Self-report fatigue questionnaires in multiple sclerosis, Parkinson's disease and stroke: a systematic review of measurement properties

Cortical-striatal network functional connectivity markers in poststroke fatigue: a single-centre fMRI case-control study protocol

INTRODUCTION

Structural and functional abnormalities in the cortical-striatal network (CSN) are hypothesised to play a key role in the pathogenesis of neurological disease-associated fatigue. Some small-scale functional MRI (fMRI) studies have suggested that poststroke fatigue (PSF) is related to focal functional connectivity (FC) changes. To date, there has been no published large-scale fMRI study on PSF. This planned study will examine the role of the CSN FC on PSF.

METHODS AND ANALYSIS

The planned study will be a prospective cohort study conducted at the Neurology Unit of the Prince of Wales Hospital. We will recruit 738 participants. The project duration will be 36 months. A psychiatrist will administer the Fatigue Severity Scale (FSS) at 3 months (P1) following the index stroke. PSF is defined as an FSS Score≥4.0. PSF severity will be defined by the FSS total score at P1. Participants with PSF at P1 will undergo two follow-up assessments at 9 (P2) and 15 (P3) months post stroke. PSF remission at P2 or P3 will be defined as a 50% reduction in FSS. Participants will undergo MRI examinations within 2 weeks of the 3-month poststroke assessment. Structural MRI, resting-state fMRI and diffusion tensor imaging will be performed. FC, structural connectivity, infarcts, cerebral microbleeds and white matter hyperintensities will be analysed. For the primary analysis, the effect of PSF on the FC, structural connectivity and diffusion metrics of CSN of stroke survivors, voxel-wise two-sample t-tests will be performed with FDR correction for multiple comparison and significance level set at p<0.05.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster clinical research ethics committee. The study findings will be shared through peer-reviewed journal publications, national and international conferences and social media platforms.

Mental health and neurodevelopmental patient-reported outcome measures (PROMs) for children and young people with epilepsy: A systematic review

Children and young people with epilepsy are at higher risk of mental health disorders and atypical neurodevelopmental outcomes compared to the general population. It is essential to detect such comorbidities early in children with epilepsy and provide appropriate interventions, to improve clinical outcomes. We aimed to identify and evaluate the measurement properties of Patient-Reported Outcome Measures (PROMs) that have been validated specifically to measure mental health and neurodevelopmental outcomes in children and/or young people with epilepsy. We searched Embase, Medline, and PsycINFO in May 2023 for relevant studies. Mental health was defined as psychological symptoms (e.g., anxiety, depression, psychosis) and/or behavioural difficulties (e.g., conduct disorders). Neurodevelopmental outcomes included neurodevelopmental disorder traits such as attention-deficit hyperactivity disorder (ADHD) and autistic spectrum disorders. We assessed methodological quality using Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidance. Twelve papers were identified that psychometrically evaluated 13 relevant PROMs (two epilepsy-specific, eleven generic). The appraisal of the PROMs was limited by the availability of only one or two published articles for each, and incomplete psychometric evaluations in some cases. The tool demonstrating the strongest evidence was The Neurological Disorders Depression Inventory-Epilepsy for Youth. The ADHD Rating Scale-IV and The Paediatric Symptom Checklist -17 demonstrated good evidence in favour of at least two measurement properties. This review identified only a small number of mental health and neurodevelopmental PROMs evaluated specifically in paediatric epilepsy. There is a need for further validation of mental health and neurodevelopmental PROMs in children with epilepsy.

Validation of the Turkish version of the Neurological Fatigue Index for Stroke

INTRODUCTION

Post-stroke fatigue is an often overlooked problem that hinders recovery. Therefore, stroke patients should be evaluated for fatigue during the recovery period. This study aimed to adapt the Neurological Fatigue Index for Stroke (NFI-Stroke) into the Turkish language.

METHODS

This methodological study was carried out on 110 stroke patients admitted to a university hospital in Istanbul. In addition to the NFI-Stroke, Functional Independence Measure, National Institutes of Health Stroke Scale, modified-Rankin Scale, Fatigue Severity-Scale, and Stroke Self Efficacy Questionnaire were used to collect data.

RESULTS

Since the linguistic validity study of the scale has already been carried out, only psychometric properties were evaluated. The items in the scale were grouped under two factors. The Cronbach`s alpha coefficient was found to be 0.96 for the physical sub-dimension and 0.84 for the cognitive sub-dimension. Item-total correlation coefficients were found between 0.74-0.91 for the physical sub-dimension, and 0.82-0.91 for the cognitive sub-dimension. The test-retest evaluation confirmed the consistency of the responses to the scale against time. The scale was correlated with other scales used in the study as expected.

CONCLUSIONS

The NFI-Stroke will be useful in clinical practice in assessment of fatigue, which may affect the adaptation of patients to rehabilitation.

Study protocol of a double-blind randomized control trial of transcranial direct current stimulation in post-stroke fatigue

Rationale

Post-stroke fatigue (PSF) is a frequent problem in stroke survivors and often hinders their rehabilitation. PSF is difficult to treat, and pharmacological therapy is often ineffective. Transcranial direct current stimulation (tDCS) can modulate motor, sensory, cognitive and behavioral responses, as it alters neuronal activity by delivering a small amount of current via the scalp to the cortex, resulting in prolonged alterations to brain function. tDCS has been studied for the treatment of fatigue associated with other neurological diseases, namely, multiple sclerosis, Parkinson's disease and post-polio syndrome.

Aims

This proposed project will examine the effect of tDCS on PSF.

Sample size estimates

We will recruit 156 participants aged 18 to 80 with chronic stroke and allocate them equally to two groups (i.e., n = 78 per group).

Methods and design

This proposed project will be a double-blind randomized control trial. The participants will be randomly divided into two groups. The control group will receive sham tDCS, and the treatment group will receive active tDCS. The latter treatment will involve application of a constant 2-mA current via one 5 × 5-cm anodal electrode positioned on the scalp over the C3 or C4 positions (motor cortex) of the lesioned hemisphere and one cathodal electrode positioned at the ipsilateral shoulder in two 20-min sessions per day for 5 days. The period of follow-up will be 4 weeks.

Study outcomes

The primary outcome measure will be a change in fatigue severity, as measured using the modified fatigue impact scale (MFIS). The participants' scores on the MFIS (total score and physical, cognitive and psychosocial subscores) will be collected before treatment (T0), after 10 treatment sessions, i.e., 1 day after the fifth treatment day (T1), and 1 week (T2), 2 weeks (T3) and 4 weeks (T4) thereafter. Both per-protocol analysis and intention-to-treat analysis will be performed.

Discussion

This proposed project will provide proof-of-concept, i.e., demonstrate the benefits of tDCS for the treatment of PSF. The beneficiaries are the subjects participated in the study. This will stimulate further research to optimize tDCS parameters for the treatment of PSF.

Clinical trial registration

www.Chictr.org.cn, identifier: ChiCTR2100052515.

Leveraging Emerging Technologies to Expand Accessibility and Improve Precision in Rehabilitation and Exercise for People with Disabilities

Physical rehabilitation and exercise training have emerged as promising solutions for improving health, restoring function, and preserving quality of life in populations that face disparate health challenges related to disability. Despite the immense potential for rehabilitation and exercise to help people with disabilities live longer, healthier, and more independent lives, people with disabilities can experience physical, psychosocial, environmental, and economic barriers that limit their ability to participate in rehabilitation, exercise, and other physical activities. Together, these barriers contribute to health inequities in people with disabilities, by disproportionately limiting their ability to participate in health-promoting physical activities, relative to people without disabilities. Therefore, there is great need for research and innovation focusing on the development of strategies to expand accessibility and promote participation in rehabilitation and exercise programs for people with disabilities. Here, we discuss how cutting-edge technologies related to telecommunications, wearables, virtual and augmented reality, artificial intelligence, and cloud computing are providing new opportunities to improve accessibility in rehabilitation and exercise for people with disabilities. In addition, we highlight new frontiers in digital health technology and emerging lines of scientific research that will shape the future of precision care strategies for people with disabilities.

Validating the Fatigue Scale for Motor and Cognitive Function (FSMC) in chronic stroke

BACKGROUND

Post-stroke fatigue can manifest as both physical and mental fatigue. The Fatigue Scale for Motor and Cognitive Functions (FSMC) evaluates fatigue on the motor and cognitive domains separately, however, the psychometric properties of this measure in stroke have not been reported.

OBJECTIVE

To determine the internal consistency, test-retest reliability, and concurrent validity of the FSMC in chronic stroke.

METHODS

Thirty-four participants with chronic stroke (55.26±12.27 years of age; 59.53±89.21 months post-stroke) completed the FSMC on two separate visits. Internal consistency and reliability of the FSMC were examined using Cronbach's alpha and two-way mixed effects intraclass correlation coefficients (ICC), respectively. Correlation between the FSMC and the Fatigue Severity Scale and Visual Analog Scale-Fatigue was used to assess concurrent validity.

RESULTS

Internal consistency was excellent (Cronbach's alpha > 0.9) and reliability was moderate to good (ICC = 0.72-0.81) for all FSMC scores. The FSMC demonstrated moderate to good concurrent validity with the Fatigue Severity Scale (ρ= 0.66-0.72) but only fair concurrent validity with the Visual Analog Scale-Fatigue (ρ= 0.37-0.44).

CONCLUSION

The FSMC is a valid and reliable measure of post-stroke fatigue and may be a useful tool to examine physical fatigue and cognitive fatigue in chronic stroke.

