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HEMIPARETICGAIT

AND
ANKLEFOOTORTHOSES

ToniPa8,PT,DPT,GCS
Topics

Describethepurposeofananklefootorthosis
(AFO)
DiscussthevarioustypesofAFO
IdenKfywhenanAFOisindicated
DiscusstheKmeframewhenanAFOshouldbe
ordered
OrthoKc
DeniKon:

Adevicethatisa8achedorappliedtothe
externalsurfaceofthebodywiththeintentto
improvefuncKon,restrictmoKonorprovide
support.
OrthoKc
DevicefordynamiccontrolandstabilizaKonof
abodypart
SystemaKcapproachforprescripKonand
formulaKon
Biomechanicalcontrol
MechanicalproperKesarecontrolledbyt4he
layoutofthetrimlineand/orstructural
reinforcements
Purpose
Preventdeformity/promoteopKmalskeletal
alignment
FacilitatefuncKon
OpKmizemovement
Increasesafety
Providestability
Providestability
Blockaberrantmovement
Assistorresistjointmovements
FuncKonsofanAFO
Increasestabilityduringweightbearing
Assistwithstancelimbprogression
ShockabsorpKon
EnergyconservaKon
ProtecKonofsoXKssue
Facilitateclearanceofswinglimb
Facilitateheelstrike
Eects
Controlequinus
ControlsupinaKon
Controlgenurecurvatum
Increasewalkingspeed
Maintainfoot/ankleingoodalignment
Promoteamorenormalgaitpa8ern
CompensateforimpairedposiKonalsense
Preventinjuriesfromwalkingonadeadfoot
UseofanAFOcan
IncreaseweightexcursiontohemipareKcside
IncreasestanceduraKonofhemipareKclimb
HelpequalizeweightdistribuKonduringdual
legstance

BUTwillnotenhancegaitsymmetry
GoalsofAFOforhemipareKcgait
MaintainROMintheaectedjoints
ImprovebalanceandpropriocepKon
Encourageweightbearingontheaectedlimb
PromoteindependentambulaKonassoonas
possible
Facilitateamorenormalgaitpa8ern
PromoteneuroplasKcity
Howitworks
3pointforcesystem
3pointpressuresystem
Twoforces:
ProximalanddistalforcesinonedirecKonatthe
malleolusandbularhead

Thirdforce:
InoppositedirecKonsomewhereinbetween
Forcesystems

Resistancetoplantarexion
Thefulcrumisattheankle
Downwardresistancetoplantarexion
Upwardcounterforce

Ankleiskeptindorsiexionviafootplateandankle
jointoftheorthosis
NHSQualityImprovementScotland
BiomechanicalEects
PosiKveinuenceonalignmentandmoKon
duringswingandstancephases
PosiKveeectonthehipandkneejoints
NonbiomechanicalEects
Increasedindependence
Benecialpsychologicalresponse
Improvementinqualityoflife
CochraneReview
14trials,429subjects
UseofalowerlimborthoKccanimprove
walkingandbalance,overalleectis
signicant
BUTtheincludedstudiesonlylookedatthe
immediateeectson:
Speed(disability)
Step/stridelength(impairment)
Balance(weightdistribuKoninstance)
TypesofAFOs

Solid
Dynamic
Leafspring
Hinged
Dorsiexionassist
Plantarexionstop
Anterior
Toeo
SolidAFO
FootisheldinaxedposiKon
Theankleissetasclosetoneutralaspossible
MaximalimmobilizaKon
Advantages
Assistwithfootclearanceduringswingphase
PreposiKonthefootforheelstrike
Provideexternalanklestability
SolidAFO

Lightweight;singlepieceofplasKc
LimitedanklemoKonwillnegaKvelyimpact
theknee;genurecurvatum
Leastexpensive
Easiesttodon/do
Canbecustommadeorotheshelf
SolidAFO
Shouldonlybeconsideredforusewhen:
Thereisnomediolateralinstability
ThereisnotoneorspasKcity
Thereisnoneedtoinuencethehiporknee
Inotherwords.

