The reliability of the MSFC and its components

Effects of backward walking training on balance, gait, and functional mobility in people with multiple sclerosis: A randomized controlled study

BACKGROUND

Backward walking training (BWT) can have a positive effect on balance, gait, and functional mobility in neurological diseases; however, the effectiveness of BWT has not been examined in multiple sclerosis (MS). Therefore, the study aimed to investigate the effects of BWT on balance, gait, and functional mobility in people with MS (PwMS).

METHOD

Nineteen PwMS were randomly allocated to either the experimental group (n=10) and the control group (n=9). The experimental group received BWT in addition to conventional walking training (CWT) while the control group only received CWT. Both groups performed training three times a week for 8 weeks. Participants were assessed with the Berg Balance Scale (BBS), four square step test (FSST), activities-specific balance confidence scale (ABC), timed 25-foot walk test (T25FW), dynamic gait index (DGI), 3-meter backward walk test (3MBWT), Multiple Sclerosis Walking Scale-12 (MSWS-12), and timed up and go test (TUG) before and after training.

RESULTS

After training, both groups showed significant improvements on the T25FW, and TUG (p<0.05) while only the experimental group showed significant improvements on the BBS, FSST, ABC, DGI, 3MBWT, and MSWS-12 (p<0.05). The experimental group significantly improved more than the control group in all outcomes (p<0.05) except for the T25FW (p=0.202).

CONCLUSION

BWT in addition to CWT is an effective way to improve balance, gait, and functional mobility for PwMS. These results suggest that BWT may be a potentially useful treatment approach when added to CWT in the rehabilitation of MS.

Neuromodulation-induced prehabilitation to leverage neuroplasticity before brain tumor surgery: a single-cohort feasibility trial protocol

Introduction

Neurosurgery for brain tumors needs to find a complex balance between the effective removal of targeted tissue and the preservation of surrounding brain areas. Neuromodulation-induced cortical prehabilitation (NICP) is a promising strategy that combines temporary inhibition of critical areas (virtual lesion) with intensive behavioral training to foster the activation of alternative brain resources. By progressively reducing the functional relevance of targeted areas, the goal is to facilitate resection with reduced risks of neurological sequelae. However, it is still unclear which modality (invasive vs. non-invasive neuromodulation) and volume of therapy (behavioral training) may be optimal in terms of feasibility and efficacy.

Methods and analysis

Patients undertake between 10 and 20 daily sessions consisting of neuromodulation coupled with intensive task training, individualized based on the target site and neurological functions at risk of being compromised. The primary outcome of the proposed pilot, single-cohort trial is to investigate the feasibility and potential effectiveness of a non-invasive NICP protocol on neuroplasticity and post-surgical outcomes. Secondary outcomes investigating longitudinal changes (neuroimaging, neurophysiology, and clinical) are measured pre-NICP, post-NICP, and post-surgery.

Ethics and dissemination

Ethics approval was obtained from the Research Ethical Committee of Fundació Unió Catalana d'Hospitals (approval number: CEI 21/65, version 1, 13/07/2021). The results of the study will be submitted to a peer-reviewed journal and presented at scientific congresses.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05844605.

Neurodegeneration and its potential markers in the diagnosing of secondary progressive multiple sclerosis. A review

Approximately 70% of relapsing-remitting multiple sclerosis (RRMS) patients will develop secondary progressive multiple sclerosis (SPMS) within 10-15 years. This progression is characterized by a gradual decline in neurological functionality and increasing limitations of daily activities. Growing evidence suggests that both inflammation and neurodegeneration are associated with various pathological processes throughout the development of MS; therefore, to delay disease progression, it is critical to initiate disease-modifying therapy as soon as it is diagnosed. Currently, a diagnosis of SPMS requires a retrospective assessment of physical disability exacerbation, usually over the previous 6-12 months, which results in a delay of up to 3 years. Hence, there is a need to identify reliable and objective biomarkers for predicting and defining SPMS conversion. This review presents current knowledge of such biomarkers in the context of neurodegeneration associated with MS, and SPMS conversion.

The TRACK-MS Test Battery: A Very Brief Tool to Track Multiple Sclerosis-Related Cognitive Impairment

Tracking cognition in patients with multiple sclerosis (MS) is important for detection of disease progression but it is often not performed in routine settings due to time constraints. This exploratory cohort study aims to develop a very brief repeatable tracking tool with comparable test quality criteria to the current gold standard, the Brief International Cognitive Assessment for MS (BICAMS). The study included 88 participants (22 healthy controls, 66 MS patients) who were examined at baseline and at one-year follow-up. As a validity criterion for the six administered cognitive tests, we assessed the difference between MS patients and HC, and the correlation with MS-related disability. Combining the two tests with the highest validity-the Controlled Oral Word Association Test and Symbol Digit Modalities Test-yielded an administration time of 5 min. Comparing this new TRACK-MS test battery with the 15 min BICAMS indicated that TRACK-MS showed larger differences between MS patients and healthy controls, a higher correlation with MS-related disability, smaller practice effects, and a good test-retest reliability. We provide evidence that TRACK-MS, although faster to administer, showed at least comparable quality criteria as the BICAMS. As the study was exploratory, replication of these results is necessary.

Menopausal symptoms and hormone therapy in women with multiple sclerosis: A baseline-controlled study

BACKGROUND

Depression, sleep disturbances, and cognitive difficulties impair the quality of life in people with multiple sclerosis (MS). Similar symptoms are also frequent during the menopausal transition. In clinical practice, it is important to consider the multifactorial causes of these overlapping symptoms and the potential benefits of menopausal hormone therapy (MHT). The objective of this study was to evaluate vasomotor symptoms (VMS), mood, sleep, and cognition of menopausal women with and without MS at baseline and during one year of MHT.

METHODS

In this prospective baseline-controlled study, peri- and early postmenopausal participants with (n=14) and without (n=13) MS received MHT containing 1 or 2 mg of estradiol and cyclical 10 mg dydrogesterone for one year. VMS frequency, depressive symptoms (measured by Beck Depression Inventory), insomnia severity (Insomnia Severity Index), and cognitive performance (Paced Auditory Serial Addition Test; PASAT, Symbol Digit Modalities Test; SDMT) were evaluated at baseline and at 3 and 12 months of treatment. Differences in the outcome measures between groups at baseline were assessed using the Mann-Whitney U test. Changes during follow-up compared to baseline within groups were evaluated by Wilcoxon Signed Ranks Test. P < 0.05 was considered for statistical significance. MS activity was monitored by clinical assessment and brain MRI at baseline and at 12 months.

