How common is it for a person with MS to have problems walking?

According to the National Multiple Sclerosis Society, an estimated 2.3 million people have multiple sclerosis and that number continues to grow worldwide every year.  Problems walking is the most common cause of falls and injuries. Statistics show that approximately 50-70% of people with MS fall on a regular basis.

A recent study, conducted by scientists and physicians in accordance with the National Multiple Sclerosis Society reported that nearly 30% of people who reported falling, fell several times, which all resulted in an injury of some type.

Enhancing an individual’s ability to walk safely while preventing a fall, is crucial. Not only do falls cause injuries, the time necessary to recuperate from strained or sprained muscles or broken bones can make walking (gait) problems worse and reduce the person’s independence.

What are the top fall risk factors?

People with MS generally fall inside their home, but that is not say that the risk of falling decreases outside, at work or while out in the community.

Falls are most common when people are doing everyday activities such as; bathing, dressing, cooking, cleaning, or walking in unfamiliar areas or crowds outside the home.

Risk factors for falls are multifaceted and can include the following:

• Slow walking
• Balance problems
• Problems with sensation of where your body is while waking (example – If the person is unable to fully feel their feet on the group they are more likely to under or over step and fall)
• Neurological problems if a person is unable to judge where their body is in relation to a wall, stairs, a street sign, curb etc. (because the signal from the brain to the body is interrupted) a fall is likely
• Medications, some medications can make the person dizzy, or affect the message system and the person may perceive something to be closer or further away than it is
• Incorrect use of canes or walkers or trying to walk without an assistive device

What are some strategies to help prevent falls?

There are several self-management strategies a person can use to help prevent the risk of falling.

• Take close look at your home and identify anything that could possibly pose a fall risk. Once they are identified “fall proof” them. For example; Throw rugs are a fall hazard for everyone, not just people with MS – either get rid of throw rugs or secure them to the floor so they do not unexpectedly move while you are walking across them.
• Always use the correct mobility device whether it be a cane or a walker, this will decrease your risk of falling greatly.
• If you fall more often when you are tried, then try to limit your walking or walk with assistance during those times.
• If your medication makes you dizzy or unsteady, plan to sit for a period of time, until you know it is safer for you to be up and moving around.
• If you are experiencing severe weakness in your lower body, going to be in a crowd, walking a long distance or for a long time or any situation where you feel walking may be a problem use a wheelchair or scooter.

What defines relapsing-remitting MS (RRMS)?

The majority of people who are diagnosed with MS will receive a diagnosis of relapsing-remitting MS. In fact, according to the National Multiple Sclerosis Society, “approximately 85% of people with MS are initially diagnosed with RRMS.”

In relapsing-remitting MS, there are flare-ups of the disease (relapses) and periods of remission when symptoms may or may not be present. In this way, some symptoms may become permanent. Relapses are acute periods where neurological functioning gets measurably worse.

Your MS treatment team, likely your neurologist, looks for activity using MRIs. They will be looking for new gadolinium-enhancing lesions or growing T2 lesions during a specific timeframe.

In addition to measuring the current relapsing-remitting MS activity, clinicians will measure your level of disability. This is used to track the status of MS.

Taken together, these measures help your treatment team evaluate the treatment plan and track the progression of the disease. Most people with RRMS will eventually transition to secondary progressive MS.

Symptoms of relapsing-remitting MS

Relapsing-remitting MS is generally marked by relapses that last at least 24-hours. During a relapse, the symptoms may get worse. Common symptoms of RRMS include one or more of the following:

• Sensitivity to heat
• Difficulty seeing or vision problems
• Fatigue
• Muscle weakness
• Numbness, particularly in the feet
• Memory problems
• Difficulty thinking clearly
• Depression
• Difficulty walking or balancing
• Urgently needing to urinate

Diagnosing relapsing-remitting MS

There are a variety of tests your physician may use to help diagnose RRMS. Your physician will ask you a series of questions about your symptoms; keep in mind that these questions are important in order to help rule out any other diseases, such as rheumatoid arthritis, that may cause similar symptoms.

