Program Evaluation Results of a Structured Group Exercise Program in Individuals with Multiple Sclerosis

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1 Program Evaluation Results of a Structured Group Exercise Program in Individuals with Multiple Sclerosis Mary E. Charlton, PhD; Kelley Pettee Gabriel, PhD; Terry Munsinger, RN, BSN; Lorene Schmaderer, PT, MPT; Kathleen M. Healey, PhD, APRN Although research-based and anecdotal evidence support the beneficial role of physical activity in symptom management among individuals with multiple sclerosis (MS), the integration of physical activity into the lifestyles of people with disabilities remains a challenge. The purposes of this study were to evaluate the feasibility and perceived effectiveness of a group Jazzercise program that was modified to fit the needs of individuals with MS. The study population included patients diagnosed with definite MS who were receiving care at the University of Nebraska Medical Center. Eleven of 14 initial participants remained in the program after 16 weeks and were mailed a short anonymous questionnaire designed to assess self-reported improvement in balance, confidence, coordination, energy, flexibility, mood, and strength, and to determine satisfaction and motivation to continue the course. Nine of the 11 participants (82%) at week 16 returned the survey. Of the nine respondents, all (100%) reported improvements in mood and energy, seven (77.8%) reported improvements in confidence, six (66.7%) reported improvements in flexibility and strength, and five (55.6%) reported improvements in balance and coordination. All nine respondents indicated that they enjoyed the class and were motivated to continue the program. The results provide justification for continued evaluation of this unique structured group exercise program in individuals with MS. A larger sample size and a more rigorous study design are needed to further examine the impact of the program on physiologic and psychosocial factors in individuals with MS. Int J MS Care. 2010;12: Because there is currently no cure for multiple sclerosis (MS), the management of related symptoms is critical to improve the health and well-being of individuals living with this chronic condition. Both research-based and anecdotal evidence support the beneficial role of physical activity, often through structured exercise programs, for symptom management among individuals with MS. 1,2 Romberg et al. 1 showed improvements in the Multiple Sclerosis Functional Composite (MSFC) score, which includes walking speed, manual dexterity, and cognition, among individuals randomized to a progressive exercise program that From the Rural Health Resource Center, Veterans Administration Medical Center, Iowa City, IA, USA (MEC); Department of Health Promotion, Social and Behavioral Health (KPG) and Department of Neurological Sciences (KMH), University of Nebraska Medical Center, Omaha, USA; and Neurological Sciences (TM) and Physical Therapy Department (LS), The Nebraska Medical Center, Omaha, USA. Correspondence: Mary E. Charlton, PhD, Deputy Director, Rural Health Resource Center, Veterans Administration Medical Center, 601 Hwy. 6 West, Iowa City, IA 52246; mary.charlton@va.gov. combined resistance (3 4 times per week) with aerobic training (1 time per week) compared with control subjects. Fatigue and health-related quality of life, two common problems among people with MS, have also been shown to improve with physical activity, as supported by a meta-analysis performed by Motl and Gosney. 2 However, other studies examining the relationship between physical activity and fatigue have not demonstrated this relationship. One possible explanation for the inconclusive findings in this area may relate to the methods used to ascertain fatigue. For example, in a review, Dalgas et al. 3 noted that studies that used a multidimensional tool to measure fatigue (Modified Fatigue Impact Scale [MFIS] or Multidimensional Fatigue Inventory [MFI]) reported a beneficial effect of endurance training on fatigue, whereas those that employed a unidimensional tool (Fatigue Severity Scale [FSS]) found no association. This important discrepancy suggests that unidimensional tools may not be sensitive enough to detect improvements related to fatigue and may not elicit enough varia- 92

2 Structured Group Exercise Program in MS Program Description The Jazzercise Lite program, a low-impact version of the original Jazzercise program, was offered to MS patients at UNMC beginning in March Early evening classes were held twice per week for 45 minutes per session. This program used a Lite Circuit Format and included both aerobic and resistance training in each session. All sessions began with an initial 3- to 4-minute warm-up, which consisted of a flexibility routine that was designed to isolate large muscle groups using gentle, passive stretching. The warm-up segment was followed by a series of three individual routines (two aerobic and one resistance), which were choreographed to individual songs, each lasting 3 to 4 minutes. This series of routines was repeated throughout the class (approximately three times per class). The tempo of the songs and intensity of the routines gradually increased during the first half of the class and decreased during the second half. Strong emphasis was placed on core strengthening throughout both the aerobic and resistance routines. All classes ended with a choreographed 3- to 4-minute cooldown, which consisted of gentle stretching. Handicap parking spaces and valet parking were made available as needed. Exercise rooms were well ventilated, and numerous circulating fans were distributed throughout the room to minimize heat-related symption in fatigue levels to detect a statistically significant relationship with physical activity. Although numerous studies support the benefits of physical activity