title: Systematic Review: The Effectiveness of Interventions to Reduce Falls and Improve Balance in Adults With Multiple Sclerosis.
abstract: OBJECTIVE
  To evaluate the effectiveness of interventions in reducing falls and/or improving balance as a falls risk in multiple sclerosis (MS).
  
  
  METHODS
  Computer-based and manual searches included the following medical subject heading keywords: "Multiple Sclerosis AND accidental falls" OR "Multiple Sclerosis AND postural balance" OR "Multiple Sclerosis AND exercise" OR "Multiple Sclerosis AND physical/physio therapy" NOT animals. All literature published to November 2014 with available full-text details were included.
  
  
  METHODS
  Studies were reviewed against the PICO (participants, interventions, comparisons, outcomes) selection criteria: P, adults with MS; I, falls management/balance rehabilitation interventions; C, randomized/quasi-randomized studies comparing intervention with usual care or placebo control; O, falls outcomes and measures of balance. Fifteen articles of the original 529 search results were included.
  
  
  METHODS
  Two reviewers independently extracted data and assessed methodological quality using the Cochrane Risk of Bias tool.
  
  
  RESULTS
  Random-effects meta-analysis indicated a small decrease in falls risk (risk ratio, .74), although the 95% confidence interval (CI) crossed 1 (95% CI, .12-4.38). The pooled standardized mean difference (SMD) for balance outcomes was .55 (95% CI, .35-.74). SMD varied significantly between exercise subgroupings; gait, balance, and functional training interventions yielded the greatest pooled effect size (ES) (SMD=.82; 95% CI, 0.55-1.10). There was a moderate positive correlation between program volume (min/wk) and ES (Cohen's d) (r=.70, P=.009), and a moderate negative correlation between program duration in weeks and ES (r=-.62, P=.03). Variations in interventions and outcomes and methodological limitations mean that results must be viewed with caution.
  
  
  CONCLUSIONS
  This review suggests that balance may improve through exercise interventions, but that the magnitude of the improvements achieved in existing programs may not be sufficient to impact falls outcomes. Supporting participants to achieve an appropriate intensity of practice of highly challenging balance activities appears to be critical to maximizing effectiveness.
authors.affiliation: School of Health Professions, Plymouth University, Devon, United Kingdom. Electronic address: hilary.gunn100@plymouth.ac.uk.
authors.forename: Hilary
authors.initials: H
authors.lastname: Gunn
authors.affiliation: Northern Devon Healthcare Trust, Devon, United Kingdom.
authors.forename: Sophie
authors.initials: S
authors.lastname: Markevics
authors.affiliation: School of Health Professions, Plymouth University, Devon, United Kingdom.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Haas
authors.affiliation: School of Health Professions, Plymouth University, Devon, United Kingdom.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Marsden
authors.affiliation: School of Health Professions, Plymouth University, Devon, United Kingdom.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Freeman
mesh_terms: D000056:Accident Prevention; D000058:Accidental Falls / Q000517:prevention & control*; D000328:Adult; D006801:Humans; D009103:Multiple Sclerosis / Q000503:physiopathology* / Q000534:rehabilitation*; D026741:Physical Therapy Modalities; D004856:Postural Balance / Q000502:physiology*
keywords: Accidental falls; Exercise therapy; Multiple sclerosis; Physical therapy modalities; Postural balance; Rehabilitation; Review, systematic