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Original Investigation

Exercise Promotion in Multiple Sclerosis Through the Patient–Provider Interaction: Development of Practice Models

Richardson, Emma V.1; Fifolt, Matthew2; Barstow, Elizabeth A.3; Motl, Robert W.1

Author Information
Translational Journal of the ACSM: April 1, 2020 - Volume 5 - Issue 7 - p 59-68
doi: 10.1249/TJX.0000000000000119
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Abstract

INTRODUCTION

Exercise training is beneficial for restoration of function, management of symptoms, and improvement of health-related quality of life among persons living with multiple sclerosis (MS) (1,2). Nevertheless, fewer than 20% of persons with MS engage in sufficient amounts of physical activity and exercise training for accruing the aforementioned benefits (3,4). Indeed, persons with MS engage in substantially less physical activity than do the general population. One recent meta-analysis indicated that persons with MS are 1 full SD less physically active than the general population who are already alarmingly physically inactive (5). We further note that the rate of meeting public health guidelines for physical activity is lower in MS than in the general population (3). This has engendered a conundrum—exercise offers wide-ranging benefits, but people with MS generally are not participating in this behavior sufficiently.

There are numerous reasons why persons with MS do not engage in exercise such as physical and cognition impairments, balance problems, fear of falling, fatigue and depression, and bladder issues (6); however, a further reason may be the gap between evidence-based benefits of exercise and translating these benefits into behavior change among persons with MS (1). Research has highlighted that persons with MS often receive conflicting information on exercise from health care providers (HCPs) (7), and HCPs may not have sufficient resources for exercise promotion (8). Such issues may be addressed by a new, systematic process for promoting exercise through the patient–provider interaction. This possibility is supported by observations that persons with MS actively seek information on exercise from HCPs (9) and further view HCPs as credible messengers (1). Such a focus on the patient–provider interaction might represent a key factor in translating evidence into the adoption and maintenance of exercise behaviors among people with MS.

We are aware of two qualitative research studies that identified the wants and needs of persons with MS and HCPs regarding the promotion of exercise in comprehensive MS care (9,10). Persons with MS desired (a) information and knowledge on the benefits of exercise and exercise prescription, (b) materials that facilitated home and community exercise, and (c) tools for initiating and maintaining exercise behavior from HCPs (9). HCPs desired (a) opportunities for exercise promotion through the health care system, (b) education on exercise for persons with MS, and (c) tools and strategies that would help promote exercise among persons with MS (6). Such qualitative research informed the generation of a conceptual model regarding exercise promotion during the patient–provider interaction in comprehensive MS care (11). This conceptual model has been evaluated and further refined in sequential qualitative studies of persons with MS (12) and HCPs (13). The rigorous vetting process resulted in a final conceptual model that was perceived by both persons with MS and HCPs as a strong representation of exercise promotion through the patient–provider interaction in comprehensive MS care (13). The conceptual model involves three hierarchically organized, interactive layers representing 1) the necessary exercise promotion training HCPs require; 2) the interactive, dynamic exercise consultation between the patient and the provider that prepares the patient for exercise; and 3) ongoing support patients receive from HCPs regarding the initiation and long term maintenance of exercise behavior. These three layers support the ultimate goal of shifting the distributing of exercise engaged among people with MS, and this is represented through shifting the physical inactivity scale atop the pyramid.

The next step for improving promotion of exercise through the patient–provider interaction involves the translation of this conceptual model into practice models outlining the processes of how exercise can be promoted among people with MS. The development of these practice models can bridge the gap between theory, practice, and policy regarding exercise promotion. Such practice models provide HCPs with a streamlined approach for guiding the process of exercise promotion through the identification of roles and responsibilities across different scenarios within the comprehensive care center as part of a multidisciplinary team. Accordingly, we have developed practice models and checklists based on the aforementioned formative qualitative research (9,10) and conceptual model evaluations (12,13). Such models represent the translation stage of moving the conceptual model into clinical exercise promotion through the patient–provider interaction in a comprehensive MS care settings.

