal autoimmune response that causes multi- aerobic training improves walking capacity in persons with focal demyelination and neurodegeneration, leading to a wide multiple sclerosis (MS), data are limited about the potential range of neurologic symptoms and a gradual deterioration benefits of Nordic walking (NW) for this population. This of physical and cognitive ability over time.1 Resulting from study evaluates the effectiveness of outdoor NW training on a combination of symptoms and deficits such as spasticity, walking capacity and related quality of life for people with MS compared with cycloergometer and treadmill aerobic training. weakness, fatigue, ataxia, and balance and cognitive problems, impaired ambulation affects up to 80% of patients with MS.2 METHODS: A single-blinded (evaluator), randomized, 2-arm clinical trial was designed. Walking is perceived as one of the most valuable abilities within the spectrum of disability,3 and walking difficulties RESULTS: A total of 57 patients with MS (38 women and 19 men; have a high impact on the quality of life (QOL) of people with mean ± SD age, 51.98 ± 9.93 years; mean ± SD disease duration, MS.4 As physical deconditioning (reduction of aerobic capac- 14.75 ± 8.52 years) were included. Both therapeutic modalities improved walking distance as measured by the 6-Minute Walk ity, balance, and muscle strength) contributes to increased Test after the training period. The NW group showed significant walking disability, increasing physical activity could represent improvement on the physical and emotional subscales of the an essential intervention to improve motor capacity and, Multiple Sclerosis Quality of Life–54 compared with the cycloer- specifically, walking ability in this population.5 gometer and treadmill group, which showed improvement only on In the past decade, different publications have shown that the physical subscale. physical activity is highly recommendable to preserve the CONCLUSIONS: Both training modalities proved to be of equal physical and emotional state of people with MS, as well as to benefit in improving the walking capacity of people with MS, prevent complications arising from inactivity.6 Despite the but outdoor NW training also seems to have a beneficial effect on the emotional component of health-related quality of life. benefits of exercise described in such literature, people with MS have a high tendency to be sedentary compared with con- Int J MS Care. 2023;25(3):118-123. doi:10.7224/1537-2073.2021-070 trols.7 These results are particularly important because physi- cal exercise is key to maintaining good health and reducing the risk of inactivity-related diseases such as osteoporosis, dia- betes, obesity, cancer, and cardiovascular disease, some with a high incidence in MS.8 Different exercise modalities have demonstrated a positive effect on different physical or functional parameters in people with MS.9,10 Aerobic exercise with a cycloergometer or a tread- mill has a beneficial effect on fatigue and endurance in walk- ing capacity.11 Other studies have shown that aerobic training can improve not only self-referred fatigue but also maximum walking distance, mood, and feelings of self-efficacy.12,13 Achieving greater adherence to rehabilitation programs depends largely on the patients’ feelings of self-efficacy and From the Neurology-Neuroimmunology Department and Neurorehabilitation Unit, Multiple Sclerosis Centre of Catalonia, Vall d’Hebron University Hospital Barcelona, Barcelona, Spain (CS-M, MJC, DFX, GLS, SSP, IGC, ERMM, JS-G, XM); and Department of Physiotherapy, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain (CS-M). Correspondence: Carme Santoyo-Medina, MSc, PT, Neurology-Neuroimmunology Department and Neurorehabilitation Unit, Multiple Sclerosis Centre of Catalonia, Vall d’Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, Barcelona, Spain, 08035; email: csantoyo@cem-cat.org. Note: Supplementary material for this article is available at IJMSC.org. © 2023 Consortium of Multiple Sclerosis Centers. International Journal of MS Care Vol. 25 | No. 3 | May/June 2023 118 Santoyo-Medina et al enjoyment.14,15 In recent years, physical activity has become logic treatments/CONSORT extension for noninferiority or part of numerous clinical practice guidelines, promoting inclu- equivalence trials.24,25 sive physical activity strategies