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Englund S, Frisell T, Qu Y, Gandhi K, Hultén A, Kierkegaard M, Piehl F, Longinetti E. Trajectories of self-reported fatigue following initiation of multiple sclerosis disease-modifying therapy. J Neurol Neurosurg Psychiatry 2024:jnnp-2024-333595. [PMID: 38744460 DOI: 10.1136/jnnp-2024-333595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/02/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND We analysed the COMparison Between All immunoTherapies for Multiple Sclerosis (NCT03193866), a Swedish nationwide observational study in relapsing-remitting multiple sclerosis (RRMS), to identify trajectories of fatigue and their association with physical disability following start of disease-modifying therapy (DMT). METHODS Using a group-modelling approach, we assessed trajectories of fatigue with the Fatigue Scale for Motor and Cognitive Functions and physical disability with Expanded Disability Status Scale among 1587 and 1818 individuals who initiated a first DMT and had a first DMT switch, respectively, followed during 2011-2022. We investigated predictors of fatigue trajectories using group membership as a multinomial outcome and calculated conditional probabilities linking membership across the trajectories. RESULTS We identified five trajectories of fatigue in participants who initiated their first DMT: no fatigue (mean starting values=23.7; 18.2% of population), low (35.5; 23.9%), mild (49.0; 21.6%), moderate (61.3; 20.1%) and severe (78.7; 16.1%). While no, low, mild and severe fatigue trajectories remained stable, the moderate trajectory increased to severe fatigue. Similarly, we identified six fatigue trajectories among participants who did a DMT switch, all indicating stable values over time. Women initiating a first DMT were more likely than men to display a severe fatigue trajectory, relative to the no fatigue one. There was a strong association between fatigue and physical disability trajectories. CONCLUSIONS In this cohort of people with actively treated RRMS, self-reported fatigue remained stable or increased over the years following DMT start. There was a strong association between fatigue and disability after DMT start.
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Affiliation(s)
- Simon Englund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ying Qu
- GCSO, Janssen Pharmaceuticals, Stockholm, Sweden
| | - Kavita Gandhi
- Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | | | - Marie Kierkegaard
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Academic Specialist Center, Center of Neurology, Stockholm Health Services, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Elisa Longinetti
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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2
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Kampaite A, Gustafsson R, York EN, Foley P, MacDougall NJJ, Bastin ME, Chandran S, Waldman AD, Meijboom R. Brain connectivity changes underlying depression and fatigue in relapsing-remitting multiple sclerosis: A systematic review. PLoS One 2024; 19:e0299634. [PMID: 38551913 PMCID: PMC10980255 DOI: 10.1371/journal.pone.0299634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 02/13/2024] [Indexed: 04/01/2024] Open
Abstract
Multiple Sclerosis (MS) is an autoimmune disease affecting the central nervous system, characterised by neuroinflammation and neurodegeneration. Fatigue and depression are common, debilitating, and intertwined symptoms in people with relapsing-remitting MS (pwRRMS). An increased understanding of brain changes and mechanisms underlying fatigue and depression in RRMS could lead to more effective interventions and enhancement of quality of life. To elucidate the relationship between depression and fatigue and brain connectivity in pwRRMS we conducted a systematic review. Searched databases were PubMed, Web-of-Science and Scopus. Inclusion criteria were: studied participants with RRMS (n ≥ 20; ≥ 18 years old) and differentiated between MS subtypes; published between 2001-01-01 and 2023-01-18; used fatigue and depression assessments validated for MS; included brain structural, functional magnetic resonance imaging (fMRI) or diffusion MRI (dMRI). Sixty studies met the criteria: 18 dMRI (15 fatigue, 5 depression) and 22 fMRI (20 fatigue, 5 depression) studies. The literature was heterogeneous; half of studies reported no correlation between brain connectivity measures and fatigue or depression. Positive findings showed that abnormal cortico-limbic structural and functional connectivity was associated with depression. Fatigue was linked to connectivity measures in cortico-thalamic-basal-ganglial networks. Additionally, both depression and fatigue were related to altered cingulum structural connectivity, and functional connectivity involving thalamus, cerebellum, frontal lobe, ventral tegmental area, striatum, default mode and attention networks, and supramarginal, precentral, and postcentral gyri. Qualitative analysis suggests structural and functional connectivity changes, possibly due to axonal and/or myelin loss, in the cortico-thalamic-basal-ganglial and cortico-limbic network may underlie fatigue and depression in pwRRMS, respectively, but the overall results were inconclusive, possibly explained by heterogeneity and limited number of studies. This highlights the need for further studies including advanced MRI to detect more subtle brain changes in association with depression and fatigue. Future studies using optimised imaging protocols and validated depression and fatigue measures are required to clarify the substrates underlying these symptoms in pwRRMS.
