Therapeutic effect of gait training with two types of ankle-foot orthoses on the gait of the stroke patients in the recovery phase.

Objectives: This study aimed to demonstrate the therapeutic effect of gait training using ankle-foot orthoses (AFOs) on the gait of stroke patients when not wearing AFOs with two different types of AFO, an AFO with an oil damper (AFO-OD) that resists plantarflexion and an AFO with a plantarflexion stop (AFO-PS), and to display the possible differences between the AFO types. Patients and methods: Forty-two patients (38 males, 4 males, mean age: 59.7±10.9; range, 38 to 81 years) with subacute stroke were randomized to either an AFO-PS or an AFO-OD group. Participants were given gait training in a two-week period by physiotherapists wearing their allocated AFO. Nineteen patients were assigned to the AFO-PS group and 20 to the AFO-OD group. Patients' gait without an AFO before gait training and then after two weeks of training wearing allocated AFOs was recorded through a three-dimensional movement capture system. Results: A therapeutic effect through two weeks of continuous use of AFOs and gait training was found in both AFO groups (main effect of time) in the spatiotemporal factors, ankle joint moments, ankle power generation, shank-to-vertical angle, and center of gravity velocity throughout the stance phase, pre-swing knee angular velocity, and hip flexion moment in pre-swing. The results did not show a large interaction between two AFOs group. Conclusion: These findings reveal that both AFOs had significant therapeutic effects on stroke gait. There was no significant difference between the two AFO groups. Further studies with a control group representing the effects of gait training without wearing an AFO are needed.

Ankle-foot orthosis with an oil damper versus nonarticulated ankle-foot orthosis in the gait of patients with subacute stroke: a randomized controlled trial.

BACKGROUND: Gait improvement in patients with stroke has been examined in terms of use or non-use of an ankle-foot orthosis (AFO), but the effects of different kinds of AFOs remain unclear. In this study, the effect on gait of using an AFO with an oil damper (AFO-OD), which has plantarflexion stiffness without dorsiflexion resistance, was compared with a nonarticulated AFO, which has both dorsiflexion and plantarflexion stiffness, in a randomized controlled trial. METHODS: Forty-one patients (31 men, 10 women; mean age 58.4 ± 11.3 years) in the subacute phase of stroke were randomly allocated to two groups to undergo gait training for 1 h daily over 2 weeks by physiotherapists while wearing an AFO-OD or a nonarticulated AFO. A motion capture system was utilized to measure shod gait without orthosis at baseline and after training with the allocated AFO. Data analysis focused on the joint kinematics and kinetics, spatial and temporal parameters, ground reaction force, and shank-to-vertical angle. Unpaired t-test or Mann-Whitney U test was performed to clarify the difference in gait with an AFO between the two AFO groups after training, with a significance level of p = 0.05. RESULTS: Thirty-six patients completed the study (17 in the AFO-OD group and 19 in the nonarticulated AFO group). The ankle joint was more dorsiflexed in single stance (p = 0.008, effect size r = 0.46) and peak ankle power absorption was larger in stance (p = 0.007, r = 0.55) in the AFO-OD group compared with the nonarticulated AFO group. Peak power absorption varied among patients in the AFO-OD group. Increased dorsiflexion angles were also found at initial contact (p = 0.008, r = 1.51), pre-swing (p = 0.045, r = 0.91), and the swing phase (p = 0.045, r = 0.91) in the AFO-OD group. There was no difference in peak plantarflexion moment, ankle power generation, spatial or temporal parameters, ground reaction force, or shank-to-vertical angle between the two groups. CONCLUSIONS: The results of this study showed that an AFO with plantarflexion stiffness but without dorsiflexion resistance produced greater improvement in ankle joint kinematics and kinetics compared with the nonarticulated AFO, but the results of peak power absorption varied greatly among patients. Trial registration UMIN000028126, Registered 1 August 2017, https://upload.umin.ac.jp/cgi-bin/icdr/ctr_menu_form_reg.cgi?recptno=R000032197.

Differences in mediolateral dynamic stability during gait initiation according to whether the non-paretic or paretic leg is used as the leading limb.

We investigated mediolateral dynamic stability at first foot off and first initial contact during gait initiation according to whether the paretic or non-paretic leg was used as the leading limb. Thirty-eight individuals with stroke initiated gait with the paretic and non-paretic legs as the leading limb, and their movements were measured using a 3D motion analysis system. Margin of stability (i.e., the length between the extrapolated center of mass and lateral border of the stance foot) was used as an index of dynamic stability, with a large value indicating dynamic stability in the lateral direction. However, an excessively large margin of stability value (i.e., when the extrapolated center of mass is outside the medial border of the stance foot) indicates dynamic instability in the medial direction. Differences in the margin of stability between tasks were compared using the Wilcoxon signed-rank test. The minimum margin of stability was observed just before first foot off. When the non-paretic leg was used as the leading limb, the margin of stability tended to be excessively large at first foot off compared with when the paretic leg was used (p < 0.001). In other words, the extrapolated center of mass was outside the medial border of the paretic stance foot. In conclusion, lateral stability was achieved when using the non-paretic leading limb because the extrapolated center of mass was located outside the medial border of the stance foot. However, medial dynamic stability was lower for the non-paretic leading limb compared with the paretic leading limb.