We adopted a quality improvement approach and examined if the practice models are translatable and applicable for comprehensive MS care. Quality improvement approaches are an essential, first step for implementing and disseminating materials into clinical practice in health care settings (14). Quality improvement is a systems approach to improving existing services or products (15). Based on the Model for Improvement, Plan-Do-Study-Act (PDSA) is a quality improvement strategy to generate knowledge and gain support for changes by examining them before implementation (16). Unlike traditional investigations in which a power analysis is conducted to determine the necessary sample size, PDSAs rely on rapid examination among a limited number of individuals to evaluate change ideas. The goal of PDSA cycles in health care settings is to learn quickly and make adjustments to increase the chances of delivering and sustaining the desired improvement. We posited that the practice models and checklists developed from empirical data and the conceptual model will contain the necessary resources regarding exercise promotion in comprehensive MS care. Accordingly, we adopted a PDSA (17) approach for evaluating and refining these practice models and checklists for exercise promotion through the patient–provider interaction in comprehensive MS care. This approach should facilitate the creation of tangible resources for health care provider use in exercise promotion during MS care. Such work will improve the delivery of exercise promotion and support within comprehensive MS care.

METHODS

Study Design

We adopted the PDSA quality improvement methodology for gathering feedback and evaluations from neurologists, nurse practitioners, physical therapists (PTs), and occupational therapists (OTs) regarding the practice models and checklists. The PDSA method has been advocated as an effective protocol for improving health service delivery through reciprocal, iterative cycles of evaluation (18,19). The PDSA method followed accepted guidelines (18) and facilitated our interest in improving the efficiency, effectiveness, and applicability of the models we developed for HCPs in MS care.

Plan

The first stage of our approach involved ascertaining how to effectively evaluate and improve the practice models and checklists for the purpose of disseminating these resources into comprehensive MS care. To do so, we designed a survey using Qualtrics™ containing Likert scale (1–5) and open-ended questions regarding HCP perceptions of the practice models and checklists, and how the practice models could be implemented; the resources/training need to implement models; and ideas for improving the models.

Do

In line with focusing on a small sample size as a first step of PDSA, we sent a letter of invitation containing the survey link to 20 participants (5 neurologists, 5 nurse practitioners, 5 PTs, and 5 OTs) who had participated in previous research and expressed interest in being further involved in this line of inquiry. Fifteen participants were male and five were female, with age ranging between 30 and 62 y (mean, 44 y) and years of practice ranged between 5 and 36 y (mean, 15 y). Thirteen comprehensive MS care centers from 13 states were represented. The first cycle of the PDSA method requires a small sample size to collect just enough data to inform the best action forward (20). This allowed us to quickly ascertain strengths, weaknesses, and necessary changes of the models. Participants were specifically selected based on profession, location in the United States, the comprehensive care structure (i.e., a structure within a large HCP team or a small HCP team), and location in an urban or rural area. These factors all ensured maximal variation of experience and comprehensive care center setting for ensuring the different scenarios we depicted in the models were represented and would work in real world application.

Study

After the completion of data collection within the time frame, we adopted a case study approach to review the data. This involves an in-depth exploration from multiple perspectives of the complexity and understanding of a particular project, policy, institution, program, or strategy in a bounded context (21).

Act

We made changes based on HCP feedback through discussion and reflexivity with the research team.

Data Collection

We used a Qualtrics online survey to collect quality improvement data from HCPs regarding practice models for promoting exercise in comprehensive MS care. The online survey comprised seven blocks of questions, including an informed consent page. Demographic questions asked participant age, sex, profession, years of experience, and location. These questions were followed by scenario-based questions regarding clarity and relatability of the practice models, patient criteria, and HCP checklists in explaining the process of promoting exercise with the patient. Questions further asked respondents to reflect on the appropriateness of tasks in the model based on professional roles and confidence using the tool in the real world. A copy of the online survey with program logic can be found as Supplemental Digital Content. The survey link was sent via e-mail in mid-February, with seven e-mail reminders sent before closing the survey on March 31, 2019.

