Health-related quality of life and its relationship to cognitive and emotional functioning in multiple sclerosis patients

A Cognitive Occupation-Based programme for people with MS: acceptability, feasibility, and experiences of people with multiple sclerosis

PURPOSE

COB-MS is an eight-session, Cognitive Occupation-Based programme for people with both MS and cognitive difficulty - designed to enhance cognition and daily functioning, through a combination of goal-setting, cognitive strategy engagement, group activities, home-practice activities and one-on-one sessions. This research aims to investigate the acceptability of COB-MS from the perspective of people living with MS, as well as the occupational therapists who facilitated the programme.

MATERIALS AND METHODS

Two content analyses were conducted on interview data from (n = 11) COB-MS participants and (n = 8) COB-MS facilitators. Thematic analysis was also conducted on the participant interview data.

RESULTS

Through a, primary, content analysis, participants reported that the COB-MS provided both a positive experience and quality resources. Qualitative improvement and utilisation of their learning beyond completion of the intervention were also identified. Four themes were identified via, secondary, thematic analysis: (1) Group interaction within COB-MS was vital; (2) Online COB-MS had positive and negative effects on participation; (3) COB-MS as a provider of clarity; and (4) Using learned strategies after the completion of COB-MS. Recommendations for future administration are provided.

CONCLUSIONS

Findings suggest COB-MS acceptability, as well as appropriateness and feasibility, indicative of progression to a definitive trial in future research.

TRIAL REGISTRATION

ISRCTN: ISRCTN11462710. Registered on 9 September 2019.

Determinants of self-perceived quality of life in mildly disabled multiple sclerosis patients: a cross-sectional study

INTRODUCTION

While the determinants influencing self-perceived health-related quality of life (spHRQoL) in persons with multiple sclerosis (pwMS) and severe physical impairment have been well investigated, their impact on pwMS with mild disability is poorly addressed. We aimed to investigate possible drivers of spHRQoL among Sardinian pwMS with an EDSS lower than 2.5.

METHODS

A sample of 87 fully ambulatory (EDSS < 2.5) pwMS were included after screening for major cognitive impairment. spHRQoL was measured with the Italian version of 36-Item Short Form Health Survey (SF-36). The Physical Component Summary (PCS) and Mental Component Summary (MCS) were used as dependent variables for univariate analysis with Cognitive Behavioral Assessment (CBA) and specific individual factors as independent variables. Subsequent multivariate general linear models (GLMs) for PCS and MCS respectively were run after stepwise regression. Normative data referring to Italian population were used for comparison.

RESULTS

As compared to normative data, no statistically significant difference was found for PCS, while MCS was reduced. Multivariate GLMs showed a significant association between lower PCS scores and presence of psychosomatic symptoms, older age and fatigue (p < 0.05). Furthermore, a significant association was shown between lower MCS scores and presence of anxiety (p < 0.001).

CONCLUSION

Mood, presence of psychosomatic symptoms, fatigue and age can have a relevant impact on spHRQoL in people with mildly disabling MS and should be considered in the management of such individuals.

Dynamic Cognitive-Motor Training versus Cognitive Computer-Based Training in People with Multiple Sclerosis: A Preliminary Randomized Controlled Trial with 2-Month Follow-Up

Background: Recent studies underscore the intricate relationship between cognitive and motor impairments in Multiple Sclerosis (MS), often exacerbated by CNS damage compromising neural connections. These cognitive-motor deficits contribute to reduced efficiency in daily activities and heightened risks of falls and accidents. The combination of challenging cognitive-motor training in a more ecological setting could improve cognitive functions in people with MS (PwMS). Objective: This study aims to compare the impact of dynamic cognitive-motor training versus computer-based cognitive training on overall cognitive efficiency in PwMS. Methods: Thirty-eight PwMS were recruited through the neurorehabilitation services of an Institute of research and health. Twenty-four participants were randomly assigned to the Cognitive-Motor group (CMg) and Cognitive Therapy group (CTg). Participants underwent three training sessions per week for four weeks, each lasting 50 min. The primary outcome was a comprehensive cognitive assessment using the Cognitive Impairment Index (CII), and the secondary outcomes were the Multiple Sclerosis Quality of Life Questionnaire MSQOL-54 and the Stroop Color Word Interference Test (SCWT). Results: Significant differences in the CII scores across T0, T1, and T2, as indicated by Friedman's test (χ2(2) = 14.558, p = .001), were found in the CMg. A significant difference in the change in health subscale of the MSQOL-54 was observed when comparing the groups across T0, T1, and T2 (χ2(2) = 6.059, p = .048). There were also statistically significant differences for the emotional well-being (χ2(2) = 7.581, p = .023) and health distress (χ2(2) = 11.902, p = .003) subscales. Post hoc analysis showed a statistically significant improvement in health-related quality of life (HRQOL) for the former at T1 vs. T0 (Z = -2.502, p = .012 and for the latter at T2 vs. T0 (Z = -2.670, p = .008), respectively. Conclusions: Our results support the combination of cognitive-motor training to enhance cognitive functional outcomes and quality of life compared to computer-based cognitive training in PwMS.

The Early Initiation Advantages of Physical Therapy in Multiple Sclerosis-A Pilot Study

(1) Background: Multiple sclerosis (MS), a chronic progressive neurological disorder which affects the central nervous system (CNS), can result in disorders of all the functions controlled by the CNS: motor, sensory, cognitive and emotional. Physical therapy (PT), conducted through proprioceptive neuromuscular facilitation (PNF) techniques, can be customized to the individual patient's needs and has the potential to improve the patient's evolution. This study aims to establish if PT based on PNF techniques has a beneficial role in MS treatment. (2) Methods: We performed a prospective study on 40 patients who were diagnosed with MS and previously treated only with MS drug treatment (DT). These patients have participated in a PT program throughout one year. At the beginning and at the end of our study, after one year, we have assessed the following parameters: timed walk for 25 feet (Timed 25-Foot Walk test- T25FW test), dexterity of the upper limbs (9-Hole Peg Test-9HPT), disability level (Expanded Disability Status Scale-EDSS) and cognitive function (Paced Auditory Serial Addition Test-PASAT. (3) Results: In subjects in the early stages of MS, lower limb mobility improved significantly, T25FW decreasing from 6.46 to 5.80 (p < 0.001) and upper limb ability increased significantly in the dominant hand, 9HPT decreasing from 17.73 to 16.97 (p = 0.006) and not significantly in the non-dominant hand, 9HPT decreasing from 17.73 to 17.50 (p = 0.255). Furthermore, among these subjects, cognitive performance improved; their PASAT increased from 52.14 to 54.14 (p = 0.036), while the level of disability of these subjects improved only slightly, the EDSS scale evolving from 3.08 to 2.91 (p = 0.650). (4) Conclusions: In patients with early forms of MS, combining DT with a PT program based on PNF techniques results in: regaining muscle strength in the lower limbs, improving coordination while walking, correcting dexterity in the upper limbs and increasing the ability to concentrate.

The risk of dementia in multiple sclerosis and neuromyelitis optica spectrum disorder

Introduction

Cognitive impairment is a common feature of multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). However, there is a lack of population-based study of dementia risk in these disorders. In the present study, the risk of dementia in MS and NMOSD patients in Republic of Korea was estimated.

Methods

Data analyzed in this study were obtained from the Korean National Health Insurance Service (KNHIS) database between January 2010 and December 2017. The study included 1,347 MS patients and 1,460 NMOSD patients ≥40 years of age who had not been diagnosed with dementia within 1 year prior to the index date. Matched controls were selected based on age, sex, and the presence of hypertension, diabetes mellitus, or dyslipidemia.

Results

In MS and NMOSD patients, the risk of developing any dementia [adjusted hazard ratio (aHR) = 2.34; 95% confidence interval (CI) = 1.84-2.96 and aHR = 2.19; 95% CI = 1.61-3.00, respectively], Alzheimer's disease [AD; aHR = 2.23; 95% confidence interval (CI) = 1.70-2.91 and aHR = 1.99; 95% CI = 1.38-2.88, respectively], and vascular dementia (aHR = 3.75; 95% CI = 1.91-7.35 and aHR = 3.21; 95% CI = 1.47-7.02, respectively) was higher compared with the matched controls. NMOSD patients had a lower risk of any dementia and AD compared with MS patients after adjusting for age, sex, income, hypertension, diabetes, and dyslipidemia (aHR = 0.67 and 0.62).

Conclusion

The risk of dementia increased in MS and NMOSD patients and dementia risk was higher in MS than in NMOSD.

Insulin resistance is associated with cognitive dysfunction in multiple sclerosis patients: A cross-sectional study

Multiple sclerosis (MS) is a progressive inflammatory neurodegenerative disease of the nervous system accompanied by demyelination. MS-associated cognitive impairments mainly involve recent memory, information processing speed, stable memory, and executive function. Moreover, MS is associated with impaired glucose and insulin metabolism, which can exacerbate cognitive decline. The present study aimed to compare the cognitive status of MS patients with and without insulin resistance. In this cross-sectional study, 74 relapsing-remitting multiple sclerosis diagnosed patients were enrolled. Indicators of insulin resistance, including fasting blood glucose, insulin level, and homeostatic model assessment of insulin resistance (HOMA-IR) index, were measured. They were then divided into two groups based on the results of the HOMA-IR index. Cognition status was evaluated by the minimal assessment of cognitive function in multiple sclerosis battery. The prevalence of insulin resistance was 37.8%, and the prevalence of cognitive decline was estimated to be 67.56%. Mean scores of the California verbal learning test (CVLT), CVLT delayed free recall, controlled oral word association test, and judgment of line orientation tests were significantly lower in MS patients with insulin resistance than without. In addition, a negative correlation was demonstrated between the results of the CVLT, CVLT delayed free recall, controlled oral word association test, judgment of line orientation tests, brief visuospatial memory test, and Delis-Kaplan executive function system sorting tests and fasting insulin levels. Greater verbal memory and spatial comprehension impairments were observed in MS patients with insulin resistance.

The effectiveness of anodal tDCS and cognitive training on cognitive functions in multiple sclerosis; a randomized, double-blind, parallel-group study

BACKGROUND

Forty to 70% of patients with multiple sclerosis (MS) suffer from cognitive impairment during their illness. Only a few studies have examined the effects of anodal transcranial direct current stimulation (a-tDCS) along with cognitive training on cognitive performance in MS patients. This study aims to determine whether multi-session a-tDCS with or without cognitive training impacts cognitive performance in MS.

METHODS

Eighty MS patients received a-tDCS, cognitive training, a-tDCS plus cognitive training, and sham for ten consecutive daily sessions. Cognitive function (including episodic memory, attention, and inhibitory control, working memory, and visuospatial skill) was measured at baseline, week 4, and week 12 after the intervention.

RESULTS

All cognitive functions significantly improved after the intervention compared to the sham condition. This effect also showed persistence during follow-up for some cognitive tasks in the a-tDCS and a-tDCS combined cognitive training groups. Although the cognitive training group experienced an immediate improvement in attention and inhibitory control, the difference was not significant at follow-up. Also, there were no significant differences between these three groups in cognitive scores after the intervention.

CONCLUSION

a-tDCS alone and a-tDCS paired with or without cognitive training as compared to sham appears to be a promising therapeutic option for cognitive performance in MS patients.

Capturing cognitive changes in multiple sclerosis by performance-based functional and virtual reality assessments

Cognitive impairment (CI) has been recognized as one of the core multiple sclerosis (MS) symptoms that profoundly impact lives of people with MS (PwMS). Clinical trials have begun to focus on cognition as a primary or secondary outcome, but translating improvements in cognitive testing scores to functioning in the real world is difficult. Performance-based functional assessments and virtual reality (VR) assessments, which incorporate real-world challenges, have been proposed as a way to better assess functional cognition (i.e., cognitive performance and its impact on real-life cognitive functioning of PwMS) and could address the difficulty in evaluating the impact of a treatment on real-world functioning. In this narrative review, we identify and summarize some of the promising recent research applications of performance-based functional assessments and VR tools to assess functional cognition in MS. Overall, most of the studies suggest that functional and VR assessments can detect cognitive differences between people with and without MS and between PwMS with and without CI. Furthermore, performance on some of the functional and VR assessments was associated with performance on standard cognitive assessments. However, developing any guidelines on how to implement these assessments in clinical practice is difficult because of the relatively small sample size across these studies. Performance-based functional and VR assessments represent an innovative approach to increasing sensitivity of how cognitive impairments/abilities present in the daily life of PwMS. More studies, with a larger sample size, robust research methods, and pre- and post-treatment assessments, are warranted to validate relevant, accessible functional and VR assessments before implementing these assessment approaches in clinical practice.

Biopsychosocial Correlates of Quality of Life in Multiple Sclerosis Patients

Multiple sclerosis (MS) is a demyelinating chronic disease that has had increasing prevalence over the last years. We have investigated whether the perceived quality of life is reduced in multiple sclerosis patients compared to control participants with a cross-sectional approach, and how it relates to sociodemographic, clinical, and psychosocial variables in MS with multiple regression. To that end, a group of MS patients (n = 50) and a control group (n = 50) that was matched for age and education level filled in the WHOQOL-BREF (perceived quality of life across four domains) and a sociodemographic questionnaire. The participants in the MS group also filled in a clinical questionnaire and three instruments measuring psychosocial variables (the DASS-21 for depression, anxiety, and stress, the Brief-COPE for coping skills, and the Meaning in Life Scale). The results showed that the perceived quality of life was lower in the MS group than in the control group. Multiple regression models incorporating the variables that showed significant correlations with the quality of life indicated that age, professional status, recovery from relapses, depression, active coping, and meaning in life predicted at least one domain of the quality of life. Meaning in life predicted the quality of life in all four of the domains. Although the quality of life in MS is linked to multiple biopsychosocial variables, meaning in life seems crucial.

Reduction in cognitive processing speed surrounding multiple sclerosis relapse

Objective

The purpose of this study was to explore the longitudinal relationship between multiple sclerosis (MS) relapses and information processing efficiency among persons with relapsing–remitting MS.

Methods

We conducted a Swedish nationwide cohort study of persons with incident relapsing–remitting MS (2001–2019). Relapse information and symbol digit modalities test (SDMT) scores were obtained from the Swedish MS Registry. Follow‐up was categorized into 2 periods based on relapse status: “relapse” (90 days pre‐relapse to 730 days post‐relapse, subdivided into 10 periods) and “remission.” Linear mixed models compared SDMT scores during the relapse periods to SDMT scores recorded during remission (reference) with results reported as β‐coefficients and 95% confidence intervals (CIs), adjusted for age, sex, SDMT type (written vs oral), time‐varying, disease‐modifying therapy exposure and sequence of SDMT.

Results

Over a mean (SD) follow‐up of 10.7 (4.3) years, 31,529 distinct SDMTs were recorded among 3,877 persons with MS. There was a significant decline in information processing efficiency that lasted from 30 days pre‐relapse up to 550 days post‐relapse, with the largest decline occurring 0 to 30 days post‐relapse (β‐coefficient: −4.00 (95% CI = −4.61 to −3.39), relative to the period of remission.

Interpretation

We found evidence of cognitive change up to 1 month prior to relapse onset. The reduction in SDMT lasted 1.5 years and was clinically significant up to 3 months post‐relapse. These results suggest that the effects of a relapse on cognition are longer than previously thought and highlight the importance of reducing relapse rates as a potential means of preserving cognitive function. ANN NEUROL 2022;91:417–423

Impact of clinical outcomes and imaging measures on health-related quality of life in secondary progressive MS

Background:

Health-related quality of life (HRQOL) outcomes are often included as secondary outcomes in clinical trials in secondary progressive MS (SPMS), but little is known about the longitudinal association of HRQOL and clinical and imaging outcome measures in SPMS.

Objective:

To assess the association of change in clinical and imaging outcomes with HRQOL in people with SPMS.

Methods:

We used data from ASCEND, a large randomized controlled trial (n = 889), to investigate the association of significant worsening on the Expanded Disability Status Scale (EDSS), Timed 25 Foot Walk (T25FW), Nine Hole Peg Test (NHPT), Symbol Digit Modalities Test (SDMT), and change in lesional and volumetric imaging outcomes with significant worsening on the 36-Item Short Form Health Survey (SF-36) and the Multiple Sclerosis Impact Scale (MSIS-29) during 2 years of follow-up using logistic regression models.

Results:

HRQOL measures were most associated with EDSS and T25FW, less so with NHPT and SDMT, and not associated with lesional and volumetric imaging outcomes.

Discussion:

Worsening of the EDSS and T25FW was associated with two commonly used HRQOL measures. These outcomes therefore appear to be more patient relevant than either the NHPT or SDMT in the context of a 2-year clinical trial.

The role of expectations and future-oriented cognitions in quality of life of people with multiple sclerosis: A systematic review

PURPOSE

Multiple Sclerosis (MS) is a highly variable condition characterised by uncertainty of disease course which can make formation of expectations about the future difficult. This systematic review aimed to examine associations between expectations, or Future Oriented Cognitions (FOCs), and Quality of Life (QOL) in people with MS (PwMS).

METHODS

Following PRISMA guidelines, literature up to October 2019 was searched using Medline, EMBASE, PsycINFO and Web of Science. Quantitative studies that investigated relationships between FOCs and QOL in PwMS (assessed using a standardised QOL assessment) were considered for inclusion. After data extraction, results were analysed using narrative synthesis, focusing on the valence of FOCs (positive, negative, unvalenced). Quality appraisal was conducted using the Mixed Methods Appraisal Tool (MMAT). All stages of the review were patient-led by a person with MS.

