Systematic Review of Correlates and Determinants of Physical Activity in Persons With Multiple Sclerosis

Social Cognitive Theory Variables as Correlates of Physical Activity Behavior Among Hispanics With Multiple Sclerosis

OBJECTIVE

To examine the association between social cognitive theory (SCT) variables and physical activity (PA) behavior in Hispanic adults with multiple sclerosis (MS).

DESIGN

Observational, survey study.

SETTING

General community.

PARTICIPANTS

Inclusion criteria: (a) age 18 years or older, (b) self-identify as Hispanic or Latino, (c) diagnosis of MS, and (d) English or Spanish as primary language. Two hundred forty-three individuals opened the survey, 24 individuals did not meet inclusion criteria, and 66 individuals were excluded due to not completing any of the SCT variable measures (N=153).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

PA was measured using the Godin Leisure Time Exercise Questionnaire (GLTEQ) total and Health Contribution Scores (HCS). SCT variables included standard measures of exercise self-efficacy, planning, goal setting, outcome expectations, social support, and functional impairment.

RESULTS

The final sample included 153 participants with a mean (SD) age of 43 (11) years, 78% identified as women, 57% were employed, and 63% had a college degree or higher. The mean (SD) MS disease duration was 11 (9) years, 74% of participants reported relapsing remitting MS, and median (interquartile range) Patient Determined Disease Steps (PDDS) score was 3.0 (3.0). Significant correlations were observed between all SCT variables and both GLTEQ total and GLTEQ HCS scores (P<.001). Forward stepwise regression with Akaike's Information Criterion (AICC) identified PDDS, age, exercise planning, exercise self-efficacy, and exercise goal setting as the most appropriate covariates and SCT variables to include in a multivariable model examining independent contributions on GLTEQ HCS scores. The multivariable, linear regression analysis indicated that PDDS (Standardized B=-.280, P<.001), exercise planning (Standardized B=.214, P<.05), and exercise self-efficacy (Standardized B=.183, P<.05) explained 42.4% of variance in GLTEQ HCS scores.

CONCLUSIONS

This study provides a contribution to the literature by identifying SCT variables that correlate with PA behavior among Hispanics with MS that may guide the creation of culturally appropriate PA programs.

Effects of multidisciplinary inpatient rehabilitation on everyday life physical activity and gait in patients with multiple sclerosis

BACKGROUND

Multiple sclerosis is a progressive neurological disease that affects the central nervous system, resulting in various symptoms. Among these, impaired mobility and fatigue stand out as the most prevalent. The progressive worsening of symptoms adversely alters quality of life, social interactions and participation in activities of daily living. The main objective of this study is to bring new insights into the impact of a multidisciplinary inpatient rehabilitation on supervised walking tests, physical activity (PA) behavior and everyday gait patterns.

METHODS

A total of 52 patients, diagnosed with multiple sclerosis, were evaluated before and after 3 weeks of inpatient rehabilitation. Each measurement period consisted of clinical assessments and 7 days home monitoring using foot-mounted sensors. In addition, we considered two subgroups based on the Expanded Disability Status Scale (EDSS) scores: 'mild' (EDSS < 5) and 'severe' (EDSS ≥ 5) disability levels.

RESULTS

Significant improvements in fatigue, quality of life and perceived mobility were reported. In addition, walking capacity, as assessed by the 10-m walking test, two-minute walk test and timed-up-and-go test, improved significantly after rehabilitation. Regarding the home assessment, mildly disabled patients significantly increased their locomotion per day and complexity of daily PA pattern after rehabilitation, while severely disabled patients did not significantly change. There were distinct and significant differences in gait metrics (i.e., gait speed, stride length, cadence) between mildly and severely disabled patients, but the statistical models did not show a significant overall rehabilitation effect on these gait metrics.

CONCLUSION

Inpatient rehabilitation showed beneficial effects on self-reported mobility, self-rated health questionnaires, and walking capacity in both mildly and severely disabled patients. However, these improvements do not necessarily translate to home performance in severely disabled patients, or only marginally in mildly disabled patients. Motivational and behavioral factors should also be considered and incorporated into treatment strategies.

Relationship between physical activity and coping with stress in people with multiple sclerosis: A moderated mediation model with self-efficacy and disability level as variables

Purpose

An increasing number of studies support the beneficial relationship between physical activity and stress coping in people with multiple sclerosis (MS). However, there has been limited understanding of the variables that may influence the nature of this relationship. Therefore, based on the social-cognitive framework and previous research, we aimed to examine the association between the habitual physical activity of people with MS and their coping effectiveness. Furthermore, we sought to determine the extent to which self-efficacy acts as a mediator in this relationship, considering the level of disability as a moderator variable.

Methods

In this cross-sectional study, a total of 351 people with MS participated. The participants were asked to complete several assessment tools, including the Mini-COPE Inventory for Measurement-Coping with Stress, the Generalized Self-Efficacy Scale, and the Godin Leisure-Time Exercise Questionnaire. Additionally, a neurologist assessed the severity of the disease using the Expanded Disability Status Scale. Information on the demographic and clinical characteristics of the participants was collected via a self-report survey. Two moderated mediation analyses were conducted as part of the study.

Results

The study findings indicated a positive correlation between engagement in physical activity and self-efficacy among participants with high and medium disability levels. This, in turn, demonstrated a positive association with effective stress-coping strategies and a negative association with ineffective coping methods. In particular, a significant relationship was observed between involvement in physical activity and self-efficacy in participants with high disability, while it was not statistically significant in participants with low disability.

Conclusion

Physical activity was associated with improved psychosocial functioning in people with high levels of disability caused by MS. This association may be attributed to factors such as increased self-efficacy and improved stress coping. However, the relationship between physical activity and psychosocial functioning was less evident in people with low disability caused by MS.

Facilitators and barriers to participation in physical activities in children and adolescents living with cerebral palsy: a scoping review

PURPOSE

This scoping review aimed to synthetize personal and environmental facilitators and barriers to participation in physical activities among youths living with cerebral palsy.

METHODS

A systematic literature search was performed in five databases: CINAHL, EMBASE, MEDLINE, PsycINFO, Cochrane, WEB OF SCIENCE. The studies were selected by two independent researchers based on inclusion and exclusion criteria. A semi-quantitative evaluation assessed the consistency of results for a given variable. Variables displaying consistent associations were classified based on the Physical Activity for people with Disability Model.

RESULTS

The electronic search yielded 10 795 articles, of which 57 were included. The main barriers to physical activity identified were motor impairments (30 studies), older age (15 studies), pain (6 studies), attendance in regular school (6 studies), and communication problems (4 studies). Barriers such as upper limb impairment and visual deficit were less frequently studied, while cognitive attributes, adapted physical environments and positive attitude, and family support were identified as facilitators.

CONCLUSION

Personal and environmental factors influencing physical activities behaviors among youths living with cerebral palsy are multiple and complex since they interact with each other. Rehabilitation interventions need to adopt a person-based approach to address barriers and reinforce facilitators.IMPLICATIONS FOR REHABILITATION:Physical activity participation among youths with cerebral palsy is a multidimensional phenomenon, dependent on different personal and environmental factors.Gross motor impairments, communication problems, and pain were the most common personal factors limiting physical activity participation.Environmental factors consistently associated with physical activity participation were school settings, physical environment such as transportation, and social and family support and attitude.Rehabilitation interventions to promote an active lifestyle should consider not only personal factors but their interaction with the child's environment.

