USE of ROCKER SHOES in GAIT ASSISTANCE for MULTIPLE SCLEROSIS PATIENTS

(WORKSHOP CONFERENCE)

 

Jacqueline Perry, MD.

Director, Pathokinesiology Service 

Rancho Los Amigos Hospital 

Downey, California

 

FEBRUARY 1, 1979

 

VETERANS ADMINISTRATION PROSTHETICS CENTER

252 SEVENTH AVENUE

NEW YORK, NEW YORK 10001

 

 

INTRODUCTION

 

A 3-day workshop conference on special shoes for persons with multiple sclerosis was conducted by the Veterans Administration Prosthetics Center, September 22 - 24, 1976, at the VA Regional Office, 252 Seventh Avenue in New York City.  The following persons participated:

 Clinical Program Inventor

Carolyn Clawson

 Veterans Administration Participants

Anthony Staros, Director

Edward Peizer, Ph.D., Assistant Director

Gustav Rubin, M.D., Orthopedic Consultant

Martin Mussman, D.P.M., Podiatric Medicine

Carl Mason, Staff Engineer

Donald Wright, Coordinator, Clinical Evaluation Services

  Veterans Administration Participants (cont’d.)

Malcolm Dixon, Physical Therapist

Anthony Altobelli, Chief, Orthopedic Shoe Service

William Rohman, Visual Information Specialist

 Rancho Los Amigos Hospital Participants

Jacqueline Perry, M.D., Director, Pathokinesiology Service

Daniel Antonelli; M.S., Co-Director

Thomas Lunsford, Chief, Orthotic Service

Visitors from the Multiple Sclerosis Society

Harry Weaver, M.D., Consultant,  National Multiple Sclerosis Society

William Reynolds, M.D., Deputy Director, Research Program

James 0. Simmons, M.D., Director – Medical Programs Department

John J. Wood, Assistant National Director Community and Patient Services

John F. Larberg, National Director - Community and Patient Services

Betty J. Marshall, Education Programs Consultant

 

BACKGROUND

             Multiple sclerosis is a chronic idiopathic condition that usually occurs in young adults.  The fatty insulation material of the brain and spinal cord disintegrates and is eventually replaced by hard scar tissue.  These sclerotic or hardened areas may appear anywhere in the nervous system and may lead to any combination of irregular eye movements, slurred speech, emotional disturbances, head tremors, lack of balance, incontinence, and spastic paralysis.  The disease is progressive, with remissions and exacerbations.

 Mrs. Carolyn Clawson suffers from multiple sclerosis. Shortly after becoming wheelchair bound by the progression of her disease, a friend, who happened to be wearing a pair of Danish clog shoes, suggested she try them to see if they might help her walk.  She followed her friend’s advice and immediately found that she could stand with markedly greater ease and security.  Following this brief success, she or­dered her own shoes and began experimenting with them.  With the shoes, she soon became fully ambulatory (without them, she still walked poorly, even with crutches).

         News of this accomplishment began to spread and led others with walking impairments to come to her for help. In the past 7 years, through these contacts, she has fitted about 3 thousand persons.  And during this time, she has also become convinced that the only effective clog style was the style number 5152 for women and 8515 for men. 

Her procedure was such that only if she and the patient observed a significant change in the patient’s gait by using clog shoes, was that person allowed to purchase his or her own shoes.  She followed this up by sending a questionnaire to 450 recipients of clog shoes and received a 40 percent response:  90 percent of these acknowledged that the shoes were helpful.  These methods further confirmed her earlier findings that the 5152 and 8515 styles were critical. Mrs. Clawson has used her proceeds from selling shoes to document her patients’ efforts on film, with and without clog shoes. 

To find out why certain clog styles were effective while others were not, she consulted the Pathokinesiology Service at Rancho Los Amigos Hospital in Downey, California. The Pathokinesiology Service staff provided assistance in identifying the gait pathomechanics of persons benefiting from the clog shoe, and the clinical criteria for selection of patients.  During these studies, the term “Rocker Shoe” was coined.  And in expanding the applicability of these shoes, Mrs. Clawson has identified several needed shoe modifications, including a broader heel, adjustable closures, several designs of support straps, and an enclosed heel counter.

