Elsevier

Gait & Posture

Volume 51, January 2017, Pages 25-35
Gait & Posture

Review
Gait deficits in people with multiple sclerosis: A systematic review and meta-analysis

https://doi.org/10.1016/j.gaitpost.2016.09.026Get rights and content

Highlights

  • Multiple Sclerosis has a significant effect on many gait parameters.

  • This effect is considerable despite the relatively low disability levels examined.

  • This effect is amplified under conditions of increased pace.

  • Considerations towards mobility assessment and rehabilitation are discussed.

  • Further research necessary to determine relationship of findings to falls.

Abstract

Background

Multiple Sclerosis (MS) results in postural instability and gait abnormalities which are associated with accidental falls.

Objective

This systematic review and meta-analysis aims to quantify the effect of MS on gait to inform the development of falls prevention interventions.

Methods

A systematic literature search identified case-control studies investigating differences in gait variables between people with MS and healthy controls. Meta-analysis examined the effect of MS on gait under normal and fast paced conditions.

Results

Forty-one studies of people with Expanded Disability Status Scale (EDSS) 1.8 to 4.5 were included, of which 32 contributed to meta-analysis. A large effect of MS was found on stride length (Standardised Mean Difference, SMD = 1.27, 95% CI{0.93, 1.61}), velocity (SMD = 1.12, 95% CI{0.85, 1.39}), double support duration (SMD = 0.85, 95% CI{0.51, 1.2}), step length (SMD = 1.15, 95% CI{0.75, 1.5})and swing phase duration (SMD = 1.23, 95% CI{0.06, 2.41}). A moderate effect was found on step width and stride time with the smallest effect found on cadence (SMD = 0.43, 95% CI{0.14, 0.72}). All effect sizes increased for variables investigated under a fast walking pace condition (for example the effect on cadence increased to SMD = 1.15, 95% CI{0.42, 1.88}).

Conclusions

MS has a significant effect on gait even for those with relatively low EDSS. This effect is amplified when walking at faster speeds suggesting this condition may be more beneficial for assessment and treatment. No studies investigated the association between these deficits and falls. Further investigation relating to the predictive or protective nature of these deficits in relation to falls is warranted.

Introduction

Multiple Sclerosis (MS) is a neurodegenerative disease characterised by the inflammatory-mediated demyelination of axons throughout the central nervous system [1]. With a predominantly young age of onset, MS is currently the leading cause of disability in young-middle aged adults in the developed world [2]. MS is notably heterogeneous in both its symptomatic presentation and clinical progression [3] with motor, sensory and cognitive impairments frequently observed in varying magnitudes [4]. These impairments predispose a reduction in postural control resulting in instability for people with multiple sclerosis (pwMS) stemming from a diversity of constraints and systems [5].

In terms of functional capacity, postural instability during gait poses a significant threat to the quality of life of the individual. Up to 85% of this population report mobility impairments [6] and gait is perceived as the most important bodily function across the MS disability spectrum [7]. Postural instability during gait increases an individual’s likelihood of experiencing a fall [8], [9]. PwMS frequently display a cautious gait pattern hypothesised to be an attempt to reduce such postural instability and increase the overall control of the movement [10]. However such proactive responses may contradictorily precipitate a loss of postural control through a reduction in quality of certain gait variables in favour of increasing the quality of others, consequently increasing the likelihood of falls occurring [10]. Falls are associated with significant physical, psychological and social morbidity for pwMS [11], [12], [13]. Fall rates in this population are considerably high; with recent literature indicating that approximately 56% will experience a fall in any three-month period [14]. Consistently studies report that the majority of these falls occur during activities involving gait [15], [16], [17] and an association between gait tasks and accidental falls in pwMS has been well documented [9].

The association between postural instability, gait abnormalities and falls in this population suggest that these are key factors that must be addressed by falls prevention interventions. To this end, the assessment, maintenance and promotion of mobility have become increasingly important in this development of falls prevention strategies for pwMS [18], [19]. Understanding the extent of and quantifying the deficits in gait is key to developing theory based interventions to reduce falls for pwMS.

A number of primary research studies have quantified the deficits in gait in pwMS when compared to their healthy peers. To date, no review has systematically pooled the evidence from these studies to quantify the totality of these deficits and investigate their association with falls. Accordingly, this systematic review and meta-analysis aims to identify and quantify deficits in gait in pwMS when compared to a healthy population, with the goal of informing falls prevention interventions for this population.

Section snippets

Study design

This study consists of a systematic review and meta-analysis of case-control studies. The recommendations of the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group [20] were followed to standardise the conduct and reporting of the review.

Search strategy

A literature search was conducted in May 2015. The search was carried out by a PhD student (L.C.) through the following databases; Ebsco (Academic Search Complete, AMED, CINAHL, Medline, PsychArticles, PsychInfo, SportDiscus, Biomedical

Study identification

Fig. 1 provides details of study identification and selection. A total of 8252 studies were retrieved through database searches, following duplicate removal 4979 studies remained. Exclusion based on title and abstract resulted in 81 full texts being examined for eligibility. Forty studies did not meet the prerequisite inclusion criteria. Kalron et al. [25], [26] reported the same outcomes across the same population in two papers therefore findings from the former study only were included to

Discussion

This systematic review and meta-analysis aimed to quantify the effect of MS on gait when compared to healthy controls. As postural instability during gait is associated with falls in pwMS it is important to understand this effect so that falls prevention interventions for this population address the relevant impairments.

