coordination and/or cause weakness, poor
difficulty with walking, which is also cal ed
balance, numbness, or spasticity (abnormal
ambulation. The term “gait” refers more
increase in muscle tone). Visual or cognitive
specifically to the manner or pattern of
problems can also interfere with walking.
walking (for example “unsteady gait”).
studies suggest that half the people with
sometimes leading to social isolation.
“Gait problems in ms are al over the map,”
observes sue Kushner, a physical therapist
Gait problems in ms are caused by a variety
at slippery rock university in Pennsylvania,
of factors. ms frequently causes fatigue,
with long experience in multiple sclerosis.
“This makes walking problems difficult to
address.” Difficult, but not impossible.
if you are having difficulty walking or keeping
Your healthcare provider wil probably refer
your balance, if fatigue turns your legs to
you to a physical therapist (Pt) for this
jel y, don’t despair — speak up. many walking
problems can be significantly improved with
mechanics of your gait, a Pt may ask you
physical therapy, exercise, the right assistive
to walk across a room or down a hal way in
device, or medication, including the newly-
order to observe coordination, positioning
below]. You are not “giving in” when you seek
be asked to provide your medical history.
treatment. untreated walking problems can
You may also be asked to perform tests that
lead to emotional distress, injuries, added
measure muscle strength, fatigue levels,
fatigue, and suspicion by other people that
range of motion, spasticity, and balance.
your abnormal gait stems from alcohol or
some Pts use video cameras to record their
observations. computerized devices such as
talking with your primary healthcare provider
also be used to quantify gait and balance.
about getting an accurate assessment of your
The good news is that gait evaluation is
gait pattern is an important step toward
maintaining and enhancing your mobility.
Ampyra™ampyra™ (dalfampridine, formerly called fampridine sR) was approved by the U.s. food and Drug administration (fDa) in January 2010 to improve walking in people with Ms. this oral medication contains a sustained-release formula of 4-aminopyridine, which blocks tiny pores (or potassium channels) on the surface of nerve fibers. blocking potassium channels may improve the conduction of nerve signals in nerve fibers whose insulating myelin coating has been damaged by Ms. in the clinical trials of ampyra, a significantly greater proportion of people on treatment had a consistent improvement in walking speed compared to those who took placebo. and those who experienced increased walking speed also demonstrated improvement in leg strength. ampyra can be used by people with all forms of Ms, along with whatever disease-modifying therapy they are taking. this medication should not be used by anyone with a history of seizures or moderate to severe renal disease. for additional information, contact the ampyra support line at 1-888-881-1918.
once the factors involved in your particular
two new devices — the WalkAide and Ness
l300 — are now available to assist in the
Pt and your healthcare provider wil work
sending low-level electrical impulses to the
peroneal (sometimes called fibular) nerve,
which signals leg muscles to lift the foot.
reimbursement for Pt. review your coverage
Although many users find these devices easier
to avoid nasty surprises. Your physician and
to wear and more convenient than AFos, not
everyone with ms experiences positive results
help you battle for the coverage required to
address your problems. or you may need to
peroneal nerve must be capable of sending
pay physical therapy costs yourself. it is wise
a signal and the muscles must be capable of
to be frank and upfront with your Pt about
receiving it. in ms, a variety of complications
cost, payment plans, and the benefits you
may prevent this from happening. You should
be evaluated by a Pt to determine if the
WalkAide or Ness l300 would work for you.
These devices are also a great deal more
walking. Damage to neurons (nerve cells)
weakness in ms isn’t the same as the couch-
nervous system input that normal y guides
potato syndrome that can be addressed by
the act of walking. The result may be legs
strength training.” in fact, the wrong kind of
exercise will do nothing to improve walking
Foot drop is a specific kind of weakness that
and can lead to fatigue and increased weakness.
results from poor nerve conduction to the
Dr. Francois Bethoux of the mellen center
muscles used to flex the ankle. A person
for ms treatment and research in cleveland
with foot drop finds it difficult to lift one
is a strong advocate of exercise for people
or both feet fully while walking, making it
with ms. However, he cautions “most ms
difficult to manage curbs, stairs, and uneven
patients cannot tolerate the levels of exercise
surfaces. The right assistive device is often
the most effective strategy. A brace cal ed an
ankle-foot orthotic (AFo) is often prescribed.
increase in ms symptoms. similarly, what is
good exercise for one person with ms may
not be good for another.” experience shows
that even a small amount of exercise helps,
as long as it is repeated at least 5 days per
people can learn appropriate exercises as
wel as ways to compensate for lost strength.
difficult, it can result in falls and injuries. A
loss of balance and coordination can produce
muscle weakness that interferes with walking
a swaying, uneven gait — called ataxia —
is not the same thing as ms fatigue, which
that is often mistaken for drunkenness.
