A Randomised Controlled Trial of an Exercise Plus Behaviour Change Intervention in People With MS: the "Step it Up" Study Protocol

1. Background and study aims Exercise has consistently yielded short-term, positive effects on health outcomes in people with multiple sclerosis (MS). However, these effects have not been maintained in the long-term. Behaviour change interventions aim to promote long-term positive lifestyle change. This study, namely, "Step it Up" will compare the effect of an exercise plus Social Cognitive Theory (SCT)-based behaviour change intervention with an exercise plus control education intervention on walking mobility among people with MS. Our hypothesis is that those in the exercise and SCT-based intervention will achieve significantly more improvement in walking mobility than the control group post-intervention (12 weeks) and that this improvement will be maintained at 24- and 36- week follow up.
2. What does the study involve? Exercise plus contact control education intervention The control group will receive an exercise and a didactic control education component. The exercise intervention will include aerobic and strengthening components and will be delivered by physiotherapists. The aim of the exercise component is to progressively increase the intensity of both aerobic and strengthening activities to enable the participants to reach the recently published MS exercise guidelines (Latimer- Cheung et al 2013). The aerobic activity will be walking, the intensity of which will be monitored using step rate measured using the Yamax digiwalker pedometer* (which will be provided to all participants) and an exercise log to document duration of walking exercise and number of steps taken. It is widely accepted that 100 steps per minute equates to three MET or moderate intensity physically active (PA) among people with MS (Agiovlasitis and Motl 2014). Participants will begin with 10 minutes of walking twice weekly at a rate of 100 steps/minute and increase incrementally in 5 minute intervals over 5 weeks until they reach the guideline of 30 minutes twice weekly (Latimer-Cheung et al 2013).

The strengthening programme is based on a community-based exercise programme that has been evaluated previously (Garrett et al 2013) and will consist of 10 exercises targeting major muscle groups for the upper and lower extremities using elastic resistance band. Participants will begin with one set of 10-15 repetitions and gradually increase the number of sets, repetitions and level of resistance until they meet the target of two sets of each exercise twice weekly with sufficient resistance that they are failing on the 12th repetition. Over the 10-week programme participants will attend the group exercise class on six occasions, supplemented with a telephone coaching call in the weeks without classes (intervention weeks 4, 6, 7 and 9). These telephone calls will consist of direct questions about the frequency, intensity, type and duration of exercise they have completed and whether they have experienced any adverse events or relapses. After each of the group exercise classes the control group will receive an education session about topics unrelated to physical activity behaviour, e.g. diet, vitamin D, sleep, temperature and hydration, and immunisations and vaccinations.

Exercise plus SCT-based intervention The exercise plus SCT-based intervention group will receive the same exercise intervention as the control group (as described in the previous section).This group will also receive a behaviour change intervention based on the principles of SCT. The SCT-based education sessions will be delivered after each exercise session by physiotherapists and will incorporate the principle elements of SCT including self-efficacy, outcome expectations, impediments and goal-setting. Beyond providing presentation notes, individual reflection and written exercises, group discussion on each of the principles of SCT, and providing on-going feedback on all aspects of PA behaviour, the program will include video files of people with MS discussing PA behaviour and their experiences of initiating and maintaining a physically-active lifestyle. On the weeks when the participants do not attend group sessions, they will receive a telephone coaching call from the physiotherapist. These coaching calls will consist of guided conversations that consider the components of SCT delivered in the previous session and a revision of other components.

4. What are the possible benefits and risks of participating? Benefits to the participants include access to a free physiotherapy-led exercise programme, of which benefits such as improved aerobic capacity, mobility, fatigue, mood, muscle strength are anticipated. The education session may also help participants to keep those benefits for longer. The investigators do not envisage any adverse effects of these interventions.

5. Where is the study run from? This study has been organised by Clinical Therapies, University of Limerick.