Improving cognition in people with multiple sclerosis: study protocol for a multiarm, randomised, blinded trial of multidomain cognitive rehabilitation using a video-serious game (E-SEP cognition)

Introduction

Multiple sclerosis (MS) is a prevalent neurological disease characterised by disseminated areas of demyelination and atrophy within the central nervous system, inducing cognitive disorders in 45%-65% of persons with MS (PwMS). Neuropsychology and neuroimaging studies provide evidence of the effectiveness of cognitive rehabilitation interventions, including memory and attention. Recently, serious game therapy (SGT) has been used in rehabilitation to improve cognitive processing speed. The aim of this study is to describe the protocol of a randomised controlled trial (RCT) to test the efficacy of a tablet-based cognitive home intervention among ambulatory PwMS, in comparison to a standardised neuropsychological rehabilitation.

Methods and analysis

This will be a parallel-assignment, double-blinded, RCT. One hundred and fifty (75 per arm) PwMS will be randomly assigned to receive cognitive rehabilitation session over 4 months (four 20-min sessions/week) of either: (1) tablet-based SGT or (2) conventional cognitive exercises. The same assessor will evaluate outcome measures at three points: at baseline (T0), after the 16 therapy sessions weeks (T1), and 6 months after the end of treatment (T2). The primary outcomes were the scores from the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS). Data analysis will be performed to compare the efficacy of the two treatments. We expect superior efficiency of tablet-based SGT in contrast to conventional cognitive exercises, based on BICAMS measures of speed processing information and episodic memory.

Ethics and dissemination

The trial protocol is registered on ClinicalTrials.Gov (NCT04694534) and benefits from a favourable opinion from an ethics committee (RC-P0066-2018-A00411-54).

Impact of physical activity, physical fitness and exercises on cognitive impairment in patients with multiple sclerosis: A review of evidence and underlying mechanisms

Cognitive impairment in persons with MS (pwMS) occurs commonly, early and independently of other clinical features of the disease. MS-related cognitive impairment is mainly characterized by weakening of information processing speed, working memory and episodic memory. Much evidence, based on both neuropsychological and neuroimaging outcomes, highlights successful cognitive rehabilitation interventions. In this context, promotion of physical activity and exercise training could be a dual, motor and cognitive, rehabilitation method. The aim of this article is, firstly, to review existing evidence regarding the effects of exercise on cognition among pwMS, and secondly, to explore the possible mechanisms of action of the cognitive-motor coupling.

Upper limb contribution during tandem gait in multiple sclerosis: An early marker of balance impairments

Tandem gait is widely used during clinical exams to evaluate dynamic balance in chronic diseases, such as multiple sclerosis (MS). The early detection of balance impairments in MS is challenging to improve the understanding of patients' complaints. The objective was to propose two indexes to quantify the contributions and inefficiency of limb and trunk movements during tandem gait in early-stage MS patients. Fifteen patients with remitting-relapsed MS, with a median Expanded Disability Status Scale of 2.5 [0-4] were compared to 15 matched healthy participants. Three-dimensional motion analysis was performed during tandem gait to calculate spatiotemporal parameters, contribution and inefficiency indexes, based on the linear momentum of body segments. Compared to healthy participants, MS patients at the early stage of disease executed tandem gait with higher speed (p = 0.03) and increased step length (p = 0.03). The contribution indexes of upper limbs were significantly decreased during swing phase in MS patients. The inefficiency index for the upper limbs were around twice higher for MS patients compared to healthy participants. Since the additional movements concerned only light body segments and not contribute to the whole-body forward progression during tandem gait, they could reflected more both upper limb movements alterations and restoring movements to avoid loss of balance during tandem gait around swing phase in MS. These quantified indexes could be used as physical markers to quantify both the balance deterioration and the efficiency of rehabilitation program during the follow up of MS from the early stage of their disease.

Pregnancy and neuromyelitis optica spectrum disorders: 2022 recommendations from the French Multiple Sclerosis Society

BACKGROUND

In 2020, the French Multiple Sclerosis (MS) Society (SFSEP) decided to develop a national evidence-based consensus on pregnancy in MS. As neuromyelitis optica spectrum disorders (NMOSD) shares a series of commonalities with MS, but also some significant differences, specific recommendations had to be developed.

OBJECTIVES

To establish recommendations on pregnancy in women with NMOSD.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and universities databases (January 1975 through June 2021). The RAND/UCLA appropriateness method, which was developed to synthesise the scientific literature and expert opinions on health care topics, was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A sub-group of nine NMOSD experts was dedicated to analysing available data on NMOSD. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 66 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, loco-regional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses, and disease-modifying treatments.

