Balance & stability with MS

Jodi: Hi everyone. I would like, of course, to begin by acknowledgement of country and the spirit of reconciliation MS Plus acknowledges the traditional custodians of the country throughout Australia and their connections to land, sea and community. We pay our respects to Elders past and present and extend that respect to all Aboriginal and Torres Strait Islanders.

Mahenddra who's an MS physiotherapist and myself, MS nurse practitioner and I'm also an executive manager here at MS Plus. Anything that we discuss can always raise people issues for people with MS. MS can affect many aspects of your life and losing functions, losing things that you were able to previously do, and that includes balance, can have a real impact on people and can certainly really contribute to mental health issues, and sometimes discussing those can be really triggering for people. So please reach out to any of these services, or you can call us at Plus Connect as well, too, if you feel like you need to have a chat because a problem shared is a problem solved.

What we're going to cover today is I'm going to talk a little bit about understanding balance and assessing balance in MS. And how I used to do it as a nurse practitioner and then Mahenddra is going to come on delightfully to really talk about some practical things that you can do to improve your balance. And just a little bit of a deep dive into the psychological and emotional impact that losing your balance can have on people and the implications of losing your balance. And it's certainly something that I know well about in MS.

So, we talk about balance quite flippantly we? But it is in fact an extraordinarily complex ability of the human body to maintain equilibrium and stability when you are stationary or moving. And it's one of the reasons why even subtle differences can have a huge impact on quality of life and it also sort of impacts everything that we do if we don't have good balance and good coordination. There's so many different elements of the human body and the nervous system that go into creating this ability for us to balance and we often think of the yoga pose of someone just standing there holding balance but balance is also about the ability to maintain postural stability when you're going for a walk and that's called dynamic balance or when you're moving and that's called dynamic balance and static balance.

So, we'll talk a little bit more about all the different functions and all the different elements that enable us to keep a balanced dynamically and statically. But let's get into why is balance important. And I remember so well a story that I've never forgotten. It was a young lady who was relatively, oh she's mid 20s which is young for me, and she had MS and really if you MS, like lots of people with MS, you wouldn't have really realised anything was wrong. She was diagnosed with MS and her wedding was in six months and the MS had affected her balance. And all she wanted to do was wear the special high heels that she wanted to wear walking down the aisle. And so, we really got invested in getting her to that goal. And as I said, it was very subtle, but she couldn't walk in high heels. And she really wanted to do that for her wedding. And so, with a lot of physiotherapy that she, that was really specific particularly focused on getting her balance back again. She was, I was very excited when she brought in photos and showed me her shoes and her wedding doing that.

So, balance is important. That's just a really subtle way, but balance is important for performing all the activities of daily living. Like many of us need balance to do anything ranging from walking in high heel shoes right down to being able to do the cooking and the planning and all sorts of things. Balance is important for many, many aspects of activity of daily living. Balance is important to also reduce the risk of falls and injuries. That we all are frightened of falls and Mahenddra 's going to talk to us a little bit about, fear of falling impact us but it also creates injuries and when you are living with MS, having another injury is certainly not a cumulative thing that you want to be able to have to manage in your life. So, you're having balance is really important to reduce the risk of falls and injuries. And all of those things add up to the last ball, which is having, enhancing overall quality of life. If you are struggling with balance, it can impact your quality of life significantly, and that's why we're really focused it at the moment at MS Plus because we do understand that balance can impact every aspect of your life, and there is so much that you can do to help improve it.

So, let's go a little bit to talking about MS affects balance. Now, one of the particular challenges in MS management is that MS affects balance in so many different ways, and that's because of the multiple systems that are involved in balance. One of the systems is your vestibular function and that when we talk about vestibular function We often talk about our ears and coordination a little bit harder to visualize how your ears are involved in balance, but we often talk about the vestibular function. We often also talk about the motor function and motor function is your fine motor function is stuff like holding your fingers together or getting your feet in the right position all can which impact balance. Gross motor coordination is the moving of the big muscles to keep your coordination going. And then the other aspect that is involved in balance is sensory. Sensory disturbances involve what we call proprioception. And proprioception is this masterful ability of the brain to understand where your body is in space. So, when I put my arm out, I can, proprioception is what is allowing me to understand where my arm is in space, which we take all these things for granted, proprioception we take for granted. But it's commonly impacted in MS, and it can sometimes be disrupted. The other thing that MS can impair is sensory balance. So, if you have different feeling in your feet if you have particularly one side's different from another, it can really impair your balance because those messages then that are going up to your brain are quite distorted from how you're feeling the ground beneath your feet. The other thing that we depend on to keep our balance is our eyes. And our eyes really, of course, keep us, we know if you close your eyes, you can lose balance quite quickly. And so, one of the things that we use to keep ourselves in balance all the time is our visual, is our vision and our eyes.

