Fatigue characteristics in multiple sclerosis: the North American Research Committee on Multiple Sclerosis (NARCOMS) survey

The correlation between symptomatic fatigue to definite measures of gait in people with multiple sclerosis

There is a general consensus relating to the multidimensional aspects of fatigue in people with multiple sclerosis (PwMS), however, the exact impact of this symptom on gait is not fully understood. Our primary aim was to examine the relationship between definite parameters of gait with self-reported symptomatic fatigue in PwMS according to their level of neurological impairment. Spatio-temporal parameters of gait were studied using an electronic walkway. The Multiple Sclerosis Walking Scale (MSWS-12) questionnaire, a patient-rated measure of walking ability was collected. The Modified Fatigue Impact Scale (MFIS) questionnaire was used to determine the level of symptomatic fatigue. One hundred and one PwMS (61 women) were included in the study analysis. Subjects were divided into mild and moderate neurological impaired groups. Fatigue was correlated with 5 (out of 14) spatiotemporal parameters. However, correlation scores were all <0.35, thus considered as weak correlations. In the mild group, the double support period was the only variable positively correlated to fatigue (Spearman's rho=0.28, P=0.05). In the moderate group, step and stride length were solely negatively correlated to fatigue (Spearman's rho=0.32, P=0.03). In contrast to the definite gait parameters, the MSWS-12 self-questionnaire was moderately positively correlated to the level of fatigue. Scores for the total, mild and moderate groups were 0.54, 0.57 and 0.51; P<0.01, respectively. The present results indicate that modifications in spatio-temporal parameters of gait are not closely related to symptomatic fatigue in PwMS. On the contrary, the self-reported MSWS-12 questionnaire is predisposed to level of fatigue in PwMS.

Exploration of changes in disability after menopause in a longitudinal multiple sclerosis cohort

BACKGROUND

Onset of multiple sclerosis (MS) is typically in early adulthood. The impact, if any, of menopause on the MS course is unknown. Our objective was to determine whether menopause is associated with changes in MS severity in a longitudinal clinical cohort.

METHODS

Responses from an ongoing reproductive questionnaire deployed in all active female CLIMB observational study participants with a diagnosis of clinically isolated syndrome (CIS) or MS were analyzed when the response rate was 60%. Reproductive data were linked with clinical severity measures that were prospectively collected every six months, including our primary measure, the Expanded Disability Status Scale (EDSS).

RESULTS

Over one-half of the respondents (368 of 724 women) were postmenopausal. Median age at natural menopause was 51.5 years. In our primary analysis of 124 women who were followed longitudinally (mean duration 10.4 years) through their menopausal transition (natural or surgical), menopause represented an inflection point in their EDSS changes (difference of 0.076 units; 95% CI 0.010-0.14; p = 0.024). These findings were not explained by vitamin D levels, nor changes in treatment or smoking status over this period. There was no effect of hormone replacement therapy (HRT) exposure, but HRT use was low.

CONCLUSIONS

We observed a possible worsening of MS disability after menopause. Larger cohorts are required to assess any HRT effects.

Atrophy of reward-related striatal structures in fatigued MS patients is independent of physical disability

BACKGROUND

MRI studies have shown gray-matter abnormalities in fatigued multiple sclerosis (MS) patients. However, given that physical disability is highly correlated to MS fatigue, it is often difficult to disentangle its effect in these MRI findings.

OBJECTIVE

The objective of this research paper is to investigate gray-matter damage in mildly disabled MS patients, addressing which variables were better related to fatigue while controlling for physical disability and depression.

METHODS

Forty-nine relapsing-remitting MS (RRMS) patients and 30 controls underwent MRI (3T). Fatigue was assessed using the Fatigue Severity Scale (FSS). Multivariate logistic regression was performed to assess the contribution of clinical and MRI metrics to fatigue. Statistical analyses were performed controlling for disability and depression.

RESULTS

Fatigue was present in 22 (44.9%) patients. FSS score was highly correlated with EDSS (p = 0.00001). Patients with fatigue had lower brain cortical and subcortical gray-matter volumes. However, after controlling for EDSS, only the caudate and the accumbens volumes remained statistically significant.

CONCLUSIONS

Fatigued MS patients have a global cortical and subcortical gray-matter atrophy that seems largely related to higher physical disability. However, striatal structures involved in effort-reward functions exhibited smaller volumes in fatigued patients, independently of physical disability and depressive symptoms, supporting the theory of cortico-striatal network impairment in MS fatigue.

Antiepileptic and Antidepressive Polypharmacy in Patients with Multiple Sclerosis

Objective. Patients with multiple sclerosis (MS) are often suffering from neuropathic pain. Antiepileptic drugs (AEDs) and tricyclic antidepressants (TCAs) are commonly used and are susceptible to be involved in drug interactions. The aim of this retrospective study was to investigate the prevalence of use of antiepileptic and antidepressive drugs in MS patients and to discuss the theoretical potential for interactions. Methods. Review of the medical records from all patients treated at a dedicated MS rehabilitation centre in Norway between 2009 and 2012. Results. In total 1090 patients attended a rehabilitation stay during the study period. Of these, 342 (31%; 249 females) with mean age of 53 (±10) years and EDSS 4.8 (±1.7) used at least one AED (gabapentin 12.7%, pregabalin 7.7%, clonazepam 7.8%, and carbamazepine 2.6%) or amitriptyline (9.7%). Polypharmacy was widespread (mean 5.4 drugs) with 60% using additional CNS-active drugs with a propensity to be involved in interactions. Age, gender, and EDSS scores did not differ significantly between those using and not using AED/amitriptyline. Conclusion. One-third of MS patients attending a rehabilitation stay receive AED/amitriptyline treatment. The high prevalence of polypharmacy and use of CNS-active drugs calls for awareness of especially pharmacodynamic interactions and possible excessive adverse effects.

Effectiveness of glatiramer acetate compared to other multiple sclerosis therapies

OBJECTIVE

To assess the effectiveness of glatiramer acetate (GA) compared to other multiple sclerosis (MS) therapies in routine clinical practice.

MATERIALS AND METHODS

Observational cohort study carried out in MS patients treated with GA (GA cohort) or other MS therapies -switched from GA- (non-GA cohort). Study data were obtained through review of our MS patient database. The primary endpoint was the Expanded Disability Status Scale (EDSS) scores reached at the end of treatment/last check-up.

