Balance

People with multiple sclerosis who experience balance problems face a higher risk of falls, which can reduce mobility, physical activity, confidence, and social engagement, making it important to discuss any balance concerns or falls with a healthcare professional. Treatment typically involves a personalized plan that may include physical therapy, home-safety modifications, assistive equipment, and lifestyle changes to improve balance, reduce fall risk, and maintain independence and quality of life.

Anyone experiencing problems with balance and multiple sclerosis is at a much greater risk of falling. Individuals who are having falls or are fearful of falling need to tell their healthcare professional so a plan may be developed to reduce this risk. Some individuals mistakenly think that nothing can be done to help with balance, or they may feel embarrassed to admit that they have fallen, but speaking with one’s healthcare professional is vitally important.

Although the prevalence of balance problems in MS is well-documented, the profound impact of those challenges is not always fully appreciated, even by the people experiencing them. When individuals are having challenges with balance and the risk of falling is increased, their mobility is affected. As a result, they will often reduce their physical activities, including exercise and going outdoors. They also tend to have a lower self-image, and this can affect both their relationships and their desire to socialize.

Treatment Programs for Balance Issues in MS

One’s doctor will ask for a thorough history of an individual’s problems with balance and falling. This is the first step needed in developing a plan tailored to one’s specific balance challenges and needs. In addition, the doctor will need to work with both the person with MS as well as the care partner to explore the circumstances when imbalance is experienced and a plan can be figured out together.

The evaluation includes looking at functional movements, such as sitting, standing, and walking, as well as the assessment of strength, range of motion, spasticity, vision, and vestibular (inner ear) function. In terms of strength, focusing on the legs and core is particularly important.

Once an individual’s particular needs are identified, the physical therapist or other healthcare professional will design a program specifically for that individual, typically involving exercises, environmental considerations, and equipment (if appropriate).

Physical Therapy Exercises

Exercises generally focus on enhancing strength, range of motion, balance, and vestibular function, and often involve practicing changes in position, from sitting to standing, and – in a safe corner – shifting one’s weight forward and backward and from side to side. A healthcare professional needs to identify which exercises are appropriate for a person’s physical condition and functional needs.

Environmental Considerations

Environmental considerations include attention to maintaining balance on different types of interior and exterior surfaces, negotiating ramps and stairs, and maintaining balance in dynamic situations, such as a sidewalk crowded with people hurrying past.

Within a house, particular vigilance is needed in the kitchen and the bathroom, the two rooms in the home where people tend to be most active and face the most hazards, such as stepping into and out of a shower or tub, or moving from one workstation to another during meal preparation. Attending to other fall hazards, such as removing area rugs, is another important strategy. The kitchen and bathroom also can be the hottest rooms in a home, whether due to a pot steaming on the stovetop or the warm mist generated by a long shower, which can be problematic for people with the heat sensitivity frequently seen in MS.

Safety and Mobility Equipment

With respect to equipment, practical, individualized strategies can help people with MS maintain balance and reduce fall risk. Among other strategies, these can include wearing firm-soled shoes, using a cane or walker, and equipping bathrooms with bath chairs, tub benches, grab bars, and raised toilet seats or commodes.

Balance Problems and Falls

As noted earlier, anyone with MS who is experiencing problems with balance is at a much greater risk of falling. Individuals who are having falls or are fearful of falling need to tell their healthcare professional so a plan may be developed to reduce this risk. Recognizing the risk factors and making the appropriate lifestyle changes are vital to one’s safety and well-being.

Recognizing Risk Factors

Research shows that among people with MS, the risk for falls tends to be greater:

In secondary-progressive multiple sclerosis (SPMS), as compared to relapsing-remitting multiple sclerosis (RRMS)
With increasing age
At transition points, such as when people move from RRMS to SPMS, or first begin using an adaptive walking device

Additionally, the risk of falling also increases with the number of medications a person is taking. Both the types as well as the number of medications someone is taking have an impact on fall risk. For this reason, it is important for people with MS and their providers to carefully consider the need for each medication prescribed and to weigh the benefits and potential risks involved in its use.

Lifestyle Changes

In many cases, the risk of falling is increased not by factors beyond a person’s control, but by reluctance to take steps that would reduce that risk. Examples of such steps include using an adaptive walking device or switching from high-heeled shoes to equally fashionable but safer flats.

In addition, many individuals are hesitant to use assistive equipment such as a scooter or wheelchair, and may view this as a sign of weakness or giving in to the disease. However, mobility devices provide the benefits of conserving energy and increasing safety, allowing people to have more energy and strength to safely increase their physical activities.

For people experiencing changes in mobility or lifestyle, working with a mental health professional as well as with a neurologist and physical therapist can be of much benefit. Adding a mental health professional to your healthcare team can be very helpful in adjusting to these changes.

References

Cameron MH, Hildebrand A, Hugos C, Woolscroft L. A walking aid selection, training, and education program (ADSTEP) to prevent falls in multiple sclerosis: a randomized controlled trial. Mult Scler J. 2024. DOI: 10.1177/13524585241265031.
Cameron MH, Karstens L, Hoang P, Bourdette D, Lord S. Medications are associated with falls in people with multiple sclerosis: a prospective cohort study. Int J MS Care. 2015;17:207–214.
Cameron MH, Nilsagard Y. Balance, gait, and falls in multiple sclerosis. Chapter 15. Handbook Clin Neurol. 2018;159:237-250.
Judd GI, Hildebrand AD, Goldman MD, Cameron MH. Relationship between balance confidence and social engagement in people with multiple sclerosis. Mult Scler Relat Disord. 2022 Jan:57:103440. Doi:10.1016/jmsard.2021.103440.

Reviewed by MSAA Chief Medical Officer Barry Hendin, MD
Contributors: Michelle H. Cameron, MD, PT, MCR and Mandy Rohrig, DPT, MSCS