Fatigue in Multiple Sclerosis
Conditions
Keywords
Fatigue, MS, Multiple Sclerosis, Exercise, Physical activity, Physical training, Fingolimod
Brief summary
This study evaluated the effect of an individualized web-based physical training in fingolimod -treated patients.
Detailed description
In this study, it was planned to randomize 226 participants. However, only 178 participants were randomized during a timeframe of 2 years and 8 months. Therefore, the study was terminated due to slow enrollment and low participant compliance to the physical training schedule.
Interventions
OTHERPhysical exercise
Strength training exercises are performed against own body weight or with training aids like elastic rubber bands or gym balls. All exercises are home-based. To increase balance and core stability, a subset of exercises is performed on shaky ground and/or one-legged. Exercise intensity, duration and frequency are individually assigned by a sports therapist. For each muscle group, a set of exercises of increasing difficulty allows for individual and progressive training adaption. Therapists can choose from an exercise database of approximately 150 different strength exercises with different graduation.
Sponsors
Novartis Pharmaceuticals
Study design
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 65 Years
Healthy volunteers
No
Inclusion criteria
* Subjects with relapsing remitting MS defined by 2010 revised McDonald criteria * Patients with Expanded Disability Status Scale (EDSS) score of 0-3.5 (including) * Immunomodulatory treatment with prescribed fingolimod for at least one month prior to baseline * Fatigue score assessed by mFIS of equal or greater than 14 at screening * Neurologically stable with no evidence of relapse within 30 days prior to inclusion date
Exclusion criteria
* Patients who have been treated with: * systemic corticosteroids or immunoglobulins within 1 month prior to randomization; * immunosuppressive medications such as azathioprine, cyclophosphamide, or methotrexate within 3 months prior to randomization; * monoclonal antibodies (including natalizumab) within 3 months prior to randomization; * mitoxantrone within 6 months prior to randomization * cladribine at any time. * Patients with any medically unstable condition, as assessed by the primary treating physician at each site. * Patients with any of the following cardiovascular conditions : * history of cardiac arrest; * history of myocardial infarction or with current unstable ischemic heart disease; * history of angina pectoris due to coronary spasm or history of Raynaud syndrome * Heart failure (NYHA III-IV) or any severe cardiac disease as determined by the investigator; * history or presence of a second-degree AV block, Type II or a third-degree AV * block * patients receiving Class Ia (ajmaline, disopyramide, procainamide, quinidine) or * III antiarrhythmic drugs (e.g., amiodarone, bretylium, sotalol, ibulitide, azimilide, * dofelitide); * proven history of sick sinus syndrome or sino-atrial heart block; * uncontrolled hypertension * Clinically relevant internal disease (e.g. uncorrected anemia) or orthopedic diseases (e.g. scoliosis) that might interfere with physical training * Any severe disability or clinical impairment that can prevent the patient to meet all study requirements at the investigator's discretion Other protocol-defined inclusion/
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change From Baseline in Fatigue as Measured by the Modified Fatigue Impact Scale (mFIS ). | Baseline, 6 months | The mFIS provides an assessment of the effects of fatigue in terms of physical, cognitive, and psychosocial functioning. It is a 21-item, structured, self-report questionnaire that generally can be completed with little or no intervention from an interviewer. The mFIS score ranged from 0 (not tired) to 84 (tired). A negative change from baseline indicates improvement. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Change in Leg Strength and Trunk Strength | baseline, 6 months | Isometric and dynamic muscular strength was measured by an Isomed 2000 isometric measurement device (knee flexion/tension, trunk flexion/extension). Isomed 2000 device measures muscular flexion and tension under standardized training conditions. A positive change from baseline indicates improvement. |
| Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Leg Strength Endurance | baseline, 6 months | Isometric and dynamic muscular strength was measured by an Isomed 2000 isometric measurement device (knee flexion/tension, trunk flexion/extension). Isomed 2000 device measures muscular flexion and tension under standardized training conditions. A positive change from baseline indicates improvement. |
| Change From Baseline in Quality of Life as Measured by the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) | Baseline, 6 months, 12 months | The Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) consists of 44 items, 28 of which are the basis for computation of five subscale scores reflecting major dimensions of health-related quality of life (HRQoL) in MS: Fatigue/Thinking (4 items), Mobility lower limb (5 items), Mobility upper limb (5 items), Social function (6 items) and Mood (eight items). Subscales and total score range from 1 to 5, with high scores indicating a lower quality of life. In this study, the total score and following 3 subscales: fatigue/thinking, mobility lower limb and mobility upper limb only were analyzed. A negative change from baseline indicates improvement. |
| Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Sit-to-stand Test | baseline, 6 months | The Sit to Stand Test is a functional outcome measure of the lower-extremity muscle power. The test was performed 3 times with one minute rest in between. The best attempt out of three was used for the analysis. A positive change from baseline indicates improvement. |
