Fatigue in multiple sclerosis: mechanisms, evaluation, and treatment

Establishment of regression-based isometric strength reference values for the upper limb in persons with multiple sclerosis

BACKGROUND

Muscle weakness is common and significantly affects persons with multiple sclerosis (PwMS), with dysfunction in upper limb (UL) muscle groups occurring in approximately 60% of PwMS.

OBJECTIVE

To develop gender-specific regression-based prediction equations, with 95% confidence intervals for maximal bilateral UL isometric strength (shoulder abduction and adduction, wrist flexion and extension) and hand grip strength in PwMS.

DESIGN

Cross-sectional study.

SETTING

Comprehensive MS center.

PARTICIPANTS

256 PwMS.

INTERVENTIONS

Not Applicable.

MAIN OUTCOME MEASURES

Shoulder abduction and adduction and wrist flexion and extension isometric strength (Biodex System 4 Pro Dynamometer) and hand grip strength (Jamar handheld dynamometer) were measured. Disease characteristics (disability and disease duration) and demographics (age, height, and weight) were collected. Regression-based predictive equations were generated for the UL muscle groups for each gender and limb, using age, height, weight, disability, and disease duration as covariates. Variables were compared between genders using the Mann-Whitney U test. Maximal voluntary contraction (MVC) reference values (mean ± SD) were reported based on age (<30, 30-39, 40-49, 50-59, 60-69 years) and disability (mild, moderate, severe ambulant, and severe nonambulant) for each gender and limb.

RESULTS

Regression-based equations were developed for both genders' strongest and weakest limb, accounting for age, height, weight, disability, and disease duration. MVC was higher in men than women (p < .001) in all muscle groups. Overall, MVC was significantly related to age in 14, height in 5, weight in 6, disability in 14, and disease duration in none of the 20 models.

CONCLUSION

This is the first study to provide regression-based prediction equations for strongest and weakest MVC of UL muscle groups and demonstrated an inverse relationship between MVC with disability and age. Regression-based reference strength values can help clinicians understand muscular strength along a spectrum of PwMS and can aid in goal setting and education for realistic outcomes.

The use of modafinil for the treatment of fatigue in multiple sclerosis: A systematic review and meta-analysis of controlled clinical trials

INTRODUCTION

Multiple sclerosis (MS) is a debilitating neurological condition affecting nearly one million people across the United States. Among the most prominent symptoms of the condition are excessive fatigue and daytime sleepiness. Numerous clinical trials have investigated the efficacy of modafinil in addressing fatigue among these patients.

OBJECTIVE

The objective of the present study is to assess the safety and efficacy of modafinil for the treatment of fatigue in MS.

METHODOLOGY

An electronic search of PUBMED, ScienceDirect, and Cochrane Central was conducted for articles published from inception to December 2023 using search terms such as "modafinil," "fatigue," and "MS."

RESULTS

Seven studies were included in our analysis. Modafinil leads to a meaningful reduction in fatigue when compared with placebo, as measured by Modified Fatigue Impact Scale [mean difference (MD) = -4.42 [-8.01, -.84]; I2 = 45%; p = .02] and Epworth Sleepiness Scale [MD = -.87 [-1.64, -.10]; I2 = 0%; p = .03]. Modafinil also demonstrated a greater risk of precipitating adverse events (e.g., insomnia, gastrointestinal symptoms) when compared with placebo [RR = 1.30 [1.03, 1.66]; I2 = 0%; p = .03]. In quality-of-life assessments, modafinil was associated with overall improvement in well-being [standardized mean difference = .18 [.01, .35]; I2 = 56%; p = .04].

CONCLUSION

The data indicates that modafinil confers a therapeutic benefit when treating fatigue in patients with MS and improves overall quality of life; however, there is a risk of precipitating adverse events. Ultimately, higher quality of evidence may be required to better inform clinical management.

Clinical outcome analysis of patients with multiple sclerosis - Analysis from the UK Medical Cannabis Registry

INTRODUCTION

Whilst disease-modifying therapies are the cornerstone for treatment of multiple sclerosis (MS), there is a need to develop novel therapeutics for the symptomatic sequalae of the disease. Cannabis-based medicinal products (CBMPs) have been suggested as a potential therapy for the associated pain, spasticity, and mental health disorders. However, there is a paucity of clinical evidence on CBMPs in MS. The aim of this study is to assess changes in MS-specific and general health-related quality of life (HRQoL) outcomes alongside adverse event incidence in patients prescribed CBMPs for MS from the UK Medical Cannabis Registry (UKMCR).

METHOD

Patients prescribed CBMPs for MS symptoms for longer than one month were identified from the UKMCR. The primary outcomes were changes from baseline in MS Quality of Life-54 (MSQoL-54), Generalised Anxiety Disorder-7 (GAD-7), Single-Item Sleep Quality Scale (SQS), and EQ-5D-5L scales at one month, three months and six months. p < 0.050 was defined as statistically significant.

RESULTS

141 patients met the inclusion criteria for the study. There was an improvement in the following subscales of the MSQoL-54 at 6 months: change in health scale, cognitive function, mental health composition, physical health, role limitations due to physical limitation and due to emotional problems, as well as social and sexual function (p < 0.050). There were also improvements in the EQ-5D-5L index value, GAD-7 and SQS (p < 0.050). 146 (103.55 %) adverse events were reported in total. Most were considered mild (n = 47; 33.33 %) and moderate (n = 72; 51.06 %).

CONCLUSIONS

This preliminary analysis demonstrates a possible association with improved general health-related quality of life in those prescribed CBMPs for MS. Moreover, the results suggest that CBMPs are well-tolerated in the first 6 months of treatment. However, this must be interpreted with caution considering the limitations of the observational study design.

Determinants of self-perceived quality of life in mildly disabled multiple sclerosis patients: a cross-sectional study

INTRODUCTION

While the determinants influencing self-perceived health-related quality of life (spHRQoL) in persons with multiple sclerosis (pwMS) and severe physical impairment have been well investigated, their impact on pwMS with mild disability is poorly addressed. We aimed to investigate possible drivers of spHRQoL among Sardinian pwMS with an EDSS lower than 2.5.

METHODS

A sample of 87 fully ambulatory (EDSS < 2.5) pwMS were included after screening for major cognitive impairment. spHRQoL was measured with the Italian version of 36-Item Short Form Health Survey (SF-36). The Physical Component Summary (PCS) and Mental Component Summary (MCS) were used as dependent variables for univariate analysis with Cognitive Behavioral Assessment (CBA) and specific individual factors as independent variables. Subsequent multivariate general linear models (GLMs) for PCS and MCS respectively were run after stepwise regression. Normative data referring to Italian population were used for comparison.

RESULTS

As compared to normative data, no statistically significant difference was found for PCS, while MCS was reduced. Multivariate GLMs showed a significant association between lower PCS scores and presence of psychosomatic symptoms, older age and fatigue (p < 0.05). Furthermore, a significant association was shown between lower MCS scores and presence of anxiety (p < 0.001).

CONCLUSION

Mood, presence of psychosomatic symptoms, fatigue and age can have a relevant impact on spHRQoL in people with mildly disabling MS and should be considered in the management of such individuals.

Can Laparoscopic Surgery Reduce Fatigue in Women with Endometriosis?-A Pilot Study

Background: Fatigue is mentioned as one of the most significant symptoms of endometriosis. The impact of laparoscopic endometriosis surgeries on fatigue remains unknown. The aim of this study was to investigate, for the first time, the effect of laparoscopic surgery in endometriosis patients, with the complete removal of endometriotic lesions, on the severity of fatigue. Methods: This is a single-center prospective pilot study including 58 participants. Participants were recruited at the Tertiary Endometriosis Referral Center of the Medical University of Vienna between February 2020 and November 2021. Thirty patients with histologically proven endometriosis were compared to a control group of 28 patients who underwent a laparoscopy for benign gynecologic conditions other than endometriosis. All participants were interviewed using the Fatigue Severity Scale before their surgery and 6 months afterward. Relationships between variables were established using regression analysis and associations were quantified as odds ratios. Results: Fatigue was significantly more severe preoperatively in patients with endometriosis when compared to controls ((odds ratio (OR): 1.82; 95% confidence interval (CI): 1.24-2.67, p < 0.01). Six months postoperatively, the fatigue severity score of endometriosis patients decreased significantly (p < 0.01). In multivariate analysis, fatigue was significantly associated with endometriosis (OR: 4.50, CI: 1.14-17.8, p < 0.05), when adjusted for abdominal pain and menstrual bleeding. Fatigue in patients with endometriosis was not associated with disease stage or the presence of deep endometriosis. Conclusions: Fatigue is a frequent and bothersome symptom in patients with endometriosis. Within our study, we demonstrated for the first time that fatigue responds to surgical treatment. The management of fatigue is crucial to improving patients' quality of life.

