Review article
Cognitive behavioral therapies and multiple sclerosis fatigue: A review of literature

https://doi.org/10.1016/j.jocn.2018.03.024Get rights and content

Highlights

  • Fatigue is a frequent and debilitating symptom in multiple sclerosis (MS)

  • Pharmacological therapies have modest efficacy and numerous side effects.

  • Fourteen studies employed cognitive behavioral therapies (CBT) in MS fatigue.

  • CBT seem to have positive effects on MS fatigue.

  • The onset and duration of CBT effects merit further assessment.

Abstract

Background

Patients with multiple sclerosis (MS) commonly suffer from fatigue, a multidimensional symptom with physical, cognitive and psychosocial components that can drastically alter the quality of life. Despite its debilitating nature, the current treatment options are limited by their modest efficacy and numerous side effects. Cognitive behavioral therapies (CBT) have been applied in MS patients and might be of help in relieving fatigue. This constitutes the main objective of the current review.

Methods

Computerized databases (Medline/PubMed, Scopus) were consulted till January 2018, and a research was conducted according to PRISMA guidelines in order to identify original research articles published at any time in English and French languages on cognitive behavioral therapies and MS fatigue as a primary outcome. The following key terms were used: (‘multiple sclerosis’ OR ‘MS’) AND (‘fatigue’) AND (‘cognitive behavioral therapy’ OR ‘CBT’ OR ‘cognitive therapy’ OR ‘CT’ OR ‘behavioral therapy’ OR ‘BT’ OR ‘psychotherapy’).

Results

Fourteen papers matched the above criteria (11 trials, 2 methods and 1 study addressing CBT mechanisms of action). CBT seems to have positive effects on MS fatigue. However, the onset and duration of effects varied across the studies.

Conclusion

These data highlight the promising effects of CBT in MS fatigue. Admitting the limited number of studies, more protocols are needed before drawing any conclusion. Future works might benefit from combining CBT with emerging therapies such as non-invasive brain stimulation techniques which also yielded promising results in the setting of MS. This may help in long-term maintenance of fatigue relief.

Introduction

Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system (CNS) that usually appears between 20 and 40 years of age. From a pathophysiological perspective, the disease is characterized by processes of demyelination and axonal loss. Depending on the location and extent of lesions, patients would experience various symptoms such as motor weakness, sensory deficit, impaired balance, and urinary disturbance, to cite a few. Recent years have seen a growing interest in studying the emotional and cognitive deficits in MS population. In fact, psychiatric comorbidities can affect up to 95% of MS patients at some point during their lifetime [1]. As for cognitive decline, it would occur in up to 65% of patients and may involve any cognitive domain such as working memory, information processing speed, attention, learning and executive function, but also social cognition which has recently gained more interest in MS [2], [3]. Another important debilitating symptom of this disease is fatigue which could affect up to 75–90% of MS patients [4], [5], [6]. No clear definition exists in the literature regarding this complaint which is usually perceived as a ‘lack of energy’, ‘lack of motivation’, ‘tiredness’, ‘exhaustion’ or ‘subjective lack of mental or cognitive energy’ [6]. Most importantly, fatigue can drastically impact patients’ quality of life (QoL) and may result in serious socio-economic difficulties, namely loss of employment [6]. Despite its debilitating nature, the available pharmacological interventions are limited by their modest efficacy and numerous side effects [4], [6]; and this constitutes a real challenge for health care providers in charge of this population. Facing this reality, there was a growing interest in the application of non-pharmacological interventions for the treatment of this symptom. Among these approaches, psychotherapies seem to be of great interest in this context. In particular, cognitive behavioral therapies (CBT), have been tried and could play a role in the management of MS fatigue.

The aim of the current work is to review the available literature on CBT in MS. First, an overview of the pathophysiology of MS fatigue will be provided. This will be followed by a brief definition of CBT along with the relevant studies performed in the context of MS fatigue. Finally, some recommendations will be given for future studies aiming to enhance their outcome in the management of this difficult-to-treat symptom. Pharmacological and other alternative interventions are discussed elsewhere and are beyond the scope of the present work [4], [5], [6], [7], [8].

Section snippets

Pathophysiology of fatigue in multiple sclerosis

Before dealing with the therapeutic options of MS fatigue, it is essential to understand the pathophysiology of this symptom. In recent works, fatigue has been suggested to arise from the underlying pathophysiological mechanisms of the disease itself. In other words, the immune dysregulation, which stands at the origin of MS, would result in demyelination, neurodegeneration and synaptopathy in several brain areas that take part in what was described as the ‘cortico-striato-thalamo-cortical

Study selection

A research was conducted independently by both coauthors according to PRISMA guidelines [14] in order to identify original research articles published till January 2018 in English and French languages about CBT in MS fatigue. Only studies that considered fatigue as the primary outcome were considered for this review. The following key terms were used: (‘multiple sclerosis’ OR ‘MS’) AND (‘fatigue’) AND (‘cognitive behavioral therapy’ OR ‘CBT’ OR ‘cognitive therapy’ OR ‘CT’ OR ‘behavioral

Conclusion

The aim of this review was to analyze the available data regarding CBT in MS fatigue. An inconsistency exists among the available literature regarding the adapted methods where they included patients with primary or secondary fatigue and applied CBT or CBT-components that varied in intensity (6–12 weekly sessions, each 25 to 120-min in duration) and were administered solely or combined with other interventions (i.e. energy effectiveness or phone call support). Interventions were delivered in an

Disclosure

This work did not receive any specific grant. MAC declares no conflict of interest. SSA declares having received travel grants or compensation from Genzyme, Biogen, Novartis and Roche.

References (34)

  • J.F. Sumowski et al.

    Cognition in multiple sclerosis: state of the field and priorities for the future

    Neurology

    (2018)
  • M.A. Chalah et al.

    Fatigue in multiple sclerosis: neural correlates and the role of non-invasive brain stimulation

    Front Cell Neurosci

    (2015)
  • S.S. Ayache et al.

    Multiple sclerosis fatigue, its neural correlates, and its modulation with tDCS

    Fortschr Neurol Psychiatr

    (2017)
  • M. Asano et al.

    A scoping review of rehabilitation interventions that reduce fatigue among adults with multiple sclerosis

    Disabil Rehabil

    (2015)
  • K. van Kessel et al.

    A randomized controlled trial of cognitive behavior therapy for multiple sclerosis fatigue

    Psychosom Med

    (2008)
  • D. Moher et al.

    Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement

    BMJ

    (2009)
  • D.C. Mohr et al.

    Reduction in disability in a randomized controlled trial of telephone-administered cognitive-behavioral therapy

    Health Psychol

    (2007)
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