#009: Motoric Cognitive Risk (MCR) Syndrome in MS. Interview with Dr. Alon Kalron

Today I’m talking with Dr. Alon Kalron about the Motoric Cognitive Risk syndrome (MCR) and what it means for people with MS. MCR describes the combination of physical and cognitive symptoms that, along with a fear of falling, lead to a higher likelihood of actually falling. And you can imagine that it’s much better to prevent falls when you have MS, as the recovery time is usually longer and it can have further negative effects on quality of life and disease progression.

That’s why Alon provides insights into the topic and tips on what to do preventively.

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Introduction - who is Alon Kalron?

Nele Handwerker: Hello, Alon. It’s really nice to have you on the show today. And a warm welcome to Tel Aviv in Israel. #00:00:04#

Dr. Alon Kalron: Thank you very much. It’s great to be a host on your podcast. #00:00:10#

Nele Handwerker: Thank you. And before we start with the interview, it would be lovely if you could introduce yourself to the listeners, so they know who is here on the show today. #00:00:21#

Dr. Alon Kalron: Yeah, no problem. My name is Dr. Alon Kalron. I’m professional physical therapist working in the field with MS, a little over 15 years already. I have been working as a clinician also at the Sheba MS Center. It’s the largest center in Israel following over 4,000 patients with MS. In Israel, we have about 8,000. And also, I’m chair of the Department of Physical Therapy at Tel Aviv University at the faculty of medicine. #00:01:01#

Personal motivation for your career choice?

Dr. Alon Kalron: It started about 15 years ago when one of my mentors introduced me to the field of MS, mainly from the research perspective. And it was interesting at that time many things about MS at least physical issues, I mean, were understood, but most generally. And he advised me and said why not? We take a look into MS and the physical property is a little bit, especially walking and balance and physical activity to take a deeper look into this population, because relatively at that case much less was known compared to today. #00:01:59#

Nele Handwerker: Yeah, I can understand. And it’s great that we are going even deeper into certain topics.

Understanding Motoric Cognitive Risk (MCR) Syndrome in MS

Could you please explain what Motor Cognitive Risk (MCR) syndrome is and how it is related to Multiple Sclerosis (MS)?

Dr. Alon Kalron: Yeah, for sure. MCR is actually syndrome that was taken from Alzheimer’s. It’s a combination of people who have both walking difficulties and the cognitive impairment. , I mean, instead of looking at each one separately, motor cognitive risk syndrome, let’s look into both of them in the people. It was originally taken from Alzheimer’s. It’s a risk factor for old people or elders who will develop Alzheimer’s. But we all know that in MS, both walking difficulties and cognitive problems are very common. So I said why not? We look at both of these syndromes specifically in the MS population. So basically the term is people who suffer from both walking difficulties, especially looking at walking speed. They walk slower compared to the normal population. And they have cognitive issues, which looking directly at memory, they suffer from deficits in their memory. So this is the basic term, first of all. #00:03:47#

What is the prevalence of MCR in MS patients, and how does it vary by disability, disease duration, perceived fatigue, and fear of falling?

Dr. Alon Kalron: Yeah, sure. So according to a publication that we published on this issue, we examined 618 people with MS in total. That we had information about both the walking speed and cognitive issues. We did it with some electronic devices. I mean, it’s not just clinical measure, but also some kind of…we used electronic walkway to measure the walking speed. It’s called the GAITRite® mat. It’s just people walking across a mat. And then we collect all kinds of information. In this case, we focus specifically on speed. And we had information about cognitive issues. It was through a cognitive battery, computerized battery that we collect cognitive difficulties in many different sub domains. And we could know if it’s under normal. I mean, it’s abnormal, yes or no. So according to our information, it was almost a little bit above 10% of the population that suffered from both. They had also slow walking speed and cognitive problems; that the 10% is very high, considered very high compared to elders, let’s say. So, this was a prevalence of people with MS. #00:05:32#

Nele Handwerker: Great. Thank you. #00:05:34#

Dr. Alon Kalron: We found that it was related with many different issues in MS. We found that it was related to disability level. What we called…we all know the EDSS. And those with higher EDSS had a higher percentage of MCR. And we also found that it was also related with people who suffer more from fear of falling. It was also very high correlation. And also with fatigue, perceived fatigue that we know that is a very common syndrome in people with MS. #00:06:13#

How does MCR affect the daily life and functionality of people with MS?