 

Previous Contributions by Rancho Los Amigos Hospital 

Prior to the VAPC workshop conference, the Pathokine­siology Service at Rancho performed certain efficiency tests on the Rocker Shoes.  These tests and their results are as follows: 

Efficiency Test Results. 

Separate studies were conducted on 2 different series of shoes to determine the toe force required to initiate rocker action.  The first study, in comparing different styles of shoes, demonstrated that, by far, the model number 5152 clog shoe required less force from the patient than any of the other models tested. This finding held true for widely different shoe sizes. The basic finding in the first study was that the roll point of the 5152 Rocker Shoe was located at 58 percent of shoe length when measured from the posterior margin of the insole heel (the lateral margin measurement was 63 percent).  The second study was concerned entirely with different shoe sizes, and although the clog confirmed previous measurements, there was a wider variation in roll point: between 58 percent and 65 percent, depending on shoe length. Heel contour also appeared to be significant. 

Gait Interpretations and Clinical Criteria.

Using normal standing postures and walking patterns of trunk and limb motions as criteria, numerous “before-and-after” slides and films accumulated by Mrs. Clawson, and the results obtained from 2 days of testing at Rancho, were visually analyzed for their similarities and differences.  The resulting interpretations were then compared to Mrs. Clawson’s success-and-failure fitting experiences. 

Two findings characterized those patients whose gait was conspicuously improved by Rocker Shoes:  they had sustained ankle plantar flexion throughout stance, most notably in the terminal phase, and the limb appeared stiff in both stance and swing, with a prominent delay or marked lack of knee flexion during swing. 

The normal walking pattern of motion during stance phase can be likened to a spoke of a wheel revolving about a single pivot.  This presents 3 functional requirements:

  1. Selective foot and ankle function to create an active rocker as the foot progresses through heel strike, foot flat (mid-stance), and heel off support.
  2. Adequate strength and timing of hip- and knee-extensor muscles and ankle-plantar flexors to assure sufficient knee stability for body-weight support.
  3. Passive knee flexion at the end of the stance phase to prepare the limb for swing.

The Rocker Shoes can substitute for the loss of foot and ankle rocker action (i.e., functional requirements a. and c. above) but the patient must have retained sufficient strength of hip and knee extensors and ankle-plantar flexors to provide the required limb stability (functional requirement b. above).

 

WORKSHOP PLAN

 

The planning phase of the workshop produced a threefold objective:

a.                          Determine whether comparable gait improvements in multiple sclerosis patients could be accomplished in different settings.

b.                         Test the proposed clinical criteria for selection of patients and Rocker-Shoe prescriptions.

c.                          Delineate fitting and training procedure. 

METHOD 

Mrs. Clawson and a 3-member rehabilitation team from Rancho Los Amigos Hospital met with equivalent VAPC representatives to finalize the selection of patients, fit these patients, train them to walk with Rocker Shoes, record their performance for measured as well as observational assessments, and interpret the results.

In preparing for the workshop, 9 men who are regular attendees of the VA Multiple Sclerosis Clinic, were selected as potential candidates for Rocker-Shoe prescription in accordance with the clinical criteria provided by Rancho.

After Mrs. Clawson and Dr. Perry reviewed their gait characteristics on film, 5 were selected as the most likely candidates although only 2 were considered to be truly adequate.  One person dropped out after a brief trial with the shoe, 50 4 were available for the full study.  Their ages ranged from 42 to 59 or an average of 52.5 years. 

PROCEDURE 

Each subject, in turn, completed the entire procedure during one visit.  The initial step was a careful explanation of the procedure ad expectations. 

Shoe Managment 

Each patient was fitted with a Rocker Shoe (number 8515) of proper size and an appropriate support strap (Single Longitudinal Loop, Figure-of-8 or Circle “T”) was used to stabilize the shoe on the foot to the required degree. Also inserted as needed was a dorsal vamp pad to improve shoe fit, and because varus proved to be a serious threat for 3 patients, a temporary single-lateral-bar (upright) orthosis was added for all 3.

Gait Training 

Mrs. Clawson began her training session (learning to walk with Rocker Shoes) by having her subject stand quietly in a  ully upright position.  An absence of all forward leaning at the hips was emphasized.  Then she encouraged the patient to roll onto his toes and thereby experience rocker action assistance before taking the first step. She then had him walk with a wide base while reaching forward for a “long” step, especially with the better limb (i.e., actually throw the limb forward).  Any customary crutch support was continued. 

