Fatigue Profiles in Patients with Multiple Sclerosis are Based on Severity of Fatigue and not on Dimensions of Fatigue

Fatigue related to Multiple Sclerosis (MS) is considered a multidimensional symptom, manifesting in several dimensions such as physical, cognitive, and psychosocial fatigue. This study investigated in 264 patients with severe primary MS-related fatigue (median MS duration 6.8 years, mean age 48.1 years, 75% women) whether subgroups can be distinguished based on these dimensions. Subsequently, we tested whether MS-related

The presence of attentional and interpretation biases in patients with severe MS-related fatigue

Objective: Severe fatigue is a prevalent and disabling symptom in Multiple Sclerosis (MS). This study tested if a fatigue and physical activity-related attentional bias (AB), and a somatic interpretation bias (IB) is present in severely fatigued patients with MS, compared to healthy controls and patients with chronic fatigue syndrome (CFS/ME). Method: Severely fatigued patients with MS or CFS/ME and healthy controls completed a Visual Probe Task (VPT) assessing fatigue and physical activity-related AB, and an IB task that assesses the tendency to interpret ambiguous information in either a somatically threatening way or in a more neutral manner. The VPT was completed by 38 MS patients, 44 CFS/ME patients, and 46 healthy controls, the IB task by respectively 156, 40 and 46 participants. Results: ANOVA showed no statistical significant group differences in a fatigue-related AB or physical activity-related AB (omnibus test of interaction between topic*condition: F2,125 = 1.87; p = .159). Both patient groups showed a tendency to interpret ambiguous information in a somatically threatening way compared to healthy controls (F1,2 = 27.61, p &lt; .001). This IB was significantly stronger in MS patients compared to ME/CFS patients. IB was significantly correlated with cognitive responses to symptoms in MS patients. Conclusion: MS patients tend to interpret ambiguous information in a somatically threatening way. This may feed into unhelpful ways of dealing with symptoms, possibly contributing to perpetuation of severe fatigue in MS. Keywords: attentional bias, interpretation bias, fatigue, multiple sclerosis<br/

The effectiveness of aerobic training, cognitive behavioural therapy, and energy conservation management in treating MS-related fatigue: The design of the TREFAMS-ACE programme

Background: TREFAMS is an acronym for TReating FAtigue in Multiple Sclerosis, while ACE refers to the rehabilitation treatment methods under study, that is, Aerobic training, Cognitive behavioural therapy, and Energy conservation management. The TREFAMS-ACE research programme consists of four studies and has two main objectives: (1) to assess the effectiveness of three different rehabilitation treatment strategies in reducing fatigue and improving societal participation in patients with MS; and (2) to study the neurobiological mechanisms of action that underlie treatment effects and MS-related fatigue in general.Methods/Design: Ambulatory patients (n = 270) suffering from MS-related fatigue will be recruited to three single-blinded randomised clinical trials (RCTs). In each RCT, 90 patients will be randomly allocated to the trial-specific intervention or to a low-intensity intervention that is the same for all RCTs. This low-intensity intervention consists of three individual consultations with a specialised MS-nurse. The trial-specific interventions are Aerobic Training, Cognitive Behavioural Therapy, and Energy Conservation Management. These interventions consist of 12 individual therapist-supervised sessions with additional intervention-specific home exercises. The therapy period lasts 16 weeks. All RCTs have the same design and the same primary outcome measures: fatigue - measured with the Checklist Individual Strength, and participation - measured with the Impact on Participation and Autonomy questionnaire. Outcomes will be assessed 1 week prior to, and at 0, 8, 16, 26 and 52 weeks after randomisation. The assessors will be blinded to allocation. Pro- and anti-inflammatory cytokines in serum, salivary cortisol, physical fitness, physical activity, coping, self-efficacy, illness cognitions and other determinants will be longitudinally measured in order to study the neurobiological mechanisms of action.Discussion: The TREFAMS-ACE programme is unique in its aim to assess the effectiveness of three rehabilitation treatments. The programme will provide important insights regarding the most effective tre

