<strong>June</strong> 20<strong>09</strong>KUWAIT MEDICAL JOURNAL 137Fig. 2: Represents dynamic posturography after treatment in MS patients (CES = 60%).DISCUSSIONBalance problems and falls are common inpeople with MS but their cause and nature are notwell understood. It is known that MS affects manyareas of the central nervous system that can impactpostural responses to maintain balance, includingthe cerebellum and the spinal cord [13] . Ambulatorypatients with MS frequently present with poorbalance [14] .Our data demonstrate that there was a statisticallysignificant increase of BBS and CES after treatmentas compared to results before treatment. Also, astatistically significant increase in static and dynamicbalance functions was observed after treatment ascompared to results before treatment. These datasuggest that good balance control after treatmentcould be explained by changes of the somatosensorysystem rather than vestibular and/or visual systemsand the CDP can provide a useful tool for quantitativedetection of imbalance in patients with MS.This study agrees with other studies. Cha et alreported that BBS showed statistically significantimprovement in functional status in patientswith MS [15] . Dalla et al studied treatment that wasbased on postural feedback on standing balanceplatform. After rehabilitative treatment the clinicaland functional finding and standing balance wasimproved [16] . CDP facilitates measurement ofstanding balance and permits a quantificationof the role of proprioception, vision and thevestibular system in the maintenance of standingbalance [17] .Jackson et al studied twenty-seven patients withmild MS by CDP. They found poor performance ofbalance which probably indicates a disruption of theintegration of visual, vestibular, and somatosensoryinformation in MS. Although patients with earlyMS and patients with purely vestibular disordersoften have similar complaints, they have quitedifferent profile of abnormalities in posturographytesting [18] .
138Effects of Visual Feedback Balance Training by Using Computerized Dynamic Posturography...<strong>June</strong> 20<strong>09</strong>Balance deficits in people with MS appear tobe caused by somatosensory and not by cerebellarinvolvement in some MS patients [13] . Some MSpatients had a vestibular dysfunction pattern ora combined visual-vestibular or somatosensoryvestibularimpairment. Posturography mightserve as one method to evaluate the functionalconsequences of a vestibular deficit in patients withMS [19] .In our study, we found impaired balance inpatients with relapsing remitting multiple sclerosis(RRMS). But other authors found that balance in MSpatients is impaired in RRMS, secondary progressiveMS (SPMS) and primary progressive MS (PPMS).There were some differences of balance betweenprevious groups in all the balance tests [20] .Some authors found balance impairmentsincluding minimal balance deficits of the BBS andimpaired center of pressure displacement duringstanding in MS [7] . Achiemere suggests that dynamicposturography can provide useful diagnosticinformation in patients with balance disturbances inMS patients [21] .In contrast to our results, Frzovic et al. reportedthat there were no differences between MS and controlgroups on the ability to maintain standing balance.There was little change in balance from morningto afternoon in participants with MS, despite anincrease in self-rated fatigue [6] . Some authors foundthe MS patients had a vestibular dysfunction patternor a combined visual-vestibular or somatosensoryvestibularimpairment [19] . There is a disruption of theintegration of visual, vestibular, and somatosensoryinformation in patients with early MS and patientswith purely vestibular disorders in posturographytesting in MS [18] .One possible explanation for our findings is thatthe CNS damage, caused by MS is supposed to reflectsome change in the structure of the posture controlsystem such as the impairment of the somatosensorysystem, rather than a specific lesion of vestibularand / or visual modalities [22] . Jackson et al foundpoor performance of balance and abnormalities inposturography testing which indicates a disruptionof the integration of somatosensory, visual orvestibular information in MS [18] .This study briefly describes the results of ourexperience in visual feedback training by usingthe dynamic posturography for MS patients. Thisstudy also represents the first attempt in Kuwait touse the dynamic posturography equipment as anassessment tool to study the effect of visual feedbacktraining in MS patients. Further research in use of theposturography equipment is needed to study variousmechanisms of balance dysfunction in patients withMS.LimitationsThe small number of the study subjects may havesome influence on the outcome and the authors arecontinuing the study by adding more subjects.ACKNOWLEDGMENTSWe acknowledge the help of our colleagues inthe Physical Medicine and Rehabilitation Hospital,Kuwait for their assistance in this study.REFERENCES1. Williams NP, Roland PS, Yellin W. Vestibularevaluation in patients with early multiple sclerosis.Am J Otol 1997; 18:93-100.2. Noseworthy JH, Lucchinetti C, Rodriguez M,Weinshenker BG. Multiple sclerosis. N Engl J Med2000; 343:938-952.3. Shumway-Cook A, Woollacott M. Motor Control:Theory and practical applications. Baltimore,Lippincott Williams and Wilkins, 2001; p163-191.4. Lanska DJ, Goetz CG. Romberg’s sign: development,adoption, and adaptation in the 19th century.Neurology 2000; 55:1201-1206.5. 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