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Wearables for the Bladder: Stakeholder Perspectives on Moving Multiple Sclerosis Bladder Dysfunction Interventions Into the 21st Century

 Bladder dysfunction (BD) is common in people with multiple sclerosis (MS) and can reduce participation in daily life. Detecting BD early allows for effective prevention-focused treatments such as pelvic floor physical therapy. Pairing neurotechnology with patient-reported outcomes to remotely measure BD could significantly improve monitoring and treatment of BD. Therefore, we describe the process and findings of stakeholder engagement from a human-centered design process to assemble a wearables for the bladder (WeB) kit.

Four people with MS with varying BD severity, and 5 MS clinical/research experts had 4 virtual meetings. Commercially available bladder tools were graded for ability to evaluate, monitor, or treat BD. The Health Information Technology Usability Evaluation Scale (utility, usability, feasibility) was used for evaluation. Scoring was performed individually and as a group.

Of the 11 devices, 5 obtained mean scores of greater than 6 of 10 for likability, usability, and device utility. The 2 highest scoring (9/10) devices were selected for the pilot. One device measures bladder urine levels, reporting the number/frequency of voids/leaks; the other guides pelvic floor exercises by pairing games on an app with biofeedback from intravaginal sensors. We uncovered critical differences in experts’ and patients’ appreciation of the tools, and the collaborative engagement led to substantial revisions of initial tool scores.

This process underscores the critical role of stakeholder engagement in the selection of digital tools, especially in sensitive domains like pelvic function. Ongoing clinical validation of the selected tools will yield a validated, user-friendly WeB kit that is able to fill gaps in our ability to evaluate BD treatments in people with MS, ultimately reducing the impact of BD on quality of life.

From the Weill Institute for Neurosciences, Department of Neurology (VJB, NS, RB); Department of Physical Therapy and Rehabilitation Science (VJB, LM), Department of Urology (MEVK, AMS), University of California San Francisco, San Francisco, CA. 

 Valerie J. Block, DPTSc, PT, 1651 4th St, Room 612E, San Francisco, CA 94158; 

The authors are grateful for the contributions of Doreen McClurg, PhD. She contributed to the study design and stakeholder engagement as an expert in women’s health in MS. Subsequently she could not be contacted for inclusion as an author of this paper.

Valerie J. Block, DPTSc, PT, is supported by the National Multiple Sclerosis Society Career Transition award. Anne M. Suskind, MD, MAS, is a paid consultant on an Agency for Healthcare Research and Quality grant and for the Flume Catheter Company. Riley Bove, MD, MMSc, is funded by the National Multiple Sclerosis Society Harry Weaver Award, the National Institutes of Health, the Department of Defense, and the National Science Foundation, as well as Biogen, Novartis, and Roche Genentech. She has received personal fees for consulting from Alexion, EMD Serono, Genzyme Sanofi, Horizon, Jansen, and TG Therapeutics. The remaining authors have no relevant disclosures.

A version of this work was a platform presentation at the annual meeting of the Consortium of Multiple Sclerosis Centers; May 2023; Aurora, Colorado.

Ambulatory disability is 1 of the most prominent and visible symptoms in multiple sclerosis (MS) and serves as the foundation for many rating scales, including the Expanded Disability Status Scale (EDSS)

 However, other less visible symptoms, including bladder dysfunction (BD), significantly impact people with MS. BD typically emerges within a decade of diagnosis and progressively worsens over time, and is distinct from acute relapse-related BD.

 BD may encompass symptoms such as both frequent and urgent urination, frequent nighttime urination (nocturia), and incomplete bladder emptying, which can also lead to significant urinary incontinence. It not only impacts primary functioning but also leads to secondary consequences, such as reduced physical activity, increased fatigue (presumably from interrupted sleep if nocturia is present), physical deconditioning, and reduced quality of life (QOL).

 BD poses health and safety risks, including recurrent urinary tract infections, falls,

 and significant health care costs, yet it remains largely underresearched.

