Health Behaviors, Wellness, and Multiple Sclerosis Amid COVID-19
Why focus on multiple sclerosis (MS) and wellness during the coronavirus disease 2019 (COVID-19) pandemic? People with MS have considerable experience coping with the uncertainty that goes along with having a highly variable, progressive disease. The COVID-19 pandemic presents new uncertainties that likely challenge the coping resources of persons with MS and cause disruptions in lifestyle habits and choices that affect wellness. Anxiety, depression, loneliness, and sedentary behavior are common in MS and now may be exacerbated by the physical distancing necessitated by the pandemic. In this context, the promotion of wellness through health behaviors has never been more important, and rehabilitation providers play a critical role in promoting wellness in the population with MS, across the life span, during this pandemic. Although derived from the MS literature, the following evidence-based physical, nutritional, and emotional wellness recommendations are relevant to not only people with MS but also to other rehabilitation populations who are adversely affected by the decreased physical and social activity, uncertainty, economic hardship, and other lifestyle restrictions common to this time.
There is convincing evidence that exercise and physical activity can improve walking, balance, fatigue, depression, and quality of life in people with MS. 1 There are also benefits in MS for cognition, anxiety, and pain. 2,3 Vascular comorbidities are common and have a major effect in MS, 4 and may even worsen the severity of COVID-19. Evidence from the general population indicates that exercise and physical activity reduce the prevalence and severity of conditions. 5,6 These benefits may be applicable in MS, 7 and possibly affect disability progression in MS. 8 We recommend that health care providers reinforce the importance of sitting less and moving more on a daily basis by engaging in lifestyle physical activity and/or exercise amid the pandemic and after. 9,10 This may include simple modifications such as multiple short bouts of ambulatory and wheelchair-based physical activity in or outside the home throughout the day. Specific exercise training guidelines indicate that persons with MS should undertake 2-3 d/wk of aerobic exercise (10-30min at a moderate intensity) and 2-3 d/wk of resistance exercise (1-3 sets of between 8 and 15 repetition maximum). 11 Providers should highlight, with all patients, the importance of engaging in physical activity or exercise, maintaining a current routine, and consulting with professionals before making substantial or risky changes.
Physical activity has many benefits, including on psychological and physical health, such that maintaining and/or increasing physical activity among people with MS could have substantial benefits during the COVID-19 pandemic. For more specific guidelines, we refer you to resources available from the National Multiple Sclerosis Society on physical activity and exercise for people living with MS.
There is emerging evidence for the value of maintaining a healthy diet in both adult and pediatric MS. Higher scores on a healthy diet index (ie, higher consumption of fruits and vegetables, lower consumption of red meats and fats) have been associated with less depression, lower levels of disability, and higher patient-reported quality of life in MS. [12] [13] [14] However, 70% of Americans eat the Standard American Diet, and that includes people with MS. The Standard American Diet is a diet low in fruit and vegetable consumption and high in saturated fat, sodium, and refined sugar. Such a diet is associated with an increased risk of hypertension, cardiovascular disease, type 2 diabetes and obesity. 14,15 Obesity, diabetes, and severe cardiovascular disease have been identified as risk factors for serious illness from COVID-19. 16 In MS, lower levels of vascular comorbidities that include cardiovascular disease, diabetes, hypertension, hypercholesterolemia, and peripheral vascular disease have been shown to extend the ability to walk without assistance by approximately 6 years. 17 We recommend that providers keep in mind that there is not sufficient scientific evidence for recommending a specific diet in MS. What providers can do is encourage their patients with MS to maintain simple healthy diet habits that include: (1) make at least half your plate at meals fruits and vegetables (excluding starchy vegetables); (2) choose healthy fats that include olive oil and grapeseed oil as well as fish and poultry that are lower in saturated fat; (3) add whole foods; and (4) read food labels; any food that has less than 5 ingredients is less likely to have excess sodium and refined sugar. Key advice during this COVID-19 pandemic is to start with a small change rather than a diet overhaul by phasing in healthy foods and healthy eating habits while reducing the less healthy ones. We recommend that providers remind their patients that diet is important in MS because it affects MS disability, emotional wellness, and quality of life. For many, the COVID-19 pandemic has been a time of uncertainty and powerlessness; having control over diet is empowering and offers the opportunity 