RESULTS

Depressive symptoms were more common in MS group, while vasomotor and insomnia symptoms were equally common. During follow-up with MHT, VMS frequency decreased in both groups. Depressive symptoms decreased at 3 months (p = 0.031 with MS; p = 0.024 without MS) and the reduction was sustained at 12 months (p = 0.017; p = 0.042, respectively). Alleviation in insomnia symptoms was seen in participants without MS at 3 months (p = 0.029) and in those participants with MS suffering insomnia at baseline (p = 0.016 at 3 months; p = 0.047 at 12 months). Both groups improved their performance in PASAT, but no significant change was observed in SDMT. MS activity at baseline was mainly stable, and no increase in activity was detected during MHT.

CONCLUSION

Improvements in vasomotor, depressive, and insomnia symptoms observed during one year of MHT are encouraging and suggest that larger placebo-controlled studies of MHT in women with MS are warranted. Cognitive implications were inconclusive because the findings in PASAT likely result from practice effect. MHT did not show any adverse effect on MS activity and increasing safety data will hopefully facilitate patient recruitment for future studies.

Cerebellar Contributions to Motor and Cognitive Control in Multiple Sclerosis✰✰✰

OBJECTIVE

To evaluate relationships between specific cerebellar regions and common clinical measures of motor and cognitive function in persons with multiple sclerosis (PwMS).

DESIGN

Cross-sectional.

SETTING

Laboratory.

PARTICIPANTS

Twenty-nine PwMS and 28 age- and sex-matched controls without multiple sclerosis (MS) (N=57).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Both diffusion and lobule magnetic resonance imaging analyses and common clinical measures of motor and cognitive function were used to examine structure-function relationships in the cerebellum.

RESULTS

PwMS demonstrate significantly worse motor and cognitive function than controls, including weaker strength, slower walking, and poorer performance on the Symbol Digit Modalities Test, but demonstrate no differences in cerebellar volume. However, PwMS demonstrate significantly worse diffusivity (mean diffusivity: P=.0003; axial diffusivity: P=.0015; radial diffusivity: P=.0005; fractional anisotropy: P=.016) of the superior cerebellar peduncle, the primary output of the cerebellum. Increased volume of the motor lobules (I-V, VIII) was significantly related to better motor (P<.022) and cognitive (P=.046) performance, and increased volume of the cognitive lobules (VI-VII) was also related to better motor (P<.032) and cognitive (P=.008) performance, supporting the role of the cerebellum in both motor and cognitive functioning.

CONCLUSIONS

These data highlight the contributions of the cerebellum to both motor and cognitive function in PwMS. Using novel neuroimaging techniques to examine structure-function relationships in PwMS improves our understanding of individualized differences in this heterogeneous group and may provide an avenue for targeted, individualized rehabilitation aimed at improving cerebellar dysfunction in MS.

Reliability and agreement of the Nine Hole Peg Test in patients with unilateral spastic cerebral palsy

Upper extremity involvement is one of the most common motor impairments in children with unilateral spastic cerebral palsy (CP). One tool for the assessment of manual function in CP is the Nine Hole Peg Test (NHPT). However, the reliability of the NHPT in patients with unilateral CP is unknown. This study aimed to analyze the intra-rater inter-session reliability of the NHPT in unilateral spastic CP, for its use in clinical practice and research. A total of 27 participants with spastic unilateral CP were included. Reliability was verified by the intraclass correlation coefficient (ICC), standard error of measurement, and minimum detectable change. The agreement was analyzed by the Bland-Altman method. An excellent intra-rater reliability was observed for the non-affected side (ICC = 0.94) and the affected side (ICC = 0.96). The minimal detectable change was 4 and 12 s for the non-affected and affected side, respectively. There were no significant biases between repetitions.   Conclusions: The NHPT showed excellent intra-rater inter-session reliability in patients with spastic unilateral CP. In addition, the test shows adequate agreement and proportionally small errors to assess manual dexterity. What is Known: • The Nine Hole Peg Test (NHPT) is widely used to assess dexterity in patients with neurological conditions. • The NHPT has demonstrated appropriate measurement properties in healthy children and adults with neurological conditions. What is New: • The NHPT presents excellent reliability, small measurement errors, and adequate agreement for the assessment of patients with cerebral palsy. • The measurement error of the NHPT in unilateral cerebral palsy may be up to 13% of the total time to perform it.

Clinical and Paraclinical Biomarkers and the Hitches to Assess Conversion to Secondary Progressive Multiple Sclerosis: A Systematic Review

Conversion to secondary progressive (SP) course is the decisive factor for long-term prognosis in relapsing multiple sclerosis (MS), generally considered the clinical equivalent of progressive MS-associated neuroaxonal degeneration. Evidence is accumulating that both inflammation and neurodegeneration are present along a continuum of pathologic processes in all phases of MS. While inflammation is the prominent feature in early stages, its quality changes and relative importance to disease course decreases while neurodegenerative processes prevail with ongoing disease. Consequently, anti-inflammatory disease-modifying therapies successfully used in relapsing MS are ineffective in SPMS, whereas specific treatment for the latter is increasingly a focus of MS research. Therefore, the prevention, but also the (anticipatory) diagnosis of SPMS, is of crucial importance. The problem is that currently SPMS diagnosis is exclusively based on retrospectively assessing the increase of overt physical disability usually over the past 6–12 months. This inevitably results in a delay of diagnosis of up to 3 years resulting in periods of uncertainty and, thus, making early therapy adaptation to prevent SPMS conversion impossible. Hence, there is an urgent need for reliable and objective biomarkers to prospectively predict and define SPMS conversion. Here, we review current evidence on clinical parameters, magnetic resonance imaging and optical coherence tomography measures, and serum and cerebrospinal fluid biomarkers in the context of MS-associated neurodegeneration and SPMS conversion. Ultimately, we discuss the necessity of multimodal approaches in order to approach objective definition and prediction of conversion to SPMS.

