Case-Based Review

Understanding and Treating Balance Impairment in Multiple Sclerosis



Ms. D also noted that her MS significantly impacts her ability to walk both in terms of effort and distance and adversely affects her participation in social events. Supplemental to her balance exercise program, aerobic exercise, particularly treadmill walking, may offer some benefit both in terms of her endurance as well as gait. While some of the more targeted modalities such as hippotherapy, yoga, and kickboxing have not been extensively studied, they do offer promise and could be used as adjuncts in order to facilitate Ms. D’s motivation and adherence through more diverse programming. Lastly, and although requiring further study, cognitive-behavioral interventions and patient education may be warranted to help Ms. D overcome her fear of falling, low exercise self-efficacy, and any negative beliefs regarding the potential benefits of exercise.

  • What additional research is needed?

Although valuable insight has been gained from studies of balance and gait impairment with MS, many contexts remain understudied, particularly with regard to understanding both the neuroanatomical and neurophysiologic pathologies that underlie the behavioral impairments of balance and gait in MS. Further, the value of applying this knowledge of balance impairment to clinical diagnostics and prognostics requires further study in order to develop the most cost- and time-effective exams and evidence-based treatment approaches.

Based on the research to date, it remains difficult to draw definitive evidenced-based conclusions regarding what specific exercise mode or training dose would be most beneficial for Ms. D and others with MS. Moreover, while there exists some evidence of efficacious balance outcomes from exercise training, many of the studies involved individuals with mild MS. Only a few studies to date have included those with more advanced disability, thus making prescription generalizations to those more moderately affected by MS tenuous. Irrespective of specific approach, all modalities of balance-oriented interventions require larger controlled studies, inclusion of those with advancing disability status, long-term follow-up, an evaluation of optimal dose or duration, and outcomes on the neural mechanisms of effect.


Challenges to balance and mobility present serious consequences for those with MS, as falls and fear of falling lead to poor health outcomes and low quality of life. Given that postural impairments result from a diverse set of deficits in different underlying control systems, therapeutic intervention should be multimodal. Exercise prescription should address all affected contexts of postural control, including sensory and motor strategy training during postural transitions as well as induced postural perturbations, strength development, and gait activity. Evidence from clinical trials suggests that targeted balance oriented exercise in people with MS has the potential to improve balance and functional mobility, although more rigorous study on the topic is needed.

Corresponding author: Susan L. Kasser, PhD, Dept. of Rehabilitation and Movement Science, Univ. of Vermont, 306 Rowell Bldg, 106 Carrigan Dr, Burlington, VT 05405, [email protected]

Financial disclosures: None.


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