Treatment of upper motoneuron plantarflexion contractures by using an adjustable ankle-foot orthosis

OBJECTIVE: To assess the effectiveness of an adjustable ankle-foot orthosis in the treatment of plantarflexion contractures after central nervous system injury or disease. DESIGN: Prospective, nonrandomized, interventional trial. SETTING: University medical center's acute inpatient rehabilitation hospital. PARTICIPANTS: Nine ankles with plantarflexion contractures that could not be passively reduced to less than neutral position occurring in 6 patients with stroke or other acquired brain injury. INTERVENTION: To assure differentiation between spastic deformity and true contracture, patients received a 2% lidocaine block of the posterior tibial nerve. The adjustable ankle-foot orthosis was then applied on the affected ankle for 23 hours per day for 14 days. Adjustments to increase dorsiflexion passive range of motion (PROM) ranged from 0 degrees to 4.5 degrees and were attempted every 48 to 72 hours. MAIN OUTCOME MEASURES: Dorsiflexion PROM at the ankle with the knee extended. RESULTS: Increased PROM (average, 20.1 degrees; range, 6 degrees--36 degrees ) was statistically significant (p =.0078). Complications related to pressure with erythema or blister formation associated with pain occurred in 44% of treated ankles at some time during the 2-week trial period. CONCLUSION: Plantarflexion contractures can be significantly reduced by using the adjustable ankle-foot orthosis with minimal complications.     

Ankle-foot orthoses: effect on gait abnormalities in tibial nerve paralysis

To study the biomechanical effects of gastrocnemius-soleus dysfunction and its potential remediation, the gait patterns of six able-bodied young adults were analyzed before and after induced temporary tibial nerve paralysis. Ambulation with the tibial nerve block was performed with and without the assistance of an ankle-foot orthosis (AFO) with a rigid anterior stop adjusted to either 5 degrees plantarflexion or 5 degrees dorsiflexion. The gait abnormalities resulting from tibial nerve paralysis include delayed advancement of the center of pressure, delayed ipsilateral heeloff and early contralateral heelstrike, decreased steplength, decreased ankle dorsiflexion moment, and increased knee flexion moment. This study provides quantitative information on the degree to which these abnormalities were corrected by appropriately adjusted AFOs. When using an AFO with an anterior stop, subjects with tibial nerve paralysis had improved advancement of the center of pressure (p less than 0.01). The body's ground reactive force line moved forward more normally, pivoting over the metatarsal head area and raising the heel earlier than observed with uncorrected tibial nerve paralysis, thus approximating the normal ankle dorsiflexion moment, normal timing of gait events, normal advancement of the hip, and normal steplength. The AFO with the anterior stop set at 5 degrees plantarflexion was more effective in restoring the values to normal than the AFO with the anterior stop set at 5 degrees dorsiflexion, but still did not consistently achieve the normal values. Only by using the AFO with the anterior stop set at 5 degrees plantarflexion was the increased knee flexion moment observed during the block reduced to normal levels (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Immediate effect of different ankle-foot orthosis functions with the same dorsiflexed setting of initial ankle joint angle on walking ability in individuals with chronic stroke: a randomized crossover trial

[Purpose] To investigate how different ankle-foot orthosis functions with the same dorsiflexed setting of initial ankle joint angle affect the walking ability in individuals with chronic stroke. [Participants and Methods] In this randomized crossover study, participants underwent a 10-m walking test and walked on a WalkWay MW-1000 three times under these conditions: (1) without ankle-foot orthosis; (2) with ankle-foot orthosis with an adjustable posterior strut at 5° of fixed dorsiflexion; and (3) with ankle-foot orthosis with an adjustable posterior strut at 5–20° of restricted dorsiflexion. The primary outcome was walking speed on the 10-m walking test. The secondary outcomes were walking speed and spatiotemporal factors measured by the WalkWay MW-1000. [Results] Fifteen individuals (mean [standard deviation] age, 60.9 [8.6] years; male, 12) were enrolled. Walking speeds of the ankle-foot orthosis with fixed and restricted dorsiflexion groups were significantly higher than those without the orthosis; however, no outcomes differed significantly between ankle-foot orthosis with fixed versus restricted dorsiflexion groups. [Conclusion] In individuals with chronic stroke, ankle-foot orthosis function may be less important than the dorsiflexed setting of initial ankle joint angle in the ankle-foot orthosis.     

