Disability in multiple sclerosis: a reference for patients and clinicians

Sirtuins and Metabolism Biomarkers in Relapsing-Remitting and Secondary Progressive Multiple Sclerosis: a Correlation Study with Clinical Outcomes and Cognitive Impairments

Multiple sclerosis (MS) is a primary inflammatory demyelinating disease with different clinical courses and subtypes. The present study aimed to determine whether mitochondrial dysfunction and sirtuins 1 and 3, as metabolism and epigenetic modifying factors, might contribute to MS disease progression measured by physical disability and cognitive impairment.The volunteers (n = 20 controls, n = 59 MS) were recruited and assessed for cognitive function and disability scores; then, patients were clinically classified as relapsing-remitting (RR) in remission phase, RR in relapse phase, and secondary progressive MS. We measured sirtuin (SIRT) 1 and 3 levels, mitochondrial complex I, IV, aconitase, and α-ketoglutarate dehydrogenase (α-KGD) activity in the peripheral blood mononuclear cells (PBMCs). Furthermore, SIRT1, pyruvate, lactate, and cytochrome c (Cyt c) were determined in plasma. Finally, we performed postmortem tissue immunohistochemistry to assess the level of SIRT1 and SIRT3 in the brain lesions of patients with MS.Increased disability and cognitive impairment in patients were correlated. Plasma level of lactate showed a correlation with the disability in MS patients; moreover, a trend toward increased Cyt c plasma level was observed. Investigation of PBMCs exhibited decreased SIRT1 during the relapse phase along with a reduced complex IV activity in all MS subgroups. α-KGD activity was significantly increased in the RR-remission, and SIRT3 was elevated in RR-relapse group. This elevation correlated with disability and cognitive impairment. Finally, immunohistochemistry demonstrated increased levels of SIRT1 and 3 in the brain active lesion of patients with MS.Our data suggest that mitochondrial dysfunction and alteration in some epigenetics and metabolism modifying factors in the CNS and peripheral blood cells may contribute or correlate with MS progression.

Associations between diet and disease progression and symptomatology in multiple sclerosis: A systematic review of observational studies

BACKGROUND

Although many people with MS (pwMS) modify their diet after diagnosis, there is still no consensus on dietary recommendations for pwMS. A number of observational studies have explored associations of diet and MS progression, but no studies have systematically reviewed the evidence. This systematic review aimed to provide an objective synthesis of the evidence for associations between diet and MS progression, including symptoms and clinical outcomes from observational studies.

METHODS

We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic database searches were performed for studies completed up to 26 July 2023 using PubMed (Medline), Web of Science, CINAHL, Embase (Ovid), and Scopus, followed by citation and reference list checking. We included studies using diet quality scores or dietary indices. Studies assessing individual foods, nutrients, or dietary supplements were excluded. We used the Newcastle-Ottawa Scale to assess the risk of bias of included studies.

RESULTS

Thirty-two studies met the inclusion criteria. Of these, 20 were cross-sectional and 12 prospective. The most frequent outcomes assessed were disability (n = 19), quality of life (n = 12), fatigue (n = 12), depression (n = 9), relapse (n = 8), anxiety (n = 3), and magnetic resonance imaging (MRI) outcomes (n = 4). Based on prospective studies, this review suggests that diet might be associated with quality of life and disability. There were also potential effects of higher diet quality scores on improved fatigue, disability, depression, anxiety, and MRI outcomes but more evidence is needed from prospective studies.

CONCLUSIONS

Observational studies show some evidence for an association between diet and MS symptoms, particularly quality of life and disability. However, the impact of diet on other MS outcomes remains inconclusive. Ultimately, our findings suggest more evidence is needed from prospective studies and well-designed tailored intervention studies to confirm associations.

Performance Measures and Plasma Biomarker Levels in Patients with Multiple Sclerosis after 14 Days of Fampridine Treatment: An Explorative Study

Peripheral cytokine levels may serve as biomarkers for treatment response and disease monitoring in patients with multiple sclerosis (pwMS). The objectives were to assess changes in plasma biomarkers in PwMS after 14 days of fampridine treatment and to explore correlations between changes in performance measures and plasma biomarkers. We included 27 PwMS, 14 women and 13 men, aged 52.0 ± 11.6 years, with a disease duration of 17 ± 8.5 years, and an Expanded Disability Status Scale of 6 [IQR 5.0/6.5]. Gait and hand function were assessed using performance tests completed prior to fampridine and after 14 days of treatment. Venous blood was obtained, and chemiluminescence analysis conducted to assess plasma cytokines and neurodegenerative markers. All performance measures demonstrated improvements. Biomarkers showed decreased tumor necrosis factor (TNF) receptor-2 levels. Associations were found between change scores in (i) Six Spot Step Test and Interleukin (IL)-2, IL-8, and IL-17 levels; (ii) timed 25-foot walk and interferon-γ, IL-2, IL-8, TNF-α, and neurofilament light levels, and (iii) 12-Item Multiple Sclerosis Walking Scale and IL-17 levels. The associations may reflect increased MS-related inflammatory activity rather than a fampridine-induced response or that a higher level of inflammation induces a better response to fampridine.

Association between serum multi-protein biomarker profile and real-world disability in multiple sclerosis

Few studies examined blood biomarkers informative of patient-reported outcome (PRO) of disability in people with multiple sclerosis (MS). We examined the associations between serum multi-protein biomarker profiles and patient-reported MS disability. In this cross-sectional study (2017-2020), adults with diagnosis of MS (or precursors) from two independent clinic-based cohorts were divided into a training and test set. For predictors, we examined seven clinical factors (age at sample collection, sex, race/ethnicity, disease subtype, disease duration, disease-modifying therapy [DMT], and time interval between sample collection and closest PRO assessment) and 19 serum protein biomarkers potentially associated with MS disease activity endpoints identified from prior studies. We trained machine learning (ML) models (Least Absolute Shrinkage and Selection Operator regression [LASSO], Random Forest, Extreme Gradient Boosting, Support Vector Machines, stacking ensemble learning, and stacking classification) for predicting Patient Determined Disease Steps (PDDS) score as the primary endpoint and reported model performance using the held-out test set. The study included 431 participants (mean age 49 years, 81% women, 94% non-Hispanic White). For binary PDDS score, combined feature input of routine clinical factors and the 19 proteins consistently outperformed base models (comprising clinical features alone or clinical features plus one single protein at a time) in predicting severe (PDDS ≥ 4) versus mild/moderate (PDDS < 4) disability across multiple machine learning approaches, with LASSO achieving the best area under the curve (AUCPDDS = 0.91) and other metrics. For ordinal PDDS score, LASSO model comprising combined clinical factors and 19 proteins as feature input (R2PDDS = 0.31) again outperformed base models. The two best-performing LASSO models (i.e., binary and ordinal PDDS score) shared six clinical features (age, sex, race/ethnicity, disease subtype, disease duration, DMT efficacy) and nine proteins (cluster of differentiation 6, CUB-domain-containing protein 1, contactin-2, interleukin-12 subunit-beta, neurofilament light chain [NfL], protogenin, serpin family A member 9, tumor necrosis factor superfamily member 13B, versican). By comparison, LASSO models with clinical features plus one single protein at a time as feature input did not select either NfL or glial fibrillary acidic protein (GFAP) as a final feature. Forcing either NfL or GFAP as a single protein feature into models did not improve performance beyond clinical features alone. Stacking classification model using five functional pathways to represent multiple proteins as meta-features implicated those involved in neuroaxonal integrity as significant contributors to predictive performance. Thus, serum multi-protein biomarker profiles improve the prediction of real-world MS disability status beyond clinical profile alone or clinical profile plus single protein biomarker, reaching clinically actionable performance.

Longitudinal associations between quality of diet and disability over 7.5 years in an international sample of people with multiple sclerosis

BACKGROUND AND PURPOSE

Modifiable lifestyle factors, including diet, have been implicated in multiple sclerosis (MS) progression, but prospective evidence is limited. The aim of this study was to examine prospective relationships between quality of diet and subsequent disability over 7.5 years in an international cohort of people living with MS (pwMS).

METHODS

Data from 602 participants in the HOLISM (Health Outcomes and Lifestyle In a Sample of people with Multiple sclerosis) study were analysed. Quality of diet was assessed using the modified Diet Habits Questionnaire (DHQ). Disability was assessed using the Patient-determined MS Severity Score (P-MSSS). Characteristics of disability were assessed by log-binomial, log-multinomial and linear regression, adjusted for demographic and clinical covariates, as appropriate.

RESULTS

Higher baseline total DHQ scores (>80-89, >89%) were associated with lower risks of increased P-MSSS at 7.5 years (adjusted risk ratio [aRR] 0.46, 95% confidence interval [CI] 0.23, 0.91 and aRR 0.48, 95% CI 0.26, 0.89, respectively), and with less P-MSSS accrual (aβ = -0.38, 95% CI -0.78, 0.01 and aβ = -0.44, 95% CI -0.81, -0.06). Of the DHQ domains, fat subscore was most strongly associated with subsequent disability. Participants with reducing baseline-to-2.5- years total DHQ scores had greater risk of increased P-MSSS at 7.5 years (aRR 2.77, 95% CI 1.18, 6.53) and higher P-MSSS accrual (aβ = 0.30, 95% CI 0.01, 0.60). Participants reporting baseline meat and dairy consumption had greater risk of increased P-MSSS at 7.5 years (aRR 2.06, 95% CI 1.23, 3.45 and aRR 2.02, 95% CI 1.25, 3.25) and higher P-MSSS accrual (aβ = 0.28, 95% CI 0.02, 0.54 and aβ = 0.43, 95% CI 0.16, 0.69, respectively). However, reported meat consumption was confounded by quality of diet. Changes in meat or dairy consumption from baseline were inconsistently associated with subsequent disability.

CONCLUSIONS

We show for the first time robust long-term associations between quality of diet and subsequent disability progression in pwMS. Subject to replication, dietary modification may represent a point of intervention for reducing disability in pwMS.

