Systematic literature review and validity evaluation of the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC) in patients with multiple sclerosis

Sandra Meyer-Moock, You-Shan Feng, Mathias Maeurer, Franz-Werner Dippel, Thomas Kohlmann, Sandra Meyer-Moock, You-Shan Feng, Mathias Maeurer, Franz-Werner Dippel, Thomas Kohlmann

Abstract

Background: There are a number of instruments that describe severity and progression of multiple sclerosis and they are increasingly used as endpoints to assess the effectiveness of therapeutic interventions. We examined to what extent the psychometric properties of two accepted instruments--EDSS and MSFC--meet methodological standards and the value they have in clinical trials.

Methods: We conducted a systematic literature search in relevant databases [MEDLINE (PubMed), ISI Web of Science, EMBASE, PsycINFO & PSYNDEX, CINAHL] yielding 3,860 results. Relevant full-text publications were identified using abstract and then full-text reviews, and the literature was reviewed.

Results: For evaluation of psychometric properties (validity, reliability, sensitivity of change) of EDSS and MSFC, 120 relevant full-text publications were identified, 54 of them assessed the EDSS, 26 the MSFC and 40 included both instruments. The EDSS has some documented weaknesses in reliability and sensitivity to change. The main limitations of the MSFC are learning effects and the z-scores method used to calculate the total score. However, the methodological criterion of validity applies sufficiently for both instruments.For use in clinical studies, we found the EDSS to be preferred as a primary and secondary outcome measure in recent studies (50 EDSS, 9 MSFC).

Conclusions: Recognizing their strengths and weaknesses, both EDSS and MSFC are suitable to detect the effectiveness of clinical interventions and to monitor disease progression. Almost all publications identify the EDSS as the most widely used tool to measure disease outcomes in clinical trials. Despite some limitations, both instruments are accepted as endpoints and neither are discussed as surrogate parameters in identified publications. A great advantage of the EDSS is its international acceptance (e.g. by EMA) as a primary endpoint in clinical trials and its broad use in trials, enabling cross-study comparisons.

Figures

Figure 1
Figure 1
Selection process of methodological publications for EDSS and/or MSFC.

References

    1. Weinshenker BG. The natural history of multiple sclerosis. Clin Neurol Neurosurg. 1995;13:119–146.
    1. Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale. Neurology. 1983;5:580–583.
    1. Cutter GR, Baier ML, Rudick RA, Cookfair DL, Fischer JS, Petkau J, Syndulko K, Weinshenker BG, Antel JP, Confavreux C, Ellison GM, Lublin F, Miller AE, Rao SM, Reingold S, Thompson A, Willoughby A. Development of a multiple sclerosis functional composite as a clinical trial outcome measure. Brain. 1999;122:871–882. doi: 10.1093/brain/122.5.871.
    1. Fischer JS, Rudick RA, Cutter GR, Reingold SC. The Multiple Sclerosis Functional Composite Measure (MSFC): an integrated approach to MS clinical outcome. National MS Society Clinical Outcomes Assessment Task Force. Mult Scler. 1999;5(4):244–250.
    1. Baier ML, Cutter GR, Ruck RA. Low-contrast letter acuity testing captures visual dysfunction in patients with multiple sclerosis. Neurology. 2005;64:992–995. doi: 10.1212/01.WNL.0000154521.40686.63.
    1. Balcer LJ. Clinical outcome measures for research in multiple sclerosis. J Neuroophthalmol. 2001;21:296–301. doi: 10.1097/00041327-200112000-00014.
    1. Balcer LJ, Baier ML, Cohen JA, Kooijmans MF, Sandrock AW, Nano-Schiavi ML, Pfohl DC, Mills M, Bowen J, Ford C, Heidenreich FR, Jacobs DA, Markowitz CE, Stuart WH, Ying GS, Galetta SL, Maguire MG, Cutter GR. Contrast letter acuity as a visual component for the multiple sclerosis functional composite. Neurology. 2003;61:1367–1373. doi: 10.1212/01.WNL.0000094315.19931.90.