Dr. Alon Kalron: MCR, I mean, we can’t take it out of the context of just looking at mobility and cognition. And we all know that people who suffer from mobility deficits, it’s a large impact on the quality of life. I mean, also just walking to do the daily living things. So many of them have to use walking aids and different kinds of devices for the mobility. So, of course, it limits all kinds of things that are related to walking, but also cognition. I mean, if you do both have cognitive problems then we know that it also affects your ability to all kinds, executive functions and memory tasks. And we know that the combination of both is quite alarming for people with MS. And it should be considered by healthcare providers, to look at both syndrome for these people. #00:07:28#

Are there specific risk factors that contribute to the development of MCR in people with MS?

Dr. Alon Kalron: It’s very hard. Like many things in MS, it’s very difficult to look at predictors or how they recover…it’s like asking about disease progression, actually. And we all know that it’s very hard to predict disease progression. We know, however, that there are certain things that, I mean, limit or we can stay stop. But at least they decrease the rate of progression, for instance, exercise. We know that it’s very important for people with MS. I put aside the medication. That we all know the medication generally, not even looking into each different company, but we know that it’s helping to limit the rate of progression. But also, things like exercise that I’m also very interested in. We know that people who exercise more, these outcomes like walking disability is much better. And if we look at cognitive issues, we know that people who have more social interactions, it’s very important for these people. Let’s say any activity that triggers cognitive challenges is something that we can say is in favor of these patients. And if we look on the longer run, it decreases the rate to develop the MCR. So, these are very important things that people with MS should acknowledge. #00:09:30#

What are the potential cognitive impairments associated with MCR, and how do they affect the overall well-being of people with MS?

Dr. Alon Kalron: We know that cognitive issues could develop as solely the major issue with people with MS. And it could come with combination with the other syndromes itself. It’s hard to say exactly what negatively affects cognition. We know that in some ways, it could be related with background of what we call the cognitive reserve that people develop throughout their lives. If it’s social activities, hobbies, many different aspects can be related with cognition. But as I said, the best advice is to keep interaction and, what we say, use the brain. I mean, once we use it, I can’t say we don’t lose it, but we preserve it. So, it’s very important. We know that it’s also related with fatigue that people complain. People who complain that they suffer more fatigue. We also know that there’s cognitive issues in the background. Or maybe not in the background, it’s in front. But it’s related. So these issues, I mean, it should…there are different ways to deal with it, but it’s very important to find the path even on the visual base. #00:11:27#

Nele Handwerker: Yeah. And you have to use both. Yes. Your brain and your muscles, right? #00:11:32#

Dr. Alon Kalron: My brain and muscles, they work together great. I mean, movement; they say that movement doesn’t have any…I mean, it’s a way to use your brain. I mean, behind movement, there’s some kind of goal. You’re trying to do something. And the goals are using the brain. So, these things, the combination goes well together. #00:12:00#

The Relationship between MCR and MS

Can you provide some insights into the relationship between MCR and physical disability in MS? How do these factors interact?

Dr. Alon Kalron: A as I said, the MCR is highly related with the EDSS, with the rate of disability. People with high, I mean, what we call moderate or severe disability, we can see the larger proportion of the MCR. I can’t say there’s a cause effect. I mean, it’s the disability. And the MCR is a picture of the disability. It’s not that it’s creating the disability. It’s just looking at it at a different way. But of course, it’s…as I said, the MCR is a different perspective of combining two major disabilities, the mobility and the cognition. #00:12:58#

Nele Handwerker: So this answers already the next question.

Is there a relationship between the duration of MS and the likelihood of developing MCR? If so, how does this relationship manifest?

Dr. Alon Kalron: I mean, there is a relationship, but it’s not as clear as disability by itself. Because we know that the disease progression is very different between patients. Of course, those with progressive disease as the relationship is faster. I mean, it goes side by side. But we know that patients, in many times, there’s a long gap between attacks or between the rate of progression. So, it’s much more related to the disability by itself than the disease duration. #00:13:50#

How does perceived fatigue influence the presence and progression of MCR in MS patients?

Dr. Alon Kalron: We looked at the perceived fatigue as social. We know that fatigue is different components. We have the cognitive, social, physical. And fatigue generally is highly related with cognitive deficits. So, we can see that people with higher fatigue also have much more cases of MCR. You know, always you can’t say the cause or who is first or who is second. But let’s say by our study now, it was cross-sectional. We just looking at the population itself. But we know that they’re related to each other, these common symptoms. #00:14:51#

What impact does fear of falling have on the development and management of MCR in people with MS?

