Quantitative functional measures in MS: what is a reliable change?

Psychometric measurement properties and reference values of the six-spot step test, the six-minute walk test, the 25-foot walk test, and the 12-item multiple sclerosis walking scale in people with multiple sclerosis

This review investigated the psychometric properties of the most commonly used short-, long-, complex- and patient-reported walking outcome measures in multiple sclerosis(MS): the timed-25-foot walk test (T25FW), the six-minute walk test (6MWT), the six-spot step-test (SSST), and the 12-item MS walking scale (MSWS-12), along with reported reference data of these tests.

METHODS

Based on PubMed and Embase searches, psychometric as well as descriptive data of T25FW, 6MWT, SSST, and MSWS-12 were extracted from studies evaluating persons with MS (pwMS). Descriptive data was also extracted from healthy controls (HC), if reported. Data was displayed as median [IQR].

RESULTS

A total of n=84 studies (N=36.929 pwMS, 64% females, age 49.6 [43;51] yrs; N=3.093 HC, 40.0 [37.5;47.5] yrs) were included. In pwMS, expanded disability status scale (EDSS) was 4.0 [3.0;4.8], patient determined disease scale (PDDS) 2.6 [2.0;3.0], time since diagnosis 11.6 [9.9;13.2] yrs, and MS-phenotypes (RR/SP/PP/unknown) were 68/19/10/3%. PwMS performed substantially worse than HC across all walking capacity outcomes. Weak to strong associations were found for construct validity (r=0.29-0.88, EDSS or PDDS and walking capacity or ability outcomes) and concurrent validity (r=0.16-0.88 between walking capacity and ability, r=0.73-0.95 between walking capacity outcomes). Ecological validity showed weak to moderate associations between daily steps and walking outcomes (r=0.42-0.68). Good to excellent test-retest, intrarater, and interrater reliability were reported across outcomes (ICC=0.71-1.00). Responsiveness was most frequently reported as the minimal-clinically-important-difference, minimal-detectable-change, or as the minimal-important-change (data not shown).

CONCLUSION

Overall the T25FW, 6MWT, SSST, and MSWS-12 demonstrate moderate to excellent psychometric properties (i.e., valid, reliable, and responsive to changes), which make them clinically useful and applicable to research.

Head and neck cooling enhance exercise tolerance in individuals with multiple sclerosis

BACKGROUND

Individuals with Multiple Sclerosis (MS) experience impairments in heat dissipation, compromising core temperature regulation during exercise.

OBJECTIVE

To examine the efficacy of combined head-and-neck cooling as administered via a commercially available cooling cap and neck wrap in mitigating increases in core temperature during exercise.

METHODS

On separate days, ten (7 females) adults (46.1 ± 11.6 years) with relapsing-remitting MS performed semi-recumbent cycling consisting of an incremental exercise bout to volitional fatigue in a temperate environment (23 °C, 50 % relative humidity) while undergoing head-and-neck cooling using a cooling cap and neck wrap maintained at 10 °C (COLD) or 24-26 °C (NEUTRAL). Prior to and following a 30-minute post-exercise recovery, functional capacity was assessed by a battery of tests consisting of a 2-minute walk test, Timed 25-Foot Walk test, sit-to-stand test, and Berg Balance Scale. Core (ingestible pill) and skin temperatures were recorded continuously. The level of fatigue was measured with questionnaires.

RESULTS

The duration of the incremental exercise test increased with the application of COLD (28.4 ± 5.1 min) versus NEUTRAL water (vs 20.8 ± 5.1 min) (p = 0.001) and was paralleled by a significant reduction in body temperatures (∼1 °C, p < 0.05). The distance covered during the 2-min walk test performed after the incremental exercise test increased with the COLD (176.5 ± 0.6 m), relative to the NEUTRAL condition (147.7 ± 43.5 m) (p = 0.01). Fatigue levels did not change between conditions.

CONCLUSION

We show that head-and-neck cooling with cold water effectively enhances exercise tolerance and mitigates increases in core temperature during exercise in individuals with MS.

A phase II trial examining the safety and preliminary efficacy of repetitive transcranial magnetic stimulation (rTMS) for people living with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic neurological condition and the leading cause of non-traumatic disability in young adults. MS pathogenesis leads to the death of oligodendrocytes, demyelination, and progressive central nervous system neurodegeneration. Endogenous remyelination occurs in people with MS (PwMS) but is insufficient to repair the damage. Our preclinical studies in mice indicate that endogenous remyelination can be supported by the delivery of repetitive transcranial magnetic stimulation (rTMS). Our phase I trial concluded that 20 sessions of rTMS, delivered over 5 weeks, are safe and feasible for PwMS. This phase II trial aims to investigate the safety and preliminary efficacy of rTMS for PwMS.

METHODS

Participants must be aged 18-65 years, diagnosed with MS by a neurologist, stable and relapse free for 6 months, have an Extended Disability Status Scale (EDSS) between 1.5 and 6 (inclusive), willing to travel to a study site every weekday for 4 consecutive weeks, and able to provide informed consent and access the internet. Participants from multiple centres will be randomised 2:1 (rTMS to sham) stratified by sex. The intervention will be delivered with a Magstim Rapid2 stimulator device and circular 90-mm coil or MagVenture MagPro stimulator device with C100 circular coil, positioned to stimulate a broad area including frontal and parietal cortices. For the rTMS group, pulse intensity will be set at 18% (MagVenture) or 25% (Magstim) of maximum stimulator output (MSO), and rTMS applied as intermittent theta burst stimulation (iTBS) (~ 3 min per side; 600 pulses). For the sham group, the procedure will be the same, but the intensity is set at 0%. Each participant will attend 20 intervention sessions over a maximum of 5 weeks. Outcome measures include MS Functional Composite Score (primary), Fatigue Severity Scale, Hospital Anxiety and Depression Scale, Quality of Life, and Pittsburgh Sleep Quality Index/Numeric Rating Scale and adverse events (secondary) and advanced MRI metrics (tertiary). Outcomes will be measured at baseline and after completing the intervention.

DISCUSSION

This study will determine if rTMS can improve functional outcomes or other MS symptoms and determine whether rTMS has the potential to promote remyelination in PwMS.

TRIAL REGISTRATION

Registered with Australian New Zealand Clinical Trials Registry, 20 January 2022; ACTRN12622000064707.

Impact of sex on clinical outcome in early Multiple Sclerosis

BACKGROUND

Previous evidence suggests sex differences in the clinical course of relapsing remitting multiple sclerosis (RRMS), but comprehensive early-stage prospective studies are lacking. We aim to quantify the impact of sex on clinical outcomes in early-stage RRMS.

METHODS

Utilizing prospective cohort data, we assessed the impact of biological sex on time-to-relapse, disability progression (Expanded Disability Status Scale [EDSS]), extremity function (Nine-Hole Peg Test, Timed-25-food walk test), cognition (Paced Auditory Serial Addition Test, Symbol Digit Modalities Test), quality-of-life (Hamburg Quality of Life Questionnaire in Multiple Sclerosis, Short-Form-36), fatigue (Fatigue Severity Scale, Fatigue Scale for Motor and Cognitive functions), and depression (Beck Depression Inventory-II) in clinically isolated syndrome (CIS) or RRMS patients. Inclusion was within 12 months of symptom onset. Linear, negative binomial, mixed, and Cox models estimated male vs. female effects at the four-year follow-up including baseline-to-follow-up course.

RESULTS

We included 149 patients (65.1 % female). Eighty-five completed four-year follow-up. No sex differences in time-to-relapse emerged (HR = 0.91;95 %CI = 0.53-1.58). Males had no increased risk of EDSS worsening (OR = 0.75;95 %CI = 0.21-2.35) compared to females. Similarly, minor/no sex differences emerged in other outcomes.

CONCLUSIONS

Four years after first manifestation, neither disease activity (disability progression and relapse rate) nor patient-reported outcomes showed sex-related disparities in this early-MS-cohort.

CLINICALTRIALS

GOV IDENTIFIER

NCT01371071.

Predictive value of synaptic plasticity for functional decline in patients with multiple sclerosis

Background

Previous research suggested that quadripulse (QPS)-induced synaptic plasticity is associated with both cognitive and motor function in patients with multiple sclerosis (MS) and does not appear to be reduced compared to healthy controls (HCs).

Objective

This study aimed to explore the relationship between the degree of QPS-induced plasticity and clinically significant decline in motor and cognitive functions over time. We hypothesized that MS patients experiencing functional decline would exhibit lower levels of baseline plasticity compared to those without decline.

Methods

QPS-induced plasticity was evaluated in 80 MS patients (56 with relapsing-remitting MS and 24 with progressive MS), and 69 age-, sex-, and education-matched HCs. Cognitive and motor functions, as well as overall disability status were evaluated annually over a median follow-up period of 2 years. Clinically meaningful change thresholds were predefined for each outcome measure. Linear mixed-effects models, Cox proportional hazard models, logistic regression, and receiver-operating characteristic analysis were applied to analyse the relationship between baseline plasticity and clinical progression in the symbol digit modalities test, brief visuospatial memory test revised (BVMT-R), nine-hole peg test (NHPT), timed 25-foot walk test, and expanded disability status scale.

Results

Overall, the patient cohort showed no clinically relevant change in any functional outcome over time. Variability in performance was observed across time points in both patients and HCs. MS patients who experienced clinically relevant decline in manual dexterity and/or visuospatial learning and memory had significantly lower levels of synaptic plasticity at baseline compared to those without such decline (NHPT: β = -0.25, p = 0.02; BVMT-R: β = -0.50, p = 0.005). Receiver-operating characteristic analysis underscored the predictive utility of baseline synaptic plasticity in discerning between patients experiencing functional decline and those maintaining stability only for visuospatial learning and memory (area under the curve = 0.85).

Conclusion

Our study suggests that QPS-induced plasticity could be linked to clinically relevant functional decline in patients with MS. However, to solidify these findings, longer follow-up periods are warranted, especially in cohorts with higher prevalences of functional decline. Additionally, the variability in cognitive performance in both patients with MS and HCs underscores the importance of conducting further research on reliable change based on neuropsychological tests.

Hand Grip Strength as a Predictive Tool for Upper Extremity Functionality, Balance, and Quality of Life in People With Multiple Sclerosis

BACKGROUND

Upper extremity strength and function are rarely assessed in routine multiple sclerosis (MS) care. This study aimed to evaluate hand muscle strength and functionality in individuals with MS and investigate correlations with upper extremity function, cognitive status, health-related quality of life (HRQOL), and balance.

METHODS

A cross-sectional study was conducted with 45 consecutive individuals with MS between the ages of 18 and 65. Upper limb motor strength was evaluated using a hand grip strength dynamometer. Upper limb functional capacity was assessed using the Nine-Hole Peg Test (9HPT) and the Duruoz Hand Index (DHI). Balance, coordination, and falls were measured with the Berg Balance Scale (BBS), Falls Efficacy Scale (FES), and the 30-Second Chair Stand Test (30CST). Cognitive function was evaluated using the Montreal Cognitive Assessment instrument and the Symbol Digit Modalities Test. Level of HRQOL was assessed using the self-reported 54-item MS Quality of Life-54 questionnaire.

RESULTS

Out of the 45 participants (80% women, mean age 36.6 ± 8.6 years), higher hand grip dynamometer measures were strongly correlated with better DHI, 9HPT, BBS, FES, and 30CST scores. In the regression analysis, a 1-unit increase in dynamometer measures led to a 0.383 increase in overall HRQOL score.

CONCLUSIONS

This study demonstrates that increased hand grip strength (HGS) is associated with better hand functionality, balance, and HRQOL in individuals with MS. It provides evidence to support more systematic measurement of HGS in the care of people with MS.

Motor Evoked Potential-A Pilot Study Looking at Reliability and Clinical Correlations in Multiple Sclerosis

PURPOSE

Multiple sclerosis (MS) is a clinically heterogeneous disease. Biomarkers that can assess pathological processes that are unseen with conventional imaging remain an unmet need in MS disease management. Motor evoked potentials (MEPs) could be such a biomarker. To determine and follow longitudinal MEP reliability and correlations with clinical measures in MS patients.

METHODS

This is a single-center study in alemtuzumab-treated MS patients to evaluate temporal reliability of MEPs, identify MEP minimum detectible differences, and explore correlations with existing clinical scales. Ten MS patients recently treated with alemtuzumab were evaluated every 6 months over 3 years. Clinical evaluations consisted of expanded disability status scale, timed 25-foot walk, 6-minute walk, and nine-hole peg test. MEPs were measured twice, 2 weeks apart, every 6 months.

RESULTS

Eight patients completed all 3 years of study. The intraclass correlation coefficient for MEP parameters ranged from 0.76 to 0.98. TA latency and amplitude with facilitation significantly and strongly correlated with all clinical measures, whereas the MEP duration modestly correlated. Biceps latency with facilitation significantly and moderately correlated with 9-hole peg test. Longitudinal correlations demonstrated good predictive values for either clinical deterioration or improvement.

CONCLUSIONS

MEPs have excellent intrapatient and intrarater reliability, and TA MEPs significantly and strongly correlated with expanded disability status scale, 6-minute walk, and timed 25-foot walk, whereas biceps MEPs significantly and moderately correlated with nine-hole peg test. Further studies using larger cohorts of MS patients are indicated.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT02623946.

Providing meaningful interpretation of performance outcome measures by co-calibration with patient-reported outcomes through the Rasch model: illustration with multiple sclerosis measures

Performance outcome (PerfO) measures are based on tasks performed by patients in a controlled environment, making their meaningful interpretation challenging to establish. Co-calibrating PerfO and patient-reported outcome (PRO) measures of the same target concept allow for interpretation of the PerfO with the item content of the PRO. The Rasch model applied to the discretized PerfO measure together with the PRO items allows expressing parameters related to the PerfO measure in the PRO metric for it to be linked to the PRO responses. We applied this approach to two PerfO measures used in multiple sclerosis (MS) for walking and manual ability: the Timed 25-Foot Walk (T25FW) and the 9-Hole Peg Test (9HPT). To determine meaningful interpretation of these two PerfO measures, they were co-calibrated with two PRO measures of closely related concepts, the MS walking scale - 12 items (MSWS-12) and the ABILHAND, using the data of 2,043 subjects from five global clinical trials in MS. The probabilistic relationships between the PerfO measures and the PRO metrics were used to express the response pattern to the PRO items as a function of the unit of the PerfOs. This example illustrates the promises of the co-calibration approach for the interpretation of PerfO measures but also highlights the challenges associated with it, mostly related to the quality of the PRO metric in terms of coverage of the targeted concept. Co-calibration with PRO measures could also be an adequate solution for interpretation of digital sensor measures whose meaningfulness is also often questioned.

Threshold definitions for significant change on the timed 25-foot walk and nine-hole peg test in primary progressive multiple sclerosis

BACKGROUND AND PURPOSE

The timed 25-foot walk (T25FW) and nine-hole peg test (NHPT) exhibit random variability in the short term. A threshold of ≥20% change from baseline has been used to indicate true disability change, but other threshold definitions may be better suited to exclude false and include true change events. The aim of this study was to use patient-level original trial data to investigate the short-term variation in T25FW and NHPT, and to compare its extent with disability change at 12-month follow-up in people with primary progressive multiple sclerosis (PPMS).

METHODS

We used original patient-level data from PROMISE, a large PPMS trial. In this trial, three separate T25FW and NHPT measurements were performed 1 week apart during screening. We used these repeated measures to describe the extent of short-term variation. We used binary logistic regression models to investigate the association between screening characteristics and unacceptable short-term variation.

RESULTS

The traditional 20% threshold excluded a reasonable number of false change events, while also yielding a large number of change events at follow-up. Increasing index values on the T25FW and NHPT were associated with higher short-term variation.

CONCLUSIONS

The traditional ≥20% change threshold for the T25FW and NHPT represents a reasonable compromise between reducing the number of false change events and achieving the largest number of change events in people with PPMS. Our analyses inform the design of clinical trials in PPMS.

Longitudinal Changes in Cognitive Test Scores in Patients With Relapsing-Remitting Multiple Sclerosis: An Analysis of the DECIDE Dataset

BACKGROUND AND OBJECTIVES

Cognitive impairment is a common and impactful symptom of relapsing-remitting multiple sclerosis (RRMS). Cognitive outcome measures are often used in cross-sectional studies, but their performance as longitudinal outcome measures in clinical trials is not widely researched. In this study, we used data from a large clinical trial to describe change on the Symbol Digit Modalities Test (SDMT) and the Paced Auditory Serial Addition Test (PASAT) over up to 144 weeks of follow-up.

