Miho Asano

Meta-analysis of three different types of fatigue management interventions for people with multiple sclerosis: exercise, education, and medication.

Fatigue is a common symptom of multiple sclerosis (MS) with negative impacts extending from general functioning to quality of life. Both the cause and consequences of MS fatigue are considered multidimensional and necessitate multidisciplinary treatment for successful symptom management. Clinical practice guidelines suggest medication and rehabilitation for managing fatigue. This review summarized available research literature about three types of fatigue management interventions (exercise, education, and medication) to provide comprehensive perspective on treatment options and facilitate a comparison of their effectiveness. We researched PubMed, Embase, and CINAHL (August 2013). Search terms included multiple sclerosis, fatigue, energy conservation, Amantadine, Modafinil, and randomized controlled trial. The search identified 230 citations. After the full-text review, 18 rehabilitation and 7 pharmacological trials targeting fatigue were selected. Rehabilitation interventions appeared to have stronger and more significant effects on reducing the impact or severity of patient-reported fatigue compared to medication. Pharmacological agents, including fatigue medication, are important but often do not enable people with MS to cope with their existing disabilities. MS fatigue affects various components of ones health and wellbeing. People with MS experiencing fatigue and their healthcare providers should consider a full spectrum of effective fatigue management interventions, from exercise to educational strategies in conjunction with medication.

Exercise barriers and preferences among women and men with multiple sclerosis

Purpose: The primary objective of this study was to estimate the extent to which women and men with MS present different exercise barriers. The secondary objective was to estimate the extent to which women and men with MS present different perceived-health, depressive symptoms, and current exercise routines or preferences. Methods: This was a cross sectional survey. Results: 417 people with MS completed a survey of exercise barriers and current exercise routines, perceived-health and depressive symptoms. The top three exercise barriers were: too tired; impairment; and lack of time, regardless of their gender. Regardless of their gender, three times/week and 60 min/session was identified as the most common current exercise structure among physically active participants. The top three currently preferred exercise by men included walking, strengthening/weights and flexibility/stretch exercise. Women reported the same three exercises but flexibility/stretch exercise were slightly more popular than other exercise. Similarities in perceived health status and depressive symptoms were seen between women and men; expect more men were diagnosed with progressive MS (20% higher) than women, leading to a higher rate of men reporting problems with mobility. Conclusion: Women and men with MS differed very little on exercise barriers and current exercise routines, perceived health and depressive symptoms. Even though MS is generally considered a woman’s disease, this study did not find a strong need to develop gender specific exercise or physical activity interventions for this population. Implications for Rehabilitation Exercise interventions need to be tailored to accommodate individuals’ needs and lifestyles in order to modify or eliminate common barriers – too tired, impairment, and lack of time. No strong evidence was found to support the need to develop gender specific exercise interventions, even though MS is generally considered a woman’s disease.

A scoping review of rehabilitation interventions that reduce fatigue among adults with multiple sclerosis

Abstract Objective: To identify and summarize available research literature about rehabilitation interventions for multiple sclerosis (MS) fatigue management. Methods: Database searches (PubMed, EMBASE, CINAHL and PsychINFO) were conducted in October 2011 and last updated in July 2013. To be included, studies must have been published in a peer-reviewed scientific journal, written in English and included an intervention to manage MS fatigue. Effect size (ES) were calculated for the quantitative studies to estimate intervention effects, and major themes were summarized for the qualitative studies. Results: Thirty-eight studies were included in this review. A variety of exercise and behavior change interventions were prescribed to adults with MS. The two most common interventions were progressive resistive training and fatigue management programs. Three exercise intervention studies and nine behavior change intervention studies with quantitative data presented significant ES. Four studies with qualitative data supported the positive impact of certain exercise and behavior change interventions. Conclusions: This review identified a variety of exercise and behavior change interventions for MS fatigue management. While the findings may provide helpful information to inform practice, future researchers need to develop and evaluate knowledge translation strategies to facilitate the application of this evidence to daily practice to advance MS rehabilitation care. Implications for Rehabilitation Both exercise and behavior change interventions demonstrate some degree of effectiveness for managing MS fatigue. Effect sizes for exercise and behavior change interventions are similar, although the populations examined are different. Overall, evidence for exercise focuses on people who are less disabled, while evidence for behavior change interventions includes a broader population. Future researchers need to develop and evaluate knowledge translation strategies that facilitate application of evidence in daily practice in order to advance MS rehabilitation.

