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Bruce JM, Cozart JS, Shook RP, Befort C, Siengsukon CF, Simon S, Lynch SG, Mahmoud R, Drees B, Posson P, Hibbing PR, Huebner J, Bradish T, Robichaud J, Bruce AS. Modifying diet and exercise in multiple sclerosis (MoDEMS): A randomized controlled trial for behavioral weight loss in adults with multiple sclerosis and obesity. Mult Scler 2023; 29:1860-1871. [PMID: 38018409 DOI: 10.1177/13524585231213241] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND Obesity is a risk factor for developing multiple sclerosis (MS) and MS-related disability. The efficacy of behavioral weight loss interventions among people with MS (pwMS) remains largely unknown. OBJECTIVE Examine whether a group-based telehealth weight loss intervention produces clinically significant weight loss in pwMS and obesity. METHODS Seventy-one pwMS were randomized to the weight loss intervention or treatment-as-usual (TAU). The 6-month program promoted established guidelines for calorie reduction and increased physical activity. Anthropometric measurements, mobility tasks, self-report questionnaires, and accelerometry were used to assess changes at follow-up. RESULTS Mean percent weight loss in the treatment group was 8.6% compared to 0.7% in the TAU group (p < .001). Sixty-five percent of participants in the intervention achieved clinically meaningful weight loss (⩾ 5%). Participants in the treatment group engaged in 46.2 minutes/week more moderate-to-vigorous physical activity than TAU participants (p = .017) and showed improvements in quality of life (p = .012). Weight loss was associated with improved mobility (p = .003) and reduced fatiguability (p = .008). CONCLUSION Findings demonstrate the efficacy of a behavioral intervention for pwMS and obesity, with clinically significant weight loss for two-thirds of participants in the treatment condition. Weight loss may also lead to improved mobility and quality of life.
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Affiliation(s)
- Jared M Bruce
- Department of Biomedical and Health Informatics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Departments of Neurology and Psychiatry, University Health, Kansas City, MO, USA
| | - Julia S Cozart
- Department of Biomedical and Health Informatics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Department of Psychology, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Robin P Shook
- Center for Children's Healthy Lifestyles and Nutrition, Children's Mercy Hospital, Kansas City, MO, USA
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Christie Befort
- Department of Population Health, University Kansas Medical Center, Kansas City, KS, USA
| | - Catherine F Siengsukon
- Department of Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas City, KS, USA
| | - Stephen Simon
- Department of Biomedical and Health Informatics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Sharon G Lynch
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Rola Mahmoud
- Department of Neurology, Saint Luke's Hospital, Kansas City, MO, USA
- Department of Neurology, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Betty Drees
- Department of Biomedical and Health Informatics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Department of Internal Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Graduate School of the Stowers Institute for Medical Research, Kansas City, MO, USA
| | - Paige Posson
- Center for Children's Healthy Lifestyles and Nutrition, Children's Mercy Hospital, Kansas City, MO, USA
| | - Paul R Hibbing
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, USA
| | - Joanie Huebner
- Department of Community and Family Medicine, University Health Lakewood Medical Center, Kansas City, MO, USA
| | - Taylor Bradish
- Department of Biomedical and Health Informatics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Jade Robichaud
- Department of Biomedical and Health Informatics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Amanda S Bruce
- Center for Children's Healthy Lifestyles and Nutrition, Children's Mercy Hospital, Kansas City, MO, USA
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, KS, USA
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2
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Regnault A, Meunier J, Ciesluk A, Cheng W, Zhu B. Providing meaningful interpretation of performance outcome measures by co-calibration with patient-reported outcomes through the Rasch model: illustration with multiple sclerosis measures. J Biopharm Stat 2023:1-21. [PMID: 38007615 DOI: 10.1080/10543406.2023.2280557] [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: 01/21/2023] [Accepted: 10/27/2023] [Indexed: 11/27/2023]
Abstract
Performance outcome (PerfO) measures are based on tasks performed by patients in a controlled environment, making their meaningful interpretation challenging to establish. Co-calibrating PerfO and patient-reported outcome (PRO) measures of the same target concept allow for interpretation of the PerfO with the item content of the PRO. The Rasch model applied to the discretized PerfO measure together with the PRO items allows expressing parameters related to the PerfO measure in the PRO metric for it to be linked to the PRO responses. We applied this approach to two PerfO measures used in multiple sclerosis (MS) for walking and manual ability: the Timed 25-Foot Walk (T25FW) and the 9-Hole Peg Test (9HPT). To determine meaningful interpretation of these two PerfO measures, they were co-calibrated with two PRO measures of closely related concepts, the MS walking scale - 12 items (MSWS-12) and the ABILHAND, using the data of 2,043 subjects from five global clinical trials in MS. The probabilistic relationships between the PerfO measures and the PRO metrics were used to express the response pattern to the PRO items as a function of the unit of the PerfOs. This example illustrates the promises of the co-calibration approach for the interpretation of PerfO measures but also highlights the challenges associated with it, mostly related to the quality of the PRO metric in terms of coverage of the targeted concept. Co-calibration with PRO measures could also be an adequate solution for interpretation of digital sensor measures whose meaningfulness is also often questioned.
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Affiliation(s)
| | | | | | | | - Bing Zhu
- Biogen, Cambridge, Massachusetts, USA
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3
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Koch MW, Repovic P, Mostert J, Bowen JD, Comtois J, Strijbis E, Uitdehaag B, Cutter G. Threshold definitions for significant change on the timed 25-foot walk and nine-hole peg test in primary progressive multiple sclerosis. Eur J Neurol 2023; 30:2761-2768. [PMID: 37306560 DOI: 10.1111/ene.15920] [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: 02/14/2023] [Revised: 04/11/2023] [Accepted: 06/08/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND PURPOSE The timed 25-foot walk (T25FW) and nine-hole peg test (NHPT) exhibit random variability in the short term. A threshold of ≥20% change from baseline has been used to indicate true disability change, but other threshold definitions may be better suited to exclude false and include true change events. The aim of this study was to use patient-level original trial data to investigate the short-term variation in T25FW and NHPT, and to compare its extent with disability change at 12-month follow-up in people with primary progressive multiple sclerosis (PPMS). METHODS We used original patient-level data from PROMISE, a large PPMS trial. In this trial, three separate T25FW and NHPT measurements were performed 1 week apart during screening. We used these repeated measures to describe the extent of short-term variation. We used binary logistic regression models to investigate the association between screening characteristics and unacceptable short-term variation. RESULTS The traditional 20% threshold excluded a reasonable number of false change events, while also yielding a large number of change events at follow-up. Increasing index values on the T25FW and NHPT were associated with higher short-term variation. CONCLUSIONS The traditional ≥20% change threshold for the T25FW and NHPT represents a reasonable compromise between reducing the number of false change events and achieving the largest number of change events in people with PPMS. Our analyses inform the design of clinical trials in PPMS.
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Affiliation(s)
- Marcus W Koch
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Pavle Repovic
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Jop Mostert
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | - James D Bowen
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Jacynthe Comtois
- Department of Medicine, Neurology service, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
- Département de neurosciences, Faculté de médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Eva Strijbis
- Department of Neurology, MS Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Bernard Uitdehaag
- Department of Neurology, MS Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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4
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Ezegbe C, Zarghami A, van der Mei I, Alty J, Honan C, Taylor B. Instruments measuring change in cognitive function in multiple sclerosis: A systematic review. Brain Behav 2023; 13:e3009. [PMID: 37062948 PMCID: PMC10275522 DOI: 10.1002/brb3.3009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic demyelinating/neurodegenerative disease associated with change in cognitive function (CF) over time. This systematic review aims to describe the instruments used to measure change in CF over time in people with MS (PwMS). METHODS PubMed, OVID, Web of Science, and Scopus databases were searched in English until May 2021. Articles were included if they had at least 100 participants and at least a 1-year interval between baseline and last follow-up measurement of CF. Results were quantitatively synthesized, presented in tables and risk of bias was assessed with the Newcastle-Ottawa Scale. RESULTS Fifty-seven articles met the inclusion criteria (41,623 PwMS and 1105 controls). An intervention (drug/rehabilitation) was assessed in 22 articles. In the studies that used a test battery, Visual and verbal learning and memory were the most frequently measured domains, but when studies that used test battery or a single test are combined, Information processing speed was the most measured. The Symbol Digit Modalities Test (SDMT) was the most frequently used test as a single test and in a test battery combined. Most studied assessed "change in CF" as cognitive decline defined as 1 or more tests measured as ≥ 1.5 SD from the study control or normative mean in a test battery at baseline and follow-up. Meta-analysis of change in SDMT scores with seven articles indicated a nonstatistically significant -0.03 (95% CI -0.14, 0.09) decrease in mean SDMT score per year. CONCLUSION This study highlights the slow rate of measured change in cognition in PwMS and emphasizes the lack of a gold standard test and consistency in measuring cognitive change at the population level. More sensitive testing utilizing multiple domains and longer follow-up may define subgroups where CF change follows different trajectories thus allowing targeted interventions to directly support those where CF is at greatest risk of becoming a clinically meaningful issue.
