Is your foot drop a drag? Talk to a Neurological Physiotherapist!

Following a stroke, it is common to have difficulties lifting the foot when walking. This can be a major frustration! It is often due to a weakness in muscles that pull up the foot at the ankle joint (dorsiflexion), it can also be due to lack of co-ordination in these muscles such that they are unable to work fast enough to pull up the foot during walking. In addition there can be stiffness in the calf muscles and loss of movement at the ankle (some people may have spasticity in their calf muscles as well which can make it difficult to quickly move the foot up) In addition slow lifting at the hip and bending at the knee due to weakness and loss of co-ordination of hip and knee muscles can limit how quickly the knee bends - which can further compound the problem. Together, these movement patterns make it hard to swing the foot through with walking, which can then lead to trips, falls and compensatory changes to walking patterns. It will often lead to hitching at the hip and trunk, and slow, careful steps in order to walk safely. This can be very effortful! There are many treatment ideas that can assist with walking that you should be aware of, so you can discuss this with your neurological physiotherapist.

Specific Exercises

A neurological physiotherapist will assess your walking, strength, sensation, balance, and coordination and determine what type of exercises could help the most. These exercises may include a variety of movements to practice that may help strengthen muscles at the ankle, knee and hip. A neurological physiotherapist may also help you learn new movement skills to improve the timing and coordination of muscle activation. Stepping tasks and specific practice of walking and balancing can be designed to ensure they are relevant to your daily life and goals.

Neurological physiotherapists can help design a program at the right level of difficulty that can help you learn new skills with additional opportunities for loads of practice. There are a number of ways training can be used to promote neuroplasticity to enhance these training effects. In order to fit in the amount of practice needed to encourage these training effects, strategies will often be needed to find ways to ensure these exercises become part of your daily routine. Exercise groups, exercise diaries, reminders, clear goals, designing some variety, rest intervals, and rewards for effort can all help with motivation and confidence.

Sometimes your neurological physiotherapist, together with your GP, can suggest a referral to a spasticity clinic to consider additional treatments such as botulinum toxin injection into tight muscles, which might be helpful with walking (1).

Ankle Foot Orthosis

If the foot dragging really limits your mobility, then an individually fitted Ankle Foot Orthosis (AFO) might assist with walking pattern and allow you to walk more easily (2). AFOs come in different shapes and sizes. Some of them are made from durable plastic and can extend further up the back of your lower leg or underneath your foot. Some can provide support at the ankle for stability and can also help prevent your knee from hyperextending back too far when you put weight through the leg. Many AFOs can provide some stability with standing but limit the size of your steps and can be too restrictive. In this case, hinged AFOs can allow more dorsiflexion at the ankle, while still preventing foot drop into plantarflexion. Some AFOs, such as those made from carbon fibre, can even help provide some propulsion forwards which can make walking easier and more energy efficient (3). With all AFOs there is often a trade-off between assisting stability with standing balance and making walking easier. As the situation changes, AFOs should be reviewed and updated to ensure they meet your needs. We recommend that all orthoses are individually fitted. This is why it is useful for your neurological physiotherapist to work with an orthotist to help develop the best option for your needs. This is another nice example of why effective multidisciplinary working is so important.

An alternative to AFOs are dorsiflexion-assist ankle supports that help lift the foot via attachments to the laces or shoe. These are quite simple ‘off-the-shelf’ devices that can also be trialled. While there are no large research trails showing the benefit of these devices with stroke, they have been used to help footdrop with walking in many neurological populations for a long time! There are several types available, all with slight variations. Discuss with your neurological physiotherapist to see if these are worth a try.

Functional Electrical Stimulation

There is a selection of devices that can stimulate the nerve that controls the dorsiflexor muscles to lift your foot as you walk (4). This is called Functional Electrical Stimulation (FES). FES is not suitable for everyone but can be trialled to see if it is likely to improve walking. FES can have some advantages for some people as it may be more comfortable than having an AFO in the shoe and it provides some more muscle activity. Again, this is a device worth trialling with your neurological physiotherapists and/or orthotist to see it is an option. Ankle stiffness, muscle activity response to stimulation, walking speed, comfort, personal preference, and cost/funding are all important considerations.

As you see, there are quite a few treatment options used to manage foot drop after stroke. A neurological physiotherapist with experience in stroke rehabilitation can advise you on which of these options are worth exploring and can liaise with other health professionals to provide you with all the best options.

Associate Professor James McLoughlin*

Director Advanced Neuro Rehab, advancedneurorehab.com.au

Teaching Specialist Flinders University

*James has been a lecturer in Stroke Rehabilitation at Flinders University for over 15 years.

References

1. Foley, N. & Murie‐Fernandez, M. Does the treatment of spastic equinovarus deformity following stroke with botulinum toxin increase gait velocity? A systematic review and meta‐ European journal of (2010).

1. Tyson, S. F. & Kent, R. M. Effects of an ankle-foot orthosis on balance and walking after stroke: a systematic review and pooled meta-analysis. Phys. Med. Rehabil. 94, 1377–1385 (2013).

1. Erel, S., Uygur, F., Engin Simsek, I. & Yakut, Y. The effects of dynamic ankle-foot orthoses in chronic stroke patients at three-month follow-up: a randomized controlled trial. Rehabil. 25, 515–523 (2011).

1. Howlett, O. A., Lannin, N. A., Ada, L. & McKinstry, C. Functional electrical stimulation improves activity after stroke: a systematic review with meta-analysis. Phys. Med. Rehabil. 96, 934–943 (2015).