Clinical outcome measures for research in multiple sclerosis

Identify the report as a systematic review

Background: To examine the relationship of vitamin B12 and folate concentrations to cognitive function, fatigue measures, physical function, quality of life (patient-centred outcomes) and homocysteine plasma concentrations (intermediate marker of cobalamin and folate deficiency) for patients with Multiple Sclerosis (MS). Methods: Systematic searches for eligible articles of MEDLINE, CINAHL, EMBASE, Scopus, Web of Science and OpenGray databases were conducted from 1983 in March 2021. Heterogeneity, Weighted Mean Difference (WMD) and Confidence Intervals (CI) calculated using Random Effects Model. Results: Sixteen studies were included involving; 616 MS patients and 655 healthy controls. 14 of these had acceptable or better quality but there was high heterogeneity. No difference was found between MS, healthy controls for folate and cobalamin concentrations; WMD 0.00ug/L (95% CI: -0.01, 0.01) and WMD 7.01pmol/L (95% CI: -25.54, 39.55) respectively. MS group showed mild-to-moderate disability WMD was 2.78 (95% CI: 2.00, 3.56). MS may be associated with elevated plasma homocysteine concentrations on average 2.47µmol/L more than healthy controls. Discussion: Physical ability of MS group was worse than healthy controls, but there was no difference in folate and cobalamin concentrations. This suggests folate and cobalamin are not influential factors in worsening physical function. There may be an association between worse cognitive function, and increased homocysteine concentrations. Results were inconclusive due to high heterogeneity and limited number of studies. A core outcome set would enable easier synthesis of future results.

Predicting Multiple Sclerosis From Gait Dynamics Using an Instrumented Treadmill: A Machine Learning Approach

OBJECTIVE

Multiple Sclerosis (MS) is a neurological condition which widely affects people 50-60 years of age. While clinical presentations of MS are highly heterogeneous, mobility limitations are one of the most frequent symptoms. This study examines a machine learning (ML) framework for identifying MS through spatiotemporal and kinetic gait features.

METHODS

In this study, gait data during self-paced walking on an instrumented treadmill from 20 persons with MS and 20 age, weight, height, and gender-matched healthy older adults (HOA) were obtained. We explored two strategies to normalize data and minimize dependence on subject demographics; size-normalization (standard body size-based normalization) and regress-normalization (regression-based normalization using scaling factors derived by regressing gait features on multiple subject demographics); and proposed an ML based methodology to classify individual strides of older persons with MS (PwMS) from healthy controls. We generalized both across different walking tasks and subjects.

RESULTS

We observed that regress-normalization improved the accuracy of identifying pathological gait using ML when compared to size-normalization. When generalizing from comfortable walking to walking while talking, gradient boosting machine achieved the optimal subject classification accuracy and AUC of 94.3 and 1.0, respectively and for subject generalization, a multilayer perceptron resulted in the best accuracy and AUC of 80% and 0.86, respectively, both with regression-normalized data.

CONCLUSION

The integration of gait data and ML may provide a viable patient-centric approach to aid clinicians in monitoring MS.

SIGNIFICANCE

The results of this study have future implications for the way regression normalized gait features may be clinically used to design ML-based disease prediction strategies and monitor disease progression in PwMS.

Simulating Visibility and Reading Performance in Low Vision

PURPOSE

Low vision reduces text visibility and causes difficulties in reading. A valid low-vision simulation could be used to evaluate the accessibility of digital text for readers with low vision. We examined the validity of a digital simulation for replicating the text visibility and reading performance of low-vision individuals.

METHODS

Low-vision visibility was modeled with contrast sensitivity functions (CSFs) with parameters to represent reduced acuity and contrast sensitivity. Digital filtering incorporating these CSFs were applied to digital versions of the Lighthouse Letter Acuity Chart and the Pelli-Robson Contrast Sensitivity Chart. Reading performance (reading acuity, critical print size, and maximum reading speed) was assessed with filtered versions of the MNREAD reading acuity Chart. Thirty-six normally sighted young adults completed chart testing under normal and simulated low-vision conditions. Fifty-eight low-vision subjects (thirty with macular pathology and twenty-eight with non-macular pathology) and fifteen normally sighted older subjects completed chart testing with their habitual viewing. We hypothesized that the performance of the normally sighted young adults under simulated low-vision conditions would match the corresponding performance of actual low-vision subjects.

RESULTS

When simulating low-vision conditions with visual acuity better than 1.50 logMAR (Snellen 20/630) and contrast sensitivity better than 0.15 log unit, the simulation adequately reduced the acuity and contrast sensitivity in normally sighted young subjects to the desired low-vision levels. When performing the MNREAD test with simulated low vision, the normally sighted young adults had faster maximum reading speed than both the Non-macular and Macular groups, by an average of 0.07 and 0.12 log word per minute, respectively. However, they adequately replicated the reading acuity as well as the critical print size, up to 2.00 logMAR of both low-vision groups.

CONCLUSION

A low-vision simulation based on clinical measures of visual acuity and contrast sensitivity can provide good estimates of reading performance and the accessibility of digital text for a broad range of low-vision conditions.

The immediate effect of stroboscopic visual training on information-processing time in people with multiple sclerosis: an exploratory study

Stroboscopic visual training (SVT) is a form of training aimed at improving visual and perceptual performance by having individuals perform activities under conditions of intermittent vision. The efficacy of SVT has never been examined in people with multiple sclerosis (PwMS), therefore, our aim was to examine the immediate effect of SVT on cognitive function, gait and static balance performance in PwMS. This assessor-blinded, randomized crossover study included 26 PwMS, 16 females, mean age 47.9 and median EDSS score 4.5. Participants attended two sessions: SVT and control training. Exercises for both the SVT and control sessions were based on ball-catching tasks. Training sessions were identical in length (40-50 min) and type of exercise drills. The difference between the two practice regimes was that the SVT session was performed wearing stroboscopic glasses and the control training was performed with similar glasses without lenses. Cognition was evaluated by a computerized software (Mindstreams^®, NeuroTrax Corp., NY). Gait and balance were evaluated via wearable accelerometers (APDM, Oregon, USA). Outcome measures were collected twice during a single session, prior to training and immediately afterward. Information processing speed (p = 0.003) increased at the post-evaluation compared with baseline, solely in the SVT session. No differences between pre-post evaluations were observed for other cognitive scores following the SVT session. No differences between pre-post measurements were noted for gait and balance following the SVT session. The present study's results justify performing future RCT studies to examine the effects of a longer SVT program on cognition in PwMS.