Development and evaluation of the Norwegian Fatigue Characteristics and Interference Measure (FCIM) for stroke survivors: cognitive interviews and Rasch analysis

PURPOSE

There is need for a comprehensive measure of post-stroke fatigue with sound measurement properties. This study aimed to develop the Norwegian Fatigue Characteristics and Interference Measure (FCIM) and assess its content validity, structural validity, and internal consistency.

METHOD

This study consisted of three steps: (1) an expert panel developed version 1.0 of the Norwegian FCIM, (2) its content validity was assessed in cognitive interviews with stroke patients (N = 15), (3) a convenience sample of stroke patients (N = 169) completed an online questionnaire with the FCIM, Fatigue Severity Scale, and sociodemographic information; validity and reliability were assessed using Rasch analysis.

RESULTS

FCIM version 1.0 included a 10-item characteristics subscale, a 20-item interference subscale, and two pre-stroke fatigue items. The cognitive interviews revealed content validity issues, resulting in two interference items being removed and five items being flagged but retained for Rasch analysis (version 2.0). Rasch analysis led to removal of four items from the characteristics subscale and six more from the interference subscale. The final six-item characteristics subscale and 12-item interference subscale (version 3.0) both showed adequate fit to the Rasch model with indications of unidimensionality and local independence. The interference subscale had a high person separation index. No significant differential item function (DIF) was found in relation to gender, but one item demonstrated DIF in relation to age.

CONCLUSION

The cognitive interviews and Rasch analysis demonstrated that the Norwegian version of the FCIM has high content validity, structural validity, and internal consistency. Future research should assess its construct validity, reliability, and responsiveness.

The effect of disease modifying therapies on fatigue in multiple sclerosis

INTRODUCTION

Fatigue is one of the most common and debilitating symptoms in people with multiple sclerosis (PwMS). Disease-modifying therapies (DMTs) are currently the gold standard in the treatment of MS and their effectiveness has been assessed through randomized clinical trials (RCTs). However, there is limited evidence on the impact of DMTs on fatigue in (PwMS). We conducted a systematic review to 1) understand whether fatigue is included as an outcome in MS trials of DMTs; 2) determine the effects on fatigue of treating MS with DMTs and 3) assess the quality of MS trials including fatigue as an outcome.

METHODS

Two independent researchers systematically searched MEDLINE, EMBASE and ClinicalTrials.gov from 1993 to January 2023 for RCTs that measured fatigue as an outcome. Adherence to reporting standards was assessed with the Consolidated Standards of Reporting Trials (CONSORT)-Patient-Reported Outcomes (PRO), while the risk of bias (RoB) was assessed with the RoB 2 tool by the Cochrane Handbook for Systematic Reviews of Interventions. The systematic review protocol was registered in PROSPERO (CRD42022383321).

RESULTS

The search strategy identified 130 RCTs of DMTs of which 7 (5%) assessed fatigue as an outcome. Of the 7 trials, only two presented statistically significant results. In addition, the reporting of fatigue among RCTs was suboptimal with a mean adherence to the CONSORT-PRO Statement of 36% across all trials. Of the 7 trials included, four were assessed as 'high' RoB..

CONCLUSIONS

Fatigue has a major impact on PwMS yet there is limited trial-based evidence on the impact of DMTs on fatigue. Assessment of fatigue as an outcome is underrepresented in trials of DMTs and the reporting of PRO trial data is suboptimal. Thus, it is imperative that MS researchers conduct RCTs that include fatigue as an outcome, to support clinicians and people with MS (PwMS) to consider the impact of the different DMTs on fatigue.

Is Cardiorespiratory Fitness Independently Associated with Fatigue in Patients with Transient Ischemic Attack or Minor Stroke?

Fatigue is a common complaint and a disabling symptom among patients following transient ischemic attack (TIA) or minor stroke. In patients with stroke, decreased cardiorespiratory fitness (CRF) is believed to be related to increased severity of post-stroke fatigue (PSF). However, this association between PSF and CRF in patients with TIA or minor stroke has been less investigated, and currently there is no proven treatment for PSF. We aimed to determine the association between PSF and CRF in patients with TIA or minor stroke and to find out whether this association was distorted by confounders. A cross-sectional association study was conducted among a total of 119 patients with TIA or minor stroke. PSF was measured by the Fatigue Severity Scale (FSS) and CRF was quantified by maximal exercise capacity (V̇O2max). The FSS showed a significant association with V̇O2max (ß = −0.061, SE: 0.022; p = 0.007). This association was confounded by anxiety (ß = −0.044, SE: 0.020; p = 0.028) and depression (ß = −0.030, SE: 0.022; p = 0.177) as measured by the subscales of the Hospital Anxiety and Depression Scale (HADS). After controlling for HADS scores on depression and anxiety, the univariate relationship between V̇O2max and FSS was no longer significant. These results suggest that the association between PSF and CRF in patients with TIA or minor stroke is weak and significantly confounded by the factors of depression and anxiety.

Mobile App Interventions for Parkinson's Disease, Multiple Sclerosis and Stroke: A Systematic Literature Review

Central nervous system diseases (CNSDs) lead to significant disability worldwide. Mobile app interventions have recently shown the potential to facilitate monitoring and medical management of patients with CNSDs. In this direction, the characteristics of the mobile apps used in research studies and their level of clinical effectiveness need to be explored in order to advance the multidisciplinary research required in the field of mobile app interventions for CNSDs. A systematic review of mobile app interventions for three major CNSDs, i.e., Parkinson's disease (PD), multiple sclerosis (MS), and stroke, which impose significant burden on people and health care systems around the globe, is presented. A literature search in the bibliographic databases of PubMed and Scopus was performed. Identified studies were assessed in terms of quality, and synthesized according to target disease, mobile app characteristics, study design and outcomes. Overall, 21 studies were included in the review. A total of 3 studies targeted PD (14%), 4 studies targeted MS (19%), and 14 studies targeted stroke (67%). Most studies presented a weak-to-moderate methodological quality. Study samples were small, with 15 studies (71%) including less than 50 participants, and only 4 studies (19%) reporting a study duration of 6 months or more. The majority of the mobile apps focused on exercise and physical rehabilitation. In total, 16 studies (76%) reported positive outcomes related to physical activity and motor function, cognition, quality of life, and education, whereas 5 studies (24%) clearly reported no difference compared to usual care. Mobile app interventions are promising to improve outcomes concerning patient's physical activity, motor ability, cognition, quality of life and education for patients with PD, MS, and Stroke. However, rigorous studies are required to demonstrate robust evidence of their clinical effectiveness.

Safety and tolerability of adjunct non-invasive vagus nerve stimulation in people with parkinson's: a study protocol

BACKGROUND

Parkinson's disease (PD) is the fastest growing neurological condition worldwide. Recent theories suggest that symptoms of PD may arise due to spread of Lewy-body pathology where the process begins in the gut and propagate transynaptically via the vagus nerve to the central nervous system. In PD, gait impairments are common motor manifestations that are progressive and can appear early in the disease course. As therapies to mitigate gait impairments are limited, novel interventions targeting these and their consequences, i.e., reducing the risk of falls, are urgently needed. Non-invasive vagus nerve stimulation (nVNS) is a neuromodulation technique targeting the vagus nerve. We recently showed in a small pilot trial that a single dose of nVNS improved (decreased) discrete gait variability characteristics in those receiving active stimulation relative to those receiving sham stimulation. Further multi-dose, multi-session studies are needed to assess the safety and tolerability of the stimulation and if improvement in gait is sustained over time.

DESIGN

This will be an investigator-initiated, single-site, proof-of-concept, double-blind sham-controlled randomised pilot trial in 40 people with PD. Participants will be randomly assigned on a 1:1 ratio to receive either active or sham transcutaneous cervical VNS. All participants will undergo comprehensive cognitive, autonomic and gait assessments during three sessions over 24 weeks, in addition to remote monitoring of ambulatory activity and falls, and exploratory analyses of cholinergic peripheral plasma markers. The primary outcome measure is the safety and tolerability of multi-dose nVNS in PD. Secondary outcomes include improvements in gait, cognition and autonomic function that will be summarised using descriptive statistics.

DISCUSSION

This study will report on the proportion of eligible and enrolled patients, rates of eligibility and reasons for ineligibility. Adverse events will be recorded informing on the safety and device tolerability in PD. This study will additionally provide us with information for sample size calculations for future studies and evidence whether improvement in gait control is enhanced when nVNS is delivered repeatedly and sustained over time.

TRIAL REGISTRATION

This trial is prospectively registered at www.isrctn.com/ISRCTN19394828 . Registered August 23, 2021.

[Psychometric Evaluation of the 'German Neurological Fatigue Index for Multiple Sclerosis (NFI-MS-G)' in a Sample of Rehabilitation Patients with Multiple Sclerosis]

PURPOSE

The purpose of this study was to provide a patient-reported outcome measure for people with multiple sclerosis (MS) comprehensively reflecting the construct of fatigue and developed upon the assumptions of the Rasch model. The Neurological Fatigue Index - Multiple Sclerosis (NFI-MS) is based on both a medical and patient-described symptom framework of fatigue and has been validated. Therefore, in this study the German version of the NFI-MS (NFI-MS-G) consisting of a physical and cognitive subscale and a summary scale was validated.

METHOD

In this bi-centre-study, 309 people with MS undergoing outpatient rehabilitation or being≥2 months before or after their inpatient rehabilitation completed the German NFI-MS-G twice within 14-21 days together with other questionnaires. Correlation with established questionnaires and Rasch analysis were used for its validation. Additionally, psychometric properties of known-groups validity, internal consistency, test-retest reliability, measurement precision and readability were tested. Finally, the English NFI-MS and German NFI-MS-G were compared with each other to equate the language versions.

