These findings highlight the need for more comprehensive assessments of walking impairment in patients with MS and further evaluation from the patient's perspective.

Upper extremity (UE) dysfunction may be present in up to ~80% of individuals with multiple sclerosis (MS), although its importance may be under-recognized relative to walking impairment, which is the hallmark symptom of MS. Upper extremity dysfunction affects independence and can impact the ability to use walking aids. Under-recognition of UE dysfunction may result in part from limited availability of performance-based and patient self-report measures that are validated for use in MS and that can be readily incorporated into clinical practice for screening and regularly scheduled assessments. In addition to the 9-Hole Peg Test, which is part of the Multiple Sclerosis Functional Composite, there are several performance-based measures that are generally used in the rehabilitation setting. These measures include the Box and Block Test, the Action Research Arm Test, the Test d'Evaluation de la performance des Membres Supérieurs des Personnes Agées, and the Jebsen-Taylor Test of Hand Function. Several of these measures were developed for use in stroke, although in contrast to stroke, which is characterized by unilateral dysfunction, UE impairment in MS is generally bilateral, and should be assessed as such. Similarly, patient-reported UE measures are available, including Disabilities of the Arm, Shoulder, and Hand (DASH) and its shorter version, QuickDASH, the Manual Ability Measure, and ABILHAND, although none has been psychometrically validated for MS. Recently, item response theory was used to develop a Neuro-QOL (Quality of Life) UE measure and a Patient-Reported Outcomes Measurement Information System UE measure; neither of these have demonstrated sensitivity to change, limiting their use for longitudinal assessment. Consequently, although work is still needed to develop and validate performance-based and patient-reported measures of UE function that are suitable for use in daily MS clinical practice, currently available UE measures can be recommended for incorporation into MS management, albeit with an understanding of their limitations.

Clinical signs and symptoms of spasticity include hypertonia, involuntary movements (spasms, clonus), decreased range of motion, contractures, and often spasm-related pain. When spasticity is refractory to medical management, patients may be referred for intrathecal baclofen (ITB) pump placement. We reviewed a cohort of amyotrophic lateral sclerosis (ALS) patients with intractable spasticity requiring ITB to further define the impact of ITB on pain relief in this patient population. From 2003 to 2005, eight patients (mean age 43.8 years; 5 men, 3 women) with ALS received ITB for pain associated with intractable spasticity at our institution. Mean disease duration preoperatively was 47.4 months, mean follow-up was 9.8 months, and pain was evaluated using a 0-10 scoring system. All patients experienced spasticity relief in response to a preoperative bolus test injection of ITB (25-50 microg) via lumbar puncture. Following ITB pump placement, the average reduction of pain was 54% (P = 0.0082). Six patients (75%) experienced pain score reduction, three of whom had complete pain relief. Postoperative pain reduction was predicted by the degree of pain reduction following preoperative ITB test injection. These results support ITB as a treatment modality for pain associated with spasticity in ALS.

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Background/Aims: Traditionally, physical therapy for gait and balance training takes place in a gym setting, which may not fully reproduce situations in everyday activities. The Computer Assisted Rehabilitation ENvironment system provides an immersive virtual environment, allowing a simulation of complex conditions conducive to gait and balance training. The purpose of this study was to determine: (1) the feasibility and safety of using the Computer Assisted Rehabilitation ENvironment system for physical therapy sessions with multiple sclerosis patients, and (2) pre-post treatment changes observed with the Computer Assisted Rehabilitation ENvironment system compared to traditional physical therapy. Findings: Data from functional outcome measures Berg Balance Scale, Timed Up and Go test, Timed 25-Foot Walk, and 6-Minute Walk Test were extracted from the medical records of 62 patients with multiple sclerosis who had at least three physical therapy sessions in either environment. Statistically significant within-group improvements were observed for all outcome measures in the physical therapy Computer Assisted Rehabilitation ENvironment system group (P<0.05), and only for Berg Balance Scale in the traditional physical therapy group. There was a significant between-group difference in favour of physical therapy with the Computer Assisted Rehabilitation ENvironment system for the Timed 25-Foot Walk (P=0.022). Conclusions: The results suggest the Computer Assisted Rehabilitation ENvironment system is a safe and effective tool for physical therapy-led gait and balance training for individuals with multiple sclerosis.

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Test); and a validated VE user questionnaire. Results: 18 participants (20 enrolled) completed the study (8 PT and 10 VE). Body mass index was higher (pZ0.02) and time from disease onset was shorter (pZ0.02) in the PT group. No statistically significant between-group differences in change on outcome measures were observed. There were significant within-group pre-post intervention changes for PT (T25FW velocity pZ0.01, dZ0.62; stride length pZ0.02, dZ0.38; PHQ-8 pZ0.03, dZ-0.25), and VE (dual-task step width pZ0.01, dZ0.48; GAD-7 pZ0.04, dZ-0.58). Participant satisfaction with the VE system was high. Conclusions: We found no significant difference between PT and VE on multidimensional outcomes, while significant changes were observed within each group. Further research is needed to better understand the usefulness of virtual reality in MS rehabilitation.

Multiple sclerosis (MS) is a complex neurological disease that requires comprehensive multidiscipli-nary care to maximize patient outcomes. A multidisciplinary health care team treating MS patients often consists of neurologists, physiatrists, nurses, physician assistants or nurse practitioners, and physical and occupational therapists, many of whom are specialists in MS. This article clarifies the role of the physical therapist in the care of patients within a multidisciplinary MS clinic.