for MS symptom management and quality of life, integrating exercise into lifestyles, especially in individuals with disabilities, can be challenging. People with disabilities remain one of the most physically inactive subgroups in the United States. According to 2005 Behavioral Risk Factor Surveillance System (BRFSS) data, % of individuals with a disability report being physically inactive during a typical week, twice the proportion of adults without a disability who report being physically inactive during their leisure time. Numerous factors have been identified as barriers to physical activity in individuals with MS, including social attitudes regarding the ability to be physically active, safety considerations while being physically active, physical environment (ie, handicap accessibility), and lack of available structured exercise programs or access to these programs. The identification of structured exercise programs that address factors that have traditionally limited participation in physical activity among individuals with MS is needed. Jazzercise Inc is a structured group exercise program that includes aerobic and resistance training as well as flexibility exercises in the context of jazz dancing to the beat of popular music. 5 In addition, specific physical activities that are designed to improve multiple facets of physical fitness (ie, cardiorespiratory and muscular fitness as well as flexibility and balance) are included in each session, thereby producing an effective, efficient, and comprehensive program. The program has maintained high reproducibility because instructors become certified through a rigorous training program. To our knowledge, the feasibility and perceived effectiveness of a structured group exercise program for individuals with MS that incorporates activities designed to improve multiple facets of physical fitness has not previously been reported in the literature. Therefore, the aims of this study were to evaluate the feasibility and perceived effectiveness of a Jazzercise program that has been modified to fit the special needs of individuals with MS and to justify the continuation of the program at the study site. Methods Study Population The study population consisted of women diagnosed with definite MS who lived in the Mid-Town section of Omaha, Nebraska, and had at least one clinic visit at the University of Nebraska Medical Center (UNMC) Multiple Sclerosis Clinic between January 1 and March 30, There was a community circuit program already established for people with MS in the west part of town, and the Mid-Town neighborhood was targeted because there was no program tailored for people with MS in the area. A limited number of patients were recruited because of space limitations due to room size. Women were initially targeted for the program because Jazzercise has traditionally been oriented toward women. Therefore, men are not included in the current study; however, the program has since been expanded to include men. Individuals with all types of MS (relapsing-remitting, secondary progressive, etc.) were eligible for the program. Physicians and nurse practitioners from the MS Clinic recommended the program to individuals who had not developed regular exercise routines. Patients were eligible to participate in the program regardless of ambulatory status (ie, independent, with assistive device, or wheelchair-bound). The study was approved by the institutional review board at the UNMC. Written consent of subjects was not obtained because the survey was anonymous and participant identifiers were not used. 93

3 Charlton et al. toms. Participants were instructed to bring bottles of ice water and were asked to wear light clothing and supportive shoes. At the first exercise session, participants were provided with cooling collars and were asked to bring them back at each subsequent session. Participants were also encouraged to bring a buddy at no extra cost to assist them if needed with either the exercises or transportation. The initial launch of the program was funded by the National Multiple Sclerosis Society Nebraska Chapter and included program fees for 10 participants for 1 month (8 sessions). Beyond the first month, the cost per participant was $30.00 per month. Participants who could not afford these out-of-pocket costs could apply for additional funds through the Direct Assistance Program offered by the National Multiple Sclerosis Society Nebraska Chapter. Previous studies have shown that exercise leadership plays an important role in program participation. 6 The same two Jazzercise instructors led the class throughout the 16-week study. Instructions were clear and brief, and the leaders demonstrated the exercises each time to allow for consistency from one session to the next. The routines were structured to allow more mobile participants to travel the length of the room, led by one instructor, while the seated participants were provided with an alternate routine, led by the second instructor. The seated participants were encouraged to sit in the front of the class so that the instructor was not obstructed by other participants standing in front of them. The modifications made to the Jazzercise Lite program to facilitate active participation by individuals who used assistive devices consisted primarily of incorporating more moderate- to high-intensity upper-body exercises that were performed with and without resistance. These exercises were performed in a seated or standing position, whereas the regular Jazzercise class incorporates floor routines for abdominal and core training. Participants were encouraged to work at a moderate intensity level. Because of the preliminary nature of the study, no physiologic measures were included. Study Variables Sixteen weeks after the initiation of the Jazzercise Lite program, participants were mailed a questionnaire and a stamped