Evaluation of the Modified Fatigue Impact Scale in four different European countries

Psychological Resilience and Vulnerability as Mediators Between Adverse Life Events and Fatigue, Motor Dysfunction, and Paresthesia in Multiple Sclerosis

OBJECTIVE

Adverse life events have been associated with exacerbating multiple sclerosis (MS) symptoms, but results have been variable, raising the question on the role of other psychological factors. This study examined the role of psychological resilience and vulnerability as mediators between adverse life events on MS symptoms.

METHODS

Participants with MS (N = 1239) were aged 18 to 81 years (mean [SD] = 45.6 [10.4] years), and 84.5% were female. MS symptoms were measured by the modified Fatigue Severity Scale, modified Fatigue Assessment Scale, Motor Dysfunction Assessment Scale, Paraesthesiae Spell Duration Scale, and the Paraesthesiae Cumulative Duration Scale. Psychological measures included the Connor-Davidson Resilience Scale, Resilience Scale for Adults, Psychological Vulnerability Scale, the vulnerability section of the Defence Style Questionnaire, and the Adverse Life Events Assessment Scale. Regression analyses and structural equation modeling were performed.

RESULTS

Adverse life events during the preceding 60 days were associated with fatigue, motor dysfunction, and paresthesia, but with small effect sizes (β from 0.07 to 0.15; p ≤ .014). A structural equation model by which resilience mediated less and vulnerability more MS symptoms after adverse life events during the preceding 60 days showed a statistically significant fit with the data of a moderate to good degree (p < .001; goodness-of-fit statistic = 0.725; root mean square error of approximation = 0.047). Vulnerability played a markedly larger role than did resilience.

CONCLUSION

The results suggest that psychological resilience and vulnerability play mediating roles in the relation between adverse life events and MS symptoms, but other psychological factors also need to be investigated.

Impact of depression and fatigue on relapsing remitting multiple sclerosis in Kingdom of Saudi Arabia

Objectives:

To determine relationship between fatigue, depression with the registration in multiple sclerosis (MS) society activity, and stress with the risk developing a new attack in patients with Relapsing remitting MS (RRMS) in the Kingdom of Saudi Arabia (KSA).

Methods:

This was a cohort retrospective study conducted in the KSA between July 2018 and July 2019 which included a total of 465 RRMS patients. Data were collected during interviews using the Beck Depression Inventory (BDI) and Modified Fatigue Impacts Scale (MFIS). Demographic and clinical data were also collected.

Results:

Of 465 participants, 317 expressed psychological stress before the last attack, 67 of whom developed an attack within 4 weeks, and 250 of whom developed an attack after 4 weeks. Significantly lower BDI scores were associated with registration in MS associations (p=0.003, df = 5). Significantly lower MFIS scores were associated with registration in MS associations (p=0.001, df = 5).

Conclusion:

The majority of RRMS patients have a significant fatigue and depression, and there are significant relationships between registration in the MS society and MFIS and BDI scores where patients who officially registered in MS society have lower score in MFIS and BDI. we recommend regular follow-ups with a psychologist and/or registration with MS societies.

The clinical correlates of participation levels in people with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) has a huge impact on patients and affects their ability to participate in meaningful activities.

OBJECTIVE

To identify motor and non-motor factors that are associated with the participation level in instrumental activities of daily living (IADL), leisure, social and religious activities in people with MS.

METHOD

This is a cross-sectional study conducted on 110 individuals with MS. The used outcome measures are: Arabic version of the Activity Card Sort, Berg Balance Scale, Modified Fatigue Impact Scale, Nine Hole Peg Test, 6-Minute Walk Test, Brief International Cognitive Assessment for Multiple Sclerosis, Stroop test and Hospital Anxiety and Depression Scale.

RESULTS

Hand function, balance, gender and cognitive status can predict the participation in IADL (R2 = 0.425, P < 0.0001); depression, age, and cognitive status can predict the participation in leisure activities (R2 = 0.372, P < 0.0001), and fatigue, balance and cognitive status can predict social activities participation (R2 = 0.492, P < 0.000).

CONCLUSION

Balance, cognition and fatigue affect the level of participation in instrumental activities of daily living, leisure, and religious and social activities.

Spatial constraints and cognitive fatigue affect motor imagery of walking in people with multiple sclerosis

Motor imagery (MI) is the mental simulation of an action without any overt motor execution. Interestingly, a temporal coupling between durations of real and imagined movements, i.e., the so-called isochrony principle, has been demonstrated in healthy adults. On the contrary, anisochrony has frequently been reported in elderly subjects or those with neurological disease such as Parkinson disease or multiple sclerosis (MS). Here, we tested whether people with MS (PwMS) may have impaired MI when they imagined themselves walking on paths with different widths. When required to mentally simulate a walking movement along a constrained pathway, PwMS tended to overestimate mental movement duration with respect to actual movement duration. Interestingly, in line with previous evidence, cognitive fatigue was found to play a role in the MI of PwMS. These results suggest that investigating the relationship between cognitive fatigue and MI performances could be key to shedding new light on the motor representation of PwMS and providing critical insights into effective and tailored rehabilitative treatments.

The patients' perspective on the perceived difficulties of dual-tasking: development and validation of the Dual-task Impact on Daily-living Activities Questionnaire (DIDA-Q)

BACKGROUND

Everyday-life activities often require performing dual tasks (DT), with consequent possible occurrence of motor-cognitive or motor-motor interference. This could reduce quality of life, in particular in people with neurological diseases. However, there is lack of validated tools to assess the patients' perspective on DT difficulties in this population. Therefore, we developed the Dual-task Impact on Daily-living Activities-Questionnaire (DIDA-Q) and tested its psychometric properties in people with multiple sclerosis (PwMS).

METHODS

Items were generated based on existing scales, DT paradigms used in previous studies and the opinion of a multi-stakeholder group, including both experts and PwMS. Twenty DT constituted the preliminary version of the DIDA-Q which was administered to 230 PwMS. The psychometric properties of the scale were evaluated including internal consistency, validity and reliability.

RESULTS

Nineteen items survived after exploratory factor analysis, showing a three-factor solution which identifies the components mostly contributing to DT perceived difficulty (i.e., balance and mobility, cognition and upper-limb ability). The DIDA-Q appropriately fits the graded response model, with first evaluations supporting internal consistency (Cronbach's alpha=0.95), validity (70% of the hypotheses for convergent and discriminant constructs confirmed) and reliability (intraclass correlation coefficients=0.95) of this tool.

CONCLUSION

The DIDA-Q could be used in research and clinical settings to discriminate individuals with low vs. high cognitive-motor or motor-motor interference, and to develop and evaluate the efficacy of personalized DT rehabilitative treatments in PwMS.

Quality of life, fatigue and seizure severity in people living with epilepsy in a selected Nigerian population

BACKGROUND

Epilepsy, a chronic seizure disorder, can cause elevated fatigue and reduced quality of life (QOL) of the sufferers. Hence, improving QOL, seizure severity (SS) and fatigue are important areas of therapeutic interventions for people living with epilepsy (PLWE). Therefore, there is need to ascertain the levels and interrelationships among these constructs in PLWE.

OBJECTIVE

This study compared fatigue and QOL of PLWE with those of apparently healthy individuals (AHIs) and also determined the interrelationships between fatigue, QOL and SS in PLWE.

METHOD

This cross-sectional survey involved 91 PLWE and 101 AHIs consecutively recruited from purposively selected hospitals and hosting communities. The Short-form Health Survey (SF-36) questionnaire, the Fatigue Severity Scale, the Modified Fatigue Impact Scale and the Seizure Severity Questionnaire were used to evaluate QOL, fatigue severity (FS), fatigue impact (FI) and SS respectively. Data was analyzed using frequency count, proportions, mean and standard deviation, range, Chi-square test, Mann-Whitney U test and Spearman-rank order correlation. Alpha level was set at 0.05.

