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Bae M, Khodabandeloo S, VanNostrand M, Gell NM, Kasser SL. Reliability and validity of the ratings of perceived stability scale as a measure of balance exercise intensity in persons with multiple sclerosis. Disabil Rehabil 2024:1-7. [PMID: 39224017 DOI: 10.1080/09638288.2024.2395455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 08/14/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE The study aimed to determine the test-retest reliability and concurrent validity of the Ratings of Perceived Stability (RPS) scale as a measure of balance exercise intensity in persons with multiple sclerosis (MS). METHODS Twenty participants with MS (mean age: 58.1 ± 15.29; 60% female) performed 14 balance tasks on two separate occasions wearing body-worn inertial sensors and rated their perceived stability for each task. Sensor data included sway velocity and angle, gait speed, turn velocity, and lean angle. Intraclass correlation coefficients (ICC) and Spearman rank correlations (rs) were employed to assess reliability and validity, respectively. RESULTS The RPS showed good to excellent test-retest reliability (ICC> 0.75) on 12 out of the 14 tasks. The stability ratings revealed moderate relationships with postural sway outcomes in static balance tasks (rs: 0.49 to 0.77) and weak to moderate associations with gait speed (rs: -0.69 to -0.14). Ratings of stability were also strongly related to turn velocity (rs= -0.77) and moderately related to lean angle (rs= 0.58). CONCLUSIONS The RPS scale offers a promising clinical tool to measure balance exercise intensity for persons with MS. This standardized scale allows for tailored balance training with a novel means for exercise monitoring and progression in this population.
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Affiliation(s)
- Myeongjin Bae
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont, USA
| | - Sadegh Khodabandeloo
- Department of Mechanical Engineering, University of Vermont, Burlington, Vermont, USA
| | - Michael VanNostrand
- Department of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Nancy M Gell
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont, USA
| | - Susan L Kasser
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont, USA
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Qiao Y(S, Santanasto AJ, Coen PM, Cawthon PM, Cummings SR, Forman DE, Goodpaster BH, Harezlak J, Hawkins M, Kritchevsky SB, Nicklas BJ, Toledo FGS, Toto PE, Newman AB, Glynn NW. Associations between skeletal muscle energetics and accelerometry-based performance fatigability: Study of Muscle, Mobility and Aging. Aging Cell 2024; 23:e14015. [PMID: 37843879 PMCID: PMC11166367 DOI: 10.1111/acel.14015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023] Open
Abstract
Performance fatigability is typically experienced as insufficient energy to complete daily physical tasks, particularly with advancing age, often progressing toward dependency. Thus, understanding the etiology of performance fatigability, especially cellular-level biological mechanisms, may help to delay the onset of mobility disability. We hypothesized that skeletal muscle energetics may be important contributors to performance fatigability. Participants in the Study of Muscle, Mobility and Aging completed a usual-paced 400-m walk wearing a wrist-worn ActiGraph GT9X to derive the Pittsburgh Performance Fatigability Index (PPFI, higher scores = more severe fatigability) that quantifies percent decline in individual cadence-versus-time trajectory from their maximal cadence. Complex I&II-supported maximal oxidative phosphorylation (max OXPHOS) and complex I&II-supported electron transfer system (max ETS) were quantified ex vivo using high-resolution respirometry in permeabilized fiber bundles from vastus lateralis muscle biopsies. Maximal adenosine triphosphate production (ATPmax) was assessed in vivo by 31P magnetic resonance spectroscopy. We conducted tobit regressions to examine associations of max OXPHOS, max ETS, and ATPmax with PPFI, adjusting for technician/site, demographic characteristics, and total activity count over 7-day free-living among older adults (N = 795, 70-94 years, 58% women) with complete PPFI scores and ≥1 energetics measure. Median PPFI score was 1.4% [25th-75th percentile: 0%-2.9%]. After full adjustment, each 1 standard deviation lower max OXPHOS, max ETS, and ATPmax were associated with 0.55 (95% CI: 0.26-0.84), 0.39 (95% CI: 0.09-0.70), and 0.54 (95% CI: 0.27-0.81) higher PPFI score, respectively. Our findings suggested that therapeutics targeting muscle energetics may potentially mitigate fatigability and lessen susceptibility to disability among older adults.
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Affiliation(s)
- Yujia (Susanna) Qiao
- Department of Epidemiology, School of Public HealthUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Adam J. Santanasto
- Department of Epidemiology, School of Public HealthUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Paul M. Coen
- AdventHealth, Translational Research InstituteOrlandoFloridaUSA
| | - Peggy M. Cawthon
- San Francisco Coordinating CenterCalifornia Pacific Medical Center Research InstituteSan FranciscoCaliforniaUSA
- Department of Epidemiology and Biostatistics, School of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Steven R. Cummings
- San Francisco Coordinating CenterCalifornia Pacific Medical Center Research InstituteSan FranciscoCaliforniaUSA
- Department of Epidemiology and Biostatistics, School of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Daniel E. Forman
- Department of Medicine (Geriatrics and Cardiology)University of Pittsburgh, and Geriatrics, Research, Education, and Clinical Center (GRECC), VA Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | | | - Jaroslaw Harezlak
- Department of Epidemiology and Biostatistics, School of Public Health‐BloomingtonIndiana UniversityBloomingtonIndianaUSA
| | - Marquis Hawkins
- Department of Epidemiology, School of Public HealthUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Stephen B. Kritchevsky
- Gerontology and Geriatric MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Barbara J. Nicklas
- Gerontology and Geriatric MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Frederico G. S. Toledo
- Division of Endocrinology and Metabolism, Department of MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Pamela E. Toto
- Department of Occupational TherapyUniversity of Pittsburgh School of Health and Rehabilitation SciencesPittsburghPennsylvaniaUSA
| | - Anne B. Newman
- Department of Epidemiology, School of Public HealthUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Nancy W. Glynn
- Department of Epidemiology, School of Public HealthUniversity of PittsburghPittsburghPennsylvaniaUSA
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Alharbi MD, Khan F. The measurement of fatigability severity in individuals with multiple sclerosis and healthy controls. Mult Scler Relat Disord 2024; 85:105568. [PMID: 38520949 DOI: 10.1016/j.msard.2024.105568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 03/13/2024] [Accepted: 03/19/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Multiple Sclerosis (MS) is a chronic disease that substantially diminishes one's ability to undertake daily living activities. Fatigue has been reported by at least 80 % of persons with MS (PwMS). Yet, little is known concerning the quantification of fatigability using prolonged walking tests. OBJECTIVES To compare fatigability severity measures using the 10-minute walk test for PwMS against age- and gender-matched healthy controls (HCs). METHODS Participants included 53 ambulatory PwMS and 49 HCs. Perceived fatigability was measured by dividing a participant's change in self-reported tiredness by the number of meters walked. Performance fatigability was calculated by dividing the change in walking speed (at 2.5 and 10 min) by the total distance walked in meters. RESULTS There was a significant difference in perceived fatigability between PwMS and HCs (mean difference: 2.73 ± 0.83; p = 0.001) and in performance fatigability (mean difference: 0.24 ± 0.11; p = 0.01). Moreover, there were significant differences in speed and distance at all time points (p ≤ 0.05) between PwMS and HCs. CONCLUSIONS PwMS have significant walking deficits as reflected by greater fatigability in both perceived and performance measures. These methods can enhance therapeutic strategies that improve the walking performances of PwMS.
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Affiliation(s)
- Mutasim D Alharbi
- Department of Physical Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, P.O. Box 80200, Jeddah 21589, Saudi Arabia.
| | - Fayaz Khan
- Department of Physical Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, P.O. Box 80200, Jeddah 21589, Saudi Arabia
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Matias-Guiu JA, González-Rosa J, Hernández MÁ, Martínez-Ginés ML, Portolés A, Pérez-Macías N, Benito-León J, Padrón I, Prieto J, Matias-Guiu J. Amantadine and/or transcranial magnetic stimulation for fatigue associated with multiple sclerosis (FETEM): study protocol for a phase 3 randomised, double-blind, cross-over, controlled clinical trial. BMJ Open 2024; 14:e078661. [PMID: 38176857 PMCID: PMC10773341 DOI: 10.1136/bmjopen-2023-078661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION Fatigue is one of the most disabling symptoms of multiple sclerosis (MS), and effective treatments are lacking. Amantadine is one of the most used treatments, although its efficacy is under debate. Transcranial magnetic stimulation (TMS) is a promising intervention that has shown positive effects in some preliminary investigations. We aim to investigate the effect of 6 weeks of amantadine and/or TMS in fatigue due to MS. METHODS AND ANALYSIS The study is a national, multicentre, phase 3, randomised, double-blind, cross-over, placebo-controlled and sham-controlled clinical trial. Adult patients with relapsing-remitting MS, Expanded Disability Status Scale score of 1.5-4.5 and Fatigue Severity Score>4 are eligible for the trial. Participants will be randomised to one of the sequences of the study. Each sequence consists of four periods of 6 weeks of treatment and three washout periods of 12-18 weeks. All patients will receive all the combinations of therapies. The primary outcome is the Modified Fatigue Impact Scale. The secondary outcomes are the Symbol Digit Modalities Test (cognition), Beck Depression Inventory-II (depressive symptoms) and Short-Survey 12 (quality of life). Safety and cost-effectiveness will also be evaluated. An exploratory substudy including MRI and blood biomarkers will be conducted. ETHICS AND DISSEMINATION The study is approved by the Ethics Committee of the Hospital Clinico San Carlos and the Spanish Agency of Medications and Medical Devices. All study findings will be published in scientific peer-reviewed journals and presented at relevant scientific conferences. TRIAL REGISTRATION NUMBER EudraCT 2021-004868-95; NCT05809414.
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Affiliation(s)
- Jordi A Matias-Guiu
- Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
| | - Javier González-Rosa
- Department of Psychology, University of Cadiz, Cadiz, Spain
- Institute of Research and Biomedical Innovation of Cadiz, Cadiz, Spain
| | | | - Maria Luisa Martínez-Ginés
- Department of Neurology, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Antonio Portolés
- Department of Pharmacology and Toxicology, Universidad Complutense de Madrid, Madrid, Spain
- Unidad de Investigación Clínica y Ensayos Clínicos (UICEC), Instituto de Investigacion Sanitaria Hospital Clinico San Carlos, Madrid, Spain
| | - Natalia Pérez-Macías
- Unidad de Investigación Clínica y Ensayos Clínicos (UICEC), Instituto de Investigacion Sanitaria Hospital Clinico San Carlos, Madrid, Spain
| | - Julián Benito-León
- Department of Neurology, Hospital Universitario 12 de Octubre, Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Universidad Complutense, Madrid, Spain
| | - Iván Padrón
- Department of Developmental Psychology and Education, Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, La Laguna, Spain
| | - Julio Prieto
- Department of Clinical Neurophysiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Jorge Matias-Guiu
- Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
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Chen W, Jiang T, Huang H, Zeng J. Post-stroke fatigue: a review of development, prevalence, predisposing factors, measurements, and treatments. Front Neurol 2023; 14:1298915. [PMID: 38187145 PMCID: PMC10768193 DOI: 10.3389/fneur.2023.1298915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/01/2023] [Indexed: 01/09/2024] Open
Abstract
Background Post-stroke fatigue (PSF) is a ubiquitous and overwhelming symptom for most stroke survivors. However, there are no effective management strategies for PSF, which is partly due to our limited understanding. Objective In this paper, we review the development, prevalence, predisposing factors, measurements, and treatments of PSF. Results PSF is an independent symptom after stroke, with a prevalence ranging from 42 to 53%, which depends on the selection of measurement tools and stroke characteristics. It is affected by biological, physical, and psychological factors, among which inflammation may play a key role. Conclusion Numerous but non-specific evaluation measurement tools limit the management of PSF. In clinical practice, it may be beneficial to identify PSF by combining scales and objective indexes, such as walking tests and electromyographic examinations. There are no evidence-based interventions to improve PSF. However, increasing evidence suggests that transcranial direct-current stimulation and mindfulness-based interventions may become promising treatments. Further studies are urgently needed to better understand the etiology of PSF, thereby providing the basis for developing new measurement tools and targeted treatments.
