Fatigue in multiple sclerosis: a comparison of different rating scales and correlation to clinical parameters

The association between perceived fatigue and actual level of physical activity in multiple sclerosis

BACKGROUND

Both fatigue and reduced physical activity are important consequences of multiple sclerosis (MS). However, their mutual association is poorly understood.

OBJECTIVE

The objective of the study was to determine the relation between perceived fatigue and home-based recording of motor activity in patients with MS.

METHODS

Found associations were checked for confounding by age, Expanded Disability Status Scales (EDSS), disease duration, sub-type of MS, anxiety, and depression. Forty-three ambulatory patients with MS were recruited. Ambulatory physical activity was recorded for 24 hours. Fatigue was assessed with the Fatigue Severity Scale (FSS), the Modified Fatigue Impact Scale (MFIS) and the Checklist Individual Strength (CIS20R). Linear regression was applied after which potential confounding factors were introduced in a multivariate regression model.

RESULTS

No significant associations between physical activity and fatigue scores were found, except for the MFIS sub-scale 'physical activity' (ß(physical_activity) [ß(pa)] = -0.044; SE = 0.020). The association between physical activity and the FSS score was distorted by age, MS-type, anxiety and depression and the association between physical activity and the MFIS score by age and depression. The inverse association between MFIS sub-scale 'physical activity' and physical activity was significantly strengthened by adjusting for age (ß(pa) = - 0.052; SE = 0.019), sub-type of MS (ß(pa) = - 0.048; SE = 0.020), anxiety (ß(pa) = - 0.070; SE = 0.023) and depression (ß(pa) = - 0.083; SE = 0.023).

CONCLUSIONS

In MS, there is no, or at best a weak association between severity of perceived fatigue and physical activity. Depending on the fatigue questionnaire used, patient characteristics such as age, type of MS, depression and anxiety are factors that may affect this relationship.

HAGIL (Hamburg Vigil Study): a randomized placebo-controlled double-blind study with modafinil for treatment of fatigue in patients with multiple sclerosis

Objective: To reassess the effect of modafinil, a wakefulness-promoting artificial psychostimulant, on fatigue and neuropsychological measures in patients with multiple sclerosis.

Methods: Multiple sclerosis (MS) patients with a baseline score of ≥4 on the Fatigue Severity Scale (FSS) and an Expanded Disability Status Scale score <7 were eligible for the 8-week randomized, double-blind, placebo-controlled study. Modafinil was dosed up to 200 mg/day within 1 week. Assessments were performed at baseline and after 4 and 8 weeks. The primary outcome parameter was the mean change of the FSS mean score. Secondary outcome variables were other questionnaires covering fatigue, daytime sleepiness and sleep quality. Cognitive impairment was assessed by the oral version of the Symbol Digit Modalities Test (SDMT) and the Paced Auditory Serial Addition Test (PASAT).

Results: The study included 121 MS patients. Dropout rate was 9%. Both treatment groups showed improvements through time. While mean FSS at 8 weeks showed a trend difference between groups in the intention-to-treat analysis, the primary endpoint was not met. Assessment of cognitive impairment by SDMT and PASAT showed contradictory results. All other secondary endpoints were not met. There was no major safety concern.

Conclusions: In general, the study does not support modafinil as an effective treatment for MS fatigue. However, the study shows the need for new study designs and endpoints in MS fatigue studies.

Fatigue in multiple sclerosis is closely related to sleep disorders: a polysomnographic cross-sectional study

BACKGROUND

Sleep disorders can cause tiredness. The relationship between sleep disorders and fatigue in patients with multiple sclerosis (MS) has not yet been investigated systematically.

OBJECTIVE

To investigate the relationship between fatigue and sleep disorders in patients with MS.

METHODS

Some 66 MS patients 20 to 66 years old were studied by overnight polysomnography. Using a cut-off point of 45 in the Modified Fatigue Impact Scale (MFIS), the entire cohort was stratified into a fatigued MS subgroup (n=26) and a non-fatigued MS subgroup (n=40).

RESULTS

Of the fatigued MS patients, 96% (n=25) were suffering from a relevant sleep disorder, along with 60% of the non-fatigued MS patients (n=24) (p=0.001). Sleep-related breathing disorders were more frequent in the fatigued MS patients (27%) than in the non-fatigued MS patients (2.5%). Significantly higher MFIS values were detected in all (fatigued and non-fatigued) patients with relevant sleep disorders (mean MFIS 42.8; SD 18.3) than in patients without relevant sleep disorders (mean MFIS 20.5; SD 17.0) (p<0.001). Suffering from a sleep disorder was associated with an increased risk of fatigue in MS (odds ratio: 18.5; 95% CI 1.6-208; p=0.018).

CONCLUSION

Our results demonstrate a clear and significant relationship between fatigue and sleep disorders.

Measuring fatigue in patients with multiple sclerosis: reproducibility, responsiveness and concurrent validity of three Dutch self-report questionnaires

PURPOSE

To determine the reproducibility, responsiveness and concurrent validity of Dutch versions of the Fatigue Severity Scale (FSS), Modified Fatigue Impact Scale (MFIS), and Checklist Individual Strength (CIS20R) in patients with multiple sclerosis (MS).

METHOD

Forthy-three ambulatory patients with MS (mean age 48.7 years; SD 7 years; 30 women; median Expanded Disability Status Scale score 3.5) completed the questionnaires twice within 1 week. The Intraclass Correlation Coefficients (ICCs), Bland and Altman analysis, the smallest detectable change (SDC) and the minimal detectable change (MDC) were calculated. Concurrent validity was determined by Pearson's correlation coefficients.

RESULTS

ICCs ranged from 0.76 (FSS), to 0.85 (MFIS) to 0.81 (CIS20R). Bland and Altman analysis showed no significant systematic differences between assessments. MDCs were 20.7% (FSS), 19.23% (MFIS), and 17.7% (CIS20R). Pearson correlation coefficients were r = 0.66 (FSS-MFIS), r = 0.54 (MFIS-CIS20R) and r = 0.42 (CIS20R-FSS).

CONCLUSION

Despite good test-retest reliability of FSS, MFIS and the CIS20R, the present study shows that fatigue questionnaires are not very responsive for change in patients with MS. This finding suggests that future trials should monitor profiles of fatigue by repeated measurements rather than pre-post assessments alone. The moderate associations suggest that the three questionnaires largely measure different aspects of perceived fatigue.

