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The Impact of COVID-19 on the Employment of People With Multiple Sclerosis: A Multiple Methods Study

Multiple sclerosis (MS) disease factors, such as cognitive impairment, can cause disruptions in meaningful activities, also known as illness intrusiveness. Although the association between specific objective measures of cognition and illness intrusiveness has been documented in MS, the contributions of individuals’ perceptions of their cognition or whether any psychological factors can buffer the relationship have yet to be explored. This study aimed to (1) simultaneously examine objective processing speed and subjective cognition as disease factors contributing to illness intrusiveness and (2) explore whether resilience moderates the relationship between cognition and illness intrusiveness.

Participants (N = 112) were individuals with MS who completed the Illness Intrusiveness Ratings Scale (IIRS), Symbol Digit Modalities Test (SDMT), Perceived Deficits Questionnaire (PDQ), and MS Resiliency Scale (MSRS) as part of a larger cross-sectional study. A hierarchical linear regression was done, followed by individual moderation analyses.

 = .003) were independent predictors of the IIRS. There was no evidence of moderation in either model, although the MSRS independently contributed to the IIRS.

Among individuals with MS, objective processing speed and subjective cognition were independently associated with illness intrusiveness, highlighting the importance of considering both cognitive performance and perceptions as contributing factors to life disruptions.

From the Neuroscience Program (AG, SAR) and Department of Psychology (SAR), Trinity College, Hartford, CT; Multiple Sclerosis Center of Excellence West, Veterans Affairs, Seattle, WA (APT); Rehabilitation Care Service, VA Puget Sound Health Care System, Seattle, WA (APT); Department of Rehabilitation Medicine, University of Washington, Seattle, WA (APT); Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY (FWF); Holy Name Medical Center Multiple Sclerosis Center, Teaneck, NJ (FWF); Mandell Center for Multiple Sclerosis, Mount Sinai Rehabilitation Hospital, Trinity Health Of New England, Hartford, CT (LON, ESG); Department of Rehabilitative Medicine (LON, ESG) and Department of Medical Sciences (ESG), Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT; Department of Neurology, University of Connecticut School of Medicine, Farmington, CT (ESG). 

Elizabeth S. Gromisch, PhD, 490 Blue Hills Avenue,Hartford, CT 06112; 

: elizabeth.gromisch@trinityhealthofne.org.

The views and opinions expressed in this article reflect those of the authors and do not necessarily reflect those of the United States Department of Veterans Affairs. The Patient Determined Disease Steps (PDDS) is provided for use by the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry (narcoms.org/pdds). NARCOMS is supported in part by the Consortium of Multiple Sclerosis Centers (CMSC) and the CMSC Foundation.

 The parent study was supported by a pilot grant from the National Multiple Sclerosis Society (NMSS; grant number PP-1901-33103). Elizabeth S. Gromisch, PhD, is also an NMSS Harry Weaver Scholar.

 The data were presented as a poster at the 2023 annual meeting of the Consortium of Multiple Sclerosis Centers, May 31-June 3, Aurora, CO.

Multiple sclerosis (MS) is a neurological disorder that affects millions of individuals worldwide.

 With an average onset at age 32 years, it is the most common neurological cause of disability for young adults.

 As a result of disease-related changes, individuals with MS can experience diminished health-related quality of life (HRQOL).

 A significant component of HRQOL is illness intrusiveness, or the extent to which chronic illness disrupts daily life activities such as relationships, work, and other interests.

 Individuals with MS tend to endorse higher levels of illness intrusiveness compared with individuals with other conditions, such as rheumatoid arthritis and end-stage renal disease.

 Illness intrusiveness has been conceptualized as the outcome of several factors, including both the direct impact of various characteristics of a disease and/or its treatments and the extent to which these characteristics are moderated by psychological, contextual, and social risk and protective factors.

 Consequently, examinations of illness intrusiveness should consider the potential contribution of both of these influences.

Several disease factors have been explored as contributing to illness intrusiveness in individuals with MS,

 including cognitive impairment, which is estimated to occur in up to 70% of individuals with MS.

 Processing speed is the most common cognitive deficit in MS

 and an underlying contributor of other cognitive issues, such as executive function, working memory, and attention.

