Exercise in the management of persons with multiple sclerosis

Physical Activity Moderates the Association Between Pain and Depressive Symptoms Among Persons with Multiple Sclerosis

OBJECTIVE

The present study examined physical activity as a possible moderator in the relationship between pain and depressive symptoms among persons with multiple sclerosis (PwMS).

METHOD

Fifty-three PwMS completed a comprehensive neuropsychological test battery and psychosocial questionnaires. Pain was operationalized as a composite of measures from the Brief Pain Inventory. Metabolic equivalents (METs) of energy expended during self-reported vigorous activity (VA), moderate activity (MA), and walking, as well as global physical activity which combined the three, were derived from the International Physical Activity Questionnaire-Short Form. Self-reported physical activity was measured using the Cognitive Health Questionnaire Exercise Scale. Regressions on depressive symptoms (Beck Depression Inventory-Fast Screen) examining both conceptualizations of physical activity, pain, and their interactions were explored.

RESULTS

Regression analyses revealed that interactions between pain and each measure of global physical activity were significant (p = .01). Simple effects tests revealed that pain only influenced depressive symptoms in PwMS with low global physical activity METs (p < .001) and low overall self-reported physical activity (p < .001). The separate interactions between pain and METs during self-reported VA, MA, and walking on depressive symptoms were not significant.

CONCLUSION

We found that global physical activity moderated the relationship between pain and depressive symptoms in MS. Specifically, pain influenced depressive symptoms in PwMS who engaged in less overall physical activity. These results highlight the importance of screening PwMS for pain and suggest that behavioral interventions aimed at increasing overall lifestyle physical activity may be useful in improving depressive outcomes in PwMS with pain.

Virtual reality rehabilitation in patients affected by multiple sclerosis: Impact on quality of life and sexual functions

BACKGROUND

Multiple Sclerosis (MS) can present several neurological symptoms with a progression that often leads to loss of cognitive and physical abilities. Sexual dysfunctions are frequent, although underestimated, MS symptoms significantly affecting the quality of life of these patients. The primary objective of this study was to assess the effectiveness of VR rehabilitation in enhancing the quality of life in individuals with MS. The secondary objective aimed to investigate whether the improvement in quality of life would also lead to enhanced sexual satisfaction and sexual function.

MATERIALS AND METHODS

Patients diagnosed with relapsing-remitting and secondary progressive MS and attending from November 2018 to March 2020 the Rehabilitation Laboratory of IRCCS Neurolesi "Bonino Pulejo" in Messina, Italy were enrolled in this study. All patients were randomized into either the control group (CG: 35 patients) that received traditional cognitive rehabilitation (CR) or the experimental group (EG: 35) undergoing VR.

RESULTS

The EG showed substantial improvements in various aspects of Multiple Sclerosis Quality of Life (MSQOL) between T0 and T1. Sexual function significantly improved, along with sexual satisfaction. Conversely, the CG achieved significant changes only in overall quality of life. Pearson's correlations highlighted the positive associations between sexual function and satisfaction, as well as with physical and mental well-being, underscoring the importance of improving sexual function as a marker of overall health.

DISCUSSION

This study is meant as exploratory as it addresses a fundamental yet overlooked aspect of rehabilitation, i.e., sexual function and sexual satisfaction, which could potentially be enhanced through rehabilitation in a VR environment. Registration DOI number: DOI 10.17605/OSF.IO/NB4MJ.

Multiple sclerosis in the elderly: a retrospective cohort study

BACKGROUND

There is a lack of knowledge of disease course, prognosis, comorbidities and potential treatments of elderly MS patients.

OBJECTIVE

To characterize the disease course including disability progression and relapses, to quantify the use of DMTs and to identify comorbidities and risk factors for progression in elderly multiple sclerosis (MS) patients.

METHODS

This is a retrospective study of 1200 Austrian MS patients older than 55 years as of May 1st, 2017 representing roughly one-third of all the MS patients of this age in Austria. Data were collected from 15 MS centers including demographics, first symptom at onset, number of relapses, evolvement of disability, medication, and comorbidities.

RESULTS

Median observation time was 17.1 years with 957 (80%) relapsing and 243 (20%) progressive onsets. Average age at diagnosis was 45 years with a female predominance of 71%. Three-hundred and twenty-six (27%) patients were never treated with a DMT, while most treated patients received interferons (496; 41%) at some point. At last follow-up, 420 (35%) patients were still treated with a DMT. No difference was found between treated and never-treated patients in terms of clinical outcome; however, patients with worse disability progression had significantly more DMT switches. Pyramidal onset, number of comorbidities, dementia, epilepsy, and psychiatric conditions as well as a higher number of relapses were associated with worse outcome. The risk of reaching EDSS 6 rose with every additional comorbidity by 22%. In late and very-late-onset MS (LOMS, VLOMS) time to diagnosis took nearly twice the time compared to adult and early onset (AEOMS). The overall annualized relapse rate (ARR) decreased over time and patients with AEOMS had significantly higher ARR compared to LOMS and VLOMS. Four percent of MS patients had five medications or more fulfilling criteria of polypharmacy and 20% of psychiatric drugs were administered without a matching diagnosis.

CONCLUSIONS

In this study, we identified number of comorbidities, pyramidal and cerebellar signs, and a higher number of relapses as unfavorable prognostic factors in elderly MS patients filling gaps of knowledge in patients usually underrepresented in clinical trials and may guide future therapeutic studies.

Rehabilitation therapy versus drug-only therapy in patients with multiple sclerosis

Background/aim

The treatment for multiple sclerosis (MS) does not cure the disease, but it is intended to reduce the intensity, duration, and frequency of symptoms. Rehabilitation therapy (RT), including an individualized physical therapy program (PTP) and adapted occupational therapy (OT), has benefits in terms of aerobic capacity, muscle strength, coordination, and ability to perform activities of daily living (ADL). The primary objective of this study was to examine the efficacy of RT comprising PTP, OT, and drug treatment (DT) versus DT alone in patients with MS. Another objective was to highlight the importance of continuing the PT and OT at home, in the long term, practically for their entire life.

