Depression and fatigue in patients with multiple sclerosis

Associations between fatigue impact and physical and neurobehavioural factors: An exploration in people with progressive multiple sclerosis

BACKGROUND

Fatigue is common in people with multiple sclerosis (MS). Understanding the relationship between fatigue, physical and neurobehavioural factors is important to inform future research and practice. Few studies explore this explicitly in people with progressive MS (pwPMS).

OBJECTIVE

To explore relationships between self-reported fatigue, physical and neurobehavioural measures in a large, international progressive MS sample of cognitively impaired people recruited to the CogEx trial.

METHODS

Baseline assessments of fatigue (Modified Fatigue Impact Scale; MFIS), aerobic capacity (VO2peak), time in moderate-vigorous physical activity (MVPA; accelerometery over seven-days), walking performance (6-minute walk test; 6MWT), self-reported walking difficulty (MS Walking Scale; MSWS-12), anxiety and depression (Hospital Anxiety and Depression Scale; HADS and Beck Depression Inventory-II; BDI-II), and disease impact (MS Impact Scale-29, MSIS-29) were assessed. Participants were categorised as fatigued (MFISTotal >=38) or non-fatigued (MFISTotal ≤38).

STATISTICAL ANALYSIS

Differences in individuals categorised as fatigued or non-fatigued were assessed (t-tests, chi square). Pearson's correlation and partial correlations (adjusted for EDSS score, country, sex, and depressive symptoms) determined associations with MFISTotal, MFISPhysical, MFISCognitive and MFISPsychosocial, and the other measures. Multivariable logistic regression evaluated the independent association of fatigue (categorised MFISTotal) with physical and neurobehavioural measures.

RESULTS

The sample comprised 308 pwPMS (62 % female, 27 % primary progressive, 73 % secondary progressive), mean age 52.5 ± 7.2 yrs, median EDSS score 6.0 (4.5-6.5), mean MFISTotal 44.1 ± 17.1, with 67.2 % categorised as fatigued. Fatigued participants walked shorter distances (6MWT, p = 0.043), had worse MSWS-12 scores (p < 0.001), and lower average % in MVPA (p = 0.026). The magnitude of associations was mostly weak between MFISTotal and physical measures (r = 0.13 to 0.18), apart from the MSWS-12 where it was strong (r = 0.51). The magnitude of correlations were strong between the MFISTotal and neurobehavioural measures of anxiety (r = 0.56), depression (r = 0.59), and measures of disease impact (MSIS-physical r = 0.67; MSIS-mental r = 0.71). This pattern was broadly similar for the MSIF subscales. The multivariable model indicated a five-point increase in MSWS-12 was associated with a 14 % increase in the odds of being fatigued (OR [95 %CI]: 1.14 [1.07-1.22], p < 0.0001) CONCLUSION: Management of fatigue should consider both physical and neurobehavioural factors, in cognitively impaired persons with progressive MS.

Understanding the mechanisms of fatigue in multiple sclerosis: linking interoception, metacognition and white matter dysconnectivity

One of the most prominent symptoms in multiple sclerosis is pathological fatigue, often described by sufferers as one of the most debilitating symptoms, affecting quality of life and employment. However, the mechanisms of both, physical and cognitive fatigue in multiple sclerosis remain elusive. Here, we use behavioural tasks and quantitative MRI to investigate the neural correlates of interoception (the ability to sense internal bodily signals) and metacognition (the ability of the brain to assess its own performance), in modulating cognitive fatigue. Assuming that structural damage caused by multiple sclerosis pathology might impair the neural pathways subtending interoception and/or metacognition, we considered three alternative hypotheses to explain fatigue as a consequence of, respectively: (i) reduced interoceptive accuracy, (ii) reduced interoceptive insight or (iii) reduced global metacognition. We then explored associations between these behavioural measures and white matter microstructure, assessed by diffusion and magnetisation transfer MRI. Seventy-one relapsing-remitting multiple sclerosis patients participated in this cross-sectional study (mean age 43, 62% female). Patient outcomes relevant for fatigue were measured, including disability, disease duration, depression, anxiety, sleepiness, cognitive function, disease modifying treatment and quality of life. Interoceptive and metacognitive parameters were measured using heartbeat tracking and discrimination tasks, and metacognitive visual and memory tasks. MRI was performed in 69 participants, including diffusion tensor MRI, neurite orientation dispersion and density imaging and quantitative magnetisation transfer. Associations between interoception and metacognition and the odds of high cognitive fatigue were tested by unconditional binomial logistic regression. The odds of cognitive fatigue were higher in the people with low interoceptive insight (P = 0.03), while no significant relationships were found between fatigue and other interoceptive or metacognitive parameters, suggesting a specific impairment in interoceptive metacognition, rather than interoception generally, or metacognition generally. Diffusion MRI-derived fractional anisotropy and neurite density index showed significant (P < 0.05) negative associations with cognitive fatigue in a widespread bilateral white matter network. Moreover, there was a significant (P < 0.05) interaction between cognitive fatigue and interoceptive insight, suggesting that the poorer the white matter structure, the lower the interoceptive insight, and the worse the fatigue. The results point towards metacognitive impairment confined to the interoceptive domain, in relapsing-remitting patients with cognitive fatigue. The neural basis of this impairment is supported by a widespread white matter network in which loss of neurite density plays a role.

Do fatigue and depression have a bivariate association with device-measured physical activity behavior in persons with multiple sclerosis?

PURPOSE

This study examined the bivariate association between fatigue and depression symptoms and physical activity behavior in persons with multiple sclerosis (MS).

METHODS

The sample of adults with MS completed the Fatigue Severity Scale (FSS) and the Hospital Anxiety and Depression Scale (HADS) and wore a waist mounted accelerometer during waking hours for 7 days. We categorized participants as having elevated fatigue and depression based on cut-points for the FSS (i.e., 4+ as indicative of severe fatigue) and the HADS (i.e., 8+ as indicative of elevated depressive symptoms). We used a two-way multivariate analysis of variance (MANOVA) to examine the contribution of fatigue and depression to volume and pattern of sedentary, light (LPA) and moderate-to-vigorous physical activity (MVPA).

RESULTS

Results indicated no bivariate association between fatigue and depression and measures of physical activity behavior. The MANOVA indicated there was a significant association between fatigue and MVPA (F = 2.30, p = 0.032) and steps/day (F = 13.6, p < 0.001), independent of depression symptoms. There was no association between depression symptoms and physical activity behavior.

CONCLUSIONS

This study demonstrated an interrelation between fatigue symptoms and MVPA and steps/day in MS, independent of depression symptoms, and this should be considered in the future design and delivery of physical activity interventions in MS.IMPLICATIONS FOR REHABILIATIONFatigue and depression are prevalent and burdensome symptoms of multiple sclerosis (MS).These symptoms can collectively worsen psychological and functional outcomes in MS.Fatigue symptoms may impact ambulatory physical activity to a greater degree than depression symptom status in persons with MS.Fatigue is an important consideration when designing behavior change interventions targeted at promoting physical activity in persons with MS.

Structural MRI measures are associated with fatigue severity and persistence in a large, real-world cohort of people with multiple sclerosis

BACKGROUND

Results of research on radiological hallmarks of multiple sclerosis (MS) fatigue have been conflicting.

OBJECTIVE

To investigate the associations of lesion and brain compartment volumes with fatigue severity and persistence in people with multiple sclerosis (PwMS).

METHODS

The Multiple Sclerosis Partners Advancing Technology and Health Solutions (MS PATHS) network collects standardized data during routine care of PwMS from 10 healthcare institutions. Magnetic resonance imaging (MRI) predictors included baseline brain parenchymal (BPF) and gray matter fractions (GMF) and T2 lesion volume (T2LV). The Quality of Life in Neurological Disorders (Neuro-QOL) fatigue subscore was analyzed linearly and categorically using T-score cutpoints, with a period of elevated symptoms defined as T-score ⩾ mean + 0.5 SD over follow-up.

RESULTS

At baseline, of 4012 participants (average age: 45.6 ± 11.8 years; 73% female; 31% progressive MS), 2058 (51%) had no fatigue, 629 (16%) had mild fatigue, and 1325 (33%) had moderate-to-severe fatigue. One SD greater baseline BPF and GMF were associated with 0.83 (p < 0.001) and 0.38 (p = 0.02) lower values in the baseline Neuro-QOL fatigue T-score. A 1 SD lower log of total T2LV was associated with a 0.49 (p < 0.001) lower baseline fatigue T-score. Higher BPF and lower T2LV at baseline were associated with lower odds of subsequent periods of elevated fatigue.

CONCLUSION

Baseline lesion burden and lower generalized whole-brain volumes were associated with MS fatigue in cross-sectional and longitudinal analyses in a large, real-world cohort of PwMS.

Clinical variables influencing the perception of fatigue in people with multiple sclerosis: a cross-sectional study using FSIQ-RMS

BACKGROUND

Physical fatigue is one of the most disabling symptoms in people with Multiple Sclerosis (PwMS). Several factors might influence the development of fatigue, such as gender, education, body mass index (BMI), Expanded Disability Status Scale (EDSS), disease duration, working status (Ws), physiotherapy (Ph), and disease-modifying therapies (DMTs). Fatigue Symptoms and Impacts Questionnaire-Relapsing Multiple Sclerosis (FSIQ-RMS) is a patient-reported outcome (PRO) that allows one to define the impact of fatigue in PwMS clearly. This study aimed to assess fatigue impact on PwMS by using FSIQ-RMS.

METHODS

The participants were enrolled from May to July 2021 in MS Centers of Sant'Andrea Hospital and Policlinico Umberto I Hospital in Rome. Fatigue was evaluated using the FSIQ-RMS, validated, and culturally adapted in Italian. Clinical and demographic data were collected at the same time.

RESULTS

We enrolled 178 PwMS [Female 74.16%; RMS 82.58%, SPMS 17.52%]. FSIQ-RMS scores were significantly correlated with EDSS (p-value < 0.01). Analysis of variance between means showed a statistically significant difference between the BMI groups at the 24hours_FSIQ-RMS score and the 7days_FSIQ-RMS score (p < 0.01), with the lower BMI group having the highest scores. Furthermore, perceived fatigue significantly improved both in subjects performing Ph (p < 0.05) and in those who actively work (p < 0.01).

CONCLUSIONS

The use of FSIQ-RMS in a real-world setting confirmed that underweight and high levels of disability are closely related to fatigue. In addition, Ph and active Ws are strongly correlated with fatigue in PwMS.

Brain connectivity changes underlying depression and fatigue in relapsing-remitting multiple sclerosis: A systematic review

Multiple Sclerosis (MS) is an autoimmune disease affecting the central nervous system, characterised by neuroinflammation and neurodegeneration. Fatigue and depression are common, debilitating, and intertwined symptoms in people with relapsing-remitting MS (pwRRMS). An increased understanding of brain changes and mechanisms underlying fatigue and depression in RRMS could lead to more effective interventions and enhancement of quality of life. To elucidate the relationship between depression and fatigue and brain connectivity in pwRRMS we conducted a systematic review. Searched databases were PubMed, Web-of-Science and Scopus. Inclusion criteria were: studied participants with RRMS (n ≥ 20; ≥ 18 years old) and differentiated between MS subtypes; published between 2001-01-01 and 2023-01-18; used fatigue and depression assessments validated for MS; included brain structural, functional magnetic resonance imaging (fMRI) or diffusion MRI (dMRI). Sixty studies met the criteria: 18 dMRI (15 fatigue, 5 depression) and 22 fMRI (20 fatigue, 5 depression) studies. The literature was heterogeneous; half of studies reported no correlation between brain connectivity measures and fatigue or depression. Positive findings showed that abnormal cortico-limbic structural and functional connectivity was associated with depression. Fatigue was linked to connectivity measures in cortico-thalamic-basal-ganglial networks. Additionally, both depression and fatigue were related to altered cingulum structural connectivity, and functional connectivity involving thalamus, cerebellum, frontal lobe, ventral tegmental area, striatum, default mode and attention networks, and supramarginal, precentral, and postcentral gyri. Qualitative analysis suggests structural and functional connectivity changes, possibly due to axonal and/or myelin loss, in the cortico-thalamic-basal-ganglial and cortico-limbic network may underlie fatigue and depression in pwRRMS, respectively, but the overall results were inconclusive, possibly explained by heterogeneity and limited number of studies. This highlights the need for further studies including advanced MRI to detect more subtle brain changes in association with depression and fatigue. Future studies using optimised imaging protocols and validated depression and fatigue measures are required to clarify the substrates underlying these symptoms in pwRRMS.

Exploring humanistic burden of fatigue in adults with multiple sclerosis: an analysis of US National Health and Wellness Survey data

BACKGROUND

This retrospective study examined the humanistic burden of fatigue in patients with relapsing-remitting multiple sclerosis (RRMS), compared with adults without MS, using data from the 2017 and 2019 US National Health and Wellness Survey.

METHODS

The 5-item Modified Fatigue Impact Scale (MFIS-5) was used to assess level of fatigue (MFIS-5 score <15: low fatigue [LF]; MFIS-5 score ≥15: high fatigue [HF]) in patients with RRMS. Health-related quality of life (HRQoL) measures (Short Form 36-Item Health Survey version 2, Euroqol-5 Dimensions-5 Levels [EQ-5D-5L], Patient Health Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder-7 [GAD-7], Perceived Deficits Questionnaire-5) and treatment-related characteristics were assessed.

RESULTS

In total, 498 respondents were identified as RRMS (n=375 RRMS+LF, n=123 RRMS+HF) and compared with 1,494 matched non-MS controls. RRMS+LF and RRMS+HF had significantly lower Short Form 6 Dimensions health utility, Mental and Physical Component Summary, and EQ-5D-5L scores and higher PHQ-9 and GAD-7 scores, compared with matched non-MS controls (all p<0.001); scores were worse for RRMS+HF than RRMS+LF across all measures (all p<0.001). A higher proportion of RRMS+HF reported moderate-to-severe depression and moderate-to-severe anxiety, compared with RRMS+LF and matched non-MS controls (both p<0.001). Fatigue was a significant predictor of poor HRQoL across all measures (all p<0.001).

CONCLUSIONS

Patients with RRMS experienced lower HRQoL with higher levels of fatigue, highlighting an unmet need. Results may help to inform physician-patient communication and shared decision-making to address fatigue and its associated impact on patients' HRQoL.

Relationship between quality of life, self-efficacy and social support in patients with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) causes patients' perceptions of self-efficacy and social support to decline. Patients with MS have to change day-to-day activities and encounter various physical and psychosocial problems while adapting to the new lifestyle.

AIMS

The research aimed to define the quality of life, self-efficacy and social support in patients with MS and to determine the relationship between quality of life, perception of self-efficacy and perceived social support. It is descriptive and correlational research. Data were collected using surveys.