| Change From Baseline in Depression as Measured by the Beck Depression Inventory Second Edition (BDI-II) | Baseline, 6 months | The Beck Depression Inventory Second Edition (BDI-II) is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression as listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. Each of the 21 items corresponding to a symptom of depression is summed to give a single score for the BDI-II. There is a four-point scale for each item ranging from 0 to 3. The total score ranges from 0 - 63. Total score of 0-13 is considered minimal range, 14-19 is mild, 20-28 is moderate, and 29-63 is severe. A negative change from baseline indicates improvement. |
| Change From Baseline in Aerobic Capacity (VO2max) as Measured by a Physical Endurance Spiroergometry on a Treadmill | Baseline, 6 months | Physical endurance spiroergometry was accomplished. Ergometry was assessed according to national guidelines of the German society for sports medicine. Ergometry is a combined examination of circulation and lung function and was performed as a submaximal or maximal test depending on the participant's individual performance. A negative change from baseline indicates improvement. |
| Change From Baseline in Peak Expiratory Flow as Measured by a Physical Endurance Spiroergometry on a Treadmill | Baseline, 6 months | Physical endurance spiroergometry was accomplished. Ergometry was assessed according to national guidelines of the German society for sports medicine. Ergometry is a combined examination of circulation and lung function and was performed as a submaximal or maximal test depending on the participant's individual performance. A positive change from baseline indicates improvement. |
| Change From Baseline in Fatigue as Measured by the WEIMuS (Würzburg Fatigue Inventory for MS) | Baseline, 6 months | The WEIMuS (Würzburg Fatigue Inventory for MS) scale is a validated self-assessment instrument to quantify the degree of fatigue. The scale consists of 17 items with 5 categories that are scored from '0' to '4'. The subscores for cognitive and physical fatigue range from 0 to 36 and from 0 to 32, respectively, with the total sum score ranging from 0 to 68; higher scores indicate higher degrees of fatigue. A negative change from baseline indicates improvement. |
Countries
Germany
Participant flow
Recruitment details
Participants were randomized1:1 to receive a structured physical intervention (e-training) or no physical intervention (waiting).
Pre-assignment details
At the end of the 6 month core phase (phase 1), participants in the waiting group had the option to receive e-training for 6 months in the phase 2 optional extension. Participants in the e-training group had the option to continue their e-training for another 6 months in the phase 2 extension.
Participants by arm
| Arm | Count |
|---|---|
| E-training Fingolimod as baseline immunomodulatory multiple sclerosis treatment was prescribed as per clinical practice. During phase 1, participants randomized to this arm had an introductory group session, hosted by a sports therapist. The individual training schedule was comprised of strength exercises twice a week for 30-45 minutes and endurance training once a week for 20-60 minutes for 6 months. The participants documented each training session thoroughly via the web-based application (duration, type of exercises, number of repetitions and sets, perceived exertion). A standard course of corticosteroids (methylprednisolone) on an inpatient or outpatient basis was allowed for treatment of relapses as clinically warranted. Steroid treatment consisted of 3-5 days and up to 1,000 mg methylprednisolone/day. After 6 months, Phase 2, the same Phase 1 regimen applied. | 94 |
| Waiting Fingolimod as baseline immunomodulatory multiple sclerosis treatment is prescribed as per clinical practice. During Phase 1, participants randomized to this arm did not receive e-training exercise. After a 6 month waiting period, phase 2, participants had an introductory group session, hosted by a sports therapist. The individual training schedule was comprised of strength exercises twice a week for 30-45 minutes and endurance training once a week for 20-60 minutes for 6 months. The participants documented each training session thoroughly via the web-based application (duration, type of exercises, number of repetitions and sets, perceived exertion). A standard course of corticosteroids (methylprednisolone) on an inpatient or outpatient basis was allowed for treatment of relapses as clinically warranted. Steroid treatment consisted of 3-5 days and up to 1,000 mg methylprednisolone/day. | 84 |
| Total | 178 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Phase 1 | Adverse Event | 2 | 1 |
| Phase 1 | Lost to Follow-up | 1 | 0 |
| Phase 1 | Visit 6a omitted | 1 | 0 |
| Phase 1 | Withdrawal by Subject | 6 | 5 |
| Phase 2 | Adverse Event | 1 | 1 |
| Phase 2 | Lost to Follow-up | 1 | 1 |
| Phase 2 | Permanent interruption of fingolimod | 0 | 1 |
| Phase 2 | Withdrawal by Subject | 4 | 3 |
Baseline characteristics
| Characteristic | E-training | Waiting | Total |
|---|---|---|---|
| Age, Continuous | 40.9 Years STANDARD_DEVIATION 10.4 | 39.4 Years STANDARD_DEVIATION 8.7 | 40.2 Years STANDARD_DEVIATION 9.6 |
| Sex: Female, Male Female | 65 Participants | 57 Participants | 122 Participants |
| Sex: Female, Male Male | 29 Participants | 27 Participants | 56 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 58 / 94 | 59 / 84 |
| serious Total, serious adverse events | 5 / 94 | 9 / 84 |
Outcome results
Primary
Change From Baseline in Fatigue as Measured by the Modified Fatigue Impact Scale (mFIS ).