RESULTS

A total of 180 patients were included: GA cohort n = 120, non-GA cohort n = 60. Patients in the GA cohort showed better EDSS scores at the end of treatment/last check-up (mean ± SD, 2.8 ± 1.8 vs. 3.9 ± 2.2; P = 0.001) and were 1.65 times more likely to show better EDSS scores compared to the non-GA cohort (odds ratio, 0.606; 95%CI, 0.436-0.843; P = 0.003). Patients in the GA cohort showed longer mean time to reach EDSS scores of 6 (209.1 [95%CI, 187.6-230.6] vs. 164.3 [95% CI, 137.0-191.6] months; P = 0.004) and slower disability progression (hazard ratio, 0.415 [95%CI, 0.286-0.603]; P < 0.001). The annualized relapse rate was lower in the GA cohort (mean ± SD, 0.5 ± 0.5 vs. 0.8 ± 0.5; P = 0.001) and patients' quality of life was improved in this study cohort compared to the non-GA cohort (mean ± SD, 0.7 ± 0.1 vs. 0.6 ± 0.2; P = 0.01).

CONCLUSIONS

GA may slow down the progression of EDSS scores to a greater extent than other MS therapies, as well as achieving a greater reduction in relapses and a greater improvement in patients' quality of life. Switching from GA to other MS therapies has not proved to entail a better response to treatment.

The Effect of Biofeedback as a Psychological Intervention in Multiple Sclerosis: A Randomized Controlled Study

BACKGROUND

Relaxation, mindfulness, social support, and education (RMSSE) have been shown to improve emotional symptoms, coping, and fatigue in multiple sclerosis (MS). Biofeedback was trialed as a psychological intervention, designed to improve self-control, in two groups of patients with MS. Both groups received RMSSE, and one group additionally received biofeedback.

METHODS

Forty people with relapsing-remitting MS were recruited from three sites in Sydney, Australia. The mean disability score (Expanded Disability Status Scale; EDSS) was 2.41 ± 1.46 (95% confidence interval [CI], 1.46-3.36); the mean age in years was 45.9 ± 12.42 (95% CI, 41.92-49.87). Participants were randomly assigned to two active treatment groups (n = 20 per group). All participants received one 1-hour session per week for 3 weeks of RMSSE, while biofeedback equipment measured breathing rate and muscle tension. Members of one group used biofeedback screens to regulate physiological response.

RESULTS

Whole-group pre- and post-treatment scores demonstrated a reduction of 38% for anxiety and 39% for depression scores (P = .007 and P = .009, respectively). A post-treatment comparison failed to demonstrate any significant difference between the two active treatment groups in anxiety and depression scores. The biofeedback group showed significant pre- to post-treatment improvement or trends toward improvement in anxiety, fatigue, and stress (P = .05, .02, and .03, respectively). Comparison of pre-post treatment results between groups showed improvements for the biofeedback group in breathing rate and muscle tension (P = .06 and .09).

CONCLUSIONS

For relapsing-remitting MS patients receiving biofeedback in addition to RMSSE, there was a demonstrable reduction in anxiety, fatigue, and stress. There was also a trend toward significant reduction of breathing rate and muscle tension in favor of biofeedback.

Medication use in a large international sample of people with multiple sclerosis: associations with quality of life, relapse rate and disability

OBJECTIVES

To examine associations between medication use and health-related quality of life (HRQOL), relapse rate and disability in an international cohort of people with multiple sclerosis (PwMS).

METHODS

Using Web 2.0 platforms, the authors recruited PwMS who completed survey items on demographics, medication use, HRQOL, relapse rate and disability.

RESULTS

Of 2276 respondents from 56 countries, approximately half were taking a disease-modifying drug (DMD), most commonly glatiramer acetate or an interferon. Use of DMDs was not consistently associated with HRQOL. Individually, glatiramer acetate was associated with better HRQOL when compared with other DMDs or no DMD use. Overall, DMD use was neither associated with disability nor lower relapse rate, although those taking a DMD >12 months had 23.9% fewer relapses than those not taking a DMD. Polypharmacy, defined as those taking five or more over the counter, prescription or herbal medications, irrespective of DMD use, was associated with markedly worse HRQOL across all domains.

DISCUSSION

There was no consistent association of DMD use with better health outcomes in this large international \sample of PwMS, although relapse rate appears lower for those taking a DMD for >12 months. Glatiramer acetate had associations with better HRQOL compared with other DMDs.

Multimodal intervention improves fatigue and quality of life in subjects with progressive multiple sclerosis: a pilot study

Background

Fatigue is a disabling symptom of multiple sclerosis (MS) and reduces quality of life. The aim of this study was to investigate the effects of a multimodal intervention, including a modified Paleolithic diet, nutritional supplements, stretching, strengthening exercises with electrical stimulation of trunk and lower limb muscles, and stress management on perceived fatigue and quality of life of persons with progressive MS.

Methods

Twenty subjects with progressive MS and average Expanded Disability Status Scale (EDSS) score of 6.2 (range: 3.5–8.0) participated in the 12-month phase of the study. Assessments were completed at baseline and at 3 months, 6 months, 9 months, and 12 months. Safety analyses were based on monthly side effects questionnaires and blood analyses at 1 month, 3 months, 6 months, 9 months, and 12 months.

Results

Subjects showed good adherence (assessed from subjects’ daily logs) with this intervention and did not report any serious side effects. Fatigue Severity Scale (FSS) and Performance Scales-fatigue subscale scores decreased in 12 months (P<0.0005). Average FSS scores of eleven subjects showed clinically significant reduction (more than two points, high response) at 3 months, and this improvement was sustained until 12 months. Remaining subjects (n=9, low responders) either showed inconsistent or less than one point decrease in average FSS scores in the 12 months. Energy and general health scores of RAND 36-item Health Survey (Short Form-36) increased during the study (P<0.05). Decrease in FSS scores during the 12 months was associated with shorter disease duration (r=0.511, P=0.011), and lower baseline Patient Determined Disease Steps score (r_s=0.563, P=0.005) and EDSS scores (r_s=0.501, P=0.012). Compared to low responders, high responders had lower level of physical disability (P<0.05) and lower intake of gluten, dairy products, and eggs (P=0.036) at baseline. High responders undertook longer duration of massage and stretches per muscle (P<0.05) in 12 months.