RESULTS

PLWE had significantly lower QOL compared to AHIs (U = 3057.00;p < 0.01). The two groups however experienced similar fatigue severity, but PWE suffered greater fatigue impact (U = 2798.00;p < 0.01). Significant relationships existed among FI, FS, SS and QOL in PLWE (p < 0.01).

CONCLUSION

Compared with AHIs, PLWE had poorer QOL, similar FS, and higher FI. QOL of PLWE was negatively associated with SS, FI and FS. Clinical interventions geared towards minimizing seizure, severity and impact of fatigue may improve the QOL of PLWE.

Validation of the Italian version of the Multiple Sclerosis Intimacy and Sexuality Questionnaire-19

BACKGROUND

People with multiple sclerosis (MS) may experience sexual dysfunction throughout the disease course. Validated scales to assess sexual dysfunction in MS for Italian patients are lacking. Hence, we aimed at validating Multiple Sclerosis Intimacy and Sexuality Questionnaire (MSISQ-19) for Italian MS patients.

METHODS

We included both male and female MS patients. Each patient completed the Italian translation of the MSISQ-19. Construct validity was explored by the exploratory factor analysis and the Cronbach's alpha coefficient. Test-retest stability and concurrent internal and external validity were examined by Pearson' correlation coefficients.

RESULTS

We enrolled 369 MS patients (323 female and 46 male). Italian MSISQ-19 showed a Cronbach's alpha of 0.92. MSISQ-19 test and retest total scores correlated between each other (r = 0.48, p = 0.01). MSISQ-19 total score also correlated with primary, secondary and tertiary subscales (p < 0.001).

CONCLUSION

The Italian Version of the MSISQ-19 showed satisfactory internal consistency and reliability with moderately adequate test-retest reproducibility, suggesting that it may be used as a valuable measure of sexual dysfunction in the Italian population.

Regional microglial activation in the substantia nigra is linked with fatigue in MS

OBJECTIVE

The goal of our study is to assess the role of microglial activation in MS-associated fatigue (MSAF) using [F-18]PBR06-PET.

METHODS

Fatigue severity was measured using the Modified Fatigue Impact Scale (MFIS) in 12 subjects with MS (7 relapsing-remitting and 5 secondary progressive) and 10 healthy control participants who underwent [F-18]PBR06-PET. The MFIS provides a total fatigue score as well as physical, cognitive, and psychosocial fatigue subscale scores. Standardized Uptake Value (SUV) 60-90 minute frame PET maps were coregistered to 3T MRI. Voxel-by-voxel analysis using Statistical Parametric Mapping and atlas-based regional analyses were performed. SUV ratios (SUVRs) were global brain normalized.

RESULTS

Peak voxel-based level of significance for correlation between total fatigue score and PET uptake was localized to the right substantia nigra (T-score 4.67, p = 0.001). Similarly, SUVRs derived from atlas-based segmentation of the substantia nigra showed significant correlation with MFIS (r = 0.76, p = 0.004). On multiple regression, the right substantia nigra was an independent predictor of total MFIS (p = 0.02) and cognitive MFIS subscale values (p = 0.007), after adjustment for age, disability, and depression. Several additional areas of significant correlations with fatigue scores were identified, including the right parahippocampal gyrus, right precuneus, and juxtacortical white matter (all p < 0.05). There was no correlation between fatigue scores and brain atrophy and lesion load in patients with MS.

CONCLUSION

Substantia nigra microglial activation is linked to fatigue in MS. Microglial activation across key brain regions may represent a unifying mechanism for MSAF, and further evaluation of neuroimmunologic basis of MSAF is warranted.

Exploring the Impact of Fatigue in Progressive Multiple Sclerosis: A Mixed-Methods Analysis

BACKGROUND

Patient-focused literature on fatigue in progressive forms of multiple sclerosis (MS) is sparse. This study aimed to explore progressive MS patients' experiences of fatigue.

METHODS

Adult patients in the United States with primary progressive MS (n=21) and secondary progressive MS (n=23), recruited from research panels, completed the following PRO measures: Patient Global Impression of Severity (Fatigue) (PGI-F); Fatigue Scale of Motor and Cognitive Functions (FSMC); Modified Fatigue Impact Scale (MFIS); Patient Health Questionnaire, two-item version (PHQ-2); and Patient Determined Disease Steps (PDDS). Patients subsequently participated in a 45-minute semistructured telephone interview and were asked to describe their MS symptoms and to comment on how MS affected their day-to-day lives. More detailed questions followed on the nature of their fatigue, including symptoms, impacts, frequency, and bothersomeness.

RESULTS

Patients' mean age was 52.5 years, mean time since diagnosis was 14.7 years, and 81.8% were female. 79.5% of patients were unemployed and/or receiving disability benefits. Of all spontaneously reported MS symptoms, fatigue was the most common (n=38, 86.4%), followed by ambulation problems (n=31, 70.5%) and muscle weakness (n=25, 56.8%). Patients used the words "tired," "exhausted," "wiped out," and having "little or no energy" to describe their fatigue. More patients rated fatigue as their "most troubling symptom" (n=17, 38.6%) compared with other MS-related symptoms. Half of patients reported feeling constantly fatigued, and more than 90% reported experiencing fatigue at least daily. The top three most frequently reported negative impacts of fatigue were social functioning, emotional well-being, and cognitive functioning (all >80%). Patients described themselves as "homebodies," as fatigue limited their social interactions with friends and family and impacted the types of activities they could participate in. Patients attributed their inability to think clearly or focus for long periods of time to their fatigue. Patients also reported experiencing depression and anxiety because of their fatigue, which would often have further negative effects on their relationships with friends and family. On the fatigue PRO measures, mean (standard deviation) scores were 75.2 (14.7) on the FSMC and 55.0 (15.2) on the MFIS. Most participants scored in the "high" fatigue category on the FSMC (84.1%) and above the clinically significant fatigue threshold (86.4%). MFIS and FSMC total scores correlated with PGI-F (polyserial correlations r=0.74 and r=0.62, both p<0.01) and PHQ-2 (r=0.56 and r=0.57, both p<0.01), but not with PDDS (r=0.09 and r=0.02, both p>0.05).

CONCLUSIONS

Fatigue is a common, troublesome, and disabling symptom which has a profound impact on patients' daily lives, as evidenced by qualitative analyses and high scores on established fatigue measures observed in this sample. These findings provide insights into the burden of fatigue and can inform its measurement in both clinical and research settings. Treatments that improve the symptoms of fatigue or prevent exacerbations are needed for patients with progressive MS.

Cognitive Fatigability is Independent of Subjective Cognitive Fatigue and Mood in Multiple Sclerosis

BACKGROUND

Sustained cognitive testing is used to detect cognitive fatigability and is often considered a substitute for subjective cognitive fatigue (CF). However, the relationship between cognitive fatigability and subjective CF in people with multiple sclerosis (PwMS) remains undetermined.

OBJECTIVE

To explore potential associations between fatigability induced by sustained cognitive testing and subjective CF in PwMS.

METHODS

We gave 120 PwMS and 60 demographically matched, healthy individuals the Beck Depression Inventory-FastScreen (BDI-FS) to measure mood and the Modified Fatigue Impact Scale to measure CF. In addition, we used the Quotient ADHD Test, a sustained attention test, to measure cognitive fatigability. We also explored potential correlations between the individuals' performance on the sustained attention test and thalamic volume using recent MRI scans.

RESULTS

Forty-one (34.2%) of the PwMS exhibited cognitive fatigability. These 41 were found to be significantly older (P=0.006), had been diagnosed with the disease for longer (P=0.03), had higher scores (P<0.001) on the Expanded Disability Status Scale, and had reduced thalamic volume (P=0.04) compared with the 79 (65.8%) PwMS not exhibiting cognitive fatigability. The PwMS exhibiting cognitive fatigability scored similarly on the BDI-FS (P=0.21) and self-reported similar rates of CF (P=0.62) as the PwMS not exhibiting cognitive fatigability.