Barriers to the prompt detection of BD include a lack of time among clinicians, discomfort in managing BD if it was not emphasized during neurological training, and the level of detail in patient reporting. Patients often perceive BD as embarrassing, sensitive, or tied to aging, leading to the belief that nothing can be done to improve or maintain the symptoms. This can lead to a lack of communication regarding available BD treatment options.

 Frequently, patients only bring up bladder issues with their clinician once symptoms have progressed to a point where invasive treatments like surgery are the only viable option.

 Identifying BD early would allow for noninvasive, prevention-based treatments, such as pelvic floor physical therapy (PT),

The integration of neurotechnology and patient-reported outcomes (PROs) for remote monitoring would represent a substantial improvement in monitoring and treating BD. The current evaluation of BD severity relies on intrusive in-clinic assessments (eg, post-void residuals, urodynamic testing) and extended monitoring predominantly hinges on PROs. Although PROs are critical for documenting the patient experience, they may be less accurate due to recollection inconsistency and variations in deficit perception. To ensure successful adoption of novel technologies in clinical care and research, it is crucial to involve users, including clinicians and patients, in the development process and device selection. Therefore, our overall objective was to engage stakeholders in a human-centered design (HCD) process to develop a wearables for the bladder (WeB) kit with the goal of enhancing the evaluation, monitoring, and treatment of BD in people with MS. Subsequently, the WeB kit will be validated against gold-standard evaluation metrics, and its utility and effectiveness to improve the intensity, duration, and frequency of pelvic floor PT interventions will be tested in a clinical trial.

The study was based on the theories and stages of HCD, prioritizing the usability and requirements of a tool’s intended users (in this case, patients and clinicians). The development process consisted of extensive stakeholder engagement and evaluation of tool usability utilizing the Health Information Technology Usability Evaluation Model (Health-ITUEM) and Scoring (Health ITUES).

The HCD model is a problem-solving approach that places individual users at the core of the development process, creating solutions customized to their specific needs.

 Although wearable technologies for bladder monitoring are commercially available, to our knowledge, they have not been tested individually or in combination in people with MS. To increase the likelihood that the devices chosen would be used and successful, each round of device selection and scoring used the Health-ITUEM and ITUES, including both subjective and objective outcomes. The subjective outcomes focused on satisfaction, specifically perceived ease of use and perceived usefulness of each device evaluated. In addition, variables associated with the potential WeB kit tools were considered, including their alignment with HCD principles and their capacity to engage patients.

 These variables included usefulness, ease of use/learnability, effectiveness, and how much participants liked the device overall. The devices were tested by the stakeholders, both clinicians and patients, in their homes.

Four virtual stakeholder meetings were held between April 2021 and May 2022. To accommodate COVID-19 restrictions and geographical barriers, meetings were conducted via the University of California San Francisco (USCF) Zoom video platform (

Clinician stakeholders were contacted either by email or in person and invited to participate. Patients who had previously granted research participation consent, or who had known BD, were invited via secure email communication. The UCSF institutional review board (IRB #21-33653) approved all study activities and informed consent was obtained from all participants. No compensation was provided for participation.

The clinicians were a neuro-urologist (AMS), an MS neurologist (RB), a pelvic floor physical therapist (LM), an MS remote monitoring expert and physical therapist (VJB), and an international women’s health expert (Doreen McClurg, PhD). The patients were 3 women and 1 man with MS who had varying degrees of BD (all with documented bladder-related issues in their electronic medical records). They had different levels of technical literacy and were aged between 36 and 68 years.

 summarizes the initial devices selected for evaluation and assessment in Round 1, encompassing their respective inclusion/exclusion during stages of the evaluation process. A summary of the devices evaluated in each round, culminating in the selection of the devices for the pilot studies, is presented in 

On a 10-point scale, the DFree, Perifit, and Innovo devices scored a 7 or above, were available in the United States for purchase at the time of the study, and were chosen for testing by stakeholders (full details in 

). The Carin Pro was not in stock at the time of the study. Notably, although the Uromonitor, eCoin, and BlueWind RENOVA (since renamed Revi) were thought to be promising, they were still under investigation and not available for commercial use at the time of the study.

