Alyssa M. Bamer

Falls in Multiple Sclerosis

To examine incidence, associated factors, and health care provider (HCP) response to falls in persons with multiple sclerosis (MS).

Prevalence of sleep problems in individuals with multiple sclerosis.

Background Sleep disturbance in multiple sclerosis has received little research attention despite the potential influence it may have on disease impact. Objective To estimate the prevalence of sleep disorders in a large community sample of individuals with multiple sclerosis. Methods A cross-sectional self-report survey of 1063 persons with multiple sclerosis. Sleep was assessed using the Womens Health Initiative Insomnia Rating Scale and Medical Outcomes Study Sleep measure. Results The prevalence of sleep problems in multiple sclerosis is significantly higher than in the general population or other chronic diseases and may affect women with multiple sclerosis more than men. Conclusion Sleep disturbance should routinely be evaluated in patients with multiple sclerosis and new interventions developed.

Comparing CESD-10, PHQ-9, and PROMIS depression instruments in individuals with multiple sclerosis.

PURPOSE This study evaluated psychometric properties of the Patient Health Questionnaire-9 (PHQ-9), the Center for Epidemiological Studies Depression Scale-10 (CESD-10), and the 8-item PROMIS Depression Short Form (PROMIS-D-8; 8b short form) in a sample of individuals living with multiple sclerosis (MS). RESEARCH METHOD Data were collected by a self-reported mailed survey of a community sample of people living with MS (n = 455). Factor structure, interitem reliability, convergent/discriminant validity and assignment to categories of depression severity were examined. RESULTS A 1-factor, confirmatory factor analytic model had adequate fit for all instruments. Scores on the depression scales were more highly correlated with one another than with scores on measures of pain, sleep disturbance, and fatigue. The CESD-10 categorized about 37% of participants as having significant depressive symptoms. At least moderate depression was indicated for 24% of participants by PHQ-9. PROMIS-D-8 identified 19% of participants as having at least moderate depressive symptoms and about 7% having at least moderately severe depression. None of the examined scales had ceiling effects, but the PROMIS-D-8 had a floor effect. CONCLUSIONS Overall, scores on all 3 scales demonstrated essential unidimensionality and had acceptable interitem reliability and convergent/discriminant validity. Researchers and clinicians can choose any of these scales to measure depressive symptoms in individuals living with MS. The PHQ-9 offers validated cutoff scores for diagnosing clinical depression. The PROMIS-D-8 measure minimizes the impact of somatic features on the assessment of depression and allows for flexible administration, including Computerize Adaptive Testing (CAT). The CESD-10 measures 2 aspects of depression, depressed mood and lack of positive affect, while still providing an interpretable total score.

Comparison of the psychometric properties of two fatigue scales in multiple sclerosis.

OBJECTIVE To compare psychometric functioning of the Fatigue Severity Scale (FSS; Krupp, LaRocca, Muir-Nash, & Steinberg, 1989) and the Modified Fatigue Impact Scale (MFIS; MSCCPG, 1998) in a community sample of persons with multiple sclerosis (MS). METHOD A self-report survey including the FSS, MFIS, demographic, and other health measures was completed by 1271 individuals with MS. Analyses evaluated the reliability and validity of the scales, assessed their dimensional structures, and estimated levels of floor and ceiling effects. Item response theory (IRT) was used to evaluate the precision of the MFIS and FSS at different levels of fatigue. RESULTS Participants had a mean score on the FSS of 5.1 and of 44.2 on the MFIS. Cronbachs alpha values for FSS and MFIS were all 0.93 or greater. Known-groups and discriminant validity of MFIS and FSS scores were supported by the analyses. The MFIS had low floor and ceiling effects, and the FSS had low floor and moderate ceiling effects. Unidimensionality was supported for both scales. IRT analyses indicate that the FSS is less precise in measuring both low and high levels of fatigue, compared with the MFIS. CONCLUSIONS Researchers and clinicians interested in measuring physical aspects of fatigue in samples whose fatigue ranges from mild to moderate can choose either instrument. For those interested in measuring both physical and cognitive aspects of fatigue, and whose sample is expected to have higher levels of fatigue, the MFIS is a better choice even though it is longer. IRT analyses suggest that both scales could be shortened without a significant loss of precision.

