Review article (meta-analysis)| Volume 99, ISSUE 10, P2059-2075, October 2018

Changing Physical Activity Behavior in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis

Published:January 11, 2018DOI:



      To (1) systematically review the literature on behavioral interventions for people with multiple sclerosis (MS) that aim to change physical activity (PA) behavior; and (2) explore whether these interventions are clinically effective in improving PA, are theory based, and use established behavior change techniques (BCTs).

      Data Sources

      A systematic electronic search was conducted on databases EBSCO (including AMED, Biomedical Reference Collection: Expanded, CINHAL, MEDLINE, PsycArticles, PsycInfo), PubMed, EMBASE, and Web of Science from April 2017 to May 2017.

      Study Selection

      Studies were included if (1) the interventions aimed to change PA behavior among people with MS; (2) PA was recognized as a primary outcome measure; and (3) they had a randomized controlled trial (RCT) design.

      Data Extraction

      The resulting behavioral interventions were coded using the Theory Coding Scheme and the CALO-RE taxonomy to assess theory base and BCTs. A meta-analysis was conducted to assess effectiveness.

      Data Synthesis

      Fourteen RCTs were included. Combined, there was a significant (P=.0003; d=1.00; 95% confidence interval, .46–1.53) short-term change in self-report PA behavior for studies with nonactive control groups. There was no change in objective or long-term PA. Studies failed to discuss results in relation to theory and did not attempt to refine theory. Fifty percent of BCTs within the CALO-RE were used, with BCTs of “goal-setting” and “action-planning” being the most frequently used.


      Current evidence supports the efficacy of PA intervention on subjective but not objective outcomes. However, conclusions from this review should be interpreted with caution because of the small number of studies included and small sample size. Further, while using theory in intervention design, interventions in this review have not reported the refining of theory. Exploration of the use of additional BCTs to change PA behavior is also required within future interventions.


      List of abbreviations:

      BCT (behavior change technique), CI (confidence interval), MD (mean difference), MS (multiple sclerosis), PA (physical activity), RCT (randomized controlled trial), SMD (standardized mean difference), TCS (Theory Coding Scheme)
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        • World Health Organization
        Atlas: multiple sclerosis resources in the world, 2008.
        World Health Organization, Geneva2008
        • Fogarty E.
        • Walsh C.
        • McGuigan C.
        • Tubridy N.
        • Barry M.
        Direct and indirect economic consequences of multiple sclerosis in Ireland.
        Appl Health Econ Health Policy. 2014; 12: 635-645
        • Kjølhede T.
        • Vissing K.
        • Dalgas U.
        Multiple sclerosis and progressive resistance training: a systematic review.
        Mult Scler. 2012; 18: 1215-1228
        • Pilutti L.A.
        • Greenlee T.A.
        • Motl R.W.
        • Nickrent M.S.
        • Petruzzello S.J.
        Effects of exercise training on fatigue in multiple sclerosis: a meta-analysis.
        Psychosom Med. 2013; 75: 575-580
        • Gunn H.
        • Markevics S.
        • Haas B.
        • Marsden J.
        • Freeman J.
        Systematic review: the effectiveness of interventions to reduce falls and improve balance in adults with multiple sclerosis.
        Arch Phys Med Rehabil. 2015; 96: 1898-1912
        • Snook E.M.
        • Motl R.W.
        • Gliottoni R.C.
        The effect of walking mobility on the measurement of physical activity using accelerometry in multiple sclerosis.
        Clin Rehabil. 2009; 23: 248-258
        • Motl R.W.
        • Gosney J.L.
        Effect of exercise training on quality of life in multiple sclerosis: a meta-analysis.
        Mult Scler. 2008; 14: 129-135
        • Kinnett-Hopkins D.
        • Adamson B.
        • Rougeau K.
        • Motl R.
        People with MS are less physically active than healthy controls but as active as those with other chronic diseases: an updated meta-analysis.
        Mult Scler Relat Disord. 2017; 13: 38-43
        • Michie S.
        • Prestwich A.
        Are interventions theory-based? Development of a theory coding scheme.
        Health Psychol. 2010; 29: 1
        • Larkin L.
        • Gallagher S.
        • Cramp F.
        • Brand C.
        • Fraser A.
        • Kennedy N.
        Behaviour change interventions to promote physical activity in rheumatoid arthritis: a systematic review.
        Rheumatol Int. 2015; 35: 1631-1640
        • Avery L.
        • Flynn D.
        • Van Wersch A.
        • Sniehotta F.F.
        • Trenell M.I.
        Changing physical activity behavior in type 2 diabetes: a systematic review and meta-analysis of behavioral interventions.
        Diabetes Care. 2012; 35: 2681-2689
        • Michie S.
        • Johnston M.
        • Abraham C.
        • Lawton R.
        • Parker D.
        • Walker A.
        Making psychological theory useful for implementing evidence based practice: a consensus approach.
        Qual Saf Health Care. 2005; 14: 26-33
        • Michie S.
        • van Stralen M.M.
        • West R.
        The behaviour change wheel: a new method for characterising and designing behaviour change interventions.
        Implement Sci. 2011; 6: 42
        • Larkin L.
        • Kennedy N.
        • Gallagher S.
        Promoting physical activity in rheumatoid arthritis: a narrative review of behaviour change theories.
        Disabil Rehabil. 2015; 37: 2359-2366
        • Ayling K.
        • Brierley S.
        • Johnson B.
        • Heller S.
        • Eiser C.
        Efficacy of theory-based interventions for young people with type 1 diabetes: a systematic review and meta-analysis.
        Br J Health Psychol. 2015; 20: 428-446
        • Suh Y.
        • Weikert M.
        • Dlugonski D.
        • Balantrapu S.
        • Motl R.W.
        Social cognitive variables as correlates of physical activity in persons with multiple sclerosis: findings from a longitudinal, observational study.
        Behav Med. 2011; 37: 87-94
        • Michie S.
        • Richardson M.
        • Johnston M.
        • et al.
        The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions.
        Ann Behav Med. 2013; 46: 81-95
        • West R.
        • Walia A.
        • Hyder N.
        • Shahab L.
        • Michie S.
        Behavior change techniques used by the English Stop Smoking Services and their associations with short-term quit outcomes.
        Nicotine Tob Res. 2010; 12: 742-747
        • Abraham C.
        • Michie S.
        A taxonomy of behavior change techniques used in interventions.
        Health Psychol. 2008; 27: 379
        • Michie S.
        • Ashford S.
        • Sniehotta F.F.
        • Dombrowski S.U.
        • Bishop A.
        • French D.P.
        A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the CALO-RE taxonomy.
        Psychol Health. 2011; 26: 1479-1498
        • Abraham C.
        • Kelly M.P.
        • West R.
        • Michie S.
        The UK National Institute for Health and Clinical Excellence public health guidance on behaviour change: a brief introduction.
        Psychol Health Med. 2009; 14: 1-8
        • Shirazipour C.H.
        • Baillie C.P.
        • Galaviz K.
        • Jarvis J.W.
        • Latimer-Cheung A.E.
        Evaluating the theoretical content of online physical activity information for people with multiple sclerosis.
        Int J MS Care. 2015; 17: 91-100
        • Sangelaji B.
        • Smith C.M.
        • Paul L.
        • Sampath K.K.
