Cognitive rehabilitation and mindfulness in multiple sclerosis (REMIND-MS): a study protocol for a randomised controlled trial

Background

Cognitive problems frequently occur in patients with multiple sclerosis (MS) and profoundly affect their quality of life. So far, the best cognitive treatment options for MS patients are a matter of debate. Therefore, this study aims to investigate the effectiveness of two promising non-pharmacological treatments: cognitive rehabilitation therapy (CRT) and mindfulness-based cognitive therapy (MBCT). Furthermore, this study aims to gain additional knowledge about the aetiology of cognitive problems among MS patients, since this may help to develop and guide effective cognitive treatments.

Methods/design

In a dual-centre, single-blind randomised controlled trial (RCT), 120 MS patients will be randomised into one of three parallel groups: CRT, MBCT or enhanced treatment as usual (ETAU). Both CRT and MBCT consist of a structured 9-week program. ETAU consists of one appointment with an MS specialist nurse. Measurements will be performed at baseline, post-intervention and 6 months after the interventions. The primary outcome measure is the level of subjective cognitive complaints. Secondary outcome measures are objective cognitive function, functional brain network measures (using magnetoencephalography), psychological symptoms, well-being, quality of life and daily life functioning.

Discussion

To our knowledge, this will be the first RCT that investigates the effect of MBCT on cognitive function among MS patients. In addition, studying the effect of CRT on cognitive function may provide direction to the contradictory evidence that is currently available. This study will also provide information on changes in functional brain networks in relation to cognitive function. To conclude, this study may help to understand and treat cognitive problems among MS patients.

Trial registration

This trial was prospectively registered at the Dutch Trial Registration (number NTR6459, registered on 31 May 2017).

Effectiveness of energy conservation management on fatigue and participation in multiple sclerosis: A randomized controlled trial

Background:

Fatigue is a frequently reported and disabling symptom in multiple sclerosis (MS).

Objective:

To investigate the effectiveness of an individual energy conservation management (ECM) intervention on fatigue and participation in persons with primary MS-related fatigue.

Methods:

A total of 86 severely fatigued and ambulatory adults with a definite diagnosis of MS were randomized in a single-blind, two-parallel-arm randomized clinical trial to the ECM group or the information-only control group in outpatient rehabilitation departments. Blinded assessments were carried out at baseline and at 8, 16, 26 and 52 weeks after randomization. Primary outcomes were fatigue (fatigue subscale of Checklist Individual Strength – CIS20r) and participation (Impact on Participation and Autonomy scale – IPA).

Results:

Modified intention-to-treat analysis was based on 76 randomized patients (ECM, n = 36; MS nurse, n=40). No significant ECM effects were found for fatigue (overall difference CIS20r between the groups = −0.81; 95% confidence interval (CI), −3.71 to 2.11) or for four out of five IPA domains. An overall unfavourable effect was found in the ECM group for the IPA domain social relations (difference between the groups = 0.19; 95% CI, 0.03 to 0.35).

Conclusion:

The individual ECM format used in this study did not reduce MS-related fatigue and restrictions in participation more than an information-only control condition.

Cognitive behavioral therapy positively affects fatigue in patients with multiple sclerosis: Results of a randomized controlled trial

Background:

Fatigue is a common symptom in multiple sclerosis (MS) and often restricts societal participation. Cognitive behavioral therapy (CBT) may alleviate MS-related fatigue, but evidence in literature is inconclusive.

Objective:

To evaluate the effectiveness of CBT to improve MS-related fatigue and participation.

Methods:

In a multi-center, assessor-masked, randomized controlled trial, participants with severe MS-related fatigue were assigned to CBT or control treatment. CBT consisted of 12 individual sessions with a psychologist trained in CBT, the control treatment consisted of three consultations with a MS nurse, both delivered over 16 weeks. Assessments were at baseline, 8, 16 (i.e. post-intervention), 26, and 52 weeks post-baseline. Primary outcomes were the Checklist Individual Strength-fatigue subscale (CIS20r fatigue) and the Impact on Participation and Autonomy questionnaire (IPA). Data were analyzed according to the intention-to-treat principle, using mixed-model analysis.

