Exercise and Quality of Life Among People With Multiple Sclerosis: Looking Beyond Physical Functioning to Mental Health and Participation in Life

Turner AP, Kivlahan DR, Haselkorn JK. Exercise and quality of life among people with multiple sclerosis: looking beyond physical functioning to mental health and participation in life.

Objective

To describe the prevalence of exercise in a national sample of veterans with multiple sclerosis (MS) and the association of exercise with quality of life, including physical health, mental health, and participation restriction.

Design

Cross-sectional cohort study linking computerized medical records to mailed survey data from 1999.

Setting

Veterans Health Administration.

Participants

Veterans with MS (N=2995; 86.5% men) who received services in the Veterans Health Administration and returned survey questionnaires.

Interventions

Not applicable.

Main Outcome Measures

Demographic information, Veteran RAND 36-Item Health Survey (VR-36), self-reported exercise frequency.

Results

Among all survey respondents with MS, only 28.6% (95% confidence interval, 26.9-30.2) endorsed any exercise. In adjusted logistic regression, exercise was associated with younger age, more education, living alone, lower levels of bodily pain, and higher body mass index. After adjusting for demographic variables and medical comorbidities, exercise was associated with better physical and mental health. People who exercised reported they had better social functioning and better role functioning (participation in life despite physical and emotional difficulties).

Conclusions

Exercise in veterans with MS is uncommon. In the context of chronic illness care, the identification of exercise patterns and promotion of physical activity may represent an important opportunity to improve mental health and quality of life among people with MS. Intervention should address factors associated with lower rates of exercise including age, education, and pain.     

Examining the Relationship Between Cognition and Driving Performance in Multiple Sclerosis

Schultheis MT, Weisser V, Ang J, Elovic E, Nead R, Sestito N, Fleksher C, Millis SR. Examining the relationship between cognition and driving performance in multiple sclerosis.

Objective

To identify cognitive predictors of driving performance after multiple sclerosis (MS).

Design

Prospective design examining predictive value of cognitive measures on driving performance.

Setting

All data were collected in an outpatient research setting and an outpatient driver rehabilitation program.

Participants

Participants were community-dwelling persons (N=66) with clinically defined MS (86% relapsing-remitting, 14% progressive) with a mean age of 43.47 years. All were active drivers who met vision requirements established by their respective states, and none required adaptive driving equipment.

Intervention

Not applicable.

Main Outcome Measures

Participants were administered a comprehensive neuropsychologic assessment and a clinical behind-the-wheel (BTW) driving evaluation. Additional measures of driving performance included history of traffic violations and collisions (since MS onset).

Results

Logistic regression indicated that information processing speed (Symbol Digit Modality Test [SDMT]) was the strongest predictor of BTW performance. A logistic regression revealed that the strongest predictors of collision and violation frequency were visuospatial learning and recall (7/24 Spatial Recall Test [SPART 7/24]).

Conclusions

These findings indicate that information processing and visuospatial skills are predictive of driving performance among persons with MS. These measures (SDMT and SPART 7/24) may serve as screening methods for identifying the potential impact of cognitive impairment on driving. Furthermore, the findings raise questions regarding the appropriateness of the BTW evaluation to evaluate driving difficulties accurately among individuals with MS.     

Possible Influence of the Route of Treatment Administration on Treatment Adherence in Patients With Multiple Sclerosis

