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Effect of physical therapy with and without dalfampridine on gait in people with multiple sclerosis

 

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Effect of physical therapy with and without dalfampridine on gait in people with multiple sclerosis

A Capstone Project by Whitney Huryta

Poster Session 2017

Brief Background Information on MS

Multiple Sclerosis (MS) is a chronic neurodegenerative disease that is characterized by inflammation in the central nervous system and degradation of myelin on the nerve axon1. The symptoms of MS are variable and can widely impact patients2,3. Common symptoms include balance, sensory, visual, bladder, bowel and coordination impairment, pain, spasticity, fatigue, and cognitive changes2,3. Additionally, approximately 50% of patients with MS require a walking aid within 10 years of diagnosis without intervention4.

Description of Project Need

There are multiple interventions that have been successful in improving outcomes for patients with multiple sclerosis (MS), in regards to both medicinal and therapeutic options5,6,2. However it is unknown whether or not one intervention is better than another in improving outcomes (in regards to balance or gait parameters, for example) in patients with MS1,7. One drug that has been shown to improve gait parameters for patients with MS includes dalfampridine extended release (D-ER) or Ampyra®8,9. Additionally, research has demonstrated that participation in physical therapy can also improve gait and balance outcomes in patients who have MS1,10. Therefore, to further explore which interventions maximize positive outcomes for patients with MS, this capstone project, guided by Dr. Prue Plummer, is specifically focused on determining the impact of dalfampridine extended release (D-ER) with and without the use of a gait training protocol, (which includes multiple balance-focused components).

Audience and Setting

            Given that MS is chronic and neurodegenerative, patients who have this condition generally work with a team of healthcare professionals throughout their lifetime. Consequently, multiple audiences will benefit from the findings of this study, including people with MS, clinicians who work with patients that have MS, both in the medical, osteopathic and rehabilitation divisions, as well as researchers and academics. For this reason, the capstone project will primarily involve presenting the results of this study’s findings to academic, research and clinical peers in the form of a poster both at the UNC Human Movement Science symposium and at the NC APTA conference. Additionally, contributions will be made to publishing this work in a peer-reviewed journal article. The aim of the project is to enhance clinical practice and inform future research on the most effective interventions to improve gait and balance parameters in patients with MS, which will be achieved through conducting research and presenting the findings through multiple platforms to reach clinicians, researchers, and patients with MS.

Products
In preparation for conducting research within the lab, I completed a critically appraised topic focused on determining whether dynamic balance exercises or functional strengthening interventions are more effective at improving balance outcomes for people with MS. This was an important consideration as the interventions we implemented with research participants included aspects of both dynamic balance and functional strengthening, in attempts to improve gait and reduce falls risk. While my final literature search is much greater than this CAT, this paper reflects my first step in the evidence review.

Critically Appraised Topic- Dynamic Balance Exercise or Strengthening

After having worked with several research participants, recording and analyzing data and generating conclusions, Jessica Reynolds and I submitted the following abstract to the Human Movement Science Symposium in 2017:

2017 Huryta & Reynolds HMSC Abstract

Our abstract was accepted and we presented our research as a poster presentation on March 31, 2017.

2017 HMSC Poster- Effect of physical therapy with and without dalfampridine on gait in people with MS

We are in the midst of data collection, as we are continuing to work with research participants. Moving forward, new data will be added into the analysis and conclusions will be updated as appropriate. An abstract will be submitted to the 2017 Fall NCPTA conference by July 14. If the abstract is accepted, a poster will be presented during the conference from October 12 through the 14th in Winston-Salem, NC.

Furthermore, I am also composing a manuscript that will be submitted to the International Journal of MS Care by the end of 2017.

Evaluation

I have sought out feedback throughout the project from committee members, peers, research participants, and those in attendance at the HMSC symposium. This feedback has been utilized to make enhancements to this project. As the project is ongoing, I will continue to seek feedback and make adjustments.

Reflection and Self-assessment

The original goals of this project included:

  1. To demonstrate proficiency in working with research participants by leading a therapy session with minimal assistance from advisor.
  2. To exhibit professionalism throughout the completion of the capstone project by completing all work in timely manner, effectively communicating with committee and team members, as well as prompt attendance at meetings.
  3. To be able to effectively present research findings to peers through the presentation of a poster at the Human Movement Science Symposium at UNC.
  4. To effectively present research findings and implications to peers, clinicians, and researchers of a wider audience through presentation of a poser at APTA’s NC conference.
  5. To further develop scientific writing and communication skills through contributing to publication of research findings in a peer reviewed journal article.

