Tired of not knowing what that fatigue score means? Normative data of the Modified Fatigue Impact Scale (MFIS)

Efficacy of pharmacologic treatments for fatigue in multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Fatigue is commonly experienced amongst persons with multiple sclerosis (PwMS), decreasing quality of life and increasing the economic burden of care. Several pharmacologic treatments have been studied in randomized clinical trials (RCTs) for fatigue in MS, with conflicting results.

METHODS

We performed a systematic search for RCTs through PubMed and CENTRAL to determine the efficacy and tolerability of amantadine, modafinil, methylphenidate, and 4-aminopyridine as treatments for fatigue in adults with MS in comparison to placebo or other interventions. Outcomes were fatigue severity as measured by Fatigue Severity Scale (FSS), Modified Fatigue Impact Scale (MFIS), or Visual Analog Scale, and frequency of discontinuation due to side effects. Forest plots were generated (random effects model), standardized mean differences (SMD) were used for continuous outcomes, and risk ratio was calculated for the dichotomous outcome. The risk of bias was assessed with the Cochrane risk-of-bias tool, and GRADEpro GDT was used to summarize the evidence.

RESULTS

Of 259 screened studies, 16 met the inclusion criteria for this review. SMD showed a change of -0.26 (95 % CI, -0.54, 0.01) in the direction of medications, representing a decrease of 0.29 in FSS or 3.90 in MFIS (minimally important difference is 0.45 for FSS and 4 for MFIS). The pooled risk ratio for discontinuation was 2.11 (95 % CI, 1.19, 3.77), favoring controls. Most studies were without substantial risk of bias, but the certainty of evidence was low.

CONCLUSION

The studied medications have minimal to no efficacy and an uncertain clinical significance in reducing fatigue in PwMS.

Energy management education for persons living with long COVID-related fatigue (EMERGE): protocol of a two-parallel arms target trial emulation study in a multicentre outpatient intervention setting with an online control group register

INTRODUCTION

Energy management education (EME) is a manualised, evidence-based self-management education programme developed and delivered by occupational therapists for persons living with chronic disease-related fatigue. Studies have shown that EME can positively affect self-efficacy, fatigue impact and quality of life in persons with chronic conditions, while data on persons with long COVID are lacking.The primary aim is to evaluate if adding EME to the standard care improves outcomes in persons with long COVID-related fatigue. The secondary aim is to explore the energy management behavioural strategies applied in daily routines and investigate the influencing factors of implementing behavioural changes. The third aim is to perform a cost-effectiveness analysis of EME.

METHODS AND ANALYSIS

Using observational data, we will emulate a prospective two-parallel arms target trial to assess whether adding EME to the standard care is associated with improved outcomes in patients with long COVID-related fatigue. The estimated sample size to detect a post-intervention difference of 1.5 points in self-efficacy to implement energy conservation strategies with 90% power (0.05 alpha) is 122 people (1:1 ratio).Persons with long COVID-related fatigue who follow EME as part of their standard care will be recruited and included in the experimental group (EG), while potential participants for the control group (CG) will be recruited from a register and prospectively matched to a participant in the EG by applying the propensity score technique. The 'standard of care' of the CG will include any intervention, except occupational therapy-based EME in peer groups. The causal contrast of interest will be the per-protocol effect. Four self-reported questionnaires (fatigue impact, self-efficacy in performing energy management strategies, competency in performing daily activities, health-related quality of life) will be administered at baseline (T0; week 0), after lesson 7 (T1; week 6), post-intervention (T2; week 14) and follow-up (T3, week 24). Our main assessment will be at T2. Disease-related and productivity cost data will be collected, and a cost-effectiveness profile of the EME intervention will be compared with standard care.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the competent Swiss ethics commission.Findings will be reported (1) to the study participants; (2) to patient organisations and hospitals supporting EMERGE; (3) to funding bodies; (4) to the national and international occupational therapy community and healthcare policy; (5) will be presented at local, national, and international conferences and (6) will be disseminated by peer-review publications.

Differential Fatigue Profile in Patients with Post-COVID Condition, Fibromyalgia, and Multiple Sclerosis

Background/Objectives: Fatigue is a prevalent and debilitating symptom in Post-COVID Condition (PCC), fibromyalgia, and multiple sclerosis (MS). Although these conditions share clinical similarities, the underlying mechanisms of fatigue across these conditions may differ and remain poorly understood. This study aimed to compare the intensity and characteristics of fatigue in these three conditions to identify shared and distinct features. Methods: We conducted a cross-sectional study involving 429 participants: 219 with PCC, 112 with fibromyalgia, and 98 with MS. Participants completed a questionnaire specifically developed for the study via the Google Forms platform. This questionnaire was developed by a group of professionals in the hospital specializing in fatigue related to these three conditions, in collaboration with expert patients. The questionnaire was reported following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) recommendations. Results: Fatigue intensity was significantly higher in PCC and fibromyalgia compared to MS. Some differences in fatigue characteristics were observed: MS patients reported more fatigue in response to heat and a greater impact of mood on fatigue. Furthermore, delayed fatigue and reduced benefits from rest were more pronounced in both PCC and fibromyalgia. No significant differences were found regarding cognitive fatigue or difficulties in predicting the ability to perform activities. Conclusions: These results underscore some clinical characteristics in the intensity and quality of fatigue across PCC, fibromyalgia, and MS. These findings could suggest different mechanisms in the pathophysiology of the fatigue. Our study underscores the need for tailored diagnostic tools and interventions in managing fatigue in these three conditions.

From "invisible" to "audible": Features extracted during simple speech tasks classify patient-reported fatigue in multiple sclerosis

BACKGROUND

Fatigue is a major "invisible" symptom in people with multiple sclerosis (PwMS), which may affect speech. Automated speech analysis is an objective, rapid tool to capture digital speech biomarkers linked to functional outcomes.

OBJECTIVE

To use automated speech analysis to assess multiple sclerosis (MS) fatigue metrics.