is a feeling of lack of energy. But ms fatigue
“Balance is a complex system,” observes
fatigue is so common in ms, an assessment
susan e. Bennett, Pt, DPt, Ncs, clinical
will include exploration of these problems
Associate Professor at the university at
Buffalo. “When it doesn’t work effectively,
mobility aid to manage fatigue and muscle
a comprehensive examination by a physical
ination includes evaluation of muscle strength,
spasticity or stiffness of the muscles, and
walking, not give up on it! using an aid is
the specialized balance system consisting of
not an all or nothing choice. many people
vision, inner ear and sensation in the legs.
continue to walk, and to work on improving
it is important to identify the underlying
their walking, while using an aid. They find
problems so the best rehabilitation can be
that assistive devices al ow them to get where
they want to go without exhausting all their
energy reserves, and without being at risk of
“Therapeutic strategies that may help balance
falling. marie e., of rhode island, who lives
deficits include eye muscle exercises, move-
with progressive ms, got a fold-up wheelchair
ments of the head activating the inner ear, as
for outings that involve long distances. using
well as “core” strengthening, stretching and
it lets her focus on shopping or seeing the
strengthening the legs. Aerobic activity,
sights instead of concentrating al her energy
stretching, and strengthening specific muscles
can address some of the “secondary” reasons
for balance difficulties,” says Bennett. “A cane or walker may be prescribed for
safe and independent walking. utilizing an
assistive device is much safer than reaching
for the walls or furniture,” Bennett notes.
installing grab bars around the home can
As a person moves, the nervous system sends
also make transfers easier and daily activities
streams of signals to muscle groups to expand
safer. Getting rid of clutter and area rugs
minimizes the risk of tripping and falling.
interfere with these coordinated events,
they shouldn’t. spasticity can cause uneven
gait. in addition, muscles in spastic limbs
may atrophy from lack of use, and joints
loss of feeling or tingling in the legs or
may develop contractures (freezing in one
feet indicate that the brain is not receiving
painful position) if they remain rigid over
accurate sensory input. As marie e. describes
time. loss of range of motion can make it
it, “it’s like i’m wearing thick heavy boots so
difficult to perform simple daily activities.
solutions may involve using a cane, walker,
or canadian crutch (which has an arm cuff
The right mix of stretching, exercise and
and grab handle). The mobility aid relays
medications can control spasticity, improve
missing information to the brain by carrying
serious complications described above. A
device into the hand and arm. Visual cues
Pt can recommend individualized and safe
may also work. People learn to watch where
techniques for stretching and exercising,
their feet are falling to compensate for the
and appropriate assistive devices. Baclofen
and tizanidine are the medications most often
used to treat spasticity. other treatments such
marie likes the convenience of collapsible
as botulinum toxin (Botox) and intrathecal
canes, which can be easily stowed in a bag
in some patients. controlling spasticity is a
long-term effort. Good management cal s for
a team approach, with the individual, the
physician or nurse, and the Pt al contributing
spasticity is abnormal muscle tone or tightness
sometimes spasticity actual y helps preserve
function. For example, the increased tone
spasms. spasticity can be uncomfortable,
allows some people who have weak legs to
walk or stand more easily. However, Dr. mindy
los Amigos National rehabilitation center
(rancho), which is part of the los Angeles
warns against relying on spasticity too much.
Janet l., of Philadelphia, pulled up to a
“excessive stress on joints or muscles can
neighborhood delicatessen and decided to
lead to unnecessary permanent damage,”
leave her cane in the car. “it didn’t seem that
far to walk,” she thought. As she threaded her
way past some outdoor tables, she suddenly
lost her balance — and fel across a stranger’s
lap. “i was so mortified i wanted to cry,” she
recalled. But she had the presence of mind
it is embarrassing as well as frightening
to fall down in public. People have been
known to stop going out at all to avoid the
“come here often?” she asked. They both
possibility of a fal . But staying put at home
started laughing. she pulled herself up and
is not much of a solution. in fact it may
explained that she sometimes loses her balance
Kathy Dieruf, assistant professor in the
Physical Therapy Program at the university
National ms society. she knows that it’s
“The painful consequences of a prior fall or
not always easy to keep a sense of humor
current fear of fal ing may lead to a devastating
in this kind of situation, but for her it’s
downward spiral of decreased activity, decreased
the best strategy. As she puts it, “ms is not
strength and endurance, diminished range
of motion, and increased impairment that
may actually add to the risk of falling.”
to handle the problems.” A former dancer,
Janet is keenly aware of the ways in which
While it is essential to preserve one’s mobility
in and outside their home, this should be
done in a safe way. modifications to the
environment (e.g., ramps), devices (e.g.,
“Keep moving! it’s important to be in the
cane, walker, scooter), and common sense
all can help you enjoy an active life without
excessive fatigue or risk of injury from fal ing.