Inverse association between arterial stiffness and perceived fatigue independent of disability status and BMI in multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is an immune-mediated, neurodegenerative disease of the central nervous system. Fatigue represents one of the most prevalent and limiting symptoms of MS, and is associated with vascular dysfunction, notably increased arterial stiffness.

OBJECTIVE

This study examined the relationship between arterial stiffness and perceived fatigue in persons with MS.

METHODS

The sample of 52 persons with MS (71.2% Female; Age: 46.7 ± 12.3 yrs.) completed arterial stiffness and fatigue assessments as baseline for an exercise training intervention. Applanation tonometry measured arterial stiffness, pulsatility and waveform characteristics, and yielded the following outcomes: carotid-femoral pulse wave velocity (cfPWV), carotid pulse-pressure (cPP), and aortic augmentation pressure (AP). Perceived fatigue was measured using the Fatigue Severity Scale (FSS).

RESULTS

The mean (SD) scores for cfPWV, cPP, and AP were 7.0 ± 1.8 m/s, 35.7 ± 8.8 mmHg, 8.2 ± 6.2 mmHg, respectively. The mean (SD) FSS score was 4.6 ± 1.4 and indicated elevated fatigue. There were statistically significant (p < .05) inverse correlations between cfPWV (r = -.32), cPP (r = -.37) and AP (r = -.32) with FSS scores, and the correlations remained significant even after controlling for disability, body mass index, age, and sex.

CONCLUSION

Our results indicate a consistent pattern of inverse relationships between arterial stiffness, pulsatility, and waveforms with fatigue independent of disability, body mass index, age, and sex in MS. This could be explained by lower sympathetic activation linking higher arterial stiffness, pulsatility and augmentation pressure with lower fatigue in persons with MS.

The measurement of fatigability severity in individuals with multiple sclerosis and healthy controls

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.

The Impact of COVID-19 on Fatigue in Multiple Sclerosis

BACKGROUND

Although the COVID-19 quarantine required everyone to make lifestyle changes, it may have had especially profound implications for individuals who experience multiple sclerosis (MS)-related fatigue. Individuals with MS who suffer from fatigue are at risk of worsening symptoms and already predisposed to inactivity and social isolation. The objective of this study was to examine the impact of the COVID-19 national quarantine and related restrictions on mental, emotional, and physical fatigue in persons with MS in the United States.

METHODS

We conducted a survey open to all adults (>18 years) with MS within the United States. The survey gathered demographic information and asked how the COVID-19 pandemic impacted their physical, mental, and emotional fatigue.

RESULTS

The survey was completed by 600 individuals, 478 with relapsing MS and 122 with progressive MS. There was a significant 2-way interaction of time by fatigue type; both physical and emotional fatigue significantly increased during the pandemic (P <.01) and remained significantly higher after the pandemic than prior to the pandemic (P <.01). Mental fatigue increased significantly during the pandemic (P <.01) and although it remained higher, on average, after the pandemic, it was not significantly different from the level before the pandemic.

CONCLUSIONS

Individuals with MS experienced increases in physical, mental, and emotional fatigue over the course of the COVID-19 quarantine. Even after the lifting of quarantine restrictions, these levels have not returned to baseline. To adequately address fatigue, it is critical that health care professionals inquire about all types of fatigue in persons with MS.

The presence of attentional and interpretation biases in patients with severe MS-related fatigue

OBJECTIVE

Severe fatigue is a prevalent and disabling symptom in multiple sclerosis (MS). This study tested if a fatigue- and physical activity-related attentional bias (AB) and a somatic interpretation bias (IB) are present in severely fatigued patients with MS. Biases were compared to healthy controls and patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).

METHOD

Severely fatigued patients with MS or ME/CFS and healthy controls completed a Visual Probe Task (VPT) assessing fatigue- and physical activity-related AB and an IB task that assesses the tendency to interpret ambiguous information in either a somatically threatening way or in a more neutral manner. The VPT was completed by 38 MS patients, 44 ME/CFS patients, and 46 healthy controls; the IB task was completed by 156, 40 and 46 participants respectively.

RESULTS

ANOVA showed no statistically significant group differences in a fatigue-related AB or physical activity-related AB (omnibus test of interaction between topic × condition: F2,125 = 1.87; p = .159). Both patient groups showed a tendency to interpret ambiguous information in a somatically threatening way compared to healthy controls (F1,2 = 27.61, p < .001). This IB was significantly stronger in MS patients compared to ME/CFS patients. IB was significantly correlated with cognitive responses to symptoms in MS patients.

CONCLUSION

MS patients tend to interpret ambiguous information in a somatically threatening way. This may feed into unhelpful ways of dealing with symptoms, possibly contributing to the perpetuation of severe fatigue in MS.

Stressful life events and depression and fatigue in people with multiple sclerosis: a cross-sectional analysis of an international cohort

BACKGROUND

Relationships between stressful life events (SLEs) and health outcomes in people living with multiple sclerosis (plwMS), beyond relapse, are not well-established. We examined associations between SLEs and fatigue and symptoms of depression in plwMS.

METHODS

948 participants were queried whether they had experienced any of the 16 SLEs (Holmes-Rahe Social Readjustment Rating Scale) in the preceding 12 months. SLEs were summated to estimate SLE number and SLE load (weighted for the degree of associated stress). Cross-sectional associations between SLE (number, load and individual) and fatigue, and depressive symptoms were examined using log-binomial or log-multinomial regression adjusted for age, sex, relapse symptoms, education, MS type at baseline, disability, fatigue, comorbidity, depression, and antidepressant/antifatigue medications, as appropriate. Sub-analyses restricted to SLEs with a negative emotional impact were performed.

RESULTS

Median SLE number and load were 2 (IQR 1-2) and 57 (IQR 28-97), respectively. SLE number and load were not associated with a higher prevalence of fatigue, or depressive symptoms, even when restricting analyses to SLEs with a perceived negative emotional impact. A new relationship or family member with a negative impact was associated with a threefold and 2.5-fold higher prevalence of depressive symptoms, respectively. Serious illness was associated with a 28% higher prevalence of depressive symptoms.

CONCLUSION

Psychological support for SLEs, and/or intervention targeted to SLE appraisal, may be beneficial in mitigating the adverse effects of SLEs with a perceived negative emotional impact on depressive symptoms in plwMS. Potential associations between serious illness and increased prevalence of depressive symptoms may warrant further investigation.

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

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

Meaningful digital biomarkers derived from wearable sensors to predict daily fatigue in multiple sclerosis patients and healthy controls

Fatigue is the most common symptom among multiple sclerosis (MS) patients and severely affects the quality of life. We investigate how perceived fatigue can be predicted using biomarkers collected from an arm-worn wearable sensor for MS patients (n = 51) and a healthy control group (n = 23) at an unprecedented time resolution of more than five times per day. On average, during our two-week study, participants reported their level of fatigue 51 times totaling more than 3,700 data points. Using interpretable generalized additive models, we find that increased physical activity, heart rate, sympathetic activity, and parasympathetic activity while awake and asleep relate to perceived fatigue throughout the day-partly affected by dysfunction of the ANS. We believe our analysis opens up new research opportunities for fine-grained modeling of perceived fatigue based on passively collected physiological signals using wearables-for MS patients and healthy controls alike.

Insomnia, Fatigue, Bladder Disorders and Mood Disorders among Polish Patients with Multiple Sclerosis: Cross-Sectional Study

BACKGROUND

To investigate the prevalence of sleep disorders in patients with multiple sclerosis (PwMS) in comparison to healthy controls (HCs), we aim to explore the correlation between sleep disorders and fatigue, bladder dysfunction, mood disorders in PwMS.

METHODS

This study involved 175 PwMS and 115 HCs. We conducted a self-administered survey using questionnaires (the authors' questionnaire, the Athens Insomnia Scale (AIS), the Epworth Sleepiness Scale (ESS), the Modified Fatigue Impact Scale (MFIS), the Fatigue Severity Scale (FSS), the Hospital Anxiety and Depression Scale (HADS), and the Numerical Rating Scale (NRS). The neurological disability was determined using Expanded Disability Status Scale. Logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

According to AIS, insomnia was found in 20.6% of PwMS compared to 9.6% of HCs (p < 0.001). Comparing female and male PwMS, we observed that insomnia was more prevalent among female PwMS (25.95% vs. 4.55%, respectively, p < 0.05). Excessive daytime sleepiness was more prevalent in female PwMS (p < 0.05). Female PwMS were more fatigue based on the FSS and the MFIS (p < 0.05). Bladder disorders were observed in 39.43% of PwMS and were significantly linked to MS (p < 0.001). Sleep disturbances were associated with anxiety disorders (OR = 0.22, 95% CI 0.12-0.32 p < 0.001), bladder dysfunction (OR = 0.52 95% CI 0.16-0.87 p < 0.05), and female gender (OR = 0.49, 95% CI 0.037-0.94 p < 0.05).

CONCLUSIONS

Insomnia is prevalent among PwMS. Our study revealed independent predictors of sleep disturbances among PwMS: female gender, bladder disorders, and anxiety.

