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Abstract Background Chronic fatigue and inactivity are prevalent problems among individuals with multiple sclerosis (MS) and may independently or interactively have detrimental effects on quality of life and ability to participate in life roles. However, no studies to date have systematically evaluated the benefits of an intervention for both managing fatigue and promoting physical activity in individuals with MS. This study involves a randomized controlled trial to examine the effectiveness of a telehealth intervention that supports individuals with MS in managing fatigue and increasing physical activity levels. Methods/Design A randomly-allocated, three-parallel group, time-series design with a social support program serving as the control group will be used to accomplish the purpose of the study. Our goal is to recruit 189 ambulatory individuals with MS who will be randomized into one of three telehealth interventions: (1) a contact-control social support intervention, (2) a physical activity-only intervention, and (3) a physical activity plus fatigue management intervention. All interventions will last 12 weeks and will be delivered entirely over the phone. Our hypothesis is that, in comparison to the contact-control condition, both the physical activity-only intervention and the physical activity plus fatigue management intervention will yield significant increases in physical activity levels as well as improve fatigue and health and function, with the physical activity plus fatigue management intervention yielding significantly larger improvements. To test this hypothesis, outcome measures will be administered at Weeks 1, 12, and 24. Primary outcomes will be the Fatigue Impact Scale, the Godin Leisure-Time Exercise Questionnaire (GLTEQ), and Actigraph accelerometers. Secondary outcomes will include the SF-12 Survey, Mental Health Inventory, Multiple Sclerosis Impact Scale, the Community Participation Indicator, and psychosocial constructs (e.g., self-efficacy). Discussion The proposed study is novel, in that it represents a multi-disciplinary effort to merge two promising lines of research on MS: fatigue management and physical activity promotion. Collectively, the proposed study will be the largest randomized controlled trial to examine the effects of a lifestyle physical activity intervention in people with MS. Trial registration NCT01572714

Background: Multiple sclerosis (MS) affects nearly 1 million people and is estimated to cost $85.4 billion in the United States annually. People with MS have significant barriers to receiving care and telemedicine could substantially improve access to specialized, comprehensive care. In cross-sectional analyses, telemedicine has been shown to be feasible, have high patient and clinician satisfaction, reduce patient costs and burden, and enable a reasonable assessment of disability. However, no studies exist evaluating the longitudinal impact of telemedicine care for MS. Here we describe the study protocol for VIRtual versus UsuAL In-office care for Multiple Sclerosis (VIRTUAL-MS). The main objective of the study is to evaluate the impact of telemedicine for MS care on: patient clinical outcomes, economic costs, patient, and clinician experience., Methods: This two-site randomized clinical trial will enroll 120 adults with a recent diagnosis of MS and randomize 1:1 to receive in-clinic vs. telemedicine care for 24 months. The primary outcome of the study is worsening in any one of the four Multiple Sclerosis Functional Composite 4 (MSFC4) measures at 24 months. Other study outcomes include patient and clinician satisfaction, major healthcare costs, Expanded Disability Status Scale, treatment adherence, and digital outcomes., Conclusion: The results of this study will directly address the key gaps in knowledge about longitudinal telemedicine-enabled care in an MS population. It will inform clinical care implementation as well as design of trials in MS and other chronic conditions., Trial Registration: NCT05660187., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Marisa McGinley has received research support from the National Institutes of Health, Novartis, Biogen, and Genentech. She has also received consulting fees from Genentech, EMD Serono, and Octave. Josh Carlson has received research support from the National Institutes of Health and the Institute for Clinical and Economic Review. He has also received consulting fees from Genentech, Pfizer, and Takeda. Jennifer Reihm reports no disclosures. Matthew Plow has received research support from the NIH, American Heart Association, National Multiple Sclerosis Society, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, Consortium of Multiple Sclerosis Centers, Department of Defence, Seibyl Foundation. Megan Roser reports no disclosures. Nikki Sisodia reports no disclosures. Jeffrey A. Cohen has received personal compensation for consulting for Astoria, Bristol-Myers Squibb, Convelo, EMD Serono, FiNS Therapeutics, INMune, and Sandoz; and serving as an Editor of Multiple Sclerosis Journal. Anita D. Misra-Hebert has received research support from the Patient-Centered Outcomes Research Institute, National Institutes of Health, Agency for Healthcare Research and Quality, Ohio Department of Medicaid, Bayer, Novo Nordisk and Merck. Ann Lazar has received research support from the PCORI, NIH, DOD, and the University of California Office of the President Historically Black Colleges and University Initiative. She serves on NIH funded Data and Safety Monitoring Board (DMSB). She also receives funding for her role as the Statistical Editor for World Journal of Surgery and International Journal of Radiation Oncology, Biology, Physics. Riley Bove has received research support from NIH, DOD, National Multiple Sclerosis Harry Weaver Award, and from Biogen, Novartis, Eli Lilly and F Hoffman-LaRoche. She has received personal advisory board or consulting fees from EMD Serono, Horizon, Janssen, and TG Therapeutics., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the adaptations made and to examine interrater reliability and feasibility of administering a telehealth version of the Multiple Sclerosis Functional Composite (tele-MSFC)., Design: The Multiple Sclerosis Functional Composite (MSFC) is a commonly used, in-person clinical outcome assessment. It is composed of the timed 25-Foot Walk Test (T25FWT), Nine-Hole Peg Test (NHPT), and Paced Auditory Serial Addition Test (PASAT). The MSFC was adapted for videoconference administration as part of a larger clinical trial. One of the adaptations included administering a timed 12.5-Foot Walk Test (T12.5FWT) for participants who did not have adequate space in their homes for the T25FWT. Participants, examiners, and raters completed surveys online about their satisfaction and experience with tele-MSFC., Setting: Participants underwent the tele-MSFC in their homes using a laptop or smartphone while examiners scored the tele-MSFC in real-time at a remote location., Participants: Community-dwelling adults (n=61) with mild-to-moderate multiple sclerosis (MS) symptoms., Interventions: Not applicable., Main Outcome Measure: Tele-MSFC., Results: Intraclass correlation coefficients (ICC) assessed interrater reliability between the examiner and 2 independent raters who later scored a recording of the tele-MSFC. Interrater reliability was excellent (ICC>0.90) for all tests, including the T12.5FWT. Participants were highly satisfied with tele-MSFC. However, challenges included adequate space for T25FWT, technical difficulties, and safety and privacy considerations of individuals with moderate impairments who were requested to have their caregivers present during testing., Conclusion: The tele-MSFC is reliable and feasible to administer with adaptations for community-dwelling adults with mild to moderate MS symptoms. Further validation of T12.5FWT is needed., (© 2024 The Authors.)