METHODS

We used the data set from DECIDE (clinicaltrials.gov identifier NCT01064401), a large randomized controlled RRMS trial to describe change on the SDMT and PASAT over 144 weeks of follow-up. We compared change on these cognitive outcomes with change on the timed 25-foot walk (T25FW), a well-established physical outcome measure. We investigated several definitions for clinically meaningful change: any change, 4-point change, 8-point change, and 20% change for the SDMT, any change, 4-point change, and 20% change for the PASAT, and 20% change for the T25FW.

RESULTS

DECIDE included 1,814 trial participants. SDMT and PASAT scores steadily improved throughout follow-up: the SDMT from a mean 48.2 (SD, 16.1) points at baseline to 52.6 (SD 15.2) at 144 weeks and the PASAT from 47.0 (SD 11.3) at baseline to 50.0 (SD 10.8) at 144 weeks. This improvement in scores is most likely due to a practice effect. Throughout the trial, participants were more likely to experience improvement than worsening of their SDMT and PASAT performance, whereas the number of worsening events on the T25FW steadily increased. Changing the definition of clinically meaningful change for the SDMT and PASAT or using a 6-month confirmation changed the overall number of worsening or improvement events but did not affect the overall behavior of these measures.

DISCUSSION

Our findings suggest that the SDMT and PASAT scores do not accurately reflect the steady cognitive decline that people with RRMS experience. Both outcomes show postbaseline increases in scores, which complicates the interpretation of these outcome measures in clinical trials. More research into the size of these changes is needed before recommending a general threshold for clinically meaningful longitudinal change.

Responsiveness of Persian 12-Item multiple sclerosis walking scale: a replication study

OBJECTIVE

To re-explore the responsiveness of the Persian version of Multiple Sclerosis Walking Scale-12 (MSWS-12p) to physiotherapy intervention and determine the minimally clinically important change (MCIC). This study followed a prospective cohort design. Patients with MS (PwMS) underwent physiotherapy treatment for 10 sessions. The outcome measures were the MSWS-12p and Timed 25-Foot Walk test (T25-FW). Data was collected before and after ten sessions of physiotherapy. The effect sizes and the area under receiver operating characteristics curve (AUC) and MCIC were calculated.

RESULTS

Thirty PwMS (16 female, mean age 43.07 years) participated in the study. The effect sizes for MSWS-12p were moderate (0.52, 0.64). The change scores of MSWS-12p showed excellent correlation with the dichotomized smallest detectable change (SDC) criterion (Eta coefficient test = 0.84). There was no correlation between the MSWS-12p total change scores and the T25-FW (r = - 0.14, p = 0.45). The AUC was perfect and the MCIC for the MSWS-12p was calculated 10.0 points. The MSWS-12p is responsive and demonstrates changes after physiotherapy. Changes > 10.0 points on MSWS-12p total score should be considered as true improvement after physiotherapy.

Personalized monitoring of ambulatory function with a smartphone 2-minute walk test in multiple sclerosis

BACKGROUND

Remote smartphone-based 2-minute walking tests (s2MWTs) allow frequent and potentially sensitive measurements of ambulatory function.

OBJECTIVE

To investigate the s2MWT on assessment of, and responsiveness to change in ambulatory function in MS.

METHODS

One hundred two multiple sclerosis (MS) patients and 24 healthy controls (HCs) performed weekly s2MWTs on self-owned smartphones for 12 and 3 months, respectively. The timed 25-foot walk test (T25FW) and Expanded Disability Status Scale (EDSS) were assessed at 3-month intervals. Anchor-based (using T25FW and EDSS) and distribution-based (curve fitting) methods were used to assess responsiveness of the s2MWT. A local linear trend model was used to fit weekly s2MWT scores of individual patients.

RESULTS

A total of 4811 and 355 s2MWT scores were obtained in patients (n = 94) and HC (n = 22), respectively. s2MWT demonstrated large variability (65.6 m) compared to the average score (129.5 m), and was inadequately responsive to anchor-based change in clinical outcomes. Curve fitting separated the trend from noise in high temporal resolution individual-level data, and statistically reliable changes were detected in 45% of patients.

CONCLUSIONS

In group-level analyses, clinically relevant change was insufficiently detected due to large variability with sporadic measurements. Individual-level curve fitting reduced the variability in s2MWT, enabling the detection of statistically reliable change in ambulatory function.

The nine hole peg test as an outcome measure in progressive MS trials

BACKGROUND

The nine-hole peg test (NHPT) is the outcome measure with the least change in secondary and primary progressive MS (SPMS and PPMS) trials. The Standard NHPT is defined as the average of four measurements, two in each hand. Little is known about the performance of alternative NHPT scoring methods as longitudinal outcome measures in progressive MS. Non-ambulatory people with progressive MS are now generally excluded from clinical trials, and there is little information on longitudinal NHPT change in this patient group. In this investigation, we used patient-level data from two large randomized controlled trials in progressive MS to explore alternative NHPT scoring methods and NHPT change in non-ambulatory people with progressive MS.

METHODS

We used patient-level data from the ASCEND (SPMS, n = 889) and PROMISE (PPMS, n = 943) clinical trials to compare significant change on the Standard NHPT with the alternatives dominant hand (DH), non-dominant hand (NDH), and either hand (EH) NHPT in ambulatory and non-ambulatory trial participants.

RESULTS

The Standard NHPT changed slowly and showed few worsening events, as did the DH and NDH alternatives. Using the EH NHPT resulted in a substantial increase of worsening events. Non-ambulatory trial participants with PPMS experienced more NHPT worsening than ambulatory participants, especially when using the EH NHPT.

CONCLUSION

Using the EH NHPT yielded substantially more worsening events in people with progressive MS. Clinical trials in non-ambulatory people may be possible with the NHPT as the primary outcome measure. More research into the precision of these measures in this patient group is necessary.

Overall Disability Response Score: An integrated endpoint to assess disability improvement and worsening over time in patients with multiple sclerosis

BACKGROUND

Overall Disability Response Score (ODRS) is a composite endpoint including Expanded Disability Status Scale, Timed 25-foot Walk, and 9-Hole Peg Test, designed to quantify both disability improvement and worsening in multiple sclerosis (MS).

OBJECTIVE

To assess the sensitivity and clinical meaningfulness of ODRS using natalizumab Phase 3 data sets (AFFIRM in relapsing-remitting MS and ASCEND in secondary progressive MS).

METHODS

Differences in ODRS over 96 weeks, ODRS at Week 96, and slope of ODRS change per year between natalizumab and placebo groups were analyzed. Correlation between ODRS and changes in patient-reported outcomes was also analyzed.

RESULTS

The difference (95% confidence interval (CI)) in the ODRS over 96 weeks between natalizumab and placebo groups was 0.34 (0.21-0.46) in AFFIRM (p < 0.001), and 0.18 (0.03-0.34) in ASCEND (p = 0.021). Significant differences between treatment arms were also observed in ODRS at Week 96 and in the slope of change per year in both studies. There was a significant linear correlation between ODRS at Week 96 and the change from baseline in both the physical and mental components of the 36-item Short Form Survey (SF-36) in both studies.

CONCLUSION

This analysis supports ODRS as a sensitive and potentially clinically meaningful disability outcome measure in MS.

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.

A prospective study to validate the expanded timed get-up-and-go in a population with multiple sclerosis

Background

Timed 25-foot walk (T25FW) test serves as gold standard in care of persons with multiple sclerosis (PwMS) and as walking measure of regulatory trials.

Objective

To validate and determine the clinical utility of Expanded Timed Get-Up and Go (ETGUG) as a disability measure in MS.

Methods

ETGUG intra-rater and inter-rater reproducibility was determined in 65 PwMS that were examined twice in two centres over 1-week. Values below the 5th and above the 95th percentile were considered minimally detectable change. A longitudinal cohort (32.4 months) of 145 PwMS from New York State MS Consortium (NYSMSC) was used for clinical validation as a predictor of disability worsening measured by Expanded Disability Status Scale (EDSS).

Results

ETGUG and T25FW had noteworthy intra-rater and inter-rater reproducibility (Cronbach coefficient>0.949). One-week ETGUG difference ranged from 15.07% to −14.84% (5th and 95th percentile). Over the NYSMSC follow-up, PwMS had significant slowing in walking as measured by ETGUG (20.8 to 25.9s, p = 0.009) but not by T25FW. 15% ETGUG worsening had similar ability to predict EDSS worsening when compared to 20% T25FW worsening (AUC 0.596 vs. 0.552).

Conclusion

Over 32-month follow-up, PwMS experience slowing in ETGUG walking time but not in T25FW. Although the scoring may be more challenging, ETGUG could be more sensitive to change and provide more comprehensive measure of lower extremity performance and ambulation in PwMS.

Treatment with electrical stimulation of sensory nerves improves motor function and disability status in persons with multiple sclerosis: A pilot study

Declines in motor function are closely associated with decreases in sensory function in multiple sclerosis (MS). The purpose of our study was to assess the changes in motor function and disability status elicited by transcutaneous electrical nerve stimulation (TENS) to limb muscles of individuals with MS. Fifteen persons with MS and 11 age-matched healthy controls were evaluated before and after receiving 9 treatment sessions during which TENS was applied over the tibialis anterior and rectus femoris muscles of each leg, and over the median nerve and the thenar eminence of each hand. Each evaluation session involved completing two questionnaires (fatigue and walking limitations) and assessing walking performance (2-min test and 25-ft test), dynamic balance (chair-rise test), manual dexterity (grooved pegboard test), and muscle function of hands and legs (strength and force steadiness tests). The MS group exhibited improvements in the 25-ft test (P = 0.001), 2-min test (P = 0.002), chair-rise test (P = 0.008), grooved pegboard test (P = 0.008), and reductions in the self-reported levels of fatigue and walking limitation scores (P = 0.02, d = 0.52; P = 0.008, r = 0.50 respectively). In contrast, there were no statistically significant changes in the Control group. There were no significant changes in either muscle strength or force steadiness for either group. TENS elicited significant improvements in motor function and self-reported disability status in persons with MS. Some improvements reached clinically meaningful levels.

Taopatch® combined with home-based training protocol to prevent sedentary lifestyle and biochemical changes in MS patients during COVID-19 pandemic

In Multiple sclerosis (MS) it is important to preserve the residual physiological functions of subjects. The aim of the present study was to investigate the influence of nanotechnological device treatment combined with home-based training program (TP) on lactate level, hand grip strength and cervical mobility on MS patients. Seventeen MS patients were enrolled in the study and randomly assigned to an experimental group (EG) in which the Taopatch^® nanotechnological device was applied or to a control group (CG). All the participants carried out a cervical range of motion (1) assessment and the hand grip test at baseline (T0) and after TP (T1), also investigating the lactate levels to figure out if there could be a correlation with the possible changes in the investigated parameters. The results showed no significant differences in both groups for ROM. As regards the hand grip test, EG showed a statistically significant improvement on strength for both hands, dominant (p = 0.01) and non-dominant (p = 0.04), while the CG showed an improvement only for the non-dominant hand (p = 0.001). No correlation was found between baseline lactate level and cervical ROM change. We can definitely conclude that exercise and Taopatch^® can help to improve and maintain hand strength in MS subjects and also can prevent sedentary lifestyle during the COVID-19 pandemic time. These are preliminary results that need further investigations, possibly increasing sample size and lengthening time of intervention.

A Phase 3, double-blind, placebo-controlled efficacy and safety study of ADS-5102 (Amantadine) extended-release capsules in people with multiple sclerosis and walking impairment

Background:

ADS-5102, a delayed-release, extended-release (DR/ER) amantadine, improved walking speed in MS in a Phase 2 trial.

Objective:

The aim of this study was to present primary results of a Phase 3, double-blind, ADS-5102 trial (INROADS) for walking speed.

Methods:

Adult participants with MS and walking impairment, not currently using amantadine or dalfampridine, underwent 4-week placebo run-in before randomization 1:1:1 to placebo, 137 or 274 mg/day ADS-5102 for 12 weeks. Primary outcome was the proportion of responders (20% increase in Timed 25-Foot Walk (T25FW) speed) for 274 mg ADS-5102 versus placebo at end of double-blind (Study Week 16). Additional measures included Timed Up and Go (TUG), 2-Minute Walk Test (2MWT), and 12-item Multiple Sclerosis Walking Scale (MSWS-12).

Results:

In total, 558 participants were randomized and received double-blind treatment. Significantly more participants responded with 274 mg ADS-5102 (21.1%) versus placebo (11.3%). Mean T25FW speed also significantly improved (0.19 ft/s) versus placebo (0.07 ft/s). Other measures were not significant using prespecified hierarchical testing procedure. Adverse events led to discontinuation for 3.8% (placebo), 6.4% (137 mg ADS-5102), and 20.5% (274 mg ADS-5102).

Conclusion:

INROADS met its primary endpoint, showing a significantly greater proportion of participants with meaningful improvement in walking speed for 274 mg ADS-5102 versus placebo. Numeric dose response was seen for some secondary efficacy outcomes and adverse events.

Outcome measures assisting treatment optimization in multiple sclerosis

Objective

To review instruments used to assess disease stability or progression in persons with multiple sclerosis (pwMS) that can guide clinicians in optimizing therapy.

Methods

A non-systematic review of scientific literature was undertaken to explore modalities of monitoring symptoms and the disease evolution of MS.

Results

Multiple outcome measures, or tools, have been developed for use in MS research as well as for the clinical management of pwMS. Beginning with the Expanded Disability Status Scale, introduced in 1983, clinicians and researchers have developed monitoring modalities to assess all aspects of MS and the neurological impairment it causes.

Conclusions

Much progress has been made in recent decades for the management of MS and for the evaluation of disease progression. New technology, such as wearable sensors, will provide new opportunities to better understand changes in function, dexterity, and cognition. Essential work over the decades since EDSS was introduced continues to improve our ability to treat this debilitating disease.

Failed, Interrupted, or Inconclusive Trials on Neuroprotective and Neuroregenerative Treatment Strategies in Multiple Sclerosis: Update 2015-2020

In the recent past, a plethora of drugs have been approved for the treatment of multiple sclerosis (MS). These therapeutics are mainly confined to immunomodulatory or immunosuppressive strategies but do not sufficiently address remyelination and neuroprotection. However, several neuroregenerative agents have shown potential in pre-clinical research and entered Phase I to III clinical trials. Although none of these compounds have yet proceeded to approval, understanding the causes of failure can broaden our knowledge about neuroprotection and neuroregeneration in MS. Moreover, most of the investigated approaches are characterised by consistent mechanisms of action and proved convincing efficacy in animal studies. Therefore, learning from their failure will help us to enforce the translation of findings acquired in pre-clinical studies into clinical application. Here, we summarise trials on MS treatment published since 2015 that have either failed or were interrupted due to a lack of efficacy, adverse events, or for other reasons. We further outline the rationale underlying these drugs and analyse the background of failure to gather new insights into MS pathophysiology and optimise future study designs. For conciseness, this review focuses on agents promoting remyelination and medications with primarily neuroprotective properties or unconventional approaches. Failed clinical trials that pursue immunomodulation are presented in a separate article.

Psychometric properties of measures of upper limb activity performance in adults with and without spasticity undergoing neurorehabilitation-A systematic review

INTRODUCTION

This systematic review appraises the measurement quality of tools which assess activity and/or participation in adults with upper limb spasticity arising from neurological impairment, including methodological quality of the psychometric studies. Differences in the measurement quality of the tools for adults with a neurological impairment, but without upper limb spasticity, is also presented.

METHODS

29 measurement tools identified in a published review were appraised in this systematic review. For each identified tool, we searched 3 databases (Medline, Embase, CINAHL) to identify psychometric studies completed with neurorehabilitation samples. Methodological quality of instrument evaluations was assessed with use of the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Synthesis of ratings allowed an overall rating of the psychometric evidence for each measurement tool to be calculated.

RESULTS

149 articles describing the development or evaluation of psychometric properties of 22 activity and/or participation measurement tools were included. Evidence specific to tool use for adults with spasticity was identified within only 15 of the 149 articles and provided evidence for 9 measurement tools only. Overall, COSMIN appraisal highlighted a lack of evidence of measurement quality. Synthesis of ratings demonstrated all measures had psychometric weaknesses or gaps in evidence (particularly for use of tools with adults with spasticity).

