title: Patient education for people with multiple sclerosis-associated fatigue: A systematic review.
abstract: BACKGROUND
  Multiple Sclerosis (MS) is an inflammatory and neurodegenerative disease often causing decreased quality of life, social withdrawal and unemployment. Studies examining the effect of pharmacological interventions demonstrated only minor effects, whereas non-pharmacological interventions as e.g. patient education programs have shown promising results.
  
  
  OBJECTIVE
  We aim to systematically review the literature to determine the effect of patient education programs on fatigue in MS.
  
  
  METHODS
  We conducted a comprehensive search in PubMed for randomized controlled trials (RCTs) that evaluated patient education programs for MS-related fatigue. Interventions evaluating physical exercise and/or pharmacological treatments were not included. Meta-analyses were performed using the generic inverse variance method.
  
  
  RESULTS
  The search identified 856 citations. After full-text screening we identified ten trials that met the inclusion criteria. Data of 1021 participants were analyzed. Meta-analyses showed significant positive effects on fatigue severity (weighted mean difference -0.43; 95% CI -0.74 to -0.11) and fatigue impact (-0.48; -0.82 to -0.15), but not for depression (-0.35 (95% CI -0.75 to 0.05; p = 0.08). Essentially, we categorized patient education programs into two types: firstly, interventions with a focus on cognitive-behavioral therapy (CBT) and secondly, interventions that teach patients ways of managing daily fatigue. CBT-based approaches seem to generate better results in reducing patient-reported fatigue severity. Analysing CBT studies only, the pooled weighted mean difference for fatigue severity was -0.60 (95% CI; -1.08 to -0.11) compared to non-CBT approaches (-0.20; 95% CI; -0.60 to -0.19). Furthermore, interventions employing an individual approach seem to reduce fatigue more effectively than group-based approaches (pooled weighted mean difference for fatigue severity in face-to-face studies was -0.80 (95% CI; -1.13 to -0.47) compared to group-based studies with -0,17 (95% CI; -0,39 to 0,05). Longest follow-up data were available for 12 months post-intervention.
  
  
  CONCLUSIONS
  Overall, included studies demonstrated that educational programs and especially CBT-based approaches have a positive effect on reducing fatigue. Since fatigue is thought to be a multidimensional symptom, it should be treated with a multidimensional approach targeting patients' behavior as well as their emotional and mental attitude towards fatigue. However, the clinical relevance of the treatment effects i.e. the relevance for patients' daily functioning remains unclear and long-term effects, i.e. sustainability of effects beyond 6 months, warrants further work. This review has been registered in the PROSPERO international prospective register of systematic reviews data base (Registration number: CRD42014014224).
authors.affiliation: Institute of Neuroimmunology and Department of Neurology, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Maria Janina
authors.initials: MJ
authors.lastname: Wendebourg
authors.affiliation: Institute of Neuroimmunology and Department of Neurology, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Heesen
authors.affiliation: School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada.
authors.forename: Marcia
authors.initials: M
authors.lastname: Finlayson
authors.affiliation: GAIA AG, Hamburg, Germany.
authors.forename: Björn
authors.initials: B
authors.lastname: Meyer
authors.affiliation: Institute of Neuroimmunology and Department of Neurology, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Jana
authors.initials: J
authors.lastname: Pöttgen
authors.affiliation: Nursing Research Unit, Institute of Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany.
authors.forename: Sascha
authors.initials: S
authors.lastname: Köpke
mesh_terms: D003863:Depression; D019468:Disease Management; D005221:Fatigue / Q000175:diagnosis / Q000209:etiology* / Q000523:psychology; D006801:Humans; D009103:Multiple Sclerosis / Q000150:complications*; D010353:Patient Education as Topic; D063868:Patient Outcome Assessment; D011788:Quality of Life; D012720:Severity of Illness Index