Foot Orthoses

Background

Orthoses need to support physiotherapy as well as surgical treatment. Related to patient’s pathological gait, physician’s requirements and the rehabilitative goals, orthotists must produce an orthoses that using an adjustable ankle joint system with preloaded disc springs can store the energy brought in by the body weight and produce a tuning effect on patient’s gait and sense of balance. Many studies established the functional value of common and well-known ankle foot orthoses (AFOs) by developing pathological gait. Solid AFOs (SAFOs) do not allow any ankle movements and are used for patients with spasticity. The so-called Floor Reaction AFO (FRAFO) is a ventral shell orthoses that blocks any ankle joint movement, enables the knee extension in terminal stance, but is controindicated in patients with an hyperextended knee. HAFO or classical hinged AFO are designed with elastomer spring joints without any spring effect or any dorsal stop that blocks any plantar flexion and enables a dorsiflexion with defined pivot point in the anatomical ankle joint. PLS-AFOs or posterior leaf spring AFOs, have commonly a high carbon spring effect but do neither have a pivot point, a defined or adjustable range of movement nor an adjustable alignment.

Aim

To perform a comparative spatio-temporal gait evaluation by using SAFO or solid AFO (Codivilla spring) and FRAFO or so-called floor reaction AFO (Toe-Off) vs an innovative dynamic hinged Ankle-Foot-Orthoses designed with an innovative ankle joint system called Neuroswing (DAFONS) on patients affected by different pathological gait patterns secondary to different central nervous system damages.

Study design

Comparative investigational study.

Setting

A rehabilitation institute for the treatment of neurological gait disorders.

Population

Five patients affected by different neurological gait pattern were recruited for the aim of this study in line with an informed consent and simple inclusion (cooperating patient, evidence of pathological gait pattern, bearer of a DAFONS) and exclusion (not cooperating patient, evidence of a physiological gait pattern, not bearer of a DAFONS) criteria.

Methods

In line with a personalized operating flow-chart, each patient

underwent to a:

visual gait analysis (VGA), focusing attention on orthostatic and orthodynamic trunk attitude, core stability and hip range of movement in stance and swing, knee and ankle stability and movement attitude in stance and swing, analytical and global movement attitude of the trunk-hip-lower limb unit, biomechanical movement profile of the ankle during the stance and swing phase of gait
spatio-temporal BTS-G Walk sensor gait analysis, focusing attention on the average value of the Test duration (sec), Gait speed (m/sec), Gait cadence (steps/min), N° of step cycle on the left side, N° of step cycle on the right side, Stride lenght on the left and on the right (% cycle lenght), Stance phase duration on the left and on the right (% cycle), Swing phase duration on the left and on the right (% cycle), Double gait support duration on the left and on the right (% cycle).
Patient’s observational and instrumental evaluation was performed under 4 conditions: 1) without AFO or in free walk;

2) wearing a Codivilla spring; 3) wearing a FRAFO (Toe-Off); and 4) wearing a DAFONS.

Main outcomes and results

A task-specific evaluation was made at time T0 (clinical and functional outpatient evaluation), time T1 (1 week from T1, planning stage of DAFONS manufacturing), time T2 (3 days from T1, DAFONS custom-made manufacturing and orthoses proof before delivery), and time T3 (10 days from T2, delivery and evaluation of DAFONS approriateness) using: a. objective gait analysis (VGA), b. spatio-temporal BTS-G Walk sensor gait analysis by using a wireless device consisting of a triaxial accelerometer and gyroscope with a magnetometer inside. After our comprehensive evaluation we observed at time T3:

an amelioration of gait quality (increase of patient’s trunk and hip dynamic stability, amelioration of the knee and ankle orthostatic and orthodynamic control on the affected and unaffected side) with the use of DAFONS in all those patients (P1, P3 and P5) who showed a neurocognitive competence with a related functional grade of neurorehabilitative re- learning attitude of the physiological gait pattern and with a compromised perceptive control of gait and core stability;
a different trend of spatio-temporal raw data in each patient in our study conditions;
a decrease of test duration by using DAFONS that cannot be
observed in the other study conditions in all patients;

an increase of test duration in patient P1 and P5 (> in P5) compared to patients P2, P3 and P4 by using Toe-Off orthosis that cannot be observed by using Codivilla spring and DAFONS;
in line with the non parametric Friedman test, a statistical significant difference [Χ2(3)=9; p=0,029] in the test duration (sec) by using Toe-Off orthosis vs DAFONS (76,62 vs 51,04) (Z=-2,023; p<0,05) and by using Codivilla spring vs Toe-Off orthosis (57,44 vs 76,62 (Z=-2,023; p<0,05);
no statistical significant differences in the comparative BTS spatio-temporal analysis of the other study conditions (FW vs Codivilla, FW vs Toe-Off, FW vs DAFONS and Codivilla vs DAFONS).
Conclusions

