ORIGINAL ARTICLE
Exercise and Quality of Life Among People With Multiple
Sclerosis: Looking Beyond Physical Functioning to Mental
Health and Participation in Life
Aaron P. Turner, PhD, Daniel R. Kivlahan, PhD, Jodie K. Haselkorn, MD, MPH
ABSTRACT. Turner AP, Kivlahan DR, Haselkorn JK. Ex-
ercise and quality of life among people with multiple sclerosis:
looking beyond physical functioning to mental health and
participation in life. Arch Phys Med Rehabil 2009;90:420-8.
Objective: To describe the prevalence of exercise in a
national sample of veterans with multiple sclerosis (MS) and
the association of exercise with quality of life, including phys-
ical health, mental health, and participation restriction.
Design: Cross-sectional cohort study linking computerized
medical records to mailed survey data from 1999.
Setting: Veterans Health Administration.
Participants: Veterans with MS (N!2995; 86.5% men)
who received services in the Veterans Health Administration
and returned survey questionnaires.
Interventions: Not applicable.
Main Outcome Measures: Demographic information, Vet-
eran RAND 36-Item Health Survey (VR-36), self-reported
exercise frequency.
Results: Among all survey respondents with MS, only
28.6% (95% confidence interval, 26.9–30.2) endorsed any
exercise. In adjusted logistic regression, exercise was associ-
ated with younger age, more education, living alone, lower
levels of bodily pain, and higher body mass index. After
adjusting for demographic variables and medical comorbidi-
ties, exercise was associated with better physical and mental
health. People who exercised reported they had better social
functioning and better role functioning (participation in life
despite physical and emotional difficulties).
Conclusions: Exercise in veterans with MS is uncommon.
In the context of chronic illness care, the identification of
exercise patterns and promotion of physical activity may rep-
resent an important opportunity to improve mental health and
quality of life among people with MS. Intervention should
address factors associated with lower rates of exercise includ-
ing age, education, and pain.
Key Words: Exercise; Health status; Mental health; Multi-
ple sclerosis; Quality of life; Rehabilitation.
Published by Elsevier Inc on behalf of the American Con-
gress of Rehabilitation Medicine.
MULTIPLE SCLEROSIS IS a chronic degenerative disor-der of the central nervous system affecting as many as
350,000 people in the United States.1 It is associated with a
host of unpredictable and disabling symptoms that include, but
are not limited to, sensory and motor loss, fatigue, difficulties
with balance, sexual functioning, pain, cognitive impairment,
and depression.2-5 MS is typically diagnosed between the ages
of 20 and 40 years, and because most people have a relatively
healthy lifespan, they usually have a prolonged course of
illness.4,6 Over the past several decades, researchers have made
significant progress in identifying the neuropathology of MS
using techniques such as magnetic resonance imaging, and in
slowing the disease process using disease-modifying therapies.
Nonetheless, MS remains a disease without a definitive cure,
and as a result, there is a substantial need for individuals with
MS to identify ways they can manage the disease and limit its
impact on functioning and QOL.
Health-promoting behaviors, such as exercise, represent an
important way people with MS may participate in the disease
management process. The significant and wide-ranging bene-
fits of exercise for overall health have been extensively docu-
mented in many populations7-9 and include reduced blood
pressure,10 body fat,11 and risk of coronary heart disease,12 as
well as improvements in bone density,13 mental status,14 and
psychologic well being.15,16
In past decades, people with MS were often advised to avoid
significant physical activity because of concerns that it might
induce fatigue or even facilitate an exacerbation of the disease
itself.17-19 However, a growing body of evidence linking exer-
cise to improved physical functioning has had an important
impact on clinician practice patterns. Current findings suggest
that people with MS receive substantial benefit from physical
activity. Several clinical trials have examined the benefits of
formal exercise programs. Although interventions have varied
From the Veterans Affairs Puget Sound Health Care System (Turner, Kivlahan,
Haselkorn); Veterans Affairs Multiple Sclerosis Center of Excellence West (Turner,
Haselkorn); Veterans Affairs Center of Excellence in Substance Abuse Treatment and
Education (Turner, Kivlahan); Department of Rehabilitation Medicine (Turner, Ha-
selkorn), Department of Psychiatry and Behavioral Sciences (Kivlahan), Department
of Epidemiology (Haselkorn), University of Washington, Seattle, WA.
Supported by Department of Veterans Affairs Rehabilitation Research and Devel-
opment Service Career Development Award (grant no. B4927W), Veterans Affairs
Center of Excellence in Substance Abuse Treatment and Education, the Veterans
Affairs Multiple Sclerosis Center of Excellence West, and the Veterans Affairs Office
of Quality and Performance.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Reprint requests to Aaron P. Turner, PhD, VA Puget Sound Health Care System,
Rehabilitation Care Services, S-117, 1660 S Columbian Way, Seattle, WA, 98108,
e-mail: Aaron.Turner@va.gov.