Measuring Treatment Response in Progressive Multiple Sclerosis-Considerations for Adapting to an Era of Multiple Treatment Options

Disability in multiple sclerosis accrues predominantly in the progressive forms of the disease. While disease-modifying treatment of relapsing MS has drastically evolved over the last quarter-century, the development of efficient drugs for preventing or at least delaying disability in progressive MS has proven more challenging. In that way, many drugs (especially disease-modifying treatments) have been researched in the aspect of delaying disability progression in patients with a progressive course of the disease. While there are some disease-modifying treatments approved for progressive multiple sclerosis, their effect is moderate and limited mostly to patients with clinical and/or radiological signs of disease activity. Several phase III trials have used different primary outcomes with different time frames to define disease progression and to evaluate the efficacy of a disease-modifying treatment. The lack of sufficiently sensitive outcome measures could be a possible explanation for the negative clinical trials in progressive multiple sclerosis. On the other hand, even with a potential outcome measure that would be sensitive enough to determine disease progression and, thus, the efficacy or failure of a disease-modifying treatment, the question of clinical relevance remains unanswered. In this systematic review, we analyzed outcome measures and definitions of disease progression in phase III clinical trials in primary and secondary progressive multiple sclerosis. We discuss advantages and disadvantages of clinical and paraclinical outcome measures aiming for practical ways of combining them to detect disability progression more sensitively both in future clinical trials and current clinical routine.

Combining Magnetization Transfer Ratio MRI and Quantitative Measures of Walking Improves the Identification of Fallers in MS

Multiple sclerosis (MS) impacts balance and walking function, resulting in accidental falls. History of falls and clinical assessment are commonly used for fall prediction, yet these measures have limited predictive validity. Falls are multifactorial; consideration of disease-specific pathology may be critical for improving fall prediction in MS. The objective of this study was to examine the predictive value of clinical measures (i.e., walking, strength, sensation) and corticospinal tract (CST) MRI measures, both discretely and combined, to fall status in MS. Twenty-nine individuals with relapsing-remitting MS (mean ± SD age: 48.7 ± 11.5 years; 17 females; Expanded Disability Status Scale (EDSS): 4.0 (range 1-6.5); symptom duration: 11.9 ± 8.7 years; 14 fallers) participated in a 3T brain MRI including diffusion tensor imaging and magnetization transfer ratio (MTR) and clinical tests of walking, strength, sensation and falls history. Clinical measures of walking were significantly associated with CST fractional anisotropy and MTR. A model including CST MTR, walk velocity and vibration sensation explained >31% of the variance in fall status (R2 = 0.3181) and accurately distinguished 73.8% fallers, which was superior to stand-alone models that included only MRI or clinical measures. This study advances the field by combining clinical and MRI measures to improve fall prediction accuracy in MS.

Long-term worsening of different body functions in persons with progressive multiple sclerosis

Background

It is unclear whether EDSS is responsive to disability worsening in advanced MS.

Objective

To explore the dynamics of disability worsening in persons with advanced-stage MS (EDSS ≥5.5) using three disability worsening definitions (EDSS, Rivermead Mobility Index (RMI), 9-Hole Peg Test (9-HPT)).

Methods

EDSS-, RMI- and 9-HPT-based disability worsening were assessed over a minimum of two years in a cohort of 286 persons with advanced MS attending inpatient rehabilitation using Kaplan-Meier Curves and multivariable Cox regression. Furthermore, the correspondence between EDSS-, RMI- and 9-HPT-based disability worsening was analyzed.

Results

Disability progression was observed in 49% (9-HPT), 52% (EDSS) and 53% (RMI), with 9-HPT-based worsening slightly lagging behind. The Multiple Sclerosis Severity Score (MSSS) was the only consistent factor predicting disability worsening based on all three definitions (EDSS: hazard ratio 1.48 [1.30;1.68]; RMI: 1.12 [0.99;1.27]; 9-HPT: 1.36 [1.18;1.57]). Correspondence between EDSS and the other definitions (9-HPT and RMI) was 44.3% and 55.7% at time of EDSS progression and 65.1% and 72.5% overall, respectively.

Conclusion

In persons with advanced-stage MS, half still developed disability worsening in different functional systems over a median of 6 years. MSSS seems a valid predictor for disability worsening in all three outcome measures in advanced MS.

Reliability of Outcome Measures in Clinical Trials in Secondary Progressive Multiple Sclerosis

OBJECTIVE

To investigate the reliability of clinical outcomes in secondary progressive multiple sclerosis (SPMS) trials, we compared the frequency of progression and improvement events on different clinical outcome measures in the placebo arms of 2 large randomized controlled trial (RCT) datasets.

METHODS

Using original trial data from the placebo arms of IMPACT (International MS Secondary Progressive Avonex Controlled Trial) and ASCEND (A Clinical Study of the Efficacy of Natalizumab on Reducing Disability Progression in Participants With Secondary Progressive Multiple Sclerosis), 2 large RCTs in SPMS, we compared disability progression and similarly defined improvement with and without 3- or 6-month confirmation on the outcome measures Expanded Disability Status Scale (EDSS), Timed 25-Foot Walk (T25FW), 9-Hole Peg Test (9HPT), and their combinations.

RESULTS

In both datasets, the EDSS showed the highest rates of improvement over time, and the smallest difference between progression and improvement rates, followed by the T25FW and the 9HPT. For the T25FW and 9HPT, improvement rates were fairly stable over time and remained at below or around the 10% level. For the EDSS, improvement rates increased in parallel with disability progression rates.

CONCLUSIONS

All investigated outcome measures in SPMS showed some evidence of random variation and measurement error, the T25FW and 9HPT less so than the more established outcome EDSS. Our findings are relevant for the design and critical appraisal of trials in SPMS.

Effect of video-based exergaming on arm and cognitive function in persons with multiple sclerosis: A randomized controlled trial

BACKGROUND

Developments in rehabilitation technology such as video-based exergaming contributes to the treatment process as well as to increase the active participation of persons with multiple sclerosis (pwMS). The aim was to investigate the effect of video-based exergaming training on upper extremity and cognitive function as well as core stability, walking, depression, fatigue, and quality of life in pwMS.

METHODS

This randomized controlled trial included 60 pwMS who were randomly divided into three groups; video-based exergaming (n = 21), conventional rehabilitation (n = 19), and control groups (n = 20). The experimental groups received therapy sessions once a week for 8 weeks. All the participants were assessed at baseline and after 8 weeks. The outcome measures included upper extremity and cognitive functions as well as core stability, walking, depression, fatigue, and quality of life measures.

RESULTS

Significant improvements were observed in the primary outcome, measured by Nine-Hole Peg Test in the video-based exergaming [before= 25.8 (11.1) s; after= 22.3 (11.0) s] and conventional rehabilitation [before= 23.3 (8.1) s; after= 19.9 (3.8) s] groups (p < 0.05). Cognitive functions (with the exception of processing speed in the conventional rehabilitation group), most of the lower extremity functions, balance-related measures, fatigue and quality of life levels were significantly improved in the video-based exergaming and conventional rehabilitation groups, however, only the depression level was significantly decreased in the video-based exergaming (p < 0.05). Several significant differences were observed in the changes of the control group compared to the video-based exergaming and conventional rehabilitation groups (p < 0.05).