Differences in paretic lower limb loading and fluidity in sit-to-walk according to selection of the leading limb in individuals with stroke.

BACKGROUND: Sit-to-walk is an asymmetric task that is challenging for individuals with stroke, and paretic limb loading at seat-off and movement fluidity may change according to whether the non-paretic or paretic leg is used as the leading limb. This study aimed to investigate differences in paretic limb loading and fluidity depending on whether the non-paretic limb or paretic limb was used as the leading limb. METHODS: Thirty-eight individuals with stroke performed sit-to-walk with each leg as the leading limb, and their movements were measured using a 3D motion analysis system. The paired t-test or Wilcoxon signed-rank test was used to assess differences according to limb selection in paretic limb loading ratio at seat-off and fluidity (Fluidity Index: ratio of the lowest to peak forward velocity before first initial contact). FINDINGS: Twenty-two of 38 participants preferred to use the paretic limb as the leading limb. When leading with the paretic limb, the paretic limb loading ratio was significantly larger (p = 0.002), and the Fluidity Index was lower (p = 0.007). INTERPRETATION: Sit-to-walk with the paretic leading limb seems to be an adaptive movement because many participants preferred leading with the paretic limb. However, selection of the leading limb in sit-to-walk involves a biomechanical tradeoff between paretic limb loading at seat-off and movement fluidity in individuals with stroke. Use of the paretic leading limb requires loading capacity of this limb, and the non-paretic leading limb must have high balance ability to merge sit-to-stand and gait initiation.

Abnormal Gait Movements Prior to a Near Fall in Individuals After Stroke.

OBJECTIVE: To investigate the abnormal kinematic and kinetic movements in the last gait cycle before a near fall in individuals poststroke, where a near fall is defined as a physical therapist feeling the need to stabilize a patient. DESIGN: Retrospective study. SETTING: A rehabilitation center. PARTICIPANTS: Twenty-five adults (22 men, 3 women; N=25) with an average age of 66.3 years and mean duration from stroke of 4 months who required manual assistance for a sudden imbalance during routine 3-dimensional motion analysis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We compared the averaged usual gait cycle and the last cycle before the near-falling gait cycle (pre-near-falling gait cycle). We obtained the following spatiotemporal parameters: gait velocity, gait cycle duration, mediolateral center of mass displacement, step length, step width, joint moments, and angular displacement of the trunk in a cycle. Peak values of joint moments and trunk angle displacement were calculated. RESULTS: Etiology for near falls included toe trip, mediolateral perturbation, and knee collapse. We found the following significant differences in the pre-near-falling gait cycle compared with the usual gait cycle: decreased gait velocity, prolonged total cycle time, and excessive mediolateral center of mass displacement. CONCLUSIONS: Decreased gait velocity, prolonged cycle time, and excessive mediolateral center of mass displacement may be a sign of an impending fall in people with impaired gait after stroke.

Comparison of ankle-foot orthoses with plantar flexion stop and plantar flexion resistance in the gait of stroke patients: A randomized controlled trial.

BACKGROUND: The effect of plantar flexion resistance of ankle-foot orthoses on the ankle and knee joints is well known, but its effect on the hip joint and upper body movement during the gait of stroke patients remains unclear. OBJECTIVES: To compare the effect of an ankle-foot orthosis with plantar flexion stop and an ankle-foot orthosis with plantar flexion resistance on the gait of stroke patients in the subacute phase. STUDY DESIGN: Randomized controlled trial. METHODS: A total of 42 stroke patients (mean age = 59.9 ± 10.9 years, 36 men and 4 women) in the subacute phase were randomized to each ankle-foot orthosis group in a parallel controlled trial with no blinding. Patients received gait training from physiotherapists using the specified ankle-foot orthosis for 2 weeks. Shod gait without an ankle-foot orthosis before training and gait with an ankle-foot orthosis after training were measured by three-dimensional motion analysis. RESULTS: A total of 20 patients were analyzed in each group. Significant differences were found in pelvic and thoracic tilt angles between the two groups. Compared with the gait without an ankle-foot orthosis, the pelvis showed forward tilt when patients walked with an ankle-foot orthosis with plantar flexion stop, and the thorax showed decreased forward tilt when the patients walked with an ankle-foot orthosis with plantar flexion resistance. CONCLUSION: The difference in ankle-foot orthosis function in sagittal plantar flexion resistance affected the alignment of the upper body and the pelvis during the gait of stroke patients in the subacute phase. Clinical relevance Maintaining upright posture is important in gait rehabilitation. The findings of this study suggest that the ankle-foot orthosis with plantar flexion resistance facilitated better alignment of the upper body and pelvis during the gait of stroke patients in subacute phase. This type of ankle-foot orthosis could be beneficial for patients with malalignment of the upper body and pelvis.