Fatigue may improve equally after balance and endurance training in multiple sclerosis: a randomised, crossover clinical trial

Introduction

Fatigue and poor balance are frequent and severe problems in multiple sclerosis (MS) that may interact. Endurance training is known to be effective on fatigue. This study aims to test if balance training is more effective against MS fatigue.

Methods

A randomised crossover trial was run, recruiting 31 MS people (21 women; median age: 46 years, range: 30-64; median EDSS: 4, range: 2.5-5). Participants received balance and endurance training alternately (15 one-to-one sessions, 5 days/week) and were assessed before (T0), after (T1), and 30 days after treatment ended (T2). The Modified Fatigue Impact Scale (MFIS) with scores linearised through Rasch analysis was the primary outcome (the lower the measure, the better the condition, i.e., the lower the fatigue symptoms). The Equiscale balance scale and posturography (EquiTest) were used to assess balance. Linear mixed-effects models with ANOVA were used for significance testing.

Results

Thirteen participants had no carryover effect and were included in the primary analysis. Fatigue significantly changed across the three time points (F2,58 = 16.0; p < 0.001), but no difference across treatments was found. Altogether, both treatments significantly improved the MFIS measure at T1 (95%CI: -1.24 logits; mean: -1.67 to -0.81 logits) and T2 (95%CI: -1.04; mean: -1.49 to -0.60) compared to T0 (95%CI: -0.51; mean: -0.95 to -0.08; p ≤ 0.001). Equiscale and posturography highlighted balance improvement after balance training but not after endurance training.

Conclusion

Balance and endurance training could similarly reduce fatigue in MS patients in the short term. However, only balance training also improved balance in MS.

Characterization of an Italian population with neurological disorders in a rehabilitation setting using ClinFIT

OBJECTIVE

To examine the functioning profile of people with neurological disorders who access rehabilitation services through ClinFIT Generic-30.

METHODS

The functioning profile of people with neurological disorders accessing rehabilitation services was examined using the ClinFIT Generic-30, and the results compared with existing core set (neurological health conditions acute and post-acute,stroke, Multiple Sclerosis, Traumatic Brain Injury,Spinal Cord Injury).

RESULTS

Data for 364 people were analysed. The 10 most commonly impaired ICF categories included 3 for Body Functions (exercise tolerance functions (b455), mobility of joint functions (b710), and muscle power functions (b730)) and 7 for Activities and Participation (carrying out daily routine (d230), handling stress and other psychological demands (d240), changing basic body position (d410), maintaining a body position (d415), transferring oneself (d420), walking (d450), and moving around (d455)), while the ICF categories that were severely impaired (ICF qualifiers 3 and 4) in more than 30% of the study cohort were: muscle power functions (b730), carrying out daily routine (d230), walking (d450), moving around (d455), doing housework (d640), and assisting others (d660).

DISCUSSION

The current study data suggests that  ClinFIT Generic-30 appears to effectively identify impairments and/or restrictions, as perceived by individuals affected by selected health conditions.

CONCLUSION

ClinFIT Generic-30 is a tool that can be used to characterize functioning profile in people with different neurological disorders and to collect important information not addressed by the disease-specific core sets (neurological health conditions acute and post-acute,stroke, Multiple Sclerosis, Traumatic Brain Injury,Spinal Cord Injury).

Autoimmune demyelination alters hypothalamic transcriptome and endocrine function

The hypothalamus is a brain structure that is deputed to maintain organism homeostasis by regulating autonomic function and hormonal production as part of the neuroendocrine system. Dysfunction in hypothalamic activity results in behavioral alterations, depression, metabolic syndromes, fatigue, and infertility. Remarkably, many of these symptoms are associated with multiple sclerosis (MS), a chronic autoimmune disorder of the central nervous system (CNS) characterized by focal demyelination, immune cell infiltration into the brain parenchyma, and neurodegeneration. Furthermore, altered hormonal levels have been documented in MS patients, suggesting the putative involvement of hypothalamic deficits in MS clinical manifestations. Yet, a systematic analysis of hypothalamic function in response to neuroinflammatory stress is still lacking. To fill this gap, here we performed a longitudinal profiling of the hypothalamic transcriptome upon experimental autoimmune encephalomyelitis (EAE)-a murine disease model recapitulating key MS phenotypes at both histopathological and molecular levels. We show that changes in gene expression connected with an anti-inflammatory response start already at pre-onset and persist along EAE progression. Altered levels of hypothalamic neuropeptides were also detected, which possibly underlie homeostatic responses to stress and aberrant feeding behaviors. Last, a thorough investigation of the principal endocrine glands highlighted defects in the main steroidogenic pathways upon disease. Collectively, our findings corroborate the central role of hypothalamic dysfunction in CNS autoimmunity.

Overview of the Current Pathophysiology of Fatigue in Multiple Sclerosis, Its Diagnosis and Treatment Options - Review Article

Fatigue is a common, debilitating and often underestimated symptom in patients with multiple sclerosis (MS). The exact pathophysiological mechanism of fatigue in MS is still unknown. However, there are many theories involving different immunological, metabolic and inflammatory mechanisms of fatigue. Owing to the subjective nature of this symptom, its diagnosis is still very limited and is still based only on diagnostic questionnaires. Although several therapeutic agents have been used in the past to try to influence fatigue in MS patients, no single effective approach for the treatment of fatigue has yet been found. This review article aims to provide the reader with information on the current theories on the origin and mechanism of fatigue in MS, as well as diagnostic procedures and, finally, current therapeutic strategies for the management of fatigue in MS patients.

Psychological factors and brain magnetic resonance imaging metrics associated with fatigue in persons with multiple sclerosis

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.

Comparing two relaxation procedures to ease fatigue in multiple sclerosis: a single-blind randomized controlled trial

BACKGROUND

Various relaxation procedures have been proposed to reduce fatigue in multiple sclerosis (MS). However, it is unknown, which type of relaxation has the largest effect on fatigue reduction and on autonomic nervous system (ANS) activity.

OBJECTIVE

We aimed to compare two biofeedback-supported relaxation exercises: a deep breathing (DB) exercise and progressive muscle relaxation (PMR), which may ameliorate MS fatigue and alter ANS activity.

METHODS

We performed a single-blind randomized clinical trial, introducing MS patients (n = 34) to the DB or PMR exercise. We first tested cardiovagal integrity, reflected by changes in heart rate variability (HRV) in response to DB. Participants then performed a fatigue-inducing vigilance task, followed by the DB or PMR. State fatigue was recorded consecutively at baseline, after the vigilance task, and after the relaxation exercise, along with HRV reflecting ANS activity.

RESULTS

Only patients assigned to the PMR group experienced a significant drop in fatigue, whereas both relaxation exercises changed ANS activity. MS patients showed the expected autonomic response during the cardiovagal reflex test. The vigilance task elevated short-term feelings of fatigue and significantly reduced HRV parameters of parasympathetic activity. Trait fatigue was negatively correlated with HRV during the second half of the vigilance task.

CONCLUSION

PMR alleviates short-term feelings of fatigue in persons with MS. The vigilance task in combination with HRV measurements may be helpful for evaluating relaxation procedures as a treatment of fatigue. Hereby, future studies should ensure longer and more frequent relaxation exercises and focus on patients with weak to moderate fatigue.

TRIAL REGISTRATION

Trial Registry: DRKS00024358.

The effect of disease modifying therapies on fatigue in multiple sclerosis

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Initial Cervical Spinal Cord Demyelinating Lesions are not Associated with Restless Legs Syndrome in Patients with Multiple Sclerosis

Purpose

This study aims to determine the prevalence and severity of restless legs syndrome (RLS) in patients with multiple sclerosis (MS) and its association with spinal cord lesions, fatigue, quality of life, and sleep disturbance.

Methods

We recruited 222 consecutive MS patients admitted to MS outpatient clinic. Beck's Depression Inventory (BDI), Fatigue Severity Scale (FSS), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and MS Quality of Life-54 (MSQoL-54) questionnaire scores of all patients were measured. Initial cervical spinal cord magnetic resonance imaging (MRI) of the patients at first clinical evaluation for diagnosis was reviewed for accompanying demyelinating lesions.

Results

RLS was diagnosed in 53 (23.87%) patients. RLS was associated with poor sleep, worse quality of life, increased fatigue, and depressive mood. The sleep quality index, FSS, and MSQoL-54 physical composite scores significantly correlated with RLS severity (P < 0.001, P = 0.001, P < 0.001, respectively). Of the 200 patients, 127 (63.5%) had spinal cord lesions. 22.83% of the patients with cervical spinal cord lesions had RLS comorbidity. We found no significant difference regarding spinal cord demyelinating lesions between RLS positives and negatives. (P = 0.77). In addition, having multiple spinal cord demyelinating lesions did not differ between the two groups (P = 0.84). Besides, the severity of RLS symptoms did not differ in patients who had a single cervical spinal lesion and those who had multiple lesions (P = 0.35).

