Promoting physical activity engagement for people with multiple sclerosis living in rural settings: a proof-of-concept case study

Background

Many studies have demonstrated that exercise and physical activity can reduce symptoms, increase cardiopulmonary health and improve quality of life for people with multiple sclerosis (pwMS) [1–14]. Physical disability is common in pwMS because multiple sclerosis (MS) exacerbations and disease progression result in secondary impairments, such as diffuse muscle weakness and poor cardiovascular fitness [15]. Coupled with low exercise self-efficacy [16,17], fear of exercising and high levels of fatigue, physical disability can lead to a progressively sedentary lifestyle [18]. Many studies have examined the effectiveness of physical exercise provision and behaviour change interventions to increase the adherence for people with MS in a laboratory-based or health provider-based clinic [3,11–14,19–23], but few studies have explored exercise/physical activity participation and adherence in a home setting. Barriers to physical activity participation for many [24], particularly those living in rural areas [24–26], include dependence on experienced rehabilitation specialists [27], transport and service delivery high costs [28] and issues of limited accessibility to health-promoting practices. Thus, home- or community-based programmes which encourage pwMS to be more physically active are increasingly being investigated [29].

Aims

The aim of this study was to explore whether a combination of a 12-week Web-based physiotherapy (WBP) programme followed by Blue Prescription (BP) intervention (an intervention targeting behaviour change) is acceptable and practicable for pwMS who live in rural locations.

Methods

Design

This proof-of-concept study used a mixed-methods case study design, where each participant received WBP for 12 weeks followed by BP for 12 weeks. Interventions were delivered by a New Zealand registered physiotherapist, trained in the delivery of both interventions. Participants were assessed at baseline, after the first 12 weeks and after the second 12 weeks. Follow-up evaluations were conducted 6 months after the interventions.

Recruitment

Four pwMS were recruited from the Otago branch of the New Zealand MS Society. All participants were asked to provide written informed consent prior to taking part.

Inclusion and exclusion criteria

Inclusion criteria were as follows: a diagnosis of MS of any type and disability status based on the Patient Determined Disease Steps (PDDS) scale [30], aged 18 years or more, access to a computer/tablet with internet access and basic computer skills or had a person who could help them to use a computer.

Exclusion criteria were recent disease relapse (<3 months), currently participating in regular exercise programmes, receiving regular rehabilitation or participating in other clinical trials, and the presence of comorbidities, such as cardiac, orthopaedic or neurological conditions that would prevent them from taking part in physical activity.

Intervention

The 12 weeks of WBP was delivered via a website designed and evaluated for pwMS [31] containing a library of over 200 exercises, each exercise page consisted of a video clip, audio and text description of each exercise and a timer. The physiotherapists had one face-to-face visit with each participant. Based on this first visit, exercise goals with the participant were agreed and an individualised exercise programme prescribed using the web-based resource. Participants were asked to complete a digital diary of exercise participation via the internet, available for remote viewing by the physiotherapist who could alter the patient’s programme, dependent on progress, and monitor adherence and adverse events. After 12 weeks of WBP, the participants received the BP approach for 12 weeks [32–35]. Participants were visited face to face by the same research physiotherapist and together, using the technique of motivational interviewing [36], decided on what physical activity the participant would like to engage in, how often and for how long. The physiotherapist via Skype or telephone conducted the second and third sessions to continue the decision process, provide further advice or information, assist the person in accessing their chosen activity, identify any barriers to their continuation of their chosen physical activity and encourage them to solve problem. During this period, the therapist and the participant were in contact via telephone, email or text message to enable the physiotherapist to support the participant’s engagement in their chosen activity as appropriate.

Outcome measures

Outcome measurement occurred at four time points: (a) before starting WBP, (b) at 12-week (between WBP completion and commencement of BP), (c) at 24-week (on completion of BP) and (d) at 6-month follow-up after BP completion. The interview was conducted at 24 weeks after completion of both interventions.

Primary outcome

Qualitative data

Qualitative data explored the perception of participants and the research physiotherapist involved in this study and were gathered through:

1. Semi-strucutred, in-depth interviews with participants and the research physiotherapist.

2. Participants’ diaries in WBP website where they could document ideas, opinions or concerns.

3. The participants’ and physiotherapists’ email history.

Secondary outcomes

Physical activity

Quantitative and self-report modes of physical activity evaluation were used in order to clarify the advantages and disadvantages of each: (a) Two different activity monitors (SensWear^© (BodyMedia Inc., Pittsburgh, PA) and Garmin Vivoactive^©, Olathe, KS) and (b) a physical activity questionnaire (Godin Leisure-Time Exercise Questionnaire (GLTEQ)) [37]. The validity and reliability of each method have been confirmed in ambulatory pwMS [38–40].