CONCLUSION

Cognitive fatigability induced by sustained cognitive testing is not an accurate clinical alternative to subjective CF. This study provides evidence to support cognitive fatigability and CF in PwMS as two distinct concepts.

Study protocol: improving cognition in people with progressive multiple sclerosis: a multi-arm, randomized, blinded, sham-controlled trial of cognitive rehabilitation and aerobic exercise (COGEx)

BACKGROUND

Cognitive dysfunction affects up to 70% of people with progressive MS (PMS). It can exert a deleterious effect on activities of daily living, employment and relationships. Preliminary evidence suggests that performance can improve with cognitive rehabilitation (CR) and aerobic exercise (EX), but existing data are predominantly from people with relapsing-remitting MS without cognitive impairment. There is therefore a need to investigate whether this is also the case in people with progressive forms of the disease who have objectively identified cognitive impairment. It is hypothesized that CR and EX are effective treatments for people with PMS who have cognitive impairment, in particular processing speed (PS) deficits, and that a combination of these two treatments is more effective than each individual treatment given alone. We further hypothesize that improvements in PS will be associated with modifications of functional and/or structural plasticity within specific brain networks/regions involved in PS measured with advanced MRI techniques.

METHODS

This study is a multisite, randomized, double-blinded, sham controlled clinical trial of CR and aerobic exercise. Three hundred and sixty subjects from 11 sites will be randomly assigned into one of four groups: CR plus aerobic exercise; CR plus sham exercise; CR sham plus aerobic exercise and CR sham plus sham exercise. Subjects will participate in the assigned treatments for 12 weeks, twice a week. All subjects will have a cognitive and physical assessment at baseline, 12 weeks and 24 weeks. In an embedded sub-study, approximately 30% of subjects will undergo structural and functional MRI to investigate the neural mechanisms underlying the behavioral response. The primary outcome is the Symbol Digit Modalities Test (SDMT) measuring PS. Secondary outcome measures include: indices of verbal and non-verbal memory, depression, walking speed and a dual cognitive-motor task and MRI.

DISCUSSION

The study is being undertaken in 6 countries (11 centres) in multiple languages (English, Italian, Danish, Dutch); with testing material validated and standardized in these languages. The rationale for this approach is to obtain a robustly powered sample size and to demonstrate that these two interventions can be given effectively in multiple countries and in different languages.

TRIAL REGISTRATION

The trial was registered on September 20th 2018 at www.clinicaltrials.gov having identifier NCT03679468. Registration was performed before recruitment was initiated.

Responsiveness and clinically meaningful changes for the Persian versions of the multiple sclerosis walking scale-12 and the modified fatigue impact scale following balance and gait rehabilitation in people with multiple sclerosis

Background and Purpose: The Multiple sclerosis walking scale-12 (MSWS-12) and the Modified Fatigue Impact Scale (MFIS) are two popular outcome measures applied widely for assessing self-perceived walking ability and fatigue in people with multiple sclerosis (PwMS). The present study aimed to examine responsiveness and clinically meaningful changes for the Persian versions of the MSWS-12 and the MFIS following balance and gait rehabilitation in PwMS.Methods: Fifty-eight PwMS completed the Persian versions of the MSWS-12 and the MFIS before and after 4 weeks of balance and gait rehabilitation. Also, a 7-point global rating scale as an external criterion of change was completed at the post-intervention evaluation. The area under the receiver operating characteristics curve (AUC) and the correlation analysis were used to assess the responsiveness. In addition, the minimally clinically important change (MCIC) was measured to determine clinically meaningful changes following rehabilitation.Results: The AUC values for the Persian MSWS-12 and MFIS were 0.74 and 0.73, respectively. There were good to excellent correlations between the global rating scale of change and the Persian MSWS-12 (Gamma = 0.77) also MFIS (Gamma = 0.80) change scores (p = .001). Moreover, the MCICs of 7.5 and 4 points were obtained for the Persian MSWS-12 and MFIS, respectively.Conclusion: The Persian versions of the MSWS-12 and the MFIS were responsive outcome measures for monitoring changes in walking and fatigue after balance and gait rehabilitation in PwMS. The calculation of MCIC values would enhance the interpretation of changes in clinical and research settings.

The relationship between executive functions and fluid intelligence in multiple sclerosis

BACKGROUND & OBJECTIVE

Deficits in cognitive functions dependent upon the integrity of the prefrontal cortex have been described in Multiple Sclerosis (MS). In a series of studies we have shown that fluid intelligence (g) is a substantial contributor to frontal deficits and that, for some classical "executive" tasks, frontal deficits were entirely explained by g. However, for another group of frontal tasks deficits remained once g was introduced as a covariate. This second set of tests included multitasking and theory of mind tasks. In the present study, we aimed at determining the role of fluid intelligence in frontal deficits seen in patients with MS.

METHODS

A group of patients with Relapsing Remitting MS (n = 36) and a group of control subjects (n = 42) were assessed with a battery of classical executive tests (which included the Wisconsin Card Sorting Test, Verbal Fluency, and Trail Making Test B), a multitasking test, a theory of mind test and a fluid intelligence test.

RESULTS

MS patients showed significant deficits in the fluid intelligence task. We found differences between patients and control subjects in all tests except for the multitasking test. The differences in the classical executive tests became non-significant once fluid intelligence was introduced as a covariate, but differences in theory of mind remained.

CONCLUSIONS

The present results suggest that fluid intelligence can be affected in MS and that this impairment can play a role in the executive deficits described in MS.

Factors associated with fatigue in CNS inflammatory diseases with AQP4 and MOG antibodies

Objective

Fatigue is a common and disabling symptom amongst people with multiple sclerosis, however it has not been compared across the central nervous system (CNS) inflammatory diseases associated with aquaporin‐4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibodies (Ab). We explored the factors associated with fatigue within and across the two diseases, and compared fatigue levels between them.

Methods

We performed a cross‐sectional study of 90 AQP4‐Ab and 44 MOG‐Ab patients. Fatigue was assessed using the Modified Fatigue Impact Scale (MFIS). Clinical, demographic, and psychometric (anxiety, depression, pain) data were used as independent variables. Multivariable linear regression was used to identify significant independent variables associated with fatigue within and across the two diseases.

Results

Within AQP4‐Ab patients, age (P = 0.002), disease duration (P = 0.004), number of clinical attacks (P = 0.001), disability (P = 0.007), pain interference (P < 0.001), anxiety (P = 0.026), and depression (P < 0.001) were significant independent variables. Interestingly, disease duration had a negative association with fatigue (P = 0.004). Within MOG‐Ab patients, pain interference score (P < 0.001) and anxiety (P = 0.001) were significant independent variables. Although fatigue was worse in AQP4‐Ab patients compared to MOG‐Ab patients (P = 0.008) in all patients as well as in those who ever had transverse myelitis (P = 0.023), this was driven by the differences in age, disability and pain interference rather than antibody subtype itself.

Interpretation

Multiple factors, but not the antibody specificity, appear to contribute to fatigue in antibody positive CNS inflammatory diseases. A multifaceted treatment approach is needed to better manage the physical, cognitive, and psychosocial aspects of fatigue in these patients.

A wearable sensor identifies alterations in community ambulation in multiple sclerosis: contributors to real-world gait quality and physical activity

People with multiple sclerosis (pwMS) often suffer from gait impairments. These changes in gait have been well studied in laboratory and clinical settings. A thorough investigation of gait alterations during community ambulation and their contributing factors, however, is lacking. The aim of the present study was to evaluate community ambulation and physical activity in pwMS and healthy controls and to compare in-lab gait to community ambulation. To this end, 104 subjects were studied: 44 pwMS and 60 healthy controls (whose age was similar to the controls). The subjects wore a tri-axial, lower back accelerometer during usual-walking and dual-task walking in the lab and during community ambulation (1 week) to evaluate the amount, type, and quality of activity. The results showed that during community ambulation, pwMS took fewer steps and walked more slowly, with greater asymmetry, and larger stride-to-stride variability, compared to the healthy controls (p < 0.001). Gait speed during most of community ambulation was significantly lower than the in-lab usual-walking value and similar to the in-lab dual-tasking value. Significant group (pwMS /controls)-by-walking condition (in-lab/community ambulation) interactions were observed (e.g., gait speed). Greater disability was associated with fewer steps and reduced gait speed during community ambulation. In contrast, physical fatigue was correlated with sedentary activity, but was not related to any of the measures of community ambulation gait quality including gait speed. This disparity suggests that more than one mechanism contributes to community ambulation and physical activity in pwMS. Together, these findings demonstrate that during community ambulation, pwMS have marked gait alterations in multiple gait features, reminiscent of dual-task walking measured in the laboratory. Disease-related factors associated with these changes might be targets of rehabilitation.