Conclusion

A multimodal intervention may reduce fatigue and improve quality of life of subjects with progressive MS. Larger randomized controlled trials with blinded raters are needed to prove efficacy of this intervention on MS-related fatigue.

Clinically significant fatigue: prevalence and associated factors in an international sample of adults with multiple sclerosis recruited via the internet

Background

Fatigue contributes a significant burden of disease for people with multiple sclerosis (PwMS). Modifiable lifestyle factors have been recognized as having a role in a range of morbidity outcomes in PwMS. There is significant potential to prevent and treat fatigue in PwMS by addressing modifiable risk factors.

Objectives

To explore the associations between clinically significant fatigue and demographic factors, clinical factors (health-related quality of life, disability and relapse rate) and modifiable lifestyle, disease-modifying drugs (DMD) and supplement use in a large international sample of PwMS.

Methods

PwMS were recruited to the study via Web 2.0 platforms and completed a comprehensive survey measuring demographic, lifestyle and clinical characteristics, including health-related quality of life, disability, and relapse rate.

Results

Of 2469 participants with confirmed MS, 2138 (86.6%) completed a validated measure of clinically significant fatigue, the Fatigue Severity Scale. Participants were predominantly female from English speaking countries, with relatively high levels of education, and due to recruitment methods may have been highly pro-active about engaging in lifestyle management and self-help. Approximately two thirds of our sample (1402/2138; 65.6% (95% CI 63.7–67.7)) screened positive for clinically significant fatigue. Bivariate associations were present between clinically significant fatigue and several demographic, clinical, lifestyle, and medication variables. After controlling for level of disability and a range of stable socio-demographic variables, we found increased odds of fatigue associated with obesity, DMD use, poor diet, and reduced odds of fatigue with exercise, fish consumption, moderate alcohol use, and supplementation with vitamin D and flaxseed oil.

Conclusion

This study supports strong and significant associations between clinically significant fatigue and modifiable lifestyle factors. Longitudinal follow-up of this sample may help clarify the contribution of reverse causation to our findings. Further research is required to explore these associations including randomized controlled trials of lifestyle interventions that may alleviate fatigue.

Multiple Sclerosis and Employment: A Research Review Based on the International Classification of Function

Multiple sclerosis (MS) is an unpredictable, sometimes progressive chronic illness affecting people in the prime of their working lives. This article reviews the effects of MS on employment based on the World Health Organization’s International Classification of Functioning, Disability and Health model. Correlations between employment and personal, functional, environmental, and participation factors are discussed along with the need for a framework for evidence-based practice regarding the employment of people with MS.

Differential Vocational Rehabilitation Service Patterns Related to the Job Retention and Job-Seeking Needs of Individuals With Multiple Sclerosis

The experience of living with multiple sclerosis (MS) can have a profound effect on employment. The impact of MS is a complex interaction of personal, medical, functional, financial, and psychosocial variables that ultimately results in up to 80% of persons with MS leaving their jobs within 10 years of their diagnosis. The aim of this study was to investigate whether the employment status of applicants with MS who were seeking services from state vocational rehabilitation (VR) agencies could be classified based on the type of services provided. A quantitative descriptive research design employing discriminant analysis (DA) was used to determine differential services received by employed and unemployed applicants with MS. Findings indicate that persons with MS who were employed at application were more likely to receive services geared toward career stabilization (i.e., assistive technology/accommodation services, counseling and guidance, and cognitive retraining-type rehabilitative services). Conversely, the unemployed applicant group had a higher propensity to receive services focused on job placement (i.e., job readiness, job seeking, and job placement services). Although a disparity persisted between the average worker in the United States and the outcomes achieved by VR service recipients regarding weekly wages and hours, services provided by the state-federal VR program reduce this disparity. In addition, the return on investment (ROI) associated with providing services to persons with MS was calculated as providing an $8 return for every dollar spent. Persons with MS employed at application had an ROI of more than $10 for every dollar spent. Implications for persons with MS, rehabilitation counselors, health care professionals, and policymakers are provided.

Patients report worse MS symptoms after menopause: findings from an online cohort

BACKGROUND

Many women with multiple sclerosis (MS) are postmenopausal, yet the impact of menopause on MS symptoms is unknown.

OBJECTIVE

To investigate patient-reported impact of menopause in a large online research platform, PatientsLikeMe (PLM).

METHODS

A detailed reproductive history survey was deployed to PLM members, and responses were linked to PLM׳s prospectively collected patient-reported severity score (MS Rating Scale, MSRS). The MSRS has previously shown good correlation with physician-derived EDSS scores.

RESULTS

Of the 513 respondents, 55% were postmenopausal; 54% of these reported induced menopause. Median age at natural menopause was 51. Surgical menopause occurred at an earlier age (p<0.001) and was associated with more hormone replacement therapy use (p=0.02) than natural menopause. Postmenopausal status, surgical menopause, and earlier age at menopause were all associated with worse MSRS scores (p≤0.01) in regressions adjusting for age, disease type and duration.

CONCLUSION

Postmenopausal patients in this study reported worse MS disease severity. Further, this study highlights a utility for online research platforms, which allow for rapid generation of hypotheses that then require validation in clinical settings.

Lifestyle factors, demographics and medications associated with depression risk in an international sample of people with multiple sclerosis

BACKGROUND

Depression is the most common co-morbidity for people with Multiple Sclerosis (MS); irrespective of disease severity, depression has the greatest impact on quality of life. An emerging paradigm in the treatment of depression is lifestyle medicine. There is significant potential to prevent and treat depression through modification of lifestyle risk factors for people with MS. This study sought to understand the association between lifestyle risk factors, medication and depression risk through the analysis of self-reported data from a large international sample of people with MS.

METHODS

This cross-sectional analysis recruited a total of 2459 participants via Web 2.0 platforms. Survey data included socio-demographics; a range of lifestyle risk factors; medication; disease variables and depression risk using the Patient Health Questionnaire-2 (PHQ-2).