Objective: Healthcare consumers and providers are increasingly turning to digital solutions, such as curated websites. Knowing who accesses/benefits from these may improve design and development. This study investigated website usage of informal caregivers of people with multiple sclerosis and shifts in outcome plausibly associated with usage., Methods: Secondary analysis of data from a randomized clinical trial of 148 caregivers compared effectiveness of a website + tele-coaching to a website only intervention for caregivers. Groupwise differences in means/proportions were tested using t-tests and chi-square. Modified Poisson regression with a robust variance estimator and ordinal logistic regression tested the relationship between group and likelihood of website log-in. Ordinal logistic regression models examined whether caregiver characteristics were associated with website use. Generalized estimating equations (GEE) with an autoregressive correlation structure modeled the relationship between website usage and outcomes., Results: Females were more likely to access the website than males (60% vs. 43%; p = 0.05). Though not statistically significant, a possible association (POR: .85, 95% CI: .69, 1.03) between caregiver burden and website access emerged; caregivers experiencing highest levels of burden appeared less likely to engage. Usage patterns differed by treatment arm: the website-only group accessed the Caring for yourself topic significantly more (61.67% vs. 38.33%: p = .04) with similar, but insignificant, trends for other topics., Conclusions: Clinicians can be confident referring females with moderate levels of burden to website-based interventions. By contrast, male caregivers and those experiencing high levels of burden may be less likely to access these resources, pointing to the need for alternative interventions., Trial Registration: Clinicaltrials.gov, registration number: NCT0466208., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Michelle Lehman and Dr Tanya Packer are co-founders and shareholders of Think Self-Management Inc., an incorporated company that disseminates evidence-based self-management interventions. The remaining authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Caregivers of people with multiple sclerosis (MS) report poor emotional outcomes yet few interventions have been tested. The goal of this study was to compare the effectiveness of a remotely delivered intervention with 2 arms (ie, website and telecoaching vs website only) aimed at reducing depression, anxiety, stress, and distress in informal caregivers of individuals with MS., Methods: From March 2021 through August 2021, 151 care-givers were enrolled in the study. The intervention occurred over a 4-month period. The website plus telecoaching arm received (a) a monthly coaching session focused on information, skill building, and support that was delivered by a licensed social worker via videoconference or telephone, and (b) had access to a study-designed website for caregivers of individuals with MS. The website-only arm did not receive coaching sessions and had the same website access. Data were obtained at baseline, immediately after the intervention period, and 6 weeks after the intervention., Results: A linear mixed-effects model using an autoregressive covariance structure was used. It showed that the group by time interaction was statistically significant for the overall composite emotion score (depression, anxiety, stress) ( P = .037) and the stress subscale score ( P = .047), and it indicated that the website plus telecoaching arm demonstrated greater effectiveness at reducing the overall composite emotion and stress subscale scores., Conclusions: Use of a remotely delivered psychoeducational intervention that included individual coaching sessions as well as website access demonstrated preliminary efficacy in improving emotional outcomes in caregivers of individuals with MS. Further testing of the intervention with a larger sample is recommended., Competing Interests: FINANCIAL DISCLOSURES: The authors have no conflicts of interest to declare., (© 2023 Consortium of Multiple Sclerosis Centers.)

Fatigue is one of the most burdensome and disabling symptoms in numerous acute and chronic conditions and is associated with reduced participation in all aspects of daily life, for example, parenting, employment, and socialization. Historically, occupational practitioners played key roles in fatigue management by creating and implementing interventions. The American Occupational Therapy Foundation convened a Planning Grant Collective workshop with the goal to develop collaborative research ideas and proposals to advance the understanding and management of fatigue. Participants from occupational therapy and other disciplines, with expertise with fatigue or who were conducting research on fatigue, participated in a 3-day virtual workshop. Four main topics emerged: implementation science, treatment taxonomy, trial design and comparative effectiveness, and phenotyping. This white paper describes the proceedings, summarizes the discussions, and outlines recommendations from the PGC workshop on fatigue.

Background: Caregivers of persons with multiple sclerosis (MS) report high levels of distress. The National Comprehensive Cancer Network Distress Thermometer (DT) is used extensively with patients with cancer and their caregivers but has not been tested in nononcology caregivers. The purpose of this study was to examine the psychometric properties and clinical utility of the barometer portion of the DT in caregivers of persons with MS., Methods: A secondary analysis was performed of data from a randomized trial comparing the effectiveness of 2 interventions aimed at reducing psychological outcomes associated with caregiving. The DT and the 4-item Patient-Reported Outcomes Measurement Information System Anxiety and Depression scales, which were administered at baseline, were used for all analyses. Construct validity (known groups) and convergent validity (interscale correlations) were evaluated. Receiver operating characteristic curve analysis was used to evaluate clinical diagnostic test evaluation., Results: The DT had good construct validity supported by strong correlations for known-groups analyses and good convergent validity ( r = 0.70-0.72). The DT also demonstrated good discrimination for anxiety (area under the curve [AUC] = 0.83) and depression (AUC = 0.80). The optimal screening cut point on the DT was 4 for anxiety and 5 for depression., Conclusions: The barometer portion of the DT demonstrates good psychometric properties and clinical utility in caregivers of persons with MS. This is the first examination of the DT in MS care partners., Competing Interests: FINANCIAL DISCLOSURES: The authors declare no conflicts of interest., (© 2023 Consortium of Multiple Sclerosis Centers.)

