Exercise, Electrical Stimulation and Stress Reduction in the Wahls Protocol

Table of Contents

1. 1. The Three Parts Beyond the Diet
2. 2. Her Own Path from Wheelchair to Bicycle
3. 3. The 2009 Case Report: Stimulation, Then Food
4. 4. The 2010 Case Series of Nine Patients
5. 5. Electrical Stimulation as Her Program Uses It
6. 6. Stretching and Strengthening of the Trunk and Legs
7. 7. Stress Reduction: Meditation and Self-Massage
8. 8. What the Multimodal Pilot Trials Measured
9. 9. Walking, Breathing and the Web-Based Programs
10. 10. Later Research on Stimulation, Exercise and Mindfulness in Multiple Sclerosis
11. 11. Safety Facts and Limits the Papers State
12. Key Research Papers
13. Connections

1. The Three Parts Beyond the Diet

When Wahls’s University of Iowa team wrote up the program they tested in people with progressive multiple sclerosis, they listed it as a set of components rather than a single diet. In the 2017 paper on mood and thinking, the team describes the intervention as a modified Paleolithic diet with supplements plus “an exercise program (stretching and strengthening of the trunk and lower limb muscles); (3) neuromuscular electrical stimulation (EStim) of trunk and lower limb muscles; and (4) stress management (meditation and self-massage).”

The first published pilot paper, in 2014, describes the same package in its own words: a diet with supplements, stretching, strengthening exercise combined with electrical stimulation, meditation and massage. In this program the three non-diet parts are not extras added for comfort; they were built into the study design from the start and recorded day by day, so that the researchers could later ask how much each part was actually used.

The University of Iowa library’s catalogue entry for her 2014 book The Wahls Protocol summarises the same idea in one line: she combined the diet “with neuromuscular stimulation and gradual exercise”. The book itself, the catalogue notes, tells how she went from a tilt-recline wheelchair to biking eighteen miles in a day.

• Electrical stimulation — of the muscles of the trunk and the legs, the muscles that hold the body upright and move it forward.
• Exercise — stretching and strengthening of those same muscle groups, done at home.
• Stress management — meditation and self-massage, logged in minutes per day in the pilot trial.

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2. Her Own Path from Wheelchair to Bicycle

Wahls has published her own course in plain terms. On her website she writes that she was diagnosed with relapsing-remitting multiple sclerosis in 2000 and that “By 2003, I had transitioned to secondary progressive multiple sclerosis.” She underwent chemotherapy to try to slow the disease, and weakness of her back muscles left her using a tilt-recline wheelchair for four years. The University of Iowa’s Wahls Lab page uses the same phrase: the disease “confined her to a tilt-recline wheelchair for four years.”

“In December 2007, I began the Wahls Protocol®,” she writes. “Within a year, I was able to walk through the hospital without a cane and even complete an 18-mile bicycle tour.” Her site adds that she now pedals her bike to work each day.

In her account, muscle work was part of this from the beginning. The case report of her recovery, discussed in the next section, puts electrical stimulation before the change of diet in the order of events. Her University of Iowa lab page describes her recovery as the result of “a diet and lifestyle program she designed specifically for her brain” — the word “lifestyle” covering the exercise, stimulation and stress-reduction work described on this page.

Her life, training and career are covered in full on Terry Wahls: Life and Career.

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3. The 2009 Case Report: Stimulation, Then Food

In 2009 the journal Cases Journal published a case report by Reese, Shivapour, Wahls, Dudley-Javoroski and Shields titled “Neuromuscular electrical stimulation and dietary interventions to reduce oxidative stress in a secondary progressive multiple sclerosis patient leads to marked gains in function.” The patient is described as a 52-year-old woman with secondary progressive multiple sclerosis who had depended on a scooter and a cane for four years.

The report describes two steps: first neuromuscular electrical stimulation, then nutritional changes intended “to lower oxidative stress and excito-toxicity.” After eight months, the report states, she no longer used a scooter or cane and “rode her bicycle routinely 8 miles, including hills.”

The case report does not name the patient. A later paper from her own team does: Chenard and colleagues wrote in 2019 that this 2009 case report “documented Dr. Wahls’ personal use of the Wahls™ diet plus dietary supplements and neuromuscular electrical stimulation (NMES) to treat SPMS which improved mobility from <20 yards ... using bilateral support to biking and walking without assistance.” In other words, the woman in the report is Wahls herself, and the walking distance she started from was under twenty yards with support on both sides.