For assurance and safety one person walked behind the patient and a second person walked at his side or ahead of him.  Usually, Mrs. Clawson herself functioned as the second supporter; she used her own Rocker-Shoe momentum to encourage the patient to maintain his speed.  A tendency to trip was corrected by encouraging the patient to step out further than usual. 

Documentation 

Prior to the workshop meeting, all candidates were recorded on 16 mm film and interrupted-light photograph. When the most effective shoe-fit and best obtainable gait was established with the Rocker Shoes, there was further photographic documentation on 2 of the subjects. 

RESULTS 

Patient Selection 

The two basic clinical criteria:  excessive ankle plantar flexion throughout the stance phase (combined with good, though spastic, quadriceps action), and inadequate nee flexion during the swing (and pre-swing) phase, were substantiated, of these, the knee posture proved easier o detect than the pattern of ankle motion.

All patients but one, in both the preliminary selection group and the final test group, met the second criterion. Each patient displayed a “stiff-knee” gait with conspicuous loss of knee flexion during the stance and swing phases. Their ankle control during stance, however, varied con­siderably and thereby modified their potential accordingly to profit from the Rocker Shoes. 

Four patients with marked degrees of ankle dorsiflexion and sustained foot-flat postures throughout the terminal stance were considered inadequate candidates and thus were excluded from the shoe trials.  Three candidates with mild levels of terminal stance ankle dorsiflexion were accepted as questionable possibilities.  These persons also depended on a dorsiflexion assist AFO to lessen their toe drag at initial swing.  Their initial intolerance to the Rocker Shoes was transformed into a success by the addition of a lateral, single bar AFO.  The prime indication for this was the marked foot varus in swing, which accompanied the improved use of their flexor pattern due to the clog shoe.  Conveniently, the orthosis also provided resistance to dorsiflexion during stance phase.  The lack of excessive ankle dorsiflexion was sufficient to enhance the patients’ stability. 

One patient had sufficient strength of the triceps surae muscle to maintain his ankle at neutral on one side with a modest excess of plantar flexion on the other side during mid-and terminal stance; he was considered to be  the best candidate for Rocker Shoes because he demonstrated the best gains in gait.  One patient who has demonstrated a relatively normal gait pattern with the clogs and a very short stride without clogs, gained step length; but he rejected the shoes because of what he termed was their unmanly” appearance. 

Rocker Shoe Characteristics and Fitting 

A review of Mrs. Clawson ‘s experience and the Rancho data by the conference group found that the unmodified clog shoe can provide 2 rocker actions during walking: between shoe and floor, and between foot and shoe.  The former is a function of shoe-sole design, and the Latter occurs as the unfettered heel rises out of the shoe during terminal stance.  Some patients need both rocker actions while others are unable to tolerate the excess forward roll provided by the heel rise. 

Basic Fitting.

According to Mrs. Clawson, the basic fitting of the shoe consists of selecting an appropriate width and equivalent length.   (The soft tissues of the heel can protrude slightly if the basal tuberosities of the os calcis are well supported.)  Care should be taken that the patient’s toes are beyond (distal to) the toe bump in the insole.  The vamp should fit snugly because this is the prime means of stabilizing the shoe on the foot.  Often a sheepskin pad must be added for both comfort and fit.

Support Straps.

Almost all patients require a strap to keep the shoe and the foot consistently related to each other. To meet the varying needs of the patients, Mrs. Clawson uses 3 styles of straps (fig. 2).  At this time selection on a tria1 basis.  The 3 styles are described as follows:

a.                          Single Longitudinal Loop:  Passing around the ankle just above the Os calcis, the Single Longitudinal Loop Strap is fastened to the shoe along the longitudinal axis of the forefoot, between the head of the metatarsal and the posterior ankle.  The strap is designed to stabilize the shoe on the foot without significantly altering heel-rocker action.  Tension of the Achilles tendon during terminal stance creates a minor difference in strap-length requirements between this phase of gait and the period of initial contact.  Patients with extreme dependence on maximum Rocker-Shoe action will be sensitive to this small restraint.  (For these, shoe fixation must be accomplished entirely by a snug fit.) 

b.                         Figure-of-8:  Starting at the instep, 2 straps are passed behind the ankle and are fastened together anteriorly.  The semi-vertical alignment of the Figure-of-8 strap as it crosses the heel, moderately restrains the heel-shoe (foot) rocker and thereby keeps the heel from lifting out of the shoe. 

c.                          Circular “T”:  Two uprights fastened to the shoe opposite the ankle are joined to a strap that encircles the distal leg.  Only a minor degree of heel rise is permitted with the Circular “T” arrangement. 

