Blood Flow Restriction and Veterans With Multiple Sclerosis and Advanced Disability: Protocol for a Randomized Controlled Trial.

OBJECTIVE: The purpose of this study will be to determine the efficacy of low intensity lower extremity resistance training with and without blood flow restriction (BFR) on quadriceps muscle strength and thickness in veterans with advanced multiple sclerosis (MS). METHODS: This will be an assessor-blinded, 2-group (1 to 1 allocation) randomized controlled trial targeting an enrollment of 58 participants with advanced MS as defined by Patient-Determined Disease Steps scale levels 4 to 7. Both groups will complete 10 weeks of twice weekly low-load resistance training (20%-30% of 1-repetition max) targeting knee and hip extension, knee flexion, and ankle plantarflexion. The intervention group will perform all training using BFR, with limb occlusion pressures between 60% and 80% of maximal limb occlusion pressure. Primary outcomes will be quadriceps muscle strength and thickness. Secondary outcomes will include knee flexion and ankle plantarflexion strength, functional mobility, physical activity, and patient-reported measures. All outcomes will be assessed at baseline before the intervention, immediately after the intervention, and at a 2-month follow-up assessment. The change between groups postintervention and after the 2-month follow-up will be reported for all outcomes. All analyses will assume a 2-sided test of hypothesis (α = .05). IMPACT: There is very little evidence for the efficacy of exercise interventions in people with MS who have advanced mobility disability. Resistance training with BFR may be an important approach for people with advanced MS who may not tolerate more conventional, moderate-to-high intensity resistance training. The results of this study will inform clinicians regarding exercise decisions for people with advanced MS and future investigations on the role of BFR in people with MS.

Stretching is not essential for managing MS spasticity: A randomized controlled trial.

BACKGROUND: Clinical practice, expert opinion, and evidence-based guidelines recommend daily stretching as first-line treatment for multiple sclerosis (MS) spasticity, but this has not been evaluated by fully powered clinical trials. OBJECTIVE: To determine whether MS Spasticity: Take Control (STC), a guideline-based program of spasticity education and stretching exercises has different effects on the impact of spasticity than a control program of different spasticity education and range of motion (ROM) exercises. METHODS: Ambulatory people with self-reported MS spasticity were randomly assigned to STC or ROM, delivered in same duration, facilitator-led, group classes, face-to-face (F2F) initially and later virtually, due to coronavirus disease 2019 (COVID-19). Multiple Sclerosis Spasticity Scale (MSSS) scores were compared between groups at 1 (primary outcome) and 6 months after interventions. RESULTS: A total of 231 people enrolled. There was no significant difference in MSSS scores between STC and ROM at 1 month (mean difference = 0.28, 95% (confidence interval (CI)) = [-9.45 to 10.01], p = 0.955). There were significant group mean improvements in MSSS scores and most other outcomes at 1 and 6 months. CONCLUSION: Education with stretching exercises, the first-line recommended treatment for MS spasticity, and education with ROM exercises may both improve MS spasticity to a similar degree. This study debunks the belief that stretching is essential to managing MS spasticity.

Self-assessed Dynamic Gait Index correlates with physical therapist assessed Dynamic Gait Index in people with multiple sclerosis.

