People with multiple sclerosis (MS) have special needs when it comes to physical rehabilitation. Physical therapists who specialize in neurological disorders have the training, skills, and equipment to better assess patient needs and to recommend therapies to help address specific deficiencies. My own neurophysical therapist has been great at helping me to improve balance and strength.
In addition to issues stemming from muscle weakness, lack of coordination, spasticity, or deconditioning, people with MS may experience problems with dizziness, vertigo, lack of proprioception (awareness of body position in space), or impaired vestibular function (affecting spatial orientation and sense of balance). A special form of rehabilitation that can help with dizziness and vertigo is called vestibular rehabilitation therapy.
What is vestibular rehabilitation therapy?
Vestibular rehabilitation therapy (VRT), or vestibular retraining, is an exercise-based treatment program designed to improve your brain’s ability to adapt to vestibular problems and to use other senses to accommodate for deficiencies. The goals of VRT are 1) to enhance gaze stability, 2) to enhance postural stability, 3) to improve vertigo, and 4) to improve activities of daily living.
Key exercises for VRT involve head-eye movements combined with various body postures and activities, and performed maintaining balance with a reduced support base while using various orientations of the head and trunk. These exercises may be performed while conducting various upper-extremity tasks, repeating the movements that provoke vertigo, and exposing patients gradually to various sensory and motor environments that typically cause disorientation.
The customized exercises associated with VRT are relatively simple and might make symptoms worse at first, but methodical exposure to situations that exacerbate vestibular problems encourages the brain to use other senses to compensate. Before specific VRT exercises can be recommended, you must undergo a thorough clinical evaluation. Then depending on the vestibular-related problems identified, appropriate exercise may be prescribed that involves habituation, gaze stabilization, and/or balance training.
Habituation exercises are helpful for people whose symptoms of dizziness are worse with head movements or visual stimuli. The goal of habituation exercise is to reduce the symptoms through repeated exposure to specific movements or visual stimuli that cause dizziness. Over time, the intensity of dizziness will decrease as neuroplasticity helps to rewire the brain to ignore the abnormal nerve signals coming from the inner ear.
Gaze stabilization exercises help to control eye movements so that vision remains clear when a person turns their head. These exercises are good for people who report problems seeing clearly because their visual world appears to bounce or jump around. Two types of eye and head exercises are used to promote gaze stability. In one exercise, the person will fix their gaze on an object and repeatedly move his head back and forth, or up and down. In the other type of exercise, vision and sensory information from skin, muscles, or joints are used to substitute for damaged vestibular function.
Balance training exercises are customized to address specific patient needs and are used to improve physical stability. The exercises may begin with small challenges but gradually become more difficult. This encourages the body and brain to adapt to moderate challenges that tax the vestibular and somatosensory systems, but remain safe enough to prevent falls. Patients undergoing balance training exercises usually wear a belt or strap that is firmly held onto by a trained professional who accompanies them through the exercises to insure safety.
Balance exercises can be made more challenging by altering certain elements or approaches, but should always be designed to reduce environmental barriers and the risk of falls:
- Alter visual and/or somatosensory cues (e.g., eyes closed, looking in different directions, standing on form pads or less stable surface)
- Use both stationary positions and dynamic movements
- Engage in dual tasks (those that require your brain to handle more than one thing at once, such as walking and talking, or reaching and balancing at the same time)
Vestibular rehabilitation and MS
While I was undergoing balance training, the exercises seemed very simple. But they helped me to compensate for reduced sensations in my limbs, allowed me to move more confidently while walking on uneven surfaces or in the dark, and improved my ability to maintain balance while doing various tasks. The improvements seen in balance were both objective and subjective. I felt more in control and tripped less, while objective testing done by my physical therapist also showed improvement.
Vestibular rehabilitation can be effective in helping people with MS. In one clinical trial, a six-week VR program was shown to improve fatigue, impaired balance, and disability due to dizziness or disequilibrium in a small group of people with MS. Another clinical trial demonstrated that a customized eight-week VR program improved measures of static and dynamic balance in people with MS. The program also improved functional capacity, quality of life, and depression.
While the term vestibular rehabilitation therapy is not commonly used — for instance, I didn’t know that was what the approach was called when I underwent “balance training” — it is a form of physical therapy that has many benefits for people with MS. More research is needed to demonstrate the most effective ways to use VRT to help people with MS be more active and move more confidently.
See more helpful articles:
Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. J Clin Neurol. 2011;7(4):184-96. doi: 10.3988/jcn.2011.7.4.184. Epub 2011 Dec 29.
Hebert JR, Corboy JR, Manago MM, et al. Effects of vestibular rehabilitation on multiple sclerosis-related fatigue and upright postural control: a randomized controlled trial. Phys Ther. 2011;91(8):1166-83. doi: 10.2522/ptj.20100399. Epub 2011 Jun 16.
Marrie RA, Cutter GR, Tyry T. Substantial burden of dizziness in multiple sclerosis. Mult Scler Relat Disord. 2013;2(1):21-8. doi: 10.1016/j.msard.2012.08.004. Epub 2012 Sep 25.
Ozgen G, Karapolat H, Akkoc Y, et al. Is customized vestibular rehabilitation effective in patients with multiple sclerosis? A randomized controlled trial. Eur J Phys Rehabil Med. 2016;52(4):466-78. Epub 2016 Apr 6.
Pula JH, Newman-Toker DE, Kattah JC. Multiple sclerosis as a cause of the acute vestibular syndrome. J Neurol. 2013;260(6):1649-54. doi: 10.1007/s00415-013-6850-1. Epub 2013 Feb 8.
Zeigelboim B, Liberalesso P, Jurkiewicz A, Klagenberg K. Clinical benefits to vestibular rehabilitation in multiple sclerosis. Report of 4 cases. Int Tinnitus J. 2010;16(1):60-5.