Research Report

Physical Activity Behavior of People

With Multiple Sclerosis:
Understanding How They Can
H. Beckerman, PT, PhD, is Senior
Become More Physically Active Researcher, Department of Reha-
bilitation Medicine, VU University

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Heleen Beckerman, Vincent de Groot, Maarten A. Scholten, Jiska C.E. Kempen, Medical Center, PO Box 7057,
Gustaaf J. Lankhorst 1007 MB Amsterdam, the Nether-
lands, and EMGO Institute for
Health and Care Research, VU
University and VU University
Background. People with multiple sclerosis (MS) are less physically active than Medical Center, Amsterdam, the
those without the disease. Understanding the modifiable factors that are related to Netherlands. Address all corre-
physical inactivity is important for developing effective physical activity programs. spondence to Dr Beckerman at:
[email protected].
Objective. The objectives of this study were to determine levels of physical V. de Groot, MD, PhD, is Rehabil-
activity and to determine factors related to the physical activity behavior of adults itation Physician and Senior Re-
with MS by use of the Physical Activity for People With a Disability (PAD) model. The searcher, Department of Rehabili-
PAD model combines the International Classification of Functioning, Disability tation Medicine, VU University
Medical Center, and EMGO Insti-
and Health framework of disability and theoretical models of physical activity
tute for Health and Care Research,
behavior. VU University and VU University
Medical Center.
Design. This investigation was a cross-sectional study. M.A. Scholten, MD, was a medical
student, Faculty of Medicine, VU
Methods. The study participants were 106 people who had MS and who, since University Medical Center, at the
their definite diagnosis, had been participating in a prospective cohort study. Physical time of the study.
activity was assessed with the Short Questionnaire to Assess Health-Enhancing Phys- J.C.E. Kempen, PT, MSc, is a PhD
ical Activity. The independent roles of disease characteristics and demographic, candidate, Department of Reha-
cognitive-behavioral, and environmental factors were determined using question- bilitation Medicine, VU University
naires for which reliability and validity have been established. Medical Center, and EMGO Insti-
tute for Health and Care Research,
VU University and VU University
Results. The median total level of physical activity of participants with MS (mean Medical Center.
age⫽42.8 years, median Expanded Disability Status Scale score⫽3, disease dura-
tion⫽6 years) was 10.68 metabolic equivalents ⫻ h/d (interquartile range⫽3.69 – G.J. Lankhorst, MD, PhD, is Reha-
bilitation Physician, Professor, and
16.57). On average, participants spent 30 h/wk on activities with metabolic equiva- Head of the Department, Depart-
lents of 2 or more (interquartile range⫽10.7– 45.0 h/wk). The regression models ment of Rehabilitation Medicine,
predicting physical activity behavior on the basis of demographic (29.4%) and VU University Medical Center, and
disease-related (28.3%) variables explained more variance than the models based on EMGO Institute for Health and
cognitive-behavioral (12.0%) and environmental (9.1%) variables. Combining signifi- Care Research, VU University and
VU University Medical Center.
cant variables yielded a final regression model that explained 37.2% of the variance
in physical activity. Significant determinants were disease severity, a disability pen- [Beckerman H, de Groot V, Schol-
sion, and having children to care for. ten MA, et al. Physical activity be-
havior of people with multiple
sclerosis: understanding how they
Limitations. Changes in physical activity behavior were not measured. can become more physically active.
Phys Ther. 2010;90:1001–1013.]
Conclusions. Participants with MS were less active if their disease was more © 2010 American Physical Therapy
severe, if they received a disability pension, or if they had children to care for. The Association
PAD model was helpful in understanding the physical activity behavior of participants
with MS. Post a Rapid Response to
this article at:
ptjournal.apta.org

July 2010 Volume 90 Number 7 Physical Therapy f 1001

Physical Activity in Multiple Sclerosis

M
ultiple sclerosis (MS) is a population, the benefits and protec- able factors that are related to phys-
chronic, disabling disease of tive effects of a physically active life- ical inactivity is important for devel-
the central nervous system style are well known.8,9 An active oping effective physical activity
that is mainly diagnosed between the lifestyle is accompanied by various promotion programs for patients
ages of 20 and 40 years; its incidence fitness and health benefits: an in- with MS.
is approximately 6 in 100,000 peo- creased life expectancy free of dis-
ple. In addition to the neurological ability, lower risk of chronic diseases The aims of this study were to deter-
symptoms, more than 70% of pa- (eg, coronary artery disease, stroke, mine levels of physical activity and
tients with MS experience fatigue, diabetes mellitus type II, colon can- to determine factors related to the
and 50% to 60% report fatigue as one cer), and unhealthful weight gain, physical activity behavior of adults
of their worst symptoms.1 Fatigue and an increase in the rate of recov- with MS. We used the Physical Activ-
can be so persistent that it leads to ery from disability in people who are ity for People With a Disability (PAD)