METHODS

The sample consisted of 116 patients with MS. Patients who applied at the neurology in-patient and outpatient clinics between March 2021 and September 2021 were assessed for inclusion criteria. Written and verbal consent was obtained. The patients read and answered the questionnaires. Their quality of life was assessed using the Functional Assessment of Multiple Sclerosis Scale (FAMS). Self-efficacy perception was measured using the General Self-Efficacy Scale (GSE), and social support was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS).

RESULTS

The study found that the other concerns, symptoms, thinking and fatigue were most negatively affected the quality of life subscales. Perception of self-efficacy was found to be moderate, while social support was high. Analyses revealed a positive correlation between MSPSS scores, FAMS scores and GSE scores (p<0.05).

CONCLUSION

Health professionals need to provide education and counselling to manage MS-related symptoms, use therapeutic communication techniques to improve self-efficacy, give positive reinforcement and cooperate with families to increase social support.

Evaluating the effects of brain injury, disease and tasks on cognitive fatigue

Because cognitive fatigue (CF) is common and debilitating following brain injury or disease we investigated the relationships among CF, behavioral performance, and cerebral activation within and across populations by combining the data from two cross-sectional studies. Individuals with multiple sclerosis (MS) were included to model CF resulting from neurological disease; individuals who had sustained a traumatic brain injury (TBI) were included to model CF resulting from neurological insult; both groups were compared with a control group (Controls). CF was induced while neuroimaging data was acquired using two different tasks. CF significantly differed between the groups, with the clinical groups reporting more CF than Controls-a difference that was statistically significant for the TBI group and trended towards significance for the MS group. The accrual of CF did not differ across the three groups; and CF ratings were consistent across tasks. Increasing CF was associated with longer response time for all groups. The brain activation in the caudate nucleus and the thalamus was consistently correlated with CF in all three groups, while more dorsally in the caudate, activation differed across the groups. These results suggest the caudate and thalamus to be central to CF while more dorsal aspects of the caudate may be sensitive to damage associated with particular types of insult.

Impact of follow ups, time interval and study duration in diffusion & myelin MRI clinical study in MS

It is currently unknown how quantitative diffusion and myelin MRI designs affect the results of a longitudinal study. We used two independent datasets containing 6 monthly MRI measurements from 20 healthy controls and 20 relapsing-remitting multiple sclerosis (RR-MS) patients. Six designs were tested, including 3 MRI acquisitions, either over 6 months or over a shorter study duration, with balanced (same interval) or unbalanced (different interval) time intervals between MRI acquisitions. First, we show that in RR-MS patients, the brain changes over time obtained with 3 MRI acquisitions were similar to those observed with 5 MRI acquisitions and that designs with an unbalanced time interval showed the highest similarity, regardless of study duration. No significant brain changes were found in the healthy controls over the same periods. Second, the study duration affects the sample size in the RR-MS dataset; a longer study requires more subjects and vice versa. Third, the number of follow-up acquisitions and study duration affect the sensitivity and specificity of the associations with clinical parameters, and these depend on the white matter bundle and MRI measure considered. Together, this suggests that the optimal design depends on the assumption of the dynamics of change in the target population and the accuracy required to capture these dynamics. Thus, this work provides a better understanding of key factors to consider in a longitudinal study and provides clues for better strategies in clinical trial design.

NUTRISEP: Assessment of the nutritional status of patients with multiple sclerosis and link to fatigue

BACKGROUND

Fatigue is a common complaint in patients with multiple sclerosis (PwMS) and reduces quality of life. Several hypotheses for the pathogenesis of fatigue in MS are proposed ranging from neurological lesions to malnutrition, but none has been conclusively validated through clinical research.

OBJECTIVES

The goal of this study was to examine the correlation between fatigue and nutritional status and dietary habits in PwMS.

METHODS

This was a cross-sectional, multicenter study conducted at 10 French MS centers and enrolling PwMS with an Expanded Disability Status Scale (EDSS) score between 0 and 7. Plasma level of albumin, magnesium, calcium, iron, vitamin D and B12 evaluated nutritional status. A semi-structured eating behavior questionnaire has been developed to evaluate dietary habits. Evaluation of fatigue used specific questionnaire (EMIF-SEP). Quality of sleep was evaluated by visual analogue scale (VAS), depression with Beck Depression Inventory (BDI-II); dysphagia by DYsphagia in MUltiple Sclerosis questionnaire (DYMUS) and taste disorders by gustometry. Association between nutritional deficiencies and different data such as socio-demographic data, disease characteristics, swallowing and taste disorders, food intake, depression and sleep quality was investigated.

RESULTS

A total of 352 patients mean age: 48.1±10.1 years, mean duration of MS: 15.3±9.1 years and median EDSS: 4 were analyzed. Bivariate and multivariate analyses showed a statistically significant correlation between fatigue and depression and use of sleeping pills, while none of the variables related to dietary habits or nutritional status correlated significantly with fatigue.

CONCLUSIONS

Dietary habits and nutritional status have little impact on fatigue and general population nutrition recommendations remain the rule for PwMS. In cases of fatigue, specific attention should be paid to depression and use of sleeping pills.

Factors Associated With Treatment-Related Changes in Voice Volume in People With Multiple Sclerosis

BACKGROUND

Vocal disorders are frequent in people with multiple sclerosis (MS). Cognitive impairment, fatigue, depression, and other clinical characteristics can be associated with treatment effectiveness in rehabilitation. Finding baseline characteristics that identify those who are responding to treatment can help the clinical decision-making process, which can then help improve the effectiveness of voice treatment. We developed a model to identify factors associated with treatment-related improvement on voice intensity in people with MS.

METHODS

Data are from a randomized controlled trial of the effects of voice therapy. Forty-four people with MS were enrolled and randomized to receive Lee Silverman Voice Treatment LOUD, specifically addressing voice intensity, or conventional speech-therapy group. Voice intensity (dB) was measured during monologue before and after treatment and was used to differentiate those who responded (posttreatment voice intensity > 60 dB) from those who did not. Possible associated factors were cognitive impairment, fatigue, depression, disability, and disease duration. Associations were assessed by univariate logistic regression and univariate and multivariate linear regressions.

RESULTS

Mean ± SD monologue voice intensity is improved in the whole sample (before rehabilitation: 51.8 ± 4.2 dB; and after rehabilitation 57.0 ± 6.5 dB; P < .001), and 11 people with MS (27.5%) responded to treatment. Specificity of treatment was associated with the return to normal voice intensity (OR, 14.28; 95% CI, 12.17-309.56) and we found a linear association between voice improvement and the specificity of treatment (6.65 [SE = 1.54] dB; P < .05). Moreover, the analysis revealed a nonlinear association between improvement and fatigue, suggesting increased benefits for people with MS with moderate fatigue. Other factors were not significantly associated with treatment effectiveness.

CONCLUSIONS

Moderate fatigue and the specificity of the intervention seem to be key factors associated with clinically relevant improvement in voice intensity even in people with MS with a high level of disability and long disease duration.

Association of baseline self-reported fatigue with overall survival after stereotactic body radiation therapy for localized prostate cancer

Introduction

Stereotactic Body Radiation Therapy (SBRT) has emerged as a definitive therapy for localized prostate cancer (PCa). However, more data is needed to predict patient prognosis to help guide which patients will benefit most from treatment. The FACIT-Fatigue (FACIT-F) is a well validated, widely used survey for assessing fatigue. However, the role of fatigue in predicting PCa survival has yet to be studied. Herein, we investigate the role of FACIT-F as a baseline predictor for overall survival (OS) in patients undergoing SBRT for localized PCa.

