Factors associated with physical activity and exercise participation in people with multiple sclerosis: a qualitative systematic review

Figures & data

Table 1. Characteristics of the included studies.

Authors (year, country)	Focus of study	Qualitative approach	Participants with MS	Data collection
Adamson et al. [18] (2017, USA)	Understand how persons with MS describe the roles of PA and exercise as part of daily life with MS, relapses and disability identity.	Phenomenology	15 (14F, 1M); Age: 27–70; Age distribution: 20–29 (1), 30–39 (3), 40–49 (5), 50–59 (2), 60–69 (3), 70–79 (1). EDSS: 2.5–6.5; 2.5 (1), 3.0 (2), 3.5 (3), 5.0 (1), 5.5 (4), 6.0 (3), 6.5 (1). PDDS: NR. GLTEQ: 0–41 < 14 (8); 14–23 (4); >24 (3).	Semi-structured interviews
Aminian et al. [19] (2019, Canada)	Perspectives of PwMS about sedentary behaviour, physical activity, and ways to change activity behaviour.	Inductive	15 (12F, 3M); Age: 43 ± 13 (mean ± SD). Age: 20–29 (3): 30–39 (3): 40–49 (2): 50–59 (6): 60–69 (1). 10RR, 2PP, 3SP. EDSS: NR. PDDS: 1 (5), 2 (1), 3 (2), 4 (4), 5 (1), 6 (2). GLTEQ: <14 (5); 14–23 (5); >24 (5).	Semi-structured interviews
Barnard et al. [20] (2020, Australia)	Barriers and enablers to adherence to health behaviour recommendations in PwMS who attended a lifestyle intervention.	Pragmatism	18 (13F, 5M); Age: 30–39 (4): 40–49 (4): 50–59 (6): 60–69 (4). EDSS: NR. PDDS: 0 (2), 1 (7), 2 (2), 3 (1), 4 (1), 5 (1), 6 (3), 7 (1).	Semi-structured interviews
Borkoles et al. [21] (2008, UK)	Lived experiences of PwMS in relation to exercise	Phenomenology	7 (4F, 3M); Age:34–65; Mean age: 47.1 (SD 19.1) EDSS: 4–6	Semi-structured interviews
Brown et al. [22] (2012, Canada)	Barriers and facilitators influencing participation in aquafitness programs among people with MS	Phenomenology	8 (5F, 3M); Age: 47–66; 4PP; 2PR; 2RR. EDSS: NR.	Focus group and semi-structured interview
Chard [23] (2017, USA)	Identify the individual and social experiences underlying the initiation and satisfaction with aquatic exercise among persons with MS.	Grounded Theory	45 (35F, 10M); Age: Mean 55 (SD 9.4); 30RR EDSS: NR.	Semi-structured interviews
Chiu et al. [24] (2016, USA)	Barriers and facilitators that influence PA engagement among African Americans with MS	Qualitative	18 (14F, 4M); Age: 27–61; 1SP; 17RR. EDSS: NR.	Focus group and semi-structured interviews
Crank et al. [25] (2017, UK)	Exercise perceptions and experiences in PwMS before, during, and after participation in a personally tailored program designed to promote long-term maintenance of self-directed exercise.	Constructivist	33 (26F, 7M); Mean Age: 47.6 (SD 7.9); EDSS: 1.0–6.5 EDSS distribution: NR.	Focus group and semi-structured interviews
Dlugonski et al. [26] (2012, USA)	The adoption and maintenance of lifestyle physical activity.	Inductive	11F; Age 29–58; Mean Age: 42.9 (SD 10.2); Age: 20–29 (1): 30–39 (4): 40–49 (3): 50–59 (3): 11RR. EDSS: NR. PDDS: 0 (4), 1 (4), 2 (3). Active (4), Moderately active (3), Inactive (4).	Semi-structured interviews
Dodd et al. [27] (2006, Australia)	The positive and negative outcomes of a PRE programme and to identify factors that might facilitate or create barriers to the participation in and completion of a PRE programme.	Qualitative	9 (7F, 2M); Age 27–61; Mean age: 45.6 (SD 10.7); Age: 20–29 (1): 30–39 (2): 40–49 (3): 50–59 (2): 60–69 (1). DSS: 0 (4), 1 (3), 2 (2). EDSS: NR.	Semi-structured interviews
Fasczewski et al. [28] (2018, USA)	Motivation for and benefits of PA in a subset of the MS population who are highly physically active.	Phenomenology	8 (7F, 1M); 8RR; Mean age: 43.5 (SD 10.03); Age: 20–29 (1): 30–39 (2): 40–49 (3): 50–59 (1): 60–69 (1). Godin physical activity level: Active (8). EDSS: NR.	Semi-structured interviews
Giacobbi et al. [29] (2012, USA)	Factors that facilitated or impeded exercise behaviour immediately after and at 8 months completion of the resistance training intervention (secondary purpose)	Pragmatism	8F; 8RR; EDSS < 6.5. EDSS distribution: NR. Mean age = 49.86, SD = 6.94 Age 40–63; Mean age = 49.86, SD = 6.94. Age: 40–49 (4): 50–59 (3): 60–69 (1). 4 (45–60 min of PA, 1–6 days/week), 2 (15–30 min of PA, 2–3 days/week), 3 (<15 min of PA), 1–3 days/week).	Open-ended interviews
Hall-McMaster et al. [30] (2016, New Zealand)	Thoughts around motivation to be physically active among individuals with MS	Critical realism (inductive)	4 (2 F, 2 M); Age: 46–70. Physically mobile (4); Electric wheelchair (1) EDSS: NR.	Semi-structured think-aloud interviews
Kasser [31] (2009, USA)	The meaning of exercise in the lives of people with MS.	Phenomenology	12 (10F, 2M); Age 32–56. Age: 30–39 (2): 40–49 (6): 50–59 (4): Mean age: 46.25. 7RR, 2PP, 3SP. Ambulatory (9) with assistive aid (3). EDSS: NR.	Interviews
Kayes et al. [32] (2011, New Zealand)	Gain a deeper understanding of the barriers and facilitators to engagement in physical activity from the perspective of people living with MS.	Qualitative descriptive design—Charmaz’s grounded theory methodology	10 (7F, 3M); Age 34–53; Age: 30–39 (3): 40–49 (4): 50–59 (3): 4RR, 3SP, 3CP. Guys Neurological Disability Scale: 0–10 (3), 11–20 (3), 21–30 (2), 31–40 (2). Ambulatory (4) with assistive aid (6). EDSS: NR.	Semi-structured interviews
Learmonth et al. [33] (2013, UK)	Experience and perspective of a group exercise intervention.	General inductive approach	14 (10F, 4M); Age: 40–68: Age: 40–49 (7), 50–59 (5), 60–69 (2). EDSS: 5 (1), 6 (9), 6.5 (4).	Semi-structured focus groups
Learmonth et al. [34] (2015, USA)	Everyday experiences and lifestyle management strategies of wheelchair users who have MS.	Qualitative	15 (12F, 3M); Mean age: 52 (SD = 8.8); 7RR, 2PP, 6SP. Wheelchair users (15) EDSS: NR.	Standardized semi structured interview
Moffat and Paul [35] (2019, UK)	Barriers and solutions to exercise for people with MS living in Scotland who were not currently exercising regularly.	Nominal group technique	35 (24F, 11M); Age range: 18–35 = 1, 36–50 = 7, 51–65 = 17. Over 66 = 10; 14RR, 13SP, 5PP. 3 U; EDSS distribution: NR.	Group consensus development through group discussion
Plow et al. [36] (2009, USA)	Facilitators of and barriers to PA behaviour in PwMS the relevance and utility of SCT and TMSC in understanding PA behaviour among persons with MS	Modified analytical induction	13 (11F, 2M); Age 18–68; Age: 18–29 (1), 30–39 (2): 40–49 (5): 50–59 (2), 60–69 (3). 9RR, 2SP, 2U; Modified Health-Promoting Lifestyle Profile (HPLP-II): active (3), sometimes active (6), inactive (3). Mobility device (5). EDSS distribution: NR.	Semi-structured interviews