    1. Drake AS, Weinstock-Guttman B, Morrow SA, Hojnacki D, Munschauer FE, Benedict RH. Psychometrics and normative data for the multiple sclerosis functional composite: replacing the PASAT with the symbol digit modalities test. Mult Scler. 2010;16:228–237. doi: 10.1177/1352458509354552.
    1. Rudick RA, Polman CH, Cohen JA, Walton MK, Miller AE, Confavreux C, Lublin FD, Hutchinson M, O'Connor PW, Schwid SR, Balcer LJ, Lynn F, Panzara MA, Sandrock AW. Assessing disability progression with the multiple sclerosis functional composite. Mult Scler. 2009;15:984–997. doi: 10.1177/1352458509106212.
    1. Uitdehaag BMJ, Adèr HJ, Roosma TJ, de Groot V, Kalkers NF, Polman CH. Multiple sclerosis functional composite: impact of reference population and interpretation of changes. Mult Scler. 2002;8:366–371. doi: 10.1191/1352458502ms835oa.
    1. Bosma L, Kragt JJ, Brieva L, Khaleel Z. The search for responsive clinical endpoints in primary progressive multiple sclerosis. Mult Scler. 2009;15:715–720. doi: 10.1177/1352458509102626.
    1. Vaney C, Vaney S, Wade DT. SaGAS, the short and graphic ability score: an alternative scoring method for the motor components of the multiple sclerosis functional composite. Mult Scler. 2004;10:231–242. doi: 10.1191/1352458504ms1000oa.
    1. Nagels G, Geentjens L, Kos D, Vleugels L, D'hooghe MB, Van Asch P, Vuylsteke K, De Deyn PP. Paced visual serial addition test in multiple sclerosis. Clin Neurol Neurosurg. 2005;107:218–222. doi: 10.1016/j.clineuro.2004.11.016.
    1. Hauser SL, Dawson DM, Lehrich JR, Beal MF, Kevy SV, Propper RD, Mills JA, Weiner HL. Intensive immunosuppression in progressive multiple sclerosis: a randomized, three-arm study of high-dose intravenous cyclophosphamide, plasma exchange, and ACTH. N Engl J Med. 1983;308:173–180. doi: 10.1056/NEJM198301273080401.
    1. Sipe JC, Knobler RL, Braheny SL, Rice GP, Panitch HS, Oldstone MS. A neurologic rating scale (NRS) for use in multiple sclerosis. Neurology. 1984;34:1368–1372. doi: 10.1212/WNL.34.10.1368.
    1. Mickey MR, Ellison GW, Myers LW. An illness severity score for multiple sclerosis. Neurology. 1984;34:1343–1347. doi: 10.1212/WNL.34.10.1343.
    1. Sharrack B, Hughes R. The Guy’s Neurological Disability Scale (GNDS): a new disability measure for multiple sclerosis. Mult Scler. 1999;5(4):223–233.
    1. Ravnborg M, Grønbech-Jensen M, Jønsson A. The MS-impairment scale: a pragmatic approach to the assessment of impairment in patients with multiple sclerosis. Mult Scler. 1997;3:31–42. doi: 10.1177/135245859700300104.
    1. Hamilton BB, Granger CV, Shervin FS, Zielezny M, Teshman JS. In: Rehabilitation Outcomes: Analysis and Measurements. Fuhrer MJ, editor. Baltimore: Brookes; 1987. A uniform national data system for medical rehabilitation; pp. 137–147.
    1. Mumford CJ, Compston A. Problem with rating scales for multiple sclerosis: a novel approach – the CAMBS score. J Neurol. 1993;240:209–215. doi: 10.1007/BF00818706.
