Impact of Ankle-foot Orthoses on Gait and Leg Muscle Activity in Adults with Hemiplegia

Effects of ankle-foot orthosis on gait pattern and spatiotemporal indices during treadmill walking in hemiparetic stroke

Ankle-foot orthosis (AFO) is known to correct abnormal gait patterns and improve walking stability and speed in patients with hemiparesis. To quantify these benefits in post-stroke gait, a three-dimensional motion analysis of gait pattern was conducted. Forty patients with hemiparesis were enrolled. A three-dimensional motion analysis system was used to analyze patients' treadmill walking with/without an AFO. Outcome measures were 12 abnormal gait indices (forefoot contact, knee extensor thrust, retropulsion of the hip, flexed-knee gait, medial whip in the stance phase, circumduction gait, hip hiking, insufficient knee flexion during the swing phase, excessive lateral shifting of the trunk, contralateral vaulting, excessive hip external rotation, and posterior pelvic tilt), calculated using kinematic data and spatiotemporal indices, and the symmetry index of double-stance and single-stance time and step length. Forefoot contact (without AFO vs. with AFO: 71.0 vs. 65.8, P < 0.001), circumduction gait (65.0 vs. 57.9, P < 0.001), and contralateral vaulting (78.2 vs. 72.2, P = 0.003) were significantly reduced, whereas excessive hip external rotation (53.7 vs. 62.8, P = 0.003) significantly increased during walking with an AFO. Hip hiking (77.1 vs. 71.7) showed marginal reduction with the use of AFO ( P = 0.096). The absolute symmetry index of double-stance time (21.9 vs. 16.1, P = 0.014) significantly decreased during walking with an AFO. AFO effectively mitigates abnormal gait patterns typical of hemiparetic gait. A 3D motion analysis system with clinically oriented indices can help assess intervention efficacy for gait abnormalities.

Republication of "Uses of Braces and Orthotics for Conservative Management of Foot and Ankle Disorders"

Nonsurgical management is almost always considered the first-line treatment for the vast majority of foot and ankle pathologies. Foot orthoses, shoe modifications, and therapeutic footwear are considered essential tools for successful conservative management of different foot and ankle disorders. Orthopedic foot and ankle surgeons should have a meticulous understanding of the lower extremity biomechanics as well as the pathoanatomy and the sequelae of diseases affecting the foot and/or ankle. This is essential to the understanding of the desired effects of the different inserts, orthotics, shoe modifications, or braces that may be prescribed for these conditions. In this article, we will summarize the orthoses used for treatment of the most commonly encountered foot and ankle pathologies, with the exclusion of treatment for the diabetic foot because of the unique requirements of that disease process.

Combining transcutaneous interferential-current for nerve inhibition with a robotic assistant device for increasing ankle dorsiflexion in walking

BACKGROUND

A kilohertz-frequency alternating current transcutaneously applied was introduced as a novel neuromodulation technology for nerve inhibition innervating antagonist muscles. Combining this electrical nerve inhibition with a robotic assistance device has been proposed but not investigated.

RESEARCH QUESTION

This study aimed to demonstrate the effect of combining electrical nerve inhibition with a wearable robotic device on increasing ankle dorsiflexion during walking. We hypothesized that the wearable robotic device would elicit a greater ankle dorsiflexion angle with the same force in walking by applying the transcutaneous interferential-current nerve inhibition (TINI) technique to the tibial nerve.

METHODS

Eleven healthy young adults performed three experimental conditions. The ankle assistance (AA) condition was walking while wearing an ankle device with operating dorsiflexion assistance during pre-swing and swing phases. For the ankle assistance with electrical stimulation (AE) condition, TINI on the tibial nerve was additionally applied from the AA condition. In the ankle non-assistance (AN) condition, participants wore the device, but assistance was not provided. The joint angles during walking were measured and digitized through a motion analysis system.

RESULTS

During a gait cycle, immediate changes in ankle joint motions were observed in the sagittal plane. In the pre-swing phase, ankle dorsiflexion angle was significantly greater in AE condition than AA and AN. There was no significant difference in joint angle between AA and AN.

SIGNIFICANCE

This study demonstrates the effectiveness of combining TINI with a wearable robotic ankle device in increasing dorsiflexion angle during the pre-swing phase. This finding provides the feasibility of using TINI as a neuromodulation technique for assisting functional movement in human walking.

Mobility experiences of adult lower limb orthosis users: a focus group study

PURPOSE

People with lower limb impairments are often prescribed orthoses to preserve or enhance their mobility. Exploration of mobility experiences common among orthosis users may provide insights into how orthoses, and other mobility aids, are utilized and regarded. The objective of this study was to broadly explore how lower limb orthosis users describe their mobility.

MATERIALS AND METHODS

Four focus groups were held online with participants who lived in the U.S. or Canada. Participants had at least six months of experience using an ankle-foot- and/or a knee-ankle-foot-orthosis for one or both legs. All discussions were transcribed and coded. Thematic analysis was used to identify cross-cutting themes.

RESULTS

Participants included 29 orthosis users with a variety of health conditions. Inter-related themes, including personal factors, situational contexts, and assistance were identified as elements that influenced participants' mobility. Participants described a process of modifying their mobility through the use and non-use of one or more mobility aids.

CONCLUSIONS

The current study findings may assist clinicians in developing strategies to optimize orthosis users' mobility in different situations. Experiences described by participants in this study may also help researchers identify aspects of mobility most pertinent to orthosis users and inform the development of new outcome measures.Implications for RehabilitationPeople who use lower-limb orthoses share common mobility experiences, despite differences in health diagnoses.Orthosis users often have opportunities to modify their mobility by choosing to use or not use their brace(s) and/or handheld mobility aids.When providing mobility aid interventions, clinicians should consider how each patient's individual characteristics, including physical characteristics (e.g., the health condition and how it presents, pain, fatigue) and psychosocial characteristics (e.g., fear and confidence, self-motivation, emotional responses), can affect mobility.Clinicians may be able to help patients optimize their mobility by asking about environmental obstacles they regularly encounter and recommending strategies for utilization of mobility aids, including simultaneous use of multiple aids, use of one aid, or choosing not to use any aids, depending on the activity and situation.Clinicians should inquire about all mobility aids available to a patient at home and in the community, including fixed objects, and consider how new mobility aid interventions might affect the patient's mobility when used alone and in combination with other forms of assistance.

Does electrical stimulation synchronized with ankle movements better improve ankle proprioception and gait kinematics in chronic stroke? A randomized controlled study

BACKGROUND:

Individuals with stroke have impaired sensorimotor function of ankle.

OBJECTIVE:

To investigate the effects of passive biaxial ankle movement training synchronized with electrical stimulation therapy (AMT-EST) on ankle proprioception, passive range of motion (pROM), and strength, balance, and gait of chronic stroke patients.

METHODS:

Thirty-five stroke patients were randomized. The experimental group received a total of 20 AMT-EST sessions. The control group received only EST. Primary outcome measures were ankle functions. Secondary outcome measures were clinical assessments of motor, balance, and gait-related functions. All assessments were compared before and after the intervention.

RESULTS:

The experimental group had significantly improved ankle dorsiflexor strength (p = 0.015) and ankle pROM during foot supination (p = 0.026) and pronation (p = 0.004) and clinical assessment (Fugl–Meyer Assessment of the lower extremities [FM-L], Berg Balance Scale, Timed Up and Go test, Fall Efficacy Scale, walking speed, and step length; all p < 0.05) values. The regression model predicting ankle proprioception showed significantly large effects (adjusted R² = 0.493; p < 0.01) of the combined FM-L score and time since stroke.

CONCLUSION:

Biaxial AMT-EST resulted in better ankle pROM and strength than conventional EST. Ankle proprioception was not significantly improved after AMT-EST and was predicted by the FM-L score and time since stroke.

The effects of orthotics device on the balance control in multiple sclerosis patients: A systematic review and meta-analysis

BACKGROUND

Multiple sclerosis refers to a progressive autoimmune inflammatory disease in the central nervous system usually accompanied by balance disorder. Our systematic review aimed to investigate the effects of orthotic devices on balance control of multiple sclerosis patients.

METHODS

The search procedure was according to the population, intervention, comparison, and outcome (PICO) strategy. We looked into PubMed, Embase, ISI Web of Knowledge, and Scopus databases and included all studies published since 1980. Two researchers did the searches separately and evaluated the selected papers' quality based on the physiotherapy evidence database (PEDro) scale and Cochrane risk of bias tool. We did a meta-analysis to evaluate the interventions' effects on the balance factors.

RESULTS

We found nine studies, of which seven studies with 162 participants were included in our meta-analysis. Four studies investigated the effect of foot orthoses, one evaluated the effect of shoe modifications and four evaluated the effect of ankle foot orthoses. There was no significant immediate difference between the insole and control groups in center of pressure velocity change, C7 displacement, in both open and closed eyes conditions. Also, there was no significant immediate difference between ankle foot orthosis' intervention and control groups in center of pressure velocity and displacement changes in antero-posterior and medio-lateral directions, in both open and closed eyes conditions. We could not do a meta-analysis for shoe modification.

