Physical activity in multiple sclerosis: the missing prescription

The MoXFo initiative - adherence: Exercise adherence, compliance and sustainability among people with multiple sclerosis: An overview and roadmap for research

We know very little about exercise adherence, compliance and sustainability in multiple sclerosis (MS), yet adherence is seemingly important for yielding immediate and sustained health benefits. This paper is focused on exercise adherence, compliance and sustainability in the context of informing research and practice involving MS. This focus is critical for clarifying terminology for future research and providing a roadmap guiding clinical research and practice. Our objective was accomplished through a narrative summary of the literature by a panel of experts on exercise adherence from the Moving Exercise Research in Multiple Sclerosis Forward (MoXFo) initiative and a concluding summary of the state of the literature and future research directions. The panel of experts identified three overall themes (Background and Importance; Understanding and Promoting Exercise Adherence, Compliance and Sustainability and Challenges to Exercise Adherence, Compliance and Sustainability) that represented a categorization of nine subthemes. These overall themes and subthemes formed the basis of our recommendations regarding future research broadly involving exercise adherence in MS. Overall, there is limited evidence on rates and determinants of exercise adherence and compliance in MS, and little is known about techniques and interventions for immediate and long-term exercise behaviour change.

Lessons learned from clinical trials of exercise and physical activity in people with MS - guidance for improving the quality of future research

The body of research on exercise and physical activity among persons with multiple sclerosis(MS) has expanded rapidly in quantity, but not necessarily quality, over the past 20+ years. There is evidence for beneficial effects of exercise and physical activity on immune cells and neurotrophic factors, brain structure and function, walking and cognitive performance, fatigue, depression, and pain, and quality of life among persons with MS. Nevertheless, there is heterogeneity in the outcomes of exercise and physical activity, and a recognition of substantial challenges for improving the effectiveness of those behaviors in MS. To move the field forward, members of the National MS Society physical wellness research working-group pooled collective experiences for identifying challenges, logistic complexities, and opportunities for researchers in designing and conducting interventions of exercise and physical activity among persons with MS. We examined the scope of our experiences and identified collective "lessons learned" regarding the behaviors themselves; study design features and stage of research; study setting, safety, and sample selection; and implementation of randomized controlled trials(RCTs) and treatment fidelity. This paper provides a resource that can inform researchers, particularly new investigators or established investigators transitioning into MS, on conducting high-quality RCTs on exercise and physical activity in MS.

Medicalization of Exercise Through Vigilance, Productivity, and Self-Care: A Secondary Data Analysis of Qualitative Interviews Among Those With Multiple Sclerosis

Exercise is becoming more integrated into the management of multiple sclerosis (MS) and is promoted to manage impairments and symptoms. Whereas extensive research outlines factors impacting participation, less is known regarding how medicalized exercise promotion might impact views of exercise and self. We conducted a secondary data analysis to understand how medicalized exercise-promotion paradigms impact the meaning and roles of exercise among those with MS. Twenty-two interviews were selected for reanalysis with an interpretative phenomenological analysis methodology and a critical disability studies lens. Three themes were identified: Constant Vigilance (worry about exercise), Productivity and Social Engagement (exercise to feel productive, engage socially, and enhance self-worth), and Exercise as Medicine/Self-Care (exercise to manage MS, relax, improve mental well-being, prevent/reverse disability, and stay healthy). This research underscores that exercise occupies many contradictory roles reflecting a medicalized exercise-promotion paradigm for those with MS, and this should inform exercise promotion practices.

The Neurologist as an Agent of Exercise Rehabilitation in Multiple Sclerosis

This review hypothesizes that the neurologist represents the linchpin of exercise behavior change within comprehensive multiple sclerosis (MS) care settings. This is based on a series of recent articles that developed actionable practice models for accomplishing such behavior change through the neurologist as the primary agent. This provides tangible, next steps for exercise promotion in MS.

In search of a daily physical activity "sweet spot": Piloting a digital tracking intervention for people with multiple sclerosis

Objective

This pilot study tested a course-based intervention to help people with multiple sclerosis (MS) match their daily activity to symptom severity (“sweet spot”) using wearable activity trackers.

Methods

This two-phase study recruited online research network members reporting MS and who were utilizing Fitbit One™ activity trackers. In the first phase, participant interviews assessed demand based on physical activity and the use of behavior-change techniques. The second phase assessed the demand, limited efficacy, acceptability, and practicality of a “Wearables 101” course that integrated behavior change and self-experimentation principles. Tracker data were used to determine the percent of matches between daily symptom-based step goals and step counts.

Results

Participants expressed demand in the form of interest in gaining insights about a possible “sweet spot” behavioral target, if a system could be produced to support that. Limited efficacy results were mixed, with approximately one-third of participants dropping out and only half matching their daily target goals for at least 50% of days. In terms of practicality, participants commented on the burden of daily measurement and the need for a longer baseline period. Participants noted that tracking helped support an understanding of the link between activities and symptom severity, suggesting acceptability.

