See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/38079875

The perceived benefits and barriers to exercise participation in persons with

multiple sclerosis

Article in Disability and Rehabilitation · December 2009

DOI: 10.3109/09638280902980928 · Source: PubMed

CITATIONS READS

125 854

3 authors, including:

Surendran Sabapathy
Griffith University
148 PUBLICATIONS 2,690 CITATIONS

SEE PROFILE

All content following this page was uploaded by Clare Minahan on 23 October 2015.

The user has requested enhancement of the downloaded file.

This article was downloaded by: [Stroud, Nicole]
On: 17 December 2009
Access details: Access Details: [subscription number 917932884]
Publisher Informa Healthcare
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-
41 Mortimer Street, London W1T 3JH, UK

Disability & Rehabilitation

Publication details, including instructions for authors and subscription information:
http://www.informaworld.com/smpp/title~content=t713723807

The perceived benefits and barriers to exercise participation in persons

with multiple sclerosis
Nicole Stroud a; Clare Minahan a; Surendran Sabapathy a
a
School of Physiotherapy and Exercise Science, Griffith University, Gold Coast, Australia

Online publication date: 17 December 2009

To cite this Article Stroud, Nicole, Minahan, Clare and Sabapathy, Surendran(2009) 'The perceived benefits and barriers to
exercise participation in persons with multiple sclerosis', Disability & Rehabilitation, 31: 26, 2216 — 2222
To link to this Article: DOI: 10.3109/09638280902980928
URL: http://dx.doi.org/10.3109/09638280902980928

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf

This article may be used for research, teaching and private study purposes. Any substantial or
systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or
distribution in any form to anyone is expressly forbidden.

The publisher does not give any warranty express or implied or make any representation that the contents
will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses
should be independently verified with primary sources. The publisher shall not be liable for any loss,
actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly
or indirectly in connection with or arising out of the use of this material.
 Disability and Rehabilitation, 2009; 31(26): 2216–2222

RESEARCH PAPER

The perceived benefits and barriers to exercise participation in persons

with multiple sclerosis

NICOLE STROUD, CLARE MINAHAN & SURENDRAN SABAPATHY

School of Physiotherapy and Exercise Science, Griffith University, Gold Coast, Australia

Accepted April 2009

Downloaded By: [Stroud, Nicole] At: 22:43 17 December 2009

Abstract
Purpose. The purpose of this study was to examine the perceived benefits and barriers to exercise participation in persons
with multiple sclerosis (MS).
Method. A cross-sectional postal survey comprised of 93 adults with MS was conducted. Participants completed the
Exercise Benefits and Barriers Scale (EBBS), Spinal Cord Injury Exercise Self-Efficacy Scale (EXSE), Multiple Sclerosis
Impact Scale, Disease Steps Scale and International Physical Activity Questionnaire.
Results. Forty-three percent of the participants were classified as exercising individuals (EX group) as compared with non-
exercising individuals (non-EX group). Participants in the EX group reported significantly higher scores on the EBBS and
EXSE. Items related to physical performance and personal accomplishment were cited as the greatest perceived benefits to
exercise participation and those items related to physical exertion as the greatest perceived barriers to both the EX and non-
EX groups.
Conclusion. When compared with previous studies conducted in the general population, the participants in the present
study reported different perceived barriers to exercise participation. Furthermore, awareness of the benefits of physical
activity is not sufficient to promote exercise participation in persons with MS. Perceived exercise self-efficacy is shown to play
an important role in promoting exercise participation in persons with MS.

