Exercise therapy for fatigue in multiple sclerosis

Scoping review: The effects of diet, physical activity and sleep on motor and physical fatigue in people with multiple sclerosis

Physical and motor fatigue are debilitating symptoms common in multiple sclerosis (MS). Lifestyle interventions may be effective in managing MS-related fatigue. This scoping review aims to: (i) identify and summarise lifestyle interventions including those focused on diet, physical activity, and sleep, or multicomponent interventions for physical and motor fatigue management in MS; and (ii) provide recommendations for future research in this area. Database searches of MEDLINE (Ovid), Cochrane (Cochrane Library), Scopus (Elsevier), CINAHL (EBSCOhost), and Embase (Ovid) were conducted. To be included in this scoping review, studies were to be published in a peer reviewed scientific journal, focused on a non-pharmacological lifestyle intervention (physical activity, exercise, sleep, diet, or a combination), and written in English. Forty-one studies were included for analysis. Included participants were predominantly female, living with relapsing-remitting MS, with a median age of 48 years. The design of the studies comprised mainly of randomised control trials and pilot/feasibility studies. All included studies incorporated a physical activity intervention, with most examining aerobic/endurance exercise. Most studies reported an effect on improving physical/motor fatigue and a large proportion incorporated an endurance training program. To build on the current evidence and progress MS-fatigue related recommendations, further studies with larger sample sizes and a more inclusive range of MS types are required. Finally, with a gap of research investigating the role of diet and sleep on motor and physical fatigue in MS, research into this field is critically needed.

Treatments of fatigue after spinal cord injury: a systematic review and meta-analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

SETTING

Canada.

OBJECTIVES

Fatigue is one of the most common consequences of spinal cord injury (SCI). In this systematic review and meta-analysis, we examined interventions for fatigue in SCI and evaluated their effectiveness.

METHODS

MEDLINE, EMBASE, CINAHL, and PsycINFO databases were searched up to January 2024 inclusive. Randomized controlled trials (RCTs) that assessed any intervention for at least one fatigue outcome in people with SCI were included. Study quality was assessed using the Cochrane Risk of Bias Tool.

RESULTS

Initial screening identified 282 studies from which six RCTs were included in the review (N = 249). One study found that moderate-intensity arm-crank exercise significantly improved fatigue compared to a control group (p = 0.036) with a large effect size (standard mean difference [SMD] = 1.05; 95% confidence interval [CI], 0.10-2.00). Two studies assessing behavioral interventions found a moderate effect on fatigue (SMD = 0.46; 95% CI, -0.00-0.92; p = 0.05). Two studies did not find an effect of massage therapy on fatigue (SMD = 0.06; 95% CI, -0.38-0.50; p = 0.80). The risk of bias was classified as High for all but two of the RCTs.

CONCLUSIONS

These findings suggest that exercise and behavioral interventions promoting an active lifestyle may have a positive effect on fatigue. More research with larger sample sizes, including controls for co-morbid conditions like pain and depression, is needed to establish evidence-based treatments for reducing fatigue in people with SCI.

Effectiveness of Exercise on Fatigue for Patients With Heart Failure: A Systematic Review and Meta-Analysis

Exercise is the standard treatment for fatigue in heart failure (HF) patients. However, no study has investigated the effect of exercise on improving fatigue and HR-QoL in HF patients. Our study adhered to the Cochrane Handbook for Systematic Reviews of Interventions and followed the PRISMA statement. The date of the last search was October 31, 2021. We included randomized controlled trials (RCTs) using exercise to improve fatigue and HR-QoL. The combined exercise training studies showed improvement in fatigue (SMD = -.51, 95% CI = -.89 to -.12, p = .001, I2 = 48%). The IMT studies showed significantly improved fatigue (MD = -11.36, 95%CI = -15.30 to -7.41, p < .00001, I2 = 54%). However, three studies, with moderate heterogeneity (p = .10, I2 = 56%), showed non-significant changes in HR-QoL (SMD = -0.04, 95% CI = -.45 to .37, p = .83).

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of different exercise modalities on fatigue and muscular fitness in patients with multiple sclerosis: a systematic review with network, and dose-response meta-analyses

Background

Fatigue and muscular fitness are closely related to the quality of life in patients with multiple sclerosis (MS). However, the optimal exercise dosage to improve these outcomes remains unclear.

Objective

We evaluated the effects of different exercise modalities and dosages on fatigue levels and muscular fitness in patients with MS.

Methods

A systematic search was conducted across five electronic databases, including randomized controlled trials involving exercise interventions for patients with MS. The data covered literature from the establishment of each database up to August 2024. Two independent reviewers assessed the quality of the studies. Network and dose-response meta-analyses were performed using a random-effects model to evaluate the impact of exercise.

Results

A total of 84 papers were included, involving 3,786 participants. The network meta-analysis revealed that mind-body exercise (MBE) had the most significant effect on reducing fatigue (SMD = -0.94; 95% CrI: -1.3 to -0.6), followed by resistance training (RT) (SMD = -0.86; 95% CrI: -1.2 to -0.58), combined exercise (COM) (SMD = -0.70; 95% CrI: -1.2 to -0.22), and high-intensity interval training (HIIT) (SMD = -0.50; 95% CrI: -1.1 to 0.14). Additionally, HIIT were found to be the most effective in improving muscular fitness (SMD = -0.86; 95% CrI: -1.5 to -0.27), followed by COM (SMD = -0.81; 95% CrI: -1.2 to -0.41), MBE (SMD = -0.64; 95% CrI: -1.1 to -0.16), and RT (SMD = -0.62; 95% CrI: -0.89 to -0.16). Moreover, a dose as low as 240 METs-min/week was sufficient to improve fatigue, while a dose of 430 METs-min/week was required to enhance muscular fitness. The optimal dose for reducing fatigue was 650 METs-min/week, and the best dose for improving muscular fitness was 530 METs-min/week.

Conclusion

Exercise is an effective method for improving fatigue and muscular fitness in patients with MS. While MBE and COM rank relatively higher compared to other exercise modalities. The optimal exercise dosage for reducing fatigue and improving muscular fitness ranges between approximately 530 to 860 MET-minutes per week.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, CRD42024577643.

Resistance training improves functional capacities in women with multiple sclerosis: a randomized control trial

PURPOSE

This study aimed to investigate the effects of 12 weeks of resistance exercise training (RT) on oxidative status, muscle strength, functional capacity, quality of life (QoL), and fatigue in women with Multiple Sclerosis (MS).

METHODS

In this randomized control trial (ethical code: SSRI.REC-1402-101; IRCT registration code: IRCT20120912010824N3, 07.09.2023), Iran) twenty-five women with relapsing- remitting MS (aged 18-45 years and expanded disability status scale (EDSS) ≤ 4) were randomly divided in two groups MS without resistance exercise (MS + non-RT; n = 13) and with RT (12 weeks/3 times per week/ 60-80% of 1RM) (MS + RT; n = 12). "Informed" consent was obtained from all participants. Then, fifteen healthy aged-matched women participated as a control group (HCON; n = 15). Blood serum levels of oxidative stress [malondialdehyde (MDA)] and antioxidant capacity [superoxide dismutase (SOD) and glutathione peroxidase (GPx) activity] were obtained pre and post intervention. In addition, muscle strength by 5-RM test, functional capacity (for lower limb T25FWT, 2MWT, and 5STS tests and for Upper limb Manual dexterity of both hands with the (9-HPT) test and MSWS-12 questionnaire were also assessed over the same period. Also, Quality of life and fatigue were assessed pre- and post- intervention with by 31-MusiQoL questionnaire and FSMC questionnaire.