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limitations in social functioning, 50 to 80 years of age.10 –12 model as a theoretical framework.21
even in patients with minor neuro- The PAD model combines the frame-
logical deficits. A recent cohort Several clinical trials have assessed work of functioning from the Inter-
study showed that early in the the therapeutic effects of exercise in national Classification of Function-
course of MS, social functioning is people with MS.13–15 There is strong ing, Disability and Health (ICF)
seriously affected, whereas for the evidence in favor of exercise therapy with several theoretical models of
majority of patients with MS, neuro- compared with no exercise therapy, determinants of physical activity be-
logical deficits are minor and physi- but there is no evidence that specific havior (eg, the social cognitive the-
cal functioning is minimally affect- exercise programs are superior to ory, the transtheoretical model, the
ed.2 Fatigue and personality factors others in improving activities and so- health belief model, the protection
were reported to be the most impor- cial functioning. The limited contrast motivation theory, and the theory of
tant determinants of this decrease in among these exercise programs may planned behavior).21–23 All of these
social functioning.3,4 be an important reason why no dif- theories postulate that effective in-
ferences in effectiveness have been terventions that improve physical ac-
The causes of fatigue in people with reported. However, from studies of tivity behavior are due to changes in
MS are largely unknown, but one of people with disabilities, coronary ar- intermediate variables, such as cog-
the assumed causes is reduced aero- tery disease, and chronic obstructive nition, self-efficacy, knowledge, skills,
bic capacity.4 – 6 Petajan et al7 hy- pulmonary disorders, there is evi- current behavior, social support, bal-
pothesized that fatigue leads to a de- dence that high-intensity aerobic in- ance between “pros” and “cons” in
crease in physical activity, which terval training is more effective than decision making, perceived barriers
leads to impaired fitness; the latter, moderately intense aerobic endur- and benefits, and enjoyment. The ICF
in turn, leads to more fatigue. This ance training.16 –18 Although there is framework describes the multidimen-
scenario may be an important reason still much to be learned about the ex- sional aspects of functioning in people
for encouraging physical activity tent to which patients with MS can be with a disability in terms of body
programs in people with MS. Obvi- physically active and about their phys- functions and structures, activities,
ously, other important reasons for iological responses to training, inten- and participation.21–23
regular physical activity are the ex- sive exercise programs do not influ-
pected long-term positive effects on ence the progression of MS or cause Method
health and the prevention of comor- exacerbations.13,14 Participants and Design
bid health problems. In the general This study was part of a long-term
Physical inactivity is a major public prospective follow-up study of func-
health problem, particularly in peo- tional prognosis in an inception co-
Available With ple with disabilities.19 In a meta- hort of 156 patients with a definite
This Article at analysis of 13 studies of 2,360 pa- diagnosis of MS. From 1998 to 2000,
ptjournal.apta.org tients with MS, the cumulative all consecutive adult patients who
evidence suggested that patients had a recent diagnosis (⬍6 months
• The Bottom Line Podcast with MS are less physically active earlier) of MS and who were visiting
• Audio Abstracts Podcast than people without disease.20 Little the outpatient neurology clinics of 5
research has focused on physical ac- participating hospitals were invited
This article was published ahead of
print on May 27, 2010, at tivity behavior and understanding to participate in the study. Patients
ptjournal.apta.org. physical activity levels in patients with comorbid neurological disor-
with MS. Understanding the modifi- ders or systemic or malignant neo-

1002 f Physical Therapy Volume 90 Number 7 July 2010

 Physical Activity in Multiple Sclerosis

plastic diseases at baseline were ex- ing work-related activities, leisure- friends, membership in a patient or-
cluded. Full details of the design of time activities, household activities, ganization, normative beliefs of
the longitudinal study have been re- and means of transportation. Activi- other people, and environmental
ported elsewhere.2 ties with a MET of less than 2 are not barriers. All of these factors were de-
included in the SQUASH. Activity termined with existing reliable and
For the additional study of physical scores (MET ⫻ min/wk) were calcu- valid measurement scales and ques-
activity behavior, 124 patients who lated with the following formula: fre- tionnaires that have been used in
had recently completed 6-year quency (d/wk) ⫻ duration (min/ other physical activity studies.27–39
follow-up measurements were in- d) ⫻ physical intensity (different
vited to complete a mailed question- MET intensity scores). The total ac- As independent variables for demo-
naire. The results of the question- tivity score was calculated as the graphic characteristics we used age,
naire were cross-sectionally sum of the activity scores for sepa- gender, level of education (low, in-

