Mary Fitzpatrick, ANP, MSCN Michelle Cameron, MD, PT

Mary Fitzpatrick, ANP, MSCN Michelle Cameron, MD, PT

This continuing education activity is managed and accredited by Professional Education Service Group. The material presented in this activity represents the opinion of the faculty. Neither PESG, nor any accrediting organization endorses any commercial products displayed in conjunction with this activity. Commercial Support was not received for this activity.

Michelle Cameron, MD, PT has received research support from Acorda Therapeutics Mary Fitzpatrick, ANP, has attended and been compensated for a Biogen-Idec nurse advisory meeting CME Staff Disclosures Professional Education Services Group staff have no financial interest or relationships to disclose

At the conclusion of this activity, the participant will be able to: Describe the nature of gait and balance impairments common in Veterans with MS Recognize Veterans with MS with gait and balance impairments Recommend interventions to improve walking and reduce fall risk in Veterans with MS

Background Walking impairment in MS Nature of walking impairments in MS Treatment of slowed walking in Veterans with MS A VA experience with dalfampridine Falls and Imbalance in MS Prevalence and incidence of falls in MS Falls in Veterans with MS Management of imbalance and falls in MS

CNS disorder (brain, spinal cord, optic nerves) Symptoms separated in time and space Complex immune-mediated disorder

Very varied but @ initial presentation Reduced sensation (33%*) Visual changes vision loss (16%), diplopia (7%) Weakness (13%) Unsteadiness when walking (5%) Poor balance (3%) Multiple symptoms (15%) Also Spasticity Incontinence Cognitive changes All of these can affect walking and balance

Compared with health controls, people with MS: Walk more slowly Have reduced gait endurance Have reduced community mobility Take shorter steps Step more slowly Have less joint movement during gait Have more variability in most gait parameters Slow down more when performing a cognitive task

Sensory changes particularly proprioception Lower extremity weakness Lower extremity spasticity Cerebellar ataxia

Timed measures Timed 25-Foot Walk Test (for speed) 6-minute/2-minute walk test (for endurance) Timed Up and Go (for functional speed) Patient Reported Outcomes Multiple Sclerosis Walking Scale-12 a patient-based measure of the impact of MS on walking Observational Gait Analysis Watch them walk

Instrumented walkway Gait lab Gyroscopes and accelerometers

Objectives: For a 12 month cohort of patients with MS prescribed dalfampridine at a VA Medical Center, to determine tolerability and effects of dalfampridine on: walking speed, (Timed 25 foot walk) self-perceived impact of multiple sclerosis (MS) on walking, (MSWS-12) walking endurance, (2 minute timed walk) community participation, (Community Integration Questionnaire)

01/22/2010 the FDA approved dalfampridine to improve walking in patients with MS Based on research demonstrating improved walking speed on the timed 25-foot walk test (T25FWT) self-perceived walking using the Multiple Sclerosis Walking Scale-12 (MSWS-12). Since dalfampridine became clinically available, no analyses of its real-world tolerability or effectiveness have been published.

All patients prescribed dalfampridine at the Portland VA Medical Center from 10/01/10-09/30/11 T25FTW, MSWS-12, two minute timed walk (2MTW) Community Integration Questionnaire (CIQ) Baseline assessment prior to taking dalfampridine. Individuals reporting a favorable response to dalfampridine at 3-4 weeks continued to take the drug All measures repeated at 1-4 months and at follow-up MS clinic visits. Measures were compared with baseline using paired t- tests.

Time (seconds) 25 Foot Timed Walk 50 45 Mean: 13.86 ± 9.55 N = 23 Mean: 10.55 ± 6.18 N = 22, P = 0.002 Mean: 9.40 ± 2.75 N = 16, P = 0.071 40 35 30 25 20 15 10 5 0 Baseline 1-4 months 5-10 months

Score MS Walking Scale - 12 60 50 40 30 20 Mean: 53.09 5.66 N=22 Mean: 41.82 ± 11.66 N = 22, P = 0.000 Mean: 48.00 ± 9.53 N = 6, P = 0.064 10 Baseline 1-4 months 5-10 months

Distance (feet) Two Minute Timed Walk 620 520 Mean: 196.75 ± 58.92 N=20 Mean: 266.16 ± 99.94, N = 16, P = 0.008 Mean: 207.86 ± 72.62 N = 7, P = 0.967 420 320 220 120 20 Baseline 1-4 months 5-10 months

Score Community Integration Questionnaire 25 23 21 Mean: 13.26 ± 3.58 N=21 Mean: 14.40 ± 3.72, N = 20, P = 0.094 Mean: 13.75 ± 3.86 N = 4, P = 0.391 19 17 15 13 11 9 7 5 Baseline 1-4 months 5-10 months

1. 39 individuals were prescribed dalfampridine during the 12 month period analyzed. 2. 23 individuals (58%) continued beyond the initial 3-4 week trial. 3. 16 individuals (42%) stopped within 3-4 weeks due to intolerance and/or perceived lack of efficacy. There were no serious AEs. 4. Walking speed, endurance and self-perceived walking improved significantly at 1-4 month follow-up. 5. There was a trend towards improvement in walking speed and self-perceived walking at 5-10 month follow-up.