Materials and methods

Between 2020 and 2022, a follow-up observational study was conducted that included 77 patients diagnosed with MS, independent in terms of ability to perform ADL, divided into two groups: group A (39 patients who complied with the RT) and group B (38 patients who did not comply). At the beginning and end of the study, the following parameters were assessed: timed walk for 25 feet [Timed 25-Foot Walk test (T25FW test)], dexterity of the upper limbs [9-Hole Peg Test (9HPT)], and cognitive function [Paced Auditory Serial Addition Test (PASAT)].

Results

Significant improvement in the experimental group was observed regarding the mobility and the performance of leg function (T25FW, p < 0.05) and finger dexterity (9HPT, p < 0.05) for the dominant hand.

Conclusion

The current study proves the importance of combining DT with RT in MS therapy with clear benefits in regaining muscle strength in the lower limbs, thus improving coordination and balance while walking and improving dexterity in the dominant hand.

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

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

The Role of Exercise on Fatigue Among Patients With Multiple Sclerosis in the King Fahad Hospital, Madinah, Saudi Arabia: An Analytical Cross-Sectional Study

Background Multiple sclerosis (MS) is a chronic autoimmune disease caused by multiple factors. It can lead to many physical and mental symptoms. Fatigue is one of the most commonly mentioned complaints among MS patients that can affect their quality of life. Physical activity has many benefits for the physical and mental health of patients with MS. Aim To assess the role of exercise on fatigue among patients with multiple sclerosis and identify the relationship between depression, sleep quality, sociodemographic variables, and fatigue. Methods This is an analytical cross-sectional study based on a sample size of 235 patients recruited from the MS clinic at King Fahad Hospital (KFH) in Madinah. The outcome of the study was fatigue among MS patients. Data were collected through telephone calls from February to May 2022 using a structured questionnaire and scales, such as the Godin Leisure-Time Exercise Questionnaire (GLTEQ), Modified Fatigue Impact Scale (MFIS), Patient Health Questionnaire (PHQ2), and Pittsburgh Sleep Quality Index (PSQI). Data were analyzed through SPSS version 20 (IBM Corp., Armonk, NY, USA). The correlation coefficient (r), Chi-square tests, and simple and multiple logistic regression were used as found appropriate. Results Out of the total samples, 37.4% were male and 62.6% were female. The median age of patients was 36 years. The prevalence of fatigue was 37% among patients, with a reported median fatigue score of 26. It was found that 63% of the patients were physically inactive; 32.2% were overweight, 14.2% were obese; 63.8% of patients had poor sleep quality. The fatigue score was negatively correlated with the GLTEQ score, but the results were not significant (r=-0.066; P-value (level of significance)=0.335). Nonetheless, a moderately significant correlation was observed between the MFIS and PSQI and MFIS and PHQ2 (r=0.505, P=<0.001 and r=0.520, P=<0.001, respectively). The Chi-square test showed a significant association between fatigue and progressive types of MS, the primary progressive MS (PPMS), secondary progressive MS (SPMS), and relapsing-remitting MS (RRMS) (odds ratio (OR)=4.4; 95% confidence interval (CI): 2.1-8.9), P=<0.001). Depressed patients were 9.7 times more likely to develop fatigue compared to non-depressed patients (P=<0.001). Those with poor sleep quality were 4.6 times more likely to develop fatigue compared to those with good sleep quality (P=<0.001). Fifty-six percent of fatigue among MS patients were predicted by low income, progressive types, unemployment, obesity, depression, and poor sleep quality. Conclusion Fatigue is a major complaint among MS patients. Most of the patients were found to be physically inactive, depressed, and have poor sleep quality. This study found an association between physical inactivity and fatigue, but the results were not significant. There was a significant association between sociodemographic factors like low income and unemployment, poor sleep quality, obesity, progressive types of MS, depression, and fatigue. Encouraging exercise practice and implementing a regular exercise program are needed, along with weight management plans. Further studies and psychological support meetings are required, with the importance of a holistic approach to patient care.

Characterizing Relationships Between Cognitive, Mental, and Physical Health and Physical Activity Levels in Persons With Multiple Sclerosis

BACKGROUND

Although persons with multiple sclerosis (MS) are encouraged to engage in physical activity, they are less active than the general population and experience poorer emotional/cognitive health, underscoring the need for increased understanding of the factors independently associated with exercise in MS.

METHODS

Six hundred forty people with MS completed a detailed demographic survey, the Godin Leisure-Time Exercise Questionnaire, and Quality of Life in Neurological Disorders short forms. The average number of weekly sessions of exercise was examined as a count, as a binary variable (a weekly minimum of 4 sessions of physical activity), and as an ordinal variable of being active using multivariable zero-inflated negative binomial, logistic, and ordered logistic regression models, respectively. Primary predictors of interest included depression, cognitive function, positive affect, and lower extremity functioning as measured by the Quality of Life in Neurological Disorders short forms.

RESULTS

The study sample was 91% White race, 83% female, 65% with a relapsing-remitting MS diagnosis. The mean participant age was 52 years. Across analyses, body mass index and disability were inversely associated with exercising. Greater lower extremity impairment was associated with decreased odds of exercising and being active. A greater burden of depression symptoms was correlated with lower odds of engaging in physical activity. People with MS with higher self-reported cognitive functioning were less likely to engage in any exercise, but it was not associated with frequency of activities.

CONCLUSIONS

These results demonstrate associations between exercise and cognitive and emotional health in people with MS, underscoring the need to consider these factors when designing MS-targeted physical activity recommendations.

Prevalence of fatigue and its explicative variables among people with multiple sclerosis

BACKGROUND: Fatigue is the most prevalent symptom among people with multiple sclerosis (PwMS). Although exercise effectively reduces fatigue, the relationship between daily physical activity and fatigue has only recently been demonstrated. OBJECTIVE: The aim of this study was to evaluate the prevalence of fatigue and to understand the relationship with several variables in French PwMS. METHODS: Data were collected from 191 PwMS using Modified Fatigue Impact Scale (MFIS) and Fatigue Severity Scale (FSS) for fatigue, and the Godin Leisure-Time Exercise Questionnaire (GLTEQ) for physical activity. RESULTS: 110 PwMS (57%), 35 PwMS (18%) and 46 PwMS (24%) were considered as fatigued, non-fatigued and in the grey zone, respectively. Greater physical activity was observed in non-fatigued PwMS (20.2±19.8) compared to fatigued PwMS (12.5±14.1). FSS and MFIS scores were associated with physical activity (r = –0.28 and r = –0.25, respectively, p <  0.05). Using multivariate analysis, disability, physical activity and being unemployed explained 21% of the variance of the MFIS. CONCLUSIONS: The present study confirms that physical activity and fatigue are associated. Disability and unemployment status should also to be consider when assessing fatigue. Activity-oriented health policies should be redesigned to improve fatigue among PwMS.

