Patient perspectives of ankle-foot orthoses for walking ability in peripheral artery disease: A qualitative study

Selective orthotic constraint of lower limb movement during walking reveals new insights into neuromuscular adaptation

Introduction

A concern expressed by the clinical community is that the constraint of motion provided by an ankle foot orthosis (AFO) may lead the user to become dependent on its stiffness, leading to learned non-use. To examine this, we hypothesized that using an experimental AFO-footwear combination (exAFO-FC) that constrains ankle motion during walking would result in reduced soleus and tibialis anterior EMG compared to free (exAFO-FC) and control (no AFO, footwear only) conditions.

Method

A total of 14 healthy subjects walked at their preferred speed (1.34 ± 0.09 m·s-1) for 15 min, in three conditions, namely, control, free, and stop.

Results

During the stance phase of walking in the stop condition, ipsilateral soleus integrated EMG (iEMG) declined linearly, culminating in a 32.1% reduction compared to the control condition in the final 5 min interval of the protocol. In contrast, ipsilateral tibialis anterior iEMG declined in a variable fashion culminating in an 11.2% reduction compared to control in the final 5 min interval. During the swing phase, the tibialis anterior iEMG increased by 6.6% compared to the control condition during the final 5 min interval. The contralateral soleus and tibialis anterior exhibited increased iEMG in the stop condition.

Discussion

An AFO-FC functions as a biomechanical motion control device that influences the neural control system and alters the output of muscles experiencing constraints of motion.

Effects of ankle-foot orthoses on step activities in the community: a systematic review

PURPOSE

To determine the effects of ankle-foot orthoses (AFO) on step-based physical activities in individuals with neurological, orthopaedic, or cardiovascular disorders.

METHODS

Electronic searches of databases such as Scopus, PubMed, Web of Science, Embase, ProQuest, Cochrane Library, and EBSCO were conducted. Two evaluators independently searched with keywords focusing on step-based physical activities, and either articulated or non-articulated AFO. Study quality was assessed using a modified Downs and Black quality scale.

RESULTS

Eleven studies that met the inclusion criteria were selected, including four being classified as good, four as fair, and three as poor in quality. The majority of these trials found no significant effects of AFO on step activities. Only a few studies reported improvements in step counts and active times in step activity with a limited to moderate level of evidence. Subjective evaluations such as user satisfaction, and physical functionality during step activity, on the other hand, showed substantial changes with the use of AFO interventions, although there was no evidence of improvement in the quality of life.

CONCLUSIONS

Although the AFO did not seem to have a substantial effect on step activity, it appeared to play a vital role in improving the patient satisfaction level of step activity.IMPLICATIONS FOR REHABILITATIONAnkle-foot orthoses (AFO) may not significantly affect the step activity of individuals with impaired ankle-foot complex.AFO may enhance patient-reported satisfaction, physical functioning, participation, and fatigue level during step activity.The patient's perception that the AFO is beneficial is in contrast to objective data showing no significant increase in real-world activity.

Methodological and reporting quality of qualitative evidence in the field of lower limb orthoses: a systematic review

This study aimed to assess the methodological and reporting quality of qualitative studies conducted in the field of lower limb orthoses (LLOs). The following electronic databases were searched from inception to 2022: PubMed, Scopus, ProQuest, WoS, Embase, the Cochrane Central Register of Controlled Trials, and RehabData. Two authors independently screened and selected the potential studies. The methodological quality of included studies was assessed using the Critical Appraisal Skills Programs qualitative checklist. In addition, the reporting quality of included studies was assessed using the Standards for Reporting Qualitative Research (SRQR) tool. The mean methodological quality score of included studies was 8 (from min = 2 to max = 9.5), and most of the studies had a score of more than 7.5. However, SRQR findings revealed that the overall reporting quality of included studies was not desirable in that the mean score was about 15.44 (from min = 6 to max = 19.5) out of 21. In total, the methodological quality of qualitative studies published in the field of LLOs was moderate. Further, the adherence of these studies to available reporting guidelines was unsatisfactory. As a result, when designing, performing, and reporting qualitative investigations, authors should pay more attention to these criteria.

A comparison of the perceptions of wearing an ankle foot orthosis by individuals with peripheral artery disease according to their baseline-level of physical activity

INTRODUCTION

Peripheral artery disease (PAD) is a prevalent cardiovascular disease that limits an individual's ability to walk. One potential way to improve physical activity for patients with PAD is an ankle foot orthosis (AFO). Previous research has found that various factors may influence an individual's willingness to wear AFOs. However, one factor that has been understudied is an individual's baseline physical activity level prior to wearing AFOs. Therefore, the purpose of this study was to compare the perceptions of wearing AFOs for 3 months among individuals with PAD according to their baseline level of physical activity.

