What is the Multiple Sclerosis Functional Complex?

Multiple sclerosis (MS) is a lifelong neurological disorder that occurs when a person’s immune system attacks the protective covering (myelin) of nerve fibers in the brain and spinal cord. Disability in multiple sclerosis occurs from relapse, natural progression of the disease, or a combination of the two.

The Multiple Sclerosis Functional Composite (MSFC) is a standardized three-part tool for assessing disability in MS patients. The MSFC was created for clinical research to measure three key areas of disability in MS – leg function/walking, arm and hand function, and cognitive function.

This article will review these three components and discuss how to manage and score MSFC.

Components of MSFC

Developed in 1994 by the National MS Society (NMSS) Clinical Outcomes Assessment Task Force, the MSFC reflects the progression of neurological dysfunction through the following three independent tests.

Timed 25-foot walk (T25W)

The T25W measures leg function and walking.

During T25W, the patient was asked to walk 25 feet as fast as possible (called Trial 1). The patient was then immediately asked to walk back to the starting point (called Trial 2). A 5-minute rest period is allowed after Test 1, and walking aids such as crutches or walkers may be used during the test.

The test was stopped if the patient was unable to complete either Trial 1 or Trial 2 within 180 seconds.

9 Hole Nail Test (9HPT)

9HPT measures arm and hand function.

During the 9HPT, the patient was asked to place the nails one by one into nine separate holes in a plate placed on a table while sitting. Next, the patient is asked to remove the nails. Test each hand twice.

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The time it took patients to place and remove all nine nails was recorded for each trial. If the patient cannot complete the test within five minutes, stop the test.

Rhythmic Auditory Serial Addition Test (PASAT-3)

PASAT-3 measures cognitive function, specifically information processing and speed, working memory, and attention.

During PASAT-3, a cassette or compact disc (CD) player plays a series of numbers every three seconds. Ask the patient to add the numbers and record the number of correct answers.

A maximum of 3 practice tests with a set of 10 numbers are allowed before the actual test. The test was stopped if the patient did not get at least two correct answers (consecutive or incorrect) on any of the three practice trials.

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MSFC management

MSFCs are administered by trained examiners, usually neurologists (doctors who specialize in disorders of the brain and nervous system), nurses, medical assistants, or health care technicians. Administration time for all three measures is approximately 20-30 minutes.

At the beginning of the MSFC, the examiner will follow the instructions in the MSFC handbook exactly. Instructions are translated into several languages, including French, German, Dutch, Greek, and Hebrew.

MSFC examiners are trained to be friendly, approachable, professional and objective. That means they can’t share any feedback or information about the patient’s performance on the test.

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Because the entire procedure can be a little challenging and nerve-wracking, examiners are trained to help patients remain physically and emotionally comfortable during all three tests.

The test space at the MSFC is usually a separate designated room; however, the timed 25-foot walk test may be conducted in a common hallway.

To minimize any disruption, only the patient and examiner are present in the testing area. Cell phones, pagers, and watches are all turned off, and there are no obstructions or unnecessary materials in the room. A “Do Not Disturb” sign is usually placed on the door when testing.

How to Calculate MSFC Score

MSFC scores are derived by converting the scores for each component/test into Z-scores. If the test cannot be completed due to disability or fatigue, a certain number of points (not necessarily zero) will be given according to the MSFC’s instructions.

Z-scores calculated from the standardized formula were then averaged to create an overall composite score.

Z score

Z-scores compare a patient’s individual outcome to the mean in a reference population.

In MS clinical trials, composite scores can be compared between treatment and control groups to assess the benefit of certain clinical interventions, such as taking disease-modifying antirheumatic drugs (DMARDs). They can also be analyzed over time to assess the improvement or worsening of an individual’s disability.

In addition to the composite score, three separate scores are usually checked. This is because over time, patients may experience worsening disability in one area (eg, walking) but improve in another (eg, cognition) (the mental process of acquiring knowledge and understanding).

Thus, patients’ total MSFC scores can remain stable as they average across the three domains, even if their functioning is deteriorating in one dimension.


Like any clinical assessment tool or instrument, MSFC scores need to be interpreted correctly and thoughtfully.


The MSFC is a three-part tool used in clinical research to measure disability progression in people with MS. It includes assessments of leg function, arm and hand function, and cognitive function. Scores for each of the three components were converted to Z-scores and averaged to create an overall composite score.

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Scientific evidence consistently suggests that MSFC is an appropriate and valid tool for assessing the extent of impairment in MS patients. Of course, like any research tool, the MSFC has some drawbacks—for example, it doesn’t address problems related to vision, sensation, bladder, bowel, or sexual function.

In any case, gaining basic knowledge about MSFC is a sound and empowering strategy. Your neurologist may bring it up during an appointment, or you may encounter it one day if you or a loved one decides to enroll in an MS clinical trial.

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