CONCLUSION

Physicians and patients should be aware of the new and specific evidence-based recommendations of the French MS Society for pregnancy in women with NMOSD. They should help harmonise counselling and treatment practise, allowing for better individualised choices.

Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society

OBJECTIVE

The objective of this study was to develop evidence-based recommendations on pregnancy management for persons with multiple sclerosis (MS).

BACKGROUND

MS typically affects young women in their childbearing years. Increasing evidence is available to inform questions raised by MS patients and health professionals about pregnancy issues.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and university databases (January 1975 through June 2021). The RAND/UCLA appropriateness method was developed to synthesise the scientific literature and expert opinions on healthcare topics; it was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 104 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, locoregional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses and disease-modifying treatments.

CONCLUSION

The 2022 recommendations of the French MS society should be helpful to harmonise counselling and treatment practice for pregnancy in persons with MS, allowing for better and individualised choices.

Simplified stance limb kinetics patterns revealed during gait initiation in early stage of multiple sclerosis

BACKGROUND

Although patients with an early stage of Multiple Sclerosis (MS) commonly complain about balance and gait impairments, their troubles remain misunderstood. The objective was to compare body kinematics and lower limb kinetics during gait initiation between patients with MS with an EDSS score ≤ 4 and healthy participants.

METHODS

Sixteen patients with MS with a median EDSS score of 2.5 [0-4] and disease duration of 7.4 ± 4.2 years, as well as 16 healthy participants were included, and 3-D motion analysis was performed during gait initiation to calculate spatiotemporal, kinematic and kinetic parameters.

FINDINGS

The center of pressure position at the beginning of the gait initiation was more anterior (p = 0.02) in patients with MS than healthy participants. The kinetic parameters of the stance limb were highly affected in patients with MS compared to healthy participants during gait initiation. The net muscular moments for each joint were significantly different during the anticipatory postural adjustment phase with smoother variations for patients with MS compared to healthy participants.

INTERPRETATION

Early stage MS strongly affects the motor modulation of stance limb kinetics during the anticipatory postural adjustment of gait initiation, without alteration of the execution phase. The net muscular moments are sensitive in detecting unobservable balance impairments and can be used to assess disease progression at the early stage. These results suggest that early rehabilitation programs aimed at improving motor modulation and flexibility in gait initiation should be implemented.

Infections and multiple sclerosis: Recommendations from the French Multiple Sclerosis Society

INTRODUCTION

Viral, bacterial, or fungal infections are suspected of triggering multiple sclerosis (MS) and promoting relapses of the disease and are likely to be promoted by immune-active treatments. This raises questions about the infectious workup and preventive treatment of these infections prior to their initiation.

OBJECTIVES

To establish recommendations on infections and MS. Provide information to patients and healthcare professionals on the minimal infectious workup to be performed in an MS patient at diagnosis and prior to initiation of immuno-active therapy in MS.

METHODS

The recommendation attempts to answer four main questions about infections and MS. The French Group for Recommendations in Multiple Sclerosis (France4MS) did a systematic review of articles from PubMed and universities databases (from January 1975 to June 2020), using the RAND/UCLA formalized consensus method. The RAND/UCLA method has been developed to synthesize the scientific literature and expert opinions on health care topics and was used for reaching a formal agreement. Twenty-three experts contributed to the detailed review and a group of 63 multidisciplinary health professionals validated the final version of 36 recommendations.

RESULTS

It is recommended that MS patients undergo a minimal infectious workup, check their vaccination status at diagnosis, and repeat it during follow-up and before starting immunotherapy. Screening and preventive treatment of viral (group Herpes virus, HPV, JCV, HCV, HBV), bacterial (mycobacteria) and fungal (Cryptococcus) infections is recommended prior to the initiation of certain immuno-active MS therapies.

DISCUSSION AND CONCLUSIONS

At diagnosis of MS and prior to the choice of therapeutic strategy, it is recommended to update the vaccination schedule of MS patients in reference to the HCSP vaccination schedule and the SFSEP recommendations. Before starting immunosuppressive treatment, it is recommended to inform patients of the risks of infections and to look for a constitutive or acquired immune deficiency. Health professionals and patients should be informed of the updated recommendations on infections and MS.

Low back pain in patients with multiple sclerosis: A systematic review and the prevalence in a French multiple sclerosis population

PURPOSE

The prevalence and management of back pain in MS patients was assessed by a systematic review, and the results of a survey on the characteristics of low back pain in a sample of French MS patients are reported.