Conclusion

We have demonstrated the negative impact of comorbid RLS on fatigue, sleep quality, mood, and quality of life in MS patients. However, initial spinal cord lesions did not correlate with RLS comorbidity. The severity of RLS symptoms is associated with poor sleep and physical health.

Sociodemographic and Clinical Determinants of Fatigue in Multiple Sclerosis

Fatigue is the most common and disabling symptom in patients with multiple sclerosis (PwMS), representing one of the main determinants of reduced quality of life among PwMS due to its interference with social activities and work capacity. This study aimed to identify the sociodemographic determinants of fatigue in a cohort of 150 PwMS and 100 healthy controls (HCs). Fatigue was assessed using one of the most suitable and appropriate tools for measuring the degree of fatigue: the Modified Fatigue Impact Scale (MFIS). By comparing the median scores for the MFIS, we observed that the PwMS group had significantly higher MFIS scores than the HCs (p = 0.0001). In PwMS, MFIS scores correlated positively with age, total number of relapses, total disease duration, disability status, and Beck Depression Inventory-II score and negatively with cognitive performance. Patients with relapsing-remitting MS had significantly lower fatigue levels than those with secondary progressive MS (p = 0.0010). Fatigue levels were significantly lower among male than female PwMS (p = 0.0120). Other determinant factors of fatigue in our study proved to be the marital and occupational status, as well as the presence of children, but in a linear multivariate regressions analysis with MFIS score as the dependent variable, the fatigue levels were influenced only by sex, occupational status, marital status, children status, and BDI-II test results. Considering the significant impact of fatigue on the quality of life of PwMS, clinicians must diagnose fatigue as early as possible, identify its modifiable determinants, and manage it effectively to increase their quality of life.

Management of multiple sclerosis fatigue in the digital age: from assessment to treatment

Fatigue is one of the most disabling symptoms of Multiple Sclerosis (MS), affecting more than 80% of patients over the disease course. Nevertheless, it has a multi-faceted and complex nature, making its diagnosis, evaluation, and treatment extremely challenging in clinical practice. In the last years, digital supporting tools have emerged to support the care of people with MS. These include not only smartphone or table-based apps, but also wearable devices or novel techniques such as virtual reality. Furthermore, an additional effective and cost-efficient tool for the therapeutic management of people with fatigue is becoming increasingly available. Virtual reality and e-Health are viable and modern tools to both assess and treat fatigue, with a variety of applications and adaptability to patient needs and disability levels. Most importantly, they can be employed in the patient's home setting and can not only bridge clinic visits but also be complementary to the monitoring and treatment means for those MS patients who live far away from healthcare structures. In this narrative review, we discuss the current knowledge and future perspectives in the digital management of fatigue in MS. These may also serve as sources for research of novel digital biomarkers in the identification of disease activity and progression.

Effect of effleurage massage therapy on sleep disturbance, fatigue, pain, and anxiety in patients with multiple sclerosis: A quasi-experimental study

BACKGROUND

Fatigue, pain, sleep disturbance, and anxiety are prevalent symptoms of multiple sclerosis (MS) and frequent complaints in MS patients, which reduce their quality of life. Many studies have shown that massage therapy improves MS patients' symptoms. However, the effect of effleurage massage on sleep disturbance, fatigue, pain, and anxiety in patients with MS is not studied in Egypt.

AIM

To examine the effect of Effleurage massage therapy on sleep disturbance, fatigue, pain, and anxiety in patients with multiple sclerosis (MS).

METHODS

This research study has a quasi-experimental design, with control and intervention groups, and pre and post-tests conducted at the multiple sclerosis in-patient clinic at one Egyptian hospital between May 2019 and January 2020. Sixty adult female patients with MS were recruited, with 30 patients in the control group and 30 in the intervention group. The intervention group received Effleurage massage therapy intervention three times a week for two weeks, and each session lasted about 20 min. Patients in the control group received routine hospital care. Data were collected using the patient's demographic and medical data sheet, Insomnia Severity Index, Modified Fatigue Impact Scale, Numeric Pain Rating Scale, and Beck Anxiety Inventory before and after the intervention.

RESULTS

Significant improvement was observed in pain, sleep, fatigue, and anxiety in the massage group (P < 0.001).

CONCLUSION

Based on the current study, Effleurage massage intervention for MS patients could have possible clinical value for improving sleep disturbance, palliating pain, fatigue, and reducing anxiety. Egyptian nurses can integrate massage therapy into the routine nursing care of patients with MS. Effleurage massage could be an adjunct treatment modality for MS patients; however, more significant studies are needed.

Emotional competencies in multiple sclerosis

BACKGROUND

Emotional competencies (i.e., understanding emotions in self and others) are crucial for psychological well-being and successful social interaction. However, despite the deficits in psychological well-being and social interaction among individuals with multiple sclerosis (MS), emotional competencies have not been broadly investigated in MS. The present study: (1) compared emotional competencies between persons with MS and (a) previously published norms for the general population and (b) persons with major depressive disorder; and (2) investigated the association between emotional competencies and symptoms of insomnia, depression, fatigue, and paresthesia in persons with MS.

METHODS

The sample of 1135 persons with MS (mean age: 34.6 years; 81.1% female; median EDSS: 2; range: 0 - 5) self-rated emotional competencies and symptoms of insomnia, symptoms of depression, fatigue, and paresthesia. Data on emotional competencies of historical samples (general population: N = 622; mean age: 22.0 years; 61% females; outpatients with major depressive disorders (MDD); N = 50; mean age: 42.46 years; 68% females) were used for comparison.

RESULTS

Persons with MS reported lower levels of emotional competencies than both the general population (t (1, 1756) = 55.18, p < 0.001, d = 1.66; large effect size) and outpatients with MDD (t (1, 1183) = 3.48, p <0.001, d = 0.50; medium effect size). Among persons with MS, lower levels of emotional competencies were associated with higher MS-related symptoms of insomnia(r = - 0.24; p < 0.001), depression (r = - 0.42; p < 0.001), fatigue (r = - 0.31; p < 0.001), and paresthesia (r = - 0.18; p < 0.001).

CONCLUSIONS

Persons with MS reported significantly lower scores for emotional competencies when compared with the general population and outpatients with MDD. Further, lower scores for emotional competencies were associated with typical MS-related symptoms of insomnia, depression, fatigue and paresthesia. These findings suggest that emotional competencies may be an important target for intervention in persons with MS.

Longitudinal analysis and treatment of neuropsychiatric symptoms in post-acute sequelae of COVID-19

BACKGROUND

Persistent neuropsychiatric symptoms following acute COVID-19 infection are frequently reported. These include anxiety, depression, difficulty concentrating, fatigue, and insomnia. The longitudinal evolution of this neuropsychiatric burden is poorly understood and clinical guidelines concerning treatment are lacking.

OBJECTIVE

We sought to describe the longitudinal evolution of neuropsychiatric symptoms in the post-acute sequelae of COVID-19 (PASC) syndrome and examine symptom treatment at a single center.

METHODS

Consecutive participants experiencing persistent neurologic symptoms after acute COVID-19 infection were recruited from October 2020 to July 2022. Data collected included COVID-19 infection history, neurological exam and review of systems, Montreal Cognitive Assessment (MoCA), and self-reported surveys concerning neuropsychiatric symptoms and treatment. Data were collected at baseline and at 1-year follow-up.

RESULTS

A total of 106 participants (mean age 48.6, females 67%) were included in the study. At 1-year follow-up, 72.5% of participants reported at least one neuropsychiatric symptom. Over half (52.5%) of participants reported persistent fatigue. At baseline, 38.8% of all participants had met the established MoCA cut-off score of < 26 for mild cognitive impairment; this decreased to 20.0% at 1 year. COVID-19 infection severity was associated with neuro-PASC symptoms (including fatigue and anxiety) at 1 year. Overall, 29% of participants started at least one new medication for COVID-19-associated neuropsychiatric symptoms. Of the participants who started new medications, fatigue was the most common indication (44.8%) followed by insomnia (27.6%).

CONCLUSIONS

Neuropsychiatric symptoms related to neuro-PASC improve over time but can persist for over a year post-recovery. Most treatment modalities targeted neuro-PASC fatigue.

Social Cognition Impairments in Association to Clinical, Cognitive, Mood, and Fatigue Features in Multiple Sclerosis: A Study Protocol

Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system (CNS), characterized by the diffuse grey and white matter damage. Cognitive impairment (CI) is a frequent clinical feature in patients with MS (PwMS) that can be prevalent even in early disease stages, affecting the physical activity and active social participation of PwMS. Limited information is available regarding the influence of MS in social cognition (SC), which may occur independently from the overall neurocognitive dysfunction. In addition, the available information regarding the factors that influence SC in PwMS is limited, e.g., factors such as a patient's physical disability, different cognitive phenotypes, mood status, fatigue. Considering that SC is an important domain of CI in MS and may contribute to subjects' social participation and quality of life, we herein conceptualize and present the methodological design of a cross-sectional study in 100 PwMS of different disease subtypes. The study aims (a) to characterize SC impairment in PwMS in the Greek population and (b) to unveil the relationship between clinical symptoms, phenotypes of CI, mood status and fatigue in PwMS and the potential underlying impairment on tasks of SC.