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Affiliation(s)
| | - Tao Jiang
- Department of Neurology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
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Royer N, Brownstein CG, Kennouche D, Espeit L, Teston A, Boutet C, Féasson L, Camdessanché JP, Millet GY. A Comprehensive Evaluation of Multiple Sclerosis-Related Fatigue with a Special Focus on Fatigability. Med Sci Sports Exerc 2023; 55:2002-2013. [PMID: 37319414 DOI: 10.1249/mss.0000000000003233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Fatigue is the most common and disabling symptom in multiple sclerosis (MS), being reported by 55% to 78% of patients with MS (PwMS). Etiology of MS-related fatigue remains poorly understood, but an increased neuromuscular fatigability (i.e., greater loss of torque during exercise) could contribute to this phenomenon. This study aimed to characterize the correlates of MS-related fatigue in PwMS using a comprehensive group of physiological and psychosocial measures, with a particular focus on fatigability. METHODS Forty-two relapsing-remitting PwMS and 20 healthy subjects were recruited. PwMS were assigned in two groups (high (HF) and low (LF) fatigue) based on two fatigue questionnaires (Fatigue Severity Scale and Modified Fatigue Impact Scale). The main outcomes of this study are derived from incremental cycling completed to task failure (i.e., inability to pedal around 60 rpm). Maximal voluntary contraction (MVC), rating of perceived exertion, and central and peripheral parameters measured using transcranial magnetic and peripheral nerve stimulation were assessed in the knee extensor muscles before, during, and after the fatiguing task. Other potential correlates of fatigue were also tested. RESULTS MVC torque decreased to a greater extent for the HF group than LF group after the third common stage of the incremental fatiguing exercise (-15.7% ± 6.6% vs -5.9% ± 13.0%, P < 0.05), and this occurred concurrently with a higher rating of perceived exertion for HF (11.8 ± 2.5 vs 9.3 ± 2.6, P < 0.05). Subjective parameters (depression, quality of life) were worse for HF compared with LF and healthy subjects ( P < 0.001). Moreover, MVC torque loss at the final common stage and maximal heart rate explained 29% of the variance of the Modified Fatigue Impact Scale. CONCLUSIONS These results provide novel insight into the relationship between MS-related fatigue and fatigability among PwMS. The HF group exhibited greater performance fatigability, likely contributing to a higher perceived exertion than the LF group when measured during a dynamic task.
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Affiliation(s)
- Nicolas Royer
- Univ Lyon, UJM-Saint-Etienne, Inter-university Laboratory of Human Movement Biology, Saint-Etienne, FRANCE
| | - Callum G Brownstein
- Univ Lyon, UJM-Saint-Etienne, Inter-university Laboratory of Human Movement Biology, Saint-Etienne, FRANCE
| | - Djahid Kennouche
- Univ Lyon, UJM-Saint-Etienne, Inter-university Laboratory of Human Movement Biology, Saint-Etienne, FRANCE
| | - Loic Espeit
- Univ Lyon, UJM-Saint-Etienne, Inter-university Laboratory of Human Movement Biology, Saint-Etienne, FRANCE
| | - Anthony Teston
- Department of Radiology, CHU Hospital, Jean Monnet University, Saint Etienne, FRANCE
| | - Claire Boutet
- Department of Radiology, CHU Hospital, Jean Monnet University, Saint Etienne, FRANCE
| | - Léonard Féasson
- Univ Lyon, UJM-Saint-Etienne, Inter-university Laboratory of Human Movement Biology, Saint-Etienne, FRANCE
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7
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Abou L, Fritz NE, Kratz AL. Predictors of performance and perceived fatigability in people with multiple sclerosis. Neurol Res 2023; 45:994-1002. [PMID: 37655601 DOI: 10.1080/01616412.2023.2252283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND AND OBJECTIVE Fatigability is a distinct construct from fatigue that has been reported to contribute to activity limitations in people with multiple sclerosis (PwMS). Identifying predictors of performance and perceived fatigability may guide the development of interventions to mitigate fatigability. This study investigated predictors of performance and perceived fatigability among PwMS. METHODS PwMS (N = 51) completed self-report measures of demographics, clinical history, symptoms severity (Modified Fatigue Impact Scale), and functioning (PROMIS Physical Function and PROMIS Cognitive Function Abilities). Performance fatigability measures included Ambulatory Fatigue Index (AFI), Deceleration Index (DI), and Distance Walking Index (DWI). Perceived fatigability measures included Pittsburgh Fatigability Scale (PFS), Perceived Physical Exertion, and Perceived Fatigue Intensity. Performance and perceived fatigability measures were calculated based on the Timed 25-Foot Walk Test and the 6-Minute Walk Test. RESULTS Multivariable linear regression analyses indicated that PROMIS Cognitive Function was a significant independent predictor of performance fatigability measured with AFI (β = -0.515, p = 0.007), DI (β = -0.511, p = 0.008), and DWI (β = -0.516, p = 0.007). Regarding perceived fatigability, PROMIS Pain Intensity predicted Perceived Fatigue Intensity (β = 0.325, p = 0.035). PROMIS Physical Function predicted PFS Mental fatigability (β = -0.503, p < 0.001). PROMIS Physical Function (β = -0.619, p < 0.001) and Cognitive Function (β = -0.249, p = 0.037) predicted PFS Physical fatigability. CONCLUSIONS Preliminary findings suggest that self-reported functioning levels, including physical and perceived cognitive function, are potential predictors of performance and perceived fatigability in MS. Notably, perceived fatigue impact showed no association with performance or perceived fatigability. Future studies are warranted to confirm and extend our findings.
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Affiliation(s)
- Libak Abou
- Department of Physical Medicine & Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Nora E Fritz
- Departments of Health Care Sciences & Neurology, Wayne State University, Detroit, MI, USA
| | - Anna L Kratz
- Department of Physical Medicine & Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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Glynn NW, Qiao YS. Measuring and Understanding the Health Impact of Greater Fatigability in Older Adults: A Call to Action and Opportunities. FATIGUE : BIOMEDICINE, HEALTH & BEHAVIOR 2023; 11:188-201. [PMID: 38074079 PMCID: PMC10707490 DOI: 10.1080/21641846.2023.2252612] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
Different from fatigue, an instantaneous state of tiredness, weakness and lack of energy, fatigability is a trait that contextualizes whole-body fatigue to the level of activity (i.e., intensity and duration) with which the fatigue is associated. Fatigability can be perceived or performance-related. Measuring fatigability improves upon traditional fatigue measures by accounting for self-pacing as older adults likely slow down or limit their daily activity to maintain fatigue in a tolerable range. Anchoring fatigue to activities/tasks improves sensitivity and allows for meaningful comparisons across individuals/between studies, as well as evaluating change over time and treatment effects. Two well-validated approaches are utilized to measure perceived fatigability: 1) a 5-minute slow-paced (1.5 mph/0.67 m/s, 0% grade) treadmill walk immediately followed by Borg rating of perceived exertion; and 2) a self-administered 10-item questionnaire, Pittsburgh Fatigability Scale, with both physical and mental subscales. Many walking-based performance fatigability measures are based on certain lap time or distance, while the Pittsburgh Performance Fatigability Index uses raw accelerometry data to quantify percent of cadence decline over the entire long distance walking tasks. Perceived fatigability prevalence ranges from 20-90% in older adults varying by assessment tool, and is higher with advancing age and in women compared to men. Fatigability is associated with physical and cognitive function, fall risk, mobility decline, and mortality. Unfortunately, the available research lacks representativeness in terms of racial and ethnic diversity. The time is now to incorporate our established sensitive and validated fatigability measures into global research and clinical practice to better understand mechanistic underpinnings and reveal intervention effects to reduce the burden and lessen the consequences of greater fatigability worldwide.
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Affiliation(s)
- Nancy W Glynn
- Department of Epidemiology, University of Pittsburgh, School of Public Health, Pittsburgh, PA 15261
| | - Yujia Susanna Qiao
- Department of Epidemiology, University of Pittsburgh, School of Public Health, Pittsburgh, PA 15261
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Silva-Migueis H, Martínez-Jiménez EM, Casado-Hernández I, Dias A, Monteiro AJ, Martins RB, Bernardes JM, López-López D, Gómez-Salgado J. Upper-Limb Kinematic Behavior and Performance Fatigability of Elderly Participants Performing an Isometric Task: A Quasi-Experimental Study. Bioengineering (Basel) 2023; 10:bioengineering10050526. [PMID: 37237596 DOI: 10.3390/bioengineering10050526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023] Open
Abstract
Upper-limb position-sustained tasks (ULPSIT) are involved in several activities of daily living and are associated with high metabolic and ventilatory demand and fatigue. In older people, this can be critical to the performance of daily living activities, even in the absence of a disability. OBJECTIVES To understand the ULPSIT effects on upper-limb (UL) kinetics and performance fatigability in the elderly. METHODS Thirty-one (31) elderly participants (72.61 ± 5.23 years) performed an ULPSIT. The UL average acceleration (AA) and performance fatigability were measured using an inertial measurement unit (IMU) and time-to-task failure (TTF). RESULTS The findings showed significant changes in AA in the X- and Z-axes (p < 0.05). AA differences in women started earlier in the baseline cutoff in the X-axis, and in men, started earlier between cutoffs in the Z-axis. TTF was positively related to AA in men until 60% TTF. CONCLUSIONS ULPSIT produced changes in AA behavior, indicative of movement of the UL in the sagittal plane. AA behavior is sex related and suggests higher performance fatigability in women. Performance fatigability was positively related to AA only in men, where movement adjustments occurred in an early phase, though with increased activity time.
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Affiliation(s)
- Helena Silva-Migueis
- Research, Health and Podiatry Group, Department of Health Sciences, Faculty of Nursing and Podiatry, Industrial Campus of Ferrol, Universidade da Coruña, 15403 Ferrol, Spain
- Physiotherapy Department, Escola Superior de Saúde da Cruz Vermelha Portuguesa-Lisboa, 1300-125 Lisbon, Portugal
| | - Eva María Martínez-Jiménez
- Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Israel Casado-Hernández
- Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Adriano Dias
- Department of Public Health, Graduate Program in Collective/Public Health, Botucatu Medical School, Universidade Estadual Paulista/UNESP, Botucatu 18610-307, SP, Brazil
| | - Ana Júlia Monteiro
- Research, Health and Podiatry Group, Department of Health Sciences, Faculty of Nursing and Podiatry, Industrial Campus of Ferrol, Universidade da Coruña, 15403 Ferrol, Spain
- Physiotherapy Department, Escola Superior de Saúde da Cruz Vermelha Portuguesa-Lisboa, 1300-125 Lisbon, Portugal
| | - Rodrigo B Martins
- Physiotherapy Department, Escola Superior de Saúde da Cruz Vermelha Portuguesa-Lisboa, 1300-125 Lisbon, Portugal
| | - João Marcos Bernardes
- Department of Public Health, Graduate Program in Collective/Public Health, Botucatu Medical School, Universidade Estadual Paulista/UNESP, Botucatu 18610-307, SP, Brazil
| | - Daniel López-López
- Research, Health and Podiatry Group, Department of Health Sciences, Faculty of Nursing and Podiatry, Industrial Campus of Ferrol, Universidade da Coruña, 15403 Ferrol, Spain
| | - Juan Gómez-Salgado
- Departamento de Sociología, Trabajo Social y Salud Pública, Universidad de Huelva, 21004 Huelva, Spain
- Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil 092301, Ecuador
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Slowing processing speed is associated with cognitive fatigue in newly diagnosed multiple sclerosis patients. J Int Neuropsychol Soc 2023; 29:283-289. [PMID: 35465860 DOI: 10.1017/s1355617722000157] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To further investigate objective measures of cognitive fatigue (CF), defined as the inability to sustain performance over time, in newly diagnosed multiple sclerosis (MS) patients, by conducting a performance analysis on the Paced Auditory Serial Addition Test (PASAT) based on the type of errors (omissions vs. incorrect responses) committed. METHOD Sixty-two newly diagnosed patients with MS (pwMS) and 41 healthy controls (HC) completed the PASAT. Analysis of the change in performance during the test was performed by comparing the number of correct responses, incorrect responses, and omissions in the 1st versus the 3rd tertile of the PASAT. RESULTS A significant decline in accuracy over time was observed to be related to an increment in the number of omissions, significantly more pronounced in pwMS than in HC. No change in the number of incorrect responses throughout the PASAT was observed for either group. CONCLUSIONS CF can be detected even in newly diagnosed pwMS and might objectively manifest as a progressive increase in omissions during a sustained highly demanding task (i.e., PASAT). This pattern may reflect slowed processing speed and increased fatigue in pwMS. Focusing on omissions on the PASAT instead of correct responses only may improve its specificity as an objective measure of CF.
