Translate this page into:
Assessment of the impact of daily living activities and disability on the physical and mental health of Moroccan patients with multiple sclerosis
*Corresponding author: Iliass El Harchaoui, Biology and Health Laboratory, Cognitive-Behavioural Neuroscience and Nutritional Health Unit, Faculty of Science, Ibn Tofail University, Kenitra, Morocco. ilyass_harchaoui@hotmail.com
-
Received: ,
Accepted: ,
How to cite this article: El Harchaoui I, Moussa Ahmadou T, El Marnissi A, Ahami A. Assessment of the impact of daily living activities and disability on the physical and mental health of Moroccan patients with multiple sclerosis. J Neurosci Rural Pract. doi: 10.25259/JNRP_182_2025
Abstract
Objectives:
Multiple sclerosis (MS) is a neurological illness that affects the brain and spinal cord, causing disability and impairing daily tasks. We aimed to examine the links between disability, activities of daily living (ADL), and their combined impact on the physical and mental health of people diagnosed with MS.
Materials and Methods:
This study was conducted on 90 cases with MS. Various scales were used to collect data, including a self-questionnaire (sociodemographic and clinical), MS quality of life (QoL) 54, Patient Determined Disease Steps, and ADL scale.
Results:
The average age of the patients at the time of diagnosis was 28 years. Approximately 22.2% (n = 20) reported a moderate-to-severe level of disability. A highly significant negative correlation was found between a higher disability level and ADL, as well as impaired QoL for both physical (P < 0.001) and mental (P < 0.009) health. Furthermore, a highly significant difference in mean scores was observed for the QoL composite based on disability levels (physical health: P < 0.023; mental health: P < 0.035), as well as for ADL (P = 0.000) among the study participants.
Conclusion:
This study reveals that a high level of disability is strongly correlated with limitations in ADL and decreased QOL, both physical and mental health. A significant difference was observed in QOL and ADL scores as a function of disability level. This underlines the importance of appropriate management to improve patient well-being.
Keywords
Disability
Multiple sclerosis
Neuropsychology
Physical activity
Quality of life
INTRODUCTION
Multiple sclerosis (MS) is a neurological disease that affects an individual’s central nervous system (CNS). Due to its neurodegenerative nature and the resulting demyelination of nerve fibers,[1] demyelinating plaques are dispersed in time and space, resulting in symptoms such as coordination and balance disorders, sensory alterations, visual problems, and pain, all of which impact an individual’s quality of life (QoL).[2] After stroke and Parkinson’s disease, MS is considered the second most disabling chronic disease of the CNS.[3]
This disease generally manifests itself in people aged between 20 and 40, with a female predominance.[1] In this context, QoL is the central focus of this disease, due to its multidimensional aspects.[4] It not only encompasses physical health but also incorporates psychological, social, and emotional dimensions, all of which significantly impact the patient’s overall well-being. It provides the means to select appropriate tools for analyzing the different elements of a situation, often overlooked by medical norms.[5] Its significance primarily depends on the theoretical standpoint and the context in which it is used. Some instruments focus on current capabilities and restrictions related to the impact of the disease, while others delve into subjective feelings of health. In-depth studies on patients with MS have revealed that discomfort is not simply a manifestation of a deficit or handicap.[6]
People with MS face significant challenges in activities of daily living (ADL), which include physical and psychological dimensions. These challenges, such as physical and emotional changes, fear of disability, financial constraints, and misconceptions based on cultural beliefs, emerge as major concerns related to the daily activities of this patient group.[7]
The concept of health-related QOL (HRQoL) specifically assesses the impact of the disease on self-image, health status, and life satisfaction. The QoL of patients with MS is frequently assessed using the MSQoL questionnaire, considered the most commonly used standardized and disease-specific tool; its objective is to evaluate the QoL of patients with MS.[8] Therefore, this study aims to evaluate disability and ADL of patients with MS while also assessing the impact of these disorders on QoL, with the ultimate goal of facilitating the management of this neurodegenerative disease.
MATERIALS AND METHODS
Study design and setting
A cross-sectional and descriptive study was conducted to analyze patients diagnosed with MS.
The study was conducted in two major neurology departments in two regions of Morocco, where patients were hospitalized and consulted: Ibn Sina Hospital in Rabat (n = 55) and Casablanca Ibn Rochd Hospital (n = 35).
Participants
Inclusion and exclusion criteria
We included patients diagnosed with MS who consulted the department during the study. Patients with an unconfirmed diagnosis, those who did not consent to participate, and those with cognitive or neurological disorders other than MS were excluded from the study.
