Multiple sclerosis (MS) is a nontraumatic, chronic disabling disease of the central nervous system with an estimated prevalence of 1 per 1000 adults in the United States.1 MS typically causes areas of inflammation in the central nervous system that result in axonal demyelination and transection (ie, lesions). There are further neurodegenerative processes associated with MS (ie, brain atrophy). The central nervous system damage manifests in a heterogeneous manner, but one common and burdensome manifestation of MS is the impairment of walking.2,3
Walking impairment in MS is often objectively measured using performance assessments, particularly the Timed 25-Foot Walk (T25FW) and Six-Minute Walk (6MW) tests.4 The T25FW test measures walking speed over a short distance, whereas the 6MW test measures walking endurance over a longer distance. Persons with MS have demonstrated worse performance on these measures than control samples, and performance on these measures further declines across levels of worsening disability status.5,6
To date, there has been considerable research examining correlates of walking performance in MS (eg, fatigue or muscle strength), but little is known about self-efficacy and walking performance in MS. Self-efficacy is defined as one's degree of confidence in undertaking a course of action (eg, walking quickly over a 25-ft course) or regulating a behavior over time (e.g., maintaining walking speed over a prolonged, 6-minute period), and it represents a highly malleable variable based on sources articulated in social-cognitive theory.7 Those who are more confident in performing behaviors necessary for daily activities (eg, walking) may demonstrate better performance on the T25FW (ie, walk faster) and 6MW (ie, walk farther) tests. If self-efficacy is associated with walking performance, as expected, it could become a target of rehabilitation interventions and clinical care for possibly yielding improvements in walking performance among those with MS.
We identified one study that examined the association between self-efficacy based on the Multiple Sclerosis Self-Efficacy (MSSE) Scale8 and self-reported walking impairment based on the Multiple Sclerosis Walking Scale-12 (MSWS-12)9 in a sample of 89 people with MS.10 The MSSE Scale contains 2 subscales that measure confidence with performing behaviors associated with engaging in daily living activities (ie, MSSE function) and managing disease symptoms, reactions, and impact on daily life activities (ie, MSSE control). The authors reported that MSSE function (r = −0.43) and control (r = −0.44) subscale scores correlated with MSWS-12 scores in baseline data; there were similar associations in longitudinal, predictive analyses.10 Such results suggest that adults with MS who reported being more confident with performing behaviors necessary for engaging in daily living activities and managing disease symptoms, reactions, and impact reported less walking impairment. One major limitation of that study was the reliance on a self-report measure of walking, and such promising results should be confirmed with objective, walking performance measures. Additional inquiry might further confirm that the association between self-efficacy and walking is unique for functioning with MS and managing its manifestations, independent of self-efficacy for other behaviors and actions such as physical activity.
We located another study that examined the effect of 10 weeks of a structured, group motor learning process (Awareness Through Movement) compared with control (social/education classes) on balance, balance confidence, and self-efficacy measured by MSSE Scale in a sample of 12 people with MS.11 The Awareness Through Movement group demonstrated improvements in markers of balance and balance confidence but not self-efficacy based on MSSE scores. Interestingly, there were correlations between changes in MSSE subscale scores and falls and changes in outcomes from a computerized balance assessment (eg, maximum excursion, directional control, and end-point excursion). That study did not examine the effect of the intervention on walking outcomes, the association between changes in self-efficacy and walking outcomes, nor the independence of associations between the 2 subscales on the MSSE and balance outcomes.
The current cross-sectional study examined the association between self-efficacy and walking performance in a convenience sample of persons living with MS. We expected that those with higher self-efficacy for functioning with MS and managing its manifestations would demonstrate faster walking speed on the T25FW test and farther walking distance on the 6MW test. We further expected that those associations would be independent of self-efficacy for engaging in physical activity.