Conclusions

Results suggested that the intervention demand and acceptability criteria were demonstrated more strongly than limited efficacy and practicality. The matching intervention tested in this study will require refinement in baseline measurement, goal definition, and reduced data-gathering burden. Such changes may improve efficacy and practicality requirements and, by extension, later impact of the intervention on MS outcomes. Overall, these results provide justification for additional work on refining the intervention to increase practicality and efficacy.

Exploring the Specific Needs of Persons with Multiple Sclerosis for mHealth Solutions for Physical Activity: Mixed-Methods Study

Background

Multiple sclerosis (MS) is one of the world’s most common neurologic disorders, with symptoms such as fatigue, cognitive problems, and issues with mobility. Evidence suggests that physical activity (PA) helps people with MS reduce fatigue and improve quality of life. The use of mobile technologies for health has grown in recent years with little involvement from relevant stakeholders. User-centered design (UCD) is a design philosophy with the goal of creating solutions specific to the needs and tasks of the intended users. UCD involves stakeholders early and often in the design process. In a preliminary study, we assessed the landscape of commercially available MS mobile health (mHealth) apps; to our knowledge, no study has explored what persons with MS and their formal care providers think of mHealth solutions for PA.

Objective

The aim of this study was to (1) explore MS-specific needs for MS mHealth solutions for PA, (2) detect perceived obstacles and facilitators for mHealth solutions from persons with MS and health care professionals, and (3) understand the motivational aspects behind adoption of mHealth solutions for MS.

Methods

A mixed-methods design study was conducted in Kliniken Valens, Switzerland, a clinic specializing in neurological rehabilitation. We explored persons with MS and health care professionals who work with them separately. The study had a qualitative part comprising focus groups and interviews, and a quantitative part with standardized tools such as satisfaction with life scale and electronic health (eHealth) literacy.

Results

A total of 12 persons with relapsing-remitting MS and 12 health care professionals from different backgrounds participated in the study. Participants were well-educated with an even distribution between genders. Themes identified during analysis were MS-related barriers and facilitators, mHealth design considerations, and general motivational aspects. The insights generated were used to create MS personas for design purposes. Desired mHealth features were as follows: (1) activity tracking, (2) incentives for completing tasks and objectives, (3) customizable goal setting, (4) optional sociability, and (5) game-like attitude among others. Potential barriers to mHealth apps adoption were as follows: (1) rough on-boarding experiences, (2) lack of clear use benefits, and (3) disruption of the health care provider-patient relationship. Potential facilitators were identified: (1) endorsements from experts, (2) playfulness, and (3) tailored to specific persons with MS needs. A total of 4 MS personas were developed to provide designers and computer scientists means to help in the creation of future mHealth solutions for MS.

Conclusions

mHealth solutions for increasing PA in persons with MS hold promise. Allowing for realistic goal setting and positive feedback, while minimizing usability burdens, seems to be critical for the adoption of such apps. Fatigue management is especially important in this population; more attention should be brought to this area.

Descriptive epidemiology of physical activity rates in multiple sclerosis

BACKGROUND

Persons with multiple sclerosis (MS) engage in substantially less overall physical activity than healthy controls, but there is little information on public health rates of physical activity necessary for health benefits.

PURPOSE

This study examined the rates of insufficient, moderate, and sufficient physical activity in persons with MS compared with healthy controls.

METHOD

Secondary analysis of data from participants with MS (n = 1521) and healthy controls (n = 162) who completed the Godin Leisure-Time Exercise Questionnaire (GLTEQ) as part of a questionnaire battery in 14 previous investigations.

RESULTS

There were statistically significant differences in overall GLTEQ scores (F1,1666 = 96.8, P < 0.001, d = 0.83) and rates of physical activity (χ(2) (2, N = 1683) = 94.2, P < 0.001) between MS and control groups. The rates of insufficient, moderate, and sufficient physical activity in the MS group were 58.0%, 15.2%, and 26.8%, respectively. Those with MS were 2.5 times more likely to report insufficient physical activity and 2.3 times less likely to report sufficient physical activity than controls.

CONCLUSION

The majority of persons with MS were insufficiently physically active, and this segment represents the largest opportunity for successful behavior change and accumulation of associated health benefits.

Multiple sclerosis is associated with high trait anger: a case-control study

INTRODUCTION

In recent years there has been a focus on health-related quality of life in multiple sclerosis (MS) and in particular the importance of non-motor problems such as fatigue, pain, depression, anxiety, and cognitive disorders. However, little attention has been focused on other negative emotions, such as anger. Our purpose was to evaluate whether trait anger (a predisposition to experience frequent and intense episodes of anger over time) is different between persons with and without MS after controlling for depression, anxiety, and other socio-demographic variables.