Keywords: Multiple sclerosis, exercise, self-efficacy, health promotion

Introduction benefits and barriers of exercise participation in

persons with MS. Currently, only a few studies
Despite continual research, there is no cure for have investigated the determinants of physical
multiple sclerosis (MS), and pharmacological inter- activity in persons with MS [5–7]. These studies
ventions are limited in their ability to manage the have focussed predominately on the influence of self-
disease. Health-promoting activities such as parti- efficacy (perceived ability to complete a specific
cipation in regular physical activity can play an behaviour) on activity levels.
important role in the management of MS. Exercise Understanding the benefits and barriers that
participation in persons with MS has been asso- encourage and discourage individuals from enga-
ciated with many positive benefits including im- ging in health-promoting activities may be facili-
provements in muscular strength [1], and tated by the health promotion model [8]. The
reductions in feelings of fatigue [1,2] and depres- health promotion model is based on constructs of
sion [3]. However, investigations have suggested the social learning and expectancy-value theory [8],
that persons with MS are less physically active than and identifies variables (prior related behaviour,
the general healthy population [4]. In order to personal factors, perceived benefits to action,
establish effective intervention programmes that perceived barriers to action, perceived self-efficacy,
encourage regular physical activity in persons with activity-related affect, interpersonal influences
MS, it is important to identify the perceived and situational influences) that may influence the

Correspondence: Nicole Stroud, School of Physiotherapy and Exercise Science, Griffith University, Gold Coast Campus, Queens land, 4222, Australia.
E-mail: [email protected]
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa UK Ltd.
DOI: 10.3109/09638280902980928
 Perceived benefits and barriers to exercise in MS 2217

likeliness of an individual to engage in health- Participants

promoting behaviours. The three variables
from the health promotion model which are of The results of this study include the responses of
particular interest, due to their ability to be 17 men and 76 women with MS, aged 27–65 year.
modified, are perceived benefits of action, The male:female participant ratio in this study
perceived barriers to action and perceived self- (1:4) is similar to the male:female ratio of persons
efficacy [8]. with MS reported in the general population (1:3)
This study utilised the Exercise Benefits/Barriers [9]. Participants were categorised into an exercising
Scale (EBBS) [9] to investigate the perceived (EX group) or non-exercising (non-EX group)
benefits and barriers to exercise participation, and based on the results of the international physical
the Spinal Cord Injury Exercise Self-Efficacy Scale activity questionnaire (IPAQ). Clinical character-
(EXSE) [10] as a measure of exercise self-efficacy. It istics including disease severity, disease course,
is reported that physically active individuals in the years since MS diagnosis, heat sensitivity and
general population report greater perceived benefits Uthoffs phenomenon (increase or onset of symp-
and fewer perceived barriers to exercise [11,12]. toms following physical activity) were recorded
Furthermore, a relationship between self-efficacy based on participant responses to a background
and activity levels in persons with MS has previously information questionnaire, and are presented in
been observed [6–8]. Together with these previous Table I.
findings [6–8,11,12] and the observation of specific
Downloaded By: [Stroud, Nicole] At: 22:43 17 December 2009

symptoms experienced by persons with MS, we

hypothesised that (1) persons with MS will report Questionnaires
different perceived benefits and barriers to exercise
compared with those reported previously for the Several questionnaires were used in this study; a
general population, (2) persons with MS who background information questionnaire, Disease
regularly participate in physical activity will report Steps Scale, Multiple Sclerosis Impact Scale, IPAQ,
greater benefits and fewer barriers to exercise
participation than persons with MS who do not Table I. Participant clinical characteristics.
regularly participate in physical activity and (3)
persons with MS who regularly exercise will report Exercising Total MS
higher exercise self-efficacy scores than persons with group Non-exercising sample
(n ¼ 42) group (n ¼ 51) (n ¼ 93)
MS who do not participate in regular physical
activity. MS course (%)*
Relapsing-remitting 55 59 58
Secondary-progressive 26 10 18
Primary-progressive 2 20 11
Methods
Progressive-relapsing 0 2 1.0
Unknown 17 10 13
General procedures Disease duration 12 + 8 11 + 9 12 + 9
(year + SD)
Three hundred adult men and women aged 18–65 Disease steps score (%)
Zero 17 8 13
years were randomly selected from 1000 indivi-
One 29 31 30
duals living in South-East Queensland who are Two 14 12 13
registered with the multiple sclerosis society of Three 10 10 10
Queensland. An additional 118 patients listed in Four 14. 16 14
the MS patient database at the Gold Coast Five 12 14 12
Six 5 10 8
Hospital, Queensland, Australia were posted a ‘call
MSIS-29 (+ SD) 59 + 18** 74 + 23 67 + 22
for participants’ mail out. Of the 418 patients Heat sensitive (%)
invited to participate in the study, 130 (31%) Yes 90 94 92
returned the questionnaires. Thirty-five returned No 5 4 5
questionnaires were not used due to incomplete Unsure 5 2 6
Uhthoffs phenomenon (%)
responses, and two participants were excluded
Yes 64 57 61
because they indicated that their reported activity No 26 20 24
level for the previous week was not indicative of Unsure 10 24 15
their normal physical activity levels. Once the
MSIS-29, multiple sclerosis impact scale.
questionnaires had been returned, data were
*Exercising group significantly different to non-exercising group,
collated and analysed. Ethical approval for this p 5 0.05.
study was obtained from the Griffith University **Exercising group significantly different to non-exercising group,
Human Ethics Research Committee. p 5 0.001.
 2218 N. Stroud et al.

