A (0:00)

Hello. Hello and welcome back. This is going to be a conversation around ankle braces for multiple sclerosis. And I've had an idea for quite a while to record this episode because I get questions from Missing Link members and in my DMs on social media about braces for foot drop all the time. However, more recently, over the last, I would even say week, maybe even two weeks, so pretty recent, I've received so many questions about a specific ankle brace. I don't know if this company is just putting more money towards marketing or maybe it's a brand new company. But there's a company that has an ankle brace or an AFO for people with Ms. To reduce foot drop. And what they say in their video is, is just false advertising is how I would say it. And so I'm feeling a little spicy, I'm feeling a little heated. And I want you guys to have the correct information about what these ankle braces are, who is supposed to be using one, who should not be using one, what they help with the different types because there are several these marketing claims and what is true, what is not true, Q and A's of the questions that I've been receiving really over the last few years. So this is like a deep dive into ankle bracelets, races or AFOs. If you have foot drop with MS,

B (1:36)

The big question is how does someone with Ms. Actually improve their mobility, strength, energy independence? The list goes on. My name is Dr. Gretchen Holley, physical therapist and multiple sclerosis specialist. Welcome to the Missing Link podcast. Tune in as I share the top strategies and exercises to help you gain control over your life with Ms. Using research driven insights and advice from top industry experts. Whether you're newly diagnosed or have had Ms. For over 30 years, whether you have relapsing Ms. Or progressive MS, this podcast is for you. You're sure to feel empowered and inspired after each episode.

A (2:26)

Ready?

B (2:27)

Let's dive in.

A (2:35)