Over a 6-month period, we recruited a convenience sample by advertising the study on the National MS Society Local Research page and our laboratory Facebook page and contacting persons in our laboratory database. The inclusion criteria were (1) 18 to 64 years of age; (2) relapse free during the past 30 days; and (3) ambulatory with or without assistance. Of the 92 individuals with MS who underwent screening, 8 were disqualified, 14 were qualified but dropped out prior to testing, and 70 participants met inclusion criteria and were scheduled for testing. One participant did not provide self-report information resulting in a final convenience sample of 69 persons with MS for data analyses.
Self-efficacy was assessed using the MSSE Scale8 and the Exercise Self-Efficacy (EXSE) scale.12 The MSSE Scale has 18 items and measures 2 subscales of function and control. The function subscale contains 9 items and measures confidence with performing behaviors associated with engaging in daily living activities (eg, walking 100 ft on flat ground or walking 10 steps downstairs). The control subscale contains 9 items and measures confidence with managing disease symptoms, reactions, and impact on daily life activities (eg, controlling fatigue or dealing with the uncertainty of MS). The items were rated on a scale ranging between 0 and 100 with anchors of “Very uncertain” and “Very certain” and then averaged into total scores that range between 0 and 100 for both MSSE subscales. There is strong evidence for the reliability and validity of scores from the MSSE Scale in persons with MS.13
The EXSE Scale has 6 items that assess an individual's beliefs in the ability to engage in a bout of moderate-to-vigorous physical activity without stopping across increasing increments of time ranging between 10 and 60 minutes (eg, cycle at a moderately hard intensity of 10 minutes without stopping).12 The scores from the 6 items are rated on a scale from 0 (Not at all confident) through 100 (Highly confident) and averaged into a total score ranging between 0 and 100. There is strong evidence for the reliability and validity of scores from the EXSE Scale in persons with MS.14
Walking performance was assessed through the T25FW and 6MW tests. Regarding the T25FW test, participants were instructed to walk as quickly but as safely as possible over a clearly marked distance of 25 ft for 2 trials; the test was administered according to standardized instructions.15 The primary outcome of the T25FW trials was speed (ie, feet/second). Regarding the 6MW test, participants were instructed to walk as far and as fast as possible in an accessible hallway over a 6-minute period; the test was administered according to standardized instructions.16 One member of the research team followed 3 to 5 ft behind participants with a measuring wheel to quantify the distance walked in feet (ie, the primary outcome of the 6MW test) consistent with the original validation study in MS.16
This laboratory-based study was approved by the University of Illinois at Urbana-Champaign Institutional Review Board and participants provided written informed consent. Participants underwent a neurological evaluation by a neurostatus-certified examiner for generation of an Expanded Disability Status Scale17 score, measurements of height and weight, and then provided sociodemographic and clinical characteristics; these data were for characterizing the sample. Participants further completed the measures of self-efficacy and underwent the T25FW test followed by the 6MW test, and there were 15 minutes of rest between those assessments.
All data analyses were performed in IBM SPSS statistics version 22.0 (International Business Machines Corp., Armonk, NY). We provided descriptive statistics as means and standard deviations, unless otherwise noted (eg, percentage). We examined the associations among self-efficacy and walking performance scores using Pearson product moment correlation coefficients and interpreted the magnitude using guidelines of 0.1, 0.3, and 0.5 as small, moderate, and large, respectively.18 We examined the independent associations between self-efficacy and walking outcomes using linear regression analyses. These analyses involved regressing walking performance (ie, T25FW or 6MW) on MSSE subscale scores (first analysis) and MSSE and EXSE scores (second analysis) using direct entry of variables. We examined standardized β-coefficients for identifying the independent contributions of the variables in the model for explaining variance in walking outcomes.
Participants (N = 69) were primarily female (69.6%), Caucasian (94.2%), and married (59.4%) (Table 1). Nearly half of the participants were employed (49.3%), 85.5% had some college experience, and 68.1% had an annual household income greater than $40 000. The mean age was 50.5 (8.9) years. The mean body mass index (kg/m2) was 28.7 (6.6). Participants primarily had relapsing-remitting multiple sclerosis (84.1%), mild to moderate disability (median [interquartile range] Expanded Disability Status Scale score of 4.0 [2.0]), and disease duration of 14.4 (10.5) years.