EXSE and EBBS. The background information To obtain a total physical activity score, scores
questionnaire was used to obtain information on reported in the four domains: transportation, work,
demographic and disease characteristics including domestic-garden and leisure are summed. A higher
sex, age, year of MS diagnosis and disease course. score indicates a greater amount of physical activity
Disease severity was classified using the Disease performed. Individuals in this study were cate-
Steps Scale [10] and Multiple Sclerosis Impact Scale gorised into the EX group if they reported
[11]. The Disease Step Scale asks the participants to completing at least two, 30-min exercise sessions
indicate what characteristics best represent their per week during their leisure time or if their
situation and is scored on an ordinal scale between physical activity score in the leisure domain of the
0 and 6. A score of 0 ¼ normal; 1 ¼ mild disability, IPAQ was greater than 600 MET-minute per week
mild symptoms or signs; 2 ¼ moderate disability, [16]. Individuals who did not complete at least two,
visible abnormality of gait; 3 ¼ early cane, intermit- 30-min exercise sessions per week were categorised
tent use of a cane; 4 ¼ late cane, cane dependant; into non-EX group. The questionnaire asks indivi-
5 ¼ bilateral support; 6 ¼ confined to a wheelchair. duals to indicate whether the data reported are
Although the Disease Step Scale is a self-adminis- representative of their usual physical activity levels.
tered questionnaire, it has been found to correlate If data were not representative of a participant’s
significantly with the Expanded Disability Score (a usual physical activity levels, the participant was
neurologist assessed measure of disease severity) and excluded from analysis (n ¼ 2).
is recommended as an alternate measure of disability Exercise self-efficacy, an individual’s judgement
Downloaded By: [Stroud, Nicole] At: 22:43 17 December 2009

