Ambulatory Aids Research Articles

Gangschulung mit beidseitiger Teilbelastung bei Fußverletzungen

Bilateral foot injuries are not uncommon. Operative treatment usually requires partial weight bearing over several weeks. This is a challenge for physiotherapy especially for ambulation training. We describe a new rehabilitation aid allowing for bilateral limited weight bearing during ambulation. Ambulation training was initiated in the early postoperative period using the Regensburg ambulation aid. A lift system allows for exact limitation of weight bearing on both sides controlled by balances integrated into the floor. Using a rail system a 15 m free walking distance is available. This study included 10 patients with bilateral foot fractures. The functional outcome was assessed using the AOFAS score and quality of life with the SF-36 score. Plain X-rays were used to evaluate loss of correction. The control group consisted of 20 patients where ambulation training was discontinued for at least 6 weeks postoperatively. The system is very safe, during the entire period no complication was recorded. Acceptance among the patients was extremely high. Worries about unwanted weight bearing could be reduced. Patients mobilized with early ambulation training showed a better compensation of gait if compared to the control group. Secondary problems in the knee, hip or spine, as well as muscular deficiencies had a significantly lower incidence. No loss of correction could be seen in either of the two groups. The presented ambulation aid is a significant contribution to the physiotherapy of bilateral foot injuries.

Therapeutic strategies for the inherited neuropathies

More than 30 genetic causes have been identified for the inherited neuropathies collectively referred to as Charcot-Marie-Tooth (CMT) disease. Previous therapies for CMT were limited to traditional approaches such as rehabilitation medicine, ambulation aids, and pain management. Identification of the genes causing CMT has led to improved genetic counseling and assistance in family planning. Identification of these genes is beginning to delineate common molecular pathways in multiple forms of CMT that can be exploited in future molecular therapies. Scientifically based clinical trials for CMT are currently being implemented. Techniques of gene therapy are advancing to the point that they may become feasible options for patients with CMT and other neurodegenerative diseases.

‘Assessing functional differences in gross motor skills in children with cerebral palsy who use an ambulatory aid or orthoses: can the GMFM‐88 help?’

‘Assessing functional differences in gross motor skills in children with cerebral palsy who use an ambulatory aid or orthoses: can the GMFM‐88 help?’

Validity of 3 Physical Performance Measures in Inpatient Geriatric Rehabilitation

Brooks D, Davis AM, Naglie G. Validity of 3 physical performance measures in inpatient geriatric rehabilitation. Objective To evaluate the construct validity and the responsiveness of 3 measures of physical performance measures as outcome measures for frail older persons. Design Pre-post design with measures at admission and discharge. Setting Three inpatient geriatric rehabilitation programs. Participants Fifty-two subjects (35 women, 17 men; age, 80±8y). Interventions Not applicable. Main Outcome Measures Physical performance measures were Timed Up & Go (TUG) test, two-minute walk test (2MWT), and functional reach. Functional status was measured with the FIM instrument and the Modified Barthel Index. Results The TUG and 2MWT scores differed significantly in groups of patients using different ambulatory aids ( P=.006), whereas no such difference was observed for the functional reach ( P=.40). The correlations between the TUG test and FIM and between the 2MWT and FIM were –.59 and .59 ( P<.001), respectively, at admission, and –.42 and .47 ( P≤.04), respectively, at admission and discharge. The correlations between functional reach and the FIM were not significant ( P≥.09). Standardized response means were 1.1 for the TUG, 0.7 for the 2MWT, and 0.5 for functional reach. Conclusions The TUG test and 2MWT are valid and responsive outcome measures in older persons participating in geriatric rehabilitation. Functional reach was a moderately responsive outcome measure but did not consistently reflect ambulatory or functional status.