PurposeMultiple sclerosis is a chronic, demyelinating, and degenerative disease of the central nervous system with an immune-based pathologic origin. The present pilot study aimed to assess whether the change in the route of treatment administration is associated with a variation in adherence and whether there is a change in quality of life, treatment satisfaction, and fatigue.MethodsPatients with relapsing-remitting multiple sclerosis who were >18 years of age and who used to receive immunomodulatory parenteral treatment and were ready to change administration route were eligible for the study. Data were collected at baseline and 3 months later. Adherence, quality of life, treatment satisfaction, and fatigue were measured via the following questionnaires: Morisky-Green questionnaire on patient-reported medication adherence, Multiple Sclerosis Quality of Life Instrument, Treatment Satisfaction Questionnaire for Medication, and Modified Fatigue Impact Scale.FindingsThe study sample included 30 patients (mean age, 43.2 years; age range, 24–71 years; 60% female and 40% male). There was a significant improvement in adherence (p = 0.048). Mean (SD) physical and mental health quality-of-life summary scores varied from 52.50 (24.15) and 54.13 (21.24) to 67.55 (20.92) and 62.30 (21.75) (p < 0.001 and p = 0.001, d = −0.426 and d = −0.643, respectively). In the Treatment Satisfaction Questionnaire for Medication, an improvement of the score was observed in effectiveness of the medication (p = 0.0041, d = −0.563), adverse effects of the medication (p < 0.001, d = −0.976), convenience of the medication (p < 0.001, d = −1.235), and global satisfaction (p = 0.006, d = −0.725). Patients had a higher mean (SD) score (45.13 [26.7]) on the Modified Fatigue Impact Scale while receiving injectable treatment compared with that obtained with oral treatment (34.86 [23.16]; p = 0.009, d = 0.41).ImplicationsWhen the route of administration changed from injectable to oral, there was an increase in adherence, quality of life, and degree of patient satisfaction with their treatment and a decrease in the degree of fatigue.     

Balance-Based Torso-Weighting May Enhance Balance in Persons With Multiple Sclerosis: Preliminary Evidence

Widener GL, Allen DD, Gibson-Horn C. Balance-based torso-weighting may enhance balance in persons with multiple sclerosis: preliminary evidence.

Objective

To determine whether weight placed on the trunk in response to directional balance loss would enhance function and stability in people with multiple sclerosis (MS).

Design

Quasi-experimental study in which subjects served as their own controls.

Setting

Research laboratory.

Participants

Subjects (N=16) age 20 to 65 years with MS recruited through the Northern California Chapter of the National Multiple Sclerosis Society.

Interventions

Balance-based torso-weighting where up to 1.5% body weight was placed in a garment on the trunk. Subjects were tested at baseline and then in randomly ordered balance-based torso-weighting and nonweighted garment conditions.

Main Outcome Measures

Sharpened Romberg, eyes open (SREO) and Sharpened Romberg, eyes closed, computerized dynamic platform posturography (CDPP), Timed Up & Go (TUG), and 25-foot timed walk.

Results

Significant improvement (P<.014) was found with SREO in the balance-based torso-weighting compared with nonweighted conditions. CDPP eyes open and TUG showed improvements (P<.03) from baseline to balance-based torso-weighting and nonweighted conditions.

Conclusions

Improved performance in a group of adults with MS was seen when light weights were placed on the torso to counteract balance loss. Placement of weights may have the potential to produce immediate improvements in balance in this population.     

Objectively Quantified Physical Activity in Persons With Multiple Sclerosis

Objectives

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

Design

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

Setting

University.

Participants

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

Interventions

Not applicable.

Main Outcome Measures

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

Results

After controlling for covariates (ie, age, sex, education, race, income), there was a moderate (d=.68) and statistically significant (F=47.2, P<.001) difference of 13.1 minutes of MVPA per day (95% confidence interval, 9.4–16.8) between MS and controls. There was a difference in the rates of meeting public health guidelines for MVPA (χ²=50.7, P<.001) between MS patients (20%) and controls (47%). Among those with MS, minutes of MVPA significantly differed as a function of education, employment status, clinical course, disease duration, and disability status.

Conclusions

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

Predicting Exercise Capacity Through Submaximal Fitness Tests in Persons With Multiple Sclerosis

Kuspinar A, Andersen RE, Teng SY, Asano M, Mayo NE. Predicting exercise capacity through submaximal fitness tests in persons with multiple sclerosis.

Objective

To estimate, for persons with multiple sclerosis (MS), the extent to which peak oxygen consumption (Vo₂peak) can be predicted by the results on submaximal tests.

Design

Cross-sectional study.

Setting

Three MS clinics in the Greater Montreal region, Canada.

