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Objective: The purpose of this study was to test the reliability of the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" mobility and activity short forms between patients and therapist proxies. As a secondary aim, reliability was examined when patients completed their self-report before versus after the therapist evaluation., Methods: Patients being seen for an initial physical therapist (N = 70) or occupational therapist (N = 71) evaluation in the acute care hospital completed the "6-Clicks" mobility short form (if a physical therapist evaluation) or activity short form (if an occupational therapist evaluation). Whether patients completed their self-assessment before or after the evaluation was randomized. Patient- and therapist-rated "6-Clicks" raw scores were converted to AM-PAC T-scores for comparison. Reliability was assessed with intraclass correlation coefficients (ICCs) and Bland-Altman plots, and agreement was assessed with weighted kappa values., Results: The ICCs for the "6-Clicks" mobility and daily activity short forms were 0.57 (95% CI = 0.42-0.69) and 0.45 (95% CI = 0.28-0.59), respectively. For both short forms, reliability was higher when the patient completed the self-assessment after versus before the therapist evaluation (ICC = 0.67, 95% CI = 0.47-0.80 vs ICC = 0.50, 95% CI = 0.26-0.67 for the mobility short form; and ICC = 0.52, 95% CI = 0.29-0.70 vs ICC = 0.34, 95% CI = 0.06-0.56 for the activity short form)., Conclusion: Reliability of the "6-Clicks" total scores was moderate for both the mobility and activity short forms, though higher for the mobility short form and when patients' self-report occurred after the therapist evaluation., Impact: Reliability of the AM-PAC "6-Clicks" short forms is moderate when comparing scores from patients with those of therapists responding as proxies. The short forms are useful for measuring participants' function in the acute care hospital; however, it is critical to recognize limitations in reliability between clinician- and patient-reported AM-PAC scores when evaluating longitudinal change and recovery., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Physical therapists (PTs) are consulted to address functional deficits during hospitalization, but the effect of PT visit frequency on patients' outcomes is not clear., Objective: The objective of this study was to examine whether PT visit frequency is independently associated with functional improvement, discharge home, and both outcomes combined., Research Design: This was a retrospective cohort study., Subjects: Patients discharged from hospitals in 1 health system between 2017 and 2020, stratified by diagnostic subgroup: cardiothoracic and vascular, general medical/surgical, neurological, oncology, and orthopedic., Measures: PT visit frequency was categorized as ≤2, >2-4, >4-7, >7 visits/week. Functional improvement was defined as ≥5-point improvement in Activity Measure for Post-Acute Care mobility score. Other outcomes were discharge home and both outcomes combined., Results: There were 243,779 patients included. Proportions within frequency categories ranged from 11.0% (>7 visits/wk) to 40.5% (≤2 visits/wk) and varied by subgroup. In the full sample, 36% of patients improved function, 64% were discharged home, and 27% achieved both outcomes. In adjusted analyses, relative to ≤2 visits/week, the adjusted relative risk (aRR) for functional improvement increased incrementally with higher frequency (aRR=1.20, 95% confidence interval: 1.14-1.26 for >2-4 visits to aRR=1.78, 95% confidence interval: 1.55-2.03 for >7 visits). For all patients and within subgroups, the higher frequency was also associated with a greater likelihood of discharging home and achieving both outcomes., Conclusions: More frequent PT visits during hospitalization may facilitate functional improvement and discharge home. Most patients, however, receive infrequent visits. Further research is needed to determine the optimal delivery of PT services to meet individual patient needs., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Multiple sclerosis (MS) detrimentally affects cognition and quality of life (QOL). Interventions that can improve cognitive deficit and QOL in individuals with MS are desired. This pilot study investigated the possible effects of vibration training on improving cognition and QOL in individuals with MS., Methods: Eighteen adults with MS were randomized into 2 groups: training and control. The training group underwent 6 weeks of vibration training, and the control group maintained their normal lifestyle throughout the study. In both groups, before and after the training course, the disability status was evaluated by the Patient Determined Disease Steps scale and the Multiple Sclerosis Functional Composite (MSFC), cognitive function was assessed by the Behavior Rating Inventory of Executive Function-Adults (BRIEF-A) and the Buschke Selective Reminding Test (SRT), and QOL was gauged by the 36-item Short Form Health Survey (SF-36)., Results: The training was well accepted by the participants, and no major adverse event was reported. All participants finished the entire protocol. Compared with the control group, the training group showed greater improvements in MSFC score, Metacognition Index score of the BRIEF, SRT score, and physical domain score of the SF-36., Conclusions: These results suggest that vibration training could be an effective alternative training paradigm to enhance cognition and QOL in individuals with MS, and they provide an encouraging base to conduct a large-scale clinical trial., Competing Interests: FINANCIAL DISCLOSURES: Dr Yang has a relationship with Genentech (contracted research). Dr Bethoux has relationships with Springer Publishing (royalty); Biogen (receipt of intellectual property rights/patent holder, speakers’ bureau); Qr8 (receipt of intellectual property rights/patent holder); MedRhythms (consulting fees, contracted research); GW Pharmaceuticals, Genentech, Helius Medical Technologies, Osmotica, and Ipsen (consulting fees); and Adamas Pharmaceuticals (contracted research). The other authors declare no conflicts of interest., (© 2022 Consortium of Multiple Sclerosis Centers.)