Correlates of physical activity and sedentary behavior in adults living with overweight and obesity: A systematic review

Overweight and obesity are consistently associated with lower physical activity (PA) levels and greater sedentary behavior (SB) in population studies. To date, no review has evaluated the factors associated with these behaviors in the specific population who have developed obesity/overweight. The aim of this systematic review was to identify the correlates/determinants of SB and PA in adults with overweight and obesity. Five databases were searched for studies, which reported factors or outcomes relating to PA or SB in adults living with overweight/obesity, published from 1980 to 2021. The factors were categorized using a socioecological model, strength, and direction of association. Of 34,058 articles retrieved, 45 studies were included, and 155 factors were identified. Self-efficacy, intrinsic motivation, exercise enjoyment, self-perceived good health, and social support were consistently associated with higher levels of PA. Consistent negative correlations were married females, increased BMI, obesity severity, pain, number of comorbidities, lack of time, energy, and willpower, and hilly terrain. Few studies (n = 12) examined SB, and no evidence for consistent associations were found. This review identified several correlates specific to PA in this population. Further studies are required to identify directionality and distal correlates for PA and all correlate levels of SB.

What is the effect of a brief intervention to promote physical activity when delivered in a health care setting? A systematic review

ISSUE ADDRESSED

What are the effects of a brief intervention to promote physical activity (PA) delivered in a health care setting other than primary care?

METHODS

MEDLINE, EMBASE, CINAHL and PsycINFO were used to identify randomised controlled trials which evaluated the effect of brief interventions to increase PA, delivered in a health care setting. Review outcomes included subjectively or objectively measured PA, adherence to prescribed interventions, adverse events, health-related quality of life, self-efficacy and stage of change in relation to PA. Where possible, clinically homogenous studies were combined in a meta-analysis.

RESULTS

Twenty-five eligible papers were included. Brief counselling interventions were associated with increased PA compared to control, for both self-reported PA (mean difference 34 minutes/week, 95% confidence intervals [95% CI] 9-60 minutes), and pedometer (MD 1541 steps/day, 95% CI 433-2649) at medium term follow up.

CONCLUSION

Our findings suggest that some brief interventions to increase PA, delivered in the health care setting, are effective at increasing PA in the medium term. There is limited evidence for the long-term efficacy of such interventions. The wide variation in types of interventions makes it difficult to determine which intervention features optimize outcomes. SO WHAT?: Brief counselling interventions delivered in a health care setting may support improved PA. Clinicians working in health care settings should consider the implementation of brief interventions to increase PA in vulnerable patient groups, including older adults and those with chronic illness.

The role of worry in exercise and physical activity behavior of people with multiple sclerosis

Purpose:

This study is a secondary analysis of data from a mixed methods exploration of fatigue in people with multiple sclerosis (MS), a chronic autoimmune disease affecting the central nervous system. During initial analysis, worry emerged during discussions of the fatigue experience. The purpose of this study is to explore worry in relationship to exercise and physical activity behavior.

Methods:

Mixed methods were used to address the research question. 55 people with MS provided demographic and survey data (habitual physical activity, body perception, functioning). 35 participated in semi-structured interviews on the topics of fatigue, body sensations, emotions, and their effects on physical activity. Qualitative data were analyzed utilizing constructivist grounded theory. Quantitative data were analyzed utilizing multiple regression.

Results:

Qualitative theory described participants’ thoughts and experiences regarding the consequences of fatigue during activity, and how they appear to influence subsequent actions. Worry played a critical role in thought processes regarding physical activity. Aspects of body perception were weak quantitative predictors of physical activity behavior after control of physical functionality.

Conclusions:

The most significant finding of this study was the description and dialogue about worry as a factor that shapes perceptions of the benefits and value of exercise and physical activity. Physical activity practitioners could benefit from seeking to understand physical-activity-related worry when examining physical activity behavior and designing programming.

Social cognitive correlates of device-measured and self-reported physical activity in Black and White individuals with multiple sclerosis

BACKGROUND

There is increasing research interest regarding physical activity behavior among persons with multiple sclerosis (MS), yet there is little known about physical activity and its correlates in Black persons with MS.

OBJECTIVE

This cross-sectional study assessed associations among social cognitive theory (SCT) variables and device-measured and self-reported physical activity in samples of Black and White persons with MS.

METHODS

Participants included 67 Black and 141 White persons with MS who wore an ActiGraph accelerometer on a belt around the waist measuring moderate-to-vigorous physical activity (MVPA) for seven days and completed a battery of questionnaires. Questionnaires included demographic and clinical characteristics, leisure-time exercise, exercise self-efficacy, overcoming barriers self-efficacy, function, social support, exercise outcome expectations, and goal setting and planning.

RESULTS

Black participants with MS engaged in significantly less MVPA, but not sedentary behavior or light physical activity, than the White participants with MS. Black participants further had significantly lower levels of exercise self-efficacy and outcome expectations than the White sample. All SCT correlates were significantly correlated with self-reported physical activity, but only exercise and barriers self-efficacy, perceived function, and exercise goal setting were associated with device-measured MVPA. The difference in physical activity between Black and White participants with MS was accounted for by differences in exercise self-efficacy and outcome expectations.

CONCLUSIONS

Researchers should consider developing behavioral interventions that target exercise self-efficacy and outcome expectations as SCT variables for increasing physical activity in Black persons with MS.

Physical activity as a correlate of symptoms, quality of life, comorbidity, and disability status in Hispanics with multiple sclerosis

BACKGROUND

Hispanics with multiple sclerosis (MS) experience disproportionate rates of mobility disability compared to non-Hispanic Whites with MS. Physical activity (PA) is highlighted as a potential adjuvant therapy for improving MS symptoms and disease progression, however less than 30% of Hispanics with MS report sufficient levels of PA.

OBJECTIVES

The current study aimed to examine the correlates of PA behavior among Hispanics with MS in the North American Research Committee on Multiple Sclerosis Registry (NARCOMS).

METHODS

In Spring 2015, 136 NARCOMS participants identified as Hispanic and completed the International Physical Activity Questionnaire (IPAQ). IPAQ scores were converted to Health Contribution Scores (HCS) for estimating PA. The association between the HCS scores and MS symptoms (i.e., mobility, cognition, fatigue, spasticity, hand function, bowel/bladder, sensory, tremors, depression, and pain), quality of life (QOL), comorbid conditions, and disability status were evaluated using Pearson or Spearman correlation coefficients with follow-up multivariable regression analyses.

RESULTS

The mean age among participants was 58 years and 79% identified as female. The mean MS disease duration was 20 years and 68% reported relapsing disease course. The mean HCS score among participants was 15.6 ± 20.9. HCS was moderately associated with disability status (r_s = -0.39), mobility (r_s = -0.37), bowel/bladder function (r_s = -0.33), and physical health related QOL (r = 0.32). There were small associations between HCS and hand function (r_s = -0.29), fatigue (r_s = -0.20), and tremor (r_s = -0.25). Multivariable regression analyses indicated that disability status, mobility, bowel/bladder function, and physical health related QOL were all associated with HCS but did not independently contribute to the models when controlling for age, sex, and employment.

CONCLUSIONS

This study highlights correlates of PA behavior among Hispanics with MS. Researchers and clinicians may consider disability status, mobility, and physical health related QOL in future studies examining PA among Hispanics with MS.

The Relevance of Competences for a Healthy, Physically Active Lifestyle in Persons with Multiple Sclerosis: a Path Analytical Approach

To promote health and counteract the decline associated with the disease, persons with multiple sclerosis (pwMS) are advised to lead healthy, physically active lifestyles. The physical activity-related health competence (PAHCO) model posits that individuals must meet three integrated, person-related requirements for the adoption of such a lifestyle: movement competence, control competence, and self-regulation competence. To gain insights into the needs and challenges of pwMS, the goal of the present study was to empirically examine the roles of these competences within this target group. A total of 475 pwMS underwent a multidimensional, online-based assessment of PAHCO. These participants self-reported their amount of physical activity (PA), health status, disease-related, and sociodemographic information. We used a series of path analyses to investigate the relevance of the three competence areas for each individual's PA level and subjective health. Stepwise multivariate analyses revealed that self-regulation competence was significantly associated with overall PA volume. In contrast, movement competence did not contribute to this prediction. Control competence was also not related to PA level. However, in accordance with the PAHCO model, this factor exerted an independent, qualitative effect on participant health. In summary, self-regulation competence appears to play a crucial role with regard to PA volume. Specifically, control competence appears to be key for the qualitative aspect of PA promotion, characterizing the individual's application of an appropriate stimulus for the achievement of health. Integrating the promotion of self-regulation and control competences into rehabilitation practices can help to foster healthy, physically active lifestyles in pwMS.Supplemental data for this article is available online at https://doi.org/10.1080/08964289.2021.1935437 .