METHODS

A systematic search was conducted according to the PRISMA guidelines. The outcomes of interest included the prevalence of back pain, severity of pain and impact on daily activities. Moreover, the prevalence of low back pain and its consequences on daily living in a large French MS population were assessed.

RESULTS

Fourteen studies were included in the systematic review. The prevalence of back pain in MS patients ranged from 8.6 to 50%, but that of low back pain in particular ranged from 41.6 to 52.4%. Concerning the survey, 237 patients participated in the online questionnaire. The prevalence of low back pain in the French MS patients was 76.4%. The patients with chronic low back pain had more limitations in their daily life activities than those without chronic low back pain.

CONCLUSION

Patients with MS commonly suffer from low back pain, but it is still an underdiagnosed cause of pain that reduces one's ability to perform activities in daily life.

Ankle dysfunction in multiple sclerosis and the effects on walking

PURPOSE

Even in the early stage of the disease, for patients suffering from multiple sclerosis (MS), the most common and reported biomechanical alterations in the lower limb are located at the ankle joint. However, the effects of these impairments on gait deterioration should be discussed.

MATERIALS AND METHODS

This review was written according to the PRISMA guidelines. The search focussed on biomechanical changes (kinetic, kinematic, and electromyographic data) at the ankle during gait in MS patients. The search was performed in the databases: Pubmed, Web of Science, and Cochrane Library.

RESULTS

Eleven studies were included. The reduction in the ankle range of motion (RoM) induced by increased cocontractions of the tibialis anterior and triceps surae muscles could be a compensatory strategy to improve body-weight support and balance during the stance phase.

CONCLUSIONS

Future rehabilitation programmes should consider the control of weight support at the ankle during gait training.Implications for rehabilitationThe ankle supports and stabilises the body during the stance phase of gait.The reduced ankle range of motion in multiple sclerosis (MS), even at an early stage of the disease, is due to cocontractions of tibialis anterior and triceps surae and could be a compensatory strategy to be more stable.Rehabilitation programmes for MS patients should focus on the control of body segments motion during the weight transfer above the ankle.

Anticipatory postural adjustment during gait initiation in multiple sclerosis patients: A systematic review

BACKGROUND

Multiple sclerosis (MS) causes balance and walking disorders. Gait initiation is the complex transition between standing and walking and is characterized by two distinct phases: the anticipatory postural adjustment (APA) phase followed by the execution of the first step phase.

RESEARCH AIM

To determine alterations in the APA during gait initiation in patients with MS.

METHODS

A systematic search was conducted in May 2018. The search was carried out by the use of the following databases: PubMed, Web of Science and the Cochrane Library. The following keywords were used: MS, gait initiation, step initiation, and postural adjustment(s). Outcomes of interest were the variables generally used to assess APA, including electromyography, force-plate data, or video-based data, duration of APA, and length of first step. The Ottawa scale was used to assess the quality of the studies.

RESULTS

Eight case-control studies were included; one was a transverse study. A total of 215 MS patients and 116 healthy subjects were included with ages ranging from 22 to 76 years old. In MS patients, Expanded Disability Status Scale (EDSS) scores ranged from 0 to 7. APA CoP displacements were smaller in the anteroposterior axis. Four studies evaluated muscle activation during APA. The latencies of all muscles were delayed, and smaller magnitudes of muscle activity during APA were found, even in the early stage of disease. The first step was shorter in MS patients than in healthy patients. No previous study has reported joint movement or trunk inclination during gait initiation.

SIGNIFICANCE

This review illustrates the gap in knowledge of APA alterations in MS patients. APA assessment in the early stage of MS could be an interesting measure to characterize balance, dynamic control and risk of fall for such patients.

Clinical balance tests, proprioceptive system and adolescent idiopathic scoliosis

PURPOSE

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spinal column of unknown etiology. Multiple factors could be involved, including neurosensory pathways and, potentially, an elective disorder of dynamic proprioception. The purpose of this study was to determine whether routine balance tests could be used to demonstrate an elective alteration of dynamic proprioception in AIS.

METHODS

This was a multicentre case-control study based on prospectively collected clinical data, in three hospitals pediatric, with spine consultation, from January 2013 through April 2015. From an original population of 547 adolescents, inclusion and non-inclusion criteria indentified 114 adolescents with right thoracic AIS (mean age 14.5 ± 1.9 years, Cobb angle 35.7 ± 15.3°) and 81 matched adolescents without scoliosis (mean age 14.1 ± 1.9 years). Participants performed three routine clinical balance tests to assess the static and dynamic proprioception: the Fukuda-Utenberger stepping test (angle of rotation in degrees and distance of displacement in cm) to assess dynamic balance; the sharpened Romberg test and the unipedal stance test (eyes closed) to assess static balance.

