Perceived health- related quality of life in persons with multiple sclerosis with and without a vascular comorbidity.

PURPOSE: Vascular comorbidities are prevalent and can contribute to adverse health outcomes in persons with multiple sclerosis (PwMS). Understanding the association between vascular comorbidities and health-related quality of life (HRQOL) among PwMS may be beneficial in improving outcomes and disease management. This cross-sectional study aimed to examine the relationship between vascular comorbidities and the different dimensions of HRQOL in PwMS. METHODS: Participants (n = 185) were PwMS recruited from a community-based comprehensive MS care center. Demographics, comorbid conditions, and disability level were collected via a self-report REDCap survey, with the 29-item Multiple Sclerosis Quality of Life (MSQOL-29) as the outcome measure. Regression models were used to examine the association between vascular comorbidities and the MSQOL-29, controlling for age, gender, ethnicity, level of education, marital status, MS subtype, disease duration, and disability. RESULTS: Approximately 35% reported at least one vascular comorbidity, with the most common being hypertension (27.0%), followed by hyperlipidemia (24.9%) and diabetes (8.1%). After factoring in for demographics and disability, having a vascular comorbidity was associated with lower physical HRQOL (ß = - 10.05, 95% CI: - 28.24, 23.50), but not mental HRQOL (ß = - 2.61, 95% CI: - 10.54, 5.32). Hypertension was negatively associated with several dimensions of HRQOL, including Physical Function, Change in Health, Health Perceptions, Energy, and Health Distress. CONCLUSIONS:  Having at least one vascular comorbidity is associated with lower physical HRQOL, independent of demographics and level of physical disability. Focus should be directed to the physical burden and challenges vascular comorbidities may cause on the lives of PwMS.

Physical Activity and Life Stress Are Associated With Illness Intrusiveness in Persons With Multiple Sclerosis.

OBJECTIVES: To explore which modifiable lifestyle behaviors contribute to illness intrusiveness in persons with multiple sclerosis (MS). DESIGN: Cohort study. SETTING: Community-based comprehensive MS center. PARTICIPANTS: Adults with MS (N=154) who completed an online battery of self-report questionnaires. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Illness intrusiveness was measured with the 13-item Illness Intrusiveness Ratings Scale. Lifestyle behaviors were measured using the respective components of the Simple Lifestyle Indicator Questionnaire (ie, Diet, Physical Activity, Alcohol, Smoking, and Life Stress) and self-reported body mass index (BMI). RESULTS: After controlling for age, race, sex, disease duration, and level of physical disability ("disability"), life stress was associated with greater illness intrusiveness (b=4.65, P<.001), and physical activity was associated with less illness intrusiveness (b=-0.67, P=.009). Exploratory mediation analyses revealed physical activity had an indirect effect on illness intrusiveness through disability (b=-0.39, 95% CI: -0.68, -0.16). Conversely, disability also displayed an indirect effect on illness intrusiveness through physical activity (b=0.57, 95% CI: 0.12, 1.16). CONCLUSIONS: Life stress and physical activity are 2 modifiable lifestyle behaviors that contribute to illness intrusiveness, with the latter also having an indirect effect through disability. These findings may help inform future behavioral interventions for improving health-related quality of life in persons with MS.

The Role of Cognitive Impairment on Physical Therapy Attendance and Outcomes in Multiple Sclerosis.