    1. Noseworthy JH. Clinical scoring methods for multiple sclerosis. Ann Neurol. 1994;36(Supplement):S80–S85.
    1. Vickrey BG, Hays RD, Harooni R, Myers LW, Ellison GW. A health-related quality of life measure for multiple sclerosis. Qual Life Res. 1995;4:187–206. doi: 10.1007/BF02260859.
    1. Ritvo PG, Fischer JS, Miller DM, Andrews H, Paty DW, LaRocca MG. Multiple Sclerosis Quality of Life Inventory (MSQLI): a user’s Manual. New York: National Multiple Sclerosis Society; 1997.
    1. Noseworthy JH, Vandervoort MK, Wong CJ, Ebers GC. Interrater variability with the Expanded Disability Status Scale (EDSS) and Functional Systems (FS) in a multiple sclerosis clinical. Neurology. 1990;40:971–975. doi: 10.1212/WNL.40.6.971.
    1. Francis DA, Bain P, Swan AV, Hughes RA. An assessment of disability rating scales used in multiple sclerosis. Arch Neurol. 1991;48:299–301. doi: 10.1001/archneur.1991.00530150067020.
    1. Verdier-Taillefer MH, Zuber M, Lyon-Caen O, Clanet M, Gout O, Louis C, Alpérovitch A. Observer disagreement in rating neurologic impairment in multiple sclerosis: facts and consequences. Eur Neurol. 1991;31:117–119. doi: 10.1159/000116658.
    1. Goodkin DE, Cookfair D, Wende K, Bourdette D, Pullicino P, Scherokman B, Whitham R. Inter- and intrarater scoring agreement using grades 1.0 to 3.5 of the Kurtzke Expanded Disability Status Scale (EDSS) Neurology. 1992;42:859–863. doi: 10.1212/WNL.42.4.859.
    1. Marolf MV, Vaney C, Konig N, Schenj T, Prosiegel M. Evaluation of disability in multiple sclerosis patients: a comparative study of the functional independence measure, the extended barthel index and the expanded disability status scale. Clin Rehabil. 1996;10:309–313. doi: 10.1177/026921559601000408.
    1. Sharrack B, Hughes R, Soudain S, Dunn G. The psychometric properties of clinical rating scales used in multiple sclerosis. Brain J Neurol. 1999;122:141–159. doi: 10.1093/brain/122.1.141.
    1. Willoughby EW, Paty DW. Scales for rating impairment in multiple sclerosis: a critique. Neurology. 1988;38:1793–1798. doi: 10.1212/WNL.38.11.1793.
    1. Amato MP, Ponziani G. Quantification of impairment in MS: discussion of the scales in use. Mult Scler. 1999;5:216–219.
    1. Hobart J, Freeman J, Thompson A. Kurtzke scales revisted: the application of psychometric methods to clinical intuition. Brain. 2000;123:1027–1040. doi: 10.1093/brain/123.5.1027.
    1. Multiple IFNB. Sclerosis Study Group. Interferon beta-1b is effective in relapsing-remitting multiple sclerosis. I. Clinical results of a multicenter, randomized, double-blind, placebo-controlled trial. Neurology. 1993;43:655–661.
    1. PRIMS (Prevention of Relapses and Disability by Interferon beta-1a Subcutaneously in Multiple Sclerosis) Study Group. Randomised double-blind placebo-controlled study of interferon beta-1a in relapsing/remitting multiple sclerosis. Lancet. 1998;352:1498–1504. doi: 10.1016/S0140-6736(98)03334-0.
    1. Jacobs LD, Cookfair DL, Rudick RA, Herndon RM, Richert JR, Salazar AM, Fischer JS, Goodkin DE, Granger CV, Simon JH, Alam JJ, Bartoszak DM, Bourdette DN, Braiman J, Brownscheidle CM, Coats ME, Cohan SL, Dougherty DS, Kinkel RP, Mass MK, Munschauer FE 3rd, Priore RL, Pullicino PM, Scherokman BJ, Weinstock-Guttman B, Whitham RH. Intramuscular interferon beta-1a for disease progression in relapsing multiple sclerosis. The Multiple Sclerosis Collaborative Research Group (MSCRG) Ann Neurol. 1996;39:285–294. doi: 10.1002/ana.410390304.