status in MS [12]. of their ability to complete a specific behaviour [17],

The Multiple Sclerosis Impact Scale is a 29- was assessed using the EXSE. The EXSE is a 10-
itemed questionnaire that assesses an individual’s item questionnaire that uses a 4-point Likert scale
view of how their MS has impacted upon their scoring system. Higher scores are indicative of
daily functioning during the previous 2 weeks. higher perceived exercise self-efficacy. The EXSE
Participants were asked to indicate how much their is reported to be a reliable and valid measure of
MS limited their ability to perform a task, or how exercise self-efficacy in patients with spinal cord
much they were bothered by a specific symptom. injury [18].
The Multiple Sclerosis Impact Scale has been Participant’s assessment of the possible gains
found to be a reliable and valid measure of disease associated with exercise participation, and the
impact, and is suggested to be a useful and obstacles which would prevent them from engaging
responsive outcome measure in clinical research in physical activity were assessed using the EBBS.
[11,13,14]. The EBBS is a 43-item questionnaire that also
Physical activity levels were assessed using the utilises a 4-point Likert scale. The EBBS produces
results of the IPAQ. This questionnaire quantifies two scores: an EBBS benefits scale score and EBBS
physical activity performed by the individual in the barriers scale score. Higher scores on the EBBS
preceding 7 days. Subjects are scored based on the benefits scale indicates higher perceived benefits of
number of days per week, and duration of time per physical activity, whereas higher scores on the EBBS
day spent undertaking vigorous, moderate and barrier scale indicates lower perceived barriers to
walking activities in four domains (transportation, physical activity. Questions in the EBBS benefits
work, domestic-garden and leisure). scale are grouped into five categories: (1) life
The IPAQ score is reported in metabolic equiva- enhancement, (2) physical performance, (3) psycho-
lents (MET)-minute per week. One MET is defined logical outlook, (4) social interaction and (5)
as the energy spent sitting quietly and is equivalent to preventive health. Questions in the EBBS barriers
4.184 kJ kg71 h71[15]. On the basis of known scale are grouped into four categories: (1) exercise
values, different exercise intensities are assigned milieu, (2) time expenditure, (3) physical exertion
different MET values. In the IPAQ, time spent and (4) family encouragement.
completing walking activities are multiplied by 3.3, According to Sechrist et al. [19], the EBBS have
moderate activities by 4.0 and vigorous activities by good internal consistency with a Cronbach a
8.0. To calculate MET-minute per week in each of coefficient of 0.953 and 0.866 reported for the EBBS
the four domains, number of days per week an Benefits and EBBS Barrier Scales, respectively. In
activity is performed is multiplied by minutes per day the current study, a Cronbach a coefficient of 0.956
the activity is completed for, which is then multiplied for the EBBS Benefit Scale and 0.826 for the EBBS
by its respective MET value (3.3 for walking barrier scale was observed. Missing data from the
activities, 4.0 for moderate activities and 8.0 for questionnaire were handled according to the recom-
vigorous activities) [16]. Walking, moderate and mendations of Sechrist et al. [19]; if greater than 2
vigorous MET-minute per week scores are then items were missing, the subject was excluded from
added together to obtain the score for that domain. analysis (n ¼ 23), if less than 2 item responses were
 Perceived benefits and barriers to exercise in MS 2219

unanswered (n ¼ 32) the median score for that item 10%), and a greater percentage of individuals in
was utilised. the non-EX group had primary progressive MS (20%
vs. 2%).

Data analysis
Exercise self-efficacy and perceived benefits and barriers to
Data were analysed using the statistical software exercise participation
package SPSS version 15.0. Independent t tests
between participants in the EX group and non-EX The EBBS benefits and barriers, and EXSE scores of
group were performed for age, years since MS the participants are presented in Table III. The EX
diagnosis, Multiple Sclerosis Impact Scale, EXSE, group scored significantly higher on both the EBBS
EBBS Benefits Scale and EBBS Barriers Scale. A benefits (t ¼ 3.83, p 5 0.001) and barriers score
chi-square analysis was performed between the two (t ¼ 2.37, p ¼ 0.02), and the EXSE score (t ¼ 3.39,
groups for sex, type of residence, disease course, p ¼ 0.001), when compared with the non-EX group.
disease severity, heat sensitivity and the presence of The EBBS categories found to be significantly
Uhthoffs phenomenon. different between the two groups were life enhance-
ment, physical performance, psychological outlook,
social interaction and physical exertion (Table IV).
Results The highest mean scores (highest agreement) on
Downloaded By: [Stroud, Nicole] At: 22:43 17 December 2009

the EBBS benefit items for both the EX group and

Demographic and clinical characteristics of the non-EX groups were related to physical performance
participants and sense of personal accomplishment. A ranked list
of the top five benefit statement scores are presented
Forty-two of the 93 (45%) participants completed at in Table V. The lowest mean scores (highest
least two, 30-min exercise sessions per week or had a agreement) on the EBBS barrier items for both
physical activity score in the leisure domain of the
IPAQ that was greater than 600 MET-minute per
week. Selected demographic and clinical variables
are presented in Tables I and II. No significant Table III. Exercise benefits, barriers and self-efficacy scores.
differences in sex, age, years since MS diagnosis, Exercising Non-exercising Total MS
disease severity, type of residence, heat sensitivity or group group sample
the presence of Uhthoffs phenomenon were (n ¼ 42) (n ¼ 51) (n ¼ 93)
observed between the EX group and non-EX group.
EBBS benefits score 92 + 12** 83 + 12 87 + 13
Individuals in the EX group reported significantly
EBBS barriers score 40 + 5* 37 + 6 39 + 6
lower scores compared with the non-EX group on EXSE 31 + 6** 27 + 5 29 + 6
the multiple sclerosis impact scale (t ¼ 73.29,
p ¼ 0.001), and a chi-square analysis revealed sig- EBBS, exercise benefits and barriers scale; EXSE, spinal cord
injury exercise self-efficacy scale.
nificant differences in MS course (w2 (4,
*Exercising group significantly different to non-exercising group,
n ¼ 93) ¼ 11.11, p ¼ 0.025) between the two groups. p 5 0.05.
The percentage distribution of participants with **Exercising group significantly different to non-exercising group,
relapsing–remitting MS was similar between EX p 5 0.001.
group and non-EX group (55% vs. 59%). However,
a greater percentage of individuals in the EX
group had secondary progressive MS (26% vs. Table IV. Exercise benefit and barrier categories significantly
different between individuals in the exercising and non-exercising
groups.

