{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T16:36:59Z","timestamp":1790354219012,"version":"4.1.0"},"reference-count":39,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T00:00:00Z","timestamp":1770076800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"ongoing research funding program","award":["ORF-2026-847-1"],"award-info":[{"award-number":["ORF-2026-847-1"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Multiple sclerosis (MS) is a chronic neurological disorder causing physical, cognitive, and psychological impairments that affect daily functioning and quality of life (QoL). Psychological distress, cognitive deficits, and reduced physical activity often co-occur, yet their associations with QoL across disability levels are unclear. This study examined these relationships in people with relapsing\u2013remitting MS, stratified by disability severity. Materials and Methods: This cross-sectional study included 149 adults with RRMS. Disability severity was classified as mild, moderate, or severe using the Patient-Determined Disease Steps (PDDS) scale. Psychological distress was assessed using the Depression, Anxiety, and Stress Scale\u201321 (DASS-21), cognitive function using the Montreal Cognitive Assessment (MoCA), and physical activity using the International Physical Activity Questionnaire (IPAQ). QoL was evaluated using the Multiple Sclerosis International Quality of Life (MusiQoL) questionnaire. Stratified comparative analyses were conducted to examine differences in overall and domain-specific QoL according to levels of psychological distress, cognitive function, and physical activity within disability categories. Results: In participants with mild and moderate disability, higher levels of depression, anxiety, and stress were associated with lower QoL scores, particularly in domains related to activities of daily living, psychological well-being, and symptoms. Higher cognitive function and greater physical activity were associated with more favorable QoL across several domains. In those with severe disability, associations between psychological distress and QoL were less consistent, although stress remained associated with selected QoL domains. Conclusions: Psychological distress, cognitive function, and physical activity show distinct patterns of association with daily functioning and QoL across disability levels in RRMS. Although causal inferences cannot be drawn from this cross-sectional design, disability-stratified analyses provide clinically relevant insights into how these factors co-vary with QoL at different stages of disease severity.<\/jats:p>","DOI":"10.3390\/medicina62020316","type":"journal-article","created":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T12:46:11Z","timestamp":1770122771000},"page":"316","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Associations of Psychological Distress, Cognitive Function, and Physical Activity with Daily Functioning and Quality of Life Across Disability Levels in Multiple Sclerosis"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9591-5649","authenticated-orcid":false,"given":"Saad A.","family":"Alhammad","sequence":"first","affiliation":[{"name":"Rehabilitation Sciences Department, Faculty of Applied Medical Sciences, King Saud University, Riyadh 11411, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hamad T.","family":"Aldubayan","sequence":"additional","affiliation":[{"name":"Rehabilitation Department, Dammam Medical Complex, Al Khobar 31451, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Majed S.","family":"Albalawi","sequence":"additional","affiliation":[{"name":"Physical Therapy Department, Prince Fahad bin Sultan Hospital, Tabuk 47311, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alaa A.","family":"Mutawam","sequence":"additional","affiliation":[{"name":"Rehabilitation Department, Abu Areesh General Hospital, Jazan 45911, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7772-067X","authenticated-orcid":false,"given":"Sami S.","family":"Alabdulwahab","sequence":"additional","affiliation":[{"name":"Rehabilitation Sciences Department, Faculty of Applied Medical Sciences, King Saud University, Riyadh 11411, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1016\/S1474-4422(17)30470-2","article-title":"Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria","volume":"17","author":"Thompson","year":"2018","journal-title":"Lancet Neurol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"278","DOI":"10.1212\/WNL.0000000000000560","article-title":"Defining the clinical course of multiple sclerosis: The 2013 revisions","volume":"83","author":"Lublin","year":"2014","journal-title":"Neurology"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1016\/S1474-4422(18)30443-5","article-title":"Global, regional, and national burden of multiple sclerosis 1990\u20132016: A systematic analysis for the Global Burden of Disease Study 2016","volume":"18","author":"Collaborators","year":"2019","journal-title":"Lancet