The mFIS provides an assessment of the effects of fatigue in terms of physical, cognitive, and psychosocial functioning. It is a 21-item, structured, self-report questionnaire that generally can be completed with little or no intervention from an interviewer. The mFIS score ranged from 0 (not tired) to 84 (tired). A negative change from baseline indicates improvement.
Time frame: Baseline, 6 months
Population: Modified Full Analysis Set (ModFAS): The ModFAS included participants with sufficient e-training compliance.
| Arm | Measure | Value (LEAST_SQUARES_MEAN) | Dispersion |
|---|---|---|---|
| E-training | Change From Baseline in Fatigue as Measured by the Modified Fatigue Impact Scale (mFIS ). | -3.57 score on a scale | 95% Confidence Interval 11.3 |
| Waiting | Change From Baseline in Fatigue as Measured by the Modified Fatigue Impact Scale (mFIS ). | -2.10 score on a scale | 95% Confidence Interval 12.1 |
p-value: 0.457995% CI: [-5.39, 2.44]ANCOVA
Secondary
Change From Baseline in Aerobic Capacity (VO2max) as Measured by a Physical Endurance Spiroergometry on a Treadmill
Physical endurance spiroergometry was accomplished. Ergometry was assessed according to national guidelines of the German society for sports medicine. Ergometry is a combined examination of circulation and lung function and was performed as a submaximal or maximal test depending on the participant's individual performance. A negative change from baseline indicates improvement.
Time frame: Baseline, 6 months
Population: Modified Full Analysis Set (ModFAS): The ModFAS included participants with sufficient e-training compliance.
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| E-training | Change From Baseline in Aerobic Capacity (VO2max) as Measured by a Physical Endurance Spiroergometry on a Treadmill | -0.52 [ml/min/kg][watt/kg body weight] |
| Waiting | Change From Baseline in Aerobic Capacity (VO2max) as Measured by a Physical Endurance Spiroergometry on a Treadmill | -0.79 [ml/min/kg][watt/kg body weight] |
Secondary
Change From Baseline in Depression as Measured by the Beck Depression Inventory Second Edition (BDI-II)
The Beck Depression Inventory Second Edition (BDI-II) is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression as listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. Each of the 21 items corresponding to a symptom of depression is summed to give a single score for the BDI-II. There is a four-point scale for each item ranging from 0 to 3. The total score ranges from 0 - 63. Total score of 0-13 is considered minimal range, 14-19 is mild, 20-28 is moderate, and 29-63 is severe. A negative change from baseline indicates improvement.
Time frame: Baseline, 6 months
Population: Modified Full Analysis Set (ModFAS): The ModFAS included participants with sufficient e-training compliance.
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| E-training | Change From Baseline in Depression as Measured by the Beck Depression Inventory Second Edition (BDI-II) | -2.62 score on a scale |
| Waiting | Change From Baseline in Depression as Measured by the Beck Depression Inventory Second Edition (BDI-II) | -1.97 score on a scale |
Secondary
Change From Baseline in Fatigue as Measured by the WEIMuS (Würzburg Fatigue Inventory for MS)
The WEIMuS (Würzburg Fatigue Inventory for MS) scale is a validated self-assessment instrument to quantify the degree of fatigue. The scale consists of 17 items with 5 categories that are scored from '0' to '4'. The subscores for cognitive and physical fatigue range from 0 to 36 and from 0 to 32, respectively, with the total sum score ranging from 0 to 68; higher scores indicate higher degrees of fatigue. A negative change from baseline indicates improvement.
Time frame: Baseline, 6 months
Population: Modified Full Analysis Set (ModFAS): The ModFAS included participants with sufficient e-training compliance.
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| E-training | Change From Baseline in Fatigue as Measured by the WEIMuS (Würzburg Fatigue Inventory for MS) | -1.90 score on a scale |
| Waiting | Change From Baseline in Fatigue as Measured by the WEIMuS (Würzburg Fatigue Inventory for MS) | -1.12 score on a scale |
Secondary
Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Change in Leg Strength and Trunk Strength
Isometric and dynamic muscular strength was measured by an Isomed 2000 isometric measurement device (knee flexion/tension, trunk flexion/extension). Isomed 2000 device measures muscular flexion and tension under standardized training conditions. A positive change from baseline indicates improvement.
