Original research| Volume 101, ISSUE 7, P1152-1161, July 2020

Mediating Role of Resilience on Quality of Life in Individuals With Multiple Sclerosis: A Structural Equation Modeling Approach

Published:March 10, 2020DOI:



      To examine the relationship between disease-related risk factors, protective factors, coping, and resilience on quality of life in adults with multiple sclerosis (MS).


      Quantitative descriptive research employing structural equation modeling.


      Online survey fielded to community members associated with the Greater New England Chapter of the National Multiple Sclerosis Society.


      Convenience sample of 271 individuals with MS.


      Not applicable.

      Main Outcome Measures

      The Leeds Multiple Sclerosis Quality of Life (LMSQoL) scale was the primary outcome. Other measures entered into the model included the Brief Resilience Scale (BRS) and the Coping Orientation to Problems Experienced (COPE) scale modeled as 2 latent variables: emotion-based coping and problem-based coping. Disability level, fatigue, walking impairment, fear of falling, falls, and pain were modeled as a latent variable for risk factors while physical activity, self-efficacy, social support, optimism, and health locus of control were modeled as a latent variable of protective factors.


      BRS had a total effect of –0.44 on LMSQoL, significant at P<.001. Protective factors also directly and significantly increased QoL (total effect size –0.46; P<.001). Emotion-based coping and problem-based coping had insignificant effects on QoL. Risk factors had a complex influence on QoL, mediated by resilience, protective factors, emotion-based coping, and problem-based coping. Risk factors had total effect size of 0.32 on quality of life (significant at P<.001). Whereas higher risk factors decreased QoL, both directly and indirectly, resilience increased the likelihood of higher QoL with a slightly higher effect size. The model fit the data reasonably well and explained 96.7% of the variance in QoL in people with MS.


      The model suggests that developing interventions that increase protective factors and broaden and build resilience may contribute to improved quality of life in individuals with MS.


      List of abbreviations:

      BRS (Brief Resilience Scale), COPE (Coping Orientation to Problems Experienced), LMSQoL (Leeds Multiple Sclerosis Quality of Life), MHLC-C (Multidimensional Health Locus of Control–Form C), MS (multiple sclerosis), QoL (quality of life)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mitsonis C.I.
        • Potagas C.
        • Zervas I.
        • Sfagos K.
        The effects of stressful life events on the course of multiple sclerosis: a review.
        Int J Neurosci. 2009; 119: 315-335
        • Zwibel H.L.
        Contribution of impaired mobility and general symptoms to the burden of multiple sclerosis.
        Adv Therapy. 2009; 26: 1043-1057
        • Ytterberg C.
        • Johansson S.
        • Andersson M.
        • Widén Holmqvist L.
        • von Koch L.
        Variations in functioning and disability in multiple sclerosis: a two-year prospective study.
        J Neurol. 2008; 255: 967-973
        • Lobentanz I.S.
        • Asenbaum S.
        • Vass K.
        • et al.
        Factors influencing quality of life in multiple sclerosis patients: disability, depressive mood, fatigue and sleep quality.
        Acta Neurol Scand. 2004; 110: 6-13
        • Dennison L.
        • Moss-Morris R.
        • Chalder T.
        A review of psychological correlates of adjustment in patients with multiple sclerosis.
        Clin Psychol Rev. 2009; 29: 141-153
        • McCabe M.P.
        • McKern S.
        • McDonald E.
        Coping and psychological adjustment among people with multiple sclerosis.
        J Psychosom Res. 2004; 56: 355-361
        • Goretti B.
        • Portaccio E.
        • Zipoli V.
        • et al.
        Coping strategies, psychological variables and their relationship with quality of life in multiple sclerosis.
        Neurol Sci. 2009; 30: 15-20
        • Bonanno G.A.
        Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events.
        Am Psychol. 2004; 59: 20-28
        • Zautra A.J.
        • Hall J.S.
        • Murray K.E.
        Resilience: a new definition of health for people and communities.
        in: Reich J.W. Zautra A.J. Hall J.S. Handbook of adult resilience. Guilford, New York2010: 3-34
        • Carver C.S.
        Resilience and thriving: issues, models, and linkages.
        J Soc Issues. 1998; 54: 245-266
        • Windle G.
        • Bennett K.M.
        • Noyes J.
        A methodological review of resilience measurement scales.
        Health Qual Life Outcomes. 2011; 9: 1-18
        • Ryff C.D.
        • Singer B.
        Flourishing under fire: resilience as a prototype of challenged thriving.
        in: Haidt J. Keyes C.L.M. Flourishing: positive psychology and the life well lived. American Psychological Association, Washington (DC)2003: 15-36
        • Kasser S.L.
        • McCubbin J.A.
        • Hooker K.
        Variability in constraints and functional competence in adults with multiple sclerosis.
        Am J Phys Med Rehabil. 2003; 82: 517-525
        • Kasser S.L.
        • Jacobs J.V.
        • Foley J.T.
        • Cardinal B.J.
        • Maddalozzo G.F.
        A prospective evaluation of balance, gait, and strength to predict falling in women with multiple sclerosis.
        Arch Phys Med Rehabil. 2011; 92: 1840-1846
        • Peterson E.W.
        • Cho C.C.
        • von Koch L.
        • Finlayson M.L.
        Injurious falls among middle aged and older adults with multiple sclerosis.
        Arch Phys Med Rehabil. 2008; 89: 1031-1037
        • Silverman A.
        • Verrall A.
        • Alschuler K.
        • Smith A.
        • Ehde D.
        Bouncing back again, and again: a qualitative study of resilience in people with multiple sclerosis.
        Disabil Rehabil. 2016; 38: 1-9
        • Terrill A.
        • Molton I.
        • Ehde D.
        • et al.
        Resilience, age, and perceived symptoms in persons with long-term physical disabilities.
        J Health Psychol. 2016; 21: 640-649
        • Ploughman M.
        • Austin M.W.
        • Murdoch M.
        • et al.
        Factors influencing healthy aging with multiple sclerosis: a qualitative study.
        Disabil Rehabil. 2012; 34: 26-33
        • Nery-Hurwit M.
        • Yun J.
        • Ebbek V.
        Examining the roles of self-compassion and resilience on health-related quality of life for individuals with multiple sclerosis.
        Disabil Health J. 2018; 11: 256-261
        • Koelmel E.
        • Hughes A.J.
        • Alschuler K.N.
        • Ehde D.M.
        Resilience mediates the longitudinal relationships between social support and mental health outcomes in multiple sclerosis.
        Arch Phys Med Rehabil. 2017; 98: 1139-1148
        • Black R.
        • Dorstyn D.
        A biopsychosocial model of resilience for multiple sclerosis.
        J Health Psychol. 2015; 20: 1434-1444
        • Kratz A.L.
