Case-Based Review

Understanding and Treating Balance Impairment in Multiple Sclerosis



Research has shown that the balance deficits associated with MS result from a diverse set of constraints across multiple contexts of postural control [26–28] ( Table). Studies have further demonstrated that balance deficits are prevalent across disability levels in MS [29]. Abnormalities in balance and gait have even been found in those with minimal disability [30–33] or with no clinically observable impairment [34–37].

Balance Assessment

Balance assessment indicates that Ms. D cannot abduct and hold either leg to her side for any noticeable length of time, cannot reach forward adequately without lifting her heels off the ground or falling forward, and cannot stand on one leg for more than 10 seconds without losing balance. She also needs to take multiple steps to recover balance with any slight perturbation and is unable to maintain stability while standing on foam with her eyes closed. She shows significant imbalance when rising from a chair, walking forward, and turning to come back to sit.

For Ms. D, the clinical balance exam suggests pervasive impairment of hip strength, limits of stability, anticipatory postural adjustments, postural responses, sensory integration, and gait. Furthermore, her reported need to focus vision on her gait is in accordance with compensation for existing sensory impairments. Lastly, fatigue and attention demand likely enhance the presentation of balance impairment.

  • What are the consequences of balance impairments associated with MS?

Balance impairments present considerable health problems for adults with MS. Greater than 50% of individuals with MS report falling in any 6-month period [81–85], with the incidence of recurrent falls reported to be as high as 9 falls per year [86]. In addition, fall-related injuries, including fractures, are more common with MS, although this increased risk is considerably greater for women with MS than men [86–90].

Common risk factors for falling in people with MS include variable or deteriorating MS status [90–96], problems with balance or mobility [88,92–94,96–99], use of walking aids [88,93,97], lower balance confidence [86,98], reduced executive functioning [99] and greater fatigue [85]. Increased postural sway [52,99,100], slower walking speed [99], greater gait asymmetry and variability [92,101], slower choice stepping reaction time [99], impaired forward limits of stability [92,99], impaired visually dependent sway [92,99], and leg weakness [88,92] have also been found predictive of future falls in MS. A link has also emerged between cognitive impairment and fall risk [86,95,99,102].

Fear of falling and fall-induced injuries are also the most common causes of restricted activity and disability for individuals with MS [14]. Research has shown that future physical activity associates with fear of falling, and fear of falling subsequently associated with lower-limb strength asymmetry and decreased limits of stability rather than past experience of falling [103]. Similarly, the perceived benefits of physical activity and an individual’s self-efficacy to engage in physical activity predict reported levels of physical activity independent of disability level for individuals with MS [104]. Thus, psychological perception represents an important, and potentially modifiable, correlate of physical activity.

Moreover, individuals with MS experience a high risk of cardiovascular disease and other chronic health conditions associated with deconditioning, as unfavorable blood lipid levels, poor glucose profiles, and obesity have been observed in this population [105]. Comorbid conditions, secondary conditions, and health behaviors are increasingly recognized to be important factors influencing a range of outcomes in MS [107].


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