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Fampridine improves severe dysarthria in secondary-progressive multiple sclerosis

Sirs, An extended release formulation of fampridine which is also known as dalfampridine or 4-aminopyridine has been shown to improve walking speed in patients with multiple sclerosis (MS) irrespective of the course of disease and concomitant or previous immunomodulatory or immunosuppessive treatments.1 In Europe, market approval has been confined to patients with an Expanded Disability Status Scale (EDSS) of 4.0 to 7.0. Based on the pathophysiology of demyelinated axons, potassium channel blockade by fampridine might also exhibit additional symptomatic effects other than walking improvement.2 Here, we report on three patients (two females, 26 and 51 years old, and one male, 37 years old) with long-standing secondary progressive MS (mean duration of disease 16±5.6 years, range 10–21 years) and an EDSS of 7.0 suffering from severe cerebellar/pseudobulbar dysarthria who improved promptly and persistently under treatment with fampridine. Quantification and measurement of dysarthria is a matter of high complexity and a continuous clinical challenge.3 Here, we used a comprehensible and reproducible scale of intelligibility, the intelligibility rating scale of the National Technical Institute for the Deaf.4 Prior to treatment, two patients used voice computers to communicate corresponding to a level 2 of speech intelligibility according to the aforementioned scale, i.e. speech is very difficult to understand – only isolated words or phrases are intelligible. Patient three had a level 3 of speech intelligibility (with difficulty, the listener can understand about half the content of the message). After two weeks of treatment with fampridine the first two patients’ articulation improved to an extent that they regained the ability to communicate without voice computers for most of the day now corresponding to a level 3 of intelligibility. The third patient also improved considerably reaching a level 4 of intelligibility, i.e. speech is intelligible with the exception of a few words or phrases. In all three patients the clinical effect was measurable after only two weeks and is still persistent after six, eight and nine months of treatment, respectively. Despite the severe disability of all three patients, the impact of the observed improvement of articulation for social inclusion and maintenance of quality of life is invaluable. However, the clinical significance of the above observation is limited by the small sample size and the uncontrolled, unblinded approach. Placebo-controlled, prospective studies might clarify the possible role of fampridine as a symptomatic treatment for severe dysarthria in MS patients.