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

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

Neurovegetative symptoms in patients with multiple sclerosis: fatigue, not depression

Elucidating the relationship between fatigue and depression in multiple sclerosis (MS) patients is complicated by ambiguity regarding how these two constructs should be delineated. Neurovegetative symptoms of depression may reflect depression in MS patients, as they do in non-neurological populations; instead these items may measure disease-related fatigue; or disease-related fatigue and depression may reflect the same syndrome in MS patients. The present study sought to evaluate these possibilities by characterizing the underlying factor structure of self-report items designed to measure fatigue and depression symptoms. Questionnaires designed to measure fatigue and depression were administered to 174 MS patients and 84 healthy controls, and these items were subject to factor analysis. Results suggest that neurovegetative symptoms are poor indicators of depression in MS patients. Neurovegetative depression items were removed from the final model due to poor psychometric properties, or they loaded on Fatigue or Sleep Disturbance factors. The correlation between latent factors Depression and Fatigue was large (.47), but does not indicate that these phenomena are manifestations of the same construct. Hence, the results of this study support the notion that vegetative symptoms of depression do not reflect depression in MS patients, but instead measure symptoms of fatigue and sleep disturbance.

Individualized alpha activity and frontal asymmetry in major depression

Lateralized differences in frontal alpha power in individuals with major depressive disorder (MDD) are thought to reflect an aberrant affective processing style. However research into anterior alpha asymmetry and MDD has often produced conflicting results. The current study aimed to investigate whether individualized alpha bandwidths provide a more sensitive measure of anterior alpha asymmetry in MDD than the traditional fixed 8-13 Hz alpha band. Resting EEG was recorded from 34 right-handed female participants (18 controls, 16 MDD). Each participant's Individual Alpha Frequency was used to delineate a broad individualized alpha band and three individualized narrow alpha sub-bands: lower alpha1, lower alpha 2 and upper alpha. Activity within the broad and narrow individualized bandwidths and within the traditional fixed alpha band were used to compare a) controls and acutely depressed individuals and b) medicated and unmedicated MDD participants. Individualizing and subdividing the alpha bandwidth did not add appreciably to the sensitivity of anterior alpha asymmetry in MDD as no significant differences in lateralized alpha power between controls and MDD participants were observed in any alpha bandwidth. This finding was consistent under two reference schemes and across multiple scalp locations. Within the MDD group, antidepressant use was associated with significantly greater right than left hemispheric power in the lower alpha 1 band. The relevance of this finding is discussed in relation to the electrophysiological correlates of antidepressant medication use, lateralized differences in affective processing and treatment resistant MDD.

The relationship between fatigue and other clinical features of multiple sclerosis

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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.

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.

Comparing endurance- and resistance-exercise training in people with multiple sclerosis: a randomized pilot study

Objective: The purpose of this study was to compare adaptations in functional and quality of life measures following endurance- and resistance-exercise training in people with multiple sclerosis.

Design: Cross-over design with an eight-week washout period.

Setting: Community health centre.

Subjects: Sixteen individuals with multiple sclerosis.

Intervention: Subjects completed both an eight-week endurance- and an eight-week resistance-exercise training programme in a randomized order. The exercise training comprised individualized progressive programmes that were completed twice weekly in a supervised group setting.

Main measures: Grip strength, functional reach, four step square, timed up and go and six-minute walk tests, Multiple Sclerosis Impact and Modified Fatigue Impact Scales, Becks Depression Inventory and the Health Status Questionnaire Short Form-36.

Results: Sixteen of 21 (76%) subjects completed the study. Subjects attended 13.2 ± 1.6 endurance- and 15.8 ± 1.9 resistance-exercise training sessions. No adverse events were reported. No significant differences ( P < 0.05) in any outcome measures were observed between the two exercise training programmes either at baseline or following the completion of both training programmes.

Conclusion: Both endurance- and resistance-exercise training were well tolerated and appear to provide similar effects for people with multiple sclerosis, but larger studies are required to confirm these findings.

Assessment and rehabilitation of cognitive impairment in multiple sclerosis

Patients with multiple sclerosis (MS) have a substantial risk of cognitive dysfunction, even in the earliest stages of the disease, where there is minimum physical disability. Despite the high prevalence rates and the significant impact of cognitive dysfunction on quality of life in this population, cognitive functions are not routinely assessed due to the high cost and time consumption. This article provides an overview of the current state of knowledge related to cognition in MS and on the optimal approach to neuropsychological assessment of this population. It then focuses on the pharmacological and other treatment options available for MS patients with, or at risk for developing, cognitive impairment. The available immune-modulating agents may reduce the development of new lesions and therefore prevent or minimize the progression of cognitive decline. However, there is currently insufficient evidence concerning the efficiency of symptomatic treatment in MS. There is also currently no optimal non-pharmacological treatment strategy for cognitive decline in MS, as the studies published to date report heterogeneous results. Nevertheless, non-pharmacological treatments such as cognitive rehabilitation may benefit some MS patients. As cognition is increasingly recognized as a major feature of MS, its assessment and rehabilitation will become a greater priority.

Impact of autologous hematopoetic stem cell transplantation on the quality of life of patients with multiple sclerosis

OBJECTIVE: To evaluate the impact of autologous hematopoetic stem cell transplantation (autoHSCT) in the health related quality of life (HRQL) in patients with multiple sclerosis. METHOD: The sample consisted of 34 patients, over 18 years old, treated at a University Hospital in the state of São Paulo, Brazil. For data collection MOS SF-36 and EDSS scales were applied at three time points: admission of the patient, hospital discharge and 1 year posttransplantation. RESULTS: 27 patients (79%) showed stabilization or neurological improvement 1 year posttransplantation. At this time point, there was statistically significant improvement in all domains of the HRQoL. When EDSS scores were correlated with the domains of the MOS SF-36 scale, statistically significant correlations were found with physical functioning at the three time points analysed. CONCLUSION: In spite of the high risk of complications of the procedure, the HSCT had positive impact in the health related quality of life.

Correlation of self-assessed fatigue and alertness in multiple sclerosis

Background: Fatigue is the most common symptom in multiple sclerosis patients, but is difficult to measure; quantification thus relies on self-assessed questionnaires.

Objective: To evaluate a battery of neuropsychological tests regarding their capacity to objectify self-reported fatigue.

Methods: We assessed the correlation between age, gender, education, Kurtzke’s Expanded Disability Status Scale, depression, fatigue and neuropsychological testing using a cross-sectional approach in 110 multiple sclerosis patients. Fatigue was measured with the Fatigue Severity Scale. Cognition was measured using a series of neuropsychological tests including three subtests of the Test of Attentional Performance, the Brief Repeatable Battery of Neuropsychological Tests and the Faces Symbol Test.