Effects of two types of exercise training on psychological well-being, sleep and physical fitness in patients with high-grade glioma (WHO III and IV)

BACKGROUND

There is evidence that regular exercise training has the potential to improve psychological well-being among cancer survivors. However, limited findings are available for individuals with high-grade glioma (HGG; WHO grade III and IV) after neurosurgery and undergoing radiochemotherapy. Given this, endurance and strengths training were employed to investigate their impact on symptoms of depression, feelings of stress and anxiety, fatigue, insomnia, and physical fitness, compared to an active control condition.

METHODS

A total of 29 patients (M = 52.07, SD = 12.45, 55.2% women) participated in this randomized controlled trial (RCT). After neurosurgical treatment and during adjuvant radiotherapy and chemotherapy or combined radiochemotherapy, patients were randomly assigned to the following conditions: Endurance training (n = 10); strengths training (n = 11); active control condition (n = 8). At baseline, three weeks and six weeks later at the end of the study physical fitness was objectively measured with a 6-min walk test (6MWT) and a handgrip test. Participants completed a series of questionnaires covering sociodemographic information, symptoms of depression, stress, anxiety, fatigue, and insomnia. Further, experts rated participants' severity of symptoms of depression.

RESULTS

Over time and compared to the strengths and active control condition, self-rated symptoms of depression, state and trait anxiety, stress and insomnia decreased in the endurance condition. Over time and compared to the endurance and active control condition, no changes on symptoms of depression, anxiety, stress, or insomnia were observed in the strengths condition. Over time and compared to the endurance and strengths condition, symptoms of depression (self-ratings), stress, insomnia and fatigue decreased in the active control condition. Fatigue increased in both exercising conditions. Over time and irrespective from the study condition, physical fitness did neither improve nor decrease.

CONCLUSIONS

The pattern of results suggests that endurance training and an active control condition improved dimensions of depression, stress, and anxiety, while mere strengths training appeared to neither improve, nor decrease dimensions of psychological functioning. Further, exercise interventions did not change physical fitness, but increased fatigue. Overall, endurance training and an active control condition appeared to favorably impact on psychological well-being among patients with high-grade glioma after neurosurgery and undergoing radiochemotherapy.

Therapeutic Effects of the Pilates Method in Patients with Multiple Sclerosis: A Systematic Review

The Pilates Method is a rehabilitation tool with verified benefits in pain management, physical function, and quality of life in many different physiotherapy areas. It could be beneficial for patients with multiple sclerosis (pwMS). The aim of the study was to summarize current evidence for the effectiveness of Pilates in pwMS. A comprehensive search of Cinahl, Scopus, Web of Science, PEDro, and PubMed (including PubMed Central and Medline) was conducted to examine randomized controlled trials (RCT) that included Pilates intervention in multiple sclerosis. The PEDro scale and the Cochrane risk-of-bias tool, RoB-2, were used to evaluate risk of bias for RCT. Twenty RCT (999 patients) were included. Ten were of good quality (PEDro), and seven had low risk of bias (RoB-2). Pilates improves balance, gait, physical-functional conditions (muscular strength, core stability, aerobic capacity, and body composition), and cognitive functions. Fatigue, quality of life, and psychological function did not show clear improvement. There was good adherence to Pilates intervention (average adherence ≥ 80%). Cumulative data suggest that Pilates can be a rehabilitation tool for pwMS. High adherence and few adverse effects were reported. Future research is needed to develop clinical protocols that could maximize therapeutic effects of Pilates for pwMS.

Alterations in Leg Muscle Glucose Uptake and Inter-Limb Asymmetry after a Single Session of tDCS in Four People with Multiple Sclerosis

Asymmetrical lower limb weakness is an early symptom and significant contributor to the progressive worsening of walking ability in people with multiple sclerosis (PwMS). Transcranial direct current stimulation (tDCS) may effectively increase neural drive to the more-affected lower limb and, therefore, increase symmetrical activation. Four PwMS (1 female, age range: 27–57) underwent one session each of 3 mA or SHAM tDCS over the motor cortex corresponding to their more-affected limb followed by 20 min of treadmill walking at a self-selected speed. Two min into the treadmill task, the subjects were injected with the glucose analog [¹⁸F]fluorodeoxyglucose (FDG). Immediately after treadmill walking, the subjects underwent whole-body positron emission tomography (PET) imaging. Glucose uptake (GU) values were compared between the legs, the spatial distribution of FDG was assessed to estimate glucose uptake heterogeneity (GUh), and GU asymmetry indices (AIs) were calculated. After tDCS, GU was altered, and GUh was decreased in various muscle groups in each subject. Additionally, AIs went from asymmetric to symmetric after tDCS in the subjects that demonstrated asymmetrical glucose uptake during SHAM. These results indicate that tDCS improved GU asymmetries, potentially from an increased neural drive and a more efficient muscle activation strategy of the lower limb in PwMS.

When Much Is Too Much-Compared to Light Exercisers, Heavy Exercisers Report More Mental Health Issues and Stress, but Less Sleep Complaints

BACKGROUND

Physical inactivity has become a global somatic and mental health issue. To counterbalance, promoting regular physical activity appears plausible, above all among adults, where physical inactivity is particularly high. However, some, but sparse, research also indicates that excessive exercising might be associated with unfavorable mental health dimensions. Here, we tested the hypothesis that excessive exercising was associated with more mental health issues. To this end, we assessed mental health issues, stress, mental toughness, and sleep disturbances among heavy and light adult exercisers.

METHODS

A total of 200 adults (mean age: 35 years; 62% females) took part in the study. Of those, 100 were heavy exercisers (18-22 h/week), and 100 were light exercisers (1-6 h/week). Participants completed questionnaires covering sociodemographic information, mental health issues, perceived stress, mental toughness, and sleep disturbances.