 Examination of the role of cognition in illness intrusiveness has produced mixed findings, likely due to differences in the cognitive domains assessed. Two studies did not find a relationship between complex attention (measured with the Paced Auditory Serial Addition Test; PASAT) and illness intrusiveness.

 However, both verbal learning (via the California Verbal Learning Test first edition; CVLT)

 and processing speed (via the Symbol Digit Modalities Test; SDMT)

 were associated with illness intrusiveness, with the latter study noting that illness intrusiveness acted as a significant intermediary between cognition and mood.

To date, all studies investigating the role of cognitive impairment in illness intrusiveness among individuals with MS have used performance-based measures (ie, objective cognition).

 The potential role of self-reported cognitive functioning (ie, subjective cognition) remains unknown. Although subjective cognition can be influenced by factors such as depression and fatigue,

 it can provide insights into individuals’ perceptions of their functioning, which may influence how intrusive they view their MS to be. The association between subjective cognition and illness intrusiveness has been documented in individuals with metastatic non–small cell lung cancer; those who reported clinically significant cognitive concerns had higher levels of illness intrusiveness.

 However, illness intrusiveness was not associated with performance-based cognitive impairment in this population, as determined through a multidomain cognitive battery.

 In those with MS, there is evidence that both objective and subjective cognition contribute to HRQOL, though they may influence HRQOL through different pathways.

Based on the theoretical model of illness intrusiveness,

 the relationship between a disease factor and illness intrusiveness may be moderated by psychological factors. Using this conceptualization, a protective psychological factor could buffer the negative effects that cognitive impairment has on illness intrusiveness. Buffering effects that are amenable to psychological modification hold considerable promise as potential targets for interventional strategies. One consideration is resilience, a positive psychological construct associated with adjustment to chronic conditions, including better functional outcomes.

 Resilience has been positively associated with HRQOL

 in individuals with MS, although the latter was no longer significant after controlling for mood and fatigue. In populations without MS, resilience has been related to fewer cognitive problems

This study aims to expand the literature on the role of cognition in illness intrusiveness in MS. The primary aim is to examine simultaneously the association of objective processing speed and subjective cognition as disease factors associated with illness intrusiveness. The hypothesis is that both slowed processing speed and greater perceived cognitive difficulties will be independently associated with illness intrusiveness. A secondary aim is to explore whether resilience moderates the relationship between cognition and illness intrusiveness. Given the positive associations of resilience with HRQOL in MS

 in other populations, we believe that the strength between illness intrusiveness and objective processing speed and between illness intrusiveness and subjective cognition will be buffered by higher resilience.

Study data used were part of a secondary analysis of a cross-sectional study conducted at the Trinity Health of New England Mandell Center for Multiple Sclerosis Care and Neuroscience Research and were collected between June 2019 and September 2020.

 The variables used for current analyses were extracted from the existing data set. As noted in the parent study, inclusion criteria for participants (N = 112) were (1) MS diagnosis, (2) age 18 to 89 years, (3) English speaker, and (4) relapse-free period for the past 2 months.

 Individuals with MS and other comorbidities, such as chronic medical (eg, hypertension) and mental health (eg, depression) conditions, were eligible. The sample size for the parent study was calculated to have adequate power for a linear regression, allowing for a medium effect size, up to 11 variables, and an α of 0.05.

 The study was approved by the Trinity Health of New England Institutional Review Board and all participants were required to sign an informed consent before participation.

 the average participant was 51.03 years old (SD = 12.23) with 15.21 years (SD = 2.29) of education. Most participants were women (74.1%), White (85.7%), and non-Hispanic (92.0%) and had moderate levels of disability (median 2; range, 0-7) as measured by the Patient Determined Disease Steps (PDDS) scale.

 The most common type of MS was relapsing-remitting (n = 90). On average, participants had a disease duration of 14.40 years (SD = 9.31).

Participants completed a questionnaire designed specifically for the parent study

; for the current study, gender, age, race, ethnicity, and education were extracted for analyses, with type of MS and disease duration used for descriptive purposes only. Race was recategorized as White and non-White secondary to low counts of other categories (Black, multiracial, or other). Disability was self-reported using the PDDS, in which responses ranged from 0 (normal) to 8 (bedridden).