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combined with the scores at the rate questions. A theoretical maxi- termediate, or high), a disability pen-
6-year follow-up after the diagnosis mum activity score has not been sion (none, partial, or full), income
of MS. All patients gave written in- established.25,26 (low, medium, high, or unknown),
formed consent prior to participa- living arrangement (living alone or
tion in the study. Potential determinants of physi- living with others), and having chil-
cal activity. Many personal and en- dren to care for (yes or no).
Measurement Instruments vironmental factors may influence
Physical activity. Physical activ- physical activity behavior.11,21,22 Per- As disease-related factors we used
ity can be defined as a behavior that sonal factors include demographic type of MS onset (relapsing-remitting
involves all large-muscle movements factors; disease-related factors; and or non–relapsing-remitting); scores
for various purposes throughout the cognitive and behavioral factors, on the Expanded Disability Status
day. Metabolic equivalents (METs) such as knowledge of the effects of Scale (EDSS), the Fatigue Severity
are commonly used to express the physical activity on health, attitude Scale (FSS), the Center for Epidemi-
intensity of physical activities.24 The toward physical activity, self- ologic Studies Depression (CES-D)
MET is the ratio of the working met- efficacy, perceived benefits and bar- Scale, and the Cumulative Illness Rat-
abolic rate to the resting metabolic riers, motivation to adhere, and past ing Scale (CIRS); and the EuroQol
rate. One MET is defined as the en- physical activity behavior. Environ- 5-domain index (EQ-5D) utility
ergy cost of sitting quietly and is mental factors include the social in- score.27–32 With the exception of the
equivalent to a caloric consumption fluence of family members and EQ-5D, these disease-related factors
of 1 kcal/kg/h. For adults (up to the
age of 55 years), activities with a
MET ranging from 2 to less than 4,
ranging from 4 to less than 6.5, and The Bottom Line
6.5 or greater are classified as light,
moderate, and vigorously intense, re- What do we already know about this topic?
spectively. For older adults (more
than 55 years of age), activities with People with multiple sclerosis are less physically active than those with-
a MET ranging from 2 to less than 3, out the disease. Modifiable factors that are related to physical inactivity
ranging from 3 to less than 5, and 5 are important for developing effective physical activity programs.
or greater are classified as light, mod-
What new information does this study offer?
erate, and vigorously intense,
respectively.8,9 Three modifiable factors were identified: disease severity, receiving a
disability pension, and having children to care for.
The level of physical activity was as-
sessed with the Short Questionnaire If you’re a patient, what might these findings mean
to Assess Health-Enhancing Physical for you?
Activity (SQUASH).25 The SQUASH is
a self-report questionnaire that asks Patients should try to change their personal circumstances in order to stay
participants to recall their physical physically active, such as finding effective ways to keep their job and
activity during an average week in continue to perform work-related activities, slowing down the disease
the preceding month.25 The progression, and finding support to care for their children.
SQUASH contains questions regard-

July 2010 Volume 90 Number 7 Physical Therapy f 1003

Physical Activity in Multiple Sclerosis

are at the ICF level of body functions and discomfort, and anxiety and de- barriers might reduce their ability to
and structures.22 pression.32 Each domain is scored in engage in physical activity.36
3 categories: no problems, some
The EDSS assesses 7 neurological sys- problems, and serious problems. An The 5-item Exercise Stage of Change
tems (visual/optical, brain stem, py- overall EQ-5D utility score then is Questionnaire was used to assess
ramidal, cerebellar, bowel/bladder, calculated by subtracting from 1 a each participant’s stage of change
mental, and other) and provides in- weighted value for each category. In for regular moderate or vigorous
formation about walking ability, use the present study, we used the physical activity.37 Five stages were
of walking aids, and ability to per- Dutch tariff to calculate the EQ-5D distinguished: precontemplation,
form self-care activities. Scores on utility score.33 Thus, an individual contemplation, preparation, action,
the EDSS range from 0 to 10.27 Lower who has no perceived problems in and maintenance.37 The stage of
scores (0 –3) are calculated with a any domain would have an EQ-5D change can actually be seen as a

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scoring paradigm based on the utility score of 1, indicating a state of combination of physical activity sta-
scores obtained from the neurologi- perfect health. Death results in a util- tus and attitude toward physical
cal systems, intermediate scores ity score of 0. activity.
(3.5– 6) are predominantly based on
walking ability, and higher scores Among cognitive and behavioral fac- The motivation to adhere to the nor-
(6.5–10) are mainly based on the in- tors, self-efficacy was assessed with mative expectations (beliefs) of fam-
ability to perform self-care activities. the 12-item Self-Efficacy for Exercise ily members and friends was mea-
Behavior Scale, which has 2 sub- sured with 5 items. Ten questions
The FSS measures an individual’s per- scales: making time and resisting re- with “yes” or “no” answers were
ceived level of fatigue in a variety of lapse.34 Participants with MS were used to assess the participant’s
situations. Scores on the FSS range asked to indicate how confident they knowledge of the effects of physical
from 0 (lowest possible fatigue were that they could be physically activity on health.38 The past behav-
score) to 7 (highest possible fatigue active in a variety of situations, such ior of participants was assessed with
score), with valid cutoff values of as “making time for my physical ac- 1 question regarding at least 6
less than 4 indicating no fatigue and tivity program.” months of regular physical activity in
of 4 or greater indicating fatigue.28 the past (answered with “yes” or
Attitude toward physical activity is “no”).
The CES-D Scale is a 20-item list that what people think and express
classifies people as having no de- about a physically active lifestyle for Among environmental factors, social
pression (scores of 0 –15) or having themselves. We assessed attitude influence is what other people think
depressive symptoms (scores of with the Physical Activity Enjoyment about a physically active lifestyle for
16 – 60).29,30 Scale, which consists of 18 state- the participant. Social support for
ments (11 positive and 7 negative).35 physical activity was measured sepa-
Comorbidity in addition to MS was After rescaling of the negative state- rately for family members and
measured with the CIRS, which is a ments, possible scores on the Physi- friends with the Support for Exercise
short, physician-rated, comprehen- cal Activity Enjoyment Scale range Habits Scales developed by Sallis
sive, and reliable instrument that can from 18 to 90. et al.39 The participants rated how
be used to assess the burden of often (from 1 [never] to 5 [very of-
chronic medical illness.31 The scale Perceived benefits of a physically ac- ten]) family members and friends
consists of 13 relatively independent tive lifestyle were assessed with a supported them in 13 situations (eg,
categories grouped under body sys- 14-item scale on which participants “. . . performed physical activities
tems. Severity is rated on a 5-point with MS could rate their agreement with me”).
scale, ranging from “none” to “ex- with positive statements about the
tremely severe.” In the present possible effects of regular physical The normative expectations (beliefs)
study, we dichotomized the scores activity (eg, “If I participate in regu- of family members and friends were
into 0 (no comorbidity) and greater lar physical activity, I will feel less measured with 5 items. As described
than or equal to 1 (comorbidity). stressed.”).36 earlier, we also assessed the motiva-
tion of participants to adhere to
The EQ-5D, developed by the Euro- Personal barriers for physical activity these referent norms.
QoL Group, measures perceived were measured with a 17-item ques-
health outcomes in 5 domains: mo- tionnaire on which participants Environmental barriers to physical
bility, self-care, usual activities, pain could indicate how often personal activity were measured with a 14-

