Comparing two relaxation procedures to ease fatigue in multiple sclerosis: a single-blind randomized controlled trial.

BACKGROUND: Various relaxation procedures have been proposed to reduce fatigue in multiple sclerosis (MS). However, it is unknown, which type of relaxation has the largest effect on fatigue reduction and on autonomic nervous system (ANS) activity. OBJECTIVE: We aimed to compare two biofeedback-supported relaxation exercises: a deep breathing (DB) exercise and progressive muscle relaxation (PMR), which may ameliorate MS fatigue and alter ANS activity. METHODS: We performed a single-blind randomized clinical trial, introducing MS patients (n = 34) to the DB or PMR exercise. We first tested cardiovagal integrity, reflected by changes in heart rate variability (HRV) in response to DB. Participants then performed a fatigue-inducing vigilance task, followed by the DB or PMR. State fatigue was recorded consecutively at baseline, after the vigilance task, and after the relaxation exercise, along with HRV reflecting ANS activity. RESULTS: Only patients assigned to the PMR group experienced a significant drop in fatigue, whereas both relaxation exercises changed ANS activity. MS patients showed the expected autonomic response during the cardiovagal reflex test. The vigilance task elevated short-term feelings of fatigue and significantly reduced HRV parameters of parasympathetic activity. Trait fatigue was negatively correlated with HRV during the second half of the vigilance task. CONCLUSION: PMR alleviates short-term feelings of fatigue in persons with MS. The vigilance task in combination with HRV measurements may be helpful for evaluating relaxation procedures as a treatment of fatigue. Hereby, future studies should ensure longer and more frequent relaxation exercises and focus on patients with weak to moderate fatigue. TRIAL REGISTRATION: Trial Registry: DRKS00024358.

Experiences of persons with multiple sclerosis with rehabilitation-a qualitative interview study.

BACKGROUND: Managing multiple sclerosis (MS) includes different treatment approaches. Rehabilitation is a key strategy in MS for improving functioning, activity and participation. As part of a larger study on overall patient experiences with different treatment approaches, this study aims to give an overview of different patients' experiences and perspectives on inpatient rehabilitation in MS. METHODS: We conducted problem-centered interviews in 50 persons with MS in Germany, of whom most had relapsing-remitting MS. We used the maximum variation sampling method during recruitment. Data were analyzed thematically. RESULTS: As a result of the analysis, three major themes were identified: 1) factors contributing to the decision-making concerning rehabilitation, 2) experience with the rehabilitation setting, 3) benefits of rehabilitation treatments. The treating physicians' attitude had a major impact on the decision to either opt for rehabilitation or not. Setting goals prior to rehabilitation was given a high priority. Exchanging experiences with other persons with MS presented a major benefit from rehabilitation while for some being separated from regular daily life resulted in a more ambiguous attitude ranging from appreciation of escaping daily hassles to substantial behavioral change management. CONCLUSION: Patients reported various experiences in the process of decision-making with regard to rehabilitation. Physicians´ advice, goal setting and the selection of the most suitable rehabilitation clinic were considered most relevant.

Reaching higher: External scapula assistance can improve upper limb function in humans with irreversible scapula alata.