that facilitate exercising in the community, including specific programs for people with MS.16 Participants Nordic walking (NW) is one of the fastest growing rec- The sample consisted of 72 adults diagnosed as having MS reational activities today. It has its roots in Finland, where according to the McDonald criteria,26 with no signs of MS exac- “walking with poles” was introduced as a summer training erbation or corticosteroid treatment less than 6 months earlier, method for cross-country skiing. Walking with poles involves a slight risk of falls (Berg Balance Scale scores ≥48),27 and who movement in the upper body, thereby partially removing referred to walking fatigue and restriction in their usual walking strain on the lower extremities and the lumbosacral spine, and perimeter during the past 6 months. Patients with neurologic provides a higher energy expenditure, quantified by 20% to disorders other than MS, moderate-severe spasticity (modified 40%, compared with the standard stride.17 The NW poles are Ashworth scale score >2),28 nonstable cardiovascular disease, adapted ski poles with a special strap that allows the pole to diabetes mellitus, arthritis, acute pain, peripheral neuropathies, be released during the swing, keeping the trunk in an upright, severe orthopedic problems, psychiatric problems, pregnancy, Downloaded from http://meridian.allenpress.com/ijmsc/article-pdf/25/3/118/3218331/i1537-2073-25-3-118.pdf by guest on 31 May 2023 symmetrical position while walking. Nordic walking poles other involvement in fatigue or gait training, severe cognitive are also longer than trekking poles, angling back at 45° when impairment, or an inability to maintain a continuous walking you plant them on the ground. Using the poles with each pace for a minimum of 15 minutes were excluded. Participants step pushes the body forward, facilitating longer strides and were recruited at the Multiple Sclerosis Center of Catalonia based increasing walking velocity. In addition, the lower subjective on the clinical data obtained from their last rehabilitative admis- perception of fatigue and greater confidence when walking sion; a personal interview in which the objectives and methods with poles improves mood and enjoyment during NW.18 of the study were explained was conducted, and then informed For all these reasons, NW has become a valuable thera- consent was signed. Participant flow through recruitment/enroll- peutic tool in many pathologic and neurologic disorders, ment is included in FIGURE S1, available online at IJMSC.org. especially in Parkinson disease. Different studies show that walking with poles, and thus activating the arms as well as Randomization and Therapy Allocation the legs, improves both motor and nonmotor symptoms in An assignment sequence was randomly generated with a 1:1 Parkinson disease.19-21 ratio using Sealed Envelope Ltd 2015 software (https://www. A recent publication studied the effect of NW performed sealedenvelope.com). indoors by people with MS.22 In this case series study, a 12-week NW indoor training program showed a limited effect on self- Rehabilitation Program Format and Volume perceived fatigue and functional mobility, possibly due to the For both groups, the dose, frequency, and basic structure of small sample and the low intensity of the sessions. However, the training sessions were identical: twenty 60-minute ses- higher levels of functional mobility and walking distance sions twice a week. Each session was 10 minutes of warm-up were achieved by all participants. In contrast, another study exercises, 40 minutes of NW or C&T training, and 10 minutes showed that trekking poles could be a useful and well-accepted of cool-down and stretching exercises. Both groups’ training assistive device for walking impairment in people with MS.23 increased in intensity across the 20 sessions according to their Low cost, versatility, and the possibility of being outdoors age, baseline cardiovascular status, and effort response. with other people make NW an activity with great potential to A heart rate monitor, model Polar FT1 (Polar), attached to increase regular physical activity and social participation for the xiphoid, was used to control the cardiovascular effort dur- people with MS. If outdoor NW training showed a comparable ing the sessions for both groups. The maximum heart rate efficacy to