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

Health-related quality of life in relapsing remitting multiple sclerosis patients during treatment with glatiramer acetate: a prospective, observational, international, multi-centre study

Background

Glatiramer acetate (GA) and interferon-beta (INFb) are first-line disease modifying drugs for relapsing remitting multiple sclerosis (RRMS). Treatment with INFb is associated with a significant increase in health-related quality of life (HR-QoL) in the first 12 months. It is not known whether HR-QoL increases during treatment with GA.

Methods

197 RRMS patients, 106 without and 91 with prior immunomodulation/immunosuppression, were studied for HR-QoL (Leeds Multiple Sclerosis-QoL [LMS-QoL] scale, score range 0 - 32), fatigue (Fatigue Impact Scale [FIS]) and depressed mood (Beck Depression Inventory-Short Form [BDI-SF]) at baseline and 6 and 12 months after start of GA treatment.

Results

At 6 and 12 months mean LMS-QoL scores were significantly increased in the treatment-naive patient group (p < 0.001), not in the pre-treated group. At month 12 43% of treatment-naïve patients had improved HR-QoL (increase LMS-QoL score 3 or more points) (p < 0.001). Likewise, mean FIS scores were decreased at months 6 and 12 in the treatment-naïve group (p < 0.01), not in the pre-treated group. In both groups mean BDI-SF scores did not change. No demographic or clinical baseline factor was predictive of HR-QoL increase. HR-QoL changes were zero to negative for patients who had discontinued GA before month 12 (28.4% of patients).

Conclusions

In RRMS patients without prior immunomodulation/immunosuppression treatment with GA was associated with an increase in HR-QoL in the first 6 months, that was sustained at 12 months. In 4 out of 10 patients HR-QoL improved. Increase in HR-QoL was associated with decrease in fatigue.

Quality of life in multiple sclerosis

An overall aim of treatment in multiple sclerosis is to lower the negative impact of the disease on functioning and quality of life of patients. Therefore, a measurement of functioning and quality of life should be included in the evaluation of the effectiveness of treatment. The most commonly used quality of life questionnaires, either generic or specific, were presented in this paper,. Information about clinical and functional status is useful in the interpretation of the quality of life assessment results. Because of that, instruments for the assessment of depression, cognitive functions, functional ability and fatigue in multiple sclerosis were also described.

Quality of life in multiple sclerosis: determinants, measurement, and use in clinical practice

Multiple sclerosis (MS) is a complex demyelinating disease with a relatively unpredictable course. It is well established that MS has a significant impact on health-related quality of life (HRQL) for individuals at all stages of the disease. It is argued that clinicians offer treatment to their patients for three reasons: 1) to increase longevity, 2) to prevent future morbidity, and 3) to make patients feel better. To assess how well they are accomplishing the third of these goals, clinicians have come to depend on the direct measurement of patients' HRQL. We review the many physical and emotional symptoms and other consequences of MS that negatively influence HRQL, how HRQL is measured, the unique information these measures provide compared with clinical parameters, the benefit of treatment interventions, and how to include HRQL assessment and data from other sources in clinical encounters and suggest measures to consider for clinical use.

MS quality of life, depression, and fatigue improve after mindfulness training: a randomized trial

OBJECTIVE

Health-related quality of life (HRQOL) is often much reduced among individuals with multiple sclerosis (MS), and incidences of depression, fatigue, and anxiety are high. We examined effects of a mindfulness-based intervention (MBI) compared to usual care (UC) upon HRQOL, depression, and fatigue among adults with relapsing-remitting or secondary progressive MS.

METHODS

A total of 150 patients were randomly assigned to the intervention (n = 76) or to UC (n = 74). MBI consisted of a structured 8-week program of mindfulness training. Assessments were made at baseline, postintervention, and 6 months follow-up. Primary outcomes included disease-specific and disease-aspecific HRQOL, depression, and fatigue. Anxiety, personal goal attainment, and adherence to homework were secondary outcomes.

