Deirdre Dlugonski

Internet intervention for increasing physical activity in persons with multiple sclerosis

Background:Physical activity has been associated with improvements in walking mobility and quality of life in persons with multiple sclerosis (MS), and yet this population is largely sedentary and inactive compared with the general population. Objectives:We conducted a pilot, randomized controlled trial (RCT) for examining the effect of an Internet intervention based on social cognitive theory (SCT) for favorably increasing physical activity among persons with MS. We further examined variables from SCT as possible mediators of the Internet intervention. Methods:We randomly allocated 54 persons with MS into either an Internet intervention condition or a waitlist control condition. The participants completed measures of physical activity, self-efficacy, outcome expectations, functional limitations, and goal setting before and after the 12-week period. Results:The intervention group reported a statistically significant (p = 0.01) and large increase in physical activity over time (d = 0.72), whereas the control group had a small (d = 0.04) and non-significant change in physical activity (p = 0.71). The intervention group further reported a statistically significant (p = 0.001) and large increase in goal setting over time (d = 0.97), whereas the control group had a small (d = −0.13) and non-significant change (p = 0.17). The change in goal setting over time mediated the effect of the Internet intervention on physical activity behavior. Conclusions:This pilot study sets the stage for a subsequent RCT that includes a larger sample of persons with MS, longer intervention period along with a follow-up, objective measure of physical activity, and secondary outcomes of walking mobility and QOL.

Physical activity and multiple sclerosis: new insights regarding inactivity.

There is increasing recognition that physical activity has beneficial consequences among persons with multiple sclerosis (MS), but there is concern regarding the current degree of physical inactivity in this population because of limitations with previous research and increased recognition of health behaviors in MS. This study compared physical activity levels between large samples of persons with mild MS and matched controls using validated measures of physical activity.

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.

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 ( ) effect size indicated that there was a large, statistically significant condition-by-time interaction on physical activity ( ). Cohens 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.

Psychometric properties of the Fatigue Severity Scale and the Modified Fatigue Impact Scale

OBJECTIVE Fatigue is one of the most common, debilitating and life altering symptoms experienced by those with multiple sclerosis (MS) and has become the focus of therapeutic interventions and clinical rehabilitation. There is limited evidence regarding the psychometric properties and clinical relevance of fatigue outcomes for interpreting the effectiveness of intervention and rehabilitation strategies. This study determined the reliability, precision and clinically important change of the uni-dimensional Fatigue Severity Scale (FSS) and the multi-dimensional Modified Fatigue Impact Scale (MFIS). METHODS The FSS and MFIS along with physical, psychological and cognitive clinical outcomes were administered to a sample of 82 persons with MS in a clinical research setting on two time points, separated by six months. Intraclass correlation coefficient (ICC) analyses established reliability; standard error of measurement (SEM) and coefficient of variation (CV) determined precision; minimal detectable change (MDC) defined clinically important change. RESULTS Participants varied in type of MS and disability status, with 77% of participants classified as having substantial fatigue, based on the criteria of a mean FSS score ≥4. The MFIS (ICC=0.863) and the FSS (ICC=0.751) had acceptable reliability over six months. Precision was reasonable for both scales (based on SEM and CV estimates) but better for the FSS. MDC estimates were established and were lower for the FSS. CONCLUSION Reliability of the FSS and MFIS falls within acceptable ranges, and precision and clinically important change estimates provide guidelines for interpreting change in scores from these outcomes in clinical research of intervention and rehabilitation approaches for managing fatigue.

Increasing physical activity in multiple sclerosis: Replicating Internet intervention effects using objective and self-report outcomes

Our previous research indicated that an Internet intervention was effective in increasing self-reported physical activity in persons with multiple sclerosis (MS). The present study examined the efficacy of the same Internet intervention in persons with MS by using both objective and self-report measures of physical activity. Participants (N = 21) wore an accelerometer around the waist for 7 days and then completed the International Physical Activity Questionnaire (IPAQ) and Godin Leisure-Time Exercise Questionnaire (GLTEQ) before and after receiving the 12-week Internet intervention. The Internet intervention resulted in moderate increases in accelerometer activity counts (d = 0.68) and steps counts (d = 0.60), and this was paralleled by small increases in IPAQ (d = 0.43) and GLTEQ (d = 0.34) scores. The number of weeks that persons logged on was correlated with change in accelerometer activity counts (r = 0.42) and step counts (r = 0.37) but not change in IPAQ (r = 0.10) or GLTEQ (r = 0.08) scores. The novel contribution of this study was the observation that an Internet intervention was efficacious for increasing physical activity in persons with MS by using both objective and self-report measures.