BACKGROUND: Scapular dyskinesis, i.e., the deviant mobility or function of the scapula, hampers upper limb function in daily life. A typical sign of scapular dyskinesis is a scapula alata-a protrusion of the shoulder blade during arm elevation. While some reversible causes of scapula alata can be treated with therapy, other, irreversible causes require invasive surgical interventions. When surgery is not an option, however, severe limitations arise as standard approaches for assisting the scapula in daily life do not exist. The aim of this study was to quantify functional improvements when external, i.e., non-invasive, scapula assistance is provided. METHODS: The study was designed as a randomized controlled crossover trial. Eight participants with a scapula alata due to muscular dystrophy performed arm elevations in shoulder flexion and abduction while unassisted (baseline), externally assisted by a trained therapist, and externally assisted by a novel, textile-based scapula orthosis. RESULTS: With therapist assistance, average arm elevation increased by 17.3° in flexion (p < 0.001, 95% confidence interval of the mean [Formula: see text]), and by 11.2° in abduction (p < 0.01, [Formula: see text]), constituting the potential of external scapula assistance. With orthosis assistance, average arm elevation increased by 6.2° in flexion ([Formula: see text]) and by 5.8° in abduction ([Formula: see text]). Remarkably, in three participants, the orthosis was at least as effective as the therapist. Moreover, orthosis assistance reduced average perceived exertion by 1.25 points (Borg Scale) when elevating a filled bottle during a simulated daily living task. CONCLUSION: These findings indicate a large potential for future advancements in orthotics. Already now, the textile-based scapula orthosis presented here is a feasible tool for leveraging the benefits of external scapula assistance when a therapist is unavailable, as encountered in daily life scenarios. Trial Registration ClincalTrials.gov (ID NCT04154098). Registered: November 6th 2019, https://clinicaltrials.gov/ct2/show/NCT04154098?term=scapula+orthosis&draw=2&rank=1.

Cortical, subcortical and spinal neural correlates of slackline training-induced balance performance improvements.

Humans develop posture and balance control during childhood. Interestingly, adults can also learn to master new complex balance tasks, but the underlying neural mechanisms are not fully understood yet. Here, we combined broad scale brain connectivity fMRI at rest and spinal excitability measurements during movement. Six weeks of slackline training improved the capability to walk on a slackline which was paralleled by functional connectivity changes in brain regions associated with posture and balance control and by task-specific changes of spinal excitability. Importantly, the performance of trainees was not better than control participants in a different, untrained balance task. In conclusion, slackline training induced large-scale neuroplasticity which solely transferred into highly task specific performance improvements.

Neural correlates of effort-dependent and effort-independent cognitive fatigue components in patients with multiple sclerosis.

BACKGROUND: Among patients with multiple sclerosis (MS), fatigue is the most commonly reported symptom. It can be subdivided into an effort-dependent (fatigability) and an effort-independent component (trait-fatigue). OBJECTIVE: The objective was to disentangle activity changes associated with effort-independent "trait-fatigue" from those associated with effort-dependent fatigability in MS patients. METHODS: This study employed behavioral measures and functional magnetic imaging to investigate neural changes in MS patients associated with fatigue. A total of 40 MS patients and 22 age-matched healthy controls performed in a fatigue-inducing N-back task. Effort-independent fatigue was assessed using the Fatigue Scale of Motor and Cognition (FSMC) questionnaire. RESULTS: Effort-independent fatigue was observed to be reflected by activity increases in fronto-striatal-subcortical networks primarily involved in the maintenance of homeostatic processes and in motor and cognitive control. Effort-dependent fatigue (fatigability) leads to activity decreases in attention-related cortical and subcortical networks. CONCLUSION: These results indicate that effort-independent (fatigue) and effort-dependent fatigue (fatigability) in MS patients have functionally related but fundamentally different neural correlates. Fatigue in MS as a general phenomenon is reflected by complex interactions of activity increases in control networks (effort-independent component) and activity reductions in executive networks (effort-dependent component) of brain areas.

Trait Self-Control Outperforms Trait Fatigue in Predicting MS Patients' Cortical and Perceptual Responses to an Exhaustive Task.

