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Grijalvo M, Ordieres-Meré J, Villalba-Díez J, Aladro-Benito Y, Martín-Ávila G, Simon-Hurtado A, Vivaracho-Pascual C. Sufficiency for PSS tracking gait disorders in multiple sclerosis: A managerial perspective. Heliyon 2024; 10:e30001. [PMID: 38707444 PMCID: PMC11066638 DOI: 10.1016/j.heliyon.2024.e30001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/07/2024] Open
Abstract
This study primarily aimed to explore the capabilities of digitalisation in the healthcare context, focusing on a specific disease. In this case, the study examined the potential of remote monitoring of gait to address the sensitivity of multiple sclerosis progression to gait characteristics by adopting a non-invasive approach to remotely quantify gait disturbances in a patient's daily life. To better understand the managerial aspects associated with this approach, the researchers conducted a literature review along with a set of semi-structured interviews. The target population included MS patients as well as the key agents involved in their care: patients' family members, neurologists, MS nurses, physiotherapists, medical directors, and pharmacist. The study identifies the perceived barriers and drivers that could contribute to the successful deployment of PSS remote gait monitoring as a healthcare service: i) At mega-level governance. Implications on privacy and security data are notable barriers missing on the speech. ii) At macro level, funding is highlighted as main barrier. The cost and lack of health system subsidies may render initiatives unsustainable, as emphasised by the interviewees. iii) At meso level, useable data is recognised as a driver. The data collection process can align with diverse interests to create value and business opportunities for the ecosystem actors, enhance care, attract stakeholders, such as insurers and pharma, and form partnerships. iv) At micro-level processes, we find two potential barriers: wearable device and app usability (comfort, navigation, efficiency) and organisational/behavioural aspects (training, digital affinity, skills), which are crucial for value creation in innovation ecosystems among patients and healthcare professionals. Finally, we find an interesting gap in the literature and interviews. Stakeholders' limited awareness of technological demands, especially from information technologies, for a successful long-term service, can be consider two key barriers for PSS.
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Affiliation(s)
- Mercedes Grijalvo
- Department of Organizational Engineering, Business Administration and Statistics, Universidad Politécnica de Madrid, Madrid, Spain
| | - Joaquín Ordieres-Meré
- Department of Organizational Engineering, Business Administration and Statistics, Universidad Politécnica de Madrid, Madrid, Spain
| | | | - Yolanda Aladro-Benito
- Department of Neurology, Getafe University Hospital, Madrid, Spain
- Faculty of Biomedical and Health Sciences, European University of Madrid, Madrid, Spain
| | | | - Arancha Simon-Hurtado
- Departamento de Informática, Escuela de Ingeniería Informática de Valladolid, Universidad de Valladolid, Paseo de Belén 15, 47011, Valladolid, Spain
| | - Carlos Vivaracho-Pascual
- Departamento de Informática, Escuela de Ingeniería Informática de Valladolid, Universidad de Valladolid, Paseo de Belén 15, 47011, Valladolid, Spain
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van Beek JJW, Lehnick D, Pastore-Wapp M, Wapp S, Kamm CP, Nef T, Vanbellingen T. Tablet app-based dexterity training in multiple sclerosis (TAD-MS): a randomized controlled trial. Disabil Rehabil Assist Technol 2024; 19:889-899. [PMID: 36308305 DOI: 10.1080/17483107.2022.2131915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/12/2022] [Accepted: 09/22/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE Mobile health applications (mHealth apps) may lead to health benefits. In recent years, the use of apps in multiple sclerosis (MS) has increased. Apps to train and improve dexterity in MS are scarce. This study investigated the effectiveness of a tablet app-based home-based training to improve dexterity in individuals with MS. MATERIALS AND METHODS In a randomized controlled trial, two standardized 4-week home-based interventions focussing on different aspects of dexterity and upper limb function were compared. Assessments were done at baseline, post-intervention and 12-week follow-up. The primary endpoint was the Arm Function in Multiple Sclerosis Questionnaire, a dexterity-related measure of patient-reported activities of daily living. Secondary endpoints were dexterous function, grip strength and health-related quality of life. RESULTS Forty-eight individuals were randomly assigned to a tablet app-based program (n = 26) or a control strengthening exercise program (n = 22). No significant differences were found for the primary endpoint (p = 0.35). Some significant differences in favour of the app-group were found in fine coordinated finger movements and strength. No significant differences were found at the 12-week follow-up for all endpoints. Adherence in both groups was above 90%. CONCLUSIONS App-based training was not superior compared to a control strengthening exercise program concerning the arm- and hand function from the participant's perspective. However, app-based training was found to be effective in improving specific dimensions (finger movements and strength), and can easily be applied at home. Therefore, individuals living with MS with impaired dexterity should consider app-based training. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov NCT03369470.