Methods

A retrospective review was conducted of 1358 patients who received SBRT monotherapy between January 2008 to April 2021 at an academic, tertiary referral center. FACIT-F scores (range 0 to 52) were summed for patients who answered all 13-items on the survey. FACIT-F total scores of ≥35 represented severe fatigue. Patients receiving androgen deprivation therapy were excluded. Differences in fatigue groups were evaluated using chi-squared tests. OS rates were determined using the Kaplan-Meier method and predictors of OS were evaluated using Cox proportional hazard method.

Results

Baseline full FACIT-F scores and survival data was available for 891 patients. 5-year OS was 87.6% and 95.2%, respectively, for the severely fatigued and non-fatigued groups. Chi-squared analysis of fatigue groups showed no significant difference in the following categories: D'Amico risk group, age, ethnicity, grade group, T-stage, or PSA density. Severe fatigue was associated with a significant decrease in OS (hazard ratio 2.76; 95%CI 1.55 - 4.89). The Cox proportional hazard model revealed that age and FACIT-F were both statistically significant (p <0.05).

Conclusion

Baseline FACIT-F scores are significantly associated with OS. Higher FACIT-F scores, representing less fatigued patients, are associated with an overall survival benefit. These results indicate that the FACIT-F survey could serve as an additional metric for clinicians in determining prognostic factors for patients undergoing SBRT.

Self-reported work productivity in people with multiple sclerosis and its association with mental and physical health

PURPOSE

This study aimed to identify mental health, physical health, demographic and disease characteristics relating to work productivity in people with multiple sclerosis (MS).

METHODS

In this cross-sectional study, 236 employed people with MS (median age = 42 years, 78.8% female) underwent neurological and neuropsychological assessments. Additionally, they completed questionnaires inquiring about work productivity (presenteeism: reduced productivity while working, and absenteeism: loss of productivity due to absence from work), mental and physical health, demographic and disease characteristics. Multiple linear and logistic regression analyses were performed with presenteeism and absenteeism as dependent variables, respectively.

RESULTS

A model with mental and physical health factors significantly predicted presenteeism F(11,202) = 11.33, p < 0.001, R² = 0.38; a higher cognitive (p < 0.001) and physical impact (p = 0.042) of fatigue were associated with more presenteeism. A model with only mental health factors significantly predicted absenteeism; χ²(11)=37.72, p < 0.001, with R² = 0.27 (Nagelkerke) and R² = 0.16 (Cox and Snell). Specifically, we observed that more symptoms of depression (p = 0.041) and a higher cognitive impact of fatigue (p = 0.011) were significantly associated with more absenteeism.

CONCLUSIONS

In people with MS, both cognitive and physical impact of fatigue are positively related to presenteeism, while symptoms of depression and cognitive impact of fatigue are positively related to absenteeism.Implications for rehabilitationMultiple sclerosis (MS) affects people of working age, significantly interfering with work productivity.Higher cognitive and physical impact of fatigue were associated with more presenteeism in workers with MS.A higher cognitive impact of fatigue and more depressive symptoms were associated with absenteeism in workers with MS.Occupational and healthcare professionals should be aware of the impact of both physical and mental health on work productivity in workers with MS.

Patient's perspective in clinical practice to assess and predict disability in multiple sclerosis

The information provided by a person with multiple sclerosis (MS) may anticipate changes in the course of the disease. To explore the role of a set of standardized patient-reported outcomes (PRO) in predicting disability progression in MS an observational study was conducted in two cohorts of 30 and 86 persons with progressive MS (pwPMS) and relapsing MS (pwRMS), respectively. The associations between baseline clinical, biochemical variables and results on MS quality of life scale (MusiQol), Modified Fatigue Impact Scale (MFIS) and Beck Depression Inventory II (BDI-II) were analyzed. The progression of disability after 2 years of follow-up in pwRMS was investigated. We show that PRO differentiated pwRMS and pwPMS cohorts with lower MusiQoL and higher MFIS and BDI-II scores in the latter. Only MFIS was correlated with disability in pwRMS and high scores in the physical MFIS domain associated with worse performance in 9HPT, and a trend in T25FW and SDMT. Instead, the cognitive MFIS domain was correlated with CHI3L1 in cerebrospinal fluid, a biomarker of progression. At the end of the study, global MFIS and BDI-II were found to be independent risk factors for disability independent of relapse. Although all PRO measures explored were altered in pwPMS, baseline MFIS discriminated current and prospective disability in pwRMS, identifying patients at risk of progression.

The Economic and Humanistic Burden of Pediatric-Onset Multiple Sclerosis

Background: Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease of the central nervous system. Pediatric-onset MS (POMS), defined as onset of MS before 18 years of age, is estimated to account for 2% to 5% of the MS population worldwide. Objectives: To conduct a literature review focused on the healthcare resource utilization and cost as well as quality-of-life (QOL) outcomes among patients with POMS. Methods: We conducted a systematic literature review of English-language studies published after September 2010 in MEDLINE and Embase to describe the global economic healthcare resource utilization and costs and humanistic (QOL) burden in patients with POMS. Results: We found 11 studies that reported on healthcare resource utilization, cost, or insurance coverage and 36 studies that reported on QOL outcomes in patients with POMS. Patients with POMS had higher rates of primary care visits (1.41 [1.29-1.54]), hospital visits (10.74 [8.95-12.90]), and admissions (rate ratio, 4.27 [2.92-6.25];OR, 15.2 [12.0-19.1]) compared with healthy controls. Mean per-patient costs in the United States were $5907 across all settings per year of follow-up between 2002 and 2012; mean costs per hospital stay were $38 543 (in 2015 USD) between 2004 and 2013. Three studies reported psychosocial scores between 71.59 and 79.7, and 8 studies reported physical health scores between 74.62 to 82.75 using the Pediatric Quality of Life Measurement Model (PedsQLTM). Twelve studies used the PedsQL™ Multidimensional Fatigue Scale. Mean scores on the self-reported general fatigue scale ranged from 63.15 to 78.5. Quality-of-life scores were lower than those of healthy controls. Discussion: Our review presents a uniquely broad and recent overview of the global economic and humanistic burden of patients with POMS. Additional research on healthcare resource utilization and cost would provide a more robust understanding of the economic burden in this population. Conclusions: Healthcare resource utilization and costs are high in this population, and patients report reduced QOL and significant fatigue compared with healthy children and adolescents.

Validity and reliability characteristics of the Silhouettes Fatigue Scale in measuring multiple sclerosis-related fatigue in Turkish-speaking adults

BACKGROUND

The purpose of this study is to investigate the reliability and validity as well as the clinical utility of the Silhouettes Fatigue Scale (SFS), a single-item visual scale to assess fatigue, in adult patients with multiple sclerosis (MS).

METHODS

The study included 61 MS patients and 73 matched healthy controls. Demographic data and disease-related variables of all participants were recorded. Then, the SFS, Visual Analogue Scale (VAS)-fatigue, Fatigue Impact Scale (FIS), Fatigue Severity Scale (FSS), and Beck Depression Inventory (BDI) were applied. SFS, VAS-fatigue, and FSS were repeated after one week. Reliability was evaluated with the intra-class correlation coefficient (ICC) and Bland-Altman analysis. Validity was tested by comparison of healthy controls and patients with MS and correlations with other scales. Accuracy and clinical utility were also evaluated.