RESULTS

The NFI-MS-G showed good internal construct validity, convergent and known-groups validity and internal consistency (Cronbach's alpha 0.84-0.93). The physical subscale showed minor local dependencies between items 1 and 7, 2 and 3 and 4 to 6, that could be treated by combining the respective items to testlets. Unidimensionality was found for the physical and cognitive subscales but not for the summary scale. Replacing the summary scale, a 2-domains subtest measuring the higher-order construct of fatigue was created. Good test-retest reliability (Lin's concordance correlation coefficient of 0.86-0.90) and low floor and ceiling effects were demonstrated. The NFI-MS-G was found easily readable and invariant across groups of gender, age, disease duration, timepoint and centre.

CONCLUSION

The German version of the NFI-MS comprehensively represents the construct of fatigue and has adequate psychometric properties. The German version differs from the English original version with respect to a lack of unidimensionality of the summary scale and minor local dependencies of the physical subscale that could be canceled out using a testlet analysis.

High-intensity resistance training in people with multiple sclerosis experiencing fatigue: A randomised controlled trial

BACKGROUND

Exercise studies including only fatigued persons with multiple sclerosis (PwMS) with fatigue as primary endpoint are lacking.

OBJECTIVE

To evaluate the effects of high-intensity resistance training (HIRT) on self-reported fatigue in fatigued PwMS in a single center randomised controlled trial.

METHODS

We recruited 71 PwMS scoring ≥ 53 on the Fatigue Scale for Motor and Cognitive Functions (FSMC), who were randomised 1:1 to either twice (group A) or once (group B) weekly supervised HIRT for twelve weeks. A non-randomised FSMC score-matched group (n=69) served as non-intervention control.

RESULTS

Between HIRT-group differences were non-significant for primary and most secondary endpoints. Mean difference in FSMC score (95% confidence intervals) was -10.9 (-14.8; -6.9) in group A and -9.8 (-13.2; -6.3) in group B. Corresponding values for combined HIRT groups vs non-intervention control were -10.3 (-12.9; -7.7) and 1.5 (-0.6;3.6), respectively, p<0.001. Secondary endpoints also improved in both HIRT groups, though only Hospital Anxiety and Depression Scale anxiety and MS Impact Scale-29 psychological subscales significantly favoured the twice a week HIRT (group A). As an exploratory endpoint, changes in plasma inflammatory protein markers were associated with reduced FSMC scores in the pooled material.

CONCLUSION

The finding that HIRT in fatigued PwMS leads to clinically relevant reductions in self-reported fatigue, associated with changes in plasma inflammatory protein levels, provide evidence for recommending HIRT for fatigued PwMS.

Online advice for the symptomatic management of post-stroke fatigue: A scoping review

BACKGROUND

Limited medical evidence for managing post-stroke fatigue leads stroke survivors to seek information through other sources. This scoping review aimed to identify and assess the range and quality of web-based recommendations for managing post-stroke fatigue.

METHODS

Publicly accessible websites providing advice for post-stroke fatigue management were considered for review using the Joanna Briggs Institute's methodology. Using the search term "fatigue stroke", the first two pages of results from each search engine (Google, Yahoo, and Bing) were assessed against predetermined criteria. Findings were reported in accordance with PRISMA-ScR checklist. Quality and readability were also assessed.

RESULTS

Fifty-seven websites were identified; 16 primary and 11 linked websites met the inclusion criteria and demonstrated moderate to high quality and high readability. Primary websites were curated by non-government organizations (n = 10/16), companies (n = 4/16) or were media and blog websites (n = 2/16). Additional resources were provided on linked websites. All websites provided non-pharmacological advice, with four also describing pharmacological management. Many websites included advice related to physical activity modification (n = 18/27) and energy conservation strategies (e.g. activity prioritization, planning, pacing) (n = 26/27). Direction to seek health professional advice appeared frequently (n = 16/27).

CONCLUSIONS

The quality of publicly available web-based advice for people with post-stroke fatigue was moderate to high in most websites, with high readability. Energy conservation strategies and physical activity modification appear frequently. The general nature of the advice provided on most websites is supported by direction to healthcare professionals (i.e., clinical referral) who may assist in the practical individualization of strategies for managing post-stroke fatigue.

RObotic-Assisted Rehabilitation for balance and gait in Stroke patients (ROAR-S): study protocol for a preliminary randomized controlled trial

Background

Stroke, the incidence of which increases with age, has a negative impact on motor and cognitive performance, quality of life, and the independence of the person and his or her family, leading to a number of direct and indirect costs. Motor recovery is essential, especially in elderly patients, to enable the patient to be independent in activities of daily living and to prevent falls. Several studies have shown how robotic training associated with physical therapy influenced functional and motor outcomes of walking after stroke by improving endurance and walking strategies.

Considering data from previous studies and patients’ needs in gait and balance control, we hypothesized that robot-assisted balance treatment associated with physical therapy may be more effective than usual therapy performed by a physical therapist in terms of improving static, dynamic balance and gait, on fatigue and cognitive performance.

Methods

This is an interventional, single-blinded, preliminary randomized control trial. Twenty-four patients of both sexes will be recruited, evaluated, and treated at the UOC Rehabilitation and Physical Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome from January to December 2022. Patients will be randomized into two groups: the experimental group will perform specific rehabilitation for balance disorder using the Hunova® robotic platform (Movendo Technology srl, Genoa, IT) for 3 times a week, for 4 weeks (12 total sessions), and for 45 min of treatment, in addition to conventional treatment, while the conventional group (GC) will perform only conventional treatment as per daily routine. All patients will undergo clinical and instrumental evaluation at the beginning and end of the 4 weeks of treatment.

Conclusions

The study aims to evaluate the improvement in balance, fatigue, quality of life, and motor and cognitive performance after combined conventional and robotic balance treatment with Hunova® (Movendo Technology srl, Genoa, IT) compared with conventional therapy alone. Robotic assessment to identify the most appropriate and individualized rehabilitation treatment may allow reducing disability and improving quality of life in the frail population. This would reduce direct and indirect social costs of care and treatment for the National Health Service and caregivers.

Trial registration

ClinicalTrials.gov NCT05280587. Registered on March 15, 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06812-w.

Employment and ability to work after kidney transplantation in the Netherlands: The impact of preemptive versus non-preemptive kidney transplantation

BACKGROUND

Work can have a major positive impact on health and wellbeing. Employment of kidney transplant recipients (KTR) of working age is much lower than in the general population. The first aim of this study was to examine the impact of a preemptive kidney transplantation (PKT) on employment, in addition to other possible influencing factors. The second aim was to explore differences in work ability, absenteeism and work performance among employed KTR with different types of transplantations.

METHODS

A cross-sectional survey study was conducted between 2018 and 2019 in nine Dutch hospitals. PKT as potential predictor of employment was examined. Furthermore, work ability, absenteeism and loss of work performance were compared between employed preemptive recipients with a living donor (L-PKT) and non-preemptive recipients with a living donor (L-nPKT) and with a deceased donor (D-nPKT).

RESULTS

Two hundred and twenty four KTR participated; 71% reported having paid work. Paid work was more common among PKT recipients (82% vs. 65% in L-nPKT and 55% in D-nPKT) and recipients who were younger (OR .950, 95%CI .913-.989), had no comorbidities (1 comorbidity: OR .397, 95%CI .167-.942; 2 comorbidities: OR .347, 95%CI .142-.844), had less fatigue (OR .974, 95%CI .962-.987) and had mentally demanding work tasks (only in comparison with physically demanding tasks, OR .342, 95%CI .145-.806). If recipients were employed, D-nPKT recipients worked fewer hours (mean 24.6±11.3 vs. PKT 31.1±9.6, L-nPKT 30.1±9.5) and D-nPKT and L-nPKT recipients received more often supplemental disability benefits (32 and 33.3%, respectively) compared to PKT recipients (9.9%). No differences were found for self-reported ability to work, sick leave (absenteeism) and loss of work performance with the exception of limitations in functioning at work.

CONCLUSIONS

Preemptive kidney transplantation recipients with a kidney from a living donor are employed more often, work more hours per week (only in comparison with D-nPKT) and have a partial disability benefit less often than nPKT recipients. More knowledge regarding treatments supporting sustainable participation in the labor force is needed as work has a positive impact on recipients' health and wellbeing and is also beneficial for society as a whole.

A comparison of the measurement properties of the PROMIS Fatigue (MS) 8a against legacy fatigue questionnaires

BACKGROUND

Amidst the growing number of patient-reported outcome (PRO) measures of fatigue being used in multiple sclerosis (MS) clinical trials and clinics, evidence-based consensus on the most appropriate and generalizable measures across different settings would be beneficial for clinical research and patient care. The objective of this research was to compare the validity and responsiveness of scores from the PROMIS Fatigue (MS) 8a with those of the Fatigue Severity Scale (FSS) and the Modified Fatigue Impact Scale (MFIS), across US and UK MS populations.

METHODS

Two observational studies were performed in MS populations as part of a PRO measure development project, including a cross-sectional study in two tertiary US MS centers (n = 340) and a 96-week longitudinal study in the UK MS Register cohort (n = 352). In post-hoc analyses, we examined  relative validity, based on ability to discriminate across patient groups with different fatigue levels or functional status at baseline (i.e., ANOVA-F PRO_X ÷ ANOVA-F PROMIS (MS) 8a), and relative responsiveness, based on baseline-to-Week-52 score change (effect sizes) across fatigue or functional status response groups .