Personality Traits and Fatigue in Multiple Sclerosis: A Narrative Review

(1) Background: Multiple sclerosis (MS) is a chronic neurodegenerative autoimmune disease. Fatigue is a prevalent and debilitating symptom that significantly impacts the quality of life of these patients. A relationship between personality traits and fatigue in MS has been hypothesized but not clearly defined. (2) Methods: A literature search was carried out from databases up to April 2023 for studies correlating personality traits and fatigue in patients suffering from MS. (3) Results: A total of ten articles was included; most of the studies depict a neuroticism-fatigue correlation; however, they were not consistent in terms of the fatigue, personality, and covariate assessments. (4) Conclusions: The clinical and methodological heterogeneity of the included studies prevented us from drawing any firm conclusion on the link between personality traits and fatigue in MS. Several models of personality and different fatigue assessments have been found. Despite this, a common pathway shows that the neuroticism trait or similar personality patterns has a role in fatigue diagnosis. This may be a useful target to improve the quality of life and enhance the modification of the disease treatment results. Further homogeneous and longitudinal studies are needed.

The Early Initiation Advantages of Physical Therapy in Multiple Sclerosis-A Pilot Study

(1) Background: Multiple sclerosis (MS), a chronic progressive neurological disorder which affects the central nervous system (CNS), can result in disorders of all the functions controlled by the CNS: motor, sensory, cognitive and emotional. Physical therapy (PT), conducted through proprioceptive neuromuscular facilitation (PNF) techniques, can be customized to the individual patient's needs and has the potential to improve the patient's evolution. This study aims to establish if PT based on PNF techniques has a beneficial role in MS treatment. (2) Methods: We performed a prospective study on 40 patients who were diagnosed with MS and previously treated only with MS drug treatment (DT). These patients have participated in a PT program throughout one year. At the beginning and at the end of our study, after one year, we have assessed the following parameters: timed walk for 25 feet (Timed 25-Foot Walk test- T25FW test), dexterity of the upper limbs (9-Hole Peg Test-9HPT), disability level (Expanded Disability Status Scale-EDSS) and cognitive function (Paced Auditory Serial Addition Test-PASAT. (3) Results: In subjects in the early stages of MS, lower limb mobility improved significantly, T25FW decreasing from 6.46 to 5.80 (p < 0.001) and upper limb ability increased significantly in the dominant hand, 9HPT decreasing from 17.73 to 16.97 (p = 0.006) and not significantly in the non-dominant hand, 9HPT decreasing from 17.73 to 17.50 (p = 0.255). Furthermore, among these subjects, cognitive performance improved; their PASAT increased from 52.14 to 54.14 (p = 0.036), while the level of disability of these subjects improved only slightly, the EDSS scale evolving from 3.08 to 2.91 (p = 0.650). (4) Conclusions: In patients with early forms of MS, combining DT with a PT program based on PNF techniques results in: regaining muscle strength in the lower limbs, improving coordination while walking, correcting dexterity in the upper limbs and increasing the ability to concentrate.

The Role of Exercise on Fatigue Among Patients With Multiple Sclerosis in the King Fahad Hospital, Madinah, Saudi Arabia: An Analytical Cross-Sectional Study

Background Multiple sclerosis (MS) is a chronic autoimmune disease caused by multiple factors. It can lead to many physical and mental symptoms. Fatigue is one of the most commonly mentioned complaints among MS patients that can affect their quality of life. Physical activity has many benefits for the physical and mental health of patients with MS. Aim To assess the role of exercise on fatigue among patients with multiple sclerosis and identify the relationship between depression, sleep quality, sociodemographic variables, and fatigue. Methods This is an analytical cross-sectional study based on a sample size of 235 patients recruited from the MS clinic at King Fahad Hospital (KFH) in Madinah. The outcome of the study was fatigue among MS patients. Data were collected through telephone calls from February to May 2022 using a structured questionnaire and scales, such as the Godin Leisure-Time Exercise Questionnaire (GLTEQ), Modified Fatigue Impact Scale (MFIS), Patient Health Questionnaire (PHQ2), and Pittsburgh Sleep Quality Index (PSQI). Data were analyzed through SPSS version 20 (IBM Corp., Armonk, NY, USA). The correlation coefficient (r), Chi-square tests, and simple and multiple logistic regression were used as found appropriate. Results Out of the total samples, 37.4% were male and 62.6% were female. The median age of patients was 36 years. The prevalence of fatigue was 37% among patients, with a reported median fatigue score of 26. It was found that 63% of the patients were physically inactive; 32.2% were overweight, 14.2% were obese; 63.8% of patients had poor sleep quality. The fatigue score was negatively correlated with the GLTEQ score, but the results were not significant (r=-0.066; P-value (level of significance)=0.335). Nonetheless, a moderately significant correlation was observed between the MFIS and PSQI and MFIS and PHQ2 (r=0.505, P=<0.001 and r=0.520, P=<0.001, respectively). The Chi-square test showed a significant association between fatigue and progressive types of MS, the primary progressive MS (PPMS), secondary progressive MS (SPMS), and relapsing-remitting MS (RRMS) (odds ratio (OR)=4.4; 95% confidence interval (CI): 2.1-8.9), P=<0.001). Depressed patients were 9.7 times more likely to develop fatigue compared to non-depressed patients (P=<0.001). Those with poor sleep quality were 4.6 times more likely to develop fatigue compared to those with good sleep quality (P=<0.001). Fifty-six percent of fatigue among MS patients were predicted by low income, progressive types, unemployment, obesity, depression, and poor sleep quality. Conclusion Fatigue is a major complaint among MS patients. Most of the patients were found to be physically inactive, depressed, and have poor sleep quality. This study found an association between physical inactivity and fatigue, but the results were not significant. There was a significant association between sociodemographic factors like low income and unemployment, poor sleep quality, obesity, progressive types of MS, depression, and fatigue. Encouraging exercise practice and implementing a regular exercise program are needed, along with weight management plans. Further studies and psychological support meetings are required, with the importance of a holistic approach to patient care.

Exploring the relation between reserve and fatigue in multiple sclerosis

INTRODUCTION

Intellectual enrichment and brain reserve modulate the expression of cognitive and motor disability in multiple sclerosis (MS). Their association with fatigue, one of the most debilitating and common symptoms of MS, has never been explored.

MATERIALS AND METHODS

Forty-eight MS patients underwent clinical and MRI examination at baseline and after 1 year. Physical and cognitive MS-related fatigue were evaluated via Modified Fatigue Impact subscales (MFIS-P and MFIS-C). Differences in reserve indexes between fatigued and non-fatigued patients were tested. The relationship between clinico-demographic features, global brain structural damage, indexes of reserve (age-adjusted intracranial volume and cognitive reserve index) and fatigue were tested via correlations and hierarchical linear/binary logistic regression, to predict MFIS-P and MFIS-C (at baseline) or new-onset fatigue and meaningful worsening in MFIS (at follow-up).

RESULTS

At baseline, although a significant difference was identified for cognitive reserve questionnaire between fatigued and non-fatigued patients (18.19 ± 4.76 versus 15.15 ± 3.56, p = 0.015), only depression accounted for significant variance in MFIS-P and MFIS-C (R²=0.248, p = 0.002; R²=0.252, p<0.001). MFIS-T, MFIS-P and MFIS-C changes over time were associated to depression changes over time (r = 0.56, r = 0.55, and r = 0.57, respectively; all p<0.001). Indexes of reserve did not differ between non-fatigued patients and patients developing new-onset fatigue at follow-up. None of the baseline features was able to predict the new-onset fatigue or meaningful worsening in MFIS at follow-up.

CONCLUSIONS

Among the explored features, only depression was strongly associated to both physical and cognitive fatigue. Intellectual enrichment and brain reserve did not seem to affect fatigue symptoms in MS patients.

The Effect of Meditation-Based Interventions on Patients with Fatigue Symptoms: A Systematic Review and Meta-Analysis

Persistent fatigue constitutes a prevalent and debilitating symptom in several diseases. The symptom is not effectively alleviated by pharmaceutical treatments, and meditation has been proposed as a non-pharmacological intervention. Indeed, meditation has been shown to reduce inflammatory/immune problems, pain, stress, anxiety and depression which are associated with pathological fatigue. This review synthesizes data from randomized control trials (RCTs) that explored the effect of meditation-based interventions (MeBIs) on fatigue in pathological conditions. Eight databases were searched from inception to April 2020. Thirty-four RCTs met eligibility criteria and covered six conditions (68% cancer), 32 of which were included in the meta-analysis. The main analysis showed an effect in favor of MeBIs compared to control groups (g = 0.62). Separate moderator analyses assessing control group, pathological condition, and MeBI type, highlighted a significantly moderating role of the control group. Indeed, compared to actively controlled studies, studies using a passive control group were associated with a statistically significantly more beneficial impact of the MeBIs (g = 0.83). These results indicate that MeBIs alleviate pathological fatigue and it seems that the studies with a passive control group showed a greater effect of MeBI on the reduction of fatigue compared to studies using active control groups. However, the specific effect of meditation type and pathological condition should be analyzed with more studies, and there remains a need to assess meditation effects on different types of fatigue (i.e., physical and mental) and in additional conditions (e.g., post-COVID-19).