User-Centered Configuration of Soft Hip Flexion Exosuit Designs to Assist Individuals with Multiple Sclerosis Through Simulated Human-in-the-Loop Optimization

Soft exosuits hold promise as assistive technology for people with gait deficits owing to a variety of causes. A key aspect of providing useful assistance is to keep the human user at the center of all considerations made in the design, configuration, and prescribed use of an assistive device. This work details a method for informing the configuration of a soft hip flexion exosuit by 1) modeling the user's shape and movements in order to simulate the mechanical interaction of the exosuit and user, 2) incorporating the mechanical effects of the exosuit into a muscle-driven musculoskeletal gait simulation, and 3) using the results of these simulations to define a cost function that is minimized via Bayesian optimization. This process is carried out for models of four different people with multiple sclerosis, and the final optimized configurations for each subject are compared. For all users, the estimated metabolic cost of transport was reduced below baseline, no-device levels. This work represents a step toward more individualized, user-centric modeling of assistive devices, and demonstrates a system for informing the physical configuration of an exosuit on a case-by-case basis using real patient data.

Comparison of physical performance, gait, balance, falls efficacy, and step reaction time in individuals with multiple sclerosis

OBJECTIVE

The study aimed to investigate the physical performance, gait, balance, falls efficacy, and step reaction time in individuals with MS.

METHODS

A total of 60 individuals (30 individuals with MS and 30 age and sex-matched healthy controls) were enrolled. Individuals' physical performance was evaluated with the Timed Up and Go Test (TUG) and Five-Times-Sit-to-Stand Test (FTSTS). Activities-specific Balance Confidence (ABC) Scale, 12-item Multiple Sclerosis Walking Scale (MSWS-12v2) and Falls Efficacy Scale International (FES-I) were used to assess the balance, gait and fall efficacy of the participants. Individuals' step reaction time (SRT) was calculated with video-based software. The time between the step command and the first contact of the foot with the ground in the first step was recorded.

RESULTS

The mean age of the individuals with MS and the control group was 38.5 ± 9.4 years and 33.9 ± 11.7 years, respectively. Significant differences existed between the groups in SRT, FES-I, ABC, and FTSTS (p < 0.05). There was no significant correlation between SRT with any other parameter (p > 0.05). TUG was moderately correlated with MSWS-12 and FES-I (r1 =0.426, r2 =0.495, p < 0.05). Besides, there was a moderate correlation between ABC with TUG and FTSTS (r1 =-0.605, r2 =-0.468, p < 0.05). A high degree correlation was found between MSWS-12 with FES-I and ABC (r1 =0.843, r2 =-0.834, p < 0.05).

CONCLUSION

Individuals with MS have decreased SRTs. However, this condition was not found to be related to physical performance. Further studies should focus on the association of SRT with cognitive and psychosocial parameters.

Biochemical biomarkers for multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is the most frequent demyelinating disease of the central nervous system. Although there is currently no definite cure for MS, new therapies have recently been developed based on a continuous search for new biomarkers.

DEVELOPMENT

MS diagnosis relies on the integration of clinical, imaging and laboratory findings as there is still no singlepathognomonicclinical feature or diagnostic laboratory biomarker. The most commonly laboratory test used is the presence of immunoglobulin G oligoclonal bands (OCB) in cerebrospinal fluid of MS patients. This test is now included in the 2017 McDonald criteria as a biomarker of dissemination in time. Nevertheless, there are other biomarkers currently in use such as kappa free light chain, which has shown higher sensitivity and specificity for MS diagnosis than OCB. In addition, other potential laboratory tests involved in neuronal damage, demyelination and/or inflammation could be used for detecting MS.

CONCLUSIONS

CSF and serum biomarkers have been reviewed for their use in MS diagnosis and prognosis to stablish an accurate and prompt MS diagnosis, crucial to implement an adequate treatment and to optimize clinical outcomes over time.

Study protocol for an online lifestyle modification education course for people living with multiple sclerosis: the multiple sclerosis online course (MSOC)

BACKGROUND

People living with multiple sclerosis (plwMS) seek access to information on evidence-based lifestyle-related risk factors associated with multiple sclerosis (MS). As the internet has made delivery of lifestyle information increasingly accessible and cost-effective, we designed the Multiple Sclerosis Online Course (MSOC) to deliver a multimodal lifestyle modification program for plwMS. Two MS online courses were developed: the intervention course based on lifestyle recommendations of the Overcoming Multiple Sclerosis (OMS) program and the standard-care course representing standard lifestyle recommendations from other MS websites. We examined for feasibility in a pilot randomised controlled trial (RCT), where satisfactory completion and accessibility were achieved across both study arms. From this success, a protocol for a larger RCT was developed to examine the effectiveness of MSOC in improving health-related quality of life (HRQoL) and other health outcomes in plwMS.

METHODS/DESIGN

This single-blinded RCT will recruit n = 1,054 plwMS. Participants in the intervention arm will receive access to a MSOC with seven modules providing evidence-based information on the OMS program. Participants in the control group will receive access to a MSOC of identical format, with seven modules providing general MS-related information and lifestyle recommendations sourced from popular MS websites, e.g. MS societies. Participants will complete questionnaires at baseline and at 6, 12, and 30 months after course completion. The primary endpoint is HRQoL, as measured by MSQOL-54 (both physical and mental health domains) at 12 months following course completion. Secondary outcomes are changes to depression, anxiety, fatigue, disability, and self-efficacy as measured by Hospital Anxiety and Depression Scale, Patient-Determined Disease Steps and University of Washington Self-Efficacy Scale, respectively, assessed at each timepoint. Further assessments will include quantitative post-course evaluation, adoption and maintenance of behaviour change from follow-up survey data, and qualitative analysis of participants' outcomes and reasons for course completion or non-completion.

DISCUSSION

This RCT aims to determine whether an online intervention course delivering evidence-based lifestyle modification recommendations based on the Overcoming Multiple Sclerosis program to plwMS is more effective at improving HRQoL, and other health outcomes post-intervention, compared with an online standard-care course.

TRIAL REGISTRATION

This trial was registered prospectively with the Australian New Zealand Clinical Trials Registry, www.anzctr.org.au , identifier ACTRN12621001605886.

DATE OF REGISTRATION

25 November 2021.

"Brain age" predicts disability accumulation in multiple sclerosis

OBJECTIVE

Neurodegenerative conditions often manifest radiologically with the appearance of premature aging. Multiple sclerosis (MS) biomarkers related to lesion burden are well developed, but measures of neurodegeneration are less well-developed. The appearance of premature aging quantified by machine learning applied to structural MRI assesses neurodegenerative pathology. We assess the explanatory and predictive power of "brain age" analysis on disability in MS using a large, real-world dataset.

METHODS

Brain age analysis is predicated on the over-estimation of predicted brain age in patients with more advanced pathology. We compared the performance of three brain age algorithms in a large, longitudinal dataset (>13,000 imaging sessions from >6,000 individual MS patients). Effects of MS, MS disease course, disability, lesion burden, and DMT efficacy were assessed using linear mixed effects models.

RESULTS

MS was associated with advanced predicted brain age cross-sectionally and accelerated brain aging longitudinally in all techniques. While MS disease course (relapsing vs. progressive) did contribute to advanced brain age, disability was the primary correlate of advanced brain age. We found that advanced brain age at study enrollment predicted more disability accumulation longitudinally. Lastly, a more youthful appearing brain (predicted brain age less than actual age) was associated with decreased disability.

INTERPRETATION

Brain age is a technically tractable and clinically relevant biomarker of disease pathology that correlates with and predicts increasing disability in MS. Advanced brain age predicts future disability accumulation.

Neuroprotective influence of macular xanthophylls and retinal integrity on cognitive function among persons with multiple sclerosis

BACKGROUND

No studies to date have examined if macular xanthophyll accumulation and retinal integrity are independently associated with cognitive function in individuals with multiple sclerosis (MS). This study explored whether macular xanthophyll accumulation and structural morphometry in the retina were associated with behavioral performance and neuroelectric function during a computerized cognitive task among persons with MS and healthy controls (HCs).

METHODS

42 HCs and 42 individuals with MS aged 18-64 years were enrolled. Macular pigment optical density (MPOD) was measured using heterochromatic flicker photometry. Optic disc retinal nerve fiber layer (odRNFL), macular retinal nerve fiber layer, and total macular volume were assessed via optical coherence tomography. Attentional inhibition was assessed using an Eriksen flanker task while underlying neuroelectric function was recorded using event-related potentials.

RESULTS

Persons with MS had a slower reaction time, lower accuracy, and delayed P3 peak latency time during both congruent and incongruent trials compared with HCs. Within the MS group, MPOD explained variance in incongruent P3 peak latency, and odRNFL explained variance in congruent reaction time and congruent P3 peak latency.

CONCLUSIONS

Persons with MS exhibited poorer attentional inhibition and slower processing speed, yet higher MPOD and odRNFL levels were independently associated with greater attentional inhibition and faster processing speed among persons with MS. Future interventions are necessary to determine if improvements in these metrics may promote cognitive function among persons with MS.

Higher diet quality is associated with short and long-term benefits on SF-6D health state utilities: a 5-year cohort study in an international sample of people with multiple sclerosis

BACKGROUND/PURPOSE

Health state utilities (HSU) are a subjective measure of an individual's health-related quality of life (HRQoL), adjusted by societal or patient relative preference weights for living in different states of health-related quality of life (HRQoL), derived from patient-reported responses to multi-attribute utility instrument (MAUI), and can be used as inputs for cost-utility analyses and in clinical assessment. This research assessed associations of diet with subsequent HSU in a large international cohort of people living with multiple sclerosis (MS), a progressive autoimmune condition of the central nervous system.

METHODS

HSUs were generated from responses to Short-Form Six-Dimension (SF-6D) MAUI, and quality-of-the-diet by Diet Habits Questionnaire (DHQ). Cross-sectional, and short- and long-term prospective associations of DHQ with HSU evaluated by linear regression at 2.5- and 5-years. Pooled prospective associations between DHQ and HSU evaluated using linear and quantile regression. Analyses adjusted for relevant demographic and clinical covariates.

