Physical therapist perspectives on walking treatments for people with multiple sclerosis

Physical therapist perspectives on walking treatments for people with multiple sclerosis

By Andrea Stewart, PhD, SPT

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Background

Multiple sclerosis (MS) is an unpredictable neurodegenerative disease of the central nervous system caused by an immune-mediated demyelination process of neurons that typically leads to debilitating illness (1,2). Common symptoms include muscle weakness, spasticity, fatigue, and balance and coordination deficits, all of which can affect one’s ability to walk (1). The current definition of a treatment “responder” (to pharmacological management) for gait impairments in individuals with MS is controversial for lacking patient-centeredness and failing to capture meaningful walking change. A common outcome used to determine whether a patient is responding to walking treatments is gait speed. In studies involving the pharmacological “walking drug,” dalfampridine extended-release (D-ER, Ampyra®), treatment failure is defined as less than 20% improvement in gait speed (2,3). However, is faster walking an indicator of improvement from the perspectives of patients and clinicians?

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Statement of need

In the pharmacological studies mentioned above, a large majority (60%) of patients on D-ER, Ampyra fail to respond (in terms of gait speed) to drug treatment alone (2,3). To evaluate the benefit of a physical therapy program involving gait training and exercise as an alternative or adjunct treatment for this patient group, meaningful treatment outcomes first need to be identified to elevate patient-centered care. High-quality, value-based care must incorporate the perspectives of both the clinician and the patient into treatment approaches and patient outcomes, yet currently, there are few studies in the literature that define “clinically meaningful improvement” in walking-related outcomes for people with MS. A better understanding of therapists’ decision-making processes and the identification of meaningful treatment strategies and patient-centered outcome measures will allow for better informed future research studies and excellent quality clinical practice.

I conducted a brief literature review on rehabilitative studies that have used the statistical value, Minimal Clinically Important Difference (MCID), for gait measures in individuals with MS to better understand definitions of meaningful walking change in this population. The literature review is linked below under ‘products.’

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Project overview

The development of my capstone project evolved from a research project that I initiated in the fall semester of 2017 with Dr. Prue Plummer, PhD, PT along with fellow DPT student, Jessica Anderson. The project involved conducting qualitative research with focus groups and interviews of physical therapists and people living with MS. The aim of the research was to engage both groups to better understand perceptions of meaningful treatments and outcomes for people with MS who have walking difficulties. For my capstone project, I focused on perspectives of physical therapists. I encourage readers to also explore Jessica’s capstone to learn more about her project that focused on perspectives of individuals living with MS.

The key questions underlying my capstone are the following: 1) How do physical therapists make treatment decisions to address walking difficulties in patients who have MS? 2) How do physical therapists assess whether a treatment is working?

Our research project has continued into the spring semester of 2018 and is ongoing. For my capstone, I continued to collect data via an online survey that we adapted from the focus group question route (questions are linked below for reference). Thematic analysis involved reviewing transcripts that were professionally transcribed from the audio recordings of the focus groups/interviews to identify key themes that emerged from discussions with our participants. Key themes and salient participant quotations were organized in a matrix of summarized results (linked below). I presented the findings from this project as a PowerPoint presentation (linked below) and discussion to clinicians (mainly physical therapists) at UNC Hospital’s rehabilitation group.

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Products

• Literature review
• Focus group questions for physical therapists
• Online survey for physical therapists
• Matrix
• PowerPoint presentation “Physical therapist perspectives on walking treatments for patients with multiple sclerosis”

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Evaluation and self-assessment

The evaluation survey for my presentation and a summary of the attendee’s responses are posted below. Overall, the presentation was well received by clinicians at UNC Hospital and it generated thoughtful discussion among attendees about the accuracy and appropriateness of measures commonly used to assess patient safety, mobility, and walking.

• Evaluation handout
• Evaluation summary of responses

I am grateful for the opportunity to be involved in this research opportunity to further our understanding of meaningful walking treatments for people with MS. I learned a great deal about clinical research and specifically, how to conduct a qualitative study. Through regular meetings with Dr. Plummer and readings from the primary literature on focus group research, I have become more familiar with the methodology and ethical concerns for conducting qualitative research with people. I have a deeper appreciation for the amount of work and organization that goes into conducting an effective focus group, from the somewhat difficult process of recruiting participants, having a focused question route, guiding discussion effectively, and taking careful notes to capture non-verbal communication. I discovered that analyzing qualitative data (in our case, transcripts) requires a rigorous review of the text and notes. Distilling the salient information into a summarized matrix of our findings was a rewarding challenge.

Some of the challenges that I faced included the uncertainty of recruiting a sufficient number of participants for the study. We were able to reach out to colleagues at the Center for Rehabilitative Care at UNC, and I attended an MS conference in Raleigh to distribute our focus group flyers and talk with clinicians about our research. I learned that successful recruitment can require a longer time period than anticipated. Fortunately, the study is ongoing, and we developed online surveys to continue collecting data.

Overall, I am very satisfied with my work on this research project and the products that I produced for clinicians working with patients with MS. Throughout the process, I maintained contact in-person and via email with my committee and continually integrated their expert feedback into the products, including the presentation and literature review. I also held a practice presentation with Dr. Plummer and Jessica, which helped me improve the flow and organization of my slides and identify areas that needed improvement and further practice. I will continue to receive and integrate feedback from my committee and peers through this website.

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Acknowledgements

I would like to thank Dr. Prue Plummer for her guidance and support throughout this project. Her passion for clinical research and evidence-based practice has fostered my continued enthusiasm for research. Through her mentorship, I have learned the value of staying organized, holding to a timeline but also being flexible, and reading and thinking critically.

I am grateful to my classmate, Jessica Anderson, who I worked closely with on the initial research project under Dr. Plummer’s guidance. Her high standards for herself and others as well as the work she puts herself into helped to keep me focused and driven.

I would also like to thank my committee members, Diane Meyer, PT, NDT and April Xayavong, PT, DPT, MSCS who were always thoughtful and prompt in their communication and feedback. They were both instrumental in reviewing my final capstone products.

Finally, I am grateful for the MS STEP UP scholar program, the program’s Volunteer Leadership Team, and the National Multiple Sclerosis Society for their ongoing support. The program has provided me with unique opportunities, such as working with individuals with MS, mentoring from expert clinicians, and learning in-depth about MS through additional coursework and attending a national MS conference (the Consortium of Multiple Sclerosis Centers).

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References

1. Home : National Multiple Sclerosis Society. Available at: http://www.nationalmssociety.org/. Accessed September 16, 2017.
2. Tettey P, Siejka D, Simpson S, et al. Frequency of Comorbidities and Their Association with Clinical Disability and Relapse in Multiple Sclerosis. Neuroepidemiology 2016;46(2):106-113. doi:10.1159/000442203.
3. Goodman AD, Brown TR, Edwards KR, et al. A phase 3 trial of extended release oral dalfampridine in multiple sclerosis. Ann. Neurol. 2010;68(4):494-502. doi:10.1002/ana.22240.
4. Goodman AD, Brown TR, Krupp LB, et al. Sustained-release oral fampridine in multiple sclerosis: a randomised, double-blind, controlled trial. The Lancet 2009;373(9665):732-738. doi:10.1016/S0140-6736(09)60442-6.