How responsive is the Multiple Sclerosis Impact Scale (MSIS-29)? A comparison with some other self report scales

Associations between fatigue impact and physical and neurobehavioural factors: An exploration in people with progressive multiple sclerosis

BACKGROUND

Fatigue is common in people with multiple sclerosis (MS). Understanding the relationship between fatigue, physical and neurobehavioural factors is important to inform future research and practice. Few studies explore this explicitly in people with progressive MS (pwPMS).

OBJECTIVE

To explore relationships between self-reported fatigue, physical and neurobehavioural measures in a large, international progressive MS sample of cognitively impaired people recruited to the CogEx trial.

METHODS

Baseline assessments of fatigue (Modified Fatigue Impact Scale; MFIS), aerobic capacity (VO2peak), time in moderate-vigorous physical activity (MVPA; accelerometery over seven-days), walking performance (6-minute walk test; 6MWT), self-reported walking difficulty (MS Walking Scale; MSWS-12), anxiety and depression (Hospital Anxiety and Depression Scale; HADS and Beck Depression Inventory-II; BDI-II), and disease impact (MS Impact Scale-29, MSIS-29) were assessed. Participants were categorised as fatigued (MFISTotal >=38) or non-fatigued (MFISTotal ≤38).

STATISTICAL ANALYSIS

Differences in individuals categorised as fatigued or non-fatigued were assessed (t-tests, chi square). Pearson's correlation and partial correlations (adjusted for EDSS score, country, sex, and depressive symptoms) determined associations with MFISTotal, MFISPhysical, MFISCognitive and MFISPsychosocial, and the other measures. Multivariable logistic regression evaluated the independent association of fatigue (categorised MFISTotal) with physical and neurobehavioural measures.

RESULTS

The sample comprised 308 pwPMS (62 % female, 27 % primary progressive, 73 % secondary progressive), mean age 52.5 ± 7.2 yrs, median EDSS score 6.0 (4.5-6.5), mean MFISTotal 44.1 ± 17.1, with 67.2 % categorised as fatigued. Fatigued participants walked shorter distances (6MWT, p = 0.043), had worse MSWS-12 scores (p < 0.001), and lower average % in MVPA (p = 0.026). The magnitude of associations was mostly weak between MFISTotal and physical measures (r = 0.13 to 0.18), apart from the MSWS-12 where it was strong (r = 0.51). The magnitude of correlations were strong between the MFISTotal and neurobehavioural measures of anxiety (r = 0.56), depression (r = 0.59), and measures of disease impact (MSIS-physical r = 0.67; MSIS-mental r = 0.71). This pattern was broadly similar for the MSIF subscales. The multivariable model indicated a five-point increase in MSWS-12 was associated with a 14 % increase in the odds of being fatigued (OR [95 %CI]: 1.14 [1.07-1.22], p < 0.0001) CONCLUSION: Management of fatigue should consider both physical and neurobehavioural factors, in cognitively impaired persons with progressive MS.

Prevalence, treatment and correlates of depression in multiple sclerosis

BACKGROUND

The prevalence of depression in Multiple Sclerosis (MS) is often assessed by administering patient reported outcome measures (PROMs) examining depressive symptomatology to population cohorts; a recent review summarised 12 such studies, eight of which used the Hospital Anxiety and Depression Scale-Depression (HADS-D). In clinical practice, depression is diagnosed by an individual structured clinical interview; diagnosis often leads to treatment options including antidepressant medication. It follows that an MS population will include those whose current depressive symptoms meet threshold for depression diagnosis, plus those who previously met diagnostic criteria for depression and have been treated such that depressive symptoms have improved below that threshold. We examined a large MS population to establish a multi-attribute estimate of depression, taking into account probable depression on HADS-D, as well as anti-depressant medication use and co-morbidity data reporting current treatment for depression. We then studied associations with demographic and health status measures and the trajectories of depressive symptoms over time.

METHODS

Participants were recruited into the UK-wide Trajectories of Outcome in Neurological Conditions-MS (TONiC-MS) study, with demographic and disease data from clinical records, PROMs collected at intervals of at least 9 months, as well as co-morbidities and medication. Interval level conversions of PROM data followed Rasch analysis. Logistic regression examined associations of demographic characteristics and symptoms with depression. Finally, a group-based trajectory model was applied to those with depression.

RESULTS

Baseline data in 5633 participants showed the prevalence of depression to be 25.3 % (CI: 24.2-26.5). There were significant differences in prevalence by MS subtype: relapsing 23.2 % (CI: 21.8- 24.5), primary progressive 25.8 % (CI: 22.5-29.3), secondary progressive 31.5 % (CI: 29.0-34.0); disability: EDSS 0-4 19.2 % (CI: 17.8-20.6), EDSS ≥4.5 31.9 % (CI: 30.2-33.6); and age: 42-57 years 27.7 % (CI: 26.0-29.3), above or below this range 23.1 % (CI: 21.6-24.7). Fatigue, disability, self-efficacy and self esteem correlated with depression with a large effect size (>0.8) whereas sleep, spasticity pain, vision and bladder had an effect size >0.5. The logistic regression model (N = 4938) correctly classified 80 % with 93 % specificity: risk of depression was increased with disability, fatigue, anxiety, more comorbidities or current smoking. Higher self-efficacy or self esteem and marriage reduced depression. Trajectory analysis of depressive symptoms over 40 months in those with depression (N = 1096) showed three groups: 19.1 % with low symptoms, 49.2 % with greater symptoms between the threshold of possible and probable depression, and 31.7 % with high depressive symptoms. 29.9 % (CI: 27.6-32.3) of depressed subjects were untreated, conversely of those treated, 26.1 % still had a symptom level consistent with a probable case (CI: 23.5-28.9).

CONCLUSION

A multi-attribute estimate of depression in MS is essential because using only screening questionnaires, diagnoses or antidepressant medication all under-estimate the true prevalence. Depression affects 25.3 % of those with MS, almost half of those with depression were either untreated or still had symptoms indicating probable depression despite treatment. Services for depression in MS must be pro-active and flexible, recognising the heterogeneity of outcomes and reaching out to those with ongoing symptoms.

Tablet app-based dexterity training in multiple sclerosis (TAD-MS): a randomized controlled trial

PURPOSE

Mobile health applications (mHealth apps) may lead to health benefits. In recent years, the use of apps in multiple sclerosis (MS) has increased. Apps to train and improve dexterity in MS are scarce. This study investigated the effectiveness of a tablet app-based home-based training to improve dexterity in individuals with MS.

MATERIALS AND METHODS

In a randomized controlled trial, two standardized 4-week home-based interventions focussing on different aspects of dexterity and upper limb function were compared. Assessments were done at baseline, post-intervention and 12-week follow-up. The primary endpoint was the Arm Function in Multiple Sclerosis Questionnaire, a dexterity-related measure of patient-reported activities of daily living. Secondary endpoints were dexterous function, grip strength and health-related quality of life.

RESULTS

Forty-eight individuals were randomly assigned to a tablet app-based program (n = 26) or a control strengthening exercise program (n = 22). No significant differences were found for the primary endpoint (p = 0.35). Some significant differences in favour of the app-group were found in fine coordinated finger movements and strength. No significant differences were found at the 12-week follow-up for all endpoints. Adherence in both groups was above 90%.

CONCLUSIONS

App-based training was not superior compared to a control strengthening exercise program concerning the arm- and hand function from the participant's perspective. However, app-based training was found to be effective in improving specific dimensions (finger movements and strength), and can easily be applied at home. Therefore, individuals living with MS with impaired dexterity should consider app-based training.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT03369470.

Variability of Multiple Sclerosis Walking Scale and Multiple Sclerosis Impact Scale Scores in People Without Multiple Sclerosis

Introduction  Many people with multiple sclerosis (pwMS) experience problems with mobility at some point in their disease course. The Multiple Sclerosis Impact Scale (MSIS) and Multiple Sclerosis Walking Scale (MSWS) are validated patient-reported outcome measures of physical impairment in pwMS. The range of scores on MSIS and MSWS in people without MS (pwoMS) are not well understood. Methods People over the age of 16 who did not have a diagnosis of multiple sclerosis (MS) were invited to complete an online survey consisting of a general health questionnaire, MSIS and the MSWS. Scores for MSIS and MSWS from pwoMS were compared to those from a cohort of 35 pwMS from a previous study. Scores for MSIS and MSWS were correlated with age, sex and comorbidities in pwoMS. Results One hundred eighty-nine ambulant pwoMS were recruited (52.5% female), aged over 16 years of age. Ninety-nine percent reported no difficulty with walking, 89.4% were non-smokers, and 14% had a physical co-morbidity. None used a walking aid. For pwoMS, the MSIS score was a mean of 39.14±13.75 (range 29-127), compared to a mean of 77.2±24.94 (range 40-126) for pwMS. For pwoMS, the mean MSWS score was 8.46±16.2 (0-87) compared to a mean of 56.9±28.9 (4-100) for pwMS. There was no significant effect of sex or smoking on MSIS or MSWS scores in pwoMS. Presence of a physical co-morbidity was associated with significantly higher MSIS and MSWS scores in pwoMS. There was a significant correlation of increasing age with increasing MSWS score in pwoMS but no correlation of age with MSIS score. Conclusion There is a wide range of MSWS and MSIS scores in pwoMS. The age and presence of comorbidities influence both MSWS and MSIS scores. Our findings have implications for the selection of control groups for clinical studies in pwMS.

Cycling in primary progressive multiple sclerosis (CYPRO): study protocol for a randomized controlled superiority trial evaluating the effects of high-intensity interval training in persons with primary progressive multiple sclerosis

BACKGROUND

Primary progressive multiple sclerosis (PPMS) is the least prevalent multiple sclerosis (MS) phenotype. For persons with PPMS (pwPPMS), pharmacological treatment options are limited. As a complementary non-pharmacological treatment, endurance training improves the health-related quality of life (HRQoL), numerous MS symptoms, and MS-related performance impediments. High-intensity interval training (HIIT) has been shown to induce superior effects compared to moderate-intensity continuous training (MCT). As current evidence is based on MS samples with mixed phenotypes, generalizability to pwPPMS remains unclear.

