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MS research update - Balance rehabilitation in MS: can it improve stability? - 16 June 2014

Summary

Balance problems are common in MS. Lesions in the areas of the brain responsible for movement and balance or in the sense systems can cause problems with balance, which can result in walking difficulties and sometimes falls.

Although balance in MS has been studied previously, little is known about if the senses can be retrained or improved after lesions and damage, through rehabilitation and training. This study examined balance rehabilitation to see if it could improve stability in people with MS.

The study found that for people given balance rehabilitation tailored to their specific sensory impairments, there were significant improvements in stability and balance. Members of this group who were very unsteady and falling before rehabilitation, were also more steady and balanced when tested after the rehabilitation period and less likely to fall.

The study results indicate that after rehabilitation people with MS can recover from sensory impairments and improve their balance and this may help prevent falls.

Background

Having good balance relies on the accurate detection of input from the senses, (for example vision, hearing, touch) and the brain processing and integrating this information in the correct way.

Balance problems are common in MS. Lesions in the areas of the brain responsible for movement and balance or in the sense areas and systems can cause problems with balance, which can result in walking difficulties and sometimes falls.

Although balance in MS has been studied previously, little is known about if the senses can be retrained or improved after lesions and damage, through rehabilitation and training.

This study examines if tailored balance rehabilitation can improve stability in people with MS.

How this study was carried out

53 people with MS took part in the study. To be able to take part all had to have the ability to stand independently for at least 30 seconds and be able to walk for six metres, with or without an assistive device, such as a walking stick. 45% of the participants had a diagnosis of relapsing remitting MS, 49% secondary progressive MS and 6% primary progressive MS.

An initial assessment was carried out which included an EDSS (a commonly used measure of disability) assessment and the Berg Balance Scale, which tests balance through 14 tasks, including balancing on one foot, standing up from sitting down and reaching to pick an object up from the ground. Following this initial assessment participants were randomly assigned to either the experimental or control group.

All participants received 15 treatment sessions, each lasting 45 over a period of three weeks.

The experimental group received balance rehabilitation to improve motor (movement) and sensory (information from the senses) techniques for maintaining balance. As well as basic movement exercises, in this group each person was also given exercises that were tailored to their own personal sensory impairments. These were aimed to try and get them to use and improve their most impaired sense, so this usually meant doing exercises with their eyes shut to improve the vestibular (balance and movement sense in the inner ear) and somatosensory (touch, including pain, temperature and pressure) information. Further exercises were then added, which were performed on a foam surface to make the information the brain was receiving even more challenging.

The control group received the basic rehabilitation programme, which included techniques to improve the range of movement and ability to change into a different position. All exercises were performed with their eyes open and on a solid surface.

All participants were assessed on a stabilometric platform before and after the three week rehabilitation programme. This is a computerised device, which contains many sensors, to determine the balance and posture of the person standing on it. A standard stabilometric platform looks like a set of bathroom scales, but the one used in this study was built into a stand which had a support frame around it, to prevent falls and injury.

What was found

The study found that there were significant improvements in stability and balance for those in the experimental group. They were significantly more stable in four out of the six tests, including when tested with their eyes closed standing on a firm surface and also when they had their eyes open or closed when standing on a more unstable foam surface. There was no difference between the groups when tested on a firm surface with their eyes open.

The researchers also found that balance rehabilitation meant that people were less likely to lose their balance. Members of the experimental group who were very unsteady and falling before rehabilitation, were more steady and balanced when tested after the rehabilitation period.

What does it mean?

The study results indicate that after rehabilitation people with MS can recover from sensory impairments and improve their balance. The exercises used were tailored to each individual's impairments and the results showed that with training, people could become less dependent on visual information and improve their use of information coming from their other senses to improve their balance.

The authors conclude that the study results show that balance rehabilitation may improve balance, and stability and so may help prevent falls.

Cattaneo D, Jonsdottir J, Regola A , et al.
Stabilometric assessment of context dependent balance recovery in persons with multiple sclerosis: a randomized controlled study..
J Neuroeng Rehabil. 2014 Jun 10;11(1):100. [Epub ahead of print]
abstract
Read the full text of this paper

More about balance

MS can affect balance in a number of ways, both directly and indirectly.

Balance problems can be caused by interruptions to the communication between the brain and the rest of the body. A lesion may mean messages coming to and from the brain from other parts of the body do not get through properly and so the brain cannot process the information correctly as it only has part of the picture. A good example of this is dizziness and vertigo. In MS, these symptoms are caused by damage to areas that coordinate perception and the response to visual and spatial information. The damage causes a breakdown in the coordination, which makes it difficult to remain upright, even when standing still and being supported.

Sensory problems may affect the way in which someone walks and therefore affect their balance. For example, numbness can mean an individual cannot tell how their feet are touching the ground, or pain may mean they walk more tentatively or try not to put too much weight through the painful leg, making them walk in an unstable and unbalanced way.

There are also a number of other MS symptoms which can worsen balance and increase the risk of falling. These include, weakness and numbness, muscle stiffness, spasticity and spasms, tremor, visual problems and fatigue.

Because there are a number of factors which can affect balance, it is important that balance problems are investigated thoroughly by a physiotherapist or other health professional. They can then suggest treatments to improve balance. Balance problems can be managed to some extent by being aware of factors that make balance worse and being aware of potential factors that might increase the risk of a fall. These issues are discussed in the MS Trust's book Falls: managing the ups and downs of MS.