Improving the Action Research Arm test: a unidimensional hierarchical scale

The Action Research Arm (ARA) test is a performance test of upper extremity motor function which consists of 19 items divided into four hierarchical subtests. This multidimensionality has not yet been tested empirically. To investigate the dimensionality of the ARA test. Cross-sectional study involving a sample of 63 chronic stroke patients. A Mokken scale analysis was performed. The Mokken scale analysis revealed one strong unidimensional scale containing all 19 items, of which the scalability coefficient H was 0.79, while H per item ranged from 0.69 to 0.86. The reliability coefficient rho equalled 0.98, indicating a very high internal consistency. A subset of 15 out of 19 items showed an invariant hierarchical item-ordering. The ARA test is a unidimensional scale. The use of subtests, as proposed in the original description of the instrument, is not supported by the present findings. The 15-item scale presented here can be used for adaptive testing, i.e. using only a selected subset of items based on prior knowledge about the patient's abilities, thus minimizing testing tim

Minimally important change determined by a visual method integrating an anchor-based and a distribution-based approach

Background: Minimally important changes (MIC) in scores help interpret results from health status instruments. Various distribution-based and anchor-based approaches have been proposed to assess MIC. Objectives: To describe and apply a visual method, called the anchor-based MIC distribution method, which integrates both approaches. Method: Using an anchor, patients are categorized as persons with an important improvement, an important deterioration, or without important change. For these three groups the distribution of the change scores on the health status instrument are depicted in a graph. We present two cut-off points for an MIC: the ROC cut-off point and the 95% limit cut-off point. Results: We illustrate our anchor-based MIC distribution method determining the MIC for the Pain Intensity Numerical Rating Scale in patients with low back pain, using two conceivable definitions of minimal important change on the anchor. The graph shows the distribution of the scores of the health status instrument for the relevant categories on the anchor, and also the consequences of choosing the ROC cut-off point or the 95% limit cut-off point. Discussion: The anchor-based MIC distribution method provides a general framework, applicable to all kind of anchors. This method forces researchers to choose and justify their choice of an appropriate anchor and to define minimal importance on that anchor. The MIC is not an invariable characteristic of a measurement instrument, but may depend, among other things, on the perspective from which minimal importance is considered and the baseline values on the measurement instrument under study. A balance needs to be struck between the practicality of a single MIC value and the validity of a range of MIC values. © 2006 Springer Science+Business Media B.V

Physical and Cognitive Functioning After 3 Years Can Be Predicted Using Information From the Diagnostic Process in Recently Diagnosed Multiple Sclerosis

Objective\ud To predict functioning after 3 years in patients with recently diagnosed multiple sclerosis (MS).\ud \ud Design\ud Inception cohort with 3 years of follow-up. At baseline, predictors were obtained from medical history taking, neurologic examination, and magnetic resonance imaging (MRI).\ud \ud Setting\ud Neurology outpatient clinic.\ud \ud Participants\ud Patients with MS (N=156); 146 with complete follow-up.\ud \ud Interventions\ud Not applicable.\ud \ud Main Outcome Measures\ud Inability to walk at least 500m, impaired dexterity, cognitive impairments, incontinence, inability to drive a car or use public transportation, social dysfunction, and reliance on a disability pension.\ud \ud Results\ud Clinical prediction rules were constructed for the models that were well calibrated (sufficient agreement between predicted and observed outcomes, based on visual inspection of calibration curves) and that showed sufficient discrimination (area under the receiver operation characteristic curve >.70) after internal bootstrap validation. The models for the inability to walk at least 500m, impaired dexterity, and cognitive impairments were well calibrated. Discrimination was sufficient for all 7 models, except the one predicting social dysfunction (.67). The inability to walk at least 500m was predicted by the perceived ability to walk, impairment of the cerebellar tract, and the number of MRI lesions in the spinal cord. Impaired dexterity was predicted by the perceived ability to use the hands, impairments of the pyramidal, cerebellar, and sensory tracts, and the T2-weighted infratentorial lesion load. Cognitive impairment was predicted by age, gender, the perceived ability to concentrate, and the T2-weighted supratentorial lesion load.\ud \ud Conclusions\ud Inability to walk at least 500m, impaired dexterity, and cognitive impairments can be predicted with predictors that are derived from medical history taking, neurologic examination, and MRI shortly after a definite diagnosis of MS has been made.\ud \u

