MS patient
Monica Schmieder
Description
Collection
Title:
MS patient
Creator:
Monica Schmieder
Date:
3/1/2007
Text:
I posted the following question a few weeks ago. Thank you for your responses. In case you are interested, some of the replies I received are also below.
I have seen an MS patient with foot drop of her right foot. Statically, she is able to dorsiflex, but when she walks, her foot planter flexes and causes the toe drag. So it seems that her gastrocnemius is firing at the wrong time of her gait cycle and will not allow her foot to dorsiflex during the swing phase. Has anyone seen this and if so, how did you address the foot drop?
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Our company, DeRoyal, manufactures a dynamic ankle orthosis that applies a low load to the gastro area, pushing downward on the heel and allowing the foot to dorsiflex naturally. This unit, the DeROM Ankle is available through SPS, Pel, Knit-Rite, Fillauer, Cascade & Kingsley. You can see the orthosis on our web site: www.deroyal.com.
I had pretty good success fitting this type of pt with the otto bock walk on afo. Because it is very lightweight and provides just enough to help pick up the toes the pts seem to like it-just gives them some pick up and a little spring when they walk and it isn't bulky or heavy. Seemed to work the best.
I have had countless MS patients that display the same symptoms. What I found was that the dorsiflexors test well statically but fatigue out within three to five steps. It has been my experience that Manual Muscle test is not a reliable tool for these patients. I use interview and therapist observations as well as shoe wear patterns more than MM test. In any event,if this is the case I brace as normal for foot drop, being sure to evaluate heel cord tone and tightness.
I just evaluated an MS patient last week who had an extension synergy - he ambulates with the knee in full extension and a lot of PF tone. He's a successful WalkAide wearer. He can get great DF/Eversion when he is sitting, but the DF is limited to about 90 degrees when he's ambulating. I wonder if you're patient has some extension tone when standing/ambulating.
The Step-Smart brace is embraced by many M.S. patients. This would
allow you as the practitioner to dial in the proper amount of
resistance using the Jacob Joint.
The custom solution (through our central fab) is guaranteed, so you can
return it for a full refund if it does not solve this issue.
www.insightful-products.com
I think you have a tone reflex going on. See if this pt. also has clonus. I betcha they do.
So you need support but not excitement to the foot on ground contact. I would go with a OOS to secure the foot, or a inner boot flexible shell to surround the foot, and lock in with a rigid footplate. I would use Double Action joints due to her dig. of MS the condition will probably get worse, and you will not regret having the adjustment.
OttoBock Salt Lake just did such an orthosis for me and it turned out real nice.
Your MS patients' anterior tibials are unable to fire because
demyelination (cord) has interrupted the nerve supply - unless
medical scientists come up with a re-myelinating solution etc. she
will not regain lost voluntary powered dorsiflexion and depending on
the type (classification) of MS and medical treatment (drug
therapy) her symptoms may progress slowly, rapidly or remain
static.
Have you done a full muscle strength work-up of both lower limbs,
or, only an observational gait analysis which demonstrated a foot
slap steppage gait pattern typical of a common peroneal nerve
palsy? With a full work-up you might be surprised by what you
discover.
If you do a muscle strength test I would be surprised if you didn't
find some loss of plantar flexor power (it may not be measurable) -
do it at the end of the day, her dorsiflexors will remain relatively
unchanged. She may have some loss of Quads but this could
also be v.difficult to measure - ask her about knee flexion instability
i.e. if she feels a bit wobbly on her knee(s) occasionally.
The most common difficulty for MS patients is fatigue. Anything
that you provide needs to be lightweight to avoid contributing to this
debilitating systemic state.
This patient's neurologist would have done a physical work-up and
this informational, if available, would be useful to have whilst doing
your own assessment.
The following recommendation is based on an assumption that the
paresis is flaccid and there is no achilles syndrome (shortening).
Therefore she does not need ML or AP motion limiting ankle
control.
