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Fahy A, Maguire R. Potentially modifiable associates of anxiety in people with multiple sclerosis: a systematic review. Disabil Rehabil 2022; 44:8201-8212. [PMID: 35040719 DOI: 10.1080/09638288.2021.2022776] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE A high percentage of people with multiple sclerosis (PwMS) experience anxiety, which can negatively impact quality of life. Despite this, anxiety in PwMS remains under researched. This review aims to identify associates with anxiety in PwMS that are amenable to change, with a view to informing the development of interventions in the area. MATERIALS AND METHODS The following databases were searched for studies investigating anxiety in PwMS from 2015 to 2021: PsycINFO, PubMed, EMBASE, Web of Science. The search consisted of keywords relating to MS and fear, anxiety or worry. Once screening was completed by two reviewers, a narrative synthesis was used to analyze the data, with the MMAT used for quality appraisal. RESULTS Of the 3117 unique abstracts screened, 39 studies met the criteria for inclusion. Evidence was found linking anxiety in PwMS to several modifiable factors broadly categorized as either psychological, social or lifestyle factors. Perceptions of self and one's ability to cope/adjust to MS emerged as important psychological factors. Physical activity and social support from friends were also linked with improved anxiety outcomes. CONCLUSIONS Anxiety in PwMS is linked to a number of modifiable factors. Findings may help inform the development of rehabilitation interventions to decrease anxiety in MS.Implications for rehabilitationThis review highlights interventions which have successfully lowered anxiety in people with MS (PwMS); however, there is a clear need for the development of further interventions which target the pathologically specific concerns surrounding anxiety in this population.We show how a number of factors amenable to change associate with anxiety, suggesting that these factors may be appropriate targets for anxiety interventions in PwMS.Enhancing physical activity and self-efficacy are important means in which healthcare professionals can reduce anxiety in MS.Identifying ways of encouraging positive coping and increasing social support are further targets for improving comorbid anxiety in PwMS.Focusing on the modifiable factors highlighted here offers considerable potential for enhancing psychological wellbeing in this group.
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Affiliation(s)
- Austin Fahy
- Department of Psychology, Maynooth University, Maynooth, Ireland
| | - Rebecca Maguire
- Department of Psychology, Maynooth University, Maynooth, Ireland
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Jongen PJ, van Mastrigt GA, Heerings M, Visser LH, Ruimschotel RP, Hussaarts A, Duyverman L, Valkenburg-Vissers J, Cornelissen J, Bos M, van Droffelaar M, Donders R. Effect of an intensive 3-day social cognitive treatment (can do treatment) on control self-efficacy in patients with relapsing remitting multiple sclerosis and low disability: A single-centre randomized controlled trial. PLoS One 2019; 14:e0223482. [PMID: 31600271 PMCID: PMC6786633 DOI: 10.1371/journal.pone.0223482] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/20/2019] [Indexed: 11/19/2022] Open
Abstract
In patients with chronic disorders, control self-efficacy is the confidence with managing symptoms and coping with the demands of illness. Can do treatment (CDT) is an intensive, 3-day, social cognitive theory-based, multidisciplinary treatment that focuses on identification of stressors, goal setting, exploration of boundaries, and establishment of new boundaries. An uncontrolled study showed that patients with relapsing remitting multiple sclerosis (RRMS) and low-disability had improved control self-efficacy six months after CDT. Hence, in a 6-month, single-centre, randomized (1:1), unmasked, controlled trial in RRMS patients with Expanded Disability Status Scale (EDSS) score ≤4.0, we compared CDT with no intervention and the option to receive CDT after completion of study participation. Follow-up assessments were at one, three and six months. Primary endpoint was control self-efficacy (Multiple Sclerosis Self-Efficacy Scale Control [MSSES-C] (minimum 90, maximum 900) at six months. Secondary endpoints were functional self-efficacy (MSSES-F), participation and autonomy (Impact on Participation and Autonomy questionnaire [IPA]), health-related quality of life (MS Quality of Life-54 Items questionnaire [MSQoL-54]), anxiety, depression (Hospital Anxiety and Depression Scale [HADS]) and coping skills (Utrecht Coping List [UCL]) at six months. Tertiary endpoint was care-related strain on support partners (Caregiver Strain Index) at six months. Of the 158 patients that were included, 79 were assigned to CDT and 79 to the control group. Two CDT patients discontinued treatment prematurely. Sixty-one (77%) control patients chose to receive CDT after study participation. Intention-to-treat ANCOVA analyses were performed with follow-up values as dependent, and condition, baseline values, disease duration and gender as