Additionally, a clinician will also check your sense of balance, vision, and cognition. This helps in the diagnostic stage and can serve as a benchmark for future comparisons.

Finally, you will also need an MRI scan of your spine and brain. This is used to determine if there are areas of damage in your spinal cord and/or brain that may indicate you have MS.

The results of these tests, questions, symptoms, and observations are all used to determine the appropriate diagnosis.

Managing relapsing-remitting MS

NOTE: If you believe that you may have multiple sclerosis, you should bring up your concerns and begin the diagnostic process with a doctor. While there is not a cure for MS, clinicians can accurately identify the disease and develop a personalized treatment plan.

Your physician may prescribe medications to help ease muscle spasms, depression, and/or fatigue when battling RRMS. In addition to medications, the following lifestyle changes may help manage symptoms:

• Attending physical therapy
• Eating a diet low in saturated and trans fats
• Avoiding smoking
• Exercising a moderate amount
• Getting plenty of sleep
• Trying to avoid becoming overheated

Potential cause of MS: Environment

Researchers have noticed an increased pattern in cases of multiple sclerosis in countries that are located the furthest from the equator. Sun exposure is one way for the body to get vitamin D. The correlation between decreased sun exposure and increased levels of MS has led some to believe that a vitamin D deficiency may play a causal role in multiple sclerosis. 

Vitamin D is extremely beneficial for your immune system. People who are closer to the equator are naturally exposed to more sunlight and as a result, their bodies may be able to produce more vitamin D.

Research published in the journal Neurology in October 2017 seems to confirm this correlation. The study used serum samples from over 800,000 women in the Finnish Maternity cohort. Using an an adjusted conditional logistic regression, the researchers found that an increase in vitamin D [25(OH)D — also known as calcifediol or 25-hydroxyvitamin D] of 50 nmol/L was associated with a 39% reduced risk of multiple sclerosis.

The researchers concluded: “These results directly support vitamin D deficiency as a risk factor for MS.”

Other environmental factors may also be risk factors for MS. There has also been evidence showing that smoking may play an important role in the development of the disease. Research has shown that smoking may increase a person’s risk for developing MS and it is also associated with a more severe and rapid progression of the disease.

Potential MS cause: Infectious triggers

The initial exposure to a wide range of viruses, bacteria, and other microbes that occur during childhood are generally known to cause inflammation and demyelination (damage to the myelin sheath). This means it is possible for a virus or other form of infection to trigger the development MS.

Dozens of bacteria and viruses that have been investigated to determine if they may lead to the onset of MS, including:

• Human herpes virus-6 (HHV-6)
• Measles virus
• Epstein-Barr virus (EBV)
• Canine distemper
• Chlamydia pneumonia

To date, none of the potential causes studies have been proven as a definitive cause of MS.

Potential MS cause: Genetic factors

Although MS is not consider to be hereditary disease, research has shown that having a first-line relative, such as a sibling or parent with multiple sclerosis may significantly increase a person’s risk of developing the disease. In fact, one study found that a child has 10-times the risk of developing MS if both of parents have it.

Studies have shown there is a significantly increased prevalence of certain genes in a population with higher rates of MS. Many researchers believe that people with multiple sclerosis are born with a genetic predisposition to certain, unknown environmental agents. Then, upon exposure to the trigger, the body begins the immune-mediated response.

Research published in June 2016 worked to identify the gene mutation responsible for the onset of multiple sclerosis. Identifying a mutation in the gene: NR1H3 — the researchers found that there was a 70% chance of developing MS when the mutation was present.