RESULTS

Among 839 participants, baseline DHQ scores showed short- and long-term associations with subsequent HSU, each 10-unit increase in total DHQ score associated with 0.008-0.012 higher HSU (out of 1.00). These associations were dose-dependent, those in the top two quartiles of baseline DHQ scores having 0.01-0.03 higher HSU at follow-up, 0.03 being the threshold for a minimally clinically important difference. Fat, fiber, and fruit/vegetable DHQ subscores were most strongly and consistently associated with better HSU outcomes. However, baseline meat and dairy consumption were associated with 0.01-0.02 lower HSU at subsequent follow-up.

CONCLUSIONS

A higher quality-of-the-diet showed robust prospective relationships with higher HSUs 2.5- and 5-years later, substantiating previous cross-sectional relationships in this cohort. Subject to replication, these results suggest interventions to improve the quality-of-the-diet may be effective to improve HRQoL in people living with MS.

Effects of constraint induced movement therapy in patients with multiple sclerosis: A systematic review

BACKGROUND

Multiple sclerosis (MS) is a chronic neurodegenerative disorder of the central nervous system (CNS) that commonly affects young and middle-aged adults. Neurodegeneration of the CNS affects its functions such as sensorimotor, autonomic and cognitive functions. Affectation of motor function can result in disability in performance of daily life activities. Thus, effective rehabilitation interventions are needed to help prevent disability in patients with MS. One of these interventions is the constraint induced movement therapy (CIMT). The CIMT is used to improve motor function in patients with stroke and other neurological conditions. Recently, its use in patients with MS is gaining ground. The aim of this study is to carry out a systematic review and meta-analysis to determine from the literature, the effects of CIMT on upper limb function in patients with MS.

METHODS

PubMED, Embase, Web of Science (WoS), PEDro, and CENTRAL were searched until October 2022. Randomized controlled trials in patients with MS who were 18 years and above were included. Data on the characteristics of the study participants such as disease duration, type of MS, the mean scores of the outcomes of interest such as motor function and use of the arm in daily activities, and white matter integrity were extracted. Methodological quality and risks of bias of the included studies were assessed using PEDro scale and Cochrane risks of bias tool. The data was analysed using both narrative and quantitative syntheses. In the quantitative synthesis, random effect model meta-analysis of the mean and standard deviation of the scores on the outcomes of interest and the study sample size (for both the CIMT and the control group) post intervention was carried out. In addition, percentage of variation across the studies due to heterogeneity (I²) was considered significant when it is between 50% and 90% at p < 0.05.

RESULTS

Two studies comprising of 4 published articles with good methodological quality were included in the study. The results showed that, CIMT is safe and improved white matter integrity, motor function, muscle strength, dexterity, real-world arm use and biomechanical parameters post intervention. However, although there was a trend towards better improvement in the CIMT group in all the outcomes, there was no statistically significant difference between groups in motor function (SMD=0.44, 95% CI=-0.20 to 1.07, p = 0.18) and quality of movement (SMD=0.96, -1.15 to 3.07, p = 0.37).

CONCLUSION

CIMT can be used in patients with MS since it is safe as well as effective at improving functional outcomes. However, more studies are required to confirm its safety and effectiveness.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effect of intermittent vs. continuous walking on distance to fatigue in persons with multiple sclerosis

PURPOSE

Previous studies provided evidence that persons with Multiple Sclerosis (pwMS) who walk intermittently experience less fatigue and walk longer distances than when walking continuously. However, total distance pwMS can walk in either condition is unknown. We examined time and distance to fatigability in pwMS comparing intermittent walking (IW) to continuous walking (CW).

MATERIALS AND METHODS

18 pwMS, with Expanded Disability Status Scale median of 4.75 [range = 2-6.5, IQR = 2.5] participated in this randomized crossover study. The IW condition consisted of alternating 30 s treadmill walking and 30 s seated rests. The CW condition consisted of treadmill walking without breaks. Treadmill speed (TS) was determined by an overground 2-min walk test. Walking fatigability was determined by participants walking on the treadmill, until gait fatigue was noted by patient or examiners. Total time and distance to gait fatigue, and subjective fatigue as measured by the Visual analog scale of fatigue were recorded.

RESULTS

Participants had significantly longer duration and distance to fatigue in the IW condition than the CW condition (ps ≤ 0.037). No difference in VASF scores between the two conditions were noted.

CONCLUSION

In this sample, IW allowed pwMS to perform a greater volume of walking and can be an option to improve walking endurance in this population.IMPLICATIONS FOR REHABILITATIONMultiple sclerosis (MS) is a disease that progressively impacts walking, resulting in a decrease in the maximum distance that a person with MS can walk.Intermittent walking has been shown to improve 6-min walk test performance in persons with MS (pwMS) compared to continuous walking, but its effects on longer and shorter walks is not known.The use of distance to fatigue should be considered a viable option for measuring walking fatigability in pwMS as it does not exclude persons based on their ability to complete a 6-min walk, nor would it be too easy for persons with pwMS with mild disability.By using distance to fatigue as an outcome measure, this study provides evidence that intermittent walking results in less fatigability regardless of walking ability.PwMS, regardless of their walking ability, can walk longer distances intermittently than continuously, suggesting that clinical treatment of walking fatigability in pwMS should utilize intermittent rather than continuous walking training.

Multimodal Agility-Based Exercise Training for Persons With Multiple Sclerosis: A New Framework

INTRODUCTION

Multimodal agility-based exercise training (MAT) has been described as a framework for fall prevention in the elderly but might also be a valuable concept for exercise training in persons with Multiple Sclerosis (pwMS).

THE PROBLEM

Current recommendations advise pwMS to perform a multitude of different exercise training activities, as each of these has its separate evidence. However, pwMS struggle even more than the general population to be physically active. Additionally, Multiple Sclerosis often leads to co-occurring mobility and cognitive dysfunctions, for which simultaneous, time-efficient, and engaging training approaches are still limited in clinical practice and healthcare.

THE SOLUTION

The MAT framework has been developed to integratively improve cardiovascular, neuromuscular, and cognitive function by combining aspects of perception and orientation, change of direction, as well as stop-and-go patterns (ie, agility), in a group-training format. For pwMS, the MAT framework is conceptualized to include 3 Components: standing balance, dynamic balance (including functional leg strength), and agility-based exercises. Within these Components sensory, cognitive, and cardiovascular challenges can be adapted to individual needs.

RECOMMENDATIONS

We recommend investigating multimodal exercise interventions that go beyond easily standardized, unimodal types of exercise (eg, aerobic or resistance exercise), which could allow for time-efficient training, targeting multiple frequent symptoms of persons with mild disability at once. MAT should be compared to unimodal approaches, regarding sensor-based gait outcomes, fatigue-related outcomes, cognition, as well as neuroprotective, and (supportive) disease-modifying effects.

Gait quality and function after fampridine treatment in patients with multiple sclerosis - A prospective cohort study

BACKGROUND

Fampridine has shown to improve walking speed, motor control, and balance in patients with multiple sclerosis. However, potential fampridine-induced changes in gait quality and underlying mechanisms, evaluated by three-dimensional gait analysis, are poorly examined. The aim was to examine if two weeks of fampridine treatment would improve gait quality (using Gait Profile Score and Gait Variable Scores from three-dimensional gait analysis) and gait function (using performance-based tests, spatiotemporal parameters, and self-perceived gait function).

METHODS

14 participants with multiple sclerosis were included (9 women and 5 men, age 53.6 ± 12.8 years, disease duration 21 ± 9.1 years) in this cohort study. Tests were completed prior to fampridine and after 14 (± 1) days of treatment. Three-dimensional gait analyses were completed, and kinematic measures were calculated for overall gait quality using Gait Profile Score, and for joint-specific variables, Gait Variable Scores. Gait function was assessed using spatiotemporal parameters, performance-based tests, and a patient-reported outcome measure. Student's paired t-test/Wilcoxon signed rank test were used to compare baseline and follow-up variables. Sample size calculation for Gait Profile Score required at least 9 participants.

FINDINGS

No fampridine-induced improvements in gait quality were demonstrated. For gait function, improvements were found in performance-based tests (Timed 25-Foot Walk: -11.5%; Six Spot Step Test: -13.9%; 2-Minute Walk Test: 18.2%) and self-perceived gait function (12-itemMS Walking Scale: -35.2%).

INTERPRETATION

Although two weeks of fampridine treatment in patients with multiple sclerosis improved gait function, there was no change in overall kinematic quality of gait.

TRIAL REGISTRATION

This work was collected as a part of a registered clinical trial (MUST): ClinicalTrials.govNCT03847545.

Driving ability and predictors for driving performance in Multiple Sclerosis: A systematic review

OBJECTIVE

To provide an overview of the evidence on driving ability in persons with multiple sclerosis (PwMS), specifically to (i) study the impact of MS impairment on driving ability and (ii) evaluate predictors for driving performance in MS.

METHODS

To identify relevant studies, different electronic databases were screened in accordance with PRISMA guidelines; this includes reference lists of review articles, primary studies, and trial registers for protocols. Furthermore, experts in the field were contacted. Two reviewers independently screened titles, abstracts, and full-texts to identify relevant articles targeting driving in people with MS that investigated driving-related issues with a formal driving assessment (defined as either an on-road driving assessment; or naturalistic driving in a car equipped with video cameras to record the driving; or a driving simulator with a steering wheel, a brake pedal, and an accelerator).

RESULTS

Twenty-four publications, with 15 unique samples (n = 806 PwMS), were identified. To assess driving ability, on-road tests (14 papers) and driving simulators (10 papers) were used. All studies showed moderate to high study quality in the CASP assessment. About 6 to 38% of PwMS failed the on-road tests, showing difficulties in different areas of driving. Similarly, PwMS showed several problems in driving simulations. Cognitive and visual impairment appeared to most impact driving ability, but the evidence was insufficient and inconsistent.

CONCLUSION

There is an urgent need for more research and standardized guidelines for clinicians as one in five PwMS might not be able to drive safely. On-road tests may be the gold standard in assessing driving ability, but on-road protocols are heterogeneous and not infallible. Driving simulators assess driving ability in a standardized way, but without standardized routes and driving outcomes, comparability between studies is difficult. Different aspects, such as cognitive impairment or vision problems, impact driving ability negatively and should be taken into consideration when making decisions about recommending driving cessation.