Illness Intrusiveness Ratings Scale (IIRS)

The IIRS is a 13-item self-report measure in which participants rate the level of intrusiveness of their MS in different aspects of their lives (eg, health, work, and relationships) using a Likert scale ranging from 1 (not very much) to 7 (very much).

 The total score (range, 13-91) is calculated by summing all the items, with higher scores indicative of greater intrusiveness.

 with an internal consistency (α) of 0.88 noted in the current sample.

The SDMT is a performance-based measure of cognitive functioning that taps into multiple domains, including processing speed.

 It was selected as the measure of objective cognition as it is a sensitive measure for MS-related cognitive impairment

 and is often used as a screening measure.

 The oral version of the test was used, in which participants stated the number that corresponded with the symbol.

 A z score was generated based on the number of correct responses within 90 seconds using published normative data adjusted for age and education.

 The same normative data were used in a previous study examining the SDMT in relation to the IIRS.

The PDQ assesses participants’ perceptions of their attention/concentration, retrospective memory, prospective memory, and planning/organization.

 The measure contains 20 cognitive difficulties, and participants rate how often they have experienced them over the past 4 weeks using a Likert scale ranging from 0 (never) to 4 (almost always).

 The total score (range, 0-80) is calculated by summing all the items, with higher scores indicative of greater cognitive difficulties.

 In the current sample, the PDQ had an internal consistency of 0.94.

Multiple Sclerosis Resiliency Scale (MSRS)

Resilience was measured with the MSRS, which taps into the psychological, social, and physical factors associated with resilience in MS.

 For each of the 25 items, participants use a Likert scale to indicate their level of agreement. The total score (range, 25-100) is calculated by summing all the items, with higher scores indicative of greater resilience.

 The MSRS has strong psychometric properties,

 and the measure had an internal consistency of 0.86 in the current sample.

IBM SPSS version 26 was used for data analyses. A hierarchical linear regression was used to examine the associations of objective processing speed and subjective cognition with illness intrusiveness. Age, gender, race, ethnicity, and education were included in the first step to control for demographics that might influence the model. For instance, the PDQ does not have demographically corrected scores, while race/ethnicity differences have been noted on the SDMT.

 In addition, a study has shown that men with MS can present with more cognitive impairment than women.

 The PDQ and SDMT were entered into steps 2 and 3 of the regression, respectively, to assess their individual contributions to illness intrusiveness. All assumptions for a hierarchical regression were met including linearity, homoscedasticity, and independence.

 was used to conduct the moderation analyses, with cognition as the independent variable, illness intrusiveness as the dependent variable, and resilience as the moderator (

). As the macro allows for only 1 independent variable in the model, 2 separate moderation analyses were conducted: 1 with the PDQ and 1 with the SDMT. Based on the nonsignificance of the covariates in the hierarchical linear regression, none were included in the mediation analyses. Moderation was considered to have occurred if the interaction term was significant.

Participants’ scores on the IIRS, SDMT, PDQ, and MSRS are reported in 

. The PDQ was significantly associated with the IIRS (b = 0.53, 95% CI [.29-.77]; P < .001), accounting for 15% of the variance in the model. The association remained significant when the SDMT was added in the next step (

). The SDMT was also a significant factor (b = –4.17, 95% CI [–6.90 to –1.45]; P = .003), accounting for 7% of the model’s variance.

Although both the PDQ (b = 0.31, 95% CI [.09-.53]; P = .006) and MSRS (b = –0.61, 95% CI [–.90 to –.33]; P < .001) were independently related to the IIRS, there was no evidence of moderation (

). Similarly, there was no evidence of moderation when the SDMT was the cognition variable (

This study aimed to expand upon the literature examining the role of cognition in illness intrusiveness in MS. As hypothesized, both objective processing speed and subjective cognition were found to be independently associated with illness intrusiveness in MS. The current findings are consistent with previous work documenting the connection between the SDMT and IIRS,

 in which slower processing speed was associated with higher illness intrusiveness. These results support the conceptualization that cognitive impairment is a disease factor in the model of illness intrusiveness

 for individuals with MS. Worse performance on the SDMT has been associated with greater difficulties with functional activities.

