Multiple Sclerosis Journal - October 2017 - 1436
731159
editorial2017
MSJ0010.1177/1352458517731159Multiple Sclerosis JournalR Moss-Morris and S Norton
MULTIPLE
SCLEROSIS
JOURNAL
MSJ
Editorial
Aerobic exercise, cognitive behavioural therapy
and energy conservation management for
multiple sclerosis (MS) fatigue: Are three trials
better than one?
Multiple Sclerosis Journal
2017, Vol. 23(11) 1436-1440
DOI: 10.1177/
https://doi.org/10.1177/1352458517731159
1352458517731159
https://doi.org/10.1177/1352458517731159
© The Author(s), 2017.
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Rona Moss-Morris and Sam Norton
This edition of Multiple Sclerosis Journal includes
reports from three randomised controlled trials
(RCTs) of cognitive behaviour therapy,1 aerobic training2 and energy conservation3 management for the
treatment of MS fatigue. The three trials were led by
separate research teams as part of the Dutch
TREFAMS-ACE consortium.4 Each trial compared
one of the active treatments against a standardised
control condition of three 45-minute individual faceto-face consultations with experienced and trained
MS nurses over a 4-month period. The MS nurses
gave patients a standardised brochure about fatigue.
Patients had the opportunity to discuss their fatigue
and set goals for managing fatigue. In contrast, the
three active treatments (summarised in Table 1)
included 12 45-minute individual face-to face treatment sessions with a health professional over the
same time period. Participants in all three trials were
followed up over 12 months. The primary outcomes,
Checklist Individual Strengths (CIS20R)5 domain
fatigue and Impact on Participation and Autonomy
Questionnaire (IPA)6 were identical in all studies.
Secondary outcomes included the Modified Fatigue
Impact Scale7 and the Fatigue Severity Scale.8 Energy
conservation management (ECM) showed no significant improvements over the control condition on any
outcomes. The cognitive behavioural therapy (CBT)
and aerobic training RCTs reported positive effects on
the primary and secondary fatigue measures at the
end of treatment, but effects were lost at 52-week
follow-up. None of the trials found a positive effect
for the active interventions on IPA at any follow-up
point.
The three trials have addressed several limitations
prevalent in many RCTs of interventions for MS
fatigue conducted to date, particularly exercise interventions.9 Multiple therapists have been included in
each active arm making the results more generalisable.
1436
Attention has been paid to assessing treatment fidelity,
measuring treatment compliance and collecting serious
adverse events. This makes it easy to determine that the
active treatment interventions studied here are acceptable to patients and safe to administer, as reported
adherence rates were high and adverse events low
(none directly linked to the interventions themselves).
Further confirmation of acceptability can be inferred
from the reports of dropout during the intervention.
This varied across the interventions with 7 out of 43
(16%) for exercise, 2 out of 44 for CBT (5%) and 8 out
of 42 for EC (19%), suggesting that the CBT treatment
protocol may be the most acceptable intervention.
Risk of bias has been minimised through concealed
random allocation to treatment arms, assessors were
blind to treatment arm allocation and most patients
were followed up even where they had dropped out of
treatment. Furthermore, the studies provide good
examples of clear and transparent reporting. The studies were registered with ISRCTN and the protocol
published.4 The trials are written following CONSORT
guidelines10 and detailed descriptive data across all
time points are presented in the appendices. The treatments in each arm are clearly described using TIDieR
guidance for describing complex interventions.11
Correspondence to:
R Moss-Morris
Health Psychology Section,
Department of Psychology,
Institute of Psychiatry,
Psychology & Neuroscience,
King's College London, 5th
Floor Bermondsey Wing,
Guy's Hospital Campus,
London Bridge, London SE1
9RT, UK.
rona.moss-morris@kcl.
ac.uk
Rona Moss-Morris
Sam Norton
Health Psychology Section,
Department of Psychology,
Institute of Psychiatry,
Psychology & Neuroscience,
King's College London,
London, UK
Despite these strengths, these trials do have some
limitations. One is the trials are open to attrition
bias.12 The percentage of data lost to follow-up and
final analysis is summarised in Table 1. The CBT and
exercise RCTs lost substantially more participants
from the control group than the experimental group at
long-term follow-up. The ECM study excluded some
participants from the final intention to treat (ITT)
analysis. These weaknesses could have been partly
addressed by including a treatment effect sensitivity
analysis for attrition. In addition, to provide a clearer
picture of the subsample not included in the analysis,
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Table of Contents for the Digital Edition of Multiple Sclerosis Journal - October 2017
Contents
Multiple Sclerosis Journal - October 2017 - Cover1
Multiple Sclerosis Journal - October 2017 - Cover2
Multiple Sclerosis Journal - October 2017 - Contents
Multiple Sclerosis Journal - October 2017 - ii
Multiple Sclerosis Journal - October 2017 - iii
Multiple Sclerosis Journal - October 2017 - 1436
Multiple Sclerosis Journal - October 2017 - 1437
Multiple Sclerosis Journal - October 2017 - 1438
Multiple Sclerosis Journal - October 2017 - 1439
Multiple Sclerosis Journal - October 2017 - 1440
Multiple Sclerosis Journal - October 2017 - 1441
Multiple Sclerosis Journal - October 2017 - 1442
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Multiple Sclerosis Journal - October 2017 - 1446
Multiple Sclerosis Journal - October 2017 - 1447
Multiple Sclerosis Journal - October 2017 - 1448
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Multiple Sclerosis Journal - October 2017 - 1455
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Multiple Sclerosis Journal - October 2017 - 1457
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Multiple Sclerosis Journal - October 2017 - 1541
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Multiple Sclerosis Journal - October 2017 - Cover3
Multiple Sclerosis Journal - October 2017 - Cover4
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