0003-9993/09/9003-00171$36.00/0
doi:10.1016/j.apmr.2008.09.558
List of Abbreviations
BMI body mass index
CI confidence interval
ICF International Classification of Functioning,
Disability and Health
LHS Large Health Survey
MS multiple sclerosis
OR odds ratio
QOL quality of life
SF-36 36-Item Short Form Health Survey version 1.0
VA Veterans Affairs
VR-36 Veteran RAND 36-Item Health Survey
420
Arch Phys Med Rehabil Vol 90, March 2009

considerably in modality and their relative emphasis on
strength and endurance, exercise training has increased walk-
ing speed, endurance, strength, balance, and aerobic capacity,
and reduced fatigue.20-26 In addition, trials of physical therapy
and inpatient rehabilitation, which include but are not limited
to exercise, have also produced improvements in mobility and
global disability, and decreases in MS-related symptoms.27-34
Exercise has been shown to be safe and very well tolerated
among people with MS.20,23,24
The relationship between exercise and psychologic well
being in MS is less well established, but some studies also
suggest that increased physical activity may make important
contributions to mental health. Petajan et al21 found that a
structured and professionally guided outpatient exercise pro-
gram brought significant decreases in depression, anger, and
fatigue for participants with MS relative to controls. Wiles et
al29 reported a physical therapy intervention for MS had a
positive impact on depression and anxiety. More generally,
people with MS who have higher levels of physical activity
have been shown to endorse greater satisfaction with life.35
These results are consistent with an increasing literature be-
yond MS suggesting that exercise may improve mood states
and mental health in the general public, and among other
populations with disabilities.36-41 Nonetheless, not all studies
of exercise in MS have shown positive mental health bene-
fits,22,32 and questions about the nature and extent of this
relationship remain.
In addition to physical and mental health, there is increasing
recognition that health professionals should look beyond im-
pairments and deficits and define functioning more broadly to
include overall QOL.18 One well established roadmap for op-
erationalizing this very broad concept is the ICF championed
by the World Health Organization.42 The ICF proposes a
taxonomy of functioning that includes impairments (ie, prob-
lems in body function or structure), activity limitations (ie,
difficulty in executing activities), and participation restrictions
(ie, lack of involvement in community, social, occupational,
and other meaningful and desirable life pursuits). A person’s
QOL is determined by a combination of all 3 of these factors,
as well the environment in which they occur. Each level of
functioning is partially but not entirely determined by the
previous level. As previously suggested, it is this final level,
participation restriction, that is most often neglected by an
overly narrow focus on illness at the expense of recognizing the
larger impact of illness on life.
Despite growing interest in research on QOL, data examin-
ing the relationship between exercise and participation restric-
tion in MS are sparse and relatively equivocal. Two studies
examining structured exercise training programs, one a group-
based outpatient intervention,21 the other an addition to an
inpatient rehabilitation program,25 have reported greater im-
provements in self-reported social interaction in their exercise
treatment conditions. A study by Freeman et al34 found inpa-
tient rehabilitation had a positive impact on participation, using
a measure that included social and occupational functioning,
although exercise itself was not quantified and was only 1
component of the overall treatment. Other authors have found
no impact of exercise on participation32 and no association
between exercise capacity and leisure physical activity.43 In a
large, prospective evaluation, Stuifbergen et al44 found a pos-
itive association between exercise and a global measure of
QOL, but participation was not specifically delineated. Conse-
quently, understanding of the potential impact of exercise on
social and community participation is limited.
The current study is intended to serve several purposes. First,
it provides an estimate of self-reported exercise in a large,
national sample of people with MS. In particular, this sample of
predominantly male veterans represents an important opportu-
nity to examine the physical activity of men with MS, a group
that is typically underrepresented in MS research. Second, this
study examines correlates of exercise in this population. It is
hypothesized that barriers to activity, including but not limited
to older age, pain, and greater BMI, will be associated with
lower levels of exercise. Third, the current study explores the
relationship between exercise and both physical and mental
functioning (mental health), with the expectation based on
existing literature that all 3 will be positively correlated. Men-
tal functioning is of particular interest because it has not
received as much attention in existing literature. Finally, the
investigation of greatest interest in this study is the relationship
between exercise and participation restriction. It is hypothe-
sized that after controlling for physical functioning, mental
health, and other covariates, exercise will be positively asso-
ciated with 3 other subscales of the VR-36 (Role Emotional,
Role Physical, Social Functioning) that most closely corre-
spond to the ICF category of participation restrictions.
METHODS
This current study is a cross-sectional, secondary data anal-
ysis of a cohort created by the linkage of a VA national
administrative database containing medical record information
with a mailed national health survey conducted in 1999.
Participants
Potential participants were first drawn from the VA MS
National Data Repository, a database containing information
on all veterans receiving MS-related health care services within
Veterans Health Administration from 1998 to 2004. The re-
pository is updated periodically, but at the time of the data
extraction for this study, it contained 32,009 unique cases.
To reduce inaccurate ascertainment because of coding er-
rors, people were included in a final target population only
if they met 1 or more of the following 4 criteria: (1) they had
an inpatient hospitalization for MS (hospitalization was
coded with the International Classification of Diseases di-
agnostic code 340 for MS), (2) they had received a disease-
modifying agent (interferon !-1a, interferon !-1b, or glati-
ramer acetate) used only to treat MS, (3) they were VA
service connected for MS (the diagnosis had been confirmed
through a medical review process for purposes of VA reim-
bursement of services), or (4) they had at least 1 outpatient
encounter for which the primary ICD diagnosis code was
340 during each year in which they received some VA
medical service. The process of identifying a target popula-
tion within the VA MS National Data Repository by means
of a search algorithm has been validated by chart review in
previous work and has been shown to be an effective means
of eliminating people who do not have MS.45 A total of
17,470 veterans were included in the target population.
Information on people in the target population was then
linked to data from the VA Office of Quality and Performance
1999 LHS.46 The LHS was conducted to establish the health
status and health behavior patterns of a nationally representa-
tive sample of veterans receiving care across the VA health
care system. The overall LHS was returned by 877,775 of 1.4
million enrollees who were mailed surveys (63.1% response
rate). Similarly, among people with MS in the target popula-
tion, the LHS was returned by 2994 of 4685 enrollees who
were mailed surveys (63.9% response rate). All procedures
were approved by the local human subjects review committee.
421EXERCISE IN MULTIPLE SCLEROSIS, Turner
Arch Phys Med Rehabil Vol 90, March 2009