*4.4. Limitations and Strengths*

Several limitations to this study should be considered, including a lack of a comparator group of healthy controls or pre-pandemic assessment of stress and coping in MS subjects. The study group cannot be treated as population-based because of its moderate size and some bias it was subjected to. The online survey (though distributed nationwide) favored those who have access to internet and are interested in activity of MS patients' organizations, while the printed version was distributed only in the two major outpatient centers in one region. A comparison of findings from these two subgroups of respondents revealed differences mainly in demographic but not MS-related items. Therefore, considering the moderate number of participants, we did not conduct further analyses for each subgroup separately.

Furthermore, the diagnosis of MS and disease-related issues were not verified through medical records or physician's opinion but only based on self-observation, which might have posed some ambiguity. The items on health-related issues either included a range of options to choose from (major MS symptoms, type of disease, treatment regimen) or allowed free-text answers (coexisting diseases, new symptoms), which might have also affected the results.

However, we believe that the findings from this study allow a better insight into MS patients' perspective of pandemic burden. Lessons learned from their experience may contribute to identification of the major aspects of pandemic impact, including some concealed and indirectly harmful issues, and expected long-term consequences. These aspects need to be addressed during the ongoing pandemic, but also in future plans of effective MS management [6,10,32]. Despite relatively preserved medical services, the patients suffered mainly from a disruption in holistic system of their support and pandemic effects on their economic status and daily living. Thus, informational and educational materials should focus not only on the current pandemic or MS-related issues, but also concern healthy lifestyle, effective coping and maintaining relationships [6,11]. Pandemic experiences might encourage a wider use of innovations: e.g., telehealth consultations, online physiotherapy programs. In view of long-term pandemic consequences, support and counseling should be provided in the field of mental well-being, as well as economic and work-related aspects [6,31].
