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Which exercise and behavioural interventions show most promise for treating fatigue in multiple sclerosis? A network meta-analysis 2021 Harrison et al

Discussion in 'Health News and Research unrelated to ME/CFS' started by Sly Saint, May 3, 2021 at 2:13 PM.

  1. Sly Saint

    Sly Saint Senior Member (Voting Rights)

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    Anthony Harrison, Reza Safari Tom Mercer,
    Federica Picariello, Marietta L van der Linden, Claire White, Rona Moss-Morris Sam Norton**

    Abstract
    Background:

    Fatigue is a common, debilitating symptom of multiple sclerosis (MS) without a current standardised treatment.

    Objective:
    The aim of this systematic review with network meta-analyses was to estimate the relative effectiveness of both fatigue-targeted and non-targeted exercise, behavioural and combined (behavioural and exercise) interventions.

    Methods:
    Nine electronic databases up to August 2018 were searched, and 113 trials (n = 6909) were included: 34 were fatigue-targeted and 79 non-fatigue-targeted trials. Intervention characteristics were extracted using the Template for Intervention Description and Replication guidelines. Certainty of evidence was assessed using GRADE.

    Results:
    Pairwise meta-analyses showed that exercise interventions demonstrated moderate to large effects across subtypes regardless of treatment target, with the largest effect for balance exercise (SMD = 0.84). Cognitive behavioural therapies (CBTs) showed moderate to large effects (SMD = 0.60), with fatigue-targeted treatments showing larger effects than those targeting distress. Network meta-analysis showed that balance exercise performed significantly better compared to other exercise and behavioural intervention subtypes, except CBT. CBT was estimated to be superior to energy conservation and other behavioural interventions. Combined exercise also had a moderate to large effect.

    Conclusion:
    Treatment recommendations for balance and combined exercise are tentative as the certainty of the evidence was moderate. The certainty of the evidence for CBT was high.

    https://journals.sagepub.com/doi/10.1177/1352458521996002


     
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  2. cassava7

    cassava7 Senior Member (Voting Rights)

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    The authors assessed risk of bias (RoB) with Cochrane's RoB methodology but:

    In assessing RoB, performance bias was not considered for the overall quality judgement as lack of blinding of participants and healthcare professional is an inherent limitation in studies of behavioural and exercise interventions​

    The abstract is also misleading: the results that it mentions are post-treatment, not at follow-up.

    Pooled effect sizes post-treatment (top) vs. at 3 to 6-month follow-up (bottom) relative to treatment as usual:

    [​IMG]


    [​IMG]

    Note: "Estimates of the effect at longer-term follow-up versus TAU where only one study was available are not presented (balance exercise, combined exercise and emotional expression therapy)."

    At follow-up, energy conservation had a SMD of -0.31. This is essentially the same as all other interventions that include psychotherapy or physical activity, the most effective (supposedly) of which range from SMD -0.39 to -0.33. This suggests that most of the improvement came from response bias.

    As for the quality of the 103 trials that were included, only 33 had a 3-6 month follow-up and 9 had a 7-12 month follow-up.

    I suppose this tells us that the answer to the authors' question (the title) is none, but the positive spin in their phrasing ("show the most promise") indicates that the review was not meant to find a negative result. Though it is expected that Moss-Morris displays allegiance bias towards psychotherapy and exercise. A honest conclusion would have been that the quality of the evidence for these interventions is poor, as for ME, and that the evidence does not suggest they are beneficial.

    ETA: balance exercise seems more specific to MS than the other general interventions, but I don't see how it could reduce fatigue.
     
    Last edited: May 3, 2021 at 4:05 PM
  3. Jonathan Edwards

    Jonathan Edwards Senior Member (Voting Rights)

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    Nothing like spelling out your stupidity in your paper.

    Like 'no need to take high winds into account in judging the reliability of materials for tall buildings in the Caribbean because high winds are inherent to the Caribbean'.