Background: The growing trend in providing palliative care and end-of-life services has dictated that healthcare providers be adequately trained to care for people with serious illnesses, such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). These progressive inflammatory diseases lead to physical, cognitive and emotional deficits and have exceptionally high care demands leading to high levels of distress. Because the impact on the delivery of patient care is influenced by the specialists' knowledge and comfort discussing end-of-life issues, it is concerning that interventions to address unmet palliative care needs in MS and NMOSD rarely include clinician-patient dyads. Objectives: To evaluate the neurology clinicians' knowledge and level of comfort discussing palliative care and end-of-life issues. Design: A cross sectional survey was conducted. The statistical analyses included frequencies, chi square statistics and logistic regression. Setting/Subjects: 414 MS specialists answered an online anonymous survey. The survey was conducted using email distributions to MS professionals through the Consortium of MS Centers (CMSC), the International Organization of MS Nurses (IOMSN) and the UK Nurses' MS Organization. Measurement: The "End of Life Professional Caregiver Survey" (EPCS) was used to collect data. Results: The majority of the multidisciplinary professionals were female, white, nurses, and older than 40 years of age. 41% had their own advance directives and 57.6% had end-of-life basic training. There was a statistically significant association between end-of-life training or having advance directives and comfort discussing palliative care and end of life issues. Professionals that had basic end-of-life training and their own advance directives had higher comfort discussing code status, specific end-of-life issues, and advance directive planning. Conclusions: Basic end-of-life training and having advance directives among MS professionals were associated with better communication of palliative care and end-of-life domains with patients and their care partners.

Objectives: To determine the efficacy of high-intensity cycling to improve walking capacity in individuals with chronic stroke, identify variables that predict improvement in walking capacity, and quantify the relationship between the 6-minute walk test (6MWT) and cardiopulmonary exercise (CPX) test variables., Design: Secondary analysis of data from 2 randomized controlled trials., Setting: Research laboratory., Participants: Individuals with chronic stroke (N=43)., Interventions: Participants were randomized to 1 of the following time-matched interventions, occurring 3 times per week for 8 weeks: (1) forced aerobic exercise and upper extremity repetitive task practice (FE+RTP [n=16]), (2) voluntary aerobic exercise and upper extremity repetitive task practice (VE+RTP [n=14]), or (3) a non-aerobic control group (n=13)., Main Outcome Measure: Change in walking capacity as measured by the 6MWT from baseline to the end of treatment (EOT)., Results: Significant increases were observed in distance traveled during the 6MWT at the EOT compared with baseline in the FE+RTP (P<.001) and VE+RTP (P<.001) groups, but not in the control group (P=.21). Among aerobic exercise participants, a multivariate regression analysis revealed that cycling cadence, power output, and baseline 6MWT distance were significant predictors of change in walking capacity., Conclusions: An 8-week aerobic cycling intervention prescribed at 60% to 80% of heart rate reserve and moderate to high cadence and resistance led to significant improvements in walking capacity in our cohort of individuals with chronic stroke. Individuals with low baseline walking capacity levels may benefit most from aerobic cycling to improve over ground locomotion. Although the 6MWT did not elicit a cardiorespiratory response comparable to the maximal exertion CPX test, the 6MWT can be considered a valid and clinically relevant submaximal test of cardiorespiratory function in individuals with chronic stroke., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: In the clinic, the assessment of patients with multiple sclerosis (MS) is typically qualitative and non-standardized., Objectives: To describe the MS Performance Test (MSPT), an iPad Air ® 2 (Apple, Cupertino, CA, USA)-based neurological assessment platform allowing patients to input relevant information without the aid of a medical technician, creating a longitudinal, clinically meaningful, digital medical record. To report results from human factor (HF) and usability studies, and the initial large-scale implementation in a practice setting., Methods: The HF study examined use-error patterns in small groups of MS patients and healthy controls (n = 14), the usability study assessed the effectiveness of patient interaction with the tool by patients with a range of MS disability (n = 60) in a clinical setting, and the implementation study deployed the MSPT across a diverse population of patients (n = 1000) in a large MS center for routine clinical care., Results: MSPT assessments were completed by all users in the HF study; minor changes to design were recommended. In the usability study, 73% of patients with MS completed the MSPT, with an average administration time of 32 min; 85% described their experience with the tool as satisfactory. In the initial implementation for routine care, 84% of patients with MS completed the MSPT, with an average administration time of 28 min., Conclusion: Patients with MS with varying disability levels completed the MSPT with minimal or no supervision, resulting in comprehensive, efficient, standardized, quantitative, clinically meaningful data collection as part of routine medical care, thus allowing for large-scale, real-world evidence generation., Funding: Biogen., Trial Registration: NCT02664324.

