Multiple Sclerosis Performance Test: validation of self-administered neuroperformance modules.

BACKGROUND AND PURPOSE: The purpose was to determine the test-retest reliability, practice effects, convergent validity and sensitivity to multiple sclerosis (MS) disability of neuroperformance subtests from the patient self-administered Multiple Sclerosis Performance Test (MSPT) designed to assess low contrast vision (Contrast Sensitivity Test, CST), upper extremity motor function (Manual Dexterity Test, MDT) and lower extremity motor function (Walking Speed Test, WST) and to introduce the concept of regression-based norms to aid clinical interpretation of performance scores using the MSPT cognition test (Processing Speed Test, PST) as an example. METHODS: Substudy 1 assessed test-retest reliability, practice effects and convergent validity of the CST, MDT and WST in 30 MS patients and 30 healthy controls. Substudy 2 examined sensitivity to MS disability in over 600 MS patients as part of their routine clinic assessment. Substudy 3 compared performance on the PST in research volunteers and clinical samples. RESULTS: The CST, MDT and WST were shown to be reliable, valid and sensitive to MS outcomes. Performance was comparable to technician-administered testing. PST performance was poorer in the clinical sample compared with the research volunteer sample. CONCLUSIONS: The self-administered MSPT neuroperformance modules produce reliable, objective metrics that can be used in clinical practice and support outcomes research. Published studies which require patient voluntary consent may underestimate the rate of cognitive dysfunction observed in a clinical setting.

Is the impact of fatigue related to walking capacity and perceived ability in persons with multiple sclerosis? A multicenter study.

BACKGROUND: The relationship between fatigue impact and walking capacity and perceived ability in patients with multiple sclerosis (MS) is inconclusive in the existing literature. A better understanding might guide new treatment avenues for fatigue and/or walking capacity in patients with MS. OBJECTIVE: To investigate the relationship between the subjective impact of fatigue and objective walking capacity as well as subjective walking ability in MS patients. METHODS: A cross-sectional multicenter study design was applied. Ambulatory MS patients (n = 189, age: 47.6 ±â€¯10.5 years; gender: 115/74 women/men; Expanded Disability Status Scale (EDSS): 4.1 ±â€¯1.8 [range: 0-6.5]) were tested at 11 sites. Objective tests of walking capacity included short walking tests (Timed 25-Foot Walk (T25FW), 10-Metre Walk Test (10mWT) at usual and fastest speed and the timed up and go (TUG)), and long walking tests (2- and 6-Minute Walk Tests (MWT). Subjective walking ability was tested applying the Multiple Sclerosis Walking Scale-12 (MSWS-12). Fatigue impact was measured by the self-reported modified fatigue impact scale (MFIS) consisting of a total score (MFIStotal) and three subscales (MFISphysical, MFIScognitive and MFISpsychosocial). Uni- and multivariate regression analysis were performed to evaluate the relation between walking and fatigue impact. RESULTS: MFIStotal was negatively related with long (6MWT, r = -0.14, p = 0.05) and short composite (TUG, r = -0.22, p = 0.003) walking measures. MFISphysical showed a significant albeit weak relationship to walking speed in all walking capacity tests (r = -0.22 to -0.33, p < .0001), which persisted in the multivariate linear regression analysis. Subjective walking ability (MSWS-12) was related to MFIStotal (r = 0.49, p < 0.0001), as well as to all other subscales of MFIS (r = 0.24-0.63, p < 0.001), showing stronger relationships than objective measures of walking. CONCLUSIONS: The physical impact of fatigue is weakly related to objective walking capacity, while general, physical, cognitive and psychosocial fatigue impact are weakly to moderately related to subjective walking ability, when analysed in a large heterogeneous sample of MS patients.

Neuro-QOL: brief measures of health-related quality of life for clinical research in neurology.