Physical activity behaviour up to 1 year post-rehabilitation among adults with physical disabilities and/or chronic diseases: results of the prospective cohort study ReSpAct

BACKGROUND

Little is known of physical activity behaviour among adults with a disability and/or chronic disease during and up to 1 year post-rehabilitation. We aimed to explore (1) dose characteristics of physical activity behaviour among adults with physical disabilities and/or chronic diseases during that period, and (2) the effects of personal characteristics and diagnosis on the development of physical activity over time.

METHODS

Adults with physical disabilities and/or chronic diseases (N=1256), enrolled in the Rehabilitation, Sports and Active lifestyle study, were followed with questionnaires: 3-6 weeks before (T0) and 14 (T1), 33 (T2) and 52 (T3) weeks after discharge from rehabilitation. Physical activity was assessed with the adapted version of the Short Questionnaire to ASsess Health enhancing physical activity. Dose characteristics of physical activity were descriptively analysed. Multilevel regression models were performed to assess physical activity over time and the effect of personal and diagnosis characteristics on physical activity over time.

RESULTS

Median total physical activity ranged from 1545 (IQR: 853-2453) at T0 to 1710 (IQR: 960-2730) at T3 min/week. Household (495-600 min/week) and light-intensity (900-998 min/week) activities accrued the most minutes. Analyses showed a significant increase in total physical activity moderate-intensity to vigorous-intensity physical activity and work/commuting physical activity for all time points (T1-T3) compared with baseline (T0). Diagnosis, age, sex and body mass index had a significant effect on baseline total physical activity.

CONCLUSION

Physical activity is highly diverse among adults with physical disabilities and/or chronic diseases. Understanding this diversity in physical activity can help improve physical activity promotion activities.

Validity and reliability of the Persian version of the exercise self-efficacy scale in people with multiple sclerosis

BACKGROUND

Exercise self-efficacy has been identified as one of the primary determinants of physical activity in people with multiple sclerosis (MS). Therefore, assessment of exercise self-efficacy is important to be measured with valid and reliable scale to provide tailored interventions.

MATERIALS AND METHODS

The English version of the exercise self-efficacy scale was translated into Persian using a forward-backward translation approach. Factorial validity was conducted using the expletory factor analysis (EFA) and the confirmatory factor analysis (CFA). In addition, construct validity was performed using convergent and known-group validity. Reliability was evaluated by internal consistency and test-retest reliability. Participants were recruited from two hospitals (MS clinics).

RESULTS

Expletory factor analysis identified a single factor structure which explained 64.7% variance in exercise self-efficacy scale (EXSE). CFA supported a single factor structure with a good model fit. Average variance extracted = 0.60 and composite reliability = 0.93 values confirmed the convergent validity. The known-group validity was verified with significant differences between subgroups. The Cronbach's alpha coefficient = 0.93 and intraclass correlation coefficient = 0.85 supported reliability of EXSE scale.

CONCLUSIONS

Our findings provided sufficient evidence of validity and reliability for EXSE scale in people with MS. This measure can utilize by researchers and health-care providers in studies and clinical practice as a robust measure to assess exercise self-efficacy and to develop interventions in people with MS.

Correlates of Objectively Measured Physical Activity Among People With Multiple Sclerosis: A Cross-Sectional Study

Background: Identifying correlates of physical activity (PA) for people with multiple sclerosis (MS) is essential to design effective PA interventions.

Methods: Participants completed a battery of questionnaires and wore an ActiGraph accelerometer. Light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) (min/day) were calculated. Associations were examined using multiple linear regression adjusted for demographic and clinical confounders.

Results: Fifty-eight adults with MS participated (mean ± SD age: 56.8 ± 9.2 yr; 67% women). MS type was associated with time in LPA. Participants with secondary progressive MS (B = −54.0, 95% CI −84.7 to −23.3) and primary progressive MS (B = −42.9, 95% CI −77.5 to −8.3) spent less time in LPA than those with relapsing remitting MS. Walking capacity, assessed using the 12-item MS walking scale (MSWS-12), was associated with time in MVPA (B = −0.36, 95% CI −0.72 to −0.01).

Conclusion: This work identifies walking capacity and type of MS as correlates of PA, which may indicate development of interventions to promote PA.

Translation and validation of the Persian version of Godin Leisure-Time Exercise Questionnaire in patients with multiple sclerosis

Study Design

Psychometric study.

Objective

The purpose of this study is to translate, culturally adapt and evaluate the validity and reliability of the Persian (Farsi) version of GLTEQ in patients with multiple sclerosis.

Methods

This study had three phases, including translation of the questionnaire into Persian and making cultural adaptation, evaluation of pre-final version of questionnaire’s comprehensibility in a pilot study, and investigation of reliability and validity of the final version of the translated questionnaire. Content validity, and convergent validity (correlations among the Persian version of GLTEQ and Global physical activity questionnaire (GPAQ), and international physical activity questionnaire (IPAQ)) and after all test-retest reliability were studied.

Results

The subjects were 87 MS patients. The Persian version demonstrated moderate to good convergent validity; the correlation coefficient between the Persian version and GPAQ was r=0.64 (p<0.001), and between the Persian version and IPAQ was r=0.59 (p<0.001). The test-retest reliability was strong (Intra-class Correlation (ICC) value ranged between 0.908 and 0.992). Besides, its face validity and content validity were acceptable.

Conclusions

The Persian version of GLTEQ is a valid and reliable instrument to assess physical activity in patients with MS. This questionnaire can be a step toward standardization of physical activity measurement in patients with MS. Also, in research, it provides the possibilities to carry on a comparative study across cultures using the same outcome measure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02465-5.

What gait features influence the amount and intensity of physical activity in people with multiple sclerosis?

Although the mutual relationship between ambulation and physical activity (PA) in people with multiple sclerosis (pwMS) has been described in several studies, there is still a lack of detailed information about the way in which specific aspects of the gait cycle are associated with amount and intensity of PA. This study aimed to verify the existence of possible relationships among PA parameters and the spatio-temporal parameters of gait when both are instrumentally assessed.Thirty-one pwMS (17F, 14 M, mean age 52.5, mean Expanded Disability Status Scale (EDSS) score 3.1) were requested to wear a tri-axial accelerometer 24 hours/day for 7 consecutive days and underwent an instrumental gait analysis, performed using an inertial sensor located on the low back, immediately before the PA assessment period. Main spatio-temporal parameters of gait (i.e., gait speed, stride length, cadence and duration of stance, swing, and double support phase) were extracted by processing trunk accelerations. PA was quantified using average number of daily steps and percentage of time spent at different PA intensity, the latter calculated using cut-point sets previously validated for MS. The existence of possible relationships between PA and gait parameters was assessed using Spearman rank correlation coefficient rho.Gait speed and stride length were the parameters with the highest number of significant correlations with PA features. In particular, they were found moderately to largely correlated with number of daily steps (rho 0.62, P< .001), percentage of sedentary activity (rho = -0.44, P < .001) and percentage of moderate-to-vigorous activity (rho = 0.48, P < .001). Small to moderate significant correlations were observed between PA intensity and duration of stance, swing and double support phases.The data obtained suggest that the most relevant determinants associated with higher and more intense levels of PA in free-living conditions are gait speed and stride length. The simultaneous quantitative assessment of gait parameters and PA levels might represent a useful support for physical therapists in tailoring optimized rehabilitative and training interventions.

