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Schwid SR, Petrie MD, McDermott MP, Tierney DS, Mason DH, Goodman AD. Quantitative assessment of sustained-release 4-aminopyridine for symptomatic treatment of multiple sclerosis. Mult Scler 2016. [DOI: 10.1177/135245859600200517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- S R Schwid
- Department of Neurology, University of Rochester Medical Center, Box 605, Rochester, NY 14642, USA
| | - M D Petrie
- Department of Neurology, University of Rochester Medical Center, Box 605, Rochester, NY 14642, USA
| | - M P McDermott
- Department of Neurology, University of Rochester Medical Center, Box 605, Rochester, NY 14642, USA
| | - D S Tierney
- Department of Neurology, University of Rochester Medical Center, Box 605, Rochester, NY 14642, USA
| | - D H Mason
- Department of Neurology, University of Rochester Medical Center, Box 605, Rochester, NY 14642, USA
| | - A D Goodman
- Department of Neurology, University of Rochester Medical Center, Box 605, Rochester, NY 14642, USA
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Noyes K, Bajorska A, Chappel A, Schwid SR, Mehta LR, Weinstock-Guttman B, Holloway RG, Dick AW. Cost-effectiveness of disease-modifying therapy for multiple sclerosis: a population-based study. Neurology 2011; 77:355-63. [PMID: 21775734 PMCID: PMC3140799 DOI: 10.1212/wnl.0b013e3182270402] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 02/18/2011] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of disease-modifying therapies (DMTs) in the United States compared to basic supportive therapy without DMT for patients with relapsing multiple sclerosis (MS). METHODS Using data from a longitudinal MS survey, we generated 10-year disease progression paths for an MS cohort. We used first-order annual Markov models to estimate transitional probabilities. Costs associated with losses of employment were obtained from the Bureau of Labor Statistics. Medical costs were estimated using the Centers for Medicare and Medicaid Services reimbursement rates and other sources. Outcomes were measured as gains in quality-adjusted life-years (QALY) and relapse-free years. Monte Carlo simulations, resampling methods, and sensitivity analyses were conducted to evaluate model uncertainty. RESULTS Using DMT for 10 years resulted in modest health gains for all DMTs compared to treatment without DMT (0.082 QALY or <1 quality-adjusted month gain for glatiramer acetate, and 0.126-0.192 QALY gain for interferons). The cost-effectiveness of all DMTs far exceeded $800,000/QALY. Reducing the cost of DMTs had by far the greatest impact on the cost-effectiveness of these treatments (e.g., cost reduction by 67% would improve the probability of Avonex being cost-effective at $164,000/QALY to 50%). Compared to treating patients with all levels of disease, starting DMT earlier was associated with a lower (more favorable) incremental cost-effectiveness ratio compared to initiating treatment at any disease state. CONCLUSION Use of DMT in MS results in health gains that come at a very high cost.
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Affiliation(s)
- K Noyes
- Department of Community and Preventive Medicine, University of Rochester, 601 Elmwood Ave., Box 644, Rochester, NY 14620, USA.
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Krupp LB, Christodoulou C, Melville P, Scherl WF, Pai LY, Muenz LR, He D, Benedict RHB, Goodman A, Rizvi S, Schwid SR, Weinstock-Guttman B, Westervelt HJ, Wishart H. Multicenter randomized clinical trial of donepezil for memory impairment in multiple sclerosis. Neurology 2011; 76:1500-7. [PMID: 21519001 DOI: 10.1212/wnl.0b013e318218107a] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The goal of this study was to determine if memory would be improved by donepezil as compared to placebo in a multicenter, double-blind, randomized clinical trial (RCT). METHODS Donepezil 10 mg daily was compared to placebo to treat memory impairment. Eligibility criteria included the following: age 18-59 years, clinically definite multiple sclerosis (MS), and performance ≤ ½ SD below published norms on the Rey Auditory Verbal Learning Test (RAVLT). Neuropsychological assessments were performed at baseline and 24 weeks. Primary outcomes were change on the Selective Reminding Test (SRT) of verbal memory and the participant's impression of memory change. Secondary outcomes included changes on other neuropsychological tests and the evaluating clinician's impression of memory change. RESULTS A total of 120 participants were enrolled and randomized to either donepezil or placebo. No significant treatment effects were found between groups on either primary outcome of memory or any secondary cognitive outcomes. A trend was noted for the clinician's impression of memory change in favor of donepezil (37.7%) vs placebo (23.7%) (p = 0.097). No serious or unanticipated adverse events attributed to study medication developed. CONCLUSIONS Donepezil did not improve memory as compared to placebo on either of the primary outcomes in this study. CLASSIFICATION OF EVIDENCE This study provides Class I evidence which does not support the hypothesis that 10 mg of donepezil daily for 24 weeks is superior to placebo in improving cognition as measured by the SRT in people with MS whose baseline RAVLT score was 0.5 SD or more below average.
