A pragmatic parallel arm multi-centre randomised controlled trial to assess the effectiveness and cost-effectiveness of a group-based fatigue management programme (FACETS) for people with multiple sclerosis

Cognitive behavioural therapy for fatigue in patients with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Treatment of fatigue is important for many patients with multiple sclerosis (MS). While pharmacological options have not shown consistent benefit, psychological interventions offer another avenue of treatment. Cognitive behavioural therapy (CBT) involves strategies to change maladaptive cognition and illness behaviours that modulate how patients with MS respond to fatigue. The aim of this study was to perform a systematic review and meta-analysis to determine the effectiveness of CBT for the treatment of fatigue in patients with MS.

METHODS

Five databases (Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, Embase, Emcare and PsycINFO) were searched up until 31 July 2023. Randomised controlled trials involving adult patients with MS and fatigue, comparing CBT with another intervention or usual treatment were included. Studies were required to measure fatigue severity and/or the impact of fatigue as the primary outcome(s). Each study was assessed for bias using the Cochrane Risk of Bias tool version 2. Studies with sufficient data were used for meta-analysis to quantify the short- and long-term effects of CBT on MS-related fatigue. The level of certainty provided by the body of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework.

RESULTS

Eight studies were included in the review and six studies contributed to the meta-analysis. Most studies had a low overall risk of bias. CBT interventions differed in the number, duration and frequency of sessions, mode of delivery and therapist. There were significant short- (standardised mean difference (SMD) -0.58, 95% confidence interval (95%CI) -0.85 to -0.31, P-value < 0.0001) and long-term (SMD -0.36, 95%CI -0.52 to -0.19, P-value < 0.0001) effects supporting CBT. The evidence provided a low level of certainty for the short-term effect because of heterogeneity of results and possible publication bias, while there was high certainty for the long-term result.

CONCLUSION

The study provides secondary evidence that CBT has moderate short-term and small long-term effects in reducing fatigue in patients with MS. CBT should be regarded as a viable evidence-based intervention, particularly in the absence of established alternatives. Future research should identify the ideal characteristics of a fatigue-specific CBT intervention, patient factors that predict treatment response and strategies to maintain initial improvements over time.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

STATISTICAL ANALYSIS

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

RESULTS

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

Education for fatigue management in people with multiple sclerosis: Systematic review and meta-analysis

BACKGROUND AND PURPOSE

Fatigue is a common and disabling symptom in multiple sclerosis (MS). Educational interventions have shown potential to reduce fatigue. The aim was to systematically review the current best evidence on patient education programmes for MS-related fatigue.

METHODS

This was a systematic review and meta-analysis following Cochrane methodology. A systematic search was conducted in eight databases (September 2023). Moreover, reference lists and trial registers were searched and experts in the field were contacted. Randomized controlled trials were included evaluating patient education programmes for people with MS with the primary aim of reducing fatigue.

RESULTS

In total, 1176 studies were identified and assessed by two independent reviewers; 15 studies (1473 participants) were included. All interventions provided information and education about different aspects of MS-related fatigue with different forms of application, some with components of psychological interventions. Amongst those, the most frequently applied were cognitive behavioural therapy (n = 5) and energy-conservation-based approaches (n = 4). Studies differed considerably concerning mode of intervention delivery, number of participants and length of follow-up. Interventions reduced fatigue severity (eight studies, n = 878, standardized mean difference -0.28; 95% confidence interval -0.53 to -0.03; low certainty) and fatigue impact (nine studies, n = 824, standardized mean difference -0.21; 95% confidence interval -0.42 to 0.00; moderate certainty) directly after the intervention. Mixed results were found for long-term effects on fatigue, for secondary endpoints (depressive symptoms, quality of life, coping) and for subgroup analyses.

CONCLUSION

Educational interventions for people with MS-related fatigue may be effective in reducing fatigue in the short term. More research is needed on long-term effects and the importance of specific intervention components, delivery and context.

Perspectives on fatigue management among veterans living with multiple sclerosis

BACKGROUND

Chronic fatigue is one of the most common, disabling, and least understood symptoms of many chronic health conditions including multiple sclerosis (MS). A multidisciplinary rehabilitative treatment approach is recommended for MS-related fatigue, but few people with MS have access to such treatment. In-person and telehealth cognitive behavioral therapy (CBT) for fatigue is an emerging acceptable and effective treatment for MS-related fatigue in civilians that has not been studied in Veterans with MS, a population that is more likely to be older, male, unemployed, and disabled. The present study aimed to understand how Veterans with MS (1) describe their fatigue and (2) manage their fatigue, and (3) perceive telehealth CBT for MS-related fatigue.

METHOD

Twenty-four Veterans with MS completed semi-structured interviews and a brief survey. For descriptive purposes, the survey included questionnaires on demographics, fatigue, psychosocial functioning, depression, and pain. Thematic analysis with a combined deductive and inductive approach was used to analyze interview transcripts.

RESULTS

Three themes emerged. First, "experience of MS fatigue as 'one big tapestry'" described fatigue as deficits in physical and mental energy that were fluctuating and complex in their interaction with biological factors. Veterans described that MS fatigue negatively impacted daily activities of living, emotions, and cognitive functioning. Second, "managing MS fatigue through trial and error" revealed that Veterans expend significant time and effort learning and trialing fatigue management strategies based on their personal beliefs, military training/experiences, provider recommendations, and iterative learning. Most Veterans described energy management, relaxation, exercise, and adaptive thinking as helpful for managing fatigue. Interestingly, the helpfulness of medication for fatigue was highly variable, and none of the Veterans described medication as a standalone fatigue treatment. The third theme, "practicing flexibility with telehealth CBT for MS fatigue" revealed Veteran's enthusiasm about telehealth CBT for MS-related fatigue and highlighted the importance of flexible delivery to meet individual needs.

CONCLUSION

Veteran participants shared their experience of MS-related fatigue as well as management strategies that are consistent with previous research in civilians with MS fatigue. Notably, Veterans' preference for flexible nonpharmacological intervention can inform adaptation of telehealth CBT for Veterans with MS fatigue.

A systematic review of the impact of therapeutic education programs on the quality of life of people with Multiple Sclerosis

Background

Faced with a deemed mediocre quality of life (QoL) in people with multiple sclerosis (pwMS), the effectiveness of therapeutic education (TPE) programs is called into question. This systematic review is conducted to examine the impact of the TPE programs on the QoL of pwMS.

Methods

A search was performed in three databases (PubMed, Web of Science and Scopus) to identify relevant studies published between 2007 and 2022. The review followed the PRISMA guidelines. Two reviewers independently extracted data on the study and program characteristics. These data were presented in tables for detailed synthesis and descriptive analyses. The selected studies underwent assessment using recommended evaluation tools.

Results

Of the 21 studies included in the review, 13 found a significant improvement in QoL, which was maintained during follow-up testing in 42% of the studies. TPE programs that focused on patients' individual needs and aimed to develop their skills in a personalized manner appeared to promote QoL. Interaction formats (individual, group, remote), session duration [range=1.5-28] and number of sessions [range=1-18] varied between the studies reviewed.

Conclusion

Thoughtful, structured design of educational programs requires a match between the educational aspects specific to each individual and the appropriate choice of content, delivery modalities of the interventions and evaluation protocol, as well as a reasonable follow-up time. The conclusions drawn could serve as guidelines to direct future research towards optimal educational interventions.

Systematic Review Registration

PROSPERO CRD42022338651.

A systematic mapping review of clinical guidelines for the management of fatigue in long-term physical health conditions

PURPOSE

Despite a high prevalence of fatigue and its importance to patients, many people with long-term conditions do not receive fatigue management as part of their treatment. This review is aimed to identify clinical guidance for the management of fatigue in long-term physical health conditions.

METHODS

A systematic mapping review was conducted in accordance with Social Care Institute for Excellence systematic review guidance. Bibliographic databases and guideline repositories were searched for clinical guidelines for long-term conditions, published between January 2008 and July 2018, with a search for updates conducted in May 2023. Data were extracted on the recommendations made for managing fatigue and, where cited, the underlying research evidence used to support these recommendations was also extracted.

RESULTS

The review included 221 guidelines on 67 different long-term conditions. Only 30 (13.6%) of the guidelines contained recommendations for managing fatigue. These were categorised as clinical (e.g. conduct further investigations), pharmacological, behavioural (e.g. physical activity), psychological, nutritional, complementary, environmental, and multicomponent. The guidelines rated much of the evidence for fatigue management as fairly low quality, highlighting the need to develop and test fatigue-management strategies in high-quality trials.

CONCLUSION

This review highlights that management of fatigue is a very important neglected area in the clinical guidelines for managing long-term conditions.

Protocol for a pragmatic randomised controlled feasibility study of MS WorkSmart: an online intervention for Australians with MS who are employed

INTRODUCTION

Multiple sclerosis (MS) causes a wide variety of symptoms. Loss of income due to sickness and early retirement comprise one-third of the total cost of MS in Australia. An intervention that maximises work productivity and keeps people with MS in the workforce for longer could provide a large societal cost saving and improve quality of life. The aim is to test the feasibility of delivering and evaluating a 10-week digitally delivered intervention called 'MS WorkSmart'. Findings will provide insights into participant profiles and address key methodological and procedural uncertainties (recruitment, retention, intervention adherence and engagement, and selection of primary outcome) in preparation for a subsequent definitive trial.

METHODS AND ANALYSIS

A parallel-arm randomised controlled feasibility study, comparing those randomised to receive the MS WorkSmart package plus usual care (n=20) to those receiving usual care only (n=20). Australians with MS, aged 18-60 years, who are employed, and self-report work instability will be recruited from the Australian MS Longitudinal Study. Online surveys, at baseline and 1-month postintervention, will include MS-related work productivity loss and risk of job loss, MS work behaviour self-efficacy, health-related quality of life, fatigue severity, MS symptom impact on work, intention to retire due to MS, MS-related work difficulties, and awareness and readiness for change at work. Qualitative feedback will be obtained via a semistructured survey following the intervention (for participants) and via interviews (coaches). Analyses will be primarily descriptive and focus on the feasibility and acceptability of the intervention and study procedures. Progression criteria will guide decisions around whether to progress to a full trial.

ETHICS AND DISSEMINATION

The study has been approved by the University of Tasmania Human Research Ethics Committee (H0024544). Findings will be disseminated via publication in peer-reviewed journals, conference presentations and community presentations.

TRIAL REGISTRATION NUMBER

ACTRN12622000826741.

Use of pragmatic randomized trials in multiple sclerosis: A systematic overview

BACKGROUND

Pragmatic trials are increasingly recognized for providing real-world evidence on treatment choices.