Results: According to the Fatigue Severity Scale 51.4% of the cohort were fatigued (scores ≥4). Age, education and depression showed a significant correlation with the Fatigue Severity Scale. Only 5.5% of the cohort exhibited cognitive impairment in the Brief Repeatable Battery of Neuropsychological Tests scores. After correction for age, education, Expanded Disability Status Scale and depression, Fatigue Severity Scale scores were an independent predictor of performance in the alertness subtest of the Test of Attentional Performance (standardized coefficient beta = 0.298, p = 0.014).

Conclusion: The alertness subtest of the Test of Attentional Performance may offer an objective method of evaluating self-reported fatigue, and may therefore — in addition to the Fatigue Severity Scale — be a suitable tool for the assessment of multiple sclerosis patients complaining of fatigue.

The contribution of disease severity, depression and negative affectivity to fatigue in multiple sclerosis: a comparison with ulcerative colitis

BACKGROUND

Fatigue is one of the most common and troubling symptoms of multiple sclerosis (MS) and more severe and disabling than fatigue in other somatic populations. Although fatigue seems MS specific, its pathogenesis is still poorly understood.

OBJECTIVE

To study the disease specificity of fatigue in MS by comparing its level, its physical and psychological correlates to those of patients with ulcerative colitis (UC), a peripheral chronic auto-immune disease. We focused on the relative contribution of disease severity, depression and negative affectivity to fatigue in both patient samples.

METHODS

A total of 88 MS and 76 UC patients were included in this cross-sectional study. Fatigue, depression and negative affectivity were assessed respectively with the physical and mental fatigue subscales of the Multidimensional Fatigue Inventory, the depression subscale of the Hospital Anxiety and Depression Scale, and the neuroticism subscale of the Dutch NEO Five-Factor Inventory. The Expanded Disability Status Scale and the Colitis Activity Index were used to measure disease severity in MS and UC patients respectively.

RESULTS

While levels of both physical and mental fatigue were significantly higher in MS patients than in UC patients, there were no group differences in the contribution of disease severity, depression and negative affectivity to both physical and mental fatigue.

CONCLUSION

Although levels of fatigue are higher for MS patients when compared with UC patients, the correlates of fatigue do not indicate MS specificity. As such our results support a transdiagnostic approach to fatigue in MS.

Modafinil for the treatment of multiple sclerosis-related fatigue

OBJECTIVE

To review the efficacy and safety of off-label use of modafinil in the treatment of multiple sclerosis (MS)-related fatigue.

DATA SOURCES

Literature was accessed via MEDLINE (1966-January 2010) and International Pharmaceutical Abstracts (1960-2010), using the medical subject heading terms modafinil, multiple sclerosis, and fatigue.

STUDY SELECTION AND DATA EXTRACTION

All English-language, peer reviewed publications were analyzed for relevance. Studies appropriate to the objective were evaluated, including 3 open-label trials, 1 single-blind trial, and 2 randomized placebo-controlled trials.

DATA SYNTHESIS

Fatigue symptoms, assessed by a variety of self-reported symptom scales, improved in each of the uncontrolled studies reviewed when participants with MS received modafinil 200 mg or less daily for up to 12 weeks. These benefits were not maintained, however, in one uncontrolled study when modafinil was increased to 400 mg daily. Of the 2 randomized, controlled trials, 1 study found that modafinil 200 mg once daily resulted in a reduction in fatigue symptoms measured by the Fatigue Severity Scale at 8 weeks. The other study found no difference in the reduction of fatigue symptoms, measured by the Modified Fatigue Impact Scale at 5 weeks, between the placebo group and patients who received modafinil 100-200 mg twice daily. The most common adverse reactions associated with modafinil use in all studies included gastrointestinal and central nervous system effects.

CONCLUSIONS

Based on the available data, use of modafinil for the treatment of MS-related fatigue has demonstrated benefit in all uncontrolled studies but has conflicting results from 2 controlled studies. Modafinil is a reasonable therapeutic option in this patient population, although larger, long-term, randomized controlled studies are necessary to further elucidate the appropriate dose of modafinil, its effects on MS-related fatigue, and adverse effects associated with its use.

Clinical trial of a formal group fatigue program in multiple sclerosis

Fatigue: Take Control is a novel program to teach fatigue management to people with multiple sclerosis (MS) following recommendations in the Fatigue and Multiple Sclerosis guideline. Fatigue: Take Control includes six 2-hour group sessions with DVD viewing, discussion and homework and accompanying participant and leader workbooks. While many people have participated in Fatigue: Take Control programs, its efficacy has not been determined. The objective of this study was to determine whether participation in Fatigue: Take Control reduces fatigue and increases self-efficacy in people with MS. Thirty participants were randomly assigned to a group who immediately participated in the program (FTC) or a wait-list group (WL). The primary outcome was the Modified Fatigue Impact Scale (MFIS) and secondary outcomes were the Multiple Sclerosis Self-Efficacy Scale (MSSE) and the Fatigue Severity Scale (FSS). The MFIS was administered on 10 occasions. Other measures were administered on four occasions. A mixed model tested the effects using all observations. Compared with the WL, the FTC group had significantly more improvement on the MFIS [F(1, 269) = 7.079, p = 0.008] and the MSSE [F(1, 111) = 5.636, p = 0.019]. No significant effect was found for the FSS. Across all visits, fatigue was significantly lower and self-efficacy was significantly higher for the FTC group compared with the WL group. This pilot study demonstrated significant effects in fatigue and self-efficacy among subjects taking the Fatigue: Take Control program, suggesting that this comprehensive program based on the Fatigue and Multiple Sclerosis guideline may be beneficial in MS.

Ventromedial prefrontal cortex modulates fatigue after penetrating traumatic brain injury

BACKGROUND

Fatigue is a common and disabling symptom in neurologic disorders including traumatic penetrating brain injury (PBI). Despite fatigue's prevalence and impact on quality of life, its pathophysiology is not understood. Studies on effort perception in healthy subjects, animal behavioral paradigms, and recent evidence in different clinical populations suggest that ventromedial prefrontal cortex could play a significant role in fatigue pathophysiology in neurologic conditions.

METHODS

We enrolled 97 PBI patients and 37 control subjects drawn from the Vietnam Head Injury Study registry. Fatigue was assessed with a self-report questionnaire and a clinician-rated instrument; lesion location and volume were evaluated on CT scans. PBI patients were divided in 3 groups according to lesion location: a nonfrontal lesion group, a ventromedial prefrontal cortex lesion (vmPFC) group, and a dorso/lateral prefrontal cortex (d/lPFC) group. Fatigue scores were compared among the 3 PBI groups and the healthy controls.