RESULTS

SFS scores were 4.49 ± 3.11 (mean ± SD) in MS patients and 1.40 ± 1.44 in healthy controls (p < .001). The ICC for SFS was 0.946. The mean difference between test-retest measurements of SFS was -0.04651 (-95% CI, -0.4815-0.38848), and there was no systemic bias. SFS scores were not correlated with the expanded disability status scale, whereas they were poorly correlated with BDI. Correlations ranging from poor to good were calculated between the SFS and other fatigue-related scales. The optimum cut-off score of the SFS scale was four, with a sensitivity of 0.72 and a specificity of 0.84.

CONCLUSION

This study demonstrated that the SFS is a reliable, responsive, and valid scale with acceptable sensitivity and specificity to assess and quantify clinically significant fatigue in MS patients. These findings as well as the brief and understandable nature of the SFS were encouraging that this scale has good clinical utility.

Interpreting the clinical importance of the relationship between subjective fatigue and cognitive impairment in multiple sclerosis (MS): How BICAMS performance is affected by MS-related fatigue

BACKGROUND

There is evidence that subjective fatigue can influence cognitive functioning in multiple sclerosis (MS). DeLuca et al.'s (2004) Relative Consequence Model proposes that impairments to other high-level cognitive functions, such as memory, result from the disease's effect on information processing speed.

OBJECTIVE

The primary aims of the study were to investigate both 1) the relationship between subjective fatigue and cognitive functioning, as measured by the widely used Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) in MS; and 2) the consequential effect of fatigue on information processing speed as predicted by the Relative Consequence Model.

METHODS

192 participants with MS attending tertiary referral MS centre completed the Modified Fatigue Impact Scale and BICAMS.

RESULTS

Multiple correlation analyses determined that there were statistically significant relationships between all domains assessed by the BICAMS and levels of fatigue, such that higher levels of self-reported fatigue were associated with lower performance on information-processing, and visual and verbal learning. After controlling for information processing speed, the strength of correlation between fatigue and learning performance weakened. Linear regression analysis showed that fatigue predicted the most variance in verbal learning and 11.7% of the overall variance in BICAMS performance.

CONCLUSION

Subjective fatigue and objective cognitive performance in MS are related. Caution is advised in the interpretation of BICAMS scores in cases where high levels of fatigue are present, and more detailed neuropsychological assessments may be required in order to accurately identify objective cognitive impairment independent of subjective fatigue.

Current perspectives on the diagnosis and management of fatigue in multiple sclerosis

INTRODUCTION

Fatigue is a common and debilitating symptom among multiple sclerosis (MS) patients with a prevalence up to 81% and with a considerable impact on quality of life. However, its subjective nature makes it difficult to define and quantify in clinical practice. Research aimed at a more precise definition and knowledge of this construct is thus continuously growing.

AREAS COVERED

This review summarizes the most relevant updates available on PubMed up to July 1^st 2022 regarding: the assessment methods that aim to measure the concept of fatigue (as opposed to fatigability), the possible treatment pathways currently available to clinicians, interconnection with the pathophysiological substrates and with the common comorbidities of MS, such as depression and mood disorders.

EXPERT OPINION

The in-depth study of fatigue can help to better understand its actual impact on MS patients and can stimulate clinicians towards a more valid approach, through a targeted analysis of this symptom. Considering fatigue from a multidimensional perspective allows the use of patient-tailored methods for its identification and subsequent treatment by different professional figures. Better identification of methods and treatment pathways would reduce the extremely negative impact of fatigue on MS patients' quality of life.

Fatigue in multiple sclerosis: A UK MS-register based study

BACKGROUND

Fatigue is a widely experienced, incapacitating symptom of MS. It hinders daily functioning and has deleterious effects on quality of life. The UK MS Register is an online registry of over 20,000 participants with MS. The aim of this study was to estimate the prevalence, predictors, and impact of fatigue on people with MS using data from the UKMS register.

METHODS

All participants who completed the Fatigue Severity Scale (FSS), WebEDSS, Hospital Anxiety and Depression Scale (HADS) within 28 days of each other were selected from the UK MS Register. Data on age, gender, duration and type of MS, use of disease modifying drugs and comorbidities were obtained from the UKMS register. We categorised people with FSS score of 5 or more as with fatigue and those with scores of 4 or less as without fatigue. Descriptive statistics and logistical and multiple regressions were used to explore predictors of fatigue and the effect of fatigue on mobility (MS Walking Scale), physical and psychological aspects of life (MS Impact Scale) and quality of life (European Quality of Life 5D-3 L).

RESULTS

Amongst the 20,946 participants of the UK MS registry, 4620 completed FSS. Out of these, 775 (mean age= 54.71 years, SD= 10.90; mean duration of MS diagnosis =13.21 years, SD=9.75) had completed the FSS, Web EDSS and Hospital Anxiety and Depression Scale within 28 days of each other. 427 (55.1%) of pwMS had a FSS score >5 consistent with clinical fatigue. Logistic regression analysis showed that depression (p=<0.001), duration of MS (p = 0.017), secondary progressive MS (p = 0.001) and EDSS (p=<0.001) predicted fatigue. FSS scores had a significant negative impact on both psychological (p > 0.001) and physical (p > 0.001) domains of the MS Impact scale, MS walking scale (p = 0.003) and EQoL (p = 0.005).

CONCLUSIONS

Fatigue was a common symptom amongst people with MS. Depression, longer duration of MS, secondary progressive MS, and high EDSS predicted fatigue. Fatigue had an adverse effect on physical activities, mobility, psychological wellbeing, and quality of life of people with MS.

Barriers to quality of life in patients with multiple sclerosis: a qualitative study

BACKGROUND

Multiple sclerosis (MS) is a chronic progressive disease of the central nervous system that affects the patients' quality of life. This research was conducted with the aim of identifying the barriers of quality of life in patients with MS.

METHODS

This qualitative study was conducted through a conventional content analysis approach. We used the purposeful sampling with maximum diversity in terms of gender, age, education, marital status and employment. Data were collected through semi-structured interviews with 18 patients with multiple sclerosis referred to the MS Association of Isfahan. Interviews were conducted to the point of information saturation.

RESULTS

Through the content analysis of the interviews, we identified 2 main categories and 11 sub-categories. The main categories include intrapersonal problems (physical problems, psychological disorders, turbulent future, functional limitations, job loss and pennilessness), and environmental barriers (disease and treatment process, fatigue of caregivers, information deficiency about MS, family tensions, lack of social support and fun and entertainment).

CONCLUSIONS

In order to improve the quality of life in these patients, there is a need for attention and practical measures in the field of identified factors. By removing barriers such as providing educational and counseling services to the patients and their families, adapting the urban structure, providing financial support and adequate insurance coverage, the authorities can take measures to ensure patients' health and improve their quality of life.

Italian translation and validation of fatigue symptoms and impacts questionnaire in relapsing multiple sclerosis (FSIQ-RMS)

BACKGROUND

Fatigue is a disabling symptom of multiple sclerosis (MS) and impacts on daily life. The Fatigue Symptoms and Impacts Questionnaire-Relapsing Multiple Sclerosis (FSIQ-RMS) is a new 20-item tool that investigates the aspects of fatigue in MS. It concerns motor, cognitive, social, and emotional aspects of fatigue. We aim at validating the Italian version of FSIQ-RMS in an Italian population of MS patients and demonstrate its reliability and construct validity.

METHODS

We included patients with diagnosis of MS, age between 18 and 70 years with ability to participate in a 90-min interview. Each patient completed the Italian version of FSIQ-RMS and Fatigue Severity Scale (FSS) at the same time. Construct validity was explored by the exploratory factor analysis; reliability was assessed with Cronbach's alpha; and test-retest stability was examined through intraclass correlation coefficient (ICC). Concurrent validity was calculated using Pearson's correlation.

