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Background: Obstructive sleep apnea (OSA) screening questionnaires have been evaluated in Multiple Sclerosis (MS) but not yet validated in patients with advanced disease. The aim of this study is to identify OSA predictive factors in advanced MS and to discuss screening strategies., Methods: Oximetry data from 125 patients were retrospectively derived from polysomnographic reports. Univariate and multivariate analysis were used to determine predictive factors for OSA. A two-level screening model was assessed combining the oxygen desaturation index (ODI) and a method of visual analysis., Results: multivariate analysis showed that among the clinical factors only age and snoring were associated with OSA. Usual predictive factors such as sleepiness, Body mass index (BMI) or sex were not significantly associated with increased Apnea Hypopnea Index (AHI). The ODI was highly predictive (p < 0.0001) and correctly identified 84.1 % of patients with moderate OSA and 93.8 % with severe OSA. The visual analysis model combined with the ODI did not outperform the properties of ODI used alone., Conclusion: As the usual clinical predictors are not associated with OSA in patients with advanced MS, questionnaires developed for the general population are not appropriate in these patients. Nocturnal oximetry seems a pertinent, ambulatory and accessible method for OSA screening in this population., Competing Interests: Declaration of competing interest The Authors declares that there is no conflict of interest in relation to this work., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Fatigue is a disabling symptom of multiple sclerosis (MS). The lack of effective therapeutics has promoted the development of cognitive behavioural therapy (CBT)-based fatigue management programmes. However, their efficacy does not sustain over time. We proposed to test the long-term effectiveness of a 6-week fatigue programme supplemented with four booster sessions ('FACETS+') in patients with relapsing remitting MS (RRMS) and fatigue., Methods: This multicentre, randomised, controlled, open-label, parallel-group trial versus standard care enrolled patients with RRMS and fatigue. Participants were randomised to either FACETS+ plus standard care or standard care alone. The primary outcome measure was fatigue impact (Modified Fatigue Impact Scale (MFIS) at 12 months) based on intention-to-treat analyses., Results: From May 2017 to September 2020, 162 patients were screened; 105 were randomly assigned to FACETS+ (n=57) or standard care (n=48) and 88 completed the primary outcome assessment for the MFIS. At month 12, participants showed improved MFIS compared with baseline in the intervention group (mean difference (MD)=14.0 points; (95% CI 6.45 to 21.5)) and the control group (MD=6.1 points; (95% CI -0.30 to 12.5)) with a significant between-group difference in favour of the intervention group (adjusted MD=7.89 points; (95% CI 1.26 to 14.52), standardised effect size=0.52, p=0.021). No trial-related serious adverse events were reported., Conclusions: A 6-week CBT-based programme with four booster sessions is superior to standard care alone to treat MS-related fatigue in the long term (12 months follow-up). The results support the use of the FACETS+ programme for the treatment of MS-related fatigue., Trial Registration Number: NCT03758820., Competing Interests: Competing interests: OH has competing interests with Bayer Schering, Merck, Teva, Genzyme, Novartis and BiogenIdec (support for attending meeting or travel, and consulting fees). The other authors have no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There are limited real-world data on the use of botulinum toxin type A (BoNT-A) in patients with multiple sclerosis (MS). Accordingly, this nationwide, population-based, retrospective cohort study aimed to describe BoNT-A treatment trends in patients with MS between 2014 and 2020 in France. This study extracted data from the French National Hospital Discharge Database ( Programme de Médicalisation des Systèmes d'Information , PMSI) covering the entire French population. Among 105,206 patients coded with MS, we identified those who received ≥1 BoNT-A injection, administered within striated muscle for MS-related spasticity and/or within the detrusor smooth muscle for neurogenic detrusor overactivity (NDO). A total of 8427 patients (8.0%) received BoNT-A injections for spasticity, 52.9% of whom received ≥3 BoNT-A injections with 61.9% of the repeated injections administered every 3 to 6 months. A total of 2912 patients (2.8%) received BoNT-A injections for NDO, with a mean of 4.7 injections per patient. Most repeated BoNT-A injections within the detrusor smooth muscle (60.0%) were administered every 5 to 8 months. There were 585 patients (0.6%) who received both BoNT-A injections within striated muscle and the detrusor smooth muscle. Overall, our study highlights a broad range of BoNT-A treatment practices between 2014 and 2020 in patients with MS.