Data Analysis

To analyze data, we adopted a collective case study design. A collective case study contains a number of cases that may be studied concurrently or consecutively to investigate a phenomenon (21). By extending analyses to several cases, this can provide a more in-depth, detailed, comprehensive, and holistic examination of a particular system, as well as the ability to make naturalistic generalizations for wider practice (22). By doing collective case studies, we could explore how the models resonated with participants regarding current experiences and practice, and identify what needed to be changed to be more realistic in real-world application. This would provide more promise for wider dissemination and policy practice in comprehensive MS care. We did collective case studies of each model incorporating the perceptions of neurologists, nurse practitioners, PTs, and OTs to understand and meaningfully evaluate the specific models in full context. To analyze data, we used descriptive statistics and content analysis, and thereafter, the research team, comprising all authors, reviewed and analyzed the feedback from each participant and noted data pertaining to improving the models. The team then discussed each suggestion in isolation until consensus was made about including suggestions into a new evolution of the model. Numerous revisions of the practice models were designed and vetted by the team. The final revised practice models are presented.

RESULTS

Model 1: Minimal HCP Intervention

Model 1 (Fig. 1) depicts the simplest course of exercise promotion for patients with MS, outlining the course to take (a) if the patient is interested in exercise and requires minimal HCP interaction to exercise safely (i.e., no MS-related physical deficits or comorbidities) or (b) if the patient has no insurance reimbursement for PT/OT intervention. The neurologist plays the main role in this scenario by introducing and discussing the concept of exercise as a therapeutic strategy for managing MS. The neurologist then ‘hands-off’ the patient to the nurse. The nurse promotes exercise by having a more in-depth consultation with the patient and provides them with an exercise toolkit (this could be provided by the Exercise Neuroscience Research Lab [ENRL], University of Alabama at Birmingham as an example). The patient is encouraged to use the toolkit to exercise independently and is supported through regular periodic check-ins via e-mail every 3 wk by nurses, and check-ins with the neurologist at follow-up appointments.

Figure 1
Figure 1:
Practice model 1 depicts the simplest course of exercise promotion for patients with MS, outlining the course to take (a) if the patient is interested in exercise and requires minimal HCP interaction to exercise safely (i.e., no MS-related physical deficits or comorbidities) or (b) if the patient has no insurance reimbursement for PT/OT intervention.

Overall, model 1 was reviewed favorably by HCPs. OTs highly rated the clarity of model 1, registering a collective score of 5.00/6.00. This score indicates that OTs had no questions after reading it. Neurologists (4.00/6.00), nurses (4.00/6.00), and PTs (3.86/6.00) identified model 1 to be clear but needing some clarification:

Who checks the insurance reimbursement? Would the neurologist have that info prior to the PT visit with the neurologist? Does the patient have the option to cash pay or get assistance with payment of PT/OT? I may have missed this info but what is the toolkit. Who is determining patient criteria? Deficits for PA? Can patient participate safely? Is there a questionnaire is it the neurologist simply asking? (PT 3)

Nurses rated the relatability of the model as 4.50/6.00, indicating that these components would occur about half the time in comprehensive MS care. Scores for neurologists (3.67), PTs (3.50), and OTs (3.50) were lower than those for nurses, suggesting that these components would occur in real-world comprehensive MS care sometimes to about half the time. In particular, these parties noted that nurses as an intermediary who promoted exercise were not likely part of the clinic structure:

I have never been familiar with a clinic structure that involved nursing in exercise recommendations. Even patients without deficits are likely to be concerned about appropriate exercises and appropriate exercise intensities. A direct referral to therapy would be most appropriate. (OT 2)

HCPs were, however, positive with feedback regarding consideration made for patients without insurance reimbursement:

I am not accustomed to, nor have I truly given consideration to, such a nurse’s role in this process. With one significant exception: it is wonderful to see consideration, and a plan, given to patients who have no insurance coverage for OT/PT. (OT 1)

Neurologists noted that the tasks assigned to them when promoting exercise in model 1 were quite appropriate (4.33/6.00). PTs rated tasks as either slightly or quite appropriate (3.50/6.00), but nurses and OTs reported tasks to be slightly appropriate (3.00/6.00 tied). HCPs were unconvinced about the nurse’s role in promoting exercise; “I would not correspond with the nurse regarding patient progress with exercise.” (PT 4); “Not appropriate due to my time constraints in clinic” (Nurse 1).

Neurologists and OTs rated confidence levels as high regarding implementing model 1 in comprehensive care, registering scores of 86.67 and 85.00, respectively. PTs rated fairly high confidence (77.50), but nurses rated low levels of confidence in implementing model 1 (40.50). This lack of confidence is understandable considering previous indications that the nurse role in this scenario is not relatable or appropriate within comprehensive MS care centers, or consistent with the assigned responsibilities of nurses.

Model 2: Moderate HCP Intervention

Model 2 (Fig. 2) depicts the course of exercise promotion for patients who require moderate health care intervention before engaging in exercise independently. This scenario outlines the course HCPs might take if the patient is interested in exercise but has (a) a physical deficit that requires short-term PT/OT or nurse intervention and (b) insurance reimbursement. The neurologist plays the initiator role in this model by introducing and discussing the concept of exercise as a therapeutic strategy for managing MS, and then hands-off to the nurse. The nurse plays an intermediary role in this scenario by deciding if the patient needs immediate PT/OT intervention before engaging in independent exercise. Neurologists and nurses both stated that referrals were ordered by the neurologists but handled primarily by the nurse practitioner, and the nurse practitioner had more opportunity to speak with the patient in-depth about alternative strategies for managing MS (13). If the nurse regards the patient as ready to exercise despite deficits, the nurse follows the same checklist as model 1; a key difference, however, is the nurse making the patient aware of the option for PT/OT referral. If the nurse judges that the patient needs PT/OT intervention before engaging in exercise, the patient is referred to PT/OT immediately. The role of PT/OT in this model is to address the physical deficits of the patient, correspond with the nurse and neurologist regarding patient progress, and provide ongoing support regarding the patient’s exercise behavior. After this intervention, the patient is supported through regular periodic check-ins via e-mail every 3 wk by nurse and check-ins with the neurologist at follow-up appointments.

Figure 2
Figure 2:
Practice model 2 depicts the course of exercise promotion for patients who require moderate health care intervention before engaging in exercise independently. This scenario outlines the course HCPs might take if the patient is interested in exercise but has (a) a physical deficit that requires short-term PT/OT or nurse intervention and (b) insurance reimbursement.

HCPs were moderately favorable of model 2. OTs highly rated the clarity of the model, registering a collective score of 5.00/6.00. This score indicates that OTs had no questions after reading it. PTs and neurologists identified model 2 to be clear but needed some clarification, registering scores of 4.67 and 4.00, respectively; “Who determines patient criteria? Why does the patient go to the nurse instead of directly to PT. Why is nursing in the middle of the communication about physical activity?” (PT 1). Nurses (2.00/6.00) noted that parts of the model were clear, but overall, it was confusing, making identical statements with model 1, regarding clarity; “What does ready for exercise mean? What healthcare intervention is needed?” (Nurse 1).

Neurologists, OTs, and nurses rated the relatability of the model as 4.50/6.00 (tied). PTs (3.33/6.00) suggested that these components would only happen sometimes in comprehensive MS care; “Again the route through nursing would not happen. Our nurses see 1% of all patients that our scheduled with a neurologist or ARNP on a given clinic day.” (PT 1).