METHODS

CYPRO is a parallel-group, single-center, and single-blind randomized controlled superiority trial evaluating the effects of HIIT compared to MCT in pwPPMS. Sixty-one pwPPMS are randomized (1:1) to perform volume-matched HIIT or MCT sessions on bicycle ergometers two to three times per week in addition to standard rehabilitative care during their three-week inpatient stay at Valens rehabilitation clinic, Switzerland. Standard rehabilitative care comprises endurance and strength training, physiotherapy, and occupational therapy. HIIT sessions include six 90-second intervals at 95% peak heart rate (HR_peak), interspersed by 90-second active breaks with unloaded pedaling, aimed to reach 60%HR_peak. MCT represents the standard treatment at Valens rehabilitation clinic and is performed as continuous cycling at 60%HR_peak for the duration of 26 minutes. The primary outcome is cardiorespiratory fitness, assessed as peak oxygen consumption (V̇O_2peak) during cardiopulmonary exercise testing (CPET). Secondary outcomes include peak power output during CPET, walking capacity, cognitive performance, HRQoL, fatigue, anxiety and depressive symptoms, and blood-derived biomarkers (e.g., serum neurofilament light chain, glial fibrillary acidic protein, kynurenine pathway metabolites) related to MS pathophysiology. All outcomes are assessed at baseline and discharge after three weeks. Venous blood sampling is additionally performed immediately and two hours after the first HIIT or MCT session.

DISCUSSION

CYPRO will expand current knowledge on symptom management and rehabilitation in MS to the subpopulation of pwPPMS, and will contribute to the exploration of potential disease-modifying effects of endurance training in MS. The superiority design of CYPRO will allow deriving explicit recommendations on endurance training design in pwPPMS that can be readily translated into clinical practice.

TRIAL REGISTRATION

CYPRO has been prospectively registered at ClinicalTrials.gov on 8 February 2022 (NCT05229861).

Association between early treatment of multiple sclerosis and patient-reported outcomes: a nationwide observational cohort study

BACKGROUND

Timing of disease-modifying therapy affects clinical disability in multiple sclerosis, but it is not known whether patient reported outcomes are also affected. This study investigates the relationship between treatment timing and patient-reported symptoms and health-related quality of life.

METHODS

This was a nationwide observational cohort study of adults with relapsing multiple sclerosis, with disease onset between 2001 and 2016, and commenced on disease-modifying treatment within 4 years from disease onset. Patients commencing treatment within 0-2 years were compared with patients commencing treatment at 2-4 years. Indication bias was mitigated by propensity matching. Outcomes were patient-reported symptoms and health-related quality of life as measured by the Multiple Sclerosis Impact Scale (MSIS-29) and EuroQol-5 Dimensions-3 Level (EQ-5D). The follow-up period was 4-10 years from disease onset.

RESULTS

There were 2648 patients (69% female, median age 32.8) eligible for matching. Mean follow-up time was 3.7 years. Based on 780 matched patients, each year of treatment delay was associated with a worse MSIS physical score by 2.75 points (95% CI 1.29 to 4.20), and worse MSIS psychological score by 2.02 points (95% CI 0.03 to 3.78), in the adjusted models.Among 690 matched patients, earlier treatment start was not associated with EQ-5D score during the follow-up.

CONCLUSIONS

Earlier commencement of disease-modifying treatment was associated with better patient-reported physical symptoms when measured using a disease-specific metric; however, general quality of life was not affected. This indicates that other factors may inform patients' overall quality of life.

Translingual neurostimulation combined with physical therapy to improve walking and balance in multiple sclerosis (NeuroMSTraLS): Study protocol for a randomized controlled trial

INTRODUCTION

Physical rehabilitation restores lost function and promotes brain plasticity in people with Multiple Sclerosis (MS). Research groups worldwide are testing the therapeutic effects of combining non-invasive neuromodulation with physical therapy (PT) to further improve functional outcomes in neurological disorders but with mixed results. Whether such devices enhance function is not clear. We present the rationale and study design for a randomized controlled trial evaluating if there is additional benefit to the synergistic pairing of translingual neurostimulation (TLNS) with PT to improve walking and balance in MS.

METHODS AND ANALYSIS

A parallel group [PT + TLNS or PT + Sham], quadruple-blinded, randomized controlled trial. Participants (N = 52) with gait and balance deficits due to relapsing-remitting or progressive MS, who are between 18 and 70 years of age, will be recruited through patient registries in Newfoundland & Labrador and Saskatchewan, Canada. All participants will receive 14 weeks of PT while wearing either a TLNS or sham device. Dynamic Gait Index is the primary outcome. Secondary outcomes include fast walking speed, subjective ratings of fatigue, MS impact, and quality of life. Outcomes are assessed at baseline (Pre), after 14 weeks of therapy (Post), and 26 weeks (Follow Up). We employ multiple methods to ensure treatment fidelity including activity and device use monitoring. Primary and secondary outcomes will be analyzed using linear mixed-effect models. We will control for baseline score and site to test the effects of Time (Post vs. Follow-Up), Group and the Group x Time interaction as fixed effects. A random intercept of participant will account for the repeated measures in the Time variable. Participants must complete the Post testing to be included in the analysis.

ETHICS AND DISSEMINATION

The Human Research Ethics Boards in Newfoundland & Labrador (HREB#2021.085) & Saskatchewan (HREB Bio 2578) approved the protocol. Dissemination avenues include peer-reviewed journals, conferences and patient-oriented communications.

Cognitive impairment in people with multiple sclerosis: Perception vs. performance - factors that drive perception of impairment differ for patients and clinicians

BACKGROUND

Neurologists' perceptions of the presence of cognitive impairment (CI) in people with multiple sclerosis (PwMS) may not always align with findings of objective cognitive assessment. The accuracy of self-reported CI in PwMS can also be highly variable across individuals, and may not align with objective measurement of cognitive disturbances. Research suggests that additional factors impact perceived cognitive ability, such as depression and fatigue. Objective cognitive screening regardless of patient or neurologist perception has been recommended but still is often limited in routine care. Moreover, comprehensive neuropsychological assessment is even less routinely done.

OBJECTIVE

To explore how neurologists' perceptions of PwMS' CI compare to the perception of the patient by determining whether PwMS and their clinicians are accurate in detecting the presence and degree of CI as defined by a multi-domain validated computerized test battery in PwMS, as well as investigate what factors influence perception of CI in each group.

METHODS

PwMS completed a computerized multi-domain cognitive testing battery, and self-reported measures of disease impact (MSIS-29), fatigue (MFIS), and depression (BDI-II). Disability was assessed by the clinician using the Expanded Disability Status Scale (EDSS). Clinicians and patients also provided an estimation of cognitive deficits along a Likert scale.

RESULTS

In this cohort of PwMS (N=202, age range: 20 to 88, gender: 71% female), their level of accuracy in detecting attention deficits (k = -.028, p = .010) was low but statistically significant. In contrast, clinicians' accuracy in detecting global CI (k = -.037, p < .001) and a number of specific domain deficits was moderate. Fatigue (p < .001) and cognitive performance (p = .012) significantly predicted patient perceived cognitive deficits. Clinician perceived cognitive performance was significantly predicted by multiple factors: cognitive scores (p < .001), physical disability (p = .011), age (p = .021), and depression (p = .038).

CONCLUSION

The need to objectively screen for CI in PwMS, regardless of perception, can be aided by a better understanding of the agreement and discrepancies between the patient and clinician regarding perceived cognitive disturbances and the presence of CI defined by a multi-dimensional objective screening battery.

Development, validation and item reduction of a food literacy questionnaire (IFLQ-19) with Australian adults

Background

Food literacy is theorised to improve diet quality, nutrition behaviours, social connectedness and food security. The definition and conceptualisation by Vidgen & Gallegos, consisting of 11 theoretical components within the four domains of planning and managing, selecting, preparing and eating, is currently the most highly cited framework. However, a valid and reliable questionnaire is needed to comprehensively measure this conceptualisation. Therefore, this study draws on existing item pools to develop a comprehensive food literacy questionnaire using item response theory.

Methods

Five hundred Australian adults were recruited in Study 1 to refine a food literacy item pool using principal component analysis (PCA) and item response theory (IRT) which involved detailed item analysis on targeting, responsiveness, validity and reliability. Another 500 participants were recruited in Study 2 to replicate item analysis on validity and reliability on the refined item pool, and 250 of these participants re-completed the food literacy questionnaire to determine its test–retest reliability.

Results

The PCA saw the 171-item pool reduced to 100-items across 19 statistical components of food literacy. After the thresholds of 26 items were combined, responses to the food literacy questionnaire had ordered thresholds (targeting), acceptable item locations (< -0.01 to + 1.53) and appropriateness of the measurement model (n = 92% expected responses) (responsiveness), met outfit mean-squares MSQ (0.48—1.42) (validity) and had high person, item separation (> 0.99) and test–retest (ICC 2,1 0.55–0.88) scores (reliability).

Conclusions

We developed a 100-item food literacy questionnaire, the IFLQ-19 to comprehensively address the Vidgen & Gallegos theoretical domains and components with good targeting, responsiveness, reliability and validity in a diverse sample of Australian adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01351-8.

The MSIS-29 and SF-36 as outcomes in secondary progressive MS trials

Background:

Patient-reported outcome measures (PROMs) are often used in clinical research, but little is known about their performance as longitudinal outcomes.

Methods:

We used data from ASCEND, a large SPMS trial (n = 889), to investigate changes on the Short Form Health Survey 36 (SF-36 v2) and the Multiple Sclerosis Impact Scale (MSIS-29) over 2 years of follow-up.