RESULTS

Compared with light exercisers, heavy exercisers reported higher mental health issues, more stress, but also higher mental toughness scores and less sleep disturbances. Higher age, lower mental toughness scores, heavy exerciser-status, and more sleep disturbances predicted higher mental health complaints.

CONCLUSIONS

Compared with light exercising, heavy exercising might be associated with more mental health issues. As such, it appears that the association between exercise frequency, intensity, and duration and psychological well-being might be related to an optimum point, but not to a maximum point. In a similar vein, heavily exercising athletes, their coaches, parents, and representatives of sports associations should get sensitized to possible adverse psychological effects of excessive physical activity patterns.

Impact of Moderate Individually Tailored Physical Activity in Multiple Sclerosis Patients with Fatigue on Functional, Cognitive, Emotional State, and Postural Stability

Multiple sclerosis (MS) is a chronic disease, with fatigue syndrome as one of the main symptoms. The aim of this study was to demonstrate that moderate physical activity (MPA) may have a beneficial effect on postural stability, balance, and clinical parameters. The research group consisted of 137 randomized patients hospitalized at the Department of Neurological Rehabilitation, Medical University of Lodz. Finally, 76 patients were qualified who were divided into two groups—high fatigue (HF) and low fatigue (LF). Participants were assessed twice: before and after a 4-week MPA program using: the Expanded Disability Status Scale (EDSS), the Fatigue Severity Scale (FSS), the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), the Beck Depression Inventory (BDI), and the Geriatric Depression Scale (GDS), and stabilometric platform tests were performed. Results obtained after the 4-week MPA program showed a positive effect of the MPA with differences between LF and HF groups. The MPA was more effective in MS patients with LF in cognitive functions, functional status, and postural stability but among HF patients in an emotional state, especially in MS patients below 65 years, although in total, both groups benefited from the MPA.

Multiple Sclerosis in Saudi Arabia: Clinical, Social, and Psychological Aspects of the Disease

Introduction

Multiple sclerosis (MS) is a chronic autoimmune disorder that affects the central nervous system characterized by demyelinating lesions that are disseminated in space and time. Depression is a common symptom in MS, and the pathogenesis is multifactorial. In Saudi Arabia, there is limited current literature about the incidence and relationship between depression and MS. This study is an attempt meant to address the point prevalence of depression, risk factors, and relationship to disease-modifying therapy. In addition, we describe several clinical, nutritional, and social aspects of MS.

Methods

A descriptive cross-sectional study was conducted in Jeddah, Saudi Arabia. The target sample in this study consisted of patients in Saudi Arabia with MS. Data collected included a depression questionnaire based on PHQ9, compliance on therapy, the preferred therapy, and the impact of the disease on daily activity and economic state.

Results

A total of 341 Saudi MS patients were enrolled in the present study. The gender distribution showed that 65.4% (n=223) of the study population were females. The mean age of the patients was 34.80±9.907 years. Most of the patients who were included in this study (95.6%) had depressive symptoms in variant levels. Variable changes in depression levels were detected in both genders specifically moderate depression was most common in males (33%) while females had moderately severe depression (38%). Numbers of relapses, future vision, and changes in workout were associated with statistically significant depression levels.

Conclusion

Depressive symptoms are common in patients with MS. Although all disease-modifying therapies are available in Saudi Arabia, MS clinics with multidisciplinary care are not yet efficiently activated. Non-pharmacological interventions such as smoking cessation, exercise, and psychological health should be part of the management of any patient with MS.

Multiple sclerosis hospitalizations among users of oral disease-modifying therapies

BACKGROUND

Oral disease-modifying therapies, namely dimethyl fumarate, fingolimod and teriflunomide, have become standard treatments for multiple sclerosis. Clinical trials demonstrated a reduction in annual relapse rate, but real-world data is lacking, particularly in older adults. The objective of our study is to evaluate the real-world effectiveness of oral disease-modifying therapies among individuals with multiple sclerosis.

METHODS

We used Optum^TM Clinformatics^TM Data Mart, a large dataset representative of commercially insured individuals in the United States, to conduct a retrospective cohort study of adult users of three oral disease-modifying therapies from September 2010 through September 2015. The therapies of interest included dimethyl fumarate, teriflunomide, and fingolimod. Hospitalization for multiple sclerosis, an approximation of the clinical trial endpoint for relapse, was the study outcome. Cox proportional hazards models were built to evaluate the association of demographic and clinical factors with multiple sclerosis hospitalization. A subgroup analysis was performed on individuals ages 55 years or older.

RESULTS

We identified 1,823, 318, and 1,156 users of dimethyl fumarate, teriflunomide, and fingolimod that met our inclusion criteria, respectively. Rates of hospitalizations for multiple sclerosis were low among these 3,297 persons (1,041 ages 55+): 36/1,000 patient-years for dimethyl fumarate, 43/1,000 for teriflunomide, and 45/1,000 for fingolimod. Multiple sclerosis hospitalization was associated with therapy switching (adjusted hazard ratio 2.21, 95% confidence interval 1.57-2.84), minority (1.44, 1.10-1.89), and history of relapse in the year preceding oral therapy initiation (5.25, 3.89-7.09).

CONCLUSION

Oral disease-modifying therapies are comparably effective for the outcome of multiple sclerosis hospitalization, even in older adults.

Impact of aerobic exercise on clinical and magnetic resonance imaging biomarkers in persons with multiple sclerosis: An exploratory randomized controlled trial

BACKGROUND

There is insufficient knowledge about how aerobic exercise impacts the disease process of multiple sclerosis, which is characterized by accumulation of white matter lesions and accelerated brain atrophy.

OBJECTIVE

To examine the effect of aerobic exercise on neuroinflammation and neurodegeneration by magnetic resonance imaging and clinical measures of disease activity and progression in persons with multiple sclerosis.

PATIENTS AND METHODS

An exploratory 12-week randomized control trial including an intervention group (n = 14, 12 weeks of aerobic exercise twice weekly) and a control group (n = 14, continuation of usual lifestyle). Primary outcomes were magnetic resonance imaging measures (lesion load, brain structure volume change), while secondary outcomes included disability measures, blood cytokine levels, cognitive tests and patient-reported outcomes.

