Multiple Sclerosis Journal - October 2017 - 1549

LE van den Akker, H Beckerman et al.
Table 2. (Continued)
Baseline

RAP self-care (0-10)a
RAP occupational (0-14)a
RAP relationships (0-9)a

CBT
Control
CBT
Control
CBT
Control

T8

T16

T26

T52

Mean (SD)

n

Mean (SD)

n

Mean (SD)

n

Mean (SD)

n

Mean (SD)

n

10.1 (2.8)
9.4 (2.3)
7.3 (1.9)
6.9 (2.0)
5.0 (2.1)
4.2 (1.9)

42
45
42
44
44
45

9.3 (2.1)
9.8 (2.4)
6.4 (2.0)
7.4 (2.6)
4.0 (1.9)
3.7 (1.5)

41
42
40
42
41
42

9.8 (2.3)
9.3 (2.5)
6.7 (4.0)
6.7 (2.2)
3.7 (1.6)
3.5 (1.3)

39
41
41
41
41
42

10.3 (4.2)
9.9 (2.6)
6.4 (2.3)
7.2 (2.0)
3.7 (1.7)
3.5 (1.3)

38
38
38
35
40
37

10.3 (2.8)
10.4 (2.4)
7.2 (2.1)
7.1 (2.0)
4.2 (1.9)
3.7 (1.4)

39
38
38
39
37
39

CBT: cognitive behavioral therapy; CIS20r: Checklist Individual Strength; IPA: Impact on Participation and Autonomy; FSS: Fatigue Severity Scale; MFIS:
Modified Fatigue Impact Scale; SF: Short Form; RAP: Rehabilitation Activity Profile; SD: standard deviation.
aLower is better.

cessation. Summarizing the results, the study found
positive short-term effects of CBT on MS-related
fatigue compared to the MS nurse consultations.
The results regarding societal participation were not
as positive. Except for one positive and significant
result on IPA work and education at T26, we found no
significant effect of CBT compared to the MS nurse
control condition. The participants did not show substantial limitations on the IPA at baseline, which could
be interpreted as a ceiling effect; there was little room
for improvement. Furthermore, a note of caution
about the interpretation of the IPA is due here; it might
not be the most suitable tool to measure societal participation. However, the secondary participation
measures, SF36 and RAP, also failed to show significant between-group differences, with the exception of
SF36 physical role functioning at T8. This leads us to
conclude that CBT for MS-related fatigue did not
influence participation in this study.
Some strengths of this study need to be highlighted.
First of all, we had a follow-up period of 1 year. Only
three studies have provided long-term (8-12 months)
follow-up data.10,26,27 A second (methodological)
strength of the current study was that we excluded
patients with fatigue potentially caused by other factors (e.g. depression, primary sleep disorders). This
led to the inclusion of patients with primary
MS-related fatigue and the results can therefore be
generalized to any ambulant population with primary
MS-related fatigue. It should be noted that only 5% of
the patient population that was assessed for eligibility
was excluded because of high depression scores (see
flow chart), which indicates that the vast majority of
this source population suffers from pure primary
MS-related fatigue. A third strength of the current
study was that the therapy was only provided by
certified psychologists with CBT training. A fourth
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strength was that both interventions were delivered by
multiple independent therapists, which decreases the
risk of contamination between study groups and
increases the generalizability of the study results to
other clinical settings and therapists. Finally, this is
the first study in which CBT was tailored to the
patients' needs, that is, only modules were applied
that were relevant for the patient as shown by the
baseline assessment of perpetuating factors, whereas
previous CBT studies used a fixed treatment
protocol.28
Some limitations should be considered when interpreting the results. First, recruitment bias might have
occurred toward patients who were highly motivated
to start with CBT and who were willing to be treated
by a psychologist.29 The fast drop-out of five persons
in the MS nurse study group is likely related to patient
preferences and the disappointment about treatment
allocation. Furthermore, drop-out and treatment
adherence might be caused by attentional problems
and impaired working memory. However, the number
of drop-outs was still lower than the 20% that we
accounted for. Second, in this type of research, it is
hard to control for all non-specific treatment effects.
However, three MS nurse consultations was the maximum amount of sessions, since providing more sessions would be regarded as an intervention, rather
than a control condition. Finally, CBT is an expensive
and intensive treatment. However, even more expensive and intensive treatment with unknown effectiveness is provided for MS-related fatigue. Therefore,
searching for new methods to provide CBT, with the
use of for example e-health methods, might provide a
solution.
This study makes several noteworthy contributions
to the field of CBT treatment of MS-related fatigue.
The current results seem to be consistent with the
1549
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Table of Contents for the Digital Edition of Multiple Sclerosis Journal - October 2017