CONCLUSION

Few studies have assessed the effects of orthoses on balance control in multiple sclerosis patients. Studies on ankle foot and foot orthoses show inconsistent results. According to our meta-analysis, orthotic interventions do not seem to improve the balance of people with multiple sclerosis.

Effects of ankle-foot orthoses on the stability of post-stroke hemiparetic gait

BACKGROUND

Ankle-foot orthoses are used to improve gait stability in patients with post-stroke gait; however, there is not enough evidence to support their beneficial impact on gait stability.

AIM

To investigate the effects of ankle-foot orthoses on post-stroke gait stability.

DESIGN

An experimental study with repeated measurements of gait parameters with and without orthosis.

SETTING

Inpatients and outpatients in the Fujita Health University Hospital, Toyoake, Japan.

POPULATION

Thirty-two patients (22 males; mean age 48.3±20.0 years) with post-stroke hemiparesis participated in the study.

METHODS

Three-dimensional treadmill gait analysis was performed with and without ankle-foot orthosis for each participant. Spatiotemporal parameters, their coefficient of variation, and margin of stability were evaluated. Toe clearance, another major target of orthosis, was also examined. The effect of orthosis in the patients with severe (not able to move within the full range of motion, defying gravity) and mild ankle impairment (able to move within the full range but have problem with speed and/or smoothness of the ankle movement) was compared.

RESULTS

In the total group comparison, the decrease in the coefficient of variation of step width (P=0.012), and margin of stability on the paretic side (P=0.023) were observed. In the severe ankle impairment groups, the decreased in the coefficient of variation of the non-paretic step length (P=0.007), stride length (P=0.037), and step width (P=0.033) and margin of stability on the paretic side (P=0.006) were observed. No significant effects were observed in the mild ankle impairment group; rather, the coefficient of variation of non-paretic step length increased with the use of orthosis in this group (P=0.043); however, toe clearance increased with the use of ankle-foot orthosis (P=0.041).

CONCLUSIONS

Ankle-foot orthoses improved gait stability indices; however, the effect was either not significant or showed possible worsening in the patients with mild ankle impairment, while the effect on toe clearance was significant. These results suggest that the effects of using orthoses in patients with mild impairment should be carefully evaluated.

CLINICAL REHABILITATION IMPACT

Understanding the effects of ankle-foot orthoses on the stability of post-stroke gait and their relationship with ankle impairment severity may support clinical decision-making while prescribing orthosis for post-stroke hemiparesis.

Effects of Citrus depressa Hayata Fruit Extract on Thigh Muscles Mass and Composition in Subacute Stroke Patients: A Double-Blind, Randomized, Controlled Pilot Trial

Objective: This pilot study evaluated the effects of Citrus depressa Hayata fruit extract (CFEx) on thigh muscle cross-sectional area (CSA) and composition in subacute stroke patients with hemiparesis who were undergoing rehabilitation. Design and Intervention: This double-blinded, placebo-controlled, randomized pilot trial included 40 subacute stroke patients with moderate-to-severe hemiparesis, and they were randomly assigned to receive CFEx or placebo supplements for 12 weeks. The thigh muscle CSA was measured by computed tomography as total muscle area defined by Hounsfield units (HU) values of -29 to 150 HU. The total muscle area was divided into muscle area with fat infiltration and normal muscle area to evaluate muscle composition (-29 to 29 and 30 to 150 HU, respectively). Results: At baseline, the total muscle area and normal muscle area in the paretic thigh were lower than those in the nonparetic thigh. The nonparetic normal muscle area was significantly higher in the CFEx group than in the placebo group at 12 weeks, whereas the total muscle area was not different. Conclusions: The thigh muscle CSA and composition in the paretic side have already deteriorated in patients with moderate-to-severe hemiparesis at the subacute stroke stage. CFEx supplementation during rehabilitation might improve the nonparetic thigh muscle composition in subacute stroke patients. Findings of this study are needed to be verified by a large-scale randomized trial since this study was a pilot study with a small sample size. Trial registration: UMIN Clinical Trial Registry (UMIN ID: UMIN000012902).

The effect of three dimensional printing hinged ankle foot orthosis for equinovarus control in stroke patients

BACKGROUND

Hemiplegic stroke patients often suffered from equinovarus foot which result in plantar pressure overload over lateral sole. 3D printing is a promising technique utilized in orthosis fabrication, and the effects on plantar pressure remains unclear. The aim in this study focus on the effect of 3D printed ankle foot orthosis, by measuring plantar parameters.

METHODS

Ten patients with first-ever unilateral stroke were enrolled in this study. All patients performed 10-m walk test in 3 conditions, including ambulation with 3D printed hinged ankle foot orthosis, anterior ankle foot orthosis, and bare foot. The plantar contact area, maximum force, and peak pressure were collected and evaluate using Pedar X in-sole system. Plantar parameters symmetric analysis was conducted to assess the similarity between hemiplegic leg and unaffected leg. We used Quebec User Evaluation of Satisfaction with Assistive Technology questionnaire to survey patients' subjective satisfaction.

FINDINGS

Walking with 3D printed ankle foot orthosis revealed significant increase in medial midfoot peak pressure compared to bare foot walking. Plantar parameters symmetric analysis illustrated more even medial midfoot contact area compared to bare foot walking. In satisfaction survey, walking with 3D printed ankle foot orthosis outweighs anterior ankle foot orthosis in fitting and durableness.

INTERPRETATION

Dynamic plantar pressure measurement is useful for evaluation of equinovarus deformity in hemiplegic stroke patients. Wearing 3D printed ankle foot orthosis increase plantar pressure in medial midfoot area. And medial midfoot contact area is also more symmetry.

Anterior or Posterior Ankle Foot Orthoses for Ankle Spasticity: Which One Is Better?

Background and Objectives: Ankle foot orthoses (AFOs) are commonly used by stroke patients to walk safely and efficiently. Both posterior AFOs (PAFOs) and anterior AFOs (AAFOs) are available. The objective of this study was to compare the efficacy of AAFOs and PAFOs in the treatment of ankle spasticity. Materials and Methods: A crossover design with randomization for the interventions and blinded assessors was used. Twenty patients with chronic stroke, a Modified Ashworth Scale (MAS) score of the ankle joint of 2, and a Tardieu angle ≥20 degrees were recruited. The patients were assigned to wear either an AAFO or PAFO at random and subsequently crossover to the other AFO. Results: Twenty stroke patients with ankle spasticity were recruited. The mean age was 46.60 (38−60) years. The mean time since stroke onset was 9.35 (6−15) months. It was discovered that the AAFO improved walking speed as well as the stretch reflex dynamic electromyography (dEMG) and walking dEMG amplitudes of the medial gastrocnemius muscles more significantly than the PAFO (p < 0.05). Conclusions: The AAFO had greater efficacy in reducing both static and dynamic ankle spasticity, and allowed for faster walking than the PAFO. The stretch reflex and walking dEMG amplitudes could be used for quantitative spasticity assessment.

Treatment of knee hyperextension in post-stroke gait. A systematic review

BACKGROUND

Post-stroke, patients exhibit considerable variations in gait patterns. One of the variations that can be present in post-stroke gait is knee hyperextension in the stance phase.

RESEARCH QUESTION

What is the current evidence for the effectiveness of the treatment of knee hyperextension in post-stroke gait?

METHODS

MEDLINE, EMBASE, PEDro, CINAHL, and the Cochrane library were searched for relevant controlled trials. Two researchers independently extracted the data and assessed the methological quality. A best evidence synthesis was conducted to summarize the results.

RESULTS

Eight controlled trials (5 RCTs, 3 CCTs) were included. Three types of interventions were identified: proprioceptive training, orthotic treatment, and functional electrostimulation (FES). In the included studies, the time since the stroke occurrence varied from the (sub)acute phase to the chronic phase. Only short-term effects were investigated. The adjustment from a form of proprioceptive training to physiotherapy training programs seems to be effective (moderate evidence) for treating knee hyperextension in gait, as applied in the subacute phase post-stroke. Neither evidence for effects on gait speed nor gait symmetry were found as a result of proprioceptive training. Orthoses that cover the knee have some effects (limited evidence) on knee hyperextension and gait speed. No evidence was found for FES.

SIGNIFICANCE

This is the first systematic literature review on the effectiveness of interventions on knee hyperextension in post-stroke gait. We found promising results (moderate evidence) for some "proprioceptive approaches" as an add-on therapy to physiotherapy training programs for treating knee hyperextension during the subacute phase post-stroke, in the short-term. Therefore, initially, clinicians should implement a training program with a proprioceptive approach in order to restore knee control in these patients. Because only studies reporting short-term results were found, more high-quality RCTs and CCTs are needed that also study mid- and long-term effects.