A cross-sectional study examining multiple mobility device use and fall status among middle-aged and older adults with multiple sclerosis

Abstract Purpose: To document the prevalence of multiple mobility device use among adults with multiple sclerosis (MS) (≥55 years) and examine the association between falls status (faller/non-faller) and the number of mobility devices used. Methods: Cross-sectional data generated through telephone interviews with 353 participants was used for this secondary analysis. Descriptive statistics were used to address the first study purpose. Multiple device use was measured by the number of devices used, which ranged from 0 (never use a cane, walker, manual wheelchair, or power wheelchair/scooter) to 4 (use all four mobility devices at least some of the time). Logistic regression analysis was used to address the second purpose, with fall status used as the dependent variable (non-fallers [<1 per year] versus fallers [≥1 per year]). Results: Just under 60% of participants reported the use of at least two mobility devices. For each additional mobility device used, the odds of being a faller increased by 1.47 times (95% CI = 1.14–1.90). Conclusion: Multiple mobility device use was common and the greater number of devices used, the greater the likelihood of being a faller. To prevent falls, this association requires further research to determine directionality. Implications for Rehabilitation The high prevalence of multiple mobility device use points to the importance of asking about all devices a person uses, not just the primary one. Regression findings point to the need for comprehensive fall risk assessment and raise questions about whether different approaches to fall prevention intervention may be required for different clients. Including discussions and education about how to select the “right” device for different activities may be useful in the context of improving mobility status and reducing fall risk. Adequate practice with each device and “refreshers” when a device is not used to regularly may also be valuable.

People With Multiple Sclerosis Use Many Fall Prevention Strategies but Still Fall Frequently

OBJECTIVE To compare the use of fall prevention strategies by people with multiple sclerosis (MS) who do or do not fall. DESIGN Prospective cohort. All assessments were completed between January 2011 and December 2011. Data used in this analysis were collected as part of an observational study that included baseline assessment followed by prospective counting of falls using fall calendars. SETTING Veterans Affairs and university medical centers. PARTICIPANTS People with MS (N=58) of any subtype, aged 18 to 50 years, with Expanded Disability Status Scale score ≤ 6.0, recruited from MS clinics at the Portland VA Medical Center and Oregon Health and Science University and from the surrounding areas. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Measures included the occurrence of falls over 3 months and scores on the Fall Prevention Strategy Survey (FPSS) and the relations between fall prevention strategy use reported on the FPSS and falls. RESULTS A total of 52 subjects completed the study. Of these, 33 (63%) subjects fell at least once in the 3-month period, and 19 (36%) subjects did not fall. The mean total FPSS score for the fallers was significantly higher than the nonfallers (mean ± SD, 8.1 ± 6.4 vs 4.0 ± 4.1; range, 0-20 vs 0-15; P=.007), and FPSS scores correlated with monthly fall rates (ρ=.49, P=.01). A higher proportion of fallers than nonfallers used the strategies of turning on lights at home, asking others for help, and talking to a health care professional about fall prevention. However, both groups rarely talked to a health care professional about fall prevention or asked a provider to check whether any medications might increase fall risk. CONCLUSIONS People with MS who fall use more fall prevention strategies than those who do not fall.

Adherence in multiple sclerosis (ADAMS): Classification, relevance, and research needs. A meeting report

Background: Adherence to medical interventions is a global problem. With an increasing amount of partially effective but expensive drug treatments adherence is increasingly relevant in multiple sclerosis (MS). Perceived lack of efficacy and side effects as well as neuropsychiatric factors such as forgetfulness, fatigue and depression are major determinants. However, research on adherence to behavioural interventions as part of rehabilitative interventions has only rarely been studied. Methods: In a one-day meeting health researchers as well as patient representatives and other stakeholders discussed adherence issues in MS and developed a general draft research agenda within a focus group session. Results: The focus group addressed four major areas: (1) focussing patients and their informal team; (2) studying health care professionals; (3) comparing practice across cultures; and (4) studying new adherence interventions. Conclusions: A focus on patient preferences as well as a non-judgemental discussion on adherence issues with patients should be at the core of adherence work.

Rehabilitation interventions for the management of multiple sclerosis relapse: a short scoping review.