Results:

Between 2011 and 2014, 91 patients were randomized (CBT: n = 44; control: n = 47). Between-group analysis showed a positive post-intervention effect for CBT on CIS20r fatigue (T16: −6.7 (95% confidence interval (CI) = −10.7; −2.7) points) that diminished during follow-up (T52: 0.5 (95% CI = −3.6; 4.4)). No clinically relevant effects were found on societal participation.

Conclusion:

Severe MS-related fatigue can be reduced effectively with CBT in the short term. More research is needed on how to maintain this effect over the long term.

Does aerobic training alleviate fatigue and improve societal participation in patients with multiple sclerosis? A randomized controlled trial

Background:

Evidence supporting the effectiveness of aerobic training, specific for fatigue, in severely fatigued patients with multiple sclerosis (MS) is lacking.

Objective:

To estimate the effectiveness of aerobic training on MS-related fatigue and societal participation in ambulant patients with severe MS-related fatigue.

Methods:

Patients (N = 90) with severe MS-related fatigue were allocated to 16-week aerobic training or control intervention. Primary outcomes were perceived fatigue (Checklist Individual Strength (CIS20r) fatigue subscale) and societal participation. An improvement of ⩾8 points on the CIS20r fatigue subscale was considered clinically relevant. Outcomes were assessed by a blinded observer at baseline, 2, 4, 6 and 12 months.

Results:

Of the 89 patients that started treatment (median Expanded Disability Status Scale (interquartile range), 3.0 (2.0–3.6); mean CIS20r fatigue subscale (standard deviation (SD)), 42.6 (8.0)), 43 received aerobic training and 46 received the control intervention. A significant post-intervention between-group mean difference (MD) on the CIS20r fatigue subscale of 4.708 (95% confidence interval (CI) = 1.003–8.412; p = 0.014) points was found in favour of aerobic training that, however, was not sustained during follow-up. No effect was found on societal participation.

Conclusion:

Aerobic training in MS patients with severe fatigue does not lead to a clinically meaningful reduction in fatigue or societal participation when compared to a low-intensity control intervention.

Evaluation of a new Transmural Trauma Care Model (TTCM) for the rehabilitation of trauma patients: a study protocol

BACKGROUND

Improved organization of trauma care in the acute phase has reduced mortality of trauma patients. However, there has been limited attention for the optimal organization of post-clinical rehabilitation of trauma patients. Therefore we developed a Transmural Trauma Care Model (TTCM). This TTCM consists of four equally important components: 1) intake and follow up consultations by a multidisciplinary team consisting of trauma surgeon and hospital based trauma physical therapist, 2) coordination and individual goal setting for each patient by this team, 3) primary care physical therapy by specialized physical therapists organized in a network and 4) E-health support for transmural communication and treatment according to protocols. The aim of the current study is to assess the cost-effectiveness of the TTCM.

METHODS

Patients will be recruited from the outpatient clinic for trauma patients of the VU University Medical Center (VUmc) if they have at least one fracture and were discharged home. A controlled-before-and-after study design will be used to compare the TTCM with regular care. Measurements will take place after the first outpatient clinical visit and after 3, 6 and 9 months. Prior to the implementation of the TTCM, 200 patients (50 patients per time point) will be included in the control group. After implementation 100 patients will be included in the intervention group and prospectively followed. Between-group comparisons will be made separately for each time point. In addition, the recovery pattern of patients in the intervention group will be studied using longitudinal data analysis methods. Effectiveness will be evaluated in terms of health-related quality of life (HR-QOL), pain, functional status, patient satisfaction, and perceived recovery. Cost-effectiveness will be assessed from a societal perspective, meaning that all costs related to the TTCM will be taken into account including intervention, health care, absenteeism, presenteeism and unpaid productivity. Additionally, a process evaluation will be performed to explore the extent to which the TTCM was implemented as intended, and to identify possible facilitators and barriers associated with its implementation.

DISCUSSION

This planned research will give insight into the feasibility of the TTCM model in clinical practice and will give a first indication of the cost-effectiveness of the TTCM and help us to further develop post-clinical trauma care.