A case report describes one person. It shows what happened to that person; it cannot show which part of a combined program caused the change, or whether the same would happen to someone else. Wahls’s next step was to try the stimulation-and-exercise part with other patients.

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4. The 2010 Case Series of Nine Patients

In 2010 Wahls, Reese, Kaplan and Darling published a case series in the Journal of Alternative and Complementary Medicine titled “Rehabilitation with neuromuscular electrical stimulation leads to functional gains in ambulation in patients with secondary progressive and primary progressive multiple sclerosis.” Ambulation means walking.

The series describes nine patients with progressive multiple sclerosis — seven with the secondary progressive form and two with the primary progressive form — who were treated in a physical-therapy practice. Each received neuromuscular electrical stimulation together with a home-exercise program. The stimulation was given for a mean of 140 days.

Disability was tracked with the Expanded Disability Status Scale (EDSS), the standard 0-to-10 scale used in multiple sclerosis, on which a lower score means less disability. The authors report that the mean Expanded Disability Status Scale score improved by 0.78 points.

In the paper, the authors describe neuromuscular electrical stimulation as “an approved Food and Drug Administration treatment modality for muscle spasm, muscle pain, and disuse atrophy” — disuse atrophy being the wasting of muscles that are not used, a common problem in people whose walking is limited.

The title calls the study a case series report: nine treated patients, no comparison group. It was the bridge between her own single case and the larger, structured pilot trials her team began in 2010.

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5. Electrical Stimulation as Her Program Uses It

Neuromuscular electrical stimulation sends small electrical pulses through pads placed on the skin over a muscle, making the muscle contract. It is used in rehabilitation to make weak muscles work when the person cannot yet make them work hard enough on their own. The site’s animation of the neuromuscular junction shows the normal nerve-to-muscle signal that the stimulation stands in for, and muscle contraction shows what happens inside the muscle when it fires.

In Wahls’s program the stimulation is aimed at a specific set of muscles: the 2017 trial paper names the “trunk and lower limb muscles.” These are the muscles of posture and walking — the back weakness that had put her into a tilt-recline wheelchair is a trunk problem, and walking depends on the hips, thighs and lower legs.

The program pairs stimulation with exercise rather than using it alone. The 2014 pilot paper describes the component as “strengthening with electrical stimulation”: the electrical pulses are applied while the person does strengthening work, so that the muscle contracts harder than it would by effort alone. The 2010 case series likewise combined the stimulation sessions in a physical-therapy practice with a home-exercise program.

Wahls’s papers do not name a device, and this page names none. In the 2010 series the stimulation was delivered in a physical-therapy practice.

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6. Stretching and Strengthening of the Trunk and Legs

The exercise part of the Wahls program, as her trial papers describe it, is “stretching and strengthening of the trunk and lower limb muscles.” It is a home program: the 2010 case series speaks of a “home-exercise program” given alongside the stimulation sessions.

The book description in the University of Iowa catalogue uses the word “gradual” — she combined the diet with neuromuscular stimulation and gradual exercise. Her own story runs from a wheelchair, to walking the hospital halls without a cane, to an 18-mile bicycle tour within a year of starting, to cycling to work each day.

In the later program for people newly diagnosed with multiple sclerosis (section 9), her team replaced the stretching-strengthening-stimulation package with a walking program and breathing exercise, coached remotely. The site’s own pages on exercise and breathwork cover those practices in general.

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7. Stress Reduction: Meditation and Self-Massage

The fourth component of the program is stress management, which her team’s papers define as “meditation and self-massage.” The pilot trial tracked how many minutes a day participants spent on each.

The 2014 pilot paper reports how much of each was actually done. Over the study, participants averaged 13.3 minutes of meditation a day and 7.2 minutes of massage a day.

The 2017 paper on mood and thinking looked at whether the amount of each component people used was linked to the changes seen. It reports that greater participation in the program as a whole went with larger improvements in anxiety, depression and executive function (the planning and organising skills of the brain), and that the changes were tied more closely to the diet than to the dose of exercise or of stress management.

The site’s pages on meditation and stress management cover these practices beyond multiple sclerosis.

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8. What the Multimodal Pilot Trials Measured

Between 2010 and 2014 Wahls’s team ran a single-arm, open-label pilot study (ClinicalTrials.gov NCT01381354) of the full program — diet, supplements, stretching, strengthening with electrical stimulation, meditation and massage — in people with progressive multiple sclerosis. Single-arm means there was no comparison group; open-label means everyone knew what they were doing. The full trial story is on Wahls Multimodal Pilot Studies in Progressive Multiple Sclerosis; the parts that touch exercise and stimulation are these.