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Argentinean consensus recommendations for the use of telemedicine in clinical practice in adult people with multiple sclerosis. Neurol Sci 2023; 44:667-676. [PMID: 36319902 PMCID: PMC9628297 DOI: 10.1007/s10072-022-06471-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/20/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND The use of telemedicine has quickly increased during of the COVID-19 pandemic. Given that unmet needs and barriers to multiple sclerosis (MS) care have been reported, telemedicine has become an interesting option to the care of these patients. The objective of these consensus recommendations was to elaborate a guideline for the management of people with MS using telemedicine in order to contribute to an effective and high-quality healthcare. METHODS A panel of Argentinean neurologist's experts in neuroimmunological diseases and dedicated to the diagnosis, management,and care of MS patients gathered virtually during 2021 and 2022 to conduct a consensus recommendation on the use of telemedicine in clinical practice in adult people with MS. To reach consensus, the methodology of "formal consensus RAND/UCLA Appropriateness method" was used. RESULTS Recommendations were established based on relevant published evidence and expert opinion focusing on definitions, general characteristics and ethical standards, diagnosis of MS, follow-up (evaluation of disability and relapses of MS), identification and treatment of relapses, and finally disease-modifying treatments using telemedicine. CONCLUSION The recommendations of this consensus would provide a useful guide for the proper use of telemedicine for the assessment, follow-up, management, and treatment of people with MS. We suggest the use of these guidelines to all the Argentine neurologists committed to the care of people with MS.
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Karpatkin H, Rachwani J, Rhodes R, Rodriguez L, Rodriguez R, Rubeo A, Cohen E. The effect of intermittent vs. continuous walking on distance to fatigue in persons with multiple sclerosis. Disabil Rehabil 2022; 44:8429-8435. [PMID: 35297715 DOI: 10.1080/09638288.2021.2018055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE Previous studies provided evidence that persons with Multiple Sclerosis (pwMS) who walk intermittently experience less fatigue and walk longer distances than when walking continuously. However, total distance pwMS can walk in either condition is unknown. We examined time and distance to fatigability in pwMS comparing intermittent walking (IW) to continuous walking (CW). MATERIALS AND METHODS 18 pwMS, with Expanded Disability Status Scale median of 4.75 [range = 2-6.5, IQR = 2.5] participated in this randomized crossover study. The IW condition consisted of alternating 30 s treadmill walking and 30 s seated rests. The CW condition consisted of treadmill walking without breaks. Treadmill speed (TS) was determined by an overground 2-min walk test. Walking fatigability was determined by participants walking on the treadmill, until gait fatigue was noted by patient or examiners. Total time and distance to gait fatigue, and subjective fatigue as measured by the Visual analog scale of fatigue were recorded. RESULTS Participants had significantly longer duration and distance to fatigue in the IW condition than the CW condition (ps ≤ 0.037). No difference in VASF scores between the two conditions were noted. CONCLUSION In this sample, IW allowed pwMS to perform a greater volume of walking and can be an option to improve walking endurance in this population.IMPLICATIONS FOR REHABILITATIONMultiple sclerosis (MS) is a disease that progressively impacts walking, resulting in a decrease in the maximum distance that a person with MS can walk.Intermittent walking has been shown to improve 6-min walk test performance in persons with MS (pwMS) compared to continuous walking, but its effects on longer and shorter walks is not known.The use of distance to fatigue should be considered a viable option for measuring walking fatigability in pwMS as it does not exclude persons based on their ability to complete a 6-min walk, nor would it be too easy for persons with pwMS with mild disability.By using distance to fatigue as an outcome measure, this study provides evidence that intermittent walking results in less fatigability regardless of walking ability.PwMS, regardless of their walking ability, can walk longer distances intermittently than continuously, suggesting that clinical treatment of walking fatigability in pwMS should utilize intermittent rather than continuous walking training.
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Affiliation(s)
- Herbert Karpatkin
- Department of Physical Therapy, Hunter College, City University of New York, New York, NY, USA
| | - Jaya Rachwani
- Department of Physical Therapy, Hunter College, City University of New York, New York, NY, USA
| | - Rachel Rhodes
- Department of Physical Therapy, Hunter College, City University of New York, New York, NY, USA
| | - Lourdes Rodriguez
- Department of Physical Therapy, Hunter College, City University of New York, New York, NY, USA
| | - Rosie Rodriguez
- Department of Physical Therapy, Hunter College, City University of New York, New York, NY, USA
| | - Anna Rubeo
- Department of Physical Therapy, Hunter College, City University of New York, New York, NY, USA
| | - Evan Cohen
- Department of Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey, Blackwood, NJ, USA
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Royer N, Coates K, Aboodarda SJ, Camdessanché JP, Millet GY. How is neuromuscular fatigability affected by perceived fatigue and disability in people with multiple sclerosis? Front Neurol 2022; 13:983643. [DOI: 10.3389/fneur.2022.983643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/23/2022] [Indexed: 11/13/2022] Open
Abstract
Whereas fatigue is recognized to be the main complaint of patients with multiple sclerosis (PwMS), its etiology, and particularly the role of resistance to fatigability and its interplay with disability level, remains unclear. The purposes of this review were to (i) clarify the relationship between fatigue/disability and neuromuscular performance in PwMS and (ii) review the corticospinal and muscular mechanisms of voluntary muscle contraction that are altered by multiple sclerosis, and how they may be influenced by disability level or fatigue. Neuromuscular function at rest and during exercise are more susceptible to impairement, due to deficits in voluntary activation, when the disability is greater. Fatigue level is related to resistance to fatigability but not to neuromuscular function at rest. Neurophysiological parameters related to signal transmission such as central motor conduction time, motor evoked potentials amplitude and latency are affected by disability and fatigue levels but their relative role in the impaired production of torque remain unclear. Nonetheless, cortical reorganization represents the most likely explanation for the heightened fatigability during exercise for highly fatigued and/or disabled PwMS. Further research is needed to decipher how the fatigue and disability could influence fatigability for an ecological task, especially at the corticospinal level.
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Qiao Y(S, Harezlak J, Moored KD, Urbanek JK, Boudreau RM, Toto P, Hawkins M, Santanasto AJ, Schrack JA, Simonsick EM, Glynn NW. Development of a Novel Accelerometry-Based Performance Fatigability Measure for Older Adults. Med Sci Sports Exerc 2022; 54:1782-1793. [PMID: 35763596 PMCID: PMC9481701 DOI: 10.1249/mss.0000000000002966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Efforts to study performance fatigability have been limited because of measurement constrains. Accelerometry and advanced statistical methods may enable us to quantify performance fatigability more granularly via objective detection of performance decline. Thus, we developed the Pittsburgh Performance Fatigability Index (PPFI) using triaxial raw accelerations from wrist-worn accelerometer from two in-laboratory 400-m walks. METHODS Sixty-three older adults from our cross-sectional study (mean age, 78 yr; 56% women; 88% White) completed fast-paced ( n = 59) and/or usual-paced 400-m walks ( n = 56) with valid accelerometer data. Participants wore ActiGraph GT3X+ accelerometers (The ActiGraph LLC, Pensacola, FL) on nondominant wrist during the walking task. Triaxial raw accelerations from accelerometers were used to compute PPFI, which quantifies percentage of area under the observed gait cadence-versus-time trajectory during a 400-m walk to a hypothetical area that would be produced if the participant sustained maximal cadence throughout the entire walk. RESULTS Higher PPFI scores (higher score = greater fatigability) correlated with worse physical function, slower chair stands speed and gait speed, worse cardiorespiratory fitness and mobility, and lower leg peak power (| ρ | = 0.36-0.61 from fast-paced and | ρ | = 0.28-0.67 from usual-paced walks, all P < 0.05). PPFI scores from both walks remained associated with chair stands speed, gait speed, fitness, and mobility, after adjustment for sex, age, race, weight, height, and smoking status; PPFI scores from the fast-paced walk were associated with leg peak power. CONCLUSIONS Our findings revealed that the objective PPFI is a sensitive measure of performance fatigability for older adults and can serve as a risk assessment tool or outcome measure in future studies and clinical practice.
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Affiliation(s)
- Yujia (Susanna) Qiao
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, PA
| | - Jaroslaw Harezlak
- Department of Epidemiology and Biostatistics, School of Public Health-Bloomington, Indiana University, Bloomington, IN
| | - Kyle D. Moored
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, PA
| | - Jacek K. Urbanek
- Division of Geriatric Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Robert M. Boudreau
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, PA
| | - Pamela Toto
- Department of Occupational Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA
| | - Marquis Hawkins
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, PA
| | - Adam J. Santanasto
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, PA
| | - Jennifer A. Schrack
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Center on Aging and Health, Johns Hopkins University, Baltimore, MD
| | | | - Nancy W. Glynn
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, PA
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Wolf F, Nielsen J, Saliger J, Hennecken E, Eschweiler M, Folkerts AK, Karbe H, Zimmer P. Randomised controlled pilot and feasibility study of multimodal agility-based exercise training (MAT) versus strength and endurance training (SET) to improve multiple sclerosis-related fatigue and fatigability during inpatient rehabilitation (ReFEx): study protocol. BMJ Open 2022; 12:e062160. [PMID: 36357342 PMCID: PMC9454066 DOI: 10.1136/bmjopen-2022-062160] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 08/14/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Subjective fatigue and objectively assessed fatigability are common symptoms in persons with multiple sclerosis (pwMS). Recent work has suggested a positive effect of balance and motor control training (BMCT) in reducing fatigue. It is unclear whether this effect can also be attained during inpatient rehabilitation. Multimodal agility-based exercise training (MAT) has been developed as a framework that incorporates BMCT with added agility components but has not been applied to pwMS. Therefore, this study will evaluate the feasibility of a randomised controlled trial comparing MAT against strength and endurance training (SET) for the improvement of MS-related fatigue and fatigability in a German neurological rehabilitation centre. METHODS AND ANALYSIS A total of 24 pwMS (Expanded Disability Status Scale ≤5.0, Fatigue Scale for Motor and Cognitive Functions ≥53) will be randomly assigned to either SET or land and water-based MAT for 4-6 weeks during inpatient rehabilitation. Assessments of subjective fatigue, motor and cognitive fatigability, cognitive and cardiorespiratory performance, and balance confidence will be performed at admission and discharge. Subjective fatigue will also be assessed at 1, 4 and 12 weeks after discharge. Feasibility outcomes will include patients' acceptance of study procedures and interventions, recruitment rate, retention rate, time needed to complete baseline assessments, intervention adherence and fidelity. All quantitative outcomes will be reported descriptively. A total of 12 pwMS (6 per group) will be interviewed to gain insights into participants' experiences during study participation. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Ethics Committee of the University of Bonn (reference number: 543/20). Dissemination of findings is planned via peer-reviewed journals, conferences and media releases. TRIAL REGISTRATION NUMBER DRKS00023943.
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Affiliation(s)
- Florian Wolf
- Neurological Rehabilitation Centre Godeshoehe, Bonn, Germany
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiovascular Research and Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Jörn Nielsen
- Neurological Rehabilitation Centre Godeshoehe, Bonn, Germany
- Department of Medical Psychology, Neuropsychology and Gender Studies, Center for Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Jochen Saliger
- Neurological Rehabilitation Centre Godeshoehe, Bonn, Germany
| | - Eva Hennecken
- Neurological Rehabilitation Centre Godeshoehe, Bonn, Germany
| | - Mareike Eschweiler
- Neurological Rehabilitation Centre Godeshoehe, Bonn, Germany
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Ann-Kristin Folkerts
- Department of Medical Psychology, Neuropsychology and Gender Studies, Center for Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Hans Karbe
- Neurological Rehabilitation Centre Godeshoehe, Bonn, Germany
| | - Philipp Zimmer
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund, Germany
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Influence of an Upper Limb Isometric Task in Perceived and Performance Fatigability of Elderly Subjects: A Quasi-Experimental Study. BIOLOGY 2022; 11:biology11081175. [PMID: 36009802 PMCID: PMC9405323 DOI: 10.3390/biology11081175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/26/2022] [Accepted: 07/30/2022] [Indexed: 11/16/2022]
Abstract
Isometric activity can be used as a strategy to improve health, fitness, and functional performance in the elderly population, but differences in fatigability may occur. This study aimed to understand fatigability behavior during an upper limb isometric task (ULIT) and the role of health status and physical activity in the fatigability of elderly participants. Thirty-two (32) elderly participants (72.5 ± 5.18 years) were instructed to perform ULIT. The Borg CR10 scale and task failure point (TTF) were used to measure perceived and performance fatigability. Self-reported measures were used to assess the quality of life and physical activity level. A significant relationship between perceived and performance fatigability was found only in the final phase of activity (p < 0.01). Significant correlations were found between perceived fatigability and the social functioning dimension (p < 0.05), and between performance fatigability (TTF) and BMI (p < 0.01), physical functioning (p < 0.01), and role functioning/physical (p < 0.05) dimensions. In conclusion, ULIT produces changes in fatigability of elderly people, which are positively related in the final stage of the activity. Changes in fatigability are negatively related to BMI. It is also negatively related to health, social functioning, physical functioning and role functioning/physical quality of life dimensions.
