Editorial - Volume 20, Issue 5 - September 2018

Our readers are undoubtedly used to discovering, in each issue of IJMSC, articles addressing a mosaic of topics that together draw a picture of comprehensive MS care. As it happens, all of the articles contained in the September/October 2018 issue relate to how individuals with MS move within their environments. This is not by design (our annual theme issue will be published at the end of the year) but, in my opinion, reflects the high prevalence and profound consequences of altered motion in MS, and the strong focus within the MS community on better understanding, measuring, and helping our patients remediate or adapt to motion-related problems.

Along with neural control, the integrity of the musculoskeletal system is necessary for adequate motion. While the presence of musculoskeletal comorbidity was shown to be associated with higher disability levels in MS, evidence on the outcomes of treatment for musculoskeletal issues in the setting of MS is scarce. This lack of evidence impedes patient education and clinical decision making, particularly with regard to surgery. The latest CME/CNE article, authored by Gutman and colleagues, on the outcomes of total hip or knee replacement surgery in a series of 30 individuals with MS, provides insight into the variability of functional results in the context of neurologic impairment.

Three articles contribute evidence on three major treatment modalities for gait and walking impairment in MS: symptomatic pharmacotherapy, rehabilitation, and assistive technology. Leone and colleagues report improvement of spatiotemporal gait parameters, walking capacity, and self-reported walking limitations after rehabilitation in 42 individuals with MS from four centers in three countries, with more disabled individuals exhibiting a larger magnitude of effect. Street and Singleton followed a cohort of 145 users of peroneal nerve functional electrical stimulation for foot drop for 5 years and found that functional electrical stimulation continues to produce an immediate improvement of walking speed (“orthotic effect”) despite evidence of progression of gait disturbance over time. In the case report from Plummer and colleagues, combining gait training with dalfampridine therapy resulted in greater improvement of walking speed than the medication alone. Although all of these studies were uncontrolled, they represent pragmatic observations in clinical environments that will help foster future research.

Balance is another element of mobility that is commonly affected by MS. Investigation of treatments for balance impairment requires valid, reliable, and sensitive measures. Mitchell and colleagues explored the validity and reliability of the Balance Evaluation Systems Test (BESTest) and proposed a minimal detectable change value of 10%.

Compared to lower extremity motor control, upper extremity motor control in MS is unfortunately a less common publication topic. The literature review on upper limb intention tremor by McCreary and colleagues highlights crucial gaps in evidence: not only is there a need for more research on the pathophysiology of intention tremor, but the few published treatment studies have significant methodological limitations and lack homogeneity in the outcome measures used.

The multiple facets within the single domain of motor consequences of MS, of which the contents of this issue offer only a few examples, impress upon me the infinite complexity of comprehensive MS care. Such care addresses many more issues (cognitive impairment, elimination dysfunction, and emotional disorders, to name a few) while taking into account the unique characteristics of each individual within a specific human and physical environment.