Multiple Sclerosis Journal - October 2017 - 1542

709361
research-article2017

MSJ0010.1177/1352458517709361Multiple Sclerosis JournalLE van den Akker, H Beckerman

MULTIPLE
SCLEROSIS
JOURNAL

MSJ

Original Research Paper

Cognitive behavioral therapy positively affects
fatigue in patients with multiple sclerosis:
Results of a randomized controlled trial

Multiple Sclerosis Journal
2017, Vol. 23(11) 1542-1553
DOI: 10.1177/
https://doi.org/10.1177/1352458517709361
1352458517709361
https://doi.org/10.1177/1352458517709361
© The Author(s), 2017.
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Lizanne E van den Akker, Heleen Beckerman, Emma H Collette, Jos WR Twisk, Gijs Bleijenberg,
Joost Dekker, Hans Knoop and Vincent de Groot; TREFAMS-ACE Study Group

Abstract
Background: Fatigue is a common symptom in multiple sclerosis (MS) and often restricts societal participation. Cognitive behavioral therapy (CBT) may alleviate MS-related fatigue, but evidence in literature is inconclusive.
Objective: To evaluate the effectiveness of CBT to improve MS-related fatigue and participation.
Methods: In a multi-center, assessor-masked, randomized controlled trial, participants with severe MSrelated fatigue were assigned to CBT or control treatment. CBT consisted of 12 individual sessions with a
psychologist trained in CBT, the control treatment consisted of three consultations with a MS nurse, both
delivered over 16 weeks. Assessments were at baseline, 8, 16 (i.e. post-intervention), 26, and 52 weeks
post-baseline. Primary outcomes were the Checklist Individual Strength-fatigue subscale (CIS20r fatigue)
and the Impact on Participation and Autonomy questionnaire (IPA). Data were analyzed according to the
intention-to-treat principle, using mixed-model analysis.
Results: Between 2011 and 2014, 91 patients were randomized (CBT: n = 44; control: n = 47). Betweengroup analysis showed a positive post-intervention effect for CBT on CIS20r fatigue (T16: −6.7 (95%
confidence interval (CI) = −10.7; −2.7) points) that diminished during follow-up (T52: 0.5 (95% CI = −3.6;
4.4)). No clinically relevant effects were found on societal participation.
Conclusion: Severe MS-related fatigue can be reduced effectively with CBT in the short term. More
research is needed on how to maintain this effect over the long term.
Keywords: Multiple sclerosis, fatigue, cognitive behavior therapy, randomized controlled trial, MS
nurse, participation, rehabilitation medicine
Date received: 13 November 2016; revised: 25 March 2017; accepted: 14 April 2017

Introduction
Patients with multiple sclerosis (MS) frequently
report fatigue as one of their most troublesome
symptoms.1-3 It negatively affects societal participation and health-related quality of life,4,5 but remains
poorly understood.2 Current approaches to decrease
MS-related fatigue include pharmacological and
non-pharmacological treatments or a combination of
these approaches.
A recent review concluded that non-pharmacological
interventions (both exercise and psychological/educational interventions) appear to reduce fatigue more than
commonly prescribed pharmacological treatments.6,7

1542

Furthermore, it appears that psychological interventions can be a clinically feasible and cost-effective
treatment for MS-related fatigue.7 To provide a starting
point for the treatment of MS-related fatigue, Van
Kessel and Moss-Morris8 developed a cognitive behavioral model to explain the persistence of MS-related
fatigue. This model encompasses both disease-related
factors and psychological factors identified in the literature. According to this model, disease-related factors trigger fatigue in MS, and cognitive, emotional,
and behavioral factors then determine the extent to
which fatigue influences daily life.8 In addition, this
theoretical model suggests that the combination of
these factors may perpetuate or worsen MS-related

Correspondence to:
LE van den Akker
Department of Rehabilitation
Medicine, MS Center
Amsterdam, VU University
Medical Center, PO Box
7057, 1007 MB Amsterdam,
The Netherlands.
l.vandenakker@vumc.nl
Lizanne E van den Akker
Heleen Beckerman
Vincent de Groot
Department of Rehabilitation
Medicine, MS Center
Amsterdam, VU University
Medical Center, Amsterdam,
The Netherlands/EMGO
Institute for Health and Care
Research, VU University
Medical Center, Amsterdam,
The Netherlands
Emma H Collette
Department of Rehabilitation
Medicine, MS Center
Amsterdam, VU University
Medical Center, Amsterdam,
The Netherlands/Department
of Medical Psychology, VU
University Medical Center,
Amsterdam, The Netherlands
Jos W R Twisk
Department of Epidemiology
and Biostatistics, VU
University Medical Center,
Amsterdam, The Netherlands
Gijs Bleijenberg
Expert Centre for Chronic
Fatigue, Radboud University
Nijmegen Medical Centre,
Nijmegen, The Netherlands
Joost Dekker
Department of Rehabilitation
Medicine, MS Center
Amsterdam, VU University
Medical Center, Amsterdam,
The Netherlands/Department
of Psychiatry, VU University
Medical Center, Amsterdam,
The Netherlands
Hans Knoop
Expert Centre for Chronic
Fatigue, Radboud University
Nijmegen Medical Centre,
Nijmegen, The Netherlands/
Department of Medical
Psychology, Academic
Medical Centre (AMC),
University of Amsterdam,
Amsterdam, The Netherlands

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