RESULTS

Individuals with vmPFC lesions were significantly more fatigued than individuals with d/lPFC lesions, individuals with nonfrontal lesions, and healthy controls, while these 3 latter groups were equally fatigued. VmPFC volume was correlated with fatigue scores, showing that the larger the lesion volume, the higher the fatigue scores.

CONCLUSIONS

We demonstrated that ventromedial prefrontal cortex lesion (vmPFC) plays a critical role in penetrating brain injury-related fatigue, providing a rationale to link fatigue to different vmPFC functions such as effort and reward perception. The identification of the anatomic and cognitive basis of fatigue can contribute to developing pathophysiology-based treatments for this disabling symptom.

CSF hypocretin-1 concentrations correlate with the level of fatigue in multiple sclerosis patients

Considering the multiplicity of symptoms associated with multiple sclerosis (MS), there is possibility that hypocretin system function might be involved in the pathogenesis of the disease. The current study aimed to investigate the hypocretin-1 levels in cerebrospinal fluid (CSF) of MS patients in relation to different neurological deficit measures including: Ambulation Index (AI), Expanded Disability Status Scale (EDSS), Fatigue Severity Scale (FSS), and Epworth Sleepiness Scale (ESS) in relapse-onset MS patients. 53 subjects were included into the study: 38 patients with a diagnosis of MS and 15 healthy controls. Among MS patients, 25 had relapsing-remitting and 13 secondary progressive MS. CSF hypocretin-1 levels did not differ between MS patients and healthy controls (p>0.05). A positive correlation between hypocretin-1 level and fatigue level was found in MS patients (p<0.05) and this effect was even stronger in the MS subgroup suffering from fatigue (p=0.01). Hypocretin system seems to be generally unchanged in MS but a positive correlation between hypocretin-1 level and fatigue may indicate involvement of some compensatory mechanisms stimulating the production of the neuropeptide in MS patients.

Fatigue, mood and quality of life improve in MS patients after progressive resistance training

Fatigue occurs in the majority of multiple sclerosis patients and therapeutic possibilities are few. Fatigue, mood and quality of life were studied in patients with multiple sclerosis following progressive resistance training leading to improvement of muscular strength and functional capacity. Fatigue (Fatigue Severity Scale, FSS), mood (Major Depression Inventory, MDI) and quality of life (physical and mental component scores, PCS and MCS, of SF36) were scored at start, end and follow-up of a randomized controlled clinical trial of 12 weeks of progressive resistance training in moderately disabled (Expanded Disability Status Scale, EDSS: 3—5.5) multiple sclerosis patients including a Control group ( n = 15) and an Exercise group ( n = 16). Fatigue (FSS > 4) was present in all patients. Scores of FSS, MDI, PCS—SF36 and MCS—SF36 were comparable at start of study in the two groups. Fatigue improved during exercise by —0.6 (95% confidence interval (CI) —1.4 to 0.4) a.u. vs. 0.1 (95% CI —0.4 to 0.6) a.u. in controls ( p = 0.04), mood improved by —2.4 (95% CI —4.1 to 0.7) a.u. vs. 1.1 (—1.2 to 3.4) a.u. in controls ( p = 0.01) and quality of life (PCS—SF36) improved by 3.5 (95% CI 1.4—5.7) a.u. vs. —1.0 (95% CI —3.4—1.4) a.u. in controls ( p = 0.01). The beneficial effect of progressive resistance training on all scores was maintained at follow-up after further 12 weeks. Fatigue, mood and quality of life all improved following progressive resistance training, the beneficial effect being maintained for at least 12 weeks after end of intervention.

Communicating about the experience of pain and fatigue in disability

PURPOSE

To examine the experiences of people with chronic disabling conditions as they communicate with health care providers about pain and fatigue.

METHOD

Twenty-three adults with a variety of chronic disabling conditions participated in 5 focus groups. The following issues were raised: tell me about your pain/fatigue; what things go along with pain/fatigue? how do you talk about pain/fatigue with your health care provider (HCP)? What should your HCP know that they do not ask you about?

RESULTS

Results of qualitative analysis suggested two major themes. The first theme was labeled "Putting it in words" and suggests that both pain and fatigue are described in many ways, including the dimensions of type, intensity, level of interference and temporal aspects. Participants reported difficulty with responding to a single question that asked them to assign a number to their level of pain or fatigue. The second theme was labeled, "Let's talk about it" and suggested that participants wanted HCPs "to listen and believe me when I describe my experience". They wanted to be asked about how pain or fatigue interferes with life and about compensatory strategies rather than being asked to rate symptom intensity. Participants wished to be viewed as experts and to be actively involved in decisions about their health care.

CONCLUSIONS

Pain and fatigue were viewed as having many facets that are associated in complex ways with other aspects of the health/disability condition. From the participants' perspective, assignment of a pain intensity rating does not represent the complexity of their pain experience. Suggestions are provided for HCPs when communicating about pain and fatigue with people with chronic conditions.

Endurance exercise improves walking distance in MS patients with fatigue

OBJECTIVES

Effects of endurance training in multiple sclerosis (MS) patients complaining of motor fatigue.

MATERIALS AND METHODS

Thirty MS patients complaining of fatigue with low to moderate disabilities randomly allocated to the intervention (thrice weekly 45-min intervals of endurance exercise) or control treatment (three 45-min episodes of stretching, balance training and coordination), both as 'add-on' therapy for 3 weeks during inpatient rehabilitation.

RESULTS

Maximal walking distance before intervention averaged 1043 +/- 568 and 1163 +/- 750 m in the two groups. The intervention group increased its maximal walking distance by 650 +/- 474 m. The control group extended its walking distance by 96 +/- 70 m.

CONCLUSIONS

The present data confirm a strong effect of endurance exercise on maximal walking distance. Remarkably, there were no parallel improvements on the Modified Fatigue Impact Scale, the Beck Depression Inventory and the Hamburg Quality of Life Questionnaire for MS.

Subjective fatigue is not associated with cognitive impairment in multiple sclerosis: cross-sectional and longitudinal analysis

Background

Studies in multiple sclerosis (MS) report conflicting conclusions regarding fatigue and cognition, which may partly be due to the use of small sample sizes and frequent reliance on a cross-sectional approach.

Objective

The ability to distinguish between these two disabling symptoms is necessary in order to properly assess and treat MS patients.