Table II. Participant demographic characteristics. Exercising Non-exercising

group (n ¼ 42) group (n ¼ 51)
Exercising Non-exercising Total MS
group group sample Life enhancement 34 + 5** 31 + 6
(n ¼ 42) (n ¼ 51) (n ¼ 93) Physical performance 30 + 4** 28 + 4
Psychological outlook 24 + 3** 21 + 4
Age (year + SD) 50 + 10 50 + 11 50 + 10 Social interaction 11 + 2** 9+2
Sex (% male) 21 16 18 Physical exertion 7 + 2* 6+2
Type of residence (%)
City 12 6 9 *Exercising group significantly different to non-exercising group,
Suburb 71 73 72 p 5 0.05.
Rural 17 22 19 **Exercising group significantly different to non-exercising group,
p 5 0.001.
 2220 N. Stroud et al.

Table V. Top five ranked perceived benefits to exercise in persons with multiple sclerosis.

Exercising group Non-exercising group

Statement Mean SD Statement Mean SD

Exercise gives me a sense 3.57 0.51 Exercise improves functioning 3.27 0.49
of personal accomplishment of my cardiovascular system
Exercise increases my 3.55 0.50 Exercise increases my 3.24 0.51
muscle strength muscle strength
Exercise increases my level 3.55 0.50 Exercise increases my level 3.20 0.60
of physical fitness of physical fitness
Exercise improves 3.55 0.58 Exercise gives me a sense 3.18 0.55
functioning of my of personal accomplishment
cardiovascular system
My muscle tone is 3.47 0.55 My muscle tone is improved 3.16 0.58
improved with exercise with exercise

Table VI. Top five ranked perceived barriers to exercise in persons with multiple sclerosis.

Exercising group Non-exercising group

Downloaded By: [Stroud, Nicole] At: 22:43 17 December 2009

Statement Mean SD Statement Mean SD

Exercise tires me 2.07 0.71 Exercise tires me 1.82 0.74

I am fatigued by exercise 2.19 0.71 I am fatigued by exercise 1.84 0.67
Exercise is hard work for me 2.24 0.73 Exercise is hard work for me 1.92 0.82
There are too few places for me to exercise 2.76 0.79 Places for me to exercise are too far away 2.63 0.92
Exercise facilities do not have convenient schedules for me 2.81 0.74 There are too few places for me to exercise 2.69 0.79

The EBBS barriers scale is reverse scored, therefore the items with the lowest mean represent highest agreement.