return address envelope. The questionnaire consisted of ten questions, with responses indicated on a 5-point Likert scale, ranging from 1 for strongly disagree to 5 for strongly agree. The first seven questions evaluated participant-reported improvement in the following areas: balance, confidence, coordination, energy, flexibility, mood, and strength. The psychometric properties of this questionnaire have not yet been evaluated but are based on common physical and emotional challenges that are reported by individuals with MS. 6 The final three questions assessed whether the participants enjoyed the Jazzercise Lite program, were satisfied with the course, and were motivated to continue the course. In addition, the questionnaire contained two openended questions asking the participants to provide suggestions for course improvement and general comments. The full questionnaire is presented in Table 1. Statistical Analysis Univariate analysis was conducted to describe the proportion of respondents who reported improvement related to each of the domains, and to calculate a median, mean, and standard deviation for the values of responses for each question. SAS software, version 9.2 (SAS Institute, Inc, Cary, NC) was used to perform all statistical analyses. Results Fourteen female participants started Jazzercise Lite in early March Two participants moved away from the Mid-Town area, and one dropped out of the program; consequently, 11 of the original 14 participants remained in the program at week 16. The average age of Table 1. Questionnaire 1. My strength has improved since I joined the Jazzercise 2. My energy has improved since I joined the Jazzercise 3. My flexibility has improved since I joined the Jazzercise 4. My balance has improved since I joined the Jazzercise 5. My coordination has improved since I joined the Jazzercise 6. My mood has improved since I joined the Jazzercise 7. My confidence has improved since I joined the Jazzercise 8. Overall, I have enjoyed the Jazzercise 9. At this point, I feel motivated to continue with the Jazzercise 10. Overall, I am satisfied with the Jazzercise 11. Do you have any suggestions as to how we could improve the Jazzercise class? 12. Do you have any other comments about the Jazzercise class? Note: Responses for questions 1 to 10 were indicated on a 5-point Likert scale ranging from 1 for strongly disagree to 5 for strongly agree. Questions 11 and 12 were open-ended. 94

4 Structured Group Exercise Program in MS these 11 participants was 54 years (range, years). The class was 83% white, 8% African American, and 8% Hispanic. Four of the 11 participants used walkers, of whom one attended several of the program sessions in a wheelchair. These four participants performed the modified Jazzercise Lite routines in a seated position. The remaining seven participants were ambulatory without assistance. The attendance rate at a typical class was 67% to 75%. Questionnaires were mailed to the 11 participants at week 16. Nine of the 11 participants completed and returned the surveys after the 16-week program, for a response rate of 82%. The mean scores for each of the items are displayed in Table 2. All subjects strongly agreed that they enjoyed the course, were satisfied with the course, and were motivated to continue attending the classes. The scores related to the psychological elements of confidence, mood, and energy had a mean above 4.0, meaning that nearly all subjects strongly agreed or agreed that they experienced improvements in these domains. Flexibility and strength had the next highest mean scores, followed by balance and coordination. In a pattern similar to that shown in Table 2, Table 3 illustrates that the largest proportions of people experienced improvement in confidence, mood, and energy. Flexibility and strength were the next most commonly experienced improvements. Just over half of the people experienced improvement in balance and coordination. All survey respondents indicated that they enjoyed the class, were motivated to continue with it, and were satisfied with the Several comments included praise for the instructors, and the only repeated suggestion for improvement was to obtain a larger room. Finally, a participant who was confined to an assistive device stated that sitting in front was critical to Table 2. Summary statistics for Jazzercise survey (N = 9 for all items) Item Mean score SD Range of scores Balance Confidence Coordination Energy Flexibility Mood Strength Enjoyed Motivated Satisfied Table 3. Number and percentage of those who either agreed or strongly agreed Item No. (%) Balance 5 (55.56) Confidence 7 (77.78) Coordination 5 (55.56) Energy 9 (100.00) Flexibility 6 (66.67) Mood 9 (100.00) Strength 6 (66.67) Enjoyed 9 (100.00) Motivated 9 (100.00) Satisfied 9 (100.00) her attendance, and that if she had been behind more mobile participants, she would have been discouraged. Discussion To our knowledge, this was the first study that examined the feasibility of a structured group exercise program that incorporated physical activities designed to improve many facets of physical fitness (ie, cardiorespiratory and muscular fitness, flexibility, and balance) among individuals with MS. All participants surveyed indicated that their energy level improved; although the study sample size was small, this finding suggests that the Jazzercise Lite program may improve willingness to participate in physical activity, which in turn may help manage symptoms such as fatigue, the most common symptom reported among individuals with MS. 7 Because the survey was anonymous, we were not able to correlate responses with different types or levels of severity of MS, but all participants tolerated the program and no adverse events were reported, which supports the acceptability of the Jazzercise Lite program among individuals with MS. Furthermore, the recorded attendance rate was high throughout the 16-week period, which suggests good adherence. All participants strongly agreed that they enjoyed the program, were satisfied with it, and were motivated to continue. Several key factors that were included in the program design may have contributed to the high attendance rate. Although a true experimental study design with a larger sample size would be necessary to achieve more conclusive results, the preliminary findings gleaned from the current study suggest that with the proper accommodations and accessibility, people with disabilities may be very able and willing to be physically active. It is likely that the special accommodations that were made, 95