Plow et al. [37] (2014, USA)	Perceived barriers, motivators and strategies for engaging in a PA program	Mixed methods, issue-focused analysis approach	24F; Age (inclusion criteria) 18–65; 24RR; walk 25 feet with or without a cane. EDSS distribution: NR.	Semi-structured interviews
Richardson et al. [38] (2022, USA)	Exercise experiences of persons with MS living in the southeast of the US.	Inductive, Interpretivist paradigm, Relativist approach	32 (24F, 8M); Age 24–72; Avg: 50. Age: 18–29 (1), 30–39 (5): 40–49 (8): 50–59 (13), 60–69 (3), 70–79 (2). 32RR. EDSS distribution: NR.	Semi-structured interviews
Schneider and Young [39] (2010, Canada)	The lived experiences of women living with multiple sclerosis and their perceived barriers to accessing physical activity.	Phenomenology	7F; Age 41–55; Mean age: 50.4. 40–49 (2): 50–59 (5), 4RR, 3PP. EDSS distribution: NR.	Semi-structured interviews
Silveira et al. [40] (2020, USA)	Exercise perceptions and behaviours of persons with MS who use wheelchairs for mobility	Interpretivist paradigm, deductive qualitative design	20 (16F, 4M); Age 39–77; Mean age: 64.1 (SD = 8.7); 30–39 (1): 50–59 (4), 60–69 (8), 70–79 (7). 4RR, 16 PR. Wheelchair users (20). Regular vs. inconsistent exercisers: 12 vs. 8. EDSS distribution: NR.	Semi-structured interviews
Smith et al. [41] (2011, New Zealand)	Experiences of PwMS-related fatigue, who participated in a range of community-based exercise activities.	Interpretive description	9F; Age 28–70; 5RR, 3SP, 1U Walk independently with or without walking aids. Exercise once a week. EDSS distribution: NR.	Interviews
Smith et al. [42] (2013, New Zealand)	Investigate experiences of participating in a feasibility trial of a novel physiotherapy intervention (Blue Prescription).	General inductive approach	27 (23F, 4M); Mean age: 51 (SD = 11.1); Age 34–71; Age: 30–39 (5): 40–49 (9), 50–59 (6), 60–69 (6), 70–79 (1). 8RR, 3PP, 7SP, 9U. Mobility: walking with aid (12), walking without aid (10), wheelchair (5). EDSS distribution: NR.	Semi-structured interviews
Smith et al. [43] (2015, New Zealand)	Influence of fatigue on the community exercise participation in men. Potential differences between men’s and women’s responses to fatigue	Interpretive description	18M; Age 36–68; 10RR, 5PP, 3SP. EDSS distribution: NR.	Semi-structured interviews
Smith et al. [44] (2019, Australia)	Experience of participation in sport and exercise for individuals with MS who have minimal disability	Descriptive methodology, Interpretive paradigm	16 (14F, 2M); Age 27–61; EDSS level of 1.3 (SD: 1.3, range 0–4). EDSS distribution: NR. Mean age: 41 (SD: 10.9, range 27–61).	Focus group interviews
Stennett et al. [45] (2020, UK)	Explore the everyday meanings of exercise and physical activity in community dwelling people with MS	Qualitative approach	16 (12F, 4M); Age 47–72. Age: 40–49 (2), 50–59 (3), 60–69 (7),70–79 (4). 2RR, 5PP, 4SP, 5U. Mobility: with aid (9), without aid (5), wheelchair (2). EDSS distribution: NR.	Semi-structured interviews
Adamson et al. [46] (2022, USA)	Gain an in-depth understanding on barriers to PA and exercise among individuals with MS across a spectrum of MS impairment.	Non-reductionist materialist ontology subjectivist epistemology	23 (19F,4M); Age: 18–29 (1); 30–39 (4): 40–49 (4): 50–59 (6): 60–69 (8). SR-EDSS: 0–3.5 (9); 4–6 (8); 6.5+ (6); Type of MS: NR; HCS: High (8); Moderate (6); Low (9)	Semi-structured interviews