Contribution of ankle-foot orthosis moment in regulating ankle and knee motions during gait in individuals post-stroke

BackgroundAnkle-foot orthosis moment resisting plantarflexion has systematic effects on ankle and knee joint motion in individuals post-stroke. However, it is not known how much ankle-foot orthosis moment is generated to regulate their motion. The aim of this study was to quantify the contribution of an articulated ankle-foot orthosis moment to regulate ankle and knee joint motion during gait in individuals post-stroke.MethodsGait data were collected from 10 individuals post-stroke using a Bertec split-belt instrumented treadmill and a Vicon 3-dimensional motion analysis system. Each participant wore an articulated ankle-foot orthosis whose moment resisting plantarflexion was adjustable at four levels. Ankle-foot orthosis moment while walking was calculated under the four levels based on angle-moment relationship of the ankle-foot orthosis around the ankle joint measured by bench testing. The ankle-foot orthosis moment and the joint angular position (ankle and knee) relationship in a gait cycle was plotted to quantify the ankle-foot orthosis moment needed to regulate the joint motion.FindingsAnkle and knee joint motion were regulated according to the amount of ankle-foot orthosis moment during gait. The ankle-foot orthosis maintained the ankle angular position in dorsiflexion and knee angular position in flexion throughout a gait cycle when it generated moment from − 0.029 (0.011) to − 0.062 (0.019) Nm/kg (moment resisting plantarflexion was defined as negative).InterpretationsQuantifying the contribution of ankle-foot orthosis moment needed to regulate lower limb joints within a specific range of motion could provide valuable criteria to design an ankle-foot orthosis for individuals post-stroke.     

Low-load, prolonged stretch in treatment of elbow flexion contractures secondary to head trauma: a case report

Joint contractures are a frequent complication of head trauma and often require extensive physical therapy intervention. Traditional methods of treatment, including passive stretching and range-of-motion exercises, have proven to be of limited benefit in contracture reduction. Low-load, prolonged stretch has been shown to be more effective than traditional methods of treatment in producing the desired elongation of connective tissue. A splinting device known as the Dynasplint is designed to provide this type of stretch. The purpose of this case report is to describe the application of the Dynasplint in the successful treatment of a patient with elbow flexion contracture secondary to head trauma.     

Customized adjustable orthoses: their use in spasticity

Spastic contractures are a common problem which frequently requires the use of splinting or casting. Customized adjustable orthoses can reduce contractures without the problems often associated with these procedures. These devices reduced contractures in a head-injured patient's severely spastic wrist and ankles. As a wrist contracture decreased, the patient increasingly used her arm and hand for feeding, grooming, and leisure activities. The plastic orthoses, molded to the individual limb, incorporate Klenzak or Lehrman fracture brace joints. Custom fit positions spastic limbs and promotes improved range of motion. Small brace joint adjustments are done at intervals to promote slow stretch of spastic limbs; since the device remains on during the adjustment, there is no loss of range of motion. The device may be removed for skin monitoring. The patient maintains joint range, as the orthosis becomes a permanent part of the home program. High cost of the device is potentially offset by the advantages of decreased skin morbidity, reduced therapist time in making adjustment, and maintenance of gains in range of motion. Such orthoses also have been used for elbow contractures.     

脑瘫儿童内收肌痉挛的继发损伤与处理

内收肌痉挛是脑瘫儿童的常见症状。已经发现内收肌的超微结构会出现一些病理性变化,如果不能得到及时有效的处理,可能出现继发障碍,如髋关节脱位、肌腱短缩、关节挛缩、髋关节疼痛等。内收肌痉挛的处理方法包括内收肌牵拉训练、矫形器与训练器、选择性脊神经后根切断术、闭孔神经前支切断术、内收肌肌腱切断术、酚阻滞术、肉毒毒素注射、鞘内注射巴氯酚等,各有其优势和劣势。     

Delayed cervical spinal cord injury after high voltage electrical injury: a case report.