conventional aerobic training, it could be used as (MHR) was determined using the general formula 220 – age. part of MS rehabilitation treatment and recommended for The heart rate reserve was determined by subtracting resting patients with limited walking capacity. Thus, the main objec- heart rate from the MHR. The target heart rate ranged from tive of the present study was to determine whether the effect of approximately 60% to 70% of the heart rate reserve + resting NW is equal to that of conventional aerobic training by means heart rate. During the sessions, physiotherapists regularly of cycloergometer and treadmill (C&T) in the improvement of monitored the heart rate to ensure that it remained within the walking capacity and related QOL in people with MS. parameters stipulated for each patient. The NW training pro- gram was designed and performed by physical therapists qual- METHODS ified as NW instructors. During the first 2 sessions participants A 2-arm (NW training vs C&T training), randomized clinical were taught the proper NW technique adapted to each par- trial with a blinded assessor was conducted. The study was ticipant’s gait pattern. The NW sessions took place in groups of approved by the Ethics Committee Commission of Vall d’Hebron 4 to 6 patients on outdoor circuits, tracing urban routes and University Hospital (register PR[AG]2015) and registered in dirt tracks. Participants were encouraged to gradually increase the clinicaltrials.gov database (NCT03976128). The methods distance walked and trail difficulty, starting with flat terrain follow the criteria of the CONSORT (Consolidated Standards and introducing inclines and stairs throughout sessions to of Reporting Trials) guide for clinical trials of nonpharmaco- increase aerobic exercise load to at least 60% MHR. 119 Vol. 25 | No. 3 | May/June 2023 International Journal of MS Care Nordic Walking and MS Aerobic Training TABLE 1. Change in Outcome Measures Nordic walking (n = 27) Cycling and treadmill (n = 25) Before After Change P valuea Before After Change P valuea 402.18 ± 442.69 ± 40.51 (–57.10 343.81 ± 377.42 ± 33.61 (–52.94 6MWT, m <.001b .001b 92.93 96.62 to 23.92) 106.35 120.27 to 14.27) 0.33 (0.08 - 0.26 (–0.11 to T25FWT, s 6.32 ± 1.48 5.99 ± 1.44 .009b 7.50 ± 3.12 7.24 ± 3.60 .104 0.57) 0.64) –0.48 (–1.79 –1.52 (–2.84 BBS 52.92 ± 3.07 53.40 ± 3.58 .45 49.52 ± 6.38 51.04 ± 5.61 .026b to 0.83) to –0.19) 0.81 (0.37 - 0.53 (–0.08 to TUG, s 8.88 ± 2.26 8.07 ± 2.04 .001b 10.31 ±4.13 9.78 ± 3.94 .089 1.24) 0.14) 2.813 (–0.625 52.072 ± 8.125 (2.188 ABC scale 59.24 ± 20.64 62.45 ± 21.11 .109 60.64 ± 23.31 .006b to 7.5) 20.19 - 13) Downloaded from http://meridian.allenpress.com/ijmsc/article-pdf/25/3/118/3218331/i1537-2073-25-3-118.pdf by guest on 31 May 2023 –7.50 (–11.5 MSWS-12 34.50 ± 12.02 30.50 ± 6.36 –4 (–8 to 0) .317 40.36 ± 10.98 32.56 ± 12.80 <.001b to –4) –6 (–10.50 MFIS 44.48 ± 21.35 38,48 ± 22.71 .005b 52.56 ± 15.17 43.64 ± 15.79 –9 (–14 to –4) .003b to 2) –6.57 (–11.27 –4.64 (–9.24 MSQOL-54P 54.15 ± 19.40 60.39 ± 19.23 .008b 47.44 ± 15.87 52.08 ± 17.90 .048b to –1.88) to –0.03) –6.15 (–11.20 –5.44 (–12.45 MSQOL-54E 63.46 ± 22.28 69.62 ± 19.83 .019b 58.37 ± 18.89 63.82 ± 15.53 .122 to –1.10) to 1.56) 6MWT, 6-Minute Walk Test; ABC, Activities-specific Balance Confidence; BBS, Berg Balance Scale; MFIS, Modified Fatigue Impact Scale; MSQOL-54E, Multiple Sclerosis Quality of Life–54 Emotional; MSQOL-54P, Multiple Sclerosis Quality of Life–54 Physical; MSWS-12, 12-item Multiple Sclerosis Walking Scale; T25FWT, Timed 25-Foot Walk Test; TUG, Timed Up and Go Test. Note: Before and after values are expressed as mean ± SD and change values as mean (95% CI). a P values are calculated by Student t test. b Statistically significant. The C&T training used the MOTOmed viva 2 cycloergom- Disability Status Scale,31 the Timed Up and Go test,32 the Berg eter (RECK-Technik GmbH & Co KG) and the Cruiser High Balance Scale,27 the 12-item Multiple Sclerosis Walking Scale,33 Performance Treadmill (Trueform). In the first session, the the Activities-specific Balance Confidence scale,34 the Modified base speed for the treadmill and the cycloergometer resistance Fatigue Impact Scale,35 and the Multiple Sclerosis Quality of were established for each patient. A comfortable speed was Life–54 (MSQOL-54).36 found in which the patient could exercise throughout the allocated