The Two-Minute Walk Test in Persons with Multiple Sclerosis: Correlations of Cadence with Free-Living Walking Do Not Support Ecological Validity

The two-minute walk test (2MWT) is a frequently used walking capacity test in persons with multiple sclerosis (pwMS). However, less is known about its relevance with regards to walking capacity during free-living walking performance. Therefore, the ecological validity of the 2MWT was tested by 1. computing free-living minutes with the same intensity (cadence) as during the 2MWT and 2. investigating the relationship between 2MWT cadence and minutes with the same cadence during free-living walking. 20 pwMS aged 44.2 ± 12.2 (Expanded Disability Status Scale (EDSS) score of 3.1 ± 1.4) performed a 2MWT and wore an accelerometer for seven days. The number of pwMS reaching 100%, 90%, 80% or 70% of 2MWT cadence for at least one minute a day and minutes/day with at least 100%, 90%, 80% and 70% of 2MWT cadence during free-living walking was calculated. Six participants reached 100% of the 2MWT cadence for at least one minute/day during free-living walking. A total of 80% 2MWT cadence was the first intensity category that was reached by all participants during free-living walking. No significant correlation was found between cadence in the 2MWT and minutes in which this cadence was reached during free-living walking. Ecological validity with regard to walking intensity could not be confirmed in our study sample.

Does Multiple Sclerosis Differently Impact Physical Activity in Women and Man? A Quantitative Study Based on Wearable Accelerometers

In people with multiple sclerosis (pwMS), fatigue, weakness and spasticity may reduce mobility and promote sedentary behavior. However, little is known about the existence of possible differences in the way MS modifies the propensity to perform physical activity (PA) in men and women. The present study aimed to partly close this gap by means of quantitative analysis carried out using wearable sensors. Forty-five pwMS (23 F, 22 M, mean age 50.3) and 41 unaffected age- and sex-matched individuals wore a tri-axial accelerometer 24 h/day for 7 consecutive days. Raw data were processed to calculate average number of daily steps, vector magnitude (VM) counts, and percentage of time spent in sedentary behavior and in PA of different intensities (i.e., light and moderate-to-vigorous, MVPA). Women with MS spent more time in sedentary behavior and exhibited a reduced amount of light intensity activity with respect to men, while MVPA was similar across sexes. However, in comparison with unaffected individuals, the overall PA patterns appear significantly modified mostly in women who, in presence of the disease, present increased sedentary behavior, reduced MVPA, number of daily steps and VM counts. The findings of the present study highlight the urgency of including sex as variable in all studies on PA in pwMS.

Physical Activity, Resilience, Sense of Coherence and Coping in People with Multiple Sclerosis in the Situation Derived from COVID-19

The confinement forced by COVID-19 can have repercussions on the health of people diagnosed with multiple sclerosis. The objective of this study is to analyze the relationships between physical activity, a sense of coherence, resilience and coping among people diagnosed with Multiple Sclerosis during the health emergency situation. To achieve this goal, this transversal descriptive study included 84 patients that belonged to multiple sclerosis associations during the period of confinement. Participants filled out the Physical Activity (IPAQ-SF), Sense of Coherence (SOC-13), Resilience Scale (ER-14) and coping (COPE-28) questionnaires. The results showed that the average age was 46.9 and that 67.9% had Relapsing Remittent Multiple Sclerosis diagnosed on average 13.9 years ago. They had a high degree (33.3%) and moderate degree (34.5%) of physical activity, high levels of resilience, while the level of a sense of coherence was average and the most commonly used strategies for coping were active confrontation and religion. Physical activity was not related to the rest of the studied variables, but there were correlations between the other variables. The people with multiple sclerosis who belong to patient associations have remained physically active during the obligatory confinement period and have elevated degrees of resilience and an average sense of coherence, as well as using suitable coping strategies, which is why the social-health resource of belonging to a patient association could be boosting these variables that are beneficial to their health.

A qualitative exploration of the participants' experience of a web-based physiotherapy program for people with multiple sclerosis: Does it impact on the ability to increase and sustain engagement in physical activity?

Background: Web-based exercise and physical activity interventions are being developed as a potential way to help people with multiple sclerosis achieve and maintain increased physical activity levels. Seeking feedback from people who have used such interventions will help guide the development process.Methods: In-depth interviews were used to explore the experiences of participants who used a web-based physiotherapy intervention as part of a feasibility randomized controlled trial. Interviews were audio-recorded, transcribed verbatim and analyzed using thematic analysis.Results: Eleven people (age 28-68) were interviewed. Most perceived that their physical activity had increased, primarily due to completing twice-weekly web-based physiotherapy sessions. Three key themes were identified. 'It's all in one place' encompasses the value of having a convenient and portable program. 'Keeping an eye' captures people's thoughts regarding the supervision offered by the physiotherapist, through the website, and 'Hopes and expectations' reflects the importance of having opportunity to discuss what may be gained from using such a program.Conclusions: This intervention offered a convenient, flexible and portable physiotherapy program which most people perceived helped them achieve and sustain increased levels of physical activity. Talking with people about expectations is important, particularly if a person's condition is deteriorating.IMPLICATIONS FOR REHABILITATIONWhen discussing the potential benefits of exercise programs with people with multiple sclerosis it is important to have honest and open conversations about the expectations of what may be achieved. This is particularly important for people with progressive disease.Web-based interventions may be most valuable to people who are technology literate, seek flexibility regarding where and when to exercise, prefer to exercise independently and have the confidence and skills to self-manage.Trial registration: ClinicalTrials.gov identifier: NCT02508961.

Pedometers, the frustrating motivators: a qualitative investigation of users' experiences of the Yamax SW-200 among people with multiple sclerosis

Purpose: Self-monitoring may represent a mechanism to enhance physical activity among people with multiple sclerosis. To optimise activity monitoring as a behavioural tool to increase physical activity, user experience must be understood. This study evaluated user experience of the Yamax SW-200 Digi-walker pedometer in a group of people with MS.Methods: Semi-structured interviews were conducted with 15 adults who participated in a 12-week pedometer-supported behavioural change intervention, the iStep-MS trial. Interviews were audio-recorded and transcribed verbatim. Data were analysed using the Framework Method.Results: An overarching theme Pedometers, the frustrating motivators captures the complex and often contradictory experience of the pedometer. Sub-themes include: Increasing activity awareness, which describes the pedometer's utility in raising activity consciousness; Numeric motivation provides insight into dual motivating and demotivating experiences of using an objective feedback device; (Un) usability focuses on practical concerns encountered in the day-to-day use of the monitor.Conclusion: The Yamax SW-200 Digi-walker raised awareness and enhanced participant motivation to engage in physical activity. Accuracy and usability concerns highlighted warrant consideration in the selection of this pedometer within a population with multiple sclerosis. Trial registration: Changing physical activity behaviour in people with MS: the iStep-MS trial; ISRCTN15343862; https://doi.org/10.1186/ISRCTN15343862Implications for rehabilitationUse of self-monitoring tools such as pedometers can enhance physical activity awareness.Objective, numeric step count feedback is an effective motivational tool for physical activity.Accuracy and usability concerns may limit the value of the Yamax SW-200 Digiwalker for people with MS.Identification of individualised, reliable, usable and acceptable tools is important to ensure engagement with self-monitoring.

Assessment of a home-based standing frame programme in people with progressive multiple sclerosis (SUMS): a pragmatic, multi-centre, randomised, controlled trial and cost-effectiveness analysis

Background

People severely impaired with progressive multiple sclerosis spend much of their day sitting, with very few options to improve motor function. As a result, secondary physical and psychosocial complications can occur. Effective and feasible self-management strategies are needed to reduce sedentary behaviour and enhance motor function. In this study, we aimed to assess the clinical and cost effectiveness of a home-based, self-managed, standing frame programme.