Methods

In a retrospective analysis, we assessed the correlation between fatigue and neuropsychological (NP) testing using a cross-sectional ( n = 465) and longitudinal approach ( n = 69). Cognition was measured using a comprehensive battery called the Minimal Assessment of Cognitive Function in MS (MACFIMS), and fatigue was measured with the Fatigue Severity Scale (FSS). FSS scores were categorized as normal (≤4.0), borderline fatigue (4 < FSS < 5.0), and fatigued (≥5.0). Repeat assessments ( n = 69) were categorized as improved or worsened by a change in FSS of either 0.5 or 1.0.

Results

MS patients had significantly higher FSS scores than normal controls ( P < 0.001). No correlation was found between FSS and NP scores in either cross-sectional or longitudinal analyses. Fatigue was moderately correlated with depression, assessed using the Beck Depression Inventory Fast Screen (BDIFS) ( r = 0.44, P < 0.001). Longitudinally, there was a medium correlation between change in FSS and BDIFS ( r = 0.34, P = 0.001), but no significant differences on NP scores using either definition of change.

Conclusion

We conclude that self-reported fatigue, while correlated with self-reported depression, is not significantly related to cognitive capacity in MS.

Effect of resistance training on risk of coronary artery disease in women with multiple sclerosis

The effects of a lower-extremity progressive resistance-training program (PRT) on risk factors for coronary artery disease (CAD) were determined in patients with multiple sclerosis (MS). Twelve ambulatory women with MS (47.3+/-4.7 years; Expanded Disability Status Score (EDSS), 4.00+/-1.37) completed twice weekly lower-body PRT for 8 weeks. Knee extensor and ankle flexor strength improved significantly (p<0.05) after training, and self-reported fatigue decreased (p<0.05). Serum triglyceride concentrations decreased (p<0.05) but body-weight and fatness, blood pressure, and serum glucose, total cholesterol and high-density lipoprotein cholesterol were unchanged. However, the number of CAD risk factors that reached the clinical threshold for each subject declined after PRT, suggesting that resistance training can promote CAD risk reduction in ambulatory female MS subjects.

Progressive resistance exercise for people with multiple sclerosis

PURPOSE

This study aimed to determine if participation in a progressive resistance exercise (PRE) programme can: (1) increase the ability to generate maximal muscle force, (2) increase muscle endurance, (3) increase functional activity, and (4) improve overall psychological function of people with multiple sclerosis (MS).

METHODS

A pre-post single group research design with a 4-week baseline familiarisation phase was used. Nine people (mean age 45.6 years, SD 10.7) with MS attended a gymnasium three times over 4 weeks for familiarization. Participants then completed a twice-weekly 10-week PRE programme, with two sets of 10 - 12 repetitions of each exercise. Outcome measures of muscle strength (1RM for arms and legs), muscle endurance (repetitions at half 1RM), walking speed, the 2-min walk test (2MWT), a timed stairs test, and the impact of MS on physical and psychological function were taken at weeks 2, 4, and 14.

RESULTS

Participants attended 94.3% (SD 8.2%) of the training sessions, with no adverse events. After accounting for baseline stability, significant improvements (P < 0.05) were found in arm strength (14.4%), leg endurance (170.9%), fast walking speed (6.1%), and there was a trend for increased distance in the 2MWT (P = 0.06). The perceived impact of MS on physical function was reduced (P = 0.02).

CONCLUSIONS

Adults with MS benefited from a PRE programme by improving muscle performance and physical activities, without adverse events. These findings suggest that PRE may be a feasible and useful fitness alternative for people with mild to moderate disability due to MS.

Restless leg syndrome, sleep quality and fatigue in multiple sclerosis patients

We have tested the hypothesis that restless leg syndrome (RLS) is related to quality of sleep, fatigue and clinical disability in multiple sclerosis (MS). The diagnosis of RLS used the four minimum criteria defined by the International Restless Legs Syndrome Study Group. Fatigue was assessed by the Fatigue Severity Scale (FSS >27), quality of sleep by the Pittsburgh Sleep Quality Index (PSQI >6), excessive daytime sleepiness by the Epworth Sleepiness Scale (ESS >10) and clinical disability by the Expanded Disability Status Scale (EDSS). Forty-four patients (32 women) aged 14 to 64 years (43 +/- 14) with disease from 0.4 to 23 years (6.7 +/- 5.9) were evaluated. Thirty-five were classified as relapsing-remitting, 5 as primary progressive and 4 as secondary progressive. EDSS varied from 0 to 8.0 (3.6 +/- 2.0). RLS was detected in 12 cases (27%). Patients with RLS presented greater disability (P = 0.01), poorer sleep (P = 0.02) and greater levels of fatigue (P = 0.03). Impaired sleep was present in 23 (52%) and excessive daytime sleepiness in 3 cases (6.8%). Fatigue was present in 32 subjects (73%) and was associated with clinical disability (P = 0.000) and sleep quality (P = 0.002). Age, gender, disease duration, MS pattern, excessive daytime sleepiness and the presence of upper motor neuron signs were not associated with the presence of RLS. Fatigue was best explained by clinical disability and poor sleep quality. Awareness of RLS among health care professionals may contribute to improvement in MS management.

Randomized, double-blind, placebo-controlled trial of iron supplementation in female soldiers during military training: effects on iron status, physical performance, and mood

BACKGROUND

Decrements in iron status have been reported in female soldiers during military training. Diminished iron status adversely affects physical and cognitive performance.

OBJECTIVE

We wanted to determine whether iron supplementation could prevent decrements in iron status and improve measures of physical performance and cognitive status in female soldiers during basic combat training (BCT).

DESIGN

In this 8-wk randomized, double-blind, placebo-controlled trial, soldier volunteers (n = 219) were provided with capsules containing either 100 mg ferrous sulfate or a placebo. Iron status indicator assays were performed pre- and post-BCT. Two-mile running time was assessed post-BCT; mood was assessed by using the Profile of Mood States questionnaire pre- and post-BCT.

RESULTS

The BCT course affected iron status: red blood cell distribution width and soluble transferrin receptor were elevated (P < 0.05), and serum ferritin was lowered (P < 0.05) post-BCT. Iron supplementation attenuated the decrement in iron status; group-by-time interactions (P < 0.01) were observed for serum ferritin and soluble transferrin receptor. Iron supplementation resulted in improved (P < 0.05) vigor scores on the Profile of Mood States post-BCT and in faster running time (P < 0.05) in volunteers reporting to BCT with iron deficiency anemia.

