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Imam Subadi
Abstract
Walking ability after stroke is often disrupted because of muscle weakness, spasticity,
and impaired sensorimotor control. These impairments have an important impact in patients life
and considerable costs for health and social services. The recovery of walking function occurs
usually in the first 6 months after stroke. Although the majority of stroke patients achieve an
independent gait, many do not reach a walking level that enable them to perform all their daily
activities.
Drop foot is a neuromuscular disorders affecting the lower limbs often related to
hemiparesis which is characterized as a paralysis or weakness of the dorsiflexor muscles of the
foot and ankle, resulting in the dragging of the foot and toes during gait. This will impair normal
gait functions resulting in abnormal gait patterns, higher energy expenditure, unstable gait,
increased risks of falling, delayed ambulation and additional physiological pathologies.
Rehabilitation therapy has been clinically accepted as an effective approach to treating
neurological motor dysfunctions resulting from stroke. One of the goals of rehabilitation is to
retrain functional skills related to the activities of daily living (ADL) for patients. Ambulation is
considered one of the more important ADL skills to improve in order to allow the patient to have
an independent lifestyle. Yet, regaining the ability to walk is a major goal during rehabilitation of
stroke patients. Ankle Foot Orthosis (AFO) is frequently prescribed for hemiplegic patients to
correct ankle joint alignment, increase walking speed, and reduce energy expenditure during
ambulation.
Introduction
Walking ability after stroke is often disrupted because of muscle weakness, spasticity,
and impaired sensorimotor control (Abe, 2009). These impairments have an important impact in
patients life and considerable costs for health and social services (Belda-Lois, 2011). The
recovery of walking function occurs usually in the first 6 months after stroke (Jorgensen, 1995).
Only 23% to 37% of persons who have sustained a stroke are able to walk independently during
the first week, but there is general agreement that 50-80% of survivors can walk unaided at 3
weeks or at discharge and by 6 months this figure may be as high as 85% (Olney, 1995).
Drop foot is a neuromuscular disorder affecting the lower limbs often relates to
hemiparesis which is characterized as a paralysis or weakness of the dorsiflexor muscles of the
foot and ankle, resulting in the dragging of the foot and toes during gait. This will impair normal
gait functions resulting in abnormal gait patterns, higher energy expenditure, unstable gait,
increased risks of falling, delayed ambulation and additional physiological pathologies. Patients
counteract the effects by exaggerating the knee and hip flexion to provide foot clearance (Chang,
2006).
Rehabilitation therapy has been clinically accepted as an effective approach to treat
neurological motor dysfunctions resulting from stroke. One of the goals of rehabilitation is to
retrain functional skills related to the activities of daily living (ADL) for patients. Ambulation is
considered one of the more important ADL skills to improve in order to allow the patient to have
an independent lifestyle (Chang, 2006). Yet, regaining the ability to walk is a major goal during
rehabilitation of stroke patients. Ankle Foot Orthosis (AFO) is frequently prescribed for
hemiplegic patients to correct ankle joint alignment, increase walking speed, and reduce energy
expenditure during ambulation (Abe, 2009).
Figure 1. Three point pressure systems of the ankle foot. Three point pressure control systems to prevent
dorsiflexion (A), plantarflexion (B), inversion (C), eversion (D), abduction (E), adduction (F).
Provided they are adequately stiff, AFOs can prevent plantarflexion of the foot in swing
phase and improve ground clearance, reducing the risk of tripping (Fig. 2). They do this by
applying a system of the three forces to the posterior calf, the plantar surface of the foot near the
metatarsal heads, and the dorsum of the foot near the ankle joint. In some cases the shoe is able
to provide adequate force at the dorsum of the foot, but where there is increased tone an ankle
strap should be considered. This should be positioned so that it applies the force at approximately
a 450 angle. An ankle strap may also help maintain the foot in the correct position in the AFO
while the shoe is being applied. Ankle straps should be non-elasticated for efficient force
transmission, and may take the form of single strap or a figure of 8 crossover strap.
In orthoses, changing the lever arm or the surface area of the orthosis can alter the
magnitude of a 3 PP system as shown by the formula for pressure, (pressure = force / surface
area). For example, in Figure 3A, an AFO provides a 3PP system to prevent the foot from
plantarflexing about the ankle axis due to the spastic triceps surae muscle. The proximal lever
arm of the orthosis very short, and relatively high corrective force is needed to prevent
plantarflexion of the foot. The surface area of the calf bands is also small, resulting in relatively
high pressures being exerted on the skin. Increasing the surface area of the posterior calf part of
the AFO (Fig. 2B) decreases the pressure on the skin. Increasing the lever arm of the orthosis
(Fig. 2C) also decreases the pressure magnitude of the force. The optimum solution for
decreasing pressure is to maximize both the surface area and lever arm for any orthosis (Fig.
2D).
During swing phase, the foot and or orthosis does not touch the ground and no GRF is
generated (Fig. 3A). When the foot or orthosis/shoe combination contacts to the ground, a GRF
is applied by the ground to lower extremity (Fig. 3B, C). This application of the GRF to the
lower extremity creates moments about the anatomical joints above. The resulting motion at the
anatomical joints is dependent on the position of the line of action of the GRF and the movement
available at the anatomical joints. If the line of action of the GRF goes through the anatomical
joint then no moment or rotational motion will be created about that joint. If the line of action of
the GRF is aligned to one side of the anatomical joint then a moment is created about the joint.
The GRF will then rotate the segment about the joint unless it is restricted by counteracting
moments from muscles, ligaments, etc. In Figure 3B the line of action of the GRF goes posterior
to the ankle axis producing a plantarflexion moment and if the plantarflexion moment is
unopposed, the foot will plantarflex to the ground. If the movement at one anatomical joint is
blocked by an orthosis, the GRF creates a moment about the next free joint proximal to it. Figure
3C illustrates how the use of an orthosis and GRF control can prevent knee hyperextension
Supination of the foot affects the subtalar joint and the midtarsal joint, and the AFO must
control both simultaneously. At the subtalar joint, hindfoot inversion is controlled by forces
applied to the medial aspect of the heel (calcaneus), the area above the lateral malleolus, and at
the medial aspect of the proximal calf. At the midtarsal joint, internal rotation of the forefoot
(adduction) is controlled by the application of forces to the medial heel (calcaneus), the lateral
midfoot (midtarsal joint) and along the first metatarsal shaft. Full correction of supination is
important as if it is not addressed this foot position may contribute to the generation of increased
varus moments at the knee, which can lead to ligamentous laxity (lateral collateral ligament) and
increasing varus deformity over time. In the presence of deformity that is not fully correctable,
wedging should be added to the underside of the AFO.
By controlling the alignment and motion of the ankle joint, an AFO can realign the GRF
in stance phase, as a way that positively influences its relationship to both the knee and the hip. It
does this by realigning the tibia to more normal position of approximately 100 forward
inclination. It also ensures that the entire plantar surface of the foot bears weight, rather than just
the lateral forefoot, which means that the GRF is moved posteriorly. The combination of
posterior placement of the GRF and anterior placement of the knee ensures that the GRF now
passes closer to the knee, therefore reducing the external knee extension moment and improving
knee alignment. The fact that the GRF is now only slightly anterior to the knee creates an
appropriate extension moment for knee stability, while facilitating knee flexion for swing phase.
With the tibia is maintained in this alignment, the femur can also incline forward approximately
100 and the hip joint can be moved anteriorly, without knee hyperextension which would be the
case if the tibia was vertical. The combination of anterior placement of the hip and posterior
placement of the GRF means that the abnormal external flexion moment at the hip can be
reduced or even replaced with an external extension moment, which is normal in the second half
of stance.
Design and system considerations
The polymer AFO design is the most frequently used AFO for this patients population.
The design vary from very stable (solid AFO) to vary limited in term of motion control. The
following descriptions are designs of orthosis (Malas, 2001):
1. Solid AFO : Solid describes the motion allowed at the ankle joint. The ankle is held
in a solid position, with no movement in any plane. This orthosis is designed in either
metal or plastic. It provides dorsiflexion stop/ plantarflexion stop in swing phase. In
stance phase, it influences the knee in extension to reduce buckling of the knee. This
design is typically indicated for early stage of stroke recovery when the patient has
difficulty with maintenance of normal standing balance.
2. The articulated AFO (free dorsiflexion) is indicated when the ankle has weak
dorsiflexors or adequate ROM is present. The AFO is design with a plantarflexion
stop/ free dorsiflexion. The tibia is allowed to rotate anteriorly over the ankle joint in
stance. The knee is not allowed to hyperextend in stance. Knee control is the indicator
for this design. If a patient has weak knee extensors and will buckle in stance phase,
this design is not recommended.
3. Metal AFOs with stirrup attachment to a shoe are commonly used when the
pathology dictates this orthosis. Indications are diabetic feet, edema, allergies, skin
tolerance, and sensation.
4. Knee Ankle Foot Orthosis (KAFO) is indicated when control of the knee is needed. If
the patient has gross instability at knee, then crossing the knee joint is necessary to
provide stability. This orthosis may be of interim or definitive nature. In addition,
knee joint ROM can be increased utilizing a KAFO.
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