OBJECTIVE: To address the need for brief, reliable, valid, and standardized quality of life (QOL) assessment applicable across neurologic conditions. METHODS: Drawing from larger calibrated item banks, we developed short measures (8-9 items each) of 13 different QOL domains across physical, mental, and social health and evaluated their validity and reliability. Three samples were utilized during short form development: general population (Internet-based, n = 2,113); clinical panel (Internet-based, n = 553); and clinical outpatient (clinic-based, n = 581). All short forms are expressed as T scores with a mean of 50 and SD of 10. RESULTS: Internal consistency (Cronbach α) of the 13 short forms ranged from 0.85 to 0.97. Correlations between short form and full-length item bank scores ranged from 0.88 to 0.99 (0.82-0.96 after removing common items from banks). Online respondents were asked whether they had any of 19 different chronic health conditions, and whether or not those reported conditions interfered with ability to function normally. All short forms, across physical, mental, and social health, were able to separate people who reported no health condition from those who reported 1-2 or 3 or more. In addition, scores on all 13 domains were worse for people who acknowledged being limited by the health conditions they reported, compared to those who reported conditions but were not limited by them. CONCLUSION: These 13 brief measures of self-reported QOL are reliable and show preliminary evidence of concurrent validity inasmuch as they differentiate people based upon number of reported health conditions and whether those reported conditions impede normal function.

Effect of time of day on walking capacity and self-reported fatigue in persons with multiple sclerosis: a multi-center trial.

BACKGROUND: Many persons with multiple sclerosis (PwMS) report increased fatigue in the afternoon and evening compared with the morning. It is commonly accepted that physical capacity also decreases as time of day progresses, potentially influencing the outcomes of testing. OBJECTIVE: The objective of this article was to determine whether self-reported fatigue level and walking capacity are influenced by time of day in PwMS. METHODS: A total of 102 PwMS from 8 centers in 5 countries, with a diverse level of ambulatory dysfunction (Expanded Disability Status Scale [EDSS] <6.5), participated. Patients performed walking capacity tests and reported fatigue level at three different time points (morning, noon, afternoon) during 1 day. Walking capacity was measured with the 6-Minute Walk Test (6MWT) and the 10-m walk test performed at usual and fastest speed. Self-reported fatigue was measured by the Rochester Fatigue Diary (RFD). Subgroups with mild (EDSS 1.5-4.0, n = 53) and moderate (EDSS 4.5-6.5, n = 49) ambulatory dysfunction were formed, as changes during the day were hypothesized to depend on disability status. RESULTS: Subgroups had different degree of ambulatory dysfunction (p < 0.001) but reported similar fatigue levels. Although RFD scores were affected by time of day with significant differences between morning and noon/afternoon (p < 0.0001), no changes in walking capacity were found in any subgroup. Additional analyses on subgroups distinguished by diurnal change in self-reported fatigue failed to reveal analogous changes in walking capacity. CONCLUSIONS: Testing of walking capacity is unaffected by time of day, despite changes in subjective fatigue.

Sensitivity to change of the Quebec Back Pain Disability Scale and the Dallas Pain Questionnaire.

OBJECTIVE: To study and compare the sensitivities to change of the French versions of the Quebec Back Pain Disability Scale (QBPDS) and the Dallas Pain Questionnaire (DPQ). METHOD: A retrospective study of the medical records of 30 chronic low back pain (LBP) outpatients undergoing a 4-week functional training program in a physical medicine and rehabilitation unit. Physical data (a visual analogue pain scale, the Schöber index, Sorensen and Shirado tests and the finger-to-floor distance) and functional status (QBPDS and DPQ scores) were measured at D0 and D25. Sensitivity to change was assessed in terms of the standardized response mean (SRM) and the effect size (ES). RESULTS: With the exception of the DPQ's "social interest" domain, all QBPDS and DPQ scores improved significantly over the course of the rehabilitation programme. Sensitivity to change was high for the QBPDS (SRM=0.80; ES=0.62) but only moderate for the DPQ (SRM=0.59; ES=0.61). DISCUSSION-CONCLUSION: Our results show that the QBPDS was more sensitive to clinical change than the DPQ in a sample of chronic LBP sufferers. It would be interesting to assess this sensitivity in a population of acute LBP patients and to evaluate the long-term effects of a functional rehabilitation program on the DPQ's "social interest" domain.

Effect of training programs and exercise in adult stroke patients: literature review.