RESULTS

A total of 13 studies met the review inclusion criteria, with a combined sample size of 4,179. Of these studies, 11 involved measures of positive FOCs, most commonly self-efficacy, one measured a negative FOC, with one FOC unclassified. Nine studies found significant associations between QOL and self-efficacy. Although other positively valenced constructs were less frequently reported, significant associations with higher QOL were also evidenced.

CONCLUSIONS

Identifying ways to foster positive FOCs, particularly self-efficacy, may have beneficial effects on QOL. More research is needed to understand the impacts of negative FOCs on QOL to determine whether these processes could be meaningfully targeted in interventions.

Managing Cognitive Dysfunction in Multiple Sclerosis: A Snapshot of Changes in Screening, Assessment, and Treatment Practices

Background: Cognitive dysfunction is prevalent in multiple sclerosis (MS) and can have a negative effect on several aspects of the daily lives of persons with MS. In 2010, members of the Consortium of Multiple Sclerosis Centers (CMSC) were surveyed to understand MS clinicians’ screening, assessment, and treatment practices for cognitive problems. Given the advancements made in the field in the past decade, it was deemed time to reevaluate how cognitive dysfunction is managed in the clinical setting.

Methods: An online questionnaire was completed by 56 CMSC members in which they were asked to describe their clinical practices, procedures for screening and further evaluation, and treatment recommendations for cognitive dysfunction. Participants were also asked whether their practice had changed in terms of the number of cognitive screenings, prescriptions for cognitive problems, and referrals for neuropsychological assessment and cognitive remediation in the past 5 years to allow for clinicians who had not been in practice for 10 years.

Results: Participants reported an increase in the number of cognitive screenings and referrals for neuropsychological assessments and cognitive remediation during the past 5 years. Compared with 2010, participants endorsed greater use of person-administered screening measures, such as the Symbol Digit Modalities Test, and fewer prescriptions for medications to improve cognitive functioning.

Conclusions: Clinical practices are becoming more in line with the literature, with increased use of cognitive screening and remediation. Continued attention to cognitive problems will be an ongoing important component of MS-related care.

Does depression in multiple sclerosis mediate effects of cognitive functioning on quality of life?

PURPOSE

Patients with multiple sclerosis (MS) are at significant risk for decreased quality of life (QoL), in part due to factors such as cognitive impairment and depression. However, objective versus subjective assessments of cognitive functioning may differentially predict QoL, and it remains unknown whether they each impact QoL through levels of depression. The aims of the present study included (1) testing the effects of cognitive impairment on MS-related QoL via depression symptoms and (2) examining whether perceived and objective cognitive functioning differentially predict QoL through depression.

METHODS

Patients formally diagnosed with MS (N = 128) participated in cognitive assessment (Brief International Cognitive Assessment for Multiple Sclerosis) and completed self-report measures of perceived cognitive functioning (perceived deficits questionnaire), depression (Hospital Anxiety and Depression Scale), and MS-related QoL (functional assessment of multiple sclerosis).

RESULTS

Mediational hypotheses were tested by regression and structural equation modeling. As hypothesized, both perceived and objective cognitive functioning independently predicted lower QoL controlling for the effects of depression (p < 0.001). Consistent with hypotheses, depression mediated effects of both perceived (95% CI [0.31, 0.68]) and objective cognitive functioning (95% CI [0.09, 6.96]) on QoL when tested in separate models. However, when both predictors were modeled simultaneously, depression only mediated the effects of perceived (not objective) cognitive functioning (95% CI for standardized effect [0.10, 0.61]).

CONCLUSIONS

This study, thus, suggests the need to conceptualize different pathways by which objective and subjective cognitive impairment may shape QoL in the lives of individuals with MS.

Mobile health (mHealth) usage, barriers, and technological considerations in persons with multiple sclerosis: a literature review

OBJECTIVES

Persons with multiple sclerosis (MS) can face a number of potential healthcare-related barriers, for which mobile health (mHealth) technology can be potentially beneficial. This review aimed to understand the frequency, current uses, and potential barriers with mHealth usage among persons with MS.

METHODS

A query string was used to identify articles on PubMed, MEDLINE, CINAHL, and IEEE Xplore that were published in English between January 2010 and December 2019. Abstracts were reviewed and selected based on a priori inclusion and exclusion criteria. Fifty-nine peer-reviewed research studies related to the study questions are summarized.

RESULTS

The majority of persons with MS were reported as using smartphones, although rates of mHealth utilization varied widely. mHealth usage was grouped into 3 broad categories: (1) disability and symptom measurement; (2) interventions and symptom management; and (3) tracking and promoting adherence. While there have been an increasing number of mHealth options, certain limitations associated with MS (eg, poor dexterity, memory problems) may affect usage, although including persons with MS in the design process can address some of these issues.

DISCUSSION

Given the increased attention to mHealth in this population and the current need for telehealth and at home devices, it is important that persons with MS and healthcare providers are involved in the development of new mHealth tools to ensure that the end product meets their needs. Considerations for addressing the potential mHealth use barriers in persons with MS are discussed.

Experiences and perceived outcomes of persons with multiple sclerosis from participating in a randomized controlled trial testing implementation of the Canadian Physical Activity Guidelines for Adults with MS: an embedded qualitative study

PURPOSE

To describe the experiences and outcomes of participants who enrolled in a randomized controlled trial testing implementation of the Canadian Physical Activity Guidelines for Adults with Multiple Sclerosis.

MATERIALS AND METHODS

Fifty-six persons with MS who enrolled in the trial participated in the current study which involved a semi-structured interview at 16-week follow-up. Interview data were analyzed using thematic analysis.

RESULTS

Of the 56 participants, 26 ended up enrolling in a community-based exercise program specialized for persons with multiple sclerosis (MS), 7 joined another gym, 4 trained at home, and 17 took part in no specific program. Across all study participants, positive outcomes were reported across a number of domains including mental function, knowledge about the physical activity (PA) and MS, physical function, advocacy of PA to peers, daily participation, and body awareness. For those who enrolled in the community-based program, having a supportive and inclusive environment was critical to their PA experiences. Furthermore, environmental supports, particularly knowledgeable and supportive trainers and similar peers, contributed largely to the positive mental changes and increased knowledge gained.

CONCLUSIONS

Our study provides support for the promotion of PA in persons with MS and the development of community-based programs adapted for people with MS.IMPLICATIONS FOR REHABILITATIONEngaging in regular physical activity is associated with many positive benefits and outcomes for people with MS.Supportive elements such as a community of peers who also have MS, adaptive equipment, and trainers who are knowledgeable about MS are especially important for creating positive experiences including enjoyment from and desire to engage in regular physical activity.This study provides support for further advocacy (e.g., by persons with MS directly) and referral to community-based exercise programs adapted for people with MS.

Effects of transcranial direct current stimulation on cognitive dysfunction in multiple sclerosis

BACKGROUND

Around 40%-70% of patients with multiple sclerosis (MS) may experience cognitive impairments during the course of their disease with detrimental effects on social and occupational activities. Transcranial direct current stimulation (tDCS has been investigated in pain, fatigue, and mood disorders related to MS, but to date, few studies have examined effects of tDCS on cognitive performance in MS.

OBJECTIVE

The current study aimed to investigate the effects of a multi-session tDCS protocol on cognitive performance and resting-state brain electrical activities in patients with MS.

METHODS

Twenty-four eligible MS patients were randomly assigned to real (anodal) or sham tDCS groups. Before and after 8 consecutive daily tDCS sessions over the left dorsolateral prefrontal cortex (DLPFC), patients' cognitive performance was assessed using the Cambridge Brain Sciences-Cognitive Platform (CBS-CP). Cortical electrical activity was also evaluated using quantitative electroencephalography (QEEG) analysis at baseline and after the intervention.

RESULTS

Compared to the sham condition, significant improvement in reasoning and executive functions of the patients in the real tDCS group was observed. Attention was also improved considerably but not statistically significantly following real tDCS. However, no significant changes in resting-state brain activities were observed after stimulation in either group.

CONCLUSION

Anodal tDCS over the left DLPFC appears to be a promising therapeutic option for cognitive dysfunction in patients with MS. Larger studies are required to confirm these findings and to investigate underlying neuronal mechanisms.

Group cognitive rehabilitation to reduce the psychological impact of multiple sclerosis on quality of life: the CRAMMS RCT

BACKGROUND

People with multiple sclerosis have problems with memory and attention. The effectiveness of cognitive rehabilitation has not been established.

OBJECTIVES

The objectives were to assess the clinical effectiveness and cost-effectiveness of a cognitive rehabilitation programme for people with multiple sclerosis.

DESIGN

This was a multicentre, randomised controlled trial in which participants were randomised in a ratio of 6 : 5 to receive cognitive rehabilitation plus usual care or usual care alone. Participants were assessed at 6 and 12 months after randomisation.

SETTING

The trial was set in hospital neurology clinics and community services.