1004 f Physical Therapy Volume 90 Number 7 July 2010

 Physical Activity in Multiple Sclerosis

item questionnaire on which partic- Table 1.

ipants could indicate how often cer- Demographic and Disease-Related Characteristics of 106 Participants with Multiple
tain barriers might reduce their Sclerosisa
ability to engage in physical activi- No. of % of
ty.36 Membership in a patient organi- Characteristic Participants Participants
zation also was included in the Demographic
analysis. Age (y)

20–35 31 29.2
Data Analysis
36–50 52 49.1
Most of the instruments that are used
to measure potential cognitive- 51–65 23 21.7

behavioral and environmental deter- Gender

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minants consist of 5-point Likert Male 40 37.7
scales. To make it possible for us to Female 66 62.3
estimate a meaningful total score for
Level of educationb
each measure, 75% of the items had
Low 24 22.9
to be answered. Overall, higher
scores indicated higher self-efficacy, Intermediate 42 40.0

more perceived benefits, more per- High 39 37.1

ceived barriers, more social support, Disability pensionb
and so forth. No 44 42.7

Yes, partial 22 21.4

Because several theoretical models
Yes, full 37 35.9
are combined in the PAD model, in-
cluding many interrelated determi- Income

nants, we used a stepwise analysis Low (⬍1,500 Euros) 56 52.8

approach to explain and understand Medium (1,500–2,500 Euros) 25 23.6
the variance in the total physical ac- High (⬎2,500 Euros) 6 5.7
tivity behavior of our participants, as
Unknown 19 17.9
measured with the SQUASH (in
Living arrangementb
MET ⫻ h/wk). After the univariate
analyses, significant variables (with a Living alone 20 19.2

liberal P value of ⱕ.20) were re- Living with others 84 80.8

tained and tested in 4 subsequent Children to care forb
regression analyses. Collinearity be- No 52 50.0
tween the remaining variables was Yes 52 50.0
checked but did not result in the
Disease related
exclusion of variables for the next
step. For each of the 4 sets of deter- Type of onset

minants, that is, demographic, Relapsing-remitting 88 83.0

disease-related, cognitive-behavioral, Non–relapsing-remitting 18 17.0
and environmental variables, we EDSS b

constructed a multivariate regression

0–3 56 53.3
model; from each of these 4 regres-
3.5–6 40 38.1
sion models, the significant variables
(Pⱕ.05) were further analyzed in the 6.5–10 9 8.6

final regression model. All statistical (Continued)

analyses were performed with SPSS
version 15.0.* Role of the Funding Source lands Organization for Health Re-
This study was carried out as part of search and Development (ZonMw
the FUPRO-MS II project, “Long- Project: 1435.0020). The funding
Term Prognosis of Functional Out- agency had no influence on the de-
* SPSS Inc, 233 S Wacker Dr, Chicago, IL come in Neurological Disorders,” sign, conduct, or reporting of the
60606. and was supported by the Nether- study.

July 2010 Volume 90 Number 7 Physical Therapy f 1005

Physical Activity in Multiple Sclerosis

Table 1. Fifty-five participants engaged in 1 or

Continued more sports activities each week (1
No. of % of
sport, n⫽44; 2 sports, n⫽10; 4
Characteristic Participants Participants sports, n⫽1), of which fitness, swim-
FSSb ming, and gymnastics were the most
popular. On average, 30 min/wk (in-
No fatigue (⬍4) 21 20.2
terquartile range⫽0 –105 min/wk)
Fatigue (ⱖ4) 83 79.8
were spent on sports activities by
CES-D Scaleb the total group (Tab. 2).
No depression (⬍16) 77 74.8