INTRODUCTION: An increasing number of training programs are proposed for the rehabilitation of patients after stroke, with positive results published but without formal validation, and without recommendations regarding indications for specific techniques and procedures. OBJECTIVE: To review data from the literature about training and exercise programs for stroke patients and to describe the efficacy, limitations, and effect of such programs on organ systems. METHODS: A search of MedLINE and relevant medical journals for articles of clinical trials, meta-analyses, and literature reviews pertaining to physical training and exercise programs after stroke. RESULTS: We found 58 articles reporting on various training and exercise techniques (walking, cardiovascular training, muscle strengthening, and others) and their results (on the cardiovascular, musculoskeletal, and neurologic systems, as well as functional status) in hemiplegic stroke patients. DISCUSSION-CONCLUSION: Training and exercise programs have value in stroke rehabilitation, and published results are, in general, promising. However, differences in the populations tested, methods, and criteria for analysis do not allow for recommending specific procedures.

Fatigue and multiple sclerosis.

Even if the definition and pathophysiology of fatigue in multiple sclerosis (MS) are still debated, and despite the scarcity of objective markers correlated with the subjective sensation of fatigue, a review of the literature shows the importance of its detection and management, and allows one to propose therapeutic strategies. Fatigue is not only the most frequently reported symptom in MS, but also a frequent source of activity and participation limitations, psychological distress, and impairment of quality of life. Its management, which must be initiated early, is based on a comprehensive evaluation of its characteristics and consequences (sometimes with the use of scales such as the Fatigue Severity Scale and the Modified Fatigue Impact Scale), and on the identification of many potential contributing factors (psychological disorders, sleep disturbances, pain, infections and other comorbidities, medications, and deconditioning). Rehabilitative interventions are essential to the treatment of fatigue. Beyond the traditional energy conservation strategies and cooling techniques, several randomized controlled studies have demonstrated the positive impact of aerobic exercise. Medications are partially beneficial, and with the exception of amantadine, their efficacy has not been confirmed by randomized double-blind trials.

[Is very old age a prognostic factor for outcome after a first stroke?]. / L'âge très élevé constitue-t-il un facteur pronostique du devenir après un premier accident vasculaire cérébral?

AIM: To determine whether very old age, older than 80 years, after a stroke is a significant predictor of mortality, orientation to a specific care pathway after the acute phase and functional status at 6 months after the stroke. PATIENTS: A sample of 112 consecutive patients admitted to the emergency department because of a first stroke, with hemiplegia and/or aphasia over 6 months, who satisfied strict inclusion/exclusion criteria. Forty-seven patients were older than 80. METHOD: After initial diagnosis and enrolment in the study, follow-up assessments were conducted at 48 hours, 15 days and 6 months. Demographic, medical, and radiographic data were collected, and patients were evaluated on the NIHSS, MMSE, Barthel Index, FIM(TM) and FAM scales. Descriptive statistics were generated, as were uni- and multivariate between group comparisons. RESULTS: Our study shows that after a first stroke, old age is significantly associated with a high rate of death, a low rate of orientation to a physical medicine and rehabilitation unit and return to home but not poorer functional outcome. CONCLUSION: Old age is therefore a determinant of post stroke management. Further studies are needed to evaluate whether in patient rehabilitation would result in significant functional benefit, considering the high cost of care, high risk of recurrent stroke, and high rate of death.

[Evaluation and multiple sclerosis]. / Evaluation et sclérose en plaques.

We conducted a review of existing assessment tools that can be useful to physical medicine and rehabilitation professionals involved in the management of patients with multiple sclerosis (MS). Most generic tools traditionally used in neurorehabilitation, such as gait tests, the functional independence measure, or the SF-36, can be applied to MS, but few have been tested on large patient samples. Disease-specific scales often seem more pertinent and sensitive to change, and their qualities and limitations are better known through clinical trials of disease-modifying therapies.

[Low back pain disability assessment tools]. / Outils de mesure des paramètres fonctionnels dans la lombalgie.

