Behavioral Interventions to Improve Sleep Outcomes in Individuals With Multiple Sclerosis: A Systematic Review

BACKGROUND

Sleep disturbances are common in individuals with multiple sclerosis. The objective of this systematic review was to determine effective behavioral interventions to improve their sleep.

METHODS

Literature searches were performed in December 2021 in Ovid MEDLINE, Elsevier Embase, and Web of Science, along with hand searching for grey literature and cited references. Four reviewers independently reviewed titles and abstracts (2 reviewers for each article; n = 830) and the full-text articles (n = 81). Consensus for inclusion was achieved by a fifth reviewer. Thirty-seven articles were eligible for inclusion. Four reviewers extracted relevant data from each study (2 reviewers for each article) using a standard data extraction table. Consensus was achieved for completeness and accuracy of the data extraction table by a fifth reviewer. The same 4 reviewers conducted a quality appraisal of each article to assess the risk of bias and quality of the articles, and consensus was achieved by a fifth reviewer as needed. Descriptive data were used for types of interventions, sleep outcomes, results, and key components across interventions.

RESULTS

Overall, the cognitive behavioral therapy for insomnia, cognitive behavioral therapy/psychotherapy, and education/self-management support interventions reported positive improvements in sleep outcomes. Quality appraisal scores ranged from low to high, indicating potential for bias.

CONCLUSIONS

Variability in the intervention type, intervention dose, outcomes used, training/expertise of interventionist, specific sample, and study quality made it difficult to compare and synthesize results. Further research is necessary to demonstrate the efficacy of most of the interventions.

Experiences of the Redesigning Daily Occupation programme - a qualitative study among persons with neurological diseases

BACKGROUND

The Redesigning Daily Occupations (ReDO) is a programme targeting persons who need to restructure activities and routines to achieve a healthier balance in everyday life. Issues that often is needed for persons with neurological diseases.

AIMS/OBJECTIVES

To describe how persons with neurological disease experienced the ReDo-programme and to investigate how their occupational patterns and fatigue changed during the programme.

MATERIAL AND METHODS

A mixed method study with a convergent parallel design including ten participants. Questionnaires and individual semi-structured interviews have been used and data analysed by descriptive statistics and thematic analysis.

RESULTS

The findings indicated an increased participation in everyday life after the intervention. Furthermore, the main theme showed that the intervention enabled reflections and new insight. Sub-themes included: feeling pressured to perform, being part of a group and changing occupational pattern.

CONCLUSIONS

Participants valued being a group; however, they experienced the intensity as being too high. The content of the intervention enabled reflections and new insights regarding their occupational pattern, which was experienced as a starting point towards behavioural changes and re-prioritisation of occupations in everyday life.

SIGNIFICANCE

A modified version with lower intensity and careful goal setting might be valuable for persons with neurological diseases.

Managing Fatigue: Experiences From a 6-week Course for Adults With Cerebral Palsy

Objective

To explore experiences of a 6-week Fatigue Management course (FMC) in adults with cerebral palsy (CP).

Design

A qualitative study using semi-structured interviews. The study process followed the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Setting

The study was conducted in southeastern Sweden in an out-patient setting.

Participants

Adults (N=8) with CP who had participated in FMC.

Interventions

Not applicable.

Main Outcome Measure

Qualitative content analysis of the transcribed interviews led to identification of a main category, categories, and subcategories, describing the participants' experiences of FMC.

Results

The analysis identified 2 categories: Awareness regarding fatigue, with the 2 subcategories: A better understanding, and The feeling of not being alone; and Perceive opportunities for changes, with the 3 subcategories: Understanding the need for changes, Demanding process, and Taking steps toward change. These categories were summed up in the main category describing the participants' experiences of FMC: A challenging and eye-opening course that gave deeper self-understanding and thoughts about making changes.

Conclusions

Overall, the participants described positive experiences of FMC, with increased awareness regarding fatigue and insight regarding the possibilities for change. Nevertheless, there were challenges in coping with the extensive information and with the home assignments. This study gives promising results regarding the applicability of FMC for adults with CP. However, there is a need for course modifications with more targeted and differentiated content that is manageable and does not overload the participants. The modifications should include extended time, the addition of individual support, and follow-up between sessions, to increase participants' opportunities to implement new strategies and initiate behavioral change.