Results:

PROM scores changed little over the 2 years of follow-up. In contrast to physical disability measures, there was no consistent trend in PROM change: significant worsening occurred about as often as improvement. Using a 6-month confirmation reduced the number of both worsening and improvement events without altering their relative balance. There was no clear difference in worsening events in groups based on population characteristics, nor was there a noticeable effect using different thresholds for clinically significant change.

Conclusion:

We found little consistent change in MSIS-29 and SF-36 over 2 years of follow-up in people with SPMS. Our findings show a disconnect between disability worsening and PROM change in this population. Our findings raise caution about the use of these PROMs as primary outcome measures in SPMS trials and call for a critical reappraisal of the longitudinal use of these measures in SPMS trials.

The late onset of emotional distress in people with progressive multiple sclerosis during the Covid-19 pandemic: longitudinal findings from the CogEx study

OBJECTIVE

An earlier follow-up study from the CogEx rehabilitation trial showed little change in symptoms of depression, anxiety and psychological distress during the first COVID-19 lockdown compared to pre-pandemic measurements. Here, we provide a second follow-up set of behavioral data on the CogEx sample.

METHODS

This was an ancillary, longitudinal follow-up study in CogEx, a randomized controlled trial of exercise and cognitive rehabilitation in people with progressive MS involving 11 centres in North America and Europe. Only individuals impaired on the Symbol Digit Modalities Test (SDMT) were included. Participants repeated the COVID Impact survey administered approximately a year later and completed self-report measures of depression, anxiety and MS symptoms that had been obtained at the trial baseline and during the first COVID Impact survey. Participants who completed the second COVID Impact follow-up were included. To identify predictors of the participants' ratings of their mental and physical well-being, step-wise linear regression was conducted.

RESULTS

Of the 131 participants who completed the first COVID impact survey, 74 participants completed the second follow-up survey (mean age 52 (SD = 6.4) years, 62.2% female, mean disease duration 16.4 (SD = 9.0) years, median EDSS 6.0). Pandemic restrictions prevented data collection from sites in Denmark and England (n = 57). The average time between measurements was 11.4 (SD = 5.56) months. There were no significant differences in age, sex, EDSS, disease course and duration between those who participated in the current follow-up study (n = 74) and the group that could not (n = 57). One participant had COVID in the time between assessments. Participants now took a more negative view of their mental/psychological well-being (p = 0.0001), physical well-being (p = 0.0009) and disease course (p = 0.005) compared to their last assessment. Depression scores increased on the HADS-depression scale (p = 0.01) and now exceeded the clinically significant threshold of ≥ 8.0 for the first time. Anxiety scores on the HADS remained unchanged. Poorer mental well-being was predicted by HADS depression scores (p = 0.012) and a secondary-progressive disease course (p = 0.0004).

CONCLUSIONS

A longer follow-up period revealed the later onset of clinically significant depressive symptoms on the HADS and a decline in self-perceptions of mental and physical well-being associated with the COVID-19 pandemic relative to the first follow-up data point.

TRIAL REGISTRATION

The trial was registered on September 20th 2018 at www.

CLINICALTRIALS

gov having identifier NCT03679468. Registration was performed before recruitment was initiated.

Validation of the General Health Questionnaire 12 for assessing psychological distress in patients with chronic low back pain

BACKGROUND

The General Health Questionnaire 12 (GHQ-12) is a short easy-to-use scale to assess psychological distress. The GHQ-12 has not been validated for assessing psychological distress in patients with chronic low back pain (LBP).

OBJECTIVE

To investigate the psychometric properties of the GHQ-12 in patients with chronic LBP.

METHODS

The study involved a population of patients undergoing functional restoration for chronic LBP. The intraclass coefficient correlation was used for test-retest reliability (good if > 0.7) and the standard error measurement for absolute reliability. Construct validity was assessed with the Spearman correlation coefficient (moderate and high if r⩾ 0.35 and 0.5, respectively) and internal consistency with Cronbach's alpha (suitable if > 0.7). Responsiveness was assessed by the Wilcoxon test and effect size.

RESULTS

Four hundred and five patients were included. The intraclass coefficient correlation was 0.73 and standard error measurement 2.49. The GHQ-12 showed high convergence with the Beck Depression Inventory and subscales of the Dallas Pain Questionnaire for anxiety and depression and for sociability. It showed moderate convergence with the Quebec Back Pain Disability Scale and subscales of the Dallas Pain Questionnaire for daily activities and for leisure and occupation. Cronbach's alpha was 0.89. The GHQ-12 score changed after functional restoration. It was lower (better) with than without improvement.

CONCLUSIONS

We provide validation of the GHQ-12 for assessing psychological distress in patients with chronic LBP.

Comparing the MSIS-29 and the Health Utilities Index Mark III in Multiple Sclerosis

Objective: Since the properties of health-related quality of life measures vary across samples, studies directly comparing the properties of different measures can be useful in understanding their relative strengths and limitations. We aimed to compare the psychometric properties of the Health Utilities Index Mark III (HUI3) and the Multiple Sclerosis Impact Scale-29 (MSIS-29).

Methods: In Spring 2020, North American Research Committee on Multiple Sclerosis (NARCOMS) Registry participants completed the HUI3, MSIS-29, Patient Determined Disease Steps (PDDS) and SymptoMScreen. For the HUI3 and MSIS-29 we assessed floor and ceiling effects, construct validity, and internal consistency reliability. We used relative efficiency to compare the discriminating ability of the two measures with respect to disability.

Results: We included 5,664 participants in the analysis, with mean (SD) age 63 (10.1) years; 4,579 (80.8%) were women. For the HUI3 the mean (SD) score was 0.44 (0.32), for the MSIS-29 physical it was 34.0 (24.2) and for the MSIS-29 psychological it was 25.9 (20.4). Neither of the measures had floor or ceiling effects, and internal consistency reliability was &gt; 0.70 for both. The HUI3 and MSIS-29 physical were strongly correlated (r = −0.78; 95%CI:−0.79,−0.77). The correlation between the HUI3 and MSIS-29 psychological was weaker but remained moderately strong (r = −0.64; 95%CI:−0.66,−0.63). After adjusting for sociodemographic and clinical factors, relative efficiency to discriminate between disability (PDDS) groups was highest for the MSIS-29 physical scale, followed by the HUI3.

Conclusion: Both measures had adequate validity and reliability. The MSIS-29 physical discriminated between disability groups better than the HUI3.

Patient-Reported Questionnaires in Multiple Sclerosis Rehabilitation: Responsiveness and Minimal Important Difference of the French Version of the Multiple Sclerosis Questionnaire for Physiotherapists

Purpose: The aim of this study was to evaluate the responsiveness and minimal important difference (MID) of the French version of the Multiple Sclerosis Questionnaire for Physiotherapists (MSQPT). Method: A distribution-based approach was used. Patients (32) were recruited from inpatient and outpatient settings; they completed both the MSQPT and the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) at baseline and again at 6 months or discharge. Responsiveness was evaluated using effect size (ES), standardized response mean (SRM), and modified SRM (MSRM), and the relative efficiency between the MSQPT and HAQUAMS was calculated. Distribution-based MID estimates were calculated for 0.33 SD, standard error of measurement, and minimal detectable change. Results: The main ES ranged from 0.41 (low) to 1.23 (high). The SRM (-0.89 to 2.69) was generally higher than the ES. The main MSRMs were acceptably low (-0.03 to 0.19). Although the MSQPT seemed more efficient than the HAQUAMS in detecting improved activity and participation, it was less efficient at identifying their deterioration. In a comparison of responsiveness and MID between the German and French versions of the MSQPT, the differences between estimates were small. Conclusions: The available evidence indicates that the French MSQPT is a responsive questionnaire with MIDs that are similar to those of the original German version.

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.

Postural stability is a valid and meaningful disability metric in progressive MS with potential for use in neuroprotective therapy trials

BACKGROUND

Balance impairment is observed in up to 70% of people with MS (pwMS) and worsens with disease progression. Posturography using a force platform is the current gold standard in the measurement of balance. However, posturography has not been adequately studied or widely accepted for use as a disability outcome measure for pwMS. Importantly, the recent emergence of both successful and failed neuroprotective therapy trials in progressive MS has emphasised the need for new disability outcome measures for people with progressive MS. The main objectives of this study were to evaluate the clinical validity, reliability and feasibility of posturography as a disability metric in progressive MS.

METHODS

This was a prospective cross-sectional study. We recruited 73 people with progressive MS (age 18-65 years, EDSS 3.5-6.0). Participants stood in the centre of a force platform, feet comfortably apart, under various conditions: (i) eyes open (EO), (ii) eyes closed (EC) - a single task, each lasting ninety seconds; and simultaneous EO with a cognitive test: (iii) N-Back, a three-minute test whereby participants were instructed to click the mouse when two identical letters were displayed consecutively on a screen, (iv) Sustained Attention Response Task, a five-minute test whereby participants were instructed to click the mouse for every number "1″ to "9″ except "3″ - i.e., dual-tasks. Additionally, we performed a battery of validated physical and cognitive outcome measures. Posturographic data was processed using Matlab. Statistical analysis was performed using SPSS version 26. We used multiple linear regression modelling to determine whether significant univariate correlations between posturography and clinical metrics were independent of covariates that may influence the associations seen. A two-tailed significance level of 0.05 was used.