RESULTS

In total approximately one fifth (19.3%) of our sample screened positive for depression (PHQ-2 score ≥3). Several demographic factors were significantly associated with this depression risk in bivariate analysis. Regression analyses showed that poor diet, low levels of exercise, obesity, smoking, marked social isolation and taking interferon were associated with greater depression risk. Participants who supplemented with omega 3s, particularly flaxseed oil, had frequent fish consumption, supplemented with vitamin D, meditated, and had moderate alcohol consumption had significantly reduced depression risk.

CONCLUSIONS

This study demonstrates a significant association between modifiable lifestyle factors and depression risk. Planned longitudinal follow up may clarify causality. Clinicians and people with MS should be aware of the wide range of modifiable lifestyle factors that may reduce depression risk as part of a comprehensive secondary and tertiary preventive medical approach to managing MS.

Fostering adherence to injectable disease-modifying therapies in multiple sclerosis

Multiple sclerosis requires long-term management, often with disease-modifying therapies. Poor medication adherence, especially to injectables, can increase relapse and hospitalisation rates and consume healthcare resources. We discuss adherence definitions and terminology and its prevalence in multiple sclerosis (MS). Typical causes of poor adherence in patients with MS include: insufficient efficacy or tolerability, concurrent disorders, and consequences of MS (e.g., forgetfulness, depression, fatigue and poor motor skills). Ways to improve adherence rates are reviewed, focusing on interdisciplinary healthcare teams, good communication between healthcare workers and patients (and their families), ongoing support and digital tools to promote adherence. We consider open communication and continuing education to be key, and that MS nurses have a pivotal role in ensuring patients' adherence to MS medicines.

Gender differences in autoimmune disease

Autoimmune diseases are a range of diseases in which the immune response to self-antigens results in damage or dysfunction of tissues. Autoimmune diseases can be systemic or can affect specific organs or body systems. For most autoimmune diseases there is a clear sex difference in prevalence, whereby females are generally more frequently affected than males. In this review, we consider gender differences in systemic and organ-specific autoimmune diseases, and we summarize human data that outlines the prevalence of common autoimmune diseases specific to adult males and females in countries commonly surveyed. We discuss possible mechanisms for sex specific differences including gender differences in immune response and organ vulnerability, reproductive capacity including pregnancy, sex hormones, genetic predisposition, parental inheritance, and epigenetics. Evidence demonstrates that gender has a significant influence on the development of autoimmune disease. Thus, considerations of gender should be at the forefront of all studies that attempt to define mechanisms that underpin autoimmune disease.

Does fatigue occur in MS patients without disability?

BACKGROUND

Motor dysfunction and fatigue are the most common impairments that are associated with multiple sclerosis (MS). Walk tests and scales demonstrate the presence of fatigue in patients with MS with different levels of disability.

OBJECTIVE

To evaluate objective and subjective fatigue in MS patients without disability.

METHODS

Were selected MS patients with relapsing remitting clinical course, from 18 to 55 years old and EDSS 0 to 1.5; controls were paired for age, gender, body mass index, and physical activity level. Fatigue caused by pulmonary diseases, anemia, diabetes, thyroid disease, psychiatry diseases (except depression), and orthopedic and rheumatologic diseases are excluded. All participants performed the 6-minute walk test (6MWT), the MS Functional Composite (MSFC), and completed the Modified Fatigue Impact Scale (MFIS) and the Beck Depression Inventory. A multivariate model was applied to identify the variables associated with fatigue.

RESULTS

54 individuals were selected (31 patients; 23 controls). In the MSFC and 6MWT, no significant difference was observed between the groups. A MFIS total score indicated fatigue in 35% of the patients, 42% in the physical domain, 25.8% in the cognitive domain, and 29% in the psychosocial domain, which differed from the controls in all comparisons. Fatigue was associated with MS, low-physical activity, and mood disorders.

CONCLUSIONS

Fatigue occurs in patients with MS in the absence of motor dysfunction and is associated with the disease itself, the sedentary lifestyle, and mood disorders. The 6MWT is not useful to demonstrate motor fatigue in subjects without neurological disability.

Children and adolescents adjustment to parental multiple sclerosis: a systematic review

BACKGROUND

Families are the primary source of support and care for most children. In Western societies, 4 to 12% of children live in households where a parent has a chronic illness. Exposure to early-life stressors, including parenting stress, parental depression and parental chronic disease could lead to harmful changes in children's social, emotional or behavioural functioning. Little is known about the child living with a parent who has Multiple Sclerosis (MS). We systematically reviewed the literature regarding possible effects of having a parent with MS on the child's or adolescent's psychosocial adjustment.

METHODS

The following databases: MEDLINE, PsychInfo, CINAHL, EMBASE, Web of Knowledge, ERIC, and ProQuest Digital Dissertations were searched (from 1806 to December 2012). References from relevant articles were also manually searched. Selected studies were evaluated using the Graphic Appraisal Tool for Epidemiology (GATE).

RESULTS

The search yielded 3133 titles; 70 articles were selected for full text review. Eighteen studies met inclusion criteria. Fourteen studies employed quantitative techniques, of which 13 were cross-sectional and one was longitudinal. Four studies were both qualitative and cross-sectional in design. Only 2 of 18 studies were rated as having high methodological quality. Overall, eight studies reported that children of MS patients exhibited negative psychosocial traits compared with children of "healthy" parents. Specifically for adolescents, greater family responsibilities were linked to lower social relationships and higher distress. Three studies indicated that parental MS was associated with positive adjustment in children and adolescents, such as higher personal competence, while four found no statistically significant differences.

CONCLUSION

Although having a parent with MS was often reported to have negative psychosocial effects on children and adolescents, there was a lack of consensus and some positive aspects were also found. However, few high quality studies were identified which makes it difficult to draw evidence-based conclusions at this point. There are potentially important, long-term impacts of early life stressors, such as having a parent with a chronic disease, on subsequent life chances and health, and thus more extensive and higher quality research in this area is greatly needed.

