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

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.

Carbon fiber ankle-foot orthoses in impaired populations: A systematic review

BACKGROUND

Carbon fiber is increasingly being used in ankle-foot orthoses (AFOs). Orthotic devices and carbon fiber-containing devices have been shown to reduce pain and improve function in multiple patient populations. Although the number of publications and interest in carbon fiber AFOs is growing, a systematic evaluation of their effects is lacking.

OBJECTIVES

To characterize the effects of carbon fiber AFOs in impaired individuals.

STUDY DESIGN

Qualitative systematic review.

METHODS

Systematic searches in PubMed, Embase, CINAHL, and Cochrane Library were completed in July 2020. The results were deduplicated, screened, and assessed for quality by independent reviewers. Articles were excluded if they had nonhuman subjects, only healthy subjects, or included active control systems, motors, or other power sources.

RESULTS

Seventy-eight articles were included in the qualitative synthesis. Most articles were of low to moderate methodological quality. Five commonly used devices were identified: the Intrepid Dynamic Exoskeletal Orthosis, ToeOff, WalkOn, Neuro Swing, and Chignon. The devices have unique designs and are associated with specific populations. The Intrepid Dynamic Exoskeletal Orthosis was used in individuals with lower-limb trauma, the Neuro Swing and ToeOff in individuals with neurological disorders, the Chignon in individuals with hemiplegia and stroke, and the WalkOn in people with hemiplegia and cerebral palsy. Each device produced favorable outcomes in their respective populations of interest, such as increased walking speed, reduced pain, or improved balance.

CONCLUSIONS

The mechanical characteristics and designs of carbon fiber AFOs improve outcomes in the populations in which they are most studied. Future literature should diligently report patient population, device used, and fitting procedures.

Advances in the clinical application of orthotic devices for stroke and spinal cord injury since 2013

Stroke and spinal cord injury are common neurological disorders that can cause various dysfunctions. Motor dysfunction is a common dysfunction that easily leads to complications such as joint stiffness and muscle contracture and markedly impairs the daily living activities and long-term prognosis of patients. Orthotic devices can prevent or compensate for motor dysfunctions. Using orthotic devices early can help prevent and correct deformities and treat muscle and joint problems. An orthotic device is also an effective rehabilitation tool for improving motor function and compensatory abilities. In this study, we reviewed the epidemiological characteristics of stroke and spinal cord injury, provided the therapeutic effect and recent advances in the application of conventional and new types of orthotic devices used in stroke and spinal cord injury in different joints of the upper and lower limbs, identified the shortcomings with these orthotics, and suggested directions for future research.

Prescription practices for rigid ankle-foot orthoses among UK orthotists

OBJECTIVE

The purpose of this study was to investigate rigid ankle-foot orthosis (AFO) prescription practices for adult men among UK orthotists.

DESIGN

A cross-sectional study using a survey was distributed online to UK orthotists by the British Association of Prosthetists and Orthotists to its members and through social media and orthotic networks. The survey was completed between November 1, 2020, and November 29, 2020.

MAIN OUTCOME MEASURES

Descriptive statistics of survey results include information related to the material used, the thickness of the material, positive cast rectification, AFO reinforcement, footplate design, padding, strapping system, and height of AFO.

RESULTS

One hundred participants completed the survey, which equates to a response rate of 30.5% of the British Association of Prosthetists and Orthotists members targeted. A clear consensus emerged on the design of a bespoke rigid AFO for the hypothetical patient in this study, which is detailed as follows: 1) 4.5 mm copolymer polypropylene, 2) no additional reinforcement, 3) full-length footplate with mediolateral trimlines terminating behind the metatarsal heads, 4) 3-point correction with parallel sides, 5) padded VELCRO straps with D-rings at the calf and heel, 6) no forefoot or other additional strapping, 7) 3-mm PORON (international Ltd) padding at the malleoli, and 8) AFO height that finishes 2 cm below the fibular head.

CONCLUSIONS

This study has highlighted a consensus on AFO prescription/design among UK orthotists surveyed, based on the hypothetical patient described in this study.

A Clinical Practice Guideline for the Use of Ankle-Foot Orthoses and Functional Electrical Stimulation Post-Stroke

BACKGROUND

Level of ambulation following stroke is a long-term predictor of participation and disability. Decreased lower extremity motor control can impact ambulation and overall mobility. The purpose of this clinical practice guideline (CPG) is to provide evidence to guide clinical decision-making for the use of either ankle-foot orthosis (AFO) or functional electrical stimulation (FES) as an intervention to improve body function and structure, activity, and participation as defined by the International Classification of Functioning, Disability and Health (ICF) for individuals with poststroke hemiplegia with decreased lower extremity motor control.

