A review of randomized controlled trials on balance interventions highlighted the effects for improved mobility and balance in multiple sclerosis.
Chiara Corrini, PT
Findings from a recent systematic review and dose response meta-analysis, provided evidence for the effects of balance intervention to improve mobility and balance in patients with multiple sclerosis (MS).1 This review was the first of its kind and demonstrated the importance of physiotherapy for patients with MS to improve these aspects as mobility impairments and falls often occur in within the condition.
Balance as the primary outcome were assessed in 29 studies (40.8%), while 42 studies (59.1%) had it as a secondary outcome or no specification as a primary or secondary outcomes. No active interventions as comparator were observed in 33 trials (46.5%) and 38 trials (53.5%) had an active control group present. Notably, high intensity and task-oriented interventions were associated with better treatment outcomes in the meta-analysis.
Lead author Chiara Corrini, PT, physical therapist researcher, LaRiCE lab: Gait and Balance Disorders Laboratory, Department of Neurorehabilitation, IRCSS Fondazione Don Carlo Gnocchi, Milan, Italy, and colleagues wrote, “Our results agree with two main principles of neurological rehabilitation stating that specificity of intervention and the amount of practice (dosage) are two pillars of motor recovery. It seems that a high dosage of rehabilitation interventions lasting more than 40 min should be specifically delivered to improve balance impairments according to task-oriented principles.”1
Studies included in the review focused on the effects of neurological rehabilitation on mobility and balance in patients with MS, including methods of rehabilitation interventions, comparisons with experimental and control, balance clinical scales, and randomized controlled trials. A meta-analysis was conducted to assess the linear trends of the effects of dose responses as well as a 1-stage linear mixed effects meta-regression for the estimated dose response curves.
From a list of 5020 full text reviews, 196 studies were retrieved and 71 studies, consisting of 3306 participants, were included. There was one cross over study and70 randomized controlled trials with a mean sample size in each study of 46.5 (±28.6), a mean age of 48.3 (±7.0), disease duration of 11.6 (±6.1) years, and Expanded Disability Status Scale score of 4.4 (±1.4) points. In the first meta regression analysis, a strong relationship in intensity-balance outcomes was observed. Corrini et al noted that this is, “suggesting stronger effects in trials having treatment sessions lasting more than 40 min.” Although not all treatment methods had similar effects, such as with task-oriented interventions,2 which were most effective for improvement in mobility and balance in MS.3
Using a cohort of more than 2500 patients with MS on disease-modifying therapies, treatment initiation within the first 2 years of disease onset was more beneficial on patient-reported outcomes than 2-4 years postonset.
A medium pooled effect size for balance interventions (standardized mean difference [SMD], 0.41; 95% CI, 0.22-0.59) were observed in 20 studies with individual data (n = 1016). Additionally, in 14 studies (n = 696) that used balance as a primary outcome and Berg Balance Scale (BBS) as a primary endpoint, there was a mean difference of 3.58 points (95% CI, 1.79-5.38, P <.0001) in favor of interventions. In the meta-analysis, 20 studies showed an association between better outcomes, including higher training log of intensity (β = 1.26; SEβ = 0.51; P = .02), and task-oriented interventions (β = 0.38; SEβ = 0.17; P = .05).
Limitations of the review included poorly or not reported important outcomes and little focus on patient-reported outcomes. Also, follow-up periods were not considered in clinical and statistical heterogeneity of RCTs, and the dose failed to recognize the level of participant effort in an exercise to program outcome along with workload intensity of the different types of interventions.
Corrini and colleagues noted, “the results suggest that a physiotherapy intervention may have a clinically significant effect on balance during transfers and static postures, however, more studies are needed to better understand the impact of rehabilitation on dynamic balance, quality of life, social participation, depression, and anxiety that are outcomes often neglected in RCT.”1
Therefore, the authors concluded that further research is needed on high-quality studies that experiment with larger samples and that have longer follow-ups. These studies would assist in developing balance and gait recommendations on treatment for patients with MS. Also, more studies could produce a new category for rehabilitation interventions, under the classification of interventions for MS.
