Focus on: using orthoses to improve walking difficulties in MS
Many people with MS experience walking difficulties. For some, this might be a weakness in the leg, for others foot drop and stumbling. Here orthotist, Emma Davidson, explains how orthotic devices – such as braces and splints – can help to manage these problems, enabling people to maintain their mobility and keep doing the activities they enjoy most.
What is an orthotist?
Orthotists provide gait analysis and engineering solutions to people with problems affecting the neuromuscular and skeletal systems. We treat a wide range of conditions including MS, diabetes, and arthritis, as well as sports injuries and trauma.
What are orthoses?
An orthosis is any brace worn on the body, including insoles, ankle and knee braces, spinal jackets and wrist supports.
Orthoses differ from prostheses because the people we treat haven’t lost a limb, but require external support to a part of their body which has reduced function.
Orthoses can help people with MS in several ways; they can improve mobility, eliminate gait deviations, reduce the risk of falls, reduce pain, and prevent the risk of developing skin pressure sores.
Ankle-foot orthosis (AFO)
An ankle-foot orthosis, or AFO, is probably the most commonly used orthotic device among people with MS. An AFO is any brace that covers the foot and ankle area and is sometimes referred to as a ‘splint’.
The materials used differ depending on the support needed, they can be completely rigid to immobilise the ankle or they may be more flexible to encourage movement in certain directions. The AFOs we prescribe can be an off-the-shelf product or completely custom-made for the person, it all depends on the clinical need.
Elasticated supports such as a ‘Foot up’ or Prim Airmed are often used in the early stages of treating a footdrop. These are excellent devices to help lift the foot when there is an isolated weakness. The main benefit of this style of device is that there is nothing hard within the shoe however they do require footwear with the ability to attach the clips.
Prescription insoles can be made from a cast or 3D scan of the person’s foot and are inserted into the shoe. They can be used to correct problems such as abnormal walking patterns, reduce pain or relieve pressure on certain areas of the foot. Like AFOs, insoles can be an off-the-shelf or custom-made device.
Resting splints may also be used. Quite often people with MS have problems with muscle contractures or increased muscle tone that causes tightness of joints. As part of contracture management, you might have Botox injections and a stretching programme, but you can also be given a resting brace from orthotics, for example for your hand or wrist, to help rest or support it in a better position.
Positional braces can be sheepskin lined and are moulded to the best position you can get your wrist and hand into. They’re strapped on with Velcro and worn overnight to provide a passive stretch.
There are similar braces for the ankle. People who have Achilles tendon contractures or tightness around the ankle can wear a positional splint at night to create a stretch.
Sport Specific Orthoses
Most Ankle foot orthoses are designed with walking in mind, not to say that they cant be used for sport however, it was often not what their intended purpose is. Sport specific orthoses are often not available on the NHS requiring suffers to purchase these devices privately.
Carbon Fibre AFO's
Using AFOs to treat foot drop
An ankle-foot orthosis may be used for foot drop, but sometimes it’s a more complex picture.
Often in MS, people don’t have drop foot or a weakness of their ankle dorsiflexors (the muscles at the front of your ankle) in isolation. There’s often other subtle symptoms involved – such as other weakness, balance issues, changes in muscle tone, fatigue or issues with sensation – but it all gets clumped together under foot drop because the foot catching on the floor is what is seen clinically.
It’s essential to establish what’s causing the drop foot. An AFO would be the right treatment option for ankle weakness, but if it’s caused by weakness somewhere else, it may not be appropriate.
How visible are they?
Most orthoses are designed to be worn next to the skin, under your clothes – so they’re discreet from that point of view.
However, the greater the functional loss, the more support is needed, which may require a bulkier orthotic, so they’re not always invisible.
Getting used to wearing an orthosis
It’s a gradual process over a few weeks to get used to any type of orthosis. Your orthotist should give you advice on a gradual breaking in period. They will give you wear and care advice around checking your skin for any abrasions or pressure points, the most suitable type of socks and shoes to wear, and whether you need to wear a barrier (like a legging) next to your skin.
An orthosis doesn’t necessarily have to be worn all the time – it depends on the functional loss, when you need the support and whether it’s a functional day splint or resting splint.
Some people wear an orthosis morning until night. Others come to us because they’re struggling with a specific activity (such as running a 5k) so the brace is only worn during that activity. If you have an orthosis for walking, then you’d take it off at night when you’re resting.
There’s still a stigma attached to braces. People think they’ll be a heavy, archaic device and don’t always see them in a positive way.
A lot of people with MS who I’ve treated have benefited from their orthosis. A rewarding part of the job is enabling people to continue to do the things and hobbies they enjoy. People then start to see their orthosis as a positive addition to their lifestyle, rather than a negative one.
Early intervention is important in orthotics. The earlier you go, the more options are available. Once you’ve got very established gait deviations, tightness in certain joints or established weakness, the choices are narrowed. Early assessment means there’s a wider variety of devices that might be suitable for you. Don’t be afraid to go to orthotics – it’s not a scary place!
Unfortunately some people with MS develop in addition to a foot drop, weakness in the muscles that provide stability to the knee. This can present itself in the feeling of the knee giving way or may even result in the knee buckling leading to a fall. If this weakness progresses there may be the requirement to wear a knee brace or Knee Ankle Foot Orthosis (KAFO) to ensure safe mobilisation. We often see resistance to the use of such devices due to the stigma and view that such devices are a step backwards. This unfortunately this often leads to other issues developing such as knee hyperextension which can limit the options available. Again the earlier the intervention the smaller the device can often be. The aim of bracing at the knee is to improve mobility and safety, KAFOs and knee braces can often increase the distance you can walk by delaying fatigue in the muscles stabilising the knee. Stance control devices such as the freewalk can be a good early intervention that can assist mobility for many years.
FreeWalk from OttoBock
Who covers the cost?
All NHS health boards have an orthotics service which supply a wide range of orthoses, both stock and custom-made, on the NHS. Some more high-end devices are only available privately, such as custom-made carbon fibre braces or Silicone Ankle Foot Orthoses (SAFO).
Carbon fibre is thinner, lighter and more durable than plastic, but it’s not as cost effective for the NHS. Some designs can provide energy return providing a literal spring to your step.
SAFO’s offer the most cosmetic options as they can be roughly matched to skin tone and are worn directly against the skin.
Getting a referral
Some NHS departments accept self-referrals, but it varies depending on the area. All orthotics departments accept GP referrals, or a referral from a neurologist, MS nurse, physio or occupational therapist.
Emma Davidson is a clinical specialist orthotist working at Buchanan Orthotics in Glasgow. The clinic provides an orthotics service privately and appointments can be booked here.
Emma also runs a monthly walking clinic at Revive MS Support, the MS Therapy Centre in Glasgow.
Email: [email protected]
Call: 0141 440 1999
Address: 603 Helen Street, Glasgow, Scotland, G51 3AR
Online Booking: Buchanan Clinic Appointments