        • Braley T.J.
        • Foxen-Craft E.
        • Scott E.
        • Murphy J.F.
        • Murphy S.L.
        How do pain, fatigue, depressive and cognitive symptoms relate to well-being and social and physical functioning in the daily lives of individuals with multiple sclerosis?.
        Arch Phys Med Rehabil. 2017; 98: 2160-2166
        • Rintala A.
        • Hakkinen A.
        • Paltamaa J.
        Ten-year follow-up of health-related quality of life among ambulatory persons with multiple sclerosis at baseline.
        Qual Life Res. 2016; 25: 3119-3127
        • Matsuda P.N.
        • Shumway-Cook A.
        • Ciol M.A.
        • Bombardier C.H.
        • Kartin D.A.
        Understanding falls in multiple sclerosis: association of mobility status, concerns about falling, and accumulated impairments.
        Phys Ther. 2012; 92: 407-415
        • Strober L.B.
        Quality of life and psychological well-being in the early stages of multiple sclerosis (MS): importance of adopting a biopsychosocial model.
        Disabil Health J. 2018; 11: 555-561
        • Hohol M.J.
        • Orav E.J.
        • Weiner H.L.
        Disease steps in multiple sclerosis: a longitudinal study comparing Disease Steps and EDSS to evaluate disease progression.
        Mult Scler. 1999; 5: 349-354
        • Nevitt M.C.
        • Cummings S.R.
        • Kidd S.
        • Black D.
        Risk factors for recurrent nonsyncopal falls: a prospective study.
        JAMA. 1989; 261: 2663-2668
        • Smith B.W.
        • Dalen J.
        • Wiggins K.
        • Tooley E.
        • Christopher P.
        • Bernard J.
        The Brief Resilience Scale: assessing the ability to bounce back.
        Int J Behav Med. 2008; 15: 194-200
        • Carver C.S.
        • Scheier M.F.
        • Weintraub J.K.
        Assessing coping strategies: a theoretically based approach.
        J Pers Soc Psychol. 1989; 56: 267-283
        • Lode K.
        • Bru E.
        • Klevan G.
        • Myhr K.M.
        • Nyland H.
        • Larsen J.P.
        Coping with multiple sclerosis: a 5-year follow-up study.
        Acta Neurol Scand. 2010; 122: 336-342
        • Lode K.
        • Bru E.
        • Klevan G.
        • Myhr K.M.
        • Nyland H.
        • Larsen J.P.
        Depressive symptoms and coping in newly diagnosed patients with multiple sclerosis.
        Mult Scler. 2009; 15: 638-643
        • Cutrona C.E.
        • Russell D.W.
        The provisions of social relationships and adaptation to stress.
        Adv Pers Relat. 1987; 1: 37-67
        • Chiu C.Y.
        • Motl R.W.
        • Ditchman N.
        Validation of the Social Provisions Scale in people with multiple sclerosis.
        Rehabil Psych. 2016; 61: 297-307
        • Scheier M.F.
        • Carver C.S.
        • Bridges M.W.
        Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a re-evaluation of the Life Orientation Test.
        J Pers Soc Psychol. 1994; 67: 1063-1078
        • Hart S.L.
        • Vella L.
        • Mohr D.C.
        Relationships among depressive symptoms, benefit-finding, optimism, and positive affect in multiple sclerosis patients after psychotherapy for depression.
        Health Psychol. 2008; 27: 230-238
        • Wallston K.A.
        • Stein M.J.
        • Smith C.A.
        Form C of the MHLC scales: a condition-specific measure of locus of control.
        J Personal Assess. 1994; 63: 534-553
        • Moshki M.
        • Ghofranipour F.
        • Hajizadeh E.
        • Azadfallah P.
        Validity and reliability of the multidimensional health locus of control scale for college students.
        BMC Public Health. 2007; 7: 295
        • Schwartz C.E.
        • Coulthard-Morris L.
        • Zeng Q.
        • Retzlaff P.
        Measuring self-efficacy in people with multiple sclerosis: a validation study.
        Arch Phys Med Rehabil. 1996; 77: 394-398
        • Hobart J.C.
        • Riazi A.
        • Lamping D.L.
        • Fitzpatrick R.
        • Thompson A.J.
        Measuring the impact of MS on walking ability: the 12-Item MS Walking Scale (MSWS-12).
        Neurology. 2003; 60: 31-36
        • McGuigan C.
        • Hutchinson M.
        Confirming the validity and responsiveness of the Multiple Sclerosis Walking Scale-12 (MSWS-12).
        Neurology. 2004; 62: 2103-2105
        • Yardley L.
        • Beyer N.
        • Hauer K.
        • Kempen G.
        • Piot-Ziegler C.
        • Todd C.
        Development and initial validation of the Falls Efficacy Scale-International (FES-I).
        Age Ageing. 2005; 36: 614-619
        • van Vliet R.
        • Hoang P.
        • Lord S.
        • Gandevia S.
        • Delbaere K.
        Falls Efficacy Scale-International: a cross-sectional validation in people with multiple sclerosis.
        Arch Phys Med Rehabil. 2013; 94: 883-889