In line with our observational gait analysis (VGA), we observed that by correcting the static alignment and physisological range of movement of patient’s ankle joint with the use of DAFONS we can influence and modulate the static and dynamic knee attitude and patient’s postural stability during gait. We also concluded that fine tuning to an individual patient can be achieved by adjusting the degree of AFO’s exoskeleton hardness through a specific carbon structure or by changing three mechanical properties of our ankle joint: a. orthosis ankle joint alignment, b. spring force, c. ankle joint range of motion (ROM).

In polio survivors with calf muscle weakness, dorsiflexion-restricting ankle-foot orthoses (DR-AFOs) aim to improve gait in order to reduce walking-related problems such as instability or increased energy cost. However, evidence on the efficacy of DR-AFOs in polio survivors is lacking. We investigated the effect of DR-AFOs on gait biomechanics, walking energy cost, speed, and perceived waking ability in this patient group. Sixteen polio survivors with calf muscle weakness underwent 3D-gait analyses to assess gait biomechanics when walking with a DR-AFOs and with shoes only. Ambulant registration of gas-exchange during a 6 min walk test determined walking energy cost, and comfortable gait speed was calculated from the walked distance during this test. Perceived walking ability was assessed using purposely-designed questionnaires. Compared with shoes-only, walking with the DR-AFOs significantly increased forward progression of the center of pressure (CoP) in mid-stance and it reduced ...

Introduction Cerebral palsy (CP) is a posture and movement disorder and different therapeutic modalities, such as the use of braces, have sought to favor selective motor control and muscle coordination in such patients. The aim of the proposed study is to determine the effect of the combination of posture-control insoles and ankle-foot orthoses (AFOs) improving functional limitation in children with CP. Methods/Design The sample will be composed of 24 children with CP between four and 12 years of age. After the signing of the statement of informed consent, the children will be randomly allocated to two groups: a control group using AFOs alone and an experimental group using both posture-control insoles and AFOs. Evaluations will be performed on five occasions: without any accessory (insoles or AFOs), immediately after, one month after, six months after and one year after AFOs or insole and AFOs use. The evaluation will involve the analysis of gait, static and functional balance, mob...

The aim of this paper was to create an updated Australian guideline on footwear for people with diabetes. We reviewed new footwear publications, (inter)national guidelines, and consensus expert opinion alongside the 2013 Australian footwear guideline to formulate updated recommendations. We recommend health professionals managing people with diabetes should: (1) Advise people with diabetes to wear footwear that fits, protects and accommodates the shape of their feet. (2) Advise people with diabetes to always wear socks within their footwear, in order to reduce shear and friction. (3) Educate people with diabetes, their relatives and caregivers on the importance of wearing appropriate footwear to prevent foot ulceration. (4) Instruct people with diabetes at intermediate- or high-risk of foot ulceration to obtain footwear from an appropriately trained professional to ensure it fits, protects and accommodates the shape of their feet. (5) Motivate people with diabetes at intermediate- o...

Ankle-foot orthoses (AFOs) are prescribed for the management of gait-related problems. Prescription of AFOs is based on empirical techniques due to the low level of evidence-based research on their efficacy, but primarily poor understanding of their mechanical characteristics. This study aimed to establish a method that would allow the quantification of the contribution of AFOs in the control of the ankle joint during gait. A possible way of achieving this aim would be to measure strain on the AFO during walking by the use of strain gauges. Following successful experimentation with the application of strain gauges to polypropylene tensile specimens, an AFO was instrumented by attaching strain gauges to it so as to allow the moment generated on the AFO in the sagittal plane about the ankle to be measured. Walking trials using this AFO on an able-bodied subject indicated good step-to-step repeatability. The use of an instrumented AFO in conjunction with kinematic and kinetic data acqu...

The use of knee-ankle-foot orthoses with drop locked knee joints produces some limitations for walking in subjects with quadriceps muscle weakness. The development of stance control orthoses can potentially improve their functionality. The aim of this review was to compare the evidence of the effect of stance control orthoses to knee-ankle-foot orthoses with drop locked knee joints in improving kinematic variables and energy efficiency of walking by subjects with quadriceps muscle weakness caused by different pathologies. Literature review. Based on selected keywords and their composition, a search was performed in Google Scholar, PubMed, ScienceDirect, and ISI Web of Knowledge databases. In total, 18 articles were finally chosen for review. The results of this study demonstrated that this type of orthosis can improve the walking parameters of subjects with quadriceps muscle weakness and spinal cord injury patients when compared to a locked knee-ankle-foot orthosis. There is evidenc...