Patients with multiple sclerosis (PwMS) frequently suffer from fatigue, but this debilitating symptom is not yet fully understood. We propose that self-control can be conceptually and mechanistically linked to the fatigue concept and might help explain some of the diversity on how PwMS who suffer from fatigue deal with this symptom. To test this claim, we first assessed how cortical oxygenation and measures of motor and cognitive state fatigue change during a strenuous physical task, and then we tested the predictive validity of trait fatigue and trait self-control in explaining the observed changes. A sample of N = 51 PwMS first completed a test battery to collect trait measures of fatigue and self-control. PwMS then performed an isometric hand contraction task at 10% of their maximum voluntary contraction until exhaustion while we repeatedly assessed ratings of perceived cognitive and motor exertion. In addition, we continuously measured oxygenation of the prefrontal cortex (PFC) using functional near-infrared spectroscopy. Linear mixed-effect models revealed significant increases in perceived motor and cognitive exertion, as well as increases in PFC oxygenation. Hierarchical stepwise regression analyses showed that higher trait self-control predicted a less steep increase in PFC oxygenation and perceived cognitive exertion, while trait fatigue did not predict change in any dependent variable. These results provide preliminary evidence for the suggested link between self-control and fatigue. As self-control can be enhanced with training, this finding possibly has important implications for devising nonpharmacological interventions to help patients deal with symptoms of fatigue.

Motor Imagery Impairment in Postacute Stroke Patients.

Not much is known about how well stroke patients are able to perform motor imagery (MI) and which MI abilities are preserved after stroke. We therefore applied three different MI tasks (one mental chronometry task, one mental rotation task, and one EEG-based neurofeedback task) to a sample of postacute stroke patients (n = 20) and age-matched healthy controls (n = 20) for addressing the following questions: First, which of the MI tasks indicate impairment in stroke patients and are impairments restricted to the paretic side? Second, is there a relationship between MI impairment and sensory loss or paresis severity? And third, do the results of the different MI tasks converge? Significant differences between the stroke and control groups were found in all three MI tasks. However, only the mental chronometry task and EEG analysis revealed paresis side-specific effects. Moreover, sensitivity loss contributed to a performance drop in the mental rotation task. The findings indicate that although MI abilities may be impaired after stroke, most patients retain their ability for MI EEG-based neurofeedback. Interestingly, performance in the different MI measures did not strongly correlate, neither in stroke patients nor in healthy controls. We conclude that one MI measure is not sufficient to fully assess an individual's MI abilities.

Exergaming with additional postural demands improves balance and gait in patients with multiple sclerosis as much as conventional balance training and leads to high adherence to home-based balance training.

OBJECTIVE: To assess the effectiveness of and adherence to an exergame balance training program with additional postural demands in patients with multiple sclerosis (MS). DESIGN: Matched controlled trial, assessment of balance before and after different balance training programs, and adherence to home-based balance exercise in the 6 months after the training. SETTING: A neurorehabilitation facility and center for MS. PARTICIPANTS: Patients with balance problems (N=70) matched into 1 of the training groups according to age as well as balance and gait performance in 4 tests. Nine patients dropped out of the study because of scheduling problems. The mean age of the 61 remaining participants was 47±9 years, and their Expanded Disability Status Scale score was 3±1. INTERVENTIONS: Three weeks of (1) conventional balance training (control), (2) exergame training (playing exergames on an unstable platform), or (3) single-task (ST) exercises on the unstable platform. MAIN OUTCOME MEASURES: Test scores in balance tests and gait analyses under ST and dual-task (DT) situations. Furthermore, in the 6 months after the rehabilitation training, the frequency and type of balance training were assessed by using questionnaires. RESULTS: All 3 groups showed significantly improved balance and gait scores. Only the exergame training group showed significantly higher improvements in the DT condition of the gait test than in the ST condition. Adherence to home-based balance training differed significantly between groups (highest adherence in the exergame training group). CONCLUSIONS: Playing exergames on an unstable surface seems to be an effective way to improve balance and gait in patients with MS, especially in DT situations. The integration of exergames seems to have a positive effect on adherence and is thus potentially beneficial for the long-term effectiveness of rehabilitation programs.

Induction of cognitive fatigue in MS patients through cognitive and physical load.