BACKGROUND AND PURPOSE: Many persons with multiple sclerosis (PwMS) experience cognitive impairments, which may affect their ability to engage in physical therapy. There is limited information on how cognitive impairments are associated with PwMS' ability to participate and improve their functional outcomes. This study aimed to assess the relationship between cognitive functioning and PwMS' attendance, total goal attainment, and functional improvement following physical therapy intervention. METHODS: Participants (n = 45) were PwMS who participated in a larger self-management study and enrolled in physical therapy within the past 2 years. Objective cognitive functioning was examined using tests of prospective memory, retrospective memory, working memory, and processing speed, along with a self-report measure. Bivariate analyses were conducted to examine the relationship between cognitive functioning and each physical therapy outcome (session attendance, attaining goals, and changes in functional outcome measures), followed by logistic regressions with age, education, gender, and disability level as covariates. RESULTS: Difficulty learning new verbal information was associated with a greater likelihood of "no showing" one or more of their physical therapy sessions. Reductions in working memory and processing speed were associated with PwMS not meeting all their rehabilitation goals. Despite deficits in new learning, memory, and processing speed, 85.2% of those with pre-/postscores showed improvements in at least one functional outcome measure following physical therapy intervention. DISCUSSION AND CONCLUSIONS: These findings demonstrate the ability for PwMS to make functional motor gains despite the presence of cognitive impairments and highlight the potential contributions of cognitive functioning on attendance and goal attainment of physical therapy intervention.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A362, which includes background, methods, results, and discussion in the authors' own voices).

Demographic and Clinical Factors Are Associated With Frequent Short-Notice Cancellations in Veterans With Multiple Sclerosis on Disease Modifying Therapies.

OBJECTIVES: (1) To identify the rate of short-notice canceled appointments in a large national sample of persons with multiple sclerosis (MS) and (2) examine the demographic and clinical factors associated with frequent cancellations. DESIGN: Retrospective cross-sectional cohort using electronic health records. SETTING: Veterans Health Administration. PARTICIPANTS: Veterans with MS (N=3742) who were part of the Veterans Health Administraiton's MS Center of Excellence Data Repository and (1) had at least one outpatient appointment at the VA in 2013, (2) were alive in 2015, and (3) were prescribed a disease modifying therapy (DMT). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Frequent short-notice cancellations, defined as >20% of scheduled appointments canceled with less than 24-hour notification over a 24-month period. This threshold was based on the definition of ≤80% for suboptimal treatment adherence. Several demographics and clinical variables were examined as potential explanatory factors. RESULTS: Approximately 75% (n=2827) had at least 1 short-notice cancellation, with more than 3% (n=117) categorized as frequent cancelers. The odds of frequent cancellations were greater in women (odds ratio [OR], 1.81; P=.004) and among 18- to 44-year-olds (OR, 2.77; P=.004) and 45- to 64-year-olds (OR, 2.49; P=.003) compared to those over 65. The odds were lower among persons who lived <25 miles away (OR, 0.58; P=.043) compared with persons who lived ≥75 miles away and those who had at least 1 emergency department visit (OR, 0.55; P=.012). CONCLUSIONS: Short-notice cancellations are common in persons with MS, although few have more than 20%. These findings highlight who is at greater risk for frequent cancellation and disruptions in their care. Although additional research is needed, the results provide insights into how clinics may approach handling frequent short-notice cancellations among persons with MS.

What Biopsychosocial Factors Explain Self-management Behaviors in Multiple Sclerosis? The Role of Demographics, Cognition, Personality, and Psychosocial and Physical Functioning.

OBJECTIVES: To examine the biopsychosocial correlates of overall and individual self-management behaviors in persons with multiple sclerosis (MS), including demographics, co-occurring medical diagnoses, cognition, personality traits, and psychosocial and physical functioning as variables. DESIGN: Prospective cross-sectional cohort study. SETTING: Community-based comprehensive MS center. PARTICIPANTS: Adults with MS (n=112) who completed a brief neuropsychological battery that included a self-report survey and performance-based measures of cognitive function. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The MS Self-management Scale-Revised total score was the primary outcome and its 5 subscales (Healthcare Provider Relationship/Communication, Treatment Adherence/Barriers, Social/Family Support, MS Knowledge and Information, Health Maintenance Behaviors) were secondary outcomes. RESULTS: Disease-modifying therapy usage (ß=0.39), social support (ß=0.31), subjective prospective memory (ß=-0.25), emotional well-being (ß=0.20), and histories of diabetes (ß=-0.18) and high cholesterol (ß=0.15) were significantly associated with overall self-management in a multivariate model. Correlates of individual self-management behaviors are also described. CONCLUSIONS: The findings provide insights into the biopsychosocial characteristics contributing to the overall and individual self-management behaviors of persons with multiple sclerosis. The next steps will be to evaluate these factors in a clinical intervention.