RESULTS

RT led to improvements in muscle strength for leg extension, lying leg curl, bench press movements (P < 0.001, P < 0.001, P < 0.001, respectively). Moreover, compared with the MS + non-RT group, RT demonstrated increased functional capacity (Timed 25 ft Walk Test, Two-Minute Walk Test, 5-Time Sit-To-Stand Test, Twelve Item MS Walking Scale (P < 0.001, P < 0.001, P < 0.001, P < 0.001, respectively). Dexterity of the left hand but not the right hand also improved (P < 0.01, P = 0.057, respectively). Improvements were also found for fatigue and QoL (P < 0.01, P < 0.05). However, the mean changes of MDA, SOD and GPx noted in RT group were not statistically significant (P˃0.05, P˃0.05, P˃0.05, respectively).

CONCLUSIONS

RT has positive effects on muscle strength, functional capacity, and quality of life while reducing fatigue in this population. However, markers of oxidative stress were not affected. When we consider the clear role in MS pathogenesis and progression, antioxidant increases in relation to a reduction in pro-oxidant capacity would have provided a positive and important clinical development for people with MS.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Game-Based eHealth Interventions for the Reduction of Fatigue in People With Chronic Diseases: Systematic Review and Meta-Analysis

BACKGROUND

Fatigue is a common and debilitating side effect of chronic diseases, significantly impacting patients' quality of life. While physical exercise and psychological treatments have been shown to reduce fatigue, patients often struggle with adherence to these interventions in clinical practice. Game-based eHealth interventions are believed to address adherence issues by making the intervention more accessible and engaging.

OBJECTIVE

This study aims to compile empirical evidence on game-based eHealth interventions for fatigue in individuals with chronic diseases and to evaluate their effectiveness in alleviating fatigue.

METHODS

A comprehensive literature search was performed across Embase, MEDLINE ALL, PsycINFO, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar in August 2021. Study characteristics and outcomes from the included studies were extracted, and a random-effects meta-analysis was conducted. Sensitivity and subgroup analyses were performed to identify sources of heterogeneity.

RESULTS

Of 1742 studies identified, 17 were included in the meta-analysis. These studies covered 5 different chronic diseases: multiple sclerosis (n=10), cancer (n=3), renal disease (n=2), stroke (n=1), and Parkinson disease (n=1). All but 1 study used exergaming interventions. The meta-analysis revealed a significant moderate effect size in reducing fatigue favoring the experimental interventions (standardized mean difference [SMD] -0.65, 95% CI -1.09 to -0.21, P=.003) compared with control conditions consisting of conventional care and no care. However, heterogeneity was high (I2=85.87%). Subgroup analyses were conducted for the 2 most prevalent diseases. The effect size for the multiple sclerosis subgroup showed a trend in favor of eHealth interventions (SMD -0.47, 95% CI -0.95 to 0.01, P=.05, I2=63.10%), but was not significant for the cancer group (SMD 0.61, 95% CI -0.36 to 1.58, P=.22). Balance exercises appeared particularly effective in reducing fatigue (SMD -1.19, 95% CI -1.95 to -0.42, P=.002).

CONCLUSIONS

Game-based eHealth interventions appear effective in reducing fatigue in individuals with chronic diseases. Further research is needed to reinforce these findings and explore their impact on specific diseases. Additionally, there is a lack of investigation into interventions beyond exergaming within the field of game-based learning.

At home e-based physical exercise programs in patients with multiple sclerosis: a scoping review

Introduction

Physical exercise (PE) improves symptoms and quality of life in people with multiple sclerosis (pwMS). However, incorporating PE into daily lives of pwMS pose difficulties. As an alternative to in-person PE, e-based PE has been proposed because of its advantages in terms of accessibility and convenience.

Objective

To synthesize existing evidence on e-based PE at home in adults MS and discuss study designs, rehabilitation programs, intervention effects and possible knowledge gaps.

Methods

In this scoping review, a systematic search in electronic databases including Embase, Medline, CINAHL and Cochrane Library was conducted following the PRISMA guidelines. Peer-reviewed articles in English on e-based PE interventional studies at home involving adult pwMS, published from 2008 until April 2023, were identified and exported to Covidence. Data from the included studies were extracted and synthesized. This scoping review identified different types of e-based PE interventions used in pwMS across different study designs, but when evaluating intervention effects, this review focused solely on randomized controlled trials (RCTs).

Results

A total of 3,006 studies were retrieved and 179 studies were screened in full text, resulting in the inclusion of 54 studies with a total of 2,359 pwMS. Of those, 33 were RCTs and three were qualitative studies. The studies reported on various e-based interventions including video-based programs, telerehabilitation, and web-based programs. The interventions evaluated muscle strength, cardiorespiratory fitness, walking speed, endurance, balance, and fatigue, as well as symptoms of depression and cognitive dysfunction. E-based PE interventions at home in RCTs demonstrated improvement of depressive symptoms and anxiety, while inconsistent results were reported for fatigue, walking speed and balance. No significant benefits were observed regarding dexterity. Results were generally heterogeneous and were limited by small sample sizes. Several limitations were identified, such as lack of physical activity assessment prior to the intervention and poor reporting of duration, intensity, frequency and adherence to e-based PE interventions.

Conclusion

E-based PE interventions in pwMS may improve MS-related symptoms, but the study quality is generally low, and findings are often inconsistent. Several important limitations of the existing literature have been identified in the present review, which can guide future research.

"Activity Matters was great - I now realize: if I move, I'm fitter.": development and process evaluation of a web-based program for persons with multiple sclerosis

PURPOSE

Research shows that persons with mild to moderate multiple sclerosis are less physically active than healthy controls even though they would benefit from it. This study focusses on the feasibility testing and process evaluation of the pilot study of Activity Matters, a twelve-week web-based program, from Ireland, to increase physical activity in this population.

MATERIALS AND METHODS

The intervention was adapted to local circumstances in Hamburg, Germany and consists of eleven modules incorporating behavior change techniques. After feasibility had been confirmed, 43 persons with multiple sclerosis participated in a pilot study with a pre-post, single-group intervention design. Qualitative data was collected with questionnaires and semi structured interviews. Physical activity level and stage of change was measured quantitatively.

RESULTS

Participants had a mean age of 49.5 years (SD 9.29) and an average Patient Determined Disease Step Score of 2.2 (SD 1.47). Thirty-six participants answered the follow-up questionnaire. On average 9.8 modules were processed within 13 weeks. Each tool for behavior change was perceived as helpful except the chat group. Physical activity levels increased significantly from pre- to post intervention (p-value 0.042, Cohen's d = 0.35).

CONCLUSIONS

The results indicate that Activity Matters is feasible and satisfactory and may change activity levels.

High-intensity interval training improves bone remodeling, lipid profile, and physical function in multiple sclerosis patients

Multiple sclerosis (MS) is a demyelinating and neurodegenerative disease due to an autoimmune chronic inflammatory response, yet the etiology is currently not completely understood. It is already known that physical activity plays an essential role in improving quality of life, especially in neuropathological conditions. The study was aimed to investigate the possible benefits of high-intensity interval training (HIIT) in bone and lipid metabolism markers, and neuromotor abilities in MS patients. 130 participants were recruited; 16 subjects with MS met the inclusion criteria and were included in the data analysis. The patients were randomly assigned to two groups: a Control group (CG) (34.88 ± 4.45 yrs) that didn't perform any physical activity and the Exercise group (EG) (36.20 ± 7.80 yrs) that performed HIIT protocol. The training program was conducted remotely by a kinesiologist. It was performed three times a week for 8 weeks. At the beginning (T0) and the end of the study (T1) physical function tests, bone remodelling markers, and lipid markers analyses were performed. After 8 weeks of training the wall squat (s) (T0 = 27.18  ±  4.21; T1 = 41.68 ± 5.38, p ≤ 0.01) and Time Up and Go test (s) (T0 = 7.65 ± 0.43; T1 = 6.34 ± 0.38 p ≤ 0.01) performances improved; lipid markers analysis showed a decrease in Total (mg/dl) (T0 = 187.22 ± 15.73; T1 = 173.44 ± 13.03, p ≤ 0.05) and LDL (mg/dl) (T0 = 108 ± 21.08; T1 = 95.02 ± 17.99, p < 0.05) cholesterol levels. Additionally, the levels of osteocalcin (µg/L), a marker of bone formation increased (T0 = 20.88 ± 4.22; T1 = 23.66 ± 6.24, p < 0.05), 25-OH Vitamin D (µg/L) improved after 8 weeks (T0 = 21.11 ± 7.11; T1 = 27.66 ± 7.59, p < 0.05). HIIT had an effect on lower limb strength and gait control, improved bone formation, and lipid management, in MS patients.