The objective of the study was to investigate whether cognitive fatigue in patients with multiple sclerosis (MS) is a spontaneous phenomenon or whether it can be provoked or exacerbated through cognitive effort and motor exercise. Thirty two patients with definite MS and cognitive fatigue according to the Fatigue Scale for Motor and Cognitive Functions (FSMC ≥ 22) performed attention tests (alertness, selective, and divided attention subtests from the TAP test battery for attention performance) twice during rest (baseline), and before and after treadmill training and cognitive load (a standardised battery of neuropsychological tests lasting 2.5 hours). Subjective exhaustion was assessed with a 10-point rating scale. Tonic alertness turned out to be the most sensitive test and showed significantly increased reaction times after treadmill training and after cognitive load. Patients' subjective assessment of exhaustion (10-point rating scale) and the objective test results were discrepant. In contrast, healthy control subjects (N = 20) did not show any decline of performance in the subtest alertness after cognitive or physical load. Data favour the concept that fatigue is induced by physical and mental load. Discrepancies between subjective and objective assessment offer therapeutic options. The common notion of a purely "subjective" lack of physical and/or mental energy should be reconsidered.

Functional neurological symptoms are a frequent and relevant comorbidity in patients with multiple sclerosis.

Introduction: Functional neurological symptoms (FNS) in multiple sclerosis (MS) have shown to be underinvestigated even though neurological diseases such as MS represent a risk factor for developing FNS. Comorbidity of FNS and MS can produce high personal and social costs since FNS patients have high healthcare utilization costs and a quality of life at least as impaired as in patients with disorders with underlying structural pathology. This study aims to assess comorbid FNS in patients with MS (pwMS) and investigate whether FNS in pwMS are associated with poorer health-related quality of life and work ability. Methods: Newly admitted patients (234) with MS were studied during their stay at Kliniken Schmieder, a neurological rehabilitation clinic in Konstanz, Germany. The degree to which the overall clinical picture was explained by MS pathology was rated by neurologists and allied health practitioners on a five-point Likert scale. Additionally, neurologists rated each symptom reported by the patients. Health-related quality of life was assessed using a self-report questionnaire and work ability was assessed using the mean number of hours worked per day and information regarding disability pension as reported by patients. Results: In 55.1% of cases, the clinical picture was completely explained by structural pathology due to MS. 17.1% of pwMS presented an overall clinical picture half or less of which could be explained by underlying structural pathology. PwMS with a higher comorbid FNS burden had a lower health-related quality of life and reported fewer working hours per day than pwMS with symptoms explained by structural pathology. Furthermore, pwMS with a full disability pension had a higher comorbid FNS burden than pwMS with no or partial disability pension. Discussion: These results show that FNS should be addressed diagnostically and therapeutically since such symptoms are an important comorbidity in MS that is related to poorer health-related quality of life and lower work ability.

Association of blood lipids with onset and prognosis of amyotrophic lateral sclerosis: results from the ALS Swabia registry.

BACKGROUND: To date, the role of blood lipid levels and their association with the onset and prognosis of ALS is controversial. We explored these associations in a large, population-based case-control study. METHODS: Between October 2010 and June 2014, 336 ALS patients (mean age 65.7 ± 10.7; 57.7% male) and 487 sex- and age-matched controls from the same geographic region were recruited within the ALS registry in Southwest Germany. Triglycerides and cholesterol (high-density lipoprotein (HDL), low-density lipoprotein (LDL), total) were measured. The ALS cohort was followed up for vital status. Conditional logistic regression models were applied to calculate odds ratio (OR) for risk of ALS associated with serum lipid concentrations. In ALS patients only, survival models were used to appraise the prognostic value. RESULTS: High concentration of total cholesterol (OR 1.60, 95% confidence interval (CI) 1.03-2.49, top vs. bottom quartile), but not HDL, LDL, LDL-HDL ratio, or triglycerides, was positively associated with the risk of ALS. During the median follow-up time of 88.9 months, 291 deaths occurred among 336 ALS patients. In the adjusted survival analysis, higher HDL (HR 1.72, 95% CI 1.19-2.50) and LDL cholesterol levels (HR 1.58, 95% CI 1.11-2.26) were associated with higher mortality in ALS patients. In contrast, higher triglyceride levels were associated with lower mortality (HR 0.68, 95% CI 0.48-0.96). CONCLUSION: The results highlight the importance to distinguish cholesterol from triglycerides when considering the prognostic role of lipid metabolism in ALS. It further strengthens the rationale for a triglyceride-rich diet, while the negative impact of cholesterol must be further explored.