The main qualitative feedback from the stakeholders regarding each device from Round 1, including the anticipated benefits, disadvantages, and key features for users (patients and clinicians) is summarized in 

Overall, the devices were worn by the 5 clinicians and 4 patients for an average of 2 days at home.

DFree: Four patients and 3 clinicians liked the device and rated it as useful for “visualizing the changes in bladder fullness over time” (7.4/10). More than 50% found it useful for helping to focus on other activities rather than planning restroom breaks, preventing accidents, and managing BD in general (

Notably, the DFree was updated during the stakeholder evaluation process from an ultrasound device with an external wire connecting it to a clip-on Bluetooth device (that was hard to conceal) to a smaller, more discreet device. Participants had the opportunity to retest the newer model and this increased the overall score from 6.8 to 9.0 of 10.

Perifit: A smaller group of stakeholders (4 individuals) assessed the tool in person, as opposed to the 8 who evaluated the DFree device. Several individuals opted not to use it because it is an intravaginal device, citing personal preferences, while the male stakeholder was unable to test it. The Perifit scored high on ease of use and treatment utility. The higher average score for “helping to focus attention on activities of daily living, rather than managing BD” was derived from the discussions, indicating that the score was influenced by the perceived potential gains that the Perifit could offer if included in a treatment program.

Innovo: The device received a likability score of 0 from the stakeholders. A particular concern was about electric shocks near genitalia. Overall, it received a low recommendation score for use in the WeB kit.

Round 3 Define Phase and Round 4 Develop Phase 

During stakeholder meetings, it became evident that clinicians and patients had substantial differences in their perceptions of the tools. For instance, clinicians substantially revised initially low usability scores for the DFree in response to patient recognition of the tool’s potential benefits. One striking example was the enthusiasm among patients for the potential advantages of using these devices to monitor urine volume, in contrast to the conventional practice of adhering to fixed voiding schedules every 3 hours (timed voiding). This shift in perspective was primarily motivated by the potential to enhance personal freedom and mobility, especially outside of the home. Similarly, the gaming feature of the Perifit Kegel exerciser, initially perceived by clinicians as potentially juvenile, proved to be visually effective and highly engaging when tested by patients.

It’s worth noting that, at this point in the study, we had to limit inclusion to female participants due to the specific mechanics of certain devices included in our kit. However, our commitment to inclusivity remains strong, and exploration of devices suitable for male participants to expand the reach and impact of our WeB kit is ongoing.

For the pilot WeB kit, the DFree and the Perifit were chosen for remote symptom monitoring. For the DFree, experts suggested validation against in-clinic post-void residual testing and conventional measures (ie, 3-day bladder diary) of bladder function. Stakeholders proposed comparing scores on a Perifit game that evaluates muscle strength with Manual Muscle Testing scores. This idea was shelved for future studies as additional funding would be needed for the single-user devices.

The DFree and Perifit were also both chosen as tools to include in the pelvic floor physical therapy (PFPT) pilot WeB kit, as each device offers unique potential benefits and recommended usage strategies. The Perifit scored as the most useful WeB device to augment the intensity, duration, and frequency treatment of PFPT objectives. The short, predefined games, the real-time feedback (closed loop), and the prescription suitability were highlighted as benefits by the clinician stakeholders. The patient stakeholders also rated the device as potentially useful to maintain exercise programs between PFPT sessions, citing potential benefits to improving adherence to the overall PFPT home exercise program.

The DFree was also chosen as a potential adjunct to PFPT training. Stakeholders proposed that participants could use the devices to monitor and suppress urges when experiencing strong sensations of urgency, helping to correlate these sensations with visualized (biofeedback) bladder volume. Additionally, stakeholders highlighted the opportunity for bladder training with guidance from pelvic floor physical therapists, suggesting that participants set a specific threshold volume for voiding, which could adapt as they receive training, akin to the principles of timed voiding in standard care, but with greater autonomy and personalization.