Methods

SUMS was a pragmatic, multicentre, randomised controlled superiority trial of people with progressive multiple sclerosis and severe mobility impairment, undertaken in eight centres from two regions in the UK. The study had assessor-blinded outcome assessments with use of clinician-rated and patient-rated measures at baseline, 20 weeks, and 36 weeks. After baseline assessment, participants were randomised (1:1) by computer-generated assignment to either a standing frame programme plus usual care or usual care alone. The intervention consisted of two home-based physiotherapy sessions (60 min each) to set up the standing frame programme, supported by six follow-up telephone calls (15 min per call). Participants were asked to stand for 30 min, three times per week over 20 weeks, and encouraged to continue in the longer term, although no further physiotherapy support was provided. The primary clinical outcome was motor function measured by the Amended Motor Club Assessment (AMCA) score at week 36, analysed in the modified intention-to-treat population (excluding only patients who were deemed ineligible after randomisation, those who withdrew from the trial and were unwilling for their previously collected data to be used, or those who did not provide baseline and week 36 measurements). A 9-point AMCA score change was considered clinically meaningful a priori. Adverse events were collected through a daily preformatted patient diary throughout the 36 weeks and analysed in the modified intention-to-treat population. An economic assessment established the resources required to provide the standing frame programme, estimated intervention costs, and estimate cost effectiveness. This trial is registered with the International Standard Randomised Controlled Trials, number ISRCTN69614598.

Findings

Between Sept 16, 2015, and April 28, 2017, 285 people with progressive multiple sclerosis were screened for eligibility, and 140 were randomly assigned to either the standing frame group (n=71) or the usual care group (n=69). Of these, 122 completed the primary outcome assessment (61 participants in both groups) for the modified intention-to-treat analysis. The use of the standing frame resulted in a significant increase in AMCA score compared with that for usual care alone, with a fully adjusted between-group difference in AMCA score at 36 weeks of 4·7 points (95% CI 1·9–7·5; p=0·0014). For adverse events collected through patient diaries, we observed a disparity between the two groups in the frequency of short-term musculoskeletal pain (486 [41%] of 1188 adverse events in the standing frame group vs 160 [22%] of 736 adverse events in the usual care group), which was potentially related to the intervention. The musculoskeletal pain lasted longer than 7 days in five participants (two in the standing frame group and three in the usual care group). No serious adverse events related to the study occurred. The standing frame group had a mean 0·018 (95% CI −0·014 to 0·051) additional quality-adjusted life-years (QALYs) compared with those of the usual care group, and the estimated incremental cost-per-QALY was approximately £14 700.

Interpretation

The standing frame programme significantly increased motor function in people with severe progressive multiple sclerosis, although not to the degree that was considered a priori as clinically meaningful. The standing frame is one of the first physiotherapy interventions to be effective in this population. We suggest that the programme is feasible as a home-based, self-managed intervention that could be routinely implemented in clinical practice in the UK.

Funding

UK National Institute of Health Research.

Adherence and drop-out in randomized controlled trials of exercise interventions in people with multiple sclerosis: A systematic review and meta-analyses

BACKGROUND

The short-term benefits of exercise in people with multiple sclerosis (MS) are well established. To sustain benefits exercise needs to continue long-term. Despite important clinical implications, no systematic reviews have synthesized evidence on adherence and drop-out in MS exercise interventions.

OBJECTIVES

1) To summarize reported adherence and drop-out data from randomized controlled trials (RCTs) of exercise interventions, and 2) identify moderators related to adherence and drop-out.

METHODS

Nine databases were electronically searched in October 2018. Included studies were RCTs of exercise interventions in adults with MS published from January 1993 to October 2018. Abstracts and full texts were independently screened and selected for inclusion by two reviewers. Methodological quality was assessed using the TESTEX rating scale.

RESULTS

Ninety three articles reporting 81 studies were included. Forty one studies (51%) reported both adherence and drop-out data during the intervention period with three (4%) also reporting follow-up data. Of the 41 studies, < 25% pre-defined adherence or described how adherence was measured. Meta-analyses of 59 interventions (41 studies) showed a pooled adherence estimate of 0.87 (95% CI 0.83 to 0.90) and 0.73 (CI 0.68-0.78) when including drop-outs. Mean age, proportion of females and intervention duration were inversely associated with adherence.

CONCLUSION

Little consensus existed on definition of adherence or determination of drop-out in MS exercise studies, with reporting generally of poor quality, if done at all. Hence it is largely unknown what can moderate adherence and whether exercise continued following an exercise intervention. Researchers should ensure clear transparent measurement and reporting of adherence and drop-out data in future trials.

Exercise participation and promotion in the multiple sclerosis community; perspectives across varying socio-ecological levels

Purpose: We undertook a qualitative study that explored exercise participation and exercise promotion in the multiple sclerosis (MS) community who live in regional or remote areas of Australia. By simultaneously gathering views from persons with MS, carers, healthcare providers and healthcare managers we aimed to gather unique perspectives which represented views from across socio-ecological levels of MS healthcare.Methods: We used interpretive description methodology, and conducted semi-structured interviews or focus groups with people with MS (n = 28), carers (n = 8), healthcare providers (n = 12) and managers/supervisors of MS healthcare systems (n = 16). Data were analysed using thematic analysis.Results: We identified three themes with 10 subthemes. The first theme was "Factors associated with exercise engagement" for the people with MS, from individual, interpersonal, organisational and community/public policy perspectives. The second theme was "Factors influencing the MS community's promotion of exercise" focusing on carers, healthcare providers and healthcare systems. The third theme was "Motivators to increase exercise promotion" which should be delivered by the MS community across varying socio-ecological levels of healthcare to encourage exercise participation.Conclusion: We identified new evidence on the factors which influence the MS community's promotion of exercise and we now better understand that training on exercise should be provided to the wider MS community, and exercise services should be considered locally and perhaps delivered via teleheath.IMPLICATIONS FOR REHABILITATIONCohesive healthcare campaigns, and clinical guidelines based on empirical evidence should be established for symptom management in MS with a focus on the role of exercise.Symptom management strategies should consider the whole MS community, including patients, carers, healthcare professional and healthcare co-ordinators.Internal factors (e.g., emotion and motivation) and broader factors (e.g., funding and location) must be considered when designing exercise interventions in persons with MS.

Center-Based Group and Home-Based Individual Exercise Programs Have Similar Impacts on Gait and Balance in People With Multiple Sclerosis: A Randomized Trial

BACKGROUND

Group and home-based exercises to improve function in people with multiple sclerosis (MS) are common but have little underpinning evidence.

OBJECTIVE

To determine the comparative effectiveness of a center-based group versus home-based individual 8-week exercise program to improve gait and balance in people with MS.

DESIGN

Prospective, randomized controlled trial.

SETTING

Community center-based and home-based exercise program.

PARTICIPANTS

Fifty people with MS were randomized and completed allocated intervention (n = 26 center, n = 24 home), 47 completed post-assessment and 44 follow-up assessment.

METHODS

The center- and home-based groups completed an 8-week progressive functional and balance training exercise program. The center-based groups of four to six were supervised by a physiotherapist. The home-based group was provided with telephone support.

MAIN OUTCOME MEASUREMENTS

The primary outcome was gait speed (10-meter walk test). Secondary outcomes were gait endurance (6-minute walk test) and balance (Berg Balance Scale). Outcome assessments were conducted at baseline, immediately postintervention and at 8-week follow-up.

RESULTS

There was no statistically significant difference between groups in gait speed post training, with a mean difference of 0.01 m/s, 95% CI -0.36 to 0.37. There were no group effects, time effects, or interactions for gait speed, endurance, or balance. In both groups, gait speed improved to a level that met minimal clinically important differences.

CONCLUSIONS

Gait speed, endurance, and balance did not statistically improve in either group; however, gait speed changes met minimally important differences.

Boccia as a Rehabilitation Intervention for Adults With Severe Mobility Limitations Due to Neuromuscular and Other Neurological Disorders: Feasibility and Effects on Upper Limb Impairments

Purpose

Scant research exists regarding the effects of playing Boccia as a rehabilitation strategy for people with severe mobility limitations due to neuromuscular and other neurological disorders. This study is aimed at identifying the feasibility and effects of playing Boccia on the upper limb impairments of people with severe mobility limitations due to neuromuscular and other neurological disorders.

