*4.3. MS Related Factors*

Only 25% of the study group experienced a relapse during the pandemic, while more than a half reported an increased frequency or severity of their major MS-related complaints. In the study of Motolese et al. [2], only 20% of the patients experienced new or enhanced MS symptoms (mainly sensory impairment and fatigue), while the other authors did not focus on occurrence of relapses during the pandemic.

Our MS patients who reported an increase in chronic symptoms declared a higher level of perceived stress. However, there was no difference in PSS-10 results between those who had relapsed or not. Stress was often considered as a possible trigger of clinical or radiological MS activity, as well as the effect of adverse outcome of the disease [32–40]. A diversity of results from particular studies suggests a complexity of links between stress

and MS course, including a "vicious cycle" mechanism. There are also contradictory findings from studies investigating the course of MS during extreme traumatic situations. No increase in relapses was observed in Japanese patients following the great earthquake in 2016 [40] or in Israeli patients exposed to Persian Gulf war in 1991 [41]. On the contrary, more frequent relapses (associated with greater subjective stress) were noted during the Hezbollah–Israel war in 2006, with life threat and displacement identified as the main sources of stress [42]. During the COVID-19 pandemic, a higher anxiety level was shown in the Egyptian patients with relapses [12] while no such association was confirmed for the U.S. ones [1]. It seems that major stressful events do not directly affect MS activity, but their impact is mediated by individual perception, as well as by support provided to the patients [43].

Interestingly, no significant relationships were found in the study group between level of stress or coping model and any MS-related measures. Only more severe disability (assisted walk) was associated with greater preference for problem-focused coping strategies, and the level of stress was higher for those who declared the need for extra help during pandemic. Thus, it seems that the impact upon social functioning was more related to stress and coping than the disease itself. It should be highlighted that the vast majority of our respondents declared minor or mild disability and relapsing-remitting type of MS. Furthermore, in comparison with other studies [1,13,14], relatively small percentage of our patients received second-line DMT (apparently due to more benign or stable course of disease). Perhaps those with more active MS and greater disability, who did not participate in the survey, would perceive themselves as more endangered by severe COVID-19 infection, which could have affected the overall results.

With regard to the management of health issues, ca. 20% of our respondents had problems with the access to a neurologist and initiating or continuing DMT, while almost a half complained of limited availability of rehabilitation or primary health care facilities. Otherwise, there was a small proportion of those who canceled their visits due to fear of infection. The studies conducted in U.S. MS populations demonstrated greater disturbances in health care services, both from the providers' and patients' side [30,31] Throughout the countries, appropriate preventive measures were arranged for MS care centers [44,45]. For reimbursement reasons, DMT in Poland are provided under the charge of the specialist centers, within the unified schedule supervised by National Health Fund. Thus, the main framework for the treatment and its monitoring was usually maintained, although local disruptions might have occurred due to health-related or organizational consequences of the pandemic. According to national recommendations for health care settings and the statement of Polish MS experts [5], safety measures were undertaken at MS centers: e.g., the schedule of visits adjusted to maintain distance, obligatory use of masks and hand disinfection, screening for symptoms of infection at the entrance. Depending on local resources, remote consultations were being arranged (phone calls, video calls, sending comments and diagnostic tests results via e-mail). Our respondents seemed satisfied with a specialist care and with information on their current situation, offered probably also by the patients' organizations.