 Due to these increased functional issues, individuals with slowed processing speed may view their MS as more intrusive.

 on the relationship between objective cognition and illness intrusiveness in MS may be due to the measures used. Although both the SDMT and PASAT are recommended for use in MS,

 the 2 tasks vary in cognitive demands. In addition, the SDMT has been found to be the most sensitive measure for MS-related cognitive impairment

 and may be a better representation of cognition as a disease factor in the theoretical model. That said, as the SDMT does not measure all the cognitive domains that can be affected by MS, that some aspects of cognition do not contribute to illness intrusiveness cannot be ruled out.

Not only was subjective cognition significantly associated with illness intrusiveness, but it also accounted for slightly more variance than objective processing speed. These findings indicate that among individuals with MS, both their performance and their perceptions of their cognitive functioning contribute to illness intrusiveness. In other words, their view of their cognitive functioning can shape how intrusive they regard their MS to be, independent of their actual level of impairment. This is particularly important for clinicians to consider given that subjective ratings of cognition do not necessarily correspond to objective performance.

 Although an individual may be performing within normal limits on a neuropsychological measure, they may endorse having cognitive issues in their daily life, which could contribute to their higher illness intrusiveness. These findings are in line with other MS research that found that both objective and subjective cognition contribute to HRQOL,

 but they are in contrast to the study by Eggen and colleagues

 in metastatic non–small cell lung cancer, in which only subjective cognition was associated with illness intrusiveness. Although this may reflect differences in how cognition contributes to illness intrusiveness in different diseases, it may also be due to how cognition was measured. Eggen and colleagues

 categorized their participants as impaired/nonimpaired, whereas the current study looked at objective processing speed as a continuous measure.

An intervention for individuals with MS would need to consider both objective and subjective functioning when targeting cognition to reduce illness intrusiveness. Approaches in other populations have included teaching problem-solving strategies for specific symptoms and providing psychoeducation on how these symptoms can contribute to illness intrusiveness.

 For example, strategies include teaching patients cognitive compensatory strategies, such as taking additional time to do tasks and pacing,

 and identifying situations where they might be used. The psychoeducation component can include discussions on how MS affects cognition, as well as how other symptoms like depression and fatigue can negatively influence one’s views of their own functioning.

 Cognitive-focused interventions have been shown to have an effect on objective cognition, as well as levels of anxiety and depression.

 Furthermore, individuals with MS who have undergone cognitive-focused interventions endorse improved knowledge and quality of life, as well as changes in their perceptions.

 While the IIRS has yet to be an outcome measure for a cognitive-focused intervention in MS, future studies may consider this to evaluate whether these approaches can help reduce illness intrusiveness.

Although it was hypothesized that resilience would buffer the relationship between cognition and illness intrusiveness, this was not observed. Instead, resilience independently contributed to illness intrusiveness, regardless of whether cognition was measured subjectively or objectively. In both models, higher resilience was associated with lower illness intrusiveness, consistent with other research in MS showing a positive association between resilience and HRQOL.

 Although the role of resilience as a moderator was conceptualized using the theoretical model of illness intrusiveness,

 in which psychological factors moderate between disease factors and illness intrusiveness, these findings suggest that resilience may contribute to illness intrusiveness through another pathway. Given the direct effects of resilience on illness intrusiveness in both models, resilience may be reconceptualized as a 

 in the illness intrusiveness model, which acts similarly in the model to a 

 It has been suggested that resilience can be learned over time,

 with several studies in MS focusing on building resilience.

If resilience is still to be conceptualized as a 

 in the theoretical model, then it may either moderate the relationship between illness intrusiveness and subjective well-being or act directly on subjective well-being.

 found that cognition contributed to illness intrusiveness, which, in turn, influenced depressive symptom severity. In MS, it is possible that resilience could moderate between illness intrusiveness and mood, given the inverse relationship between resilience and psychological distress.

 As subjective and objective cognition have been found to act on HRQOL in MS through different pathways,

 there are likely other factors involved in the relationship between cognition and illness intrusiveness, including other potential moderators. Although a path model would allow for an examination of different interactions of several factors, that would require a more robust sample size than that of the current study.