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Affiliation(s)
- Agniete Kampaite
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Imaging, Edinburgh Imaging Facility, University of Edinburgh, Edinburgh, United Kingdom
| | - Rebecka Gustafsson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Elizabeth N. York
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Imaging, Edinburgh Imaging Facility, University of Edinburgh, Edinburgh, United Kingdom
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, United Kingdom
| | - Peter Foley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, United Kingdom
| | - Niall J. J. MacDougall
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, United Kingdom
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Mark E. Bastin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Imaging, Edinburgh Imaging Facility, University of Edinburgh, Edinburgh, United Kingdom
| | - Siddharthan Chandran
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, United Kingdom
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Adam D. Waldman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Imaging, Edinburgh Imaging Facility, University of Edinburgh, Edinburgh, United Kingdom
| | - Rozanna Meijboom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Imaging, Edinburgh Imaging Facility, University of Edinburgh, Edinburgh, United Kingdom
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3
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Hechenberger S, Helmlinger B, Penner IK, Pirpamer L, Fruhwirth V, Heschl B, Ropele S, Wurth S, Damulina A, Eppinger S, Demjaha R, Khalil M, Pinter D, Enzinger C. Psychological factors and brain magnetic resonance imaging metrics associated with fatigue in persons with multiple sclerosis. J Neurol Sci 2023; 454:120833. [PMID: 37866195 DOI: 10.1016/j.jns.2023.120833] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/11/2023] [Accepted: 10/08/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Besides demographics and clinical factors, psychological variables and brain-tissue changes have been associated with fatigue in persons with multiple sclerosis (pwMS). Identifying predictors of fatigue could help to improve therapeutic approaches for pwMS. Therefore, we investigated predictors of fatigue using a multifactorial approach. METHODS 136 pwMS and 49 normal controls (NC) underwent clinical, neuropsychological, and magnetic resonance imaging examinations. We assessed fatigue using the "Fatigue Scale for Motor and Cognitive Functions", yielding a total, motor, and cognitive fatigue score. We further analyzed global and subcortical brain volumes, white matter lesions and microstructural changes (examining fractional anisotropy; FA) along the cortico striatal thalamo cortical (CSTC) loop. Potential demographic, clinical, psychological, and magnetic resonance imaging predictors of total, motor, and cognitive fatigue were explored using multifactorial linear regression models. RESULTS 53% of pwMS and 20% of NC demonstrated fatigue. Besides demographics and clinical data, total fatigue in pwMS was predicted by higher levels of depression and reduced microstructural tissue integrity in the CSTC loop (adjusted R2 = 0.52, p < 0.001). More specifically, motor fatigue was predicted by lower education, female sex, higher physical disability, higher levels of depression, and self-efficacy (adjusted R2 = 0.54, p < 0.001). Cognitive fatigue was also predicted by higher levels of depression and lower self-efficacy, but in addition by FA reductions in the CSTC loop (adjusted R2 = 0.45, p < 0.001). CONCLUSIONS Our results indicate that depression and self-efficacy strongly predict fatigue in MS. Incremental variance in total and cognitive fatigue was explained by microstructural changes along the CSTC loop, beyond demographics, clinical, and psychological variables.
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Affiliation(s)
- Stefanie Hechenberger
- Medical University of Graz, Research Unit for Neuronal Plasticity and Repair, Graz, Austria; Medical University of Graz, Department of Neurology, Graz, Austria
| | - Birgit Helmlinger
- Medical University of Graz, Research Unit for Neuronal Plasticity and Repair, Graz, Austria; Medical University of Graz, Department of Neurology, Graz, Austria
| | - Iris-Katharina Penner
- Department of Neurology. Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Lukas Pirpamer
- Medical University of Graz, Department of Neurology, Graz, Austria; Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Viktoria Fruhwirth
- Medical University of Graz, Research Unit for Neuronal Plasticity and Repair, Graz, Austria; Medical University of Graz, Department of Neurology, Graz, Austria
| | - Bettina Heschl
- Medical University of Graz, Department of Neurology, Graz, Austria
| | - Stefan Ropele
- Medical University of Graz, Department of Neurology, Graz, Austria
| | - Sebastian Wurth
- Medical University of Graz, Department of Neurology, Graz, Austria
| | - Anna Damulina
- Medical University of Graz, Department of Neurology, Graz, Austria
| | - Sebastian Eppinger
- Medical University of Graz, Department of Neurology, Graz, Austria; Medical University of Graz, Division of Neuroradiology & Interventional Radiology, Department of Radiology, Graz, Austria
| | - Rina Demjaha
- Medical University of Graz, Department of Neurology, Graz, Austria; Medical University of Graz, Neurology Biomarker Research Unit, Graz, Austria
| | - Michael Khalil
- Medical University of Graz, Department of Neurology, Graz, Austria; Medical University of Graz, Neurology Biomarker Research Unit, Graz, Austria
| | - Daniela Pinter
- Medical University of Graz, Research Unit for Neuronal Plasticity and Repair, Graz, Austria; Medical University of Graz, Department of Neurology, Graz, Austria.