RESULTS

Mean ± standard deviation (SD) age was 44.6 ± 11.3/50.0 ± 9.7; and 72.9%/77.3% were female (US/UK samples). The mean PROMIS Fatigue (MS) 8a T-score ± SD at baseline was 57.7 ± 10.5/58.9 ± 9.3 (US/UK samples). Compared with the PROMIS Fatigue (MS) 8a, relative validity (anchor: Global Health Score [GHS] fatigue global question) was 85% for MFIS symptom score, 48% for MFIS total score, and 44% for the FSS. Relative to the FSS, PROMIS Fatigue (MS) 8a scores were more sensitive to worsening (effect size = -0.43 versus -0.18) as well as improvement (effect size = 0.5 versus 0.2) in fatigue (≥1-point increase/decrease in GHS fatigue global question) over 52 weeks of follow-up. A similar pattern of score changes was observed based on a second anchor.

CONCLUSION

The PROMIS Fatigue (MS) 8a scores showed higher responsiveness to fatigue changes than those of the FSS. The PROMIS measure also had higher precision in differentiating levels of fatigue compared to the FSS, the MFIS physical, and MFIS total scores. These differences have practical implications for the application of these questionnaires in both clinical practice and research settings (e.g., sample size estimation in clinical trials).

Improved prediction of early cognitive impairment in multiple sclerosis combining blood and imaging biomarkers

Disability in multiple sclerosis is generally classified by sensory and motor symptoms, yet cognitive impairment has been identified as a frequent manifestation already in the early disease stages. Imaging- and more recently blood-based biomarkers have become increasingly important for understanding cognitive decline associated with multiple sclerosis. Thus, we sought to determine the prognostic utility of serum neurofilament light chain levels alone and in combination with MRI markers by examining their ability to predict cognitive impairment in early multiple sclerosis. A comprehensive and detailed assessment of 152 early multiple sclerosis patients (Expanded Disability Status Scale: 1.3 ± 1.2, mean age: 33.0 ± 10.0 years) was performed, which included serum neurofilament light chain measurement, MRI markers (i.e. T₂-hyperintense lesion volume and grey matter volume) acquisition and completion of a set of cognitive tests (Symbol Digits Modalities Test, Paced Auditory Serial Addition Test, Verbal Learning and Memory Test) and mood questionnaires (Hospital Anxiety and Depression scale, Fatigue Scale for Motor and Cognitive Functions). Support vector regression, a branch of unsupervised machine learning, was applied to test serum neurofilament light chain and combination models of biomarkers for the prediction of neuropsychological test performance. The support vector regression results were validated in a replication cohort of 101 early multiple sclerosis patients (Expanded Disability Status Scale: 1.1 ± 1.2, mean age: 34.4 ± 10.6 years). Higher serum neurofilament light chain levels were associated with worse Symbol Digits Modalities Test scores after adjusting for age, sex Expanded Disability Status Scale, disease duration and disease-modifying therapy (B = −0.561; SE = 0.192; P = 0.004; 95% CI = −0.940 to −0.182). Besides this association, serum neurofilament light chain levels were not linked to any other cognitive or mood measures (all P-values > 0.05). The tripartite combination of serum neurofilament light chain levels, lesion volume and grey matter volume showed a cross-validated accuracy of 88.7% (90.8% in the replication cohort) in predicting Symbol Digits Modalities Test performance in the support vector regression approach, and outperformed each single biomarker (accuracy range: 68.6–75.6% and 68.9–77.8% in the replication cohort), as well as the dual biomarker combinations (accuracy range: 71.8–82.3% and 72.6–85.6% in the replication cohort). Taken together, early neuro-axonal loss reflects worse information processing speed, the key deficit underlying cognitive dysfunction in multiple sclerosis. Our findings demonstrate that combining blood and imaging measures improves the accuracy of predicting cognitive impairment, highlighting the clinical utility of cross-modal biomarkers in multiple sclerosis.

The Role of Remote Monitoring in Evaluating Fatigue in Multiple Sclerosis: A Review

Fatigue is one of the most common multiple sclerosis (MS) symptoms. Despite this, monitoring and measuring fatigue (subjective lack of energy)- and fatigability (objectively measurable and quantifiable performance decline)- in people with MS have remained challenging. Traditionally, administration of self-report questionnaires during in-person visits has been used to measure fatigue. However, remote measurement and monitoring of fatigue and fatigability have become feasible in the past decade. Traditional questionnaires can be administered through the web in any setting. The ubiquitous availability of smartphones allows for momentary and frequent measurement of MS fatigue in the ecological home-setting. This approach reduces the recall bias inherent in many traditional questionnaires and demonstrates the fluctuation of fatigue that cannot be captured by standard measures. Wearable devices can assess patients' fatigability and activity levels, often influenced by the severity of subjective fatigue. Remote monitoring of fatigue, fatigability, and activity in real-world situations can facilitate quantifying symptom-severity in clinical and research settings. Combining remote measures of fatigue as well as objective fatigability in a single construct, composite score, may provide a more comprehensive outcome. The more granular data obtained through remote monitoring techniques may also help with the development of interventions aimed at improving fatigue and lowering the burden of this disabling symptom.

Multiple sclerosis-related fatigue lacks a unified definition: A narrative review

Fatigue is the most common symptom in multiple sclerosis (MS). Although MS-related fatigue (MS-F) strongly affects quality of life and social performance of patients, there is currently a lack of knowledge about its pathophysiology, which in turns leads to poor objective diagnosis and management. Recent studies have attempted to explain potential etiologies as well as treatments for MS-F. However, it seems that without a consensus on its nature, these data could not provide a route to a successful approach. In this Article, we review definitions, epidemiology, risk factors and correlated comorbidities, pathophysiology, assessment methods, neuroimaging findings, and pharmacological and nonpharmacological treatments of MS-F. Further studies are warranted to define fatigue in MS patients more accurately, which could result in precise diagnosis and management.

Subcortical volumes as early predictors of fatigue in multiple sclerosis

OBJECTIVE

Fatigue is a frequent and severe symptom in multiple sclerosis (MS), but its pathophysiological origin remains incompletely understood. We aimed to examine the predictive value of subcortical gray matter volumes for fatigue severity at disease onset and after four years by applying structural equation modeling (SEM).

METHODS

This multi-center cohort study included 601 treatment-naive MS patients after the first demyelinating event. All patients underwent a standardized 3T MRI protocol. A subgroup of 230 patients with available clinical follow-up data after four years was also analyzed. Associations of subcortical volumes (included into SEM) with MS-related fatigue were studied regarding their predictive value. In addition, subcortical regions that have a central role in the brain network (hubs) were determined through structural covariance network (SCN) analysis.

RESULTS

Predictive causal modeling identified volumes of the caudate (s [standardized path coefficient]=0.763, p=0.003 [left]; s=0.755, p=0.006 [right]), putamen (s=0.614, p=0.002 [left]; s=0.606, p=0.003 [right]) and pallidum (s=0.606, p=0.012 [left]; s=0.606, p=0.012 [right]) as prognostic factors for fatigue severity in the cross-sectional cohort. Moreover, the volume of the pons was additionally predictive for fatigue severity in the longitudinal cohort (s=0.605, p=0.013). In the SCN analysis, network hubs in patients with fatigue worsening were detected in the putamen (p=0.008 [left]; p=0.007 [right]) and pons (p=0.0001).

INTERPRETATION

We unveiled predictive associations of specific subcortical gray matter volumes with fatigue in an early and initially untreated MS cohort. The colocalization of these subcortical structures with network hubs suggests an early role of these brain regions in terms of fatigue evolution. This article is protected by copyright. All rights reserved.

Which exercise and behavioural interventions show most promise for treating fatigue in multiple sclerosis? A network meta-analysis

BACKGROUND

Fatigue is a common, debilitating symptom of multiple sclerosis (MS) without a current standardised treatment.

OBJECTIVE

The aim of this systematic review with network meta-analyses was to estimate the relative effectiveness of both fatigue-targeted and non-targeted exercise, behavioural and combined (behavioural and exercise) interventions.

METHODS

Nine electronic databases up to August 2018 were searched, and 113 trials (n = 6909) were included: 34 were fatigue-targeted and 79 non-fatigue-targeted trials. Intervention characteristics were extracted using the Template for Intervention Description and Replication guidelines. Certainty of evidence was assessed using GRADE.

RESULTS

Pairwise meta-analyses showed that exercise interventions demonstrated moderate to large effects across subtypes regardless of treatment target, with the largest effect for balance exercise (SMD = 0.84). Cognitive behavioural therapies (CBTs) showed moderate to large effects (SMD = 0.60), with fatigue-targeted treatments showing larger effects than those targeting distress. Network meta-analysis showed that balance exercise performed significantly better compared to other exercise and behavioural intervention subtypes, except CBT. CBT was estimated to be superior to energy conservation and other behavioural interventions. Combined exercise also had a moderate to large effect.

CONCLUSION

Treatment recommendations for balance and combined exercise are tentative as the certainty of the evidence was moderate. The certainty of the evidence for CBT was high.

Distinguishing between Fatigue and Fatigability in Multiple Sclerosis

Fatigue is one of the most common debilitating symptoms reported by persons with multiple sclerosis (MS). It reflects feelings of tiredness, lack of energy, low motivation, and difficulty in concentrating. It can be measured at a specific instant in time as a perception that arises from interoceptive networks involved in the regulation of homeostasis. Such ratings indicate the state level of fatigue and likely reflect an inability to correct deviations from a balanced homeostatic state. In contrast, the trait level of fatigue is quantified in terms of work capacity (fatigability), which can be either estimated (perceived fatigability) or measured (objective fatigability). Clinically, fatigue is most often quantified with questionnaires that require respondents to estimate their past capacity to perform several cognitive, physical, and psychosocial tasks. These retrospective estimates provide a measure of perceived fatigability. In contrast, the change in an outcome variable during the actual performance of a task provides an objective measure of fatigability. Perceived and objective fatigability do not assess the same underlying construct. Persons with MS who report elevated trait levels of fatigue exhibit deficits in interoceptive networks (insula and dorsal anterior cingulate cortex), including increased functional connectivity during challenging tasks. The state and trait levels of fatigue reported by an individual can be modulated by reward and pain pathways. Understanding the distinction between fatigue and fatigability is critical for the development of effective strategies to reduce the burden of the symptom for individuals with MS.