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Affiliation(s)
- Judith J W van Beek
- Neurocenter, Cantonal Hospital Lucerne, Lucerne, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Dirk Lehnick
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Manuela Pastore-Wapp
- Neurocenter, Cantonal Hospital Lucerne, Lucerne, Switzerland
- ARTORG Center for Biomedical Engineering Research, Gerontechnology & Rehabilitation Group, University of Bern, Bern, Switzerland
| | - Simona Wapp
- Neurocenter, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Christian P Kamm
- Neurocenter, Cantonal Hospital Lucerne, Lucerne, Switzerland
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Tobias Nef
- ARTORG Center for Biomedical Engineering Research, Gerontechnology & Rehabilitation Group, University of Bern, Bern, Switzerland
| | - Tim Vanbellingen
- Neurocenter, Cantonal Hospital Lucerne, Lucerne, Switzerland
- ARTORG Center for Biomedical Engineering Research, Gerontechnology & Rehabilitation Group, University of Bern, Bern, Switzerland
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3
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Elkefi S, Blecker S, Bitan Y. Health Information Technology Supporting Adherence Memory Disorder Patients: A Systematic Literature Review. Appl Clin Inform 2024; 15:85-100. [PMID: 38295858 PMCID: PMC10830240 DOI: 10.1055/s-0043-1776792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/09/2023] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND People with memory disorders have difficulty adhering to treatments. With technological advances, it remains important to investigate the potential of health information technology (HIT) in supporting medication adherence among them. OBJECTIVES This review investigates the role of HIT in supporting adherence to medication and therapies among patients with memory issues. It also captures the factors that impact technology adherence interventions. METHODS We searched the literature for relevant publications published until March 15, 2023, using technology to support adherence among patients with memory issues (dementia, Alzheimer's, amnesia, mild cognitive impairment, memory loss, etc.). The review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We conducted a quality assessment of the papers following the Mixed Methods Appraisal Tool. RESULTS Fifteen studies were included after carefully reviewing the 3,773 articles in the search. Methodological quality, as appraised, ranged from 80 to 100% with eight studies rated 100%. The studies overall did not have a high risk of bias. Thus, all of the 15 studies were included. Technologies investigated were classified into four groups based on their impact: therapeutic patient education, simplifying treatment regimens, early follow-up visits and short-term treatment goals, and reminder programs. Different technologies were used (automatic drug dispensers or boxes, mobile health-based interventions, game-based interventions, e-health-based interventions, patient portals, and virtual reality). The factors impacting patients' adherence to technology-based treatment and medication were clustered into human-computer interaction and integration challenges. CONCLUSION This study contributes to the literature by classifying the technologies that supported medication adherence among patients with memory issues in four groups. It also explores and presents the possible limitations of existing solutions to drive future research in supporting care for people with memory disorders.
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Affiliation(s)
- Safa Elkefi
- School of Nursing, Columbia University Medical School, Columbia University, United States
- Langone health, New York University Medical School, New York University, New York, United States
| | - Saul Blecker
- Langone health, New York University Medical School, New York University, New York, United States
| | - Yuval Bitan
- Department of Health Policy and Management, Ben-Guiron University of the Negev, Beer Sheva, Israel
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4
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Guilcher SJ, Cadel L, He A, Cimino SR, Ahmed M, Ho CH, Hitzig SL, McCarthy LM, Patel T, Hahn-Goldberg S, Lofters AK, Packer TL. Medication self-management toolkits for adults with multiple sclerosis: A scoping review. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 10:100282. [PMID: 37396110 PMCID: PMC10314208 DOI: 10.1016/j.rcsop.2023.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 07/04/2023] Open
Abstract
Background Multiple sclerosis (MS) is an autoimmune disease that is often treated with multiple medications. Managing multiple medications, also known as polypharmacy, can be challenging for persons with MS. Toolkits are instructional resources designed to promote behaviour change. Toolkits may support medication self-management for adults with MS, as they have been useful in other populations with chronic conditions. Objective The main purpose of this review was to identify and summarize medication self-management toolkits for MS, as related to the design, delivery, components, and measures used to evaluate implementation and/or outcomes. Methods A scoping review was conducted following guidelines by JBI. Articles were included if they focused on adults (18 years or older) with MS. Results Six articles reporting on four unique toolkits were included. Most toolkits were technology-based, including mobile or online applications, with only one toolkit being paper-based. The toolkits varied in type, frequency, and duration of medication management support. Varying outcomes were also identified, but there were improvements reported in symptom management, medication adherence, decision-making, and quality of life. The six studies were quantitative in design, with no studies exploring the user experience from a qualitative or mixed-methods design. Conclusions There is limited research on medication self-management toolkits among adults with MS. Future development, implementation, and evaluation mixed-methods research are needed to explore user experiences and overall design of toolkits.
