Exercise is effective for managing symptoms and improving quality of life among people with multiple sclerosis (MS). However, African Americans are underrepresented in MS exercise trials, partly due to limited recruitment resources and avenues tailored to this demographic. This paper describes participant outreach and recruitment strategies for an ongoing, remotely delivered, culturally tailored exercise training program for African American individuals with MS.

Initially, a passive, indirect approach in the form of virtual outreach was employed, distributing study information through MS organizations, local experts, community leaders, patient representatives, and others in the southern United States. The effectiveness of these outreach and recruitment strategies in screening and enrolling was assessed using study coordinator and participant data.

Over 15 months, the outreach methods successfully recruited 80 African Americans with MS into the clinical trial. Following a delayed start and slower initial recruitment, active outreach strategies were incorporated (eg, in-person engagements at local MS events, recreation and community centers, health care facilities, and schools). Additional tactics included study website enhancements, an informational video, email templates, and updates to the study flyer. Most participants (64.9%) were recruited through MS organizations, with virtual platforms (ie, websites, social media; 14.3%) and support groups (9.1%) also contributing to recruitment success.

This study demonstrates the effectiveness of a multipronged, experience-informed approach for successfully enrolling African Americans with MS into clinical trials. While MS organizations proved pivotal for recruiting and enrolling African Americans with MS, leveraging diverse recruitment outlets highlighted the importance of multifaceted strategies for engaging participants from minority backgrounds in research.

From the Department of Health Behavior, The University of Alabama at Birmingham, Birmingham, AL (WNN DP); Department of Kinesiology and Nutrition, The University of Illinois at Chicago, Chicago, IL (DG, VF, RWM); NORC at the University of Chicago, Chicago, IL (EF); Joi Life Wellness Group Multiple Sclerosis Center, Atlanta, GA (MJW); and the School of Kinesiology, University of Michigan, Ann Arbor, MI (DK-H). 

Whitney N. Neal, Department of Medicine, The University of Alabama at Birmingham, 1717 11th Ave S, Birmingham, AL, 35205; 

: wneal@uabmc.edu. Robert W. Motl, PhD, Department of Kinesiology and Nutrition, The University of Illinois at Chicago, 1919 West Taylor St, Chicago, IL, 60612; 

The authors declare no conflicts of interest.

This research is funded through a grant from the Bristol Myers Squibb Foundation (BMSF). All statements in this paper reflect those of the authors and do not necessarily reflect the views of the BMSF.

 The study design and preliminary data from the clinical trial were presented as an oral presentation at the Consortium of Multiple Sclerosis Centers Annual Meeting; May 29-June 1, 2024; Nashville, Tennessee.

Whitney N. Neal, PhD

Denise Gomez, BA

Victoria Flores, PhD

Edson Flores, MPH

Mitzi J. Williams, MD

Dominique Kinnett-Hopkins, PhD

Dorothy Pekmezi, PhD

Robert W. Motl, PhD

Establish a research team that reflects the diversity, values, and perspectives of underrepresented communities to enhance recruitment efforts.

Develop a comprehensive, multifaceted recruitment and engagement plan aligned with best practices for diversifying clinical trials for persons with multiple sclerosis.

Exercise training is highly effective for managing symptoms and improving health-related quality of life among persons with multiple sclerosis (MS),

 yet African American (AA) individuals with MS report lower levels of physical activity participation than White individuals.

 This may, in part, be associated with the observation that the majority of exercise training randomized controlled trials (RCTs) involving people with MS lack information on the race or ethnicity of participants (n = 44, 81%), and in the 9 studies that did collect those data, only 1.7% of participants self-identified as AA.

 There is an absence of evidence of the benefits of exercise training, and rehabilitation broadly, in AA individuals with MS, thereby undermining efforts for behavior change and health promotion.

One potential reason for the limited recruitment and inclusion of diverse samples of people with MS in exercise training RCTs may be that recruitment has often been achieved through a single avenue, typically an MS specialty clinic (84.7%) or an MS organization (13.2%).

 These avenues increase confidence that the people recruited will meet necessary diagnostic criteria for MS, but they may result in limited minority representation based on inequitable health care access across racial and ethnic groups. One review reported that AA and Hispanic people with neurological illnesses, including MS, were less likely to access outpatient neurological care and more likely to seek care in the emergency department compared with their White counterparts.

 Another study observed that AA participants were more likely to cite newspapers or magazines and others with MS as trustworthy sources of research information and less likely to trust universities compared with White participants.

 This suggests that relying on recruitment through MS clinics and organizations alone may impact the diversity of resulting samples.

Effective recruitment of AA participants with MS may require multipronged, nontraditional avenues such as collaboration with nonspecialist community providers and local agencies.

 We are aware of 2 papers involving exercise interventions for people with MS that provide detailed data on multipronged recruitment strategies.

 The papers highlight the use of consultant mail-outs, engagement of clinical partners, and trial awareness strategies; however, neither study described specific strategies for the inclusion of participants from underrepresented groups or included data on the race or ethnicity of the enrolled participants.

