Is the use of a cane and a brace (AFO) considered unilateral or bilateral assistance?The use of an ankle foot orthortic device is considered as "no assistance", therefore only the cane should be taken into account. So I suggest to rate this combination as "unilateral assistance".
One of our patients refused to do the ambulation part of the EDSS as she didn't want to be too fatigued for the rest of the day (we tried to encourage her, but she continued to refuse). She stated she felt she would be able to do 1/2 the walk. How do we rate a patient like this?Sometimes it might not be possible to encourage a patient to do the ambulation part, although this situation should be avoided if procurable, of course. In this case you have to rely on the patient's statement and assume she could walk 250 metres resulting in an EDSS Score of 4.5.
Patient needs bilateral assistance due to severe gait ataxia. Muscular strength is BMRC grade 5 in all muscle groups. Which EDSS score should be assigned? If the patient needs bilateral assistance to walk due to severe ataxia, the EDSS Score will be 6.0, given that the Patient is able to walk more than 120 metres.
How to determine the unrestricted walking depending on age and phisical state. For example if patient replies that he can walk 5000 metrs - is it enough for "unrestricted walking", or he has to walk more than 5000m. Are there recomendations? If the patient is reliable and you consider 5000 metres as normal, compared with healthy individuals of similar age and physical condition you can rate ambulation as "unrestricted". You do not have to make the patient walk more then 5000 metres.
On history if patient discloses that her day-day activity needs bilateral assistance, for eg, going out shopping she needs a walker or holds on to a trolley, in the house holds on to the wall and furnitures...This patient can still walk 200mts unaided with a waddling slow gait, what is her EDSS? To determine the ambulation score you have to rate the patient's best possible performance. So ambulation score in this case is 3 resulting in an EDSS score of 5.0, even if she uses a walker in everyday life.
The manual says, "If the walking distance is < 500 meters, the EDSS step must be >= 4, depending on the ranges provided in part 10 of this manual (> 100, > 200, > 300)." In which circumstance would the EDSS be exactly 4.0? A walking distance lower than 500 meters should not correspond to an EDSS below 4.5, should it?If the walking distance is below 500m the EDSS is 4,5 or 5,0 depending on the FS-Sores; if walking distance is below 300m the EDSS is 5,0 (independent from the FS-Scores); if the walking distance is below 200 the EDSS is 5,5 and in rare cases with an ambulation below 100m without assistance, the EDSS is 6,0. Otherwise with using an assistance, the EDSS is 6,0 or 6,5, depending on the type of assistance required when walking and the walking range. An EDSS of 4 you receive if walking distance is at least 500m (otherwise EDSS would be 4,5 or worse) and the combination of FS fulfill the criteria of EDSS 4 (see last page of booklet). Please be aware, with fully ambulatory you can get any EDSS between 2 and 5, depending on the FS-combinations. With an unrestricted walking distance the EDSS range would be (theoretical) between 0 and 5.
By which criteria, the EDSS is defined in patients with no unrestricted ambulation with a walking distance above 500 meters? For an EDSS step of 4.0, a lower limit for the walking distance is given with 500 meters, but no upper limit, where lower EDSS steps would apply? What criteria define the EDSS in patients with a walking distance of 800, 1200 or 3000 meters?For any walking distance equal or above 500m (but not unrestricted) which is defined as "fully ambulatory", the EDSS step can be anything between 2.0 and 5.0, depending on the FS scores. The criteria, next to the observed walking for a minimum distance of 500 meters is the maximal unassisted walking distance reported by the patient. The upper limit is any walking distance below unrestricted (which means the patient is able to walk a distance without assistance that is regarded as normal, compared with healthy individuals of similar age and physical condition).
In a prior question (under the Ambulation section in the public forum) with a person who needed to touch the wall AFTER walking 110 meters and then completing the total of 500 meters, without further aid or rest, you suggested the EDSS is 5.5. Did he not also walk 390 meters without assistance for an EDSS of 4.5? The question I also raise is, if a person has two performances, do you score the better or worse one?Thank you for this remark.
Also, the exceptions to the Ambulation Functional Score section indicate that unilateral assistance walking >= 50 meters is an EDSS of 6.0, while < 50 meters is 6.5. But the main text indicates that 100 meters is the cut-off for 6.0.
Also, the exceptions to the Ambulation Functional Score section indicate that bilateral assistance walking >= 120 meters is an EDSS of 6.0, while < 10-120 meters is 6.5. But the main text indicates that "at least 20 meters" is the cut-off for 6.5.
Could you clarify the discrepancy in the numbers?
Indeed, always the patient's best performance should be rated, so in this case EDSS should be 4.5 as the patient was able to walk 390 metres. One could argue that the reater should have encouraged the patient to complete the "second" 500 metres to determine the walking range correctly.