Participants

A center-stratified random sample of 135 women and 48 men was drawn (N=183). A subgroup of 59 subjects with MS, who were able to perform the step test, was selected from this sample to complete the maximal exercise test.

Interventions

Not applicable.

Main Outcome Measure

Vo₂peak.

Results

In this sample (mean age ± SD, 39 ± 9y; median Expanded Disability Status Scale=1.5), the mean Vo₂peak ± SD was 27.6 ± 7.3mL·kg⁻¹·min⁻¹. This value is considerably low when compared with healthy persons, ranking below the 25th percentile for both men and women. In a multivariate regression analysis, the step test and grip strength were identified as the only significant predictors of Vo₂peak. When combined with body weight, grip strength and the step test explained 74% of the variance in Vo₂peak.

Conclusions

Patients with MS with a mild degree of disability exhibit marked reductions in exercise capacity. Also, in persons with MS, submaximal tests are good predictors of exercise capacity. These measures may be used in clinical settings to help assess and monitor maximum oxygen consumption and in research to evaluate the effect of exercise-related interventions. Furthermore, they will allow people with MS to self-monitor their exercise capacity and be more actively engaged in taking charge of their fitness level.     

Improved Physical Fitness Correlates With Improved Cognition in Multiple Sclerosis

Objective

To determine whether there is an association between improvements in objective measures of physical fitness and performance on cognitive tests in people with multiple sclerosis (MS).

Design

Post hoc correlational analysis in which people demonstrating physical improvement were compared with those not demonstrating physical improvement.

Setting

Individuals with MS residing in the community.

Participants

Adults with clinically confirmed MS (N=88) who participated in a controlled trial of a telephone-based health promotion intervention, chose to work on exercise, and completed the pre- and postintervention assessments.

Interventions

Participants were measured for strength (isokinetic dynamometer), aerobic fitness (bicycle ergometer), and cognition (Paced Auditory Serial Addition Test [PASAT], Trail Making Test [TMT]) at baseline and 12 weeks later. Change in fitness was calculated by subtracting each participant's baseline score from the outcome score, and then transforming the difference to a z score. Individuals with a z score ≥1 on any fitness measure were placed in the physically improved group (n=25). All others were in the physically not improved group (n=57).

Main Outcome Measures

TMT, PASAT.

Results

After controlling for covariates (age, sex, ethnicity, education, disease activity, MS type), there was a significant group-by-time interaction, suggesting that cognitive functioning changed over time based on level of fitness. Participants in the physically improved group demonstrated improved performance on measures of executive functioning after 12 weeks of exercise.

Conclusions

The results of this study lend support to the hypothesis that change in fitness is associated with improved executive functioning in people with MS.     

Alcohol Misuse and Multiple Sclerosis

Turner AP, Hawkins EJ, Haselkorn JK, Kivlahan DR. Alcohol misuse and multiple sclerosis.

Objective

To describe the prevalence of alcohol misuse and medical advice to reduce drinking in a national sample of veterans with multiple sclerosis (MS).

Design

Cross-sectional cohort study linking computerized medical record information to mailed survey data from 2004 through 2006.

Setting

Veterans Health Administration (VHA).

Participants

Two thousand six hundred fifty-five of 4929 veterans with MS who received services in VHA between 2004 and 2006 and also a survey questionnaire (53.9% response rate).

Interventions

Not applicable.

Main Outcome Measures

Demographic information, Short-Form 12-Item Health Survey Mental Component Summary and Physical Component Summary, Alcohol Use Disorders Identification Test Consumption questions, and questions assessing depressive symptoms and the receipt of alcohol-related advice from a medical professional.