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Affiliation(s)
- L B Krupp
- Department of Neurology, State University of New York at Stony Brook, Stony Brook, NY 11794-8121, USA.
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Rudick RA, Polman CH, Cohen JA, Walton MK, Miller AE, Confavreux C, Lublin FD, Hutchinson M, O'Connor PW, Schwid SR, Balcer LJ, Lynn F, Panzara MA, Sandrock AW. Assessing disability progression with the Multiple Sclerosis Functional Composite. Mult Scler 2009; 15:984-97. [PMID: 19667023 DOI: 10.1177/1352458509106212] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The initial Multiple Sclerosis Functional Composite (MSFC) proposal was a three-part composite of quantitative measures of ambulation, upper extremity function, and cognitive function expressed as a single composite Z-score. However, the clinical meaning of an MSFC Z-score change is not obvious. This study instead used MSFC component data to define a patient-specific disease progression event. OBJECTIVE Evaluate a new method for analyzing disability progression using the MSFC. METHODS MSFC progression was defined as worsening from baseline on scores of at least one MSFC component by 20% (MSFC Progression-20) or 15% (MSFC Progression-15), sustained for >or=3 months. Progression rates were determined using data from natalizumab clinical studies (Natalizumab Safety and Efficacy in Relapsing Remitting Multiple Sclerosis [AFFIRM] and Safety and Efficacy of Natalizumab in Combination With Interferon Beta-1a in Patients With Relapsing Remitting Multiple Sclerosis [SENTINEL]). Correlations between MSFC progression and other clinical measures were determined, as was sensitivity to treatment effects. RESULTS Substantial numbers of patients met MSFC progression criteria, with MSFC Progression-15 being more sensitive than MSFC Progression-20, at both 1 and 2 years. MSFC Progression-20 and MSFC Progression-15 were related significantly to Expanded Disability Status Scale (EDSS) score change, relapse rate, and the SF-36 Physical Component Summary (PCS) score change. MSFC Progression-20 and MSFC Progression-15 at 1 year were predictive of EDSS progression at 2 years. Both MSFC progression end points demonstrated treatment effects in AFFIRM, and results were replicated in SENTINEL. CONCLUSION MSFC Progression-20 and MSFC Progression-15 are sensitive measures of disability progression; correlate with EDSS, relapse rates, and SF-36 PCS; and are capable of demonstrating therapeutic effects in randomized, controlled clinical studies.
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Affiliation(s)
- R A Rudick
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH 44106, USA.
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Mehta LR, Schwid SR, Arnold DL, Cutter GR, Aradhye S, Balcer LJ, Calabresi PA, Cohen JA, Cole PE, Glanzman R, Goelz S, Inglese M, Kapoor R, Kappos L, Kreitman R, Lublin FD, Mann A, Marrie RA, O'Looney P, Polman CH, Ravina BM, Reingold SC, Richert JR, Sandrock AW, Waubant E. Proof of concept studies for tissue-protective agents in multiple sclerosis. Mult Scler 2009; 15:542-6. [PMID: 19389749 DOI: 10.1177/1352458508101939] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is considerable interest in tissue-protective treatments for multiple sclerosis (MS). METHODS AND OBJECTIVES We convened a group of MS clinical trialists and related researchers to discuss designs for proof of concept studies utilizing currently available data and assessment methods. RESULTS Our favored design was a randomized, double-blind, parallel-group study of active treatment versus placebo focusing on changes in brain volume from a post-baseline scan (3-6 months after starting treatment) to the final visit 1 year later. Study designs aimed at reducing residual deficits following acute exacerbations are less straightforward, depending greatly on the anticipated rapidity of treatment effect onset. CONCLUSIONS The next step would be to perform one or more studies of potential tissue-protective agents with these designs in mind, creating the longitudinal data necessary to refine endpoint selection, eligibility criteria, and sample size estimates for future trials.