| | - Christian Enzinger
- Medical University of Graz, Research Unit for Neuronal Plasticity and Repair, Graz, Austria; Medical University of Graz, Department of Neurology, Graz, Austria
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4
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Salter A. Severity and worsening of fatigue among individuals with multiple sclerosis. Mult Scler J Exp Transl Clin 2023; 9:20552173231167079. [PMID: 37101754 PMCID: PMC10123908 DOI: 10.1177/20552173231167079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/15/2023] [Indexed: 04/28/2023] Open
Abstract
Background Fatigue is associated with reduced quality of life and social participation, and poor employment outcomes. However, most studies examining fatigue are limited by small sample sizes or short follow-up periods. Objective To characterize the natural history of fatigue. Methods The North American Research Committee on Multiple Sclerosis Registry participants with ≥7 years of longitudinal data between 2004 and 2019 and a relapsing disease course were included. A subset of participants enrolled within 5 years of diagnosis was identified. The Fatigue Performance Scale assessed fatigue and ≥1-point increase in Fatigue Performance Scale sustained at the next survey defined fatigue worsening. Results Of 3057 participants with longitudinal data, 944 were within 5 years of multiple sclerosis diagnosis. Most participants (52%) reported fatigue worsening during follow-up. Median time to fatigue worsening ranged from 3.5 to 5 years at lower levels of index fatigue. Fatigue worsening was associated with lower annual income, increasing disability, lower initial fatigue level, taking injectable disease-modifying therapies and increasing depression levels in the relapsing multiple sclerosis participants. Conclusion Most multiple sclerosis participants early in their disease suffer from fatigue and at least half reported fatigue worsening over time. Understanding factors associated with fatigue may help to identify populations most at risk of fatigue worsening will be informative for the overall management of patients with multiple sclerosis.
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Affiliation(s)
- Amber Salter
- Amber Salter,
UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8806, USA.
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5
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Prolonged visual evoked potential latency predicts longitudinal worsening of fatigue in people with multiple sclerosis. Mult Scler Relat Disord 2022; 67:104073. [DOI: 10.1016/j.msard.2022.104073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/25/2022] [Accepted: 07/24/2022] [Indexed: 11/19/2022]
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The Complex Interplay Between Trait Fatigue and Cognition in Multiple Sclerosis. Psychol Belg 2022; 62:108-122. [PMID: 35414944 PMCID: PMC8932362 DOI: 10.5334/pb.1125] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/21/2022] [Indexed: 11/20/2022] Open
Abstract
Cognitive impairments are frequent in patients with Multiple Sclerosis (MS). Yet, the influence of MS-related symptoms on cognitive status is not clear. Studies investigating the impact of trait fatigue along with anxio-depressive symptoms on cognition are seldom, and even less considered fatigue as multidimensional. Moreover, these studies provided conflicting results. Twenty-nine MS patients and 28 healthy controls, matched on age, gender and education underwent a full comprehensive neuropsychological assessment. Anxio-depressive and fatigue symptoms were assessed using the HAD scale and the MFIS, respectively. Six composite scores were derived from the neuropsychological assessment, reflecting the cognitive domains of working memory, verbal and visual learning, executive functions, attention and processing speed. Stepwise regression analyses were conducted in each group to investigate if trait cognitive and physical fatigue, depression and anxiety are relevant predictors of performance in each cognitive domain. In order to control for disease progression, patient’s EDSS score was also entered as predictor variable. In the MS group, trait physical fatigue was the only significant predictor of working memory score. Cognitive fatigue was a predictor for executive functioning performance and for processing speed (as well as EDSS score for processing speed). In the healthy controls group, only an association between executive functioning and depression was observed. Fatigue predicted cognition in MS patients only, beyond anxio-depressive symptoms and disease progression. Considering fatigue as a multidimensional symptom is paramount to better understand its association with cognition, as physical and cognitive fatigue are predictors of different cognitive processes.
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7
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Hoffmeister J, Basso MR, Reynolds B, Whiteside D, Mulligan R, Arnett PA, Combs DR. Effects of diminished positive mood and depressed mood upon verbal learning and memory among people with multiple sclerosis. J Clin Exp Neuropsychol 2021; 43:117-128. [PMID: 33622171 DOI: 10.1080/13803395.2020.1853066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: Cognitive impairment affects as many as 65% of people with multiple sclerosis (PWMS), and memory impairment confers greater severity of disability and functional impairment. Depression is also common among PWMS, and lifetime prevalence rates are as high as 50%. Research has yet to clearly define the relationship between memory dysfunction and depression among PWMS, and may reflect incomplete assessment of depressive symptoms. The present study examined different aspects of depressive symptoms including anhedonia (i.e., diminished positive mood) and their relationships with verbal learning and memory among PWMS.Method: Participants were 48 healthy individuals and 96 PWMS. They were primarily Caucasian (90.3%) and female (75.0%). Participants completed the California Verbal Learning Test-2 (CVLT-2) to assess verbal learning and memory and the Chicago Multiscale Depression inventory to assess depressed mood (CMDI-Mood) and diminished positive mood (CMDI-DPM).Results: Linear regression revealed that the main effect of CMDI-DPM and the interaction of CMDI-DPM and CMDI-Mood significantly explained variance across learning, recall, and recognition CVLT-2 indices. Follow-up analyses indicated that CMDI-DPM was only significant in the absence of high CMDI-Mood scores. CMDI-Mood explained variance in only CVLT-2 Trial B.Conclusions: Depressed mood had little direct effect upon memory performance in PWMS. In the absence of severe depressed mood, higher levels of positive mood corresponded to better memory performance. However, the impact of diminished positive mood was rendered null among those endorsing high levels of depressed mood. These data may imply that anhedonia corresponds with poorer memory function among PWMS, and suggests that investigators and clinicians should assess multiple mood dimensions among PWMS.
