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January 30, 2018; 90 (5) Article

Effects of physical comorbidities on disability progression in multiple sclerosis

Tingting Zhang, Helen Tremlett, Feng Zhu, Elaine Kingwell, John D. Fisk, Virender Bhan, Trudy Campbell, Karen Stadnyk, Robert Carruthers, Christina Wolfson, Sharon Warren, Ruth Ann Marrie, for the CIHR Team in the Epidemiology and Impact of Comorbidity on Multiple Sclerosis
First published January 3, 2018, DOI: https://doi.org/10.1212/WNL.0000000000004885
Tingting Zhang
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Helen Tremlett
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Feng Zhu
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Elaine Kingwell
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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John D. Fisk
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Virender Bhan
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Trudy Campbell
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Karen Stadnyk
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Robert Carruthers
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Christina Wolfson
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Sharon Warren
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Ruth Ann Marrie
From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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From the Department of Health Services, Policy and Practice (T.Z.), Brown University School of Public Health, Providence, RI; Department of Medicine (H.T., F.Z., E.K., R.C.), Division of Neurology and Centre for Brain Health, University of British Columbia, Vancouver; Department of Medicine (J.D.F., V.B., T.C.), Department of Psychiatry (J.D.F.), and School of Nursing (T.C.), Dalhousie University; Nova Scotia Health Authority (J.D.F., V.B., K.S.), Halifax; Department of Epidemiology and Biostatistics and Occupational Health (C.W.), McGill University; The Research Institute of the McGill University Health Centre (C.W.), Montreal, Quebec; Faculty of Rehabilitation Medicine (S.W.), University of Alberta, Edmonton; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
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Citation
Effects of physical comorbidities on disability progression in multiple sclerosis
Tingting Zhang, Helen Tremlett, Feng Zhu, Elaine Kingwell, John D. Fisk, Virender Bhan, Trudy Campbell, Karen Stadnyk, Robert Carruthers, Christina Wolfson, Sharon Warren, Ruth Ann Marrie, for the CIHR Team in the Epidemiology and Impact of Comorbidity on Multiple Sclerosis
Neurology Jan 2018, 90 (5) e419-e427; DOI: 10.1212/WNL.0000000000004885

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Abstract

Objective To examine the association between physical comorbidities and disability progression in multiple sclerosis (MS).

Methods We conducted a retrospective cohort study using linked health administrative and clinical databases in 2 Canadian provinces. Participants included adults with incident MS between 1990 and 2010 who entered the cohort at their MS symptom onset date. Comorbidity status was identified with validated algorithms for health administrative data and was measured during the 1 year before study entry and throughout the study period. The outcome was the Expanded Disability Status Scale (EDSS) score as recorded at each clinic visit. We used generalized estimating equations to examine the association between physical comorbidities and EDSS scores over time, adjusting for sex, age, cohort entry year, use of disease-modifying drugs, disease course, and socioeconomic status. Meta-analyses were used to estimate overall effects across the 2 provinces.

Results We identified 3,166 individuals with incident MS. Physical comorbidity was associated with disability; with each additional comorbidity, there was a mean increase in the EDSS score of 0.18 (95% confidence interval [CI] 0.09–0.28). Among specific comorbidities, the presence of ischemic heart disease (IHD) or epilepsy was associated with higher EDSS scores (IHD 0.31, 95% CI 0.01–0.61; epilepsy 0.68, 95% CI 0.11–1.26).

Conclusions Physical comorbidities are associated with an apparent increase in MS disability progression. Appropriate management of comorbidities needs to be determined to optimize outcomes.

Glossary

CI=
confidence interval;
DMD=
disease-modifying drug;
DMSRU=
Dalhousie MS Research Unit;
EDSS=
Expanded Disability Status Scale;
GEE=
generalized estimating equation;
IHD=
ischemic heart disease;
MS=
multiple sclerosis;
SES=
socioeconomic status

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Coinvestigators are listed at http://links.lww.com/WNL/A88.

  • Received February 6, 2017.
  • Accepted in final form October 26, 2017.
  • © 2018 American Academy of Neurology
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