TRIAL REGISTRATION

Trial registration number: NTR5474 . The Netherlands National Trial Register (NTR). Registered 12 October 2015.

Psychological adjustment to chronic disease and rehabilitation - an exploration

PURPOSE

Psychological adjustment has a major impact on chronic disease health outcomes. However, the classification of psychological adjustment is unclear in the current version of the International Classification of Functioning, Disability and Health (ICF). We aim (i) to characterize the process of psychological adjustment to chronic disease, and (ii) to analyze how various categories of the psychological adjustment process could be incorporated into the ICF.

METHOD

We provide a summary of models of psychological adjustment to chronic disease. We also evaluate various options for incorporating categories of psychological adjustment into the ICF.

RESULTS

Acute and ongoing illness stressors; emotional, cognitive and behavioral responses; personal background; and social and environmental background are major categories in the adjustment process. These categories could, in principle, be integrated with various components of the ICF. Any future revision of the ICF should explicitly incorporate psychological adjustment and its (sub)categories.

CONCLUSION

The ICF could incorporate categories of psychological adjustment to chronic disease, although several adaptations and clarifications will be required. Implications for Rehabilitation In the context of an ageing society and large numbers of people living with chronic diseases, it is essential to understand psychological adjustment to chronic disease. However, the classification of psychological adjustment to chronic disease is unclear in the current version of the International Classification of Functioning, Disability and Health (ICF). We demonstrate that the ICF could incorporate categories of psychological adjustment to chronic disease, although several adaptations and clarifications would first be required. We suggest that these adaptations and clarifications should be considered in any future revision of the ICF.

Effectiveness of cognitive behavioral therapy for the treatment of fatigue in patients with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Fatigue is a frequently occurring symptom of multiple sclerosis (MS) that limits social participation.

OBJECTIVE

To systematically determine the short and long-term effects of cognitive behavioral therapy (CBT) for the treatment of MS-related fatigue.

DATA SOURCES

Pubmed, Cochrane, EMBASE, Psychology and Behavioral Sciences Collection, ERIC, PsychINFO, Cinahl, PsycARTICLES, and relevant trial registers were searched up to February 2016. In addition, references from retrieved articles were examined.

STUDY SELECTION

Studies were included if participants had MS, fatigue was a primary outcome measure, the intervention was CBT, and the design was a randomized controlled trial. The search was performed by two independent reviewers, three CBT experts determined whether interventions were CBT.

DATA EXTRACTION

Data on patient and study characteristics and fatigue were systematically extracted using a standardized data extraction form. Two independent reviewers assessed risk of bias using the Cochrane Collaboration risk of bias tool. In the event of disagreement, a third reviewer was consulted.

DATA SYNTHESIS

Of the 994 identified studies, 4 studies were included in the meta-analysis, comprising 193 CBT-treated patients and 210 patients who underwent a control treatment. Meta-analyses of these studies showed that CBT treatment had a positive short-term effect on fatigue (standardized mean difference [SMD]=-0.47; 95% confidence interval [CI]=-0.88; -0.06; I²=73%). In addition, three studies showed a long-term positive effect of CBT (SMD=-0.30; CI -0.51; -0.08; I²=0%).

CONCLUSIONS

This review found that the use of CBT for the treatment of fatigue in patients with MS has a moderately positive short-term effect. However, this effect decreases with cessation of treatment.

Measurement properties of the Arm Function in Multiple Sclerosis Questionnaire (AMSQ): a study based on Classical Test Theory

PURPOSE

The construct validity, test-retest reliability, and measurement error of the Arm Function in Multiple Sclerosis Questionnaire (AMSQ) were examined. Additionally, the influence of administration-method on reliability and measurement error was investigated.

METHOD

112 Dutch adult MS-patients from an academic- and a residential care-facility participated. Questionnaires were administered on paper, online or as interview, and patients performed several performance tests. Construct validity was assessed by testing pre-defined hypotheses. Reliability was assessed using Intraclass Correlation Coefficients (ICCs), Standard Error of Measurements (SEMs) and Smallest Detectable Changes (SDCs).