As many of you would know, MS can affect every one of those different systems and commonly does. If we start from the top and we think about our eyes MS can commonly cause double vision, problems with our eyes moving together in synchronicity, so the muscles around the eyes can be affected, and other things like the actual vision, color vision, can be affected in MS as well too. So that can really, that visual loss. Particularly, again, if it's one eye and not the other eye, which is common in MS, they can really affect people's balance. Then sensory disturbance, which I talked about, can impair actual proprioception, but also sensory imbalances on one side of your body. If one side of your body feels different from another side of your body, you know you're going to be slightly off kilter, or sometimes more obviously off kilter.

Then MS can also cause muscle weakness and spasticity, and that compromises the body, particularly the core muscles of your body. Even things like MS commonly affects our hip extensor muscles as a starting point when we're looking at muscle weakness and sometimes people aren't even aware of that in MS that they've got hip flexor, what we call hip flexor weakness and that can really distort your ability to maintain your muscle stability as well too, particularly when you're walking. Other things are coordination problems. There's a part of your brain called the cerebellum that masterfully connects our coordination. Lesions in MS in the brain can affect basic coordination problems in the cerebellum as well too. And then we know cognitive changes can also impact balance in MS and cognitive changes such as slower processing, slower speed is a really good example. I see something and then a process that I need to move out the way and that can impact balance and how you move about as well too. So, it's just so many different things that MS causes in people can impact balance.

There are also lots of other reasons for balance problems and it's really important when you are thinking about that and it's one of the things that make the management of balance disorders so incredibly complicated is that there are many other aspects and many other causes of balance problems not just MS. And sometimes not uncommonly, you'll have multiple causes of balance problems. Aging, as we age, we all lose our balance and need to work harder to keep balance. Some medications can really impair balance and coordination as well, and it's really important when you're thinking your balance has got worse or you're worried about your balance then to do a medication check to make sure that it's none of your medications that may or may not be contributing to balance disorders. Other musculoskeletal problems, not just MS, can cause balance problems. Non-MS visual problems, they happen as well too with people. So often people need glasses for lots of different reasons, not just MS. Vestibular disorders, that's inner ear disorders in particular, can cause problems with balance and infections, when people have infections and colds, particularly ear infections, they can infect balance, and other medical conditions as well too. For instance, low blood pressure, that can be another thing that can really impact your ability to balance. It's sort of the core of you, I often used to think balance was right at the core of keeping me upright in all aspects of my life, so it's just how important it is.

So how that translates to some of the symptoms and challenges related to balance in MS. Many people talk about having dizziness and vertigo. There's often a mixed, and I'll answer one of our pre questions now in terms of what is dizziness and what is vertigo. There's often quite a bit of confusion about this. Vertigo is a type of dizziness that is associated with the room spinning around. It is a very distinct feeling of a spinning around room. Whereas dizziness is a broader term that sort of relates to any sort of sensation of light-headedness, unsteadiness, or imbalance. The reason why it's important to differentiate the two, particularly in MS, is because vertigo in itself is commonly related with other conditions, particularly a type of condition in the women who are plus 50. So, a lot of women, more women than men have MS and so that's called BPPV, that benign positional vertigo. Non paroxysmal positional vertigo. That's a very common we often undiagnosed people's vertigo as related to that instead of instead of MS. And fortunately, that is very easily fixable with some exercises. So, it's really important to understand that those two are different because it often gives a little bit of a clue as to what might be going on in terms of it could be something else. Other considerations for vertigo is very much associated with many years and, and ear problems, whereas dizziness can be lots of other things.

The other challenge can be walking difficulties and performing activities of daily living. That could be a real challenge with some of the symptoms, when you have impaired balance. It also significantly increases people's fatigue. And that is because, not for everybody, but for the majority of people. I speak about majorities, not minorities. There are always people on the on the minority end. But the majority of people having impaired balance means that you are investing more energy into all your activities of daily living because you are needing by default to be more aware of the of the things around you as you try and balance.

And so can increase fatigue as well too. Poor balance can relate to can cause decreased fine motor skills and that can impact reading, writing, typing. All the things that we take for granted really that we're able to do every single day and can significantly be a challenge in in people with MS. And as we've talked about too a significant increased risk of falls and injuries come for people with balance impairments in MS.

There are also some hidden impacts of balance problems that we don't actually see quite so obviously. One of those that is really important to think about when we are tackling balance as a challenge in MS is the lack of confidence of going out and about. A lot of people that fear of falling but also fear of how many times have we all heard people say people think I'm drunk because I'm wobbling and I'm not balanced and I don't want to go out anymore because people feel that I'm just not quite coordinated. Lots of people feel really uncomfortable if they've got even minor balance impairments of going out in public transport. I would often say to people that nothing could clear a crowd better than a fold out stick. And so, they were feeling like people around them really impaired that balance just to even if they didn't really necessarily need a stick, it was a good trick to clear the space a little bit in public transport or in crowded areas. So, I said that would, that might be a bit of a trick. I think a few people took me up on it. Lots of people felt uncomfortable in crowds, in public transport. Just going to work, really worried about, just had that lack of confidence in getting out and about. And that sort of related to what other people will think. That was my most common resistance when I did the stick, when you didn't really need a stick trick. Most people just felt, what will people think of them then? And that's really hard. That's really, really tough. And if your balance makes you look a bit wobbly, then people are so quick to make assumptions, aren't they? And not think about what might be the rest of people's stories. And that could be something that really can impact your mental health significantly. It can create significant impacts at work, where you might need to make adjustments, and even if they're subtle adjustments or you're not quite as quick at things as you used to be able to be, and your typing is impacted, you need a big recommendation for voice to text, and all of those things can build up to causing further anxiety and stress in people with balance problems.