Exploring Characteristic Features in Gait Patterns for Predicting Multiple Sclerosis

Multiple Sclerosis (MS), an autoimmune and demyelinating disease, is one the most prevalent neurological disabilities in young adults. It results in damage of the central nervous system, disrupting communication between the patient's brain, spinal cord and body. Mobility limitations is one of the earliest symptoms and affects a majority of persons with Multiple Sclerosis. We are working towards an effort to characterize individuals with MS, from those without, on the basis of variations in the gait patterns. In the proposed work, statistical methods were used to identify differentiating gait data features for MS characterization. The prediction algorithms built upon these characteristic features will help clinicians develop effective and early cure and therapy designs for persons with Multiple Sclerosis.

Turning is an important marker of balance confidence and walking limitation in persons with multiple sclerosis

The standard functional tool for gait assessment in multiple sclerosis (MS) clinical trials has been the 25-Foot Timed Walk Test, a measure of gait speed. Straight-line gait assessment may not reflect adequately upon balance and coordination. Walking tests with turns may add additional information towards understanding gait and balance status, and be more reflective of ambulation in the community. Understanding the impact of turn parameters on patient-reported outcomes of balance and walking would help MS clinicians better formulate treatment plans for persons with gait limitations. In this study, ninety-one persons with MS (Expanded Disability Status Score; EDSS, range: 0–6.5) were enrolled in an initial cross-sectional study. Twenty-four subjects (EDSS, range:1.0–6.0) completed a follow-up visit an average of 12 months later. Spatiotemporal gait analysis was collected at both visits using APDM Opal wireless body-worn sensors while performing the Timed-Up-and-Go (TUG) and 6-Minute Walk Test (6MWT). For both cross-sectional and longitudinal data, regression analyses determined the impact on the addition of turning parameters to stride velocity (SV), in the prediction of self-reported balance confidence (Activities-Specific Balance Confidence Scale (ABC)) and walking limitation (12-item Multiple Sclerosis Walking Scale (MSWS-12)). The addition of 6MWT peak turn velocity (PTV) to 6MWT SV increased the predictive power of the 6MWT for the ABC from 20% to 33%, and increased the predictive power from 28% to 41% for the MSWS-12. TUG PTV added to TUG SV also strengthened the relationship of the TUG for the ABC from 19% to 28%, and 27% to 36% for the MSWS-12. For those with 1 year follow-up, percent change in turn number of steps (TNS%Δ) during the 6MWT added to 6MWT SV%Δ improved the modeling of ABC%Δ from 24% to 33%. 6MWT PTV%Δ added to 6MWT SV%Δ increased the predictive power of MSWS-12%Δ from 8% to 27%. Conclusively, turn parameters improved modeling of self-perceived balance confidence and walking limitations when added to the commonly utilized measure of gait speed. Tests of longer durations with multiple turns, as opposed to shorter durations with a single turn, modeled longitudinal change more accurately. Turn speed and stability should be qualitatively assessed during the clinic visit, and use of multi-faceted tests such as the TUG or 6MWT may be required to fully understand gait deterioration in persons with MS.

Exercise response in Parkinson's disease: insights from a cross-sectional comparison with sedentary controls and a per-protocol analysis of a randomised controlled trial

OBJECTIVES

To investigate the acute and adaptation cardiovascular and metabolic training responses in people with Parkinson's disease (pwP).

DESIGN

(1) A cross-sectional study of exercise response of pwP compared with sedentary controls and (2) an interventional study of exercise training in pwP.

SETTING

Community leisure facilities.

PARTICIPANTS

pwP (n=83) and sedentary controls (n=55).

INTERVENTIONS

Study 1 included participants from a two-arm-parallel single-blind phase II randomised controlled trial (RCT), that undertook a baseline maximal incremental exercise test and study 2 included those randomised to the exercise group in the RCT, who completed a 6-month weekly exercise programme (n=37). The intervention study 2 was a prescribed exercise program consisting of sessions lasting 60 min, two times a week over a 6-month period. The control group followed the same protocol which derived the same cardiorespiratory parameters, except that they were instructed to aim for a cadence of ~60 revolutions per minute and the unloaded phase lasted 3 min with an initial step of 25 W.

PRIMARY AND SECONDARY OUTCOME MEASURES

Stepwise incremental exercise test to volitional exhaustion was the primary outcome measure.

RESULTS

Study 1 showed higher maximum values for heart rate (HR), VO₂ L/min, VCO₂ L/min and ventilation L/min for the control group; respiratory exchange ratio (RER), perceived exertion and O₂ pulse (VO₂ L/min/HR) did not differ between groups. In study 2, for pwP who adhered to training (n=37), RER increased significantly and although there was no significant change in aerobic capacity or HR response, reduced blood pressure was found.

CONCLUSIONS

An abnormal cardiovascular response to exercise was observed in pwP compared to controls. After the exercise programme, metabolic deficiencies remained for pwP. These observations add to the pathogenic understanding of PD, acknowledge an underling metabolic contribution and support that certain cardiovascular symptoms may improve as a result of this type of exercise.

Efficacy of daclizumab beta versus intramuscular interferon beta-1a on disability progression across patient demographic and disease activity subgroups in DECIDE

Background:

Demonstration of clinical benefits on disability progression measures is an important attribute of effective multiple sclerosis (MS) treatments.

Objective:

Examine efficacy of daclizumab beta versus intramuscular (IM) interferon beta-1a on measures of disability progression in patient subgroups from DECIDE.

Methods:

Twenty-four-week confirmed disability progression (CDP), 24-week sustained worsening on a modified Multiple Sclerosis Functional Composite (MSFCS) where 3-Second Paced Auditory Serial Addition Test was replaced by Symbol Digit Modalities Test, and proportion of patients with clinically meaningful worsening in 29-Item Multiple Sclerosis Impact Scale physical impact subscale (MSIS-29 PHYS) score from baseline to week 96 were examined in the overall population and subgroups defined by baseline demographic/disease characteristics.