Variable
After explaining each item of the questionnaire and clarifying the inclusion and exclusion criteria, we provided the patients with a questionnaire during their consultation. To prevent visual, motor, or cognitive difficulties from complicating self-assessment, the questionnaire was administered in a quiet environment.
Study population
In this study, conducted on 90 cases, data collection was performed using a kit composed of several questionnaires, including sociodemographic and clinical, as well as scales such as the patient determined disease steps (PDDS), the MSQOL-54, and the ADL scale.
Study measures
Sociodemographic
Used to collect information such as age, age at diagnosis, and gender.
PDDS
Created by Hohol et al. (1995), is employed to evaluate disability associated with MS.[9,10] It consists of nine ordinal levels, ranging from 0 (normal) to 8 (bedridden).[11] PDDS scores categorize disability into three levels: Mild, moderate, and severe.[12,13]
MSQoL-54
Which consists of 18 extra questions tailored to MS patients[14] and the Short form-36 items for a general QoL evaluation,[15] will be used to measure QoL. This questionnaire provides two composite score domains: Physical health composite (PHC) and mental health composite (MHC). The MSQoL-54 was proposed by Vickrey et al. in 1995.[14] In our research, we utilized the French–Canadian adaptation,[16] a scale ranging from 0 (poor QoL) to 100 (better QoL).[17]
ADL
This assessment is conducted using a questionnaire scale focusing on basic activities, including feeding, dressing, transferring objects, continence, and toileting. A deterioration in one or more of these activities indicates a reduction in the individual’s functional independence. The responses are recorded and presented as an average score, with values ranging from 0 (total dependence) to 100 (total independence) for these activities.[18,19]
Statistical analysis
The data were analyzed using the Statistical Package for the Social Sciences version 25. We provided the mean and standard deviation (SD) as well as the percentage for qualitative variables. Analysis of variance, Linear regression analysis was performed, and Spearman’s rank correlation was used to analyze the correlation between variables. A P < 0.05 was considered statistically significant.
Ethics approval
All procedures received approval from the management of Ibn Sina Hospital in Rabat, and all information collected was anonymized to guarantee the privacy and confidentiality of participants.
RESULTS
Sociodemographic and clinical characteristics
Our study included 90 cases with MS, 75.6% of whom were women. The current age of our patients is 35 ± 10.19 years.
For the analysis of the PHC score, the average was 48.74 ± 1.49. On the other hand, the average score for the MHC was 43.19 ± 1.64. The descriptive analysis of the ADL scale shows a mean score of 52.89 ± 1.45. The distribution of the scores based on the scale reveals the following: 10% (n = 9) are completely independent in most activities. However, 57.78% (n = 52) are partially dependent, able to perform certain activities, but very slowly and with significant effort. Finally, 32.22% (n = 29) are more dependent, requiring assistance to perform all activities.
The data analysis shows that, for PHC, the mean for females is 47.3 ± 13.84, while that for males is 53.21 ± 14.29; regarding MHC, the mean for females is 41.31 ± 16.52, and for males, it is 49.00 ± 10.50, suggesting that males have better physical and mental health. For ADL, the mean for females is 51.76 ± 14.03, while that for males is 56.36 ± 12.55. Finally, for disability status, the median for females is 3.45 ± 3.50, and for males, it is 3.21 ± 0.75 [Table 1].
| Variable | Female (n=68) Mean (SD) |
Male (n=22) Mean (SD) |
Total (n=90) Mean (SD) |
P-value |
|---|---|---|---|---|
| Age | 45.07 (22.83) | 38.86 (14.16) | 35 (10.2) | <0.235 |
| MSQoL | ||||
| PHC | 47.3 (13.84) | 53.21 (14.29) | 49 (1.5) | <0.088 |
| MHC | 41.31 (16.52) | 49.00 (10.50) | 43 (1.6) | <0.043 |
| PDDS | 3.45 (3.50) | 3.21 (0.75) | 2.6 (1.6) | <0.305 |
| ADL | 51.76 (14.03) | 56.36 (12.55) | 53 (1.5) | <0.174 |
MSQoL: Multiple sclerosis quality of life, PHC: Physical health composite, MHC: Mental health composite, PDDS: Patient determined disease steps, ADL: Activity of daily living, SD: Standard deviation, Significant at P< 0.05 level
Table 2 demonstrates that the regression models account for a considerable amount of variance in both PHC (87.1%) and MHC (76.3%) scores. This emphasizes the significant influence of ADL and PDDS on the QoL among patients with MS. The results underscore the critical role of functional independence and disease progression in shaping both physical and mental health outcomes within this patient group.