Time frame: baseline, 6 months
Population: Modified Full Analysis Set (ModFAS): The ModFAS included participants with sufficient e-training compliance.
| Arm | Measure | Group | Value (LEAST_SQUARES_MEAN) |
|---|---|---|---|
| E-training | Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Change in Leg Strength and Trunk Strength | Leg strength | 0.50 newton meter |
| E-training | Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Change in Leg Strength and Trunk Strength | Trunk strength | 0.08 newton meter |
| Waiting | Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Change in Leg Strength and Trunk Strength | Leg strength | 1.63 newton meter |
| Waiting | Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Change in Leg Strength and Trunk Strength | Trunk strength | 0.12 newton meter |
Secondary
Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Leg Strength Endurance
Isometric and dynamic muscular strength was measured by an Isomed 2000 isometric measurement device (knee flexion/tension, trunk flexion/extension). Isomed 2000 device measures muscular flexion and tension under standardized training conditions. A positive change from baseline indicates improvement.
Time frame: baseline, 6 months
Population: Modified Full Analysis Set (ModFAS): The ModFAS included participants with sufficient e-training compliance.
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| E-training | Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Leg Strength Endurance | 51.28 joule |
| Waiting | Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Leg Strength Endurance | 130.80 joule |
Secondary
Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Sit-to-stand Test
The Sit to Stand Test is a functional outcome measure of the lower-extremity muscle power. The test was performed 3 times with one minute rest in between. The best attempt out of three was used for the analysis. A positive change from baseline indicates improvement.
Time frame: baseline, 6 months
Population: The ModFAS, which included participants with sufficient e-training compliance, was considered for the analysis. Only participants with both baseline and month 6 values were analyzed.
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| E-training | Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Sit-to-stand Test | 0.03 watt/kilogram body weight |
| Waiting | Change From Baseline in Isometric and Dynamic Muscular Strength as Measured by Sit-to-stand Test | 0.27 watt/kilogram body weight |
Secondary
Change From Baseline in Peak Expiratory Flow as Measured by a Physical Endurance Spiroergometry on a Treadmill
Physical endurance spiroergometry was accomplished. Ergometry was assessed according to national guidelines of the German society for sports medicine. Ergometry is a combined examination of circulation and lung function and was performed as a submaximal or maximal test depending on the participant's individual performance. A positive change from baseline indicates improvement.
Time frame: Baseline, 6 months
Population: The ModFAS, which included participants with sufficient e-training compliance, was considered for the analysis. Only participants with both baseline and month 6 values were analyzed.
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| E-training | Change From Baseline in Peak Expiratory Flow as Measured by a Physical Endurance Spiroergometry on a Treadmill | 0.05 L/s |
| Waiting | Change From Baseline in Peak Expiratory Flow as Measured by a Physical Endurance Spiroergometry on a Treadmill | 0.01 L/s |
Secondary
Change From Baseline in Quality of Life as Measured by the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS)
The Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) consists of 44 items, 28 of which are the basis for computation of five subscale scores reflecting major dimensions of health-related quality of life (HRQoL) in MS: Fatigue/Thinking (4 items), Mobility lower limb (5 items), Mobility upper limb (5 items), Social function (6 items) and Mood (eight items). Subscales and total score range from 1 to 5, with high scores indicating a lower quality of life. In this study, the total score and following 3 subscales: fatigue/thinking, mobility lower limb and mobility upper limb only were analyzed. A negative change from baseline indicates improvement.
Time frame: Baseline, 6 months, 12 months
Population: Modified Full Analysis Set (ModFAS): The ModFAS included participants with sufficient e-training compliance.
| Arm | Measure | Group | Value (LEAST_SQUARES_MEAN) |
|---|---|---|---|
| E-training | Change From Baseline in Quality of Life as Measured by the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) | Total score | -0.11 score on a scale |
| E-training | Change From Baseline in Quality of Life as Measured by the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) | Fatigue/thinking | -0.30 score on a scale |
| E-training | Change From Baseline in Quality of Life as Measured by the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) | Mobility lower limb | -0.00 score on a scale |
| E-training | Change From Baseline in Quality of Life as Measured by the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) | Mobility upper limb | -0.00 score on a scale |
| Waiting | Change From Baseline in Quality of Life as Measured by the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) | Mobility upper limb | 0.12 score on a scale |
| Waiting | Change From Baseline in Quality of Life as Measured by the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) | Total score | -0.02 score on a scale |
| Waiting | Change From Baseline in Quality of Life as Measured by the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) | Mobility lower limb | 0.08 score on a scale |
| Waiting | Change From Baseline in Quality of Life as Measured by the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) | Fatigue/thinking | -0.16 score on a scale |