Medical Therapeutic Yoga for multiple sclerosis: Examining self-efficacy for physical activity, motivation for physical activity, and quality of life outcomes

Abstract

Purpose:

Multiple Sclerosis (MS) is an incurable neurodegenerative disease that results in deficits in physical and cognitive function, and often fosters low levels of self-efficacy for physical activity, motivation for physical activity, and quality of life¹. Drug therapies, physical therapy rehabilitation, and lifestyle modifications such as increased physical activity are standard protocol for symptom management, yet persons with MS tend to be physically inactive^2,3. Additionally, single-modality interventions do not inherently address the challenges faced concurrently by individuals with MS^4,5.

Methods:

This project examined the effects of a 5-week holistic biopsychosocial Medical Therapeutic Yoga program on physical activity behavior outcomes in individuals diagnosed with MS. A mixed-methods approach was used to examine self-efficacy for physical activity, motivation for physical activity, and quality of life outcomes in 15 participants.

Results:

Quantitative measures demonstrated increased self-efficacy (t(14) = −2.23, p = .042), and emotional quality of life (t(14) = −2.66, p = .019). Responses to an open-ended written questionnaire and follow-up interviews indicated overall positive response to the program including increases in self-efficacy for physical activity, motivation for physical activity, and quality of life. These results may help future holistic programming for individuals with MS incorporate behavioral interventions with therapeutic rehabilitation to increase physical activity adherence.

Background

Multiple Sclerosis (MS) is an incurable, inflammatory, neurodegenerative disease characterized by unpredictable demyelination resulting in deficits in physical function, coordination, strength, and cognition along with increased fatigue ⁶. These impairments in body function may also result in low levels of self-worth, global self-efficacy, and increased levels of anxiety and depression ^3,7–9. Resultantly, motivation for physical activity and other health behaviors decreases ^10,11. All of the aforementioned symptoms contribute to lower levels of physical activity and result in further physical deconditioning ^1,12. Standard treatment protocol for MS includes drug therapies in conjunction with lifestyle modifications such as diet and exercise ^13,14. Regular physical activity can help to manage symptoms and provide benefits such as improved strength, cardiovascular health, and quality of life ¹⁵.

Although physical activity has been shown to aid symptom management and improve quality of life in individuals diagnosed with MS ^1,16, persons diagnosed with MS tend to be physically inactive ^15,17. Very few individuals diagnosed with MS meet the recommended guidelines for physical activity of 30 minutes per day at least three days per week ^2,18. Reasons for this include physical challenges such as fatigue, muscle soreness, pain, and heat sensitivity ^2,16. Consequently, recent research has focused on methods and modalities for successfully increasing physical activity participation in individuals diagnosed with MS ^1,17. One such physical activity modality that has been explored is yoga ¹⁹.

Yoga and MS

Yoga is an ancient mind-body practice that incorporates meditation, breathing, philosophy, and deep relaxation with physical exercise ²⁰. Yoga has been shown to improve cognitive function, balance, coordination, strength, and flexibility in both healthy and chronic disease populations ²⁰. Specifically, for individuals diagnosed with MS, physical activity in the form of yoga has demonstrated improved gait, balance, emotional functioning, body awareness, motivation, social interaction, and reduced fatigue and stress ^19,21. For these reasons, yoga is becoming a popular form of physical activity for management of MS symptoms ^19,20, however yoga has not been explored in depth as a therapeutic treatment modality for individuals diagnosed with MS.

The Current Study

Recent research supports designing physical activity interventions for individuals diagnosed with MS that focus on increasing self-efficacy for physical activity and autonomous motivation ^11,22 while incorporating group settings ^23,24. It is well recognized that increasing self-efficacy (situation-specific self-confidence) for a behavior increases the behavior, resulting in increased motivation and long-term behavior change^25,26. Therefore, the current study sought to incorporate programming that increased self-efficacy for physical activity into a group yoga setting designed for rehabilitative purposes as the impetus for developing positive physical activity behaviors in individuals diagnosed with MS. The specific programming chosen was Medical Therapeutic Yoga (MTY), a form of yoga that was developed by a physical therapist for use by clinicians specializing in rehabilitation. MTY uses a holistic biopsychosocial approach to implement patient care, placing a heavy emphasis on axial stability during physical posture performance while simultaneously encouraging self-awareness and reflection ²⁷. Working within the biopsychosocial framework proposed by MTY also requires incorporating behavioral and social objectives with physical outcomes to increase the overall effectiveness of the intervention. This can be done by including activities that target improvements in self-efficacy for physical activity ²⁶ and internalized (autonomous) motivation for physical activity ¹¹, and creating a supportive and enjoyable group climate. Consequently, in addition to therapeutic benefits, a MTY program has the potential to provide the behavioral and social benefits research suggests are necessary to positively impact physical activity behavior ^19,21. For these reasons, MTY was deemed the appropriate framework to meet the objectives of this project.