time at a speed of 60 to 80 rpm, with an increase in Statistical Analysis heart rate of at least 60% of the MHR. From these baselines, The 2001-2015 Sealed Enveloped Ltd program “randomization the speed and resistance progressively increased throughout and online databases for clinical trials” was used to calculate the training period. If there was good patient tolerance, every the sample size (https://www.sealedenvelope.com/power 3 training sessions the speed of the treadmill was increased /continuous-noninferior). Alpha values of 2.5% and beta values by 0.2 km/h and the resistance of the cycloergometer was of 20% (power of 80%) were used. Assuming a standard devia- increased by 1 point. tion of 100 m and a difference of 77 m as the minimal detectable change in walking distance,37 27 patients were needed in each Mobility Measures arm of the study. If there was no difference between the NW and Outcome assessments were performed 3 times (T1, T2, and T3: C&T treatments, the trial would require 60 patients to achieve pretraining, post training, and 3 months post training, respec- 80% certainty that the upper limit of a 95% CI will be below the tively). The 10-week training program took place between T1 noninferiority margin of 77. Allowing for a 10% patient dropout and T2. After the training period, participants were encour- rate, recruitment was increased to 33 patients per arm. aged to stay active and exercise daily without any specific Data were entered and processed using IBM SPSS Statistics guidelines. The frequency or type of physical activity devel- for Windows, version 26.0 (IBM Corp). The level of signifi- oped between T2 and T3 was not controlled. cance was set at P < .05. The effect of both training modali- Comparisons were made between and within groups ties was analyzed comparing the pretraining and posttrain- based on the following timed tests and scales, as well as the ing values according to the Student t test and the χ 2 test. patient-reported outcome. Primary outcome measures were Noninferiority was assessed by estimating the difference the 6-Minute Walk Test (6MWT) 29 and the Timed 25-Foot (95% CI) between the initial and final mean values, following Walk test.30 Secondary outcome measures were the Expanded International Journal of MS Care Vol. 25 | No. 3 | May/June 2023 120 Santoyo-Medina et al TABLE 2. Adjusted Analysis of 6MWT Change Nordic walking (n = 27) Cycling and treadmill (n = 25) Adjusted difference Baseline 20 sessions Baseline 20 sessions P valuea (95% CI) 7.78 (–15.23 to 6MWT, mean ± SD, m 396.82 ± 91.88 437.68 ± 95.26 348.08 ± 107.30 381.18 ± 121.21 .501 –30.79) 6MWT, 6-Minute Walk Test. a P value calculated by Student t test for independent samples. the CONSORT recommendation. The analysis was conducted An adjusted analysis of the differences between the treat- per protocol. ments is shown in relation to the 6MWT as the main out- An analysis of the central tendency measures of the quanti- come in TABLE 2. There was no significant difference (P = tative variables was performed using the Kolmogorov-Smirnov .501) between the groups. Furthermore, the upper limit of Downloaded from http://meridian.allenpress.com/ijmsc/article-pdf/25/3/118/3218331/i1537-2073-25-3-118.pdf by guest on 31 May 2023 test to verify that there were no statistically significant differ- the 95% CI was below 77 m, the value that was established as ences between the NW and C&T groups. The Student t test was a noninferiority margin. used for independent samples in the variables that followed a FIGURE S2 shows the effect of both therapeutic modalities normal distribution, and the Mann-Whitney U test was used on distance walked, walking speed, and health-related QOL for those that were not normally distributed. at T1, T2, and T3. Only the improvements observed in the 6MWT at T2 remained statistically significant at T3 in the RESULTS NW group. Significant gains in all other parameters at T2 Of the 72 eligible participants, 7 chose not to participate because were not maintained at T3. the training program did not fit their work schedule, 6 did not No serious adverse effects appeared in either group. Some meet the selection criteria, and 2 were excluded because they patients reported a higher level of fatigue in the hours after could not attend the treatment sessions during several of the training, but they had a complete