Table 1. -
Sociodemographic and Clinical Characteristics for the Study Sample
|Sex (% female/male)
|Age, (mean [SD]), y
|Race (% Caucasian/Other)
|BMI (kg/m2) (mean (SD))
|Marital status (% married/unmarried)
|Employed (% employed/unemployed)
|Education (% some college/no college)
|Annual household income (%>$40 000/<$40 000)
|EDSS, median (IQR)
|Disease course (% RRMS/PMS)
|Disease duration, y
Abbreviations: BMI, body mass index; EDSS, Expanded Disability Status Scale; IQR, interquartile range; PMS, progressive course of MS; RRMS, relapsing-remitting multiple sclerosis.
We provide the mean scores and standard deviations along with range of scores for the MSSE, EXSE, T25FW, and 6MW in Table 2. The mean T25FW and 6MW scores reflect worse short- and long-walking performance, respectively, compared with healthy control populations in previous research involving persons with MS.5,6 For example, in previous research, the mean 6MW distance for comparison subjects was 2034 ft,16 whereas the mean score for those with MS in the current study was 1522 ft.
Table 2. -
Descriptive Statistics for the Measures of Self-efficacy and Walking Performance
|MSSE, function (0-100)
|MSSE, control (0-100)
Abbreviations: EXSE, Exercise Self-efficacy Scale; MSSE, Multiple Sclerosis Self-efficacy Scale; 6MW, 6-Minute Walk; T25FW, Timed 25-Foot Walk.
We provide the bivariate correlations between scores from the measures of self-efficacy and walking outcomes in Table 3. Of note, function subscale scores on the MSSE Scale correlated more strongly with T25FW (r = 0.55) than did the control subscale (r = 0.40) and EXSE (r = 0.38) scores, and both function (r = 0.67) and control (r = 0.53) subscale scores on the MSSE Scale correlated more strongly with 6MW than did EXSE scores (r = 0.40). The correlations between function and walking outcomes were strong in magnitude, whereas the correlations between control and walking were moderate to strong.
Table 3. -
Bivariate Correlations Among Scores From the Measures of Self-efficacy and Walking Performancea
|1. MSSE, function (0-100)
|2. MSSE, control (0-100)
|3. EXSE (0-100)
|4. T25FW (ft/s)
|5. 6MW (ft)
Abbreviations: EXSE, Exercise Self-efficacy Scale; MSSE, Multiple Sclerosis Self-efficacy Scale; 6MW, 6-Minute Walk; T25FW, Timed 25-Foot Walk.
aAll correlations are significant at P < 0.001.
The first analysis regressed T25FW on both subscales from the MSSE (F2,65 = 14.4, P < 0.001, R2 = 0.31). The function subscale (β = 0.58), but not control subscale (β = −0.03), was significantly associated with T25FW speed. This was repeated for the 6MW (F2,65 = 25.2, P < 0.001, R2 = 0.44). The results again indicated that the function subscale (β = 0.60), but not control subscale (β = −0.08), was significantly associated with 6MW distance.
The next analysis regressed T25FW on the MSSE function subscale and EXSE (F2,65 = 15.4, P < 0.001, R2 = 0.32). The results indicated that the function subscale (β = 0.49), but not EXSE (β = 0.14), was significantly associated with T25FW speed. This was repeated for the 6MW (F2,65 = 26.1, P < 0.001, R2 = 0.45). The results similarly indicated that the function subscale (β = 0.61), but not EXSE (β = 0.12), was significantly associated with 6MW distance.
The present study examined the associations between self-efficacy and walking performance in a convenience sample of persons with MS, and our results indicated that self-efficacy for function was the primary correlate of walking speed and endurance in the present sample. This can be interpreted such that confidence with performing behaviors associated with engaging in daily living activities (eg, walking 100 ft on flat ground or walking 10 steps downstairs) is a stronger correlate of actual walking performance than is self-efficacy for managing MS (eg, controlling fatigue or dealing with the uncertainty of MS) or engaging in physical activity (eg, cycle at a moderately hard intensity of 10 minutes without stopping).