METHODS

157 consecutive MS patients were enrolled in the study and compared to eighty age, gender, and education-matched healthy controls. Participants were administered affective trait measures (Beck Depression Inventory, Beck Anxiety Inventory) and the trait anger measure (the Spanish adapted version of the State-Trait Anger Expression Inventory-2 [STAXI-2]).

RESULTS

MS patients had significantly higher scores on anger intensity (state anger) and trait anger than did controls. They also had a trend to experience direct anger toward other persons or objects in the environment (higher anger expression-out score) and to hold in or suppress angry feelings (higher anger expression-in score). However, in a regression analysis that adjusted for different demographic and clinical variables, we found that diagnosis category (MS patient vs. control) was associated with none of the highest quartiles of STAXI-2 scores, except for the Trait Anger scale (odds ratios between 2.35 and 3.50).

CONCLUSIONS

The present study provides further evidence that MS is independently associated with high trait anger.

Randomized controlled trial of a behavioral intervention targeting symptoms and physical activity in multiple sclerosis

Background:

Exercise training is beneficial, but most persons with multiple sclerosis (MS) are sedentary and physically inactive. This has prompted a new focus on the promotion of lifestyle physical activity in MS. We previously designed, tested, and refined a behavioral intervention delivered through the Internet that successfully increased lifestyle physical activity in MS, but have not evaluated the effects on secondary symptomatic and health-related quality of life (HRQOL) outcomes.

Objective:

We conducted a 6-month randomized controlled trial (RCT) that examined the efficacy of an Internet-delivered, behavioral intervention for improving outcomes of fatigue, depression, anxiety, pain, sleep quality, and HRQOL in 82 ambulatory persons with MS. The secondary aim was to replicate previous results regarding change in free-living physical activity.

Results:

There was a significant and positive effect of the intervention on fatigue severity ( p=.001, ηρ2=.15) and its physical impact ( p=.008, ηρ2=.09), depression ( p=.006, ηρ2=.10), and anxiety ( p=.006, ηρ2=.10). There were non-significant improvements in pain ( p=.08, ηρ2=.04), sleep quality ( p=.06, ηρ2=.05), and physical HRQOL ( p=.06, ηρ2=.05). We replicated our previous results by demonstrating an increase in self-reported physical activity ( p=.001, ηρ2=.13).

Conclusions:

Our results support behavioral interventions targeting lifestyle physical activity as an alternative approach for managing symptoms in MS.

Longitudinal change in physical activity and its correlates in relapsing-remitting multiple sclerosis

BACKGROUND

Physical activity is beneficial for people with multiple sclerosis (MS), but this population is largely inactive. There is minimal information on change in physical activity and its correlates for informing the development of behavioral interventions.

OBJECTIVE

This study examined change in physical activity and its symptomatic, social-cognitive, and ambulatory or disability correlates over a 2.5-year period of time in people with relapsing-remitting multiple sclerosis.

METHODS

On 6 occasions, each separated by 6 months, people (N=269) with relapsing-remitting multiple sclerosis completed assessments of symptoms, self-efficacy, walking impairment, disability, and physical activity. The participants wore an accelerometer for 7 days. The change in study variables over 6 time points was examined with unconditional latent growth curve modeling. The association among changes in study variables over time was examined using conditional latent growth curve modeling, and the associations were expressed as standardized path coefficients (β).

RESULTS

There were significant linear changes in self-reported and objectively measured physical activity, self-efficacy, walking impairment, and disability over the 2.5-year period; there were no changes in fatigue, depression, and pain. The changes in self-reported and objective physical activity were associated with change in self-efficacy (β=.49 and β=.61, respectively), after controlling for other variables and confounders.

LIMITATIONS

The primary limitations of the study were the generalizability of results among those with progressive multiple sclerosis and inclusion of a single variable from social-cognitive theory.

CONCLUSIONS

Researchers should consider designing interventions that target self-efficacy for the promotion and maintenance of physical activity in this population.

Objectively quantified physical activity in persons with multiple sclerosis

OBJECTIVES

To investigate levels of moderate-to-vigorous physical activity (MVPA) in a large sample of persons with multiple sclerosis (MS) and controls using accelerometry as a measure of physical activity, and to compare the rates of meeting public health guidelines for MVPA (ie, 30min/d) between persons with MS and controls.

DESIGN

Secondary analysis of a combined data set of persons with MS and healthy controls from 13 previous investigations of physical activity over a 8-year period (2005-2013).

SETTING

University.