To facilitate recruitment of AA individuals with MS into exercise training RCTs, and perhaps rehabilitation more broadly, the field requires greater awareness of the unique needs and preferences of the target population. This paper describes our experiences and lessons learned with outreach and recruitment strategies implemented in an ongoing RCT of a remotely delivered, culturally tailored exercise training program for AA persons with MS.

 We also report on the strategies that were most effective in screening and enrolling participants. These strategies may help future researchers recruit participants with MS from underrepresented populations into RCTs of exercise training and, perhaps, other rehabilitation research.

The Targeted Exercise for African-Americans with MS (TEAAMS) study examines the effects of a 16-week, remotely delivered, culturally tailored aerobic and resistance exercise training program compared with an active control condition (stretching and flexibility) for immediate and sustained improvements in walking and other outcomes among AA persons with MS located in the southern portion of the US. The primary outcomes are walking dysfunction, as measured by the Multiple Sclerosis Walking Scale (MSWS-12), and mobility disability based on the Patient-Determined Disease Steps (PDDS). Outcomes are assessed remotely via Qualtrics at baseline, immediately post intervention (4 months), and 4 months post intervention (8 months). The University of Illinois at Chicago (UIC) Institutional Review Board approved this study, and all participants provided informed consent before enrollment. The TEAAMS study protocol has been described fully elsewhere.

(E.F. and D.G.) before entering the trial. The primary criteria for inclusion and exclusion are included in 

. Participants who satisfy the initial eligibility assessment complete a second screening on walking dysfunction (MSWS-12 score of 25-75 on a 100-point scale) and mobility disability (PDDS score of 2-6 on an 8-point scale).

TEAAMS Study Primary Inclusion and Exclusion Criteria

The power analysis indicated enrollment of 80 participants (40 per group) to yield appropriate power for testing the time × condition interaction on the main trial outcome of walking impairment. The final enrollment goal is 100 participants (50 per group) based on an anticipated dropout rate of approximately 20%. The project is funded for 4 years, and the initial enrollment target was 5 participants per month over 20 months, with recruitment beginning in November 2022.

The sociocultural and historical factors surrounding the recruitment of underrepresented groups mentioned in the introduction influenced decisions about staffing, collaborators for recruitment efforts, and recruitment strategies. We began planning recruitment activities in July 2022 during a team meeting. The meeting included the study principal investigator (White male, Illinois resident) and co-investigator (White female, Alabama resident), project coordinator (Hispanic/Latino male, Illinois resident), outreach coordinator (Black female, Alabama resident), consultant (Black female, Michigan resident), and behavioral coach (Filipino female, Illinois resident). The principal investigator (PI; R.W.M.) described the purpose of the study, its eligibility requirements, and preliminary plans for recruitment (eg, development of a study name and logo). The group then brainstormed potential recruitment strategies and sources and discussed the rationale of our recruitment strategy (ie, existing health inequities among AA individuals with MS living in the southeast) and the logistics of virtual recruitment and outreach. We decided that study outreach activities to support participant recruitment would be performed by the University of Alabama at Birmingham (UAB) outreach coordinator (W.N.N.), under the supervision of the UAB-site PI (D.P.). The UIC would play a passive role in outreach and oversee participant screening, consenting, data collection, participant monitoring, intervention delivery, and data analysis and interpretation.

The initial and subsequent team meetings allowed for the development of an explicit marketing plan, discussion of logistics for participant screening and enrollment, and identification of additional recruitment sources, strategies, and methods. Participants would be recruited in groups or waves staggered at 4-month intervals, with the first wave of participants beginning the intervention in December 2022 and assessments for the final wave planned for November 2024. We aimed to screen 30 to 40 participants per wave and enroll 20 participants per wave for our sample size goal of 100 participants in 20 months.

Description of Our Original Outreach and Recruitment Strategy

Our outreach and recruitment strategy considered participant-level barriers for diverse populations, including lack of access to competent care, lack of awareness of clinical trial opportunities, mistrust, and systemic racism and discrimination. Because previous research suggests that AA individuals with MS are less likely to trust universities as sources of research information,

 the lead outreach coordinator did not share study information directly with AA individuals with MS. Instead, the original plan focused on a passive, indirect approach to recruitment in the form of virtual outreach to MS organizations, local experts in the disease area, trusted community leaders, and patient advocates. We anticipated initiating outreach and recruitment efforts one state at a time, starting with Alabama. See 

for an overview of the original recruitment strategy.

 TEAAMS Original Outreach and Recruitment Plan

To ensure recognition of the TEAAMS study, a logo (

) was developed to be included on all study materials for project branding and recognition. We created a study website to provide a brief overview of the study, eligibility information, and contact details for the study team (https://projectteaams.ahs .uic.edu/). Program materials were modified to include culturally appropriate content based on formative feedback from a national sample of AA individuals with MS.

 The modifications included (1) images of AAs in the program manual, newsletters, and videos; (2) resources and tips that address culturally relevant barriers to exercise; and (3) inspirational quotes rooted in faith and/or well-known quotes.