Spasticity is one of the most disabling symptoms in multiple sclerosis (MS). Botulinum toxin injection (BTI) is a first-line treatment for focal spasticity. There is a lack of evidence of a functional improvement following BTI in MS-related spasticity. To describe goal-setting for BTI in MS, and evaluate the degree of attainment, using goal attainment scaling (GAS) 4-to-6 weeks after injection session, a one-year multi-center retrospective observational study assessing goal-setting and achievement during BTI session in spastic patients with MS was set up. Following the GAS method, patients and their physicians set up to three goals and scored their achievement 4 to 6 weeks thereafter. Commonly used goals from three centers were combined into a standardized list and 125 single BTI sessions were analyzed. The most frequent goals regarded lower limb (LL) impairments (equinovarus foot, toe claw) or locomotion (stability, walking distance, clinging) and accounted for 89.1%, versus 10.9% for upper limb (UL), mostly for mild-to-moderate MS. Overall, goals were frequently achieved (85.77%) mainly when related to gait and mobility rather than hygiene and ease of care. This study gives an overview on the most frequent, relevant, and achievable goals to be set in real-life practice of BTI for spasticity management in MS.

Introduction: Motor and swallowing dysfunctions in multiple sclerosis (MS) unbalance calorie intake and energy expenditure, modifying nutritional status. Only one study has described nutritional status in MS patients at early disease stages (median Expanded Disability Status Scale [EDSS] = 3), but this has never been assessed in the most severe cases. The goal of the present study was to describe nutritional status in advanced-stage MS., Methods: The study was a non-interventional retrospective analysis of a prospective registry. We reviewed medical files of consecutive MS patients admitted for annual follow-up in a physical and rehabilitation medicine unit between May 2016 and October 2018. Malnutrition for frail people, according to the French Health Authority (Haute Autorité de Santé [HAS]) definition, was our composite primary outcome criterion: body mass index (BMI) <21 kg/m 2 and/or albumin<35 g/L. First, we performed a descriptive analysis of the nutritional status. Second, we studied the association between malnutrition and MS characteristics in univariate and multivariate analyses., Results: A total of 163 patients with median EDSS = 8 [7; 8.5] were included. Ninety-three patients (57%) met HAS malnutrition criteria (36% with albumin <35 g/L, 31% with BMI <21 kg/m 2 and 10% with both). Malnutrition was associated in univariate analysis with MS severity (EDSS ≥8.5, p = 0.0003), primary progressive type of MS (p = 0.01) and swallowing disorders (p = 0.002). Multivariate analysis showed that low disability status (EDSS <7) was the only independent (protective) factor associated with malnutrition (OR = 0.2, p = 0.03)., Conclusions: Malnutrition is frequent in advanced stages of MS and is probably a key point for therapeutics, which has never been demonstrated previously. A standardized evaluation should be developed to improve nutritional therapeutic strategies in this population., (© 2022 European Academy of Neurology.)

Objective: Fatigue and fatigability are common problems in patients with multiple sclerosis, which might be improved by rehabilitation. The aim of this pilot study was to assess changes in the fatigue and fatigability of knee extensors in patients with multiple sclerosis after a short intensive, combined rehabilitation programme (including physiotherapy primarily focused on gait and balance, endurance and resistance training)., Methods: Twenty-three patients with multiple sclerosis (10 men, 13 women) underwent isokinetic evaluations of fatigability of the knee extensor muscles during concentric contractions and rated a self-reported fatigue scale (Modified Fatigue Impact Scale; MFIS) before and after a rehabilitation programme. Patients performed rehabilitation for 150 min, 4 days per week for 4 weeks, with physiotherapy focused primarily on gait and balance, endurance training and resistance training., Results: After rehabilitation, perception of fatigue decreased significantly (median MFIS scores [1st; 3rd quartiles], pre: 44 [33; 53] vs post: 33.5 [16; 43]; <0.00025). Moment fatigue index increased (pre: 37.70±13.40 vs post: 48.10±9.39; p<0.0125), but end-test moment did not change. After rehabilitation, strength increased during both isometric and concentric contraction (mean first 5 and mean 50 contractions of the fatigue protocol) (p<0.0125). After rehabilitation, neuromuscular efficiency improved (p<0.0125)., Conclusion: After a short, intensive, combined rehabilitation programme, fatigue decreased but fatigability increased (moment fatigue index). Indeed, fatigability increased because strength in the initial state increased and strength in the fatigued state did not change. Although the rehabilitation programme was designed so that resistance training was carried out after endurance training to specifically train muscles in a fatigued state, no improvements in strength in the fatigued state were measured.

