Abstract

Objective

Individuals with multiple sclerosis (MS) often exhibit reduced levels of physical activity (PA), which are influenced by psychological factors, including depression and perceptions of exercise. Accordingly, this study aimed to assess PA levels among individuals with MS and to examine the associations between depression, exercise perception, and PA levels.

Materials and Methods

A total of 80 individuals with MS (mean age: 32.71±9.22 years) participated in this cross-sectional study. Depression was evaluated using the Beck Depression Inventory, exercise perception was measured with the Exercise Benefits/Barriers Scale, and PA levels was determined through the International Physical Activity Questionnaire-Short Form.

Results

The majority of participants were classified as minimally active (72.5%), whereas 8.8% were inactive and 18.8% were very active. A weak but positive correlation was identified between depression and exercise barriers (r=0.443, p<0.001), as well as between depression and body mass index (r=0.314, p=0.005). No significant correlation was observed between depression and total PA level. Participants most frequently cited physical effort and environmental limitations as major barriers to exercise.

Conclusion

Although most individuals with MS acknowledge the advantages of exercise, depression, and perceived barriers can impede their participation in PA. Addressing both psychological and environmental factors may enhance exercise adherence and overall disease management in this population.

Introduction

Multiple sclerosis (MS) is a progressive, chronic, demyelinating disease that affects the white matter and subcortical structures of the central nervous system (CNS). Individuals with MS experience symptoms such as balance disorders, fatigue, muscle weakness, and sensory disturbances in the early stages, and widespread disability resulting from spasticity, bladder dysfunction, depression, pain, and cognitive impairment in the later stages (1, 2). Nearly 2.5 million people worldwide are affected by this disease (3). MS causes progressive damage to the CNS, leading to symptoms including pain, fatigue, depression, mobility limitations, and reduced quality of life (QOL) (4-6). The neurodegenerative process associated with axonal and neuronal loss contributes to disease progression and various forms of CNS damage (6). Such CNS damage can result in pain, fatigue, depression, ambulatory and cognitive dysfunction, deconditioning, and diminished QOL (4).

Over the past decade, increasing evidence has shown that engaging in physical activity (PA) alleviates the aforementioned problems in individuals with MS and enhances their QOL. However, compared with the general population, individuals with MS engage in insufficient PA (1, 7). PA has been demonstrated to reduce fatigue, depression, impairment, cognitive and walking difficulties, and to improve cardiorespiratory fitness, muscle strength, balance, endurance, and QOL (8, 9). Recent studies published in 2025 have further highlighted these associations, examining internet-based PA promotion programs, aerobic exercise interventions, and perceived benefits and barriers among MS populations (10-12). Consequently, PA has been recognized as one of the most effective therapeutic strategies for comprehensive MS care (7), and guidelines have been established to promote PA within this population (13). Depression is one of the most common comorbidities in MS and is known to decrease motivation and adherence to PA. Moreover, patient’s perceptions of the benefits and barriers of exercise strongly influence their willingness to engage in regular activity. Because both psychological and perceptual factors can determine exercise behavior, examining their interaction offers clinically relevant insights that can inform the design of more effective rehabilitation strategies aimed at increasing participation in PA and improving QOL in individuals with MS. The present study aimed to determine the PA levels of individuals with MS and to investigate the relationship between depression, exercise perception, and PA levels. We hypothesized that higher depression levels would be associated with greater perceived barriers to exercise and lower PA levels in individuals with MS.

Materials and Methods

Study Design

The study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement (Supplementary Table 1). A descriptive study design was employed.

Participants

The inclusion criteria for the study were a diagnosis of MS, literacy, and the absence of hearing or vision problems. The exclusion criteria included cognitive impairment and being in the active attack phase. The demographic information collected at registration included age, height, weight, and sex, along with self-reported data on marital status, education level, active employment status, and regular exercise habits. In addition, disease type and disability level [Expended Disability Status score (EDSS)] were determined by a neurologist. Ethical approval for the study was obtained from the Ethics Committee of Fenerbahce University (decision no: 6, date: 01.09.2021). Participant recruitment occurred between September 3, 2021 and March 3, 2022, following ethics approval granted on September 1, 2021. Questionnaires created using Google Forms were distributed to a total of 189 individuals with MS. Based on the inclusion criteria, 80 participants with MS (57 women and 23 men) were included in the study (Figure 1). A power analysis determined that a minimum of 78 participants was required to detect correlations among Beck Depression Inventory (BDI), Exercise Benefits/Barriers Scale (EBBS), and International Physical Activity Questionnaire (IPAQ) scores with a medium effect size (p=0.30), power of 0.80, and α=0.05 (14). Similar sample sizes have been reported in previous MS studies investigating PA, psychological factors, and exercise perception [Stroud et al. (15), n=84; Husu et al. (16), n=62]. Therefore, our final sample of 80 participants met the calculated requirement and was consistent with previous literature. Written informed consent for the use of data in research was obtained from all participants at enrollment.

Outcome Measures

The EBBS was used to assess exercise perception (17, 18). The BDI (19) was used to evaluate depression levels, and the IPAQ was used to measure PA levels (20).

Expended Disability Status Score

The EDSS is widely used worldwide to evaluate and monitor neurological examinations in patients with demyelinating diseases such as MS and neuromyelitis optica. It assesses functional status on a scale from 0 to 10, where 0 indicates normal function and 10 indicates death due to MS. Lower scores represent less disability (21).

International Physical Activity Questionnaire

The IPAQ is available in long and short forms. The short form, introduced in 1996 by Michael Booth MD, was designed to determine the relationship between health and PA levels in adults. Saglam et al. (20) confirmed the validity and reliability of the Turkish version, with a Cronbach’s alpha coefficient of 0.75. The short form includes seven items that collect information on time spent walking, and engaging in moderate-to-vigorous or intense activities. Participants report the number of days and duration of vigorous PA, moderate-intensity PA, and walking during the previous week. The time spent in sedentary behavior (sitting, lying down) is also recorded. PA level is expressed in metabolic equivalent task (MET)-minutes. One MET is defined as 3.5 mL/kg per min, representing the amount of oxygen consumed per kilogram of body weight per minute at rest. Standard MET values in the IPAQ are 8.0 for vigorous activity, 4.0 for moderate activity, and 3.3 for walking. Total MET values are calculated based on the number of days and duration of PA performed during the past week (22). PA levels are categorized into three groups (23):

Inactive (category 1): The lowest level of PA; activities not meeting the criteria for categories 2 and 3.

Minimally Active (category 2): Individuals who meet one of the following criteria: a) vigorous activity for at least 20 minutes on 3 or more days, b) moderate-intensity activity or walking for at least 30 minutes per day on 5 or more days, c) moderate-intensity activity and walking totaling to at least 600 MET-min/week across 5 or more days.

Very Active (category 3): Equivalent to about one hour or more of moderate-intensity activity per day, sufficient for health benefits. a) vigorous activity on at least 3 days, yielding a minimum of 1500 MET-min/week, or b) a combination of 7 or more days of walking, moderate, or vigorous activity totaling at least 3000 MET-min/week.

The following MET values were used for IPAQ data analysis:

Walking=3.3 METs

Moderate PA=4.0 METs

Intense PA=8.0 METs

Exercise Benefits/Barriers Scale

The EBBS, developed by Sechrist et al. (17), assesses individuals’ perceptions of the benefits and barriers associated with exercise. Higher total EBBS scores indicate greater recognition of exercise benefits. The Turkish version of the scale was validated by Ortabag et al. (18), with a Cronbach’s alpha coefficient of 0.95. The scale consists of 43 Likert-type items rated as “1: strongly disagree, 2: disagree, 3: agree, 4: strongly agree.” The total score range for the benefits scale is 29-116, and for the barriers scale, 14-56. Higher Benefit scores reflect greater perceived exercise benefits, whereas higher barriers scores indicate stronger perceived exercise Barriers (Table 1) (18).