The effect of anterior ankle-foot orthosis and posterior ankle-foot orthosis on functional ambulation in stroke patients

Background

The goal of rehabilitation after stroke is to restore safe and sufficient function to hemiplegic patients, and prescription of an ankle-foot orthosis (AFO) to improve speed and functional ambulation is a part of this program.

Objective

This crossover randomized interventional study aimed to evaluate the effect of an anterior ankle-foot orthosis (AAFO) and posterior leaf-spring ankle-foot orthosis (PLS AFO) on speed and functional ambulation in hemiplegic stroke patients.

Method

Clinical assessments were performed on 11 hemiplegic stroke patients by the AAFO, PLS AFO, and wearing shoes. Functional ambulation was measured by the 6-min walking test, Timed Up and Go Test, Time Up and Down Stair Test, and Functional Ambulation Category. Walking speed was measured by the 10-m test.

Results

Both PLS AFO and AAFO significantly improved the performance of TUDS and TUG tests in hemiplegic patients. However, by using PLS AFO, walking distance was significantly greater than walking with shoes. There was no significant effect on the walking speed improvement using PLS AFO or AAFO compared to wearing shoes.

Conclusions

The positive effects of the AAFO and PLS AFO on functional ambulation were significant. By using PLS AFO, hemiplegic patients could walk a longer distance than wearing shoes.

Design and Initial Validation of a Multiple Degree-of-Freedom Joint for an Ankle-Foot Orthosis

This paper presents the novel design of a Multi-Degree-Of-Freedom joint (M-DOF) for an Ankle-Foot Orthosis (AFO) that aims to improve upon the commercially available Double Action Joint (DAJ). The M-DOF is designed to maintain the functionality of the DAJ, while increasing dorsiflexion stiffness and introducing inversion/eversion. This increase in range of motion is designed to produce greater engagement from lower limb muscles during gait. The M-DOF was experimentally validated with one able-bodied and one stroke subject. Across walking speeds, the M-DOF AFO minimally affected the able-bodied subject's joint kinematics. The stroke subject's ankle dorsiflexion/plantarflexion and knee flexion were not heavily altered when wearing the M-DOF AFO, compared to the DAJ AFO. The new DOF allowed by the M-DOF AFO increased the inversion/eversion of the ankle by ~3°, without introducing any new compensations compared to their gait with the DAJ AFO.

Smart Skin: Vision-Based Soft Pressure Sensing System for In-Home Hand Rehabilitation

We introduce a novel in-home hand rehabilitation system for monitoring hand motions and assessing grip forces of stroke patients. The overall system is composed of a sensing device and a computer vision system. The sensing device is a lightweight cylindrical object for easy grip and manipulation, which is covered by a passive sensing layer called "Smart Skin." The Smart Skin is fabricated using soft silicone elastomer, which contains embedded microchannels partially filled with colored fluid. When the Smart Skin is compressed by grip forces, the colored fluid rises and fills in the top surface display area. Then, the computer vision system captures the image of the display area through a red-green-blue camera, detects the length change of the liquid through image processing, and eventually maps the liquid length to the calibrated force for estimating the gripping force. The passive sensing mechanism of the proposed Smart Skin device works in conjunction with a single camera setup, making the system simple and easy to use, while also requiring minimum maintenance effort. Our system, on one hand, aims to support home-based rehabilitation therapy with minimal or no supervision by recording the training process and the force data, which can be automatically conveyed to physical therapists. In contrast, the therapists can also remotely instruct the patients with their training prescriptions through online videos. This study first describes the design, fabrication, and calibration of the Smart Skin, and the algorithm for image processing, and then presents experimental results from the integrated system. The Smart Skin prototype shows a relatively linear relationship between the applied force and the length change of the liquid in the range of 0-35 N. The computer vision system shows the estimation error <4% and a relatively high stability in estimation under different hand motions.

Biomechanical analysis of an unpowered hip flexion orthosis on individuals with and without multiple sclerosis

BACKGROUND

Gait impairment is a common complication of multiple sclerosis (MS). Gait limitations such as limited hip flexion, foot drop, and knee hyperextension often require external devices like crutches, canes, and orthoses. The effects of mobility-assistive technologies (MATs) prescribed to people with MS are not well understood, and current devices do not cater to the specific needs of these individuals. To address this, a passive unilateral hip flexion-assisting orthosis (HFO) was developed that uses resistance bands spanning the hip joint to redirect energy in the gait cycle. The purpose of this study was to investigate the short-term effects of the HFO on gait mechanics and muscle activation for people with and without MS. We hypothesized that (1) hip flexion would increase in the limb wearing the device, and (2) that muscle activity would increase in hip extensors, and decrease in hip flexors and plantar flexors.

METHODS

Five healthy subjects and five subjects with MS walked for minute-long sessions with the device using three different levels of band stiffness. We analyzed peak hip flexion and extension angles, lower limb joint work, and muscle activity in eight muscles on the lower limbs and trunk. Single-subjects analysis was used due to inter-subject variability.

RESULTS

For subjects with MS, the HFO caused an increase in peak hip flexion angle and a decrease in peak hip extension angle, confirming our first hypothesis. Healthy subjects showed less pronounced kinematic changes when using the device. Power generated at the hip was increased in most subjects while using the HFO. The second hypothesis was not confirmed, as muscle activity showed inconsistent results, however several subjects demonstrated increased hip extensor and trunk muscle activity with the HFO.

CONCLUSIONS

This exploratory study showed that the HFO was well-tolerated by healthy subjects and subjects with MS, and that it promoted more normative kinematics at the hip for those with MS. Future studies with longer exposure to the HFO and personalized assistance parameters are needed to understand the efficacy of the HFO for mobility assistance and rehabilitation for people with MS.

Impact of an ankle foot orthosis on reactive stepping in young adults

BACKGROUND

Ankle-foot orthoses (AFOs) have been shown to improve gait and static balance in individuals with lower extremity weakness and instability. However, the effects of AFOs on dynamic balance reactions including reactive stepping responses are not well known. Therefore, the purpose of this study was to determine the effects of an AFO on reactive stepping responses in healthy young adults.

RESEARCH QUESTION

Does an AFO alter reactive stepping responses in healthy young adults?

METHODS

Twenty healthy young adults completed 10 reactive stepping trials using a lean-and-release system for each of three AFO conditions: 1) no AFO, 2) AFO on left leg and 3) AFO on right leg. Trials were recorded using 3D motion capture and force plates. Stepping limb preference and temporal, spatial, and kinematic variables were measured. Differences between conditions were determined by a one-way ANOVA with a Tukey post-hoc.

RESULTS

With no AFO, participants demonstrated a preference for stepping with the right leg, 7.0 ± 3.9 of 10 trials. With an AFO on the right leg, this preference decreased to 5.7 ± 4.4 (p = 0.03). With an AFO on the left leg, this preference increased to 8.1 ± 3.3 (p = 0.03). Reaction times were not significantly different between conditions, but participants took a significantly shorter reactive step with the leg wearing the AFO. Peak ankle, knee, and hip joint angles were significantly less with the AFO on the stepping limb compared to the stance limb.

SIGNIFICANCE

This study shows that AFO use can influence reactive stepping limb preference and stepping limb kinematics in healthy young adults. These results can inform future research on AFO users with gait impairments. These finding may also be helpful in developing interventions to address the specific effects of an AFO on reactive stepping responses.

Role of the newly designed Ankle Foot Orthosis on balance related parametersin drop foot post stroke patients

BACKGROUND

Passive and hybrid passive ankle foot orthoses (AFOs) are often prescribed in post stroke drop foot; however, the effects of these AFOs on balance related parameters in these patients seem unclear. Accordingly, the aim of current study was to evaluate the role of the newly designed hybrid passive and Posterior Leaf Spring (PLS) AFOs on balance related parameters including: self-reported balance confidence (ABC), Timed Up and Go Test (TUG) and Berg Balance Scale (BBS) in post stroke drop foot patients.

METHODS

Fifteen post stroke drop foot patients were recruited in current study. Then, ABC, TUG and BBS were assessed with newly designed AFO and PLS AFO.

RESULTS

The results of this study were shown a significant improvement in ABC, TUG and BBS scores with the newly designed AFO than PLS AFO (p < 0.05).

CONCLUSION

This study suggested that the newly designed AFO was improved the balance related parameters than PLS AFO.

Ankle-foot orthoses improve walking but do not reduce dual-task costs after stroke

BACKGROUND

Cognitive-motor interference, as measured by dual-task walking (performing a mental task while walking), affects many clinical populations. Ankle-foot orthoses (AFOs) are lower-leg splints prescribed to provide stability to the foot and ankle, as well as prevent foot drop, a gait deficit common after stroke. AFO use has been shown to improve gait parameters such as speed and step time, which are often negatively impacted by dual-task walking.

