Reviewed by Tyler Tice, PT, DPT, OCS, ATC
Introduction:
Neuromuscular disorders that result in the demyelination of neurons, like multiple sclerosis (MS), experience several motor, sensory, and cognitive deficits over the disease’s progression. Reduction in balance capabilities is common among this population and is a major reason for these patients to seek out physical therapists to combat the degeneration that occurs over time. It is well understood and recommended that all older adults with chronic health conditions like MS participate in moderate to high-intensity balance training at least 2-3 times per week to avoid increasing their risk of falls. This review looked to synthesize how training frequency, intensity, time components, duration, and progression in balance training can be best completed for people living with MS.
Methods:
This review included 40 eligible studies which had to be of randomized control/clinical trial or systematic review in origin. Inclusion criteria required all participants to be adults with a diagnosis of MS, a severity level of 7.5 or lower on the Expanded Disability Status Scale, be able to transfer from one seated position to another independently, and at least 50% of exercise interventions used in the trials must have been directly relate to challenging balance control.
Conclusions of the Study:
This study effectively synthesized the major components of designing a balance training program. The majority of the exercises performed challenged general motor and sensory deficits commonly seen in MS, but fewer studies included training of reactive motor strategies, and even less challenged tasks requiring cognitive dual tasking. This aspect was surprising as cognitive dual-tasking ability is a strong indicator of potential fall risk for patients with MS. The balance training progression among each of the studies also had no specific method and seemed to be specific to the clinician treating the patient. The researchers stated that the exact order in which progression is made does not matter whether that is through changing the base of support, the cognitive demand of the task, or the somatosensory deficit being targeted as long as the task is challenging the patient’s specific deficits. Balance training intensity also had no common system among any of the studies and was oddly not measured often. Two studies utilized visual displacement of the center of mass and the excessive corrective upper limb movements as indicators of failure of an exercise, while others cited the patient’s perception of difficulty as their marker for intensity. The researchers concluded that there is a current lack of evidence providing clinicians with specific parameters to program and progress their patients and that future research should be performed to determine better guidelines for treating MS patients.
Clinical Implications:
Based on this review, the current state of evidence on exercise programming specifics for balance training in patients living with MS is mostly inconclusive. The best method of proceeding with treating individuals with MS would be to first identify what systems have been affected most by the MS, whether it is more motor, sensory, or cognitive. The second step would be to determine your progression model based on how the patient presents and their goals. For example, deciding when to incorporate cognitive dual tasks or to reduce the patient’s base of support first. Furthermore, when gauging the intensity of balance exercise it is recommended to determine the patient’s perception of intensity, such as with an RPE scale, and to also gauge the patient’s difficulty through observing the visual displacement of the patient’s center of mass and any excessive corrective upper limb movement. Combining the use of both these factors should improve the reliability of determining the patient’s exercise intensity. By taking these components into account a PT should be able to effectively program and progress a patient’s balance training program and tailor it to their goals.
References:
Brincks, J., Dalgas, U., Franzén, E., Callesen, J., Wallin, A., & Johansson, S. (2023). Unwrapping the “Black Box” of balance training in people with multiple sclerosis – a descriptive systematic review of intervention components, progression, and intensity. Multiple Sclerosis and Related Disorders, 69, 104412. https://doi.org/10.1016/j.msard.2022.104412