Management of fatigue in persons with multiple sclerosis

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.

Dalfampridine in the treatment of primary fatigue in patients with multiple sclerosis: a randomized clinical trail

INTRODUCTION

Fatigue is a highly prevalent debilitating symptom among patients with multiple sclerosis (PwMS), which markedly affects the quality of life. The present study aimed to evaluate the effect of extended-release fampridine on fatigue in PwMS.

METHODS

This was a randomized, double-blind clinical trial on 77 PwMS with a complaint of fatigue, aged over 18 years old, randomized to extended-release fampridine (n = 44) or placebo (n = 35) for 12 weeks. Fatigue and motor function were assessed at baseline and end point.

RESULTS

A total of 88 patients were recruited, of whom 77 were analyzed. 80.5% were female, with a median age of 38. 87% were diagnosed with relapsing-remitting MS (RRMS) with a median disease duration of 96 months. Fingolimod (37.7%) was considered the most frequently used DMT, followed by ani-CD20s (32.5%). The total median MFIS score was 43.5 and 37 in the fampridine and placebo groups which were not significantly different (p > 0.05). After 12 weeks, the total MFIS improved in both groups compared to the baseline, which was significant in the active group (p = 0.04). However, the final end point total MFIS was still comparable between the two groups (p = 0.11).

CONCLUSION

The present study revealed a positive short-term effect of extended-release fampridine on MFIS in PwMS. However, this effect was not significantly superior to the placebo.

The effect of reiki on fatigue and sleep quality in individuals with multiple sclerosis: a randomised controlled study

The aim of the study is to investigate the effect of the application of Reiki on fatigue and sleep quality in people with MS. The study is a randomised controlled study. A total of 60 people (control group = 30, intervention group = 30) participated in this study. Personal Information Form, Piper Fatigue Scale (PFS) and Pittsburg Sleep Quality Index (PSQI) were used to collect data. It was found that the PFS and PSQI total and subcomponent scores of the intervention group decreased after Reiki compared to the control group and this was statistically significant (p < 0.05). The study showed that Reiki was significantly effective in improving fatigue and sleep quality in people with MS. As Reiki is a simple, inexpensive and accessible method, it was suggested that its use in the management of MS should be encouraged and maintained in nursing practice.

A Biopsychosocial Approach to Persistent Post-COVID-19 Fatigue and Cognitive Complaints: Results of the Prospective Multicenter NeNeSCo Study

OBJECTIVE

To evaluate whether psychological and social factors complement biomedical factors in understanding post-COVID-19 fatigue and cognitive complaints. Additionally, to incorporate objective (neuro-cognitive) and subjective (patient-reported) variables in identifying factors related to post-COVID-19 fatigue and cognitive complaints.

DESIGN

Prospective, multicenter cohort study.

SETTING

Six Dutch hospitals.

PARTICIPANTS

205 initially hospitalized (March-June 2020), confirmed patients with SARS-CoV-2, aged ≥18 years, physically able to visit the hospital, without prior cognitive deficit, magnetic resonance imaging (MRI) contraindication, or severe neurologic damage post-hospital discharge (N=205).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Nine months post-hospital discharge, a 3T MRI scan and cognitive testing were performed and patients completed questionnaires. Medical data were retrieved from medical dossiers. Hierarchical regression analyses were performed on fatigue severity (Fatigue Severity Scale; FSS) and cognitive complaints (Cognitive Consequences after Intensive Care Admission; CLC-IC; dichotomized into CLC-high/low). Variable blocks: (1) Demographic and premorbid factors (sex, age, education, comorbidities), (2) Illness severity (ICU/general ward, PROMIS physical functioning [PROMIS-PF]), (3) Neuro-cognitive factors (self-reported neurological symptoms, MRI abnormalities, cognitive performance), (4) Psychological and social factors (Hospital Anxiety and Depression Scale [HADS], Utrecht Coping List, Social Support List), and (5) Fatigue or cognitive complaints.

RESULTS

The final models explained 60% (FSS) and 48% (CLC-IC) variance, with most blocks (except neuro-cognitive factors for FSS) significantly contributing. Psychological and social factors accounted for 5% (FSS) and 11% (CLC-IC) unique variance. Higher FSS scores were associated with younger age (P=.01), lower PROMIS-PF (P<.001), higher HADS-Depression (P=.03), and CLC-high (P=.04). Greater odds of CLC-high were observed in individuals perceiving more social support (OR=1.07, P<.05).

CONCLUSIONS

Results show that psychological and social factors add to biomedical factors in explaining persistent post-COVID-19 fatigue and cognitive complaints. Objective neuro-cognitive factors were not associated with symptoms. Findings highlight the importance of multidomain treatment, including psychosocial care, which may not target biologically-rooted symptoms directly but may reduce associated distress.

Exploring humanistic burden of fatigue in adults with multiple sclerosis: an analysis of US National Health and Wellness Survey data

BACKGROUND

This retrospective study examined the humanistic burden of fatigue in patients with relapsing-remitting multiple sclerosis (RRMS), compared with adults without MS, using data from the 2017 and 2019 US National Health and Wellness Survey.

METHODS

The 5-item Modified Fatigue Impact Scale (MFIS-5) was used to assess level of fatigue (MFIS-5 score <15: low fatigue [LF]; MFIS-5 score ≥15: high fatigue [HF]) in patients with RRMS. Health-related quality of life (HRQoL) measures (Short Form 36-Item Health Survey version 2, Euroqol-5 Dimensions-5 Levels [EQ-5D-5L], Patient Health Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder-7 [GAD-7], Perceived Deficits Questionnaire-5) and treatment-related characteristics were assessed.

RESULTS

In total, 498 respondents were identified as RRMS (n=375 RRMS+LF, n=123 RRMS+HF) and compared with 1,494 matched non-MS controls. RRMS+LF and RRMS+HF had significantly lower Short Form 6 Dimensions health utility, Mental and Physical Component Summary, and EQ-5D-5L scores and higher PHQ-9 and GAD-7 scores, compared with matched non-MS controls (all p<0.001); scores were worse for RRMS+HF than RRMS+LF across all measures (all p<0.001). A higher proportion of RRMS+HF reported moderate-to-severe depression and moderate-to-severe anxiety, compared with RRMS+LF and matched non-MS controls (both p<0.001). Fatigue was a significant predictor of poor HRQoL across all measures (all p<0.001).

CONCLUSIONS

Patients with RRMS experienced lower HRQoL with higher levels of fatigue, highlighting an unmet need. Results may help to inform physician-patient communication and shared decision-making to address fatigue and its associated impact on patients' HRQoL.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Sedentary behaviour and related factors in people with multiple sclerosis

BACKGROUND

Sedentary behaviour is a major problem in persons with multiple sclerosis (pwMS). However, little is known about the related factors of sedentary behaviour in MS. Our study aimed to examine the association between sedentary behaviour and physical activity level, fear of falling, and fatigue.

METHOD

Demographic and clinical data have been recorded. Sedentary behaviour was assessed with the Marshall Sitting Questionnaire, physical activity level was evaluated with the Godin Leisure Time Exercise Questionnaire, fear of falling was evaluated with the Fall Efficacy Scale International, and fatigue was evaluated with the modified fatigue impact scale (MFIS). The Timed 25-Foot Walk, 6-Minute Walk Test, Timed Up and Go Test, and 12-Item Multiple Sclerosis Walking Scale were also used to assess walking and perceived walking disability.