Validity and reliability of the fatigue impact scale in stroke

BACKGROUND

Fatigue is one of the significant problems of post-stroke patients as it causes a decreased quality of life. Although the fatigue impact scale (FIS) is used in stroke, it lacks validation studies.

OBJECTIVE

This study evaluates the psychometric properties of the FIS in patients with stroke.

SUBJECTS AND METHODS

A total of 41 subjects with stroke and 41 control subjects admitted to Physical Medicine and Rehabilitation Department were included. Convergent validity was assessed using the SF-36 vitality (SF-36 v) scale and the fatigue severity scale (FSS). Divergent validity was assessed using the Hospital Anxiety and Depression Scale (HADS).

RESULTS

All subscores of the FIS were significantly higher in the stroke group than in the control group (p < .05). FIS showed excellent internal consistency in stroke patients (Cronbach's alpha = 0.946). There was a negative correlation among FIS and SF-36 v (r = -0.506, p = .001), and a positive correlation between the HADS anxiety score (r = 0.356, p = .026) and the HADS depression score (r = 0.293, p = .071). FIS total scores were weakly correlated with the FSS (r = 0.323, p = 0.039). The test-retest reliability of FIS was good in terms of its cognitive, physical, and psychosocial subscales and total scores, with ICC values of 0.78, 0.73, 0.80, and 0.83, respectively.

CONCLUSION

FIS is a valid and reliable multidimensional scale that sensitively discriminated fatigue in the stroke patients from that in the control subjects.

Measurement properties of patient-reported outcome measures for pruritus: An updated systematic review

This systematic review aims to provide an update on measurement properties of patient-reported outcome measures for pruritus. A Medline literature search was conducted to update the systematic review published by Schoch et al. in 2017 and to identify new validation studies published between October 2015 and July 2019. The methodological quality of validation studies was assessed based on the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist and the measurement properties of patient-reported outcome measures were evaluated. Nineteen new studies were included and added to the 22 studies identified in the previously published review. Evidence from all 41 studies evaluating 38 different measures was summarized. Outcome measures were mapped to one of three constructs where possible: pruritus intensity, pruritus severity, pruritus-specific health-related quality of life. COSMIN rating revealed mixed results with deficiencies in methodological quality of many studies across all constructs. The most appropriate pruritus severity measure was the "Itch Severity Scale". "Itchy Quality of Life" and the disease-specific "Uremic Pruritus in Dialysis Scale" achieved most promising results considering the construct pruritus-specific health-related quality of life. For pruritus intensity, nine measures performed similarly well.

Standardizing fatigue measurement in multiple sclerosis: the validity, responsiveness and score interpretation of the PROMIS SF v1.0 - Fatigue (MS) 8a

BACKGROUND

Fatigue is one of the most common and the single most disabling symptom of multiple sclerosis (MS). However, there is a lack of consensus on the most appropriate fatigue measures in clinical practice and research, based upon rigorously validated, generalizable, and publicly available instruments. The objective of this research was to generate additional evidence regarding the validity and applicability of the PROMIS SF v1.0 - Fatigue (MS) 8a, including content validity, reliability, construct validity and responsiveness, as well as to assess minimal important difference (MID) estimates and a score interpretation tool to aide meaningful individual level score interpretation.

METHODS

A mixed-methods, sequential design was followed. Cognitive debriefing (CD) interviews (n=29) were performed with MS patients, to assess the relevance and comprehensiveness of the PROMIS Fatigue (MS) 8a scores. To evaluate the psychometric properties of the PROMIS Fatigue (MS) 8a, two observational studies were conducted: a cross-sectional study at two US MS centers (n=296), and a 96-week longitudinal study in a UK MS Register cohort (n=384). Main outcomes and measures were estimates of known-groups validity, convergence validity, reliability, and responsiveness, a guide for interpreting PROMIS Fatigue (MS) 8a T-scores, and anchor-based MID estimates.

RESULTS

The CD interviews confirmed the comprehensiveness and relevance of the PROMIS Fatigue (MS) 8a in assessing MS fatigue. Cronbach's alpha (>0.9) and intra-class correlation coefficient (≥0.9) for test-retest scores at 5-7 days follow-up, supported strong internal consistency and test-retest reliability. Hypothesized differences were found across patient groups in patient reported fatigue and related concepts (analysis of variance [ANOVA], P <0.001). PROMIS Fatigue (MS) 8a scores were sensitive to bi-directional changes in fatigue (GHS fatigue global question) and physical health (PROMIS GHS GPH), over a 52-week follow-up. Score changes of 3.4-4 points are proposed as MID criteria for minimal improvement or worsening in fatigue.

CONCLUSION

This research extends the evidence supporting the content validity and the robust psychometric performance of the PROMIS Fatigue (MS) 8a across US and UK MS populations. Importantly, data supporting the measure's integration in clinical practice and research, including meaningful score interpretation, are now available.

A Bio-Psycho-Social Co-created Intervention for Young Adults With Multiple Sclerosis (ESPRIMO): Rationale and Study Protocol for a Feasibility Study

BACKGROUND

Multiple sclerosis (MS), the most common neurological disease that causes disability in youth, does not only affect physical functions but is also associated with cognitive impairment, fatigue, depression, and anxiety and can significantly impact health-related quality of life (HRQoL). Since MS is generally diagnosed at a young age-a period of great significance for personal, relational, and professional development-adaptation can become highly challenging. Therefore, enhancing the competence of young people to adaptively cope with these potential challenges is of utmost importance in order to promote their potentialities and talents. It has been shown that psychological interventions targeting MS patients can enhance resilience and HRQoL and that regular physical activity (PA) and social engagement can improve psychological well-being. However, literature on the development of global interventions based on the bio-psycho-social model of the disease is missing. Even less attention has been paid to interventions dedicated to young adults with MS (YawMS) and to the involvement of patients in the development of such programs.

AIMS

In collaboration with MS patients, this study aims to develop a bio-psycho-social intervention (ESPRIMO) for YawMS, aiming to improve their HRQoL and to explore its feasibility, acceptability, and effects.

METHODS

To tailor the intervention to the specific needs of YawMS, "patient engagement principles" will be adopted in the co-creation phase, performing a web survey and focus groups with patients and healthcare professionals. In the intervention phase, a pilot sample of 60 young adults with MS will be enrolled. The co-created intervention, composed of group sessions over a 12-week period, will cover psycho-social strategies and include physical activities. Adopting a longitudinal, pre-post evaluation design, self-report questionnaires measuring HRQoL and other bio-psycho-social features (e.g., resilience, well-being, mindfulness traits, self-efficacy, perceived social support, psychological symptoms, illness perception, committed action, fatigue, attitudes, subjective norms, perceived behavioral control, motivation, perception of autonomy support for PA, barriers and intentions to PA) will be administered, the quantity and quality of PA will be measured, and a questionnaire developed by the authors will be used to evaluate the feasibility and acceptability of the ESPRIMO intervention.

Negative Mood States Are Related to the Characteristics of Facial Expression Drawing: A Cross-Sectional Study

An assessment of mood or emotion is important in developing mental health measures, and facial expressions are strongly related to mood or emotion. This study thus aimed to examine the relationship between levels of negative mood and characteristics of mouth parts when moods are drawn as facial expressions on a common platform. A cross-sectional study of Japanese college freshmen was conducted, and 1,068 valid responses were analyzed. The questionnaire survey consisted of participants’ characteristics, the Profile of Mood States (POMS), and a sheet of facial expression drawing (FACED), and the sheet was digitized and analyzed using an image-analysis software. Based on the total POMS score as an index of negative mood, the participants were divided into four groups: low (L), normal (N), high (H), and very high (VH). Lengths of drawn lines and between both mouth corners were significantly longer, and circularity and roundness were significantly higher in the L group. With increasing levels of negative mood, significant decreasing trends were observed in these lengths. Convex downward and enclosed figures were significantly predominant in the L group, while convex upward figures were significantly predominant and a tendency toward predominance of no drawn mouths or line figures was found in the H and VH groups. Our results suggest that mood states can be significantly related to the size and figure characteristics of drawn mouths of FACED on a non-verbal common platform. That is, these findings mean that subjects with low negative mood may draw a greater and rounder mouth and figures that may be enclosed and downward convex, while subjects with a high negative mood may not draw the line, or if any, may draw the line shorter and upward convex.

Dynamic functional connectivity as a neural correlate of fatigue in multiple sclerosis

BACKGROUND

More than 80% of multiple sclerosis (MS) patients experience symptoms of fatigue. MS-related fatigue is only partly explained by structural (lesions and atrophy) and functional (brain activation and conventional static functional connectivity) brain properties.

OBJECTIVES

To investigate the relationship of dynamic functional connectivity (dFC) with fatigue in MS patients and to compare dFC with commonly used clinical and MRI parameters.

METHODS

In 35 relapsing-remitting MS patients (age: 42.83 years, female/male: 20/15, disease duration: 11 years) and 19 healthy controls (HCs) (age: 41.38 years, female/male: 11/8), fatigue was measured using the CIS-20r questionnaire at baseline and at 6-month follow-up. All subjects underwent structural and resting-state functional MRI at baseline. Global static functional connectivity (sFC) and dynamic functional connectivity (dFC) were calculated. dFC was assessed using a sliding-window approach by calculating the summed difference (diff) and coefficient of variation (cv) across windows. Moreover, regional connectivity between regions previously associated with fatigue in MS was estimated (i.e. basal ganglia and regions of the Default Mode Network (DMN): medial prefrontal, posterior cingulate and precuneal cortices). Hierarchical regression analyses were performed with forward selection to identify the most important correlates of fatigue at baseline. Results were not corrected for multiple testing due to the exploratory nature of the study.

RESULTS

Patients were more fatigued than HCs at baseline (p = 0.001) and follow-up (p = 0.002) and fatigue in patients was stable over time (p = 0.213). Patients had significantly higher baseline global dFC than HCs, but no difference in basal ganglia-DMN dFC. In the regression model for baseline fatigue in patients, basal ganglia-DMN dFC-cv (standardized β = -0.353) explained 12.5% additional variance on top of EDSS (p = 0.032). Post-hoc analysis revealed higher basal ganglia-DMN dFC-cv in non-fatigued patients compared to healthy controls (p = 0.013), whereas fatigued patients and healthy controls showed similar basal ganglia-DMN dFC.

CONCLUSIONS

Less dynamic connectivity between the basal ganglia and the cortex is associated with greater fatigue in MS patients, independent of disability status. Within patients, lower dynamics of these connections could relate to lower efficiency and increased fatigue. Increased dynamics in non-fatigued patients compared to healthy controls might represent a network organization that protects against fatigue or signal early network dysfunction.

Reduction of fatigue and anger-hostility by the oral administration of 5-aminolevulinic acid phosphate: a randomized, double-blind, placebo-controlled, parallel study

Although large populations feel fatigue, the standardized medicinal therapy is currently absent. In this study, we determined whether 5-aminolevulinic acid (5-ALA) supplementation alleviates the feeling of fatigue in healthy subjects who feel chronic physical tiredness. Males and females between ages of 20 and 64 who felt physical fatigue on a daily basis, with a visual analogue scale (VAS) for fatigue ≥ 40 mm, a T-score of Fatigue-Inertia in the Profile of Mood States—Second Edition—Adult (POMS2-A) ≥ 50, and a T-score of Vigor-Activity in POMS2-A ≤ 60 were recruited. Seventy eligible participants were randomly assigned to either a 5-ALA or a placebo group. During the 8 weeks of consumption, the subjects completed VAS questionnaires for fatigue and POMS2-A at 4-week intervals. The VAS values for overall feeling of fatigue and feeling of work-related fatigue, and the Anger-Hostility subscale of POMS2-A were decreased by 5-ALA with significant time × group interaction effects (p = 0.040, 0.020, and 0.045, respectively). Besides, the 5-ALA group showed significant differences in Fatigue-Inertia, Depression-Dejection and Total Mood Disturbance scores, when compared between pre- and post-intervention, while the placebo group did not. In conclusion, the oral administration of 5-ALA improves fatigue and negative mood in subjects who constantly feel physical fatigue.

This clinical trial was registered with University hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) as UMIN000031528 on 2/3/2018.

Trajectories of health-related quality of life among people with a physical disability and/or chronic disease during and after rehabilitation: a longitudinal cohort study

Purpose

To identify Health-related Quality of Life (HR-QoL) trajectories in a large heterogeneous cohort of people with a physical disability and/or chronic disease during and after rehabilitation and to determine which factors before discharge are associated with longitudinal trajectory membership.

Methods

A total of 1100 people with a physical disability and/or chronic disease were included from the longitudinal cohort study Rehabilitation, Sports and Active lifestyle. All participants participated in a physical activity promotion programme in Dutch rehabilitation care. HR-QoL was assessed using the RAND-12 Health Status Inventory questionnaire at baseline (T0: 3–6 weeks before discharge) and at 14 (T1), 33 (T2) and 52 (T3) weeks after discharge from rehabilitation. A data-driven approach using Latent Class Growth Mixture modelling was used to determine HR-QoL trajectories. Multiple binomial multivariable logistic regression analyses were used to determine person-, disease- and lifestyle-related factors associated with trajectory membership.

Results

Three HR-QoL trajectories were identified: moderate (N = 635), high (N = 429) and recovery (N = 36). Trajectory membership was associated with person-related factors (age and body mass index), disease-related factors (perceived fatigue, perceived pain and acceptance of the disease) and one lifestyle-related factor (alcohol consumption) before discharge from rehabilitation.

Conclusions

Most of the people who participated in a physical activity promotion programme obtained a relatively stable but moderate HR-QoL. The identified HR-QoL trajectories among our heterogeneous cohort are disease-overarching. Our findings suggest that people in rehabilitation may benefit from person-centred advice on management of fatigue and pain (e.g. activity pacing) and the acceptance of the disability.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02647-7) contains supplementary material, which is available to authorized users.

The neurological fatigue index for stroke. Reliability of a Norwegian version

OBJECTIVE

The aim of this study was to examine the test-retest reliability, internal consistency, and floor and ceiling effects of a Norwegian version of the Neurological Fatigue Index for Stroke (NFI-Stroke).

METHOD

To evaluate the psychometric properties of the NFI-Stroke, persons with stroke were recruited. Inclusion criteria were: ≥18 years; a performance of ≥4 seconds on the Clock-Drawing Test; and participants had to speak and understand Norwegian. Test-retest reliability, internal consistency, and floor and ceiling effects were evaluated with Spearman's rho, Weighted Kappa, Cronbach's Alpha, corrected total-item correlation, percentage of the total score, and responses to each item.

RESULT

Of 82 eligible, 66 respondents were included in the project. NFI-Stroke has a test-retest reliability of 0.89, 0.89, and 0.87 with Spearman's rho and 0.55-0.78 with Weighted Kappa. For the subgroup chronic stroke, Spearman's rho was 0.89, 0.86, and 0.93, and Weighted Kappa was 0.61-0.91. For the subgroup sub-acute stroke, Spearman's rho was 0.48, 0.55, and 0.51, and Weighted Kappa was 0.02-0.54. Cronbach's Alpha was 0.90. For the physical subscale, alpha was 0.89, and for the cognitive subscale 0.74. Corrected total-item correlation for NFI-Stroke was 0.50-0.78, 0.55-0.79 for the physical subscale, and 0.46-0.60 for the cognitive subscale. None scored the highest nor lowest possible score of the questionnaire.

CONCLUSION

NFI-Stroke has high test-retest reliability, and high internal consistency with neither floor nor ceiling effects for persons with stroke. The questionnaire may be useful both in general rehabilitation in institutions as well as in the municipal health services.

Fatigue in Parkinson's disease: Brazilian validation of the modified fatigue impact scale

BACKGROUND

The instruments that measure the impact of fatigue on physical, cognitive and psychosocial aspects has yet to be validated in Brazilian population with Parkinson's disease (PD). The aim of this study was to cross-culturally adapt and assess the psychometric properties of the Brazilian version of the Modified Fatigue Impact Scale (MFIS-PD/BR).

METHODS

Ninety PD individuals were recruited. The adaptation of the MFIS-PD was performed by translation and back translation methodology. Psychometric analysis was applied in order to perform the administration of the socio-clinical questionnaire, Mini-Mental State Examination (MMSE), Unified Parkinson's Disease Rating Scale (UPDRS Part I-IV), Hoehn-Yahr disability scale (HY), hospital anxiety and depression scale (HADS), Geriatric Depression Scale (GDS), fatigue severity scale (FSS), Parkinson Fatigue Scale (PFS-16), and MFIS-PD/BR with retest of the MFIS-PD/BR after 7 days.

RESULTS

The adaptation phase kept the same items of original MFIS-PD. The Cronbach's alpha for the MFIS-PD/BR was 0.878 when all responses items were scored. The test-retest intraclass correlation coefficients was above 0.80 (p<0.01) for the MFIS-PD/BR score, which was moderately correlated with the HADS, GDS, MDS-UPDRS score total and non-motor experiences of daily living, FSS and PFS-16. It was revealed the MFIS-PD/BR>29 points as cut-off point to indicate fatigued subjects with accuracy of 0.835 (p<0.001).

CONCLUSIONS

The MFIS-PD/BR is valid and reproducible to use in assessing the fatigue symptom in Brazilian PD subjects.

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.

Effects of a 3-Week In-Hospital Body Weight Reduction Program on Cardiovascular Risk Factors, Muscle Performance, and Fatigue: A Retrospective Study in a Population of Obese Adults with or without Metabolic Syndrome

Background. In clinical practice, there is the diffuse conviction that obese subjects with metabolic syndrome may be more difficult to treat. Objectives and Methods. The aim of the present study was that to investigate the effectiveness of a 3-week in-hospital body weight reduction program (BWRP) in a large population of obese subjects with and without metabolic syndrome (n = 1922; 222 men and 1700 women, age range 18–83 yr). Outcomes such as body mass index (BMI), total (TOT) and HDL cholesterol, systolic and diastolic blood pressures (SBP and DBP, respectively), coronary heart disease (CHD) score, fatigue severity score (FSS), and stair climbing test (SCT) time were evaluated before and after the intervention (Δ). A sex-, BMI-, and age-related stratification of the obese population with or without metabolic syndrome was applied. Results. When compared to obese subjects without metabolic syndrome, at the basal conditions, obese subjects had a poorer cardiometabolic profile, as demonstrated by higher triglycerides, TOT-cholesterol, DBP, SBP, and CHD score, and a more compromised muscle performance (evaluated by SCT), associated with more perception of fatigue (measured by FSS). Nevertheless, obese subjects with metabolic syndrome obtained more benefits from BWRP than those without metabolic syndrome for some outcomes (i.e., ΔTOT-cholesterol, ΔSBP, and ΔCHD score). Despite these differences, the BWRP-induced weight loss was similar between the two groups (i.e., ΔBMI) as well as the gain of muscle performance (i.e., ΔSCT) and the reduction of fatigue (i.e., ΔFSS). Interestingly, the potentially deleterious fall in HDL-cholesterol levels after BWRP was less evident in obese subjects with metabolic syndrome than those without metabolic syndrome. When pooling all data, the ΔCHD score was associated with age, sex, and metabolic syndrome. The remaining outcomes, such as ΔBMI, ΔFSS, and ΔSCT time, were associated with sex and age but not with metabolic syndrome. Finally, ΔBMI was positively correlated with ΔCHD score, ΔFSS, and ΔSCT time in both obese subjects without metabolic syndrome and obese subjects with metabolic syndrome. Conclusions. When comparing obese subjects undergoing a BWRP, metabolic syndrome is not a negative predictive factor affecting the effectiveness of this intervention in terms of weight loss, muscle performance, and psychological well-being.