Factors contributing to falls in people with multiple sclerosis: The exploration of the moderation and mediation effects

BACKGROUND

The prevalence of multiple sclerosis (MS) has significantly increased in recent decades. People with MS have a high risk of falling; these falls may lead to serious injuries, affecting their quality of life PURPOSE: The aim of this study is to assess the factors affecting falls in people with MS and map out the most significant ones. This study also aims to determine whether fatigue has a moderation effect and balance has a mediation effect on falls in people with MS METHODS: In total, 103 people with MS with a mean age of 32.09 ± 7.17 were enrolled. All subjects were assessed for multiple variables including balance using the Berg Balance Scale (BBS), speed of gait using the Timed Up and Go (TUG) test, fear of falling using the Falls Efficacy Scale-International (FES-I), level of fatigue using the Modified Fatigue Impact Scale (MFIS), and lower limb muscle strength using a handheld digital dynamometer RESULTS: Simple binary logistic regression analysis showed significant results for BBS (OR: 10.88; 95% CI: 4.24-27.96; p < 0.0001), TUG (OR: 1.18; 95% CI: 1.09-1.28; p < 0.0001), FES-I (OR: 1.06; 95% CI: 1.02-1.10; p = 0.001), and MFIS (OR: 1.04; 95% CI: 1.02-1.07; p < 0.0001) as factors affecting falls. According to multivariate analysis, balance (OR: 3.924; 95% CI: 1.307-11.780, p = 0.015), speed of gait (OR: 1.122; 95% CI: 1.023-1.231; p = 0.015), and fatigue (OR: 1.029; 95% CI: 1.002-1.058; p = 0.038) were the strongest predicting factors of falls. Hayes's PROCESS analysis showed that fatigue had a significant moderation effect on the relationship between gait speed and falls (MFIS; β; 0.10; p < 0.0001; 95% CI: 0.07-0.14) and balance had a mediation effect on the relationship between gait speed and falls (BBS; indirect effect; 0.08; 95% CI: 0.02-0.13) CONCLUSIONS: People with MS with impaired balance, slower gait speeds, higher levels of fatigue, and a fear of falling were at a high risk of falling. The relationship between gait speed and falls can be mediated by impaired balance and moderated by the level of fatigue. Our data suggest that targeting balance and fatigue while developing rehabilitation interventions could decrease the incidence of falls among people with MS.

Exploring the impact of exercise and essential amino acid plus cholecalciferol supplementation on physical fitness and body composition in multiple sclerosis: A case study

Key Clinical Message

In MS patients, especially those frail or malnourished, combining home-based exercise twice weekly with essential amino acids and vitamin D may improve body composition, strength, and physical performance, enabling long-term functional improvements.

Abstract

Multiple sclerosis (MS) is associated with reduced bone and muscle strength and function. We aimed to investigate the effectiveness of a 24-week intervention in a 57-year-old frail female with MS. The participant completed a 2×/week exercise intervention and ingested 2×/day a supplement containing 7.5 g essential amino acids and 500 IU cholecalciferol. Body composition, 6-m gait speed (GS), handgrip strength (HGS), 30-sec arm-curl test (30ACT), 6-min walking test (6MWT), 30-sec chair-stand test (30CST), and plasma concentrations of 25-hydroxyvitamin D₃ [25(OH)D₃], insulin-like growth factor 1 (IGF-1), and amino acids were assessed at baseline, and at Weeks 12 and 24. Plasma 25(OH)D₃ increased from 23.2 to 41.3 ng/mL and IGF-1 from 131.6 to 140.7 ng/mL from baseline to post-intervention. BMI, total lean tissue mass (LTM), fat mass, bone mineral content, and the sum of 17 amino acids increased by 3.8, 1.0, 3.5, 0.2, and 19%, respectively, at Week 24. There were clinically significant increases in regional LTM (6.9% arms and 6.3% legs) and large increases in GS (67.3%), dominant HGS (31.5%), non-dominant HGS (11.8%), dominant 30ACT (100%), non-dominant 30ACT (116.7%), 6MWT (125.6%), and 30CST (44.4%). The current intervention was effective in improving components of physical fitness and body composition in a female with MS.

Measurement Properties' Evaluation of the Arabic Version of the Patient-Specific Functional Scale in Patients with Multiple Sclerosis

Purpose: The aim of this study was to assess the reliability and validity of the Arabic version of the patient-specific functional scale (PSFS-Ar) in patients with multiple sclerosis (MS) disorder. Materials and Methods: Reliability and validity were examined in patients with multiple sclerosis using a longitudinal cohort study design. One hundred (N = 100) patients with MS were recruited to examine the PSFS-Ar, test-retest reliability (using the interclass correlation coefficient model 2,1 (ICC_2,1)), construct validity (using the hypothesis testing method), and floor-ceiling effect. Results: A total of 100 participants completed the PSFS-Ar (34% male, 66% female). The PSFS-Ar showed an excellent test-retest reliability score (ICC_2,1 = 0.87; 95% confidence interval, 0.75-0.93). The SEM of the PSFS-Ar was 0.80, while the MDC₉₅ was 1.87, indicating an acceptable measurement error. The construct validity of the PSFS-Ar was 100% correlated with the predefined hypotheses. As hypothesized, the correlation analysis revealed positive correlations between the PSFS-Ar and the RAND-36 domains of physical functioning (0.5), role limitations due to physical health problems (0.37), energy/fatigue (0.35), and emotional well-being (0.19). There was no floor or ceiling effect in this study. Conclusions: The study results showed that the PSFS-Ar is a self-reported outcome measure that is useful for detecting specific functional difficulties in patients with multiple sclerosis. Patients are able to express and report a variety of functional limitations easily and effectively, as well as to measure their response to physical therapy. The PSFS-Ar is, therefore, recommended for use in Arabic-speaking countries for clinical practice and research for patients with multiple sclerosis.

Digital Phenotypes of Instability and Fatigue Derived From Daily Standing Transitions in Persons With Multiple Sclerosis

Impairment in persons with multiple sclerosis (PwMS) can often be attributed to symptoms of motor instability and fatigue. Symptom monitoring and queued interventions often target these symptoms. Clinical metrics are currently limited to objective physician assessments or subjective patient reported measures. Recent research has turned to wearables for improving the objectivity and temporal resolution of assessment. Our group has previously observed wearable assessment of supervised and unsupervised standing transitions to be predictive of fall-risk in PwMS. Here we extend the application of standing transition quantification to longitudinal home monitoring of symptoms. Subjects (N=23) with varying degrees of MS impairment were recruited and monitored with accelerometry for a total of  ∼  6 weeks each. These data were processed using a preexisting framework, applying a deep learning activity classifier to isolate periods of standing transition from which descriptive features were extracted for analysis. Participants completed daily and biweekly assessments describing their symptoms. From these data, Canonical Correlation Analysis was used to derive digital phenotypes of MS instability and fatigue. We find these phenotypes capable of distinguishing fallers from non-fallers, and further that they demonstrate a capacity to characterize symptoms at both daily and sub-daily resolutions. These results represent promising support for future applications of wearables, which may soon augment or replace current metrics in longitudinal monitoring of PwMS.

Targeting Sigma Receptors for the Treatment of Neurodegenerative and Neurodevelopmental Disorders

The sigma-1 receptor is a 223 amino acid-long protein with a recently identified structure. The sigma-2 receptor is a genetically unrelated protein with a similarly shaped binding pocket and acts to influence cellular activities similar to the sigma-1 receptor. Both proteins are highly expressed in neuronal tissues. As such, they have become targets for treating neurological diseases, including Alzheimer's disease (AD), Huntington's disease (HD), Parkinson's disease (PD), multiple sclerosis (MS), Rett syndrome (RS), developmental and epileptic encephalopathies (DEE), and motor neuron disease/amyotrophic lateral sclerosis (MND/ALS). In recent years, there have been many pre-clinical and clinical studies of sigma receptor (1 and 2) ligands for treating neurological disease. Drugs such as blarcamesine, dextromethorphan and pridopidine, which have sigma-1 receptor activity as part of their pharmacological profile, are effective in treating multiple aspects of several neurological diseases. Furthermore, several sigma-2 receptor ligands are under investigation, including CT1812, rivastigmine and SAS0132. This review aims to provide a current and up-to-date analysis of the current clinical and pre-clinical data of drugs with sigma receptor activities for treating neurological disease.