SYSTEMATIC REVIEW REGISTRATION

Identifier [10.17605/OSF.IO/WTG9J].

The size and behavior of virtual objects have influence on functional exercise and motivation of persons with multiple sclerosis: a randomized study

The consequences of multiple sclerosis are problems with limb movement, coordination, and vision. Heretofore a combination of therapy and additional medications can alter the course of the disease and reduce upper extremity disability. We developed a virtual environment for pick-and-place tasks as a supportive tool to address the problem of challenging task in occupational therapy. The primary objective of the study was to investigate the influence of size and bounce on proximal and fine motor performance and intrinsic motivation. The secondary objective was to examine how the absence of challenge may decrease intrinsic motivation and heart rate. The randomized trial involved 84/107 eligible inpatients with multiple sclerosis. They were divided into 4 groups by computer randomization: Group 1 small and bouncing, Group 2 small and non-bouncing, Group 3 large and bouncing, and Group 4 large and non-bouncing virtual cubes. Each participant completed 50 sessions of up to 2 min each in approximately 14 days. Before commencement of the study the participants completed visuospatial and cognitive tests. Participants' subjective experiences were assessed daily using the intrinsic motivation inventory. Before and after the study, the box and block test and the 9-hole peg test were administered. Kinematic analysis showed significant differences between groups (average manipulation time p = 0.008, inserted cubes p = 0.004). Group 4 was the most successful (inserted cubes > 9) and the fastest (63.4 SD 25.8 s), but had low pressure/tension and heart rate. Group 1 was the slowest (88.9 SD 28.2 s) but had increased interest/enjoyment in the task under higher pressure/tension. There were substantial differences in intrinsic motivation between the 1st and last sessions within groups (Cohen's U3 < 0.3 or > 0.8). The size and behavior of virtual objects may be important for training proximal movements and fine motor skills in people with multiple sclerosis. Furthermore, the demonstrated approach proved to be effective and may reduce upper extremity disability in the long term if intrinsic motivation can be sustained longer with a challenging task.Trial registration The small scale randomized pilot trial has been registered at ClinicalTrials.gov Identifier: NCT04266444, 12/02/2020, https://clinicaltrials.gov/ct2/show/NCT04266444 .

Systematic review of participant characteristics in theory-based behavior change interventions for physical activity in multiple sclerosis: are we missing those with the greatest potential for lifelong benefits?

PURPOSE

This study examined participant characteristics, particularly disease duration, in theory-based physical activity behavior change trials in multiple sclerosis (MS) and summarized theoretical frameworks and changes in physical activity outcomes.

MATERIALS AND METHODS

PubMed, CINAHL, Embase, and Scopus were searched to identify potential trials. One reviewer screened titles and abstracts, and two reviewers then independently screened full-text articles based on predetermined eligibility criteria. Data were extracted by one reviewer and checked by a second reviewer.

RESULTS

Among 33 trials reviewed, only one trial reported a mean disease duration of less than five years (i.e., 4.5 years) for the sample. The remaining trials included samples with a mean disease duration of 6.7 years or longer. The most common theories used were Social Cognitive Theory, Trans-theoretical Model, and Motivational Interviewing. The effects on physical activity were heterogeneous; device-measured outcomes increased in 41.4% of studies, self-reported outcomes improved in 72.4%. Adherence (≥80%) was reported in 34.5% of studies.

CONCLUSIONS

There is little focus on persons with MS in the early disease course in physical activity behavior change interventions. Future research should include comprehensive theoretical approaches for more homogeneous effects across outcome measures when targeting those in the early stage and all MS populations.IMPLICATIONS FOR REHABILITATIONTheory-based physical activity behavior change interventions have not included persons with multiple sclerosis (MS) in the early disease course (<5 years since diagnosis).Disease duration has not been a criterion used to include or exclude participants in the reviewed theory-based behavior change interventions for physical activity in people with MS.The theory-based behavior change interventions in this review positively affected short-term physical activity levels in people with MS.

Development and deployment of cyclical focal muscle vibration system to improve walking performance in multiple sclerosis

Vibration, a potent mechanical stimulus for activating muscle spindle primary afferents, may improve gait performance in persons with multiple sclerosis (MS), but has yet to be developed and deployed for multiple leg muscles with application during walking training. This study explored the development of a cyclic focal muscle vibration (FMV) system, and the deployment feasibility to correct MS walking swing phase deficits in order to determine whether this intervention warrants comprehensive study. The system was deployed during twelve, two-hour sessions of walking with cyclic FMV over six weeks. Participants served as their own control. Blood pressure, heart rate, walking speed, kinematics (peak hip, knee and ankle angles during swing), toe clearance, and step length were measured before and after deployment with blood pressure and heart rate monitored during deployment. During system deployment, there were no untoward sensations and physiological changes in blood pressure and heart rate, and volitional improvements were found in walking speed, improved swing phase kinematics, toe clearance and step length. This FMV training system was developed and deployed to improve joint flexion during walking in those with MS, and it demonstrated feasibility and benefits. Further study will determine the most effective vibration frequency and dose, carryover effects, and those most likely to benefit from this intervention.

Multiple Sclerosis Severity Score (MSSS) improves the accuracy of individualized prediction in MS

Background:

The MSBase prediction model of treatment response leverages multiple demographic and clinical characteristics to estimate hazards of relapses, confirmed disability accumulation (CDA), and confirmed disability improvement (CDI). The model did not include Multiple Sclerosis Severity Score (MSSS), a disease duration-adjusted ranked score of disability.

Objective:

To incorporate MSSS into the MSBase prediction model and compare model accuracy with and without MSSS.

Methods:

The associations between MSSS and relapse, CDA, and CDI were evaluated with marginal proportional hazards models adjusted for three principal components representative of patients’ demographic and clinical characteristics. The model fit with and without MSSS was assessed with penalized r2 and Harrell C.

Results:

A total of 5866 MS patients were started on disease-modifying therapy during prospective follow-up (age 38.4 ± 10.6 years; 72% female; disease duration 8.5 ± 7.7 years). Including MSSS into the model improved the accuracy of individual prediction of relapses by 31%, of CDA by 23%, and of CDI by 24% (Harrell C) and increased the amount of variance explained for relapses by 49%, for CDI by 11%, and for CDA by 10% as compared with the original model.

Conclusion:

Addition of a single, readily available metric, MSSS, to the comprehensive MSBase prediction model considerably improved the individual accuracy of prognostics in MS.

Physical exercise therapy for autoimmune neuroinflammation: Application of knowledge from animal models to patient care

Physical exercise (PE) impacts various autoimmune diseases. Accordingly, clinical trials demonstrated the safety of PE in multiple sclerosis (MS) patients and indicated beneficial outcomes. There is also an increasing body of research on the beneficial effects of exercise on experimental autoimmune encephalomyelitis (EAE), the animal model of MS, and various mechanisms underlying these effects were suggested. However, despite the documented favorable impact of PE on our health, we still lack a thorough understanding of its effects on autoimmune neuroinflammation and specific guidelines of PE therapy for MS patients are lacking. To that end, current findings on the impact of PE on autoimmune neuroinflammation, both in human MS and animal models are reviewed. The concept of personalized PE therapy for autoimmune neuroinflammation is discussed, and future research for providing biological rationale for clinical trials to pave the road for precise PE therapy in MS patients is described.

Automated Analysis of the Two-Minute Walk Test in Clinical Practice Using Accelerometer Data

One of the core problems for people with multiple sclerosis (pwMS) is the impairment of their ability to walk, which can be severely restrictive in everyday life. Therefore, monitoring of ambulatory function is of great importance to be able to effectively counteract disease progression. An extensive gait analysis, such as the Dresden protocol for multidimensional walking assessment, covers several facets of walking impairment including a 2-min walk test, in which the distance taken by the patient in two minutes is measured by an odometer. Using this approach, it is questionable how precise the measuring methods are at recording the distance traveled. In this project, we investigate whether the current measurement can be replaced by a digital measurement method based on accelerometers (six Opal sensors from the Mobility Lab system) that are attached to the patient’s body. We developed two algorithms using these data and compared the validity of these approaches using the results from 2-min walk tests from 562 pwMS that were collected with a gold-standard odometer. In 48.4% of pwMS, we detected an average relative measurement error of less than 5%, while results from 25.8% of the pwMS showed a relative measurement error of up to 10%. The algorithm had difficulties correctly calculating the walking distances in another 25.8% of pwMS; these results showed a measurement error of more than 20%. A main reason for this moderate performance was the variety of pathologically altered gait patterns in pwMS that may complicate the step detection. Overall, both algorithms achieved favorable levels of agreement (r = 0.884 and r = 0.980) with the odometer. Finally, we present suggestions for improvement of the measurement system to be implemented in the future.

Development of Registry Data to Create Interactive Doctor-Patient Platforms for Personalized Patient Care, Taking the Example of the DESTINY System

“Real-world evidence (RWE)” is becoming increasingly important in order to integrate the results of randomized studies into everyday clinical practice. The data collection of RWE is usually derived from large-scale national and international registries, often driven by academic centers. We have developed a digitalized doctor–patient platform called DESTINY (DatabasE-assiSted Therapy decIsioN support sYstem) that is utilized by NeuroTransData (NTD), a network of neurologists and psychiatrists throughout Germany. This platform can be integrated into everyday practice and, as well as being used for scientific evaluations in healthcare research, can also serve as an individual, personalized treatment application. Its various modules allow for a timely identification of side-effects or interactions of treatments, can involve patients via the “My NTC Health Guide” portal, and can collect data of individual disease histories that are integrated into innovative algorithms, e.g., for the prediction of treatment response [currently available for multiple sclerosis (MS), with other indications in the pipeline]. Here, we describe the doctor–patient platform DESTINY for outpatient neurological practices and its contribution to improved treatment success as well as reduction of healthcare costs. Platforms like DESTINY may facilitate the goal of personalized healthcare.

