Most people with multiple sclerosis (MS) experience the debilitating effects of fatigue on activities of daily living, employment, social interactions, and overall health and quality of life.1 Exercise interventions can reduce self-reported fatigue in people with MS.2,3 To date, these interventions have been delivered in person. However, people with MS are often challenged in accessing these exercise interventions due to emotional (fear, lack of confidence), physical (inaccessible facilities, geographic location), economic, or knowledge-related (lack of knowledgeable providers or resources) barriers.4-6 However, MS is a chronic disease and fatigue is an ongoing problem for many people with MS. Thus, accessible, sustainable, affordable, and effective interventions must be developed to reduce MS fatigue.

Telephone-delivered interventions can bridge the gap between the distinct needs of people with MS and specialized MS providers. In the current issue of the Journal of Neurologic Physical Therapy, Kranz et al7 report findings from a pre/postintervention pilot study to determine the feasibility and acceptability of a telephone-delivered exercise intervention to reduce fatigue in people with MS. A secondary goal was to compare the feasibility and accessibility, as well as changes in fatigue and various secondary outcomes, with the otherwise identical intervention delivered in person.

Participants in both groups attended the majority of the 8 training sessions (either in person or via telephone delivery), and there were no adverse events. In addition, both groups similarly scored the intervention highly acceptable. These findings alone suggest that either the in-person or the telephone-delivered intervention are viable options for people with MS and they increase the accessibility of the intervention to more people with MS. Providers could use the telephone-delivered intervention for patients who live too far to come in for training or could use this program on-site to reduce fatigue, increase endurance, and build capacity before initiating rehabilitation.

The opportunity to choose a telephone-delivered intervention may be particularly beneficial for people with high levels of fatigue who are challenged in getting to a facility or even walking from the parking deck to the building where the intervention is being delivered before they start exercising. That the in-person exercise intervention was as feasible, acceptable, and effective as the telephone-delivered is also meaningful, as some people may value venturing out of their home to a facility and interacting with others like themselves. Finally, just being able to choose from 2 equally effective options offers people with MS the choice of intervention, provided there is a program available, or they have the materials and tools at hand.

Overall, there were no obvious differences in outcomes between the 2 groups, suggesting that the telephone-delivered version was as effective as in-person delivery for reducing subjective fatigue and pain in people with MS, as well as increasing activity and improving sleep and MS fatigue self-efficacy. However, one should proceed with caution before prescribing the telephone-delivered exercise intervention used in this study to any person with MS, with any level of functional ability. Participants in this study were able to ambulate, with Patient Determined Disease Steps (PDDS) scores ranging from 1 to 5. Although there were no statistically significant differences between the 2 groups, participants in the telephone group had overall less disability (median PDDS = 2, IQR = 1-3, or "no limitations in walking") than those in the in-person group (median PDDS = 3.5, IQR = 3-5, or "gait disability interferes with daily activity"). Similarly, people in the telephone group completed the Timed 25-foot walk test in less than 6 seconds (pre = 5.2, post = 4.8), while those in the in-person group took more than 6 seconds (pre = 7.0, post = 6.3), indicating greater functional deficits.8 Thus, it is not clear whether people with more disability would be safe or achieve the same outcomes in the telephone-delivered intervention. Physical therapists should consider this before choosing an intervention delivery mode.

More people (7/9) in the telephone group than in the in-person group (6/10) achieved their target heart rate; those in the telephone group also increased their exercise band resistance more than those in the in-person group (113%-283% vs 64%-117%, respectively). These findings might suggest that participants in the telephone group exercised at a higher level than those in the in-person group. On the other hand, the difference between the 2 groups' progression of resistance could be related to the level of supervision provided. Specifically, physical therapists for the in-person group observed the participant performing the exercises each week and determined the appropriate progression. Thus, it is likely that participants in the in-person group received feedback about movement quality and thus were not increasing the amount of resistance if they were not able to perform the movement with safe and appropriate posture and form. Those in the telephone group increased their resistance without such guidance since the physical therapist could not see them perform the exercises via the telephone-delivered session. Patients who require more guidance or feedback, or who have more difficulty with the exercises, might perform better and achieve greater benefits with the in-person intervention.

Finally, the design of the exercise intervention is clinically relevant. The intervention not simply comprises physical exercises but also includes an education and training module each week. Participants were provided with the exercises and guidelines for how to progress the exercises and met once a week for 8 weeks with a physical therapist for training, either in person or via telephone. Discussion topics for these sessions addressed common barriers to exercise and management of fatigue. Learmonth and colleagues9,10 used a similar approach of combining physical exercises based on the Guidelines for Exercise in MS with education and coaching to increase self-reported exercise behaviors. The coaching in that study was provided via video chats, another form of telerehabilitation. Although the primary outcomes were different between these 2 studies, the positive outcomes in both suggest that combining a progressive exercise program with a structured behavioral intervention may be more effective than either exercise or education and coaching alone. Furthermore, these findings suggest that a telerehabilitation approach to delivering the intervention may be as effective as in-person delivery of the same intervention. Physical therapists might consider utilizing this approach to address fatigue (as well as other) outcomes in people with MS who are still able to ambulate.

REFERENCES