Dr. Alon Kalron: First of all, fear of falling, if I look at it separately from falling by itself, is also a symptom that has to be looked at. Because fear of falling by itself, even those who don’t fall, many times they limit their activities, because the fear itself is something that we have to confront. It’s combined with most the cognitive and the mobility because people who fear tend to, let’s say, do less activities. Like go out less out of the house. And then their physical conditioning gets worse. And we know that those with MCR have a high level of fear falling. So as I said, fear falling that we know, is a highly prevalence in MCR. Is something that physical doctors or just people have to ask themselves if they suffer from this fear of fallings, because it can be helped. I mean, you can develop all kinds of different strategies to reduce this symptom that is very important in my view. #00:16:27#

Nele Handwerker: So it’s not a downward spiral and limiting. #00:16:32#

Dr. Alon Kalron: And fear and deconditioning. And they go less and they do less. And then the cognitive issues start to take a larger account. And something with proper guidance, I mean, you could actually help many of these patients. #00:16:51#

Nele Handwerker: Fantastic. And that’s was a great introduction for the next topic.

Managing MCR in MS Patients

Are there specific strategies or interventions that can help MS patients manage MCR and mitigate its effects?

Dr. Alon Kalron: Okay. And like I said, if someone is categorized as MCR, he has both cognitive issues. He has working disabilities. Now we must look at both. And as I said, there’s many ways by managing to direct both. As I said before, physical activity is one of the main issues, in my view, not only but many. Because physical activity improves mobility for sure, but also it helps cognitive issues. There’s also some kind of combination between these two for practice, let’s say. We call it the dual tasking training. Dual tasking training is, let’s say, you’re doing a motor activity like walking, but at the same time, we’re giving all kinds of different cognitive challenges. And then once you have to do both at the same time, you can actually improve each one of them separately.

I mean, instead of just walking or practicing walking or practicing cognitive training, let’s say, in a sitting position, once you do both, it’s a way…I give an example. But let’s say we did a study once that people were walking, and at the same time they had to do all kinds of numerical calculations or give specific names according to the alphabet. And you do it while you must maintain your balance, or you have to attain your walking. And we saw some promising results of people that improve both their walking and their cognitive issues once they did it together. So it’s also an interesting way to manage these deficits in MCR. #00:19:10#

Nele Handwerker: Great. And if you do it outside, you can even get some vitamin D. Fantastic. And more oxygen. #00:19:16#

Dr. Alon Kalron: I mean, in daily life, we do both things. When people walk outside or you have to get to somewhere, it’s navigation. Let’s say I have to get to a shop, or I get to a place that I don’t know exactly where, you’re doing those things because you have to walk, and you have to think where to…#00:19:33#

Nele Handwerker: How to get there. #00:19:34#

Dr. Alon Kalron: Yeah. So it’s some kind of a daily life activity. We could look at it. #00:19:38#

Nele Handwerker: Yeah. And you can train that. Yes. And they do that when I have my…they haven’t dressed then where I am at the MS center, they have this gait map or a gait thing. And I have to do it, and then I have to do something with the alphabet and zip within numeric. But not for training, but for checking if my walking is still fine. So I do this every half a year. #00:20:00#

Dr. Alon Kalron: I think there’s something that’s also famous that could also help. I haven’t checked it, but I think potentially it could work. I don’t remember how it’s called. But you know the navigation in the woods, you do all kinds of activities with a map. #00:20:18#

Nele Handwerker: Yeah. Where you kind of treasury hunt. #00:20:22#

Dr. Alon Kalron: Yeah. It’s like a sport, but if I look at it for people with MS, you know, if you don’t look at it as a competition just for fun, I think it’s a great thing to do. Just doing an activity, combining some cognitive challenge how to get to certain places. And you have nature. The nature always helps. #00:20:41#

Nele Handwerker: Absolutely. It relaxes and you have these different…you can smell different things that’s good for your senses, because they train the brain as well. Right? #00:20:53#

Dr. Alon Kalron: And you have another two very important factors. It’s fun. Why not put fun. And fun is always helps. And it could be as some kind of a social interaction, people could do it together at groups. So these are kind of things that will help all different symptoms that people with MS suffer. #00:21:14#