Neurol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1038\/s41572-018-0041-4","article-title":"Multiple sclerosis","volume":"4","author":"Filippi","year":"2018","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1022","DOI":"10.1212\/WNL.0000000000000768","article-title":"Atlas of Multiple Sclerosis 2013: A growing global problem with widespread inequity","volume":"83","author":"Browne","year":"2014","journal-title":"Neurology"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"860","DOI":"10.1016\/S1474-4422(20)30277-5","article-title":"Cognitive impairment in multiple sclerosis: Clinical management, MRI, and therapeutic avenues","volume":"19","author":"Benedict","year":"2020","journal-title":"Lancet Neurol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1097\/WCO.0b013e328346a43b","article-title":"Cognition in multiple sclerosis","volume":"24","author":"Langdon","year":"2011","journal-title":"Curr. Opin. Neurol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1170","DOI":"10.1001\/jamaneurol.2024.2920","article-title":"Comorbidity and Disease Activity in Multiple Sclerosis","volume":"81","author":"Salter","year":"2024","journal-title":"JAMA Neurol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"105633","DOI":"10.1016\/j.msard.2024.105633","article-title":"Focusing on neural mechanisms of exercise training benefits in multiple sclerosis","volume":"86","author":"Sandroff","year":"2024","journal-title":"Mult. Scler. Relat. Disord."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1007\/s11910-015-0585-6","article-title":"Benefits of Exercise Training in Multiple Sclerosis","volume":"15","author":"Motl","year":"2015","journal-title":"Curr. Neurol. Neurosci. Rep."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e041249","DOI":"10.1136\/bmjopen-2020-041249","article-title":"Quality of life in adults with multiple sclerosis: A systematic review","volume":"10","author":"Conrad","year":"2020","journal-title":"BMJ Open"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Gomez-Melero, S., Caballero-Villarraso, J., Escribano, B.M., Galvao-Carmona, A., Tunez, I., and Aguera-Morales, E. (2024). Impact of Cognitive Impairment on Quality of Life in Multiple Sclerosis Patients-A Comprehensive Review. J. Clin. Med., 13.","DOI":"10.3390\/jcm13113321"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1191\/1352458502ms845oa","article-title":"The multiple sclerosis functional composite: A new clinical outcome measure for multiple sderosis trials","volume":"8","author":"Rudick","year":"2002","journal-title":"Mult. Scler."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1007\/BF02260859","article-title":"A health-related quality of life measure for multiple sclerosis","volume":"4","author":"Vickrey","year":"1995","journal-title":"Qual. Life Res."},{"key":"ref_15","first-page":"243","article-title":"Physical activity assessment among patients with multiple sclerosis in Saudi Arabia","volume":"28","author":"Alkahtani","year":"2023","journal-title":"Neurosci. J."},{"key":"ref_16","first-page":"261","article-title":"Quality of life among multiple sclerosis patients in Saudi Arabia","volume":"22","author":"Algahtani","year":"2017","journal-title":"Neurosci. J."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"AlMarzooqi, M.A., and Saller, F. (2022). Physical Activity Counseling in Saudi Arabia: A Systematic Review of Content, Outcomes, and Barriers. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph192316350"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"428","DOI":"10.1111\/ppc.12293","article-title":"Depression and perceived social support among Saudi patients with multiple sclerosis","volume":"54","author":"Hyarat","year":"2018","journal-title":"Perspect. Psychiatr. Care"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"175","DOI":"10.3758\/BF03193146","article-title":"G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences","volume":"39","author":"Faul","year":"2007","journal-title":"Behav. Res. Methods"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Learmonth, Y.C., Motl, R.W., Sandroff, B.M., Pula, J.H., and Cadavid, D. (2013). Validation of patient determined disease steps (PDDS) scale scores in persons with multiple sclerosis. BMC Neurol., 13.","DOI":"10.1186\/1471-2377-13-37"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1281","DOI":"10.1080\/09593985.2020.1839988","article-title":"Translation and validation of the Arabic version of the patient determined disease steps in people with multiple sclerosis","volume":"38","author":"Aldughmi","year":"2022","journal-title":"Physiother. Theory Pract."