The current study addressed both the physical benefits (increased physical functioning) and the psychosocial needs (increased self-efficacy, self-determined motivation) through a MTY intervention to develop physical activity behavior change. The goal of this pilot study was to tailor the five-week MTY program to the aforementioned biopsychosocial needs of individuals diagnosed with MS. The intervention focused on increasing feelings of competence and functional ability while creating a positive group environment for physical therapy and reflection. The holistic approach of the program integrated aspects of physical therapy, physical activity, and psychological behavior change to increase physical activity participation, benefits, and overall quality of life. The purpose of this study was to assess the behavioral outcomes of a MTY program through examining pre-and post- participation survey data in combination with participant interviews regarding perceived outcomes and reflections.

Methods

Research was approved by the Institutional Review Board of the overseeing university. A mixed-methods approach, using a written questionnaire with previously developed and validated measures to help understand and quantify participant’s behaviors, was combined with open-ended responses to develop depth of meaning for the participant experience.

Participants

Participants were recruited from a local non-profit physical therapy program called MSFit that was offered monthly at a local community-based exercise facility, through local MS self-help groups, local neurologist and physical therapy offices, and with posted flyers and in-service educational sessions at the community-based exercise facility. For inclusion, participants had to be over the age of 18, have a physician’s diagnosis of MS, and a Patient-Determined Disease Step ²⁸ score of 0 to 6. There were no specific criteria for the type of MS diagnosed or time since diagnosis. Exclusion criteria included uncontrolled hypertension, and the inability to safely participate in group exercise due to cognitive or physical limitations. Medical readiness screening was performed by a licensed physical therapist to determine eligibility.

Procedures

Initial screening and all subsequent sessions took place at the community-based exercise facility. The protocol included seven sessions; one session for initial testing, five sessions for the MTY intervention – which included yoga-based physical activity, behavior change programming, and journaling – and one session for exit testing. Post-intervention participants were invited to participate in structured interviews. Informed consent was obtained prior to entrance testing. Entrance and exit testing lasted approximately one hour: participants first completed the physical measures (about 45 minutes) and then completed a written behavioral questionnaire (about 15 minutes). During exit testing the written questionnaire included additional open-ended program evaluation questions.

A follow-up structured interview was used to examine the impact of the behavioral portion of the project, more specifically, to assess the retention of the physical activity behaviors learned during the program. The interview was conducted via phone or in-person three- to six-months post intervention. Open-ended questions were asked regarding benefits, challenges, and physical activity outcomes resulting from the MTY participation (appendix 1). Detailed field notes were taken to collect data.

Intervention

The intervention was a collaboration between an exercise scientist specializing in exercise psychology and a physical therapist specializing in neurological impairment who had training in MTY techniques. Both researchers were actively involved in directing each group session. The exercise psychology expert provided education on physical activity behavior change with topics consisting of work-life balance, recognizing personal strengths and weaknesses, building a personal support network, confidence building, and goal setting. The physical therapist taught the physical activity component which included included upper extremity coordination, lower extremity strength, flexibility, single limb balance, and respiratory function, and the relaxation component. Sessions were conducted in an interactive manner to enhance social cohesion and participants were encouraged throughout the sessions to share their individual experiences. Each session ended with a group discussion about concrete ways to incorporate the information and skills from the session into participants’ daily lives for the upcoming week.

MTY sessions lasted 90 minutes and were comprised of 30% education, 40% exercise, and 30% relaxation meditation to target specific challenges typically experienced by individuals diagnosed with MS. Sessions began with education on various topics related to physical activity and personal health and the participants were asked to consider how these concepts affected their quality of life and physical activity adherence. During the intervention, journal prompts with these same topics were given to the participant. These prompts asked the individual to reflect on ways to increase physical activity behavior and ask for support to improve their overall quality of life. The in-class journals were not shared with the research team but were used as another means of self-reflection for the participants. Participants were encouraged to continue physical activity behavior at home and were asked weekly to anonymously report at-home physical activity. Class size varied from three to five participants and were offered multiple times over a six-month period.