Nele Handwerker: Yeah. And for the people who live in the cities, they can do it even in the parks. It would be, yeah, kind of a bit nature. #00:21:21#

Dr. Alon Kalron: I mean, if you remind, it’s things that people…once we used to play these things as young children, going into finding things. Going back, back to the…#00:21:34#

Nele Handwerker: To childhood. #00:21:36#

Dr. Alon Kalron: Yeah. They were very nice games. Actually childhood games in many aspects, they’re developing cognition and our physical abilities. It’s something maybe we could look back into. #00:21:53#

Nele Handwerker: Absolutely.

What is the role of healthcare professionals in the management of MCR? What types of professionals are best suited to treat this syndrome?

Dr. Alon Kalron: I think many. I mean, first, to detect it, it’s the physician, neurologist that are aware of the physical condition, walking ability. It’s a checkup that the physician should manage. Foremost, detective. And as a treatment, I think a physical therapist. It could be also cognitive is more psychologist, or people who are trained for cognitive training, should also be involved. And if we’re talking about physical activity, educational trainers, personal trainers. With proper guidance, I think they could all work together and work for the best of the patients. #00:22:49#

Can you explain the importance of early detection and treatment of MCR in MS? How does this impact long-term outcomes and quality of life?

Dr. Alon Kalron: I think as many aspects as possible of MS, the faster people are receiving the proper treatment. I mean, we see it in all directions of MS. The education is given earlier. Everything is given earlier because they said that once you lose, it’s hard to…I mean, it’s easier to preserve brain volume, brain activities or everything that’s related to the brain before damage occurs. So even in this case, the earlier the better. But still, we want people to maintain their normal life. And, you know, it should be combined with normal activities. It’s not that someone…it’s best way to preserve, to maintain the disease and to decrease the disease progression. So I suggest earlier the better. And to modulate the activity according to daily life. For young people, of course, it’s different than older people. But everyone could benefit from some kind of tailor program. #00:24:13#

Lifestyle, Support, and Advocacy for MS Patients with MCR

Can MS patients make lifestyle changes or practice self-care to minimize the impact of MCR on their daily lives?

Dr. Alon Kalron: No, I think we talked about it quite a lot. I like it when people insert activities, but it doesn’t interfere with their normal life activities. You know, people have a job, have a family, have many things that they must combine. It’s important to put into these significant activities. You know, physical activity doesn’t have to be some kind of extreme sport. Physical activity is just, you know, instead of going by the elevator, take the stairs. Or even small, everything counts. They say every step counts. So, every activity, brain activity, physical activity counts. I mean, take advantage of what the daily life gives, puts in front of you. And I think this is a very important advice. #00:25:27#

Nele Handwerker: And maybe you see the young children as good examples. I mean, when I go with my little one to the playground, I use these things on the playground as well to train my balance or some other things when I don’t have to hold her hand. #00:25:44#

Dr. Alon Kalron: But just use it. I mean, just chasing her is activity. #00:25:48#

Nele Handwerker: Yes, of course. #00:25:49#

Dr. Alon Kalron: That’s extreme physical activity sometimes. #00:25:52#

Nele Handwerker: Yes. #00:25:53#

Dr. Alon Kalron: Taking care. Yeah. #00:25:54#

What support systems or resources are available to help MS patients dealing with MCR? Are there certain organizations or communities that offer help?

Dr. Alon Kalron: It’s not specific. It’s goes with all other healthcare organizations with MS. We don’t look at it as a specific issue. The things that are common that are used today are the same in this aspect. #00:26:32#

How can MS patients proactively advocate for themselves and ensure they receive appropriate care and support for MCR?