• Fatigue, first report (2014). Thirteen people entered the run-in, ten were eligible, eight completed the study and six were fully adherent for twelve months. Scores on the Fatigue Severity Scale fell from 5.7 to 3.32 (p=0.0008). The authors call it a “small, uncontrolled pilot study”.
• Fatigue and quality of life, full cohort (2015). Twenty people with progressive multiple sclerosis and a mean Expanded Disability Status Scale score of 6.2. Fatigue fell over twelve months. Eleven were “high responders” (a drop of more than two points) by three months, and the drop was sustained. The authors write: “Larger randomized controlled trials with blinded raters are needed”.
• Gait and balance (2017). For the whole group there was no significant change in walking. The group split in two: ten responders improved their timed-up-and-go test by 31% and their 25-foot walk speed by 30%, while ten non-responders deteriorated.
• Mood and thinking (2017). Greater participation went with larger improvements in anxiety, depression and executive function, tied more to diet than to exercise or stress-management dose.
• Blood fats and cardiometabolic markers (2019, 2025). Lipid changes were associated with less fatigue; the 2025 analysis reports that the intervention “did not negatively impact glycemic and lipid profiles”, with no significant changes.

The gait paper is the one most directly about the muscle side of the program, since walking speed and the timed-up-and-go test (standing up from a chair, walking a short distance, turning and sitting down) depend on trunk and leg strength. Its result was mixed: half the group improved and half got worse.

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9. Walking, Breathing and the Web-Based Programs

Her team’s later work moved the non-diet parts of the program toward things people can do at home without equipment. A 2024 quasi-experimental pilot study (NCT04009005) enrolled 29 people newly diagnosed with multiple sclerosis who had declined disease-modifying therapy. They were coached remotely on diet, a walking program and breathing exercise, and were compared with 15 people on standard care. The paper reports that outcomes were “not worse than” standard care for mental quality of life, mood, fatigue and cognition. Non-inferiority is the claim the study was designed to test; it is not a claim that the program was better.

In 2023 her group also published a randomized waitlist-control trial of a web-based program designed to help people with multiple sclerosis adopt wellness behaviors to self-manage fatigue and improve quality of life. In a waitlist design, one group starts the program at once and the other starts later, serving as the comparison in the meantime.

Fuller detail on these studies is on the multimodal pilot studies page and the randomized diet trials page.

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10. Later Research on Stimulation, Exercise and Mindfulness in Multiple Sclerosis

Other research groups have studied each of the three non-diet parts of the Wahls program in people with multiple sclerosis, separately from her work. Their papers are described here by what they set out to examine.

Electrical stimulation

• Almuklass and colleagues (2018) ran a double-blind randomized trial of neuromuscular electrical stimulation in people with multiple sclerosis; the title states its finding that pulse width (how long each electrical pulse lasts) does not influence the gains achieved.
• Scalia and colleagues (2024) studied whether neuromuscular electrical stimulation changes spinal excitability (how readily the spinal cord’s nerve circuits fire) in people with multiple sclerosis; the title states that it does not.
• McClurg and colleagues tested neuromuscular electrical stimulation for bladder problems in multiple sclerosis: a 2006 randomized pilot comparing pelvic floor muscle training, biofeedback and stimulation, and a 2008 double-blind, placebo-controlled randomized trial for lower urinary tract dysfunction.
• Etoom and colleagues (2018) published a systematic review and meta-analysis of physiotherapy interventions, including electrical stimulation, for spasticity (muscle stiffness) in multiple sclerosis.

Exercise

• Latimer-Cheung and colleagues (2013) published a systematic review of exercise training and its effects on fitness, mobility, fatigue and health-related quality of life in adults with multiple sclerosis, written to inform guideline development.
• Andreasen, Stenager and Dalgas (2011) reviewed the effect of exercise therapy on fatigue in multiple sclerosis.
• Motl and colleagues (2017) reviewed exercise in patients with multiple sclerosis in The Lancet Neurology.

Mindfulness and meditation

• Carletto and colleagues (2020) published a systematic review and meta-analysis of mindfulness-based interventions for the improvement of well-being in people with multiple sclerosis.

The general topic of multiple sclerosis — its forms, its course and its history — is covered on the site’s Multiple Sclerosis page.

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11. Safety Facts and Limits the Papers State

The papers behind this part of the Wahls program state their own limits, and those limits are part of the record.

