Balance and Eye Training Program Succeeds in MS Patients

Balance and fatigue outcomes improved even in patients with lesionsAction Points

An integrated program of balance and eye-movement exercises improved balance, dizziness, fatigue, and quality of life in people with multiple sclerosis (MS), researchers reported.

In a randomized controlled trial, MS patients who had at least minimally impaired balance and fatigue experienced improved outcomes with Balance and Eye-Movement Exercises for Persons with Multiple Sclerosis (BEEMS) training, even when brainstem or cerebellar lesions were present.

 In 6 weeks from baseline, BEEMS participants achieved greater improvements than controls in Computerized Dynamic Posturography-Sensory Organization Test (CDP-SOT) composite, Dizziness Handicap Inventory (DHI) total, Modified Fatigue Impact Scale (MFIS) total, and Short Form-36 Health Status Questionnaire (SF-36) mental and physical scores, reported Jeffrey Hebert, PT, PhD, of the University of Colorado School of Medicine in Aurora, and colleagues.

And at 14 weeks from baseline, they bettered controls in CDP-SOT composite, DHI total, MFIS total, and SF-36 mental and physical scores, they wrote in Neurology.

Response differences in patients with brainstem or cerebellar lesions were evident at 6 weeks, but not sustained at 14 weeks, they added.

“The results of this study should inform how we deliver balance retraining in a population at high risk of falls,” wrote Susan Bennett, DPT, EdD, of the University at Buffalo in New York, and Victoria Leavitt, PhD, of Columbia University Medical Center in New York City, in an accompanying editorial. “These findings are promising and encourage future work to further probe the benefits and mechanisms of BEEMS.”

“Most rehabilitation programs to improve balance have focused mainly on strength exercises and balance exercises that are not designed for the specific problems of people with MS,” Hebert said in a statement. “We wanted to see if performing balance and eye movement exercises while processing multiple different sensory information could help people improve their balance and fatigue issues.”

This investigation was a follow-up to a pilot study and was an examiner-blinded trial with three phases:

  • 2-week baseline phase
  • 6-week treatment phase 1
  • 8-week treatment phase 2

During the baseline phase, the researchers obtained outcome measures twice to control for learning effects of the dynamic posturography-based balance test.

Adult patients were included if they had clinically definite MS and the ability to ambulate 100 m with intermittent or unilateral constant use of an assistive device. “The inclusion of participants who required use of an assistive device is another strength of this study because these persons have a greater challenge with balance,” noted Bennett and Leavitt.

The researchers randomized 88 participants (44 BEEMS, 44 controls) and 76 patients completed the trial.

Participants were screened for balance (CDP-SOT ≤82 of 100) and fatigue (MFIS ≥22 of 84). The CDP-SOT cutoff is the clinically meaningful difference of 8 points below that of healthy adults, the authors noted; the MFIS score is greater than the clinically relevant change of 15 reported for pharmaceutical interventions.

 Patients performed BEEMS training twice weekly with supervision and daily at home. The program consisted of three components: standing on difference surfaces, mobility-based walking with and without head movements, and visual stability including voluntary saccadic movements, smooth pursuits, and gaze stability.

“Of specific interest in this study was the presence of unsteady gaze fixation, which may reduce eye-hand coordination, and dysmetric saccades, which may interfere with guided stepping,” Bennett and Leavitt noted.

Additional training included visual input alterations such as ball tossing, somatosensory alterations that involved changing surfaces, and vestibular input alterations that affected yaw and pitch directions and whole-body movements.

From baseline to 6 weeks, BEEMS participants experienced greater improvements than controls in CDP-SOT composite (model-estimated difference in change 4.9, P=0.006), DHI total (−13.5, P<0.0001), MFIS total (−11.4, P<0.0001), SF-36 Mental (5.6, P=0.0006), and SF-36 Physical (3.5, P=0.004) scores.

From baseline to 14 weeks, the BEEM group had better CDP-SOT composite (8.3, P< 0.0001), DHI total (−13.9, P<0.0001), MFIS total (−12.3, P<0.0001), SF-36 Mental (3.9, P=0.02), and SF-36 Physical (3.2, P=0.01) scores.

BEEMS participants with brainstem or cerebellar lesion involvement experienced greater improvements compared with those without in CDP-SOT composite (5.26, P=0.04) and MFIS total (−7.6, P=0.02) scores from baseline to 6 weeks, but those differences were not sustained by 14 weeks.

“Overall, these findings demonstrate that the BEEMS protocol improved balance, consistent with previous nonspecific intervention studies, and resulted in greater improvements of dizziness and fatigue,” the authors wrote. “These findings suggest that vestibular rehabilitation and eye/head/limb coordination under progressively more challenging conditions should be included in physical interventions.”

Study limitations included an insufficient sample size to compare BEEMS patients against controls by lesion/no lesion. Gait outcomes that challenge postural control and clinical measures of balance should be considered in the future, the authors noted. The only measures related to the vestibulo-ocular reflex were the gaze stabilization and dynamic visual acuity tests; future investigations should include direct assessments like the head impulse test, they added.

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