 joined the MJH Life Sciences team in October 2020. Follow her on Twitter 

Victoria Johnson

the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) Forum 2021

, February 25-27, found that a quick and simple 

 may be an important tool in identifying patients with mild to moderate multiple sclerosis (MS) at risk of falling.

Presenter Ishu Arpan, PT, PhD, senior research associate, neurology department, Oregon Health & Science University, and colleagues found that instrumented postural sway measures that differentiate people with MS from healthy controls (HC) can also differentiate fallers from non-fallers with MS.

Arpan and colleagues confirmed established findings that people with MS performed significantly worse on the instrumented postural sway test compared to HC. They isolated MS-specific measures, such as increased jerk, range, and the root mean square of sway, that were then used to successfully differentiate fallers from non-fallers in the MS group. The sway measures were significantly higher in people with MS that reported falls in the last 6 months compared to those who did not.

reached out to Arpan to learn more about the dangers of falls in MS. She also gave an overview of her study’s findings.

: Can you talk about the dangers of falls in MS?

 Balance impairment is an early and common symptom in people with MS. Balance control depends upon accurate somatosensory information from the feet up the spinal cord as well as motor control systems that are affected, even early in MS. Poor balance control leads to an increased risk of falling. In fact, fall rates in people with MS are even higher than for much older adults without MS. Falling reduces the quality of life in people with MS as it limits functional independence, can lead to physical injury, and places an emotional and financial burden on the faller and their families. Studies have shown that even fear of falling, associated with the increased risk of falls, can decrease participation in society and impact emotional and physical health. For example, fear of falling and high risk of falling may prevent young adults with MS from actively engaging in the workforce and pursuing their careers. Early identification of people with MS at high risk of falling will allow earlier interventions for fall prevention.

Can you give an overview of your study and its findings?

Standing balance was measured in 22 people with MS and 20 age-matched controls without MS using an instrumented postural sway test. Participants were instructed to stand on a firm surface for 30 seconds with eyes open wearing a wireless inertial sensor (Opal sensors by APDM) on the lower back. We found that postural sway measures (jerk, range, and area) were greater in people with MS compared to controls indicating poor standing balance control in the MS group. When participants in the MS group were categorized as fallers or non-fallers based on prior history of falls in the past 6 months, we found that balance control in non-fallers with MS was similar to the controls, whereas balance control was significantly worse in the MS group with the history of previous falls.

I would like to add that even though in this abstract we only talked about the balance impairments during the standing task, the overall goal of our project was to predict falls from both balance and gait impairments. The unpublished results from our study indicate that a prediction model consisting of both postural sway range (a standing balance measure) and local dynamic stability (a gait measure; Arpan et al. 2020) account for approximately 93% of the variance separating fallers from non-fallers.

Transcript edited for clarity. For more coverage of ACTRIMS Forum 2021, 

1. Rude A, Prewitt AL, Horak F, Arpan I. Feasibility of postural sway measures to predict falls in multiple sclerosis. Presented at ACTRIMS Annual Forum; February 25-27, 2021. Abstract P027
2. Arpan I, Fino PC, Fling BW, Horak F. Local dynamic stability during long-fatiguing walks in people with multiple sclerosis. Gait Posture. 2020 Feb;76:122-127. doi: 10.1016/j.gaitpost.2019.10.032.

Articles

Ishu Arpan, PhD, senior research associate at Oregon Health & Science University, discussed her team’s investigations into identifying patients with MS at risk of falling. 

Identifying Those at Risk of Falling in Multiple Sclerosis

A majority of multiple sclerosis (MS) health care professionals used 

 with their patients and were satisfied with its use, according to a recent survey. The results were presented at the 

Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS)

, February 25-27, by Peter Keszler, DO, chief resident, department of neurology, George Washington University School of Medicine and Health Sciences, and colleagues.

“Many patients with MS are separated by geographic distance and disability from MS clinical centers in the US, with 30% not receiving specialty MS care. Telemedicine, defined broadly as the use of telehealth technologies to provide clinical care when distance separates patients and providers, has the potential to fill some of the gap in the provision of specialty MS services. The COVID-19 pandemic has forced providers to use telemedicine for most outpatient care to maintain social distancing,” Keszler and colleagues wrote. 

Keszler and colleagues created a 34-question survey in order to collect a representative sample of opinions on the use of telemedicine among a diverse group of health care professionals involved with MS care. They then placed the survey on the Qualtrex web-platform and distributed it to a multidisciplinary group of professionals across the US. Collected responses were analyzed with Qualtrex web-analytical software and statistical analysis system.

A total of 100 participants began the survey and 91 fully completed it. The respondents were 40.7% neurologists, 28.6% nurse practitioners and physicians' assistants, 14.3% nurses, 7.7% psychologists and neuropsychologists, 3.3% social workers, 2.2% physical therapists and occupational therapists, and 1.1% pharmacists.