JUSTSAYNO
PosteriorLeafSpring
Providesmediolateralstabilitythrough
trimlines
Holdstheankleat90degreesduringswingto
assistwithfootclearanceandpreposiKonthe
footforheelstrike
Allowsforexibilityattheankle
SubsKtutesforeccentriccontracKonofthe
anteriorKbialis
Providescontrolledplantarexion
PosteriorLeafSpring
AllowsenoughdorsiexionforKbial
advancement
Providessignicantstabilityattheanklejoint
Allowsforamorenormalmovementpa8ern
ButnotfullDForPF
HingedAFO

Incorporatesamechanicalanklejointbetween
thefootandthecalf
ThereistruearKculaKonwithasingleaxisof
moKon;mustbealignedoverthetrueankle
joint
Controlskneehyperextension
Allowsforanevenmorenormalmovement
pa8ern
HingedAFO
ControlsanklemoKon
Blocksplantarexion
Increasesdorsiexionduringswing
Goodcontrolofinversion/eversion
Canhelpcontrolkneehyperextension
Thehingeallowsnormalanklemovementso
minimalfuncKonaldisrupKon
Closesttonormalgait
HingedAFO
Indicatedforearlystagesofgaittraining
becauseofadaptability
Dorsiexionassistcanbeaddedinthe
presenceofacKvedorsiexors
Aplantarexionstopcanbeaddedtolimited
theamountofplantarexion

Bothcanberemovedlaterifnolongerneeded
HingedAFO
MustbecustommadeforthepaKent
CantakeuptotwodaysforfabricaKon
CanbeusedinthepresenceofspasKcityor
muscletone
Moreexpensive
Morediculttodon/do
Musthavesomequadcontrolforindependent
gait
HingedAFO
AnteriorAFO
Easiertodon/do
Designdoesntallowformuchofafootplate
NotindicatedforpaKentswithfootinstability
DoesntpreposiKonthefootforheelstrike
Assistswithtoeo
Somedesignsarelighterweight
Be8erforsomeonewithskinproblemsorwho
cantmanageahingedAFO
AnteriorAFO
Canbecustommadeorotheshelf
Goodforpeoplewhowanttowalkbarefoot
Allowsanklemovementsogaitpa8ernismore
normal
Be8erthanasolidAFO
GroundReacKon
Lightweight
Doesntcontrolmediolateralinstability
Generallysolidwithexibilitybuiltintothe
shaX
Indicatedwhenlackoffootclearanceisthe
onlyproblem
Doesntworkwellforheavierpeople
ToeOAFO
SpecicbrandofgroundreacKonAFO
Madeofcarbonberorsimilaralloy
GroundreacKonAFO
Verylightweight
Doesntprovideanklestability
Easiertodo/doandhideunderclothing
Veryexpensive
HemipareKcGaitCharacterisKcs
Problemswithtrunk/limbcoordinaKon
Asymmetricalweightbearing
Decreasedweightacceptanceduringstance
phaseonhemipareKclimb
Toe/footdrag
Instabilitypresentatkneeandankle
HemipareKcGaitCharacterisKcs
Slowspeed(maybeabehavioraladaptaKon)
Poorendurance/increasedenergydemand
Mechanicallyinecient
ProblemwithKmingandgeneraKnggraded
muscleacKvity
Walkingspeedfrequentlydoesntreturnto
normal
SpecicdeviaKons

Inadequatehipexion
CanbeintenKonaltodecreasedemandonthehip
Causedbyweakorinecienthipexors
Impairedmotorcontrolresultsininabilityto
rapidlyexhip
Inabilitytocleartheoorwiththefoot
Interfereswithlimbadvancement
Decreasessteplength
SpecicdeviaKons

HipabducKon
CompensatoryacKontohelpwithfoot
clearance(circumducKon)
HipadducKon
Resultsfromcontralateralpelvicdrop
Ipsilateralpelvicdrop
Weakhipexors
Decreasesoppositelimbstancestability
SpecicdeviaKons

