Foot drop in Multiple Sclerosis

[Erica]

I thought I would post this case as I need some help from some of the neuro trained therapists out there! Briefly, I have a patient who is about 50+ yrs old, male, has MS for about 15 yrs, baclofen pump, uses lofstrands, afo on right ankle. Never had PT at all (which quite shocked me!). His wife, who comes into the practice, thought it would be a good idea for him to come in since she comes anyway.
I have been treating him for a little bit now. The facility I work in is mostly orthopaedics and we don't have a mat table. The first time I saw him-he was so stiff I thought he was going to fall off the table!:)
Treatment so far has consisted of stretching, some PNF gait and pelvic work and some somatics/feldenkrais patterns. The other day I was stretching him and decided to put his right leg into the FABER position, and all of a sudden he started to dorsiflex his ankle with control.
I thought about and realized I put him into some flexor synergy pattern (completely by accident I have to say!) which gave him the ability, I think, to DF his ankle. Which of course does not translate to gait for him at this point.
I am wondering how can I tap into this to see if I can make it work a little better for him? Any ideas or strategies?
Thanks a million
Erica

[clarett]

Hi

I need a little more information before answering you.
You stated that he's very stiff - where? and why? (I'm guessing because of spasticity but I don't want to guess).
Is the lack of movement in DF due to spasticity or muscle weakness?
The answers will make a big difference with where you can go from here.
Great that you got any active DF at all though!

I don't have easy internet access I'm afraid so I won't be back online til Monday but I'll check and get back to you then.:teeth:
Have a good weekend
Clare

[Erica]

Thanks for replying Clare. I believe his stiffness stems from the spasticity. He is generally very stiff in his hamstrings, calves, adductors, low back -he held himself very rigid-although this has improved alot.
My feeling on the DF is that it is from the spasticity with some weakness-but I think his tone overpowers him.
Thanks for your help!
Erica

[nari]

Erica,

There are all sorts of surprises with MS patients. I don't know what the FABER position is, but the ability to move unexpectedly, even temporarily, can appear out of the blue. Perhaps the main thing that initiated movement was not so much the 'flexor' but the 'synergy' bit.

What is the left LE like? Could he do some mirror work?

I once had a female patient in terminal stages of MS (in hospital) who learned to move her totally immobile left arm - just by looking at it, and thinking about moving it. It didn't help her condition, but it sure made her feel so happy.

I'd keep going the way you are, as long as he is fully aware of no guarantees.

Nari

[Erica]

Hi Nari,
Thanks for the response. The FABER position is the flexion, abd, external rotation position of the hip. I basically had his right leg (in supine) open like indian style sitting with his right ankle resting on top of his left knee.
His left leg is much better-flexibility wise he is tight in the same musculature as the right but his strength at the ankle is good.

The mirror therapy is a good idea, I had not thought of it. I rec'd a mirror box when I took the explain pain course last year so I will try it!

He has asked me to point to the muscles we are trying to move and having him think about it has helped alot-he tells me he is more aware.

Erica

[clarett]

Hi Erica

Sorry - I have to be really quick - I don't have much time on the computer.
Positioning is really important in reducing the spasticity - positioning at night and while sitting.
If he sleeps on his back then pillows under the knees (or a wedge) and sometimes under the lower legs will help or if he sleeps in his side pillows between the legs and supporting back and front as he finds comfortable.
When he's sitting - look for his legs to be as supported as possible and the sides of his trunk too - if he needs it.
Then build on what Nari said - start him in the FABER position and get him to repeatedly DF, concentrating on the sensation of the movment from initiation through to release. Don't exercise to fatigue. He needs to relearn the sensation of creating the movement and of the movement itself. Then very gradually see whether he can retain the movement while slowly decreasing the FABER position.
It may be the synergy pattern that helped to elicit active DF or it may be that the leg is very supported in that position, allowing a decrease i tone to occur which then allows movement.
Try eliciting the movement in different positions while having the leg fully supported and see whether that helps.

Hope that helps and let us know how he's doing.
Clare

[Erica]

Thanks Clare. Will try that when he comes in tomorrow. I'll be back with an update after.
Erica

[bobmfrptx]

Erica,
I have used EMS to the anterior tib to provide a feedback loop in order to reestablish proprioception. Usually after 10 to 12 10 second contractions the client has better active control. I use 10 sec on 10 sec off and sustain the contraction with active recruitment as well to tolerance. Didn't look at the literature about this, but clinically it helps the client "find" the right switch for active control.
bob

[Erica]

Hi Bob,
I made an attempt at that a couple of weeks ago-but abandoned it for some reason. Don't remember why-I think I was focussing more on flexibility and decreasing tone. There is so much to work on with this guy-I could take my pick on any given day. Maybe I'll try it again.
Erica

[bobmfrptx]

Erica
I find that if it will work it works the first time. The EMS seems to provide necessary feedback loop to combat the muscle amnesia. Give it another try in varying positions of the LE and trunk inclination.
Bob

[Erica]

Saw my patient today. I did my usual stretching and then put him in the Faber position and there he went again with the dorsi flexion, actively and with some measurable control. We persisted with that for a while and then I brought out the mirror box.

He began actively dorsiflexing his left foot while the right one was in the box and after about 1 minute he said I think my right foot wants to move and I said, "well let it move" and it did! IT WAS WILD.

Was it as good as the left? No way, but it was moving and moving better than it did last week. I could have spent all day with this guy dorsiflexing his foot in the mirrox box. After a while the foot got tired and he had to take a rest but let me tell you, for lack of a better word, this was spectacular to see I have to say. I must admit he was impressed too.
Love the mirror box! :thumbs_up
Erica

[nari]

Mirrors are great, aren't they?

Did he understand the neurology behind mirrors? On the other hand he was probably so excited he couldn't care less for now.

Nari

[Erica]

Hi Nari,
I explained the neurology behind it for him and I think he grasped the concept more or less. But you are right, he was so fixated on the other foot moving, it probably went in one ear and out the other, so to speak!
Erica