Regarding your second point we are well aware of the discrepancy caused by the introduction of the Ambulation Score. This was done in the first place to increase the consistency in determination of the walking range with assistance. As long as this discrepancy is not resolved, we strongly recommend to use only the definitions under the Ambulation Score section to calculate EDSS scores of 6.0 and 6.5.
Also, the manual says, "If the walkingAn EDSS of 4 you receive if walking distance is at least 500m (otherwise EDSS would be 4,5 or worse) and the combination of FS fulfill the criteria of EDSS 4 (see last page of booklet).
distance is < 500 meters, the EDSS step must be >= 4, depending on the ranges provided in part 10 of this manual (> 100, > 200, > 300)." In which circumstance would the EDSS be exactly 4.0? A walking distance lower than 500 meters should not correspond to an EDSS below 4.5, should it?
Please be aware, with fully ambulatory you can get any EDSS between 2 and 5, depending on the FS-combinations. With an unrestricted walking distance the range would be (theoretical) between 0 and 5.
EDSS score of patient who can walk 80 m without help is 6,0?Concerning the walking distance the EDSS is 6.0 if the walking range < 100 meters without assistance. Please be aware that if an assistance is needed, for an EDSS of 6.0 you would require for the use of an unilateral assistance at least 50 m, for the use of a bilateral assistance at least 120m at minimum.
Does an examining neurologist have to observe the 500 M ambulation or can this be delegated to a study staff member. Our physicians do observe ambulation, but not the entire 500 meter walk.In general you should observe the patient walking unassisted for a minimum distance of 500 meters and measure the time needed.
This task can be delegated to a well trained study nurse if she knows that she has to motivate the patient for best performance but taking measures for safety against falls. She should also know how to react to short stops or touching the wall or the accompanying person because of ataxia.
We are being advised from a sponsor that if a patient utilizes a cane (even intermittently), knowledge of that use automatically puts patient at a 5.5. This is regardless of whether or not the patient can walk the 100 meters or more without assistance. I've never heard this and wanted to verify.No - that is wrong. If a patient can walk without a cane 100 meters or more the EDSS will be 5.5 or lower. If he is able to walk >/= 200 meters without a cane, EDSS would be 5.0. If the patient needs unilateral
assistance, and is not able to walk without assistance a minimum of 100 m, then the EDSS will be 6.0 or higher - depending on the assistance required when walking AND the walking range. Knowledge about the occasional use of a cane alone does not qualify for a 5.5. What is observed on the day of examination is deciding about the score.
If 1 FS =3 and others =2 with ambulation >500 m, the final EDSS is 4.0.1 FS =3 and others =2 (at least more than 2 FS=2) with an ambulation 500 m, will result into a final EDSS of 4.0.
Is this correct?
The term "fully ambulatory" is not synonymous with "unrestricted".
"Fully ambulatory" means at least 500 meters of ambulation, but the
subject would usually have some restrictions.
So therefore at least the pyramidal or cerebellar FS must be =/> 2.
An EDSS from 0 up to 1.5 requires an "unrestricted" in ambulation.
If a subject is unable to walk even with assistance at the minimum of 100 meters due to severe back problem, how is the ambulation scored?If these problems are not due to multiple sclerosis, the Walking-Distance-Restriction will not be taken into consideration for assessment. So the result would be = fully ambulatory, able to walk 500 meters, if you do not have any reason to assume that a walking range restriction exists that would be caused by MS. If a restriction due to MS exists you would assign the appropriate grade. If you are not able to make this assessment you would leave this part open and mark "NOT ASSESSABLE".
If a patient needs support of another person or needs to touch the wall after walking for stabilization after 110 meters but continues on to walk 500 meters, what is there EDSS? Please be specific as to whether they are walking but restricted or that they are demonstrating fatigue.If a person needs assistance by another person (equivalent to bilateral assistance) or needs to touch the wall for the rest of the 500 meters, AFTER walking 110 meters without aid or rest, the EDSS is 5.5. The actual performance is crucial, not the interpretation as long as the reason is MS related (eg "motor weekness vs fatigue": assess according to performance; but not "fracture of tibia because of car accident" : in such case you either have to estimate the impact of MS or in case of doubt refrain from scoring these items).
Is the use of an ankle foot orthotic (AFO) device considered unilateral assistance?No. If a patient requires only an AFO for ambulation and does not require any other type of assistive device, such as a cane or crutch, then the use of an AFO is not considered unilateral assistance.
For example, if a patient is able to walk 150 meters without a cane or crutch, but requires an AFO, the EDSS step is 5.5, not 6.0.
Is a walker considered bilateral assistance?Yes