METHODS

A review of literature published through November 2019 was performed across 7 databases for all studies involving stroke and AFO or FES. Data extracted included time post-stroke, participant characteristics, device types, outcomes assessed, and intervention parameters. Outcomes were examined upon initial application and after training. Recommendations were determined on the basis of the strength of the evidence and the potential benefits, harm, risks, or costs of providing AFO or FES.

RESULTS/DISCUSSION

One-hundred twenty-two meta-analyses, systematic reviews, randomized controlled trials, and cohort studies were included. Strong evidence exists that AFO and FES can each increase gait speed, mobility, and dynamic balance. Moderate evidence exists that AFO and FES increase quality of life, walking endurance, and muscle activation, and weak evidence exists for improving gait kinematics. AFO or FES should not be used to decrease plantarflexor spasticity. Studies that directly compare AFO and FES do not indicate overall superiority of one over the other. But evidence suggests that AFO may lead to more compensatory effects while FES may lead to more therapeutic effects. Due to the potential for gains at any phase post-stroke, the most appropriate device for an individual may change, and reassessments should be completed to ensure the device is meeting the individual's needs.

LIMITATIONS

This CPG cannot address the effects of one type of AFO over another for the majority of outcomes, as studies used a variety of AFO types and rarely differentiated effects. The recommendations also do not address the severity of hemiparesis, and most studies included participants with varied baseline ambulation ability.

SUMMARY

This CPG suggests that AFO and FES both lead to improvements post-stroke. Future studies should examine timing of provision, device types, intervention duration and delivery, longer term follow-up, responders versus nonresponders, and individuals with greater impairments.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for people with poststroke hemiplegia who have decreased lower extremity motor control that impacts ambulation and overall mobility.A Video Abstract is available as supplemental digital content from the authors (available at: http://links.lww.com/JNPT/A335).

Effects of two different types of ankle-foot orthoses on gait outcomes in patients with subacute stroke: a randomized crossover trial

OBJECTIVE

To identify whether patients in the subacute stage of stroke, with foot drop, would have better gait outcomes when using a double-adjustable AFO (DA AFO) or a posterior leaf spring AFO (PLS AFO) at baseline without practice and to determine whether one week of practice would significantly change gait outcomes with either of the AFOs.

DESIGN

Within-subject 2 × 2 repeated measures design.

SETTING

Postacute and outpatient rehabilitation center.

PARTICIPANTS

Twenty individuals with mean age of 57 years (SD: 12.0 years) with subacute stroke.

INTERVENTIONS

Participants were measured using DA AFO and PLS AFO at baseline. Follow-up measurements were taken after one week of practice with each type of AFO in randomly assigned order.

OUTCOME MEASURES

Gait endurance (6-Minute Walk Test (6MWT)), gait symmetry, and gait velocity at self-selected and fast-paced velocity measured using GAITRite gait analysis system and patient report of AFO preference.

RESULTS

At baseline, no significant differences were found between the 2 AFOs (P > 0.05). There was no significant interaction (P > 0.05) of AFO and practice for gait endurance, symmetry, and velocity. Main effect of practice was significant for gait endurance (P < 0.001), self-selected velocity (P = 0.001), and fast-paced velocity (P < 0.001). In all, 16 participants preferred using DA AFO for walking.

CONCLUSIONS

No difference between DA AFO and PLS AFO was found on measures of gait endurance, symmetry, and velocity at baseline or after practice. With practice over time, participants improved in gait endurance and velocity regardless of AFO type.

Accuracy and repeatability of smartphone sensors for measuring shank-to-vertical angle

BACKGROUND

Assessments of human movement are clinically important. However, accurate measurements are often unavailable due to the need for expensive equipment or intensive processing. For orthotists and therapists, shank-to-vertical angle is one critical measure used to assess gait and guide prescriptions. Smartphone-based sensors may provide a widely available platform to expand access to this measurement.

OBJECTIVES

Assess accuracy and repeatability of smartphone-based measurement of shank-to-vertical angle compared to marker-based 3D motion analysis.

STUDY DESIGN

Repeated-measures.

METHODS

Four licensed clinicians (two physical therapists and two orthotists) measured shank-to-vertical angle during gait with a smartphone attached to the anterior or lateral shank surface of unimpaired adults. We compared the shank-to-vertical angle calculated from the smartphone's inertial measurement unit to marker-based measurements. Each clinician completed three sessions/day on two days with each participant to assess repeatability.