CONCLUSION

This study suggests that video-based exergaming is almost as effective as conventional rehabilitation regarding improving walking, upper and lower extremity functions, cognitive functions, fatigue, depression, and health-related quality of life in pwMS.

Measuring Hand Dexterity in People With Parkinson's Disease: Reliability of Pegboard Tests

IMPORTANCE

Knowledge regarding the reliability of pegboard tests when used to measure dexterity in people with Parkinson's disease (PD) is currently limited.

OBJECTIVE

To examine the test-retest and interrater reliability of the 9-Hole Peg Test (9HPT) and Purdue Pegboard Test (PPT) in people with PD.

DESIGN

Cross-sectional observational study. For test-retest reliability, tests were completed on 2 days, 1 wk apart, in the "on" phase and "end-of-dose" period of participants' medication cycle. For interrater reliability, occupational therapists and physical therapists rated prerecorded pegboard test performance of participants with PD.

SETTING

Test-retest reliability was determined in participants' homes or in a university department. Interrater reliability was determined in a university department or a hospital setting.

PARTICIPANTS

Test-retest reliability was determined with volunteers diagnosed with PD (N = 30). Interrater reliability was determined with a convenience sample of occupational and physical therapists (N = 11).

OUTCOMES AND MEASURES

The 9HPT and PPT are commonly used measures of manual dexterity.

RESULTS

PPT subtests showed higher test-retest reliability (intraclass correlation coefficients [ICCs] ≥ .90) in both phases of the medication cycle compared with the 9HPT (ICCs = .70-.81). Minimal detectable change scores indicated acceptable measurement error for both tools. Interrater reliability for recorded performance of each measure was very good (ICCs > .99), with no calculable measurement error.

CONCLUSIONS AND RELEVANCE

Although both tools showed adequate test-retest and interrater reliability, results suggest that the PPT may be a more reliable measure of dexterity loss in people with PD.

WHAT THIS ARTICLE ADDS

This study informs the clinical measurement of the loss of manual dexterity in people with PD, a frequent problem reported by people living with this disorder.

Upper Extremity Capability Tests in Multiple Sclerosis

Multiple sclerosis is a chronic demyelinating disease. Since attacks are accompanied by psychiatric and physical disabilities, additional symptoms such as withdrawal from the social environment and psychiatric disorders are also observed. It is very important to evaluate patients adequately and correctly, to determine the disability, and treat them with appropriate clinical approach. For this reason, Expanded Disability Status Scale score and upper extremity capacity measurement tests are used in many studies by investigators. These tests provide detailed examination on the patient's upper limbs, and indirectly provide information about their cognitive function. A multi-disciplinary approach for multiple sclerosis patients is the most crucial factor in clinical follow-up and treatment success.

Short-term interval aerobic exercise training does not improve memory functioning in relapsing-remitting multiple sclerosis-a randomized controlled trial

Background

Only few aerobic exercise intervention trials specifically targeting cognitive functioning have been performed in multiple sclerosis.

Objective and Methods

This randomized controlled trial with 34 patients in the intervention group (IG) (mean: 38.2 years (±9.6)) and 34 patients in the control group (CG) (mean: 39.6 years (±9.7)) aimed to determine the effects of aerobic exercise on cognition in relapsing-remitting multiple sclerosis (RRMS). The primary outcome was verbal learning assessed by the verbal learning and memory test (VLMT). Patients were randomized to an IG or a waitlist CG. Patients in the IG exercised according to an individually tailored training schedule (with two to three sessions per week for 12 weeks). The primary analysis was carried out using the intention-to-treat (ITT) sample with ANCOVA adjusting for baseline scores.

Results

A total of 77 patients with RRMS were screened and 68 participants randomized (CG n = 34; IG n = 34). The sample comprised 68% females, had a mean age of 39 years, a mean disease duration of 6.3 years, and a mean expanded disability status scale of 1.8. No significant effects were detected in the ITT analysis for the primary endpoint VLMT or any other cognitive measures. Moreover, no significant treatment effects were observed for quality of life, fatigue, or depressive symptoms.

Conclusion

This study failed to demonstrate beneficial effects of aerobic exercise on cognition in RRMS. The trial was prospectively registered at clinicaltrials.gov (NCT02005237).

Recommended outcome measures for inpatient rehabilitation of multiple sclerosis are not appropriate for the patients with substantially impaired mobility

BACKGROUND

In multiple sclerosis (MS) rehabilitation, most currently used outcome measures were validated in patients with a relapsing remitting MS and mild to moderate impairments. We aimed to assess whether these measures were also adequate in more impaired patients, frequently encountered in those with progressive MS (PMS).

METHODS

Outcome measurements were extracted from medical records of 229 patients with PMS undergoing 3 weeks of routine inpatient rehabilitation between 2011 and 2015. We assessed the acceptability of Nine-Hole Peg Test (9HPT), Timed 25-Foot Walk (T25FW), 2-Minute Walk Test (2MWT), Rivermead Mobility Index (RMI) and the Functional Independence Measure (FIM) by analysing their statistical distributions, concurrent validity by comparing Spearman correlations with pre-specified hypotheses, and responsiveness across impairment status by calculating standardized response means.

RESULTS

Our concurrent validity hypotheses were mainly satisfied. However, all outcome measures had skewed distributions, showed low variability, and thus were inadequately discriminative. Moreover, 9HPT was never responsive across the impairment states, whereas the T25FW was responsive for mildly impaired patients, and the 2MWT for mild to moderate MS, respectively. Generic multi-items measures such as RMI and FIM-motor were adequately responsive for all severity levels.

CONCLUSIONS

Currently used outcome measures are inadequate for patients with impaired mobility, and there is a dire need of specifically designed outcome measures for routine care that are less burdensome and short-term responsive.

Relation of serum levels of homocysteine, vitamin B12 and folate to cognitive functions in multiple sclerosis patients

BACKGROUND

Hyperhomocysteinemia, vitamin B12 and folate deficiency have been linked to cognitive dysfunction in multiple sclerosis (MS) patients.

OBJECTIVE

This study aimed to investigate the relation of serum homocysteine (Hcy), vitamin B12 and folate to cognitive functions in MS patients.

SUBJECTS AND METHODS

Forty-five MS patients and twenty matched healthy controls were included. Subjects were submitted to cognitive assessment using a selected psychometric battery and measurement of serum levels of homocysteine, B12 and folic acid.