A Multicenter VA Study of the Format and Content of Internal Medicine Morning Report.

BACKGROUND: There are more than five hundred internal medicine residency programs in the USA, involving 27,000 residents. Morning report is a central educational activity in resident education, but no recent studies describe its format or content. OBJECTIVE: To describe the format and content of internal medicine morning reports. DESIGN AND PARTICIPANTS: Prospective observational study of morning reports occurring between September 1, 2018, and April 30, 2019, in ten different VA academic medical centers in the USA. MAIN MEASURES: Report format, number and type of learner, number and background of attending, frequency of learner participation, and the type of media used. Content areas including quality and safety, high-value care, social determinants of health, evidence-based medicine, ethics, and bedside teaching. For case-based reports, the duration of different aspects of the case was recorded, the ultimate diagnosis when known, and if the case was scripted or unscripted. RESULTS: A total of 225 morning reports were observed. Reports were predominantly case-based, moderated by a chief resident, utilized digital presentation slides, and involved a range of learners including medicine residents, medical students, and non-physician learners. The most common attending physician present was a hospitalist. Reports typically involved a single case, which the chief resident reviewed prior to report and prepared a teaching presentation using digital presentation slides. One-half of cases were categorized as either rare or life-threatening. The most common category of diagnosis was medication side effects. Quality and safety, high-value care, social determinants of health, and evidence-based medicine were commonly discussed. Medical ethics was rarely addressed. CONCLUSIONS: Although a wide range of formats and content were described, internal medicine morning report most commonly involves a single case that is prepared ahead of time by the chief resident, uses digital presentation slides, and emphasizes history, differential diagnosis, didactics, and rare or life-threatening diseases.

The influence of trait mindfulness on depression in multiple sclerosis: potential implications for treatment.

PURPOSE: This study seeks to add to existing literature on depression and illness intrusiveness in chronic disorders by examining, (1) how the perceived intrusiveness of multiple sclerosis (MS) leads to depression, (2) and the mediating role trait mindfulness plays in this relationship METHODS: Participants (N = 755) were persons with MS (PwMS) recruited through the North American Research Committee on MS (NARCOMS) registry (a larger study). Participants completed the Illness Intrusiveness Ratings Scale, the Hospital Anxiety and Depression Scale and the Mindful Attention Awareness Scale. A mediation model assessed if trait mindfulness mediates the relationship between illness intrusiveness and depression RESULTS: Illness intrusiveness predicted trait mindfulness (a = - 4.54; p < .001), trait mindfulness predicted depression (b = - .04; p < .001); there was a direct effect of illness intrusiveness on depression (c' = 2.53; p < .001) and an indirect effect on depression (ab = .17, 95% BCa CI [.10, .25]) when trait mindfulness was in the model, which represented a medium size effect, R2med = .10 [95% CI .07, .14] CONCLUSION: Trait mindfulness mediates the relationship between illness intrusiveness and depression in PwMS. Providers could provide psychoeducation on the benefits of mindfulness and mindfulness-based interventions.

Risk Factors for Suboptimal Medication Adherence in Persons With Multiple Sclerosis: Development of an Electronic Health Record-Based Explanatory Model for Disease-Modifying Therapy Use.

