Renown physical therapist Herb Karpatkin sees multiple sclerosis as a disease of mobility. “Persons with MS don't complain that their myelin is bothering them, but that they are having trouble walking or balancing.” In this feature for ActiveMSers, he provides three essential keys for maximizing walking endurance with this disease based on decades of experience working with the MS population.
Although most physicians see multiple sclerosis as a disease of demyelination and inflammation, as a physical therapist I see MS as a disease of mobility. Persons with MS don’t complain that their myelin is bothering them, but that they are having trouble walking or balancing. What makes the mobility loss in MS different from mobility loss in other conditions?
First, it is progressive; persons with MS will often show a worsening of gait and mobility over time. Each year it seems that their ability to walk becomes slightly worse, and the distance that they are able to walk becomes progressively shorter. Second, it is multifactorial; there are multiple reasons for gait loss in MS—the issue can be with strength, flexibility, sensation, endurance and a host of others. This is one of the things that make MS so challenging for clinicians—that there is no “typical” presentation. Third, it fatigues; probably the most common symptom in MS is fatigue. By fatigue I mean a slow worsening of gait quality and quantity while the person is walking. In most persons with MS I see a familiar pattern when I assess their gait: The first 1-3 minutes usually look relatively OK, but as the person continues to walk, the gait deteriorates more and more and after a while, the person’s walking is severely impaired if not altogether stopped.
This indicates to me that one of the best ways to help someone with MS improve their gait is to improve their endurance. Simply put, I see it as the job of the therapist to try to increase the distance that the person with MS can walk without being overwhelmed by fatigue.
Improving gait endurance in MS can be difficult due to the very nature of the disease. The best way to improve endurance for any activity, regardless of the diagnosis, is to increase the volume, or amount of the activity you are trying to improve. Unfortunately, that is very difficult for persons with MS due to the fatigue. If someone with MS tried to increase endurance by walking progressively longer distances, each time they reached a certain distance, fatigue would occur and they would be unable to continue. How can someone with MS improve the volume of their walking when increasing the volume simply leads to fatigue?
The answer is simply to take breaks. Most training programs that persons with MS attempt are continuous in nature, i.e., they exercise without a break. Recent research has shown that if MSers simply take breaks while they exercise they can walk longer distances and experience less fatigue. This type of exercise is called intermittent training and it has been shown to be effective not only in MS but in patients with cardiac conditions, obesity, and arthritis. It is also commonly used in improving athletic performance in disabled and non-disabled athletes.
An example of using intermittent training would be the following: imagine a person with MS cannot walk for longer than 10 minutes continuously without experiencing severe difficulties. He or she therefore would have difficulty increasing the total distance he could walk. Rather than having the person walk to exhaustion each time, I would suggest that the person only walks 3-4 minutes at a time, either resting or stretching for a few minutes in between each walk. He would do this 4-5 times, and as a result walk 12-20 minutes total, and probably with a better gait quality. The total volume of walking would be greater than if the person just walked continuously, and because fatigue was minimized, the overall quality would be greater. By training intermittently as opposed to continuously, walking endurance may significantly improve.
A second intervention that persons with MS can use to improve their gait endurance is also quite simple: cooling. A fundamental physiologic reason for gait endurance impairment in MS is that transmission through demyelinated nerves decreases as temperature goes up. More, simply the hotter someone with MS gets, the harder it is for them to performed a sustained activity. This makes exercise extremely problematic for someone with MS as sustained exercise can increase core temperature. This is one of the reasons that intermittent walking may be so effective in helping persons with MS: the rest breaks allow core temperature to lower.
Another relatively straightforward way of lowering core temperature is simply to lower the temperature of the environment you are exercising in. This can be done in a number of ways—making sure you exercise in a cooled room, not wearing excessive clothing when you walk, and even sipping a cold drink while you are exercising can be effective. Many persons with MS use cooling garments as they exercise to limit the effects of core temperature increase. The use of cooling garments such as vests, hats, and wraps have proven to be extremely helpful to persons with MS, especially when they need to walk in hotter and more humid days. ActiveMSers has a detailed overview of the types of cooling vests available as well as reviews and tests of popular vests. Some cooling gear can be obtained for free from the Multiple Sclerosis Association of America and the Multiple Sclerosis Foundation.
A third way that all persons with MS could likely improve their gait endurance is to stretch, especially their calf muscles and hamstrings, as these are often the muscles that tighten up and increase gait fatigue. Although many persons with MS stretch, few do it long enough or correctly. Although we don’t have the space here to go in depth into how best to stretch, the basic rule is “go gentle, go long.” What this means is that the stretch should be relatively gentle (not painful) and should be held for an extended period of time (think several minutes, not a few seconds). This will result in increasing the length of the muscle and allowing walking to take less energy.
Gait endurance is an important problem for persons with multiple sclerosis. However it is important to realize that there are several ways of addressing it that are relatively simple and have been shown to be effective. The important thing is to not give up on restoring your mobility.