Should I stay or should I go? A prospective investigation examining individual factors impacting employment status among individuals with multiple sclerosis (MS)

Barriers for work in people with multiple sclerosis: a Norwegian cultural adaptation and validation of the short version of the multiple sclerosis work difficulties questionnaire

Background and purpose

Multiple sclerosis (MS) is associated with high rates of unemployment, and barriers for work are essential to identify in the regular follow-up of these people. The current study aimed to culturally adapt and evaluate the psychometric properties of the Norwegian version of the Multiple Sclerosis Work Difficulties Questionnaire-23 (MSWDQ-23).

Methods

Following backward and forward translation, the Norwegian version of the MSWDQ-23 (MSWDQ-23NV) was completed by 229 people with multiple sclerosis (MS). Validity was evaluated through confirmatory factor analysis and by associating scores with employment status, disability, and health-related quality of life outcome measures. Convergent validity was checked by correlating MSWDQ-23 scores with alternative study measures. Internal consistencies were examined by Cronbach's alfa.

Results

A good fit for the data was demonstrated for the MSWDQ-23NV in confirmatory factor analysis, with excellent internal consistencies also demonstrated for the full scale and its subscales (physical barriers, psychological/cognitive barriers, external barriers). The MSWDQ-23NV subscales were related in the expected direction to health-related quality of life outcome measures. While higher scores on the physical barriers subscale was strongly associated with higher levels of disability and progressive MS types, higher scores on all subscales were associated with not working in the past year.

Discussion

The Norwegian MSWDQ-23 is an internally consistent and valid instrument to measure perceived work difficulties in persons with all types of MS in a Norwegian-speaking population. The MSWDQ-23NV can be considered a useful tool for health care professionals to assess self-reported work difficulties in persons with MS. The Norwegian MSWDQ-23 scale should be examined for test-retest reliability and considered implemented in the regular follow up at the MS-outpatient clinics in Norway to support employment maintenance.

Neuropsychology intervention for managing invisible symptoms of MS (NIMIS-MS) group: A pilot effectiveness and acceptability study

BACKGROUND

People with MS (pwMS) commonly experience a range of hidden symptoms, including cognitive impairment, anxiety and depression, fatigue, pain, and sensory difficulties. These "invisible" symptoms can significantly impact wellbeing, relationships, employment and life goals. We developed a novel bespoke online group neuropsychological intervention combining psychoeducation and cognitive rehabilitation with an Acceptance and Commitment Therapy (ACT)-informed approach for pwMS in an acute tertiary hospital. This 'Neuropsychological Intervention for Managing Invisible Symptoms' in MS (NIMIS-MS) consisted of 6 sessions, each with a psychoeducation and ACT component. The content included psychoeducation around managing cognitive difficulties, fatigue, pain, sleep and other unpleasant sensations in MS with the general approach of understanding, monitoring, and recognising patterns and potential triggers. Specific cognitive rehabilitation and fatigue management strategies were introduced. The ACT-informed component focussed on three core ACT areas of the 'Triflex' of psychological flexibility (Harris, 2019): Being Present, Opening Up, and Doing What Matters.

METHODS

118 pwMS attended the NIMIS-MS group intervention which was delivered 14 times in six-week blocks over an 18-month period. To evaluate the effectiveness and acceptability, participants completed measures of depression and anxiety (HADS), functional impairment (WSAS), Values- Progress (VQ) and Values- Obstruction (VQ), and Acceptance of MS (MSAS) pre and post NIMIs-MS group intervention. Qualitative feedback was obtained during focus groups after the final session and via online feedback questionnaires RESULTS: Pre-post analysis showed that symptoms of depression and anxiety were significantly lower and acceptance of MS was significantly higher following completion of the NIMIS-MS group. Qualitative feedback showed that participants reported that they felt more equipped to manage the "invisible" symptoms of MS following completion of the group, and benefited from using ACT-based strategies and techniques. Participants highly valued the peer support that evolved during the NIMIS-MS groups. The online format was considered more accessible than in-person groups, due to less concerns of travel time, cost, fatigue, and comfort and infection.

