An Online Mindfulness Intervention for People With ALS and Their Caregivers

Quality of Life in people with ALS is not related to physical function, but is related to psychological, existential, and support factors. ALS caregivers demonstrate considerable burden and low QOL. It has been proposed by the investigators that it is time for the ALS field to develop "best practices" that use psychological intervention to improve QOL, reducing psychological distress in people with ALS and their caregivers. A disease that is as inexorably progressive and physically devastating as ALS also inevitably has an immense psychological impact on caregivers, both at the time of diagnosis and throughout the course of the disease. Yet, there is scant research on psychological interventions for ALS patients and caregivers.

Over 35 years of research demonstrate that mindfulness-based interventions comprise some of the most promising behavioral treatments in QOL improvement for people with chronic disorders.This work is based on socio-cognitive aspects of mindfulness, conceptualized as having a flexible state of mind that incorporates active engagement in the present and being sensitive to context and perspective. In over 35 years of research it has been shown that a higher state of mindfulness correlates with an improved QOL. In addition, mindfulness may lead to an improvement in some physiological as well as psychological measures. The literature on mindfulness in other disorders, combined with preliminary data on mindfulness in ALS patients and their caregivers, provides a strong evidence-based platform for proposing a careful study of the effects of mindfulness on psychological and physiological measures of ALS patients and their caregivers. The investigators conducted an exploratory investigation on a large sample (100+) of people with ALS about the influence of mindfulness on QOL and the course of the disease. The investigators found that mindfulness predicted positive QOL and psychological well-being, reducing anxiety and depression. That was quite expected. However, another finding was that mindfulness positively influenced the changes in physical symptoms: subjects with higher mindfulness experienced a slower progression of the disease, as measured by the self- administered ALS Functional Rating Scale (SA-ALSFRS). Furthermore, mindfulness was a significant predictor of positive QOL and psychological well-being in ALS caregivers, with a protective effect against anxiety and depression.

Fifty (50) participants with ALS, together with each subject's primary caregiver (i.e., an expected overall sample of 100 subjects), will be directly recruited from the Hershey Medical Center ALS Clinic at Penn State University. Participants will sign IRS-approved informed consent documents. Both patients and caregivers may be recruited even if a component of the dyad (patient-caregiver) opts not to join the study (i.e. patients and caregivers alone may be recruited). ALS patient-caregiver couples will be considered as a single subject for randomisation purposes (meaning that both the patient and the caregiver are randomly allocated to the same group). Subjects will be randomized into two groups (employing true randomization from atmospheric noise, www.random.org): an intervention group and a control group. Subjects in the intervention group will participate in the online mindfulness program, in addition to standard clinical care.

The intervention for each patient-caregiver pair will commence immediately after recruitment, on a rolling basis. Participants from the control group will be placed on a waiting list and will receive the standard care that they would receive if not in the study. Participants from both groups will be assessed 4 times: at recruitment (T1, baseline); after completing the intervention, or 5 weeks after recruitment for the control group (T2, post- treatment); three months after recruitment (T3); six months after recruitment (T4).

The primary outcome measure will be QOL (assessed with the ALS-Specific Quality of Life-Revised instrument, the ALSSQOL-R) in ALS subjects. Secondary outcomes from ALS subjects will be: depression and anxiety (assessed with the Hospital Anxiety and Depression Scale), attained mindfulness level (assessed with the Langer Mindfulness Scale) functional, cognitive and respiratory variables, assessed respectively with the Self-Administered ALS Functional Rating Scale-Revised, the Edinburgh Cognitive Assessment and Forced Vital Capacity. Caregivers outcomes, considered as secondary outcomes, will be QOL (assessed with the Short Form-36), depression and anxiety (assessed with the Hospital Anxiety and Depression Scale), care burden (assessed with the Zarit Burden Inventory) and mindfulness (assessed with the Langer Mindfulness Scale). A sub-sample of the subjects from the intervention group may be invited to a semi-structured interview about the experience with the treatment.

After the last assessment, subjects in the control group will have the option to enter the mindfulness program. All the subjects will have the option to continue to use the program after the 5-week intervention.