RESULTS

We recruited 71 pwMS [49 were female (69 %), mean age:38.08 years, median EDSS:1.5]. The mean daily sitting time was 593.54 min (∼10 h). No significant correlation was found between sitting times and demographics, leisure time physical activity, fear of falling, walking, perceived walking disability, and neurological disability level (p > 0.05). Logistic regression analysis indicated that being male increased the risk of sedentary behaviour by 3.08 times, being employed increased the risk of sitting by 4.65 times, and each point increase in MFIS scores resulted in a 1.03-fold elevation in the odds of prolonged sitting.

CONCLUSION

The fact that pwMS, even with a mild disability spend almost 10 h sitting highlights the significance of sedentary behaviour in this population. Developing strategies to address modifiable factors, such as fatigue, may be effective in reducing sedentary behaviour.

Improving the quality of self-management in discharged patients with multiple sclerosis: a best practice implementation project

OBJECTIVES

This project determined current compliance with best practice recommendations for self-management in patients with multiple sclerosis (MS) and used a web-based intervention to implement strategies to improve the quality of self-management in discharged patients with MS.

METHODS

Guided by the JBI Evidence-based Model of Health care, this project applied the 7 phases of the JBI Evidence Implementation Framework to improve the quality of self-management in MS patients.

RESULTS

After implementation, compliance significantly improved across all criteria compared with the baseline audit. All patients were assessed to determine their ability to self-manage (Criterion 1). All health care providers were trained to facilitate self-management and behavioral change (Criterion 2). All patients had self-management goals and action plans that were set together by both health care providers and patients (Criteria 3, 5, 6, 7). All patients received education through online patient education courses and were given an education handbook (Criterion 4). The agreed action plan was documented (Criterion 8). All members of the multidisciplinary team coordinated the services required by the patients (Criterion 9) and provided appropriate support to help patients achieve their goals and solve problems through a WeChat group and the communication module on the self-management online platform (Criterion 10).

CONCLUSION

This implementation project effectively promoted practice change by enhancing patients' knowledge of self-management and staff awareness of delivering self-management support to MS patients.

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

Trial Registry: DRKS00024358.

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

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

Thoughts on Fatigue in Multiple Sclerosis Patients

Chronic fatigue is a common symptom in people with multiple sclerosis (PwMS) and presents as a reversible motor and cognitive impairment with reduced motivation and a desire to rest. The presentation of fatigue symptomatology in PwMS can be spontaneous or induced by mental or physical activity, temperature and humidity fluctuations, acute infections, and even food ingestion. Even though the exacerbation of fatigue symptomatology due to heat reaction is well established, the role of environmental temperature (ambient temperature and relative humidity) is not yet fully understood, and there is not enough systematic evidence regarding its effect. In this article, we present our opinion (based on the current literature and clinical experience) regarding the role of environmental temperature in the manifestation of fatigue symptomatology in PwMS.

Saudi Consensus Recommendations on the Management of Multiple Sclerosis: Symptom Management and Vaccination

This article deals with recommendations on the management of symptoms of MS and on the provision of vaccinations in patients receiving disease-modifying therapies (DMTs). Symptoms of MS, such as fatigue, depression, urinary symptoms, spasticity, impairment of gait, and sexual dysfunction, are common in this population. Recognizing and addressing these symptoms is key to maintaining the quality of life of people with MS. Vaccination status should be reviewed and updated prior to initiation of DMTs. In general, vaccination should be avoided for variable periods after the initiation of some DMTs. Live attenuated vaccines are contraindicated and should be considered on a case-by-case basis. These consensus recommendations will present the best practices for vaccination in Saudi Arabia before, during, and after the COVID-19 pandemic. The recommendations will be updated periodically and as needed as new evidence becomes available.

Physical Exercise as a Potential Treatment for Fatigue in Parkinson's Disease? A Systematic Review and Meta-Analysis of Pharmacological and Non-Pharmacological Interventions

BACKGROUND

Fatigue is one of the most common and debilitating non-motor symptoms among patients with Parkinson's disease (PD) and significantly impacts quality of life. Therefore, effective treatment options are needed.

OBJECTIVE

To provide an update on randomized controlled trials (RCTs) including pharmacological and non-pharmacological (but non-surgical) treatments that examine the effects of fatigue on PD patients.

METHODS

We searched the MEDLINE, EMBASE, PsycINFO, CENTRAL, and CINAHL databases for (cross-over) RCTs on pharmacological and non-pharmacological interventions for treating fatigue in PD patients until May 2021. Meta-analyses for random-effects models were calculated when two or more studies on the same treatment option were available using standardized mean differences (SMDs) with 95% confidence intervals (CIs).

RESULTS

Fourteen pharmacological and 16 non-pharmacological intervention RCTs were identified. For pharmacological approaches, a meta-analysis could only be performed for modafinil compared to placebo (n = 2) revealing a non-significant effect on fatigue (SMD = - 0.21, 95% CI - 0.74-0.31, p = 0.43). Regarding non-pharmacological approaches, physical exercise (n = 8) following different training approaches versus passive or placebo control groups showed a small significant effect (SMD = - 0.37, 95% CI - 0.69- - 0.05, p = 0.02) which could not be demonstrated for acupuncture vs. sham-acupuncture (SMD = 0.16, 95% CI - 0.19-0.50, p = 0.37).

CONCLUSION

Physical exercise may be a promising strategy to treat fatigue in PD patients. Further research is required to examine the efficacy of this treatment strategy and further interventions. Future studies should differentiate treatment effects on physical and mental fatigue as the different underlying mechanisms of these symptoms may lead to different treatment responses. More effort is required to develop, evaluate, and implement holistic fatigue management strategies for PD patients.

Making Visible the Invisible: Automatically Measured Global and Regional Brain Volume Is Associated with Cognitive Impairment and Fatigue in Multiple Sclerosis

In multiple sclerosis (MS), the transition from relapsing-remitting to the secondary-progressive phase is characterized by a progression independent of relapse activity (PIRA), resulting in physical disability accumulation and invisible symptoms, i.e., fatigue and cognitive impairment (CI). These symptoms are related to neurodegenerative processes and have been correlated with MRI measures of brain atrophy only at a group level; however, the application in clinical practice of atrophy-based measurements for single-patient evaluation is yet to be fully investigated. In the present study, we aimed to evaluate the association between brain atrophy, measured with easy-to-use automatic software, and the "invisible" MS symptoms of cognition and fatigue. A total of 69 MS patients were included in the study; cognitive impairment and fatigue (FSS) (in addition to neurological disability, EDSS) were assessed and correlated with brain volumes calculated using the automated software QyScore^® which is validated for single-patient use in the clinical setting. Results showed that the cognitive status was accurately reflected by measures of atrophy, with a sensitivity of up to 90%. CI patients showed a lower volume compared to cognitively normal patients in the whole brain (p = 0.017), gray matter (p = 0.042), insula (p = 0.035), cerebellum (p = 0.008), and limbic lobe (p = 0.049). FSS was associated with temporal lobe (r = -0.37, p = 0.013) and insular (r = -0.36, p = 0.019) volumes. The volumes of the same regions were also associated with EDSS. The global/regional atrophy results, assessed with automatic and easy-to-use software, correlated with cognitive and fatigue symptoms, thus supporting the clinical application in routine patient management.

The impact of Inflammatory Bowel Disease related fatigue on Health-Related Quality of Life: a qualitative semi-structured interview study

Background

Fatigue is a frequently reported symptom of Inflammatory Bowel Disease (IBD), having a negative impact on Health-Related Quality of Life (HRQoL). Patients' experiences of this have not been researched in IBD.

