Abstract: Activity Available Online: To access the article, post-test, and evaluation online, go to http://www.cmscscholar.org. Target Audience: The target audience for this activity is physicians, physician assistants, nursing professionals, and other health care providers involved in the management of patients with multiple sclerosis (MS). Learning Objectives: 1) Identify the extent, range, and nature of the recent evidence on shared decision making and patient autonomy in MS. 2) Examine the limitations of the current available evidence and resulting research/knowledge gaps. Accreditation Statement: In support of improving patient care, this activity has been planned and implemented by the Consortium of Multiple Sclerosis Centers (CMSC) and Delaware Media Group. The CMSC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Physician Credit: The CMSC designates this journal-based activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurse Credit: The CMSC designates this enduring material for 1.0 contact hour (none in the area of pharmacology). Disclosures: Francois Bethoux, MD, Editor in Chief of the International Journal of MS Care (IJMSC), has served as Physician Planner for this activity. He has disclosed relationships with Springer Publishing (royalty), Qr8 (receipt of intellectual property rights/patent holder), Biogen (receipt of intellectual property rights/patent holder, speakers’ bureau), GW Pharma (consulting fee), MedRhythms (consulting fee, contracted research), Genentech (consulting fee), Helius (consulting fee), and Adamas Pharmaceuticals (contracted research). Laurie Scudder, DNP, NP, has served as Reviewer for this activity. She has disclosed no relevant financial relationships. Anne Christin Rahn, PhD, has disclosed no relevant financial relationships. Alessandra Solari, MD, has disclosed relationships with Biogen, Merck Serono, Novartis, Almirall, and Excemed (personal fees for speaker honoraria). Heleen Beckerman, PhD, has disclosed no relevant financial relationships. Richard Nicholas, PhD, has disclosed relationships with Biogen, Roche, and Novartis (consulting fee) and Novartis, Biogen, Roche, and Sanofi (principal investigator on MS trials). David Wilkie, PhD, has disclosed no relevant financial relationships. Christoph Heesen, MD, has disclosed no relevant financial relationships. Andrea Giordano, MSc, has disclosed no relevant financial relationships. The peer reviewer for IJMSC has disclosed relationships with Biogen, Novartis, Roche, and Sanofi Genzyme (consulting fee, speakers’ bureau, contracted research); EMD Serono (consulting fee, speakers’ bureau); and Alexion and Teva Neuroscience (consulting fee). The staff at IJMSC, CMSC, and Delaware Media Group who are in a position to influence content have disclosed no relevant financial relationships. Note: Financial relationships may have changed in the interval between listing these disclosures and publication of the article. Method of Participation: Release Date: December 1, 2020 Valid for Credit Through: December 1, 2021 In order to receive CME/CNE credit, participants must: 1) Review the continuing education information, including learning objectives and author disclosures.2) Study the educational content.3) Complete the post-test and evaluation, which are available at http://www.cmscscholar.org Statements of Credit are awarded upon successful completion of the evaluation and the post-test with a passing score of & gt;70%. The post-test may be retaken if necessary. There is no fee to participate in this activity. Disclosure of Unlabeled Use: This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the FDA. The CMSC and Delaware Media Group do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the CMSC or Delaware Media Group. Disclaimer: Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any medications, diagnostic procedures, or treatments discussed in this publication should not be used by clinicians or other health care professionals without first evaluating their patients’ conditions, considering possible contraindications or risks, reviewing any applicable manufacturer’s product information, and comparing any therapeutic approach with the recommendations of other authorities.

Abstract: Background: The Action Research Arm (ARA) test is a performance test of upper extremity motor function which consists of 19 items divided into four hierarchical subtests. This multidimensionality has not yet been tested empirically. Objective: To investigate the dimensionality of the ARA test. Design: Cross-sectional study involving a sample of 63 chronic stroke patients. Methods: A Mokken scale analysis was performed. Results: The Mokken scale analysis revealed one strong unidimensional scale containing all 19 items, of which the scalability coefficient H was 0.79, while H per item ranged from 0.69 to 0.86. The reliability coefficient rho equalled 0.98, indicating a very high internal consistency. A subset of 15 out of 19 items showed an invariant hierarchical item-ordering. Conclusion: The ARA test is a unidimensional scale. The use of subtests, as proposed in the original description of the instrument, is not supported by the present findings. The 15-item scale presented here can be used for adaptive testing, i.e. using only a selected subset of items based on prior knowledge about the patient's abilities, thus minimizing testing time.

Abstract: Objective: Assessment of the available evidence for the effectiveness of exercise therapy to improve arm function in patients who have suffered from a stroke. Methods: A systematic search of bibliographical databases and reference checking were performed to identify publications on randomized controlled trials (RCTs) which evaluated the effect of exercise therapy on arm function in stroke patients. The methodological quality was assessed systematically by two raters, based on a standardized list of methodological criteria. Study characteristics, such as the chronicity and severity of impairment of the patient population, the amount and duration of interventions, and specific methodological criteria, were related to reported effects. Results: Thirteen RCTs were identified, six of which reported positive results on an arm function test. In five of these six studies there was a contrast in amount or duration of exercise therapy between groups. Methodological scores ranged from 5 to 15 (maximum possible score: 19 points). Conclusion: Insufficient evidence made it impossible to draw definitive conclusions about the effectiveness of exercise therapy on arm function in stroke patients. The difference in results between studies with and without contrast in the amount or duration of exercise therapy between groups suggests that more exercise therapy may be beneficial.