Evaluating the Educational Experience of Physiotherapy Students Using the Fitness and Mobility Exercise (FAME) Programme to Learn about Neurological Conditions: An Exploratory Study

Purpose

Group exercise has the potential to be a cost-effective way to improve functional outcomes for those living with neurological injury. Leading group exercise is a foundational competency for entry-to-practice for physiotherapy students. The overall objective of this study was to examine the student experience of using the Fitness and Mobility Exercise (FAME) programme to learn about neurological conditions in a group setting.

Methods

Sixteen physiotherapy students filled out a single point in time survey at the end of their placement during which they had the opportunity to use FAME with their clients twice a week. The survey had Likert and open-ended questions and demographic information. Likert responses were calculated as means. Open-ended questions were analyzed using thematic analysis.

Results

The Likert questions were answered with almost entirely positive results. The main themes from the open-ended questions were how to personalize the class, characteristics of individual clients shape the class experience and factors that make the class successful.

Conclusions

Overall, the physiotherapy students found using FAME to be a positive experience. From the student perspective, using FAME during placement was an effective way to learn about neurological conditions as well as to develop skills to manage a group exercise class.

Clinical variables influencing the perception of fatigue in people with multiple sclerosis: a cross-sectional study using FSIQ-RMS

BACKGROUND

Physical fatigue is one of the most disabling symptoms in people with Multiple Sclerosis (PwMS). Several factors might influence the development of fatigue, such as gender, education, body mass index (BMI), Expanded Disability Status Scale (EDSS), disease duration, working status (Ws), physiotherapy (Ph), and disease-modifying therapies (DMTs). Fatigue Symptoms and Impacts Questionnaire-Relapsing Multiple Sclerosis (FSIQ-RMS) is a patient-reported outcome (PRO) that allows one to define the impact of fatigue in PwMS clearly. This study aimed to assess fatigue impact on PwMS by using FSIQ-RMS.

METHODS

The participants were enrolled from May to July 2021 in MS Centers of Sant'Andrea Hospital and Policlinico Umberto I Hospital in Rome. Fatigue was evaluated using the FSIQ-RMS, validated, and culturally adapted in Italian. Clinical and demographic data were collected at the same time.

RESULTS

We enrolled 178 PwMS [Female 74.16%; RMS 82.58%, SPMS 17.52%]. FSIQ-RMS scores were significantly correlated with EDSS (p-value < 0.01). Analysis of variance between means showed a statistically significant difference between the BMI groups at the 24hours_FSIQ-RMS score and the 7days_FSIQ-RMS score (p < 0.01), with the lower BMI group having the highest scores. Furthermore, perceived fatigue significantly improved both in subjects performing Ph (p < 0.05) and in those who actively work (p < 0.01).

CONCLUSIONS

The use of FSIQ-RMS in a real-world setting confirmed that underweight and high levels of disability are closely related to fatigue. In addition, Ph and active Ws are strongly correlated with fatigue in PwMS.

Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review

Multiple Sclerosis (MS) management in individuals aged 55 and above presents unique challenges due to the complex interaction between aging, comorbidities, immunosenescence, and MS pathophysiology. This comprehensive review explores the evolving landscape of MS in older adults, including the increased incidence and prevalence of MS in this age group, the shift in disease phenotypes from relapsing-remitting to progressive forms, and the presence of multimorbidity and polypharmacy. We aim to provide an updated review of the available evidence of disease-modifying treatments (DMTs) in older patients, including the efficacy and safety of existing therapies, emerging treatments such as Bruton tyrosine kinase (BTKs) inhibitors and those targeting remyelination and neuroprotection, and the critical decisions surrounding the initiation, de-escalation, and discontinuation of DMTs. Non-pharmacologic approaches, including physical therapy, neuromodulation therapies, cognitive rehabilitation, and psychotherapy, are also examined for their role in holistic care. The importance of MS Care Units and advance care planning are explored as a cornerstone in providing patient-centric care, ensuring alignment with patient preferences in the disease trajectory. Finally, the review emphasizes the need for personalized management and continuous monitoring of MS patients, alongside advocating for inclusive study designs in clinical research to improve the management of this growing patient demographic.

Association between healthy lifestyles and post-COVID-19 syndrome among college students

BACKGROUND

Post-COVID-19 syndrome still occurs in some populations. A healthy lifestyle is widely recognized as a first-line treatment to increase the body's antiviral resistance and tissue repair, but it is unclear whether a healthy lifestyle can promote or alleviate the symptoms of post-COVID-19 syndrome.

METHODS

A stratified random sampling method was used to select 498 participants from three universities in Fujian as the target of the questionnaire survey. The survey focused on students' healthy lifestyles and the symptoms of fatigue, anxiety, dyspnea, and depression that are common in post-COVID-19 syndrome.

RESULTS

Two months after developing COVID-19, some students continued to experience fatigue, anxiety, dyspnea, and depression, with fatigue being the most prominent symptom. The results of the study showed that there was a significant negative correlation (P < 0.01) between a healthy lifestyle and fatigue, anxiety, dyspnea, and depression among university students. Furthermore, when analyzing the different subdimensions of healthy lifestyles among university students, it was found that all dimensions showed varying degrees of negative correlation with fatigue, anxiety, dyspnea, and depression, except for health-related behaviors and interpersonal behaviors, which showed no relationship with fatigue (P < 0.01).

CONCLUSIONS

By improving healthy lifestyles, long-term COVID-19 symptoms can be reduced and improved and contribute positively to patient recovery, providing a viable rehabilitation option for long-term COVID-19 patients.

MS care: integrating advanced therapies and holistic management

Lifestyle and environmental factors are key determinants in disease causality and progression in neurological conditions, including multiple sclerosis (MS). Lack of exercise, poor diet, tobacco smoking, excessive alcohol intake, social determinants of health, concomitant medications, poor sleep and comorbidities can exacerbate MS pathological processes by impacting brain health and depleting neurological reserves, resulting in more rapid disease worsening. In addition to using disease-modifying therapies to alter the disease course, therapeutic strategies in MS should aim to preserve as much neurological reserve as possible by promoting the adoption of a "brain-healthy" and "metabolically-healthy" lifestyle. Here, we recommend self-regulated lifestyle modifications that have the potential to improve brain health, directly impact on disease progression and improve outcomes in people with MS. We emphasise the importance of self-management and adopting a multidisciplinary, collaborative and person-centred approach to care that encompasses the healthcare team, family members and community support groups.

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.

Implementation of Remote Activity Sensing to Support a Rehabilitation Aftercare Program: Observational Mixed Methods Study With Patients and Health Care Professionals

BACKGROUND

Physical activity is central to maintaining the quality of life for patients with complex chronic conditions and is thus at the core of neurorehabilitation. However, maintaining activity improvements in daily life is challenging. The novel Stay With It program aims to promote physical activity after neurorehabilitation by cultivating self-monitoring skills and habits.

OBJECTIVE

We examined the implementation of the Stay With It program at the Valens Rehabilitation Centre in Switzerland using the normalization process theory framework, focusing on 3 research aims. We aimed to examine the challenges and facilitators of program implementation from the perspectives of patients and health care professionals. We aimed to evaluate the potential of activity sensors to support program implementation and patient acceptance. Finally, we aimed to evaluate patients' engagement in physical activity after rehabilitation, patients' self-reported achievement of home activity goals, and factors influencing physical activity.

