AGING WITH MS: AN EMERGING HEALTH CHALLENGE Multiple sclerosis (MS) is a chronic neuroinflammatory, often disabling disease, and a leading cause of nontraumatic neurological disability in young adults (1). However, the demographics of MS are changing rapidly. Nearly 1 million adults are living with MS in the United States, and approximately half are now over the age of 55 yr (2). Similar trends are being observed globally, with older adults representing the fastest-growing segment of the MS population (3). This demographic shift poses significant challenges, as older adults with MS experience faster disability progression, greater functional decline, and higher rates of multimorbidity than both younger adults with MS and age-matched peers without MS (4,5). Although principles of healthy aging and personal responsibility apply to all individuals, MS fundamentally alters the aging trajectory. In addition to normative age-related declines, people aging with MS face progressive neurodegeneration, fluctuating symptoms, and cumulative disease burden that can limit the ability to engage in and sustain healthy behaviors. These disease-specific challenges necessitate tailored, supportive, and clinically integrated lifestyle strategies rather than reliance on individual behavior change alone. As people with MS are living longer, the consequences of disease-related neurodegeneration are compounded by age-related declines in neural, physical, and cognitive function, as well as age-related comorbidities (6). To this end, treatment and disease management in older adults with MS have become increasingly complex (6). Current models of MS care—centered largely on pharmacological disease-modifying therapies (DMTs)—are ill-equipped to address these aging-related issues (Table 1). There is limited safety and efficacy information on DMTs in older adults with MS (6), as pivotal clinical trials have often excluded individuals over the age of 55, among other factors (7). Moreover, high-efficacy DMTs primarily target immune-mediated disease activity but do not effectively address functional declines in cognition or mobility. These therapies also carry increased risks in older adults with MS, and their benefits in this age group have been questioned (7). Collectively, there is little evidence to guide concrete treatment decisions for this rapidly growing segment of the MS population (6). As a result, many older adults with MS are left without effective interventions for maintaining or prolonging cognitive and physical function. This underscores a critical need for complementary behavioral strategies that directly target function, symptoms, and quality of life—namely, structured exercise training. In fact, evidence-based exercise recommendations from the American College of Sports Medicine (ACSM) for older adults and for individuals with MS are available (8). However, these recommendations are presented separately and do not address the combined needs of older adults living with MS. TABLE 1 - Summary of Current Treatment Approaches in Multiple Sclerosis. Treatment Category Primary Purpose Key Limitation 1. Disease-modifying therapies (DMTs) Reduce relapse rate and inflammatory disease activity Limited impact on physical function, cognition, and aging-related outcomes 2. Hematopoietic stem cell transplantation (HSCT) Halt aggressive inflammatory disease High risk; limited eligibility; not designed to support long-term functional health 3. Symptom management—pharmacology Manage fatigue, pain, spasticity, mood Symptom-focused; does not prevent functional decline 4. Rehabilitation therapies—physical therapy Address mobility and daily function Often episodic and impairment-focused 5. Exercise and physical activity Support physical, cognitive, and overall health Not routinely embedded in standard MS care EXERCISE TRAINING: A TRANSLATIONAL STRATEGY FOR HEALTHY AGING WITH MS Exercise training, defined as planned, structured, and repetitive physical activity aimed at improving physical fitness and function (9), is a powerful non-pharmacological strategy to support healthy aging. In older adults, the benefits of exercise for mobility, cognitive function, and independence are well established (10). Among younger adults with MS, exercise training is safe, feasible, and efficacious in improving gait, balance, fatigue, mood, and quality of life; and guidelines exist to promote safe participation in physical activity and exercise among this population (11). While limited, early evidence suggests that these benefits extend to older adults with MS. Pilot trials have shown promising feasibility, safety, and initial effectiveness of exercise-based interventions in this group. For instance, Sosnoff et al. (12) conducted a pilot randomized controlled trial and demonstrated initial feasibility, safety, and effectiveness of a home-based exercise program for fall-risk reduction in older adults with MS. Similarly, Sebastião et al. (13) investigated the feasibility and preliminary efficacy of the Square-Stepping Exercise, a cognitive-motor intervention, in older adults with MS. Their findings provided initial evidence supporting the feasibility, safety, and acceptability of the Square-Stepping Exercise for older adults with MS and highlighted its potential to improve mobility and cognitive function. Recently, Gaemelke et al. (14) outlined the protocol for a research trial designed to investigate the effects of power training—a subcategory of resistance training that emphasizes explosive movements—on neurodegeneration, neuromuscular, and physical function in older adults with MS. This study aims to explore the potential role of resistance-based training in mitigating MS-related physical and cognitive