independent variables. The mean (standard deviation [SD]) MSSES-C score in the CDT group vs. control group at baseline was 468 (162) vs. 477 (136), and at six months 578 (166) vs. 540 (135) (p = 0.100). Secondary and tertiary endpoints did not differ between groups, except for the UCL palliative reaction score being slightly higher in the CDT group (p = 0.039). On post hoc analyses the MSSES-C score at one and three months was higher in the CDT vs. control group: 597 (114) vs. 491 (131) (p<0.0001) and 561 (160) vs. 514 (143) (p = 0.018), respectively; and at one month the MSSES-F, IPA Limitations, HADS Anxiety and Depression, and MSQoL-54 Mental and Physical scores were also in favour of the CDT group. We conclude that in low-disability RRMS patients, the intensive 3-day social cognitive theory-based CDT did not improve control self-efficacy at six months follow-up compared to waitlist controls. The absence of a between-group difference at six months relates to a gradual improvement in the control group. In all, this social cognitive theory-based approach for improving self-efficacy needs further investigation before being broadly applied in RRMS patients.
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Affiliation(s)
- Peter Joseph Jongen
- Department of Community & Occupational Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
- MS4 Research Institute, Nijmegen, the Netherlands
- * E-mail: ,
| | - Ghislaine A. van Mastrigt
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Marco Heerings
- National Multiple Sclerosis Foundation, Rotterdam, the Netherlands
| | - Leo H. Visser
- Department of Neurology, St. Elisabeth Hospital, Tilburg, the Netherlands
- University of Humanistic Studies, Utrecht, the Netherlands
| | | | | | - Lotte Duyverman
- Medical Psychiatric Centre PsyToBe, Rotterdam, the Netherlands
| | | | | | - Michel Bos
- Department of Neurology, St. Anna Hospital, Geldrop, the Netherlands
| | | | - Rogier Donders
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
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van Mastrigt GA, Evers SM, Heerings M, Visser LH, Ruimschotel RP, Hussaarts A, Duyverman L, Valkenburg-Vissers J, Cornelissen J, Bos M, van Droffelaar M, Jongen PJ. 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. J Med Econ 2019; 22:967-980. [PMID: 31084442 DOI: 10.1080/13696998.2019.1609300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Ghislaine A van Mastrigt
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University , Maastricht , The Netherlands
| | - Silvia M Evers
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University , Maastricht , The Netherlands
- Department of Public Mental Healthcare, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Center for Economic Evaluations , Utrecht , The Netherlands
| | - Marco Heerings
- National Multiple Sclerosis Foundation , Rotterdam , The Netherlands
| | - Leo H Visser
- Department of Neurology, St. Elisabeth Hospital , Tilburg , The Netherlands
- University of Humanistic Studies , Utrecht , The Netherlands
| | | | - Astrid Hussaarts
- National Multiple Sclerosis Foundation , Rotterdam , The Netherlands
| | - Lotte Duyverman
- Medical Psychiatric Centre PsyToBe , Rotterdam , The Netherlands
| | | | | | - Michel Bos
- Department of Neurology, St. Anna Hospital , Geldrop , The Netherlands
| | | | - Peter J Jongen
- Department of Community & Occupational Medicine, University Medical Centre Groningen , Groningen , The Netherlands
- MS4 Research Institute , Nijmegen , The Netherlands
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D'Amico E, Haase R, Ziemssen T. Review: Patient-reported outcomes in multiple sclerosis care. Mult Scler Relat Disord 2019; 33:61-66. [PMID: 31154262 DOI: 10.1016/j.msard.2019.05.019] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 05/14/2019] [Accepted: 05/24/2019] [Indexed: 01/14/2023]
Abstract
Patient-reported outcomes (PROs) are increasingly used in multiple sclerosis (MS) research and clinical practice for understanding the effects that the disease and its treatments have on patients' lives. PROs are captured directly from patients and include symptoms, function, health status, and health-related quality of life. No universal guidance on appropriateness of each applied tool exists. However, collecting clear and comprehensive outcome measures represents the first step of patient centered therapeutic management. The importance of PRO assessment is expected to continue to grow in the future. But in current MS reality, PROs are selected and used without a clear justification, and only few PROs are of adequate psychometric quality. There is a clear need for the development of high-quality; MS-specific PROs that assess the true concerns of patients and that evaluate the impact of both clinical and non-clinical interventions on a variety of outcomes. In this perspective review, we describe the importance of and methods for using PRO in MS by defining and identifying the used PROs in MS. Moreover, we will outline the challenges and key unanswered questions for routine use of PROs in MS discussing potential interventions to accelerate the integration of PROs in the clinical management of MS.