Shoe Modification Needs 

Widening of the heel, a requirement that was previously identified by Mrs. Clawson, was conspicuously confirmed by the workshop experience.  A marked increase in foot inversion accompanied the stimulation of knee and hip flexion during swing.  Consequently, during stance only the lateral margin of the foot was presented at heel strike for weight acceptance. This postural insecurity was further aggravated by the narrow shoe heel which, being undercut 0.8 cm and 5.2 cm high, pre­sented quite an influential lever.  Candidate T.D. displayed this effect very conspicuously.  With his standard shoes, by taking slow, short strides, no inversion was present.  Yet with the Rocker-Shoe an inversion stop AFO was needed to avoid intolerable twisting of his ankles.  Similarly, severe inversion also occurred with the other 3 patients.  The contrast, however, was not as great because they routinely wore a double-upright dorsiflexion-assist orthosis with their standard shoes.  This would automatically block foot inversion as well. 

Enclosure of the heel for a more standard shoe appear­ance and for inclement weather was also previously recognized by Mrs. Clawson and confirmed by the workshop experience: patient M.B. quickly rejected the shoes as being “unmanly,” even though they lengthened his stride significantly. Limitations in design related directly to the varying degrees of heel restraint different patients tolerated, relative to the level of rocker action assistance they needed for an effective gait. 

Gait Analyses 

Case 1.  Patient T.D. exhibited the greatest gain in walking ability with the Rocker Shoes.  He exhibited modest bilateral involvement.  In addition, his gait deficits most closely paralleled the clinical criteria presented to the study group.

a.        Standard Shoe Gait (Walking With One Cane For Assistance): 

1.                                            Left:  Initial floor contact was made with minimal heel strike due to the combined effects of a short step, flexed knee (1010°), and ankle plantar flexion (10°) (Fig. 3).  Loading of the limb led to a rapid reversal of knee pos­ture into 50 hyperextension, which persisted throughout the stance period.  The ankle also retained plantar-flexed, causing marked curtailment of limb advancement in mid- and terminal stance, and pre­mature heel rise (Fig. 4).  The sequelae of these gait deviations were total absence of knee flexion during the acceleration (pre-swing) stance phase and subsequent limita­tion of knee flexion in initial swing (Fig. 5).  As a result, the period of maximum knee flexion occurred in mid-swing as the swing foot passed the stance foot.  Knee extension was incomplete in terminal swing (10° knee flexion).  

2.                                            Right:  The limb exhibited a similar gait pattern except during terminal stance.  At this time the ankle dorsiflexed about 10° while knee hyperextension was maintained.  This postural combination implied weakness of the soleus, which might lessen the effectiveness of the Rocker Shoes. 

b.       Walking with Rocker Shoes And Using A Cane: 

 All phases of the patient’s gait pattern approached normal with the exception that an obstructive level of varus during swing phase was introduced.  This was controlled with a temporary single-lateral-bar (inversion strap) AFO.  The patient lacked the confidence to step out spontaneously. However, with Mrs. Clawson’ 5 guidance and continued use of his cane, the patient walked fairly rapidly and with an improved gait.

Heel-strike was restored, although his knee remained slightly flexed at initial contact (Fig. 6).  Loading the limb increased the knee flexion (perhaps restraint of passive ankle plantar flexion by the orthosis increased the lever effect of heel-strike).  Progressive extension of the knee during mid-stance occurred in a relatively normal manner with graduated restraint of the tibia’s forward travel as the femur and trunk advanced more rapidly. 

c.             Case 1 Summary:

  Maximum Knee Flexion
  Velocity  Stride Length       Right  Left
Standard Shoes  15.9 cm/sec   38.3 in.         44.5° 36.5°
Rocker Shoes     40.1 cm/sec  53.3 in. 44.0°  41.5°
Difference  +56%    +40%    

 Case 2.  Weakness limited to the right side of patient I.H. was confirmed by the gait deviation pattern.