METHODS

Eighty-four PwMS completed scripted and spontaneous speech tasks; fatigue was assessed with Modified Fatigue Impact Scale (MFIS). Speech was processed using an automated speech analysis pipeline (ki elements: SIGMA speech processing library) to transcribe speech and extract features. Regression models assessed associations between speech features and fatigue and validated in a separate set of 30 participants.

RESULTS

Cohort characteristics were as follows: mean age 49.8 (standard deviation (SD) = 13.6), 71.4% female, 85% relapsing-onset, median Expanded Disability Status Scale (EDSS) 2.5 (range: 0-6.5), mean MFIS 27.6 (SD = 19.4), and 30% with MFIS > 38. MFIS moderately correlated with pitch (R = 0.32, p = 0.005), pause duration (R = 0.33, p = 0.007), and utterance duration (R = 0.31, p = 0.0111). A logistic model using speech features from multiple tasks accurately classified MFIS in training (area under the curve (AUC) = 0.95, R2 = 0.59, p < 0.001) and test sets (AUC = 0.93, R2 = 0.54, p = 0.0222). Adjusting for EDSS, processing speed, and depression in sensitivity analyses did not impact model accuracy.

CONCLUSION

Fatigue may be assessed using simple, low-burden speech tasks that correlate with gold-standard subjective fatigue measures.

Fatigue in Multiple Sclerosis: A Resting-State EEG Microstate Study

Fatigue affects approximately 80% of people with Multiple Sclerosis (PwMS) and can impact several domains of daily life. However, the neural underpinnings of fatigue in MS are still not completely clear. The aim of our study was to investigate the spontaneous large-scale networks functioning associated with fatigue in PwMS using the EEG microstate approach with a spectral decomposition. Forty-three relapsing-remitting MS patients and twenty-four healthy controls (HCs) were recruited. All participants underwent an administration of Modified Fatigue Impact scale (MFIS) and a 15-min resting-state high-density EEG recording. We compared the microstates of healthy subjects, fatigued (F-MS) and non-fatigued (nF-MS) patients with MS; correlations with clinical and behavioral fatigue scores were also analyzed. Microstates analysis showed six templates across groups and frequencies. We found that in the F-MS emerged a significant decrease of microstate F, associated to the salience network, in the broadband and in the beta band. Moreover, the microstate B, associated to the visual network, showed a significant increase in fatigued patients than healthy subjects in broadband and beta bands. The multiple linear regression showed that the high cognitive fatigue was predicted by both an increase and decrease, respectively, in delta band microstate B and beta band microstate F. On the other hand, higher physical fatigue was predicted with lower occurrence microstate F in beta band. The current findings suggest that in MS the higher level of fatigue might be related to a maladaptive functioning of the salience and visual network.

Global prevalence of fatigue in patients with multiple sclerosis: a systematic review and meta-analysis

Background

Fatigue is one of the most common and burdensome symptoms for patients with multiple sclerosis (PwMS), considerably impacting their quality of life and employment. Numerous reports have described the prevalence of MS-related fatigue, but there is no global consensus on this matter.

Objective

To examine the global prevalence of MS-related fatigue and identify sources of heterogeneity in the published literature.

Methods

A systematic review and meta-analysis were conducted. A comprehensive search of the PubMed, EMBASE, Cochrane Library, Web of Science, PsycINFO, CINAHL, China National Knowledge Infrastructure (CNKI), and Wanfang database for potential literature from 2000 to January 31, 2024. A random effects model was used to calculate the prevalence of MS-related fatigue. Subgroup analyses and a meta-regression were used to explore the sources of heterogeneity.

Results

Sixty-nine studies from 27 countries were included. The global prevalence of MS-related fatigue was 59.1%, and it has decreased every decade since 2000. Fatigue was prevalent among females, those with lower education levels, those who were older, those with greater disability, and those with longer MS durations. The meta-regression revealed that fatigue measurement instruments were the largest source of heterogeneity.

Conclusion

The prevalence of MS-related fatigue is quite high. Healthcare professionals should screen for and manage fatigue for PwMS as early as possible and pay attention to populations with a high prevalence of fatigue. The high heterogeneity among the prevalence rates due to differences in the fatigue scales suggests the importance of reaching a consensus on the best screening tools for MS-related fatigue.

Neural basis of fatigue in post-COVID syndrome and relationships with cognitive complaints and cognition

The main objective was to evaluate structural and functional connectivity correlates of fatigue in post-COVID syndrome, and to investigate the relationships with an objective measure of mental fatigue and with subjective cognitive complaints. One-hundred and twenty-nine patients were recruited after 14.79 ± 7.17 months. Patients were evaluated with fatigue, neuropsychological, and subjective cognitive complaints assessments. Structural and functional magnetic resonance imaging were acquired, and functional connectivity, white matter diffusivity and grey matter volume were evaluated. Fatigue was present in 86 % of patients, and was highly correlated to subjective cognitive complaints. Fatigue was associated with structural and functional connectivity mostly in frontal areas but also temporal, and cerebellar areas, showing mental fatigue different pattern of functional connectivity correlates compared to physical fatigue. White matter diffusivity correlates were similar in fatigue and subjective cognitive complaints, located in the forceps minor, anterior corona radiata and anterior cingulum. Findings confirm that fatigue in post-COVID syndrome is related to cerebral connectivity patterns, evidencing its brain substrates. Moreover, results highlight the relationship between fatigue and subjective cognitive complaints. These findings point out the relevance of the multidisciplinary assessment of post-COVID syndrome patients with subjective cognitive complaints, in order to unravel the symptomatology beneath the patient's complaints.

Multimodal neuroimaging in Long-COVID and its correlates with cognition 1.8 years after SARS-CoV-2 infection: a cross-sectional study of the Aliança ProHEpiC-19 Cognitiu

Introduction

There is a growing interest in the effect of Long-COVID (LC) on cognition, and neuroimaging allows us to gain insight into the structural and functional changes underlying cognitive impairment in LC. We used multimodal neuroimaging data in combination with neuropsychological evaluations to study cognitive complaints in a cohort of LC patients with mild to moderate severity symptoms.