OBJECTIVE

The objective of this study is to investigate the use and characteristics of pragmatic trials in multiple sclerosis (MS).

METHODS

Systematic literature search and analysis of pragmatic trials on any intervention published up to 2022. The assessment of pragmatism with PRECIS-2 (PRagmatic Explanatory Continuum Indicator Summary-2) is performed.

RESULTS

We identified 48 pragmatic trials published 1967-2022 that included a median of 82 participants (interquartile range (IQR) = 42-160) to assess typically supportive care interventions (n = 41; 85%). Only seven trials assessed drugs (15%). Only three trials (6%) included >500 participants. Trials were mostly from the United Kingdom (n = 18; 38%), Italy (n = 6; 13%), the United States and Denmark (each n = 5; 10%). Primary outcomes were diverse, for example, quality-of-life, physical functioning, or disease activity. Only 1 trial (2%) used routinely collected data for outcome ascertainment. No trial was very pragmatic in all design aspects, but 14 trials (29%) were widely pragmatic (i.e. PRECIS-2 score ⩾ 4/5 in all domains).

CONCLUSION

Only few and mostly small pragmatic trials exist in MS which rarely assess drugs. Despite the widely available routine data infrastructures, very few trials utilize them. There is an urgent need to leverage the potential of this pioneering study design to provide useful randomized real-world evidence.

Long-term effectiveness of a cognitive behavioural therapy (CBT) in the management of fatigue in patients with relapsing remitting multiple sclerosis (RRMS): a multicentre, randomised, open-label, controlled trial versus standard care

BACKGROUND

Fatigue is a disabling symptom of multiple sclerosis (MS). The lack of effective therapeutics has promoted the development of cognitive behavioural therapy (CBT)-based fatigue management programmes. However, their efficacy does not sustain over time. We proposed to test the long-term effectiveness of a 6-week fatigue programme supplemented with four booster sessions ('FACETS+') in patients with relapsing remitting MS (RRMS) and fatigue.

METHODS

This multicentre, randomised, controlled, open-label, parallel-group trial versus standard care enrolled patients with RRMS and fatigue. Participants were randomised to either FACETS+ plus standard care or standard care alone. The primary outcome measure was fatigue impact (Modified Fatigue Impact Scale (MFIS) at 12 months) based on intention-to-treat analyses.

RESULTS

From May 2017 to September 2020, 162 patients were screened; 105 were randomly assigned to FACETS+ (n=57) or standard care (n=48) and 88 completed the primary outcome assessment for the MFIS. At month 12, participants showed improved MFIS compared with baseline in the intervention group (mean difference (MD)=14.0 points; (95% CI 6.45 to 21.5)) and the control group (MD=6.1 points; (95% CI -0.30 to 12.5)) with a significant between-group difference in favour of the intervention group (adjusted MD=7.89 points; (95% CI 1.26 to 14.52), standardised effect size=0.52, p=0.021). No trial-related serious adverse events were reported.

CONCLUSIONS

A 6-week CBT-based programme with four booster sessions is superior to standard care alone to treat MS-related fatigue in the long term (12 months follow-up). The results support the use of the FACETS+ programme for the treatment of MS-related fatigue.

TRIAL REGISTRATION NUMBER

NCT03758820.

Effectiveness of a blended booster programme for the long-term outcome of cognitive behavioural therapy for MS-related fatigue: A randomized controlled trial

BACKGROUND

Cognitive behavioural therapy (CBT) reduces MS-related fatigue. However, studies on the long-term effects show inconsistent findings.

OBJECTIVE

To evaluate whether a blended booster programme improves the outcome of CBT for MS-related fatigue on fatigue severity at 1-year follow-up.

METHOD

A multicentre randomized clinical trial in which 126 patients with MS were allocated to either a booster programme or no booster programme (control), after following 20-week tailored CBT for MS-related fatigue. Primary outcome was fatigue severity assessed with the Checklist Individual Strength fatigue subscale 1 year after start of treatment (T52). Mixed model analysis was performed by a statistician blinded for treatment-allocation to determine between-group differences in fatigue severity.

RESULTS

Fatigue severity at 1-year follow-up did not differ significantly between the booster (N = 62) and control condition (N = 64) (B = -2.01, 95% confidence interval (CI) = -4.76 to 0.75). No significant increase in fatigue severity was found at T52 compared with directly post-treatment (T20) in both conditions (B = 0.44, 95% CI = -0.97 to 1.85).

CONCLUSION

Effects of CBT were sustained up to 1 year in both conditions. The booster programme did not significantly improve the long-term outcome of CBT for MS-related fatigue.

TRIAL REGISTRATION

Dutch Trial Register (NTR6966), registered 18 January 2018 https://www.trialregister.nl/trial/6782.

Using participatory action research to develop a new self-management program: Results from the design stage of Managing My MS My Way

BACKGROUND

Self-management programs have been used with success in several clinical populations, and there is a growing body of evidence to support their use among persons with multiple sclerosis (MS). This group aimed to develop a novel self-management program, Managing My MS My Way (M⁴W), which is based in social cognitive theory and contains evidence-based strategies that have been shown to be effective for persons with MS. Furthermore, persons with MS would serve as stakeholders throughout the development process to ensure that the program would be useful and encourage adoption. This paper outlines the initial development stages of M⁴W, including determining 1) stakeholders' interest in a self-management program, 2) the general focus of the program, 3) the delivery method of the program, 4) the content of the program, and 5) potential barriers and adaptations.

METHODS

A three-stage study consisting of an anonymous survey (n = 187) to determine interest, topic, and delivery format; semi-structured interviews (n = 6) to follow-up on the survey results; and semi-structured interviews (n = 10) to refine the content and identify barriers.

RESULTS

Over 80% of survey participants were somewhat or very interested in a self-management program. Fatigue was the topic with the greatest amount of interest (64.7%). An internet-based program (e.g., mobile health or mHealth) was the most preferred delivery method (37.4%), with the first group of stakeholders proposing a module-based system with an initial in-person orientation session. The second group of stakeholders were overall enthusiastic about the program, giving moderate to high confidence scores for each of the proposed interventional strategies. Suggestions included skipping sections that were not applicable to them, setting reminders, and seeing their progress (e.g., visualizing their fatigue scores as they move through the program). In addition, stakeholders recommended larger font sizes and speech-to-text entry.

CONCLUSIONS

Input from the stakeholders has been incorporated into the prototype of M⁴W. The next steps will be to test this prototype with another group of stakeholders to assess its initial usability and identify issues before developing the functional prototype.

Coping as a Moderator of Associations Between Symptoms and Functional and Affective Outcomes in the Daily Lives of Individuals With Multiple Sclerosis

BACKGROUND

Pain and fatigue are highly prevalent in multiple sclerosis (MS) and are associated with adverse physical, social, and psychological outcomes. There is a critical need to identify modifiable factors that can reduce the impact of these symptoms on daily life.

PURPOSE

This study examined the moderating role of dispositional coping in the relationships between daily fluctuations (i.e., deviations from a person's usual level) in pain and fatigue and same-day functional/affective outcomes.

METHODS

Adults with MS (N = 102) completed a self-report measure of dispositional coping (Brief COPE), followed by 7 days of ecological momentary assessment of pain and fatigue and end-of-day diaries assessing same-day pain interference, fatigue impact, social participation, upper extremity and lower extremity functioning, depressive symptoms, and positive affect and well-being (PAWB). Multilevel models tested interactions between daily symptom fluctuations and dispositional coping (avoidant/approach) in predicting same-day outcomes.

RESULTS

Higher approach coping mitigated the same-day association between pain and pain interference, whereas higher avoidant coping augmented this association. Daily PAWB benefits were seen for those who reported high approach coping and low avoidant coping; effects were only observed on days of low pain (for approach coping) and low fatigue (for avoidant coping). Avoidant coping was associated with worse fatigue impact, social participation, lower extremity functioning, and depressive symptoms.

CONCLUSIONS

When faced with pain and fatigue, avoidant coping is associated with increased, and approach coping with decreased, functional/affective difficulties in the daily lives of individuals with MS. Altering coping strategy use may reduce the impact of pain and fatigue.

Mapping two decades of multiple sclerosis rehabilitation trials: A systematic scoping review and call to action to advance the study of race and ethnicity in rehabilitation research

BACKGROUND

Multiple sclerosis (MS), is prevalent across many racial and ethnic groups, and disproportionately impacts racially minoritized populations. Rehabilitation interventions are an important component of comprehensive MS care. Yet, we do not know the extent to which MS rehabilitation trials consider race and ethnicity in defining eligibility criteria, planning recruitment strategies, selecting outcome measures, supporting intervention delivery, and designing approaches to promote adherence and retention.

METHODS

We conducted a scoping review of five databases (MEDLINE, CINAHL, Cochrane Central, EMBASE, and Web of Science) to locate randomized controlled rehabilitation trials published from January 2002 to March 2022. We extracted data from relevant studies, assessed their methodological quality, and narratively summarized results. Reporting of this review is in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

RESULTS

Fifty-six studies of neurorehabilitation (n = 3), cognitive rehabilitation (n = 6), exercise training (n = 9) and self-management (n = 38) interventions were included in this review. The studies were predominantly from North America (n = 44; 73%) or Europe (n = 12; 20%) and included 4280 participants. Most participants (n = 3669; 86%) were Caucasians. Less than 10% of participants were Black (n = 282), Latinx/Hispanic (n = 60), Asian (n = 46), Indigenous (n = 7), or Arab (n = 2). Few studies discussed how race and/or ethnicity were considered in trial planning or execution.

CONCLUSIONS

Without consistent and systematic attention to race and ethnicity, both in terms of trial design and reporting, it is impossible to know how MS rehabilitation interventions will translate into real-world applications. This call to action - to the MS rehabilitation research community to ensure trial and intervention processes that accommodate the needs of diverse racial and ethnic groups - is an important first step in addressing inequities in rehabilitation care for persons with MS.

The relation between cognitive-behavioural responses to symptoms in patients with long term medical conditions and the outcome of cognitive behavioural therapy for fatigue - A secondary analysis of four RCTs

BACKGROUND

Cognitive behavioural therapy (CBT) is effective in reducing fatigue across long-term conditions (LTCs). This study evaluated whether cognitive and behavioural responses to symptoms: 1) differ between LTCs and 2) moderate and/or mediate the effect of CBT on fatigue.