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Patejdl R, Zettl UK. The pathophysiology of motor fatigue and fatigability in multiple sclerosis. Front Neurol 2022; 13:891415. [PMID: 35968278 PMCID: PMC9363784 DOI: 10.3389/fneur.2022.891415] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple Sclerosis (MS) is a heterogeneous immune mediated disease of the central nervous system (CNS). Fatigue is one of the most common and disabling symptom of MS. It interferes with daily activities on the level of cognition and motor endurance. Motor fatigue can either result from lesions in cortical networks or motor pathways (“primary fatigue”) or it may be a consequence of detraining with subsequent adaptions of muscle and autonomic function. Programmed exercise interventions are used frequently to increase physical fitness in MS-patients. Studies investigating the effects of training on aerobic capacity, objective endurance and perceived fatigability have yielded heterogenous results, most likely due to the heterogeneity of interventions and patients, but probably also due to the non-uniform pathophysiology of fatigability among MS-patients. The aim of this review is to summarize the current knowledge on the pathophysiology of motor fatigability with special reference to the basic exercise physiology that underlies our understanding of both pathogenesis and treatment interventions.
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Affiliation(s)
- Robert Patejdl
- Oscar Langendorff Institute of Physiology, Rostock University Medical Center, Rostock, Germany
- *Correspondence: Robert Patejdl
| | - Uwe K. Zettl
- Department of Neurology, Clinical Neuroimmunology Section, Rostock University Medical Center, Rostock, Germany
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Marchesi O, Vizzino C, Filippi M, Rocca MA. Current perspectives on the diagnosis and management of fatigue in multiple sclerosis. Expert Rev Neurother 2022; 22:681-693. [PMID: 35881416 DOI: 10.1080/14737175.2022.2106854] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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 1st 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.
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Affiliation(s)
- Olga Marchesi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carmen Vizzino
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurorehabilitation Unit and IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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Sobczak AM, Bohaterewicz B, Ceglarek A, Zyrkowska A, Fafrowicz M, Slowik A, Wnuk M, Marona M, Nowak K, Zur-Wyrozumska K, Marek T. Brain Under Fatigue – Can Perceived Fatigability in Multiple Sclerosis Be Seen on the Level of Functional Brain Network Architecture? Front Hum Neurosci 2022; 16:852981. [PMID: 35620154 PMCID: PMC9128356 DOI: 10.3389/fnhum.2022.852981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Fatigue is one of the most common symptoms of multiple sclerosis (MS), significantly affecting the functioning of the patients. However, the neural underpinnings of physical and mental fatigue in MS are still vague. The aim of our study was to investigate the functional architecture of resting-state networks associated with fatigue in patients with MS. Methods The sum of 107 high-functioning patients underwent a resting-state scanning session and filled out the 9-item Fatigue Severity Scale (FSS). Based on the FSS score, we identified patients with different levels of fatigue using the cluster analysis. The low-fatigue group consisted of n = 53 subjects, while the high-fatigue group n = 48. The neuroimaging data were analyzed in terms of functional connectivity (FC) between various resting-state networks as well as amplitude of low-frequency fluctuation (ALFF) and fractional amplitude of low-frequency fluctuations (fALFF). Results Two-sample t-test revealed between-group differences in FC of posterior salience network (SN). No differences occurred in default mode network (DMN) and sensorimotor network (SMN). Moreover, differences in fALFF were shown in the right middle frontal gyrus and right superior frontal gyrus, however, no ALFF differences took place. Conclusion Current study revealed significant functional network (FN) architecture between-group differences associated with fatigue. Present results suggest the higher level of fatigue is related to deficits in awareness as well as higher interoceptive awareness and nociception.
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Affiliation(s)
- Anna Maria Sobczak
- Department of Cognitive Neuroscience and Neuroergonomics, Institute of Applied Psychology, Jagiellonian University, Kraków, Poland
- *Correspondence: Anna Maria Sobczak,
| | - Bartosz Bohaterewicz
- Department of Cognitive Neuroscience and Neuroergonomics, Institute of Applied Psychology, Jagiellonian University, Kraków, Poland
- Department of Psychology of Individual Differences, Psychological Diagnosis, and Psychometrics, Institute of Psychology, University of Social Sciences and Humanities, Warsaw, Poland
| | - Anna Ceglarek
- Department of Cognitive Neuroscience and Neuroergonomics, Institute of Applied Psychology, Jagiellonian University, Kraków, Poland
| | - Aleksandra Zyrkowska
- Department of Cognitive Neuroscience and Neuroergonomics, Institute of Applied Psychology, Jagiellonian University, Kraków, Poland
| | - Magdalena Fafrowicz
- Department of Cognitive Neuroscience and Neuroergonomics, Institute of Applied Psychology, Jagiellonian University, Kraków, Poland
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Collegium Medicum, Kraków, Poland
- Department of Neurology, University Hospital in Krakow, Kraków, Poland
| | - Marcin Wnuk
- Department of Neurology, Jagiellonian University Collegium Medicum, Kraków, Poland
- Department of Neurology, University Hospital in Krakow, Kraków, Poland
| | - Monika Marona
- Department of Neurology, Jagiellonian University Collegium Medicum, Kraków, Poland
- Department of Neurology, University Hospital in Krakow, Kraków, Poland
| | - Klaudia Nowak
- Department of Neurology, Jagiellonian University Collegium Medicum, Kraków, Poland
- Department of Neurology, University Hospital in Krakow, Kraków, Poland
| | - Kamila Zur-Wyrozumska
- Department of Medical Education, Jagiellonian University Medical College, Kraków, Poland
- Department of Neurology, 5th Military Hospital, Kraków, Poland
| | - Tadeusz Marek
- Department of Cognitive Neuroscience and Neuroergonomics, Institute of Applied Psychology, Jagiellonian University, Kraków, Poland
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Delgado-Álvarez A, Matías-Guiu JA, Delgado-Alonso C, Cuevas C, Palacios-Sarmiento M, Vidorreta-Ballesteros L, Montero-Escribano P, Matías-Guiu J. Validation of two new scales for the assessment of fatigue in Multiple Sclerosis: F-2-MS and FACIT-F. Mult Scler Relat Disord 2022; 63:103826. [PMID: 35487033 DOI: 10.1016/j.msard.2022.103826] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/08/2022] [Accepted: 04/21/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Fatigue is one of the most common symptoms in neurology, especially in MS patients with a prevalence of 65%. It is described as the most disabling symptom by 40% of MS patients. This study aimed to validate the Functional Assessment of Chronic Illness Therapy fatigue version (FACIT-F) and the F-2-MS scale, a new tool to distinguish between fatigue and fatigability. METHODS One hundred and fifteen patients with relapsing-remitting MS were enrolled. All patients completed a comprehensive neuropsychological battery, previously validated in MS. Fatigue was evaluated using the Fatigue Severity Scale (FSS), the Modified version of the Fatigue Impact Scale (MFIS), the Functional Assessment of Chronic Illness Therapy measure system (fatigue version) (FCIT-F), and a new tool for the assessment of fatigue and fatigability: the F-2-MS scale. Internal consistency was estimated with Cronbach's Alpha. For intergroup comparisons, Student's t-test and Pearson's chi-squared test were used. Pearson's correlation test was calculated for quantitative variables. Cohen's d was calculated to evaluate the effect size. Binary logistic regression was performed, considering the presence of fatigue as a criterion variable, and the FACIT-F and F-2-MS scores were added as predictor variables. ROC curves were also estimated. We conducted a confirmatory factor analysis for the F-2-MS scale, considering two latent factors. RESULTS FACIT-F and F-2-MS showed high internal consistency. Both scales were highly correlated with MFIS and FSS, and showed a low correlation with Symbol Digit Modalities Test. There were significant differences between fatigued and non-fatigued patients on FACIT-F and F-2-MS scores with large effect sizes. Both scales showed AUC > 0.90 and achieved a correct classification >87%. Confirmatory factor analysis showed moderate evidence of two dimensions on the F-2-MS scale. CONCLUSIONS The FACIT-F and F-2-MS scales showed appropriated psychometric properties to be used as fatigue measures in clinical and research settings, allowing a correct distinction between patients with and without fatigue, and contributing to the understanding of the complexities of fatigue in MS.
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Affiliation(s)
- Alfonso Delgado-Álvarez
- Department of Neurology, Hospital Clinico San Carlos, San Carlos Institute for Health Research (IdiSSC). Universidad Complutense, Profesor Martin Lagos St., Madrid 28040, Spain
| | - Jordi A Matías-Guiu
- Department of Neurology, Hospital Clinico San Carlos, San Carlos Institute for Health Research (IdiSSC). Universidad Complutense, Profesor Martin Lagos St., Madrid 28040, Spain.
| | - Cristina Delgado-Alonso
- Department of Neurology, Hospital Clinico San Carlos, San Carlos Institute for Health Research (IdiSSC). Universidad Complutense, Profesor Martin Lagos St., Madrid 28040, Spain
| | - Constanza Cuevas
- Department of Neurology, Hospital Clinico San Carlos, San Carlos Institute for Health Research (IdiSSC). Universidad Complutense, Profesor Martin Lagos St., Madrid 28040, Spain
| | - Marta Palacios-Sarmiento
- Department of Neurology, Hospital Clinico San Carlos, San Carlos Institute for Health Research (IdiSSC). Universidad Complutense, Profesor Martin Lagos St., Madrid 28040, Spain
| | - Lucía Vidorreta-Ballesteros
- Department of Neurology, Hospital Clinico San Carlos, San Carlos Institute for Health Research (IdiSSC). Universidad Complutense, Profesor Martin Lagos St., Madrid 28040, Spain
| | - Paloma Montero-Escribano
- Department of Neurology, Hospital Clinico San Carlos, San Carlos Institute for Health Research (IdiSSC). Universidad Complutense, Profesor Martin Lagos St., Madrid 28040, Spain
| | - Jorge Matías-Guiu
- Department of Neurology, Hospital Clinico San Carlos, San Carlos Institute for Health Research (IdiSSC). Universidad Complutense, Profesor Martin Lagos St., Madrid 28040, Spain
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Gulde P, Rieckmann P. The Association Between Actigraphy-Derived Behavioral Clusters and Self-Reported Fatigue in Persons With Multiple Sclerosis: Cross-sectional Study. JMIR Rehabil Assist Technol 2022; 9:e31164. [PMID: 35297774 PMCID: PMC8972102 DOI: 10.2196/31164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/06/2021] [Accepted: 12/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background Persons with multiple sclerosis frequently report increased levels of fatigue and fatigability. However, behavioral surrogates that are strongly associated with self-reports are lacking, which limits research and treatment. Objective The aim of this study was to derive distinct behavioral syndromes that are reflected by self-reports concerning fatigue and fatigability. Methods We collected actigraphic data of 30 persons with multiple sclerosis over a period of 1 week during an inpatient stay at a neurorehabilitation facility. Further, participants completed the German fatigue severity scale. A principal component analysis of actigraphic parameters was performed to extract the latent component levels of behaviors that reflect fatigue (quantity of activity) and fatigability (fragmentation of activity). The resulting components were used in a cluster analysis. Results Analyses suggested 3 clusters, one with high activity (d=0.65-1.57) and low clinical disability levels (d=0.91-1.39), one with high levels of sedentary behavior (d=1.06-1.58), and one with strong activity fragmentation (d=1.39-1.94). The cluster with high levels of sedentary behavior further revealed strong differences from the other clusters concerning participants’ reported levels of fatigue (d=0.99-1.28). Conclusions Cluster analysis data proved to be feasible to meaningfully differentiate between different behavioral syndromes. Self-reports reflected the different behavioral syndromes strongly. Testing of additional domains (eg, volition or processing speed) and assessments during everyday life seem warranted to better understand the origins of reported fatigue symptomatology.