So, it's more than just what's on the outside, there are also all these hidden impacts of balance problems. So, the fun part, maybe not the fun part, but for some, but assessing balance. And assessing balance is a complicated procedure really, because there's lots of different elements that you can do, and everyone who you see is going to assess your balance slightly differently. You might see a GP and they might look at the way that they test balance from a little bit of a different lens to the way your neurologist might assess balance. But I'm going to talk a little bit about a general overview for this. Clinical history is really important. What you're telling physiotherapist or the doctor who's assessing you about how your balance can impact you, about what things you can and can't do, are really important aspects of making sure that you, you get that right. Most doctors and physios and occupational therapists, they'll all ask you questions about how your balance is impacting you, and it's really good to have concrete examples of what you can and can't do.

In terms of neurological examination, there's lots of different tests that you can do to assess balance. And for many people here, they would have been to a neurologist before and be very familiar with some of these ones. The most common one that they do is what's called a Romberg's test. And I know that most people were not that fond of this test. It's when you, I'm going to stand up now. So, when you stand up, close your eyes and hold your hands out in front of you. And for people who have balance problems, as soon as you close your eyes, they start to rock, and that's why the neurologist will often stand behind you to make sure that you're that you're not going to fall over. So, it's a really common test for balancing people with MS. And it does particularly looking at it sort of covers lots of areas where balance can be affected. You might have your eyes tested at the neurologist. That's another way that they might put together the pieces of the puzzle about the about balance that you might have. You might do another test, which is called a hand flip test. And that sometimes can So that's really looking at coordination and you can see people's coordination by doing the hand flip test. You might never know why you've done all these tests. Another one looking at coordination is the finger to nose test as well. So, people following somebody's nose doctor's finger or physio's finger and pointing to where that is. And that's another way of telling where balance may or may not be impaired by people. And sometimes it's subtle that you didn't even realise it. We often picked up coordination problems doing this hand flip test. I'm very fast at it, but that's why I've given the example many, many times. And I've seen people be very fast at it too. The other thing that people might do is a heel, a heel toe test. And that's a really good indicator of balance where you walk from heel to toe as you walk along. And that can really, you know, people with balance impairment can really struggle with that one. The other one might be when you're lying on the bed, and they get you to run your heel up and down your shin. Or they get you to tap your foot according to what, according to the tapping with them. They're all things that can build up a picture about balance in neurological examination. So, all of those tests that seem odd things to have to do really help the neurologists and physiotherapists understand the degree of your balance impairment and also the areas where we might be able to work on to be able to improve that balance.

The other thing that probably physiotherapists tend to do more than neurologists is look at functional movements and balance assessments. And there are a myriad of these where the physio might pull out a few questions for you and say, okay, can you tell me, you know, can you do this? Can you do that? One of them is called the Berg Balance Scale, and that's a very widely used assessment tool. But the physiotherapists tend to have a whole kit of tools, and often they are looking at what areas can improve on as well too. And then they do what's called functional ones, and that's when they actually ask you to perform an activity, and then they can assess balance from there. That might be getting up and down from a chair, it might be going for a walk as well too, but they're all about functional movement, actually doing something and assessing someone doing that at the same time. The next thing which I which we didn't really use much in the MS clinic. In fact, I think I only heard one or two people who have told me about advanced testing for their balance. But this was called postgeography and wearable inertial sensors. So, postgeography involves using force platforms or wearable sensors to measure postural sway and stability during standing and walking tasks. So, it kind of looks like the person's put up in a harness there and then they measure someone's postural sway and balance.

That's something that is not regularly offered to people with balance problems and I don't know Mahenddra you might be able to talk a little bit more about that because it's not something that's a regular test or examination for people. But there are lots of different ways that we can advance test balance.

So, I've talked a little bit about some of the things that they do in Neurological assessments, I think I've covered them all. Romberg's, the other one was the pronated drift. That's when you hold your hands out like this and people with impaired balance arm can just go floating off into paradise. So that's another thing that they might do. The hand flip test, the heel toe test. finger to nose or foot tapping or heel shin. Sensory examination, that's really important to be able to have a look at. Visual examination, vestibular assessment as well too, that can be quite a complex way of looking at lots of different elements of the vestibular system. Muscle tone, reflexes and strength are also assessed, and we talked about how changes in muscle tone and reflexes and strength can really impact balance. And then there's what's called a cranial nerve assessment, which people can do. They're all part of putting together a picture for how balance can be impacted or how your balance might be impacted in MS.