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Affiliation(s)
- Chigozie Ezegbe
- Multiple Sclerosis Research Flagship, Menzies Institute for Medical ResearchUniversity of TasmaniaHobartTasmaniaAustralia
| | - Amin Zarghami
- Multiple Sclerosis Research Flagship, Menzies Institute for Medical ResearchUniversity of TasmaniaHobartTasmaniaAustralia
| | - Ingrid van der Mei
- Multiple Sclerosis Research Flagship, Menzies Institute for Medical ResearchUniversity of TasmaniaHobartTasmaniaAustralia
| | - Jane Alty
- Wicking Dementia Research and Education CentreUniversity of TasmaniaHobartTasmaniaAustralia
- Neurology DepartmentRoyal Hobart HospitalHobartTasmaniaAustralia
| | - Cynthia Honan
- School of Psychological SciencesUniversity of TasmaniaLauncestonTasmaniaAustralia
| | - Bruce Taylor
- Multiple Sclerosis Research Flagship, Menzies Institute for Medical ResearchUniversity of TasmaniaHobartTasmaniaAustralia
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Damasceno A, Pimentel-Silva LR, Damasceno BP, Cendes F. Are we ready to define cognitive worsening in MS? How different cutoffs detect future cognitive worsening after six years of follow-up. Mult Scler Relat Disord 2023; 69:104402. [PMID: 36379184 DOI: 10.1016/j.msard.2022.104402] [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: 08/19/2022] [Revised: 09/24/2022] [Accepted: 11/05/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although cognitive evaluation has been incorporated in recent MS clinical trials, the definition of cognitive progression is not clear and recent data are questioning the 4-point cutoff using the SDMT at the individual level. We aimed to evaluate the behavior of cognitive performance over time using different cutoffs. METHODS Cognitive performance over six years was analyzed in a cohort of 42 relapsing-remitting MS patients and 30 controls using verbal/visual memory and information processing speed tests. Fixed cutoffs were: 10% and 20% change (all tests) and a 4- and 8-point change (SDMT). The relative cutoff established by regression-based models was a 1SD change. RESULTS The distributions of "worsening", "stability", and "improvement" showed low concordance rates across the cutoffs (p < 0.001 for most comparisons). Most patients classified with worsening initially using fixed cutoffs had subsequent improvement in all cognitive tests, yielding a low sensitivity to predict later cognitive worsening. Using the relative cutoff, the proportion of patients with subsequent improvement was noticeably smaller. CONCLUSIONS Fixed cutoffs classify a high proportion of patients with cognitive improvement. Most patients categorized with worsening initially presented subsequent improvement. Instead, the relative cutoff generally had a better performance. These data raise concerns about how we are defining cognitive worsening so far, especially at the individual level.
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Affiliation(s)
- Alfredo Damasceno
- Department of Neurology, University of Campinas (UNICAMP), Campinas, Brazil; Laboratory of Neuroimaging, University of Campinas (UNICAMP), Campinas, Brazil.
| | | | | | - Fernando Cendes
- Department of Neurology, University of Campinas (UNICAMP), Campinas, Brazil; Laboratory of Neuroimaging, University of Campinas (UNICAMP), Campinas, Brazil
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Krajnc N, Bsteh G, Berger T. Clinical and Paraclinical Biomarkers and the Hitches to Assess Conversion to Secondary Progressive Multiple Sclerosis: A Systematic Review. Front Neurol 2021; 12:666868. [PMID: 34512500 PMCID: PMC8427301 DOI: 10.3389/fneur.2021.666868] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria.,Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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7
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Measuring Treatment Response in Progressive Multiple Sclerosis-Considerations for Adapting to an Era of Multiple Treatment Options. Biomolecules 2021; 11:biom11091342. [PMID: 34572555 PMCID: PMC8470215 DOI: 10.3390/biom11091342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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8
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Meca-Lallana V, Berenguer-Ruiz L, Carreres-Polo J, Eichau-Madueño S, Ferrer-Lozano J, Forero L, Higueras Y, Téllez Lara N, Vidal-Jordana A, Pérez-Miralles FC. Deciphering Multiple Sclerosis Progression. Front Neurol 2021; 12:608491. [PMID: 33897583 PMCID: PMC8058428 DOI: 10.3389/fneur.2021.608491] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 03/11/2021] [Indexed: 12/12/2022] Open
Abstract
Multiple sclerosis (MS) is primarily an inflammatory and degenerative disease of the central nervous system, triggered by unknown environmental factors in patients with predisposing genetic risk profiles. The prevention of neurological disability is one of the essential goals to be achieved in a patient with MS. However, the pathogenic mechanisms driving the progressive phase of the disease remain unknown. It was described that the pathophysiological mechanisms associated with disease progression are present from disease onset. In daily practice, there is a lack of clinical, radiological, or biological markers that favor an early detection of the disease's progression. Different definitions of disability progression were used in clinical trials. According to the most descriptive, progression was defined as a minimum increase in the Expanded Disability Status Scale (EDSS) of 1.5, 1.0, or 0.5 from a baseline level of 0, 1.0–5.0, and 5.5, respectively. Nevertheless, the EDSS is not the most sensitive scale to assess progression, and there is no consensus regarding any specific diagnostic criteria for disability progression. This review document discusses the current pathophysiological concepts associated with MS progression, the different measurement strategies, the biomarkers associated with disability progression, and the available pharmacologic therapeutic approaches.
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Affiliation(s)
- Virginia Meca-Lallana
- Multiple Sclerosis Unit, Neurology Department, Fundación de Investigación Biomédica, Hospital Universitario de la Princesa, Madrid, Spain
| | | | - Joan Carreres-Polo
- Neuroradiology Section, Radiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Sara Eichau-Madueño
- Multiple Sclerosis CSUR Unit, Neurology Department, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Jaime Ferrer-Lozano
- Department of Pathology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Lucía Forero
- Neurology Department, Hospital Puerta del Mar, Cádiz, Spain
| | - Yolanda Higueras
- Neurology Department, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Hospital Universitario Gregorio Marañón, Madrid, Spain.,Department of Experimental Psychology, Cognitive Processes and Speech Therapy, Universidad Complutense, Madrid, Spain
| | - Nieves Téllez Lara
- Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Angela Vidal-Jordana
- Neurology/Neuroimmunology Department, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Francisco Carlos Pérez-Miralles
- Neuroimmunology Unit, Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Department of Medicine, University of València, Valencia, Spain
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Solaro C, Cattaneo D, Basteris A, Carpinella I, De Luca A, Mueller M, Bertoni R, Ferrarin M, Sanguineti V. Haptic vs sensorimotor training in the treatment of upper limb dysfunction in multiple sclerosis: A multi-center, randomised controlled trial. J Neurol Sci 2020; 412:116743. [PMID: 32145522 DOI: 10.1016/j.jns.2020.116743] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/11/2020] [Accepted: 02/17/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND In multiple sclerosis (MS) exercise improves upper limb functions, but it is unclear what training types are more effective. OBJECTIVE This study compares robot-assisted training based on haptic or sensorimotor exercise. METHODS 41clinically definite MS subjects with upper limb impairment were randomised into two groups: (i) Haptic and (ii) Sensorimotor. Subjects in the Haptic performed a robot-assisted training protocol designed to counteract incoordination and weakness. The task -interaction with a virtual mass-spring system against a resistive load- requires coordination skills. Task difficulty and magnitude of resistive load were automatically adjusted to the individual impairment. Subjects in the Sensorimotor performed reaching movements under visual control; the robot generated no forces. Both groups underwent eight training sessions (40 min/session, 2 sessions/week). Treatment outcome were 9HPT and ARAT scores. RESULTS The average 9HPT score decreased from 74±9 s to 61±8 s for the Haptic and from 49±6 s to 44±6 s. We found a significant Treatment (p=.0453) and Time differences (p=.005), but no significant Treatment×Time interactions although we found that the absolute change was only significant in the Haptic group (p=.011). We observed no significant changes in the ARAT score. Participants tolerated treatments well with a low drop-out rate. In the subjects evaluated at after 12 week (11 subject in sensory-motor and 17 in haptic group) no retention of the effect was found. CONCLUSIONS Task oriented training may improve upper limb function in persons with MS especially in prevalent pyramidal impaired subjects without maintain the effects after three months. CLINICAL TRIAL REGISTRATION NUMBER NCT02711566 (clinicaltrial.gov).
