Walking Ambulation

Movement impairment frequently is associated with MS, and difficulty in walking is a major type of such impairment. Walking is an activity that we value, perhaps far beyond its true value. Walking usually is done to get somewhere—it is a means of transportation. If walking becomes impaired, another more practical means to accomplish the same goal should be substituted, theoretically without too much emotional trauma. This is easy to say but more difficult in practice. However, understanding why we walk may help when selecting appropriate devices to aid in walking.

Weak foot muscles may cause a foot drop, in which the toes of the weak foot touch the ground before the heel, thereby disrupting balance. Because there is no way to strengthen a weakened foot, compensation techniques become essential.

It is particularly important to wear proper shoes. I recommend a leather-soled oxford. The laces gives maximum stability to the foot, and the smooth leather sole prevents the sticking that often occurs with crepe or similar types of soles that can throw you off balance. Leather soles wear with time and need to be replaced rather frequently, but their advantages far outweigh this minor problem. A plastic (polypropylene) insert often is added to the shoe to keep the foot from dropping. This lightweight brace (an ankle-foot orthosis, or AFO) picks up the foot and allows it to follow through in the normal heel-foot manner.

An AFO also may be designed to decrease spasticity by tilting the foot to a specified angle and keeping it from turning in or out (inverting or everting). Its proper use decreases fatigue while increasing stability. To provide optimal support, such orthoses must be fitted by a specialist called an orthotist. AFOs have been improved in the past few years so that they can be hinged and placed at virtually any appropriate angle. The newer AFOs are stronger and more helpful than previous types.

A metal brace that fits outside the shoe may be needed if there is a significant increase in tone at the ankle, which is perceived as

Klenzak Foot Brace

stiffness. The brace is a springloaded device that keeps the toe from dropping. Fortunately, the development of new lightweight materials, including plastics and aluminum, has decreased the need to use the more cumbersome heavy metal (Klenzak™) braces.

If your hip muscles also are weak, you will swing your leg out in front to allow the foot to clear the ground. To maintain stability while doing this, the knee often is forced back farther than it should be, resulting in a condition termed hyperextension. This movement puts significant stress on your knee. After a while it will begin to hurt and may become swollen from arthritis. To prevent this condition from developing, a device called a Swedish hyperextension cage may be fashioned to prevent the knee from snapping back. A cus tom-made knee brace may be necessary if the knee cage cannot be fitted properly.

With the aid of such devices, walking with less fatigue may again become realistic. However, if balance also is a problem, another assistive device may be needed such as a cane. Braces, canes, and crutches should be regarded as "tools" in the same way that a hammer or a drill is a carpenter's tool. It is wrong to think that you are "giving in" by using a cane or a brace. If a carpenter wants to drill a hole, he must use the proper drill or the hole will be wrong. A person with impaired mobility who does not use the right tool cannot accomplish the job of walking. Although it may be difficult at first, try not to have negative emotional feelings about using assistive devices. They simply are tools to improve mobility.

A cane usually is carried in the hand opposite the weak leg. The activity of walking is reciprocal; that is, the left hand goes forward with the right foot, and vice versa. When a person walks with a cane, the cane should precede or accompany the weak leg. Walking with a cane held on the weak side may cause a noticeable limp.

If weakness is pronounced in both legs, two canes may be needed. The same reciprocal pattern applies: the left foot and right hand go forward together; the right foot and left hand go together. Walking in this fashion is slower, but there always are three points on the ground to provide increased balance and stability.

When walking stairs, the saying that applies is "up with the good, down with the bad." Step up first with the strong leg when climbing stairs, and step down first with the weak leg when descending. This pattern makes the strong leg do all the work of lifting and lowering. Again, the cane should accompany or precede the weak leg. Use a railing for support whenever possible. If a railing is on the same side as the cane, merely shift the cane to the other hand and use the stair-walking pattern described.

If balance and weakness are more severe, it may be necessary to use forearm (Lofstrand™) crutches. These crutches provide greater stability than a standard cane, and their use does not require as much strength in the upper extremities. The patterns described for walking with a cane apply equally to walking with the aid of forearm crutches.

A walker may be the proper assistive tool if your balance is especially poor. The usual pattern to be used is as follows: walker forward at arms length, weak leg, then strong leg. Take normal-sized steps, and avoid stepping past the front of the walker. Walkers come in many varieties. If your gait needs maximum stability, it is best to use a walker without wheels. Some of the newer types have larger wheels as well as seats. They can move very smoothly and allow you to take rest periods by locking the brakes and sitting.

To measure the proper height for all assistive devices, place the device six inches away from the side of the foot, and adjust the handles so that the elbow is bent approximately 25 degrees. As with any specialized tool, it is important to have the right tool, to have it fitted properly, and to know how to use it correctly. An experienced physical therapist should be helpful in ensuring a proper fit.

If walking is still extremely difficult or impossible despite the selection of excellent devices, a wheelchair may be your correct choice. You should not resist using a wheelchair; try to view it simply another mobility tool. Selecting from the many types of wheelchairs available depends on many factors, including your size and weight, strength, and level of energy. A standard manual wheelchair often does not offer people with MS sufficient independence because of the fatigue that is generated by operating the chair and the coordination that is necessary to control it.

Three-wheeled motorized scooters are a boon for people with MS because they do not carry the negative stigma with which regular wheelchairs may be inappropriately perceived. Although scooters are extremely useful, they are best used by people who have retained some means of walking, because their seating systems are not designed for sitting all day. Those who do not possess the ambulatory skills necessary to use a three-wheeler appropriately may achieve independence with one of the newer lightweight motorized wheelchairs.

Three Wheeled Motorized Scooter

Lightweight three-wheeled scooter with tiller steering and hand brake.

(Courtesy of Bruno Incorporated).

Lightweight three-wheeled scooter with tiller steering and hand brake.

(Courtesy of Bruno Incorporated).

The key to choosing a chair or a scooter is independence. The proper device should be selected to regain control and independence in the environment. Again, help from a physical therapist, occupational therapist, or a physician who understands the use of the chair is necessary to select the most appropriate one.

There is no reason not to be mobile in today's world. The right assistive device coupled with the right attitude can make all the difference. You must remember that the idea is to get where you want to go. It really does not matter how you get there.

If you need an assistive device to maintain your mobility, transportation by car, bus, van, or other means should accommodate the

Ambulation Assistance Devices
Common styles of power bases used to provide electric-powered mobility.

device. You will need proper consultation for van lifts, and it is essential to learn about local public transportation that will accommodate the devices. Working toward accessibility is in everyone's best interest and should be encouraged in every way that is appropriate to your living situation.

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  • manfredo
    Does the good leg or bad leg go first in ambulation with assistive device?
    7 years ago

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