Meta-analysis of three different types of fatigue management interventions for people with multiple sclerosis: exercise, education, and medication

Fatigue is a common symptom of multiple sclerosis (MS) with negative impacts extending from general functioning to quality of life. Both the cause and consequences of MS fatigue are considered multidimensional and necessitate multidisciplinary treatment for successful symptom management. Clinical practice guidelines suggest medication and rehabilitation for managing fatigue. This review summarized available research literature about three types of fatigue management interventions (exercise, education, and medication) to provide comprehensive perspective on treatment options and facilitate a comparison of their effectiveness. We researched PubMed, Embase, and CINAHL (August 2013). Search terms included multiple sclerosis, fatigue, energy conservation, Amantadine, Modafinil, and randomized controlled trial. The search identified 230 citations. After the full-text review, 18 rehabilitation and 7 pharmacological trials targeting fatigue were selected. Rehabilitation interventions appeared to have stronger and more significant effects on reducing the impact or severity of patient-reported fatigue compared to medication. Pharmacological agents, including fatigue medication, are important but often do not enable people with MS to cope with their existing disabilities. MS fatigue affects various components of one's health and wellbeing. People with MS experiencing fatigue and their healthcare providers should consider a full spectrum of effective fatigue management interventions, from exercise to educational strategies in conjunction with medication.

Physical activity in subjects with multiple sclerosis with focus on gender differences: a survey

Background

There is increasing research that examines gender-issues in multiple sclerosis (MS), but little focus has been placed on gender-issues regarding physical activity. The aim of the present study was to describe levels of physical activity, self-efficacy for physical activity, fall-related self-efficacy, social support for physical activity, fatigue levels and the impact of MS on daily life, in addition to investigating gender differences.

Methods

The sample for this cross-sectional cohort study consisted of 287 (84 men; 29.3%) adults with MS recruited from the Swedish Multiple Sclerosis Registry. A questionnaire was sent to the subjects consisting of the self-administrated measurements: Physical Activity Disability Survey – Revised, Exercise Self-Efficacy Scale, Falls- Efficacy Scale (Swedish version), Social Influences on Physical Activity, Fatigue Severity Scale and Multiple Sclerosis Impact Scale. Response rate was 58.2%.

Results

Men were less physically active, had lower self-efficacy for physical activity and lower fall-related self-efficacy than women. This was explained by men being more physically affected by the disease. Men also received less social support for physical activity from family members. The level of fatigue and psychological consequences of the disease were similar between the genders in the total sample, but subgroups of women with moderate MS and relapsing remitting MS experienced more fatigue than men.

Conclusions

Men were less physically active, probably a result of being more physically affected by the disease. Men being more physically affected explained most of the gender differences found in this study. However, the number of men in the subgroup analyses was small and more research is needed. A gender perspective should be considered in strategies for promoting physical activity in subjects with MS, e.g. men may need more support to be physically active.

Treatment satisfaction, adherence and behavioral assessment in patients de-escalating from natalizumab to interferon β

Background

De-escalating natalizumab (NTZ) to interferon beta 1b (IFN B 1B) is a possible treatment option in multiple sclerosis (MS) patients interrupting NTZ because of increased risk of progressive multifocal leukoencephalopathy (PML). The aim of this study was to evaluate satisfaction and adherence to treatment, behavioral and fatigue changes in patients switched to IFN B 1B compared to continued NTZ treatment.

Methods

A 1 year, prospective, randomized, rater-blinded, parallel-group study. Nineteen relapsing remitting (RR) MS patients, randomly assigned to undergo either NTZ (n = 10) or IFN B 1B (n = 9) treatment, who had previously received NTZ for at least 12 months with disease stability and fearing or at risk for PML were included. Patients underwent behavioral and treatment assessments at baseline, after 24-week and 1 year follow-up. Behavioral assessment included measures of cognition, fatigue and quality of life. Treatment assessment included measures of satisfaction, persistence and adherence to treatment. Clinical-radiological disease activity and safety were also assessed.

Results

Baseline characteristics of patients were similar between groups except for Euro Quality Visual Analogue Scale, being higher in the NTZ group (p = 0.04). Within-group comparisons at the three time points, as well as interaction analysis of treatment effect over time did not show any statistically significant differences in behavioral or treatment assessments, but a coherent trend favoring NTZ over IFN B 1B.

Conclusions

De-escalating NTZ to IFN B 1B is feasible and associated with overall good patient related outcome and persistently stable behavioral measures.

Changes in Fatigue and Cognition in Patients with Relapsing Forms of Multiple Sclerosis Treated with Natalizumab: The ENER-G Study

Fatigue and cognitive impairment are debilitating features of multiple sclerosis (MS). ENER-G was a 12-month, open-label, multicenter, single-arm observational study designed to evaluate changes in fatigue and cognition in MS patients treated with natalizumab. Adults with relapsing MS and initiating natalizumab were enrolled. The primary endpoint was change in Visual Analog Scale for Fatigue (VAS-F) score over 12 weeks. Changes in Modified Fatigue Impact Scale (MFIS) score, Fatigue Severity Scale (FSS) score, and cognitive performance, using Automated Neuropsychological Assessment Metrics (ANAM), were also assessed. Patients (N = 89) had a mean age of 41 years and a median Expanded Disability Status Scale score of 3.0, and 83% had used at least two prior MS therapies. Significant improvements were observed and maintained at 12 weeks in VAS-F (mean ± SD baseline score, 77.7 ± 10.2; mean ± SD change, -14.9 ± 17.1; P < .0001), MFIS (mean baseline score, 59.1 ± 12.2; mean change, -7.4 ± 11.8; P < .0001), and FSS (median baseline score, 6.3 [range, 3.9-7.0]; median change, -0.4 [range, -2.9-1.4]; P < .0001). Cognitive performance remained stable or improved (depending on the ANAM measure). Thus significant improvements in fatigue were maintained over time, and cognitive performance improved or remained stable up to 48 weeks after initiation of natalizumab in MS patients with some degree of fatigue.

Developing a wellness program for people with multiple sclerosis: description and initial results

Because multiple sclerosis (MS) is a multidimensional chronic disease, effective management of the illness requires a multidimensional approach. We describe a wellness program that was designed to facilitate positive health choices throughout the course of MS and present initial data analyses. We hypothesized that over the course of the program, participants would demonstrate improvement in the domains assessed. The wellness program included educational sessions in physical, mental, social, intellectual, and spiritual domains specifically targeting improved self-efficacy, physical functioning, coping skills, symptom management, and nutrition. An outcomes data collection software program was adapted to facilitate real-time patient self-report and clinician entry data collection for many domains throughout the wellness program. Initial assessment of serial measures (intake to discharge) from 65 people with MS showed improvement in several domains, including functional status (P < .05), fatigue (P < .05), fear-avoidance beliefs regarding physical activities (P < .05), depression (P < .05), somatization (P < .05), and pain (P < .05). In addition, using a model of risk for interpersonal distress, patients whose risk of elevated depression and anxiety decreased over the course of the program reported greater gains in functional status (P < .05). The results suggest possible future treatment strategies and indicate strengths and weaknesses of the wellness program, which are being used to improve the program.