OBJECTIVE: To determine which factors are associated with suboptimal disease-modifying therapy (DMT) adherence and to develop an explanatory model that could be used to identify individuals at risk and potentially inform interventions. DESIGN: Cross-sectional cohort study using electronic health records. SETTING: Veterans Health Administration (VA). PARTICIPANTS: Veterans with multiple sclerosis (MS) (N=2939; 79.69% men) who received care through the VA and were included in the VA MS Center of Excellence Data Repository. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Suboptimal DMT adherence (<80%), demographics, co-occurring conditions, and health care use. RESULTS: Nearly 31% of participants had suboptimal adherence. Flags for suboptimal adherence included >20% missed appointments (odds ratio [OR], 3.78; 95% CI, 2.45-2.82), traumatic brain injuries (OR, 1.55; 95% CI, 1.12-2.14), age younger than 59 years (OR, 1.47; 95% CI, 1.23-1.74), ≥1 emergency department visits (OR, 1.40; 95% CI, 1.18-1.67), mood disorders (ie, depressive and bipolar disorders) (OR, 1.40; 95% CI, 1.18-1.66), and service connection (OR, 1.22; 95% CI, 1.01-1.47). Hyperlipidemia (OR, 0.77; 95% CI, 0.65-0.92) and being issued a wheelchair (OR, 0.83; 95% CI, 0.70-1.00) were associated with lower risk. CONCLUSIONS: Suboptimal adherence to DMTs continues to be an issue. Interventions that focus on person-level barriers should be urgently explored to increase adherence and improve self-management abilities.

The effects of cognitive-focused interventions on cognition and psychological well-being in persons with multiple sclerosis: A meta-analysis.

Cognitive impairment affects more than half of persons with multiple sclerosis (PwMS), and it is associated with difficulties in multiple aspects of daily functioning. There is a growing body of literature that has explored the use of cognitive-focused interventions in PwMS, which aim to improve cognition-related function through drill and practice exercises, training in compensatory strategies, or a combination of the two. The current study aimed to expand upon previously published meta-analyses in this area, exploring the effects of cognitive-focused interventions on objective and subjective functioning in PwMS, as well as determining demographic and treatment-related factors that may influence intervention efficacy. Thirty-three studies, with a total of 1890 participants, were included in the meta-analysis. Outcome measures were categorised based on the domain they presumably assessed. For objective cognitive functioning, weighted effect-size analysis revealed small effects of cognitive-focused interventions on working memory (g = 0.31) and visual learning (g = 0.32). Small mean effect sizes were also noted on self-reported anxiety (g = -0.30) and depression (g = -0.23). Cognitive-focused interventions did not produce changes in subjective cognitive functioning. Moderating variables and clinical applications are also discussed.

Sex differences in predictors of illness intrusiveness in persons with multiple sclerosis.

PURPOSE: Multiple sclerosis (MS) is a complex, chronic disease that can have debilitating effects on daily activities and well-being, compromising health-related quality of life. One underlying determinant of quality of life (QOL) is perceived illness intrusiveness, which examines the disruptiveness of the condition and/or its related treatment on engagement in interest and activities, in turn affecting psychological functioning. There is evidence that persons with MS (PwMS) have higher level of illness intrusiveness compared to those with other chronic conditions; however, limited research exists on differences by sex. This study aimed to explore these possible differences between men and women, hypothesizing that men with MS will have overall higher illness intrusiveness (lower QOL) when compared to women with MS. METHODS: A total of 922 PwMS were primarily recruited through the North American Research Committee on MS Registry. The participants completed a one-time anonymous online survey. Illness intrusiveness was measured using the Illness Intrusiveness Ratings Scale (IIRS) total score and three subscales. Independent t-tests determined differences in demographics, disease characteristics, and IIRS outcomes. Hierarchical regressions were then used to further assess whether sex was a significant predictor of illness intrusiveness. RESULTS: Men exhibited greater overall, intimacy, and relationship and personal development-related perceived illness intrusiveness. However, sex was only a significant predictor of the Intimacy IIRS subscale after accounting for age, disability, and depression. CONCLUSIONS: These findings highlight the intrusiveness of MS on intimacy and sexual functioning, particularly among men. Potential clinical implications and future directions are discussed.

The impact of sexual dysfunction on health-related quality of life in people with multiple sclerosis.