High voltage electrical injuries usually cause devastating consequences for patients, most of which result in permanent disability. Spinal cord injury (SCI) caused by high voltage electrical injury is uncommon in the literature. We present a 29-year-old male patient who was diagnosed as having delayed SCI after high voltage electrical injury. The patient developed muscle weakness in the lower extremities with the loss of pinprick sensation below the fifth cervical spinal segment, 2 days after the high voltage electrical injury. Magnetic resonance imaging of the brain, cervical and thoracic spine was normal. Nerve conduction and needle electromyography studies were normal, except for bilateral tibial and left median somatosensory-evoked potentials. The findings on initial examination and neurophysical investigation showed incomplete cervical SCI at the C5 level. He was able to walk with a pair of canes and bilateral ankle-foot orthosis at the end of the 2-month rehabilitation. Follow-up physical and electrophysiological examination of the patient 15 months after injury showed further improvement. The patient was able to walk with a pair of canes without orthoses. Electrophysiological studies are useful instruments in the diagnosis and follow-up of these patients. Early rehabilitation is essential to obtain a favorable outcome in patients with SCI caused by high voltage electrical injury.     

Multiple sclerosis: Part I. Common physical disabilities and rehabilitation

Rehabilitation of the multiple sclerosis patient must be individualized because of the varied manifestations and fluctuating course of the disease. The activity schedule must be modified to compensate for muscle weakness and fatigability. Spasticity and the preventable complication of joint contractures may be treated with joint ranging, medications, motor-point blocks and surgical intervention. Mobility problems, such as foot drop, may be improved with an ankle-foot orthosis, but ultimately a patient may require a wheelchair. Measures to prevent pressure sores include position change, pressure release, incontinence management and special equipment.     

Effect of Ankle-foot Orthosis on Lower Limb Muscle Activities and Static Balance of Stroke Patients Authors’ Names

[Purpose] This study examined the effects of an ankle-foot orthosis worn during balance training on lower limb muscle activity and static balance of chronic stroke patients. [Subjects] The subjects were twenty-five inpatients receiving physical therapy for chronic stroke. [Methods] The chronic stroke patients were divided into two groups: thirteen patients were assigned to the ankle-foot orthosis group, while the remaining twelve patients wore only their shoes. Each group performed balance training for 20 minutes, twice per day, 5 days per week, for 6 weeks. The lower limb muscle activities of the paralyzed side tibialis anterior, medial gastrocnemius, and the stability index were measured before and after the 6-week intervention. [Results] Comparison of the groups indicated a significant difference in the muscle activity of the paralyzed side tibialis anterior and the stability index of the eyes-open standing position. After the intervention, the ankle-foot orthosis group evidenced a significant difference in the muscle activities of the paralyzed side tibialis anterior and paralyzed side medial gastrocnemius as well as the stability index of the eyes-open standing position, eyes-closed standing position, eyes-open standing position on a sponge, and eyes-closed standing position on a sponge. The group that only wore their shoes showed significant differences in the stability indexes of eyes-open standing and eyes-open standing on a sponge. [Conclusion] Using the ankle-foot orthosis was effective during the initial training of lower limb muscle activities and the static balance training of chronic stroke patients. However, it was not effective for a variety of dynamic situations.Key words: Ankle-foot orthosis, Lower limb muscle activity, Static balance     

A patellar-tendon-bearing orthosis used in pediatric burn rehabilitation.

Burn rehabilitation in children presents a difficult challenge. Hypertrophic scar formation is accelerated in this population due primarily to the growth of normal surrounding tissue. Many patients who develop burn wound contractures of the foot and ankle are rendered nonambulatory. We describe a pediatric patients who developed fixed bilateral equinovarus deformities secondary to thermal injury. A patellar-tendon-bearing orthosis was fabricated for this patient to unload the foot-ankle complex with major weight bearing forces at the patellar tendon and tibial condyles. Through the incorporation of this orthosis with a full therapeutic rehabilitation program, the patient was able to ambulate independently using a rolling walker. We recommend the use of the patellar-tendon-bearing orthosis for those pediatric burn victims who develop foot-ankle contractures to allow for ambulation until such time as additional, more aggressive treatment is tolerated, or on a more permanent basis, if necessary.     