BACKGROUND: The Dynamic Gait Index (DGI) is a clinical measure of walking ability comprised of eight walking tasks. In people with multiple sclerosis (PwMS) the DGI has demonstrated validity, reliability, and ability to identify fallers. A self-assessed version of the DGI that demonstrates concurrent validity with the original DGI in people with MS would be valuable for remote assessment of walking ability. We therefore developed a questionnaire-based self-assessed version of the DGI (sDGI) that asks participants to self-rate their predicted ability to perform the eight DGI walking tasks. The purpose of this study was to determine the validity and internal consistency of the sDGI in people with MS who had self-reported gait impairment. METHODS: We enrolled 53 ambulatory people with MS with self-reported gait impairment. Participants completed the sDGI, the Multiple Sclerosis Walking Scale-12 (MSWS-12), the Telephone Interview for Cognitive Status (TICS), and self-reported their number of falls in the past 3 months. Then, up to 4 weeks later, they completed the DGI by in-person evaluation by a physical therapist (PT). We calculated the internal consistency of the sDGI and concordance between the sDGI and DGI. To determine if cognition impacted concordance, we calculated concordance in the cognitively impaired and non-impaired groups and also tested the difference between groups. We also calculated correlation between the sDGI and the DGI and the MSWS-12. The ability of the sDGI and the DGI to identify fallers was evaluated using receiver operating characteristic curves. RESULTS: 51 participants completed the study. They had a mean age of 60.9 (SD 11.5) years, median PDDS of 4.0 (interquartile range 3, 5), 32 % used walking aids, 25 % were cognitively impaired, and 62 % were female. The sDGI was internally consistent (Cronbach's alpha 0.85, 95 % CI 0.76, 0.90) but was not concordant (CCC = 0.45, 95 % CI: 0.28-0.60) with the DGI. Concordance between the sDGI and DGI was not different for cognitively intact versus cognitively impaired individuals. The sDGI was moderately correlated with the DGI (R = 0.64, p < 0.01) and strongly correlated with the MSWS-12 (R = -0.71, p < 0.01). Neither the sDGI nor the DGI identified fallers in this sample. CONCLUSION: The moderate to strong correlation among the sDGI, DGI and MSWS-12 supports the validity of the sDGI as a measure of walking ability in people with MS. However, because there is poor concordance between the sDGI and the DGI performed in clinic by a PT in both cognitively intact and cognitively impaired participants, the sDGI should not be used as a substitute for the DGI. The sDGI could be used as a screening tool because most participants underestimated their walking performance compared to assessment by a PT so the sDGI would be unlikely to miss poor walking ability. As neither the sDGI nor the DGI identified fallers in this sample, our results do not support using these tools to identify fallers in people with MS and self-reported gait impairment.

Identifying trajectories and predictors of chemotherapy-induced peripheral neuropathy symptoms, physical functioning, and falls across treatment and recovery in adults treated with neurotoxic chemotherapy: the PATTERN observational study protocol (NCT05790538).

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating and dose-limiting side effect of systemic cancer therapy. In many cancer survivors, CIPN persists after treatment ends and is associated with functional impairments, abnormal gait patterns, falls, and diminished quality of life. However, little is known regarding which patients are most likely to develop CIPN symptoms that impair mobility and increase fall risk, when this risk develops, or the optimal timing of early intervention efforts to mitigate the impact of CIPN on functioning and fall risk. This study will address these knowledge gaps by (1) characterizing trajectories of symptoms, functioning, and falls before, during, and after treatment in adults prescribed neurotoxic chemotherapy for cancer; and (2) determining the simplest set of predictors for identifying individuals at risk for CIPN-related functional decline and falls. METHODS: We will enroll 200 participants into a prospective, observational study before initiating chemotherapy and up to 1 year after completing chemotherapy. Eligible participants are aged 40-85 years, diagnosed with stage I-III cancer, and scheduled to receive neurotoxic chemotherapy. We perform objective assessments of vibratory and touch sensation (biothesiometry, tuning fork, monofilament tests), standing and dynamic balance (quiet stance, Timed-Up-and-Go tests), and upper and lower extremity strength (handgrip dynamometry, 5-time repeated chair stand test) in the clinic at baseline, every 4-6 weeks during chemotherapy, and quarterly for 1 year post-chemotherapy. Participants wear devices that passively and continuously measure daily gait quality and physical activity for 1 week after each objective assessment and self-report symptoms (CIPN, insomnia, fatigue, dizziness, pain, cognition, anxiety, and depressive symptoms) and falls via weekly electronic surveys. We will use structural equation modeling, including growth mixture modeling, to examine patterns in trajectories of changes in symptoms, functioning, and falls associated with neurotoxic chemotherapy and then search for distinct risk profiles for CIPN. DISCUSSION: Identifying simple, early predictors of functional decline and fall risk in adults with cancer receiving neurotoxic chemotherapy will help identify individuals who would benefit from early and targeted interventions to prevent CIPN-related falls and disability. TRIAL REGISTRATION: This study was retrospectively registered with ClinicalTrials.gov (NCT05790538) on 3/30/2023.