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Affiliation(s)
- Claudio Solaro
- Department of Rehabilitation, Mons L Novarese Hospital, Moncrivello, Italy; Department of Head and Neck, ASL 3 Genovese, Genoa, Italy.
| | - Davide Cattaneo
- Department of Neurorehabilitation, Don Gnocchi Foundation IRCCS, Milan, Italy
| | - Angelo Basteris
- Department of Informatics, Bioengineering, Robotics and Systems Engineering, University of Genoa, Genoa, Italy; Recover Injury Research Centre, Griffith University, Gold Coast, Australia
| | - Ilaria Carpinella
- Department of Biomedical Technology, Don Gnocchi Foundation IRCCS, Milan, Italy
| | - Alice De Luca
- Department of Informatics, Bioengineering, Robotics and Systems Engineering, University of Genoa, Genoa, Italy
| | - Margit Mueller
- Department of Head and Neck, ASL 3 Genovese, Genoa, Italy
| | - Rita Bertoni
- Department of Neurorehabilitation, Don Gnocchi Foundation IRCCS, Milan, Italy
| | - Maurizio Ferrarin
- Department of Biomedical Technology, Don Gnocchi Foundation IRCCS, Milan, Italy
| | - Vittorio Sanguineti
- Department of Informatics, Bioengineering, Robotics and Systems Engineering, University of Genoa, Genoa, Italy
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10
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Mayssam EN, Eid C, Khoury SJ, Hannoun S. "No evidence of disease activity": Is it an aspirational therapeutic goal in multiple sclerosis? Mult Scler Relat Disord 2020; 40:101935. [PMID: 31951861 DOI: 10.1016/j.msard.2020.101935] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/02/2020] [Accepted: 01/04/2020] [Indexed: 01/01/2023]
Abstract
'No evidence of disease activity' (NEDA) that has been identified as a potential outcome measure for the evaluation of DMTs effects. The concept has been adopted from other diseases such as cancer where treatment is intended to free the patient from the disease. Disease-free status has been substituted by NEDA in MS, since we are limited when it comes to fully evaluating the underlying disease. In general, NEDA, otherwise termed as NEDA-3, is defined by the lack of disease activity based on the absence of clinical relapses, disability progression with the expanded disability status score (EDSS), and radiological activity. Recently, brain atrophy, a highly predictive marker of disability progression, has been added as a fourth component (NEDA-4). The use of this composite allowed a more comprehensive assessment of the disease activity. Indeed, it has an important role in clinical trials as a secondary outcome in addition to primary endpoints. However, the evidence is insufficient regarding the ability of NEDA to predict future disability and treatment response. Moreover, combining different composites does not eliminate the limitation of each, therefore the use of NEDA in clinical routine is still not implemented. The aim of this review is first to report from the literature the available definitions of NEDA and its different variants, and second, evaluate the importance of its use as a surrogate marker to assess the efficacy of different DMTs.
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Affiliation(s)
- El Najjar Mayssam
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Riad El Solh 1107 2020. P.O.Box: 11-0236, Beirut, Lebanon
| | - Cynthia Eid
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Riad El Solh 1107 2020. P.O.Box: 11-0236, Beirut, Lebanon
| | - Samia J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Riad El Solh 1107 2020. P.O.Box: 11-0236, Beirut, Lebanon; Abu-Haidar Neuroscience Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Salem Hannoun
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Riad El Solh 1107 2020. P.O.Box: 11-0236, Beirut, Lebanon; Abu-Haidar Neuroscience Institute, American University of Beirut Medical Center, Beirut, Lebanon.
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11
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Goldman MD, LaRocca NG, Rudick RA, Hudson LD, Chin PS, Francis GS, Jacobs A, Kapoor R, Matthews PM, Mowry EM, Balcer LJ, Panzara M, Phillips G, Uitdehaag BMJ, Cohen JA. Evaluation of multiple sclerosis disability outcome measures using pooled clinical trial data. Neurology 2019; 93:e1921-e1931. [PMID: 31641014 PMCID: PMC6885577 DOI: 10.1212/wnl.0000000000008519] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/24/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE We report analyses of a pooled database by the Multiple Sclerosis Outcome Assessments Consortium to evaluate 4 proposed components of a multidimensional test battery. METHODS Standardized data on 12,776 participants, comprising demographics, multiple sclerosis disease characteristics, Expanded Disability Status Scale (EDSS) score, performance measures, and Short Form-36 Physical Component Summary (SF-36 PCS), were pooled from control and treatment arms of 14 clinical trials. Analyses of Timed 25-Foot Walk (T25FW), 9-Hole Peg Test (9HPT), Low Contrast Letter Acuity (LCLA), and Symbol Digit Modalities Test (SDMT) included measurement properties; construct, convergent, and known group validity; and longitudinal performance of the measures individually and when combined into a multidimensional test battery relative to the EDSS and SF-36 to determine sensitivity and clinical meaningfulness. RESULTS The performance measures had excellent test-retest reliability and showed expected differences between subgroups based on disease duration and EDSS level. Progression rates in detecting time to 3-month confirmed worsening were lower for T25FW and 9HPT compared to EDSS, while progression rates for LCLA and SDMT were similar to EDSS. When the 4 measures were analyzed as a multidimensional measure rather than as individual measures, progression on any one performance measure was more sensitive than the EDSS. Worsening on the performance measures analyzed individually or as a multidimensional test battery was associated with clinically meaningful SF-36 PCS score worsening, supporting clinical meaningfulness of designated performance test score worsening. CONCLUSION These results support the use of the 4 proposed performance measures, individually or combined into a multidimensional test battery as study outcome measures.
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Affiliation(s)
- Myla D Goldman
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Nicholas G LaRocca
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Richard A Rudick
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Lynn D Hudson
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Peter S Chin
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Gordon S Francis
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Adam Jacobs
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Raj Kapoor
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Paul M Matthews
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Ellen M Mowry
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Laura J Balcer
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Michael Panzara
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Glenn Phillips
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Bernard M J Uitdehaag
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH
| | - Jeffrey A Cohen
- From the University of Virginia (M.D.G.), Charlottesville; National Multiple Sclerosis Society (N.G.L.), New York, NY; Biogen (R.A.R., G.P.), Cambridge, MA; Critical Path Institute (L.D.H.), Tucson, AZ; Genentech (P.S.C.), South San Francisco, CA; Independent Neurology Clinical Development Consultant (G.S.F.); Premier Research (A.J.), Wokingham, UK; UCL Institute of Neurology (R.K.), London, UK; Imperial College London and UK Dementia Research Institute (P.M.M.); Johns Hopkins (E.M.M.), Baltimore, MD; New York University School of Medicine (L.J.B.), NY; Wave Life Sciences (M.P.), Cambridge, MA; VU University Medical Center (B.M.J.U.), Amsterdam, the Netherlands; and Cleveland Clinic (J.A.C.), OH.
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Responder rates to fampridine differ between clinical subgroups of MS patients and patient reported outcome influences treatment decision making. Mult Scler Relat Disord 2019; 38:101489. [PMID: 31731213 DOI: 10.1016/j.msard.2019.101489] [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: 12/14/2018] [Revised: 10/06/2019] [Accepted: 10/30/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Fampridine is an effective treatment to improve ambulation for some multiple sclerosis (MS) patients. Remarkable discrepancies exist between responder rates in clinical trials and the proportion of patients continuing treatment in clinical practice. This may be related to clinical phenotypes of MS patients, and the influence of patient reported outcome (PRO) on treatment decision making. OBJECTIVE To analyse responder rates to fampridine on ambulation and upper extremity function (UEF) and the influence on treatment decision making in different clinical subgroups in a real-world setting. METHODS MS patients with ambulatory impairment treated with fampridine were included. Patients were subdivided based on disease duration, clinical phenotype, Expanded Disability Status Scale (EDSS), baseline walking speed, and presence of UEF impairment. Ambulatory response was assessed with the Timed 25-Foot Walk (T25FW, responder defined as ≥20% improvement) and with the MS Walking Scale (MSWS, responder defined as ≥8 points improvement) as a PRO. For patients also reporting impaired UEF, the Arm Function in MS Questionnaire (AMSQ, responder defined as ≥15 improvement) was the PRO of choice. Decision on treatment continuation was based on improvement of T25FW, MSWS and the clinicians' overall impression for improvement. RESULTS In total 344 patients were included of which 75.3% continued treatment. More patients with a relapsing clinical phenotype continued treatment vs patients with a progressive phenotype (83.6 vs 68.6%, p < 0.01). A positive linear trend was found between severity of walking disability, as determined by baseline walking speed, and T25FW response (p < 0.01), while there was an inverse linear association between walking disability and MSWS response (p = 0.03). However, the proportion of patients continuing treatment was similar between subgroups of baseline walking speed. Impaired UEF was reported by 183 (66.5%) patients, of which 64 (39.3%) were AMSQ responders. Patients responding on AMSQ compared to non-responders, were also more frequently MSWS responders (82.8 vs 65.3%, p = 0.02), while response on T25FW was similar, and continued treatment more often (85.9 vs 70.7%, p = 0.04). This suggests an influence of PRO on treatment decision making. CONCLUSION Responder rates and treatment continuation of fampridine differed between clinical subgroups of MS. PROs influenced treatment decision making of fampridine in clinical practice, particularly in patients with mild ambulatory impairment or those reporting UEF impairment. To some extent, these findings explain discrepancies found between clinical trials and clinical practice, and support the importance of subgroup analyses and incorporation of PROs in clinical trials. For clinical practice, using PROs to assess patients experience in conjunction with performance measures helps in treatment decision making.