Modifications of the Original Recruitment Strategy

We anticipated that most individuals would be recruited through the methods described in Table 1, yet regular engagement among the research team, feedback from trusted community leaders and patient advocates, and trial-and-error provided opportunities to improve the scope and effectiveness of outreach efforts through modifications to the original recruitment strategy. The recruitment and enrollment period was extended from 20 to 22 months (November 2022 to September 2024) due to a delayed intervention start by 1 month and the initial recruitment rate being slower than expected. After the first wave of participants, we modified our recruitment and enrollment timeline (ie, enrollment staggered at 4-month intervals with 20 participants per wave) so that subsequent waves began at 2-month intervals with 6 to 10 participants per wave. Outreach and recruitment efforts were expanded to include all states per wave and targeted Southern states (ie, Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas). After the initial months of recruitment, we shifted our focus from contacting churches and health ministries to partnering with other community organizations, such as public libraries; local and AA-owned newspapers; and AA civil, social, or fraternal organizations. Virtual, primarily passive, outreach efforts were broadened to include active strategies (eg, face-to-face engagement at local recreation or community centers, senior centers, health care facilities, schools, and community or health fairs).

Modifications to outreach and recruitment materials included: (1) creating a short video describing the study, which was provided to champions and change agents (eg, faith-based organizations, social media influencers, community organizations) for online sharing (see supplementary content); (2) updating email templates used to contact champions and change agents to increase response rates (eg, using lay language for support group leaders, defining MS for non–disease-specific organizations, personalizing to location, adding headshot to signature); (3) adding a prescreening form to the study website that allows interested individuals to be contacted by the study coordinator; and (4) revising the language on the study flyer to highlight the benefits of participating in the study and including a QR code to direct participants to the website and prescreening form (

 Iterations of the TEAAMS Study Recruitment Flyer

As of February 2024, the outreach coordinators contacted 453 entities, including MS organizations, health care providers, community organizations, patient representatives, universities, and professional organizations. The response rates from the entities differed by category, with MS organizations (ie, National Multiple Sclerosis Society [NMSS], Multiple Sclerosis Association of America [MSAA], North American Research Committee on Multiple Sclerosis [NARCOMS], National African Americans with Multiple Sclerosis Registry [NAAMSR], Accelerated Cure Project [ACP], Multiple Sclerosis Views and News [MSV&N], and Multiple Sclerosis Foundation [MSF]) yielding the highest response rates. Those organizations supported our outreach efforts by sharing study information through emails, newsletters, and social media with registry members who met our basic eligibility criteria (ie, self-identify as Black or AA, live in 1 of the included states), or by providing direct access to self-help group leaders for further community outreach (MSF). Of the 24 directly contacted MSF self-help groups, 4 agreed to distribute study flyers, and 2 requested an information session. Both sessions were conducted via Zoom and included an introduction to general and MS-specific benefits of physical activity, recommendations for becoming and staying physically active, and an overview of the TEAAMS study, followed by a question-and-answer session. Additionally, the NMSS and MSV&N facilitated recruitment opportunities by inviting the lead outreach coordinator to local events (eg, fundraising walks, luncheons, and information sessions) to distribute TEAAMS study information. The NMSS also featured a blog post on their Momentum Magazine website describing how the TEAAMS study contributed to the need for more culturally competent research (https://www.nationalmssociety.org/news-and-magazine/momentum-magazine/research-and-science/breaking-the-cycle-of-exclusion). While few individually owned physical therapy clinics responded to our request to share study information with their clients, a partnership was established with a large physical therapy provider to distribute information to clinicians and patients at over 500 clinics throughout the South.

Of the 42 AA-owned newspapers contacted, one (

) published an article regarding the importance of exercise for AAs with MS and the TEAAMS study (https://tntribune.com/teaams-project-shines-light-on-ms-and-the-black  -community/). Surprisingly, focusing on predominantly AA churches and health ministries was one of the less effective outreach strategies. Only 3 of the 51 African Methodist Episcopal and Missionary Baptist churches contacted responded to our email and/or phone calls. The pastors agreed to share the study flyer with congregation members, though it was unclear if any members were diagnosed with MS. Other community-based professional organizations, including Black in Neuro, the National Black Nurses Association, and the Council on Black Health, played a supportive role by disseminating study information within their professional networks.

Although quantifying the exact impact of distributing letters and study flyers to over 164 public libraries and medical facilities within our target area is difficult, we know that at least 4 neurology clinics shared study information with patients, as evidenced by participants mentioning how they learned about TEAAMS. Other less frequent approaches include sharing study information via universities with established community networks and distributing flyers via community health workers. We explored using paid traditional advertisements (ie, television, radio, newspaper) but ultimately found these options to exceed our study’s budget constraints. Nevertheless, we allocated a small portion of the budget to collaborate with an ethnic disease-specific organization (We Are ILL) to distribute the study flyer to their existing member registry that contained over 1300 individuals.