Movement behavior remains stable in stroke survivors within the first two months after returning home

BACKGROUND AND PURPOSE

The aim of this study is to investigate changes in movement behaviors, sedentary behavior and physical activity, and to identify potential movement behavior trajectory subgroups within the first two months after discharge from the hospital to the home setting in first-time stroke patients.

METHODS

A total of 140 participants were included. Within three weeks after discharge, participants received an accelerometer, which they wore continuously for five weeks to objectively measure movement behavior outcomes. The movement behavior outcomes of interest were the mean time spent in sedentary behavior (SB), light physical activity (LPA) and moderate to vigorous physical activity (MVPA); the mean time spent in MVPA bouts ≥ 10 minutes; and the weighted median sedentary bout. Generalized estimation equation analyses were performed to investigate overall changes in movement behavior outcomes. Latent class growth analyses were performed to identify patient subgroups of movement behavior outcome trajectories.

RESULTS

In the first week, the participants spent an average, of 9.22 hours (67.03%) per day in SB, 3.87 hours (27.95%) per day in LPA and 0.70 hours (5.02%) per day in MVPA. Within the entire sample, a small but significant decrease in SB and increase in LPA were found in the first weeks in the home setting. For each movement behavior outcome variable, two or three distinctive subgroup trajectories were found. Although subgroup trajectories for each movement behavior outcome were identified, no relevant changes over time were found.

CONCLUSION

Overall, the majority of stroke survivors are highly sedentary and a substantial part is inactive in the period immediately after discharge from hospital care. Movement behavior outcomes remain fairly stable during this period, although distinctive subgroup trajectories were found for each movement behavior outcome. Future research should investigate whether movement behavior outcomes cluster in patterns.

Minimal Clinically Important Differences for Patient-Reported Outcome Measures of Fatigue in Patients With COPD Following Pulmonary Rehabilitation

BACKGROUND

Fatigue is a burdensome and prevailing symptom in patients with COPD. Pulmonary rehabilitation (PR) improves fatigue; however, interpreting when such improvement is clinically relevant is challenging. Minimal clinically important differences (MCIDs) for instruments assessing fatigue are warranted to better tailor PR and guide clinical decisions.

RESEARCH QUESTION

This study estimated MCIDs for the Functional Assessment of Chronic Illness Therapy-Fatigue Subscale (FACIT-FS), the modified FACIT-FS, and the Checklist Individual Strength-Fatigue Subscale in patients with COPD following PR.

STUDY DESIGN AND METHODS

Data from patients with COPD who completed a 12-week community-based PR program were used to compute the MCIDs. The pooled MCID was estimated by calculating the arithmetic weighted mean, resulting from the combination of anchor-based (weight, two-thirds) and distribution-based (weight, one-third) methods. Anchors were patients' and physiotherapists' Global Rating of Change Scale, COPD Assessment Test, St. George's Respiratory Questionnaire (SGRQ), and exacerbations. To estimate MCIDs, we used mean change, receiver-operating characteristic curves, and linear regression analysis for anchor-based approaches, and 0.5 × SD, SE of measurement, 1.96 × SE of measurement, and minimal detectable change for distribution-based approaches.

RESULTS

Fifty-three patients with COPD (79% male, 68.4 ± 7.6 years of age, and FEV₁ 48.7 ± 17.4% predicted) were included in the analysis. Exacerbations and the SGRQ-impact and the SGRQ-total scores fulfilled the requirements to be used as anchors. Pooled MCIDs were 4.7 for FACIT-FS, 3.8 for the modified FACIT-FS, and 9.3 for the Checklist Individual Strength-Fatigue Subscale.

INTRPRETATION

The MCIDs proposed in this study can be used by different stakeholders to interpret PR effectiveness.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03799666; URL: www.clinicaltrials.gov.

Feasibility and short-term effects of Activity Coach+: a physical activity intervention in hard-to-reach people with a physical disability

PURPOSE

Existing physical activity interventions do not reach a considerable proportion of physically disabled people. This study assessed feasibility and short-term effects of Activity Coach+, a community-based intervention especially targeting this hard-to-reach population.

METHODS

Feasibility was determined by reach, dropouts, and compliance with the protocol. Physical activity was measured with the Activ8 accelerometer and the adapted SQUASH questionnaire. Health outcomes were assessed by body composition, blood pressure, hand grip force, 10-metre walk test, 6-minute walk test, and the Berg Balance Scale. The RAND-36, Exercise Self-Efficacy Scale, Fatigue Severity Scale, and IMPACT-S were administered. Measurements were performed at baseline and after 2 and 4 months. Changes over time were analysed by Friedman tests.

RESULTS

Twenty-nine participants enrolled during the first 4 months, of whom two dropped out. Intervention components were employed in 86-100% of the participants. Physical activity did not change after the implementation of Activity Coach+. Body mass index (p = 0.006), diastolic blood pressure (p = 0.032), walking ability (p = 0.002), exercise capacity (p = 0.013), balance (p = 0.014), and vitality (p = 0.049) changed over time.

CONCLUSIONS

Activity Coach + is feasible in a community setting. Indications for effectivity of Activity Coach + in hard-to-reach people with a physical disability were found.Implications for rehabilitationActivity Coach + was able to reach physically disabled people living in community, a population that is assumed hard-to-reach.Activity Coach + was feasible in a population of persons with a physical disability that was heterogeneous with respect to age and (severity of) disability.The current study provides the first indications for the beneficial health effects of Activity Coach + in hard-to-reach people with a physical disability.

Brazilian version of the Multidimensional Fatigue Inventory for Parkinson’s disease

Abstract Introduction: The multidimensional fatigue inventory (MFI) has not been applied in Brazilian Parkinson`s disease (PD) population due to the lack of validation. Objective: The aim of this study was to cross-culturally adapt, to validate, and investigate the psychometric properties of Brazilian version of the MFI in PD. Method: Idiopathic PD individuals (N = 90) were recruited. The MFI was translated into Brazilian Portuguese using established forward-backward translation procedures, and the psychometric properties were evaluated. All individuals were assessed by socio-clinical questionnaire, Mini-Mental State Examination (MMSE), Unified Parkinson’s Disease Rating Scale (MDS-UPDRS Part I-IV), Hoehn-Yahr disability scale (HY), hospital anxiety and depression scale (HADS), fatigue severity scale (FSS), Parkinson Fatigue Scale (PFS-16) and MFI-PD/ BR with retest of the MFI-PD/BR after seven days. Results: The adaptation phase kept the same items of original MFI-PD. No data missing, floor nor ceiling effects were found. The overall Cronbach's alpha coefficient for the 20 items was 0.81, ranging from 0.73 to 0.81 for each of the five subscales. Bland and Altman analysis showed no systematic differences between assessments. The intraclass correlation coefficient test-retest was higher or equal 0.70 (p < 0.01) for the MFI-PD/BR score, which was moderately correlated with the HADS, MDS-UPDRS score (motor examination, motor and non-motor experiences of daily living and motor complications), FSS and PFS-16. It was revealed the MFI-PD/ BR > 55 points as cut-off point to indicate fatigued subjects with accuracy of 0.84 (p < 0.001). Conclusion: The MFI-PD/BR can be considered a valid and reproducible instrument for assessing PD-related fatigue.

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.

Avaliação da qualidade de vida em portadores de esclerose múltipla: impacto da fadiga, ansiedade e depressão

RESUMO O objetivo do estudo foi avaliar a percepção da qualidade de vida em pacientes com esclerose múltipla (EM) e verificar se há associação com fadiga, ansiedade e depressão. Trata-se de um estudo transversal com amostra composta por 100 indivíduos com diagnóstico de EM cadastrados no Centro de Referência para Atenção ao Paciente Portador de Doença Desmielinizante do Hospital da Restauração. Foram aplicadas: a escala de determinação funcional da qualidade de vida na EM (Defu), a escala modificada do impacto da fadiga (MFIS-BR) e a escala hospitalar de ansiedade (HAD-a) e depressão (HAD-d). Os pacientes com a forma clínica primariamente progressiva apresentaram pior percepção da qualidade de vida (66,90±3,47) quando comparados às formas secundariamente progressivas (71,65±5,92) e remitente-recorrente (79,00±6,62), com diferença estatística significativa (p<0,001). Houve forte correlação positiva entre os escores da Defu e da MFIS-BR (r=0,84), e forte correlação negativa entre Defu e HAD-a (r=−0,85) e Defu e HAD-d (r=−0,82). A diminuição da percepção da qualidade de vida em pacientes com EM é mais crítica nas formas progressivas da doença e tem associação com a presença de fadiga, depressão e ansiedade.