The methodological quality of the 41 included case-control studies was varied. The findings demonstrate that there are significant differences across the groups, in particular

Conclusions

The results of this systematic review and meta-analysis indicate that MS has a significant effect on gait, both at a self-selected and increased pace. This effect is considerable despite the relatively low EDSS scores of the populations included and may be more pronounced in those with more advanced disease status. These findings highlight a number of clinical implications relating to both the assessment and treatment of gait for pwMS. Further investigation relating to the predictive or

Conflict of interest statement

The authors declare that there is no conflict of interest.

Acknowledgements

The authors wish to thank the Dr. Ross Anderson and the MS Research Team at the University of Limerick for their assistance and feedback throughout the preparation of this article. PhD student L.C. is funded by the Multiple Sclerosis Society of Ireland through the Ireland Fund.

References (72)

  • U. Givon et al.

    Gait analysis in multiple sclerosis: characterization of temporal–spatial parameters using GAITRite functional ambulation system

    Gait Posture

    (2009)
  • J.M. Huisinga et al.

    Postural response latencies are related to balance control during standing and walking in patients with multiple sclerosis

    Arch. Phys. Med. Rehabil.

    (2014)
  • A. Kalron et al.

    Gait and jogging parameters in people with minimally impaired multiple sclerosis

    Gait Posture

    (2014)
  • L.A. Pilutti et al.

    Gait and six-minute walk performance in persons with multiple sclerosis

    J. Neurol. Sci.

    (2013)
  • J.G. Remelius et al.

    Gait impairments in persons with multiple sclerosis across preferred and fixed walking speeds

    Arch. Phys. Med. Rehabil.

    (2012)
  • M.J. Socie et al.

    Gait variability and disability in multiple sclerosis

    Gait Posture

    (2013)
  • J.J. Sosnoff et al.

    Quantifying gait abnormalities in persons with multiple sclerosis with minimal disability

    Gait Posture

    (2012)
  • R.I. Spain et al.

    Body-worn motion sensors detect balance and gait deficits in people with multiple sclerosis who have normal walking speed

    Gait Posture

    (2012)
  • S.R. Wurdeman et al.

    Multiple sclerosis affects the frequency content in the vertical ground reaction forces during walking

    Clin. Biomech. (Bristol, Avon)

    (2011)
  • A. Yahia et al.

    Relationship between muscular strength, gait and postural parameters in multiple sclerosis

    Ann. Phys. Rehabil. Med.

    (2011)
  • F.E. Huxham et al.

    Theoretical considerations in balance assessment

    Aust. J. Physiother.

    (2001)
  • S. Coote et al.

    Level of mobility limitations and falls status in persons with multiple sclerosis

    Arch. Phys. Med. Rehabil.

    (2014)
  • J.M. Hausdorff et al.

    Gait variability and fall risk in community-living older adults: a 1-year prospective study

    Arch. Phys. Med. Rehabil.

    (2001)
  • A. Compston, A. Coles, Multiple sclerosis, The Lancet, 372,...
  • S.L. Kasser et al.

    Treating balance impairment in multiple sclerosis

    J. Clin. Outcomes Manage.

    (2014)
  • N.G. LaRocca

    Impact of walking impairment in multiple sclerosis

    Patient: Patient-Centered Outcomes Res.

    (2011)
  • C. Heesen et al.

    Patient perception of bodily functions in multiple sclerosis: gait and visual function are the most valuable

    Mult. Scler.

    (2008)
  • F.B. Horak

    Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls

    Age Ageing

    (2006)
  • C. Gianni et al.

    A systematic review of factors associated with accidental falls in people with multiple sclerosis: a meta-analytic approach

    Clin. Rehabil.

    (2014)
  • R.E.A. van Emmerik, S.L. Jones, M.A. Busa, J.G. Remelius, J.L. Averill, Enhancing Postural Stability and Adaptability...
  • P.N. Matsuda et al.

    Understanding falls in multiple sclerosis: association of mobility status, concerns about falling, and accumulated impairments

    Phys. Ther.

    (2012)
  • Y. Nilsagård et al.

    Falls in people with MS—an individual data meta-analysis from studies from Australia, Sweden, United Kingdom and the United States

    Mult. Scler. J.

    (2014)
  • L. Comber et al.

    The causes, context and consequences of falls in people with multiple sclerosis: preliminary results from an irish cross-sectional study

    Int. J. MS Care

    (2015)
  • D. Cattaneo et al.

    Targeting dynamic balance in falls-Prevention interventions in multiple sclerosis

    Int. J. MS Care

    (2014)
  • J.J. Sosnoff et al.

    Reducing falls and improving mobility in multiple sclerosis

    Expert Rev. Neurother.

    (2015)
  • D.F. Stroup et al.

    Meta-analysis of observational studies in epidemiology: a proposal for reporting

    JAMA

    (2000)
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