Fatigue Profiles in Patients with Multiple Sclerosis are Based on Severity of Fatigue and not on Dimensions of Fatigue

Fatigue related to Multiple Sclerosis (MS) is considered a multidimensional symptom, manifesting in several dimensions such as physical, cognitive, and psychosocial fatigue. This study investigated in 264 patients with severe primary MS-related fatigue (median MS duration 6.8 years, mean age 48.1 years, 75% women) whether subgroups can be distinguished based on these dimensions. Subsequently, we tested whether MS-related fatigue consists of a single common unidimensional factor. Subscale scores on four self-reported fatigue questionnaires, including the Checklist of Individual Strength, the Modified Fatigue Impact Scale, the Fatigue Severity Scale and the SF36 vitality, were used in a cluster analysis to identify patients with similar fatigue characteristics. Next, all 54 items were included in exploratory factor analysis to test unidimensionality. Study results show that in patients with a treatment indication for primary MS-related fatigue, fatigue profiles are based on severity and not on the various dimensions of fatigue. The three profiles found, suggested one underlying fatigue dimension, but this could not be confirmed. Factor analysis of all 54 items resulted in 8 factors, confirming the multidimensional construct of the included fatigue questionnaires.

Effectiveness of monopolar dielectric transmission of pulsed electromagnetic fields for multiple sclerosis-related pain: a pilot study

INTRODUCTION

Pain is highly prevalent in patients with multiple sclerosis (MS); it is chronic in 50% of cases and is classified as nociceptive, neuropathic, or mixed-type. Pain affects quality of life, sleep, and the activities of daily living. Electrotherapy is an interesting alternative or complementary treatment in the management of pain in MS, with new innovations constantly appearing.

MATERIAL AND METHODS

This study evaluates the effectiveness of treatment with monopolar dielectric transmission of pulsed electromagnetic fields (PEMF) for pain associated with MS. We performed a randomised, placebo-controlled clinical trial including 24 patients, who were assessed with the Brief Pain Inventory, the Multiple Sclerosis International Quality of Life questionnaire, the Beck Depression Inventory, and the Modified Fatigue Impact Scale.

RESULTS

Statistically significant improvements were observed in maximum and mean pain scores, as well as in the impact of pain on work, personal relationships, and sleep and rest. Not significant differences were found between the treatment and placebo groups.

CONCLUSIONS

Treatment with PEMF may be effective in reducing pain in patients with MS, although further research is necessary to confirm its effectiveness over placebo and to differentiate which type of pain may be more susceptible to this treatment.

Factors affecting MS patients' health-related quality of life and measurement challenges in Lebanon and the MENA region

Background

In the Middle East and North Africa (MENA) region, few studies explored the quality of life of multiple sclerosis patients and the factors affecting it.

Objective

The objective of this study was to explore studies on multiple sclerosis quality of life in the MENA area through a comprehensive literature review. To validate the Multiple sclerosis international Quality of Life (MusiQoL) and Modified Fatigue Impact Scale (MFIS) in Arabic, and investigate the impact of sociodemographic and clinical variables of Lebanese multiple sclerosis patients on quality of life.

Methods

As part of an ongoing observational prospective research study, data from 663 stable multiple sclerosis patients were analysed.

Results

In Lebanese multiple sclerosis patients, the Arabic MusiQoL and MFIS seem to be accurate and valid tools with high reliability coefficients and confirmatory factor analytic indices. Variables such as age and disease type predicted multiple sclerosis quality of life, yet were significantly affected by psychosocial fatigue. The influence of sociodemographic and clinical variables on quality of life dimensions varied. Being a woman with multiple sclerosis, receiving medications and experiencing physical fatigue worsens the psychological wellbeing quality of life dimension.

Conclusion

Several sociodemographic and clinical variables predicted the health-related quality of life dimensions of multiple sclerosis patients in MENA. Further in-depth investigation to guide more targeted clinical management is recommended. We encourage using validated multidimensional tools to measure quality of life in MENA such as the Arabic MusiQoL.

Assessing life balance of European people with multiple sclerosis: A multicenter clinimetric study within the RIMS network

BACKGROUND

Life balance is defined as "a satisfying pattern of daily activity that is healthful, meaningful, and sustainable to an individual within the context of his or her current life circumstances". To assess life balance, the self-report instrument Life Balance Inventory (LBI) has been developed in the US. The aim of this study was to evaluate cross-cultural, construct validity and test-retest reliability of translated versions of the LBI in people with multiple sclerosis (MS) within different European cultures (Dutch, Flemish, Slovenian, and Spanish).

METHOD

The LBI was translated according to the principles of forward/backward translation and the cultural adaption process of patient-reported outcomes and evaluated in people with MS in each country/language area. LBI (score range 1-3; higher scores refer to better balance) was registered twice with an interval of 7 days to evaluate test-retest reliability using Intraclass Correlation Coefficients (ICCs) and Bland Altman analyses. To evaluate construct validity, Pearson correlations of the LBI with quality of life, fatigue, depression and self-efficacy were explored.

RESULTS

The total sample (n = 313, 50 ± 11 years of age, MS duration 13 ± 8 years) consisted of five subsamples: Dutch (n = 81, 74% women, 54 ± 9.6 years of age), Flemish 1 (n = 42, 57% women, 49 ± 12 years), Flemish 2 (n = 105, 63% women, 50 ± 10.6 years), Slovenian (n = 48, 79% women, 44 ± 11.2 years) and Spanish (n = 37, 62% women, 47 ± 9.0 years). Baseline total LBI scores differed between subsamples (F(4, 312)=7.19, p < 0.001). ICC [95% CI] of total LBI was 0.88 [0.83-0.92] (Flemish 2), 0.65 [0.39-0.82] (Flemish 1), 0.55 [0.37-0.69] (Dutch), 0.45 [0.15-0.67] (Spanish) and 0.35 [0.07-0.59] (Slovenian). Systematic error was present in one sample; no proportional bias occurred. Correlations ranged from 0.05 to 0.55 for quality of life and self-efficacy, from -0.50 to 0.05 for fatigue and from -0.44 to -0.28 for depression, not fully supporting the hypotheses.

CONCLUSION

The study results provide limited support for test-retest reliability, cross-cultural and construct validity of the LBI in different European subsamples. Although LBI may serve as a supportive tool in goalsetting in rehabilitation, the current version of LBI is not recommended for (international) research purposes.

Cross cultural adaptation and psychometric evaluation of an Arabic version of the modified fatigue impact scale in people with multiple sclerosis

BACKGROUND

Fatigue is a common symptom in multiple sclerosis and has significant impacts on participation and quality of life. Thus, fatigue assessment in this population is always a necessity.

OBJECTIVES

to examine the underlying structure, validity and test-retest reliability of an Arabic translated and culturally adapted version of the Modified Fatigue Impact scale (A-MFIS).

METHODS

The study was carried out into two phases: firstly, the English version of the MFIS was translated into Arabic and secondly, a detailed analysis of the psychometric properties and the structure of the translated version was conducted using Principle Component Analysis (PCA). Convergent validity was assessed by comparison with measures of disease severity, quality of life and with another measure of fatigue. Test retest reliability was assessed with intra-class correlations.

