Gait In Multiple Sclerosis

Objective
To evaluate the correlation between Gait speed and strength in Multiple Sclerosis (MS) with particular regard to patients presenting with Proprioceptive Loss.

Methods
Gait evaluation and IsoKinetic testing of muscular function were performed in 20 patients with unaided Gait (Expanded Disability Status Scale < 6).

Patients were separated into two groups in relation to the occurrence of SomatoSensory involvement: Pyramidal group (8 patients) and Sensory-Pyramidal group (12 patients).

Ten healthy subjects of similar age, sex, and height constituted a control group to evaluate Gait parameters.

Results
In the whole patient group, Gait speed was reduced and strongly related to Hamstring peak torque but not with Quadriceps peak torque.

The Gait speed and peak torques of Quadriceps and Hamstrings were similar in both groups of patients.

However, in the patients with Proprioceptive Loss there was both a strong correlation between Gait speed and Hamstring torque and a significant correlation with Quadriceps torque. In the Pyramidal group there was poor or no correlation.

Conclusion
In patients with undifferentiated MS there is some correlation between Gait speed and muscle strength.

In the case of Sensory Loss, a higher contribution of both Flexor and Extensors of the lower limbs was observed, suggesting that muscular compensation occurred in this situation to maintain Gait speed.

These results are relevant to assess rehabilitation modalities in MS.

Subclinical evidence of Gait abnormalities were identified in a group of seven patients with Multiple Sclerosis, EDSS scored 0 - 2, without functional limitations.

A movement analysis technique was used to identify Gait parameters indicative of Impaired Motor Function during Walking.

Abnormalities related primarily to Time-Distance Parameters were identified regardless the severity of the clinical score:

1. Reduced Speed Of Progression
   • Shorter Strides
   • Prolonged Double Support Phase
2. Muscular Function
   • Premature Recruitment Of Gastrocnemius
   • Late Relaxation of Tibialis Anterior during Stance Phase

The Gait analysis procedure was able to provide the clinician with evidence of Motor abnormalities prior to functional disturbance observable by a trained physician.

These minimal dysfunctions may have resulted from Reflex Mechanisms impaired by Delayed Transmission through long loop pathways or else as a result of a nonspecific Protective Gait strategy to improve Balance Control.

The technique described in this study may be useful to identify earlier starting points for follow-up and PhysioTherapy.

Multiple Sclerosis, seems to be a rare disease however in the population herein studied it is similar to the one described by others, in Brazil and abroad.

We studied 50 patients classified according Poser's Criteria that were followed at the Dept of Neurology UNIFESP-EPM from 1983 to 1995. The clinical findings of these 50 patients were similar to those described in other series.

We found a high prevalence among female young patients who presented Relapsing/Remitting evolution. The most common symptoms were those related to Pyramidal and Cerebellar Dysfunctions.

The EDSS score seems to be worse in patients with specific Cerebellar and Pyramidal Signs, higher number of relapses and longer time of disease but it is not related to the number of White Matter lesions found at MRI.

The objective of this study was to examine the relationships between continuous measures of Ambulatory Impairment in MS patients and their ordinal counterparts. Much of the disability caused by MS is due to Ambulatory Impairment.

The Expanded Disability Severity Scale (EDSS) and the Ambulation Index (AI) are ordinal measures of MS severity based largely on the Maximal Distance subjects can walk (Dmax) and the time to walk 8 m (T8), respectively.

At EDSS levels 6.0 to 7.0 and AI levels 3 to 6, scores are defined more by the use of ambulatory aids, rather than by Dmax or T8. We determined Dmax (up to 500 m), T8, the EDSS score, and the AI in 237 ambulatory MS patients.

The maximal distance subjects could walk and T8 were strongly related to their ordinal counterparts (Spearman r = 0.65 and 0.91, respectively), but the continuous measures showed considerable variability within EDSS and AI levels that the ordinal scales did not reflect.

Most of the variability occurred at EDSS levels 6.0 to 7.0 and AI levels 3 to 6. Because the use of an aid did not clearly predict Dmax or T8.

Many patients in these ranges had better ambulatory function based on the continuous measures than those with less disability according to the ordinal scales.

We found that Dmax and T8 provide more precise information about Ambulatory Impairment in MS than do the EDSS and AI.

Allowing better discrimination of differences between patients and potentially greater sensitivity to detect therapeutic effects in clinical trials.