BACKGROUND This review was undertaken to identify and summarize the existing evidence regarding postrelapse rehabilitation interventions in people with multiple sclerosis (MS). METHODS Literature searches were conducted within the following databases: CINAHL Plus with Full Text, MEDLINE via Ovid, and PsycINFO via CSA Illumina. The following terms were searched as subject headings or keywords: choice behavior, counseling, decision making, disease management, health education, health promotion, patient education, patient participation, patient satisfaction, psychotherapy, rehabilitation, self-care, self-management. Then these searches were combined with the subject headings for relapsing-remitting multiple sclerosis and subject heading or keywords for recurrence/relapse. Through the initial database search and additional citation search, 260 potentially relevant citations were identified. After screening the titles and abstracts as well as the citation search results, the reviewers agreed to keep five studies for the full-text reviews. Three rehabilitation intervention studies were included in the final review. RESULTS A combined total of 145 adults who experienced a relapse within the previous 5 months received 3 to 18 days of rehabilitation. All three studies suggested the benefit of multidisciplinary rehabilitation for individuals with MS to improve impairment or disability. CONCLUSIONS The three multidisciplinary rehabilitation interventions included in this review appear to be effective in improving impairment or disability of people with MS who experienced a relapse. Given the limited number of studies and their methodological limitations, the results must be interpreted cautiously. Further investigation is needed to better understand the rehabilitation needs of people with MS after relapse in order to improve research and care.

When is a research question not a research question

BACKGROUND Research is undertaken to answer important questions yet often the question is poorly expressed and lacks information on the population, the exposure or intervention, the comparison, and the outcome. An optimal research question sets out what the investigator wants to know, not what the investigator might do, nor what the results of the study might ultimately contribute. OBJECTIVE The purpose of this paper is to estimate the extent to which rehabilitation scientists optimally define their research questions. METHODS A cross-sectional survey of the rehabilitation research articles published during 2008. Two raters independently rated each question according to pre-specified criteria; a third rater adjudicated all discrepant ratings. RESULTS The proportion of the 258 articles with a question formulated as methods or expected contribution and not as what knowledge was being sought was 65%; 30% of questions required reworking. The designs which most often had poorly formulated research questions were randomized trials, cross-sectional and measurement studies. CONCLUSION Formulating the research question is not purely a semantic concern. When the question is poorly formulated, the design, analysis, sample size calculations, and presentation of results may not be optimal. The gap between research and clinical practice could be bridged by a clear, complete, and informative research question.

Understanding and living with multiple sclerosis fatigue

Introduction Fatigue substantially affects the lives of many people with multiple sclerosis. This study aimed to further our understanding of the experience of living with multiple sclerosis fatigue by exploring how people became aware of and understood their multiple sclerosis fatigue and how they accommodate it in their daily lives. Method The study used an existential approach to thematic analysis. Thirteen in-depth, semi-structured interviews with people who experienced multiple sclerosis fatigue were conducted and analysed. Results Participants developed an understanding of multiple sclerosis fatigue through gaining awareness of its effect on their lives, seeking information themselves and being informed by health professionals. Participants described how they began to understand the effect of fatigue in their lives and make decisions about how to accommodate it. They discussed the challenges associated with helping others to understand their multiple sclerosis fatigue. Conclusion Lay and expert explanations, the phenomenological notions of lived experience, self-identity and embodiment and stigma associated with invisible disability were useful concepts for understanding the results. Clinicians should consider these concepts when supporting people with multiple sclerosis fatigue to understand the effect of fatigue in their daily lives and use fatigue management strategies to make effective lifestyle changes to accommodate it.

Goals Set After Completing a Teleconference-Delivered Program for Managing Multiple Sclerosis Fatigue

Setting goals can be a valuable skill to self-manage multiple sclerosis (MS) fatigue. A better understanding of the goals set by people with MS after completing a fatigue management program can assist health care professionals with tailoring interventions for clients. This study aimed to describe the focus of goals set by people with MS after a teleconference-delivered fatigue management program and to evaluate the extent to which participants were able to achieve their goals over time. In total, 485 goals were set by 81 participants. Over a follow-up period, 64 participants rated 284 goals regarding progress made toward goal achievement. Approximately 50% of the rated goals were considered achieved. The most common type of goal achieved was that of instrumental activities of daily living. Short-term goals were more likely to be achieved. This study highlights the need for and importance of promoting and teaching goal-setting skills to people with MS.