In addition to the restrictions on the complexity of the model that we examined, there are other limitations that need to be considered. Only the SDMT was used to measure objective cognition, and although sensitive to MS-related cognitive impairment,

 it does not assess other aspects of cognition, such as executive functioning, language, and visuospatial skills. Future studies could explore whether global cognition or only specific cognitive domains contribute to illness intrusiveness. Although the current study assumed causal relationships based on the theoretical model of illness intrusiveness,

 it is important to note that the study was cross-sectional. To definitively state that cognitive impairment leads to greater illness intrusiveness, a longitudinal investigation, where changes in both metrics can be observed over time, would be needed. Finally, although demographics such as race and ethnicity were not significant in the hierarchical linear regression, the sample was largely White and non-Hispanic, which may have influenced the generalizability of the results. As such, future studies should consider a more diverse sample, which would allow for the examination of demographics in the model.

Among individuals with MS, both objective processing speed and subjective cognition were independently associated with illness intrusiveness. Resilience, however, did not moderate the relationship between cognition and illness intrusiveness, although it directly affected illness intrusiveness. Not only do these findings bolster previous work on the role of cognition as a disease factor in the theoretical model of illness intrusiveness, but they also highlight the importance of considering both cognitive performance and perceptions as contributing factors to illness intrusiveness in MS. Addressing cognitive concerns may be an avenue for future interventions targeting illness intrusiveness in this population.

Expanding the Connection Between Cognition and Illness Intrusiveness in Multiple Sclerosis

 To access the article and evaluation online, go to 

 The target audience for this activity is physicians, advanced practice clinicians, nursing professionals, mental health professionals, social workers, and other health care providers involved in the management of patients with multiple sclerosis (MS).

1. Discuss the potential role of pain impact, depression symptoms, and level of social support on walking-related physical therapy (PT) goal attainment in individuals with MS.

2. Recognize potential avenues for a multidisciplinary approach for determining and addresses psychosocial barriers to PT goal attainment in individuals with MS.

In support of improving patient care, this activity has been planned and implemented by the Consortium of Multiple Sclerosis Centers (CMSC) and Intellisphere, LLC. The CMSC is jointly accredited by the Accreditation Council for Continuing Medical Education, the Accreditation Council for Pharmacy Education, and the American Nurses Credentialing Center, to provide continuing education for the health care team.

This activity was planned by and for the health care team, and learners will receive 0.5 Interprofessional Continuing Education credit for learning and change.

 The CMSC designates this journal-based activity for a maximum of 0.5 

™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 The CMSC designates this enduring material for 0.5 contact hour of nursing continuing professional development (none in the area of pharmacology).

 This activity is awarded 0.5 continuing education (CE) credit.

 As a jointly accredited organization, the CMSC is approved to offer social work continuing education by the Association of Social Work Boards Approved Continuing Education program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 0.5 general continuing education credits.

 It is the policy of the CMSC to mitigate all relevant financial disclosures from planners, faculty, and other persons that can affect the content of this CE activity. For this activity, all relevant disclosures have been mitigated.

, have disclosed no relevant financial relationships. Authors 

Kayla E. Gomes, DPT, PT, NCS; Kaitlin E. Riegler, PhD; Heather M. DelMastro, MS; Aaron P. Turner, PhD; Lindsay O. Neto, MPH; 

have disclosed no relevant financial relationships.

, CMSC, and Intellisphere, LLC, who are in a position to influence content have disclosed no relevant financial relationships. 

, CMSC continuing education director, has served as a planner and reviewer for this activity. She has disclosed no relevant financial relationships.

Release Date: March 1, 2025; valid for Credit through: March 1, 2026.

(1) Review the continuing education information, including learning objectives and author disclosures.

(3) Complete the evaluation, which is available at 

Statements of Credit are awarded upon successful completion of the evaluation. There is no fee to participate in this activity.

 This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the US Food and Drug Administration. The CMSC and Intellisphere, LLC, do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the CMSC or Intellisphere, LLC.

 Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any medications, diagnostic procedures, or treatments discussed in this publication should not be used by clinicians or other health care professionals without first evaluating their patients’ conditions, considering possible contraindications or risks, reviewing any applicable manufacturer's product information, and comparing any therapeutic approach with the recommendations of other authorities.

