Addressing Foot Drop in Multiple Sclerosis: A patient case

Background:

Prior to beginning my journey in the DPT program at UNC, I began participating as a cyclist and fundraiser in BikeMS events. These charitable events organized and hosted across the country by the National Multiple Sclerosis Society are key for funding ground-breaking research to find a cure for multiple sclerosis (MS), but also opened my eyes to the numerous lives which MS impacts every day. As I began my physical therapy education, it was clear to me that physical therapists play an important role in assisting these individuals and their loved ones in managing this neurodegenerative disease. I was fortunate to be chosen to participate in the MS STEP UP Scholarship program at UNC, which allows the student to develop expanded skills and knowledge in the management of multiple sclerosis (MS).

As a MS STEP UP scholar, I have completed problem-based learning modules, led a journal club, completed a clinical rotation at the International MS Management Practice, and presented a patient case in the DPT program’s Grand Rounds as well as part of the National MS Society’s Webinar Series. As part of my Evidence Based Practice II coursework, I completed a critically appraised topic focused on the use of ankle-foot orthoses (AFOs) and functional electrical stimulation (FES) to increase walking speed and endurance in persons with MS (pwMS). These combined experiences have provided a foundation on which to build my capstone project, which further explores addressing the common impairment of foot-drop in pwMS. As patients with MS may present to physical therapy with a variety of clinical presentations, the educational module and patient case in this Capstone project aim to provide the student with the opportunity to see an example of how foot-drop may be treated in MS and the clinical decision-making process involved.

 

Project Overview and Purpose:

Multiple sclerosis is the most common cause of non-traumatic neurological disability in young adults,¹ and has recently been estimated to be twice as prevalent in the Unites States than previously reported.² That’s nearly 1 million individuals living with MS in this country! Walking difficulty is among the most common mobility limitations experienced by pwMS, and may be due to a variety of signs and symptoms including spasticity, balance deficits, sensory impairment, fatigue, and lower limb weakness.³ That said, physical therapists are vital for many pwMS for assistance in maximizing mobility by addressing walking difficulty throughout the disease course. While foot drop is a common impairment in MS as well as other neurological conditions such as stroke, the underlying pathology is inherently different in MS. The most common form of ankle-foot weakness in MS is characterized by both muscular weakness of the dorsiflexors as well as motor fatigue.⁴ This may additionally be complicated by a combination of peripheral and central fatigue in MS.^4,5 Furthermore, as there is no universal pathway to the loss of walking ability in MS, patients may present with a wide variety of impairments which can contribute to walking ability decline, even in the early stages of the disease.^4,6 This underlines the importance of ensuring physical therapists’ understanding of how to effectively assess and manage walking difficulty due to foot drop in MS.

 

Statement of Need:

Although MS is included in the Neuromuscular Assessment and Treatment course curriculum in the DPT program, students may not have the opportunity to work with, and therefore observe, patients with walking difficulty due to MS presenting to physical therapy. Additionally, the treatment of foot-drop in MS may present the physical therapist with challenging clinical decisions regarding treatment options in this population. After discussion with Dr. Vicki Mercer and Dr. Karen McCullough, the faculty responsible for developing and teaching these courses, it was determined that that there is a need for well-constructed clinical case reports, with actual patient video footage, that would be available to all UNC DPT students to further their understanding of the assessment and clinical decision-making involved in this complex patient population. Therefore, the focus of this project on addressing foot-drop in MS merges evidence-based treatment and assessment with an actual patient case to augment student’s learning and bolster their clinical toolkit for managing patients with MS.

 

Products:

This project builds upon my critically appraised topic (CAT) completed in Evidence Based Practice II which explored the use of FES and AFOs to address foot drop in MS and the benefits of these treatments on walking speed and endurance. As part of this Capstone project I have produced 2 additional products: (1) An evidence table that builds upon the research that I completed in my CAT to explore the use of othoses to treat foot drop in MS; (2) An educational voicethread module which merges this evidence with a patient case report to highlight clinical decision-making in providing evidence-based and patient-centered care to address foot drop in MS. Each of these products may be accessed via the links below:

 

• Critically Appraised Topic (CAT)
• Voicethread: “Addressing Foot Drop in MS: A patient case”
• CAPSTONE Evidence Table Final

 

Evaluation:

Throughout the completion of this Capstone project I was able to receive constructive feedback from my Capstone advisor, Dr. Prue Plummer, PT, PhD, and my committee members, Dr. Vicki Mercer, PT, PhD and Dr. Corrine Bohling, DPT. This was extremely valuable in development and editing of my final project products as well as planning logistics in the patient case portion. As the products of the project are intended for use in the Neuromuscular Assessment and Treatment II course which takes place in the Fall, I was not able to receive immediate feedback from DPT students themselves. I have created Pre- and Post-Module Surveys intended for this, which will enable me to have feedback from the intended audience and assess the effectiveness of my module in meeting its learning objectives. These can be accessed in the link below:

Pre-Module Survey

Post-Module Survey

Self-Assessment:

I feel that I devoted significant time and thought to the products in this Capstone project. Inclusion of the patient case with video footage is an integral part of this project, and one that I knew could potentially be a barrier due to patient consent, organizational approvals, and timing. I underestimated the extent that this would be a barrier, but despite a significant delay in receiving legal approval to film a patient, I was able to locate a patient, perform relevant research, and develop meaningful products through hard work. Originally, I wanted to focus more on the use of orthoses in the treatment of foot drop in MS, as these are the standard treatment in this population. Due to the delay in approval and timeline requirements, I was not able to delay choosing a patient for the case any longer. While the patient in this case uses and strongly prefers FES as her treatment for foot drop, I was grateful that she was so willing to trial different AFOs for the purpose of the project. I feel that this allowed me to effectively discuss the indications/contraindication to different bracing options as well as other barriers to treatment such as patient preference and cost. I do feel like after completing this case report, it is much easier to have the patient chosen first rather than to choose a topic and then find a patient to fit – certainly if time is a factor.

Overall, I strongly believe that I built upon my previous knowledge in this area while also creating what I hope will be an effective teaching tool for future DPT students.

 

Acknowledgments:

I would like to thank my committee members Dr. Vicki Mercer, PT, PhD and Dr. Corinne Bohling, PT, DPT. Specifically, I thank Dr. Mercer for her help with filming and feedback to ensure that the products in this project were congruent with the DPT curriculum. Thank you to Dr. Bohling for working with me to find a patient and coordinate my time at UNC’s CRC.

I would like to thank my Capstone advisor, Dr. Prue Plummer, PhD, PT, for her expertise in MS and dedication to research in this patient population. Her feedback on the products in this Capstone are invaluable.

I would also like to thank Dr. Karen McCulloch, PT, PhD, NCS, FAPTA, for her assistance with loading video files for this project, which was a huge help. To quote her, “Computers are great until you can’t get them to do what you want them to.”

I would like to thank Diane Meyer PT, MSCS and CJ Hamilton, PT, DPT, MSCS, therapists at UNC’s CRC, for working with me in filming during treatment sessions.

Last, but certainly far from least, I would like to that the patient that agreed to be part of this project. I am so grateful for her willingness to participate and share her experience with me and the students at UNC. This project would not have been possible without her, and it is individuals such as her that inspire me to pursue a meaningful career in physical therapy.

 

 

 

References:

image: https://thebestyoumagazine.co/your-feet-are-made-for-walking/

1. Dimitrov LG, Turner B. What’s new in multiple sclerosis? Br J Gen Pract 2014;64(629):612-613. doi:10.3399/bjgp14X682609.
2. Wallin MT, Culpepper WJ, Campbell JD, et al. The prevalence of MS in the United States: A population-based estimate using health claims data. Neurology 2019;92(10):e1029-e1040. doi:10.1212/WNL.0000000000007035.
3. Walking (Gait) Difficulties : National Multiple Sclerosis Society. Available at: https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Walking-Gait-Balance-Coordination. Accessed April 15, 2019.
4. Stevens V, Goodman K, Rough K, Kraft GH. Gait impairment and optimizing mobility in multiple sclerosis. Phys. Med. Rehabil. Clin. N. Am. 2013;24(4):573-592. doi:10.1016/j.pmr.2013.07.002.
5. Mount J, Dacko S. Effects of dorsiflexor endurance exercises on foot drop secondary to multiple sclerosis: a pilot study. NeuroRehabilitation 2006;21(1):43-50.
6. Wening J, Ford J, Jouett LD. Orthotics and FES for maintenance of walking in patients with MS. Dis. Mon. 2013;59(8):284-289. doi:10.1016/j.disamonth.2013.03.016.