Energy conservation for fatigue management in multiple sclerosis: a pilot randomized controlled trial

Objective:

To develop and test the feasibility of an energy conservation programme to manage fatigue in multiple sclerosis.

Design:

A pilot randomized controlled trial.

Setting:

Community setting.

Subjects:

People with multiple sclerosis reporting fatigue.

Interventions:

An energy conservation programme was compared to a peer support group. Both interventions were delivered in group format with 2-hour sessions once a week for five weeks. Patients’ views about the interventions were sought in discussion groups one week post intervention.

Main measures:

The primary feasibility outcomes were recruitment and adherence. Other outcome measures were the Fatigue Impact Scale, Fatigue Severity Scale, MS-Impact Scale-29, MS Self-efficacy Scale, Beck’s Depression Scale-Fast Screen and Epworth Sleepiness Scale. Outcomes were administered at baseline, post intervention, 6-week and 3-month follow-up.

Results:

Almost 30% of the people approached to take part in the study did not commit to participation because of transport/time issues. Twenty-three patients took part in the study. Three patients dropped out, one reporting adverse effects. A power calculation indicated that a sample of 56 (28 per group) would be required for a main randomized controlled trial. Patients valued peer support and those in the energy conservation group described the programme as useful, but reported difficulties completing some practice activities.

Conclusion:

An energy conservation programme in the community is feasible and welcomed by people with multiple sclerosis. However, future research needs to consider longer follow-ups and practical issues to improve recruitment rate by accommodating to patients’ needs.

Multi-centre parallel arm randomised controlled trial to assess the effectiveness and cost-effectiveness of a group-based cognitive behavioural approach to managing fatigue in people with multiple sclerosis

BACKGROUND

Fatigue is one of the most commonly reported and debilitating symptoms of multiple sclerosis (MS); approximately two-thirds of people with MS consider it to be one of their three most troubling symptoms. It may limit or prevent participation in everyday activities, work, leisure, and social pursuits, reduce psychological well-being and is one of the key precipitants of early retirement. Energy effectiveness approaches have been shown to be effective in reducing MS-fatigue, increasing self-efficacy and improving quality of life. Cognitive behavioural approaches have been found to be effective for managing fatigue in other conditions, such as chronic fatigue syndrome, and more recently, in MS. The aim of this pragmatic trial is to evaluate the clinical and cost-effectiveness of a recently developed group-based fatigue management intervention (that blends cognitive behavioural and energy effectiveness approaches) compared with current local practice.

METHODS/DESIGN

This is a multi-centre parallel arm block-randomised controlled trial (RCT) of a six session group-based fatigue management intervention, delivered by health professionals, compared with current local practice. 180 consenting adults with a confirmed diagnosis of MS and significant fatigue levels, recruited via secondary/primary care or newsletters/websites, will be randomised to receive the fatigue management intervention or current local practice. An economic evaluation will be undertaken alongside the trial. Primary outcomes are fatigue severity, self-efficacy and disease-specific quality of life. Secondary outcomes include fatigue impact, general quality of life, mood, activity patterns, and cost-effectiveness. Outcomes in those receiving the fatigue management intervention will be measured 1 week prior to, and 1, 4, and 12 months after the intervention (and at equivalent times in those receiving current local practice). A qualitative component will examine what aspects of the fatigue management intervention participants found helpful/unhelpful and barriers to change.

DISCUSSION

This trial is the fourth stage of a research programme that has followed the Medical Research Council guidance for developing and evaluating complex interventions. What makes the intervention unique is that it blends cognitive behavioural and energy effectiveness approaches. A potential strength of the intervention is that it could be integrated into existing service delivery models as it has been designed to be delivered by staff already working with people with MS. Service users will be involved throughout this research.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN76517470.

Development and preliminary evaluation of a cognitive behavioural approach to fatigue management in people with multiple sclerosis

OBJECTIVES

(i) To develop a group-based intervention for the management of multiple sclerosis (MS) fatigue incorporating energy effectiveness and cognitive behavioural approaches and (ii) to undertake a process and preliminary evaluation.

METHODS

Drawing upon a literature search, a local model of good practice and the views of service users and health professionals, a manualised group-based fatigue management programme was developed, designed to be delivered by health professionals. A process and preliminary outcome evaluation was undertaken. Sixteen participants attended across two iterations. Participant feedback, obtained via a focus group and evaluation questionnaires, was used to refine the programme. Outcomes were collected pre- and post-programme (including fatigue severity, quality of life, self-efficacy).