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1111\/j.1532-5415.2005.53221.x","article-title":"The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment","volume":"53","author":"Nasreddine","year":"2005","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1381","DOI":"10.1249\/01.MSS.0000078924.61453.FB","article-title":"International physical activity questionnaire: 12-country reliability and validity","volume":"35","author":"Craig","year":"2003","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1017\/S1368980007184299","article-title":"Health-enhancing physical activity among Saudi adults using the International Physical Activity Questionnaire (IPAQ)","volume":"10","year":"2007","journal-title":"Public Health Nutr."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Lovibond, S.H. (1995). Manual for the Depression Anxiety Stress Scales, Sydney Psychology Foundation.","DOI":"10.1037\/t01004-000"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1177\/1352458507080733","article-title":"Validation of the Multiple Sclerosis International Quality of Life questionnaire","volume":"14","author":"Simeoni","year":"2008","journal-title":"Mult. Scler."},{"key":"ref_27","first-page":"10538135251344929","article-title":"Validation of the Arabic Version of Multiple Sclerosis Quality of Life-29 (MSCOL-29-Ar): Cross-cultural Adaptation and Psychometric Analysis","volume":"57","author":"Alsharafi","year":"2025","journal-title":"NeuroRehabilitation"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1016\/j.soncn.2009.11.008","article-title":"Health-related quality of life and culture","volume":"26","author":"Padilla","year":"2010","journal-title":"Semin. Oncol. Nurs."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Pourhaji, F., Taraghdar, M.M., Peyman, N., Jamali, J., and Tehrani, H. (2024). Explaining the burden of cultural factors on MS disease: A qualitative study of the experiences of women with multiple sclerosis. BMC Womens Health, 24.","DOI":"10.1186\/s12905-024-03328-0"},{"key":"ref_30","first-page":"140","article-title":"Quality of life assessment among multiple sclerosis patients in Saudi Arabia","volume":"23","author":"Alhazzani","year":"2018","journal-title":"Neurosci. J."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1177\/135245859900500410","article-title":"Recent developments in the assessment of quality of life in multiple sclerosis (MS)","volume":"5","author":"Fischer","year":"1999","journal-title":"Mult. Scler."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1016\/S1474-4422(12)70059-5","article-title":"Disability outcome measures in multiple sclerosis clinical trials: Current status and future prospects","volume":"11","author":"Cohen","year":"2012","journal-title":"Lancet Neurol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"S227","DOI":"10.1007\/s10072-010-0372-8","article-title":"Coping strategies, cognitive impairment, psychological variables and their relationship with quality of life in multiple sclerosis","volume":"31","author":"Goretti","year":"2010","journal-title":"Neurol. Sci."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"104966","DOI":"10.1016\/j.msard.2023.104966","article-title":"Multiple sclerosis and quality of life: The role of cognitive impairment on quality of life in people with multiple sclerosis","volume":"79","author":"Bergmann","year":"2023","journal-title":"Mult. Scler. Relat. Disord."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"290","DOI":"10.1097\/MRR.0b013e32834ad479","article-title":"Quality of life in patients with multiple sclerosis: The impact of depression, fatigue, and disability","volume":"34","author":"Kaya","year":"2011","journal-title":"Int. J. Rehabil. Res."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1038\/nrneurol.2017.33","article-title":"Comorbidity in multiple sclerosis: Implications for patient care","volume":"13","author":"Marrie","year":"2017","journal-title":"Nat. Rev. Neurol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1177\/13524585241301613","article-title":"Exercise as a Therapeutic Intervention in Multiple Sclerosis","volume":"30","author":"Pilutti","year":"2024","journal-title":"Mult. Scler."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1038\/nrneurol.2014.139","article-title":"The link between multiple sclerosis and depression","volume":"10","author":"Feinstein","year":"2014","journal-title":"Nat. Rev. Neurol."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Alanazi, A.M., Almutairi, A.M., Aldhahi, M.I., Alotaibi, T.F., AbuNurah, H.Y., Olayan, L.H., Aljuhani, T.K., Alanazi, A.A., Aldriwesh, M.G., and Alamri, H.S. (2023). The Intersection of Health Rehabilitation Services with Quality of Life in Saudi Arabia: Current Status and Future Needs. Healthcare, 11.","DOI":"10.3390\/healthcare11030389"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/2\/316\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T13:13:40Z","timestamp":1770124420000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/2\/316"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,3]]},"references-count":39,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,2]]}},"alternative-id":["medicina62020316"],"URL":"https:\/\/doi.org\/10.3390\/medicina62020316","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,3]]}}}