Faculty Bibliography

BACKGROUND: Multiple sclerosis is a polysymptomatic disease. Little is known about relative contributions of the different multiple sclerosis symptoms to self-perception of health. OBJECTIVES: To investigate the relationship between symptom severity in 11 domains affected by multiple sclerosis and self-rated health. METHODS: Multiple sclerosis patients in two multiple sclerosis centers assessed self-rated health with a validated instrument and symptom burden with symptoMScreen, a validated battery of Likert scales for 11 domains commonly affected by multiple sclerosis. Pearson correlations and multivariate linear regressions were used to investigate the relationship between symptoMScreen scores and self-rated health. RESULTS: Among 1865 multiple sclerosis outpatients (68% women, 78% with relapsing-remitting multiple sclerosis, mean age 46.38 +/- 12.47 years, disease duration 13.43 +/- 10.04 years), average self-rated health score was 2.30 ('moderate to good'). Symptom burden (composite symptoMScreen score) highly correlated with self-rated health (r = 0.68, P < 0.0001) as did each of the symptoMScreen domain subscores. In regression analysis, pain (t = 7.00), ambulation (t = 6.91), and fatigue (t = 5.85) contributed the highest amount of variance in self-rated health (P < 0.001). CONCLUSIONS: Pain contributed the most to multiple sclerosis outpatients' perception of health, followed by gait dysfunction and fatigue. These findings suggest that 'invisible disability' may be more important to patients' sense of wellbeing than physical disability, and challenge the notion that physical disability should be the primary outcome measure in multiple sclerosis.

Objective: To investigate indications for and outcomes of total hip and knee arthroplasty in patients with multiple sclerosis (MS). Background: MS patients may need joint replacement due to MS-related factors, such as falls or avascular necrosis, or for unrelated indications (eg primary/secondary osteoarthritis). Literature on outcomes of total joint replacement in MS patients is limited to case reports that highlight surgical complications or unusual presentations. There are no systematic reviews of indications for and short- and long-term outcomes of hip and knee arthroplasty in MS patients. Design/Methods: Retrospective chart review of NYU MS Center patients who underwent hip or knee arthroplasty after MS onset. Results: 13 MS patients followed at NYU MS Care Center underwent hip (N=8) or knee (N=5) replacement at NYU. Average age at surgery was 56+/-11 years (range 35-69 years) and MS duration was 16+/-9 years; 10/13 were female. 3 patients had prior joint trauma and 1 had avascular necrosis of the hip presumably from steroid use; the remainder suffered from osteoarthritis. Ambulatory status before surgery was: 4-walking unassisted, 7 - cane, 2 - bilateral assistance. Ambulatory status after surgery at last follow up was: 8 walking unassisted, 3 using a cane, and 2 using a walker. Perioperative complications included acute blood loss in 4, pneumonia in 2, DVT in 1, and urinary retention in 1. Reoperation was required in 1 patient for recurrent hip dislocation. Conclusions: Orthopaedic literature focuses on perioperative complications after total joint arthroplasty in MS patients, but our data on unselected patients show that the surgery appears to benefit most of them, though (mostly) non-neurologic complications were seen in approximately half of the cases. These data can help optimize selection and surgical management of MS patients who are considering knee or hip replacement. We intend to present additional data on our patients that will include patient-reported outcomes

The objective of this study was to describe SymptoMScreen, an in-house developed tool for rapid assessment of MS symptom severity in routine clinical practice, and to validate SymptoMScreen against Performance Scales (PS). MS patients typically experience symptoms in many neurologic domains. A tool that would enable MS patients to efficiently relay their symptom severity across multiple domains to the healthcare providers could lead to improved symptom management. We developed "SymptoMScreen," a battery of 7-point Likert scales for 12 distinct domains commonly affected by MS: mobility, dexterity, body pain, sensation, bladder function, fatigue, vision, dizziness, cognition, depression, and anxiety. We administered SymptoMScreen and PS scales to consecutive MS patients at a specialty MS Care Center. We assessed the criterion and construct validity of SymptoMScreen by calculating Spearmen rank correlations between the SymptoMScreen composite score and PS composite score, and between SymptoMScreen subscale and the respective PS subscale scores, where applicable. A total of 410 patients with MS (age 46.6 +/- 12.9 years; 74% female; mean disease duration 12.2 +/- 8.7 years) completed the SymptoMScreen and PSs during their clinic visit. Composite SymptoMScreen score correlated strongly with combined PS score (r = 0.88, p < 0.0001). SymptoMScreen sub scores correlated strongly with the criterion measures of the respective PS (r = 0.69-0.87, p < 0.0001). Test-retest reliability of SymptoMScreen and its subscales was excellent (r = 0.71-0.94, p < .0001). SymptoMScreen is a single-page battery of Likert scales that assesses symptom impact in 12 domains commonly affected in MS. It has excellent criterion and construct validity. SymptoMScreen is patient and clinician friendly, takes approximately one minute to complete, and can help better document, understand, and manage patients' symptoms in routine clinical practice. SymptoMScreen is freely available to clinicians and researchers.

OBJECTIVE: This study evaluated the effect of relapse phenotype on disability accumulation in multiple sclerosis. METHODS: Analysis of prospectively collected data was conducted in 19,504 patients with relapse-onset multiple sclerosis and minimum 1-year prospective follow-up from the MSBase cohort study. Multivariable linear regression models assessed associations between relapse incidence, phenotype and changes in disability (quantified with Expanded Disability Status Scale and its Functional System scores). Sensitivity analyses were conducted. RESULTS: In 34,858 relapses recorded during 136,462 patient-years (median follow-up 5.9 years), higher relapse incidence was associated with greater disability accumulation (beta = 0.16, p < 0.001). Relapses of all phenotypes promoted disability accumulation, with the most pronounced increase associated with pyramidal (beta = 0.27 (0.25-0.29)), cerebellar (beta = 0.35 (0.30-0.39)) and bowel/bladder (beta = 0.42 (0.35-0.49)) phenotypes (mean (95% confidence interval)). Higher incidence of each relapse phenotype was associated with an increase in disability in the corresponding neurological domain, as well as anatomically related domains. CONCLUSION: Relapses are associated with accumulation of neurological disability. Relapses in pyramidal, cerebellar and bowel/bladder systems have the greatest association with disability change. Therefore, prevention of these relapses is an important objective of disease-modifying therapy. The differential impact of relapse phenotypes on disability outcomes could influence management of treatment failure in multiple sclerosis.