    1. Johnson KP, Brooks BR, Cohen JA, Ford CC, Goldstein J, Lisak RP, Myers LW, Panitch HS, Rose JW, Schiffer RB. Copolymer 1 reduces relapse rate and improves disability in relapsing-remitting multiple sclerosis: results of a phase III multicenter, double-blind, placebo-controlled trial. Neurology. 1995;45(7):1268–1276. doi: 10.1212/WNL.45.7.1268.
    1. Paty DW, Li DK. Interferon beta-1bis effective in relapsing-remitting multiple sclerosis. II. MRI analyses results of a multicenter, randomized, double-blind, placebo-controlled trial UBCMS/MRI study group and the IFNB multiple sclerosis study group. Neurology. 1993;43:622–667. doi: 10.1212/WNL.43.3_Part_1.622.
    1. Wolinsky JS, Narayana PA, Johnson KP. United-States open-label glatiramer acetate extension trial for relapsing multiple sclerosis: MRI and clinical correlates. Multiple Sclerosis Study Group and the MRI Analysis Center. Mult Scler. 2001;7:33–41.
    1. Coles AJ, Compston DA, Selmaj KW, Lake SL, Moran S, Margolin DH, Norris K, Tandon PK. Alemtuzumab vs. interferon beta-1a in early multiple sclerosis. N Engl J Med. 2008;359:1786–1801.
    1. Polman CH, O’Connor PW, Havrdova E, Hutchinson M, Kappos L, Miller DH, Phillips JT, Lublin FD, Giovannoni G, Wajgt A, Toal M, Lynn F, Panzara MA, Sandrock AW. AFFIRM Investigators. A randomized, placebo-controlled trial of natalizumab for relapsing multiple sclerosis. N Engl J Med. 2006;354:899–891. doi: 10.1056/NEJMoa044397.
    1. Rudick RA, Stuart WH, Calabresi PA, Confavreux C, Galetta SL, Radue EW, Lublin FD, Weinstock-Guttman B, Wynn DR, Lynn F, Panzara MA, Sandrock AW. SENTINEL Investigators. Natalizumab plus interferon beta-1a for relapsing multiple sclerosis. N Engl J Med. 2006;354:911–923. doi: 10.1056/NEJMoa044396.
    1. European Medicines Agency (EMA) Guideline of clinical investigation of medical products for the treatment of Multiple Sclerosis. Draft. EMA/CHMP/771815/2011, Rev 2,20 September 2012. .
    1. Amato MP, Groppi C, Siracusa G. Fratiglioni. Inter and intra-observer reliability in Kurtzke scoring systems in multiple sclerosis. Ital J Neurol Sci. 1987;Supplement 6:129–131.
    1. Amato MP, Fratiglioni L, Groppi C, Siracusa G, Amaducci L. Interrater reliability in assessing functional systems and disability on the Kurtzke scale in multiple sclerosis. Arch Neurol. 1988;45:746–748. doi: 10.1001/archneur.1988.00520310052017.
    1. Amato MP, Portaccio E. Clinical outcome measures in multiple sclerosis. J Neurol Sci. 2007;259:118–122. doi: 10.1016/j.jns.2006.06.031.
    1. Ebers GC, Heigenhauser L, Daumer M, Lederer C, Noseworthy JH. Disability as an outcome in MS clinical trials. Neurology. 2008;71:624–631. doi: 10.1212/01.wnl.0000313034.46883.16.
    1. Brosseau L, Wolfson C. The inter-rater reliability and construct validity of the functional independence measure for multiple sclerosis subjects. Clin Rehabil. 1994;8:107–115. doi: 10.1177/026921559400800203.