RESULTS

The effects of aerobic exercise on whole brain and grey matter atrophy were minor. Surprisingly, the observed effect on volume (atrophy) in selected brain substructures was heterogeneous. Putaminal and posterior cingulate volumes decreased, parahippocampal gyrus volume increased, thalamus and amygdala volume remained the same, and active lesion load and count decreased. However, apart from weak improvements in walking speed and brain-derived neurotrophic factor levels, there was no effect of aerobic exercise on other clinical, cognitive or patient-reported outcomes.

CONCLUSION

These results suggest that aerobic exercise in persons with multiple sclerosis has a positive effect on the volume of some of the substructures of the brain, possibly indicating a slowing of the neurodegenerative process in these regions, but a negative impact on the volume of some other substructures, with unclear implications. Further research is needed to determine whether the slight decrease in active lesion volume and count implies an anti-inflammatory effect of aerobic exercise, and the exact significance of the heterogeneous results of volumetric assessments.

A pilot study of the impact of an exercise intervention on brain structure, cognition, and psychosocial symptoms in individuals with relapsing-remitting multiple sclerosis

BACKGROUND

Despite pharmacological treatment, many individuals with multiple sclerosis (MS) continue to experience symptoms and medication side effects. Exercise holds promise for MS, but changes in brain structure following exercise have not been thoroughly investigated, and important cognitive and psychosocial variables are rarely primary outcomes. The aim of this pilot study was to investigate whether a 12-week exercise intervention would improve white matter integrity in the brain, or cognition, symptoms of fatigue, and depressed mood for individuals with relapsing-remitting MS (RRMS).

METHOD

Thirteen participants completed 12 weeks of speeded walking. Baseline and post-intervention testing included 3T diffusion tensor imaging (DTI) to assess white matter and neuropsychological testing to assess cognition, fatigue, and mood. Image pre-processing and analyses were performed in functional magnetic resonance imaging of the Brain Software Library.

RESULTS

Post-intervention, there were no significant changes in white matter compared to baseline. Post-intervention, individuals with RRMS performed significantly better on the Symbol Digit Modalities Test (SDMT), reported fewer perceived memory problems, and endorsed less fatigue. Performance was not significantly different on Trails or Digit Span, and there were no significant changes in reports of mood.

CONCLUSION

Although 12 weeks of speeded walking did not improve white matter integrity, exercise may hold promise for managing some symptoms of RRMS in the context of this study population.

What gait features influence the amount and intensity of physical activity in people with multiple sclerosis?

Although the mutual relationship between ambulation and physical activity (PA) in people with multiple sclerosis (pwMS) has been described in several studies, there is still a lack of detailed information about the way in which specific aspects of the gait cycle are associated with amount and intensity of PA. This study aimed to verify the existence of possible relationships among PA parameters and the spatio-temporal parameters of gait when both are instrumentally assessed.Thirty-one pwMS (17F, 14 M, mean age 52.5, mean Expanded Disability Status Scale (EDSS) score 3.1) were requested to wear a tri-axial accelerometer 24 hours/day for 7 consecutive days and underwent an instrumental gait analysis, performed using an inertial sensor located on the low back, immediately before the PA assessment period. Main spatio-temporal parameters of gait (i.e., gait speed, stride length, cadence and duration of stance, swing, and double support phase) were extracted by processing trunk accelerations. PA was quantified using average number of daily steps and percentage of time spent at different PA intensity, the latter calculated using cut-point sets previously validated for MS. The existence of possible relationships between PA and gait parameters was assessed using Spearman rank correlation coefficient rho.Gait speed and stride length were the parameters with the highest number of significant correlations with PA features. In particular, they were found moderately to largely correlated with number of daily steps (rho 0.62, P< .001), percentage of sedentary activity (rho = -0.44, P < .001) and percentage of moderate-to-vigorous activity (rho = 0.48, P < .001). Small to moderate significant correlations were observed between PA intensity and duration of stance, swing and double support phases.The data obtained suggest that the most relevant determinants associated with higher and more intense levels of PA in free-living conditions are gait speed and stride length. The simultaneous quantitative assessment of gait parameters and PA levels might represent a useful support for physical therapists in tailoring optimized rehabilitative and training interventions.

Does Multiple Sclerosis Differently Impact Physical Activity in Women and Man? A Quantitative Study Based on Wearable Accelerometers

In people with multiple sclerosis (pwMS), fatigue, weakness and spasticity may reduce mobility and promote sedentary behavior. However, little is known about the existence of possible differences in the way MS modifies the propensity to perform physical activity (PA) in men and women. The present study aimed to partly close this gap by means of quantitative analysis carried out using wearable sensors. Forty-five pwMS (23 F, 22 M, mean age 50.3) and 41 unaffected age- and sex-matched individuals wore a tri-axial accelerometer 24 h/day for 7 consecutive days. Raw data were processed to calculate average number of daily steps, vector magnitude (VM) counts, and percentage of time spent in sedentary behavior and in PA of different intensities (i.e., light and moderate-to-vigorous, MVPA). Women with MS spent more time in sedentary behavior and exhibited a reduced amount of light intensity activity with respect to men, while MVPA was similar across sexes. However, in comparison with unaffected individuals, the overall PA patterns appear significantly modified mostly in women who, in presence of the disease, present increased sedentary behavior, reduced MVPA, number of daily steps and VM counts. The findings of the present study highlight the urgency of including sex as variable in all studies on PA in pwMS.

Sempere Á, Vera-Garcia FJ, Barbado D. Understanding the Deterioration of Gait, Postural Control, Lower Limb Strength and Perceived Fatigue Across the Disability Spectrum of People with Multiple Sclerosis

Disability progression is a prominent feature of multiple sclerosis (MS). However, little is known about the extent to which physical condition parameters and perceived fatigue evolve during the disease. We analyzed how strength, balance, core stability and perceived fatigue differ among different cohorts of people with MS (PwMS) with different disability degrees and how these contribute to patients' gait speed and functional mobility. Sixty-three PwMS divided into three groups according to the "Expanded Disability Status Scale" (MS1: EDSS ≤ 1.5; MS2: 2 ≤ EDSS ≤ 3.5; MS3: 4 ≤ EDSS ≤ 6) and 22 healthy controls (HC) participated in this study. MS1 showed lower balance and hip strength compared to HC. MS2 showed lower balance, core stability, gait speed, and functional mobility than MS1. MS3 showed lower gait speed, functional mobility, balance, and knee flexion strength than MS2. No between-group differences were observed in perceived fatigue. Relative weight analysis showed that strength, balance and core stability explained 60%-70% of the variance in gait speed and functional mobility. The decline of each parameter did not evolve at the same rate across the different stages of the disease, being knee flexion strength and balance the most influential factors in the disability progression. Overall, these results provide useful information to guide exercise prescription at different stages of MS.