RESULTS

Focus group feedback suggested the programme was well received, reflected in high attendance and positive ratings on evaluation questionnaires. At follow-up, despite the small sample size, there were significant improvements in perceived self-efficacy for managing fatigue.

CONCLUSION

An evidence-based fatigue management intervention has been developed and preliminary findings look promising. In the next phase we will examine whether the programme transfers satisfactorily to other centres and collect data in preparation for a randomised controlled trial (RCT).

PRACTICE IMPLICATIONS

Implications for practice will emerge when the results of our RCT are published.

Psychometric evaluation of the Energy Conservation Strategies Survey

OBJECTIVE

To examine the internal consistency and test-retest reliability of the Energy Conservation Strategies Survey (ECSS), a tool that was specifically designed to determine if people with multiple sclerosis who attended the six-week energy conservation course actually implemented the strategies taught to them.

DESIGN

The instrument ECSS was administered at six weeks and seven weeks post intervention to evaluate the test-retest reliability, while data from six weeks post intervention were utilized to assess the internal consistency of the ECSS.

SETTING

Community locations in Illinois and Minnesota, USA.

SUBJECTS

Data from 53 participants with multiple sclerosis living in the community were utilized for the psychometric study.

MEASURES

Energy Conservation Strategies Survey.

RESULTS

The internal consistency of 0.92 reveals that all the items are consistent with each other and measure a single construct. Inferential analyses using intraclass correlation coefficient indicates good test-retest reliability (intraclass correlation coefficient (ICC) = 0.79).

CONCLUSION

Findings of the study suggest that the ECSS exhibits high internal consistency and good test-retest reliability. The study implies that the ECSS could be valuable in measuring changes in behaviour over time among people with multiple sclerosis after the completion of the six-week energy conservation course provided by occupational therapists.

Results of a fatigue management programme in multiple sclerosis

Fatigue in patients with multiple sclerosis (MS) is a complex symptom that is notoriously difficult to treat, not least because it is extremely subjective and is experienced differently by each patient. Owing to the prevalence of this symptom, most patients with MS who are seen in outpatient settings complain of fatigue and experience the disabling effect it can have upon day-to-day living. Managing and treating this symptom is a challenge, although there is some evidence that applying fatigue management principles can potentially reduce the debilitating effect fatigue has on patients (Welham, 1995). This article reviews the evidence base surrounding the management and treatment of fatigue that is applied in clinical practice. It describes the fatigue management programme that had been introduced for people with MS at the authors' workplace, and evaluated whether applying fatigue management principles can make a difference to people's ability to self-care. The effect this symptom has upon people's quality of life will also be explored.

Occupational therapy for multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) patients are referred to occupational therapy with complaints about fatigue, limb weakness, alteration of upper extremity fine motor coordination, loss of sensation and spasticity that causes limitations in performance of activities of daily living and social participation. The primary purpose of occupational therapy is to enable individuals to participate in self-care, work and leisure activities that they want or need to perform.

OBJECTIVES

To determine whether occupational therapy interventions in MS patients improve outcome on functional ability, social participation and/or health related quality of life.

SEARCH STRATEGY

Relevant full length articles were identified by electronical searches in Medline, Cinahl, Embase, Amed, Scisearch and The Cochrane MS Group Trials Register. The reference list of identified studies and reviews were examined for additional references. Date of last search: December 2002.

SELECTION CRITERIA

Controlled (randomized and non-randomized) and other than controlled studies addressing occupational therapy for MS patients were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

The methodological quality of the included trials was independently assessed by two reviewers. Disagreements were resolved by discussion. A list proposed by Van Tulder et al. (Van Tulder 1997) was used to assess the methodological quality. For outcome measures, standardized mean differences were calculated. The results were analysed using a best-evidence synthesis based on type of design, methodological quality and the significant findings of outcome and/or process measures.

MAIN RESULTS

Only one randomized clinical trial was identified. Two other included studies were a controlled clinical trial and a study with a pre-post test design. The studies included 271 patients in total. Two studies evaluated an energy-conservation course for groups of patients and one study evaluated a counselling intervention. The results of the energy conservation studies could be biased because of the designs used, the poor methodological quality and the small number of included patients. The high quality RCT on counselling reported non-significant results.

REVIEWER'S CONCLUSIONS

On basis of this review no conclusions can be stated whether occupational therapy improves outcome in MS patients. The lack of (randomized controlled) efficacy studies in most intervention categories of OT shows an urgent need for future research in occupational therapy for multiple sclerosis. Initially, a survey of occupational therapy practice for MS patients including the characteristics and needs of these patients is necessary to develop a research agenda for efficacy studies.