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.

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.

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 ).

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.

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.

MS Spasticity: Take Control (STC) for ambulatory adults: protocol for a randomized controlled trial.

BACKGROUND: Spasticity affects 60-80% of people with multiple sclerosis (MS), impacting activity, participation and quality of life. We developed the group delivered spasticity self-management program, "MS Spasticity: Take Control" (STC), with DVDs for education and lower extremity stretching. STC is based on an international guideline and recommendations from systematic reviews and emphasizes the importance of stretching with specific stretching exercises. Our pilot trial (n = 38) compared STC followed by one month of home stretching practice to unguided use of the National MS Society (NMSS) brochure titled "Stretching for People with MS: An Illustrated Manual," also followed by one month of home stretching practice. In this pilot trial, STC showed promising effects on the impact of spasticity (MS Spasticity Scale-88) and other self-report and physical performance measures. We will now carry out a fully-powered trial to evaluate the effect of STC compared to a comparably delivered control program on the impact and severity of spasticity in people with MS and self-reported lower extremity spasticity. METHODS: Two hundred-twenty ambulatory adults with MS self-reported spasticity interfering with daily activities will be randomized 1:1 to STC or control, using the same NMSS brochure used in the pilot study, with both programs delivered in groups with trained facilitators. Outcomes are the impact of spasticity with the MS Spasticity Scale-88, the severity of spasticity with the Numeric Rating Scale for Spasticity, other self-report questionnaires, and physical performance walking measures at baseline and one and 6 months after the interventions. DISCUSSION: Stretching is the cornerstone of spasticity management. Stretching takes time and energy every day. Unfortunately, beyond the logical expectation that regular stretching should help prevent muscle shortening and contractures in the presence of spasticity, there is very little data on the effects of stretching on spasticity in people with MS or any other condition. Our pilot trial of STC suggested that education and stretching help reduce the impact of spasticity. To definitively determine if this education and instructional program with daily stretching practice is effective, a fully powered trial with a comparable control intervention and facilitators who did not create STC is needed. Here we report the protocol for this trial. TRIAL REGISTRATION: NCT03166930 May 25, 2017.

Incidence of falls among adults with cerebral palsy: a cohort study using primary care data.

AIM: To compare the rate of falls between adults with and without cerebral palsy (CP). METHOD: We used primary care data on 1705 adults with CP and 5115 adults without CP matched for age, sex, and general practice attended. We compared odds of experiencing a fall between adults with and without CP using conditional logistic regression. We compared the rate of falls using a negative binomial model. RESULTS: Participants were 3628 males (53%) and 3192 females (47%) (median age 29y, interquartile range 20-42y) at the start of follow-up. Follow-up was 14 617 person-years for adults with CP and 56 816 person-years for adults without CP. Of adults with CP, 15.3% experienced at least one fall compared to 5.7% of adults without CP. Adults with CP had 3.64 times (95% confidence interval [CI] 2.98-4.45) the odds of experiencing a fall compared to adults without CP. The rate of falls was 30.5 per 1000 person-years and 6.7 per 1000 person-years for adults with and without CP respectively (rate ratio 5.83, 95% CI 4.84-7.02) INTERPRETATION: Adults with CP are more likely to fall, and fall more often, than adults without CP. The causes and consequences of falls in adults with CP need examination. WHAT THIS PAPER ADDS: Twenty adults with CP and 5.3 adults without CP experienced at least one fall per 1000 person-years. Adults with CP experienced 30.5 falls per 1000 person-years compared to 6.7 falls per 1000 person-years among adults without CP. Adults with CP had 3.64 times the odds of experiencing a fall compared to adults without CP. Adults with CP experienced 5.83 times more falls than adults without CP.

Cannabis use for symptom relief in multiple sclerosis: A cross-sectional survey of webinar attendees in the US and Canada.