Footat
Weakquadriceps
Excessivekneeexion
ExcessivePF/weakorabsentDF
DecreasedKbialmovement
Decreasedabilitytoabsorbshock
SpecicdeviaKons
Increasedplantarexion
PFhypertonicity
Weakquadriceps
WeakorabsentDF
ImpairedorabsentpropriocepKon
DecreasedshockabsorpKon
DecreasedforwardprogressionofKbia
Decreasedfootclearance
ImpairedfootposiKonforiniKalcontact
SpecicdeviaKons
Excessivekneeexion
Resultsfromexcessivehipexion
Decreasedcontralaterallimbstabilityduring
stance
PosteriorpelvicKlt
InabilitytoselecKveextendthekneewhilethe
hipisexed
Increasedextensordemand
Impairedoorcontact
Decreasedsteplength
SpecicdeviaKons
Backwardlean
Todecreasedthedemandonthehipextensors
Toassistwithlimbadvancement
Decreasesforwardmomentum
SpecicdeviaKons
Forwardlean
Deceasesdemandonquadriceps
SubsKtutesforimpairedpropriocepKonor
vision(eldcuts,neglect,hemianopsias)
AssistswithforwardprogressofKbiaover
anklewhenmovingintoPF
Increasesstabilityduringforwardprogression
SpecicdeviaKons
LateralLean
Weakhipabductors
Assistswithfootclearance(with
circumducKon)
Decreasesforwardmomentum
EnergyDemandsandhemipareKcgait
PaKent'swithgaitdisturbanceshavediculty
usinggravitytoassistthem.Thereforethey
resulttousingmuscleacKvity.
Ittakes65%moreenergytowalkcomparedto
normalsubjects
Slowerspeedsaremoredicultysothey
requiremoreenergyexpenditure
Problemswithlackofmomentumand
overcominginerKa
Therefore

AnAFOwontxgaitpa8erndisturbances
butwillmakegaitmoreecient
Improvingfootplacementandcontrol
decreasesthedemandontheothersegments
FacilitaKngheelstrikeassistswithgeneraKng
thestepreexanduidityofmovement
Lessenergyisrequiredforwalking
Increasingtoeclearanceimprovesbalanceand
decreasesfallrisk
So
UsinganAFOtoassistwithfootclearancewill
decreaseenergycost,increasemechanical
eciencyandfacilitateamorenormal
movementpa8ern
Itisntnormaltodragafoot,excessivelyexa
kneeorhip,circumductalegormaintainknee
extensiontopreventfalling
Compensatorystrategies
AcutelyaXerastroke
Thebrainwilldowhateverithastodoto
generatemovement
Itssecondpriorityistonotfalldown
Wontputweightonunstableorneglectedleg
CantcontrolDF/PFifnosensoryfeedback
Willlockthekneeinextensiontocreateafeeling
ofstability
Wehavetohelpthebrain
Itwilllearnwhatevermovementpa8ernswe
allowittogenerate
AnAFOgivesthebrainafeelingofstability
throughdierentfeedbackmechanisms
AFOsprovideanklestability,thefootstays
whereithasbeenplacedanddoesntroll
undertheleg
Thelegbecomeseasiertoadvance
AFOgait
GaitwithanAFOisnotanormalmovement
pa8ernbecausePFisinhibited
HingedAFOsarebe8er,buthavingPFiseven
be8er.ThehingeallowsDFnotPF.
ItisatradeobetweenlackofPFand
abnormalpa8ernvs.increasedenergy
eciencyandanklestability
NeuroplasKcity
NeuroplasKcityrequiresrepeKKon
UsinganAFOmakeswalkingeasiersothe
numberofstepstakenincreases
Thebrainadaptstothedemandplacedonit
Inthiscasethedemandisamorenormalgait
pa8ern
Ifbadhabitsarepermi8ed,thebrainwill
conKnuetousethem
NeuroplasKcity
GaittrainingpoststrokeisacombinaKonof
facilitaKngnormalmovementandgeqngthe
paKentmobile
AFOscanbeusedtohelprestorenormal
movementortocompensateforlackof
normalmovement
SelecKon
DoesthepaKenthaveadequateUEstrength
forassisKvedevices?
DoesthepaKenthaveadequateLEstrengthto
advancethelimb?WithanAFOandshoe?
WillthepaKentbeabletodon/dotheAFO
independentlyorhaveadequateassist?
WhatisthecondiKonofthepaKentsskin?
DoesthepaKenthaveadequatecogniKon?
SelecKon
WhatdeviaKonsneedtobeaddressed?
Sensorydecits
IsquadacKvaKonpresent?
IsacKveDFpresent?
Isedemaaproblem?
Isthegoalmobilityorstability?
WillthepaKentconKnuetousetheAFOaXer
discharge?
Timeframes