| MSQoL | Beta | R2 | R2ajuster | t-value | P-value | 95% CI |
|---|---|---|---|---|---|---|
| PHC | ||||||
| ADL | 0.933 | 0.871 | 0.870 | 24.406 | <0.000 | 0.879–1.034 |
| PDDS | −0.353 | 0.125 | 0.115 | −3.543 | <0.001 | −4.919–1.384 |
| MHC | ||||||
| ADL | 0.873 | 0.763 | 0.760 | 16.811 | <0.000 | 0.871–1.105 |
| PDDS | −0.273 | 0.074 | 0.064 | −2.661 | <0.009 | −4.695–0.681 |
MSQoL: Multiple sclerosis quality of life, PHC: Physical health composite, MHC: Mental health composite, PDDS: Patient determined disease steps, ADL: Activity of daily living, CI: Confidence interval, Highly significant at P< 0.01 level
Relationship between ADL, disability, and QOL composites
Table 3 demonstrates a correlation of physical and MHCs; it is strongly and positively significant with ADL (r = 0.933; r = 0.873). However, the latter is negatively associated with PDDS (r = −0.280; P < 0.008).
| Variables | PHC | MHC | ADL | |||
|---|---|---|---|---|---|---|
| r | P-value | r | P-value | r | P-value | |
| PDDS | −0.353** | <0.001** | −0.273** | <0.009** | −0.280** | <0.008** |
| ADL | 0.933** | <0.000** | 0.873** | <0.000** | - | - |
PHC: Physical health composite, MHC: Mental health composite, ADL: Activity daily living, PDDS: Patient determined disease steps, **Highly significant at P< 0.01 level
DISCUSSION
In our study, 22.2% of patients experienced mobility difficulties, while 77.8% did not encounter this issue, with an average of 2.47. This finding is consistent with other studies indicating that more than half of the cases are physically independent and do not have mobility problems. In the United States, a study has reported a significant proportion of patients have a median of PDDS level below 4.[20] Similarly, a study conducted in France with 98 MS patients revealed that more than 50% of those do not have mobility problems.[21]
Our study’s findings emphasize the major impact of impairment on daily activities and QoL for people with MS. The average age at diagnosis underscores that MS can affect individuals at a relatively young stage of their lives.
The negative correlation between disability level and activities related to daily life indicates that physical limitations have direct repercussions on patients’ ability to perform essential daily tasks. Moreover, the significant impairment of physical and mental QoL among patients with more severe disability underscores the importance of a holistic approach in MS management, addressing both physical and mental aspects of health.
The observed differences in average QoL scores based on disability levels and ADL reinforce the idea that addressing physical disability should be integrated into individualized care plans. Specifically, the results highlight the importance of targeting interventions aimed at improving ADL to enhance the QoL of MS patients.
The assessment of the severity of disability resulting from MS is typically conducted using the Expanded Disability Status Scale (EDSS). In our study, we opted to collect data on disability level using the PDDS scale. The average PDDS score was 2.57, with extreme values ranging from 0 to 6. This result is consistent with previous research,[22] which reports an evaluation of 3.0, with a variation of 0.3 compared to other studies.[20,21,23]
No assessment of disability or validation of the PDDS has been identified in the Moroccan population with MS, noting that this method has been replaced by the EDSS scale. A Moroccan study on 75 patients with MS revealed an average EDSS of 4.067;[24] 22.2% had a PDDS greater than 4, similar to a Turkish study.[25]
Physical disability, assessed by the PDDS score, significantly influences scores of HRQoL, both physical and mental. This influence is more pronounced on the physical score (P= 0.023) than on the mental score (P = 0.035). The impact of disability on QoL is further highlighted when comparing physical and mental health, showing a significant difference between mild and moderate levels of disability. These results are consistent with other studies on the QoL of patients with MS.[26] While Vickrey et al. (2015) noted significant differences between patients capable of walking unaided and those needing assistance.[27]
A Polish study in 2016[28] also confirmed the negative impact of disability on the QoL of patients with MS. Furthermore, progression of disability has been associated with negative impacts on physical, psychological, and social QoL in several studies.[29-32]
However, despite these advantages, the PDDS scale presents potential benefits, including its cost-effectiveness and ease of self-administration by patients with MS. Its brevity makes it a particularly useful tool in large epidemiological studies or studies requiring frequent reassessments, where clinical or performance-based measures would be difficult to apply.
The components of physical and mental health of the MSQoL-54 decreased with increasing disability. However, patients with an estimated PDDS between 4.5 and 6.5 were significantly different from those with a lower PDDS (0–4.0). The results indicate that while the inability to walk is accompanied by a significant deterioration in HRQoL, mild limitation (need for walking assistance) does not result in a decisive further drop in most domains of QoL.