PARTICIPANTS

Participants were people with multiple sclerosis who had cognitive problems, were aged 18-69 years, could travel to attend group sessions and gave informed consent.

INTERVENTION

The intervention was a group cognitive rehabilitation programme delivered weekly by an assistant psychologist to between four and six participants for 10 weeks.

MAIN OUTCOME MEASURES

The primary outcome was the Multiple Sclerosis Impact Scale - Psychological subscale at 12 months. Secondary outcomes included results from the Everyday Memory Questionnaire, the 30-Item General Health Questionnaire, the EuroQol-5 Dimensions, five-level version and a service use questionnaire from participants, and the Everyday Memory Questionnaire - relative version and the Modified Carer Strain Index from a relative or friend of the participant.

RESULTS

Of the 449 participants randomised, 245 were allocated to cognitive rehabilitation (intervention group) and 204 were allocated to usual care (control group). Of these, 214 in the intervention group and 173 in the control group were included in the primary analysis. There was no clinically important difference in the Multiple Sclerosis Impact Scale - Psychological subscale score between the two groups at the 12-month follow-up (adjusted difference in means -0.6, 95% confidence interval -1.5 to 0.3; p = 0.20). There were no important differences between the groups in relation to cognitive abilities, fatigue, employment, or carer strain at follow-up. However, there were differences, although small, between the groups in the Multiple Sclerosis Impact Scale - Psychological subscale score at 6 months (adjusted difference in means -0.9, 95% confidence interval -1.7 to -0.1; p = 0.03) and in everyday memory on the Everyday Memory Questionnaire as reported by participants at 6 (adjusted difference in means -5.3, 95% confidence interval -8.7 to -1.9) and 12 months (adjusted difference in means -4.4, 95% confidence interval -7.8 to -0.9) and by relatives at 6 (adjusted difference in means -5.4, 95% confidence interval -9.1 to -1.7) and 12 months (adjusted difference in means -5.5, 95% confidence interval -9.6 to -1.5) in favour of the cognitive rehabilitation group. There were also differences in mood on the 30-Item General Health Questionnaire at 6 (adjusted difference in means -3.4, 95% confidence interval -5.9 to -0.8) and 12 months (adjusted difference in means -3.4, 95% confidence interval -6.2 to -0.6) in favour of the cognitive rehabilitation group. A qualitative analysis indicated perceived benefits of the intervention. There was no evidence of a difference in costs (adjusted difference in means -£574.93, 95% confidence interval -£1878.93 to £729.07) or quality-adjusted life-year gain (adjusted difference in means 0.00, 95% confidence interval -0.02 to 0.02). No safety concerns were raised and no deaths were reported.

LIMITATIONS

The trial included a sample of participants who had relatively severe cognitive problems in daily life. The trial was not powered to perform subgroup analyses. Participants could not be blinded to treatment allocation.

CONCLUSIONS

This cognitive rehabilitation programme had no long-term benefits on quality of life for people with multiple sclerosis.

FUTURE WORK

Future research should evaluate the selection of those who may benefit from cognitive rehabilitation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN09697576.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 4. See the National Institute for Health Research Journals Library website for further project information.

Short-term data on disease activity, cognition, mood, stigma and employment outcomes in a cohort of patients with primary progressive multiple sclerosis (UPPMS study)

BACKGROUND

Primary progressive multiple sclerosis (PPMS) has long been defined by progressive disability accrual in the absence of initial relapses. However, its underlying neurodegenerative process seems to be accompanied by central nervous system inflammation. A new classification defined multiple sclerosis courses according to clinical/radiological activity and progression. We provide further insight into PPMS activity according to this classification and other daily living aspects.

METHODS

This was a multicentre, prospective, cohort study including 55 adult patients with PPMS according to 2010 McDonald criteria, within ten years from neurologic symptom onset and not receiving disease-modifying therapies during the past six months, who were followed up for 12 months. The primary study endpoint was the percentage of patients with active disease based on clinical relapses and/or magnetic resonance activity. Disability progression, cognitive function, physical/psychological impact, depression symptoms, stigma and employment were secondary endpoints.

RESULTS

Eleven (25.6%) patients exhibited multiple sclerosis activity throughout the 12-month study follow-up. Fourteen showed non-active multiple sclerosis without progression, 11 non-active multiple sclerosis with progression, 6 active multiple sclerosis without progression and 4 active multiple sclerosis with progression; one patient with disease activity was not assessable for progression. Cognitive function scores remained unchanged or increased, disease physical impact was maintained and disease psychological impact significantly decreased. The proportion of patients with depression symptoms or stigma remained without significant changes as well as employment outcomes.

CONCLUSION

This study shows that one-fourth of PPMS patients may exhibit disease activity over one year, with disability progression in approximately one-third but without worsening of cognitive function, disease impact, depression, stigma or employment outcomes.

Early neuropsychological markers of cognitive involvement in multiple sclerosis

BACKGROUND

Cognitive impairment due to multiple sclerosis (MS) is common and often limits occupational functioning, contributes to disability, and reduces quality of life. Early detection of cognitive involvement in MS is critical for treatment planning and intervention, and frequent, regular cognitive monitoring may provide insight into subtle changes in disease progression.

OBJECTIVE

To compare the sensitivity and specificity of clinical, computer-based and experimental measures to early cognitive involvement in MS.

METHODS

Cognitive functioning was compared in MS participants early in the disease course to matched healthy controls using conventional, computer-based and functional assessments: the Brief International Cognitive Assessment in MS (BICAMS); the computer-based Cogstate Brief Battery (CBB); the Attention Network Test-Interaction (ANT-I), including intra-individual variability; and the Test of Everyday Cognitive Ability (TECA), a functional measure of instrumental activities of daily living.

RESULTS

MS participants (n = 25, mean disease duration= 5.82 ± 3.65 years) and demographically matched healthy controls (n = 29) completed the cognitive assessments. The Cogstate measure of choice reaction time (AUC = 0.73, p = .004), intra-individual variability on the ANT-I (AUC = 0.79, p = .001), and TECA (AUC = 0.78, p = .001) scores were the most sensitive and specific markers of cognitive involvement in MS.

CONCLUSIONS

Brief, repeatable, computer-based measures of reaction time and variability detect early MS associated cognitive involvement.

Identifying Early Neuropsychological Indicators of Cognitive Involvement in Multiple Sclerosis

Multiple sclerosis (MS) is a debilitating disease of the central nervous system that is most commonly seen in early to middle adulthood, although it can be diagnosed during childhood or later in life. While cognitive impairment can become more prevalent and severe as the disease progresses, signs of cognitive involvement can be apparent in the early stages of the disease. In this review, we discuss the prevalence and types of cognitive impairment seen in early MS, including the specific measures used to identify them, as well as the challenges in characterizing their frequency and progression. In addition to examining the progression of early cognitive involvement over time, we explore the clinical factors associated with early cognitive involvement, including demographics, level of physical disability, disease modifying therapy use, vocational status, and psychological and physical symptoms. Given the prevalence and functional impact these impairments can have for persons with MS, considerations for clinicians are provided, such as the role of early cognitive screenings and the importance of comprehensive neuropsychological assessments.

Contributing Factors to the Quality of Life in Multiple Sclerosis

Introduction:

Multiple sclerosis (MS) is a chronic, inflammatory, (auto) immune disease of the central nervous system (CNS). Quality of life (QoL) refers to the perception of an individual’s life in the context of the system of culture and values in which they live.

Aim:

The aim of the study was to determine the distribution of cognitive disorders in people with MS.

Methods:

The prospective study included 135 participants with MS and 50 healthy participants. Participants were divided into three groups: the first group consisted of 85 participants where the disease lasted longer than one year, the second group consisted of 50 participants with newly diagnosed MS, the third group consisted of 50 healthy participants. The instruments of clinical assessment were: Extended Disability Score in Multiple Sclerosis Patients, Mini Mental Status, Beck Depression Scale, and Quality of Life Scale (SF-36, Contemporary Health Survey).

Results:

The quality of life related to health is impaired in the physical, mental dimension and overall quality of life. In the first group of participants, 62% had mild depression, and in the second group 38% of participants, while more severe forms were recorded in 16% of participants in both groups. As depression increases, the quality of life decreases in all measured dimensions, which would mean that depression negatively affects the quality of life. The results of all dimensions as well as the overall quality of life score are worse with the increase in the degree of clinical disability, for both groups of study patients.

Conclusion:

Quality of life is impaired in MS patients, and a higher degree of clinical disability and an increase in depressive disorder are predictors of deteriorating quality of life in MS patients.

Testing social cognition in multiple sclerosis: Difference between emotion recognition and theory of mind and its influence on quality of life

BACKGROUND

Deficits in social cognition can occur in multiple sclerosis (MS) patients, and different methods are utilized for its assessment. The aim of this study was to compare two tests of social cognition in a cohort of multiple sclerosis patients with respect to other clinical variables. Additionally, the impact of social cognition on quality of life was investigated.