CONCLUSION

Evaluation suggests that our novel NIMIS-MS groups is an acceptable, beneficial and feasible approach for providing neuropsychological interventions to individuals with MS.

Humor in rehabilitation professions: a scoping review

PURPOSE

Studying humor in the rehabilitation professions is important given its positive effects on health and well-being. We conducted a scoping review to understand how the use of humor has been explored in the existing literature in four rehabilitation professions. The rehabilitation professions included audiology, speech-language pathology, physical therapy, and occupational therapy.

MATERIALS AND METHODS

The five-stage method identified by Arksey and O'Malley was used to conduct this review. Six databases were searched. We included 57 articles in our final review, summarized in a narrative synthesis.

RESULTS

We generated seven themes in our analysis: (1) humour as a management strategy in therapy; (2) humour as a power establisher vs. equalizer; (3) humour as a coping mechanism in rehabilitation; (4) conceptualizations of non-verbal humor cues in therapy; (5) Is humour trainable? (6) Humor used to foster group cohesion; and (7) Attitudes and beliefs surrounding humor practice.

CONCLUSIONS

Our findings emphasize the importance of using humor in the rehabilitation professions, and the ways in which humor is conceptualized in a multitude of ways for both clinician and client. Future work is needed to further understand the presence and use of humor in rehabilitation professions.IMPLICATIONS FOR REHABILITATIONIn a scoping review of the literature, this study showed that humor was used mainly positively in rehabilitation by the included professions of audiology, speech-language pathology, physical therapy, and occupational therapy and contributed to a sense of belonging.Humor may be an effective way to improve management of client/clinician relations as well as improving group cohesion in rehabilitation settings.In the rehabilitation professions of audiology, speech-language pathology, physical therapy, and occupational therapy, non-verbal humor cues were used in instances where communication was difficult or impaired for clients.

Keeping it together: The role of social integration on health and psychological well-being among individuals with multiple sclerosis

Research indicates that people with multiple sclerosis (MS) are more likely to report poorer health and well-being than their peers without MS. Fortunately, it is also known that an individual's social and lifestyle factors play a great role on maintaining and promoting one's health and overall well-being. The present study aimed to examine the role that social integration and social support, in particular have on health and psychological well-being (PWB) among individuals with MS. One hundred and eighty three individuals with MS completed measures of social and lifestyle factors, personality, physical and mental health, MS disease symptomatology and PWB. Cross sectional, regression analyses were conducted to determine the role of social and other lifestyle factors (e.g., diet/exercise) on health and PWB. A subset of this sample (108) completed a follow-up assessment. Longitudinal analyses of this sample were also conducted. Consistent with previous findings, the presence of social integration and social support were significant predictors of health and PWB even when taking into account other lifestyle factors (i.e., diet/exercise, substance use, smoking), cardiovascular risk, demographics (i.e., gender, age, education, relationship status) and personality. The role of social integration and support on health and PWB is well established. Present findings confirmed these associations among individuals with MS. These findings suggest that social integration and social support should be a crucial part of MS management and that further interventional studies aimed at improving social integration and reducing social isolation are warranted in an effort to promote and maintain overall health and well-being.

Online Peer Support for People With Multiple Sclerosis: A Narrative Synthesis Systematic Review

BACKGROUND

People with multiple sclerosis often experience depression and anxiety, negatively affecting their quality of life, especially their social life. Peer support, whether in person or online, could improve social connection and coping. Online peer support allows people to engage from their home at a time that suits them. We sought to explore the benefits and challenges of online peer support and to identify successful elements of online peer support for people with multiple sclerosis.

METHODS

Using the narrative synthesis method, 6 databases were searched in April 2020 for articles published between 1989 and 2020; the search was updated in May 2022. The quality of the included studies was assessed using the Critical Appraisal Skills Programme qualitative research checklist and the Downs and Black checklist.