Disproved theories on the cause of MS

While there is still speculation into the mechanisms leading to the onset of multiple sclerosis, some theories have been disproved. Some of these disproved theories include:

• Living with dogs or small pets
• Having allergies
• Experiencing physical trauma
• Exposure to heavy metals such as lead or mercury
• Consuming aspartame

Multiple Sclerosis Treatment Team

Neurologist

Typically, prior to being formally diagnosed with multiple sclerosis, you will be referred to a neurologist because of certain symptoms. Some neurologists specialize in MS, while others treat a broader range of neurological disorders.

Because of this experience and specialization, your neurologist will serve as the cornerstone of your MS treatment team. Be sure to build around a neurologist that you trust.

Neurologists are doctors that have studied the nervous system. To help measure the nervous system, neurologists may use the following tools and tests:

• Computed axial tomography (CAT) scans
• Magnetic resonance imaging (MRI)
• Ultrasounds of the head and/or neck
• Electroencephalography (EEG)
• Nerve conduction studies (NCS)
• Examination of gait
• Tests of reflexes or sensation

Physiatrist

Physiatrists are also known as Physical Medicine and Rehabilitation physicians. They are doctors that may have sub-specializations including brain injury, spinal cord injuries, sports medicine, and more.

Often, a physiatrist will be the leader of the rehabilitation team. The goals of working with a physiatrist is to develop a treatment plan that helps you live at your highest level possible while minimizing any limitations you may experience. These goals can be attained through the use of exercises and assistive devices.

Primary Care Doctor (PCP)

Your primary care doctor is focussed on your overall health. She will act as the point person or coordinator of your care team, not just your MS treatment team.

While your neurologist will likely act as the key decision maker for you MS treatment, it is useful for your PCP and neurologist to work together. MS can cause challenges throughout your body and it can be challenging to find the root cause of symptoms without a collaborative treatment team.

Occupational Therapists, Physical Therapists, & Speech/Language Pathologists

These clinicians specialize in rehabilitation to promote mobility, function, and quality of life. They can be useful for rebuilding strength and flexibility to ensure autonomy and quality of life.

An occupational therapist’s job is to find ways to make it easier for you to accomplish your day-to-day goals including tasks like cooking, eating, getting dressed, and more. An occupational therapist will work with you, your family, and your community to find clever ways to let you continue to live your own way.

If you are having a hard time managing pain or staying active, adding a physical therapist to your MS treatment team can help. Your joints will be healthier if they are active, and finding ways to keep you active is what your PT is best at.

Speech/language pathologists (S/LP) provide support and solutions for speech production to ensure clear and accurate communications. They can also help with swallowing problems to make sure that eating is safe.

Psychologists, Psychiatrists, Neuropsychologists, & Counselors

These doctors and counselors specialize in the study of behavior and the mind. They help support people and develop strategies to combat depression, anxiety, stress management, fear and phobia management, and more

These providers can also track and help improve cognitive changes including memory problems, attention issues, and difficulty with complex problem-solving.

Note: Psychiatrists are able to write prescriptions whereas psychologists and counselors rely on non-medicinal methods only.

Dietitians and Nutritionists

NOTE: Dietitians receive specialized training and a degree – they can either be registered dietitians (RD) or registered dietitian nutritionist (RDN). The term dietitian can only be used by those that have met the professional requirements which include a bachelor’s degree with accredited nutrition curriculum, satisfactory performance on a registration exam, and an internship at an approved facility. View additional information on the qualifications here.

The term nutritionist is NOT protected. That means that any person may call themselves a nutritionist whether they have any specialized training or not – and some accreditations are astoundingly easy to receive. To this point, Dr. Ben Goldacre was able to have his dead cat, Hettie, accredited as a professional member of the American Association of Nutritional Consultants for just $60. Because of this, it is important to research the background of any nutritional information you receive and maintain an open dialogue with your gastroenterologist and primary care physician about your health.

• Dietitians change the foods you eat to help assess, diagnose, and treat nutritional problems.
• Dietitians may establish individual health plans to meet goals and can leverage special services, including tube feedings, diets, and more.

