Understanding and Treating Balance Impairment in Multiple Sclerosis

From the Department of Rehabilitation and Movement Science, University of Vermont, Burlington, VT.

Abstract

• Objective: To provide insight into the mechanisms and treatment options associated with balance impairments in individuals with multiple sclerosis (MS).
• Methods: Systematic reviews, randomized controlled trials, and noncontrolled studies were examined to collect current data regarding treatment options aimed at improving balance in MS.
• Results: Balance deficits are common in individuals with MS and result from a diverse set of constraints across multiple systems of postural control. Poor balance often leads to increased fall risk, reduced physical activity, added comorbidities, and decreased quality of life. A variety of exercise options are available for individuals with MS who experience balance and mobility problems. Physical interventions include targeted therapies, such as vestibular rehabilitation and weighted torso training, as well as more general exercise and balance training prescriptions.
• Conclusion: The evidence, albeit preliminary, suggests that therapeutic intervention aimed at ameliorating balance deficits associated with MS be multimodal. Exercise prescriptions should include sensory and motor strategy training, strength development, as well as functional gait activities. Further evidence-based research is needed to improve the management of balance deficits in those with MS and to identify the impact of improved balance on activity participation and quality of life.

Multiple sclerosis (MS) is one of the most common nontraumatic neurologic causes of disability among young adults. With greater awareness and improved diagnostics, more people are being diagnosed with the disease today than in the past. Prevalence estimates in the United States range from 90 to 135 per 100,000 individuals [1], with approximately 400,000 people currently diagnosed [2,3].

MS is a chronic inflammatory disease of the central nervous system typically characterized by increasing muscle weakness, spasticity, fatigue, pain, depression, visual and sensory disturbances, and cognitive difficulties. The clinical course of MS is highly variable and often unpredictable with increasing disability and physical decline spanning a 30- to 40-year period post diagnosis [4]. During this time, advancing symptoms can lead to a number of comorbidities and negatively impact daily functioning, mobility, and community participation [5–7]. From a public health standpoint, the early and disabling impact of symptoms and prolonged physical decline create a significant economic burden. The projected national heath care costs of MS are greater than $7 billion annually [8], with the average total annual cost per patient estimated at over $47,000 [9]. Of this annual cost, indirect costs associated with lost productivity represent the single highest component cost [9,10].

Of the wide range of disease-related challenges, mobility difficulties are most significant. Over 90% of people with MS report mobility difficulties [11], and maintaining mobility is consistently ranked as one of the highest priorities for this group, independent of disease duration or disability level [10,12]. Several studies have demonstrated that loss of balance and mobility contributes to substantial patient burden [13] and lower perceived quality of life [10]. Moreover, poor balance and increased fall risk have been associated with reduced physical activity and other health-related behaviors [14,15].

Because balance and mobility limitations are so prevalent and impacting, targeted treatments aimed at maintaining ambulation and function are critical goals in the management of MS. It is important for physicians and rehabilitation professionals to understand and recognize the underlying sensorimotor mechanisms related to postural instability and initiate appropriate evidenced-based treatments that can improve balance, reduce fall risk, and enhance quality of life for individuals with MS. This review seeks to analyze the evidence on the physical interventions aimed at ameliorating balance and mobility impairments associated with MS in the context of a case example.