Gait characteristics of MSers in the absence of disability.

No disability on EDSS but subtle deficits when assessed with more sensitive test. #MSBlog #MSResearch 

“This study demonstrates a point I have made on numerous occasions that despite having little, or no, disability on the EDSS, a physician-rated scale, when you do more challenging and detailed assessments MSers have subtle deficits. The so called hidden, early burden, of this disease is not detected using the EDSS. These deficits are not noticed or ignored as most MSers have compensatory mechanisms to cope with them. The problem starts when these compensatory mechanisms, or the so called brain reserve, is exhausted; this is when fixed disability or progressive disease starts. The so called MS iceberg just got a whole lot bigger.” 

“These hidden deficits although subtle do manifest in other ways, for example fatigue and reduced attention and concentration spans. The so called hidden deficits probably account for a lot of problems MSers have in the competitive environments, in particular in work and on the sports field.” 

“Is there a solution to iceberg problem? Yes, you should not ignore it and do not simply that because you are well and fully functional that your MS is in remission and/or not causing damage. You need to ask your neurologist to assess your MS disease activity using more sensitive tools, in particular using MRI.”

Nogueira et al. Gait characteristics of multiple sclerosis patients in the absence of clinical disability. Disabil Rehabil. 2013 Aug;35(17):1472-8

Purpose: Motor deficits in lower extremities and gait abnormalities are a major feature of MS. MSers with minimal clinical disability have subtle gait changes. The aim of this study was to analyze the gait characteristics of MSers in the absence of clinical disability.

Method: A case-control study was carried out with 12 MSers and 12 matched healthy controls. The subjects underwent a clinical neurological evaluation to determine their disability level (EDSS ≤ 1.5). Then, the subjects were referred for completion self-report questionnaires (gait, perceived balance confidence, physical activity and fatigue), gait clinical trials, and 3D kinematic analysis.

Results: MSers showed more impairment of perceived fatigue, perceived of walking impact and perceived balance confidence, despite having no disability. Gait characteristics showed no differences when they were determined by clinical observation. The 3D kinematic analysis of gait showed slight but significant changes in ankle movement.

Conclusion: MSers with no clinical disability have discrete changes in gait that can be evidenced by perceived impact on walking and kinematic evaluation, mainly of ankle movement. Moreover, there is a decrease in perceived balance confidence and an increase in perceived fatigue, which are correlated despite having different origins.

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • I'm coming round to the view that prevention is the only real option. Once the disease starts, even at the earliest stage, it's too late. I was dx in my late 30s with RRMS, but was always rubbish at sport at school (never very quick / underlying lethargy – glandular fever at 14). I wonder if this was an early indication that things had started to go wrong. Really hope the Charcot project is a success for future generations. I suspect the frustations aired on this site reflects the fact that those of us with the disease know we're never going to be well again.

  • Agreed (re frustrations) – the days of hoping that some form of therapy/cure would happen in time to make a real difference is an optimistic hope I have learned to relegate to the bin, sadly. So frustrating that I was pleased to not be deemed 'bad enough' to be offered DMDs when they might have reduced future disability. 🙁

  • Agree that early treatment with effective DMTs hopefully resulting in cessation is a paramount option but we haven't really scratched the surface regarding neuroprotective therapies which can be used as an adjunctive option in early MS but also can be used in the later stages of MS where DMTs are likely to have less efficacy. We have a mound of experimental data on candidates from our mouse studies and now Prof G is getting the clinical trials underway 2 are ongoing. My feeling is that a combination of effective DMTs and neuroprotectants will make a real difference. There is now a real focus on the later stages of MS as evidenced by an increasing number of clinical trials in this area with the newer effective DMTs and who knows, the Charcot project may come up trups too.
    I wish (as you do) that the progress could be faster.

  • Dear Mouse Doctor and Professor G,
    There's one way to reduce your local neurologist to helpless laughter. Imagine, if you will, the doctors' lounge after consulting hours on MS clinic day and the following conversation.

    Doctor (still wiping tears of laughter from eyes) 'Do you know what three of my RRMS patients asked for?'
    Other neurologist; 'Go on, what was it this time, CCSVI? LDN? Lemtrada?'
    Doctor: 'No. I'm quoting now, but, but (sniggers) they read it on the Barts blog!'
    "Is there a solution to iceberg problem? Yes, you should not ignore it and do not simply that because you are well and fully functional that your MS is in remission and/or not causing damage. You need to ask your neurologist to assess your MS disease activity using more sensitive tools, in particular using MRI."

    Annual MRIs…..? What planet are these patients on?'
    Pause whilst other doctor wipes up spilt coffee.

    The end.

    Pause whilst other doctor cleans up spilt coffee.
    The end.

    • That was quite creative, Anon 11:13am, and true in a way.

      MRIs cost too much money to administer and the NHS often wastes money with ultrasound scans on ligament/ muscle damage when they ought to order an MRI scan. The NHS are charged £300 for every MRI scan and additional hundreds for radiologist examinations. The cost is far too much, which means MSers are rarely scanned again after initial diagnosis.

      Prof G isn't living in the world that MSers like us are. We have to fight for everything. Neurology teams see us as an inconvenience; people beyond hope.

      The Charcot Project will probably fail the way attempts to link viruses as the causation of cancer did in the '90s. Neuroprotective therapies remain a pipedream. We are given 'maybes' when what we should have by now is 'sure things'. The goodwill MS campaigns have had until now are losing support. Our eyes are opening and it's safe to say that we've been had.

    • EBV and Burkitt's lymphoma, HPV and cervical cancers…….cancer has many different triggers, pathways etc.:-)
      Agreed, pace of drug development and other therapies is too slow.

  • Thankyou for this post.

    In the early stagesl, I think, there is ofen a disjunct between how the day to day experience living it (with the knockon hard to pin down cognition and fatigue impacts) and how low edss or less visible symptons are viewed by others including a surprising and significant proportion of medical professinals.

    I have heard medical researchers and ms society staffers (in Oz) quite dismissive of ms-ers that are still scoring relatively low on the EDSS but have left the workforce or changed to part time work within only a few years of diagnosis. There seemed to be a lack of comprehension of just how much 'below the iceberg' stuff was/is going on for many.

  • You are living I another world with lots of the posts. 1.Not one of you has MS .2. You would not cope if you did and 3. Many need to be sacked or resign for their real lack of knowledge instead of copying and pasting links to cover your backs

By Prof G



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