Okay, so let's first dive into what is an afo. And I'm always a little surprised of how many people with ms, even people who have foot drop or drop foot, they've never heard of an afo. So an AFO is a type of. I just call them ankle braces. I think we all can envision what an ankle brace looks like, but an AFO is a specific type of ankle brace and it stands for ankle foot orthosis. So it is technically an orthotic and it's a brace or orthotic that is worn on your ankle. And we'll get into the different types, some of them can also help with knee support, but it's something that you wear on your ankle, usually inside your shoe. So there's a plate that goes on the bottom of your shoe and then it extends up and attaches to your ankle. And the primary purpose for this is to reduce foot drop. And one thing that is extremely important to understand is that these specific braces reduce foot drop by limiting the amount of movement and in your ankle, which is very different from a different type of ankle brace. So, aka, the reason you don't have foot drop is because your ankle's not moving, not because it's necessarily getting stronger or because it's this miraculous device that is helping with movement. It's limiting your movement, which is why your foot is no longer dropping. AFOs have been around for quite a while. And back in the beginning of their existence, most of them were plain plastic. So for a while, this was the most common. They're very durable. They are oftentimes custom molded to your leg. So you'll work with an orthotist and they come take a mold of your calf, lower leg, ankle, foot, the whole shebang, and they will give you a brace that was fitted specifically to that mold. There's a few different varieties within the plastic model, so some of them don't move at all. It just locks your ankle in a specific position. Others do allow for some movement. But other materials that AFO can be made from is carbon fiber. Carbon fiber is becoming more and more popular. It's been around for a while as well, but when I see a new company launch an AFO more recently, it tends to be carbon fiber. And one reason for this is because carbon fiber is pretty lightweight. It's strong, it's flexible. So this is often preferred by the person using it because it's not as heavy. And when you have ms, you might already be experiencing heaviness. So this takes away one of those barriers. Materials can also be made out of metal or leather. Definitely an older style. I don't personally know anyone who uses a metal AFO anymore, or leather. The reason it's important to be aware that there's all of these options for materials is because it is possible to find one that works for you and your symptoms. Again, if heaviness is an issue for you, you're probably going to want to go with a lighter weight one, but if that's not an issue, maybe you go with a more rigid one. It's going to depend on how much movement you have or don't have in your ankle, how much strength you have or don't have in your ankle. There's a lot of different factors and they all fit into your shoes a bit differently as well. So again, the main reason that people use an AFO is for foot drop. Drop foot, foot drag, as we discuss quite frequently, there's lots of different names for it. And if you're unaware if you have it or not, it's when you're walking, your toes drag or scuff the ground. So sometimes people aren't even aware that they have drop foot until they look at the bottom of their shoes and they see more heavy scuff marks, sometimes even holes in the bottom of one of their shoes, more so towards the toes versus the other shoe. So if you're unaware, take a look at your shoes. They can give you some great insight. And by using an afo, it can make walking safer, it can prevent tripping and falls, it can help you maintain ability to walk, but independence, it can reduce fatigue from compensatory movements, it can reduce fear of falling. So they can be very beneficial. We're about to get into different types of AFOs, but one thing that I want to share before we dive into that is if you are listening to even just what we've said within the first few minutes of this conversation and you're feeling like, ooh, that's for me, I want an afo. It's my opinion as an Ms. Specialized physical therapist that you really should work with an orthotist. There are orthotic clinics that you can go to in the United States. One of the most common ones that I'm aware of, where they have a bunch of different locations in a bunch of different states, is the hanger clinic. But there's others as well, and there might even be some small business ones more local to you. So you want to find an orthotist who can help you pick the right one for you. Because as we've talked about, there is lots of different considerations when you're looking into getting an afo. When I was working in person at a physical therapy clinic, I actually connected with a local orthotist and she would come to the physical therapy clinic anytime I had a patient who was interested in getting one. So if you're going to PT in person, ask them, do you know of an orthotist? Can you call and have them come here free of charge to help me figure out which would be the best one? Now, there are also off the shelf options, and we'll we'll dive into what these look like because they tend to be pretty popular. I personally think they're popular because they're just easier. You don't have to go to an orthotist or a physical therapist. They're not custom, of course, it's not molded to your leg. It's not for your specific level of strength or spasticity or weakness or whatever symptoms you're experiencing. The off the shelf ones are ready made, less expensive, faster to get, you just order them online. So, you know, just some considerations there. But I do personally think that professional fitting is ideal. However, it might not be available to you. You might also live in an area where there are no orthotists that you can feasibly get to. So off the shelf is the best option for you. In terms of design of AFOs, there's lots of different ones and again, it's going to depend on what your symptoms are and how your walking is affected by your Ms. Or your diagnosis. So there are some rigid AFOs, which, as I discussed earlier, these are typically plastic ones. There's little or no movement involved. It just keeps your ankle stuck in this one position so that there's zero chances