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Journal Information
Vol. 48. Issue C.
Pages 28-31 (July - December 2018)
Vol. 48. Issue C.
Pages 28-31 (July - December 2018)
Case report
DOI: 10.1016/j.sedeng.2018.06.001
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Analysis and rehabilitation of balance and gait in a patient with multiple sclerosis
Análisis y reeducación del equilibrio y la marcha en paciente con esclerosis múltiple
Carlos Luque-Morenoa,b,c,
Corresponding author

Corresponding author.
, Gonzalo Garvey-Canivellb, Fátima Cano-Bravod
a Laboratorio de Análisis del Movimiento, Hospital Universitario Virgen del Rocío, Sevilla, Spain
b Departamento de Fisioterapia, Universidad de Sevilla, Sevilla, Spain
c Departamento de Enfermería y Fisioterapia, Universidad de Cádiz, Cádiz, Spain
d Comunidad Terapéutica de Salud Mental II, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Tables (1)
Table 1. Comparative table of temporal and spatial variation parameters of gait (pre-test, normality and post-test).

Multiple sclerosis is an autoimmune disease that causes progressive disability in young adults, in which they experience motor and sensory dysfunctions that contribute to alterations in balance and gait. The aim of this study is to determine these alterations in a 29-year-old patient with primary progressive multiple sclerosis, and to describe and implement a physiotherapeutic intervention (40min/day, 2 days/week for 5 months), and objectify the results through instrumental gait analysis. An increase was obtained in the muscular balance (Daniels Test) in the right lower limb, and in balance using the Berg Balance Scale (6 points), as well as a decrease in spasticity in the Modified Ashworth Scale in the right triceps surae. There was also an improvement in the spatiotemporal gait parameters, an increase in average speed by 0.11m, a decrease of 4.7 steps/min of the cadence, a decrease in step width by 0.03m, and an increase in stride lengths (0.08m right, 0.09m left). The data suggested a functional improvement, even in the case of a progressive disease. The joint action of an interdisciplinary team is essential to reinforce the physiotherapy treatment in these patients, as well as the use of innovative assessment tools that allow us to achieve the most optimal treatments.

Multiple sclerosis
Neurologic gait disorders
Postural balance

La esclerosis múltiple es una enfermedad autoinmune que causa discapacidad progresiva en adultos jóvenes, quienes experimentan disfunciones motoras y sensitivas que contribuyen a las alteraciones del equilibrio y de la marcha. El objetivo del presente estudio es determinar estas alteraciones en una paciente de 29 años de edad con esclerosis múltiple progresiva primaria, describir e implementar una intervención fisioterapéutica (40min/día, 2 días/semana durante 5 meses) y objetivar los resultados mediante un sistema de análisis instrumentalizado de la marcha. Se obtuvo un aumento en el balance muscular (test de Daniels) en el miembro inferior derecho y el equilibrio (6 puntos) mediante la escala del equilibrio de Berg, y una disminución de la espasticidad en la escala modificada de Ashworth en el tríceps sural derecho. Los parámetros espacio-temporales de la marcha mejoraron: aumento de la velocidad media en un 0,11m/s, disminución de 4,7 pasos/minuto en la cadencia, disminución de la anchura del paso en 0,03m y aumento 0,08m en la longitud de paso derecho y de 0,09m en el izquierdo. Los datos implicaron una mejora funcional, aun tratándose de una enfermedad progresiva. Resulta fundamental una actuación conjunta del equipo interdisciplinar para reforzar el tratamiento de fisioterapia en estos pacientes, así como el uso de herramientas de evaluación innovadoras que nos permitan implementar los tratamientos más óptimos.