5 Charlton et al. including valet parking, handicap-accessible entrances, and a well-ventilated space, improved enjoyment of and satisfaction with the program, thereby increasing attendance. This observation aligns with previous work by Sharon et al., 8 which showed that accessibility of an exercise facility was related to program adherence. In addition, the social stigma of being disabled and having to attend a community health club or gym that often does not cater to individuals with disabilities was replaced by social support of fellow program participants with similar disabilities; both accessibility and social support are factors that have been shown to improve program adherence. 9 The positive influence of social support on program adherence may have also been facilitated by allowing a family member or friend to participate in the program at no extra expense to the participants. The group exercise format may have also facilitated a social support network among the participants. Free text comments written on surveys included statements such as, I was recently diagnosed with MS and this class has done wonders for my morale. The camaraderie between the instructors and the students is wonderful! and I have enjoyed meeting the other participants. It was also observed by the instructors that participants regularly went out for coffee together after Other benefits of the group exercise format among individuals with diverse functional levels include the reduced cost per participant and more efficient use of resources such as room space and instructor time. However, it is important to note that because individuals PracticePoints Improvements in psychosocial elements (confidence, mood, and energy) were reported by nearly all participants with MS in the group Jazzercise program who responded to our survey. In addition, over half of the respondents strongly agreed or agreed that they experienced improvements in balance and coordination, flexibility, and strength. All respondents indicated that they enjoyed the class and were motivated to continue the program. Offering this type of program in community or clinic settings may help increase physical activity levels in individuals with MS. of varying functional ability were included in the same class, some participants may not have reached optimal aerobic levels because of the modified routines. Further study with objective measures such as heart rate is needed to examine whether participants, regardless of functional ability, are achieving intensity goals needed to improve cardiorespiratory fitness (ie, moderate to high intensity). This study had several limitations, including a small sample size, self-reported data, and a short follow-up period. Also, survey results could have been affected by social desirability bias. However, the survey was administered anonymously to minimize this bias to the extent possible. Further, because the purpose of this study was to examine the feasibility of the Jazzercise Lite program among individuals with MS, the clinical characteristics (eg, functional level) of the study population were not measured. Further research is needed using a larger sample size, a randomized controlled trial study design, and the use of clinical and physiologic measurements to examine the impact of the Jazzercise Lite program on physiologic and psychosocial factors in individuals with MS. In addition, a mixed-methods approach could elucidate factors that may lead to increased adherence and satisfaction with the program. The results of this feasibility study provide the justification needed to continue to evaluate this novel structured group exercise program in individuals with MS. o Acknowledgments: We would like to acknowledge the two dedicated Jazzercise instructors and franchise owners, Sally Lorenzen and Mary Beth Brandeau; the enthusiastic study participants; and Sue Nardie for editing the manuscript. Financial Disclosures: The authors have no conflicts of interest to disclose. References 1. Romberg A, Virtanen A, Ruutiainen J. Long-term exercise improves functional impairment but not quality of life in multiple sclerosis. J Neurol. 2005;252: Motl RW, Gosney JL. Effect of exercise training on quality of life in multiple sclerosis: a meta-analysis. Mult Scler. 2008;14: Dalgas U, Stenager E, Ingemann-Hansen T. Multiple sclerosis and physical exercise: recommendations for the application of resistance-, endurance- and combined training. Mult Scler. 2008;14: US Department of Health and Human Services. Healthy People Chapter 6: Disability and Secondary Conditions. healthypeople.gov/document/html/volume1/06disability.htm. Accessed June 2, Jazzercise Inc. Accessed June 2, Stuifbergen AK, Roberts GJ. Health promotion practices of women with multiple sclerosis. Arch Phys Med Rehabil. 1997;78(suppl 5):S3 S9. 7. Bakshi R. Fatigue associated with multiple sclerosis: diagnosis, impact and management. Mult Scler. 2003;9: Sharon BF, Hennessy CH, Brandon LJ, Boyette LW. Older adults experiences of a strength training program. J Nutr Health Aging. 1997;1: Boyette LW, Sharon BF, Brandon LJ. Exercise adherence for a strength training program in older adults. J Nutr Health Aging. 1997;1: