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Accelerometer measured physical activity and sedentary time in individuals with multiple sclerosis versus age matched controls: A systematic review and meta-analysis

  • Eilidh Macdonald
    Correspondence
    Corresponding author.
    Affiliations
    Institute of Clinical Exercise & Health Sciences, School of Science and Sport, University of the West of Scotland, Stephenson Place, Hamilton International Technology Park, South Lanarkshire, Scotland G72 0HL, United Kingdom
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  • Duncan Buchan
    Affiliations
    Institute of Clinical Exercise & Health Sciences, School of Science and Sport, University of the West of Scotland, Stephenson Place, Hamilton International Technology Park, South Lanarkshire, Scotland G72 0HL, United Kingdom
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  • Luke Cerexhe
    Affiliations
    Institute of Clinical Exercise & Health Sciences, School of Science and Sport, University of the West of Scotland, Stephenson Place, Hamilton International Technology Park, South Lanarkshire, Scotland G72 0HL, United Kingdom
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  • Linda Renfrew
    Affiliations
    Douglas Grant Rehabilitation Unit, Ayrshire Central Hospital, Kilwinning Road, Irvine, Ayrshire, Scotland KA12 8SS, United Kingdom
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  • Nicholas Sculthorpe
    Affiliations
    Institute of Clinical Exercise & Health Sciences, School of Science and Sport, University of the West of Scotland, Stephenson Place, Hamilton International Technology Park, South Lanarkshire, Scotland G72 0HL, United Kingdom
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Open AccessPublished:December 08, 2022DOI:https://doi.org/10.1016/j.msard.2022.104462

      Abstract

      Background

      People with Multiple Sclerosis (PwMS) find it more difficult to engage in physical activity (PA) than healthy controls. Accelerometers can be used to measure sedentary time and free-living physical activity, understanding the differences between PwMS and controls can help inform changes such as interventions to promote a more active lifestyle. This in turn will help prevent secondary conditions and reduce symptom progression.

      Objective

      To conduct a systematic review and meta-analysis on accelerometer measured sedentary behavior and physical activity between PwMS and healthy controls.

      Methods

      A systematic search of five databases (PubMed, Web of Science, Ovid, Science Direct and CINAHIL) from inception until 22nd November 2019. Inclusion criteria was (1) included a group of participants with a definite diagnosis of multiple sclerosis of any type; (2) have 3 or more days of PA monitoring using accelerometers during free living conditions; (3) include age matched healthy controls; (4) assess adults over the age of 18; (5) reported data had to have been reported in a manner suitable for quantitative pooling including: percent of time spent sedentary, minutes per day of sedentary, light, moderate, vigorous activity (moderate and vigorous totaled together), steps per day or counts per day.

      Results

      Initial search produced 9021 papers, after applying inclusion criteria 21 eligible papers were included in the study. One paper was a longitudinal study from which only baseline data was included. One paper was a reliability and validity study, with data for PwMS versus controls in the validity section. All other papers are cross sectional, with one being a pilot study and another a random control study. One paper used two devices in unison, only one set of data is included in the statistics. Outcome data was available for 1098 participants, 579 PwMS and 519 healthy controls. Significant differences were seen in all categories tested: (1) sedentary time (min/day), standard mean difference -0.286, P = 0.044, n = 4 studies; (2) relative sedentary time (%/day), standard mean difference -0.646, P = 0.000, n = 5 studies; (3) LPA (min/day), standard mean difference 0.337, P = 0.039, n = 5 studies; (4) relative LPA (%/day), standard mean difference 0.211, P = 0.152, n = studies; (5) MVPA (min/day), standard mean difference 0.801, P = 0.000, n = 8 studies; (6) relative MVPA (%/day), mean difference 0.914, P = 0.000, n = 5 studies; (7) step count, standard mean difference 0.894, P = 0.000, n = 8 studies; (8) activity count, standard mean difference 0.693, P = 0.000, n = 13 studies.

      Conclusion

      PwMS are more sedentary and engage in less LPA, MVPA, steps per day and accelerometer counts per day than healthy controls when measured using accelerometers during free-living conditions.

      Keywords

      1. Introduction

      Multiple sclerosis (MS) is an autoimmune disease characterized by chronic inflammation, oligodendrocyte destruction and demyelination causing lesions throughout the central nervous system (CNS), from which the condition derives its name (‘many scars’) (
      • Reipert B.
      Multiple sclerosis: a short review of the disease and its differences between men and women.
      ). These lesions’ cause irreparable damage and impair the function of both somatic and autonomic branches of the CNS (
      • Lensch E.
      • Jost W.H.
      Autonomic disorders in multiple sclerosis.
      ). However, the diffuse nature of damage to the CNS means that there is no consistent pattern as to which systems are affected, and consequently symptoms are frequently idiosyncratic, with wide variations in the type of impairments, the degree of impairment and, the rate of decline over time (
      • Murray T.J.
      The history of multiple sclerosis: the changing frame of the disease over the centuries.
      ). Nevertheless, while the symptoms experienced by people with MS (PwMS) are heterogenous, common symptoms of the condition include muscle spasticity, tremor, impaired motor control, numbness, pain, fatigue, cognitive dysfunction, and depression.
      Several of these symptoms make it difficult for individuals with MS to participate in physical activity (PA). Fatigue, will frequently leave PwMS with little energy to engage in PA (
      • Kalron A.
      • Menascu S.
      • Frid L.
      • Aloni R.
      • Achiron A.
      Physical activity in mild multiple sclerosis: contribution of perceived fatigue, energy cost, and speed of walking.
      ;
      • Kratz A.L.
      • Fritz N.E.
      • Braley T.J.
      • Scott E.L.
      • Foxen-Craft E.
      • Murphy S.L.
      Daily temporal associations between physical activity and symptoms in multiple sclerosis.
      ) while the effects of spasticity, muscle tremor and impaired motor control can cause significant impairments in mobility (
      • Kalron A.
      • Aloni R.
      • Givon U.
      • Menascu S.
      Fear of falling, not falls, impacts leisure-time physical activity in people with multiple sclerosis.
      ;
      • Klaren R.E.
      • Pilutti L.A.
      • Sandroff B.M.
      • Motl R.W.
      Impairment and disability in persons with MS: do functional performance or functional limitations matter?.
      ;
      • Sebastião E.
      • Learmonth Y.C.
      • Motl R.W.
      Lower physical activity in persons with multiple sclerosis at increased fall risk: a cross-sectional study.
      ;
      • Williams A.E.
      • Vietri J.T.
      • Isherwood G.
      • Flor A.
      Symptoms and association with health outcomes in relapsing-remitting multiple sclerosis: results of a US patient survey.
      ) which may deteriorate further as the disease progresses (
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ). Moreover, psychological factors such as depression, and impaired cognitive function may make managing daily tasks difficult, and prevent engagement with more active lifestyles (
      • Sadeghi Bahmani D.
      • Calabrese P.
      • Merkt H.
      • Naegelin Y.
      • Gerber M.
      • Pühse U.
      • Holsboer-Trachsler E.
      • Brand S.
      Multiple sclerosis: associations between physical disability and depression are not mediated by self-reported physical activity.
      ). Overall, these factors contribute to an increase in time spent being sedentary and reduced time engaged in moderate or vigorous intensity PA (MVPA) resulting in an elevated risk of secondary comorbidities including cardiovascular disease (CVD), stroke and type 2 diabetes (
      • Wens I.
      • Dalgas U.
      • Stenager E.
      • Eijnde B.O.
      Risk factors related to cardiovascular diseases and the metabolic syndrome in multiple sclerosis - a systematic review.
      ). Correspondingly, previous work has suggested that the majority of PwMS do not engage in adequate PA, especially MVPA (
      • Klaren R.E.
      • Motl R.W.
      • Dlugonski D.
      • Sandroff B.M.
      • Pilutti L.A.
      Objectively quantified physical activity in persons with multiple sclerosis.
      ;
      • Motl R.W.
      • McAuley E.
      • Sandroff B.M.
      • Hubbard E.A.
      Descriptive epidemiology of physical activity rates in multiple sclerosis.
      ,
      • Motl R.W.
      • McAuley E.
      • Snook E.M.
      Physical activity and multiple sclerosis: a meta-analysis.
      , p. 05) despite evidence indicating that it can improve fatigue, balance, quality of life, and slow disease progression (
      • Ensari I.
      • Motl R.W.
      • Pilutti L.A.
      Exercise training improves depressive symptoms in people with multiple sclerosis: results of a meta-analysis.
      ;
      • Motl R.W.
      • Dlugonski D.
      • Pilutti L.
      • Sandroff B.
      • McAuley E.
      Premorbid physical activity predicts disability progression in relapsing-remitting multiple sclerosis.
      ;
      • Pilutti L.A.
      • Greenlee T.A.
      • Motl R.W.
      • Nickrent M.S.
      • Petruzzello S.J.
      Effects of exercise training on fatigue in multiple sclerosis: a meta-analysis.
      ;
      • Sebastião E.
      • Learmonth Y.C.
      • Motl R.W.
      Lower physical activity in persons with multiple sclerosis at increased fall risk: a cross-sectional study.
      ).
      Early work assessing levels of PA in PwMS used questionnaire and self-reported measures of PA, while more recently, objective assessment using accelerometers has become the dominant technique. Indeed, accelerometry has been validated as a measure of walking performance (
      • Klaren R.E.
      • Hubbard E.A.
      • Zhu W.
      • Motl R.W.
      Reliability of accelerometer scores for measuring sedentary and physical activity behaviors in persons with multiple sclerosis.
      ;
      • Motl R.W.
      • Pilutti L.
      • Sandroff B.M.
      • Dlugonski D.
      • Sosnoff J.J.
      • Pula J.H.
      Accelerometry as a measure of walking behavior in multiple sclerosis.
      ) and physical activity (
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      ;
      • Motl R.W.
      • McAuley E.
      • Snook E.M.
      • Scott J.A.
      Validity of physical activity measures in ambulatory individuals with multiple sclerosis.
      ) for people with MS, and population specific cut-points for different levels of physical activity have been developed (
      • Sandroff B.M.
      • Motl R.W.
      • Suh Y.
      Accelerometer output and its association with energy expenditure in persons with multiple sclerosis.
      ,
      • Sandroff B.M.
      • Riskin B.J.
      • Agiovlasitis S.
      • Motl R.W.
      Accelerometer cut-points derived during over-ground walking in persons with mild, moderate, and severe multiple sclerosis.
      ). While previous reviews have suggested that PwMS fail to get sufficient PA, there are some important limitations to note. An early review by
      • Motl R.W.
      • McAuley E.
      • Snook E.M.
      Physical activity and multiple sclerosis: a meta-analysis.
      , combined self-reported and objective assessments of PA commenting on effect size when comparing between PwMS and controls, preventing effective pooling of accelerometer only outcomes as the data was not available. Additionally, there are concerns over the accuracy of self-reported measures. Participants have been found to over report their activity levels, especially those with lower levels of fitness (
      • Sallis J.F.
      • Saelens B.E.
      Assessment of physical activity by self-report: status, limitations, and future directions.
      ;
      • Shook R.P.
      • Gribben N.C.
      • Hand G.A.
      • Paluch A.E.
      • Welk G.J.
      • Jakicic J.M.
      • Hutto B.
      • Burgess S.
      • Blair S.N.
      Subjective estimation of physical activity using the international physical activity questionnaire varies by fitness level.
      ). Additionally factors such as social desirability (the tendency to keep to cultural ‘norms’) and social approval (the need to obtain a ‘good’ test score (
      • Hebert J.R.
      • Ma Y.
      • Clemow L.
      • Ockene I.S.
      • Saperia G.
      • Stanek E.J.
      • Merriam P.A.
      • Ockene J.K.
      Gender differences in social desirability and social approval bias in dietary self-report.
      )) mean that self-reported measures seldom capture even 50% of the variance in physical activity (
      • Durante R.
      • Ainsworth B.E.
      The recall of physical activity: using a cognitive model of the question-answering process.
      ). Additionally, the increase in studies using objective measures since then, means that an updated review using only objective measures is warranted. More recently a meta-analysis by
      • Casey B.
      • Coote S.
      • Galvin R.
      • Donnelly A.
      Objective physical activity levels in people with multiple sclerosis: a meta-analysis.
      assessed objective measures of PA in people with MS and while comprehensive, they chose to compare their data to NAHNES activity data rather than to non-MS control groups. Since the NAHNES data is specific to the US it is not clear if its use as a control variable is appropriate for studies in other locations. Moreover, there have been some criticisms of the validity and reliability of some NAHNES data sets, primarily under reporting of data sets including body mass index (BMI) and total energy expenditure (TEE) among other variables (
      • Archer E.
      • Hand G.A.
      • Blair S.N.
      Validity of U.S. nutritional surveillance: national health and nutrition examination survey caloric energy intake data, 1971–2010.
      ). Similarly,
      • Block V.A.J.
      • Pitsch E.
      • Tahir P.
      • Cree B.A.C.
      • Allen D.D.
      • Gelfand J.M.
      Remote physical activity monitoring in neurological disease: a systematic review.
      assessed remote activity monitoring in a variety of neurological conditions using a variety of activity monitoring devices, including accelerometers, step-counters, and making conclusions about objectively measured PA in PwMS difficult. Moreover, because of these different methods of data collection they were unable to undertake statistical pooling of PA outcomes.
      Consequently, there are no current reviews that have compared physical activity levels, sedentary time or step and activity counts of people with MS to healthy controls within the same study, which have used accelerometry. Therefore, the aim of this review is to systematically review the literature regarding objective assessment of sedentary time, MVPA, LPA, step and activity counts in PwMS compared to healthy, matched controls, and to provide quantitative data pooling to determine if differences exist in time spent in different PA domains between PwMS and healthy controls.

      2. Methods

      This systematic review and meta-analysis followed the reporting guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement by
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      a systematic search processes, evaluation, analysis, and reporting was conducted.

      2.1 Search strategy

      An electronic database search was conducted to procure English language papers comparing accelerometer data from people with multiple sclerosis and controls. Five databases (PubMed, Web of Science, Ovid, Science Direct and CINAHIL) were searched from inception until 22nd November 2019. The search included the keywords: (“multiple sclerosis AND Actigraph OR accelerometer”), (“multiple sclerosis AND physical activity OR sedentary behaviour”), (“multiple sclerosis AND MVPA”), (“multiple sclerosis AND light physical activity”), (multiple sclerosis AND step count”), (“multiple sclerosis AND sedentary time”). Light physical activity was used instead of the abbreviation LPA as this incurred search results relating to lysophosphatidic acid. A second search to find journals relating to sedentary time was also conducted after realizing that sedentary behavior is a term relating to posture, although it has been used frequently in the past to denote sedentary time which is studied in this review. A specific search for Actigraph accelerometers was applied as they are the most frequently utilized monitors on the market for objective physical activity measurements in MS populations (
      • Sandroff B.M.
      • Motl R.W.
      • Pilutti L.A.
      • Learmonth Y.C.
      • Ensari I.
      • Dlugonski D.
      • Klaren R.E.
      • Balantrapu S.
      • Riskin B.J.
      Accuracy of StepWatchTM and ActiGraph accelerometers for measuring steps taken among persons with multiple sclerosis.
      ). A manual search of previously published relevant meta-analysis and systematic reviews was also conducted, as was a review of the reference lists of studies included in this review.

      2.2 Inclusion criteria

      To be included studies had to: (1) included a group of participants with a definite diagnosis of multiple sclerosis of any type; (2) have 3 or more days of monitoring free living conditions with an accelerometer; (3) include age matched healthy controls; (4) assess adults over the age of 18; (5) reported data had to have been reported in a manner suitable for quantitative pooling including: percent of time spent sedentary, minutes per day of sedentary, light, moderate, vigorous activity (moderate and vigorous totaled together), steps per day or counts per day.

      2.3 Study selection

      All papers were transferred to a reference manager (Zotero: V 5.0.60, Fairfax, VA, USA). Articles were screened for duplicates. The remaining papers were screened using title, then abstracts. Subsequently, remaining papers were then analyzed by reading the full text identifying relevant studies. Abstract only papers, conference papers and posters were excluded. If there were no results reported of an original study i.e. reviews, secondary analysis or study protocols, they were eliminated. Papers were further excluded if they did not provide accelerometer data, only correlations and other statistical measures.

      2.4 Data extraction

      Data was extracted and entered in a spreadsheet (Microsoft® Excel 2016, Microsoft Corporation, Redmond, WA, USA). The following fields were collected: MS type, years diagnosed, gender, age, disease severity (using Expanded Disability Status Scale (EDSS) or Patient Determined Disease Steps (PDDS)), intervention duration, objectives, findings, other outcomes, biometric outcomes, and the presence of other cardio metabolic diseases. Accelerometer fields included: outcomes, make/model, cut points used, calibration, position worn, valid days for collection, duration, wear time criteria, and wear time. Accelerometer outcomes were further examined, data procured from the different studies included: percent of time spent sedentary, minutes per day sedentary, light physical activity, moderate PA, vigorous PA, MVPA, steps per day and counts per day.
      Studies that provided percent of wear time for the different categories of physical activity were equated to minutes per day by using the percentage from the average daily wear time (min) provided for each group. All other data was converted to give a value per day, weekly data was divided by seven, hourly data was multiplied by hours per day the device was worn. The quality of each study was evaluated using a 20 question appraisal of cross sectional studies form (AXIS) provided by the British Medical Journal (BMJ) (
      • Downes M.J.
      • Brennan M.L.
      • Williams H.C.
      • Dean R.S.
      Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS).
      ).

      2.5 Statistical analyses

      Meta-analyses were executed using Comprehensive Meta-Analysis (Biostat, V 2.2.064, Englewood, NJ, USA). Pooled data using a random-effects model were used to investigate differences between healthy controls and PwMS. Due to the likely differences in device, wear time, and calibration protocols, studies were assessed using standardized mean differences (SMD) rather than differences in means. Mean, standard deviation and sample size for PwMS and healthy controls for each variable of interest were used to determine overall effect size using a random effects model.

      3. Results

      3.1 Search results

      The search criteria and review process are outlined in Fig. 1. The initial search using the five databases produced 9021 papers. One paper was extracted after reviewing similar systematic review and meta-analysis. After removal of duplicates 5314 papers remained. Initial filtering for inclusion and exclusion criteria via title and abstract resulted in the removal of 5280 papers. Full papers of the remaining 34 articles were assessed with a further 13 removed (two reviews, two secondary analysis, two included children, one did not age match controls, three provided less than three days of data, three papers displayed or collected results in a different format; one only shared five-minute counts, one measured walking speed, and one provided no written results only a graph). Subsequently, 21 eligible papers were included in the study.
      Fig 1
      Fig. 1The PRISMA flow diagram with numbers of included and excluded articles at each step of the review process.
      One paper was a longitudinal study with accelerometer data collected in baseline and week eight. Only the baseline data was extracted for use in this study due to the statistical powers of analyzing the number of participants, also, to ensure the behavioral change of the study did not reflect on the study as all other papers used baseline data (
      • Hale L.A.
      • Pal J.
      • Becker I.
      Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer.
      ). One paper was a reliability and validity study, with data for PwMS versus controls in the validity section (
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      ). All other papers are cross sectional, (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      ;
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ;
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ;
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      ;
      • Klassen L.
      • Schachter C.
      • Scudds R.
      An exploratory study of two measures of free-living physical activity for people with multiple sclerosis.
      ;
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      ;
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      ;
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ,
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ),
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      used two devices in unison (Actigraph 7164 and GT3X), only data collected using the 7164 are included in the statistics due to the GT3X being calculated as one axis making comparison to the three axis mode in all other studies using the GT3X model collected in this review balanced.

      3.2 Demographic information

      Twenty-one papers included in the analysis had a total of 1098 participants, including 519 controls (73.5% female) and 579 people with a definite diagnosis of multiple sclerosis (76.7% female). The mean age of controls was 46.6 ± 10.79 years versus 47.9 ± 9.48 years for PwMS. 15 papers included figures on years since diagnosis, with a resulting mean was 10.9 ± 6.8 years (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      ;
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ;
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ;
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      ;
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ,
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ). One paper recruited people classified as relapse remittent (
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ), one specifically primary progressive multiple sclerosis (
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      ), 13 others included a mix of multiple sclerosis classifications (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      ;
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ;
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      ;
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ,
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ). Fourteen papers specified the number of relapse remittent cases and the combined average was 75.1% (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      ;
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ;
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ,
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      ;
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ). Eleven papers reported BMI (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ;
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ;
      • Klassen L.
      • Schachter C.
      • Scudds R.
      An exploratory study of two measures of free-living physical activity for people with multiple sclerosis.
      ;
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      ;
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      ;
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ), with a further seven reporting height and weight (
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ;
      • Hale L.A.
      • Pal J.
      • Becker I.
      Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer.
      ;
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ,
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ), which was converted to provide BMI figures. The combined BMI average of the 18 papers was 25.49 for controls and 26.09 for PwMS. Thirteen studies reported on EDSS with five providing an average (
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      ;
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ;
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ), one provided a range (
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      ), and seven a median (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      ;
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      ;
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      ;
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      ;
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      ). Seven papers provided a PDDS score 3 providing a mean (
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ), and four a median value (
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ). All participants were ambulatory with some requiring an assistive device i.e. a cane or walking frame. Demographic information shown in Tables 1 and 2.
      Table 1Demographic information and study quality.
      Author / YearBMJ AXIS Score (x/20)Sample SizeMS Sample SizeControl Sample SizeMS BMI (kg/m2) ± S.DControl BMI (kg/m2) ± S.DMS Sex (% female)Control Sex (% female)MS Age (years) ± S.DControl Age (years) ± S.D
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      1766333327.9
      BMI calculated from height and weight figures so no standard deviation available.
      26.3
      BMI calculated from height and weight figures so no standard deviation available.
      828247.5 ± 10.647.7 ± 11.3
      • Klassen L.
      • Schachter C.
      • Scudds R.
      An exploratory study of two measures of free-living physical activity for people with multiple sclerosis.
      163627924.7 ± 3.824.6 ± 3.8708947.7 ± 6.9741.6 ± 4.4
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      1751252627.5 ± 526.6 ± 5.310010048.1 ± 9.748.2 ± 10.1
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      1982414126.7
      BMI calculated from height and weight figures so no standard deviation available.
      26.3
      BMI calculated from height and weight figures so no standard deviation available.
      87.887.847.4 ± 8.847.4 ± 9.1
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      1928141428.5 ± 8.527.6 ± 4.971.428.652 ± 11.754.1 ± 13.5
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      1946232324.8 ± 4.323.4 ± 2.678.378.345.7 ± 10.245.7 ± 10.2
      • Hale L.A.
      • Pal J.
      • Becker I.
      Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer.
      192011925.4
      BMI calculated from height and weight figures so no standard deviation available.
      24.8
      BMI calculated from height and weight figures so no standard deviation available.
      72.78950.7 ± 11.851 ± 18.1
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      1880404028.5 ± 6.927.1 ± 562.562.565.3 ± 4.366.5 ± 6.7
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      191268838NRNR8471.144 ± 8.8235.05 ± 12.38
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      1951193224 ± 3.5225.3 ± 5.1168.468.839.74 ± 10.6739.34 ± 13.85
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      1962313125.7
      BMI calculated from height and weight figures so no standard deviation available.
      24.4
      BMI calculated from height and weight figures so no standard deviation available.
      87.187.143.4 ± 7.742.4 ± 7.5
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      1756263026 ± 3.525.3 ± 3.961.566.750.9 ± 5.249.7 ± 8.3
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      1925131226.1
      BMI calculated from height and weight figures so no standard deviation available.
      23.3
      BMI calculated from height and weight figures so no standard deviation available.
      694247.6 ± 10.8145.5 ± 18.71
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      20154777726.8
      BMI calculated from height and weight figures so no standard deviation available.
      26.4
      BMI calculated from height and weight figures so no standard deviation available.
      858547.3 ± 9.747 ± 10.5
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      1924101427 ± 4.525.7 ± 4.49078.645 ± 846 ± 7
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      1966333327 ± 7.1826.4 ± 6.4981.881.847 ± 10.5147 ± 11.31
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      1929151427.7 ± 6.126.5 ± 453.342.953.7 ± 10.554.6 ± 9.6
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      16179821.7
      BMI calculated from height and weight figures so no standard deviation available.
      26.4
      BMI calculated from height and weight figures so no standard deviation available.
      66.75047 ± 642 ± 5.66
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      18291910NRNR476047.2 ± 12.139.6 ± 12.3
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      15201010NRNR10010037.9 ± 10.137.5 ± 12.6
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      1730151523.7 ± 3.5422.4 ± 3.12939351.13 ± 14.8251.07 ± 13.46
      MS – Multiple Sclerosis, NR – Not reported,
      low asterisk BMI calculated from height and weight figures so no standard deviation available.
      Table 2Multiple sclerosis information.
      Author / YearDiagnosed (years) ± S.DMS SubtypeRelapse Remittent (%)EDSS MedianEDSS MeanPDDS MedianPDDS Mean
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      9.2 ± 6.7all852
      • Klassen L.
      • Schachter C.
      • Scudds R.
      An exploratory study of two measures of free-living physical activity for people with multiple sclerosis.
      NRNRNR2.6
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      9.8 ± 7.2all841.9
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      11 ± 7.9all90.21
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      13.2 ± 8.2all42.95
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      9.3 ± 7.1RR/SP872
      • Hale L.A.
      • Pal J.
      • Becker I.
      Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer.
      NRNRNR
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      21.5 ± 8.6all67.54
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      12.67 ± 5.81all83
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      6.96 ± 5.71NRNR1.64
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      8.6 ± 6.3all93.52
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      NRall69.24
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      7.5 ± 3.61RR1002.5
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      10.1 ± 7.3all861
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      12 ± 8RR/PP904.6
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      9.2 ± 6.7allNR2
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      NRPP05
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      11 ± 6NRNR4
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      NRNRNR5.5
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      NRNRNR4
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      11.4
      No standard deviation available.
      all73.34.13
      MS – Multiple Sclerosis, RR – Relapse Remittent, SP – Secondary Progressive, PP – Primary Progressive, all – all Multiple Sclerosis subtypes.
      low asterisk No standard deviation available.

      3.3 Accelerometers

      The Actigraph 7164 was used in six studies (
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      ;
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      ;
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ). The G1TM was used in three studies (
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      ;
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ;
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      ). The GT3X in four studies (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ). One study used both the 7164 and the GT3X device simultaneously, however for the purposes of the current analysis the results used in this analysis were of the 7164 (
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      ;
      • Motl Robert W.
      • Pilutti L.A.
      • Learmonth Y.C.
      • Goldman M.D.
      • Brown T.
      Clinical importance of steps taken per day among persons with multiple sclerosis.
      ). TriTrac RD3 model was used in one study (
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      ). The updated TriTrac version the RT3 used in two studies (
      • Hale L.A.
      • Pal J.
      • Becker I.
      Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer.
      ;
      • Klassen L.
      • Schachter C.
      • Scudds R.
      An exploratory study of two measures of free-living physical activity for people with multiple sclerosis.
      ). Other accelerometers used are the Actical in two studies (
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ). The SWA Mini was used in one study (
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      ). The Stepwatch, Step Activity Monitor (SAM) which is a pedometer which uses accelerometry, therefore is included in this review was used in two studies (
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ).
      In terms of accelerometer placement, one study placed the device on the central back (
      • Hale L.A.
      • Pal J.
      • Becker I.
      Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer.
      ). 10 studies had participants wear the device at the waist, four did not indicate a specific placement (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      ;
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      ;
      • Klassen L.
      • Schachter C.
      • Scudds R.
      An exploratory study of two measures of free-living physical activity for people with multiple sclerosis.
      ). The most popular placement throughout the studies specified the non-dominant hip at the waist position (
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ,
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ). A final study specified the waist and a hip placement but no specific side (
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ).
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      specified a right hip placement and two studies stated the non-dominant hip with no mention of a waist placement (
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ). One study used the right ankle as placement for the device (
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      ). Three studies used arm placement for their devices,
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      and
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      used the non-dominant wrist, and
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      used the right tricep. Three studies did not provided placement position (
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ;
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      ).
      The most common epoch used by 13 papers was 60 s (
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      ;
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ;
      • Hale L.A.
      • Pal J.
      • Becker I.
      Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer.
      ;
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ;
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      ;
      • Klassen L.
      • Schachter C.
      • Scudds R.
      An exploratory study of two measures of free-living physical activity for people with multiple sclerosis.
      ;
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      ;
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ,
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      ;
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      ).
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      specified ten second epochs and
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      used the extremely low value of one second for their epoch. Six studies did not provide data on epoch length (
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      ;
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ). Sampling frequency was poorly reported, only four papers specifying a value,
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      and
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      used 30 Hz and
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      and
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      used 10 Hz.
      In terms of the monitoring period, in which the participants wore their accelerometers,
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      used three days wear time,
      • Klassen L.
      • Schachter C.
      • Scudds R.
      An exploratory study of two measures of free-living physical activity for people with multiple sclerosis.
      had four days,
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      chose six days and the remaining papers used the more standardized seven-day period of data collection (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      ;
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      ;
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ;
      • Hale L.A.
      • Pal J.
      • Becker I.
      Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer.
      ;
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ;
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      ;
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      ;
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ,
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ). Twelve papers included information on minimum valid days of accelerometer data need for inclusion. Four papers accepted a minimum of three days, which is the lowest end of the scale (
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ).
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      adopted a four-day period of validation,
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      and
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      selected a five-day period. At the highest end of the scale
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      stated a six-day minimum and four papers expected data for all seven days of testing at the highest end of the wear time scale (
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      ;
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ;
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      ;
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      ). Several studies did adopt, state, or reach, the criteria of a valid day as ≥10 h wear time without periods exceeding 60 min of continuous zeroes per day, with at least 3 valid days of wear time as the inclusion criteria in their subsequent analyses (
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      ;
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      ;
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      ;
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      ). This approach is considered acceptable for generating a reliable estimate of usual physical activity in persons with MS (
      • Colley R.
      • Connor Gorber S.
      • Tremblay M.S.
      Quality control and data reduction procedures for accelerometry-derived measures of physical activity.
      ;
      • Motl R.W.
      • Zhu W.
      • Park Y.
      • McAuley E.
      • Scott J.A.
      • Snook E.M.
      Reliability of scores from physical activity monitors in adults with multiple sclerosis.
      ). Two further papers explicitly mentioned wear time criteria,
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      required ≥660min/day (9 h) with periods of 180min continuous 0 excluded, for 5 days and
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      aired on the more conservative side with an inclusion criteria of ≥8 h per day for all 7 days of monitoring. Furthermore, from the results and reasons for exclusion it appears that other studies did achieve the validated monitoring period although they did not expressly state it in their requirements (
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      ;
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      ;
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      ). Without knowing wear time it is difficult to determine if the rest of the papers met this goal (
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      ;
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      ;
      • Hale L.A.
      • Pal J.
      • Becker I.
      Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer.
      ;
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ;
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      ;
      • Klassen L.
      • Schachter C.
      • Scudds R.
      An exploratory study of two measures of free-living physical activity for people with multiple sclerosis.
      ;
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      ;
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      ;
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      ). In order to accommodate as many papers as possible into this study and due to a lack of information there is no specified wear time in terms of hours that validate a day or minimum number of days data required, only a requirement for the device to be sent out to participants for a minimum of three days Information shown in Table 3.
      Table 3Accelerometer information.
      Author / YearAccelerometer

      Placement

      Duration (days)

      Minimum Duration(days)