Symptomatic treatment and management of multiple sclerosis

The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.

Prevalence of fatigue in patients with multiple sclerosis and its effect on the quality of life

Objective:

This prospective study was carried out to observe the prevalence of fatigue in patients with multiple sclerosis (MS) and its effect on quality-of-life (QoL).

Study Design and Setting:

Prospective observational study in a University Tertiary Research Hospital in India.

Patients and Methods:

A total of 31 patients (25 females) with definite MS according to McDonald's criteria presented in out-patient/admitted in the Department of Neurology (between February 2010 and December 2011) were included in the study. Disease severity was evaluated using the Kurtzke's expanded disability status scale (EDSS). Fatigue was assessed using Krupp's fatigue severity scale (FSS). QoL was assessed by the World Health Organization QoL-BREF questionnaire.

Results:

The mean age of patients was 30.1 ± 9.1 years. The mean age at first symptom was 25.23 ± 6.4 years. The mean number of relapses was 4.7 ± 3.6 in the patients. The mean duration of illness was 4.9 ± 4.4 years. The mean EDSS score was 3.5 ± 2.2. Mean fatigue score was 38.7 ± 18.5 (cut-off value 36 in FSS). The prevalence of fatigue in patients with MS was 58.1% (18/31). MS patients with fatigue were significantly more impaired (P < 0.05) on all QoL domains (i.e., physical, psychosocial, social, and environment) than MS patients without fatigue.

Conclusion:

Prevalence of fatigue was found to be high in the MS patients in the study. All four domains of QoL were significantly more impaired in the group with fatigue than in those without fatigue.

Fatigue in healthy and diseased individuals

OBJECTIVES

Although fatigue is experienced by everyone, its definition and classification remains under debate.

METHODS

A review of the previously published data on fatigue.

RESULTS

Fatigue is influenced by age, gender, physical condition, type of food, latency to last meal, mental status, psychological conditions, personality type, life experience, and the health status of an individual. Fatigue may not only be a symptom but also a measurable and quantifiable dimension, also known as fatigability. Additionally, it may be classified as a condition occurring at rest or under exercise or stress, as physiologic reaction or pathologic condition, as spontaneous phenomenon or triggerable state, as resistant or irresistant to preconditioning, training, or attitude, as prominent or collateral experience, and as accessible or inaccessible to any type of treatment or intervention. Fatigue may be the sole symptom of a disease or one among others. It may be also classified as acute or chronic. Quantification of fatigability is achievable by fatigue scores, force measurement, electromyography, or other means. Fatigue and fatigability need to be delineated from conditions such as sleepiness, apathy, exhaustion, exercise intolerance, lack of vigor, weakness, inertia, or tiredness. Among neurological disorders, the prevalence of fatigue is particularly increased in multiple sclerosis, amyotrophic lateral sclerosis, Parkinson disease, traumatic brain injury, stroke, and bleeding and also in neuromuscular disorders. Fatigue may be influenced by training, mental preconditioning, or drugs.

CONCLUSIONS

Fatigue needs to be recognized as an important condition that is not only a symptom but may also be quantified and can be modified by various measures depending on the underlying cause.

Association of fish consumption and Ω 3 supplementation with quality of life, disability and disease activity in an international cohort of people with multiple sclerosis

The role of fish consumption and omega 3 supplementation in multiple sclerosis (MS) is controversial, although there is some evidence to support a beneficial effect. We surveyed a large cohort of people with MS recruited via Web 2.0 platforms, requesting information on type of MS, relapse rates, disability, health-related quality of life, frequency of fish consumption and omega 3 supplementation, including type and dose, using validated tools where possible. We aimed to determine whether there was an association between fish consumption and omega 3 supplementation and quality of life, disability and disease activity for people with MS. Univariate and multivariate analyses were undertaken. Of 2469 respondents, 1493 (60.5%) had relapsing-remitting MS. Those consuming fish more frequently and those taking omega 3 supplements had significantly better quality of life, in all domains, and less disability. For fish consumption, there was a clear dose-response relationship for these associations. There were also trends towards lower relapse rates and reduced disease activity; flaxseed oil supplementation was associated with over 60% lower relapse rate over the previous 12 months. Further dietary studies and randomised controlled trials of omega 3 supplementation for people with MS are required, preferably using flaxseed oil.

Validation of patient determined disease steps (PDDS) scale scores in persons with multiple sclerosis

Background

The Patient Determined Disease Steps (PDDS) is a promising patient-reported outcome (PRO) of disability in multiple sclerosis (MS). To date, there is limited evidence regarding the validity of PDDS scores, despite its sound conceptual development and broad inclusion in MS research. This study examined the validity of the PDDS based on (1) the association with Expanded Disability Status Scale (EDSS) scores and (2) the pattern of associations between PDDS and EDSS scores with Functional System (FS) scores as well as ambulatory and other outcomes.

Methods

96 persons with MS provided demographic/clinical information, completed the PDDS and other PROs including the Multiple Sclerosis Walking Scale-12 (MSWS-12), and underwent a neurological examination for generating FS and EDSS scores. Participants completed assessments of cognition, ambulation including the 6-minute walk (6 MW), and wore an accelerometer during waking hours over seven days.

Results

There was a strong correlation between EDSS and PDDS scores (ρ = .783). PDDS and EDSS scores were strongly correlated with Pyramidal (ρ = .578 &ρ = .647, respectively) and Cerebellar (ρ = .501 &ρ = .528, respectively) FS scores as well as 6 MW distance (ρ = .704 &ρ = .805, respectively), MSWS-12 scores (ρ = .801 &ρ = .729, respectively), and accelerometer steps/day (ρ = -.740 &ρ = -.717, respectively).