Measurement

Demographics, self-report physical activity levels, and current MS disease presentation were assessed using a series of questionnaires. Participants were asked to self-report disability level using the Patient-Determined Disease Step – a single question ordinal scale that asked the participant to rate the severity of their MS symptoms from 0 (normal) to 8 (bedridden). This measure allows for a snapshot of disability level when it is not possible to do a full medical assessment ²⁸. The Patient Determined Disease Step was developed as a self-report reflection of the clinical standard Expanded Disability Status Score neurological assessment done by physicians ²⁹, and has been validated as an effective alternative means for assessing disease step ³⁰. Physical activity levels were measured using the Godin Leisure Time Physical Activity Scale (Godin) – a six question test which measures the frequency that individuals engage in bouts of physical activity at light, moderate, or strenuous levels³¹. The higher the overall score, the more physical activity the individual participated in, with individuals being classified as either “active” and “insufficiently active” ³² based on a cutoff score of ≥ 24. The Godin measure has good test–retest reliability (.84) ³¹ and reviews of physical activity measures support its use in various clinical populations ^33,34.

Outcome measures.

The contextual measures included questionnaires to assess the participants’ self-efficacy and self-determined motivation for physical activity and perceptions of quality of life. Self-efficacy for physical activity was assessed using the Markus Self-Efficacy for Physical Activity Scale (MSES) ³⁵. The MSES is a five-question assessment that measures self-efficacy for physical activity in common physical activity situations which may be perceived as difficult, such as lack of time or poor weather ³⁵. It is used to assess the individual’s confidence in their ability to continue physical activity participation in these challenging situations, with the idea that the higher the individual’s self-efficacy, the easier it is to successfully navigate challenges. Test-retest reliability has been demonstrated at .90 and it has shown adequate internal consistency at .82 ³⁵. Self-determined motivation was measured using The Behavioral Regulation in Exercise Questionnaire – Version 2 ³⁶. This 19 question measure was used to assess overall internalized motivation for physical activity, also called a relative autonomy index ³⁶. Good reliability at .86 and internal consistency .83 have been demonstrated ³⁷. The Quality of Life Survey is a 32 question measure that was used to assesses perceived quality of life and is comprised of seven subscales: social, spiritual, emotional, cognitive, physical, activities of daily living/functional, and integrated/overall quality of life ³⁸. Confirmatory factor analyses demonstrates good internal consistency, with alpha .76-.95 ³⁹ and shows good test-retest reliability ⁴⁰. At-home physical activity was measured with a single written question, which asked participants anonymously to rate his or her at-home success with physical activity on a scale of 1–10 for the previous seven days.

Qualitative Data.

During exit testing, participants were asked on the written questionnaire to describe their perceptions of a) benefits, b) motivation for participation, c) barriers to maintaining PA participation, and d) suggested program improvements. Response length varied from a single word to short phrases.

After program completion, researchers contacted the participants via email and/or phone to request follow up interviews. Structured interviews were conducted in-person or via phone between three- and six-months post-participation. The interview questions asked participants to reflect on a) the most important thing he/she learned from MTY, b) the impact MTY had on his/her quality of life/wellness, and c) to describe/reflect on his/her overall MTY experience. Participants were also given an opportunity to provide any additional thoughts or feedback they felt was appropriate. Interviews lasted between 10 and 20 minutes and were conversational in nature.

Data Analysis

Questionnaire data were entered into a spreadsheet throughout the data collection and upon study completion were cleaned and screened for normality. Data were then analyzed using IBM SPSS (version 24). Demographic information was calculated using basic descriptives, pre- and post-test comparisons using paired samples t-tests. Weekly adherence information was calculated with a one-way analysis of variance.

A qualitative descriptive approach was used for the open-ended questionnaire responses and structured interview responses ⁴¹. The open-ended questionnaire responses collected during exit testing were first categorized independently into like-responses by two members of the research team ⁴². Team members then met and confirmed all categorization. Any discrepancies were discussed until a consensus could be reached ⁴². Following this, a numeric summary of each category was tallied ⁴¹. This process was repeated for each question. Some participants provided more than one idea (categorical response) for a single question, each of those responses was categorized separately to retain all ideas.