While I have not yet completed all of these goals, I have completed all goals relevant to this point in the project (goals 1-3). This project has informed my practice through knowledge gained, as well as, through improving communication, professionalism, research and presentation skills. This capstone project has also furthered my ability to utilize evidence-based physical therapy in my own practice. Additionally, this project has allowed me to further my communication and education skills among peers as well as other interdisciplinary professionals, as I have worked effectively with collaborators.

There have been several challenges while completing this project, including difficulty with recruitment of research participants, challenges in data collection due to participant circumstances and in finding facility collaborators for providing interventions. Through we are continuing to collect data, well past our original timeline, I have learned that it is important to be flexible when conducting research. I have also demonstrated positivity, dedication, and diligence throughout the project.

Several areas I will continue to develop as the project continues, include scientific writing skills, incorporating feedback from others, as well as setting and maintaining deadlines. I will need to follow-through on the last two goals I have set for this project, and continue to seek more formal feedback from those involved in the project.

Acknowledgements

There are many people who collaborated on this project in participant recruitment, completion of evaluations and interventions, funding sources and more.

I would like to thank Prue Plummer, as she served as a mentor, committee member, advisor, and primary project investigator. I would also like to thank Jessica Reynolds, who served as a close partner in this project. Additionally, I would like to thank Corinne Bohling for her commitment to this project in serving as a committee member and providing valuable feedback.

Furthermore, thank you to Dr. GozdeIyigunand Jasmine Martin for conducting the evaluations. I sincerely thank the staff at Steps For Recovery and at Campbell University DPT for providing facilities. I am also grateful to Amy Thomas, Corinne Bohling, Alexis Williams, and Ellese Nickles who provided PT interventions.

This research was supported by the National Multiple Sclerosis Society (PP-1503-03495, Plummer).

References

  1. Doring A, Pfueller CF, Paul F, Dorr J. Exercise in multiple sclerosis — an integral component of disease management. EPMA J. 2012;3(1):2. doi:10.1007/s13167-011-0136-4.
  2. Tintoré M. Advances in the management of multiple sclerosis symptoms: pathophysiology and assessment of spasticity in multiple sclerosis. Neurodegener Dis Manag. 2015;5(6 Suppl):15-17. doi:10.2217/nmt.15.56.
  3. Nicholas R, Rashid W. Multiple sclerosis. BMJ Clin Evid. 2012;pii1202(July 2011):1-67.
  4. Nylander A, Hafler DA. Multiple sclerosis. 2012;122(4). doi:10.1172/JCI58649.
  5. Dalgas U, Stenager E, Ingemann-Hansen T. Review: Multiple sclerosis and physical exercise: recommendations for the application of resistance-, endurance- and combined training. Mult Scler J. 2008;14(1):35-53. doi:10.1177/1352458507079445.
  6. Cohen JA. Emerging therapies for relapsing multiple sclerosis. Arch Neurol. 2009;66(7):821-828. doi:66/7/821 [pii]\r10.1001/archneurol.2009.104.
  7. Rietberg MB, Brooks D, Uitdehaag, Bernar MJ, Kwakkel G. Exercise therapy for multiple sclerosis. Cochrane Database Syst Rev. 2005;(1. Art. No.: CD003980). doi:10.1002/14651858.CD003980.pub2.
  8. Applebee A, Goodman AD, Mayadev AS, et al. Effects of Dalfampridine Extended-release Tablets on 6-minute Walk Distance in Patients With Multiple Sclerosis: A Post Hoc Analysis of a Double-blind, Placebo-controlled Trial. Clin Ther. 2015;37(12):2780-2787. doi:10.1016/j.clinthera.2015.10.014.
  9. Goodman AD, Bethoux F, Brown TR, et al. Long-term safety and efficacy of dalfampridine for walking impairment in patients with multiple sclerosis: Results of open-label extensions of two Phase 3 clinical trials. Mult Scler J. 2015;21(10):1322-1331. doi:10.1177/1352458514563591.
  10. Paltamaa J, Sjogren T, Peurala SH, Heinonen A. Effects of physiotherapy interventions on balance in multiple sclerosis : A systematic review and meta-analysis of randomized controlled trials. J Rehabil Med. 2012;44(10):811-823. doi:10.2340/16501977-1047.

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