Using Body-Worn Sensors to Detect Changes in Balance and Mobility After Acute Aerobic Exercise in Adults with Multiple Sclerosis

Background

Current mobility and functional assessments do not capture the subtle changes in balance and gait that may predispose people with multiple sclerosis (MS) to falling. The purpose of this study was to use clinical and instrumented measures to examine the effects of an acute bout of aerobic exercise on balance and gait in individuals with MS.

Methods

Ten adults with MS performed 15 minutes of moderate-intensity recumbent cycling or 15 minutes of rest. Exercise and rest visit order was randomized and separated by 1 week. Balance and mobility were assessed before, immediately after, and 2 hours after each test condition.

Results

There were no significant differences across measurement periods for Timed 25-Foot Walk test times or Brief Balance Evaluation Systems Test scores. Significant improvements in mean sway radius and sway velocity when standing on foam and in percentage of stance stride time variability were found immediately after exercise compared with immediately after rest.

Conclusions

This study lends further evidence that individuals with MS can safely engage in single bouts of aerobic exercise without detrimental short-term effects on function and may actually receive some short-term benefit regarding standing postural sway and gait variability. Future research should examine the dose-dependent relationship of varying types, intensities, or timing of exercise necessary to elicit short-term functional benefit and long-term health outcomes.

Evaluation of Power Production Asymmetry during Cycling in Persons with Multiple Sclerosis

Lower limb asymmetries have been observed in persons with multiple sclerosis (PwMS), and have been associated with mobility impairment. An incremental cycling test was performed on a cycle ergometer to determine peak power output (PPO) and peak oxygen consumption (VO₂peak). Then, participants cycled at 50%, 60%, and 70% of their PPO to assess the contribution of each lower limb to power production. Two-way repeated measures ANOVA was used to detect group × intensity differences in power production asymmetry. Eight PwMS and six healthy individuals (Non-MS) completed the study. No statistically significant (p > 0.05) group × intensity interactions or main effects were present when examining between-limb differences in power production. The current data do not indicate a statistically significant difference in power production asymmetry between groups and exercise intensities. Previous research has established a 10% difference between contralateral limbs as a threshold for asymmetry. The average asymmetry in power production in PwMS exceeded the 10% threshold at all measured outputs, suggesting the presence of asymmetry in power production.

Compared to an active control condition, in persons with multiple sclerosis two different types of exercise training improved sleep and depression, but not fatigue, paresthesia, and intolerance of uncertainty

BACKGROUND

In persons with multiple sclerosis (MS), physical activity favorably impacts on psychological well-being. The aims of the present study were to investigate the influence of physical activity on depression, fatigue, sleep, paresthesia, and personality traits (intolerance of uncertainty), and to explore, if endurance training or coordinative training are superior to an active control condition.

METHODS

92 female individuals with MS (mean age: 37.36 years; mean EDSS: 2.43) took part in this intervention study. Participants were randomly assigned either to endurance training, coordinative training, or to an active control condition. At baseline, 4 weeks, and 8 weeks later at the end of the study, participants completed questionnaires on sleep, depression, fatigue, paresthesia and intolerance of uncertainty. Exercise training interventions took place three times/week for 45 min/session. Participants in the active control condition also met with the same duration and frequency.

RESULTS

Sleep complaints and symptoms of depression decreased over time, but more so in the exercising groups, compared to the active control group. No changes over time and between groups were observed for fatigue, paresthesia, and intolerance of uncertainty.

CONCLUSIONS

Both endurance and coordinative exercising had the potential to favorably impact on some aspects of cognitive-emotional processing, while also an active control condition appeared to have a positive impact.

The relationship between physical activity and symptoms of fatigue, mood, and perceived cognitive impairment in adults with multiple sclerosis

Introduction: Multiple Sclerosis (MS) is achronic neurological condition that requires costly treatment for aconstellation of motor and sensory symptoms, as well as fatigue, depression, and cognitive problems. Given that this pharmacological treatment often results in side effects, there is acrucial need for low-costbehavioral treatments that are effective in further reducing MS symptoms. It has been hypothesized that physical activity may slow the neurodegenerative progression of MS. The aim of the current study was to investigate the relationship between physical activity and commonly reported MS symptoms, including fatigue, depression, and perceived cognitive impairment. Method: 86 individuals with MS responded to amail-outquestionnaire. Physical activity, fatigue, mood, and perceived cognitive impairment were assessed using the following measures: Godin Leisure-TimeExercise Questionnaire (GLTEQ), Modified Fatigue Impact Scale (MFIS), Patient Health Questionnaire (PHQ-9), and Patient Deficit Questionnaire (PDQ). Descriptive and correlational statistics were calculated to investigate the relationship between scores on the GLTEQ and scores on the MFIS, PHQ-9, and PDQ. Results: Overall, there was asignificant negative relationship between physical activity (GLTEQ) and fatigue (MFIS; r= -.34, p= .002) and depression (PHQ-9; r= -.23, p= .034) in individuals with MS. There was not asignificant relationship between physical activity and overall perceived cognitive dysfunction (PDQ; r= -.19, p= .08), but when the PDQ subscales were examined, there was asignificant relationship with perceived retrospective (r = 0.24, p= .03) and prospective memory abilities (r = -.22, p= .04). When the RRMS and progressive subtypes were examined separately, we observed asimilar pattern of results for the RRMS group, but the progressive MS group did not reach significance. Conclusions: Individuals with MS who reported more strenuous and/or frequent physical activity, reported fewer problems with fatigue, depression, and perceived memory abilities.