Palabras clave:
Esclerosis múltiple
Trastornos neurológicos de la marcha
Balance postural
Full Text

Multiple sclerosis (MS) is a degenerative autoimmune disease which affects the central nervous system and causes progressive disability in young adults. Even in the initial stages of the disease variable neurological impairments such as motor weakness, spasticity, ataxia and common sensory changes may lead to significant impairment of gait.1 Over 80% of patients with MS suffer from spasticity which is more predominant in the lower limbs (LL), and especially in the hip flexors and adductors, as well as in the knee flexors, ankle plantar flexors and dorsiflexors. Some authors show that the spasticity of the triceps surae muscle appears to have a negative effect on balance and gait in people with MS.2

Givon et al.1 analysed the spatiotemporal gait parameters of 81 MS patients and compared them with a control group of 25 subjects. They reported a reduction of mean speed, a reduction in cadence and stride of both LL, in addition to a significant increase in the support base whilst in movement. Remelius et al.3 compared the changes of the spatiotemporal gait variables in MS patients whilst walking at a comfortable speed and at a prefixed speed. When the test was completed whilst walking at a comfortable speed, the subjects with MS reduced their speed, cadence, stride length and swing phase. In an attempt to increase stability whilst walking the subjects increased stride width and double stance phase. It is important to determine in these patients that changes of gait were due to the previously described degenerations or the compensations made to make up for these shortcomings.

Balance dysfunctions have been associated with an increased risk of falling. Specific balance training exercises have demonstrated they can improve balance in MS, with emerging evidence of the positive effects in improving gait. This training would include visuo-proprioceptive training and virtual reality exercise, among others.4 It has been estimated that at least 50% of people with MS will require a device to help them walk within the first 10 years after diagnosis and this may reduce the risk of falls, and musculoskeletal effort and stress. Some authors have studied the influence which the use of a stick has in gait in MS: an increase in speed, cadence, stride length and the stance phase was noted and a drop in the double stance phase and monopodal support phase.5

Evidence of the treatment effectiveness in functional improvement is limited. Apart from new drugs,6 the general consensus regarding MS is that symptoms decrease when therapeutic exercise is well organised and programmed. Negahban et al.7 reported significant improvements in spasticity, balance and speed of gait when they applied 15 sessions of massage and physical exercise distributed over 5 weeks. Physiotherapy offers interesting functional solutions. The aim of this study is to determine changes in balance and gait in a patient with MS, describe and implement a physiotherapeutic intervention and embody the results in a clinical scale and instrumentalised gait analysis system.

DevelopmentPresentation of the clinical case

A 29-year-old female was diagnosed with primary progressive MS 3 years ago. Since then she had noticed a progressive increase of symptoms. She highlighted right-sided hemiparesis, predominantly distal in the right lower limb (RLL). She presented at the Neurological Physiotherapy Unit of the University Hospital Virgen del Rocío (Seville) as an outpatient.

Initial assessment

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    Joint balance: free range of joint (without limitations of passive movement).

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    Muscle balance in RLL (Daniels test: measurement of muscle strength on a scale of 0 to a maximum of 5): hip (3 flexor, 5 extensor, 2 abductors, 4 adductors); knee (4 flexors, 3 extensor); ankle (4 plantar flexors, 3 dorsal flexors). In LLL reduced but functional.

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    Altered proprioceptive sensitivity (difficulty in positioning different segments of the lower limb without visual control).

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    Tone in Modified Ashworth Scale (MAS: clinical scale for the evaluation of spasticity from 0 without increase in tone to 4 with stiff extremity in flexion or extension): 1+MAS in right triceps surae, 1 in right iliac psoas and 1 in right rectus femoris muscle (Duncan-Ely test positive right: spasticity in right rectus femoris), with bilateral popliteal angle of 40° and 0 MAS in hamstrings. Regarding reflexes, bilateral extensor plantar response (more marked in the right limb).

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    Balance: 43/56 in the Berg Balance Scale (BBS), failing mainly in the last items, such as standing on one leg.