Efficacy of adding selective electrical muscle stimulation to usual physical therapy for Bell's palsy: immediate and six-month outcomes.

Bell's palsy is the most common cause of facial paralysis, affecting one in every 60 people in their lifetime. Transcutaneously applied selective electrical muscle stimulation could potentially accelerate recovery from Bell's palsy but this intervention remains controversial. Studies have shown benefit, but concerns for lack of efficacy and potential for worsening synkinesis remain. We performed a prospective controlled trial comparing outcomes at initial recovery and six months later with selective electrical muscle stimulation and usual physical therapy versus usual physical therapy alone in adults with acute Bell's palsy. Outcomes were facial function assessed with the House Brackman and eFACE scales. Outcomes were evaluated at discharge and six months after discharge. Discharge occurred when participants were judged to be fully recovered by their treating therapist and supervisor. 38 adults participated in the study. Participants in the electrical stimulation group achieved maximal recovery twice as fast as the control group (2.5 weeks versus 5.2 weeks) with no significant differences in facial function or synkinesis between groups at any time point. This study is the first human trial of electrical stimulation in Bell's palsy to follow patients 6 months from recovery and supports that selective electrical muscle stimulation accelerates recovery and does not increase synkinesis.

Risky movement: Assessing fall risk in people with multiple sclerosis with wearable sensors and beacon-based smart-home monitoring.

BACKGROUND: People with multiple sclerosis (PwMS) fall frequently causing injury, social isolation, and decreased quality of life. Identifying locations and behaviors associated with high fall risk could help direct fall prevention interventions. Here we describe a smart-home system for assessing how mobility metrics relate to real-world fall risk in PwMS. METHODS: We performed a secondary analysis of a dataset of real-world falls collected from PwMS to identify patterns associated with increased fall risk. Thirty-four individuals were tracked over eight weeks with an inertial sensor comprising a triaxial accelerometer and time-of-flight radio transmitter, which communicated with beacons positioned throughout the home. We evaluated associations between locations in the home and movement behaviors prior to a fall compared with time periods when no falls occurred using metrics including gait initiation, time-spent-moving, movement length, and an entropy-based metric that quantifies movement complexity using transitions between rooms in the home. We also explored how fall risk may be related to the percent of times that a participant paused while walking (pauses-while-walking). RESULTS: Seventeen of the participants monitored sustained a total of 105 falls that were recorded. More falls occurred while walking (52%) than when stationary despite participants being largely sedentary, only walking 1.5±3.3% (median ± IQR) of the time that they were in their home. A total of 28% of falls occurred within one second of gait initiation. As the percentage of pauses-while-walking increased from 20 to 60%, the likelihood of a fall increased by nearly 3 times from 0.06 to 0.16%. Movement complexity, which was quantified using the entropy of room transitions, was significantly higher in the 10 min preceding falls compared with other 10-min time segments not preceding falls (1.15 ± 0.47 vs. 0.96 ± 0.24, P = 0.02). Path length was significantly longer (151.3 ± 156.1 m vs. 95.0 ± 157.2 m, P = 0.003) in the ten minutes preceding a fall compared with non-fall periods. Fall risk also varied among rooms but not consistently across participants. CONCLUSIONS: Movement metrics derived from wearable sensors and smart-home tracking systems are associated with fall risk in PwMS. More pauses-while-walking, and more complex, longer movement trajectories are associated with increased fall risk. FUNDING: Department of Veterans Affairs (RX001831-01A1). National Science Foundation (#2030859).