BACKGROUND: Sexual dysfunction is a prevalent symptom in multiple sclerosis (MS) that may affect patients' health-related quality of life (HrQoL). OBJECTIVE: The objective of this paper is to examine the impact of sexual dysfunction on HrQoL in a large national sample using The Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ-19). METHODS: Participants were recruited from a large MS registry, the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry. Participants self-reported demographic information and completed the Patient Determined Disease Steps (PDDS), MSISQ-19, and the Short Form-12 (SF-12). RESULTS: The study population included 6183 persons (mean age: 50.6, SD = 9.6; 74.7% female, 42.3% currently employed). Using multivariate hierarchical regression analyses, all variables excluding gender predicted both the physical component summary (PCS-12) and the mental component summary (MCS-12) of the SF-12. Scores on the MSISQ-19 uniquely accounted for 3% of the variance in PCS-12 scores while disability level, as measured by PDDS, accounted for 31% of the variance. Conversely, MSISQ-19 scores uniquely accounted for 13% of the variance in MCS-12 scores, whereas disability level accounted for less than 1% of the variance. CONCLUSION: In patients with MS, sexual dysfunction has a much larger detrimental impact on the mental health aspects of HrQoL than severity of physical disability.

The association between sleep disorders and resilience in persons with multiple sclerosis.

While lower resilience has been connected to self-reported sleep problems in persons with multiple sclerosis (PwMS), there has yet to be an examination with diagnosed sleep disorders. This study examined differences in resilience (MS Resiliency Scale) between PwMS with sleep disorders (n = 27), sleep problems (n = 39), and no sleep disorders/problems (n = 46). PwMS with sleep disorders had significantly lower resilience than PwMS with no sleep disorders/problems (p = .035), with support from family and friends driving this difference. These findings further illustrate the connection between sleep and resilience in PwMS, highlighting the importance of social support in this relationship.

Patterns of prospective memory errors differ in persons with multiple sclerosis.

INTRODUCTION: Prospective memory (PM) deficits have been documented in multiple sclerosis (MS). This study aimed to explore the specific types of errors made by persons with MS (PwMS), including differences between PwMS and healthy controls (HC) and PwMS who do and do not have impairments in processing speed and/or verbal learning and memory. METHOD: PwMS (n = 111) and HC (n = 75) completed the Memory for Intentions Test (MIST), an objective measure of PM that has five types of errors that can be coded (PM failure, task substitution, loss of content, loss of time, and random errors). The number and types of PM errors were calculated for the overall MIST and six subscales, which break down performance by types of delay (2-Minute and 15-Minute), cue (Time and Event), and response (Verbal and Action). Impairment was defined as performing < 1.5 SD on either the Symbol Digit Modalities Test (SDMT) or Rey Auditory Verbal Learning Test (RAVLT). Bivariate analyses were used to examine group differences, with post-hoc pairwise comparisons with Bonferroni corrections. RESULTS: Nearly 93% of PwMS made at least one PM error, compared to 76% of HC (V = .24, p = .001). The most commonly made PM error by PwMS was loss of content errors (45.0%). PwMS made significantly more task substitution errors (26.4% vs. 7.6%, p < .001) and fewer loss of time errors (9.5% vs. 21.2%, p < .001) than HC. Impaired PwMS made more errors than non-impaired PwMS, specifically PM failures on time-based tasks. CONCLUSIONS: PM errors are common in PwMS, particularly when there are longer delays and time-based cues. Not only do PwMS make more errors than demographically similar HC, but they exhibit different cognitive process failures.

Improving prospective memory in persons with multiple sclerosis via telehealth: A randomized feasibility study.