RESULTS

MS patients showed significant worse performance in cognitive scales compared to controls (P  ≤ 0.05). Serum homocysteine, vitamin B12 and folate showed no significant difference between patients and controls (P  > 0.05). Serum homocysteine was negatively correlated with total score of Addenbrooke's Cognitive Examination (ACE), paced auditory serial addition test and controlled oral word association test scores. Serum vitamin B12 was positively correlated with ACE language, visuospatial and total scores and negatively correlated with trail making B score. Serum folate was significantly positively correlated with ACE language and total scores. Homocysteine was the only significant predictor for cognitive impairment in MS patients.

CONCLUSION

Serum homocysteine may play a role in cognitive dysfunction in MS patients.

Distinguishing among multiple sclerosis fallers, near-fallers and non-fallers

BACKGROUND

Fall rates among adults with multiple sclerosis are consistently greater than 50%, but near-falls (i.e. a trip or stumble) are often undocumented. Furthermore, little is known about the circumstances surrounding fall and near-fall events. The purpose of this study was to examine the similarities and differences among non-fallers, near-fallers and fallers with multiple sclerosis, including the circumstances that surround falls and near-falls.

METHODS

In a single visit, 135 multiple sclerosis participants completed the Hopkins Falls Grading Scale, a custom questionnaire investigating circumstances surrounding falls and near-falls, and performed the Timed Up and Go and Timed 25-Foot Walk tests. Mann-Whitney tests were used to examine differences between fallers, near-fallers and non-fallers. Multiple logistic regression with AIC criterion was used to examine associations of circumstances with the odds of falling vs. near-falling. Cumulative odds ordinal logistic regression was used to analyze the association between each of the walking tests and the susceptibility of the individual for falls or near-falls.

RESULTS

30% of individuals reported falls, while 44% reported near-falls over a 1-year period. Non-fallers completed the walking tests more quickly than near-fallers (p < 0.0045), and fallers (p < 0.0001); near-fallers and fallers demonstrated similar motor profiles. Individuals were more likely to sustain a fall rather than a near-fall under the following circumstances: transferring outside the home (p = 0.015) and tripping over an obstacle (p = 0.025). Performing 1-second slower on the walking tests increased the odds of a history of a fall by 6-20%.

CONCLUSION

Near-falls occur commonly in individuals with MS; near-fallers and fallers reported similar circumstances surrounding fall events and demonstrated similar performance on standard timed walking tests. Clinicians monitoring individuals with MS should consider evaluation of the circumstances surrounding falls in combination with quantitative walking measures to improve determination of fall risk and appropriate rehabilitation interventions.

Quantitative measures of walking and strength provide insight into brain corticospinal tract pathology in multiple sclerosis

At least 85% of individuals with multiple sclerosis report walking dysfunction as their primary complaint. Walking and strength measures are common clinical measures to mark increasing disability or improvement with rehabilitation. Previous studies have shown an association between strength or walking ability and spinal cord MRI measures, and strength measures with brainstem corticospinal tract magnetization transfer ratio. However, the relationship between walking performance and brain corticospinal tract magnetization transfer imaging measures and the contribution of clinical measurements of walking and strength to the underlying integrity of the corticospinal tract has not been explored in multiple sclerosis. The objectives of this study were explore the relationship of quantitative measures of walking and strength to whole-brain corticospinal tract-specific MRI measures and to determine the contribution of quantitative measures of function in addition to basic clinical measures (age, gender, symptom duration and Expanded Disability Status Scale) to structural imaging measures of the corticospinal tract. We hypothesized that quantitative walking and strength measures would be related to brain corticospinal tract-specific measures, and would provide insight into the heterogeneity of brain pathology. Twenty-nine individuals with relapsing-remitting multiple sclerosis (mean(SD) age 48.7 (11.5) years; symptom duration 11.9(8.7); 17 females; median[range] Expanded Disability Status Scale 4.0 [1.0-6.5]) and 29 age and gender-matched healthy controls (age 50.8(11.6) years; 20 females) participated in clinical tests of strength and walking (Timed Up and Go, Timed 25 Foot Walk, Two Minute Walk Test ) as well as 3 T imaging including diffusion tensor imaging and magnetization transfer imaging. Individuals with multiple sclerosis were weaker (p = 0.0024) and walked slower (p = 0.0013) compared to controls. Quantitative measures of walking and strength were significantly related to corticospinal tract fractional anisotropy (r > 0.26; p < 0.04) and magnetization transfer ratio (r > 0.29; p < 0.03) measures. Although the Expanded Disability Status Scale was highly correlated with walking measures, it was not significantly related to either corticospinal tract fractional anisotropy or magnetization transfer ratio (p > 0.05). Walk velocity was a significant contributor to magnetization transfer ratio (p = 0.006) and fractional anisotropy (p = 0.011) in regression modeling that included both quantitative measures of function and basic clinical information. Quantitative measures of strength and walking are associated with brain corticospinal tract pathology. The addition of these quantitative measures to basic clinical information explains more of the variance in corticospinal tract fractional anisotropy and magnetization transfer ratio than the basic clinical information alone. Outcome measurement for multiple sclerosis clinical trials has been notoriously challenging; the use of quantitative measures of strength and walking along with tract-specific imaging methods may improve our ability to monitor disease change over time, with intervention, and provide needed guidelines for developing more effective targeted rehabilitation strategies.

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.

Can we define a rehabilitation strategy for cognitive impairment in progressive multiple sclerosis? A critical appraisal

Cognitive impairment (CI) has been shown to be severe in patients with progressive forms of multiple sclerosis (MS), and the most frequently impaired domains are sustained attention, information processing speed, memory, and executive functions. In contrast to relapsing forms of MS, where studies have shown favorable results from cognitive rehabilitation, there is a lack of data on cognitive rehabilitation in progressive forms of MS. A specific approach in assessing CI and in designing and administering rehabilitation training for patients with progressive forms of MS is needed.

Longitudinal relationships among posturography and gait measures in multiple sclerosis

OBJECTIVE

Gait and balance dysfunction frequently occurs early in the multiple sclerosis (MS) disease course. Hence, we sought to determine the longitudinal relationships among quantitative measures of gait and balance in individuals with MS.

METHODS

Fifty-seven ambulatory individuals with MS (28 relapsing-remitting, 29 progressive) were evaluated using posturography, quantitative sensorimotor and gait measures, and overall MS disability with the Expanded Disability Status Scale at each session.