Background: Respiratory disorders in multiple sclerosis (MS) are an important issue. They can occur early during the course of the disease, are associated with the neurological impairment, and can lead to pneumonia and respiratory failure, which are the main causes of death in advanced MS. Prevailing impaired expiratory muscles and cough abilities has been demonstrated in this population and might constitute a specific target for rehabilitation interventions. However, international guidelines lack recommendations regarding respiratory rehabilitation in MS. Here we performed a systematic review of the published literature related to respiratory rehabilitation in MS., Methods: We searched the databases MEDLINE via PubMed, PEDro and Cochrane Library for English or French reports of clinical trials and well-designed cohorts published up to December 2016 with no restriction on start date by using the search terms "multiple sclerosis", "respiratory rehabilitation", "respiratory muscle training", "lung volume recruitment", "cough assistance", and "mechanical in-exsufflation". Literature reviews, case reports and physiological studies were excluded. The Maastricht criteria were used to assess the quality of clinical trials. We followed the Oxford Centre for Evidence-Based Medicine guidelines to determine level of evidence and grade of recommendations., Results: Among the 21 reports of studies initially selected, 11 were retained for review. Seven studies were randomized controlled trials (RCTs), 2 were non-RCTs, and 2 were observational studies. Respiratory muscle training (inspiratory and/or expiratory) by use of a portable resistive mouthpiece was the most frequently evaluated technique, with 2 level-1 RCTs. Another level-1 RCT evaluated deep-breathing exercises. All reviewed studies evaluated home-based rehabilitation programs and focused on spirometric outcomes. The disparities in outcome measures among published studies did not allow for a meta-analysis and cough assistance devices were not evaluated in this population., Conclusion: Although respiratory muscle training can improve maximal respiratory pressure in MS and lung volume recruitment can slow the decline in vital capacity, evidence is lacking to recommend specific respiratory rehabilitation programs adapted to the level of disability induced by the disease., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Fatigue is a common problem in patients with multiple sclerosis; however, the impact of neuromuscular and perceived fatigue on locomotor performance is currently unknown in these patients., Aim: The aim of this study was: 1) to determine the relationship between perceived and neuromuscular fatigue and locomotor performance in patients with multiple sclerosis; 2) to determine if neuromuscular and perceived fatigue depend on the severity of the pathology defined by the Expanded disability status scale score (EDSS)., Design: Observational study., Setting: Outpatients from a hospital rehabilitation department., Population: Thirty patients with multiple sclerosis underwent clinical (spasticity, strength, perceived fatigue and locomotor performance) and isokinetic evaluations (peak torque of knee flexor and extensor muscles and neuromuscular fatigue of knee extensor muscles)., Methods: The main outcome measures were perceived and neuromuscular fatigue and locomotor performance. Secondary outcomes were strength of the weakest limb and peak isometric torque of knee flexor and extensor muscles, spasticity, EDSS., Results: There were no significant correlations between perceived or neuromuscular fatigue and locomotor performance. Locomotor performance was correlated with EDSS, spasticity, strength of the weakest limb and peak isometric torque of knee flexor and extensor muscles. Eighty‑three percent of the variance of the 6MWT could be explained by EDSS score, strength of the weakest limb (MRCsum), torque produced during the last five contractions of the fatigue protocol and peak isometric torque of knee flexor muscles. Patients with moderate disability (EDSS Score 4-6) had greater levels of neuromuscular fatigue than patients with mild disability (<4)., Conclusions: Although fatigue is a disabling symptom of multiple sclerosis, and neuromuscular fatigue was found to be higher in more disabled patients, locomotor performance was correlated with strength and spasticity but not with fatigue., Clinical Rehabilitation Impact: Nevertheless, fatigue was related to 6MWT performance since torque produced during the last five contractions of the fatigue protocol was one of the factors which explained performance.