Severity and worsening of fatigue among individuals with multiple sclerosis

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.

Neural bases of motor fatigue in multiple sclerosis: A multimodal approach using neuromuscular assessment and TMS-EEG

Motor fatigue is one of the most common symptoms in multiple sclerosis (MS) patients. Previous studies suggested that increased motor fatigue in MS may arise at the central nervous system level. However, the mechanisms underlying central motor fatigue in MS are still unclear. This paper investigated whether central motor fatigue in MS reflects impaired corticospinal transmission or suboptimal primary motor cortex (M1) output (supraspinal fatigue). Furthermore, we sought to identify whether central motor fatigue is associated with abnormal M1 excitability and connectivity within the sensorimotor network. Twenty-two patients affected by relapsing-remitting MS and 15 healthy controls (HCs) performed repeated blocks of contraction at different percentages of maximal voluntary contraction with the right first dorsal interosseus muscle until exhaustion. Peripheral, central, and supraspinal components of motor fatigue were quantified by a neuromuscular assessment based on the superimposed twitch evoked by peripheral nerve and transcranial magnetic stimulation (TMS). Corticospinal transmission, excitability and inhibition during the task were tested by measurement of motor evoked potential (MEP) latency, amplitude, and cortical silent period (CSP). M1 excitability and connectivity was measured by TMS-evoked electroencephalography (EEG) potentials (TEPs) elicited by M1 stimulation before and after the task. Patients completed fewer blocks of contraction and showed higher values of central and supraspinal fatigue than HCs. We found no MEP or CSP differences between MS patients and HCs. Patients showed a post-fatigue increase in TEPs propagation from M1 to the rest of the cortex and in source-reconstructed activity within the sensorimotor network, in contrast to the reduction observed in HCs. Post-fatigue increase in source-reconstructed TEPs correlated with supraspinal fatigue values. To conclude, MS-related motor fatigue is caused by central mechanisms related explicitly to suboptimal M1 output rather than impaired corticospinal transmission. Furthermore, by adopting a TMS-EEG approach, we proved that suboptimal M1 output in MS patients is associated with abnormal task-related modulation of M1 connectivity within the sensorimotor network. Our findings shed new light on the central mechanisms of motor fatigue in MS by highlighting a possible role of abnormal sensorimotor network dynamics. These novel results may point to new therapeutical targets for fatigue in MS.

The relevance of fatigue to relapse rate in multiple sclerosis: Applying patient preference data to the OPTIMUM trial

BACKGROUND

In the OPTIMUM trial in patients with relapsing MS, treatment differences in annualized relapse rate (ARR, 0.088) and change in fatigue at week 108 (3.57 points, measured using the Fatigue Symptoms and Impacts Questionnaire-Relapsing Multiple Sclerosis, symptom domain (FSIQ-RMS-S)) favored ponesimod over teriflunomide. However, the importance of the fatigue outcome to patients was unclear.

OBJECTIVE

To assess the importance of the OPTIMUM FSIQ-RMS-S results using data from an MS discrete choice experiment (DCE).

METHODS

The DCE included components to correlate levels of physical and cognitive fatigue with FSIQ-RMS-S scores. Changes in relapses/year and time to MS progression equivalent to the treatment difference in fatigue in OPTIMUM were determined for similar fatigue levels as mean baseline fatigue in OPTIMUM.

RESULTS

DCE participants would accept 0.06 more relapses/year or a 0.15-0.17 year decrease in time to MS progression for a 3.57-point difference in physical fatigue on the FSIQ-RMS-S. To improve cognitive fatigue by 3.57-points on the FSIQ-RMS-S, DCE participants would accept 0.09-0.10 more relapses/year or a 0.24-0.28 year decrease in time to MS progression.

CONCLUSION

MS patients would accept 0.06 more relapses/year to change their fatigue by a similar magnitude as the between-treatment difference observed in the OPTIMUM trial.

The impact of WATSU as Physiotherapy Method on Fatigue for People Diagnosed with Multiple Sclerosis

Aim: To identify the impact of WATSU method on fatigue which has an impact on sleep and quality of life, pain and depression or its aggravation. Materials and Methods: The study involved the four participants. The following instruments were used: Multiple Sclerosis Quality of Life questionnaire; Pittsburgh Sleep Quality Index; Burns Depression Checklist; Fatigue Impact Scale. The study was carried out in medical center in Lithuania from 09-11-2019 till 18-01-2020 during 10 weeks. Each participant of the study received ten WATSU sessions. The research data was processed using SPSS Statistics 20. Qualitative Outcome Measures were conducted by content analysis, observation, semi-structured individual interview methods. Results: After 10 sessions, fatigue lessened in all people investigated. Initially, the average of fatigue was 70 points and decreased to 34 points after the investigation. The average sleep quality index was as high as 5 points, after ten weeks the average decreased to 3 points. Changes in assessment of major to mild depression: initially, the average was 36 points, which decreased to 14 points after ten weeks. Conclusions: The WATSU method was effective in reducing fatigue as a physiotherapy method. Along with changes in fatigue, the Pittsburgh Sleep Quality Index decreased, energy and motivation increased, quality of life improved, level of depression reduced, and the change was statistically significant. While assessing the quality of life, pain was found to be decreased – it became less frequent after ten weeks of sessions and less intense or even absent, its influence on daily activities decreased.

Validity and reliability of the Tampa Kinesiophobia-Fatigue Scale in patients with multiple sclerosis

BACKGROUND

Kinesiophobia can be a barrier for physical activity in patients with multiple sclerosis (PwMS) and it can develop as a result of fear and avoidance reactions due to fatigue. However, there is no valid and reliable scale available to assess kinesiophobia due to fatigue in PwMS.

AIMS

To investigate the test-retest reliability and construct validity of the Tampa Scale of Kinesiophobia-Fatigue (TSK-F) in PwMS.

METHODS

Eighty-seven PwMS were included in the study. In addition to TSK-F, the following measurements were used for construct validity: Expanded Disability Status Scale (EDSS), Fatigue Severity Scale (FSS), Fatigue Impact Scale (FIS), 6-Minute Walking Test (6MWT), International Physical Activity Questionnaire (IPAQ), Beck Depression Inventory (BDI), Multiple Sclerosis Quality of Life Scale-54 (MSQoL-54). TSK-F was administered twice (3-7 days apart) to measure test-retest reliability.

RESULTS

The intraclass correlation coefficient of the TSK-F was 0.867. It had a weak correlation with the IPAQ and EDSS, moderate correlation with the MSQoL-54 and 6MWT, and strong correlation with the BDI, FSS, and FIS (respectively, rho - 0.345, rho 0.365, rho 0.544, rho - 0.449, rho 0.690, rho 0.602, rho 0.650). The scale had good performance to discriminate the disease severity with the area under the curve (AUC) value 0.730.

CONCLUSIONS

TSK-F has excellent reliability and moderate-to-good validity in evaluating kinesiophobia and the scale may be a useful outcome measurement for assessment of kinesiophobia due to fatigue in PwMS.

Correlation of disability with quality of life in patients with multiple sclerosis treated with natalizumab: primary results and post hoc analysis of the TYSabri ImPROvement study (PROTYS)

Background

In patients with multiple sclerosis (MS), relapses and disability progression have been associated with decreased health-related quality of life (HRQoL).

Methods

PROTYS, a prospective, multicentre, single-arm, observational study in seven Swiss MS centres, evaluated correlations between change in disability status (measured through the Expanded Disability Status Scale (EDSS)) and HRQoL changes (measured through the global Multiple Sclerosis International Quality of Life (MusiQoL) index questionnaire) in 35 patients with relapsing remitting MS on natalizumab for 1 year. In addition, several other scales were also used, such as: Multiple Sclerosis Intimacy and Sexuality Questionnaire-19, EuroQoL-5 Dimension, and Fatigue Scale of Motor and Cognitive Function. A post hoc analysis further assessed the association between HRQoL changes after 1 year and the MusiQoL subscores and other patient-reported outcome (PRO) measures.

Results

At 1 year, patients were categorised into 'EDSS improved' (6/35), 'EDSS stable' (28/35) and 'EDSS worsened' (1/35). Mean disability scores decreased for 'EDSS improved' and 'EDSS stable' but increased for 'EDSS worsened'. Mean MusiQoL index score for 'EDSS improved' increased from 61.2 at baseline to 66.3 at 1 year, while the 'EDSS stable' group increased from 67.9 to 70.8. No meaningful statistical relationship was observed between EDSS group and changes in MusiQoL score. For the post hoc analysis, patients were categorised in 'MusiQoL improved' (n=21) and 'MusiQoL worsened' (n=14) groups. MusiQoL subscores for 'symptoms,' 'psychological well-being' and 'activities of daily living', as well as scores for several related PRO measures, correlated with improvement of the MusiQoL global index. There was no correlation between the changes in MusiQoL global index and EDSS score.

