The e-MSWS-12: improving the multiple sclerosis walking scale using item response theory

The Effectiveness of a Single Dry Needling Session on Gait and Quality of Life in Multiple Sclerosis: A Double-Blind Randomized Sham-Controlled Pilot Trial

INTRODUCTION

Gait disorders are a major cause of disability and reduced health-related quality of life in people with multiple sclerosis (pwMS). Dry needling (DN) has demonstrated positive results to improve gait parameters in patients with stroke. The main aim of this study was to evaluate the effect of a single session of DN in the gait performance of pwMS.

METHODS

A double-blind parallel randomized sham-controlled pilot trial was conducted. Study participants received a single session of active DN or sham DN in the gastrocnemius medialis muscle. Pre-treatment and immediately post-treatment measurements were taken, as well as at one and four weeks after the intervention. Outcomes related to gait performance (Timed 25-Foot Walk), self-perceived walking capacity (Multiple Sclerosis Walking Scale), risk of falls (Timed Up and Go test), disability level (Expanded Disability Status Score) and quality of life (Multiple Sclerosis Quality of Life-54 questionnaire and Analogic Quality of Life scale) were evaluated.

RESULTS

18 patients who had multiple sclerosis participated in the study. The group who received active DN showed within-group significant statistical differences immediately after treatment for gait performance (p = 0.008) and risk of falls (p = 0.008), as well as for self-perceived walking capacity at one week (p = 0.017) and four weeks (p = 0.011) and quality of life at four weeks (p = 0.014). Regarding the comparison between groups, only significant results were obtained in the physical domain of the quality of life at four weeks (p = 0.014).

CONCLUSIONS

DN seems to be a promising therapeutic tool for the treatment of gait disorders in pwMS. However, when results were compared with sham DN, no differences were found.

Translation and validation of the multiple sclerosis walking scale 12 for the German population - the MSWS-12/D

BACKGROUND

Gait impairment is a relevant problem in persons with multiple sclerosis (pwMS). The Multiple Sclerosis Walking Scale 12 (MSWS-12) is a valid Patient Reported Outcome Measure (PROM) to evaluate walking ability in pwMS. The aim of this study was to provide a linguistically valid translation of MSWS-12 into German language (MSWS-12/D) and to evaluate its psychometric properties.

METHODS

The MSWS-12 was translated in a process modified from guidelines for the cross-cultural adaption of PROMs, and a pre-test was applied in a small sample of 20 pwMS to evaluate comprehensibility and acceptance. Psychometric properties (floor and ceiling effects, internal consistency, construct validity) were then assessed in 124 pwMS seen at academic MS centers. Construct validity was evaluated against Expanded Disability Status Scale (EDSS) and maximum gait speed in the Timed 25-Foot Walk (T25FW).

RESULTS

Although the sample covered a wide spectrum of symptom severity, the majority had rather low levels of disability (EDSS median 2.0) and 6.5% scored EDSS of 0. In this sample, MSWS-12/D showed floor effects (36% with score 0) and for internal consistency, a Cronbach's alpha of 0.98 was calculated. MSWS-12/D score showed a relevant correlation to EDSS (ρ = 0.73) and T25FW speed (r=-0.72).

CONCLUSION

We provide MSWS-12/D as a linguistically valid German version of MSWS-12. Psychometric properties (acceptance, floor and ceiling effects, internal consistency and construct validity) in pwMS were similar to those described for the original version. This indicates that MSWS-12/D can be applied as equivalent to the original version in German speaking pwMS. Results support the relevance of PROMs to capture patient perception of walking ability in addition to performance-based assessments such as maximum walking speed or maximum walking distance.

Editorial Commentary: Legacy Patient-Reported Outcome Measures Are Superior to Patient-Reported Outcomes Measurement Information System for Assessing Function After Hip Arthroscopy

Patient-reported outcome measures (PROMs) are critical tools in hip preservation research for evaluating the efficacy of current treatments, as well as identifying risk factors associated with suboptimal outcomes. These measures have been used for quality improvement, for monitoring of health plan performance, and even for reimbursement models. Over the past 2 decades, legacy hip outcome scores have been developed that are patient-centric and evaluate hip-specific function after surgery. There has been a recent trend in using the Patient-Reported Outcomes Measurement Information System (PROMIS), a tool developed by the National Institutes of Health for evaluating PROMs, in the field of hip arthroscopy. However, on the basis of the evidence in the literature, it is unlikely that PROMIS is superior to legacy PROMs regarding evaluation of hip function, nor is it as responsive to quantifying meaningful changes in function that are important to patients. As such, clinicians and researchers alike should likely continue using legacy PROMs to evaluate patients' functional outcomes after hip arthroscopy while continuing to explore the clinical applications of other PROMIS domains.

Patient-Reported Outcomes Measurement Information System Test Is Less Responsive Than Legacy Hip-Specific Patient-Reported Outcome Measures in Patients Undergoing Arthroscopy for Femoroacetabular Impingement Syndrome

Purpose

To evaluate and compare the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) computerized adaptive test and PROMIS Pain Interference (PI) instruments versus legacy patient-reported outcome measures (PROMs) in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome at 1-year follow-up.

Methods

Patients undergoing primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome without concomitant procedures performed by a single surgeon between August 2018 and January 2019 were identified. The PROMIS PF score, PROMIS PI score, Hip Outcome Score–Activities of Daily Living Subscale (HOS-ADL), Hip Outcome Score–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool 12 (iHOT-12), and visual analog scale (VAS) pain score were obtained preoperatively and at 6 months and 1 year postoperatively. Bivariate correlation analyses between PROMIS and legacy PROMs were performed. The floor and ceiling effects, responsiveness, and relative efficiency (RE) of each PROM were calculated.

Results

This study included 124 patients with an average age of 32.7 ± 12.3 years. The PROMIS PF score showed very good correlations with the HOS-ADL (r = 0.73, P < .001) and mHHS (r = 0.70, P < .001) and good correlations with the HOS-SS (r = 0.62, P < .001), iHOT-12 score (r = 0.62, P < .001), and VAS pain score (r = –0.64, P < .001). The PROMIS PI score showed very good inverse correlations with the HOS-ADL (r = –0.72, P < .001) and mHHS (r = –0.79, P < .001) and good correlations with the HOS-SS (r = –0.64, P < .001), iHOT-12 score (r = –0.65, P < .001), and VAS pain score (r = 0.65, P < .001). No floor effect was observed for any measure. Ceiling effects were not observed in the PROMIS PROMs but were detected for the HOS-ADL (16.1%) and mHHS (19.3%). The effect size was large for all outcomes: iHOT-12 score, d = 1.77; HOS-ADL, d = 1.37; HOS-SS, d = 1.45; PROMIS PI score, d = 1.05; and PROMIS PF score, d = 1.01. The iHOT-12 score was more responsive than the PROMIS PI score (RE = 1.69), PROMIS PF score (RE = 1.75), HOS-ADL (RE = 1.29), and HOS-SS (RE = 1.22).

Conclusions

At 1-year follow-up, PROMIS PROMs displayed very good correlations with legacy PROMs. However, PROMIS PROMs had lower effect sizes and were not as responsive as legacy PROMs.

Level of Evidence

Level II, development of diagnostic criteria on the basis of consecutive patients.

Defining Clinically Significant Improvement on the Patient-Reported Outcomes Measurement Information System Test at 1-Year Follow-up for Patients Undergoing Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome

BACKGROUND

Although minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB) have been defined for hip-specific legacy patient-reported outcome measures, these metrics have not been defined for the Patient-Reported Outcomes Measurement Information System (PROMIS) instruments for patients undergoing hip arthroscopy.

PURPOSE

To define the MCID, PASS, and SCB thresholds for the PROMIS Physical Function (PF) computerized adaptive test (CAT) and PROMIS Pain Interference (PI) instruments in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

Patients undergoing primary hip arthroscopy between August 2018 and January 2019 for the treatment of FAIS were retrospectively analyzed. Patients were administered the PROMIS-PF, PROMIS-PI, Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports Subscale, modified Harris Hip Score, and International Hip Outcome Tool-12 preoperatively and at 1 year postoperatively. MCID was calculated using the distribution method, whereas PASS and SCB were calculated using an anchor-based method. Patients achieving clinically significant outcomes (CSOs) were compared with those who did not achieve CSOs via chi-square and independent-samples t tests, and a multivariate logistic regression was conducted to determine predictors of CSO achievement.