METHODS

Patients were enrolled if they had a disease that was either chronic or at risk for chronicity and participated in the Stay With It program. Patients were assessed at baseline, the end of rehabilitation, and a 3-month follow-up. The health care professionals designated to deliver the program were surveyed before and after program implementation. We used a mixed methods approach combining standardized questionnaires, activity-sensing data (patients only), and free-text questions.

RESULTS

This study included 23 patients and 13 health care professionals. The diverse needs of patients and organizational hurdles were major challenges to program implementation. Patients' intrinsic motivation and health care professionals' commitment to refining the program emerged as key facilitators. Both groups recognized the value of activity sensors in supporting program implementation and sustainability. Although patients appreciated the sensor's ability to monitor, motivate, and quantify activity, health care professionals saw the sensor as a motivational tool but expressed concerns about technical difficulties and potential inaccuracies. Physical activity levels after patients returned home varied considerably, both within and between individuals. The self-reported achievement of activity goals at home also varied, in part because of vague definitions. Common barriers to maintaining activity at home were declining health and fatigue often resulting from heat and pain. At the 3-month follow-up, 35% (8/23) of the patients withdrew from the study, with most citing deteriorating physical health as the reason and that monitoring and discussing their low activity would negatively affect their mental health.

CONCLUSIONS

Integrating aftercare programs like Stay With It into routine care is vital for maintaining physical activity postrehabilitation. Although activity trackers show promise in promoting motivation through monitoring, they may lead to frustration during health declines. Their acceptability may also be influenced by an individual's health status, habits, and technical skills. Our study highlights the importance of considering health care professionals' perspectives when integrating new interventions into routine care.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

Trial Registry: DRKS00024358.

The MoxFo initiative - outcomes: Outcome measures in studies of exercise training in multiple sclerosis; scoping review of reviews and classification according to the ICF framework

BACKGROUND

The number of published studies of exercise training in multiple sclerosis (MS) has grown exponentially with increasing numbers of outcomes capturing exercise effects. This has complicated the selection of relevant indicators and interpretation of intervention effects.

OBJECTIVES

The Outcomes subgroup of the MoXFo initiative aimed to (1) identify outcome measures and biomarkers in studies of exercise training in MS; (2) systematically map retrieved outcomes to International Classification of Functioning, Disability and Health (ICF) categories; (3) identify gaps where relevant ICF categories have been omitted.

METHODS

Electronic databases and registers were searched from 2010 to July 2020 to identify systematic reviews or meta-analyses of controlled trials of exercise training on any outcome in MS. Retrieved outcomes/biomarkers were mapped to the corresponding ICF category.

RESULTS

Eighty-one review articles reporting 235 different outcomes were included. The outcomes corresponded to 15 chapters and 45 categories within the ICF. Outcomes mapped primarily to body function (30 categories) and activities and participation (9 categories) components. Few outcomes mapped to body structures (2 categories) or environmental factors (1 category).

CONCLUSION

This sets the stage to develop a resource for researchers/clinicians that will aid in the selection of appropriate outcomes/biomarkers when examining exercise effects in MS.

Multiple sclerosis and exercise-A disease-modifying intervention of mice or men?

Research suggests that physical exercise can promote an anti-inflammatory and neuroprotective state. If so, increasing or optimizing exercise could be considered a 'disease-modifying intervention' in neuroinflammatory diseases, such as multiple sclerosis (MS). Exercise intervention studies conducted in animal models of MS are promising. Various aerobic and strength training regimes have been shown to delay disease onset and to reduce both the clinical and pathological disease severity in mice. However, fundamental differences between the physiology of animals and humans, the disease states studied, and the timing of exercise intervention are significant. In animal models of MS, most exercise interventions begin before disease initiation and before any clinical sign of disease. In contrast, studies in humans recruit participants on average nearly a decade after diagnosis and often once disability is established. If, as is thought to be the case for disease-modifying treatments, the immunomodulatory effect of exercise decreases with advancing disease duration, current studies may therefore fail to detect the true disease-modifying potential. Clinical studies in early disease cohorts are needed to determine the role of exercise as a disease-modifying intervention for people with MS.

Unraveling the interplay between daily life fatigue and physical activity after subarachnoid hemorrhage: an ecological momentary assessment and accelerometry study

BACKGROUND

Fatigue is one of the most commonly reported symptoms after subarachnoid hemorrhage (SAH) and is indirectly associated with physical activity (PA). Associations between fatigue and PA are primarily examined based on conventional measures (i.e. a single fatigue score or average PA levels), thereby assuming that fatigue and PA do not fluctuate over time. However, levels of fatigue and PA may not be stable and may interrelate dynamically in daily life. Insight in direct relationships between fatigue and PA in daily life, could add to the development of personalized rehabilitation strategies. Therefore we aimed to examine bidirectional relationships between momentary fatigue and PA in people with SAH.

METHODS

People (n = 38) with SAH who suffer from chronic fatigue were included in an observational study using Ecological Momentary Assessment (EMA) and accelerometry. Momentary fatigue was assessed on a scale from 1 to 7 (no to extreme fatigue), assessed with 10-11 prompts per day for 7 consecutive days using EMA with a mobile phone. PA was continuously measured during this 7-day period with a thigh-worn Activ8 accelerometer and expressed as total minutes of standing, walking, running and cycling in a period of 45 min before and after a momentary fatigue prompt. Multilevel mixed model analyses including random effects were conducted.

RESULTS

Mean age was 53.2 years (SD = 13.4), 58% female, and mean time post SAH onset was 9.5 months (SD = 2.1). Multilevel analyses with only time effects to predict fatigue and PA revealed that fatigue significantly (p < 0.001) increased over the day and PA significantly (p < 0.001) decreased. In addition, more PA was significantly associated with higher subsequent fatigue (β = 0.004, p < 0.05) and higher fatigue was significantly associated with less subsequent PA (β=-0.736, p < 0.05). Moreover, these associations significantly differed between participants (p < 0.001).

CONCLUSIONS

By combining EMA measures of fatigue with accelerometer-based PA we found that fatigue and PA are bidirectionally associated. In addition, these associations differ among participants. Given these different bidirectional associations, rehabilitation aimed at reducing fatigue should comprise personalized strategies to improve both fatigue and PA simultaneously, for example by combining exercise therapy with cognitive behavioral and/or energy management therapy.

Health behaviors of people with multiple sclerosis and its associations with MS related outcomes: a German clinical cohort

Background

Health behaviors in persons with multiple sclerosis (pwMS) have been associated with MS-related disease outcomes.

Objective

The aim of the study was to gain knowledge about current patient health behaviors in a convenience sample representative for pwMS presenting to a large university-based outpatient clinic and to investigate associations between modifiable risk factors with physical impairment, quality of life (QoL) and cardiovascular comorbidities.

Methods

A questionnaire was administered at the MS Outpatient Clinic of the University Medical Center Hamburg Eppendorf asking for health behaviors regarding dietary habits assessed with the German adaptation of the validated Spanish short Diet Quality Screener (sDQS), level of physical activity assessed with the Godin Leisure Time Questionnaire (GLTEQ) and tobacco smoking. Participants were asked to report cardiovascular comorbidities using items from the Self-Report Comorbidity Questionnaire for Multiple Sclerosis. Additionally, cardiovascular risk factors like blood pressure, height and weight (to calculate BMI) and waist circumference were measured. MS specific clinical data, e.g., disease course, duration, disability and MS-specific QoL were collected from the clinical database. Descriptive analyses were performed and multivariate regression analyses for complete cases were carried out for each of the three outcome variables including all mentioned modifiable risk factors (dietary behavior, smoking, physical activity and BMI) as independent variables.