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Affiliation(s)
- Philipp Gulde
- Center for Clinical Neuroplasticity, Medical Park Loipl, Medical Park Societas Europaea, Bischofswiesen, Germany.,Human Movement Science, Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Peter Rieckmann
- Center for Clinical Neuroplasticity, Medical Park Loipl, Medical Park Societas Europaea, Bischofswiesen, Germany
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Plow M, Gunzler DD. Disentangling self-reported fatigue, depression, and cognitive impairment in people with multiple sclerosis. Mult Scler Relat Disord 2022; 61:103736. [PMID: 35405560 DOI: 10.1016/j.msard.2022.103736] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/15/2022] [Accepted: 03/10/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fatigue is a common problem among people with multiple sclerosis (MS) and can have a negative effect on mental, physical, and social function. Self-reported measures of MS fatigue are often operationalized as a multi-dimensional symptom. However, questions remain about how best to account for the multi-dimensional aspects of self-reported fatigue and whether these aspects are distinct entities. Thus, the purpose of this study was to explore the overlap and distinctions between self-reported measures of the severity and impact of fatigue, between mental and physical fatigue, and between mental fatigue, depressive symptoms, and cognitive impairment. METHODS An observational study was conducted with 289 participants with MS . The questionnaires were the Unidimensional Fatigue Impact Scale (UFIS), the Chalder Fatigue Scale (CFS), the Fatigue Scale for Motor and Cognitive Functions (FSMC), the Multiple Sclerosis Neuropsychological Screening Questionnaire (MSNSQ), and the Quality of Life in Neurological Disorders short form for depression (Neuro-QoL). Spearman's correlation coefficient was used to examine the bivariate correlations between composite and subscale scores. Exploratory structural equation modeling (ESEM) was used to determine the factor structure under a pre-specified number of factors to retain in the modeling of multiple items across questionnaires and examine model fit. Subsequently for poor fitting models in an iterative procedure to determine a better fitting multidimensional model, we posited a bifactor confirmatory factor analysis model. RESULTS The bivariate correlation analysis revealed that subscales from the same questionnaire measuring different aspects of fatigue had the highest correlations (r = 0.61-0.68), subscales from different questionnaires measuring the same aspect of fatigue had the next highest correlations (r = 0.43-0.60), and subscales from different questionnaires measuring different aspects of fatigue had the lowest correlations (r = 0.34-0.40). Bifactor models with a general fatigue factor and subdomains pertaining to impact, severity, and mental and physical fatigue had relatively good model fits compared to models omitting the subdomains. However, an ESEM model using subscales from the CFS and FSMC fit poorly and did not adequately identify separate factors for mental and physical fatigue. An ESEM model with separate factors for self-reported mental fatigue, depressive symptoms, and cognitive impairment was a good fit. CONCLUSIONS The working study hypothesis that fatigue constructs would be moderately correlated yet distinct entities was generally supported by the results of the study. However, we found that our hypothesized separation into a latent dimension existed only when the items or subscales came from the same questionnaire, in which case their level of specificity in terms of target, action, context, and time elements for measuring fatigue were consistent. The implications for the principle of compatibility in measuring self-reported MS fatigue are discussed.
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Affiliation(s)
- Matthew Plow
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, United States.
| | - Douglas D Gunzler
- Population and Quantitative Health Sciences, Metrohealth Medical Center, School of Medicine, Case Western Reserve University, 2500 Metrohealth Drive, Cleveland, OH, United States
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The aerobic capacity – fatigue relationship in persons with Multiple Sclerosis is not reproducible in a pooled analysis of two randomized controlled trials. Mult Scler Relat Disord 2022; 58:103476. [DOI: 10.1016/j.msard.2021.103476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/29/2021] [Accepted: 12/24/2021] [Indexed: 11/23/2022]
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Factor structure, reliability, inter-rater agreement and convergent validity of the parent and child Italian versions of the paediatric quality of life inventory multidimensional fatigue scale for children and adolescents in paediatric inpatients with obesity and their parents. Eat Weight Disord 2022; 27:295-306. [PMID: 33786737 DOI: 10.1007/s40519-021-01152-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/11/2021] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE This study aimed to examine the factor structure, reliability, inter-rater agreement and convergent validity of the child and parent Italian versions of the paediatric quality of life inventory multidimensional fatigue scale (PedsQL-MFS) in paediatric inpatients with obesity and one of their parents. METHODS 100 pairs of children/adolescents (64% female, mean age = 15.34) with obesity and one of their parents completed the PedsQL-MFS and the Child Behaviour Checklist (CBCL) or the Youth Self Report. RESULTS Confirmatory Factor Analysis indicated that the three correlated first-order factors model corresponding to the published subscales demonstrated acceptable fit and achieved strict invariance across parent and child informants. Bifactor Analysis supported the multidimensionality and the reliability of the total and subscale scores as multidimensional composites. Parent-child agreement was low with latent means higher for parent reports. PedsQL-MFS total scores were strongly correlated with Somatic Complaints scores on the CBCL, and moderately associated with anxiety, depression, social problems and school problems. CONCLUSIONS Total scores of the child and parent Italian versions of the PedsQL-MFS demonstrated good reliability and convergent validity in paediatric inpatients with obesity and their parents, and are complementary rather than interchangeable. LEVEL OF EVIDENCE No level of evidence.
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25
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Martignon C, Laginestra FG, Giuriato G, Pedrinolla A, Barbi C, DI Vico IA, Tinazzi M, Schena F, Venturelli M. Evidence that Neuromuscular Fatigue Is not a Dogma in Patients with Parkinson's Disease. Med Sci Sports Exerc 2022; 54:247-257. [PMID: 34559731 DOI: 10.1249/mss.0000000000002791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Given the increased level of fatigue frequently reported by patients with Parkinson's disease (PD), this study investigated the interaction between central and peripheral components of neuromuscular fatigue (NF) in this population compared with healthy peers. METHODS Changes in maximal voluntary activation (ΔVA, central fatigue) and potentiated twitch force (ΔQtw,pot, peripheral fatigue) pre-post exercise were determined via the interpolated twitch technique in 10 patients with PD and 10 healthy controls (CTRL) matched for age, sex, and physical activity. Pulmonary gas exchange, femoral blood flow, and quadriceps EMG were measured during a fatiguing exercise (85% of peak power output [PPO]). For a specific comparison, on another day, CTRL repeat the fatiguing test matching the time to failure (TTF) and PPO of PD. RESULTS At 85% of PPO (PD, 21 ± 7 W; CTRL, 37 ± 22 W), both groups have similar TTF (~5.9 min), pulmonary gas exchange, femoral blood flow, and EMG. After this exercise, the maximal voluntary contraction (MVC) force and Qtwpot decreased equally in both groups (-16%, P = 0.483; -43%, P = 0.932), whereas VA decreased in PD compared with CTRL (-3.8% vs -1.1%, P = 0.040). At the same PPO and TTF of PD (21 W; 5.4 min), CTRL showed a constant drop in MVC, and Qtwpot (-14%, P = 0.854; -39%, P = 0.540), instead VA decreased more in PD than in CTRL (-3.8% vs -0.7%, P = 0.028). CONCLUSIONS In PD, central NF seems exacerbated by the fatiguing task which, however, does not alter peripheral fatigue. This, besides the TTF like CTRL, suggests that physical activity may limit NF and counterbalance PD-induced degeneration through peripheral adaptations.
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Affiliation(s)
- Camilla Martignon
- Department of Neurosciences, Biomedicine, and Movement, University of Verona, ITALY
| | | | - Gaia Giuriato
- Department of Neurosciences, Biomedicine, and Movement, University of Verona, ITALY
| | - Anna Pedrinolla
- Department of Neurosciences, Biomedicine, and Movement, University of Verona, ITALY
| | - Chiara Barbi
- Department of Neurosciences, Biomedicine, and Movement, University of Verona, ITALY
| | | | - Michele Tinazzi
- Department of Neurosciences, Biomedicine, and Movement, University of Verona, ITALY
| | - Federico Schena
- Department of Neurosciences, Biomedicine, and Movement, University of Verona, ITALY
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Barrios L, Amon R, Oldrati P, Hilty M, Holz C, Lutterotti A. Cognitive fatigability assessment test (cFAST): Development of a new instrument to assess cognitive fatigability and pilot study on its association to perceived fatigue in multiple sclerosis. Digit Health 2022; 8:20552076221117740. [PMID: 36046638 PMCID: PMC9421030 DOI: 10.1177/20552076221117740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/06/2022] [Accepted: 07/18/2022] [Indexed: 11/28/2022] Open
Abstract
Background Fatigue is a common symptom of many diseases, including multiple sclerosis. It manifests as a cognitive or physical condition. Fatigue is poorly understood, and effective therapies are missing. Furthermore, there is a lack of methods to measure fatigue objectively. Fatigability, the measurable decline in performance during a task, has been suggested as a complementary method to quantify fatigue. Objective To develop a new and objective measurement of cognitive fatigability and investigate its association with perceived fatigue. Methods We introduced the cognitive fatigability assessment test (cFAST), a novel smartphone-based test to quantify cognitive fatigability. Forty-two people with multiple sclerosis (23 fatigued and 19 non-fatigued, defined by the Fatigue Scale for Motor and Cognitive Functions) took part in our validation study. Patients completed cFAST twice. We used t-tests, Monte Carlo sampling, and area under the receiver operating characteristic curves to evaluate our approach using two sets of proposed metrics. Results When classifying fatigue, our fatigability metric Δresponse time has a mean area under the receiver operating characteristic curve of 0.74 (95% CI 0.64–0.84), making it the best performing metric for this task. Furthermore, Δresponse time shows a statistically significant difference between the fatigued and non-fatigued groups (t = 2.27, P = .03). Particularly, cognitively-fatigued patients decline in performance, while non-fatigued patients do not. Conclusions We introduce cFAST, a new instrument to quantify cognitive fatigability. Our pilot study provides evidence that cognitive fatigability assessment test produces a quantifiable drop in cognitive performance in a short period. Furthermore, our results indicate that cFAST may have the potential to serve as a surrogate for subjective cognitive fatigue. cFAST is significantly shorter than the existing fatigability assessments and does not require specialized equipment. Thus, it could enable frequent and remote monitoring, which could substantially aid clinicians in better understanding and treating fatigue.
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Affiliation(s)
- Liliana Barrios
- Department of Computer Science, ETH Zurich, Zurich, Switzerland
| | - Rok Amon
- University Hospital of Zurich, Zurich, Switzerland
| | - Pietro Oldrati
- University Hospital of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Marc Hilty
- University Hospital of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Christian Holz
- Department of Computer Science, ETH Zurich, Zurich, Switzerland
| | - Andreas Lutterotti
- University Hospital of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Neurozentrum Bellevue and Department of Neurology Hirslanden, Zurich, Switzerland
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27
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Treatment of multiple sclerosis fatigue with the synthetic psychoactive drug modafinil. Exp Neurol 2021; 347:113906. [PMID: 34710403 DOI: 10.1016/j.expneurol.2021.113906] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/15/2021] [Accepted: 10/23/2021] [Indexed: 12/17/2022]
Abstract
Multiple sclerosis (MS) is a complex disorder characterized by a broad spectrum of symptoms that evolve throughout the disease. Symptoms can be categorized as visible and invisible based on external sight recognition. However, although others poorly recognize it, invisible symptoms such as mood dysfunction, neuropathic pain, or fatigue can significantly affect activities of daily living and the quality of life of people with MS (PwMS). PwMS frequently complain of fatigue, which has physical or cognitive manifestations. Fatigue in MS does not improve or resolve with rest, and it is disproportionate with respect to the exerted effort. Fatigue management in MS is challenging, and a few pharmacological approaches have been successfully proposed. Among them, the drug modafinil has attracted attention because of its properties as a synthetic psychoactive drug. In this review, we focus on the evidence available to date, supporting the use of modafinil in MS fatigue. However, despite the availability of some trials evaluating the effects of modafinil on fatigue, their contrasting results failed to support its usefulness in fatigue management in MS.