Results:

Daclizumab beta significantly reduced risk of 24-week CDP (hazard ratio (HR), 0.73; 95% confidence interval (95% CI), 0.55–0.98), risk of 24-week sustained MSFCS progression (HR, 0.80; 95% CI, 0.67–0.95), and odds of clinically meaningful worsening in MSIS-29 PHYS (odds ratio, 0.76; 95% CI, 0.60–0.95) versus IM interferon beta-1a. Point estimates showed trends favoring daclizumab beta over IM interferon beta-1a across several patient subgroups for all three outcome measures.

Conclusion:

Daclizumab beta showed consistent benefit versus IM interferon beta-1a across measures assessing patient disability/function and across a range of clinical baseline characteristics in patients with relapsing-remitting MS.

Phase II randomised controlled trial of a 6-month self-managed community exercise programme for people with Parkinson's disease

BACKGROUND

Evidence for longer term exercise delivery for people with Parkinson's disease (PwP) is deficient.

AIM

Evaluate safety and adherence to a minimally supported community exercise intervention and estimate effect sizes (ES).

METHODS

2-arm parallel phase II randomised controlled trial with blind assessment. PwP able to walk ≥100 m and with no contraindication to exercise were recruited from the Thames valley, UK, and randomised (1:1) to intervention (exercise) or control (handwriting) groups, via a concealed computer-generated list. Groups received a 6-month, twice weekly programme. Exercise was undertaken in community facilities (30 min aerobic and 30 min resistance) and handwriting at home, both were delivered through workbooks with monthly support visits. Primary outcome was a 2 min walk, with motor symptoms (Movement Disorder Society Unified Parkinson's Disease Rating Scale, MDS-UPDRS III), fitness, health and well-being measured.

RESULTS

Between December 2011 and August 2013, n=53 (n=54 analysed) were allocated to exercise and n=52 (n=51 analysed) to handwriting. N=37 adhered to the exercise, most attending ≥1 session/week. Aerobic exercise was performed in 99% of attended sessions and resistance in 95%. Attrition and adverse events (AEs) were similar between groups, no serious AEs (n=2 exercise, n=3 handwriting) were related, exercise group-related AEs (n=2) did not discontinue intervention. Largest effects were for motor symptoms (2 min walk ES=0.20 (95% CI -0.44 to 0.45) and MDS-UPDRS III ES=-0.30 (95% CI 0.07 to 0.54)) in favour of exercise over the 12-month follow-up period. Some small effects were observed in fitness and well-being measures (ES>0.1).

CONCLUSIONS

PwP exercised safely and the possible long-term benefits observed support a substantive evaluation of this community programme.

TRIAL REGISTRATION NUMBER

NCT01439022.

Application of diffusional kurtosis imaging to detect occult brain damage in multiple sclerosis and neuromyelitis optica

Multiple sclerosis (MS) and neuromyelitis optica (NMO) are two common types of inflammatory demyelinating disease of the central nervous system. Early distinction of NMO from MS is crucial but quite challenging. In this study, 13 NMO spectrum disorder patients (Expanded Disability Status Scale (EDSS) of 3.0 ± 1.7, ranging from 2 to 6.5; disease duration of 5.3 ± 4.7 years), 17 relapsing-remitting MS patients (EDSS of 2.6 ± 1.4, ranging from 1 to 5.5; disease duration of 7.9 ± 7.8 years) and 18 healthy volunteers were recruited. Diffusional kurtosis imaging was employed to discriminate NMO and MS patients at the early or stable stage from each other, and from healthy volunteers. The presence of alterations in diffusion and diffusional kurtosis metrics in normal-appearing white matter (NAWM) and diffusely increased mean diffusivity (MD) in the cortical normal-appearing gray matter (NAGM) favors the diagnosis of MS rather than NMO. Meanwhile, normal diffusivities and kurtosis metrics in all NAWM as well as increases in MD in the frontal and temporal NAGM suggest NMO. Our results suggest that diffusion and diffusional kurtosis metrics may well aid in discriminating the two diseases.

Study design of PANGAEA 2.0, a non-interventional study on RRMS patients to be switched to fingolimod

BACKGROUND

The therapeutic options for patients with Multiple Sclerosis (MS) have steadily increased due to the approval of new substances that now supplement traditional first-line agents, demanding a paradigm shift in the assessment of disease activity and treatment response in clinical routine. Here, we report the study design of PANGAEA 2.0 (Post-Authorization Non-interventional GermAn treatment benefit study of GilEnyA in MS patients), a non-interventional study in patients with relapsing-remitting MS (RRMS) identify patients with disease activity and monitor their disease course after treatment switch to fingolimod (Gilenya®), an oral medication approved for patients with highly active RRMS.

METHOD/DESIGN

In the first phase of the PANGAEA 2.0 study the disease activity status of patients receiving a disease-modifying therapy (DMT) is evaluated in order to identify patients at risk of disease progression. This evaluation is based on outcome parameters for both clinical disease activity and magnetic resonance imaging (MRI), and subclinical measures, describing disease activity from the physician's and the patient's perspective. In the second phase of the study, 1500 RRMS patients identified as being non-responders and switched to fingolimod (oral, 0.5 mg/daily) are followed-up for 3 years. Data on relapse activity, disability progression, MRI lesions, and brain volume loss will be assessed in accordance to 'no evidence of disease activity-4' (NEDA-4). The modified Rio score, currently validated for the evaluation of treatment response to interferons, will be used to evaluate the treatment response to fingolimod. The MS management software MSDS3D will guide physicians through the complex processes of diagnosis and treatment. A sub-study further analyzes the benefits of a standardized quantitative evaluation of routine MRI scans by a central reading facility. PANGAEA 2.0 is being conducted between June 2015 and December 2019 in 350 neurological practices and centers in Germany, including 100 centers participating in the sub-study.

DISCUSSION

PANGAEA 2.0 will not only evaluate the long-term benefit of a treatment change to fingolimod but also the applicability of new concepts of data acquisition, assessment of MS disease activity and evaluation of treatment response for the in clinical routine.