METHOD

Data were used from four Randomized Controlled Trials testing the efficacy of CBT for fatigue in Chronic Fatigue Syndrome/ME (N = 240), Multiple Sclerosis (N = 90), Type 1 Diabetes Mellitus (N = 120) and Q-fever fatigue syndrome (N = 155). Fatigue severity, assessed with the Checklist Individual Strength, was the primary outcome. Differences in fatigue perpetuating factors, assessed with the Cognitive Behavioural Responses to Symptoms Questionnaire (CBRQ), between diagnostic groups were tested using ANCOVAs. Linear regression and mediation analyses were used to investigate moderation and mediation by CBRQ scores of the treatment effect.

RESULTS

There were small to moderate differences in CBRQ scores between LTCs. Patients with higher scores on the subscales damage beliefs and avoidance/resting behaviour at baseline showed less improvement following CBT, irrespective of diagnosis. Reduction in fear avoidance, catastrophising and avoidance/resting behaviour mediated the positive effect of CBT on fatigue across diagnostic groups.

DISCUSSION

The same cognitive-behavioural responses to fatigue moderate and mediate treatment outcome across conditions, supporting a transdiagnostic approach to fatigue.

Understanding lifestyle self-management regimens that improve the life quality of people living with multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Lifestyle self-management as an intervention for people living with multiple sclerosis (plwMS) is an emerging area of research. Previous reviews have highlighted a need to systematically identify effective self-management regimens that influence the health and well-being of plwMS using a common metric of success.

OBJECTIVES

To examine the effectiveness of lifestyle self-management strategies and interventions aimed at improving the quality of life (QOL), and/or disability of plwMS. The review also aimed to narratively explore common elements of self-management interventions that were effective at improving the outcomes of interest.

METHODS

A systematic search was performed using five scientific databases. The review process followed the Cochrane Handbook for Systematic Reviews of Interventions  and was registered with PROSPERO (Ref: CRD42021235982).

RESULTS

A total of 57 studies including 5830 individuals diagnosed with MS, met the inclusion criteria. Self-management interventions included physical activity, fatigue, dietary, stress/coping, emotional, symptom and medical management, and lifestyle and wellbeing programs. Self-reported QOL improved in 35 of 47 studies. Dietary intervention had no statistically significant overall effect on reducing MS disability, (P = 0.18). Heterogeneity limited the ability to pool the effects from a large number of eligible studies of the same design.

CONCLUSION

Multicomponent self-management interventions, multimodal delivery methods, and cognitive behavioural theory principles were common elements of self-management interventions that improved the QOL of plwMS. However, these results should be interpreted with caution and care should be taken in its clinical application. This review has the potential to inform future management practices for plwMS and has revealed a significant gap in the literature, warranting high-quality, large-scale experimental, and observational studies that address lifestyle management.

A systematic review of economic analyses of psychological interventions and therapies in health-related settings

Background

This review aims to synthesise evidence on the economic impact of psychological interventions and therapies when applied to a broad range of physical health conditions.

Methods

The following bibliographic databases were searched for relevant articles: MEDLINE (Ovid), EMBASE (Ovid) and PsycINFO (Ebsco). As this review was intended to update an earlier review, the date range for the search was restricted to between January 2012 and September 2018. Reference lists from the review articles were also searched for relevant articles. Study quality was evaluated using the Scottish Intercollegiate Network Guidelines (SIGN) appraisal checklists for both economic studies and Randomised Controlled Trials (RCTs). When the economic analyses did not provide sufficient detail for quality evaluation, the original RCT papers were sought and these were also evaluated. Half of the papers were quality rated by a second author. Initial agreement was high and all disagreements were resolved by discussion.

Results

This yielded 1408 unique articles, reduced to 134 following screening of the title and abstract. The full texts of the remaining articles were reviewed by at least one team member and all exclusions were discussed and agreed by the team. This left 46 original research articles, alongside five systematic reviews. Fifty-seven per cent of the articles were deemed to be of high quality, with the remainder of acceptable quality. Fifteen different medical conditions were covered, with chronic pain (10 articles) and cancer (9 articles) being the two most investigated health conditions. Three quarters of the papers reviewed showed evidence for the cost-effectiveness of psychological interventions in physical health, with the clearest evidence being in the field of chronic pain and cancer.

Conclusions

This paper provides a comprehensive integration of the research on the cost-effectiveness of psychological therapies in physical health. Whilst the evidence for cost-effectiveness in chronic pain and cancer is encouraging, some health conditions require further study. Clearly, as the primary research is international, and was therefore conducted across varying health care systems, caution must be exercised when applying the results to counties outside of those covered. Despite this, the results are of potential relevance to service providers and funders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08158-0.

Fatigue self-management led by occupational therapists and/or physiotherapists for chronic conditions: A systematic review and meta-analysis

OBJECTIVE

The aim of this study was to investigate the effectiveness of occupational therapist-/physiotherapist-guided fatigue self-management for individuals with chronic conditions.

METHODS

Eight databases, including MEDLINE and EMBASE, were searched until September 2019 to identify relevant studies. Randomised controlled trials and quasi-experimental studies of self-management interventions specifically developed or delivered by occupational therapists/physiotherapists to improve fatigue symptoms of individuals with chronic conditions were included. A narrative synthesis and meta-analysis were conducted to determine the effectiveness of fatigue self-management.

RESULTS

Thirty-eight studies were included, and fatigue self-management approaches led by occupational therapists/physiotherapists were divided into six categories based on the intervention focus: exercise, energy conservation, multimodal programmes, activity pacing, cognitive-behavioural therapy, and comprehensive fatigue management. While all exercise programmes reported significant improvement in fatigue, other categories showed both significant improvement and no improvement in fatigue. Meta-analysis yielded a standardised mean difference of the overall 13 studies: 0.42 (95% confidence interval:-0.62 to - 0.21); standardised mean difference of the seven exercise studies was -0.55 (95% confidence interval: -0.78 to -0.31).

DISCUSSION

Physical exercises inspired by the self-management principles may have positive impacts on fatigue symptoms, quality of life, and other functional abilities.

Exploring Patient Outcomes After Participation in an Inpatient Occupation-Based Group: A Longitudinal Observational Cohort Study

IMPORTANCE

Occupation-based interventions are used during inpatient rehabilitation, and group models may enhance intervention delivery. However, little is known about the impact of occupation-based groups on patient outcomes.

OBJECTIVE

To examine the effect of an occupation-based group on patient outcome measures of instrumental activities of daily living (IADL) skills over time and explore demographic differences among patients.

DESIGN

Longitudinal observational cohort study with four time points: preintervention, postintervention, 30-day follow-up, and 90-day follow-up.

SETTING

Tertiary hospital general rehabilitation ward.

PARTICIPANTS

Inpatient adults age 18 or older recruited using consecutive sampling from those referred to the group.

INTERVENTION

The LifeSkills group, which focused on repetitive practice of meaningful occupation-based activities.

OUTCOMES AND MEASURES

Demographic data were obtained, and the Canadian Occupational Performance Measure (COPM), Goal Attainment Scaling, Lawton IADL scale, and a self-efficacy scale were administered at each data point.

RESULTS

Thirty people (21 women, 9 men; ages 35-91 yr) participated, with 5 lost to follow-up. A statistically significant increase in scores postintervention occurred on all measures and was also seen at 90-day follow-up for COPM occupational performance, satisfaction, and self-efficacy scores. Lawton IADL scale scores at follow-up were lower than those at preintervention and statistically significant. No significant differences were found for age and diagnosis.

CONCLUSIONS AND RELEVANCE

Positive patient outcomes of goal achievement, occupational performance, satisfaction, and self-efficacy were seen at discharge, with evidence of sustainability over time. This could be a resource alternative for addressing skill retraining because people with different diagnoses and in different age groups benefited equally. What This Article Adds: Occupation-based group programs have encouraging application in general inpatient rehabilitation for addressing patient outcomes.

Fatigue self-management education in persons with disease-related fatigue: A comprehensive review of the effectiveness on fatigue and quality of life

OBJECTIVES

To systematically synthesize the effectiveness of fatigue self-management education (SME) on fatigue and quality of life (QoL) in persons with disease-related fatigue, and to describe the intervention characteristics.

METHODS

We systematically reviewed the literature on SMEs in people with disease-related fatigue. We included randomized controlled trials (RCT), which aimed to improve self-management skills for fatigue in daily life. We synthesized the effectiveness and mapped the intervention characteristics.

RESULTS

We included 26 RCTs studying samples from eight disease groups. At follow-up, 46% studies reported statistically significant improvements on fatigue and 46% on QoL. For persons with cancer 6/8 and multiple sclerosis 8/10 RCTs showed positive evidence in favor of SME. The range of effect sizes was wide (d: 0.0 ->0.8). Delivery modalities (inpatient, outpatient, home), interactions (individual, group, remote), and duration [range (h): 1-17.5] varied.

CONCLUSIONS

The overall evidence on the effectiveness of SMEs on fatigue and QoL is limited and inconsistent. For persons with cancer and multiple sclerosis, the evidence provides a positive effect. The RCTs with medium to large effect on QoL indicate the potential benefit of SMEs.

PRACTICAL IMPLICATION

Duration and peer interaction should be considered when tailoring SMEs to populations and contexts.

Moderators of Improvements in Fatigue Impact After a Self-management Intervention in Multiple Sclerosis: A Secondary Analysis of a Randomized Controlled Trial

ABSTRACT

Fatigue is one of the most common and disabling symptoms of multiple sclerosis. A recent randomized controlled trial comparing a fatigue self-management program and a general multiple sclerosis education program found that both programs improved fatigue in participants with multiple sclerosis. Participants were randomized to a self-management program (fatigue: take control, n = 109) or a multiple sclerosis education program (multiple sclerosis: take control, n = 109). This secondary analysis of that trial used multilevel moderation analysis to examine moderators of treatment-related effects on fatigue (Modified Fatigue Impact Scale) from baseline through the 6-mo follow-up. The following potential treatment moderators were examined: age, sex, cohabitation/marital status, and baseline levels of self-efficacy, depression symptoms, and sleep quality. Cohabitation status (living with or without a spouse/partner) interacted with intervention group and time to predict fatigue impact (P = 0.04). Fatigue: take control participants who lived with a spouse/partner showed a marginal effect in greater rate of improvement in fatigue compared with those who lived alone (P = 0.08). However, rates of improvement in fatigue in multiple sclerosis: take control participants were similar in those living with or without a spouse/partner. These findings suggest that living with a spouse or partner may facilitate benefit from self-management interventions for multiple sclerosis-related fatigue. Future research should investigate the contribution of supportive others in self-management of fatigue in multiple sclerosis.

Defining routine fatigue care in Multiple Sclerosis in the United Kingdom: What treatments are offered and who gets them?