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Affiliation(s)
| | | | - Bradley Reynolds
- Department of Psychology, The University of Tulsa, Tulsa, OK, USA
| | | | - Ryan Mulligan
- Department of Psychology, The University of Tulsa, Tulsa, OK, USA
| | - Peter A Arnett
- Department of Psychology, Pennsylvania State University, State College, PA, USA
| | - Dennis R Combs
- Department of Psychology, University of Texas at Tyler, Tyler, TX, USA
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8
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Selective Cerebellar Atrophy Associates with Depression and Fatigue in the Early Phases of Relapse-Onset Multiple Sclerosis. THE CEREBELLUM 2020; 19:192-200. [PMID: 31898280 DOI: 10.1007/s12311-019-01096-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cerebellar dysfunctions have been associated to depressive disorders and cognitive impairment in neurodegenerative diseases. The objective is to analyze the associations between cerebellar atrophy, depression, and fatigue in the early phases of relapse-onset multiple sclerosis (RRMS). Sixty-one RRMS patients and 50 healthy controls (HC) were enrolled and clinically evaluated by means of expanded disability status scale (EDSS), Rao's brief repeatable battery of neuropsychological tests (BRB-NT), Delis-Kaplan executive function system sorting test, beck depression inventory II (BDI-II), and fatigue severity scale (FSS). The relationships between MRI variables and clinical scores were assessed. Depressed RRMS (dRRMS) had significantly lower Vermis Crus I volume compared with not depressed RRMS (ndRRMS) (p = 0.009). Vermis Crus I volume was lower in dRRMS suffering from fatigue than in ndRRMS without fatigue (p = 0.01). The hierarchical regression models which included demographic and clinical data (age, sex, and disease duration, FSS or BDI-II) and cerebellar volumes disclosed that cerebellar lobule right V atrophy explained an increase of 4% of the variability in FSS (p = 0.25) and Vermis Crus I atrophy explained an increase of 6% of variability in BDI-II (p = 0.049). Since clinical onset, atrophy of specific cerebellar lobules associates with important clinical aspects of RRMS. Cerebellar pathology may be one of the determinants of fatigue and depression that contribute to worsen disability in RRMS.
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9
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Veldhuijzen van Zanten J, Douglas MR, Ntoumanis N. Fatigue and fluctuations in physical and psychological wellbeing in people with multiple sclerosis: A longitudinal study. Mult Scler Relat Disord 2020; 47:102602. [PMID: 33176231 DOI: 10.1016/j.msard.2020.102602] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/22/2020] [Accepted: 10/23/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Fatigue is a highly prevalent and disabling symptom of multiple sclerosis (MS). The aetiology remains unclear, potentially resulting from neuroinflammatory or neurodegenerative processes, mood disturbance, MS symptoms including pain, poor sleep, physical decompensation or medication side effects. Cross-sectional associations have been reported between fatigue and markers of physical and psychological health in people with MS. The current study examined if fluctuations in markers of physical and psychological wellbeing were associated with between-person differences in fatigue in MS. METHODS Longitudinal data of up to 7 years was available of 3369 people with MS who were enrolled in the UK MS Register. Participants completed MS impact scale ratings and MS walking scales up to 4 times per year for up to 7 years. Fatigue was assessed at one time point using the Fatigue Severity Scale. Multilevel analyses were conducted to examine the degree of variance in the outcome measures accounted for by fatigue. RESULTS Fatigue was associated with fluctuations in depression, MS impact, and walking ability, and to a lesser extent with fluctuations in anxiety and perceived health status. Interference of fatigue in participation in social activities and work-related responsibilities and the physical effects of fatigue were most strongly related to MS-related outcomes. CONCLUSION Given the strong associations between fatigue and many MS outcomes, fatigue management interventions are likely to impact on different aspects of physical and psychological wellbeing in MS.
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Affiliation(s)
- Jet Veldhuijzen van Zanten
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, UK; Department of Neurology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Birmingham, UK.
| | - Michael R Douglas
- Department of Neurology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Birmingham, UK; College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Nikos Ntoumanis
- Physical Activity and Well-Being Research Group, School of Psychology, Curtin University, Western Australia, Australia
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10
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Chan LLY, Okubo Y, Brodie MA, Lord SR. Mobility performance predicts incident depression: A systematic review and meta-analysis. Exp Gerontol 2020; 142:111116. [PMID: 33086078 DOI: 10.1016/j.exger.2020.111116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 09/30/2020] [Accepted: 10/09/2020] [Indexed: 01/11/2023]
Abstract
Impaired mobility often co-occurs with depression. However, there is no systematic review evidence as to whether mobility impairments precede the onset of depression. The objective of this systematic review and meta-analysis was to evaluate whether mobility impairment could predict incident depression. A systematic search of cohort studies were performed in MEDLINE, EMBASE, CINAHL and PsycINFO. The target population was people with no depressive symptoms at baseline and follow-up for depression or depressive symptoms of at least three months. Of 1061 identified abstracts, 13 studies met the review eligibility criteria. The majority of included studies (8 out of 13) were of high methodological quality. Follow-up periods ranged from 12 months to 16 years. Gait speed was the most consistently reported mobility measure. Participants with slow gait speed were at higher risk of developing depressive symptoms (pooled OR = 1.93, 95%CI: 1.54 to 2.42, 11 studies). This review shows that slow gait speed is predictive of the onset of depressive symptoms. Systematic review registration number: CRD42020153791.