RESULTS

145 subjects participated in the study. The PCA revealed that the instrument has two main factors "cognitive" and "physical", rather than the original three factors scale. Significant correlations were found between the A-MFIS and measures of disease severity and quality of life (P<0.05). Furthermore, the A-MFIS subscale and total scores have good to high test-retest reliability.

CONCLUSION

The A-MFIS has high reliability and concurrent validity with other measures of disease severity and quality of life.

Cognitive fatigability is a quantifiable distinct phenomenon in multiple sclerosis

Cognitive fatigability in multiple sclerosis represents the decrease in cognitive performance over time. It is a frequent symptom that negatively affects quality of life and ability to work. There are no objective measures of cognitive fatigability. This study aimed at quantifying cognitive fatigability despite the learning effect and to clarify whether cognitive fatigability represents a free-standing phenomenon rather than an aspect of cognitive impairment. We measured information processing speed with the Symbol Digit Modalities Test, and the number of right answers was recorded every 30 s for 180 s. We approximated the number of right answers as function of time with two logarithmic models, one including a first-order term alone and the other adding also a second-order term. The coefficient of the latter (B) may quantify performance deflection and may represent cognitive fatigability. We tested 173 patients with multiple sclerosis, including 119 cognitively impaired and 54 cognitively preserved patients, and 35 healthy subjects. The performance of cognitively preserved patients showed a deflection at the end of task that was detected neither in controls nor in cognitively impaired patients and needed a second-order term to be approximated (p < .03, F = 14.02). B was explained neither by depression nor fatigue. We proposed for the first time a method to quantify cognitive fatigue via a second-order least square fit model, easily usable in the clinical practice. By using this novel approach, cognitive fatigability results to be a free-standing phenomenon that is more evident in cognitively preserved than in cognitive impaired patients.

Assessing fatigue in multiple sclerosis: Psychometric properties of the five-item Modified Fatigue Impact Scale (MFIS-5)

Fatigue in multiple sclerosis is a key symptom associated with work-related problems and poor quality of life outcomes. The five-item Modified Fatigue Impact Scale is a brief self-assessment tool for measuring the impact of fatigue on cognitive, physical and psychosocial function. A non-interventional, cross-sectional study was conducted to assess dimensionality and item characteristics of the five-item Modified Fatigue Impact Scale in multiple sclerosis. A total of 302 subjects were studied. Mokken analysis found the five-item Modified Fatigue Impact Scale is a strong one-dimensional scale (overall scalability index H = 0.67) with high reliability (Cronbach's alpha = 0.90). The confirmatory factor analysis model confirmed the one-dimensional structure (comparative fit index = 1.0, root-mean-square error of approximation = 0.035). Samejima's model fitted well as an unconstrained model with different item difficulties. The five-item Modified Fatigue Impact Scale shows appropriate psychometric characteristics and may constitute a valuable and easy-to-implement addition to measure the impact of fatigue in clinical practice.

Unemployment in multiple sclerosis across the ages: How factors of unemployment differ among the decades of life

Rates of unemployment in multiple sclerosis are high. Certain disease, psychological, and person-specific factors contribute to these high rates. The present study examined these factors and associated risk of unemployment by age. Participants (n = 221) completed an online survey on employment. Participants were broken down by decade of life. Several factors predicted whether someone felt as if they needed to leave the workforce. However, the extent to which these factors contributed to unemployment risk varied by age. Interventions aimed at maintaining employment should address these factors and take into consideration one's stage of life, disease, and career.

Deterioration of specific aspects of gait during the instrumented 6-min walk test among people with multiple sclerosis

Prolonged walking is typically impaired among people with multiple sclerosis (pwMS), however, it is unclear what the contributing factors are or how to evaluate this deterioration. We aimed to determine which gait features become worse during sustained walking and to examine the clinical correlates of gait fatigability in pwMS. Fifty-eight pwMS performed the 6-min walk test while wearing body-fixed sensors. Multiple gait domains (e.g., pace, rhythm, variability, asymmetry and complexity) were compared across each minute of the test and between mild- and moderate-disability patient groups. Associations between the decline in gait performance (i.e., gait fatigability) and patient-reported gait disability, fatigue and falls were also determined. Cadence, stride time variability, stride regularity, step regularity and gait complexity significantly deteriorated during the test. In contrast, somewhat surprisingly, gait speed and swing time asymmetry did not change. As expected, subjects with moderate disability (n = 24) walked more poorly in most gait domains compared to the mild-disability group (n = 34). Interestingly, a group × fatigue interaction effect was observed for cadence and gait complexity; these measures decreased over time in the moderate-disability group, but not in the mild group. Gait fatigability rate was significantly correlated with physical fatigue, gait disability, and fall history. These findings suggest that sustained walking affects specific aspects of gait, which can be used as markers for fatigability in MS. This effect on gait depends on the degree of disability, and may increase fall risk in pwMS. To more fully understand and monitor correlates that reflect everyday walking in pwMS, multiple domains of gait should be quantified.

A randomized pragmatic trial of telephone-delivered cognitive behavioral-therapy, modafinil, and combination therapy of both for fatigue in multiple sclerosis: The design of the "COMBO-MS" trial

BACKGROUND

Fatigue is one of the most common and disabling chronic symptoms in multiple sclerosis (MS). Optimization of available treatments for MS-related fatigue has been stymied by lack of comparative effectiveness research that focuses on real-world treatment delivery methods and potential modification of treatment effect by other chronic MS symptoms or disability level. This report describes the design of a patient centered, comparative effectiveness trial of cognitive behavioral-therapy (CBT), modafinil, and combination therapy of both for fatigue in MS ("COMBO-MS").

METHODS

We describe the methods of this pragmatic comparative effectiveness trial that is guided by a team of patient, family, provider, community, and payer stakeholders. Eligible participants with MS and significant fatigue severity are randomly assigned (1:1:1) to received either CBT, modafinil, or a combination of CBT and modafinil for 12 weeks. The primary outcome is change in fatigue impact as measured by the Modified Fatigue Impact Scale (MFIS) at 12 weeks. Secondary outcome measures include ecological momentary assessment (EMA) measures of fatigue intensity, fatigue interference, and fatigability (measured over 7 days' time at baseline and at 12 weeks), and change in MFIS score at 24 weeks.

PROJECTED OUTCOMES

We hypothesize that combination therapy will more effectively ameliorate fatigue severity than either monotherapy, and that heterogeneity of treatment effects will be found based on depression status, presence of known or suspected sleep disorder, and disease severity. Study findings will assist patients, providers, payers, and policy makers to provide more effective care for managing fatigue in MS.

Effect of dalfampridine on information processing speed impairment in multiple sclerosis

Objective

To test a possible benefit of dalfampridine on information processing speed (IPS), a key function for cognitive impairment (CogIm) in multiple sclerosis (MS).

Methods

In this randomized, double-blind, placebo-controlled trial, we included patients with a score on the Symbol Digit Modalities Test (SDMT) under the 10th percentile of the reference value. Patients were randomized in a 2:1 ratio to receive dalfampridine 10 mg or placebo twice daily for 12 weeks. They underwent a comprehensive neuropsychological evaluation at screening (T0), at the end of treatment (T1), and after a 4-week follow-up (T2). The primary endpoint was improvement in SDMT.

Results

Out of 208 patients screened, 120 were randomized to receive either dalfampridine (n = 80) or placebo (n = 40). At T1, the dalfampridine group presented an increase of SDMT scores vs placebo group (mean change 9.9 [95% confidence interval (CI) 8.5–11.4] vs 5.2 [95% CI 2.8–7.6], p = 0.0018; d = 0.60 for raw score; and 0.8 [95% CI 0.6–1] vs 0.3 [95% CI 0.0–0.5], p = 0.0013; d = 0.61 for z scores; by linear mixed model with robust standard error). The improvement was not sustained at T2. A beneficial effect of dalfampridine was observed in the Paced Auditory Serial Addition Test and in cognitive fatigue.

Conclusion

Dalfampridine could be considered as an effective treatment option for IPS impairment in MS.

