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Multiple Sclerosis and Walking

MS AND WALKING
GMARC46 MD (physician with MS)

The simple act of putting one foot in front of the other and taking a step may not be so simple for a person with MS. It requires intact nerve pathways to coordinate position, balance, movement and sensation to take that step. What does not require any thought at all for an unaffected individual idual now becomes a planned process for a person with MS. Prior advertising campaigns always referred to MS as "the great crippler of young adults" and showed someone in a wheelchair as their poster display. We now know that this picture does not always have to be the end result for MS. Problems with walking in MS patients can be caused by various factors some of which we can attempt to control. We refer to difficulties associated with walking as gait disturbances. With MS, the problems may arise from spasticity, sensory defects, muscle weakness or loss of balance or any combination of the above. The same disorders may affect the upper limbs, but this is less common, and of course has different consequences.

SPASTICITY

People use this term to mean many different things. If you're old enough to remember, both Milton Berle and Jerry Lewis imitated a spastic way of walking in their comedy routines. The best popular example of a really spastic way of walking was Boris Karloff as Frankenstein's monster. The legs are rigid, and are moved in a jerky manner. The lower limbs do not move easily and may have to be placed into position by using one's arms. There may be a rhythmic tremor of the leg when one is sitting while the leg is resting on the floor. This  is referred to as clonus. The leg muscles are kept somewhat contracted which is also referred to as increased muscle tone or hypertonicity. Walking with spastic muscles requires the expenditure of more energy than normal which leads to fatigue. The s simplest way of combating spasticity is by doing stretching exercises which lengthens the muscle, making it more flexible. Physical therapists can outline a program of stretching exercises which can be done every other day or more frequently depending upo n the individual. Another modality of treatment involves electrical stimulation of muscles which may be beneficial.

The medical treatment of spasticity involves the use of drugs known as skeletal muscle relaxants. The drug of choice is BACLOFEN or as it is known under its trade name Lioresal. Dosage varies with the individual, but the drug is started out at a low do se and then is increased every three days until the desired dose is achieved. Unfortunately, the side effects of the drug if too high a dose is taken include loss of balance, sleepiness and weakness indistinguishable from the symptoms of MS. BACLOFEN sh ould not be stopped abruptly. The drug is taken orally but presently there is a completed trial in which the drug is given directly into the spinal fluid. This is reserved for rather severe cases. In some instances, MS patients have come to rely upon a certain degree of spasticity to keep their muscles locked thereby assisting themselves in standing or keeping balanced. In that instance, BACLOFEN would make their gait problems worse until the proper dosage could be determined.

Other drugs used as skeletal muscle relaxants in MS include DIAZEPAM (trade name Valium) and DANTROLENE (trade name Dantrium). Valium may cause excessive sedation and physical and/or mental dependence. Dantrium may have gastrointestinal side effects an d carries the risk of liver damage. They are used if the patient cannot tolerate Lioresal and careful monitoring of the individual would be necessary.

BALANCE

A sense of balance can be best appreciated by one who has lost it. To demonstrate the delicacy of balance in MS does not require a high wire act at the circus. Walking across a carpet with a thick pile or attempting to maneuver through a park's unleveled ground is all that is needed to prove this. A sneeze constantly demonstrates Newton's Third Law of Thermodynamics. If you're not holding on to something, you might be picking yourself up off the floor. Carrying a box in one's arms throws off whatever is left of one precious balance and interferes with that seemingly minor activity.

Most physical therapists feel that exercises can help to improve balance. It may require an individual to be looking at his or her feet to make sure that one is positioning them correctly. By necessity, an MS patient with loss of balance will develop a wide-based gait to have more steadiness. The use of a cane provides a third limb, turning a person into a tripod. This helps by giving a broader base of support. Many clients use a cane outside the home where there aren't any convenient walls to provide balance. Your physical therapist can instruct you in the use of a cane as well as helping you to determine if two canes or a walker is more suitable. Wearing flat shoes instead of one with raised heels are helpful and ridding the house of throw rugs and shag carpets are good ideas. Unfortunately, I know of no medicines at present that has been shown to be of use in combating the problems of loss of balance.