RESULTS

Of 10,987 unique articles identified through the database search, 11 were included. Benefits of online peer support included sharing information and experiences and emotional support. Successful elements included having a dedicated space to save information and the convenience of online peer support. Challenges included verification of information and the lack of nonverbal communication.

CONCLUSIONS

Online peer support can help those unable to access in-person support groups and can reduce the risk of social isolation. However, multiple sclerosis symptoms may make it difficult to use technological devices. Research is needed to further explore potential barriers to online peer support.

Work difficulties in people with multiple sclerosis: The role of anxiety, depression and coping

Background

Symptoms of anxiety and depression affect the daily life of people with multiple sclerosis (MS). This study examined work difficulties and their relationship with anxiety, depression and coping style in people with MS.

Methods

219 employed people with MS (median age  =  43 years, 79% female) completed questionnaires on anxiety, depression, coping style, demographics and work difficulties, and underwent a neurological examination. Two regression analyses were performed with work difficulties as the dependent variable and either anxiety or depression as continuous independent variables. Coping style, age, gender, educational level, MS-related disability and disease duration were added as additional predictors, as well as interaction terms between coping style and either symptoms of depression or anxiety.

Results

A significant model was found (F_(10,205)  =  13.14, p < 0.001, R²  =  0.39) in which anxiety, emotion- and avoidance-oriented coping and MS-related disability were positively related to work difficulties. The analysis of depression resulted in a significant model (F_(10,205)  =  14.98, p < 0.001, R²  =  0.42) in which depression, emotion- and avoidance-oriented coping and MS-related disability were positively related to work difficulties. None of the interaction effects were significant.

Conclusions

Work difficulties were positively related to anxiety, depression, emotion- and avoidance-oriented coping and MS-related disability in workers with MS.

Real-World Evidence for Favourable Quality-of-Life Outcomes in Hungarian Patients with Relapsing-Remitting Multiple Sclerosis Treated for Two Years with Oral Teriflunomide: Results of the Teri-REAL Study

Relapsing-remitting multiple sclerosis (RRMS) is a degenerative, inflammatory disease of the central nervous system in which symptoms and disability progression vary significantly among patients. Teri-REAL was a prospective, real-world observational study that examined quality-of-life (QoL) and treatment outcomes in a Hungarian cohort of RRMS patients treated with once-daily oral teriflunomide. QoL was assessed at baseline, 12, and 24 months with the Multiple Sclerosis Quality of Life-54 (MSQoL-54) questionnaire. Other measurements included disease progression (Patient Determined Disease Steps [PDDS]), clinical efficacy (relapses), fatigue (Fatigue Impact Scale [FIS]), depression (Beck Depression Inventory [BDI]), cognition (Brief International Cognitive Assessment in MS [BICAMS]), persistence and safety. 212 patients were enrolled (69.1% female, 50.5% treatment naïve), with 146 (69%) completing the study. Statistically significant improvements in subscales of the MSQoL-54 versus baseline were found at Month 12 and Month 24. Significant improvements were also observed for individual components of the BICAMS score at 24 months, while PDDS, FIS and BDI scores remained stable. The mean annualised relapse rate was 0.08 ± 0.32. There were 93 safety events, most of which were mild to moderate. Improved QoL and cognitive outcomes in teriflunomide-treated patients over 2 years offer a unique perspective to this real-world study.

Perceived Fatigue Impact and Cognitive Variability in Multiple Sclerosis

OBJECTIVE

People with Multiple Sclerosis (PwMS) and healthy controls (HCs) were evaluated on cognitive variability indices and we examined the relationship between fatigue and cognitive variability between these groups. Intraindividual variability (IIV) on a neuropsychological test battery was hypothesized to mediate the group differences expected in fatigue.