The follow up interview notes from the structured interviews conducted 3- to 6-months post participation were first read by two separate researchers individually and a list of like-responses was created for each question. During analysis, if a response did not fit into an existing response category, a new category was added until an exhaustive list of responses was compiled ⁴². Following category development, the research team met and discussed the individual coding until all categories were agreed upon, as is acceptable protocol for consensus coding ⁴². The final categories were shaped by the actual responses of the participants while remaining in line with the research questions ⁴¹. After all coding was agreed upon, individual responses for each question were counted and a numeric summary for each category was compiled.

Results

Questionnaire

Sixteen individuals diagnosed with MS aged 30–70 years (55.1 years ± 9.93), 14 female and two males, participated in the MTY intervention in one of four, seven-week cohorts. Data were collected over a six-month time period. All data from the four cohorts were combined. One female participant did not complete the entire program due to scheduling challenges and was removed from the analysis, leaving a sample of 15. Participants had been diagnosed with MS ranging from four months to 32 years (mean MS duration was 14.7 ± 11.72 years) and self-reported a range of MS-related symptoms (table 1). Patient Determined Disease Step scores ranged from 0 to 6, with a mean score of 2.9 (±1.79). Physical Activity levels as reported by the Godin ranged from 0 to 51 with a mean of 22.2 (±16.81), classifying the sample as insufficiently active. Less than half (seven) of the 15 participants reported sufficient levels of physical activity to be considered active and five reported no physical activity participation at all. For sociodemographic characteristics on individual participants see table 2.

Table 1.

Self-reported MS symptoms

Theme/Description	Number of participants	Percentage of total
Fatigue	13	72.2
Balance problems and dizziness with movement	9	60.0
Coordination	7	46.6
Numbness and/or tingling	5	33.3
Gait related issues	5	33.3
“Thinking” or cognitive delays	2	13.3
Nerve pain	2	13.3
“Feeling that back will/cannot [provide] support”	1	6.7
Vision problems	1	6.7

Table 2.

Sociodemographic Characteristics of Participants

Participant Male (M)/Female (F)	Age	MS Type+	PDDS**	Years with MS	Physical Activity Level Pre++	Physical Activity Level Post++
F1	48	RRMS	3	23	45	48
F2	58	RRMS	3	4	0	9
F3 *	43	RRMS	0	5	0	n/a
F4	49	RRMS	0	6	52	68
F5	63	RRMS	5	28	15	0
F6	57	RRMS	0	4	48	54
F7	66	RRMS	4	32	9	9
F8	47	unknown	4	23	0	30
F9	70	PPMS	5	25	31	36.5
F10	52	RRMS	2	4	15.5	21
F11	50	RRMS	2	13	22.5	5
M12	59	PPMS	4	0.5	5	15
F13	63	SPMS	6	23	11	9
F14	69	RRMS	2	38	41	45
F15	54	RRMS	3	3	9	0
M16	30	RRMS	1	2	0	15

^*Did not complete the program and was removed from data analysis

⁺RRMS – Relapsing remitting MS; SPMS – Secondary progressive MS; PPMS – Primary progressive MS

^**PDDS – Patient Determined Disease Step self-report score

⁺⁺As determined by Godin Leisure-Time Physical Activity Questionnaire – active ± 150 minutes of moderate to vigorous activity per week; insufficiently active < 150 minutes per week

Outcome measures indicated a significant difference in self-efficacy for physical activity between pre- and post-test, t(14) = 2.233, p = .042. Self-determined motivation, using the relative autonomy index calculation of the Behavioral Regulation in Exercise Questionnaire – Version 2, was not significant, t(14) = 1.53, p = .147. The Quality of Life Survey subscale of emotional quality of life (t(14) = −2.661, p = .019) indicated a significant change between pre- and post-test. All other Quality of Life Survey subscales and integrated quality of life were non-significant. There were no significant changes in weekly at-home physical activity participation from weeks two to five, F(3,56) = .680, p = .568) and results of the Godin Leisure Time Physical Activity Scale showed no difference in physical activity behavior pre- and post-part For all results on measures please see table 3.

Table 3.