RESULTS

Average absolute differences in shank-to-vertical angle measured with a smartphone versus marker-based 3D motion analysis during gait were 0.67 ± 0.25° and 4.89 ± 0.72°, with anterior or lateral smartphone positions, respectively. The inter- and intra-day repeatability of shank-to-vertical angle were within 2° for both smartphone positions.

CONCLUSIONS

Smartphone sensors can be used to measure shank-to-vertical angle with high accuracy and repeatability during unimpaired gait, providing a widely available tool for quantitative gait assessments.

CLINICAL RELEVANCE

Smartphone sensors demonstrated high accuracy and repeatability for monitoring shank-to-vertical angle during gait. Measurement of shank-to-vertical angle from the front of the shank was more accurate than the side of the shank. Smartphones may expand access to quantitative assessments of gait.

Effects of acupuncture treatment on motor function in patients with subacute hemorrhagic stroke: A randomized controlled study

OBJECTIVE

The aim of this study was to evaluate the additional effects of acupuncture treatment on motor function in patients with subacute hemorrhagic stroke.

DESIGN

One hundred and thirty-four patients with subacute hemorrhagic stroke were randomized to receive acupuncture treatment plus conventional treatment (treatment group) or conventional treatment only (control group). Acupuncture treatments were given in 24 sessions over 4 weeks, with 3-month follow-up period. Blinded evaluation was based on Fugl-Meyer Assessment, Barthel Index with an intention-to-treat analysis. For those patients who were able to walk, a three-dimensional gait analysis system was employed to objectively record spatiotemporal and kinematic parameters.

RESULTS

Compared with control group, the treatment group showed a significantly greater over-time improvement in total Fugl-Meyer, lower-limb Fugl-Meyer, but not in upper-limb Fugl-Meyer and Barthel Index. The spatiotemporal parameters of velocity, step length, cadence, step width all showed significant difference between the 2 groups. The velocity in treatment group decreased unexpectedly at day 14, then increased sharply and overcame control group at day 28. The treatment group also showed a significantly greater increase in peak circumduction, peak hip hiking, hip range of motion, knee range of motion and a tendency for the ankle range of motion.

CONCLUSIONS

Acupuncture may promote the motor function recovery of hemorrhagic stroke patients in subacute phase mainly by enhancing the lower limb ability. It probably diminishes the compensation strategies earlier to correct the abnormal gait pattern. Although this adjustment may result in a compromise in the improvement of gait velocity temporarily, patients would benefit from it in a long run.

Orthotic care needs in a cohort of neurological rehabilitation inpatients

AIM

Orthotic management is frequently part of the rehabilitation of various neurological conditions in adults such as stroke, peripheral neuropathies, spinal cord injuries and multiple sclerosis. Despite this, there are limited data available on the implementation of orthotic care in practice. The primary aim of this study is to establish the proportion of inpatients in a mixed neurorehabilitation cohort which receive orthotic assessment and treatment. The secondary aim was to document the overall care pathway.

METHODS

Existing data were reviewed retrospectively. Data gathered included patient demographics such as age, gender and diagnosis, type of orthoses prescribed, number of orthotic treatment sessions required and outcome measures used. The paper was prepared in accordance with the STROBE statement for observational studies.

RESULTS

During a 6 month period, 54 patients were admitted as inpatients. Of these, 25 (46%) were referred to the orthotic service for assessment, with 23 (43%) receiving a lower limb orthosis and 19 (35%) subsequently being discharged using either an ankle-foot orthosis or knee-ankle-foot orthosis. The conditions most commonly seen were stroke (40%), incomplete spinal cord injuries (28%) and peripheral neuropathies (16%). Significant improvements were recorded at discharge using the Functional Independence Measure (FIM) and Functional Assessment Measure (FAM). Various aspects of the orthotic care process are described.

CONCLUSIONS

This study suggests that orthotic treatment is needed with high frequency in a mixed inpatient neurorehabilitation cohort. In terms of service planning, these data support existing the recommendation that neurological rehabilitation centres should have good access to orthotic services.Implications for rehabilitationCustom orthoses such as AFOs and KAFOs are frequently needed by neurological rehabilitation inpatients.Orthoses may facilitate standing and walking at an earlier stage during rehabilitation.Those responsible for neurological rehabilitation services should ensure appropriate access to orthotic services.

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.