Background

Fatigue is common and disabling in Multiple Sclerosis (MS). A recent meta-analytic systematic review reported 113 trials of exercise and behavioural interventions for fatigue, yet patients consistently describe fatigue being under-treated. The extent of the research-to-practice gap is yet to be documented.

Objective

To describe what fatigue treatments people with MS (pwMS) in the United Kingdom (UK) have been offered.

Methods

A cross-sectional survey of pwMS on the UK MS Register (UKMSR). Data on fatigue treatments offered were collected using an online questionnaire developed with patient input and summarised using descriptive statistics. Sociodemographic, MS-related, and psychological factors associated with treatment offered were evaluated using a logistic regression model.

Results

4,367 respondents completed the survey, 90.3% reported experiencing fatigue. Of these, 30.8% reported having been offered at least one type of pharmacological/non-pharmacological treatment for fatigue. Pharmacological treatments were more commonly offered (22.4%) compared to non-pharmacological treatments (12.6%; 2.9% exercise and 5.9% behavioural therapy). In the logistic regression model, older age, working, shorter time since MS diagnosis, and lower fatigue were associated with lower odds of having been offered treatment for fatigue.

Conclusion

This study accentuates the extent of the unmet need for fatigue treatment in MS in the UK.

Creating a Digital Toolkit to Reduce Fatigue and Promote Quality of Life in Multiple Sclerosis: Participatory Design and Usability Study

Background

Fatigue is one of the most common and debilitating symptoms of multiple sclerosis (MS), experienced by more than 80% of people with MS. FACETS (Fatigue: Applying Cognitive Behavioral and Energy Effectiveness Techniques to Lifestyle) is an evidence-based, face-to-face, 6-session group fatigue management program for people with MS. Homework tasks are an integral part of FACETS and are currently undertaken in a paper-based form. Feedback from a consultation undertaken with FACETS attendees and health care professionals with experience in delivering the FACETS program suggested that being able to complete the homework tasks digitally would be desirable, potentially enhancing engagement and adherence and enabling on-the-go access to fit into busy lifestyles. Relative to other long-term conditions, there are few apps specifically for MS and, of those available, many have been developed with little or no input from people with MS.

Objective

The purpose of this mixed methods study was to create a digital toolkit comprising the homework tasks (eg, activity diary, goal planner, thought diary) of the FACETS program for people with MS, considering end users’ unique requirements throughout the design, build, prototyping, and testing stages.

Methods

Phase 1 involved the elicitation of detailed user requirements for the toolkit via 2 focus groups with previous attendees of FACETS (n=3 and n=6) and wireframing. Phase 2 involved supervised usability testing with people with MS (n=11) with iterative prototyping. The usability sessions involved going through test scenarios using the FACETS toolkit on an Android test phone with video capture and concurrent think-aloud followed by completion of the System Usability Scale (SUS) and a semistructured interview collecting feedback about design, content, and functionality.

Results

The mean SUS score for the digital toolkit was 74.3 (SD 16.8, 95% CI 63.2-85.6; range 37.5-95), which equates to an adjective rating of good and a B grade (70th-79th percentile range) on the Sauro-Lewis curved grading scale. A number of usability and design issues (such as simplifying overall screen flow to better meet users’ needs) and suggestions for improvements (such as using location-based services and displaying personalized information and progress via a central dashboard) were addressed and implemented during the usability testing cycle.

Conclusions

This work highlights the importance of the participation of people with MS across the entire development cycle, working to a human-centered design methodology to enable a considered and MS-centered solution to be developed. Continued horizon scanning for emergent technological enhancements will enable us to identify opportunities for further improvements to the FACETS toolkit prior to launch. The toolkit supports self-monitoring and management of fatigue and has potential applicability to other long-term conditions where fatigue is a significant issue.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Self-efficacy training as an adjunct to exercise in a person with progressive multiple sclerosis: a case report

Background: Increasing self-efficacy to exercise and minimizing disease-related barriers has been shown to improve physical activity levels and quality of life (QOL) in persons with multiple sclerosis (MS). Currently, little research has examined exercise self-efficacy in persons with more advanced MS. Purpose: Explore the effects of a self-efficacy plus exercise intervention on physical activity endurance and level, QOL, and fatigue in an individual with advanced MS and low self-efficacy.Methods: The participant was a 60-year-old, severely disabled female with secondary progressive MS and an Expanded Disability Status Score (EDSS) of 8. The 8-week intervention consisted of weekly discussions and MS-related education; four one-on-one sessions with a MS "mentor;" daily journal to record sleep quality, fatigue level, and physical activity. Outcomes included a modified 5-meter walk test (5MWT), MS Impact Scale (MSIS-29), Exercise Self-Efficacy Scale (EX-ES), Modified Fatigue Impact Scale (MFIS), MS Self-Efficacy Scale (MS-SES), Patient Health Questionnaire-9 (PHQ-9), and daily physical activity monitoring. Outcomes were assessed at baseline (week 0), post-intervention (week 8), and 8 weeks post intervention (week 16). The participant continued her regular exercise routine independently throughout the study period.Results: There were notable improvements in EX-ES, MFIS, PHQ-9, MSIS-29 psychological subscale, sleep quality, and morning fatigue ratings post intervention, some of which were retained at follow up.Conclusion: The findings illustrate that an 8-week self-efficacy intervention increased exercise self-efficacy, QOL, and reduced perceived fatigue in a severely disabled individual with progressive MS. Future research should examine self-efficacy interventions in a larger sample size of persons with progressive MS.

Perceptions of fatigue and fatigue management interventions among people with multiple sclerosis: a systematic literature review and narrative synthesis

Background/Aims

Fatigue is the most common symptom of multiple sclerosis. Evidence supports the effectiveness of fatigue management interventions for people with multiple sclerosis. This review aimed to identify how people with multiple sclerosis experience fatigue and to examine their perceptions of fatigue management interventions.

Methods

The review was conducted systematically, searching the following electronic databases: AMED, CINAHL Complete, eBook Nursing Collection, ERIC, Health Source: Nursing/Academic Edition, MEDLINE, APA PsycArticles, and APA PsycInfo for original peer-reviewed empirical research published in English between January 2000 and June 2020. Qualitative and mixed-methods studies that captured the perspectives of people with multiple sclerosis on their fatigue and/or their perceptions of fatigue management interventions were included. A narrative synthesis was used to synthesise the findings.

Results

A total of 23 qualitative and eight mixed-methods studies were extracted comprising a total of 662 people with multiple sclerosis (relapsing remitting n=293; secondary progressive n=129; primary progressive n=73; relapsing progressive n=3; benign n=2; fulminant n=1; type of multiple sclerosis not reported n=161). Fatigue was perceived by people with multiple sclerosis as a debilitating symptom of the condition and which they felt impacted adversely on their lives. A lack of understanding from others about multiple sclerosis fatigue was challenging for people with multiple sclerosis. People with multiple sclerosis valued the physical and psychosocial-based content of fatigue management interventions and felt fatigue management interventions enabled them to legitimise their fatigue and feel more in control of their fatigue.

Conclusions

From the perspective of people with multiple sclerosis, fatigue is a central and debilitating feature of the everyday experience of living with multiple sclerosis. Research on the potential of fatigue management interventions to foster control for people with multiple sclerosis to help them manage their fatigue is warranted. Healthcare professionals should consider how they can empower people with multiple sclerosis to educate others about their fatigue. Some evidence being generated for practice might not be sufficiently contextualised to different forms of multiple sclerosis.

Group cognitive rehabilitation to reduce the psychological impact of multiple sclerosis on quality of life: the CRAMMS RCT

BACKGROUND

People with multiple sclerosis have problems with memory and attention. The effectiveness of cognitive rehabilitation has not been established.

OBJECTIVES

The objectives were to assess the clinical effectiveness and cost-effectiveness of a cognitive rehabilitation programme for people with multiple sclerosis.

DESIGN

This was a multicentre, randomised controlled trial in which participants were randomised in a ratio of 6 : 5 to receive cognitive rehabilitation plus usual care or usual care alone. Participants were assessed at 6 and 12 months after randomisation.

SETTING

The trial was set in hospital neurology clinics and community services.

PARTICIPANTS

Participants were people with multiple sclerosis who had cognitive problems, were aged 18-69 years, could travel to attend group sessions and gave informed consent.

INTERVENTION

The intervention was a group cognitive rehabilitation programme delivered weekly by an assistant psychologist to between four and six participants for 10 weeks.

MAIN OUTCOME MEASURES

The primary outcome was the Multiple Sclerosis Impact Scale - Psychological subscale at 12 months. Secondary outcomes included results from the Everyday Memory Questionnaire, the 30-Item General Health Questionnaire, the EuroQol-5 Dimensions, five-level version and a service use questionnaire from participants, and the Everyday Memory Questionnaire - relative version and the Modified Carer Strain Index from a relative or friend of the participant.

RESULTS

Of the 449 participants randomised, 245 were allocated to cognitive rehabilitation (intervention group) and 204 were allocated to usual care (control group). Of these, 214 in the intervention group and 173 in the control group were included in the primary analysis. There was no clinically important difference in the Multiple Sclerosis Impact Scale - Psychological subscale score between the two groups at the 12-month follow-up (adjusted difference in means -0.6, 95% confidence interval -1.5 to 0.3; p = 0.20). There were no important differences between the groups in relation to cognitive abilities, fatigue, employment, or carer strain at follow-up. However, there were differences, although small, between the groups in the Multiple Sclerosis Impact Scale - Psychological subscale score at 6 months (adjusted difference in means -0.9, 95% confidence interval -1.7 to -0.1; p = 0.03) and in everyday memory on the Everyday Memory Questionnaire as reported by participants at 6 (adjusted difference in means -5.3, 95% confidence interval -8.7 to -1.9) and 12 months (adjusted difference in means -4.4, 95% confidence interval -7.8 to -0.9) and by relatives at 6 (adjusted difference in means -5.4, 95% confidence interval -9.1 to -1.7) and 12 months (adjusted difference in means -5.5, 95% confidence interval -9.6 to -1.5) in favour of the cognitive rehabilitation group. There were also differences in mood on the 30-Item General Health Questionnaire at 6 (adjusted difference in means -3.4, 95% confidence interval -5.9 to -0.8) and 12 months (adjusted difference in means -3.4, 95% confidence interval -6.2 to -0.6) in favour of the cognitive rehabilitation group. A qualitative analysis indicated perceived benefits of the intervention. There was no evidence of a difference in costs (adjusted difference in means -£574.93, 95% confidence interval -£1878.93 to £729.07) or quality-adjusted life-year gain (adjusted difference in means 0.00, 95% confidence interval -0.02 to 0.02). No safety concerns were raised and no deaths were reported.