WEAKNESS

It is hard to walk if you feel that your legs are encased in two cylinders of concrete. Depending upon the individual's course of disease, the weakness may occur gradually or present itself rather abruptly. In any case, the affected individual will be walking and exercising less than before. A maxim used in medicine (and other situations, I'm sure) is use it or lose it. This is certainly true for muscles. With the curtailment of exercise, muscles will waste away or atrophy which will compound the muscle weakness. The goal of exercise is not to increase muscle size but to maintain strength. This is best done at first under the supervision of your doctor and/or physical therapist. Each person's individual exercise program should take into account many factors such as the muscles that are involved, whether the person is having a relapse or not, the present level of endurance, how an exercise program fits into one's everyday activities, etc. Doing exercises in a pool is easier and allows one to work out longer before fatigue sets in. The buoyancy of the water allows an individual to be more flexible and stronger than he/she is out of water. If the pool is heated, it should not be more than 72 degrees since heat brings out fatigue and symptoms. Exercise also leads to feelings of self-worth, may provide a social outlet and improves general overall health.

Although exercise can improve strength, flexibility and endurance, there is a down side to this activity. There is a fine line separating the benefits of exercise and the problems of fatigue. You seem to have only just so much energy allotted to you for that day and if you choose to expend a portion of that energy on exercise, you will have that much less for that day or until you have had a significant rest. Therefore, some decisions have to be made. Whereas the short-term effects of exercise may lead to decreased mobility that day, the long-term effects may lead to increased endurance and muscular strength over time, thereby increasing mobility. On the days of the week that you propose to exercise, you should plan to schedule nothing major for that day. Stretching exercises are set apart from your exercise program and should be done on at least a daily basis. You will be the best judge of how much exercise is too much. As you continue your program, you will probably be able to do more and will find that it will become less difficult to achieve your goals.

SENSORY DISTURBANCES

Sensory losses cause gait disturbances in MS by not allowing you to feel the ground. To remedy this problem, one might use a cane in order to feel the ground by sensing it with your hands. Another sense that my be damaged is proprioception or position sense. If it's intact, it tells us where are our body parts are even if we cannot see them. How else would you know where to scratch your back when you have an itch there. You are also able to tell if your legs are crossed when you're sitting or if they are on the ground without looking at them. Proprioception helps us walk through a darkened room without losing our balance because of where the walls and floor are. Our vision compensates for proprioceptive loss by providing much of the same information. Unfortunately, with MS, it may become dangerous to walk and look around at the sights without losing one's balance and subsequently falling. Likewise, walking into a darkened movie theater or a room without lights at night can pose significant problems. Aids such as a cane or walker may assist in preventing injury as would a night light or flashlight for those late night trips to the bathroom.

As I have been mentioning, there are mechanical aids to assist MS patients who are having difficulty in walking, namely braces, canes, wheelchairs and scooters. Unfortunately, many individuals look upon these tools as signs of deterioration and the admission of defeat. The use of a wheelchair may be viewed as "giving in to the disease", and should be avoided at all costs. This attitude is all-too-common and all-too-self-limiting. It takes a change of outlook to look at these aids as a positive assist. Even if one can still walk, sitting down will allow you to have more energy for the rest of the day. If you have the choice to sit rather than stand, I doubt that many MS patients will prefer to remain on their feet. The same principle should apply to wheelchairs and scooters. If the opportunity presents itself, choose riding rather than walking and forget about perceived appearances. You will be able to do more things with your life. Similarly, the use of a cane which isn't as dramatic as a wheel chair, is an assist that allows you to participate in activities for a longer time and in a safer manner. The first time I used a cane wasn't that bad, but I was curious what others would think. The first time I was in a wheelchair was difficult and I was self-conscious, angry and ashamed. However, I survived it and each time was less traumatic. I am doing and seeing more now than I had done in the past two years plus I'm not as tired. Totaling up all the columns, I have definitely come out ahead. As far as braces and orthotics are concerned, they are usually prescribed by your physician and/or physical therapist to correct unstable joints caused by weakened muscles or to correct foot drop (when your toe strikes the ground before your heel.)

Not all MS patients have difficulty with gait while others cannot walk at all. Still others may have a problem that clears up over time. Twenty years after diagnosis, about 40-60% of the MS population are still ambulatory. By all means, speak to your physician if you feel that any of the above situations apply to you.