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Affiliation(s)
- L R Mehta
- University of Rochester Department of Neurology, Rochester, NY, USA.
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Abstract
OBJECTIVE To model the long-term risks and benefits of natalizumab in individuals with relapsing multiple sclerosis (MS). METHODS We created a Markov model to evaluate treatment effects on reducing relapses and slowing disease progression using published natural history data and clinical trial results. Health changes, measured in quality-adjusted life-years (QALYs), were based on patient health preferences. Patient cohorts treated with no disease-modifying treatment, natalizumab, subcutaneous interferon beta-1a, and a theoretical "perfect" MS treatment were modeled. Sensitivity analysis was used to explore model uncertainty, including varying risks of developing progressive multifocal leukoencephalopathy (PML). RESULTS Treatment with natalizumab resulted in 9.50 QALYs over a 20-year time horizon, a gain of 0.80 QALYs over the untreated cohort and 0.38 QALYs over interferon beta-1a. The health loss due to PML was small (-0.06 QALYs). To offset natalizumab's incremental health gain over interferon beta-1a, the risk had to increase from 1 to 7.6 PML per 1,000 patients treated over 17.9 months. The "perfect" MS treatment accumulated 10.59 QALYs over the 20-year time horizon, 1.89 QALYs above the untreated cohort. Interferon beta-1a resulted in greater QALY gains compared with natalizumab if natalizumab's relative relapse reduction was reduced from 68% to 35% or if interferon beta-1a's relative reduction was increased from 32% to 65%. CONCLUSIONS A more than sevenfold increase in actual risk of progressive multifocal leukoencephalopathy was required to decrease natalizumab's health gain below that of interferon beta-1a, and there remains considerable room for additional gains in health (>50%) beyond those already achieved with current therapies.
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Affiliation(s)
- J P Thompson
- Department of Neurology, University of Rochester, Rochester, NY, USA
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Goodman AD, Brown TR, Cohen JA, Krupp LB, Schapiro R, Schwid SR, Cohen R, Marinucci LN, Blight AR. Dose comparison trial of sustained-release fampridine in multiple sclerosis. Neurology 2008; 71:1134-41. [PMID: 18672472 DOI: 10.1212/01.wnl.0000326213.89576.0e] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the efficacy and safety of three different doses of sustained-release fampridine in people with multiple sclerosis (MS). METHOD This multicenter, randomized, double-blind, placebo-controlled, parallel-group study recruited 206 participants at 24 centers in the United States and Canada. After a single-blind, 2-week placebo run-in, participants were randomly assigned to receive fampridine (10, 15, or 20 mg twice daily) or placebo for 15 weeks. The primary efficacy variable was percent change in walking speed based on the timed 25-foot walk. RESULTS Trends for increased walking speed were consistent across dose groups vs placebo, but not significant, on the prospective analysis. An increase from baseline in lower extremity strength during the 12-week stable-dose period was seen in the groups receiving 10- and 15-mg doses, compared with placebo (p = 0.018 and 0.003). There were no significant changes in other secondary assessments. Post hoc analysis revealed subsets of participants in each dose group with walking speeds during the treatment period that were consistently faster than during the nontreatment period. There were significantly more "consistent responders" in the drug-treated groups than in the placebo group (36.7% compared with 8.5%). Consistent responders showed significantly greater improvement in self-assessed ambulation on the 12-Item MS Walking Scale than did nonresponders. Fampridine was generally well tolerated. Severe and serious adverse events were more frequent at the highest dose. CONCLUSIONS This phase 2 study suggests that a subgroup of patients, when treated with fampridine, experiences a clinically relevant improvement in walking ability, which is sustained for at least 14 weeks.
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Affiliation(s)
- A D Goodman
- Multiple Sclerosis Center, Chief Neuroimmunology Unit, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave., Room 6-8521, Box 605, Rochester, NY 14642, USA.