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28
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Enoka RM, Almuklass AM, Alenazy M, Alvarez E, Duchateau J. Distinguishing between Fatigue and Fatigability in Multiple Sclerosis. Neurorehabil Neural Repair 2021; 35:960-973. [PMID: 34583577 DOI: 10.1177/15459683211046257] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Roger M Enoka
- Department of Integrative Physiology, 1877University of Colorado Boulder, Boulder, CO, USA
| | - Awad M Almuklass
- College of Medicine, 48149King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohammed Alenazy
- Department of Integrative Physiology, 1877University of Colorado Boulder, Boulder, CO, USA
| | - Enrique Alvarez
- Department of Neurology, 129263University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jacques Duchateau
- Laboratory of Applied Biology and Neurophysiology, ULB Neuroscience Institute, 26659Université Libre de Bruxelles, Brussels, Belgium
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Clinical manifestation and perceived symptoms of walking-related performance fatigability in persons with multiple sclerosis. Int J Rehabil Res 2021; 44:118-125. [PMID: 33534273 DOI: 10.1097/mrr.0000000000000457] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fatigue and walking difficulties are common impairments and activity limitations in persons with multiple sclerosis (PwMS). Walking fatigability (WF) can be measured by a Distance Walked Index and is defined as a decline in walking distance of 10% or more during the six-minute walking test (6MWT). However, the clinical manifestation and perceived symptoms related to fatigability are still not well documented. Forty-nine PwMS [Expanded Disability Status Scale (EDSS) ≤6] and 28 healthy controls (HC) performed a 6MWT. The perceived severity of 11 common symptoms was rated on a visual analogue scale of 0-10 before, immediately after, and 10, 20 and 30 minutes after the 6MWT by means of the symptom inventory. Short motor impairment screening tests at baseline together with other descriptive measures were performed. Twenty pwMS were categorized in the WF group and were more disabled (EDSS: 4.16 ± 1.41) than the non-walking fatigability group (n = 29, EDSS: 2.62 ± 1.94). PwMS showed exacerbations of several perceived symptoms in MS, where most symptoms returned to baseline within 10 minutes after the walking test. The WF group showed significantly more muscle weakness and gait impairment, together with balance problems, and experienced an increase in spasticity, pain and dizziness after 6MWT. Our findings showed that perceived severity of symptoms are higher in pwMS presenting WF, and increase temporally after the 6MWT. Future research with quantitative measurement during and after walking is recommended.
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30
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Solvang PK, Heiaas I, Romsland G, Søberg HL. The unexpected other: Challenges and strategies after acquired impairment. Health (London) 2021; 27:345-361. [PMID: 34075795 DOI: 10.1177/13634593211021482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
People experiencing traumatic brain injury or multitrauma will often live with problems in functioning for a profound period in life. A situation of great complexity emerges involving both the experience of an impaired body and the experience of a changed social position. This article addresses the intricate relations between the altered body, personal ambitions, and social surroundings in the first 2-3 years after an injury. The conceptual framework centers around the process of change, applying concepts such as the unexpected other and biographical reconstruction. Twenty-one people of working age were interviewed two times. All interviewees had experienced traumatic brain injury or multitrauma. A thematic narrative analysis was applied. Consequences of the injury took place at a carnal level where fatigue is something completely different from becoming exhausted and where elimination of body waste takes place through practices novel to the injured person. Living with impairment also took place at the level of social interaction. Here, family relations, shame, and establishing a new identity seemed profoundly important. This article makes two novel contributions. First, it emphasizes more than previous studies do that the daily management of altered body functions is more important for independence and wellbeing. Second, the article identifies the narrative about the accident as an important issue for injured people to settle.
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Affiliation(s)
| | - Ida Heiaas
- Oslo Metropolitan University, Norway.,Norwegian Women's Public Health Association, Norway
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31
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Influence of Demographic Characteristics and Muscle Strength on the Occupational Fatigue Exhaustion Recovery Scale in Career Firefighters. J Occup Environ Med 2021; 62:223-226. [PMID: 31895733 DOI: 10.1097/jom.0000000000001806] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Little is known regarding how individual characteristics and changes in muscle strength across a shift cycle are associated with the Occupational Fatigue Exhaustion Recovery scale in career firefighters. METHODS Thirty-two career firefighters completed lower body maximal strength testing prior to and following three 24-hour on-off shifts. Demographic data were collected prior to the first shift and the OFER15 questionnaire was completed following the last shift. RESULTS Increased age was associated with greater acute and chronic fatigue and poorer recovery. A positive percent change in strength following a shift cycle was related to better recovery. Age was the only significant predictor of acute and chronic fatigue, while age and the change in strength were significant predictors of inter-shift recovery. CONCLUSIONS Increased age influences all dimensions of work-related fatigue, with changes in muscle strength influencing inter-shift recovery in career firefighters.
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Post-stroke fatigue: how it relates to motor fatigability and other modifiable factors in people with chronic stroke. Acta Neurol Belg 2021; 121:181-189. [PMID: 32740873 DOI: 10.1007/s13760-020-01453-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
Post-stroke fatigue (PSF) is a common symptom associated with disability and decreased quality of life. Distinction can be made between perceived fatigue and fatigability. The first aim of this study was to evaluate the prevalence of perceived fatigue and fatigability amongst patients with chronic stroke and to explore how these two parameters relate. The second aim was to study the relationship between modifiable factors (sleep disorders, anxiety, depression and activities of daily living) and fatigue in this population. Sixty-two patients with chronic stroke (> 6 months) were included. Perceived fatigue was evaluated using the Fatigue Severity Scale (FSS). Motor fatigability was assessed with the percent change in meters walked from first to last minute of the 6-min Walk Test and an isometric muscular fatigability test. Subjects also completed self-report questionnaires assessing anxiety and depression (Hospital Anxiety and Depression Scale-HADS), sleep quality (Pittsburgh Sleep Quality Index-PSQI) and activity limitations (ACTIVLIM-stroke). Seventy-one percent of participants presented PSF. There was no correlation between the FSS and motor fatigability. FSS significantly correlated with HADS-Anxiety (ρ = 0.53, P < 0.001), HADS-depression (ρ = 0.63, P < 0.001), PSQI (ρ = 0.51, P < 0.001) and ACTIVLIM (ρ = - 0.30, P < 0.05). A linear regression model showed that the HADS-Depression, the PSQI and the ACTIVLIM explained 46% of the variance of the FSS. A high proportion of chronic stroke patients presents PSF, with no relation between their fatigue and fatigability. Perceived fatigue is associated with potentially modifiable factors: anxious and depressive symptoms, poor sleep quality and activity limitations. Registered at ClinicalTrials.gov (NCT04277234) (21/02/2019).
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Eizaguirre MB, Ciufia N, Roman MS, Martínez Canyazo C, Alonso R, Silva B, Pita C, Garcea O, Vanotti S. Perceived fatigue in multiple sclerosis: The importance of highlighting its impact on quality of life, social network and cognition. Clin Neurol Neurosurg 2020; 199:106265. [DOI: 10.1016/j.clineuro.2020.106265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 08/22/2020] [Accepted: 09/30/2020] [Indexed: 02/06/2023]
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Cohen ET, Karpatkin HI, DiCarrado S, Zervas M. A clinical reasoning framework for fatigue for neurologic physical therapy. PHYSICAL THERAPY REVIEWS 2020. [DOI: 10.1080/10833196.2020.1834329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Evan T. Cohen
- Department of Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey, Blackwood, NJ, USA
| | - Herb I. Karpatkin
- Department of Physical Therapy, Hunter College, City University of New York, New York, NY, USA
| | | | - Michael Zervas
- Department of Physical Therapy, Hunter College, City University of New York, New York, NY, USA
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Lam KH, Meijer KA, Loonstra FC, Coerver E, Twose J, Redeman E, Moraal B, Barkhof F, de Groot V, Uitdehaag B, Killestein J. Real-world keystroke dynamics are a potentially valid biomarker for clinical disability in multiple sclerosis. Mult Scler 2020; 27:1421-1431. [PMID: 33150823 PMCID: PMC8358561 DOI: 10.1177/1352458520968797] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Clinical measures in multiple sclerosis (MS) face limitations that may be overcome by utilising smartphone keyboard interactions acquired continuously and remotely during regular typing. Objective: The aim of this study was to determine the reliability and validity of keystroke dynamics to assess clinical aspects of MS. Methods: In total, 102 MS patients and 24 controls were included in this observational study. Keyboard interactions were obtained with the Neurokeys keyboard app. Eight timing-related keystroke features were assessed for reliability with intraclass correlation coefficients (ICCs); construct validity by analysing group differences (in fatigue, gadolinium-enhancing lesions on magnetic resonance imaging (MRI), and patients vs controls); and concurrent validity by correlating with disability measures. Results: Reliability was moderate in two (ICC = 0.601 and 0.742) and good to excellent in the remaining six features (ICC = 0.760–0.965). Patients had significantly higher keystroke latencies than controls. Latency between key presses correlated the highest with Expanded Disability Status Scale (r = 0.407) and latency between key releases with Nine-Hole Peg Test and Symbol Digit Modalities Test (ρ = 0.503 and r = −0.553, respectively), ps < 0.001. Conclusion: Keystroke dynamics were reliable, distinguished patients and controls, and were associated with clinical disability measures. Consequently, keystroke dynamics are a promising valid surrogate marker for clinical disability in MS.
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Affiliation(s)
- K H Lam
- Department of Neurology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, MS Center Amsterdam, Amsterdam, The Netherlands
| | - K A Meijer
- Neurocast B.V., Amsterdam, The Netherlands
| | - F C Loonstra
- Department of Neurology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, MS Center Amsterdam, Amsterdam, The Netherlands
| | - Eme Coerver
- Department of Neurology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, MS Center Amsterdam, Amsterdam, The Netherlands
| | - J Twose
- Neurocast B.V., Amsterdam, The Netherlands
| | - E Redeman
- Neurocast B.V., Amsterdam, The Netherlands
| | - B Moraal
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, MS Center Amsterdam, Amsterdam, The Netherlands
| | - F Barkhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, MS Center Amsterdam, Amsterdam, The Netherlands/Queen Square Institute of Neurology and Centre for Medical Image Computing, University College London, London, UK
| | - V de Groot
- Department of Rehabilitation Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Bmj Uitdehaag
- Department of Neurology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, MS Center Amsterdam, Amsterdam, The Netherlands
| | - J Killestein
- Department of Neurology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, MS Center Amsterdam, Amsterdam, The Netherlands
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Coates KD, Aboodarda SJ, Krüger RL, Martin T, Metz LM, Jarvis SE, Millet GY. Multiple sclerosis-related fatigue: the role of impaired corticospinal responses and heightened exercise fatigability. J Neurophysiol 2020; 124:1131-1143. [PMID: 32877296 DOI: 10.1152/jn.00165.2020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
It is unclear whether motor fatigability and perceived fatigue share a common pathophysiology in people with multiple sclerosis (PwMS). This cross-sectional investigation explored the relationship between the mechanisms of motor fatigability from cycling and fatigue severity in PwMS. Thirteen highly fatigued (HF) and thirteen nonfatigued (LF) PwMS and thirteen healthy controls (CON) completed a step test until volitional exhaustion on an innovative cycle ergometer. Neuromuscular evaluations involving femoral nerve electrical stimulation and transcranial magnetic stimulation were performed every 3 min throughout cycling. One-way ANOVA at baseline and exhaustion uncovered evidence of consistently smaller motor evoked potential (MEP) amplitudes (P = 0.011) and prolonged MEP latencies (P = 0.041) in HF as well as a greater decline in maximal voluntary contraction force (HF: 63 ± 13%; LF: 75 ± 13%; CON: 73 ± 11% of pre; P = 0.037) and potentiated twitch force (HF: 35 ± 13%; LF: 50 ± 16%; CON: 47 ± 17% of pre; P = 0.049) in HF at volitional exhaustion. Hierarchical regression determined that fatigue severity on the Fatigue Severity Scale was predicted by prolonged MEP latencies (change in r2 = 0.389), elevated peripheral muscle fatigability (change in r2 = 0.183), and depressive symptoms (change in r2 = 0.213). These findings indicate that MS-related fatigue is distinguished by disrupted corticospinal responsiveness, which could suggest progressive pathology, but fatigability from whole body exercise and depressive symptoms also influence perceptions of fatigue in PwMS.NEW & NOTEWORTHY The etiology of fatigability from whole body exercise was examined for the first time to accurately elucidate the relationship between fatigue and fatigability in multiple sclerosis (MS). Compromised corticospinal responsiveness predicted fatigue severity, providing a novel, objective indicator of fatigue in MS. Although the impaired corticomotor transmission did not aggravate muscle activation in this group of people with multiple sclerosis (PwMS) of lower disability, heightened muscle fatigability was seen to contribute to perceptions of fatigue in PwMS.