Body function and composition objective measurement

The 5-repetition sit-to-stand test [41] and the waist–hip ratio (WHR) [42] were used as measures of function and body composition, respectively. Both measures demonstrate adequate reliability and validity [42].

Questionnaires

• The Multiple Sclerosis Impact Scale 29 V2 (quality of life in MS) [42].

• Modified Fatigue Impact Scale (fatigue) [42].

• Exercise Self-efficacy Scale [43,44].

• Hospital Anxiety and Depression Scale [45].

Data analysis

Due to the small sample size of this study, quantitative data were reported for each individual. An inductive thematic analysis was used to analyse qualitative data [46] based on Braun and Clarke 2006 [47].

Results

Four participants were recruited from two regions in the South Island of New Zealand (Table 1).

Table 1. Study participants’ demographic characteristics.

	Age (years)	Sex	MS type	First diagnosis	PDDS
Case 1	75	F	Unknown	1995	6
Case 2	65	F	SP	1982	5
Case 3	56	F	RR	2014	1
Case 4	56	F	SP	1986	5

f: Female; MS: multiple sclerosis; PDDS: Patient Determined Disease Steps; SP: secondary progressive; RR: relapse remission.

Participant physical activities based on their SensWear and GLTEQ results, fatigue and quality of life are illustrated in Figures 1–4.

Figure 1. Daily steps (SensWear).

Figure 2. Physical activity (GLTEQ).

Figure 3. Fatigue (MFIS).

Figure 4. Quality of life (MSIS-29).

Also, the body function and composition objective measurement are reported in Table 2.

Table 2. Body function and composition objective measurement.

Participants	WHR1	WHR2	WHR3	5STS1	5STS2	5STS3
Case 1	0.915	0.923	0.914	22.58	23.07	23.14
Case 2	0.914	0.950	0.932	27	27.44	28.14
Case 3	0.9	0.934	0.905	17	16.53	17.03
Case 4	0.893	0.981	0.971	21.27	17.08	18.82

WHR: waist–hip ratio; 5STS: 5-repetition sit-to-stand test (second).

Qualitative analysis

Four themes were identified which reflected participants’ experiences:

1. Need for more motivation:

   Participants expressed that the intervention needed to be more motivating. Participants found the programme interesting in the earlier weeks of WBP. However, as the intervention progressed, it became ‘boring’, (Case 4), ‘tedious’, (Case 1) or ‘monotonous’ (Case 2).

2. Social support is helpful:

   In the second theme, participants expressed their need for social support for exercise:

   ‘I like the idea of support. I have got a good support group around me … when I need them, I can contact them… so that is good’. (Case 2)

3. Less disability more benefit:

   Some participants believed the combined intervention might be more useful for people with a lower level of disability:

   ‘But hopefully something good comes out of the whole programme…I guess some people would have been at different levels of exercises … Because I’ve had MS for 30 years, 15–20 years ago I was a lot more active than I am now’. (Case 4)

4. Technology’s pros and cons:

   Participants reported advantages and disadvantages regarding technology that fall into three categories:

   • 4.1) the acceptability of the telerehabilitation concept:

     I think the idea is really good ah especially for rural people. (Case 1)

   • 4.2) overall dissatisfaction of using the activity monitors:

     ‘That [activity monitor] is very uncomfortable on especially when you are sleeping’. (Case 4)

   • 4.3) positive and negative aspects of website use such as:

     ‘Forgotten the website password’ (Case 4), or ‘easy to load onto [website]’ (Cases 2 and 3)

Two themes represented the experience of physiotherapists;

1. An appropriate intervention but needs improvement:

   ‘It definitely could be a good concept’ or ‘It has been good trying to help them’.

   And they suggested ‘it should be improved in some ways’ such as make a more organised list of exercises in WBP website.

2. Need more education:

   Physiotherapists’ expressed a need for more education for both the physiotherapist and the participants in order to improve delivery of the programme: general knowledge about MS, technology utilised in the intervention and methods to increase participant motivation (such as a motivational interviewing).

Discussion and conclusion

Participants and physiotherapists thought the combined intervention was positive in terms of internet use and technology and motivating pwMS to be more physically active. Motivation to be more physically active happened through social support, connecting with specialists and professional supervision. Possible reasons for this may be the expressed fear of isolation (Cases 1, 2 and 4) by the telerehabilitation. Also, ‘Action Plan’, ‘Monitoring’ and ‘Social Support’ are BCIs found to be effective in encouraging increasing engagement in physical activity [48,49].

Issues highlighted in the current study that should be considered for future larger scale studies were technological issues, lack of motivational interviewing training/computer operation of the physiotherapist and participants, and the need for more built-in motivational factors.