OBJECTIVES: To identify and compare low back pain functional assessment tools and to determine their characteristics and the selection criteria for their use. MATERIALS AND METHOD: We systematically searched Medline with the key words: low back pain, scale validity, questionnaire, assessment, outcome, and functional evaluation and with some data from the "Guide des Outils de Mesure et d'Evaluation en Médecine Physique et de Réadaptation", which allowed us to complete the search on specific tools including the Roland Disability Questionnaire, Dallas Pain Questionnaire, Quebec Back Pain Questionnaire, and Oswestry Back Pain Questionnaire. We restricted our analysis to studies about the psychometric properties of functional tools. RESULTS: We identified 19 scales or questionnaires, 9 specifically for low back pain and with a concept of functional incapacity. Four tools are recognised as having good psychometric properties and are widely used with linguistic adaptations in different countries. We also identified 10 generic tools proposed to assess outcome in low back pain, which are more conceptually linked to perceived health status, quality of life, and pain assessment. CONCLUSION: A "gold standard" to evaluate disability in low back pain does not exist, but only 4 tools (the Dallas Pain Questionnaire, Roland Disability Questionnaire, Quebec Back Pain Disability Scale and Oswestry Low Back Pain Disability Questionnaire) demonstrated strong qualities (content and construct validity, feasibility, linguistic adaptation and international use).

Incidence of seizures in patients with multiple sclerosis treated with intrathecal baclofen.

Oral and intrathecal baclofen (ITB) have been associated with epileptic seizures. The authors observed a higher incidence of epileptic seizures in 99 patients with multiple sclerosis (MS) treated with ITB vs a matched control group (7% vs 1%, p < 0.05). Three patients with MS on ITB developed status epilepticus. Seizures were often associated with additional triggering factors.

[Evaluation of the handicap and the quality of life in spinal cord injuries: study in a population of 58 patients living at home]. / Evaluation du handicap et de la qualité de vie chez les blessés médullaires: étude d'un échantillon de population de 58 sujets vivant à domicile.

GOAL: The main purpose of this study was to identify objective factors (social and economic status, impairments, functional limitations) contributing to the subjective quality of life of subjects presenting with residual neurological deficits from a traumatic spinal cord injury (SCI) and living at home. SUBJECTS AND METHOD: This is a cross-sectional descriptive study of a sample of SCI patients followed at a Physical Medicine and Rehabilitation facility. After informed consent was obtained, a clinical and functional examination was conducted and questionnaires were filled out by the subjects. The following parameters were assessed: impairments (sensory and motor ASIA scores), disability (Barthel Index and Functional Independence Measure), and quality of life (Reintegration to Normal Living Index and Nottingham Health Profile). RESULTS: Fifty-eight subjects completed the study (mean age 41.38 +/-13.55 years and mean delay from onset 6.24 +/- 6.06 years). There was a strong significant correlation between the level of quality of life and the current age, the age at the time of the accident and the disability level, particularly for the dimensions of physical independence, social integration and mobility. CONCLUSION: Our results are consistent with published data, which identify age as a determining factor of quality of life after SCI. Our review of the literature indicated that time from onset influences quality of life. Longitudinal studies, taking into account the levels of social participation, are needed to better understand the impact of time on quality of life after SCI.

[Relationship between burden of care at home and functional independence level after stroke]. / Relation entre la charge en soins à domicile et le niveau dindépendance fonctionnelle à la suite dun accident vasculaire cérébral.

OBJECTIVE: To determine the relationship between functional disability assessed with the Functional Independence Measure (FIM) and burden of care in hemiplegic stroke patients living at home. METHOD: The population is constituted of stroke survivors, initially treated in an academic inpatient Physical Medicine and Rehabilitation unit. Assessments included an evaluation of impairments (aphasia, negligence, cognitive impairment, motor impairment : Fugl-Meyer (FM) scale), disability (Functional Independence Measure (FIM) ), and burden of care (physical assistance and supervision). RESULTS: Forty-five subjects and their caregiver completed the assessments. Time spent on physical assistance and supervision were significantly correlated with FM and FIM scores. Cognitive deficits correlated with supervision time but not with physical assistance time. DISCUSSION-CONCLUSION: These results confirm the predictive value of functional independence measure relative to burden of care in a population of stroke patients with hemiplegia living at home. These results show that cognitive impairments are more specifically correlated with supervision time. This must be confirmed by studies taking into account functional and cognitive conditions of the patient, functional and psychological conditions of life of caregiver and also economical and environmental conditions of life.

Outcomes following physical restraint reduction programs in two acute care hospitals.

