From Games to New Drug Therapies: VA Improving Mobility for MS Patients

by U.S. Medicine

August 1, 2013

By Annette M. Boyle

BALTIMORE – Veterans with multiple sclerosis soon might find that having fun helps retain or improve mobility. A recent study published in the journal Neurorehabilitation and Neural Repair found that home use of the Nintendo Wii Balance Board System (WBBS) appears to improve balance and walking speed in MS patients. 1

Preliminary research also indicates the reverse is true: that moving more improves mood. MS Patients participating in an Internet-based behavioral intervention walked more and reported less depression, anxiety and fatigue, according to a presentation at the joint meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis (CMSC-ACTRIMS).2

The two studies support the multimodal approach to treatment of mobility issues used to help the 16,000 veterans with multiple sclerosis (MS) who seek care at the VA. Veterans with MS frequently face mobility issues, as the disease can cause weakness, spasticity, ataxia and sensory deficits in the legs, said Mitchell Wallin, MD, MPH, clinical associate director, VA MS Center of Excellence-East in Baltimore.

“Multidisciplinary clinical evaluations involving neurologists, physical therapists, occupational therapists and physiatrists is the best way to assess mobility problems in MS,” Wallin told U.S. Medicine. “There are often multiple neurological systems involved that require medication, bracing, physical therapy and occupational therapy approaches.”

Air Force and National Guard veteran Jeanne Goldy-Sanitate, who has MS, participates in the National Veterans TEE Tournament in Iowa, a program to develop skills in bowling and golf for veterans with disabilities. VA photo

Improving Balance

Current research suggests that balance impairments in people with early stage MS are primarily the result of deficits in proprioception, the ability to determine the body’s position in space without the use of visual cues. Proprioceptive information from the ankles is the primary sensory feedback used to maintain balance, according to the National Multiple Sclerosis Society (NMSS) website.

“Because MS impairs the ability of nerves to conduct information, it is likely that problems with transmitting proprioceptive information all the way from the ankles to the brain (and back again) play a big role in deficits in balance control,” said Brett Fling, PhD, NMSS fellow, Oregon Health and Science University, Portland. Balance boards train the proprioceptive system by providing onscreen feedback as users shift their weight.

Several VA departments use the game system, including physical therapy and occupational therapy. “A big benefit is that it’s a motivator and gives patients great feedback,” said Stacy Flynn, a physical therapist in the Houston VAMC.

In the Neurorehabilitation and Neural Repair study, researchers conducted a 24-week randomized, crossover study of 36 patients with balance disorders caused by MS. At 12- and 24-week measurements, patients improved balance as indicated by force platform measures, increased speed in a 25-foot timed walking test and improved results on the 29-item MS Impact Scale.

The physical symptoms of MS often make patients wary of exercise or even walking, which leads to further muscle weakness and reduction in mobility. A study presented at CMSC-ACTRIMS suggests Internet-based coaching may provide a relatively simple way to break this downward cycle, particularly for an organization as experienced in delivering telemedicine services as the VA.

Researchers recruited 82 patients, who were split equally into intervention or wait-list control groups. The intervention group received access to a website that provided information on increasing physical activity and individual video coaching chat sessions that used social cognitive therapy techniques to encourage behavior change.

Participants had a median Expanded Disability Status Score (EDSS) of 3.5 to start and an average age of 49 years. About 25% used canes or walkers to assist with mobility. Participants who received the intervention increased their average daily step counts from 4,000 to about 5,500, according to presenter Lara Pilutti, PhD, of the University of Illinois at Urbana-Champaign. The intervention group also showed significant improvement on measures of fatigue, depression and anxiety, compared to controls.2

Drug Therapies

Medications also have been shown to help with mobility issues in MS.

“The major MS disease modifying therapies have some variable success at slowing disability in the short term, which involves in many cases gait function,” Wallin said.

VA clinicians may prescribe the injectables interferon beta-1a and 1b or glatiramer or the oral medication fingolimod. Two other disease modifying medications, the infusion therapies mitoxantrone and natalizumab, are generally considered second-line therapies because of their side effects, according to the VA website.

Beyond those, “dalfampradine is the major FDA-approved medication that can improve gait function,” Wallin said. The first drug that addresses specific symptoms of MS, “dalfampridine is effective in reducing the 25-foot walk time in approximately 30% of patients who are started on the drug,” he noted. Clinical trials indicate that patients who respond to the drug also might benefit from increased muscle strength in the hip flexors, knee flexors and extensors and ankle dorsi-flexors. Because of the variability in response to the drug, “the VA Criteria for Use mandates that some improvement in walking is demonstrated to continue prescribing this medication,” Wallin noted.

Dalfampridine works primarily by blocking potassium channels, which might become too active in MS. It also might increase neurotransmitter release by enabling greater calcium influx at presynaptic terminals. It is contraindicated for patients with moderate or severe kidney impairment, and patients with mild renal impairment should be monitored because of increased risk of seizures, according to the Food and Drug Administration.

  1. Prosperini L, Fortuna D, Giannì C, Leonardi L, Marchetti MR, Pozzilli C. Home-Based Balance Training Using the Wii Balance Board: A Randomized, Crossover Pilot Study in Multiple Sclerosis. Neurorehabilitation and Neural Repair. 2013 Mar 11. [Epub ahead of print]
  2. Pilutti L, et al. “RCT of a behavioral intervention targeting physical activity and symptoms in MS.” CMSC-ACTRIMS 2013; Abstract SX23.

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