Observation and execution of upper-limb movements as a tool for rehabilitation of motor deficits in paretic stroke patients: protocol of a randomized clinical trial.

BACKGROUND: Evidence exist that motor observation activates the same cortical motor areas that are involved in the performance of the observed actions. The so called "mirror neuron system" has been proposed to be responsible for this phenomenon. We employ this neural system and its capability to re-enact stored motor representations as a tool for rehabilitating motor control. In our new neurorehabilitative schema (videotherapy) we combine observation of daily actions with concomitant physical training of the observed actions focusing on the upper limbs. Following a pilot study in chronic patients in an ambulatory setting, we currently designed a new multicenter clinical study dedicated to patients in the sub-acute state after stroke using a home-based self-induced training. Within our protocol we assess 1) the capability of action observation to elicit rehabilitational effects in the motor system, and 2) the capacity of this schema to be performed by patients without assistance from a physiotherapist. The results of this study would be of high health and economical relevance. METHODS/DESIGN: A controlled, randomized, multicenter, paralleled, 6 month follow-up study will be conducted on three groups of patients: one group will be given the experimental treatment whereas the other two will participate in control treatments. All patients will undergo their usual rehabilitative treatment beside participation in the study. The experimental condition consists in the observation and immediate imitation of common daily hand and arm actions. The two parallel control groups are a placebo group and a group receiving usual rehabilitation without any trial-related treatment. Trial randomization is provided via external data management. The primary efficacy endpoint is the improvement of the experimental group in a standardized motor function test (Wolf Motor Function Test) relative to control groups. Further assessments refer to subjective and qualitative rehabilitational scores. This study has been reviewed and approved by the ethics committee of Aachen University. DISCUSSION: This therapy provides an extension of therapeutic procedures for recovery after stroke and emphasizes the importance of action perception in neurorehabilitation The results of the study could become implemented into the wide physiotherapeutic practice, for example as an ad on and individualized therapy.

Action imagery combined with action observation activates more corticomotor regions than action observation alone.

BACKGROUND AND PURPOSE: Both action observation (AO) and action imagery have been proposed as therapeutic options for stroke rehabilitation. Currently, it is not clear to what extent their underlying neuronal mechanisms differ from each other and whether one of these therapeutic options might be preferable for this purpose. METHODS: Twenty-six neurologically healthy subjects were investigated using functional magnetic resonance imaging during AO alone and during AO with additional action imagery of video clips showing simple, object-related hand actions. RESULTS: The blood oxygenation level dependent (BOLD) signal induced by AO increased in a bihemispheric, symmetrical network of areas including the occipital, superior, and inferior parietal cortex, dorsal and ventral premotor regions, and the prefrontal cortex. The addition of imagery to the AO elicited additional activation in both cerebellar hemispheres, caudate nucleus, ventral and dorsal premotor cortex, inferior parietal cortex, and the supplementary motor area. DISCUSSION AND CONCLUSION: These data reveal more profound activations of the motor system during AO in conjunction with imagery than during AO alone. These results may have important implications for neurorehabilitation and motor learning.

Effects of a 6-Min Treadmill Walking Test on Dual-Task Gait Performance and Prefrontal Hemodynamics in People With Multiple Sclerosis.