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    Gait: a recording was made in the Movement Analysis Laboratory of the University Hospital Virgen del Rocío (Seville) with the BTS (Italy) movement capture system, which comprised 6 infrared optoelectronic cameras, 2 video cameras and one Kistler dynamometric platform, integrated into a control station using the Davis gait protocol. The patient was asked to walk spontaneously several times and 6 stride cycles were recorded, with which the mean was obtained and the standard deviation. Table 1 (pre-test) contains the results obtained in the initial evaluation.

    Table 1.

    Comparative table of temporal and spatial variation parameters of gait (pre-test, normality and post-test).

    Support phase (%)  61±3.9  68.4±59.6±1.2  59.3±1.8  61.4±2.5  62.2±1.5 
    Swing phase (%)  39±3.9  31.6±40.4±1.2  40.7±1.8  38.6±2.5  31.8±1.5 
    Double stance (%)  12.6±1.9  17.2±3.5  13.4±1.1  12.5±11  15.2±3.2  15.4±1.7 
    Support phase (s)  .78±.1  .88±.09  .63±.02  .63±.04  .81±.04  .93±.08 
    Swing phase (s)  .5±.05  .4±.03  .43±.02  .43±.02  .51±.04  .43±.2 
    Stride time (s)  1.28±.11  1.28±.11  1.06±.03  1.05±.05  1.32±.05  1.37±.09 
    Cadence (steps/min)  94.4±8.49113.844±7.30289.7±4.11
    Length of step (m)  .31±.14  .3±.13  .73±.02  .74±.02  .39±.02  .39±.02 
    Speed (m/s)  .65±.12  .65±.1  1.39±.06  1.39±.07  .63±.04  .63±.06 
    Balance speed (m/s)  1.53±.26  1.81±.25  3.3±.14  3.27±.2  1.52±.11  1.74±.11 
    Stride length (m)  .82±.08  .82±.07  1.47±.08  1.47±.06  .84±.03  .85±.03 
    Step width (m)  .19±.04  .19±.04  .11±.03  .13±.01  .16±.01  .16±.01 
    Mean speed (m/s)  .49±.071.39±.06.6±.4

Planning and care

The patient was administered baclofen as an anti-spastic drug treatment. Based on the findings from the clinical scales and gait movement analysis (kinematic and kinetic) a physiotherapeutic programme was designed (40min/day, 2 days per week for 5 months), aimed at reaching an improvement in balance and gait functionality. Neuromeningeal mobility techniques were used, together with analytical and global muscle stretching (postural and overall re-education), neuromotor methods such as Bobath proprioceptive neuromuscular facilitation and sensory motor methods such as therapeutic cognitive exercise (first grade exercises to control the exaggerated reaction on stretching and the improvement in proprioception, second and third grade for recruitment of motor units, especially to control the spasticity of the triceps surae and improve muscle potential). Guidelines were given for the use of a static bicycle at home, without weight-bearing, since this has been demonstrated to reduce the Hoffman reflex and spasticity in MAS in MS patients.2 Prior to treatment the patient received one-hour personal training sessions in a gymn with anaerobic training with weights and aerobic training on a treadmill. Due to the fatigue stated by the patient on carrying out some of her everyday activities, we recommended that training session be suspended and to start hippotherapy session aimed at maintaining postural tone, working on the dissociation of the scapular and pelvic girdle and gait direction. The patient was shown active stretching guidelines always at reduced speed with Theraband (psoas iliac, triceps surae and anterior rectus femoris of the quadriceps), affecting the hypertonic muscles.

Integration of all the analytical work was highly relevant for re-education regarding gait, with focus placed on the phases of the cycle in which the greatest difficulties were found, especially in the mean stance phase due to a lack of balance, the weakness of the psoas-iliac muscle, quadriceps, triceps surae and gluteus medius (which provoked a collapse of the knee in sagittal plane and a misalignment in frontal plane) together with the spasticity of the triceps surae, which could contribute to instability in stance. Eccentric exercise was chosen for spasticity control and for “task-orientated motor relearning” The primary functional objective of this re-education was the increase in gait speed, reducing dramatic compensations to achieve the most economical gait possible on an energy-intensive scale.