As of February 2024, approximately 393 persons with MS have expressed interest in the study, and 354 (90.1%) were contacted by the project coordinator. Of the contacted individuals, 205 (57.9%) were scheduled for phone screenings, and 192 (54.2%) underwent eligibility assessments. Among those assessed, 88 were eligible for participation, and 8 declined to participate, resulting in the enrollment of 80 (41.7%) participants (

). Of the 104 individuals deemed ineligible for the study, the majority (71.2%) were excluded due to protocol-defined criteria associated with disease status and physical activity levels: 19 individuals (18.3%) did not meet the walking dysfunction criterion, 37 (35.6%) failed to meet both the ambulatory disability and walking dysfunction criteria, and 18 (17.3%) did not meet the physical activity, ambulatory disability, or walking dysfunction criteria. Two (1.9%) individuals were excluded based on not self-identifying as Black or African American, and 12 individuals (11.5%) were excluded as they did not self-identify as residing in the southern US.

Projected Number of Participants vs Cumulative Number of Participants

Of the 393 interested participants, 268 (68.2%) completed the website prescreening form, and 111 (28.2%) contacted the project coordinator via email. Other initial contact methods included phone calls (n = 28, 7.1%) and referrals from neurologists (n = 6, 1.5%), with some potential participants utilizing multiple contact methods.

Recruitment methods for 40.1% (n = 77) of the 192 participants assessed for eligibility were identified (

). The yield varied by recruitment method, with referrals from disease-specific organizations (eg, NMSS, NAAMSR, ACP, MSAA, We Are ILL, and MSF newsletters) being the most effective (n = 50, 64.9%). Other effective recruitment methods included referrals from MS organization–affiliated support groups (n = 7, 9.1%) and virtual platforms, such as websites, Facebook, and disease-specific podcasts (n = 11, 14.3%).

This paper describes participant recruitment strategies implemented for a remotely delivered, culturally tailored exercise training program for AA individuals with MS and provides a resource for future researchers conducting inclusive rehabilitation research with underrepresented populations. Although the trial is ongoing, the TEAAMS study implemented a multipronged approach to recruitment that involved primarily passive outreach strategies to achieve 88.9% of our recruitment goal after 15 months (80 enrolled participants divided by 90 expected eligible and enrolled by February 2024).

Most participants (64.9%) were recruited via MS organizations, in line with a previous exercise training intervention for persons with MS.

 Although recruitment data were not available for most screened participants (60%), noticeable increases in interest were observed following the inclusion of study information in MS organization newsletters. A recent study indicated that MS organizations and MS websites/blogs were the top 2 sources for research information reported by people with MS, with no differences between racial and ethnic groups.

 Awareness of MS in AAs has prompted disease-specific organizations to provide more resources and programs catered to this segment of the MS population, likely contributing to increased response rates. Moreover, the variety in how participants learned of the study highlights the necessity for variable recruitment strategies. For instance, 7 individuals assessed for eligibility learned about the study from 1 of the 6 support groups that agreed to distribute our flyers.

Initial recruitment progressed more slowly than expected, but we ultimately achieved an average monthly enrollment rate of 5.3 participants. While seldom detailed in existing literature, this metric surpasses the enrollment rate of a comparable large-scale MS exercise trial, which reported 3.5 participants enrolled per month

; however, this study required regular in-person attendance, unlike our home-based training program. Physical activity and exercise training interventions involving other populations, such as AA women living in Alabama and older AA breast cancer survivors, have reported similar enrollment rates at 7.0 per month

 respectively, suggesting that our recruitment rate is a realistic target for future remote exercise training interventions for AA adults with MS.

Matching the race of the research staff with the desired participants is beneficial to study recruitment and retention

; other factors such as class, education, personality, and shared values may also influence the recruitment of AA individuals into clinical trials.

 Our study team was intentionally diverse across these dimensions to foster recruitment of a more diverse study sample. The lead outreach coordinator (W.N.N.), a lifelong resident of the AA community in Alabama, leveraged personal experiences and local knowledge to effectively support TEAAMS study recruitment. Team members, including consultants and coordinators, came from other underrepresented backgrounds, sharing similar knowledge and values. We strongly suggest that future research teams mirror the diversity, values, and experiences of the underrepresented communities they seek to engage in their recruitment efforts.

Multipronged, Nontraditional Recruitment Strategies

The development of our comprehensive, multifaceted recruitment and engagement plan aligns with recommendations to diversify clinical trials for people with MS.

 Our approach combined 7 passive strategies, from traditional partnerships with MS organizations to engaging local libraries and ethnic organizations, which is more than the reported 5 strategies utilized in previous MS research studies.

 Multiple passive, nontraditional approaches, such as engaging with nonspecialist community providers, local community agencies, and patient partners, were effective for identifying AAs with MS living in the South.

The study’s unique structure, with the lead site (UIC) in a supportive role and UAB directing outreach, enhanced recruitment efforts. This is similar to other studies using institutional support to reach underrepresented groups.

 The lead study site’s management of enrollment activities allowed the lead outreach coordinator to develop innovative recruitment materials and quickly pivot to integrate active outreach strategies. Although direct impact is challenging to quantify, this focused approach to outreach and engagement facilitated the identification of nearly 500 potential collaborators.

Weekly videoconferences with the research team identified recruitment challenges and devised timely solutions. This adaptability led to the development of improved strategies for identifying potential participants. For instance, to counter recruitment slowdowns, we broadened our outreach to include local event attendance, which enhanced connections with disease-specific organizations, maintained study visibility, and uncovered new opportunities for support and recruitment.