Purpose: Fatigue is a common symptom of multiple sclerosis (MS) and can adversely affect all aspect of quality of life. The etiology of fatigue remains unclear, and its treatments are suboptimal. Characterizing the phenotypes of fatigued persons with MS may help advance research on fatigue's etiology and identify ways to personalize fatigue interventions to improve quality of life. The purpose of this study was to identify fatigue phenotypes; examine phenotype stability overtime; and characterize phenotypes by health and function, social and environmental determinants, psychosocial factors, and engagement in healthy behaviors., Methods: We conducted a longitudinal study over a 3-month period with 289 fatigued participants with MS. To identify fatigue phenotypes and determine transition probabilities, we used latent profile and transition analyses with valid self-report measures of mental and physical fatigue severity, the mental and physical impact of fatigue, depression, anxiety, and sleep quality. We used ANOVAs and effect sizes to characterize differences among phenotypes., Results: The best fitting model included six subgroups of participants: Mild Phenotype, Mild-to-Moderate Phenotype, Moderate-to-Severe Phenotype, Severe Phenotype, Fatigue-dominant Phenotype, and Mental Health-dominant Phenotype. The transition analysis indicated that phenotypic membership was highly stable. Variables with a large eta squared effect size included environmental barriers, self-efficacy, and fatigue catastrophizing., Conclusion: These results indicate that the magnitude of fatigue experienced may be more important to consider than the type of fatigue when characterizing fatigue phenotypes. Future research should explore whether tailoring interventions to environmental barriers, self-efficacy, and fatigue catastrophizing reduce the likelihood of transitioning to a more severe phenotype., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

The body of research on exercise and physical activity among persons with multiple sclerosis(MS) has expanded rapidly in quantity, but not necessarily quality, over the past 20+ years. There is evidence for beneficial effects of exercise and physical activity on immune cells and neurotrophic factors, brain structure and function, walking and cognitive performance, fatigue, depression, and pain, and quality of life among persons with MS. Nevertheless, there is heterogeneity in the outcomes of exercise and physical activity, and a recognition of substantial challenges for improving the effectiveness of those behaviors in MS. To move the field forward, members of the National MS Society physical wellness research working-group pooled collective experiences for identifying challenges, logistic complexities, and opportunities for researchers in designing and conducting interventions of exercise and physical activity among persons with MS. We examined the scope of our experiences and identified collective "lessons learned" regarding the behaviors themselves; study design features and stage of research; study setting, safety, and sample selection; and implementation of randomized controlled trials(RCTs) and treatment fidelity. This paper provides a resource that can inform researchers, particularly new investigators or established investigators transitioning into MS, on conducting high-quality RCTs on exercise and physical activity in MS., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest regarding this paper, and there was no source of funding for this paper., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: Telerehabilitation may be effective on average but is not equally effective among all people with multiple sclerosis (MS). Thus, the purpose of this secondary analysis of a randomized controlled trial was to explore whether baseline characteristics of participants with MS influence fatigue and physical activity outcomes of three telerehabilitation interventions., Methods: Participants were randomized to contact-control intervention (CC), physical activity-only intervention (PA-only), and physical activity plus fatigue self-management intervention (FM+). The 12-week interventions were delivered over the phone. Sociodemographic (age and income), clinical (comorbidities, mental function and physical function), psychosocial (self-efficacy, outcome expectations and goal-setting), and behavioural baseline characteristics (step count and fatigue self-management behaviors) were used in a moderated regression analysis and a responder analysis to examine their influence on the Fatigue Impact Scale (FIS) and Godin Leisure-Time Exercise Questionnaire (GLTEQ) at post-test (i.e. immediately post-interventions)., Results: No interactions terms were statistically significant in the moderation analysis. However, the responder analysis showed that baseline psychosocial characteristics and mental function were significantly different ( p  < 0.05) between responders and non-responders. Specifically, non-responders on the FIS at post-test in the PA-only intervention had significantly lower baseline scores in goal setting for engaging in fatigue self-management behaviours. Also, non-responders on the GLTEQ at post-test in the FM+ intervention had significantly worse baseline scores in mental function., Discussion: Further research is needed to understand the complex relationship among baseline characteristics, telerehabilitation and response heterogeneity. We discuss how research on examining response heterogeneity may be advanced by conducting mega-clinical trials, secondary analyses of big data, meta-analyses and employing non-traditional research designs., Trial Registration: Clinicaltrials.gov (NCT01572714).

Background: Fatigue is a common problem among people with multiple sclerosis (MS) and can have a negative effect on mental, physical, and social function. Self-reported measures of MS fatigue are often operationalized as a multi-dimensional symptom. However, questions remain about how best to account for the multi-dimensional aspects of self-reported fatigue and whether these aspects are distinct entities. Thus, the purpose of this study was to explore the overlap and distinctions between self-reported measures of the severity and impact of fatigue, between mental and physical fatigue, and between mental fatigue, depressive symptoms, and cognitive impairment., Methods: An observational study was conducted with 289 participants with MS . The questionnaires were the Unidimensional Fatigue Impact Scale (UFIS), the Chalder Fatigue Scale (CFS), the Fatigue Scale for Motor and Cognitive Functions (FSMC), the Multiple Sclerosis Neuropsychological Screening Questionnaire (MSNSQ), and the Quality of Life in Neurological Disorders short form for depression (Neuro-QoL). Spearman's correlation coefficient was used to examine the bivariate correlations between composite and subscale scores. Exploratory structural equation modeling (ESEM) was used to determine the factor structure under a pre-specified number of factors to retain in the modeling of multiple items across questionnaires and examine model fit. Subsequently for poor fitting models in an iterative procedure to determine a better fitting multidimensional model, we posited a bifactor confirmatory factor analysis model., Results: The bivariate correlation analysis revealed that subscales from the same questionnaire measuring different aspects of fatigue had the highest correlations (r = 0.61-0.68), subscales from different questionnaires measuring the same aspect of fatigue had the next highest correlations (r = 0.43-0.60), and subscales from different questionnaires measuring different aspects of fatigue had the lowest correlations (r = 0.34-0.40). Bifactor models with a general fatigue factor and subdomains pertaining to impact, severity, and mental and physical fatigue had relatively good model fits compared to models omitting the subdomains. However, an ESEM model using subscales from the CFS and FSMC fit poorly and did not adequately identify separate factors for mental and physical fatigue. An ESEM model with separate factors for self-reported mental fatigue, depressive symptoms, and cognitive impairment was a good fit., Conclusions: The working study hypothesis that fatigue constructs would be moderately correlated yet distinct entities was generally supported by the results of the study. However, we found that our hypothesized separation into a latent dimension existed only when the items or subscales came from the same questionnaire, in which case their level of specificity in terms of target, action, context, and time elements for measuring fatigue were consistent. The implications for the principle of compatibility in measuring self-reported MS fatigue are discussed., (Copyright © 2022. Published by Elsevier B.V.)