Sociodemographic and clinical characteristics of diet adherence and relationship with diet quality in an international cohort of people with multiple sclerosis

BACKGROUND

Diet has been associated with the onset and progression of multiple sclerosis (MS). Multiple diets, varying in recommendations, have been proposed as beneficial to people with MS. The characteristics of those who follow specific diet-programs and the relationships of these diet-programs with diet quality is under-explored.

METHODS

Data from the HOLISM study were analysed. Adherence to selected MS-specific diets (Ashton Embry Best Bet, McDougall, Overcoming MS (OMS), Palaeolithic, Swank, and Wahls Elimination) were each queried on 5-point Likert scales, and moderate (≥3/5) and rigorous (≥4/5) adherence defined. Sociodemographic and clinical characteristics of adherence were evaluated by log-binomial regression. Relationships of diet-program adherence with diet quality as measured by Diet Habits Questionnaire were assessed by linear and log-binomial regression, as appropriate, adjusted for age, sex, socioeconomic status (SES), education, and clinically significant fatigue.

RESULTS

Forty-nine percent of participants reported at least 12-month adherence to a diet-program for their MS. Of these, 31.3% rigorously adhered to OMS, 4.9% to Swank, 1.7% to Wahls, and <1.5% to other diet-programs. Only adherence to any diet-program, OMS, Wahls, and Swank, were quantitatively assessed. Females, and participants of lower-than-average SES and longer disease duration were less adherent to any diet-program for MS, as well as those with higher disability, more clinically significant fatigue, greater depression risk, and more comorbidities. Those with higher-than-average SES were more adherent, as were those with higher physical and mental quality of life. Similar relationships were seen for OMS diet-program adherence. Adherence to Wahls diet-program was higher among those with progressive MS types and longer disease duration. No associations were found for adherence to Swank diet-program. Overall diet quality was higher among participants following any diet-program, particularly OMS and Swank, but not Wahls.

CONCLUSION

Greater adherence to MS specific diets was associated with higher SES, and higher quality of life. Following any diet program was associated with higher overall diet quality, with those adhering to the OMS diet having the highest diet quality. These results may inform health professionals in providing guidance to patients regarding diet in MS.

The Role of Disease Acceptance, Life Satisfaction, and Stress Perception on the Quality of Life Among Patients With Multiple Sclerosis: A Descriptive and Correlational Study

PURPOSE

The aim of this study was to evaluate the relationship between illness acceptance, life satisfaction, stress intensity, and their impact on the quality of life (QOL) in patients with multiple sclerosis (MS).

DESIGN

Descriptive and correlational study.

METHODS

A group of 100 patients with MS responded to the Expanded Disability Status Scale, the World Health Organization Quality of Life Brief (WHOQOL-BREF) Scale, the Acceptance of Illness Scale (AIS), the Perceived Stress Scale (PSS-10), the Satisfaction With Life Scale (SWLS), and a sociodemographic questionnaire.

FINDINGS

A significant relationship was shown between the mean scores of AIS, SWLS, PSS-10, and WHOQOL-BREF; however, there was no relationship between the mean scores of AIS, SWLS, PSS-10, WHOQOL-BREF and the Expanded Disability Status Scale.

CONCLUSION

Quality of life in patients with MS is positively affected by higher level of disease acceptance and life satisfaction as well as a lower level of perceived stress.

CLINICAL RELEVANCE

Rehabilitation nurses should consider the patient's disease acceptance, QOL, perceived stress, disability level, and satisfaction of life in planning and implementing a comprehensive rehabilitation plan.

Outcomes of pregnancy in Egyptian women with multiple sclerosis in the new treatment era: a multi-center retrospective observational study

Background

Pregnancy is a recent growing issue in multiple sclerosis (MS) and the update in the diagnostic criteria of MS and introduction of many disease-modifying therapies (DMTs) may cause changes in the relationship between MS, pregnancy, and breastfeeding. This study aimed to investigate the effect of pregnancy and breastfeeding on MS and vice versa. A retrospective observational study was conducted to include MS women with a history of at least one pregnancy during the last 7 years. Data were collected from the archived files in addition to a self-administrating questionnaire. The annualized relapsing rate (ARR) was calculated before, during, and after pregnancy.

Results

We included 116 successful pregnancies from 93 MS women with mean age 32.74 ± 5.12 years. Interferon-beta was the commonly used DMT during and after pregnancy. Despite the ARR during the two years preceding the conception was 0.36 (95% CI 0.32–0.41), this rate was significantly decreased during first, second, and third trimester (0.07; 95% CI 0.04–0.15, 0.10; 95% CI 0.03–0.17, and 0.15; 95% CI 0.08–0.24, respectively; P-value < 0.001 in all). Furthermore, this ARR was significantly decreased during the first and last three months after delivery (0.27; 95% CI 0.16–0.39; P-value = 0.037, and 0.24; 95% CI 0.17–0.38; P-value = 0.023). Exclusive breastfeeding was associated with deceased risk of postpartum relapse, with HR 0.31 (95% CI 0.12–0.67; P = 0.002).

Conclusions

Pregnancy is protective from MS relapse, with a significant decrease of ARR from the pre-pregnancy period. Postpartum reactivation of the disease occurs from the third month after labor, rather than the early postpartum period. Exclusive breastfeeding for at least 2 months decreased the risk of postpartum relapse.

Macular Xanthophylls and Markers of the Anterior Visual Pathway among Persons with Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) can cause retinal thinning among persons with MS with optic neuritis (MS-ON). Macular xanthophylls are carotenoids that comprise the macular pigment, filtering blue light and countering photo-oxidation. However, macular xanthophyll status and its implications for markers of neuroaxonal degeneration have not been examined in MS.

OBJECTIVES

This study characterized differences in macular and serum xanthophylls, and retinal morphometry [retinal nerve fiber layer thickness at the macular (mRNFL) and optic disc (odRNFL) and total macular volume (TMV)] in individuals with MS and healthy controls (HC). Associations between macular pigment optical density (MPOD) and retinal morphometry were also examined.

METHODS

Adults aged 45-64 y (HC, n = 42; MS, n = 40) participated in a cross-sectional study. MPOD was measured via heterochromatic flicker photometry. Retinal morphometry was measured via optical coherence tomography (OCT). Serum carotenoids were quantified using HPLC. Dietary carotenoids were collected using 7-d records. One-factor ANOVA was conducted to determine group effects on macular, serum, and dietary carotenoids. Partial correlations examined the relations between MPOD, retinal morphometry, diet, and serum carotenoids.

RESULTS

Relative to HC, persons with MS-ON had lower MPOD (Cohen's d = 0.84, P = 0.014), lower odRNFL (Cohen's d = 2.16, P <0.001), lower mRNFL (Cohen's d = 0.57, P = 0.028), and lower TMV (Cohen's d = 0.95, P = 0.011). MS without ON (MS) had lower odRNFL (Cohen's d = 0.93, P = 0.001) than HC and lower serum lutein than MS-ON subjects (Cohen's d = 0.65, P = 0.014). Among MS, MPOD was positively correlated with odRNFL thickness (ρ = 0.43, P = 0.049) and TMV (ρ = 0.45, P = 0.039), whereas odRNFL was negatively correlated with serum lutein (ρ = -0.68, P = 0.016) and zeaxanthin (ρ = -0.62, P = 0.028).

CONCLUSIONS

Persons with MS-ON exhibited poorer xanthophyll status in the macula and serum. MPOD was associated with beneficial anatomical features in the MS group. These findings warrant confirmation with larger cohorts and prospective trials to evaluate xanthophyll effects on the anterior visual pathway in MS.

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

Background:

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Higher-quality diet and non-consumption of meat are associated with less self-determined disability progression in people with multiple sclerosis: A longitudinal cohort study

Background and purpose

Modifiable lifestyle factors, including diet, may affect clinical outcomes in multiple sclerosis (MS). This study assessed the relationships between diet, and disability, fatigue, and depression risk in people with MS.

Methods

Participants from the Health Outcomes and Lifestyle In a Sample of people with Multiple sclerosis (HOLISM) international cohort were assessed over 2.5 years. Dietary data were obtained using a modified Diet Habits Questionnaire (DHQ), disability using the calculated Patient‐determined MS Severity Score (P‐MSSS), fatigue using the Fatigue Severity Scale, and depression risk using the Patient Health Questionnaire‐2. Participants reported whether they were experiencing symptoms due to a recent relapse. Cross‐sectional and prospective relationships of diet and disease outcomes were explored, adjusted for relevant confounders.

Results

Among 1,346 participants, higher DHQ scores showed significant dose‐dependent associations with lower frequencies of severe disability, fatigue, and depression risk, cross‐sectionally. Prospectively, higher baseline DHQ scores were associated with a lower risk of increasing disability, those above the median having 41% and 36% lower risk of increasing disability, and 0.30 P‐MSSS points less disability progression, but were not associated with fatigue or depression risk. Meat consumption was associated with 0.22 P‐MSSS points higher disability cross‐sectionally, while prospectively, baseline meat consumption was associated with 76% higher risk of increasing disability and 0.18 P‐MSSS points higher disability progression. Dairy consumption showed mixed associations cross‐sectionally and prospectively.

Conclusions

These results show that better quality of diet, as well as not consuming meat, were associated with reduced disability progression in people with MS. Substantiation of these findings in other settings may inform opportunities to manage disability progression in people with MS using dietary modifications.