    1. Rothwell PM, McDowell Z, Wong CK, Dorman PJ. Doctors and patients don’t agree: cross sectional study of patient’s and doctors’ perceptions and assessments of disability in multiple sclerosis. Br Med J. 1997;314:1580–1583. doi: 10.1136/bmj.314.7094.1580.
    1. Schwid SR, Goodman AD, Mattson DH, Mihai C, Donohoe KM, Petrie MD, Scheid EA, Dudman JT, McDermott MP. The measurement of ambulatory impairment in multiple sclerosis. Neurology. 1997;49:1419–1424. doi: 10.1212/WNL.49.5.1419.
    1. Cohen RA, Kessler HR, Fischer M. The Extended Disability Status Scale (EDSS) as a predictor of impairments of functional activities of daily living in multiple-sclerosis. J Neurol Sci. 1993;115:132–135. doi: 10.1016/0022-510X(93)90215-K.
    1. Gaspari M, Roveda G, Scandellari C, Stecchi S. An expert system for the evaluation of EDSS in multiple sclerosis. Artif Intell Med. 2002;25:187–210. doi: 10.1016/S0933-3657(02)00015-5.
    1. Cohen JA, Fischer JS, Bolibrush DM, Jak AJ, Kniker JE, Mertz LA, Skaramagas TT, Cutter GR. Intrarater and interrater reliability of the MS functional composite outcome measure. Neurology. 2000;54:802–806. doi: 10.1212/WNL.54.4.802.
    1. Hohol MJ, Orav EJ, Weiner HL. Disease steps in multiple-sclerosis - a simple approach to evaluate disease progression. Neurology. 1995;45:251–255. doi: 10.1212/WNL.45.2.251.
    1. Hutchinson J, Hutchinson M. The functional limitations profile may be a valid, reliable and sensitive measure of disability in multiple-sclerosis. J Neurol. 1995;242:650–657. doi: 10.1007/BF00866915.
    1. Schwid SR, Goodman AD, Apatoff BR, Coyle PK, Jacobs LD, Krupp LB, Miller AE, Wende KE, Brownscheidle CM. New York State Multiple Sclero. Are quantitative functional measures more sensitive to worsening MS than traditional measures? Neurology. 2000;55:1901–1903. doi: 10.1212/WNL.55.12.1901.
    1. Vaney C, Blaurock H, Gattlen B, Meisels C. Assessing mobility in multiple sclerosis using the rivermead mobility index and gait speed. Clin Rehabil. 1996;10:216–226. doi: 10.1177/026921559601000306.
    1. Koziol JA, Frutos A, Sipe JC, Romine JS, Beutler E. A comparison of two neurologic scoring instruments for multiple sclerosis. J Neurol. 1996;243:209–213. doi: 10.1007/BF00868516.
    1. Hohol MJ, Orav EJ, Weiner HL. Disease steps in multiple sclerosis: a longitudinal study comparing disease steps and EDSS to evaluate disease progression. Mult Scler. 1999;5:349–354.
    1. Ravnborg M, Blinkenberg M, Sellebjerg F, Ballegaard M, Larsen SH, Sørensen PS. Responsiveness of the multiple sclerosis impairment scale in comparison with the expanded disability status scale. Mult Scler. 2005;11:81–84. doi: 10.1191/1352458505ms1120oa.
    1. Barker-Collo SL. Quality of life in multiple sclerosis: does information-processing speed have an independent effect? Arch Clin Neuropsychol. 2006;21:167–174. doi: 10.1016/j.acn.2005.08.008.
    1. Hyland M, Rudick RA. Challenges to clinical trials in multiple sclerosis: outcome measures in the era of disease-modifying drugs. Curr Opin Neurol. 2011;24:255–26. doi: 10.1097/WCO.0b013e3283460542.
    1. Drulovic J, Riise T, Nortvedt M, Pekmezovic T. Manigoda. Self-rated physical health predicts change in disability in multiple sclerosis. Mult Scler. 2008;14:999–1002. doi: 10.1177/1352458508088917.
