Dettmers, Christian
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Motor Performance Fatigability in MS
This chapter focuses primarily on gait-related motor performance fatigability, which can be defined as a decrease in gait performance in response to sustained walking tasks. After the definition of terms, the clinician’s as well as the patient’s views on this topic are described. This is followed by a brief overview of linear and nonlinear gait analysis approaches and the derived fatigue indices currently applied to quantify gait-related motor performance fatigability. Furthermore, the effect of sustained motor and cognitive activity on performance fatigability measures as well as the relationship between motor performance fatigability and trait fatigue as well as trait self-control measures are briefly discussed. Finally, literature on pharmacological as well as non-pharmacological treatments for alleviating motor performance fatigability in people with Multiple Sclerosis is presented.
Fatigue und Fatigability bei Patienten mit Multipler Sklerose vor und nach kognitiver Belastung versus Entspannung – eine Pilotstudie
Fatigue, ein subjektives Gefühl extremer Erschöpfung, wird von Multiple Sklerose (MS)-Betroffenen als eines der belastendsten Symptome ihrer Krankheit beschrieben. Dennoch ist das Konstrukt der Fatigue noch nicht vollständig verstanden, was auch der uneindeutigen Unterscheidung subjektiver Empfindungen von Erschöpfung (Fatigue) und objektiv messbarer Leistungseinbußen (Fatigability) aufgrund von Anstrengung geschuldet ist. Die vorliegende Studie untersucht, inwiefern durch kognitive Belastung induzierte subjektive Erschöpfung mit objektiv messbaren Leistungseinbußen einhergeht. Zur Untersuchung dieser Fragestellung nahmen 24 MS-Betroffene jeweils an zwei experimentellen Sitzungen teil. In einer Sitzung fand eine 3-stündige kognitive Belastungsintervention und in der anderen Sitzung eine halbstündige Entspannungsintervention statt. Jeweils vor und nach der Intervention wurde das subjektive Befinden der Teilnehmenden mit Hilfe eines Fragebogens erfasst sowie die aktuelle Reaktionszeitleistung mittels der Alertness-Testung der Testbatterie zur Aufmerksamkeitsprüfung (TAP 2.3.1) gemessen. Die Reaktionszeitleistung verschlechterte sich nach der Belastungsintervention. Ebenso gaben die Teilnehmenden nach der Belastungsintervention eine signifikant schlechtere Befindlichkeit an. Die Entspannungsintervention führte zu keinen signifikanten Veränderungen in Befindlichkeit oder Leistungsfähigkeit. Obgleich sich auf Gruppenebene ein ähnliches Muster über alle Teilnehmenden hinweg bei subjektiver und objektiv gemessener Erschöpfung abzeichnete, korrelierten das Absinken der Befindlichkeit und die Verschlechterung der Reaktionszeitleistung nicht. Die Studienergebnisse deuten darauf hin, dass Fatigue als subjektives Empfinden und Fatigability als objektiv messbare Leistungsreduktion möglicherweise separate Aspekte darstellen. Es wird ein Arbeitsmodell diskutiert, welches die Trennung sowie die Operationalisierung vorgeschlagener Konstrukte unter Berücksichtigung von State- und Trait-Komponenten umfasst.
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 (β = 0.33) and detached/avoidant coping (Detached Protector; β = 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.
The relation between memory and decision-making in multiple sclerosis patients
Background.
Impairments in long-term and working memory are widespread in Multiple Sclerosis (MS), setting on in early disease stages. These memory impairments may limit patients’ ability to take informed and competent medical decisions, too. In healthy populations, memory abilities predict decision quality across a wide range of tasks. These studies suggest that higher working memory capacity supports decisions in cognitively taxing tasks, whereas better semantic memory facilitates decisions in tasks requiring knowledge retrieval. In individuals with MS, previous studies have linked less accurate decisions to memory deficits and reduced executive functioning, too. However, these studies focussed on decisions under risk and did not broadly assess decision making skills. We aimed to fill this gap in a cross-sectional study.
Methods.