METHOD

Fifty-nine PwMS and 51 HCs completed a psychosocial interview and battery of neuropsychological tests and questionnaires during a 1-day visit. Fatigue in this study was measured with the Fatigue Impact Scale (FIS), a self-report multidimensional measure of fatigue. IIV was operationalized using two different measures, a maximum discrepancy score (MDS) and intraindividual standard deviation (ISD), in two cognitive domains, memory and attention/processing speed. Two mediation analyses with group (PwMS or HCs) as the independent variable, variability composite (memory or attention/processing speed) measures as the mediators, total residual fatigue (after accounting for age) as the outcome, and depression as a covariate were conducted. The Baron and Kenny approach to testing mediation and the PROCESS macro for testing the strength of the indirect effect were used.

RESULTS

Results of a mediation analysis using 5000 bootstrap samples indicated that IIV in domains of both attention/processing speed and memory significantly mediated the effect of patient status on total residual fatigue.

CONCLUSION

IIV is an objective performance measure that is related to differences in fatigue impact between PwMS and HCs. PwMS experience more variability across tests of attention/processing speed and memory and this experience of variable performance may increase the impact of fatigue.

Prevalence and burden of multiple sclerosis-related fatigue: a systematic literature review

BACKGROUND

Multiple sclerosis (MS) is a chronic, demyelinating disease of the central nervous system that results in progressive and irreversible disability. Fatigue is one of the most common MS-related symptoms and is characterized by a persistent lack of energy that impairs daily functioning. The burden of MS-related fatigue is complex and multidimensional, and to our knowledge, no systematic literature review has been conducted on this subject. The purpose of this study was to conduct a systematic literature review on the epidemiology and burden of fatigue in people with multiple sclerosis (pwMS).

METHODS

Systematic searches were conducted in MEDLINE, Embase, and Evidence-Based Medicine Reviews to identify relevant studies of fatigue in pwMS. English-language records published from 2010 to January 2020 that met predefined eligibility criteria were included. We initially selected studies that reported quality of life (QoL) and economic outcomes according to categories of fatigue (e.g., fatigued vs non-fatigued). Studies assessing associations between economic outcomes and fatigue as a continuous measure were later included to supplement the available data.

RESULTS

The search identified 8147 unique records, 54 of which met the inclusion criteria. Of these, 39 reported epidemiological outcomes, 11 reported QoL, and 9 reported economic outcomes. The supplementary screen for economic studies with fatigue as a continuous measure included an additional 20 records. Fatigue prevalence in pwMS ranged from 36.5 to 78.0%. MS-related fatigue was consistently associated with significantly lower QoL. Results on the economic impact of fatigue were heterogeneous, but most studies reported a significant association between presence or severity of fatigue and employment status, capacity to work, and sick leave. There was a gap in evidence regarding the direct costs of MS-related fatigue and the burden experienced by caregivers of pwMS.

CONCLUSION

Fatigue is a prevalent symptom in pwMS and is associated with considerable QoL and economic burden. There are gaps in the evidence related to the direct costs of MS-related fatigue and the burden of fatigue on caregivers. Addressing fatigue over the clinical course of the disease may improve health and economic outcomes for patients with MS.

Cognitive Fatigability, not Fatigue predicts employment status in patients with MS three months after rehabilitation

BACKGROUND

Fatigue is potentially the most important factor causing unemployment in people with Multiple Sclerosis (PwMS). Widely accepted is a discrimination between fatigue as subjective sensation and fatigability as objective measure of change in performance. The aim of this study was to identify, whether cognitive fatigue or cognitive fatigability is a better predictor for employment status three months after discharge from a neurological rehabilitation center.

METHODS

64 PwMS (mean age 48.9, 43 females, mean time since diagnosis 14.7 years, median Expanded Disability Status Scale (EDSS) 3.8), complaining of fatigue and reporting difficulties with their working capacity, participated in a cognitive loading task during inpatient rehabilitation. Reaction time performance was measured using a standardized alertness test (TAP-M). Tonic alertness was measured at 8 a.m., 11 a.m. and 2 p.m. Patients worked on a standardized test battery during the morning and after lunch to induce fatigability. All of them completed the Fatigue Scale for Motor and Cognition (FSMC), a standardized questionnaire to rate the trait component of cognitive and motor fatigue. Their employment status was rated within a standardized interview by phone three months after discharge from the clinic.