Objective: To compare quadriceps fatigability during maximal concentric contractions in persons with multiple sclerosis (MS) and healthy subjects., Design: Observational study., Setting: Hospital rehabilitation department., Participants: Persons with MS (n=38) and healthy subjects (n=14) were included (N=52). Torque of the knee flexor and extensor muscles and fatigability of the knee extensor muscles were evaluated using an isokinetic device. Surface electromyographic activity of the rectus femoris, vastus lateralis, biceps femoris, and semitendinosus muscles was recorded., Interventions: None., Main Outcome Measure: Muscle fatigability (torque fatigue index)., Results: The torque fatigue index was lower in persons with MS than in healthy subjects, but when torque was normalized to maximal isometric peak torque, persons with MS and healthy subjects finished the fatigue protocol at exactly the same level of relative strength (50% of the maximal isometric peak torque). Moreover, the reduction in torque was primarily because of a reduction in neuromuscular efficiency, with no changes of coactivation of antagonist muscles., Conclusions: Although fatigue is a disabling symptom of MS, persons with MS develop less muscle fatigability than healthy subjects during repeated maximal concentric contractions, but they end up at the same level of relative strength., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Respiratory disorders are a major cause of morbidity and mortality in multiple sclerosis (MS). Mainly reported in walking patients, they are poorly explored when walking is severely impaired. To characterize respiratory impairment in patients with advanced MS., Methods: From 2012 to 2015, patients with MS with an Expanded Disability Status Scale (EDSS) score of ≥7 who were referred for functional and rehabilitation evaluation underwent pulmonary function tests to study lung volumes, cough efficacy and respiratory muscle pressures., Results: Among 73 patients with a median EDSS score of 8 [7.5; 8.5], 72.6% had impaired respiratory function with a mean vital capacity (VC) of 57.9 ± 33.5% of theoretical value. Severe impairment (VC < 50%) was found for 34 (46.6%) patients. Cough was impaired in 45 (61.6%) patients, with a mean cough peak flow of 3.14 ± 1.9 L/s and severe impairment (cough peak flow < 2.67 L/s) in 27 (37.0%) patients. Overall, the results suggested predominant expiratory muscle dysfunction and non-predominant diaphragm impairment. EDSS score was correlated with VC but not with any other clinical data., Conclusion: Restrictive respiratory failure is frequent in severely impaired patients with MS, predominantly involves expiratory muscles, does not involve diaphragm weakness and is associated with cough impairments., (© 2017 EAN.)

Background: Coactivation of agonist and antagonist lower limb muscles during gait stiffens joints and ensures stability. In patients with multiple sclerosis, coactivation of lower limb muscles might be a compensatory mechanism to cope with impairments of balance and gait., Objective: The aim of this study was to assess coactivation of agonist and antagonist muscles at the knee and ankle joints during gait in patients with multiple sclerosis, and to evaluate the relationship between muscle coactivation and disability, gait performance, dynamic ankle strength measured during gait, and postural stability., Methods: The magnitude and duration of coactivation of agonist-antagonist muscle pairs at the knee and ankle were determined for both lower limbs (more and less-affected) in 14 patients with multiple sclerosis and 11 healthy subjects walking at a spontaneous speed, using 3D-gait analysis., Results: In the patient group, coactivation was increased in the knee muscles during single support (proximal strategy) and in the ankle muscles during double support (distal strategy). The magnitude of coactivation was highest in the patients with the slowest gait, the greatest motor impairment and the most instability., Conclusion: Increased muscle coactivation is likely a compensatory mechanism to limit the number of degrees of freedom during gait in patients with multiple sclerosis, particularly when postural stability is impaired.