RESULTS

124 patients with a mean age of 32.7 ± 12.3 years were included in the analysis. The threshold scores required to achieve MCID, PASS, and SCB, respectively, were as follows: PROMIS-PI (-3.1, 53.7, 51.9) and PROMIS-PF (3.3, 47.0, 49.9). Patients achieved any MCID, PASS, and SCB for PROMIS scores at a rate of 89.0%, 71.8%, and 62.1%, respectively, compared with 87.1%, 76.6%, and 71.8% for legacy patient-reported outcome measurements. For PROMIS-PF, higher preoperative PROMIS-PF score was a positive predictor of CSO achievement, and patients achieving SCB were significantly younger (30.3 ± 12 vs 35.6 ± 12 years; P = .017) with significantly lower body mass index (BMI) (24.7 ± 6.4 vs 27.9 ± 7; P = .009). Preoperative chronic pain and history of orthopaedic surgery were negative predictors of PROMIS-PI CSO achievement, whereas higher (worse) preoperative PROMIS-PI scores were a positive predictor.

CONCLUSION

Our study defined the MCID, PASS, and SCB for the PROMIS-PF CAT and PROMIS-PI CAT at 1 year postoperatively. Patients with higher preoperative PROMIS scores, younger age, and lower BMI were more likely to achieve CSO, whereas preoperative chronic pain and history of orthopaedic surgery were negative predictors of CSO achievement.

Improving our understanding of the most important items of the Multiple Sclerosis Walking Scale-12 indicating mobility dysfunction: Secondary results from a RIMS multicenter study

BACKGROUND

The 12-item Multiple Sclerosis Walking Scale (MSWS-12) is currently the most widely validated, patient-reported outcome measure assessing patients' perception of the impact of multiple sclerosis (MS) on walking ability. To date, the majority of previous studies investigating the MSWS-12 have focused on the total score despite individual items being potentially informative. Therefore, our objective was to examine the associations between the individual items of the MSWS-12 and mobility and whether these associations depend on disability level.

METHODS

Participants completed the MSWS-12, Two-Minute Walk Test (2MWT), Timed 25-Foot Walk (T25FW), Timed Up and Go Test (TUG) and the Four Square Step Test (FSST). Subsequently, they were divided into two groups according to their disability level, classified as either "mildly" or "moderately-severely" disabled. The correlation between individual items of the MSWS-12 and clinical measures of mobility were separately examined by Spearman's correlation coefficients; linear regression analyses were performed for each disability group, with/without adjusting for cognition, age and gender.

RESULTS

242 people with MS (PwMS), 108 mildly and 134 moderately-severely disabled, were included. Stronger correlations between the MSWS-12 items and mobility tests were found in the mildly disabled compared to the moderately-severely disabled group. The linear regression analysis showed that in the mildly disabled, item 9 (use of support outdoors) explained 35.4%, 30.8%, and 23.7% of the variance related to the 2MWT, T25FW and TUG, respectively. As for the moderately-severely disabled, the linear regression analysis presented a model which included item 8 (use of support indoors), explaining 31.6%, 18.0%, 20.2% and 9.5% of the variance related to the 2MWT, T25FWT, TUG and FSST, respectively.

CONCLUSIONS

Items 8 and 9 of the MSWS-12 focusing on the patient's use of walking support in and outdoors, provide a robust indicator of mobility capabilities for mildly and moderately-severely disabled PwMS.

The Impact of Workers' Compensation on Patient-Reported Outcomes Measurement Information System Upper Extremity and Legacy Outcome Measures in Patients Undergoing Arthroscopic Rotator Cuff Repair

PURPOSE

To examine the preoperative performance of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) with respect to legacy scores in patients receiving rotator cuff repair (RCR). In addition, to define the impact of Workers' Compensation (WC) status on both performance and floor and ceiling effects.

METHODS

The PROMIS UE CAT was administered preoperatively alongside legacy patient-reported outcome measures (PROMs) to patients undergoing isolated arthroscopic RCR from November 2017 to September 2018. Performance was assessed using Spearman correlation coefficients, and floor and ceiling effects were examined.