Orthosis - initially, keep it simple:
Do not interfere with ankle ROM, this person will be sensitive to
any alteration in her weight line that will impact on knee stability -
stair descent could become a problem.
Deal with the issue in a similar manner to a flaccid common
peroneal palsy i.e. Tamarack dorsi-assist ankle joints in a
copolymer AFO with no plantar flexion stop. ML control and torque
of the AFO are not issues but many MS patients are affected by
heat retention - cut a large window in the posterior proximal shell to
reduce weight/heat - carry your plantar trim to just distal to the
met. heads. Experiment with tamarack ankle stiffness starting
with a minimal durometer and be guided by your patient's feedback
and not entirely on observation - you will probably find that she will
select a durometer that is less than the stiffness required for
optimal gait. This is because she will not particularly like the
minimally induced knee flexion moment following heel strike that
you can't see but she can feel. Include stair descent in your
observational gait analysis.
I have tried off the shelf carbon composite solutions i.e. Trulife
Matrix etc. but have found these to be more useful as a secondary
device that is more suited to sedentary low activity use i.e similar
to slippers worn within the house.
This is very common in MS patients - they have good conscious motor
control and can dorsiflex 5/5 open chain, but walk as if they were 0/5
with flaccid footdrop. The pathophysiology behind this is the MS caused
dysfunction of the Muscle Spindles and Golgi Ligament Endings in the
proprioceptive system, causing them to loose their ability to trigger
the stretch reflex. The anterior tibialis looses it's turn-on
mechanism and never fires reactively during function.
Now because the ankle is plantarflexing, the gastroc can't be turned on
because it's shortening and not being stretched. Nix that idea.
Gravity is making the toes point to the ground.
We've had great luck with the ToeOFF in helping these patients have a
much more normal, dynamic and propulsive gait.
The PFlexrs are the strong muscle group and over fire in MS..I have had
great success using the Ossur Graphite lite...great fit and the only thing
to do is get a bigger shoe I have a personal friend who swears by
them..she's bilat...But if the knee is involved there is not blocking the
hyperextension
I have seen an MS patient with foot drop of her right foot. Statically, she is able to dorsiflex, but when she walks, her foot planter flexes and causes the toe drag. So it seems that her gastrocnemius is firing at the wrong time of her gait cycle and will not allow her foot to dorsiflex during the swing phase. Has anyone seen this and if so, how did you address the foot drop?
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Our company, DeRoyal, manufactures a dynamic ankle orthosis that applies a low load to the gastro area, pushing downward on the heel and allowing the foot to dorsiflex naturally. This unit, the DeROM Ankle is available through SPS, Pel, Knit-Rite, Fillauer, Cascade & Kingsley. You can see the orthosis on our web site: www.deroyal.com.
I had pretty good success fitting this type of pt with the otto bock walk on afo. Because it is very lightweight and provides just enough to help pick up the toes the pts seem to like it-just gives them some pick up and a little spring when they walk and it isn't bulky or heavy. Seemed to work the best.
I have had countless MS patients that display the same symptoms. What I found was that the dorsiflexors test well statically but fatigue out within three to five steps. It has been my experience that Manual Muscle test is not a reliable tool for these patients. I use interview and therapist observations as well as shoe wear patterns more than MM test. In any event,if this is the case I brace as normal for foot drop, being sure to evaluate heel cord tone and tightness.
I just evaluated an MS patient last week who had an extension synergy - he ambulates with the knee in full extension and a lot of PF tone. He's a successful WalkAide wearer. He can get great DF/Eversion when he is sitting, but the DF is limited to about 90 degrees when he's ambulating. I wonder if you're patient has some extension tone when standing/ambulating.
The Step-Smart brace is embraced by many M.S. patients. This would
allow you as the practitioner to dial in the proper amount of
resistance using the Jacob Joint.
The custom solution (through our central fab) is guaranteed, so you can
return it for a full refund if it does not solve this issue.
www.insightful-products.com
I think you have a tone reflex going on. See if this pt. also has clonus. I betcha they do.