So, the key points for me is balance is keeping you upright and as I said that balance is keeping you upright. We often talk about life, work, balance and when we talk about balance it's really significant and I think because of impacts so many people with MS. It's really important to think about getting your balance right and doing something about it because it impacts every aspect of your functioning. The problems are usually complicated because there's often multiple things causing the problem in the first place and MS affects it in many ways. There are other things, make sure you always exclude other things that can cause balance impairments as well too, and balance assessment has many elements to it. And sometimes it takes more than one person to do the balance assessment.

Just finally, one of the really important things in MS management is to make sure that you have regular assessments because often these things can go undetected. Changes can occur that you're really not quite aware of. One thing I learned in my years of being an MS nurse is that people with MS are masterful at adaptation. And they just keep adapting and adapting until you stop and say, hang on, what's happened there? And it really is, I've just adapted. I've just changed my life. It was sort of, oh yeah, I didn't even realise I was doing that. I just adapted to the situation of what I needed to do. And so that's where it comes in to have that regular assessment, that extra set of eyes, that a minimum every six months is checking you out. And that's because you can have early detection of symptoms. There are subtle changes that can happen that you're not even aware of. Regular assessments also mean that you can get the right treatment planned for you and that you're aware of what might be going on. I spoke to someone yesterday and she said, why do I need to see the doctor more than, you know, every year to get my thing? And I said, because you never know what they know. There might be something new and chances are they're not going to be able to communicate it to everybody they see unless you come in with them. So it's a good reason as well too. And they also might have found new physiotherapists or new ways of addressing the problems associated with balance and the many things in MS. It means that you feel that you're a bit more in control of the situation. Regular assessments can be very empowering. They can prevent secondary complications through early detection. Also, they can optimise that symptom management as well too if you are. So regular assessments are really important in MS, in all of MS management, but also in thinking about balance management.

In terms of discussing balance issues with your healthcare providers, it's really important that you communicate openly, that you provide details chronologically and in detail. Very handy thing is to bring succinct notes. Another thing is to get someone to take a video, a short video of you walking. If you've got a specific time, when your balance is worse, and by the time you see the neurologist, it's not there, or you find it hard to describe the words. Take a short video of you walking, and that can be, or trying to do something where you notice that I really have trouble with this and I don't know why, I'm videoing myself doing that. It's a great way to communicate, or even ask your physio to, or your family member to take a video of you doing something as well too.

Make sure you include all your medications and treatments when you're having a discussion so that you can deep dive and make sure there's not anything else that's contributing to balance, including in your discussion what you've tried, what works and what doesn't work. That's sort of a really common question.

But if you've got this prepared, you will, you know, come to the appointment saying, okay, this is my number one problem is balance. Here's what this means for me, here's what I've done, here's what I've tried, here's what makes it worse, here's what doesn't. And then feel free to ask questions as well too, about who's going to do what. Often you sort of end up ending the conversation with your neurologist. We all know lots of forgotten, but I would commonly say to people, right, your job is to do XYZ. My job is to do XYZ. And we'll go from there and sometimes I'd write that down, but if you can write that down and say, right, just confirming you're going to contact my GP to make a physio referral or I'm going to do that, that's my job. What's the plan here? So, working with your health care providers to make sure that you make the most of those appointments. And that includes working, you know, I've talked about neurologists, but that absolutely includes working with nurses and physiotherapists and OTs. All of these things will help you be more engaged and feel more in control.

Now, the good stuff, I'm going to hand over to Mahenddra who is going to talk to you about some strategies for improving your health.

Mahenddra: Thanks, Jodi. Hi everyone, my name is Mahenddra. I'm one of the physios here at MS Plus. That was really good bit of information that we got about balance and falls, you know, the interchange with MS with multiple sclerosis.

So, I was going to have a bit of a chat about physical therapy and exercise programs and just a little bit more about balance. So physical therapy, physiotherapy, exercise physiology and the like are really important tools in the management of falls trying to improve your balance. So, balance, as Jodi was saying, is made up of a couple of different domains. There's your proprioception, which is your joint awareness in space, your vision, and your sensation. But one of the other things that puts it all together is strength. So strength is really important as well.

With your proprioception, which is your joint awareness in space. Imagine you've got your ankle and you've turned your ankle a little bit. What happens as soon as you're walking on an uneven surface and you turn your ankle a little bit, that nerve stretches a little bit, sends a message saying, hey, you've actually just turned your anchor a little bit. Your brain sends a message back down again to get you to correct it. So that's a very, very important process for you to try to regain your balance. But in people with neurological conditions and as well as people who have gotten a little bit older, that ability to get that quick reflex decreases. What that means is you might have turned your foot a little bit and you're not aware of it and you continue walking. And that's where the danger is, where you might have a fall.