BACKGROUND: With the expansion of medical and recreational legalization of cannabis, there is growing interest in cannabis use by people with multiple sclerosis (MS). Research supports that cannabis relieves MS-related pain and spasticity, two common symptoms of MS. However, there is limited information available about cannabis use in people with MS across the United States and Canada. METHODS: 1,015 people with MS in the US and Canada participated in an informational webinar on cannabis for the control of MS symptoms. Attendees were presented with three questions about their use of cannabis for MS symptoms and their knowledge of the medical legality of cannabis in their state. Demographics and MS characteristics were obtained from webinar registration. The legality of cannabis (not legal, legal for medical use only, and legal for recreational and medical use) and the number of years since medical legalization at the time of this webinar were determined for all states. Using logistic regression, we analyzed associations between individual characteristics (demographics, disease severity and legal status), cannabis use, and knowledge of legality. RESULTS: Of the 1,015 webinar registrants, 54% (n = 548) answered the question, "Have you used marijuana in the past year to help control your MS symptoms?" and were included in the analyses. Statistically significant associations were seen between cannabis use and local legal status of cannabis (recreational vs. not legal: OR 4.55, 95% CI: [1.70-12.14], p = 0.002), years since medical legalization of cannabis (for each year since legalization: OR 1.06, 95% CI: [1.02 - 1.10], p = 0.004), disease severity (severe vs. mild disability: OR 3.41, 95% CI: [1.23 - 9.46] p = 0.018) and gender (male vs. female: OR 2.33, 95% CI: [1.10-4.94], p = 0.027). Accuracy of knowledge of local cannabis legality was significantly associated with cannabis use in the past year (users vs. non-users: OR 2.52, p = 0.014), local legal status of cannabis (medical only vs. not legal: OR 0.30, p = 0.001; recreational vs. not legal: OR 4.98, p = 0.039), years since legalization of cannabis (for each increased year since legalization: OR 1.15, p < 0.001), and country of residence (Canada vs. USA: OR 0.42, p = 0.021). CONCLUSIONS: This study supports that cannabis use for MS symptoms is more common in states where cannabis laws are more permissive and where cannabis has been legal for longer, in those with more severe MS, and in men. Accurate knowledge of local cannabis legality is more common in those who report using cannabis for their MS in the past year. Those living in states where cannabis is legal for medical use only are less likely to be aware of legal status than those in either recreationally-legal or non-legal states, but awareness of legal status increases with time since medical legalization. Canadians are less likely than Americans to be accurate in their perception of the legal status of cannabis.

Assessment and Measurement of Spasticity in MS: State of the Evidence.

PURPOSE OF REVIEW: The purpose of this review is to familiarize the reader with assessments and measurement of spasticity in people with multiple sclerosis (MS). Spasticity affects 60-84% of people with MS, worsening as disability worsens and impacting activity, participation, and quality of life. Spasticity manifests in many ways, including spasms, resistance to passive stretch, pain, and perception of tightness, and can affect muscles throughout the body, making assessment and quantification of spasticity challenging but important. Assessment tools include those quantified by clinicians, instrumentation, and patients. RECENT FINDINGS: Most tools for measuring spasticity are based on clinician scoring, were developed many years ago, and have undergone minimal recent advances. More recent developments are patient-reported outcome measures for spasticity, including the Numeric Rating Scale for Spasticity (NRS-S) and the disease-specific Multiple Sclerosis Spasticity Scale-88 (MSSS), and, most recently, imaging through elastography. MS-related spasticity is common and often disabling. There are various spasticity measurement tools available, each with advantages and limitations. Newer tools are likely to be developed as our understanding of spasticity in MS grows.

Evaluation of a web-based fall prevention program among people with multiple sclerosis.

BACKGROUND: Falls are common and impactful in people with multiple sclerosis (MS) but currently there is no accepted standard of care for fall prevention in MS. Evidence supports that the in-person, group-based, Free from Falls (FFF) program is associated with both immediate and six-month sustained improvements in mobility and balance and a reduction in falls, but program attendance is limited by access to the class at a given time and location and by the cost and availability of trained facilitators. Therefore, we developed and evaluated an online, web-based version of FFF, Free from Falls Online (FFFO). METHODS: Thirty people with MS who reported falling at least twice in the previous two months were randomized to FFFO or to a control group. FFFO consists of eight weekly sessions, each with an instructional and exercise component. Subjects in the control group were given a brochure on minimizing fall risk, a letter was sent to their treating physician informing them that the subject reported falling, and these subjects were invited to use the FFFO program at study completion. Outcomes included baseline demographics, falls prospectively reported for the eight weeks of intervention and the following three months, and a program satisfaction survey for the active group. Regression models were used to test for associations between treatment group and fall incidence. RESULTS: Subjects' mean age was 55.8 years, 70% were female, 73% had progressive MS, median Expanded Disability Status Scale (EDSS) score was 6.0, and subjects reported a median of two falls in the month prior to study enrollment. Although, in general, regression models demonstrated trends that those in the intervention group were less likely to fall than those in the control group, statistical significance was only achieved (p = 0.0038) with a post hoc model evaluating the relationship between the square of days and the probability of not falling. This model supported that those in the intervention group were slightly less likely to fall than those in the control group. This difference was most prominent in the first month of the study, less prominent in the following month, and not sustained three months following the intervention. User experience with FFFO was overall positive, with over 75% reporting the web-based program easy to learn and to use, 85% reporting the program was easy to follow, 62% reporting the material to be useful, and 77% finding the exercises to be a useful component of the program. CONCLUSION: This study supports the viability of online delivery of self-management strategies in MS, suggests that FFFO may help prevent falls in people with MS, and provides the preliminary data needed to verify the findings of this pilot study of FFFO with a fully powered randomized controlled trial in people with MS.