Walking speed, endurance, and self-perceived walking were improved at 1-4 months with dalfampridine. Community participation was not significantly improved at 1-4 month follow-up. More complete follow-up of the sample is needed to reliably and validly assess longer term impacts

>75% complain of balance abnormalities >50% fall in 3 months 12% had an injurious fall in 6 months 50% with an injurious fall ever Balance abnormalities occur in those with minimal or undetectable impairments, as well as in those with significant impairments

Balance control of center of mass over base of support Postural control - Control of the body s position in space, when stationary or moving Fall unintentional change in position resulting in coming to rest on the ground or at a lower level

% Falls in 12 months How many people with MS fall? 489 Neurology inpatients 34% had fallen in the last year 32% of those with MS had fallen in the last year 70 60 50 40 30 20 10 0 PD Sync PNP EPIL SD MND MS PSY Stroke Pain Neurological Diagnosis PD Parkinson s disease Sync Syncope PNP Polyneuropathy SD Spinal disorders EPIL Epilepsy MND Motor neuron disease MS Multiple sclerosis PSY Psychogenic Falls in Frequent Neurological Diseases, Stolze et al J Neurology, 251:79-84, 2004

Risk of Falls in Subjects with MS Cattaneo D, DeNuzzo C, Fascia T, et al. Risks of falls in subjects with multiple sclerosis. Arch Phys Med Rehabil. 2002;83(6):864-7. 50 people with MS in Italy 54% (27/50) reported 1 or more falls in the previous 2 months 32% (17/50)reported 2 or more falls in the previous 2 months

Falling in People with MS Aged 45-90 years Finlayson, ML, Peterson EW. Arch Phys Med Rehabil. 2006;87:1274-9 1,089 people with MS in the Midwest US 52% reported falling at least once in the prior 6 months Nilsagard, 48/76 (63%) people with MS in Sweden recorded 270 falls in 3 months

58 people with MS in Portand falls in 2 mo - # who fell 30/58 (52%) # w/ 2 falls - 16/58 (28%) falls in 12 mo # who fell 43/58 (74%) # w/ 2 falls - 36/58 (62%) # w/ > 10 falls - 5/58 (9%)

Falls in Veterans with MS in VISN20 195,417 Veterans in VISN20 (NW USA), 721 with MS Unadjusted odds of an injurious fall was 1.9 times higher in veterans with MS than in veterans without MS For females: Odds were 3 times higher for veterans with MS than for veterans without MS (OR 3.0, 95% CI 1.6-5.5) For males: Odds were 1.2 times higher for veterans with MS than for veterans without MS (OR 1.2, 95% CI 0.8-2.1)

Fear of falling Injuries and death Impaired balance Impaired walking Use of a walking aide Disturbed proprioception Spasticity More severe MS Lower income Leg weakness

Divided attention Reduced muscular endurance Fatigue Heat sensitivity

Have you fallen in the last year? Questionnaires Activities-specific Balance Confidence (ABC) Falls Efficacy Scale (FES) Dizziness Handicap Inventory (DHI) Fall diaries Romberg Clinical Tests Berg Balance Scale Functional Reach Balance Evaluation Systems Test (BESTest)

Based on General common pathophysiology Somatosensory dysfunction Impaired central integration Individual examination and assessment

Gait assistive devices Exercise/balance training Safety strategies Home modifications

Enhance input TENS, strap or brace on leg Light touch cane Auditory input Tongue stimulation Practice Substitution Increase reliance on vision and vestibular Avoidance Avoid low light Avoid uneven surfaces

A cane or hiking poles to provide proprioceptive information more than support

Light touch increases proprioceptive input No Touch Light Touch Heavy Touch A-P M-L Center of Pressure M-L M-L Dickstein and Horak Gait and Posture, 2000

Practice Dual task Avoid Dual/multiple task

Walking and talking Walking and head turns Walking and visual distraction Walking and auditory distraction

Foot wear Home hazards Lights Trips

Many Veterans with MS have impaired walking and poor balance and fall frequently There are many ways to assess gait and imbalance in Veterans with MS Interventions to improve gait and imbalance in Veterans with MS include: Medications Devices Exercise Environmental modifications

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