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13
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Wolinsky JS, Montalban X, Hauser SL, Giovannoni G, Vermersch P, Bernasconi C, Deol-Bhullar G, Garren H, Chin P, Belachew S, Kappos L. Evaluation of no evidence of progression or active disease (NEPAD) in patients with primary progressive multiple sclerosis in the ORATORIO trial. Ann Neurol 2019; 84:527-536. [PMID: 30155979 PMCID: PMC6220799 DOI: 10.1002/ana.25313] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 08/08/2018] [Accepted: 08/12/2018] [Indexed: 12/15/2022]
Abstract
Objective No evidence of progression or active disease (NEPAD) is a novel combined endpoint defined by the absence of both progression and inflammatory disease activity in primary progressive multiple sclerosis (PPMS). In the placebo‐controlled phase III ORATORIO study (NCT01194570), we investigated the effect of ocrelizumab on this comprehensive outcome and its components in a post‐hoc analysis. Methods The proportion of patients with NEPAD (no evidence of progression [NEP; no 12‐week confirmed progression of ≥1/≥0.5 points on the Expanded Disability Status Scale if the baseline score was ≤5.5/>5.5 points, respectively; no 12‐week confirmed progression of ≥20% on the Timed 25‐Foot Walk test and 9‐Hole Peg Test], no brain magnetic resonance imaging activity [no new/enlarging T2 lesions and no T1 gadolinium‐enhancing lesions], and no protocol‐defined relapse) from baseline to week 120 was determined in ocrelizumab‐ (600 mg; n = 465) and placebo‐treated (n = 234) patients. Results The majority of ORATORIO study patients with PPMS experienced clinical progression or evidence of disease activity. From baseline to week 120, 29.9% and 42.7% ocrelizumab‐treated compared to 9.4% and 29.1% placebo‐treated patients maintained NEPAD (relative risk [95% confidence interval {CI}], 3.15 [2.07–4.79]; p < 0.001) and NEP (relative risk [95% CI], 1.47 [1.17–1.84]; p < 0.001), respectively. Effects on the individual components of both measures were consistent with the compound outcomes. Interpretation Compared to placebo, ocrelizumab enhanced 3‐fold the proportion of PPMS patients with no evidence of either progression or inflammatory disease activity. NEPAD may represent a sensitive and meaningful comprehensive measure of disease control in patients with PPMS. Ann Neurol 2018;84:527–536
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Affiliation(s)
- Jerry S Wolinsky
- McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Xavier Montalban
- Division of Neurology, University of Toronto, Toronto, ON, Canada.,Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | | | | | | | | | - Peter Chin
- Genentech, Inc., South San Francisco, CA
| | | | - Ludwig Kappos
- University Hospital Basel, University of Basel, Basel, Switzerland
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14
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Fox EJ, Markowitz C, Applebee A, Montalban X, Wolinsky JS, Belachew S, Fiore D, Pei J, Musch B, Giovannoni G. Ocrelizumab reduces progression of upper extremity impairment in patients with primary progressive multiple sclerosis: Findings from the phase III randomized ORATORIO trial. Mult Scler 2018; 24:1862-1870. [PMID: 30415593 PMCID: PMC6282157 DOI: 10.1177/1352458518808189] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Upper extremity (UE) impairment is common with primary progressive multiple
sclerosis (PPMS). Objective: This exploratory analysis examined the effects of ocrelizumab on confirmed
progression (CP) and confirmed improvement (CI) in UE impairment in patients
from ORATORIO. Methods: Patients with PPMS received ocrelizumab 600 mg or placebo every 24 weeks for
⩾120 weeks. The Nine-Hole Peg Test (9HPT) was administered at baseline (BL)
and every 12 weeks thereafter. Prespecified exploratory endpoints included
change in 9HPT time and proportion of patients with CP of ⩾20% in 9HPT.
Analysis populations included intention-to-treat (ITT) patients and
subgroups stratified by BL 9HPT time and Expanded Disability Status Scale.
Post hoc analyses included the proportion of patients achieving more severe
thresholds of CP and the proportion achieving CI in 9HPT. Results: Among ITT patients, ocrelizumab significantly reduced the change in 9HPT time
over 120 weeks, the risk of CP of ⩾20% in 9HPT time for both hands and the
risk of more severe 9HPT progression versus placebo. Numerical trends also
favoured ocrelizumab versus placebo with respect to achieving CI. Consistent
directional trends were observed in subgroup analyses. Conclusion: Ocrelizumab reduces the risk of UE disability progression and may increase
the possibility of improvement versus placebo in PPMS.
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Affiliation(s)
- Edward J Fox
- Central Texas Neurology Consultants and Dell Medical School, The University of Texas at Austin, Round Rock, TX, USA
| | - Clyde Markowitz
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Angela Applebee
- Department of Neurology, St. Peter's Health Partners, Albany, NY, USA
| | - Xavier Montalban
- Division of Neurology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada/ Department of Neurology/Neuroimmunology, Centre d'Esclerosi Múltiple de Catalunya (CEMCAT), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jerry S Wolinsky
- McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | | | | | - Jinglan Pei
- Genentech, Inc., South San Francisco, CA, USA
| | - Bruno Musch
- Genentech, Inc., South San Francisco, CA, USA
| | - Gavin Giovannoni
- Department of Neurology, Queen Mary University of London, London, UK
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Connick P, De Angelis F, Parker RA, Plantone D, Doshi A, John N, Stutters J, MacManus D, Prados Carrasco F, Barkhof F, Ourselin S, Braisher M, Ross M, Cranswick G, Pavitt SH, Giovannoni G, Gandini Wheeler-Kingshott CA, Hawkins C, Sharrack B, Bastow R, Weir CJ, Stallard N, Chandran S, Chataway J. Multiple Sclerosis-Secondary Progressive Multi-Arm Randomisation Trial (MS-SMART): a multiarm phase IIb randomised, double-blind, placebo-controlled clinical trial comparing the efficacy of three neuroprotective drugs in secondary progressive multiple sclerosis. BMJ Open 2018; 8:e021944. [PMID: 30166303 PMCID: PMC6119433 DOI: 10.1136/bmjopen-2018-021944] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/18/2018] [Accepted: 06/20/2018] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION The major unmet need in multiple sclerosis (MS) is for neuroprotective therapies that can slow (or ideally stop) the rate of disease progression. The UK MS Society Clinical Trials Network (CTN) was initiated in 2007 with the purpose of developing a national, efficient, multiarm trial of repurposed drugs. Key underpinning work was commissioned by the CTN to inform the design, outcome selection and drug choice including animal models and a systematic review. This identified seven leading oral agents for repurposing as neuroprotective therapies in secondary progressive MS (SPMS). The purpose of the Multiple Sclerosis-Secondary Progressive Multi-Arm Randomisation Trial (MS-SMART) will be to evaluate the neuroprotective efficacy of three of these drugs, selected with distinct mechanistic actions and previous evidence of likely efficacy, against a common placebo arm. The interventions chosen were: amiloride (acid-sensing ion channel antagonist); fluoxetine (selective serotonin reuptake inhibitor) and riluzole (glutamate antagonist). METHODS AND ANALYSIS Patients with progressing SPMS will be randomised 1:1:1:1 to amiloride, fluoxetine, riluzole or matched placebo and followed for 96 weeks. The primary outcome will be the percentage brain volume change (PBVC) between baseline and 96 weeks, derived from structural MR brain imaging data using the Structural Image Evaluation, using Normalisation, of Atrophy method. With a sample size of 90 per arm, this will give 90% power to detect a 40% reduction in PBVC in any active arm compared with placebo and 80% power to detect a 35% reduction (analysing by analysis of covariance and with adjustment for multiple comparisons of three 1.67% two-sided tests), giving a 5% overall two-sided significance level. MS-SMART is not powered to detect differences between the three active treatment arms. Allowing for a 20% dropout rate, 110 patients per arm will be randomised. The study will take place at Neuroscience centres in England and Scotland. ETHICS AND DISSEMINATION MS-SMART was approved by the Scotland A Research Ethics Committee on 13 January 2013 (REC reference: 13/SS/0007). Results of the study will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBERS NCT01910259; 2012-005394-31; ISRCTN28440672.