Clinical and Pathological Features of Pachyonychia Congenita

Pachyonychia congenita (PC) is a rare genodermatosis affecting the nails, skin, oral mucosae, larynx, hair, and teeth. Pathogenic mutations in keratins K6a or K16 are associated with the PC-1 phenotype whereas K6b and K17 mutations are associated with the PC-2 phenotype. Analysis of clinical, pathological, and genetic data from the literature and two research registries reveal that >97% of PC cases exhibit fingernail and toenail thickening, and painful plantar keratoderma. Prospective evaluation of 57 PC patients from 41 families revealed variable clinical findings: hyperhidrosis (79%), oral leukokeratosis (75%), follicular keratosis (65%), palmar keratoderma (60%), cutaneous cysts (35%), hoarseness or laryngeal involvement (16%), coarse or twisted hair (26%), early primary tooth loss (14%), and presence of natal or prenatal teeth (2%). Stratification of these data by keratin mutation confirmed the increased incidence of cyst formation and natal teeth among PC-2 patients, although cysts were more commonly seen in PC-1 than previously reported (25%-33%). Previously unreported clinical features of PC include development of painful oral and nipple lesions during breastfeeding, copious production of waxy material in ears, and inability to walk without an ambulatory aid (50%). Possible pathogenic mechanisms are discussed with respect to the clinicopathologic and genetic correlations observed.

Assessing functional differences in gross motor skills in children with cerebral palsy who use an ambulatory aid or orthoses: can the GMFM-88 help?

The purpose of this study was to determine whether the Gross Motor Function Measure (GMFM-88) is sensitive to within-child changes in function as a result of children who use an ambulatory aid or orthoses in comparison with unaided or barefoot function. Data from 257 children (140 males, 117 females) with cerebral palsy (CP) were analyzed from a 5-year longitudinal study. The children's age ranged from 2 to 15 years (mean 7y 4mo; SD 2y 11mo), and type of CP, included spastic (n=206 [80.2%1), dyskinetic (n=13 [5.1%]), ataxic (n=9 [3.5%]), hypotonic or mixed (n=27 [10.5%]), and those missing (n=2 [0.8%]), and in motor ability (Gross Motor Function Classification System [GMFCS] levels I, n=40, II, n=34, m, n=93, IV, n=76, and V, n=14). Paired t-tests between barefoot and aided assessments showed significantly higher GMFM-88 total scores overall (n=257) for aided assessment and for three subgroups (ankle-foot orthoses only, ambulatory aid only, ankle-foot orthoses plus ambulatory aid), providing evidence that the GMFM-88 is sensitive to functional changes as a result of using an aid and/or orthoses. With regard to changes within the orthoses-only group, significant changes varied by GMFCS level. The GMFM-88 might provide a clinically useful tool to help in understanding the impact of ambulatory aids and orthoses on gross motor skills of children with CP.

Partial weight-bearing gait using conventional assistive devices

Youdas JW, Kotajarvi BJ, Padgett DJ, Kaufman KR. Partial weight-bearing gait using conventional assistive devices. ObjectiveTo determine if subjects can offload the right lower extremity to a targeted amount of weight bearing using assistive devices. DesignCase series. SettingMotion analysis laboratory. ParticipantsTen healthy subjects (5 men, 5 women) without lower-extremity injury and minimal experience using ambulatory aids. InterventionsBefore data collection subjects were trained by a physical therapist to offload the right lower extremity by 50% by using an assistive device and a bathroom scale for feedback on weight reduction. Main outcome measuresVertical ground reaction force was measured by using forceplates while subjects walked at a self-selected speed by using a 3-point partial weight-bearing (PWB) gait pattern with axillary crutches, forearm crutches, and wheeled walker. We also measured vertical ground reaction force by using a single-point cane. ResultsEach gait aid significantly reduced the right lower-extremity peak vertical ground reaction force. Participants were able to achieve the target of approximately 50% weight reduction with the axillary (50% reduction) and forearm (56% reduction) crutches. The wheeled walker resulted in a peak vertical load of 64% of body weight, which was in excess of the target load. A single-point cane produced a peak vertical load of 76% of body weight. ConclusionsBy using a bathroom scale, healthy subjects could be trained to achieve a target goal of 50% PWB with axillary and forearm crutches. A wheeled walker resulted in weight bearing greater than the target of 50% of body weight. Subjects were able to offload the right lower extremity by about 25% of body weight by using a single-point cane.

