Gait Disturbances in Multiple Sclerosis

Gait disturbances are among the most visible and impactful symptoms of multiple sclerosis (MS). They affect daily functioning, social life, confidence in movement, and the risk of falls. Although the mechanisms of gait impairment in MS vary, modern rehabilitation strategies and therapeutic options can significantly improve mobility and help maintain independence.

Why Does Gait Impairment Occur in MS?

Walking is a complex and finely coordinated process requiring synchronized work of the cerebral cortex, spinal pathways, peripheral nerves, muscles, and sensory systems. In MS, demyelinating lesions and axonal damage interrupt signal conduction at multiple levels.

Gait impairment in MS may present in many ways, but one of the earliest and most noticeable symptoms is foot drop. This symptom often appears even in patients who are otherwise relatively preserved. Foot drop is frequently the first sign that the pathways controlling dorsiflexion are becoming compromised.

Other mechanisms contributing to gait disturbances include:

• Muscle weakness — weakness of hip, knee, and ankle flexors and extensors;
• Coordination deficits — cerebellar ataxia, unsteadiness, “loose” or wide-based gait;
• Sensory disturbances — reduced proprioception, numbness, “cotton legs” sensation;
• Spasticity — increased muscle tone, “stiff legs,” difficulty with flexion and extension;
• Fatigue and Uhthoff’s phenomenon — worsening of walking at the end of the day, in heat, or after exertion.

How Common Are Gait Disturbances?

According to various studies, up to 80% of patients with MS experience gait impairment at some point. Even in early stages, many people notice unsteadiness, difficulty walking on uneven ground, climbing stairs, walking fast, or turning.

The most common gait manifestations include:

• Foot drop — weakness of the muscles lifting the forefoot (often the earliest and most obvious symptom in otherwise preserved patients);
• Spastic gait — legs “spring,” difficulty extending the knee, the leg swings outward in a semicircle;
• Ataxic gait — unsteadiness, oscillation of the trunk, difficulty walking in the dark or with eyes closed;
• Slowed walking speed and shorter step length — early markers of progression.

How Is Gait Evaluated in MS?

EDSS (Expanded Disability Status Scale)

Walking ability is central to EDSS scoring. Transitions between 4.0–7.0 almost entirely depend on the maximum walking distance, need for rest, and use of assistive devices.

MSFC (Multiple Sclerosis Functional Composite)

The MSFC includes the T25-FW (Timed 25-Foot Walk) — the time it takes to walk 25 feet (≈7.6 m). A ≥20% improvement in T25-FW is clinically meaningful for MS patients.

The Problem: Lack of Real-World Objective Monitoring

Traditional clinic-based tests do not always reflect real-life walking. New technologies are emerging:

• wearable sensors (accelerometers, gyroscopes);
• computerized walkways and force platforms;
• video-based gait analysis with AI algorithms;
• mobile apps tracking physical activity and gait parameters.

These technologies are not yet routine but are gradually solving the problem of objective gait monitoring and fall-risk prediction.

Foot Drop

Foot drop is one of the most frequent and early gait disturbances in MS. It may occur even in patients who otherwise feel well and lead a normal life.

Foot drop develops due to weakness of the dorsiflexor muscles (primarily the tibialis anterior) or impaired conduction along the corticospinal pathways or peroneal nerve. As a result:

• the toes “catch” the ground during swing phase;
• tripping and falls become more common, especially on uneven terrain and stairs;
• a compensatory high-stepping gait (steppage) appears;
• hip and lower back muscles become overloaded.

Correcting foot drop is a key element of MS rehabilitation because it reduces fall risk and prevents maladaptive gait patterns.

How Can Gait Be Improved in MS?

1. Medication: Dalfampridine

Dalfampridine (4-aminopyridine extended-release) is the first medication specifically developed to improve walking in MS. It blocks potassium channels and enhances conduction along demyelinated axons.

• Clinical studies show that ~35–40% of patients experience meaningful improvement in walking speed.
• T25-FW speed improves, along with endurance and subjective gait perception.
• The effect appears within days or weeks and disappears after discontinuation.

Dalfampridine requires a neurologist’s assessment due to contraindications (mainly seizure risk).

2. Rehabilitation and Assistive Devices

Rehabilitation is central to MS gait management. Evidence clearly shows which training modalities are most effective.

Strength and Functional Training

• Resistance training provides the strongest improvement in fatigue and functional capacity, especially in programs lasting more than 8 weeks.
• Aerobic exercise (walking, cycling, swimming) improves endurance and overall wellbeing.
• Balance and coordination exercises help reduce fall risk.