BACKGROUND: Persons with multiple sclerosis (PwMS) can experience deficits in prospective memory (PM) or "remembering to remember," which are associated with functional difficulties. However, no cognitive rehabilitation intervention has specifically addressed improving PM in PwMS. The Telehealth PM Intervention (TPMI) provides a novel combination of two strategies-visual imagery and implementation intentions-that have each been beneficial in other populations. This study aimed to evaluate the feasibility of TPMI and its preliminary efficacy, which could be used to inform future trials. METHODS: Participants (n = 35) were PwMS who were pre-screened and endorsed experiencing problems "remembering places they have to be" and "things they have to do." After completing a baseline evaluation, which included objective (Memory for Intentions Test; MIST) and subjective (Perceived Deficits Questionnaire; PDQ-PM) measures of PM, participants were randomized to either the active treatment (TPMI; n = 17) or active control group (Control; n = 18). TPMI was offered through remote one-on-one sessions twice a week over a four-week period. Participants were asked about treatment credibility and expectancy during the first session. The MIST and PDQ-PM were repeated at post-treatment, where treatment satisfaction was also captured. Mann-Whitney U and chi-square tests were used to examine the feasibility measures, while repeated measures ANOVAs were used to examine changes in the PM outcomes. RESULTS: A total of 88.2 % of the TPMI group completed all eight sessions, with moderate-to-high (≥7 out of 10) treatment credibility/expectancy and satisfaction reported by 93.3 % and 86.7 %, respectively. While there were no significant effects on overall PM, the TPMI group had an improvement in objective time-based PM after adjusting for baseline differences (F(1,29) = 4.61, p = 0.040; d = 0.80). Furthermore, the TPMI group had a significant reduction in the number of time-based loss of content errors compared to the Control group, which remained significant after covariate adjustment (F(1,25) = 4.29, p = 0.049; d = 0.83). CONCLUSIONS: TPMI is a feasible intervention, with high completion rates and moderate-to-high treatment ratings, that can be delivered remotely. Early evidence shows its potential benefit for improving time-based PM, a particular concern for PwMS, which should be further evaluated in a larger clinical trial.

Using Objective and Subjective Measures of Cognition to Predict Instrumental Activities of Daily Living Abilities in Multiple Sclerosis.

BACKGROUND: Cognitive impairment, difficulty performing basic activities of daily living (ADLs) and instrumental ADLs (IADLs), depression, and fatigue are common among individuals with multiple sclerosis (MS). Some associations between these symptoms are known; however, many of their relationships remain unclear. This study investigated the contributions of subjective and objective cognition, depressive symptom severity, and fatigue on ADLs and IADLs. METHODS: Participants (N = 217) were individuals with MS from a comprehensive MS center, participating in a larger study characterizing upper extremity function in MS. Outcome measures of ADL and IADL abilities were the Functional Status Index-Assistance (FSI-A) and Functional Status Index-Difficulty (FSI-D) and the Test D'évaluation Des Membres Supérieurs de Personnes Âgées (TEMPA). Predictors were objective cognition (Symbol Digit Modalities Test; SDMT), subjective cognition (Performance Scales©-Cognition; PS-C), depressive symptom severity (Center for Epidemiologic Studies Depression Scale; CES-D-10), and fatigue (Modified Fatigue Impact Scale; MFIS-5). Correlations were conducted, followed by hierarchal linear regressions. The SDMT and PS-C were entered into separate models. RESULTS: After controlling for demographics, the SDMT significantly predicted the TEMPA and FSI-A, while the PS-C predicted only the FSI-D. The CES-D-10 predicted the FSI-D even after accounting for PS-C and SDMT, while the MFIS-5 only predicted the FSI-D when the SDMT was included. Neither the CES-D-10 nor MFIS-5 significantly predicted the FSI-A or TEMPA. CONCLUSIONS: The way an individual with MS perceived their symptoms significantly contributed to their reported difficulty with functional tasks, while only their objective cognitive functioning predicted ADL and IADL performance and the level of assistance they would require.

Establishment of regression-based isometric strength reference values for the upper limb in persons with multiple sclerosis.