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Affiliation(s)
- L L Y Chan
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Y Okubo
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - M A Brodie
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
| | - S R Lord
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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11
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Greeke EE, Chua AS, Healy BC, Rintell DJ, Chitnis T, Glanz BI. Depression and fatigue in patients with multiple sclerosis. J Neurol Sci 2017; 380:236-241. [DOI: 10.1016/j.jns.2017.07.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 07/24/2017] [Accepted: 07/29/2017] [Indexed: 10/19/2022]
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12
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Vanotti S, Smerbeck A, Eizaguirre MB, Saladino ML, Benedict RRH, Caceres FJ. BICAMS in the Argentine population: Relationship with clinical and sociodemographic variables. APPLIED NEUROPSYCHOLOGY-ADULT 2017; 25:424-433. [PMID: 28534643 DOI: 10.1080/23279095.2017.1323751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) was developed to provide valid assessment of cognitive impairment in multiple sclerosis (MS). The relationship between clinical and social variables and cognitive disorders has been extensively studied, but primarily in developed countries with a focus on other cognitive measures or batteries. The objectives of this study were to analyze the relationship between the BICAMS data and key clinical and sociodemographic variables in the Argentine MS population. A total of 50 MS patients were administered the Argentinean BICAMS Battery, comprised of the Symbol Digit Modalities Test (SDMT), the California Verbal Learning Test I (CVLT I), and the Brief Visuospatial Memory Test Revised (BVMTR). Disease progression, fatigue, depression, self-reported and informant report cognitive status, and employment status were assessed. Disease progression and employment status were most strongly associated with overall BICAMS performance (η2 effect size values ranging from .302 to .624, all comparisons statistically significant). Informant rating of patient cognition, age, depression, disease duration, fatigue, and work hours were significantly associated as well. Gender, years of education, and patient-reported cognitive status were nonpredictive. A similar pattern was seen at the individual test level, with more variables related to the SDMT and CVLT I than BVMTR. BICAMS is strongly associated with overall disease progression and employment status.
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Affiliation(s)
- Sandra Vanotti
- a Multiple Sclerosis Clinic , INEBA - Neurosciences Institute of Buenos Aires , Buenos Aires , Argentina
| | - A Smerbeck
- b Department of Psychology , Rochester Institute of Technology , Rochester , New York , USA
| | - María B Eizaguirre
- a Multiple Sclerosis Clinic , INEBA - Neurosciences Institute of Buenos Aires , Buenos Aires , Argentina
| | - Maria L Saladino
- a Multiple Sclerosis Clinic , INEBA - Neurosciences Institute of Buenos Aires , Buenos Aires , Argentina
| | - Ralph R H Benedict
- c SUNY at Buffalo School of Medicine, Neurology , Buffalo , New York , USA
| | - Fernando J Caceres
- a Multiple Sclerosis Clinic , INEBA - Neurosciences Institute of Buenos Aires , Buenos Aires , Argentina
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13
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Stuke H, Hanken K, Hirsch J, Klein J, Wittig F, Kastrup A, Hildebrandt H. Cross-Sectional and Longitudinal Relationships between Depressive Symptoms and Brain Atrophy in MS Patients. Front Hum Neurosci 2016; 10:622. [PMID: 28018194 PMCID: PMC5159697 DOI: 10.3389/fnhum.2016.00622] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 11/22/2016] [Indexed: 01/12/2023] Open
Abstract
Introduction: Depressive symptoms are a frequent and distressing phenomenon in Multiple Sclerosis (MS) patients. Cross-sectional research links these symptoms to reduced brain gray matter volumes in parts of the prefrontal and temporal lobe as well as subcortical structures like the hippocampus, nucleus caudatus and globus pallidus. Nevertheless, prospective relationships between regional gray matter volume and the course of depressive symptoms are poorly understood. Methods: Forty-four patients with relapsing–remitting or secondary progressive MS participated in a prospective study with two assessments of depressive symptoms and high-resolution MRI with an inter-test-interval of 17 months. Relationships between baseline gray matter volume and baseline depressive symptoms, as well as prospective associations between the development of atrophy and depression were assessed using voxel-based morphometry (VBM). Results: Cross-sectional analyses revealed an association between depressive symptoms and gray matter loss in the left temporal lobe. Prospective analysis showed that gray matter losses in the right middle cingulate and middle frontal gyrus at baseline predicted increasing depressive symptoms during follow-up. Increase in depressive symptoms was related to a concomitant increase in atrophy in the left thalamus and right globus pallidus. Discussion: Our results fit well into the concept of a disturbed cortico–striatal–pallido–thalamic loop in depression. In this framework, progressive gray matter loss in limbic basal ganglia structures including globus pallidus and thalamus may lead to depression-typical deficits in hedonic motivation, whereas atrophy of the prefrontal cortex may contribute to maladaptive coping strategies, promoting an unfavorable development of depressive symptoms.