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Affiliation(s)
- Emanuele D'Amico
- MS Center, Department G.F. Ingrassia, University of Catania, Italy
| | - Rocco Haase
- MS Center, Center of Clinical Neuroscience, Neurological University Clinic Dresden, Germany
| | - Tjalf Ziemssen
- MS Center, Center of Clinical Neuroscience, Neurological University Clinic Dresden, Germany.
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Bogosian A, Morgan M, Moss-Morris R. Multiple challenges for people after transitioning to secondary progressive multiple sclerosis: a qualitative study. BMJ Open 2019; 9:e026421. [PMID: 30852548 PMCID: PMC6429969 DOI: 10.1136/bmjopen-2018-026421] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Transitioning to secondary progressive multiple sclerosis (SPMS) is demanding for both patients and healthcare professionals. The particular challenges and the ways patients cope are poorly understood. The present study examines what challenges people face when diagnosed with SPMS by exploring experiences of people who have transitioned recently (up to 5 years). DESIGN Semistructured qualitative interviews at two time points a year apart. Interviews were analysed using inductive thematic analysis. SETTING UK. PARTICIPANTS We interviewed 21 people at baseline and 17 participated in the follow-up interviews. RESULTS The majority of participants reported expecting to transition to SPMS, and the diagnosis did not make much difference to them. Participants described increasing emotional and physical challenges after transitioning to SPMS and between the first and second interviews. Planning, using distractions and maintaining social roles helped participants cope with the increased challenges. The same coping strategies were used between the two interviews. Participants felt there was not much left to do regarding the management of their symptoms. A key theme was the sense of abandonment from healthcare services after transitioning to SPMS. CONCLUSIONS After transitioning to SPMS, people are faced with multiple challenges. Participants described a lack of directions for symptoms management and lack of support from the healthcare system. An integrated multidisciplinary healthcare approach is crucial at the progressive stage of the disease to alleviate feelings of helplessness and promote symptom management.
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Affiliation(s)
| | - Myfanwy Morgan
- Institute of Pharmaceutical Science, King’s College London, London, UK
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Hemmatpoor B, Gholami ALI, Parnian S, Seyedoshohadaee M. The Effect of Life Skills Training on the Self-Management of Patients with Multiple Sclerosis. J Med Life 2018; 11:387-393. [PMID: 30894899 PMCID: PMC6418331 DOI: 10.25122/jml-2018-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 10/10/2018] [Indexed: 11/21/2022] Open
Abstract
Background: Training sessions are the most common framework used to provide self-management for patients with multiple sclerosis Objective: This study was conducted to determine the effect of life skills training on the self-management of patients with multiple sclerosis. Findings showed that life skills training had a significant effect on the overall self-management score; thus, self-management of patients increased after training life skills (F = 25.1821, P <0.01). Materials and Methods: This semi-experimental study was conducted on 80 subjects with MS in the MS Society in Tehran (Iran) in 2016. The experimental group received four one-hour sessions of life skills training. The control group received routine care. Patients of both groups filled MS self-management (MSSM) scales at baseline and a month after the last training session. Independent t-test was used to compare findings between the two groups; pairwise t-test was used to compare results before and after the test. Covariance test was used to present the research results and data was analyzed by using SPSS21. Findings: Mean and standard deviation of age were 32.22±8.88 and 33.02±10.34 in the control and experimental groups, respectively. Results: Comparison of total self-management showed a significant difference between the control and experimental groups after receiving life skill training (P<0.01). Moreover, there was a significant difference in the mean of total self-management in the experimental group before and after the intervention; self-management increased after intervention (p-value<0.001). Conclusion: This study showed the positive effect of life skills training because its main goal is to prepare and help patients solve problems and deal with difficulties resulting from the disease. Therefore, life skill training is suggested for patients suffering from MS.