Materials and Methods

Seven people played Boccia three times per week for 20 weeks as part of the rehabilitation process, while other seven kept up with their usual rehabilitation schedule. Attrition, adherence, adverse effects, participation and completion rate were registered to assess feasibility. The effects of the program on grip, pinch strength and upper-limb active range of motion were assessed by means of a dynamometer and a goniometer.

Results and Conclusions

The program was feasible, although no effects were observed after its completion on variables assessed, except for hand flexion and ulnar deviation active range of motion. In a group of people with severe disability due to neuromuscular and other neurological disorders, playing Boccia as part of a multidisciplinary rehabilitation program was shown to be a feasible therapy. However, practicing this game did not lead to significant improvements in upper limb impairments, except for wrist flexion and ulnar deviation active range of motion.

Daily Temporal Associations Between Physical Activity and Symptoms in Multiple Sclerosis

Background

Symptom severity is negatively associated with physical activity in multiple sclerosis (MS). However, it is unclear how physical activity and symptoms correlate on a day-to-day basis in persons with MS.

Purpose

To determine the temporal within-person associations of pain, fatigue, depressed mood, and perceived cognitive function with physical activity in MS.

Methods

Ambulatory adults with MS (N = 107) completed 7 days of home monitoring. Continuous physical activity data (assessed via wrist-worn accelerometer) and concurrent ecological momentary assessment (5X/day) of pain, fatigue, depressed mood, and perceived cognitive function were collected. Data were analyzed using multilevel mixed modeling.

Results

Fatigue and depressed mood demonstrated bidirectional associations with physical activity, whereas pain and cognitive function did not. Higher than usual fatigue (B = -5.83, p = .001) and depressed mood (B = -4.12, p = .03) were followed by decreased physical activity. In contrast, higher than usual physical activity was associated with subsequent decline in fatigue (B = -0.001, p = .02) and depressed mood (B = -0.0007, p = .02); however, the association between physical activity and fatigue varied across the day.

Conclusions

Physical activity is dynamically related to fatigue and mood on a moment-to-moment basis in MS. Efforts to increase physical activity in MS must incorporate a focus on how symptoms affect and are affected by activity.

Effect of remote ischaemic preconditioning on walking in people with multiple sclerosis: double-blind randomised controlled trial

Background

Remote ischaemic preconditioning (RIPC) is the exposure of body parts to brief periods of circulatory occlusion and reperfusion. Recent studies have also shown that RIPC can improve exercise performance in healthy individuals.

Objective

This study aimed to assess the effect of RIPC on walking in people with multiple sclerosis (MS).

Methods

This was a double-blind randomised controlled clinical trial. We used three cycles of RIPC delivered by occluding the upper arm with a blood pressure (BP) cuff inflated to a pressure of 30 mm Hg above the systolic BP. In patients in the sham intervention group, the BP cuff was inflated only to 30 mm Hg below diastolic BP. Outcome measures included the Six-Minute Walk Test (6MWT), gait speed, the Borg rate of perceived exertion (RPE) scale, the tolerability of the RIPC using a Numerical Rating Scale for discomfort from 0 to 10, and adverse events. We identified responders meeting the minimal clinically important difference (MCID) established in the literature in each group.

Results

Seventy-five participants completed the study (RIPC: 38 and Sham: 37). The distance walked during the 6MWT improved by 1.9% in the sham group and 5.7% in the RIPC group (p=0.012). The number of responders meeting MCID criteria in the RIPC group was significantly greater compared with the sham intervention group. No serious adverse events occurred.

Conclusion

Single cycle of RIPC resulted in immediate improvement in walking distances during 6MWT in people with MS.

Trial registration numbers

NCT03153553

Moving exercise research in multiple sclerosis forward (the MoXFo initiative): Developing consensus statements for research

Exercise as a subset of physical activity is a cornerstone in the management of multiple sclerosis (MS) based on its pleotropic effects. There is an exponential increase in the quantity of research on exercise in MS, yet a number of barriers associated with study content and quality hamper rapid progress in the field. To address these barriers and accelerate discovery, a new international partnership of MS-related experts in exercise has emerged with the goal of advancing the research agenda. As a first step, the expert panel met in May 2018 and identified the most urgent areas for moving the field forward, and discussed the framework for such a process. This led to identification of five themes, namely "Definitions and terminology," "Study methodology," "Reporting and outcomes," "Adherence to exercise," and "Mechanisms of action." Based on the identified themes, five expert groups have been formed, that will further (a) outline the challenges per theme and (b) provide recommendations for moving forward. We aim to involve and collaborate with people with MS/MS organizations (e.g. Multiple Sclerosis International Federation (MSIF) and European Multiple Sclerosis Platform (EMSP)) in all of these five themes. The generation of this thematic framework with multi-expert perspectives can bolster the quality and scope of exercise studies in MS that may ultimately improve the daily lives of people with MS.

'I can do this': a qualitative exploration of acceptability and experiences of a physical activity behaviour change intervention in people with multiple sclerosis in the UK

OBJECTIVES

The purpose of this study was to explore the experiences of people with multiple sclerosis (MS) who participated in iStep-MS, a feasibility randomised controlled trial of a behaviour change intervention that aimed to increase physical activity and reduce sedentary behaviour.

DESIGN

A qualitative approach was undertaken embedded in the feasibility randomised controlled trial. One-to-one semi-structured interviews were conducted and analysed using Framework analysis.

SETTING

Participants were recruited from a single MS therapy centre in the southeast of England, UK.

PARTICIPANTS

Sixty people with MS were randomly allocated in a 1:1 ratio to the intervention or usual care. Following a purposive sampling strategy, 15 participants from the intervention arm undertook 1:1 semi-structured interviews.

INTERVENTIONS

The iStep-MS intervention consisted of four therapist-led sessions over 12 weeks, supported by a handbook and pedometer.

RESULTS

Three themes were identified from the data. "I can do this": developing competence in physical activity highlights the enhanced physical activity confidence gained through goal setting and accomplishment. "I felt valued": the nurturing culture provides an overview of the supportive and non-judgemental environment created by the programme structure and therapeutic relationship. Finally, "What can I do?": empowered enactment describes the transition from the supported iStep-MS intervention to intrinsically motivated physical activity enactment.

CONCLUSIONS

Overall, this study supports the acceptability of the iStep-MS intervention and identified key areas that supported participants to be physically active.

TRIAL REGISTRATION NUMBER

ISRCTN15343862.

Social Cognitive Theory and Physical Activity in Older Adults with Multiple Sclerosis

Background

The expanding population of older adults with multiple sclerosis (MS) likely experiences many of the same benefits of physical activity (PA) as younger and middle-aged adults with MS. However, participation in PA is exceedingly low in this segment of the MS population. This study examined variables from social cognitive theory (SCT) as correlates of PA in older adults with MS to inform the subsequent development of behavioral interventions.

Methods

Older adults with MS (≥60 years of age, N = 180) completed an online survey including demographic and clinical characteristics, SCT variables (exercise self-efficacy, exercise goal setting, social support, and outcome expectations), and PA (total PA [TPA] and moderate-to-vigorous PA [MVPA]).

Results

Bivariate correlation analyses indicated that all SCT variables were significantly associated with TPA and MVPA (all P ≤ .001). Hierarchical linear regression analyses indicated that disability status was a significant correlate of TPA (β = -0.48, R² = 0.23) and MVPA (β = -0.44, R² = 0.19) in step 1; disability and self-efficacy were significant correlates of TPA (disability β = -0.20, self-efficacy β = 0.59, R² = 0.50) and MVPA (disability β = -0.16, self-efficacy β = 0.60, R² = 0.47) in step 2; and disability, self-efficacy, and exercise goal setting were significant correlates of TPA (disability β = -0.21, self-efficacy β = 0.50, exercise goal setting β = 0.14, R² = 0.55) and MVPA (disability β = -0.17, self-efficacy β = 0.51, exercise goal setting β = 0.15, R² = 0.51) in step 3.

Conclusions

These results suggest that behavioral interventions focusing on self-efficacy and exercise goal setting as targets from SCT may be appropriate for increasing PA in older adults with MS.