Many individuals with multiple sclerosis (MS) have difficulty walking, which may prompt a physical therapy (PT) referral. Psychosocial factors, including mood, pain, and social support, may affect patients’ participation and overall success in meeting PT goals; however, this has yet to be examined in MS. This study aimed to explore the associations between walking-related PT goal attainment and psychosocial factors.

Participants (N = 41) were individuals with MS from a larger study who engaged in PT per usual care during a 2-year study window. They had at least 1 walking-related goal in their PT plan of care, which could be based on subjective (eg, Multiple Sclerosis Walking Scale-12) or objective measurement (eg, 6-Minute Walk Test). Examined psychosocial factors included impact of pain and fatigue, depression and anxiety symptom severity, and social support. Group differences were examined using bivariate analyses.

Participants who met all their walking-related PT goals had lower levels of pain impact (14.15 ± 5.22 vs 19.14 ± 5.29; 

= 0.95) and symptoms of depression (5.45 ± 3.53 vs 7.71 ± 3.51; 

= 0.64) and greater social support (median: 14.00 vs 12.00; 

Caregivers for people with MS showed relatively high resilience levels, positively correlating with quality of life and reduced caregiver burden. Furthermore, resilience correlated inversely with neuroticism and positively with extroversion and conscientiousness. Future research should target personalized interventions, particularly for caregivers with low resilience.

From the Physical Medicine and Rehabilitation, VA Connecticut Healthcare System, Newington, CT (KEG); the Princeton Neuropsychology and the Sports Concussion Center of New Jersey, Princeton, NJ (KER); Mandell Center for Multiple Sclerosis, Mount Sinai Rehabilitation Hospital, Trinity Health Of New England, Hartford, CT (HMD, LON, ESG); the Department of Rehabilitative Medicine (HMD, LON, ESG) and the Department of Medical Sciences (ESG), Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT; Multiple Sclerosis Centers of Excellence, Veterans Affairs, Seattle, WA (APT); Rehabilitation Care Service, VA Puget Sound Health Care System, Seattle, WA (APT); Department of Rehabilitation Medicine, University of Washington, Seattle, WA (APT); Department of Neurology, University of Connecticut School of Medicine, Farmington, CT (ESG). 

Elizabeth S. Gromisch, PhD, 490 Blue Hills Avenue, Hartford, CT 06112; 

 elizabeth.gromisch@trinityhealthofne.org.

 The authors wish to thank Jennifer A. Ruiz, DPT, PT, for her review of an earlier version of the abstract.

The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of the United States Department of Veterans Affairs.

The Patient-Determined Disease Steps is provided for use by the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry (www.narcoms.org/pdds). NARCOMS is supported in part by the Consortium of Multiple Sclerosis Centers (CMSC) and the CMSC Foundation.

 The authors have disclosed no relevant conflicts.

The parent study was funded by a pilot grant from the National Multiple Sclerosis Society (NMSS; PP-1901-33103). Elizabeth S. Gromisch, PhD, is a Harry Weaver Scholar of the NMSS.

An earlier version of the results from this study was presented at the annual meeting of the Consortium of Multiple Sclerosis Centers, May 31-June 3, 2023, in Aurora, Colorado.

Impaired mobility and gait dysfunction have been identified as important priorities for individuals with multiple sclerosis (MS) as they greatly affect their quality of life.

 Physical therapy (PT) is a vital component of MS care that has been proven to enhance walking endurance, walking speed, and dynamic functional walking.

 When constructing plans of care and goals, physical therapists consider factors such as limitations in function and participation, as well as psychosocial factors.

 Understanding factors that either create barriers to or promote achievement of goals can help physical therapists identify ways to individualize treatment plans or consider outside referrals and resources.

 and are associated with decreased physical activity levels and functional impairments.

 Many individuals report that pain interferes with their mobility,

 and greater subjective fatigue has been associated with declines in walking speed,

However, physical activity and exercise have been shown to reduce fatigue in MS,

 and there is some evidence that they can also alleviate pain.

 Maladaptive thought processes (eg, catastrophizing) also play a role in an individual’s experience of pain and fatigue, acting as mediators between symptom intensity, impact, and mood

Psychiatric diagnoses, such as anxiety and depression, are frequently seen in individuals with MS and are associated with pain and fatigue.