Results

Among all survey respondents with MS, the prevalence of alcohol misuse for the sample was 13.9% (confidence interval [CI], 12.5-15.2), with 11.9% (CI, 10.6-13.2) and 2.0% (CI, 1.4-2.5) of participants scoring in the mild/moderate and severe range of alcohol misuse, respectively. In contrast to community samples there was no difference in prevalence by sex. In multivariate logistic regression, age younger than 60 years (<50y; adjusted odds ratio [AOR]=1.66; CI, 1.17-2.37, and 50-59; AOR=1.64; CI, 1.19-2.27), employment (AOR=1.54; CI, 1.06-2.24) and better physical health (AOR=1.02; CI, 1.01-1.04) were associated with a higher likelihood of alcohol misuse. Among persons who screened positive for alcohol misuse, only 26.2% (CI, 21.5-30.9) reported they had received advice from a medical provider in the past year to decrease or abstain from drinking. Self-report of advice was more likely among those endorsing severe misuse (AOR=3.65; CI, 1.85-7.17) and less likely among those with better mental health (AOR=0.97; CI, 0.94-1.00).

Conclusions

Despite the numerous health and social consequences of alcohol misuse, routine screening and intervention for people with MS remain uncommon. Brief screening and advice to reduce or refrain from alcohol use can be accomplished in as little as 5 minutes and can be incorporated into the regular course of medical care.     

Actual Reality: A New Approach to Functional Assessment in Persons With Multiple Sclerosis

Goverover Y, O'Brien AR, Moore NB, DeLuca J. Actual Reality: a new approach to functional assessment in persons with multiple sclerosis.

Objective

To examine the use of an innovative approach for assessing everyday life activities of people with multiple sclerosis (MS): Actual Reality. Actual Reality is a performance-based assessment approach that involves the use of the internet to perform real, everyday life activities.

Design

A between-subjects design.

Setting

Outpatient rehabilitation institute.

Participants

Persons (n=21) with clinically definite MS and healthy controls (HCs) (n=18) without any reported neurologic disabilities participated in this study. Participants were between the ages of 21 to 60 years, and the sample consisted of volunteer sample.

Interventions

Not applicable.

Main Outcome Measures

Participants were asked to access the internet to purchase airline tickets for a round trip flight and were administered the Minimal Assessment of Cognitive Functioning in Multiple Sclerosis. Participants also completed questionnaires to assess quality of life (Functional Assessment of Multiple Sclerosis), functional status (Functional Behavior Profile), and prior Internet experience.

Results

The MS group displayed significantly more difficulties than the HC group in accurately and independently completing the Actual Reality task primarily because of cognitive impairment. Self-report of quality of life and functional status were not correlated with Actual Reality performance in the group of people with MS. However, the self-report measures were significantly associated with affective symptomatology.

Conclusions

These results provide initial evidence supporting the use of the Actual Reality approach in assessing persons with MS performing everyday life activities. Actual Reality is a significant step forward in increasing the sensitivity, accessibility, and relevancy of functional assessments in people with cognitive and physical disabilities.     

Postural Response Latencies Are Related to Balance Control During Standing and Walking in Patients With Multiple Sclerosis

Objective

To understand and examine the relation between postural response latencies obtained during postural perturbations and representative measures of balance during standing (sway variables) and walking (trunk motion).

Design

Cross-sectional.

Setting

University medical center.

Participants

Persons with multiple sclerosis (MS) (n=40) were compared with similar aged control subjects (n=20). There were 20 subjects with MS in the normal walking velocity group and 20 subjects with MS who had slow walking velocity based on a timed 25-foot walk (T25FW) of <5 seconds.

Interventions

None.

Main Outcome Measures

Postural response latency, sway variables, trunk motion variables.

Results

We found that subjects with MS with both slow or normal walking velocities had significantly longer postural response latencies than the healthy control group. Postural response latency was not correlated with the T25FW. Postural response latency was significantly correlated with center of pressure sway variables during quiet standing (root mean square: ρ=.334, P=.04; range: ρ=.385, P=.017; mean velocity: ρ=.337, P=.038; total sway area: ρ=.393, P=.015). Postural response latency was also significantly correlated with motion of the trunk during walking (sagittal plane range of motion: ρ=.316, P=.05; SD of transverse plane range of motion: ρ=−.43, P=.006).

Conclusions

These findings clearly indicate that slow postural responses to external perturbations in patients with MS contribute to disturbances in balance control during both standing and walking.     

