Kinematic Features of Rear-Foot Motion Using Anterior and Posterior Ankle-Foot Orthoses in Stroke Patients With Hemiplegic Gait

doi:10.1016/j.apmr.2010.09.013

Archives of Physical Medicine and Rehabilitation

Volume 91, Issue 12, December 2010, Pages 1862-1868

https://doi.org/10.1016/j.apmr.2010.09.013 Get rights and content

Abstract

Chen C-C, Hong W-H, Wang C-M, Chen C-K, Wu KP-H, Kang C-F, Tang SF. Kinematic features of rear-foot motion using anterior and posterior ankle-foot orthoses in stroke patients with hemiplegic gait.

Objective

To evaluate the kinematic features of rear-foot motion during gait in hemiplegic stroke patients, using anterior ankle-foot orthoses (AFOs), posterior AFOs, and no orthotic assistance.

Design

Crossover design with randomization for the interventions.

Setting

A rehabilitation center for adults with neurologic disorders.

Participants

Patients with hemiplegia due to stroke (n=14) and able-bodied subjects (n=11).

Interventions

Subjects with hemiplegia were measured walking under 3 conditions with randomized sequences: (1) with an anterior AFO, (2) with a posterior AFO, and (3) without an AFO. Control subjects were measured walking without an AFO to provide a normative reference.

Main Outcome Measures

Rear-foot kinematic change in the sagittal, coronal, and transverse planes.

Results

In the sagittal plane, compared with walking with an anterior AFO or without an AFO, the posterior AFO significantly decreased plantar flexion to neutral at initial heel contact (P=.001) and the swing phase (P<.001), and increased dorsiflexion at the stance phase (P=.002). In the coronal plane, the anterior AFO significantly increased maximal eversion to neutral (less inversion) at the stance phase (P=.025), and decreased the maximal inversion angle at the swing phase when compared with using no AFO (P=.005). The posterior AFO also decreased the maximal inversion angle at the swing phase as compared with no AFO (P=.005). In the transverse plane, when compared with walking without an AFO, the anterior AFO and posterior AFO decreased the adduction angle significantly at initial heel contact (P=.004).

Conclusions

For poststroke hemiplegic gait, the posterior AFO is better than the anterior AFO in enhancing rear-foot dorsiflexion during a whole gait cycle. The anterior AFO decreases rear-foot inversion in both the stance and swing phases, and the posterior AFO decreases the rear-foot inversion in the swing phase when compared with using no AFO.

Section snippets

Participants

For this study, we recruited 14 stroke subjects with hemiplegia. The inclusion criteria for the study group were as follows: (1) diagnosis of unilateral hemiplegia caused by either hemorrhagic or ischemic stroke; (2) ability to follow simple verbal commands or instructions; and (3) ability to ambulate independently. Subjects were excluded if they had any of the following conditions: (1) medical problems other than stroke that would interfere with their gait; or (2) foot-related premorbid or

Results

Descriptive information regarding the 14 participants with hemiplegia is listed in table 1. Comparisons of demographic data, including age, sex, body height, and body weight between the stroke and normative subjects are listed in table 2. The hemiplegic stroke subjects walked at a significantly slower, self-selected, comfortable walking speed and had decreased step length and longer cycle times than the control group. When comparing the anterior AFO, posterior AFO, and barefoot conditions in

Discussion

The incidence of equinovarus foot in stabilized vascular hemiplegia was reported to be about 18%.¹⁷ The equinovarus foot shifts weight-bearing from the heel to the lateral plantar surface, which can cause loss of balance and reduce walking safety. This condition also has a strong correlation to the presence of claw toes.18, 19 An AFO has often been prescribed to facilitate ankle control for the equinus foot, the varus foot, or both. This study investigated the kinematic change in rear-foot

Conclusions

The results of our study suggest that for poststroke hemiplegic gait, the posterior AFO is better than the anterior AFO in enhancing rear-foot dorsiflexion during the whole gait cycle. The anterior AFO decreases rear-foot inversion in both the stance and swing phases, and the posterior AFO decreases the rear-foot inversion in the swing phase as compared with using no AFO. The choice between an anterior AFO and a posterior AFO should be made by considering not only the patients' preference and

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Cited by (36)