Foot Drop Correction: Solutions Available in Israel

Foot drop can be managed with both orthoses and functional electrical stimulation (FES):

• Dictus — a lightweight dynamic foot-lift system attached to the shoe and lower leg; often used for mild to moderate foot drop and almost invisible under clothing.
• AFO (ankle-foot orthosis) — ankle-stabilizing devices:
  • rigid plastic AFOs for severe weakness;
  • carbon-fiber spring orthoses for more physiological gait;
  • flexible “dynamic” designs for daily walking.
• Functional electrical stimulation (FES) — devices stimulating the common peroneal nerve during swing phase, producing dorsiflexion and improving foot clearance. FES has demonstrated efficacy in increasing walking speed and distance.
• Bioness L300 / L300 Go — leading FES systems. Sensors detect gait phase, and the calf cuff stimulates the nerve to lift the foot. Studies show improved walking speed and quality of life.

The choice among Dictus, AFO, and FES depends on weakness severity, degree of spasticity, lifestyle, and goals. A combined approach is often optimal.

Hippotherapy and Other Specialized Approaches

Hippotherapy (riding-based therapy or horse-movement simulation platforms) has demonstrated improvements in balance, gait, spasticity, and quality of life in both pilot and randomized studies.

Additional methods include:

• robot-assisted gait training (Lokomat-type systems and exoskeletons);
• pool exercise for reduced joint loading and easier movement;
• yoga and gentle stretching, effective for fatigue and balance.

3. Spasticity Management — Balancing Movement and Stability

Spasticity is a common cause of gait impairment in MS. It may hinder movement (foot inversion, difficulty extending the knee) but sometimes provides needed support for standing.

Treatment options include:

• oral medications (baclofen, tizanidine, etc.);
• physiotherapy, stretching, orthoses;
• botulinum toxin injections into overactive muscles to improve gait pattern.

Important: excessive tone reduction may decrease weight-bearing ability. Therefore, botulinum toxin treatment must be carefully tailored to maintain stability while improving gait.

Future Directions: Exoskeletons, Neurointerfaces, and Artificial Intelligence

Exoskeletons and Robotic Walking

Stationary robotic systems and wearable exoskeletons are already used in major rehabilitation centers. They help:

• train correct gait patterns safely;
• increase range of motion;
• reduce spasticity and strengthen muscles;
• maintain motivation through objective progress tracking.

Neurointerfaces and “Brain Chips”

Research on invasive and non-invasive neurointerfaces (including projects similar to Neuralink) has already enabled partial movement restoration in spinal cord injury. For MS, potential directions include:

• spinal pathway electrical modulation;
• bypass of demyelinated segments via neuroprosthetics;
• cortical signal decoding with direct muscle or nerve stimulation.

Artificial Intelligence for Gait Analysis

Computer-vision algorithms can now extract dozens of gait parameters from video. In the future this may allow:

• earlier detection of gait deterioration;
• individualized rehabilitation and FES planning;
• prediction of fall risk and disability progression.

What Can Patients Do Right Now?

• Discuss gait evaluation (EDSS, T25-FW, other tests) and the possibility of dalfampridine therapy with a neurologist.
• Consult a rehabilitation specialist or physiotherapist for personalized exercise planning.
• Assess the need for orthoses or FES (Dictus, AFO, Bioness, etc.).
• Check for spasticity and discuss treatment options, including botulinum toxin therapy.
• Ensure a safe home environment: remove loose rugs, secure cables, improve lighting.
• Avoid overheating and plan activities with fatigue in mind.
• Maintain regular physical activity — individually adapted and supervised.

With properly selected therapy and rehabilitation, many gait disturbances in MS can be significantly reduced, improving quality of life.

Key References

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3. Cameron MH, et al. Dalfampridine improves walking speed, walking endurance, and community participation in veterans with multiple sclerosis: a longitudinal cohort study. Mult Scler. 2014;20(6):733–738. DOI: 10.1177/1352458513507356.
4. Barrett CL, Mann GE, Taylor PN, Strike P. A randomized trial to investigate the effects of functional electrical stimulation and therapeutic exercise on walking performance for people with multiple sclerosis. Mult Scler. 2009;15(4):493–504. DOI: 10.1177/1352458508101320.
5. Miller L, et al. Functional electrical stimulation for foot drop in multiple sclerosis: a systematic review and meta-analysis. J Rehabil Med. 2017;49(6):c. DOI: 10.2340/16501977-2136.
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7. Motl RW, Gosney JL. Effect of exercise training on fatigue in multiple sclerosis: a meta-analysis. Mult Scler. 2011;17(6):681–693. DOI: 10.1177/1352458511401120.
8. Oken BS, et al. Randomized controlled trial of yoga and exercise in multiple sclerosis. Neurology. 2004;62(11):2058–2064. DOI: 10.1212/01.WNL.0000129534.88602.5C.
9. Vermöhlen V, et al. Hippotherapy for patients with multiple sclerosis (MS-HIPPO): a multicenter randomized controlled trial. Mult Scler. 2017;23(5):e-pub ahead of print. DOI: 10.1177/1352458517721354.
10. Koutra C, Malliou VJ, Liga M, Daskalaki K, Stefanakis M. Hippotherapy and exercise in multiple sclerosis: effects on gait, fatigue, and quality of life. Int J Human Movement and Sports Sciences. 2025;13(4):889–900. DOI: 10.13189/saj.2025.130425.