PTs and OTs noted that the tasks assigned when promoting exercise in model 2 were appropriate (5.00/6.00 tied). Neurologists rated tasks as quite appropriate (4.00/6.00), but nurses rated tasks as slightly appropriate (3.00/6.00). Both parties discussed the lack of applicability regarding the hand-off process between the neurologist and the nurse; “The problem, again, is that there is no connection between neurologist and PT. Nursing in most situations would provide general education and encouragement but specifics of exercise would come from a therapist or trainer of some kind.” (Neurologist 1)

PTs and neurologists rated very high confidence levels for implementing model 2 in comprehensive care, registering scores of 91.67 and 91.00, respectively. OTs and nurses rated fairly high confidence (71.00 and 68.00, respectively).

Model 3: Significant HCP Intervention

Model 3 (Fig. 3) depicts the course of exercise promotion for patients who require significant health care intervention before engaging in exercise independently. This scenario outlines the course HCPs are advised to take if the patient is interested in exercise but (a) lacks confidence or knowledge of how to exercise, (b) presents deficits that require significant PT/OT intervention before engaging in independent exercise, and (c) presents with insurance reimbursement. The neurologist’s role is identical to that of model 2: introducing exercise as a strategy and referring to the nurse. The nurse, again, plays an intermediary role by having a one-on-one consultation with the patient, providing them with the exercise toolkit, and referring them to PT/OT. The PT/OT adopts the same responsibilities as model 2, but with the anticipation that the deficits will be more severe and require a longer intervention plan. When the patient is ready to exercise safely, the patient is supported through check-ins via e-mail by nurses every 3 wk and with the neurologist at follow-up appointments.

Figure 3
Figure 3:
Practice model 3 depicts the course of exercise promotion for patients who require significant health care intervention before engaging in exercise independently. This scenario outlines the course HCPs are advised to take if the patient is interested in exercise but (A) lacks confidence or knowledge of how to exercise, (b) presents deficits that require significant PT/OT intervention before engaging in independent exercise, and (c) presents with insurance reimbursement.

Model 3 was the most positively reviewed by HCPs. OTs (5.00/6.00), nurses (5.00/6.00), and PTs (4.67/6.00) highly rated the clarity of the model. Neurologists (3.00/6.00) identified model 3 to be clear but had some concerns:

I would not refer a patient to PT unless they expressed willingness to try it, nor would I advise nursing education if the patient is up front about not wishing to participate. The one scenario in which it is helpful would be the willing patient who for whatever reason (social, physical, etc) does not know how to begin…With exercise, the goals can be more nebulous because patients are more interested in feeling better, even if they don’t have specific functional endpoints in mind. (Neuro 1)

Nurses rated the relatability of the model as 5.00/6.00, indicating that these components would happen most of the time in comprehensive MS care. OTs, neurologists, and PTs registered lower scores at 3.50/6.00 and 3.33/6.00 (tied), respectively. These professionals indicated that these components would only happen sometimes in comprehensive MS care and emphasized a multidisciplinary approach was necessary:

In these cases, a multidisciplinary approach might be very helpful and perhaps this should be spelled out in the checklist. The neurologist, but more likely the nurse, could be tasked with identifying whether referral to other health care professional would be beneficial to help with self-efficacy around physical activity. (PT 3)

OTs, PTs, and nurses noted that the tasks assigned to them when promoting exercise in model 3 were either very appropriate (5.50/6.00 and 5.00/6.00) or quite appropriate (5.00/6.00). Neurologists indicated that tasks associated with model 3 were quite appropriate (4.00/6.00); these individuals would do some tasks, mainly referring to PTs rather than nurses; “The problem, again, is that there is no connection between neurologist and PT. Nursing in most situations would provide general education and encouragement but specifics of exercise would come from a therapist or trainer of some kind.” (PT 1)

PTs and neurologists rated very high confidence levels in implementing model 3 in comprehensive care, registering scores of 91.67 and 91.00, respectively. OTs and nurses rated fairly high confidence (71.00 and 68.00, respectively).