CONCLUSIONS

The systematic search, appraisal and synthesis revealed that currently there is insufficient measurement quality evidence to recommend one tool over another. Notwithstanding this conclusion, newer tools specifically designed for use with people with neurological conditions who have upper limb spasticity, have emergent measurement properties that warrant further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014013190.

Fall-related functional impairments in patients with neurological gait disorder

Falls are common in patients with neurological disorders and are a primary cause of injuries. Nonetheless, fall-associated gait characteristics are poorly understood in these patients. Objective, quantitative gait analysis is an important tool to identify the principal fall-related motor characteristics and to advance fall prevention in patients with neurological disorders. Fall incidence was assessed in 60 subjects with different neurological disorders. Patients underwent a comprehensive set of functional assessments including instrumented gait analysis, computerized postural assessments and clinical walking tests. Determinants of falls were assessed by binary logistic regression analysis and receiver operator characteristics (ROC). The best single determinant of fallers was a step length reduction at slow walking speed reaching an accuracy of 67.2% (ROC AUC: 0.669; p = 0.027). The combination of 4 spatio-temporal gait parameters including step length and parameters of variability and asymmetry were able to classify fallers and non-fallers with an accuracy of 81.0% (ROC AUC: 0.882; p < 0.001). These findings suggest significant differences in specific spatio-temporal gait parameters between fallers and non-fallers among neurological patients. Fall-related impairments were mainly identified for spatio-temporal gait characteristics, suggesting that instrumented, objective gait analysis is an important tool to estimate patients' fall risk. Our results highlight pivotal fall-related walking deficits that might be targeted by future rehabilitative interventions that aim at attenuating falls.

Natalizumab is associated with early improvement of working ability in relapsing-remitting multiple sclerosis patients: WANT observational study results

BACKGROUND

The Work Ability in Natalizumab-Treated MS Patients (WANT) study assessed work ability, quality of life, and cognitive processing speed during natalizumab treatment.

METHODS

WANT was a 1-year, prospective, multicenter observational study conducted in Italy. Inclusion criteria included relapsing-remitting multiple sclerosis (MS), natalizumab treatment, full-time worker status, and loss of working hours due to MS as measured by the Work Productivity and Activity Impairment Questionnaire for MS (WPAI:MS). The primary endpoint was change in WPAI:MS domain scores after 1 year on natalizumab. Secondary endpoints included change in annualized relapse rate (ARR), Multiple Sclerosis Impact Scale (MSIS-29) score, and Symbol Digit Modalities Test (SDMT) score.

RESULTS

At enrollment, the 91 patients had a mean age of 38.3 (standard deviation [SD], 9.0) years and a mean ARR of 1.5 (SD, 0.8). After 1 year, improvements were observed in all WPAI:MS domains, with significant reductions in Absenteeism (-4.2 [SD, 26.0], p = 0.0190) and Work Productivity Loss (-7.2 [SD, 28.6]; p = 0.0456). These changes were accompanied by a low ARR (0.1), and 87.9% of patients were relapse free. Significant improvement was observed in MSIS-29 physical and psychological domains (reductions of 2.8 [SD, 11.6; p = 0.0295] and 6.3 [SD, 15.6; p = 0.0007], respectively) and SDMT score (increase of 2.4 [SD, 7.9; p = 0.0006]). Adverse events were reported in 32 of 104 patients (30.8%).

CONCLUSIONS

The reductions in Absenteeism and Work Productivity Loss and the improved physical and psychological functioning reported after 1 year of natalizumab treatment in real-world settings extend our understanding of natalizumab's effects on patient-centric and health economics outcomes.

Smartphone Accelerometry: A Smart and Reliable Measurement of Real-Life Physical Activity in Multiple Sclerosis and Healthy Individuals

Background: Mobility impairment is common in persons with multiple sclerosis (pwMS) and can be assessed with clinical tests and surveys that have restricted ecological validity. Commercial research-based accelerometers are considered to be more valuable as they measure real-life mobility. Smartphone accelerometry might be an easily accessible alternative.

Objective: To explore smartphone accelerometry in comparison to clinical tests, surveys, and a wrist-worn ActiGraph in pwMS and controls.

Methods: Sixty-seven pwMS and 70 matched controls underwent mobility tests and surveys. Real-life data were collected with a smartphone and an ActiGraph over 7 days. We explored different smartphone metrics in a technical validation course and computed afterward correlation between ActiGraph (steps per minute), smartphone accelerometry (variance of vector magnitude), clinical tests, and surveys. We also determined the ability to separate between patients and controls as well as between different disability groups.

Results: Based on the technical validation, we found the variance of the vector magnitude as a reliable estimate to discriminate wear time and no wear-time of the smartphone. Due to a further association with different activity levels, it was selected for real-life analyses. In the cross-sectional study, ActiGraph correlated moderately (r = 0.43, p < 0.05) with the smartphone but less with clinical tests (rho between |0.211| and |0.337|). Smartphone data showed stronger correlations with age (rho = −0.487) and clinical tests (rho between |0.565| and |0.605|). ActiGraph only differed between pwMS and controls (p < 0.001) but not between disability groups. At the same time, the smartphone showed differences between pwMS and controls, between RRMS and PP-/SPMS, and between participants with/without ambulatory impairment (all p < 0.001).

Conclusions: Smartphone accelerometry provides better estimates of mobility and disability than a wrist-worn standard accelerometer in a free-living context for both controls and pwMS. Given the fact that no additional device is needed, smartphone accelerometry might be a convenient outcome of real-life ambulation in healthy individuals and chronic diseases such as MS.

Haptic vs sensorimotor training in the treatment of upper limb dysfunction in multiple sclerosis: A multi-center, randomised controlled trial

BACKGROUND

In multiple sclerosis (MS) exercise improves upper limb functions, but it is unclear what training types are more effective.

OBJECTIVE

This study compares robot-assisted training based on haptic or sensorimotor exercise.

METHODS

41clinically definite MS subjects with upper limb impairment were randomised into two groups: (i) Haptic and (ii) Sensorimotor. Subjects in the Haptic performed a robot-assisted training protocol designed to counteract incoordination and weakness. The task -interaction with a virtual mass-spring system against a resistive load- requires coordination skills. Task difficulty and magnitude of resistive load were automatically adjusted to the individual impairment. Subjects in the Sensorimotor performed reaching movements under visual control; the robot generated no forces. Both groups underwent eight training sessions (40 min/session, 2 sessions/week). Treatment outcome were 9HPT and ARAT scores.

RESULTS

The average 9HPT score decreased from 74±9 s to 61±8 s for the Haptic and from 49±6 s to 44±6 s. We found a significant Treatment (p=.0453) and Time differences (p=.005), but no significant Treatment×Time interactions although we found that the absolute change was only significant in the Haptic group (p=.011). We observed no significant changes in the ARAT score. Participants tolerated treatments well with a low drop-out rate. In the subjects evaluated at after 12 week (11 subject in sensory-motor and 17 in haptic group) no retention of the effect was found.

CONCLUSIONS

Task oriented training may improve upper limb function in persons with MS especially in prevalent pyramidal impaired subjects without maintain the effects after three months.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02711566 (clinicaltrial.gov).

Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations

The Canadian Multiple Sclerosis Working Group has updated its treatment optimization recommendations (TORs) on the optimal use of disease-modifying therapies for patients with all forms of multiple sclerosis (MS). Recommendations provide guidance on initiating effective treatment early in the course of disease, monitoring response to therapy, and modifying or switching therapies to optimize disease control. The current TORs also address the treatment of pediatric MS, progressive MS and the identification and treatment of aggressive forms of the disease. Newer therapies offer improved efficacy, but also have potential safety concerns that must be adequately balanced, notably when treatment sequencing is considered. There are added discussions regarding the management of pregnancy, the future potential of biomarkers and consideration as to when it may be prudent to stop therapy. These TORs are meant to be used and interpreted by all neurologists with a special interest in the management of MS.

Evaluation of multiple sclerosis disability outcome measures using pooled clinical trial data

OBJECTIVE

We report analyses of a pooled database by the Multiple Sclerosis Outcome Assessments Consortium to evaluate 4 proposed components of a multidimensional test battery.