    Methinks they do protest too much again.
     
  4. cassava7

    cassava7 Senior Member (Voting Rights)

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    I am concerned that the MS Society funded this study:

    The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Multiple Sclerosis Society UK (Grant No. 26).​

    Worth noting, this study is based on the same data as a 2019 meta-analysis [1], published under almost the same title, with the only change being the type of data analysis (normal meta-analysis vs. "network meta-analysis" here). I am skeptical as to whether it qualifies as new/original work, at least sufficiently so as to warrant another submission to a journal.

    [1] Moss-Morris R, Harrison AM, Safari R, Norton S, van der Linden ML, Picariello F, Thomas S, White C, Mercer T. Which behavioural and exercise interventions targeting fatigue show the most promise in multiple sclerosis? A systematic review with narrative synthesis and meta-analysis. Behav Res Ther. 2021 Feb;137:103464. doi: 10.1016/j.brat.2019.103464. Epub 2019 Aug 28. PMID: 31780252.
     
  5. rvallee

    rvallee Senior Member (Voting Rights)

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    Here they go again pretending those numbers mean anything and that fiddling with those numbers counts as "work". None of those numbers relate to anything in real life anymore than assigning colors to emotions means something. And they are seriously comparing different things with different aims using made-up numbers.

    Then dispensing themselves of having to assess bias because the entire field is built on bias and therefore bias shouldn't be counted against? What in the hell? Obviously what it means is that bias needs far more stricter requirements than in other circumstances. Here it's not less requirements it's none at all, full dispensation.

    What are the journals even doing anymore? This is basically a comparison of apples, oranges and raisins with a bunch of other fruits, including tomatoes of course. They even allow for headlines that would count as yellow journalism? The headline clearly implies such interventions must work. What a bunch of crap.

    Zero difference between this and Scientology's Thetan-reading machines. Ghosts in the machine, ghosts of aliens past. Exactly the same. These people are out of their damn minds and the whole system is broken. Obviously CBT "works" because it influences how participants rate their Thetan levels, oops I mean fatigue, same thing to them basically, it's just a magical number that needs to be changed.
     
    Last edited: May 3, 2021 at 5:07 PM
  6. FMMM1

    FMMM1 Senior Member (Voting Rights)

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    So basically they are saying all "behavioural and exercise interventions" are crap.
     
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  7. Peter Trewhitt

    Peter Trewhitt Senior Member (Voting Rights)

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    Surely they are saying all evaluations of “behavioural and exercise interventions” are inherently crap, but because we can’t do anything about it we will ignore that fact and pretend they are OK.

    Which is wrong in two counts, firstly if something is inherently crap, that is not a justification for pretending that it is not crap, but also there are various ways of compensating for or reducing the inherent bias in unblinded trials, such as objective rather than subjective outcome measures.

    (ie How to write an article demonstrating you misunderstand your own misunderstanding.)
     
  8. Jonathan Edwards

    Jonathan Edwards Senior Member (Voting Rights)

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    Unless we are misunderstanding their misunderstanding of their misunderstanding.
    Maybe they understand only too well - but don't understand how silly what they write looks.
     
  9. Barry

    Barry Senior Member (Voting Rights)

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    This does seem to be a very common form of bias - the bias of recognising a source of bias but electing to ignore it because no one knows how to deal with it ... as if that must make it all alright then. I have encountered this "so what else are we supposed to do?" mindset with engineers also, engineers who are very proficient in many other respects. A sort of "burying one's head in the sand and just blunder on regardless" approach ... no doubt BPS psychologists understand it well and could write a paper on it :rolleyes: :p.
     
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  10. FMMM1

    FMMM1 Senior Member (Voting Rights)

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    How to write an article without acknowledge you could do better/good quality studies i.e. using the methods you @Peter Trewhitt set out!

    I think @Jonathan Edwards is correct i.e. they (surely) must know it's possible to do carry out a properly validated study.