Background: Fatigue is one of the most common and disabling symptoms in people with multiple sclerosis (MS). Fatigue self-management behaviors may be effective in reducing the impact of fatigue in people with MS. However, few studies have examined the factors that influence engagement in fatigue self-management behaviors., Objective: Identify factors that directly and indirectly influence fatigue self-management behaviors., Methods: Participants with MS (n = 287) completed online questionnaires at baseline and 6-weeks. Guided by the Self- and Family Management Framework, we examined the influence of health status, resources and environment, healthcare utilization, and self-management processes on fatigue self-management behaviors at 6-weeks. Multiple regression and path analyses were conducted., Results: The final regression model variables accounted for 41.58% of the variance in fatigue self-management behaviors, which included outcome expectations (β= 0.287), disability (β= 0.265), environmental barriers (β= 0.188), self-efficacy (β= 0.153), symptom severity (β= 0.113), living in an urban community (β= -0.108), and living alone (β= 0.103). Path analysis indicated that outcome expectations may mediate the relationship between disability levels and fatigue self-management behavior., Conclusions: Health status (i.e., disability and symptom severity), environmental factors (e.g., living situation), and self-management processes (i.e., self-efficacy and outcome expectations) may play an important role in influencing engagement in fatigue self-management behaviors.

Background: Of the approximately 1 million people living with multiple sclerosis in the United States, more than half receive informal, unpaid care or support from family or friends (caregivers). These caregivers report high levels of stress, anxiety, and negative emotions. Few researchers have conducted psychoeducational interventions for these caregivers., Objective: This paper presents a protocol for a randomized clinical trial that aims to test the efficacy of two interventions for improving stress, anxiety, depression, and negative emotions for caregivers of persons with multiple sclerosis., Methods: Participants included any self-identified family or friend caregiver of a person with multiple sclerosis. Data collection began in April 2021 and is expected to continue until November 2021. Participants will be randomized to receive either a website-only or a website-coaching intervention delivered for 6 weeks. Data will be collected at baseline, 6 weeks after baseline (after delivery of intervention), and 6 weeks later., Results: The protocol was approved by the institutional review board of the Case Western Reserve University on January 21, 2021 (protocol 20201484). As of May 2021, 66 participants were enrolled., Conclusions: Our findings will have implications for identifying the efficacy of two types of interventions developed for caregivers of persons with multiple sclerosis to reduce negative psychological outcomes associated with caregiving., Trial Registration: ClinicalTrials.gov NCT04662008; http://clinicaltrials.gov/ct2/show/NCT04662008., International Registered Report Identifier (irrid): DERR1-10.2196/30617., (©Sara L Douglas, Matthew Plow, Tanya Packer, Amy R Lipson, Michelle J Lehman. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 26.08.2021.)

Introduction: Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system. It is considered a major cause of non-traumatic disability in young adults. One of the most common and disabling symptoms of MS is fatigue. MS fatigue can impact all aspects of quality of life, including physical, mental and social function. Fortunately, fatigue self-management interventions, such as ' Managing Fatigue: A 6 week energy conservation course' , can decrease the impact of fatigue and improve health-related quality of life. The purpose of this study is to compare three modes of delivering the Managing Fatigue intervention-two remote delivery formats (teleconference and internet) and one in-person format-on perceptions of fatigue and its impact on physical, mental and social function., Methods and Analysis: A non-inferiority randomised clinical trial is being conducted to compare the three delivery formats (1:1:1 allocation ratio) among 582 participants with MS living in the Midwestern and Northeastern United States. The hypothesis is that teleconference and internet versions of the intervention are non-inferior to the traditional mode of clinical service delivery (ie, one to one, in person) in terms of the primary outcome of self-reported fatigue impact (ie, Fatigue Impact Scale) and the secondary outcome of health-related quality of life (ie, Multiple Sclerosis Impact Scale). Outcomes are being measured at baseline, 2 months, 3 months and 6 months. The primary analysis tool will be linear mixed effects model. The prespecified inferiority margin for the primary outcome is 10 points. We will also examine whether baseline characteristics (eg, sociodemographic) moderate outcomes of the Managing Fatigue intervention and whether changes in self-efficacy and fatigue self-management behaviours mediate changes in outcomes., Ethics and Dissemination: The protocol is approved centrally by the institutional review board at Case Western Reserve University. Eligible participants give consent before being enrolled and randomised into the study. The study results will be disseminated through relevant advocacy organisations, newsletters to participants, publication in peer-reviewed journals and presentations at scientific conferences., Trial Registration Number: NCT03550170; Pre-results., Competing Interests: Competing interests: FB has financial relationships with pharmaceutical and devices companies outside the submitted work., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: People with multiple sclerosis (MS) often experience fatigue, which is aggravated by inactivity. Identifying mediators of changes in physical activity (PA) and fatigue self-management (FSM) behaviors could optimize future interventions that reduce the impact of MS fatigue., Purpose to: examine the effects of telephone-delivered interventions on Social Cognitive Theory constructs and test whether these constructs mediated secondary outcomes of PA and FSM behaviors., Methods: Participants with MS (n = 208; Mean age = 52.1; Female = 84.6%) were randomized into contact-control intervention (CC), PA-only intervention, and PA+FSM intervention. Step count (Actigraphy) and FSM behaviors as well as self-efficacy, outcome expectations, and goal setting for PA and FSM were measured at baseline, post-test (12 weeks), and follow-up (24 weeks). Path analyses using bias-corrected bootstrapped 95% confidence intervals (CI) determined whether constructs at post-test mediated behaviors at follow-up when adjusting for baseline measures., Results: Path analysis indicated that PA-only (β = 0.50, p < .001) and PA+FSM interventions (β = 0.42, p < .010) had an effect on goal setting for PA, and that PA + FSM intervention had an effect on self-efficacy for FSM (β = 0.48, p = .011) and outcome expectations for FSM (β = 0.42, p = .029). Goal setting for PA at post-test mediated the effects of PA-only (β = 159.45, CI = 5.399, 371.996) and PA + FSM interventions (β = 133.17, CI = 3.104, 355.349) on step count at follow-up. Outcome expectations for FSM at post-test mediated the effects of PA + FSM intervention on FSM behaviors at follow-up (β = 0.02, CI = 0.001, 0.058)., Conclusions: Goal setting for PA and outcome expectations for FSM may be important constructs to target in telephone-delivered interventions designed to reduce the impact of MS fatigue., Trial Registration: Clinicaltrials.gov (NCT01572714)., (© Society of Behavioral Medicine 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: This randomized controlled pilot study examined the feasibility and efficacy of a SystemCHANGE™ (SC) weight management intervention in adults with either multiple sclerosis or stroke., Methods: Participants (n = 61) were randomized into two interventions: SC, which taught skills to modify personal environments, or active-control (AC), which taught health behavior guidelines. Sessions were held weekly for 12 weeks. Feasibility measures included recruitment and attrition rates. The primary outcome of body weight and secondary outcomes of emotional well-being and healthy behaviors were measured before and after the interventions., Results: Average recruitment rate was 3.6 participants per month. Attrition rate was 14.8%. On average, 9.1 sessions were completed for SC and 10.7 for AC. Differences in weight loss were non-significant between interventions (P = 0.182), but significantly declined across both interventions (P = 0.011). Physical activity (P = 0.002), depression (P < 0.001), anxiety (P = 0.023), and self-efficacy (P = 0.022) all significantly improved for SC compared to AC., Conclusions: SC was feasible to implement and efficacious in improving secondary outcomes of emotional well-being and healthy behaviors, but was not efficacious in improving the primary outcome of weight loss. More research is needed to optimize SC., Practice Implications: SC might be an alternative approach to cognitive-behavioral therapy for promoting emotional well-being and healthy behaviors., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To compare the effectiveness of telephone-delivered interventions on fatigue, physical activity, and quality of life outcomes in adults with multiple sclerosis (MS)., Design: A single-blinded, randomized controlled trial. Participants were randomized to contact-control intervention (CC), physical activity-only intervention (PA-only), and physical activity plus fatigue self-management intervention (FM+). Outcomes were measured at baseline (2wk prerandomization), posttest (14wk postrandomization), and follow-up (26wk postrandomization)., Setting: Telephone-delivered in Midwest and Northeast regions of the United States., Participants: Inactive adults with MS (N=208) and moderate-to-severe fatigue., Interventions: Three or 6 group teleconferences followed by 4 individually tailored phone calls delivered during 12 weeks. An occupational therapist and research assistant delivered the teleconferences and tailored phone calls, respectively., Main Outcome Measures: Primary outcomes were self-report fatigue and physical activity measured with the Fatigue Impact Scale and Godin Leisure-Time Exercise Questionnaire, respectively. Secondary outcomes included quality of life measured with the Multiple Sclerosis Impact Scale and moderate-to-vigorous exercise and step count measured with an accelerometer., Results: Linear mixed effects models showed FM+ significantly improved self-reported fatigue (β=-11.08; P=.03) and physical activity (β=0.54; P=.01) compared with CC at posttest. However, FM+ had nonsignificant differences compared with PA-only on self-report fatigue (β=-1.08, P=.84) and physical activity (β=0.09; P=.68) at posttest. PA-only had significant improvements compared with CC on moderate-to-vigorous exercise (β=0.38; P=.02) at posttest and step count at posttest (β=1.30; P<.01) and follow-up (β=1.31; P=.01) measured with an accelerometer. FM+ and PA-only had nonsignificant differences compared with CC on quality of life., Conclusions: Group teleconferences followed by tailored phone calls have a small yet statistically significant effect in promoting physical activity and reducing fatigue impact in people with MS., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