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Affiliation(s)
- Sara J.T. Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S3M2, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario L5B1B8, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario M5G1V7, Canada
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario M2M2G1, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario M5T3M6, Canada
| | - Lauren Cadel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S3M2, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario L5B1B8, Canada
| | - Andrea He
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S3M2, Canada
| | - Stephanie R. Cimino
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S3M2, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario M5G1V7, Canada
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario M2M2G1, Canada
| | - Maham Ahmed
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S3M2, Canada
| | - Chester H. Ho
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Alberta, Edmonton, Alberta T6G2G4, Canada
| | - Sander L. Hitzig
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario M5G1V7, Canada
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario M2M2G1, Canada
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario M5G1V7, Canada
| | - Lisa M. McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S3M2, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario L5B1B8, Canada
- School of Pharmacy, University of Waterloo, Kitchener, Ontario N2G 1C5, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario M5G1V7, Canada
- Women's College Research Institute, Toronto, Ontario M5G1N8, Canada
| | - Tejal Patel
- School of Pharmacy, University of Waterloo, Kitchener, Ontario N2G 1C5, Canada
- Schlegel-University of Waterloo Research Institute of Aging, Waterloo, Ontario N2J0E2, Canada
| | - Shoshana Hahn-Goldberg
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S3M2, Canada
- OpenLab, University Health Network, Toronto, Ontario M5G2C4, Canada
| | - Aisha K. Lofters
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario M5G1V7, Canada
- Women's College Research Institute, Toronto, Ontario M5G1N8, Canada
| | - Tanya L. Packer
- Schools of Occupational Therapy and Health Administration, Dalhousie University, Halifax, Nova Scotia B3H4R2, Canada
- Department of Nursing, Umeå University, Umeå, Sweden
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5
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Gromisch ES, Ehde DM, Neto LO, Haselkorn JK, Agresta T, Gokhale SS, Turner AP. Using participatory action research to develop a new self-management program: Results from the design stage of Managing My MS My Way. Mult Scler Relat Disord 2023; 74:104720. [PMID: 37084496 DOI: 10.1016/j.msard.2023.104720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/30/2023] [Accepted: 04/15/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Self-management programs have been used with success in several clinical populations, and there is a growing body of evidence to support their use among persons with multiple sclerosis (MS). This group aimed to develop a novel self-management program, Managing My MS My Way (M4W), which is based in social cognitive theory and contains evidence-based strategies that have been shown to be effective for persons with MS. Furthermore, persons with MS would serve as stakeholders throughout the development process to ensure that the program would be useful and encourage adoption. This paper outlines the initial development stages of M4W, including determining 1) stakeholders' interest in a self-management program, 2) the general focus of the program, 3) the delivery method of the program, 4) the content of the program, and 5) potential barriers and adaptations. METHODS A three-stage study consisting of an anonymous survey (n = 187) to determine interest, topic, and delivery format; semi-structured interviews (n = 6) to follow-up on the survey results; and semi-structured interviews (n = 10) to refine the content and identify barriers. RESULTS Over 80% of survey participants were somewhat or very interested in a self-management program. Fatigue was the topic with the greatest amount of interest (64.7%). An internet-based program (e.g., mobile health or mHealth) was the most preferred delivery method (37.4%), with the first group of stakeholders proposing a module-based system with an initial in-person orientation session. The second group of stakeholders were overall enthusiastic about the program, giving moderate to high confidence scores for each of the proposed interventional strategies. Suggestions included skipping sections that were not applicable to them, setting reminders, and seeing their progress (e.g., visualizing their fatigue scores as they move through the program). In addition, stakeholders recommended larger font sizes and speech-to-text entry. CONCLUSIONS Input from the stakeholders has been incorporated into the prototype of M4W. The next steps will be to test this prototype with another group of stakeholders to assess its initial usability and identify issues before developing the functional prototype.
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Affiliation(s)
- Elizabeth S Gromisch
- Mandell Center for Multiple Sclerosis, Mount Sinai Rehabilitation Hospital, Trinity Health Of New England, 490 Blue Hills Avenue, Hartford, CT 06112, USA; Department of Rehabilitative Medicine, Frank H. Netter MD School of Medicine at Quinnipiac University, 370 Bassett Road, North Haven, CT 06473, USA; Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, 370 Bassett Road, North Haven, CT 06473, USA; Department of Neurology, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT 06030, USA.
| | - Dawn M Ehde
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
| | - Lindsay O Neto
- Mandell Center for Multiple Sclerosis, Mount Sinai Rehabilitation Hospital, Trinity Health Of New England, 490 Blue Hills Avenue, Hartford, CT 06112, USA; Department of Rehabilitative Medicine, Frank H. Netter MD School of Medicine at Quinnipiac University, 370 Bassett Road, North Haven, CT 06473, USA
| | - Jodie K Haselkorn
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA; Multiple Sclerosis Center of Excellence West, Veterans Affairs, 1660 South Columbian Way, Seattle, WA 98108, USA; Rehabilitation Care Service, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Epidemiology, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
| | - Thomas Agresta
- Department of Family Medicine, University of Connecticut Health Center, 99 Woodland Street, Hartford, CT 06105, USA; Center for Quantitative Medicine, University of Connecticut Health Center, 195 Farmington Avenue, Farmington, CT 06032, USA
| | - Swapna S Gokhale
- Department of Computer Science and Engineering, University of Connecticut, Storrs, CT, 06269, USA
| | - Aaron P Turner
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA; Multiple Sclerosis Center of Excellence West, Veterans Affairs, 1660 South Columbian Way, Seattle, WA 98108, USA; Rehabilitation Care Service, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA
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6
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Keogh A, Alcock L, Brown P, Buckley E, Brozgol M, Gazit E, Hansen C, Scott K, Schwickert L, Becker C, Hausdorff JM, Maetzler W, Rochester L, Sharrack B, Vogiatzis I, Yarnall A, Mazzà C, Caulfield B. Acceptability of wearable devices for measuring mobility remotely: Observations from the Mobilise-D technical validation study. Digit Health 2023; 9:20552076221150745. [PMID: 36756644 PMCID: PMC9900162 DOI: 10.1177/20552076221150745] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 12/26/2022] [Indexed: 02/05/2023] Open
Abstract
Background This study aimed to explore the acceptability of a wearable device for remotely measuring mobility in the Mobilise-D technical validation study (TVS), and to explore the acceptability of using digital tools to monitor health. Methods Participants (N = 106) in the TVS wore a waist-worn device (McRoberts Dynaport MM + ) for one week. Following this, acceptability of the device was measured using two questionnaires: The Comfort Rating Scale (CRS) and a previously validated questionnaire. A subset of participants (n = 36) also completed semi-structured interviews to further determine device acceptability and to explore their opinions of the use of digital tools to monitor their health. Questionnaire results were analysed descriptively and interviews using a content analysis. Results The device was considered both comfortable (median CRS (IQR; min-max) = 0.0 (0.0; 0-20) on a scale from 0-20 where lower scores signify better comfort) and acceptable (5.0 (0.5; 3.0-5.0) on a scale from 1-5 where higher scores signify better acceptability). Interviews showed it was easy to use, did not interfere with daily activities, and was comfortable. The following themes emerged from participants' as being important to digital technology: altered expectations for themselves, the use of technology, trust, and communication with healthcare professionals. Conclusions Digital tools may bridge existing communication gaps between patients and clinicians and participants are open to this. This work indicates that waist-worn devices are supported, but further work with patient advisors should be undertaken to understand some of the key issues highlighted. This will form part of the ongoing work of the Mobilise-D consortium.