踝足矫形器数学模型、应用处方及其早期应用对脑卒中患者偏瘫步态影响的趋势分析

随着多体系统动力学理论和计算机技术的发展,矫形器的计算机辅助设计和制造(CAD/CAM)技术已经日趋成熟,利用这项新技术可建立人体和矫形器的数学力学模型,通过模拟计算来确定矫形器处方、预测疗效和康复效果.踝足矫形器(AFO)早期应用对于脑卒中患者脑功能恢复、偏瘫步态恢复以及对于纠正异常步态起重要作用,在康复临床矫形器处方中,建立相应的数学模型,推测足踝功能变化和脑卒中后脑功能恢复的作用和机制,这对偏瘫步态的分析、矫形器的设计和患者步态的恢复等方面都会产生积极影响.     

The effects of simulated knee-flexion contractures on standing balance

The effects of simulated unilateral and bilateral knee-flexion contractures on standing balance were studied by testing 15 normal subjects on a Kistler force platform. Postural sway (mediolateral and anteroposterior travel) and the mean position of the center of pressure (as a percentage of the distance between the midlines of the feet and from heels to toes) were determined from 20 s of data. Unilateral and bilateral knee-flexion contractures of 15 degrees and 30 degrees were simulated for each subject by means of an adjustable line from the subject's waist to the sole of each foot. Paired t tests were used to compare balance parameters while standing with the simulated contractures with those during relaxed standing. Mediolateral travel increased by a mean difference of 3.6 cm with a 30 degree unilateral contracture (P less than 0.01) and by 5.0 cm with 30 degrees bilateral contractures (P less than 0.01). Anteroposterior travel increased by 4.7 cm (P less than 0.05) and 8.8 cm (P = 0.08) with 15 degrees and 30 degrees bilateral contractures, respectively. With a unilateral contracture of 30 degrees, the center of pressure shifted 15.6% (P less than 0.0005) toward the unflexed side, changes that were not eliminated by correction of the induced leg-length discrepancy. The center of pressure moved anteriorly by 8.3% with 30 degrees bilateral contractures (P less than 0.001). The results provide insight into how knee-flexion contractures alter standing balance, and underline the importance of preventing and treating this common disorder.     

Contractures in frail nursing home residents

Contractures are a common but preventable consequence of prolonged physical immobility among nursing home residents. Significant for their associated costs in institutions rendering care to frail elder residents, contractures further reduce mobility and increase the risk of other outcomes of decreased mobility, such as pressure ulcers. This secondary analysis examines the prevalence of contractures in 273 residents who participated in an interventional study focusing on reducing restrictive siderails. Almost two thirds of the participants had at least 1 contracture, with the most common locations being the shoulder and knee. Presence of pain and being non-White were significant predictors of contracture presence. This study highlights the high prevalence of contractures, the underlying factors associated with them, and the need to prevent or minimize contracture formation, including the role restorative nursing care plays in this avoidable condition.     

Orthotic technique for dystonia musculorum deformans

Tone reducing, inhibitive casting, and orthoses have been effectively used in patients with cerebral palsy and head injury to improve gait patterns and decrease tone. We present a patient with dystonia musculorum deformans who had severe inversion and supination of his left foot with weight bearing. He did poorly with metal double-upright ankle-foot orthoses with lateral T-strap. A tone-reducing ankle-foot orthosis (TRAFO) was successful in decreasing problems with abrasions and allowing him to walk without assistive devices.     