In terms of the way that you try to reduce the risk of having a fall, there are three different methods that you use. So, the first method is if I come in and shove you on your back, you're going to try and use your ankles to find your balance and that's where that proprioception gives your brain that feedback and tells yourself it's moving. If that doesn't work and you're going to have a fall, you start to go to your hips, where you use your hips to try and find that balance. And if that doesn't work, you take a step to try to reduce the impact of that fall. So, the stepping method is a really important part of trying to regain your balance. But if we come back to what we were talking about earlier, when you lose some of that sensational, that feedback to your brain, or if you lose some of that proprioception, you miss the two phases completely. And you sort of go from part one to part three. But if you haven't taken that step or you're not aware of it, that's when you go down, boom, straight on the floor.

And very often if you ask someone who's had a fall, can you tell me what happened with that fall? They'll say to you, I'm not sure one minute I was standing up, the next minute I was on the floor. And that's because the body hasn't had that time to process the fall. And I think one part of physiotherapy or exercise physiology that's really important is trying to reteach that step method. So, if you can take a step, whether it's to the side or coming forward when you're having a fall, you're going to reduce the impact of the fall by being able to reduce the momentum. So, if you're going down and you take two or three steps, Hopefully, if you do have a fall, it's going to be a much gentler fall compared to one that you go straight down like that. So, the stepping method is a huge part of the education around folds management and balance management. And of course, the other one is a falls management plan. So, falls management plan is coming up with a plan for if you do have a fall, what do you do? How are you going to get up off the floor in your house? Is there a position that you could get into that would allow you to stand up in an easier way? That might mean crawling to a piece of furniture that allows you to put your hands up and stand up or it might be crawling to a staircase and inching yourself up the staircase to a point where you're comfortable then stand up.

If you have a fall and you've hurt yourself, what do you do? You have a watch or something that you can use to call the ambulance or someone that you know to come in and get you that assistance. Because if you hurt yourself and you can't put weight on a leg, the best case, the best thing that you should do is call an ambulance to make sure it's not your hip or some other area that you've had a fracture or something like that.

The other thing that's really important with exercise and Falls management or balance is that in order for you to see a change in your balance, it needs to be something that actually challenges you in session. So, if I just do a very simple exercise of me standing still and doing a little bit of this and that, it's not going to do very much versus me putting you in a position where you feel as though you might actually have a fall. So, putting yourself in a position where you might actually have a fall will then teach your body the way to respond to that if it were to come up again. That's very important and it's something that can be difficult to do by yourself at home because of course. There is a risk that you might actually have a fall, but in a gym setting or with a therapist, if you've got someone who's close by, you can manage that risk and make sure you don't have a fall, but also challenge your system in a way that could be effective in hopefully reducing your risk of having a fall, but improving your balance as well.

There were also a couple of studies done where they looked at the difference between training purely for strength and training for balance and they found that training for balance, because the method that you're training is going to involve some form of strength training, show an equivalent response to strength training in terms of building up your muscle. And I think that's another very important fact with strength. So, strength, of course, is your ability to control what you're doing, your movement, and your stability. And as we get older, so anything, anyone above the age of 50, You see a natural decrease in your muscle mass in your legs and your arms which means there's less tolerance to any sort of perturbation whether it's internal or external. Someone gives you a push or whether you're moving your hands around and that throws you off a little bit. But all the evidence suggests that with training, with consistent exercise training, that the senesce or the change in muscle mass, the deterioration is much slower compared to someone who has done no exercise. So very, very important tool to manage your balance and to reduce your, your risk of having a fall.

Exercise is one part of the management of having a falls and the other one is using some form of assistive device devices or techniques to help with that management. I think Jodi was talking about gate aids, single point stick, that is very important. So, if you're finding that you're going to be negotiating uneven terrain, or if you're going for a walk that's a bit longer than what you normally go for, and you know that fatigue is going to play a bit of a part in you being able to get there. If you have foot drop for instance, using a gait aid, whether it's a single point stick, a four-wheel frame, a wheelchair even, or a gutter frame could be the difference between you having a comfortable walking period or losing a balance and having a fall. And I think very often when you're negotiating areas that you have not been to before, you want to try to reduce your risk as much as possible. And when you've got a gait aid, it just means that you're not having to think about every step as much as you would have to if you don't have a gait aid. So, I'm sure you've been in that situation before where you're going on a bit of a walk, change from cobblestones to bitumen to grass and you're actually thinking about every step that you're taking, you're focusing on your feet, you're looking around, you're scanning and its exhausting. And that's going to add to your fatigue. And if one element of your fatigue is a change in your strength, i. e. a foot drop or you can't quite lift up your foot, that's going to come on faster, which means that your foot starts to drag, which means that you're thinking harder about that foot, and it sort of creates a situation where you're going to get more fatigue even faster. And something like a gait aid could be put in place to help alleviate that quite quickly.

An ankle foot orthosis, coming back to the foot drop, is something which sort of attaches in from your shin and over your foot to reduce the impact foot drop and allow that foot clearance. So, it's going to get you walking a little bit better but hopefully also stopping you from catching your foot on something as you're walking and again just reducing some of that mental load to allow you to concentrate on what you're doing a bit more.