Results from Quantitative Measures

Measure	Pre-MTY	Post- MTY	Significance
MSES +	12.8 ± 1.10	14.9 ± 1.03	.042*
BREQ-2 RAI ++	22.7 ± 6.21	28.7 ±5.71	.147
QoL – Social **	18.2 ± 3.21	19.5 ± 3.56	.106
QoL – Spiritual **	19.4 ± 3.87	20.3 ± 4.04	.105
QoL – Emotional **	17.4 ± 3.35	18.9 ± 3.41	.019*
QoL – Cognitive **	16.4 ± 2.97	17.5 ± 3.00	.100
QoL – Physical **	13.6 ± 4.11	14.7 ± 4.37	.175
QoL – Activities of Daily Living **	10.2 ± 2.18	11.0 ± 2.03	.181
QoL – Integrated **	15.2 ± 3.03	16.2 ± 2.54	.073

^*significant at p < .05 level

⁺MSES – Markus Self-Efficacy for Physical Activity Scale

⁺⁺BREQ-2 RAI – Behavioral Regulation in Exercise Questionnaire – Version 2, Relative Autonomy Index

^**QoL – The Quality of Life Survey, with individual subscales

Open-ended Questionnaire Responses

All 15 participants answered the open-ended questions upon program exit. Open-ended survey responses to the program were overwhelmingly positive. The aspects of the program the participants liked the most included learning controlled breathing, prioritizing self-care, developing focused physical control of movement and balance, and exploring effective means of work-life balance. Participants noted that their greatest motivators for exercise were an improvement in quality of life/functioning, improved balance, and the social interactions. The biggest barriers to maintaining physical activity participation were fatigue, time, and motivation. Suggestions for program improvement included a longer program (more sessions) and visual handouts/instructional videos, with four participants stating that no improvements were needed. See table 4 for responses to all open-ended questionnaire questions.

Table 4.

Open-ended questionnaire responses

Perceived benefits from participating in Medical Therapeutic Yoga for MS
Theme/Description	Number of participants	Percentage of total
New modes of exercise	11	73.3
Balance (physical)	7	46.6
Breathing	7	46.6
Social and/or emotional support	6	40.0
Relaxation	3	20.0
Motivation to participate in Medical Therapeutic Yoga for MS
Theme/Description	Number of participants	Percentage of total
Improvement in QoL/functioning	10	66.6
Improvement in balance	5	33.3
Social interaction	5	33.3
Body image	2	13.3
Biggest barrier faced in maintaining regular physical activity
Theme/Description	Number of participants	Percentage of total
[Lack of] stamina or energy, fatigue	6	40.0
Time, extracurriculars, schedule conflicts	6	40.0
Motivation to do it alone	6	40.0
Work-life balance	3	20.0
Heat (high temperatures)	1	6.7
Don’t like exercising	1	6.7
Suggested Improvements to Medical Therapeutic Yoga for MS
Theme/Description	Number of participants	Percentage of total
More yoga sessions	8	53.3
Visual descriptions	7	38.9
No improvements necessary	4	26.7
Peppermint essential oils and water	1	6.7
Text reminders	1	6.7
MTY for MS training for YWCA yoga instructors	1	6.7

Follow-up Interviews

Eleven of the 15 participants agreed to the follow-up interviews, three in-person and eight via phone. The remaining four were unable to participate due to scheduling conflicts (3 participants) and phone number change (1 participant). All interviews were conducted over a single two-week period. Depending on when a participant completed the program, his/her individual interview occurred between three- and six-months post-participation. Follow-up interviews indicated overall positive reflections of the MTY program and indicated retention of behaviors with nine of the 11 participants reporting continued use of yoga skills in their everyday lives.

What is the most important thing you learned from MTY for MS?

Participants overwhelmingly cited the specific exercises and skills that they learned in response to this question with “balance exercises”, mentioned most often. One participant stated “At first I thought yoga was silly but it really started to work with my balance and stretching.” (F9) Breathing and relaxation also proved impactful with seven participants indicating they were still using these skills. One individual stated that due to the breathing exercises “I can do more” because “mentally I feel like I’m doing something.” (F5) Although not specifically stated, these types of responses are congruent with the development of self-efficacy and were echoed by a majority of participants. For a complete list of responses please see table 5.

Table 5.

Structured Interview Responses

Most important thing learned from Medical Therapeutic Yoga for MS
Theme/Description	Number of participants	Percentage
Balance exercises	9	81.8
Breathing and relaxation	7	63.6
Mindfulness	7	63.6
“I can do it”, “I can do things”, “Confidence”	6	54.5
“Keep up with it”, “Importance of exercise”	4	36.4
Stretching exercises	3	27.3
Osteoporosis awareness in relation to exercise	2	18.2
Impact Medical Therapeutic Yoga for MS participation has had on quality of life/wellness
Theme/Description	Number of participants	Percentage
Learning proper form for exercises, learning new exercises	4	36.4
Stress reduction relating to life balance and/or relaxation	4	36.4
Confidence in overcoming challenges	3	27.3
Sense of community with similar people	3	27.3
Ability to complete *ADL’s	2	18.2
Alternate strategies to practicing yoga	1	9.1
Overall experience in Medical Therapeutic Yoga for MS
Theme/Description	Number of participants	Percentage
Loved the program	9	81.8
Wish there were more classes that catered to individuals with MS	5	45.5
Hope for a future with MS	4	36.4
Learned that “I am able to use my body”/Can do more than I thought	4	36.4
Wanted a more concrete schedule	2	18.2

^*ADL’s = activities of daily living

What impact has MTY for MS had on your quality of life?

Participants listed numerous ways they saw the things they learned in MTY translating to quality of life outcomes. One participant reflected “[I learned] to use my body...I learned that you can still function, you just adjust to a new normal, just keep trying.” (F15) The idea of learning to adjust to a new normal and move forward was repeated by six other participants. One participant responded, “I can do things; I can walk I can use my body to work for me” (F7) and emphasized the realization that through the program she noticed that her body was still able to “do it” in reference to daily activities and tasks. The focus on life balance helped participants develop a skill that they saw as impactful to their overall quality of life. Balancing work, life, and health was mentioned by multiple participants as an important take away from the program that was helping them live better lives. For a complete list of responses see table 5.

Can you reflect on your overall experiences (positive and negative) in MTY for MS?

When asked what their overall experience was with the program the major response was that they “loved” it with one individual stating: “I feel blessed for being able to participate.” (F2) Another participant stated that to her, the class imparted a “mental situation that encourages thoughts like ‘you believe you can do things.’” (F1) Participants felt hopeful for the future and wished there were more programs specifically for those living with MS. For a complete list of responses see table 5.

Discussion

This project was a conscious effort to develop a MTY intervention for individuals diagnosed with MS using a biopsychosocial model that combined aspects of behavior change and physical therapy in a rehabilitation setting. As with any program of this type, it is important to understand both the observed outcomes and the participant perceptions of those outcomes. The behavioral aspects of the program showed promising results for MTY to increase self-efficacy for physical activity, autonomous motivation for physical activity, and lead to positive reported impacts on quality of life.

Self-efficacy is a driving factor in motivation for physical activity participation ^26,35. For the MTY participants, increased self-efficacy for physical activity was seen in the quantitative measures pre-and post-participation and were evident in the open-ended questionnaire responses and interviews. Overall, they felt more confident in their ability to balance and engage in physical activity post intervention. Increases in self-efficacy for physical activity are well-supported in the literature and are expected with a physical activity intervention of this type ^3,43,44. The novel aspect of this intervention is the timeframe in which these increases in self-efficacy for physical activity were seen. Most interventions designed for effective behavior change are longer in duration ^26,35,45 – usually 12–16 weeks – whereas participants only did MTY for five weeks. This success could suggests that within a biopsychosocial framework it may be possible to achieve effective results in an abbreviated program. Due to the limited nature of the data, including small sample size, lack of control group, and no true measurement of program efficacy, these results are not currently generalizable. However, these increases seen in self-efficacy for physical activity are promising and deserve more in-depth explorations in the future.

There were no significant changes observed in self-determined motivation for physical activity in the quantitative data. These results are not surprising given the small sample size and short duration of the intervention. Autonomous motivation is developed through building internal value, which facilitates the desire for maintaining the behavior ⁴⁶. The open-ended responses and interviews did suggest a shift in the mindset of the participants toward a more internalized view of the exercises learned in MTY and for physical activity in general. Participants acknowledged the need for physical activity and saw a direct connection between the MTY exercises and the physical improvements in functioning they experienced. This connection is the first step toward internalizing motivation. By seeing the connection between physical activity and the desired outcome (improved functioning), the physical activity behavior becomes more desirable and motivation is internalized. It is possible with a longer timeframe that the changes reported in the open-ended response and interviews would be reflected in quantitative measures as well.

In addition to the increased self-efficacy and autonomous motivation, it is likely that the social connections formed by participants contributed to their overall positive responses to MTY. Participants appeared to easily and quickly develop strong personal bonds and seemed to enjoy each other’s company as part of the group. The idea of attending classes for those with MS, and being able to do physical activity with others who understood, was seen as beneficial and cited by participants as improving quality of life. Social support influences physical activity behavior and overall well-being and is important to retention of physical activity behavior ⁴⁷. Creating a welcoming and cohesive group environment is part of an effective biopsychosocial approach to rehabilitation interventions. This intervention appears to have created such an environment, which was beneficial for participants.

All of the participants noted that their greatest motivator for exercise was the idea of improving quality of life and this was the primary reason participants gave for initially enrolling in MTY. This is congruent with previous studies linking exercise to quality of life enhancement ^4,17,11. Participants associated the improvements they experienced in physical ability (balance, coordination, flexibility), psychological ability (confidence, relaxation, stress reduction), and social connections with increased quality of life. Interestingly, the only Quality of Life Survey subscale that showed significant improvement was emotional quality of life. This may be due to the small sample size. It is also important to consider that quantifying quality of life improvements is complex and may not be effectively measured using a questionnaire ⁴⁸. Based on the participant responses it is clear that there was a perception of quality of life improvements from MTY participation.

This project, as with all research, is not without its limitations. With only 15 participants, a short (5-week) intervention, and lack of control group, results and generalizability are limited in scope beyond the current sample. The current research should be used as a starting point in developing future explorations with a larger and more diverse sample and longer intervention duration. As the next phase of this project continues, a larger sample size and the introduction of a control group will increase confidence in the results and give a clearer picture of outcomes. Human interaction is always unpredictable and as the first cohorts involved in the study, researchers were developing the nuances of standardizing protocols. Future directions will continue to refine the interaction protocols between instructors and participants.

Conclusion

This pilot study was an attempt to incorporate a biopsychosocial model to develop a more global approach to MS treatment. The goal was to address the needs of the entire person and facilitate health behavior change that included increased physical activity behavior by combining behavioral constructs with a physical therapy rehabilitation protocol in a group setting. Improved quality of life was not a direct outcome goal of this program yet aspects of quality of life were enhanced using this approach. These data were able to capture information often missed in the quantitative studies frequently performed by rehabilitation providers and points to the need for further cross-collaborative studies that allow both qualitative and quantitative data analysis. As more information about the impact of physical activity on quality of life is gained, research needs to explore the biopsychosocial influence on this relationship in the context of therapeutic interventions. The information gained from this program is being used to educate local yoga teachers, expand program reach, and inform future research.

Implications for Rehabilitation.

• Multiple sclerosis is a neurological disease impacting physical and cognitive functioning that may be managed with a combination of drug therapies, rehabilitation, and physical activity.

• Individuals diagnosed with multiple sclerosis tend to be physically inactive and physical inactivity is a challenge for optimal disease management.

• Medical Therapeutic Yoga offers an interdisciplinary biopsychosocial framework to simultaneously address the behavioral challenges and physical impairments facing individuals diagnosed with multiple sclerosis.

• Health care providers should consider developing programs that use a biopsychosocial framework to aid in developing long-term adherence in health behaviors such as physical activity participation.

APPENDIX

Appendix 1: Medical Therapeutic Yoga for MS – Follow-up interview questions.

Participants were contacted via the preferred method of contact between 3- and 6-months post participation for a follow up interview which included the following questions:

1. What (if any) skills are you still using from MTY?

2. What is the biggest thing you think you learned from MTY?

3. Are you participating in any yoga classes now?

4. What, if any, impact has MTY made on your wellness/quality of life?

5. How confident do you feel about accomplishing your day-to-day tasks? What are the biggest challenges you face? How do you navigate those challenges?

6. Describe how you cope with stressors and/or fatigue.

7. What physical activity do you participate in?

8. Is there anything else you would like to tell us about your experiences with MTY now that you have been done with the class for (3 or 6) months?