You can also view or download some balance exercises for people with MS, watch our balance and posture exercise videos online or order the free DVD.

Research by topic areas...

Assessment tools

Boeschoten RE, Uitdehaag BM, van Oppen P, et al.
A computer-based screening method for distress in patients with multiple sclerosis: a feasibility study.
JMIR Res Protoc. 2014 Jun 4;3(2):e29.
abstract
Read the full text of this paper

Carers

Schofield D, Cunich M, Shrestha R, et al.
The impact of chronic conditions of care recipients on the labour force participation of informal carers in Australia: which conditions are associated with higher rates of non-participation in the labour force?
BMC Public Health. 2014 Jun 5;14(1):561. [Epub ahead of print]
abstract
Read the full text of this paper (PDF)

Causes of MS

O'Gorman C, Broadley SA.
Smoking and multiple sclerosis: evidence for latitudinal and temporal variation.
J Neurol. 2014 Jun 13. [Epub ahead of print]
abstract

CCSVI

Jedynak W, Cieszanowski A.
Is there any relation between chronic cerebrospinal venous insufficiency and multiple sclerosis? - a critical review.
Pol J Radiol. 2014;79:131-136. Review.
abstract
Read the full text of this paper

Costello F, Modi J, Lautner D, et al.
Validity of the diagnostic criteria for chronic cerebrospinal venous insufficiency and association with multiple sclerosis.
CMAJ. 2014 Jun 2. [Epub ahead of print]
abstract
Read the full text of this paper

Co-existing conditions

Simpson RJ, McLean G, Guthrie B, et al.
Physical and mental health comorbidity is common in people with multiple sclerosis: nationally representative cross-sectional population database analysis.
BMC Neurol. 2014 Jun 13;14(1):128. [Epub ahead of print]
abstract
Read the full text of this paper (PDF)

Tinghög P, Björkenstam C, Carstensen J, et al.
Co-morbidities increase the risk of disability pension among MS patients: a population-based nationwide cohort study.
BMC Neurol. 2014 Jun 3;14(1):117. [Epub ahead of print]
abstract
Read the full text of this paper (PDF)

Disease modifying treatments

van Pesch V, Bartholomé E, Bissay V, et al.
Safety and efficacy of natalizumab in Belgian multiple sclerosis patients: subgroup analysis of the natalizumab observational program.
Acta Neurol Belg. 2014 Jun 11. [Epub ahead of print]
abstract

O'Connor P, Goodman A, Kappos L, et al.
Long-term safety and effectiveness of natalizumab redosing and treatment in the STRATA MS Study.
Neurology. 2014 Jun 4. [Epub ahead of print]
abstract

Bozic C, Subramanyam M, Richman S, et al.
Anti-JC virus (JCV) antibody prevalence in the JCV Epidemiology in MS (JEMS) trial.
Eur J Neurol. 2014 Feb;21(2):299-304.
abstract

Other

Dehning M, Kim J, Nguyen CM, et al.
Neuropsychological Performance, Brain Imaging, and Driving Violations in Multiple Sclerosis.
Arch Phys Med Rehabil. 2014 Jun 11. [Epub ahead of print]
abstract

Physical activity

Wajda DA, Motl RW, Sosnoff JJ.
Correlates of dual task cost of standing balance in individuals with multiple sclerosis.
Gait Posture. 2014 May 9. [Epub ahead of print]
abstract

Ickmans K, Simoens F, Nijs J, et al.
Recovery of peripheral muscle function from fatiguing exercise and daily physical activity level in patients with multiple sclerosis: A case-control study.
Clin Neurol Neurosurg. 2014 Jul;122:97-105.
abstract

Straudi S, Martinuzzi C, Pavarelli C, et al.
A task-oriented circuit training in multiple sclerosis: a feasibility study.
BMC Neurol. 2014 Jun 7;14(1):124. [Epub ahead of print]
abstract
Read the full text of this paper (PDF)

Gandolfi M, Geroin C, Picelli A, et al.
Robot-assisted vs. sensory integration training in treating gait and balance dysfunctions in patients with multiple sclerosis: a randomized controlled trial.
Front Hum Neurosci. 2014;8:318.
abstract
Read the full text of this paper

Hunt CM, Widener G, Allen DD.
Variability in postural control with and without balance-based torso weighting in people with multiple sclerosis and healthy controls.
Phys Ther. 2014 Jun 5. [Epub ahead of print]
abstract

Pregnancy and childbirth

Borisow N, Paul F, Ohlraun S, et al.
Pregnancy in multiple sclerosis: a questionnaire study.
PLoS One. 2014;9(6):e99106.
abstract
Read the full text of this paper

Psychological aspects

Dobryakova E, Wylie GR, DeLuca J, et al.
A pilot study examining functional brain activity 6 months after memory retraining in MS: the MEMREHAB trial.
Brain Imaging Behav. 2014 Jun 14. [Epub ahead of print]
abstract

Symptoms and symptom management

Cordeau D, Courtois F.
Sexual disorders in women with MS: Assessment and management.
Ann Phys Rehabil Med. 2014 Jun 5. [Epub ahead of print]
abstract

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