Walking impairment is a common symptom associated with disease states including multiple sclerosis (MS) and Parkinson's disease, spinal cord injury and other forms of trauma, and general impairment due to aging.
Treatment of walking impairment associated with chronic disease often involves the use of a customized range of diagnostic, monitoring, and interventional strategies, collectively known as a treatment "armamentarium" or "tool kit."
In the treatment of walking impairment in MS, elements of the tool kit include drug therapy, appropriate use of assistive mobility devices, exercise, physical therapy (PT), occupational therapy (OT), yoga, dietary intervention and broader wellness strategies.
Factors including the introduction of new drugs or mobility devices, availability of new data, strategies in clinician and patient education, trends in reimbursement and access to specialized services continually reshape the range of treatment options available.
Clinicians who treat patients with walking impairment are frequently challenged to review factors that can influence treatment decisions, including additions to the literature related to mobility.
For example, a study showing that resistance training produced statistically significant improvements at three and six months in several clinical trials that established measures of walking, including the Timed Up and Go Test and the Berg Balance Scale in patients with MS, invited new assessments of the benefits of training in the continuum of MS care.1
Clinical research also supports early and appropriate use of assistive mobility devices and PT in the treatment of walking impairment.2
In addition to treatment strategies supported by clinical data, treatment specialists in MS report that they regularly use information from clinical training programs, peer-to-peer exchanges, leading patient treatment centers, industry and patient advocates to make decisions related to the treatment of walking impairment. They report that these factors regularly play a role in influencing decisions related to diagnosis, patient monitoring, benchmark assessments of mobility, drug therapy and assistive mobility devices.
New Treatment Options in MS Care
MS continues to be associated with a considerable patient burden, including poorer quality of life relative to the general population3,4 and reductions in daily function, socioeconomic status, and work productivity.5-8
The introductions of new treatment strategies and drug therapies, including disease-modifying agents (interferon beta-1a, interferon beta-1b, glatiramer acetate, natalizumab and fingolimod) have presented clinicians with additional options to manage MS.
In 2010, the U.S. Food and Drug Administration (FDA) approved dalfampridine extended release tablets (dalfampridine-ER; sustained-, modified, or prolonged-release fampridine outside the U.S.) for the improvement of walking in patients with MS, the first therapy targeting a specific MS symptom.
Botox (onabotulinumtoxin A) was approved in 2010 for the treatment of spasticity and Nuedexta (quinidine/dextromethorphan) was also approved for the treatment of pseudobulbar affect associated with MS.
The introduction of these therapies has positioned clinicians to take a more active role in symptom management related to walking impairment, the issue that patients report to be the most challenging aspect of living with MS.9
Managing Walking Impairment
Walking impairment is one of the most common consequences of MS.10 People living with MS typically walk with a shorter stride length due to conditions such as spasticity, incoordination, weakness and vestibular disturbance.11
In a survey of more than 1,200 adults living with MS, six in ten (61%) reported that difficulty walking interfered with their ability to work, resulting in a loss of personal income.12
Also, 60% of respondents with walking difficulties had to miss at least one major personal event as a result, and 32% reported that difficulty walking has caused them to feel isolated.12
The introduction of disease management therapies (DMTs) produced rapid changes in the disease management paradigm in MS.13 Following their introduction, DMTs were positioned as platform drugs for relapse management as well as decreasing MRI activity and delaying disability.13
While DMTs are an important part of managing MS by themselves, evidence suggests that they can also be combined with other treatments to target different aspects of immunopathogenesis or different therapeutic targets such as inflammation or neuroprotection.
The importance of symptom management in MS has long been a recurring theme of comprehensive disease management.14-17 Some studies suggest that symptomatic treatment can more favorably enhance quality of life for people living with MS compared to treatment with DMTs.17 This paradigm is consistent with a multimodal approach to disease management, originally proposed to include disease modification where applicable, treatment of relapses, and a multidisciplinary approach to symptomatic treatment encompassing pharmacologic and non-pharmacologic therapies.18
Comprehensive Care Model
The introduction of dalfampridine-ER has helped to expand awareness of the incidence and impact of walking impairment in MS among patients and healthcare providers. This has increased demand for adequate and accurate information related to walking impairment and the role of targeted symptom management in MS care.
Drug therapy for the treatment of walking problems is also positioned to enhance the role and outcomes of rehabilitation as both an episodic feature of disease management and a component of maximal function and wellness strategies.
Patients and healthcare providers often need adequate information to be able to predict, monitor, and assess changes in function to interpret the impact that changes in walking function can have. A regularly scheduled program of rehabilitation and treatment provides a platform for ongoing assessment and evaluation of changes in walking ability.
A comprehensive care program can also provide insights related to corrective strategies, including assistive devices, advantageous lifestyle modifications, medical care, appropriate use of exercise, and frequency and intensity of PT or OT services.
A comprehensive care model in MS should be supported by educational materials targeted to the range of healthcare professionals involved in patient care, including physicians, nurse practitioners, nurses, rehabilitation professionals and home health aides.
Based on the amount of time many non-physician healthcare professionals spend with patients, they are often well positioned to play an active role in monitoring, referral, and patient education related to symptom management. Information about the assessment and treatment of walking impairment in MS should also be available to healthcare providers in long-term care, home care, or other settings.
Healthcare professionals should also work to develop achievable goals that reflect appropriate expectations based on a patient's individual experience and potential.
Factors to be considered in developing goals include results of benchmark testing, history of disease progression, degree of compromise, response to drug therapy and other forms of intervention and access to specialized care. Guidelines should support appropriate referrals to PT and OT services for patients.
Baseline measures of walking function should be implemented at time of diagnosis, or at first indication of walking impairment and thereafter at regular intervals. Assessments through use of quality-of-life instruments or functional assessment scales, such as the patient-reported 12-item Multiple Sclerosis Walking Scale (MSWS-12),19 can further enhance evaluation.
Assessments, especially at baseline, for other MS-associated symptoms such as fatigue, spasticity, and cognitive function can also help to assess the course of symptomatic MS and to individualize therapy.
With these changes in place, efforts to improve MS care may be further supported by the adoption of a treatment worksheet or checklist including a review of treatment protocols. The worksheet can outline the elements of a comprehensive evaluation for ambulation and also identify the elements of an appropriate care model. This resource may be important for all healthcare service providers in MS care, especially for those who are not affiliated with specialized MS treatment centers.
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19. Hobart JC, Riazi A, Lamping DL, Fitzpatrick R, Thompson AJ. Measuring the impact of MS on walking ability: the 12-Item MS Walking Scale (MSWS-12). Neurology. 2003;60:31-36.
June Halper is founder and executive director of the International Organization of Multiple Sclerosis Nurses, Hackensack, N.J.; Amy Perrin Ross, is Neuroscience Program Coordinator, Department of Neurosciences, Loyola University Medical Center, Maywood, Ill.; and Marie Namey, is an advanced practice nurse in Ohio at the Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic.