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Nauta IM, van Dam M, Bertens D, Kessels RPC, Fasotti L, Uitdehaag BMJ, Speckens AEM, de Jong BA. Improved quality of life and psychological symptoms following mindfulness and cognitive rehabilitation in multiple sclerosis and their mediating role for cognition: a randomized controlled trial. J Neurol 2024:10.1007/s00415-024-12327-y. [PMID: 38653820 DOI: 10.1007/s00415-024-12327-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Multiple sclerosis (MS) frequently gives rise to depressive and anxiety symptoms, but these are often undertreated. This study investigated the effect of mindfulness-based cognitive therapy (MBCT) and cognitive rehabilitation therapy (CRT) on psychological outcomes and quality of life (QoL), and whether they mediate treatment effects on MS-related cognitive problems. METHODS This randomized controlled trial included MS patients with cognitive complaints (n = 99) and compared MBCT (n = 32) and CRT (n = 32) to enhanced treatment as usual (n = 35). Baseline, post-treatment and 6-months follow-up assessments included patient-reported outcome measures (PROMS) and cognitive outcomes (self-reported and neuropsychological assessment). PROMS concerned psychological symptoms, well-being, QoL, and daily life function. Linear mixed models indicated intervention effects on PROMS and mediation effects of PROMS on cognitive outcomes. RESULTS MBCT positively affected depressive symptoms (Cohen's d (d) = -0.46), fatigue (d = -0.39), brooding (d = -0.34), mindfulness skills (d = 0.49), and mental QoL (d = -0.73) at post-treatment. Effects on mindfulness skills remained significant 6 months later (d = 0.42). CRT positively affected depressive symptoms (d = -0.46), mindfulness skills (d = 0.37), and mental QoL (d = -0.45) at post-treatment, but not at 6-month follow-up. No effects on anxiety, well-being, self-compassion, physical QoL, and daily life function were found. Treatment effects on self-reported, but not objective, cognition were mediated by psychological symptoms and mindfulness skills. CONCLUSIONS MBCT and CRT reduced a wide array of psychological symptoms and improved mental QoL. These improvements seemed to impact self-reported cognitive problems after both treatments, whereas objective cognitive improvements after MBCT seemed independent of improvement in psychological symptoms. Future studies should investigate long-term sustainability of these beneficial effects. TRIAL REGISTRATION The trial was prospectively registered in the Dutch Trial registry on 31 May 2017 (NL6285; https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6459 ).
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Affiliation(s)
- Ilse M Nauta
- Department of Neurology, MS Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Maureen van Dam
- Department of Anatomy and Neurosciences, MS Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Location VUmc, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
- Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Wassenaarseweg 52, Leiden, The Netherlands.
| | - Dirk Bertens
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
- Klimmendaal Rehabilitation Center, Arnhem, The Netherlands
| | - Roy P C Kessels
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
- Klimmendaal Rehabilitation Center, Arnhem, The Netherlands
- Vincent Van Gogh Institute for Psychiatry, Venray, The Netherlands
- Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luciano Fasotti
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
- Klimmendaal Rehabilitation Center, Arnhem, The Netherlands
| | - Bernard M J Uitdehaag
- Department of Neurology, MS Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Anne E M Speckens
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Brigit A de Jong
- Department of Neurology, MS Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
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Turkowitch D, Donkers SJ, Costa SL, Vaduvathiriyan P, Williams J, Siengsukon C. Behavioral Interventions to Improve Sleep Outcomes in Individuals With Multiple Sclerosis: A Systematic Review. Int J MS Care 2024; 26:22-29. [PMID: 38213676 PMCID: PMC10779715 DOI: 10.7224/1537-2073.2022-110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
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.
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Affiliation(s)
- David Turkowitch
- From the Department of Physical Therapy, Rehabilitation Science, and Athletic Training (DT, CS) and AR Dykes Library (PV), University of Kansas Medical Center, Kansas City, KS, USA
| | - Sarah J. Donkers
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, SK, Canada (SJD)
| | - Silvana L. Costa
- Center for Neuropsychology and Neuroscience Research, Kessler Foundation, East Hanover, NJ, USA (SLC)
- Department of Physical Medicine and Rehabilitation, Rutgers–New Jersey Medical School, Newark, NJ, USA (SLC)
| | - Prasanna Vaduvathiriyan
- From the Department of Physical Therapy, Rehabilitation Science, and Athletic Training (DT, CS) and AR Dykes Library (PV), University of Kansas Medical Center, Kansas City, KS, USA
| | - Joy Williams
- Rehabilitation Services, Kaiser Permanente Sacramento, Sacramento, CA, USA (JW)
| | - Catherine Siengsukon
- From the Department of Physical Therapy, Rehabilitation Science, and Athletic Training (DT, CS) and AR Dykes Library (PV), University of Kansas Medical Center, Kansas City, KS, USA
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Valentine TR, Kuzu D, Kratz AL. Coping as a Moderator of Associations Between Symptoms and Functional and Affective Outcomes in the Daily Lives of Individuals With Multiple Sclerosis. Ann Behav Med 2023; 57:249-259. [PMID: 36591810 PMCID: PMC10074037 DOI: 10.1093/abm/kaac050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Pain and fatigue are highly prevalent in multiple sclerosis (MS) and are associated with adverse physical, social, and psychological outcomes. There is a critical need to identify modifiable factors that can reduce the impact of these symptoms on daily life. PURPOSE This study examined the moderating role of dispositional coping in the relationships between daily fluctuations (i.e., deviations from a person's usual level) in pain and fatigue and same-day functional/affective outcomes. METHODS Adults with MS (N = 102) completed a self-report measure of dispositional coping (Brief COPE), followed by 7 days of ecological momentary assessment of pain and fatigue and end-of-day diaries assessing same-day pain interference, fatigue impact, social participation, upper extremity and lower extremity functioning, depressive symptoms, and positive affect and well-being (PAWB). Multilevel models tested interactions between daily symptom fluctuations and dispositional coping (avoidant/approach) in predicting same-day outcomes. RESULTS Higher approach coping mitigated the same-day association between pain and pain interference, whereas higher avoidant coping augmented this association. Daily PAWB benefits were seen for those who reported high approach coping and low avoidant coping; effects were only observed on days of low pain (for approach coping) and low fatigue (for avoidant coping). Avoidant coping was associated with worse fatigue impact, social participation, lower extremity functioning, and depressive symptoms. CONCLUSIONS When faced with pain and fatigue, avoidant coping is associated with increased, and approach coping with decreased, functional/affective difficulties in the daily lives of individuals with MS. Altering coping strategy use may reduce the impact of pain and fatigue.
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Affiliation(s)
- Thomas R Valentine
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Duygu Kuzu
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Anna L Kratz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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Cognitive rehabilitation and mindfulness reduce cognitive complaints in multiple sclerosis (REMIND-MS): A randomized controlled trial. Mult Scler Relat Disord 2023; 71:104529. [PMID: 36736039 DOI: 10.1016/j.msard.2023.104529] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 01/04/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Cognitive problems, both complaints and objective impairments, are frequent and disabling in patients with multiple sclerosis (MS) and profoundly affect daily living. However, intervention studies that focus on cognitive problems that patients experience in their daily lives are limited. This study therefore aimed to investigate the effectiveness of cognitive rehabilitation therapy (CRT) and mindfulness-based cognitive therapy (MBCT) on patient-reported cognitive complaints in MS. METHODS In this randomized-controlled trial, MS patients with cognitive complaints completed questionnaires and underwent neuropsychological assessments at baseline, post-treatment and 6-month follow-up. Patient-reported cognitive complaints were primarily investigated. Secondary outcomes included personalized cognitive goals and objective cognitive function. CRT and MBCT were compared to enhanced treatment as usual (ETAU) using linear mixed models. RESULTS Patients were randomized into CRT (n = 37), MBCT (n = 36) or ETAU (n = 37), of whom 100 completed the study. Both CRT and MBCT positively affected patient-reported cognitive complaints compared to ETAU at post-treatment (p<.05), but not 6 months later. At 6-month follow-up, CRT had a positive effect on personalized cognitive goals (p=.028) and MBCT on processing speed (p=.027). Patients with less cognitive complaints at baseline benefited more from CRT on the Cognitive Failures Questionnaire (i.e. primary outcome measuring cognitive complaints) at post-treatment (p=.012-.040), and those with better processing speed at baseline benefited more from MBCT (p=.016). CONCLUSION Both CRT and MBCT alleviated cognitive complaints in MS patients immediately after treatment completion, but these benefits did not persist. In the long term, CRT showed benefits on personalized cognitive goals and MBCT on processing speed. These results thereby provide insight in the specific contributions of available cognitive treatments for MS patients.
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Online Mindfulness-Based Cognitive Therapy for People with Parkinson’s Disease and Their Caregivers: a Pilot Study. JOURNAL OF TECHNOLOGY IN BEHAVIORAL SCIENCE 2022; 7:381-395. [PMID: 35527798 PMCID: PMC9059916 DOI: 10.1007/s41347-022-00261-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/16/2022] [Accepted: 04/22/2022] [Indexed: 12/01/2022]
Abstract
Anxiety and depression are common non-motor symptoms of Parkinson’s disease (PD). Caregivers of people with PD may experience severe caregiver burden. This study explored the feasibility and potential benefits of an online mindfulness-based cognitive therapy (MBCT) intervention for improving anxiety and depressive symptoms in people with PD and their caregivers (ClinicalTrials.gov NCT04469049, 7/8/2020). People with PD or parkinsonism and anxiety and/or depressive symptoms and caregivers of people with PD participated in one of three online MBCT groups. Demographic variables, pre- and post-MBCT behavioral measures (GAD-7, PHQ-9, Five Facet Mindfulness Questionnaire — FFMQ-15, Caregiver Self-Assessment Questionnaire — CSAQ), and satisfaction surveys were collected. Descriptive statistics were used to summarize data. Pre- and post-MBCT behavioral scores were compared using mixed-effect models. Fifty-six potential participants were assessed for eligibility. Twenty-eight entered MBCT groups; all but one completed the intervention. The overall sample analyzed (22 people with PD, 4 caregivers) showed significant GAD-7 and PHQ-9 score reductions and FFMQ-15 total and observing and non-reactivity subscale score increases (all p’s < 0.05). Participants with PD and anxiety symptoms (n = 14) had a significant GAD-7 score reduction; those with PD and depressive symptoms (n = 12) had a significant PHQ-9 score reduction (both p’s < 0.05). Participants with PD also had a significant FFMQ-15 observing subscale score increase (p < 0.05). The caregiver sample was too small to be analyzed separately. Online MBCT is feasible (as measured by high attendance, completion rate, and participant satisfaction) and may be effective in improving anxiety and depressive symptoms in people with PD.
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Sadeghi-Bahmani D, Esmaeili L, Mokhtari F, Sadeghi L, Afsharzadeh M, Shaygannejad V, Mirmosayyeb O, Goldstein-Piekarski AN, Gross JJ. Effects of Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Stress Reduction (MBSR) on Symptoms and Emotional Competencies in Individuals with Multiple Sclerosis. Mult Scler Relat Disord 2022; 67:104029. [DOI: 10.1016/j.msard.2022.104029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/15/2022] [Accepted: 07/03/2022] [Indexed: 10/31/2022]
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Zarotti N, Eccles F, Broyd A, Longinotti C, Mobley A, Simpson J. Third wave cognitive behavioural therapies for people with multiple sclerosis: a scoping review. Disabil Rehabil 2022; 45:1720-1735. [PMID: 35514235 DOI: 10.1080/09638288.2022.2069292] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Multiple sclerosis (MS) is a chronic condition linked to a wide range of psychological difficulties. While traditional cognitive behavioural therapy has been studied extensively with people with MS, much less is known about more recent "third wave" approaches. METHODS A scoping review was carried out by performing a systematic search across MEDLINE Complete, PsycINFO, CINAHL, Academic Search Ultimate, and Cochrane Library up to January 2022. RESULTS From an initial return of 8306 citations, 35 studies were included, 20 of which were randomised controlled trials (RCTs). These showed that four third wave approaches have been investigated with people with MS to date: acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT). MBSR and MBCT may be helpful to address a range of psychological difficulties up to three months post-intervention. However, MS-specific adaptations may be required, and more evidence is needed on longer-term effectiveness. Limited evidence is also available for DBT and ACT, but additional research is warranted before any recommendation can be made. CONCLUSIONS As third wave approaches keep being refined, further more rigorous investigations are needed to implement them to the benefit of people with MS. Implications for RehabilitationMultiple sclerosis is linked to a wide range of psychological difficulties in adults.Little is currently known on third wave psychotherapies for people with MS.Mindfulness-based stress reduction and mindfulness-based cognitive therapy may be helpful to address a wide range of difficulties in MS.Specific adaptations may be needed to deliver suitable therapies to people with MS.Additional research is warranted to build on preliminary findings for DBT and ACT.
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Affiliation(s)
- Nicolò Zarotti
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Fiona Eccles
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Annabel Broyd
- University College London Hospitals NHS Trust, London, UK
| | | | - Amanda Mobley
- Worcestershire Health and Care NHS Trust, Worcester, UK
| | - Jane Simpson
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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Dornhoffer JR, Liu YF, Zhao EE, Rizk HG. Does Cognitive Dysfunction Correlate With Dizziness Severity in Meniére's Disease Patients. Otol Neurotol 2021; 42:e323-e331. [PMID: 33555758 DOI: 10.1097/mao.0000000000002958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Characterize the relationship between cognitive dysfunction and the dizziness severity in Meniére's disease (MD) patients. STUDY DESIGN Retrospective review. SETTING University-based tertiary medical center. PATIENTS Three hundred patients were evaluated for MD from 2015 to 2019. Excluding comorbid or alternative vestibular disorders, 29 patients with definite MD and available pre- and postintervention data were included for analysis. INTERVENTIONS A progressive protocol of salt restriction, diuretics, steroid and/or gentamycin injection, and endolymphatic sac decompression for those refractory to medical therapy. MAIN OUTCOME MEASURES Quality of life measured with the Dizziness Handicap Inventory (DHI) and cognitive function measured with the Cognitive Failures Questionnaire (CFQ). Pre- and posttreatment DHI and DHI subscale scores and change in these scores were correlated with pre- and posttreatment CFQ scores and change in CFQ with therapy. RESULTS Analysis showed a number of limited associations between improvement in DHI and improvement in CFQ. Total DHI scores failed to correlate scores or variation in scores with change in CFQ (p = 0.091 and p = 0.085, respectively). Improvement in the CFQ false-triggering domain was significantly associated with improvement in the DHI physical subscale (r = 0.491, p = 0.007) and was nonsignificantly associated with improvement in total DHI and DHI emotional subscale scores (r = 0.422, p = 0.016 and r = 0.399, p = 0.032). CONCLUSIONS The DHI correlates with several pre- and posttreatment measures of cognitive dysfunction (CFQ) in MD patients. However, change in DHI and CFQ with therapy correlate poorly. Overall, the commonly used DHI may fail to adequately assess cognitive dysfunction in MD patients possibly due to factors not directly implicated by measures of vestibular dysfunction, such as central nervous system or cognitive dysfunction; however, the specific physical and emotional subscales may offer helpful insight into cognitive dysfunction change/improvement with treatment.
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Affiliation(s)
- James R Dornhoffer
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Yuan F Liu
- Department of Otolaryngology - Head and Neck Surgery, Loma Linda University Health, Loma Linda, California
| | - Elise E Zhao
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Habib G Rizk
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
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Donisi V, Gajofatto A, Mazzi MA, Gobbin F, Busch IM, Ghellere A, Klonova A, Rudi D, Vitali F, Schena F, Del Piccolo L, Rimondini M. A Bio-Psycho-Social Co-created Intervention for Young Adults With Multiple Sclerosis (ESPRIMO): Rationale and Study Protocol for a Feasibility Study. Front Psychol 2021; 12:598726. [PMID: 33708157 PMCID: PMC7940381 DOI: 10.3389/fpsyg.2021.598726] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/18/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Multiple sclerosis (MS), the most common neurological disease that causes disability in youth, does not only affect physical functions but is also associated with cognitive impairment, fatigue, depression, and anxiety and can significantly impact health-related quality of life (HRQoL). Since MS is generally diagnosed at a young age-a period of great significance for personal, relational, and professional development-adaptation can become highly challenging. Therefore, enhancing the competence of young people to adaptively cope with these potential challenges is of utmost importance in order to promote their potentialities and talents. It has been shown that psychological interventions targeting MS patients can enhance resilience and HRQoL and that regular physical activity (PA) and social engagement can improve psychological well-being. However, literature on the development of global interventions based on the bio-psycho-social model of the disease is missing. Even less attention has been paid to interventions dedicated to young adults with MS (YawMS) and to the involvement of patients in the development of such programs. AIMS In collaboration with MS patients, this study aims to develop a bio-psycho-social intervention (ESPRIMO) for YawMS, aiming to improve their HRQoL and to explore its feasibility, acceptability, and effects. METHODS To tailor the intervention to the specific needs of YawMS, "patient engagement principles" will be adopted in the co-creation phase, performing a web survey and focus groups with patients and healthcare professionals. In the intervention phase, a pilot sample of 60 young adults with MS will be enrolled. The co-created intervention, composed of group sessions over a 12-week period, will cover psycho-social strategies and include physical activities. Adopting a longitudinal, pre-post evaluation design, self-report questionnaires measuring HRQoL and other bio-psycho-social features (e.g., resilience, well-being, mindfulness traits, self-efficacy, perceived social support, psychological symptoms, illness perception, committed action, fatigue, attitudes, subjective norms, perceived behavioral control, motivation, perception of autonomy support for PA, barriers and intentions to PA) will be administered, the quantity and quality of PA will be measured, and a questionnaire developed by the authors will be used to evaluate the feasibility and acceptability of the ESPRIMO intervention.
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Affiliation(s)
- Valeria Donisi
- Section of Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Alberto Gajofatto
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Maria Angela Mazzi
- Section of Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Francesca Gobbin
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Isolde Martina Busch
- Section of Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Annamaria Ghellere
- Section of Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Alina Klonova
- Section of Movement Sciences, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Latvian Academy of Sport Education, Riga, Latvia
| | - Doriana Rudi
- Section of Movement Sciences, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Francesca Vitali
- Section of Movement Sciences, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Federico Schena
- Section of Movement Sciences, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Lidia Del Piccolo
- Section of Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Michela Rimondini
- Section of Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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Cross-Sectional Analysis of Cognitive Dysfunction in Patients With Vestibular Disorders. Ear Hear 2020; 41:1020-1027. [DOI: 10.1097/aud.0000000000000825] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Russell RD, Black LJ, Pham NM, Begley A. The effectiveness of emotional wellness programs on mental health outcomes for adults with multiple sclerosis: a systematic review and meta-analysis. Mult Scler Relat Disord 2020; 44:102171. [PMID: 32554283 DOI: 10.1016/j.msard.2020.102171] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND People with multiple sclerosis (MS) have a greater prevalence of depression and anxiety than the general population. Emotional wellness programs (any psychological or psychosocial interventions that focus on awareness, acceptance, managing, or challenging thoughts and feelings) could be important for people with MS. However, there have been no reviews on the effectiveness of emotional wellness programs for people with MS. The objective of this review was to determine the effectiveness of emotional wellness programs on mental health outcomes for adults with MS. INCLUSION CRITERIA Randomised controlled trials (RCTs) and quasi-experimental trials evaluating emotional wellness programs for adults with any form of MS were included. Mental health outcomes included were depression, anxiety, quality of life, and stress. The comparator groups were waitlist controls, usual care, or another intervention. METHODS This review was registered with PROSPERO (registration number CRD42019131082) and conducted in accordance with PRISMA guidelines. CINAHL, Cochrane, MEDLINE, PsycInfo, Web of Science, ProQuest Dissertations and Theses, Cochrane register of Controlled Trials, and Google Scholar were searched for English- language publications. Titles and abstracts were initially screened, followed by a screen of full text articles. Studies were critically appraised for methodological quality using the JBI standardised critical appraisal checklists. Data were extracted on intervention details, study outcome measures, behaviour change techniques, and results. Random effects meta-analyses were performed for outcomes assessed in at least five studies, with results reported as the standardised mean difference (SMD). RESULTS This review comprised 25 RCTs and four quasi-experimental studies (n participants=2323); 21 were included in meta-analyses. Meta-analyses produced statistically significant results favouring the interventions (SMD (95% CI) for depression -0.55 (-0.87, -0.24); anxiety -0.42 (-0.70, -0.14); quality of life 0.28 (0.14, 0.43); and stress -1.00 (-1.58, -0.43)). The most commonly used behaviour change techniques were behaviour practice/rehearsal, social comparison, and social support. CONCLUSIONS This review provides evidence to support the effectiveness of emotional wellness programs for improving mental health outcomes in adults with MS. However, these findings should be interpreted with caution given the high degree of heterogeneity between the studies, and potential for biases in analysis due to missing data and/or incomplete reporting.
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Affiliation(s)
- R D Russell
- School of Public Health, Curtin University, Perth, Australia
| | - L J Black
- School of Public Health, Curtin University, Perth, Australia
| | - N M Pham
- School of Public Health, Curtin University, Perth, Australia; Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen, Vietnam
| | - A Begley
- School of Public Health, Curtin University, Perth, Australia.
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Zhao XR, Chen ZF, Kang CY, Liu RX, Bai JY, Cao YP, Cheng YQ, Xu XF, Zhang YL. Mindfulness-based cognitive therapy is associated with distinct resting-state neural patterns in patients with generalized anxiety disorder. Asia Pac Psychiatry 2019; 11:e12368. [PMID: 31353828 DOI: 10.1111/appy.12368] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 06/13/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Mindfulness-based cognitive therapy (MBCT) may be effective for generalized anxiety disorder (GAD); however, the neural mechanism is poorly understood. In this study, we examined the potential neural mechanisms through which MBCT may reduce anxiety in patients with mild-to-moderate GAD. METHODS Eight weekly group MBCT sessions (2 h each) were conducted with 32 GAD patients. Resting-state functional magnetic resonance imaging (fMRI) was used, along with clinical and mindfulness profiles. A regional homogeneity (ReHo) approach was applied, and resting-state functional connectivity in the default mode network (DMN) using the posterior cingulate cortex (PCC) seed was examined. RESULTS MBCT reduced the anxiety and increased the mindfulness abilities of patients. After MBCT, patients had reduced ReHo in broad regions of the limbic system, along with increased DMN functional connectivity in the anterior cingulate cortex (ACC) and bilateral insula. Overlapping regions of reduced ReHo and increased DMN functional connectivity were observed in the mid-cingulate cortex (MCC) and bilateral insula. The increased PCC-ACC and PCC-insula functional connectivity following MBCT were related to anxiety improvements, suggesting a potential therapeutic mechanism for mindfulness-based therapies. DISCUSSION Group MBCT treatment appears to have effectively reduced anxiety symptoms in patients with mild-to-moderate GAD. Activation and functional connectivity appeared significantly different across some limbic regions after MBCT treatment. The salience network showed reduced ReHo and increased connectivity to the PCC. The DMN functional connectivity of the MCC may indicate reduced anxiety and improved mindfulness in GAD patients.
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Affiliation(s)
- Xing-Rong Zhao
- Mental Health Institute, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China.,Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Zhuang-Fei Chen
- Medical Faculty, Kunming University of Science and Technology, Kunming, Yunnan, China
| | - Chuan-Yuan Kang
- Department of Clinical Psychology, East Hospital Affiliated to Tongji University, Shanghai, China
| | - Rui-Xiang Liu
- Department of Clinical Psychology, The Second People's Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Jun-Yun Bai
- Department of Geriatrics, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Yu-Ping Cao
- Mental Health Institute, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yu-Qi Cheng
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xiu-Feng Xu
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Ya-Lin Zhang
- Mental Health Institute, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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13
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Xia T, Hu H, Seritan AL, Eisendrath S. The Many Roads to Mindfulness: A Review of Nonmindfulness-Based Interventions that Increase Mindfulness. J Altern Complement Med 2019; 25:874-889. [PMID: 31241348 DOI: 10.1089/acm.2019.0137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives: Mindfulness-based interventions (MBIs) have become increasingly popular for treating various physical and mental disorders. An increase in mindfulness levels through the teaching of mindfulness meditation is the most well-studied mechanism of MBIs. Recent studies, however, suggest that an increase in mindfulness is also observed in physical or psychosocial interventions not explicitly labeled as MBIs, or what the authors call non-MBIs. The authors aimed to review what non-MBIs can increase mindfulness levels despite not explicitly teaching mindfulness meditation. Design: The authors conducted a literature search for studies that included a non-MBI study arm measuring pre- and postintervention mindfulness levels using one of the following eight validated self-reported mindfulness questionnaires: Five-Faceted Mindfulness Questionnaire, Mindful Awareness and Attention Scale, Freiburg Mindfulness Inventory, Toronto Mindfulness Scale, Philadelphia Mindfulness Scale, Kentucky Inventory of Mindfulness Skills, Child and Adolescent Mindfulness Measure, and Cognitive and Affective Mindfulness Scale-Revised. The authors identified 69 non-MBI study arms from 51 independent studies of the non-MBI itself or as active controls of an MBI under investigation. The authors documented or calculated, if not provided, effect sizes (ES) for changes in mindfulness levels following these interventions. Results: Among the 69 non-MBI arms, 36 showed no effect for change in mindfulness (ES <0.20), 3 were indeterminate (no ES available or unable to calculate), 13 had small effects (0.20 < ES <0.5), 13 had medium effects (0.50 < ES <0.80), 3 had large effects (0.80 < ES <1.3), and 1 had a very large effect (ES >1.3) for change in mindfulness. Conclusions: Analysis of the characteristics of non-MBIs with significant increases in mindfulness levels suggested some commonalities between MBIs and non-MBIs, shedding light on a spectrum of mindfulness-related interventions and the possibility that there are many roads to developing mindfulness.
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Affiliation(s)
- Tom Xia
- Department of Psychiatry and Behavioral Sciences, Keck School of Medicine of USC, Los Angeles, CA
| | - Hiroe Hu
- College of Osteopathic Medicine, Touro University California, Vallejo, CA.,Department of Social and Behavioral Sciences, University of California San Francisco School of Nursing, San Francisco, CA
| | - Andreea L Seritan
- Department of Psychiatry, University of California San Francisco, San Francisco, CA.,Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA
| | - Stuart Eisendrath
- Department of Psychiatry, University of California San Francisco, San Francisco, CA.,Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA
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14
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Manjaly ZM, Harrison NA, Critchley HD, Do CT, Stefanics G, Wenderoth N, Lutterotti A, Müller A, Stephan KE. Pathophysiological and cognitive mechanisms of fatigue in multiple sclerosis. J Neurol Neurosurg Psychiatry 2019; 90:642-651. [PMID: 30683707 PMCID: PMC6581095 DOI: 10.1136/jnnp-2018-320050] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 02/07/2023]
Abstract
Fatigue is one of the most common symptoms in multiple sclerosis (MS), with a major impact on patients' quality of life. Currently, treatment proceeds by trial and error with limited success, probably due to the presence of multiple different underlying mechanisms. Recent neuroscientific advances offer the potential to develop tools for differentiating these mechanisms in individual patients and ultimately provide a principled basis for treatment selection. However, development of these tools for differential diagnosis will require guidance by pathophysiological and cognitive theories that propose mechanisms which can be assessed in individual patients. This article provides an overview of contemporary pathophysiological theories of fatigue in MS and discusses how the mechanisms they propose may become measurable with emerging technologies and thus lay a foundation for future personalised treatments.
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Affiliation(s)
- Zina-Mary Manjaly
- Department of Neurology, Schulthess Clinic, Zürich, Switzerland .,Department of Health Sciences and Technology, ETH Zurich, Zürich, Switzerland
| | - Neil A Harrison
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Sussex Partnership NHS Foundation Trust, Brighton, UK
| | - Hugo D Critchley
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Sussex Partnership NHS Foundation Trust, Brighton, UK
| | - Cao Tri Do
- Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Gabor Stefanics
- Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland.,Laboratory for Social and Neural Systems Research (SNS), Department of Economics, University of Zurich, Zurich, Switzerland
| | - Nicole Wenderoth
- Department of Health Sciences and Technology, ETH Zurich, Zürich, Switzerland
| | - Andreas Lutterotti
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Alfred Müller
- Department of Neurology, Schulthess Clinic, Zürich, Switzerland
| | - Klaas Enno Stephan
- Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland.,Wellcome Centre for Human Neuroimaging, University College London, London, UK.,Max Planck Institute for Metabolism Research, Cologne, Germany
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15
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Senders A, Hanes D, Bourdette D, Carson K, Marshall LM, Shinto L. Impact of mindfulness-based stress reduction for people with multiple sclerosis at 8 weeks and 12 months: A randomized clinical trial. Mult Scler 2018; 25:1178-1188. [PMID: 29985095 DOI: 10.1177/1352458518786650] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Mindfulness training is often used as a therapeutic intervention to manage stress and enhance emotional well-being, yet trials for multiple sclerosis (MS) are limited and few have used an active control. OBJECTIVE Assess the feasibility of mindfulness-based stress reduction (MBSR) for people with MS and evaluate the efficacy of MBSR compared to an education control. METHODS We conducted a single-blind, randomized trial of MBSR versus education control among 62 adults with MS. Primary outcomes were measures of feasibility. Secondary outcomes included perceived stress, anxiety, depression, fatigue, pain, resilience, and the Paced Auditory Serial Addition Test, assessed at baseline, 8 weeks, and 12 months. Mean scores for secondary outcome measures were compared between groups at each time point and within groups across time by analyses of covariance or paired t-tests, respectively. RESULTS Successful recruitment and retention demonstrated feasibility. Improvements in several secondary outcomes were observed among both MBSR and control groups. However, differences between the groups were not statistically significant at either 8 weeks or 12 months. CONCLUSION Emotional well-being improved with both MBSR and education. Spontaneous improvement cannot be ruled out as an explanation for findings and additional studies that evaluate the impact of mindfulness training to improve emotional health are warranted.
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Affiliation(s)
- Angela Senders
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA/Department of Neurology, Oregon Health & Science University, Portland, OR, USA/OHSU-PSU School of Public Health, Portland, OR, USA
| | - Douglas Hanes
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Dennis Bourdette
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Kimberly Carson
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Lynn M Marshall
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA/OHSU-PSU School of Public Health, Portland, OR, USA
| | - Lynne Shinto
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
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16
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Chalah MA, Ayache SS. Cognitive behavioral therapies and multiple sclerosis fatigue: A review of literature. J Clin Neurosci 2018; 52:1-4. [DOI: 10.1016/j.jocn.2018.03.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 03/11/2018] [Indexed: 01/02/2023]
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17
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Willekens B, Perrotta G, Cras P, Cools N. Into the Moment: Does Mindfulness Affect Biological Pathways in Multiple Sclerosis? Front Behav Neurosci 2018; 12:103. [PMID: 29872382 PMCID: PMC5972188 DOI: 10.3389/fnbeh.2018.00103] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 04/30/2018] [Indexed: 01/01/2023] Open
Abstract
Mindfulness was introduced in the Western world by Jon Kabat-Zinn in 1979. He defined it as "awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally." Since then, research on mindfulness-based interventions (MBIs) has increased exponentially both in health and disease, including in patients with neurodegenerative diseases such as dementia and Parkinson's disease. Research on the effect of mindfulness and multiple sclerosis (MS) only recently gained interest. Several studies completed since 2010 provided evidence that mindfulness improves quality of life (QoL), depression and fatigue in MS patients. In addition to patient-reported outcome measures, potential effects on cognitive function have been investigated only to a very limited extent. However, research on laboratory biomarkers and neuroimaging, capable to deliver proof-of-concept of this behavioral treatment in MS, is mainly lacking. In this perspective, we illustrate possible neurobiological mechanisms, including the tripartite interaction between the brain, the immune system and neuroendocrine regulation, through which this treatment might affect multiple sclerosis symptoms. We propose to (1) include immunological and/or neuroimaging biomarkers as standard outcome measures in future research dedicated to mindfulness and MS to help explain the clinical improvements seen in fatigue and depression; (2) to investigate effects on enhancing cognitive reserve and cognitive function; and (3) to investigate the effects of mindfulness on the disease course in MS.
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Affiliation(s)
- Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Antwerp, Belgium.,Laboratory of Experimental Hematology, Faculty of Medicine and Health Sciences, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | | | - Patrick Cras
- Department of Neurology, Antwerp University Hospital, Antwerp, Belgium.,Department of Neurology, Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Neurology, Laboratory for Neurobiology, Born-Bunge Institute, University of Antwerp, Antwerp, Belgium
| | - Nathalie Cools
- Laboratory of Experimental Hematology, Faculty of Medicine and Health Sciences, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
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18
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Venasse M, Edwards T, Pilutti LA. Exploring Wellness Interventions in Progressive Multiple Sclerosis: an Evidence-Based Review. Curr Treat Options Neurol 2018; 20:13. [PMID: 29637453 DOI: 10.1007/s11940-018-0497-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW There has been recent interest in the role of lifestyle and wellness-based approaches in the treatment and management of multiple sclerosis (MS). These approaches may be particularly relevant for patients with progressive MS, considering limited therapeutic options currently available. The purpose of this review is to examine the role of wellness-based interventions including exercise training, emotional well-being therapies, and dietary modification in patients with progressive MS. RECENT FINDINGS We conducted a literature search on the efficacy of wellness-based interventions in patients with progressive MS published between 1985 and July 2017. The level of evidence for each trial was evaluated using the American Academy of Neurology criteria. Overall, 21 articles reporting on 16 wellness-based interventions were identified: ten trials involved exercise training, three involved emotional wellness therapies, two involved dietary modification, and one was a combined wellness intervention. There is level C evidence (possibly effective; one class II study) for the efficacy of aerobic exercise training on cardiorespiratory fitness in patients with progressive MS. There is level B evidence (probably effective; one class I study) for the efficacy of mindfulness training on psychological distress, depression, anxiety, pain, and quality of life in patients with progressive MS. There is inadequate evidence (level U) for efficacy of dietary modification (one class III study and one class IV study) and combined wellness interventions involving exercise training, meditation, and dietary modification (one class IV study). High-quality research is needed to provide evidence-based recommendations for wellness behaviors and lifestyle change in patients with progressive MS.
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Affiliation(s)
- Myriam Venasse
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Thomas Edwards
- School of Human Kinetics, University of Ottawa, Ottawa, Canada
| | - Lara A Pilutti
- Interdisciplinary School of Health Sciences, Brain and Mind Research Institute, University of Ottawa, 200 Lees Avenue, Ottawa, ON, K1N 6N5, Canada.
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19
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Hughes AJ, Dunn KM, Chaffee T. Sleep Disturbance and Cognitive Dysfunction in Multiple Sclerosis: a Systematic Review. Curr Neurol Neurosci Rep 2018; 18:2. [PMID: 29380072 DOI: 10.1007/s11910-018-0809-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW The present review summarizes recent research on the association between sleep disturbance and cognitive dysfunction in MS. Assessment methodology, domain-specific associations between sleep disturbance and cognitive dysfunction, and implications for future research and treatment are discussed. RECENT FINDINGS All 12 studies included in this review found significant associations between sleep disturbance and cognitive dysfunction; however, results varied considerably depending on the assessment method used and the cognitive domain assessed. Self-reported sleep disturbance generally predicted self-report but not objective measures of cognitive dysfunction. Objective sleep measures (e.g., polysomnography, actigraphy) generally predicted objective impairments in processing speed and attention; however, objective sleep disturbance was more variable in predicting performance in other cognitive domains (e.g., memory, executive function). Sleep disturbance may help predict future cognitive decline in MS. Results highlight the need to integrate sleep assessment into routine MS care. Interventions aimed treating sleep disturbance may offer promise for improving cognitive dysfunction in MS.
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Affiliation(s)
- Abbey J Hughes
- Department of Physical Medicine and Rehabilitation, Division for Rehabilitation Psychology and Neuropsychology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Katherine M Dunn
- Department of Physical Medicine and Rehabilitation, Division for Rehabilitation Psychology and Neuropsychology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Psychology, Loyola University Maryland, Baltimore, MD, USA
| | - Trisha Chaffee
- Department of Physical Medicine and Rehabilitation, Division for Rehabilitation Psychology and Neuropsychology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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