Methods

Semi-structured interviews were conducted with adults with Crohn's Disease from out-patient clinics in the United Kingdom. Interviews were audio-recorded and transcribed verbatim, then analysed using thematic analysis.

Results

Fourteen participant interviews were conducted. Three key themes were identified: 1) 'The new normal' established through adaptation and acceptance; 2) 'Energy as a resource' describing attempts to better manage fatigue through planning and prioritising tasks; 3) 'Keeping healthy' encompasses participants' beliefs that 'good health' allows better management of fatigue.

Conclusion

Participants establish a 'new' normality, through maintaining the same or similar level of employment/education activities. However, this is often at the expense of social activities. Further research is required to explore patient led self-management interventions in IBD fatigue.

Online psychological interventions to improve symptoms in multiple sclerosis: A systematic review: Online psychological interventions in Multiple Sclerosis

The aim of this systematic review was to assess the effectiveness of Internet-based psychological interventions in the treatment of physical, socio-affective and cognitive symptoms and quality of life (QoL) in people with multiple sclerosis (pwMS) to provide currently available evidence. Systematic searches for eligible studies were carried out in four databases (August 2021) using key words. Studies were screened, data extracted, quality appraised and analysed by three independent reviewers, using predefined criteria and following the PRISMA rules. Study quality was assessed using Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields QUALSYST tool. Physical, socio-affective and cognitive symptoms and QoL were the primary outcomes. Thirteen studies were included. Two principal approaches were reported: Cognitive behavioural therapy (CBT) and mindfulness-based interventions (MBI). Interventions varied from tailored versions to videoconference by a clinician, duration mean 8 weeks, delivered via individually and groups, all online. The review found that iCBT interventions were effective for improve depression, anxiety, fatigue and QoL, and slightly in cognitive functioning in pwMS, whereas MBI interventions reported benefits in depression, anxiety, stress and QoL, and less evidence in fatigue. Generally, study quality was acceptable in most studies; eleven of the studies scored a low risk of bias on all items in the Qualsyst Tool, whereas only two studies were considered unacceptable. Psychological online interventions may improve physical, socio-affective and cognitive symptoms as well as QoL in pwMS, overcoming the face-to-face barriers (i.e. disability). Contact with the therapist and groups sessions have been identified as enablers of the online interventions. Nevertheless, the limited number of studies and the heterogeneity of health outcomes reported made difficult to afford robust conclusions on psychological intervention effects in pwMS.

Investigating the influence of an effort-reward interaction on cognitive fatigue in individuals with multiple sclerosis

This study examined whether an alteration in the effort-reward relationship, a theoretical framework based on cognitive neuroscience, could explain cognitive fatigue. Forty persons with MS and 40 healthy age- and education-matched cognitively healthy controls (HC) participated in a computerized switching task with orthogonal high- and low-demand (effort) and reward manipulations. We used the Visual Analog Scale of Fatigue (VAS-F) to assess subjective state fatigue before and after each condition during the task. We used mixed-effects models to estimate the association and interaction between effort and reward and their relationship to subjective fatigue and task performance. We found the high-demand condition was associated with increased VAS-F scores (p < .001), longer response times (RT) (p < .001) and lower accuracy (p < .001). The high-reward condition was associated with faster RT (p = .006) and higher accuracy (p = .03). There was no interaction effect between effort and reward on VAS-F scores or performance. Participants with MS reported higher VAS-F scores (p = .02). Across all conditions, participants with MS were slower (p < .001) and slower as a function of condition demand compared with HC (p < .001). This behavioural study did not find evidence that an effort-reward interaction is associated with cognitive fatigue. However, our findings support the role of effort in subjective cognitive fatigue and both effort and reward on task performance. In future studies, more salient reward manipulations could be necessary to identify effort-reward interactions on subjective cognitive fatigue.

Interpreting the clinical importance of the relationship between subjective fatigue and cognitive impairment in multiple sclerosis (MS): How BICAMS performance is affected by MS-related fatigue

BACKGROUND

There is evidence that subjective fatigue can influence cognitive functioning in multiple sclerosis (MS). DeLuca et al.'s (2004) Relative Consequence Model proposes that impairments to other high-level cognitive functions, such as memory, result from the disease's effect on information processing speed.

OBJECTIVE

The primary aims of the study were to investigate both 1) the relationship between subjective fatigue and cognitive functioning, as measured by the widely used Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) in MS; and 2) the consequential effect of fatigue on information processing speed as predicted by the Relative Consequence Model.

METHODS

192 participants with MS attending tertiary referral MS centre completed the Modified Fatigue Impact Scale and BICAMS.

RESULTS

Multiple correlation analyses determined that there were statistically significant relationships between all domains assessed by the BICAMS and levels of fatigue, such that higher levels of self-reported fatigue were associated with lower performance on information-processing, and visual and verbal learning. After controlling for information processing speed, the strength of correlation between fatigue and learning performance weakened. Linear regression analysis showed that fatigue predicted the most variance in verbal learning and 11.7% of the overall variance in BICAMS performance.

CONCLUSION

Subjective fatigue and objective cognitive performance in MS are related. Caution is advised in the interpretation of BICAMS scores in cases where high levels of fatigue are present, and more detailed neuropsychological assessments may be required in order to accurately identify objective cognitive impairment independent of subjective fatigue.

Mapping grip-force related brain activity after a fatiguing motor task in multiple sclerosis

BACKGROUND

Motor fatigue is common in multiple sclerosis (MS), but its pathophysiology is still poorly understood. Here we used functional magnetic resonance imaging (fMRI) to delineate how the acute induction of motor fatigue alters functional activity of the motor system and how these activity changes are related to motor fatigue.

METHOD

Forty-four right-handed mildly disabled patients with relapsing-remitting MS and 25 healthy controls performed a maximal tonic precision grip with their right hand until they developed motor fatigue. Before and after the fatiguing task, participants performed a non-fatiguing tonic grip force task, producing 15-20% of their maximum grip force based on visual feedback. Task related brain activity was mapped with blood-oxygen level dependent fMRI at 3 T. Statistical parametric mapping was used to identify relative changes in task-related activation from the pre-fatigue to the recovery MRI session.

RESULTS

Following fatigue induction, task performance was perturbed in both groups, and task-related activation increased in the right (ipsilateral) primary motor hand area. In patients with MS, task-related activity increased bilaterally during the recovery phase in the ventrolateral portion of the middle putamen and lateral prefrontal cortex relative to controls. The more patients increased task-related activity in left dorsal premotor cortex after the fatiguing task, the less they experienced motor fatigue during daily life.

CONCLUSION

Patients with MS show enhanced functional engagement of the associative cortico-basal ganglia loop following acute induction of motor fatigue in the contralateral hand. This may reflect increased mental effort to generate movements in the recovery phase after fatigue induction. The ability to recruit the contralateral dorsal premotor cortex after fatigue induction may constitute a protective mechanism against experiencing motor fatigue in everyday life.