Wheelchair mobility is a prerequisite to being able to carry out important activities and to participate in social life. Level of satisfaction with the wheelchair and overall quality of life were found to be positively associated. The aim of this study was to determine the level of satisfaction of French manual wheelchair (MW) users and caregivers with MW characteristics. A total of 132 users and 76 caregivers completed a questionnaire about their level of satisfaction with their MW characteristics. Satisfaction scores were independent of age, sex, reason for MW use, and time of use. As a whole, MW users are satisfied. However, a few parameters such as MW weight and difficulties propelling outdoors demonstrate a low level of satisfaction among users. MW weight, brakes, and height of pushing handles are the less satisfying elements among caregivers. In conclusion, the majority of French MW users are satisfied, but some characteristics, such as weight, must be optimized. Considering caregiver needs is paramount when aiming to improve MW parameters such as brakes or pushing handles. Improvement in some wheelchair parameters seems to be important in achieving improved level of satisfaction and increased participation and active lifestyle among MW users and caregivers.

Spasticity is a commonly seen symptom in patients with multiple sclerosis (MS). The vast majority of patients will suffer from this symptom during the course of the disease, and one- third of patients considers that spasticity contributes to a greater part of their disability. The symptom is frequently disabling. It can, however, allow some activities to be performed. Treatment of the symptom is sometimes deleterious, which is why strict assessment of the consequences of spasticity and anticipation of the outcome of antispastic treatment are necessary. Clinical scales, such as the Ashworth and Tardieu scales, are used in clinical practice. The essential element is not, however, assessment of the symptom, but its repercussions on activities of everyday life. It is important to make a list of what patients consider to be disabling situations to verify that they are truly consequences of spasticity. Considering the heterogeneity of clinical expression of spasticity in patients with MS, the use of a scale such as goal attainment scaling (GAS) can probably be totally adapted for the assessment of the effects of antispastic treatment., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objective. To assess by simulation the cost-effectiveness of intrathecal baclofen (ITB) therapy compared with conventional medical treatments for patients with disabling spasticity and functional dependence caused by any neurological disease. Methods. Two models were created to simulate therapeutic strategies for managing severe spasticity, one with and one without the use of ITB, to assess various treatment sequences over 2 years based on current medical practices in France. Successful treatment at each evaluation was defined as a combination of: (1) the increased patient and caregiver satisfaction as assessed by goal attainment scaling (GAS), and (2) a decrease of at least 1 point on the Ashworth score. Probabilistic sensitivity analyses were performed using 5000 Monte-Carlo simulations taking into account specific distribution curves for direct costs and effectiveness parameters in each treatment option. Results. The model simulations suggest that including ITB as a first option strategy in the management of function of severely impaired patients with disabling spasticity results in a higher success rate (78.7% vs 59.3%; P < .001). In addition, the ITB therapy model revealed a lower cost (€59 391 vs €88 272; P < .001) and an overall more favorable cost-effectiveness ratio (€75 204/success vs €148 822/success; P < .001), compared with conventional medical management without ITB. Conclusion. Within the assumptions of our modeling, ITB therapy evaluated by a combination of treatment success criteria at 6-month intervals over a 2-year period may be a cost-effective strategy compared to conventional medical management alone. [ABSTRACT FROM AUTHOR]

Introduction/Background Fatigue and fatigability are common problems in patients with multiple sclerosis (MS). The aim of this study was to explore the impact of a combined rehabilitation program on fatigue and on fatigability of knee extensor muscles in patients with MS. Material and method Twenty-three patients with MS were included in this study. Knee extensor muscles strength and fatigability were assessed using an isokinetic ergometer and perceived fatigue was assessed with a self-reported fatigue scale (Modified Fatigue Impact scale) before and after the rehabilitation program. The combined rehabilitation program included sessions on balance and gait training; sessions of endurance and resistance training. Results After rehabilitation, fatigue decreased significantly, on the other hand, torque fatigability index increased. Strength at the beginning of the fatigability protocol increased but strength at the end of the fatigability protocol did not change. Conclusion Combined rehabilitation program increased strength and decreased fatigue. However, torque fatigability index increased because the program enhanced strength at the beginning of the fatigability protocol but not at the end of the fatigability protocol. [ABSTRACT FROM AUTHOR]