OBJECTIVES

Our objective was to establish whether AFOs could protect against cognitive-motor interference, as measured by dual-task walking, following post-stroke hemiplegia.

METHODS

A total of 21 individuals with post-stroke hemiplegia that use an AFO completed a dual-task walking paradigm in the form of a 2 (walking with vs. without a concurrent cognitive task) by 2 (walking with vs. without an AFO) repeated-measures design. Changes to both motor and cognitive performance were analyzed.

RESULTS

The results suggest that the use of an AFO improves gait overall in both single- and dual-task walking, particularly with respect to stride regularity, but there were no interactions to suggest that AFOs reduce the cognitive-motor dual-task costs themselves. A lack of differences in cognitive performance during dual-task walking with and without the AFO suggests that the AFO's benefit to motor performance cannot be attributed to task prioritization.

CONCLUSIONS

These data support the use of AFOs to improve certain gait parameters for post-stroke hemiplegia, but AFOs do not appear to protect against cognitive-motor interference during dual-task walking. Future research should pursue alternate therapeutics for ameliorating task-specific declines under cognitively demanding circumstances.

Relations between knee and ankle muscle coactivation and temporospatial gait measures in patients without hypertonia early after stroke

It is unclear whether muscle coactivation during gait is altered early after stroke and among which muscles. We sought to characterize muscle coactivation during gait in subacute stroke subjects without hypertonia and explore the relationship with temporospatial parameters. In 70 stroke (23 ± 12 days post-onset) and 29 age-matched healthy subjects, surface electromyography signals were used to calculate coactivation magnitude and duration between rectus femoris and medial hamstring (knee antagonistic coactivation), tibialis anterior and medial gastrocnemius (ankle antagonistic coactivation), and rectus femoris and medial gastrocnemius (extensor synergistic coactivation) during early double-support (DS1), early single-support (SS1), late single-support (SS2), late double-support (DS2), and swing (SW). Compared to both free and very-slow speeds of controls, stroke subjects had bilaterally decreased ankle coactivation magnitude in SS2 and duration in SS1 and SS2 as well as increased extensor coactivation magnitude in DS2 and SW. Both non-paretic knee and ankle coactivation magnitudes in SS2 moderately correlated with most temporospatial parameters (|r| ≥ 0.40). Antagonistic and synergistic coactivation patterns of the knee and ankle muscles during gait are altered bilaterally in subacute stroke subjects without lower limb hypertonia suggesting impairments in motor control. Greater coactivation magnitudes in the non-paretic knee and both ankles during the terminal stance (SS2) are associated with the overall worse gait performance. Unlike previously reported excessive coactivation or no change in chronic stroke, bilaterally decreased and increased coactivation patterns are present in subacute stroke. These findings warrant longitudinal studies to examine the evolution of changes in muscle coactivation from subacute to chronic stroke.

The effect of tuning ankle foot orthoses-footwear combinations on gait kinematics of children with cerebral palsy: A case series

STUDY DESIGN

Case series.

BACKGROUND

AFOs are a commonly prescribed medical device given to children with cerebral palsy (CP) in an attempt to improve their gait. The current literature is equivocal on the effects AFOs have on the gait of children with CP. The vast majority of AFOs issued are not subject to AFO-FC tuning. There are emerging studies investigating the effects tuning AFO-FCs has on the gait of children with CP. However, the research is limited, and there is a lack of quantitative data.

OBJECTIVE

To compare the kinematics of tuned versus non-tuned gait in children with CP.

METHODS

Gait analysis assessment of five children aged between 7-11 years with a diagnosis of CP (one hemiplegic and four diplegic participants, two female, three male, with a Gross Motor Functional Classification System (GMFCS) of 2) at a Gait Analysis Laboratory.

RESULTS

In comparison to barefoot and non-tuned gait, walking with a tuned AFO-FC produced improvements in several key gait parameters. Including hip flexion and extension, posterior pelvic tilt and knee extension. Results also indicated that the type of gait pattern demonstrated by the participant affected the outcomes of tuning.

CONCLUSIONS

Tuning the AFO-FC of children with CP has the potential to improve hip function, pelvic function, knee extension in stance phase and knee flexion during swing phase and that a non-tuned AFO-FC can potentially decrease hip function, posterior pelvic tilt and increase knee extension.

CLINICAL RELEVANCE

Whilst AFO-FC tuning has been recommended for routine clinical practice, there still remains a paucity of research on the kinematic effects of using a tuned AFO-FC compared to a non-tuned. This paper provides a comparison of kinematics on children with CP, during barefoot, non-tuned and tuned AFO-FC walking with a view to inform clinical practice.

Limited fascicle shortening and fascicle rotation may be associated with impaired voluntary force-generating capacity in pennate muscles of chronic stroke survivors

BACKGROUND

Muscle weakness is one of the most common motor impairments after stroke. A variety of progressive muscular changes are reported in chronic stroke survivors, and it is now feasible to consider these changes as an added source of weakness. However, the net contributions of such muscular changes towards muscle weakness have not been fully quantified.

METHODS

Accordingly, this study aims: (1) to compare muscle architecture of the human medial gastrocnemius between paretic and non-paretic sides in seven chronic hemispheric stroke survivors under passive conditions; (2) to characterize fascicle behavior (i.e., fascicle shortening and fascicle rotation) of the muscle during voluntary isometric contractions; and (3) to assess potential associations between muscle architectural parameters and muscle weakness. Muscle architecture of the medial gastrocnemius (including fascicle length, fascicle pennation angle, and muscle thickness) was characterized using B-mode ultrasonography, and fascicle behavior was then quantified as a function of isometric plantarflexion torque normalized to body mass.

FINDINGS

Our experimental results showed that under passive conditions, there was a significant difference in fascicle length and muscle thickness between paretic and non-paretic muscles, but no difference in resting fascicle pennation angle. However, during isometric contraction, both fascicle shortening and fascicle rotation on the paretic side were significantly decreased, compared to the non-paretic side. Moreover, the relative (i.e., paretic/non-paretic) fascicle rotation-shortening ratio (i.e., fascicle rotation per fascicle shortening) was strongly correlated with the relative maximum voluntary isometric plantarflexion torque.

INTERPRETATION

This association implies that such fascicle changes could impair the force-generating capacity of the muscle in chronic stroke survivors.

Offline assistance optimization of a soft exosuit for augmenting ankle power of stroke survivors during walking

Locomotor impairments afflict more than 80% of people poststroke. Our group has previously developed a unilateral ankle exosuit aimed at assisting the paretic ankle joint of stroke survivors during walking. While studies to date have shown promising biomechanical and physiological changes, there remains opportunity to better understand how changes in plantarflexion (PF) assistance profiles impact wearer response. In healthy populations, studies explicitly varying augmentation power have been informative about how exosuit users are sensitive to changes in PF assistance; however there are challenges in applying existing methods to a medical population where significantly higher gait variability and limited walking capacity exist. This paper details an offline assistance optimization scheme that uses pre-recorded biomechanics data to generate torque profiles designed to deliver either positive or negative augmentation power in PF while being less sensitive to stride-by-stride variability. Additionally, we describe an admittance-control strategy that can effectively deliver PF force with RMS error less than 10 N. A preliminary study on six people poststroke demonstrates that offline assistance optimization can successfully isolate positive and negative augmentation power. Moreover, we show that in people poststroke, positive augmentation power effected changes in total positive ankle power while delivering negative augmentation power had no effect on total negative ankle power.

Equinovarus foot in stroke survivors with spasticity: a narrative review of muscle–tendon morphology and force production adaptation

Background/Aims

Spastic paresis is the most common motor disorder in stroke survivors and can cause various types of muscle overactivity. This can lead to the development of spastic equinovarus foot, producing an inadequate base of support that limits locomotion and weight transfers. Physical therapists require better knowledge of the effects of spastic equinovarus foot in order to administer effective clinical treatment. Therefore, the aim of the present review was to describe changes in the muscle morphology and force production of stroke survivors with spastic equinovarus foot in relation to gait performance.

Methods

A narrative review of research into the effects of spastic paresis and equinovarus foot in stroke survivors was undertaken.

Results

There were a total of 20 identified studies that observed muscle-tendon morphology and force production in stroke survivors. All studies included in the present review reported several changes in muscle and tendon biomechanical properties as results of the spastic muscle overactivity.

Conclusions

Stroke survivors with spastic equinovarus foot experience muscle and tendon morphology that result in decreased force production, muscle power and gait performance.