BACKGROUND: Physical restraint rates can be reduced safely in long term care settings, but the strategies used to prevent wandering, falls, and patient aggression have not been tested for their effectiveness in preventing therapy disruption. A restraint reduction program (RRP) consisting of four core components (administrative, educational, consultative, and feedback) was implemented in 1998-1999 in 14 units at two acute care hospitals in geographically distant cities. METHODS: The RRP was targeted at units with prevalence rates of > or = 4% for non-intensive care units (non-ICUs) and > or = 25% for ICUs, as well as two additional units. The RRP was implemented by an interdisciplinary team consisting of geriatricians and nurse specialists. RESULTS: Of the 16,605 admissions to the RRP units, 2,772 cases received RRP consultations. Only six units (four of seven general units and two of six ICUs) demonstrated a relative reduction of > or = 20% in the physical restraint use rate. No increase in secondary outcomes of patient falls and therapy disruptions (patient-initiated discontinuation or dislodgment of therapeutic devices) occurred, injury rates were low, and no deaths occurred as a direct result of either a fall or therapy disruption event. DISCUSSION: Given the minimal success in the ICU settings, further studies are needed to determine effective nonrestraint strategies for critical care patients. ICU clinicians need to be persuaded of the favorable risk-to-benefit ratio of alternatives to physical restraint before they will change their practice patterns. SUMMARY: Efforts to identify more effective interventions that match patient needs and to identify non-clinician factors that affect physical restraint use are needed.

Recovery following acute exacerbations of multiple sclerosis: from impairment to quality of life.

To observe the pattern of recovery after treatment with intravenous Methylprednisolone (i.v. MP) for a relapse of multiple sclerosis (MS), and to determine the best time to plan further interventions such as rehabilitation, we assessed consecutive outpatients (n = 24) treated with i.v. MP for a relapse over a period of 12 weeks. Outcomes measures used were the Expanded Disability Status Scale (EDSS), the Incapacity Status Scale (ISS), the MOS Short Form-36 (SF-36), the Mental Health Inventory (MHI), and the MS-Related Symptom Checklist (MSSCL). There was statistically significant early improvement of EDSS and ISS scores, which was sustained until week 12, and significant improvement of MHI and MSSCL scores between 4 and 12 weeks. Although trends for improvement of scores reflecting the same pattern of recovery were observed with the SF-36 physical and mental composites, these changes did not reach statistical significance. Our results suggest that improvement of impairments and disability after treatment with i.v. MP for a relapse of MS occurs early, while improvement of subjective health status is delayed. Even after maximum improvement is reached, patients are left with multiple symptoms and functional limitations, and may benefit from additional rehabilitative interventions.

[Functional assessment scales and lower limb amputation]. / Echelles d'évaluation fonctionnelle et amputation du membre inférieur.

INTRODUCTION: This paper is a review of the literature on assessment tools in lower limb amputees. MATERIAL AND METHODS: The authors have research on Medline(R) data base the different tools with keys words "lower limb amputee or amputation, functional evaluation or outcome assessment tools, activity of daily living", and have completed the research with the references of papers. RESULTS: A comprehensive approach of the consequences of an amputation and of the outcome of prosthetic care should include an evaluation of gait, use of the prosthesis in activities of daily life, acceptability and satisfaction with the device. DISCUSSION: Functional assessment tools that are validated are recent, and most of them were developed in English. They take into account the use and the acceptance of the device, but there is no study using them for an important sample population. CONCLUSION: It is now necessary to translate the recent tools into French, and to confirm their validity and sensitivity to change.

A meta-analysis of methylprednisolone in recovery from multiple sclerosis exacerbations.

Despite recent advances in multiple sclerosis treatment, patients experience relapses for which standard treatment remains glucocorticosteroids (GCS). However, there is limited information comparing doses or routes of administration for different GCS types or the benefit of GCS compared to natural recovery. Currently, high dose (HD) methylprednisolone (MP) is the preferred therapy. We conducted meta-analyses of published studies assessing MP at different doses and in comparison to other steroid products or no treatment. Relevant studies were identified through predetermined processes and five articles met the inclusion criteria. Three studies compared HD MP to placebo; two studies compared the effect of HD MP and low dose (LD) MP; only one accepted report compared HD MP to another GCS. This report could not be included in a meta-analysis. The meta-analysis of HD MP vsplacebo studies indicated a mean treatment difference of 0.76 in Expanded Disability Status Score (EDSS) changes from baseline. The meta-analysis of HD and LD MP demonstrated no difference in EDSS change. Despite these rather obvious findings, these meta-analyses have been valuable in identifying further research questions. We recommend studies to determine optimum benefit related to dosage, timing for starting therapy and the most appropriate GCS type. Given the advances in MS therapeutics, these studies will have to include patients on additional disease modifying therapy. Multiple Sclerosis (2000) 6 267 - 273

Changes in the quality of life of hemiplegic stroke patients with time: a preliminary report.