Beck Depression Inventory

The BDI was developed by Beck in 1961 to measure depression risk and the severity and progression of depressive symptoms in adults. The Turkish version’s reliability and validity were confirmed by Hisli (24), with a Cronbach’s alpha coefficient of 0.80 and validity coefficient of 0.74. It is a one-dimensional, 4-point Likert-type scale consisting of 21 items, each scored from 0 and 3 according to symptom severity. The pathological cut-off point is 17, with total scores ranging from 0 to 63. Score ranges are defined as follows: 0-9, no depression; 10-16, mild depression; 17-24, moderate depression; 25 and above, severe depressive symptoms (24). The BDI has been translated into multiple languages and shown strong cross-cultural reliability and validity. It has been used in Turkiye by Hisli (24) and Aktürk et al. (19) in various research and clinical settings, with Cronbach’s alpha values of 0.80 and 0.85, respectively.

Statistical Analysis

Data analysis was performed using SPSS 22.0. Sample size was determined by power analysis. Descriptive characteristics of the participants were analyzed using percentage and frequency distributions. Mean and standard deviation (SD) values were calculated for scale analyses. Effect size was determined using Cohen’s (d) and eta-squared (η²) coefficients. Comparisons by demographic variables (sex, marital status, education) were exploratory and analyzed using frequency/percentage distributions and chi-square tests where applicable. No formal correction for multiple testing was applied.

Results

Key Characteristics of the Patients

The study initially included 189 individuals with MS and an EDSS score between 1 and 5. However, based on the exclusion criteria, data from 80 patients who completed the survey were analyzed. The participants’ ages ranged from 18 to 63 years, with a mean of 32.71±9.22 years. The mean disease duration ranged from 1 to 40 years, with an average of 3.81±5.46 years. Detailed information on key characteristics is provided in Table 2.

The mean ± SD, minimum, and maximum scores of participants for the EBBS, IPAQ, and BDI are presented in Table 3. As shown in Table 3, the total IPAQ scores demonstrated high variability (mean ± SD=2116±1825 MET-min/week), indicating a skewed distribution of self-reported PA.

The frequency and percentage distribution of participants’ PA levels are shown in Figure 2. Based on the PA classification, 7 participants (8.8%) were inactive, 58 (72.5%) were minimally active, and 15 (18.8%) were very active.

The parameters examined and the results of the correlation analyses are presented in Table 4.

The correlation between age, body mass index (BMI), EDSS, disease duration, total benefits, total barriers, total EBBS, depression, and IPAQ scores revealed the following: a positive weak correlation between EDSS and age (r=0.433, p<0.001); a positive moderate correlation between disease duration and age (r=0.537, p<0.001); a positive moderate correlation between disease duration and EDSS (r=0.535, p<0.001); a positive weak correlation between total barriers and BMI (r=0.347, p=0.002); a positive very high correlation between EBBS total and total benefits (r=0.949, p<0.001); a positive weak correlation between depression and BMI (r=0.314, p=0.005); and a positive weak correlation between depression and total barriers (r=0.443, p<0.001). No other correlations were statistically significant (p>0.05).

The results of all analyses comparing scale scores according to descriptive characteristics are provided in Table 5. Total benefits, barriers, EBBS total, depression, and PA scores did not differ significantly by sex (p>0.05). Total benefits, EBBS total, and depression scores showed no significant differences by marital status (p>0.05). Similarly, total benefits, barriers, EBBS total, depression, and PA scores did not differ significantly by education level (p>0.05). Benefits, barriers, EBBS total, depression, and PA scores were also not significantly different according to active employment status (p>0.05). Finally, EBBS total and depression scores showed no significant difference according to regular exercise status (p>0.05).