Results

In this sample of 399 pwMS the mean age was 42 years (SD 12.8) with a mean disease duration since diagnosis of 7.4 years (SD 8.4) and a mean EDSS of 2.8 (SD 1.9). 24% were current smokers, 44% were insufficiently physically active and 54% did not follow a healthy dietary pattern. 49% of this relatively young clinical population was overweight and 27% reported one or more cardiovascular comorbidities. Most modifiable risk factors showed no convincing associations with MS-related disease outcomes in the multiple regression analyses.

Conclusion

This clinical cohort of pwMS shows a high prevalence of critical health behaviors and comorbidities and emphasizes the need for monitoring, education and assistance for behavior change in this population.

A network analysis of the long-term quality of life and mental distress of COVID-19 survivors 1 year after hospital discharge

Objectives

COVID-19 survivors suffer from persistent mental distress and impaired quality of life (QOL) after recovery from the infection. However, the symptom-symptom interaction between these psychological variables remained unexplored. The present study aimed to determine the symptom network of mental distress (depression, anxiety, sleep disturbance, fatigue, and post-traumatic stress disorder) and their association with QOL among 535 COVID-19 survivors 1 year after hospital discharge.

Methods

9-item Patient Health Questionnaire, 7-item Generalized Anxiety Disorder Scale, Chalder fatigue scale, Impact of Event Scale-Revised, Pittsburgh Sleep Quality Index, and 36-Item Short-Form Health Survey were applied to measure depression, anxiety, fatigue, PTSD, sleep disturbances, and QOL, respectively. Two networks were estimated using Gaussian graphical model. Network 1 consisted of mental symptoms to determine the central and bridge symptoms. Network 2 additionally included QOL to determine which mental symptoms were mostly related to QOL.

Results

60% of the COVID-19 survivors experienced mental distress 1 year after hospital discharge. Uncontrollable and excessive worry, psychomotor symptoms, intrusion, and daytime dysfunction were the most central symptoms. Daytime dysfunction and fatigue (especially mental fatigue and loss of energy) served as the bridge symptoms across the mental distress network and exhibited the most substantial association with QOL.

Conclusion

Our study demonstrated several key symptoms that played a vital role in mental distress and QOL among COVID-19 survivors. Prompt screening and targeted interventions for these symptoms might hold great promise in preventing mental distress and improving QOL in COVID-19 survivors.

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

BACKGROUND

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

Telerehabilitation during the COVID-19 pandemic, what are the determinants of satisfaction for chronic diseases? a retrospective study

Background

During the Covid-19 health crisis, telerehabilitation provided a solution to ensure the continuity of care. Since then, it has been offered as an alternative to face-to-face rehabilitation in chronic conditions. Data measuring satisfaction are essential to adapt and increase the effectiveness of this type of programme.

Aim and scope

This research focused on determining the most significant determinants of participant satisfaction in a telerehabilitation programme.

Methods

We conducted a retrospective study by analysing the satisfaction questionnaire used from the start of the programme.

Result

Two hundred and ten (210) participants completed the programme; 180 questionnaires were filled in and 175 analyzed of which 70 with chronic low back pain (CLBP), 59 for multiple sclerosis (MS) and 22 with parkinson's disease (PD). Satisfaction was high for all participants (scoring out of 10, mean = 8.22 sd = 1.53), but the determinants reported for the three main conditions involved in the programme differed. Main determinant was "benefice" for CLBP (p = 1.23e-05), "home exercises adapted" for MS (p = 0.000679) and "interest in staying at home" for PD (p = 1.84e-05).

Conclusion

Depending on the context of the condition/disease, the drivers of satisfaction were not identical. Knowledge of these determinants will allow us to further improve the programme. However, some unresolved questions remain regarding the place of therapists, their role and the skills required for a successful telerehabilitation programme. Further studies are required to understand the impact.

A review of current rehabilitation practices and their benefits in patients with multiple sclerosis

Multiple sclerosis (MS) is a chronic, debilitating disease characterised by demyelination of the nerves of the central nervous system that results in patients progressively losing the ability to perform daily tasks. As there is no cure for this disease, rehabilitation therapy is an important aspect of care; assisting patients to regain or retain function and improve their physical, mental and social wellbeing. At present there is no current consistent model of care for MS, likely due to the variable symptom presentation. Various forms of rehabilitation therapy are available, and these include physical rehabilitation methods, such as balance and gait therapy, speech and respiration rehabilitation, and occupational therapy. Contrary to previous understanding, exercise-based therapies have shown various benefits for patients with MS, and in addition to improving MS-related physical symptoms, have been shown to reduce the risk of developing cardiovascular disease and can improve cognitive function. Cognition rehabilitation therapy specifically focuses on behavioural tasks and is divided into two main forms: compensatory rehabilitation, which offers cognitive functioning benefits, and restorative rehabilitation, which offers memory benefits. Excitation therapies include cranial stimulation and other stimulation rehabilitation methods such as focal muscle vibration therapy and these non-invasive techniques may improve patient's physical ability. Additionally, more novel rehabilitation methods include robot-assisted gait therapy and telerehabilitation, both of which are expected to play progressively more prominent roles in the future of rehabilitation therapy. The structure of the care team has been found to impact patient outcomes, and both in- and out-patient care settings have been found to be beneficial, dependant on the patient's circumstances, with certain patients better suited to a particular setting. While a single point of care is recommended for patients, a multidisciplinary care team and regular reassessment is recommended to manage changing symptoms and ensure continuity of care. The importance of the critical components of rehabilitation have been identified, and these are of vital importance in achieving beneficial outcomes. These components include the patients' participation in the treatment, goal setting with a multidisciplinary care team, a guiding-light purpose for the patient, which focusses on recognizing their personal potential and obtaining improvements through a tailored plan. The final critical component of rehabilitation is the results measurement, which highlights the need for a quantifiable reduction in impairment and improvement in activity and participation. Overall, a lack of standardisation in outcome measurements makes comparison challenging. This is particularly important when comparing standard methods of care with more novel rehabilitation techniques. However, within the broad area of rehabilitation therapies, it is clear that patients with MS can benefit from rehabilitation practices; physically, mentally and socially.

Exercise therapy for fatigue in multiple sclerosis

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

Post stroke intervention trial in fatigue (POSITIF): Randomised multicentre feasibility trial

OBJECTIVE

To test the feasibility of a telephone delivered intervention, informed by cognitive behavioural principles, for post-stroke fatigue, and estimated its effect on fatigue and other outcomes.

DESIGN

Randomised controlled parallel group trial.

SETTING

Three Scottish stroke services.

SUBJECTS

Stroke survivors with fatigue three months to two years post-stroke onset.

INTERVENTIONS

Seven telephone calls (fortnightly then a 'booster session' at 16 weeks) of a manualised intervention, plus information about fatigue, versus information only.

MAIN MEASURES

Feasibility of trial methods, and collected outcome measures (fatigue, mood, anxiety, social participation, quality of life, return to work) just before randomisation, at the end of treatment (four months after randomisation) and at six months after randomisation.

RESULTS

Between October 2018 and January 2020, we invited 886 stroke survivors to participate in postal screening: 188/886 (21%) returned questionnaires and consented, of whom 76/188 (40%) were eligible and returned baseline forms; 64/76 (84%) returned six month follow-up questionnaires. Of the 39 allocated the intervention, 23 (59%) attended at least four sessions. At six months, there were no significant differences between the groups (adjusted mean differences in Fatigue Assessment Scale -0.619 (95% CI -4.9631, 3.694; p = 0.768), the Generalised Anxiety Disorder 7 -0.178 (95% CI -3.823, 3.467, p = 0.92), and the Patient Health Questionnaire -0.247 (95% CI -2.935, 2.442, p = 0.851). There were no between-group differences in quality of life, social participation or return to work.

CONCLUSION

Patients can be recruited to a trial of this design. These data will inform the design of further trials in post-stroke fatigue.