A critical aspect of many rehabilitation interventions for people with multiple sclerosis (MS) is incorporating strategies that support behavior change. The main purpose of this topical review was to summarize recent randomized clinical trials (RCTs) of rehabilitation interventions in which participants learn and apply skills or engage in healthy behaviors. The Capability, Opportunity, Motivation, and Behavior (COM-B) framework was used to broadly classify behavior-change strategies. The included RCTs varied widely in terms of dosing, delivery format, and types of interventionist. Commonly used behavior-change strategies include education, persuasion, and training. We recommend that researchers and clinicians use frameworks like Behavior Change Wheel and Behavior Change Technique Taxonomy to describe and classify intervention strategies used to promote behavior change. We also recommend more sophisticated RCTs be conducted (e.g. sequential multiple assignment randomized trial and three-arm RCTs) to better understand ways of promoting behavior change in rehabilitation interventions.

Background: Our primary aim was to evaluate the effects of 2 family-based obesity management interventions compared with a control group on BMI in low-income adolescents with overweight or obesity., Methods: In this randomized clinical trial, 360 urban-residing youth and a parent were randomly assigned to 1 of 2 behaviorally distinct family interventions or an education-only control group. Eligible children were entering the sixth grade with a BMI ≥85th percentile. Interventions were 3 years in length; data were collected annually for 3 years. Effects of the interventions on BMI slope (primary outcome) over 3 years and a set of secondary outcomes were assessed., Results: Participants were primarily African American (77%), had a family income of <25 000 per year, and obese at enrollment (68%). BMI increased over time in all study groups, with group increases ranging from 0.95 to 1.08. In an intent-to-treat analysis, no significant differences were found in adjusted BMI slopes between either of the family-based interventions and the control group ( P = .35). No differences were found between the experimental and control groups on secondary outcomes of diet, physical activity, sleep, perceived stress, or cardiometabolic factors. No evidence of effect modification of the study arms by sex, race and/or ethnicity, household income, baseline levels of child and parent obesity, or exposure to a school fitness program were found., Conclusions: In this low-income, adolescent population, neither of the family-based interventions improved BMI or health-related secondary outcomes. Future interventions should more fully address poverty and other social issues contributing to childhood obesity., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Background: People with multiple sclerosis (MS) have identified "wellness" and associated behaviors as a high priority based on "social media listening" undertaken by the National MS Society (i.e. the Society)., Objective: The Society recently convened a group that consisted of researchers with experience in MS and wellness-related research, Society staff members, and an individual with MS for developing recommendations regarding a wellness research agenda., Method: The members of the group engaged in focal reviews and discussions involving the state of science within three approaches for promoting wellness in MS, namely diet, exercise, and emotional wellness., Results: That process informed a group-mediated activity for developing and prioritizing research goals for wellness in MS. This served as a background for articulating the mission and objectives of the Society's Wellness Research Working Group., Conclusion: The primary mission of the Wellness Research Working Group is the provision of scientific evidence supporting the application of lifestyle, behavioral, and psychosocial approaches for promoting optimal health of mind, body, and spirit (i.e. wellness) in people with MS as well as managing the disease and its consequences.