METHODS

Standardized data on 12,776 participants, comprising demographics, multiple sclerosis disease characteristics, Expanded Disability Status Scale (EDSS) score, performance measures, and Short Form-36 Physical Component Summary (SF-36 PCS), were pooled from control and treatment arms of 14 clinical trials. Analyses of Timed 25-Foot Walk (T25FW), 9-Hole Peg Test (9HPT), Low Contrast Letter Acuity (LCLA), and Symbol Digit Modalities Test (SDMT) included measurement properties; construct, convergent, and known group validity; and longitudinal performance of the measures individually and when combined into a multidimensional test battery relative to the EDSS and SF-36 to determine sensitivity and clinical meaningfulness.

RESULTS

The performance measures had excellent test-retest reliability and showed expected differences between subgroups based on disease duration and EDSS level. Progression rates in detecting time to 3-month confirmed worsening were lower for T25FW and 9HPT compared to EDSS, while progression rates for LCLA and SDMT were similar to EDSS. When the 4 measures were analyzed as a multidimensional measure rather than as individual measures, progression on any one performance measure was more sensitive than the EDSS. Worsening on the performance measures analyzed individually or as a multidimensional test battery was associated with clinically meaningful SF-36 PCS score worsening, supporting clinical meaningfulness of designated performance test score worsening.

CONCLUSION

These results support the use of the 4 proposed performance measures, individually or combined into a multidimensional test battery as study outcome measures.

Responder rates to fampridine differ between clinical subgroups of MS patients and patient reported outcome influences treatment decision making

BACKGROUND

Fampridine is an effective treatment to improve ambulation for some multiple sclerosis (MS) patients. Remarkable discrepancies exist between responder rates in clinical trials and the proportion of patients continuing treatment in clinical practice. This may be related to clinical phenotypes of MS patients, and the influence of patient reported outcome (PRO) on treatment decision making.

OBJECTIVE

To analyse responder rates to fampridine on ambulation and upper extremity function (UEF) and the influence on treatment decision making in different clinical subgroups in a real-world setting.

METHODS

MS patients with ambulatory impairment treated with fampridine were included. Patients were subdivided based on disease duration, clinical phenotype, Expanded Disability Status Scale (EDSS), baseline walking speed, and presence of UEF impairment. Ambulatory response was assessed with the Timed 25-Foot Walk (T25FW, responder defined as ≥20% improvement) and with the MS Walking Scale (MSWS, responder defined as ≥8 points improvement) as a PRO. For patients also reporting impaired UEF, the Arm Function in MS Questionnaire (AMSQ, responder defined as ≥15 improvement) was the PRO of choice. Decision on treatment continuation was based on improvement of T25FW, MSWS and the clinicians' overall impression for improvement.

RESULTS

In total 344 patients were included of which 75.3% continued treatment. More patients with a relapsing clinical phenotype continued treatment vs patients with a progressive phenotype (83.6 vs 68.6%, p < 0.01). A positive linear trend was found between severity of walking disability, as determined by baseline walking speed, and T25FW response (p < 0.01), while there was an inverse linear association between walking disability and MSWS response (p = 0.03). However, the proportion of patients continuing treatment was similar between subgroups of baseline walking speed. Impaired UEF was reported by 183 (66.5%) patients, of which 64 (39.3%) were AMSQ responders. Patients responding on AMSQ compared to non-responders, were also more frequently MSWS responders (82.8 vs 65.3%, p = 0.02), while response on T25FW was similar, and continued treatment more often (85.9 vs 70.7%, p = 0.04). This suggests an influence of PRO on treatment decision making.

CONCLUSION

Responder rates and treatment continuation of fampridine differed between clinical subgroups of MS. PROs influenced treatment decision making of fampridine in clinical practice, particularly in patients with mild ambulatory impairment or those reporting UEF impairment. To some extent, these findings explain discrepancies found between clinical trials and clinical practice, and support the importance of subgroup analyses and incorporation of PROs in clinical trials. For clinical practice, using PROs to assess patients experience in conjunction with performance measures helps in treatment decision making.

Repeated assessment of key clinical walking measures can induce confounding practice effects

Accurate functional outcome measures are critical for both clinical trials and routine patient assessments. Many functional outcomes improve with test repetition, a phenomenon that can confound the findings of longitudinal assessments. In this viewpoint, we tackle the poorly considered issue of practice effects in prevailing clinical walking tests based on current literature, while also presenting the original data from our own work, in which we investigated practice effects in the timed 25-foot walk (T25FW), timed-up and go (TUG), and 2-minute walk test (2MWT). In these tests, performed on 3 consecutive days in 10 patients with multiple sclerosis and 40 healthy controls, we observed significant practice effects in several established walking outcomes, including a 9.0% improvement in patients' TUG performance (p = 0.0146). Pre-training in these walking tests prior to baseline measurement may mitigate practice effects, thereby improving the accuracy and value of their repeated use in research and clinical settings.

Longitudinal assessment of hand function in individuals with multiple sclerosis

OBJECTIVE

Little is known about the frequency and severity of hand dysfunction in individuals with multiple sclerosis (MS). Hence, we sought to determine the extent that quantitative tests of hand function detect changes over time, evaluate their relationship to global disability measures, and identify predictors of hand function.

METHODS

One-hundred and forty-seven individuals with MS were included (96 women, 84 relapsing-remitting MS [RRMS]) along with 35 age-and-sex matched controls. Quantitative tests of hand function (grip strength, pinch strength, 9 hole peg test [9HPT], finger tapping) and leg strength were acquired and normalized to age and sex. Expanded Disability Status Scale (EDSS) and timed 25 foot walk were also obtained. Spearman correlations, multivariate regression models and mixed effects linear regression were used for analysis.

RESULTS

Our cohort had an EDSS of 3.6 ± 2.2 (median ± SD) and age 44.6 ± 11.9 years. Follow up time was up to 5 years. At baseline, 14/63 individuals with progressive MS (PMS) required more than twice as much time to complete the 9HPT using their dominant hand, compared to controls. Similarly, 11 individuals with PMS had less than 50% of grip strength and 6 had less than 50% of pinch strength, compared to controls. Additionally, 7 individuals with PMS were found to be at least 50% slower than controls in finger tapping. Over two years, 27/85 individuals with MS had more than 20% worsening in their 9HPT results from baseline (17 RRMS, 10 PMS) and 37/74 (20 RRMS, 17 PMS) had more than 20% worsening in their grip strength compared to baseline.

CONCLUSIONS

Hand function is commonly impaired in individuals with MS. Assessing hand dysfunction with dynamometry and the 9HPT could help improve the precision of detecting changes in hand function over time in MS, and may be more sensitive in detecting changes in PMS. These quantitative tests may be useful as outcome measures in clinical trials using neuroprotective or reparative therapies and rehabilitative interventions.

Gait tests in multiple sclerosis: Reliability and cut-off values

BACKGROUND

Gait limitation is one of the most common disabilities in people with multiple sclerosis (MS). Several studies have used gait parameters to determine the effects of different therapies. However, few studies have determined their reproducibility, also the therapeutic effects could be overestimated.

RESEARCH QUESTION

To examine the reproducibility in gait measurements during short and long distances.

METHODS

In this cross-sectional study we recruited a group of MS patients and compare it to a control group. The participants performed the following tests in a fixed order: a 25-foot walk at a comfortable speed, at a fast speed and during a dual task, a timed up-and-go test (TUG) and a six- minute walk test (6MWT). Two measurements were conducted a week apart. Systematic error was evaluated by the Student t-test, reliability by the intra-class correlation coefficients (ICC) and agreement by the minimum detectable change (MDC₉₅).

RESULTS

A total of 58 people with MS and 19 healthy people were included. The absence of systematic error was only found for the fast speed condition. The reliability of the gait parameters had moderate to high ICC values (ICC > 0.7) except for the dual task cost (DTC) which was 0.45. The MDC₉₅ was higher in people with MS compared to healthy people, and it was higher in people with MS for gait speeds in all conditions (> 34%). For the TUG and 6MWT, the MDC₉₅ were 51.5% and 31.7% respectively. For people with MS the smallest MDC₉₅ was found for the stance time for all conditions (6.8%), whereas the highest was found for the dual task cost (158.7%).

SIGNIFICANCE

The MDC₉₅ values were higher than the cut-off point based on the minimally important clinical difference (MICD) proposed in previous studies. Thus, the MDC₉₅ should be used as a cut-off rather than MICD values.