Development of an integrated conceptual model of multiple sclerosis spasticity.

PURPOSE: Spasticity is common in multiple sclerosis (MS), often leading to functional limitations and disability. We developed a conceptual model of spasticity in MS integrating expert opinion, recent literature, and experiences of clinicians and people with MS spasticity. METHODS: A conceptual model was developed based on a targeted literature review of articles published between 2014 and 2019, followed by input from clinicians, then input from participants with MS spasticity. Multidisciplinary experts on spasticity provided guidance at each step. RESULTS: Key concepts of the integrated spasticity conceptual model included: moderators; triggers; modifiers; treatment; objective manifestations; subjective experience; physical, functional, social, and emotional/psychological impacts; and long-term consequences. Participants with MS spasticity most frequently endorsed spasms, tightness, and pain as descriptors of spasticity. Some participants with MS spasticity had difficulty distinguishing spasticity from other MS symptoms (e.g. muscle weakness). Some triggers, emotional/psychological impacts, and long-term consequences of spasticity reported by participants with MS spasticity were not previously identified in the published literature. CONCLUSIONS: This conceptual model of spasticity, integrating published literature with the experience of clinicians, people with MS spasticity, and experts, demonstrates the complex, multidimensional nature of MS spasticity. This model may be used to improve clinician-patient dialogue, research, and patient care.

Many people with multiple sclerosis (MS) have spasticity, generally in the lower limbs, but this symptom is complex and multidimensional and therefore difficult to characterize.MS spasticity may be influenced by moderators, triggers, modifiers, and treatment, all of which can affect objective measures and the subjective experience of spasticity.MS spasticity can have physical, functional, social, and emotional/psychological impacts as well as long-term consequences that can affect rehabilitation and ultimately reduce health-related quality of life for people with MS.Given that people with MS may view spasticity differently than their rehabilitation providers, providers should ask patients about their spasticity, including their moderators, triggers, modifiers, experience, impacts, long-term consequences, and effects on quality of life.This conceptual model provides a framework to improve clinician-patient dialogue, research, and rehabilitation for MS spasticity.

Polypharmacy in Multiple Sclerosis: Prevalence, Risks, and Mitigation Strategies.

PURPOSE OF REVIEW: Polypharmacy, the use of ≥ 5 medications, is common in people with multiple sclerosis and is associated with negative outcomes. The use of multiple medications is common for symptom management in people with multiple sclerosis, but risks drug-drug interactions and additive side effects. Multiple sclerosis providers should therefore focus on the appropriateness and risks versus benefits of pharmacotherapy in each patient. This review describes the prevalence and risks associated with polypharmacy in people with multiple sclerosis and offers strategies to identify and mitigate inappropriate polypharmacy. RECENT FINDINGS: Research in people with multiple sclerosis has identified risk factors and negative outcomes associated with polypharmacy. Medication class-specific investigations highlight their contribution to potentially inappropriate polypharmacy in people with multiple sclerosis. People with multiple sclerosis are at risk for inappropriate polypharmacy. Multiple sclerosis providers should review medications and consider their appropriateness and potential for deprescribing within the context of each patient.

Reliability, Validity, and Responsiveness of the Patient-Specific Functional Scale for Measuring Mobility-Related Goals in People With Multiple Sclerosis.