Methods

We conducted a 3T brain magnetic resonance imaging (MRI) study with diffusion tensor imaging (DTI) and functional MRI (fMRI) sequences on 53 LC patients 1.8 years after acute COVID-19 onset. We administered neuropsychological tests to evaluate cognitive domains and examined correlations with Tract-Based Spatial Statistics (TBSS) and resting state.

Results

We included 53 participants with LC (mean age, 48.23 years; 88.7% females). According to the Frascati criteria, more than half of the participants had deficits in the executive (59%) and attentional (55%) domains, while 40% had impairments in the memory domain. Only one participant (1.89%) showed problems in the visuospatial and visuoconstructive domain. We observed that increased radial diffusivity in different white matter tracts was negatively correlated with the memory domain. Our results showed that higher resting state activity in the fronto-parietal network was associated with lower memory performance. Moreover, we detected increased functional connectivity among the bilateral hippocampus, the right hippocampus and the left amygdala, and the right hippocampus and the left middle temporal gyrus. These connectivity patterns were inversely related to memory and did not survive false discovery rate (FDR) correction.

Discussion

People with LC exhibit cognitive impairments linked to long-lasting changes in brain structure and function, which justify the cognitive alterations detected.

Prospective evaluation of the relationship between cognition and recovery outcomes after cardiac arrest

PURPOSE

Cognitive function is often impaired for cardiac arrest (CA) survivors due to hypoxic-ischemic brain injury. Whether cognitive impairment at hospital discharge is associated with recovery defined as functional status and fatigue measured at 1-month post-discharge is not known.

METHODS

Consecutive CA patients admitted at an academic center (May 14, 2021-June 23, 2023) were assessed for cognitive impairment (modified Telephone Interview for Cognitive Status, TICS-m < 33) and depressive symptoms (8-item Patient Health Questionnaire) at hospital discharge. Poor functional status (primary outcome; modified Rankin Scale, mRS > 3) and fatigue severity (patient-reported outcome; Modified Fatigue Impact Scale) were assessed 1-month post-discharge. Hierarchical regressions tested associations of cognitive function with outcomes.

RESULTS

Of 112 participants (mean age 54.4 ± 14.8; 38% female; 43% White race, 20% Black race, 29% Hispanic ethnicity) completing discharge TICS-m, 63 (56%) had indicated cognitive impairment, and 68 (61%) had poor 1-month functional outcome. Worse discharge cognitive function was independently associated with a higher risk of poor 1-month functional outcome (OR = 0.88, 95% CI [0.79, 0.98], p = 0.02) after adjusting for age, education, sex, race, ethnicity, length of hospital stay, comorbidities, and depressive symptoms. Fatigue severity lacked significant associations with cognitive function, but was associated with depressive symptoms (B = 1.03 [0.00, 2.05], p = 0.04).

CONCLUSION

Cognitive function at discharge after CA was significantly and independently associated with functional outcome 1 month after hospital discharge. Psychological distress contributed to fatigue severity. This highlights the need for screening and addressing cognitive and emotional problems pre-hospital discharge.

Fatigue in individuals with multiple sclerosis: Is there a relationship with walking speed and mobility?

BACKGROUND

Fatigue is a common symptom in patients with multiple sclerosis and it can lead to activity limitations. Thus, it is important to analyze the relationship between fatigue and activity outcomes, such as walking speed and mobility.

OBJECTIVES

To investigate the relationship between fatigue and walking speed and mobility in individuals with multiple sclerosis.

METHODS

A cross-sectional study was performed. Adults with multiple sclerosis, without cognitive impairments and who were able to walk were recruited. Fatigue was assessed with the Modified Fatigue Impact Scale (MFIS). Walking speed, usual and fast, was assessed with the 10-meter Walk Test (10MWT), and mobility with the Timed Up and Go Test (TUG). Pearson correlation analysis was performed. A significance level of 5 % was used.

RESULTS

Thirty participants were included, most of the relapsing-remitting multiple sclerosis (n = 24, 80 %). A mean age of 41 (11) years and the median Expanded Disability Status Scale (EDSS) score was 2.65 (2.18) points. Mean MFIS score was 41.87 ± 19.42 points, mean usual walking speed was 1.02 ± 0.28 m/s, mean fast walking speed was 1.55 ± 0.48 m/s, and the mean total time in the TUG was 10.07 ± 3.05 s. A significant negative correlation of moderate magnitude was found between fatigue and usual walking speed (r=₋0.51, p < 0.05). A significant negative correlation of moderate magnitude was found between fatigue and fast walking speed (r=₋0.54, p < 0.05). A significant, positive correlation of moderate magnitude was found between fatigue and mobility (r = 0.54, p < 0.05).

CONCLUSION

There was a correlation between fatigue and walking speed and mobility in individuals with multiple sclerosis. These results highlight the need to assess fatigue in individuals with multiple sclerosis, since the presence of fatigue is associated with reduced walking speed and mobility.

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.

Usefulness of the MFIS-K, FSS, and FACIT-F Fatigue Scales in Korean Patients With MS, NMOSD, and MOGAD

BACKGROUND AND PURPOSE

Fatigue is common in demyelinating disorders of the central nervous system (CNS), including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). We aimed to validate the usefulness of the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and the Fatigue Severity Scale (FSS) relative to the Korean version of the Modified Fatigue Impact Scale (MFIS-K) in Korean patients with MS, NMOSD, and MOGAD.

METHODS

There were 294 patients with MS (n=120), NMOSD (n=103), or MOGAD (n=71) enrolled in a prospective demyelinating CNS registry. Fatigue was measured using the FACIT-F, MFIS-K, and FSS. Sleep quality, quality of life, depression, and pain were evaluated using the Pittsburgh Sleep Quality Index (PSQI), 36-item Short-Form Survey (SF-36), and Beck Depression Inventory-II (BDI-II).