METHODS

In total, 50 patients were included in the study. Two tests of social cognition, emotion recognition and theory of mind, were performed and controlled for disease disability, depression, fatigue, and cognition in a multiple linear regression. Assessment of quality of life was also conducted.

RESULTS

Accuracy on emotion recognition was better compared to theory of mind (86.5 ± 9.5% and 63.6 ± 10.1%, respectively). Cognition was associated with both social cognition tasks, accounting for more variance in the emotion recognition task. Quality of life was not related to social cognition.

CONCLUSION

Studies on social cognition in MS have to keep in mind the higher degree of cognitive influence of emotion recognition compared to theory of mind.

Effects of Comorbid Fibromyalgia Syndrome on activities of daily living in multiple sclerosis patients

OBJECTIVE

To investigate the frequency of Comorbid Fibromyalgia Syndrome and its effects on quality of life and activities of daily living without any known psychiatric problem (schizophrenia or bipolar disorder) or severe disability, other than depression, in patients with multiple sclerosis, which is known to be a chronic disease in young adults.

METHODS

The study included 103 patients diagnosed with multiple sclerosis, following McDonald criteria, who had relapsing remitting disease. The Fibromyalgia Impact Questionnaire, Beck Anxiety Inventory, Beck Depression Inventory, Pittsburgh Sleep Quality Index, Fatigue Severity Scale, and Multiple Sclerosis Quality of Life-54 were applied for all patients. Results were analyzed using statistical methods.

RESULTS

Mean age was 35.04±8.72 years in the study population. The Expanded Disability Status Scale (EDSS) score was 2.21±0.93. Comorbid Fibromyalgia Syndrome was detected in 20 patients (19.4%). The mean score of Multiple Sclerosis Quality of Life-54 was found to be significantly higher in multiple sclerosis patients with Comorbid Fibromyalgia Syndrome when compared to those without it (34.80±9.14 versus 71.67±13.95; p<0.05).

CONCLUSION

These results indicate that increased frequency of Comorbid Fibromyalgia Syndrome in multiple sclerosis causes worsening in activities of daily living and quality of life, delayed diagnosis, disability progression, and increased admission rates. Questioning and appropriately managing Comorbid Fibromyalgia Syndrome in clinical practice are important to improve the quality of life in multiple sclerosis patients.

Neuropsychological assessments and psychotherapeutic services in Veterans with multiple sclerosis: Rates of utilization and their associations with socio-demographics and clinical characteristics using Veterans Health Administration-based data

BACKGROUND

As cognitive, emotional, and health-related behavioral issues are prevalent among persons with multiple sclerosis (MS), mental health services are a valuable component of comprehensive care. However, it is unknown how many participate in neuropsychological and psychotherapeutic services, and whether the presence of certain co-occurring conditions increase service use. This study aimed to examine the frequency and associated factors (e.g., age, gender, education, race/ethnicity, and co-occurring conditions) of neuropsychological and psychotherapeutic service utilization in the Veterans Health Administration (VHA) among Veterans with MS.

METHODS

Data were extracted from VHA Corporate Data Warehouse as part of the Women Veterans Cohort Study (WVCS), a longitudinal project with Veterans who served during the Iraq and Afghanistan conflicts. Participants (n = 1,686) were Veterans from the overall WVCS dataset who had three or more VHA MS-related encounters (inpatient, outpatient, and/or disease modifying therapy) within one calendar year between fiscal years 2010 and 2015. Neuropsychological assessment participation was identified by procedural codes 96118 and 96119, while psychotherapeutic services were defined using 90804, 90806, 90808, 96150, 96151, and 96152. Bivariate analyses were conducted to identify socio-demographics and clinical characteristics that differed between Veterans who did and did not use these services. Service dates were compared to the diagnosis dates of the co-occurring conditions to determine whether the majority of the diagnoses preceded the service (e.g., a recognized problem) or were coded the day of or after the initial appointment (e.g., a suspected problem), which informed what co-occurring conditions and participants were included in the subsequent logistic regressions.

RESULTS

Two hundred eighty-one Veterans (16.67%) participated in a neuropsychological assessment. Veterans who had an evaluation had higher rates of several co-occurring conditions (ps <0.01), though no significant relationships emerged with any of the socio-demographic variables and participation. After controlling for age, gender, education, and race/ethnicity, two previously diagnosed co-occurring conditions predicted service utilization: traumatic brain injuries (TBIs; OR: 2.33, 95% CI: 1.60, 3.35) and mood disorders (i.e., depressive and bipolar disorders; OR: 1.71, 95% CI: 1.26, 2.31). Psychotherapeutic service usage was more common, occurring in over 45% (n = 771) of the sample. Service utilization was associated with several co-occurring conditions (ps <0.001), as well as level of education (p = .003). Focusing on participants who were diagnosed the day of or after the initial encounter, five co-occurring conditions were predictors of psychotherapeutic service use: mood disorders (OR: 1.81, 95% CI: 1.34, 2.46), anxiety disorders (OR: 1.38, 95% CI: 1.03, 1.85), sleep disorders (OR: 1.55, 95% CI: 1.19, 2.01), alcohol-related disorders (OR: 3.29, 95% CI: 1.79, 6.21), and cognitive disorders (OR: 3.72, 95% CI: 2.29, 6.16).

CONCLUSIONS

These findings suggest that these services are being utilized by clinicians and Veterans to address the clinical complexity related to having MS and one or more of these other conditions.

Patient Attitudes to Routine Cognitive Testing in Multiple Sclerosis

BACKGROUND AND AIM

In recent years, cognitive dysfunction (CD) in multiple sclerosis (MS) has received increased attention. Neuropsychological tests have been developed allowing to monitor changes in patients' cognitive functions. Knowledge is lacking, however, about patients' attitudes towards introducing routine cognitive testing. It was the aim of this qualitative study to explore this.

MATERIALS AND METHODS

Based on a literature study, semi-structured interview guides were designed and used in qualitative interviews with 12 Danish patients. Participants were selected to represent different perspectives on CD and included patients with relapsing-remitting MS (RRMS) and secondary-progressive MS (SPMS), women and men with varying time since diagnosis and cognitive test scores using the Symbol Digit Modalities Test (SDMT). The data were analysed using a constructivist approach in order to identify significant relations between the quality of life (QoL) impact of CD, and attitudes towards routine cognitive testing.

RESULTS

Most participants reported several subtypes of CD, yet objective CD did not coincide with subjective CD nor did it translate directly into poorer QoL. Overall, CD appeared to have larger impact on the QoL of patients with RRMS and higher SDMT scores, compared to patients with SPMS and lower SDMT scores. The QoL impact of CD manifested itself in the encounter between individual symptoms, expectations, coping and meaningful activities. All patients supported an introduction of routine cognitive testing, but patients with RRMS and SPMS had different main reasons to do so. These were related to supporting research, optimising treatment decisions, and providing documentation of this invisible MS symptom.

CONCLUSION

All aspects of MS patients' QoL may be affected by CD. Introducing routine cognitive testing was widely supported by patients in all phases of MS calling for comprehensive care taking both physical and cognitive difficulties into account.

Factors affecting MS patients' health-related quality of life and measurement challenges in Lebanon and the MENA region

Background

In the Middle East and North Africa (MENA) region, few studies explored the quality of life of multiple sclerosis patients and the factors affecting it.

Objective

The objective of this study was to explore studies on multiple sclerosis quality of life in the MENA area through a comprehensive literature review. To validate the Multiple sclerosis international Quality of Life (MusiQoL) and Modified Fatigue Impact Scale (MFIS) in Arabic, and investigate the impact of sociodemographic and clinical variables of Lebanese multiple sclerosis patients on quality of life.

Methods

As part of an ongoing observational prospective research study, data from 663 stable multiple sclerosis patients were analysed.

Results

In Lebanese multiple sclerosis patients, the Arabic MusiQoL and MFIS seem to be accurate and valid tools with high reliability coefficients and confirmatory factor analytic indices. Variables such as age and disease type predicted multiple sclerosis quality of life, yet were significantly affected by psychosocial fatigue. The influence of sociodemographic and clinical variables on quality of life dimensions varied. Being a woman with multiple sclerosis, receiving medications and experiencing physical fatigue worsens the psychological wellbeing quality of life dimension.

Conclusion

Several sociodemographic and clinical variables predicted the health-related quality of life dimensions of multiple sclerosis patients in MENA. Further in-depth investigation to guide more targeted clinical management is recommended. We encourage using validated multidimensional tools to measure quality of life in MENA such as the Arabic MusiQoL.

Can semantic fluency be used as an alternative or additional measure in the abbreviated Minimal Assessment of Cognitive Function in Multiple Sclerosis (aMACFIMS)?

BACKGROUND

The abbreviated Minimal Assessment of Cognitive Function in Multiple Sclerosis (aMACFIMS) was designed using four shortened measures from the MACFIMS. Semantic fluency was suggested as an alternative task; however, its equivalency as part of this battery has yet to be examined.

