Case-Based Review

Understanding and Treating Balance Impairment in Multiple Sclerosis



Further History

Consistent with the consequences of balance and mobility impairment, Ms. D reports that she loses her balance and nearly falls at least 1 time per week while engaged in daily activities. She also shares that she fell 2 months ago while walking outside and across the lawn to get the mail. Her confidence is low for many daily tasks such as climbing stairs, picking up objects from the floor, reaching when on tiptoes, or walking on ramps or on slippery surfaces. While Ms. D is independent in all activities of daily living, she currently does not work due to her fatigue and poor balance. She indicates that she is not very physically active and feels somewhat isolated and depressed because her balance and mobility challenges keep her from going out with friends and socializing.

  • What exercise approaches are available to ameliorate the balance deficits associated with MS?

There are a variety of therapeutic approaches for the treatment of poor balance in MS. While pharmacologic treatment typically encompasses disease-modifying therapies, specific medications can also help in the management of symptoms (ie, fatigue, spasticity, gait variability) that can negatively impact balance and mobility. Other rehabilitative strategies for balance impairment include gait training, assistive devices for mobility, and environmental modifications for fall prevention. Although all of these avenues offer viable treatment options for improving balance, exercise is increasingly appreciated as an important adjunct to the rehabilitation management of MS [107], especially in terms of improving balance deficits, optimizing daily functioning, and increasing participation across various life contexts.

The diversity of exercise options available for individuals with MS who experience balance and mobility problems is expanding. Moreover, mounting evidence suggests that exercise is well tolerated by participants with the disease[108–110] and that individuals with MS can exercise sufficiently to improve their fitness, function, and quality of life [109,110]. Given the inherent variability of MS and the heterogeneity of symptoms and disease course across individuals, however, no one exercise prescription is optimal for all those diagnosed. Instead, treatment goals must be individualized and functionally based [107] with ongoing evaluation and modification of treatment plans due to disease progression, symptom fluctuations, and functional decline [107,111]. Regardless of specific approach, the aim of any exercise intervention is to reduce activity limitations, encourage participation, and facilitate independence and life satisfaction in those with the disease [112].

Resistance Training

There have been several structured reviews of exercise research in MS [108,110,113,114]. The existing evidence supports resistance exercise as compared with no exercise for improving general balance [115] or performing tasks such as a chair transfer [116] or sit-to-stand [117]. Two randomized controlled trials (RCTs) also revealed significant increases in functional reach (ie, limits of stability) as a result of progressive resistance exercise [118,119]. Resistance exercise has not, however, facilitated greater benefit over traditional rehabilitation in other postural control contexts such as those involving postural transitions, sensory integration, or postural sway [120–122].

The effects of resistance training on mobility have also been inconsistent. While several studies showed no significant improvement in functional mobility [118,122,123], a positive improvement was observed in other research [119,124,125]. Likewise, stair climbing was shown to improve in 2 noncontrolled studies [125,126] and one RCT [117] but not in another [127].

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