RESULTS

Of 73 participants, mean age 52.4 (8.5) years, mean MS disease duration 13.8 (10.3) years, median EDSS 5.0 (IQR 4.0-6.0), 44 (60.4%) were female. EO-Path-Length independently predicted upper extremity function (9-Hole-Peg-Test) with a larger effect size (adjusted R²=20.0%, p = 0.001) than that for walking measures (Timed 25-Foot Walk, adjusted R²=1.6%, p = 0.01; Two-Minute Walk Test, adjusted R²=7.2%, p = 0.002), while controlling for age, disease duration, height, weight, and sex. The addition of EO-Mediolateral-Displacement to the MS Functional Composite (MSFC) created a four-component z-score that increased the variance explained for quality of life (QOL) by 62.1%. Postural stability was significantly lower with mediolateral vs anteroposterior direction of sway, removal of vision, increased body weight, male sex, and fampridine use. Postural stability improved during dual-tasks compared to EO single task. Posturography detected significant worsening of balance over a single prolonged stance.

CONCLUSION

Postural stability independently predicted a wide range of clinical metrics including upper extremity function, walking ability, cognition and QOL, therefore establishing construct and concurrent validity as a disability outcome measure for people with progressive MS. Additionally, posturography is a quantitative, non-invasive, quick-and-easy-to-administer, and highly sensitive device, demonstrating its high feasibility for use as a time- and resource-efficient disability metric in neuroprotective therapy trials for progressive MS.

Psychometric properties of the Croatian version of the depression, anxiety, and stress scale-21 and multiple sclerosis impact scale-29 in multiple sclerosis patients

OBJECTIVES

Depression, anxiety, stress, and physical disabilities are a common complaint in people with multiple sclerosis (MS), and monitoring of these symptoms are based on self-report questionnaires. The objective of this study was to determine psychometric properties of the Croatian version of the Depression, Anxiety, and Stress Scale-21 (DASS-21) and Multiple Sclerosis Impact Scale-29 (MSIS-29) in people with MS.

MATERIALS AND METHODS

We included data on 163 people with MS registered in the Association of multiple sclerosis societies of Croatia (AMSSC). Patients' demographic information, education level, and disease-related variables were ascertained. DASS-21 was applied for assessing depression, anxiety, and stress, while MSIS-29 scale was used for assessment of the physical and psychological impact of MS disease. Psychometric properties were examined by estimating the validity and reliability of the DASS-21 and MSIS-29 scale. Predictive validity of DASS-21 subscales and relevant demographic and disease-related variables was examined by the hierarchical regression model.

RESULTS

The Croatian version of the three DASS-21 subscales and two MSIS-29 subscales had excellent internal consistencies (Cronbach's alpha coefficients 0.88-0.93) and good convergent validity, as expressed by inter-correlations between DASS-21 and MSIS-29 subscales. Hierarchical regression analysis using MSIS-29 subscales as criterion variables showed consistent evidence for the predictive validity of depression, anxiety, and stress on psychological impact, and predictive validity of age, EDSS, and anxiety on physical impact.

CONCLUSIONS

The Croatian versions of DASS-21 and MSIS-29 are reliable and valid scales in people with MS.

Response heterogeneity in a randomized controlled trial of telerehabilitation interventions among adults with multiple sclerosis

INTRODUCTION

Telerehabilitation may be effective on average but is not equally effective among all people with multiple sclerosis (MS). Thus, the purpose of this secondary analysis of a randomized controlled trial was to explore whether baseline characteristics of participants with MS influence fatigue and physical activity outcomes of three telerehabilitation interventions.

METHODS

Participants were randomized to contact-control intervention (CC), physical activity-only intervention (PA-only), and physical activity plus fatigue self-management intervention (FM+). The 12-week interventions were delivered over the phone. Sociodemographic (age and income), clinical (comorbidities, mental function and physical function), psychosocial (self-efficacy, outcome expectations and goal-setting), and behavioural baseline characteristics (step count and fatigue self-management behaviors) were used in a moderated regression analysis and a responder analysis to examine their influence on the Fatigue Impact Scale (FIS) and Godin Leisure-Time Exercise Questionnaire (GLTEQ) at post-test (i.e. immediately post-interventions).

RESULTS

No interactions terms were statistically significant in the moderation analysis. However, the responder analysis showed that baseline psychosocial characteristics and mental function were significantly different (p < 0.05) between responders and non-responders. Specifically, non-responders on the FIS at post-test in the PA-only intervention had significantly lower baseline scores in goal setting for engaging in fatigue self-management behaviours. Also, non-responders on the GLTEQ at post-test in the FM+ intervention had significantly worse baseline scores in mental function.

DISCUSSION

Further research is needed to understand the complex relationship among baseline characteristics, telerehabilitation and response heterogeneity. We discuss how research on examining response heterogeneity may be advanced by conducting mega-clinical trials, secondary analyses of big data, meta-analyses and employing non-traditional research designs.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT01572714).

A self-management programme to reduce falls and improve safe mobility in people with secondary progressive MS: the BRiMS feasibility RCT

BACKGROUND

Balance, mobility impairments and falls are common problems for people with multiple sclerosis (MS). Our ongoing research has led to the development of Balance Right in MS (BRiMS), a 13-week home- and group-based exercise and education programme intended to improve balance and encourage safer mobility.

OBJECTIVE

This feasibility trial aimed to obtain the necessary data and operational experience to finalise the planning of a future definitive multicentre randomised controlled trial.

DESIGN

Randomised controlled feasibility trial. Participants were block randomised 1 : 1. Researcher-blinded assessments were scheduled at baseline and at 15 and 27 weeks post randomisation. As is appropriate in a feasibility trial, statistical analyses were descriptive rather than involving formal/inferential comparisons. The qualitative elements utilised template analysis as the chosen analytical framework.

SETTING

Four sites across the UK.

PARTICIPANTS

Eligibility criteria included having a diagnosis of secondary progressive MS, an Expanded Disability Status Scale (EDSS) score of between ≥ 4.0 and ≤ 7.0 points and a self-report of two or more falls in the preceding 6 months.

INTERVENTIONS

Intervention - manualised 13-week education and exercise programme (BRiMS) plus usual care. Comparator - usual care alone.

MAIN OUTCOME MEASURES

Trial feasibility, proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls), feasibility of the BRiMS programme (via process evaluation) and economic data.

RESULTS

A total of 56 participants (mean age 59.7 years, standard deviation 9.7 years; 66% female; median EDSS score of 6.0 points, interquartile range 6.0-6.5 points) were recruited in 5 months; 30 were block randomised to the intervention group. The demographic and clinical data were broadly comparable at baseline; however, the intervention group scored worse on the majority of baseline outcome measures. Eleven participants (19.6%) withdrew or were lost to follow-up. Worsening of MS-related symptoms unrelated to the trial was the most common reason (n = 5) for withdrawal. Potential primary and secondary outcomes and economic data had completion rates of > 98% for all those assessed. However, the overall return rate for the patient-reported falls diary was 62%. After adjusting for baseline score, the differences between the groups (intervention compared with usual care) at week 27 for the potential primary outcomes were MS Walking Scale (12-item) version 2 -7.7 [95% confidence interval (CI) -17.2 to 1.8], MS Impact Scale (29-item) version 2 (MSIS-29vs2) physical 0.6 (95% CI -7.8 to 9) and MSIS-29vs2 psychological -0.4 (95% CI -9.9 to 9) (negative score indicates improvement). After the removal of one outlier, a total of 715 falls were self-reported over the 27-week trial period, with substantial variation between individuals (range 0-93 falls). Of these 715 falls, 101 (14%) were reported as injurious. Qualitative feedback indicated that trial processes and participant burden were acceptable, and participants highlighted physical and behavioural changes that they perceived to result from undertaking BRiMS. Engagement varied, influenced by a range of condition- and context-related factors. Suggestions to improve the utility and accessibility of BRiMS were highlighted.

CONCLUSIONS

The results suggest that the trial procedures are feasible and acceptable, and retention, programme engagement and outcome completion rates were sufficient to satisfy the a priori progression criteria. Challenges were experienced in some areas of data collection, such as completion of daily diaries.

FUTURE WORK

Further development of BRiMS is required to address logistical issues and enhance user-satisfaction and adherence. Following this, a definitive trial to assess the clinical effectiveness and cost-effectiveness of the BRiMS intervention is warranted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13587999.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 27. See the NIHR Journals Library website for further project information.

A Pilot Study to Explore Patient Satisfaction With a Virtual Rehabilitation Program in Multiple Sclerosis: The RehabVR Study Protocol

Background: Virtual reality (VR) has emerged as a promising treatment approach in rehabilitation for patients with multiple sclerosis (MS) due to its potential to increase patient motivation and rehabilitation adherence. One of the key features for rehabilitation adherence is patient satisfaction with the VR rehabilitation (VRR) program, and information on user satisfaction and not only effectiveness is required to systematically include VRR in routine clinical practice. Given that information on patient satisfaction with VRR is scarce, the primary objective of this study is to assess long-term patient satisfaction with a novel VRR program. This program has been specifically designed for MS patients by a multidisciplinary team of specialists, based on an effective conventional rehabilitation (CR) program. Secondarily, discomfort with VRR will be evaluated, and therapy adherence and changes in a variety of domains typically affected by MS will be compared between patients receiving VRR and patients receiving CR. Methods: In this prospective single-center 6-months follow-up study, 32 and 16 MS patients will receive VRR or CR, respectively. Patients will attend twice weekly rehabilitation sessions on site during 4 weeks, and they will continue with rehabilitation at home for five additional months. Satisfaction, assessed by the User Satisfaction Evaluation Questionnaire (USEQ), at 6 months of the VRR program initiation will be the primary outcome. Secondary outcomes include adherence, disability, spasms and spasticity, balance, fatigue, activities of daily living (ADLs), depression, anxiety, work status, cognition, demographic, and clinical characteristics (in the VRR and CR groups), and discomfort (in the VRR group). Outcome measures will be assessed at baseline, and at 1 and 6 months of rehabilitation initiation. Discussion: The study is intended to provide a better understanding of long-term patient satisfaction with a VRR program specifically designed for MS patients. Additionally, the study will provide information on long-term adherence, changes in motor symptoms, cognitive functions and patient-reported outcomes after the rehabilitation program. The results from this study will help to gather valuable knowledge on the use of rehabilitation with a new VR tool in MS patients.