LIMITATIONS

The trial included a sample of participants who had relatively severe cognitive problems in daily life. The trial was not powered to perform subgroup analyses. Participants could not be blinded to treatment allocation.

CONCLUSIONS

This cognitive rehabilitation programme had no long-term benefits on quality of life for people with multiple sclerosis.

FUTURE WORK

Future research should evaluate the selection of those who may benefit from cognitive rehabilitation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN09697576.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 4. See the National Institute for Health Research Journals Library website for further project information.

The "Managing Fatigue" programme - experiences shared by MS participants

BACKGROUND

The "Managing Fatigue" (MF) programme can help people living with Multiple sclerosis (MS) manage fatigue in their everyday lives. The programme has been proven feasible with Swedish occupational therapists, but there is a lack of knowledge of how MS participants experience the programme, and what they learned from participating in the programme.

AIM

To describe how Swedish MS participants experience the content and structure of the Swedish MF programme, as well as what they learned from participating in the programme.

MATERIAL AND METHODS

Qualitative interviews were performed with nine MS participants, and data were analysed according to direct content analysis.

RESULTS

Participants experienced programme material was relevant, and they valued the structured sessions that utilised different teaching forms. Participants described the group format and the experienced course leader nurtured their learning process. They learned occupational skills to save energy, to re-value daily occupations, and initiated a process of change, but individual support is needed after programme completion.

CONCLUSION AND SIGNIFICANCE

Findings support programme feasibility among MS participants, and show the importance of being able to practice skills to handle fatigue in everyday life. Future studies should consider adding outcome measures focussing on engagement in occupations when evaluating programme effectiveness.

Effectiveness of Group Counseling with a Client-Centered Approach Based on the GATHER Principles on Sexual Satisfaction in Women with Multiple Sclerosis: A Randomized Clinical Trial

Background

Multiple sclerosis (MS) is the most prevalent progressive sensory/neurological disability in young adults, with important psychological consequences. The present study was designed to assess the effectiveness of group counseling with a client-centered approach based on the GATHER principles on sexual satisfaction in women with MS.

Methods

In this clinical trial, conducted from January 2018 to May 2019, in the MS Referral Center of Tehran (Iran), 72 eligible participants were assigned to intervention and control groups (36 in each group) via simple randomization. The intervention group received group counseling based on the client-centered approach, while the control group received routine counseling. Data were collected using the Larson Sexual Satisfaction Questionnaire (LSSQ) at three different time points: before the intervention, after the final session, and one month after the intervention. The collected data were analyzed in SPSS software (version 19). In order to analyze the obtained data, independent t test, Mann-Whitney U test, paired t test, Wilcoxon test, Chi-square test, Fisher exact test, and Friedman test were used.

Results

The mean score of sexual satisfaction before the intervention showed no statistically significant difference between the two groups. Based on the Friedman test in the intervention group, the trend of changes in the mean score of sexual satisfaction had a significant difference before the intervention, after the final session, and one month after the intervention (P=0.001); however, no significant difference was observed in the control group.

Conclusion

Our results showed the effectiveness of group counseling with a client-centered approach based on the GATHER principles on sexual satisfaction and intimacy among women with MS. Trial Registration Number IRCT20180110038302N3.

Design considerations for a multiple sclerosis fatigue mobile app MS Energize: A pragmatic iterative approach using usability testing and resonance checks

Multiple sclerosis (MS) is a chronic neurological condition affecting around 2.2 million people worldwide. The illness includes a range of symptoms, with fatigue considered to be one of the most disabling. This paper describes how a pragmatic and iterative approach, supported by usability and resonance testing, was used to build a minimum viable product of MS Energize-or MS Energise in UK English regions. MS Energise is a mobile application focused on self-management of fatigue for people with MS. The iterative approach included various stages of testing, during which user feedback including comments about interface, navigation and content, was sought to inform incremental app development and continual improvement. Usability testing was conducted with 11 people with longstanding multiple sclerosis in New Zealand and the United Kingdom, and focused on particular sections of the app as well as the accessibility of the app to users with MS. Two participants contributed to further resonance testing post-release to ensure the app was perceived as relevant and useful to the user. The usability testing and resonance testing phases suggested that user experience of MS Energise was mostly positive. Participants provided a number of suggestions for improvements to aspects of content and design; some of which we implemented during our app development process. Findings will also contribute to future planning and design iteration to enhance the user experience. The next step is further improvement of MS Energise prior to a trial of its clinical and cost effectiveness.

Evidence-Based Rehabilitation for Multiple Sclerosis Made Easy: The Online Applying Evidence with Confidence (APPECO) Platform

With the current rate in growth of evidence in multiple sclerosis (MS) rehabilitation, systematic reviews and clinical guidelines typically lag behind the most currently published research findings. In addition, most health care professionals lack the time, resources, or adequate skills to identify and evaluate new evidence, and hands-on tools to implement the latest evidence into clinical practice are often lacking or not readily available. The Applying Evidence with Confidence (APPECO) platform is a newly developed online tool that addresses these key challenges. APPECO was initiated as a proof-of-concept for the common MS symptoms fatigue and cognitive function. Subsequently, intervention studies about depression, pain, and mobility were added. APPECO currently hosts detailed information from 250 randomized clinical trials, 293 interventions, and 1250 effect sizes on 53 patient outcomes. Few studies with high quality (ie, low risk of bias) are available specifically designed to test the benefits of MS rehabilitation on fatigue (n = 5 [2.4%]), cognitive function (n = 4 [1.6%]), and depression (n = 2 [0.8%]). No high-quality studies were included for pain and mobility. APPECO has the potential to address key challenges in evidence-based rehabilitation medicine for MS and to facilitate swift knowledge translation from evidence into clinical practice. Sustainability of APPECO depends on a continuous resource impulse (eg, financial, time, editorial management, platform maintenance) to ensure up-to-date information across all relevant MS symptoms and activity limitations (≈2-6 randomized controlled trials per month). Ways to optimize knowledge translation in the absence of high-quality evidence in APPECO need to be explored further.

Balance Right in Multiple Sclerosis (BRiMS): a feasibility randomised controlled trial of a falls prevention programme

Background

Balance, mobility impairments and falls are problematic for people with multiple sclerosis (MS). The “Balance Right in MS (BRiMS)” intervention, a 13-week home and group-based exercise and education programme, aims to improve balance and minimise falls. This study aimed to evaluate the feasibility of undertaking a multi-centre randomised controlled trial and to collect the necessary data to design a definitive trial.

Methods

This randomised controlled feasibility study recruited from four United Kingdom NHS clinical neurology services. Patients ≥ 18 years with secondary progressive MS (Expanded Disability Status Scale 4 to 7) reporting more than two falls in the preceding 6 months were recruited. Participants were block-randomised to either a manualised 13-week education and exercise programme (BRiMS) plus usual care, or usual care alone.

Feasibility assessment evaluated recruitment and retention rates, adherence to group assignment and data completeness. Proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls) and economic data were collected at baseline, 13 and 27 weeks, and participants completed daily paper falls diaries.

Results

Fifty-six participants (mean age 59.7 years, 66% female, median EDSS 6.0) were recruited in 5 months; 30 randomised to the intervention group. Ten (18%) participants withdrew, 7 from the intervention group. Two additional participants were lost to follow up at the final assessment point. Completion rates were > 98% for all outcomes apart from the falls diary (return rate 62%).

After adjusting for baseline score, mean intervention—usual care between-group differences for the potential primary outcomes at week 27 were MS Walking Scale-12v2: − 7.7 (95% confidence interval [CI] − 17.2 to 1.8) and MS Impact Scale-29v2: physical 0.6 (CI − 7.8 to 9), psychological − 0.4 (CI − 9.9 to 9). In total, 715 falls were reported, rate ratio (intervention:usual care) for falls 0.81 (0.41 to 2.26) and injurious falls 0.44 (0.41 to 2.23).

Conclusions

Procedures were practical, and retention, programme engagement and outcome completion rates satisfied a priori progression criteria. Challenges were experienced in completion and return of daily falls diaries. Refinement of methods for reporting falls is therefore required, but we consider a full trial to be feasible.

Trial registration

ISRCTN13587999

Date of registration: 29 September 2016

[Effects of rehabilitation on fatigue, disability and quality of life in people with multiple sclerosis: A systematic review]

OBJECTIVE

To assess the effectiveness of rehabilitation, highlighting the role of Occupational Therapy, in people with multiple sclerosis, in terms of disability, fatigue and quality of life.

MATERIALS AND METHODS

A literature search was carried out in the BVS, Cochrane, OT-Seeker, PubMed and PEDro databases.

INCLUSION CRITERIA

Controlled clinical trials published between January 2011 and April 2019 in Spanish or English with a score of ≥5 on the PEDro scale whose purpose was rehabilitation through the use of assistive technology, skills training, vestibular rehabilitation, behaviour modification, therapeutic education or specific Occupational Therapy interventions.

RESULTS

A total of 16 studies (1,279 subjects) were included. Rehabilitation improved patients' fatigue and disability and slightly enhanced their quality of life.

CONCLUSIONS

Rehabilitation can provide benefits to the performance of people with multiple sclerosis by reducing their perceived fatigue and disability.

LIMITATIONS

The heterogeneity of the sample, the type and duration of the interventions and variability of the instruments for measuring results.

Occupational therapy consensus recommendations for functional neurological disorder

BACKGROUND

People with functional neurological disorder (FND) are commonly seen by occupational therapists; however, there are limited descriptions in the literature about the type of interventions that are likely to be helpful. This document aims to address this issue by providing consensus recommendations for occupational therapy assessment and intervention.

METHODS

The recommendations were developed in four stages. Stage 1: an invitation was sent to occupational therapists with expertise in FND in different countries to complete two surveys exploring their opinions regarding best practice for assessment and interventions for FND. Stage 2: a face-to-face meeting of multidisciplinary clinical experts in FND discussed and debated the data from stage 1, aiming to achieve consensus on each issue. Stage 3: recommendations based on the meeting were drafted. Stage 4: successive drafts of recommendations were circulated among the multidisciplinary group until consensus was achieved.

RESULTS

We recommend that occupational therapy treatment for FND is based on a biopsychosocial aetiological framework. Education, rehabilitation within functional activity and the use of taught self-management strategies are central to occupational therapy intervention for FND. Several aspects of occupational therapy for FND are distinct from therapy for other neurological conditions. Examples to illustrate the recommendations are included within this document.