impairment in older adults. Similarly, Zheng et al. (15) recently described the protocol for a research trial examining the benefits of a remotely delivered exercise training program tailored for older adults with MS. Their NIH Stage-I randomized controlled trial is exploring the feasibility of combining aerobic and resistance training via a telehealth platform, demonstrating the potential for scalable, accessible interventions. Collectively, these studies reflect a growing recognition of the importance—and potential—of exercise interventions to promote function, reduce symptoms, and improve quality of life in older adults living with MS. Importantly, aging is accompanied by progressive declines in all physiological systems, including the musculoskeletal and cardiovascular systems. Such declines result in dynapenia, kratopenia, sarcopenia, reductions in bone mineral density, and declines in cardiorespiratory fitness, all of which contribute to functional limitations in later life. In people with MS, these age-related changes may be compounded by disease-related factors such as neurodegeneration, chronic inflammation, and high levels of inactivity, potentially accelerating functional declines (16). While the benefits of exercise are well established, we underscore an important future research direction of resistance exercise training interventions aimed at developing muscular fitness (i.e., muscular strength, endurance, and power) in older adults with MS (8). Given that adequate muscular fitness is essential for preserving mobility, balance, and independence, reducing fall risk and fatigability, and supporting engagement in physical activity in older adults from the general population, resistance exercise training has the clear potential to result in similar benefits in older adults with MS. With respect to aerobic exercise in people with MS, research indicates that exercise intensity influences physiological and functional adaptations. Although moderate-intensity aerobic exercise remains the most commonly prescribed and well-tolerated approach in people with MS, emerging evidence suggests that high-intensity aerobic exercise may confer greater benefits for cardiorespiratory fitness and aspects of cognitive function (17). However, we note that there is an overall lack of true dose-response aerobic exercise training research in MS. BRIDGING THE GAP: FROM RESEARCH TO REAL-WORLD APPLICATION Despite these early efforts, significant gaps remain. Most exercise studies in MS have targeted younger adults, with minimal attention to the unique needs and constraints of aging with MS (18). In addition, MS exercise trials typically enroll a much larger proportion of women than men, aligning with the well-established sex distribution of MS prevalence. As such, sex-specific considerations and analyses have been applied inconsistently, and it is not clear if responses to exercise interventions differ by sex, particularly among older adults with MS. Greater attention to potential sex-related differences in exercise tolerance, symptom expression, and physiological adaptation may be important for optimizing the translation of exercise interventions to aging populations with MS. Yet the translational potential is clear: research from both young adults with MS and in older adults from the general population supports exercise as a foundational strategy for maintaining function and independence (10,18). Supporting healthy aging in people with MS requires moving beyond general lifestyle recommendations toward structured, individualized, and accessible exercise support. This includes tailoring programs to account for prevalent symptoms and comorbidities, while leveraging flexible delivery models such as home-based, group, and telehealth formats. Such approaches reduce participation barriers and enable sustained engagement in exercise across the aging process. Implementation research can help determine how these tailored exercise programs are best adopted, delivered, and sustained in routine MS care and community settings. To truly capitalize on this opportunity, future efforts should focus on: (A) Adaptation and tailoring: Exercise programs should account for fatigue, fall risk, comorbidities, and neurocognitive impairment; (B) Delivery models: Remote/hybrid/telehealth approaches, group-based sessions, and home-based formats can overcome common participation barriers such as accessibility to exercise programs; and (C) Scalability and implementation: Integration into rehabilitation and community programs is essential for broad impact. Figure 1 illustrates our conceptual model for how exercise training can mitigate aging-related challenges in older adults with MS and promote healthy longevity.Figure 1:: Conceptual model for how exercise training can mitigate aging-related challenges in older adults with MS and promote healthy longevity.INTEGRATING EXERCISE INTO MS CARE: A PARADIGM SHIFT Building on the paradigm shift articulated by Dalgas et al. (19), healthcare professionals, qualified exercise professionals, researchers, and stakeholders in MS care must reframe how we support aging with MS. Rather than treating exercise as an optional or adjunctive recommendation, it should be recognized as a core component of long-term care—parallel to physical therapy, medication management, or routine screening, as is done in gerontological care in the general population. In this context, clinical triage and symptom management led by rehabilitation physicians can play a central role in identifying functional limitations, safety considerations, and individualized goals, while coordinated referral to guided exercise and lifestyle programs enables personalized, progressive, and sustainable physical