OBJECTIVES

1) To determine the optimal semantic fluency raw score cut-offs; 2) compare the modified aMACFIMS (with semantic fluency) to the standard aMACFIMS (with phonemic fluency); and 3) compare the expanded aMACFIMS (with both verbal fluency measures) to the Brief International Cognitive Assessment in MS (BICAMS).

METHODS

Receiver-operating-characteristic curves were used to identify the optimal cut-off at -1.5 and - 2.0 standard deviation (SD) impairment criteria (n = 335). The diagnostic accuracies were compared between the different versions of the aMACFIMS and BICAMS (n = 146).

RESULTS

The raw score cut-offs for semantic fluency (13 and 11 words) had high sensitivity (100%) and specificity (96.6% - 98.6%). The modified aMACFIMS did not significantly differ from the standard aMACFIMS. The expanded aMACFIMS had stronger specificity (84.8%) and positive predictive value (85.9%) than the BICAMS.

CONCLUSIONS

Semantic fluency can be used as an alternative, though including both measures results in the most effective aMACFIMS version. Using semantic fluency may be especially valuable when evaluating older PwMS.

A Pilot Study to Assess At-Home Speed of Processing Training for Individuals with Multiple Sclerosis

Objective

Cognitive impairment is a common symptom of multiple sclerosis (MS), yet treatment is currently limited. The primary goal of this pilot study was to assess the feasibility and acceptability of an at-home, five-week computerized speed of processing (SOP) training intervention for MS patients. In addition, we examined the utility of the intervention to improve speed of information processing, memory, executive function, and health-related quality of life (HRQOL).

Method

Fifteen subjects were assigned five weeks of SOP training, two times per week, for a total of ten sessions. Subjects were trained on five computerized SOP tasks that required processing of increasingly complex visual stimuli in successively shorter presentation times. Subjects were given a neuropsychological test battery that included measures of speed of information processing, verbal memory, visual spatial memory, and executive function. Subjects were also administered patient-reported outcome (PRO) measures to assess HRQOL, depression, and work productivity. Neuropsychological and PRO batteries were completed at baseline and after five weeks.

Results

Eighty percent of subjects completed the five-week intervention (n = 12). Significant improvements were observed on some, but not all, measures of speed of information processing, verbal memory, and executive function. There were no significant changes in HRQOL.

Conclusion

This pilot study supports the feasibility of an at-home SOP training intervention for individuals with MS. SOP training was associated with improvements in several cognitive domains. Larger, randomized controlled trials are warranted.

Determinants of quality of life in relapsing-remitting and progressive multiple sclerosis

BACKGROUND

Numerous factors can affect multiple sclerosis (MS) patients' quality of life (QoL). We investigated how physical impairment, upper extremity function, cognitive impairment, cognitive reserve, symptoms of psychological distress, depression, fatigue as well as age and disease duration contribute to patient-reported measures of QoL in relapse-remitting MS (RRMS) and progressive MS (PMS).

METHODS

39 patients with RRMS and 16 patients with PMS were evaluated for physical impairment (EDSS assessed by a neurologist), upper extremity function (9-hole peg test), cognitive deficits (broad neuropsychological test battery), cognitive reserves (highest obtained degree of education and vocabulary), symptoms of psychological distress (Symptom Checklist-90-R), depression (Beck Depression Inventory) and fatigue (Fatigue Scale for Motor and Cognitive Functions). The effects of these variables on QoL, as measured with the EQ-5D-3L, were tested with a multivariate analysis of variance.

RESULTS

Degree of education, MS disease type, disease duration, BDI and SCL-90-R-scores affected significantly the EQ-5D index. Post-hoc analysis revealed that patients with university education, RRMS, shorter disease duration as well as less depression and psychological distress symptoms had significantly higher EQ-5D indices. No significant effects were observed for measures of physical disability, cognitive impairment or fatigue.

CONCLUSIONS

Depression and psychological distress symptoms are among the factors with the most essential impact on subjective well-being in MS patients. Since they can be targeted by both psychopharmacological and psychotherapeutic treatment, focusing on mental comorbidity could substantially increase QoL in MS.

Biomedical Variables and Adaptation to Disease and Health-Related Quality of Life in Polish Patients with MS

The aim of this research was to assess the level of adaptation to multiple sclerosis (Sclerosis multiplex; MS) and health-related quality of life (HRQoL) of the study population as well as to determine the relationship between biomedical factors related to the course of multiple sclerosis, adaptation to the disease, and HRQoL. Analysis of medical records, clinical and psychological interviews, the Extended Disability Status Scale (EDSS), Guy’s Neurological Disability Scale (GNDS), the Acceptance of Illness Scale (AIS), and the Multiple Sclerosis Impact Scale 29 (MSIS-29) were collected from 137 patients with MS. It was found that there was a relation between motor impairment, neurological disability, adaptation to illness, and HRQoL; it was also found that there were negative correlations between adaptation to illness and the severity of lower-limb disability, fatigue, mood disorders, other problems related to MS, and upper-limb disability. Of all the symptoms, lower-limb disability, fatigue, and mood disorders had the strongest relation with adaptation. All of the analysed symptoms were found to correlate with HRQoL. Of all the symptoms, HRQoL was most affected by lower- and upper-limb disability, fatigue, other MS problems, and mood disorders.

Health State Values Derived from People with Multiple Sclerosis for a Condition-Specific Preference-Based Measure: Multiple Sclerosis Impact Scale-Eight Dimensions-Patient Version (MSIS-8D-P)

OBJECTIVE

In economic evaluation, health outcomes are commonly quantified using quality-adjusted life-years (QALYs) derived from the preferences of a sample of the general population. It can be argued that this approach ignores the preferences of people with experience of the condition, and that patient preferences have a place in the valuation of health outcomes. Here we report the estimation of a preference-based index for an existing condition-specific preference-based measure for multiple sclerosis (MS), the MSIS-8D, based on the preferences of people with MS.

STUDY DESIGN

Internet time trade-off (TTO) survey, eliciting preferences from people with MS.

METHODS

We elicited preferences from a sample of people with MS (N = 1635) across 169 MSIS-8D health states, using the TTO technique. We fitted ordinary least squares and random effects models to the survey data to estimate values for all health states described by the MSIS-8D.

RESULTS

The new patient-derived index (the MSIS-8D-P) provides values ranging from 0.893 for the best possible health state to 0.138 for the worst state. The MSIS-8D-P exhibits good discriminative validity, identifying expected significant differences between groups based on presence/absence of MS, type of MS, and duration since diagnosis.

CONCLUSIONS

The MSIS-8D-P index of values for MS-specific health states provides an opportunity to estimate QALYs based on patient preferences, for use in economic evaluations of treatments for MS. More broadly, it adds to the methods and data available to consider the health-related quality of life of people with MS to inform resource allocation and individual-level decisions regarding treatments for MS.

The subtleties of cognitive decline in multiple sclerosis: an exploratory study using hierarchichal cluster analysis of CANTAB results

Background

It is essential to investigate cognitive deficits in multiple sclerosis (MS) to develop evidence-based cognitive rehabilitation strategies. Here we refined cognitive decline assessment using the automated tests of the Cambridge Neuropsychological Test Automated Battery (CANTAB) and hierarchical cluster analysis.

Methods

We searched for groups of distinct cognitive profiles in 35 relapsing-remitting MS outpatients and 32 healthy controls. All individuals participated in an automated assessment (CANTAB) and in a pencil and paper general neuropsychological evaluation.

Results

Hierarchical cluster analysis of the CANTAB results revealed two distinct groups of patients based mainly on the Simple Reaction Time (RTI) and on the Mean Latency of Rapid Visual Processing (RVP). The general neuropsychological assessment did not show any statistically significant differences between the cluster groups. Compared to the healthy control group, all MS outpatients had lower scores for RTI, RVP, paired associate learning, and delayed matching to sample. We also analyzed the associations between CANTAB results and age, education, sex, pharmacological treatment, physical activity, employment status, and the Expanded Disability Status Scale (EDSS). Although limited by the small number of observations, our findings suggest a weak correlation between performance on the CANTAB and age, education, and EDSS scores.

Conclusions

We suggest that the use of selected large-scale automated visuospatial tests from the CANTAB in combination with multivariate statistical analyses may reveal subtle and earlier changes in information processing speed and cognition. This may expand our ability to define the limits between normal and impaired cognition in patients with Multiple Sclerosis.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1141-1) contains supplementary material, which is available to authorized users.

Pediatric-onset multiple sclerosis is associated with reduced parental health–related quality of life and family functioning

Background:

Diagnosis of multiple sclerosis (MS) during childhood has the potential to impact the affected child’s self-perception and the health-related quality of life (HRQoL) of the family.

Objective:

To evaluate the impact of chronic disease, in children ascertained as having MS and their families, when compared to those with monophasic acquired demyelinating syndrome (monoADS).