groups were those items relating to physical exertion in this study were those items related to physical
and access to exercise facilities. Table VI presents a exertion (e.g. ‘exercise tires me’, ‘I am fatigued by
ranked list of the top five barrier statements. exercise’ and ‘exercise is hard work for me’). As with
the high-ranked benefit items, these perceived
barriers to exercise were similar irrespective of
Discussion current physical activity levels (EX group vs. non-
EX group). This suggests that even persons with MS
In the present study, the most highly rated who regularly exercise need to overcome issues
perceived benefits to exercise participation were related to physical exertion when undertaking
those items related to improvements in physical physical activity.
performance and health, as well as experiencing a When the top-ranked perceived benefits and
sense of personal accomplishment. Perceived ben- barriers in the participants of this study are
efits of action refer to the individual’s assessment of compared with those reported in healthy popula-
the possible gains associated with engaging in a tions [21,22], it appears that, like the general
particular health-promoting behaviour [20]. As healthy population, persons with MS are aware that
these perceived benefits to exercise were ranked regular exercise participation will improve physical
highest in both the EX group and non-EX group, it performance. Additionally, the subjects in this study
suggests that although important, simply being also reported that a perceived benefit to exercise
aware of the positive benefits associated with would be that exercise will provide a sense of
exercise participation is not sufficient to facilitate personal accomplishment. It could be speculated
participation in regular physical activity in persons that due to the physical impairments and fatigue
with MS. commonly experienced by persons with MS, in-
Perceived barriers to action provide information dividuals with this disease may perceived exercise to
about an individual’s assessment of the potential be a greater challenge than individuals in the
obstacles which prevent the individual from engaging general population.
in a health-promoting behaviour [20]. The most In the general population, time is the most
highly ranked perceived barriers to exercise reported common reported barrier to exercise [21,22],
 Perceived benefits and barriers to exercise in MS 2221

whereas participants in this study reported factors health promoting behaviours such as exercise
relating to physical exertion as the greatest barrier to participation [5–7,30]. The results of the present
exercise participation. This physical exertion may be study support these findings. We found that exercise
the result of physical limitations including mobility self-efficacy was significantly greater in those parti-
and gait impairments, muscle weakness and balance cipants in the EX group. This may explain why
deficits or the onset of symptoms and fatigue participants in the EX group did not perceive the
following physical activity [23–25]. These results barriers to exercise to be as great as those in the non-
highlight the need for health care professionals to EX group. Thus, strategies that improve exercise
develop and implement exercise intervention pro- self-efficacy in persons with MS may play a key role
grammes that minimise or enable persons with MS in promoting exercise participation in individuals
to overcome the difficulties associated with exercise, with this disease.
in particular those elements associated with physical This study has a few limitations that need to be
exertion. Several exercise intervention studies have considered when interpreting the results of this
reported improvements in chronic fatigue levels in study. First, physical activity levels and health
persons with MS [26]. Therefore, it is possible that indicators such as disease severity and course were
an increased awareness of the benefits of exercise on self-reported and were not assessed by a neurologist.
fatigue levels may minimise this perceived barrier to Because of the variability and changing course of
exercise and facilitate participation in physical MS, it is possible that some participants may have
activity, especially when fatigue is one of the most incorrectly identified their disease course and sever-
Downloaded By: [Stroud, Nicole] At: 22:43 17 December 2009

common symptoms reported in persons with MS ity. Additionally, this study only had a response rate
[27,28]. of 31% which is considerably lower than two
Although participants in both the EX group and previous postal surveys related to physical activity
non-EX group reported a similar ranked list of in persons with MS. These two previous studies
perceived benefits and barriers to exercise, the EBBS reported response rates of 90% and 64% [31,32].
scores were significantly different between the two The low response rate in the present study may have
groups. The EX group reported that regular exercise lead to overestimating physical activity levels in
participation was more beneficial in the following persons with MS, as health-conscious individuals
EBBS benefit categories: life enhancement, physical may have been more inclined to participate in the
performance, psychological outlook and social inter- study. Because of the relatively small number of
action. The non-EX group rated those items in the participants with progressive forms of MS in this
physical exertion category as a greater barrier to study, the results of this study may not accurately
exercise participation. represent individuals with all types of MS. Further-
Given the difference in these EBBS scores, and the more, due to the cross-sectional nature of the current
finding that there were no significant differences in study no causal relationships can be implied.
disease severity between the two groups in this study, In conclusion, the findings of this study suggest
we need to ask the question why some persons with that in order to facilitate exercise participation in this
MS exercise and others do not? Do participants in clinical population, strategies that minimise physical
the EX group, exercise simply because they have exertion need to be addressed. Although recent
stronger views about the benefits of regular exercise, studies suggest that regular physical activity may
and/or perceive the barriers to exercise to be not as improve functional ability and decrease fatigue in
great? Or is there another influencing factor that persons with MS [33,34], research investigating the
prevents some persons with MS from participating in mode of physical activities that can provide persons
regular physical activity? with MS both physical and psychological benefit, and
The exercise self-efficacy scores reported by the limit side-effects such as exercise-induced fatigue is
participants in this study may help to explain warranted.
exercise status. The health promotion model Persons with MS need to be educated about the
suggests that even when the perceived benefits of different modes of exercise training that are available
an activity are high and perceived barriers low, an and how exercises can be modified to accommodate
individual may not engage in an activity if perceived their physical abilities and symptoms. We believe
self-efficacy is low. Perceived self-efficacy refers to that persons with MS also need to be further
an individual’s judgement of their capability to educated about the benefits of exercise, emphasising
perform a specific behaviour successfully [29]. that regular exercise has the potential to improve
Individuals tend to undertake activities they feel chronic fatigue levels. Addressing and overcoming
they are capable of performing and avoid those tasks the barriers to exercise participation for persons with
which they believe exceed their capabilities [17]. MS may lead to improvements in exercise self-
Previous studies in persons with MS suggest that efficacy, and subsequently improve exercise partici-
there is a relationship between self-efficacy and pation rates.
 2222 N. Stroud et al.

