Gait Re-education in Multiple Sclerosis(MS)

Original Editor - Eugenie Lamprecht Top Contributors - Eugenie Lamprecht

Introduction

Multiple Sclerosis (MS) is an autoimmune disorder which 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[1]. About 1 million individuals suffer from MS in the USA alone and seem to be more common in individuals between 20-50 years of age. Women are also 3 times more likely to develop MS than men[2].

Individuals with MS mainly present with the following symptoms;

  • Muscle weakness,
  • Sensory disturbances,
  • Spasticity, and
  • Ataxic movement patterns[3].

Characteristics of the gait patterns of individuals with MS

Individuals with MS often present with gait ataxia[4], which may 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;

  • Reduced gait speed
  • Swing phase: Circumduction and vaulting during 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)
  • 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[5].

Common outcome measures such as the timed-up-and-go or the six-minute walk test (6MWT) are great to assess 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[5].

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[5].

1. Tone & Spasticity

  • Passive sustained stretches
  • Joint compressions and weight-bearing
  • Positioning
  • Strengthening synergistic muscles
  • Orthoses[6]

2. 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 ankle joints. By maintaining or improving joint ROM, compensatory patterns may be prevented[5].

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

3. Strength

By improving trunk and general lower limb strength, especially active dorsiflexion, compensatory patterns may be prevented[5]. Resistance training is also proven to effectively improve gait patterns among individuals with MS[7].

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

[2]


4. Balance & Coordination

Improving balance and coordination is essential for safe and independent mobility[10].

[11]

5. Sensory & proprioceptive retraining

Sensory and proprioceptive retraining is important in order to effectively improve balance and reduce the risk of falling[10].

  • Brush therapy (using different textures and lightly brush 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.[12]

6. Treadmill training

Body-weight supported treadmill training (BWSTT) is also proven to effectively improve gait among individuals with MS.[13]

7. Hydrotherapy

Hydrotherapy is proven to effectively treat pain[14] among individuals with MS as well as ROM, strengthening and functional training among individuals suffering from neurological conditions such as MS[15].

8. Robotic-assisted gait training

More and more research is indicating the effectiveness of robotic-assisted gait training especially because it improves endurance and balance. It's also proven to reduce depression and therefore improve quality of life (QoL)[16]

[17]

References

  1. Sospedra M, Martin R. Immunology of multiple sclerosis. Annu. Rev. Immunol.. 2005 Apr 23;23:683-747.
  2. National Multiple Sclerosis Society. Who gets MS (epidemiology)
  3. Straudi S, Fanciullacci C, Martinuzzi C, Pavarelli C, Rossi B, Chisari C, Basaglia N. The effects of robot-assisted gait training in progressive multiple sclerosis: a randomized controlled trial. Multiple Sclerosis Journal. 2016 Mar;22(3):373-84
  4. Kelleher KJ, Spence W, Solomonidis S, Apatsidis D. The characterisation of gait patterns of people with multiple sclerosis. Disability and rehabilitation. 2010 Jan 1;32(15):1242-50.
  5. 5.0 5.1 5.2 5.3 5.4 Psarakis M, Greene DA, Cole MH, Lord SR, Hoang P, Brodie M. Wearable technology reveals gait compensations, unstable walking patterns and fatigue in people with multiple sclerosis. Physiological measurement. 2018 Jul 13;39(7):075004.
  6. Elbasiouny SM, Moroz D, Bakr MM, Mushahwar VK. Management of spasticity after spinal cord injury: current techniques and future directions. Neurorehabilitation and neural repair. 2010 Jan;24(1):23-33.
  7. Gutierrez GM, Chow JW, Tillman MD, McCoy SC, Castellano V, White LJ. Resistance training improves gait kinematics in persons with multiple sclerosis. Archives of physical medicine and rehabilitation. 2005 Sep 1;86(9):1824-9
  8. The MS Gym. Introduction to Strength Training For MS. Available from:https://www.youtube.com/watch?v=yDGWZxJyFA4 [last accessed 5/21/2020]
  9. MS Society. Simple seated exercise workout | Move more with MS. Available from: https://www.youtube.com/watch?v=OYp61i_y4VQ [last accessed 5/21/2020]
  10. 10.0 10.1 Gunn H, Markevics S, Haas B, Marsden J, Freeman J. Systematic review: the effectiveness of interventions to reduce falls and improve balance in adults with multiple sclerosis. Archives of physical medicine and rehabilitation. 2015 Oct 1;96(10):1898-912.
  11. MS Society. Improve your balance and stability workout | Move more with MS. Available from: https://www.youtube.com/watch?v=0DTnlCCxS7s [last accessed 5/21/202]
  12. Phillips C, Blakey G, Essick GK. Sensory retraining: a cognitive behavioral therapy for altered sensation. Atlas of the oral and maxillofacial surgery clinics of North America. 2011 Mar 1;19(1):109-18.
  13. Pilutti LA, Lelli DA, Paulseth JE, Crome M, Jiang S, Rathbone MP, Hicks AL. Effects of 12 weeks of supported treadmill training on functional ability and quality of life in progressive multiple sclerosis: a pilot study. Archives of physical medicine and rehabilitation. 2011 Jan 1;92(1):31-6
  14. Castro-Sánchez AM, Matarán-Peñarrocha GA, Lara-Palomo I, Saavedra-Hernández M, Arroyo-Morales M, Moreno-Lorenzo C. Hydrotherapy for the treatment of pain in people with multiple sclerosis: a randomized controlled trial. Evidence-based complementary and alternative medicine. 2012;2012.
  15. Geytenbeek J. Evidence for effective hydrotherapy. Physiotherapy. 2002 Sep 1;88(9):514-29.
  16. Straudi S, Fanciullacci C, Martinuzzi C, Pavarelli C, Rossi B, Chisari C, Basaglia N. The effects of robot-assisted gait training in progressive multiple sclerosis: a randomized controlled trial. Multiple Sclerosis Journal. 2016 Mar;22(3):373-84.
  17. Cleveland Clinic. Multiple Sclerosis Patients May Walk Easier With Robotic Device. Available from: https://www.youtube.com/watch?v=ORZTsg6ZvWg [last accessed 5/21/2020]