Limitations on mobility for clients diagnosed with multiple sclerosis (MS) hinder their movement and independent living. The challenges for those with MS can be twofold: physical and environmental.

Physical challenges are condition-specific and may include impaired balance, decreased strength, fatigue, and tonal issues such as increased tone, muscle spasms, and spasticity. Loss of movement and flexibility in the ankles is also common. Medications used to treat MS may make the patient sleepy or more fatigued, further enhancing the physical challenges related to mobility.

Environmental challenges often begin at home. Stairs may impede access to certain items and areas, hindering routine chores such as activities of daily living. For patients who are able to work, workplace environmental challenges are often significant, even with handicapped-accessible buildings. It is hard to imagine things that were very much part of one's daily routine can become so labor intensive.

Fortunately, clients with MS have a wide variety of mobility aids and assistive technologies available to help them lead mobile, fulfilling lives, and to overcome the physical and environmental obstacles they face. Therapists have an obligation to stay up to date on the latest treatment techniques and technologies to provide patients with the best possible care.

BEFORE CHOOSING AN AID

When choosing mobility aids for patients, it is important to evaluate each patient's level of function, whether he/or she is already using a particular device, and how it is working for him or her. It is equally important to inquire about devices they have already tried, why they may not have worked, and why a change was required. People with MS know their bodies, and simply asking them for their feedback and insight is key to making the proper recommendations.

It is important to identify individual issues, such as tripping or falling, fatigue levels, and when symptoms worsen. Clients' symptoms may worsen depending on the time of day or temperature, thus increasing their fatigue levels and affecting their mobility.

SELECTION OF DEVICES

It is important to consider the progression and type of MS an individual lives with before choosing a mobility device. Knowing the rate and ramifications of exacerbations is also helpful. For instance, when was the first exacerbation, how often does it occur, and is any function lost after the exacerbation or is there a steady decline in function each time.

Therapists know that what works now for a patient might not work in 6 months. Generally, a power mobility device (power wheelchair or scooter) should be prescribed to meet the client's needs for the next 5 years. If a patient is currently using a molded ankle-foot orthosis or brace, he or she may subsequently need a cane and then a rolling walker. Patients who currently have braces and/or walkers may need a power wheelchair or scooter. Patients with MS do not always follow the typical progression of mobility aids because of their fluctuating status and symptoms. Therapists should recommend a device that offers the most adjustability and options to the individual to meet his or her varying needs.

Scooters may not always be in patients' long-term best interests because of the lack of adjustability they offer. Scooters require significant sitting balance and energy levels while offering little opportunity for modification. Balancing a patient's preference and functional level, as well as the progressive nature of their diagnosis, is key in a successful outcome of intervention.

NEW TECHNOLOGY

Numerous mobility options are using advanced technologies to assist clients with MS. One that seems to be popular with many patients is the Bioness L300. This is a wireless device that attaches to the patient's lower extremities and uses functional electrical stimulation to assist dorsiflexion.

The Lokomat®, by Hocoma, Zurich, Switzerland, is a robotic gait orthosis that guides the legs according to a preprogrammed physiological gait pattern. The computer-controlled guidance allows individual adjustments of different gait parameters.¹

For companies selling a wide array of mobility products, visit our Online Buyer's Guide.

The Walkaide®, Innovative Neurotronics, Irvine, Calif, is a medical device that helps to improve walking ability of people suffering from foot drop. It uses functional electrical stimulation to restore the typical nerve-to-muscle signals in the leg and foot to help lift the foot at the appropriate time during the gait cycle. The Walkaide consists of a battery-operated electrical stimulator, two electrodes, and electrode leads. It is applied directly to the patient's leg.²

The MOTOmed, by Reck MOTOmed®, Betzenweiler, Germany, simulates riding a bicycle. It can be power-assisted to take the patient's legs through the motion, but can also be active assisted for patients who have the ability to pedal it. It does have a spasticity component, and its direction can be reversed. This feature is particularly useful if the patient is having a muscle spasm, because the reverse direction can help decrease the spasm. The patient can sit at the MOTOmed in a wheelchair or a regular chair.

The BalanceMaster, by Neurocom International Inc, Clackamas, Ore, is a computerized piece of equipment that can be helpful in improving the patient's balance. It is used by having the individual stand on a platform. It then assesses where the patient is lacking in balance, and it can also be used to challenge the patient's balance, thus helping to improve their skill and ability to ambulate safely.

Some clients with MS who are fairly mobile may be interested in having adaptations made to their cars so that they are able to continue driving. Whenever a neurological impairment exists where individuals cannot move their lower extremities or feet in a safe manner to drive a car, the individual must be tested. The test identifies if it is possible to adapt the vehicle to be safely drivable for the patient. Then, different adaptations must be tested on the vehicle to identify which ones are necessary. Subsequently, follow-up testing ensures the car has been properly modified. This testing is conducted in a simulator setting.

Some large rehabilitation programs, including Good Shepherd Rehabilitation Network, based in Allentown, Pa, have adaptive driver programs associated with them. However, insurance rarely covers adaptations to cars. Sometimes, special programs may be able to assist with costs.

LONG-TERM WELLNESS

Clients diagnosed with MS have numerous options to assist in and support long-term mobility conditioning.

At Good Shepherd, patients are offered tools and exercise programs to incorporate into their lifestyle postrehabilitation.

Patients should be encouraged to take control of their wellness. They can call local YMCAs, gyms, or senior centers and ask about their offerings. Mobility is improved with increased movement. If patients are not exercising and moving, they will regress.

CASE STUDY

Jane (not her real name), a female in her mid-40s, was referred to Good Shepherd. She hated her molded ankle-foot orthosis and stopped using it on her own. She was not able to walk far and could not walk at all on uneven terrain. She had a significant fatigue problem and fell regularly.

She received a general education session on fatigue and MS, and was provided with an exercise program based on her needs. During her rehabilitation program, she tried the Bioness L300 and found it to be quite successful in helping her overcome her challenges. Jane was very fortunate to get the Bioness L300 paid for through her insurance company, and she wears the Bioness L300 on her lower extremities as her orthotic.

Within 4 to 6 months, she was able to perform dorsiflexion regularly and clears her toes when she walks. More importantly, Jane reports her quality of life has improved. She is now more mobile and is able to go shopping and participate in community activities.

In conclusion, there are many possibilities in helping individuals with MS to maximize their mobility. It is important for therapists to stay up to date with new treatment options and technologies available to benefit those with MS.

Adrienne Levey, MSPT, ATP, is a PT with the Good Shepherd Rehabilitation Network and the Colonial Intermediate Unit 20 of Pennsylvania. She has been treating clients with MS for more than 10 years and is certified as an Assistive Technology Practitioner. Recently, she has expanded her exposure in physical therapy to the pediatric field. For more information, contact .

REFERENCES

1. Locomat, an automated treadmill that rebuilds muscles after stroke. medGadget. Available at: www.medgadget.com. Accessed August 10, 2007.
2. Innovative Neurotronics. Available at: www.walkaide.com. Accessed August 10, 2007.