Darlene Stough

A Home-Based Walking Program Using Rhythmic Auditory Stimulation Improves Gait Performance in Patients With Multiple Sclerosis: A Pilot Study

Background. Few interventions have been successful in improving gait dysfunction in patients with multiple sclerosis (MS). Rhythmic auditory stimulation (RAS) has demonstrated positive results on gait performance in other neurologically impaired populations. Objective. To measure the effects of RAS on quantitative walking parameters in ambulatory patients with MS. Methods. Ten MS patients with gait disturbance were randomly assigned to receive RAS versus no intervention for 2 weeks. All participants received RAS for another 2 weeks. Between weekly clinic visits, they were provided with MP3 players containing songs whose tempo was 10% above the participant’s spontaneous cadence and were instructed to walk to the music 20 minutes daily. Quantitative gait parameters were measured using the GAITRite system. Results. A statistically significant decrease between groups was found for change in double-support time (left, P = .0176; right, P = .0247), whereas trends with medium to high effect sizes were found for other gait parameters, including walking speed. A pooled within-group analysis showed significant improvement of cadence, stride length, step length, velocity, and normalized velocity after 1 week of treatment. Satisfaction level with RAS was high. Conclusions. These results in a convenience sample of MS patients demonstrate the feasibility and safety of RAS when used at home and suggest a potential benefit on gait parameters.

Intrathecal baclofen for spasticity-related pain in amyotrophic lateral sclerosis: Efficacy and factors associated with pain relief

Clinical signs and symptoms of spasticity include hypertonia, involuntary movements (spasms, clonus), decreased range of motion, contractures, and often spasm‐related pain. When spasticity is refractory to medical management, patients may be referred for intrathecal baclofen (ITB) pump placement. We reviewed a cohort of amyotrophic lateral sclerosis (ALS) patients with intractable spasticity requiring ITB to further define the impact of ITB on pain relief in this patient population. From 2003 to 2005, eight patients (mean age 43.8 years; 5 men, 3 women) with ALS received ITB for pain associated with intractable spasticity at our institution. Mean disease duration preoperatively was 47.4 months, mean follow‐up was 9.8 months, and pain was evaluated using a 0–10 scoring system. All patients experienced spasticity relief in response to a preoperative bolus test injection of ITB (25–50 μg) via lumbar puncture. Following ITB pump placement, the average reduction of pain was 54% (P = 0.0082). Six patients (75%) experienced pain score reduction, three of whom had complete pain relief. Postoperative pain reduction was predicted by the degree of pain reduction following preoperative ITB test injection. These results support ITB as a treatment modality for pain associated with spasticity in ALS. Muscle Nerve, 2007

The multiple sclerosis performance test (MSPT): An iPad-based disability assessment tool

Precise measurement of neurological and neuropsychological impairment and disability in multiple sclerosis is challenging. We report a new test, the Multiple Sclerosis Performance Test (MSPT), which represents a new approach to quantifying MS related disability. The MSPT takes advantage of advances in computer technology, information technology, biomechanics, and clinical measurement science. The resulting MSPT represents a computer-based platform for precise, valid measurement of MS severity. Based on, but extending the Multiple Sclerosis Functional Composite (MSFC), the MSPT provides precise, quantitative data on walking speed, balance, manual dexterity, visual function, and cognitive processing speed. The MSPT was tested by 51 MS patients and 49 healthy controls (HC). MSPT scores were highly reproducible, correlated strongly with technician-administered test scores, discriminated MS from HC and severe from mild MS, and correlated with patient reported outcomes. Measures of reliability, sensitivity, and clinical meaning for MSPT scores were favorable compared with technician-based testing. The MSPT is a potentially transformative approach for collecting MS disability outcome data for patient care and research. Because the testing is computer-based, test performance can be analyzed in traditional or novel ways and data can be directly entered into research or clinical databases. The MSPT could be widely disseminated to clinicians in practice settings who are not connected to clinical trial performance sites or who are practicing in rural settings, drastically improving access to clinical trials for clinicians and patients. The MSPT could be adapted to out of clinic settings, like the patient’s home, thereby providing more meaningful real world data. The MSPT represents a new paradigm for neuroperformance testing. This method could have the same transformative effect on clinical care and research in MS as standardized computer-adapted testing has had in the education field, with clear potential to accelerate progress in clinical care and research.