Functional electrical stimulation is when you're using some form of electrical stimulation to bypass the brain. So, in an upper motor neuron nerve syndrome, i. e. MS, you've got your brain, you've got your spinal cord, and then you've got a nerve that comes up from a spinal cord to attach onto a muscle. So, the problem's not with the muscle, the problems with the brain and the messaging from the brain. So, with a functional electrical stimulator, what you're doing is you're taking the brain out of the equation and you're actually stimulating the nerve from this point over here by putting on a TENS machine or you've also got walk aids and those sort of things which you can put in your foot, the device will stimulate the nerve which causes a contraction of the muscle. So, for instance if you're walking and there is a particular pattern to your walking and you know that like say every second step your foot drags, you can set up a functional electrical stimulation machine to be able to stimulate your tibialis anterior nerve to lift up your foot at that point as you're walking. So, you get that foot clearance in a nice pattern. However, it doesn't work with everyone, if you don't have a clear pattern with how you're walking, you might find that it's not as effective.

With training your muscles as well, some people might find the TENS machine is quite useful in building up muscle mass. So, for instance if you can't engage your quad or you can't engage part of your leg that's using a particular muscle because of that disconnect between the brain and the nerve, you can put your TENS machine on the area and stimulate that muscle to get hypertrophy. It'll take a long time, but you can use that muscle. And it also encourages you, you know, by looking at the muscle you encourage that feedback to the brain, which encourages a bit of neuroplasticity as well. I think there was a study that was done, and this is not really related to neurology, MS in particular, but there was a, they were doing a study on a monkey, and the nose was still attached to the head. They went on a lunch break, and the monkey was watching them eat their lunch. And when they were watching because it's so attached, on the screen, the areas that were being so stimulated in the brain were the same areas that would be stimulated if the monkey was actually eating. So, by watching yourself do something, whether it's an electrical stimulation or whether you're watching someone do it for you, you are actually triggering the area of the brain that you use for doing that. And you can actually build up that and hopefully maybe change some of that end product a little bit too.

Visual aids are very important. Jodi was talking about, you know, vision and the importance of that for walking. This is the equivalent of you going to the toilet at night in your house without your glasses on. Oh, not without glasses on, without your light on. So, you might find that negotiating even a very familiar area becomes much harder at night, but if you turn on the light, wham, much easier. So, things like lights or whether it is glasses. So, if you know you're short sighted or long sighted or if you are affected because of double vision and you take that into account in some form of visual aid, you're likely going to have a better chance of avoiding a fall or improving your balance. Because it means that you can concentrate on other areas, other aspects of your balance rather than your vision.

Spoke to this a little bit, but yes, lights are really important. So, you've got your environment that you're in, what can you do to try to make sure that you're not putting yourself at a higher risk of a fall or injury? Lights are very important at night. If you're going to go for a walk in the neighborhood at night, you want to make sure that it is well lit, or if you've got a torch on you to handle, to carry around, to make sure you can see any undulating surfaces or any changes in surfaces that you're walking on.

Proper shoes are very, very important. Some shoes are heavier than others. You might find that wearing a particular shoe over time makes you get fatigued a little bit faster. So it might be that if you're going on a longer walk, you're going to wear a shoe that is lighter and easier for you to clear that foot. With shoes, you've got different, of course, sizes of your sole. Some of them are a little bit higher, some of them are a bit lower. The higher the sole, your base of support reduces slightly, which means you're again at a higher risk of having a fall. So, if you're going to go out and you're going to be walking a couple of meters, you might choose a different pair of shoes. If you're going out and you're going to do a fair bit of walking, you might be wearing something that's a little bit more built for that purpose.

Planning is really important on the patients. I'm seeing she said that when she goes out. She actually googles a venue before she goes out, she works out where the toilet is, what she needs to do to get to the toilet and how far she would need to walk from her car to get into the site. And that means she can prepare for it and when it happens on the day she can work out, you know, shoes, whether she's going to bring a stick or whether she's going to bring her four-wheel frame. And it also means that there's another little less mental load where she's not having to go there and then start to think about that in a new position or where she's a little bit worried about what to do. Planning also works when it comes to doing exercise, you want to set up the space that you're doing the exercise in to make sure you've got something to grab onto. It could be making sure that if you're going to the kitchen, that that's going to be a clear pathway. And then you've got things to hold on to get to the kitchen. Same with the bathroom or the toilet, whether it's a lift or something to make that a little bit easier. Planning is a really important part of ensuring that your balance is being maintained.

And of course, clutter. Have you got a dog or a cat that's an unpredictable element to you walking around at night or in the day? Are they going to get involved with your feet as you're walking? Do you have three carpets that have larger lips that catch on you when you're walking? Well, those are things that we can try to reduce in order to try to mitigate the risk of having a fall. Of course with an animal you can't reduce your, you don't want to take your animal outside or anything but what you can do is you can be more aware of it and you stand up, you check, nope, clear, coast is clear, off I go and walk and that way you're just reducing that risk of having a fall again.