To assess any interactions or associations with MS symptom-specific questionnaires, PROs were selected as a group (from list of the most commonly used questionaries encompassing BD and other MS symptoms from the literature), combining urology and pelvic floor PT expertise. These are detailed in 

Anonymous credentials would be assigned to all devices in the WeB kit, and weekly (or biweekly) reports would be available for the therapist and research team to review. This would enable a prompt and closed-loop adjustment of the home program intervention and detection of adherence in an objective manner. Stakeholders recommended 3 to 5 days of DFree use a month for the monitoring phase (3 months), and as much as possible, with a set minimum threshold (1-3 days a week), for the intervention pilot phase. It was noted by all stakeholders that duration and frequency should be PFPT recommended after the initial evaluation visit. Patient stakeholders recommended training videos, not just written instructions, on the use, maintenance, and protocol for each WeB device.

Our pilot study findings underscore the critical importance of inclusive stakeholder engagement in choosing devices to monitor and potentially treat bladder dysfunction, a domain that is particularly sensitive, personal, and understudied.

 The insights gained from clinicians and patients shaped the selection of devices that not only met users’ preferences but also had the potential for widespread adoption. Without this invaluable input, our approach and outcomes might have been entirely different.

The difference in the perceptions of clinicians and patients regarding device utility was significant in this study. For instance, a device considered least useful by experts received high patient ratings, emphasizing the importance of including patient perspectives in device development for personal domains like pelvic function and BD. Moreover, there was a divergence in views regarding the optimal timing and duration of device usage. This reflects the challenge of balancing data acquisition with patient burden. Ultimately, we agreed on a suitable monitoring duration of 5 days per month for the DFree in this pilot study. The meetings also revealed a debate on device usage frequency throughout the study, highlighting the need for ongoing collaboration between health care professionals and patients to align monitoring and treatment protocols with patient preferences.

Progressing through the pilot study and beyond, it is vital that feedback from patients continues to shape our research. The ongoing input is valuable for collaborating with device manufacturers to enhance the suitability of BD devices for individuals with neurological disorders. Remote monitoring of functional domains in people with MS is a burgeoning field, with a multitude of research papers regarding validation and cross-sectional outcomes (in particular, for physical activity and walking in MS). However, it is essential to continue the process of transitioning WeB devices from their primary role as monitoring tools to their integration into rehabilitation interventions. In the case of BD, incorporating devices with traditional PFPT approaches signifies a move toward not only more objective, continuous, and remote monitoring but also actively treating individuals with BD.

The study had several limitations. It is important to acknowledge that larger-scale studies involving more diverse stakeholder cohorts are needed to further explore and substantiate these initial findings. Such studies will provide a more comprehensive understanding of the potential benefits and limitations of these devices in a broader context and contribute to the ongoing improvement of BD management strategies for individuals with MS. This version of the WeB kit proved to be exclusively for women. Additional research efforts are required to cater to the diverse needs of all sexes and genders in the comprehensive evaluation, monitoring, and management of BD in the context of MS.

After development, the WeB kit will be validated against gold-standard evaluation metrics, and its utility and effectiveness to enhance PFPT outcomes will be tested in a clinical trial. To our knowledge, there are no trials using commercially available, at-home bladder wearables in people with MS, underscoring the innovative potential of the WeB kit to complement existing treatments such as medications, PFPT, and surgical or Botox (onabotulinumtoxinA) procedures. If the results of the pilot studies are clinically meaningful, the WeB kit may emerge as a promising solution to address critical gaps in our ability to measure and manage BD in people with MS. By potentially reducing the adverse impact of BD on QOL, these devices could significantly improve the overall well-being of individuals with MS.

 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; 

These findings highlight the potential links between psychosocial factors and the attainment of walking-related goals by individuals who have MS. Further evaluation into psychosocial impact on PT plans of care is needed to help guide targeted assessment and intervention approaches.

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 

) was calculated for each comparison, with the effects for χ

, Fisher exact tests, median tests, and Mann-Whitney 

for consistency. Differences were considered small (0.2), medium (0.5), or large (0.8).46

Participants attended an average of 7.95 (SD = 4.57) PT sessions, and had a median of 3 walking-related goals. The demographics and disease-related characteristics are reported in 

20) met all their walking-related PT goals. The 2 groups did not differ in terms of the number of walking-related goals, attended PT sessions, or months between assessments, nor were there any significant differences in their demographics or disease-related characteristics (Table 1).