Self-reported work productivity in people with multiple sclerosis and its association with mental and physical health

PURPOSE

This study aimed to identify mental health, physical health, demographic and disease characteristics relating to work productivity in people with multiple sclerosis (MS).

METHODS

In this cross-sectional study, 236 employed people with MS (median age = 42 years, 78.8% female) underwent neurological and neuropsychological assessments. Additionally, they completed questionnaires inquiring about work productivity (presenteeism: reduced productivity while working, and absenteeism: loss of productivity due to absence from work), mental and physical health, demographic and disease characteristics. Multiple linear and logistic regression analyses were performed with presenteeism and absenteeism as dependent variables, respectively.

RESULTS

A model with mental and physical health factors significantly predicted presenteeism F(11,202) = 11.33, p < 0.001, R² = 0.38; a higher cognitive (p < 0.001) and physical impact (p = 0.042) of fatigue were associated with more presenteeism. A model with only mental health factors significantly predicted absenteeism; χ²(11)=37.72, p < 0.001, with R² = 0.27 (Nagelkerke) and R² = 0.16 (Cox and Snell). Specifically, we observed that more symptoms of depression (p = 0.041) and a higher cognitive impact of fatigue (p = 0.011) were significantly associated with more absenteeism.

CONCLUSIONS

In people with MS, both cognitive and physical impact of fatigue are positively related to presenteeism, while symptoms of depression and cognitive impact of fatigue are positively related to absenteeism.Implications for rehabilitationMultiple sclerosis (MS) affects people of working age, significantly interfering with work productivity.Higher cognitive and physical impact of fatigue were associated with more presenteeism in workers with MS.A higher cognitive impact of fatigue and more depressive symptoms were associated with absenteeism in workers with MS.Occupational and healthcare professionals should be aware of the impact of both physical and mental health on work productivity in workers with MS.

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.

The Effect of Combining Transcranial Direct Current Stimulation Treatment and an Exercise Program on Fragility in a Population with Multiple Sclerosis: Cross-Over Design Trial

BACKGROUND

The relationship between fragility and neurological diseases is extensive and affects many patients with multiple sclerosis (MS), whose risk factors are related to fragility.

OBJECTIVE

To study the effects of exercise and transcranial direct current stimulation (tDCS) in MS patients with fatigue from four dimensions: functional mobility, balance, fatigue, and depression.

METHODS

A total of 12 patients who belonged to two associations of people with physical disabilities participated. Functional mobility, depression, balance, and fatigue were assessed before and after the intervention. Transcranial direct current stimulation and the exercise program were carried out over a 4-week period with a wash-out period of 5 months.

RESULTS

After the application of tDCS, we found significant improvements in balance (p < 0.05, g = 0.632), depression (p < 0.05, g = 0.402), functional mobility (p < 0.05, g = 0.297), and fatigue (p < 0.05, g = 0.526). After the exercise program, significant improvements were shown in balance (p < 0.01, g = 0.418), depression (p < 0.001, g = 0.540), functional mobility (p < 0.01, g = 0.262), and fatigue (p < 0.01, g = 0.742). Two-way mixed-measures ANOVA showed that all variables improved in both groups, with significant differences over time but not between groups. Secondary analysis showed significant correlations between balance and functional mobility (r = 0.671, p = 0.017), depression and fatigue (r = 0.586, p = 0.044) and between intensity of rehabilitation and balance (r = 0.622, p = 0.031).

CONCLUSION

Participating in an exercise program and receiving tDCS separately improved the variables of depression, balance, mobility, and fatigue.

IL-6 and TNF-α responses to acute and regular exercise in adult individuals with multiple sclerosis (MS): a systematic review and meta-analysis

BACKGROUND

In both the general population and people with multiple sclerosis (PwMS), physical exercise is associated with improved mental well-being. Moreover, there is evidence of the possible protection of physical activity against disease progression in multiple sclerosis (MS). However, the question arises if acute or regular exercise has any impact on the immune system in PwMS. To answer this question, we performed a systematic review and meta-analysis on both plasma and serum cytokine levels (IL-6 and TNF-α) before and after acute and regular exercise among PwMS and compared to healthy controls.

METHOD

We performed an online search via PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane Library till September 2021 to identify original studies on IL-6 and TNF-α changes after acute and regular exercise in PwMS and controls. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 11 original studies were included in the meta-analysis. Sensitivity analyses were used to identify the origins of heterogeneity. R 4.0.4 was used to perform the meta-analysis of IL-6 and TNF-α levels before and after acute and regular exercise in PwMS, compared to controls. This study does not qualify for a clinical trial number.

RESULTS

IL-6 levels did neither increase nor decrease after acute and regular exercise in PwMS, and compared to controls (pre- vs. post-intervention: Standardized Mean Difference (SMD) -0.09, 95% CI [-0.29; 0.11], p-value = 0.37, PwMS vs. Control: SMD -0.08, 95% CI [-0.33; 0.16], p-value = 0.47). In PwMS, TNF-α levels decreased after regular exercise and when TNF-α levels of both acute and regular exercise were pooled (pre- vs. post-intervention: SMD -0.51, 95% CI [-0.91; 0.11], p-value = 0.01, PwMS vs. Control: SMD -0.23, 95% CI [-0.66; 0.18], p-value = 0.26). TNF-α levels did neither increase nor decrease after acute and regular exercise in PwMS, when compared to controls.

CONCLUSION

This systematic review and meta-analysis show that exercise does not lead to significant changes in peripheral levels of IL-6 in PwMS in contrast to the observed response in healthy subjects and other medical contexts. However, regular exercise had a specific anti-inflammatory effect on blood TNF-α levels in PwMS. It remains to be investigated why PwMS display this different exercise-induced pattern of cytokines.

The pathophysiology of motor fatigue and fatigability in multiple sclerosis

Multiple Sclerosis (MS) is a heterogeneous immune mediated disease of the central nervous system (CNS). Fatigue is one of the most common and disabling symptom of MS. It interferes with daily activities on the level of cognition and motor endurance. Motor fatigue can either result from lesions in cortical networks or motor pathways (“primary fatigue”) or it may be a consequence of detraining with subsequent adaptions of muscle and autonomic function. Programmed exercise interventions are used frequently to increase physical fitness in MS-patients. Studies investigating the effects of training on aerobic capacity, objective endurance and perceived fatigability have yielded heterogenous results, most likely due to the heterogeneity of interventions and patients, but probably also due to the non-uniform pathophysiology of fatigability among MS-patients. The aim of this review is to summarize the current knowledge on the pathophysiology of motor fatigability with special reference to the basic exercise physiology that underlies our understanding of both pathogenesis and treatment interventions.

Disability and Fatigue in Multiple Sclerosis: Can Rehabilitation Improve Them through a Structured Retraining Program?

Functional rehabilitation programs in multiple sclerosis have demonstrated their efficacy in improving fatigue. The assessment of functional impairment, however, is more difficult. The purpose is to assess fatigue and disability as a first study measure and to verify their improvement after a specific functional rehabilitation program. An analytical, longitudinal, prospective, and experimental study was carried out with 51 patients aged 18-55 years, with an Expanded Disability Status Scale (EDSS) between 2 and 6.5 who were being followed up in outpatient clinics of the Rehabilitation Service of La Princesa Hospital. The fatigue and disability outcomes before and after a structured exercise training program were evaluated, with each subject acting as their own control. The variables were measured using the Modified Fatigue Impact Scale (MFIS), Barthel Index (BI), and Functional Independence Scale (FIM). Differences according to recurrent or progressive course of the disease are assessed. Improvement in the FIM scale was observed after the retraining program (p = 0.016) and was maintained in the medium term (p = 0.042). This improvement is not statistically significant in Barthel Index. Improvement in MFIS is observed after the program (p < 0.001) and 4-6 months after the end. Both disease courses experience the same improvements with no statistically significant differences between them. The retraining program improves fatigue and multiple sclerosis-related functionality in the short and medium term. There are no differences according to disease course. Both experience the same positive changes with our intervention.