Fear of falling, balance is one thing, but fear of falling is a massive contributor to an increase in falls. So, what happens is let's say you're going out and you and you have a fall. The first thing you do is you say to yourself, I don't want to go out again, I'm not going to put myself in that position where I could have a fall again. So, to do that, I'm going to stay at home and be careful. You don't have a fall for a couple of months, but what happens is because you're not going out and doing things, your muscles begin to atrophy, you begin to lose some of your reflexes, and that means that you're more prone to having another fall. And then you have another fall, and that makes you even more fearful of having a fall, and it just perpetuates a situation of you becoming worse and worse with your balance and having multiple falls. I think one of the indicators of an increased falls risk is having had a fall in the past. And it's a difficult one, because if you had a fall and you bruised your hip and you really hurt your knee, the last thing you want to do is put yourself in a situation where you're going to have another fall.

But what you need to do is be able to, A, identify how that fall happened. B, put in equipment or things that could change that risk of having a fall or the environment. C is you want to be seeing a therapist or someone who could then help you to build up that confidence once again and to challenge you in those sessions. So, coming back to what we said before, in order to see an improvement in your balance, you need to be challenging your balance. So, you don't, you want to be doing things that are difficult and are going to make you worry. Because that means when you then go out and it's not a difficult situation, well you've got that in your tank and you're ready to go without any issue.

So, fear of falling is a very real thing. The anxiety around falling can really limit what you want to do socially. Even work could be difficult. Well, if you need to get public transport to work, and you've had a fall on your way to your train station, that means you're going to keep that negative feeling around that public transport, and you might not want to do that anymore.

But there are definitely things that you can train and put into place to help to alleviate that in some instances.

So, I think we're just going through a couple of the different strategies when it comes around coping with balance. Strength exercise is a huge one. Balance training but remembering it's one that needs to be challenging your balance.

Assistive devices, this would be something you talk about with your neurologist, with your therapist. The other thing that you can do too is, I think Jodi mentioned spasticity as being one of the reasons why you might have poor balance, and spasticity is a very interesting one. Because Spasticity is that change in your brain's ability to understand a reflex that is going through and that can cause hyperreflexia or stiffness or a catching as you're moving and that's definitely a huge barrier to balance but interestingly with spasticity it's definitely a conversation for neurologists because in some people you might use that spasticity or that stiffness to give you more stability. But in other people, that specificity actually is a huge detriment to you finding a balance. So, it's not as easy as, I'm going to go off and get Botox. It's going to be, let's check out to see what particular muscle's being affected. Let's work out which muscles might be beneficial in having that Botox done, or Baclofen. Baclofen's another one that you can have for systemic change to your specificity. And then working out if that's the most appropriate thing for you. And I'm sure, as most people tell you with MS, It's not one size fits all. Everyone's MS is their own personal MS, and their presentation is different. It is a discussion with a doctor or with a physiotherapist about whether this is the right track for you, but absolutely something that could have a huge effect on your balance.

Body awareness is very important. So, with that balance training will come body awareness, that proprioception or that ability to judge where your body is at any given time. Any energy conservation, so having an assistive device will hopefully reduce fatigue. Planning will hopefully reduce fatigue because fatigue makes your weakness become more prevalent, which will have a huge effect on your balance as well.

So absolutely, you need to have a good team around you to be able to support you, and it's not one answer to balance or reducing your risk of falls. It's going to be a multidisciplinary approach, whether it's going to be drugs, whether it's going to be equipment, whether it's going to be home set up, whether it's going to be exercising, whether it's going to be information from your neurologist around what we can affect. So, there's a lot of things that interplay with the decisions around falls and balance.

So, support networks and mental wellbeing, of course, again, very, very important. And this is because cognitive load or stress can be a huge reason why you might have another fall and a huge reason why you might not want to participate in things, that you might have a fall in. So it could be that if you're going to go out, you want to have a good support base around you when you do go out. For instance, you might go out with a support worker who you're confident with and you feel comfortable with, who's going to be able to help you get your gait aid out of the car. You might be, you might go out with your family or if you got by yourself, you're going to put things in place, whether it's going to be a taxi, whether it's going to be a gait aid to make sure that you're not putting too much cognitive load on yourself and ensuring they're able to tolerate that.

Mental wellbeing, of course, is very important because, you know, there's definitely a link between stress and an increase in your symptoms. So, if you're feeling more stressed, more agitated, more worried about something, the chances of you sort of becoming symptomatic are higher as well. So, if you can manage that stress by being able to plan for it and you know, you put yourself in situations where you've tried a similar sort of thing before, you're going to have a better outcome. It's just like how, you know, if you've always got that person who's gone, who comes and says, oh, I've got a sore knee. Why do you have a sore knee? I went for a 10 kilometer run. Oh, how often do you go running? This is my first run ever. So that person has some plans for that run, and they really sore from it. And very often that person doesn't do more running in the future. So similar with that, if you want to go out and do something, it's taking all the precautions that you can and maybe starting with gentle re instruction back into to going back into the community of doing another task and you can tolerate it and then in your brain you go yeah, that was great, I had no issue with that. I'm going to try that a little bit more. So small increments allow you to build up your confidence to allow you to do something, that could be a more complicated down the track.