Effect of ankle-foot orthosis on level walking in healthy subjects

An ankle-foot orthosis is often prescribed in the rehabilitation of patients with neurological motor disorders such as hemiparesis. However, walking with a unilateral ankle-foot orthosis may not be effectively achieved just by trying to reproduce normal intact walking with a symmetrical gait pattern. Understanding skills to facilitate walking gait with a unilateral ankle-foot orthosis has implications for better rehabilitative interventions to help restore walking ability in patients with stroke. We, therefore, analyzed the kinematics and ground reaction forces of walking with and without an ankle-foot orthosis in healthy subjects to infer the possible skills to facilitate walking gait with a unilateral ankle-foot orthosis. Adult male participants were asked to walk with and without an ankle-foot orthosis across two force platforms set in a wooden walkway, and body kinematics and ground reaction force profiles in the sagittal plane were simultaneously recorded. We found that the forward tilting angle of the trunk at the time of toe-off of the leg with the ankle-foot orthosis was significantly larger than that of the leg without the ankle-foot orthosis, to adaptively compensate for the loss of ankle joint mobility due to the unilateral ankle-foot orthosis. Furthermore, the peak vertical ground reaction force at heel-contact was significantly larger in the leg without the ankle-foot orthosis than in the leg with the ankle-foot orthosis owing to the fact that the stance phase duration of the leg with the ankle-foot orthosis was relatively shorter. Such information may potentially be applied to facilitate walking training in stroke patients wearing a unilateral ankle-foot orthosis.

Daily Use of Bilateral Custom-Made Ankle-Foot Orthoses for Fall Prevention in Older Adults: A Randomized Controlled Trial

OBJECTIVE

To examine the effects of bilateral custom-made ankle-foot orthoses (AFOs) to prevent falls for older adults with concern about or at risk for falling over 12-month daily use.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Community-dwelling older adults.

INTERVENTION

Half of the participants were randomly allocated to an intervention group (IG) that received fitted walking shoes and bilateral custom-made AFOs, and the other half were randomly allocated to a control group (CG) that only received fitted walking shoes.

MEASUREMENTS

Self-reported fall history of 12-month duration was investigated at baseline and 12-month follow-up for both groups. Fall incidence rate and proportion of fallers were used as outcome measures to determine effects of 12-month footwear intervention in either group.

PARTICIPANTS

Adults aged 65 years and older with concern about or at risk for falling (n = 44).

RESULTS

No significant between-group differences in participant characteristics were observed at the baseline (P = .144-.882). Within the IG, significant reductions were found in the fall incidence rate (P = .039) and the proportion of fallers (P = .036) at the 12-month follow-up compared to the baseline. Within the CG, no significant change was found at the 12-month follow-up compared to the baseline for the fall incidence rate (P = .217) or the proportion of fallers (P = .757). When comparing the IG with the CG, there was no significant difference in the change from the baseline to the 12-month follow-up for the fall incidence rate (P = .572) or the proportion of fallers (P = .080).

CONCLUSION

This study failed to demonstrate a significant benefit of bilateral custom-made AFOs to reduce falls compared to fitted walking shoes. However, the AFO users had significant reductions in falls compared to the preceding year. A future study with a larger sample size is recommended to confirm these observations. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT02819011. J Am Geriatr Soc 67:1656-1661, 2019.

Post-stroke ankle-foot orthoses: Examining referral trends in the Scottish multi-disciplinary team

PURPOSE

As per the Best Practice Statement: Use of Ankle-Foot Orthoses Following Stroke (BPS), members of the stroke multidisciplinary team should refer stroke patients with mobility problems to orthotics. Therefore, the objectives of this study were to (1) assess awareness of the BPS; (2) assess referral patterns and trends; and (3) identify barriers to referral to the Orthotic Service in Scotland.

METHODS

An online survey of the stroke MDT, working in Scotland, whose current role involves work with stroke patients. A survey was distributed via the Scottish Stroke Allied Health Professionals Forum, Scottish Stroke Nurses Forum, British Association of Stroke Physicians, and Scottish Stroke Managed Clinical Networks.

RESULTS

Statistically significant association was found between: Awareness of BPS and NHS Board Area; Profession and whether clinicians have referred to orthotics; Confidence in assessment criteria and profession; Referral to departments other than Orthotics and profession.

CONCLUSION

Physiotherapists are relied upon by members of the Stroke MDT to identify mobility problems and refer to Orthotics. The BPS should be re-disseminated, particularly to the East of Scotland and GPs, to improve awareness of referral criteria. Reduced waiting list times and joint physiotherapist-orthotist clinics may reduce referral barriers to the Orthotic Service.

The effect of ankle-foot orthoses on fall/near fall incidence in patients with (sub-)acute stroke: A randomized controlled trial

Falls are commonly reported post-stroke. Ankle-foot orthoses (AFOs) are often provided to improve safety and walking, but the effect of their use in the reduction of falls after stroke is unknown. A randomized controlled trial (RCT) on the effects of AFO-provision after stroke was performed. Effects on clinical scales, 3D-gait kinematics and muscle-activity were previously reported. This paper aims to study the effects of AFO-provision on occurrence and circumstances of falls/near falls. The RCT included unilateral hemiparetic stroke patients. AFOs were provided either early (study week 1) or delayed (study week 9). Both groups were compared in the first eight weeks of the study and diaries were used to register falls/near falls and their circumstances. Follow-up measurements were performed in week 9–52, in which both groups were provided with AFOs. Functional Ambulation Categories and Berg Balance Scale were assessed to determine walking independence and balance, respectively. Last known scores were noted in case of an incident. Thirty-three subjects were included (16 early, 17 delayed). In week 1–8, the early group, who were provided with AFOs, fell significantly more frequently compared with the delayed group, 11 versus 4 times, respectively (Incidence Rate Ratio = 2.9, p = 0.039). Out of the falls recorded in the early group, 63.6% occurred without wearing AFOs. Most of these falls occurred during transfers (36.4%) and standing (27.3%), and notably it were the subjects who did not have independent walking ability. No differences were found for near falls in week 1–8, or for falls/near falls in week 9–52. Six severe consequences (including fractures) were reported from a fall. To conclude, the subjects provided with AFOs early after stroke reported a higher number of falls, compared to the subjects that had not yet been provided with AFOs. However, in the subjects provided with AFOs, 63.6% of the falls occurred whilst without wearing the AFO. Furthermore, the majority of these incidents took place whilst subjects had no independent walking ability. This raises an interesting question of the importance of careful instructions to patients and their relatives, and the influence of potential cognitive impairments on the ability of the subjects to take on these instructions.

Physical therapist's clinical reasoning in patients with gait impairments from hemiplegia

Background: During stroke rehabilitation, physical therapists (PTs) perform gait analysis and design treatments based on this analysis. Objectives: To investigate the current trends in PTs clinical reasoning in assessing and managing gait in persons with hemiplegia. Design: A qualitative study using a phenomenological approach using a semi-structured interview protocol with FG. Methods: Participants consisted of expert and novice PTs working in a neurologic rehabilitation setting. FG were conducted in person and via web. Constant comparative qualitative analysis was used to analyze the qualitative data. Results: A total of 22 PTs participated in five FG (2 novice and 3 expert groups). From the analysis of qualitative data, five themes emerged. Novice and experienced clinicians: 1) take a systematic approach to examination and evaluation of persons with hemiplegia; 2) are in agreement in common gait deficits found in persons with hemiplegia; 3) may differ in their approach to treatment based on the amount of experience of the clinician; 4) generally agree on the manner in which orthotics are used in the management of persons with hemiplegia; and 5) demonstrate professional accountability to patients concerning the use of orthotic devices. Conclusions: This qualitative study provided insight into the variability in PTs' strategies for gait analysis, and their identification and interpretation of common deviations and impairments in persons with hemiplegia following stroke. Reluctance to utilize orthotics for patients with hemiplegia was a consistent theme across FG.

A novel hinged ankle foot orthosis for gait performance in chronic hemiplegic stroke survivors: a feasibility study

Stroke survivors with gait disturbances may use ankle foot orthoses (AFOs). However, most AFOs come in one-piece styles, which make it difficult for spasticity-affected stroke survivors to don. AFOs are also limited since they do not properly prevent ankle joint for foot drop by itself. Therefore, the present study developed a novel hinged AFO by adding a locking device to a hinged joint. We then tested its feasibility in 9 hemiplegic stroke survivors by investigating temporal-spatial gait parameters using the GAITRite in the following 3 conditions: no AFO, traditional AFO, and novel hinged AFO. There was no significant difference in spatiotemporal gait parameters among the different conditions. There were greater decreases in gait velocity, cadence, step length, and stride length in the novel hinged AFO group than in the no AFO and traditional AFO groups. This novel hinged AFO was developed to prevent foot drop. However, the AFO did not show significant differences in gait parameters because it consists of metal with extra weight and volume. Functionally, it prevented foot drop. It also improved convenience by its releasable design. Thus, further studies are needed to develop an AFO that improves gait and is convenient to use for hemiplegic stroke survivors.