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Affiliation(s)
- Kyla D Coates
- Neuromuscular Fatigue Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Saied Jalal Aboodarda
- Neuromuscular Fatigue Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Renata L Krüger
- Neuromuscular Fatigue Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Tristan Martin
- Neuromuscular Fatigue Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Unité Mixte de Recherche-S 1075 Comete Moblites: Vieillissement Pathologies Santé, Institut National de la Santé et de la Recherche Médicale, Normandy University, Caen, France
| | - Luanne M Metz
- Hotchkiss Brain Institute and the Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Scott E Jarvis
- Hotchkiss Brain Institute and the Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Guillaume Y Millet
- Neuromuscular Fatigue Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Inter-University Laboratory of Human Movement Biology, Jean Monnet University-Saint-Etienne, University of Lyon, Saint-Etienne, France.,Institut Universitaire de France, Paris, France
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Greenhouse-Tucknott A, Wrightson JG, Raynsford M, Harrison NA, Dekerle J. Interactions between perceptions of fatigue, effort, and affect decrease knee extensor endurance performance following upper body motor activity, independent of changes in neuromuscular function. Psychophysiology 2020; 57:e13602. [PMID: 32578885 DOI: 10.1111/psyp.13602] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 04/22/2020] [Accepted: 05/04/2020] [Indexed: 12/20/2022]
Abstract
Prior exercise has previously been shown to impair subsequent endurance performance in non-activated muscles. Declines in the neuromuscular function and altered perceptual/affective responses offer possible mechanisms through which endurance performance may be limited in these remote muscle groups. We thus conducted two experiments to better understand these performance-limiting mechanisms. In the first experiment, we examined the effect of prior handgrip exercise on the behavioral, perceptual, and affective responses to a sustained, sub-maximal contraction of the knee extensors. In the second experiment, transcranial magnetic stimulation was used to assess the neuromuscular function of the knee extensors before and after the handgrip exercise. The results of the first experiment demonstrated prior handgrip exercise increased the perceptions of effort and reduced affective valence during the subsequent knee extensor endurance exercise. Both effort and affect were associated with endurance performance. Subjective ratings of fatigue were also increased by the preceding handgrip exercise but were not directly related to knee extensor endurance performance. However, perceptions of fatigue were correlated with heightened effort perception and reduced affect during the knee extensor contraction. In the second experiment, prior handgrip exercise did not significantly alter the neuromuscular function of the knee extensors. The findings of the present study indicate that motor performance in the lower limbs following demanding exercise in the upper body appears to be regulated by complex, cognitive-emotional interactions, which may emerge independent of altered neuromuscular function. Subjective fatigue states are implicated in the control of perceptual and affective processes responsible for the regulation of endurance performance.
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Affiliation(s)
| | - J G Wrightson
- Fatigue and Exercise Laboratory, University of Brighton, Brighton, UK.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M Raynsford
- Fatigue and Exercise Laboratory, University of Brighton, Brighton, UK
| | - N A Harrison
- Immunopsychiatry Research Group, Cardiff University, Cardiff, UK.,Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Sussex Partnership NHS Foundation Trust, Brighton, UK
| | - J Dekerle
- Fatigue and Exercise Laboratory, University of Brighton, Brighton, UK
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38
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Taul-Madsen L, Dalgas U, Kjølhede T, Hvid LG, Petersen T, Riemenschneider M. A Head-to-Head Comparison of an Isometric and a Concentric Fatigability Protocol and the Association With Fatigue and Walking in Persons With Multiple Sclerosis. Neurorehabil Neural Repair 2020; 34:523-532. [DOI: 10.1177/1545968320920250] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Fatigue is one of the most frequent symptoms in persons with multiple sclerosis (MS). Distinction is made between subjective perceptions of fatigue and objective measures of fatigability. Fatigability can be measured by different protocols. Yet no studies have compared isometric and concentric contraction protocols of the lower extremities head-to-head. Therefore, the purpose of the present study was to (1) compare 2 such protocols head-to-head and (2) to investigate the association between fatigability evoked by the 2 protocols and measures of fatigue and walking. Methods. A total of 45 patients with MS had their walking capacity measured objectively by the 6-minute walk test (6MWT) and subjectively by the 12-item Multiple Sclerosis Walking Scale (MSWS-12). Fatigue was measured by the Modified Fatigue Impact Scale (MFIS) and fatigability by 2 knee extension protocols: sustained isometric and concentric. Results. The sustained isometric protocol induced a higher degree of fatigability than the concentric protocol ( P < .01). Regression analyses revealed that sustained isometric fatigability was not associated with either measures of fatigue or walking (all r2 = 0.00; P = .85-.99), whereas the concentric protocol was significantly associated with fatigue ( r2 = 0.20; P < .01), 6MWT ( r2 = 0.09; P < .05), and MSWS-12 ( r2 = 0.16; P < .01). Furthermore, after adjusting for maximal strength and sex, concentric fatigability remained a strong and significant predictor of fatigue (β = 0.49) and walking (6MWT: β = −0.26; MSWS: β = 0.37). Conclusion. This study provides the first evidence that a lower-extremity concentric fatigability protocol provides superior reflection of both fatigue and walking when compared with a sustained isometric protocol. We suggest that concentric protocols should be the focus of future studies investigating fatigability.
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Affiliation(s)
| | - Ulrik Dalgas
- Exercise Biology, Department of Public Health, Aarhus University, Denmark
| | - Tue Kjølhede
- Exercise Biology, Department of Public Health, Aarhus University, Denmark
- Centre for Innovative Medical Technology, Odense University Hospital, Denmark
| | - Lars G. Hvid
- Exercise Biology, Department of Public Health, Aarhus University, Denmark
| | - Thor Petersen
- Department of Neurology, The Multiple Sclerosis Clinic, Aarhus University Hospital, Denmark
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Davis LA, Alenazy MS, Almuklass AM, Feeney DF, Vieira T, Botter A, Enoka RM. Force control during submaximal isometric contractions is associated with walking performance in persons with multiple sclerosis. J Neurophysiol 2020; 123:2191-2200. [PMID: 32347151 DOI: 10.1152/jn.00085.2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Individuals with multiple sclerosis (MS) experience progressive declines in movement capabilities, especially walking performance. The purpose of our study was to compare the amount of variance in walking performance that could be explained by the functional capabilities of lower leg muscles in persons with MS and a sex- and age-matched control group. Participants performed two walking tests (6-min walk and 25-ft walk), strength tests for the plantar flexor and dorsiflexor muscles, and steady submaximal (10% and 20% maximum) isometric contractions. High-density electromyography (EMG) was recorded during the steady contractions, and the signals were decomposed to identify the discharge times of concurrently active motor units. There were significant differences between the two groups in the force fluctuations during the steady contractions (force steadiness), the strength of the plantar flexor and dorsiflexor muscles, and the discharge characteristics during the steady contractions. Performance on the two walking tests by the MS group was moderately associated with force steadiness of the plantar flexor and dorsiflexor muscles; worse force steadiness was associated with poorer walking performance. In contrast, the performance of the control group was associated with muscle strength (25-ft test) and force steadiness of the dorsiflexors and variance in common input of motor units to the plantar flexors (6-min test). These findings indicate that a reduction in the ability to maintain a steady force during submaximal isometric contractions is moderately associated with walking performance of persons with MS.NEW & NOTEWORTHY The variance in walking endurance and walking speed was associated with force control of the lower leg muscles during submaximal isometric contractions in individuals with multiple sclerosis (MS). In contrast, the fast walking speed of a sex- and age-matched control group was associated with the strength of lower leg muscles. These findings indicate that moderate declines in the walking performance of persons with MS are more associated with impairments in force control rather than decreases in muscle strength.
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Affiliation(s)
- Leah A Davis
- Department of Integrative Physiology University of Colorado, Boulder, Colorado
| | - Mohammed S Alenazy
- Department of Integrative Physiology University of Colorado, Boulder, Colorado
| | - Awad M Almuklass
- Department of Integrative Physiology University of Colorado, Boulder, Colorado
| | - Daniel F Feeney
- Department of Integrative Physiology University of Colorado, Boulder, Colorado
| | - Taian Vieira
- Department of Integrative Physiology University of Colorado, Boulder, Colorado
| | - Alberto Botter
- Department of Integrative Physiology University of Colorado, Boulder, Colorado
| | - Roger M Enoka
- Department of Integrative Physiology University of Colorado, Boulder, Colorado
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40
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Drebinger D, Rasche L, Kroneberg D, Althoff P, Bellmann-Strobl J, Weygandt M, Paul F, Brandt AU, Schmitz-Hübsch T. Association Between Fatigue and Motor Exertion in Patients With Multiple Sclerosis-a Prospective Study. Front Neurol 2020; 11:208. [PMID: 32351439 PMCID: PMC7174662 DOI: 10.3389/fneur.2020.00208] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/09/2020] [Indexed: 12/31/2022] Open
Abstract
Background: Fatigue in multiple sclerosis (MS) is conceived as a multidimensional construct. Objectives: This study aims to describe the changes of balance and gait parameters after 6 min of walking (6 MW) as potential quantitative markers for perceptions of state fatigue and trait fatigue in MS. Methods: A total of 19 patients with MS (17 with fatigue) and 24 healthy subjects underwent static posturography, gait analysis, and ratings of perceived exertion before and after 6 MW. Results: 6 MW was perceived as exhaustive, but both groups featured more dynamic comfortable speed walking after 6 MW. Shorter stride length at maximum speed and increased postural sway after 6 MW indicated fatigability of balance and gait in MS group only. While most changes were related to higher levels of perceived exertion after 6 MW (state fatigue), higher fatigue ratings (trait fatigue) were only associated with less increase in arm swing at comfortable speed. Further analysis revealed different associations of trait fatigue and performance fatigability with disability and motor functions. Performance fatigability was most closely related to the Expanded Disability Status Scale, while for trait fatigue, the strongest correlations were seen with balance function and handgrip strength. Conclusions: Fatigability of performance was closely related to perceptions of exertion after 6 MW (state fatigue) and disability in MS but distinct from fatigue ratings, conceived as trait fatigue. Our study identified postural sway, arm swing during gait, and hand grip strength as unexpected potential motor indicators of fatigue ratings in MS.
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Affiliation(s)
- Daniel Drebinger
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ludwig Rasche
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Neurology, Park Clinic Weissensee, Berlin, Germany
| | - Daniel Kroneberg
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Patrik Althoff
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Judith Bellmann-Strobl
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Weygandt
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander U Brandt
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Tanja Schmitz-Hübsch
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
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41
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Leithead C, Bradshaw M, Salmond S, Dreker MR. Experiences of multiple sclerosis patients with self-management of fatigue: a qualitative systematic review protocol. JBI Evid Synth 2020; 18:619-625. [PMID: 32197022 DOI: 10.11124/jbisrir-2017-003986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review is to explore and synthesize the evidence on the experience of self-managing multiple sclerosis fatigue among adult patients. INTRODUCTION Multiple sclerosis is a growing neurologic auto-immune disease, and fatigue is considered one of the most common and debilitating side effects. Understanding how multiple sclerosis patients experience fatigue, the cause of their fatigue, as well as how they self-manage their fatigue will better inform healthcare providers and patients. INCLUSION CRITERIA The review will consider qualitative studies investigating the perceptions, experiences and meaning of fatigue associated with multiple sclerosis, the factors contributing to fatigue and the self-management strategies used to control fatigue in adults. Studies that include adult patients diagnosed with multiple sclerosis and experiencing fatigue, regardless of their participation in pharmacological interventions and non-pharmacological interventions, will be included. Any patients with multiple sclerosis residing in hospital-based care or residential in patient care will not be included. METHODS A three-step search strategy will be utilized in this review. The initial step consists of a limited search in MEDLINE and CINAHL using "multiple sclerosis" and "fatigue" as search terms. Studies will be excluded if they have not been translated into English, but will not be limited by date. Each article will go through a preliminary review based on title and abstract to exclude any articles not pertaining to this study. After the search is completed, two reviewers will individually appraise retrieved qualitative studies for methodological quality prior to inclusion in the review. Findings will be pooled using meta-aggregation, and a ConQual Summary of Findings will be presented.