    1. Fisk JD, Brown MG, Sketris IS, Metz LM, Murray TJ, Stadnyk KJ. A comparison of health utility measures for the evaluation of multiple sclerosis treatments. J Neurol Neurosurg Psychiatry. 2005;76:58–63. doi: 10.1136/jnnp.2003.017897.
    1. Twork S, Wiesmeth S, Spindler M, Wirtz M, Schipper S, Pöhlau D, Klewer J, Kugler J. Disability status and quality of life in multiple sclerosis: non-linearity of the Expanded Disability Status Scale (EDSS) Health Qual Life Outcomes. 2010;8:55. doi: 10.1186/1477-7525-8-55.
    1. Healy B, Chitnis T, Engler D. Improving power to dect disease progression in multiple sclerosis through alternative analysis strategies. J Neurol. 2011;258:1812–1819. doi: 10.1007/s00415-011-6021-1.
    1. Goodkin DE. EDSS reliability. Neurology. 1991;41:322. doi: 10.1212/WNL.41.2_Part_1.322.
    1. Brochet B, Deloire MS, Bonnet M, Salort-Campana E, Ouallet JC, Petry KG, Dousset V. Should SDMT substitute for PASAT in MSFC? A 5-year longitudinal study. Mult Scler J. 2008;14:1242–1249. doi: 10.1177/1352458508094398.
    1. Kalkers NF, Bergers L, de Groot V, Lazeron RH, van Walderveen MA, Uitdehaag BM, Polman CH, Barkhof F. Concurrent validity of the MS functional composite using MRI as a biological disease marker. Neurology. 2001;56:215–219. doi: 10.1212/WNL.56.2.215.
    1. Hoogervorst ELJ, Kalkers NF, Cutter GR, Uitdehaag BM, Polman CH. The patient’s perception of a (reliable) change in the Multiple Sclerosis Functional Composite. Mult Scler. 2004;10:55–60. doi: 10.1191/1352458504ms972oa.
    1. Miller DM, Rudick RA, Cutter G, Baier M, Fischer JS. Clinical significance of the multiple sclerosis functional composite: relationship to patient-reported quality of life. Arch Neurol. 2000;57:1319–1324.
    1. Ozakbas S, Cagiran I, Ormeci B, Idiman E. Correlations between multiple sclerosis functional composite, expanded disability status scale and health-related quality of life during and after treatment of relapses in patients with multiple sclerosis. J Neurol Sci. 2004;218:3–7. doi: 10.1016/j.jns.2003.09.015.
    1. Honarmand K, Akbar N, Kou N, Feinstein A. Predicting employment status in multiple sclerosis patients: the utility of the MS functional composite. J Neurol. 2011;258:244–249. doi: 10.1007/s00415-010-5736-8.
    1. Cohen JA, Reingold SC, Polman CH, Wolinsky JS. Disability outcome measures in multiple sclerosis clinical trials: current status and future prospects. Lancet Neurol. 2012;11:467–476. doi: 10.1016/S1474-4422(12)70059-5.
    1. Rudick RA, Cutter G, Reinold S. The multiple sclerosis functional composite: a new clinical outcome measure for multiple sclerosis. Mult Scler. 2002;8:359–365. doi: 10.1191/1352458502ms845oa.
    1. Cohen JA, Cutter GR, Fischer JS, Goodman AD, Heidenreich FR, Jak AJ, Kniker JE, Kooijmans MF, Lull JM, Sandrock AW, Simon JH, Simonian NA, Whitaker JN. Use of the multiple sclerosis functional composite as an outcome measure in a phase 3 clinical trial. Arch Neurol. 2001;58:961–967. doi: 10.1001/archneur.58.6.961.
    1. Hoogervorst ELJ, Kalkers NF, Uitdehaag BM, Polman CH. A study validating changes in the multiple sclerosis functional composite. Arch Neurol. 2002;59:113–116. doi: 10.1001/archneur.59.1.113.
