Table 1.

Behavioral health principles supporting components of the CoachMS platform.

			Behavioral health principles adopted
Study schedule	Components		Construct or intervention function	Definition, examples
Baseline evaluation
Assess baseline function and needs	• Neurological evaluation and history • Plan 2 weeks of baseline observation (see on-study monitoring for details)
	• Physical therapy evaluation:		Evaluate Capability, Motivation, Opportunity through individualized interview (Table S1/Supplementary Appendix 1; e.g., for opportunity: “Barriers to activity?” or “Recreational facility availability?”)
2-Week check in tele-video visit
Review function	• Review STEPS • Review symptom scores
Revise capability, motivation and opportunity	• Reassess capability, motivation and opportunity in light of symptom and activity monitoring		Capability	Capacity to engage in the concerned activity, e.g. hand function strong enough for self-catheterization
			Motivation	Processes energizing people to engage in the concerned behavior, e.g. confidence they can achieve STEPS goal with CoachMS-team advice (self-efficacy)
			Opportunity	All factors outside their control that could influence engagement in the concerned behavior, e.g. availability of an accessible swimming pool nearby; friends available for weekly walk; safety of the neighborhood for walking
Personalized goal setting	Examples • Bladder: reduce nocturia from 3 events to <1 • Ambulation: increase STEPS by 2,000 daily • Mood: reduce depression to mild category		Modeling	Providing a STEPS goals based on active patients in that EDSS category
Comprehensive care plan	• Create action plan • Communicate recommendations with primary clinician		Care plan derived from evidence-based approaches described in Supplementary Appendix 2, personalized for patient based on Capacity, Motivation, Opportunity.
	Symptom	Behavioral Example	Education	Educate on the importance of setting attainable physical activity and symptom management goals with the intention of modulating health behaviors
	• Bladder • Ambulation • Mood	• Education on diet and reducing fluid intake late in the day • Plan to park further from stores; drive to a reservoir to walk on flat surface on weekends • Contact treating clinician for an antidepressant prescription
			Incentivization	Recommend they set the Fitbit to vibrate when average step count (STEPS) goals reached
			Coercion	Discuss the negative effects of sedentarism, especially in people with MS
			Environmental restructuring	Recommend that patient join a gym closer to home or reorganize their living room for safe activity e.g. make space for a wide area with a mat and sturdy furniture for support
			Enablement	Communicate recommendations with primary neurologist to reduce barriers to asking for a prescription change Provide web-links to adapted, specific material to assist with exercising
On-study symptom self-monitoring (weeks 2–12)
Patient self-reports symptoms and tracks activity	Weekly REDCap Surveys • Bladder: Actionable Bladder Symptom Screening Tool ABSST-9 • Ambulation: Hopkins Falling Scale (falls); Continuous ambulatory monitoring (Fitbit Flex) • Mood: PHQ-4; depression and anxiety.		Education	Patient becomes more aware of their symptoms and how they interact
CoachMS group only: on-study closed-loop symptom monitoring and response (weeks 2–12)
Study team monitors symptoms Targeted contact for symptom worsening/stasis	Definitions of symptom worsening • ABSST-9: a first-time occurrence of a score $\ge$16, or increase $\ge \mathrm{ }$2 • PHQ-4: a first-time occurrence of score $\ge$10, or increase $\ge$4 • Hopkins Fall Scale: $\ge$1 fall Or >800 Fitbit STEPS decrease averaged over a valid week.		Persuasion	Repeated contact by study team stimulates action
			Incentivization	Achieving goals will be noted by study team, who will in turn call less often
			Coercion	Repeated contact until reach goals
			Environmental restructuring	Continue to troubleshoot barrier posed by physical or social context
			Modeling	Continue to encourage a STEPS goals based on active patients in that EDSS category
			Enablement	Continue to provide feedback to the treating clinician to provide a new prescription.

EDSS: Expanded Disability Status Scale; ABSST-9: Actionable Bladder Symptom Screening Tool; PHQ-4: 4-item Patient Health Questionnaire; STEPS: average daily step count.