The reliability, precision and clinically meaningful change of walking assessments in multiple sclerosis

Background: Assessing walking impairment in those with multiple sclerosis (MS) is common, however little is known about the reliability, precision and clinically important change of walking outcomes. Objective: The purpose of this study was to determine the reliability, precision and clinically important change of the Timed 25-Foot Walk (T25FW), Six-Minute Walk (6MW), Multiple Sclerosis Walking Scale-12 (MSWS-12) and accelerometry. Methods: Data were collected from 82 persons with MS at two time points, six months apart. Analyses were undertaken for the whole sample and stratified based on disability level and usage of walking aids. Intraclass correlation coefficient (ICC) analyses established reliability: standard error of measurement (SEM) and coefficient of variation (CV) determined precision; and minimal detectable change (MDC) defined clinically important change. Results: All outcome measures were reliable with precision and MDC varying between measures in the whole sample: T25FW: ICC=0.991; SEM=1 s; CV=6.2%; MDC=2.7 s (36%), 6MW: ICC=0.959; SEM=32 m; CV=6.2%; MDC=88 m (20%), MSWS-12: ICC=0.927; SEM=8; CV=27%; MDC=22 (53%), accelerometry counts/day: ICC=0.883; SEM=28450; CV=17%; MDC=78860 (52%), accelerometry steps/day: ICC=0.907; SEM=726; CV=16%; MDC=2011 (45%). Variation in these estimates was seen based on disability level and walking aid. Conclusion: The reliability of these outcomes is good and falls within acceptable ranges. Precision and clinically important change estimates provide guidelines for interpreting these outcomes in clinical and research settings.

Quantifying gait impairment in multiple sclerosis using GAITRite™ technology

This pilot study investigated the validity of the functional ambulatory profile (FAP) score from the GAITRite electronic pathway in persons with multiple sclerosis (PwMS) who had onset of walking impairment. Thirteen PwMS who had Expanded Disability Status Scale (EDSS) scores of 4.0-6.0 performed four trials on GAITRite™ pathway, and completed a multidimensional walking assessment including performance tests (timed 25 foot walk; T25FW, timed up and go; TUG), self reports of walking ability (Multiple Sclerosis Walking Scale-12; MSWS-12) and function (Late Life Function and Disability Inventory; LL-FDI), and free-living walking behavior (accelerometry). The FAP score correlated strongly with neurological disability (EDSS, ρ=-0.81), walking performance (T25FW, ρ=-0.82; TUG, ρ=-0.88) and self-reported walking function (LL-FDI, ρ=0.81), and moderately with self-reported walking impairment (MSWS-12, ρ=0.49) and free-living walking behavior (accelerometry, ρ=0.52). This suggests that the FAP score is a valid marker of gait impairment in PwMS who have onset of walking impairment.

Combined Training Improves Walking Mobility in Persons With Significant Disability From Multiple Sclerosis: A Pilot Study

Background and Purpose: The disabling consequences of multiple sclerosis (MS) emphasize the significance of developing physiologically relevant strategies for rehabilitation of function. This pilot study examined changes in walking function associated with combined exercise training consisting of aerobic, resistance, and balance activities in persons with MS who had recent onset of gait impairment. Methods: Thirteen participants with significant disability due to MS (Expanded Disability Status Scale range = 4.0–6.0) completed the Multiple Sclerosis Walking Scale–12, 2 trials of the Timed 25-Foot Walk, the Timed Up & Go, and functional ambulation profile score derived from 4 walking trials on an instrumented walkway (GaitRite) before and after an 8-week training period. The training program was designed by a physical therapist and was performed 3 days per week under the supervision of an exercise specialist. In week 1, the session was 15 minutes in duration (ie, 5 minutes of each mode of exercise), session durations were increased by approximately 5 minutes per week up to a maximum of 60 minutes in week 8 (ie, 20 minutes of each mode of exercise). Results: There were significant improvements in Multiple Sclerosis Walking Scale–12 scores (Mpre = 56.0, Mpost = 46.7, P = 0.03, d = 0.56), Timed 25-Foot Walk (Mpre = 11.7, Mpost = 9.8, P = 0.004, d = 0.90) and Timed Up & Go (Mpre = 16.0, Mpost = 13.0, P = 0.01, d = 0.72) performance, and functional ambulation profile score (Mpre = 72.8, Mpost = 77.6, P = 0.02, d = 0.65). Discussion and Conclusion: These results suggest that a moderately intense, comprehensive, combined exercise training program represents a rehabilitation strategy that is associated with improved walking mobility in a small sample of persons with MS who have recent onset of gait impairment.

Accelerometry and Its Association With Objective Markers of Walking Limitations in Ambulatory Adults With Multiple Sclerosis

OBJECTIVE To validate accelerometry based on its correlations with 6-minute walk distance (6MWD) and oxygen cost of walking as objective markers of walking limitations in multiple sclerosis (MS). DESIGN Cross-sectional. SETTING Laboratory and general community. PARTICIPANTS Ambulatory participants with MS (N=26) who resided in the local community. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Patient Determined Disease Steps (PDDS) scale and Multiple Sclerosis Walking Scale-12 (MSWS-12); 6-minute walk test while wearing a portable metabolic unit for measuring the 6MWD and oxygen cost of walking; accelerometer during the waking hours of a 7-day period. RESULTS The average of total daily movement counts from the accelerometer correlated significantly and strongly with MSWS-12 scores (ρ=-.681, P=.001), PDDS scores (ρ=-.609, P=.001), 6MWD (ρ=.519, P=.003), and oxygen cost of walking (ρ=-.541, P=.002). CONCLUSIONS We provide evidence that further supports the validity of accelerometry as a measure of walking limitations in ambulatory persons with MS.