Mohammed Sanjak

Quality improvement in neurology: Amyotrophic lateral sclerosis quality measures Report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology

Amyotrophic lateral sclerosis (ALS) is a lethal, progressive neurodegenerative disease characterized by loss of motor neurons.1 Patients with ALS lose function in the limbs, speech, swallowing, and breathing muscles. The cause of the disease is still not known for most patients. Approximately 25,000 people in the United States have ALS, and 5,000 people are diagnosed with ALS annually in the United States.1 Most patients die from respiratory failure 2 to 5 years after onset of symptoms. Cognitive dysfunction is seen in 20% to 50% of patients.2 The disease burden for patients and caregivers is enormous. The average cost of care has been estimated at

Supported Treadmill Ambulation for Amyotrophic Lateral Sclerosis: A Pilot Study

50,000 per patient per year.3

Parkinson patients as partners in care

OBJECTIVES To determine the feasibility, tolerability, safety, and exercise treatment-effect size of repetitive rhythmic exercise mediated by supported treadmill ambulation training (STAT) for patients with amyotrophic lateral sclerosis (ALS). DESIGN Interventional with repeated-measures design. SETTING Multidisciplinary ALS clinic at academic medical center. PARTICIPANTS Convenience sample of patients with ALS (N=9) who were ambulatory with assistive devices (Sinaki-Mulder stages II-III). INTERVENTIONS Repetitive rhythmic exercise-STAT (30min total; 5min of exercise intercalated with 5min of rest) performed 3 times a week for 8 weeks. MAIN OUTCOME MEASURE ALS Functional Rating Scale-Revised (ALSFRS-R), percentage of predicted vital capacity (VC), total lower-extremities manual muscle test (MMT), rate of perceived exertion (RPE), Fatigue Severity Scale (FSS), and maximum voluntary isometric contraction (MVIC) in 10 lower and 10 upper extremities. Gait performance, which included walking distance, speed, steps, and stride length, was evaluated during treadmill and ground 6-minute walk tests (6MWTs) and 25-foot walk test (25FWT). RESULTS Feasibility issues decreased screened participants by 4 patients (31%). Nine patients were enrolled, but 6 patients (67%) completed the study and 3 (23% of original cohort; 33% of enrolled cohort) could not complete the exercise intervention because of non-ALS-related medical problems. Tolerability of the intervention measures during the treadmill 6MWT showed improvement in RPE (P≤.05) and FSS score (P≥.05). Safety measures (ALSFRS-R, VC, MMT) showed no decrease and showed statistical improvement in ALSFRS-R score (P≤.05) during the study interval. Exercise treatment-effect size showed variable improvements. Gait speed, distance, and stride length during the treadmill 6MWT improved significantly (P≤.05) after 4 weeks and improvements were maintained after 8 weeks compared with baseline. Walking distance during the ground 6MWT increased significantly after 4 weeks and was maintained after 8 weeks compared with baseline (P≤.05). Walking speed during the 25FWT and lower-extremity MVIC improved, but were not statistically significant. CONCLUSIONS Repetitive rhythmic exercise-STAT is feasible, tolerated, and safe for patients with ALS. Repetitive rhythmic exercise-STAT treatment-effect size across a number of ALS-related measures was consistent with improved work capacity and gait function in patients with ALS who are dependent on assistive devices for ambulation. Repetitive rhythmic exercise-STAT should be evaluated further in larger studies to determine the stability of this improved function in relation to the rate of progression of the underlying ALS.

Quality improvement in neurology: Amyotrophic Lateral Sclerosis Quality Measures

Increasing physical activity, as part of an active lifestyle, is an important health goal for individuals with Parkinsons disease (PD). Exercise can positively impact health related quality of life. Given this, how can we promote physically active lifestyles among PD patients (most of whom are sedentary)? Here we suggest that health care professionals could significantly expand their impact by collaborating with PD patients and their spouses (or caregivers) as partners-in-care. We outline reasons why partners-in-care approaches are important in PD, including the need to increase social capital, which deals with issues of trust and the value of social networks in linking members of a community. We then present results of a qualitative study involving partners-in-care exercise beliefs among 19 PD patients and spouses, and conclude with our perspective on future benefits of this approach.

Motor Neuron Disease

Original publication: “Quality improvement in neurology: Amyotrophic Lateral Sclerosis Quality Measures”, November 2013, Neurology Print ISSN: 0028-3878. Online ISSN: 1526-632X.

Surgeon fatigue and postural stability: is robotic better than laparoscopic surgery?