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Affiliation(s)
- Alison Keogh
- Insight Centre for Data Analytics, O’Brien Science Centre,
University
College Dublin, Dublin, Ireland,School of Public Health, Physiotherapy and Sports Science,
University
College Dublin, Dublin, Ireland,Alison Keogh, Insight Centre for Data
Analytics, 3rd Floor Science Centre East, University College Dublin, Ireland
| | - Lisa Alcock
- Translational and Clinical Research Institute, Faculty of Medical
Sciences, Newcastle
University, Newcastle upon Tyne, UK
| | - Philip Brown
- Physiotherapy
Department, The Newcastle Upon Tyne Hospitals NHS Foundation
Trust, Newcastle Upon Tyne, UK
| | - Ellen Buckley
- INSIGNEO Institute for in silico Medicine,
The University
of Sheffield, Sheffield, UK,Department of Mechanical Engineering,
The University
of Sheffield, Sheffield, UK
| | - Marina Brozgol
- Center for the Study of Movement, Cognition and Mobility,
Neurological Institute, Tel Aviv Sourasky Medical
Center, Tel Aviv, Israel
| | - Eran Gazit
- Center for the Study of Movement, Cognition and Mobility,
Neurological Institute, Tel Aviv Sourasky Medical
Center, Tel Aviv, Israel
| | - Clint Hansen
- Department of Neurology, University Medical Center Schleswig-Holstein
Campus Kiel, Kiel, Germany
| | - Kirsty Scott
- INSIGNEO Institute for in silico Medicine,
The University
of Sheffield, Sheffield, UK,Department of Mechanical Engineering,
The University
of Sheffield, Sheffield, UK
| | - Lars Schwickert
- Gesellschaft für Medizinische Forschung,
Robert-Bosch
Foundation GmbH, Stuttgart, Germany
| | - Clemens Becker
- Gesellschaft für Medizinische Forschung,
Robert-Bosch
Foundation GmbH, Stuttgart, Germany
| | - Jeffrey M. Hausdorff
- Center for the Study of Movement, Cognition and Mobility,
Neurological Institute, Tel Aviv Sourasky Medical
Center, Tel Aviv, Israel,Department of Physical Therapy, Sackler Faculty of Medicine &
Sagol School of Neuroscience, Tel Aviv
University, Tel Aviv, Israel
| | - Walter Maetzler
- Department of Neurology, University Medical Center Schleswig-Holstein
Campus Kiel, Kiel, Germany
| | - Lynn Rochester
- Translational and Clinical Research Institute, Faculty of Medical
Sciences, Newcastle
University, Newcastle upon Tyne, UK,Physiotherapy
Department, The Newcastle Upon Tyne Hospitals NHS Foundation
Trust, Newcastle Upon Tyne, UK
| | - Basil Sharrack
- Department of Neuroscience and Sheffield NIHR Translational
Neuroscience BRC, Sheffield
Teaching Hospitals NHS Foundation Trust,
Sheffield, UK
| | - Ioannis Vogiatzis
- Department of Sport, Exercise and Rehabilitation,
Northumbria
University Newcastle, Newcastle upon Tyne,
UK
| | - Alison Yarnall
- Translational and Clinical Research Institute, Faculty of Medical
Sciences, Newcastle
University, Newcastle upon Tyne, UK
| | - Claudia Mazzà
- INSIGNEO Institute for in silico Medicine,
The University
of Sheffield, Sheffield, UK,Department of Mechanical Engineering,
The University
of Sheffield, Sheffield, UK
| | - Brian Caulfield
- Insight Centre for Data Analytics, O’Brien Science Centre,
University
College Dublin, Dublin, Ireland,School of Public Health, Physiotherapy and Sports Science,
University
College Dublin, Dublin, Ireland
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7
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Giovannoni G, Alvarez E, Tutton E, Hoffmann O, Xu Y, Vermersch P, Oreja-Guevara C, Trojano M, Gold R, Robles-Cedeño R, Khwaja M, Stadler B, Vandercappellen J, Ziemssen T. Development and usability testing of your MS questionnaire: A patient-based digital tool to monitor symptoms of multiple sclerosis. Digit Health 2023; 9:20552076231173531. [PMID: 37205165 PMCID: PMC10185975 DOI: 10.1177/20552076231173531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 04/14/2023] [Indexed: 05/21/2023] Open
Abstract
Objectives We describe the development of Your Multiple Sclerosis Questionnaire and present the real-world usability testing results of Your Multiple Sclerosis Questionnaire. Methods The Your Multiple Sclerosis Questionnaire tool was developed in four stages to collect feedback from people living with MS (plwMS), patient organizations, and clinicians on content, format, and applicability. To assess its usability, 13 clinicians across 7 countries completed an online survey after using the tool with plwMS in a total of 261 consultations from September, 2020 to July, 2021. Results The initial Your Multiple Sclerosis Questionnaire version was based on findings from previous research developing MSProDiscuss™, a clinician-completed tool. Subsequently, insights from plwMS obtained during cognitive debriefing, patient councils and advisory boards led to changes including the addition of mood and sexual problems and the definition of relapse. All 13 clinicians completed the individual survey, whereas 10 clinicians completed the final survey. Clinicians "strongly agreed" or "agreed" that Your Multiple Sclerosis Questionnaire was easy to use and understand (98.5%; 257/261 patient consultations). The clinicians were willing to use the tool again with the same patient (98.1%; 256/261 patient consultations). All clinicians who completed the final survey (100%; 10/10) reported the tool to have a positive influence on their clinical practice, helped patients engage with their MS, facilitated discussion with patients, and complemented neurological assessment. Conclusion Your Multiple Sclerosis Questionnaire benefits both plwMS and clinicians by facilitating a structured discussion and engaging the plwMS to self-monitor and self-manage. Your Multiple Sclerosis Questionnaire is compatible with telemedicine practice and integration of the tool into electronic health records would enable tracking of the disease evolution and individual monitoring of MS symptoms over time.
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Affiliation(s)
- Gavin Giovannoni
- Blizard Institute, Barts and The London
School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | | | - Olaf Hoffmann
- Department of Neurology, Alexianer St
Josefs Hospital, Potsdam, Germany
- Brandenburg Medical School Theodor
Fontane, Neuruppin, Germany
| | - Yan Xu
- Multiple Sclerosis Center, Department
of Neurology, Peking Union Medical College Hospital, Peking Union Medical College,
Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Patrick Vermersch
- University of Lille, Inserm UMR U1172
LilNCog, CHU Lille, FHU Precise, Lille, France
| | | | - Maria Trojano
- Department of Basic Medical Science,
Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Ralf Gold
- Department of Neurology, St
Josef-Hospital/Ruhr-University Bochum, Bochum, Germany
| | | | | | | | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience,
Department of Neurology, Carl Gustav Carus University Clinic, Technische Universität
Dresden, Dresden, Germany
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8
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Sieber C, Haag C, Polhemus A, Sylvester R, Kool J, Gonzenbach R, von Wyl V. Feasibility and scalability of a fitness tracker study: Results from a longitudinal analysis of persons with multiple sclerosis. Front Digit Health 2023; 5:1006932. [PMID: 36926468 PMCID: PMC10012422 DOI: 10.3389/fdgth.2023.1006932] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 02/06/2023] [Indexed: 03/08/2023] Open
Abstract
Background Consumer-grade fitness trackers offer exciting opportunities to study persons with chronic diseases in greater detail and in their daily-life environment. However, attempts to bring fitness tracker measurement campaigns from tightly controlled clinical environments to home settings are often challenged by deteriorating study compliance or by organizational and resource limitations. Objectives By revisiting the study design and patient-reported experiences of a partly remote study with fitness trackers (BarKA-MS study), we aimed to qualitatively explore the relationship between overall study compliance and scalability. On that account, we aimed to derive lessons learned on strengths, weaknesses, and technical challenges for the conduct of future studies. Methods The two-phased BarKA-MS study employed Fitbit Inspire HR and electronic surveys to monitor physical activity in 45 people with multiple sclerosis in a rehabilitation setting and in their natural surroundings at home for up to 8 weeks. We examined and quantified the recruitment and compliance in terms of questionnaire completion and device wear time. Furthermore, we qualitatively evaluated experiences with devices according to participants' survey-collected reports. Finally, we reviewed the BarKA-MS study conduct characteristics for its scalability according to the Intervention Scalability Assessment Tool checklist. Results Weekly electronic surveys completion reached 96%. On average, the Fitbit data revealed 99% and 97% valid wear days at the rehabilitation clinic and in the home setting, respectively. Positive experiences with the device were predominant: only 17% of the feedbacks had a negative connotation, mostly pertaining to perceived measurement inaccuracies. Twenty-five major topics and study characteristics relating to compliance were identified. They broadly fell into the three categories: "effectiveness of support measures", "recruitment and compliance barriers", and "technical challenges". The scalability assessment revealed that the highly individualized support measures, which contributed greatly to the high study compliance, may face substantial scalability challenges due to the strong human involvement and limited potential for standardization. Conclusion The personal interactions and highly individualized participant support positively influenced study compliance and retention. But the major human involvement in these support actions will pose scalability challenges due to resource limitations. Study conductors should anticipate this potential compliance-scalability trade-off already in the design phase.
