A Physical and Psychological Approach to Managing Fatigue in Myasthenia Gravis: A Pilot Study.

BackgroundFatigue in myasthenia gravis (MG) is common and difficult to manage. Unlike myasthenic weakness it is not amenable to drug therapies.ObjectiveOur primary aim was to investigate whether a combination of physical and psychological therapy would help address symptoms of fatigue in MG patients, who have stable disease but residual problematic fatigue. Our secondary aim was to quantitate fatigue by applying different scores and to ascertain which would be most relevant to apply in MG.MethodsWe recruited 10 MG patients with stable disease and who suffer from fatigue. Nine of these 10 patients participated in a 10-week program that involved physical and psychological intervention. We quantified their fatigue using the modified fatigue impact scale (MFIS), the visual analogue fatigue scale (VAFS) and the fatigue severity scale (FSS) at the start of the study, at various intervals during the program and 3 months later.ResultsDuring the program, there was a small improvement in the physical and psychosocial subscale of the MFIS. There was a significant improvement (p < 0.01) in the VAFS at the end of the program. No clear improvement was noted in FSS. Three months later, all fatigue scores declined to baseline but 50% of patients had made some life-style changes.ConclusionsThis is a small pilot study, which utilized a combined approach with physical and psychological therapy, and showed some benefit in improving fatigue in patients with MG. The improvement was small and unsustained. Because of the small patient cohort, one cannot derive any firm conclusions and a larger study is required to investigate this further.

Positive PsychoTherapy in ABI Rehab (PoPsTAR): A pilot randomised controlled trial.

Psychological distress is common following acquired brain injury (ABI), but the evidence base for psychotherapeutic interventions is small and equivocal. Positive psychotherapy aims to foster well-being by increasing experiences of pleasure, engagement and meaning. In this pilot trial, we investigated the feasibility and acceptability of brief positive psychotherapy in adults with ABI and emotional distress. Participants were randomised to brief positive psychotherapy plus usual treatment, or usual treatment only. Brief positive psychotherapy was delivered over eight individual out-patient sessions, by one research psychologist. A blinded assessor administered the Depression Anxiety Stress Scales (DASS-21) and the Authentic Happiness Inventory (AHI) at 5, 9 and 20 weeks post-baseline. Of 27 participants randomised (median age 57; 63% male; 82% ischaemic stroke survivors; median 5.7 months post-injury), 14 were assigned to positive psychotherapy, of whom 8 completed treatment. The intervention was feasible to deliver with excellent fidelity, and was acceptable to participants. Retention at 20 weeks was 63% overall. A full-scale trial would need to retain n = 39 per group to end-point, to detect a significant difference in change scores on the DASS-21 Depression scale of 7 points (two-tailed alpha = .05, power = .80). Trials including an active control arm would require larger sample sizes. We conclude that a full-scale trial to investigate efficacy is warranted.

The sensitivity of a virtual reality task to planning and prospective memory impairments: group differences and the efficacy of periodic alerts on performance.

Executive functions have been argued to be the most vulnerable to brain injury. In providing an analogue of everyday situations amenable to control and management virtual reality (VR) may offer better insights into planning deficits consequent upon brain injury. Here 17 participants with a non-progressive brain injury and reported executive difficulties in everyday life were asked to perform a VR task (working in a furniture storage unit) that emphasised planning, rule following and prospective memory tasks. When compared with an age and IQ-matched control group, the patients were significantly poorer in terms of their strategy, their time-based prospective memory, the overall time required and their propensity to break rules. An examination of sensitivity and specificity of the VR task to group membership (brain-injured or control) showed that, with specificity set at maximum, sensitivity was only modest (at just over 50%). A second component to the study investigated whether the patients' performance could be improved by periodic auditory alerts. Previous studies have demonstrated that such cues can improve performance on laboratory tests, executive tests and everyday prospective memory tasks. Here, no significant changes in performance were detected. Potential reasons for this finding are discussed, including symptom severity and differences in the tasks employed in previous studies.

Rehabilitation of executive dysfunction following brain injury: "content-free" cueing improves everyday prospective memory performance.

Prospective memory (PM) is often claimed to rely upon executive as well as mnemonic resources. Here, we examined the contribution of executive functions towards PM by providing intermittent support for monitoring processes using "content-free" cues, which carried no direct information regarding the PM task itself. Twenty participants with non-progressive brain injury and PM difficulties received brief training in linking a cue phrase "STOP!" with pausing current activity and reviewing stored goals. The efficacy of this strategy was examined with a PM task requiring participants to make telephone calls to a voicemail service at four set times each day for 10 days. Task content was encoded using errorless learning to minimise retrospective memory-based failures. On five randomly selected days, eight text messages reading simply "STOP!" were sent to participants' mobile telephones, but crucially not within an hour of a target time. Striking improvements in performance were observed on cued days, thus demonstrating a within-subjects experimental modulation of PM performance using cues that carry no information other than by association with participants' stored memory of their intentions. In addition to the theoretical insights, the time course over which the effect was observed constitutes encouraging evidence that such strategies are useful in helping to remediate some negative consequences of executive dysfunction. It is proposed that this benefit results from enhanced efficiency of goal management via increased monitoring of current and future goals, and the steps necessary to achieve them, perhaps compensating for under-functioning fronto-parietal attention systems.

Frequency of behavioural problems at one year following traumatic brain injury: correspondence between patient and caregiver reports.

A group of 62 adults with significant (i.e., ventilation required for > 24 hours) traumatic brain injury (TBI) were assessed approximately one year following their injury. The people with TBI and their primary caregivers completed the patient and relative/friend versions respectively, of the 20-item Head Injury Behaviour Rating Scale (HIBS). Responses by the patient and caregiver groups were compared for the total number of problems reported and the frequency of specific problem behaviours. The caregiver group reported a greater total number of problem behaviours and a higher frequency for 19 of the 20 specific behaviours. These differences between the patients' and caregivers' reports were statistically significant for seven of the 19 problem behaviours. The majority (86%) of these significant differences were on items from the Behavioural Regulation, rather than the Emotional Regulation, subscale of the HIBS. The implications of these findings for the practice of neuropsychological rehabilitation are presented.

Caregiver burden during the year following severe traumatic brain injury.

Fifty-two primary caregivers of people with a severe traumatic brain injury (TBI) were assessed at 6-months and 1-year postinjury. Caregiver appraisal of the person with TBI's physical, cognitive, emotional, behavioural, and social functioning was assessed. Caregiver psychosocial functioning and levels of subjective and objective burden were also assessed. Some aspects of the difficulties reported for the people with TBI remained stable, while others increased in frequency, over time. At 6-months postinjury, approximately one third of caregivers reported clinically significant symptoms of anxiety and depression, and poor social adjustment. By 1-year postinjury, the prevalence of anxiety and depression remained the same, although only one-quarter continued to report poor social adjustment. There was some evidence of adaptation by caregivers, as the frequency with which various types of objective burden were reported remained stable, while the distress caused by these decreased in the first year postinjury. It appears that the impact on caregivers of physical impairment is comparatively short-lived and that caregivers learn some practical ways to manage the behavioural problems of the people with TBI. Despite this, over time the person with TBI's behavioural and cognitive problems begins to play a larger role in the level of distress experienced by the caregiver. However, it is the person with TBI's social isolation that has a stable and consistent role in the experience of subjective burden for primary caregivers in the first year postinjury.