Prevalence of speech disorders

41-51% of MS Warriors may experience symptoms of dysarthria according to a number of studies reported by the National Multiple Sclerosis Society. These studies have relied on a clinical diagnosis for speech disorders. When self-reporting is used, the prevalence of speech disorders varies.

Study conducted in United States and published in 1985

• Dysarthria prevalence: 23%
• Cohort size: 656 people with MS

Study conducted in Sweden and published in 1994

• Dysarthria prevalence: 44%
• Cohort size: 200 people with MS

Preliminary study conducted in South Africa and published in 2002

• Dysarthria prevalence: 57%
• Cohort size: 30 people with MS

Symptoms of dysarthria

Dysarthria is categorized by slow and/or slurred speech that is often difficult for other people to understand. With dysarthria, there are both vocal symptoms and physical/neuromuscular symptoms. Common symptoms include:

• Slurred speech
• Speaking too rapidly or too slowly
• Speaking too loudly or too quietly
• Raspy, strained speech
• Speaking with an abnormal rhythm or with uneven volume
• Monotone speech
• Jaw-jerking reflexes
• Irregular eye movements

Causes of dysarthria in MS

Dysarthria is caused by a neuromuscular impairment that causes instabilities in the brain that regulate the motor control of the speech system. People with MS can develop lesions throughout the brain, including in the parts of the brain that control speech: the left hemisphere of the cerebrum and the brainstem.

In addition to the impact of lesions, MS also causes weakness, spasticity (stiff muscles), sluggishness, and ataxia (issues with muscle coordination). Ataxia can impact the coordination of the parts of the body needed for speech including the tongue, mandible, lips, vocal cords, soft palate, and diaphragm.

These different mechanisms result in speech disorders having a wide array of symptoms and underlying causes. Because of this, there are 3 types of dysarthria that can result from the location of lesions in the brain. The three types are:

1. Ataxic
   • Caused by generalized or bilateral lesions on the cerebellum
2. Spastic
   • Caused by bilateral lesions of the neuron pathways
3. Mixed
   • Caused by generalized or bilateral lesions of the cerebellum, white matter, spinal cord, and/or the brainstem

Symptoms of dysphonia

In slight contrast to speech disorders, dysphonia is a vocal disorder. Dysphonia is the scientific name for hoarseness or having a hoarse voice.

Symptoms are often changes to the quality of the voice including the voice being:

• Harsh
• Nasally
• Hoarse
• Breathy

Causes of dysphonia

In dysphonia, the larynx (voice box) functions improperly as air moves through it. When functioning properly, the vocal folds are moved toward the midline of the vocal tract by exhaled air. This also causes vibrations of the vocal folds which produce the voice.

There are a number of causes of dysphonia including vocal abuse. If you’ve lost your voice from cheering or yelling, you have experienced dysphonia. This isn’t the only cause, though. Neuromuscular issues, including multiple sclerosis and Parkinson’s disease, growths and polyps, allergens, and systemic diseases can also cause symptoms.

Treatment options for speech disorders

If you believe you are experiencing any signs or symptoms of speech disorders, you should talk through your concerns with your MS Treatment Team.

There are a number of exercise and strengthening exercises that can be used to help people with MS battle:

• Biofeedback
  • A gauge that can measure elements of the voice (including loudness and phrase length) during speech
  • Helps with breath control and breathing patterns during speech
• Exercise the muscles
  • Strengthening the muscles associated with speech including the tongue, mandible, lips, vocal cords, soft palate, and diaphragm improve speech
• Speech therapy
  • Speech pathologists have created programs to help overcome specific symptoms associated with speech disorders

Is multiple sclerosis an autoimmune disease?

According to the National Multiple Sclerosis Society, multiple sclerosis is an immune-mediated disease. There is discussion among experts whether it is accurate to call MS an autoimmune disease (such as lupus, Crohn’s disease, and rheumatoid arthritis).