Depressive symptoms (ⱖ16) 26 25.2 According to international guide-

lines for regular physical activity,

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b
CIRS
64% (68/106) of the participants in
No comorbidity (0) 75 71.4
our study were insufficiently physi-
Comorbidity (ⱖ1) 30 28.6
cally active; that is, they were not
a
The EuroQol 5-domain index scores were as follows: median⫽0.78, 25th–75th percentiles⫽0.69 – engaged in moderately intense phys-
0.86. EDSS⫽Expanded Disability Status Scale, FSS⫽Fatigue Severity Scale, CES-D⫽Center for
Epidemiologic Studies Depression, CIRS⫽Cumulative Illness Rating Scale. ical activities (METⱖ4) for at least 30
b
Because of missing values, the total number does not equal 106. minutes on 5 days per week or vig-
orously intense aerobic activities
(METⱖ6.5) for a minimum of 20
minutes on 3 days per week.8
Results Physical Activity
Participant Characteristics The total activity score and domain
Determinants of Physical Activity
Of the 124 participants with MS who scores on the SQUASH are shown in
The demographic and disease-
were invited to participate, 106 Table 2. The median total activity
related characteristics of the partici-
(86%) completed the questionnaire score was 10.68 MET ⫻ h/d (inter-
pants are shown in Table 1. Table 3
on physical activity behavior. The quartile range⫽3.69 –16.57), with a
shows their cognitive-behavioral and
main demographic and disease- minimum of 0 for 6 participants and
environmental characteristics. With
related characteristics of these par- a maximum of 35.86 for 1 highly
respect to the stage of change, 16
ticipants are summarized in Table 1. active participant. The median total
participants (⬃15%) were in the pre-
The 40 men (38%) and 66 women time spent on physical activities
contemplation stage (ie, they were
(62%) had a mean age of 42.7 years (METⱖ2) was 1,815 minutes, or ap-
physically inactive people who did
(SD⫽9.6 years), and more than half proximately 30 h/wk (interquartile
not intend to become active in the
of the participants received a partial range⫽640 –2,700 minutes). Most of
next 6 months), 9 (⬃8.%) were in
or full disability pension. Eighty- this time was spent on activities with
the contemplation stage, and 14
eight participants had a relapsing- a light intensity (MET⫽2– 4), such as
(⬃13%) were in the preparation stage
remitting type of MS onset, and 18 light household activities. Only
(currently but not regularly active).
had a non–relapsing-remitting type 16.5% of the participants performed
On the other hand, 49 participants
of MS onset. The median EDSS score activities with a vigorous intensity
were regularly physically active.
was 3.0 (interquartile range⫽2.0 – (Tab. 2).
However, because of misunderstand-
4.0), although 9 participants had an
ing the instructions or missing val-
EDSS score of 6.5 or higher. All par- Most of the participants reported
ues, the stage of change of 18 partic-
ticipants were living independently that they performed some household
ipants was unknown.
(ie, were not institutionalized). The activities and leisure-time activities,
majority of the participants (⬃80%) such as walking, cycling, gardening,
On the physical activity knowledge
experienced fatigue (FSS score of or odd jobs. The SQUASH results
test, about 22% of the participants
ⱖ4), and about 25% had depressive showed that about 42% of the partic-
scored all 10 items correctly. They
symptoms, according to the CES-D ipants had no work-related physical
perceived more personal barriers
Scale. As determined from the CIRS, activities (MET ⫻ min/wk⫽0). Walk-
than environmental barriers, and the
about 29% of the participants had 1 ing or cycling to and from work or
most important items were lack of
or more comorbid diseases. The me- school applied to 35% of the
energy, fatigue, activity that was too
dian EQ-5D score was 0.78 (inter- participants.
heavy, poor health, no self-
quartile range⫽0.69 – 0.87).
discipline, and social constraints or
obligations. With respect to the ben-

1006 f Physical Therapy Volume 90 Number 7 July 2010

 Physical Activity in Multiple Sclerosis

Table 2.
Level of Physical Activity in Participants With Multiple Sclerosisa

Min/wk Activity Score No. (%) of

Participants
Physical Activity, METⴛmin/wk Median P25–P75 Median P25–P75 With No Activitiesb

Commuting to and from work or school 0 0–60 0 0–150 67 (65.0)

Walking 0 0–0 0 0–0 88 (85.4)

Cycling 0 0–6 0 0–30 77 (74.8)

Activities at work or school 420 0–1,440 900 0–3,600 43 (41.7)

Light 180 0–1,200 360 0–2,400 48 (46.6)

Intense 0 0–0 0 0–0 86 (83.5)

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Household activities 480 230–1,050 1,260 480–2,280 15 (14.6)

Light 450 210–840 900 420–1,680 15 (14.6)

Intense 0 0–60 0 0–300 61 (59.2)

Leisure-time activitiesc 130 20–360 420 80–1,200 25 (24.3)

Walking 20 0–120 30 0–240 50 (48.5)

Cycling 0 0–75 0 0–420 53 (51.5)

Gardening 0 0–30 0 0–150 67 (65.0)

Odd jobs 0 0–15 0 0–16 76 (73.8)

Sports activities 30 0–105 120 0–540 49 (47.6)

Total activities 1,815 640–2,700 4,486 1,550–6,960 6 (5.8)

All activities together, by intensity

Light (MET⫽2–4) 1,260 510–2,310 2,520 960–4,620 9 (8.7)

Moderate (MET⫽4–6.5) 150 30–320 750 150–1,620 23 (22.3)

Vigorous (METⱖ6.5) 0 0–0 0 0–0 86 (83.5)

a
As measured with the Short Questionnaire to Assess Health-Enhancing Physical Activity. MET⫽metabolic equivalent, P25⫽25th percentile, P75⫽75th
percentile.
b Because of missing values, the data are based on 103 participants.
c
Leisure-time activities other than sports activities.