The Role of Remote Monitoring in Evaluating Fatigue in Multiple Sclerosis: A Review

Fatigue is one of the most common multiple sclerosis (MS) symptoms. Despite this, monitoring and measuring fatigue (subjective lack of energy)- and fatigability (objectively measurable and quantifiable performance decline)- in people with MS have remained challenging. Traditionally, administration of self-report questionnaires during in-person visits has been used to measure fatigue. However, remote measurement and monitoring of fatigue and fatigability have become feasible in the past decade. Traditional questionnaires can be administered through the web in any setting. The ubiquitous availability of smartphones allows for momentary and frequent measurement of MS fatigue in the ecological home-setting. This approach reduces the recall bias inherent in many traditional questionnaires and demonstrates the fluctuation of fatigue that cannot be captured by standard measures. Wearable devices can assess patients' fatigability and activity levels, often influenced by the severity of subjective fatigue. Remote monitoring of fatigue, fatigability, and activity in real-world situations can facilitate quantifying symptom-severity in clinical and research settings. Combining remote measures of fatigue as well as objective fatigability in a single construct, composite score, may provide a more comprehensive outcome. The more granular data obtained through remote monitoring techniques may also help with the development of interventions aimed at improving fatigue and lowering the burden of this disabling symptom.

Yoga, immunity and COVID-19: A scoping review

Yoga is recognized and practiced for different levels of prevention since antiquity. The current scoping review aimed to identify and document the evidence reporting the effect of yoga interventions on immunity against COVID-19 infection. Three databases--PubMed, Cochrane, and Google Scholar, were searched to identify eligible studies. Articles published in English after 2010 and assessing the impact of any form of yoga (such as yogasanas, meditations, or pranayamas) on immunological markers were included in the review. The studies without information of the intervention on immunity markers, and experience sharing reviews were excluded. The search yielded 45 eligible articles with majority of the studies being published from the USA and India. Most of the studies were randomized controlled trials, enrolling the adult population with a specific focus on diseases like HIV, cancer, and heart failure. It was observed that a variety of yoga interventions along with meditation and pranayama, in different combinations were used by the authors. However, all these studies unanimously reported improvement in immunological profile (indicated by improved biochemical markers) of an individual (irrespective of disease state and type) with yoga. Moreover, the beneficial effects of these traditional Indian interventions were also found to have a positive impact on overall physical and physiological wellbeing and quality of life. Findings from the existing literature indicate that the practice of yoga has the potential to strengthen cell-mediated immunity and hence could be used as an effective preventive measure against COVID-19 where immunity plays a critical role.

Impact of COVID-19 lockdown on progressive multiple sclerosis patients

INTRODUCTION

The COVID-19 pandemic caused major changes in the lifestyle and in the access to health services worldwide. Progressive multiple sclerosis (pMS) patients are a vulnerable population at high risk of disability worsening.

OBJECTIVE AND METHODS

The objective of this study was to assess the health outcomes of COVID-19 lockdown in a cohort of 225 pMS patients.

RESULTS

Worsening of neurological disability (19.7%) and fatigue (32.4%), depression (30.4%), and weight increase (28.3%) were observed in pMS patients during lockdown, along with discontinuation of regular physical exercise (47.1%) and of physical therapy (59.3%).

CONCLUSION

These results highlight the adverse impact, on pMS patients, of the public health measures implemented for the containment of the pandemic.

Multiple sclerosis-related fatigue lacks a unified definition: A narrative review

Fatigue is the most common symptom in multiple sclerosis (MS). Although MS-related fatigue (MS-F) strongly affects quality of life and social performance of patients, there is currently a lack of knowledge about its pathophysiology, which in turns leads to poor objective diagnosis and management. Recent studies have attempted to explain potential etiologies as well as treatments for MS-F. However, it seems that without a consensus on its nature, these data could not provide a route to a successful approach. In this Article, we review definitions, epidemiology, risk factors and correlated comorbidities, pathophysiology, assessment methods, neuroimaging findings, and pharmacological and nonpharmacological treatments of MS-F. Further studies are warranted to define fatigue in MS patients more accurately, which could result in precise diagnosis and management.

A focus group study to inform design of a symptom management intervention for adults with atrial fibrillation

Background

Current symptom management approaches for patients with atrial fibrillation (AF) focus on addressing heart rhythm and do not include management of behavioral or emotional contributors to symptom manifestation or severity.

Objective

To inform content development of a digitally delivered AF symptom self-management program by exploring patients’ experiences of the impact of AF symptoms and their perspectives on behavioral approaches to symptom management.

Methods

This was a qualitative study of 3 focus groups composed of adults living with symptomatic AF. Group transcripts underwent thematic content analysis to identify themes and subthemes. Themes were matched to available self-management strategies that could be adapted for use in a digitally delivered AF symptom self-management program.

Results

Six major themes (with subthemes) were identified: symptoms (anxiety, fatigue, stress/other negative emotions, AF-specific symptoms, heart rhythm); social aspects (social impact, social support); AF treatments (medication, procedures); health behaviors (sleep, physical activity, hydration, breathing/mindfulness/relaxation); positive emotions; and AF education and information gathering. Symptom self-management strategies were identified that could be used to address these symptom-related themes.

Conclusion

Patients with AF reported a wide range of emotional, physical, and social impacts of the condition. They endorsed attempts to self-manage symptoms and an interest in learning more about how to effectively self-manage. Findings indicate the potential for a digital self-management program to address existing gaps in AF symptom–related care.

Therapeutic Effects of the Pilates Method in Patients with Multiple Sclerosis: A Systematic Review

The Pilates Method is a rehabilitation tool with verified benefits in pain management, physical function, and quality of life in many different physiotherapy areas. It could be beneficial for patients with multiple sclerosis (pwMS). The aim of the study was to summarize current evidence for the effectiveness of Pilates in pwMS. A comprehensive search of Cinahl, Scopus, Web of Science, PEDro, and PubMed (including PubMed Central and Medline) was conducted to examine randomized controlled trials (RCT) that included Pilates intervention in multiple sclerosis. The PEDro scale and the Cochrane risk-of-bias tool, RoB-2, were used to evaluate risk of bias for RCT. Twenty RCT (999 patients) were included. Ten were of good quality (PEDro), and seven had low risk of bias (RoB-2). Pilates improves balance, gait, physical-functional conditions (muscular strength, core stability, aerobic capacity, and body composition), and cognitive functions. Fatigue, quality of life, and psychological function did not show clear improvement. There was good adherence to Pilates intervention (average adherence ≥ 80%). Cumulative data suggest that Pilates can be a rehabilitation tool for pwMS. High adherence and few adverse effects were reported. Future research is needed to develop clinical protocols that could maximize therapeutic effects of Pilates for pwMS.

Translation and validation of the Persian version of Godin Leisure-Time Exercise Questionnaire in patients with multiple sclerosis

Study Design

Psychometric study.

Objective

The purpose of this study is to translate, culturally adapt and evaluate the validity and reliability of the Persian (Farsi) version of GLTEQ in patients with multiple sclerosis.

Methods

This study had three phases, including translation of the questionnaire into Persian and making cultural adaptation, evaluation of pre-final version of questionnaire’s comprehensibility in a pilot study, and investigation of reliability and validity of the final version of the translated questionnaire. Content validity, and convergent validity (correlations among the Persian version of GLTEQ and Global physical activity questionnaire (GPAQ), and international physical activity questionnaire (IPAQ)) and after all test-retest reliability were studied.

Results

The subjects were 87 MS patients. The Persian version demonstrated moderate to good convergent validity; the correlation coefficient between the Persian version and GPAQ was r=0.64 (p<0.001), and between the Persian version and IPAQ was r=0.59 (p<0.001). The test-retest reliability was strong (Intra-class Correlation (ICC) value ranged between 0.908 and 0.992). Besides, its face validity and content validity were acceptable.

