Life with MS

The Ambulation Equation: Exercise + Physical Therapy = Greater Mobility

By Pat Provance, PT, MSCS
One of the most expressed goals by people with MS is “to keep walking” or “to walk better.” While the focus is often on ambulation issues, many other factors affect a person’s independence and safe mobility, including movements such as sitting and standing, and getting up from the floor. 
When mobility challenges enter the picture, people with MS may become frustrated and eventually decrease their overall level of activity. This often leads to disuse weakness and deconditioning – which are preventable (and reversible).  Exercises designed to improve necessary functional skills are essential for achieving better strength, balance, and mobility. 
While exercising on your own is important, a physical therapist can provide guidance to make sure the activities you choose are suited to your abilities. If possible, everyone with MS should receive a baseline evaluation from a physical therapist experienced in MS care. Ideally this should be done soon after diagnosis – but at the very least, at the first signs of problems with balance, walking, or endurance. An evaluation can spotlight many subtle symptoms that can be addressed before they worsen into significant issues. These include: 
Fatigue/decreased endurance
Foot drop/drag (especially at the end of the day)
Weakness in leg(s) and/or trunk
• De-conditioning
• Mild spasticity (increased muscle tone, which worsens with fatigue)
• Muscle tightness from inactivity
• Compensatory movement patterns (such as “hiking” the hip or leaning to the back or side to clear the weak leg when walking)
• Problems with balance (which may include falls, “near-falls” and/or difficulty with curbs or stairs)
• Impaired vision or sensation
“Wobbly” walking 
Resolution, or better control of the above symptoms, often requires behavioral or lifestyle modifications, including wise energy management practices, corrective exercises, and compensatory strategies.
When assistance is needed
Evaluation of walking and gait training are extremely important and should be done both at the beginning and at the end of the therapy session to gauge the effect of fatigue. If the therapy department has a variety of trial ambulation aids, they can be tested to see which (perhaps several) work best.
Many people with MS are initially reluctant to accept a walking aid and often delay going to therapy. Common reasons include: “I know they’ll want me to use a cane”, “if I start using an aid, I’ll be dependent on it”, “people will stare at me”, or “it means that my MS is getting worse!”  
Behavior modification and attitude adjustment can be difficult at first, but are essential to proactive success in improving functional ambulation. Ambulation aids should be regarded as “tools” that have the potential to normalize one’s walking pattern. This can result in less fatigue, improved posture and balance, less pain, more endurance, and correct training of the walking muscles. Other positive outcomes are improved self esteem, independence, safety, increased overall activity, and expanded participation in community activities.
Many “tools” to aid ambulation are on the market, and a professional should assess and prescribe those best suited to each person’s needs. The experienced PT can advise the physician regarding the needed prescription or letter of medical necessity. Often several aids will be prescribed to meet the varying needs for support, distance and other factors. Some of the most popular ambulation aids are:
Folding canes: The most comfortable have a “palm grip” or a cushioned handgrip.
Lightweight forearm crutches: Most people prefer full cuffs, cushioned hand-grips, and adjustable forearm lengths.
Four-wheeled rolling walkers: These are for the active community user, providing distance training and the opportunity to sit and rest when needed. Most prefer a lightweight model with 8-inch swivel wheels, a flip-up seat, no front crossbar, user friendly brakes, and a flexible backrest.
Foot drop braces: The new lightweight carbon models are popular, but expensive, and only work for certain types of foot drop. 
Functional Electrical Stimulation: This is a fairly new wireless technology that delivers electrical stimulation to pull the foot up. It is not appropriate for all cases of foot drop, is extremely expensive, and to date is rarely covered by insurance. A PT evaluation (by someone experienced in this technology) is highly recommended if you think you are a candidate.
Another consideration often overlooked is proper footwear. Shoes should be lightweight and supportive (enclosed heel), preferably with a good cushioned insole and arch support. Sneakers with rubber soles can provide stability, but may cause the foot to occasionally “stick” if foot drag or slide is an uncorrected problem.
Practice with ambulation aids to smooth the gait pattern and establish good walking habits, instead of just using them on a “bad day.” Many people who initially use their “tools” for regular training gain strength and then use them only as needed for longer distances, energy conservation, and worsening symptoms during MS flare-ups. Set reasonable goals, walk tall, and be safe!
Pat Provance, PT, MSCS, is a physical therapist and certified specialist in MS care. She practiced for more than 35 years in Baltimore, until her “semi-retirement” to Florida in late 2006. Since that time she has continued to “try to make a difference” by teaching patients and healthcare professionals around the country, consulting, and writing. In addition to being a friend of the MSF, Pat is a clinical consultant with the NMSS and on the Healthcare Advisory Council of MSAA.
(Last reviewed 2/2010)