efits of regular physical activity, they Understanding Physical Activity explained 12% of the variance in
were less convinced. The 3 benefits Behavior: Stepwise Analyses physical activity. Participants who
that received the highest scores Table 4 shows which variables re- experienced more personal barriers
were improved fitness, larger mus- mained for inclusion in the multivar- were less active; on the other hand,
cles, and increased muscle strength. iate regression analysis after the uni- participants who were less moti-
Participants with positive intentions variate analyses. Three demographic vated or less willing to adhere to the
and at higher stages of change iden- variables (age, disability pension, normative expectations of their fam-
tified more benefits of physical activ- and having children to care for) were ily members and friends (ie, were
ity and experienced fewer personal significantly related to less physical better able to resist social pressure)
and environmental barriers. activity and explained 29.4% of the were more active. None of the other
variance in the SQUASH scores cognitive or behavioral factors were
At the time of the interview, about (Tab. 4). In the second model, a associated with physical activity.
33% of the participants indicated higher EDSS score, that is, more se- Less variance was explained by the
that they intended to be more phys- vere MS, and fatigue (FSS score of environmental variables (9.1%). Re-
ically active in the next 6 months, ⱖ4) resulted in significantly less markably, participants who were
about 31% were in doubt, and about physical activity. These 2 disease- members of a patient organization
36% had no intention of increasing related determinants explained (60% of the study population) were
their level of activity. Fifty-nine per- 28.3% of the variance. With respect less physically active than those who
cent of the participants expected to the long list of cognitive and be- were not members.
that they would need an MS-specific havioral determinants, only 2 deter-
exercise program in the near future. minants were actually significant and

July 2010 Volume 90 Number 7 Physical Therapy f 1007

Physical Activity in Multiple Sclerosis

Table 3.
Cognitive-Behavioral and Environmental Characteristics of 106 Participants With Multiple Sclerosisa

No. of % of
Characteristic Participants Participants Median P25–P75

Cognitive-behavioral

Exercise stage of change (n⫽106)

Precontemplation 16 15.1

Contemplation 9 8.5

Preparation 14 13.2

Action 5 4.7

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Maintenance 44 41.5

No classification 18 17.0

Regularly active in the past (n⫽95)

Yes 71 74.7

No 24 25.3

Intention to perform more sports activities in the next 6 mo (n⫽101)

Yes 33 32.7

Doubtful 31 30.7

No 37 36.6

Knowledge of physical activity (n⫽101)

All items correct 22 21.8

One or more items not correct 79 78.2

Self-Efficacy for Exercise Behavior Scale

Making time for exercise (range of scores⫽5–30) (n⫽100) 19.5 16–24.75

Resisting relapse (range of scores⫽5–30) (n⫽101) 20 16–24

Physical Activity Enjoyment Scale (range of scores⫽18–90) (n⫽97) 71 62.0–76.5

Perceived benefits (range of scores⫽14–70) (n⫽99) 53 47.0–56.0

Personal barriers (range of scores⫽17–85) (n⫽102) 36 28.9–42.25

b
Motivation to adhere (range of scores⫽1–5) (n⫽96) 2.67 0.86

Environmental

Support for Exercise Habits Scales

Family members (range of scores⫽13–65) (n⫽98) 27 20.0–33.25

Friends (range of scores⫽13–65) (n⫽99) 21 15–29

Normative beliefs (range of scores⫽1–5) (n⫽95)b 2.45 1.28

Environmental barriers (range of scores⫽14–70) (n⫽101) 22 18–27

Membership in a patient organization (n⫽104)

No 41 39.4

Yes 63 60.6
a
P25⫽25th percentile, P75⫽75th percentile.
b
Reported as mean and standard deviation rather than median and P25–P75.

In the final regression model longer significantly related to physi- children to care for. Participants
(Tab. 4), including the significant cal activity. The most important vari- were less active if their disease was
variables from the previous 4 mod- ables explaining current physical ac- more severe, if they received a dis-
els, age, fatigue, and all initially sig- tivity behavior in participants with ability pension, or if they had chil-
nificant cognitive-behavioral and en- MS were disease severity, reliance on dren to care for. The final model ac-
vironmental variables were no a full disability pension, and having

1008 f Physical Therapy Volume 90 Number 7 July 2010

 Physical Activity in Multiple Sclerosis

Table 4.
Multivariate Regression Analysis of Physical Activity in Participants With Multiple Sclerosisa

Four Separate Models Final Modelb

95% 95%
Regression Models and Standardized Confidence Adjusted Standardized Confidence
Determinants ␤ B Interval R2 ␤ B Interval

Demographic 0.294

Age ⫺.261 ⫺1.591 ⫺2.628, ⫺0.554

Disability pensionc

No

Yes, part time ⫺.231 ⫺33.138 ⫺59.778, ⫺6.588 ⫺.140 ⫺19.197 ⫺44.331, 5.936

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Yes, full time ⫺.483 ⫺58.860 ⫺81.021, ⫺36.699 ⫺.341 ⫺39.453 ⫺61.041, ⫺17.865

Children to care for, yesc ⫺.258 ⫺30.179 ⫺50.286, ⫺10.072 ⫺.248 ⫺27.333 ⫺46.195, ⫺8.470

Disease related 0.283

EDSS ⫺.431 ⫺15.473 ⫺21.913, ⫺9.033 ⫺.416 ⫺14.728 ⫺20.877, ⫺8.578

FSS, fatigue, yesc ⫺.223 ⫺33.368 ⫺60.240, ⫺6.496

Cognitive-behavioral 0.120

Personal barriers ⫺.308 ⫺1.840 ⫺3.108, ⫺0.573

Motivation to adhere .248 15.437 2.213, 28.860

Environmental 0.091

Membership in a patient ⫺.250 ⫺27.475 ⫺49.920, ⫺5.029

organization, yesc

Normative beliefs .201 8.861 ⫺0.155, 17.878

a
Demographic, disease-related, cognitive-behavioral, and environmental variables were combined in the analysis. The dependent variable was the score on
the Short Questionnaire to Assess Health-Enhancing Physical Activity, calculated as metabolic equivalents ⫻ hours per week. EDSS⫽Expanded Disability
Status Scale, FSS⫽Fatigue Severity Scale.
b
The adjusted R2 of the final model was .372.
c
The “No” category was used as a reference.