The expression of diacylglycerol kinase isoforms α and ζ correlates with the progression of experimental autoimmune encephalomyelitis in rats

Multiple sclerosis (MS) is characterized by neuroinflammation and neurodegeneration, whose precise processes are not fully understood. Diacylglycerol kinase (DGK) isozymes of α, β, γ and ζ expressed abundantly in the brain and/or the immune system, may be regulatory targets for MS. In this study, we analyzed the four DGK isozymes along the induction, peak and recovery phases in an experimental autoimmune encephalomyelitis (EAE) rat model of MS. The expression of these DGK isozymes and the diacylglycerol (DAG) pathway in the EAE rat brainstems were analyzed by qRT-PCR, immunohistochemistry, immunofluorescence double staining, western blotting and ELISA. Our results showed that the mRNA content of the four DGK isozymes decreased significantly, and their immunoreactivity in myelin sheathes (DGKα, β) and neurons (DGKγ, ζ) became weaker at the beginning of the induction phase. With the progressive increase in clinical signs, DGKα, DGKγ and DGKζ mRNA increased and DGKβ mRNA decreased, and microglia were involved in the formation of perivascular cuffing. In the peak phase, both DGKα and DGKζ were expressed in neurons and inflammatory cells, and DGKζ was also positive in microglia. During the recovery phase, the mRNA content and immunoreactivity of these DGK isozymes generally reached normal levels. Moreover, our results revealed that changes in DAG accumulation and PKCδ phosphorylation were almost the same as those of DGKα and DGKζ mRNA. In summary, the four DGK isozymes are involved in the EAE process. The predominant and broad presence of DGKα and DGKζ suggests that they may regulate the pathological process by attenuating DAG/PKCδ pathway signaling during EAE evolution.

Two healthy lifestyle scores are associated with lower subsequent fatigue risk using inverse probability weighting in an international longitudinal cohort of people with multiple sclerosis

BACKGROUND AND PURPOSE

Several modifiable lifestyle factors have been associated with the onset and health outcomes of multiple sclerosis (MS), including clinically significant fatigue. A combined lifestyle score approach represents one method of assessing their relationship with clinical outcomes. The aim was to examine the association of two lifestyle scores with clinically significant fatigue and change thereof over 2.5 years' follow-up using inverse probability treatment weighting (IPTW).

METHODS

Data on sociodemographic, lifestyle, and clinical characteristics surveyed from an international cohort of people with MS at baseline and at 2.5-year follow-up were used. Fatigue was defined by the Fatigue Severity Scale (FSS >5) and healthy lifestyle by the Healthy Lifestyle Index Score (HLIS) and the Smoking, Nutrition, Alcohol Consumption and Physical Activity (SNAP) score. Analyses were by IPTW accounting for age, sex, MS type, disability, treated comorbidity number, immunomodulatory medication use, prescription antifatigue medication use, and ongoing relapse symptoms.

RESULTS

In total, 1268 participants completed the FSS at both time points; approximately 62% had fatigue. Using doubly robust IPTW, high (>11/20) HLIS (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.81-0.98) and high (>3/5) SNAP (OR 0.82, 95% CI 0.73-0.90) were each associated with lower risk of fatigue at follow-up. Evaluating change in fatigue, a higher SNAP score was associated with a lower risk of fatigue (OR 0.89, 95% CI 0.80-0.97) but the score for HLIS did not reach statistical significance (OR 0.93, 95% CI 0.85-1.01).

CONCLUSION

These results suggest a robust role for key lifestyle factors in preventing clinically significant fatigue and may represent a place for lifestyle modification in improving clinical outcomes in MS.

Association of Disease Severity and Socioeconomic Status in Black and White Americans With Multiple Sclerosis

OBJECTIVE

To compare clinical and imaging features of multiple sclerosis (MS) severity between Black Americans (BA) and White Americans (WA) and evaluate the role of socioeconomic status.

METHODS

We compared BA and WA participants in the Multiple Sclerosis Partners Advancing Technology Health Solutions (MS PATHS) cohort with respect to MS characteristics including self-reported disability, objective neurologic function assessments, and quantitative brain MRI measurements, after covariate adjustment (including education level, employment, or insurance as socioeconomic indicators). In a subgroup, we evaluated within-race, neighborhood-level indicators of socioeconomic status (SES) using 9-digit ZIP codes.

RESULTS

Of 1,214 BAs and 7,530 WAs with MS, BAs were younger, had lower education level, and were more likely to have Medicaid insurance or be disabled or unemployed than WAs. BAs had worse self-reported disability (1.47-fold greater odds of severe vs. mild disability, 95% CI 1.18, 1.86) and worse performances on tests of cognitive processing speed (-5.06 fewer correct, CI -5.72, -4.41), walking (0.66 seconds slower, 95% CI 0.36, 0.96) and manual dexterity (2.11 seconds slower, 95% CI 1.69, 2.54). BAs had more brain MRI lesions and lower overall and gray matter brain volumes, including reduced thalamic (-0.77 mL, 95% CI -0.91, -0.64), cortical (-30.63 mL, 95% CI -35.93, -25.33), and deep (-1.58 mL, 95% CI -1.92, -1.23) gray matter volumes. While lower SES correlated with worse neuroperformance scores in WAs, this association was less clear in BA.

CONCLUSION

We observed a greater burden of disease in BAs with MS relative to WAs with MS, despite adjustment for SES indicators. Beyond SES, future longitudinal studies should also consider roles of other societal constructs (e.g., systemic racism). Such studies will be important for identifying prognostic factors and optimal treatment strategies among BAs with MS is warranted.

Biomechanical analysis of an unpowered hip flexion orthosis on individuals with and without multiple sclerosis

BACKGROUND

Gait impairment is a common complication of multiple sclerosis (MS). Gait limitations such as limited hip flexion, foot drop, and knee hyperextension often require external devices like crutches, canes, and orthoses. The effects of mobility-assistive technologies (MATs) prescribed to people with MS are not well understood, and current devices do not cater to the specific needs of these individuals. To address this, a passive unilateral hip flexion-assisting orthosis (HFO) was developed that uses resistance bands spanning the hip joint to redirect energy in the gait cycle. The purpose of this study was to investigate the short-term effects of the HFO on gait mechanics and muscle activation for people with and without MS. We hypothesized that (1) hip flexion would increase in the limb wearing the device, and (2) that muscle activity would increase in hip extensors, and decrease in hip flexors and plantar flexors.

METHODS

Five healthy subjects and five subjects with MS walked for minute-long sessions with the device using three different levels of band stiffness. We analyzed peak hip flexion and extension angles, lower limb joint work, and muscle activity in eight muscles on the lower limbs and trunk. Single-subjects analysis was used due to inter-subject variability.

RESULTS

For subjects with MS, the HFO caused an increase in peak hip flexion angle and a decrease in peak hip extension angle, confirming our first hypothesis. Healthy subjects showed less pronounced kinematic changes when using the device. Power generated at the hip was increased in most subjects while using the HFO. The second hypothesis was not confirmed, as muscle activity showed inconsistent results, however several subjects demonstrated increased hip extensor and trunk muscle activity with the HFO.

CONCLUSIONS

This exploratory study showed that the HFO was well-tolerated by healthy subjects and subjects with MS, and that it promoted more normative kinematics at the hip for those with MS. Future studies with longer exposure to the HFO and personalized assistance parameters are needed to understand the efficacy of the HFO for mobility assistance and rehabilitation for people with MS.

The functional reach test in people with multiple sclerosis: a reliability and validity study

Background: Limits of stability (LOS) is a major component of balance dysfunction in people with multiple sclerosis (MS). The functional reach test (FRT) is a clinical LOS assessment; however, its psychometric properties have not been investigated in people with MS yet. Objectives: To investigate: (1) the intrarater, interrater, and test-retest reliability of the FRT in people with MS; (2) the minimum detectable change (MDC) in the FRT distances; (3) the concurrent and discriminant validity of the FRT; and (4) the cutoff distance that best discriminates people with MS from healthy people and fallers from non-fallers with MS.Methods: Forty-three people with MS and 36 healthy people participated in this study. The FRT was administered along with the instrumented LOS test, Berg Balance Scale, Four Square Step Test, Timed Up and Go Test, and Expanded Disability Status Scale. The FRT was repeated by the same rater after 2 min from the first test session to determine the intrarater reliability and was simultaneously conducted by two independent raters to determine the interrater reliability. The FRT was also repeated after 7-10 days to determine the test-retest reliability. The reliability was quantified using intraclass correlation coefficients (ICC), Bland-Altman plots, and the MDC. The validity was assessed by correlating the FRT distances with the scores of other measures and by comparing the FRT distances between the MS group and healthy people, and between the fallers and non-fallers in the MS group.Results: The FRT demonstrated good to excellent intrarater, interrater, and test-retest reliability with an ICC (3,1) of 0.80-0.88 (p < .001), an ICC (3,2) of 0.94-0.97 (p < .001), an ICC (2,3) of 0.84-0.86 (p < .001), respectively. Bland-Altman analyses showed no systematic bias between the assessments. The MDC was 8.28 centimeters. The FRT was correlated with the other outcome measures (correlation coefficients ranged from 0.31 to 0.79, p < .05 for all). Significant differences in the FRT distances were found between people with MS and healthy people; however, no significant difference was found between the fallers and non-fallers with MS (p < .001 and p = .09, respectively). The cutoff distance of 35.5 centimeters best discriminates healthy people from people with MS while of 28.5 centimeters did not discriminate between the fallers and non-fallers with MS.Conclusions: The FRT is a reliable, valid, and easy-to-administer tool for assessing LOS in people with MS.

Effects of hippotherapy on postural balance, functional mobility, self-perceived fatigue, and quality of life in people with relapsing-remitting multiple sclerosis: Secondary results of an exploratory clinical trial

BACKGROUND

Multiple sclerosis (MS) results in worsening of postural balance, functional mobility, and self-perceived fatigue as influences of quality of life.

OBJECTIVE

To examine the effects of hippotherapy on postural balance, functional mobility, self-perceived fatigue, and quality of life in people with MS.

METHODS

Participants were assigned into a hippotherapy intervention group (n= 17) or a control group (n= 16). The intervention included 16 sessions of 30-minutes of hippotherapy conducted twice a week whereas the control group was maintained their therapeutic routine. Postural balance was evaluated as CoP speed (cm/s) and CoP 95% elliptical area (cm²) using a force platform under 4 experimental conditions: stable surface/ eyes open, stable surface/ eyes closed, foam surface/ eyes open, and foam surface/ eyes closed. Functional mobility was evaluated by the Timed Up and Go (TUG) test. The Fatigue Severity Scale (FSS) and Modified Fatigue Impact Scale (MFIS) measured perceived fatigue, and the Functional Assessment of Multiple Sclerosis (FAMS) measured quality of life. The data were examined using mixed model ANOVA with Bonferroni post hoc.

