EFFECTS OF AN 8-WEEK SELF-EFFICACY PLUS EXERCISE INTERVENTION ON PHYSICAL ACTIVITY, QUALITY OF LIFE, AND FATIGUE IN AN INDIVIDUAL WITH PROGRESSIVE MS

EFFECTS OF AN 8-WEEK SELF-EFFICACY PLUS EXERCISE INTERVENTION ON PHYSICAL ACTIVITY, QUALITY OF LIFE, AND FATIGUE IN AN INDIVIDUAL WITH PROGRESSIVE MS

By Heather Eustis, SPT

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For my capstone I designed and conducted a single-subject study as a research elective during the fall semester. As one of the 2013 recipients of the Multiple Sclerosis Standardized Training and Education Program with University Partners (MS STEP UP) Scholarship, I have spent the last 2 years researching all about MS and discovering areas of interest. One of my main interests was utilizing the construct of self-efficacy to help improve physical activity in persons with advanced MS. As a component of my research, I focused my CAT on this topic. Based off my research, I designed my study to focus on a self-efficacy building intervention on 1 female participant with secondary-progressive MS and severe disability. My study was approved by the local Institutional Review Board and consisted of an 8 week self-efficacy plus exercise intervention followed by a 2 month follow up period. After collecting all the data I wrote an abstract for the study which I submitted to the Consortium of Multiple Sclerosis Centers (CMSC) annual 2015 conference. My abstract was selected to be a platform presentation. In May 2015 I will present my study during a 15 minute oral presentation at CMSC. Additionally, I have been working on writing the full manuscript for my study which I intend to submit to the Journal of Neurologic Physical Therapy (JNPT). My advisor Dr. Prue Plummer has been an amazing component in this process helping to guide me during each step of the way. Below is an overview of my study.

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Introduction:

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system characterized by an unpredictable and progressive decline in mobility, cognition and other physiologic functions.^1,2 Due to the chronic and progressive nature of the disease, individuals with MS are susceptible to noncompliance in health promoting behaviors secondary to many barriers to adherence that span across physical, emotional, social and environmental domains.^1–4 Individuals with more advanced MS, such as secondary-progressive MS (SPMS) and primary-progressive MS (PPMS), are particularly susceptible to these barriers as these individuals present with greater functional impairment and subsequent reduced quality of life (QOL) when compared to the most common type of MS, relapsing-remitting MS (RRMS).^4–7

Fatigue is one of the most common symptoms of MS and can play a significant role in a person’s ability to adhere to an exercise program.⁸ MS-related fatigue combined with decreased mobility often leads to the secondary symptom of depression, which further makes exercise difficult.⁸  Physical activity has been shown to help manage these symptoms as well as improve functional mobility. Due to the beneficial effects of exercise, it is not surprising that exercise interventions for MS have developed rapidly.^7,9–14 Despite the benefits, a large percentage of persons with MS remain inactive, often due to physical (i.e. fatigue) and psychological (i.e. low self-efficacy) barriers that limit sustainability and adherence of an exercise program.^12,15–17 Inactivity is particularly prevalent among people with progressive forms of MS, where there is a greater disease burden. Promoting physical activity in this population may require more than just simple instruction and handouts. Therefore, identifying behavioral mediators of physical activity in individuals with MS may help healthcare providers design a sustainable exercise intervention.^18,19 Self-efficacy has been recognized as one such mediator, and has been the focus of many behavioral interventions for persons with MS.^{5,12,16,20–22}

Self-efficacy, as proposed by Albert Bandura, is a construct of Social-Cognitive Theory that “specifies a core set of determinants, the mechanism through which they work, and the optimal ways of translating this knowledge into effective health practices”.²³ Bandura further defines self-efficacy as someone’s belief to overcome barriers by use of innate abilities.²³ High self-efficacy translates into higher goal setting and compliance in reaching that goal with the opposite being true for someone with low self-efficacy.²³

Currently, little research has examined self-efficacy in persons with more advanced MS and/or severe disability defined as an Expanded Disability Status Score (EDSS) of ≥7, indicating the individual is primarily restricted to a wheelchair. Most of the research has utilized subjects with RRMS and/or minimal to moderate disability levels (i.e. they are either independently ambulatory or require minimal assistive devices for ambulation such as a single-point cane and/or ankle-foot-orthosis).^{13,18,24–28} The ability to sustain an exercise program becomes much more challenging among people with more advanced MS and may require additional strategies to promote physical activity, such as self-efficacy interventions. The purpose of this single-subject design was to examine the effects of a self-efficacy plus exercise intervention on physical activity endurance, QOL, fatigue and physical activity level in an individual with SPMS and low self-reported self-efficacy.