• Setting. In the 2010 case series the stimulation was given in a physical-therapy practice, alongside a home-exercise program, not as unsupervised home use.
• Regulatory status as the authors state it. The 2010 paper describes neuromuscular electrical stimulation as an approved Food and Drug Administration treatment modality for muscle spasm, muscle pain and disuse atrophy. That approval, as the paper words it, is for those uses; it is not an approval for treating multiple sclerosis.
• Not everyone improved. In the 2017 gait study, ten participants got worse while ten got better, and the whole group showed no significant change in walking.
• Drop-out. In the 2014 pilot, eight of ten eligible people completed the study and six were fully adherent for twelve months; the program asked a lot of participants every day.
• Design. The case report described one person, the case series nine, and the pilot trial had no comparison group. The authors themselves call the pilot “small” and “uncontrolled” and write that larger randomized controlled trials with blinded raters are needed.
• Which part did what. Because stimulation, exercise, stress management and diet were combined, these studies cannot separate the effect of each. Her team’s own 2017 analysis found mood and thinking changes tied more to diet than to the exercise or stress-management dose.
• Blood markers. The 2025 cardiometabolic analysis of the same cohort reports that the program did not negatively affect blood sugar or blood-fat profiles.

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Key Research Papers

1. Wahls TL, Reese D, Kaplan D, Darling WG. Rehabilitation with neuromuscular electrical stimulation leads to functional gains in ambulation in patients with secondary progressive and primary progressive multiple sclerosis: a case series report. J Altern Complement Med. 2010;16(12):1343-9. — PubMed PMID: 21138391
2. Reese D, Shivapour ET, Wahls TL, Dudley-Javoroski SD, Shields R. Neuromuscular electrical stimulation and dietary interventions to reduce oxidative stress in a secondary progressive multiple sclerosis patient leads to marked gains in function: a case report. Cases J. 2009;2:7601. — PubMed PMID: 19918474
3. Chenard CA, Rubenstein LM, Snetselaar LG, Wahls TL. Nutrient Composition Comparison between a Modified Paleolithic Diet for Multiple Sclerosis and the Recommended Healthy U.S.-Style Eating Pattern. Nutrients. 2019;11(3):537. — PubMed PMID: 30832289
4. Bisht B, Darling WG, Grossmann RE, Shivapour ET, Lutgendorf SK, Snetselaar LG, et al. A multimodal intervention for patients with secondary progressive multiple sclerosis: feasibility and effect on fatigue. J Altern Complement Med. 2014;20(5):347-55. — PubMed PMID: 24476345
5. Bisht B, Darling WG, Shivapour ET, Lutgendorf SK, Snetselaar LG, Chenard CA, et al. Multimodal intervention improves fatigue and quality of life in subjects with progressive multiple sclerosis: a pilot study. Degener Neurol Neuromuscul Dis. 2015;5:19-35. — PubMed PMID: 30728736
6. Bisht B, Darling WG, White EC, White KA, Shivapour ET, Zimmerman MB, et al. Effects of a multimodal intervention on gait and balance of subjects with progressive multiple sclerosis: a prospective longitudinal pilot study. Degener Neurol Neuromuscul Dis. 2017;7:79-93. — PubMed PMID: 30050380
7. Lee JE, Bisht B, Hall MJ, Rubenstein LM, Louison R, Klein DT, et al. A Multimodal, Nonpharmacologic Intervention Improves Mood and Cognitive Function in People with Multiple Sclerosis. J Am Coll Nutr. 2017;36(3):150-168. — PubMed PMID: 28394724
8. Fellows Maxwell K, Wahls T, Browne RW, Rubenstein L, Bisht B, Chenard CA, et al. Lipid profile is associated with decreased fatigue in individuals with progressive multiple sclerosis following a diet-based intervention: Results from a pilot study. PLoS One. 2019;14(6):e0218075. — PubMed PMID: 31211794
9. Martinez AS, Bastian AJ, Shemirani F, Titcomb TJ, Bisht B, Darling WG, et al. Effects of a Multimodal Lifestyle Intervention on Cardiometabolic Markers in People with Progressive Multiple Sclerosis: A Secondary Analysis of a Pilot Study. Nutrients. 2025;17(7):1163. — PubMed PMID: 40218921