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Affiliation(s)
- Chloé Sieber
- Institute for Implementation Science in Health Care, Faculty of Medicine, University of Zürich, Zürich, Switzerland.,Epidemiology and Biostatistics and Prevention Institute, Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Christina Haag
- Institute for Implementation Science in Health Care, Faculty of Medicine, University of Zürich, Zürich, Switzerland.,Epidemiology and Biostatistics and Prevention Institute, Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Ashley Polhemus
- Epidemiology and Biostatistics and Prevention Institute, Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Ramona Sylvester
- Research Department Physiotherapy, Rehabilitation Centre, Valens, Switzerland
| | - Jan Kool
- Research Department Physiotherapy, Rehabilitation Centre, Valens, Switzerland
| | - Roman Gonzenbach
- Research Department Physiotherapy, Rehabilitation Centre, Valens, Switzerland
| | - Viktor von Wyl
- Institute for Implementation Science in Health Care, Faculty of Medicine, University of Zürich, Zürich, Switzerland.,Epidemiology and Biostatistics and Prevention Institute, Faculty of Medicine, University of Zürich, Zürich, Switzerland
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9
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Nittas V, Zecca C, Kamm CP, Kuhle J, Chan A, von Wyl V. Digital health for chronic disease management: An exploratory method to investigating technology adoption potential. PLoS One 2023; 18:e0284477. [PMID: 37053272 PMCID: PMC10101441 DOI: 10.1371/journal.pone.0284477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/31/2023] [Indexed: 04/15/2023] Open
Abstract
INTRODUCTION The availability of consumer-facing health technologies for chronic disease management is skyrocketing, yet most are limited by low adoption rates. Improving adoption requires a better understanding of a target population's previous exposure to technology. We propose a low-resource approach of capturing and clustering technology exposure, as a mean to better understand patients and target health technologies. METHODS Using Multiple Sclerosis (MS) as a case study, we applied exploratory multivariate factorial analyses to survey data from the Swiss MS Registry. We calculated individual-level factor scorings, aiming to investigate possible technology adoption clusters with similar digital behavior patterns. The resulting clusters were transformed using radar and then compared across sociodemographic and health status characteristics. RESULTS Our analysis included data from 990 respondents, resulting in three clusters, which we defined as the (1) average users, (2) health-interested users, and (3) low frequency users. The average user uses consumer-facing technology regularly, mainly for daily, regular activities and less so for health-related purposes. The health-interested user also uses technology regularly, for daily activities as well as health-related purposes. The low-frequency user uses technology infrequently. CONCLUSIONS Only about 10% of our sample has been regularly using (adopting) consumer-facing technology for MS and health-related purposes. That might indicate that many of the current consumer-facing technologies for MS are only attractive to a small proportion of patients. The relatively low-resource exploratory analyses proposed here may allow for a better characterization of prospective user populations and ultimately, future patient-facing technologies that will be targeted to a broader audience.
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Affiliation(s)
- Vasileios Nittas
- Biostatistics & Prevention Institute, Epidemiology, University of Zurich, Zurich, Switzerland
- Department of Health Sciences and Technology, Health Ethics and Policy Lab, ETH Zurich, Zurich, Switzerland
| | - Chiara Zecca
- Department of Neurology, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Christian P Kamm
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Neurology and Neurorehabilitation Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Viktor von Wyl
- Biostatistics & Prevention Institute, Epidemiology, University of Zurich, Zurich, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
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10
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Salimzadeh Z, Damanabi S, Ferdousi R, Shaafi S, Kalankesh LR. A mobile app (IDoThis) for multiple sclerosis self-management: development and initial evaluation. BMC Med Inform Decis Mak 2022; 22:328. [PMID: 36514043 PMCID: PMC9745928 DOI: 10.1186/s12911-022-02078-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is one of the most common neurological disorders worldwide, and self-management is considered an essential dimension in its control. This study aimed to develop an evidence-based mobile application for MS self-management and evaluate it. METHODS This study was undertaken in three phases: content preparation, design, and evaluation. In the content preparation phase, the researchers extracted MS self-management needs based on related guidelines and guides, existing apps on the self-management of MS, and the field experts' views and confirmation. The design phase was conducted in five steps: defining app functionalities, depicting the wireframe, preparing the media, coding the app, and testing the app's performance. The app was developed using the Android Studio environment and Java programming language for the Android operating system. The performance of the developed app was tested separately in several turns, and existing defects were corrected in each turn. Finally, after using the app for three weeks, the app was evaluated for its short-term impact on MS management and user-friendliness using a researcher-constructed questionnaire from participants' (N = 20) perspectives. RESULTS The IDoThis app is an offline app for people with MS that includes five main modules: three modules for training or informing users about different aspects of MS, one module for monitoring the user's MS condition, and a reporting module. In the initial evaluation of the app, 75% (n = 15) of participants mentioned that using this app improved MS self-management status at intermediate and higher levels, but 25% (n = 5) of the participants mentioned that the effect of using the app on the self-management tasks was low or was very low. The majority of users rated the user-friendliness of the app as high. The users found the sections "exercises in MS" and "monitoring of MS status" beneficial to their self-management. Still, the fatigue and sleep management sections are needed to meet users' expectations. CONCLUSION Using IDoThis app as a self-management tool for individuals with MS appears feasible, that can meet the need for a free and accessible self-management tool for individuals with MS. Future directions should consider the users' fatigue and sleep management expectations.