Calibration of Accelerometer Output for Ambulatory Adults With Multiple Sclerosis

Motl RW, Snook EM, Agiovlasitis S, Suh Y. Calibration of accelerometer output for ambulatory adults with multiple sclerosis.

Objectives

To examine the association between the rates of accelerometer activity counts and energy expenditure during walking in persons with multiple sclerosis (MS) versus controls and then to calibrate the output of accelerometers for computing time spent in light, moderate, and vigorous physical activity based on common metabolic equivalent unit categories in persons with MS.

Design

Mixed-model design.

Setting

Laboratory.

Participants

People with MS (n=24) and people without MS (n=24) who were similar in age, sex, height, and weight.

Interventions

The participants undertook three 6-minute periods of walking at 3.2, 4.8, and 6.4km·h⁻¹ on a motor-driven treadmill.

Main Outcome Measures

Activity counts and energy expenditure were measured with an accelerometer worn on the right hip and open-circuit spirometry, respectively.

Results

The results indicated that (1) persons with MS had greater energy expenditure, but not activity counts, during walking on a treadmill than did controls; (2) there was a strong linear relationship between activity counts and energy expenditure during treadmill walking, but the slope of the relationship was steeper in persons with MS than in controls; and (3) the cut-points for light, moderate, and vigorous physical activity were lower in persons with MS than in controls.

Conclusions

Such findings provide evidence for a strong linear relationship between activity counts and energy expenditure during walking in persons with MS and cut-points based on counts per minute for quantifying time spent in light, moderate, and vigorous physical activity using accelerometers in this population.     

Efficacy and Safety of a Hip Flexion Assist Orthosis in Ambulatory Multiple Sclerosis Patients

Sutliff MH, Naft JM, Stough DK, Lee JC, Arrigain SS, Bethoux FA. Efficacy and safety of a hip flexion assist orthosis in ambulatory multiple sclerosis patients.

Objective

To evaluate the efficacy and safety of a hip flexion assist orthosis (HFAO) in ambulatory patients with multiple sclerosis (MS).

Design

Fourteen week pre- and postintervention uncontrolled trial.

Setting

Outpatient rehabilitation clinic within an MS center.

Participants

Ambulatory MS patients (N=21) with unilateral (or unilateral predominant) hip flexor weakness.

Intervention

Subjects were fitted with the HFAO on the weaker side, trained to use the device, and given a wear schedule. Subjects completed 2 baseline evaluations and follow-up testing at 8 and 12 weeks.

Main Outcome Measures

Lower-extremity manual muscle testing, pain, and gait performance (Timed 25-Foot Walk, Timed Up & Go, 6-minute walk test, Mellen Center Gait Test). Subject satisfaction was evaluated by using a 9-item custom questionnaire.

Results

There was a statistically significant improvement of strength in the affected lower extremity at 8 and 12 weeks (effect size [ES]=0.63; ES=1.32, respectively), of pain at 12 weeks only (ES=−0.64), and of all gait tests at 8 and 12 weeks (ES range, 0.38–1.33). The overall mean satisfaction score at 12 weeks was 39 (maximum score, 45). No serious adverse events were recorded during the study. The most frequent side effect of the HFAO was low back pain (19%). No side effects led to discontinuation of the HFAO use during the study.

Conclusions

The HFAO was safe and well tolerated. HFAO use was associated with significant improvement of gait performance as well as improvement of strength in the lower extremity fitted with the HFAO. Subjective reports suggest that there was an increase in daily life activity level.     

Level of Mobility Limitations and Falls Status in Persons With Multiple Sclerosis

Objective

To investigate whether fall rates are constant across levels of mobility limitations.

Design

Secondary analysis of baseline assessments from a stratified randomized controlled trial.

Setting

Community.

Participants

Persons with multiple sclerosis (N=365) were divided into 5 groups based on the mobility section of the Guy's Neurological Disability Scale (GNDS): no walking impairment (n=82); impaired walking, no aid (n=87); unilateral support (n=76); bilateral support to walk (n=78); or occasional wheelchair user (n=42).

