MS Symptom Management: Imbalance
Let's go back to talking about my good friend Joanne. When we started working together, she explained that it was common for her to fall, which probably happened a few times a week. "It was no big deal," she would say, "I don't usually get hurt or anything. It's just hard to get back up." In recent studies, it has been found that about 54% of people with MS report they had a fall in the previous two months, and 63% reported a fall within the last nine months. Falls can result in minor to significant injury, but they can also contribute to a loss of confidence, progressive limitation of activities, and social isolation. Many factors can lead to falls, including biological factors directly resulting from the MS or medications, behavioral characteristics, and environmental factors.
Sources and Risk Factors for Falls
Biological Factors
Many of the symptoms we have previously discussed in this series are major biological risk factors, including muscle weakness causing foot drop or other gait impairments, spasticity, fatigue, and heat intolerance.
Sensory deficits could include numbness, tingling, or impaired proprioception (the ability to perceive where that limb is in space).
Vertigo/Dizziness is a huge topic and will have its own post one day! Vertigo is a sensation of spinning. It may be due to a condition called BPPV (check out my blog posts on BPPV and treatment options: Vertigo: An Overview of Benign Paroxysmal Positional Vertigo (BPPV) — Movement Matters Physical Therapy (movementmatters-pt.com) and Vertigo: Testing and Treatment for BPPV — Movement Matters Physical Therapy (movementmatters-pt.com)) that is easily treated with physical therapy. People with MS are at increased risk of having episodes of BPPV during the disease course. Dizziness is a sense of lightheadedness, imbalance, or feeling like you are veering/on a boat. This can be caused by a vestibular/inner ear problem, or it can be a primary symptom of MS due to lesions in the brain.
Ataxia is a particular gait impairment that can occur in MS. It is characterized by a swaying or uncoordinated pattern.
Vision problems can be particularly problematic when it comes to balance. Some common impairments include double vision, blurry vision, loss of peripheral vision, impaired contrast, or depth perception.
Pain is one of the most significant contributors to falls in general. In MS, the pain can be neurogenic (from the demyelination itself). It can be due to a sensory issue (numbness/tingling), spasticity, or a musculoskeletal source. Many people experience pain in their back, hips, and knees due to the increased energy expenditure and changes in posture due to spasticity or weakness changing their gait pattern.
Cognitive changes can contribute to calls with changes in your attention and perception
Bowel and/or bladder dysfunction may cause people to rush to the bathroom, get up frequently at night when tired or drowsy in the dark.
Medications - many medications prescribed as disease-modifying therapies or for symptom management can be associated with fatigue, weakness, or dizziness.
Behavioral Factors- You can change these!
Reduced Activity/Deconditioning leads to loss of muscle tone and disuse weakness. This weakness is different from the primary muscle weakness from demyelination of the nerve and is directly related to a decline in a person's activity level. Deconditioning can also lead to poor trunk control and posture, decreased bone density, or inefficient breathing.
Fear of Falling: I cannot begin to explain how large a role fear can play on balance. Fear is a normal response to protect ourselves from harm. The tricky part is to make sure it is a healthy amount of fear. On the one hand, you do not want to be overconfident in your abilities or become comfortable with falling. However, on the other hand, too much fear leads to more falls as well. People tend to be overcautious, slow their walking speed, look down at their feet, or "furniture walk," all of which can increase a person's risk for falls.
Environmental: You can change many of these!
Common risk factors in the home include clutter, poor lighting, rugs, thresholds, stairs, high cabinets, exposed electrical cords, or tight bathroom spaces.
Common risk factors in the community include cracks in sidewalks, uneven ground, curbs, stairs, or large crowds.
How Physical Therapy Can Help!
Our balance is made up of 3 essential systems:
The visual system (what you see).
The vestibular system (the inner ear).
The somatosensory system (what you feel through touch and orientation of your joints).
To have the optimal ability to perceive where our body is in space (balance), we need to have all 3 systems working together efficiently. If 1 system is not working correctly, the other 2 systems can learn to help compensate. When it comes to Multiple Sclerosis (MS), any of these 3 systems can be affected, so we must consider them all.
Testing
Your physical therapist can test for specific impairments that may be contributing to balance for you. For example, they may test your visual and vestibular systems together, check your sensation in your legs and feet, and test for any biological risk factors described above, such as weakness, spasticity, or ask about bowel/bladder issues. In addition, they can perform specific tests of your static balance, which is your ability to balance when standing still, such as standing with your feet together, eyes closed, or on one leg. Then, they would test your dynamic balance, which is your ability to balance when moving, such as reaching for something, turning your body, or bending over to pick something up.
Exercises to Help with Balance
I am always hesitant to give people exercises at home for their balance because I do not want anyone to fall or get hurt while attempting. You must always practice your balance somewhere that you can easily grab onto something if needed. You can also use a corner where you can lean into a wall if you get unsteady. If you have problems with your balance, you should see a physical therapist or another qualified medical practitioner before attempting.
Static Balance
To improve your static balance, you can gradually reduce your base of support. If the first position is too easy, you can progress to the next one. Hold 3 times for 30 seconds.
Romberg - start here, put your feet together so that they are touching
Tandem Stance- 1 foot is directly in front of the other (if Romberg was too easy, but this is too difficult, you can put 1 foot halfway in front of the other).
Split-Stance - standing with 1 foot on the ground and the other directly in front of it up on a step
Single-Leg Stance- standing on 1 leg
*to make any of these positions more challenging, you can perform with your eyes closed (make sure you have someone standing next to you) or standing on a folded blanket or pillow for an extra challenge
Dynamic Balance
Head Turns/Nods - use one of the stance positions described above (choose one that is not too difficult to start with). Get your balance in that position, then turn your head side to side 10 times (5 to each side). Rest at least 30 seconds and repeat, nodding your head up and down 10 times (5 up and 5 down).
Walking with Head Movement - Start at the beginning of a hallway so that you can touch the wall for support if needed. Then, slowly turn your head from side to side as you walk down the hallway. Rest 30 seconds, then repeat, nodding your head up and down.
Tandem Gait - The sobriety test! Start at the beginning of a hallway again so you can touch for support if needed. Look straight ahead (NOT DOWN AT YOU FEET!). And walk forward 1 foot directly in front of the other, heel to toe.
Again, this is so important; if you are having trouble with your balance, especially if you have any vertigo or dizziness, seek out a physical therapist before trying to improve your balance on your own. But, again, safety is the most important thing.
Assistive Devices and Fall Recovery
We talked a great deal about the time and place for the use of assistive devices in the post about gait impairments, be sure to check it out if you missed it! MS Symptom Managment: Gait Impairments — Movement Matters Physical Therapy (movementmatters-pt.com). "Furniture Walking" is something I hear very frequently and can be very dangerous because the furniture does not move with you. If you need that support, we must get you fitted for the suitable device. Then, we can work together to safely transition you off of it when appropriate.
Unfortunately, no matter how much we work to prevent them, falls do happen (hopefully fewer and further between). Your physical therapist should always look to work on fall recovery strategies with you. Depending on the strength and mobility in your core and legs, you may be able to get up unassisted or use a nearby object/chair. They can teach family members how to safely assist you so that they don't get hurt or advise when you should call for help in the event of a fall.
Next week will be our final week in his series of MS Symptom Management. We will put all the pieces together to demonstrate who physical therapy can help improve mobility, pain, and quality of life for people with Multiple Sclerosis. We will give specific examples of exercise programs and provide resources!
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Disclaimer
This blog is provided for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health providers with any questions you may have regarding a medical condition.
