MEDICAL JUSTIFICATION OF THE ROCKER SHOES AS A THERAPEUTIC REHABILITATIVE DEVICE

Patient care falls into two categories, curative medicine and rehabilitative medicine.  Rehabilitation is a formal therapeutic program designed to reduce the disabling effect of permanent impairment. 1,3,5,8, two approaches are used. First is optimization of residual physical capacity by muscle strengthening, joint mobilization and the teaching of substitutive functional techniques which, circumvent the physical limitation.  The second phase of rehabilitation involves the use of devices to improve function.  These include crutches, wheelchairs, braces (orthoses),  artificial limbs.  Rocker shoes are a recent addition to this list.  The basic rehabilitation procedures are not disease specific, though maximum effectiveness often depends on subtle modifications that accommodate the uniqueness of the various diseases2.

  Multiple sclerosis is an upper motor neuron disease which is characterized by significant spasticity and mass extensor and flexor synergies of the limb muscles.  The etiology is demyelination of the motor neurons within the spinal cord.  Position sense and other sensibilities remain in tact until late in the disease.  Weakness also, is a late development.  Both the spasticity and primitive mass patterns impair walking by blocking normal ankle and knee passive mobility.  The heel height, combined  with the contour of the rocker shoes, accommodate the primitive postural equines and lack of ankle mobility6.  Forward progress, under the persons intact strength, is facilitated and knee unlocked for swing. 

 Several other upper motor neuron diseases, also, can cause a similar pattern of spasticity and mass extensor/flexor limb control superimposed on residual strength and sensation.  These are hemeplegia from a stroke7, spastic cerebral palsy4, brain injury and spinal cord injury5.  The Rocker shoe mechanics have the same capacity to improve these patients ability to walk.  The medical indications for the Rocker shoes are determined by the patient’s functional characteristics rather than the etiological pathology.  There are no clinical tests to precisely quantitate the qualities of motor control, spasticity, sensation and balance or determine the exact mixture of impairment at the hip, knee and ankle.  Consequently, the general qualities are the indications and the final determination of effectiveness is made by clinical trial.  This is true for all  upper motor neuron patients, including Multiple Sclerosis.  

  Less frequently, arthritis and musculoskeletal trauma also cause mobility limitation and deformity at the ankle, which inhibit forward progression in walking.  This in turn obstructs the initiation of knee flexion at the end of stance (pre-swing).  In the slow velocity patient with limited ability to substitute, a Rocker shoe offers a better rehabilitative means of improving the patient’s walking ability than a mere heel lift or custom molded shoe.  Again, one is assessing the mixture of the patient’s physical impairment, natural ability to substitute and the effectiveness of a device.  The indication would be the generic criteria, with effectiveness demonstrated by clinical trial.(3)  For these reasons it is not inappropriate to include stroke and “other conditions” as situations which could be helped in the general descriptive flyer for the Clawson Rocker Shoes.  Also, from the rehabilitation viewpoint, the Rocker shoe is therapeutic.  The multiple sclerosis study should be considered a demonstration model of the way patients with similar ankle mobility limitations can be helped by a particular device.  Neither the disability nor the device is disease specific.   

References:

1 Gullickson, G Jr. and Licht S.   Definition and Philosophy of Rehabilitation Medicine.  In Light S (ed) Rehabilitation and Medicine.. Elizabeth Light (pub), New Haven. Conn. 1968,  CH 1:1-8

2 Licht S Table of Contents, in Licht S ( Ed ) Rehabilitation and Medicine.  Elizabeth Licht (Pub), New Haven, Conn.  1968

3 Perry J.     Rehabilitation:  a definition, in Nickel V: (ed) Orthopedic Rehabilitation.  Churchill Livingstone, N.Y.  1982 xi

4 Perry J. Cerebral Palsy Gait. In Samilson RL (ed) Orthopaedic Aspects of Cerebral Palsy. J.B. Lippincott Co., Philadelphia, 1975 CH 4B:71-88

5 Perry, J.    Rehabilitation of the Neurologically disabled patient:  Principles,  practice and scientific basis.  J Neurosurgery    58: 799-816, 1983

6 Perry J.  Gronley JK, Lundsford T.    Rocker shoe as a walking aid in Multiple Sclerosis.  Arch Phys Med Rehabil.   62:59-65, 1981

7 Perry J and Montgomery J.     Gait of the stroke patient and orthotic indications. in Bradstater ME and Basmajian JV (ed) Stroke Rehabilitation.  Williams & Wilkins, Baltimore,  1987, CH 9: 246-282.

8 Stolob WC  Comprehensive rehabilitation:  Evaluation and treatment.  In Stolov WC and Clowers MR (eds) Handbook of Severe Disability.  US Dept Education, Rehabilitation Services administration.  U.S. Gov.  Print Off.   1981, CH 1:1-1 

NOTE:   This treatise was written by Dr. Jacqueline Perry to justify terming the CLAWSON ROCKER  a therapeutic walking aid for the FDA.  It summarizes the concept and use of this unique shoe in a concise and understandable manner.   

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