offers product information, resources, and
links. Their advice is worth noting: “to select
devices most appropriate to your needs, we
We human beings are distinguished by our
ability to develop technologies that make
with professional advice, product evaluations,
tasks easier. in a sense, all technology from
safety pins to super-sonic jets is “assistive”
technology, helping us to accomplish feats
Do-it-Yourselfers run the very real risk
we couldn’t do otherwise. When physical
of using devices incorrectly and causing
disability develops, canes, braces, walkers,
unnecessary damage to their muscles or joints.
wheelchairs, and scooters assist. They help
occupational therapist should assist you in
The idea is not appealing initially. to many
selecting the correct device to enhance your
people, a cane represents “feebleness” — a
mobility, in adjusting the device, and in
wheelchair or scooter says that ms has “taken
training you so you can use it appropriately
and safely. sue Kushner encourages her clients
to choose devices that are aesthetical y pleasing.
And there are attractive choices available.
the right assistive technology end up with
a very different perspective. They recognize
Janet, the former dancer, used the internet
that a brace or cane allows them to walk
to locate designer cane makers, and she now
with confidence; a wheelchair or scooter
has a col ection in different colors and styles,
provides safety, speed, and saves energy for
including a glittery lucite cane that she used
more important things. A rehab professional
when she was a bridesmaid in a friend’s
with ms experience can help people improve
their gait and manage fatigue, weakness,
professionals look for individual solutions
to individual gait problems. the assistive technology industry offers
Full or partial reimbursement for assistive
options aplenty — from rolling walkers to
technology (or durable medical equipment)
weighted 4-pronged canes; from ultra-light
may be available through private or public
power-assist wheelchairs to fully-powered
insurance, community organizations, social
multi-level wheelchairs. There are excel ent web
service agencies, or your state’s vocational
sites with information about such equipment.
rehabilitation agency. remember to explore
A good starting place is ABleDAtA (able-
veteran’s benefits if you have done military
data.com), a federally-funded project that
service. reimbursement programs require a
prescription from a physician or a rehabilitation
Dr. Aisen, for one, is optimistic that research
professional, and a statement that explains
being done in other conditions, such as spinal
the medical necessity of the purchase. The
cord injury and stroke, will eventually prove
statement may take some careful preparation.
useful in ms. There is some evidence that
intensive, repetitive physical therapy can
People with ms often fail to fit into standard
improve damaged neural function, perhaps
disability categories because gait problems
by stimulating the brain to create new neural
various forms of aerobic exercise and weight
strength and the ability to walk. According
to Barbara Giesser, mD, clinical Director
n clearly communicate these requirements to
your physician or therapist, as reimbursement
will depend on supporting material from your
Geffen school of medicine, “The research
is helping us identify what types of exercise
n contact your National Ms society chapter
work best to address ms symptoms, as well
for assistance if your healthcare provider is
as how frequent and intense the exercise
“it is important to have a strong advocate
tailored to the needs of each individual.”
to explain why a device is justified,” says Dr.
innovations in assistive technology are also
expected to continue at a brisk pace — in
part to keep up with aging baby-boomers.
lighter, more flexible mobility aids with
sporty styling and cheerful colors are already
available. “sick” is out and “active” is in for
people who compensate for disabilities with
At present, people with walking limitations
related to ms remain mobile and independent
through physical therapy, exercise, medication,
and assistive technology. New ways to prevent
permanent losses and to improve the tech-
nology that compensates for losses are in
The society publishes many other pamphlets
and articles about various aspects of ms.
Visit nationalMSsociety.org/brochures Ampyra: A New Medication to Improve
to download them, or call your chapter at
Walking featuring Patricia K. coyle, mD. nationalMSsociety.org/ampyra nationalMSsociety.org/dalfampridine
n stretching with a helper for People with Ms
ampyra is a trademark of acorda therapeutics. botox is a registered trademark of allergan, inc.
* the National Multiple sclerosis society is proud
to be a source of information about multiple sclerosis. Our comments are based on professional advice, published experience and expert opinion, but do not represent individual therapeutic recommendation or prescription. for specific information and advice, consult your personal physician.
2010 National Multiple sclerosis society
Persistent Idiopathic Facial Pain (Previously “Atypical Facial Pain”) Definition Persistent idiopathic facial pain (PIFP), previously termed “atypical facial pain,” is a persistent facial pain that does not have the characteristics of cranial neuralgias and cannot be better attributed to a different disorder. Epidemiology The prevalence of PIFP is far less frequent than that o
Overview of Presentation: What’s it al Goals- Differentiate between programs Eligibility Rules Coverage Basic Rights and Responsibilities Keeping Eligibility Appealing Adverse Decisions 1965 Federal matching dollars for state dollars Entitlement Program- You’re eligible, you apply, States have authority to administer, increase eligibility to additional gr