Original research| Volume 100, ISSUE 11, P2079-2088, November 2019

Oxygen Cost During Mobility Tasks and Its Relationship to Fatigue in Progressive Multiple Sclerosis

Published:April 23, 2019DOI:


      • People with progressive multiple sclerosis (MS) consume 2.81 times more energy during mobility tasks.
      • Accumulation of oxygen cost and fatigue suggest deconditioning in persons with MS.
      • Oxygen cost of walking is a significant predictor of fatigue in progressive MS.



      To compare the oxygen costs of mobility tasks between individuals with progressive multiple sclerosis (MS) using walking aids and matched controls and to determine whether oxygen cost predicted fatigue.


      Cross-sectional descriptive.


      A rehabilitation research laboratory.


      A total of 14 adults with progressive MS (mean age ± SD [y], 54.07±8.46) using walking aids and 8 age- and sex-matched controls without MS (N=22).


      Participants performed 5 mobility tasks (rolling in bed, lying to sitting, sitting to standing, walking, climbing steps) wearing a portable metabolic cart.

      Main Outcome Measures

      Oxygen consumption ( V ˙ o2) during mobility tasks, maximal V ˙ o2 during graded maximal exercise test, perceived exertion, and task-induced fatigue were measured on a visual analog scale before and after mobility tasks.


      People with progressive MS had significantly higher oxygen cost in all tasks compared to controls (P<.05): climbing steps (3.60 times more in MS), rolling in bed (3.53), walking (3.10), lying to sitting (2.50), and sitting to standing (1.82). There was a strong, positive correlation between task-induced fatigue and oxygen cost of walking, (ρ [13]=0.626, P=.022).


      People with progressive MS used 2.81 times more energy on average for mobility tasks compared to controls. People with progressive MS experienced accumulation of oxygen cost, fatigue, and exertion when repeating tasks and higher oxygen cost during walking was related to greater perception of fatigue. Our findings suggest that rehabilitation interventions that increase endurance during functional tasks could help reduce fatigue in people with progressive MS who use walking aids.


      List of abbreviations:

      GXT (graded exercise testing), MS (multiple sclerosis), VAS (visual analog scale), V˙o2 (oxygen consumption per unit time), V˙o2max (maximal oxygen consumption), RPE (rating of perceived exertion)
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        • Minden S.L.
        • Frankel D.
        • Hadden L.
        • Perloffp J.
        • Srinath K.P.
        • Hoaglin D.C.
        The Sonya Slifka Longitudinal Multiple Sclerosis Study: methods and sample characteristics.
        Mult Scler. 2006; 12: 24-38
        • Patrick E.
        • Christodoulou C.
        • Krupp L.B.
        Longitudinal correlates of fatigue in multiple sclerosis.
        Mult Scler. 2009; 15: 258-261
        • Feinstein A.
        • Freeman J.
        • Lo A.C.
        Treatment of progressive multiple sclerosis: what works, what does not, and what is needed.
        Lancet Neurol. 2015; 14: 194-207
        • Bakshi R.
        Fatigue associated with multiple sclerosis: diagnosis, impact and management.
        Mult Scler. 2003; 9: 219-227
        • Bol Y.
        • Duits A.A.
        • Lousberg R.
        • et al.
        Fatigue and physical disability in patients with multiple sclerosis: a structural equation modeling approach.
        J Behav Med. 2010; 33: 355-363
        • Comi G.
        • Leocani L.
        • Rossi P.
        • Colombo B.
        Physiopathology and treatment of fatigue in multiple sclerosis.
        J Neurol. 2001; 248: 174-179
        • Krupp L.B.
        • Serafin D.J.
        • Christodoulou C.
        Multiple sclerosis-associated fatigue.
        Expert Rev Neurother. 2010; 10: 1437-1447
        • Vucic S.
        • Burke D.
        • Kiernan M.C.
        Fatigue in multiple sclerosis: mechanisms and management.
        Clin Neurophysiol. 2010; 121: 809-817
        • MacAllister W.S.
        • Krupp L.B.
        Multiple sclerosis–related fatigue.
        Phys Med Rehabil Clin N Am. 2005; 16: 483-502
        • Langeskov-Christensen M.
        • Bisson E.J.
        • Finlayson M.L.
        • Dalgas U.
        Potential pathophysiological pathways that can explain the positive effects of exercise on fatigue in multiple sclerosis: a scoping review.
        J Neurol Sci. 2017; 373: 307-320
        • Grover G.
        • Ploughman M.
        • Philpott D.T.
        • et al.
        Environmental temperature and exercise modality independently impact central and muscle fatigue among people with multiple sclerosis.
        Mult Scler J Exp Transl Clin. 2017; 3 (2055217317747625)
        • Arafah A.
        • Kuspinar A.
        • Mayo N.
        Untangling perception of fatigue and fatigability: first steps.
        Austin J Mult Scler Neuroimmunol. 2015; 2: 1-7
        • Zijdewind I.
        • Prak R.F.
        • Wolkorte R.
        Fatigue and fatigability in persons with multiple sclerosis.
        Exerc Sport Sci Rev. 2016; 44: 123-128
        • Iriarte J.
        • Castro P.
        Correlation between sympotom fatigue and muscular fatigue in multiple sclerosis.
        Eur J Neurol. 1998; 5: 579-585
        • Ng A.V.
        • Miller R.G.
        • Gelinas D.
        • Kent-Braun J.A.
        Functional relationships of central and peripheral muscle alterations in multiple sclerosis.
        Muscle Nerve. 2004; 29: 843-852
        • Sharma K.R.
        • Kent-Braun J.A.
        • Mynhier M.A.
        • Weiner M.W.
        • Miller R.G.
        Evidence of an abnormal intramuscular component of fatigue in multiple sclerosis.
        Muscle Nerve. 1995; 18: 1403-1411
        • Sheean G.L.
        • Murray N.M.
        • Rothwell J.C.
        • Miller D.H.
        • Thompson A.J.
        An electrophysiological study of the mechanism of fatigue in multiple sclerosis.
        Brain. 1997; 120: 299-315
        • Waters R.L.
        • Mulroy S.
        The energy expenditure of normal and pathologic gait.
        Gait Posture. 1999; 9: 207-231
        • Coote S.
        • O’Dwyer C.
        Energy expenditure during everyday activities–a study comparing people with varying mobility limitations due to multiple sclerosis and healthy controls.
        Disabil Rehabil. 2014; 36: 2059-2064
        • Alexander N.B.
        • Galecki A.T.
        • Grenier M.L.
        • et al.
        Task-specific resistance training to improve the ability of activities of daily living-impaired older adults to rise from a bed and from a chair.
        J Am Geriatr Soc. 2001; 49: 1418-1427
        • Alexander N.B.
        • Grunawalt J.C.
        • Carlos S.
        • Augustine J.
        Bed mobility task performance in older adults.
        J Rehabil Res Dev. 2000; 37: 633-638
        • Ainsworth B.E.
        • Haskell W.L.
        • Herrmann S.D.
        • et al.
        2011 Compendium of Physical Activities: a second update of codes and MET values.
        Med Sci Sports Exerc. 2011; 43: 1575-1581
        • Conger S.A.
        • Bassett Jr., D.R.
        A compendium of energy costs of physical activities for individuals who use manual wheelchairs.
        Adapt Phys Activ Q. 2011; 28: 310-325
        • Kozey S.L.
        • Lyden K.
        • Howe C.A.
        • Staudenmayer J.W.
        • Freedson P.S.
        Accelerometer output and MET values of common physical activities.
        Med Sci Sports Exerc. 2010; 42: 1776-1784
        • Polman C.H.
        • Reingold S.C.
        • Banwell B.
        • et al.