RESULTS

CoP speed and CoP 95% elliptical area (p < .05) significantly decreased across all testing conditions for the intervention group compared with control. The TUG improved over time in the intervention group (p = .001) as did the FSS (p < .001). In addition, there was also an improvement for the score and all the MFIS domains (p < .005) for the intervention group compared with control and for FAMS improved over time in the intervention group (p < .05).

CONCLUSION

Hippotherapy improved postural balance, functional mobility, fatigue, and quality of life in people with relapsing-remitting MS. This suggests that hippotherapy may be a useful approach for complimentary treatment among people with MS.

What gait features influence the amount and intensity of physical activity in people with multiple sclerosis?

Although the mutual relationship between ambulation and physical activity (PA) in people with multiple sclerosis (pwMS) has been described in several studies, there is still a lack of detailed information about the way in which specific aspects of the gait cycle are associated with amount and intensity of PA. This study aimed to verify the existence of possible relationships among PA parameters and the spatio-temporal parameters of gait when both are instrumentally assessed.Thirty-one pwMS (17F, 14 M, mean age 52.5, mean Expanded Disability Status Scale (EDSS) score 3.1) were requested to wear a tri-axial accelerometer 24 hours/day for 7 consecutive days and underwent an instrumental gait analysis, performed using an inertial sensor located on the low back, immediately before the PA assessment period. Main spatio-temporal parameters of gait (i.e., gait speed, stride length, cadence and duration of stance, swing, and double support phase) were extracted by processing trunk accelerations. PA was quantified using average number of daily steps and percentage of time spent at different PA intensity, the latter calculated using cut-point sets previously validated for MS. The existence of possible relationships between PA and gait parameters was assessed using Spearman rank correlation coefficient rho.Gait speed and stride length were the parameters with the highest number of significant correlations with PA features. In particular, they were found moderately to largely correlated with number of daily steps (rho 0.62, P< .001), percentage of sedentary activity (rho = -0.44, P < .001) and percentage of moderate-to-vigorous activity (rho = 0.48, P < .001). Small to moderate significant correlations were observed between PA intensity and duration of stance, swing and double support phases.The data obtained suggest that the most relevant determinants associated with higher and more intense levels of PA in free-living conditions are gait speed and stride length. The simultaneous quantitative assessment of gait parameters and PA levels might represent a useful support for physical therapists in tailoring optimized rehabilitative and training interventions.

Self-reported use of vitamin D supplements is associated with higher physical quality of life scores in multiple sclerosis

BACKGROUND

Sun exposure and vitamin D, including intake and serum levels, have been associated with reduced risk of MS onset and less progression and may affect quality of life (QoL). We investigated the prospective relationship of these factors with QoL from baseline to 2.5 years' follow-up, in an international cohort of people with MS.

METHODS

Data derive from the HOLISM international cohort. Sun exposure and vitamin D supplement use were queried at both timepoints. QoL was assessed by MSQOL-54, estimating physical and mental health QoL composite scores. Characteristics of QoL were assessed by linear regression, adjusted for age, sex, socioeconomic status, treated comorbidity number, MS type, disability, clinically significant fatigue, prescription antidepressant medication use, and ongoing relapse symptoms, and baseline QoL score, as appropriate, estimating adjusted coefficients (aβ).

RESULTS

At 2.5-year review, QoL scores were higher among those reporting taking vitamin D supplements (physical: aβ=3.58, 95%CI=1.35-5.80; mental: aβ=3.08, 95%CI=0.72-5.44), particularly average daily dose over 5,000IU/d. Baseline-reported vitamin D supplementation was associated with greater increase in physical (aβ=1.02, 95%CI=0.22-1.81), but not mental QoL (aβ=0.11, 95%CI=-1.00-1.23). Sun exposure was cross-sectionally associated with higher QoL scores at follow-up but was not associated with change in QoL.

CONCLUSIONS

Self-reported vitamin D supplement use was cross-sectionally associated with higher physical and mental QoL, but prospectively only with increased physical QoL.

Influence of Multiple Sclerosis on Spatiotemporal Gait Parameters: A Systematic Review and Meta-Regression

OBJECTIVE

To quantify the effect of multiple sclerosis (MS) on spatiotemporal gait characteristics accounting for disability severity and fall classification.

DATA SOURCES

MEDLINE (1946-August 2018), Allied and Complementary Medicine Database (1985-2018 August), and PsycINFO (1806-August 2018) were searched for terms on MS and gait.

STUDY SELECTION

Dual independent screening was conducted to identify observational, cross-sectional studies that compared adults with MS grouped according to Expanded Disability Status Scale (EDSS) level or fall history, reported on spatiotemporal gait characteristics, and were published in English. The search retrieved 5891 results, of which 12 studies satisfied the inclusion criteria.

DATA EXTRACTION

Two authors worked independently to extract and verify data on publication details, study methodology, participant characteristics, gait outcomes, conclusions, and limitations. Risk of bias was assessed using the QualSyst critical appraisal tool. A random-effects meta-regression and meta-analysis were conducted on pooled data.

DATA SYNTHESIS

All studies received quality ratings of very good to excellent and collectively examined 1513 individuals with MS. With every 1-point increase in EDSS, significant changes (P<.05) were observed in gait speed (-0.12 m/s; 95% confidence interval (CI), 0.08-0.15), step length (-0.04 m; 95% CI, 0.03-0.05), step time (+0.04 seconds; 95% CI, 0.02-0.06), step time variability (+0.009 seconds; 95% CI, 0.003-0.016), stride time (+0.08 seconds; 95% CI, 0.03-0.12), cadence (-4.4 steps per minute; 95% CI, 2.3-6.4), stance phase duration (+0.8% gait cycle; 95% CI, 0.1-1.5), and double support time (+3.5% gait cycle; 95% CI, 1.5-5.4). Recent fallers exhibited an 18% (95% CI, 13%-23%) reduction in gait speed compared with nonfallers (P<.001).

CONCLUSIONS

This review provides the most accurate reference values to-date that can be used to assess the effectiveness of MS gait training programs and therapeutic techniques for individuals who differ on disability severity and fall classification. Some gait adaptations could be part of adopting a more cautious gait strategy and should be factored into the design of future interventions.

Prevalence and patterns of subclinical motor and cognitive impairments in non-disabled individuals with early multiple sclerosis: a multicenter cross-sectional study

BACKGROUND

Motor and cognitive disorders appear early in the course of multiple sclerosis (MS) and develop gradually over time.

OBJECTIVE

To study the frequency and pattern of subtle functional disorders in people with MS (PwMS) with no overt signs of disability in an early phase of the disease and their association with walking impairments in daily activities.

METHODS

In this cross-sectional study, we recruited PwMS with an Expanded Disability Status Scale (EDSS) score ≤ 2.5 and disease duration ≤ 5 years. Participants were assessed with functional scales rating walking endurance (6-Min Walk Test), perceived walking ability (Twelve-item Multiple Sclerosis Walking Scale), balance (Fullerton Advanced Balance scale_short), manual dexterity (Nine Hole Peg Test), fatigue (Fatigue Severity Scale), and cognitive impairments (Brief International Cognitive Assessment).

RESULTS

About 90% of the 82 PwMS (mean [SD] EDSS score 1.5 [0.7] and disease duration 2.2 [1.7] years) showed endurance values below the expected score; almost 30% showed impairment, and for 57%, perceived walking ability score was abnormal. Balance was impaired in 48% of participants, as was manual dexterity (29%) and fatigue (24%), but only a few showed cognitive impairments. Only 11% of PwMS had no abnormal score on the scales used in the assessment. As compared with EDSS score 0 to 1.5, with EDSS score 2 to 2.5, performance was worse for endurance (difference ±61.0 m, p=0.016), perceived walking ability (-11 points, p=0.002), balance (+1.9 points, p=0.005), manual dexterity (-2.8 sec, p=0.004), and fatigue (-1.3 points, p=0.013). Factors that predicted perceived walking ability were balance (B = -1.37, p<0.001) and fatigue (B = 5.11, p<0.001) rather than endurance (B = -0.01, p=048).

CONCLUSION

Even PwMS with no clinical disability and classified as having "no problem walking" present walking and other functional deficits when assessed with specific functional tests. The addition of specific tools could better identify subtle motor and cognitive deficits. Finally, the assessment of balance disorders and fatigue is important to understand individuals' perceived walking impairments in daily activities.

Clinical characteristics of a large multi-center cohort of people with multiple sclerosis over age 60

BACKGROUND

As the peak prevalence of multiple sclerosis (MS) shifts due to an aging patient population, understanding the characteristics that define this older cohort to improve overall management is critical. We sought to determine the clinical characteristics of people with MS over age 60.

METHODS

Demographics, clinical characteristics, MS disease history, and Multiple Sclerosis Performance Test (MSPT) patient-reported outcomes and neuroperformance tests (NPTs) were collected from 10 academic MS centers in the US and Europe participating in the MS Partners Advancing Technology Health Solutions (MS PATHS) system. We characterized demographic and disease characteristics of included participants using descriptive statistics. We characterized prevalence of comorbidities and compared with estimated prevalences from the National Health and Nutrition Examination Survey (NHANES) respondents aged ≥60 years in 2017-2018.

RESULTS

We identified 2738 individuals over age 60 from MS PATHS, with 58.1% relapsing-remitting (RR) and 41.9% progressive. Our results showed median age (RR=65.7 years, progressive=66.0 years), age of symptom onset (RR and progressive=40.9 years), and disease duration (RR=22.8 years, progressive=23.3 years). Over two-thirds of individuals in our cohort were treated with DMTs. The most common DMT used in RR patients were interferons (17.6%) and glatiramer acetate (16.3%), while glatiramer acetate was the most common (12.0%) in progressive patients. Progressive patients had higher disability (higher median PDDS scores, worse Neuro-Qol T-scores, and worse NPTs) compared to the RR group. Pain was the most common comorbidity, followed by cardiac disease, depression, hypertension, dyslipidemia, and obesity. Compared to older NHANES participants, older people with MS were more likely to have depression (MS PATHS: 51.5% [95% CI: 49.5% to 53.5%] vs. NHANES: 21.7% [95% CI: 1619.3% to 22.2%]) and osteoporosis (MS PATHS: 12.7% [95% CI: 11.3% to 14.1%] vs. NHANES: 8.2% [95% CI: 6.2% to 10.3%]); they were less likely to be obese (MS PATHS: 29.4% [95% CI: 27.7% to 31.2%] vs. NHANES: 45.1% [95% CI: 38.9% to 51.3%]) and have diabetes (MS PATHS: 12.3% [95% CI: 11.1% to 13.6%] vs. NHANES: 22.5% [95% CI: 18.8% to 25.7%]).