Effects of altering heel wedge properties on gait with the Intrepid Dynamic Exoskeletal Orthosis

BACKGROUND

The Intrepid Dynamic Exoskeletal Orthosis is a custom-made dynamic response carbon fiber device. A heel wedge, which sits in the shoe, is an integral part of the orthosis-heel wedge-shoe system. Because the device restricts ankle movement, the system must compensate to simulate plantarflexion and allow smooth forward progression during gait.

OBJECTIVES

To determine the influence of wedge height and durometer on the walking gait of individuals using the Intrepid Dynamic Exoskeletal Orthosis.

STUDY DESIGN

Repeated measures.

METHODS

Twelve individuals walked over level ground with their Intrepid Dynamic Exoskeletal Orthosis and six different heel wedges of soft or firm durometer and 1, 2, or 3 cm height. Center of pressure velocity, joint moments, and roll-over shape were calculated for each wedge.

RESULTS

Height and durometer significantly affected time to peak center of pressure velocity, time to peak internal dorsiflexion and knee extension moments, time to ankle moment zero crossing, and roll-over shape center of curvature anterior-posterior position. Wedge height had a significant influence on peak center of pressure velocity, peak dorsiflexion moment, time to peak knee extension moment, and roll-over shape radius and vertical center of curvature.

CONCLUSION

Changes in wedge height and durometer systematically affected foot loading. Participants preferred wedges which produced ankle moment zero crossing timing, peak internal knee extension moment timing, and roll-over shape center of curvature anterior-posterior position close to that of able-bodied individuals. Clinical relevance Adjusting the heel wedge is a simple, straightforward way to adjust the orthosis-heel wedge-shoe system. Changing wedge height and durometer significantly alters loading of the foot and has great potential to improve an individual's gait.

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 effect of different ankle and knee supports on balance in early ambulation of post-stroke hemiplegic patients

The purpose of this study was to compare the effects of different ankle and knee supports on balance in early ambulation of post-stroke hemiplegic patients. This is a randomized experimental study. The study sample included 20 hemiplegic patients who were able to stand with support and who had been diagnosed with a cerebrovascular accident within the last month. A knee immobilization brace (KIB) was first placed on each individual (first application), followed by placement of knee immobilizer brace and Foot Lifter Orthosis ® (FLO) (second application), and lastly, placement of KIB and rigid taping (RT) (third application). The balance parameters of the patients were evaluated using the Korebalance system. The mean age of the patients was 65.1 ± 4.7 years, and the mean number of days that had passed since stroke occurred was 14.6 ± 4.97. In calculating the front/left balance scores of the applications, statistically significant differences were observed in the comparisons of all three supports and first-second applications performed (p = 0.041 and p = 0.021, respectively). Regarding the total scores between the applications, statistically significant differences were determined in balance in the comparisons on all three supports, in comparisons between the first and second applications, and in the comparisons between the second and third applications (p = 0.004, p = 0.007, and p = 0.001, respectively). Based on the findings from this study, it is recommended that the use of a knee immobilizer brace in combination with a foot lifter orthosis for post-stroke hemiplegic patients in early ambulation can lead to considerably improved standing balance.

Effect of ankle foot orthosis on gait parameters and functional ambulation in patients with stroke

Objectives

This study aims to investigate the effect of ankle foot orthosis (AFO) on temporospatial parameters, ankle kinematics, and functional ambulation level in patients with stroke.

Patients and methods

Records of 286 adult patients with stroke assessed in the gait and motion analysis laboratory between April 2005 and January 2013 were reviewed. The data of 28 patients (16 males, 12 females; mean age 43.2±15.9 years; range 20 to 72 years) who were analyzed with and without AFO during the same session were selected for the study. Temporospatial parameters (walking speed, cadence, opposite foot contact, double support time, single support time, step time, and step length) and ankle kinematics (ankle dorsiflexion at initial contact and midswing) were measured using the Vicon 512 motion analysis system. The video and medical records of patients were examined to determine their ambulation level according to Functional Ambulation Category.

Results

Walking speed, cadence, and ankle dorsiflexion at initial contact and midswing were significantly increased while walking with AFO compared to walking barefoot (p<0.05). There were significant reduction in step time and significant increase in step length and opposite foot contact with AFO on the affected side (p<0.05). Single support time reduced significantly with AFO on the unaffected side (p<0.05). Functional Ambulation Category score improved significantly with use of AFO (p<0.05).

Conclusion

The use of AFO has positive effects on gait parameters and functional ambulation in patients with stroke.

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.