Effectiveness of Daily Use of Bilateral Custom-Made Ankle-Foot Orthoses on Balance, Fear of Falling, and Physical Activity in Older Adults: A Randomized Controlled Trial

BACKGROUND

Foot problems are prevalent in older adults, which may increase the risk and concern for falls. Ankle-foot orthoses (AFO) have been shown to be effective in the stabilization of lower extremities, but their long-term effectiveness in improving balance and their potential to encourage older adults to become more physically active are still debated.

OBJECTIVE

This randomized controlled trial investigated the effectiveness of daily use of a custom-made AFO on balance, fear of falling, and physical activity in older adults.

STUDY DESIGN

Forty-four older adults with concern about or at risk for falling were randomly allocated to either the control group (CG; 77.3% female, age 75.6 ± 6.5 years, BMI 29.3 ± 6.4) or the intervention group (IG; 63.6% female, age 73.7 ± 6.3 years, BMI = 27.8 ± 4.8). The IG received walking shoes and bilateral custom-made AFO. The CG received only walking shoes. At the baseline and 6-month follow-ups, balance and physical activity were assessed using validated wearable instrumentation and fear of falling was assessed using the Fall Efficacy Scale-International (FES-I). Adherence and acceptability toward wearing the AFO were assessed using self-reported questionnaires at the 6-month follow-up.

RESULTS

No significant between-group difference was observed at baseline (p = 0.144-0.882). Compared to baseline and the CG, hip, ankle, and center-of-mass (COM) sways were significantly reduced at the 6-month follow-up in the IG while standing with the feet together during the eyes-open condition (p = 0.005-0.040). Within the IG, the FES-I was reduced significantly (p = 0.036) and there was an increasing trend in the number of walking bouts with a medium effect size (d = 0.52, p = 0.440) compared to baseline. However, there were no significant changes in FES-I and physical activity measures in the CG (p = 0.122-0.894). The reduction in COM sway in the IG was moderately correlated with adherence (r = -0.484, p = 0.047) and strongly correlated with baseline COM sway (r = -0.903, p < 0.001).

CONCLUSION

Results suggest that bilateral custom-made AFO plus walking shoes is effective in improving balance compared to walking shoes alone, and it significantly reduces the fear of falling, with a nonsignificant but noticeable positive trend in physical activity, compared to baseline. The results also suggest that older adults with poor balance at baseline and higher daily adherence to using the AFO will gain more benefit from the AFO intervention.

Comparison of ankle-foot orthoses with plantar flexion stop and plantar flexion resistance in the gait of stroke patients: A randomized controlled trial

BACKGROUND

The effect of plantar flexion resistance of ankle-foot orthoses on the ankle and knee joints is well known, but its effect on the hip joint and upper body movement during the gait of stroke patients remains unclear.

OBJECTIVES

To compare the effect of an ankle-foot orthosis with plantar flexion stop and an ankle-foot orthosis with plantar flexion resistance on the gait of stroke patients in the subacute phase.

STUDY DESIGN

Randomized controlled trial.

METHODS

A total of 42 stroke patients (mean age = 59.9 ± 10.9 years, 36 men and 4 women) in the subacute phase were randomized to each ankle-foot orthosis group in a parallel controlled trial with no blinding. Patients received gait training from physiotherapists using the specified ankle-foot orthosis for 2 weeks. Shod gait without an ankle-foot orthosis before training and gait with an ankle-foot orthosis after training were measured by three-dimensional motion analysis.

RESULTS

A total of 20 patients were analyzed in each group. Significant differences were found in pelvic and thoracic tilt angles between the two groups. Compared with the gait without an ankle-foot orthosis, the pelvis showed forward tilt when patients walked with an ankle-foot orthosis with plantar flexion stop, and the thorax showed decreased forward tilt when the patients walked with an ankle-foot orthosis with plantar flexion resistance.

CONCLUSION

The difference in ankle-foot orthosis function in sagittal plantar flexion resistance affected the alignment of the upper body and the pelvis during the gait of stroke patients in the subacute phase. Clinical relevance Maintaining upright posture is important in gait rehabilitation. The findings of this study suggest that the ankle-foot orthosis with plantar flexion resistance facilitated better alignment of the upper body and pelvis during the gait of stroke patients in subacute phase. This type of ankle-foot orthosis could be beneficial for patients with malalignment of the upper body and pelvis.

Effect of postural insoles on gait pattern in individuals with hemiparesis: A randomized controlled clinical trial

INTRODUCTION

Recovering the ability to walk is an important goal of physical therapy for patients who have survived cerebrovascular accident (stroke). Orthotics can provide a reduction in plantar flexion of the ankle, leading to greater stability in the stance phase of the gait cycle. Postural insoles can be used to reorganize the tone of muscle chains, which exerts an influence on postural control through correction reflexes. The aim of the present study was to perform kinematic and spatiotemporal analyses of gait in stroke survivors with hemiparesis during postural insole usage.

MATERIAL AND METHODS

Twenty stroke victims were randomly divided into two groups: 12 in the experimental group, who used insoles with corrective elements specifically designed for equinovarus foot, and eight in the control group, who used placebo insoles with no corrective elements. Both groups were also submitted to conventional physical therapy. The subjects were analyzed immediately following insole placement and after three months of insole usage. The SMART-D 140^® system (BTS Engineering) with eight cameras sensitive to infrared light and the 32-channel SMART-D INTEGRATED WORKSTATION^® were used for the three-dimensional gait evaluation.

RESULTS

Significant improvements were found in kinematic range of movement in the ankle and knee as well as gains in ankle dorsiflexion and knee flexion in the experimental group in comparison to the control group after three months of using the insoles.

CONCLUSION

Postural insoles offer significant benefits to stroke survivors regarding the kinematics of gait, as evidenced by gains in ankle dorsiflexion and knee flexion after three months of usage in combination with conventional physical therapy.

Uses of Braces and Orthotics for Conservative Management of Foot and Ankle Disorders

Nonsurgical management is almost always considered the first-line treatment for the vast majority of foot and ankle pathologies. Foot orthoses, shoe modifications, and therapeutic footwear are considered essential tools for successful conservative management of different foot and ankle disorders. Orthopedic foot and ankle surgeons should have a meticulous understanding of the lower extremity biomechanics as well as the pathoanatomy and the sequelae of diseases affecting the foot and/or ankle. This is essential to the understanding of the desired effects of the different inserts, orthotics, shoe modifications, or braces that may be prescribed for these conditions. In this article, we will summarize the orthoses used for treatment of the most commonly encountered foot and ankle pathologies, with the exclusion of treatment for the diabetic foot because of the unique requirements of that disease process.

The influence of early or delayed provision of ankle-foot orthoses on pelvis, hip and knee kinematics in patients with sub-acute stroke: A randomized controlled trial

BACKGROUND

Compensatory pelvis, hip- and knee movements are reported after stroke to overcome insufficient foot-clearance. Ankle-foot orthoses (AFOs) are often used to improve foot-clearance, but the optimal timing of AFO-provision post-stroke is unknown. Early AFO-provision to prevent foot-drop might decrease the development of compensatory movements, but it is unknown whether timing of AFO-provision affects post-stroke kinematics.

RESEARCH QUESTIONS

1) To compare the effect of AFO-provision at two different points in time (early versus delayed) on frontal pelvis and hip, and sagittal hip and knee kinematics in patients with sub-acute stroke. Effects were assessed after 26 weeks; 2) To study whether possible changes in kinematics or walking speed during the 26-weeks follow-up period differed between both groups.

METHOD

An explorative randomized controlled trial was performed, including unilateral hemiparetic patients maximal six weeks post-stroke with indication for AFO-use. Subjects were randomly assigned to AFO-provision early (at inclusion) or delayed (eight weeks later). 3D gait-analysis with and without AFO was performed in randomized order. Measurements were performed in study-week 1, 9, 17 and 26.

RESULTS

Twenty-six subjects (15 early, 11 delayed) were analyzed. After 26 weeks, no differences in kinematics were found between both groups for any of the joint angles, both for the without and with AFO-condition. Changes in kinematics during the 26-weeks follow-up period did not differ between both groups for any of the joint angles during walking without AFO. Significant differences in changes in walking speed during the 26-weeks follow-up were found (p = 0.034), corresponding to the first eight weeks after AFO-provision.

SIGNIFICANCE

Results indicate that early or delayed AFO-use post-stroke does not influence pelvis, hip and knee movements after 26 weeks, despite that AFO-use properly corrected drop-foot. AFOs should be provided to improve drop-foot post-stroke, but not with the intention to influence development of compensatory patterns around pelvis and hip.

The impact of ankle-foot orthoses on toe clearance strategy in hemiparetic gait: a cross-sectional study

BACKGROUND

Ankle-foot orthoses (AFOs) are frequently used to improve gait stability, toe clearance, and gait efficiency in individuals with hemiparesis. During the swing phase, AFOs enhance lower limb advancement by facilitating the improvement of toe clearance and the reduction of compensatory movements. Clinical monitoring via kinematic analysis would further clarify the changes in biomechanical factors that lead to the beneficial effects of AFOs. The purpose of this study was to investigate the actual impact of AFOs on toe clearance, and determine the best strategy to achieve toe clearance (including compensatory movements) during the swing phase.