PARTICIPANTS

Participants with MS (n=800) were recruited primarily within Illinois through multiple sources, including print and e-mail flyers and an online advertisement on the National Multiple Sclerosis Society website. Healthy controls (n=137) were recruited via public e-mail postings delivered across the university community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Levels of MVPA and meeting public health guidelines for MVPA between persons with MS and controls.

RESULTS

After controlling for covariates (ie, age, sex, education, race, income), there was a moderate (d=.68) and statistically significant (F=47.2, P<.001) difference of 13.1 minutes of MVPA per day (95% confidence interval, 9.4-16.8) between MS and controls. There was a difference in the rates of meeting public health guidelines for MVPA (χ(2)=50.7, P<.001) between MS patients (20%) and controls (47%). Among those with MS, minutes of MVPA significantly differed as a function of education, employment status, clinical course, disease duration, and disability status.

CONCLUSIONS

We provide data using an objective physical activity measure and a large sample to indicate that only a small proportion of persons with MS are achieving adequate amounts of daily MVPA.

The benefits of exercise training in multiple sclerosis

Multiple sclerosis (MS) is an immune-mediated disease characterized by inflammatory demyelination and neurodegeneration within the CNS. This damage of CNS structures leads to deficits of body functions, which, in turn, affect patient activities, such as walking, and participation. The pathogenesis and resulting consequences of MS have been described as concepts within the International Classification of Functioning, Disability and Health (ICF) model--an international standard to describe and measure health and disability. Evidence suggests that exercise training in people with MS has the potential to target and improve many of the components outlined in the ICF model. Although the body of research examining the effects of exercise training on depression, cognition and participatory outcomes is not sufficiently developed, some preliminary evidence is promising. Exercise training is proposed to affect inflammation, neurodegeneration, and CNS structures, but current evidence is limited. In this Review, we discuss evidence from clinical trials that suggests beneficial effects of exercise training on muscle strength, aerobic capacity and walking performance, and on fatigue, gait, balance and quality of life. Issues with current studies and areas of future research are highlighted.

Meanings, motivations, and strategies for engaging in physical activity among women with multiple sclerosis

PURPOSE

The aim of the current study was to better understand the adoption and maintenance of physical activity from the perspective of women with multiple sclerosis (MS).

METHODS

Participants (N = 11) were women with MS who had low levels of disability and who engaged in varying levels of physical activity. Participants completed two semi-structured, audio taped interviews focusing on their beliefs, motivators, and experiences of physical activity.

RESULTS

Across all activity levels participants reported similar beliefs and motivations related to being physically active including the desire to be "normal", savoring current health, enjoyment of the activity, "feeling good" after activity, weight control, and maintenance of physical function. Active and inactive participants differed in the practical strategies they reportedly used to adopt and maintain physical activity, such as prioritizing and scheduling physical activity, managing disease-specific barriers, and building social support networks.

CONCLUSIONS

A consideration of these beliefs, motivations, and strategies may be useful for designing behavioral interventions to increase physical activity that are sensitive to the needs and preferences of women with MS.

Internet-delivered behavioral intervention to increase physical activity in persons with multiple sclerosis: sustainability and secondary outcomes

Physical activity is associated with many benefits, but persons with multiple sclerosis (MS) are less physically active than the general population. There is a critical need for research on methods of increasing and sustaining the physical activity levels of this population. This randomized controlled trial examined the efficacy of an Internet-delivered and theory-based behavioral intervention that was supplemented with video coaching for increasing and sustaining physical activity over time in persons with MS. Physically inactive, ambulatory persons with MS (N = 45) were randomly assigned to intervention (n = 22) or control (n = 23) conditions and completed a battery of questionnaires before, after, and three months after a 12-week intervention period. Data analyses were conducted in PASW 18.0. Partial eta squared ([Formula: see text]) effect size indicated that there was a large, statistically significant condition-by-time interaction on physical activity ([Formula: see text]). Cohen's d effect sizes indicated that the intervention group had a large increase in physical activity after the 12-week trial (d = .98) that was sustained over a three-month follow-up (d = .79). The current study supports the efficacy of a behavioral intervention for increasing and sustaining physical activity in a sample of persons with MS.

Increasing physical activity in multiple sclerosis using a behavioral intervention

The present study adopted an interrupted time-series design for identifying the possibility of behavioral reactivity and examining the effect of an Internet-delivered behavioral intervention for increasing self-reported and objectively-measured physical activity among persons with multiple sclerosis (MS). Participants (n = 18) wore an accelerometer for 7 days and completed a battery of questionnaires to measure physical activity at 3 time points (before and after a 3-month period of no treatment and again after a 3-month period of treatment). There was a small change in objectively-measured, but not self-reported, physical activity in the period of no treatment, whereas there was a large increase in self-reported and objectively-measured physical activity in the period of treatment. These findings both complement and extend previous research and further support the efficacy of the current Internet behavioral intervention for increasing physical activity in persons with MS.