RESULTS

Our cohort's age was 45.8 ± 10.4 years (mean ± SD), follow-up time 32.8 ± 15.4 months, median Expanded Disability Status Scale score 3.5, and 56% were women. Poorer performance on balance measures was related to slower walking velocity. Two posturography measures, the anterior-posterior sway and sway during static eyes open, feet apart conditions, were significant contributors to walk velocity over time (approximate R(2) = 0.95), such that poorer performance on the posturography measures was related to slower walking velocity. Similarly, the anterior-posterior sway and sway during static eyes closed, feet together conditions were also significant contributors to the Timed 25-Foot Walk performance over time (approximate R(2) = 0.83).

CONCLUSIONS

This longitudinal cohort study establishes a strong relationship between clinical gait measures and posturography. The data show that increases in static posturography and reductions in dynamic posturography are associated with a decline in walk velocity and Timed 25-Foot Walk performance over time. Furthermore, longitudinal balance measures predict future walking performance. Quantitative walking and balance measures are important additions to clinical testing to explore longitudinal change and understand fall risk in this progressive disease population.

Functional clinical outcomes in multiple sclerosis: Current status and future prospects

For decades, the Expanded Disability Status Scale (EDSS) has been the principal measure of disability in clinical trials in patients with multiple sclerosis (MS) and in clinical practice. However, this test is dominated by effects on ambulation. Composite endpoints may provide a more sensitive measure of MS-related disability through the measurement of additional neurological functions. The MS Functional Composite (MSFC) includes a walking test (25-ft walk) plus tests of upper extremity dexterity (9-hole peg test) and cognitive function (Paced Auditory serial Addition test [PASAT]). Replacing PASAT with the Symbol Digit Modality test, a more sensitive test preferred by patients, may improve the clinical utility of the MSFC. In addition, disease-specific measures of QoL may be used alongside the MSFC (which does not include measurement of QoL). Clinical data suggest that disease-modifying therapies may delay or prevent relapse, and better composite measures will be valuable in the assessment of disease activity-free status in people with MS.

Associations of upper limb disability measures on different levels of the International Classification of Functioning, Disability and Health in people with multiple sclerosis

BACKGROUND

It is unknown how impairments caused by multiple sclerosis (MS) affect upper limb capacity, performance, and community integration.

OBJECTIVE

The aim of this study was to investigate the extent to which impairments explained the variance in activity level and participation level measures of the International Classification of Functioning, Disability and Health (ICF) and the extent to which upper limb capacity measures explained perceived performance on the activity level in people with MS and different dexterity levels.

DESIGN

This was a cross-sectional study.

METHODS

A total of 105 people with MS (median Expanded Disability Status Scale=6.5) were assessed with measures on the ICF body functions and structures level (strength, active range of motion of the wrist, tactile sensitivity, tremor, spasticity, and pain), activity level (Nine-Hole Peg Test [NHPT], Action Research Arm Test, and Manual Ability Measure-36 [MAM-36]), and participation level (Community Integration Questionnaire). The sample was divided into low- and high-dexterity subgroups on the basis of the median score on the NHPT.

RESULTS

In the total group, muscle strength, tactile sensitivity of the thumb, and intention tremor explained 53% to 64% of the variance in activity level measures. In the low-dexterity subgroup, muscle strength and active range of motion explained 43% to 71% of the variance in activity level measures. In the high-dexterity subgroup, only 35% of the variance in the MAM-36 was explained by muscle strength. Capacity measures (NHPT and Action Research Arm Test) were moderately to highly associated with perceived performance (MAM-36) in the low-dexterity subgroup.

LIMITATIONS

Some outcome measures showed ceiling effects in people with MS and a high dexterity level.

CONCLUSIONS

Upper limb muscle strength is the most important impairment affecting capacity and perceived performance in daily life. Associations among outcome measures differ in people with MS and different dexterity levels.

Using perceptive computing in multiple sclerosis - the Short Maximum Speed Walk test

BACKGROUND

We investigated the applicability and feasibility of perceptive computing assisted gait analysis in multiple sclerosis (MS) patients using Microsoft Kinect™. To detect the maximum walking speed and the degree of spatial sway, we established a computerized and observer-independent measure, which we named Short Maximum Speed Walk (SMSW), and compared it to established clinical measures of gait disability in MS, namely the Expanded Disability Status Scale (EDSS) and the Timed 25-Foot Walk (T25FW).

METHODS

Cross-sectional study of 22 MS patients (age mean ± SD 43 ± 9 years, 13 female) and 22 age and gender matched healthy control subjects (HC) (age 37 ± 11 years, 13 female). The disability level of each MS patient was graded using the EDSS (median 3.0, range 0.0-6.0). All subjects then performed the SMSW and the Timed 25-Foot Walk (T25FW). The SMSW comprised five gait parameters, which together assessed average walking speed and gait stability in different dimensions (left/right, up/down and 3D deviation).

RESULTS

SMSW average walking speed was slower in MS patients (1.6 ± 0.3 m/sec) than in HC (1.8 ± 0.4 m/sec) (p = 0.005) and correlated well with EDSS (Spearman's Rho 0.676, p < 0.001). Furthermore, SMSW revealed higher left/right deviation in MS patients compared to HC. SMSW showed high recognition quality and retest-reliability (covariance 0.13 m/sec, ICC 0.965, p < 0.001). There was a significant correlation between SMSW average walking speed and T25FW (Pearson's R = -0.447, p = 0.042).

CONCLUSION

Our data suggest that ambulation tests using Microsoft Kinect™ are feasible, well tolerated and can detect clinical gait disturbances in patients with MS. The retest-reliability was on par with the T25FW.

Systematic literature review and validity evaluation of the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC) in patients with multiple sclerosis

BACKGROUND

There are a number of instruments that describe severity and progression of multiple sclerosis and they are increasingly used as endpoints to assess the effectiveness of therapeutic interventions. We examined to what extent the psychometric properties of two accepted instruments--EDSS and MSFC--meet methodological standards and the value they have in clinical trials.

METHODS

We conducted a systematic literature search in relevant databases [MEDLINE (PubMed), ISI Web of Science, EMBASE, PsycINFO & PSYNDEX, CINAHL] yielding 3,860 results. Relevant full-text publications were identified using abstract and then full-text reviews, and the literature was reviewed.

RESULTS

For evaluation of psychometric properties (validity, reliability, sensitivity of change) of EDSS and MSFC, 120 relevant full-text publications were identified, 54 of them assessed the EDSS, 26 the MSFC and 40 included both instruments. The EDSS has some documented weaknesses in reliability and sensitivity to change. The main limitations of the MSFC are learning effects and the z-scores method used to calculate the total score. However, the methodological criterion of validity applies sufficiently for both instruments.For use in clinical studies, we found the EDSS to be preferred as a primary and secondary outcome measure in recent studies (50 EDSS, 9 MSFC).