Twoschoolsofthought
Putthemonassoonaspossibletogetthe
paKentupandweightbearing
CompensaKontoallowmovement
Waitandseewhatmotorreturndevelops,
thenorder
SKllneuroplasKcitybutdierentdeniKonofwhat
demandisplacedonthebrain
Timeframes
Iputthemonassoonaspossible.
Addsanklestabilityforstandingandtransfers
Controlsthefoot
Facilitatesnormalmovement
Allowsmetocontroltheankleeasierduring
gaittraining
Icanalwaystakeitolater(andhave)
ChronicStroke
IntheliteraturetherearetwoKmeframes
Acutestroke(uptosixmonths)
Chronicstroke(>6months)

MostoftheneuroplasKcchangesareseeninthe
rstsixmonths.

BUTimprovementingaitandfuncKonaltest
scorescanoccuratanyKmeframe.
ChronicStroke
Increasedvelocity
Increasedstrikelength
Increasedenergyeciency
MayposiKvelyaectweightdistribuKon
ImprovementsintheBERGandTUG
FallprevenKon
BWSTT
PuristssaynotoanAFO
Believemustfacilitatenormalmovementatall
jointsatallKmes
Thatisveryenergydependentandlaborintensive
UseoftheAFOallowsforcontrolofthefootat
ankleattheknee
UsetheAFOunKlthepaKentdevelopsproximal
control;thenonlyforovergroundgait.
References
Ca8aneoD,MarazziniF,CrippaA,CardiniR.DostaKcordynamicAFOs
improvebalance?ClinicalRehabilitaKon2002;16:894899.
ChenC,HonW,ChuN,LewY,LewH,TangS.Eectsofananterior
anklefootorthosisonposturalstabilityinstrokepaKentswith
hemiplegia.AmJMedRehabilit.2008;87:815820.
DanielssonA.,SunnerhagenS.Energyexpenditureinstrokesubjects
walkingwithacarboncompositeanklefootorthosis.HRehabMed
2004;165168.
FranceschiniM,MassucciM,FerrariL,AgoeKM,ParolC.Eectsofan
anklefootorthosisonspaKotemporalparametersandenergycost
ofhemipareKcgait.ClinicalRehabilitaKon2003;17:368372.
LusardiM,Nielsen,C.OrthoKcsandProstheKcsinRehabilitaKon,2nd
ediKon.Saunders/Elsevier,St.Louis,MO.
References
LosAmigosNaKonalRehabilitaKonCenter,PhysicalTherapy
Department.RecommendaKonsforOrthoKcAssessment,
DecisionMakingandPrescripKon.LowerlegorthoKcs:
anklefootorthoKc(AFO),2005,Downy,CA
MaedaN,KatoJ,AzumoY,OkyyamaS.YoneiS,MurakaniM,
ShimadaT.Energyexpenditureandwalkingabilityinstroke
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2009,Retrievedfromwww.Nhshealthquality.org
References
SimonsC,AsseldonkE,vaderKooijH,GeurtsA,BuurkeJ.Anklefoot
orthoKcsinstroke:EectsonfuncKonalbalance,weightbearing,
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TysonS,KentR.OrthoKcdevicesaXerstrokeandothernon
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DatabaseofSystemicRevies.2009.Issue3.Art.No.:CD003694
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WangR,YenL,WangM,YangY.Eectsofan
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