Fatigue is one of the most limiting symptoms in people with multiple sclerosis (pwMS) and can be subdivided into trait and state fatigue. Activity-induced state fatigue describes the temporary decline in motor and/or cognitive performance (motor and cognitive performance fatigability, respectively) and/or the increase in the perception of fatigue (perceived fatigability) in response to motor or cognitive tasks. To the best of our knowledge, the effects of a 6-min walk test (6MWT), which was often used to assess motor performance fatigability in pwMS, on motor-cognitive dual-task performance (i.e., walking + arithmetic task) and prefrontal cortex (PFC) hemodynamics are not well-known. This is of importance, since daily activities are often performed as multitasks and a worse dual-task walking performance is associated with an increased risk of falling. Consequently, we investigated the effect of a fast 6MWT (comfort velocity + 15%) performed on a treadmill on motor-cognitive performance fatigability (spatio-temporal gait parameters/accuracy during the arithmetic task) and perceived fatigability measures (rating of perceived exhaustion; RPE) as well as PFC hemodynamics recorded during dual-task walking in pwMS and healthy controls (HCs). Twenty pwMS (48.3 ± 9.0 years; 13 females/7 males; expanded disability status scale 2.7 ± 1.0, first diagnosis 13.8 ± 8.8 years) and 24 HC with similar age and sex (48.6 ± 7.9 years; 17 females/7 males) were included. Only cognitive performance fatigability (increased error rate) during dual-task walking was found after the fast 6MWT on the treadmill in pwMS. However, the changes in gait parameters did not indicate motor performance fatigability, although both the groups reported perceived fatigability (increased RPE) after the fast 6MWT. Moreover, no change in the PFC activation was detected in both groups. Our results suggest that the intensity and/or duration of the fast 6MWT was not sufficient to induce motor performance fatigability in pwMS. These factors should be addressed by future studies on this topic, which should also consider further parameters, e.g., muscular oxygenation and/or myoelectrical activity, to verify that exercise intensity and/or duration was appropriate to induce motor performance fatigability in pwMS. Clinical Trial Register: DRKS00021057.

Prominent Fatigue but No Motor Fatigability in Non-Hospitalized Patients With Post-COVID-Syndrome.

Objectives: Fatigue is a frequent and often disabling symptom in patients with post-COVID syndrome. To better understand and evaluate the symptom of motor fatigue in the context of the post-COVID syndrome, we conducted treadmill walking tests to detect the phenomenon of motor fatigability or to evaluate whether evidence of organic lesions of the motor system could be found, similar to patients with multiple sclerosis. Method: Twenty-nine non-hospitalized patients with post-COVID syndrome completed the Fatigue Scale for Motor and Cognitive Function (FSMC) questionnaire to determine the trait component of subjective fatigue before they were tested on a treadmill walking at a moderate speed for up to 60 min or until exhaustion. During the walking test oxygen uptake, ventilation and acceleration data of both feet were collected. To determine motor performance fatigability, the Fatigue Index Kliniken Schmieder (FKS) was calculated using the attractor method. Results: The average walking duration was 42.7 ± 18.6 min with 15 subjects stopping the walking test prematurely. The FSMC score revealed a severe cognitive (37.6 ± 8.2) and motor (37.1 ± 7.8) fatigue averaged over all subjects but only two subjects showed an FKS above the normal range (>4), representing performance fatigability. There was no significant correlation between subjective fatigue (FSMC) and FKS as well as walking time. Absolute values of oxygen uptake and ventilation were in the normal range reported in literature (r = 0.9, p < 0.05), although eight subjects did not produce a steady-state behavior. Conclusion: Almost all patients with post-COVID syndrome and subjectively severe motor fatigue, did not show motor fatigability nor severe metabolic anomalies. This is argued against organic, permanent damage to the motor system, as is often seen in MS. Many of the patients were - to our and their own surprise - motorically more exertable than expected.

Instrumented Assessment of Motor Performance Fatigability During the 6-Min Walk Test in Mildly Affected People With Multiple Sclerosis.