CONCLUSIONS

Recognizing their strengths and weaknesses, both EDSS and MSFC are suitable to detect the effectiveness of clinical interventions and to monitor disease progression. Almost all publications identify the EDSS as the most widely used tool to measure disease outcomes in clinical trials. Despite some limitations, both instruments are accepted as endpoints and neither are discussed as surrogate parameters in identified publications. A great advantage of the EDSS is its international acceptance (e.g. by EMA) as a primary endpoint in clinical trials and its broad use in trials, enabling cross-study comparisons.

Assessing upper limb function in multiple sclerosis

The need to fully assess upper limb function in multiple sclerosis (MS) has become increasingly clear with recent studies revealing a high prevalence of upper limb dysfunction in persons with MS leading to increased dependency and reduced quality of life. It is important that clinicians and researchers use tailored outcome measures to systematically describe upper limb (dys)function and evaluate potential deterioration or improvement on treatment. This topical review provides a comprehensive summary of currently used upper limb outcome measures in MS, classified according to the levels of the International Classification of Functioning (ICF). The clinical utility, strengths, weaknesses and psychometric properties of common upper limb outcome measures are discussed. Based on this information, recommendations for selecting appropriate upper limb outcome measures are given. The current shortcomings in assessment which need to be addressed are identified.

Upper limb assessment in multiple sclerosis: a systematic review of outcome measures and their psychometric properties

OBJECTIVE

To provide an overview of applied upper limb outcome measures in multiple sclerosis (MS) according to the International Classification of Functioning, Disability and Health (ICF) levels and to review their psychometric properties in MS.

DATA SOURCES

PubMed and Web of Knowledge.

STUDY SELECTION

Articles published until June 2013 were selected when written in English, published in the last 25 years, peer reviewed, including >5 persons with MS, and including standardized clinical upper limb outcome measures. Included articles were screened based on title/abstract and full text by 2 independent reviewers. In case of doubt, feedback from a third independent reviewer was obtained. Additionally, references lists were checked for relevant articles. Of the articles, 109 met the selection criteria and were included for data extraction.

DATA EXTRACTION

All reported clinical upper limb outcome measures were extracted from the included studies and classified according to the ICF levels by 2 independent reviewers. In addition, available psychometric properties (reliability, validity, responsiveness) in MS were summarized and discussed.

DATA SYNTHESIS

A diversity of outcome measures assessing impairments on the body functions and structures level (n=33), upper limb capacity (n=11), and performance (n=8) on the activity level were extracted from 109 articles. Hand grip strength and the nine-hole peg test (NHPT) were the most frequently used outcome measures. However, multiple outcome measures are necessary to encapsulate the multidimensional character of the upper limb function. The psychometric properties were insufficiently documented for most of the outcome measures, except for the NHPT.

CONCLUSIONS

The results of this review may help with the selection of appropriate outcome measures and may guide future research regarding the psychometric properties in MS.

Determining the Presence of Reliable Change over Time in Multiple Sclerosis: Evidence from the PASAT, Adjusting-PSAT, and Stroop Test

People with multiple sclerosis (MS) often undergo repeated assessments. Methods for determining whether an individual's change in test results over time is reliable require further study. A sample of individuals with MS (N = 52) was assessed at baseline and at 6-month follow-up using the Paced Auditory Serial Addition Test (PASAT), Simple Adjusting-Paced Serial Addition Test (A-PSAT), and Victoria Stroop test. Two methods for determining the reliability of an individual's change over time were examined. The Reliable Change Index (RCI) identified few individuals who declined reliably between baseline and 6-month follow-up. The standard deviation (SD) method of calculation resulted in reliable declines for a small number of individuals on most measures. Use of the SD method resulted in a larger number of individuals who improved reliably. Responsiveness of individuals to treatment effects can be lost in group analyses. The data presented here provide clinicians with an approach for determining whether an individual's change over time on commonly used neuropsychological tests reflects reliable improvement or decline.

Repeatability of the timed 25-foot walk test for individuals with multiple sclerosis

OBJECTIVE

The purpose of this study was to determine if there is a practice effect present in the timed 25-foot walk in ambulatory individuals with multiple sclerosis.

DESIGN

Thirty six people (30 women and 6 men) diagnosed with relapsing remitting multiple sclerosis participated in two testing sessions, one week apart. Each participant performed two sequential trials of the timed 25-foot walk test per session and the walk performance was measured with a laser timing system.

RESULTS

We observed improvements in walking speed between the two trials of session one (trial one: 6.42 (0.09) vs. trail two: 5.97 (0.08) seconds, p < 0.001). Within session two, performance remained stable (trial three: 5.71 (0.07) vs. trial four: 5.63 (0.07) seconds, p > 0.05). We also observed a significant improvement in walking speed when averages of the two trials were compared across sessions (session 1: 6.19 (0.09) vs. session 2: 5.67 (0.07) seconds, p < 0.01).

CONCLUSIONS

Based on our results, familiarization of the timed 25-foot walk test improves stability of walk performance scores in ambulatory individuals with relapsing remitting multiple sclerosis.

Assessment set for evaluation of clinical outcomes in multiple sclerosis: psychometric properties

Purpose:

Multiple sclerosis (MS) manifests itself in a wide range of symptoms. Physiotherapy plays an important role in the treatment of those symptoms connected with mobility. For this therapy to be at its most effective it should be based on a systematic examination that is able to describe and classify damaged clinical functions meaningfully. The purpose of this study was to develop and validate a battery of tests and composite tests that can be used to systematically evaluate clinical features of MS treatable by physiotherapy.

Methods:

The authors assembled a proposed battery of tests comprising known, standard, and validated assessments (low-contrast letter acuity testing; the Motricity Index; the Modified Ashworth Scale; the Berg Balance Scale; scales of postural reactions, tremor, dysdiadochokinesia, and dysmetria; the Nine-Hole Peg Test; the Timed 25-Foot Walk; and the 3-minute version of the Paced Auditory Serial Addition Test) and one test (knee hyperextension) of the authors’ own. Normalization was calculated and six composite assessments were measured. Seventeen ambulatory subjects with MS were tested twice with the assessment set before undergoing physiotherapy, and 12 were also tested with the assessment set after the physiotherapy. The test–retest reliability, stability, internal consistency of composite measurements, sensitivity to changes after therapy, and correlation between measurements and the Kurtzke Expanded Disability Status Scale score were evaluated for all tests in the assessment set.

Results:

A good internal consistency was confirmed for all tests in the proposed battery, and most of the tests also showed good test–retest reliability. While no significant changes occurred without treatment, significant posttreatment improvement was proved in all tests except for low-contrast letter acuity testing, where only a trend to improvement was proved.