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Affiliation(s)
- Behzad Hemmatpoor
- Clinical Research Development Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - ALI Gholami
- Clinical Research Development Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shima Parnian
- Department of Medical-Surgical Nursing, Iran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Seyedoshohadaee
- Department of Medical-Surgical Nursing, Iran University of Medical Sciences, Tehran, Iran
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Boland P, Levack WMM, Hudson S, Bell E. A qualitative exploration of barriers and facilitators to coping experienced by couples when one has multiple sclerosis. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2018. [DOI: 10.12968/ijtr.2018.25.5.240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Pauline Boland
- Lecturer, Clinical Therapies, University of Limerick, Republic of Ireland
| | - William MM Levack
- Associate professor, Rehabilitation, Teaching and Research Unit and Associate Dean of Research, University of Otago, Wellington, New Zealand
| | - Sheena Hudson
- Associate researcher, Rehabilitation, Teaching and Research Unit, University of Otago, Wellington, New Zealand
| | - Elliot Bell
- Lecturer and clinical psychologist, Psychological Medicine and Rehabilitation Teaching and Research Unit, University of Otago, Wellington, New Zealand
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Jongen PJ, Ruimschotel RP, Museler-Kreijns YM, Dragstra T, Duyverman L, Valkenburg-Vissers J, Cornelissen J, Lagrand R, Donders R, Hartog A. Improved health-related quality of life, participation, and autonomy in patients with treatment-resistant chronic pain after an intensive social cognitive intervention with the participation of support partners. J Pain Res 2017; 10:2725-2738. [PMID: 29238216 PMCID: PMC5716312 DOI: 10.2147/jpr.s137609] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Despite the availability of various specific treatments, most patients with chronic pain (CP) consider their pain problem as undertreated. Recently, multiple sclerosis (MS) patients who were given an intensive 3-day social cognitive treatment with the participation of support partners experienced lasting improvements in health-related quality of life (HRQoL) and self-efficacy. In this study, a similar intervention was given to treatment-resistant CP patients with stressors, relational problems with support partner, and distress, anxiety or depression. Before and 1, 3, and 6 months after the intervention, patients completed the Euro-Qol 5 Dimensions 5 Levels (EQ-5D-5L) and Impact on Participation and Autonomy (IPA) questionnaires (primary outcomes), and the Survey Of Pain Attitudes (SOPA), the Four-Dimensional Symptom Questionnaire (4DSQ) (distress, depression, anxiety, and somatization), and Visual Analog Scale for pain intensity, whereas the support partners completed the Caregiver Strain Index (CSI) questionnaire. Differences between baseline and post-treatment were tested via paired t-tests (significance level 0.05). Of the 39 patients who were included, 34 (87.2%) completed the 3-day treatment. At 1, 3, and 6 months, improvements were seen in EQ-5D-5L-Index (+40.6%; +22.4%; +31.7%), Health Today (+61.8%; +36.3%; +46.8%), Control attitude (+45.8%; not significant [NS]; +55.0%) and decreases in IPA-Problems (−14.8%; NS; −20.4%), Harm attitude (−18.9%; −15.0%; −17.7%), Distress (−17.7%; −31.8%; −37.1%), and Depression (−37.4%; −31.4%; −35.7%) scores. The CSI score had decreased by −29.0%, −21.4%, and −25.9%, respectively. In conclusion, after an intensive 3-day social cognitive intervention, treatment-resistant CP patients experienced substantial and lasting improvements in HRQoL and in problematic limitations to participation and autonomy, in association with improvements in pain attitudes, depression, and distress. To assess whether this innovative approach may be an effective treatment for this subgroup of CP patients, future randomized controlled studies are needed.
