Critical Appraisal of Evidence for Improving Gait Speed in People with Multiple Sclerosis: Dalfampridine Versus Gait Training

Patient and Clinician Perspectives of Physical Therapy for Walking Difficulties in Multiple Sclerosis

Gait speed is frequently the primary efficacy endpoint in clinical trials of interventions targeting mobility in people with multiple sclerosis (MS). However, it is unclear whether increased gait speed is a meaningful outcome for people living with MS. The purpose of this study was to identify the most important aspects of mobility for people with MS and physical therapists and to explore how patients and clinicians perceive whether physical therapy has been effective. Forty-six people with MS and 23 physical therapy clinicians participated in a focus group, one-on-one interview, or electronic survey. The focus group and interview data were transcribed and coded to identify themes. Free-text survey responses were also coded, and multiple-choice options were analyzed for frequency. Among people with MS, falls and difficulties getting out into the community were identified as highly important mobility limitations. Clinicians also identified falls and safety as a priority. Walking speed was infrequently described as a problem, and although gait speed is often measured by clinicians, improving gait speed is rarely a treatment goal. Despite their emphasis on safety, clinicians lacked certainty about how to objectively measure improvements in safety. People with MS evaluated physical therapy effectiveness based on the ease by which they can do things and acknowledged that "not getting worse" is a positive outcome. Clinicians evaluated effectiveness based on the amount of change in objective outcome measures and by patient and caregiver reports of improved function. These findings indicate that gait speed is not of major importance to people with MS or physical therapy clinicians. People with MS want to be able to walk further and without an assistive device, and they want to avoid falls. Clinicians want to maximize safety while improving functional ability. Clinicians and patients may differ in their expected outcomes from physical therapy.

Dalfampridine for Mobility Limitations in People With Multiple Sclerosis May Be Augmented by Physical Therapy: A Non-randomized Two-Group Proof-of-Concept Pilot Study

Purpose: To demonstrate proof-of-concept for a combined physical therapy and pharmacological intervention and obtain preliminary estimates of the therapeutic efficacy of a motor-relearning physical therapy intervention with and without concurrent dalfampridine treatment on gait speed in people with mobility limitations due to multiple sclerosis (MS).

Methods: Using a non-randomized, two-group design, 4 individuals with MS newly prescribed dalfampridine as part of their routine medical care, and 4 individuals with MS not taking dalfampridine completed a 3-week drug run-in or no-treatment baseline, respectively. After 3 weeks, all participants commenced physical therapy twice weekly for 6 weeks. Participants taking dalfampridine took the medication for the study duration. The physical therapy program comprised functional strengthening, gait training, balance training, and dual-task training. The primary outcome was Timed 25-foot Walk (T25FW) at the end of the 6-week physical therapy program.

Results: For the 4 participants taking dalfampridine, average improvement in T25FW on drug only was 12.8% (95% CI 1.2 to 24.4%). During the 6-week physical therapy phase, both groups significantly improved T25FW, but the effect tended to favor the group taking dalfampridine (mean difference = −0.93 s, 95% CI −1.9 to 0.07 s, p = 0.064, d = 1.6). Whereas the physical therapy group had average T25FW improvement of 10.8% (95% CI 1.0 to 20.5%), the physical therapy plus dalfampridine group demonstrated average improvement of 20.7% (95% CI 3.8 to 37.6%).

Conclusions: Further research is warranted to examine whether dalfampridine for mobility impairment may be augmented by physical therapy in people with MS.

Case Report: Combining Dalfampridine with Multicomponent Exercise and Gait Training in a Person with Multiple Sclerosis

Background

Dalfampridine extended release (D-ER) improves gait speed in some people with multiple sclerosis (MS), but many patients who take D-ER demonstrate only small improvements of questionable clinical significance. Physical therapy (PT) may augment the treatment effects of D-ER on the nervous system and improve clinical outcomes. This case report describes the successful use of D-ER combined with multicomponent PT in a patient who did not have a clinically important change in gait speed with D-ER alone.

Methods

A 59-year-old woman with a 6-year history of relapsing-remitting MS was prescribed D-ER by her neurologist. After 3 weeks of D-ER therapy (10 mg twice daily), she demonstrated only a 7.1% improvement in the Timed 25-Foot Walk test. She then commenced PT consisting of two 40-minute sessions per week for 6 weeks while continuing D-ER therapy. Training focused on gait, balance, coordination, functional strengthening, and dual-task performance.

Results

After 6 weeks of D-ER + PT, she had a further 14.6% improvement in Timed 25-Foot Walk gait speed, for a total improvement of 20.7%, which elevated her above the clinically meaningful threshold of 20%. Similar patterns of improvement were also observed for self-selected gait speed in single- and dual-task conditions. Improvements in fast and dual-task gait speed were retained 3 weeks later.

Conclusions

For this patient, combining PT with D-ER therapy improved gait speed more than the use of D-ER alone. Further investigation of D-ER + PT or PT as an alternative to D-ER in patients with submeaningful medication response is warranted.

Therapies for mobility disability in persons with multiple sclerosis

INTRODUCTION

Mobility disability is one of the most widespread and impactful consequences of multiple sclerosis (MS). Disease modifying drugs (DMDs) may delay the progression of disability over time; however, there is minimal evidence supporting the efficacy of DMDs for reversing mobility disability or restoring ambulatory function in persons with MS. Areas covered: This review outlines symptomatic pharmacologic and non-pharmacologic therapeutic approaches that target mobility disability with the goal of restoring and improving walking function. First, the efficacy of dalfampridine, currently the only Food and Drug Administration approved symptomatic pharmacologic agent that improves walking in persons with MS is described. Next, a review of the efficacy of non-pharmacologic therapies for improving walking, including exercise training, physical therapy, and gait training is given. Last, guidance on future research on mobility in MS is provided by emphasizing the importance of combinatory treatment approaches that include multiple intervention modalities, as the best treatment plan likely involves a comprehensive, multidisciplinary approach. Expert commentary: There has been an increased effort to develop symptom-specific treatments in MS that directly target mobility disability; however, more research is needed to determine the efficacy of these rehabilitative strategies alone and together for improving walking in persons with MS.