Methods:

In a national prospective cohort study of pediatric acquired demyelinating syndromes (ADS), the HRQoL of children and their families was captured using the Pediatric Quality of Life Inventory (PedsQL™) Modules.

Results:

Participants (58 MS; 178 monoADS) provided cross-sectional HRQoL data a median (interquartile range (IQR)) of 4.1 (2.0–6.0) years after disease onset. The HRQoL of parents of children with MS and their family functioning was lower when compared to that of parents and families of children with monoADS (both p < 0.001); parents of children with MS reported greater emotional dysfunction, worry, worse communication, and lower family functioning irrespective of clinical disease activity. Self-reports of the MS and monoADS participants did not suggest a difference in overall HRQoL or fatigue after adjusting for age of the child at the time of assessment.

Conclusion:

While children with MS did not self-report lower HRQoL compared to children who experienced monoADS, the diagnosis of MS during childhood was negatively associated with parental HRQoL and family functioning.

The disease burden of Multiple Sclerosis from the individual and population perspective: Which symptoms matter most?

BACKGROUND

MS symptoms affect many functional domains. Knowing the specific impact of symptoms on health-related quality of life (HRQoL) is vital for successful disease and symptom management in MS. We aimed at investigating how specific MS symptoms contribute to the disease burden in individuals and from a population perspective.

METHODS

We included 855 Swiss Multiple Sclerosis Registry participants with a relapsing-remitting form (RRMS) or a progressive form (PMS). HRQoL was measured with the EuroQol 5-Dimension EQ-5D-index and EQ-Visual Analogue Scale (EQ-VAS) on 0-100% scales. Their associations with 20 symptoms, socio-demographic and clinical information were explored in median regression models, stratified by RRMS and PMS.

RESULTS

We included 611 participants with RRMS and 244 with PMS. In RRMS, gait (-6.5%) and balance problems (-5.1%) had the largest EQ-5D-index reductions, and were also important at the population level (frequencies 45% and 52%). Fatigue, depression, and spasticity (frequencies 74.1%, 31%, 38%) also contributed to the population disease burden. In PMS, spasticity, paralysis, and bowel problems had the largest impact on EQ-5D-index, both at the individual and population levels. The largest impact on EQ-VAS at population level was associated in RRMS with balance problems, depression, dizziness, and spasticity, while in PMS with weakness, pain, and paralysis.

CONCLUSIONS

While HRQoL at population level is most affected by balance problems, spasticity, and depression in RRMS, the biggest HRQoL losses in PMS are caused by spasticity, paralysis, weakness, and pain. Many symptoms with the largest effects in individuals substantially contribute to the population disease burden.

Quality of life and psychological well-being in the early stages of multiple sclerosis (MS): Importance of adopting a biopsychosocial model

BACKGROUND

Reductions in quality of life (QOL) exist among individuals with multiple sclerosis (MS).

OBJECTIVE

The present investigation aimed to adopt a biopsychosocial model in examining QOL in the early stages of MS.

METHODS

Individuals with MS (34 with average to low QOL and 35 with high QOL) were compared on measures of disease symptoms, psychological functioning, personality, self-efficacy, locus of control (LOC), social support, and coping to determine the most salient predictors of QOL.

RESULTS

Individuals were matched on disease course and duration. Individuals with lower QOL reported more fatigue, sleep problems, pain, depression, and anxiety (d = 0.83-1.49, p's < 0.001). They also reported lower levels of self-efficacy, LOC, and social support (d = 0.75-1.50 p's < 0.01). They indicated higher levels of neuroticism (d = 1.31, p < .001) and lower levels of extraversion (d = 1.21, p < .001) and reported greater levels of disengagement as a means of coping (d = 0.75, p = .002). Those with high QOL endorsed more use of adaptive coping (d = 0.52 - 0.86, p's < 0.05). When taken together, LOC and anxiety were the most significant predictors, accounting for 40% of the variance.

CONCLUSION

Even early on in the illness, there exists differing levels of QOL. Identifying the psychological and social variables as well as the disease related factors is important, and in this case, may make a much greater contribution. Efforts to assure routine assessment and effective intervention aimed at these factors are warranted, particularly as an early intervention to assure maintenance/improvement in QOL among individuals with MS.

Psychiatric comorbidity is associated with disability progression in multiple sclerosis

OBJECTIVE

Emerging evidence suggests that comorbidity may influence disability outcomes in multiple sclerosis (MS); we investigated the association between psychiatric comorbidity and MS disability progression in a large multiclinic population.

METHODS

This retrospective cohort study accessed prospectively collected information from linked clinical and population-based health administrative databases in the Canadian provinces of British Columbia and Nova Scotia. Persons with MS who had depression, anxiety, or bipolar disorder were identified using validated algorithms using physician and hospital visits. Multivariable linear regression models fitted using an identity link with generalized estimating equations were used to determine the association between psychiatric comorbidity and disability using all available Expanded Disability Status Scale (EDSS) scores.

RESULTS

A total of 2,312 incident cases of adult-onset MS were followed for a mean of 10.5 years, during which time 35.8% met criteria for a mood or anxiety disorder. The presence of a mood or anxiety disorder was associated with a higher EDSS score (β coefficient = 0.28, p = 0.0002, adjusted for disease duration and course, age, sex, socioeconomic status, physical comorbidity count, and disease-modifying therapy exposure). Findings were statistically significant among women (β coefficient = 0.31, p = 0.0004), but not men (β coefficient 0.22, p = 0.17).

CONCLUSION

Presence of psychiatric comorbidities, which were common in our incident MS cohort, increased the severity of subsequent neurologic disability. Optimizing management of psychiatric comorbidities should be explored as a means of potentially mitigating disability progression in MS.

Progressive multiple sclerosis, cognitive function, and quality of life

Background

Patients with progressive multiple sclerosis (MS) often have cognitive impairment in addition to physical impairment. The burden of cognitive and physical impairment progresses over time, and may be major determinants of quality of life. The aim of this study was to assess to which degree quality of life correlates with physical and cognitive function in progressive MS.

Methods

This is a retrospective study of 52 patients with primary progressive (N = 18) and secondary progressive MS (N = 34). Physical disability was assessed using the Expanded Disability Status Scale, Timed 25 Foot Walk (T25FW) test and 9-Hole Peg Test (9HPT). Cognitive function was assessed using Symbol Digit Modalities Test (SDMT), Paced Auditory Serial Addition Test, and Trail Making Test B (TRAIL-B). In addition, quality of life was assessed by the Short Form 36 (SF-36) questionnaire.

Results

Only measures of cognitive function correlated with the overall SF-36 quality of life score and the Mental Component Summary score from the SF-36. The only physical measure that correlated with a measure of quality of life was T25FW test, which correlated with the Physical Component Summary from the SF-36. We found no other significant correlations between the measures of cognitive function and the overall physical measures but interestingly, we found a possible relationship between the 9HPT score for the nondominant hand and the SDMT and TRAIL-B.

Conclusion

Our findings support inclusion of measures of cognitive function in the assessment of patients with progressive MS as these correlated closer with quality of life than measures of physical impairment.

The Turkish validation of the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) battery

Background

Cognitive impairment may be seen in as many as 43–70% of patients with multiple sclerosis (MS) and may be observed in all MS subtypes. The Brief International Cognitive Assessment in Multiple Sclerosis (BICAMS) battery may be used to evaluate cognition status. The purpose of the current study is to validate the BICAMS battery in Turkish.

Methods

Patients with MS attending our clinic between September 2014 and April 2015 were invited to participate. Healthy control participants were matched in terms of age, gender and years of education.

Results

One hundred seventy-three MS patients and 153 healthy control participants were enrolled in the study. MS patients performed significantly worse in all trials than the members of the healthy control group. In addition, cognitive dysfunction was identified in 78 of the 173 (45.1%) patients. In the MS with cognitive impairment group, 64 out of 151 (42.4%) subjects were RRMS patients, 12 out of 18 (66.7%) were secondary progressive MS patients, and 2 out of 4 (50%) were primer progressive MS patients.

Conclusions

The BICAMS has been proposed for assessing cognitive impairment in MS patients. This study shows that the battery is suitable for use in Turkey.

Indication of Cognitive Change and Associated Risk Factor after Thoracic Surgery in the Elderly: A Pilot Study

Background: This pilot study investigated the effects of partial pulmonary lobectomy lung surgery on cognitive functions of elderly Japanese patients. It is recognized that elderly patients undergoing surgery have increased risk of Postoperative Cognitive Decline (POCD), a condition in which learning, memory, and processing speed is greatly reduced after surgery. Since elderly patients are more likely to exhibit symptoms of POCD, the incidence is increasing as the population receiving surgery is aging.