10. Saxby SM, Shemirani F, Crippes LJ, Ehlinger MA, Brooks L, Bisht B, et al. Effects of a Remote Multimodal Intervention Involving Diet, Walking Program, and Breathing Exercise on Quality of Life Among Newly Diagnosed People with Multiple Sclerosis: A Quasi-Experimental Non-Inferiority Pilot Study. Degener Neurol Neuromuscul Dis. 2024;14:1-14. — PubMed PMID: 38222092
11. Titcomb TJ, Sherwood M, Ehlinger M, Saxby SM, Shemirani F, Eyck PT, et al. Evaluation of a web-based program for the adoption of wellness behaviors to self-manage fatigue and improve quality of life among people with multiple sclerosis: A randomized waitlist-control trial. Mult Scler Relat Disord. 2023;77:104858. — PubMed PMID: 37399671
12. Almuklass AM, Davis L, Hamilton LD, Hebert JR, Alvarez E, Enoka RM. Pulse Width Does Not Influence the Gains Achieved With Neuromuscular Electrical Stimulation in People With Multiple Sclerosis: Double-Blind, Randomized Trial. Neurorehabil Neural Repair. 2018;32(1):84-93. — PubMed PMID: 29366377
13. Scalia M, Borzuola R, Parrella M, Borriello G, Sica F, Monteleone F, et al. Neuromuscular Electrical Stimulation Does Not Influence Spinal Excitability in Multiple Sclerosis Patients. J Clin Med. 2024;13(3):704. — PubMed PMID: 38337396
14. McClurg D, Ashe RG, Marshall K, Lowe-Strong AS. Comparison of pelvic floor muscle training, electromyography biofeedback, and neuromuscular electrical stimulation for bladder dysfunction in people with multiple sclerosis: a randomized pilot study. Neurourol Urodyn. 2006;25(4):337-48. — PubMed PMID: 16637070
15. McClurg D, Ashe RG, Lowe-Strong AS. Neuromuscular electrical stimulation and the treatment of lower urinary tract dysfunction in multiple sclerosis – a double blind, placebo controlled, randomised clinical trial. Neurourol Urodyn. 2008;27(3):231-7. — PubMed PMID: 17705160
16. Etoom M, Khraiwesh Y, Lena F, Hawamdeh M, Hawamdeh Z, Centonze D, et al. Effectiveness of Physiotherapy Interventions on Spasticity in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis. Am J Phys Med Rehabil. 2018;97(11):793-807. — PubMed PMID: 29794531
17. Latimer-Cheung AE, Pilutti LA, Hicks AL, Martin Ginis KA, Fenuta AM, MacKibbon KA, et al. Effects of exercise training on fitness, mobility, fatigue, and health-related quality of life among adults with multiple sclerosis: a systematic review to inform guideline development. Arch Phys Med Rehabil. 2013;94(9):1800-1828.e3. — PubMed PMID: 23669008
18. Andreasen AK, Stenager E, Dalgas U. The effect of exercise therapy on fatigue in multiple sclerosis. Mult Scler. 2011;17(9):1041-54. — PubMed PMID: 21467189
19. Motl RW, Sandroff BM, Kwakkel G, Dalgas U, Feinstein A, Heesen C, et al. Exercise in patients with multiple sclerosis. Lancet Neurol. 2017;16(10):848-856. — PubMed PMID: 28920890
20. Carletto S, Cavalera C, Sadowski I, Rovaris M, Borghi M, Khoury B, et al. Mindfulness-Based Interventions for the Improvement of Well-Being in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis. Psychosom Med. 2020;82(6):600-613. — PubMed PMID: 32541543

PubMed Topic Searches

1. Neuromuscular electrical stimulation and multiple sclerosis
2. Exercise training in progressive multiple sclerosis
3. Meditation and mindfulness in multiple sclerosis
4. Wahls TL: multimodal intervention studies

Further Reading

• Terry Wahls — About (her own account of her illness and recovery)
• University of Iowa, Wahls Lab — Terry Wahls, MD, MBA
• Iowa Research Online — catalogue entry for The Wahls Protocol (2014)
• ClinicalTrials.gov NCT01381354 — nutrition, neuromuscular electrical stimulation and secondary progressive Multiple Sclerosis

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Connections

• Dr. Terry Wahls and the Wahls Protocol
• Terry Wahls: Life and Career
• The Wahls Protocol Diet Levels and Food Rules
• Minding My Mitochondria: Nutrients for the Brain
• Wahls Multimodal Pilot Studies in Progressive Multiple Sclerosis
• Wahls Diet Randomized Trials in Multiple Sclerosis
• Terry Wahls: Books and Legacy
• Contemporary Practitioners
• Multiple Sclerosis
• Meditation
• Exercise
• Stress Management