The emotional impact of the COVID-19 pandemic on individuals with progressive multiple sclerosis

Objective

Individuals with pre-existing chronic illness have shown increased anxiety and depression due to COVID-19. Here, we examine the impact of the COVID-19 pandemic on emotional symptomatology and quality of life in individuals with Progressive Multiple Sclerosis (PMS).

Methods

Data were obtained during a randomized clinical trial on rehabilitation taking place at 11 centers in North America and Europe. Participants included 131 individuals with PMS. Study procedures were interrupted in accordance with governmental restrictions as COVID-19 spread. During study closure, a COVID Impact Survey was administered via telephone or email to all participants, along with measures of depressive symptoms, anxiety symptoms, quality of life, and MS symptomatology that were previously administered pre-pandemic.

Results

4% of respondents reported COVID-19 infection. No significant changes were noted in anxiety, quality of life, or the impact of MS symptomatology on daily life from baseline to lockdown. While total HADS-depression scores increased significantly at follow-up, this did not translate into more participants scoring above the HADS threshold for clinically significant depression. No significant relationships were noted between disease duration, processing speed ability or EDSS, and changes in symptoms of depression or anxiety. Most participants reported the impact of the virus on their psychological well-being, with a little impact on financial well-being. The perceived impact of the pandemic on physical and psychological well-being was correlated with the impact of MS symptomatology on daily life, as well as changes in depression.

Conclusions

Overall, little change was noted in symptoms of depression or anxiety or overall quality of life.

Development and Validation of the Rasch-Built Overall Amyotrophic Lateral Sclerosis Disability Scale (ROADS)

Importance

A new outcome measure for overall disability level with improved responsiveness is needed for amyotrophic lateral sclerosis (ALS) clinical trials.

Objective

To describe the creation and development of a new self-reported ALS disability scale with improved item targeting and psychometric properties that used a mathematically rigorous Rasch methodology.

Design, Setting, and Participants

A preliminary ALS disability questionnaire with 119 questions was created based on literature review, clinical judgement of an expert panel, and patient input. Patients with ALS were recruited from January 2017 to June 2019 from the Emory University and Atlanta VA Medical Center ALS clinics, both in Atlanta, Georgia, during regularly scheduled clinic appointments to complete the draft questionnaire and standard ALS outcome measures. All consecutive patients seen at the Emory University and Atlanta VA Medical Center ALS clinics during the recruitment period with a diagnosis of ALS who were able to provide informed consent were invited to participate in the study. Rasch analyses were performed, and items were systematically removed based on missing data, model fit, disordered thresholds, item bias, and clinical judgment. A total of 509 patients with ALS were seen at the 2 sites during the recruitment period, and 264 patients provided informed consent.

Interventions

Participants completed the draft Rasch questionnaire and the revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R).

Main Outcomes and Measures

Rasch analyses and standard scale metrics were performed to create the new scale, and Rasch analyses were performed on the ALSFRS-R for comparison.

Results

Overall, 243 participants with ALS completed the draft questionnaire, and 230 participants were included for Rasch analyses. The mean (SD) age for study participants was 61.9 (11.1) years, 146 (60.1%) were men, and site of onset was 23.0% bulbar (n = 56), 36.2% upper extremity (n = 88), and 39.5% lower extremity (n = 96). A 28-question Rasch-Built Overall ALS Disability Scale (ROADS) was constructed with each item scored 0, 1, or 2. The ROADS fulfilled Rasch model requirements, demonstrated improved item targeting compared with the ALSFRS-R, and had test-retest reliability of 0.97. Individual question fit statistics demonstrated infit values from 0.68 to 1.37 and outfit values from 0.66 to 1.43. The difference between the empirical variance explained by the measures and the modeled variance was 0.1%. The ALSFRS-R violated Rasch model expectations and demonstrated disordered thresholds for 9 of 12 questions; 13 of 48 answer choices on the ALSFRS-R were never the most probable answer choice for any overall disability level.

Conclusions and Relevance

In this study, the 28-question, self-reported ROADS, which is linearly weighted, had improved item targeting compared with the ALSFRS-R, had high test-retest reliability, and was validated. ROADS may serve as a valuable and easily accessible outcome measure for use in ALS trials and in the clinic with improved responsiveness compared with the ALSFRS-R.

Study protocol: improving cognition in people with progressive multiple sclerosis: a multi-arm, randomized, blinded, sham-controlled trial of cognitive rehabilitation and aerobic exercise (COGEx)

BACKGROUND

Cognitive dysfunction affects up to 70% of people with progressive MS (PMS). It can exert a deleterious effect on activities of daily living, employment and relationships. Preliminary evidence suggests that performance can improve with cognitive rehabilitation (CR) and aerobic exercise (EX), but existing data are predominantly from people with relapsing-remitting MS without cognitive impairment. There is therefore a need to investigate whether this is also the case in people with progressive forms of the disease who have objectively identified cognitive impairment. It is hypothesized that CR and EX are effective treatments for people with PMS who have cognitive impairment, in particular processing speed (PS) deficits, and that a combination of these two treatments is more effective than each individual treatment given alone. We further hypothesize that improvements in PS will be associated with modifications of functional and/or structural plasticity within specific brain networks/regions involved in PS measured with advanced MRI techniques.

METHODS

This study is a multisite, randomized, double-blinded, sham controlled clinical trial of CR and aerobic exercise. Three hundred and sixty subjects from 11 sites will be randomly assigned into one of four groups: CR plus aerobic exercise; CR plus sham exercise; CR sham plus aerobic exercise and CR sham plus sham exercise. Subjects will participate in the assigned treatments for 12 weeks, twice a week. All subjects will have a cognitive and physical assessment at baseline, 12 weeks and 24 weeks. In an embedded sub-study, approximately 30% of subjects will undergo structural and functional MRI to investigate the neural mechanisms underlying the behavioral response. The primary outcome is the Symbol Digit Modalities Test (SDMT) measuring PS. Secondary outcome measures include: indices of verbal and non-verbal memory, depression, walking speed and a dual cognitive-motor task and MRI.

DISCUSSION

The study is being undertaken in 6 countries (11 centres) in multiple languages (English, Italian, Danish, Dutch); with testing material validated and standardized in these languages. The rationale for this approach is to obtain a robustly powered sample size and to demonstrate that these two interventions can be given effectively in multiple countries and in different languages.

TRIAL REGISTRATION

The trial was registered on September 20th 2018 at www.clinicaltrials.gov having identifier NCT03679468. Registration was performed before recruitment was initiated.

Tablet App Based Dexterity Training in Multiple Sclerosis (TAD-MS): Research Protocol of a Randomized Controlled Trial

Introduction: Patients with Multiple Sclerosis exhibit disturbed dexterity, leading to difficulties in fine motor skills such as buttoning a T-shirt or hand-writing. Consequently, activities of daily living and quality of life are affected. The aim of the present study is to investigate the effectiveness of a tablet app-based home-based training intervention to improve dexterity in patients with Multiple Sclerosis. Methods: An observer-blinded randomized controlled trial will be performed. Seventy patients with Multiple Sclerosis with self-reported difficulties in dexterity while executing activities of daily living will be recruited. After baseline assessment, participants are randomized to either an intervention group (n = 35) or control group (n = 35) by a computerized procedure. Blinded assessments will be done at baseline, post-intervention (after 4 weeks) and 12 weeks follow-up. The home-based intervention consists of a 4-week tablet app-based dexterity program. The app contains six dexterity games in which finger coordination, tapping, pinch grip is required. The control group will receive a Thera-band training program focused on strengthening the upper limb. The primary outcome is the Arm function of Multiple Sclerosis Questionnaire, a measure of patient-reported activities of daily living related dexterity. Secondary outcomes are dexterous function, hand strength, and quality of life. Discussion: This study will evaluate the effects of tablet app-based training for dexterity in patients with Multiple Sclerosis. We hypothesize that a challenging app-based dexterity program will improve dexterity both in the short term and the long-term. The improved finger and hand functions are expected to generalize to improved activities of daily living and quality of life.

Exploring cued and non-cued motor imagery interventions in people with multiple sclerosis: a randomised feasibility trial and reliability study

Background

Motor imagery (MI) is increasingly used in neurorehabilitation to facilitate motor performance. Our previous study results demonstrated significantly improved walking after rhythmic-cued MI in people with multiple sclerosis (pwMS). The present feasibility study was aimed to obtain preliminary information of changes in walking, fatigue, quality of life (QoL) and MI ability following cued and non-cued MI in pwMS. The study further investigated the feasibility of a larger study and examined the reliability of a two-dimensional gait analysis system.

Methods

At the MS-Clinic, Department of Neurology, Medical University of Innsbruck, Austria, 15 adult pwMS (1.5–4.5 on the Expanded Disability Status Scale, 13 females) were randomised to one of three groups: 24 sessions of 17 min of MI with music and verbal cueing (MVMI), with music alone (MMI), or non-cued (MI). Descriptive statistics were reported for all outcomes. Primary outcomes were walking speed (Timed 25-Foot Walk) and walking distance (6-Minute Walk Test). Secondary outcomes were recruitment rate, retention, adherence, acceptability, adverse events, MI ability (Kinaesthetic and Visual Imagery Questionnaire, Time-Dependent MI test), fatigue (Modified Fatigue Impact Scale) and QoL (Multiple Sclerosis Impact Scale-29). The reliability of a gait analysis system used to assess gait synchronisation with music beat was tested.