Study Website and Online Prescreening Form

A prescreening form on the study website (https://projectteaams.ahs.uic.edu/) emerged as the top method for potential participant contact, with 68.2% using this method to indicate their interest. All recruitment materials, such as flyers and information in organizational newsletters, directed individuals to the study website, which explained the TEAAMS study in lay language, alongside details about the research team and online interest form (hosted via Qualtrics). Given the extensive online presence of MS resources,

 the large number of potential participants recruited via the website prescreening form suggests that this may be an effective strategy for increasing research engagement among AAs with MS.

Despite previous research suggesting that faith-based settings could effectively recruit AAs into clinical research trials,

 our outreach attempts had limited success. Fewer than 6% of the African Methodist Episcopal and Missionary Baptist churches we contacted responded to our emails and/or phone calls, leading us to refocus our outreach efforts toward other community organizations, such as public libraries and local and AA-owned newspapers. The lack of success with churches might stem from relying on passive outreach methods without first establishing rapport with church leaders and members. In contrast, previous research suggests that a prior working relationship with churches may play a role in recruitment success,

 highlighting the importance of fostering relationships with the churches before requesting recruitment assistance.

This study is not without limitations. Notably, we could only trace the enrollment source for 40.1% of participants. This gap stems from the omission of a referral question in the screening form; the coordinator collected such details post screening. Future research should include referral tracking in initial questionnaires to gauge recruitment strategy effectiveness. In addition, fewer than half of the participants assessed for eligibility were enrolled in the study, with reasons for ineligibility primarily related to not meeting inclusion criteria for walking dysfunction. Eligibility of interested participants may have been further limited by our requirement for internet access. Lastly, the focus on AA individuals with MS in the southern US likely limits the applicability of these results to other regions.

This paper highlights the importance of a flexible, comprehensive, multifaceted plan for recruitment and engagement of AAs with MS in exercise training RCTs. Despite the effectiveness of referrals from MS organizations, the diversity of how participants learned about the study showcases the success of integrating multiple traditional and nontraditional approaches. To our knowledge, this is the first paper to report recruitment strategies in an exercise RCT specifically for AAs with MS, offering a framework for future research to incorporate underrepresented groups in exercise RCTs and perhaps broader rehabilitation studies.

Motl RW, Sandroff BM, Kwakkel G, et al. Exercise in patients with multiple sclerosis. 

. 2017;10(16):848-856. doi:10.1016/S1474-4422(17)30281-8

Kinnett-Hopkins D, Motl RW. Social cognitive correlates of physical activity in Black individuals with multiple sclerosis. 

. 2016;97(4):590-595. doi:10.1016/j.apmr.2015.12.011

Kinnett-Hopkins D, Motl R. Results of a feasibility study of a patient informed, racially tailored home-based exercise program for Black persons with multiple sclerosis. 

. 2018;75:1-8. doi:10.1016/j.cct.2018.10.009

Lai B, Cederberg K, Vanderbom KA, Bickel CS, Rimmer JH, Motl RW. Characteristics of adults with neurologic disability recruited for exercise trials: a secondary analysis. 

. 2018;35(4):476-497. doi:10.1123/apaq.2017-0109

Finlayson M, Al-Mashita L, Sandhu R. Participant diversity in clinical trials of rehabilitation interventions for people with multiple sclerosis: a scoping review. 

. 2023;29(9):1149-1157. doi:10.1177/13524585231189670

Amezcua L, Rivera VM, Vazquez TC, Baezconde-Garbanati L, Langer-Gould A. Health disparities, inequities, and social determinants of health in multiple sclerosis and related disorders in the US: a review. 

. 2021;78(12):1515-1524. doi:10.1001/jamaneurol.2021.3416

Pimentel Maldonado DA, Moreno A, Williams MJ, et al. Perceptions and preferences regarding multiple sclerosis research among racial and ethnic groups. 

. 2021;23(4):170-177. doi:10.7224/1537-2073.2019-131

Carter A, Humphreys L, Snowdon N, et al. Participant recruitment into a randomised controlled trial of exercise therapy for people with multiple sclerosis. 

. 2015;16:468. doi:10.1186/s13063-015-0996-3

Tracy TF, Young HJ, Lai B, et al. Supporting successful recruitment in a randomized control trial comparing clinic and home-based exercise among adults with multiple sclerosis. 

. 2022;8(1):35. doi:10.1186/s40900-022-00366-6

Motl RW, Kinnett-Hopkins D, Neal W, Flores E, Pekmezi D, Flores V. Targeted exercise for African-Americans with multiple sclerosis: Project TEAAMS. 

. 2023;126:107088. doi:10.1016/j.cct.2023.107088

Kinnett-Hopkins D, Motl R. Preferences for exercise among Black individuals with multiple sclerosis. 

. 2019;5(1):2055217319834715. doi:10.1177/2055217319834715

Pekmezi D, Ainsworth C, Joseph RP, et al. Pilot trial of a home-based physical activity program for African American women. 