There are conflicting results regarding the changes in spatio-temporal gait parameters during the 6-min walk test (6MWT) as indicators of gait-related motor performance fatigability (PF) in people with Multiple Sclerosis (pwMS). To further analyze if gait-related motor PF can be quantified using instrumented gait analysis during the 6MWT, we investigated: (i) whether gait parameters recorded during the first or second minute were more stable and thus the better baseline to assess motor PF and (ii) if the minimum toe clearance (MTC) together with "classical" spatio-temporal gait parameters can be used to quantify motor PF in pwMS. Nineteen mildly affected pwMS [12 women/7 men; 47.8 ± 9.0 years; the Expanded Disability Status Scale (EDSS): 2.7 ± 1.0] and 24 healthy controls (HC; 15 women/9 men; 48.8 ± 7.6 years) completed the 6MWT equipped with inertial measurement units. Data were analyzed using the attractor method to compare the stability of gait parameters and, besides "classical" spatio-temporal gait parameters, the MTC was calculated as a potential new marker for motor PF in pwMS as this was shown in healthy older adults. It was found that (i) gait parameters were more stable in the second than in the first minute and (ii) gait-related motor PF could not be detected based on spatio-temporal gait parameters, including the MTC. Descriptive analysis indicated a decrease in MTC variability, which is assumed to be indicative for motor PF, toward the end of the 6MWT in some pwMS. Future studies should investigate gait parameters for the assessment of motor PF in pwMS recorded during more intense and/or longer walking protocols, taking the level of disability into account. Furthermore, using gait parameters recorded in the first minute of the 6MWT as a baseline for the assessment of motor PF should be avoided.

Objective assessment of motor fatigue in Multiple Sclerosis using kinematic gait analysis: a pilot study.

BACKGROUND: Fatigue is a frequent and serious symptom in patients with Multiple Sclerosis (MS). However, to date there are only few methods for the objective assessment of fatigue. The aim of this study was to develop a method for the objective assessment of motor fatigue using kinematic gait analysis based on treadmill walking and an infrared-guided system. PATIENTS AND METHODS: Fourteen patients with clinically definite MS participated in this study. Fatigue was defined according to the Fatigue Scale for Motor and Cognition (FSMC). Patients underwent a physical exertion test involving walking at their pre-determined patient-specific preferred walking speed until they reached complete exhaustion. Gait was recorded using a video camera, a three line-scanning camera system with 11 infrared sensors. Step length, width and height, maximum circumduction with the right and left leg, maximum knee flexion angle of the right and left leg, and trunk sway were measured and compared using paired t-tests (α = 0.005). In addition, variability in these parameters during one-minute intervals was examined. The fatigue index was defined as the number of significant mean and SD changes from the beginning to the end of the exertion test relative to the total number of gait kinematic parameters. RESULTS: Clearly, for some patients the mean gait parameters were more affected than the variability of their movements while other patients had smaller differences in mean gait parameters with greater increases in variability. Finally, for other patients gait changes with physical exertion manifested both in changes in mean gait parameters and in altered variability. The variability and fatigue indices correlated significantly with the motoric but not with the cognitive dimension of the FSMC score (R = -0.602 and R = -0.592, respectively; P < 0.026). CONCLUSIONS: Changes in gait patterns following a physical exertion test in patients with MS suffering from motor fatigue can be measured objectively. These changes in gait patterns can be described using the motor fatigue index and represent an objective measure to assess motor fatigue in MS patients. The results of this study have important implications for the assessments and treatment evaluations of fatigue in MS.

Cognitive Fatigability, not Fatigue predicts employment status in patients with MS three months after rehabilitation.