RESULTS

We enrolled 171 patients (126 female and 45 male), 83% with relapsing MS (RMS), and 17% with secondary progressive MS (SPMS). Italian FSIQ-RMS showed a Cronbach's alpha of 0.92; ICC was 0.96. Pearson's correlation coefficient between FSIQ-RMS and FSS total score was statistically significant (p < 0.01); FSIQ-RMS inversely correlated also with BMI and positively with EDSS.

CONCLUSION

The Italian version of FSIQ-RMS has excellent psychometric properties and can be used in research and clinical setting to evaluate physical, cognitive, and social fatigue in both RMS and SPMS.

Assessment of factors associated with depression and anxiety among pwMS in Saudi Arabia

Background

Multiple sclerosis (MS) is an inflammatory chronic disease that is characterized by an increased prevalence of adverse mental health outcomes in patients with MS (pwMS). The main aim of this study is to investigate the factors of depression and anxiety in pwMS in the Kingdom of Saudi Arabia (KSA).

Materials and methods

This is a cross-sectional study conducted in KSA during the period from March to June 2020. Participants were recruited from the Neuroimmunology clinics in King Fahad Medical City (KFMC) and King Saud University medical city (KSUMC)in Riyadh City, KSA. The Hospital Anxiety and Depression Scale (HADS) was used to measure depression and anxiety. Fatigue Severity Scale (FSS) was used to measure fatigue in pwMS. A simple random sampling technique was utilized to select participants and the data were analyzed using SPSS v.24.0.

Results

A total of 529 participants participated in this study with a response rate of 53.1%. The prevalences of anxiety and depression were 35.3% and 19.7%, respectively. The findings also revealed that depression was more likely to be significantly affected by being male, low education, unemployment, physical inactivity, and fatigue but the anxiety was significantly affected by region, unemployment, short duration since last MS relapse, physical inactivity, and fatigue.

Conclusion

Anxiety and depression are not uncommon in pwMS. Given their impact on the lives of affected patients, early detection and management of these symptoms and their associated factors are crucial.

The Complex Interplay Between Trait Fatigue and Cognition in Multiple Sclerosis

Cognitive impairments are frequent in patients with Multiple Sclerosis (MS). Yet, the influence of MS-related symptoms on cognitive status is not clear. Studies investigating the impact of trait fatigue along with anxio-depressive symptoms on cognition are seldom, and even less considered fatigue as multidimensional. Moreover, these studies provided conflicting results.

Twenty-nine MS patients and 28 healthy controls, matched on age, gender and education underwent a full comprehensive neuropsychological assessment. Anxio-depressive and fatigue symptoms were assessed using the HAD scale and the MFIS, respectively. Six composite scores were derived from the neuropsychological assessment, reflecting the cognitive domains of working memory, verbal and visual learning, executive functions, attention and processing speed. Stepwise regression analyses were conducted in each group to investigate if trait cognitive and physical fatigue, depression and anxiety are relevant predictors of performance in each cognitive domain. In order to control for disease progression, patient’s EDSS score was also entered as predictor variable.

In the MS group, trait physical fatigue was the only significant predictor of working memory score. Cognitive fatigue was a predictor for executive functioning performance and for processing speed (as well as EDSS score for processing speed). In the healthy controls group, only an association between executive functioning and depression was observed.

Fatigue predicted cognition in MS patients only, beyond anxio-depressive symptoms and disease progression. Considering fatigue as a multidimensional symptom is paramount to better understand its association with cognition, as physical and cognitive fatigue are predictors of different cognitive processes.

The Impact of Motor Disability and the Level of Fatigue on Adherence to Therapeutic Recommendations in Patients with Multiple Sclerosis Treated with Immunomodulation

Aim: The aim of the study was to clarify whether the motor disability and the fatigue-related syndrome affect the level of compliance with therapeutic recommendations. Methods: Prospective studies were conducted among 165 patients treated under the drug program - Treatment of Multiple Sclerosis (MS) at the Department of Neurology and Clinical Neuroimmunology of the Regional Specialist Hospital in Grudziadz (Poland). The research was carried out by the method of diagnostic survey, questionnaire technique with the use of standardized research tools. The Adherence in Chronic Diseases Scale (ACDS) was used to assess the level of compliance with therapeutic recommendations. The Expanded Disability Status Scale (EDSS) was used to assess the degree of disability, and the Modified Fatigue Impact Scale (MFIS) was used to assess the degree of disability. The Chi-square test, Shapiro-Wilk test and Kruskal-Wallis were used. Results: The statistical analysis showed that there is a relationship (p=0.0055) between the patient's motor disability assessed in the EDSS scale and the level of compliance with therapeutic recommendations assessed in the ACDS scale. The higher the patient's disability level (EDSS 4.5-6.5), the lower the treatment adherence rate. The conducted research shows that the average score in the MFIS scale for individual levels of compliance with therapeutic recommendations expressed in the ACDS scale is, respectively: for the low level - 38.3 MFIS points, for the medium level - 34.4 MFIS points and for the high level- 33.2 MFIS points. The obtained results were not statistically significant (p=0.6098). Conclusion: It was found that the level of adherence to therapeutic recommendations in patients with relapsing-remitting multiple sclerosis treated with immunomodulation in the study group remained high. There is a relationship between the patient's disability and the level of adherence to therapeutic recommendations.

Depression in multiple sclerosis: Is one approach for its management enough?

BACKGROUND

Major depression disorder (MDD) and severe depression symptoms are highly prevalent in multiple sclerosis (MS). Depression can worsen symptoms of MS and is associated with significantly reduced quality of life and increased risk of suicide. Currently, there is no gold-standard, single treatment available for depression in MS. Pharmacotherapy, cognitive behavior therapy (CBT), and exercise training individually are moderately, yet incompletely, efficacious for managing depression in the general population and MS.

PURPOSE

This review provides an overview of evidence from meta-analyses and systematic reviews for current treatments of depression in persons with MS. This review further develops the rationale for using a combinatory treatment approach in persons with MS.

METHODS

We performed a narrative review of meta-analyses and systematic reviews regarding the current state of evidence for the three most common treatments of depression in persons with MS (i.e., antidepressant medication, cognitive-behavior therapy, and exercise training). We provide a concise assessment of the overall effect of these treatments on depression in the general population and then persons with MS. We further note short-comings of research on these treatments for depression.

CONCLUSION

There is no single, gold-standard treatment for depression in MS, and we proposed that combinatory treatments should be considered for the management of depression in MS. However, there is a paucity of evidence for the use of combinatory therapy on depression and its outcomes in persons with MS, and this supports direct examination of the feasibility and efficacy of such combinatory approaches for MDD in MS.