So you need support but not excitement to the foot on ground contact. I would go with a OOS to secure the foot, or a inner boot flexible shell to surround the foot, and lock in with a rigid footplate. I would use Double Action joints due to her dig. of MS the condition will probably get worse, and you will not regret having the adjustment.
OttoBock Salt Lake just did such an orthosis for me and it turned out real nice.
Your MS patients' anterior tibials are unable to fire because
demyelination (cord) has interrupted the nerve supply - unless
medical scientists come up with a re-myelinating solution etc. she
will not regain lost voluntary powered dorsiflexion and depending on
the type (classification) of MS and medical treatment (drug
therapy) her symptoms may progress slowly, rapidly or remain
static.
Have you done a full muscle strength work-up of both lower limbs,
or, only an observational gait analysis which demonstrated a foot
slap steppage gait pattern typical of a common peroneal nerve
palsy? With a full work-up you might be surprised by what you
discover.
If you do a muscle strength test I would be surprised if you didn't
find some loss of plantar flexor power (it may not be measurable) -
do it at the end of the day, her dorsiflexors will remain relatively
unchanged. She may have some loss of Quads but this could
also be v.difficult to measure - ask her about knee flexion instability
i.e. if she feels a bit wobbly on her knee(s) occasionally.
The most common difficulty for MS patients is fatigue. Anything
that you provide needs to be lightweight to avoid contributing to this
debilitating systemic state.
This patient's neurologist would have done a physical work-up and
this informational, if available, would be useful to have whilst doing
your own assessment.
The following recommendation is based on an assumption that the
paresis is flaccid and there is no achilles syndrome (shortening).
Therefore she does not need ML or AP motion limiting ankle
control.
Orthosis - initially, keep it simple:
Do not interfere with ankle ROM, this person will be sensitive to
any alteration in her weight line that will impact on knee stability -
stair descent could become a problem.
Deal with the issue in a similar manner to a flaccid common
peroneal palsy i.e. Tamarack dorsi-assist ankle joints in a
copolymer AFO with no plantar flexion stop. ML control and torque
of the AFO are not issues but many MS patients are affected by
heat retention - cut a large window in the posterior proximal shell to
reduce weight/heat - carry your plantar trim to just distal to the
met. heads. Experiment with tamarack ankle stiffness starting
with a minimal durometer and be guided by your patient's feedback
and not entirely on observation - you will probably find that she will
select a durometer that is less than the stiffness required for
optimal gait. This is because she will not particularly like the
minimally induced knee flexion moment following heel strike that
you can't see but she can feel. Include stair descent in your
observational gait analysis.
I have tried off the shelf carbon composite solutions i.e. Trulife
Matrix etc. but have found these to be more useful as a secondary
device that is more suited to sedentary low activity use i.e similar
to slippers worn within the house.
This is very common in MS patients - they have good conscious motor
control and can dorsiflex 5/5 open chain, but walk as if they were 0/5
with flaccid footdrop. The pathophysiology behind this is the MS caused
dysfunction of the Muscle Spindles and Golgi Ligament Endings in the
proprioceptive system, causing them to loose their ability to trigger
the stretch reflex. The anterior tibialis looses it's turn-on
mechanism and never fires reactively during function.
Now because the ankle is plantarflexing, the gastroc can't be turned on
because it's shortening and not being stretched. Nix that idea.
Gravity is making the toes point to the ground.
We've had great luck with the ToeOFF in helping these patients have a
much more normal, dynamic and propulsive gait.
The PFlexrs are the strong muscle group and over fire in MS..I have had
great success using the Ossur Graphite lite...great fit and the only thing
to do is get a bigger shoe I have a personal friend who swears by
them..she's bilat...But if the knee is involved there is not blocking the
hyperextension
Citation
Monica Schmieder, “MS patient,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 4, 2024, https://library.drfop.org/items/show/227993.