. 2017;49(12):2528-2536. doi:10.1249/MSS.0000000000001370

Owusu C, Nock NL, Feuntes V, et al. IMPROVE, a community-based exercise intervention versus support group to improve functional and health outcomes among older African American and Non-Hispanic White breast cancer survivors from diverse socioeconomic backgrounds: recruitment strategies and baseline characteristics. 

. 2021;127(11):1836-1846. doi:10.1002/cncr.33430

Garza MA, Quinn SC, Li Y, et al. The influence of race and ethnicity on becoming a human subject: factors associated with participation in research. 

. 2017;7:57-63. doi:10.1016/j.conctc.2017.05.009

Smith YR, Johnson AM, Newman LA, Greene A, Johnson TR, Rogers JL. Perceptions of clinical research participation among African American women. 

. 2007;16(3):423-428. doi:10.1089/jwh.2006.0124

Marrie RA, Chataway J, Bierer BE, et al. Enhancing diversity of clinical trial populations in multiple sclerosis. 

. 2023;29(9):1174-1185. doi:10.1177/13524585231189677

Carter CR, Maki J, Ackermann N, Waters EA. Inclusive recruitment strategies to maximize sociodemographic diversity among participants: a St. Louis
case study. 

. 2023;8(1):23814683231183646. doi:10.1177
/23814683231183646

Stromgren C. Community outreach through web resources: multiple sclerosis. 

. 2002;21(1):61-70. doi:10.1300/J115v21n01_05

Campbell AD, Szaflarski M. Health programming priorities among faith communities in Jefferson County, Alabama. 

. 2021;40(4):371-394. doi:10.1080/15426432.2021.1907837

Whitt-Glover MC, Borden SL, Alexander DS, Kennedy BM, Goldmon MV. Recruiting African American churches to participate in research: the learning and developing individual exercise skills for a better life study. 

. 2016;17(2):297-306. doi:10.1177/1524839915623499

Recruitment of African American Adults With Multiple Sclerosis Into Randomized Controlled Trials of Exercise Training: Lessons Learned From Project TEAAMS

In the absence of gait automaticity, the need to allocate cognitive resources to walking has implications for everyday mobility and community participation. The purpose of this study was to examine the effects of different attentionally demanding conditions on gait metrics in people with multiple sclerosis (MS).

Twenty-one individuals (11 with MS, 10 without MS) wore wireless inertial sensors and completed 1-minute walking trials under 4 different attentional conditions: no-attentional-instruction, focus on gait quality, attention to a narrative discourse task, and attentional switching. Walking trials were performed at a self-selected and fast-paced walking speed. A 3-way linear mixed model including conditions, groups, speeds, and interactions was used to evaluate the effects on gait speed and stride length variability.

Participants with MS demonstrated slower gait speed and greater gait variability in all attentional conditions than participants without MS. During self-paced walking, participants with MS showed the greatest decline in mobility metrics during the attentional switch condition. When walking fast, significant differences were observed for both the divided attention and attentional switching conditions, with divided attention having the greatest effect on gait speed and attentional switching resulting in the greatest decrease in gait variability.

Difficult walking conditions, such as attentional switching, elicit greater gait deficits in people with MS. Evaluating attentional switching may be useful for mobility assessment in people with MS, and incorporating this attentional technique in future mobility training may improve stability and prevent falls.

From the Department of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan (MV) and the Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont (MB, SLK). 

: Michael VanNostrand, PhD, 259 Mack Avenue, #2305, Detroit, MI, 48201; 

The authors declare no conflicts of interest for
this study.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

This work, in part, was presented previously as 2 posters at the North American Federation of Adapted Physical Activity Conference; October 11-13, 2022; St. Catharines, Ontario, Canada.

Michael VanNostrand, PhD

Myeongjin Bae, PhD

Susan L. Kasser, PhD

Walking while directing attention to other cognitively demanding tasks can negatively impact gait stability in people with multiple sclerosis.

Interventions targeting mobility should include attentional switching tasks to improve real-world ambulation and reduce fall risk.

Well-controlled and coordinated walking is essential for safe and successful community mobility, with automaticity—defined as the ability to walk with minimal reliance on attention-demanding cognitive resources—serving as a critical component of efficient gait.

 Automaticity allows individuals to walk without the need for continuous attentional monitoring, preserving cognitive capacity for navigating complex and dynamic environments.

When automaticity is compromised, walking becomes increasingly dependent on cognitive control, resulting in competition for attentional resources and contributing to gait difficulties and impaired performance of concurrent tasks.

 This is particularly relevant for individuals with multiple sclerosis (MS), who often exhibit reduced walking automaticity

 and report needing to consciously direct attention to their walking in order to maintain stability.

 Such compensatory strategies are concerning, as attentional difficulties have been shown to negatively impact walking

 and are associated with increased fall risk in this population.

 Accordingly, understanding how attentional deficits influence gait has important real-world implications.

While research has reported that between 20% and 50% of adults with MS have specific attentional difficulties,

much of the attentional research regarding gait has focused on walking while dividing attention (ie, dual tasking).

 Yet, to walk safely and successfully, individuals not only have to divide attention but must also be able to flexibly prioritize and switch attention in accordance with the demands of everyday conditions and circumstances.

