Knowledge of the impact of MS on the person and the ability to assess symptom progression are critical to providing effective monitoring and evaluating DMTs [4]. Since the COVID-19 pandemic, many of the healthcare facilities encouraged the use of telephone-based assessment tools as an alternative way to follow up the MS patients, which will eventually decrease the risk of spread of such contagious disease by “staying safe at home.”
Most of the MS patients eventually experience walking difficulties. In this study, the Hauser Ambulation index was used to assess ambulation of the patient and hence the degree of disability. The EDSS scoring system remains a standard and well-established tool for assessing disability in MS patients. It is known that an EDSS score of 4 or more indicates that the patient has a degree of walking disabilities, or needs a walking aid or wheelchair [5], gaining over the concern that it is an ambulation-based measure. Since the EDSS is the main tool for the assessment of disability at our unit, we postulated that the Hauser Ambulation index can be a telephone-based alternative for assessing disability. The results showed that the Hauser Ambulation index was significantly correlated with the EDSS score done 1 month or less apart from the telephone call (P<0.001).
This supports that the Hauser Ambulation index can be a helpful tool for assessing ambulation in MS patients. It may be recommended to assess physical disability for MS patients. However, we would like to note the importance to monitor other disabilities in MS patients such as cognitive impairment which may be troublesome for many patients and may require symptomatic treatment.
The results of the MSNQ showed that one-third of the study population had evidence of cognitive and/or neuropsychological impairment. Although the MSNQ was not sensitive enough to detect cognitive impairment as the scores could be misled by the patient’s affect [6], we adopted it in this study because it is a relatively short and easy tool and can be self-reported, so can be implemented in mobile applications later on. Of course, these results had been correlated with other tools for assessing the cognitive functions and depression for confirming the credibility of this telephone-based tool, and this is a future scope for our center when those patients attend physically their next scheduled visits.
The lack of an association between the presence of cognitive and/or neuropsychological impairment (detected by MSNQ) and the clinical features of the disease (as disease duration, EDSS scoring, and type of MS) can be explained by the fact the cognitive impairment does not undergo a similar progression as physical disability [7].
In one study, the increase in the EDSS score did not predict deterioration in cognitive status [8]. Another study that compared patients with SPMS who did not have significantly greater disability than patients with RRMS reported a significant difference regarding cognitive impairment [7]. Moreover, some studies showed impaired neuropsychological performance in patients with clinically isolated syndrome and patients with no physical disability [9, 10].
This highlights the fact that physical disability and cognitive impairment are rather quite different features of MS that need to be monitored separately; in other words, cognitive functions cannot be judged based on the degree of physical disability. Physical disability seems to be related to the duration of disease, unlike cognitive impairment [7].
In this study, post hoc analysis regarding the cognitive and psychological impairment component of SMSS revealed that the patients who answered “Never” had significantly lower MSNQ scores compared to those who answered “Sometimes,” “Often,” and “Always,” which points that the cognitive and psychological impairment component of SMSS can be a reliable tool for a rough assessment of cognitive and psychological impairment in patients with MS.
On the contrary, the absence of significant difference after the comparison of the EDSS scores of the patients regarding the sensory-motor impairment component of SMSS may weaken its role as a rough tool for estimation of physical disability.
As it happened for many of the daily activities, the COVID-19 pandemic may have necessitated the engagement of alternative or complementary tools to monitor MS patients. The telephone-based assessments may be informative to the neurologist in monitoring MS patients especially if such information can be gathered effectively via reliable and valid standardized self-report questionnaires. One study investigated the modified telephone interview for cognitive status, a previously validated phone assessment for cognitive function in healthy elderly populations to detect mild cognitive impairment, in MS patients and demonstrated that a remotely administered cognitive assessment is quite feasible for conducting large epidemiologic studies in MS [11].
It is advised that assessments shall address the appearance of any new symptoms, walking disability, and cognitive functioning in order to have appropriate information about the patient’s status. The tools are recommended to be easily understood by the patient and if done via a telephone call shall not exceed 15 min as we noticed that most of the patients got bored from long telephone calls. Our future studies will implement strategies to assess the satisfaction of patients and physicians about such kind of assessments. We think about a mobile application that can include the assessment tools, which makes it easy for the patient to fulfill the items of the tools then being collected for analysis.
Lastly, it appears that remote monitoring is emerging as a new modality that can enable the neurologist to monitor their patients, and it is highly likely that we will continue to embrace the benefits of telemedicine and telephone-based assessments, and therefore, future directions shall include more evidence-based research on the diagnostic accuracy and reducing disparities in the access to telemedicine [12].