Off-loading of the ulcer area is extremely important for the healing of plantar ulcers. Off-loading with total contact cast (TCC) may be superior to other off-loading strategies studied so far, but practical limitations can dissuade clinicians from using this modality. This study was conducted to evaluate the efficacy of TCC compared with that of a pressure-relieving ankle foot orthosis (PRAFO) in healing of diabetic neuropathic foot ulcers and their effect on gait parameters. Thirty adult diabetic patients attending the foot clinic with neuropathic plantar ulcers irrespective of sex, age, duration and type of diabetes were randomly assigned to 1 of 2 off-loading modalities (TCC and PRAFO). Main outcome measures were ulcer healing after 4 weeks of randomization and effect of each of the modalities on various gait parameters. The percentage reduction of the ulcer surface area at 4 weeks from baseline was 75.75 ± 9.25 with TCC and 34.72 ± 13.07 with PRAFO, which was significantly diff...

Background. Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist. Objective. To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke. Methods. In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scal...

A clinical records audit of the University of South Australia&#39;s podiatry clinic clients attending in 2010 was undertaken to determine prevalence of symptomatic flexible pes planus, presenting reasons and treatment options most frequently used. Analysis of rearfoot measures (resting calcaneal stance position, subtalar joint range of motion) between those prescribed a vertical (heel) or inverted (heel) cast pour and a medial heel (Kirby) skive was undertaken. Of 223 clinical records audited, 50% (111/223) of clients were assessed with flexible pes planus, 77% (86/111) of clients with pes planus presented with back or lower limb pain and 58% (64/111) were prescribed customised foot orthoses. Of 42 prescriptions for customised foot orthoses audited; 64% (27/42) were prescribed a vertical (heel) cast pour, 36% (15/42) an inverted (heel) cast pour and 19% (8/42) received a medial heel (Kirby) skive. Those prescribed a medial heel (Kirby) skive had a more everted resting calcaneal stan...

Ankle-foot orthosis (AFO) is the most frequently used type of orthosis in children with cerebral palsy (CP). AFOs are designed either to improve function or to prevent or treat muscle contractures. The purpose of the present study was to analyse the use of, the indications for, and the outcome of using AFO, relative to age and gross motor function in a total population of children with cerebral palsy. A cross-sectional study was performed of 2200 children (58% boys, 42% girls), 0-19 years old (median age 7 years), based on data from the national Swedish follow-up programme and registry for CP. To analyse the outcome of passive ankle dorsiflexion, data was compared between 2011 and 2012. The Gross motor classification system (GMFCS) levels of included children was as follows: I (n = 879), II (n = 357), III (n = 230), IV (n = 374) and V (n = 355). AFOs were used by 1127 (51%) of the children. In 215 children (10%), the indication was to improve function, in 251 (11%) to maintain or in...

Peroneus longus acts as a foot evertor and pronator, thus ensuring stability of the talocrural joint by curbing inversion movement of the rearfoot. Increased activation of the peroneus longus muscle in the stance phase could have a stabilising effect on the ankle joint. This study aimed to determine whether the activity of the peroneus longus muscle could be increased by the targeted use of a specially formed lateral pressure element in a customised orthopaedic insole. This was a laboratory-based study that utilised a randomised crossover design. Thirty-four healthy participants walked along a walkway in neutral footwear wearing a control insole or a sensorimotor insole with a lateral pressure point adjacent to the tendon of the peroneus longus muscle. The electromyographic muscle activity of the peroneus longus and tibialis anterior muscles was measured using surface electromyography. Contact with the ground was recorded via two pressure sensors under the sole of the shoe. Muscle a...

In polio survivors with calf muscle weakness, dorsiflexion-restricting ankle-foot orthoses (DR-AFOs) aim to improve gait in order to reduce walking-related problems such as instability or increased energy cost. However, evidence on the efficacy of DR-AFOs in polio survivors is lacking. We investigated the effect of DR-AFOs on gait biomechanics, walking energy cost, speed, and perceived waking ability in this patient group. Sixteen polio survivors with calf muscle weakness underwent 3D-gait analyses to assess gait biomechanics when walking with a DR-AFOs and with shoes only. Ambulant registration of gas-exchange during a 6 min walk test determined walking energy cost, and comfortable gait speed was calculated from the walked distance during this test. Perceived walking ability was assessed using purposely-designed questionnaires. Compared with shoes-only, walking with the DR-AFOs significantly increased forward progression of the center of pressure (CoP) in mid-stance and it reduced ...

BACKGROUND: Plantar ulcers pose a frequent serious complication in the neuropathic foot. Previous studies suggested that ulcer initiation occurs within the plantar soft tissue rather than on the plantar surface. This study investigated the effectiveness of different shaped silicone insoles on the reduction of both plantar soft tissue strain and pressure. The authors have found no previous experimental studies on the effectiveness of insole shape on reducing plantar soft tissue strain during standing. METHODS: A custom molded silicone insole which allowed passage of ultrasound to the plantar surface of the foot was prototyped for this study. Soft tissue strain was computed from soft tissue thickness measured using ultrasound in five conditions: unloaded, barefoot, wearing a prefabricated silicone insole, wearing the custom molded silicone insole alone then with a metatarsal pad. Plantar pressure was measured for the same conditions. FINDINGS: The custom molded insole was found to sig...

Background: Functional hallux limitus (FHL) has been implicated in the development of metatarsophalangeal joint osteoarthritis. Objectives: To determine whether cut-out orthosis treatment increases plantarflexion of the first metatarsal by increasing its declination angle. Study design: Cross-sectional study. Methods: A total of 46 female volunteers with an average age of 25.66 ± 5.70 years (range: 19–42 years) and FHL participated in the study. We assessed the degrees of movement of the first metatarsal and proximal phalanx bones at the first metatarsophalangeal joint without and while wearing the cut-out orthosis using the 3Space Fastrak® via sensors. Results: The movement of the plantarflexión declination angle of the first metatarsal bone was higher using the orthosis 29.84° ± 5.98° versus without orthosis 27.69° ± 5.91° (p &lt; 0.031°). Use of sandals may have minimized the magnitude of movement changes associated with orthosis versus non-orthosis use. Conclusion: The cut-out o...

Objectives: Patellofemoral pain syndrome (PFPS) is one of the significant causes of knee
pain that results in reduced functional performance.Interventional foot orthotics may lead to
improvement in symptoms. In this study, the effects of custom-made foot orthoses with medial
heel skive technique on pain and functional performance after four weeks were evaluated.
Methods: Fourteen subjects with PFPS were given custom-made foot orthoses. The pain and
function parameters were evaluated with a visual analog scale (VAS) and Kujala Patellofemoral
Score (KPS) before the treatment and at four weeks follow-up.
Results: Significant improvements in pain was observed in participants with initial pain at
four weeks (P<0.001). Also, an increased functional performance was seen in individuals with
PFPS at four weeks (P<0.001).
Discussion: In this study, the custom-made foot orthoses with medial heel skive technique was
found to be an effective conservative treatment to reduce the pain and improve the functional
performance of patients with PFPS.

More than 670,000 total knee replacements are performed annually in the United States; however, high-quality evidence to support the effectiveness of the procedure, as compared with nonsurgical interventions, is lacking. In this randomized, controlled trial, we enrolled 100 patients with moderate-to-severe knee osteoarthritis who were eligible for unilateral total knee replacement. Patients were randomly assigned to undergo total knee replacement followed by 12 weeks of nonsurgical treatment (total-knee-replacement group) or to receive only the 12 weeks of nonsurgical treatment (nonsurgical-treatment group), which was delivered by physiotherapists and dietitians and consisted of exercise, education, dietary advice, use of insoles, and pain medication. The primary outcome was the change from baseline to 12 months in the mean score on four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, activities of daily living, and quality of life (KOOS4); scores ra...

The purpose of this study was to investigate the characteristics of biomechanical and clinical measurements in relation to the knee adduction moment when wearing a standard shoe and a shoe design for individuals with knee osteoarthritis (Flex-OA). Kinematic and kinetic data were collected from thirty-two healthy individuals (64 knees) using a ten camera motion analysis system and four force plates. Subjects performed 5 walking trials under the two conditions and the magnitude of individuals&#39; biomechanical responses where explored in relation to the clinical assessment of the Foot Posture Index, hip rotation range, strength of hip rotators, and active ankle-foot motion, all of which have been described as possible compensation mechanisms in knee osteoarthritis. Significant reductions in the first peak of the knee adduction moment (KAM) during stance phase (9.3%) were recorded (p&lt;0.0001). However, despite this difference, 22 of 64 knees showed either no change or an increased K...