Multiple Sclerosis


Disease Progression in Multiple Sclerosis I. Impaired Mobility and Its Impact on Limitations of Activities and Social Participation


Jürg Kesselring


Head, Department of Neurology and Neurorehabilitation, Rehabilitation Centre, Valens, and Professor of Clinical Neurology and Neurorehabilitation, University of Bern and Neuroscience Centre, Zürich


Abstract


Limitations in activities of daily living are important to an individual’s life, and the progressive nature of multiple sclerosis (MS) can have a significant impact on the patient’s quality of life (QoL). Monitoring low-level limitations of activities during the early stages of MS should be encouraged, as it can indicate advancing neurological damage. Clinical data and survey evidence from numerous research groups suggest that impaired mobility is a large contributory factor to diminished QoL. Although these studies have demonstrated the negative effect of reduced mobility, there remains a substantial need for greater recognition of the presence and effects of disabilities, including reduced mobility, fatigue, pain, depression and spasticity, and the need for targeted treatments for specific impairments. In this review, literature describing the impact on the lives of patient is presented; because of the variability in speed of progression and prognosis with early mobility loss, the need for early, continuous and consistent assessment is suggested.


Keywords Multiple sclerosis, walking ability, mobility, activity and social participation, determination of walking ability


Disclosure: Jürg Kesselring serves or has served on data safety monitoring and advisory boards of clinical trials in multiple sclerosis sponsored by Biogen, Novartis, Serono, Schering and Wyeth. Acknowledgement: Editorial assistance was provided by James Gilbart at Touch Briefings. Received: 14 June 2010 Accepted: 1 July 2010 Citation: European Neurological Review, 2010;5(1):56–60 Correspondence: Jürg Kesselring, Head, Department of Neurology and Neurorehabilitation, Rehabilitation Centre, Neuroscience Centre Zurich, CH 7317 Valens, Switzerland. E: kesselring.klival@spin.ch


Support: The publication of this article was funded by Biogen Idec, Inc. The views and opinions expressed are those of the author and not necessarily those of Biogen Idec, Inc.


Patients with multiple sclerosis (MS) typically present with a clinically isolated syndrome (CIS), which eventually develops into relapsing– remitting MS (RRMS); after a varying number of years, most patients transform into secondary progressive MS (SPMS). An alternative course is primary progressive MS (PPMS), which develops more rapidly from onset and is also inevitably accompanied by some decline in walking ability.1


In early MS, the prognosis after disease


onset is highly variable and the time taken to progress to irreversible disability is generally unpredictable.


A number of studies have shown that disease onset in later life generally results in more rapid progression. This was shown in a study of 1,844 patients with MS in France, which found that individuals who were diagnosed with MS at up to 29 years of age took a median of 33 years to progress to a disability status score of 7 (unable to walk more than 10m without rest and/or support), whereas in patients diagnosed at over 50 years of age, a similar progression was seen in a median of only 17 years (see Figure 1).2


In the same study, progression from RRMS


to SPMS was estimated to occur in about 2.5% of patients per year and the median time to conversion was 19.1 years.3


These findings also


indicate that increasing disability in MS occurs at widely varying rates, but it is inevitable that over periods of many years, the abilities of patients will decline and they will require increasing levels of support.


56


Of all the limitations of activities that can affect patients with MS, the loss of walking ability is the most feared.8


Walking ability normally declines during the course of MS; this decline may even be present, © TOUCH BRIEFINGS 2010


Most clinical trials and studies of patients with MS have focused on RRMS. As a consequence, there is a large body of information available on this phase of the disease, but less on progression and disability during later stages of MS. This deficiency needs to be addressed. In SPMS, disability is more apparent, severely restricting the functions and activities of patients, and it is more difficult to treat than at earlier phases of the disease. Interventions designed to stop or more effectively delay progression of disability in MS are a substantial unmet clinical need.


The currently available treatments for MS are targeted primarily at reducing inflammation, and have been shown to reduce relapse rates and pathological activity as detected by magnetic resonance imaging (MRI). However, these treatments are not sufficient on their own, as they do not address decreasing axonal function.4


Managing MS must therefore also involve managing the symptoms of disease progression, in particular limitations of activities and social participation, an area of research that continues to require development.4–7


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