RESULTS

Attrition was low in the intervention group (5%) and attendance rate high (92%). Employing intention-to-treat analysis, MBI, compared with UC, improved nonphysical dimensions of primary outcomes at postintervention and follow-up (p < 0.002); effect sizes, 0.4-0.9 posttreatment and 0.3-0.5 at follow-up. When analyses were repeated among subgroups with clinically relevant levels of preintervention depression, fatigue, or anxiety, postintervention and follow-up effects remained significant and effect sizes were larger than for the total sample.

CONCLUSIONS

In addition to evidence of improved HRQOL and well-being, these findings demonstrate broad feasibility and acceptance of, as well as satisfaction and adherence with, a program of mindfulness training for patients with MS. The results may also have treatment implications for other chronic disorders that diminish HRQOL.

CLASSIFICATION OF EVIDENCE

This trial provides Class III evidence that MBI compared with UC improved HRQOL, fatigue, and depression up to 6 months postintervention.

Patient-orientated longitudinal study of multiple sclerosis in south west England (The South West Impact of Multiple Sclerosis Project, SWIMS) 1: protocol and baseline characteristics of cohort

Background

There is a need for greater understanding of the impact of multiple sclerosis (MS) from the perspective of individuals with the condition. The South West Impact of MS Project (SWIMS) has been designed to improve understanding of disease impact using a patient-centred approach. The purpose is to (1) develop improved measurement instruments for clinical trials, (2) evaluate longitudinal performance of a variety of patient-reported outcome measures, (3) develop prognostic predictors for use in individualising drug treatment for patients, particularly early on in the disease course.

Methods

This is a patient-centred, prospective, longitudinal study of multiple sclerosis and clinically isolated syndrome (CIS) in south west England. The study area comprises two counties with a population of approximately 1.7 million and an estimated 1,800 cases of MS. Self-completion questionnaires are administered to participants every six months (for people with MS) or 12 months (CIS). Here we present descriptive statistics of the baseline data provided by 967 participants with MS.

Results

Seventy-five percent of those approached consented to participate. The male:female ratio was 1.00:3.01 (n = 967). Average (standard deviation) age at time of entry to SWIMS was 51.6 (11.5) years (n = 961) and median (interquartile range) time since first symptom was 13.3 (6.8 to 24.5) years (n = 934). Fatigue was the most commonly reported symptom, with 80% of participants experiencing fatigue at baseline. Although medication use for symptom control was common, there was little evidence of effectiveness, particularly for fatigue. Nineteen percent of participants were unable to classify their subtype of MS. When patient-reported subtype was compared to neurologist assessment for a sample of participants (n = 396), agreement in disease sub-type was achieved in 63% of cases. There were 836 relapses, reported by 931 participants, in the twelve months prior to baseline. Twenty-three percent of the relapsing-remitting group and 12% of the total sample were receiving disease-modifying therapy at baseline.

Conclusions

Demographics of this sample were similar to published data for the UK. Overall, the results broadly reflect clinical experience in confirming high symptom prevalence, with relatively little complete symptom relief. Participants often had difficulty in defining MS relapses and their own MS type.

Validation of the Fatigue Impact Scale in Hungarian patients with multiple sclerosis

PURPOSE

Fatigue is one of the most frequent complaints of patients with multiple sclerosis (MS). The Fatigue Impact Scale (FIS), one of the 30 available fatigue questionnaires, is commonly applied because it evaluates multidimensional aspects of fatigue. The main purposes of this study were to test the validity, test-retest reliability, and internal consistency of the Hungarian version of the FIS.

METHODS

One hundred and eleven MS patients and 85 healthy control (HC) subjects completed the FIS and the Beck Depression Inventory, a large majority of them on two occasions, 3 months apart.

RESULTS

The total FIS score and subscale scores differed statistically between the MS patients and the HC subjects in both FIS sessions. In the test-retest reliability assessment, statistically, the intraclass correlation coefficients were high in both the MS and HC groups. Cronbach's alpha values were also notably high.