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Affiliation(s)
- Heiner Stuke
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin Berlin, Germany
| | - Katrin Hanken
- Department of Psychology, University of OldenburgOldenburg, Germany; Department of Neurology, Klinikum Bremen-OstBremen, Germany
| | - Jochen Hirsch
- Fraunhofer MEVIS Institute for Medical Image Computing Bremen, Germany
| | - Jan Klein
- Fraunhofer MEVIS Institute for Medical Image Computing Bremen, Germany
| | - Fabian Wittig
- Department of Psychology, University of OldenburgOldenburg, Germany; Fraunhofer MEVIS Institute for Medical Image ComputingBremen, Germany
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Ost Bremen, Germany
| | - Helmut Hildebrandt
- Department of Psychology, University of OldenburgOldenburg, Germany; Department of Neurology, Klinikum Bremen-OstBremen, Germany
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Sander C, Eling P, Hanken K, Klein J, Kastrup A, Hildebrandt H. The Impact of MS-Related Cognitive Fatigue on Future Brain Parenchymal Loss and Relapse: A 17-Month Follow-up Study. Front Neurol 2016; 7:155. [PMID: 27708613 PMCID: PMC5030297 DOI: 10.3389/fneur.2016.00155] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/06/2016] [Indexed: 11/13/2022] Open
Abstract
Background Fatigue is a disabling syndrome in multiple sclerosis (MS), which may be associated with inflammation and faster disease progression. Objective To analyze the significance of cognitive fatigue for subsequent disease progression. Method We followed 46 MS patients and 14 healthy controls in a study over 17 months. At the beginning (t1) and at the end (t2) of the study participants scored their fatigue, performed the Multiple Sclerosis Functional Composite and received MRI scanning, encompassing MPR T1, FLAIR, and DTI sequences. At t1, MS patients were divided into those with and those without cognitive fatigue (cut-off score for moderate cognitive fatigue of the Fatigue Scale for Motor and Cognition). We calculated ANCOVAs for repeated measurement to analyze the relevance of cognitive fatigue status for the number of relapses and for MRI parameters. Results At t1, but not at t2, patients with cognitive fatigue showed increased axial and radial diffusivity of corpus callosum fibers. At t2, these patients showed significantly more loss of brain parenchyma and greater enlargement of lateral ventricles. Moreover, they developed more relapses, but there was no difference in lesion load or in performance deterioration. Additional analyses showed that only cognitive fatigue but not a more general score for fatigue (Fatigue Severity Scale) had an impact on the worsening of the disease status. Conclusion Patients with cognitive fatigue may develop more brain atrophy and relapses during the next 17 months than patients without cognitive fatigue. Hence, experiencing cognitive fatigue might indicate more aggressive inflammatory processes and subsequent neurodegeneration.
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Affiliation(s)
- Carina Sander
- Department of Psychology, University of Oldenburg, Oldenburg, Germany; Rehazentrum Wilhelmshaven, Wilhelmshaven, Germany
| | - Paul Eling
- Donders Institute for Brain, Cognition and Behaviour, Radboud University , Nijmegen , Netherlands
| | - Katrin Hanken
- Department of Psychology, University of Oldenburg, Oldenburg, Germany; Department of Neurology, Klinikum Bremen-Ost, Bremen, Germany
| | - Jan Klein
- Fraunhofer MEVIS Institute for Medical Image Computing , Bremen , Germany
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Ost , Bremen , Germany
| | - Helmut Hildebrandt
- Department of Psychology, University of Oldenburg, Oldenburg, Germany; Department of Neurology, Klinikum Bremen-Ost, Bremen, Germany
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Spessotto CV, Cavalli H, Eboni ACB, Machado RB, Mousquer AM, Palazzo LB, Finkelsztejn A, Goncalves MVM, Sato HK, Siquineli F, Fragoso YD. Patients’ satisfaction with and views about treatment with disease-modifying drugs in multiple sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:617-20. [DOI: 10.1590/0004-282x20160091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/08/2016] [Indexed: 11/22/2022]
Abstract
ABSTRACT Objective The treatment of multiple sclerosis (MS) with disease-modifying-drugs (DMDs) is evolving and new drugs are reaching the market. Efficacy and safety aspects of the drugs are crucial, but the patients’ satisfaction with the treatment must be taken into consideration. Methods Individual interview with patients with MS regarding their satisfaction and points of view on the treatment with DMDs. Results One hundred and twenty eight patients attending specialized MS Units in five different cities were interviewed. Over 80% of patients were very satisfied with the drugs in use regarding convenience and perceived benefits. The only aspect scoring lesser values was tolerability. Conclusion Parameters for improving treatment in MS must include efficacy, safety, and patient satisfaction with the given DMD.