RESULTS

Mean cognitive fatigue according to the FSMC was 38.9 ± 7.4 and mean motor fatigue 41.0 ± 5.6, indicating severe cognitive and motor fatigue. 15 (88%) of 17 patients working fulltime had severe fatigue according to the FSMC. The cognitive subscale of the FSMC ("FSMC cognition") did not correlate (r_s = -.084, p = .512) and the motor subscale of the FSMC ("FSMC motor") correlated rather weakly but not significantly (r_s= -.220, p = .080) with the employment status. In contrast, there was a significant and medium correlation between alertness at 8 a.m. (alertness₁) and employment status (r_s = -.304, p = .014). Ordered logistic regression revealed that only alertness₁ and the alertness difference between afternoon and noon (alertness difference₃₂) predicted significantly the employment status. The FSMC motor and cognition subscales had no predictive value for employment.

CONCLUSION

Cognitive fatigability (tonic alertness at 8 a.m. or increase of reaction time during the afternoon) is more adequate to predict employment status in PwMS three months after discharge from the clinic than the subjective sensation of fatigue as determined by the FSMC.

Fatigue und Fatigability bei Multipler Sklerose – Leistungsbeurteilung

Fatigue ist eines der häufigsten Symptome bei Patienten mit Multipler Sklerose (MS) 1 2. Fatigue kann das Symptom sein, das die berufliche Leistungsfähigkeit am gravierendsten beeinträchtigt 3 4. Der Großteil der MS-Patienten ist im erwerbsfähigen Alter. Für die sozialmedizinische Leistungsbeurteilung ist besonders problematisch, dass es sich bei der Fatigue um ein subjektives Phänomen handelt, dass nicht objektiv messbar ist.

Treatment and management of cognitive dysfunction in patients with multiple sclerosis

Cognitive impairment is a common and devastating manifestation of multiple sclerosis (MS). Although disease-modifying therapies have been efficacious for reducing relapse rates in MS, such treatments are ineffective for treating cognitive dysfunction. Alternative treatment approaches for mitigating cognitive problems are greatly needed in this population. To date, cognitive rehabilitation and exercise training have been identified as possible candidates for treating MS-related cognitive impairment; however, cognitive dysfunction is still often considered to be poorly managed in patients with MS. This Review provides a comprehensive overview of recent developments in the treatment and management of cognitive impairment in people with MS. We describe the theoretical rationales, current states of the science, field-wide challenges and recent advances in cognitive rehabilitation and exercise training for treating MS-related cognitive impairment. We also discuss future directions for research into the treatment of cognitive impairment in MS that should set the stage for the inclusion of cognitive rehabilitation and exercise training into clinical practice within the next decade.

Brain atrophy and employment in multiple sclerosis patients: a 10-year follow-up study

Background

Multiple sclerosis is often associated with unemployment. The contribution of grey matter atrophy to unemployment is unclear.

Objectives

To identify magnetic resonance imaging biomarkers of grey matter and clinical symptoms associated with unemployment in multiple sclerosis patients.

Methods

Demographic, clinical data and 1.5 T magnetic resonance imaging scans were collected in 81 patients at the time of inclusion and after 5 and 10 years. Global and tissue-specific volumes were calculated at each time point. Statistical analysis was performed using a mixed linear model.

Results

At baseline 31 (38%) of the patients were unemployed, at 5-year follow-up 44 (59%) and at 10-year follow-up 34 (81%) were unemployed. The unemployed patients had significantly lower subcortical deep grey matter volume (P < 0.001), specifically thalamus, pallidus, putamen and hippocampal volumes, and cortical volume (P = 0.011); and significantly greater T1 (P < 0.001)/T2 (P < 0.001) lesion volume than the employed patient group at baseline. Subcortical deep grey matter volumes, and to a lesser degree cortical volume, were significantly associated with unemployment throughout the follow-up.