TRIAL REGISTRATION

BfArM6532; Trial Registration Date: 20/05/2015.

Detection of postural sway abnormalities by wireless inertial sensors in minimally disabled patients with multiple sclerosis: a case-control study

Background

Common clinical neurological exams can be insensitive to balance and mobility impairment at the early stages of multiple sclerosis (MS) and may not correspond with patient reports. Instrumented measurement of standing postural sway with inertial motion sensors may provide sensitive measures of balance impairment and better correspond with patient reports.

Methods

While wearing wireless inertial sensors, 20 subjects with MS – Expanded Disability Status Scale of less than 3.0 and a Timed 25 Foot Walk of 5 sec or less – and 20 age- and sex-matched control subjects stood with eyes open and eyes closed on a foam surface. Forty-six outcome measures of postural sway were derived. A stepwise logistic regression model determined which measures of instrumented sway provide independent predictors of group status. Subjects with MS also completed the Activities-Specific Balance Confidence (ABC) scale and the 12-Item MS Walking Scale (MSWS-12) as measures of subject-reported balance and mobility impairment.

Results

The regression model identified medio-lateral sway path length and medio-lateral range of sway acceleration amplitude, each in the eyes-open condition, as the only two significant independent predictors to differentiate subjects with MS from those without MS (model chi-squared = 34.55, p < 0.0001): accuracy = 87.5 %, positive likelihood ratio = 6 (2.09–17.21), negative likelihood ratio = 0.12 (0.03–0.44). Range of sway acceleration amplitude significantly correlated with both ABC (Spearman’s r = −0.567, p = 0.009) and MSWS-12 scores (Spearman’s r = −0.590, p = 0.006).

Conclusions

Postural sway abnormalities in subjects with MS who are minimally disabled were detected using wireless inertial sensors and may signify a superior sensitivity to identify balance impairment prior to developing clinically evident disability or impaired gait speed. Further study is needed to confirm the clinical significance and predictive value of these objectively identified balance impairments.

Motor network efficiency and disability in multiple sclerosis

OBJECTIVE

To develop a composite MRI-based measure of motor network integrity, and determine if it explains disability better than conventional MRI measures in patients with multiple sclerosis (MS).

METHODS

Tract density imaging and constrained spherical deconvolution tractography were used to identify motor network connections in 22 controls. Fractional anisotropy (FA), magnetization transfer ratio (MTR), and normalized volume were computed in each tract in 71 people with relapse onset MS. Principal component analysis was used to distill the FA, MTR, and tract volume data into a single metric for each tract, which in turn was used to compute a composite measure of motor network efficiency (composite NE) using graph theory. Associations were investigated between the Expanded Disability Status Scale (EDSS) and the following MRI measures: composite motor NE, NE calculated using FA alone, FA averaged in the combined motor network tracts, brain T2 lesion volume, brain parenchymal fraction, normal-appearing white matter MTR, and cervical cord cross-sectional area.

RESULTS

In univariable analysis, composite motor NE explained 58% of the variation in EDSS in the whole MS group, more than twice that of the other MRI measures investigated. In a multivariable regression model, only composite NE and disease duration were independently associated with EDSS.

CONCLUSIONS

A composite MRI measure of motor NE was able to predict disability substantially better than conventional non-network-based MRI measures.

An Eye on Brain Integrity: Acute Optic Neuritis Affects Resting State Functional Connectivity

PURPOSE

Currently, the ability for imaging to capture brain adaptations to injury that occurs in multiple sclerosis (MS) is limited. In particular, how the brain initially contends with the earliest clinical manifestations of white matter injury has yet to be defined. The purpose of this study was to determine the impact of acute optic neuritis (ON) on resting state functional connectivity magnetic resonance imaging (rs-fcMRI).

METHODS

Fifteen patients with a clinically isolated syndrome of acute ON were evaluated at an academic center in a prospective study. Subjects were assessed with structural and functional vision measures, including optical coherence tomography (OCT), high- and low-contrast letter acuity testing, and visual fields and quality-of-life measures (VFQ-25). The rs-fcMRI was compared with age- and sex-matched healthy controls.

RESULTS

We observed reduced functional connectivity within the visual system and a loss of anticorrelations between the visual system and nonvisual networks. Stronger functional connectivity between visual regions correlated with better quality of life, as measured by the VFQ-25, and better acuity scores for both high- and low-contrast testing in the affected eye.

CONCLUSIONS

The rs-fcMRI functional connectivity changes within (intranetwork) and between (internetwork) resting state networks occur after acute ON, indicating immediate cortical responses to focal inflammatory demyelination. Thus, focal white matter injury in the central nervous system acutely results in widespread network alterations that may lead to functional neurologic changes seen in MS.

Outcome measures in relapsing-remitting multiple sclerosis: capturing disability and disease progression in clinical trials

Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease that manifests as acute relapses and progressive disability. As a primary endpoint for clinical trials in MS, disability is difficult to both characterize and measure. Furthermore, the recovery from relapses and the rate of disability vary considerably among patients. Given these challenges, investigators have developed and studied the performance of various outcome measures and surrogate endpoints in MS clinical trials. This review defines the outcome measures and surrogate endpoints used to date in MS clinical trials and presents challenges in the design of both adult and pediatric trials.

Predictors of executive complaints and executive deficits in multiple sclerosis

OBJECTIVES

To investigate executive complaints and objective executive deficits and their relations to both depression and neurological function in multiple sclerosis (MS).

MATERIALS AND METHODS

One hundred and twenty MS patients participating in multidisciplinary rehabilitation underwent assessment with the Expanded Disability Status Scale (EDSS), neuropsychological tests of executive function, self-report measures of executive function (BRIEF-A), and depression (BDI-II).

RESULTS

Multivariate regression analysis showed that moderate depression and above (BDI-II > 20) significantly predicted a high degree of subjective executive complaints. Multivariate regression analysis showed that EDSS scores above 4.3 significantly predicted executive cognitive deficit, measured by neuropsychological tests.

CONCLUSION

Among the study variables, depression was the strongest predictor of executive complaints. A high degree of neurological disability was the strongest predictor for executive deficit, measured by neuropsychological tests.