METHODS

Accelerometer-derived physical activity prior to AFO prescription was used to classify participants into either a higher or lower activity group. Semi-structured interviews were conducted at 1.5 and 3-months after wearing the AFOs to assess participants' perceptions of using the orthosis. Data were analyzed by a directed content analysis approach, then the percentage of respondents for each theme were calculated and compared between higher and lower activity groups.

FINDINGS

Several differences were found. Participants in the higher activity group more often reported positive impacts from wearing the AFOs. Additionally, participants who were in the lower activity group more often reported the AFOs caused physical pain while participants in the higher activity group more often reported the device was uncomfortable during daily activities.

CONCLUSION

Baseline physical activity levels may help to better understand barriers to wear and needed support to increase adherence to an AFO wear prescription, especially for patients with PAD with limited activity.

Exploring telehealth interventions to monitor rehabilitation in patients with peripheral artery disease

Peripheral artery disease is a manifestation of systemic atherosclerosis, and these patients often have claudication pain in the legs during activity. This leads to generally adopting an inactive lifestyle; hence, even small changes in physical activity could reduce the risk of an adverse cardiovascular event. For patients with peripheral artery disease compliance with non-invasive interventions like assistive devices and long-term exercise therapy is important for improved health outcomes. Benefits to patients can only be measured if patients with peripheral artery disease adhere to the intervention and barriers are identified with improved solutions. The effect of mobile health including pedometers and smartphone technological applications in motivating the patient to continue adhering to the intervention and persist in physical activity is a new venture to be explored.

Mechanical adaptations in walking using carbon fiber ankle foot orthoses for patients with peripheral artery disease

BACKGROUND

The effectiveness of community-based walking programs for patients with peripheral artery disease (PAD) can be limited by calf claudication during exercise. Recent evidence finds adding carbon fiber ankle foot orthoses (AFO) to a walking program can result in improvements in patient mobility and delay claudication onset when walking.

RESEARCH QUESTION

How may carbon fiber AFO alter ankle walking mechanics and corresponding triceps surae muscle recruitment in a manner that could improve patient mobility?

METHODS

In this repeated measures cohort study, fifteen patients with PAD were fit with bilateral AFO before completing self-paced gait analysis including electromyography. Patients were then given standard advice to walk at home using the devices for 12 weeks. Twelve patients completed follow-up testing.

RESULTS

There were no significant interactions between main effects for any variable of interest (p ≥ 0.189). Further, there were no within-subjects main effects for testing time for self-selected gait speed or any of the kinetic or kinematic variables (p ≥ 0.435). There were significant main effects for AFO use with reductions in dorsi flexion (p < 0.001), plantar flexion at toe off (p < 0.001), ankle plantar flexor moment (p = 0.037), and ankle plantar flexor power (p < 0.001). Triceps surae recruitment did not change between AFO conditions (p > 0.05).

SIGNIFICANCE

Adding carbon fiber AFO limits peak ankle motion and joint power during self-paced walking for people with PAD while maintaining their walking speed. These gait adaptions were maintained over our 12 weeks of walking practice time. A resulting decrease in plantar flexor power while maintaining gait speed may provide the mechanism by which AFO can delay claudication onset which are major barrier to PAD walking programs. Calf muscle recruitment was maintained when adding the AFO which suggests sufficient muscle exertion could exist to maintain muscle integrity with sustained AFO use.

Long-term use of an ankle-foot orthosis intervention in patients with peripheral artery disease using the integrated promoting action on research implementation in health services (i-PARIHS) framework

BACKGROUND

Peripheral artery disease (PAD) is a cardiovascular disease that limits patients' walking ability. Persistent ankle-foot orthosis (AFO) use may increase the distance patients can walk as well as physical activity.

PURPOSE

The purpose of the study was to determine the implementation and patients' perspectives related to the use or disuse of the AFO intervention six months post-intervention. This study was guided by a semi-structured interview and survey based on the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) constructs.

DESIGN

A convergent mixed methods design was used to evaluate participants' perceptions six months following a three-month AFO intervention. A survey and semi-structured questionnaire based on the i-PARIHS constructs were administered and analyzed.

