Multiple Sclerosis Journal - October 2017 - 1525

M Heine, O Verschuren et al.
Despite the robust study design, this study shows some
limitations. First, it took 1 year longer than expected to
recruit the required 90 patients with MS with severe
fatigue. Fatigue has been previously identified as one
of the key barriers to engaging in physical activity for
patients with MS.27 This may have delayed the inclusion and raised concerns regarding the implementation
of (high-intensity) exercise as a means to improve
fatigue in patients with pre-existing severe levels of
fatigue. However, being an important barrier to engage
in physical activity, this also reduces the likelihood of
an increase in physical activity in patients allocated to
the control condition. Second, the actual training
response in terms of physical fitness was marginal yet
in line with previous work.9 Future research should elucidate the fundamental question as to the trainability of
persons with multiple sclerosis as well as whether the
magnitude of change in physical fitness mediates the
change in MS-related fatigue.
On the basis of this study and previous research, we
conclude that despite the small significant positive
post-intervention effect and the absence of associated
harm, aerobic training does not lead to clinically relevant improvements in MS-related fatigue and societal
participation. This conclusion does not imply that aerobic training should not be used in clinical practice.
Exercise therapy, and aerobic training in particular, has
proven efficacy in the treatment and prevention of
physical deconditioning, mobility problems, secondary
health risks and potentially in disease progression.6,9,10
Acknowledgements
This study has been performed on behalf of the Treating
Fatigue in Multiple Sclerosis: Aerobic Training,
Cognitive Behavioural Therapy, Energy Conservation
management (TREFAMS-ACE) Study Group: V de
Groot and H Beckerman (programme coordination), A
Malekzadeh, LE van den Akker, M Looijmans (until
September 2013), SA Sanches (until February 2012), J
Dekker, EH Collette, BW van Oosten, CE Teunissen,
MA Blankenstein, ICJM Eijssen, M Rietberg (VU
University Medical Center, Amsterdam); M Heine, O
Verschuren, G Kwakkel, JMA Visser-Meily, IGL van
de Port (until February 2012), E Lindeman (until
September 2012) (Center of Excellence for
Rehabilitation Medicine, University Medical Centre
Utrecht and Rehabilitation Centre, De Hoogstraat,
Utrecht); LJM Blikman, J van Meeteren, JBJ
Bussmann, HJ Stam, RQ Hintzen (Erasmus MC,
University Medical Center, Rotterdam); HGA Hacking,
EL Hoogervorst, STFM Frequin (St Antonius Hospital,
Nieuwegein); H Knoop, BA de Jong (until January
2014), G Bleijenberg (until April 2012) (University
Medical Center St Radboud, Nijmegen); FAJ de Laat
journals.sagepub.com/home/msj

(Libra Rehabilitation Medicine & Audiology -
location Leijpark, Tilburg); MC Verhulsdonck
(Rehabilitation
Center,
Sint
Maartenskliniek,
Nijmegen); EThL van Munster (Jeroen Bosch Hospital,
Den Bosch); CJ Oosterwijk, GJ Aarts (until March
2013) (Dutch patient organization, Multiple Sclerosis
Vereniging Nederland (MSVN), The Hague).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The TREFAMS-ACE study was
funded by the Fonds NutsOhra (ZonMw 89000005).
The funding organization had no role in the design
and conduct of the study; collection, management,
analysis and interpretation of data; preparation,
review or approval of the manuscript; and decision to
submit the manuscript for publication.

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Table of Contents for the Digital Edition of Multiple Sclerosis Journal - October 2017