The prevalence of overweight and obesity in veterans with multiple sclerosis

Khurana SR, Bamer AM, Turner AP, Wadhwani RV, Bowen JD, Leipertz SL, Haselkorn JK: The prevalence of overweight and obesity in veterans with multiple sclerosis. Am J Phys Med Rehabil 2009;88:83–91. Objectives:To estimate the prevalence and factors associated with overweight and obesity in veterans with multiple sclerosis (MS) enrolled in the Veterans Health Administration (VA) and to compare the prevalence in this group with gender-specific published rates for the general population of veterans receiving outpatient care at VA medical facilities. Design:Cross-sectional cohort study linking electronic medical record information to mailed survey from 1999 to 2004. A total of 4703 veterans with MS enrolled in VA who returned questionnaires as part of two cross-sectional studies. Main outcome measures included body mass index, demographic information, Veteran RAND 36-item Health Survey, frequency of physical exercise, and other health conditions. Results:Overall, 28% of female and 42.8% of male veterans with MS were overweight. Another 25% of women and 21.2% of male veterans met the criteria for obesity. Compared with a historical cohort of veterans enrolled in the VA, veterans with MS had a slightly higher adjusted prevalence of overweight than did veterans in general (42.3% vs. 39.6%, respectively) but a lower adjusted prevalence of obesity (20.1% vs. 33.1%). In adjusted logistic regression, age, smoking, and lower levels of pain were associated with a lower likelihood of overweight or obesity. Being male, married, employed and having arthritis and diabetes were associated with a greater likelihood of overweight or obesity. Conclusions:Overweight and obesity are a problem for more than 60% of veterans with MS in the VA. Screening for overweight and obesity should be done routinely. Interventions to prevent and manage excessive weight in individuals with MS should be developed and evaluated.

University of Washington Self-Efficacy Scale: A New Self-Efficacy Scale for People With Disabilities

OBJECTIVE To develop a self-efficacy scale for people living with multiple sclerosis (MS) and spinal cord injury (SCI) that can be used across diagnostic conditions. DESIGN The scale was developed using modern psychometric methods including item response theory. Items were administered at 3 time-points of a longitudinal survey of individuals with MS and SCI. SETTING Survey participants with MS were recruited from the National MS Society, and participants with SCI were recruited from the Northwest Regional Spinal Cord Injury Model System and the Shepherd Center at the Virginia Crawford Research Institute in Atlanta, GA. PARTICIPANTS Adults aged 18 years and older reporting a definitive diagnosis of MS (N=473) or SCI (N=253). INTERVENTIONS None. MAIN OUTCOME MEASURES Evaluation of the new self-efficacy measure called the University of Washington Self-Efficacy Scale (UW-SES) included comparisons with the Chronic Disease Self-Efficacy Scale and other patient-reported outcome measures. RESULTS UW-SES has excellent psychometric properties including well-functioning response categories, no floor effects, and low ceiling effects. A long form (17 items) and a short form (6 items) are available. The correlation between the score on the newly developed scale and the Chronic Disease Self-Efficacy Scale was high (.83), providing support for convergent validity. Higher self-efficacy scores were statistically significantly associated with better mental health, better physical health, less fatigue, less stress, less pain interference, less pain, fewer sleep problems, and lower depressive symptoms. CONCLUSIONS The UW-SES is a psychometrically sound instrument for measuring self-efficacy, validated in MS and SCI, and can be used across both conditions. Both the long form and the short form are available free of charge.

Do Somatic and Cognitive Symptoms of Traumatic Brain Injury Confound Depression Screening

OBJECTIVE To evaluate whether items of the Patient Health Questionnaire 9 (PHQ-9) function differently in persons with traumatic brain injury (TBI) than in persons from a primary care sample. DESIGN This study was a retrospective analysis of responses to the PHQ-9 collected in 2 previous studies. Responses to the PHQ-9 were modeled using item response theory, and the presence of DIF was evaluated using ordinal logistic regression. SETTING Eight primary care sites and a single trauma center in Washington state. PARTICIPANTS Participants (N=3365) were persons from 8 primary care sites (n=3000) and a consecutive sample of persons with complicated mild to severe TBI from a trauma center who were 1 year postinjury (n=365). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE PHQ-9. RESULTS No PHQ-9 item demonstrated statistically significant or meaningful DIF attributable to TBI. A sensitivity analysis failed to show that the cumulative effects of nonsignificant DIF resulted in a systematic inflation of PHQ-9 total scores. Therefore, the results also do not support the hypothesis that cumulative DIF for PHQ-9 items spuriously inflates the numbers of persons with TBI screened as potentially having major depressive disorder. CONCLUSIONS The PHQ-9 is a valid screener of major depressive disorder in people with complicated mild to severe TBI, and all symptoms can be counted toward the diagnosis of major depressive disorder without special concern about overdiagnosis or unnecessary treatment.