Trial registration

2013-002558-64 EU Clinical Trials Register.

Classification of evidence

This study provides Class I evidence that for patients with MS with low scores on the SDMT, dalfampridine improves IPS.

Intensity-dependent clinical effects of an individualized technology-supported task-oriented upper limb training program in Multiple Sclerosis: A pilot randomized controlled trial

BACKGROUND

Task-oriented training promotes functional recovery in Multiple Sclerosis (MS). Know-how to determine an individualized training intensity and intensity-dependent effects are, however, unknown. The objective of the study was to investigate the feasibility and the clinical effects of a task-oriented upper limb training program at different individualized training intensities with conventional occupational therapy.

METHODS

People with MS (n = 20, EDSS range 4-8) were divided into three groups, receiving task-oriented training at 100% (n = 7) or 50% (n = 8) of their individual maximal number of repetitions, or conventional occupational therapy (n = 5). Effects were evaluated using different upper limb capacity and perceived performance measures on activity level, and measures on body functions and structures level.

RESULTS

Mixed model analyses revealed significant improvements (p < 0.05) over time on the Box and block test (BBT), Action Research Arm Test and the Manual Ability Measure-36. Significant interaction effects (group*time) in favor of the task-oriented group training at the highest intensity were found for BBT and static fatigue index during a maximal sustained handgrip strength test.

CONCLUSION

All participants were able to perform the task-oriented training at their individualized intensity without any adverse effects. Several improvements over time were found for all intervention groups, however the results suggest a superiority of task-oriented training at 100%. CLINICAL TRIAL REGISTRATION NUMBER ON CLINICALTRIALS.GOV: = NCT02688231.

Percutaneous transluminal angioplasty for treatment of chronic cerebrospinal venous insufficiency (CCSVI) in people with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a leading cause of neurological disability in young adults. The most widely accepted hypothesis regarding its pathogenesis is that it is an immune-mediated disease. It has been hypothesised that intraluminal defects, compression, or hypoplasia in the internal jugular or azygos veins may be important factors in the pathogenesis of MS. This condition has been named 'chronic cerebrospinal venous insufficiency' (CCSVI). It has been suggested that these intraluminal defects restrict the normal blood flow from the brain and spinal cord, causing the deposition of iron in the brain and the eventual triggering of an auto-immune response. The proposed treatment for CCSVI is venous percutaneous transluminal angioplasty (PTA), which is claimed to improve the blood flow in the brain thereby alleviating some of the symptoms of MS. This is an update of a review first published in 2012.

OBJECTIVES

To assess the benefit and safety of venous PTA in people with MS and CCSVI.

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group's Specialised Register up to 30 August 2018, CENTRAL (in the Cochrane Library 2018, issue 8), MEDLINE up to 30 August 2018, Embase up to 30 August 2018, metaRegister of Controlled Trials, ClinicalTrials.gov., the Australian New Zealand Clinical Trials Registry, and the World Health Organization (WHO) International Clinical Trials Registry platform. We examined the bibliographies of the included and excluded studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which PTA and sham interventions were compared in adults with MS and CCSVI.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility and risk of bias, and extracted data. We reported results as risk ratios (RR) with 95% confidence intervals (CI). We performed statistical analyses using the random-effects model; and we assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included three RCTs (238 participants) in this update. One hundred and thirty-four participants were randomised to PTA and 104 to sham treatment. We attributed low risk of bias to two (67%) studies for sequence generation and two (67%) studies for performance bias. All studies were at a low risk of detection bias, attrition bias, reporting bias and other potential sources of bias.There was moderate-quality evidence to suggest that venous PTA did not increase the proportion of patients who had operative or post-operative serious adverse events compared with the sham procedure (RR 3.33, 95% CI 0.36 to 30.44; 3 studies, 238 participants); nor did it increase the proportion of patients who improved on a functional composite measure including walking control, balance, manual dexterity, postvoid residual urine volume, and visual acuity over 12-month follow-up (RR 0.84, 95% CI 0.55 to 1.30; 1 study, 110 participants); nor did it reduce the proportion of patients who experienced new relapses at six- or 12-month follow-up (RR 0.87, 95% CI 0.51 to 1.49; 3 studies, 235 participants). There was no effect of venous PTA on disability worsening measured by the Expanded Disability Status Scale, which was reported at follow-up intervals of six months (one study), 11 months (one study) and 12 months (one study). Quality of life was reported in two studies with no difference between treatment groups. Moderate or severe pain during or post venography was reported in both PTA and sham-procedure participants in all included studies. Venous PTA was not effective in restoring blood flow assessed at one-month (one study) or 12-month follow-up (one study).

AUTHORS' CONCLUSIONS

This systematic review identified moderate-quality evidence that, compared with sham procedure, venous PTA intervention did not provide benefit on patient-centred outcomes (disability, physical or cognitive functions, relapses, quality of life) in people with MS. Venous PTA has proven to be a safe technique but in view of the available evidence of its ineffectiveness, this intervention cannot be recommended in people with MS. All ongoing trials were withdrawn or terminated and hence this updated review is conclusive. No further randomised clinical studies are needed.

Neural mechanisms of perceptual decision-making and their link to neuropsychiatric symptoms in multiple sclerosis

BACKGROUND

Decision-making (DM) capabilities are impaired in multiple sclerosis (MS). A variety of researchers hypothesized that this impairment is associated with reduced quality of life (QoL) and neuropsychiatric symptoms. Studies explicitly testing this hypothesis, however, are rare, provided inconclusive results, or evaluated only a limited selection of DM domains. Consequently, we conducted the first MS study on perceptual DM (e.g. deciding whether a car will fit into a parking lot based on a visual percept) to test this assumption.

METHODS

Specifically, we used an fMRI task that measured brain activity in 30 MS patients and 19 healthy controls (HCs) while the participants repeatedly decided whether objects referenced indirectly via their written object names would fit into a shoebox to investigate neural mechanisms of perceptual DM. The objects varied in size and thus decision difficulty. From these data, we determined voxel-wise brain activity parameters reflecting (i) decision difficulty and (ii) decision speed and related them to behavioral DM performance, QoL, mild to moderate depressive symptoms, and fatigue.

RESULTS

Patients showed reduced DM performance. Activity reflecting decision difficulty in the middle temporal gyrus was negatively related to DM performance across MS patients and HCs; activity reflecting decision speed in MS patients was associated with depressive symptoms and fatigue in areas of the dorsal visual stream.

CONCLUSION

The study shows that the perceptual DM capacity is reduced in MS. Moreover, the link between neural mechanisms of perceptual DM and neuropsychiatric symptoms suggests that an impairment in this domain is clinically relevant.

Impaired Self-Other Distinction and Subcortical Gray-Matter Alterations Characterize Socio-Cognitive Disturbances in Multiple Sclerosis

Introduction: Recent studies of patients with multiple sclerosis (MS) have revealed disturbances in distinct components of social cognition, such as impaired mentalizing and empathy. The present study investigated this socio-cognitive profile in MS patients in more detail, by examining their performance on tasks measuring more fundamental components of social cognition and any associated disruptions to gray-matter volume (GMV). Methods: We compared 43 patients with relapse-remitting MS with 43 age- and sex-matched healthy controls (HCs) on clinical characteristics (depression, fatigue), cognitive processing speed, and three aspects of low-level social cognition; specifically, imitative tendencies, visual perspective taking, and emotion recognition. Using voxel-based morphometry, we then explored relationships between GMV and these clinical and behavioral measures. Results: Patients exhibited significantly slower processing speed, poorer perspective taking, and less imitation compared with HCs. These impairments were related to reduced GMV throughout the putamen, thalami, and anterior insula, predominantly in the left hemisphere. Surprisingly, differences between the groups in emotion recognition were not significant. Conclusion: Less imitation and poorer perspective taking indicate a cognitive self-bias when faced with conflicting self- and other-representations. This suggests that impaired self-other distinction, and an associated subcortical pattern of GM atrophy, might underlie the socio-cognitive disturbances observed in MS.