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Polman CH, Reingold SC, Barkhof F, Calabresi PA, Clanet M, Cohen JA, Cutter GR, Freedman MS, Kappos L, Lublin FD, McFarland HF, Metz LM, Miller AE, Montalban X, O'Connor PW, Panitch H, Richert JR, Petkau J, Schwid SR, Sormani MP, Thompson AJ, Weinshenker BG, Wolinsky JS. Ethics of placebo-controlled clinical trials in multiple sclerosis: A reassessment. Neurology 2008; 70:1134-40. [DOI: 10.1212/01.wnl.0000306410.84794.4d] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
Using published data, we quantified the risk and benefits of natalizumab in relapsing multiple sclerosis using quality-adjusted life years (QALYs) as a metric. Over the first 2 years of therapy, the negative health effects from progressive multifocal leukoencephalopathy were small (loss of 0.001 QALYs) relative to the positive effects on relapses and disability resulting in 0.033 QALYs (12 quality-adjusted days) gained. For context, we performed an analogous calculation for interferon beta-1a, which also had a net health benefit of 0.033 QALYs (12 quality-adjusted days).
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Affiliation(s)
- E R Dorsey
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14620, USA.
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Abstract
The authors examined age effects on adverse events from two randomized, controlled trials of rasagiline, comparing younger (younger than 70 years) and older (70 years and older) subjects. Older patients were more prone to serious adverse effects than younger patients, but there was no statistical interaction between age and rasagiline exposure. This absence of an age-rasagiline interaction suggests that rasagiline does not require special safety precautions for elderly subjects with Parkinson disease.
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Affiliation(s)
- C G Goetz
- Rush University Medical Center, Chicago, IL 60612, USA.
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Griggs RC, Gross RA, Mink JW, Riggs GH, Schwid SR. Message from the Editors to our U.S. and International Reviewers. Neurology 2005. [DOI: 10.1212/01.wnl.0000200983.02453.1e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Schwid SR, Marler JR. Clinical Trials Recruiting Section: A new resource for a daunting problem. Neurology 2004. [DOI: 10.1212/01.wnl.0000131905.43402.da] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Schwid SR, Tyler CM, Scheid EA, Weinstein A, Goodman AD, McDermott MP. A reply to the letter Cognitive fatigue in multiple sclerosis by Kos D, Kerchkofs E, Nagels G, Geentjens L. Mult Scler 2004. [DOI: 10.1191/1352458504ms1012xx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- S R Schwid
- University of Rochester, Department of Neurology, Rochester, NY, USA,
| | - C M Tyler
- University of Rochester, Department of Neurology, Rochester, NY, USA
| | - E A Scheid
- University of Rochester, Department of Neurology, Rochester, NY, USA
| | - A Weinstein
- University of Rochester, Department of Neurology, Rochester, NY, USA
| | - A D Goodman
- University of Rochester, Department of Neurology, Rochester, NY, USA
| | - M P McDermott
- University of Rochester, Department of Neurology, Rochester, NY, USA
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Griggs RC, Gross RA, Mink JW, McDermott MP, Schwid SR. Message from the Editors to our ad hoc Reviewers. Neurology 2003. [DOI: 10.1212/wnl.61.12.1640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Griggs RC, Gross RA, Mink JW, McDermott MP, Schwid SR. Message from the Editors to our ad hoc Reviewers. Neurology 2003. [DOI: 10.1212/wnl.60.12.1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Griggs RC, Gross RA, Mink JW, Mcdermott MP, Schwid SR. Neurology 2002; 59:1828-1832. [DOI: 10.1212/wnl.59.12.1828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
As a first step toward understanding which changes should be considered as meaningful, the authors assessed the reliability of quantitative functional tests on 5 consecutive days in 63 patients with MS, determining the range of measurement variability present when patients are clinically stable. Time to walk 25 feet (T25FW) and the 9-hole peg test (9HPT) varied by <20% of individual mean scores on repeated testing. Therefore, a 20% change on these tests can be considered to be the threshold that reliably indicates a true change in function for an individual.
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Affiliation(s)
- S R Schwid
- Department of Neurology, University of Rochester Medical Center, NY, USA.
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Schwid SR, Goodman AD, Apatoff BR, Coyle PK, Jacobs LD, Krupp LB, Miller AE, Wende KE, Brownscheidle CM. Are quantitative functional measures more sensitive to worsening MS than traditional measures? Neurology 2000; 55:1901-3. [PMID: 11134392 DOI: 10.1212/wnl.55.12.1901] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The authors used data collected prospectively during a multicenter trial in 133 patients with secondary progressive MS to assess the relative sensitivity of quantitative functional tests and traditional measures, including the Expanded Disability Status Scale (EDSS) and Ambulation Index. Quantitative functional measures worsened in 69% of patients during an average of 6 months of observation, whereas the Clinical Global Impression of Change worsened in 33% and the EDSS worsened in 25% of patients. These changes should be interpreted in the context of the test-retest reliability for each measure.
