Mary Fitzpatrick, BSN, MPH, ANP

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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education credit for this activity, please visit:
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