SETTING

Vascular surgery clinic and biomechanics research laboratory.

PARTICIPANTS

Patients (N = 7; male, 100%; age, 71.9 ± 0.6.7y; body mass index, 29.0 ± 0.5.5; ankle brachial index 0.50 ± 0.17) with claudication completed the study.

INTERVENTIONS

A certified orthotist fit participants with an AFO that was worn for 3 months.

MAIN OUTCOME MEASURES

Qualitative analysis of semi-structured interviews and quantitative analysis of the survey.

RESULTS

The highest positive ratings were seen in the dimensions of usability and cost-effectiveness. The patients found the AFO device and instructions to wear, easy when starting the intervention and there were no out-of-pocket costs. The lower scores and challenges faced with observability and relative advantage domains indicated issues related to motivation for sustained use of the AFO.

CONCLUSIONS

Barriers associated with AFO function that prevent common activities and poor health seem to be the biggest issue for not wanting to wear the AFO after the 3-month intervention. Addressing patients' perceptions and challenges to wearing the AFO is essential to increasing compliance and physical activity. Future research should concentrate on understanding the compatibility of orthotic device interventions with the subject's lifestyle.

CLINICAL TRIAL REGISTRATION NO

NCT02902211.

Patient Compliance With Wearing Lower Limb Assistive Devices: A Scoping Review

OBJECTIVE

The aim of this scoping review was to identify information on compliance with wearing orthoses and other supportive devices, to discuss the barriers to adherence, and to suggest strategies for improvement based on these findings.

METHODS

Online databases of PubMed, Web of Science, and the Cochrane Library were searched for articles about patients' compliance with regard to lower limb assistive devices. In addition, a methodological quality control process was conducted. Studies were included if in the English language and related to compliance and adherence to the lower limb assistive device. Exclusion was based on first reading the abstract and then the full manuscript confirming content was not related to orthotic devices and compliance.

RESULTS

Twelve studies were included. The data revealed between 6% and 80% of patients were not using a prescribed device. Barriers to the use of the orthotic device included medical, functional, device properties and lack of proper fit. Strategies for improved compliance included better communication between patient and clinician, patient education, and improved comfort and device esthetics.

CONCLUSIONS

Individualized orthotic adjustments, rehabilitation, and patient education were promising for increasing adherence. Despite positive aspects of improvements in gait, balance in elderly, and a sense of security produced by using assistive devices, compliance remains less than ideal due to barriers. As compliance in recent studies has not improved, continued work in this area is essential to realize the benefits of technological advances in orthotic and assistive devices.

Assessing Wear Time and Perceptions of Wearing an Ankle Foot Orthosis in Patients with Peripheral Artery Disease

BACKGROUND

Peripheral artery disease (PAD) is a cardiovascular disease that effects patients' walking ability. An ankle foot orthosis (AFO) may improve patients' walking distances. Little research has explored if patients wear a prescribed AFO and their perceptions of wearing the device.

OBJECTIVE

To assess wear time of an AFO and explore perceptions of wearing the device in patients with peripheral artery disease.

DESIGN

Convergent mixed methods.

SETTING

The study was administered through a tertiary care medical center and the research subjects used the device in an outpatient setting in and out of their homes during their regular activities.

PARTICIPANTS

Patients were referred to the study by their vascular surgeon. Thirty-six patients, all older adult males, were enrolled in this study. Fourteen patients completed the study and 11 supplied sufficient accelerometer data.

INTERVENTIONS

An AFO was worn for 3 months. An accelerometer was placed on the AFO for 7 days at midpoint (1.5 months) and endpoint of the intervention (3 months) to assess wear time. Semi-structured interviews explored patients' perceptions of wearing the AFO.

MAIN OUTCOME MEASURE

The primary outcome measure was wear time measured objectively via accelerometer and subjectively via interview.

RESULTS

Patients (n = 14) wore the AFO around 8 hours/day. Most patients felt they wore the AFO a majority of the time. Patients reported barriers such as challenges wearing the AFO during daily household activities (using stairs, being on uneven terrain), discomfort, clothing or footwear issues, and driving challenges. Positive impacts of wearing the AFO were also reported, primarily the ability to walk further.

CONCLUSIONS

An AFO may be an acceptable therapeutic intervention to improve perceived walking performance in older adult males with PAD. Addressing patients' perceptions of the AFO and barriers to wear are essential to increasing the positive impact the device has on patients' ambulatory activity. This article is protected by copyright. All rights reserved.