Glatiramer Acetate Treatment in Multiple Sclerosis-Associated Fatigue-Beneficial Effects on Self-Assessment Scales But Not on Molecular Markers

Although fatigue is a common symptom in multiple sclerosis (MS), its pathomechanisms are incompletely understood. Glatiramer acetate (GA), an immunomodulatory agent approved for treatment of relapsing-remitting MS (RRMS), possesses unique mechanisms of action and has been shown to exhibit beneficial effects on MS fatigue. The objective of this study was to correlate clinical, neuropsychological, and immunological parameters in RRMS patients with fatigue before and during treatment with GA. In a prospective, open-label, multicenter trial, 30 patients with RRMS and fatigue were treated with GA for 12 months. Inclusion criterion was the presence of fatigue as one of the most frequent and disabling symptoms. Before and during treatment, fatigue was assessed using the Fatigue Severity Scale (FSS), the MS-FSS, and the Modified Fatigue Impact Scale (MFIS). In addition, fatigue and quality of life were assessed using the Visual Analog Scales (VAS). Laboratory assessments included screening of 188 parameters using real-time PCR microarrays followed by further analysis of several cytokines, chemokines, and neurotrophic factors. Fatigue self-assessments were completed in 25 patients. After 12 months of treatment with GA, 13 of these patients improved in all three scales (with the most prominent effects on the MFIS), whereas 5 patients had deteriorated. The remaining 7 patients exhibited inconsistent effects within the three scales. Fatigue and overall quality of life had improved, as assessed via VAS. Laboratory assessments revealed heterogeneous mRNA levels of cytokines, chemokines, and neurotrophic factors. In conclusion, we were not able to correlate clinical and molecular effects of GA in patients with RRMS and fatigue.

Disability and its association with psychological factors in multiple sclerosis patients

BACKGROUND

Multiple Sclerosis (MS) is a neurological, and immune-mediated demyelinating disease. Psychological factors in MS disease and psychosocial interventions based on these factors have a major role in the adjustment of MS patients toward their disease. The aim of the study was to compare the psychological components of happiness, psychological well-being, love of life, meaning in life, and somatic health between MS patients with low Expanded Disability Status Scale (EDSS) scores and MS patients with higher EDSS scores.

METHOD

A sample of 128 patients with MS was recruited. Patients were administered the EDSS, the Self-Rating Scale of Happiness (SRH), the World Health Organization-five Well-Being Index (WHO-5), the Love of Life Scale (LLS), the Meaning in Life Questionnaire (MLQ) and the Patient Health Questionnaire-15 (PHQ-15). Patients with EDSS>3 (cases) and EDSS≤3 (controls) were compared.

RESULTS

The cases had lower scores for happiness, love of life, psychological well-being, meaning in life, the present of meaning in life subscale, and somatic health, compared with the controls. The differences between cases and controls remained statistically significant after controlling for age and sex.

CONCLUSION

Positive health promotion and education intervention programs to reduce disability and increase MS patients' well-being should be one of the priorities in the Iran healthcare system for MS patients. Therapists should take these components into account when working with MS patients with moderate and severe disability.

Chronic fatigue and depression due to multiple sclerosis: Immune-inflammatory pathways, tryptophan catabolites and the gut-brain axis as possible shared pathways

Chronic fatigue and major depression (MDD)-like symptoms are common manifestations of multiple sclerosis (MS), both with huge impact on quality of life. Depression can manifest itself as fatigue, and depressive symptoms are often mistaken for fatigue, and vice versa. The two conditions are sometimes difficult to differentiate, and their relationship is unclear. Whether chronic fatigue and depression occur primarily, secondarily or coincidentally with activated immune-inflammatory pathways in MS is still under debate. We have carried out a descriptive review aiming to gain a deeper understanding of the relationship between chronic fatigue and depression in MS, and the shared pathways that underpin both conditions. This review focuses on immune-inflammatory pathways, the kynurenine pathway and the gut-brain axis. It seems likely that proinflammatory cytokines, tryptophan catabolites (the KYN pathway) and the gut-brain axis are involved in the mechanisms causing chronic fatigue and MDD-like symptoms in MS. However, the evidence base is weak, and more research is needed. In order to advance our understanding of the underlying pathological mechanisms, MS-related fatigue and depression should be examined using a longitudinal design and both immune-inflammatory and KYN pathway biomarkers should be measured, relevant clinical characteristics judiciously registered, and self-report instruments for both fatigue and depression should be used.

Determinants of low bone mineral density in people with multiple sclerosis: Role of physical activity

BACKGROUND

People with multiple sclerosis (PwMS) have reduced bone mineral density (BMD), but the causes are unclear. Some factors that may cause reduced BMD in PwMS have been understudied, including physical activity, inflammation, cortisol, symptomatic fatigue, and depression. The aim of this study was to investigate factors that may uniquely contribute to reduced BMD in PwMS as compared to people without MS. We hypothesized that physical activity would be the primary determinant of low BMD in PwMS, with additional contributions from inflammation and sympathetic nervous system activation.

METHODS

We tested 23 PwMS (16 women; median EDSS: 2) and 22 control participants (16 women). BMD was measured from the femoral neck and lumbar spine with dual x-ray absorptiometry. Disability was measured with the Expanded Disability Status Scale, and functional capacity was measured with the Multiple Sclerosis Functional Composite. Questionnaires measured symptomatic fatigue and depression. A blood draw was used to measure calcium, phosphate, vitamin D, N-terminal telopeptide, osteopontin, and cytokine markers of inflammation. Physical activity was measured with accelerometry. Salivary cortisol and cardiac heart rate variability also were obtained. All outcome variables were compared between groups with independent samples t-tests. Variables that were different between groups and significantly correlated (Pearson product-moment) with femoral neck BMD, were included in a theoretical model to explain femoral neck BMD. The expected direction of relations in the theoretical model were developed based upon the results of previous research. A Bayesian path analysis was used to test the relations of predictive variables with femoral neck BMD and interrelations among predictive variables, as detailed in the theoretical model.

RESULTS

PwMS had lower BMD at the femoral neck than controls (p = =0.04; mean difference: -0.09; 95% CI: -0.2, -0.004; Cohen's d = =0.65), and there was a smaller, statistically non-significant difference in BMD at the lumbar spine (p = =0.07; mean difference: -0.08; 95% CI: -0.17, 0.007; Cohen's d = =0.59). PwMS also had lower functional capacity (p ≤ 0.001; Cohen's d = =1.50), greater fatigue (p<0.001; Cohen's d = =1.88), greater depression (p<0.001; d = =1.31), and decreased physical activity (p = =0.03; Cohen's d = =0.62). Using path analysis to test our theoretical model, we found that disability (standardized estimate= -0.17), physical activity (standardized estimate=0.39), symptomatic fatigue (standardized estimate= -0.36), depression (standardized estimate= -0.30), and inflammatory markers (standardized estimate=0.27) explained 51% of the variance in femoral neck BMD. Inflammatory markers were also predictive of disability (standardized estimate=0.44) and physical activity (standardized estimate= -0.40). Symptomatic fatigue and depression were correlated (r = =0.64).

CONCLUSION

Physical activity, symptomatic fatigue, depression, disability, and inflammation all contributed independently to decreased femoral neck BMD in PWMS. Bone metabolism in PwMS is complex. Efforts to increase physical activity and address symptomatic fatigue and depression may improve bone mineral density in PwMS. Future research should investigate the mechanisms through which symptomatic fatigue and depression contribute to reduced BMD in PwMS.

Quality of life in patients with multiple sclerosis and its association with depressive symptoms and physical disability

OBJECTIVE

The aim of this work was to evaluate the quality of life of patients with multiple sclerosis and its association with depressive symptoms and physical health.

METHOD

A total of 117 patients clinically diagnosed with Multiple Sclerosis (MS) were studied. The MSQOL-54 scale was applied. The depressive symptoms were assessed using the Beck Depression Inventory (BDI), while degree of physical disability was evaluated with the EDSS (Expanded Disability Status Scale). The results of these last two instruments were associated with MSQOL-54 to determine its influence on the perception of quality of life.

RESULTS

We evaluated 65 women (56%) and 52 men (44%), with a mean age of 35 years, a mean age of 27 years at the time of diagnosis, and a mean evolution of 8 years. 88% of the patients showed the relapsing-remitting subtype; 42% had paid employment; 29% of the studied patients required help to perform daily activities; 75% took disease-modifying medications. They obtained on average a score of 3.62 ± 2.30 on the EDSS and 11.5 ± 9.21 on the BDI. The general average in MSQOL-54 was 64.67 ± 17.52.