Expanded disability status scale progression assessment heterogeneity in multiple sclerosis according to geographical areas

Using placebo data from 3 randomized multiple sclerosis (MS) trials with uniform inclusion criteria, we investigated heterogeneity of Expanded Disability Status Scale (EDSS) progression by geographical areas. Our analysis revealed a significantly lower EDSS progression in Eastern European countries (10.8%) compared with Western Europe (13.1%) or the USA/Canada (21.4%, p < 0.001); EDSS improvement behaved the same way. This heterogeneity is not explained by differences of baseline variables. No differences were detected on more easily quantifiable measures, the Timed 25-Foot Walk or the Multiple Sclerosis Functional Composite. At a time when disease progression represents the target for future interventions in MS, establishment of more quantitative and objective outcomes remains a key priority of MS research. Ann Neurol 2018;84:621-625.

Objective and subjective measures of dalfampridine efficacy in clinical practice

Background

Multiple sclerosis affects mobility in over 80% of patients. Dalfampridine is the only approved treatment for walking impairment in multiple sclerosis. We assessed dalfampridine utilization in our practice and investigated response using timed 25 foot walk (T25FW) improvement and a patient-reported ambulation inventory.

Methods

Chart review identified patients with multiple sclerosis for whom dalfampridine was prescribed. T25FW data were extracted from medical records. Participants completed a dalfampridine-specific version of the multiple sclerosis walking scale (dMSWS-12) to assess the qualitative impact of dalfampridine on ambulation. We evaluated two responder categories: liberally defined as any improvement in T25FW; and over 20% T25FW improvement.

Results

The dMSWS-12 questionnaire was completed by 39 patients. Eighteen patients (46%) did not show any T25FW improvement. Of the 21 patients (54%) with T25FW improvement, four patients (11%) showed improvement greater than 20%. Analysis of dMSWS-12 scores showed a median score of 40 (range 12–60). Eleven patients (28%) showed no improvement (dMSWS-12 score ≤36). In contrast to objective T25FW improvement (54%), 28 patients (72%) reported improvement in walking ability (dMSWS-12 score ≥37).

Conclusion

Our results suggest that T25FW alone might not be sufficient for response characterization and that adding patient-reported measures may further elucidate the therapeutic response.

Novel computer-based testing shows multi-domain cognitive dysfunction in patients with multiple sclerosis

Background

Although cognitive dysfunction is a leading cause of disability and poor quality of life in patients with multiple sclerosis (MS), it is infrequently tested in routine clinical evaluation. Development of a cognitive testing paradigm that captured MS-related cognitive dysfunction and could be obtained in a routine clinical setting may increase surveillance and recognition of cognitive dysfunction.

Objectives

This was a pilot study to determine if Cognivue could find cognitive performance differences between patients with MS and healthy controls (HC).Methods: A total of 24 patients with MS and 12 HCs between 18 and 50 years old were enrolled. Baseline testing included an Expanded Disability Scale (EDSS), paced auditory serial additions test (PASAT), symbol digit modalities test (SDMT) and Cognivue. Subjects then had repeat testing every 1-2 months for a maximum of three tests.

Results

Significant differences were found between MS and HC on SDMT, PASAT, and Cognivue Total score. Most Cognivue subtests showed significant differences between MS and HC. Cognivue scores correlated with both SDMT and PASAT and had high test-retest reliability in HCs.

Conclusion

Cognivue was able to detect multi-domain cognitive dysfunction in MS. Further studies to determine validity of Cognivue in MS with comparison with neuropsychological testing and sensitivity to clinical change are still needed.

Profiling walking dysfunction in multiple sclerosis: characterisation, classification and progression over time

Gait dysfunction is a common and relevant symptom in multiple sclerosis (MS). This study aimed to profile gait pathology in gait-impaired patients with MS using comprehensive 3D gait analysis and clinical walking tests. Thirty-seven patients with MS walked on the treadmill at their individual, sustainable speed while 20 healthy control subjects walked at all the different patient's paces, allowing for comparisons independent of walking velocity. Kinematic analysis revealed pronounced restrictions in knee and ankle joint excursion, increased gait variability and asymmetry along with impaired dynamic stability in patients. The most discriminative single gait parameter, differentiating patients from controls with an accuracy of 83.3% (χ2 test; p = 0.0001), was reduced knee range of motion. Based on hierarchical cluster and principal component analysis, three principal pathological gait patterns were identified: a spastic-paretic, an ataxia-like, and an unstable gait. Follow-up assessments after 1 year indicated deterioration of walking function, particularly in patients with spastic-paretic gait patterns. Our findings suggest that impaired knee/ankle control is common in patients with MS. Personalised gait profiles and clustering algorithms may be promising tools for stratifying patients and to inform patient-tailored exercise programs. Responsive, objective outcome measures are important for monitoring disease progression and treatment effects in MS trials.

Walking measures to evaluate assistive technology for foot drop in multiple sclerosis: A systematic review of psychometric properties

BACKGROUND

Foot drop in people with multiple sclerosis (pwMS) often managed with assistive technologies, such as functional electrical stimulation and ankle foot orthoses. No evidence synthesis exists for the psychometric properties of outcomes used to evaluate the efficacy of these interventions.

OBJECTIVE

This systematic review aimed to identify the outcome measures reported to assess the benefits of assistive technology for pwMS and then synthesize the psychometric evidence in pwMS for a subset of these measures.

METHODS

Two searches in eight databases were conducted up to May 2017. Methodological quality was rated using the COSMIN guidelines. Overall level of evidence was scored according to the Cochrane criteria.

RESULTS

The first search identified 27 measures, with the 10 m walk test, gait kinematics and Physiological Cost Index (PCI) most frequently used. The second search resulted in 41 studies evaluating 10 measures related to walking performance. Strong levels of evidence were found for the internal consistency and test-retest reliability of the Multiple Sclerosis Walking Scale-12 and for the construct validity for Timed 25 Foot Walk. No psychometric studies were identified for gait kinematics and PCI in pwMS. There was a lack of evidence for measurement error and responsiveness.

CONCLUSION

Although a strong level of evidence exists for some measures included in this review, there was an absence of psychometric studies on commonly used measures such as gait kinematics. Future psychometric studies should evaluate a wider range of walking related measures used to assess the efficacy of interventions to treat foot drop in pwMS.

Brain atrophy and disability worsening in primary progressive multiple sclerosis: insights from the INFORMS study

Objective

To investigate the relationship between brain volume and disability worsening over ≥3 years in the natural history of primary progressive multiple sclerosis using data from the placebo group of the INFORMS trial (n = 487; clinicaltrials.gov NCT00731692).

Methods

Magnetic resonance imaging scans were collected annually. Brain volume loss was determined using SIENA. Patients were stratified by baseline normalized brain volume after adjusting for demographic and disease-burden covariates.

Results

Baseline normalized brain volume was predictive of disability worsening: Risk of 3-month confirmed disability progression was reduced by 36% for high versus low baseline normalized brain volume (Cox's model hazard ratio 0.64, P = 0.0339; log-rank test: P = 0.0297). Moreover, on-study brain volume loss was significantly associated with disability worsening (P = 0.012) and was evident in patients with or without new lesions or relapses. Brain volume loss depended significantly on baseline T2 lesion volume (P < 0.0001). Despite low inflammatory activity at baseline (13% of patients had gadolinium-enhancing lesions) and throughout the study (mean 0.5 new/enlarging T2 lesions and 172 mm³ T2 lesion volume increase per year), baseline T2 lesion volume was substantial (mean 10 cm³). Lower normalized brain volume at baseline correlated with higher baseline T2 volume and older age (both P < 0.0001).

Interpretation

Baseline brain volume and the rate of ongoing brain atrophy are significantly associated with disability worsening in primary progressive multiple sclerosis. Brain volume loss is significantly related to baseline T2 lesion volume, but partially independent of new lesion activity, which might explain the limited efficacy of anti-inflammatory treatment.

Test–retest agreement and reliability of the Six Spot Step Test in persons with multiple sclerosis

Background:

The Six Spot Step Test (SSST) extends traditional walking outcomes in persons with multiple sclerosis (PwMS) by further challenging components of coordination and balance. Nonetheless, the test–retest agreement of the SSST has not been investigated.