        • Ritvo P.G.
        • Fischer J.S.
        • Miller D.M.
        • Andrews H.
        • Paty D.
        • LaRocca N.G.
        Multiple sclerosis quality of life inventory: a user’s manual.
        National Multiple Sclerosis Society, New York1997
        • Rietberg M.B.
        • Van Wegen E.E.
        • et al.
        Measuring fatigue in patients with multiple sclerosis: reproducibility, responsiveness and concurrent validity of three Dutch self-report questionnaires.
        Disabil Rehabil. 2010; 32: 1870-1876
        • Amtmann D.
        • Bamer A.M.
        • Noonan V.
        • Lang N.
        • Kim J.
        • Cook K.F.
        Comparison of the psychometric properties of two fatigue scales in multiple sclerosis.
        Rehabil Psychol. 2012; 57: 159-166
        • Godin G.S.
        • Shephard R.J.
        A simple method to assess exercise behavior in the community.
        Can J Appl Sport Sci. 1985; 10: 141-146
        • Gosney J.L.
        • Scott J.A.
        • Snook E.M.
        • Motl R.W.
        Physical activity and multiple sclerosis: validity of self-report and objective measures.
        Fam Community Health. 2007; 3: 144-150
        • Ford H.L.
        • Gerry E.
        • Tennant A.
        • Whally D.
        • Haigh R.
        • Johnson M.H.
        Developing a disease-specific quality of life measure for people with multiple sclerosis.
        Clin Rehabil. 2001; 15: 247-258
        • Nicholl L.
        • Hobart J.C.
        • Cramp A.F.
        • Lowe-Strong A.S.
        Measuring quality of life in multiple sclerosis: not as simple as it sounds.
        Mult Scler. 2005; 11: 708-712
        • Acock A.C.
        Discovering structural equation modeling using Stata.
        Stata Press, College Station2013
        • Ullman J.B.
        • Bentler P.M.
        Structural equation modeling.
        in: Schinka J.A. Velicer W.F. Handbook of psychology: research methods in psychology. Somerset: John Wiley & Sons, 2003: 607-634
        • Brown T.A.
        Confirmatory factor analysis for applied research.
        Guilford Publications, New York2014
        • Bentler P.M.
        Causal modeling via structural equation systems.
        in: Nesselroade J.R. Cattell R.B. Handbook of multivariate experimental psychology. Perspectives on individual differences. Springer, Boston1988
        • Jongen J.J.
        Health-related quality of life in patients with multiple sclerosis: impact of disease-modifying drugs.
        CNS Drugs. 2017; 31: 585-602
        • Learmonth Y.C.
        • Hubbard E.A.
        • McAuley E.
        • Motl R.W.
        Psychometric properties of quality of life and health-related quality of life assessments in people with multiple sclerosis.
        Qual Life Res. 2014; 23: 2015-2023
        • Lily O.
        • McFadden E.
        • Hensor E.
        • Johnson M.
        • Ford H.
        Disease-specific quality of life in multiple sclerosis: the effect of disease modifying treatment.
        Mult Scler. 2006; 12: 808-813
        • Ford H.L.
        • Gerry E.
        • Johnson M.H.
        • Tennant A.
        Health status and quality of life of people with multiple sclerosis.
        Dis Rehabil. 2001; 23: 516-521
        • Smith B.W.
        • Epstein E.E.
        • Ortiz J.A.
        • Christopher P.K.
        • Tooley E.M.
        The foundations of resilience: what are the critical resources for bouncing back from stress?.
        in: Prince-Embury S. Saklofske D.H. Resilience in children, adolescents, and adults: translating research into practice. The Springer series on human exceptionality. Springer, New York2013: 167-187
        • Sheeran P.
        • Harris P.R.
        • Epton T.
        Does heightening risk appraisals change people’s intentions and behavior? A meta-analysis of experimental studies.
        Psych Bull. 2014; 140: 511-543
        • Rimal R.N.
        • Real K.
        Perceived risk and efficacy beliefs as motivators of change: use of the risk perception attitude framework to understand health behaviors.
        Hum Comm Res. 2003; 29: 370-399
        • Baker J.P.
        • Berenbaum H.
        Emotional approach and problem-focused coping: a comparison of potentially adaptive strategies.
        Cog Emotion. 2007; 21: 95-118
        • Lode K.
        • Larsen J.P.
        • Bru E.
        • Klevan G.
        • Myhr K.M.
        • Nyland H.
        Patient information and coping styles in multiple sclerosis.
        Multiple Sclerosis. 2007; 13: 792-799
        • Tan-Kristanto S.
        • Kiropoulos L.
        Resilience, self-efficacy, coping styles and depressive and anxiety symptoms in those newly diagnosed with multiple sclerosis.
        Psych Health Med. 2015; 20: 1-11
        • Vitali S.
        Finding quality of life despite MS: harnessing resilience.
        Int MS J. 2011; 17: 94-99