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Affiliation(s)
- S R Schwid
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
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Schwid SR, Thornton CA, Pandya S, Manzur KL, Sanjak M, Petrie MD, McDermott MP, Goodman AD. Quantitative assessment of motor fatigue and strength in MS. Neurology 1999; 53:743-50. [PMID: 10489035 DOI: 10.1212/wnl.53.4.743] [Citation(s) in RCA: 167] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the test-retest reliability of strength and fatigue measurements in patients with MS and in healthy control subjects, and to examine associations among motor fatigue, strength, and ambulatory impairment in MS patients. BACKGROUND Motor fatigue, defined as the loss of the maximal capacity to generate force during exercise, and weakness are common in patients with MS. METHOD Twenty ambulatory MS patients and 20 age- and sex-matched healthy control subjects participated in the study. Test-retest reliability was assessed in two identical testing sessions, separated by 3 to 5 days. Maximal voluntary isometric strength was determined by fixed myometry of seven muscle groups on each side. Motor fatigue was assessed using three exercise protocols: sustained maximal contractions (static fatigue), repetitive maximal contractions, and walking as far as 500 m. Four analysis models for static fatigue were examined for their test-retest reliability and their ability to discriminate between normal fatigue and pathologic fatigue from MS. RESULTS Test-retest reliability in MS patients was excellent for isometric strength and very good for static fatigue. Test-retest reliability was lower for exercise protocols that involved repetitive contractions or ambulation. Compared with healthy control subjects, MS patients were weak in lower extremity muscles, but upper extremity strength was relatively preserved. Fatigue was greater in MS patients, even in muscles that were not clearly weak. There were no significant associations between strength and fatigue in any of the muscles tested. A fatigue analysis model based on the area under the force-versus-time curve gave the best combination of reliability and sensitivity to detect differences between MS patients and healthy control subjects. CONCLUSIONS Strength and motor fatigue can be measured reliably in patients with MS. MS patients experience more fatigue than healthy control subjects during sustained contractions, repetitive contractions, and ambulation. Motor fatigue appears to be distinct from weakness because the degree of fatigue was not associated with the degree of weakness in individual muscles. Quantitative assessment of strength and fatigue may be useful to monitor changes in motor function over time in MS patients.
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Affiliation(s)
- S R Schwid
- University of Rochester Medical Center, Department of Neurology, NY 14642, USA
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Roos K, Schwid SR. Neurology in the Tropics. Neurology 1999. [DOI: 10.1212/wnl.53.5.1162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
There is increasing impetus to begin disease-modifying therapy for relapsing multiple (R-MS) early, before the development of irreversible tissue damage and resultant permanent disability. However, all of the currently-approved therapies for relapsing multiple sclerosis are only partially effective for patients as a group. Treatment failure can be due to noncompliance with therapy, intolerable adverse effects, the development of neutralizing antibodies, or non-responsive disease. Neurologists managing patients on disease-modifying therapy for R-MS must remain vigilant for these issues and take appropriate action when necessary.
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Affiliation(s)
- J A Cohen
- Mellen Center for Multiple Sclerosis Treatment and Research, Department of Neurology, Cleveland Clinic Foundation, OH 44195, USA.