Use of cognitive aids and other assistive technology by individuals with multiple sclerosis

Purpose. To investigate the use of assistive technology (AT), unmet needs for AT, and examine correlates of use of memory aids and cognitive strategies among individuals with multiple sclerosis (MS). Method. A cross-sectional study of 1,063 community dwelling adults with MS in Washington State. A self-report survey assessed use of AT as well as depression, fatigue, mobility, and other demographic and disease related variables. Results. Some 70% of respondents reported using memory strategies and 50.7% reported using electronic memory aids. The strongest correlate of use of electronic memory aids was endorsement of difficulties thinking (OR: 2.09, p < 0.001) though younger age, higher education, and report of higher fatigue were also significant. Fatigue (OR: 1.27, p < 0.001) and depression (OR: 0.89, p < 0.001) were highly associated with use of memory strategies. Subjects who were older, unemployed, more depressed, and have more mobility disability were less likely to use memory strategies. Conculsions. Use of AT for memory is widespread and further research should be conducted on efficacy of AT. Many individuals who might be presumed to need AT for memory most (older, less educated, more disability) are least likely to report use. Healthcare providers are urged to ask about memory AT and make appropriate referrals.

Beyond fatigue: Assessing variables associated with sleep problems and use of sleep medications in multiple sclerosis

Background: Recent research indicates that sleep disturbances are common in persons with multiple sclerosis (MS), though research to date has primarily focused on the relationship between fatigue and sleep. In order to improve treatment of sleep disorders in MS, a better understanding of other factors that contribute to MS sleep disturbance and use of sleep medications in this population is needed. Methods: Individuals with MS (N = 473) involved in an ongoing self-report survey study were asked to report on use of over-the-counter and prescription sleep medications. Participants completed the Medical Outcomes Study Sleep (MOSS) scale and other common self-report symptom measures. Multiple regression was used to evaluate factors associated with sleep problems and descriptive statistics were generated to examine use of sleep medications. Results: The mean score on the MOSS scale was 35.9 (standard deviation, 20.2) and 46.8% of the sample had moderate or severe sleep problems. The majority of participants did not use over-the-counter (78%) or prescription (70%) sleep medications. In a regression model variables statistically significantly associated with sleep problems included depression, nighttime leg cramps, younger age, pain, female sex, fatigue, shorter duration of MS, and nocturia. The model explained 45% of the variance in sleep problems. Of the variance explained, depression accounted for the majority of variance in sleep problems (33%), with other variables explaining significantly less variance. Conclusions: Regression results indicate that fatigue may play a minor role in sleep disturbance in MS and that clinicians should consider the interrelationship between depression and sleep problems when treating either symptom in this population. More research is needed to explore the possibility of under-treatment of sleep disorders in MS and examine the potential effectiveness of nonpharmaceutical treatment options.

Validation study of prevalence and correlates of depressive symptomatology in multiple sclerosis

OBJECTIVE To validate previous research findings on the prevalence of and factors associated with depressive symptoms in a community-dwelling sample of individuals with multiple sclerosis (MS). METHOD A cross-sectional survey study of 530 individuals with MS from Eastern Washington (EW) was conducted and compared to a previous cross-sectional survey study of 738 individuals with MS from Western Washington (WW). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D), and multivariate logistic regression was employed to detect related factors. RESULTS Prevalence of depressive symptoms was similar in both populations (EW 51%, WW 45%). Factors associated with a clinically significant level of depressive symptoms (CES-D > or =16) in both groups were greater disease severity, shorter disease duration, lower education and less social support (all P<.01). Lower age was also associated with a significant level of depressive symptoms in the WW but not in the EW sample. CONCLUSIONS Despite differences in disease-related and demographic factors, predictors of depressive symptoms were highly similar in both MS study populations.