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The survey collected responses from November 2019 to September 2020. Most respondents (75.8%) reported using telemedicine to care for patients with MS. Of those who used telemedicine, 97% used CVT and 71% used telephone telemedicine. Other telemedicine approaches were used less commonly, with only 10.1% of respondents using store and forward telemedicine, and 1.4% using remote patients monitoring. 

During the COVID-19 pandemic, the rate of telemedicine utilization increased from 15% of practice encounters to 72.8% of encounters. Most respondents (92.8%) were either very or somewhat satisfied with their last telemedicine visit and 94.2% of respondents reported a desire to continue using telemedicine. The most common drawback of telemedicine, as reported by 84.6% of respondents, was the inability to complete a full neurological exam.

“Telemedicine can provide a valid alternative to in person visits. Further study is needed to evaluate how opinions on telemedicine have continued to evolve as providers become more and more accustomed to its use and what barriers may exist that are limiting the utilization of store and forward and remote patient monitoring,” Keszler and colleagues concluded.

Telemedicine use has grown in the MS field, and this adaptation toward a more digital world has been an ongoing conversation for those treating this population. Leigh Charvet, PhD, clinical neuropsychologist, Division of MS, NYU Langone Health, recently came on the 

 to discuss the work she and colleagues have done in validating and assessing digital therapeutics and telemedicine approaches in MS, and how these interventions might make an impact on the invisible symptoms of the disease. One key point Charvet made was that it can help with wider data collection on the MS population.

“There’s a segment of people living with MS who are left out of a lot of clinical trials right now, and they face even more burden to get to a clinic visit to receive some type of therapy for a trial. We’ve been encouraged by being able to reach so many more people than are typically reached in a clinical trial to evaluate these therapies,” Charvet told 

The increase in telemedicine use was a somewhat broad trend across medical specialties, of course, due to the pandemic’s limiting of in-person visits. 

 spoke with physicians all over the country about the impact it had on their clinical practice in 2020, and our Year in Review series compiled those insights into one place. To check out those insights, 

For more coverage of ACTRIMS Forum 2021, 

Keszler P, Maloni H, Miles Z, Jin S, Wallin M. Telemedicine utilization and perceptions of multiple sclerosis health care providers. Presented at ACTRIMS Annual Forum; February 25-27, 2021. Abstract P172

Researchers found that the percentage of telemedicine visits increased from 15% to 72.8% during the COVID-19 pandemic. 

Multiple Sclerosis Care Professionals Satisfied With Clinical Video Telemedicine Visits

 (MT) for posterior circulation is a safe and feasible therapy option for patients that experienced stroke attributed to primary distal medium vessel occlusion (DMVO) of the posterior cerebral artery (PCA) of the P2 or P3 segment when compared to standard medical treatment (SMT) with or without intravenous thrombectomy (IVT).

The mean difference in National Institute of Health Stroke Scale (NIHSS) score decrease from admission between MET and SMT cohorts was –1.5 points (95% CI, 3.2 to −0.8; 

 = .06). The largest effects of MT were seen in the subgroup of patients with NIHSS scores of 10 or higher at admission, with a mean difference of –5.6 (95% CI, −10.9 to −0.2; 

 = .04), as well as patients without IVT (mean difference, −3.0 [95% CI, −5.0 to −0.9]; 

"This study suggested that, although rarely performed at comprehensive stroke centers, mechanical thrombectomy for posterior circulation DMVO is a safe, and technically feasible treatment option for occlusions of the P2 or P3 segment of the PCA compared with standard medical treatment with or without IVT,” wrote first author Lukas Meyer, MD, radiology resident, University Medical Center Hamburg-Eppendorf, and colleagues.

Meyer and colleagues analyzed data from 184 propensity score-matched patients in participating centers throughout Europe, the US, and Asia, between January 2010 and June 2020. The patients had a median age of 74 years (interquartile range [IQR], 62-81) and 95 (51.6%) were women. Posterior circulation DMVOs were located in the P2 segment of the PCA in 149 patients (81.0%) and in the P3 segment in 35 patients (19.0%).

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The researchers found that the SMT cohort received significantly more IVT (53 of 92; 57.6%) than the MT cohort (37 of 92; 40.2%; 

 = .01). The median time from onset to groin puncture was 197 minutes (IQR, 148-277) in the MT cohort. The median time from onset to imaging was 141 minutes (104-216) and to IVT application was 151 minutes (IQR, 120-201) in the SMT cohort. 

The MT cohort had a mean NIHSS score decrease from admission of 3.9 points (95% CI, –5.4 to –2.5) while the SMT cohort had a mean decrease of 2.4 points (95% CI, –3.2 to –1.6). 

The researchers performed multivariable logistic regression analysis and found that higher NIHSS scores on admission (adjusted OR [aOR], 1.19 [95% CI, 1.08-1.31]; 

 <.001) and a successful first-pass effect (aOR, 2.32 [95% CI, 1.03-5.20]; 

 = .04) were independent factors in reaching early neurological improvement (ENI) in the MT cohort. Within the SMT cohort, P3 occlusions (aOR, 4.25 [95% CI, 1.27-14.22]; 

 = .02), and IVT were independently associated with reaching ENI (aOR, 2.69 [95% CI, 0.98-7.37]; 

Excellent functional outcomes (modified Rankin Scale [mRS] score ≤1) were observed in 51 patients (66.2%) in the MT cohort and 31 patients (54.4%) in the SMT cohort at 90-day follow-up. Overall, mRS score distributions in the MT cohort (median, 1; IQR, 0-2) points and SMT cohort (median, 0; IQR, 1-2.5; 

 = .26) did not differ significantly at 90-day follow-up. 

Symptomatic intracranial hemorrhage and symptomatic intracerebral hemorrhage each occurred in 4 patients (4.3%) in each treatment cohort. The overall mortality in both cohorts was 4.9% (n = 9) during hospital stay and 13.4% (n = 18) at 90-day follow-up, including 3 patients in the MT cohort who died from a non-stroke-related cause. Mortality rates did not differ significantly between the treatment groups (

 ≥.4). Patients with an NIHSS score of 10 or higher on admission, an mTICI score of 2a or lower, or SMT treatment with ineligibility for IVT had the highest relative mortality rates.

“A randomly-controlled trial that compares MT with SMT is warranted to evaluate the use of thrombectomy for posterior circulation DMVO and to resolve clinical equipoise in acute therapeutic decision-making,” Meyer and colleagues concluded.

Meyer L, Stracke CP, Jungi N, et al. Thrombectomy for primary distal posterior cerebral artery occlusion stroke: The TOPMOST Study. 

 Published online February 22, 2021. doi: 10.1001/jamaneurol.2021.0001

Researchers found that higher NIHSS scores on admission and a successful first-pass effect were predictors of reaching early neurological improvement. 

Mechanical Thrombectomy Efficacious in Distal Medium Vessel Occlusion

A recent study clarified characteristics of patients with multiple sclerosis (MS) receiving 

 (Ocrevus; Genentech) treatment among varying demographic groups.

The study was presented by Alana Jones, MD-PhD graduate student, University of Alabama at Birmingham, and colleagues at the 

“Ocrelizumab is a recombinant human anti-CD20 monoclonal antibody, which causes B-cells depletion and is approved for treatment of primary progressive multiple sclerosis (PPMS) and relapsing MS (RMS). Since approval in 2017, over 100,000 MS patients have been treated with ocrelizumab,” Jones and colleagues wrote.

The researchers conducted a retrospective chart review at a large tertiary referral MS Center in order to understand the rationale for use of ocrelizumab in patients with PPMS and RMS, as well as patient reasons for switching from other disease modifying therapies (DMTs), as a majority had done so. 

Jones and colleagues analyzed data from the 252 patients seen at the University of Alabama at Birmingham MS Center that were treated with ocrelizumab through January 2020. Of these patients, 158 (63%) had RMS, 94 (37%) had PPMS, and 53 (21%) were treatment naïve. Patients were mostly female (n = 176; 70.2%); 35 (67.5%) were Caucasian and 80 (31.7%) were African American (AA).

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Patients with PPMS had a mean age of 58.5 years while patients with RMS were significantly younger, with a mean age of 44.8 years (

 ≤.05). They also had a longer duration of disease (mean, 16.5 years) compared to patients with RMS (mean, 11.3 years). No difference was found in the mean number of DMTs prior to ocrelizumab treatment.

AA patients with RMS (mean, 43.2 years) and PPMS (mean, 55.9 years) were younger than Caucasian patients with RMS (mean, 45.8 years) and PPMS (59.2 years), despite similar disease duration in both groups.

Physician rationales for DMT change were mostly due to suboptimal response (overall, 46.2%; RMS, 41.5%; PPMS, 56.3%; 

 ≤.05). Patient rationales for requesting treatment change were mostly due to adverse effects (overall, 22.1%; RMS, 29.6%; PPMS, 6.3%; 

 ≤.05) and personal choice/convenience (overall, 29.1%; RMS, 26.0%; PPMS, 37%; 

“This retrospective cohort of all patients provides understanding of the types of patients seen at a tertiary referral center and treated with ocrelizumab. PPMS patients tended to be older (as expected) but with longer disease duration before starting DMT; likely because of lack of effective DMTs for this MS subtype previously. AA MS patients were younger at the time of switching to Ocrelizumab, likely secondary to more aggressive disease or potentially differential response to DMT,” Jones and colleagues concluded.

Manouvakhova O, Jones A, Bashir K. Observations regarding ocrelizumab use at a tertiary referral MS center. Presented at ACTRIMS Annual Forum; February 25-27, 2021. Abstract P076

Researchers also found that patients with progressive MS had longer disease duration before starting DMTs than those with relapsing MS. 

Victoria Johnson

Articles

Identifying Those at Risk of Falling in Multiple Sclerosis

Multiple Sclerosis Care Professionals Satisfied With Clinical Video Telemedicine Visits

Mechanical Thrombectomy Efficacious in Distal Medium Vessel Occlusion

African American Patients With MS Switch to Ocrelizumab Treatment Earlier than Caucasian Patients