Hundred thirty-seven participants with MS were recruited during their stay in an MS specialized rehabilitation centre. In a first test session, participants completed a standardized test battery for working memory and semantic memory, the inventory for memory diagnostics. In a second test session, participants filled out the Adult Decision Making Competence battery (A-DMC). This version of the A-DMC measured decision making competence on five subscales: Resistance to Framing Effects, Under/Overconfidence, Applying Decision Rules, Consistency in Risk Perception, and Resistance to Sunk Cost Effects. In addition, participants were screened for depression and cognitive fatigue.
Results.
Working memory was impaired in most participants, whereas semantic memory was not impaired. To understand which memory abilities underlie distinct components of decision making in people with MS, we used structural equation modelling. Replicating previous findings in a healthy sample, working memory capacity was associated with the ability to recall semantic knowledge. Participants with lower working memory capacity were less resistant to framing effects and adhered to decision rules less. In contrast, participants with worse semantic memory assessed their own knowledge less accurately, perceived risks less consistently, and made more errors in applying decision rules. Cognitive fatigue and depression unlikely explain these relationships. Conclusions.
Taken together, our study suggests that the memory problems, frequently reported in MS patients, may reach out to higher-order cognitive functions, such as decision making skills. Supporting shared decision-making and patient autonomy within MS thus requires to take memory impairments into account and to match the information provided to the patient’s memory abilities.
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.
Fatigue in Multiple Sclerosis Is Associated With Childhood Adversities
Fatigue is a common and disabling symptom in patients with Multiple Sclerosis (PwMS). Its pathogenesis, however, is still not fully understood. Potential psychological roots, in particular, have received little attention to date. The present study examined the association of childhood adversities, specific trait characteristics, and MS disease characteristics with fatigue symptoms utilizing path analysis. Five hundred and seventy-one PwMS participated in an online survey. Standardized psychometric tools were applied. The Childhood Trauma Questionnaire (CTQ) served to assess childhood adversities. Trait variables were alexithymia (Toronto Alexithymia Scale; TAS-26) and early maladaptive schemas (Young Schema Questionnaire; YSQ). Current pathology comprised depression (Beck’s Depression Inventory FastScreen; BDI-FS) and anxiety symptoms (State-Trait Anxiety Inventory; STAI-state), as well as physical disability (Patient determined Disease Steps; PDDS). The Fatigue Scale for Motor and Cognitive Functions (FSMC) was the primary outcome variable measuring fatigue. PwMS displayed high levels of fatigue and depression (mean FSMC score: 72; mean BDI-II score: 18). The final path model revealed that CTQ emotional neglect and emotional abuse remained as the only significant childhood adversity variables associated with fatigue. There were differential associations for the trait variables and current pathology: TAS-26, the YSQ domain impaired autonomy and performance, as well as all current pathology measures had direct effects on fatigue symptoms, accounting for 28.2% of the FSMC variance. Bayesian estimation also revealed indirect effects from the two CTQ subscales on FSMC. The final model fitted the data well, also after a cross-validation check and after replacing the FSMC with the Chalder Fatigue Questionnaire (CFQ). This study suggests an association psychological factors on fatigue in Multiple Sclerosis. Childhood adversities, as well as specific trait characteristics, seem to be associated with current pathology and fatigue symptoms. The article discusses potential implications and limitations.
The role of perceived energy and self-beliefs for physical activity and sports activity of patients with multiple sclerosis and chronic stroke
Physical activity counteracts some of the negative consequences associated with chronic neurological diseases. Here, we describe the levels of physical activity (PA) and sports activity (Sport) in patients with multiple sclerosis (pMS, n = 59) and chronic stroke (pStroke, n = 67) and test compliance with the recommendation for health-promoting physical activity of the World-Health Organization (WHO). Secondly, we tested for differences between the groups of patients, and thirdly, we examined relationships between PA and Sport with psychological indicators of perceived energy (fatigue and vitality) and self-beliefs (self-efficacy and self-control). Psychological constructs were assessed with validated measures from different disciplines in Psychology. A statistical aim was to describe interpretations gained by (non-) parametric Bayesian and Null- Hypothesis-Significance Testing statistics (NHST) on the example of the conducted tests for differences and relationships. Descriptive analyses revealed that pMS and pStroke complied with recommendations of the WHO, but with large variance indicating that patient groups are not homogenous. Tests for differences showed that the PA difference between pMS and pStroke can be attributed to the higher proportion of women in the pMS sample as they engage more in household chores (important part of PA). Tests for relationships showed that for pStroke, vitality, self-control, and self-efficacy were positively related to the level of sports activity. Furthermore, pStroke who were sport active had lower fatigue and higher self-control and self-efficacy scores than sport inactive people. Although they address slightly different questions, the Bayesian and the NHST approach led to similar general conclusions.