Participants who met all their goals had lower pain impact (

= 0.95) and depression symptom severity (

= 0.64). They also described receiving more support from their family and friends (

= 0.79). While they had lower levels of fatigue impact and anxiety symptom severity, these differences did not reach significance (Table 1).

The relationships between psychosocial factors and walking in individuals with MS are complex and interrelated

 and may impact the achievement of mobility and gait-related goals. This study was the first to explore the associations between psychosocial factors and the attainment of walking-related goals, focusing on whether there were 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 PT goals. In this sample, 48.8% of participants met all their walking-related PT goals. These individuals had lower pain impact and depression symptom severity and higher levels of social support. While connections between walking difficulties and pain,

 have been documented in MS, the current results provide initial evidence that these psychosocial factors may contribute to walking-related PT goal attainment. Although the analyses were limited to simple differences between individuals who did and did not meet their goals, and further evaluation is still needed for more definitive conclusions, the findings still have meaningful implications for clinical practice and future research.

Routine psychosocial assessments may help physical therapists identify potential issues with pain interference, depression, or limited social support. Currently, the National Multiple Sclerosis Society recommends yearly depression screenings for individuals with MS

 and the Academy of Neurologic Physical Therapy’s MS Task Force has recommended measuring pain, mood, and social function.

 Ideally, physical therapists could collaborate with mental health professionals who can do more in-depth assessments into these issues, including how psychological factors may be contributing to the pain perceptions of individuals with MS.

 The multidisciplinary team could then determine patient need, potential barriers to goal attainment, and what treatment approach should be used. Not only would this streamline the assessment process, but it might lead to more efficient multidisciplinary rehabilitation approaches.

Addressing physical and psychological issues concurrently may be beneficial for individuals with MS. A recent meta-analysis of the effectiveness of nonpharmacological rehabilitation interventions for MS-related pain management found that several mind-body therapies (eg, mindfulness, cognitive behavioral therapy [CBT], breathing techniques, and self-management) resulted in significant improvement in pain intensity ratings.

 For depression, combinatory interventions, including components of exercise therapy, CBT, and pharmacotherapy, have potential for individuals with MS.

 In addition, motivational interviewing (MI), an approach that empowers health behavior changes, has been associated with improvements in physical activity among individuals with MS, which in turn resulted in improved depression and fatigue symptomatology.

 Because MI builds a patient’s motivation to change and strengthens their commitment to change,

 incorporating this approach as an adjunct treatment to PT may reduce barriers to goal attainment.

Finally, in addition to facilitating family members’ participation to support patients’ goals, physical therapists could consider referrals to additional services that can help promote other sources of support (eg, peer support groups) or distribution of psychoeducational materials that provide details on the management of MS symptoms that can be shared with family and friends (eg, caregiver programs). Future research should consider evaluating whether these multidisciplinary approaches can increase PT goal attainment and whether particular strategies are more efficacious for certain patients.

Despite these potential clinical implications, the current findings are limited due to the small sample size and statistical approach. Because the study was only powered enough to detect large effects, this explains the nonsignificant differences that had a medium effect (eg, fatigue impact). A larger sample size would allow for a model that accounts for demographic, disease-related, and environmental factors such as disability, walking-impairment severity, assistive device usage, socioeconomic status, living situation, and education, as well as examination of all the psychosocial factors simultaneously. For example, how much the impact of pain influences a person’s goal attainment may differ by level of disability, and this finding could be used to inform the care plan. In addition, some of the participants completed the course of PT prior to completing study measures while some completed PT afterward. This limits the ability of the current study to determine the directionality of some of the observed associations between psychosocial factors and achievement of PT goals. It should also be noted that the sample was homogenous, with most participants being White (87.8%), non-Hispanic (90.2%) individuals with relapsing-remitting MS (73.2%), thus limiting generalizability.