Akbar et al. [47] (2022, Canada)	Describe the perceived experiences and outcomes of individuals	Constructivist approach	56 (39F,17M); 34RR, 10PP, 12SP. Mean age: 46.8 (SD = 10). EDSS distribution: NR.	Semi-structured interviews
Clarke and Coote [48] (2015, Ireland)	Explore the perceptions of participants of 10 weeks of group exercise in the community	Qualitative research design	14, Mean age: 53.9 (SD 13.0). 11RR, 3SP. Guy’s Neurological Disability Scale: 0–2 EDSS distribution: NR.	Focus groups
Fifolt et al. [49] (2020, USA)	Exercise behaviours of persons with multiple sclerosis (MS) through the articulated lens of social cognitive theory	Interpretivism (secondary qualitative analysis)	50 (34F, 15M, 1NR), Mean age: 49.2 (SD: 10.3). 18–29 (1), 30–39 (9), 40–49 (10), 50–59 (22), 60–69 (7), NR (1), RR40, PP1, SP5, B3, NR (1). EDSS: mild to moderate disability. EDSS distribution: NR.	Interviews
Kim et al. [50] (2022, USA)	Perspectives of adults with MS following participation in a 3-month clinic- and home-based exercise rehabilitation program	Qualitative (thematic analysis)	20 (19F, 1M); Mean age: 50 (SD = 11). 14RR, 4PR, 1 U. PDDS: 14 mild, 2 moderate, 4 severe. EDSS distribution: NR.	Semi-structured interviews
Koopmans et al. [51] (2022, Canada)	Experiences of physical activity for people with MS during the COVID-19 pandemic and identify barriers and facilitators to physical activity behaviour.	Qualitative approach framed by the social ecological model	11 (9F, 2M); Age: 18–33 (2); 34–49 (5); 50–64 (4). Mean age: 45.1 (SD = 11.9). 6RR, 4SP, 1U. EDSS distribution: NR.	Semi-structured interviews
Palmer et al. [52] (2022, USA)	Impact of COVID-19 lockdown restrictions on exercise behaviour among people with MS	Ontological relativism and epistemological constructivism	8F; Age: 40–49 (4): 50–59 (3): 60–69 (1). Mean age: 51.5 (SD = 6.5). PDDS: mild (1), moderate (5), severe (2). EDSS: 4.5 (1), 5 (1), 6 (6).	Semi-structured interviews
Russell et al. [53] (2022, Ireland)	Experiences of people with MS taking part in a behaviour change group physical activity intervention with a novel social cognitive theory component	Subjectivist perspective	17 (14F, 3M) Mean age: 42.88 (SD = 9.35) Mean PDSS: 1.41 (SD = 1) Mean EDSS: 3.26 (SD = 0.59) EDSS distribution: NR.	Semi-structured interviews
van der Linden et al. [54] (2014, UK)	To establish the characteristics of both barriers and facilitators to their participation in the Pilates exercise programme.	Constructivist phenomenological perspective	10 (5M, 5F), 10SP, EDSS: 7–8 (10). 10 Wheelchair users. EDSS distribution: NR.	Focus groups
Ware et al. [55] (2022, USA)	Role of worry related to fatigue in exercise and physical activity behaviour in people with MS.	Constructivist grounded theory	35 Details: NR EDSS distribution: NR.	Semi-structured interviews
Wilkinson et al. [56] (2022, UK)	Understanding of the experience of PA amongst adults with RRMS during a relapse	Interpretivist phenomenological approach	15 (11F, 4M); 15RR; Age: 18–24 (1); 25–34 (1); 35–44 (7); 45–55 (5); 55–64 (1). PDDS: 11 mild, 4 moderate EDSS distribution: NR.	Semi-structured interview