Declaration of interest: The authors report no 16. Sjostrom M, Ainsworth B, Bauman A, Bull A, Craig C, Sallis
conflicts of interest. The authors alone are respon- J. Guidelines for data processing and analysis of the
international physical activity questionnaire (IPAQ) – short
sible for the content and writing of the article. and long forms. Internet. 2005. Electronic Citation. http://
www.ipaq.ki.se/ipaq.htm. Last accessed 5 January 2008.
17. Bandura A. Self-efficacy: towards a unifying theory of
References behavioural change. Psychol Rev 1977;84:191–215.
18. Kroll T, Kehn M, Ho PS, Groah S. The SCI Exercise Self-
1. White LJ, McCoy SC, Castellano V, Gutierrez G, Stevens JE, Efficacy Scale (ESES): development and psychometric prop-
Walter GA, Vandenborne K. Resistance training improves erties. Int J Behav Nutr Phys Act 2007;4:34.
strength and functional capacity in persons with multiple 19. Sechrist KR, Walker SN, Pender NJ. Development and
sclerosis. Mult Scler 2004;10:668–674. psychometric evaluation of the exercise benefits/barriers scale.
2. Gutierrez GM, Chow JW, Tillman MD, McCoy SC, Res Nurs Health 1987;10:357–365.
Castellano V, White LJ. Resistance training improves gait 20. Brown SA. Measuring perceived benefits and perceived
kinematics in persons with multiple sclerosis. Arch Phys Med barriers for physical activity. Am J Health Behav 2005;29:
Rehabil 2005;86:1824–1829. 107–116.
3. Tesar N, Baumhackl U, Kopp M, Gunther V. Effects of 21. Zunft HJ, Friebe D, Seppelt B, Widhalm K, Remaut de
psychological group therapy in patients with multiple sclerosis. Winter AM, Vaz de Almeida MD, Kearney JM, Gibney M.
Acta Neurol Scand 2003;107:394–399. Perceived benefits and barriers to physical activity in a
4. Nortvedt M, Riise T, Maeland J. Multiple sclerosis and nationally representative sample in the European Union.
lifestyle factors: the Hordaland Health Study. Neurol Sci Public Health Nutr 1999;2:153–160.
2005;26:334–339. 22. Booth ML, Bauman A, Owen N, Gore CJ. Physical activity
5. Morris KS, McAuley E, Motl RW. Self-efficacy and environ- preferences, preferred sources of assistance, and perceived
Downloaded By: [Stroud, Nicole] At: 22:43 17 December 2009

