The influence of warm versus cold climate on the effect of physiotherapy in multiple sclerosis Introduction Multiple sclerosis (MS) is an inflammatory disease of the central nervous system (CNS) that, in most patients, is characterized by repeated relapses and accumulation of disability (1). In addition to relapse- and disease-modifying treatments, symp- tomatic interventions, including physiotherapy and rehabilitation, are essential for the patientÕs func- tioning and wellbeing (2, 3). Several studies have documented the efficacy of physiotherapy in MS (4–6), which has been recommended implemented early in the course of the disease (7). Previously, patients with MS were not recom- mended to exercise because symptoms might worsen with elevation of body temperature. Thermal sensitivity has been reported in patients with MS (8), but the relationship between endog- enous and exogenous sources of heat and MS symptoms remains unclear (9). Thermal sensitivity has been found associated with fatigue in MS (10) and may as well influence the patientÕs benefit from physiotherapy and exercise. Nevertheless, several anecdotic reports from individual patients and the Norwegian MS Society indicate that physical function may improve in a warm climate. This has led to a discussion of whether patients with MS living in a cold climate might benefit from phys- iotherapy in a warm climate. Swedish patients with MS have for several decades received treatment in a warm climate, but the climate effect needs to be further investigated. However, treatment in a warm Acta Neurol Scand 2011: 124: 45–52 DOI: 10.1111/j.1600-0404.2010.01407.x Ó 2010 John Wiley & Sons A ⁄ S ACTA NEUROLOGICA SCANDINAVICA Smedal T, Myhr K-M, Aarseth JH, Gjelsvik B, Beiske AG, Glad SB, Strand LI. The influence of warm versus cold climate on the effect of physiotherapy in multiple sclerosis. Acta Neurol Scand: 2011: 124: 45–52. Ó 2010 John Wiley & Sons A/S. Objective –To compare the effect of inpatient physiotherapy in a warm versus cold climate in short- and long-term perspectives. Methods – Sixty multiple sclerosis (MS) patients with gait problems, without heat intolerance, were included in a randomized cross-over study of 4-week inpatient physiotherapy in warm (Spain) and cold (Norway) climate. The primary outcome, 6-min walk test (6MWT), and secondary physical performance and self-reported measures were scored at screening, baseline, after treatment and at 3 and 6 months of follow- up. Treatment effects were analysed by mixed models. Results –After treatment, the mean walking distance had increased by 70 m in Spain and 49 m in Norway (P = 0.060). Improvement in favour of warm climate was demonstrated at 6 months of follow-up, 43 m (Spain) compared to 20 m (Norway) (P = 0.048). The patients reported less exertion after walking (6MWT) in favour of treatment in Spain at all time points (P < 0.05). No significant differences in change were detected for the other physical performance measures. Most self- reported measures showed more improvement after treatment in Spain, but these improvements were not sustained at follow- up. Conclusion –The results indicate that MS patients without heat intolerance have additional benefits from physiotherapy in a warm climate. T. Smedal 1,2,3 , K-M. Myhr 1,4 , J. H. Aarseth 1 , B. Gjelsvik 5 , A. G. Beiske 6 , S. B. Glad 1,4 , L. I. Strand 3,5 1 Department of Neurology, The Norwegian Multiple Sclerosis Competence Centre, Haukeland University Hospital, Bergen; 2 Section for Climate Therapy, Oslo University Hospital, Oslo; 3 Department of Public Health and Primary Health Care, Physiotherapy Research Group, University of Bergen, Bergen; 4 Department of Clinical Medicine, University of Bergen, Bergen; 5 Department of Physiotherapy, Haukeland University Hospital, Bergen; 6 Department of Neurology, University Hospital, Akershus, Lørenskog, Norway Key words: cross-over trial; mixed model; multiple sclerosis; physical performance measures; physical therapy; the Bobath concept; warm climate; 6-min walk test Tori Smedal, The Norwegian Multiple Sclerosis Com- petence Centre, Department of Neurology, Haukeland University Hospital, N-5021 Bergen, Norway Tel.: +47 55975045 Fax: +47 55975901 e-mail: tori.smedal@helse-bergen.no Accepted for publication June 10, 2010 45