RESULTS

For construct validity (N = 105) 9 of 13 hypotheses were confirmed (69%). As expected, the AMSQ showed moderate to strong relationships with the instruments measuring similar constructs. The test-retest reliability coefficient was 0.96 (95% Confidence Interval 0.94-0.97); SEM was 6.3 (6.3% of scale range); SDC was 17.5 (on a sale from 0 to 100). Different administration-methods showed good reliability (ICC 0.88-0.94) and small standard errors (SEM 5.6-7.2).

CONCLUSION

The AMSQ shows satisfying results for validity and excellent reliability; allowing for proper use in research. Due to a large SDC value, caution is needed when using the AMSQ in individual patient care. Further research should determine whether the SDC is smaller than the minimal important change. Implications for Rehabilitation The Arm Function in Multiple Sclerosis Questionnaire (AMSQ) measures activity limitations due to hand and arm functioning in patients with Multiple Sclerosis (MS). Results of this study confirm adequate validity and reliability of the AMSQ in patient with MS. The equivalence of scores from online, paper or interview administration is supported. A change score of ≥18 points on the scale of the AMSQ (on a scale 0-100) needs to occur to be certain a change beyond measurement error has occurred in an individual patient.

The role of appraisal and coping style in relation with societal participation in fatigued patients with multiple sclerosis: a cross-sectional multiple mediator analysis

To determine the relationship between appraisal and societal participation in fatigued patients with Multiple Sclerosis (MS), and whether this relation is mediated by coping styles. 265 severely-fatigued MS patients. Appraisal, a latent construct, was created from the General Self-Efficacy Scale and the helplessness and acceptance subscales of the Illness Cognition Questionnaire. Coping styles were assessed using the Coping Inventory Stressful Situations (CISS21) and societal participation was assessed using the Impact on Participation and Autonomy. A multiple mediator model was developed and tested by structural equation modeling on cross-sectional data. We corrected for confounding by disease-related factors. Mediation was determined using a product-of-coefficients approach. A significant relationship existed between appraisal and participation (β = 0.21, 95 % CI 0.04–0.39). The pathways via coping styles were not significant. In patients with severe MS-related fatigue, appraisal and societal participation show a positive relationship that is not mediated by coping styles.

A computer-based screening method for distress in patients with multiple sclerosis: a feasibility study

Background

In multiple sclerosis (MS) patients, symptoms of anxiety, depression, pain, and cognitive impairment are highly prevalent and contribute to lower wellbeing. As these physical and psychological symptoms of distress often stay unnoticed, regular screening could offer possibilities to identify and refer impaired patients to appropriate care.

Objective

The aim of our study was to pilot a new computer-based method in 43 MS patients to efficiently screen for a variety of psychological and physical symptoms of distress.

Methods

Data on feasibility and psychological and physical distress (anxiety, depression, fatigue, physical disability, cognitive functioning) were collected via a touch screen computer. Referral to psychosocial care and rehabilitation was retrospectively checked.

Results

The results demonstrated that most patients (35/40, 88%) considered the screening meaningful and the system easily usable (37/40, 93%). Average completion time of the screening was below 8 minutes. Many patients (35/40, 88%) had elevated distress levels, of whom the majority was referred.

Conclusions

These findings imply that computer-based screening for MS-related distress incorporated in clinical care is feasible and aids to identify psychological or physical needs. A randomized controlled trial with follow-up should address whether this screening method could be more effective than routine care, and whether it can improve costs and efficiency of care.

Intrathecal baclofen treatment in dystonic cerebral palsy: a randomized clinical trial: the IDYS trial

Background

Dystonic cerebral palsy is primarily caused by damage to the basal ganglia and central cortex. The daily care of these patients can be difficult due to dystonic movements. Intrathecal baclofen treatment is a potential treatment option for dystonia and has become common practice. Despite this widespread adoption, high quality evidence on the effects of intrathecal baclofen treatment on daily activities is lacking and prospective data are needed to judge the usefulness and indications for dystonic cerebral palsy. The primary aim of this study is to provide level one clinical evidence for the effects of intrathecal baclofen treatment on the level of activities and participation in dystonic cerebral palsy patients. Furthermore, we hope to identify clinical characteristics that will predict a beneficial effect of intrathecal baclofen in an individual patient.