    1. Pascual AM, Boscá I, Coret F, Escutia M, Bernat A, Casanova B. Evaluation of response of multiple sclerosis (MS) relapse to oral high-dose methylprednisolone: usefulness of MS functional composite and Expanded Disability Status Scale. Eur J Neurol. 2008;15:284–288. doi: 10.1111/j.1468-1331.2008.02061.x.
    1. Kalkers NF, de Groot V, Lazeron RH, Killestein J, Adèr HJ, Barkhof F, Lankhorst GJ, Polman CH. MS functional composite - relation to disease phenotype and disability strata. Neurology. 2000;54:1233–1239. doi: 10.1212/WNL.54.6.1233.
    1. Miller DM, Cohen JA, Kooijmans M, Tsao E, Cutter G, Baier M. Change in clinician-assessed measures of multiple sclerosis and subject-reported quality of life: results from the IMPACT study. Mult Scler. 2006;12:180–186. doi: 10.1191/135248506ms1270oa.
    1. Rosti-Otajarvi E, Hämäläinen P, Koivisto K, Hokkanen L. The reliability of the MSFC and its components. Acta Neurol Scand. 2008;117:421–427.
    1. Schwid SR, Goodman AD, McDermott MP, Bever CF, Cook SD. Quantitative functional measures in MS: What is a reliable change? Neurology. 2002;58:1294–1296. doi: 10.1212/WNL.58.8.1294.
    1. Bosma LVAE, Kragt JJ, Brieva L, Khaleeli Z, Montalban X, Polman CH, Thompson AJ, Tintoré M, Uitdehaag BM. Progression on the multiple sclerosis functional composite in multiple sclerosis: what is the optimal cut-off for the three components? Mult Scler J. 2010;16:862–867. doi: 10.1177/1352458510370464.
    1. Solari A, Radice D, Manneschi L, Motti L, Montanari E. The multiple sclerosis functional composite: different practice effects in the three test components. J Neurol Sci. 2005;228:71–74. doi: 10.1016/j.jns.2004.09.033.
    1. Ozakbas S, Ormeci B, Idiman E. Utilization of the multiple sclerosis functional composite in follow-up: relationship to disease phenotype, disability and treatment strategies. J Neurol Sci. 2005;232:65–69. doi: 10.1016/j.jns.2005.01.008.
    1. Patzold T, Schwengelbeck M, Ossege LM, Malin JP, Sindern E. Changes of the MS functional composite and EDSS during and after treatment of relapses with methylprednisolone in patients with multiple sclerosis. Acta Neurol Scand. 2002;105:164–168.
    1. Kragt JJ, van der Linden FA, Nielsen JM, Uitdehaag BM, Polman CH. Clinical impact of 20% worsening on timed 25-foot walk and 9-hole peg test in multiple sclerosis. Mult Scler. 2006;12:594–598. doi: 10.1177/1352458506070768.
    1. Coo H, Hopman WM, Edgar CM, McBride EV, Brunet DG. The Paced Auditory Serial Addition Test: to what extent is it performed as instructed, and is it associated with disease course? Mult Scler. 2005;11:85–89. doi: 10.1191/1352458505ms1124oa.
    1. Fox RJ, Lee JC, Rudick RA. Optimal reference population for the multiple sclerosis functional composite. Mult Scler. 2007;13:909–914. doi: 10.1177/1352458507076950.
    1. Kaufman M, Moyer D, Norton J. The significant change for the timed 25-foot walk in the multiple sclerosis functional composite. Mult Scler. 2000;6:286–290.
    1. Kragt JJ, Nielsen IM, van der Linden FA, Uitdehaag BM, Polman CH. How similar are commonly combined criteria for EDSS progression in multiple sclerosis? Mult Scler. 2006;12:782–786. doi: 10.1177/1352458506070931.

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