Systematic literature review and validity evaluation of the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC) in patients with multiple sclerosis

BACKGROUND

There are a number of instruments that describe severity and progression of multiple sclerosis and they are increasingly used as endpoints to assess the effectiveness of therapeutic interventions. We examined to what extent the psychometric properties of two accepted instruments--EDSS and MSFC--meet methodological standards and the value they have in clinical trials.

METHODS

We conducted a systematic literature search in relevant databases [MEDLINE (PubMed), ISI Web of Science, EMBASE, PsycINFO & PSYNDEX, CINAHL] yielding 3,860 results. Relevant full-text publications were identified using abstract and then full-text reviews, and the literature was reviewed.

RESULTS

For evaluation of psychometric properties (validity, reliability, sensitivity of change) of EDSS and MSFC, 120 relevant full-text publications were identified, 54 of them assessed the EDSS, 26 the MSFC and 40 included both instruments. The EDSS has some documented weaknesses in reliability and sensitivity to change. The main limitations of the MSFC are learning effects and the z-scores method used to calculate the total score. However, the methodological criterion of validity applies sufficiently for both instruments.For use in clinical studies, we found the EDSS to be preferred as a primary and secondary outcome measure in recent studies (50 EDSS, 9 MSFC).

CONCLUSIONS

Recognizing their strengths and weaknesses, both EDSS and MSFC are suitable to detect the effectiveness of clinical interventions and to monitor disease progression. Almost all publications identify the EDSS as the most widely used tool to measure disease outcomes in clinical trials. Despite some limitations, both instruments are accepted as endpoints and neither are discussed as surrogate parameters in identified publications. A great advantage of the EDSS is its international acceptance (e.g. by EMA) as a primary endpoint in clinical trials and its broad use in trials, enabling cross-study comparisons.

Content comparison of multidimensional, patient-reported outcome measures in multiple sclerosis rehabilitation and the ICF

SUMMARY Multiple sclerosis (MS) is a complex condition, with long-term physical, cognitive and behavioral disabilities, and lifestyle consequences. Individuals with MS require regular evaluation for persisting disability and psychological sequelae. This should incorporate patients’ perspectives on functioning and health. This review summarizes and compares the content of commonly used multidimensional, patient-reported outcome measures in MS in relation to the International Classification of Functioning, Disability and Health comprehensive MS Core set. The focused domains of these measures, the commonalities and discrepancies, and breadth and depth of coverage in relation to the MS Core set are discussed. Understanding of the content of these instruments is needed for clinicians/researchers to make an informed choice for the selection of the most appropriate instrument to capture the variability inherent in MS for treatment efficacy.

Dexterity, visual perception, and activities of daily living in persons with multiple sclerosis

ABSTRACT The purposes of this study were to compare dexterity, visual perception, and abilities to carry out activities of daily living (ADL) in persons with different multiple sclerosis (MS) subtypes and to determine what relationships exist between the three variables. Fifty-six persons with MS were administered tests of dexterity, visual perception, and ADL ability. Demographic variables and scores on Kurtzke's Expanded Disability Status Scale were also collected. Scores from the chronic-progressive group were significantly higher than those of the benign and progressive-relapsing groups for the Nine-Hole Peg Test-Left Hand, Grooved Peg Test, and Functional Status Index (except Functional Status Index-Pain). There were no differences between the MS groups for any demographic variables except on the Expanded Disability Status Scale. Visual perception did not correlate with dexterity or ADL ability, and only dexterity scores for the left hand correlated with ADL ability. Persons with the severer subtype of MS were significantly impaired compared with the least severe group for dexterity and ADL ability. Decreased dexterity was associated with needing more assistance and having more perceived difficulty with ADL.

Measures of visual pathway structure and function in MS: Clinical usefulness and role for MS trials

Over the past decade, the visual pathway in multiple sclerosis (MS) has become an important system for assessing both patient function and disease burden. Abnormalities of low-contrast acuity, long recognized as important correlates of driving, facial recognition, and other activities of daily living, are now noted to be common among patients with MS, even among those with no history of acute optic neuritis (ON). Low-contrast letter acuity scores correlate well with brain MRI lesion burden, visual-evoked potential (VEP) amplitudes, health-related quality of life (QOL), and retinal nerve fiber layer (RNFL) axonal and neuronal loss as measured by optical coherence tomography (OCT). Axonal and neuronal degeneration in MS is likely to be an important cause of visual impairment and disability, particularly among patients with progressive MS subtypes. With the advent of OCT and the use of low-contrast letter acuity charts in MS research and clinical trials, the structure-function correlations afforded by the anterior visual pathway can be assessed and potentially harnessed as a model for testing new therapies. Recent advances in OCT, such as high resolution spectral-domain techniques and computerized algorithms for image analysis, have allowed for measurement of specific retinal layers, including the ganglion cell (GCL) neuronal layer and its intimately associated, thin layer of interneurons, the inner plexiform layer (IPL). Longitudinal collaborative studies of GCL+IPL thinning and RNFL axonal loss are providing an in vivo view into neuroretinal pathology, and are providing new insights into how the visual pathway may reflect overall mechanisms of disease in MS.

Pharmacotherapeuetic Options for the Treatment of Multiple Sclerosis

Multiple sclerosis is the most common progressive and disabling neurological condition in young adults. Neuro-inflammation is an early and persistent change and forms the basis of most pharmacotherapy for this disease. Immunomodulatory drugs are mainly biologies (β-interferons, a four amino acid peptide, and a monoclonal antibody to a cell adhesion molecule on the blood-CNS barrier) that either attenuate the inflammatory response or block the movement of immune cells into the CNS. They reduce the rate of relapse, but have little or no effect on the progression of disability. The market landscape for MS drugs is in the midst of major change because the patent life of many of these medicines will soon expire, which will lead to the emergence of biosimilars. In addition, new small molecule immunomodulatory and palliative drugs have entered the market, with more in the pipeline; a number of monoclonal antibodies and other immunomodulatory drugs are also in clinical development.

Exercise and disease progression in multiple sclerosis: can exercise slow down the progression of multiple sclerosis?