Efficacy and Safety of a Hip Flexion Assist Orthosis in Ambulatory Multiple Sclerosis Patients

OBJECTIVE To evaluate the efficacy and safety of a hip flexion assist orthosis (HFAO) in ambulatory patients with multiple sclerosis (MS). DESIGN Fourteen week pre- and postintervention uncontrolled trial. SETTING Outpatient rehabilitation clinic within an MS center. PARTICIPANTS Ambulatory MS patients (N=21) with unilateral (or unilateral predominant) hip flexor weakness. INTERVENTION Subjects were fitted with the HFAO on the weaker side, trained to use the device, and given a wear schedule. Subjects completed 2 baseline evaluations and follow-up testing at 8 and 12 weeks. MAIN OUTCOME MEASURES Lower-extremity manual muscle testing, pain, and gait performance (Timed 25-Foot Walk, Timed Up & Go, 6-minute walk test, Mellen Center Gait Test). Subject satisfaction was evaluated by using a 9-item custom questionnaire. RESULTS There was a statistically significant improvement of strength in the affected lower extremity at 8 and 12 weeks (effect size [ES]=0.63; ES=1.32, respectively), of pain at 12 weeks only (ES=-0.64), and of all gait tests at 8 and 12 weeks (ES range, 0.38-1.33). The overall mean satisfaction score at 12 weeks was 39 (maximum score, 45). No serious adverse events were recorded during the study. The most frequent side effect of the HFAO was low back pain (19%). No side effects led to discontinuation of the HFAO use during the study. CONCLUSIONS The HFAO was safe and well tolerated. HFAO use was associated with significant improvement of gait performance as well as improvement of strength in the lower extremity fitted with the HFAO. Subjective reports suggest that there was an increase in daily life activity level.

Prevalence of Stress Urinary Incontinence in Women with Multiple Sclerosis

Purpose The purpose of this study was to determine the prevalence of stress urinary incontinence (SUI) in women with multiple sclerosis (MS) and to what degree these women are bothered by their SUI, since there is a paucity of literature regarding the nature of SUI in this unique population of women. Methods We conducted a prospective Institutional Review Board approved study. Women scheduled for outpatient follow-up appointments at a dedicated MS center were asked to complete a questionnaire regarding urinary incontinence. Urgency urinary incontinence (UUI) and SUI were defined as an answer of slightly, moderately or greatly to the Urogenital Distress Inventory (UDI-6) question #2 and question #3, respectively. Impact of SUI on physical activity was determined by Incontinence Impact Questionnaire (IIQ-7) question #2. Results A total of 55.9% (80/143) women had SUI, 70.6% (101/143) women had UUI, and 44.8% (64/143) women had mixed urinary incontinence. The mean age was 45.8 years old (range, 20 to 72 years). Women with SUI were significantly older (mean, 47.2 vs. 41.9; P=0.023) and there was a trend towards a greater body mass index (mean, 29.3 vs. 26.5; P=0.057). Women with SUI had significantly higher IIQ-7 scores compared to women without SUI (P<0.001). Impact of urinary incontinence on physical activity was also found to be significantly greater in women with SUI (mean IIQ-7 question #2, 0.96 vs. 0.35; P<0.001). Conclusions The prevalence of SUI in women with MS is 55.9% and the presence of SUI has a significant impact on their quality of life. A comprehensive urologic evaluation of a woman with MS should include assessment of SUI.

