MS patient with dropfoot problem

[slasherkill]

Hello all,

first of all! I'm from norway and I'm studying physiotherapy in Holland.

I have a patient now at internship and he has got MS.
He has had the diagnose since 1992, then they treated him with "cortison" and that really helped alot. The symptoms almost disappeared but after 6-7 years, they came back after alot of stress. Hig biggest and "only" problem is the dropfoot.

He has strength 2 MRC on ankle dorsiflexion and hip flexion 3+ MRC. They have trained with him for the last 2 years now and very specific on the ankle problem. but the results are not good. I feel when checking his ROM that he is very stiff and have some spasticity in the M. gastrocnemius and the akilles is very tense. Is it possible to stretch that area so that it will be better after some time. or is a surgery the only way? any treatment options would be very much appreciated!

Thanks!!

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[Canuck Physio]

Hello,

Here is some interesting information about Gait in MS patients:

Gait abnormalities (Benedetti et al., 1999):
A movement analysis technique was used to identify Gait parameters indicative of Impaired Motor Function during Walking.

Abnormalities related primarily to Time-Distance Parameters were identified regardless the severity of the clinical score:

1. Reduced Speed Of Progression
* Shorter Strides
* Prolonged Double Support Phase
2. Muscular Function
* Premature Recruitment Of Gastrocnemius
* Late Relaxation of Tibialis Anterior during Stance Phase

It appears that Muscular Function is impaired in these patients, and 'movement fascilitation' and 'proprioceptive feedback' is important in enhancing the patients response to treatment.

Ref: Benedetti MG, Piperno R, Simoncini L, Bonato P, Tonini A, Giannini S. (1999) Gait Abnormalities In Minimally Impaired MS. Mult Scler 1999 Oct;5(5):363-8.

[Hessa]

whay not youtray casting for 2 weeks ,but check first weather he has diabetes or hypertention or any skin problems..
also you can yous functional electrical stimulation on tibialis anterior muscles( to stimulate its function) as it is delayed in recruitment>>
Regards>>
Hessa

[gcoe]

Hi Slasherkill

It sounds like you are on to it but here are some things you could double check on. I think that it is worth being as precise as you can about identifying the predominant impairment(s) before deciding on your management. So I suggest you be more specific and clarify in your head what is really going on ( I know you may have done this already but if not have a go).

From your assessment the patient has:


1. weakness of the dorsiflexors - One thing I would be interested to know is more about the type of contraction in tib ant the patient can produce From an assessment To prevent foot drop he needs to be able to dorsiflex within the mid to inner range prior to initial contact and also produce an eccentric contraction and initial contact - Any deficit you note would be worth tackling. I agree that FES can be very helpful here - if you have access to a unit with a heel switch then stimulate the dorsiflexors when the heel switch is off (swing phase) and stimulation is off when the heel switch is on. Have the unit slowly ramp down so that at contact response you get an eccentric contraction

2. tightness of the plantarflexors/ restricted dorsiflexion and you think spasticity is present. Carefully checked out whether this is mainly a:

a) non contractile issue with the plantar flexors, (see also if you can differentiate if it is soleus or gastrocnemius which is predominantly tight a combined program of casting wearing an AFO when not in a cast and stretches may be warranted

b) an articular problem (ankle joint stiffness to dorsiflexion) superimposed on tight plantarflexors then do the above but also include mobilisations

c) if there is a contractile/spasticity issue - have a good look at velocity dependent stretch – for a measure try the Tardieu scale for spasticity - it is a more valid test than the Ashworth scale. If spasticity is a major issue then a combination of a botox injection in to the gastroc/soleus combined with an aggressive casting, stretching and stimulation program may be helpful that is if botox is available

Hope this is of help. If you would like an English copy of the Tardieu scale I would be happy to forward it to you. the original is in French

All the best with your studies

[physiobob]

His biggest and "only" problem is the dropfoot.

Get him into a SAFO (Silicon Ankle Foot Orthoses. I have been using these now for 2 years in the UK with foot drop in some neurological patients e.g. Inclusion Body Myositis. Recently I tried going back with a patient with a foot drop post hip replacement as a way to give a quick solution. It was so bad I am never going that route again.

The S.A.F.O's are amazingly good. Have a look at the following links for more information

SAFO - The Silicone Ankle Foot Orthosis from Dorset orthopaedic, Ringwood, Dorset , UK

General Orthotics, Silicone Ankle Foot Orthosis (SAFO) & Spinal Jackets/Braces

The Silicone Ankle Foot Orthosis (SAFO), a New Generation in Orthotics | American Academy of Orthotists & Prosthetists

[slasherkill]

Thanks to all of you for the good replies! I will take a closer look next year, when I have more time.

Happy new year!

[PhysioArgos]

Thanks Bob, I'm a cardiorespiratory physio and I've never heard about SAFO. Looks very good.