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Affiliation(s)
- Zeinab Salimzadeh
- grid.412888.f0000 0001 2174 8913Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Daneshgah Ave, Tabriz, Iran
| | - Shahla Damanabi
- grid.412888.f0000 0001 2174 8913Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Daneshgah Ave, Tabriz, Iran
| | - Reza Ferdousi
- grid.412888.f0000 0001 2174 8913Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Daneshgah Ave, Tabriz, Iran
| | - Sheida Shaafi
- grid.412888.f0000 0001 2174 8913Department of Neurology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila R. Kalankesh
- grid.412888.f0000 0001 2174 8913Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Daneshgah Ave, Tabriz, Iran ,grid.412888.f0000 0001 2174 8913Health Care Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran ,grid.412888.f0000 0001 2174 8913Research Center of Psychiatry and Behavioural Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
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11
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Ziemssen T, Vandercappellen J, Jordan Mondragon V, Giovannoni G. MSProDiscuss™ Clinical Decision Support Tool for Identifying Multiple Sclerosis Progression. J Clin Med 2022; 11:jcm11154401. [PMID: 35956018 PMCID: PMC9369349 DOI: 10.3390/jcm11154401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/24/2022] [Accepted: 07/20/2022] [Indexed: 12/10/2022] Open
Abstract
This article describes the rationale for the development of the MSProDiscuss™ clinical decision support (CDS) tool, its development, and insights into how it can help neurologists improve care for patients with multiple sclerosis (MS). MS is a progressive disease characterized by heterogeneous symptoms and variable disease course. There is growing consensus that MS exists on a continuum, with overlap between relapsing–remitting and secondary progressive phenotypes. Evidence demonstrates that neuroaxonal loss occurs from the outset, that progression can occur independent of relapse activity, and that continuous underlying pathological processes may not be reflected by inflammatory activity indicative of the patient’s immune response. Early intervention can benefit patients, and there is a need for a tool that assists physicians in rapidly identifying subtle signs of MS progression. MSProDiscuss, developed with physicians and patients, facilitates a structured approach to patient consultations. It analyzes multidimensional data via an algorithm to estimate the likelihood of progression (the MSProDiscuss score), the contribution of various symptoms, and the impact of symptoms on daily living, enabling a more personalized approach to treatment and disease management. Data from CDS tools such as MSProDiscuss offer new insights into disease course and facilitate informed decision-making and a holistic approach to MS patient care.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, Carl Gustav Carus University Clinic, Fetscherstraße. 74, 01307 Dresden, Germany
- Correspondence:
| | | | | | - Gavin Giovannoni
- Blizard Institute, The Faculty of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK;
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12
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Thomas S, Pulman A, Dogan H, Jiang N, Passmore D, Pretty K, Fairbanks B, Davies Smith A, Thomas PW. Creating a Digital Toolkit to Reduce Fatigue and Promote Quality of Life in Multiple Sclerosis: Participatory Design and Usability Study. JMIR Form Res 2021; 5:e19230. [PMID: 34889744 PMCID: PMC8704114 DOI: 10.2196/19230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/29/2020] [Accepted: 09/06/2021] [Indexed: 11/21/2022] Open
Abstract
Background Fatigue is one of the most common and debilitating symptoms of multiple sclerosis (MS), experienced by more than 80% of people with MS. FACETS (Fatigue: Applying Cognitive Behavioral and Energy Effectiveness Techniques to Lifestyle) is an evidence-based, face-to-face, 6-session group fatigue management program for people with MS. Homework tasks are an integral part of FACETS and are currently undertaken in a paper-based form. Feedback from a consultation undertaken with FACETS attendees and health care professionals with experience in delivering the FACETS program suggested that being able to complete the homework tasks digitally would be desirable, potentially enhancing engagement and adherence and enabling on-the-go access to fit into busy lifestyles. Relative to other long-term conditions, there are few apps specifically for MS and, of those available, many have been developed with little or no input from people with MS. Objective The purpose of this mixed methods study was to create a digital toolkit comprising the homework tasks (eg, activity diary, goal planner, thought diary) of the FACETS program for people with MS, considering end users’ unique requirements throughout the design, build, prototyping, and testing stages. Methods Phase 1 involved the elicitation of detailed user requirements for the toolkit via 2 focus groups with previous attendees of FACETS (n=3 and n=6) and wireframing. Phase 2 involved supervised usability testing with people with MS (n=11) with iterative prototyping. The usability sessions involved going through test scenarios using the FACETS toolkit on an Android test phone with video capture and concurrent think-aloud followed by completion of the System Usability Scale (SUS) and a semistructured interview collecting feedback about design, content, and functionality. Results The mean SUS score for the digital toolkit was 74.3 (SD 16.8, 95% CI 63.2-85.6; range 37.5-95), which equates to an adjective rating of good and a B grade (70th-79th percentile range) on the Sauro-Lewis curved grading scale. A number of usability and design issues (such as simplifying overall screen flow to better meet users’ needs) and suggestions for improvements (such as using location-based services and displaying personalized information and progress via a central dashboard) were addressed and implemented during the usability testing cycle. Conclusions This work highlights the importance of the participation of people with MS across the entire development cycle, working to a human-centered design methodology to enable a considered and MS-centered solution to be developed. Continued horizon scanning for emergent technological enhancements will enable us to identify opportunities for further improvements to the FACETS toolkit prior to launch. The toolkit supports self-monitoring and management of fatigue and has potential applicability to other long-term conditions where fatigue is a significant issue.