Discussion

The main finding of this study is that individuals with MS recognize the benefits of exercise; however, they consider depression, lack of physical effort, and environmental factors as major barriers to participation. Although participants believed that depression negatively affected their PA levels, this relationship was not statistically significant.

The present study aimed to determine whether depression influences exercise perception and PA levels in individuals with MS. The mean age of the 80 participants was 32.71 years, and most were university graduates. The mean EDSS score of 2.21 indicates that participants had mild disability. Studies in the literature using this scale have shown a positive correlation between EDSS score and age (25). The positive correlations observed in our study between EDSS, age, and disease duration are consistent with these findings.

MS is a chronic neurodegenerative disease with diverse symptoms and an unpredictable course that can severely affect patient’s QOL. Among these symptoms, depression is the prevalent psychiatric disorder (28). Although it is generally mild, the proportion of patients with moderate and severe depression is quite high (8, 29). In our study, the mean BDI of 15.60 supports previous findings that MS patients commonly experience mild depression symptoms. Depression negatively affects QOL and is influenced by various factors, including socio-economic status, education level, and physical condition.

Sebastião et al. (30) reported that a high BMI is associated with increased disease risk and longer disease duration in individuals with MS. They also identified links between elevated BMI and comorbidities such as cardiovascular diseases, musculoskeletal pain, arthritis, and hypertension (30). Cambil-Martín et al. (31) found that overweight MS patients had higher levels of depression, reduced functional capacity, and poorer health compared to those of normal weight. In our study, a positive correlation was observed between BMI and BDI scores, indicating that higher BMI was associated with higher levels of depression. Furthermore, individuals with higher depression scores demonstrated lower perceptions of exercise benefits and reported greater barriers to exercise.

Because effective strategies for preventing MS remain unclear, current research increasingly focuses on managing the disease and alleviating its symptoms. PA has been shown to yield both general and specific benefits for individuals with MS (9). Numerous studies have demonstrated that PA lays a crucial role in managing MS and meeting its physical challenges (9, 15). Despite these benefits, individuals with MS tend to lead more sedentary lifestyles compared with the general populations (3, 32, 33). Multiple studies have confirmed that individuals with MS engage in less PA than healthy controls and fail to achieve sufficient PA levels despite increased efforts to promote its (3, 9). In the present study, the IPAQ results showed that most participants were inactive or minimally active, consistent with previous findings. However, the extent to which this inactivity is associated with depression remains inadequately understood. Psychological distress in individuals with MS may contribute to inactivity, yet it remains uncertain whether this stems from limited awareness of PA benefits and reduced physical energy. Only a few studies using the EBBS scale have examined these parameters together in MS populations (15, 29).

The EBBS, with includes benefit and barrier subdimensions, is a comprehensive tool assessing adults’ perceptions of exercise benefits and barriers (18-88) (34). By identifying perceived deficiencies, this scale an help enhance motivation and improve attitudes toward exercise participation. In a study conducted to examine perspective on PA and exercise using the EBBS, it was found that individuals’ awareness was insufficient to promote exercise participation, and that the most significant barrier was related to physical effort (15). Zunft et al. (32) reported that one of the key parameters preventing exercise participation is time. In our study, lack of physical effort and environmental limitations were identified as the main factors preventing exercise. Participants stated that exercising caused physical fatigue, was difficult to perform, and that lacked the appropriate environment and financial resources to overcome these challenges. They also reported that family- and time-related problems were lower-level barriers to exercise. In addition, our study revealed that depression levels constitute a major obstacle to engaging in exercise. Plow et al. (33) investigated factors limiting PA by interviewing 13 individuals with MS and found that physical factors (such as access to facilities and weather conditions), social factors (including lack of support from family and friends), and health factors (such as fatigue or depression) were influential, findings consistent with those of the present study. Likewise, our results align with those of Kayes et al. (35) who surveyed 282 individuals with MS and found that the primary barriers to PA were self-efficacy and mental fatigue. In line with these findings, Ozden et al. (12) also emphasized that individuals with MS encounter significant barriers to PA, including environmental limitations, fatigue, and depressive symptoms. Their research confirmed the predictive role of exercise perception and kinesiophobia in physical inactivity, highlighting the multidimensional nature of exercise avoidance in this population. These findings further validate the importance of assessing both physical and psychological barriers when designing rehabilitation strategies for individuals with MS.