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Affiliation(s)
- Peter Connick
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Floriana De Angelis
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | - Richard A Parker
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Domenico Plantone
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | - Anisha Doshi
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | - Nevin John
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | - Jonathan Stutters
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | - David MacManus
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | - Ferran Prados Carrasco
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
- Department of Medical Physics and Biomedical Engineering, Translational Imaging Group (TIG), Centre for Medical Image Computing (CMIC), UCL, London, UK
| | - Frederik Barkhof
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
- Department of Radiology and Nuclear Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Sebastien Ourselin
- Department of Medical Physics and Biomedical Engineering, Translational Imaging Group (TIG), Centre for Medical Image Computing (CMIC), UCL, London, UK
| | - Marie Braisher
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | - Moira Ross
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Gina Cranswick
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Sue H Pavitt
- Dental Translational and Clinical Research Unit (part of the NIHR Leeds CRF), University of Leeds, Leeds, UK
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Claudia Angela Gandini Wheeler-Kingshott
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
- Brain MRI 3T Research Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Clive Hawkins
- Keele Medical School and Institute for Science and Technology in Medicine, Keele University, Keele, UK
| | - Basil Sharrack
- Department of Neuroscience, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Jeremy Chataway
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
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Tur C, Moccia M, Barkhof F, Chataway J, Sastre-Garriga J, Thompson AJ, Ciccarelli O. Assessing treatment outcomes in multiple sclerosis trials and in the clinical setting. Nat Rev Neurol 2018; 14:75-93. [PMID: 29326424 DOI: 10.1038/nrneurol.2017.171] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Increasing numbers of drugs are being developed for the treatment of multiple sclerosis (MS). Measurement of relevant outcomes is key for assessing the efficacy of new drugs in clinical trials and for monitoring responses to disease-modifying drugs in individual patients. Most outcomes used in trial and clinical settings reflect either clinical or neuroimaging aspects of MS (such as relapse and accrual of disability or the presence of visible inflammation and brain tissue loss, respectively). However, most measures employed in clinical trials to assess treatment effects are not used in routine practice. In clinical trials, the appropriate choice of outcome measures is crucial because the results determine whether a drug is considered effective and therefore worthy of further development; in the clinic, outcome measures can guide treatment decisions, such as choosing a first-line disease-modifying drug or escalating to second-line treatment. This Review discusses clinical, neuroimaging and composite outcome measures for MS, including patient-reported outcome measures, used in both trials and the clinical setting. Its aim is to help clinicians and researchers navigate through the multiple options encountered when choosing an outcome measure. Barriers and limitations that need to be overcome to translate trial outcome measures into the clinical setting are also discussed.
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Affiliation(s)
- Carmen Tur
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK
| | - Marcello Moccia
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Federico II University, Via Sergio Pansini 5, Naples 80131, Italy
| | - Frederik Barkhof
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,Institute of Healthcare Engineering, University College London, Engineering Front Building, Room 2.01, 2nd Floor, Torrington Place, WC1E 7JE London, UK.,Vrije Universiteit (VU) University Medical Centre - Radiology and Nuclear Medicine, Van der Boechorststraat 7 F/A-114, 1081 BT Amsterdam, Netherlands.,National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK
| | - Jaume Sastre-Garriga
- Multiple Sclerosis Centre of Catalonia, Department of Neurology and Neuroimmunology, Vall d'Hebron University Hospital, 119-129, 08035 Barcelona, Spain
| | - Alan J Thompson
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK.,University College London Faculty of Brain Sciences, Institute of Neurology, Department of Brain Repair and Rehabilitation, Queen Square, London WC1N 3BG, UK
| | - Olga Ciccarelli
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK
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17
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Feys P, Lamers I, Francis G, Benedict R, Phillips G, LaRocca N, Hudson LD, Rudick R. The Nine-Hole Peg Test as a manual dexterity performance measure for multiple sclerosis. Mult Scler 2017; 23:711-720. [PMID: 28206826 PMCID: PMC5405844 DOI: 10.1177/1352458517690824] [Citation(s) in RCA: 263] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Peter Feys
- Rehabilitation Research Center (REVAL), Biomedical Research Institute (BIOMED), Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Ilse Lamers
- Rehabilitation Research Center (REVAL), Biomedical Research Institute (BIOMED), Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Gordon Francis
- Neuroscience Clinical Development, San Francisco, CA, USA
| | - Ralph Benedict
- Department of Neurology, University at Buffalo, Buffalo, NY, USA
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- Multiple Sclerosis Outcome Assessments Consortium (MSOAC), Critical Path Institute, Tucson, AZ, USA
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18
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Cohen ET, Kietrys D, Fogerite SG, Silva M, Logan K, Barone DA, Parrott JS. Feasibility and Impact of an 8-Week Integrative Yoga Program in People with Moderate Multiple Sclerosis-Related Disability: A Pilot Study. Int J MS Care 2017; 19:30-39. [PMID: 28243184 PMCID: PMC5315321 DOI: 10.7224/1537-2073.2015-046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND This pilot study determined the feasibility of a specifically designed 8-week yoga program for people with moderate multiple sclerosis (MS)-related disability. We explored the program's effect on quality of life (QOL) and physical and mental performance. METHODS We used a single-group design with repeated measurements at baseline, postintervention, and 8-week follow-up. Feasibility was examined through cost, recruitment, retention, attendance, and safety. Outcomes included the Multiple Sclerosis Quality of Life Inventory (MSQLI), 12-item Multiple Sclerosis Walking Scale (MSWS-12), Timed 25-Foot Walk test (T25FW), 6-Minute Walk Test (6MWT), Nine-Hole Peg Test (NHPT), Five-Times Sit-to-Stand Test (FTSTS), Multidirectional Reach Test (MDRT), maximum expiratory pressure, and Paced Auditory Serial Addition Test-3″ (PASAT-3″). RESULTS Fourteen participants completed the study. The program was feasible. There were significant main effects on the 36-item Short Form Health Status Survey Mental Component Summary (SF-36 MCS), Modified Fatigue Impact Scale (MFIS), Bladder Control Scale (BLCS), Perceived Deficits Questionnaire (PDQ), Mental Health Inventory (MHI), MSWS-12, T25FW, NHPT, PASAT-3″, 6MWT, FTSTS, and MDRT-Back. Improvements were found on the SF-36 MCS, MFIS, BLCS, PDQ, MHI, and MSWS-12 between baseline and postintervention. The effect on PDQ persisted at follow-up. Improvements were found on the T25FW, NHPT, 6MWT, FTSTS, and MDRT-Back between baseline and postintervention that persisted at follow-up. The PASAT-3″ did not change between baseline and postintervention but did between postintervention and follow-up. CONCLUSIONS The yoga program was safe and feasible. Improvements in certain measures of QOL and performance were seen at postintervention and follow-up.
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19
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Cadavid D, Cohen JA, Freedman MS, Goldman MD, Hartung HP, Havrdova E, Jeffery D, Kapoor R, Miller A, Sellebjerg F, Kinch D, Lee S, Shang S, Mikol D. The EDSS-Plus, an improved endpoint for disability progression in secondary progressive multiple sclerosis. Mult Scler 2016; 23:94-105. [PMID: 27003945 DOI: 10.1177/1352458516638941] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Expanded Disability Status Scale (EDSS) has wide scientific and regulatory precedent but limited ability to detect clinically relevant disability progression in secondary progressive multiple sclerosis (SPMS) patients, partly due to a lack of meaningful measurement of short-distance ambulatory and upper-extremity function. OBJECTIVE To present a rationale for a composite endpoint adding the timed 25-foot walk (T25FW) and 9-Hole Peg Test (9HPT) to EDSS for SPMS disability progression assessment. METHODS Using the International Multiple Sclerosis Secondary Progressive Avonex Clinical Trial (IMPACT) placebo arm ( n = 215) data, we analyzed disability progression using a novel progression endpoint, "EDSS-Plus," defined as progression on ⩾1 of 3 components (EDSS, T25FW, and/or 9HPT) confirmed ⩾24 weeks apart and with a ⩾20% minimum threshold change for T25FW and 9HPT. RESULTS Over 2 years, subjects classified as T25FW, 9HPT (dominant hand), or 9HPT (non-dominant hand) progressors worsened on average by 103.4%, 69.0%, and 59.2%, respectively, while non-progressors' times remained largely unchanged. Using EDSS-Plus, 59.5% of the patients had 24-week confirmed disability progression versus 24.7% (EDSS), 41.9% (T25FW), and 34.4% (9HPT (either hand)) on each component alone. CONCLUSION The 24-week confirmed minimum worsening of ⩾20% for T25FW and 9HPT clearly separates SPMS progressors from non-progressors. We propose that EDSS-Plus may represent an improved endpoint to identify SPMS disability progression.