It has been suggested that exercise (or physical activity) might have the potential to have an impact on multiple sclerosis (MS) pathology and thereby slow down the disease process in MS patients. The objective of this literature review was to identify the literature linking physical exercise (or activity) and MS disease progression. A systematic literature search was conducted in the following databases: PubMed, SweMed+, Embase, Cochrane Library, PEDro, SPORTDiscus and ISI Web of Science. Different methodological approaches to the problem have been applied including (1) longitudinal exercise studies evaluating the effects on clinical outcome measures, (2) cross-sectional studies evaluating the relationship between fitness status and MRI findings, (3) cross-sectional and longitudinal studies evaluating the relationship between exercise/physical activity and disability/relapse rate and, finally, (4) longitudinal exercise studies applying the experimental autoimmune encephalomyelitis (EAE) animal model of MS. Data from intervention studies evaluating disease progression by clinical measures (1) do not support a disease-modifying effect of exercise; however, MRI data (2), patient-reported data (3) and data from the EAE model (4) indicate a possible disease-modifying effect of exercise, but the strength of the evidence limits definite conclusions. It was concluded that some evidence supports the possibility of a disease-modifying potential of exercise (or physical activity) in MS patients, but future studies using better methodologies are needed to confirm this.

Ophthalmic features of Friedreich ataxia

PURPOSE

To describe ocular abnormalities in patients with Friedreich ataxia (FRDA).

METHODS

Patients diagnosed with FRDA by genetic analysis were invited to participate in a prospective cohort. The patients included underwent an extensive ophthalmologic examination, including low-contrast Sloan letter charts test and retinal nerve fiber layer (RNFL) thickness analysis by optical coherence tomography (OCT).

RESULTS

Twenty-three patients agreed to participate. In all, 19 patients (83%) had a visual acuity of at least 0.8 in both eyes. Fundus examination showed diffuse optic nerve pallor in four patients. However, OCT showed a decreased mean peripapillary RNFL thickness in all but three adult cases and one teenager. The RNFL thickness was found to have a positive correlation with visual acuity (P=0.001) and contrast sensitivity (P=0.001) and a negative correlation with time elapsed from diagnosis (P=0.001).

CONCLUSIONS

OCT and low contrast test sensitivity show that the visual pathway is affected in FRDA. However, in most patients there is no significant visual impairment. In a small proportion of patients visual acuity declines with disease progression. This study provides a better understanding of the ophthalmic features of FRDA.

Physical activity associated with increased resting-state functional connectivity in multiple sclerosis

Multiple sclerosis (MS) is an inflammatory disease of the central nervous system, resulting in physical, cognitive and affective disturbances, with notable declines in the ability to learn and retain new information. In this study, we examined if higher levels of physical activity in MS individuals were associated with an increased resting-state connectivity of the hippocampus and cortex, resulting in better performance on a task of episodic memory. Forty-five individuals with a clinically definite diagnosis of MS were recruited for the study. Consistent with previous reports, hippocampus was functionally connected to the posteromedial cortex, parahippocampal gyrus, superior frontal gyrus, and the medial frontal cortex. Higher levels of physical activity in MS patients were associated with an increased coherence between the hippocampus and the posteromedial cortex (PMC). The increased connectivity between these two regions, in turn, was predictive of better relational memory, such that MS patients who showed an increased coherence between the left (not right) hippocampus and the PMC also showed better relational memory. Results of the study are interpreted in light of the challenge of disentangling effects of physical activity from effects of disease severity and its neuropathological correlates.

Effects of high-intensity resistance training on strength, mobility, balance, and fatigue in individuals with multiple sclerosis: a randomized controlled trial

BACKGROUND AND PURPOSE

Resistance exercise via negative, eccentrically induced work (RENEW) has been shown to be associated with improvements in strength, mobility, and balance in multiple clinical populations. However, RENEW has not been reported for individuals with multiple sclerosis (MS).

METHODS

Nineteen individuals with MS (8 men, 11 women; age mean = 49 ± 11 years; Expanded Disability Status Scale [EDSS] mean = 5.2 ± 0.9) were randomized into either standard exercise (STAND) or standard exercise and RENEW training (RENEW) for 3×/week for 12 weeks. Outcome measures were lower extremity strength (hip/knee flexion and extension, ankle plantar and dorsiflexion, and the sum of these individual values [sum strength]); Timed Up and Go (TUG), 10-m walk, self-selected pace (TMWSS) and maximal-pace (TMWMP), stair ascent (S-A) and descent (S-D) and 6-Minute Walk Test (6MWT), Berg Balance Scale (BBS), Fatigue Severity Scale (FSS).

RESULTS

No significant time effects or interactions were observed for strength, TUG, TMWSS, TMWMP, or 6MWT. However, the mean difference in sum strength in the RENEW group was 38.60 (representing a 15% increase) compared to the sum strength observed in the STAND group with a mean difference of 5.58 (a 2% increase). A significant interaction was observed for S-A, S-D, and BBS as the STAND group improved whereas the RENEW group did not improve in these measures.

DISCUSSION AND CONCLUSIONS

Contrary to results in other populations, the addition of eccentric training to standard exercises did not result in significantly greater lower extremity strength gains in this group of individuals with MS. Further this training was not as effective as standard exercise alone in improving balance or the ability to ascend and descend stairs. Following data collection, reassessment of required sample size indicates we were likely underpowered to detect strength differences between groups.

Neuroprotection in multiple sclerosis: a therapeutic challenge for the next decade

Multiple sclerosis (MS) is the commonest cause of progressive neurological disability amongst young, Caucasian adults. MS is considered to be an auto-immune disease that results from an attack against myelin, the layer which surrounds axons. The pathophysiology of MS is complex, with both demyelination and axonal degeneration contributing to what is essentially an inflammatory neurodegenerative disease. Axonal loss is increasingly being accepted as the histopathological correlate of neurological disability. Currently, the underpinnings of neurodegeneration in MS, and how to promote neuroprotection are only partly understood. No established treatments that directly reduce nervous system damage or enhance its repair are currently available. Moreover, the ability of currently available immunomodulatory therapies used to treat MS, such as interferon-beta, to prevent long-term disability is uncertain. Results from short-term randomized-controlled trials suggest a partial benefit with regards to disability outcomes, but this is yet to be established in long-term studies. Novel neuroprotective agents have been identified in preclinical studies but their development is being hampered by the absence of appropriate clinical platforms to test them. In this article, we will discuss some of the principal therapeutic candidates that could provide neuroprotection in MS and emerging methodologies by which to test them.