Results

Participants showed adequate MI abilities. Post-intervention, improvements in walking speed, walking distance, fatigue, QoL and MI ability were observed in all groups. Success of the feasibility criteria was demonstrated by recruitment and retention rates of 8.6% (95% confidence interval, CI 5.2, 13.8%) and 100% (95% CI 76.4, 100%), which exceeded the target rates of 5.7% and 80%. Additionally, the 83% (95% CI 0.42, 0.99) adherence rate surpassed the 67% target rate. Intra-rater reliability analysis of the gait measurement instruments demonstrated excellent Intra-Class Correlation coefficients for step length of 0.978 (95% CI 0.973, 0.982) and step time of 0.880 (95% CI 0.855, 0.902).

Conclusion

Results from our study suggest that cued and non-cued MI are valuable interventions in pwMS who were able to imagine movements. A larger study appears feasible, however, substantial improvements to the methods are required such as stratified randomisation using a computer-generated sequence and blinding of the assessors.

Trial registration

ISRCTN ISRCTN92351899. Registered 10 December 2015.

Electronic supplementary material

The online version of this article (10.1186/s40945-018-0045-0) contains supplementary material, which is available to authorized users.

Patient-reported outcomes in multiple sclerosis: a systematic comparison of available measures

Multiple patient-reported outcomes (PROs) are currently being used in multiple sclerosis (MS) but their application is inconsistent and guidance on the appropriateness of each tool is lacking. The objective of our study was to identify MS-specific PROs and systematically to assess the development process and the reliability and validity of various instruments. A systematic literature search was conducted on multiple data sources, including MEDLINE, Embase (using the Ovid platform) and Google Scholar, from 1996 to March 2015. Search terms included combinations of MS, PROs and quality of life. Randomized controlled trials or observational studies conducted on patients with MS and published in English were included. In addition, the PROQOLID database was explored. The MS-specific PROs were systematically assessed using the Evaluating the Measurement of Patient-Reported Outcomes tool. In total, 8094 articles were screened and 405 PROs were identified from 1102 relevant articles. PROs were classified into MS-specific (n = 82) and non-MS-specific (n = 323). The results for the eight PROs that are most commonly used in MS clinical trials are presented here. For these eight PROs, the overall summary scores ranged between 50.1 and 68.7. The Multiple Sclerosis Impact Scale-29 had the best overall mean score (68.7), followed by the Leeds Multiple Sclerosis Quality of Life (67.0). This is the first study to provide a standardized assessment of all PROs for MS. There is a lack of data on content validity for PROs used in MS research, which indicates the need for a robust instrument in MS developed according to the US Food and Drug Administration guidelines.

Patient-reported outcomes and survival in multiple sclerosis: A 10-year retrospective cohort study using the Multiple Sclerosis Impact Scale-29

BACKGROUND

There is increasing emphasis on using patient-reported outcomes (PROs) to complement traditional clinical outcomes in medical research, including in multiple sclerosis (MS). Research, particularly in oncology and heart failure, has shown that PROs can be prognostic of hard clinical endpoints such as survival time (time from study entry until death). However, unlike in oncology or cardiology, it is unknown whether PROs are associated with survival time in neurological diseases. The Multiple Sclerosis Impact Scale-29 (MSIS-29) is a PRO sensitive to short-term change in MS, with questions covering both physical and psychological quality of life. This study aimed to investigate whether MSIS-29 scores can be prognostic for survival time in MS, using a large observational cohort of people with MS.

METHODS AND FINDINGS

From 15 July 2004 onwards, MSIS-29 questionnaires were completed by people with MS registered with the MS Society Tissue Bank (n = 2,126, repeated 1 year later with n = 872 of the original respondents). By 2014, 264 participants (12.4%) had died. Higher baseline MSIS-29 physical (MSIS-29-PHYS) score was associated with reduced survival time (subgroup with highest scores versus subgroup with lowest scores: hazard ratio [HR] 5.7, 95% CI 3.1-10.5, p < 0.001). Higher baseline MSIS-29 psychological score was also associated with reduced survival time (subgroup with highest scores versus subgroup with lowest scores: HR 2.8, 95% CI 1.8-4.4, p < 0.001). In those with high baseline MSIS-29 scores, mortality risk was even greater if the MSIS-29 score worsened over 1 year (HR 2.3, 95% CI 1.2-4.4, p = 0.02). MSIS-29-PHYS scores were associated with survival time independent of age, sex, and patient-reported Expanded Disability Status Scale score in a Cox regression analysis (per 1-SD increase in MSIS-29-PHYS score: HR 1.8, 95% CI 1.1-2.9, p = 0.03). A limitation of the study is that this cohort had high baseline age and disability levels; the prognostic value of MSIS-29 for survival time at earlier disease stages requires further investigation.

CONCLUSIONS

This study reports that PROs can be prognostic for hard clinical outcomes in neurological disease, and supports PROs as a meaningful clinical outcome for use in research and clinical settings.

Validity and reliability of the Finnish version of the Multiple Sclerosis Impact Scale-29

BACKGROUND

The Multiple Sclerosis Impact Scale-29 (MSIS-29) has been increasingly used to evaluate the self-perceived impact of multiple sclerosis (MS) on a patient.

OBJECTIVES

The aim of this study was to evaluate the psychometric properties of the Finnish version of MSIS-29 in patients with MS.

METHODS

A total of 553 patients with MS completed the MSIS-29 and self-administered questionnaires capturing information on demographics, disease characteristics and severity, perceived quality of life (EuroQol 5D-3L instrument), and fatigue (Fatigue Severity Scale).

RESULTS

The data quality for MSIS-29 was excellent, with 99.5% computable scores for the MSIS-29 physical scale and 99.3% for the MSIS-29 psychological scale. Floor and ceiling effects were minimal. Excellent Cronbach's alpha values of 0.97 and 0.90 were seen for MSIS-29 physical and psychological subscales, respectively. The physical subscale showed highest correlations with measures of physical functioning, such as disease severity and the mobility domain of the quality of life. Similarly, the psychological subscale showed highest correlations with self-reported fatigue and the anxiety/depression domains of the quality of life. MSIS-29 physical scores related strongly to disease severity, whereas the MSIS-29 psychological scores increased in mild disease but declined in more severe disease forms.

CONCLUSION

The Finnish version of MSIS-29 has satisfactory psychometric properties. Consistent with the previous recommendations, the use of two MSIS-29 subscale scores instead of a total score was supported.

The Spectrum of Functional Rating Scales in Neurology Clinical Trials

The selection of an appropriate outcome measure is crucial to the success of a clinical trial, in order to obtain accurate results, which, in turn, influence patient care and future research. Outcomes that can be directly measured are mortality/survival. More frequently, neurology clinical trials evaluate outcomes that cannot be directly measured, such as disability, cognitive function, or change in symptoms of the condition under study. These complex outcomes are abstract ideas or latent constructs and are measured using rating scales. Functional rating scales typically assess the ability of patients to perform tasks and roles for everyday life. Rating scales should be valid (measure what they are supposed to measure), reliable (provide similar results if administered under the same conditions), and responsive (able to detect clinically important changes over time). The clinical relevance of rating scales depends on their ability to detect a minimal clinically important difference, and should be distinguished from statistical significance. Most rating scales are ordinal scales and have limitations. Modern psychometric methods of Rasch analysis and item response theory, termed latent trait theory, are increasingly being utilized to convert ordinal data to interval measurements, both to validate existing scales and to develop new scales. Patient-reported outcomes are being increasingly used in clinical trials and have a role in clinical quality assessment. The PROMIS and NeuroQoL databases are excellent resources for rigorously developed and validated patient-reported outcomes.

Patient reported outcome measures of quality of end-of-life care: A systematic review

End-of-life (EoL) care¹ is increasingly used as a generic term in preference to palliative care or terminal care, particularly with reference to individuals with chronic disease, who are resident in community and long-term care (LTC) settings. This review evaluates studies based on patient reported outcome measures (PROMS) of quality of EoL care across all health-care settings. From 1041 citations, 12 studies were extracted by searches conducted in EBSCO, Scopus, Web of Science, PubMed, Cochrane, Open Grey and Google Scholar databases. At present, the evidence base for EoL care is founded on cancer care. This review highlights the paucity of studies that evaluate quality of EoL care for patients with chronic disease outside the established cancer-acute care paradigm, particularly in LTC. This review highlights the absence of any PROMs for the estimated 60% of patients in LTC with cognitive impairment. Patient-reported outcomes (PROs) are critical to understanding how EoL care services and practices affect patients' health and EoL experience. PROMs describe the quality of care from the patient's perspective and add balance to existing clinical or proxy-derived knowledge on the quality of care and services provided.

Prolonged-release fampridine treatment improved subject-reported impact of multiple sclerosis: Item-level analysis of the MSIS-29

Prolonged-release (PR) fampridine is approved to treat walking impairment in persons with multiple sclerosis (MS); however, treatment benefits may extend beyond walking. MOBILE was a phase 2, 24-week, double-blind, placebo-controlled exploratory study to assess the impact of 10mg PR-fampridine twice daily versus placebo on several subject-assessed measures. This analysis evaluated the physical and psychological health outcomes of subjects with progressing or relapsing MS from individual items of the Multiple Sclerosis Impact Scale (MSIS-29). PR-fampridine treatment (n=68) resulted in greater improvements from baseline in the MSIS-29 physical (PHYS) and psychological (PSYCH) impact subscales, with differences of 89% and 148% in mean score reduction from baseline (n=64) at week 24 versus placebo, respectively. MSIS-29 item analysis showed that a higher percentage of PR-fampridine subjects had mean improvements in 16/20 PHYS and 6/9 PSYCH items versus placebo after 24weeks. Post hoc analysis of the 12-item Multiple Sclerosis Walking Scale (MSWS-12) improver population (≥8-point mean improvement) demonstrated differences in mean reductions from baseline of 97% and 111% in PR-fampridine MSIS-29 PHYS and PSYCH subscales versus the overall placebo group over 24weeks. A higher percentage of MSWS-12 improvers treated with PR-fampridine showed mean improvements in 20/20 PHYS and 8/9 PSYCH items versus placebo at 24weeks. In conclusion, PR-fampridine resulted in physical and psychological benefits versus placebo, sustained over 24weeks.