Living Environment Evaluation by Persons with Lower-limb Impairment and Their Strategies to Access Activity Opportunities in the Early Developed Area of Tama New Town, Japan

This article examines the relation between the contemporary urban environment and disability as a deprivation of life implementation of persons with physical impairments, through a survey of actions by which persons with lower-limb impairment secure access to various activity opportunities within the early developed area of Tama New Town, Tokyo, Japan. The results of qualitative and quantitative analyses are presented below. Persons with lower-limb impairment who were interviewed in this study uniformly perceived steep slopes and stairs in staircase-style apartments and other buildings as barriers to their activities. Those who suffered impairment of limb functions after moving to the study area, in particular, experienced a shift in their perception of the built environment, from a safe and comfortable environment while they were of sound body, to a barrier after experiencing physical impairment. This experience suggests that Tama New Town is an urban space designed for able-bodied people. While living in an urban space full of barriers, the surveyed individuals have restructured their life space to enable going out by 1) restructuring the relation between physical abilities and the environment by improving the built environment (change of home and barrier-free implementation) and utilizing effective ambulatory aids and means of transport (motorized ambulatory aids and personal cars); and 2) accepting the assistance of others. However, the validity of these actions is conditioned by the ownership of fixed property and goods, the stages of family life cycle and social network development, and the embodied knowledge and information about living in that area. In the study area, to enable a home entry/exit in a medium-rise, staircase-style apartment forces people into moving from the current living area, with a high likelihood of rending useless existing resources that contribute to an enabling life space, such as the social network and knowledge. This is due to the fact that there is no assurance of relocation within the same neighborhood. However, continuing to live in their current home also means the continuation of barriers to home entry/exit. In the fragmented life space that results if such a dilemma cannot be resolved, persons with physical impairment are likely to be deprived of their life implementation.

Nursing Home Falls: A Local Perspective

Introduction: This study aims to examine the demography of falls, factors that contribute to falls and fall risk factors in residents of a nursing home for the elderly in Singapore. Materials and Methods: An 18-month follow-up study was carried out on 95 nursing home residents. Information on the subjects’ potential risk factors for falls was obtained through a review of their casenotes and physical examination. At the end of the study period, the casenotes were reviewed for any documented fall, the circumstances surrounding each fall and whether complications resulted from the fall. The likely factors and events associated with each fall were categorised where possible. Logistic regression was performed to determine the risk factors for falls. Subjects who died or were discharged during the study were included in the analysis. Results: Several subjects (72.6%) were &gt;75 years old, required assistance in activities of daily living (71.6%), cognitively impaired (52.6%), diagnosed with mental illness (49.5%) and non-ambulant (43.2%). A total of 63 falls contributed by 38 (40%) subjects were documented over 18 months, giving an incidence of 0.5 fall per bed year. Thirteen (20.6%) injuries resulted from the falls, of which 3 were fractures. Falls associated with both intrinsic and extrinsic factors were identified in 38.1% of falls. The most common intrinsic factors were gait disorders (31.7%) and confusion/difficult behaviour (31.7%). Contributory extrinsic factors include wheelchair/commode (22.2%) and bathroom-related (15.9%) incidents. Most falls occurred during ambulation (31.7%) and transfers (17.5%). On multivariate logistic regression, the only significant risk factors for falls were “need for ambulatory aids” (odds ratio, 24.4) and “cognitive impairment” (odds ratio, 8.1). Conclusion: The study confirms that falls are common amongst elderly in a local nursing home. Residents with gait instability and behavioural problems due to underlying dementia or mental illnesses are most at risk. Extrinsic factors, such as bathroom activities and the use of wheelchair/commodes, are contributory. Thus, falls reduction protocols in nursing homes should include behavioural measures, enhanced care practices and environmental modifications to be effective.

Aided gait of people with lower-limb amputations: Comparison of 4-footed and 2-wheeled walkers

Tsai HA, Kirby RL, MacLeod DA, Graham MM. Aided gait of people with lower-limb amputations: comparison of 4-footed and 2-wheeled walkers. Arch Phys Med Rehabil 2003;84:584-91. Objectives: To test the hypotheses that prosthesis-wearing people with lower-limb amputations, using 2-wheeled walkers (TWW) versus 4-footed walkers (FFW), (1) walk faster, (2) walk with fewer interruptions, (3) walk no less safely, and (4) prefer the TWW. Design: Within-subject comparisons. Setting: Rehabilitation center. Participants: Twenty prosthesis-wearing people with lower-limb amputations (13 men, 7 women) with a mean age [plusmn] standard deviation of 69[plusmn]13 years. Of the subjects, 11 had unilateral transfemoral amputations, 7 had unilateral transtibial amputations, and 2 had bilateral transtibial amputations. Intervention: Participants were trained to use both walkers. Main Outcome Measures: Five-meter walking velocity, gait pattern, need for spotter intervention, foot position with respect to the base of support of the walker, and subject preference. Results: Subjects walked 28.5% faster when using the TWW ( P[equals].000). During gait cycles, 100% of subjects brought the FFW to a complete halt, whereas only 55%, particularly subjects with transfemoral amputations, halted the TWW ( P[equals].008). There was no difference in the need for spotter intervention. Subjects with unilateral amputations placed their feet significantly more anteriorly within the walker base of support when using an FFW ( P[equals].000). Fourteen subjects preferred the TWW, and 6 chose the FFW (not significant). Conclusion: The TWW allows prosthesis-wearing people with lower-limb amputations, especially those with transtibial amputations, to walk more quickly and with less interruption, but no less safely, than the FFW. The findings have implications for ambulation training and the prescription of ambulation aids.