 

a.                    Standard Shoe Gait (Dorsiflexion Assist AFO And Forearm Crutch):

 

Right:  Initial contact was made with a relatively flat heel-strike resulting from the short step and ankle plantar flexion.  The knee, fully extended at initial contact, rapidly became hyperextended throughout stance.  The ankle persisted in plantar flexion in mid-stance with a corresponding delay in tibial advancement.  Then, in terminal stance, as the body moved forward of the supporting  foot, the ankle dorsiflexed 20°  and the heel failed to rise.  The knee remained hyperextended with noticeable quadriceps action.  Heel rise did not occur until swing was initiated. (This combination of actions implied weakness of the soleus muscle with inadequate ankle control.)

 

As swing was initiated, the knee flexed slightly (18°) and the accompanying toe drag was decreased by pelvic hiking.  Hip flexion was delayed at this time.  Once the toe cleared the ground, the knee extended and remained extended throughout mid- and terminal swing.

 

Left:  The gait pattern of this limb was within normal limits except for 10° hyperextension of the knee in pre-swing.

 

b. With Rocker Shoes (Figure-of-8 Strap, Inversion Stop AFO, And Forearm Crutch):

Right:  The Rocker Shoes improved heel-strike but there was a marked restraint of limb advancement, early hyperextension of the knee, and persistent ankle plantar flexion (excessive dorsiflexion was avoided.) Advancement of the limb in terminal stance and the initiation of knee flexion during swing depended on how far the patient stepped forward with his left limb.  This was very inconsis­tent.  The patient’s trunk was thrust forward and he appeared to lean heavily on his forearm crutch.

 

Left:  Heel-strike was accompanied by 15°  knee flexion.  This increased with limb-loading and these abruptly reversed to hyperextension (15° ).  There was a marked restraint of tibial advancement during mid-stance, then the extended limb rolled forward smoothly and initiated normal knee flexion during the pre-swing period.  Limb action during swing was also grossly normal.

 

c.             Case 2 Summary:

  Maximum Knee Flexion
  Stride Length       Right  Left
Standard Shoes 37.6 in     18° 55°
Rocker Shoes     30.6 in. 35°  60°

Case 3.  Patient C.W. has a moderately severe bilateral involvement with conspicuous muscle atrophy and very poor endurance.  He appeared close to losing his ability to walk. 

a.                    Standard Shoe Gait (No Orthopedic Equipment):This patient exhibited a marked initial swing varus and moderately excessive ankle dorsiflexion in terminal stance. 

b.                   With Rocker Shoes:  Both problems cited above were corrected by a temporary lateral bar AFO used with the Rocker Shoes.  Unfortunately, the patient fatigued rapidly and, as a result, after his initial training with the Rocker Shoes, his energy level was insufficient to record his gains. Nevertheless, it was observed that his stride length and velocity improved and, most significantly, he was able to traverse the walkway many more times than he had during the previous evaluation and recording session. 

Case 4.  Patient R.M. displayed gait difficulties of the right limb only.  His left limb provided good substitution, including vaulting for toe clearance. 

a.                                            Standard Shoe Gait (Dorsiflexion Assist With AFO And Cane):  Right initial floor contact was with a flat foot due to slight knee flexion.  During the loading response, the knee became progressively extended and went into hyperextension by mid-stance.  This condition persisted and thereby denied pre-swing knee flexion for the patient. Advancement of the right limb during swing was delayed by a very persistent toe drag that lasted through half of the swing period.  There was no evidence of active knee flexion; instead, the 400 that did occur resulted from a combination of toe drag and hip flexion to advance the thigh.  Once the toe cleared the floor, the limb moved forward with a pro­gressively extending knee.  The ankle, which was initially neutral, yielded into 200 dorsiflexion as body weight shifted forward of the supporting foot. 

b.                                           With Rocker Shoes:  Preliminary experience indicated that good improvement in gait was likely with the Rocker Shoes.  However, there was no final record made because an appropriate shoe and ankle strap was unavailable. The Figure-of-8 support and shoe fixation could not be accomplished in the limited time available.  The temporary lateral-bar AFO that was used to avoid varus, overly restricted the patient’s ankle when it was combined with a Figure-of-8 shoe support.  Other types of straps were also unavailable because Mrs. Clawson’s box of accessories was not delivered on time by the postal service. 