Objective:

To determine the within-day, day-to-day, and inter-rater agreement and reliability of the SSST in PwMS. A secondary aim was to investigate the validity of handheld timing.

Methods:

A total of 38 PwMS with an Expanded Disability Status Scale (EDSS) <6.5 completed two SSSTs with a 5-minute break in-between. After 2 days, this procedure was repeated. Bland–Altman analysis was performed to determine the 95% Limits of Agreement (LOA) and Intraclass Correlation Coefficient (ICC) was calculated. In a subgroup of 18 PwMS, the SSSTs were video-recorded and timed by a second investigator.

Results:

The relative LOA within and between days were ±15% and ±19%, while ICC were 0.987 and 0.983, respectively. A minor learning effect was found over four tests. The handheld timing error was ±0.5 seconds when compared to video-based timing.

Conclusion:

The SSST has an acceptable within- and between-day agreement and reliability. For interventional purposes, a change of >19% can be regarded as a real change. Valid timing can be performed by a handheld stopwatch.

Multiple Sclerosis and Clinical Gait Analysis before and after Fampridine: A Systematic Review

BACKGROUND

Gait impairment is one of the most disabling symptoms in people with multiple sclerosis (PwMS). Fampridine, has demonstrated a positive effect on gait speed in PwMS after 14 days of treatment but the long-term effects have not yet been demonstrated. This study reviews the long-term effects of fampridine on gait in PwMS.

SUMMARY

This systematic review was conducted according to the PRISMA statement. Studies were considered long term if treatment exceeded 28 days. From the 498 studies identified, 18 (2,200 patients) fulfilled all eligibility criteria. Only 3 studies followed-up patients for >1 year and one of these showed a non-significant improvement in the gait speed. Key Messages: Fampridine seems to be beneficial at improving gait speed in PwMS in the long term. Further long-term studies are needed on related gait and functional parameters.

Patient-reported questionnaires in MS rehabilitation: responsiveness and minimal important difference of the multiple sclerosis questionnaire for physiotherapists (MSQPT)

Background

The Multiple Sclerosis Questionnaire for Physical Therapists (MSQPT) is a patient-rated outcome questionnaire for evaluating the rehabilitation of persons with multiple sclerosis (MS). Responsiveness was evaluated, and minimal important difference (MID) estimates were calculated to provide thresholds for clinical change for four items, three sections and the total score of the MSQPT.

Methods

This multicentre study used a combined distribution- and anchor-based approach with multiple anchors and multiple rating of change questions. Responsiveness was evaluated using effect size, standardized response mean (SRM), modified SRM and relative efficiency. For distribution-based MID estimates, 0.2 and 0.33 standard deviations (SD), standard error of measurement (SEM) and minimal detectable change were used_. Triangulation of anchor- and distribution-based MID estimates provided a range of MID values for each of the four items, the three sections and the total score of the MSQPT. The MID values were tested for their sensitivity and specificity for amelioration and deterioration for each of the four items, the three sections and the total score of the MSQPT. The MID values of each item and section and of the total score with the best sensitivity and specificity were selected as thresholds for clinical change.

The outcome measures were the MSQPT, Hamburg Quality of Life Questionnaire for Multiple Sclerosis (HAQUAMS), rating of change questionnaires, Expanded Disability Status Scale, 6-metre timed walking test, Berg Balance Scale and 6-minute walking test.

Results

The effect size ranged from 0.46 to 1.49. The SRM data showed comparable results. The modified SRM ranged from 0.00 to 0.60. Anchor-based MID estimates were very low and were comparable with SD- and SEM-based estimates. The MSQPT was more responsive than the HAQUAMS in detecting improvement but less responsive in finding deterioration. The best MID estimates of the items, sections and total score, expressed in percentage of their maximum score, were between 5.4% (activity) and 22% (item 10) change for improvement and between 5.7% (total score) and 22% (item 10) change for deterioration.

Conclusions

The MSQPT is a responsive questionnaire with an adequate MID that may be used as threshold for change during rehabilitation of MS patients.

Trial registration

This trial was retrospectively (01/24/2015) registered in ClinicalTrials.gov as NCT02346279.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-017-0834-1) contains supplementary material, which is available to authorized users.

The Nine-Hole Peg Test as a manual dexterity performance measure for multiple sclerosis

Impaired manual dexterity is a frequently reported disability in people with multiple sclerosis (MS) and is increasingly prevalent with worsening disease. While various tests and patient-reported outcome measures are available, the Nine-Hole Peg Test (NHPT) is considered as a gold standard measure of manual dexterity and most frequently used in MS research and clinical practice. The MS Outcome Assessments Consortium (MSOAC) includes representatives from advocacy organizations, Food and Drug Administration (FDA), European Medicines Agency (EMA), National Institute of Neurological Disorders and Stroke (NINDS), academic institutions, and industry partners along with persons living with MS. Among the MSOAC goals are acceptance and qualification by regulators of performance outcomes that are highly reliable and valid, practical, cost-effective, and meaningful to persons with MS. A critical step for these neuroperformance metrics is elucidation of clinically relevant benchmarks, well-defined degrees of disability, and gradients of change that are deemed clinically meaningful. This article addresses the NHPT, the proposed MSOAC measure for upper extremity function. We find that the NHPT is reliable within and between test sessions, discriminates between healthy subjects and MS patients with different levels of upper limb impairment, and shows high convergent validity with other manual dexterity as well as more comprehensive upper limb measures. Ecological validity is established by its relation to perceived upper limb use in daily life and perceived difficulty in performing activities of daily living. The NHPT is responsive to deterioration in longitudinal studies, and research suggests that a 20% change in test score is commonly used to define clinically meaningful worsening, a definition that needs further validation in all stages of the disease.

Validity of the timed 25-foot walk as an ambulatory performance outcome measure for multiple sclerosis

The Multiple Sclerosis Outcome Assessments Consortium (MSOAC) includes representatives from advocacy organizations, Food and Drug Administration (FDA), European Medicines Agency (EMA), National Institute of Neurological Disorders and Stroke (NINDS), academic institutions, and industry partners along with persons living with multiple sclerosis (MS). One of the MSOAC goals is acceptance and qualification by regulators of performance outcomes that are highly reliable and valid, practical, cost-effective, and meaningful in MS. This article addresses the history, application, and psychometric properties of one such MSOAC metric of ambulation or walking namely, the timed 25-foot walk (T25FW). The T25FW has strong reliability over both brief and long periods of time in MS across a large range of disability levels. The outcome of walking speed from the T25FW has obvious real-world relevance and has correlated strongly with other measures of walking and lower extremity function. The T25FW is responsive for capturing intervention effects in pharmacological and rehabilitation trials and has an established value for capturing clinically meaningful change in ambulation. Directions for future research involve validating clinically meaningful improvements on the T25FW as well as determining whether 20% change is clinically meaningful across the disability spectrum. Researchers might further consider synchronizing accelerometers and motion sensors with the T25FW for capturing walking speed in everyday life and the patient's real environment.

Outcome Measures in Clinical Trials for Multiple Sclerosis

Due to the heterogeneous nature of the disease, it is a challenge to capture disease activity of multiple sclerosis (MS) in a reliable and valid way. Therefore, it can be difficult to assess the true efficacy of interventions in clinical trials. In phase III trials in MS, the traditionally used primary clinical outcome measures are the Expanded Disability Status Scale and the relapse rate. Secondary outcome measures in these trials are the number or volume of T2 hyperintense lesions and gadolinium-enhancing T1 lesions on magnetic resonance imaging (MRI) of the brain. These secondary outcome measures are often primary outcome measures in phase II trials in MS. Despite several limitations, the traditional clinical measures are still the mainstay for assessing treatment efficacy. Newer and potentially valuable outcome measures increasingly used or explored in MS trials are, clinically, the MS Functional Composite and patient-reported outcome measures, and on MRI, brain atrophy and the formation of persisting black holes. Several limitations of these measures have been addressed and further improvements will probably be proposed. Major improvements are the coverage of additional functional domains such as cognitive functioning and assessment of the ability to carry out activities of daily living. The development of multidimensional measures is promising because these measures have the potential to cover the full extent of MS activity and progression. In this review, we provide an overview of the historical background and recent developments of outcome measures in MS trials. We discuss the advantages and limitations of various measures, including newer assessments such as optical coherence tomography, biomarkers in body fluids and the concept of 'no evidence of disease activity'.