CONCLUSIONS

Our study characterizes a large multi-center international cohort of people with MS over age 60. This contemporary cohort appears less disabled than prior studies, which may reflect long term impact of DMT availability on the natural history of MS. The burden of comorbidity in this population was generally high. Information on DMT use, comorbidity, and disability outcome measures will be beneficial in future studies evaluating the impact of therapeutic interventions in older individuals.

[Efficacy and safety of Kinezia (fampridine) in the complex therapy of multiple sclerosis]

OBJECTIVE

To analyze the efficacy and safety of fampridine** (Valenta Pharm, Russia) in the complex therapy of multiple sclerosis (MS).

MATERIAL AND METHODS

One hundred and twenty-six patients with MS were double blind randomized to receive fampridine (n=60) or placebo (n=66). Fampridine was administered in prolonged-release form (film-coated tablets, 10 mg) at a dose of 10 mg (1 tablet) 2 times a day, for 24 weeks. The placebo group was treated in the same way. From the 12th week, all patients in the placebo group were transferred to therapy with fampridine, 10 mg 2 times a day, for another 12 weeks. Concomitant standard therapy for MS was allowed in both groups (concomitant disease-modifying medications and other treatment). The primary outcome in the study was the proportion of patients with reduced t25fw test time (determining walking speed on a 25-foot path) on at least two out of three visits compared to baseline. The mean change in Multiple Sclerosis Functional Composite (MSFC) scores from baseline was assessed at visits 4-7 (8-24 weeks).

RESULTS

The proportion of patients with reduced t25fw test time compared to the baseline level was 31.7% in the fampridine group, which is higher than in the placebo group - 3.0% (p<0.001). The overall result of the Multiple Sclerosis Functional Composite (MSFC) reflected a gradual improvement in the patient's condition during treatment period. The dynamics of MSFC result relative to the baseline level significantly differed (p<0.05) between the fampridine and placebo groups in favor of the fampridine group during all treatment periods. In the fampridine group, adverse events (AE) associated with disorders of the nervous system were more common: headache, dizziness, and coordination disorders.

CONCLUSIONS

Fampridine improves walking performance in MS patients. The Russian product fampridine has demonstrated a favorable safety profile.

Impaired consolidation of visuomotor adaptation in patients with multiple sclerosis

BACKGROUND

Apart from inflammation and neurodegeneration, the individual clinical course of multiple sclerosis (MS) might be determined by differential adaptive capacities of the central nervous system. It has been postulated that the retention of adaptive training effects may be impaired in persons with MS (PwMS).

OBJECTIVE

To investigate motor adaptation and consolidation capacities of people with MS in a visual motor adaptation task (VAT).

METHODS

A total of 23 PwMS (Expanded Disability Status Scale (EDSS) score < 6) and 20 matched healthy controls were recruited. All participants completed three sessions of a VAT where a clockwise rotation angle of 30° was introduced as perturbation during the active learning part of the paradigm. The training session (T₀ ) was repeated after 24 h (T₁ ) and 72 h (T₂ ). Directional errors and parameters of adaptation and retention were evaluated.

RESULTS

PwMS showed similar adaptation and online learning abilities as controls. However, the retention ratio was significantly lower in patients compared to controls at T1 (p = 0.036) and T2 (p = 0.039). There was no significant correlation between the overall adaptation or retention ratio and the EDSS score, respectively.

CONCLUSION

Our findings indicate intact adaptation, but limited consolidation, in patients with mild-to-moderate MS. Future studies are needed to define the neurobiological substrates of this plasticity and the extent to which it can influence clinical outcomes.

Feasibility and initial efficacy of a high-intensity interval training program using adaptive equipment in persons with multiple sclerosis who have walking disability: study protocol for a single-group, feasibility trial

Background

There is considerable evidence for the efficacy of moderate-intensity continuous exercise benefitting clinically relevant outcomes in persons with multiple sclerosis (MS). However, persons with MS who have walking disability (pwMS-wd) are severely deconditioned and may achieve superior benefits by engaging in high-intensity interval training (HIIT), especially while utilizing adaptive equipment, such as recumbent arm/leg stepping (RSTEP). The proposed study will assess the feasibility of a 12-week, RSTEP HIIT program in pwMS-wd. The secondary aim will examine changes in aerobic fitness, physical activity, ambulation, upper arm function, cognition, fatigue, and depression as clinically relevant efficacy outcomes following the 12-week, RSTEP HIIT intervention.

Methods

The study will recruit 15 pwMS-wd. Feasibility will be measured via process, resource, management, and scientific outcomes throughout the entirety of the research study. The secondary, clinically relevant outcomes will consist of a neurological exam, aerobic capacity, physical activity, ambulation, cognition, upper arm function, fatigue, and depression. Outcomes will be assessed at baseline (T1), midpoint (T2, following 6 weeks), and post-intervention (T3, following 12 weeks). The intervention will involve 12 weeks of supervised, individualized HIIT sessions two to three times per week. The individual HIIT sessions will each involve 10 cycles of 60-s intervals at the wattage associated with 90% VO_2peak followed by 60 s of active recovery intervals at 15 W, totaling 20 min in length plus 5-min warm-up and cool-down periods.

Discussion

The feasibility design of the proposed study will provide experience and preliminary data for advancing towards a proof-of-concept study comparing HIIT to moderate-intensity continuous RSTEP for improving clinically relevant outcomes in a randomized control trial design. The results will be disseminated via manuscripts for publication and a report for distribution among the National Multiple Sclerosis Society.

Trial registration

ClinicalTrials.gov NCT04416243. Retrospectively registered on June 4, 2020

Little evidence for an effect of smoking on multiple sclerosis risk: A Mendelian Randomization study

The causes of multiple sclerosis (MS) remain unknown. Smoking has been associated with MS in observational studies and is often thought of as an environmental risk factor. We used two-sample Mendelian randomization (MR) to examine whether this association is causal using genetic variants identified in genome-wide association studies (GWASs) as associated with smoking. We assessed both smoking initiation and lifetime smoking behaviour (which captures smoking duration, heaviness, and cessation). There was very limited evidence for a meaningful effect of smoking on MS susceptibility as measured using summary statistics from the International Multiple Sclerosis Genetics Consortium (IMSGC) meta-analysis, including 14,802 cases and 26,703 controls. There was no clear evidence for an effect of smoking on the risk of developing MS (smoking initiation: odds ratio [OR] 1.03, 95% confidence interval [CI] 0.92-1.61; lifetime smoking: OR 1.10, 95% CI 0.87-1.40). These findings suggest that smoking does not have a detrimental consequence on MS susceptibility. Further work is needed to determine the causal effect of smoking on MS progression.

The Dresden Protocol for Multidimensional Walking Assessment (DMWA) in Clinical Practice

Walking impairments represent one of the most debilitating symptom areas for people with multiple sclerosis (MS). It is important to detect even slightest walking impairments in order to start and optimize necessary interventions in time to counteract further progression of the disability. For this reason, a regular monitoring through gait analysis is highly necessary. At advanced stages of MS with significant walking impairment, this assessment is also necessary to optimize symptomatic treatment, choose the most suitable walking aid and plan individualized rehabilitation. In clinical practice, walking impairment is only assessed at higher levels of the disease using e.g., the Expanded Disability Status Scale (EDSS). In contrast to the EDSS, standardized functional tests such as walking speed, walking endurance and balance as well as walking quality and gait-related patient-reported outcomes allow a more holistic and sensitive assessment of walking impairment. In recent years, the MS Center Dresden has established a standardized monitoring procedure for the routine multidimensional assessment of gait and balance disorders. In the following protocol, we present the techniques and procedures for the analysis of gait and balance of people with MS at the MS Center Dresden. Patients are assessed with a multidimensional gait analysis at least once a year. This enables long-term monitoring of walking impairment, which allows early active intervention regarding further progression of disease and improves the current standard clinical practice.

Radon Exposure and Neurodegenerative Disease

Background: To carry out a systematic review of scientific literature about the association between radon exposure and neurodegenerative diseases. Methods: We performed a bibliographic search in the following databases: Pub med (Medline), Cochrane, BioMed Central and Web of Science. We collected the data by following a predetermined search strategy in which several terms werecombined. After an initial search, 77 articles were obtained.10 of which fulfilled the inclusion criteria. Five of these 10 studies were related to multiple sclerosis (MS), 2 were about motor neuron diseases (MND), in particular amyotrophic lateral sclerosis (ALS) and 3 were related to both Alzheimer's disease (AD) and Parkinson's disease (PD). Results: The majority of the included articles, suggested a possible association between radon exposure and a subsequent development of neurodegenerative diseases. Some of the studies that obtained statistically significant resultsrevealed a possible association between radon exposure and an increase in MS prevalence. Furthermore, it was also suggested that radon exposure increases MND and AD mortality. Regarding AD and PD, it was observed that certainde cay products of radon-222 (²²²Rn), specifically polonium-210 (²¹⁰Po) and bismuth-210 (²¹⁰Bi), present a characteristic distributionpattern within the brain anatomy. However, the study with the highest scientific evidence included in this review, which investigated a possible association between the concentration of residential radon gas and the MS incidence, revealed no significant results. Conclusions: It cannot be concluded, although it is observed, that there is a possible causal association between radon exposure and neurodegenerative diseases. Most of the available studies are ecological so, studies of higher statistical evidence are needed to establish a causal relationship. Further research is needed on this topic.