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Affiliation(s)
| | | | - Mark S Freedman
- University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich- Heine University, Düsseldorf, Germany
| | - Eva Havrdova
- Charles University in Prague, Prague, Czech Republic
| | | | - Raj Kapoor
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Aaron Miller
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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20
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Savin Z, Lejbkowicz I, Glass-Marmor L, Lavi I, Rosenblum S, Miller A. Effect of Fampridine-PR (prolonged released 4-aminopyridine) on the manual functions of patients with Multiple Sclerosis. J Neurol Sci 2015; 360:102-9. [PMID: 26723984 DOI: 10.1016/j.jns.2015.11.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 11/16/2015] [Accepted: 11/19/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Persons with MS (PwMS) commonly present ambulatory and manual dysfunctions. While ambulation is recognized as important to PwMS, manual dysfunction is only lately gaining attention. Fampridine-PR was approved for MS ambulatory impairments. Anecdotal evidences indicate possible therapeutic effects on manual function. OBJECTIVE To comprehensively assess the effect of Fampridine-PR on manual functions of PwMS. METHODS Twenty six PwMS with ambulatory and manual dysfunction assessed before, 1 and 3months after treatment with Fampridine-PR, applying Timed 25-Foot Walk (T25FW) for ambulation while manual functions were evaluated by several tools addressing the International Classification of Functioning (ICF) concepts. This includes hand grip and pinch strength, 9 Hole Peg Test (9HPT), Arthritis Hand Function Test (AHFT), activities of daily life (ADL) tests, ABILHAND questionnaire and Computerized Penmanship Evaluation Tool (ComPET). RESULTS Fampridine-PR increased dominant hand grip and pinch strength 1month following treatment initiation by 12% and 10% (p<0.05), respectively. 9HPT improved by 11.3% after 3months of treatment (p<0.05%) and ABILHAND improved by 16% and 31% (p<0.05%) after 1 and 3months of treatment. Mean stroke duration in air of the name writing task improved by 21% (p<0.05) following 3months of treatment. T25FW results were similar to previous reports. CONCLUSION The results of this pilot study suggest that Fampridine-PR improves manual function of PwMS. Methods herein indicate that an integrative approach may be useful for evaluation of manual function in MS and in additional neurological diseases.
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Affiliation(s)
- Ziv Savin
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Efron Street, Haifa, Israel.
| | - Izabella Lejbkowicz
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Efron Street, Haifa, Israel; Multiple Sclerosis & Brain Research Center, Carmel Medical Center, 7 Michal Street, Haifa, Israel.
| | - Lea Glass-Marmor
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Efron Street, Haifa, Israel; Multiple Sclerosis & Brain Research Center, Carmel Medical Center, 7 Michal Street, Haifa, Israel.
| | - Idit Lavi
- Department of Community Medicine and Epidemiology, Carmel Medical Center, 7 Michal Street, Haifa, Israel.
| | - Sara Rosenblum
- The Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, 199 Aba Khoushy Avenue, Haifa, Israel.
| | - Ariel Miller
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Efron Street, Haifa, Israel; Multiple Sclerosis & Brain Research Center, Carmel Medical Center, 7 Michal Street, Haifa, Israel.
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21
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Damasceno A, Damasceno BP, Cendes F. No evidence of disease activity in multiple sclerosis: Implications on cognition and brain atrophy. Mult Scler 2015; 22:64-72. [PMID: 26432855 DOI: 10.1177/1352458515604383] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/08/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND The concept of no evidence of disease activity (NEDA) has emerged as an important outcome measure for multiple sclerosis (MS). However, it is not known if maintaining NEDA has a positive impact on cognition or brain atrophy. OBJECTIVE To evaluate NEDA status after two years, addressing its implications on cognition and brain atrophy. METHODS Forty-two relapsing-remitting MS patients and 30 controls underwent MRI (3T) and cognitive evaluation (BRB-N). Forty patients performed additional evaluations, after 12 and 24 months. NEDA was defined as the absence of clinical (relapses/disability progression) and MRI activity (new T2/gadolinium-enhancing lesions). Repeated measures and multivariate analyses were performed to assess the contribution of NEDA criteria to GM atrophy. RESULTS After two years, 30.8% of the cohort had NEDA. From these, 58.3% still had worsening in ⩾2 cognitive domains. Patients with MRI activity had more cortical thinning and slightly more thalamus volume decrease. Absence of new/enlarging T2 lesions was the only predictor of cortical thinning, subcortical GM and thalamic atrophy rates. CONCLUSIONS NEDA status was achieved in a small proportion of our cohort, and did not preclude cognitive deterioration. Absence of MRI activity and especially of new/enlarging T2 lesions was associated with less cortical and subcortical GM atrophy.
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Affiliation(s)
- Alfredo Damasceno
- Departamento de Neurologia, Rua Tessália Vieira de Camargo, Universitária Zeferino Vaz, Brazil
| | | | - Fernando Cendes
- Department of Neurology, University of Campinas (UNICAMP), Brazil
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22
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Longitudinal changes in self-reported walking ability in multiple sclerosis. PLoS One 2015; 10:e0125002. [PMID: 25932911 PMCID: PMC4416760 DOI: 10.1371/journal.pone.0125002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 03/19/2015] [Indexed: 12/03/2022] Open
Abstract
Background Patient-reported outcomes are increasingly used to understand the clinical meaningfulness of multiple sclerosis disability and its treatments. For example, the 12-item Multiple Sclerosis Walking Scale (MSWS-12) measures the patient-reported impact of the disease on walking ability. Objective We studied longitudinal changes in walking ability using the MSWS-12 in a cohort of 108 patients with relapsing-remitting multiple sclerosis and moderate-to-severe disability from a single US center cohort study investigating multiple sclerosis symptoms and physical activity. Methods The MSWS-12 was completed every 6 months over 2 years together with self-reported measures of disease impact on daily life (Multiple Sclerosis Impact Scale) and walking disability (Patient Determined Disease Steps scale). Results The results revealed a high frequency of self-reported changes in walking ability at the individual level, affecting approximately 80% of patients for all four time periods. MSWS-12 scores remained stable at the group level for all four time periods. The magnitude of observed changes at the individual level was higher than the proposed minimal clinically important differences of 4 or 6 points and correlated better with Multiple Sclerosis Impact Scale physical scores than psychological scores, but little with self-reported Patient Determined Disease Steps Scale scores. Conclusions This novel finding of frequent fluctuations in self-reported walking ability is new and requires further investigation.
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Karabudak R, Dahdaleh M, Aljumah M, Alroughani R, Alsharoqi IA, AlTahan AM, Bohlega SA, Daif A, Deleu D, Amous A, Inshasi JS, Rieckmann P, Sahraian MA, Yamout BI. Functional clinical outcomes in multiple sclerosis: Current status and future prospects. Mult Scler Relat Disord 2015; 4:192-201. [PMID: 26008936 DOI: 10.1016/j.msard.2015.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/23/2015] [Accepted: 03/14/2015] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Rana Karabudak
- Hacettepe University Hospitals, Dept. of Neurology, Neuroimmunology Unit, Ankara, Turkey.
| | - Maurice Dahdaleh
- Department of Internal Medicine, Neurology Section, Arab Medical Center and Khalidi Hospital, Amman, Jordan
| | - Mohammed Aljumah
- King Abdullah International Medical Research Center, King Saud Ben Abdulaziz University for Health Sciences, NGHA, Riyadh, Saudi Arabia; Prince Mohammed bin Abdul-Aziz Hospital, Ministry of Health, Riyadh, Saudi Arabia
| | - Raed Alroughani
- Division of Neurology, Amiri Hospital, Kuwait; Division of Neurology, Dasman Diabetes Institute, Kuwait
| | - I Ahmed Alsharoqi
- Clinical Neurosciences Department, Salmaniya Medical Complex, Manama, Bahrain
| | - Abdulrahman M AlTahan
- Neurology Section, King Khalid University Hospital, King Saud University and Dallah Hospital, Saudi Arabia
| | - Saeed A Bohlega
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulkader Daif
- Neurology Section, King Khalid University Hospital, King Saud University and Dallah Hospital, Saudi Arabia
| | - Dirk Deleu
- Department of Neurology (Medicine), Hamad Medical Corporation, Doha, Qatar
| | - Amer Amous
- Merck Serono Intercontinental Region, Dubai, United Arab Emirates
| | - Jihad S Inshasi
- Neurology Department, Rashid Hospital and Dubai Medical College, Dubai Health Authority, United Arab Emirates
| | | | - Mohammed A Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Iran
| | - Bassem I Yamout
- Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
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24
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Goodman AD, Brown TR, Schapiro RT, Klingler M, Cohen R, Blight AR. A pooled analysis of two phase 3 clinical trials of dalfampridine in patients with multiple sclerosis. Int J MS Care 2014; 16:153-60. [PMID: 25337058 DOI: 10.7224/1537-2073.2013-023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Two phase 3 clinical trials demonstrated that dalfampridine extended-release 10-mg tablets (D-ER), twice daily, significantly improved walking relative to placebo in patients with multiple sclerosis (MS). The objective of this study was to evaluate the efficacy and safety of D-ER in patients with MS using pooled data from the two phase 3 trials. METHODS Data were pooled from the two trials, and D-ER was compared with placebo for timed-walk responder rate, changes in walking speed, and the 12-item Multiple Sclerosis Walking Scale (MSWS-12). Response rates were evaluated with respect to demographic and clinical characteristics. RESULTS D-ER had a significantly higher proportion of timed-walk responders relative to placebo (37.6% vs. 8.9%; P < .0001). The responder rate was independent of age, gender, race, body-mass index, type of MS, duration of MS, baseline Expanded Disability Status Scale score, baseline walking speed, and concomitant use of immunomodulatory therapies. Significant improvements were observed in walking speed and in MSWS-12 score for the pooled D-ER group compared with placebo. The safety profile was consistent with the individual studies; no new safety or tolerability concerns were identified. CONCLUSIONS D-ER demonstrated efficacy for the improvement of walking in patients with MS; response was independent of demographic and clinical characteristics.