Exploring the socio-ecological factors impacting lifestyle management of multiple sclerosis: A scoping review

BACKGROUND

Multiple sclerosis (MS) is a chronic, autoimmune, neurodegenerative disorder affecting over 2.9 million people worldwide. First line care revolves around disease modifying therapy and supporting people living with MS to manage their disease. Early management often sees lifestyle modification as people living with MS try to gain a sense of control. Lifestyle management is an evolving area of care with variable strength of evidence for different lifestyle factors.

OBJECTIVE

To explore factors that impact on the self-management of MS with a socio-ecological focus.

METHODS

A scoping review following the Joanna Briggs Institute guidelines for a systematic search was conducted across six databases with 9241 articles identified and 51 included in the review. The results were analysed in conjunction with the socio-ecological model considering the categories: individual, interpersonal, organisational, community, and public policy.

RESULTS

A map of health behaviour (lifestyle) factors extending across all levels of the socio-ecological model revealed a complex web of pathways to behavioural patterns impacting MS self-management. Factors followed a cascading effect towards either of two key principles: (1) self-identity or (2) accessibility. These principles in-turn impact on an individual's self-efficacy, and hence, effectiveness of MS self-management strategies.

CONCLUSIONS

MS care is highly individualised to the personal context and circumstances of the individual, with consideration towards suitable management strategies required. Healthcare professionals must consider these lifestyle influences and coordinate an approach to assisting people living with MS to self-manage their disease in relation to their personal circumstances. Person-centred care addressing both barriers and motivators to health behaviour changes is key to effective MS self-management.

Supporting brain health in multiple sclerosis: exploring the potential of neuroeducation combined with practical mindfulness exercises in the management of neuropsychological symptoms

OBJECTIVE

We aimed at examining the effects of a known metacognitive training in MS (MaTiMS) and its modification with an additional neuroeducational module and mindfulness-based exercises (MaTiMS-modified) on neuropsychiatric and cognitive outcomes in people with progressive multiple sclerosis (pwpMS). Exploratively, we investigated whether the modification may show an additional benefit.

METHODS

Both interventions were administered in small groups of ambulatory patients. Neuropsychological testing before and after the 3- to 4-week intervention phase comprised patient reported outcomes and cognitive tests. After 3, 6 and 12 months, participants completed online surveys. Analysis of change scores (between baseline and retest) with t-tests (Mann-Whitney U and Wilcoxon tests, respectively) and mixed ANCOVAs with repeated measures for comparison of both interventions were conducted.

RESULTS

A total of 65 pwpMS turned to a final sample of 50 (n = 15 excluded due to drop-outs, occurrence of relapse or steroid treatment). Change scores within MaTiMS revealed no significant effect on the PDQ-20 total score and only a significant effect on the subscale retrospective memory lasting 3 months with a moderate effect size. In contrast, MaTiMS-modified revealed a highly significant change in PDQ-20 total compared to baseline and significant improvements with small to moderate effect sizes on all PDQ-20 subscales (lasting until 3 months), in self-efficacy, stress, visuo-spatial working memory (moderate effect sizes), and fatigue (small effect size). While no interaction effect between time and group could be revealed, a significant main effect for time was found in PDQ-20 total.

CONCLUSION

Both MaTiMS and MaTiMS-modified positively affected perceived cognitive deficits. However, our data speak in favor of additional benefits by adding neuroeducational and mindfulness-based exercises thus being valuable methods to support brain health including self-efficacy, perceived stress, and fatigue, even in patients with a chronic and progressive brain disease.

Managing Fatigue in Parkinson's Disease: Protocol for a Pilot Randomized Controlled Trial

Background. Fatigue is a disabling symptom of Parkinson’s disease (PD). Managing Fatigue: A Six-Week Energy Conservation Intervention was developed to improve the occupational performance of people with fatigue. Efficacy of this program has not been established in PD. Purpose. This study will assess feasibility of the Managing Fatigue: Individual Program (MFIP) delivered via videoconference, the Randomized Controlled Trial (RCT) protocol, and the preliminary effectiveness of the MFIP. Methods. A mixed-methods approach nested in a pilot RCT, randomizing 54 participants 1:1 to usual care or MFIP arms, will be employed to evaluate the feasibility and preliminary effectiveness of MFIP. Qualitative and quantitative data will be collected simultaneously. Implications. Results will identify evidence for establishing protocol requirements for a full-scale RCT. Knowledge of the effectiveness of the one-to-one videoconference delivery format of the program has the potential to enhance the accessibility and the quality of care of the PD population.