RESULTS

The MFIS-K, FACIT-F, and FSS scores showed high internal consistencies and strong correlations with each other in the MS, NMOSD, and MOGAD groups. The scores on all three fatigue scales were correlated with PSQI, SF-36, and BDI-II results in the three groups. The areas under the receiver operating characteristic curves for the FSS and FACIT-F were 0.834 and 0.835, respectively, for MS, 0.877 and 0.833 for NMOSD, and 0.925 and 0.883 for MOGAD.

CONCLUSIONS

These results suggest that the MFIS-K, FSS, and FACIT-F are useful and valuable assessment instruments for evaluating fatigue in Korean patients with MS, NMOSD, and MOGAD.

Reduced Cortical Thickness Correlates of Cognitive Dysfunction in Post-COVID-19 Condition: Insights from a Long-Term Follow-up

BACKGROUND AND PURPOSE

There is a paucity of data on long-term neuroimaging findings from individuals who have developed the post-coronavirus 2019 (COVID-19) condition. Only 2 studies have investigated the correlations between cognitive assessment results and structural MR imaging in this population. This study aimed to elucidate the long-term cognitive outcomes of participants with the post-COVID-19 condition and to correlate these cognitive findings with structural MR imaging data in the post-COVID-19 condition.

MATERIALS AND METHODS

A cohort of 53 participants with the post-COVID-19 condition underwent 3T brain MR imaging with T1 and FLAIR sequences obtained a median of 1.8 years after Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection. A comprehensive neuropsychological battery was used to assess several cognitive domains in the same individuals. Correlations between cognitive domains and whole-brain voxel-based morphometry were performed. Different ROIs from FreeSurfer were used to perform the same correlations with other neuroimaging features.

RESULTS

According to the Frascati criteria, more than one-half of the participants had deficits in the attentional (55%, n = 29) and executive (59%, n = 31) domains, while 40% (n = 21) had impairment in the memory domain. Only 1 participant (1.89%) showed problems in the visuospatial and visuoconstructive domains. We observed that reduced cortical thickness in the left parahippocampal region (t(48) = 2.28, P = .03) and the right caudal-middle-frontal region (t(48) = 2.20, P = .03) was positively correlated with the memory domain.

CONCLUSIONS

Our findings suggest that cognitive impairment in individuals with the post-COVID-19 condition is associated with long-term alterations in the structure of the brain. These macrostructural changes may provide insight into the nature of cognitive symptoms.

Increased Confidence and Deeper Understanding of Fatigue Following Participation in Fatigue Education and Management Education in Systemic Sclerosis: A Mixed Methods Evaluation of a Virtual Intervention

OBJECTIVE

No fatigue-specific programs exist for people with systemic sclerosis (SSc) despite the burden of fatigue and negative impact on daily activities. This study used a convergent parallel mixed methods design to evaluate the impact of an adapted virtual intervention, Fatigue and Activity Management Education in Systemic Sclerosis (FAME-iSS), in the United States.

METHODS

Eighteen people with SSc participated in three separate six-week FAME-iSS programs. Participants completed the modified Fatigue Impact Scale (m-FIS), the Self-Efficacy for Performing Energy Conservation Strategies Assessment (SEPESCA), the Patient-Reported Outcomes Measurement Information System (PROMIS) Self-Efficacy for Managing Symptoms, and the Hospital Anxiety and Depression Scale (HADS) before, immediately after, and three months post intervention. Data were analyzed using descriptive and nonparametric inferential statistics. Participants' perceptions of the program and their use of fatigue management strategies were qualitatively analyzed using content analysis.

RESULTS

Eighty-nine percent of participants were women with a mean ± SD age of 52.0 ± 11.6 years and a mean ± SD disease duration of 13.7 ± 14.5 years, and more than 70% had a college degree. Significant improvements were observed for self-efficacy on the PROMIS Self-Efficacy for Managing Symptoms (P = 0.002) and SEPESCA (P = 0.016) immediately post intervention, which continued to significantly improve up to the three-month follow-up (P = 0.006 and 0.035, respectively). Significant improvements were also observed for the m-FIS between baseline and the three-month follow-up (P = 0.029). Participants reported a deeper understanding of fatigue and that they liked sharing strategies and experiences with each other along with the facilitator, citing that "there was a power in our group because we had a common condition."

CONCLUSION

FAME-iSS resulted in improvements in the impact of fatigue and self-efficacy for managing symptoms and performing energy conservation strategies. Feedback was positive, and the virtual format allowed for greater accessibility and sharing of strategies.

Premorbid cognitive functioning influences differences between self-reported cognitive difficulties and cognitive assessment in multiple sclerosis

Cognitive difficulties are reported in up to 60% of people with MS (pwMS). There is often a discrepancy between self-reported cognitive difficulties and performance on cognitive assessments. Some of this discrepancy can be explained by depression and fatigue. Pre-MS cognitive abilities may be another important variable in explaining differences between self-reported and assessed cognitive abilities. PwMS with high estimated premorbid cognitive functioning (ePCF) may notice cognitive difficulties in daily life whilst performing within the average range on cognitive assessments. We hypothesised that, taking into account depression and fatigue, ePCF would predict (1) differences between self-reported and assessed cognitive abilities and (2) performance on cognitive assessments. We explored whether ePCF predicted (3) self-reported cognitive difficulties. Eighty-seven pwMS completed the Test of Premorbid Functioning (TOPF), the Brief International Cognitive Assessment for MS (BICAMS), self-report measures of cognitive difficulty (MS Neuropsychological Questionnaire; MSNQ), fatigue (MS Fatigue Impact Scale; MFIS) and depression (Hospital Anxiety and Depression Scale; HADS). Results revealed that, taking into account covariates, ePCF predicted (1) differences between self-reported and assessed cognitive abilities, p < .001 (model explained 29.35% of variance), and (2) performance on cognitive assessments, p < .001 (model explained 46.00% of variance), but not (3) self-reported cognitive difficulties, p = .545 (model explained 35.10% of variance). These results provide new and unique insights into predictors of the frequently observed discrepancy between self-reported and assessed cognitive abilities for pwMS. These findings have important implications for clinical practice, including the importance of exploring premorbid factors in self-reported experience of cognitive difficulties.