Model Refinements and Improvements

HCPs suggested ways for improving all of the models. The most common suggestion was that the nurse as intermediary was not realistic regarding clinical flow in any of the models, or consistent with the duties and responsibilities of a nurse in this context:

The role of the nurse in mediating between patient and PT is confusing. There is no graphic connection between PT and neurologist even though the patient requires that the neurologist refer to PT…Direct referral to PT/OT. I see this scenario often; if PT/OT feel that there is no value in repeated visits, they develop home exercise program. (Neuro 3)

HCPs sought more information on exercise guidelines for MS and more information on the exercise toolkit; “I would like to have quick reference for guidelines for physical activity & exercise for persons with MS.” (Neuro 1). “It is not clear what the physical activity toolkit will contain and that may provide greater clarity.” (Nurse 1).

HCPs highlighted screening for comorbidities as part of the models; “The one missing piece would be a screening for co-morbidities which may require some health care provider engagement.” (PT 4).

HCPs stated that the models would be more relatable by depicting the support patients receive within and beyond the comprehensive care center:

The way it currently reads it sounds like the only option is outpatient rehab. This would only be the case in the patient without benefits, so for those who have benefits, it could become part of the PT/OT tasks. The other piece, as in scenario 1, which isn’t clear is around the patient toolkit and whether that includes different activity options including identifying local resources/locations. (PT 2)

Taking these cases studies into consideration, we refined and improved the models by (a) ensuring the nurse was not the sole intermediary for exercise promotion by adding direct referrals for PT/OT, (b) contextualizing the models within the Exercise Promotion Conceptual Model in Multiple Sclerosis (13), (c) providing information on training and resources for HCPs, (d) including comorbidities in the decision process, and (e) providing information on community support.

We further developed a quick screen process sheet (Fig. 6) that will guide neurologists in making decisions for following model 1, 2 or 3; this addresses questions and concerns regarding which HCP decides on a model of exercise promotion. By answering each question yes or no, neurologists are quickly guided to the appropriate model.

Figure 6
Figure 6:
Refined practice model 3 represents the course of exercise promotion and support if the patient (a) is interested in exercise, (b) has moderate to severe physical/cognitive deficits and/or comorbidities (requiring more than 6 wk, or more than 18 therapy sessions), and (c) has insurance.

Model 1 Improvements

Model 1 (Fig. 4) represents the course of exercise promotion, and support HCPs would follow if the patient (a) is interested in exercise, (b) does not have any physical deficits or comorbidities, and (c) is safe to exercise. This is further the course of action if the patient (a) is interested in exercise but has physical deficits and/or (b) comorbidities that cannot be addressed through PT/OT intervention (i.e., the patient has no insurance reimbursement). Before promoting exercise, the HCPs receives training on exercise promotion and receives numerous resources (outlined in the model); the scenario begins with this “prepatient” training. Within clinic, the neurologist conducts a quick screen process that informs the route of exercise promotion for the patient. The neurologist introduces exercise and briefly discusses it as a therapeutic strategy. The new model increases the flexibility of exercise promotion in a manner that fits resources, time, and comprehensive care structure. For example, if able, the neurologist can discuss exercise and provide the patient with the exercise toolkit themselves. Alternatively, the neurologist can discuss exercise and direct the patient to receive the toolkit from another HCP such as the nurse or PT/OT. The patient is finally informed of community support for supporting exercise behavior through community resources available through entities such as the ENRL. This includes tele-support on utilizing the exercise toolkit and regular check-ins through phone or e-mail regarding exercise behavior. The neurologist checks-in with the patient in subsequent appointments and, when necessary, conducts the quick screen process for modifying the approach for continued exercise promotion.

Figure 4
Figure 4:
Refined practice model 1 represents the course of exercise promotion and support HCPs would follow if the patient (a) is interested in exercise, (b) does not have any physical deficits or comorbidities, and (c) is safe to exercise. This is further the course of action if the patient (a) is interested in exercise but has physical deficits and/or (b) comorbidities that cannot be addressed through PT/OT intervention (i.e., the patient has no insurance reimbursement).