METHODS

This study included 24 patients with hemiparesis due to stroke. The gait performance of these patients with and without AFOs was compared using three-dimensional treadmill gait analysis. A kinematic analysis of the paretic limb was performed to quantify the contribution of the extent of lower limb shortening and compensatory movements (such as hip elevation and circumduction) to toe clearance. The impact of each movement related to toe clearance was assessed by analyzing the change in the vertical direction.

RESULTS

Using AFOs significantly increased toe clearance (p = 0.038). The quantified limb shortening and pelvic obliquity significantly differed between gaits performed with versus without AFOs. Among the movement indices related to toe clearance, limb shortening was increased by the use of AFOs (p < 0.0001), while hip elevation due to pelvic obliquity (representing compensatory strategies) was diminished by the use of AFOs (p = 0.003). The toe clearance strategy was not significantly affected by the stage of the hemiparetic condition (acute versus chronic) or the type of AFO (thermoplastic AFOs versus adjustable posterior strut AFOs).

CONCLUSIONS

Simplified three-dimensional gait analysis was successfully used to quantify and visualize the impact of AFOs on the toe clearance strategy of hemiparetic patients. AFO use increased the extent of toe clearance and limb shortening during the swing phase, while reducing compensatory movements. This approach to visualization of the gait strategy possibly contributes to clinical decision-making in the real clinical settings.

TRIAL REGISTRATION

UMIN000028946 . Registered 31 August 2017 (retrospectively registered).

Effectiveness of prowling with proprioceptive training on knee hyperextension among stroke subjects using videographic observation- a randomised controlled trial

INTRODUCTION

Knee hyperextension is seen in 40-68% of ambulating hemiparetics. If left untreated it may lead to laxity of posterior structures of knee resulting in early degeneration of knee leading to pain, reduced independence in activities of daily living (ADL), deformities and instability. In this study we hypothesize walking with bent knee attitude (prowling) along with proprioceptive training may help to reduce knee hyperextension during the stance phase of gait cycle.

OBJECTIVE

To test the efficacy of prowling along with proprioceptive training on knee hyperextension range, dorsiflexion range and spatio temporal parameters of gait using Wisconsin gait scale (WGS) as compared to routine physiotherapy.

METHOD

32 subjects were randomized into 2 groups- experimental and control groups. Both the groups were given routine physiotherapy. Experimental group received an additional treatment consisting of prowling along with proprioceptive training. Knee hyperextension and ankle dorsiflexion ranges were videotaped and analysed using Kinovea software, and for spatio-temporal gait parameters WGS was used.

RESULTS

In our study, the experimental group showed significant improvement over the control group with regards to knee hyperextension, dorsiflexion range and WGS score. Pre post intervention analysis, within the group, for time taken to cover the distance revealed significant improvement, however between group analysis did not reveal any significant difference.

CONCLUSION

Prowling along with proprioceptive training is effective in reducing knee hyperextension, increasing dorsiflexion range and improving spatio-temporal gait parameters.

A randomized controlled trial on providing ankle-foot orthoses in patients with (sub-)acute stroke: Short-term kinematic and spatiotemporal effects and effects of timing

Initial walking function is often limited after stroke, and regaining walking ability is an important goal in rehabilitation. Various compensatory movement strategies to ensure sufficient foot-clearance are reported. Ankle-foot orthoses (AFOs) are often prescribed to improve foot-clearance and may influence these strategies. However, research studying effects of actual AFO-provision early after stroke is limited. We conducted an explorative randomized controlled trial and aimed to study the short-term effects of AFO-provision on kinematic and spatiotemporal parameters in patients early after stroke. In addition, we studied whether timing of AFO-provision influenced these effects. Unilateral hemiparetic patients maximal six weeks post-stroke were randomly assigned to AFO-provision: early (at inclusion) or delayed (eight weeks later). Three-dimensional gait-analysis with and without AFO in randomized order was performed within two weeks after AFO-provision. Twenty subjects (8 early, 12 delayed) were analyzed. We found significant positive effects of AFO-provision for ankle dorsiflexion at initial contact, foot-off and during swing (-3.6° (7.3) vs 3.0° (3.9); 0.0° (7.4) vs 5.2° (3.7); and -6.1° (7.8) vs 2.6° (3.5), respectively), all p<0.001. No changes in knee, hip and pelvis angles were found after AFO-provision, except for knee (+2.3°) and hip flexion (+1.6°) at initial contact, p≤0.001. Significant effects of AFO-provision were found for cadence (+2.1 steps/min, p=0.026), stride duration (-0.08s, p=0.015) and single support duration (+1.0%, p=0.002). Early or delayed AFO-provision after stroke did not affect results. In conclusion, positive short-term effects of AFO-provision were found on ankle kinematics early after stroke. Timing of AFO-provision did not influence the results.

TRIAL REGISTRATION NUMBER

NTR1930.

Rigid Ankle Foot Orthosis Deteriorates Mediolateral Balance Control and Vertical Braking during Gait Initiation

Rigid ankle-foot orthoses (AFO) are commonly used for impeding foot drop during the swing phase of gait. They also reduce pain and improve gait kinematics in patients with weakness or loss of integrity of ankle-foot complex structures due to various pathological conditions. However, this comes at the price of constraining ankle joint mobility, which might affect propulsive force generation and balance control. The present study examined the effects of wearing an AFO on biomechanical variables and electromyographic activity of tibialis anterior (TA) and soleus muscles during gait initiation (GI). Nineteen healthy adults participated in the study. They initiated gait at a self-paced speed with no ankle constraint as well as wearing an AFO on the stance leg, or bilaterally. Constraining the stance leg ankle decreased TA activity ipsilaterally during the anticipatory postural adjustment (APA) of GI, and ipsilateral soleus activity during step execution. In the sagittal plane, the decrease in the stance leg TA activity reduced the backward displacement of the center of pressure (CoP) resulting in a reduction of the forward velocity of the center of mass (CoM) measured at foot contact (FC). In the frontal plane, wearing the AFO reduced the displacement of the CoP in the direction of the swing leg during the APA phase. The mediolateral velocity of the CoM increased during single-stance prompting a larger step width to recover balance. During step execution, the CoM vertical downward velocity is normally reduced in order to lessen the impact of the swing leg with the floor and facilitates the rise of the CoM that occurs during the subsequent double-support phase. The reduction in stance leg soleus activity caused by constraining the ankle weakened the vertical braking of the CoM during step execution. This caused the absolute instantaneous vertical velocity of the CoM at FC to be greater in the constrained conditions with respect to the control condition. From a rehabilitation perspective, passively- or actively-powered assistive AFOs could correct for the reduction in muscle activity and enhance balance control during GI of patients.

The effect of an ankle-foot orthosis on walking ability in chronic stroke patients: a randomized controlled trial

Objective: Regaining walking ability is a major goal during the rehabilitation of stroke patients. To support this process an ankle-foot orthosis (AFO) is often prescribed. The aim of this study is to investigate the effect of an AFO on walking ability in chronic stroke patients.

Design: Cross-over design with randomization for the interventions.

Methods: Twenty chronic stroke patients, wearing an AFO for at least six months, were included. Walking ability was operationalized as comfortable walking speed, scores on the timed up and go (TUG) test and stairs test. Patients were measured with and without their AFO, the sequence of which was randomized. Additionally, subjective impressions of self-confidence and difficulty of the tasks were scored. Clinically relevant differences based on literature were defined for walking speed (20 cm/s), the TUG test (10 s). Gathered data were statistically analysed using a paired t-test.

Results: The mean difference in favour of the AFO in walking speed was 4.8 cm/s (95% CI 0.85–8.7), in the TUG test 3.6 s (95% CI 2.4 4.8) and in the stairs test 8.6 s (95% CI 3.1 –14.1). Sixty-five per cent of the patients experienced less difficulty and 70% of the patients felt more self-confident while wearing the AFO.

Conclusions: The effect of an AFO on walking ability is statistically significant, but compared with the a priori defined differences it is too small to be clinically relevant. The effect on self-confidence suggests that other factors might play an important role in the motivation to use an AFO.

Immediate effects of an individually designed functional ankle-foot orthosis on stance and gait in hemiparetic patients

Objective: To evaluate the immediate effects of individually designed functional in-shoe ankle-foot orthoses (AFO) made of soft and hard cast on balance, standing, and gait parameters in hemiparetic patients.

Design: Crossover design with randomized order of the intervention.

Setting: A rehabilitation centre for adults with neurological disorders.

Subjects: Twenty-eight patients with hemiparesis due to stroke or traumatic brain injury.