BACKGROUND: Muscle weakness is common and significantly affects persons with multiple sclerosis (PwMS), with dysfunction in upper limb (UL) muscle groups occurring in approximately 60% of PwMS. OBJECTIVE: To develop gender-specific regression-based prediction equations, with 95% confidence intervals for maximal bilateral UL isometric strength (shoulder abduction and adduction, wrist flexion and extension) and hand grip strength in PwMS. DESIGN: Cross-sectional study. SETTING: Comprehensive MS center. PARTICIPANTS: 256 PwMS. INTERVENTIONS: Not Applicable. MAIN OUTCOME MEASURES: Shoulder abduction and adduction and wrist flexion and extension isometric strength (Biodex System 4 Pro Dynamometer) and hand grip strength (Jamar handheld dynamometer) were measured. Disease characteristics (disability and disease duration) and demographics (age, height, and weight) were collected. Regression-based predictive equations were generated for the UL muscle groups for each gender and limb, using age, height, weight, disability, and disease duration as covariates. Variables were compared between genders using the Mann-Whitney U test. Maximal voluntary contraction (MVC) reference values (mean ± SD) were reported based on age (<30, 30-39, 40-49, 50-59, 60-69 years) and disability (mild, moderate, severe ambulant, and severe nonambulant) for each gender and limb. RESULTS: Regression-based equations were developed for both genders' strongest and weakest limb, accounting for age, height, weight, disability, and disease duration. MVC was higher in men than women (p < .001) in all muscle groups. Overall, MVC was significantly related to age in 14, height in 5, weight in 6, disability in 14, and disease duration in none of the 20 models. CONCLUSION: This is the first study to provide regression-based prediction equations for strongest and weakest MVC of UL muscle groups and demonstrated an inverse relationship between MVC with disability and age. Regression-based reference strength values can help clinicians understand muscular strength along a spectrum of PwMS and can aid in goal setting and education for realistic outcomes.

Using a highly abbreviated California Verbal Learning Test-II to detect verbal memory deficits.

Multiple sclerosis (MS) is frequently accompanied by changes in verbal memory. We hypothesized that administering an abbreviated California Verbal Learning Test-II (CVLT-II) would detect verbal memory problems in MS accurately, thus serving as a potential screening tool. We performed receiver-operating-characteristic (ROC) analyses of three trials (trial 1, trial 2, and trial 1+2 combined) for raw data against standardized total scores. The results showed that at 1.5 standard deviations (SD) from the mean, the first two trials were 96.3% accurate, while at 2 SD from the mean, the first two trials combined were 97.5% accurate. We conclude that this study demonstrates than an abbreviated CVLT-II is a valid screening tool for verbal memory impairments.

Appointment attendance behaviors in multiple sclerosis: Understanding the factors that differ between no shows, short notice cancellations, and attended appointments.

BACKGROUND: There has yet to be an examination of how appointment attendance behaviors in multiple sclerosis (MS) are related to scheduling metrics and certain demographic, clinical, and behavioral factors such as cognitive functioning and personality traits. This study aimed to examine the factors that differ between no shows (NS), short notice cancellations (SNC), and attended appointments. METHODS: Participants (n = 110) were persons with MS who were enrolled in a larger cross-sectional study, during which they completed a battery of neuropsychological measures. Data about their appointments in three MS-related clinics the year prior to their study evaluation were extracted from the medical record. Bivariate analyses were done, with post-hoc tests conducted with Bonferroni corrections if there was an overall group difference. RESULTS: A higher number of SNC were noted during the winter, with 22.4% being due to the weather. SNC were also more common on Thursdays, but less frequent during the early morning time slots (7am to 9am). In contrast, NS were associated with lower annual income, weaker healthcare provider relationships, lower self-efficacy, higher levels of neuroticism, depressive symptom severity, and health distress, and greater cognitive difficulties, particularly with prospective memory. CONCLUSIONS: While SNC are related to clinic structure and situational factors like the weather, NS may be more influenced by behavioral issues, such as difficulty remembering an appointment and high levels of distress. These findings highlight potential targets for reducing the number of missed appointments in the clinic, providing opportunities for improved healthcare efficiency and most importantly health.

Identifying prospective memory deficits in multiple sclerosis: Preliminary evaluation of the criterion and ecological validity of a single item version of the memory for intentions test (MIST).