Case 5.  Patient M.B. displayed mild bilateral involvement. 

a.                          Standard Shoe Gait:  Gait pattern was essentially normal except for very short steps and a slow pace. 

b.                         With Rocker Shoes:  Steps were lengthened and velocity increased correspondingly.  However, after a brief trial the patient rejected the shoes because they appeared to him to be unmanly.

 

CONCLUSIONS 

The culling that transpired between the initial selection of patients and the ultimate success of the Rocker Shoes clinic, demonstrated that the events accompanying “heel-off” are critical to a patient’s walking effectiveness, particularly when the use of Rocker Shoes is being considered. It should be kept in mind, however, that even experienced clinicians are not accustomed to differentiating between whether or not heel-rise occurs during the terminal single-support period or during the subsequent double-support phase, when the relatively unloaded limb is preparing for swing. This timing is a critical index of calf muscle strength. If the heel-rise occurs during the terminal single-support period, there is evidence to believe that the gastroc-soleus muscle group has sufficient strength (also, the ankle will appear at neutral) (Fig. 11).  By contrast, a sustained foot-flat posture combined with visible dorsiflexion at this time, serves as an overt display of disabling calf muscle weakness (Fig. 12).  Initiation of heel-rise during the double-support period merely demonstrates that the virtually unloaded foot automatically follows the ‘notion of the-limb as it prepares for swing.  Differentiation of heel-off-timing is essential in selecting candidates for Rocker Shoes. 

Although the primary purpose of the Rocker Shoe is to roll the foot forward so that it advances the limb and trunk, a patient can tolerate this added momentum only if there is adequate knee extensor stability.  A key component of such knee stability is firm fixation of the tibia on the foot.  If the patient lacks adequate calf (soleus) muscle strength, the tibia responds excessively to the momentum of the foot and moves forward faster than the femur.  This condition produces an arc of uncontrolled knee flexion that can be quite threatening to the patient, even if he has the quadriceps strength to catch himself before he falls. When this situation occurs, an orthotic restraint must be provided to stop ankle dorsiflexion or the Rocker Shoes should be declared contraindicated. 

A second effect of Rocker Shoes is stimulation of knee flexion.  This occurs during the end of stance (pre-swing phase), when the body is sufficiently forward of the supporting foot so that the weight of the limb rests on the most anterior portion of the Rocker Shoe.  The passive knee flexion that results from such alignment also provides the knee flexor muscles with a far better lever and thereby increases their effectiveness.  Stretched hip flexors, perhaps, also tend to stimulate this action because the result is a more rapid limb swing and an activation of the basic primitive flexor synergy with improved ankle dorsiflexion (that also, however, causes unwanted foot varus because the tibialis anterior is the only foot muscle participating in this synergy). 

To safely accept the abrupt dissolution of limb stability through the induced knee flexion, the patient must have had already swung the other limb forward and transferred his trunk weight onto this limb.  Hence good balance is a basic requirement.  He must also have had sufficient mobility of the opposite limb to have swung it forward at twice the rate required for the Rocker Shoe to advance the body.  This latter requirement makes hemiplegic paresis more amenable to Rocker Shoes than bilateral involvement (a situation experienced by Mrs. Clawson). 

The effectiveness of the Rocker Shoes proved to depend on 3 factors:  (1) a snug fit and accurate placement of the foot within the shoe.  This was accomplished by size selection and padding of the vamp.  (2) Adequate freedom or curtailment of heel-to-shoe rocker action.  This was dependent upon the selection of the proper support strap, which complemented the patient’s gait pattern.  And (3) orthotic supplements. These also proved necessary in restraining inversion and excessive ankle dorsiflexion.  In addition, equally important, to maximize the effectiveness of his Rocker Shoes, the patient must learn to forego his customary substitutive and cautious motions and postures, acquire a pattern of erect standing, and freely, even vigorously, step out.  A skilled and under­standing therapist is required to transmit gait instructions accurately and coherently to his patient, and instill trust and confidence through timely assistance and encouragement. 

The necessary shoe modifications and orthotic supplements could only be determined by observing the patient’s gait, which, in turn, depended on the therapist’s skill.  Ideally, a rehabilitation team should comprise a shoe technician, an orthotist, and a physical therapist.  However, since few centers employ shoe technicians—to develop the required basic shoe modifications, such as wider heel designs and posterior shoe enclosures—this responsibility should be assumed by an orthotist.  The uniqueness of the entire Rocker-Shoe program means training programs will be required for both therapists and orthotists. 