Conclusions

Natalizumab treatment for 1 year resulted in either improved or stable EDSS status in most patients, and although no significant relationship was observed between global HRQoL change and EDSS change, several domains of HRQoL seemed to improve with natalizumab treatment.

Trial registration number

NCT02386566.

Treatment preferences in relation to fatigue of patients with relapsing multiple sclerosis: A discrete choice experiment

Background

Treatment decisions for multiple sclerosis (MS) are influenced by many factors such as disease symptoms, comorbidities, and tolerability.

Objective

To determine how much relapsing MS patients were willing to accept the worsening of certain aspects of their MS in return for improvements in symptoms or treatment convenience.

Methods

A web-based discrete choice experiment (DCE) was conducted in patients with relapsing MS. Multinomial logit models were used to estimate relative attribute importance (RAI) and to quantify attribute trade-offs.

Results

The DCE was completed by 817 participants from the US, the UK, Poland, and Russia. The most valued attributes of MS therapy to participants were effects on physical fatigue (RAI = 22.3%), cognitive fatigue (RAI = 22.0%), relapses over 2 years (RAI = 20.7%), and MS progression (RAI = 18.4%). Participants would accept six additional relapses in 2 years and a decrease of 7 years in time to disease progression to improve either cognitive or physical fatigue from "quite a bit of difficulty" to "no difficulty."

Conclusion

Patients strongly valued improving cognitive and physical fatigue and were willing to accept additional relapses or a shorter time to disease progression to have less fatigue. The impact of fatigue on MS patients' quality of life should be considered in treatment decisions.

Resilience, Stress, Well-Being, and Sleep Quality in Multiple Sclerosis

(1) Background: Multiple Sclerosis (MS) is a chronic, progressive, immune-mediated disorder that affects the Central Nervous System and is the most common cause of non-traumatic neurological disability in young adults. The study aimed to assess the levels of stress, resilience, well-being, sleep quality, and fatigue in Israeli people with MS (PwMS), and to examine the associations between these factors and the sociodemographic and clinical characteristics. These factors had never before been studied in conjunction in PwMS, nor had they been systematically addressed in Israel, the unique geopolitical situation of which may pose unique challenges. (2) Methods: This was a survey-based, cross-sectional study conducted through an Internet platform. (3) Results: Israeli PwMS who participated in the study were experiencing relatively high levels of stress and low resilience, poor sleep quality, and severe fatigue. The analysis revealed significant associations between resilience and stress, well-being, and anxiety, as well as stress and well-being, resilience, sleep quality, fatigue, and Clinically Isolated Syndrome (CIS). (4) Conclusions: the Israeli PwMS who participated in the study were experiencing higher levels of stress, lower resilience and worse sleep quality than PwMS in other countries, as compared to results previously reported in literature. The findings of this study ought to serve as a call to action for the MS care providers in Israel and warrant further research into the possible causes of the phenomenon and strategies to address it.

The association of serum carnitine levels with severity of fatigue in patients with multiple sclerosis: A pilot study

Background: Fatigue is a common complaint of patients with multiple sclerosis (MS), adversely affecting their quality of life. There is a lot of evidence showing that carnitine deficiency is linked to fatigue development and severity in some conditions. This study aimed to evaluate the association between free L-carnitine serum levels and the severity of fatigue in patients with MS. Methods: This case-control study included 30 patients with relapsing-remitting MS (RRMS) in two age-matched equal-number groups according to the presence or absence of fatigue. Fatigue was scored using the valid questionnaire of Fatigue Severity Scale (FSS) and serum level of free L-carnitine was measured simultaneously. Finally, the association between serum level of free L-carnitine and fatigue severity was evaluated in patients with MS. Results: The mean value of FSS in patients with fatigue was 48.80 ± 8.55, which was nearly two-fold higher than the group without fatigue. We found a significant correlation between the serum level of free L-carnitine and FSS and showed that the patients with fatigue had a significantly lower serum level of free L-carnitine compared to patients without fatigue (P < 0.001). Conclusion: Present study demonstrated that patients with lower serum levels of free L-carnitine were more likely to experience fatigue. We recommend that a higher dietary intake of carnitine might be a useful complementary treatment for MS-related fatigue.

Fatigue and Human Performance: An Updated Framework

Fatigue has been defined differently in the literature depending on the field of research. The inconsistent use of the term fatigue complicated scientific communication, thereby limiting progress towards a more in-depth understanding of the phenomenon. Therefore, Enoka and Duchateau (Med Sci Sports Exerc 48:2228-38, 2016, [3]) proposed a fatigue framework that distinguishes between trait fatigue (i.e., fatigue experienced by an individual over a longer period of time) and motor or cognitive task-induced state fatigue (i.e., self-reported disabling symptom derived from the two interdependent attributes performance fatigability and perceived fatigability). Thereby, performance fatigability describes a decrease in an objective performance measure, while perceived fatigability refers to the sensations that regulate the integrity of the performer. Although this framework served as a good starting point to unravel the psychophysiology of fatigue, several important aspects were not included and the interdependence of the mechanisms driving performance fatigability and perceived fatigability were not comprehensively discussed. Therefore, the present narrative review aimed to (1) update the fatigue framework suggested by Enoka and Duchateau (Med Sci Sports Exerc 48:2228-38, 2016, [3]) pertaining the taxonomy (i.e., cognitive performance fatigue and perceived cognitive fatigue were added) and important determinants that were not considered previously (e.g., effort perception, affective valence, self-regulation), (2) discuss the mechanisms underlying performance fatigue and perceived fatigue in response to motor and cognitive tasks as well as their interdependence, and (3) provide recommendations for future research on these interactions. We propose to define motor or cognitive task-induced state fatigue as a psychophysiological condition characterized by a decrease in motor or cognitive performance (i.e., motor or cognitive performance fatigue, respectively) and/or an increased perception of fatigue (i.e., perceived motor or cognitive fatigue). These dimensions are interdependent, hinge on different determinants, and depend on body homeostasis (e.g., wakefulness, core temperature) as well as several modulating factors (e.g., age, sex, diseases, characteristics of the motor or cognitive task). Consequently, there is no single factor primarily determining performance fatigue and perceived fatigue in response to motor or cognitive tasks. Instead, the relative weight of each determinant and their interaction are modulated by several factors.

The Effects of SARS-CoV-2 Infection on the Cognitive Functioning of Patients with Pre-Existing Dementia

Background

Cognitive postscripts of COVID-19, codenamed as 'cognitive COVID' or 'brain fog,' characterized by multidomain cognitive impairments, are now being reckoned as the most devastating sequelae of COVID-19. However, the impact on the already demented brain has not been studied.

Objective

We aimed to assess the cognitive functioning and neuroimaging following SARS-CoV-2 infection in patients with pre-existing dementia.

Methods

Fourteen COVID-19 survivors with pre-existing dementia (four with Alzheimer's disease, five with vascular dementia, three with Parkinson's disease dementia, and two with the behavioral variant of frontotemporal dementia) were recruited. All these patients had detailed cognitive and neuroimaging evaluations within three months before suffering from COVID-19 and one year later.

Results

Of the 14 patients, ten required hospitalization. All developed or increased white matter hyperintensities that mimicked multiple sclerosis and small vessel disease. There was a significant increase in fatigue (p = 0.001) and depression (p = 0.016) scores following COVID-19. The mean Frontal Assessment Battery (p < 0.001) and Addenbrooke's Cognitive Examination (p = 0.001) scores also significantly worsened.

Conclusion

The rapid progression of dementia, the addition of further impairments/deterioration of cognitive abilities, and the increase or new appearance of white matter lesion burden suggest that previously compromised brains have little defense to withstand a new insult (i.e., 'second hit' like infection/dysregulated immune response, and inflammation). 'Brain fog' is an ambiguous terminology without specific attribution to the spectrum of post-COVID-19 cognitive sequelae. We propose a new codename, i.e. 'FADE-IN MEMORY' (i.e., Fatigue, decreased Fluency, Attention deficit, Depression, Executive dysfunction, slowed INformation processing speed, and subcortical MEMORY impairment).

COPD-Related Fatigue: A Scoping Review

Millions of people worldwide have chronic obstructive pulmonary disease (COPD), and one of the most common and troublesome symptoms that must be managed is fatigue. While there are existing interventions to address COPD-related fatigue, not all patients experience benefit. A better understanding of the factors associated with COPD-fatigue could elucidate new approaches to address COPD-related fatigue, thereby offering relief to a greater number of patients. The purpose of this review was to identify the physiologic, psychologic, and situational factors associated with COPD-related fatigue. A total of four databases, PubMed, CINAHL, Scopus, and Google Scholar, were searched. Those that were peer reviewed, in English, and published between 2000 and 2021, were included in the review. A total of 25 articles were included in this scoping review. The following factors were related to fatigue in COPD: dyspnea, pain, anxiety, depression, and sleep. Fatigue is a debilitating symptom with factors influential to the symptom and outcomes. Research is indicated to explore targeted and personalized interventions addressing the factors related to fatigue to mitigate this widespread symptom.