MS Symptom Management: Gait Impairments

One of the most concerning symptoms of Multiple Sclerosis (MS) is falling or a new impairment in movement, particularly walking/gait. This is usually when people start to seek out physical therapy; they want to do everything in their power to maintain their ability to walk. There are many possible causes and gait impairments, many of which can be treated and significantly improved with physical therapy. This is why it is essential to get in with a physical therapist beforehand to catch gait impairments early and address them before they become a more significant issue. Gait can also be improved significantly with the use of a brace or assistive device in some instances. These orthotics or assistive devices may be temporary or only necessary during relapses or days with increased fatigue or other symptoms.

Types of Gait Impairments

Foot drop

This is one of the most common gait impairments for people with MS. The muscle in the front of the lower leg, the tibialis anterior, is one of the main muscles affected by demyelination in MS. Foot drop is the inability to dorsiflex (flex up) the foot to clear the toe during the gait cycle. When the foot does not dorsiflex efficiently, it can cause toe dragging, tripping, or an audible foot slap when contacting the ground. People typically compensate for foot drop by circumduction the hip (swinging the leg out to the side), vaulting (pushing up more with the strong side to be able to swing the leg through), or lateral lean (leaning to the side to swing the leg around/through). These compensations are sometimes necessary but not ideal. They can lead to muscle imbalances in the hips/core, leading to knee, hip, or back pain.

Forward flexed trunk

This gait impairment usually occurs due to tight hip flexors (in the front of your hip) and weak glutes (in the back of your hip). This imbalance leads to difficulty maintaining an upright posture, causing people to lean forward. This gait impairment can also lead to back and hip pain and is exacerbated by fatigue.

Scissor Gait:

This gait impairment is usually due to spasticity of the hip adductors (groin muscles) with or without weakness in the outer muscles of the hip. The tight hip adductors cause the leg to pull inward during gait, sometimes crossing over the middle, leading to imbalance, tripping over your own feet, and occasionally falling.

Imbalance

There are many potential causes of imbalance, both with gait or stationary movements, that we will discuss further next week. However, 1 cause of imbalance during gait is gastroc (calf muscle) spasticity, causing that jumping or muscle spasm we discussed last week.

How PT can help

The first thing that we would do when you come in for your evaluation is to thoroughly test your strength, flexibility and assess specifically for spasticity. As discussed previously, many of the gait impairments are due to these issues. Suppose we can get to the source of the problem. In that case, we can give you specific stretches or exercises to resolve muscle imbalances. On initial evaluation, we would also perform specific walking tests to look at gait speed which is a huge predictor of falls (timed 25-foot walk test, 10-meter walk test, or timed up and go test). We would also test your endurance using the 2 or 6-minute walk tests. PTs can also perform specific balance testing and training, which we will get info further next week.

Many different braces or orthotics can be used to address gait deficits, mainly if demyelination has occurred and caused partial loss of strength of a muscle. For example, ankle dorsiflexion assist braces can be used as very minimal and low profile tools to help with foot drop. These braces are appropriate for people who have foot drop but can still actively dorsiflex their foot. However, it may be weak or fatigue quickly. Ankle foot orthoses (AFO) can be used for people with no active dorsiflexion of the foot. It holds the foot into that flexed position so you can clear the toe during gait with minimal compensation. Other braces go up to the hip to assist with foot drop/weak hip flexors as well.

Assistive devices are also essential tools that we use in rehabilitation. I do find that many people are very resistant to using an assistive device; however, in many cases, they are temporary or only need to be used for energy conservation to prevent falls. For example, when a patient is doing rehab for foot drop, it may be beneficial for them to temporarily use a walker or cane to work on their gait pattern to break bad habits and prevent falls while they are getting stronger and learning. Then, of course, we can progress from a walker to a cane to nothing at all. Still, breaking the previously learned compensations is crucial, such as swinging the leg out to the side or leaning. Another example would be using a rollator for walking in the mall or going to a child's soccer game. The rollator is a walker with a seat that can be used for energy management. People can sit when needed or just have the additional support if they have to stand for long periods. All of this to say, if your physical therapist suggests using an assistive device, don't panic and try to be open. We will always do everything in our power to improve your ability to function and get you back to doing the things you love!

Exercises to Improve Gait

If you are experiencing any difficulty with your gait, it is imperative to see a physical therapist for a customized treatment plan that fits your needs. I have listed some of my favorite exercises to address gait impairments, particularly difficulty clearing the toe during gait, whether from foot drop or weak hip flexors.

Ankle, Knee and Hip flexion on a Stability Ball

Start lying down on your back with a stability ball under your foot/lower leg.

Actively flex your foot.

Slowly and with control, bend your hip and knee to roll the ball up toward you. Hold 2-3 seconds.

Keeping your foot flexed, straighten your leg back out, and then relax the foot. Repeat 10 times.

Prone Hip Extension with Knee Flexed

This exercise works on glute strength and hip mobility for extension during walking to help with that forward flexed posture. Start lying on your stomach with your knee bent to 90 degrees.

Squeeze through your glutes and lift your knee up off the floor. Your foot should move straight up toward the ceiling. Repeat 10 times. It is important to make sure your back muscles stay relaxed, don't lift your hips or twist your back.

If you have back pain, you can put a pillow under your stomach for support.

Toe Taps at Step

Perform this exercise standing somewhere that you can hold on for support if you get unsteady. Stand with your toes close to the step.

Keep an upright posture and lift one foot, tap your toe onto the first step and then repeat with the other leg. Repeat 10 times, alternating sides. The closer you are to the step, the more difficult it will be.

Hurdle Taps

If the previous exercise is too easy, you can use a hurdle or object (about 6 inches high to start). Stand with your toes close to the object.

Lift one knee up, keeping your foot flexed.

Tap just your heel down on the other side of the object.

Bend the knee and return to the starting position; repeat on the other leg. Repeat 10 times, alternating sides. Try not to lean to the side, swing your leg around the outside of the object, or fully step down on the other side; it should just be a tap with your heel.

Treatment with Medication

There is 1 medication that can be prescribed specifically for walking, Dalfampridine (Ampyra). It has been shown to improve walking speed, specifically for people with MS. If you think you could benefit from this, talk to your doctor to see if it is right for you!

Over the coming weeks, we will continue to discuss different symptoms commonly associated with MS. In addition, we will provide specific stretches, exercises, and guidance for maintenance from a physical therapy perspective. Next up will be Imbalance and Vertigo.

I also have more information on my website at: 

https://movementmatters-pt.com/multiple-sclerosis 

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Disclaimer

This blog is provided for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health providers with any questions you may have regarding a medical condition.