activity engagement (20). In doing so, we can move beyond disease suppression and toward promoting lifelong health and well-being. For that, the following is required: (i) Embed exercise into routine MS care pathways; (ii) Educate clinicians and providers about its safety and benefits; and (iii) Support the development of MS-specific physical activity guidelines for older adults. Together, these strategies shift the responsibility from the individual alone to a shared-care model that supports healthy aging through coordinated clinical, behavioral, and community-based resources. To this end, the ACSM and allied organizations have a critical role to play in this effort—bridging the gap between research and practice through professional training, advocacy, and knowledge dissemination. Importantly, established pre-participation screening frameworks (e.g., ACSM risk stratification and MS-specific physical activity and exercise guidelines) support the safe initiation of exercise for most individuals with MS, with medical clearance typically reserved for those with unstable symptoms, significant comorbidities, or advanced disability (21). In general, supervised exercise therapy is indicated for individuals with complex medical presentations, unstable symptoms, or elevated fall or injury risk, where clinical oversight, tailored progression, and continuous monitoring are important to ensure safety and maximize benefit. At the same time, remotely delivered or home-based programs can be safely and effectively implemented across a range of disability levels—including among people with mobility limitations—when appropriate safeguards are in place. These typically include structured risk screening, individualized exercise prescription, education on symptom self-management (e.g., heat intolerance), and ongoing professional support. Thus, the choice between supervised and remote delivery should be guided less by disability level alone and more by clinical stability, environmental safety, available supports, and patient preference. However, common barriers—including fatigue, symptom fluctuations, fear/apprehension, limited support from providers (11)—continue to hinder participation among people with MS, underscoring the need for implementation-focused research to optimize screening, referral, and delivery models through MS clinical practice settings. From an evidence-based medicine perspective, exercise therapy for older adults with MS aligns with all three core pillars (i.e., patient values, clinical expertise of healthcare professionals, and scientific evidence). A growing body of scientific evidence supports its safety, feasibility, and potential efficacy; clinical expertise and established guidelines for older adults and persons with MS inform appropriate screening, tailoring, and progression; and patient values—including preferences, symptom burden, perceived benefits, and barriers—must guide shared decision-making to optimize adherence and outcomes. CALL TO ACTION: RESEARCH AND IMPLEMENTATION PRIORITIES To accelerate this shift, a targeted research and translational agenda is essential. Below, we outline key priorities to drive progress. Evidence generation across the lifespan: Expand targeted randomized controlled trials in older adults with MS to address specific mechanistic, safety, and modality-related questions—particularly resistance training, which has demonstrated robust benefits for physical function, metabolic health, and neuroprotection in aging and neurodegenerative populations—while also clarifying optimal aerobic exercise modes and intensity levels. In parallel, leverage longitudinal cohort studies, registries, and real-world data to characterize lifelong physical activity patterns, functional trajectories, and healthy aging in people with MS. Implementation science: Test real-world strategies for delivering and sustaining exercise programs in clinical and community settings. Practice-based guidelines: Develop, validate, and disseminate age- and disease-specific recommendations to inform healthcare delivery. Policy alignment: Engage stakeholders to support reimbursement, training, and integration of exercise-based care in rehabilitation services. CONCLUSION Older adults with MS represent a growing and underserved population with unique challenges that extend beyond the reach of pharmacological care. Exercise training is a well-supported, underutilized strategy with the potential to delay disability, enhance function, and promote healthy aging in this rapidly growing segment of the MS population. By prioritizing exercise in research, clinical practice, and health systems, we can significantly and meaningfully improve the lives of older adults living with MS. Although current evidence suggests that exercise plays a critical role in mitigating physical and mental deconditioning and preserving function as individuals age with MS, further research is needed to clarify the extent to which exercise may also influence the biological and disease-related processes underlying accelerated aging in MS. The authors thank the graduate and undergraduate students in the Exercise, Aging, and Functional Ability Lab within the Department of Health and Kinesiology at the University of Illinois Urbana-Champaign for providing valuable feedback for the development of the conceptual model (Fig. 1) displayed in this commentary. The results of the current study do not constitute endorsement by the American College of Sports Medicine. The authors declare that there are no conflicts of interest and that no funding was received for the preparation of this work. This work did not involve the generation or analysis of any data.
Sebastião et al. (Wed,) studied this question.