Occupational Therapy Interventions in Adults with Multiple Sclerosis or Amyotrophic Lateral Sclerosis: A Scoping Review

This scoping review aims to describe occupational therapy interventions carried out with multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS) patients in occupational therapy. A peer review of the literature was conducted in different databases: Pubmed, Scopus, Web of Science and Embase, and in some occupational therapy journals. A search of the literature published was carried out before December 2019. The inclusion criteria were as follows: (1) articles evaluating the intervention of occupational therapy in MS or ALS including experimental, randomized, nonrandomized and exploratory studies; (2) written in English or Spanish; (3) adult population (over 18 years old). The initial search identified 836 articles of which we included 32 divided into four areas of intervention: fatigue-targeted interventions, cognitive interventions, physical interventions and others. Only 16 studies were carried out exclusively by occupational therapists. Most occupational therapy interventions are aimed at fatigue and physical rehabilitation. The majority of the studies in our review included MS patients, with little representation from the ALS population. These interventions have shown an improvement in perceived fatigue, manual dexterity, falls prevention and improvement in cognitive aspects such as memory, communication, depression and quality of life in the MS and ALS populations.

Pain-Related Activity Management Patterns as Predictors of Treatment Outcomes in Patients with Fibromyalgia Syndrome

OBJECTIVES

This study sought to determine if pre- to post-treatment changes in pain-related activity patterns (i.e., overdoing, avoidance, and pacing) were associated with pre- to post-treatment changes in function (i.e., pain interference, psychological function, and physical function) in patients with fibromyalgia syndrome who participated in either an operant learning- or an energy conservation-based training in activity management.

METHODS

Sixty-nine patients with fibromyalgia syndrome participated in an activity management treatment (32 in an operant learning group and 37 in an energy conservation group). Outcomes were assessed at pre- and post-treatment, and patients provided demographic information and completed measures assessing pain intensity, pain interference, psychological function, physical function, and pain management activity patterns. Three linear hierarchical regression analyses predicting changes in pain outcomes from changes in pacing, overdoing, and avoidant activity patterns were performed.

RESULTS

Changes in pain-related activity patterns made significant contributions to the prediction of changes in patients' function. Specifically: (a) increases in overdoing predicted reductions in pain interference; (b) decreases in avoidance predicted improvements in psychological function; and (c) increases in pacing predicted improvements in physical function.

CONCLUSIONS

This study provides support for a role of activity management treatments in improved adjustment to chronic pain. Research is needed to replicate and extend these findings in order to build an empirical basis for developing more effective chronic pain treatments for facilitating improved physical and psychological function in individuals with chronic pain.

Energy management education and occupation-related outcomes in adults with chronic diseases: A scoping review

Introduction

Fatigue is a pervasive symptom of chronic disease that often interferes with occupational performance. Our objective was to describe what is known about energy management education and occupation-related outcomes in adults with chronic diseases.

Methods

Seven electronic databases were searched for relevant literature published before August 2019. Eligible articles were full-text, available in English, and studied energy management education in adults with a chronic disease. The first author assessed article eligibility with validation from a second reviewer, extracted characteristics of included studies, and described them using descriptive statistics. A narrative synthesis of findings was conducted for each chronic disease population.

Results

Forty-four studies addressed eight different chronic disease populations. The most common program delivery format was face-to-face in a group setting (42%), 39% of programs were informed by a learning theory, and their median cumulative length was 8 hours. Positive outcomes were associated with a specific, group-based energy management program in people with multiple sclerosis. The evidence on other energy management programs and in other chronic disease populations was more limited and inconclusive.

Conclusions

Further research is needed to understand the impact of energy management education in chronic disease populations beyond multiple sclerosis, and its impact on occupational performance.