Conclusion

This study provides novel evidence supporting the PDDS as valid PRO of disability in MS.

Methodology of an International Study of People with Multiple Sclerosis Recruited through Web 2.0 Platforms: Demographics, Lifestyle, and Disease Characteristics

Background. Despite evidence of the potential importance of the role of health and lifestyle behaviours in multiple sclerosis (MS) outcomes, there has not been a significant focus on this area of research. Aim. We aimed to recruit an international sample of people with MS at baseline and over a five-year timeframe, examine their health and lifestyle behaviours, and determine the relationship of these behaviours to self-reported disability, disease activity, and quality of life. Methods. People with MS were recruited through web 2.0 platforms including interactive websites, social media, blogs, and forums and completed a comprehensive, multifaceted online questionnaire incorporating validated and researcher-derived tools. Results. 2519 participants met inclusion criteria for this study. This paper describes the study methodology in detail and provides an overview of baseline participant demographics, clinical characteristics, summary outcome variables, and health and lifestyle behaviours. The sample described is unique due to the nature of recruitment through online media and due to the engagement of the group, which appears to be well informed and proactive in lifestyle modification. Conclusion. This sample provides a sound platform to undertake novel exploratory analyses of the association between a variety of lifestyle factors and MS outcomes.

Adherence to monthly online self-assessments for short-term monitoring: a 1-year study in relapsing-remitting multiple sclerosis patients after start of disease modifying treatment

BACKGROUND

The participation of neurologists and patients in studies on the effectiveness and safety of newly authorized drugs in multiple sclerosis (MS) is insufficient. Monthly online self-assessments using patient-reported outcomes may help in short-term monitoring of neurological changes and side effects.

OBJECTIVE

Investigate in relapsing-remitting (RR) MS patients the adherence to monthly online self-assessments after the start of disease modifying treatment.

METHODS

Observational study in 39 neurological departments in The Netherlands. Patients starting glatiramer acetate treatment were instructed to complete online the Modified Fatigue Impact Scale 5-item version and the 8-item Leeds Multiple Sclerosis Quality of Life scale every month during 1 year (T0 toT12).

RESULTS

Sixty-three investigators included 163 analyzable patients. At T3, 148 (90.8%) patients had completed all questionnaires; at T6, 142 (87.1%); at T9, 133 (81.6%); and at T12, 123 (75.5%). Eight (4.9%) patients did not complete any questionnaire. Median values for inter-assessment intervals ranged from 32 to 34 days (first quartile [Q1] 30 days, third quartile [Q3] 41 days), and the final assessment was at 417 days (median: Q1 385 days, Q3 480 days). Forty-three (26.3%) patients completed the questionnaires at all time points (completion adherent) with their final assessment within 30 days after the scheduled T12 (interval adherent). Eighty (49.1%) patients were completion adherent, but not interval adherent. Forty (24.5%) patients were not completion adherent, as they discontinued assessments prematurely. Men were more interval adherent than women (47.5% vs 20.0%; P = 0.001).

CONCLUSION

The observation that three out of four (75.5%) RRMS patients completed two short questionnaires at all monthly time points during 1 year after the start of disease modifying treatment suggests that intensive online monitoring in this patient group is feasible. As only one in five (19.6%) patients adhered to the time intervals between self-assessments, measures are needed that improve the timely completion of questionnaires.

Epidemiology of neurologically disabling disorders

Neurological disorders place a considerable burden upon individuals, their families, and society. Some like stroke are common, while others like amyotrophic lateral sclerosis are much rarer. Some conditions such as multiple sclerosis are reported to vary by latitude, while others such as traumatic brain injury can vary considerably by locality. Depending upon the nature of the lesion, and factors such as time since onset, the consequences to the individual may also vary considerably, not just among different disorders, but within a given disorder. Consequently the patterns of disease incidence, its prevalence, and its consequences are complex and may vary not just because of the condition itself, but also because, for example, case ascertainment may vary from study to study. The cumulative annual incidence of disabling neurological disorders is likely to exceed 1000 per 100000, or 1% of the population. The incidence is characterized by significant variation, which is mediated by genetic, geographical, demographic, and environmental factors. While useful comparisons can be made through standardization techniques, planning for local services should be based upon local epidemiology, whenever available.

Comparison of the psychometric properties of two fatigue scales in multiple sclerosis

OBJECTIVE

To compare psychometric functioning of the Fatigue Severity Scale (FSS; Krupp, LaRocca, Muir-Nash, & Steinberg, 1989) and the Modified Fatigue Impact Scale (MFIS; MSCCPG, 1998) in a community sample of persons with multiple sclerosis (MS).

METHOD

A self-report survey including the FSS, MFIS, demographic, and other health measures was completed by 1271 individuals with MS. Analyses evaluated the reliability and validity of the scales, assessed their dimensional structures, and estimated levels of floor and ceiling effects. Item response theory (IRT) was used to evaluate the precision of the MFIS and FSS at different levels of fatigue.

RESULTS

Participants had a mean score on the FSS of 5.1 and of 44.2 on the MFIS. Cronbach's alpha values for FSS and MFIS were all 0.93 or greater. Known-groups and discriminant validity of MFIS and FSS scores were supported by the analyses. The MFIS had low floor and ceiling effects, and the FSS had low floor and moderate ceiling effects. Unidimensionality was supported for both scales. IRT analyses indicate that the FSS is less precise in measuring both low and high levels of fatigue, compared with the MFIS.

CONCLUSIONS

Researchers and clinicians interested in measuring physical aspects of fatigue in samples whose fatigue ranges from mild to moderate can choose either instrument. For those interested in measuring both physical and cognitive aspects of fatigue, and whose sample is expected to have higher levels of fatigue, the MFIS is a better choice even though it is longer. IRT analyses suggest that both scales could be shortened without a significant loss of precision.

Randomized controlled trial of a teleconference fatigue management plus physical activity intervention in adults with multiple sclerosis: rationale and research protocol

BACKGROUND

Chronic fatigue and inactivity are prevalent problems among individuals with multiple sclerosis (MS) and may independently or interactively have detrimental effects on quality of life and ability to participate in life roles. However, no studies to date have systematically evaluated the benefits of an intervention for both managing fatigue and promoting physical activity in individuals with MS. This study involves a randomized controlled trial to examine the effectiveness of a telehealth intervention that supports individuals with MS in managing fatigue and increasing physical activity levels.