CONCLUSIONS

The results of this study indicate that the FIS can be regarded as a valid and reliable scale with which to improve our understanding of the impact of fatigue on the health-related quality of life in MS patients without severe disability.

Fatigue in multiple sclerosis: mechanisms, evaluation, and treatment

Among patients with multiple sclerosis (MS), fatigue is the most commonly reported symptom, and one of the most debilitating. Despite its high prevalence and significant impact, fatigue is still poorly understood and often under-emphasized because of its complexity and subjective nature. In recent years, an abundance of literature from specialists in sleep medicine, neurology, psychiatry, psychology, physical medicine and rehabilitation, and radiology have shed light on the potential causes, impact, and treatment of MS-related fatigue. Though such a diversity of contributions clearly has advantages, few recent articles have attempted to synthesize this literature, and existing overviews have focused primarily on potential causes of fatigue rather than clinical evaluation or treatment. The aims of this review are to examine, in particular for sleep specialists, the most commonly proposed primary and secondary mechanisms of fatigue in MS, tools for assessment of fatigue in this setting, and available treatment approaches to a most common and challenging problem.

Correlation between fatigue and self-esteem in patients with multiple sclerosis

OBJECTIVE

To assess the possible association of fatigue with self-esteem in multiple sclerosis (MS) patients.

METHOD

Thirty patients were prospectively assessed. None of them presented moderate or severe depression or anxiety and their degree of disability was low (EDSS<or=3.5). They had been clinically stable for at least three months and had been receiving the same medication for at least six months. Socioeconomic level was assessed. Severity of fatigue and self-esteem were evaluated using specific, validated scales. Patients with moderate to severe anxiety and/or depression were excluded.

RESULTS

Low self-esteem correlated with fatigue (p=0.01), but not with any other variables, such as age, gender, EDSS, MS duration, number of relapses, mild depression and/or anxiety.

CONCLUSION

Greater severity of fatigue in MS correlates with low self-esteem, thus suggesting that this chronic complaint that affects so many patients can interfere with the way in which they see and value themselves.

Quality of life in multiple sclerosis: effects of current treatment options

Multiple sclerosis is the most common non-traumatic neurodegenerative disease in adults. Most of the patients present with both physical and mental deficits which reflect the dissemination of the lesions in the central nervous system, produced by the inflammatory process. The incomplete recovery after relapses, the accumulation of new deficits and the progressive nature of the condition interfere with daily activities of individuals and have a negative impact on their well-being. Indeed, studies show that quality of life measurements are constantly lower in patients with multiple sclerosis. Estimation of health-related quality of life is being increasingly recognized as necessary when analysing the effectiveness of treatment modalities and for the follow up of patients with chronic diseases such as multiple sclerosis. Current immunomodulatory interventions that are shown to reduce the frequency of relapses and delay disease progression might also have a positive effect on quality of life measurements. Additive pharmacological agents that target cognitive impairments and common symptoms such as depression, fatigue and pain, along with life-style modifications and rehabilitation programmes are also important for the appropriate management that aims to improve quality of life.

Health and quality of life in patients with relapsing multiple sclerosis: making the intangible tangible

Multiple sclerosis is diagnosed primarily in young adults with aspirations for both family and careers. For this reason, it is important to take into account the potential impact of disease and treatment on these aspirations, which relate to quality of life. Quality of life evaluations and measurements have now become an integral part of comprehensive care for multiple sclerosis patients. Moreover, quality of life endpoints are now included in most therapeutic trials of potential new treatments, as well as in observational studies of the management of multiple sclerosis. The scope of quality of life includes self-perceived status in three important domains of life, namely physical (e.g. disability, strength), psychological (e.g. depression, fatigue) and social functioning (e.g. employment, usual daily activities). A number of studies have demonstrated a positive impact on quality of life of treatment with glatiramer acetate in the above areas. Several of these included direct comparisons between glatiramer acetate and interferon-beta. it is important that quality of life issues are addressed at the outset by patients and professionals, and taken into account when choosing the most appropriate therapy for a given individual.

