Fatigue in Patients with Multiple Sclerosis in Tehran in 1398

The prevalence of multiple sclerosis (MS) has been on the rise, especially among the youth in Iran. MS is more common in the individuals in their 20s and 40s, while women are also twice as likely to develop MS compared to men. Statistics suggest that there are 2.5 million MS patients worldwide, and this figure has been reported to be 15-30 cases per 100,000 in Iran. According to the Iranian MS Association, approximately 50,000 Iranians have MS, including 9,000 registered cases, and the rate is constantly increasing. Some of the main symptoms of MS are neurological, sensory, motor, and balance disorders, and fatigue is considered to be the most debilitating and common symptom; about one-third of MS patients report fatigue within the first three years of the disease diagnosis. Fatigue is an early symptom in 40% of MS patients, and 38% experience fatigue as the first diagnostic symptom. Extensive research has assessed the correlations between MS and various demographic variables, including individual factors (age, gender, education level), familial factors (family history of the disease), social factors (support of social institutions), economic factors (monthly income), emotional factors (family support), and disease-related factors (age at onset, length of hospital stay, medication). The present study aimed to measure fatigue in a large population of MS patients and determine its association with demographic variables.

This correlational study was conducted on 296 MS patients referring to the Iranian MS Association in Tehran, Iran during June-August 2019 via computation within a specific period. Fatigue was measured using Krupp fatigue intensity (1989), which has been used in extensive medical research. The minimum and maximum possible scores in this scale are nine and 63, respectively. Scores 9-18 indicate low fatigue, scores 18-45 indicate moderate fatigue, and scores above 45 show high fatigue. In Iran, Shahvaroughi Farahani et al. (2009) have measured the internal consistency of the items in this scale, which has been confirmed at the Cronbachchr('39')s alpha coefficient of 0.96, showing that the items of this questionnaire measure a concept. In addition, the intraclass correlation-coefficient test has been applied to evaluate the relative reproducibility of the Persian version of the questionnaire, with the value reported to be 0.93. The inclusion criteria of our study were the ability to communicate, basic literacy, dealing with MS for a minimum of one year, and not being in the acute stage of the disease. Participation was completely voluntary and free. The patients were assured of confidentiality terms regarding their personal information, which was only disclosed to the research team and used for scientific purposes. Data of the patients were collected anonymously, and a code was assigned to each questionnaire to prevent the disclosure of information. Data analysis was performed in SPSS version 16 using independent t-test, ANOVA, Pearsonchr('39')s and Spearmanchr('39')s correlation-coefficient, Dchr('39')Agostino-Pearson omnibus test, a correlation matrix, and Wilcoxon matched-pairs signed ranks test.

In total, 296 MS patients were enrolled in the study with the mean age of 37.15 ± 8.85 years and mean disease duration of 29.95 ± 22.06 years. Regarding the treatment costs, 18 patients reported low treatment costs, 74 cases reported moderate costs, while 102 and 63 patients reported high and extremely high treatment costs, respectively. Notably, the variable of medical expenses was correlated with the type of patient insurance (P=0.009), and the patients with armed forces insurance paid the least expenses for their treatment. The mean exercise duration of the MS patients was 4.34 ± 2.91 hours per week, and the mean total fatigue score was 39.18 ±14.56. According to the obtained results, 31 patients (10.5%) had low fatigue, 157 patients (53.3%) had moderate fatigue, and 108 patients (36.2%) had high fatigue. A significant association was also observed between the involved organs of the patients and fatigue (P=0.004), so that fatigue was higher in the patients whose four limbs were affected by MS and those with visual impairment in addition to the four affected limbs. In the general classification of disorders in the MS patients (sensory, motor, and sensorimotor disorders), motor disorders were most prevalent (41.89%), followed by sensorimotor disorders (41.71%) and sensory disturbance (35.66%). Furthermore, a significant correlation was observed between the number of hospitalizations due to MS and fatigue (P=0.001), so that with the increased number of hospitalizations, the patients expressed more fatigue. On average, our participants had three hospitalizations, and a significant association was denoted between marital status and fatigue (P=0.042). Compared to the single patients, fatigue was more common among the married, divorced, and widowed patients. In addition, monthly income was significantly associated with fatigue (P=0.001), and the patients with inadequate income expressed more fatigue. Exercise was also significantly correlated with fatigue (P=0.018), and less fatigue was observed in the patients who had physical exercise.

Considering that fatigue is a common symptom in MS patients, special attention should be paid to the influential factors to identify, eliminate or reduce the factors that are changeable. According to the results, fatigue is one of the most debilitating and common symptoms experienced by MS patients. Therefore, these patients, their families, and the treatment team (especially nurses) must recognize the influential factors in fatigue in order to increase patient awareness and reduce fatigue in these patients. We attempted to identify and report some of the influential factors in fatigue, such as individual and psychological, environmental, and disease-related factors, in the MS patients. It is recommended that proper measures be taken to reduce the debilitative factors and strengthen the factors that reduce fatigue. Moreover, healthcare officials should plan to increase income and create suitable job opportunities for MS patients who experience the limitations caused by the disease. The family members of these patients (especially spouses) could also provide great support, which plays a key role in adapting to the disease, taking measures to reduce fatigue, adherence to the treatment regimen, and reducing the number of hospitalizations in MS patients.