Evaluating Perceived Fatigue within an Adult Spinal Muscular Atrophy Population

INTRODUCTION

Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disease characterized by progressive muscle weakness and atrophy. While chronic fatigue is a common manifestation of SMA, the field lacks comprehensive data to assess the extent of its impact. Cure SMA, an SMA patient advocacy organization, conducted an online survey of its adults with SMA community members to measure the impact of fatigue.

METHODS

All survey respondents were asked to complete questions on demographics, use of SMA treatment, and quality of life, but respondents were randomized to receive three of the following fatigue instruments: the Modified Fatigue Impact Scale (MFIS), Multidimensional Fatigue Inventory (MFI), Fatigue Severity Scale (FSS), PedsQL™ Multidimensional Fatigue (PedsQL MF) Scale, and Spinal Muscular Atrophy Health Index (SMA-HI) fatigue modules. Scales were evaluated for reliability and overall fatigue scores were evaluated by multivariate regression models to determine which variables were related to the final scores of each instrument.

RESULTS

A total of 253 adults completed the online survey. When measured against the general population, statistically significant differences were found among adults with SMA for certain variables within each measurement instrument. However, there did not appear to be differences in fatigue levels among key subgroups within the SMA population.

CONCLUSIONS

This was the first use of more than two fatigue questionnaires simultaneously in SMA. The lack of a consistent relationship between SMA severity and fatigue levels was surprising. This may be related to the lack of specificity of the instruments for this population. An SMA-specific scale is needed to evaluate differences in fatigue impact across the SMA population.

Exploring the relation between reserve and fatigue in multiple sclerosis

INTRODUCTION

Intellectual enrichment and brain reserve modulate the expression of cognitive and motor disability in multiple sclerosis (MS). Their association with fatigue, one of the most debilitating and common symptoms of MS, has never been explored.

MATERIALS AND METHODS

Forty-eight MS patients underwent clinical and MRI examination at baseline and after 1 year. Physical and cognitive MS-related fatigue were evaluated via Modified Fatigue Impact subscales (MFIS-P and MFIS-C). Differences in reserve indexes between fatigued and non-fatigued patients were tested. The relationship between clinico-demographic features, global brain structural damage, indexes of reserve (age-adjusted intracranial volume and cognitive reserve index) and fatigue were tested via correlations and hierarchical linear/binary logistic regression, to predict MFIS-P and MFIS-C (at baseline) or new-onset fatigue and meaningful worsening in MFIS (at follow-up).

RESULTS

At baseline, although a significant difference was identified for cognitive reserve questionnaire between fatigued and non-fatigued patients (18.19 ± 4.76 versus 15.15 ± 3.56, p = 0.015), only depression accounted for significant variance in MFIS-P and MFIS-C (R²=0.248, p = 0.002; R²=0.252, p<0.001). MFIS-T, MFIS-P and MFIS-C changes over time were associated to depression changes over time (r = 0.56, r = 0.55, and r = 0.57, respectively; all p<0.001). Indexes of reserve did not differ between non-fatigued patients and patients developing new-onset fatigue at follow-up. None of the baseline features was able to predict the new-onset fatigue or meaningful worsening in MFIS at follow-up.

CONCLUSIONS

Among the explored features, only depression was strongly associated to both physical and cognitive fatigue. Intellectual enrichment and brain reserve did not seem to affect fatigue symptoms in MS patients.

Multimodal neuroimaging in post-COVID syndrome and correlation with cognition

Brain changes have been reported in the first weeks after SARS-CoV-2 infection. However, limited literature exists about brain alterations in post-COVID syndrome, a condition increasingly associated with cognitive impairment. The present study aimed to evaluate brain functional and structural alterations in patients with post-COVID syndrome, and assess whether these brain alterations were related to cognitive dysfunction. Eighty-six patients with post-COVID syndrome and 36 healthy controls were recruited and underwent neuroimaging acquisition and a comprehensive neuropsychological assessment. Cognitive and neuroimaging examinations were performed 11 months after the first symptoms of SARS-CoV-2. Whole-brain functional connectivity analysis was performed. Voxel-based morphometry was performed to evaluate grey matter volume, and diffusion tensor imaging was carried out to analyse white-matter alterations. Correlations between cognition and brain changes were conducted and Bonferroni corrected. Post-COVID syndrome patients presented with functional connectivity changes, characterized by hypoconnectivity between left and right parahippocampal areas, and between bilateral orbitofrontal and cerebellar areas compared to controls. These alterations were accompanied by reduced grey matter volume in cortical, limbic and cerebellar areas, and alterations in white matter axial and mean diffusivity. Grey matter volume loss showed significant associations with cognitive dysfunction. These cognitive and brain alterations were more pronounced in hospitalized patients compared to non-hospitalized patients. No associations with vaccination status were found. The present study shows persistent structural and functional brain abnormalities 11 months after the acute infection. These changes are associated with cognitive dysfunction and contribute to a better understanding of the pathophysiology of the post-COVID syndrome.

Self-reported quality of life in symptomatic and asymptomatic women with X-linked adrenoleukodystrophy

BACKGROUND

Up to 80% of women with X-linked adrenoleukodystrophy (X-ALD) develop symptoms of myelopathy and peripheral neuropathy during their lifetime. The study's objective was to compare symptomatic versus asymptomatic women with X-ALD regarding their physical and mental well-being and quality of life.

METHODS

Data were obtained from a prospective, international, cross-sectional cohort study of women with X-ALD recruited both clinically and population based. Symptoms, quality of life, and physical and mental co-morbidities were assessed by questionnaires. Women were considered symptomatic if they reported any sign of myelopathy or peripheral neuropathy. Group differences between symptomatic versus asymptomatic women and between age groups were examined using χ² tests for categorical and independent sample t tests or analysis of variance for continuous variables.