The effects of anterior and posterior ankle-foot orthoses on sit-to-stand transfer performance in stroke patients
2022, Gait and Posture
Citation Excerpt :
Studies suggested that relative to hemiparetic patients who did not use AFOs, those who did exhibit enhanced PCM while standing by enhancing the weight-bearing capacity of the paretic leg [11] and reducing the CoP sway amplitude while stance [12]. Existing studies focused on the effects of semirigid PAFOs on PCM during dynamic tasks that require minimal ankle range of motion (RoM), such as level walking [13]. Sankaranarayan et al. [14] suggested that a solid PAFO can improve walking speed but they did not assess its effects on the PCM measured by GRF and CoP parameters during level walking.
Nonarticulated and low-temperature thermoplastic ankle–foot orthoses (AFOs) have a semirigid design and are effective in improving the postural control mechanism (PCM) in individuals with poststroke hemiparesis. AFOs with an anterior leaf (AAFOs) are more often prescribed than are AFOs with a posterior leaf (PAFOs); however, the effects of AAFOs on the PCM during sit-to-stand transfer (STST) have not been explored.
Do AAFOs and PAFOs change the PCM differently during STST?
A cross-sectional quasi-experimental design was adopted in this study. Fourteen individuals with poststroke hemiparesis (10 men and 4 women, aged between 38 and 71 years, stroke onset between 1 and 17 months) performed STST with shoes only, an AAFO with shoes, or a PAFO with shoes. Vertical ground reaction force (VGRF) and center-of-pressure (CoP) coordinates were collected using a pressure mat to calculate PCM parameters. A single-factor repeated measures analysis of variance was performed to answer the research question.
(1) The weight-bearing percentage of the paretic leg was significantly lower when the participants wore a PAFO (p = 0.018) than when they wore an AAFO (p = 0.019) during the first 5 and 5–10 s after rising. (2) A small rate of change of the VGRF increment (dF/dT) was detected when participants wore AFOs, particularly AAFO. (3) The maximum mediolateral displacement of the CoP when standing up was significantly different among the three conditions (p = 0.012).
For patients with poststroke hemiparesis, AAFO and PAFOs change the PCM during STST performance. Only AAFO improved the PCM possibly because of the rigidity and clearance of the heel region, which provide somatic sensory feedback. Therefore, rehabilitation professionals should educate hemiplegic patients who use AAFOs or PAFOs to perform dynamic daily tasks slowly for their safety.
The effect of three dimensional printing hinged ankle foot orthosis for equinovarus control in stroke patients
2022, Clinical Biomechanics
Citation Excerpt :
Thus, both A-AFO and posterior design AFO can improve equinus foot pattern during walking. When it comes to inversion deformity, research revealed that A-AFO decreased ankle inversion during both stance and swing phases, while posterior AFO can only correct ankle inversion during swing phase (Chen et al., 2010). The effect of ankle varus control in stance phase is minimal.
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.
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.
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.
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.
Effects of elastic neutral ankle-foot orthoses on 3 dimensional parameters during gait training in patients with stroke: A pilot study
2021, Journal of Bodywork and Movement Therapies
General ankle-foot orthosis (AFO) cannot be flexibly adjusted to volumetric change in the lower leg because the molding is custom-fit. Thus, we developed a flexible assistive device called elastic neutral AFO (EN-AFO) to help stroke patients hold a neutral ankle position. The purpose of this study was to investigate the effects of EN-AFO and improve gait patterns in stroke patients with rearfoot varus deformity.
Fifteen stroke patients with a varus deformity of the foot performed a walking test with and without the use of EN-AFO. Kinematic data were measured with a 3D motion analysis system with inertial measurement unit (IMU) sensors.
In the stance phase, maximal pelvic tilt and maximal ankle dorsiflexion in the affected side changed, and maximal and minimal pelvic tilts and maximal hip abduction in the less-affected limb effectively changed, as well. During the swing phase, minimal pelvic tilt and minimal ankle abduction in the affective limb greatly changed; particularly, the reduction of maximal ankle inversion was significantly cleared.
The EN-AFO was effective in controlling the tendency of foot inversion in patients with varus deformities. This is suitable for gait training, as it can adjust the orthosis stiffness according to the foot condition.
The impact of ankle-foot-orthosis (AFO) use on the compensatory stepping response required to avoid a fall during trip-like perturbations in young adults: Implications for AFO prescription and design
2020, Journal of Biomechanics