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Affiliation(s)
- Andrew D Goodman
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA (ADG); Evergreen Hospital Medical Center, Kirkland, WA, USA (TRB); Minneapolis Clinic of Neurology, Minneapolis, MN, USA (RTS); and Acorda Therapeutics, Inc., Ardsley, NY, USA (MK, RC, ARB)
| | - Theodore R Brown
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA (ADG); Evergreen Hospital Medical Center, Kirkland, WA, USA (TRB); Minneapolis Clinic of Neurology, Minneapolis, MN, USA (RTS); and Acorda Therapeutics, Inc., Ardsley, NY, USA (MK, RC, ARB)
| | - Randall T Schapiro
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA (ADG); Evergreen Hospital Medical Center, Kirkland, WA, USA (TRB); Minneapolis Clinic of Neurology, Minneapolis, MN, USA (RTS); and Acorda Therapeutics, Inc., Ardsley, NY, USA (MK, RC, ARB)
| | - Michael Klingler
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA (ADG); Evergreen Hospital Medical Center, Kirkland, WA, USA (TRB); Minneapolis Clinic of Neurology, Minneapolis, MN, USA (RTS); and Acorda Therapeutics, Inc., Ardsley, NY, USA (MK, RC, ARB)
| | - Ron Cohen
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA (ADG); Evergreen Hospital Medical Center, Kirkland, WA, USA (TRB); Minneapolis Clinic of Neurology, Minneapolis, MN, USA (RTS); and Acorda Therapeutics, Inc., Ardsley, NY, USA (MK, RC, ARB)
| | - Andrew R Blight
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA (ADG); Evergreen Hospital Medical Center, Kirkland, WA, USA (TRB); Minneapolis Clinic of Neurology, Minneapolis, MN, USA (RTS); and Acorda Therapeutics, Inc., Ardsley, NY, USA (MK, RC, ARB)
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25
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Bosma LVAE, Sonder JM, Kragt JJ, Polman CH, Uitdehaag BMJ. Detecting clinically-relevant changes in progressive multiple sclerosis. Mult Scler 2014; 21:171-9. [PMID: 25013153 DOI: 10.1177/1352458514540969] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate which changes in different clinical outcome measures contribute most to increased disease impact, as reported by the patient, in progressive multiple sclerosis (MS). METHODS From a cohort of prospectively-followed MS patients, we selected progressive patients with two visits, 4-6 years apart. We assessed long-term changes on the Expanded Disability Status Scale (EDSS), Timed 25-Foot Walk (T25FW), 9-Hole Peg Test (9HPT) and Guy's Neurological Disability Scale (GNDS). We defined the presence or absence of clinically meaningful change by using the Multiple Sclerosis Impact Scale (MSIS-29) as an anchor measure. We also studied change on recently identified sub-scales of GNDS. RESULTS Change on GNDS (especially the spinal-plus subscale) contributed most to increased disease impact. Also change on the T25FW contributed largely. Specific profiles of change in T25FW and MSIS seemed to exist (generally, a lower increase in disease impact in patients with longer disease duration and higher baseline impact/disability). In some patients a dissociation existed between increased impact, according to the MSIS-29, and objective physical worsening of the T25FW. CONCLUSION These results support using GNDS (particularly the spinal-plus domain) and T25FW in outcome measurement in progressive MS. We suggest there is a relation between baseline clinical characteristics and an increased impact at follow-up. This may have implications for patient selection in trials for progressive MS.
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Affiliation(s)
- L V A E Bosma
- VU University Medical Center, Amsterdam, The Netherlands
| | - J M Sonder
- VU University Medical Center, Amsterdam, The Netherlands
| | - J J Kragt
- VU University Medical Center, Amsterdam, The Netherlands/Reinier de Graaf Groep, Delft, The Netherlands
| | - C H Polman
- VU University Medical Center, Amsterdam, The Netherlands
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26
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Meyer-Moock S, Feng YS, Maeurer M, Dippel FW, Kohlmann T. 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. BMC Neurol 2014; 14:58. [PMID: 24666846 PMCID: PMC3986942 DOI: 10.1186/1471-2377-14-58] [Citation(s) in RCA: 386] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 03/17/2014] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Sandra Meyer-Moock
- Institute for Community Medicine, University Medicine Greifswald, Walther-Rathenau-Strasse 48, 17475 Greifswald, Germany
| | - You-Shan Feng
- Institute for Community Medicine, University Medicine Greifswald, Walther-Rathenau-Strasse 48, 17475 Greifswald, Germany
| | - Mathias Maeurer
- Department of Neurology, Caritas Krankenhaus, Bad Mergentheim, Germany
| | - Franz-Werner Dippel
- Department of Internal Medicine, Neurology and Dermatology, University of Leipzig, Leipzig, Germany
| | - Thomas Kohlmann
- Institute for Community Medicine, University Medicine Greifswald, Walther-Rathenau-Strasse 48, 17475 Greifswald, Germany
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Lamers I, Feys P. Assessing upper limb function in multiple sclerosis. Mult Scler 2014; 20:775-84. [DOI: 10.1177/1352458514525677] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 02/04/2014] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Ilse Lamers
- REVAL – Rehabilitation Research Institute, BIOMED – Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Belgium
| | - Peter Feys
- REVAL – Rehabilitation Research Institute, BIOMED – Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Belgium
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Lamers I, Kelchtermans S, Baert I, Feys P. Upper limb assessment in multiple sclerosis: a systematic review of outcome measures and their psychometric properties. Arch Phys Med Rehabil 2014; 95:1184-200. [PMID: 24631802 DOI: 10.1016/j.apmr.2014.02.023] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 01/30/2014] [Accepted: 02/25/2014] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Ilse Lamers
- Rehabilitation Research Institute, BIOMED-Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.
| | - Silke Kelchtermans
- Rehabilitation Research Institute, BIOMED-Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Ilse Baert
- Rehabilitation Research Institute, BIOMED-Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Peter Feys
- Rehabilitation Research Institute, BIOMED-Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
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Osborne LA, Gareth Noble J, Maramba IDC, Jones KH, Middleton RM, Lyons RA, Ford DV, Reed P. Outcome measures for multiple sclerosis. PHYSICAL THERAPY REVIEWS 2014. [DOI: 10.1179/1743288x13y.0000000094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Cambron M, Mostert J, Haentjens P, D'Hooghe M, Nagels G, Willekens B, Heersema D, Debruyne J, Van Hecke W, Algoed L, De Klippel N, Fosselle E, Laureys G, Merckx H, Van Wijmeersch B, Vanopdenbosch L, Verhagen W, Hupperts R, Hengstman G, Michiels V, Van Merhaegen-Wieleman A, De Keyser J. Fluoxetine in progressive multiple sclerosis (FLUOX-PMS): study protocol for a randomized controlled trial. Trials 2014; 15:37. [PMID: 24460863 PMCID: PMC3931920 DOI: 10.1186/1745-6215-15-37] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 01/14/2014] [Indexed: 11/30/2022] Open
Abstract
Background Currently available disease-modifying treatments acting by modifying the immune response are ineffective in progressive multiple sclerosis (MS), which is caused by a widespread axonal degeneration. Mechanisms suspected to be involved in this widespread axonal degeneration are reduced axonal energy metabolism, axonal glutamate toxicity, and reduced cerebral blood flow. Fluoxetine might theoretically reduce axonal degeneration in MS because it stimulates energy metabolism through enhancing glycogenolysis, stimulates the production of brain-derived neurotrophic factor, and dilates cerebral arterioles. The current document presents the protocol of a clinical trial to test the hypothesis that fluoxetine slows down the progressive phase of MS. Methods/Design The FLUOX-PMS trial is a multi-center, randomized, controlled and double-blind clinical study. A total of 120 patients with the diagnosis of either secondary or primary progressive MS will be treated either by fluoxetine (40 mg daily) or placebo for a total period of 108 weeks. The primary endpoint is the time to confirmed disease progression defined as either at least a 20% increase in the timed 25-Foot Walk or at least a 20% increase in the 9-Hole Peg Test. Secondary endpoints include the Hauser ambulation index, cognitive changes, fatigue, magnetic resonance imaging of the brain, and in a small subgroup optical coherence tomography. Discussion The FLUOX-PMS trial will gives us information as to whether fluoxetine has neuroprotective effects in patients with progressive MS. Trial Registration Eudra-CT: 2011-003775-11
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Affiliation(s)
- Melissa Cambron
- Department of Neurology, University Hospital Brussel, Center for Neurosciences Vrije Universiteit Brussel (VUB) UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
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31
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Liberatore G, Clarelli F, Nuara A, Ungaro D, Gatti R, Rovaris M, Martinelli V, Comola M, Comi G, Rossi P, Martinelli-Boneschi F. Predictors of effectiveness of multidisciplinary rehabilitation treatment on motor dysfunction in multiple sclerosis. Mult Scler 2013; 20:862-70. [PMID: 24166355 DOI: 10.1177/1352458513508834] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/15/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To identify clinical predictors of effectiveness of a motor rehabilitation treatment in a cohort of multiple sclerosis (MS) patients. MATERIALS AND METHODS We analysed 212 consecutive patients who underwent a short-term (3-7 weeks) intensive (two hours per day, five days per week), individualised, goal-oriented inpatient rehabilitation program. Activity limitation and impairment were measured on admission and discharge of the rehabilitation trial using the motor sub-items of the Functional Independence Measure (mFIM) and the Expanded Disability Status Scale (EDSS) score. Multivariate logistic regression models have been tested to evaluate the role of clinical baseline features on rehabilitation effectiveness. RESULTS According to pre-defined outcome measures, 75.1% of MS patients improved in either activity limitation (≥5 points delta mFIM) or impairment (≥1.0 delta EDSS score if baseline EDSS was ≤5.5, or ≥0.5 if baseline EDSS was >5.5), and 35.4% of MS patients improved in both outcomes. A relapsing-remitting course of disease, a more severe baseline impairment and activity limitation level, a shorter disease duration and a less severe balance dysfunction were predictive of the effectiveness of rehabilitation. DISCUSSION These data confirm that an intensive inpatient rehabilitation program is able to produce a short-term relevant improvement on clinical and functional outcome measures and suggest some clinical features which can be considered as potential predictors of the outcome of rehabilitative intervention.
