Internet Intervention for Increasing Physical Activity in Persons with Multiple Sclerosis
Motl, R. W., Dlugonski, D., Wojcicki, T. R., McAuley, E. & Mohr, D. C. (2011). Internet intervention for increasing physical activity in persons with multiple sclerosis. Multiple Sclerosis Journal, 17(1), 116-128.
Internet health interventions have begun to grow in popularity because they provide counseling and information to viewers in the comfort of their own home. While it is exciting that early evidence is showing web-delivered programs can be as effective as face-to-face programs for the general population, this is possibly even more exciting for people with disabilities who encounter numerous barriers (for example: cost, transportation, and access) to their healthful pursuits. However, the evidence for the effectiveness of these programs is limited in even the general population and almost non-existent in people with disabilities.
A recent article did focus on delivering web-based programs to people with disabilities. Motl et al. (2011) conducted a randomized controlled trial to look at the effect of an Internet intervention on increasing physical activity in people with multiple sclerosis (MS). The content of the intervention was based upon concepts from social cognitive theory (SCT), which is founded on the ideas that people learn by observing others and that behaviors both influence and are influenced by personal and environmental factors.
Participants: Fifty-four individuals with relapsing-remitting multiple sclerosis (RRMS) were randomly placed into either the Internet intervention or a control group.
Method: The length of the program was 12 weeks, with measurements taken at baseline and the end of the program. Outcome measures included physical activity levels as determined by the Godin Leisure-Time Exercise Questionnaire; self-efficacy as assessed by the Exercise Self-Efficacy Scale; outcome expectations about the benefits of exercise as measured by the Multidimensional Outcomes Expectations for Exercise Scale; goal-setting as measured by the Exercise Goal setting Scale; and disease severity using the Patient Determined Disease Steps scale.
The intervention was modified from an effective face-to-face intervention for delivery over the Internet, incorporating the concepts of self-efficacy, outcome expectations, functional limitations, and goal setting. The format included video and PDF files to support the text content. The website was updated weekly in month one, biweekly in month two, and only once in month three. The content that was provided included instructions for using a pedometer, benefits of physical activity, ways to be more physically active, goal setting, outcome expectations, self-efficacy, barriers and strategies to overcome them, social support, maintaining an active lifestyle, physical activity relapse prevention, supporting research articles, video testimonials from people with MS, and additional worksheets and questionnaires that could help individuals develop more personal relevance. Online chat sessions were held twice a week, forums were created, and a toll-free hotline and study e-mail address were available, but only to support the website. Automated e-mail announcements were also used to remind participants to log into the website. The control group received no contact throughout the 12 weeks.
Results: Twenty-three individuals in the intervention group completed the study and 25 in the control group. There were no differences between drop-outs and completers in age, height, weight, disease severity, and disease duration and there were no significant demographic differences between the two groups. They did find that this sample, in general, was initially less physically active, had lower physical and self-evaluative outcome expectations, and reported less goal-setting behavior than previous samples of people with MS who had participated in physical activity research.
The intervention group reported a statistically significant and large increase in physical activity over the 3-month period versus the control group who had a small and non-significant change. The intervention group also reported a statistically significant and large increase in goal setting over time whereas the control group did not. This change in goal setting over time mediated the effect of the Internet intervention on physical activity behavior. This is consistent with other research.
The changes in goal setting, physical, social, and self-evaluative outcome expectations, and functional limitations (but NOT self-efficacy) were significantly associated with change in physical activity in the Internet intervention group. These changes were not associated with change in physical activity in the control group. The researcher theorized that since the intervention was successful in increasing self-reported physical activity despite the reduction in self-efficacy over time, it's possible that there were overestimations of self-efficacy at baseline. The thought is that sedentary people may not have an appropriate frame of reference for reporting self-efficacy until after the experience of the 12-week intervention.
In regards to the association between baseline characteristics and changes in physical activity, the change in physical activity was significantly associated with only baseline goal setting, self-evaluative outcome expectations, and disease severity. These findings suggest that the intervention was most successful for those who did not have a personal catalog of behavioral strategies that they used for becoming more physically active as well as those with the fewest functional limitations at the start of the program.
In terms of usage, on average, 71% of participants logged in each week. The number of weeks that someone logged in was not significantly correlated with change in physical activity. Interestingly, there was a reduction in the log-in rate over the course of the study (meaning that as the study progressed, fewer people logged in each week), but this could either reflect decreasing motivation for physical activity or decreasing dependence on the site to maintain physical activity. The researchers suggested offering telephone coaching to help remedy this progressive decrease in contact.
Discussion: Only one short form for self-reporting physical activity was used, yet the major focus was an attempt to see changes in this area. More detailed information would be important to be able to expand the knowledge of how physical activity actually changed for individuals throughout the 12 weeks. This sample was considered to have minimal neurological effects from their MS, so the effectiveness of Internet-mediated physical activity programs for individuals with more extensive health concerns or more substantial functional limitations is still warranted. Fatigue was also not addressed or measured at any time point. With fatigue being such a common symptom experienced by individuals with MS, it would be helpful to see if the increases in physical activity have an effect on levels of fatigue.
This pilot study certainly sets the stage for further research that includes larger samples, longer interventions, more objective measures of activity, different disability groups, follow-up measures, and secondary outcomes of mobility and quality of life. These approaches have critical significance in delivery of health-related opportunities for individuals who encounter financial, environmental, and social barriers and have great potential for large-scale reach.