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Affiliation(s)
- Sarah Thomas
- Bournemouth University Clinical Research Unit, Department of Medical Science & Public Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, United Kingdom
| | - Andy Pulman
- Bournemouth University Clinical Research Unit, Department of Medical Science & Public Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, United Kingdom
| | - Huseyin Dogan
- Department of Computing & Informatics, Faculty of Science & Technology, Bournemouth University, Bournemouth, United Kingdom
| | - Nan Jiang
- Department of Computing & Informatics, Faculty of Science & Technology, Bournemouth University, Bournemouth, United Kingdom
| | - David Passmore
- Department of Computing & Informatics, Faculty of Science & Technology, Bournemouth University, Bournemouth, United Kingdom
| | - Keith Pretty
- Department of Computing & Informatics, Faculty of Science & Technology, Bournemouth University, Bournemouth, United Kingdom
| | - Beth Fairbanks
- Department of Computing & Informatics, Faculty of Science & Technology, Bournemouth University, Bournemouth, United Kingdom
| | - Angela Davies Smith
- Bristol & Avon Multiple Sclerosis Centre, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Peter W Thomas
- Bournemouth University Clinical Research Unit, Department of Medical Science & Public Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, United Kingdom
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13
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Gromisch ES, DeLuca J, Benedict RH, Foley FW. Managing Cognitive Dysfunction in Multiple Sclerosis: A Snapshot of Changes in Screening, Assessment, and Treatment Practices. Int J MS Care 2021; 24:104-109. [DOI: 10.7224/1537-2073.2020-139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Abstract
Background: Cognitive dysfunction is prevalent in multiple sclerosis (MS) and can have a negative effect on several aspects of the daily lives of persons with MS. In 2010, members of the Consortium of Multiple Sclerosis Centers (CMSC) were surveyed to understand MS clinicians’ screening, assessment, and treatment practices for cognitive problems. Given the advancements made in the field in the past decade, it was deemed time to reevaluate how cognitive dysfunction is managed in the clinical setting.
Methods: An online questionnaire was completed by 56 CMSC members in which they were asked to describe their clinical practices, procedures for screening and further evaluation, and treatment recommendations for cognitive dysfunction. Participants were also asked whether their practice had changed in terms of the number of cognitive screenings, prescriptions for cognitive problems, and referrals for neuropsychological assessment and cognitive remediation in the past 5 years to allow for clinicians who had not been in practice for 10 years.
Results: Participants reported an increase in the number of cognitive screenings and referrals for neuropsychological assessments and cognitive remediation during the past 5 years. Compared with 2010, participants endorsed greater use of person-administered screening measures, such as the Symbol Digit Modalities Test, and fewer prescriptions for medications to improve cognitive functioning.
Conclusions: Clinical practices are becoming more in line with the literature, with increased use of cognitive screening and remediation. Continued attention to cognitive problems will be an ongoing important component of MS-related care.
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Affiliation(s)
- Elizabeth S. Gromisch
- From the Mandell Center for Multiple Sclerosis, Mount Sinai Rehabilitation Hospital, Trinity Health Of New England, Hartford, CT, USA (ESG); Department of Neurology, University of Connecticut School of Medicine, Farmington, CT, USA (ESG); Departments of Rehabilitative Medicine and Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT, USA (ESG); Kessler
| | - John DeLuca
- From the Mandell Center for Multiple Sclerosis, Mount Sinai Rehabilitation Hospital, Trinity Health Of New England, Hartford, CT, USA (ESG); Department of Neurology, University of Connecticut School of Medicine, Farmington, CT, USA (ESG); Departments of Rehabilitative Medicine and Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT, USA (ESG); Kessler
| | - Ralph H.B. Benedict
- From the Mandell Center for Multiple Sclerosis, Mount Sinai Rehabilitation Hospital, Trinity Health Of New England, Hartford, CT, USA (ESG); Department of Neurology, University of Connecticut School of Medicine, Farmington, CT, USA (ESG); Departments of Rehabilitative Medicine and Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT, USA (ESG); Kessler
| | - Frederick W. Foley
- From the Mandell Center for Multiple Sclerosis, Mount Sinai Rehabilitation Hospital, Trinity Health Of New England, Hartford, CT, USA (ESG); Department of Neurology, University of Connecticut School of Medicine, Farmington, CT, USA (ESG); Departments of Rehabilitative Medicine and Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT, USA (ESG); Kessler
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