In an autoimmune disease, the body’s immune system misidentifies a normally occurring antigen in the body and responds to it as if it were a foreign invader. While the same type of immune response occurs for people with multiple sclerosis, no antigen has been identified yet.

Signs & symptoms of multiple sclerosis

People with multiple sclerosis experience a variety of symptoms and symptoms can vary significantly from one person to another. In fact, depending on the location of the nerve fibers that have been affected, the symptoms may even change in severity day-to-day.

Two of the most common symptoms of multiple sclerosis are extreme fatigue and difficulty walking. Other symptoms of MS include:

• Tingling or pain in various parts of the body
• Sensations of an electric-shock that may happen with certain movements of the neck, especially while bending forward
• Weakness or numbness in one or more of your limbs
  • Often occurs on one side of your body at a time, or in the trunk and legs
• Prolonged double vision
• Partial or complete vision loss
  • Typically in one eye at a time
• Slurred speech
• Dizziness
• Body tremors
• Lack of coordination and/or unsteady gait
• Problems with bladder and bowel functions
• Muscle spasticity
• Cognitive issues involving memory, concentration and problem-solving skills
• Acute or chronic pain

Course of multiple sclerosis

MS often presents itself as a relapsing-remitting disease. Symptoms may be present for a few days or weeks at a time. Then, following a relapse into high disease activity, the symptoms may partially, or completely improve.

Remission (the time between flare ups of the disease) may last months, or even years for some people. The cyclical nature of the disease and the range of symptoms possible combine to make MS incredibly unpredictable.

Relapsing-remitting MS can turn into secondary-progressive MS. In secondary-progressive MS (SPMS), the symptoms are often worse and there is little or no time remission. Previous research showed that 50% of people would develop SPMS in 10 years, and 90% of people would develop it in 25 years. But, new treatments are being developed to slow or stop this progression.

Although MS is thought to be an autoimmune disorder, it is not like catching the flu or a cold. Multiple sclerosis is an incurable, lifelong disease and the symptoms can range from mild to completely disabling.

If you suspect you may have any of the symptoms of multiple sclerosis, speak with your physician, or a neurologist, as soon as possible.

Primary fatigue

Primary fatigue is defined as fatigue caused by damage to the central nervous system including the brain, brainstem, and spinal cord. This damage can be caused by either inflammation or demyelination.

Many scientists and researchers believe that the fatigue is caused as a result of how the brain adjusts to the impact of MS.

Doctors have conducted MRI scans on people who have MS fatigue to try and learn more about this symptom. The results indicate that these individuals use a much larger area of the brain to carry out everyday activities than people without MS related fatigue. Scientist believe this could be an indication that the brain is trying to find new pathways for the messages to travel through when the normal pathways have become affected.

More research is needed to better understand the full range of primary mechanisms that are responsible for this symptom. To date, the 3 most discussed mechanisms are:

• Cytokine influences
  • Interferon-γ
  • TNF-α
• Endocrine influences
  • Hypothalamic-pituitary-adrenal (HPA) axis
  • Hormone dehydroepiandrosterone (DHEA)
• Axonal loss and altered cerebral activation
  • See above with the MRI research which examined neural pathways

Secondary fatigue

Secondary fatigue is thought to be the result of issues that are related to multiple sclerosis, but are not directly caused by the disease. These include:

• Muscle weakness
• Acute and chronic pain
• Depression
• Tremors
• Stiffness
• Bladder incontinence
• Lack of sleep or broken sleep
• Muscle cramps and spams
• Medications

Many people who suffer from MS also experience anxiety and depression, which can make a person feel more fatigued than normal.

Additionally, fatigue is a common side effect of many medications used to treat MS. Always be mindful of any medications that you take and be sure that you are taking them as prescribed. If you are taking non-prescribed medications, including over-the-counter drugs, be sure to share that information with your doctor as the medications can have different side effects when they are mixed.

NOTE: Always speak with your multiple sclerosis treatment team about physical symptoms and issues of mental health. Your clinicians can help connect you to resources and health providers in your area.