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Weinstein A, Schwid SR, Schiffer RB, McDermott MP, Giang DW, Goodman AD, Schwid SI. Neuropsychologic status in multiple sclerosis after treatment with glatiramer. Arch Neurol 1999; 56:319-24. [PMID: 10190822 DOI: 10.1001/archneur.56.3.319] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Glatiramer acetate (Copaxone) therapy reduces clinical disease activity in relapsing-remitting multiple sclerosis (MS). OBJECTIVE To study the effect of glatiramer therapy on neuropsychologic function as part of a randomized, placebo-controlled, multicenter trial. METHODS Two hundred forty-eight patients with relapsing-remitting MS and mild to moderate disability (Expanded Disability Status Scale score, <5.0) were tested before and 12 and 24 months after randomization to administration of glatiramer acetate, 20 mg/d, or matching placebo. Neuropsychologic tests examined 5 cognitive domains most often disrupted in patients with MS: sustained attention, perceptual processing, verbal and visuospatial memory, and semantic retrieval. RESULTS Baseline neuropsychologic test performance was similar in both treatment groups and was within normal range, except for impaired semantic retrieval. Mean neuropsychologic test scores were higher at 12 and 24 months than at baseline, and no differences were detected between treatment groups over time. No significant interactions were detected between treatment and either time or baseline impairment. CONCLUSIONS Our 2-year longitudinal study showed no effect of glatiramer therapy on cognitive function in relapsing-remitting MS. Although it is possible that glatiramer therapy has no effect on cognitive function, the lack of measurable decline in cognitive function in both patient groups for 2 years limits the opportunity for glatiramer to demonstrate a therapeutic effect by minimizing such decline. Emerging treatments for MS should continue to be examined for their effect on cognitive impairment because it can be a critical determinant of disability. A greater understanding of the natural history of cognitive decline in MS is essential for a rational design of these drug trials.
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Affiliation(s)
- A Weinstein
- Department of Neurology, University of Rochester Medical Center, NY 14642, USA.
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Schwid SR, Goodman AD, Mattson DH, Mihai C, Donohoe KM, Petrie MD, Scheid EA, Dudman JT, McDermott MP. The measurement of ambulatory impairment in multiple sclerosis. Neurology 1997; 49:1419-24. [PMID: 9371932 DOI: 10.1212/wnl.49.5.1419] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The objective of this study was to examine the relationships between continuous measures of ambulatory impairment in MS patients and their ordinal counterparts. Much of the disability caused by MS is due to ambulatory impairment. The Expanded Disability Severity Scale (EDSS) and the Ambulation Index (AI) are ordinal measures of MS severity based largely on the maximal distance subjects can walk (Dmax) and the time to walk 8 m (T8), respectively. At EDSS levels 6.0 to 7.0 and AI levels 3 to 6, scores are defined more by the use of ambulatory aids, rather than by Dmax or T8. We determined Dmax (up to 500 m), T8, the EDSS score, and the AI in 237 ambulatory MS patients. The maximal distance subjects could walk and T8 were strongly related to their ordinal counterparts (Spearman r = 0.65 and 0.91, respectively), but the continuous measures showed considerable variability within EDSS and AI levels that the ordinal scales did not reflect. Most of the variability occurred at EDSS levels 6.0 to 7.0 and AI levels 3 to 6. Because the use of an aid did not clearly predict Dmax or T8, many patients in these ranges had better ambulatory function based on the continuous measures than those with less disability according to the ordinal scales. We found that Dmax and T8 provide more precise information about ambulatory impairment in MS than do the EDSS and AI, allowing better discrimination of differences between patients and potentially greater sensitivity to detect therapeutic effects in clinical trials.
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Affiliation(s)
- S R Schwid
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
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Abstract
OBJECTIVE To report symptomatic autoimmune hyperthyroidism developing in patients with multiple sclerosis (MS) treated with interferon beta-1b (IFN-beta-1b). REPORT OF CASES A 44-year-old woman experienced gradually worsening fatigue, depression, and motor function several months after beginning therapy with IFN-beta-1b for MS. Graves disease associated with episodic palpitations, shortness of breath, hair loss, increased appetite, weight loss, and insomnia was confirmed with endocrinologic studies. Increased fatigue and weakness developed in a 52-year-old woman several months after starting IFN-beta-1b therapy. She also noted sweats, heat intolerance, palpitations, increased appetite, and irritability, and endocrinologic evaluation supported a diagnosis of Graves disease. CONCLUSIONS To our knowledge, this is the first report of autoimmune thyroid disease associated with IFN-beta-1b treatment in patients with MS. Psoriasis has also been reported during interferon therapy for MS, and similar phenomena occur during interferon therapy for hepatitis C. Since some symptoms of thyroid dysfunction may be difficult to distinguish from typical MS-related symptoms, thyroid hormone levels should be checked when unexplained constitutional symptoms occur during IFN-beta-1b therapy.
