Biomechanical insights into gait rehabilitation for multiple sclerosis: a narrative review of exercise modalities and progressive training approaches

Abstract Introduction Gait dysfunction is a pervasive and debilitating symptom in people with multiple sclerosis (pwMS), characterized by reduced walking speed, shorter stride length, increased gait variability, and compromised postural control, significantly reducing quality of life. The aim of this study is to examine the effects of various exercise modalities on gait biomechanics, evaluate the role of progressive training principles in optimizing outcomes, and provide an evidence-based framework for individualized gait rehabilitation in MS, with the goal of developing targeted exercise strategies to effectively address the multifactorial nature of gait impairments. Objective This narrative review critically examines the biomechanical outcomes of structured exercise interventions for gait rehabilitation in pwMS, focusing on kinematic (e.g., joint angles), kinetic (e.g., ground reaction forces), and spatiotemporal (e.g., stride length, gait speed) parameters. It also assesses the role of progressive training principles, such as overload and task specificity, in optimizing functional outcomes. Methods A comprehensive literature search was conducted in PubMed, Web of Science, and Scopus (2005 to February 2025) following PRISMA guidelines. Randomized controlled trials (RCTs) and non-randomized trials evaluating structured exercise interventions targeting gait biomechanics in pwMS were included. Although this is a narrative review, a PRISMA-style flowchart was used to transparently illustrate the literature selection process. Results The review included 15 RCTs and 6 non RCTs with sample sizes ranging from 8 to 50 participants, covering resistance training, aerobic conditioning, balance exercises, cognitive-motor training, and multimodal approaches. Key findings indicated that resistance training improved joint torque and stride length, aerobic training enhanced gait speed and endurance, and multimodal protocols yielded the most comprehensive biomechanical benefits. Conclusion High-intensity, task-specific training significantly improves gait biomechanics in pwMS, but the heterogeneity in study designs, small sample sizes, and limited follow-up periods highlight the need for more standardized RCTs. Personalized, progressive training remains essential for optimizing gait rehabilitation outcomes in this population.