Instruments for evaluation of motivations for weight loss in individuals with overweight and obesity: A systematic review and narrative synthesis

This systematic review aims to identify instruments used to assess motivations for weight loss in individuals with overweight and obesity from different age groups, such as children, adolescents, adults, and older adults. The virtual search was carried out using the PubMed, Scopus, LILACS, and ADOLEC databases, and by manual search. The following descriptors were used: questionnaire, scale, instrument, evaluation, motivation, motive, reason, “lose weight,” “losing weight,” “weight loss,” and slimming. Methodological quality was assessed according to the criteria of the COSMIN checklist. The search yielded 3,524 results, seven of which were included in the review. Six questionnaires assessing motivations for weight loss, which could be applied to various age groups, were identified. All the questionnaires presented items related to appearance and health as the main motivation for weight loss. In addition to these motivations, the questionnaires also included items related to improved sports performance, self-confidence, participation in important social events, family and social pressure, and fitting into different clothes. The most evaluated measurement properties in the studies were internal consistency, reliability, content validity, and construct validity. Regarding internal consistency, one was rated as excellent, one as fair, and three as poor. For reliability, two were rated as being of fair quality, and one as of poor quality. Two studies analyzed the content validity and the questionnaires were rated as being of poor methodological quality. Regarding structural validity, one was rated as excellent, another as fair, and another as poor quality. Only the Weight Loss Motivation Questionnaire presented excellent methodological quality for most of the analyzed criteria. There is a need to develop questionnaires that are of better methodological quality to assess motivations for weight loss. Instruments targeting the adolescent population should also be developed.

Multidisciplinary Integrated Metabolic Rehabilitation in Elderly Obese Patients: Effects on Cardiovascular Risk Factors, Fatigue and Muscle Performance

Background: Obesity is a widespread problem in the elderly, being associated with severe comorbidities negatively influencing life expectancy. Integrated multidisciplinary metabolic rehabilitation aimed to reduce body weight (BW) and fatigue, increase physical autonomy and introduce healthy life style changes has been proposed as a useful intervention to improve the general health status and quality of life of the obese geriatric population. Methods: Six hundred-eighty four severely obese subjects (F/M = 592/92; age range: 61–83 years; mean body mass index, BMI ± SD: 42.6 ± 5.6 kg/m²) were admitted to take part in a three-week in-hospital BW reduction program (BWRP), entailing energy restricted diet, psychological counselling, physical rehabilitation and nutritional education. Biochemical parameters, cardiovascular risk factors (throughout the Coronary Heart Disease Risk, CHD-R), fatigue (throughout the Fatigue Severity Scale, FSS) and lower limb muscle performance (throughout the Stair Climbing Test, SCT) were evaluated before and at the end of the BWRP. Results: A 4% BW reduction was achieved at the end of the BWRP. This finding was associated with a significant improvement of the metabolic homeostasis (i.e., decrease in total cholesterol and glucose) and a reduction of systolic blood pressure in both females and males, thus resulting in a reduction of CHD-R in the male group. Total FSS score and SCT time decreased in female and male obese patients. The effects of BWPR were comparable among all age-related subgroups (>60, 60–69 and >70 years), apart from ΔCHD-R, which was higher in male subgroups. Finally, age was negatively correlated with ΔBMI and ΔFSS. Conclusions: Though only a relatively limited number of outcomes were investigated, the present study shows that a 4% BW reduction in severely elderly obese patients is associated with positive multisystemic effects, particularly, muscle-skeletal and cardiometabolic benefits, which can favorably influence their general well-being and improve the autonomy level in performing more common daily activities. The maintenance of a healthy life style, including controlled food intake and regular physical activity, after a BWRP is obviously recommended in all elderly obese patients to further improve their clinical condition.

Biotransformation profiles from a cohort of chronic fatigue women in response to a hepatic detoxification challenge

Chronic fatigue, in its various manifestations, frequently co-occur with pain, sleep disturbances and depression and is a non-communicable condition which is rapidly becoming endemic worldwide. However, it is handicapped by a lack of objective definitions and diagnostic measures. This has prompted the World Health Organization to develop an international instrument whose intended purpose is to improve quality of life (QOL), with energy and fatigue as one domain of focus. To complement this objective, the interface between detoxification, the exposome, and xenobiotic-sensing by nuclear receptors that mediate induction of biotransformation-linked genes, is stimulating renewed attention to a rational development of strategies to identify the metabolic profiles in complex multifactorial conditions like fatigue. Here we present results from a seven-year study of a cohort of 576 female patients suffering from low to high levels of chronic fatigue, in which phase I and phase II biotransformation was assessed. The biotransformation profiles used were based on hepatic detoxification challenge tests through oral caffeine, acetaminophen and acetylsalicylic acid ingestion coupled with oxidative stress analyses. The interventions indicated normal phase I but increased phase II glucuronidation and glycination conjugation. Complementarity was indicated between a fatigue scale, medical symptoms and associated energy-related parameters by application of Chi-square Automatic Interaction Detector (CHAID) analysis. The presented study provides a cluster of data from which we propose that multidisciplinary inputs from the combination of a fatigue scale, medical symptoms and biotransformation profiles provide the rationale for the development of a comprehensive laboratory instrument for improved diagnostics and personalized interventions in patients with chronic fatigue with a view to improving their QOL.

In search of distinct MS-related fatigue subtypes: results from a multi-cohort analysis in 1.403 MS patients

Fatigue is among the most disabling symptoms in patients with multiple sclerosis (PwMS). The common distinction between cognitive and motor fatigue is typically incorporated in self-rating instruments, such as the Chalder Fatigue Questionnaire (CFQ), the Fatigue Scale for Motor and Cognitive Functions (FSMC) or the Modified Fatigue Impact Scale (MFIS). The present study investigated the factor structure of the CFQ, the FSMC and the MFIS utilizing exploratory (EFA) and confirmatory factor analysis (CFA) as well as exploratory structural equation modeling (ESEM). Data of 1.403 PwMS were analyzed, utilizing four samples. The first sample (N = 605) was assessed online and split into two stratified halves to perform EFA, CFA, and ESEM on the CFQ and FSMC. The second sample (N = 293) was another online sample. It served to calculate CFA and ESEM on the CFQ and FSMC. The third sample was gathered in a clinical setting (N = 196) and analyzed by applying CFA and ESEM to the FSMC. The fourth sample (N = 309) was assessed in a clinical setting and allowed to run a CFA and ESEM on the MFIS. Proposed factor structures of all questionnaires were largely confirmed in EFA. However, none of the calculated CFAs and ESEMs could verify the proposed factor structures of the three measures, even with oblique rotation techniques. The findings might have implications for future research into the pathophysiological basis of MS-related fatigue and could affect the suitability of such measures as outcomes for treatment trials, presumably targeting specific sub-components of fatigue.

Assessing chronic fatigue syndrome: Self-reported physical functioning and correlations with physical testing

The pathophysiology of chronic fatigue syndrome (CFS) remains unclear; no biomarkers have thus far been identified or physical tests designed to underpin its diagnosis. Assessment mainly uses Fukuda's criteria and is based on the exclusion of symptoms related to other diseases/syndromes, subjective self-reporting, and outcomes of self-report questionnaires. In order to improve the baseline assessment and progress evaluation of individuals suspected of CFS and using an association-oriented research strategy and a cross-correlational design, this study investigates possible associations between the performance on two physical tests, i.e. 'Timed Loaded Standing' (TLS), assessing trunk-arm endurance, and the 'Stops Walking with Eyes Closed while performing a secondary Cognitive Task' (SWECCT), measuring impaired automaticity of gait, and the results of two self-report questionnaires, the Checklist Individual Strength (CIS, total score and fatigue subscale score) and the physical functioning and vitality subscales of the Short Form Health Survey (SF-36) to gauge the participants' subjective feelings of fatigue and beliefs regarding their abilities to perform daily-life activities. Comparisons of the outcomes obtained in 27 female patients with a confirmed diagnosis of CFS revealed that trunk-arm endurance as measured with the TLS correlated with the SF-36 physical functioning subscale only (raw p value: 0.004). None of the other correlations were statistically significant. It is concluded that the TLS may have potential as an objective assessment tool to support the diagnosis and monitoring of treatment effects in CFS.

Reporting on the level of validity and reliability of questionnaires measuring Katakori severity: A systematic review

Objectives:

Katakori is a Japanese term for non-specific symptoms including discomfort or dull pain caused by muscle stiffness around the neck through the shoulders and is one of the most frequently reported symptoms in Japan. However, there has been no standardized patient-reported outcome measure to evaluate Katakori severity. This study aimed to investigate the reporting level on validity and reliability of patient-reported outcome measures of Katakori severity.

Method:

A systematic search in ICHUSHI, MEDLINE, EMBASE and PubMed was undertaken from inception to April 2017 without language limitations. Two authors independently undertook screening by inspecting the title and abstract. Inclusion criteria were as follows: (1) participants with Katakori symptoms, (2) reporting reliability or validity of questionnaire evaluating Katakori severity and (3) published journal articles. Studies that either of the authors retained through the screening process were inspected with full text by the two authors independently to examine eligibility of the study. Any disagreement on eligibility after full-text inspection was resolved by discussion between them. Methodological quality was rated with the COnsensus-based Standards for the selection of health Measurement INstruments checklist. Subsequently, the evidence level of each measurement property was assessed for each questionnaire. The two authors extracted data independently. Any disagreement was resolved by discussion between them.

Results:

Five questionnaires were identified in five studies. The Shoulder Pain and Disability Index and Scale for Measuring Felt Shoulder Stiffness had the highest level of methodological quality. However, excellent measurement properties were found in only two out of nine criteria. Furthermore, in particular, content validity was not investigated in any measure.

Conclusion:

There is preliminary evidence for the reliability and validity of the Shoulder Pain and Disability Index and Scale for Measuring Felt Shoulder Stiffness; however, much further research is required. Identifying or developing a patient-reported outcome measure with content validity would be a future research agenda.