that your foot is going to drop and cause you to fall. This is often the type that is used if you have zero strength in your ankle. Since there's zero strength, you need the maximum level of support. But there are other AFOs that are hinged. So there's literally a hinge you can usually on the back of the ankle that does allow for some ankle movement, AKA it can help prevent foot drop at different levels. Sometimes those hinged ones, you can change the level. So it can hinge a lot or a little. Each one is going to be a bit different. And then without getting too specific of the clinical names of the other types, there are types where there's the foot plate that goes in your shoe and then it comes up towards your knee. And sometimes the part that stems up towards your knee is in the back of your leg where your calf muscles are. Or it might be on the outside of your leg or the front of your leg. And the reason that it might be in one of those positions versus another is to help or not help when with knee mobility. So if you have knee buckling or knee hyperextension, it might be more in the front or more in the back. And again, it's not the same for everyone. So that's one reason why it is best to work with an orthotist or a physical therapist. To figure that out for you. Because if your knee is also an issue of the buckling, giving way, hyperextending, locking, whatever words we want to use, AFOs can help with that as well. So AFOs are truly not a one size fits all. However, again, it might not be feasible or accessible for you to get one of those AFOs that comes with that molding or the Orthotist review and personalization customization. So some of the popular off the shelf brands that I have seen for AFOs, I am not endorsing any of these. These are just ones that previous patients have used or missing link members are using. And so I want you to be aware that they exist. They are the Sabo step, which is spelled S A E B O step and that one is pretty lightweight. It's more of a step in design. Another option is the Ottoboc Walk on, which is more of the flexible carbon fiber that we were talking about earlier. There is the Allard Toe off afo. This one has a spring assist design which basically just means that there's a little bit of oomph in it. So as you are pushing off of your back leg, the there are features and the mechanics and material of the device and the way that it's designed allows you to have some type of spring so that it pushes your foot up. Another really common one is the Turbo Med X Turn. This has adjustable levels of support as well. Another one is the Ossur O S S U R afos. They have several different models. So if you are looking for off the shelf ones, these might be the brands that you've heard of as well. I'm sure that there are others too, but they tend to work similarly. But because it's not customized to you, we're just not 100% sure that it's the best for your specific symptoms and condition. But looks wise, they will look pretty similar. They have that foot plate that goes in the bottom of your shoe and then the extension that goes up towards your knee. Some of them are lower towards the ankle, others go all the way up towards the knee. But again, not going to be customized to you, but definitely some options that you can find online. Now, one thing that I'm super passionate about discussing and making sure people are aware of is the difference between an afo, which is what we've been talking about thus far, and what I like to call AFO alternatives, which are more of an ankle brace. They are ankle assist devices. So. So I'm going to explain what these are and how they are Different. So, AFO alternatives, or what I'm going to continue referring to is ankle braces or ankle assist devices. These are not at all the same material as the ones that we've been discussing thus far. So typically these are going to be an ankle brace of some kind. It might be made out of leather or cotton or Velcro, something that goes around your ankle. And then there's something that attaches to the shoelaces on the shoes that you're wearing or the eyelets of your shoe. So one example is something called the dictus band. It is a leather ankle brace, and then there's a really thick rubber band that extends down to to little hooks that you put in the eyelets of your shoe so that assistance from the band is going to help lift your ankle. Another one is called the Elevate360 drop foot brace. Again, it is an ankle brace that is soft. It goes around your ankle, but then there's hooks that you put in your the eyelets of your shoes, and there are strings that extend down to the eyelets of your shoe, and that's what helps you lift. Another one is the Sabo foot drop band, spelled S, A, E, B, O. Another one is the foot up brace. Another one is dosh. These are all similar in that there's an ankle component and then a shoe component. The way that the ankle and the foot component attach is what makes these different. Again, with one of them, it's a really thick rubber band. With another one, it's strings. With another one, it's actually a clip. With another one, it's Velcro. So that is a little bit different. But the way that all of these differ is that these help with foot drop by assisting you with lifting your ankle. So that's a huge difference from AFOs that help with foot drop by not letting you move your ankle. If you're not moving your ankle because it's stuck in a position, even if there's some movement allowed, that's different than with this one, you're getting assistance to lift. So another way to think of it is that an AFO prevents foot drop. It prevents this undesired movement of your foot falling, whereas these braces assist with your desired movement of lifting your ankle. So as a physical therapist, I prefer these ankle braces when appropriate. They're not appropriate for everyone. If you have zero strength in your ankle, these ankle braces are probably not going to make a difference for you, at least not right now, until you get strong enough for where they can lift. Because for these ones, you do need some strength. You don't need a ton, but you do need some strength, and that's what initiates the movement. And then the rubber band or the string or whatever it is kicks in and will further help you with lifting your ankle. These are generally less expensive than AFOs. They can be easier to get started with. And again, it's. It's better for more