mental correlates of physical activity among older women and barriers to increased activity among physically inactive
women with multiple sclerosis. Health Educ Res 2008;23: Australians. Prev Med 1997;26:131–137.
744–752. 23. Martin CL, Phillips BA, Kilpatrick TJ, Butzkueven H,
6. Snook EM, Motl RW. Physical activity behaviors in indivi- Tubridy N, McDonald E, Galea MP. Gait and balance
duals with multiple sclerosis: roles of overall and specific impairment in early multiple sclerosis in the absence of clinical
symptoms, and self-efficacy. J Pain Symptom Manage 2008; disability. Mult Scler 2006;12:620–628.
36:46–53. 24. Soyuer F, Mirza M, Erkorkmaz U. Balance performance in
7. Motl RW, Snook EM, McAuley E, Gliottoni RC. Symptoms, three forms of multiple sclerosis. Neurol Res 2006;28:555–
self-efficacy, and physical activity among individuals with 562.
multiple sclerosis. Res Nurs Health 2006;29:597–606. 25. Iriarte J, Subira ML, Castro P. Modalities of fatigue in
8. Pender NJ, Murdaugh CL, Parsons M. Health promotion in multiple sclerosis: correlation with clinical and biological
nursing practice, 5th ed. New Jersey: Pearson Education Inc; factors. Mult Scler 2000;6:124–130.
2006. 26. McCullagh R, Fitzgerald AP, Murphy RP, Cooke G. Long-
9. Orton SM, Herrera BM, Yee IM, Valdar W, Ramagopalan term benefits of exercising on quality of life and fatigue in
SV, Sadovnick AD, Ebers GC; Canadian Collaborative Study multiple sclerosis patients with mild disability: a pilot study.
Group. Sex ratio of multiple sclerosis in Canada: a long- Clin Rehabil 2008;22:206–214.
itudinal study. Lancet Neurol 2006;5:932–936. 27. Wynia K, Middel B, van Dijk JP, De Keyser JH, Reijneveld
10. Hohol MJ, Orav EJ, Weiner HL. Disease steps in multiple SA. The impact of disabilities on quality of life in people with
sclerosis: a simple approach to evaluate disease progression. multiple sclerosis. Mult Scler 2008;14:972–980.
Neurology 1995;45:251–255. 28. Vazirinejad R, Lilley J, Ward C. A health profile of adults with
11. Hobart J, Lamping D, Fitzpatrick R, Riazi A, Thompson A. multiple sclerosis living in the community. Mult Scler
The Multiple Sclerosis Impact Scale (MSIS-29): a new 2008;14:1099–1105.
patient-based outcome measure. Brain 2001;124(Part 5): 29. Bandura A. Social foundations of thought and action. A social
962–973. cognitive theory. New Jersey: Prentice-Hall Inc; 1986.
12. Hohol MJ, Orav EJ, Weiner HL. Disease steps in multiple 30. Motl RW, Snook EM. Physical activity, self-efficacy, and
sclerosis: a longitudinal study comparing disease steps and quality of life in multiple sclerosis. Ann Behav Med
EDSS to evaluate disease progression. Mult Scler 1999;5: 2008;35:111–115.
349–354. 31. Turner AP, Kivlahan DR, Haselkorn JK. Exercise and quality
13. Hoogervorst EL, Zwemmer JN, Jelles B, Polman CH, of life among people with multiple sclerosis: looking beyond
Uitdehaag BM. Multiple sclerosis impact scale (MSIS-29): physical functioning to mental health and participation in life.
relation to established measures of impairment and disability. Arch Phys Med Rehabil 2009;90:420–428.
Mult Scler 2004;10:569–574. 32. Paltamaa J, Sarasoja T, Wikstrom J, Malkia E. Physical
14. McGuigan C, Hutchinson M. The multiple sclerosis impact functioning in multiple sclerosis: a population-based study in
scale (MSIS-29) is a reliable and sensitive measure. J Neurol central Finland. J Rehabil Med 2006;38:339–345.
Neurosurg Psychiatry 2004;75:266–269. 33. Snook EM, Motl RW. Effect of exercise training on walking
15. Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz mobility in multiple sclerosis: a meta-analysis. Neurorehabil
AM, Strath SJ, O’Brien WL, Bassett DR Jr., Schmitz KH, Neural Repair 2009;23:108–116.
Emplaincourt PO, Jacobs DR Jr., Leon AS. Compendium of 34. Smith C, Hale L, Olson K, Schneiders AG. How does
physical activities: an update of activity codes and MET inten- exercise influence fatigue in people with multiple sclerosis?
sities. Med Sci Sports Exerc 2000;32(9 Suppl):S498–S504. Disabil Rehabil 2008;1–8.

View publication stats