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.

Related Articles

MS in Gulf War Veterans: Zeroing-In on Types, Disability Levels

While veterans serving in the military during the Gulf War era (GWE) appear to have higher risk for multiple sclerosis and a range of neurological illnesses, little has been documented previously on prevalent types of MS or other clinical features.

Bill to Streamline, Expand VA’s Choice Program Signed Into Law

Legislation that would streamline VA’s community care programs into one program and expand VA’s caregiver program to veterans of all eras was signed into law earlier this month..


U.S. Medicine Recommends


More From department of veterans affairs

Department of Veterans Affairs (VA)

Bill to Streamline, Expand VA’s Choice Program Signed Into Law

Legislation that would streamline VA’s community care programs into one program and expand VA’s caregiver program to veterans of all eras was signed into law earlier this month..

Department of Veterans Affairs (VA)

Despite Criticism, VA Healthcare as Good or Better Than Other Systems

The good news from a recent consultant study is that, overall, the VA healthcare system is generally equal or better than others when inpatient and outpatient quality is measured.

Department of Veterans Affairs (VA)

VA Inks Contract for Massive New Health Record System

Calling it one of the largest IT contracts in the federal government, with a ceiling of $10 billion over a decade, then-VA Acting Secretary Robert Wilkie announced that the agency signed a contract with Cerner for its new electronic health record (EHR).

Department of Veterans Affairs (VA)

Surprise! President Nominates Wilkie for Permanent VA Secretary

President Donald Trump said last month that acting VA Secretary Robert Wilkie “has done an incredible job” and, in a surprise move, nominated him for the permanent Cabinet position.

Department of Veterans Affairs (VA)

Fibromyalgia Presents Differently in Male, Female Veterans

Research on fibromyalgia, a poorly understood, chronically disabling pain syndrome, generally has focused on its clinical presentation and treatment.

Facebook Comment

Subscribe to U.S. Medicine Print Magazine

U.S. Medicine is mailed free each month to physicians, pharmacists, nurse practitioners, physician assistants and administrators working for Veterans Affairs, Department of Defense and U.S. Public Health Service.

Subscribe Now

Receive Our Email Newsletter

Stay informed about federal medical news, clinical updates and reports on government topics for the federal healthcare professional.

Sign Up