Exploring the management approaches of cytokines including viral infection and neuroinflammation for neurological disorders

Considerable evidence supports that cytokines are important mediators of pathophysiologic processes within the central nervous system (CNS). Numerous studies have documented the increased production of various cytokines in the human CNS in various neurological and neuropsychiatric disorders. Deciphering cytokine actions in the intact CNS has important implications for our understanding of the pathogenesis and treatment of these disorders. The purpose of this study is to discuss the recent research on treating cytokine storm and amyloids, including stroke, Parkinson's disease (PD), Alzheimer's disease (AD), Huntington's condition, Multi-sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS). Neuroinflammation observed in neurological disorders has a pivotal role in exacerbating Aβ burden and tau hyperphosphorylation, suggesting that stimulating cytokines in response to an undesirable external response could be a checkpoint for treating neurological disorders. Furthermore, the pro-inflammatory cytokines help our immune system through a neuroprotective mechanism in clearing viral infection by recruiting mononuclear cells. This study reveals that cytokine applications may play a vital role in providing novel regulation and methods for the therapeutic approach to neurological disorders and the causes of the deregulation, which is responsible for neuroinflammation and viral infection. However, it needs to be further investigated to clarify better the mechanisms of cytokine release in response to various stimuli, which could be the central point for treating neurological disorders.

Investigating the association of mood and fatigue with objective and subjective cognitive impairment in multiple sclerosis

Discrepancies between subjective cognitive difficulties and objective measures of cognitive function in people with MS have been identified and may be related to mood and fatigue. The aim of the present study was to examine associations of depression and fatigue with discrepancies between subjective and objective cognitive functioning in pwMS. 177 participants with MS attending a University Hospital Department of Neurology MS Outpatient clinic completed the Brief International Cognitive Assessment for MS (BICAMS), MS Neuropsychological Questionnaire (MSNQ), Hospital Anxiety and Depression Scale (HADS) and Modified Fatigue Impact Scale (MFIS). To quantify the discrepancy between objective (BICAMS) and subjective (MSNQ) cognitive functioning, discrepancy scores were calculated by subtracting MSNQ z-score from composite BICAMS z-score. Based on their discrepancy score, participants were grouped as 'Underestimated', 'Overestimated' and 'Non-discrepant'. 39% of the total sample demonstrated poorer subjective cognitive functioning than their objective cognitive performance suggested ('Underestimated'). 23% of the total sample indicated lower objective scores than their subjective report suggests ('Overestimated'). 38% participants indicated relatively no discrepancy between objective and subjective cognitive measures ('Non-discrepant'). Significant differences were observed between the discrepancy groups in terms of depression and fatigue, with the 'Underestimated' group demonstrating greater levels of depression and fatigue (ps < .01). Regression analysis indicated that cognitive fatigue and depression significantly contributed to variance in subjective cognitive functioning. Our findings suggest that subjective reports of cognitive function may be influenced by depression and fatigue, emphasising the importance of cognitive, mood and fatigue screening as part of routine clinical care.

Italian translation and validation of fatigue symptoms and impacts questionnaire in relapsing multiple sclerosis (FSIQ-RMS)

BACKGROUND

Fatigue is a disabling symptom of multiple sclerosis (MS) and impacts on daily life. The Fatigue Symptoms and Impacts Questionnaire-Relapsing Multiple Sclerosis (FSIQ-RMS) is a new 20-item tool that investigates the aspects of fatigue in MS. It concerns motor, cognitive, social, and emotional aspects of fatigue. We aim at validating the Italian version of FSIQ-RMS in an Italian population of MS patients and demonstrate its reliability and construct validity.

METHODS

We included patients with diagnosis of MS, age between 18 and 70 years with ability to participate in a 90-min interview. Each patient completed the Italian version of FSIQ-RMS and Fatigue Severity Scale (FSS) at the same time. Construct validity was explored by the exploratory factor analysis; reliability was assessed with Cronbach's alpha; and test-retest stability was examined through intraclass correlation coefficient (ICC). Concurrent validity was calculated using Pearson's correlation.

RESULTS

We enrolled 171 patients (126 female and 45 male), 83% with relapsing MS (RMS), and 17% with secondary progressive MS (SPMS). Italian FSIQ-RMS showed a Cronbach's alpha of 0.92; ICC was 0.96. Pearson's correlation coefficient between FSIQ-RMS and FSS total score was statistically significant (p < 0.01); FSIQ-RMS inversely correlated also with BMI and positively with EDSS.

CONCLUSION

The Italian version of FSIQ-RMS has excellent psychometric properties and can be used in research and clinical setting to evaluate physical, cognitive, and social fatigue in both RMS and SPMS.

Co-occurrence of Fatigue and Depression in People With Multiple Sclerosis: A Mini-Review

Fatigue and depression are common conditions diagnosed in people with multiple sclerosis (MS). Fatigue defined as subjective lack of physical and/or mental energy is present in 35–97% of people with MS, who classify it as one of the most serious symptoms interfering with daily activities and influencing the quality of life. Depression is diagnosed in about 50% of people with MS. Since fatigue and depression frequently coexists, it may be quite hard to differentiate them. Primary fatigue and primary depression in MS are caused by inflammatory, oxidative/nitrosative, and neurodegenerative processes leading to demyelination, axonal damage, and brain atrophy. In people with MS and comorbid fatigue and/or depression there is reported increased serum and cerebrospinal fluid concentration of inflammatory mediators such as tumor necrosis factor, interleukins (IL-1a, IL-1b, IL-6), interferon γ and neopterin. Moreover, the brain atrophy of prefrontal, frontal, parietotemporal regions, thalamus, and basal ganglia was observed in people with MS with fatigue and/or depression. The secondary fatigue and secondary depression in people with MS may be caused by emotional factors, sleep disorders, pain, the coexistence of other diseases, and the use of medications. In some studies, the use of disease-modifying therapies positively influenced fatigue, probably by reducing the inflammatory response, which proves that fatigue and depression are closely related to immunological factors. In this mini-review, the pathogenesis, methods of evaluation and differentiation, and possible therapies for fatigue and depression in MS are discussed.

Improving Health of People With Multiple Sclerosis From a Multicenter Randomized Controlled Study in Parallel Groups: Preliminary Results on the Efficacy of a Mindfulness Intervention and Intention Implementation Associated With a Physical Activity Program

Objectives: The objective of this study is to investigate the efficacy of psychological Interventions – Mindfulness or Implementation Intention – associated with a Physical Activity program, delivered via internet, in reducing Multiple Sclerosis symptoms.

Method: Thirty-five adults were randomly assigned to one of the three groups: a Mindfulness-Based Intervention group (N = 12), Implementation Intention group (N = 11), and a Control Group (N = 12). All the groups received the same Physical Activity program. The Mindfulness condition group received daily training in the form of pre-recorded sessions while the Implementation group elaborated their specific plans once a week. Mobility, fatigue, and the impact of the disease on the patient’s life were measured. Two measurement times are carried out in pre-post intervention, at baseline and after eight weeks.

Results: Overall, after 8 weeks intervention, results show that there was a significant increase in Walking distance in the three groups. In addition, the within-group analysis showed a statistically significant improvement between pre and post intervention on the physical component of the Disease Impact scale in the Implementation Intention group (p = 0.023) with large effect size, in the Mindfulness-Based Intervention group (p = 0.008) with a medium effect size and in the control group (p = 0.028) with small effect size. In the Implementation Intention group, all physical, psychosocial and cognitive Fatigue Impact subscales scores decreased significantly (p = 0.022, p = 0.023, and p = 0.012, respectively) and the physical component was statistically and negatively correlated (r = −0.745; p = 0.008) when Implementation Intention group practice a mild to moderate physical activity. In the Mindfulness-Based Intervention group, the physical component (MFIS) showed a statistically significant improvement (p = 0.028) but no correlation with moderate-to-vigorous physical activity (MVPA); the control group outcomes did not reveal any significant change.