counted for 37.2% of the variance in ing to the Dutch Work and Income general.40 – 44 Physical therapists, es-
the total level of physical activity. Act, after being on a sick list for 104 pecially those working in occupa-
weeks, workers can claim a disability tional health, ergonomics, and voca-
Discussion pension to compensate for part of tional rehabilitation, will be
Our results show that physical activ- the income that they have lost due to challenged to find effective ways to
ity behavior in people with MS is disability. In the present study, about successfully help people with MS
significantly explained by 3 indepen- 21% of the participants received a keep their jobs and continue to per-
dent factors: disease severity mea- partial disability pension and about form work-related physical activi-
sured with the EDSS, receiving a dis- 36% received a full disability pen- ties.40 – 43 Furthermore, extended
ability pension, and having children sion. Recently, however, various practice hours could be offered to
to care for. Cognitive-behavioral and governments have changed their pol- allow people to have access to phys-
environmental factors play less im- icies, increasingly promoting the ical therapists before or after work.
portant roles in the explanation of prevention of work disability and fa-
physical activity behavior. There- cilitating work force participation. With respect to the significance of
fore, severity of MS, receiving a dis- People with disabilities are being en- the EDSS results, low EDSS scores
ability pension, and having children couraged to continue working. mainly indicate mild disease symp-
to care for should be investigated Work contributes to personal iden- toms, intermediate EDSS scores
further to guide the development of tity and status, financial benefits, and (3.5– 6) predominantly indicate limi-
interventions to promote physical improved quality of life, but long- tations in walking, and high EDSS
activity in people with MS. term sickness absence and disability scores (6.5–10) mainly indicate an
retirement have serious negative inability to perform self-care activi-
In this respect, the disability pension consequences for employees with ties. In people with intermediate
deserves special attention. Accord- MS, their employers, and society in EDSS scores, limitations in mobility

July 2010 Volume 90 Number 7 Physical Therapy f 1009

Physical Activity in Multiple Sclerosis

may be a further barrier to physical depression (CES-D Scale), and fatigue Additionally, we used a self-report
activity and participation in non–MS- (FSS) were not correlated or were questionnaire to measure physical
specific exercise programs. Motl et only slightly correlated with self- activity. Self-report questionnaires
al45 showed that for a group of 133 reported physical activity. However, are used as practical measures of
patients with MS and a mean self- in a large survey study of 2,995 vet- physical activity in large population
reported EDSS score of 5.5, walking erans who had MS (86.5% men) and studies because they are valid, reli-
difficulty was a mediating variable who were, on average, 12 years able, and easy to administer and have
between symptoms and physical ac- older (age: X⫽55.3 years, SD⫽12.2 a low cost.49,50 However, question-
tivity; they suggested that interven- years) than people in our study pop- naires may result in socially desirable
tions to promote physical activity ulation, older age and a higher level answers, recall bias, and inaccurate
might need to include adaptive activ- of pain were associated with a lower scores. On the basis of the assump-
ities that do not require walking abil- likelihood of exercising, whereas liv- tions that more intense activities are

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ity. In this respect, the expertise of ing alone, a higher body mass index, usually easier to recall and that rela-
physical therapists is highly valued. and a higher level of education were tively short episodes of physical ac-
Furthermore, it is important to effec- associated with a higher likelihood tivity in daily routines are easily for-
tively prevent further progression of of exercising.14 Exercise was mea- gotten, the SQUASH may be more
the disease and to delay decreases in sured with a single question (“How valid for more active (healthy) pop-
EDSS scores to levels at which even often do you engage in regular activ- ulations.25,26 A meta-analysis of pa-
self-care activities are compromised. ities long enough to work up tients with MS showed that the type
Prakash et al46 recently hypothesized sweat?”). Most (71.4%) of the veter- of physical activity measurement in-
that lifestyle factors, such as physical ans reported no exercise at all, fluenced the magnitude of the ef-
activities, may have neuroprotective whereas 28.6% reported some form fects.20 There was a large mean ef-
effects in patients with MS. Further of activities 1 or more times per fect size when physical activity was
research is needed to justify this in- week.14 measured with a device such as an
teresting hypothesis. accelerometer or a pedometer,
Strengths and Limitations of the whereas there was a smaller mean
Having children to care for, adjusted Study effect size when it was measured
for disease severity and receiving a One of the major strengths of the with a self-report survey.20 This type
disability pension, was also nega- present study is the simultaneous in- of evidence implies that a device or a
tively correlated with the total level vestigation of several theoretical performance measure may be more
of physical activity, including house- models of behavioral changes and re- sensitive in detecting differences in
hold activities. Moreover, social con- lated variables in the same study physical activity.50 Nevertheless, in
straints and obligations were fre- population.45,47,48 Furthermore, our populations with abnormal gait pat-
quently mentioned as personal study had a high response rate terns, which are common symptoms
barriers. Family support or support (86%), and the study population ac- in patients with MS, little is known
from others in baby-sitting; child curately represented the inception about the validity of accelerome-
care offered by fitness centers, cohort.2 ters.51,52 Additional clinimetric evi-
sports societies, or physical therapist dence is needed for both types of
practices; and time-management With regard to the limitations of the physical activity measurements in
strategies may provide some solu- present study, we used a cross- patients with MS, given that gait and
tions to enable patients with MS to sectional design and focused on per- ambulatory abnormalities and cogni-
become more physically active and sonal and environmental determi- tive dysfunction may influence their
reduce the competing demands of nants and physical activity behavior validity and reliability.
child care. at the same time points. Future pro-
spective studies should investigate Furthermore, we chose to use the
Fatigue, type of MS onset (relapsing whether changes in the significant total physical activity score as the
or nonrelapsing), depressive symp- determinants change the physical ac- outcome of interest. Studies of other
toms, self-efficacy, perceived barri- tivity behavior of people with MS populations with MS (eg, older pa-
ers, and social support from family over time or across disease periods tients or patients in the precontem-
members and friends, among other and investigate ways to help people plation stage), studies focusing on
factors, were unrelated to the total with MS avoid becoming insuffi- separate types of physical activity
level of physical activity. These re- ciently active. (eg, work-related, leisure-time, and
sults are in agreement with those of household activities, means of trans-
Motl et al,45 who found that pain, portation, or sports participation),