Conclusion:

The proposed assessment set is a good tool for the evaluation of clinical features of MS treatable by physiotherapy. This battery of tests is applicable in both clinical practice and research.

Cognitive deficit is related to immune-cell beta-NGF in multiple sclerosis patients

OBJECTIVES

Multiple sclerosis (MS) is a chronic inflammatory demyelinating and neurodegenerative disease of the central nervous system (CNS), causing cognitive impairment in 45-65% of patients. Beta-NGF facilitates proper cholinergic transmission in the healthy CNS. In MS-damaged tissue there is a relative deficit of neurotrophins that might be compensated by peripheral blood mononuclear cells (PBMCs) synthesis. Our aim was to evaluate the relationship between PBMCs neurotrophins' expression and cognitive performance in relapsing-remitting MS (RRMS) patients.

PATIENTS AND METHODS

Beta-NGF, NT-3 and NT-4/5 levels were measured in sera and in PBMCs by ELISA method in 41 RRMS patients in remission. All patients underwent neuropsychological assessment with a battery of 10 tests evaluating a wide range of cognitive functions.

RESULTS

PBMCs beta-NGF concentration correlated significantly with spontaneous word list generation test (Pearson R=0.37, p=0.02) and 15-Word List Recall Test results (Pearson R=0.40, p<0.00). Both tests assessing semantic memory correlated significantly with the cognitive composite score, defined as a number of tests in which patients performed below group median for the given test.

CONCLUSIONS

In RRMS beta-NGF is strongly linked to cognitive performance, which makes it an attractive therapeutic target. It might play a neuroprotective role in MS, especially in the cognitive domain.

Assessing walking disability in multiple sclerosis

Most patients with multiple sclerosis (MS) eventually experience walking disability. The objective of this review was to evaluate the clinical utility of measures specific for walking in MS. Walking assessments had high reliability and were correlated with related measures, including the 12-item multiple sclerosis walking scale (MSWS-12). Shorter timed walking tests (Timed 25-foot Walk (T25FW), 10-metre Timed Walk, 30-metre Timed Walk) measure overall walking disability and are best suited for clinical settings, whereas longer timed or distance tests (100-metre Timed Walk, 6-minute Walk Test, 2-minute Walk Test) are better for the assessment of walking fatigability, distance limitations and functional capacity. The MSWS-12 measures different, but related, aspects of walking than the objective tests. The T25FW is the best characterised objective measure of walking disability and can be used across a wide range of walking disabilities. Additional work is needed to fully characterise the other objective walking assessments in MS.

The effects of heat stress on cognition in persons with multiple sclerosis

Background: Heat sensitivity and cognitive deficits are typical manifestations of multiple sclerosis (MS). Although cognitive deficits are quite well characterized, practically no data exist on the effects of heat on cognitive performances in MS.

Objective: To assess the effects of short-term heat stress on cognitive functioning in subjects with MS.

Methods: A total of 23 heat-sensitive MS and 19 healthy control (HC) subjects participated. Moderate heat exposure took place in a Finnish sauna. Cognitive functioning was measured with tests of sustained attention and processing speed, the Paced Auditory Serial Addition Test (PASAT 3” and 2”) and the computerized visual vigilance test, before, during and after heat exposure.

Results: During the heat exposure, the core body temperature of the MS group rose significantly more ( p = 0.002) than that of the HC group. The heat stress worsened the performance of the MS group in the PASAT 3” ( p = 0.025) but not in the other cognitive measures. The performance in the PASAT 3” was reversed almost to the baseline level only 1- h after the heat exposure.

Conclusions: A significant increase in core body temperature during heat stress is associated with a mild and reversible worsening of the PASAT 3” performance, while visual vigilance performance seems to remain almost unaffected.

Paced auditory serial addition test (PASAT): a very difficult test even for individuals with high intellectual capability

OBJECTIVE: To assess the difficulty of paced auditory serial addition test (PASAT) in a population of high intellectual level, under ideal cognitive testing circumstances. METHOD: One hundred medical students underwent PASAT testing. They had slept well the night before, they had eaten before the assessment, they were not using any drugs that could affect the central nervous system and they did not have depression, anxiety or any chronic disease. RESULTS: The average result from the three-second version of PASAT was 57.5% and, from the two-second version, it was 44.3%. CONCLUSION: Even under ideal circumstances, PASAT is a very difficult test for the general population. It may not be ideal for neurologists to screen, assess and follow up patients with cognitive function in multiple sclerosis.

Reliability, practice effects, and change indices for Rao’s brief repeatable battery

The role of cognitive impairment in multiple sclerosis is now widely recognized. However, there is a dearth of research on variability and practice effects of neuropsychological measures when repeated over time. The objective was to assess reliability and practice effects for Rao’s Brief Repeatable Battery of neurophysiological tests and the Stroop Test, and to provide data for correction for variability and practice effects in serial assessments.In 54 healthy controls (34 women, mean age 38.3 ± 9.1 years, mean education 12.9 ± 3.3 years), the Brief Repeatable Battery and Stroop Test were administered 3 times with an 18-month interval. Reliability was assessed by intraclass correlation coefficient and practice effects by an analysis of variance with Bonferroni’s correction for repeated measures. Test—retest reliability was from adequate to good on the Symbol Digit Modalities Test, the Stroop Test, and the Paced Auditory Serial Addition Test. The great majority of tests showed at least a moderate practice effects. Data for calculation of an individual’s change in cognitive performance for each test of the Brief Repeatable Battery and the Stroop Test were provided. Our results provide relevant information for planning and interpreting longitudinal studies on cognition and cognitive rehabilitation in multiple sclerosis.

Cognitive dysfunction in primary progressive multiple sclerosis: a neuropsychological and MRI study

Although cognitive dysfunction is known to occur in multiple sclerosis (MS), only few studies have reported cognitive performance in patients with primary progressive MS (PPMS). To find out the pattern of cognitive performance in PPMS, 28 PPMS patients underwent an extensive battery of neuropsychological tests. The results were compared to those of healthy controls ( n = 20) and patients with secondary progressive MS (SPMS, n = 28). Furthermore, the results of neuropsychological tests in PPMS were correlated to magnetic resonance imaging findings. Our study showed that the PPMS patients have deficits in several cognitive domains when compared to age-matched and education-matched controls, but the cognitive impairment in the PPMS and SPMS patients appeared to be similar. Cognitive deficits in PPMS patients correlated with diffuse brain lesion, T1- and T2-lesion load, but no correlations were found with atrophy.