Conclusion

We found significantly greater atrophy of subcortical deep grey matter and cortical volume at baseline and during follow-up in the unemployed patient group. Atrophy of subcortical deep grey matter showed a stronger association to unemployment than atrophy of cortical volume during the follow-up.

A Dutch validation study of the Multiple Sclerosis Work Difficulties Questionnaire in relapsing remitting multiple sclerosis

PURPOSE

The current study aimed to evaluate the psychometric properties of the Dutch version of the Multiple Sclerosis Work Difficulties Questionnaire-23 (MSWDQ-23).

METHODS

Two hundred and thirty-nine employed persons with multiple sclerosis (MS) and 59 healthy controls completed the MSWDQ-23. To verify the factor structure, a confirmatory factor analysis was conducted. To assess construct validity, the MSWDQ-23 scores were correlated to measures of physical disability, fatigue, cognitive and neuropsychiatric problems, depression, health-related quality of life, and work-related variables. MSWDQ-23 scores were compared within different age groups, gender, education levels, and job types. Predictive validity was assessed using a logistic regression analysis to predict a deterioration in employment status after one year based on MSWDQ-23 scores.

RESULTS

The internal consistency of the MSWDQ-23 was acceptable (α = 0.913, 95% CI = 0.897-0.928) and the results indicated a fair fit. The MSWDQ-23 showed acceptable construct validity, confirming 94% of the hypotheses. The total scale and the psychological/cognitive subscale were able to predict a deterioration in employment status after one year (χ²(1)=18.164, p < 0.001).

CONCLUSIONS

The Dutch version of the MSWDQ-23 is a valid and internally consistent instrument to measure self-reported work difficulties in persons with MS.Implications for rehabilitationThe Dutch version of the 23-item Multiple Sclerosis Work Difficulties Questionnaire (MSWDQ-23) is a reliable and valid tool to measure self-reported work difficulties in people with multiple sclerosis (MS).More psychological and cognitive work difficulties are predictive of a deteriorated employment status after one year.The MSWDQ-23 is a helpful tool for researchers and (occupational) health professionals to identify current work difficulties in persons with MS and identify persons at risk for a deterioration in employment one year later.

Unemployment in multiple sclerosis across the ages: How factors of unemployment differ among the decades of life

Rates of unemployment in multiple sclerosis are high. Certain disease, psychological, and person-specific factors contribute to these high rates. The present study examined these factors and associated risk of unemployment by age. Participants (n = 221) completed an online survey on employment. Participants were broken down by decade of life. Several factors predicted whether someone felt as if they needed to leave the workforce. However, the extent to which these factors contributed to unemployment risk varied by age. Interventions aimed at maintaining employment should address these factors and take into consideration one's stage of life, disease, and career.

Exercise in Multiple Sclerosis: Knowing is Not Enough-The Crucial Role of Intention Formation and Intention Realization

A large body of evidence supports the notion that patients with multiple sclerosis (MS) benefit from physical exercise. However, this research-based recommendation has been insufficiently translated into practice. In this commentary article, we highlight the psychological evidence for the intention-behaviour gap and discuss evidence-based recommendations for bridging this gap, with the aim to change behaviour in MS patients. It is accepted that psychological research distinguishes intention formation from intention realization and that these processes have to be considered when the aim is to enhance physical activity in MS patients. We suggest that the transtheoretical model of behaviour change is a useful and general framework for examining the process of intention formation and that a MS-specific perspective is more useful for realizing exercise intention. MS patients are faced with severe self-control demands that hinder the realization of sport and exercise goals. Specifically, MS patients experience fatigue, which imposes substantial self-control demands. Here, we suggest implementation intention as an effective tool that aids in counteracting deficits in intention realization (getting started and staying on track). We also note that research knowledge is not sufficiently translated into clinical practice. Based on an interdisciplinary approach we recommend that therapists of MS patients should be more aware of psychological theories of health behaviour change and that they should use these to improve and optimize treatment approaches.