Background
A gentleman visited me for a neurology outpatients appointment. They had a long term condition called hereditary spastic paraplegia which is a degenerative condition causing gradual weakening in muscles and an increase in muscle tone (feeling of resistance in the muscles). He was probably in his 60s and could walk short distances with 2 walking sticks; He could not climb the stairs and had stopped driving recently due to increased weakness.
He came to me as he recently suffered from sepsis and was admitted to hospital for a week. As a result of this, he became even weaker due to deconditioning and could only just about transfer himself. He visited myself a few weeks after he had gone home and thankfully could walk short distances by this point.
Goals
His main goal was to improve him mobility and increase the distance he could walk. He would also like to return to driving as this was something very important to him. Driving may not sound like an appropriate physiotherapy goal however as it was his physical limitations that affected his ability to drive, not vision or cognition, then it was something we could work towards.
Assessment
One of the most important parts of the assessment was to assess the patients current mobility. I observed him mobilise up and down the gym several times and it quickly became apparent why he was struggling to mobilise. Due to a weakness in the front of his hips, he was unable to sufficiently lift his knee when stepping which essential for us to clear the floor. Looking at his ankles, you could also see he had a symptom we refer to as “drop foot”. This refers to the inability to clear the floor with your forefoot causing the catching or dragging of it during the swing phase of walking. The mobility assessment was followed by a basic strength assessment whereby a physio will quickly screen different joints to see how effectively you can move them. As his problems related to his legs, his hips, knees and ankles were assessed. As predicted from his walking assessment, the main areas of concern were very weak hip flexors (lifting your knee) and weak ankle dorsiflexors (lifting your forefoot), however he was generally weak across all muscle groups due to his condition.
Treatment
After questioning the patient regarding his ankles, it sounds like he has suffered from drop foot for quite a long time. For this reason and due to the degenerative nature of his condition I opted to use an orthotic for his ankles instead of exercises. I provided the patient with two ankle foot orthosis, one for each foot. An ankle foot orthosis is a simple plastic splint that goes under your foot and behind your ankle to strap around your mid-calf. It is an aid for people with drop foot and functions by manually keeping their ankle at 90 degrees allowing their forefoot to easier clear the floor. Using the strength assessment the patient was provided exercises for his hip flexors, glutes and quadriceps, specifically chosen to be challenging but manageable for the patient.
Outcome
To my delight when the patient wore the ankle foot orthosis he instantly walked significantly better as he could easier clear the floor which conserves energy and allowed him to also walk further. His partner attended the appointment and said it was the best she’d seen him walk in years! I saw the patient 1 week after the initial appointment and he was still using his splints which were working great. I was really pleased to see he was also able to lift his knee significantly higher and could now begin to lift his foot up and down from a step which he wouldn’t do last time. He was provided with slightly more challenging exercises to continue with. I then contacted him by phone 1 month after and was astounded with his progress. He had returned to driving and could even go up and down the stairs, something he hadn’t done in over a year!
Summary
Something that is important to remember is that just because you may have a degenerative condition does not mean you are on a continuous decline and exercise can offer some benefits to function. Long term weakness caused by a condition such as multiple sclerosis is not always something you can improve although deconditioning from a short term illness or lack of activity is something that is reversible and a physiotherapist can help with.
This page contains the current position that Mobility Physiotherapy Limited is taking based on the latest government and our professional body guidance to ensure the health and safety of our patients.