Introduction/Background Increased muscle fatigability has been reported in patients with multiple sclerosis (MS) assessed during sustained isometric contractions however rehabilitation programs and daily life activities often involve concentric contractions. The aim of this study was to characterize knee extensor muscles fatigability in patients with MS during concentric contractions. Material and method Thirty-eight patients with MS and 14 healthy persons were included in this study. An isokinetic assessment of knee extensor muscles fatigability was carried out during a fatiguing task of 50 concentric contractions, associated with an electromyographic activity analysis of the rectus femoris, vastus lateralis, biceps femoris and semitendinosus muscles. Results Patients with MS experienced lower knee extensor muscles fatigability than healthy subjects. When torque was normalized to maximal isometric peak torque, patients with MS and healthy persons had the same level of relative strength at the end of the fatigue protocol (50% of the maximal isometric peak torque). During the fatiguing task neuromuscular efficiency decreased but coactivations of knee flexor muscles remained unchanged. Conclusion Fatigability is a common complaint in patients with MS but they experienced lower muscle fatigability than healthy persons during maximal concentric contractions, nevertheless they finished fatigue protocol at the same level of relative strength. [ABSTRACT FROM AUTHOR]

Introduction Respiratory dysfunction is one of the main causes of morbidity during the course of multiple sclerosis. We distinguish four main causes for respiratory dysfunction: respiratory muscles weakness, deglutition disorders, sleep disordered breathing, and control of breathing abnormalities [1] . Objective The main purpose of this study was to describe the respiratory function of MS patients with motor disability. Materials and methods We conducted a prospective study in MS patients with a walking disability. The respiratory dysfunction was assessed with pulmonary function tests, using spirometric and plethysmographic measures. The motor respiratory dysfunction was assessed using the vital capacity (VC), in the sitting and upright positions. Maximum inspiratory and expiratory pressures were also measured. We also reviewed the history of associated deglutition and sleep disorders. Results Over a 2-year period, 81 patients were evaluated. The median EDSS was 8 (IQ 7–8.5), the mean duration of disease was 20 years ± 11.4 and mean time since loss of walking ability 6.9 years ± 5.3. The average vital capacity was 2.41 L ± 1.08, i.e. 70,7 ± 0.3% of theoretical value. Fifty-one patients (63%) had a significative decrease of VC (<80%), being considered as severe (VC < 50%) in 23 cases (28%). Discussion In patients with severe MS, respiratory dysfunction is frequent. Its diagnosis and a better knowledge of its complications could help physicians to provide more specific care. [ABSTRACT FROM AUTHOR]

Introduction The Restless Legs Syndrome (RLS) is a sensorimotor disorder characterized by an urgent need to move the limbs (typically the legs), associated with unpleasant feelings, sometimes painful, in the evening or early night. Periodic leg movements (PLM) may occur during sleep. These are characterized by an extension movement of the hallux, dorsiflexion of the ankle and sometimes knee flexion and hip. The pathophysiology of RLS is not fully understood. Studies have shown an increased prevalence of RLS in patients with Spinal cord Injury (SCI) or Multiple Sclerosis. Objective The diagnosis of spasticity or RLS in patients complaining of repeated nocturnal spasms in patients initially seen in consultation because of spasticity resisting to pharmacological treatment. Method Prospective study, from March 2014 to March 2015, monocentric, in the MPR Service Hospital Raymond-Poincaré. Inclusion criteria: age over 18 years, SCI, MS patients, with nocturnal predominance spasms. Exclusion criteria: presence of pressure sores, unable to achieve a polysomnogram. Weekday hospital patients for predominantly nocturnal spasms resistant to pharmacological treatment of spasticity orally or even to intrathecal therapy (IT) IT baclofen, associated with sleep disorders, underwent a polysomnography. If RLS exists, 0.18 mg of pramipexole was administered to the patient, followed by a control polysomnography. Results Eleven patients (5 MS, 5 SCI and a patient with hereditary spastic paraplegia) were included. All had polysomnography for RLS. A significant improvement was experienced on 10 patients, with a important reduction PLM on polysomnography control, after administration of pramipexole. Discussion This pilot study shows that RLS may be a differential diagnosis of spasticity. The presence of nocturnal or supine position spasms, in patients with central nervous system lesions of SCI or MS types must result in the research for RLS and test the effect of dopamine agonists in the case of positive diagnosis. [ABSTRACT FROM AUTHOR]