Emotional wellness plays an influential role in the overall health of people living with MS and other chronic conditions. Depressive disorders, affecting 1 in 3 people with MS, 18 have adverse effects on cognition, pain, fatigue, adherence to exercise and disease modifying therapies, and overall quality of life. [19] [20] [21] Anxiety disorders are also more prevalent and associated with a range of negative effects on health and well-being. 21 Conversely, resilience, the ability to regain or maintain well-being despite experiencing adversity or chronic stressors, is common among people with MS 22 and positively affects MS symptoms, function, and quality of life. [23] [24] [25] Fortunately, robust evidence indicates that psychological interventions, including cognitive behavioral therapy, mindfulness-based interventions, stress management, selfhypnosis training, and/or self-management skills training, improve depression, 26,27 stress, 28 fatigue, 29 pain, 30-32 and sleep. 30, 33 Many of these interventions can successfully treat multiple symptoms, such as mood, pain, and fatigue, at once, 31 making multisymptom management feasible.
We recommend that providers assess and address patients' emotional wellness as part of standard care, both during the COVID-19 crisis and after it has passed. Because screening alone is rarely sufficient to address emotional wellness, 27 providers should collaborate with patients to generate a comprehensive plan for addressing psychosocial distress, symptom management, and adherence to other lifestyle recommendations. The rapid transition to and coverage for telehealth psychological services (both video and telephone) during the pandemic provides an opportunity for patients with MS to access psychological services from their homes. Telehealth is an effective mode of care for patients with MS, 30 and those with varying severity and symptoms can benefit from such care, including those with cognitive dysfunction. 34 If telehealth psychological care with a professional is not needed, preferred, or available, a range of empirically-informed online and self-help strategies are available. For example, My MS Toolkit (https:// mymstoolkit.com) is a free, online self-management program based on an efficacious telehealth self-management intervention. 31 Fortunately, the very behaviors and skills that can be used to improve emotional well-being in MS are skills that can help people cope with the anxiety, increased isolation, and uncertainty that many are experiencing during the COVID-19 pandemic.
There is good evidence that health behaviors can improve and sustain many components of wellness in MS. Rehabilitation providers can be powerful advocates of the benefits of physical activity, diet, and emotional wellness for MS symptom management, quality of life, and the reduction of comorbid conditions that affect both MS disability and risk of COVID-19 illness severity.
We strongly urge health care providers to share information on wellness with their patients who have MS and other chronic conditions, encouraging adoption of such behaviors. There is a pressing need for a collaborative approach for managing each person's health amid the economic and social limitations attendant to COVID-19. Fallout from these limitations will be widespread and affect health in many ways both in the short and long term. Providers are urged to collaborate with the National Multiple Sclerosis Society and other advocacy organizations to disseminate wellness materials and resources (listed below) while providing guidance tailored to each patient's needs, abilities, means and preferences.
Supplemental material and resources: https://www.nationalmssociety.org/Living-Well-With-MS/ Diet-Exercise-Healthy-Behaviors https://www.nationalmssociety.org/Living-Well-With-MS/ Emotional-Well-Being https://www.nationalmssociety.org/Resources-Support/ Library-Education-Programs/Brochures/Staying-Well https://www.nationalmssociety.org/Programs-and-Services/ Resources/Wellness-Discussion-Guide-for-People-with-MSand-T?pageZ1&orderbyZ3&orderZasc
For information specific to COVID-19 and wellness, see https://www.nationalmssociety.org/coronavirus-covid-19-informa tion American Heart Association website recipes, helpful videos, kitchen skills, and techniques: https://recipes.heart.org/en Can Do MS website with programs and services: https://www. cando-ms.org