Model 2 Improvements

Model 2 (Fig. 5) represents the course of exercise promotion and support if the patient (a) is interested in exercise, (b) has mild physical deficits and/or comorbidities (requires 2–6 wk, or less than 18 therapy sessions), and (c) has insurance. The neurologist has similar responsibilities as in model 1: screening the patient and introducing and discussing exercise as a therapeutic strategy. One key difference in model 2 is that the neurologist refers the patient to the appropriate HCP. There are two potential paths at this stage. First, if the patient will be attending therapy sessions at the center, a referral should be made to the PT/OT. The PT/OT conducts a patient evaluation and designs a program that will address the patient’s deficits. When the patient is ready to be discharged, the PT/OT provides the exercise toolkit and reinforces the community support available to the patient through entities such as the ENRL. Second, if the patient will be attending therapy sessions in the local community, a referral should be made to the nurse. The nurse provides an open or specific referral to a PT/OT. The nurse further provides the exercise toolkit and outlines the community support to be received from the ENRL. Again, the neurologist checks-in with the patient at their next appointment and performs the quick screen process if symptoms have improved/worsened.

Figure 5
Figure 5:
Refined practice model 2 represents the course of exercise promotion and support if the patient (a) is interested in exercise, (b) has mild physical deficits and/or comorbidities (requires 2–6 wk, or less than 18 therapy sessions), and (c) has insurance.

Model 3 Improvements

Model 3 (Fig. 6) represents the course of exercise promotion and support if the patient (a) is interested in exercise, (b) has moderate to severe physical/cognitive deficits and/or comorbidities (requiring more than 6 wk, or more than 18 therapy sessions), and (c) has insurance. This model follows the same path as model 2, except that the patient requires longer, more intensive PT/OT intervention.

DISCUSSION

HCPs, particularly neurologists, require practical models and resources to support them in promoting exercise within comprehensive MS care (13). We endeavored to develop these models and submit them to a rigorous vetting process to improve quality and applicability. Through the PDSA methodology, we asked neurologists, nurse practitioners, PTs and OTs how clear, relatable, and appropriate each model was within a comprehensive MS care center. We further asked about confidence with the specified role and changes to improve the models. We subsequently improved and refined the models based on HCP feedback. HCPs were generally favorable of the three models, but noted key improvements that were needed to improve the quality of exercise promotion in comprehensive MS care, namely, direct referrals to PT/OT rather than the nurse; contextualizing the models within the Exercise Promotion Conceptual Model in Multiple Sclerosis (13); providing information on training and resources for neurologist, nurse practitioners, PTs, and OTs; and providing information on community support.

This crucial first step of quality improvement brings us one step close to our ultimate goal of developing tangible resources for HCPs to effectively promote and support exercise. A key strength of this study of quality improvement is the evaluation and review of the models by HCPs currently working within comprehensive care settings, and the various different professions and care structures that are represented within these evaluations. This varied representation allowed us to thoughtfully design practice models that could work within different care structures. The rigorous methodology of PDSA further allowed us to develop resources that are contextually relevant, and reviewed by experts in the field to ensure that the models are contextually applicable. Thereafter, after a thorough vetting process, we will engage in Intervention Mapping to create the documents, resources, materials, and strategies required by HCPs before putting the process through feasibility, efficacy, and effectiveness trials. After this extensive process, we will seek to scale this process into larger implementation within comprehensive care centers across the United States. This methodology allows for the development and evolution of improved models for further study, which brings us even closer to producing resources for HCPs to use and improve the quality of exercise promotion.