Brain tissue sodium concentration in multiple sclerosis: a sodium imaging study at 3 tesla

Neuro-axonal degeneration occurs progressively from the onset of multiple sclerosis and is thought to be a significant cause of increasing clinical disability. Several histopathological studies of multiple sclerosis and experimental autoimmune encephalomyelitis have shown that the accumulation of sodium in axons can promote reverse action of the sodium/calcium exchanger that, in turn, leads to a lethal overload in intra-axonal calcium. We hypothesized that sodium magnetic resonance imaging would provide an indicator of cellular and metabolic integrity and ion homeostasis in patients with multiple sclerosis. Using a three-dimensional radial gradient-echo sequence with short echo time, we performed sodium magnetic resonance imaging at 3 T in 17 patients with relapsing-remitting multiple sclerosis and in 13 normal subjects. The absolute total tissue sodium concentration was measured in lesions and in several areas of normal-appearing white and grey matter in patients, and corresponding areas of white and grey matter in controls. A mixed model analysis of covariance was performed to compare regional tissue sodium concentration levels in patients and controls. Spearman correlations were used to determine the association of regional tissue sodium concentration levels in T(2)- and T(1)-weighted lesions with measures of normalized whole brain and grey and white matter volumes, and with expanded disability status scale scores. In patients, tissue sodium concentration levels were found to be elevated in acute and chronic lesions compared to areas of normal-appearing white matter (P < 0.0001). The tissue sodium concentration levels in areas of normal-appearing white matter were significantly higher than those in corresponding white matter regions in healthy controls (P < 0.0001). The tissue sodium concentration value averaged over lesions and over regions of normal-appearing white and grey matter was positively associated with T(2)-weighted (P < or = 0.001 for all) and T(1)-weighted (P < or = 0.006 for all) lesion volumes. In patients, only the tissue sodium concentration value averaged over regions of normal-appearing grey matter was negatively associated with the normalized grey matter volume (P = 0.0009). Finally, the expanded disability status scale score showed a mild, positive association with the mean tissue sodium concentration value in chronic lesions (P = 0.002), in regions of normal-appearing white matter (P = 0.004) and normal-appearing grey matter (P = 0.002). This study shows the feasibility of using in vivo sodium magnetic resonance imaging at 3 T in patients with multiple sclerosis. Our findings suggest that the abnormal values of the tissue sodium concentration in patients with relapsing-remitting multiple sclerosis might reflect changes in cellular composition of the lesions and/or changes in cellular and metabolic integrity. Sodium magnetic resonance imaging has the potential to provide insight into the pathophysiological mechanisms of tissue injury when correlation with histopathology becomes available.

Assessing structure and function of the afferent visual pathway in multiple sclerosis and associated optic neuritis

The afferent visual pathway is commonly affected in MS. Assessment of the afferent visual pathway using clinical, imaging and electrophysiological methods not only provides insights into the pathophysiology of MS, but also provides a method of investigating potential therapeutic measures in MS. This review summarises the various assessment methods, in particular imaging techniques of the visual pathway. Retinal nerve fibre layer (RNFL) thickness is usually reduced following an episode of optic neuritis. Techniques such as optical coherence tomography, scanning laser polarimetry, and confocal scanning laser ophthalmoscopy are used to quantify RNFL thickness. MRI of the optic nerve is not routinely used in the diagnosis of MS or optic neuritis, but is valuable in atypical cases and in research. T2- weighted images of the optic nerve usually show the hyperintense lesion in optic neuritis and gadolinium enhancement is seen in the acute attack. Quantifying atrophy of the optic nerve using MRI gives an indication of the degree of axonal loss. Magnetization transfer ratio (MTR) of the optic nerve provides an indication of myelination. Diffusion tensor imaging (DTI) of the optic nerve and optic radiation provide information about the integrity of the visual white matter tracts. Functional MRI following visual stimulation is used to assess the contribution of cortical reorganisation to functional recovery following optic neuritis. Investigations including logMAR visual acuity, Sloan contrast acuity, Farnsworth- Munsell 100-hue colour vision tests and Humphrey perimetry provide detailed quantitative information on different aspects of visual function. Visual evoked potentials identify conduction block or delay reflecting demyelination. These collective investigative methods have advanced knowledge of pathophysiological mechanisms in MS and optic neuritis. Relevant ongoing studies and future directions are discussed.

Deep gray matter atrophy in multiple sclerosis: a tensor based morphometry

Tensor based morphometry (TBM) was applied to determine the atrophy of deep gray matter (DGM) structures in 88 relapsing multiple sclerosis (MS) patients. For group analysis of atrophy, an unbiased atlas was constructed from 20 normal brains. The MS brain images were co-registered with the unbiased atlas using a symmetric inverse consistent nonlinear registration. These studies demonstrate significant atrophy of thalamus, caudate nucleus, and putamen even at a modest clinical disability, as assessed by the expanded disability status score (EDSS). A significant correlation between atrophy and EDSS was observed for different DGM structures: (thalamus: r=-0.51, p=3.85 x 10(-7); caudate nucleus: r=-0.43, p=2.35 x 10(-5); putamen: r=-0.36, p=6.12 x 10(-6)). Atrophy of these structures also correlated with 1) T2 hyperintense lesion volumes (thalamus: r=-0.56, p=9.96 x 10(-9); caudate nucleus: r=-0.31, p=3.10 x 10(-3); putamen: r=-0.50, p=6.06 x 10(-7)), 2) T1 hypointense lesion volumes (thalamus: r=-0.61, p=2.29 x 10(-10); caudate nucleus: r=-0.35, p=9.51 x 10(-4); putamen: r=-0.43, p=3.51 x 10(-5)), and 3) normalized CSF volume (thalamus: r=-0.66, p=3.55 x 10(-12); caudate nucleus: r=-0.52, p=2.31 x 10(-7), and putamen: r=-0.66, r=2.13 x 10(-12)). More severe atrophy was observed mainly in thalamus at higher EDSS. These studies appear to suggest a link between the white matter damage and DGM atrophy in MS.