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Abstract
CONCEPT Fatigue is a major concern for patients with multiple sclerosis (MS). A clear definition of MS-related fatigue is a prerequisite for appropriate instruments for fatigue assessment. In turn, accurate assessment of fatigue in MS will enhance exploration of plausible mechanisms underlying this common and distressing symptom. Content/Objectives: To provide an integrative review of the current literature on theoretical models used to study fatigue in MS, instruments used to assess fatigue and other factors that impact fatigue during the various phases of MS. DATA SOURCES PUBMED, OVID, Ovid Health Star, Ovid MEDINE, CINAHL, Health and Psychosocial Instruments (HaPI), and PsycINFO. Seventeen articles fit the inclusion criteria and were included in the review. RESULTS Definitions of MS-related fatigue are reviewed. Several studies found a link with neurotransmitter dysfunction, circadian rhythm, and the timing of fatigue. Central fatigue in MS is associated with neurotransmitters disruptions as well as circadian rhythm disorders, but the evidence is not strong. Perceptions of fatigue or fatigability may arise as either a primary or secondary manifestation of disease. Based on findings from the literature review, a theoretical model of fatigue in MS is proposed. CONCLUSION Future research on MS-related fatigue may consider a longitudinal design with a carefully selected self-report instrument to advance understanding of the underlying pathological mechanisms.
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Affiliation(s)
- Pamela Newland
- Office of Nursing Research, Goldfarb School of Nursing at Barnes Jewish College, St. Louis, MO, USA,Correspondence to: Pamela Newland, Goldfarb School of Nursing at Barnes Jewish College, Office of Nursing Research, 4483 Duncan Avenue, St. Louis, USA, MO 63110.
| | - Angela Starkweather
- Center for Advancement of Managing Pain, University of Connecticut School of Nursing, Storrs, CT, USA
| | - Matthew Sorenson
- DePaul University School of Nursing, Chicago, IL, USA,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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17
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McNicholas N, McGuigan C. A useful annual review of cognition in relapsing MS is beyond most neurologists – YES. Mult Scler 2016; 22:726-8. [DOI: 10.1177/1352458516639385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Nuala McNicholas
- Department of Neurology, St. Vincent’s University Hospital, Dublin, Ireland/School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Christopher McGuigan
- Department of Neurology, St. Vincent’s University Hospital, Dublin, Ireland/School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
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18
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Hanken K, Eling P, Klein J, Klaene E, Hildebrandt H. Different cortical underpinnings for fatigue and depression in MS? Mult Scler Relat Disord 2016; 6:81-86. [PMID: 27063629 DOI: 10.1016/j.msard.2016.02.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 02/01/2016] [Accepted: 02/06/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Fatigue is a common complaint in MS patients but its origins are still not fully understood. A major difficulty is that fatigue seems strongly correlated with depression. METHODS 95 MS patients and 15 healthy control subjects were included. The Fatigue Severity Scale and Beck's Depression Inventory were used to assess symptom-severity and to determine group membership for five groups: MS patients with and without fatigue, and with or without depressive mood, healthy controls. Participants were scanned using high-resolution structural 3D T1-weighted imaging. Cortical thickness for 84 areas was calculated using the NeuroQLab software in combination with the atlas for the Automated Anatomical Labeling software. A stepwise forward regression analysis was performed to predict group membership of the MS patients by thickness of cortical areas. We also performed a series of post-hoc ANOVAs to explore differences between the four patients groups and the healthy controls. RESULTS About 20% of the patients suffered only from fatigue or only from depressive mood. Regression analysis explained 17.3% of the variance and thickness of the right inferior parietal cortex, middle temporal pole and parahippocampus contributed significantly to the model. Patients with pure fatigue showed a specific decrease in cortical thickness in the inferior parietal lobe, patients with both depressive mood and fatigue in the right middle temporal pole. Additional ANOVAs revealed cortical thinning in the right middle cingulate cortex in the group with pure fatigue as well as the groups with depression. CONCLUSION Fatigue and depression can be dissociated in larger MS-patient groups using questionnaires and cortical thickness measures, but the cortical thickness measures only explain a small portion of variance of these neuropsychiatric symptoms.
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Affiliation(s)
- Katrin Hanken
- University of Oldenburg, Department of Psychology, 26111 Oldenburg, Germany; Klinikum Bremen-Ost, Department of Neurology, Züricher Str. 40, 28325 Bremen, Germany
| | - Paul Eling
- Radboud University Nijmegen, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Jan Klein
- Fraunhofer MEVIS Institute for Medical Image Computing, Universitätsallee 29, 28359 Bremen, Germany
| | - Esther Klaene
- Neurological Rehabilitation Unit Oldenburg, Brandenburger Straße 31, 26133 Oldenburg, Germany
| | - Helmut Hildebrandt
- University of Oldenburg, Department of Psychology, 26111 Oldenburg, Germany; Klinikum Bremen-Ost, Department of Neurology, Züricher Str. 40, 28325 Bremen, Germany.
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A Preliminary Comparative Assessment of the Role of CD8+ T Cells in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis and Multiple Sclerosis. J Immunol Res 2016; 2016:9064529. [PMID: 26881265 PMCID: PMC4736227 DOI: 10.1155/2016/9064529] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/07/2015] [Accepted: 12/15/2015] [Indexed: 12/18/2022] Open
Abstract
Background. CD8+ T cells have putative roles in the regulation of adaptive immune responses during infection. The purpose of this paper is to compare the status of CD8+ T cells in Multiple Sclerosis (MS) and Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). Methods. This preliminary investigation comprised 23 CFS/ME patients, 11 untreated MS patients, and 30 nonfatigued controls. Whole blood samples were collected from participants, stained with monoclonal antibodies, and analysed on the flow cytometer. Using the following CD markers, CD27 and CD45RA (CD45 exon isoform 4), CD8+ T cells were divided into naïve, central memory (CM), effector memory CD45RA− (EM), and effector memory CD45RA+ (EMRA) cells. Results. Surface expressions of BTLA, CD127, and CD49/CD29 were increased on subsets of CD8+ T cells from MS patients. In the CFS/ME patients CD127 was significantly decreased on all subsets of CD8+ T cells in comparison to the nonfatigued controls. PSGL-1 was significantly reduced in the CFS/ME patients in comparison to the nonfatigued controls. Conclusions. The results suggest significant deficits in the expression of receptors and adhesion molecules on subsets of CD8+ T cells in both MS and CFS/ME patients. These deficits reported may contribute to the pathogenesis of these diseases. However, larger sample size is warranted to confirm and support these encouraging preliminary findings.