CONCLUSIONS

Occupational therapists have an integral role in the multidisciplinary management of people with FND. This document forms a starting point for research aiming to develop evidence-based occupational therapy interventions for people with FND.

A self-management programme to reduce falls and improve safe mobility in people with secondary progressive MS: the BRiMS feasibility RCT

BACKGROUND

Balance, mobility impairments and falls are common problems for people with multiple sclerosis (MS). Our ongoing research has led to the development of Balance Right in MS (BRiMS), a 13-week home- and group-based exercise and education programme intended to improve balance and encourage safer mobility.

OBJECTIVE

This feasibility trial aimed to obtain the necessary data and operational experience to finalise the planning of a future definitive multicentre randomised controlled trial.

DESIGN

Randomised controlled feasibility trial. Participants were block randomised 1 : 1. Researcher-blinded assessments were scheduled at baseline and at 15 and 27 weeks post randomisation. As is appropriate in a feasibility trial, statistical analyses were descriptive rather than involving formal/inferential comparisons. The qualitative elements utilised template analysis as the chosen analytical framework.

SETTING

Four sites across the UK.

PARTICIPANTS

Eligibility criteria included having a diagnosis of secondary progressive MS, an Expanded Disability Status Scale (EDSS) score of between ≥ 4.0 and ≤ 7.0 points and a self-report of two or more falls in the preceding 6 months.

INTERVENTIONS

Intervention - manualised 13-week education and exercise programme (BRiMS) plus usual care. Comparator - usual care alone.

MAIN OUTCOME MEASURES

Trial feasibility, proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls), feasibility of the BRiMS programme (via process evaluation) and economic data.

RESULTS

A total of 56 participants (mean age 59.7 years, standard deviation 9.7 years; 66% female; median EDSS score of 6.0 points, interquartile range 6.0-6.5 points) were recruited in 5 months; 30 were block randomised to the intervention group. The demographic and clinical data were broadly comparable at baseline; however, the intervention group scored worse on the majority of baseline outcome measures. Eleven participants (19.6%) withdrew or were lost to follow-up. Worsening of MS-related symptoms unrelated to the trial was the most common reason (n = 5) for withdrawal. Potential primary and secondary outcomes and economic data had completion rates of > 98% for all those assessed. However, the overall return rate for the patient-reported falls diary was 62%. After adjusting for baseline score, the differences between the groups (intervention compared with usual care) at week 27 for the potential primary outcomes were MS Walking Scale (12-item) version 2 -7.7 [95% confidence interval (CI) -17.2 to 1.8], MS Impact Scale (29-item) version 2 (MSIS-29vs2) physical 0.6 (95% CI -7.8 to 9) and MSIS-29vs2 psychological -0.4 (95% CI -9.9 to 9) (negative score indicates improvement). After the removal of one outlier, a total of 715 falls were self-reported over the 27-week trial period, with substantial variation between individuals (range 0-93 falls). Of these 715 falls, 101 (14%) were reported as injurious. Qualitative feedback indicated that trial processes and participant burden were acceptable, and participants highlighted physical and behavioural changes that they perceived to result from undertaking BRiMS. Engagement varied, influenced by a range of condition- and context-related factors. Suggestions to improve the utility and accessibility of BRiMS were highlighted.

CONCLUSIONS

The results suggest that the trial procedures are feasible and acceptable, and retention, programme engagement and outcome completion rates were sufficient to satisfy the a priori progression criteria. Challenges were experienced in some areas of data collection, such as completion of daily diaries.

FUTURE WORK

Further development of BRiMS is required to address logistical issues and enhance user-satisfaction and adherence. Following this, a definitive trial to assess the clinical effectiveness and cost-effectiveness of the BRiMS intervention is warranted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13587999.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 27. See the NIHR Journals Library website for further project information.

Group cognitive-behavioural programme to reduce the impact of rheumatoid arthritis fatigue: the RAFT RCT with economic and qualitative evaluations

BACKGROUND

Fatigue is a major problem in rheumatoid arthritis (RA). There is evidence for the clinical effectiveness of cognitive-behavioural therapy (CBT) delivered by clinical psychologists, but few rheumatology units have psychologists.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of a group CBT programme for RA fatigue [named RAFT, i.e. Reducing Arthritis Fatigue by clinical Teams using cognitive-behavioural (CB) approaches], delivered by the rheumatology team in addition to usual care (intervention), with usual care alone (control); and to evaluate tutors' experiences of the RAFT programme.

DESIGN

A randomised controlled trial. Central trials unit computerised randomisation in four consecutive cohorts within each of the seven centres. A nested qualitative evaluation was undertaken.

SETTING

Seven hospital rheumatology units in England and Wales.

PARTICIPANTS

Adults with RA and fatigue severity of ≥ 6 [out of 10, as measured by the Bristol Rheumatoid Arthritis Fatigue Numerical Rating Scale (BRAF-NRS)] who had no recent changes in major RA medication/glucocorticoids.

INTERVENTIONS

RAFT - group CBT programme delivered by rheumatology tutor pairs (nurses/occupational therapists). Usual care - brief discussion of a RA fatigue self-management booklet with the research nurse.

MAIN OUTCOME MEASURES

Primary - fatigue impact (as measured by the BRAF-NRS) at 26 weeks. Secondary - fatigue severity/coping (as measured by the BRAF-NRS); broader fatigue impact [as measured by the Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire (BRAF-MDQ)]; self-reported clinical status; quality of life; mood; self-efficacy; and satisfaction. All data were collected at weeks 0, 6, 26, 52, 78 and 104. In addition, fatigue data were collected at weeks 10 and 18. The intention-to-treat analysis conducted was blind to treatment allocation, and adjusted for baseline scores and centre. Cost-effectiveness was explored through the intervention and RA-related health and social care costs, allowing the calculation of quality-adjusted life-years (QALYs) with the EuroQol-5 Dimensions, five-level version (EQ-5D-5L). Tutor and focus group interviews were analysed using inductive thematic analysis.

RESULTS

A total of 308 out of 333 patients completed 26 weeks (RAFT, n/N = 156/175; control, n/N = 152/158). At 26 weeks, the mean BRAF-NRS impact was reduced for the RAFT programme (-1.36 units; p < 0.001) and the control interventions (-0.88 units; p < 0.004). Regression analysis showed a difference between treatment arms in favour of the RAFT programme [adjusted mean difference -0.59 units, 95% confidence interval (CI) -1.11 to -0.06 units; p = 0.03, effect size 0.36], and this was sustained over 2 years (-0.49 units, 95% CI -0.83 to -0.14 units; p = 0.01). At 26 weeks, further fatigue differences favoured the RAFT programme (BRAF-MDQ fatigue impact: adjusted mean difference -3.42 units, 95% CI -6.44 to - 0.39 units, p = 0.03; living with fatigue: adjusted mean difference -1.19 units, 95% CI -2.17 to -0.21 units, p = 0.02; and emotional fatigue: adjusted mean difference -0.91 units, 95% CI -1.58 to -0.23 units, p = 0.01), and these fatigue differences were sustained over 2 years. Self-efficacy favoured the RAFT programme at 26 weeks (Rheumatoid Arthritis Self-Efficacy Scale: adjusted mean difference 3.05 units, 95% CI 0.43 to 5.6 units; p = 0.02), as did BRAF-NRS coping over 2 years (adjusted mean difference 0.42 units, 95% CI 0.08 to 0.77 units; p = 0.02). Fatigue severity and other clinical outcomes were not different between trial arms and no harms were reported. Satisfaction with the RAFT programme was high, with 89% of patients scoring ≥ 8 out of 10, compared with 54% of patients in the control arm rating the booklet (p < 0.0001); and 96% of patients and 68% of patients recommending the RAFT programme and the booklet, respectively, to others (p < 0.001). There was no significant difference between arms for total societal costs including the RAFT programme training and delivery (mean difference £434, 95% CI -£389 to £1258), nor QALYs gained (mean difference 0.008, 95% CI -0.008 to 0.023). The probability of the RAFT programme being cost-effective was 28-35% at the National Institute for Health and Care Excellence's thresholds of £20,000-30,000 per QALY. Tutors felt that the RAFT programme's CB approaches challenged their usual problem-solving style, helped patients make life changes and improved tutors' wider clinical practice.

LIMITATIONS

Primary outcome data were missing for 25 patients; the EQ-5D-5L might not capture fatigue change; and 30% of the 2-year economic data were missing.

CONCLUSIONS

The RAFT programme improves RA fatigue impact beyond usual care alone; this was sustained for 2 years with high patient satisfaction, enhanced team skills and no harms. The RAFT programme is < 50% likely to be cost-effective; however, NHS costs were similar between treatment arms.

FUTURE WORK

Given the paucity of RA fatigue interventions, rheumatology teams might investigate the pragmatic implementation of the RAFT programme, which is low cost.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN52709998.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 57. See the NIHR Journals Library website for further project information.

Beyond current research practice: Methodological considerations in MS rehabilitation research (is designing the perfect rehabilitation trial the Holy Grail or a Gordian knot?)

Rehabilitation is an essential aspect of symptomatic and supportive treatment for people with multiple sclerosis (MS). The number of randomised controlled trials (RCTs) for rehabilitation interventions in MS has increased over the last two decades. The design, conduct and reporting quality of some of these trials could be improved. There are, however, some specific challenges that researchers face in conducting RCTs of rehabilitation interventions, which are often 'complex interventions'. This paper explores some of the challenges of undertaking robust clinical trials in rehabilitation. We focus on issues related to (1) participant selection and sample size, (2) interventions - the 'dose', content, active ingredients, targeting, fidelity of delivery and treatment adherence, (3) control groups and (4) outcomes - choosing the right type, number, timing of outcomes, and the importance of defining a primary outcome and clinically important difference between groups. We believe that by following internationally accepted RCT guidelines, by developing a critical mass of MS rehabilitation 'trialists' through international collaboration and by continuing to critique, challenge, and develop RCT designs, we can exploit the potential of RCTs to answer important questions related to the effectiveness of rehabilitation interventions.

Testing non-inferiority of blended versus face-to-face cognitive behavioural therapy for severe fatigue in patients with multiple sclerosis and the effectiveness of blended booster sessions aimed at improving long-term outcome following both therapies: study protocol for two observer-blinded randomized clinical trials

BACKGROUND

Cognitive behavioural therapy (CBT) has been found to be effective in reducing fatigue severity in MS patients directly following treatment. However, long-term effects are inconsistent leaving room for improvement. In addition, individual face-to-face CBT draws heavily on limited treatment capacity, and the travel distance to the treatment centre can be burdensome for patients. Therefore, we developed "MS Fit", a blended CBT for MS-related fatigue, based on a face-to-face CBT protocol found effective in a previous study, and "MS Stay Fit", internet-based booster sessions to improve long-term effectiveness of CBT for MS-related fatigue. This article presents the protocol of two randomised clinical trials (RCTs) conducted within one study investigating (1) the non-inferiority of MS Fit compared with evidence-based face-to-face CBT for MS-related fatigue and (2) the effectiveness of MS Stay Fit on the long-term outcome of fatigue compared with no booster sessions.

