Gait Re-education in Multiple Sclerosis(MS)

Original Editor - Eugenie Lamprecht Top Contributors - Eugenie Lamprecht, Mohamed A Hassanin, Kim Jackson, Uchechukwu Chukwuemeka and Blessed Denzel Vhudzijena

Introduction

Multiple Sclerosis (MS) is an autoimmune disorder that causes chronic inflammation that affects the central nervous system (CNS). It can lead to severe disability as it affects motor-, sensory -, automatic- and neurocognitive function. About 1 million individuals suffer from MS in the USA alone and seems to be more common in individuals between 20-50 years of age. Women are also 3 times more likely to develop MS than men.

Individuals with MS mainly present with the following symptoms;

• Muscle weakness,
• Sensory disturbances,
• Spasticity, and
• Ataxic movement patterns.

Characteristics of the gait patterns of individuals with MS

Researches reported various gait parameters changes with people living with MS (PwMS). Spatiotemporal parameters such as gait speed, step length and/or stride length are lowering among PwMS and their reductions increase with disease severity while the step width increases .

Kinematic analyses show increase in the pelvic tilt and hiking during walking accompanied by reduction in hip maximal extension in stance as well as knee flexion in swing while both of ankle dorsiflexion in early stance and planterflexion in late stance are dropping down.

These kinematic findings are supported by kinetic and electromyographic lower limb changes e.g. decrease in the hip extensor moment in midstance as well as in ankle power during push off phase, increase in rectus femoris muscle activation throughout the gait cycle.

Individuals with MS may present with gait ataxia, which increase their risk of falling and affect their independence with locomotive tasks.

The severity is dependent on the extent of impairments present. These impairments may often lead to compensatory gait patterns such as;

• Swing phase: Circumduction and vaulting during the swing phase in order to ensure toe clearance
• Stance phase: Hyperextension of the knee in order to compensate for reduced passive ankle dorsiflexion range of motion (ROM) or due to spastic quadriceps or paretic hamstrings.
• Lateral sway of trunk
• Uncoordinated movements
• Reduced gait stability and balance
• Head sway

These compensatory gait patterns are commonly due to underlying weakness and restricted joint ROM and contractures.

Common outcome measures such as the timed-up-and-go or the six-minute walk test (6MWT) are great for assessing functional mobility but are limited when assessing the quality of gait. Assessing the quality of the individual’s gait pattern is highly dependent on the observer.

Physiotherapy Management

Early detection of gait abnormalities targeted rehabilitation interventions to address the underlying primary gait restrictions that cause gait impairments and not the compensatory patterns. Physiotherapy management in MS gait includes restorative and compensatory approaches in which restoring the normal function is the primary goal but preventing different complications using external tools e.g. orthoses is also considered.

Restorative approach aims to:

• control muscle tone.
• regain range of motion.
• improve muscle strength.
• enhance balance and coordination.
• increase sensory awareness.
• functional training.

Tone & Spasticity

• Passive sustained stretches.
• Joint compressions and weight-bearing
• Positioning
• Strengthening synergistic muscles
• Orthoses

Range of motion (ROM)

One of the main reasons for the presence of ataxic gait patterns among individuals with MS is due to contractures in the joints. By maintaining or improving joint ROM, compensatory patterns may be prevented.

• Passive ROM movement conducted by the physiotherapist.
• Active & active-assisted ROM exercises conducted by physiotherapists and individuals with MS.
• Stretching.

Strength

By improving trunk and general lower limb strength, especially active dorsiflexion, compensatory patterns may be prevented. Resistance training is also proven to effectively improve gait patterns among individuals with MS.

• Isometric-, eccentric- and concentric strengthening exercises.
• Resistance training (elastic bands, weights).

Balance & Coordination

Improving balance and coordination is essential for safe and independent mobility. Balance training can improve proprioceptive training and vice versa. These interventions can be used to improve balance:

• Double leg standing with changing width base of support (till reaching single leg standing).
• Balance exercises on wobble boards, balance pads and cushions.
• Balance exercises using the Biodex balance system.

Sensory & proprioceptive retraining

Sensory and proprioceptive retraining is important in order to effectively improve balance and reduce the risk of falling.

• Brush therapy (using different textures and lightly brushing over affected and unaffected surfaces on the skin).
• Mirror therapy (4 to 6 times per day).
• Recognizing and discriminating different shapes and sizes of objects.
• Seated and standing ankle ball proprioceptive exercises with and without support.

Functional training

1. Treadmill training: Body-weight supported treadmill training (BWSTT) is also proven to effectively improve gait among individuals with MS.
2. Hydrotherapy is proven to effectively treat pain among individuals with MS as well as ROM, strengthening and functional training among individuals suffering from neurological conditions such as MS.
3. Virtual Reality.
   

   VR gait training
4. Robotic-assisted gait training improves endurance and balance. It's also proven to reduce depression and therefore improve quality of life (QoL)

Conclusion

People living with MS experience many gait deviations at every disease stage whatever the severity or the progression type that's why it is important to corporate different types of training and methods to re-educate PwMS how to walk with the least energy expenditure and highest stability. Evidence encourages exercises and functional training whatever their types over other physiotherapy methods to improve gait among PwMS.

Related pages

• Gait.
• Gait analysis.
• Gait deviations in Neurological disorders.
• Guidelines for Adults with Multiple Sclerosis (MS).

References