        • Treharne G.J.
        • Hale L.A.
        The effectiveness of behaviour change interventions to increase physical activity participation in people with multiple sclerosis: a systematic review and meta-analysis.
        Clin Rehabil. 2016; 30: 559-576
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        Ann Intern Med. 2009; 151: W-65-W-94
        • Borenstein M.
        • Hedges L.V.
        • Higgins J.P.
        • Rothstein H.R.
        Introduction to meta-analysis.
        Wiley, Chichester2009
        • Higgins J.P.
        • Green S.
        Cochrane handbook for systematic reviews of interventions. Vol 5. Wiley Online Library, Chichester2008
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Erlbaum, Hillsdale1988
        • Bombardier C.H.
        • Ehde D.M.
        • Gibbons L.E.
        • et al.
        Telephone-based physical activity counseling for major depression in people with multiple sclerosis.
        J Consult Clin Psychol. 2013; 81: 89-99
        • Carter A.
        • Daley A.
        • Humphreys L.
        • et al.
        Pragmatic intervention for increasing self-directed exercise behaviour and improving important health outcomes in people with multiple sclerosis: a randomised controlled trial.
        Mult Scler. 2014; 20: 1112-1122
        • Carter A.M.
        • Daley A.J.
        • Kesterton S.W.
        • Woodroofe N.M.
        • Saxton J.M.
        • Sharrack B.
        Pragmatic exercise intervention in people with mild to moderate multiple sclerosis: a randomised controlled feasibility study.
        Contemp Clin Trials. 2013; 35: 40-47
        • Coote S.
        • Uszynski M.
        • Herring M.P.
        • et al.
        Effect of exercising at minimum recommendations of the multiple sclerosis exercise guideline combined with structured education or attention control education—secondary results of the step it up randomised controlled trial.
        BMC Neurol. 2017; 17: 119
        • Dlugonski D.
        • Motl R.W.
        • Mohr D.C.
        • Sandroff B.M.
        Internet-delivered behavioral intervention to increase physical activity in persons with multiple sclerosis: sustainability and secondary outcomes.
        Psychol Health Med. 2012; 17: 636-651
        • Motl R.W.
        • Dlugonski D.
        • Wojcicki T.R.
        • McAuley E.
        • Mohr D.C.
        Internet intervention for increasing physical activity in persons with multiple sclerosis.
        Mult Scler. 2011; 17: 116-128
        • Ennis M.
        • Thain J.
        • Boggild M.
        • Baker G.A.
        • Young C.A.
        A randomized controlled trial of a health promotion education programme for people with multiple sclerosis.
        Clin Rehabil. 2006; 20: 783-792
        • McAuley E.
        • Wójcicki T.R.
        • Learmonth Y.C.
        • et al.
        Effects of a DVD-delivered exercise intervention on physical function in older adults with multiple sclerosis: a pilot randomized controlled trial.
        Mult Scler J Exp Transl Clin. 2015; 1 (2055217315584838)
        • Pilutti L.A.
        • Dlugonski D.
        • Sandroff B.M.
        • Klaren R.
        • Motl R.W.
        Randomized controlled trial of a behavioral intervention targeting symptoms and physical activity in multiple sclerosis.
        Mult Scler. 2014; 20: 594-601
        • Plow M.
        • Bethoux F.
        • McDaniel C.
        • McGlynn M.
        • Marcus B.
        Randomized controlled pilot study of customized pamphlets to promote physical activity and symptom self-management in women with multiple sclerosis.
        Clin Rehabil. 2014; 28: 139-148
        • Rice I.M.
        • Rice L.A.
        • Motl R.W.
        Promoting physical activity through a manual wheelchair propulsion intervention in persons with multiple sclerosis.
        Arch Phys Med Rehabil. 2015; 96: 1850-1858
        • Sandroff B.M.
        • Klaren R.E.
        • Pilutti L.A.
        • Dlugonski D.
        • Benedict R.H.
        • Motl R.W.
        Randomized controlled trial of physical activity, cognition, and walking in multiple sclerosis.
        J Neurol. 2014; 261: 363-372
        • Stuifbergen A.K.
        • Becker H.
        • Blozis S.
        • Timmerman G.
        • Kullberg V.
        A randomized clinical trial of a wellness intervention for women with multiple sclerosis.
        Arch Phys Med Rehabil. 2003; 84: 467-476
        • Suh Y.
        • Motl R.W.
        • Olsen C.
        • Joshi I.
        Pilot trial of a social cognitive theory-based physical activity intervention delivered by nonsupervised technology in persons with multiple sclerosis.
        J Phys Act Health. 2015; 12: 924-930
        • Steene-Johannessen J.
        • Anderssen S.A.
        • van der Ploeg H.P.
        • et al.
        Are self-report measures able to define individuals as physically active or inactive?.
        Med Sci Sports Exerc. 2016; 48: 235-244
        • Dhurandhar N.
        • Schoeller D.
        • Brown A.
        • et al.
        Energy balance measurement: when something is not better than nothing.
        Int J Obes (Lond). 2015; 39: 1109-1113
        • Motl R.
        • Snook E.M.
        • McAuley E.
        • Gliottoni R.C.
        Symptoms, self-efficacy, and physical activity among individuals with multiple sclerosis.
        Res Nurs Health. 2006; 29: 597-606
        • Prestwich A.
        • Webb T.L.
        • Conner M.
        Using theory to develop and test interventions to promote changes in health behaviour: evidence, issues, and recommendations.
        Curr Opin Psychol. 2015; 5: 1-5