Introduction
Recent studies have focused on correlation between strength and Gait parameters in Hemiplegia, suggesting the interest for strength training in patients with Central Nervous System lesions.

The aim of this study was to evaluate this correlation in Multiple Sclerosis (MS) patients with special regard to the different clinical forms including Proprioceptive loss or Cerebellar Ataxia.

Patients And Method
Gait speed and muscular function were performed in 27 patients with moderate affected Gait (EDSS < 6). Gait speed was evaluated with Locometre and peak-torques of quadriceps and hamstrings were evaluated with isokinetic dynamometer.

Patients were separated in three groups related to their deficiency: Spastic group (8 patients), Spastic with Proprioceptive loss (12 patients) and spastic with Cerebellar Ataxia (7 patients). Gait parameters were evaluated in 10 healthy subjects as control group.

Results
Gait speeds (spontaneous and maximal) and peak torques of quadriceps and hamstring were similar in the three groups.

In the whole patients group, Gait speed was reduced and related to hamstring peak torque (r = 0.56 at spontaneous speed and 0.51 at high speed) but not with quadriceps peak torque.

Patients with Proprioceptive loss exhibited not only a higher correlation between Gait speed and hamstring torque (r = 0.76 and 0.65 respectively) than other patients but also with quadriceps torque (r = 0.66 and 0.59 respectively) when patients in other groups did not.

Conclusion
As it was previously pointed out in Hemiplegic patients, MS patients exhibit some correlation between Gait speed and muscle strength, mainly with hamstrings.

These correlations can change in special sensory conditions suggesting that patients with sensory loss use different muscular strategies to maintain Gait speed.

Strength training may therefore be discussed in MS including specific modalities as a function of clinical parameters.

Objective
To evaluate the impact of rehabilitation on Balance, Gait and Strength in inpatients with Multiple Sclerosis (MS).

Methods
Twenty-one in patients with MS benefited from a program of rehabilitation with evaluation before and after rehabilitation.

Balance was assessed by stabilometry, walking speed with use of a locometer device and maximal peak torque of knee extensor and flexor with use of an Isokinetic Dynamometer at 60 degrees speed.

The Functional Independence Measure (FIM) was also applied before and after rehabilitation.

Results
After rehabilitation, patients showed significant improvement in Balance with opened and closed eyes, velocity gait, strength of the lower quadriceps and the higher hamstrings and FIM values.

Absolute values of Gait speed and Strength parameters were related as were improvement in velocity speed and the higher hamstrings.

Conclusion
The results are encouraging and confirm the interest and tolerance of a program of rehabilitation among patients with MS.

This study evaluated the Gait and Balance performance of two clinically distinct groups of recently diagnosed and minimally impaired Multiple Sclerosis (MS) patients:

(Expanded Disability Status Scale range 0-2.5), compared to control subjects.

Ten MS patients with mild Pyramidal Signs (Pyramidal Functional Systems 1.0), 10 MS patients with no Pyramidal Signs (Pyramidal Functional Systems 0) and 20 age.

And gender-matched control subjects were assessed using laboratory-based Gait analysis and clinical Balance measures.

Both MS groups demonstrated reduced speed and stride length (P < 0.001), and prolonged double limb support (P < 0.02), compared to the control group.

Along with alterations in the timing of ankle muscle activity, and the pattern of ankle motion during walking, which occurred independent of Gait speed.

The Pyramidal MS group walked with reduced speed (P = 0.03) and stride length (P = 0.04), and prolonged double limb support (P =0.01), compared to the Non-Pyramidal group.

Both MS groups demonstrated concomitant Balance Impairment, performing poorly on the Functional Reach Test compared to the control group (P < 0.05).

The identification of incipient Gait and Balance Impairment in MS patients with recent disease onset suggests that motor function may begin to deteriorate in the early stages of the disease, even in the absence of clinical signs of pyramidal dysfunction.

Curr Neurol Neurosci Rep 2010 Sep;10(5):407-12

Postural control in Multiple Sclerosis: implications for fall prevention. Cameron MH, Lord S
Department of Neurology, Oregon Health and Science University, CR120, Portland, OR 97239, USA People with Multiple Sclerosis (MS) often have poor postural control, which likely underlies their increased risk of falls. Based on several studies of balance and gait in MS, it appears that the primary mechanisms underlying the observed changes are slowed Somatosensory Conduction and impaired central integration. This review of the published research on balance, gait, and falls in people with MS demonstrates that people with MS have balance impairments characterized by increased sway in quiet stance, delayed responses to postural perturbations, and a reduced ability to move toward their limits of stability. These impairments are likely causes of falls in people with MS and are consistent with the reduced gait speed, as well as decreased stride length, cadence, and joint movement, observed in most studies of gait in MS. Based on these findings, we identify several factors that may be amenable to intervention to prevent falls in people with MS.

Somatosens Mot Res 2008;25(2):113-22

Imbalance in multiple sclerosis: a result of slowed Spinal SomatoSensory Conduction

Cameron MH, Horak FB, Herndon RR, Bourdette D
Oregon Health & Science University, Department of Neurology, Portland, OR 97239-3098, USA

Balance problems and falls are common in people with Multiple Sclerosis (MS) but their cause and nature are not well understood.

It is known that MS affects many areas of the Central Nervous System that can impact Postural Responses to maintain balance, including the Cerebellum and the Spinal Cord.

Cerebellar Balance Disorders are associated with normal latencies but reduced scaling of Postural Responses.

We therefore examined the latency and scaling of Automatic Postural Responses, and their relationship to SomatoSensory Evoked Potentials (SSEPs), in ten people with MS and imbalance and ten age-, sex-matched, healthy controls.

The latency and scaling of postural responses to backward surface translations of five different velocities and amplitudes, and the latency of Spinal and Supraspinal Somatosensory Conduction, were examined.

Subjects with MS had large, but very delayed Automatic Postural Response Latencies compared to controls (161 +/- 31 ms vs. 102 +/- 21 ms, p < 0.01) and these postural response latencies correlated with the latencies of their Spinal SSEPs (r = 0.73, p < 0.01).

Subjects with MS also had normal or excessive scaling of postural response amplitude to perturbation velocity and amplitude.

Longer Latency Postural Responses were associated with less velocity scaling and more amplitude scaling.

Balance deficits in people with MS appear to be caused by slowed Spinal SomatoSensory Conduction and not by Cerebellar involvement.

People with MS appear to compensate for their slowed spinal SomatoSsensory Conduction by increasing the amplitude scaling and the magnitude of their postural responses.

Neurol Res. 2006 Jul;28(5):555-62. Balance performance in three forms of multiple sclerosis. Soyuer F, Mirza M, Erkorkmaz U. Halil Bayraktar Health Services Vocational College, Erciyes University, Kayseri, Turkey. soyuerf@erciyes.edu.tr Abstract OBJECTIVES: To compare and document balance performance between patients with multiple sclerosis (MS) and healthy control subjects and balance performance among patients with different MS forms using a set of clinical balance tests. MATERIAL AND METHODS: Twenty eight primary progressive (PPMS), 34 secondary progressive (SPMS), and 62 relapsing remitting (RRMS), totalling 124 MS patients were included in the present study. Results from patients were compared with those of 31 healthy control subjects matching in age, gender, weight and height. Ashworth scale, mini-mental state examination and motricity index were used consecutively to evaluate spasticity, cognitive impairment and lower extremity muscle strength. Vision, sensation, proprioception, cerebellar and vestibular tests were also performed on the patients. The balance performance was evaluated using a set of clinical tests including steady stance tests (eyes in opened and closed positions, feet apart, feet together, stride stance, tandem stance and single stance), self-generated perturbations (functional reach, arm raise and step test), external perturbations, Tinetti-gait and 10 m gait time tests. RESULTS: There were no differences in age, sex, weight, height, sense impairment and lower extremity strength in patients with the three MS forms (p>0.05). No difference was found among patients with the three MS forms and the control subjects in the test of eyes closed with feet apart (p>0.05). The PPMS patients in all the balance tests except tests of eyes closed with feet apart and eyes opened with feet together, SPMS patients in all the balance tests except that of eyes closed with feet apart and RRMS patients in tandem stance, single leg stance, self-generated perturbations, external perturbations, Tinetti-gait and 10 m gait time tests had weaker balance than the control subjects (p < 0.001). There were some differences between patients in the PPMS and SPMS groups in the eyes closed and feet apart test, between patients in the PPMS and RRMS groups in all the balance tests except eyes closed and feet apart and eyes opened and feet together tests and between patients in SPMS and RRMS group in all the balance tests except right and left arm raised tests (p < 0.001). CONCLUSION: Balance in MS patients is impaired. The results of the present study show that there is more impairment in progressive MS forms than in RRMS. Meanwhile, patients with progressive MS are more likely to fall.