Perceived fatigue and cognitive performance change in multiple sclerosis: Uncovering predictors beyond baseline fatigue

BACKGROUND

Fatigue is a common and disabling symptom in multiple sclerosis (MS) with a variety of direct and indirect influences, but remains poorly understood. Perceived fatigue and cognitive performance fatigability may only be weakly correlated and may have independent predictors. We adopted a multifactorial approach, utilising a measure of concurrent cognitive performance change in order to examine the clinical, psychological, and cognitive factors influencing perceived and cognitive performance fatigability in MS.

METHODS

Individuals with adult-onset MS were identified from a regional patient database and invited to complete an assessment battery during a home visit. Baseline perceived fatigue was measured using the Modified Fatigue Impact Scale, Fatigue Assessment Instrument, and a Visual Analogue Scale (VAS). The Conners Continuous Performance Test 3 (CCPT3) and VAS were administered before and after our intervention of roughly 2.5 hours of assessment, which represented a period of cognitive effort. The differences in scores formed measures of cognitive performance fatigability and perceived fatigue change, respectively. We examined differences across baseline fatigue, fatigue change and performance change classifications, using regression analysis to uncover predictors of perceived fatigue and performance change.

RESULTS

The sample comprised 61 participants who were recruited from an existing cohort of MS patients. Positive relationships with depression and emotion-focused coping, and a negative one with sleep, each predicted baseline perceived fatigue with the model explaining 53.5% of variance. Increased perceived fatigue change was not associated with baseline fatigue, cognitive impairment, disease variables or levels of disability, but was linked with higher anxiety, lower self-efficacy and gender. Most CCPT3 performance change variables did not show significant correlations with baseline clinical, psychological, or fatigue variables. However, two variables were predicted by positive relationships with estimated intelligence, whilst a negative relationship with self-efficacy and a positive one with post-intervention fatigue predicted one each.

CONCLUSION

Fatigue in MS is a multifactorial construct, with perceived fatigue and cognitive performance fatigability largely influenced by indirect psychological and cognitive factors. Future studies need to take these influences into account when developing fatigue assessment tools. Further, targeting influential fatigue drivers such as psychological variables may improve the burden of fatigue and quality of life of people with MS.

Physical activity in mild multiple sclerosis: contribution of perceived fatigue, energy cost, and speed of walking

Purpose: To clarify the relationship between leisure-time physical activity, perceived fatigue, and energy expenditure while walking in people with multiple sclerosis.Methods: Sixty-six people afflicted with multiple sclerosis (MS) (32 women) with a mild neurological disability, participated in this study. Energy expenditure was separately measured at rest, during comfortable walking and during fast walking via a portable metabolic device using breath-by-breath technology (COSMED K5, COSMED Srl, Rome, Italy). The Godin leisure-time exercise questionnaire assessed leisure-time physical activity. The Modified Fatigue Impact Scale determined the level of perceived fatigue.Results: Seventeen people with MS were classified as physically active; 49 were insufficiently active. Scores recorded on the Godin Leisure-Time Exercise Questionnaire were 47.8 (SD = 18.4), 7.0 (SD = 8.2), respectively. Insufficiently physically active people with MS walked slower at both normal and fast walking conditions. However, no differences between groups were observed in energy expenditure measures in both walking speeds. O₂ cost was 0.20 (SD = 0.13) and 0.21 (SD = 0.06) in the active and insufficiently active group, respectively. The insufficiently active group reported more perceived fatigue compared with the active patients; 33.3 (SD = 18.6) vs. 15.0 (SD = 19.0), p value = 0.002. Perceived fatigue was a significant variable maintaining a 10.4% variance related to leisure-time physical activity.Conclusions: Leisure-time physical activity was inversely associated with perceived fatigue and walking speed in persons with mild MS. Rehabilitation professionals should be aware of these relationships when planning rehabilitation strategies.Implication for rehabilitationThis study found that perceived fatigue is a barrier to physical activity participation even in people with mild multiple sclerosis and minimal disability.Insufficiently active people with multiple sclerosis expend the same amount of energy while walking as active multiple sclerosis individuals, though walking slower.The relationship between perceived fatigue and physical activity participation requires further exploration in the multiple sclerosis population.

Longitudinal associations between mindfulness and well-being in people with multiple sclerosis

Background/Objective: Depression, anxiety, fatigue, and sleep problems are typical conditions reported in people with multiple sclerosis (MS), often resulting in a reduction of their quality of life (QOL) and well-being. Mindfulness is a multifaceted and complex construct that has been increasingly explored for its correlated to well-being. Despite preliminary evidence, longitudinal data about the impact of mindfulness on QOL in MS remain limited. In addition, Langerian mindfulness, one of the prominent approaches to mindfulness, is yet unexplored in this field. The study aims to examine the longitudinal relationships between two forms of mindfulness (Langerian and contemplative) and QOL, anxiety, depression, fatigue, and sleep. Method: Within a larger randomized controlled trial of an online mindfulness-based stress reduction intervention, a cohort of 156 people with MS was recruited and assessed for both mindfulness constructs, QOL, anxiety, depression, fatigue, and sleep problems. Assessments were repeated after 2 and after another 6 months. Results: Both mindfulness constructs were highly correlated with all investigated outcomes. Both Langerian and contemplative mindfulness predicted higher QOL, lower anxiety, depression, fatigue, and sleep, over time. Conclusions: In both approaches dispositional mindfulness is a protective factor against depression, anxiety, fatigue, and sleep in people with MS.

Timed Up-and-Go and 2-Minute Walk Test in patients with multiple sclerosis with mild disability: reliability, responsiveness and link with perceived fatigue

BACKGROUND

Mobility limitations are frequent in patients with multiple sclerosis (MS), and could already be present in patients with so-called mild neurological disability (Expanded Disability Status Scale≤4). Assessing mobility in these patients is therefore of paramount importance. Timed Up-and-Go Test (TUG) and 2-Minute Walk Test (2MWT) are two clinically feasible tests which reliability and responsiveness are unknown among these patients. Whether fatigue, which is the number one symptom among these patients, is linked to these limitations remains unknown.

AIM

The aim of this study was to explore the intrarater reliability and minimal detectable change (MDC95), as an index of responsiveness, of TUG and 2MWT. To explore their link with perceived fatigue among patients with MS.

DESIGN

Cross-sectional observational study, including two measures.

SETTING

Two university hospital outpatient centers.

POPULATION

Patients (N.=63, 49 seen twice) with MS with mild disability (Expanded Disability Status Scale≤4).

METHODS

2MWT and TUG were performed twice in one occasion, and repeated 2 weeks later. Modified fatigue impact scale (MFIS) was used to assess fatigue. Intraclass coefficient correlations were calculated for immediate and 2-week reliability. MDC95 were computed. Correlations between mobility indices and fatigue were explored using Spearman's ρ.

RESULTS

Mobility was impaired in comparison to normative values (2MWT: -4.9% from normative distance; TUG: +32% from normative time). The immediate reliability was excellent for both the 2MWT (ICC=0.98) and TUG (ICC=0.98). Reliability at 2 weeks was excellent for 2MWT (ICC=0.95) and very good for TUG (ICC=0.90). MDC95 were respectively 20m (2MWT) and 1.3s (TUG). Both measures were significantly weakly correlated to total MFIS (ρ=-0.37 and 0.39, respectively; P<0.01).

CONCLUSIONS

The 2MWT and TUG are highly reliable and responsive in the assessment of respectively the walking capacity and general mobility of patients with MS with mild disability. Mobility impairments are linked to perceived fatigue among these patients.

CLINICAL REHABILITATION IMPACT

TUG and 2MWT are easy to administer and could be reliably used in so called mildly disabled patients with MS to assess mobility limitation.