RESULTS

Complete data were available from N = 180 women (mean age: 51.2 ± 13.6 years, range: 18-85), of whom 71.7% were classified as symptomatic, with prevalence increasing with age. Symptomatic versus asymptomatic women reported poorer physical and mental health, with 26.4% meeting the criteria for a clinical depression, 73.6% reporting chronic pain, 80.6% sleeping disturbances, 38.2% sexual dysfunction, and 47.3% restless legs syndrome. Large group differences were found on the physical health, but not on the mental health component of quality of life, where symptomatic women only differed when controlling for having a boy affected by X-ALD (small effect) and treatment frequency (medium effect).

CONCLUSIONS

Symptomatic women with X-ALD present with physical and psychological co-morbidities significantly reducing individuals' quality of life. The findings emphasize the need to develop new multi-disciplinary treatment options tailored to women's specific needs.

Adverse Reactions and Complication in Voluntary Blood Donors

Background

Blood transfusion is a process by which blood replacement is performed in the treatment of various diseases with disorders of the number or function of blood cells or after bleeding. Blood helps save human lives and treat various diseases. Blood and blood products for the treatment of patients are prepared from the blood of voluntary donors.

Objective

The aim of this sudy was to examine the frequency of adverse reactions in voluntary blood donors at the Polyclinic for Transfusion at the University Clinical Center Tuzla in the period 01.01.-31.12.2021. and, also, to determining the frequency, is to determine the severity of adverse reactions and the causes that led to them (gender, age, place of donation, whether they are more common during the first or repeated blood donation) as well as the consequences they leave behind.

Methods

Our research includes voluntary blood donors who, in the period from 01.01.2021 until 31.12.2021., donated blood at the Polyclinic for Transfusion at the University Clinical Center Tuzla (UCC Tuzla). All donors have been selected according to earlier set criteria, according to the recommendations of the World Health Organization and the Council of Europe (12,13), involving age (≥18 years), weight (≥55kg), hemoglobin level (≥125g/dl for women, ≥135g/dl for men), hematocrit level (≥38% for women, ≥41g/dl for men), pulse (50-100 /min) and blood pressure (120/80-160/100mmHg). Each donor voluntarily filled out a uniformed questionary that involved data about personal and family history, as well as prior blood donations.

Results

In the Polyclinic for Transfusion UCC Tuzla, a study was conducted about adverse reactions among voluntary blood donors. During 2021 there were 14191 blood donors. From that number of donors, there were 75,4% (107000) fitting donors, while those who have been returned because they haven't satisfied donating criteria were 24,6% (3487). From the number of those who have donated blood (10700), negative reactions appeared in 1,8% (195) blood donors. Figure 1 shows adverse reactions in relation to the number of blood donations and gender. When it comes to gender, adverse reactions were recorded in 75,9% (148) male donors and 24,1% (47) female donors concering the total number of donors with adverse reactions. Our research showed that the prevalence of adverse reactions in voluntary blood donors is relatively low (1.8%). The adverse reactions are the result of vasovagal reactions, and most often occur in younger people (18 to 30 years old) in 55.9% of donors.

Conclusion

Considering the low percentage of adverse reactions in relation to the total number of blood donors, and that they are mostly mild in intensity, it can be concluded that donating blood is safe process, and doesn't leave lasting consequences for the blood donor's health, and every donor returns to daily activities very quickly.

Does time heal fatigue, psychological, cognitive and disability problems in people who experience an out-of-hospital cardiac arrest? Results from the DANCAS survey study

AIMS

Out-of-hospital cardiac arrest (OHCA) survivors may suffer short-term fatigue, psychological, cognitive and disability problems, but we lack information on the proportion of survivors with these problems in the long-term. Hence, we investigated these problems in survivors 1-5 years post-OHCA and whether the results are different at different time points post-OHCA.

METHODS

All adults who survived an OHCA in Denmark from 2016 to 2019 were identified using the Danish Cardiac Arrest Registry and invited to participate in a survey between October 2020 and March 2021. The survey included the Modified Fatigue Impact Scale, Hospital Anxiety and Depression Scale, "Two simple questions" (everyday activities and mental recovery), and the 12-item World Health Organisation Disability Assessment Schedule 2.0. To investigate results at different time points, survivors were divided into four time-groups (12-24, 25-36, 37-48 and 49-56 months post-OHCA). Differences between time-groups were determined using the Kruskall-Wallis test for the mean scores and Chi-square test for the proportion of survivors with symptoms.

RESULTS

Total eligible survey population was 2116, of which 1258 survivors (60 %) responded. Overall, 29 % of survivors reported fatigue, 20 % anxiety, 15 % depression, and 27 % disability. When survivors were sub-divided by time since OHCA, no significant difference was found on either means scores or proportion between time groups (p = 0.28 to 0.88).

CONCLUSION

Up to a third of survivors report fatigue, anxiety, depression, reduced mental function and disability 1-5 years after OHCA. This proportion is the same regardless of how much time has passed supporting early screening and tailored post-OHCA interventions to help survivors adapt to their new situation.

Fatigue Among Family Medicine Physicians in Slovenia

Background

Different authors define fatigue in different ways even though it is considered a very common symptom in the primary medical care.

Objective

To explore level of fatigue among Slovene family physicians and factors contributing to fatigue.

Methods

Modified Fatigue Impact Scale was used in our research. The link to the questionnaire website was sent through the mailing list of Medical Chamber of Slovenia, the Family Medicine Union - Praktik.um, the Family Medicine Association and the Young Physicians.

Results

231 physicians answered the questionnaire in full. There were 180 (77.9%) females and 51 (22.1%) males. The average age was 45.3±10.4 years and their capitation amounted to averagely 2245.8±544.2. On average they had spent 13.1±11.3 years working as specialists. Women have significant higher levels of fatigue, 57.2% have scored above the threshold of 38 points. Working in the office after working hours at least three times in a week was significantly associated with total fatigue, adding 10.07 points to the score. The years working as a specialist is not an important statistical factor in differentiating fatigue among physicians, nor is the level of patient load. Working irregular hours is also not an important statistical factor.