    Being Mr Angry just now but logically the journal, which published this, is at least equally culpable? Is the journal at the lower end of the ranking system?
     
  11. FMMM1

    FMMM1 Senior Member (Voting Rights)

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    Yip blunder on and keep paying the mortgage --- the lovingly polished (dud) meal ticket ---

    I mean what's not to like --- the waste of tax payers money better spent on research likely to benefit people with ME/CFS --- the misrepresentation of people with ME/CFS and their consequent disenfranchisement ----
     
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  12. Michiel Tack

    Michiel Tack Senior Member (Voting Rights)

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    I'm confused isn't it simply the same study?

    EDIT: ah ok, now I see it.

    The first one was published in Behaviour Research and Therapy and is called "Which behavioural and exercise interventions targeting fatigue show the most promise in multiple sclerosis? A systematic review with narrative synthesis and meta-analysis."

    The second one was published in Multiple Sclerosis Journal and is called
    "Which exercise and behavioural interventions show most promise for treating fatigue in multiple sclerosis? A network meta-analysis."
     
    Last edited: May 4, 2021 at 8:05 AM
  13. Michiel Tack

    Michiel Tack Senior Member (Voting Rights)

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    Wow, didn't expect that someone would write this.
     
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  14. rvallee

    rvallee Senior Member (Voting Rights)

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    I don't really know what role journal editors, committees and peer reviews are supposed to be playing at this point when they let stuff like this pass through. It's one thing that someone would write that, people are weird and will try to cheat if they can. It's a whole other thing that a process involving multiple people that is supposed to act as quality control would be OK with it.

    Then again nobody but us saw anything wrong when the PACE researchers justified major changes to their analysis, turning a null result into a weak-but-obviously-fake positive, by simply saying they prefer the results and wanted to match their expectations. It's all out there, easy to find. It's completely absurd. Nobody cares.

    Usually calls of slippery slopes are alarmist but this here is a genuine case of a slippery treadmill. Every transgression to the norm accelerates future transgressions, so much that they have essentially become virtuous, likely with some BS justification about the greater good. The field of psychology is ruled by sunk cost and bias. Just amazing.
     
  15. Barry

    Barry Senior Member (Voting Rights)

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    An enlightening insight into the very unscientific mindset isn't it. Maybe they think that more openly blurting out their weird approach auto-excuses it.
     
  16. Joan Crawford

    Joan Crawford Senior Member (Voting Rights)

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    upload_2021-5-6_7-6-14.png
    One glance at the above highlights the huge incongruence with the paper's title.

    It's screamingly obvious that all of the above 'interventions' are useless at 'treating' fatigue!

    What we're the journal editors doing? Are they blind?

    These types of changes have zero real world effects.
     
  17. Joan Crawford

    Joan Crawford Senior Member (Voting Rights)

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    When I use neuropsych tests and so forth in conjunction with objective measures and questionnaires to assess patients it is really obvious that patients are vastly different to HCs. The difference is night and day.

    From a basic math perspective the change required, using objective and subjective measures, from how ill someone with ME or MS is to get close to HC functioning needs huge effect size changes. Like 4, or 5 or 15. Vast. Not 0.6 or 0.8. Literally vast.

    Part of problem seems to be the trotting out of effect sizes as defined by Cohen (small (0.2-0.4), medium(0.5-0.8) and large (0.8+)) as in someway meaningful. Nowhere do these arbitrary defined numbers link to the real world or require claims made to be reality checked. Result: endless churn of papers like this claiming they 'show' something positive, when they don't.
     
  18. Amw66

    Amw66 Senior Member (Voting Rights)

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    How does the SUCRA score relate to the confidence intervals
    I don't have too much stats knowledge . It just looks weirdly arbitrary.

    Eta phone problems this morning double posted in a single post ( I should really be a user tester as I seem to be able to do stuff with tech that noone else can ) ...
     
    Last edited: May 6, 2021 at 8:33 AM

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