Conclusion: The results of this study are very encouraging and show the feasibility of Mindfulness interventions associated with physical activity to improve the health of people with MS. Further study should assess Mindfulness interventions tailored to MS condition and using both hedonic and eudemonic measures of happiness.

Central Vestibular Functions Correlate With Fatigue and Walking Capacity in People With Multiple Sclerosis

OBJECTIVE

Imbalance and fatigue are among the most common and disabling symptoms of multiple sclerosis (MS). Vestibular rehabilitation studies demonstrate not only improvements in balance but fatigue also, suggesting a relationship between central vestibular integration and fatigue. The objective of this study was to determine whether the relationship between balance and fatigue in people with MS is seen between other measures of central vestibular integration and fatigue and to understand how central vestibular integration measures interrelate.

METHODS

This cross-sectional study consisted of 40 people with MS (age = 27-55 years, Expanded Disability Severity Scale score = 1.0-6.5) who completed vestibular ocular reflex testing, subjective visual vertical testing, static posturography, dynamic gait, 2 self-report fatigue surveys, and a 6-Minute Walk Test to assess walking capacity/physical fatigue was completed. Spearman correlations were calculated between variables.

RESULTS

Measures of central vestibular integration were significantly correlated with measures of fatigue and walking capacity and with each other. The correlations between physical fatigue and central vestibular functions were larger than self-reported fatigue correlations with central vestibular functions.

CONCLUSION

The relationship between balance and fatigue extends to other measures requiring central vestibular integration, suggesting a deficit in central vestibular processing in people with MS. These measures may compliment balance assessment as outcome measures for vestibular rehabilitation in people with MS. Fatigue measures should be included in vestibular rehabilitation as secondary outcomes.

IMPACT

Correlations between central vestibular integration and fatigue in people with MS suggest that future studies of vestibular rehabilitation should include fatigue, as a secondary outcome measure as vestibular function and fatigue may share similar a similar etiology in people with MS.

[Preliminary results of rehabilitation intervention for the correction of cognitive impairment in patients with multiple sclerosis]

One of the leading symptoms in patients with multiple sclerosis (MS) is cognitive impairment. It often affects aspects of cognition such as learning ability, memory, processing speed, and attention. It has been proven that patients often complain of difficulties in multitasking and choosing the right words. These problems are often underestimated. Various studies show that regular physical activity, mainly aerobic exercise, can potentially improve cognitive function. Positive effects on concentration, memory, and multitasking were described. In March 2019, the Tyumen regional center of MS, together with the clinical Institute of the brain (Yekaterinburg), launched a clinical study of methods for rehabilitation of cognitive disorders in patients with MS. There was a statistically significant improvement in MOCA-test scores, according to SDMT and PASSAT data in the main group of MS patients. Despite a significant improvement in cognitive function, the self-assessment of mental function according to the MSQOL54-MN test in this group of patients did not change. Our preliminary results suggest that a comprehensive and well-controlled training program can improve cognitive abilities in MS patients even after a short course of treatment.

The clinical correlates of the chair sit to stand performance in people with multiple sclerosis

Objective: This study aimed to evaluate the motor and non-motor factors associated with sit-to-stand performance in people with Multiple Sclerosis (PwMS). Design: Observational cross-sectional study. Subjects: A total of 88 individuals with MS participated in this study. Main Measures: Standing performance was measured using the five-times-sit-to-stand test (FTSTS). The Berg Balance Scale to assess balance, the 10-Meter Walking Test (10-MWT) was used to assess walking speed; the Patient Determined Disease Steps (PDDS) was used to assess disability level. Furthermore, Brief International Cognitive Assessment for MS (BICAMS) was used to assess cognitive status, Hospital Anxiety and Depression scale (HADS) to assess depression and anxiety, and the Modified Fatigue Impact scale (MFIS) to evaluate fatigue. Spearman correlation coefficient was used to determine the relationship between all these variables and the FTSTS. Furthermore, multiple linear regression was conducted to determine predictive factors of the FTSTS. Results: FTSTS score was correlated significantly with BBS, PDDS, BICAMS, 10-MWT and MFIS (r ranged from 0.3 to 0.52; P < .05). However, there was no significant correlation observed between the FTSTS and HADS-depression or HADS-anxiety. Considering the multiple regression analysis, the following factors were significantly predictive of the FTSTS: 10-MWT, MFIS and the BICAMS-z score (R²: 0.433, P < .0001). Conclusion: The study concludes that sit to stand is multifactorial and is potentially associated with walking speed, cognitive function and fatigue. These factors should be considered by healthcare professionals in interpreting the sit-to-stand performance of PwMS and in designing rehabilitation interventions.

Prevalence, co-occurrence, and trajectories of pain, fatigue, depression, and anxiety in the year following multiple sclerosis diagnosis

BACKGROUND

Pain, fatigue, depression, and anxiety are common in multiple sclerosis, but little is known about the presence, co-occurrence, and trajectories of these symptoms in the year after multiple sclerosis (MS) diagnosis.

OBJECTIVES

To determine, during the postdiagnosis year: (1) rates of pain, fatigue, depression, and anxiety; (2) rates of symptom co-occurrence; and (3) stability/change in symptom severity.

METHODS

Newly diagnosed adults with MS/clinically isolated syndrome (N = 230) completed self-report measures of pain, fatigue, depression, and anxiety at 1, 2, 3, 6, 9, and 12 months after MS diagnosis. Clinical significance was defined based on standardized cutoffs. Descriptive statistics and Sankey diagrams characterized rates and trajectories.

RESULTS

Participants endorsed clinically significant symptoms at some point in the postdiagnosis year at rates of 50.9% for pain, 62.6% for fatigue, 47.4% for depression, and 38.7% for anxiety. A majority of patients exhibited co-occurring symptoms-21.3% with two, 19.1% with three, and 17.4% with four. The proportions of patients with clinically significant symptoms were generally stable over time; however, rates of symptom development/recovery revealed fluctuations at the individual level.

CONCLUSIONS

Pain, fatigue, depression, and anxiety are prevalent in newly diagnosed MS. Prompt screening and evidence-based interventions are necessary if quality of life is to be optimized.

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.

Effective rehabilitation interventions and participation among people with multiple sclerosis: an overview of reviews

BACKGROUND

Multiple sclerosis (MS) is the most common cause of non-traumatic disability in people aged 10 to 65 years. Evidence exists for the effectiveness of multidisciplinary rehabilitation and exercise. However, the effectiveness of other rehabilitation approaches in MS needs further evaluation.

OBJECTIVE

We aimed to systematically synthesize and evaluate knowledge on effectiveness of rehabilitation interventions and determinants for participation among people with MS (pwMS) to inform clinical guidelines on rehabilitation.

METHODS

Joanna Briggs Institute methodology was used. PubMed, Embase, CINAHL, PsycINFO and Web of Science were searched for reviews, systematic reviews, meta-analyses, and meta-syntheses published during 2009-2019. All types of rehabilitation interventions provided to pwMS at any time and in all settings were eligible. Two reviewers independently screened and extracted data. The most recently published reviews on mixed and specific modalities were included. The findings were reported in a narrative summary and a mixed-methods analysis.

RESULTS

Among 108 eligible reviews, 6 qualitative or mixed-methods reviews and 66 quantitative reviews were included (total pwMS >90,000). This overview provides solid evidence for the effectiveness of a spectrum of modalities. Among the modalities, there was strong evidence for the effectiveness of multidisciplinary, cognitive and exercise approaches, physiotherapy, and occupational therapy, including full body training on functioning, and participation outcomes. Employment significantly affected quality of life; thus, vocational rehabilitation should be initiated early. Healthcare professionals should identify personal factors including relations and coping, and the rehabilitation process should involve partners or close family.