We cannot infer causality from the results of this cross-sectional study with a convenience sample, but the present results combined with previous research10 support the consideration of self-efficacy for functioning with MS as a target of focal rehabilitation efforts for improving walking speed and endurance; this might be different for balance outcomes wherein self-efficacy for controlling or managing MS seemingly is an important correlate of balance.11 An interesting observation from our results and those of others10,11 is that higher or improved MSSE scores might be important for many outcomes in MS, but this requires additional and focal research efforts using a variety of designs. We note that the median EDSS level of the participants in this study was 4.0 and corresponds with the onset of walking impairment, but this sample may not represent a segment of the MS population with substantial walking impairment typically seen by physical therapists.
We report results from bivariate analyses that self-efficacy for functioning with MS and managing its consequences as well as physical activity all correlated with 6MW and T25FW tests as performance measures of walking. The magnitude of correlations was moderate or large based on Cohen's guideline for interpreting correlation coefficients.18 We are aware of one previous study reporting that self-efficacy for function and control of MS correlated with self-reported walking measured by the MSWS-12.10 To that end, our results replicate and extend that previous study by indicating that self-efficacy is associated with an objective measurement of walking performance in MS.
Two novel features of the current article are the focus on walking performance outcomes and consideration of specificity of the type of self-efficacy. Our focus on objective measurement of walking overcomes the possibility of self-report biases driving associations in the seminal research on self-efficacy and walking in MS.10 Our inclusion of self-efficacy for physical activity and the regression analyses permitted a stronger indication that self-efficacy for functioning with MS, rather than for managing its consequences or engaging in physical activity, was the primary “type” of self-efficacy associated with walking function. Such results provide a stronger basis for understanding self-efficacy and walking in MS.
Social-cognitive theory has identified categories of factors that serve as sources for informing self-efficacy expectations.7 These 4 categories of factors are performance accomplishment/mastery, vicarious experience, verbal persuasion, and physiological/affective experiences. To that end, it may be important for researchers to consider identifying and operationalizing these categories of variables for informing future opportunities for manipulating self-efficacy for functioning with MS. This might afford a cost-effective and theory-based approach for improving walking performance in MS through future rehabilitation efforts. As an example, researchers and clinicians might focus on vicarious experience wherein a person who has low self-efficacy for functioning and walking problems learns about the experiences and successes of another person with MS who has overcome similar problems (ie, if she/he can do it, so can I). Another approach might focus on verbal persuasion wherein researchers and clinicians engage in supportive, encouraging, and informational dialogue for overcoming a person's self-doubt about functioning with MS. One last example might focus on performance accomplishment wherein researchers and clinicians establish challenging, yet manageable functional situations that a person with MS can successfully overcome. This would promote a sense of mastery that informs self-efficacy for functioning with MS and perhaps improves walking outcomes. Such examples and others could be vetted and informed through qualitative research involving persons with MS for identifying a range of approaches for targeting sources of efficacy information that would inform interventions for improving walking outcomes.
There are several limitations of the present study. The primary limitation involves the cross-sectional design wherein we cannot establish temporal sequence and causality between self-efficacy and walking performance. The other primary limitation involves the clinical characteristics of the convenience sample (ie, disability level and disease duration). The sample further was privileged on the basis of education and income status. The results of this study derive from a relatively homogeneous sample and cannot be broadly generalized among those with MS. Finally, we have previously shown in persons with MS that considerable variability in walking impairment is explained by physiological deconditioning,19 which is likely to influence perceived self-efficacy. In the present study, we did not evaluate the possible interaction between these variables.
We provide evidence of an association between self-efficacy, particularly for functioning with the disease, and walking performance in MS. These results suggest that future research replicate and extend our results for informing possible rehabilitation efforts that target walking performance in MS.
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