Measures: Postural sway, standing and gait parameters based on ground reaction forces in two conditions: Patients were randomly assigned to varying sequences of wearing AFO in footwear or wearing footwear alone.

Results: AFO significantly improved weight-bearing on the affected leg (affected/ unaffected side symmetry: 2.259 ± 1.5 with AFO versus 3.49 ± 2.5 without AFO, P B ± 0.05) and postural sway in stance (12.5 mm9 ± 5.2 with AFO versus 15.7 mm9 ± 6.7 without AFO, P < ± 0.05), double stance duration (21.19 ± 14.4% of gait cycle with AFO versus 25.99 ± 21.6% of gait cycle without AFO, P < ± 0.05), and symmetry ratios of gait parameters such as stance duration (2.09 ± 1.5 s with AFO versus 3.39 ± 3.6 s without AFO, P < ± 0.05) and deceleration forces (1.69 ± 0.5 with AFO versus 1.99 ± 0.6 without AFO, P < ± 0.05) during gait. No significant differences were observed in all other symmetry ratios of gait parameters.

Conclusion: An individually designed functional in-shoe AFO can improve stance and gait parameters, even in a single use, in patients with hemiparesis.

Effects of ankle foot orthoses on body functions and activities in people with floppy paretic ankle muscles: a systematic review

BACKGROUND

People with floppy ankle muscles paresis use ankle foot orthoses to improve their walking ability. Ankle foot orthoses also limit ankle range of motion thereby introducing additional problems. Insight in effects of ankle foot orthoses on body functions and activities in people with floppy paretic ankle muscles aids in clinical decision making and may improve adherence.

METHODS

Studies published before October 27th, 2014, were searched in Pubmed, Embase, Cinahl, and Cochrane Library. Studies evaluating effects of ankle foot orthoses on body functions and/or activities in people with floppy paretic ankle muscles were included. Studies solely focusing on people with spastic paretic ankle muscles were excluded. Study quality was assessed using a custom-made scale. Body functions and activities were defined according to the International Classification of Functioning, Disability and Health.

FINDINGS

Twenty-four studies were included, evaluating 394 participants. Participants were grouped according to paresis type (i) dorsiflexor paresis, (ii) plantar flexor paresis, (iii) both dorsiflexor and plantar flexor paresis. Dorsal, circular, and elastic ankle foot orthoses increased dorsiflexion during swing (by 4-6°, group i). Physical comfort with dorsal ankle foot orthoses was lower than that with circular ankle foot orthoses (groups i and iii). Dorsal ankle foot orthoses increased push-off moment (by 0.2-0.5 Nm/kg), increased walking efficiency, and decreased ankle range of motion (by 12-30°, groups ii and iii).

INTERPRETATION

People with dorsiflexor paresis benefit more from circular and elastic ankle foot orthoses while people with plantar flexor paresis (and dorsiflexor paresis) benefit more from dorsal ankle foot orthoses.

Biomechanical gait characteristics of naturally occurring unsuccessful foot clearance during swing in individuals with chronic stroke

BACKGROUND

Altered gait mechanics are common following stroke and may increase the risk of falls. Paretic gait impairments have been previously compared to the non-paretic limb or control participants. Unfortunately, the biomechanical parameters underlying instances of naturally occurring unsuccessful foot clearance (trips) have yet to be examined in individuals with chronic stroke.

METHODS

Gait data from 26 participants with chronic stroke were obtained on a dual-belt instrumented treadmill. Instances of successful and unsuccessful foot swing were identified. Temporal, kinematic, and kinetic measures of the paretic limb occurring during late stance, toe-off, and swing were compared between trip and non-trip steps using paired samples t-tests. An α = 0.004 was used to adjust for multiple comparisons.

FINDINGS

In the paretic limb, the ankle angle at toe off (P = 0.003; d = 0.64), knee flexion velocity at toe off (P < 0.001; d = 0.73), and peak knee extension moment during terminal stance (P < 0.001; d = 0.74) were significantly different between trips and non-trip steps. During trip steps, ankle plantarflexion at toe-off was 1.0° greater, knee flexion velocity was reduced by 17.6°/sec, and peak knee extension moment was increased by 0.011 Nm/kg · m compared to non-trip steps.

INTERPRETATION

It appears to take only minor changes in the movement of the paretic limb to result in a trip in individuals with chronic stroke. Although small, the multi-joint biomechanical changes occurring in the paretic limb during unsuccessful foot clearance result in a functionally longer limb. Thus, interventions targeting multiple joints in the paretic limb may be needed to reduce the risk of trips following stroke.

The immediate effects of fitting and tuning solid ankle-foot orthoses in early stroke rehabilitation

BACKGROUND

Ankle-foot orthoses are known to have a generally positive effect on gait in stroke, however the specifc type of AFO and the time point at which it is provided are highly variable in the currently available literature.

OBJECTIVE

The objective was to determine the immediate spatiotemporal and kinematic effect of custom-made solid ankle-foot orthoses in early stroke rehabilitation, compared to shod walking.

METHODS

Five male and three female participants were recruited to the study (n = 8), with a mean age of 57 (16) years who were 3.5 (3) weeks post-stroke. Each received a custom-made solid ankle-foot orthosis to a predefined set of design criteria and tuned using heel wedges to control the shank inclination angle during shod walking. Repeated spatiotemporal and three-dimensional gait measures were taken pre- and immediately post-intervention.

STUDY DESIGN

A pre-post-test experimental study.

RESULTS

With the solid ankle-foot orthosis, walking velocity increased from 0.22 (0.2) to 0.36 (0.3) m/s (p < 0.05), overall average step length increased from 0.28 (0.1) to 0.37 (0.1) m (p < 0.05), cadence increased from 45 (19) to 56 (19) steps/min (p < 0.05) and step length symmetry ratio increased from 0.65 (0.2) to 0.74 (0.2) (not significant). No clear changes were observed in the joint kinematics of the hip and knee.

CONCLUSION

In our small group of early stroke patients who were fitted with a solid ankle-foot orthosis, immediate significant improvements occurred in walking speed, step length and cadence, when compared to walking with shoes only.

CLINICAL RELEVANCE

This study provides evidence about the immediate effects of custom solid ankle-foot orthoses on gait of early stroke survivors. Ankle-foot orthosis design specifications are fully described for replication. This study suggests that observing global segment orientation may be more useful than joint angles when fitting and tuning ankle-foot orthoses for optimal ankle-foot orthosis/footwear alignment.

Brain-controlled functional electrical stimulation therapy for gait rehabilitation after stroke: a safety study

BACKGROUND

Many stroke survivors have significant long-term gait impairment, often involving foot drop. Current physiotherapies provide limited recovery. Orthoses substitute for ankle strength, but they provide no lasting therapeutic effect. Brain-computer interface (BCI)-controlled functional electrical stimulation (FES) is a novel rehabilitative approach that may generate permanent neurological improvements. This study explores the safety and feasibility of a foot-drop-targeted BCI-FES physiotherapy in chronic stroke survivors.

METHODS

Subjects (n = 9) operated an electroencephalogram-based BCI-FES system for foot dorsiflexion in 12 one-hour sessions over four weeks. Gait speed, dorsiflexion active range of motion (AROM), six-minute walk distance (6MWD), and Fugl-Meyer leg motor (FM-LM) scores were assessed before, during, and after therapy. The primary safety outcome measure was the proportion of subjects that deteriorated in gait speed by ≥0.16 m/s at one week or four weeks post-therapy. The secondary outcome measures were the proportion of subjects that experienced a clinically relevant decrease in dorsiflexion AROM (≥2.5°), 6MWD (≥20 %), and FM-LM score (≥10 %) at either post-therapy assessment.

RESULTS

No subjects (0/9) experienced a clinically significant deterioration in gait speed, dorsiflexion AROM, 6MWT distance, or FM-LM score at either post-therapy assessment. Five subjects demonstrated a detectable increase (≥0.06 m/s) in gait speed, three subjects demonstrated a detectable increase (≥2.5°) in dorsiflexion AROM, five subjects demonstrated a detectable increase (≥10 %) in 6MWD, and three subjects demonstrated a detectable increase (≥10 %) in FM-LM. Five of the six subjects that exhibited a detectable increase in either post-therapy gait speed or 6MWD also exhibited significant (p < 0.01 using a Mann-Whitney U test) increases in electroencephalogram event-related synchronization/desynchronization. Additionally, two subjects experienced a clinically important increase (≥0.16 m/s) in gait speed, and four subjects experienced a clinically important increase (≥20 %) in 6MWD. Linear mixed models of gait speed, dorsiflexion AROM, 6MWD, and FM-LM scores suggest that BCI-FES therapy is associated with an increase in lower motor performance at a statistically, yet not clinically, significant level.

CONCLUSION

BCI-FES therapy is safe. If it is shown to improve post-stroke gait function in future studies, it could provide a new gait rehabilitation option for severely impaired patients. Formal clinical trials are warranted.