        Diagnostic criteria for multiple sclerosis: 2010 Revisions to the McDonald criteria.
        Ann Neurol. 2011; 69: 292-302
        • Thomas S.
        • Reading J.
        • Shephard R.J.
        Revision of the physical activity readiness questionnaire (PAR-Q).
        Can J Sport Sci. 1992; 17: 338-345
        • Chetta A.
        • Rampello A.
        • Marangio E.
        • et al.
        Cardiorespiratory response to walk in multiple sclerosis patients.
        Respir Med. 2004; 98: 522-529
        • Latimer-Cheung A.E.
        • Pilutti L.A.
        • Hicks A.L.
        • et al.
        Effects of exercise training on fitness, mobility, fatigue, and health-related quality of life among adults with multiple sclerosis: a systematic review to inform guideline development.
        Arch Phys Med Rehabil. 2013; 94: 1800-1828
        • Krupp L.B.
        • LaRocca N.G.
        • Muir-Nash J.
        • Steinberg A.D.
        The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus.
        Arch Neurol. 1989; 46: 1121-1123
        • Fisk J.D.
        • Pontefract A.
        • Ritvo P.G.
        • Archibald C.J.
        • Murray T.J.
        The impact of fatigue on patients with multiple sclerosis.
        Can J Neurol Sci. 1994; 21: 9-14
        • Ware Jr., J.E.
        SF-36 health survey: manual and interpretation guide.
        New England Medical Center, the Health Institute, Boston1993
        • Ware Jr., J.E.
        SF-36 health survey update.
        Spine (Phila Pa 1976. 2000; 25: 3130-3139
        • Kelly L.P.
        • Devasahayam A.J.
        • Chaves A.R.
        • et al.
        Intensifying functional task practice to meet aerobic training guidelines in stroke survivors.
        Front Physiol. 2017; 8: 809
        • Fullmer S.
        • Benson-Davies S.
        • Earthman C.P.
        • et al.
        Evidence analysis library review of best practices for performing indirect calorimetry in healthy and non–critically ill individuals.
        J Acad Nutr Diet. 2015; 115: 1417-1446
        • Sandroff B.M.
        • Klaren R.E.
        • Pilutti L.A.
        • Motl R.W.
        Oxygen cost of walking in persons with multiple sclerosis: disability matters, but why?.
        Mult Scler Int. 2014; 2014: 7
        • Borg G.
        Borg's perceived exertion and pain scales.
        Human Kinetics, Champaign1998
        • Öztuna D.
        • Elhan A.H.
        • Tüccar E.
        Investigation of four different normality tests in terms of type 1 error rate and power under different distributions.
        Turk J Med Sci. 2006; 36: 171-176
        • Ghasemi A.
        • Zahediasl S.
        Normality tests for statistical analysis: a guide for non-statisticians.
        Int J Endocrinol Metab. 2012; 10: 486-489
        • Pereira D.G.
        • Afonso A.
        • Medeiros F.M.
        Overview of Friedman’s test and post-hoc analysis.
        Commun Stat Simul Comput. 2015; 44: 2636-2653
        • Curtin F.
        • Schulz P.
        Multiple correlations and Bonferroni’s correction.
        Biol Psychiatry. 1998; 44: 775-777
        • Meinert C.
        • Tonascia S.
        Clinical trials: design, conduct and analysis. Monographs in epidemiology and biostatistics.
        Oxford University Press, New York1986
        • Emre M.
        • de Decker C.
        Effects of cigarette smoking on motor functions in patients with multiple sclerosis.
        Arch Neurol. 1992; 49: 1243-1247
        • Paz-Ballesteros W.C.
        • Monterrubio-Flores E.A.
        • de Jesus Flores-Rivera J.
        • Corona-Vazquez T.
        • Hernandez-Giron C.
        Cigarette smoking, alcohol consumption and overweight in multiple sclerosis: disability progression.
        Arch Med Res. 2017; 48: 113-120
        • Aktan R.
        • Ozalevli S.
        Effects of smoking on respiratory problems and functional levels in multiple sclerosis patients.
        Eur Resp J. 2018; 52: PA1243
        • Ploughman M.
        Breaking down the barriers to physical activity among people with multiple sclerosis – a narrative review.
        Phys Ther Rev. 2017; 22: 124-132
        • Kroencke D.C.
        • Lynch S.G.
        • Denney D.R.
        Fatigue in multiple sclerosis: relationship to depression, disability, and disease pattern.
        Mult Scler J. 2000; 6: 131-136
        • Hemmett L.
        • Holmes J.
        • Barnes M.
        • Russell N.
        What drives quality of life in multiple sclerosis?.
        QJM. 2004; 97: 671-676
        • Chisari C.
        • Venturi M.
        • Bertolucci F.
        • Fanciullacci C.
        • Rossi B.
        Benefits of an intensive task-oriented circuit training in Multiple Sclerosis patients with mild disability.
        NeuroRehabilitation. 2014; 35: 509-518
        • Straudi S.
        • Martinuzzi C.
        • Pavarelli C.
        • et al.
        A task-oriented circuit training in multiple sclerosis: a feasibility study.
        BMC Neurol. 2014; 14: 124
        • Aktan R.
        • Ozalevli S.
        • Ozakbas S.
        Effects of cigarette smoking on respiratory problems and functional levels in multiple sclerosis patients.
        Mult Scler Relat Disord. 2018; 25: 271-275
        • Detrembleur C.
        • Dierick F.
        • Stoquart G.
        • Chantraine F.
        • Lejeune T.
        Energy cost, mechanical work, and efficiency of hemiparetic walking.
        Gait Posture. 2003; 18: 47-55