Effect of Food on the Steady-State Pharmacokinetics of Delavirdine ????????? in Patients with HIV Infection

In a prior single-dose study that examined the effect of food on delavirdine pharmacokinetics in healthy volunteers, the absorption of delavirdine mesylate was delayed and the area under the curve was reduced by 26% in the presence of food. Since the complex, nonlinear pharmacokinetics of delavirdine do not permit a simple extrapolation of the results of a single-dose study to steady state, the present multiple-dose study was performed. Thirteen stable patients with HIV-1 infection (two females, 11 males; CD4 count range 124-588 cells/mm(3)) completed a randomised, crossover study in which subjects received two 14-day treatments with delavirdine mesylate 400mg every 8 hours. In treatment A, all delavirdine doses were administered on an empty stomach and in treatment B were taken with food. A pharmacokinetic evaluation was performed on day 14 of each treatment period. An ambulatory AIDS research centre in an academic medical centre. Administration of delavirdine with and without food. Pharmacokinetic parameters for delavirdine. The maximum concentration (C(max)) [+/- standard deviation] in treatment A was 29.6 +/- 13.6muM and in treatment B it was 23.0 +/- 8.61muM (p = 0.037). The minimum concentrations (C(min)) were 9.45 +/- 6.7muM and 11.2 +/- 9.2muM, respectively (p > 0.05). The oral clearances (CL(oral)) were 17.8 +/- 41.6 L/h (treatment A) and 18.5 +/- 39.0 L/h (treatment B) [p > 0.05]. Similar patterns were observed for N-dealkylated delavirdine with a significant difference only in C(max) (4.13 vs 3.47muM [p = 0.022], treatment A vs B). These findings indicated that, in contrast to the increased CL(oral) noted in a prior single-dose study, food did not have a significant effect at steady state on the area under the plasma concentration-time curve or C(min). Although C(max) was significantly lower when the drug was taken taken with food, the clinical relevance of this parameter as compared with the trough concentration is unclear since the current focus for antiretrovirals is on maintaining trough concentrations in excess of in vitro inhibitory concentrations.

Ambulation Aid Use During the Rehabilitation of People with Lower Limb Amputations

Our objective was to describe the progression of ambulation aid use by people with lower limb amputations during their initial rehabilitation. We prospectively studied 37 people with recent lower limb amputations and a mean (SD) age of 68 (13) years. Subjects were evaluated each weekday during gait-training physiotherapy sessions, and the type and order of ambulation aids used during ambulation training were documented. The total number of gait-training sessions that we observed was 605, with a mean (SD) of 16.4 (7.7) sessions per participant and a range of 5–47. Of the 37 participants, 33 (89%) were discharged with prostheses. The mean (SD) number of aids per person was 2.9 (1.0). The percentage of participants who used each aid (presented in the mean order in which they were first used) were 76% parallel bars, 60% four-footed walkers, 81% two-wheeled walkers, 11% two crutches, 8% four-wheeled walkers, 46% two canes, and 14% one cane. People with lower limb amputations generally use a number of ambulation aids in a fairly consistent order as they progress through their initial rehabilitation. These findings have implications for the process of providing ambulation aids and provide a foundation for further study.

Effects of electrical stimulation-induced leg training on skeletal muscle adaptability in spinal cord injury.