recovery before the next ses- training weeks. Patients who met the selection criteria (N = 57) sion. There were no accidents during the sessions among the were randomly assigned to the 2 groups, 29 in the NW group NW group even though the terrain was sometimes quite steep. and 28 in the C&T group. Of these 57 patients, 5 dropped out in Overall adherence to the treatment was 91.22% (52 of 57 the follow-up period. There were no statistically significant dif- patients): 93.10% (27 of 29) in the NW group and 89.28% ferences at baseline in terms of clinical characteristics between (25 of 28) in the C&T group, with no significant differences both groups. The demographic and clinical characteristics of the between them (P = .610). whole sample and the differentiation between both groups are reported in TABLE S1. DISCUSSION After 10 weeks of training, some parameters improved sig- To our knowledge, this study is one of the first to provide nificantly. TABLE 1 shows changes in the different outcome information relating to the effects of outdoor NW on people measures in a per-protocol analysis. Both groups showed with MS. These data provide new insights into noninvasive statistically significant improvement in walking distance therapies for MS, specifically related to aerobic physical train- measured by the 6MWT, with a mean increase of 40.51 m ing where the use of poles means that individuals exercise in the NW group and 33.61 m in the C&T group. Walking both the upper and lower body. The present study shows that velocity measured by the Timed 25-Foot Walk test improved outdoor NW training is feasible for people with MS and walk- significantly only in the NW group (P = .009). In contrast, ing disability and that it is not inferior to the conventional the C&T group did not improve their walking velocity but aerobic training used in our clinical practice (ie, indoor cycling did improve their perception of walking disability measured and treadmill). These results are in contrast to those reported by the 12-item Multiple Sclerosis Walking Scale (P < .001). by Martínez-Lemos et al 22 on the effect of NW training in The NW group showed statistically significant improvement 14 people with MS on self-reported fatigue, functional mobil- in dynamic balance measured by the Timed Up and Go test ity, physical fitness, and QOL. Their protocol included 2 ses- (P = .001), and the C&T group showed a significant improve- sions per week of NW training over 3 months. The structure, ment in static balance measured by the Berg Balance Scale content, and progression of the sessions were quite similar to (P = .026) and in self-perceived balance confidence measured ours except that the NW training was indoors. There was a low by the Activities-specific Balance Confidence scale (P = .006). level of adherence to the program, and they concluded that Both groups showed significant differences in perceived their program was not feasible for people with MS and had fatigue measured by the MFIS (P = .005). In the NW group, a little effect on their levels of mobility. As mentioned, our NW significant improvement was observed in the perceived QOL sessions were in small groups and outdoors, crucial aspects in both physical subscale (P = .008) and emotional subscale to making the activity enjoyable for participants, as well as (P = .019) of the MSQOL-54, and the C&T group had a signifi- for allowing a gradual increase in intensity and difficulty cant improvement only on the physical subscale (P = .048). throughout the training program. 121 Vol. 25 | No. 3 | May/June 2023 International Journal of MS Care Nordic Walking and MS Aerobic Training In a recent study, Cohen et al23 observed that trekking poles had a positive psychosocial impact and were well accepted and preferred as an assistive device for walking for people PRACTICE with MS, especially as it has the appearance of sporting equipment rather than an assistive orthopedic device. This is especially interesting for patients initially reluctant to use POINTS an assistive device for walking but who present an increasing restriction in their walking perimeter due to fatigue, balance, or coordination problems. Because there are seemingly no other studies on the effect of outdoor NW for people with MS, we took the evidence on Nordic walking may be an effective modality of the effect of NW on Parkinson disease