Background: Physical activity is considered a comprehensive approach for managing limitations in physical function among adults with chronic disabling conditions. However, adults with chronic disabling conditions often face many barriers to engaging in physical activity. A strategy to promote physical activity among adults with chronic disabling conditions is to encourage the use of mobile health (mHealth) apps., Objective: The objective of this pilot study was to examine the potential benefits of using commercially available mHealth apps in a self-management intervention among 46 adults with musculoskeletal or neurological conditions., Methods: Participants were randomized to one of 3 intervention groups: (1) mHealth-based self-management intervention, (2) paper-based self-management intervention, and (3) contact-control intervention. Participants in all 3 groups met in person once and received 3 follow-up phone calls with a trained graduate assistant. Participants in the mHealth-based and paper-based groups received a computer tablet or a paper diary, respectively, to facilitate goal setting, self-monitoring, and action planning. Participants in the contact-control group received information on healthy behaviors without being taught skills to change behaviors. The following outcomes were measured at baseline and at the 7th week: physical activity (Physical Activity and Disability Survey-revised), psychosocial factors (self-efficacy, self-regulation, and social support), and physical function (Patient Report Outcomes Measurement Information System, 6-min walk test, 1-min chair stands, and 1-min arm curls)., Results: Repeated-measures multivariate analysis of variance (MANOVA) indicated significant differences between groups in physical activity levels (Wilks λ=0.71, F 6,76 =2.34, P=.04). Both the mHealth-based and paper-based groups had large effect size increases in planned exercise and leisure-time physical activity compared with the contact-control group (Cohen d=1.20 and d=0.82, respectively). Repeated-measures MANOVA indicated nonsignificant differences between groups in psychosocial factors (Wilks λ=0.85, F 6,76 =1.10, P=.37). However, both the mHealth-based and paper-based groups had moderate effect size improvements in self-efficacy (d=0.48 and d=0.75, respectively) and self-regulation (d=0.59 and d=0.43, respectively) compared with the contact-control group. Repeated-measures MANOVA indicated nonsignificant differences between groups in physical function (Wilks λ=0.94, F 8,66 =0.27, P=.97). There were small and nonsignificant changes between the mHealth-based and paper-based groups with regard to most outcomes. However, the mHealth-based group had moderate effect size increases (d=0.47) in planned exercise and leisure-time physical activity compared with the paper-based group., Conclusions: We found that using commercially available mHealth apps in a self-management intervention shows promise in promoting physical activity among adults with musculoskeletal and neurological conditions. Further research is needed to identify the best ways of using commercially available mobile apps in self-management interventions., Trial Registration: Clinicaltrials.gov NCT02833311; https://clinicaltrials.gov/ct2/show/NCT02833311 (Archived by WebCite at http://www.webcitation.org/6vDVSAw1w)., (©Matthew Plow, Meghan Golding. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 01.12.2017.)

Background: Individuals with stroke often have multiple cardiovascular risk factors that necessitate promoting engagement in multiple health behaviors. However, observational studies of individuals with stroke have typically focused on promoting a single health behavior. Thus, there is a poor understanding of linkages between healthy behaviors and the circumstances in which factors, such as stroke impairments, may influence a single or multiple health behaviors., Methods: We conducted a mixed methods convergent parallel study of 25 individuals with stroke to examine the relationships between stroke impairments and physical activity, sleep, and nutrition. Our goal was to gain further insight into possible strategies to promote multiple health behaviors among individuals with stroke. This study focused on physical activity, sleep, and nutrition because of their importance in achieving energy balance, maintaining a healthy weight, and reducing cardiovascular risks. Qualitative and quantitative data were collected concurrently, with the former being prioritized over the latter. Qualitative data was prioritized in order to develop a conceptual model of engagement in multiple health behaviors among individuals with stroke. Qualitative and quantitative data were analyzed independently and then were integrated during the inference stage to develop meta-inferences. The 25 individuals with stroke completed closed-ended questionnaires on healthy behaviors and physical function. They also participated in face-to-face focus groups and one-to-one phone interviews., Results: We found statistically significant and moderate correlations between hand function and healthy eating habits ( r  = 0.45), sleep disturbances and limitations in activities of daily living ( r  =  - 0.55), BMI and limitations in activities of daily living ( r  =  - 0.49), physical activity and limitations in activities of daily living ( r  = 0.41), mobility impairments and BMI ( r  =  - 0.41), sleep disturbances and physical activity ( r  =  - 0.48), sleep disturbances and BMI ( r  = 0.48), and physical activity and BMI ( r  =  - 0.45). We identified five qualitative themes: (1) Impairments: reduced autonomy, (2) Environmental forces: caregivers and information, (3) Re-evaluation: priorities and attributions, (4) Resiliency: finding motivation and solutions, and (5) Negative affectivity: stress and self-consciousness. Three meta-inferences and a conceptual model described circumstances in which factors could influence single or multiple health behaviors., Discussion: This is the first mixed methods study of individuals with stroke to elaborate on relationships between multiple health behaviors, BMI, and physical function. A conceptual model illustrates addressing sleep disturbances, activity limitations, self-image, and emotions to promote multiple health behaviors. We discuss the relevance of the meta-inferences in designing multiple behavior change interventions for individuals with stroke., Competing Interests: The authors declare there are no competing interests.

A critical public health objective is to optimize and disseminate self-management interventions for the 56.7 million adults living with chronic disabling conditions in the United States. A possible strategy to optimize the effectiveness of self-management interventions is to understand how best to tailor self-management interventions to the needs and circumstances of each participant. Thus, the purpose of this scoping review was to describe randomized controlled trials (RCTs) of tailored self-management interventions in adults with neurological and musculoskeletal conditions that characteristically result in mobility impairments. The 13 RCTs included in the scoping review typically compared tailored interventions to non-tailored interventions or usual care among adults with chronic pain, stroke, and/or arthritis. The tailored interventions were diverse in their delivery formats, dosing, behavior change techniques, and tailoring strategies. We identified 13 personal characteristics (e.g., preferences and theoretical constructs) and 4 types of assessment formats (i.e., oral history, self-report questionnaires, provider-reported assessments, and medical records) that were used to tailor the self-management interventions. It was common to tailor intervention content using self-report questionnaires that assessed personal characteristics pertaining to impairments and preferences. Content was matched to personal characteristics using clinical judgment or computer algorithms. However, few studies adequately described the decision rules for matching content. To advance the science of tailoring self-management interventions, we recommend conducting comparative effectiveness research and further developing a taxonomy to standardize descriptions of tailoring. We discuss the opportunities that are now coalescing to optimize tailored self-management. We also provide examples of how to merge concepts from the self-management literature with conceptual frameworks of tailoring from the health communication literature.