BACKGROUND AND PURPOSE: This study's purpose was to investigate the reliability, validity, and responsiveness of the Patient-Specific Functional Scale (PSFS) for measuring mobility-related goals in people with multiple sclerosis (MS). METHODS: Data from 32 participants with MS who underwent 8 to 10 weeks of rehabilitation were analyzed (Expanded Disability Status Scale scores 1.0-7.0). For the PSFS, participants identified 3 mobility-related areas where they had difficulty and rated them at baseline, 10 to 14 days later (before starting intervention), and immediately after intervention. Test-retest reliability and response stability of the PSFS were calculated using the intraclass correlation coefficient (ICC 2,1 ) and minimal detectable change (MDC 95 ), respectively. Concurrent validity of the PSFS was determined with the 12-item Multiple Sclerosis Walking Scale (MSWS-12) and the Timed 25-Foot Walk Test (T25FW). PSFS responsiveness was determined using Cohen's d , and minimal clinically important difference (MCID) was calculated based on patient-reported improvements on a Global Rating of Change (GRoC) scale. RESULTS: The PSFS total score demonstrated moderate reliability (ICC 2,1 = 0.70, 95% CI: 0.46 to 0.84) and the MDC was 2.1 points. At baseline, the PSFS was fairly and significantly correlated with the MSWS-12 ( r = -0.46, P = 0.008) but not with the T25FW. Changes in the PSFS were moderately and significantly correlated with the GRoC scale (ρ = 0.63, P < 0.001), but not with MSWS-12 or T25FW changes. The PSFS was responsive ( d = 1.7), and the MCID was 2.5 points or more to identify patient-perceived improvements based on the GRoC scale (sensitivity = 0.85, specificity = 0.76). DISCUSSION AND CONCLUSIONS: This study supports the use of the PSFS as an outcome measure in people with MS to assess mobility-related goals.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A423 ).

Protocol for an exploratory, randomised, single-blind clinical trial of aerobic exercise to promote remyelination in multiple sclerosis.

INTRODUCTION: There is an urgent need for remyelinating therapies that restore function in people with multiple sclerosis (pwMS). Aerobic exercise is a promising remyelinating strategy because it promotes remyelination in animal models both independently and synergistically with medications. Here, in this study, we present an innovative, randomised, single-blind, clinical trial designed to explore: the relationship between demyelination and mobility (part 1), and if 24 weeks of aerobic exercise promotes remyelination in pwMS (part 2). METHODS AND ANALYSIS: Sedentary participants (n=60; aged 18-64 years) with stable MS will undergo a baseline visit with the following outcomes to assess associations between demyelination and mobility (part 1): spinal cord demyelination (somatosensory-evoked potentials, SSEPs), mobility (6-Minute Timed Walk, Timed 25-Foot Walk, Timed Up and Go, 9-Hole Peg Test) and patient-reported outcomes (PROs). After baseline testing, participants with significantly prolonged SSEP latency will advance to the clinical exercise trial (part 2) and will be randomised 1:1 to active or control conditions for 24 weeks. The active condition will be aerobic stationary cycling three times per week with graded virtual supervision. The control condition will be monthly virtual MS symptom education groups (six sessions). SSEP latency (remyelination endpoint), mobility outcomes and PROs will be measured at 12 and 24 weeks in all clinical trial participants. A subset of 11 active and 11 control participants will undergo a brain MRI with quantitative T1 myelin water fraction at baseline and 24 weeks (exploratory remyelination endpoint). ETHICS AND DISSEMINATION: Ethical approval was obtained from the Oregon Health & Science University Institutional Review Board (#21045). Dissemination of findings will include peer-reviewed publications, conference presentations and media releases. The proposed study will inform the feasibility, study design and sample size for a fully powered clinical trial of aerobic exercise to promote remyelination in pwMS. TRIAL REGISTRATION NUMBER: NCT04539002.

A growth area: A review of the value of clinical studies of child growth for palaeopathology.