 Attentional switching denotes the ability to flexibly shift back and forth between multiple tasks or mental sets.

 Recent research has sought to examine outcomes associated with flexible and adaptive attentional control in individuals with MS through task-switching paradigms. Migliore et al

 found that participants with MS demonstrated greater deficits in attentional switching compared with the control group when completing a computer-based cued-switching task while seated. However, research by Shiri and colleagues

 found no relationship between cognitive flexibility and static balance in study participants when attentional switching was assessed via common neuropsychological measures. Notwithstanding the methodological differences and inconsistencies across these 2 studies, no study to date has specifically investigated whether impaired attentional switching influences walking in people with MS.

During walking, competition for attentional resources is influenced not only by the timing of concurrent tasks but also by their complexity—that is, tasks that demand greater cognitive load or involve more advanced mental processes.

 Individuals with MS tend to have a reduced capacity to recruit additional cognitive resources in response to increasing task complexity.

 Moreover, gait impairments can often be exacerbated at faster walking speeds,

 highlighting the importance of understanding how individuals with MS manage attentional switching across varying gait speeds. This is particularly important given the demands of real-world ambulation, where navigating busy or unpredictable environments often requires rapid shifts in attention and adaptive motor responses.

Given the importance of cognitive resources for optimal gait performance, isolating the effects of cognitive flexibility from other cognitive processes and under differential cognitive loads may further the development of novel therapeutic interventions designed to enhance attentional switching and facilitate gait automaticity in people with MS. As such, the purposes of this study were to compare the effects of divided attention and attentional switching on gait in adults with and without MS and to explore the differential effects of these attentional conditions when walking at self-selected or fast-paced speeds.

A convenience sample of 11 individuals with MS and 10 without MS (NoMS) was recruited. An email invitation was sent to individuals with MS listed in the authors’ research database who had participated in previous research. Additionally, a flyer was posted in the multiple sclerosis center of the local medical center. Those with MS had to self-report (1) physician-diagnosed MS and (2) minimal to moderate disability (a score of 1-4 on the Patient-Determined Disease Steps [PDDS] scale).

 Individuals with MS were excluded if they had (1) a severe exacerbation of symptoms requiring medical intervention in the previous month or (2) any health condition or diagnosis besides MS that could influence balance or ambulation. Participants without MS were matched by age (±3 years) and sex, and also had to report no health condition or diagnoses affecting balance or ambulation. This study was approved by the Institutional Review Board of the University of Vermont, and all participants provided written consent prior to data collection.

Demographic data included age, sex, years post diagnosis, and MS phenotype. For additional insight into the sample, cognitive functioning was assessed using the Symbol Digit Modalities Test (SDMT) and the Montreal Cognitive Assessment (MoCA). The SDMT, a reliable and valid measure of cognitive impairment in MS,

 evaluates constructs of attention, perceptual processing, working memory, and psychomotor speed through a timed task of matching abstract symbols to numbers. The MoCA is a sensitive and useful cognitive screening tool used to detect early and mild cognitive impairment in people with MS.

 It assesses function across the cognitive domains of attention, executive functions, memory, language, visuo-constructional skills, conceptual thinking, calculations, and orientation.

Mobility impairment was measured with the 12-item Multiple Sclerosis Walking Scale, a reliable and valid instrument,

 whereby participants self-report how much their MS impacts their ability to walk under various circumstances. The Falls Efficacy Scale–International

 was used to assess participant concerns about falling during 16 activities of daily living.

Measurements of continuous walking were derived using APDM Opals, small wireless inertial motion sensors, and its related Mobility Lab software (Clario). Sensors were placed on a participant’s lumbar spine, sternum, and both feet. Data from the Opal sensors were collected wirelessly at 128 Hz. Measurements included gait speed (m/s) and stride length variability, which was expressed as the coefficient of variation (CV [%]) and calculated by stride length SD/stride length mean to represent relative gait variability.

 These metrics have been identified as sensitive measures of dual-task mobility impairment in individuals with MS.

Participants completed eight 1-minute trials walking between 2 lines 25 feet apart. The 8 walking bouts consisted of 4 different attentional conditions at both a self-paced (SP) and a fast-paced (FP) walking speed. For the no-attentional-instruction (NI) condition, participants were simply asked to walk back and forth. For the internal-focus (IF) condition, participants were instructed to focus their attention on their gait throughout the walking bout, a task selected based on research highlighting the impact of internally focused attention on daily walking in individuals with MS.

 In the divided-attention (DA) condition, participants were asked to walk while simultaneously completing a narrative discourse task, which required them to verbally produce a detailed and coherent story in response to an open-ended prompt (eg, “trip to New York City”) while walking, or a similarly structured alternate form (eg, “moving to a new city”).

 This task has been shown to be a cognitively demanding task of natural language formulation, planning skills, and discourse production requiring substantial attentional resources.

 In the attentional-switching (AS) condition, participants were instructed to switch their attention every 15 seconds between the IF and DA tasks throughout the 1-minute bout, allowing for an assessment of their ability to flexibly shift attention between internally and externally oriented tasks—an ability that mirrors the dynamic attentional demands of real-world environments (

). All walking trials and discourse topics were randomized across participants to minimize order effects. Participants were instructed to rest, as needed, between trials to minimize the impact of fatigue from both the mobility and cognitive components of the testing paradigm.