Methods: Cognitive function was measured for all subjects (n = 12) before and after surgery using three different cognitive tests: Mini-Mental Status Exam-Japanese (MMSE-J), Frontal Assessment Battery (FAB), and a computerized Cogstate Brief Battery (CBB). Changes in these measures indicate changes in cognitive function. In addition, the 12-item General Health Questionnaire (GHQ-12), the Geriatric Depression Scale (GDS), and the 5-item Quality of Life questionnaire (QOL-5) were administered at each time point to measure mental and emotional state. Changes in outcome measures were analyzed via Wilcoxon signed-rank test. Exploratory correlation analysis was conducted using Spearman’s rho.

Results: Data show a decline in detection (DET; p = 0.045) and identification (IDN; p = 0.038). Spearman’s correlation coefficient show a significant correlation between postoperative DET scores and postoperative IDN scores (ρ = 0.78, p = 0.005), a significant correlation between change in IDN and baseline GHQ-12 scores (ρ = -0.595, p = 0.027), and a significant correlation between change in one-back (OBK) scores and duration of anesthesia (ρ = -0.72, p = 0.012).

Discussion: This was the first report to examine cognitive decline after major thoracic surgery in Japanese patients. Previous studies have evidenced that POCD is a common phenomenon after surgery, and that age is a major risk factor. The CCB measured significant change in two cognitive domains: attention and psycomotor function. This study clarified that decline in cognition is detectable in certain measures after thoracic surgery in the elderly Japanese patient population. Additionally, longer anesthetic exposure may negatively impact attention and working memory, and preoperative mental wellbeing is a possible predictor of POCD. These preliminary results have important implications and support the need for future studies.

Improvement of quality of life and its relationship with neuropsychiatric outcomes in patients with multiple sclerosis starting treatment with natalizumab: A 3-year follow-up multicentric study

BACKGROUND

Health-related quality of life (HRQoL) is impaired in multiple sclerosis (MS) but can be improved by disease-modifying therapies such as natalizumab. However, the predictive factors and neuropsychiatric correlates of HRQoL improvement are unknown.

METHODS

In this study, 48 patients with relapsing-remitting MS were included in a 3-year open-label, single group, multicenter, clinical trial (NCT01392872). HRQoL was measured by the disease-specific MusiQoL questionnaire, together with physical disability, cognition, fatigue, anxiety and depression scores at baseline, 6months, 12months, 18months and 36months after starting natalizumab therapy.

RESULTS

Compared to baseline, global HRQoL, as measured with the index of the MusiQoL, was significantly increased 6months after the beginning of natalizumab therapy, with medium effect-size (58.6±16.2 vs 69.8±18.9, p<0.001, Cohen's d=0.63). This improvement was maintained over time for up to 3years and mainly concerned activity of daily living, psychological well-being, symptoms and coping (p<0.001 for every dimensions). The variation of global HRQoL after 3years was negatively correlated with the variation of fatigue score (r=-0.44, p=0.015). Furthermore, a higher fatigue score at baseline was correlated with improvement in global HRQoL 3years afterwards (r=0.34, p=0.041), independently of age, educational level, disease duration and disability at baseline (β=2.45, p=0.020). Disability at baseline, cognitive impairment, anxiety and depression failed to predict or correlate with global HRQoL improvement in multivariate analyses.

CONCLUSION

Natalizumab improved HRQoL quickly and sustainably in patients with relapsing-remitting MS. In terms of HRQoL, natalizumab seems to benefit mostly patients with more marked fatigue at baseline.

Health-Related Quality of Life in Patients with Multiple Sclerosis: Impact of Disease-Modifying Drugs

Multiple sclerosis (MS) has a profound impact on health-related quality of life (HRQoL), a comprehensive subjective measure of the patient's health status. Assessment of HRQoL informs on the potential advantages and disadvantages of disease-modifying drugs (DMDs) beyond their effects on observer-based disability and magnetic resonance imaging abnormalities. This article reviews published data from randomized controlled trials and observational studies regarding the effects of currently available DMDs on HRQoL. Data indicate that DMD treatment is associated with prevention of worsening or with improvement of HRQoL, and that, in general, second-line DMDs may have a greater impact on HRQoL than first-line DMDs. In clinical practice, monitoring of HRQoL provides clinicians with unique information regarding disease impact and potential benefits and adverse effects of DMD treatment that may not be obtained otherwise; it might also permit early detection of an unfavorable disease course. It is suggested to assess HRQoL at the time of diagnosis and before starting or switching DMD treatment. Regular HRQoL measurements contribute to a comprehensive clinical evaluation, and may help to elucidate and quantify the patient's contribution to shared decision making regarding DMD treatment. Further studies are needed to better determine the role of HRQoL assessments in daily MS care.

Patient characteristics and determinants of quality of life in an international population with multiple sclerosis: Assessment using the MusiQoL and SF-36 questionnaires

Background: Multiple sclerosis (MS) can have psychological and socioeconomic consequences that affect patients’ health-related quality of life (HRQoL) as much as physical disability.

Objective: To determine the clinical and sociodemographic factors affecting HRQoL in a large international study using the MS International QoL (MusiQoL) questionnaire.

Methods: Patients aged >18 years with a diagnosis of MS for >6 months or clinically isolated syndrome (CIS) were enrolled. Sociodemographic and clinical data were recorded, and patients completed the MusiQoL and 36-item short form (SF-36) health survey questionnaires.

Results: In total, 1992 patients from 15 countries were enrolled (mean [standard deviation] age: 42.3 [12.5] years; 70.5% women; 70.4% with relapsing–remitting MS). Multivariate multiple regression analyses identified lower educational level, higher Expanded Disability Status Scale (EDSS) score, cognitive impairment, being single and shorter time since last relapse as significant predictors of lower MusiQoL global index scores ( p < 0.05). Older age, female sex, higher EDSS score, shorter time since last relapse and receiving current MS treatment were significant predictors of lower SF-36 physical component summary scores ( p < 0.05). The SF-36 mental component summary score was linked to occupational status, inpatient/outpatient status, time since last relapse, and whether the patient was receiving MS treatment ( p < 0.05).

Conclusion: Sociodemographic and clinical factors are linked to HRQoL in patients with MS. Interventions that affect these factors might be expected to influence HRQoL.

Impact of depression and disability on quality of life in Iranian patients with multiple sclerosis

Multiple sclerosis (MS) can influence all aspects of a patient's health. This study determines the main factors affecting quality of life (QoL) in Iranian MS patients. QoL (Multiple Sclerosis Impact Scale; MSIS-29), disability (Expanded Disability Status Scale; EDSS) and depression (Beck Depression Inventory; BDI) were assessed in 106 MS patients. EDSS, clinical course and MS duration significantly correlated with physical MSIS-29. Depression highly correlated with both physical and psychological MSIS-29. Regression analyses showed that depression and EDSS predicted physical health. Psychological health was predicted by depression. These findings highlight that depression and physical disability strongly influence QoL in Iranian MS patients. Multiple Sclerosis 2007; 13: 275–277. http://msj.sagepub.com

Orthostatic Tremor: An Update on a Rare Entity

Background

Orthostatic tremor (OT) remains among the most intriguing and poorly understood of movement disorders. Compared to Parkinson’s disease or even essential tremor, there are very few articles addressing more basic science issues. In this review, we will discuss the findings of main case series on OT, including data on etiology, pathophysiology, diagnostic approach, treatment strategies, and outcome.

Methods

Data for this review were identified by searching PUBMED (January 1966 to August 2016) for the terms “orthostatic tremor” or “shaky leg syndrome,” which yielded 219 entries. We did not exclude papers on the basis of language, country, or publication date. The electronic database searches were supplemented by articles in the authors’ files that pertained to this topic.

Results

Owing to its rarity, the current understanding of OT is limited and is mostly based on small case series or case reports. Despite this, a growing body of evidence indicates that OT might be a progressive condition that is clinically heterogeneous (primary vs. secondary cases) with a broader spectrum of clinical features, mainly cerebellar signs, and possible cognitive impairment and personality disturbances. Along with this, advanced neuroimaging techniques are now demonstrating distinct anatomical and functional changes, some of which are consistent with neuronal loss.

Discussion

OT might be a family of diseases, unified by the presence of leg tremor, but further characterized by etiological and clinical heterogeneity. More work is needed to understand the pathogenesis of this condition.

Testing the health promotion model for adherence and quality of life in individuals with multiple sclerosis

The nature of multiple sclerosis (MS) presents challenges to health-promoting behaviors (e.g. adherence) and quality of life. The Health Promotion Model (HPM) proposes that these outcomes are explained by individual characteristics (i.e. biological, social, psychological) and behavior-specific cognitions (e.g. self-efficacy). The current study sought to test the HPM in explaining self-reported adherence and MS quality of life among 121 MS patients receiving care in an MS clinic in the southeastern United States. Hierarchical regression models partially supported the HPM for adherence (R² = .27) and more fully for quality of life (QoL) (R² = .64). Depression and stigma were among the variables most strongly related to both adherence and QoL; contrary to HPM theory, self-efficacy was not significantly related to adherence but was to QoL. Thus, the HPM may help to guide strategies used to improve QoL among individuals living with MS; however, the model may need further refinement to be used with adherence.