CP: chronic progressive; DSS: Disease Steps Scale (0 = normal; 1 = mild disability; 2 = moderate disability; 3 = early cane; 4 = late cane; 5 = bilateral support; 6 = confined to wheelchair; U = unclassifiable); EDSS: Extended Disability Status Scale [1.0–4.5: able to walk without any aid, 5.0–9.5: impairment to walking/0–3.5 (mild), 4–6.5 (moderate), and 7–10 (severe)]; F: female; GLTEQ: Godin Leisure Time Exercise Questionnaire (<14: insufficiently active, 14–23: moderately active, >24: active); HCS: Health Contribution Score; M: male; NR: not reported; PR: progressive; PDDS: Patient Determined Disease Steps (≤3: mild, 4–5.5: moderate, ≥6: severe); PP: primary progressive; PwMS: people with multiple sclerosis; RR: relapsing remitting; SD: standard deviation; SP: secondary progressive; SR-EDSS: self-reported EDSS; U: unknown.

Figure 1. PRISMA flowchart.

Table 2. Critical Appraisal Skills Programme (CASP) qualitative studies checklist.

Study	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Total
Adamson et al. 2017 [18]	1	1	1	1	1	0	1	1	1	1	9
Aminian et al. 2019 [19]	1	1	1	1	1	0	1	1	1	1	9
Barnard et al. 2020 [20]	1	1	1	1	1	1	1	1	1	1	10
Borkoles et al. 2008 [21]	1	1	1	1	1	0	1	1	1	1	9
Brown et al. 2012 [22]	1	1	1	1	1	0.5	1	1	1	1	9.5
Chard 2017 [23]	1	1	1	1	1	0	1	1	1	1	9
Chiu et al. 2016 [24]	1	1	1	1	1	0	1	1	1	1	9
Crank et al. 2017 [25]	1	1	1	1	1	0	1	1	1	1	9
Dlugonski et al. 2012 [26]	1	1	1	1	1	0.5	1	1	1	1	9.5
Dodd et al. 2006 [27]	1	1	1	1	1	1	1	1	1	1	10
Fasczewski et al. 2018 [28]	1	1	1	1	1	0	1	1	1	1	9
Giacobbi et al. 2012 [29]	1	1	1	1	1	0	1	1	1	1	9
Hall-McMaster et al. 2016 [30]	1	1	1	1	1	0	1	1	1	1	9
Kasser 2009 [31]	1	1	1	1	1	0.5	1	1	1	1	9.5
Kayes et al. 2011 [32]	1	1	1	1	1	0	1	1	1	1	9
Learmonth et al. 2013 [33]	1	1	1	1	1	0.5	1	1	1	1	9.5
Learmonth et al. 2015 [34]	1	1	1	1	1	1	1	1	1	1	10
Moffat and Paul 2019 [35]	1	1	1	1	1	0	1	1	1	1	9
Plow et al. 2009 [36]	1	1	1	1	1	0	1	1	1	1	9
Plow et al. 2014 [37]	1	1	1	1	1	0	1	1	1	1	9
Richardson et al. 2022 [38]	1	1	1	1	1	1	1	1	1	1	10
Schneider and Young 2010 [39]	1	1	1	1	1	1	1	1	1	1	10
Silveira et al. 2020 [40]	1	1	1	1	1	0.5	1	1	1	1	9.5
Smith et al. 2011 [41]	1	1	1	1	1	0	1	1	1	1	9
Smith et al. 2013 [42]	1	1	1	1	1	0.5	1	1	1	1	9.5
Smith et al. 2015 [43]	1	1	1	1	1	0.5	1	1	1	1	9.5
Smith et al. 2019 [44]	1	1	1	1	1	0	1	1	1	1	9
Stennett et al. 2020 [45]	1	1	1	1	1	1	1	1	1	1	10
Adamson et al. 2022 [46]	1	1	1	1	1	0	1	1	1	1	9
Akbar et al. 2022 [47]	1	1	1	1	1	1	1	1	1	1	10
Clarke and Coote 2015 [48]	1	1	1	1	1	1	1	1	1	1	10
Fifolt et al. 2020 [49]	1	1	1	1	1	0	1	1	1	1	9
Kim et al. 2022 [50]	1	1	1	1	1	0.5	1	1	1	1	9.5
Koopmans et al. 2022 [51]	1	1	1	1	1	1	1	1	1	1	10
Palmer et al. 2022 [52]	1	1	1	1	1	0	1	1	1	1	9
Russell et al. 2022 [53]	1	1	1	1	1	0	1	1	1	1	9
van der Linden et al. 2014 [54]	1	1	1	1	1	1	1	1	1	1	10
Ware et al. 2022 [55]	1	1	1	1	1	0.5	1	1	1	1	9.5
Wilkinson et al. 2022 [56]	1	1	1	1	1	1	1	1	1	1	10

0 = No; 0.5 = Can’t Tell; 1 = Yes. Q1. Was there a clear statement of the aims of the research? Q2. Is a qualitative methodology appropriate? Q3. Was the research design appropriate to address the aims of the research? Q4. Was the recruitment strategy appropriate to the aims of the research? Q5. Was the data collected in a way that addressed the research issue? Q6. Has the relationship between researcher and participants been adequately considered? Q7. Have ethical issues been taken into consideration? Q8. Was the data analysis sufficiently rigorous? Q9. Is there a clear statement of findings? Q10. How valuable is the research?

Table 3. Main findings of the thematic synthesis.

Descriptive theme	Analytical theme
(1a) Environment (1b) Accessibility (1c) Social factors	1. External factors affect physical activity and exercise participation
(2a) Impact of MS (2b) Beliefs (2c) Knowledge (2d) Self-efficacy (2e) Motivations	2. Internal factors alter physical activity and exercise behaviour
(3a) Self-management (3b) Professional support (3c) Interventions	3. Self-management, professional support, and interventions are beneficial

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