Dr. Alon Kalron: As I said before, it’s exactly like any other physical activity and their physical disability that they need to confront. So as I said, MCR is a different way of looking at different kinds of symptoms, disabilities. It’s not by itself exactly something separately treated. It’s mobility, cognition, but at a higher degree.  For sure, these patients must be treated. #00:27:17#

Nele Handwerker: Yes. And please, I would just add, please talk about these issues when you have them with your doctor, and don’t try to be looking bold that you don’t have these issues. Please, please talk about them. So, your physician knows about it. #00:27:34#

Dr. Alon Kalron: It is very important to talk to your healthcare manager, healthcare professional, about these issues because there are treatments. And actually it’s expected that the healthcare professional would ask about it. But if not, it’s very important to talk about it, to rise the difficulties, and try to think together of solutions. The best solutions come when both sides think together. #00:28:00#

Nele Handwerker: Absolutely. And I think these questions are raised at MS experts, but not every MS patient is treated by an MS expert. So that’s why I try to mention it. Yeah. #00:28:12#

Dr. Alon Kalron: It could be also, you know, people with cognitive issues sometimes it’s also important for a family member to raise it for them. Because cognitive issues sometimes get forgotten, let’s say. So family members should also feel free to. It’s important that they also raise it, so the patient itself gets the best treatment. #00:28:34#

Is there ongoing research or progress in the field of MCR and MS that holds promise for future treatments or management strategies?

Dr. Alon Kalron: I think there’s a lot of research into the domains of MCR. And a lot of research into cognition, how to treat cognition. We know that there’s no specific medication for it. So, we’re looking at different kinds of exercise, training to improve cognition. And also, for physical or walking difficulties, there’s a lot of research looking into it. And it’s very important, as I said, much more than let’s say 10-15 years ago or 20 years ago. People are more aware, and people are looking more for advice. They’re doing much more. Many medical doctors told me that MS Departments today don’t resemble at all what was 30 years ago. It’s totally a different atmosphere. People are much more active. They’re looking to be active. And I think the treatment is getting much better even beside the medication that improved. But even in other aspects, they’re getting more. And we’re all the time exploring more and more, and new kinds of activities. #00:30:04#

Nele Handwerker: Great.

Can you share positive experiences of MS patients who have achieved good management of MCR and regained quality of life?

Dr. Alon Kalron: As I said before, I mean many patients that we know that participated in all kinds of exercise activities, we saw positive results more on the mobility. But also in cognition, there’s large studies showing, let’s say, in progressive MS. So that even is more encouraging. So I can’t say that it helps all. But as a group, it does I mean benefits a large segment of these patients. And we’re just continuing looking into these patients. #00:30:58#


Is there anything else you would like to share with the listeners?

Dr. Alon Kalron: I think I shared a lot. #00:31:08#

Nele Handwerker: You did. #00:31:09#

Dr. Alon Kalron: As I said, I think one sentence, if you want to remember one sentence, then I think „every move count“ is very important sentence. It’s also even relaxing to know that every move counts because I can do it. I can do something. And as I said, I think the future in this field is quite impressive and we’re looking forward all the time to improve health benefits in the MS population. #00:31:41#

Nele Handwerker: Yes. And maybe I can just share an insight from a German interview, which I had on sport and MS. And there was a lady sitting in the wheelchair and she started climbing. I mean, she was not exactly an MCR person. But later, she was able to play even table tennis standing and went into climbing. So, moving can be a lot, and you can start with a little piece and go from there, and increase it maybe over time. #00:32:10#

Dr. Alon Kalron: I also saw it; people are doing activities in the water. Many people I saw people are doing all kinds of paddle. I don’t remember the names exactly, but windsurfing. #00:32:24#

Nele Handwerker: Windsurfing. Wow. #00:32:27#

Dr. Alon Kalron: Look like it’s bright. And any activity that people also like, go for it. #00:32:35#

How and where can interested people follow your research activities?

Dr. Alon Kalron: So, you can follow me in the LinkedIn. In the LinkedIn, from now and then I certain posts about my activities, mainly research activities, groups that I’m involved with, research groups. So that could be a place to look me up if you want. #00:33:05#

Search on PubMed

Nele Handwerker: Great. Alon, thanks a lot for sharing all that positive insights and making people to think about that every move counts. And that it doesn’t have to go in one direction. You can turn that into a positive side if you start to train your mobility, train your cognitive functions, and you can regain things. Of course, it’s always better to preserve. You mentioned that a couple of times. But it’s also positive possible in the progressive state to gain back mobility and all that. Great. And thanks a lot for all your research. #00:33:50#

Dr. Alon Kalron: Thank you very much. It’s a privilege to participate. And I hope I’ll be listening to your podcast. #00:33:58#

Nele Handwerker: Thanks a lot. And bye-bye to Tel Aviv. #00:34:01#

Dr. Alon Kalron: Thank you very much. #00:34:04#

See you soon and try to make the best out of your life for example by staying or becoming active as much as possible,

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