Methods/Design

A double blind placebo-controlled multi-center randomized clinical trial will be performed in 30 children with dystonic cerebral palsy. Patients aged between 4 and 25 years old with a confirmed diagnosis of dystonic cerebral palsy, Gross Motor Functioning Classification System level IV or V, with lesions in the cerebral white matter, basal ganglia or central cortex and who are eligible for intrathecal baclofen treatment will be included. Group A will receive three months of continuous intrathecal baclofen treatment and group B will receive three months of placebo treatment, both via an implanted pump. After this three month period, all patients will receive intrathecal baclofen treatment, with a follow-up after nine months. The primary outcome measurement will be the effect on activities of and participation in daily life measured by Goal Attainment Scaling. Secondary outcome measurements on the level of body functions include dystonia, spasticity, pain, comfort and sleep-related breathing disorders. Side effects will be monitored and we will study whether patient characteristics influence outcome.

Discussion

The results of this study will provide data for evidence-based use of intrathecal baclofen in dystonic cerebral palsy.

Trial registration

Nederlands Trial Register, NTR3642

The effectiveness of aerobic training, cognitive behavioural therapy, and energy conservation management in treating MS-related fatigue: the design of the TREFAMS-ACE programme

BACKGROUND

TREFAMS is an acronym for TReating FAtigue in Multiple Sclerosis, while ACE refers to the rehabilitation treatment methods under study, that is, Aerobic training, Cognitive behavioural therapy, and Energy conservation management. The TREFAMS-ACE research programme consists of four studies and has two main objectives: (1) to assess the effectiveness of three different rehabilitation treatment strategies in reducing fatigue and improving societal participation in patients with MS; and (2) to study the neurobiological mechanisms of action that underlie treatment effects and MS-related fatigue in general.

METHODS/DESIGN

Ambulatory patients (n = 270) suffering from MS-related fatigue will be recruited to three single-blinded randomised clinical trials (RCTs). In each RCT, 90 patients will be randomly allocated to the trial-specific intervention or to a low-intensity intervention that is the same for all RCTs. This low-intensity intervention consists of three individual consultations with a specialised MS-nurse. The trial-specific interventions are Aerobic Training, Cognitive Behavioural Therapy, and Energy Conservation Management. These interventions consist of 12 individual therapist-supervised sessions with additional intervention-specific home exercises. The therapy period lasts 16 weeks. All RCTs have the same design and the same primary outcome measures: fatigue - measured with the Checklist Individual Strength, and participation - measured with the Impact on Participation and Autonomy questionnaire. Outcomes will be assessed 1 week prior to, and at 0, 8, 16, 26 and 52 weeks after randomisation. The assessors will be blinded to allocation. Pro- and anti-inflammatory cytokines in serum, salivary cortisol, physical fitness, physical activity, coping, self-efficacy, illness cognitions and other determinants will be longitudinally measured in order to study the neurobiological mechanisms of action.

DISCUSSION

The TREFAMS-ACE programme is unique in its aim to assess the effectiveness of three rehabilitation treatments. The programme will provide important insights regarding the most effective treatment for MS-related fatigue and the mechanisms that underlie treatment response. A major strength of the programme is that the design involves three almost identical RCTs, enabling a close comparison of the treatment strategies and a strong overall meta-analysis. The results will also support clinical practice guidelines for the treatment of MS-related fatigue.

TRIAL REGISTRATIONS

Current Controlled Trials ISRCTN69520623, ISRCTN58583714, and ISRCTN82353628.