RESULTS

There was no significant difference between AIS subjects and controls for the static tests, but there was a significant difference for the dynamic test for both measures: distance of displacement (p < 0.01) and angle of rotation (p < 0.0001). This result confirms our initial these: the dynamic proprioception is altered electively in AIS.

CONCLUSION

These findings confirm recent AIS studies. Our results might be related to immature central integration of dynamic proprioceptive input leading to a poorly adapted motor response, particularly for postural control of the, in AIS. These balance tests can be performed in routine practice. Their validity as a biomarker for screening and monitoring purposes should be assessed.

Usefulness of intra-articular botulinum toxin injections. A systematic review

Botulinum toxin is a proven and widely used treatment for numerous conditions characterized by excessive muscular contractions. Recent studies have assessed the analgesic effect of botulinum toxin in joint pain and started to unravel its mechanisms.

LITERATURE-SEARCH-METHODOLOGY

We searched the international literature via the Medline database using the term "intraarticular botulinum toxin injection" combined with any of the following terms: "knee", "ankle", "shoulder", "osteoarthritis", "adhesive capsulitis of the shoulder".

RESULTS

Of 16 selected articles about intraarticular botulinum toxin injections, 7 were randomized controlled trials done in patients with osteoarthritis, adhesive capsulitis of the shoulder, or chronic pain after joint replacement surgery. Proof of anti-nociceptive effects was obtained in some of these indications and the safety and tolerance profile was satisfactory. The studies are heterogeneous. The comparator was usually a glucocorticoid or a placebo; a single study used hyaluronic acid. Pain intensity was the primary outcome measure.

DISCUSSION-CONCLUSION

The number of randomized trials and sample sizes are too small to provide a satisfactory level of scientific evidence or statistical power. Unanswered issues include the effective dosage and the optimal dilution and injection modalities of botulinum toxin.

Eye-hand laterality and right thoracic idiopathic scoliosis

PURPOSE

The adolescent idiopathic scoliosis (AIS) pathogenesis remains unknown. Certain studies have shown that there is a correlation between manual laterality and scoliotic deviation. A full study of manual laterality needs to be paired with one for visual dominance. With the aim of physiopathological research, we have evaluated the manual and visual laterality in AIS.

METHODS

A retrospective study from prospective data collection is used to evaluate the distribution of eye-hand laterality (homogeneous or crossed) of 65 right thoracic AIS (mean age 14.8 ± 1.8 years; mean Cobb angle: 32.8°) and a control group of 65 sex and age-matched (mean age 14.6 ± 1.8 years). The manual laterality was defined by the modified Edinburgh Handedness Inventory. The evaluation of the visual laterality is done using three tests (kaleidoscope test, hole-in-the-card test, distance-hole-in-the-card test).

RESULTS

The group of right thoracic AIS presents a significantly higher frequency of crossed eye-hand laterality (63 %) than the control group (63 vs. 29.2 %; p < 0.001). In the AIS group, the most frequent association, within crossed laterality is "right hand dominant-left eye dominant" (82.9 %). There is no relationship with the Cobb angle.

CONCLUSIONS

Those with right thoracic AIS show a higher occurrence of crossed eye-hand laterality. This could point physiopathological research of AIS towards functional abnormality of the optic chiasma through underuse of cross visual pathways, and in particular accessory optic pathways. It would be useful to explore this by carrying out research on AISs through neuroimaging and neurofunctional exploration.

[General practitioners' approach to relapsing multiple sclerosis]

Management of multiple sclerosis depends on close multidisciplinary collaboration but general practitioners play a particularly important role, especially in case of relapse, due to their close relationship with the patient. The purpose of this work was to conduct a survey of general practitioners' knowledge of relapsing multiple sclerosis and ascertain their main difficulties in patient management. One hundred seventy-seven practitioners answered a written questionnaire with two headings, diagnostic criteria for relapse and therapeutic approaches. Analysis of the results showed that this common event is under recognized. While 55.9 p.cent of the general practitioners stated they diagnosed relapse by themselves, only 2.8 p.cent knew its exact definition. Differential diagnosis accounted for a large number of mistakes. Our survey also underlined the use of certain therapeutic options (low-dose oral corticosteroid therapy) for which the effectiveness has not been demonstrated. It would be important to propose specific education on relapsing multiple sclerosis for general practitioners and improve cooperation with specialists. An integrated care network might be useful.