Can People with MS Improve Their Walking?
by George Kraft, MD
|When new patients come to see me, they never say, Please fix my T-cells. They tell me theyre tripping and falling and ask if anything can be done. The answer is yes.
I first need to find out what the problem is: Is it weakness, spasticity (muscle tightness), ataxia (loss of balance), fatigue, impairment of proprioception (the inability to identify where the foot is in space), or a combination? Is it in one limb or in both?
Many people (and some therapists) immediately think brace when they see leg weakness. But that may not be the best choice. A person may actually have adequate strength, but spasticity in the ankle region is getting in the way. Tightness related to spasticity can prevent the person from bringing the toes up high enough for a smooth step forward.
A form of MS fatigue may also be involved. The persons legs are sufficiently strong but become fatigued after a few minutes of walking. This muscle fatigue, which is related to altered nerve conduction, may be severe enough to cause tripping or falling.
Spasticity can usually be controlled with medication, with careful attention to dosing. Too much medication reduces spasticity but makes the limbs floppy; too little and the limb is painfully tight. Also, the dose may need to be readjusted temporarily due to factors such as cold weather or infection. Since spasticity can also change from time to time, the person should be evaluated periodically, and the dose adjusted accordingly.
If impaired balance is involved, the person will need his or her base of support broadened by the use of a cane or a walker.
Many physical therapists have learned about techniques for improving walking primarily through work with patients who have had a stroke; but stroke is a fixed condition, unlike MS, which tends to progress. Those whose training is in sports medicine tend to focus on restoring strength and may not see the other MS-related components.
Heres how I usually start. Instead of prescribing braces, I advise wearing shoes that have a slippery toe section. I adjust the anti-spasticity medication and teach the patient to stretch the heel cord (sometimes called the Achilles tendon). Spasticity and lack of use can make the cord so tight that the heel doesnt go down or the toes up. Regular stretching actually remolds the muscle. [See box below.]
Weak muscles can be strengthened despite MS muscle fatigue. I recommend focused weight training, because results can be obtained with relatively low general effort. Lifting a leg 10 times with a weight on the large toe will have a positive effectbut you wont break a sweat doing it. I select one or two muscles to strengthen, which can be done with five minutes of daily work.
I will prescribe a brace if strengthening measures arent enough. Todays braces are unobtrusive, lightweight plastic. The heel cord stretch is important here, too, because a person has to get the heel down into the brace.
A cane, used properly, is superb for broadening a persons base of support. Canes are simple. There are hundreds of attractive choices, and people generally find them quite acceptable. If they still have a hard time with balance, we need to try a walker. Again, there are walkers in many designs and colors, and they help people walk safely. Finally, if a walker isnt enough, I talk about the ways in which a wheelchair can enable a person to be more mobile. The adjustment may not be easy, but the goal is mobility. A wheelchair isnt a prison. It gets you where you want to go.
People with MS tend to use different devices at different timesand sometimes they need nothing at all. Family, friends, and employers need to learn how variable MS can be.
Call your Society chapter about MS specialists in your area (1-800-FIGHT-MS). In some parts of the country there may not be any available within a reasonable distance. The average general-practice neurologist sees over a thousand people a year, only about 10 of whom have MS. Physical therapists may be similar. This means you and your family members have to become knowledgeable.
Tell your physical therapist about everything you learn from this. If the therapist immediately suggests a brace, ask to try working on function first.
Your Society chapter will have the name of an MS-affiliated clinical facility in your region. It is a good idea to consider evaluation at such a center periodically. Recommendations can be carried out by local care providers.
If your health-care professionals need more information or references to the scientific literature, they are invited to contact the Societys Professional Resource Center at HealthProf_info@ nmss.org.
H. Kraft, MD, is Professor of Rehabilitation Medicine at the University
of Washington in Seattle. He has been a member of the Societys Medical
Advisory Board for nearly 30 years and is the author (with Marci Catanzaro,
RN, PhD) of Living
with Multiple Sclerosis: A Wellness Approach,
2nd Edition, New York, Demos Medical Publishers, along with many scientific
This article originally appeared in the October-November 2005 issue of InsideMS.