A Quality-Adjusted Life-Year Measure for Multiple Sclerosis: Developing a Patient-Reported Health State Classification System for a Multiple Sclerosis-Specific Preference-Based Measure

BACKGROUND

Increasingly, generic preference-based measures of health-related quality of life (HRQOL) are used to estimate quality-adjusted life-years to inform resource allocation decisions. Evidence suggests that generic measures may not be appropriate for multiple sclerosis (MS).

OBJECTIVES

To report the first stage in the development of an MS-specific preference-based measure to quantify the impact of MS and its treatment: deriving a health state classification system, which is amenable to valuation, from the 29-item Multiple Sclerosis Impact Scale (MSIS-29), a widely used patient-reported outcome measure in MS.

METHODS

The dimensional structure of the MSIS-29 was determined using factor analysis and a conceptual framework of HRQOL in MS. Item performance was assessed, using Rasch analysis and psychometric criteria, to enable the selection of one item to represent each dimension of HRQOL covered by the MSIS-29. Analysis was undertaken using a sample (N = 529) from a longitudinal study of people with MS. Results were validated by repeating the analysis with a second sample (N = 528).

RESULTS

Factor analysis confirmed the two-subscale structure of the MSIS-29. Both subscales covered several conceptually independent dimensions of HRQOL. Following Rasch and psychometric analysis, an eight-dimensional classification system named the MSIS-8D was developed. Each dimension was represented by one item with four response levels.

CONCLUSIONS

Combining factor analysis with conceptual mapping, and Rasch analysis with psychometric criteria, provides a valid method of constructing a classification system for an MS-specific preference-based measure. The next stage is to obtain preference weights so that the measure can be used in studies investigating MS.

Estimating a Preference-Based Index for an Eight-Dimensional Health State Classification System for Multiple Sclerosis

BACKGROUND

Condition-specific measures are frequently used to assess the health-related quality of life of people with multiple sclerosis (MS). Such measures are unsuitable for use in economic evaluations that require estimates of cost per quality-adjusted life-year because they are not based on preferences.

OBJECTIVES

To report the estimation of a preference-based single index for an eight-dimensional instrument for MS, the Multiple Sclerosis Impact Scale - Eight Dimensions (MSIS-8D), derived from an MS-specific measure of health-related quality of life, the 29-item Multiple Sclerosis Impact Scale (MSIS-29).

METHODS

We elicited preferences for a sample of MSIS-8D states (n = 169) from a sample (n = 1702) of the UK general population. Preferences were elicited using the time trade-off technique via an Internet-based survey. We fitted regression models to these data to estimate values for all health states described by the MSIS-8D. Estimated values were assessed against MSIS-29 scores and values derived from generic preference-based measures in a large, representative sample of people with MS.

RESULTS

Participants reported that the time trade-off questions were easy to understand. Observed health state values ranged from 0.08 to 0.89. The best-performing model was a main effects, random effects model (mean absolute error = 0.04). Validation analyses support the performance of the MSIS-8D index: it correlated more strongly than did generic measures with MSIS-29 scores, and it discriminated effectively between subgroups of people with MS.

CONCLUSIONS

The MSIS-8D enables health state values to be estimated from the MSIS-29, adding to the methods available to assess health outcomes and to estimate quality-adjusted life-years for MS for use in health technology assessment and decision-making contexts.

Evaluation of an integrated multidisciplinary approach in multiple sclerosis care: A prospective, randomized, controlled study

Background

Disabled multiple sclerosis (MS) patients often need intervention of multiple specialists, resulting in a complex organization of care. How this multidisciplinary care should be organized and structured has not been studied.

Objective

The objective of this article is to address the effectiveness of an integrated multidisciplinary approach versus usual care in MS patients.

Methods

This is a prospective, randomized, controlled, monocentric clinical trial in MS patients. Two treatment strategies were compared: (i) an integrated multidisciplinary (IMD) approach, consisting of a half-day individually tailored comprehensive assessment in the MS clinic; and (ii) a standard care. The primary outcome was the impact of the strategy on quality of life (QoL) measured using the MSIS-29 scale at inclusion and after six months.

Results

Fifty MS patients were included. Median MSIS 29 score decreased over six months in the control group (−4.89) and increased in the IMD group (+2.00), with a significant difference between the two groups (p = 0.03). However, in the multivariate analysis, after adjustment of HAD-D and INTERMED score, this difference was no longer significant.

Conclusions

This prospective, randomized study is the first attempt to evaluate the multidisciplinary approach in MS patients. The results show that, contrary to our expectations, an integrated multidisciplinary approach is not superior to usual care on QoL.

Evaluation of an integrated multidisciplinary approach in multiple sclerosis care: A prospective, randomized, controlled study

BACKGROUND

Disabled multiple sclerosis (MS) patients often need intervention of multiple specialists, resulting in a complex organization of care. How this multidisciplinary care should be organized and structured has not been studied.

OBJECTIVE

The objective of this article is to address the effectiveness of an integrated multidisciplinary approach versus usual care in MS patients.

METHODS

This is a prospective, randomized, controlled, monocentric clinical trial in MS patients. Two treatment strategies were compared: (i) an integrated multidisciplinary (IMD) approach, consisting of a half-day individually tailored comprehensive assessment in the MS clinic; and (ii) a standard care. The primary outcome was the impact of the strategy on quality of life (QoL) measured using the MSIS-29 scale at inclusion and after six months.

RESULTS

Fifty MS patients were included. Median MSIS 29 score decreased over six months in the control group (-4.89) and increased in the IMD group (+2.00), with a significant difference between the two groups (p = 0.03). However, in the multivariate analysis, after adjustment of HAD-D and INTERMED score, this difference was no longer significant.

CONCLUSIONS

This prospective, randomized study is the first attempt to evaluate the multidisciplinary approach in MS patients. The results show that, contrary to our expectations, an integrated multidisciplinary approach is not superior to usual care on QoL.

Repeat infusion of autologous bone marrow cells in multiple sclerosis: protocol for a phase I extension study (SIAMMS-II)

INTRODUCTION

The 'Study of Intravenous Autologous Marrow in Multiple Sclerosis (SIAMMS)' trial was a safety and feasibility study which examined the effect of intravenous infusion of autologous bone marrow without myeloablative therapy. This trial was well tolerated and improvement was noted in the global evoked potential (GEP)--a neurophysiological secondary outcome measure recording speed of conduction in central nervous system pathways. The efficacy of intravenous delivery of autologous marrow in progressive multiple sclerosis (MS) will be examined in the phase II study the 'Assessment of Bone Marrow-Derived Cellular Therapy in Progressive Multiple Sclerosis (ACTiMuS; NCT01815632)'. In parallel with the 'ACTiMuS' study, the current study 'SIAMMS-II' will explore the feasibility of repeated, non-myeloablative autologous bone marrow-derived cell therapy in progressive MS. Furthermore, information will be obtained regarding the persistence or otherwise of improvements in conduction in central nervous system pathways observed in the original 'SIAMMS' study and whether these can be reproduced or augmented by a second infusion of autologous bone marrow-derived cells.

METHODS AND ANALYSIS

An open, prospective, single-centre phase I extension study. The six patients with progressive MS who participated in the 'SIAMMS' study will be invited to undergo repeat bone marrow harvest and receive an intravenous infusion of autologous, unfractionated bone marrow as a day-case procedure. The primary outcome measure is the number of adverse events, and secondary outcome measures will include change in clinical rating scales of disability, GEP and cranial MRI.

ETHICS AND DISSEMINATION

The study has UK National Research Ethics Committee approval (13/SW/0255). Study results will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT01932593.

Multiple sclerosis course and clinical outcomes in patients with comorbid asthma: a survey study

OBJECTIVE

To determine if comorbid asthma is associated with accumulation of multiple sclerosis (MS)-related impairment and disability.

METHOD

We sent a comprehensive questionnaire to a cohort of patients with MS and examined the association between comorbid asthma and reaching Expanded Disability Status Scale (EDSS) scores 4.0 and 6.0. Multiple Sclerosis Impact Scale (MSIS-29) scores were compared between patients with MS with and without comorbid asthma.

RESULTS

680 patients participated in our study of whom 88 (12.9%) had comorbid asthma. There was no difference in the prevalence of asthma between our MS cohort and the England general population (OR: 0.89, 95% CI 0.68 to 1.17). We did not observe a significant association between having asthma and the risk of reaching EDSS scores 4.0 and 6.0 (HR: 1.29, 95% CI 0.93 to 1.77, and HR: 1.33, 95% CI 0.93 to 1.89, respectively) after controlling for confounders. Patients with MS with asthma reported higher level of psychological impairments (coefficient: 2.29, 95% CI 0.1 to 4.49).

CONCLUSIONS

Asthma is a prevalent condition among patients with MS and it may contribute to the psychological impairment in MS. Although we did not observe significant association between comorbid asthma and physical disability in MS, it seems that the two conditions influence one another.

Longitudinal changes in self-reported walking ability in multiple sclerosis

Background

Patient-reported outcomes are increasingly used to understand the clinical meaningfulness of multiple sclerosis disability and its treatments. For example, the 12-item Multiple Sclerosis Walking Scale (MSWS-12) measures the patient-reported impact of the disease on walking ability.

Objective

We studied longitudinal changes in walking ability using the MSWS-12 in a cohort of 108 patients with relapsing-remitting multiple sclerosis and moderate-to-severe disability from a single US center cohort study investigating multiple sclerosis symptoms and physical activity.

Methods

The MSWS-12 was completed every 6 months over 2 years together with self-reported measures of disease impact on daily life (Multiple Sclerosis Impact Scale) and walking disability (Patient Determined Disease Steps scale).