Psychosocial factors are associated with whether individuals with MS meet their walking-related PT goals. These preliminary results suggest that goal attainment is associated with lower pain impact, fewer symptoms of depression, and higher levels of social support. The next step in this line of research is to conduct a larger evaluation with a more comprehensive model that accounts for demographic, disease-related, and environmental factors so more definitive conclusions can be made. Nevertheless, these findings have several clinical implications, which, if further examined, could lead to more holistic approaches to PT.

Psychosocial Factors are Associated With Walking-Related Goal Attainment in Multiple Sclerosis: A Preliminary Study

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

Recognize the complexity of fall situations and fall risk factors and apply that knowledge to obtaining information from patients about their individual fall anamnesis.

Incorporate evidence-based strategies into care that strengthen patients' awareness and self-management of fall risk.

This activity was planned by and for the health care team, and learners will receive 0.75 Interprofessional Continuing Education credit for learning and change.

 The CMSC designates this journal-based activity for a maximum of 0.75 

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The complexity of falls in people with multiple sclerosis (MS) needs further exploration to develop strategies to reduce fall risk. The aim of this study is to explore and describe factors contributing to falls and the complexity of fall situations in people with MS.

This longitudinal study used individual interviews shortly after prospective reporting of falls. Manifest analysis was used to describe frequency, place, and time of falls. The International Classification of Functioning, Disability and Health (ICF) was used for deductive content analyses to describe fall-inducing factors. Participants were adults with MS (N = 33) who had experienced falls during the past year and who did not use walking aids.

The 25 participants who fell during the study period reported 94 falls, mainly during the day (61%) and outdoors (56%). Fall situations were complex, with interaction between triggering and circumstantial factors related to all domains in the ICF, the impact of preceding factors, and fluctuating symptoms.

The complexity of fall situations can be more clearly understood and managed by considering the preceding activities and circumstances in addition to describing single risk factors. This may facilitate discussions of fall risk between health care professionals and people with MS. Individualized fall risk assessments and interventions that strengthen self-management are recommended.

From the University Healthcare Research Centre (AHW, ASF, YEN) and the Department of Physiotherapy (ASF), Faculty of Medicine and Health, Örebro University, Örebro, Sweden. 

 Ylva Nilsagård, PhD, University Healthcare Research Centre, Faculty of Medicine and Health, Örebro University, SE 70182 Örebro, Sweden; 

 The authors wish to express their gratitude to the following physiotherapists for their help in conducting this study: M. Wibom and C. Jansson at the Neurological Rehabilitation Unit, Västerås Hospital; H. Jensen and E. Cassel at the Department of Physiotherapy, Gävle County Hospital; M. Skoglund and E. Niemi Andersson at the Department of Physiotherapy, Hudiksvall Hospital; A. Borg and I. Häggblom at the Specialist Care Rehabilitation Unit, Central Hospital Karlstad; M. Måseide at the Department of Physiotherapy, Arvika Hospital; E. Östlund at the Rehabilitation Unit, Torsby Hospital; and M. Fredriksen and S. Hedström at the Department of Health, Medicine and Caring Sciences, Linköping University.

 The authors declare no conflicts of interest.

The study was supported by the Örebro University Hospital Research Foundation (Nyckelfonden) OLL-490701.

Multiple sclerosis (MS) affects approximately 2.8 million people worldwide.

 Onset is commonly between 20 and 30 years,

 with a considerably higher proportion of women being diagnosed compared with men.

 Although the incidence of MS is increasing, the disease course has become milder; contributing causes include disease-modifying therapies and increased attention to lifestyle habits and exposure to risk factors.

 People with MS report a higher fall incidence than the general population.

 Globally, the prevalence of falls for older people is 26.5% (95% CI, 23.4%-29.8%).

 A meta-analysis reported that 56% of people with mild to moderate MS reported falls during a 3-month period; 37% of them reported multiple falls.

 A higher proportion (85%) of a sample of people with MS who used walking aids reported multiple falls in an 8-month fall history.

 Fall risk seems to peak at Expanded Disability Status Scale (EDSS) scores of 4 and 6.

Leah McIntyre (née Wylie), DPT, PT

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