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Affiliation(s)
- Christine Leithead
- Rutgers School of Nursing, Rutgers University, Newark, USA.,Lawrenceville Neurology Center, Lawrenceville, USA
| | | | - Susan Salmond
- Rutgers School of Nursing, Rutgers University, Newark, USA.,The Northeast Institute for Evidence Synthesis and Translation (NEST): a Joanna Briggs Institute Centre of Excellence
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The effect of fatigue on balance performance in Parkinson's disease. Clin Park Relat Disord 2020; 3:100047. [PMID: 34316632 PMCID: PMC8298774 DOI: 10.1016/j.prdoa.2020.100047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/06/2020] [Accepted: 02/19/2020] [Indexed: 01/07/2023] Open
Abstract
Introduction Balance loss and falls are a common and multifactorial finding in persons with Parkinson's Disease (pwPD). Objective fatigability is thought to contribute to falls in other neurologic conditions, but its impact on balance in pwPD is not known. The two-fold purpose of this study was to: 1) establish that a 6-minute walk (6MWFast) is a stimulus to subjective fatigue for pwPD; and, 2) determine if the Mini Balance Evaluation Systems Test (MBT) is sensitive to change that was induced by a fatiguing condition. Methods Using a randomized crossover design, 19 research participants performed a Mini Balance Evaluation Systems Test (MBT) before and after either a ‘fast’ 6-minute walk (6MWFast) to induce fatigue or a 6-minute rest. Results VASF scores increased after the 6MWFast. Total MBT scores in research participants with Modified Hoehn and Yahr (H&Y) scores of 3.0 and above differed significantly before and after the ‘fast’ 6-minute walk (p = .007, n = 9) while participants with H&Y scores of 1.5 to 2.5 (p = .084, n = 10) did not, suggesting that more disabled pwPD were more likely to experience fatigability that interfered with balance. Conclusions A 6MWFast is a sufficient stimulus to induce subjective fatigue in pwPD and to decrease total MBT scores for more disabled pwPD. Balance evaluations should occur when pwPD are in fatigued and unfatigued states to determine whether fatigue has an impact on balance performance. Both subjective fatigue and objective fatigability can occur in Parkinsons Disease (PD). Objective fatigability may be a factor in balance impairment in persons with PD. Balance assessments in PD should be made with the patient in both a fatigued and non fatigued state.
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43
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Van Geel F, Moumdjian L, Lamers I, Bielen H, Feys P. Measuring walking-related performance fatigability in clinical practice: a systematic review. Eur J Phys Rehabil Med 2020; 56:88-103. [DOI: 10.23736/s1973-9087.19.05878-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Is Fatigue Associated With Aerobic Capacity and Muscle Strength in People With Multiple Sclerosis: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil 2019; 100:2193-2204. [DOI: 10.1016/j.apmr.2019.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/11/2019] [Accepted: 06/20/2019] [Indexed: 11/17/2022]
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Abstract
Fatigue is one of the most debilitating symptoms in patients with multiple sclerosis (MS). Despite its clinical significance, the aetiology and pathophysiology of MS-related fatigue are not well understood. Current evidence and understanding of the neuroanatomical underpinnings of MS-related fatigue are reviewed in this article. The aims of this paper are to (1) review the findings of previous structural neuroimaging studies on MS-related fatigue and summarize consistent findings regarding brain circuitry associated with fatigue in MS, (2) contextualize these findings with the neurochemistry of the relevant circuits and (3) discuss future perspectives with regard to impact on fatigue management of MS patients and methodological challenges towards improved understanding of fatigue pathogenesis. The detailed understanding of the neuroanatomical underpinnings of fatigue might contribute to the identification of novel treatment targets and factors determining treatment resistance to drugs used in current clinical practice.
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Affiliation(s)
- Miklos Palotai
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charles Rg Guttmann
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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46
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Deterioration of specific aspects of gait during the instrumented 6-min walk test among people with multiple sclerosis. J Neurol 2019; 266:3022-3030. [PMID: 31493037 DOI: 10.1007/s00415-019-09500-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/04/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022]
Abstract
Prolonged walking is typically impaired among people with multiple sclerosis (pwMS), however, it is unclear what the contributing factors are or how to evaluate this deterioration. We aimed to determine which gait features become worse during sustained walking and to examine the clinical correlates of gait fatigability in pwMS. Fifty-eight pwMS performed the 6-min walk test while wearing body-fixed sensors. Multiple gait domains (e.g., pace, rhythm, variability, asymmetry and complexity) were compared across each minute of the test and between mild- and moderate-disability patient groups. Associations between the decline in gait performance (i.e., gait fatigability) and patient-reported gait disability, fatigue and falls were also determined. Cadence, stride time variability, stride regularity, step regularity and gait complexity significantly deteriorated during the test. In contrast, somewhat surprisingly, gait speed and swing time asymmetry did not change. As expected, subjects with moderate disability (n = 24) walked more poorly in most gait domains compared to the mild-disability group (n = 34). Interestingly, a group × fatigue interaction effect was observed for cadence and gait complexity; these measures decreased over time in the moderate-disability group, but not in the mild group. Gait fatigability rate was significantly correlated with physical fatigue, gait disability, and fall history. These findings suggest that sustained walking affects specific aspects of gait, which can be used as markers for fatigability in MS. This effect on gait depends on the degree of disability, and may increase fall risk in pwMS. To more fully understand and monitor correlates that reflect everyday walking in pwMS, multiple domains of gait should be quantified.
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47
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Saccadic fatigability in the oculomotor system. J Neurol Sci 2019; 402:167-174. [DOI: 10.1016/j.jns.2019.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/29/2019] [Accepted: 05/20/2019] [Indexed: 11/17/2022]
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Foschi M, Lugaresi A. Evaluating dalfampridine for the treatment of relapsing-remitting multiple sclerosis: does it add to the treatment armamentarium? Expert Opin Pharmacother 2019; 20:1309-1320. [PMID: 31237780 DOI: 10.1080/14656566.2019.1623879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Multiple sclerosis (MS) is a demyelinating disease, causing axonal damage and disability. Dalfampridine (DAL) is an extended-release formulation of 4-aminopyridine (4AP) and broad-spectrum voltage-dependent potassium channel blocker that is reported to improve motor, visual and cognitive functions. Furthermore, it is presently the only approved drug for walking impairment in MS. Areas covered: Herein, the authors evaluate DAL as a relapsing-remitting MS treatment, reporting and commenting on all aspects of the drug including its chemistry, safety, pharmacokinetics, and cost-effectiveness. A bibliographic search was performed on PubMed using the terms 'dalfampridine OR fampridine OR 4-aminopyridine'. Expert opinion: Evidence from post-marketing studies suggests that DAL, consistent with the effects of 4AP, may not only improve walking speed, but also arm function, fatigue, mood and cognition through restored nerve conduction in central nervous system demyelinated areas. Long-term safety data confirm that the approved dose of 10 mg twice daily is generally well tolerated. However, despite the reported efficacy, the extent of the benefits is limited in real life activities, although significant improvements have been demonstrated in the clinical setting. Patients often complain of side effects (such as cramps and painful paraesthesia) or lack of efficacy. Also, its considerably higher pricing in comparison to 4AP represents an important limitation.
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Affiliation(s)
- Matteo Foschi
- a Dipartimento di Scienze Biomediche e Neuromotorie , Università di Bologna , Bologna , Italy
| | - Alessandra Lugaresi
- a Dipartimento di Scienze Biomediche e Neuromotorie , Università di Bologna , Bologna , Italy.,b IRCCS Istituto delle Scienze Neurologiche di Bologna , UOSI Riabilitazione Sclerosi Multipla , Bologna , Italy
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Occupational Therapy in Fatigue Management in Multiple Sclerosis: An Umbrella Review. Mult Scler Int 2019; 2019:2027947. [PMID: 31016045 PMCID: PMC6448334 DOI: 10.1155/2019/2027947] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/31/2019] [Accepted: 03/06/2019] [Indexed: 12/27/2022] Open
Abstract
Background. Fatigue is one of the most invalidant symptoms of Multiple Sclerosis (MS) that negatively affects occupational and work performance and social participation. Occupational therapy (OT) assessment and treatment of impairments related to fatigue can have a significant and positive impact on the quality of life. Methods. An umbrella review has been carried out to provide rehabilitative decision makers in healthcare with insight into the role of OT in fatigue management in Multiple Sclerosis. The question is, what type of treatment provided by occupational therapist is more effective in reducing fatigue in Multiple Sclerosis? A search of literature published until June 2018 was undertaken by three independent reviewers using PubMed, PEDro, and Cochrane Library database including systematic reviews and meta-analyses of the last 10 years. Results. 10 studies were selected (5 systematic reviews, 1 meta-analysis, 3 reviews, and 1 guideline). Conclusions. Fatigue management programs have moderate evidence; other strategies such as OT strategies and telerehabilitation show low evidence.
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50
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Hu M, Muhlert N, Robertson N, Winter M. Perceived fatigue and cognitive performance change in multiple sclerosis: Uncovering predictors beyond baseline fatigue. Mult Scler Relat Disord 2019; 32:46-53. [PMID: 31030019 DOI: 10.1016/j.msard.2019.04.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 03/10/2019] [Accepted: 04/10/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Fatigue is a common and disabling symptom in multiple sclerosis (MS) with a variety of direct and indirect influences, but remains poorly understood. Perceived fatigue and cognitive performance fatigability may only be weakly correlated and may have independent predictors. We adopted a multifactorial approach, utilising a measure of concurrent cognitive performance change in order to examine the clinical, psychological, and cognitive factors influencing perceived and cognitive performance fatigability in MS. METHODS Individuals with adult-onset MS were identified from a regional patient database and invited to complete an assessment battery during a home visit. Baseline perceived fatigue was measured using the Modified Fatigue Impact Scale, Fatigue Assessment Instrument, and a Visual Analogue Scale (VAS). The Conners Continuous Performance Test 3 (CCPT3) and VAS were administered before and after our intervention of roughly 2.5 hours of assessment, which represented a period of cognitive effort. The differences in scores formed measures of cognitive performance fatigability and perceived fatigue change, respectively. We examined differences across baseline fatigue, fatigue change and performance change classifications, using regression analysis to uncover predictors of perceived fatigue and performance change. RESULTS The sample comprised 61 participants who were recruited from an existing cohort of MS patients. Positive relationships with depression and emotion-focused coping, and a negative one with sleep, each predicted baseline perceived fatigue with the model explaining 53.5% of variance. Increased perceived fatigue change was not associated with baseline fatigue, cognitive impairment, disease variables or levels of disability, but was linked with higher anxiety, lower self-efficacy and gender. Most CCPT3 performance change variables did not show significant correlations with baseline clinical, psychological, or fatigue variables. However, two variables were predicted by positive relationships with estimated intelligence, whilst a negative relationship with self-efficacy and a positive one with post-intervention fatigue predicted one each. CONCLUSION Fatigue in MS is a multifactorial construct, with perceived fatigue and cognitive performance fatigability largely influenced by indirect psychological and cognitive factors. Future studies need to take these influences into account when developing fatigue assessment tools. Further, targeting influential fatigue drivers such as psychological variables may improve the burden of fatigue and quality of life of people with MS.
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Affiliation(s)
- M Hu
- University Hospital Wales, Cardiff, UK.
| | - N Muhlert
- School of Psychology, Cardiff University, Cardiff, UK; School of Psychological Sciences, University of Manchester, Manchester, UK
| | - N Robertson
- University Hospital Wales, Cardiff, UK; Institute of Psychological Medicine & Clinical Neurosciences, Cardiff University, UK
| | - M Winter
- University Hospital Wales, Cardiff, UK; School of Psychology, Cardiff University, Cardiff, UK
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