The purpose of this study was to examine the usability of Nintendo Wii Fit to promote physical activity in adults with multiple sclerosis. Qualitative interviews were conducted as part of a pilot study that examined the health outcomes of a 14-week Wii Fit home-exercise programme in 30 adults with multiple sclerosis. We found participants reported that Wii Fit helped build confidence in abilities, achieve goals related to engagement in leisure activities and remove barriers associated with going to a gym to exercise. However, Wii Fit induced initial reactions of intimidation and worries about falling, and feedback during game play reminded participants of their impairments. Wii Fit was limited in its customizability to accommodate different functional levels. Understanding how to improve the usability and customizability of commercially available exergaming technology could be of benefit to people with disabling conditions. Before conducting randomized controlled trials of commercially available exergaming technology in adults with disabling conditions, we recommend that strategies be identified to remove usability barriers so those with moderate impairments can be included in the trial. This will reduce the likelihood of ceiling effects and clinical irrelevance. In terms of clinical recommendations, rehabilitation professionals need to consider patients' functional level, surrounding environment and preferences when prescribing a Wii Fit-based exercise programme., (Copyright © 2013 John Wiley & Sons, Ltd.)

Objective: Investigate the feasibility and potential efficacy of a customized print-based intervention to promote physical activity and symptom self-management in women with multiple sclerosis., Design: A randomly allocated two-group repeated measures design, with a delayed-treatment contact group serving as the control. Participants were randomized to receive the intervention immediately (n =14) or receive it at week 12 (n =16). Outcome measures were administered at weeks 1, 12, and 24., Setting: Community-based in metropolitan area., Subjects: Thirty women with multiple sclerosis., Intervention: Prescribing a home-exercise program and following up with customized pamphlets, which are matched to participants' stage of readiness to change physical activity behavior and physical activity barriers (e.g. encouraging self-management of symptoms)., Main Measures: Physical Activity and Disability Survey-revised, Godin Leisure-Time Exercise Questionnaire, SF-12, Symptoms of Multiple Sclerosis Scale, and 6-minute walk test., Results: Intent-to-treat analyses using mixed multivariate analysis of variance (MANOVA) were conducted on (1) physical activity levels and (2) health and function outcomes. The mixed MANOVAs for physical activity levels and health and function outcomes indicated significant improvements in the immediate group compared with the delayed group (i.e. condition by time interaction was significant, Wilks' λ = 0.59, F(2, 27) = 9.31, P = 0.001 and Wilks' λ = 0.70, F(4, 25) = 2.72, P = 0.052, respectively). The intervention had moderate to large effect sizes in improving physical activity levels (d = 0.63 to 0.89), perceptions of physical function (d = 0.63), and 6-minute walk test (d=0.86)., Conclusion: This pilot study indicates that a customized print-based intervention shows promise in improving physical activity levels and health and function in women with multiple sclerosis.

We investigated the kinetic features of manual dexterity and fine motor control during a task that resembles an activity of daily living in 30 persons with relapsing-remitting multiple sclerosis (PwMS). Specifically, a novel two-transducer system was used to measure time and grip-load forces during a bimanual task that is similar to opening and closing a jar. We hypothesized that PwMS would have increased grip force production, deteriorations in kinetic timing, and preserved grip-load coupling indices compared to healthy controls (i.e., young and older adults). Increased grip force production and deterioration in timing indices were confirmed in PwMS. Abnormal grip-load coupling was exhibited by PwMS, in contrast to healthy participants. The correlation between task time and self-reported disability scores suggests that objective measurement of impaired upper-extremity movements relates to perception of overall function.

Background: Over 65% of stroke survivors are either overweight or obese and have multiple cardiovascular risk factors. However, few studies have examined the effects of comprehensive lifestyle behavior interventions to promote weight loss and control cardiovascular risk factors in stroke survivors. Thus, the purpose of this study is to examine a novel behavior change approach--SystemCHANGE™--to promote weight loss and improve health and function in stroke survivors. SystemCHANGE™ focuses on redesigning the social environment to achieve a specific goal., Methods: We will conduct a randomized controlled pilot study to examine the efficacy, feasibility, and safety of the SystemCHANGE™ weight management program in overweight and obese stroke survivors. The central hypothesis of the study is that the SystemCHANGE™ intervention will help overweight and obese stroke survivors lose 5% of their body weight, thereby improving health and function. Thirty-five stroke survivors will be randomized into either the 6-month SystemCHANGE™ intervention or a contact-control intervention. Outcome measures will be assessed at baseline and again at 3 and 6 months after the interventions. Body composition will be assessed using a Bod Pod. Patient-reported outcomes will be the Stroke Impact Scale and Reintegration to Normal Living Index. Objective outcomes will include the 6-Minute Walking Test and Rivermead Motor Assessment., Discussion: This study will be the first randomized controlled trial to evaluate the efficacy and safety of a weight management intervention in stroke survivors using the SystemCHANGE™ approach. Furthermore, it will be the first empirically-examined comprehensive lifestyle intervention designed to target physical activity, nutrition, and sleep to promote weight loss in stroke survivors., Trial Registration: ClinicalTrials.gov Identifier: NCT01776034.

Few studies have explored how people living with multiple sclerosis (MS) cope with impairments and disability to participate in nutritional behaviors, such as meal preparation and grocery shopping. Thus, we conducted a qualitative study among eight individuals with MS who experienced mobility impairments. The eight individuals participated in semistructured, face-to-face interviews that focused on obtaining narratives about day-to-day dietary habits, preparing food, grocery shopping, and going to restaurants. Interviews were analyzed using an inductive category and theme development approach. Overall themes were (a) "it's a lot of work," (b) "it's not just up to me," (c) sifting through nutritional information, and (d) "why I eat what I eat." Participants frequently reported fatigue and mobility impairments as barriers to engagement in nutritional behaviors and often described family members as the "gatekeepers" for food selection and preparation (i.e., providing tangible support). Future research should explore the effectiveness of nutritional interventions that target family dynamics and create a supportive social environment to promote healthy eating habits and nutritional autonomy.