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20
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Hanken K, Eling P, Hildebrandt H. Is there a cognitive signature for MS-related fatigue? Response to Feinstein. Mult Scler 2015; 22:575-6. [PMID: 26227002 DOI: 10.1177/1352458515595133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Katrin Hanken
- Department of Neurology, Klinikum Bremen-Ost, Germany Department of Psychology, University of Oldenburg, Germany
| | - Paul Eling
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, the Netherlands
| | - Helmut Hildebrandt
- Department of Neurology, Klinikum Bremen-Ost, Germany Department of Psychology, University of Oldenburg, Germany
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Bilgi E, Özdemir HH, Bingol A, Bulut S. Evaluation of the effects of group psychotherapy on cognitive function in patients with multiple sclerosis with cognitive dysfunction and depression. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:90-5. [DOI: 10.1590/0004-282x20140144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective This study will evaluate how decreasing depression severity via group psychotherapy affects the cognitive function of patients with multiple sclerosis (MS) who are also diagnosed with depression and cognitive dysfunction. Method MS patients completed the Brief Repeatable Battery of Neuropsychological Tests and Beck Depression Inventory (BDI). The group members diagnosed with depression and cognitive dysfunction underwent group psychotherapy for 3 months. Upon completion of psychotherapy, both tests were readministered. Results Depression and cognitive dysfunction were comorbid in 15 (13.9%) of patients. Although improvement was detected at the end of the 3-month group psychotherapy intervention, it was limited to the BDI and the Paced Auditory Test. Conclusion Group psychotherapy might decrease cognitive impairment in MS patients.
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Affiliation(s)
- Emine Bilgi
- Diskapi Yildirim Beyazit Training and Research Hospital, Turkey
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22
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Kuppuswamy A, Clark EV, Turner IF, Rothwell JC, Ward NS. Post-stroke fatigue: a deficit in corticomotor excitability? ACTA ACUST UNITED AC 2014; 138:136-48. [PMID: 25367024 DOI: 10.1093/brain/awu306] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The pathophysiology of post-stroke fatigue is poorly understood although it is thought to be a consequence of central nervous system pathophysiology. In this study we investigate the relationship between corticomotor excitability and self-reported non-exercise related fatigue in chronic stroke population. Seventy first-time non-depressed stroke survivors (60.36 ± 12.4 years, 20 females, 56.81 ± 63 months post-stroke) with minimal motor and cognitive impairment were included in the cross-sectional observational study. Fatigue was measured using two validated questionnaires: Fatigue Severity Scale 7 and Neurological Fatigue Index - Stroke. Perception of effort was measured using a 0-10 numerical rating scale in an isometric biceps hold-task and was used as a secondary measure of fatigue. Neurophysiological measures of corticomotor excitability were performed using transcranial magnetic stimulation. Corticospinal excitability was quantified using resting and active motor thresholds and stimulus-response curves of the first dorsal interosseous muscle. Intracortical M1 excitability was measured using paired pulse paradigms: short and long interval intracortical inhibition in the same hand muscle as above. Excitability of cortical and subcortical inputs that drive M1 output was measured in the biceps muscle using a modified twitch interpolation technique to provide an index of central activation failure. Stepwise regression was performed to determine the explanatory variables that significantly accounted for variance in the fatigue and perception scores. Resting motor threshold (R = 0.384; 95% confidence interval = 0.071; P = 0.036) accounted for 14.7% (R(2)) of the variation in Fatigue Severity Scale 7. Central activation failure (R = 0.416; 95% confidence interval = -1.618; P = 0.003) accounted for 17.3% (R(2)) of the variation in perceived effort score. Thus chronic stroke survivors with high fatigue exhibit high motor thresholds and those who perceive high effort have low excitability of inputs that drive motor cortex output. We suggest that low excitability of both corticospinal output and its facilitatory synaptic inputs from cortical and sub-cortical sites contribute to high levels of fatigue after stroke.
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Affiliation(s)
| | - Ella V Clark
- Sobell Department of Motor Neuroscience, Institute of Neurology, UCL, London, UK
| | - Isobel F Turner
- Sobell Department of Motor Neuroscience, Institute of Neurology, UCL, London, UK
| | - John C Rothwell
- Sobell Department of Motor Neuroscience, Institute of Neurology, UCL, London, UK
| | - Nick S Ward
- Sobell Department of Motor Neuroscience, Institute of Neurology, UCL, London, UK
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