Discussion: High-intensity training combined with detailed exercises in a
physiotherapy outdoor group was perceived to create meaningful bodily changes
and enhance PA and prospects for both PA and life. Importantly, however, some
negative experiences were also reported from the high-intensity training. Enactive
theory allowed for the illumination of new perspectives: the importance of
embodiment for self-efﬁcacy and of tailored physiotherapy and an outdoor-group
environment for exploring one’s own limits to physical capabilities. These aspects
should inform future exercise interventions in pwMS with low disability.
KEYWORDS
physical activity, physiotherapy, multiple sclerosis, qualitative study, exercise therapy,
postural balance, enactive theory
1 Introduction
Multiple sclerosis (MS) is a progressive inﬂammatory disease of
the central nervous system (CNS) that is typically diagnosed at 30–
40 years of age (1). A great concern is the signiﬁcantly lower levels
of physical activity (PA) in people with MS (pwMS) across
disability levels than in their healthy counterparts (2, 3).
Early promotion of PA and exercise is recommended due to
numerous established beneﬁts in health, symptom management
and well-being for pwMS ( 4). In particular, high-intensity
training is endorsed, as it has possible neuroprotective effects in
the disease course ( 5, 6). In addition, exercises addressing
sensorimotor impairments (e.g., reduced muscle strength,
reduced neuromuscular control) are recommended, as they target
individuals’ capability to remain physically active ( 7).
Sensorimotor impairments can inﬂuence trunk control, which is
commonly disturbed in pwMS, even when disability is low (8, 9),
and correlate with impaired balance, walking capacity and
distance ( 10, 11). PwMS ’s knowledge of exercise bene ﬁts,
attitudes and motivations, as well as contextual aspects such as
lack of optimal exercise interventions, accessibility and support,
affect the level of PA and exercise participation (12).
CoreDISTparticipation (Table 1 ) is a new comprehensive
intervention addressing sensorimotor function, trunk control,
high-intensity running/walking and work participation in pwMS
with low disability ( 13). It is based on the GroupCoreDIST 1
intervention, which has been shown to have signi ﬁcant short-
and long-term effects on trunk control, balance and walking
among pwMS (14, 15). However, no effects of the intervention
on objectively measured PA have been identiﬁed, even though
the participants reported perceptions of new possibilities to be
physically active as their sensorimotor impairments improved
(16). To address PA challenges in pwMS, GroupCoreDIST was
further developed to include a four-week period of outdoor
training, in which high-intensity walking/running and
GroupCoreDIST exercises are integrated ( Table 2 ). To our
knowledge, combinations of high-intensity training and
rehabilitation of speci ﬁc sensorimotor functions have been
sparsely explored. Patient perspectives are essential for the
evaluation of healthcare interventions ( 17); however, the new
outdoor component of CoreDISTparticipation has yet to be
investigated from a ﬁrst-person perspective. Particularly
interesting is what participants perceive as meaningful regarding
the intervention, as this is essential for motivation, motor
learning and exercise adherence (18).
To deepen our understanding of what the participants
perceive as meaningful, we turn to a theoretical perspective
that integrates bodily capacities with the construction of
meaning. Enactive theory emphasizes that making sense of the
world depends essentially on th e biological (living) body and
the phenomenological (lived or experienced) body (19), which
implies that the body is viewed as a neurobiological organism
that is concurrently experiencing, expressing and social
(embodiment) (20). Thus, what is experienced by an individual
during an exercise intervent ion is constituted by her