Contribution of impaired mobility and general symptoms to the burden of multiple sclerosis

INTRODUCTION

Few studies have evaluated the contribution of individual symptoms and impairments to the burden of multiple sclerosis (MS). This article reviews the contribution of walking impairment, fatigue, spasticity, depression, and pain, to quality of life (QOL) of the patient and economic burden of MS.

METHODS

Studies for inclusion were chosen from the literature that reported on QOL and costs in patients with MS, identified through PubMed searches (main search terms: "multiple sclerosis" combined with "quality of life," "costs," or "burden"). Articles were selected based on whether the analyses included evaluation of symptoms and impairments as contributory factors to QOL or costs.

RESULTS

Impaired mobility was ranked to be of high concern, and was suggested to be an important contributory factor to QOL, having a greater impact on physical components than mental components. Fatigue was associated with QOL, with effects on both physical and mental components of QOL, independent of disability level. Depression was inversely associated with QOL. Spasticity may affect physical components of QOL, and daily activities may be impacted in as many as 44% of patients with MS. Pain, occurring in up to 86% of patients with MS, impacts daily function and QOL across the range of physical and mental domains. The contribution of these impairments and symptoms to the economic burden has been less well characterized, although the importance of mobility to employment and productivity has been suggested by several studies.

CONCLUSIONS

Evidence suggests that impaired mobility and symptoms such as fatigue, pain, depression, and spasticity are important contributory factors to the observed reduction in QOL, and in some cases, increased costs, associated with MS. There is a need for greater recognition of the presence and effects of these disabilities, and effective targeted treatment options for specific impairments, potentially resulting in improved QOL and reduced indirect costs.

Validation of the Hospital Anxiety and Depression Scale for use with multiple sclerosis patients

Detecting clinically significant symptoms of depression and anxiety in medically ill patients using self-report rating scales presents a challenge because of somatic confounders. The Hospital Anxiety and Depression Scale (HADS) was developed with this in mind, but has never been validated for a multiple sclerosis population. Our objective was to validate the HADS for multiple sclerosis patients. Multiple sclerosis patients were interviewed for the presence of major depression (n = 180) and anxiety disorders (n = 140) with the Structured Clinical Interview for DSM-IV disorders. A receiver operating characteristic (ROC) analysis was undertaken to assess which HADS cut-off scores give the best yield with respect to diagnoses of major depression and all anxiety disorders defined by the Structured Clinical Interview for DSM-IV. A threshold score of 8 or greater on the HADS depression subscale provides a sensitivity of 90% and specificity of 87.3% (ROC area under the curve 0.938). The same cut-off score gives a sensitivity of 88.5% and a specificity of 80.7% on the anxiety subscale (ROC area under the curve 0.913), but for generalized anxiety disorder only. The study confirms the usefulness of the HADS as a marker of major depression and generalized anxiety disorder, but not other anxiety disorders, in multiple sclerosis patients.

Benefits of glatiramer acetate in the treatment of relapsing-remitting multiple sclerosis

Relapsing-remitting multiple sclerosis is a chronic, progressive disorder marked by repeated exacerbations that lead to increases in neurological disability. Glatiramer acetate and the IFN-betas are recommended as first-line agents for relapsing-remitting multiple sclerosis owing to their potential to reduce frequency and severity of relapses, decrease development of new brain lesions and delay permanent disability. After three decades of study, the preponderance of the evidence suggests that the efficacy of glatiramer acetate is similar to the IFN-betas and new data collected in more naturalistic settings suggest that it may provide improved quality of life, increased productivity and cost-effectiveness. This article will review this evidence including data from very recent head-to-head clinical trials and pharmacoeconomic analyses of cost-effectiveness.