METHODS/DESIGN

The first part of this study is an observer-blinded non-inferiority multicentre RCT, in which 166 severely fatigued MS patients will be randomly assigned (1:1 ratio, computer-generated sequence) to either face-to-face CBT or blended CBT (MS Fit) for fatigue. The primary endpoint is at 20 weeks after baseline. After this post-treatment assessment, patients will be randomly assigned again (1:1 ratio, computer generated sequence) to either MS Stay Fit consisting of two booster sessions at 2 and 4 months after end of treatment or no booster sessions. The primary endpoint of the second study is 52 weeks after baseline. Primary outcome measure in both studies is fatigue severity assessed with the fatigue severity subscale of the Checklist Individual Strength (CIS20r). Outcomes will be assessed at baseline (T0), at the end of treatment (T20), and after 39 and 52 weeks (T39 and T52).

DISCUSSION

If MS Fit is found to be non-inferior to face-to-face CBT, it will improve the accessibility of this treatment. In addition, the study aims to test whether it is possible to improve long-term effectiveness of CBT for MS-related fatigue with MS Stay Fit.

TRIAL REGISTRATION

Dutch Trial Register (NTR6966), registered 18 January 2018 https://www.trialregister.nl/trial/6782 WORLD HEALTH ORGANIZATION (WHO) TRIAL REGISTRATION DATA SET: All items from the WHO Trial Registration Data Set can be found within the protocol.

MS Energize: Field trial of an app for self-management of fatigue for people with multiple sclerosis

Multiple sclerosis (MS) is a lifelong neurological condition affecting around 2.2 million people worldwide. There are a wide range of symptoms, with fatigue reported as one of the most troublesome. MS Energize-or MS Energise in UK English regions-is an iPhone app focused on self-management of fatigue for people with MS. Based on cognitive-behavioral therapy principles, the app covers MS fatigue, how to use energy effectively, how behavior, thoughts and emotions interact and impact on MS fatigue, as well as the potential effects of bodily and environmental factors. MS Energize provides education, interactive tasks, and supports application of the principles into a user's day-to-day life. We field tested the usability and perceived usefulness of MS Energize with 11 people with longstanding multiple sclerosis in New Zealand and the United Kingdom. Participants used the app over a period of five to six weeks after which they rated the usability of the app and participated in an in-depth qualitative interview. We developed four main themes through our thematic analysis. 1. Validation of participants' own experiences of living with MS fatigue. 2. The personal cost in engaging with such an intervention. 3. Reframing experiences and adding to knowledge. 4. That the app was generally a good idea. Field testers' feedback also identified usability issues that could be addressed. In particular, the amount of text-based content in the app contributed to the app itself being fatiguing. This field-testing process has highlighted the value of the app while also guiding our roadmap for further developments to enhance usability and usefulness. The next step is further refinement of components of MS Energize in preparation for a trial of its clinical and cost effectiveness.

Development and Preliminary Evaluation of a 3-Week Inpatient Energy Management Education Program for People with Multiple Sclerosis-Related Fatigue

Background

Energy conservation strategies and cognitive behavioral therapy techniques are valid parts of outpatient fatigue management education in people with multiple sclerosis (MS). In many European countries, multidisciplinary rehabilitation for people with MS is chiefly delivered in specialized rehabilitation centers, where they benefit from short intensive inpatient rehabilitation annually. However, no evidence-based and standardized fatigue management education program compatible with the inpatient setting is available.

Methods

Based on a literature search and the expertise of occupational therapists (OTs), a manualized group-based Inpatient Energy Management Education (IEME) program for use during 3-week inpatient rehabilitation that incorporates energy conservation and cognitive behavioral management approaches was developed. An IEME pilot program operated by trained OTs included 13 people with MS-related fatigue. The experiences of the IEME users and OTs were collected during focus groups to refine the program's materials and verify its feasibility in the inpatient setting.

Results

The program was feasible in an inpatient setting and met the needs of the people with MS. Targeted behaviors were taught to all participants in a clinical context. In-charge OTs were able to effect behavioral change through IEME.

Conclusions

Users evaluated the evidence-based IEME program positively. The topics, supporting materials, and self-training tasks are useful for the promotion and facilitation of behavioral change. The next step is a clinical trial to investigate the efficacy of IEME and to evaluate relevant changes in self-efficacy, fatigue impact, and quality of life after patients return home.

Understanding fatigue in adults with visual impairment: A path analysis study of sociodemographic, psychological and health-related factors

Background

Fatigue is a disabling problem in patients with visual impairment, but its etiology is still poorly understood. Our objective was to identify the determinants of fatigue in adults with visual impairment compared to adults with normal sight.

Methods

Cross-sectional data on fatigue and sociodemographic, psychological and health-related factors was obtained with validated questionnaires. Structural equational modeling using hypothesized relationships and explorative analyses were used to identify (in)direct pathways contributing to fatigue in 247 adults with visual impairment. The model was then tested in a reference group of 151 adults with normal sight.

Results

The final model explained 64% of fatigue variance in participants with visual impairment and revealed the following factors to be directly associated with fatigue: depressive symptoms (β = 0.723, p<0.001), perceived health (β = -0.158, p = 0.004), accommodative coping (β = 0.116, p = 0.030) and somatic comorbidity (β = 0.311, p = 0.001). Self-efficacy demonstrated a beneficial indirect effect on fatigue (β = -0.228, p<0.001) mediated by depression, accommodative coping and perceived health. Sleep disorder had an indirect effect on fatigue (β = 0.656, p<0.001) mediated by depression and perceived health. After removal of sleep disorder, the model explained 58% of the fatigue variance in normally sighted adults but pathways involving accommodative coping and somatic comorbidity were not confirmed.

Conclusions

These findings suggest that depression and perceived health are important mediating factors that contribute to fatigue in persons with visual impairment and normal sight. In contrast, somatic comorbidity, sleep disorders and accommodative coping seem to have a specific contribution to vision-related fatigue. These factors should be addressed in interventions to assist individuals with visual impairment in dealing with fatigue.

An economic evaluation attached to a single-centre, parallel group, unmasked, randomized controlled trial of a 3-day intensive social cognitive treatment (can do treatment) in patients with relapsing remitting multiple sclerosis and low disability

Aims: This trial-based economic evaluation (EE) assesses from a societal perspective the cost-effectiveness of an intensive 3-day cognitive theory-based intervention (CDT), compared to care-as-usual, in patients with relapsing remitting multiple sclerosis (RRMS) and low disability (Expanded Disability Status Scale [EDDS] score < 4.0). Materials and methods: The trial of the EE was registered in the Dutch Trial Register: Trial NL5158 (NTR5298). The incremental cost-effectiveness ratio (ICER) was expressed in cost on the Control sub-scale of the Multiple Sclerosis Self-Efficacy Scale (MSSES) and the incremental cost-utility ratio (ICUR) in the cost per Quality Adjusted Life Years (QALY) using the EQ-5D-5L. Bootstrap, sensitivity, and sub-group analyses were performed to determine the robustness of the findings. Results: The two groups of 79 patients were similar in baseline characteristics. The base case ICER is situated in the northeast quadrant (€72 (40.74/€2,948)) due to a higher MSSES Control score and higher societal costs in the CDT group. The ICUR is situated in the northwest (inferior) quadrant due to losses in QALY and higher societal costs for the CDT group (-0.02/€2,948). Overall, bootstrap, sensitivity, and sub-group analyses confirm the base case findings. However, when the SF-6D is used as a study outcome, there is a high probability that the ICUR is situated in the northeast quadrant. Limitations: The relative short follow-up time (6 months) and the unexpected increase in MSSES Control in the control group. Conclusions: When using the EQ-5D-5L to calculate a QALY, CDT is not a cost-effective alternative in comparison to care as usual. However, when using self-efficacy or SF-6D as outcomes, there is a probability that CDT is cost-effective. Based on the current results, CDT for patients with RRMS clearly show its potential. However, an extended follow-up for the economic evaluation is warranted before a final decision on implementation can be made.

A randomized pragmatic trial of telephone-delivered cognitive behavioral-therapy, modafinil, and combination therapy of both for fatigue in multiple sclerosis: The design of the "COMBO-MS" trial

BACKGROUND

Fatigue is one of the most common and disabling chronic symptoms in multiple sclerosis (MS). Optimization of available treatments for MS-related fatigue has been stymied by lack of comparative effectiveness research that focuses on real-world treatment delivery methods and potential modification of treatment effect by other chronic MS symptoms or disability level. This report describes the design of a patient centered, comparative effectiveness trial of cognitive behavioral-therapy (CBT), modafinil, and combination therapy of both for fatigue in MS ("COMBO-MS").

METHODS

We describe the methods of this pragmatic comparative effectiveness trial that is guided by a team of patient, family, provider, community, and payer stakeholders. Eligible participants with MS and significant fatigue severity are randomly assigned (1:1:1) to received either CBT, modafinil, or a combination of CBT and modafinil for 12 weeks. The primary outcome is change in fatigue impact as measured by the Modified Fatigue Impact Scale (MFIS) at 12 weeks. Secondary outcome measures include ecological momentary assessment (EMA) measures of fatigue intensity, fatigue interference, and fatigability (measured over 7 days' time at baseline and at 12 weeks), and change in MFIS score at 24 weeks.

PROJECTED OUTCOMES

We hypothesize that combination therapy will more effectively ameliorate fatigue severity than either monotherapy, and that heterogeneity of treatment effects will be found based on depression status, presence of known or suspected sleep disorder, and disease severity. Study findings will assist patients, providers, payers, and policy makers to provide more effective care for managing fatigue in MS.