Conclusion

Slovenian family physicians are tired, as they have exceeded the limit given in the literature. Women are more tired, the most characteristic factor that contributes to fatigue is the extension of work in the clinic at least three times a week.

Preventive Medicine via Lifestyle Medicine Implementation Practices Should Consider Individuals' Complex Psychosocial Profile

Noncommunicable chronic diseases are associated with lifestyle behaviors. Psychological and social factors may influence the adoption of such behaviors. Being mentally and physically energized or fatigued may influence the intention-behavior gap of healthy lifestyle adoption accordingly. We investigated the associations of age, sex, lifestyle behaviors, mood, and mental and physical energy and fatigue at both the trait and state levels. The participants (N = 670) completed questionnaires assessing their sleep, mood, mental and physical state energy and fatigue, physical activity, mental workload, and diet. The ordinary least squares regression models revealed an overlap between the mental state and trait energy levels for males who consume polyphenols, have a high mental workload, and sleep well. Being younger, having a high stress level, bad sleep habits, and being confused and depressed were associated with high mental fatigue. Physical energy and fatigue shared the same commonalities with the previous results, with greater discrepancies observed between the state and trait indicators compared to that between mental energy and fatigue. Diet and stress management seem to be predictors of high physical energy, and females report higher physical fatigue levels. Health care professionals should consider this psychosocial complex profiling in their differential diagnosis and when one is implementing lifestyle behavioral changes to address the facets of preventive medicine, wellness, and health promotion.

How Much Data Is Enough? A Reliable Methodology to Examine Long-Term Wearable Data Acquisition in Gait and Postural Sway

Wearable sensors facilitate the evaluation of gait and balance impairment in the free-living environment, often with observation periods spanning weeks, months, and even years. Data supporting the minimal duration of sensor wear, which is necessary to capture representative variability in impairment measures, are needed to balance patient burden, data quality, and study cost. Prior investigations have examined the duration required for resolving a variety of movement variables (e.g., gait speed, sit-to-stand tests), but these studies use differing methodologies and have only examined a small subset of potential measures of gait and balance impairment. Notably, postural sway measures have not yet been considered in these analyses. Here, we propose a three-level framework for examining this problem. Difference testing and intra-class correlations (ICC) are used to examine the agreement in features computed from potential wear durations (levels one and two). The association between features and established patient reported outcomes at each wear duration is also considered (level three) for determining the necessary wear duration. Utilizing wearable accelerometer data continuously collected from 22 persons with multiple sclerosis (PwMS) for 6 weeks, this framework suggests that 2 to 3 days of monitoring may be sufficient to capture most of the variability in gait and sway; however, longer periods (e.g., 3 to 6 days) may be needed to establish strong correlations to patient-reported clinical measures. Regression analysis indicates that the required wear duration depends on both the observation frequency and variability of the measure being considered. This approach provides a framework for evaluating wear duration as one aspect of the comprehensive assessment, which is necessary to ensure that wearable sensor-based methods for capturing gait and balance impairment in the free-living environment are fit for purpose.

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.

Current perspectives on the diagnosis and management of fatigue in multiple sclerosis

INTRODUCTION

Fatigue is a common and debilitating symptom among multiple sclerosis (MS) patients with a prevalence up to 81% and with a considerable impact on quality of life. However, its subjective nature makes it difficult to define and quantify in clinical practice. Research aimed at a more precise definition and knowledge of this construct is thus continuously growing.

AREAS COVERED

This review summarizes the most relevant updates available on PubMed up to July 1^st 2022 regarding: the assessment methods that aim to measure the concept of fatigue (as opposed to fatigability), the possible treatment pathways currently available to clinicians, interconnection with the pathophysiological substrates and with the common comorbidities of MS, such as depression and mood disorders.

EXPERT OPINION

The in-depth study of fatigue can help to better understand its actual impact on MS patients and can stimulate clinicians towards a more valid approach, through a targeted analysis of this symptom. Considering fatigue from a multidimensional perspective allows the use of patient-tailored methods for its identification and subsequent treatment by different professional figures. Better identification of methods and treatment pathways would reduce the extremely negative impact of fatigue on MS patients' quality of life.

Multiple Sclerosis Severity Estimation and Progression Prediction Based on Machine Learning Techniques

The aim of the study is to address the Multiple Sclerosis (MS) severity estimation problem based on EDSS score and the prediction of the disease's progression with the application of Machine Learning (ML) approaches. Several ML techniques are implemented. The data are provided by the Neurology Clinic of the University Hospital of Ioannina and were collected in the framework of the ProMiSi project. The features recorded are grouped into: general demographic information, MS clinical related data, results of special tests, treatment, and comorbidities. The records from 30 patients are utilized and are recorded in three time points. The ML methods provided quite high results with 94.87% accuracy for the MS severity estimation and 83.33% for the disease's progression prediction.

Cognitive dysfunction associated with COVID-19: A comprehensive neuropsychological study

OBJECTIVE

Recent evidence suggests that patients suffering post-acute COVID syndrome frequently report cognitive complaints, but their characteristics and pathophysiology are unknown. This study aims to determine the characteristics of cognitive dysfunction in patients reporting cognitive complaints after COVID-19 and to evaluate the correlation between cognitive function and anxiety, depression, sleep, and olfactory function.

METHODS

Cross-sectional study involving 50 patients with COVID-19 reporting cognitive complaints 9.12 ± 3.46 months after the acute infection. Patients were evaluated with a comprehensive neuropsychological protocol, and scales of fatigue, depression, anxiety, sleep and an olfactory test. Normative data and an age- and education matched healthy control group were used for comparison.

RESULTS

COVID-19 patients showed a diminished performance on several tests evaluating attention and executive function, with alterations in processing speed, divided attention, selective attention, visual vigilance, intrinsic alertness, working memory, and inhibition; episodic memory; and visuospatial processing. Cognitive performance was correlated with olfactory dysfunction, and sleep quality and anxiety to a lesser extent, but not depression.

CONCLUSIONS

Patients with COVID-19 reporting cognitive symptoms showed a reduced cognitive performance, especially in the attention-concentration and executive functioning, episodic memory, and visuospatial processing domains. Future studies are necessary to disentangle the specific mechanisms associated with COVID-19 cognitive dysfunction.

The Complex Interplay Between Trait Fatigue and Cognition in Multiple Sclerosis

Cognitive impairments are frequent in patients with Multiple Sclerosis (MS). Yet, the influence of MS-related symptoms on cognitive status is not clear. Studies investigating the impact of trait fatigue along with anxio-depressive symptoms on cognition are seldom, and even less considered fatigue as multidimensional. Moreover, these studies provided conflicting results.

Twenty-nine MS patients and 28 healthy controls, matched on age, gender and education underwent a full comprehensive neuropsychological assessment. Anxio-depressive and fatigue symptoms were assessed using the HAD scale and the MFIS, respectively. Six composite scores were derived from the neuropsychological assessment, reflecting the cognitive domains of working memory, verbal and visual learning, executive functions, attention and processing speed. Stepwise regression analyses were conducted in each group to investigate if trait cognitive and physical fatigue, depression and anxiety are relevant predictors of performance in each cognitive domain. In order to control for disease progression, patient’s EDSS score was also entered as predictor variable.

In the MS group, trait physical fatigue was the only significant predictor of working memory score. Cognitive fatigue was a predictor for executive functioning performance and for processing speed (as well as EDSS score for processing speed). In the healthy controls group, only an association between executive functioning and depression was observed.

Fatigue predicted cognition in MS patients only, beyond anxio-depressive symptoms and disease progression. Considering fatigue as a multidimensional symptom is paramount to better understand its association with cognition, as physical and cognitive fatigue are predictors of different cognitive processes.

Fatigue and activity management education for individuals with systemic sclerosis: Adaptation and feasibility study of an intervention for a rare disease

Purpose

Fatigue is an overlooked symptom for musculoskeletal diseases, including rare conditions like systemic sclerosis (SSc). The purpose of this study were the following: (1) to adapt the content and delivery method of an existing fatigue intervention, and (2) to determine the feasibility of Fatigue and Activity Management Education in Systemic Sclerosis (FAME‐iSS).

Methods

In Phase 1 adaptations were recorded using the Framework for Modification and Adaptations. In Phase 2, participants completed the 6‐week FAME‐iSS intervention and baseline, post‐intervention, and 3‐month follow‐up assessments measuring fatigue levels, fatigue impact, mental health, self‐efficacy, and use of energy conservation strategies. Qualitative data included a post‐intervention focus group and 3‐month follow‐up interviews.

Results

Three main changes were made to the original intervention: (1) the content was adapted from management of Lupus‐related fatigue to management of SSc‐related fatigue, (2) context for delivery from Ireland to United States, and (3) in‐person to online format. Participants (n = 4) were 51.8 ± 12.1 years old, had been diagnosed with SSc for 12.0 ± 8.0 years, were receiving disability support, and had college degrees. All participants had 100% attendance and completed all study activities. Participants had positive comments about the programme format, content, and implementation. Post‐intervention, improvements were observed in most measures. Moderate effect sizes were noted in fatigue and self‐efficacy scores.

Conclusion

Participants' positive responses supported the need for FAME‐iSS for people with SSc. Even with the small sample, FAME‐iSS led to improvements in fatigue and use of energy conservation strategies. The online format allowed for participation and sharing of ideas, especially during the global pandemic.

Associations between fatigue impact and lifestyle factors in people with multiple sclerosis - The Danish MS hospitals rehabilitation study

BACKGROUND

The lack of medical treatment options to reduce fatigue in patients with multiple sclerosis (MS) emphasize the importance of identifying potential non-pharmacological modifiable factors, as this may help advance current treatment strategies. The aim of this study was to identify potential modifiable lifestyle factors as well as patient- and disease-related characteristics, that are associated with fatigue in a large sample of clinically well-characterized patients with MS.

METHODS

This study was a secondary analysis of a pragmatic randomized controlled trial of inpatient multidisciplinary rehabilitation in Denmark. MS patients aged 18 to 65 years and with a disease severity score ≤ 7.5 according to the Expanded Disability Status Scale participated. Data on patient- and disease-related characteristics, fatigue impact (Modified Fatigue Impact Scale (MFIS)), and on lifestyle factors (tobacco smoking, alcohol intake, and physical activity), were collected at baseline. A linear mixed model was used to compare MFIS total, physical, cognitive, and psychosocial scores across subgroups of selected characteristics. Regression analyses were used to examine associations between lifestyle factors and MFIS total, physical, cognitive, and psychosocial scores.

RESULTS

In the sample of 417 MS patients, median age was 51 years, 69% were female, median time since diagnosis was 8 years, with 41% having relapsing remitting MS. Higher MFIS total scores were observed in MS patients with shorter time since diagnosis, being a tobacco smoker, and not undertaking regular physical activity. Somewhat similar findings were observed for MFIS subscores (physical, cognitive, psychosocial), especially MFIS physical scores. In the multivariate analyses, physical activity was significantly associated with fatigue impact on total, physical and psychosocial functioning. Tobacco smoking was significantly associated with fatigue impact on psychosocial functioning. Alcohol intake was not associated with fatigue impact. None of the lifestyle factors were associated with fatigue impact on cognitive functioning. In the adjusted models time since diagnosis was significantly associated with fatigue impact on total, physical and cognitive functioning, as was disease severity with fatigue impact on physical and cognitive functioning.

CONCLUSION

Physical activity showed the most pronounced associations with fatigue impact on physical and psychosocial functioning, while the impact on cognitive functioning showed a trend. Tobacco smoking contributed significantly to impact on psychosocial functioning, while alcohol intake did not contribute to fatigue impact. Introducing or supporting maintenance of physical activity/exercise and cessation of tobacco smoking seems to be a useful approach for rehabilitation services to help patients with MS manage fatigue.