The effects of orthotics on the sensori-motor problems of the foot and ankle after stroke

The foot and ankle forms the interface between the body and ground hence stroke related changes impact on mobility but there is little research has considered the foot and ankle post-stroke. This thesis bridges these knowledge gaps to enable clinical trials to be carried out.MethodsThe initial chapters (1-3) review the knowledge about stroke-related problems in the foot and ankle and their association with mobility limitations. The following chapters (4-5) evaluate interventions targeting motor and sensory foot and ankle problems with a systematic review and clinical trial. The final chapter draws overall conclusions integrating the motor and sensory components.ResultsThere is relatively little literature concerning the foot and ankle after stroke and that available focuses on activity without examining the underlying mechanisms. Pooledanalysis of data from 251 stroke patients showed that foot sensory problems are common (37%) and significantly contribute to balance (p<0.03), mobility (p<0.01) andindependence in ADLs (p<0.001) along with muscle weakness, time since stroke, neglect and age. In all models the independent variables explained about a half of the variance in mobility measures (p<0.001).To investigate the treatment of motor impairments, a systematic review of the effect of an ankle foot orthosis (AFO) on the biomechanics of walking was undertaken. Itshowed that an AFO improved dorsiflexion at initial contact (PO.00001) and weight transfer over the affected foot (PO.001).To investigate the treatment of sensory impairments, 29 stroke survivors participated in a randomised controlled crossover trial of supplementary sensory stimulation to the foot. This stimulation improved ankle strength (P<0.03) and sensation (P<0.025), and functional balance (P<0.003).ConclusionTo date research about the foot-ankle complex post-stroke has emphasised the motor aspects. This work shows that sensory problems are also common and stroke survivors may be responsive to a sensory enhancing intervention

The effects of transcutaneous electrical nerve stimulation on strength, proprioception, balance and mobility in people with stroke: a randomized controlled cross-over trial.

OBJECTIVE: To investigate the feasibility and potential efficacy of 'activeTENS' (that is transcutaneous electrical nerve stimulation (TENS) during everyday activities) by assessing the immediate effects on strength, proprioception, balance/falls risk and mobility after stroke. DESIGN: A paired-sample randomized cross-over trial. SUBJECTS: Twenty-nine mobile chronic stroke survivors with no pre-existing conditions limiting balance or mobility or contra-indications to TENS. SETTING: University clinical research facility. INTERVENTION: A single session of 'activeTENS' delivered via a 'sock electrode' (70-130 Hz, five second cycle) plus a session of control treatment (wearing the sock electrode with no stimulation), lasting approximately two hours in total. MAIN OUTCOMES: Dorsiflexor and plantarflexor strength and proprioception using an isokinetic dyanometer, balance and falls risk (Standing Forward Reach Test) and gait speed (10-m walk test). RESULTS: All participants tolerated 'active TENS'. Most parameters improved during stimulation with activeTENS; balance (p = 0.009), gait speed (p = 0.002), plantarflexor strength (p = 0.008) and proprioception of plantarflexion (p = 0.029), except dorsiflexor strength (p = 0.194) and dorsiflexion proprioception (p = 0.078). CONCLUSIONS: The results provide initial evidence of the potential of 'active TENS' to benefit physical function after stroke which warrants further phase II trials to develop the intervention. Concerns that stimulation could have a detrimental impact on balance and increase risk of falls were not supported

A systematic review and meta-analysis of the effect of an ankle-foot orthosis on gait biomechanics after stroke

