Mobility and Ambulation

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Written by Patricia G. Provance, PT, MSCS
Semi-retired physical therapist who specializes in rehabilitation for individuals with MS

With MS, maintaining safe and independent mobility can sometimes be difficult. The result is often a marked decrease in overall activity – which leads to preventable disuse weakness and deconditioning. If 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. My recommendation is for everyone with MS to receive a baseline evaluation from a physical therapist (PT) experienced in MS care.

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 later in the day)
• Weakness in leg(s) and/or trunk
• Deconditioning
• 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 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. Employing the “Four 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.

Evaluation of walking and gait training is 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. 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. Shoes 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:

• Foot-drop brace (the new lightweight carbon models are popular, but expensive, and only work for certain types of foot drop)
• Folding canes (those with a “palm-grip” are the most comfortable)
• Lightweight forearm crutches (those with cushioned grips and full cuffs are best)
• 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)
• Functional Electrical Stimulation ([FES] – this new wireless technology is only appropriate for some; it is also expensive and may not be 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, many wheeled mobility options are available for those with limited or no ambulation abilities.

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