1010 f Physical Therapy Volume 90 Number 7 July 2010

 Physical Activity in Multiple Sclerosis

and studies of other specific sets of participation rates, adherence, and mographic, disease-related, cognitive-
determinants may further increase maintenance. Patients with MS and a behavioral, and environmental
understanding of physical activity high level of perceived control over characteristics to the physical activ-
behavior.14,53 fatigue are better able to recognize ity behavior of people with MS. On
and determine the boundaries of the basis of the determinants that we
Finally, SQUASH scores are based on healthy tiredness while exercising.48 investigated, 1 disease-related factor
MET derived from the general popu- Moreover, these patients experience (ie, EDSS scores) and 2 demographic
lation.24,25 For an individual who is positive outcomes from exercise. factors (ie, a disability pension and
healthy, it has been estimated that, However, patients with a low level having children to care for) were re-
compared with sitting quietly, en- of perceived control are less able to lated to physical activity behavior in
gaging in moderate activity results in monitor their body response to ex- 106 people who had had MS for 6
a caloric consumption that is 3– 6 ercise. Furthermore, less control years and explained 37.2% of the

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times higher (MET⫽3– 6). It is possi- seems to be related to a decrease in variance in their level of physical
ble, however, that MET for the same adherence and other negative out- activity.
activity differs between people who comes, such as perceived physical
are healthy and people who have MS deterioration, unsteady gait, reduced Dr Beckerman, Dr de Groot, and Dr Lank-
or even within subgroups of the balance, and feelings of failure, anx- horst provided concept/idea/research de-
present study population. Conse- iety, and loss of safety.54 sign, writing, and project management. Dr
quently, the absolute values may not Beckerman, Dr de Groot, and Dr Scholten
be totally accurate; therefore, com- For each patient with MS, a personal provided data collection and data analysis.
Dr Beckerman provided fund procurement,
parisons with other study popula- activity plan that integrates preven- participants, facilities/equipment, and insti-
tions may be problematic. tive and therapeutic physical activi- tutional liaisons. Ms Kempen and Dr Lank-
ties is highly recommended.9 Ideally, horst provided consultation (including re-
Further Recommendations such an activity plan should be de- view of manuscript before submission).
One of the key aims of preventive veloped and updated each year, in The study protocol was approved by the
measures in public health is to in- consultation with a physical thera- medical ethics committees of the VU Univer-
crease physical activity levels in the pist or a fitness professional (eg, a sity Medical Center, Academic Medical Cen-
general population.11 Physical thera- sports physical therapist), so that ad- ter, Sint Lucas Andreas Hospital, and Onze
Lieve Vrouwe Gasthuis in Amsterdam and by
pists could play a pivotal role in pro- equate attention is paid to therapeu- Erasmus University Medical Center in Rotter-
moting physical activity. In people tic and risk management issues re- dam, the Netherlands.
with a disability, self-management of lated to MS. Patients whose MS
This study was carried out as part of the
their health status and physical activ- precludes activity at the minimum FUPRO-MS II project, “Long-Term Prognosis
ity levels should, of course, be en- recommended level for prevention of Functional Outcome in Neurological Dis-
couraged. Stroud et al47 showed that should engage in regular MS-specific orders,” and was supported by the Nether-
patients with MS are indeed aware physical activity programs to avoid lands Organization for Health Research and
that regular exercise will improve sedentary behavior. Indeed, patients Development (ZonMw Project: 1435.0020).
their physical performance. Partici- in the precontemplation stage (ie, The material in this article was presented at
pants also reported that a perceived patients who are inactive and have the 16th European Congress of Physical and
benefit of exercise is a sense of per- no intention of making changes) are Rehabilitation Medicine; June 3– 6, 2008;
Bruges, Belgium.
sonal accomplishment. In that re- probably the most difficult to per-
cent study,47 the most highly ranked suade that they should become more This article was submitted October 23, 2009,
barriers for exercise were items re- physically active. As stated by Rim- and was accepted April 1, 2010.
lated to physical exertion (eg, “Exer- mer,23 understanding the impair- DOI: 10.2522/ptj.20090345
cise tires me,” “I am fatigued by ex- ments, activity limitations, and par-
ercise,” and “Exercise is hard work ticipation restrictions of patients
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July 2010 Volume 90 Number 7 Physical Therapy f 1013