To evaluate the influence of time on the quality of life of hemiplegic stroke patients living at home, we analyzed a sample of 45 outpatients. The sample was divided into two groups, according to the delay between the discharge time from hospital and the assessment (Group 1, fewer than 6 mo; Group 2, more than 6 mo after discharge). We hypothesized that patients in Group 2 would have a lower level of quality of life than patients in Group 1. Disability was assessed with the Functional Independence Measure, and the quality of life was assessed with the Reintegration to Normal Living Index. Both groups were comparable with regard to demographic and stroke characteristics. There was no statistically significant difference in Functional Independence Measure scores (global and subscales). Reintegration to Normal Living Index-perception of self subscale scores were significantly lower in Group 2. At the item level, quality of life scores were also significantly lower in Group 2 for indoor mobility (Mann-Whitney U test; P = 0.001), self-care needs (P = 0.005), personal relationships (P = 0.02), and the handling of life events (P = 0.05). These results confirm our hypothesis and suggest that quality of life may deteriorate in some domains over time, even when the disability level is unchanged, but these results need to be replicated in prospective studies with larger samples of stroke survivors.

Neuromuscular stimulation for upper extremity motor and functional recovery in acute hemiplegia.

BACKGROUND AND PURPOSE: The purpose of this study was to assess the efficacy of neuromuscular stimulation in enhancing the upper extremity motor and functional recovery of acute stroke survivors. METHODS: Forty-six stroke survivors admitted to an inpatient rehabilitation unit were randomly assigned to receive either neuromuscular stimulation or placebo. Twenty-eight subjects completed the study. The treatment group received surface neuromuscular stimulation to produce wrist and finger extension exercises. The control group received placebo stimulation over the paretic forearm. All subjects were treated 1 hour per day, for a total of 15 sessions. Outcomes were assessed in a blinded manner with the upper extremity component of the Fugl-Meyer Motor Assessment and the self-care component of the Functional Independence Measure at pretreatment, after treatment, and at 4 and 12 weeks after treatment. RESULTS: The treatment subjects and control subjects had comparable baseline characteristics. Parametric analyses revealed significantly greater gains in Fugl-Meyer scores for the treatment group after treatment (13.1 versus 6.5; P=0.05), at 4 weeks after treatment (17.9 versus 9.7; P=0.05), and at 12 weeks after treatment (20.6 versus 11.2; P=0.06). Functional Independence Measure scores were not different between groups at any of the time periods (P>0.10). CONCLUSIONS: Data suggest that neuromuscular stimulation enhances the upper extremity motor recovery of acute stroke survivors. However, the sample size in this study was too small to detect any significant effect of neuromuscular stimulation on self-care function.

Quality of life of the spouses of stroke patients: a preliminary study.

To study the global quality of life (QOL) of spouses of chronic stroke patients, and to determine its most pertinent factors, we assessed nine stroke patients and their spouses, using the Barthel index, the Functional Independence Measure (FIM), the Montgomery and Asberg Depression Rating Scale (MADRS), the Reintegration to Normal Living Index (RNLI), and a 10-cm visual analogue scale (VAS) to evaluate spouses' QOL. Correlation analysis was performed with the Spearman rank correlation analysis. Mean age of spouses was 53.6 +/- 11.3 years (male:female ratio, 8:1). The mean interval from stroke was 17.6 +/- 10.6 months. The spouses' median QOL score was 4.9, with a significant correlation between spouses' QOL scores and patients Barthel index scores, FIM global scores, and FIM locomotion scores. Spouses complained of the physical burden, but psychological, social, economic and marital consequences of the stroke were also reported. This study confirms the constant impact of stroke on the QOL of the spouses, and demonstrates the role of patients' physical disability. However, the VAS allows only a global approach. A self-administered composite index, exploring the consequences of the stroke on the spouses' daily life, would be a useful complement.