Studies of living children demonstrate that early life stress impacts linear growth outcomes. Stresses affecting linear growth may also impact later life health outcomes, including increased cardiometabolic disease risk. Palaeopathologists also assess the growth of children recovered from bioarchaeological contexts. Early life stresses are inferred to affect linear growth outcomes, and measurements of skeletal linear dimensions alongside other bioarchaeological information may indicate the types of challenges faced by past groups. In clinical settings, the impacts of stress on growing children are typically measured by examining height. Palaeopathologists are limited to examining bone dimensions directly and must grapple with incomplete pictures of childhood experiences that may affect growth. Palaeopathologists may use clinical growth studies to inform observations among past children; however, there may be issues with this approach. Here, we review the relationship between contemporary and palaeopathological studies of child and adolescent growth. We identify approaches to help bridge the gap between palaeopathological and biomedical growth studies. We advocate for: the creation of bone-specific growth reference information using medical imaging and greater examination of limb proportions; the inclusion of children from different global regions and life circumstances in contemporary bone growth studies; and greater collaboration and dialogue between palaeopathologists and clinicians as new studies are designed to assess linear growth past and present. We advocate for building stronger bridges between these fields to improve interpretations of growth patterns across human history and to potentially improve interventions for children living and growing today.

Free From Falls education and exercise program for reducing falls in people with multiple sclerosis: A randomized controlled trial.

BACKGROUND: People with multiple sclerosis (PwMS) fall frequently. Community-delivered exercise and education reduce falls in older adults, but their efficacy in multiple sclerosis (MS) is unknown. OBJECTIVES: To evaluate the impact of the Free From Falls (FFF) group education and exercise program on falls in PwMS. METHODS: This was a prospective, assessor-blinded, two-arm parallel randomized controlled trial. Ninety-six participants were randomized to FFF (eight weekly 2 hour sessions) or the control condition (a fall prevention brochure and informing their neurologist of their fall history). Participants counted falls prospectively from enrollment through 6 months following intervention. Effects on fall frequency were evaluated by the Bayesian analysis. RESULTS: The modeled mean fall frequency pre-intervention was 1.2 falls/month in the FFF group (95% credible intervals (CIs) = 0.8-2.0) and 1.4 falls/month in the control group (95% CI = 0.9-2.1). Fall frequency decreased by 0.6 falls/month in both groups over time (nadir 4-6 months post-intervention: FFF 0.6 falls/month (95% CI = 0.4-0.9); control 0.8 falls/month (95% CI = 0.5-1.1)). CONCLUSION: In-person group exercise and education are not superior to written education and neurologist-initiated interventions for preventing falls in PwMS.

Moderators of Improvements in Fatigue Impact After a Self-management Intervention in Multiple Sclerosis: A Secondary Analysis of a Randomized Controlled Trial.

ABSTRACT: Fatigue is one of the most common and disabling symptoms of multiple sclerosis. A recent randomized controlled trial comparing a fatigue self-management program and a general multiple sclerosis education program found that both programs improved fatigue in participants with multiple sclerosis. Participants were randomized to a self-management program (fatigue: take control, n = 109) or a multiple sclerosis education program (multiple sclerosis: take control, n = 109). This secondary analysis of that trial used multilevel moderation analysis to examine moderators of treatment-related effects on fatigue (Modified Fatigue Impact Scale) from baseline through the 6-mo follow-up. The following potential treatment moderators were examined: age, sex, cohabitation/marital status, and baseline levels of self-efficacy, depression symptoms, and sleep quality. Cohabitation status (living with or without a spouse/partner) interacted with intervention group and time to predict fatigue impact (P = 0.04). Fatigue: take control participants who lived with a spouse/partner showed a marginal effect in greater rate of improvement in fatigue compared with those who lived alone (P = 0.08). However, rates of improvement in fatigue in multiple sclerosis: take control participants were similar in those living with or without a spouse/partner. These findings suggest that living with a spouse or partner may facilitate benefit from self-management interventions for multiple sclerosis-related fatigue. Future research should investigate the contribution of supportive others in self-management of fatigue in multiple sclerosis.

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.

Relationship between balance confidence and social engagement in people with multiple sclerosis.