METHODS/DESIGN

A randomly-allocated, three-parallel group, time-series design with a social support program serving as the control group will be used to accomplish the purpose of the study. Our goal is to recruit 189 ambulatory individuals with MS who will be randomized into one of three telehealth interventions: (1) a contact-control social support intervention, (2) a physical activity-only intervention, and (3) a physical activity plus fatigue management intervention. All interventions will last 12 weeks and will be delivered entirely over the phone. Our hypothesis is that, in comparison to the contact-control condition, both the physical activity-only intervention and the physical activity plus fatigue management intervention will yield significant increases in physical activity levels as well as improve fatigue and health and function, with the physical activity plus fatigue management intervention yielding significantly larger improvements. To test this hypothesis, outcome measures will be administered at Weeks 1, 12, and 24. Primary outcomes will be the Fatigue Impact Scale, the Godin Leisure-Time Exercise Questionnaire (GLTEQ), and Actigraph accelerometers. Secondary outcomes will include the SF-12 Survey, Mental Health Inventory, Multiple Sclerosis Impact Scale, the Community Participation Indicator, and psychosocial constructs (e.g., self-efficacy).

DISCUSSION

The proposed study is novel, in that it represents a multi-disciplinary effort to merge two promising lines of research on MS: fatigue management and physical activity promotion. Collectively, the proposed study will be the largest randomized controlled trial to examine the effects of a lifestyle physical activity intervention in people with MS.

TRIAL REGISTRATION

NCT01572714.

Clinical utility of glatiramer acetate in the management of relapse frequency in multiple sclerosis

Glatiramer acetate (GA) represents one of the most common disease-modifying therapies for multiple sclerosis. GA is currently approved for patients at high risk of developing clinically definite multiple sclerosis (CDMS) after having experienced a well-defined first clinical episode (clinically isolated syndrome or CIS) and for patients with relapsing-remitting multiple sclerosis (RRMS). GA’s efficacy and effectiveness to reduce relapse frequency have been proved in placebo-controlled and observational studies. Comparative trials have also confirmed the lack of significant differences over other choices of treatment in the management of relapse frequency, and long-term studies have supported its effect at extended periods of time. Additionally, RRMS patients with suboptimal response to interferon β may benefit from reduced relapse rate after switching to GA, and those with clinically isolated syndrome may benefit from delayed conversion to CDMS. All these results, together with its proven long-term safety and positive effect on patients’ daily living, support the favorable risk-benefit of GA for multiple sclerosis treatment.

Cognitive function, depression, fatigue, and activities of daily living in patients with neuromyelitis optica after acute relapse

The status of fatigue, depression, and activities of daily living and their relationships with cognitive function in patients with neuromyelitis optica (NMO) after acute relapse has never been observed. This study investigated cognitive function, fatigue, depression, activities of daily living, and the relationships among them in NMO patients. Twenty-two NMO patients without visible lesions on conventional brain MRI after acute relapse, 22 depression patients, and 22 healthy comparison subjects received several scales to assess cognitive function, fatigue, and depression. Every NMO patient completed a survey of activities of daily living. Between-group comparisons and correlational analyses were applied to examine the differences and the relationships among them. We found that NMO patients had significantly impaired memory, decreased information processing speed, and damaged attention. Some impaired cognitive domains were significantly correlated with fatigue and depression, and activities of daily living were correlated with these impaired cognitive domains, fatigue, depression, and disability. These results confirm cognitive deficits in memory, information processing speed, and attention exist in NMO patients without visible brain lesions after acute relapse. Fatigue and depression may affect cognitive function and increase the negative impact of cognitive deficits on the activities of daily living in patients with NMO.

Sleep disorders and fatigue in multiple sclerosis: evidence for association and interaction

Fatigue is highly prevalent in multiple sclerosis (MS). It appears to be multifactorial, with "primary" or disease-related factors involved, as well as "secondary" factors, including comorbidities. Sleep disturbances are frequent in MS as well, and often result from disease-related factors. Subjective sleep disturbances in MS have been extensively studied and have been associated with fatigue. Sleep disorders in the general population have been associated with fatigue as well. However, data on objectively diagnosed sleep disorders in MS are less conclusive. Studies of sleep in MS have often suffered from low numbers of study subjects and suboptimal methodology. We review the current knowledge on sleep disturbances in MS and the relationship to fatigue. Data from neuroimaging studies and studies of molecular consequences of sleep disorders in the general population, with particular attention to sleep-disordered breathing (SDB), are briefly reviewed. Potential biologic interactions with MS are discussed in this context. We conclude that further studies of sleep disorders in MS are needed, to objectively establish their significance in this disease, and also to document any impact of treatment of sleep disorders on biologic and clinical outcomes such as fatigue.

The relationship between fatigue and other clinical features of multiple sclerosis

BACKGROUND

There has been considerable debate regarding the precise relationships between fatigue in multiple sclerosis (MS) and disease-related factors, such as disability, sleep disturbance, depression, age and sex. Existing studies give conflicting information.

OBJECTIVE

To clarify such relationships in a large cross-sectional study, using a rigorously developed measurement tool which was based on a clear definition of fatigue.

METHOD

A pack containing the Neurological Fatigue Index for MS Summary Scale, the Hospital Anxiety and Depression Scale, the Epworth Sleepiness Scale, the Multiple Sclerosis Impact Scale and questions regarding sleep and demographics was mailed to patients with MS attending two centres in the UK. All scale scores were converted to parametric measures using the Rasch measurement model. Both linear and non-linear relationships were sought.

RESULTS

Data from 635 respondents (52% response) were analysed. Fatigue was strongly related to the impact of MS. Fatigue was worse in those with progressive disease and clearly worsened once ambulation was affected. There was only weak correlation with anxiety and depression. Fatigue was not related to disease duration or patient age. There was an intimate but complex relation between fatigue and sleep. Fatigue levels were minimum at a nocturnal sleep duration of 7.5 h.

CONCLUSION

Clear relationships were found between fatigue and disability, disease type and sleep. Further physiological enquiry and trials of drug treatment and sleep modulation might be guided by these clinical relationships.