form ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION, Vol. 62 February 1981
Shoe as Walking Aid in Multiple Sclerosis
ABSTRACT. Perry J, Gronley JK, Lunsford
T: Rocker shoe as walking aid in multiple sclerosis. Arch Phys Med Rehabil
Evaluation of rocker shoes as a walking aid for multiple sclerosis patients included a mechanical analysis of the shoes, establishment of clinical criteria for appropriate patient selection, and laboratory gait measurements of patients with and without rocker shoes. Patient fitting demonstrated that the most significant measurement, the roll point, must be about 2cm proximal to the 1st metatarsal head. A snug fit as well as the addition of a heel strap was required to hold the shoe on the foot so its mechanical assistance was consistent. Rocker shoes were effective only in patients who still retained the ability to walk independently; retention of adequate hip and calf strength proved critical. Basic gait deficit was plantar flexion less than 15 ° while standing, leading to knee hypertension and forward trunk leaning, inadequate knee flexion and toe drag in swing, general awkwardness and fatigue. Gait improvement with the rocker shoes varied with clinical classification. Normal velocity and stride characteristics in rocker shoes were accompanied by a marked decrease in net energy cost. A mean saving of 150% of normal energy was gained with rocker shoes.
Rocker shoes can replace lost foot-ankle mobility when the plantar flexed posture does not exceed 15° and the patient has sufficient extensor muscle strength to control the momentum created. The elevated heel neutralizes the plantar flexed position of the foot; this restores heel strike and allows the tibia to be vertical, to allow standing erect at midstance. Excessive stretch of the calf muscles also is avoided so their spasticity is not aggravated. Slight rounding of the surface of the heel augments heel rocker action as the limb is loaded, while the contoured sole allows BW to continue forward onto the forefoot despite a lack of ankle mobility. Thus, the heel and forefoot rockers are restored and an adequate substitute for the ankle rocker is provided. Finally, during the pre-swing interval of stance, continued advancement across the curved forefoot sole passively initiates knee flexion in a normal manner. The amounts of knee flexion needed during pre-swing and initial swing also are each reduced approximately 5° by the upturned toes of the rocker shoe. These several mechanisms allow the patient to use a simple mass flexion pattern for swing and the mass extensor pattern for limb stability during stance despite basic limitations.
When weakness was
the dominant disability, rocker shoes assisted our patients to use simpler means
of attaining stance stability and to initiate knee flexion. A reduced demand for
an effective knee flexion arc was an added advantage. The critical area of
weakness proved to be the calf muscles. Active plantar flexion for tibial
stability is required during a considerable portion of the stance period. Signs
of insufficiency were either a hyperextended knee accompanied by voluntary ankle
plantar flexion when passive mobility was available or the combination of
excessive knee flexion and ankle dorsiflexion. If a stabilizing AFO was not
accepted or the patient could not activate an extensor thrust, use of the rocker
shoe was not indicated.
Orthopedic patients had the neurologic control and strength to
accommodate moderately well for their fixed talipes equinus. Standard shoes
reestablished a neutral standing posture and decreased knee flexion demands by
heel height but did not assist rolling forward over the supporting foot, as the
patient already had the capability to substitute. The extra muscular effort
needed for this task was reduced by the rocker shoes, thus, stride length was
not increased but was made easier, saving energy.
All functional advantages provided by rocker shoes depend on selecting a shoe with proper mechanics and accurate fitting. While comfort is essential, the vamp also must be snug so functional alignment is not lost during walking. Size selection must allow the calcaneous to be well supported while the apex of the metatarsal head (medial) is 1.5 to 2cm distal to the onset of the sole curvature (roll point). This leaves a small space between the metatarsal head and the floor to initiate the forefoot rocker action.
The pioneer empirical studies of
shoe fitting in MS patients by Mrs. Carolyn Clawson are gratefully acknowledged.
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