CONCLUSIONS

Quality of life, in patients with multiple sclerosis is an issue that worries health personnel, it is essential to implement strategies for reducing the impact of the disease on patients' lives, mainly through the application of programs aimed to decrees depression and improve social support.

Cognitive Functioning in Patients with Pediatric-Onset Multiple Sclerosis, an Updated Review and Future Focus

Pediatric-onset multiple sclerosis (POMS) is relatively rare, but as technology and neuroimaging advance, an increasing number of cases are identified, and our understanding of how multiple sclerosis (MS) impacts the developing brain improves. There are consistent findings in the literature highlighting the impact of MS and other demyelinating diseases on cognitive functioning and cognitive development. We also have a better understanding of how POMS impacts psychosocial functioning and functional outcomes in daily living. This paper hopes to review findings associated with cognitive and psychosocial functioning in patients with POMS, as well as explore more recent advances in the field and how they relate to cognitive and psychosocial outcomes. We also discuss the ongoing need for future studies with a focus on better understanding deficits and disease correlates, but also preventative measures and potential rehabilitation.

Microglial Phagocytosis of Neurons: Diminishing Neuronal Loss in Traumatic, Infectious, Inflammatory, and Autoimmune CNS Disorders

Errors in neuron-microglial interaction are known to lead to microglial phagocytosis of live neurons and excessive neuronal loss, potentially yielding poorer clinical outcomes. Factors that affect neuron-microglial interaction have the potential to influence the error rate. Clinical comorbidities that unfavorably impact neuron-microglial interaction may promote a higher rate of neuronal loss, to the detriment of patient outcome. This paper proposes that many common, clinically modifiable comorbidities have a common thread, in that they all influence neuron-microglial interactions. Comorbidities like traumatic brain injury, infection, stress, neuroinflammation, loss of neuronal metabolic integrity, poor growth factor status, and other factors, all have the potential to alter communication between neurons and microglia. When this occurs, microglial phagocytosis of live neurons can increase. In addition, microglia can shift into a morphological form in which they express major histocompatibility complex II (MHC-II), allowing them to function as antigen presenting cells that present neuronal debris as antigen to invading T cells. This can increase risk for the development of CNS autoimmunity, or can exacerbate existing CNS autoimmunity. The detrimental influence of these comorbidities has the potential to contribute to the mosaic of factors that determine patient outcome in some CNS pathologies that have neuropsychiatric involvement, including TBI and CNS disorders with autoimmune components, where excessive neuronal loss can yield poorer clinical outcomes. Recognition of the impact of these comorbidities may contribute to an understanding of the common clinical observation that many seemingly disparate factors contribute to the overall picture of case management and clinical outcome in these complex disorders. In a clinical setting, knowing how these comorbidities can influence neuron-microglial interaction can help focus surveillance and care on a broader group of potential therapeutic targets. Accordingly, an interest in the mechanisms underlying the influence of these factors on neuron-microglial interactions is appropriate. Neuron-microglial interaction is reviewed, and the various mechanisms by which these potential comorbidities influence neuro-microglial interaction are described.

Depressive Syndromes in Autoimmune Disorders of the Nervous System: Prevalence, Etiology, and Influence

Autoimmune diseases of the nervous system (ADNS) consist of a group of severely disabling disorders characterized by abnormal immune attack against protein components of the nervous system. This type of attack behavior may occur in the central or peripheral nervous system, and in the neuromuscular junction, resulting in neuronal damage, axonal injury, demyelination or destruction of the neuromuscular junction. While the neurological deficits of patients with ADNS have received significant research attention, the manifestation of depression tends to be ignored. In fact, depressive manifestation is common in ADNS and adds significant burden upon patients suffering from this disease. Here, we systematically reviewed the current literature to highlight the prevalence, etiology and influence of depressive manifestation in ADNS. Most autoimmune diseases of the nervous system are discussed in this paper, from multiple sclerosis, acute disseminated encephalomyelitis and autoimmune encephalitis to acute myelitis, neuromyelitis optica, Guillain-Barré syndrome and myasthenia gravis. Depressive symptoms usually develop as a comorbidity during the course of disease, but sometimes exist as a primary presentation of the disease. Psychosocial factors, long periods of disablement and chronic pain are the three most common causes of depressive symptoms in many chronic conditions, particularly in peripheral neuropathy. Furthermore, the higher prevalence of depressive symptoms in ADNS suggests that immunological dysregulation may contribute to the elevated morbidity of depression. Finally, structural lesions of the brain, and some medications for ADNS, are also thought to precipitate depressive states in ADNS.

Osteopathic Manipulative Therapy and Multiple Sclerosis: A Proof-of-Concept Study

Context

Research on the effect of osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) on chronic symptoms of multiple sclerosis (MS) is lacking.

Objective

To evaluate the effect of OMTh on chronic symptoms of MS.

Methods

Patients with MS who were evaluated at the neurology clinic at Genoa University in Italy were recruited for this study. Participants received 5 forty-minute MS health education sessions (control group) or 5 OMTh sessions (OMTh group). All participants completed a questionnaire that assessed their level of clinical disability, fatigue, depression, anxiety, and quality of life before the first session, 1 week after the final session, and 6 months after the final session. The Extended Disability Status Scale, a modified Fatigue Impact Scale, the Beck Depression Inventory-II, the Beck Anxiety Inventory, and the 12-item Short Form Health Survey were used to assess clinical disability, fatigue, depression, anxiety, and quality of life, respectively.

Results

Twenty-two participants were included in the study (10 in the control group and 12 in the OMTh group). In the OMTh group, statistically significant improvements in fatigue and depression were found 1 week after the final session (P=.002 and P<.001, respectively). An increase in quality of life was also found in the OMTh group 1 week after the final session (P=.36).

Conclusion

Results demonstrate that OMTh should be considered in the treatment of patients with chronic symptoms of MS.

Treatment choices and neuropsychological symptoms of a large cohort of early MS

Objective

To assess clinical characteristics, distribution of disease-modifying treatments (DMTs), and neuropsychological symptoms in a large cohort of patients with early-stage MS.

Methods

The German National MS Cohort is a multicenter prospective longitudinal cohort study that has recruited DMT-naive patients with clinically isolated syndrome (CIS) and relapsing-remitting MS (RRMS) since 2010. We evaluated their baseline characteristics and the prevalence of neuropsychological symptoms.

Results

Of 1,124 patients, with a 2.2:1 female-to-male ratio and median age at onset of 31.71 years (interquartile range [IQR]: 26.06–40.33), 44.6% and 55.3% had CIS and RRMS, respectively. The median Expanded Disability Status Scale (EDSS) score at baseline was 1.5 (IQR: 1.0–2.0). A proportion of 67.8% of patients started DMT after a median time of 167.0 days (IQR 90.0–377.5) since the first manifestation. A total of 64.7% and 70.4% of the 762 patients receiving early DMT were classified as CIS and RRMS, respectively. Fatigue, depressive symptoms, and cognitive dysfunction were detected in 36.5%, 33.5%, and 14.7% of patients, respectively.

Conclusion

Baseline characteristics of this large cohort of patients with early, untreated MS corroborated with other cohorts. Most patients received early DMT within the first year after disease onset, irrespective of a CIS or RRMS diagnosis. Despite the low EDSS score, neuropsychological symptoms affected a relevant proportion of patients.