Tips for managing MS fatigue

As is common with many chronic conditions, maintaining a healthy lifestyle will help decrease the severity of many symptoms. Eating healthy foods – particularly lean meats, fruits, and vegetables – can influence your energy levels. It can be useful to track the foods that you eat to get a better understanding of the source of the calories that you eat.

In addition to eating habits, the following are good strategies to help battle fatigue:

• Exercise
  • Walking, swimming, stretching, and other gentle exercises can be very useful
• Take naps
  • Even if you don’t sleep, resting can help
• Pace yourself
  • Building in time to rest during activities
• Manage stress
  • Music therapy, art therapy, and other stress relieving exercises can provide relief from stress
• Be patient with yourself

Looking for tips and tricks on how to battle fatigue? Check out support groups online and in-person.

What are SMART goals?

SMART is an acronym that can help you remember the important aspects of a good goal. All goals should be:

• S – specific
• M – measurable
• A – attainable
• R – relevant
• T – time-framed

When you follow the SMART goal setting technique it allows you to set realistic expectations, track your progress and it will help you to more easily obtain your goals. When using the SMART technique, you will think in the long term. For example, if this is your New Year’s resolution, think about what you want to accomplish the entire year and break this goal into smaller chunks of time.

A good way to start is by making two lists.

1. List #1
   • Make a list of everything you want to accomplish to help you get and stay healthy over the course of the year like walking or running a 5K or meditating for 30 minutes each day
2. List #2
   • Create a short list of specific health priorities for each month. Start with your first month and add 2 priorities. Then, only add 1 priority for each month thereafter

Digging into SMART goals

Once you have created your lists of top priorities and long-term goals, it’s time to put your plan into action. Here are the five criteria of the SMART technique for setting your health goals and allowing you to have the best chance of success.

• Specific
  • The more specific you make your goals, the better. Being specific will help you focus as well as help you see the goal being achieved.
  • Instead of saying “I’m going to start walking,”  be more detailed with your goals. For example: “I will walk around the neighborhood for 20-minutes on Monday, Wednesday and Friday morning before leaving for work.”
  • Be sure to include how long you will do this routine before increasing the behavior.
• Measurable
  • When have you achieved your goal? You won’t know unless your goal is measurable.
  • Instead of saying “I will eat better,” add an element that can be measured. For example: “I will eat 5 servings of vegetables each day.”
  • Only make goals that have solid measurable criteria.
• Achievable
  • It’s exciting to start a health program and it’s easy to get caught up in the amazing possibilities for a future YOU. But, it is extremely important that you make sure the goals you are setting are actually attainable.
  • For example, a goal of walking in a 5k charity walk in 3 months is much more achievable than making a goal to run a marathon. 
  • Gradually increase your goals as you succeed and you can build up to new goals that previously weren’t achievable.
• Realistic
  • Reaching your goal feels amazing…not reaching your goals can be discouraging. Before you commit your goals to a list on fridge, make sure they are doable.
  • Make sure your abilities and commitments will not interfere with realistically being able to achieve goals. It’s great to be ambitious, but impractical goals are easily abandoned.
• Timely
  • “Someday” will not get you out of bed early for your morning walk. Putting a date to your goals will give them accountability.
  • For example, “I will walk a 5K in 3 months and will walk for 15 minutes every Monday, Wednesday, and Friday leading up to the event.”

You can do it!

Regularly re-evaluating your goals is just as important as setting them. You can use the same SMART goals framework for re-evaluation. If it’s too easy (or too hard) you can adjust either the specifics, the measurement, or the timeframe to make it more appropriate for you.

Do not try to stick with goals that make you miserable. This will only make it more difficult to achieve them, which may eventually lead to not even attempting to achieve your ultimate goals. Choose activities that you enjoy doing and eat healthy foods that you enjoy eating.

And always remember: You’ve got this!