Case-Based Review

Understanding and Treating Balance Impairment in Multiple Sclerosis




There has been only one study to date, albeit not an RCT, that has examined kickboxing as a training modality to improve balance in MS. Although kickboxing was found to be a feasible exercise activity, not all participants demonstrated improved balance and mobility outcomes [171]. As such, further investigation of this novel treatment approach is warranted.


Hippotherapy has also been employed as a means of balance training because the multidimensional and random nature of the horse’s movement requires the rider to process increased sensory information and make the necessary anticipatory and reactive adjustments for postural control. While one study reported no improvement in postural sway after hippotherapy [172], other research has shown some benefit in balance and gait after riding [173,174]. Although preliminary, findings from 2 of the studies reveal that hippotherapy may be most beneficial for those with primary progressive MS compared to other subtypes of MS [175]. While hippotherapy may have a positive effect on balance in individuals with MS, the data is limited and lacks rigorous examination through randomized controlled study of large samples in order to allow for its advocacy as a primary rehabilitation modality at this time.

  • What exercise prescription is indicated for Ms. D?

Because Ms. D’s balance deficits have begun to limit her daily functioning and increase her risk of falling, a formal and targeted balance intervention is warranted. Research confirms that exercise would be well tolerated by Ms. D and supports the feasibility of her engaging in various exercise modalities. Although a number of exercise inter-vention studies involving people with MS have been described in the literature, their clinical utility and results in improving balance and mobility are varied. Nonetheless, there is preliminary evidence suggesting that exercise training may have positive effects on balance and functional mobility and could offer Ms. D benefit. This is especially true given that much of the exercise research included individuals with mild or minimal disability and at same stage of disease progression as Ms. D.

Since Ms. D’s balance problems stem from a range of postural impairments across multiple contexts of balance control, her treatment approach must incorporate exercises that include and integrate these underlying control systems. A targeted and multimodal balance exercise program, rather than general physical activity, may be most efficacious toward this end.

Intervention Prescription

Given the weakness in Ms. D’s lower extremities, a program of individualized and progressive exercise is recommended ( Box). Exercises should be functionally based and focus on strengthening of the hip abductors as well as knee flexors and extensors, as these muscle groups in particular have been found important in the control of balance [43,44]. In addition, Ms. D’s difficulty rising from a chair, standing on one leg, walking over uneven surfaces, and regaining balance after a slight perturbation suggest the need to prescribe exercises that facilitate both anticipatory postural adjustments as well as automatic postural responses. As such, she should be prescribed a variety of training tasks that require functionally relevant postural transitions, higher velocity movements and turns, movement over uneven surfaces, and exercise on changing bases of support [136]. It is also important that Ms. D engage in dynamic gait activities such as stepping over obstacles, moving to pick up objects from the floor, and walking in dynamic environments to further her capacity for postural preparation and responses.

Ms. D has poor ability to utilize somatosensory and vestibular inputs in order to dynamically weight the influence of multiple sensory modalities for the control of standing sway under varying sensory conditions. This visual dependence contributes to her poor balance and increases her fall risk when visual inputs are absent (ie, walking in dimly lit rooms) or when optic flow is incongruent or when visual distractions are present (ie, walking in dynamic contexts such as crowded spaces). Ms. D would benefit from exercises requiring greater use of proprioceptive and vestibular inputs, thereby facilitating improved sensory integration. Exercises performed with eyes closed as well as those completed on mats, foam, or other compliant surfaces would be beneficial. She might also benefit from specific vestibular rehabilitation exercises as this approach has resulted in improved sensory integration [143]. Given that Ms. D must regularly concentrate and focus on her balance and consistently look where she is stepping, her balance exercise program should also address her central processing and attentional deficits by including dual-task training [26].

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