Operant Learning Versus Energy Conservation Activity Pacing Treatments in a Sample of Patients With Fibromyalgia Syndrome: A Pilot Randomized Controlled Trial

This study's aim was to assess the efficacy of 2 forms of activity pacing in patients with fibromyalgia syndrome (FMS). Treatment-related changes in activity management patterns were also examined. Patients with FMS (n = 178) were randomly assigned to an operant learning (OL; delayed [n = 36] or immediate [n = 54] groups) or an energy conservation (EC; delayed [n = 35] or immediate [n = 53] groups) treatment condition. Of these, 32 OL and 37 EC patients completed treatment. Forty-three patients were allocated to the delayed treatment condition (control group). Repeated measures analyses of variance were used to examine the effects of OL and EC treatments on primary (average pain and usual fatigue), secondary (pain and fatigue interference, physical and psychological function, sleep quality, depressive symptoms, and anxiety symptoms), and tertiary (pain-related activity patterns) outcomes. Neither treatment was effective in reducing average pain or usual fatigue symptoms. Relative to EC, OL patients showed greater improvements in depressive symptoms, whereas nonsignificant trends (P values ranging between .05 and .06) were observed for pain interference, fatigue interference, and psychological function. Both treatments were associated with improvements in sleep quality and physical function, increases in pacing, and decreases in overdoing activity patterns. Reductions in activity avoidance were only found in OL. These findings suggest that OL may be more beneficial than EC and that it could potentially be viewed as an effective stand-alone activity pacing treatment for patients with FMS. Research to determine the extent to which these preliminary findings replicate is warranted. PERSPECTIVE: This article examines the efficacy of 2 forms of activity pacing in patients with fibromyalgia syndrome. The results suggest the possibility that operant learning may be more beneficial than energy conservation and could potentially be viewed as an effective stand-alone activity pacing treatment for patients with fibromyalgia syndrome.

Effectiveness of energy conservation management on fatigue and participation in multiple sclerosis: A randomized controlled trial

Background:

Fatigue is a frequently reported and disabling symptom in multiple sclerosis (MS).

Objective:

To investigate the effectiveness of an individual energy conservation management (ECM) intervention on fatigue and participation in persons with primary MS-related fatigue.

Methods:

A total of 86 severely fatigued and ambulatory adults with a definite diagnosis of MS were randomized in a single-blind, two-parallel-arm randomized clinical trial to the ECM group or the information-only control group in outpatient rehabilitation departments. Blinded assessments were carried out at baseline and at 8, 16, 26 and 52 weeks after randomization. Primary outcomes were fatigue (fatigue subscale of Checklist Individual Strength – CIS20r) and participation (Impact on Participation and Autonomy scale – IPA).

Results:

Modified intention-to-treat analysis was based on 76 randomized patients (ECM, n = 36; MS nurse, n=40). No significant ECM effects were found for fatigue (overall difference CIS20r between the groups = −0.81; 95% confidence interval (CI), −3.71 to 2.11) or for four out of five IPA domains. An overall unfavourable effect was found in the ECM group for the IPA domain social relations (difference between the groups = 0.19; 95% CI, 0.03 to 0.35).

Conclusion:

The individual ECM format used in this study did not reduce MS-related fatigue and restrictions in participation more than an information-only control condition.

Enrolling and keeping participants in multiple sclerosis self-management interventions: a systematic review and meta-analysis

OBJECTIVES

The objectives were to provide an estimate of expected enrolment and attrition rates based on published studies of existing self-management interventions for people with multiple sclerosis, and to identify contributing factors and impact on outcomes.

REVIEW METHODS

A systematic literature search was conducted using Ovid MEDLINE, PsychINFO, EMBASE, AMED, CINAHL, OT Seeker, PubMed, and the Cochrane Database of Systematic Reviews databases. Controlled trials with or without randomization using either a between-group or within-person design were included if they met specified criteria. A random-effect meta-regression analysis was conducted to estimate the overall enrolment and attrition proportions, effect of person- and study-related factors, and impact on outcomes.

