Matthew Sutliff

Contribution of impaired mobility to patient burden in multiple sclerosis

Abstract Background: Multiple sclerosis (MS) is frequently diagnosed during a person’s most productive years, and because life expectancy for patients with MS approaches that of the general population, MS is associated with a considerable economic burden from medical costs and lost productivity. In addition, there is a substantial negative impact on quality of life (QOL) and activities of daily living (ADL). While change in walking ability often is the most visible sign of MS, and the classic clinical manifestation, few studies have evaluated the relationship between mobility impairment and patient-reported outcomes like ADL and QOL. The purpose of this article is to review the contribution of mobility impairment to patient-reported outcomes in persons with MS. Methods: Searches of PubMed were performed to identify studies from the MS literature, from January 1980 through November 2008, that evaluated the contribution of mobility to the patient burden of disease. Abstracts identified using the search terms ‘multiple sclerosis AND (walking OR mobility)’ in combination with the terms ‘burden,’ ‘costs,’ ‘quality of life,’ ‘activities of daily living,’ ‘independence,’ and ‘productivity’ were reviewed for relevancy for inclusion. Findings: Although impaired mobility is more apparent with greater disease duration and at higher levels of disability, it may be present even in the early stages of MS. Maintaining mobility is ranked as one of the highest priorities among patients with MS, regardless of disease duration or disability level. Several studies have demonstrated that loss of mobility contributes to a substantial patient burden. The statistical technique of path analysis has shown how difficulty walking significantly affects physical activity in patients with MS. Impaired mobility is associated with reductions in QOL, ADL, and productivity. The primary concern related to patient independence among persons with MS, regardless of their status, is loss of mobility. It should be noted that limitations inherent in some of the studies, including heterogeneity in methodology and MS populations, may limit their generalizability. Conclusion: These findings highlight the need for more comprehensive assessments of walking impairment in patients with MS and further evaluation from the patient’s perspective.

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

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.

Rehabilitation in multiple sclerosis: Commentary on the recent AAN systematic review

Multiple sclerosis (MS) is one of the most common causes of nontraumatic neurologic disability in young adults in the United States. Historically, MS care focused on rehabilitation and symptomatic management; however, this focus broadened with the development of disease-modifying therapies (DMTs), resulting in pharmacologic treatments that effectively reduce relapses and potentially slow the progression of disability. Consequently, DMTs often dominate many discussions regarding MS care, regardless of the fact that they do not reverse disability or restore function, arguably the primary goal of those with MS. Comprehensive, multidisciplinary care goes beyond the management of DMTs in MS treatment plans and strives to improve patient outcomes, functionality, and quality of life, goals that will likely prove to hold considerable importance as health care reimbursement transitions from a fee-for-service to a value-based paradigm. It is therefore likely that achieving improvement in some of the outcomes delineated in the American Academy of Neurologys (AAN) quality measures for MS will necessitate involvement of rehabilitation specialists.1

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.