        • Larish D.D.
        • Martin P.E.
        • Mungiole M.
        Characteristic patterns of gait in the healthy old.
        Ann N Y Acad Sci. 1988; 515: 18-32
        • Waters R.
        • Perry J.
        • Antonelli D.
        • Hislop H.
        Energy cost of walking of amputees: the influence of level of amputation.
        J Bone Joint Surg Am. 1976; 58: 42-46
        • Kramer S.
        • Johnson L.
        • Bernhardt J.
        • Cumming T.
        Energy expenditure and cost during walking after stroke: a systematic review.
        Arch Phys Med Rehabil. 2016; 97: 619-632
        • Knaggs J.D.
        • Larkin K.A.
        • Manini T.M.
        Metabolic cost of daily activities and effect of mobility impairment in older adults.
        J Am Geriatr Soc. 2011; 59: 2118-2123
        • Kirkland M.
        • Downer M.
        • J Holloway B.
        • et al.
        Bipedal hopping reveals evidence of advanced neuromuscular aging among people with mild multiple sclerosis.
        J Mot Behav. 2017; 49: 505-513
        • Ploughman M.
        • Kelly L.
        Four birds with one stone? Reparative, neuroplastic, cardiorespiratory, and metabolic benefits of aerobic exercise poststroke.
        Curr Opin Neurol. 2016; 29: 684-692
        • Ploughman M.
        A new era of multiple sclerosis rehabilitation: lessons from stroke.
        Lancet Neurol. 2017; 16: 768-769
        • Sebastião E.
        • Bollaert R.E.
        • Hubbard E.A.
        • Motl R.W.
        Gait variability and energy cost of oveground walking in persons with multiple sclerosis: a cross-sectional study.
        Am J Phys Med Rehabil. 2018; 97: 646-650
        • Backus D.
        Increasing physical activity and participation in people with multiple sclerosis: a review.
        Arch Phys Med Rehabil. 2016; 97: S210-S217
        • Riemenschneider M.
        • Hvid L.G.
        • Stenager E.
        • Dalgas U.
        Is there an overlooked “window of opportunity” in MS exercise therapy? Perspectives for early MS rehabilitation.
        Mult Scler J. 2018; 24: 886-894
        • Schrack J.A.
        • Simonsick E.M.
        • Ferrucci L.
        The energetic pathway to mobility loss: an emerging new framework for longitudinal studies on aging.
        J Am Geriatr Soc. 2010; 58: S329-S336
        • Arnett S.W.
        • Laity J.H.
        • Agrawal S.K.
        • Cress M.E.
        Aerobic reserve and physical functional performance in older adults.
        Age Ageing. 2008; 37: 384-389
        • Katzel L.I.
        • Ivey F.M.
        • Sorkin J.D.
        • Macko R.F.
        • Smith B.
        • Shulman L.M.
        Impaired economy of gait and decreased six-minute walk distance in Parkinson's disease.
        Parkinsons Dis. 2012; 2012: 241754
        • Grove T.P.
        • Jones J.L.
        • Connolly S.B.
        Cardiorespiratory fitness, oxygen pulse and heart rate response following the MyAction programme.
        Br J Cardiol. 2017; 24: 25-29
        • Lennon O.C.
        • Denis R.S.
        • Grace N.
        • Blake C.
        Feasibility, criterion validity and retest reliability of exercise testing using the Astrand-rhyming test protocol with an adaptive ergometer in stroke patients.
        Disabil Rehabil. 2012; 34: 1149-1156
        • Mossberg K.A.
        • Ayala D.
        • Baker T.
        • Heard J.
        • Masel B.
        Aerobic capacity after traumatic brain injury: comparison with a nondisabled cohort.
        Arch Phys Med Rehabil. 2007; 88: 315-320
        • Ranadive M.S.
        • Yan D.H.
        • Weikert A.M.
        • et al.
        Vascular dysfunction and physical activity in multiple sclerosis.
        Med Sci Sports Exerc. 2012; 44: 238-243
        • Cole C.R.
        • Blackstone E.H.
        • Pashkow F.J.
        • Snader C.E.
        • Lauer M.S.
        Heart-rate recovery immediately after exercise as a predictor of mortality.
        N Eng J Med. 1999; 341: 1351-1357
        • Franceschini M.
        • Rampello A.
        • Bovolenta F.
        • Aiello M.
        • Tzani P.
        • Chetta A.
        Cost of walking, exertional dyspnoea and fatigue in individuals with multiple sclerosis not requiring assistive devices.
        J Rehabil Med. 2010; 42: 719-723
        • Crewe H.
        • Tucker R.
        • Noakes T.D.
        The rate of increase in rating of perceived exertion predicts the duration of exercise to fatigue at a fixed power output in different environmental conditions.
        Eur J Appl Physiol. 2008; 103: 569-577
        • Gibson A.S.
        • Baden D.A.
        • Lambert M.I.
        • et al.
        The conscious perception of the sensation of fatigue.
        Sports Med. 2003; 33: 167-176
        • Bakshi R.
        • Shaikh Z.
        • Miletich R.
        • et al.
        Fatigue in multiple sclerosis and its relationship to depression and neurologic disability.
        Mult Scler J. 2000; 6: 181-185
        • Billinger S.A.
        • Tseng B.Y.
        • Kluding P.M.
        Modified total-body recumbent stepper exercise test for assessing peak oxygen consumption in people with chronic stroke.
        Phys Ther. 2008; 88: 1188-1195
        • Billinger S.A.
        • Loudon J.K.
        • Gajewski B.J.
        Validity of a total body recumbent stepper exercise test to assess cardiorespiratory fitness.
        J Strength Cond Res. 2008; 22: 1556-1562