Symptom Awareness: Mobility Independence and Safety, Part I

Written by Patricia G. Provance, PT, MSCS

Part I: Ambulation
(Please note that Part II and Part III will appear in future issues of The Motivator.)

When we hear the word “mobility,” most thoughts turn to walking. However, being mobile amounts to much, much more. If we think back to how we developed, we first learned to roll over, sit up, crawl, pull up and stand steadily before we started to walk. As many people challenged with the rainbow of symptoms associated with MS have discovered, maintaining safe and independent mobility can sometimes be difficult.

Unfortunately, the result is often a marked decrease in overall activity – which leads to preventable disuse weakness and de-conditioning. If the downward spiral from inactivity continues, other problems can develop. These include: muscle tightness and/or weakness; increased spasticity; bowel problems (usually constipation); decreased heart and lung function; pressure sores; depression; and social isolation.

Everyone should have the goal of achieving, and then maintaining, the highest possible level of independent function. This includes safe mobility – both at home and in the community. Since the primary goal of most individuals with MS is “to keep walking” or “to walk better,” this first of three articles will focus on issues related to gait (ambulation).

My recommendation is for everyone with MS to receive a baseline evaluation from a physical therapist (PT) experienced in MS care. Ideally, this should be done soon after diagnosis – but at the very least, at the first sign of problems with balance, walking, or endurance.

An evaluation can spotlight many subtle symptoms that can be addressed before they worsen into significant issues. These symptoms might include:

  • Fatigue/decreased endurance
  • Foot drop/drag (especially at the end of the day)
  • Weakness in leg(s) and/or trunk
  • De-conditioning
  • Mild spasticity (increased tone, which gets worse with fatigue)
  • Muscle tightness from inactivity
  • Compensatory movement patterns (such as “hiking” or lifting of the hip; leaning to clear the weak leg when walking; or using arms to help stand up)
  • Problems with balance (which may include a history of falls, “near-falls,” and/or difficulty on stairs)
  • Impaired vision or sensation
  • “Wobbly” walking

All of the above problems will affect independent walking and can be targeted in a corrective program.

The invisible and disabling symptom of fatigue requires behavioral or lifestyle modifications, including wise, energy-management practices. One good strategy is to follow the adage of “Pro-active REST instead of re-active COLLAPSE!” Employing the “4 P’s” of PACING, PRIORITIZATION, PLANNING, and POSITIONING can be helpful. Additional wise energy-management practices are to avoid over-heating, work toward appropriate strengthening and conditioning, employ good sleep practices, eat a healthy diet, and when needed, use an ambulation aid. Individuals who are heat-sensitive may use cooling techniques, such as taking a cool bath, sucking on ice chips, or using cooling devices such as collars or vests, to help fight fatigue.

Muscle tightness and spasticity will respond to slow-stretching and regular position changes. Weakness and balance dysfunction can be improved with corrective and compensatory strategies.

Evaluation of walking and gait training are extremely important and should be done both at the beginning and at the end of the therapy session to gauge the effect of fatigue. It is quite helpful if the therapy department has a variety of trial ambulation aids to see which (perhaps several) works best.

Understandably, many individuals with MS are initially quite reluctant to accept a walking aid and often delay going to therapy. Common reasons include: “…because I know they’ll want me to use a cane;” “…if I start using a walking aid, I’ll be dependent on it;” “…people will stare at me;” or “…it means that my MS is getting worse!”

From the standpoint of a PT – an “attitude adjustment” is often needed. I encourage my MS patients to view ambulation aids as “tools” that have the potential to “normalize” their walking pattern. By doing so, this can result in less fatigue, improved posture and balance, less pain, more endurance, and the correct training of the walking muscles.

I have witnessed dramatic improvement in patients’ gait and endurance by initially using these aids for “training,” and later, just “as needed” for issues such as distance, energy conservation, and worsening symptoms during MS flare-ups. Another factor often overlooked is shoe type, which should be supportive (having an enclosed heel) as well as lightweight. A rubber sole can add to stability, and supportive sneakers with a good cushioned insole and arch support may be an excellent option. However, rubber soles or sneakers may not be appropriate for everyone, particularly if foot drag or slide might be a problem – because a rubber sole can cause the foot to occasionally “stick.”

Many different ambulation “tools” are on the market, so a professional should be involved in assessing and prescribing those best suited to each person’s needs. The experienced PT can advise the physician regarding the needed prescription or letter of medical necessity (LOMN). It is not unusual for several aids to be prescribed in order to meet the varying needs for support, distance, and other factors. Some of the most popular ambulation aids are:

  • Folding canes (those with a “palm-grip” are the most comfortable)
  • Lightweight forearm crutches (those with cushioned hand grips and full cuffs are the most desirable)
  • Four-wheeled rolling walkers (for the active community user, a lightweight model is preferred, along with the following favorite features: a flip-up seat, no front-cross bar, user-friendly brakes, and a flexible backrest)
  • Foot-drop brace (the new lightweight carbon models are popular, but expensive, and only work for certain types of foot drop)
  • Functional Electrical Stimulation (FES) – this new wireless technology is only appropriate for some; it is also extremely expensive and is not yet covered by insurance; a PT evaluation is highly recommended before purchasing this type of aid

Achieving and maintaining smooth, safe, and independent ambulation will certainly result in improved health and quality of life. However, when that is not possible, numerous wheeled mobility options are available for those with limited or no ambulation abilities. Exercise at any level of ambulation also plays an important role. These will be the topics of the next two articles in this series, which will include “Improving Functional Mobility with Exercise” and “Wheeled Mobility.”

MSAA, in conjunction with Acorda Therapeutics, Inc., recently conducted a survey on mobility and exercise. More than 2500 of MSAA’s clients responded. Based on the results, MSAA found that a significant majority of the respondents indicated that limitations in walking affected the activities in which they were able to participate. While many could benefit from exercise, 25 percent of the respondents had not spoken with their healthcare team about exercise, and 38 percent either never or only occasionally exercise. We hope that MSAA’s articles, such as this one on the topic of ambulation, will help to support and encourage individuals to speak to their healthcare team about the possible benefits of appropriate exercise and/or physical therapy.

This article is one of a series of three that have been written and generously provided to MSAA by Patricia G. Provance, PT, MSCS. Pat is an esteemed member of MSAA’s Healthcare Advisory Council.

Pat has 37 years of experience in physical rehabilitation, having been in clinical practice since 1971. In 1982, she started the first MS Rehabilitation Program in Maryland at The Union Memorial Hospital, in addition to her orthopedic caseload. In 2000, Pat joined the University of Maryland Medical System at Kernan Hospital to dedicate her practice to MS, and continued as a clinical consultant with the Maryland Center for MS until her “semi-retirement” in December 2006. She became an MS Certified Specialist in 2005 and continues as a clinical consultant with the National Multiple Sclerosis Society. Pat is also an active member of The Consortium of Multiple Sclerosis Centers. She currently is teaching and consulting on MS care to patients and professionals throughout the country. Publications include the clinical bulletin, “Physical Therapy in Multiple Sclerosis Rehabilitation,” and co-authorship of the textbook, Muscles, Testing and Function with Posture and Pain, 4th and 5th editions.