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Orthotic In Stroke

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).

Characteristics of hemiparetic gait


Normal human locomotion or walking is a complex motor task involving the interaction
of the neuromuscular system acting on the musculoskeletal system. Stroke patients exhibit
varying deficits in perception, muscle strength, motor control, passive mobility, sensation, tone
and balance. These impairments have significant effects upon walking ability (Yavuzer, 2007).
The common features of walking after stroke include decreased gait velocity and asymmetrical
gait pattern (Lin, 2006). Asymmetric steps are a characteristic of hemiparetic gait, with the
paretic limb having a shorter stance time and step length than of the non-paretic limb (Yavuzer,
2007). Smooth and symmetric forward progression of the body is impaired. Well-controlled
mass limb movement pattern (synergies) on the paretic side requiring compensatory adjustments
of the pelvis and non paretic side. Compensatory movements necessary for ambulation produce
abnormal displacement of the center of gravity, resulting in increased energy expenditure.
Hemiplegic walking has been found to require between 50% to 67% more metabolic energy
expenditure than that of normal participants at the same walking velocity (Woolley, 2001).
The average walking speed for subjects with stroke is lower than values for able-bodied.
Schroeder and colleagues (1995) reported the spatio-temporal characteristics of hemiplegic
patients following stroke that the average speed are about 44 m/min (SD= 22,9 m/min), a
cadence of about 84.8 steps/min (SD= 22.4 steps/min) and stride length 1.1 m (SD= 0.6 m). The
descriptions of variations in joint kinematic patterns are summarized by Burdett and colleagues.
The authors concluded that subjects major kinematic differences from able-bodied were : (1)
decrease hip flexion at initial contact, increase hip flexion at toe off, and decrease hip flexion
during mid swing; (2) more knee flexion at initial contact and less knee flexion at toe off and mid
swing; and (3) more ankle plantarflexion at initial contact and mid swing and less ankle
plantarflexion at toe off.
Hemiparetic gait is often characterized by stiff-legged gait (reduced range of knee
motion) and drop foot (lack of ankle dorsiflexion during swing) leading to raised hip during
swing (Yavuzer, 2007). This may be due to the presence of increased plantarflexor tone,
inappropriate plantarflexor activity or a plantarflexion contracture. Adequate ankle control
during gait is important for normal gait pattern. During terminal stance phase, the plantar flexors
generate a large part of energy required to move the limbs forward. Insufficient plantar flexors
power during gait leading to decrease gait velocity. A further consequence of persistent
plantarflexion is a lack of weight bearing through the heel. This means that the GRF is located at
the forefoot throughout stance rather than progressing smoothly from heel to toe, and therefore
passes further in front of the knee than normal. The combination of posterior placement of the
knee and anterior placement of the GRF leads to the creation of an excessive knee extension
moment than can lead to hyperextension. Because the knee is excessively stable in this
alignment, it becomes difficult to initiate flexion at the end of stance. The presence of knee
hyperextension during gait is common following stroke and should not be ignored. If this is not
addressed it will progress to laxity in the ligaments of the knee, instability and increasing
deformity.
Orthosis
An orthosis is defined as an externally applied device used to modify the structural or
functional characteristics of the neuromusculoskeletal system. An orthosis has also been defined
as an apparatus used to support, align, prevent or correct deformities or to improve the function
of movable parts of the body. Orthoses is the plural terminology for orthosis (Richie, 2009).
Orthotic goals are based on one or a combination of the following areas : (1) stance phase
stability, (2) foot clearance (swing), (3) prepositioning of foot, (4) adequate step length, and (5)
energy conservation. These goals may change during the recovery phase, which is a reason for
reassessment of the patients status. In addition, the orthotic goals should specify the type of
influence in the following areas: (1) motion control, (2) correction of deformity, and (3)
compensation for weakness (Malas, 2001).

Ankle Foot Orthosis (AFO)


An AFO is device worn on the lower part of the leg to provide direct control of the
motion and alignment of the ankle and foot. An AFO must be prescribed according to the
patients neurobiomechanical deficit. After the initial assessment and the data interpretation, the
orthotic recommendation can be considered.

Biomechanical effects of AFOs


To maintain the anatomical joints in a corrected position use two types of control
systems, a GRF control system and a 3PP control system (three pressure points). A number of
three point pressure control systems are employed by AFOs to prevent motion at the anatomical
joints of the ankle foot complex. The three point pressure systems used to control ankle joint
motion is a dorsiflexion (fig.1A) or plantarflexion stop and resist (fig. 1B). Subtalar joint control
requires an inversion (fig. 1C) or eversion (fig. 1D). Three point pressure systems are also
needed to prevent forefoot abduction (fig. 1E) and adduction (fig. 1F).

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

Figure 2. The effects of lever arm and surface area in AFOs


Figure 3. GRF control in the sagital plane. Before heel contact no GRF acts on the lower extremity (A). At
heel contact with no orthosis the GRF control acts to plantarflex the ankle (B). At heel contact with an AFO
the GRF control acts to flex the knee.

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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