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Affiliation(s)
- G Liberatore
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy Laboratory of Genetics of Neurological Complex Disorders, San Raffaele Scientific Institute, Italy
| | - F Clarelli
- Laboratory of Genetics of Neurological Complex Disorders, San Raffaele Scientific Institute, Italy
| | - A Nuara
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy
| | - D Ungaro
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy
| | - R Gatti
- Laboratory of Movement Analysis, San Raffaele Scientific Institute, Italy
| | - M Rovaris
- Neurorehabilitation Unit, Don C. Gnocchi Foundation ONLUS, Italy
| | - V Martinelli
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy
| | - M Comola
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy
| | - G Comi
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy
| | - P Rossi
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy Clinica Hildebrand, Centro Riabilitazione Brissago, Switzerland
| | - F Martinelli-Boneschi
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy Laboratory of Genetics of Neurological Complex Disorders, San Raffaele Scientific Institute, Italy
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Koch MW, Cutter G, Stys PK, Yong VW, Metz LM. Treatment trials in progressive MS—current challenges and future directions. Nat Rev Neurol 2013; 9:496-503. [DOI: 10.1038/nrneurol.2013.148] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ontaneda D, LaRocca N, Coetzee T, Rudick R. Revisiting the multiple sclerosis functional composite: proceedings from the National Multiple Sclerosis Society (NMSS) Task Force on Clinical Disability Measures. Mult Scler 2012; 18:1074-80. [PMID: 22740488 DOI: 10.1177/1352458512451512] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article describes proceedings from a meeting of the National Multiple Sclerosis Society (NMSS) Task Force on Clinical Disability Measures (the TF). The TF was appointed by the NMSS Research Programs Advisory Committee with the goal of pooling and analyzing existing datasets to explore the utility of novel disability outcome measures based on the Multiple Sclerosis Functional Composite (MSFC) approach. The TF seeks to determine the suitability of the MSFC approach as a primary clinical outcome measure for registration trials in MS. The TF met in Washington, DC, Dec. 14 and 15, 2011, and provided unanimous support for a collaborative approach involving representatives from academic medicine, the pharmaceutical industry, regulatory agencies, the NMSS and the Critical Path Institute. There was also unanimous agreement that analysis of existing datasets would be useful in making progress toward the objective. The TF placed high value on determining the clinical meaning of individual component measures for the MSFC, and in establishing optimal analysis methods for MSFC so that scores would be more interpretable than the originally recommended z-score method. The background for a collaborative project aimed at developing an improved disability outcome measure is described in this paper.
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Affiliation(s)
- D Ontaneda
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Cleveland, OH 44195, USA
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Abstract
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.
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Affiliation(s)
| | - Carlo Pozzilli
- Department of Neurology and Psychiatry, Sapienza University, Italy
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Abstract
In this article, the nature and course of cognitive dysfunction in MS are reviewed, particularly in the context of recent advances in our understanding of the diffuse nature of neuropathology in MS, and in the context of specific factors that may confer risk or protection for the development of cognitive impairment. In addition, assessment and screening approaches of MS-related cognitive dysfunction are discussed. MS is a condition not only restricted to the adult population, and this article includes a brief description of cognition in pediatric-onset MS. Finally, promising intervention approaches to treat cognitive problems in MS are summarized.
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Affiliation(s)
- Laura J Julian
- Department of Medicine, University of California San Francisco, 3333 California Street, STE 270, San Francisco, CA 94143-0920, USA.
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36
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Panitch H, Applebee A. Treatment of walking impairment in multiple sclerosis: an unmet need for a disease-specific disability. Expert Opin Pharmacother 2011; 12:1511-21. [PMID: 21635193 DOI: 10.1517/14656566.2011.586338] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Walking impairment is a clinical hallmark of multiple sclerosis (MS), a chronic neurologic disease characterized by axonal demyelination and dysfunction that results in progressive disability. Until recently, there were no therapies that specifically targeted the axonal dysfunction associated with walking impairment in MS. AREAS COVERED The purpose of this review is to discuss the unmet need for the treatment of walking impairment in MS patients and to evaluate how a new class of pharmacologic therapies, neurofunctional modifiers, potentially addresses this unmet need. Discussion is based on clinical experience and opinions supported by publications identified in the PubMed literature using the search terms 'multiple sclerosis' and 'mobility OR walking'. EXPERT OPINION The development and approval of new treatments for MS show promise for improving adherence to therapy and increasing the potential for clinical effectiveness. Renewed emphasis on integrating strategies that target the underlying pathophysiology with those that address symptoms of concern to patients also has the potential to improve the lives of MS patients and their caregivers. The introduction of neurofunctional modifiers, such as dalfampridine for the improvement of walking impairment, may be of benefit by improving function, mobility and overall quality of life for MS patients.
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Affiliation(s)
- Hillel Panitch
- University of Vermont College of Medicine, Neurology Service, Fletcher Allen Health Care, 1 South Prospect Street, Burlington, VT 05401, USA
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Sombekke MH, van der Voort LF, Kragt JJ, Nielsen JM, Guzel H, Visser A, Oudejans CBM, Crusius JBA, Peña AS, Vrenken H, Polman CH, Killestein J. Relevance of IL7R genotype and mRNA expression in Dutch patients with multiple sclerosis. Mult Scler 2011; 17:922-30. [DOI: 10.1177/1352458511402411] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The interleukin 7 receptor (IL7R) has been recognized as a susceptibility gene for Multiple Sclerosis (MS). Analysis of rs6897932 (the most strongly MS-associated single nucleotide polymorphism (SNP)), showed effects of genotype on the relative expression of membrane-bound to total amount of IL7R mRNA. Objective: We assessed the relevance of IL7R on MS phenotype (including clinical and magnetic resonance imaging (MRI) parameters) at DNA and mRNA level in Dutch patients with MS. Methods: The genotype of rs6897932 was analyzed in 697 patients with MS and 174 healthy controls. The relevance of genotype and carriership of the C allele on MS phenotype (disease activity and severity, using clinical and MRI parameters) was assessed. In addition, relative gene expression of membrane-bound to total IL7R mRNA was analyzed with respect to disease phenotype in a subgroup of 95 patients with early relapsing MS. Results: In particular, homozygosity for the risk allele is a risk factor for MS in our population (ORCC vs CT and TT = 1.65 (95% CI: 1.18–2.30), two-sided p = 0.004). However, no effect of genotype or the relative expression of membrane-bound IL7R (presence of exon 6–7) to total amount of IL7R mRNA (presence of exon 4–5) was found on MS phenotype. Discussion: Homozygosity for the IL7R exon 6 rs6897932 C allele is associated with a higher risk for MS in our Dutch population. No effect was found of genotype or mRNA expression on disease phenotype.
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Affiliation(s)
- MH Sombekke
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - LF van der Voort
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - JJ Kragt
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - JM Nielsen
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - H Guzel
- Image Analysis Center, VU University Medical Center, Amsterdam, The Netherlands
| | - A Visser
- Department of Clinical Chemistry, VU University Medical Center, Amsterdam, The Netherlands
| | - CBM Oudejans
- Department of Clinical Chemistry, VU University Medical Center, Amsterdam, The Netherlands
| | - JBA Crusius
- Department of Pathology (Laboratory of Immunogenetics), VU University Medical Center, Amsterdam, The Netherlands
| | - A Salvador Peña
- Department of Pathology (Laboratory of Immunogenetics), VU University Medical Center, Amsterdam, The Netherlands
| | - H Vrenken
- Department of Radiology and Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
| | - CH Polman
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - J Killestein
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
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