of the mild to moderate foot drop versus severe foot drop. Now, I do want to address the marketing claim that I discussed at the very beginning of this episode. There. There's a newer. Well, I actually don't even know if it's newer or not. I've just been hearing about it more recently. AFO that is made out of carbon fiber and it goes on your foot. One cool thing I will say about this specific one that's kind of similar to the dosh, the D O, S H, is that you don't need shoes, which I'll get into in a bit here, but it just attaches to your actual foot and your ankle. Not necessarily a shoe. You don't need a shoe for this one to work. However, the marketing claim that they are saying in their advertising is that this AFO will increase your ankle strength. And what a lot of people are messaging me about is they are sending me this video that says this, and they're asking, is this true? Can I get stronger from using this? And I really struggle. I don't like sounding like a Debbie Downer, but to my knowledge, in My gosh, what, 13 years now as a physical therapist and 11 years as an Ms. Specialist, that statement is just not true. AFOs, even the ankle braces that we've discussed, none of them are designed to increase your ankle strength. They're designed to prevent foot drop. So it is inaccurate to say that just because you're walking without foot drop means that your ankle is stronger. That is not the case. So, and even for ankle braces, those work by assisting you lifting your ankle. So you might be more likely to strengthen your muscles with an ankle brace versus an afo, but even that would be a bit of a stretch to say so. This claim that AFOs can increase your ankle strength just by wearing it is very misleading. They don't actually activate your muscles. They, most of them, prevent your muscles from working, which is why they work. So they don't actively strengthen your muscles. They can allow you to walk more, which could possibly maintain some strength in other muscles. But sometimes, and oftentimes what happens when you're wearing an afo, is that if you're wearing it all the time, your muscles in your ankle can actually get weaker. Because when you're wearing an afo, again, as I've said multiple times, it works by basically not letting your ankle move. So if your ankle's not moving, yes, that's safer for walking, but you're also not using those muscles. So if you're wearing it all the time, those muscles are now no longer working and they can get weaker. What actually increases strength so that maybe you don't even need the AFO anymore, or you don't need it as frequently is targeted exercises for the muscles that are weak and causing the foot drop and the muscles that are tight and causing the foot drop. And doing those exercises without the AFO on the role of AFOs, and in particular carbon fiber AFOs, is to provide support to your ankle and making walking feel easier and less fearful because you're not tripping so often. But it's mechanical support, it's not due to muscle building. So I would never want anyone to purchase an AFO thinking this is going to make me stronger. They are great for lots of reasons that we've already identified and I am on board with AFOs and ankle braces. But again, this claim is making people think that wearing it will get them stronger. Which leads me to my next topic, which is when to wear your AFO so that you don't get weaker, or when to wear even your ankle brace so that your ankle doesn't get weaker. So my golden rule, rule of thumb here is to wear your AFO or your ankle brace as often as you personally need to remain safe, but not any more than that. And why this matters is so often it can just be easier to leave the AFO or the ankle brace on all day. Once it's on, you just keep it on. You don't take it off till night. But I want you to consider that again, when you're doing that, you're not allowing your ankle muscles to move and work. And so if you only need to use it when you're walking long distances, then only use it when you have a long distance to walk. Don't just put it on to put it on. And also coming up with a strategic wearing schedule. So if drop foot doesn't affect you one day, because as we all know, Ms. Symptoms can affect you one day and not another, then don't wear it that day. Don't get in the habit of just wearing it because you have it. And the orthotist might even tell you Wear it every day for safety, which, yes, for safety, but if you don't need it one day and you are safe to walk without it, then don't wear it. Not wearing it allows you to use your muscles more. So think about what days you need it or don't need it. Similarly, if you tend to only need it in the afternoon or the evening when you're fatigued, but not in the morning, then wear it only in the afternoon or only in the evening, not all day long. We are trying to preserve any ankle strength that you have and calf flexibility that you have to keep using it. The more you use it, the more you are keeping those neural pathways alive, which is the connection from your brain all the way down to your ankle. I cannot tell you how many people I've worked with inside the Missing Link. And I actually, if you don't know, I have a book called the Missing Link as well. And I share lots of stories from Missing Link members in there. And there's one story in there, in the chapter that we talk about AFOs, but I hear stories like this all the time where someone has been using an AFO for years because they were told to, and their ankle was getting weaker and weaker to the point where they had to use their AFO all day, every day. And it didn't even occur to them that they shouldn't be using it all day, every day until they heard a conversation like the one we're having right now from me. And when they started implementing this off and on and doing your exercises, which we'll get into in a second, with the AFO off, she was actually able to increase her ankle strength so that she didn't need her AFO 24 7, except when sleeping. And she actually was able to use the AFO much less frequently over time because she was getting more strength in her ankle. And there's lots of people who were in the Missing Link and, you know, doing the right exercises as well, who no longer need an AFO at all. And so, again, I think the main message here is think about what your body needs, how much support, what, at what frequency, what duration is right for you, and