as a neurodegenerative outdoor aerobic training for improving walking disease reference point. Bang and Shin20 studied the effect of capacity in persons with multiple sclerosis with NW training on a treadmill compared with treadmill walking mild to moderate mobility impairment. Downloaded from http://meridian.allenpress.com/ijmsc/article-pdf/25/3/118/3218331/i1537-2073-25-3-118.pdf by guest on 31 May 2023 alone for persons with Parkinson disease, providing evidence of an additional benefit of NW training on balance and walk- Rehabilitation programs that aim to increase ing ability, even when the activity is indoors. These results physical activity levels in persons with multiple are in concordance with the present study in terms of the sclerosis may consider incorporating Nordic efficacy of NW and its noninferiority compared with C&T as walking, an inclusive modality that allows the reference training method used. In a recent systematic enjoyment while exercising in community. ■ review, Cugusi et al21 observed improvements in resting heart rate, maximum walking distance, and lower-limb muscle strength as well as in mood, apathy, and QOL after NW train- mild to moderate intensity to determine the extent to which ing compared with conventional therapy, although some lim- the training load, including aspects such as intensity and itations prevent definitive conclusions. In the present study, frequency, can be adapted. a remarkable benefit was noticed in the emotional subscale An unexpected aspect of the present study was that the of the MSQOL-54 for the NW group, which may be due to the self-evaluation of confidence in one’s own balance and enjoyable component of outdoor and group training. perception of walking ability did not improve in the NW Most noteworthy is the question of whether the benefit of group but did in the C&T group. This is surprising because NW remains in the long-term.22 Herein, the assessments at T3 NW, as an open-air activity, is much more environment- show that the benefit does last with respect to distance and dependent and demanding than C&T training. One pos- walking speed but seems to disappear in the other analyzed sible explanation could be that the NW group had to confront variables, which returned to their baseline levels after this real-life limitations and difficulties pertaining to MS during time. In our opinion, the 2 days of scheduled NW training a the training, meaning that their self-perception was harsher week constitute the commitment needed to acquire a healthy on the questionnaire. physical activity habit. On the other hand, avoiding excessive This study has several methodological limitations: The physical fatigue is crucial to ensure adherence to the program main limitation is comparing indoor exercise training with in accordance with the guidelines for physical activity for outdoor exercise training, and the exercise setting may have patients with MS. An interesting area for further research a role in exercise training responses. The study’s aim was to would be studying patients with MS’ perception of self- identify a difference between the groups and not to compare efficacy in acquiring a regular physical activity when they can them. Patients were not, therefore, split into subgroups to choose the type of activity and to then measure whether this find prognostic factors that modify the indication of this type activity is maintained over time. Based on this, we are con- of training; the great variability and dispersion of patients’ sidering a study on adherence to physical activity by patients baseline clinical characteristics would have made this very with MS with long disease durations. As McAuley et al 14 difficult. In addition, the impossibility of blinding the partici- explain, “For healthy, sedentary individuals, every aspect of pants may have caused a performance bias, thereby influenc- becoming physically active is a challenge. For those with MS, ing the results. The potential candidates showed some prefer- this challenge is greatly magnified.” ence for the NW protocol. Once randomized, those assigned We believe that the intensity and type of training must be to the C&T protocol still agreed to participate, even if it did adapted to the needs and capabilities of people with MS, as not fully match their initial expectations. an activity not regulated by specific