Many people with MS experience walking difficulties. For some this might be weakness in the leg, for others foot drop and stumbling. Orthotist, Emma Davidson, explains how orthotic devices – such as braces and splints – can help to manage these problems, enabling people to maintain their mobility and keep doing the activities they enjoy most.
Using orthoses to improve walking difficulties
21 July 2019
What is an orthotist?
Orthotists provide gait analysis and engineering solutions to people with problems affecting the neuromuscular and skeletal systems. We treat a wide range of conditions including MS, diabetes, and arthritis, as well as sports injuries and trauma.
What are orthoses?
An orthosis is any brace worn on the body, including insoles, ankle and knee braces, spinal jackets and wrist supports.
Orthoses differ from prostheses because the people we treat haven’t lost a limb, but require external support to a part of their body which has reduced function.
Orthoses can help people with MS in a number of ways; they can improve mobility, eliminate gait deviations, reduce the risk of falls, reduce pain, and prevent the risk of developing skin pressure sores.
Ankle-foot orthosis (AFO)
An ankle-foot orthosis, or AFO, is probably the most commonly used orthotic device among people with MS. An AFO is any brace that covers the foot and ankle area.
The materials used differ depending on the support needed, they can be completely rigid to immobilise the ankle or they may be more flexible to encourage movement in certain directions. The AFOs we prescribe can be an off-the-shelf product or may be completely custom-made for the person, it all depends on the clinical need.
Prescription insoles can be made from a cast of the person’s foot and are inserted into the shoe. They can be used to correct problems such as abnormal walking patterns, reduce pain or relieve pressure on certain areas of the foot. Like AFOs, insoles can be an off-the-shelf or custom-made device.
Resting splints may also be used. Quite often people with MS have problems with muscle contractures or increased muscle tone that causes tightness of joints. As part of contracture management you might have Botox injections and a stretching programme, but you can also be given a resting brace from orthotics, for example for your hand or wrist, to help rest or support it in a better position.
Positional braces can be sheepskin lined and are moulded to the best position you can get your wrist and hand into. They’re strapped on with Velcro and worn overnight to provide a passive stretch.
There are similar braces for the ankle. People who have Achilles tendon contractures or tightness round the ankle can wear a positional splint at night to create a stretch.
Using AFOs to treat foot drop
An ankle-foot orthosis may be used for foot drop, but sometimes it’s a more complex picture.
Often in MS, people don’t have drop foot or a weakness of their ankle dorsiflexors (the muscles at the front of your ankle) in isolation. There’s often other subtle symptoms involved – such as other weakness, balance issues, changes in muscle tone, fatigue or issues with sensation – but it all gets clumped together under foot drop because the foot catching on the floor is what is seen clinically.
It’s essential to establish what’s causing the drop foot. An AFO would be the right treatment option for ankle weakness, but if it’s caused by weakness somewhere else, it may not be appropriate.
How visible are they?
Most orthoses are designed to be worn next to the skin, under your clothes – so they’re discreet from that point of view.
However, the greater the functional loss, the more support is needed, which may require a bulkier orthotic, so they’re not always invisible.
Getting used to wearing an orthosis
It’s a gradual process over a few weeks to get used to any type of orthosis. Your orthotist should give you advice on a gradual breaking in period. They will give you wear and care advice around checking your skin for any abrasions or pressure points, the most suitable type of socks and shoes to wear, and whether you need to wear a barrier (like a legging) next to your skin.
An orthosis doesn’t necessarily have to be worn all the time – it depends on the functional loss, when you need the support and whether it’s a functional day splint or resting splint.
Some people wear an orthosis morning until night. Others come to us because they’re struggling with a specific activity (such as running a 5k) so the brace is only worn during that activity. If you have an orthosis for walking, then you’d take it off at night when you’re resting.
There’s still a stigma attached to braces. People think they’ll be a heavy, archaic device and don’t always see them in a positive way.
A lot of people with MS who I’ve treated have benefited from their orthosis. A rewarding part of the job is enabling people to continue to do the things and hobbies they enjoy. People then start to see their orthosis as a positive addition to their lifestyle, rather than a negative one.
Early intervention is important in orthotics. The earlier you go, the more options are available. Once you’ve got very established gait deviations, tightness in certain joints or established weakness, the choices are narrowed. Early assessment means there’s a wider variety of devices that might be suitable for you. Don’t be afraid to go to orthotics – it’s not a scary place!
Who covers the cost?
All NHS health boards have an orthotics service which supply a wide range of orthoses, both stock and custom-made, on the NHS. Some more high-end devices are only available privately, such as custom-made carbon fibre braces. Carbon fibre is thinner, lighter and more durable than plastic, but it’s not as cost effective for the NHS.
Getting a referral
Some NHS departments accept self-referrals, but it varies depending on the area. All orthotics departments accept GP referrals, or a referral from a neurologist, MS nurse, physio or occupational therapist.
Emma Davidson is a clinical specialist orthotist working at Buchanan Orthotics in Glasgow. The clinic provides an orthotics service across the whole of Argyll and Bute, and treats people on the NHS and privately. Emma also runs a monthly walking clinic at Revive MS Support, the MS Therapy Centre in Glasgow.