 Greater anxiety and increased severity of symptoms of depression have been associated with less healthy lifestyle choices and lower amounts of physical activity or exercise.

 Individuals with MS with higher anxiety or depressive symptomatology have reported more subjective walking difficulties,

 with the Multiple Sclerosis Walking Scale (MSWS- 12) explaining 19.2% of depression’s variance.

 While individuals with depression have also demonstrated lower walking velocity and cadence, these differences were no longer significant after controlling for age, gender, and disability.

Walking-related impairments are also associated with social relationships,

 with approximately two-thirds of individuals with MS reporting that their walking difficulties negatively affected relationships with friends (67%) and family (65%), respectively.

 Perceived walking ability is also connected to exercise-related support from family and friends.

 Higher levels of social support have been associated with greater physical activity

 One study found benefits in emotional well-being and health outcomes for individuals with higher social support even after controlling for negative lifestyle factors (ie, smoking, poor diet/exercise), demographics, and personality.

However, no studies have examined whether there is a relationship between psychosocial factors and PT goal attainment. Identifying whether these factors are connected to walking-related goals could prompt changes in the MS care model, such as incorporating routine psychosocial assessments or developing multidisciplinary interventions that address the contributing physical and psychological components along with walking impairments. Therefore, this study aimed to explore the associations between walking-related PT goal attainment and psychosocial factors. As a first step in this line of research, the analyses focus on differences in the impact of pain and fatigue, depression and anxiety symptom severity, and level of social support between individuals with MS who did and those who did not meet all their walking-related goals. It was hypothesized that social support would be positively associated with PT goal attainment while pain, fatigue, anxiety, and depression would be negatively associated

The study is a secondary analysis of a larger observational study that involved psychosocial assessments.

 Recruitment for the parent study included outreach to individuals interested in research and flyers displayed in specialized MS clinic waiting rooms and at community events. In addition to meeting the parent study inclusion criteria (ie, diagnosed with MS, aged between 18 and 89 years, English-speaking, and no relapses for the past 2 months), individuals in the current study also engaged in outpatient PT at either Mount Sinai Rehabilitation Hospital or St. Mary’s Hospital (both part of Trinity Health Of New England) within 2 years of the study assessment (ie, between 2017 and 2020). On average, participants completed their PT assessment 5.14 months (

Inclusion for these analyses was limited to individuals with 1 or more walking-related goal(s) in their PT plan of care. All participants had a walking-related diagnostic treatment code (eg, abnormalities in gait and mobility). The examined goals were classified by a physical therapist in the electronic medical record (EMR) as being related to the participants’ walking. No other exclusion criteria were set. A total of 41 participants (36.6% of the parent study’s sample) met these criteria and were included (

Participants signed an informed consent form approved by the Trinity Health Of New England Institutional Review Board, which allowed for prospective data collection and chart review. Information about the parent study’s procedures is detailed elsewhere.

 Age, years of education, sex, race, ethnicity, MS duration, and MS type were extracted from the study records. Due to the small sample size, primary progressive and secondary progressive MS were collapsed into a progressive MS category. The self-reported Patient-Determined Disease Steps (PDDS)

 was used to measure MS-related disability.

The EMR was queried for information on the PT plan of care (eg, treatment modality, number of sessions, and goals). Only walking-related goals were examined. All participants had SMART (specific, measurable, achievable, relevant, and time-bound) goals, in which the walking-related outcome was assessed with a subjective (eg, MSWS-12) or functional objective (eg, 6-Minute Walk Test) measurement. All evaluating physical therapists documented in the treatment notes whether the goal was met. Participants were then categorized into 2 groups: (1) meeting all their goals or (2) not meeting all their goals (including partial goal attainment).

 The measures used to assess pain and fatigue impact,

All analyses utilized IBM’s SPSS Version 26. Differences in demographic, disease-related, treatment-related, and psychosocial factors were examined using χ

 and Fisher exact tests (categorical variables), median tests (ordinal variables), 

tests (normally distributed interval variables), and Mann-Whitney 

tests (non–normally distributed interval variables). Effect size (Cohen 

Helen Ford, MD, FRCP

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