Behavioral Interventions in Multiple Sclerosis
Importance: Multiple sclerosis (MS) is a complex and unpredictable neurologic disease affecting nearly 1 million people in the US. People with MS commonly experience multiple physical and psychological symptoms such as depression, anxiety, stress, fatigue, and pain that impact functioning and quality of life. Subsequently, living with MS requires routine management of MS symptoms, adaptation to challenges, and engagement in health behaviors to promote well-being over time.
Observations: There is considerable evidence that behavioral interventions that increase cognitive and/or behavioral skills to address the challenges of day-to-day life with MS can promote resilience and reduce overall distress associated with this chronic and unpredictable disease. Brief group-based cognitive-behavioral therapy (CBT) and CBT-based interventions (eg, self-management) have been shown to reduce symptoms of depression, anxiety, stress, fatigue, and pain in people with MS, including via telehealth delivery. Likewise, mindfulness-based interventions have been shown to improve depression, anxiety, stress, fatigue, and quality of life in people with MS. Behavioral interventions also have been shown to improve health behaviors such as physical activity and adherence to disease modifying therapies in MS. Unlike other treatment options, behavioral interventions can be delivered in various formats (eg, in-person, telehealth), are time-limited, and cause few (if any) undesirable systemic side effects.
Conclusions: Behavioral intervention is an integral component of interprofessional care and key aspect of living well with MS.
Several behavioral interventions have been developed to address fatigue in MS. Using both individual and group based formats and across several modalities (eg, in-person, telephone, online modules, or a combination), behavioral fatigue interventions most commonly combine traditional general CBT skills (eg, addressing maladaptive thoughts and behaviors) with a variety of fatigue-specific skill building exercises that may include fatigue education, energy conservation strategies, improving sleep, enlisting social support, and self-management goal setting strategies.35,55-57
Pain
Chronic pain is common and disabling in people with MS.58,59 Nearly 50% report experiencing moderate to severe chronic pain.59,60 Individuals with MS reporting pain often are older, more disabled (higher Expanded Disability Status Scale score), and have longer disease duration that those who are not experiencing chronic pain.61 Patients report various types of pain in the following order of frequency: dysesthetic pain (18.1%), back pain (16.4%), painful tonic spasms (11.0%), Lhermitte sign (9.0%), visceral pain (2.9%), and trigeminal neuralgia (2.0%).61 Chronic pain has a negative impact on QOL in the areas of sleep, work, maintaining relationships, recreational activities, and overall life enjoyment.59 Additionally, research has shown that greater pain intensity and pain-related interference with activities of daily living are both associated with greater depression severity.62,63
The literature supports the use of behavioral interventions for pain in people with MS.61 Behavioral interventions include in-person exercise interventions (eg, water aerobics, cycling, rowing ergometer, treadmill walking, and resistance training), self-hypnosis, and telephone-based self-management programs based on CBT.35,64,65 As described above, CBT-based self-management programs combine learning CBT skills (eg, modifying maladaptive thoughts) with pain-specific skill building such as pain education, pacing activities, and improving sleep. Of note, MS education including, but not limited to, pain was as effective as a CBT-based self-management program in reducing pain intensity and interference.35 In addition, there is evidence to support acceptance- and mindfulness-based interventions for chronic pain, and online mindfulness-based cognitive therapy for MS related pain is currently being tested in a randomized controlled trial.35,66
Conclusion
People with MS face significant challenges in coping with and adapting to a chronic and unpredictable disease. However, there is considerable evidence that behavioral interventions can improve many of the most common and disabling symptoms in MS including depression, anxiety, stress, fatigue, and pain as well as health behavior and self-care. Research also suggests that improvements in one of these problems (eg, physical inactivity) can influence improvement in other symptoms (eg, depression and fatigue). Unlike other treatment options, behavioral interventions can be delivered in various formats (eg, in-person and electronic health), are time-limited, and cause few (if any) undesirable systemic adverse effects. Behavioral interventions are therefore, an essential part of interprofessional care and rehabilitation for patients with MS.