Interventions

Not applicable.

Main Outcome Measures

Self-reported fall history (ie, retrospective) in the preceding 3 months.

Results

One hundred twenty-four persons in the overall sample reported falling in the last 3 months (fall prevalence, 33.97%). Of the total sample, 17.8% reported 2 or more falls in the last 3 months. Chi-square analysis revealed a significant difference in the proportion of fallers across GNDS categories (χ²=42.64, P<.001). Post hoc analysis revealed that the group who walked with bilateral support had the greatest proportion of fallers (52.6%), while the group without walking impairment had the lowest proportion (15.9%). An examination of recurrent fallers as a function of group found that there were more recurrent fallers (70%) in the group that had a walking impairment but used no aid, relative to the other groups.

Conclusions

The current findings highlight that fall rates including recurrent fall prevalence are not uniform across mobility aid categories in persons with MS. Those using bilateral assistance for gait have the highest prevalence of fallers, and those with walking limitations and not yet using an aid had the greatest prevalence of multiple falls.     

Vision and Driving in Multiple Sclerosis

Schultheis MT, Manning K, Weisser V, Blasco A, Ang J, Wilkinson ME. Vision and driving in multiple sclerosis.

Objective

To examine the relationship between measures of visual dysfunction and driving performance in persons with multiple sclerosis (MS).

Design

Between-group comparison.

Setting

All data were collected in an outpatient research setting.

Participants

Persons (N=66) with MS of the relapsing remitting type (26 self-reporting visual difficulties; 40 self-reporting no visual difficulties) and 26 age- and sex-matched healthy controls.

Interventions

Not applicable.

Main Outcome Measures

Measures of vision included visual acuity, depth perception, and color perception. Driving was measured using documented accident/violation rate and self-reported driving behaviors.

Results

Quantitative analysis only revealed that MS persons with self-reported visual difficulties performed significantly worse than healthy controls on color perception (Kruskal-Wallis; χ₂²=8.89, P=.01). There were no group differences on driving behaviors, and correlational analysis revealed a lack of relationship between the selected visual (visual acuity, depth perception, color perception) and driving performance measures (documented accident/violation rate and self-limiting driving behaviors).

Conclusions

Persons with MS who self-reported difficulties with vision had acceptable visual acuity, despite demonstrating impairment in color perception. The fact that visual acuity remains the most common measure for visual fitness to drive remains problematic. There is a need to further define measures of visual dysfunction relevant to driving among this clinical population.     

Validation of the Multidimensional Outcome Expectations for Exercise Scale in Ambulatory, Symptom-Free Persons With Multiple Sclerosis

McAuley E, Motl RW, White SM, Wójcicki TR. Validation of the Multidimensional Outcome Expectations for Exercise Scale in ambulatory, symptom-free persons with multiple sclerosis.

Objective

To determine the psychometric properties of the 3-factor Multidimensional Outcome Expectations for Exercise Scale in a sample of ambulatory, symptom-free persons with multiple sclerosis (MS).

Design

Cross-sectional validation study.

Setting

Midwestern university.

Participants

Community-dwelling adults (N=242) with an established definite diagnosis of MS, as corroborated by the participant's neurologist, who were relapse free for the last 30 days and ambulatory with minimal assistance.

Interventions

Not applicable.

Main Outcome Measures

Multidimensional Outcome Expectations for Exercise Scale, physical activity, self-efficacy, and physical health status. Confirmatory factor analyses using covariance modeling and correlational analyses were used to establish factorial and construct validity.

Results

Analyses showed excellent factorial validity for the hypothesized factor structure reflecting physical, social, and self-evaluative outcome expectations. All 3 subscales were internally consistent. Theoretically, relevant correlations between outcome expectations and self-efficacy, physical activity, and physical health status were all supported.

Conclusions

The Multidimensional Outcome Expectations for Exercise Scale appears to be a reliable and valid measure of outcome expectations for exercise in this limited sample of community-dwelling adults with MS. Further validation in clinical samples is warranted.