A study on HRQoL conducted on 3157 patients with MS identified a significant correlation when comparing combined dimensions of mental and physical health based on disability level. The findings highlight the need to consider both the physical and mental health components, as well as most subscales of the MSQoL-54. In addition, the disparity between moderate and severe disabilities was significantly smaller than that between mild and moderate disabilities.[26] These surveys should be conducted within a population exhibiting mild-to-moderate disability rates to assess the impact of treatments, physical activity therapies, or functional system impairments on HRQoL.
Furthermore, it has been observed that increasing patients’ independence and autonomy in their daily activities is associated with a significant improvement in their physical and mental QoL. Conversely, a decrease in this autonomy due to more pronounced disability is correlated with a deterioration in QoL, as evidenced by research conducted in the MENA region and Turkey.[8,33,34] These studies reveal that the level of disability significantly affects QoL in its physical, psychological, social, and overall dimensions due to reduced independence in daily activities. The progression of disability leads to the emergence and aggravation of neuropsychological disorders, deteriorating QoL by impairing physical and mental health, increasing dependence for daily activities, reducing autonomy, and affecting mobility as well as cognitive abilities.
The limitations of our study are the small size of the population, the rare the illness, and the possibility of neuropsychological effects of COVID-19 on MS patients.
CONCLUSION
The results of this study confirm the significant impact of disability on the daily activities and QOL of MS patients. A significant alteration was observed between the level of disability and the physical and mental aspects of QOL.
Patients with more severe disabilities reported lower QOL scores, both physically and mentally, which also affected their performance in daily activities, underlining the need for tailored interventions. Early assessment and personalized care are essential to improving well-being.
Acknowledgment:
We express our sincere gratitude to Professor Mohamed Yahyaoui and El Hachmia Ait Ben Haddou, research professor in the neurology and neurogenetics department at the Faculty of Medicine and Pharmacy, for their support and collaboration throughout this study, as well as for their valuable contributions.
Ethical approval:
All procedures were approved by the management of Ibn Sina Hospital in Rabat, and data were anonymized to ensure participant confidentiality in accordance with the Declaration of Helsinki (1964).
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflict of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- Atlas of multiple sclerosis 2013: A growing global problem with widespread inequity. Neurology. 2014;83:1022-4.
- [CrossRef] [PubMed] [Google Scholar]
- Clinical and economic impact of a specialty care management program among patients with multiple sclerosis: A cohort study. Mult Scler. 2010;16:956-63.
- [CrossRef] [PubMed] [Google Scholar]
- The impact of disease characteristics on multiple sclerosis patients' quality of life. Epidemiol Health. 2017;39:e2017008.
- [CrossRef] [PubMed] [Google Scholar]
- Quality of life and impairment in patients with multiple sclerosis. J Neurol Neurosurg Psychiatry. 2005;76:64-9.
- [CrossRef] [PubMed] [Google Scholar]
- Cognitive impairment, health-related quality of life and vocational status at early stages of multiple sclerosis: A 7-year longitudinal study. J Neurol. 2013;260:776-84.
- [CrossRef] [PubMed] [Google Scholar]
- Confirmed disability progression provides limited predictive information regarding future disease progression in multiple sclerosis. Mult Scler J Exp Transl Clin. 2021;7:205521732199907.
- [CrossRef] [PubMed] [Google Scholar]
- Challenges in the daily living activities of patients with multiple sclerosis: A qualitative content analysis. Int J Community Based Nurs Midwifery. 2019;7:201-10.
- [Google Scholar]
- Health-related quality of life in multiple sclerosis: Links to mental health, self-esteem, and selfcompassion. Dusunen Adam J Psychiatry Neurol Sci. 2020;33:59-70.
- [CrossRef] [Google Scholar]
- Disease steps in multiple sclerosis: A simple approach to evaluate disease progression. Neurology. 1995;45:251-5.
- [CrossRef] [PubMed] [Google Scholar]
- Disease steps in multiple sclerosis: A longitudinal study comparing disease steps and EDSS to evaluate disease progression. Mult Scler. 1999;5:349-54.
- [CrossRef] [PubMed] [Google Scholar]
- Treatment patterns of multiple sclerosis patients: A comparison of veterans and non-veterans using the NARCOMS registry. Mult Scler. 2005;11:33-40.
- [CrossRef] [PubMed] [Google Scholar]
- Validation of the Brazilian version of the patient-determined disease steps scale in persons with multiple sclerosis. Mult Scler Relat Disord. 2019;30:208-14.