RESULTS

A total of 48 studies, comprising 4446 persons were identified. The estimated enrolment rate was 50.3% (95% confidence interval (CI): 49.6 to 51.1) and the estimated attrition rates in the intervention and control groups were 16.8% (95% CI: 16.2 to 17.3) and 14.4% (95% CI: 13.8 to 14.9), respectively. The main reported reason for refusing to participate was lack of interest (70.6%), while the reported reasons for dropping out were mainly owing to medical issues (26.1%) and disliking the intervention (17.9%). Trial, programme, and patient-related variables were found to influence the enrolment and/or attrition rates. Studies that had a 10% higher attrition rate had an effect size that was larger by 0.19 (95% CI: 0.17 to 0.24).

CONCLUSION

Greater understanding of the factors associated with enrolment and attrition rates would help in planning and developing a more appealing self-management intervention that patients can easily accept and incorporate into their everyday lives.

Self-Management Interventions to Prevent Depression in People with Mobility Limitations

Introduction

This focused review reports on the impact of self-management interventions on depression in people with a mobility disability.

Method

There were two phases to the search including a comprehensive scoping review of the literature examining multiple secondary conditions impacted by self-management programs (Phase 1) and a focused review of the literature detailing the impact of self-management interventions on depression (Phase 2). CINAHL, PubMed, and PsyclNFO were searched for articles published between January 1988 through August 2014 and studies were screened by the first author based on specific inclusion and exclusion criteria.

Results

Twenty-five studies met criteria with results, demonstrating a mixed effect of self-management programs on depression. Sixteen studies included an intervention and control/comparison group, of which eight (50%) had a significant effect on depression. A further nine studies did not include a control/comparison group and five found significant changes in depression and four found no change. Eighteen out of 25 studies (72%) were rated as having moderate-to-high bias and nine different outcome measures were used across studies.

Discussion

Based on the mixed findings and varied approaches adopted for intervention and outcome assessment, future research should adopt a more rigorous methodological approach to examine self-management interventions on depression.

Systematic review of the effectiveness of occupational therapy-related interventions for people with amyotrophic lateral sclerosis

We describe the results of a systematic review of the literature on occupational therapy-related interventions for people with amyotrophic lateral sclerosis (ALS). The review included 14 studies. We found limited to moderate evidence that people involved in multidisciplinary programs have longer survival than those in general care and limited evidence that those in multidisciplinary programs have a higher percentage of appropriate assistive devices and higher quality of life in social functioning and mental health. Limited evidence indicates that people with ALS are satisfied with the comfort and ease of use of their power wheelchairs (PWCs). In addition, limited evidence is available that PWCs allow people to have increased interaction in the community. Evidence also is limited that some assistive devices are more helpful than others. Moderate evidence indicates that a home exercise program of daily stretching and resistance exercise results in improved function. The implications for practice, education, and research are discussed.

Impact of comorbidity on fatigue management intervention outcomes among people with multiple sclerosis: an exploratory investigation

This exploratory secondary analysis examined whether the presence of six chronic health conditions moderated the effectiveness of a teleconference-delivered fatigue self-management education program for people with multiple sclerosis (MS). The longitudinal data used were from a randomized controlled trial involving 181 community-dwelling adults with MS. The primary outcome was fatigue impact, as measured by the Fatigue Impact Scale (FIS). Mixed-effects analysis of variance (ANOVA) models were used to determine the best-fitting model. Just under 65% (n = 112) of participants had at least one comorbid condition. Only diabetes and arthritis moderated all three FIS subscales over time. People with diabetes were slower to show improvement after intervention than people without diabetes. People with arthritis made much more dramatic initial gains compared with people without arthritis but had difficulty maintaining those gains over time. The results point to the need for greater attention to the impact of comorbidities on rehabilitation interventions. These exploratory findings suggest that fatigue self-management education protocols may need to be customized to people who are trying to incorporate MS fatigue self-management behaviors while simultaneously managing diabetes or arthritis.