then use it for that. But not any more than that, because in most cases, when you're using your AFO more often than you should, it starts leading to other symptoms, like swinging your leg around or circumducting your leg around, like swinging it to this side so that you can get your leg forward or weaker hip muscles or knee muscles. And we don't want that to happen. So let's nip it in the bud while we can. With that said, I just always want to add the disclaimer of listen to your body. Everyone's body is different, and with ms, every body's different. Day to day and even hour to hour, safety is the number one thing. If, as I am saying, try not to wear it all day. If your thought is, if I don't wear it, I'm falling down, then this advice is not for you. You should wear it all the day. We want to use it for safety first. Okay, the last point that I want to touch on before I dive into some of The Q&As that I've been receiving is exercising. Do you exercise with the AFO or the ankle bracelet on or off? What's protocol here? Now, every physical therapist might say something different, but what I believe and what I have seen really great results with when working with my missing link members, is that you have two options. You can exercise with the AFO on, and you should choose this option on days or times when you feel very unsteady or weak without it. So this is that safety first approach. If you're having a day where you think, if I take my ankle brace or my AFO off, I'm going to fall over, or, you know, I'm just flat out not going to be able to move or walk or do my routine, then keep it on. The second option, though, is to exercise without the AFO on. And this is always my number one preference when you are safe to do so. So if you can move around, if you can exercise, even stand, even take a few steps, or walk without it on safely, and you can use a mobility aid, then you should exercise without the AFO on because it allows full use of your muscles and your brain and your neural pathways, meaning you're more likely to strengthen those neural pathways, that connection between your brain and your muscles, and therefore your muscles are more likely to get stronger or at the very least, maintain what you do have. So the goal of exercising without the AFO on is to improve your ankle strength and balance through neuroplasticity. And remember what we said earlier too, which is AFOs. And these ankle braces don't build strength. They are there as a tool to minimize foot drop. But exercises, that's the component that actually allows you to maintain and build strength. So we need to have that combination approach. And if you are newer to using an ankle brace or an afo, I always recommend that you really ramp up your ankle exercises to again maintain or improve your ankle strength and not fall into that trap of, okay, well, now I have a brace, I'm just going to rely on that. And then you notice your ankle starts getting weaker. Your knee, your hip, everything's just not working the same. We don't want that to happen. If exercising without the AFO on feels scary, you can always start slow and steady. So you could start your exercises in the safest position, which is likely going to be seated because you won't have to worry about balance. And then as you get stronger, you could progress to standing with support, maybe a rollator or a countertop or two trekking poles, eventually reducing that support. And as I mentioned earlier, by focusing on strengthening exercises, some people, and I've seen this very frequently, can reduce their AFO use or ankle brace use or eliminate it entirely. However, some people will always need their AFO or ankle brace, and that's okay too. The goal here is not necessarily to never use one of these devices again. The goal is to maintain or improve your strength for safety, using or not using an afo. If you're wondering what exercises to be doing, because if you are new to my world, you might have no idea, in which case I've got lots of resources for you, including my book. There's tons of exercises for lifting your ankle. My social media channels, most importantly inside my membership called the Missing Link, there's not only exercises and demonstration videos, but calendars that tell you exactly which exercises to do each day. However, I want to mention a few here as well. So the number one exercise that I give everyone who has foot drop, and honestly, even if you don't have foot drop, this is one that I give preventatively and it's called ankle dorsiflexion or toe lifts. So there's lots of specifics to this one. But without getting too fancy and for the sake of just listing a few exercises, you're sitting, your feet are on the ground, and you lift your forefoot and midfoot up. Your heel stays down. That's the only thing that should be staying down. And then you slowly lower. This follows my principle of do the thing that's hard. When you have Ms. And if you have weakness in a specific area, the best way to strengthen it is to do the thing that's hard. So with foot drop, the thing that's hard is lifting your ankle. So what do we want to do as an exercise? Lift the ankle. Other exercises that might help are the marching exercise, so seated or standing, but you're lifting one knee up towards the ceiling and then slowly down. That can help with hip flexor strengthening. And the better hip flexor strength you have, the more time and space you have to lift your ankle. Hamstring curls is another great one. Again, seated or standing, bending your knees so that your heel comes towards your butt and then relax and release and then even practicing some form of single leg balance. So standing on one leg, with or without a mobility aid, Standing on one leg is important because for a lot of people who have foot drop, one thing that makes it worse is poor balance. And if you can only balance on one leg for one second, then that only gives you one second to bring your other leg through. And a lot needs to happen to bring your leg through. You need to be able to bend your knee and lift your ankle to reduce foot drop and march your leg. So to do all of that in one second might not be enough time. And if it's not enough time, you're much more likely to scuff your toes. But if you can stand on one leg for three seconds or five seconds, you'll have more time to bring your leg through and activate those muscles so. So that your foot drop doesn't kick in.