- [CrossRef] [PubMed] [Google Scholar]
- Spanish validation of the telephone assessed expanded disability status scale and patient determined disease steps in people with multiple sclerosis. Mult Scler Relat Disord. 2019;27:333-9.
- [CrossRef] [PubMed] [Google Scholar]
- A health-related quality of life measure for multiple sclerosis. Qual Life Res. 1995;4:187-206.
- [CrossRef] [PubMed] [Google Scholar]
- The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473-83.
- [CrossRef] [PubMed] [Google Scholar]
- Quality of life in multiple sclerosis: Translation in French Canadian of the MSQoL-54. Health Qual Life Outcomes. 2003;1:70.
- [CrossRef] [PubMed] [Google Scholar]
- Assessing multiple sclerosis-related quality of life among Iranian patients using the MSQOL-54 tool: A cross-sectional study. BMC Neurol. 2021;21:333.
- [CrossRef] [PubMed] [Google Scholar]
- Reliability of measurements of patient health status: A comparison of physician, patient, and caregiver ratings. Parkinsonism Relat Disord. 2002;8:187-92.
- [CrossRef] [PubMed] [Google Scholar]
- Postoperative medical evaluation of 26 selected patients with Parkinson's disease. J Am Geriatr Soc. 1956;4:1219-32.
- [CrossRef] [PubMed] [Google Scholar]
- Validation of patient determined disease steps (PDDS) scale scores in persons with multiple sclerosis. BMC Neurol. 2013;13:37.
- [CrossRef] [PubMed] [Google Scholar]
- Validation of the French version of the multiple sclerosis intimacy and sexuality questionnaire 15 tools which help nurse for assessing the effect of perceived multiple sclerosis symptoms on sexual activity and satisfaction. Nurs Open. 2023;10:570-8.
- [CrossRef] [PubMed] [Google Scholar]
- Serum vitamin d inversely correlates with depression scores in people with multiple sclerosis. Mult Scler Relat Disord. 2021;48:102732.
- [CrossRef] [PubMed] [Google Scholar]
- Translation and validation of the Arabic version of the patient determined disease steps in people with multiple sclerosis. Physiother Theory Pract. 2022;38:1281-8.
- [CrossRef] [PubMed] [Google Scholar]
- Association of vitamin D status with multiple sclerosis in a case-control study from Morocco. Revue Neurol (Paris). 2018;174:150-6.
- [CrossRef] [PubMed] [Google Scholar]
- Cross-cultural adaptation and validation of multiple sclerosis quality of life questionnaire (MSQOL-54) in a Turkish multiple sclerosis sample. J Neurol Sci. 2006;240:77-80.
- [CrossRef] [PubMed] [Google Scholar]
- Disability status and quality of life in multiple sclerosis: Non-linearity of the expanded disability status scale (EDSS) Health Qual Life Outcomes. 2010;8:55.
- [CrossRef] [PubMed] [Google Scholar]
- EDSS change relates to physical HRQoL while relapse occurrence relates to overall HRQoL in patients with multiple sclerosis receiving subcutaneous interferon β-1a. Mult Scler Int. 2015;2015:631989.
- [CrossRef] [PubMed] [Google Scholar]
- Self-reported quality of life in multiple sclerosis patients: Preliminary results based on the polish MS registry. Patient Prefer Adherence. 2016;10:1647-56.
- [CrossRef] [PubMed] [Google Scholar]
- Predictors of quality of life among patients with multiple sclerosis: An Italian cross-sectional study. J Neurol Sci. 2007;252:121-9.
- [CrossRef] [PubMed] [Google Scholar]
- Health-related quality of life in multiple sclerosis: Direct and indirect effects of comorbidity. Neurology. 2016;86:1417-24.
- [CrossRef] [PubMed] [Google Scholar]
- Validation of the disease-specific questionnaire MSQoL-54 in Bosnia and Herzegovina multiple sclerosis patients sample. Med Arch. 2017;71:103-6.
- [CrossRef] [PubMed] [Google Scholar]
- Validation and cross-cultural adaptation of the disease-specific questionnaire MSQOL-54 in Serbian multiple sclerosis patients sample. Qual Life Res. 2007;16:1383-7.
- [CrossRef] [PubMed] [Google Scholar]
- Factors affecting MS patients' health-related quality of life and measurement challenges in Lebanon and the MENA region. Mult Scler J Exp Transl Clin. 2020;6:2055217319848467.
- [CrossRef] [PubMed] [Google Scholar]
- Factors predicting quality of life in a group of Polish subjects with multiple sclerosis: Accounting for functional state, socio-demographic and clinical factors. Clin Neurol Neurosurg. 2012;114:341-6.
- [CrossRef] [PubMed] [Google Scholar]