RECOMMENDATIONS 

The workshop proved to be a very profitable initial exploration into the clinical potential of Rocker Shoes. Pertinent guidelines for immediate application were estab­lished and specific requirements for future development were identified.

 

Selection of Patients

 The various levels of effectiveness encountered in the workshop in modifying the patient’s gait with Rocker Shoes, confirmed the previously established clinical criteria. 

  1. Excessive ankle plantar flexion, particularly in terminal stance, was the basic indication.
  2. Inadequate knee flexion at initial swing was a second indication.
  3. In each case, the patient needed sufficient spon­taneous knee extension and ankle plantar flexion strength to stabilize these joints (or he needed orthotic assistance).

Application of Rocker Shoes 

There is a critical interdependence between shoe fit, shoe adaptation, and gait training.  To meet these require­ments, a simultaneous involvement of an orthotist and a physical therapist during the fitting procedure is required. Training programs must be developed. 

Required Shoe Modifications 

To make Rocker Shoes available, as needed, to a wider population, a number of shoe modifications are required.

  1. A wider heel to reverse or minimize a tendency toward foot inversion. 
  2. A posterior shoe enclosure to contain the anatomical heel while allowing the patient full rocker action in walking. 
  3. Appropriate orthosis (AFO’s) to control foot inver­sion or excessive ankle dorsiflexion.
  4. A mechanical balance between the rocker sole of the Rocker Shoe and a locked KAFO and AFO.

Programs 

1.             We strongly recommend that a program be initiated to fit Rocker Shoes to veterans with multiple sclerosis.  Initially, a fitting program should be established at Rancho Los Amigos Hospital in cooperation with the Wadsworth VA Hospital. Then, based on the results achieved in this initial phase, a second program should be established at the Veterans Administration Prosthetics Center in New York City in cooperation with a local VA hospital. 

2.             The second phase of this program should commence after a year’s experience gained from phase one.  In this phase, Rocker Shoe fitting programs should be established in as many hospitals as possible within the VA hospital system.  A pro­gram should then be established at Rancho Los Amigos Hospital to expand applications of Rocker Shoes to other types of disabilities (including their incorporation with locked ankle and knee orthoses). 

APPENDIX

 Case 1 - T.D.

Age:                                       53

Diagnosis:                             Multiple Sclerosis, Psychoneurosis Anxiety Reaction

Orthopedic Appliance:            Cane

History Summary:                5/14/46, received multiple sclerosis diagnosis.  Walks with a staggering gait and falls         occasionally.  Patient received injections of bejectal for many years.

 

Case 2 - I.H.

Age:                                       42

Diagnosis:                             Multiple Sclerosis / 1971

Orthopedic Appliance:        Cane

History Summary:                Patient had diplopia in 1959, which subsequently cleared.  Since then he has had right-side weakness, clumsiness of gait and hands, difficulty in ventilation, and poor vision bilaterally. Neurological symptoms began about 15 years ago.

 

Case 3 - C.W.

Age:                                       59

Diagnosis:                             Multiple Sclerosis

Orthopedic Appliance:            None

History Summary:                2/16/67, veteran complained that walking, talking and driving were very difficult.           Neurological examination discloses that there is pronounced nystagmus in gaze to the right, mild nystagmus to the left. There is mild to moderate paresis of both arms and legs.  Gait is moderately ataxic; he can walk without aid.

 

Case 4 - R.M.

Age:                                       55

Diagnosis:                             Multiple Sclerosis

Orthopedic Aid:                   RT AFO, Cane

History Summary:                On 3/13/53, a diagnosis of multiple sclerosis was established.  Gait is spastic with drop-foot on the right. Weakness in right hand and leg with spasticity is present.

 

Case 5 - M.B.

Age:                                       53

Diagnosis:                             Multiple Sclerosis, Anxiety Reaction with Complications

Orthopedic Appliance:            None

History Summary:                Had somatic symptomatology (paresthesia of arms and legs) since 1943.  June 1963, weakness and numbness of the right foot and hand were noted.  Referred to M.S. clinic in February 1964.  April 1966, developed visual difficulties. Mr. B. walks with very short steps bilaterally.  His arm swing is restricted on the right side and he uses his left hand on his thigh.

 
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