guidelines may fail to achieve real and significant benefits. A study to determine CONCLUSIONS the type of training suitable for people with MS in relation This is the first randomized clinical trial to evaluate the to the degree of physical involvement would be helpful. efficacy of outdoor NW training for people with MS. The This would involve expanding the sample size to enable results of this study demonstrate significant effects on walk- an analysis of subgroups undertaking physical activity of ing capacity, fatigue, and perceived QOL for NW. For people International Journal of MS Care Vol. 25 | No. 3 | May/June 2023 122 Santoyo-Medina et al 13. Weikert M, Dlugonski D, Balantrapu S, Motl RW. Most common types of with MS with mild to moderate disability, NW training is physical activity self-selected by people with multiple sclerosis. Int J MS Care. equivalent to C&T training in terms of improved walking 2011;13(1):16-20. doi:10.7224/1537-2073-13.1.16 velocity and distance, effects that were maintained 3 months 14. McAuley E, Motl RW, Morris KS, et al. Enhancing physical activity adherence and well-being in multiple sclerosis: a randomised controlled trial. Mult Scler. after the treatment period. In addition, outdoor NW train- 2007;13(5):652-659. doi:10.1177/1352458506072188 ing also seemed to have a beneficial effect on the emotional 15. Latimer-Cheung AE, Martin Ginis KA, Hicks AL, et al. Development of evidence- component of health-related QOL. Therefore, our experience informed physical activity guidelines for adults with multiple sclerosis. Arch Phys Med Rehabil. 2013;94(9):1829-1836.e7. doi:10.1016/j.apmr.2013.05.015 shows that outdoor NW is a valuable exercise method for the 16. National Clinical Guideline Centre. Multiple Sclerosis: Management of Multiple rehabilitation of people with MS. ■ Sclerosis in Primary and Secondary Care. National Institute for Health and Care Excellence; 2014. ACKNOWLEDGMENTS: The authors gratefully acknowledge J. Domeño, 17. Kapoor S. Nordic walking and its clinical benefits in different disorders. Disabil A. Rivera, and M. Garcia for their support during the NW sessions and Rehabil. 2013;35(19):1676. doi:10.3109/09638288.2012.756945 18. Tschentscher M, Niederseer D, Niebauer J. Health benefits of Nordic A.C. Sao and P. Carbonell for their guidance on statistical analysis. walking: a systematic review. Am J Prev Med. 2013;44(1):76-84. doi:10.1016/j .amepre.2012.09.043 FINANCIAL DISCLOSURES: Dr Montalban has received speaking 19. Kocur P, Wilk M. Nordic walking: a new form of exercise in rehabilitation. Med Downloaded from http://meridian.allenpress.com/ijmsc/article-pdf/25/3/118/3218331/i1537-2073-25-3-118.pdf by guest on 31 May 2023 honoraria and/or travel expenses for participation in scientific Rehabil. 2006;10(2):1-8. meetings and/or has been a steering committee member of clinical 20. Bang DH, Shin WS. Effects of an intensive Nordic walking intervention on the trials and/or participated in advisory boards of clinical trials in past balance function and walking ability of individuals with Parkinson’s disease: a randomized controlled pilot trial. Aging Clin Exp Res. 2017;29(5):993-999. years with Actelion, Alexion, Bayer, Biogen, Bristol-Myers Squibb/ doi:10.1007/s40520-016-0648-9 Celgene, EMD Serono, Excemed, Genzyme, Hoffmann-La Roche, 21. Cugusi L, Manca A, Dragone D, et al. Nordic walking for the management of Immunic Therapeutics, Janssen Pharmaceuticals, MedDay, Merck, people with Parkinson disease: a systematic review. PM R. 2017;9(11):1157-1166. Multiple Sclerosis International Federation, Mylan, National Multiple doi:10.1016/j.pmrj.2017.06.021 22. Martínez-Lemos I, Martínez-Aldao D, Seijo-Martínez M, Ayán C. Nordic walking for Sclerosis Society, NervGen Pharma, Novartis, Sanofi-Genzyme, people with relapsing-remittent multiple sclerosis: a case series study. Mult Scler Teva Pharmaceuticals, and TG Therapeutics. Dr Sastre-Garriga has Relat Disord. 2020;46:102479. doi:10.1016/j.msard.2020.102479 received personal fees from Biogen, Biopass Medical Systems, 23. Cohen ET, Huser S, Barone K, Barone DA. Trekking poles to aid multiple sclerosis Celgene, Merck, Orchid Pharma, and Sanofi. He is a member of the walking impairment: an exploratory comparison of the effects of assistive devices on psychosocial impact and walking. 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