OBJECTIVE: To evaluate the relationships among patient-reported balance confidence and social satisfaction and social participation in people with multiple sclerosis (pwMS). METHODS: 75 ambulatory pwMS who had sustained at least two falls or near falls in the prior two months self-reported their balance confidence (Activities-specific Balance Confidence (ABC) questionnaire) and social satisfaction and participation (Patient Reported Outcomes Measurement Information System (PROMIS) measures). Correlations between the ABC and PROMIS measures were examined using Spearman's rank correlation. RESULTS: In a cross-sectional analysis, ABC scores and PROMIS scores for social satisfaction and social participation were statistically significantly correlated (ρ 0.37-0.54, p ≤ 0.001). The correlation between balance confidence and social satisfaction was consistently stronger at each time point than between balance confidence and social participation. CONCLUSION: Self-reported balance confidence is associated with both social satisfaction and social participation in pwMS who fall. The causal direction of this relationship remains uncertain.

A multisite randomized controlled trial of two group education programs for fatigue in multiple sclerosis: Very long term (5-6 year) follow-up at one site.

BACKGROUND: A multicomponent group MS fatigue self-management program reduced fatigue impact compared to a rigorous control 12 months after enrollment. OBJECTIVES: Assess and compare changes between groups in fatigue impact and behavior changes implemented 5-6 years after enrollment. METHODS: The Modified Fatigue Impact Scale (MFIS) and a behavior change questionnaire were administered 5-6 years after enrollment. RESULTS: There were no significant changes in mean MFIS scores within or between groups from baseline to 5-6 years later. Behavior changes were of similar frequency in both groups. CONCLUSION: Fatigue impact was stable and behavior changes were similar between groups 5-6 years after a fatigue self-management program.

Comparing fall detection methods in people with multiple sclerosis: A prospective observational cohort study.

Background Falls occur across the population but are more common, and have more negative sequelae, in people with multiple sclerosis (MS). Given the prevalence and impact of falls, accurate measures of fall frequency are needed. This study compares the sensitivity and false discovery rates of three methods of fall detection: the current gold standard, prospective paper fall calendars, real-time self-reporting and automated detection, the latter two from a novel body-worn device. Methods Falls in twenty-five people with MS were recorded for eight weeks with prospective fall calendars, real-time body-worn self-report, and an automated body-worn detector concurrently. Eligible individuals were adults with MS enrolled in a randomized controlled trial of a fall prevention intervention. Entry criteria were at least two falls or near-falls in the previous two months, Expanded Disability Status Scale ≤ 6.0, community dwelling, and no MS relapse in the previous month. The sensitivity (proportion of true falls detected) and false discovery rates (proportion of false reports generated) of the fall detection methods were compared. A true fall was a fall reported by at least two methods. A false report was a fall reported by only one method. The trial is registered on ClinicalTrials.gov (NCT02583386) and is closed. Results In the 1,276 person-days of fall counting with all three methods in use simultaneously there were 1344 unique fall events. Of these, 8.5% (114) were true falls and 91.5% (1230) were false reports. Fall calendars had the lowest sensitivity (0.614) and the lowest false discovery rate (0.067). The automated detector had the highest sensitivity (0.921) and the highest false discovery rate (0.919). All methods generated under one false report per day. There were no fall detection-related adverse events. Conclusion Fall calendars likely underestimate fall frequency by around 40%. The automated detector evaluated here misses very few falls but likely overestimates the number of falls by around one fall per day. Additional research is needed to produce an ideal fall detection and counting method for use in clinical and research applications. Funding United States Department of Veterans Affairs, Rehabilitations Research and Development Service.

A cross-sectional survey of cannabis use by people with MS in Oregon and Southwest Washington.

BACKGROUND: Evidence supports that cannabinoids reduce self-reported spasticity and neuropathic pain in people with MS (PwMS), and legal access to cannabis for medical and recreational use continues to rise. However, there are limited data regarding patterns of cannabis use and perceived benefits of cannabis among PwMS in the US. This study describes the prevalence of cannabis use, routes of administration, perceived benefit of cannabis for MS, and characteristics associated with cannabis use and perception of benefit among a population of PwMS living in two states where cannabis is legal for both medical and recreational use. METHODS: A survey about treatments used by PwMS, focusing on complementary and alternative medicine (CAM), was sent to PwMS living in Oregon and Southwest Washington. This survey included questions about current and past cannabis use, route of cannabis administration, and perceived benefits, as well as personal demographics. RESULTS: Of the 1188 returned surveys, 1000 had at least 75% complete survey responses and also completed the questions about current and past cannabis use. Thirty percent (n=303) of respondents reported currently using cannabis, 21% (n=210) used in the past but not currently, and 49% (n=487) had never used cannabis. Among current users, rates of use by smoking, vaping, topicals, tinctures and oils, or edibles were similar (35-46%), and most (59%) reported using multiple routes of administration. Most (64-78%, varying by route) current and past users reported cannabis being very or somewhat beneficial for their MS. The odds of current cannabis use were higher in PwMS who: 1) were younger (OR 2.24 [95% CI 1.39-3.61] for those age 18-40 compared with age >60]; 2) had lower household income (OR 3.94 [95% CI 2.55-6.09] with annual income <$25k compared with those with >$100k); 3) had secondary progressive MS (OR 1.77 [95% CI 1.07-2.92]); and 4) had more than minimal MS disability (OR 2.05 [95% CI 1.03-4.10] for those using a walker compared to those with none/minimal disability). The odds of perceiving cannabis as beneficial for MS were higher in: 1) younger individuals (OR 5.61 [95% CI 2.62-11.98] for those age 18-40 compared with age >60); 2) those with lower household income (OR 3.35 [95% CI 1.65-6.80] with annual income <$25k compared with those with >$100k), 3) those not currently using disease modifying therapies (OR 2.32 [95% CI 1.30-4.13]), and 4) those with the greatest disability (OR 17.96; [95% CI 2.00-161.22]). CONCLUSION: In this survey, 30% of PwMS reported currently using cannabis for their MS, mostly by multiple routes of administration, and most of these people report this being helpful for their MS. People who were younger, had lower household income, had progressive disease, and had more than minimal disability were more likely to use cannabis and report it was beneficial for their MS. People who were not using disease modifying therapies were also more likely to report benefit from cannabis use.

Cannabis for medical purposes: A cross-sectional analysis of health care professionals' knowledge.

BACKGROUND: Legalization of cannabis use and the evidence base supporting both risks and benefits of cannabinoids are expanding, but our understanding of health care professionals' (HCPs) knowledge about cannabis for medical purposes is limited. Understanding of the knowledge base and knowledge gaps about medical cannabis use is critical to advanced practice registered nurses (APRNs) because they are increasingly called on to manage patients taking multiple drugs, including prescribed and unprescribed cannabis and prescription cannabinoids. PURPOSE: The purpose of this study was to examine HCPs' knowledge of clinical cannabis, including laws and regulations; risks and harms; pharmacology; and effects on pain, multiple sclerosis spasticity, and seizures as assessed with written tests before an in-person, continuing medical education program. METHODS: Total scores and differences among professions and topics were compared. RESULTS: A total of 178 of the 226 program attendees completed the test (79%) (107 [47%] physicians, 30 [13%] APRNs, and 18 [8%] registered nurses). The mean test score was 63.2% (SD = 12.7%) without significant differences among professions (F(3, 174) = 1.53; p = .21) but with significant differences among topics (χ2(7, 1068) = 201.13; p < .001). The score was lowest for effects on seizures (43.8%) and with scores below 70% for all other areas except laws and regulations (85.7%). IMPLICATIONS FOR PRACTICE: There are substantial gaps in HCPs' knowledge about the clinical effects of cannabis, especially about risks and harms, pharmacology, and the effects on pain, multiple sclerosis spasticity, and seizures. Further education may help HCPs to understand the risks and benefits of cannabis and cannabinoids across conditions.