Objectives: Stiff-person syndrome (SPS) is associated with axial rigidity superimposed on sustained muscle spasms. These symptoms commonly interfere with the performance of activities of daily living including ambulation. This retrospective case series evaluates the outcomes of screening tests and chronic infusion of intrathecal baclofen (ITB) in patients diagnosed with SPS treated in our spasticity clinic., Materials and Methods: Patients were identified from an institutional review board-approved clinical registry of ITB therapy. Data from clinical encounters were extracted from the registry and from the patients' electronic medical record. All patients with medically refractory spasticity related to SPS screened with an ITB injection were included. In addition to pertinent demographic and clinical information, data from validated outcome measures routinely used in the clinic were collected: pain Numeric Rating Scale, Spasm Frequency Scale, lower extremity Modified Ashworth Scale (MAS), and Timed 25 Foot Walk. Outcomes data for chronic ITB infusion were assessed at early (<6 months) and late follow-up (6-12 months) visits after surgery., Results: Nine patients were included, and seven received chronic ITB infusion. MAS scores were improved at early and late follow-up, and five patients experienced a reduction in pain scores. Walking performance remained stable in previously ambulatory patients. Four patients experienced complications related to ITB implantation, which resolved with medical or surgical treatment., Conclusion: Consistent with other case series, our results suggest that ITB is an effective therapy for medically intractable spasticity due to SPS, and symptom reduction can be achieved without compromising ambulation., (© 2018 International Neuromodulation Society.)

Background: Cognitive dysfunction is common in multiple sclerosis (MS) patients and has important consequences for daily activities, yet, unlike motor function, is not routinely assessed in the clinic setting. We developed the Processing Speed Test (PST), a self-administered iPad ® -based tool to measure MS-related deficits in processing speed., Objective: To determine whether the PST is valid for screening cognitive dysfunction by comparing it to the paper-and-pencil Symbol Digit Modalities Test (SDMT)., Methods: We assessed PST test-retest reliability, sensitivity of PST and SDMT in discriminating MS patients from healthy controls (HC), convergent validity between PST and SDMT, correlations between T2 lesion load and PST and SDMT, and PST performance with and without technician present during administration., Results: PST had excellent test-retest reliability, was highly correlated with SDMT, was slightly more sensitive than SDMT in discriminating MS from HC groups, and correlated better with cerebral T2 lesion load than did SDMT. Finally, PST performance was no different with or without a technician in the testing environment., Conclusion: PST has advantages over SDMT because of its efficient administration, scoring, and potential for medical record or research database integration. PST is a practical tool for routine screening of processing speed deficits in the MS clinic.