Conclusions

The Persian version of GLTEQ is a valid and reliable instrument to assess physical activity in patients with MS. This questionnaire can be a step toward standardization of physical activity measurement in patients with MS. Also, in research, it provides the possibilities to carry on a comparative study across cultures using the same outcome measure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02465-5.

Fatigue in patients with chronic disease: results from the population-based Lifelines Cohort Study

(1) To evaluate the prevalence of severe and chronic fatigue in subjects with and without chronic disease; (2) to assess to which extent multi-morbidity contributes to severe and chronic fatigue; and (3) to identify predisposing and associated factors for severe and chronic fatigue and whether these are disease-specific, trans-diagnostic, or generic. The Dutch Lifelines cohort was used, including 78,363 subjects with (n = 31,039, 53 ± 12 years, 33% male) and without (n = 47,324, 48 ± 12 years, 46% male) ≥ 1 of 23 chronic diseases. Fatigue was assessed with the Checklist Individual Strength-Fatigue. Compared to participants without a chronic disease, a higher proportion of participants with ≥ 1 chronic disease were severely (23% versus 15%, p < 0.001) and chronically (17% versus 10%, p < 0.001) fatigued. The odds of having severe fatigue (OR [95% CI]) increased from 1.6 [1.5–1.7] with one chronic disease to 5.5 [4.5–6.7] with four chronic diseases; for chronic fatigue from 1.5 [1.5–1.6] to 4.9 [3.9–6.1]. Multiple trans-diagnostic predisposing and associated factors of fatigue were found, explaining 26% of variance in fatigue in chronic disease. Severe and chronic fatigue are highly prevalent in chronic diseases. Multi-morbidity increases the odds of having severe and chronic fatigue. Several trans-diagnostic factors were associated with fatigue, providing a rationale for a trans-diagnostic approach.

Motivation for Physical Activity in Adults with Multiple Sclerosis: A Self-determination Theory–Based Approach

Background: Despite the benefits of regular physical activity (PA), most adults with multiple sclerosis (MS) are insufficiently active. Identifying the motivational correlates of PA is necessary to facilitate health behavior change. The extent to which the constructs of psychological need satisfaction and motivational regulations associate with self-determined PA in adults with the disease was examined.

Methods: Individuals with MS were provided a link to a web-based survey. There were 290 respondents: 242 women and 48 men aged 22 to 71 (mean ± SD, 49.50 ± 12.05) years with primarily mild-to-moderate mobility impairment who completed the Psychological Need Satisfaction in Exercise scale, the Behavioral Regulation in Exercise Questionnaire, and the International Physical Activity Questionnaire.

Results: Path analysis revealed that PA was best predicted by integrated regulation, competence, and mobility, explaining 28% of the variance in PA behavior. All three need satisfaction variables (relatedness, competence, and autonomy) and mobility impairment accounted for 43% of the variance in integrated regulation.

Conclusions: Increasing satisfaction of the need for relatedness, competence, and autonomy can lead to more integrated and internally motivated PA engagement in adults with MS.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is mHealth a Useful Tool for Self-Assessment and Rehabilitation of People with Multiple Sclerosis? A Systematic Review

The development of mobile technology and mobile Internet offers new possibilities in rehabilitation and clinical assessment in a longitudinal perspective for multiple sclerosis management. However, because the mobile health applications (mHealth) have only been developed recently, the level of evidence supporting the use of mHealth in people with multiple sclerosis (pwMS) is currently unclear. Therefore, this review aims to list and describe the different mHealth available for rehabilitation and self-assessment of pwMS and to define the level of evidence supporting these interventions for functioning problems categorized within the International Classification of Functioning, Disability and Health (ICF). In total, 36 studies, performed with 22 different mHealth, were included in this review, 30 about rehabilitation and six for self-assessment, representing 3091 patients. For rehabilitation, most of the studies were focusing on cognitive function and fatigue. Concerning the efficacy, we found a small but significant effect of the use of mHealth for cognitive training (Standardized Mean Difference (SMD) = 0.28 [0.12; 0.45]) and moderate effect for fatigue (SMD = 0.61 [0.47; 0.76]). mHealth is a promising tool in pwMS but more studies are needed to validate these solutions in the other ICF categories. More replications studies are also needed as most of the mHealth have only been assessed in one single study.

Symptomatic and restorative therapies in neuromyelitis optica spectrum disorders

Neuromyelitis optica spectrum disorders (NMOSD) are a group of autoimmune inflammatory conditions that primarily target the optic nerves, spinal cord, brainstem, and occasionally the cerebrum. NMOSD is characterized by recurrent attacks of visual, motor, and/or sensory dysfunction that often result in severe neurological deficits. In recent years, there has been a significant progress in relapse treatment and prevention but the residual disability per attack remains high. Although symptomatic and restorative research has been limited in NMOSD, some therapeutic approaches can be inferred from published case series and evidence from multiple sclerosis literature. In this review, we will discuss established and emerging therapeutic options for symptomatic treatment and restoration of function in NMOSD. We highlight NMOSD-specific considerations and identify potential areas for future research. The review covers pharmacologic, non-pharmacologic, and neuromodulatory approaches to neuropathic pain, tonic spasms, muscle tone abnormalities, sphincter dysfunction, motor and visual impairment, fatigue, sleep disorders, and neuropsychological symptoms. In addition, we briefly discuss remyelinating agents and mesenchymal stem cell transplantation in NMOSD.

Patient-Reported Questionnaires in Multiple Sclerosis Rehabilitation: Responsiveness and Minimal Important Difference of the French Version of the Multiple Sclerosis Questionnaire for Physiotherapists

Purpose: The aim of this study was to evaluate the responsiveness and minimal important difference (MID) of the French version of the Multiple Sclerosis Questionnaire for Physiotherapists (MSQPT). Method: A distribution-based approach was used. Patients (32) were recruited from inpatient and outpatient settings; they completed both the MSQPT and the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) at baseline and again at 6 months or discharge. Responsiveness was evaluated using effect size (ES), standardized response mean (SRM), and modified SRM (MSRM), and the relative efficiency between the MSQPT and HAQUAMS was calculated. Distribution-based MID estimates were calculated for 0.33 SD, standard error of measurement, and minimal detectable change. Results: The main ES ranged from 0.41 (low) to 1.23 (high). The SRM (-0.89 to 2.69) was generally higher than the ES. The main MSRMs were acceptably low (-0.03 to 0.19). Although the MSQPT seemed more efficient than the HAQUAMS in detecting improved activity and participation, it was less efficient at identifying their deterioration. In a comparison of responsiveness and MID between the German and French versions of the MSQPT, the differences between estimates were small. Conclusions: The available evidence indicates that the French MSQPT is a responsive questionnaire with MIDs that are similar to those of the original German version.

What Fatigue Means to Persons Living with Parkinson's Disease? A Qualitative Study

BACKGROUND

Fatigue is one of the most prevalent non-motor symptoms of Parkinson's disease (PD). Research is hampered by imprecise terminology and the lack of case definition criteria.

OBJECTIVES

To elicit the experiences of persons living with PD-related fatigue and provide ecological validation for case definition criteria.

METHODS

Qualitative interviews were conducted with 22 individuals and 4 focus groups, and analyzed using an inductive qualitative method.

RESULTS

Six core themes emerged: (i) difficulty initiating and completing important tasks; (ii) desire for others to understand their fatigue experience; (iii) heterogeneity of experiences and descriptions of fatigue; (iv) complex relationships with other non-motor symptoms; (v) variable self-management strategies; and (vi) general alignment with proposed case definition criteria.

CONCLUSIONS

PD-related fatigue impacts function, is subjectively distinguishable from other non-motor symptoms, has heterogeneous descriptions, and may be mitigated by various self-management strategies. Proposed case definition criteria appear ecologically valid and warrant further optimization and testing.