Individualised behaviour change strategies for physical activity in multiple sclerosis (IPAC-MS): protocol for a randomised controlled trial

Background

Multiple sclerosis (MS) is a chronic, degenerative disease of the central nervous system. Because of the long-term and unpredictable nature of the disease, the burden of MS is significant from both a patient and societal perspective. Despite a recent influx of disease-modifying therapies to treat MS, many individuals continue to experience disability that negatively affects productivity and quality of life. Previous research indicates that physical activity has a positive impact on walking function in individuals with MS, in addition to the usual beneficial effects on overall health. However, most people with MS are not active enough to gain these benefits, and a lack of support to initiate and maintain physical activity has been identified as a major barrier. This study will evaluate the impact of a novel intervention involving individualised behaviour change strategies delivered by neurophysiotherapists on increasing physical activity levels in individuals with MS who are currently inactive.

Methods/design

This single-blind, parallel-group, randomised controlled trial will be conducted in Saskatchewan, Canada. Eligible participants include individuals with MS who are ambulatory but identified as currently inactive by the self-reported Godin Leisure-Time Exercise Questionnaire (GLTEQ). The intervention will be delivered by neurophysiotherapists and includes individualised behaviour change strategies aimed at increasing physical activity over a 12-month period. The control group will receive usual care during the 12-month study period. The primary outcome is the change in physical activity level, as measured by the change in the GLTEQ score from baseline to 12 months. Secondary outcomes include the change in patient-reported outcome measures assessing MS-specific symptoms, confidence and quality of life.

Discussion

Physical activity has been identified as a top research priority by the MS community. Findings from this novel study may result in new knowledge that could significantly impact the management and overall health of individuals with MS.

Trial registration

ClinicalTrials.gov, NCT04027114. Registered on 10 July 2019.

A Controlled Clinical Trial on the Effects of Exercise on Cognition and Mobility in Adults With Multiple Sclerosis

OBJECTIVE

The aim of the study was to investigate the effects of a 6-mo exercise program on cognition and mobility in participants with multiple sclerosis.

DESIGN

This is a prospective, single-blind, controlled clinical trial.

SETTING

A community rehabilitation program within a large metropolitan health service.

PARTICIPANTS

Twenty-eight patients with multiple sclerosis were referred for outpatient rehabilitation.

INTERVENTIONS

Participants were allocated to one of two groups and undertook a cognitive-motor exercise program or monitoring (control group).

MAIN OUTCOME MEASURES

Cognition and mobility were the main outcome measures. Cognition was evaluated using the Mini-Mental State Examination and the Frontal Assessment Battery. Mobility was assessed with the Timed Get Up and Go test, applied with and without dual task distractors.

RESULTS

The findings showed benefits provided by exercise on cognition and mobility. Differently, participants of the control group did not have significant changes in cognition scores after 6 mos of follow-up and had a worse performance in mobility tests.

CONCLUSION

Six months of exercise provided benefits to cognition and mobility in adults with multiple sclerosis. This trial was registered prospectively with the Brazilian Clinical Trials Register, ID: RBR-9gh4km (http://www.ensaiosclinicos.gov.br/rg/?q=RBR-9gh4km).

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Recognize the physical and cognitive decline in multiple sclerosis; (2) Identify the importance of exercise on cognition and mobility in patients with multiple sclerosis; and (3) Appreciate the potential benefit of dual tasking in the rehabilitation of individuals with multiple sclerosis.Level: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Physical activity is associated with neuromuscular and physical function in patients with multiple sclerosis independent of disease severity

PURPOSE

Examine the association between physical activity and neuromuscular and physical function in patients with multiple sclerosis when also considering disease severity.

METHODS

91 patients with multiple sclerosis were enrolled. Assessments included physical activity by 7-day thigh-worn accelerometry, knee extensor neuromuscular function by dynamometry (maximal isometric muscle strength, rate of force development (0-50 ms)), and physical function by 5× sit-to-stand, 2-min walk test, and timed 25 ft walk test. Physical activity tertile comparisons along with simple and multiple regressions (adjusting for age, gender, EDSS, time since diagnosis) were performed.

RESULTS

Physical activity tertiles revealed differences (p < 0.05) in maximal muscle strength (1.77 ≈ 1.97 < 2.28 Nm/kg), rate of force development (4.66 < 8.03 ≈ 10.55 Nm/kg/s), 5× sit-to-stand (11.4 ≈ 9.7 > 8.5 s), 2-min walk test (153 < 183 < 207 m), and timed 25 ft walk test (6.3 > 4.4 > 4.3 s). Moreover, physical activity was associated (p < 0.05) with maximal muscle strength and rate of force development (r²  =  0.13-0.15) along with 5× sit-to-stand, 2-min walk test, and timed 25 ft walk test (r² = 0.18-0.24), also after adjusting for age + gender + EDSS + time since diagnosis (r² = 0.25-0.37 and 0.24-0.52), with physical activity consistently being a strong predictor.

CONCLUSIONS

Higher levels of physical activity are associated with greater neuromuscular and physical function in ambulatory patients with multiple sclerosis independent of disease severity. These findings emphasize the importance of performing regular physical activity at all stages of multiple sclerosis.IMPLICATIONS FOR REHABILITATIONPhysical activity is associated with neuromuscular and physical function, independent of disease severity.Physical activity may be important in improving or preserving neuromuscular and physical function at all stages of ambulatory multiple sclerosis patients, yet longitudinal studies are warranted.Clinicians and rehabilitation professionals should encourage ambulatory patients at all stages of their disease to be as physically active as possible.

Exercise in Multiple Sclerosis: Knowing is Not Enough-The Crucial Role of Intention Formation and Intention Realization

A large body of evidence supports the notion that patients with multiple sclerosis (MS) benefit from physical exercise. However, this research-based recommendation has been insufficiently translated into practice. In this commentary article, we highlight the psychological evidence for the intention-behaviour gap and discuss evidence-based recommendations for bridging this gap, with the aim to change behaviour in MS patients. It is accepted that psychological research distinguishes intention formation from intention realization and that these processes have to be considered when the aim is to enhance physical activity in MS patients. We suggest that the transtheoretical model of behaviour change is a useful and general framework for examining the process of intention formation and that a MS-specific perspective is more useful for realizing exercise intention. MS patients are faced with severe self-control demands that hinder the realization of sport and exercise goals. Specifically, MS patients experience fatigue, which imposes substantial self-control demands. Here, we suggest implementation intention as an effective tool that aids in counteracting deficits in intention realization (getting started and staying on track). We also note that research knowledge is not sufficiently translated into clinical practice. Based on an interdisciplinary approach we recommend that therapists of MS patients should be more aware of psychological theories of health behaviour change and that they should use these to improve and optimize treatment approaches.

Physical Activity Promotion for Persons Experiencing Disability: The Importance of Interdisciplinary Research and Practice

This paper examines the need for interdisciplinary knowledge in the formation of public health models for health-promoting physical activity (PA) for people experiencing disability. PA promotion for people experiencing disability is a multifaceted endeavor and requires navigating a multitude of complicated and interactive factors. Both disability and health are multifaceted constructs and the relationship between PA and health is embedded within a complicated web of interactive influences. PA promotion must consider interacting biological and psychosocial factors within the person and in the sociopolitical environment. Models for research and practice need to evolve from value and belief systems that center on people experiencing disability without stigmatizing them. We argue that interdisciplinary research and practice is needed in navigating the intricacies of PA promotion toward improving the health of people experiencing disability and facilitating inclusion, empowerment, and dignity.

Promotion of physical activity and exercise in multiple sclerosis: Importance of behavioral science and theory

There is an obvious disconnect between evidence of benefits and rates of participation in exercise and physical activity among people living with multiple sclerosis (MS). We propose that the problem with exercise behavior in MS (i.e. lack of broad or increasing participation by people with MS despite evidence of meaningful benefits) might be ameliorated through the inclusion of behavior change theory in the design of exercise programs and promotion efforts, as has been undertaken in other populations such as breast cancer survivors. This paper reviews Social Cognitive Theory as an example approach for informing interventions for increasing exercise and physical activity behavior outside of MS and provides an overview of current knowledge regarding the application of this theory for physical activity in MS. We then outline future research necessary for informing trials that design, implement, and test theory-based interventions for physical activity promotion in MS. If theories of behavior change are adopted for informing exercise and physical activity research in MS, we can take a major step forward in addressing the problem of exercise and physical activity participation that has plagued the field for more than 25 years.