Neuromuscular electrical stimulation has grown in popularity as a therapeutic device for training and an ambulation aid to human paralyzed muscle. Despite its current clinical use, few studies have attempted to concurrently investigate the functional and intramuscular adaptations which occur after electrical stimulation training. Six individuals with a spinal cord injury performed 10 weeks of electrical stimulation leg cycle training (30 min d(-1), 3 d week(-1)). The paralyzed vastus lateralis muscle showed significant alterations in skeletal muscle characteristics after the training, indicated by an improvement in total work output (52-112 kJ; P < 0.05), an increase in fiber cross-sectional area (18 to 41 x 10(2) microm(2); P < 0.05), a reduction in the percentage of type IIX fibers (75% to 12%; P < 0.05), a decrease in myosin heavy chain IIx (68% to 44%; P < 0.05), an increase in capillary density (2-3.5 capillaries around fiber; P < 0.05) and increases in activity levels of citrate synthase (7-16 mU mg(-1) protein) and hexokinase (1.2-2.4 mU mg(-1) protein). This study showed that 10 weeks of electrical stimulation training of human paralyzed muscle induces concurrent improvements in functional capacity and oxidative metabolism.

Dermatome Electrical Stimulation as a Therapeutic Ambulatory Aid for Incomplete Spinal Cord Injured Patients

Electrical stimulation of the L-3,4 dermatome during treadmill walking is proposed as a gait training modality in incomplete spinal cord injured patients. The dermatome stimulation proved to be efficient in diminishing the extensor tone occurring after loading of the paralyzed limb during the stance phase of walking and resulting in improved flexion of the leg during the swing phase.

Intermediate care doesn't provide all the answers.

The National Service Framework for Older People (Department of Health (DoH), 2001) identifies intermediate care services as providing a necessary bridge between existing services in hospital and primary care. These new services will comprise information/advice to enable care in the home; intensive support in the home (hospital-at-home schemes); and short-term institutional care in a supportive environment such as a community hospital, nursing/residential home or sheltered housing. These services will be provided in conjunction with others such as diagnostic and ambulatory care, aids and equipment, home improvement support and carer support. An improved 24-hour provision of primary care together with better working relationships with accident and emergency departments is also planned to effect appropriate response at the time of need.

Paraproteinemic neuropathy

Few prospective, randomized, placebo-controlled trials have been performed to guide clinicians in the management of neuropathies seen in the setting of monoclonal gammopathies (paraproteins). Recommendations must be made on the basis of clinical experience and information gleaned from various uncontrolled and open-label trials. In every instance, decisions concerning therapy must be based on the clinical setting in which the paraprotein occurs. Treatment of paraproteinemic neuropathies associated with multiple myeloma, amyloidosis, and Waldenström's macroglobulinemia should be directed at the treatment of the underlying disease. These neuropathies often remain recalcitrant to therapy. If the paraprotein results from cryoglobulinemia due to hepatitis C virus infection, interferon-alpha (with or without ribavirin) provides optimal subjective and objective relief from symptoms. For neuropathy associated with osteosclerotic myeloma (POEMS syndrome) and solitary bone lesions, radiation therapy is the most effective and least toxic initial therapy. In those patients with monoclonal gammopathies of undetermined significance (MGUS), consideration of the clinical syndrome may be very helpful in selecting appropriate treatment. Patients who fulfill diagnostic criteria for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are best treated in a manner similar to that used for idiopathic CIDP (ie, with intravenous immunoglobulin, plasma exchange, and corticosteroids). Class I evidence documents plasma exchange to be effective in peripheral neuropathies associated with MGUS of the IgG and IgA, but not IgM, types. The most difficult cases to treat are those with peripheral neuropathies associated with IgM monoclonal gammopathies, with or without reactivity to myelin-associated glycoprotein (MAG). A number of published case series propose therapeutic regimens for these conditions, yet optimal treatment remains to be established. In many cases, mildly symptomatic patients should not be subjected to the morbidity associated with current treatment regimens. In those patients requiring treatment, this author initially tries plasma exchange, followed by a course of chlorambucil if the symptoms and signs are predominantly sensory. For cases with rapid progression or significant disability, a regimen of monthly pulses with prednisone and cyclophosphamide is recommended. If improvement does not ensue, a trial of a newer agent, such as rituximab, is recommended. Supportive treatment with physical therapy, orthotics, and ambulatory aids enhances patient independence at a relatively low cost.