This research moves us one step closer to meeting the wants and needs of both persons with MS and HCPs, which have been outlined in previous research (9–13). For example, persons with MS desire (a) information and knowledge on the benefits of exercise and exercise prescription, (b) materials that facilitate home and community exercise, and (c) tools for initiating and maintaining exercise behavior (13). Importantly, people with MS seek this information from neurologists (1). The practice models developed in this article address these wants and needs by outlining (a) training and resources for HCPs to enable them to inform patients about the benefits of exercise, (b) providing an exercise toolkit that can be used at home or in a community exercise space, and (c) providing ongoing support for maintaining exercise behavior through tools within the exercise toolkit and community resources/entities such as the ENRL.

These models further answer calls from HCPs regarding the need for (a) opportunities to promote exercise, (b) education on exercise for persons with MS, and (c) tools and strategies that would help promote exercise among persons with MS (10). The practice models developed in this article answer this call by highlighting (a) opportunities to promote exercise at initial consultation, follow-up, and for each HCP; (b) providing educational materials on exercise and MS to neurologists before interacting with the patient; and (c) identifying practical resources to support neurologists in promoting exercise. Exercise promotion has been highlighted as essential in other chronic conditions, and similar models have been developed for heart disease as an example (23). This model for heart disease is strikingly similar to the conceptual model for MS regarding the involvement of neurologists, nurses, PTs, and fitness professionals; barriers within clinical practice including insurance limitations; and tools and resources for engaging and measuring exercise behavior. This supports the necessity for conceptual models for exercise promotion and that such models may be transferred between chronic conditions. However, the development of the MS conceptual model and subsequent practice models were accomplished through capturing the voices of patients with MS and HCPs and involving them in subsequent revisions, thereby providing a unique and novel approach for constructing an exercise promotion model in MS care.

By utilizing these practical models, there is the potential to positively impact the current burden placed on neurologists regarding exercise promotion, by streamlining and simplifying this process within MS care. Regarding the quick screen process, we posit that neurologists can efficiently and quickly decide which exercise promotion model a patient qualifies for, and refer according to this guidance. We anticipate that this will result in persons with MS being referred to HCPs in a more timely, efficient, and equitable manner to improve health-related quality of life. We further posit that the provision of an exercise toolkit and ongoing community support may vastly improve (though not fully achieve) equity of health care for individuals who do not have insurance reimbursement. The application of this system and resources may present costs to HCPs and patients. Such costs might include the training of HCPs and the toolkit itself. Regarding the costs of training HCPs, we have aspirations to design and deliver an exercise promotion qualification module that contributes toward HCPs mandatory training (e.g. through the American Neurological Association) to make time spent in this training worthwhile. Regarding the costs of toolkits for patients, we envision that the toolkit will cost $50, and this cost could be offset in the long-term through the development of a funding model wherein there is support from major organizations such as the National Multiple Sclerosis Society or the purchase of toolkits has a “tariff” that supports the provision of free toolkits for those without insurance or financial resources

Limitations

This study is not without limitations. The first stage of PDSA involved a small number of participants. Participants were representative of only 10 out of over 200 MS centers in the United States. This limits the generalizability of the research findings. There was a disproportionate number of PTs compared with the other HCPs. The comparably large number of PTs may have disproportionately influenced the findings. Such limitations will be overcome in the next stage of PDSA wherein we will invite a larger number of HCPs from the across the United States for evaluating the new practice models. Another limitation of the models is that these were specifically designed to fit into a comprehensive care setting; these models may not be applicable in other care settings. A further limitation of this line of research going forward is that we are not yet at a point where we have a support model for larger, scalable implementation of this process within comprehensive MS centers across the United States. We often note the ENRL as a possible example resource for small-scale implementation, but other potential platforms must be identified and could include the MS navigators program or involvement of community health workers in the promotion and support of exercise (24).

CONCLUSION

We provided practice models that were vetted by HCPs through a PDSA study design. The models were refined based on feedback and will be further evaluated in a larger PDSA study. The final models will provide the operationalization of the patient–provider interaction for exercise promotion in MS.

This research was funded by the National Multiple Sclerosis Society (grant number HC1411).

The authors report no conflict of interest with companies or manufacturers, nor do results of the present study constitute endorsement by the American College of Sports Medicine.

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