Role of ankle foot orthoses in functional stability of individuals with stroke

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.

Effect of ankle-foot orthoses on functional outcome measurements in individuals with stroke: a systematic review and meta-analysis

PURPOSE

To determine and compare the effect of ankle-foot orthosis (AFOs) types on functional outcome measurements in individuals with (sub)acute or chronic stroke impairments.

METHODS

PubMed, Web of Knowledge, Embase, Scopus, ProQuest, and Cochrane were searched from inception until September 2020. Methodological quality assessment of 30 studies was conducted based on the Downs and Black checklist. Functional indices were pooled according to their standardized mean difference (SMD) and 95% confidence intervals (CI) in a random-effect model. A narrative analysis was performed where data pooling was not feasible.

RESULTS

Overall pooled results indicated improvements in favor of AFOs versus without for the Berg Balance Scale (SMD: 0.54, CI: 0.19-0.88), timed-up and go test (SMD: -0.45, CI: -0.67 to -0.24), Functional Ambulatory Categories (SMD: 1.72, CI: 1.25-2.19), 6-Minute Walking Test (SMD: 0.91, CI: 0.53-1.28), Timed Up-Stairs (SMD: -0.35, CI: -0.64 to 0.05), and Motricity Index (SMD: 0.65, CI: 0.38-0.92). Heterogeneity was non-significant for all outcomes (I² < 50%, p > 0.05) except the Berg Balance Scale and Functional Ambulatory Categories. Additionally, there was not sufficient evidence to determine the effectiveness of specific orthotic designs over others.

CONCLUSIONS

An AFO can improve ambulatory function in stroke survivors. Future studies should explore the long-term effects of rehabilitation using AFOs and compare differences in orthotic designs.IMPLICATIONS FOR REHABILITATIONAn AFO can improve functional performance and ambulation in survivors of strokes.Wearing an AFO in rehabilitation care during the subacute phase post stroke may have beneficial effects on functional outcomes measured.There was no evidence as to the effectiveness of specific AFO designs over others.

Trunk Muscle Activation Patterns During Standing Turns in Patients With Stroke: An Electromyographic Analysis

Recent evidence indicates that turning difficulty may correlate with trunk control; however, surface electromyography has not been used to explore trunk muscle activity during turning after stroke. This study investigated trunk muscle activation patterns during standing turns in healthy controls (HCs) and patients with stroke with turning difficulty (TD) and no TD (NTD). The participants with stroke were divided into two groups according to the 180° turning duration and number of steps to determine the presence of TD. The activation patterns of the bilateral external oblique and erector spinae muscles of all the participants were recorded during 90° standing turns. A total of 14 HCs, 14 patients with TD, and 14 patients with NTD were recruited. The duration and number of steps in the turning of the TD group were greater than those of the HCs, independent of the turning direction. However, the NTD group had a significantly longer turning duration than did the HC group only toward the paretic side. Their performance was similar when turning toward the non-paretic side; this result is consistent with electromyographic findings. Both TD and NTD groups demonstrated increased amplitudes of trunk muscles compared with the HC groups. Their trunk muscles failed to maintain consistent amplitudes during the entire movement of standing turns in the direction that they required more time or steps to turn toward (i.e., turning in either direction for the TD group and turning toward the paretic side for the NTD group). Patients with stroke had augmented activation of trunk muscles during turning. When patients with TD turned toward either direction and when patients with NTD turned toward the paretic side, the flexible adaptations and selective actions of trunk muscles observed in the HCs were absent. Such distinct activation patterns during turning may contribute to poor turning performance and elevate the risk of falling. Our findings provide insights into the contribution and importance of trunk muscles during turning and the association with TD after stroke. These findings may help guide the development of more effective rehabilitation therapies that target specific muscles for those with TD.

Clinical outcome measures to evaluate the effects of orthotic management post-stroke: a systematic review

PURPOSE

To identify, and classify, according to International Classification of Functioning, Disability and Health (ICF), clinically applicable outcome measures that have been used to evaluate lower limb orthotic management post-stroke and to investigate which outcome measures recorded the largest effect sizes.

MATERIALS AND METHODS

Electronic searches were performed in Pubmed, Cochrane, Web of Science, Cinahl, Scopus and Embase databases from inception to May 2020. Articles were included if they investigated clinical outcomes in people post-stroke who had received a lower-limb orthotic intervention.

RESULTS

88 articles underwent full-text review and 54 were included in the review, which was performed in accordance with the Preferred Reporting Items for Systematic Review (PRISMA) principles. 48 different outcome measures were identified; effect sizes were able to be calculated from 39 studies. The most frequently applied outcome measures were the 10-metre Walk Test and the timed-up-and-go test. Outcome measures that recorded large effect sizes in two or more studies were the 10-metre Walk Test, Functional Reach Test, and Physiological Cost Index. When coded according to the ICF, the most frequently represented codes were d450 (Walking) and d455 (moving around).

CONCLUSIONS

Results suggest that outcome measures related to mobility (ICF chapter d4) are most often applied to evaluate orthotic management post-stroke. Effect sizes appear to be greatest in outcome measures related to velocity, balance, and energy expenditure.IMPLICATIONS FOR REHABILITATIONThe 10-meter Walk Test appears to have the greatest effect size when evaluating orthotic management post-stroke.While outcome measures related to mobility are commonly applied when evaluating orthotic management post-stroke, rehabilitation professionals should consider complementing these with measures representing the participation domain of the ICF.

Strength Evaluation and Modification of a 3D Printed Anterior Ankle Foot Orthoses

Ankle foot orthosis (AFO) is widely used to prevent foot drop and improve walking ability for individuals with cerebral palsy and stroke. However, traditional anterior AFO (TAAFO) could only last within months because the bilateral neck of TAAFO was easy to break. Currently, a 3D-printing technique is used to develop assistive devices for rehabilitation. The study aimed to implement the finite element (FE) method to revise the 3D printed AAFO (3DP-AAFO) and evaluate its strength. A 3.2 mm-thickness for the TAAFOs and 3DP-AAFOs were fabricated, respectively. The stiffness of TAAFO and 3DP-AAFO were tested by a material machine and compared to the FE model. In the FE analysis, the thickness of AAFO model was increased at the neck to enhance its strength. A plantarflexion and dorsiflexion moment were respectively subjected to 3DP-AAFO models to undergo stress analysis. Under the mechanical test, the 3DP-AAFO (K = 1.09 Nm/degree) was 7.8 times stiffer than the traditional AAFO (K = 0.14 Nm/degree). The FE results showed that thickening the 3DP-AAFO on the neck up to 4.7 mm could moderate stress concentration and increase the stiffness of the 3DP-AAFO. Therefore, the study concluded that the 3DP-AAFO was stiffer than the traditional AAFO. Increasing the appropriate thickness around neck of 3DP-AAFO could avoid neck fracture as much as possible.