Objective: To systematically review the evidence on the effects of an ankle-foot orthosis on gait biomechanics after stroke Data sources: The following databases were searched; AMED, CINHAL, Cochrane Library (Stroke section), Medline, PubMed, Science Direct and Scopus. Previous reviews, reference lists and citation tracking of the selected articles were screened and the authors of selected trials contacted for any further unpublished data. Review methods: Controlled trials of an ankle-foot orthosis on gait biomechanics in stroke survivors were identified. A modified PEDro score evaluated trial quality; those scoring 4/8 or more were selected. Information on the trial design, population, intervention, outcomes, and mean and standard deviation values for the treatment and control groups were extracted. Continuous outcomes were pooled according to their mean difference and 95% confidence intervals in a fixed-effect model. Results: Twenty trials involving 314 participants were selected. An ankle-foot orthosis had a positive effect on ankle kinematics ( P &lt; 0.00001–0.0002); knee kinematics in stance phase ( P &lt; 0.0001–0.01); kinetics ( P = 0.0001) and energy cost ( P = 0.004), but not on knee kinematics in swing phase ( P = 0.84), hip kinematics ( P &lt; 0.18–0.89) or energy expenditure ( P = 0.43). There were insufficient data for pooled analysis of individual joint moments, muscle activity or spasticity. All trials, except one, evaluated immediate effects only. Conclusions: An ankle-foot orthosis can improve the ankle and knee kinematics, kinetics and energy cost of walking in stroke survivors. </jats:sec

A comparison of the effectiveness of three types of trunk orthoses on the balance performance of older people with osteoporotic hyperkyphosis: A cross-over study

Background: Orthotic immobilization is an early treatment for osteoporotic vertebral fracture at the hyperkyphotic thoracic spine. Objective: This exploratory study compared the immediate impact of three types of trunk orthoses on the balance parameters of older people with osteoporosis hyperkyphosis. Methods: Twenty older people (aged 60–65 years) with osteoporosis kyphosis and a history of falls participated in a pilot cross-over study. Four randomized comparisons were carried out, including either soft, semi-rigid, and rigid trunk orthoses worn on the participants compared to “no orthosis” as the control condition. Kyphosis angle, Forward Reach Test, Timed Up and Go test, and postural stability during standing on a force plate were recorded and compared between study conditions using one-way repeated measures analysis of variance test. Results: All orthoses significantly reduced the kyphosis angle (p 0.01). Rigid orthosis significantly reduced the forward reach compared to “no orthosis” (p = 0.003, 95% CI: 1.08–6.3 cm). None of the orthosis induced a significant change in postural sway velocity in anteroposterior and mediolateral directions compared to the control condition (p > 0.01). Conclusion: These findings suggest that using rigid orthosis in older people with osteoporosis hyperkyphosis reduces the balance performance

Intersession reliability of center of pressure measurement during bipedal standing with different foot placement angles

Introduction: The foot placement is a determinant of the base of support and influences standing balance. The reliability of postural stability tests with different foot placement angles is unclear. Research question: To determine and compare the intra- and inter-day reliability of the center of pressure-based postural stability while standing with different foot placement angles. Method: Twenty-five healthy adults (16 females and 9 males; age: 29 ± 6 years) completed 70 s trials of eyes open and eyes closed stability tests with 0°, 15°, 30°, and 45° angles between the feet while standing on a forceplate in three sessions: two sessions were in the same day, and the third session was one-week apart. The repeatability of measurements was tested using analysis of variance, interclass correlation, and standard error of measurements. Result: Throughout the three study sessions, there was no difference in postural stability while participants stood with different foot placement angles. The interclass correlation scores ranged from 0.71 to 0.96, the standard error of measurements ranged from 2.1% to 12.9%, and no significant systematic changes (p < 0.05) occurred between the testing sessions for any foot placements. Standing with a 45° angle between the feet with closed eyes showed higher reliability values than other conditions. The intra-day reliability scores were greater than inter-day reliability. Discussion: The relative reliability of postural stability could be impacted by foot placement angles, which might alter ankle mobility and base of support dimensions. The advantages of larger foot placement angles on improving the relative reliability of postural stability could be better demonstrated in healthy people under challenging conditions such as standing with closed eyes. Conclusion: Standing with foot placement angles between 0° and 45° are reliable and a quantitative assessment of the center of pressure could be used to monitor the changes in postural stability between sessions