Descriptive statistics were performed to examine group differences with independent 

 test, Wilcoxon rank-sum test, or Fisher exact test after inspection of normality. To evaluate the effects of attentional conditions and walking speeds on gait metrics (gait speed and stride length variability), we employed a 3-way linear mixed model including attentional conditions (NI, IF, DA, AS), groups (MS, NoMS), speeds (SP, FP), and interaction terms (group × condition, group × speed, condition × speed, group × condition × speed) as fixed effects with participants as random effects to allow for the entry point to vary across participants. A linear mixed model was selected, as it accounts for the heterogeneity and correlation of repeated measures under different conditions and retains participants with partially missing data. Effect sizes and 95% CIs of the linear mixed model were calculated using fixed-effects regression coefficients. All analyses were performed using Stata 17 (StataCorp), and statistical significance was set at 

There were no significant differences in age (

 = .99) between participants with and without MS. Participants with MS had greater concerns about falling (

 < .001) than those without MS and lower cognitive functioning than the NoMS group, as indicated by SDMT (

 < .001) scores. The MS group reported a median PDDS score of 3 (ie, gait disability) and average years post diagnosis of 24.1 ± 12.8 (

The 3-way linear mixed model found significant group effects (

 < .05) in both gait metrics. Participants with MS showed significantly lower gait speed and greater stride length variability than participants without MS in all attentional conditions, regardless of speed instructions, except for stride length variability in the fast-paced internal-focus condition (

Within- and Between-Group Differences in Gait Metrics

We also observed significant speed main effects (

 < .05) in both groups. Multiple post hoc contrast comparisons indicated that participants significantly increased their gait speed when instructed to walk at a faster speed. However, no significant differences in gait speed were found between self-paced and fast-paced walking in the divided-attention condition for participants with MS. Unlike gait speed, stride length variability did not differ among walking speeds across attentional conditions (Table 2).

Results revealed different patterns of attentional condition main effects based on speed instruction and group. In self-paced walking, there were significant attentional condition main effects on gait speed in the NoMS group, but not in participants with MS (

). No significant gait speed differences were observed across any of the attentional conditions in participants with MS. The NoMS group, on the other hand, showed the greatest decline in gait speed in the attentional-switching condition compared to the no-attentional-instruction condition (B = –0.13 m/s; 95% CI, –0.20 to –0.06; 

 < .001) and the divided-attention condition (B = –0.09 m/s; 95% CI, –0.17 to –0.01; 

 = .024). Compared to gait speed, however, we observed that the attentional-switching condition resulted in the greatest stride length variability in both groups at the self-selected pace. Participants with MS demonstrated significantly greater gait variability in the attentional-switching condition than in the no-attentional-instruction condition (B = 1.28%; 95% CI, 0.18-2.37; 

 = .022) and the internal-focus conditions (B = 1.67%; 95% CI, 0.03-3.31; 

 = .043), whereas the NoMS group had greater variability in the attentional-switching condition compared to the divided-attention condition (B = 1.23%; 95% CI, 0.08-2.38; 

Self-Paced Walking by Attentional Condition

In fast-paced walking, both groups demonstrated the slowest gait speed in the divided-attention condition (

). For the MS group, the divided-attention condition (B = –0.20 m/s; 95% CI, –0.28 to –0.12; 

 < .001) resulted in slower walking speed than in the attentional-switching condition (B = –0.16 m/s; 95% CI, –0.23 to –0.08; 

 < .001) when compared to the no-attentional-instruction condition. For the NoMS group, both the divided-attention and attentional-switching conditions significantly differed from the other conditions and one another (B = –0.08 m/s; 95% CI, –0.16 to –0.001; 

 = .047), although the divided-attention condition had the greatest effect on speed. For the MS group, while the divided-attention condition elicited greater stride length variability than the no-attentional-instruction (B = 1.47%; 95% CI, 0.30-2.63; 

 = .013) and the internal-focus conditions (B = 1.41%; 95% CI, 0.23-2.59; 

Volume 27, Issue Q4

Recruitment of African American Adults With Multiple Sclerosis Into Randomized Controlled Trials of Exercise Training: Lessons Learned From Project TEAAMS

The Impact of Attentional Focus on Gait in Adults With Multiple Sclerosis: A Preliminary Investigation

Occupational Therapy Interventions Addressing Activities of Daily Living and Sleep for People With Multiple Sclerosis: A Systematic Review

Ocrelizumab Wearing-Off Phenomenon: Prevalence, Predictors, and Outcomes After Intervention

Head Rotation Impairs Balance and Walking in People With Mild to Moderate Multiple Sclerosis: A Pilot Study

Rehabilitation in Multiple Sclerosis (RiMS) Network Is Key to the World Health Organization’s Rehabilitation 2030: A Call for Action for People With Multiple Sclerosis

Navigating the Unknown: A Qualitative Exploration of the Lived Experiences of People With Multiple Sclerosis During Pregnancy