Telerehabilitation in Multiple Sclerosis: Results of a Randomized Feasibility and Efficacy Pilot Study

A prospective, randomized, three-arm, evaluator blinded study to demonstrate the feasibility of a telerehabilitation (TR) program in individuals with ambulatory deficits secondary to Multiple Sclerosis (MS) and evaluate its efficacy when compared to conventional on-site physical therapy (PT) was completed. Thirty participants were evaluated at baseline and randomized to one of three groups with intervention lasting 8 weeks: Group 1 (control)- customized unsupervised home-based exercise program (HEP) 5 days a week; Group 2 (TR)- remote PT supervised via audio/visual real-time telecommunication twice weekly; Group 3 (PT)- in-person PT at the medical facility twice weekly. Outcomes included patient reported outcomes (PROs) obtained through questionnaires, and measurements of gait and balance performed with bedside tests and a computerized system. Functional gait assessment improved from baseline in all three groups. There were no significant differences between the TR and the conventional PT groups for a variety of outcome measures. TR is a feasible method to perform PT in persons with MS and has comparable efficacy to conventional in-person PT as measured by patient reported outcomes and objective outcomes of gait and balance.

Pharmacological and Non-pharmacological Therapies of Cognitive Impairment in Multiple Sclerosis

Background

Cognitive impairment is one of the most important clinical features of neurodegenerative disorders including multiple sclerosis (MS). Conducted research shows that up to 65 percent of MS patients have cognitive deficits such as episodic memory, sustained attention, reduced verbal fluency; however, the cognitive MS domain is information processing speed. It is the first syndrome of cognitive dysfunction and the most widely affected in MS. Occasionally these impairments occur even before the appearance of physical symptoms.

Methods

Therefore, this review focused on the current status of our knowledge about possible methods of treatment cognitive impairment in MS patients including novel strategies. Research and online content was performed using Medline and EMBASE databases.

Results

The most recent research suggests that cognitive impairment is correlated with brain lesion volume and brain atrophy. The examination of the cognitive impairment is usually based on particular neuropsychological batteries. However, it can be not enough to make a precise diagnosis. This creates a demand to find markers that might be useful for identifying patients with risk of cognitive impairment at an early stage of the disease. Currently the most promising methods consist of neuroimaging indicators, such as diffusion tensor imaging, the magnetization transfer ratio, and N-acetyl aspartate levels. Diagnosis problems are strictly connected with treatment procedures. There are two main cognitive therapies: pharmacological (disease modifying drugs (DMD), symptomatic treatments) and non-pharmacological interventions that are focused on psychological and physical rehabilitation. Some trials have shown a positive association between physical activity and the cognitive function.

Conclusion

This article is an overview of the current state of knowledge related to cognition impairment treatment in MS. Additionally, novel strategies for cognitive impairments such as cryostimulation and other complementary methods are presented.

Effectiveness of and User Experience With Web-Based Interventions in Increasing Physical Activity Levels in People With Multiple Sclerosis: A Systematic Review

BACKGROUND

Supporting people with multiple sclerosis (MS) to achieve and maintain recommended levels of physical activity is important but challenging. Web-based interventions are increasingly being used to deliver targeted exercise programs and promote physical activity.

PURPOSE

The purpose of this study was to systematically review current evidence regarding the effectiveness and user experience of web-based interventions in increasing physical activity in people with MS.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, AMED, PEDro, PsychInfo, Web of Sciences, The Cochrane Library, and gray literature were searched from 1990 to September 2016.

STUDY SELECTION

English language articles reporting the use of web-based interventions to increase physical activity in adults with MS were included. Eligible quantitative studies were of any design and reported a measure of physical activity. Qualitative studies exploring users' experiences in any context were included. Of the 881 articles identified, 9 met the inclusion criteria.

DATA EXTRACTION

Two reviewers independently assessed methodological quality and extracted data using standardized critical appraisal and data extraction tools from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

DATA SYNTHESIS

Meta-analysis of self-reported physical activity questionnaire data from 4 studies demonstrated a standardized mean difference of 0.67 (95% CI = 0.43-0.92), indicating a positive effect in favor of the web-based interventions. Narrative review of accelerometry data from 3 studies indicated increases in objectively measured physical activity. No qualitative studies met the inclusion criteria.

LIMITATIONS

In the 9 included articles, only 2 different interventions (used with people who were ambulant) were reported.

CONCLUSIONS

Web-based interventions had a short-term positive effect on self-reported physical activity in people who had MS and were ambulant. Evidence is not currently available to support or refute their use in the long-term or with people who are not ambulant.

Fatigue, as measured using the Modified Fatigue Impact Scale, is a predictor of processing speed improvement induced by exercise in patients with multiple sclerosis: data from a randomized controlled trial

BACKGROUND

Few studies have evaluated the impact of physical activity (PA) on cognition and fatigue, and none have considered the effects of PA on the relationship between cognition and fatigue.

OBJECTIVES

We evaluated the effect of PA in people with multiple sclerosis (pwMS) in a 6-month-long single-blind randomized controlled trial. We focused on the impact of exercise on cognition, fatigue, and the relationship between cognition and fatigue.

METHODS

We recruited pwMS, who were then randomly assigned 1:1 to either a PA protocol group or a control group (CG). All patients underwent assessments using the Brief International Cognitive Assessment for Multiple Sclerosis including symbol digit modality test (SDMT), Berg Balance Scale (BBS), gait analysis, 6-Minute Walk Test, Timed Up and Go (TUG) test, and the Modified Fatigue Impact Scale (MFIS) at the beginning of the study (T0), at the end of the study (EOS) 24 weeks after T0, and at 24 weeks following the EOS (FU).

RESULTS

A Wilcoxon test revealed a significant effect of exercise in the PA group, but not in the CG. Significant differences between T0 and EOS were found in the spatiotemporal parameters of gait, and performance on the SDMT, TUG, BBS, and MFIS. These differences were also present during the FU period. A regression model revealed that the baseline MFIS score predicted processing speed improvement (R² = 0.65, p < 0.01), as the SDMT T score increased by 0.3 for each one-unit increase in the MFIS score at T0.

CONCLUSION

PA affects multiple aspects of the pathology in pwMS. Patients with greater fatigue must not be discouraged from exercise, as they may greatly benefit from PA. Specifically, PA was shown to improve information processing speed.

The importance of a multi-disciplinary perspective and patient activation programmes in MS management

BACKGROUND

Multiple sclerosis (MS) is a progressive disease associated with a large variety of symptoms and changing patients' needs during the disease course. In order to provide appropriate care in every disease stage and let patients live their lives to the full, a multi-disciplinary approach and patient activation is needed.

OBJECTIVE

To summarise the multi-disciplinary perspective of MS, with focus on the organisation of a multi-disciplinary care team and possibilities to support patient activation.

METHODS

This review reflects the content of the presentations, audience polling results and discussions on the multi-disciplinary perspective of MS during the second Pan-European MS Multi-stakeholder Colloquium.

RESULTS

In many countries, the neurologist with or without the support of an MS nurse is responsible for the long-term care of MS patients. When needed, they should refer to other (non-)medical specialists. However, the patient should be empowered as well to manage his/her disease and to implement a physically active lifestyle in order to improve treatment outcomes and quality of life.

CONCLUSION

To create equal access to care for MS patients across Europe, evidence-based standards of care, symptom self-monitoring tools and educational programmes for patients and healthcare professionals including non-medical treatment strategies should be developed at the European level.

Symptom Management and Lifestyle Modifications in Multiple Sclerosis

PURPOSE OF REVIEW

This article reviews the rationale and approach to symptom management and lifestyle modifications in multiple sclerosis (MS).

RECENT FINDINGS

MS symptoms are important to treat because they affect quality of life and daily activity. Appreciation of cluster symptoms (where one symptom contributes to another), changes over time, and multimodality therapeutic approaches are guiding optimized symptom management. Equally important are lifestyle modifications that enhance central nervous system reserve and function. These modifications are the foundation for a health maintenance, wellness, and vascular risk factor control program.

SUMMARY

Symptom management and lifestyle modifications are important therapeutic targets to improve the lives of patients with MS.

Effects of Sport Climbing on Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune and neurodegenerative disease of the central nervous system (CNS) with different types of disease courses (relapsing-remitting, secondary-progressive, primary progressive) that leads to physical as well as mental disability. The symptoms comprise paresis or/and paralysis, ataxia, bladder dysfunction, visual problems as well as effects on cognition. There is limited data regarding the possible effects of sport climbing respectively therapeutic climbing on patients with MS. Sport climbing offers many potentially beneficial effects for patients with MS since there are effects on coordination, muscular strength, and cognition to name the most relevant ones. Also, disease models in rodents point toward such positive outcomes of climbing. Therefore, we assessed the currently available research literature on general effects of physical exercise, impact of climbing on body and mind and therapeutic climbing for prevention or therapy for the treatment of MS. The sparse published controlled trials that investigated this sport activity on different groups of patients with neurological or geriatric diseases grossly differ in study design and outcome parameters. Nevertheless, it appears that climbing offers the opportunity to improve some of the symptoms of patients with MS and can contribute to an enhanced quality of life.

Multiple Sclerosis: Associations Between Physical Disability and Depression Are Not Mediated by Self-Reported Physical Activity

This study investigated the interrelatedness of physical disability, physical activity, and depression among patients with multiple sclerosis (MS). We hypothesized that self-reported physical activity would mediate the effect of disability on depressive symptoms. Twenty-seven patients with MS (mean age: 49 years; 44.5% females) completed self-rating scales covering sociodemographic variables, intake of antidepressants, physical activity, and symptoms of depression; disability was measured by the Expanded Disability Status Scale. We found a higher level of disability to be significantly associated with more symptoms of depression. While higher reported physical activity was descriptively associated with lower depression scores and unrelated to Expanded Disability Status Scale, physical activity levels did not mediate the effect of disability on depressive symptoms.

Physical exercise in myasthenia gravis is safe and improves neuromuscular parameters and physical performance-based measures: A pilot study

INTRODUCTION

Due to the shortage of exercise-related research in Myasthenia Gravis (MG), there are no consensus guidelines on physical exercise for MG patients.

METHODS

In this prospective pilot study, 10 MG patients with mild disease performed supervised aerobic and resistance training twice weekly for 12 weeks. The Myasthenia Gravis Composite (MGC) score, compound motor action potential (CMAP), repetitive nerve stimulation, muscle force, physical performance-based measures, serum levels of interleukin-6, muscle enzymes, and immuno-microRNAs miR-150-5p and miR-21-5p were assessed before and after the training period.

RESULTS

Physical exercise was well tolerated, and the MGC score was unchanged. Muscle resistance weights and CMAP amplitudes increased for biceps brachii and rectus femoris muscles, and physical performance-based measures improved. Muscle enzymes remained normal, whereas disease-specific microRNAs miR-150-5p and miR-21-5p were reduced after the training period.

CONCLUSIONS

We propose that general recommendations regarding physical exercise can be applied safely to well-regulated MG patients. Muscle Nerve 56: 207-214, 2017.

Concussion-Mild Traumatic Brain Injury: Recoverable Injury with Potential for Serious Sequelae

Concussion is increasingly recognized as a major public health issue. Most patients will return to baseline and experience full recovery, although a subset experiences persistent symptoms. Newer animal models and imaging studies are beginning to demonstrate that metabolic and neurovascular resolution may actually take longer than symptomatic recovery. Repeat traumatic brain injury within the metabolic window of dysfunction may result in worsened symptoms and prolonged recovery. The true risk for second impact syndrome appears to be small, and development of cerebral edema after a mild impact may be related to genetic risks rather than serial impacts.

The topographical model of multiple sclerosis: A dynamic visualization of disease course

Relapses and progression contribute to multiple sclerosis (MS) disease course, but neither the relationship between them nor the spectrum of clinical heterogeneity has been fully characterized. A hypothesis-driven, biologically informed model could build on the clinical phenotypes to encompass the dynamic admixture of factors underlying MS disease course. In this medical hypothesis, we put forth a dynamic model of MS disease course that incorporates localization and other drivers of disability to propose a clinical manifestation framework that visualizes MS in a clinically individualized way. The topographical model encapsulates 5 factors (localization of relapses and causative lesions; relapse frequency, severity, and recovery; and progression rate), visualized utilizing dynamic 3-dimensional renderings. The central hypothesis is that, like symptom recrudescence in Uhthoff phenomenon and pseudoexacerbations, progression clinically recapitulates prior relapse symptoms and unmasks previously silent lesions, incrementally revealing underlying lesion topography. The model uses real-time simulation software to depict disease course archetypes and illuminate several well-described but poorly reconciled phenomena including the clinical/MRI paradox and prognostic significance of lesion location and burden on disease outcomes. Utilization of this model could allow for earlier and more clinically precise identification of progressive MS and predictive implications can be empirically tested.