Objectives: Difficulties with prospective memory (PM) are not routinely assessed in persons with multiple sclerosis (MS) even though they can impact daily functioning. This study aimed to examine the preliminary criterion and ecological validity of a highly abbreviated Memory for Intentions Test (MIST) intended to serve as an initial screening of PM in persons with MS. Methods: Participants (n = 112) were classified as impaired if they performed 1.5 standard deviations below the normative mean on the MIST. Individual MIST trials with adequate difficulty and discriminability were examined using receiver operating characteristic analyses, with their classification accuracies, sensitivities, and specificities compared to each other. Regressions were run to evaluate their ecological validity, with appointment attendance and employment as the outcomes. Results: Two trials had a classification accuracy of ≥80%: Trial 3 (79% sensitivity, 84% specificity) and Trial 4 (57% sensitivity, 91% specificity). These two trials had comparable specificity (p=.127), with Trial 3 having slightly higher sensitivity (p=.083). Only Trial 4 was significantly associated with appointment attendance (b = 1.63, p=.047) and unemployment (aOR = 11.20, p=.027). Discussion:Trial 4 of the MIST, a verbal task with a time-based cue that requires participants to complete a pre-specified response after a 15-minute delay, has the potential to be a screener for PM.

Establishment of regression-based normative isometric strength values for major lower limb muscle groups in persons with multiple sclerosis.

BACKGROUND: Limb weakness is a major impairment that affects mobility in persons with multiple sclerosis (PwMS). Specifically, lower limb (LL) weakness can greatly affect gait and balance, while increasing fall risk and decreasing quality of life. Numerous studies have compared LL strength of PwMS to healthy controls, however none have objectively measured strength in all major LL joints (hip, knee, and ankle) in a large number of PwMS. Additionally, while discrete normative values exist for knee extensors in PwMS, there has yet to be regression-based normative isometric strength values for all major LL muscle groups. Therefore, this study aimed to develop gender-specific regression-based normative prediction equations, with 95% confidence intervals, for maximal isometric peak torque of major LL muscles in PwMS. A secondary aim was to characterize the prevalence of LL weakness in PwMS, defined as ≥ 2 SD below values reported for healthy individuals. METHODS: A convenience sample of 175 (women: n = 135) PwMS participated in a prospective, cross-sectional study where isometric peak torque of hip flexors, extensors, and abductors, knee flexors and extensors, and ankle plantarflexors and dorsiflexors were measured using the Biodex System 4 Pro-Dynamometer®. Demographics (age, height, and weight) and disease characteristics (disease duration and disability) were collected. Performances were separated for each muscle group into strongest limb and weakest limb. For each gender, regression-based equations were generated for the LL muscle groups by limb with age, height, weight, disability, and disease duration as the covariates. Descriptive statistics were used to examine the frequency of LL weakness by gender and disability level. For comparison purposes, age-stratified (<30, 30-39, 40-49, 50-59, 60-69, >70 years) and disability-stratified (mild, moderate, and severe ambulant) discrete peak torque values were also generated for each gender. RESULTS: Regression-based normative data are presented for men and women, accounting for age, height, weight, disability, and disease duration. Men were significantly stronger (P < 0.001) than women for all LL, with the men's models accounting for a greater percent of muscle strength variation than women's models for all muscle groups, except for hip extension. Disability was inversely related to strength in all of the models. LL weakness was prevalent in hip flexion (m: 47.5%; w: 63.0%) and extension (m: 92.5%; w: 88.1%), knee extension (m: 30.0%; w: 33.3%) and flexion (m: 25.0%; w: 34.8%), and ankle plantarflexion (m: 15.0%; w: 10.4%) and dorsiflexion (m: 100.0%; w: 96.3%). PwMS with mild disability had a high prevalence of ankle dorsiflexion (94.9-100.0%) and hip extension (81.4-90.0%) weakness. CONCLUSIONS: This study is the first to provide regression-based normative data of bilateral strength in all major LL muscle groups and clinically useful prevalence data on the occurrence of weakness in these muscles. Of note, PwMS had a high prevalence of ankle dorsiflexion and hip extension weakness even when they were only mildly disabled. These findings can help guide the direction of future interventions and treatments to improve muscle function in PwMS.