 

The Participant:

The participant for my study was a 60 year old Caucasian female with SPMS and an EDSS score >7. She was diagnosed with MS in 1994 at the age of 40. Magnetic resonance imaging revealed multiple lesions to her cerebellum. At the time of her participation, her most disabling symptoms were fatigue and cerebellar ataxia. She was mainly confined to a wheelchair but would engage in short distance ambulation (5-10 feet) with a rollator and at least moderate assistance by a physical therapy student helper. Usually she would be unable to walk the entire distance of her hallway and would discontinue walking after only a few feet. PT students would regularly come to her home to assist with activities of daily living and help her with her exercises. Despite doing exercises regularly she was very inactive due to the severity of her MS.

 

The Intervention:

The subject participated in an 8 week self-efficacy plus exercise intervention followed by a 2 month follow up period. The intervention consisted of the following: weekly discussions and MS-related educational presentations; 4 one-on-one sessions with a MS “mentor”; and daily journal logging to record sleep quality, fatigue level, and physical activity. Outcome measures included a modified 5 meter walk test (5MWT), MS Impact Scale (MSIS-29), Exercise Self-Efficacy Scale (ESES), Modified Fatigue Impact Scale (MFIS), MS Self-Efficacy Scale (MS-SES), Patient Health Questionnaire-9 (PHQ-9), and daily physical activity monitoring. Outcomes were assessed at baseline (wk 0), post-intervention (wk 8), and 2-months post intervention (wk 16). Additionally the participant wore an activity monitor from week 0 to 16 during all waking hours. The participant continued to engage in her regular exercise routine throughout the study period. The topics for the educational presentations were selected by the participant and included the following: assistive devices for spasticity and tremors (i.e., dynamic braces, functional electrical stimulation), online resources for MS, exercise interventions for progressive MS, and stem cell research in MS. The MS “Mentor” was a volunteer with high self-reported self-efficacy who met with the participant 4 times to discuss topics of interest (medical journal of MS, medications, exercise).The educational presentations and mentor sessions focused around the following self-efficacy building components: Identification of challenges related to the topic; strategies to overcome these challenges; what worked & what did not work; and utilization of resources.

 

The Findings:

There were notable improvements in ESES, MFIS, PHQ-9, sleep quality, and morning fatigue ratings post intervention that were retained at follow up. Gait speed was unchanged. However, the participant was unable to complete the full 5MWT at week 0 and 4 due to increased fatigue, but was able to complete the full measure at week 8 and 16. Activity monitor data revealed the participant increased the amount of steps per day she took from week 0 to 8. This increase was modest but still noteworthy considering her disability level. A final informal interview revealed that the participant found the educational and discussion sessions and mentor sessions the most useful, with the daily journal perceived as least useful. Overall the participant really enjoyed the intervention. Subjective reports included improved walking tolerance and ability to walk the full length of her hallway more often than before the intervention.

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Questionnaires (click on image to enlarge)

Questionnaire scores from week 0 (baseline), to immediately-post intervention (week 8), to 2-month follow-up (week 16) – ESES: Exercise Self-Efficacy Scale (range 0 to 100; higher score indicates better self-efficacy to exercise); MSIS-29: Multiple Sclerosis Impact Scale -29 (range 1 to 5; higher score indicates greater impact of MS on quality of life); MFIS: Modified Fatigue Impact Scale (range 0 to 84; higher score indicates greater impact of fatigue on quality of life); MS-SES: Multiple Sclerosis Self-Efficacy Scale (range 10% to 100%; higher score indicates better self-efficacy to overcome MS-related barriers); PHQ-9: Patient Health Questionarie-9 (range 0 to 31; higher score indicates increased depressive symptoms)

5 Meter Walk Test (click on image to enlarge)

*Split baseline recorded to achieve average baseline score

On week 0 and 4, test was terminated early secondary to subject fatigue and inability to finish required 5 meter distance.

Daily Journal Weekly Averages +/- Standard Error (click on image to enlarge)

Sleep quality (0, fantastic – 10, terrible) and morning and evening fatigue level (0, no fatigue – 10, worst imaginable fatigue) from week 1 to week 16.

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Conclusion:

The findings suggest that an 8-week self-efficacy intervention can increase exercise self-efficacy, QOL, and reduce perceived fatigue in a severely disabled individual with progressive MS. Additionally, one-on-one peer mentoring appears to be a very effective method for helping improve self-efficacy. Future research should examine self-efficacy interventions in a randomized controlled trial utilizing a larger sample size of persons with progressive MS and severe disability.

 

Acknowledgments:

First and foremost I would like to thank Dr. Prue Plummer for being an amazing component of this entire process. With her help I was able to develop this intervention and execute it. She has also been an amazing help during the process of writing the manuscript. I would also like to thank the participant and her husband for their time and willingness to participate in this study. Additionally, I would like to thank Chuck Willingham for volunteering his time to be the MS “mentor” during this study. He was an invaluable component of the intervention and I am very grateful for his involvement. I would also like to thank Lexie Williams and Corinne Bohling for helping with the data collection. I am also grateful for the MS STEP UP Scholarship program for presenting me with these amazing opportunities to explore my interests in MS. I am forever grateful for all those who have made this scholarship possible. Finally, I would like to thank my family and friends who supported me throughout this process.

 

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