Abstract 4329: Novel HER2 targeting antibody-drug conjugates based on DNA-interacting duocarmycin and an unique linker technology with great potential in breast cancer and NSCLC

We have generated cleavable linker-duocarmycin payloads that previously have been shown to be highly stable in human plasma and to cause excellent in vitro and in vivo efficacy when conjugated to antibodies directed against multiple targets in different models. In our HER2 program, we have used these linker-duocarmycin payloads to generate HER2-targeting antibody-drug conjugates (ADCS) and prepare these for FIM studies. HER2 is a validated target in breast (BC) and gastric cancer (GC) that is currently used to target trastuzumab towards HER2-positive BC and GC tumors. We have generated a set of cysteine-coupled ADCs using newly developed duocarmycins conjugated to a therapeutic HER2/neu antibody. In vitro studies with the anti-Her2 ADCs showed that compared to the naked Ab, the ADCs tested have gained a more than 100-fold potency and more than two-fold efficacy in cell killing capacity. Studies in HER2 positive and negative cell lines indicated that cytotoxicity was HER2- mediated. HER2 binding and ADCC activity was not affected by conjugation. Single dose and multiple dose xenograft studies in mice using a human HER2-positive breast cancer cell line showed dose-dependent anti-tumor activity of the ADCs in vivo. Patient-derived xenografts (PDx) using primary tumors from HER2-positive breast cancer and NSCLC patients demonstrated the ability of the ADC to induce complete remission of tumors that remained unresponsive to the naked Ab trastuzumab. Also taken into account toxicology studies in rodents and cynomolgous monkeys, we conclude that we have generated a new class of HER2-based ADCs that have great potential to become effective treatment for HER2-positive tumors, including breast cancer and NSCLC. From a series of compounds, a preclinical candidate was selected that is currently being prepared for Phase I clinical trials that will start in 2014.

Citation Format: Wim Dokter, Patrick Beusker, Gijs Verheijden, Ruud Ubink, Miranda van der Lee, Diels van den Dobbelsteen, Peter Goedings, Jacques Lemmens, Vincent de Groot, Marco Timmers. Novel HER2 targeting antibody-drug conjugates based on DNA-interacting duocarmycin and an unique linker technology with great potential in breast cancer and NSCLC. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4329. doi:10.1158/1538-7445.AM2013-4329

Which walking capacity tests to use in multiple sclerosis? A multicentre study providing the basis for a core set

BACKGROUND

Many different walking capacity test formats are being used. It is unclear whether walking speed, obtained from short tests, and walking distance, obtained from long tests, provide different clinical information.

OBJECTIVES

To determine the differential effect of various short and long walk test formats on gait velocity, and the actual relationship between walking speed and walking distance in multiple sclerosis (MS) patients with diverse ambulation status.

METHODS

A cross-sectional multicentre study design was applied. Ambulatory MS patients (Expanded Disability Status Scale (EDSS) 0-6.5; n = 189) were tested at 11 sites. Short tests consisted of the Timed 25-Foot Walk (static start, fastest speed) and 10-Metre Walk Test (dynamic start, usual and fastest speed). Long tests consisted of the 2- and 6-Minute Walk Tests (fastest speed). Subjects were divided into mild (EDSS 0-4; n = 99) or moderate (EDSS 4.5-6.5; n = 79) disability subgroups.

RESULTS

In both subgroups, the start protocol, instructed pace and length of test led to significantly different gait velocities. Fastest walking speed and 6-Minute walking distance showed the strongest correlation (R (2) = 0.78 in mild and R (2) = 0.81 in moderate MS; p < 0.01). Short tests' relative estimation errors for 6-Minute walking distance were 8-12% in mildly and 15-16% in moderately affected subjects. Based on the 2-Minute Walk Test, estimation errors significantly reduced to approximately 5% in both subgroups.

CONCLUSIONS

A single short test format at fastest speed accurately describes an MS patient's general walking capacity. For intervention studies, a long test is to be considered. We propose the Timed 25-Foot Walk and 2-Minute Walk Test as standards. Further research on responsiveness is needed.

Aspects of activities and participation of 7-8 year-old children with an obstetric brachial plexus injury

BACKGROUND

Children with an obstetric brachial plexus injury (OBPI) can experience problems in the performance of meaningful activities such as writing, bimanual activities, and participation in sports and leisure activities.

AIMS

To quantify the everyday functioning and participation of 7-8 year-old children with an OBPI, with special emphasis on writing, and to investigate associated characteristics.

METHODS

Parents of children with an OBPI were sent a self-report questionnaire regarding the school performance, writing abilities, bimanual hand use, and participation in sports and leisure activities of their child, assessed with the Vineland Adaptive Behavior Scales (VABS sub-scale writing), the ABILHAND-kids, and the Children's Assessment of Participation and Enjoyment (CAPE). Furthermore, questions were asked about socio-demographic variables, medical history, pain, and the use of assistive devices.

