Gait Training in Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease that causes chronic inflammation of the central nervous system (CNS) and can lead to significant disability by affecting motor, sensory, autonomic, and cognitive function¹. Approximately 1 million individuals in the USA are affected by MS, and the disease typically begins between 20 and 50 years of age¹. Women have three times the risk of developing MS compared to men².

Symptoms in People with MS

Common symptoms include³:

• Muscle weakness

• Sensory disturbances

• Spasticity

• Ataxic movement patterns

These symptoms greatly affect gait function and increase the risk of falls and reduced independence³.

Characteristic Gait Patterns in MS

People with MS (PwMS) often have altered gait patterns, with both spatial and temporal parameters affected⁴. Typical changes include:

• Reduced walking speed

• Shorter step and stride length

• Increased step width

• Progressive deterioration with disease severity⁴

Kinematic and Kinetic Changes

Kinematic analyses show that PwMS often have increased pelvic tilt and pelvic hiking during gait, as well as reduced hip extension in stance phase and reduced knee flexion in swing phase⁵.

Additionally, reduced ankle dorsiflexion is seen in early stance and decreased plantarflexion in late stance⁵.

Kinetic and EMG data also show:

• Reduced hip extension moment in mid-stance

• Reduced ankle power during push-off

• Increased activation of the rectus femoris throughout the gait cycle, affecting normal knee motion⁵

Gait Ataxia

Gait ataxia is a common challenge in PwMS and contributes to increased fall risk and reduced independence in mobility tasks⁶. The severity of ataxia depends on the degree of motor and sensory impairment.

Compensatory Gait Patterns

PwMS often develop compensatory gait patterns due to weakness, reduced joint mobility, or contractures⁷.

During swing phase:

• Circumduction (moving the leg in an arc to advance the foot)

• Vaulting (raising the heel on the opposite side to help with foot clearance)

During stance phase:

• Knee hyperextension, often compensating for reduced ankle dorsiflexion or spastic quadriceps

• Lateral trunk lean to compensate for hip or knee instability

• Reduced gait stability and poor balance

• Head sway during walking

These patterns may be aggravated by muscular weakness, joint restriction, or contractures⁷.

Assessment of Gait Function

Although functional tests such as the Timed Up and Go (TUG) and 6-Minute Walk Test (6MWT) provide important information about mobility, they have limited value in assessing gait quality⁸.

Qualitative gait analysis largely depends on the clinician’s experience and observational skill⁸.

Physiotherapy Management in Multiple Sclerosis

Early Detection and Targeted Intervention

Early identification of gait deviations is essential to implement targeted rehabilitation focusing on primary movement impairments rather than only compensatory patterns¹.

Physiotherapy management in MS includes both restorative and compensatory approaches, aiming to normalise function. Orthoses or assistive devices may also be recommended to prevent complications¹.

Restorative Approach

Goals of the restorative approach include¹:

• Regulation of muscle tone

• Restoration of joint mobility

• Increased muscle strength

• Improved balance and coordination

• Enhanced sensory awareness

• Functional task training

Tone and Spasticity

To reduce spasticity, the physiotherapist may use²:

• Passive, prolonged stretching

• Joint compression and weight-bearing activities

• Proper positioning

• Strengthening of synergistic muscles to inhibit overactive spastic muscles

• Orthoses as needed

Range of Motion (ROM)

Contractures are a common cause of ataxic gait in PwMS³. To prevent compensatory patterns, ROM should be maintained or improved through³:

• Passive joint movements by the physiotherapist

• Active and active-assisted exercises by both therapist and patient

• Systematic stretching

Strength

Improving core and lower-limb strength, especially ankle dorsiflexion, can reduce compensatory gait⁴.

Interventions⁴⁵:

• Isometric, eccentric, and concentric strengthening

• Resistance training using bands or weights

Balance and Coordination

Balance and coordination training are essential for safe and independent mobility⁶. Proprioceptive training further enhances stability⁷.

Examples⁶⁸:

• Double-limb support with gradual reduction of base of support (progressing to single-limb stance)

• Exercises on balance pads, wobble boards, and foam surfaces

• Training using a Biodex Balance System

Sensory and Proprioceptive Training

Sensory and proprioceptive exercises can reduce fall risk and improve balance⁹¹⁰¹¹.

Examples include:

• Brushing therapy with different textures¹⁰

• Mirror therapy (4–6 sessions per day)¹⁰

• Recognition and differentiation of object shapes and sizes¹⁰

• Ankle proprioception training in sitting and standing positions, with and without support¹¹

Functional Gait Training

Functional gait training is central to optimising mobility and independence¹².

Effective interventions include¹²–¹⁵:

• Treadmill training, especially Body-Weight Supported Treadmill Training (BWSTT)

• Hydrotherapy for pain relief, ROM, strength, and function improvement

• Virtual Reality (VR)-based gait training with visual feedback and motivation

• Robot-assisted gait training, shown to improve endurance, balance, and mental wellbeing

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. Coca-Tapia M, Cuesta-Gómez A, Molina-Rueda F, Carratalá-Tejada M. Gait Pattern in People with Multiple Sclerosis: A Systematic Review. Diagnostics. 2021 Mar 24;11(4):584.

5. 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.

6. 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.

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. Tilgjengelig fra: https://www.youtube.com/watch?v=yDGWZxJyFA4 (Hentet 4. juli 2025).

9. MS Society. Simple seated exercise workout | Move more with MS. Tilgjengelig fra: https://www.youtube.com/watch?v=OYp61i_y4VQ (Hentet 4. juli 2025).

10. 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. Winter L, Huang Q, V. L. Sertic J. The Effectiveness of Proprioceptive Training for Improving Motor Performance and Motor Dysfunction: A Systematic Review [Internet]. Frontiers in Rehabilitation Sciences. Frontiers; 2022. Tilgjengelig fra: https://www.frontiersin.org/articles/10.3389/fresc.2022.830166/full#B4 (Hentet 4. juli 2025).

12. MS Society. Improve your balance and stability workout | Move more with MS. Tilgjengelig fra: https://www.youtube.com/watch?v=0DTnlCCxS7s (Hentet 4. juli 2025).

13. 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.

14. Chittrakul J, Siviroj P, Sungkarat S, Sapbamrer R. Multi-System Physical Exercise Intervention for Fall Prevention and Quality of Life in Pre-Frail Older Adults: A Randomized Controlled Trial. International Journal of Environmental Research and Public Health. 2020 Apr 29;17(9):3102.

15. 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.

16. 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.

17. Geytenbeek J. Evidence for effective hydrotherapy. Physiotherapy. 2002 Sep 1;88(9):514-29.