Ankle-foot-orthoses (AFOs) are commonly prescribed to treat foot drop and enhance walking in fall-prone individuals (e.g. stroke). AFOs improve static balance but AFO-users are still at high fall risk. To our knowledge, no one has studied the biomechanical effect of AFO-use on the compensatory stepping response required to avoid falling during dynamic conditions such as trip, the leading cause of falls. The objective of this study is to evaluate the impact of a semi-rigid thermoplastic AFO on the compensatory stepping response in young healthy individuals following trip-like treadmill perturbations. We found that the AFO on the stepping leg (AFO-step) decreased trunk stability (increased trunk angle and angular velocity), shortened the compensatory step length, and reduced dynamic stability (smaller COM-BOS). AFO on the support leg (AFO-support) was only marginally different from the No-AFO condition. Detrimental changes in compensatory stepping response (e.g. decreased trunk stability) were linearly correlated to diminished propulsive impulse of the step. In summary, AFO-use on the stepping leg is associated with impaired compensatory stepping response (e.g. reduced trunk stability) and decreased propulsive impulse in young adults. It is important to note that AFO-use enhances static stability and decreases the probability of a trip/stumble occurring indicating they are important for fall prevention. Still, our results suggest that AFO-use may impair the compensatory stepping response after a trip/stumble has occurred and may suggest that preserving plantarflexion function may support the compensatory stepping response. Further study of these devices and their impact on compensatory stepping response in fall-prone individuals is warranted.
Effect of different designs of ankle-foot orthoses on gait in patients with stroke: A systematic review
2018, Gait and Posture
Citation Excerpt :
In comparison between anterior AFO and posterior AFO, statically significant changes were reported in ankle, knee, and hip kinematics[16]. However, Chen et al. found that, compared with walking with an anterior AFO, posterior AFO significantly increased ankle dorsiflexion at the stance phase and decreased ankle plantar flexion to neutral at initial contact and the swing phase[22]. Nine studies found an increase in peak ankle dorsiflexion at foot initial contact with an AFO [18,21,24,29–34].
Ankle foot orthoses (AFOs) are used to improve the gait of patients with stroke.
The current review aimed at evaluating the efficacy of different designs of AFOs and comparison between them on the gait parameters of individuals with hemiplegic stroke.
The search strategy was based on the population intervention comparison outcome (PICO) method. A search was performed in PubMed, ISI Web of Knowledge, Scopus, Science Direct, and Google Scholar databases.
A total of 27 articles were found for the final evaluation. All types of AFOs had positive effects on ankle kinematic in the first rocker and swing phases, but not on knee kinematics in the swing phase, hip kinematics or the third rocker function. All trials, except two, assessed immediate or short-term effects only. The articulated passive AFO compared with the non-articulated passive AFO had better effects on some aspects of the gait of patients with hemiplegia following stroke, more investigations are needed in this regard though.
An ankle-foot orthosis can immediately improve the dropped foot in the stance and swing phases. The effects of long-term usage and comparison among the different types of AFOs need to be evaluated.
Effect of Anterior Ankle-Foot Orthoses on Weight Shift in Persons with Stroke
2015, Archives of Physical Medicine and Rehabilitation
To examine the effects of an anterior ankle-foot orthosis (AAFO) on the speed and accuracy of weight shift in persons with stroke.
Cross sectional, repeated measures.
Neurologic rehabilitation department.
People with stroke (N=24) who were unable to voluntarily dorsiflex the foot against gravity.
The weight-shift performance was measured with and without the AAFO.
The speed and accuracy of sustained and cyclic bilateral weight shift were measured using the computerized dynamic posturography. The movement velocity, maximum excursion, and directional control of sustained weight shift were calculated using the limits of stability test. The on-axis velocity gap, directional control, and stability of cyclic bilateral weight shift were calculated using the rhythmic weight shift test.
For sustained weight shift, the maximum excursion of weight shift to the affected side was greater with the AAFO (P=.002). For cyclic bilateral weight shift, the on-axis velocity gap in the mediolateral (ML) direction was smaller at a fast speed (P=.004). The stability of the ML and anteroposterior weight shift was higher at slow (P=.002 and P<.001, respectively) and fast (P=.001 and P<.001, respectively) speeds when wearing the AAFO.
The findings demonstrated that persons with stroke who wear an AAFO might improve the excursion of the sustained weight shift to the affected side and the speed and stability of cyclic bilateral weight shift in the ML direction.

View all citing articles on Scopus

: Supported by the National Science Council, Republic of China (grant no. NSC 98-2119-M-009-019).

: Reprints are not available from the author.

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Original articleKinematic Features of Rear-Foot Motion Using Anterior and Posterior Ankle-Foot Orthoses in Stroke Patients With Hemiplegic Gait

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Participants

Results

Discussion

Conclusions

Arch Phys Med Rehabil

Gait Posture

Ann Readapt Med Phys

Gait Posture

Ann Readapt Med Phys

Arch Phys Med Rehabil

Ann Phys Rehabil Med

Arch Phys Med Rehabil

Gait Posture

Hum Mov Sci

Gait Posture

Gait abnormalities in hemiplegia: their correction by ankle-foot orthoses

Arch Phys Med Rehabil

Improving gait stability in stroke hemiplegic patients with a plastic ankle-foot orthosis

Tohoku J Exp Med

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

Clin Rehabil

Original article
Kinematic Features of Rear-Foot Motion Using Anterior and Posterior Ankle-Foot Orthoses in Stroke Patients With Hemiplegic Gait