CONCLUSIONS

Iron status is affected by BCT, and iron supplementation attenuates the decrement in indicators of iron status in female soldiers. Furthermore, iron supplementation may prove to be beneficial for mood and physical performance during the training period. Future efforts should identify and treat female soldiers or athletes who begin training regimens with iron deficiency or iron deficiency anemia.

Health perceptions and clinical characteristics of relapsing-remitting multiple sclerosis patients: baseline data from an international clinical trial

OBJECTIVE

Baseline clinical and health-related quality of life (HRQoL) data from a phase 2, multi-site, international, randomized, controlled trial were analyzed to: (1) characterize the health status of patients with relapsing-remitting multiple sclerosis (RRMS), (2) explore cross-sectional relationships between HRQoL and clinical measures, and (3) evaluate differences in HRQoL scores for subsequent validation as minimally important differences (MID).

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov, NCT00207727.

RESEARCH DESIGN AND METHODS

Baseline clinical and HRQoL data were selected and analyzed. HRQoL questionnaires included the Short Form-36 (SF-36), Fatigue Severity Scale (FSS), a Patient Assessment of multiple sclerosis (MS) Impact (PAMSI), and MS-specific symptom scales for Bladder and Bowel Control, Cognition, and Sexual Satisfaction. Standard summary statistics described the population while Pearson and Spearman correlations evaluated the baseline association between HRQoL and clinical measures. Cross-sectional estimates of MID in HRQoL scores were derived using several clinical anchors, the PAMSI, and two tests: Tukey multiple comparisons and adjacent mean difference.

RESULTS

Patients (n = 249) had a mean age of 39.0 (Standard deviation, SD = 10.5), 70% were female, 63% resided in Europe, and 96% were Caucasian. Baseline median Expanded Disability Severity Scale (EDSS) was 2.5 (range = 0.0-6.5); median disease duration was 1.9 years (range = 0.1-33.6). The worst baseline mean (normalized) SF-36 scores were for General Health (39.9), Role Physical (40.4), Physical Functioning (41.0), and Vitality (42.7). The worst MS symptom mean scores were for Cognition (6.3) and FSS (4.4). Fatigue scores indicated substantial burden and were consistent with SF-36 Vitality results. Baseline HRQoL scores (SF-36, FSS, MS symptom scales) correlated most with EDSS, Multiple Sclerosis Functional Composite (MSFC), age and disease duration. Lesion count and pre-baseline relapse rate had no meaningful association with HRQoL or other clinical measures. The MID for several HRQoL measures are proposed for confirmation in longitudinal patient datasets.

CONCLUSION

Clinical and HRQoL assessments documented health impairments in physical functioning, fatigue, and cognition among these RRMS patients with relatively short disease duration. HRQoL data varied with clinical measures and contributed new information regarding disease burden. The association between clinical and HRQoL measures was limited to cross-sectional analysis and requires confirmation in longitudinal datasets. These findings reflect an ambulatory, early-stage RRMS population that was mostly European in location or descent. The PAMSI also requires further validation as a measure of patient health status.

Use of cognitive aids and other assistive technology by individuals with multiple sclerosis

PURPOSE

To investigate the use of assistive technology (AT), unmet needs for AT, and examine correlates of use of memory aids and cognitive strategies among individuals with multiple sclerosis (MS).

METHOD

A cross-sectional study of 1,063 community dwelling adults with MS in Washington State. A self-report survey assessed use of AT as well as depression, fatigue, mobility, and other demographic and disease related variables.

RESULTS

Some 70% of respondents reported using memory strategies and 50.7% reported using electronic memory aids. The strongest correlate of use of electronic memory aids was endorsement of difficulties thinking (OR: 2.09, p < 0.001) though younger age, higher education, and report of higher fatigue were also significant. Fatigue (OR: 1.27, p < 0.001) and depression (OR: 0.89, p < 0.001) were highly associated with use of memory strategies. Subjects who were older, unemployed, more depressed, and have more mobility disability were less likely to use memory strategies.

CONCLUSIONS

Use of AT for memory is widespread and further research should be conducted on efficacy of AT. Many individuals who might be presumed to need AT for memory most (older, less educated, more disability) are least likely to report use. Healthcare providers are urged to ask about memory AT and make appropriate referrals.

Prevalence, severity, and predictors of fatigue in subjects with primary Sjögren's syndrome

OBJECTIVE

To investigate the relationship of fatigue severity to other clinical features in primary Sjögren's syndrome (SS) and to identify factors contributing to the physical and mental aspects of fatigue.

METHODS

We identified 94 subjects who met the American-European Consensus Group criteria for the classification of primary SS. Fatigue was assessed with a visual analog scale, the Fatigue Severity Scale (FSS), and the Profile of Fatigue (ProF). Associations with fatigue were compared using multivariate regression.

RESULTS

Abnormal fatigue, defined as an FSS score >or=4, was present in 67% of the subjects. Pain, helplessness, and depression were the strongest predictors of fatigue according to the FSS and the somatic fatigue domain of the ProF (ProF-S), both with and without adjustment for physiologic and serologic characteristics. Depression was associated with higher levels of fatigue; however, the majority of subjects with abnormal fatigue were not depressed. Anti-Ro/SSA-positive subjects were no more likely to report fatigue than seronegative subjects. The regression models explained 62% of the variance in FSS and 78% of the variance in ProF-S scores. Mental fatigue was correlated with depression and helplessness, but the model predicted only 54% of the variance in mental fatigue scores.

CONCLUSION

Psychosocial variables are determinants of fatigue, but only partially account for it. Although fatigue is associated with depression, depression is not the primary cause of fatigue in primary SS. Investigation of the pathophysiologic correlates of physical and mental aspects of fatigue is needed to guide the development of more effective interventions.

Validation of the fatigue severity scale in a Swiss cohort

BACKGROUND

Fatigue is highly prevalent and has a negative impact on quality of life and performance in a variety of disorders. The 9-item Fatigue Severity Scale (FSS) is one of the most commonly used self-report questionnaires to measure fatigue, but has only been validated in small sample-sized studies and in single disorders.

OBJECTIVE

To validate the FSS in healthy subjects and different disorders known to be commonly associated with fatigue.

MATERIAL AND METHODS

The FSS was administered to 454 healthy subjects, 188 patients with multiple sclerosis (MS), 235 patients with recent ischemic stroke, and 429 patients with sleep-wake disorders including narcolepsy with cataplexy (n=22), restless legs syndrome (RLS) (n=79), sleep apnea (n=108), insomnia (n=62), parasomnia (n=25), excessive daytime sleepiness/hypersomnia of other origin (n=84, and other sleep-wake disorders (n=49.