Fallvignetten aus der neurologischen Rehabilitation bei Patienten mit Post-COVID-Syndrom : Diskussionsvorschlag für die Leistungsdiagnostik
Folgeerkrankungen nach einer durchgemachten Infektion mit SARS-CoV-2 umfassen ein weites Spektrum hinsichtlich Organschädigung, Symptomatik, Dauer, Verlauf und vor allem Schwere der Erkrankung. Bei den Patienten, die lange auf einer Intensivstation beatmet wurden, wird man sehr genau nach Lungenschäden und anderen Organschäden einschließlich zerebraler, peripher neurogener und myogener Schäden suchen und klären, inwiefern die verbliebenen Defizite darauf zurückzuführen sind. Das andere Ende des Spektrums bilden Patienten, die im Rahmen des Primärinfekts nicht hospitalisiert waren, bei denen Fatigue, Muskel-, Glieder- oder Kopfschmerzen und anderes im Vordergrund stehen und deren Krankheitssymptome häufig im Verlauf eine undulierende Intensität zeigen. Bei Mitarbeitern im Gesundheitsbereich kann ein wäh- rend der Arbeit erworbener Primärinfekt zur Anerkennung als Berufskrankheit führen. In der Folgezeit auftretende Beschwerden werden vom Patienten und dann auch vom behandelnden Arzt häufig unter »Post-COVID« subsumiert, ohne dass ein ursächlicher Zusammenhang zu COVID-19 bewiesen ist. Aus dieser spezifischen und nicht repräsentativen Gruppe stellen wir einzelne Fallbeispiele dar. Wir waren überrascht, dass sich viele psychische, psychosomatische und psychiatrische Komorbiditäten fanden. Im zweiten Teil stellen wir unsere Diagnostik zur kognitiven, emotionalen und motorischen Fatigue und Fatigability dar. Insbesondere in dieser initial nicht hospitalisierten Patientengruppe bedarf es einer gründlichen somato-psychischen Differentialdiagnostik, um die Ursachen und das sozio-psychosomatische Bedingungsgefüge zu erfassen. Eine Iden- tifikation der unterschiedlichen Komponenten innerhalb des Post-COVID-Beschwerdekomplexes soll eine möglichst effiziente Therapie ermöglichen, um eine Reintegration in das soziale Leben in Alltag und Beruf anzubahnen.
Limb apraxia profiles in different clinical samples
Objective: Limb apraxia is a motor cognitive disorder that has been mainly studied in patients with dementia or left hemisphere stroke (LHS). However, limb apraxia has also been reported in patients with right hemisphere stroke (RHS), multiple sclerosis (MS) or traumatic brain injury (TBI). This study’s aim was to report detailed praxis performance profiles in samples suffering from these different neurological disorders by use of the Diagnostic Instrument for Limb Apraxia (DILA-S).
Method: 44 LHS patients, 36 RHS patients, 27 patients with dementia, 26MS and 44 TBI patients participated. The diagnostics included the imitation of meaningless and meaningful hand gestures, pantomime of tool-use, single real tool-use as well as a multistep naturalistic action task (preparing breakfast).
Results: Apraxia occurred in all tested samples but to a varying degree and with dissimilar profiles. LHS patients demonstrated most severe deficits in pantomime, but they were also vulnerable to deficits in real tool-use. Dementia patients showed high incidence rates of apraxia in almost all subscales of the DILA-S. RHS patients demonstrated difficulties in imitation and pantomime of tool-use, but they did not show severe difficulties with real tooluse. TBI patients appeared challenged by multistep naturalistic actions. The tested MS sample did not show clinically relevant symptoms in the DILA-S.
Conclusion: Different types of patients display varying limb apraxic symptoms detectable by the DILA-S. In these limb apraxia susceptible populations, testing should be warranted as standard.