BACKGROUND: Fatigue is potentially the most important factor causing unemployment in people with Multiple Sclerosis (PwMS). Widely accepted is a discrimination between fatigue as subjective sensation and fatigability as objective measure of change in performance. The aim of this study was to identify, whether cognitive fatigue or cognitive fatigability is a better predictor for employment status three months after discharge from a neurological rehabilitation center. METHODS: 64 PwMS (mean age 48.9, 43 females, mean time since diagnosis 14.7 years, median Expanded Disability Status Scale (EDSS) 3.8), complaining of fatigue and reporting difficulties with their working capacity, participated in a cognitive loading task during inpatient rehabilitation. Reaction time performance was measured using a standardized alertness test (TAP-M). Tonic alertness was measured at 8 a.m., 11 a.m. and 2 p.m. Patients worked on a standardized test battery during the morning and after lunch to induce fatigability. All of them completed the Fatigue Scale for Motor and Cognition (FSMC), a standardized questionnaire to rate the trait component of cognitive and motor fatigue. Their employment status was rated within a standardized interview by phone three months after discharge from the clinic. RESULTS: Mean cognitive fatigue according to the FSMC was 38.9 ± 7.4 and mean motor fatigue 41.0 ± 5.6, indicating severe cognitive and motor fatigue. 15 (88%) of 17 patients working fulltime had severe fatigue according to the FSMC. The cognitive subscale of the FSMC ("FSMC cognition") did not correlate (rs = -.084, p = .512) and the motor subscale of the FSMC ("FSMC motor") correlated rather weakly but not significantly (rs= -.220, p = .080) with the employment status. In contrast, there was a significant and medium correlation between alertness at 8 a.m. (alertness1) and employment status (rs = -.304, p = .014). Ordered logistic regression revealed that only alertness1 and the alertness difference between afternoon and noon (alertness difference32) predicted significantly the employment status. The FSMC motor and cognition subscales had no predictive value for employment. CONCLUSION: Cognitive fatigability (tonic alertness at 8 a.m. or increase of reaction time during the afternoon) is more adequate to predict employment status in PwMS three months after discharge from the clinic than the subjective sensation of fatigue as determined by the FSMC.

Association of Fatigue Severity With Maladaptive Coping in Multiple Sclerosis: A Data-Driven Psychodynamic Perspective.

Fatigue in persons with multiple sclerosis (PwMS) is severely disabling. However, the underlying mechanisms remain incompletely understood. Recent research suggests a link to early childhood adversities and psychological trait variables. In line with these studies, this paper took a psychodynamic perspective on MS-fatigue. It was hypothesized that fatigue could represent a manifestation of maladaptive coping with intense emotions. The schema therapeutic mode model served as a theoretical and empirically validated framework, linking psychodynamic theory and empirical research methods. The study was based on a data set of N = 571 PwMS that has also served as the basis for another publication. Data was collected online. The Schema Mode Inventory was used to quantify regulatory strategies to cope with emotionally stressful experiences. In addition, depressive symptoms (Beck's Depression Inventory - FastScreen), physical disability (Patient Determined Disease Steps), alexithymia (Toronto Alexithymia Scale-26), adverse childhood experiences (Childhood Trauma Questionnaire), and self-reported fatigue (Fatigue Scale for Motor and Cognitive Functions) were assessed. Latent profile analysis revealed three distinct groups of PwMS, based on their coping mode profiles: (1) PwMS with low maladaptive coping, (2) PwMS with avoidant/submissive coping styles, and (3) PwMS with avoidant/overcompensatory coping styles. Multivariate comparisons showed no significant difference in physical disability across the three groups. However, heightened levels of self-reported fatigue and depression symptoms occurred in PwMS with maladaptive coping styles. A path model uncovered that self-reported fatigue was robustly related to physical disability (ß = 0.33) and detached/avoidant coping (Detached Protector; ß = 0.34). There was no specific relation between any of the maladaptive coping modes and depression symptoms. Detached/avoidant coping was in turn predicted by childhood emotional abuse and neglect. The results indicate that childhood adversity and detached/avoidant coping styles may be associated with variability in MS-fatigue severity: PwMS that resort to detached/avoidant coping in response to negative emotions also tend to report heightened levels of fatigue, although they do not differ in their perceived disability from PwMS with low levels of fatigue and maladaptive coping. A link between MS-fatigue and the psychodynamic traumatic conversion model is discussed. The implications of these findings for therapeutic interventions require further study.