For the treatment of balance, apart from all of the above, the physiotherapy sessions included proprioceptive exercise and specific video console Nintendo Wii Fit exercise. Although evidence is not abundant, the literature suggests that beneficial effects may stem from these exercises.8


An increase in muscle balance was achieved at a point in hip flexors and abductors, as well as in the knee extensors in the RLL. Despite the fact that muscle balance of the triceps surae did not improve, spasticity dropped and one point was achieved in MAS. Balance improved by 6 points, with a score of 49/56 in BBS. Table 1 lists the results of the spatiotemporal parameters of gait after physiotherapy treatment.


The spatiotemporal changes of gait initially showed a reduction in mean speed of gait, cadence (number of steps/min), length of both strides, and an increase in the percentage of left stance phase, stride width, percentage of double stance and time of stride, in keeping with the data obtained by other authors.9

After the intervention, we observed greater balance between both LL in stance and oscillation phases, with a reduction of the left stance phase which the patient would probably use as compensation to gain security before intervention. The stride width was reduced and the right and left stance phases were balanced, which led to higher stability, probably related to an improvement in balance, confirmed by the clinical scales (BBS). The increase in the length of both strides correlated with an increase in gait speed. Previous data showed a more functional gait (faster and more stable at a comfortable speed). The reduction of cadence was also a positive factor, since although it was not normal, it was closer to the cadence which the subject would have to show with such a low gait speed (the subject may not have needed to take more steps per time unit to improve gait speed, using longer strides and thus a much more economical strategy). The improvement by 6 points in the BBS was far higher than the 3 points reported in the literature10 as a clinically significant minimum difference. Improvement in muscle balance at a proximal level in the RLL is positive. Since at a distal level the weakness would continue, a good option would be to make use of functional electrostimulation to make up for the lack of distal strength and avoid the situation of the patient having to use compensatory strategies which change the kinetics of more cranial joints. After kinematic-kinetic analysis of the gait, the patient was recommended to obtain a “foot-up” type foot splint for foot drop when walking long distance to avoid dramatic compensations at proximal level and to use a hiking stick (not the forearm crutch that the patient usually used, since this altered the kinematics due to excessive support and compensations) only when walking outside on unstable terrain, to ensure safety. It is essential that the other members of the interdisciplinary team, including nurses, are familiar with the care plan established by physiotherapy team so that guidelines may be reinforced and outcome optimised.


The data suggested a functional improvement, despite the disease being chronic. The combined efforts of an interdisciplinary team is essential to reinforce the physiotherapy treatment in these patients as well as the use of innovative assessment tools that allow us to apply the most optimal treatments.

U. Givon, G. Zeilig, A. Achiron.
Gait analysis in multiple sclerosis: characterization of temporal–spatial parameters using GAITRite functional ambulation system.
Gait Posture, 29 (2009), pp. 138-144
J.J. Sosnoff, E. Gappmaier, A. Frame, R.W. Motl.
Influence of spasticity on mobility and balance in persons with multiple sclerosis.
J Neurol Phys Ther, 35 (2011), pp. 129-132
J.G. Remelius, S.L. Jones, J.D. House, M.A. Busa, J.L. Averill, K. Sugumaran, et al.
Gait impairments in persons with multiple sclerosis across preferred and fixed walking speeds.
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Gait abnormalities in multiple sclerosis: pathogenesis, evaluation, and advances in treatment.
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Speed- and cane-related alterations in gait parameters in individuals with multiple sclerosis.
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Arch Phys Med Rehabil, 98 (2017), pp. 337-340

Please cite this article as: Luque-Moreno C, Garvey-Canivell G, Cano-Bravo F. Análisis y reeducación del equilibrio y la marcha en paciente con esclerosis múltiple. Rev Cient Soc Enferm Neurol. 2018;48:28–31.

Copyright © 2018. Sociedad Española de Enfermería Neurológica
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