Which behavioural and exercise interventions targeting fatigue show the most promise in multiple sclerosis? A systematic review with narrative synthesis and meta-analysis

Fatigue is a common and highly debilitating symptom of multiple sclerosis (MS). This meta-analytic systematic review with detailed narrative synthesis examined randomised-controlled (RCTs) and controlled trials of behavioural and exercise interventions targeting fatigue in adults with MS to assess which treatments offer the most promise in reducing fatigue severity/impact. Medline, EMBASE and PsycInfo electronic databases, amongst others, were searched through to August 2018. Thirty-four trials (12 exercise, 16 behavioural and 6 combined; n = 2,434 participants) met inclusion criteria. Data from 31 studies (n = 1,991 participants) contributed to the meta-analysis. Risk of bias (using the Cochrane tool) and study quality (GRADE) were assessed. The pooled (SMD) end-of-treatment effects on self-reported fatigue were: exercise interventions (n = 13) -.84 (95% CI -1.20 to -.47); behavioural interventions (n = 16) -.37 (95% CI -.53 to -.22); combined interventions (n = 5) -.16 (95% CI: -.36 to .04). Heterogeneity was high overall. Study quality was very low for exercise interventions and moderate for behavioural and combined interventions. Considering health care professional time, subgroup results suggest web-based cognitive behavioural therapy for fatigue, balance and/or multicomponent exercise interventions may be the cost-efficient therapies. These need testing in large RCTs with long-term follow-up to help define an implementable fatigue management pathway in MS.

Self-reported factors contributing to fatigue and its management in adolescents and adults with cerebral palsy

PURPOSE

To explore the self-reported factors that generate fatigue and to describe fatigue self-management strategies from the perspectives of adolescents and adults with cerebral palsy (CP).

MATERIALS AND METHODS

Text responses to open-ended questions of the Fatigue Impact and Severity Self-Assessment from 160 participants (mean age 22.4 years) across all GMFCS levels were coded using inductive line-by-line coding and then grouped together to generate larger categories for each question. Frequency counts associated with each category were then summarized descriptively by Gross Motor Function Classification System level.

RESULTS

The most commonly reported contributors to fatigue included the following: activity-related factors, general demands of life, sleep/rest, general health concerns, CP-related factors, mental health concerns, and environmental factors. The top five strategies participants reported to manage fatigue included rest or relaxation, sleeping or napping, changing or limiting their activities, being physically active, or using specific adaptations or assistive devices.

CONCLUSIONS

Results from this study suggest that there are potentially modifiable factors, including activity level and sleep, that significantly contribute to fatigue for persons with CP; these could form the basis of interventions targeted at the prevention and management of fatigue.Implications for RehabilitationAs individuals with cerebral palsy who are physically active experience significant fatigue, clinicians need to address fatigue to enable these individuals to reap the health benefits of physical activity.Providing education and support to integrate self-management techniques, such as planning and pacing, may be an effective long-term strategy to support individuals to complete highly valued tasks.Interventions targeting modifiable fatigue-generating factors such as activity level, sleep, and mental health concerns are needed.

Three-week inpatient energy management education (IEME) for persons with multiple sclerosis-related fatigue: Feasibility of a randomized clinical trial

BACKGROUND

Multiple sclerosis (MS)-related fatigue limits participation in everyday activities and has a considerable impact on quality of life (QoL), thereby affecting productivity and employment. Outpatient education interventions involving energy conservation strategies and cognitive behavioral therapy techniques are helpful. However, no inpatient program is currently available. The inpatient energy management education (IEME) program is a novel group-based intervention that lasts for 6.5 h and is conducted by a trained occupational therapist (OT) during a 3-week period of inpatient rehabilitation. Persons with MS (pwMS) and OTs previously evaluated the IEME positively in a pilot study test run. The aim of this study was to evaluate the feasibility of a research protocol and collect preliminary data on the IEME effect size.

METHODS

To assess the feasibility of conducting a randomized clinical trial, pwMS-related fatigue were recruited during a 3-week inpatient rehabilitation. Six IEME (experimental) group sessions or progressive muscle relaxation (PMR, control) group sessions comprised part of a personalized rehabilitation program. The recruitment and assessment procedures, dropout and follow-up assessment rates and the treatment fidelity were evaluated, and six telephone interviews were conducted with IEME participants after they returned home. Outcomes were fatigue impact, occupational performance, self-efficacy regarding energy conservation strategies, and QoL at baseline, discharge, and 4 months. Paired-sample and independent-samples t-tests were used to assess within- and between-group effects. Effect sizes were estimated using Cohen's d.

RESULTS

Between August and November 2017, 47 pwMS were included and randomized. The dropout rate (4.2%) was low and the sample was balanced. The PMR was a well-accepted control intervention. The OTs reported no problems in conducting the IEME, and treatment fidelity was high. IEME participants confirmed the adequacy of the IEME. Within-group differences in fatigue impact and some QoL dimensions at discharge were significant (p < 0.05) in both groups. The IEME alone resulted in significant improvements in self-efficacy regarding energy conservation strategies, with a large effect size (Cohen's d: 1.32; 95% CI: 0.54-2.1), and in the QoL physical functioning dimension at T2 (Cohen's d: 1.32; 95% CI: 2.11-0.53). IEME participants spent significantly less time in individual OT sessions. A sample size of 192 participants in a randomized controlled trial would be sufficient to detect clinically relevant between-group differences.

CONCLUSION

This feasibility study has provided promising preliminary data about the effect of the IEME. The research protocol was confirmed to be feasible and a future study is justified. This study was registered in the German Clinical Trials Register (no. DRKS00011634).

Digitizing a Face-to-Face Group Fatigue Management Program: Exploring the Views of People With Multiple Sclerosis and Health Care Professionals Via Consultation Groups and Interviews

BACKGROUND

Fatigue is one of the most common and debilitating symptoms of multiple sclerosis (MS) and is the main reason why people with MS stop working early. The MS Society in the United Kingdom funded a randomized controlled trial of FACETS-a face-to-face group-based fatigue management program for people with multiple sclerosis (pwMS)-developed by members of the research team. Given the favorable trial results and to help with implementation, the MS Society supported the design and printing of the FACETS manual and materials and the national delivery of FACETS training courses (designed by the research team) for health care professionals (HCPs). By 2015 more than 1500 pwMS had received the FACETS program, but it is not available in all areas and a face-to-face format may not be suitable for, or appeal to, everyone. For these reasons, the MS Society funded a consultation to explore an alternative Web-based model of service delivery.

OBJECTIVE

The aim of this study was to gather views about a Web-based model of service delivery from HCPs who had delivered FACETS and from pwMS who had attended FACETS.

METHODS

Telephone consultations were undertaken with FACETS-trained HCPs who had experience of delivering FACETS (n=8). Three face-to-face consultation groups were held with pwMS who had attended the FACETS program: London (n=4), Liverpool (n=4), and Bristol (n=7). The interviews and consultation groups were digitally recorded and transcribed. A thematic analysis was undertaken to identify key themes. Toward the end of the study, a roundtable meeting was held to discuss outcomes from the consultation with representatives from the MS Society, HCPs, and pwMS.

RESULTS

Key challenges and opportunities of designing and delivering an integrated Web-based version of FACETS and maintaining user engagement were identified across 7 themes (delivery, online delivery, design, group, engagement, interactivity, and HCP relationships). Particularly of interest were themes related to replicating the group dynamics and the lack of high-quality solutions that would support the FACETS' weekly homework tasks and symptom monitoring and management.

CONCLUSIONS

A minimum viable Web-based version of FACETS was suggested as the best starting point for a phased implementation, enabling a solution that could then be added to over time. It was also proposed that a separate study should look to create a free stand-alone digital toolkit focusing on the homework elements of FACETS. This study has commenced with a first version of the toolkit in development involving pwMS throughout the design and build stages to ensure a user-centered solution.

Occupational Therapy in Fatigue Management in Multiple Sclerosis: An Umbrella Review

Background. Fatigue is one of the most invalidant symptoms of Multiple Sclerosis (MS) that negatively affects occupational and work performance and social participation. Occupational therapy (OT) assessment and treatment of impairments related to fatigue can have a significant and positive impact on the quality of life. Methods. An umbrella review has been carried out to provide rehabilitative decision makers in healthcare with insight into the role of OT in fatigue management in Multiple Sclerosis. The question is, what type of treatment provided by occupational therapist is more effective in reducing fatigue in Multiple Sclerosis? A search of literature published until June 2018 was undertaken by three independent reviewers using PubMed, PEDro, and Cochrane Library database including systematic reviews and meta-analyses of the last 10 years. Results. 10 studies were selected (5 systematic reviews, 1 meta-analysis, 3 reviews, and 1 guideline). Conclusions. Fatigue management programs have moderate evidence; other strategies such as OT strategies and telerehabilitation show low evidence.

Reducing arthritis fatigue impact: two-year randomised controlled trial of cognitive behavioural approaches by rheumatology teams (RAFT)

OBJECTIVES

To see if a group course delivered by rheumatology teams using cognitive-behavioural approaches, plus usual care, reduced RA fatigue impact more than usual care alone.

METHODS

Multicentre, 2-year randomised controlled trial in RA adults (fatigue severity>6/10, no recent major medication changes). RAFT (Reducing Arthritis Fatigue: clinical Teams using CB approaches) comprises seven sessions, codelivered by pairs of trained rheumatology occupational therapists/nurses. Usual care was Arthritis Research UK fatigue booklet. Primary 26-week outcome fatigue impact (Bristol RA Fatigue Effect Numerical Rating Scale, BRAF-NRS 0-10). Intention-to-treat regression analysis adjusted for baseline scores and centre.

RESULTS

308/333 randomised patients completed 26 week data (156/175 RAFT, 152/158 Control). Mean baseline variables were similar. At 26 weeks, the adjusted difference between arms for fatigue impact change favoured RAFT (BRAF-NRS Effect -0.59, 95% CI -1.11 to -0.06), BRAF Multidimensional Questionnaire (MDQ) Total -3.42 (95% CI -6.44 to -0.39), Living with Fatigue -1.19 (95% CI -2.17 to -0.21), Emotional Fatigue -0.91 (95% CI -1.58 to -0.23); RA Self-Efficacy (RASE, +3.05, 95% CI 0.43 to 5.66) (14 secondary outcomes unchanged). Effects persisted at 2 years: BRAF-NRS Effect -0.49 (95% CI -0.83 to -0.14), BRAF MDQ Total -2.98 (95% CI -5.39 to -0.57), Living with Fatigue -0.93 (95% CI -1.75 to -0.10), Emotional Fatigue -0.90 (95% CI -1.44, to -0.37); BRAF-NRS Coping +0.42 (95% CI 0.08 to 0.77) (relevance of fatigue impact improvement uncertain). RAFT satisfaction: 89% scored > 8/10 vs 54% controls rating usual care booklet (p<0.0001).

CONCLUSION

Multiple RA fatigue impacts can be improved for 2 years by rheumatology teams delivering a group programme using cognitive behavioural approaches.

TRIAL REGISTRATION NUMBER

ISRCTN52709998.