Abstract: Cognitive behavioural therapy (CBT) reduces multiple sclerosis (MS)-related fatigue. Implementation of face-to-face CBT is hindered by limited treatment capacity and traveling distances to treatment locations. Objective: Evaluate whether blended CBT (online treatment modules supported with guidance by a therapist) is non-inferior to face-to-face CBT in reducing fatigue severity in severely fatigued patients with MS. Method: A non-inferiority multicentre randomized clinical trial, in which 166 patients with MS were allocated to either face-to-face or blended CBT. Primary outcome was fatigue severity assessed with the Checklist Individual Strength fatigue subscale directly post-treatment (week 20). Mixed model analysis was used by a statistician blinded for allocation to determine between-group differences post-treatment. The upper limit of the 95% confidence interval (CI) was compared to a pre-specified non-inferiority margin of 5.32. Results: Blended CBT ( N = 82) was non-inferior to face-to-face CBT ( N = 84) (B = 1.70, 95% CI: −1.51 to 4.90). Blended CBT significantly reduced therapist time ( B = −187.1 minutes, 95% CI: 141.0–233.3). Post hoc analysis showed more improvement ( B = −5.35, 95% CI: −9.22 to −1.48) when patients received their preferred treatment. No harm related to treatment was reported. Discussion: Blended CBT is an efficient alternative to face-to-face CBT. Offering the preferred CBT format may optimize treatment outcome.

Abstract: Exercise as a subset of physical activity is a cornerstone in the management of multiple sclerosis (MS) based on its pleotropic effects. There is an exponential increase in the quantity of research on exercise in MS, yet a number of barriers associated with study content and quality hamper rapid progress in the field. To address these barriers and accelerate discovery, a new international partnership of MS-related experts in exercise has emerged with the goal of advancing the research agenda. As a first step, the expert panel met in May 2018 and identified the most urgent areas for moving the field forward, and discussed the framework for such a process. This led to identification of five themes, namely “Definitions and terminology,” “Study methodology,” “Reporting and outcomes,” “Adherence to exercise,” and “Mechanisms of action.” Based on the identified themes, five expert groups have been formed, that will further (a) outline the challenges per theme and (b) provide recommendations for moving forward. We aim to involve and collaborate with people with MS/MS organizations (e.g. Multiple Sclerosis International Federation (MSIF) and European Multiple Sclerosis Platform (EMSP)) in all of these five themes. The generation of this thematic framework with multi-expert perspectives can bolster the quality and scope of exercise studies in MS that may ultimately improve the daily lives of people with MS.

Abstract: The Transmural Trauma Care Model (TTCM) is a refined post-clinical rehabilitation approach, in which a multidisciplinary hospital-based team guides a network of primary care physical therapists in the treatment of trauma patients. The objective of this study was to assess the effectiveness of the TTCM compared to regular care. Methods A controlled-before-and-after study was performed in a level 1 trauma center. The TTCM includes four elements: 1) a multidisciplinary team at the outpatient clinic, 2) coordination and individual goal setting for each patient by this team, 3) a network of primary care physical therapists, 4) E-health support for transmural communication. Intervention group patients were prospectively followed (3, 6 and 9 months). The control group consisted of 4 clusters of patients who either had their first consultation at the outpatient clinic 0, 3, 6 or 9 months ago. Outcomes included generic- and disease-specific health-related quality of life (HR-QOL), pain, functional status, patient satisfaction, and perceived recovery. Between-group comparisons were made using linear regression analyses. The recovery pattern of intervention group patients was identified using longitudinal data analysis methods. Results A total of 83 participants were included in the intervention group. In the control group, 202 participants were included (68 in the baseline cluster, 26 in the 3-month cluster, 51 in the 6-month cluster, 57 in the 9-month cluster). Between-group differences were statistically significant in favor of the intervention group for disease-specific HR-QOL at 9 months, pain at 6 and 9 months, functional status at 6 and 9 months, patient satisfaction at 3, 6 and 9 months, and perceived recovery at 6 months. No significant differences were found between groups for generic HR-QOL at any time point. Generic HR-QOL, disease-specific HR-QOL, pain, and functional status significantly improved in a linear fashion among intervention group patients during the nine-month follow-up period. Conclusions This study provides preliminary evidence that the TTCM is effective in improving patient related outcome measures, such as disease-specific HR-QOL, pain and functional status. A multicenter, and ideally randomized controlled trial, is required to confirm these results. Trial registration The trial is registered at the Dutch Trial Register ( NTR5474 ). Registered 12 October 2015. Retrospectively registered.