Systematic Review of Occupational Therapy–Related Interventions for People With Multiple Sclerosis: Part 1. Activity and Participation

This article is the first part of a systematic review of studies on occupational therapy–related intervention for people with multiple sclerosis (MS). The objective of this systematic review was to critically appraise and synthesize the applicable findings to address the following focused question: What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice for people with multiple sclerosis? This article focuses on occupational therapy interventions aimed at activity and participation, including programs (e.g., inpatient and outpatient rehabilitation) in which an occupational therapy practitioner was one member of the team. Part 2 (Yu & Mathiowetz, 2014) focuses on interventions within the scope of occupational therapy to remediate impairment (e.g., exercise, cognition, emotional regulation).

Activity pacing in chronic pain: concepts, evidence, and future directions

BACKGROUND

Activity pacing (AP) is a concept that is central to many chronic pain theories and treatments, yet there remains confusion regarding its definition and effects.

OBJECTIVE

To review the current knowledge concerning AP and integrate this knowledge in a manner that allows for a clear definition and useful directions for future research.

METHODS

A narrative review of the major theoretical approaches to AP and of the empirical evidence regarding the effects of AP interventions, followed by an integrative discussion.

RESULTS

The concept of AP is derived from 2 main traditions: operant and energy conservation. Although there are common elements across these traditions, significant conceptual and practical differences exist, which has led to confusion. Little empirical evidence exists concerning the efficacy of AP as a treatment for chronic pain.

DISCUSSION

Future research on AP should be based on a clear theoretical foundation, consider the context in which the AP behavior occurs and the type of pacing problem ("underactivity" vs. "overactivity"), and should examine the impact of AP treatment on multiple clinical outcomes. We provide a provisional definition of AP and specific recommendations that we believe will move the field forward.

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.

Outcome Moderators of a Fatigue Management Program for People With Multiple Sclerosis

OBJECTIVE. We determined whether age, gender, work status, or impairment moderated fatigue management program outcomes for people with multiple sclerosis (MS).

METHOD. We conducted a secondary analysis of longitudinal data from a randomized controlled trial using mixed-effects models (N = 181) and examined outcomes of fatigue impact, mental health, physical health, and self-efficacy. Measures were collected before and immediately after intervention and at 6 wk, 3 mo, and 6 mo postintervention.

RESULTS. Younger participants experienced greater reductions in fatigue impact and greater improvements in self-efficacy over time than did older participants, but we found no age differences in physical or mental health. Participants with less impairment experienced greater mental health gains and were more likely to retain these gains over time than were participants with greater impairment. Although women experienced greater fatigue impact benefits, men experienced greater mental health benefits. Work status did not moderate outcomes.

CONCLUSION. Fatigue management program outcomes for people with MS are moderated by age, gender, and impairment.

Treatment of fatigue in multiple sclerosis patients: a neurocognitive approach

The objective of the study was to treat fatigue in patients with multiple sclerosis (MS) by a neurocognitive rehabilitation program aimed at improving motor planning by using motor imagery (MI). Twenty patients with clinically definite MS complaining of fatigue were treated for five weeks with exercises of neurocognitive rehabilitation twice a week. Patients were evaluated by Fatigue Severity Scale (FSS), Modified Fatigue Impact Scale (MFIS), MSQoL54, Expanded Disability Status Scale (EDSS), and MS Functional Composite (MSFC). After treatment, a decrease in fatigue was detected with both FSS (P = 0.0001) and MFIS (P = 0.0001). MSFC (P = 0.035) and MSQoL54 (P = 0.002) scores improved compared to baseline. At six-month followup, the improvement was confirmed for fatigue (FSS, P = 0.0001; MFIS P = 0.01) and for the physical subscale of MSQoL54 (P = 0.049). No differences in disability scales were found. These results show that neurocognitive rehabilitation, based on MI, could be a strategy to treat fatigue in MS patients.

Symptomatic therapy in multiple sclerosis: a review for a multimodal approach in clinical practice

As more investigations into factors affecting the quality of life of patients with multiple sclerosis (MS) are undertaken, it is becoming increasingly apparent that certain comorbidities and associated symptoms commonly found in these patients differ in incidence, pathophysiology and other factors compared with the general population. Many of these MS-related symptoms are frequently ignored in assessments of disease status and are often not considered to be associated with the disease. Research into how such comorbidities and symptoms can be diagnosed and treated within the MS population is lacking. This information gap adds further complexity to disease management and represents an unmet need in MS, particularly as early recognition and treatment of these conditions can improve patient outcomes. In this manuscript, we sought to review the literature on the comorbidities and symptoms of MS and to summarize the evidence for treatments that have been or may be used to alleviate them.