      MS specific cut point

      Epoch

      (seconds)
      Frequency (hertz)Axis
      • Weikert M.
      • Motl R.W.
      • Suh Y.
      • McAuley E.
      • Wynn D.
      Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility?.
      Actigraph 7164Waist, non-dominant hip73NRNRNRVA
      • Klassen L.
      • Schachter C.
      • Scudds R.
      An exploratory study of two measures of free-living physical activity for people with multiple sclerosis.
      TriTrac RT3Waist4NRNR60NRVM
      • Ward C.L.
      • Suh Y.
      • Lane A.D.
      • Yan H.
      • Ranadive S.M.
      • Fernhall B.
      • Motl R.W.
      • Evans E.M.
      Body composition and physical function in women with multiple sclerosis.
      Actigraph 7164Waist, non-dominant hip7NRNRNRNRVA
      • Sandroff B.M.
      • Motl R.W.
      Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls.
      Actigraph 7164Waist, non-dominant hip6NRNR6010VA
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ActicalNon-dominant hip73NONRNR2D
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      Actigraph GT3XWaist75NO1030VM
      • Hale L.A.
      • Pal J.
      • Becker I.
      Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer.
      TriTrac RT3Central back7NRNR60NRVM
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      Actigraph GT3XNR74YESNRNRVM
      • Engelhard M.M.
      • Patek S.D.
      • Lach J.C.
      • Goldman M.D.
      Real-world walking in multiple sclerosis: separating capacity from behavior.
      Actigraph GT3XNon-dominant hip76
      MS specific cut points were used but were determined from Multiple Sclerosis Walking Scale – 12, not activity counts. VA- vertical axis, 2D- motion detected in 2 axes, VM – vector magnitude, motion detected in all 3 axes.
      YES
      60NRVM
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ActicalNon-dominant wrist77NO60NR2D
      • Sandroff B.M.
      • Klaren R.E.
      • Motl R.W.
      Relationships among physical inactivity, deconditioning, and walking impairment in persons with multiple sclerosis.
      Actigraph GT3XWaist, non-dominant hip73YES6030VM
      • Krüger T.
      • Behrens J.R.
      • Grobelny A.
      • Otte K.
      • Mansow-Model S.
      • Kayser B.
      • Bellmann-Strobl J.
      • Brandt A.U.
      • Paul F.
      • Schmitz-Hübsch T.
      Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life.
      Swa MiniLeft tricep77NO60NR2D
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Pardo G.
      Use of accelerometers to measure real-life physical activity in ambulatory individuals with multiple sclerosis: a pilot study.
      Actigraph G1TMWaist, hip7NRNR60NR2D
      • Sandroff B.M.
      • Dlugonski D.
      • Weikert M.
      • Suh Y.
      • Balantrapu S.
      • Motl R.W.
      Physical activity and multiple sclerosis: new insights regarding inactivity.
      Actigraph 7164Waist, non-dominant hip7NRYES6010VA
      • Chung L.H.
      • Angelo J.
      • van Emmerik R.E.A.
      • Kent J.A.
      Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.
      Actigraph G1TMWaist75NRNRNR2D
      • Ranadive S.M.
      • Yan H.
      • Weikert M.
      • Lane A.D.
      • Linden M.A.
      • Baynard T.
      • Motl R.W.
      • Fernhall B.
      Vascular dysfunction and physical activity in multiple sclerosis.
      Actigraph 7164NR7NRNR60NRVA
      • Scott S.M.
      • Hughes A.R.
      • Galloway S.D.R.
      • Hunter A.M.
      Surface EMG characteristics of people with multiple sclerosis during static contractions of the knee extensors.
      Actigraph G1TMRight hip77NR60NR2D
      • Kent-Braun J.A.
      • Ng A.V.
      • Castro M.
      • Weiner M.W.
      • Gelinas D.
      • Dudley G.A.
      • Miller R.G.
      Strength, skeletal muscle composition, and enzyme activity in multiple sclerosis.
      TriTrac RD3Waist7NRNR60NRVM
      • Kos D.
      • Nagels G.
      • D'Hooghe M.B.
      • Duquet W.
      • Ilsbroukx S.
      • Delbeke S.
      • Kerckhofs E.
      Measuring activity patterns using actigraphy in multiple sclerosis.
      Actigraph 7164Non-dominant wrist33NR1NRVA
      • Busse M.E.
      • Pearson O.R.
      • Deursen R.V.
      • Wiles C.M.
      Quantified measurement of activity provides insight into motor function and recovery in neurological disease.
      Stepwatch (SAM)Right ankle77NRNRNR2D
      • Freund J.E.
      • Stetts D.M.
      • Vallabhajosula S.
      Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
      Stepwatch (SAM)NR7NRNR60NR2D
      low asterisk MS specific cut points were used but were determined from Multiple Sclerosis Walking Scale – 12, not activity counts. VA- vertical axis, 2D- motion detected in 2 axes, VM – vector magnitude, motion detected in all 3 axes.

      3.4 Sedentary time

      Four studies out of 21 studies provided data on sedentary time with a pooled sample of 205 participants (96 PwMS and 109 controls) (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.
      ;
      • Ickmans K.
      • Simoens F.
      • Nijs J.
      • Kos D.
      • Cras P.
      • Willekens B.
      • Meeus M.
      Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: a case-control study.
      ). The average time spent sedentary was 532.13 ± 89.67 min for people with MS and 506.37 ± 81.55 min for controls. This equates to PwMS being sedentary for 25.042 min per day more than their sedentary counterparts. To account for differences in wear time, comparisons were assessed as standardized mean difference (SMD). This equated to an SMD of -0.286 (p = 0.044; Fig. 2).
      Fig 2
      Fig. 2Forest plot of the comparison of sedentary intensity physical activity in minutes per day between people with multiple sclerosis and healthy participants. Sample size PwMS and Control; Standard Difference in means; Lower limit; Upper limit; p-Value; Standard difference in means and CI: 95% Confidence interval.
      Five studies showed relative sedentary time, totaling 235 participants (111 PwMS and 124 controls) (
      • Blikman L.J.
      • van Meeteren J.
      • Horemans H.L.
      • Kortenhorst I.C.
      • Beckerman H.
      • Stam H.J.
      • Bussmann J.B.
      Is physical behavior affected in fatigued persons with multiple sclerosis?.
      ;
      • Bollaert R.E.
      • Motl R.W.
      Physical and cognitive functions, physical activity, and sedentary behavior in older adults with multiple sclerosis.
      ;
      • Fakolade A.
      • Finlayson M.
      • Parsons T.
      • Latimer-Cheung A.
      Correlating the physical activity patterns of people with moderate to severe multiple sclerosis disability and their family caregivers.