CONCLUSIONS

The mixed-methods analysis revealed insufficient consensus between the perspectives of pwMS on their rehabilitation and reported effects, indicating that further research should target the experiences of pwMS. Furthermore, rehabilitation should be patient-centred, focus on the complexity of needs, and be organised and performed by an experienced multidisciplinary team. Evidence-based rehabilitation should be initiated early after pwMS are diagnosed and follow international guidelines. Database registration. PROSPERO ID (CRD42020152422).

A Prospective, Observational, Cohort Study to Assess the Efficacy and Safety of Prolonged-Release Fampridine in Cognition, Fatigue, Depression, and Quality of Life in Multiple Sclerosis Patients: The FAMILY Study

Introduction

The efficacy of prolonged-release fampridine (PR-FAM) may extend in multiple sclerosis (MS) beyond walking ability. The objective of this study was to evaluate the effect of PR-FAM treatment on cognition, fatigue, depression, and quality of life (QoL) in adult patients with MS in a real-world setting.

Methods

FAMILY was a multi-center, prospective, observational, real-world cohort study of MS patients receiving PR-FAM in the outpatient setting. Patients were treated as per PR-FAM’s local prescribing information for 6 months. Standardized protocols and questionnaires were used to evaluate changes in cognition (PASAT; Paced Auditory Serial Addition Test), fatigue (MFIS; Modified Fatigue Impact Scale), depression (BDI-II; Beck Depression Inventory-II) and QoL (MusiQoL; MS International Quality-of-Life questionnaire, MSIS-29; Multiple Sclerosis Impact Scale: PHYS and PSYCH subscales) at 3 and 6 months compared to baseline.

Results

In total, 102 eligible patients from 8 sites in Greece were analysed, of whom 92 completed the study and 10 discontinued. At 6 months, PR-FAM treatment resulted in improvements from baseline in PASAT-3′′ (p = 0.044), MFIS (p < 0.001), BDI-II (p < 0.001), MusiQoL (p < 0.001) and MSIS-29-PHYS (p = 0.012) and MSIS-PSYCH (p < 0.001). A positive effect was evident already at 3 months in PASAT-3′′ (ns), MFIS (p = 0.020), BDI-II (p = 0.034), MusiQoL (p = 0.001), MSIS-29-PHYS (ns) and MSIS-29-PSYCH (p < 0.001).

Conclusions

This observational study provides new data to the current literature in support of PR-FAM’s positive effects in cognition, fatigue, depression, and QoL in a large, heterogeneous group of Greek MS patients in the real-world setting.

Trial Registration

ClinicalTrials.gov identifier, NCT03164018.

Supplementary Material

The online version of this article (10.1007/s12325-020-01606-5) contains supplementary material, which is available to authorized users.

Therapeutic Approaches to Insomnia and Fatigue in Patients with Multiple Sclerosis

The prevalence of sleep disorders in individuals with multiple sclerosis (MS) is 3-5 times higher compared to the general population. Insomnia Disorder, defined as difficulty falling asleep, maintaining sleep or waking up too early, can lead to significant fatigue, the most common and disabling symptom of MS. In addition, fatigue and insomnia in patients with MS also can overlap with and exacerbate other psychological and physical symptoms. Cognitive behavioral therapy for insomnia (CBT-I) has been shown as an effective treatment for chronic insomnia and burgeoning research has demonstrated the effectiveness of this treatment for insomnia in individuals with a variety of comorbid medical conditions including MS. The purpose of the current review will explore the literature surrounding the prevalence and impact of sleep disorders and fatigue in MS. Additionally, this review will address practical ways to help individuals with MS manage fatigue as well as how to modify typical standard behavioral treatments for insomnia to take into account special considerations for individuals with MS based on the level of disability and other comorbid issues that impact sleep.

Cognitive Fatigue Is Associated with Altered Functional Connectivity in Interoceptive and Reward Pathways in Multiple Sclerosis

Cognitive fatigue is common and debilitating among persons with multiple sclerosis (pwMS). Neural mechanisms underlying fatigue are not well understood, which results in lack of adequate treatment. The current study examined cognitive fatigue-related functional connectivity among 26 pwMS and 14 demographically matched healthy controls (HCs). Participants underwent functional magnetic resonance imaging (fMRI) scanning while performing a working memory task (n-back), with two conditions: one with higher cognitive load (2-back) to induce fatigue and one with lower cognitive load (0-back) as a control condition. Task-independent residual functional connectivity was assessed, with seeds in brain regions previously implicated in cognitive fatigue (dorsolateral prefrontal cortex (DLPFC), ventromedial prefrontal cortex (vmPFC), dorsal anterior cingulate cortex (dACC), insula, and striatum). Cognitive fatigue was measured using the Visual Analogue Scale of Fatigue (VAS-F). Results indicated that as VAS-F scores increased, HCs showed increased residual functional connectivity between the striatum and the vmPFC (crucial in reward processing) during the 2-back condition compared to the 0-back condition. In contrast, pwMS displayed increased residual functional connectivity from interoceptive hubs—the insula and the dACC—to the striatum. In conclusion, pwMS showed a hyperconnectivity within the interoceptive network and disconnection within the reward circuitry when experiencing cognitive fatigue.

New Strategies for Rehabilitation and Pharmacological Treatment of Fatigue Syndrome in Multiple Sclerosis

Multiple sclerosis (MS) is the most common autoimmune disease of the central nervous system (CNS), with an inflammatory demyelinating basis and a progressive course. The course of the disease is very diverse and unpredictable. Patients face many problems on a daily basis, such as problems with vision; sensory, balance, and gait disturbances; pain; muscle weakness; spasticity; tremor; urinary and fecal disorders; depression; and rapidly growing fatigue, which significantly influences quality of life among MS patients. Excessive fatigue occurs in most MS patients in all stages of this disease and is named MS-related fatigue. The crucial issue is the lack of effective treatment; therefore, this review focuses not only on the most common treatment methods, but also on additional novel therapies such as whole-body cryotherapy (WBC), functional electrical stimulation (FES), and non-invasive brain stimulation (NIBS). We also highlight the advantages and disadvantages of the most popular clinical scales used to measure fatigue. The entire understanding of the origins of MS-related fatigue may lead to the development of more effective strategies that can improve quality of life among MS patients. A literature search was performed using MEDLINE, EMBASE, and PEDro databases.

Personal Autonomy as Quality of Life Predictor for Multiple Sclerosis Patients

Multiple sclerosis (MS) is a chronic, severe disease, characterized by a progressive alteration in neuronal transmission, which decreases personal independence and quality of life (QoL). This study aimed to investigate the relationship between QoL and personal autonomy in patients with MS, as well as its correlation with age, educational level, and diseases severity. Twenty-six MS patients were followed-up for six months. All patients completed the 15D questionnaire two times: at T0, when they started a new treatment, and at T1 after six months of treatment. At the end point, all patients completed the Personal Autonomy Questionnaire. The average patient age was 43 years (SD = 10), and 89% of them were female. The mean severity and duration of MS were 3.5 (SD = 1.75) and 9.5 (SD = 5.1), respectively. The average QoL of MS patients at T0 was 0.66 (SD = 0.18), and that at T1 was 0.71 (SD = 0.16). The scores of patients with different types of MS, i.e., relapsing–remitting MS (RRMS) or secondary progressive MS (SPMS), were compared. SPMS patients were older than RRMS patients (mean age 47.5 vs. 39.7 years; p = 0.032), and more RRMS patients were working (0.014). SPMS patients described the same QoL and personal autonomy as RRMS patients. Results from bivariate correlation analyses showed a significant relationship between QoL and age, education, and severity of MS. Also, the analysis showed no significant correlation between QoL and personal autonomy.

Neural mechanisms underlying state mental fatigue in multiple sclerosis: a pilot study

Neuroimaging underpinnings of state (in the moment, transient) mental fatigue in multiple sclerosis (MS) are not well understood. The current pilot study examined the effect of state mental fatigue on brain activation (measured using functional magnetic resonance imaging [fMRI]) during conditions of varying cognitive loads of rapid information processing in persons with MS relative to healthy controls. Nineteen persons with MS and 17 healthy controls underwent fMRI scanning while performing a modified version of the Symbol Digit Modalities Test, which consisted of high and low cognitive load conditions with comparable visual stimulation. State mental fatigue was assessed using the Visual Analog Scale of Fatigue before and after each run of the behavioral task. Results indicated that the healthy control group recruited significantly more anterior brain regions (superior and middle frontal gyri, insula, and superior temporal gyrus) to meet increased task demands during the high cognitive load condition as fatigue level increased (p < 0.05), which was accompanied by shorter response time. In contrast, the MS group did not recruit anterior areas to the same extent as the healthy control group as task demands and fatigue increased. Indeed, the MS group continued to activate more posterior brain regions (precuneus, lingual gyrus, and middle occipital gyrus) for the high cognitive load condition (p < 0.05) with no improvement in speed. In conclusion, persons with MS may allocate neural resources less efficiently than healthy controls when faced with increased task demands, which may result in increased mental fatigue. Results of the current pilot investigation warrant replication with a larger sample size.

Fatigue Symptoms During the First Year Following ARDS

BACKGROUND

Fatigue is commonly reported by ARDS survivors, but empirical data are scarce.

RESEARCH QUESTION

This study evaluated fatigue prevalence and associated variables in a prospective study of ARDS survivors.

STUDY DESIGN AND METHODS

This analysis is part of the ARDSNet Long-Term Outcomes Study (ALTOS) conducted at 38 US hospitals. Using age- and sex-adjusted, time-averaged random effects regression models, we evaluated associations between the validated Functional Assessment of Chronic Illness Therapy-Fatigue Scale with patient and critical illness variables, and with physical, cognitive, and mental health status at 6 and 12 months following ARDS.

RESULTS

Among ARDS survivors, 501 of 711 (70%) and 436 of 659 (66%) reported clinically significant symptoms of fatigue at 6 and 12 months, respectively, with 41% and 28% reporting clinically important improvement and worsening (n = 638). At 6 months, the prevalence of fatigue (70%) was greater than that of impaired physical functioning (50%), anxiety (42%), and depression (36%); 46% reported both impaired physical function and fatigue, and 27% reported co-existing anxiety, depression, and fatigue. Fatigue was less severe in men and in those employed prior to ARDS. Critical illness variables (eg, illness severity, length of stay) had little association with fatigue symptoms. Worse physical, cognitive, and mental health symptoms were associated with greater fatigue at both the 6- and 12-month follow-up.

INTERPRETATION

During the first year following ARDS, more than two-thirds of survivors reported clinically significant fatigue symptoms. Due to frequent co-occurrence, clinicians should evaluate and manage survivors' physical, cognitive, and mental health status when fatigue is endorsed.

Bifrontal transcranial direct current stimulation modulates fatigue in multiple sclerosis: a randomized sham-controlled study

Fatigue is a frequent and debilitating symptom in patients with central nervous system diseases. Up to 90% of patients with multiple sclerosis (MS) suffer from fatigue that drastically affects the quality of life. MS patients also complain of anxiety and depressive symptoms and these three manifestations tend to cluster together in this clinical population. The objective of this work was to assess the effects of transcranial direct stimulation (tDCS), a noninvasive brain stimulation technique, on fatigue as well as anxiety and depressive symptoms. Eleven fatigued MS patients randomly received two blocks (active and sham tDCS) of five consecutive daily sessions of bifrontal tDCS (anode/cathode over the left/right prefrontal cortices, respectively) in a crossover manner, separated by a 3-week washout interval. Evaluation took place at day 1, day 5 (right after each block) and 1 week later. Active but not sham tDCS resulted in a significant improvement of fatigue at day 5 (p < 0.05), an effect that seems to last at least 1 week following the stimulation (p = 0.05). Active tDCS also significantly improved anxiety symptoms, but the effect emerged 1 week later (p < 0.05). No significant effects were obtained regarding depression (p > 0.05). Bifrontal tDCS seems to modulate fatigue in PwMS. The observed anxiolytic effects could constitute delayed after effects of tDCS or might be mediated by fatigue improvement. These findings merit to be addressed in large-scale controlled trials.

Self-Reported Fatigue Predicts Incident Stroke in a General Population: EPIC-Norfolk Prospective Population-Based Study

Background and Purpose- Fatigue is a common symptom among stroke survivors and in general practice. However, the clinical significance of fatigue and its relationship to incident stroke is unclear. The aim of this study was to examine the relationship between self-reported fatigue and the incidence of stroke in a general population. Methods- This was a prospective, population-based study. The study population was 15 654 men and women aged 39 to 79 years recruited in 1993 to 1997 and followed till March 2016. Fatigue was assessed at 18 months after baseline using the vitality domain of the Short Form 36 questionnaire. Cox proportional hazard models were constructed to describe the prospective relationship between baseline fatigue and incident stroke adjusting for age, sex, systolic blood pressure, cholesterol, physical activity, smoking status, alcohol consumption, fruit and vegetable consumption, diabetes mellitus, body mass index, vitamin supplement use, education level, Townsend deprivation index, and occupational social class. Incident stroke was ascertained using death certificates and hospital record linkage data. Results- Through 249 248 person-years of follow-up, 1509 incident strokes occurred. Participants who reported the highest level of fatigue (quartile 4) were more likely to be women, to be multimorbid, and to perceive their health as fair or poor. We observed ≈50% relative risk increase in stroke risk (hazard ratio, 1.49 [95% CI, 1.29-1.71]) in those who reported the highest level of fatigue compared with those who reported the lowest level of fatigue (Q4 versus Q1). This relationship remained unaltered regardless of anemia status, the presence or absence of chronic bronchitis, thyroid dysfunction, or depression. Conclusions- Self-report fatigue assessed by the vitality domain of the Short Form 36 questionnaire predicts the risk of future stroke at the general population level. Identifying and addressing stroke risk factors in those who report fatigue in general practice may have substantial benefit at the population level.

Management of Multiple Sclerosis Symptoms and Comorbidities

PURPOSE OF REVIEW

This article discusses the prevalence, identification, and management of multiple sclerosis (MS)-related symptoms and associated comorbidities, including complications that can present at all stages of the disease course.

RECENT FINDINGS

The impact of comorbidities on the outcome of MS is increasingly recognized. This presents an opportunity to impact the course and outcome of MS by identifying and treating associated comorbidities that may be more amenable to treatment than the underlying inflammatory and neurodegenerative disease. The identification of MS-related symptoms and comorbidities is facilitated by brief screening tools, ideally completed by the patient and automatically entered into the patient record, with therapeutic suggestions for the provider. The development of free, open-source screening tools that can be integrated with electronic health records provides opportunities to identify and treat MS-related symptoms and comorbidities at an early stage.