A scoping review of self-management interventions for adults with multiple sclerosis

The purpose of this scoping review is to identify self-management tasks and skills that are being taught in existing interventions for persons with multiple sclerosis and to describe intervention strategies used to facilitate the learning of self-management tasks and skills. Multiple strategies were used to search for studies published or in press between 1980 and 2008 that evaluated self-management interventions. The main exclusion criteria were case studies, inadequate description of the intervention, and traditional clinical patient education interventions. Two independent coders categorized the interventions by using Lorig and Holman's self-management framework and Abraham and Michie's taxonomy of behavior change techniques. Twenty-seven interventions were identified from 34 articles. Common intervention topics included fatigue management (n = 12), coping, depression, and stress management (n = 10), and medication management (n = 6). Also, no 2 interventions used the same delivery format to implement the same combination of intervention strategies. Furthermore, markedly different intervention strategies were used to improve the same outcomes. These results highlight a need to systematically test intervention strategies one at a time, or in a clear specified combination, as well as compare existing interventions to determine which are most effective in supporting persons with multiple sclerosis to learn and incorporate self-management tasks and skills.

Randomized trial of a teleconference-delivered fatigue management program for people with multiple sclerosis

BACKGROUND

Previous studies support the efficacy and effectiveness of face-to-face group-based fatigue management education for people with multiple sclerosis (MS). Nevertheless, many people are unable to access these programs due to environmental barriers.

OBJECTIVES

To test the efficacy and effectiveness of a group-based, teleconference-delivered fatigue management program for people with MS.

METHODS

A randomly allocated two-group time series design with a wait-list control group was used. In total 190 participants were allocated (94 intervention, 96 wait-list control). Primary outcomes (fatigue impact, fatigue severity, health-related quality of life (HRQOL)) were measured before, immediately after, at 6 weeks, 3 months, and 6 months post. Secondary outcome (self-efficacy) was measured at the same points. Effectiveness (intent-to-treat) and efficacy (per protocol) analyses were conducted.

RESULTS

The program was more effective and efficacious than control for reducing fatigue impact but not fatigue severity. Before and after comparisons with the pooled sample demonstrated efficacy and effectiveness for fatigue impact, fatigue severity, and 6 of 8 HRQOL dimensions. Changes were maintained for 6 months with small to moderate effect sizes.

CONCLUSION

The results offer strong support for the viability of teleconference-delivered fatigue management education for enabling people with MS to manage this disabling symptom.

Self care programs and multiple sclerosis: physical therapeutics treatment - literature review

OBJECTIVE

To clarify the therapeutic education program impact with multiple sclerosis patients, literature review. Highlight contents and efficacy.

METHOD

A non-systematic review on Medline, PubMed and Cochrane library databases from 1966 to 2010 using the following keywords: "multiple sclerosis", "self-care", "self-management" and specific symptoms keywords. Clinical trials and randomized clinical trials, as well as literature reviews published in English, French and German will be analyzed.

RESULTS

Counseling is a part of the non-pharmacological management of chronic illnesses such as multiple sclerosis. Symptoms' diversity and the different clinical forms limit standardized programs of self-care management, applicable to patients. In the literature review, counseling programs have often low metrology. A behavior change with patients and medical staff could exist. To empower the patient, to reduce symptoms' impact and to improve treatment access are the aims of educational therapy.

CONCLUSION

Therapeutic education program for multiple sclerosis patients could progress with their standardization and assessment, for each sign. To promote the educational therapy of multiple sclerosis patients, a specific training for medical staff, as specific financing are necessary.