Elbow joint, crutches and locomotion: special reference to persons with haemophilia

A 52-year-old, trans-femoral amputee with haemophilia was hospitalized because of ambulatory problems arising from the osteo-arthropathic involvement of other major articulations. Reduced function in the upper limbs, caused by the effects of recurrent haemarthroses, resulted in additional problems concerning the usage of auxiliary ambulatory aids. The advantages and disadvantages of traditional and experimental crutches highlight the functional problems of ambulation in persons with concomitant upper limb pathologies.

Patient-related barriers to pain management in ambulatory AIDS patients

A number of studies have demonstrated that pain is dramatically undertreated among patients with AIDS and that opioids in particular are rarely prescribed. To date, however, there has been no systematic attempt to examine patient-related barriers to the management of pain in AIDS. This study examines potential patient-related barriers to pain management in patients with AIDS using the Barriers Questionnaire (Ward et al., Pain, 52 (1993) 319–324), and assesses gender, racial, and other demographic differences in the endorsement of these barriers. We surveyed 199 ambulatory patients with AIDS, recruited from numerous sites in New York City, as part of an ongoing study of pain and quality of life in ambulatory AIDS patients. In addition to obtaining demographic and medical data, we administered a number of self-report questionnaires including the Brief Pain Inventory (BPI), the Brief Symptom Index (BSI), the Beck Depression Inventory (BDI), and the Memorial Symptom Assessment Scale (MSAS). Barriers to pain management were assessed using a modified version of the Barriers Questionnaire (BQ), including the original 27 questions from this self-report instrument along with an additional 12 items developed for an AIDS population. Results indicated that the most frequently endorsed BQ items were those concerning the addiction potential of pain medications and physical discomfort associated with opioid administration (e.g. injections) or side effects (e.g. nausea, constipation). There were no associations between age, gender, or HIV transmission risk factor and total scores on the BQ; however, Caucasian patients endorsed significantly fewer BQ items than did non-Caucasian patients and years of education was negatively correlated with BQ scores. Scores on the BQ were also significantly correlated with number of physical symptoms (MSAS) and scores on several self-report measures of psychological distress (the BSI Global Distress Index, BDI total scores). Patient-related barriers (i.e. BQ total scores) were significantly associated with undertreatment of pain (as measured by the Pain Management Index), and added significantly to the prediction of undertreatment in a logistic regression analysis, even after controlling for the impact of gender, education and IDU transmission risk factor. These data suggest that patient-related barriers to pain management may add to the already considerable likelihood of undertreatment of AIDS-related pain.

Total hip arthroplasty in an adult with proximal femoral focal deficiency

A 40-year-old woman with isolated unilateral proximal femoral focal deficiency presented with 2 years of gradually increasing left hip pain that interfered with her activities of daily living. A total hip arthroplasty was performed through a posterior approach. At 12 months, she had minimal discomfort about the hip, a markedly increased level of activity, and improved gait, and she required no ambulatory aids. This procedure is cautiously recommended for use in selected patients with proximal femoral focal deficiency.

The measurement of ambulatory impairment in multiple sclerosis.

The objective of this study was to examine the relationships between continuous measures of ambulatory impairment in MS patients and their ordinal counterparts. Much of the disability caused by MS is due to ambulatory impairment. The Expanded Disability Severity Scale (EDSS) and the Ambulation Index (AI) are ordinal measures of MS severity based largely on the maximal distance subjects can walk (Dmax) and the time to walk 8 m (T8), respectively. At EDSS levels 6.0 to 7.0 and AI levels 3 to 6, scores are defined more by the use of ambulatory aids, rather than by Dmax or T8. We determined Dmax (up to 500 m), T8, the EDSS score, and the AI in 237 ambulatory MS patients. The maximal distance subjects could walk and T8 were strongly related to their ordinal counterparts (Spearman r = 0.65 and 0.91, respectively), but the continuous measures showed considerable variability within EDSS and AI levels that the ordinal scales did not reflect. Most of the variability occurred at EDSS levels 6.0 to 7.0 and AI levels 3 to 6. Because the use of an aid did not clearly predict Dmax or T8, many patients in these ranges had better ambulatory function based on the continuous measures than those with less disability according to the ordinal scales. We found that Dmax and T8 provide more precise information about ambulatory impairment in MS than do the EDSS and AI, allowing better discrimination of differences between patients and potentially greater sensitivity to detect therapeutic effects in clinical trials.