RESULTS

FSS scores were 4.66 +/- 1.64 (mean +/- SD) in patients with MS, 3.90 +/- 1.85 in patients after ischemic stroke, and 4.34 +/- 1.64 in patients with sleep-wake disorders. Compared to patients, values were significantly lower in healthy subjects (3.00 +/- 1.08, P < 0.01). Scores did not correlate with gender, age, or education. Item analysis showed an excellent internal consistency and reliability (Cronbach alpha = 0.93). Test-retest variability was assessed in 104 healthy subjects, showing stable values over time (2.94 +/- 0.90 vs. 2.90 +/- 0.74; P = 0.27).

CONCLUSIONS

This first validation of a fatigue scale in a large sample size demonstrates that the FSS is a simple and reliable instrument to assess and quantify fatigue for clinical and research purposes.

Mediators and moderators of the stressor-fatigue relationship in nonclinical samples

OBJECTIVE

Two cross-sectional studies examined statistical mediators and moderators of the stressful life event (SLE)-fatigue relationship. If such factors can be delineated, they might suggest possible avenues for improving current psychological treatments for fatigue.

METHODS

In Study 1, 281 (63 males and 218 females) participants, 18 to 70 years, completed a questionnaire asking about stressors, social support, demographics, and fatigue. In Study 2, 609 (225 males and 384 females) participants, 18 to 80 years, answered questions about the abovementioned variables, and sleep quality and use of sleep medications.

RESULTS

Younger age, more SLEs, and low social support satisfaction were found to be related to fatigue levels in Study 1. These results were replicated in Study 2, and, additionally, sleep disturbance (i.e., low sleep quality, use of sleep medications) was related to fatigue levels, while age was related to fatigue via the use of sleep medications. The SLE-fatigue relationship was found to be mediated through different mechanisms in males and females: social support dissatisfaction and sleep quality mediated the relationship in females, while sleep quality mediated the relationship in males.

CONCLUSION

These results suggest that gender tailoring of psychological treatments may improve their effectiveness in treating fatigue, in particular, by targeting social support satisfaction in females and sleep hygiene in both sexes.

Use of health services in people with multiple sclerosis with and without fatigue

Objective

To explore and compare the use of health services in people with multiple sclerosis (MS) with and without fatigue.

Methods

Over a period of 30 months, the use of health services in 48 MS outpatients with persistent fatigue and 36 without fatigue was studied. Data were collected from a computerized register and by interviews, and analyzed with regard to disease severity categorized as mild or moderate/severe MS.

Results

Fatigued people with mild MS used more hospital outpatient care and primary care including rehabilitation, and a higher proportion had transportation service, compared with non-fatigued people with mild MS. In moderate/severe MS, the differences were that non-fatigued people used more occupational therapy in primary care and a higher proportion had salaried service. Regardless of MS severity, informal care was more common among fatigued people.

Conclusions

Overall, fatigued people with mild MS have more contacts with outpatient health care compared with non-fatigued people. There are few such differences in people with moderate/severe MS. The reasons for the differences in use between fatigued and non-fatigued people are not understood and need further exploration. Fatigued people more often receive informal care, thus support to caregivers are of particular importance if fatigue is present.

The psychology of fatigue in patients with multiple sclerosis: a review

Fatigue is a frequent and disabling symptom in patients with multiple sclerosis (MS), but it is difficult to define and measure. Today, MS-related fatigue is not fully understood, and evidence related to explanatory pathophysiological factors are conflicting. Here, we evaluate the contribution of psychological factors to MS-related fatigue. Insight into the possible underlying psychological mechanisms might help us to develop adequate psychological interventions and to improve the overall management of fatigue. Conceptual issues and the relationships between MS-related fatigue and mood, anxiety, cognition, personality, and cognitive-behavioral factors are discussed, and the implications for clinical practice and research are presented.

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

Background

Fatigue is a common disabling symptom of multiple sclerosis (MS) and has a significantly negative impact on quality of life. Persons with MS enrolled in the North American Research Committee on Multiple Sclerosis (NARCOMS) Patient Registry are invited to complete follow-up surveys every six months to update their original registration information. One of these surveys was designed to focus on the severity and impact of fatigue, and its association with other clinical parameters of MS such as physical disability.

Methods

In addition to the usual data collected in Registry update surveys such as demographic characteristics, MS-related medical history, disability and handicap, immunomodulatory and symptomatic therapies taken, and healthcare services used, the survey for this study included two validated self-report fatigue scales, the Fatigue Severity Scale (FSS) and the Modified Fatigue Impact Scale (MFIS) and questions about the use of symptomatic management for fatigue, both pharmacologic and non-pharmacologic treatments. This Registry update survey was mailed to all NARCOMS registrants (n = 18,595) in November 2002. Information provided by registry participants was approved for research purposes by the Yale University Institutional Review Board.

Results

The response rate for the survey was 49.5% (9205/18,595). Severe fatigue as measured with the FSS using the developer's recommended severity cutpoint of ≥ 36 was reported by 6691 (74%) of evaluable respondents (n = 9077). A higher prevalence of severe fatigue was observed in relapsing-worsening MS compared with relapsing-stable and primary progressive MS. A distinct pattern of fatigue was observed across the disability levels of the Patient-Determined Disease Steps (PDDS). Although there were no differences in the severity or impact of fatigue by immunomodulatory agents (IMA), respondents who recalled therapy changes in the prior six months reported different patterns of change in fatigue with lower fatigue levels reported after changing from interferon-β to glatiramer acetate than after changing from glatiramer acetate to interferon-β. Concomitant therapy for fatigue was used by 47.2% of the 5799 survey respondents receiving IMA.

Conclusion

Characterizing MS symptoms like fatigue can increase awareness about their impact on persons with MS and suggest recommendations for a care plan.

Longitudinal correlates of fatigue in multiple sclerosis

Objective

To determine the predictors of longitudinal changes in fatigue based on pain, mood, and neurological impairment across multiple sclerosis (MS) subtypes.

Background

Fatigue is the most common symptom of MS but remains poorly understood. The New York State Multiple Sclerosis Consortium (NYSMSC) database offers a unique opportunity to longitudinally assess a variety of potential fatigue correlates in a very large and diverse MS sample.

Design/Methods

This study examined baseline and 1-year follow-up data on 2768 patients drawn from the NYSMSC database regarding fatigability, pain, depressive symptoms, MS subtype, and expanded disability status scale (EDSS). Correlates and predictors of fatigue were assessed in correlational and multiple regression analyses.