RESULTS

Fifty three questionnaires were filled in (response 61%). According to the parents, 66% of their children were almost completely recovered, and 58% had a near normal arm function. Most of the children preferred to use their non-involved hand. More than 45% of the children complained about pain, and 39.6% had difficulties with writing, which resulted in a mean developmental delay of 8 months on the VABS sub-scale. Children with writing problems significantly more often had neurosurgery, were living with a single parent, more often received assistance at school, and had a significantly lower ABILHAND-kids score, compared to children with no writing problems.

CONCLUSIONS

Large percentages of 7-8 year-old children with an OBPI experience difficulties with writing and have musculoskeletal pain. Restrictions in participation were less pronounced.

Early central atrophy rate predicts 5 year clinical outcome in multiple sclerosis

OBJECTIVE

To examine the predictive value of central atrophy in early multiple sclerosis (MS) patients, for medium term clinical outcome.

METHODS

In 54 patients with recently diagnosed MS, clinical and MRI parameters were obtained at baseline, and after 2 and 5.5 years of follow-up. In addition to conventional MRI parameters and the annualised percentage brain volume change (aPBVC), the annualised percentage ventricular volume change (aPVVC) was quantified. Main outcome measure was disease progression, defined by an increase in Expanded Disability Status Scale of ≥1 after 5.5 years.

RESULTS

Disease progression occurred in 29 patients. aPVVC within the first two years was significantly higher in these progressing patients (median 4.76%; IQR 3.05-9.17) compared with stable patients (median 3.23%; IQR -0.1-6.02) (p=0.02). A logistic regression model selected aPVVC within the first 2 years as the only MRI marker predicting progression after 5.5 years (OR 1.17, 95% CI 1.02 to 1.35). When entering all MRI and clinical markers, again aPVVC within the first 2 years was the only MRI marker selected. While aPVVC was correlated between the two consecutive time intervals (ρ=0.41, p<0.01), aPBVC was not. Furthermore, baseline T2 lesion load and gadolinium enhancing lesion load were correlated with aPVVC in the second time interval (2-5.5 years) but not with aPBVC.

CONCLUSION

The rate of ventricular enlargement seems to be even more strongly predictive of disease progression after medium term follow-up than whole brain atrophy rate, and also outperforms lesion measures. Central atrophy rate could therefore be an important prognostic marker, especially in the early stages of MS.

Indications and effects of botulinum toxin A for obstetric brachial plexus injury: a systematic literature review

AIM

To give an overview of indications for the use of botulinum toxin A (BoNT-A) treatment for children with obstetric brachial plexus injury (OBPI), and to present the best available evidence of the effectiveness of this treatment.

METHOD

Searches were performed in Cinahl, Cochrane Library, Embase, PubMed, and Web of Science, using the keywords 'botulinum' and 'plexus', to identify articles reporting on the use of BoNT-A as a treatment for children with OBPI. Studies found through the references of related articles were also selected.

RESULTS

Ten full-text papers and six congress abstracts were included, involving 343 children. Four groups of indications could be identified: internal rotation/adduction contracture of the shoulder, limited active elbow flexion, limited active elbow extension, and pronation contracture of the lower arm. Overall, positive results were reported for all except the indication for limited active elbow extension. However, only one study was comparative in nature; all others were classified as having a low level of evidence. There was a large variation in outcome measures.

INTERPRETATION

To provide better evidence for the already partly promising results of BoNT-A treatment for children with OBPI, multicentre randomized controlled trials are needed.

In situ treatment of an infected intrathecal baclofen pump implant with gentamicin-impregnated collagen fleece

Intrathecal delivery of baclofen using a subcutaneous pump is an effective long-term treatment for spasticity. Infections of the pocket, however, are often hard to eliminate with intravenous antibiotics. If a 2-stage procedure involving removal of the pump and baclofen withdrawal will create serious problems for the patient, infections can be treated with repetitive local application of gentamicin-impregnated collagen fleece.