Purpose: The goal of this study was to evaluate the safety and tolerability of dalfampridine extended release (D-ER) in a pilot study of adults with cerebral palsy (CP) and limited ambulatory ability, and to explore drug effects on sensorimotor function., Methods: An initial double-blind, single-dose crossover study was performed in 11 individuals randomized 1:1 to receive D-ER (10 mg) or placebo, followed by a 2-day washout period and the opposite treatment, with evaluation for safety and tolerability. A twice daily dosing, double-blind, placebo-controlled, crossover study was then performed. Participants were randomized in a 1:1 ratio to 1 of 2 sequences: 1 week of D-ER (10 mg BID) or placebo, followed by a 1-week washout and 1 week of the opposite treatment. Key inclusion criteria were age 18 to 70 years, body mass index 18.0 to 30.0 kg/m 2 , diagnosis of CP, and ability to perform all study procedures. Key exclusion criteria were severe CP, moderate or severe renal impairment, history of nonfebrile seizures, and prior dalfampridine use. Primary outcomes were safety profile and tolerability. Exploratory functional outcomes comprised changes in upper and lower extremity sensorimotor function (grip and pinch strength tests), manual dexterity (Box and Block Tests), and walking speed (Timed 25-Foot Walk). The most pronounced measured functional deficit in each individual was defined as the exploratory primary functional end point. Full crossover data were analyzed by using a mixed effects model., Findings: Among the 24 total participants who were randomized to treatment and completed the twice daily dosing phase study, their mean age was 38.6 years (range, 20-62 years), 54% were women, and 83% had spastic CP. Adverse events were consistent with previous D-ER trials, most commonly headache (13% D-ER, 4% placebo), fatigue (13% D-ER, 0% placebo), insomnia (8% D-ER, 4% placebo), diarrhea (4% D-ER, 4% placebo), and nausea (4% D-ER, 4% placebo). The mixed model analysis of full crossover data identified no significant difference between D-ER and placebo in the primary functional analysis (the most pronounced deficit; P = 0.70) or in the secondary analyses (hand strength [P = 0.48], manual dexterity [P = 0.13], or walking speed [P = 0.42])., Implications: In this preliminary study of adults with CP, a BID dose of 10-mg D-ER was generally safe and well tolerated. The exploratory functional assessments for upper and lower sensorimotor deficits did not establish that the study population was markedly responsive to D-ER relative to placebo. These findings do not provide the proof-of-concept that would support further evaluation of D-ER as a potential intervention to improve function in adults with CP. ClinicalTrials.gov identifier: NCT01468350., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Spasticity is frequently reported by patients with multiple sclerosis (MS). A previously published survey of participants in the North American Research Committee on Multiple Sclerosis (NARCOMS) registry showed that higher levels of spasticity were associated with higher MS-related disability and lower quality of life, but did not investigate the impact of spasticity on daily activities, and only partially assessed spasticity management., Methods: A new cross-sectional survey was distributed to 15,679 eligible NARCOMS participants. We inquired about the degree of bother from symptoms associated with spasticity, interference with a variety of daily activities, as well as past and current treatments for spasticity., Results: Among the 10,353 responders (66 % response rate), over 80 % reported experiencing spasticity, and more than 35 % were moderately or greatly bothered by stiffness, spasms, or pain, predominantly in the lower extremities. More severe spasticity was associated with worse disability, mobility, bladder function, and fatigue. Spasticity was most frequently reported to interfere with stair climbing, walking, and sleep. Most individuals reported receiving treatment for spasticity (mainly oral medications, stretching, home exercise, and physical therapy), yet fewer than half reported being satisfied with their current treatment., Conclusion: Spasticity was reported by a large majority of patients with MS, and found to interfere with many daily activities. At the same time, patients were often dissatisfied with the effects of treatments for spasticity. Prospective studies are needed to better characterize the impact of spasticity in individuals with MS, and to optimize treatment strategies.

Many poststroke survivors develop spasticity. Spasticity is usually associated with other neurologic impairments, in particular paresis, which complicate the evaluation of its consequences and of treatment outcomes. The diagnosis and the assessment of spasticity are based on clinical examination, in particular resistance to passive movement and abnormal involuntary muscle contraction. Nonpharmacologic and pharmacologic treatments are commonly combined to manage spasticity, based on prespecified goals. There is evidence supporting the effectiveness and safety of most medications commonly used to treat spasticity; however, more evidence is needed regarding functional outcomes and the impact of combining treatment modalities., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Inactivity is a prevalent problem in the population affected with multiple sclerosis (MS). Thus, there is a need to develop and test physical activity (PA) interventions that can be widely disseminated. We conducted a formative evaluation as part of a randomized controlled trial of a pamphlet-based PA intervention among 30 women with MS. Pamphlets were customized to sub-sets of participants who shared similar symptoms and barriers to PA. Mixed methods were used to examine the intervention's influence on self-efficacy, social support, processes of change and stages of change placement, as well as explore participants' perceived barriers, motivators and strategies for engaging in a PA program. Results indicated that the intervention group significantly improved stages of change placement (F = 16.64, P < 0.01) and social support (F = 4.08, P = 0.05) in comparison to the control group. Fatigue, pain and lack of time were the commonly cited barriers to engage in the PA program; whereas the pamphlets, phone calls and action planning were cited as motivators. Participants used fatigue management strategies, enlisted social support and modified their environment to routinely engage in the PA program. Strategies were identified to improve the PA intervention in future research., (© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Botulinum toxin (BT) is a neurotoxin that paralyzes muscles by inhibiting release of acetylcholine from presynaptic vesicles at the neuromuscular junction. In people with multiple sclerosis (MS), clinical experience and research studies show that local injection of minute quantities of BT can temporarily control skeletal muscle spasticity, bladder detrusor hyperreflexia, and tremor. Specifically, BT injections have been shown to reduce muscle tone and improve passive function, and possibly improve active function, in patients with spasticity. Injection of BT into the bladder wall is a uniquely effective, safe, and durable treatment in patients with neurogenic detrusor hyperreflexia due to MS who have insufficient response or who do not tolerate oral antimuscarinic medications. This procedure has markedly reduced the need for indwelling catheters and bladder surgery. In addition, a recent study suggests BT may be effective for select patients with MS-associated upper extremity tremor. Appropriate use of BT can improve quality of life for many patients with MS.