Use of Intrathecal Baclofen for Treatment of Severe Spasticity in Selected Patients With Motor Neuron Disease

Objective. To assess the safety and efficacy of intrathecal baclofen (ITB) therapy for severe spasticity in patients with upper–motor neuron predominant motor neuron disease (U-MND). Methods. A total of 44 patients with U-MND were referred for discussion of ITB therapy. Baseline and outcomes data were extracted on 35 patients from a clinical spasticity registry at a tertiary referral center. Patients choosing to initiate ITB (n = 20) were compared with those choosing conservative therapy (n = 15). Results. At baseline, lower average pain score in the non-ITB group was the only significant difference between the 2 groups. A significant reduction in pain scores, Modified Ashworth Scale (MAS), Spasm Frequency Scale, and requirement for oral spasticity medications was observed within the ITB group at early and late follow-up. Within the non-ITB group, there was a significant increase in MAS scores between baseline and late follow-up. A statistically significant difference favoring the ITB group was observed for change in MAS score (P < .0001), Numerical Rating Scale pain score (P = .04), dose of oral baclofen (P = .002) and tizanidine (P = .003), and number of oral medications for spasticity (P = .002). There was no difference between the 2 groups in the progression of hip flexor weakness or in the proportion of patients who became nonambulatory. Conclusions. Our findings suggest that ITB can effectively reduce spasticity and related symptoms without compromising function in selected patients with U-MND.

Poster 25: Intrathecal baclofen therapy in ambulatory patients with multiple sclerosis: effect on gait speed

Abstract Objective: To evaluate whether intrathecal baclofen (ITB) therapy causes a decrease in gait speed in ambulatory patients with multiple sclerosis (MS). Design: Longitudinal pre-post intervention study (24-wk follow-up). Setting: Spasticity clinic within a large outpatient comprehensive care center for MS. Participants: Patients with intractable lower-extremity spasticity, definitively diagnosed with MS and able to walk at least 25ft with or without support. Intervention: Implantation of a programmable ITB infusion system. All patients received inpatient and/or outpatient physical therapy after surgery. Main Outcomes Measure: Gait speed calculated from the Timed 25-Foot Walk. Results: 8 patients were analyzed (75% women; mean age, 37.4±6.1y; mean disease duration, 9.7±7.9y; median Expanded Disability Status Scale [EDSS] score, 6.5). There was no significant change in EDSS score during the study. There was statistically significant improvement of Modified Ashworth Scale scores between baseline and all follow-up visits. There was no statistically significant change in gait speed. Average gait speed was .48±.35m/s at baseline, .46±.41m/s at 4 weeks, .41±.37m/s at 12 weeks, and .48±.40m/s at 24 weeks. Conclusions: Our results suggest that ITB therapy improves severe spasticity, but does not affect gait speed measured on a short distance in ambulatory MS patients, up to 6 months after surgery. Further study is needed to assess the effect of ITB on gait endurance, gait quality, and patient quality of life.

Poster 260 Intrathecal Baclofen for Severe Spasticity in Patients With Upper Motor Neuron Disease

cepts as well as general questions about physiatry. Setting: This study was conducted at a private medical school in the Chicago area. Participants: The participants were firstand second-year medical students who attended the Musculoskeletal and Neuromuscular lecture day of their Physical Diagnosis class, respectively. Interventions: Each medical student class was given a pretest questionnaire to evaluate their baseline knowledge. Each class received a 1-hour physiatry-based lecture on basic concepts of either the musculoskeletal examination for first-years medical students or the neuromuscular examination for second-year medical students. The class was then divided into small groups, and the students attended a 2-hour hands-on interactive experience with physiatry residents to practice performing their physical examination skills. Main Outcome Measures: The participants of each class were administered an identical questionnaire, first as a pretest questionnaire and then as a posttest questionnaire. The posttest results were compared to the pretest results. Results: The average for first-year medical students’ posttest results improved by 24%, and the average for second-year medical students’ posttest results improved by 14%. In addition, 11 secondyear medical students and 15 first-year medical students requested more information about PM&R. Conclusions: This study indicates that a physiatry-based lecture and an interactive experience with physiatrists is an effective way to teach medical students the musculoskeletal and neuromuscular examination and introduce them to the field of PM&R. A moreeffective approach to teaching students may include exposing medical students to PM&R during their first year of medical school by teaching the musculoskeletal examination and then returning during their second year to teach the neuromuscular examination.