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Affiliation(s)
- Peter Joseph Jongen
- Department of Community and Occupational Medicine, University Medical Centre Groningen, Groningen.,MS4 Research Institute, Nijmegen
| | | | | | | | | | | | | | - R Lagrand
- Fysio- en Manuele Therapie R. & Y.M. Lagrand, Rotterdam
| | - Rogier Donders
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - A Hartog
- DC Klinieken Rotterdam, Rotterdam
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Jongen PJ, Heerings M, Ruimschotel R, Hussaarts A, Duyverman L, van der Zande A, Valkenburg-Vissers J, van Droffelaar M, Lemmens W, Donders R, Visser LH. Intensive social cognitive treatment (can do treatment) with participation of support partners in persons with relapsing remitting multiple sclerosis: observation of improved self-efficacy, quality of life, anxiety and depression 1 year later. BMC Res Notes 2016; 9:375. [PMID: 27473375 PMCID: PMC4966822 DOI: 10.1186/s13104-016-2173-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 07/20/2016] [Indexed: 11/16/2022] Open
Abstract
Background In persons with multiple sclerosis (MS) self-efficacy positively affects health-related quality of life (HRQoL) and physical activity. In a previous study we observed that 6 months after an intensive 3-day social cognitive treatment (Can Do treatment) with the participation of support partners, self-efficacy and HRQoL had improved in persons with relapsing remitting MS (RRMS). Given the chronic nature of the disease, it is important to know whether these beneficial changes may last. Methods Can Do treatment was given to 60 persons with MS and their support partners. At baseline and 12 months after treatment self-efficacy control, self-efficacy function, physical and mental HRQoL, anxiety, depression and fatigue were assessed via self-report questionnaires. Differences were tested via a paired t test. Results Of the 57 persons with MS that completed the baseline assessment and the 3-day treatment, 38 filled in the 12th month questionnaires (response rate 66.7 %), 22 with RRMS and 14 with progressive MS. In the RR group self-efficacy control had increased by 20.2 % and physical HRQoL by 15.0 %, and depression and anxiety had decreased by 29.8 and 25.9 %, respectively (all P < 0.05); the changes in mental HRQoL (+17 %) and fatigue (−20 %) failed to be statistically significant (P = 0.087, P = 0.080, respectively). In the progressive group no changes suggestive of improvement were seen. Conclusions The findings suggest that a 3-day intensive social cognitive treatment (Can Do treatment) with the participation of support partners may have long lasting beneficial effects on the self-efficacy and HRQoL in persons with RRMS; and that improvements in anxiety and depression, not seen in the 6-month study, may yet develop at 12 months.
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Affiliation(s)
- Peter Joseph Jongen
- Department of Community and Occupational Medicine, University Medical Centre Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands. .,MS4 Research Institute, Ubbergseweg 34, 6522 KJ, Nijmegen, The Netherlands.
| | - Marco Heerings
- National Multiple Sclerosis Foundation The Netherlands, Mathenesserlaan 378, 3023 HB, Rotterdam, The Netherlands
| | - Rob Ruimschotel
- Medical Psychiatric Centre PsyToBe, Metroweg 50, 3083 BB, Rotterdam, The Netherlands
| | - Astrid Hussaarts
- National Multiple Sclerosis Foundation The Netherlands, Mathenesserlaan 378, 3023 HB, Rotterdam, The Netherlands
| | - Lotte Duyverman
- Medical Psychiatric Centre PsyToBe, Metroweg 50, 3083 BB, Rotterdam, The Netherlands
| | - Anneke van der Zande
- National Multiple Sclerosis Foundation The Netherlands, Mathenesserlaan 378, 3023 HB, Rotterdam, The Netherlands
| | | | - Maarten van Droffelaar
- National Multiple Sclerosis Foundation The Netherlands, Mathenesserlaan 378, 3023 HB, Rotterdam, The Netherlands
| | - Wim Lemmens
- Department for Health Evidence, Radboud university medical centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Rogier Donders
- Department for Health Evidence, Radboud university medical centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Leo H Visser
- Multiple Sclerosis Center Midden Brabant, EZT, Location St. Elisabeth, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands.,University of Humanistic Studies, Kromme Nieuwegracht 29, 3512 HD, Utrecht, The Netherlands
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