Objective: Investigate the feasibility and potential efficacy of a customized print-based intervention to promote physical activity and symptom self-management in women with multiple sclerosis., Design: A randomly allocated two-group repeated measures design, with a delayed-treatment contact group serving as the control. Participants were randomized to receive the intervention immediately (n =14) or receive it at week 12 (n =16). Outcome measures were administered at weeks 1, 12, and 24., Setting: Community-based in metropolitan area., Subjects: Thirty women with multiple sclerosis., Intervention: Prescribing a home-exercise program and following up with customized pamphlets, which are matched to participants' stage of readiness to change physical activity behavior and physical activity barriers (e.g. encouraging self-management of symptoms)., Main Measures: Physical Activity and Disability Survey-revised, Godin Leisure-Time Exercise Questionnaire, SF-12, Symptoms of Multiple Sclerosis Scale, and 6-minute walk test., Results: Intent-to-treat analyses using mixed multivariate analysis of variance (MANOVA) were conducted on (1) physical activity levels and (2) health and function outcomes. The mixed MANOVAs for physical activity levels and health and function outcomes indicated significant improvements in the immediate group compared with the delayed group (i.e. condition by time interaction was significant, Wilks' λ = 0.59, F(2, 27) = 9.31, P = 0.001 and Wilks' λ = 0.70, F(4, 25) = 2.72, P = 0.052, respectively). The intervention had moderate to large effect sizes in improving physical activity levels (d = 0.63 to 0.89), perceptions of physical function (d = 0.63), and 6-minute walk test (d=0.86)., Conclusion: This pilot study indicates that a customized print-based intervention shows promise in improving physical activity levels and health and function in women with multiple sclerosis.

Purpose of Review: Ambulation, and more broadly mobility, is frequently affected by multiple sclerosis (MS). The purpose of this review is to present recent developments regarding the impact, outcome measures, and management of gait disorders in MS., Recent Findings: Recently published surveys have confirmed the high prevalence of walking limitations in MS and their impact on the functional status and quality of life of MS patients and their families. Validated clinical outcome measures include the Timed 25-Foot Walk, 6-Minute Walk, and Multiple Sclerosis Walking Scale-12. Further characterization of gait disorders is allowed by gait analysis systems, as well as pedometers and oscillometers that measure walking in the patient's daily life. A growing body of evidence demonstrates the benefits of various rehabilitation interventions on walking performance. Dalfampridine, an extended-release formulation of 4-aminopyridine, is the first symptomatic medication indicated to improve walking in patients with MS. Newer assistive devices, such as the hip flexion assist device and functional electrical stimulation devices, show promising results in preliminary studies. Various treatments for spasticity can be used without compromising ambulation, but their ability to enhance gait needs to be further assessed., Summary: Gait disorders need to be identified and managed early in the course of MS, using a multimodal approach that needs to be adjusted over time based on the results of periodic assessments.

Many stroke survivors have walking limitations. The results of gait training in individuals who have had strokes are characterized by large confidence intervals for mean differences in gait parameters. An individualized approach to therapy is needed, based on personalized gait pattern indicators and sensorimotor impairments. Three-dimensional gait analysis can help clinicians design the best locomotor training strategy for their patients, and can determine whether a patient is responding to the chosen intervention. Spatiotemporal parameters allow the characterization of the gait of hemiparetic patients but, used alone, they do not allow the cause of the deviations to be inferred., (Copyright © 2013 Elsevier Inc. All rights reserved.)

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.

Multiple sclerosis (MS) has protean manifestations, and the care of people with MS presents many unique challenges. Clinicians can have an important impact on health, quality of life, and daily functioning by participating in open dialogue, tailoring focused treatment plans, and anticipating general medical needs.

Recent advances in our understanding of the diagnosis, imaging, pathology, and clinical monitoring of multiple sclerosis (MS) have significantly increased our ability to successfully treat this often perplexing neurologic disorder. Magnetic resonance imaging (MRI) is now integral to the diagnostic process. Treatment of MS can be considered as three parallel pathways: treatment of relapses, symptom management, and long-term prevention of tissue injury.