Jodi: Self-care is an important part in MS management. It can be very complicated, but it can also be thinking about the basics.

And sleep, eat, breath and move are just in terms of you know, getting enough sleep, you're eating well. Are you pausing and taking lots of deep breaths and you're making sure that you are continuing to move in the many and different ways. So, thanks Mahenddra for all those practical tips. The importance of self-care can be, is always good to be reminded of the importance of self-care in any aspect of particularly when you're presented with all these different ways, wonderful ways and things that you can do to help improve your balance.

What are some strategies for getting over the social anxiety of using a cane or aid when you don't always need it? Especially in the case of fluctuating symptoms and fatigue that is random and not always present. I always used to recommend the use of a hiking pole. Mahenddra?

Mahenddra: Definitely I think that the Nordic walking poles or hiking poles can be great.

The soft entry towards using a single point stick. I've been able to get a lot more people to convince them to get a hiking pole versus a stick. I often get the two. One of my patients said when she walks in the neighborhood with walking poles, no one would give her a second look because It's a walking pole. It's not a stick. So, she's very concerned about the stigma attached with using a single point stick. So, I think that that can be very helpful.

Two is walking poles allow you to be able to get more rhythm when you're walking, and rhythm is very important in maintaining your balance as well. So, if you walk without rhythm, very often you'll find that if something pushes you a little bit, that down you go.

So, I think walking poles can be a great intervention. Single point sticks are also great too. And often if you've got the telescopic hiking poles, they're things you can chuck in your bag. So, if you're travelling or something, you can chuck them in your bag and go. Easy to pack. You know, you can even have in your pocket, if you're finding you're getting a bit tired, you can whip them up.

And away you go.

Jodi: We had tips for training backward balance, losing balance when putting stuff into the boot of the car, etc.

Mahenddra: So, when you're working on that, you'd be working on, balance as a whole. And, and so what can happen with falling backwards is sometimes if you bent over and you come up too quickly, and that could be an issue with coordination, you might lose your balance a little bit and that tips you over.

But I think the way to fix that, and it's something that I would do with therapists, is going to be training you to pick things up, lift them up, put them away, trying to do that over and over again. Practice makes perfect. And the more you train, the more comfortable you're going to be doing it. So it could be that maybe you need to have your legs a little bit wider open.

It might mean that you need to have another point of contact with the car or something to give you that other bit of balance, but absolutely something that can be worked on.

Jodi: One person did raise the important issue in MS is doing exercise brings on fatigue. Is there any way around that? So about, should we do more exercise?

Should we be doing balancing exercises, even if our balance is not that impaired? And what about the fatigue?

Mahenddra: Yeah. So, I think definitely any form of strength work is going to be positive. Okay. But if you're working on balance in particular, you need to be working in an on an exercise that is challenging your balance.

So, for instance one easy example is in the gym, let's say you've got a cable machine. You're pulling the cable you're holding out here That cable is pulling you forward. You're trying to maintain your balance over here That's going to be something that can be helpful to balance. So, if you're doing Pilates that's great, but it's Pilates is not going to help you with your balance in a standing position. It's going to be something that helps your strength and building out your muscles in that position. That's fine but other than strength you need to be working specifically on balance. Another way of thinking about it is if you're training to run a 10 kilometer run, if you do cycling, it's going to work your cardiovascular system and work your muscles, but it's a different system to what you'd be doing running.

So absolutely fine to do your Pilates and I think strength training is vitally important in helping your balance. But you also need to be training balance specific exercises and that's a different sort of exercise as well.

In terms of fatigue Absolutely fatigue can be it can be a huge problem when it comes to exercise But and it seems counterintuitive right you do more exercise you get more time And then you feel like you're more likely to have a fall It's finding that that balance where you can you can no pun intended is finding that balance where you're doing a little bit of exercise Trying to make sure that you can tolerate that and that's going to be looking at how fatigued you are after each session, give yourself a score of 10. Well, that was really hard. I'm going to try a little bit less next time. Finding that sweet spot where you can get some good value from exercise, but not get too tired. And as you keep doing that, you will build up your endurance and allow yourself to do a bit more. Think of it like with a walking program. If I did a kilometer three or four times a week for three weeks, in four weeks’ time, I'll be able to do 1. 5 kilometers, and then I can build up from there. But if you try too much all at once, you're going to get too tired, and then you can hurt yourself, and doing too little at once, working too far underneath that capacity, means you're not challenging yourself in order to get that change in your balance or your muscles.

Jodi: That one visit to the physiotherapist can save so much time in terms of understanding your own balance issues, getting you on a program. The six week program can be life changing. It's just about getting that team together of people who can really support you. Thank you Mahenddra for all those practical tips.

Just a reminder of what we do at MS Plus, all the different services that we have available to us. Also, there's a whole lot of resources, webinars, podcasts and articles available on our website in the resource hub. And if you want to call us, it's 1800 042 138. And the Plus Connect team will certainly be there to answer any of your questions.