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“I am having more difficulty walking” is not a single symptom in multiple sclerosis. Walking impairment may result from weakness, spasticity, foot drop, ataxia, sensory loss, fatigue — and very often from several mechanisms at the same time.
The first question therefore should not be “Which brace should I buy?” or “Which medication should I take?” but why has walking changed? The answer determines the treatment.
Normal walking requires adequate strength, appropriate muscle tone, coordination, sensation, balance and endurance. Multiple sclerosis may affect any of these systems.
Weakness may affect hip flexion, knee extension, ankle dorsiflexion or several muscle groups at once.
Excessive muscle tone may interfere with knee flexion, foot clearance, hip movement or normal foot position.
The foot does not lift sufficiently during the swing phase, increasing the risk of tripping and falling.
Cerebellar pathway involvement may cause instability, a wide-based gait and difficulty turning.
Loss of proprioception may become particularly noticeable in darkness or on uneven surfaces.
MS fatigue and Uhthoff phenomenon may temporarily worsen walking speed, coordination and foot clearance.
| What the patient notices | Possible mechanism | What should be assessed | Possible approaches |
|---|---|---|---|
| Toe catches the ground | Foot drop, dorsiflexor weakness | Strength, spasticity, gait pattern, peripheral nerve function | AFO, FES, rehabilitation, sometimes treatment of contributing spasticity |
| Foot is pulled downward or inward | Spastic plantar flexors or invertors | Dynamic foot pattern and muscle overactivity | Rehabilitation, orthosis, medication, botulinum toxin |
| Legs “do not support me” | Weakness | Strength, MS activity, progression | Rehabilitation, mobility aids, treatment of the underlying cause |
| Unsteady or staggering gait | Ataxia, sensory loss, weakness | Coordination, sensation, balance | Balance training, mobility aids, environmental adaptation |
| Worse after exertion or heat | Fatigue, Uhthoff phenomenon | Temperature dependence and endurance | Pacing, cooling, graded exercise |
| Walking worsened over several days | Relapse, infection, pseudo-relapse | Neurological examination and aggravating factors | Determine the cause before changing rehabilitation |
New persistent weakness, coordination problems or deterioration in walking may require assessment for a possible MS relapse.
Fever, infection and other causes of pseudo-relapse should also be considered.
Assessment should include possible disease progression, PIRA, increasing weakness, spasticity, balance impairment and orthopedic factors.
This pattern may reflect fatigue or Uhthoff phenomenon and does not necessarily indicate new inflammatory disease activity.
“Walking looks better” or “walking feels worse” is not enough for longitudinal follow-up. A neurological examination should be combined with short functional tests.
The T25FW measures walking speed over a short distance. A change of approximately 20% is commonly considered clinically meaningful.
The 2-Minute and 6-Minute Walk Tests provide more information about walking endurance.
Assesses standing up, starting to walk, turning and overall functional mobility.
The Multiple Sclerosis Walking Scale captures the patient's perception of how MS affects walking in daily life.
Strength, tone, coordination, sensation, foot position and compensatory movements should be assessed separately.
Wearables can measure step count, walking speed, variability and real-world physical activity outside the clinic.
In foot drop, ankle dorsiflexion during the swing phase is insufficient. The toe may catch the ground, and the patient may compensate by lifting the knee higher or swinging the leg outward.
In MS, foot drop is often caused by central weakness of the ankle dorsiflexors due to corticospinal pathway damage.
However, a similar clinical picture may result from peroneal neuropathy, L5 radiculopathy, orthopedic conditions or a combination of mechanisms.
There is no universally best device. The choice depends on muscle strength, spasticity, ankle stability, walking speed, footwear and the situations in which assistance is needed.
An AFO mechanically supports the foot in a more functional position and helps reduce toe catching.
FES stimulates the peroneal nerve or relevant muscles during the appropriate phase of gait, helping dorsiflex the foot.
Dictus is a lightweight dynamic support that connects the lower leg to the shoe and mechanically assists toe clearance during walking.
It can be convenient for relatively mild foot drop, but provides less ankle control than a full AFO.
Bioness L300 Go is one of the better-known FES systems for foot drop. Other devices use a similar principle of stimulation timed to the gait cycle.
The brand is less important than correct selection and measurable improvement in the individual patient's walking.
Wearable systems are emerging that stimulate several muscle groups during different phases of gait. For example, the Cionic Neural Sleeve uses multi-channel stimulation and is designed to influence dorsiflexion and other components of lower-limb movement.
Early results in MS are interesting, but the available evidence is still based on small pilot studies. These systems should therefore be considered an evolving technology, not a proven replacement for conventional AFO or standard FES.
Fampridine (Fampyra; dalfampridine in the United States) may improve walking in some people with multiple sclerosis. It is a symptomatic treatment and does not modify the underlying course of MS.
Fampridine blocks potassium channels and may improve impulse conduction along demyelinated nerve fibers.
Some patients experience a meaningful improvement, while others do not. Treatment therefore needs an individual response assessment.
After starting treatment, walking should be reassessed. If there is no meaningful objective or subjective benefit, continuing treatment usually has little rationale.
Spasticity may affect foot position, knee flexion, hip movement and the entire gait pattern. At the same time, moderately increased tone may sometimes help compensate for weakness.
Overactivity of the gastrocnemius and soleus muscles may pull the foot downward.
Spastic muscle activity may pull the foot inward, making support less stable and increasing the risk of ankle instability.
Insufficient knee flexion during swing phase can substantially increase the effort required for walking.
Rehabilitation is most effective when it targets a specific impairment and a real functional goal, rather than simply “strengthening the legs.”
Training should target muscles that actually limit function: hip flexors, knee extensors, ankle dorsiflexors, hip extensors and other relevant muscle groups.
Walking, cycling, swimming and other adapted aerobic activities can improve endurance and overall physical capacity.
Particularly important for patients with ataxia, sensory impairment or increased fall risk.
Training focuses on activities the patient actually needs: walking, turning, stairs, standing up and changing walking speed.
Treadmill training, with body-weight support when needed, may allow a greater volume of safe walking practice.
Consistency is usually more important than occasional intensive sessions. A home program should be realistic and sustainable.
A cane, trekking pole, walker, AFO or FES system should not be viewed as a sign of “failure.” The right device may increase walking distance, reduce falls and preserve independence.
Aquatic therapy, yoga, hippotherapy and other specialized programs may be useful for selected patients, particularly for balance, general activity and confidence in movement.
They should not replace individualized strength, aerobic and task-specific rehabilitation.
A fall is not simply the result of “bad walking.” It may result from foot drop, weakness, ataxia, sensory loss, dual-task difficulty and environmental hazards acting together.
Robotic systems allow a high number of structured gait repetitions.
In MS, they are best viewed as part of multimodal rehabilitation, not as a replacement for conventional physiotherapy.
Wearable robotic systems may be used for supported standing and gait training in people with substantial mobility impairment.
Suitability depends on functional level and the capabilities of the rehabilitation center.
Accelerometers and inertial sensors can provide information about gait not only in the clinic, but during real-world daily activity.
It is important to determine whether the main mechanism is central weakness, spasticity or another cause.
Balance, strength, sensation, foot position and the need for mobility aids should be assessed.
The choice is best made after gait analysis, rather than simply from device specifications.
It may be necessary to distinguish a symptomatic gait problem from disease progression and decide on the next steps.