Autologous hematopoietic stem cell transplantation improves fatigue in multiple sclerosis

BACKGROUND

Fatigue is a common problem in multiple sclerosis (MS) affecting as many as 90% of patients. The Fatigue Impact Scale (FIS) is a validated measure of fatigue in MS patients. The cause of fatigue in MS is likely multifactorial, with some evidence that ongoing central nervous system (CNS) inflammation is a contributing factor. Immunoablation and autologous hematopoietic stem cell transplantation (aHSCT) have been shown to halt ongoing CNS inflammation.

OBJECTIVE

To investigate whether halting all ongoing inflammation with aHSCT impacts FIS scores in patients with severe MS.

METHODS

In the Canadian aHSCT study ( ClinicalTrials.gov , NCT01099930), 23 patients underwent aHSCT and had FIS prospectively collected every 6 months for 36 months of follow-up. Change in FIS was analysed by repeated-measures analysis of variance (RMANOVA) with multiple linear regression to determine independent predictors.

RESULTS

The median FIS score decreased 36%, from 36 to 23 (p = 0.001), and four patients had 100% reduction. Improvement in FIS correlated with lower age and Expanded Disability Status Scale at baseline, as well as increased independence as evidenced by a return to gainful employment and even driving.

CONCLUSION

Patients had significantly less fatigue on average after aHSCT. This may serve to better understand the contribution of ongoing CNS inflammation to fatigue peculiar to MS.

Gait pattern changes after six-minute walk test in persons with multiple sclerosis

OBJECTIVE

To examine the effect of induced fatigue on spatiotemporal gait parameters in persons with multiple sclerosis (PwMS) by using 6-min walk test (6MWT).

METHODS

A cross-sectional study with a control group (25 healthy persons) was performed. Fifty-six PwMS (37 female) were divided into three groups according to their level of disability, as measured by the expanded disability status scale (EDSS): mild (n = 23, EDSS = 1.0-3.5), moderate (n = 19, EDSS = 4.0-5.5), and severe (n = 12, EDSS = 6.0-6.5). Spatiotemporal gait parameters were measured by the GAITRite electronic walkway before and after 6MWT performance. In addition, to determine the level of fatigue in PwMS, the participants completed the questionnaire modified fatigue impact scale (MFIS) before performing the 6MWT. Statistical analyses were performed to compare intragroup and intergroup differences.

RESULTS

Fatigue level was lower in the mild (37.6 ± 20.5) versus moderate (54.3 ± 17.2) versus severe (53.6 ± 12.9) groups (p < 0.05). Significant differences were found among all the groups in terms of the distance walked during the 6MWT (p = 0.001) and of the spatiotemporal gait parameters: gait velocity (cm/s), cadence (steps/min), and step length (cm) decreased and, on the contrary, step time (sec), stance, and double support time (% gait cycle) increased when EDSS scores were higher (p < 0.05). The percentage of change (%) in the spatiotemporal gait parameters, after 6MWT performance, was statistically significant in the moderate and severe groups: gait velocity (-8.8%, -25.9%) and step length (-6.5%, -13.4%) decreased, whereas step time (3.0%, 15.0%), double support time (8.8%, 19.1%), step time asymmetry (32.1%, 64.0%), and single support asymmetry (60.0%, 74.7%) increased (p < 0.05).

CONCLUSIONS

Gait pattern worsen after performing a walking-induced fatigue test, such as 6MWT, in moderate-severe PwMS (EDSS ≥ 4.0). Identifying these gait alterations will allow physiotherapists to determine specific therapeutic objectives.

Effectiveness of monopolar dielectric transmission of pulsed electromagnetic fields for multiple sclerosis-related pain: A pilot study

INTRODUCTION

Pain is highly prevalent in patients with multiple sclerosis (MS); it is chronic in 50% of cases and is classified as nociceptive, neuropathic, or mixed-type. Pain affects quality of life, sleep, and the activities of daily living. Electrotherapy is an interesting alternative or complementary treatment in the management of pain in MS, with new innovations constantly appearing.

MATERIAL AND METHODS

This study evaluates the effectiveness of treatment with monopolar dielectric transmission of pulsed electromagnetic fields (PEMF) for pain associated with MS. We performed a randomised, placebo-controlled clinical trial including 24 patients, who were assessed with the Brief Pain Inventory, the Multiple Sclerosis International Quality of Life questionnaire, the Beck Depression Inventory, and the Modified Fatigue Impact Scale.

RESULTS

Statistically significant improvements were observed in maximum and mean pain scores, as well as in the impact of pain on work, personal relationships, and sleep and rest. Not significant differences were found between the treatment and placebo groups.

CONCLUSIONS

Treatment with PEMF may be effective in reducing pain in patients with MS, although further research is necessary to confirm its effectiveness over placebo and to differentiate which type of pain may be more susceptible to this treatment.

Multiple sclerosis: Executive dysfunction, task switching and the role of attention

Background

It has been suggested that switching ability might not be affected in multiple sclerosis (MS) as previously thought; however, whether this is true under more ‘real-world’ conditions when asymmetry in task difficulty is present has not been ascertained.

Objective

The objective of this paper is to examine the impact of task difficulty asymmetry on task switching ability in MS.

Method

An ocular motor (OM) paradigm that interleaves the simple task of looking towards a target (prosaccade, PS) with the cognitively more difficult task of looking away from a target (antisaccade, PS) was used. Two switching conditions: (1) PS switch cost, switching to a simple task from a difficult task (PS switch), relative to performing two simple tasks concurrently (PS repeat); (2) AS switch cost, switching to a difficult task from a simple task (AS switch) relative to performing two difficult tasks concurrently (AS repeat). Forty-five relapsing–remitting MS patients and 30 control individuals were compared.

Results

Controls and patients produced a similar magnitude PS switch cost, suggesting that task difficulty asymmetry does not detrimentally impact MS patients when transitioning from a more difficult task to a simpler task. However, MS patients alone found switching from the simpler PS trial to the more difficult AS trial easier (shorter latency and reduced error) than performing two AS trials consecutively (AS switch benefit). Further, MS patients performed significantly more errors than controls when required to repeat the same trial consecutively.

Conclusion

MS patients appear to find the maintenance of task-relevant processes difficult not switching per se, with deficits exacerbated under increased attentional demands.

MLC901 (NeuroAiD II™) for cognition after traumatic brain injury: a pilot randomized clinical trial

Background and purpose

Treatments to facilitate recovery after traumatic brain injury (TBI) are urgently needed. We conducted a 9‐month pilot, randomized placebo‐controlled clinical trial to examine the safety and potential effects of the herbal supplement MLC901 (NeuroAiD II™) on cognitive functioning following TBI.

Methods

Adults aged 18–65 years at 1–12 months after mild or moderate TBI were randomized to receive MLC901 (0.8 g capsules 3 times daily) or placebo for 6 months. The primary outcome was cognitive functioning as assessed by the CNS Vital Signs online neuropsychological test. Secondary outcomes included the Cognitive Failures Questionnaire, the Rivermead Post‐concussion Symptom Questionnaire (neurobehavioral sequelae), Quality of Life after Brain Injury, Hospital Anxiety and Depression Scale, Modified Fatigue Impact Scale and extended Glasgow Outcome Scale (physical disability). Assessments were completed at baseline and at 3‐, 6‐ and 9‐month follow‐up. Linear mixed‐effects models were conducted, with the primary outcome time‐point of 6 months.

Results

A total of 78 participants [mean age 37.5 ± 14.8 years, 39 (50%) female] were included in the analysis. Baseline variables were similar between groups (treatment group, n = 36; control group, n = 42). Linear mixed‐effects models controlling for time, group allocation, repeated measurements, adherence and baseline assessment scores revealed significant improvements in complex attention (P = 0.04, d = 0.6) and executive functioning (P = 0.04, d = 0.4) at 6 months in the MLC901 group compared with controls. There were no significant differences between the groups for neurobehavioral sequelae, mood, fatigue, physical disability or overall quality of life at 6 months. No serious adverse events were reported.

Conclusions

MLC901 was safe and well tolerated post‐TBI. This study provided Class I/II evidence that, for patients with mild to moderate TBI, 6 months of MLC901 improved cognitive functioning.