RESULTS

One hundred twenty-two patients (WC, n = 32; non-WC, n = 90; 62.3% male, 53.6 ± 11.5 years) were included. PROMs assessing physical function (r = 0.41-0.77) correlated more strongly to the PROMIS UE CAT than did multidomain or mental health PROMs (r = 0.25-0.61). In WC patients, the PROMIS UE CAT demonstrated diminished correlative strength relative to shoulder function PROMs. WC patients also demonstrated relative floor effects for Single Assessment Numerical Evaluation (SANE; 18.8%) and Constant-Murley (15.6%) and relative ceiling effects for the Brief Resilience Scale (53.1%), Short Form 12 Mental Component Score (50%), and Veterans Rand 12 Mental Component Score (53.1%) and were more likely to report the minimum SANE score (P < .01) and the maximum Brief Resilience Scale score (P < .01). No absolute or relative floor/ceiling effects for the PROMIS UE CAT were found.

CONCLUSIONS

Compared with a non-WC cohort, WC patients have significantly lower preoperative PROMIS UE CAT scores, are more likely to report the absolute minimum and maximum scores for various PROMs, and demonstrated relative floor and ceiling effects for PROMs assessing mental health. The absence of significant floor/ceiling effects for the PROMIS UE CAT may suggest improved outcome discrimination and may support the adoption of PROMIS UE for the assessment of functional status in WC patients with rotator cuff pathology.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

Examining the validity of the multiple-sclerosis walking scale-12 with Rasch analysis: Results from an Italian study

BACKGROUND

The Multiple Sclerosis Walking Scale (MSWS-12) has showed good psychometric properties in reports exploring its validity using Classical Test Theory methods. Findings from recent studies using Item Response Theory methods advance the idea that some aspects of the MSWS-12 does not fully comply with some requirements of sound measurement.

RESEARCH QUESTION

The present study investigated whether the measurement properties of the Italian version of the MSWS-12 met the assumptions of the Rasch model.

METHODS

Sample consisted of 199 patients with a diagnosis of MS (50% female; Mean age (SD) = 48.15 (12.33)). Analyses were performed using both unidimensional and multidimensional Rasch modeling techniques.

RESULTS

Rating scale for items assessing need for support when walking, and ability to run, showed significant functioning problems. A revision of the rating scale improved the measurement properties of these items. Items assessing need for support showed signs of multidimensionality and differential item functioning when controlling for patients' disease course and EDSS score. Additionally, included items did not appear to cover the full range of impairment as observed in the sample.

SIGNIFICANCE

Emerging findings are consistent with those from previous studies in highlighting the need for a revision of the current content of the MSWS-12, and the inclusion of new items assessing impairment at the lower end of the disability continuum.

Preoperative Performance of the PROMIS in Patients Undergoing Hip Arthroscopic Surgery for Femoroacetabular Impingement Syndrome

Background:

The Patient-Reported Outcomes Measurement Information System (PROMIS) is being increasingly evaluated for use in orthopaedic surgery. The performance of the PROMIS in patients undergoing hip preservation surgery is unknown.

Purpose:

To investigate the psychometric performance of the PROMIS compared with legacy patient-reported outcome measures (PROMs) in patients indicated for hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS).

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Data from consecutive patients who underwent primary hip arthroscopic surgery between January and October 2018 for the treatment of FAIS were collected and analyzed. Baseline data, including preoperative PROM scores and demographics, were recorded. PROMs included the PROMIS Physical Function (PF), the Hip Outcome Score (HOS), the modified Harris Hip Score (mHHS), the International Hip Outcome Tool–12 (iHOT-12), and the Veterans RAND 12-item health survey (VR-12). Pearson and Spearman coefficient analyses were used to identify correlations between continuous and noncontinuous variables, respectively. Correlation was defined as excellent (>0.80), very good (0.71-0.80), good (0.61-0.70), fair (0.41-0.60), or poor (0.21-0.40). A multivariate linear regression analysis was used to identify preoperative predictors of having higher preoperative PROMIS scores.

Results:

A total of 197 patients with a mean age and body mass index (BMI) of 32.8 ± 12.6 years and 25.7 ± 5.6 kg/m², respectively, were included in the final analysis. There were no ceiling or floor effects for the PROMIS PF score observed in the study group. With regard to hip-specific measures, PROMIS PF scores demonstrated excellent correlation with HOS–Activities of Daily Living (r = 0.801; P < .001) scores, very good correlation with mHHS (r = 0.721; P < .001) and iHOT-12 (r = 0.722; P < .001) scores, and good correlation with HOS–Sports Specific (r = 0.675; P < .001) scores. With regard to general health–related quality of life (HRQoL) measures, PROMIS PF scores demonstrated very good correlation with VR-12 mental (r = 0.721; P < .001) scores, good correlation with VR-12 physical (r = 0.618; P < .001) scores, and poor correlation with visual analog scale for pain (r = –0.365; P < .001) scores. Patients who reported being physically active were more likely to have a higher preoperative PROMIS score (β = 3.216; P = .004). Lower PROMIS scores were found in patients with a higher BMI (β = –0.236; P = .005) and in female patients (β = –2.608; P = .014).

