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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 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:
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:
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:
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.
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.
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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