Many factors have been cited in the literature as contributing to PA deficiencies. These factors were also observed in our study, which demonstrated the relationship between depression and scores on the exercise barrier/benefit questionnaire. The most significant determinants were internal, particularly an individual’s mental perception, sense of self-efficacy, and motivation level. Fifolt et al. (36) examined the relationship between exercise and self-efficacy in individuals with MS and reported that, although individuals believe in their own abilities, this perception may fluctuate over time. Enhancing self-efficacy and demonstrating individual’s capacity for success may be an effective approach to increase PA levels among individuals with MS.

Strengthening self-efficacy and reinforcing individuals’ confidence in their ability to succeed may thus represent an effective strategy for enhancing PA participation in MS. Furthermore, exercises with family members and friends may increase motivation and help make PA a sustainable part of daily life. Our findings contribute significantly to this field by showing that participants with low PA levels identified both perceived benefits and barriers to exercise. Specifically, on the exercise benefits scale, the highest mean score was observed for the physical performance subscale, while the lowest was recorded for the social interaction subscale. Participants emphasized improvements in muscle strength, physical fitness, flexibility, cardiovascular function, and endurance as the most important exercise-related benefits. Consistent with our findings, a study conducted among university students also reported the highest values for the physical performance subscale and the lowest for the social interaction subscale (37). Dalibaltaa and Davison (38) likewise found the same pattern for these subscales. Other results reported in the literature are consistent with our findings, and our study is particularly significant as it is the first to classify the EBBS according to subscales in individuals with MS. In recent years, studies have increasingly emphasizing the importance of identifying behavioral patterns and providing interventions to address deficiencies in order to increase PA levels and promote activity among individuals with MS (39). In this context, it is crucial to define depression and PA levels in MS patients and to explore their perspectives on exercise, as demonstrated in the present study. It is recommended that professionals working with individuals with MS conduct evaluations prior to implementing programs that include exercise and PA, taking into account the depression status of participants, and design interventions accordingly.

Study Limitations

Due to the length of the questionnaires, individuals with MS experienced difficulty completing them. A larger number of participants could potentially have been included through the use of shorter forms. Given the high variability observed in IPAQ scores, reporting both the mean ± SD and the median (interquartile range) would provide a more comprehensive description of the data. Although only mean ± SD values were available in the present study, this consideration should be addressed in future research. Another limitation of the study is the absence of detailed information regarding MS subtypes (RRMS, PPMS, SPMS). Since MS types may influence depression and PA levels, future studies should report and analyze subtype-specific outcomes. Additionally, because multiple subgroup comparisons were conducted without adjustments for multiple testing, the potential for type I error should be acknowledged, and these findings interpreted with caution. All outcome measures in this study were based on self-report questionnaires, which may be affected by recall and response bias. Furthermore, the cross-sectional design precludes drawing causal inferences between depression, exercise perception, and PA levels. Although the sample size met the calculated requirement, it remains relatively small and may limit the generalizability of the findings.

Conclusions

Depression influences PA levels and exercise perception in individuals with MS, highlighting the need for targeted interventions. Psychological problems may negatively affect exercise perception, leading to reduced participation in PA. Further studies are warranted in this area, as early interventions may positively influence disease prognosis. Future research should employ longitudinal designs to clarify causal relationships between depression, exercise perception, and PA. Moreover, intervention studies addressing both psychological (e.g., self-efficacy, depressive symptoms) and environmental (e.g., accessibility, social support) barriers could yield valuable insights for developing more effective rehabilitation strategies.