Impact of psychotherapy on insomnia symptoms in patients with depression and multiple sclerosis

The purpose of the study was to evaluate the prevalence of insomnia in multiple sclerosis patients with comorbid depression, associations between psychological symptoms, multiple sclerosis symptoms and insomnia, and to test effects of a 16-week protocol-based psychotherapy intervention for depression on insomnia symptoms. Participants with multiple sclerosis and depression (n = 127) were randomized to telephone administered cognitive behavioral therapy and telephone administered supportive emotion-focused therapy. Multiple sclerosis functional limitation was measured at baseline. Depression, insomnia, anxiety and quality of life were evaluated at pre treatment, mid treatment (8 weeks), and post treatment (16 weeks). Prevalence of insomnia ≥3 times per week was 78% at pre treatment and 43% at post treatment. Insomnia at baseline was associated with depression, multiple sclerosis related mood symptoms and anxiety. Middle of the night awakenings were associated with swallowing and speech problems. Improvements in insomnia were associated with improvement in depression and anxiety. Participants with residual insomnia were more likely to have major depressive disorder, greater multiple sclerosis severity, elevated anxiety and lower mental components of quality of life. Results demonstrate rates of insomnia in patients with comorbid multiple sclerosis and depression are higher than those reported in the general multiple sclerosis population and additional insomnia treatment is indicated beyond the treatment of comorbid psychological disorders.

Clinical and economic impact of a specialty care management program among patients with multiple sclerosis: a cohort study

Background: To evaluate the clinical and economic impact of a specialty care management program among patients with multiple sclerosis.

Methods: This retrospective cohort analysis included patients aged ≥18 years with ≥2 claims of multiple sclerosis diagnosis and ≥1 multiple sclerosis medications from 1 January 2004 to 30 April 2008. The outcome metrics included medication adherence and persistence, multiple sclerosis-related hospitalization, and multiple sclerosis-related cost. Multivariate analyses were performed to adjust for demographics and clinical characteristics.

Results: Among the 3993 patients identified, 78.3% participated in the program and 21.7% did not. Over 12 months, medication adherence and persistence improved among participants but deteriorated among non-participants (medication possession ratio change: +0.08 vs −0.03, p < 0.001; persistence change: +29.2 days vs −9.2 days, p < 0.001). Multiple sclerosis-related hospitalization decreased from 9.6% to 7.1% for participants, whereas it increased from 10.1% to 12.0% for the non-participant group (p < 0.001). Multiple sclerosis-related medical spending (non-pharmacy) decreased among participants, but it increased among non-participants (mean: −US$264 vs + US$1536, p < 0.001). Total multiple sclerosis-related cost for both groups increased over time (+US$4471 vs +US$4087, p < 0.001).

Conclusions: This program was associated with improved medication adherence and persistence, reduced multiple sclerosis-related hospitalization, and decreased multiple sclerosis-related medical costs. Unfortunately, the cost savings in the medical component did not offset the increased pharmacy expenditures during the 12-month follow-up period.

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.

Effectiveness of an online fatigue self-management programme for people with chronic neurological conditions: a randomized controlled trial

OBJECTIVE

To evaluate an online fatigue self-management programme in a sample of adults with chronic neurological conditions.

DESIGN

Randomized controlled trial.

SETTING

Online fatigue self-management programme delivered across Australia.

PARTICIPANTS

Ninety-five people with fatigue secondary to multiple sclerosis, Parkinson's disease or post-polio syndrome.

INTERVENTIONS

An online fatigue self-management programme, an information-only fatigue self-management programme and a control group.

MAIN MEASURES

Groups were compared at pre test, post test and at three months on primary outcomes using the Fatigue Impact Scale, Activity Card Sort and Personal Wellbeing Index.

RESULTS

With the exception of the Personal Wellbeing Index at post test (F = 3.519; P =0.034) and the Physical Subscale of the Fatigue Impact Scale at follow-up (F = 3.473; P =0.035) there were no significant differences between the three groups on primary outcomes. Post-hoc testing showed the differences to be between the information-only and control groups (P = 0.036 and P = 0.030 respectively). Improvement in the information-only group was unexpected but appears to be similar to results of other online interventions. The fatigue self-management and information-only groups performed better than the control on some secondary outcome measures. Low power in the analysis may have contributed to the findings. Repeated-measures ANCOVA showed that the fatigue self-management and the information-only groups improved over time on the Fatigue Impact Scale and the Activity Card Sort (P<0.05). The control group showed no improvements over time.

CONCLUSIONS

Although the fatigue self-management group improved over time, results did not demonstrate additional benefit in most outcome measures when compared with the control group.

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.