Results

The results revealed a high frequency of self-reported changes in walking ability at the individual level, affecting approximately 80% of patients for all four time periods. MSWS-12 scores remained stable at the group level for all four time periods. The magnitude of observed changes at the individual level was higher than the proposed minimal clinically important differences of 4 or 6 points and correlated better with Multiple Sclerosis Impact Scale physical scores than psychological scores, but little with self-reported Patient Determined Disease Steps Scale scores.

Conclusions

This novel finding of frequent fluctuations in self-reported walking ability is new and requires further investigation.

Distress improves after mindfulness training for progressive MS: A pilot randomised trial

BACKGROUND

Mindfulness-based interventions have been shown to effectively reduce anxiety, depression and pain in patients with chronic physical illnesses.

OBJECTIVES

We assessed the potential effectiveness and cost-effectiveness of a specially adapted Skype distant-delivered mindfulness intervention, designed to reduce distress for people affected by primary and secondary progressive MS.

METHODS

Forty participants were randomly assigned to the eight-week intervention (n = 19) or a waiting-list control group (n = 21). Participants completed standardised questionnaires to measure mood, impact of MS and symptom severity, quality of life and service costs at baseline, post-intervention and three-month follow-up.

RESULTS

Distress scores were lower in the intervention group compared with the control group at post-intervention and follow-up (p < 0.05), effect size -0.67 post-intervention and -0.97 at follow-up. Mean scores for pain, fatigue, anxiety, depression and impact of MS were reduced for the mindfulness group compared with control group at post-therapy and follow-up; effect sizes ranged from -0.27 to -0.99 post-intervention and -0.29 to -1.12 at follow-up. There were no differences in quality-adjusted life years, but an 87.4% probability that the intervention saves on service costs and improves outcome.

CONCLUSIONS

A mindfulness intervention delivered through Skype video conferences appears accessible, feasible and potentially effective and cost-effective for people with progressive MS.

Employment Among Working-Age Adults With Multiple Sclerosis: A Data-Mining Approach to Identifying Employment Interventions

Purpose:To examine demographic, functional, and clinical multiple sclerosis (MS) variables affecting employment status in a national sample of adults with MS in the United States.

Method:The sample included 4,142 working-age (20–65 years) Americans with MS (79.1% female) who participated in a national survey. The mean age of participants was 51.93 years (SD= 8.7). The dependent variable was employment status. The predictor variables included a set of demographic, functional, and MS variables.

Results:The chi-squared automatic interaction detector (CHAID) analysis indicated that participants who were receiving Social Security Disability Insurance (SSDI) had significantly lower rates of employment (8.6%) than those who were not receiving SSDI (53.9%). For those not receiving SSDI, the most important factor predicting employment status was MS impact on physical functioning, as measured with the Multiple Sclerosis Impact Scale Physical Impact scale.

Conclusion:The data-mining approach (i.e., CHAID analysis) provided detailed information and insight about interactions among demographic, functional, and clinical variables and employment status through the segmentation of the sample into mutually exclusive homogeneous subgroups. Implications for rehabilitation intervention, based on these subgroupings, are discussed.

Responder definition of the Multiple Sclerosis Impact Scale physical impact subscale for patients with physical worsening

BACKGROUND

The 29-item Multiple Sclerosis Impact Scale (MSIS-29) was developed to examine the impact of multiple sclerosis (MS) on physical and psychological functioning from a patient's perspective.

OBJECTIVE

To determine the responder definition (RD) of the MSIS-29 physical impact subscale (PHYS) in a group of patients with relapsing-remitting MS (RRMS) participating in a clinical trial.

METHODS

Data from the SELECT trial comparing daclizumab high-yield process with placebo in patients with RRMS were used. Physical function was evaluated in SELECT using three patient-reported outcomes measures and the Expanded Disability Status Scale (EDSS). Anchor- and distribution-based methods were used to identify an RD for the MSIS-29.

RESULTS

Results across the anchor-based approach suggested MSIS-29 PHYS RD values of 6.91 (mean), 7.14 (median) and 7.50 (mode). Distribution-based RD estimates ranged from 6.24 to 10.40. An RD of 7.50 was selected as the most appropriate threshold for physical worsening based on corresponding changes in the EDSS (primary anchor of interest).

CONCLUSION

These findings indicate that a ≥7.50 point worsening on the MSIS-29 PHYS is a reasonable and practical threshold for identifying patients with RRMS who have experienced a clinically significant change in the physical impact of MS.

Clinical outcome measures in multiple sclerosis

Clinical outcome measures are indispensable when studying the natural course of multiple sclerosis (MS) and critical for determining the effect of an intervention. For these purposes clinical outcome measures should be valid, reliable, and responsive. Moreover they should assess clinically relevant aspects of the disease. Given the nature of the disease, outcome measures in MS should be able to capture multiple clinical dimensions. Long-term disability-free survival is the ultimate goal of MS treatment. Since the observation period in clinical trials is too short to get a final answer on that outcome, clinicians and researchers rely on extrapolation of the results beyond the treatment period. Yet the long-term predictive value of most outcome measures (e.g., relapse rate) used for short-term responses has not yet been determined. The expanded disability status scale (EDSS) is the outcome measure that is most often included in MS studies. The EDSS appeals to most neurologists as it is the result of a standardized neurologic examination and neurologists know it well. However, when considered critically, the EDSS has serious weaknesses from a clinimetric point of view that limit its value as an outcome measure in MS. The search for an alternative outcome measure that can fulfill all essential requirements and will be accepted by the scientific community, clinicians, and regulatory agencies is a huge challenge.

Predictors of the physical impact of Multiple Sclerosis following community-based, exercise trial

Background:

Studies evaluating exercise interventions in people with multiple sclerosis (PwMS) demonstrate small to medium positive effects and large variability on a number of outcome measures. No study to date has tried to explain this variability.

Objective:

This paper presents a novel exploration of data examining the predictors of outcome for PwMS with minimal gait impairment following a randomised, controlled trial evaluating community-based exercise interventions ( N = 242).

Methods:

The primary variable was the physical component of the Multiple Sclerosis Impact Scale-29, version 2 (MSIS-29, v2) after a 10-week, controlled intervention period. Predictors were identified a priori and were measured at baseline. Multiple linear regression was conducted.

Results:

Four models are presented lower MSIS-29, v2 scores after the intervention period were best predicted by a lower baseline MSIS-29,v2, a lower baseline Modified Fatigue Impact Score (physical subscale), randomisation to an exercise intervention, a longer baseline walking distance measured by the Six Minute Walk Test and female gender. This model explained 57.4% of the variance (F (5, 211) = 59.24, p < 0.01).

Conclusion:

These results suggest that fatigue and walking distance at baseline contribute significantly to predicting MSIS-29, v29 (physical component) after intervention, and thus should be the focus of intervention and assessment. Exercise is an important contributor to minimising the physical impact of MS, and gender-specific interventions may be warranted.

The Canadian survey of health, lifestyle and ageing with multiple sclerosis: methodology and initial results

OBJECTIVE

People with multiple sclerosis (MS) are living longer so strategies to enhance long-term health are garnering more interest. We aimed to create a profile of ageing with MS in Canada by recruiting 1250 (5% of the Canadian population above 55 years with MS) participants and focusing data collection on health and lifestyle factors, disability, participation and quality of life to determine factors associated with healthy ageing.

DESIGN

National multicentre postal survey.

SETTING

Recruitment from Canadian MS clinics, MS Society of Canada chapters and newspaper advertisements.

PARTICIPANTS

People aged 55 years or older with MS symptoms more than 20 years.

OUTCOME MEASURES

Validated outcome measures and custom-designed questions examining MS disease characteristics, living situation, disability, comorbid conditions, fatigue, health behaviours, mental health, social support, impact of MS and others.

RESULTS

Of the 921 surveys, 743 were returned (80.7% response rate). Participants (mean age 64.6±6.2 years) reported living with MS symptoms for an average of 32.9±9.5 years and 28.6% were either wheelchair users or bedridden. There was only 5.4% missing data and 709 respondents provided optional qualitative information. According to data derived from the 2012 Canadian Community Health Survey of Canadians above 55 years of age, older people with MS from this survey sample are about eight times less likely to be employed full-time. Older people with MS were less likely to engage in regular physical activity (26.7%) compared with typical older Canadians (45.2%). However, they were more likely to abstain from alcohol and smoking.

CONCLUSIONS

Despite barriers to participation, we were able to recruit and gather detailed responses (with good data quality) from a large proportion of older Canadians with MS. The data suggest that this sample of older people with MS is less likely to be employed, are less active and more disabled than other older Canadians.

Do patient and proxy agree? Long-term changes in multiple sclerosis physical impact and walking ability on patient-reported outcome scales

Background:

Patient-reported outcome scales (PROs) are useful in monitoring changes in multiple sclerosis (MS) over time. Although these scales are reliable and valid measures in longitudinal studies in MS patients, it is unknown what the impact is when obtaining longitudinal data from proxies.

Objective:

The objective of this paper is to compare longitudinal changes in patient and proxy responses on PROs assessing physical impact of MS and walking ability.

Methods:

In a prospective observational study, data on the Multiple Sclerosis Impact Scale (MSIS-29 physical) and Multiple Sclerosis Walking Scale (MSWS-12) were obtained from 137 patient-proxy couples at baseline and at two-year follow-up. Demographic and disease-related variables explaining agreement or disagreement between patients and proxies were investigated using linear regression analyses.

Results:

Full agreement was found in 56% (MSIS) and 62% (MSWS) of the patient-proxy couples. Complete disagreement was very rare for both scales (2% MSIS, 5% MSWS). When patients were more positive than proxies, a higher age, longer disease duration, longer patient-proxy relationship and increased levels of depression, anxiety and caregiver burden in proxies were observed.

Conclusion:

In the majority of the patient-proxy couples there was agreement. Proxies can serve as a valuable source of information, but caution remains essential when using scores from proxies.