Perturbation-based Balance Training to improve postural responses and falls in people with multiple sclerosis: a randomized controlled trial

Meta-analysis on effects of trip-based perturbation training reducing fall risk

BACKGROUND

Falls are a key cause of injury across all age groups. Perturbation-based training, particularly trip-induced perturbation, has shown promise in enhancing balance recovery in lab and real-world scenarios. This study aimed to synthesize the effects of trip-based perturbation training on fall risk, quantified by the fall rate, recovery step length, margin of stability, and maximum trunk flexion angle in healthy adults.

METHODS

A literature search in major databases led to 11 qualified studies. Meta-analyses were conducted on the lab-induced fall rate, recovery step length, and maximum trunk flexion angle. Other outcome measures, such as fall rate in daily living conditions and margin of stability, were systematically reviewed to further assess the effects of trip-based perturbation training.

FINDINGS

The pooled effect size was -0.30 (p < 0.001) for the lab-induced fall rate, 0.27 (p = 0.38) for the recovery step length, and - 9.81 (p = 0.20) for the maximum trunk flexion angle. The review also revealed that the training reduced all-cause prospective falls and improved the margin of stability after a trip.

INTERPRETATION

Trip-based perturbation training significantly reduces the fall rate and enhances postural stability, as evidenced by improvements in the recovery step length, margin of stability, and trunk kinematics.

Maintaining Mobility and Balance in Multiple Sclerosis: A Systematic Review Examining Potential Impact of Symptomatic Pharmacotherapy

BACKGROUND

Mobility disability (MD) manifests as walking dysfunction and postural instability in more than 90% of people with multiple sclerosis (MS) within 10 years of disease onset. Disease-modifying pharmacotherapies reduce rates of relapses and new lesions and slow disease progression, but ongoing decline in MD can persist or result from secondary, symptomatic pharmacotherapies. This systematic review focuses on symptomatic pharmacotherapies that potentially impact markers of MD in MS.

METHODS

PubMed/Medline, Google Scholar, and Scopus were searched between January 1990 and December 2024. Eligible studies were included on the basis of the following criteria: (1) randomized, placebo-controlled trials (RCTs); (2) confirmed MS diagnosis; (3) one MD-related outcome; and (4) one symptomatic pharmacotherapy; OR (5) multiple doses of a symptomatic pharmacotherapy. Results were uploaded to Rayyan: Intelligent Systematic Review software and screened by two blinded reviewers for eligibility. Risk of bias was assessed using the PEDRo Scale for quality assessment.

RESULTS

This review included 23 RCTs (all RCTs scored good-to-excellent on PEDRo Scale); 13 RCTs examined fampridine (4-aminopyridine) for its direct effects on MD, and 10 RCTs assessed indirect effects of symptomatic pharmacotherapies, including cannabinoids (n = 9), and baclofen (n = 1) on MD. The MD outcomes included gait (25-foot walk [T25FW], kinetics, and kinematics), community mobility (12-item MS Walking Scale [MSWS-12]), endurance (6-min walk [6MW]), balance (Berg Balance Scale [BBS], Dynamic Gait Index [DGI], Six-Spot Step Test, posturography, and falls), and functional mobility (Timed Up and Go [TUG] and 5 Times Sit-to-Stand [5STS]). Fampridine significantly improved gait (T25FW, MSWS-12), endurance (6MW), and functional mobility (5STS, TUG), with the largest effect on gait speed; changes in balance were inconclusive. Indirect pharmacotherapies, specifically cannabinoids mainly reduced spasticity (Modified Ashworth Scale, nine out of nine studies), but rarely improved pain (Numerical Rating Scale, two out of nine studies) or MD outcomes (two out of nine studies). Both direct and indirect pharmacotherapies resulted in adverse effects, notably dizziness (n = 366), urinary tract infection (n = 216), and nausea (n = 150), potentially impacting MD in MS.

CONCLUSIONS

Fampridine may improve gait and functional mobility in MS, but its effect on balance requires further investigation in RCTs. Cannabinoids and baclofen may alleviate spasticity and pain, but seemingly have limited secondary effect on markers of MD, such as gait and postural stability. Clinicians should consider the impact of symptomatic pharmacotherapies on MD in MS, including potential side effects. Future research should explore integrating rehabilitation (e.g., balance training) with symptomatic pharmacotherapies, as this might enhance positive effects or combat deleterious effects on markers of MD.

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.

Effects of exercise in people with multiple sclerosis: a systematic review and meta-analysis

Background

A growing body of studies have examined the effect of exercise in people with multiple sclerosis (MS), while findings of available studies were conflicting. This meta-analysis aimed to explore the effects of exercise on balance, walking ability, walking endurance, fatigue, and quality of life in people with MS.

Methods

We searched PubMed, Web of Science, Scopus, and Cochrane databases, through March 1, 2024. Inclusion criteria were: (1) RCTs; (2) included an intervention and control group; (3) had people with MS as study subjects; (4) had balance, walking ability, walking endurance, fatigue, or quality of life as the outcome measures. Exclusion criteria were: (1) non-English publications; (2) animal model publications; (3) review articles; and (4) conference articles. A meta-analysis was conducted to calculate weighted mean difference (WMD) and 95% confidence interval (CI). Cochrane risk assessment tool and Physiotherapy Evidence Database (PEDro) scale were used to evaluate the methodological quality of the included studies.

Results

Forty studies with a total of 56 exercise groups (n = 1,300) and 40 control groups (n = 827) were eligible for meta-analysis. Exercise significantly improved BBS (WMD, 3.77; 95% CI, 3.01 to 4.53, P < 0.00001), TUG (WMD, -1.33; 95% CI, -1.57 to -1.08, P < 0.00001), MSWS-12 (WMD, -2.57; 95% CI, -3.99 to -1.15, P = 0.0004), 6MWT (WMD, 25.56; 95% CI, 16.34 to 34.79, P < 0.00001), fatigue (WMD, -4.34; 95% CI, -5.83 to -2.84, P < 0.00001), and MSQOL-54 in people with MS (WMD, 11.80; 95% CI, 5.70 to 17.90, P = 0.0002) in people with MS. Subgroup analyses showed that aerobic exercise, resistance exercise, and multicomponent training were all effective in improving fatigue in people with MS, with resistance exercise being the most effective intervention type. In addition, a younger age was associated with a larger improvement in fatigue. Furthermore, aerobic exercise and multicomponent training were all effective in improving quality of life in people with MS, with aerobic exercise being the most effective intervention type.

Conclusion

Exercise had beneficial effects in improving balance, walking ability, walking endurance, fatigue, and quality of life in people with MS. Resistance exercise and aerobic exercise are the most effective interventions for improving fatigue and quality of life in people with MS, respectively. The effect of exercise on improving fatigue was associated with the age of the participants, with the younger age of the participants, the greater the improvement in fatigue.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=371056, identifier: CRD42022371056.