For over a century, the clinical and pathological essentials of motor neuron degeneration have been described [1]. Yet to this date, no cogent, easily applied quantiative description of the course of motor neuron degeneration has been forthcoming [2]. A complete understanding of the clinical features of motor neuron disease, both in the individual and within a group of affected individuals, is necessary for the optimal conduct of therapeutic trials. Precise endpoints are required to permit statistical planning of clinical trials, which will include determination of sample size, trial duration, and mode of analysis. In this chapter we will review the strategies to be applied when determining the best measures of change in individual patients or groups of patients with motor neuron disease over different time periods. We will also analyze the different statistical needs of individual case studies and parallel placebo-controlled case studies.

Disease‐modifying drug therapies

OBJECTIVE To compare muscular fatigue and postural stability of surgeons before and after laparoscopic and robotic surgery. SUBJECTS AND METHODS The design of this study is Class II. A consecutive cohort of patients presenting at an academic tertiary-care center for scheduled gynecologic surgery was used. Routine surgical care was examined with testing of surgeon fatigue and postural measures before and after the procedure. Motor fatigue was measured using a quantitative grip dynamometer, and postural stability was measured using a nondominant, single-leg stance. A subjective fatigue score was recorded following surgery. RESULTS Primary surgeons completed testing before and after 56 surgeries. A trend toward decline in postural stability was observed more in the laparoscopy group than in the robotic group (P=.29). The fatigue index and subjective fatigue scores were not significantly different. CONCLUSIONS Similar changes in postural stability and muscular strength were observed following laparoscopic and robotic surgery. The optimal measurement tool to capture surgical fatigue remains elusive. Fatigue differences may have been more pronounced if surgical procedure degree of difficulty had been more consistent between groups.

Six-Minute Walk Test as a Measure of Walking Capacity in Ambulatory Individuals With Amyotrophic Lateral Sclerosis

The development of the disease modifying drug, riluzole, is changing the natural history of amyotrophic lateral sclerosis (ALS). Let us take the ‘classic’ ALS patient as portrayed by ALS CARE-Wisconsin (Tables 1 and 2). When ALS patients come to see us, many are already on vitamin E, as we have seen in our clinic population, and then within a short period of time they are put on a number of therapies. The main one is, of course, riluzole, the only approved disease-modifying agent for ALS at this time (Figures 1 and 2).

Promoting exercise in Parkinson's disease through community-based participatory research.

OBJECTIVE To determine the validity of the 6-minute walk test (6MWT) as an outcome measure to evaluate walking capacity in ambulatory patients with amyotrophic lateral sclerosis (ALS). DESIGN Observational study. SETTING Multidisciplinary ALS clinic at an academic medical center. PARTICIPANTS Patients with ALS (N=186) who ambulate without (stage I) or with (stage II) an assistive device. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Walking distance obtained from the 6MWT. RESULTS Participants performed the 6MWT, 25-foot walk test (25FWT), Timed Up and Go (TUG) test, lower extremity maximum voluntary isometric contraction (MVIC), ALS Functional Rating Scale-Revised (ALSFRS-R), and forced vital capacity (FVC). Walking capacity was reduced to 66% predicted of healthy subjects (75.2%±22% in stage I; 42.6%±22% in stage II). The 6MWT correlated with all other outcome measures in ambulatory patients with ALS (25FWT: r=-.74, P≤.0001; TUG test: r=-.80, P≤.0001; MVIC: r=.64, P≤.0001; percent predicted FVC: r=.25, P≤.0007; ALSFRS-R: r=.52, P≤.0001; ALSFRS-R gross motor subscore: r=.71, P≤.0001). When ambulatory patients with ALS were stratified by stage of ambulation, the 6MWT was associated with all other outcome measures in stage I (25FWT: r=-.56, P≤.0001; TUG test: r=-.66, P≤.0001; MVIC: r=.51, P≤.0001; percent predicted FVC: r=.40, P≤.02; ALSFRS-R: r=.52, P≤.0001; ALSFRS-R gross motor subscore: r=.61, P≤.0001). In stage II, the 6MWT correlated with the 25FWT (r=-.83, P≤.0001), TUG test (r=-.77, P≤.0001), MVIC (r=.47, P≤.0001), and ALSFRS gross motor subscore (r=.61, P≤.0001), but not with percent predicted FVC (r=.09, P≤.513) or ALSFRS-R (r=.21, P≤.141). CONCLUSIONS The 6MWT is a valid measure of walking capacity of ambulatory patients with ALS that is associated with measures of lower extremity muscle strength and function in both stages of ambulation. The discordance between the 6MWT with the ALSFRS-R and percent predicted FVC in stage II ambulatory patients with ALS indicates that the 6MWT is an independent measure of ambulatory function in both stages of ambulation. The 6MWT may provide a quantitative, simple, and inexpensive outcome measure of walking capacity for early stage clinical trials in ambulatory patients with ALS.