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Affiliation(s)
- S R Schwid
- Department of Neurology, University of Rochester, NY, USA
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Schwid SR, Petrie MD, McDermott MP, Tierney DS, Mason DH, Goodman AD. Quantitative assessment of sustained-release 4-aminopyridine for symptomatic treatment of multiple sclerosis. Neurology 1997; 48:817-21. [PMID: 9109861 DOI: 10.1212/wnl.48.4.817] [Citation(s) in RCA: 160] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy of 4-aminopyridine sustained release (4AP SR) (fampridine, EL-970) using quantitative measures of motor function in multiple sclerosis (MS) patients. BACKGROUND In vitro, 4AP improves conduction through demyelinated axons. A previous multicenter trial of 4AP SR using the Expanded Disability Status Scale (EDSS) as the primary outcome was unable to establish clinical efficacy. DESIGN/METHODS Ten MS patients with stable motor deficits (EDSS 6.0-7.5) were given 4AP SR 17.5 mg bid and placebo for 1 week each in a double-blind, placebo-controlled, crossover trial. Time to walk 8 meters, time to climb four stairs, maximum voluntary isometric contraction measured quantitatively (MVICT), manual muscle testing (MMT), grip strength, EDSS, and the patient's global impression were measured. RESULTS Timed gait was improved on 4AP SR compared with placebo in 9 of 10 subjects (p = 0.02). Timed stair climbing, MVICT, MMT, grip strength, and EDSS showed nonsignificant improvements on 4AP SR. Based on their global impressions, seven subjects preferred 4AP SR over placebo; only one preferred placebo. There were no serious side effects. CONCLUSION 4AP SR improved motor function in MS patients. The quantitative outcomes used in this study permit more sensitive evaluation of the therapeutic effect and promise to be useful in future trials of symptomatic treatments for MS.
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Affiliation(s)
- S R Schwid
- Department of Neurology, University of Rochester Medical Center, NY, USA
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30
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Abstract
BACKGROUND Bone mineral density is reduced in patients with multiple sclerosis (MS), but the reduction has not been shown to correlate with steroid use retrospectively. OBJECTIVE To prospectively measure bone density following a single corticosteroid pulse using dual energy x-ray absorptiometry. PATIENTS AND METHODS Thirty acutely relapsing patients with MS were given 1000 mg of methylprednisolone intravenously daily for 3 days followed by an oral prednisone taper for 2 weeks. The bone density was determined at the lumbar spine and femoral neck prior to treatment. Seventeen patients were reevaluated 2,4, and 6 months following treatment. RESULTS Prior to treatment, bone density in patients with MS was already reduced at the femoral neck compared with an age-matched reference population, but the degree of this reduction did not correlate with prior steroid exposure. Lumbar density, in contrast, was normal. Following the steroid pulse, lumbar bone density increased, becoming 1.7% greater than baseline 6 months later (P = .02). Femoral bone density did not change on average, but the patients who required a cane or walker for ambulation had a 1.6% decrease in femoral bone density, while those with better ambulation had a 2.9% increase (P = .04). CONCLUSIONS Bone density is decreased in MS. A single corticosteroid pulse did not reduce bone density in fully ambulatory patients with MS and multiple pulses did not have a cumulative effect on bone density in retrospective analysis. The change in femoral density in poorly ambulatory patients may have been related to inactivity rather than the steroid pulse.
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Affiliation(s)
- S R Schwid
- Department of Neurology, University of Rochester Medical Center, Ny, USA
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31
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Abstract
Rats infused with nicotine were initially hypophagic and lost weight. Although food intake recovered, body weight remained 8-12% below normal. Elevating (or reducing) body weight before treatment prolonged (or shortened) initial hypophagia; weight reliably stabilized at the reduced level. At this reduced weight, the treated rats' daily resting energy expenditure was comparable with that of normal-weight controls (262.3 vs 261.9 kJ.d-1.kg body wt-0.75). Reducing the weight of controls to that of treated rats caused their expenditure to drop to 250.6 kJ.d-1.kg body wt-0.75, an energy-conserving adjustment that treated rats also displayed when their weight was lowered from its already-reduced level. Terminating nicotine treatment led initially to hyperphagia, which abated upon body weight being restored to normal. Normal daily energy expenditures at reduced weights suggest that nicotine lowers regulated body energy. Acute intake adjustments associated with initiation (or cessation) of nicotine treatment can be viewed as responses appropriate to bringing body energy into balance with the altered regulation level.
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Affiliation(s)
- S R Schwid
- Department of Psychology, University of Wisconsin, Madison
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