Health-related quality of life-testing the reliability of the MSQOL-54 instrument among MS patients

The purpose of the study was to assess the reliability of the specific multiple sclerosis quality of life (MSQOL-54) instrument, which contains 54 items measuring quality of life, among Finnish multiple sclerosis (MS) patients. Nursing professionals evaluated the clarity and comprehensibility of the translated instrument, after which it was pilot-tested. The data were collected through a questionnaire survey in the spring 2004. Persons diagnosed with MS in 1999-2001 filled in the questionnaire (n = 100). The response percentage was 81%. The structural validity of the MSQOL-54 instrument was evaluated with factor analysis and the generic 15D quality of life instrument. The internal consistency of the instrument was measured with Cronbach's alpha, correlations and item analysis. According to the results, the structural validity of MSQOL-54 was good, and factor analysis yielded a clear-cut factorial model. More than half of the correlations between the comparable items of the 15D and MSQOL-54 instruments were moderate or better. The internal consistency of MSQOL-54 can hence be considered quite good: Cronbach's alpha coefficients calculated for the factors and their items ranged within 0.33-0.89. The alpha coefficient calculated for the whole instrument was 0.84. The internal consistency of MSQOL-54 was further confirmed by the results of an item analysis, which showed the correlation coefficients between the items of the different dimensions to be good (0.31-0.81). On the basis of the test results, the MSQOL-54 instrument is fairly reliable and suitable for assessing the health-related quality of life of MS patients. The reliability of MSQOL-54 should be evaluated further by a longitudinal study design in the future.

Fampridine-SR in multiple sclerosis: a randomized, double-blind, placebo-controlled, dose-ranging study

Objective To determine the safety of sustained-release 4-aminopyridine in subjects with mutiple sclerosis (MS) and to examine dose-related efficacy up to 40 mg twice daily.

Method Multicenter, randomized, double-blind, placebo-controlled, study. Following a 4-week baseline peroid, subjects were randomly assigned to receive Fampridine-SR (n=25, doses from 10 to 40 mg twice daily, increasing in 5 mg increments weekly) or placebo (n=11). A battery of assessments was performed weekly, including the MS Functional Composite (MSFC), fatigue questionnaires, and lower extremity manual muscle testing.

Results The most common adverse events were dizziness, insomnia, paresthesia, asthenia, nausea, headache, and tremor. Five subjects were discontinued from Fampridine-SR because of adverse events at doses greater than 25 mg, and these included convulsions in two subjects at doses of 30 and 35 mg twice daily. Improvement were seen in lower extremity muscle strength (prospective analysis) and walking speed (post-hoc analysis) in the Fampridine-SR group compared to placebo (unadjusted p-values of 0.01 and 0.03, respectively). There were no significant differences in other MSFC measure or fatigue scores.

Conclusions Future studies should employ doses up to 20 mg twice daily with lower extremity strength and walking speed as potential outcome measures. Multiple Sclerosis 2007; 13: 357-368. http://msj.sagepub.com

Clinical and epidemiological aspects of HTLV-II infection in São Paulo, Brazil: presence of tropical spastic paraparesis/HTLV-associated myelopathy (TSP/HAM) simile diagnosis in HIV-1-co-infected subjects

In this study, the epidemiological and clinical features observed in solely HTLV-II-infected individuals were compared to those in patients co-infected with HIV-1. A total of 380 subjects attended at the HTLV Out-Patient Clinic in the Institute of Infectious Diseases "Emilio Ribas" (IIER), São Paulo, Brazil, were evaluated every 3-6 months for the last seven years by infectious disease specialists and neurologists. Using a testing algorithm that employs the enzyme immuno assay, Western Blot and polymerase chain reaction, it was found that 201 (53%) were HTLV-I positive and 50 (13%) were infected with HTLV-II. Thirty-seven (74%) of the HTLV-II reactors were co-infected with HIV-1. Of the 13 (26%) solely HTLV-II-infected subjects, urinary tract infection was diagnosed in three (23%), one case of skin vasculitis (8%) and two cases of lumbar pain and erectile dysfunction (15%), but none myelopathy case was observed. Among 37 co-infected with HIV-1, four cases (10%) presented with tropical spastic paraparesis/HTLV-associated myelopathy (TSP/HAM) simile. Two patients showed paraparesis as the initial symptom, two cases first presented with vesical and erectile disturbances, peripheral neuropathies were observed in other five patients (13%), and seven (19%) patients showed some neurological signal or symptoms, most of them with lumbar pain (five cases). The results obtained suggest that neurological manifestations may be more frequent in HTLV-II/HIV-1-infected subjects than those infected with HTLV-II only.

Exercise and Multiple Sclerosis

The pathophysiology of multiple sclerosis (MS) is characterised by fatigue, motor weakness, spasticity, poor balance, heat sensitivity and mental depression. Also, MS symptoms may lead to physical inactivity associated with the development of secondary diseases. Persons with MS are thus challenged by their disability when attempting to pursue an active lifestyle compatible with health-related fitness. Although exercise prescription is gaining favour as a therapeutic strategy to minimise the loss of functional capacity in chronic diseases, it remains under-utilised as an intervention strategy in the MS population. However, a growing number of studies indicate that exercise in patients with mild-to-moderate MS provides similar fitness and psychological benefits as it does in healthy controls. We reviewed numerous studies describing the responses of selected MS patients to acute and chronic exercise compared with healthy controls. All training studies reported positive outcomes that outweighed potential adverse effects of the exercise intervention. Based on our review, this article highlights the role of exercise prescription in the multidisciplinary approach to MS disease management for improving and maintaining functional capacity. Despite the often unpredictable clinical course of MS, exercise programmes designed to increase cardiorespiratory fitness, muscle strength and mobility provide benefits that enhance lifestyle activity and quality of life while reducing risk of secondary disorders. Recommendations for the evaluation of cardiorespiratory fitness, muscle performance and flexibility are presented as well as basic guidelines for individualised exercise testing and training in MS. Special considerations for exercise, including medical management concerns, programme modifications and supervision, in the MS population are discussed.