Training reactive balance using trips and slips in people with multiple sclerosis: a blinded randomised controlled trial

Feasibility and preliminary effectiveness of a 2-week in-place reactive balance training program in people with multiple sclerosis

BACKGROUND & PURPOSE

Current treatments for falls in people with multiple sclerosis (PwMS) are incompletely effective. Reactive balance can prevent falls after a loss of balance and is negatively impacted by MS. Perturbation training may improve reactive balance. However, the effects of extended training and its impacts on falls are poorly understood in PwMS.

METHODS

We conducted a task-specific, multi-baseline, in-place reactive balance training program. Over 2 weeks and 6 sessions, participants were exposed to approximately 192 support-surface perturbations in four directions (forward, backward, leftward, and rightward). Reactive stepping was assessed twice before training (Baseline-1 & Baseline-2; [B1, B2], 2-weeks apart), and twice after training (Post-1 & Post-2 [P1, P2], immediately and 2 months after training). Linear mixed models assessed exposure effects (B1-B2), immediate improvement (B2-P1), and retained improvement (B2-P2). Falls were prospectively assessed for 2 months before and after training. Primary outcomes were margin of stability (MOS), latency, and length of the first reactive step after a backwards loss of balance.

RESULTS

Twenty-seven PwMS at risk of falls completed the study through P1 (immediate improvement), with 96.9 % session attendance, and minimal reported adverse events. Of these, 20 participants completed P2 (2-month retention) testing. For backward losses of balance, no significant changes were observed from exposure (B1-B2; p's ≥ 0.603). There were statistically significant immediate improvements in MOS and step latency (B2-P1; p = 0.036 & p = 0.012, respectively) and retained improvement in step latency (B2-P2; p = 0.033). For forward losses of balance, participants exhibited immediate improvement in MOS (p = 0.042) and step latency (p = 0.042). Fall counts were not lower after training compared to pre-training (p = 0.266). No adverse events were observed.

DISCUSSION

PwMS exhibited immediate and retained improvements in reactive stepping after 2-weeks of perturbation training, particularly in reactive step latency. This single-group, non-randomized clinical trial shows feasibility of reactive balance in PwMS and provides preliminary evidence of effectiveness of this intervention.

The Relation Among Reactive Stepping and Fall-Related Psychological Factors in Multiple Sclerosis

Purpose: Persons with multiple sclerosis (MS) experience changes in balance, such as poor and reactive stepping, as well as altered fall-related psychological factors, such as increased concern about falling and feared consequences about falling. Such concerns and fear may relate to and influence mobility. However, these relations are poorly understood in people with MS. This study aimed to investigate the relation between reactive stepping performance and fall-related psychological factors, as well as to assess how these relations differ between individuals who have and have not fallen. Methods: In a single session, participants completed measures regarding fall-related psychological factors (balance confidence, concern about falling, and feared consequences of falling) and completed reactive stepping tasks. Following the visit, participants completed weekly surveys for 3 months to report their falls. Spearman rho correlations were computed to examine associations between participants' reactive stepping performance and their fall-related concerns, confidence, and consequences, with a stratified analysis to compare these associations between fallers and non-fallers. Results: 44 individuals with MS participated in our study, with 27 individuals experiencing 0 falls (non-fallers) and 17 individuals experiencing at least 1 fall (fallers) in the 3-month follow-up period. Better reactive stepping performance was correlated with fewer concerns, greater confidence, and lower feared consequences related to falling. The stratified analysis revealed a greater number of significant associations for non-fallers than fallers, although the small sample of fallers reduced our ability to detect a relationship in this group. Conclusions: Reactive stepping was associated with fall-related psychological factors. Interventions targeting reactive stepping may be beneficial in enhancing fall-related psychological well-being in the MS community.

A custom-built step exergame training programme to prevent falls in people with multiple sclerosis: A multicentre randomised controlled trial

BACKGROUND

Cognitive-motor step training can improve stepping, balance and mobility in people with multiple sclerosis (MS), but effectiveness in preventing falls has not been demonstrated.

OBJECTIVES

This multisite randomised controlled trial aimed to determine whether 6 months of home-based step exergame training could reduce falls and improve associated risk factors compared with usual care in people with MS.

METHODS

In total, 461 people with MS aged 22-81 years were randomly allocated to usual care (control) or unsupervised home-based step exergame training (120 minutes/week) for 6 months. The primary outcome was rate of falls over 6 months from randomisation. Secondary outcomes included physical, cognitive and psychosocial function at 6 months and falls over 12 months.

RESULTS

Mean (standard deviation (SD)) weekly training duration was 70 (51) minutes over 6 months. Fall rates did not differ between intervention and control groups (incidence rates (95% confidence interval (CI)): 2.13 (1.57-2.69) versus 2.24 (1.35-3.13), respectively, incidence rate ratio: 0.96 (95% CI: 0.69-1.34, p = 0.816)). Intervention participants performed faster in tests of choice-stepping reaction time at 6 months. No serious training-related adverse events were reported.

CONCLUSION

The step exergame training programme did not reduce falls among people with MS. However, it significantly improved choice-stepping reaction time which is critical to ambulate safely in daily life environment.