The MoXFo initiative – study design: Considerations related to study design and methodology in exercise research for people with multiple sclerosis

Background: Exercise as a subset of physical activity is a cornerstone in the management of multiple sclerosis (MS) based on its pleiotropic effects, but continued progression of the field requires better future designs and methodologies. Objectives: This paper outlines the work of the ‘Study design and methodology’ group of the MoXFo (moving exercise research forward) initiative, and addresses critical aspects and future directions when defining the research question of interest, and subsequently, designing the study and exercise intervention in MS patients. Methods: The work is based on the formation of an international expert panel formed within the MoXFo initiative. We provide a structured and concise synthesis of exercise-specific MS research challenges and considerations when designing randomized controlled trials (RCTs). Results: Challenges and considerations are presented using the Patient population, Intervention, Comparator, Outcomes, Timing, Setting (PICOTS) framework, thereby forming a new and specific MS exercise PICOTS framework. Conclusion: We propose that researchers should carefully consider and align all elements of this MS exercise PICOTS framework when developing future research questions and study designs, ultimately improving the quality of new exercise studies in people with MS. </jats:sec

Measuring subluxation of the hemiplegic shoulder: Reliability of a method

Objective: Subluxation of the shoulder after stroke can be measured according to the method described by Van Langenberghe and Hogan. Methods: To evaluate the reliability of this method, the shoulder radiographs of 25 patients were available for this study. Two independent raters each assessed these radiographs twice. Results: The intrarater reliability was good: percentage of agreement was 88 and 84%, weighted κ, 0.69 [95% confidence interval (CI), 0.38-1 0] and 0.78 (95% CI, 0.60-0.95) for raters 1 and 2, respectively. The interrater reliability was poor: percentage of agree ment was 36 and 28%, κ, 0.11 (95% CI, 0.0-0.31) and 0.09 (95% CI, 0.0-0.23) in sessions 1 and 2, respectively. Subsequently the original method was adjusted by com bining two categories (no subluxation and beginning subluxation) into one (“no clin ically important subluxation”). Conclusions: After this adjustment of the categories, the interrater reliability improved [percentage of agreement, 72%, and κ, 0.49 (95% CI, 0.18-0.80)], but did not reach acceptable values

Minimal changes in health status questionnaires: distinction between minimally detectable change and minimally important change

Changes in scores on health status questionnaires are difficult to interpret. Several methods to determine minimally important changes (MICs) have been proposed which can broadly be divided in distribution-based and anchor-based methods. Comparisons of these methods have led to insight into essential differences between these approaches. Some authors have tried to come to a uniform measure for the MIC, such as 0.5 standard deviation and the value of one standard error of measurement (SEM). Others have emphasized the diversity of MIC values, depending on the type of anchor, the definition of minimal importance on the anchor, and characteristics of the disease under study. A closer look makes clear that some distribution-based methods have been merely focused on minimally detectable changes. For assessing minimally important changes, anchor-based methods are preferred, as they include a definition of what is minimally important. Acknowledging the distinction between minimally detectable and minimally important changes is useful, not only to avoid confusion among MIC methods, but also to gain information on two important benchmarks on the scale of a health status measurement instrument. Appreciating the distinction, it becomes possible to judge whether the minimally detectable change of a measurement instrument is sufficiently small to detect minimally important changes