Social Cognitive Theory Correlates of Physical Activity in Inactive Adults with Multiple Sclerosis

BACKGROUND

There is a growing body of evidence that physical activity (PA) improves symptoms of multiple sclerosis (MS). Despite the benefits of PA, people with MS are relatively inactive compared with their healthy counterparts. This study investigated associations between social cognitive theory (SCT) constructs and energy expenditure (EE) as an objective measure of PA in a sample of inactive people with MS.

METHODS

Participants (n = 65) completed several questionnaires and were assessed using standardized outcome measures as part of a cross-sectional analysis of baseline data from a randomized controlled trial (Step it Up).

RESULTS

The bivariate correlation analysis indicated that of all SCT constructs, only exercise self-efficacy was significantly correlated with EE (r = 0.297, P = .022). Multiple linear regression analysis found that exercise self-efficacy independently explained 9% of the variance in EE (R2 = 0.088). A model including exercise self-efficacy, exercise goal setting, exercise planning, and exercise benefits explained 17% of the variance in EE (F4,54 = 2.741, P = .038, R2 = 0.169). In this model, only exercise self-efficacy was significantly associated with EE scores (Exercise Self-Efficacy Scale β = .320, P = .016).

CONCLUSIONS

The constructs of SCT explained little of the variance of objectively measured PA in a sample of inactive people with MS who volunteered for an exercise trial. The only significant variable was exercise self-efficacy, which confirms the importance of enhancing it through PA interventions.

A randomized study to evaluate the effect of exercise on fatigue in people with relapsing-remitting multiple sclerosis treated with fingolimod

Background

Fatigue is a major symptom of multiple sclerosis (MS) in patients, and it has been shown to improve with physical exercise. Although fingolimod might lessen fatigue, it is unclear how patients treated with fingolimod react to physical activity regarding fatigue.

Objective

This study evaluated the effect of an exercise intervention on fatigue in relapsing–remitting MS patients receiving fingolimod.

Methods

People with MS (PwMS) were randomized to either a structured internet-based exercise program (e-training) or no e-training intervention. The primary endpoint was the change in the Modified Fatigue Impact Scale (mFIS) after six months.

Results

The primary analysis showed no statistically significant difference between groups in the mFIS change. Subgroup analyses revealed a beneficial effect of physical exercise for PwMS with low aerobic capacity and with low aerobic capacity plus more severe fatigue. The incidence of adverse events was similar in both groups. No cardiovascular events were reported. The majority of PwMS were relapse free.

Conclusion

Physical exercise benefits on fatigue may depend on the physical capacity of the patient and requires individualized training. Consistent with previous studies, these results suggest that physical exercise generally does not impose a risk and that this holds true also for patients receiving fingolimod.

Trial registration: ClinicalTrials.gov, NCT01490840.

Balance, gait, and falls in multiple sclerosis

Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) and the most widespread nontraumatic cause of disability in young adults around the world. MS occurs in people of all ages, races, and ethnicities. MS is characterized by clinical symptoms resulting from lesions in the brain, spinal cord, or optic nerves that can affect balance, gait, and fall risk. Lesions accumulate over time and occur in different areas of the CNS causing symptoms that include weakness, spasticity, and fatigue, as well as changes in sensation, coordination, vision, cognition, and bladder function. Thus, it is not surprising that imbalance, gait dysfunction, and falls are common in people with MS. The overwhelming majority have abnormalities of postural control and gait even early in the disease course. In all, 50-80% have balance and gait dysfunction and over 50% fall at least once each year. Balance dysfunction in MS is conceptualized as three interrelated problems: decreased ability to maintain position, limited and slowed movement towards limits of stability, and delayed responses to postural displacements and perturbations. In addition, functional balance performance may be affected by impaired dual-task integration. Walking changes in MS include reduced gait speed, impaired walking balance, and reduced walking-related physical activity. Falls in people with MS are associated with injuries, reduced participation, and increased fear of falling. A wide and growing range of rehabilitation and medical interventions are available to address the changes in balance, gait, and fall risk associated with MS.

Self-reported physical activity correlates in Swedish adults with multiple sclerosis: a cross-sectional study

Background

The benefits of physical activity in persons with Multiple Sclerosis (MS) are considerable. Knowledge about factors that correlate to physical activity is helpful in order to develop successful strategies to increase physical activity in persons with MS. Previous studies have focused on correlates to physical activity in MS, however falls self-efficacy, social support and enjoyment of physical activity are not much studied, as well as if the correlates differ with regard to disease severity. The aim of the study was to examine associations between physical activity and age, gender, employment, having children living at home, education, disease type, disease severity, fatigue, self-efficacy for physical activity, falls self-efficacy, social support and enjoyment of physical activity in a sample of persons with MS and in subgroups with regard to disease severity.

Methods

This is a cross-sectional survey study including Swedish community living adults with MS, 287 persons, response rate 58.2%. The survey included standardized self-reported scales measuring physical activity, disease severity, fatigue, self-efficacy for physical activity, falls self-efficacy, and social support. Physical activity was measured by the Physical Activity Disability Survey – Revised.

Results

Multiple regression analyzes showed that 59% (F(6,3) = 64.9, p = 0.000) of the variation in physical activity was explained by having less severe disease (β = −0.30), being employed (β = 0.26), having high falls self-efficacy (β = 0.20), having high self-efficacy for physical activity (β = 0.17), and enjoying physical activity (β = 0.11). In persons with moderate/severe MS, self-efficacy for physical activity explained physical activity.

Conclusions

Consistent with previous research in persons with MS in other countries this study shows that disease severity, employment and self-efficacy for physical activity are important for physical activity. Additional important factors were falls self-efficacy and enjoyment. More research is needed to confirm this and the subgroup differences.

Sources of Variability in Physical Activity Among Inactive People with Multiple Sclerosis

PURPOSE

Evidence supports that physical activity (PA) improves symptoms of multiple sclerosis (MS). Although application of principles from Social Cognitive Theory (SCT) may facilitate positive changes in PA behaviour among people with multiple sclerosis (pwMS), the constructs often explain limited variance in PA. This study investigated the extent to which MS symptoms, including fatigue, depression, and walking limitations combined with the SCT constructs, explained more variance in PA than SCT constructs alone among pwMS.

METHOD

Baseline data, including objectively assessed PA, exercise self-efficacy, goal setting, outcome expectations, 6-min walk test, fatigue and depression, from 65 participants of the Step It Up randomized controlled trial completed in Ireland (2016), were included. Multiple regression models quantified variance explained in PA and independent associations of (1) SCT constructs, (2) symptoms and (3) SCT constructs and symptoms.

RESULTS

Model 1 included exercise self-efficacy, exercise goal setting and multidimensional outcomes expectations for exercise and explained ~14% of the variance in PA (R ²=0.144, p < 0.05). Model 2 included walking limitations, fatigue and depression and explained 20% of the variance in PA (R ²=0.196, p < 0.01). Model 3 combined models 1 and 2 and explained variance increased to ~29% (R ²=0.288; p<0.01). In Model 3, exercise self-efficacy (β=0.30, p < 0.05), walking limitations (β=0.32, p < 0.01), fatigue (β = -0.41, p < 0.01) and depression (β = 0.34, p < 0.05) were significantly and independently associated with PA.

CONCLUSION

Findings suggest that relevant MS symptoms improved by PA, including fatigue, depression and walking limitations, and SCT constructs together explained more variance in PA than SCT constructs alone, providing support for targeting both SCT constructs and these symptoms in the multifactorial promotion of PA among pwMS.