Conclusion:

In patients with FAIS, the preoperative PROMIS PF scores demonstrated excellent to good correlation with legacy hip-specific instruments as well as with HRQoL measures. No ceiling or floor effects were identified. Notably, of the hip-specific PROMs administered, the PROMIS PF demonstrated the weakest correlation with the HOS–Sports Specific subscale. Physical activity, BMI, and sex were predictors of preoperative PROMIS scores in our patient population.

Identifying the Essential Portions of the Skill Acquisition Process Using Item Response Theory

OBJECTIVE

Item response theory (IRT) was originally developed to make performance assessments more accurate. However, IRT analysis of the intraoperative performance of surgical trainees could help identify the elements that the trainees find difficult during the skill acquisition process. The aim of this study was to identify the essential portions of the skill acquisition process of a surgical procedure using the IRT.

DESIGN

The 24-item assessment checklist was used to evaluate a recorded intra-operative performance of a laparoscopic inguinal hernia repair. The scores were analyzed using IRT to calculate the difficulty and discrimination level of each item.

SETTING

Fifteen institutes.

PARTICIPANTS

Thirty surgical trainees.

RESULTS

A total of 123 assessments were analyzed. The item analysis showed the procedure specific item "traction of peritoneum (difficulty: -0.45; discrimination: 19.37)" and generic items "instrument handling (difficulty: -0.59; discrimination: 3.82)" and "flow of procedure (difficulty: 0.09; discrimination: 3.27)" to be key elements in the skill acquisition process of the procedure.

CONCLUSIONS

Key elements in the skill acquisition process of the procedure were quantitatively identified by applying the IRT analysis. This could lead to the use of IRT in designing and developing a more effective training curriculum.

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.

Balance, gait, and falls in multiple sclerosis

Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) and the most widespread nontraumatic cause of disability in young adults around the world. MS occurs in people of all ages, races, and ethnicities. MS is characterized by clinical symptoms resulting from lesions in the brain, spinal cord, or optic nerves that can affect balance, gait, and fall risk. Lesions accumulate over time and occur in different areas of the CNS causing symptoms that include weakness, spasticity, and fatigue, as well as changes in sensation, coordination, vision, cognition, and bladder function. Thus, it is not surprising that imbalance, gait dysfunction, and falls are common in people with MS. The overwhelming majority have abnormalities of postural control and gait even early in the disease course. In all, 50-80% have balance and gait dysfunction and over 50% fall at least once each year. Balance dysfunction in MS is conceptualized as three interrelated problems: decreased ability to maintain position, limited and slowed movement towards limits of stability, and delayed responses to postural displacements and perturbations. In addition, functional balance performance may be affected by impaired dual-task integration. Walking changes in MS include reduced gait speed, impaired walking balance, and reduced walking-related physical activity. Falls in people with MS are associated with injuries, reduced participation, and increased fear of falling. A wide and growing range of rehabilitation and medical interventions are available to address the changes in balance, gait, and fall risk associated with MS.

Identifying Unbiased Items for Screening Preschoolers for Disruptive Behavior Problems

Objective

Efficient identification and referral to behavioral services are crucial in addressing early-onset disruptive behavior problems. Existing screening instruments for preschoolers are not ideal for pediatric primary care settings serving diverse populations. Eighteen candidate items for a new brief screening instrument were examined to identify those exhibiting measurement bias (i.e., differential item functioning, DIF) by child characteristics.

Method

Parents/guardians of preschool-aged children ( N = 900) from four primary care settings completed two full-length behavioral rating scales. Items measuring disruptive behavior problems were tested for DIF by child race, sex, and socioeconomic status using two approaches: item response theory-based likelihood ratio tests and ordinal logistic regression.

Results

Of 18 items, eight were identified with statistically significant DIF by at least one method.

Conclusions

The bias observed in 8 of 18 items made them undesirable for screening diverse populations of children. These items were excluded from the new brief screening tool.