Results

Baseline fatigue, pain, and depression accounted for 34.6% of the variance in 1-year follow-up fatigue scores. Fatigue was lower in relapsing–remitting subjects than in other MS subtypes. Fatigue consistently correlated at baseline and follow-up with depressive symptoms, pain severity, and EDSS. Changes in fatigue correlated with changes in other variables.

Conclusions

Predictors of fatigue at 1 year include baseline fatigue, pain, mood, and EDSS. These symptoms are also correlated at baseline, follow-up, and in change scores. Identifying predictors of fatigue may facilitate patient management.

Effects of glatiramer acetate on fatigue and days of absence from work in first-time treated relapsing-remitting multiple sclerosis

OBJECTIVES

Treatment of multiple sclerosis patients with glatiramer acetate has been demonstrated a beneficial effect on disease activity. The objective of this prospective naturalistic study was to evaluate the impact of glatiramer acetate on fatigue and work absenteeism.

METHODS

291 treatment-naïve patients with relapsing remitting multiple sclerosis were included and treated with glatiramer acetate for twelve months. Relapse rates, disability, fatigue symptoms, days of absence from work and adverse events were monitored. Fatigue was measured with the MFIS scale and with a visual analogue scale.

RESULTS

Total MFIS scores decreased by 7.6 +/- 16.4 from 34.6 to 27.0 (p < or = 0.001). Significant reductions were observed on all three subscales of the MFIS. Fatigue symptoms, assessed using a visual analogue scale, decreased by 1.04 +/- 2.88 cm from 4.47 cm to 3.43 cm (p < or = 0.001). The proportion of patients absent from work at least once was reduced by a factor of two from 65.1% to 30.1% (p < or = 0.001). Tolerance to treatment was rated as very good or good in 78.3% of patients. Adverse effects, most frequently local injection site reactions, were reported in 15.1% of patients.

CONCLUSION

Treatment with glatiramer acetate was associated with a significant improvement in fatigue symptoms and a marked reduction in absence from work. Treatment was well-tolerated. Such benefits are of relevance to overall patient well-being.

Depression in multiple sclerosis: review and theoretical proposal

Because of its high prevalence and implications for quality of life and possibly even disease progression, depression has been intensively studied in multiple sclerosis (MS) over the past 25 years. Despite the publication of numerous excellent empirical research papers on this topic during that time, the publication of theoretical work that attempts to explain depression in a comprehensive way is scarce. In this study, we present a theoretical model that attempts to integrate existing work on depression in MS and provide testable hypotheses for future work. The model suggests that risk for depression begins with the onset of MS. MS results in disease-related changes such as increased lesion burden/brain atrophy and immunological anomalies that are associated with depression in MS, but explain only a relatively limited proportion of the variance. Common sequelae of MS including fatigue, physical disability, cognitive dysfunction, and pain, have all been shown to have an inconsistent or relatively weak relationship to depression in the literature. In the model, we propose that four variables--social support, coping, conceptions of the self and illness, and stress--may moderate the relationship between the above common MS sequelae with depression and help to explain inconsistencies in the literature.

Rasch analysis of the Fatigue Severity Scale in multiple sclerosis

BACKGROUND

The 9-item, Fatigue Severity Scale (FSS-9) has been widely used as an outcome measure in multiple sclerosis (MS). Modern psychometric theory, in the form of the Rasch measurement model, has set new quality standards for outcome measures by appraising a broad range of measurement properties in addition to the reliability and validity emphasized by classical test theory.

OBJECTIVE

To appraise the FSS-9 by application of the Rasch model.

METHOD

The FSS-9 was posted to patients with clinically definite MS in two centers in the United Kingdom. Analysis was based on 416 records (55% response).

RESULTS

The 9-item scale failed to meet Rasch model expectations. Two items had poor discrimination across the scale, and two further items showed bias for factors such as age. Removal of these four items provided a valid 5-item Rasch scale that satisfied strict tests of unidimensionality.

CONCLUSION

Summating the nine items of the FSS-9 is invalid. Five items (FSS-5), which seem to be measuring the social impact of fatigue, provide a strictly unidimensional Rasch scale. Studies using the FSS-9 may need to be re-evaluated using the FSS-5, preferably using the Rasch transformed scores.

Evaluation of the six-minute walk in multiple sclerosis subjects and healthy controls

Objective To assess the characteristics of the 6-min walk (6MW) in multiple sclerosis (MS) subjects of varied disability, and controls. To assess the correlation of 6MW to subjective measures of fatigue, health status and ambulation using the modified fatigue impact scale (MFIS), short form-36 Health Questionnaire physical component score and MS walking scale (MSWS).

Methods Forty MS expanded disability status scale [(EDSS) 0—6.5] and 20 control subjects were recruited from a MS outpatient clinic. Subjects completed survey material and three 6MWs with 1-h interval rest in a single study visit.

Results There was no practice effect or fatigability with repeat 6MW tests with a one-h rest period between test sessions. The 6MW had excellent intra-[intraclass correlation coefficient (ICC) = 0.95] and inter-rater (ICC = 0.91) reliability. MS subjects demonstrated reduced 6MW distance and speed compared with controls ( P < 0.0001). Within the MS population 6MW distance was significantly reduced with increasing disability ( P = 0.05). Compared with the EDSS, the 6MW had a stronger correlation to subjective measures of ambulation and physical fatigue: MSWS ( r = -0.81 versus 0.69) and MFISphy (0.66 versus 0.63).

Conclusions The 6MW is a feasible, reproducible, and reliable measure in MS. MS subjects demonstrate motor fatigue in both 6MW distance and speed compared with controls. In MS subjects there is an inverse relationship between motor fatigue and disability. 6MW has a strong correlation to subjective measures of ambulation and physical fatigue. Multiple Sclerosis 2008; 14: 383—390. http://msj.sagepub.com

[Multiple sclerosis: cross-cultural adaptation and validation of the modified fatigue impact scale]

OBJECTIVE

The aim of this study is a cross-cultural adaptation and validation of the modified fatigue impact scale for Portuguese (MFIS-BR).

METHOD

The MFIS was translated to Portuguese and re-translated to English. Two pilot studies had been carried through to obtain the MFIS-BR, which was applied to 57 consecutive stable MS patients and 45 healthy controls. The retest was applied 30 days later.

RESULTS

In analyzing the statistics the internal consistency reability was similar to the original scale (0.74-0.86). The MFIS-BR showed ability to identify the different groups. Concerning the reliability the interclass correlation coefficient showed an excellent agreement (0.264-1.0).

CONCLUSION

The MFIS-BR fills the criteria of applicability, sensibility which are similar to the original version.