Background: Adults with multiple sclerosis (MS) have many health problems that can interfere with healthy nutritional behaviors. Self-management activities (e.g., strategies used to manage emotions and functional limitations) may help facilitate engagement in healthy nutritional behaviors. However, few studies have documented such relationships., Objective: Identify predictors of nutritional behaviors from among a set of variables (i.e., personal characteristics, health status indicators, and self-management activities) linked to the International Classification of Function., Methods: Data were obtained from an online survey of 292 individuals with MS. Significant bivariate correlates were entered into a logistic regression analysis using backward and forward selection methods to identify predictors of healthy nutritional behaviors (i.e., endorsing 4 out of 5 questions about frequently making good food choices, limiting fat intake, consuming 5 servings of fruits and vegetables, reading food labels, and eating regularly)., Results: Sex, nutritional self-efficacy, optimism/pessimism, body mass index, physical activity, emotional self-management, and communication with physician were used in the logistic analysis. Nutritional self-efficacy (β = 0.69, p < 0.001) was the strongest predictor of nutritional behaviors, followed by physician communication (β = 0.08, p = 0.029) and physical activity (β = 0.01, p = 0.035). Neither impairments nor activity limitations were significantly associated with nutritional behaviors., Conclusions: This study provides preliminary evidence that self-efficacy and self-management activities are correlates of nutritional behaviors in individuals with MS. Supporting the development of self-management skills and increasing self-efficacy might be methods for improving engagement in healthy nutritional behaviors among adults with MS., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Previous studies support the efficacy and effectiveness of face-to-face group-based fatigue management education for people with multiple sclerosis (MS). Nevertheless, many people are unable to access these programs due to environmental barriers., Objectives: To test the efficacy and effectiveness of a group-based, teleconference-delivered fatigue management program for people with MS., Methods: A randomly allocated two-group time series design with a wait-list control group was used. In total 190 participants were allocated (94 intervention, 96 wait-list control). Primary outcomes (fatigue impact, fatigue severity, health-related quality of life (HRQOL)) were measured before, immediately after, at 6 weeks, 3 months, and 6 months post. Secondary outcome (self-efficacy) was measured at the same points. Effectiveness (intent-to-treat) and efficacy (per protocol) analyses were conducted., Results: The program was more effective and efficacious than control for reducing fatigue impact but not fatigue severity. Before and after comparisons with the pooled sample demonstrated efficacy and effectiveness for fatigue impact, fatigue severity, and 6 of 8 HRQOL dimensions. Changes were maintained for 6 months with small to moderate effect sizes., Conclusion: The results offer strong support for the viability of teleconference-delivered fatigue management education for enabling people with MS to manage this disabling symptom.

We examined the potential of Nintendo Wii Fit (Nintendo Co, Ltd, Kyoto, Japan) to increase physical activity (PA) behavior and health among people with multiple sclerosis (MS). The study consisted of a repeated-measures design with a baseline control period and involved 30 people with MS who had the ability to walk 25 feet with or without a cane (26 individuals were included in the analyses). Nintendo Wii was set up in the homes of participants, who were prescribed a Wii Fit exercise program lasting 14 weeks, 3 days a week. The Physical Activity and Disability Survey, Modified Fatigue Impact Scale, and 36-item Short Form Health Status Survey were administered three times before participants gained access to Wii Fit (control period, at 2-week intervals), and three times after they received Wii Fit (posttest 1: immediately after; posttest 2: 7 weeks after; posttest 3: 14 weeks after). Mobility, balance, strength, and weight were assessed at the first pretest, immediately prior to obtaining access to Wii Fit, and 7 weeks after obtaining access to Wii Fit. Results from the questionnaires indicated that PA significantly improved at week 7, but at week 14, PA levels declined relative to week 7 and the difference was no longer significant compared with the control period. Physical assessments indicated that balance and strength significantly improved at week 7. One adverse event was reported (repetitive knee injury). Physical assessments indicated that people with MS may be able to improve their fitness levels by using Wii Fit. Future studies should incorporate behavior change strategies to promote long-term use of Wii Fit, and explore whether individuals with more severe symptoms of MS can safely use Wii Fit.

Background: There is limited understanding of the utilization of and perceived need for physical therapy services among middle-aged and older adults with multiple sclerosis (MS). The resulting knowledge gap compromises efforts for physical therapy service planning for this population., Objective: The purpose of this study was to examine the use of and need for physical therapy services in a sample of adults with MS living in the Midwestern United States., Design: This was a cross-sectional, descriptive study., Methods: Data from telephone interviews with 1,065 people with MS, aged 45 to 90 years, were used for the study. A multinomial regression model was used to determine factors associated with use of physical therapy services (never, within the past year, more than a year ago). Logistic regression analysis examined factors associated with unmet needs for these services., Results: Thirty-six percent of the sample reported never using physical therapy services, 33% reported using physical therapy services within the past year, and 31% reported using physical therapy services more than a year prior to the interview. Factors associated with recent use of physical therapy services included living in an urban or suburban community, deteriorating MS status, experiencing problems with spasticity (ie, hypertonicity), having difficulty moving inside the house, being hospitalized in the past 6 months, and seeing a family physician. These same factors were associated with unmet needs. Limitations Physical therapy service use was self-reported. Data were collected in 5 Midwestern states from people 45 years of age or older, which may limit generalizability., Conclusions: Factors associated with use of and need for physical therapy services reflect issues of access (geographical, referrals), MS status, and mobility difficulties.

Identification and prevention of community reintegration problems of veterans is an important public health mandate. However, no veteran-specific measure exists. Study purposes were to (1) develop the Community Reintegration for Service Members (CRIS) measure and (2) test the validity and reliability of the measure. Formative research identified challenges in community reintegration postdeployment. The World Health Organization's International Classification of Functioning, Disability and Health participation domain guided item-bank development. Items were refined through cognitive interviews and clinician consultation. Pilot studies with 126 veterans examined unidimensionality, internal consistency, reliability, and construct validity. Three unidimensional CRIS scales were developed. Working subjects had better CRIS scores then unemployed subjects. Subjects with posttraumatic stress disorder, substance abuse, or mental health problems had worse scores than subjects without these conditions. The correlations between the CRIS and the 36-Item Short Form Health Survey scales of role physical, role emotional, and social functioning were 0.44-0.80. CRIS has strong reliability, conceptual integrity, and construct validity.