SUMMARY

Identification and management of MS-related symptoms and comorbidities can lead to improved outcomes, improved quality of life, and reduced disease activity. The use of brief patient-reported screening tools at or before the point of care can facilitate identification of symptoms and comorbidities that may be amenable to intervention.

Thalamo-cortical dysfunction contributes to fatigability in multiple sclerosis patients: A neurophysiological study

BACKGROUND

Fatigue and fatigability are common symptoms reported by patients affected by Multiple Sclerosis (MS). The pathogenic mechanisms of such symptoms are currently unknown, but increasing evidence suggests that thalamus could play a key-role. High-frequency oscillations (HFOs) are a neurophysiological measure reflecting the activity of thalamo-cortical network. In particular, the early component is generated from thalamic axons while the late part results from neurons located in somatosensory cortex.

OBJECTIVE

To investigate the effect of a fatigue-inducing exercise on HFOs and on strength performances in MS patients and healthy controls (HCs).

METHODS

Fifteen patients and fifteen HCs participated in this study. We recorded HFOs from median nerve somatosensory evoked potentials and assessed strength performances, before and after a fatigue-inducing exercise of hand muscles.

RESULTS

Compared to HCs, after repeated fatiguing tasks, patients showed a significant reduction of early component of HFOs area and a significant increase of late component of HFOs duration. Strength performance declined both in patients and in HCs but remained lower in patients at all time-points.

CONCLUSIONS

HFOs, a neurophysiological marker of thalamo-cortical pathway, are significantly modified by fatiguing tasks in MS patients, in particular the early component that refers to the functionality of thalamic axons.

Palliative care interventions for people with multiple sclerosis

BACKGROUND

People with multiple sclerosis (MS) have complex symptoms and different types of needs. These demands include how to manage the burden of physical disability as well as how to organise daily life, restructure social roles in the family and at work, preserve personal identity and community roles, keep self-sufficiency in personal care, and how to be part of an integrated care network. Palliative care teams are trained to keep open full and competent lines of communication about symptoms and disease progression, advanced care planning, and end-of-life issues and wishes. Teams create a treatment plan for the total management of symptoms, supporting people and families on decision-making. Despite advances in research and the existence of many interventions to reduce disease activity or to slow the progression of MS, this condition remains a life-limiting disease with symptoms that impact negatively the lives of people with it and their families.

OBJECTIVES

To assess the effects (benefits and harms) of palliative care interventions compared to usual care for people with any form of multiple sclerosis: relapsing-remitting MS (RRMS), secondary-progressive MS (SPMS), primary-progressive MS (PPMS), and progressive-relapsing MS (PRMS) We also aimed to compare the effects of different palliative care interventions.

SEARCH METHODS

On 31 October 2018, we conducted a literature search in the specialised register of the Cochrane MS and Rare Diseases of the Central Nervous System Review Group, which contains trials from CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Clinical trials.gov and the World Health Organization International Clinical Trials Registry Platform. We also searched PsycINFO, PEDro and Opengrey. We also handsearched relevant journals and screened the reference lists of published reviews. We contacted researchers in palliative care and multiple sclerosis.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster randomised trials were eligible for inclusion, as well as the first phase of cross-over trials. We included studies that compared palliative care interventions versus usual care. We also included studies that compared palliative care interventions versus another type of palliative interventions.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. We summarised key results and certainty of evidence in a 'Summary of Finding' table that reported outcomes at six or more months of post-intervention.

MAIN RESULTS

Three studies (146 participants) met our selection criteria. Two studies compared multidisciplinary, fast-track palliative care versus multidisciplinary standard care while on a waiting-list control, and one study compared a multidisciplinary palliative approach versus multidisciplinary standard care at different time points (12, 16, and 24 weeks). Two were RCTs with parallel design (total 94 participants) and one was a cross-over design (52 participants). The three studies assessed palliative care as a home-based intervention. One of the three studies included participants with 'neurodegenerative diseases', with MS people being a subset of the randomised population. We assessed the risk of bias of included studies using Cochrane's 'Risk of Bias' tool.We found no evidence of differences between intervention and control groups in long-time follow-up (> six months post-intervention) for the following outcomes: mean change in health-related quality of life (SEIQoL - higher scores mean better quality of life; MD 4.80, 95% CI -12.32 to 21.92; participants = 62; studies = 1; very low-certainty evidence), serious adverse events (RR 0.97, 95% CI 0.44 to 2.12; participants = 76; studies = 1, 22 events, low-certainty evidence) and hospital admission (RR 0.78, 95% CI 0.24 to 2.52; participants = 76; studies = 1, 10 events, low-certainty evidence).The three included studies did not assess the following outcomes at long term follow-up (> six months post intervention): fatigue, anxiety, depression, disability, cognitive function, relapse-free survival, and sustained progression-free survival.We did not find any trial that compared different types of palliative care with each other.

AUTHORS' CONCLUSIONS

Based on the findings of the RCTs included in this review, we are uncertain whether palliative care interventions are beneficial for people with MS. There is low- or very low-certainty evidence regarding the difference between palliative care interventions versus usual care for long-term health-related quality of life, adverse events, and hospital admission in patients with MS. For intermediate-term follow-up, we are also uncertain about the effects of palliative care for the outcomes: health-related quality of life (measured by different assessments: SEIQoL or MSIS), disability, anxiety, and depression.

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.

A Thematic Synthesis Considering the Factors which Influence Multiple Sclerosis Related Fatigue during Physical Activity

The purpose of this study is to consider the factors that influence fatigue related to physical activity in patients with multiple sclerosis (PwMS) and to identify the necessary adaptations undertaken by patients to remain active. A review using a thematic synthesis methodology situated within a subtle realist paradigm was undertaken. The review was completed in three stages: 1) search of relevant studies; 2) critical appraisal of literature; and 3) thematic synthesis. Nineteen studies met the inclusion criteria. This included a total of 263 participants of whom 243 were PwMS (159 females, 70 males and 14 unknown). The aggregated mean age was 53.3 years and aggregated mean time living with MS post diagnosis 11.3 years. Following critical appraisal, no articles were excluded. Three major themes were identified: (1) fatigue-related consequences, (2) exercise related barriers affecting fatigue, and (3) factors that make fatigue bearable for MS individuals. The thematic synthesis identified the cycle of activity and inactivity as a result of fatigue perception. Exercise experience, professional and social support, as well as the necessary adaptation of a training programme empower PwMS to adopt a more active coping strategy and enjoy the benefits of exercise. Clinicians could consider the implementation of a suitable, individualised exercise programme to reduce PwMS's stress during physical activities.

Fatigue in multiple sclerosis: The role of thalamus

Fatigue is very common in multiple sclerosis (MS) and is often considered as its most disabling symptom. Over the last 20 years, an increasing number of studies have evaluated the pathogenetic bases of MS-related fatigue. Converging evidence from neurophysiology and neuroimaging research suggests that a dysfunction in a cortico-subcortical pathway, centered on thalamus, is involved in the pathogenesis of fatigue. However, type and significance of such dysfunction remain unknown, and some studies reported an increase in the activity and connectivity within the thalamic network, whereas others suggested its reduction. Hereby, we review the results of neuroimaging studies supporting the different hypotheses about the role of thalamic network in the pathophysiology of MS-related fatigue and discuss limitations and shortcomings of available data, highlighting the key challenges in the field and the directions for future research.