Gait abnormalities in peroneal nerve paralysis and their corrections by orthoses: a biomechanical study

Stroke, brain injury, incomplete spinal cord injuries, and peripheral neuropathies frequently result in dysfunction of the foot dorsiflexors and evertors. A controlled examination of aspects of these disabilities was conducted with normal volunteers who underwent a temporary peroneal nerve block. The effects of peroneal nerve paralysis were analyzed to quantitatively describe the resulting gait abnormalities and to assess the effectiveness of orthoses in restoring a normal gait pattern. Kinematic and kinetic measurements were made during normal ambulation, ambulation with a right peroneal nerve paralysis, and ambulation with a paralysis and an ankle-foot orthosis (AFO) with three different adjustments: a posterior stop set in 5 degrees plantarflexion, a posterior stop set in 5 degrees dorsiflexion, and spring-assisted dorsiflexion. The peroneal paralysis produced abnormalities during both the stance and swing phases of gait. During early stance there was a decrease in the length of the heelstrike phase and a reduction in the peak plantarflexion moment (p less than 0.01). During midstance there was an increase in the range of inversion-eversion achieved suggesting medial-lateral instability (p less than 0.01). The second vertical force peak and the aft-shear force peak were reduced (p less than 0.05) as were the peak dorsiflexion moment and the opposite steplength (p less than 0.01). These reductions are believed to be due to medial-lateral instability during pushoff. Subjects demonstrated a steppage gait during swing phase and increased inversion just prior to heelstrike (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Analysis of the Applicability of an Ankle-Foot Orthosis during Gait in Poststroke Patients

[Purpose] The aim of this study was to develop and assess the applicability of an experimental ankle-foot orthosis during gait in patients with hemiparesis. [Subjects and Methods] This was a noncontrolled cross-sectional study. Ten adult patients with hemiparesis but who were capable of independent gait were included in the study. Gait assessment was performed using two platforms (EMG System do Brasil), an electromyograph (EMG System do Brasil), and a video camera. The experimental orthosis consisted of a single piece that fit over the foot and 1/3 of the distal tibia and had a steel spring. [Results] There was greater activation of the rectus femoris and vastus lateralis muscles in the stance and mid-stance phases with the use of the experimental ankle-foot orthosis in comparison with the use of a polypropylene ankle-foot orthosis and no orthosis. Regarding spatial and temporal gait parameters, the individuals achieved an increase in stride length with the use of the experimental ankle-foot orthosis in comparison with the use of a polypropylene ankle-foot orthosis. [Conclusion] The results of the present study demonstrate that individuals with hemiparesis achieved an improvement in the stance and mid-stance phases of gait with the use of the experimental ankle-foot orthosis.Key words: Orthosis, Hemiparesis, Gait     

踝足矫形器改善偏瘫患者步行能力的荟萃分析

背景：已有研究表明,踝足矫形器能增加来自足部及腿骨皮肤感受器的输入信息反馈,改善踝关节位置觉,促进大脑功能重组。 目的：系统评价踝足矫形器对偏瘫患者步行能力的康复效果。 方法：应用计算机检索中国生物医学文献数据库、中国知网、万方数据库和维普数据库中,关于踝足矫形器改善偏瘫患者步行能力的随机对照试验,检索时间从建库至2013年6月。对符合标准的随机对照试验进行Meta合并分析。 结果与结论：共纳入9个随机对照研究,456例患者。Meta分析结果显示,与常规康复治疗及药物治疗相比,踝足矫形器连续治疗对改善偏瘫患者下肢运动功能、提高生活能力及10 m 最大步行速度方面具有一定的优势。因纳入文献数量有限,对其余指标如步速、左右步幅差及平衡功能等仅作了描述性分析,提示踝足矫形器是通过改善异常步态、步行速度、步频、步态周期、空间不对称、踝关节肌痉挛和平衡等,达到改善步行功能的目标。在时间不对称、双支撑相延长和跨步长等指标上无明显改变,不能确认踝足矫形器在这些指标变化中的作用。现有资料显示,踝足矫形器可在一定程度上促进偏瘫患者下肢运动功能的恢复及日常生活活动能力的提高,但仍需更多高质量、大样本、多中心的随机对照试验证实。     

Complication of lengthening and the role of post-operative care,physical and psychological rehabilitation among fibula hemimelia

There is a clear clinical need for efficient physiotherapy and rehabilitation programs during and after bone lengthening and reconstruction for gaining the optimal effect and also prevention or treatment of lengthening side effects. Pin tract infection is the most prevalent side effect during lengthening which could be prevented and treated initially via proper wound care. Muscle contractures are typically a consequence of the generated tension on the distracted muscle. It can be managed by physiotherapy initially and surgically in later severe stages. Furthermore, it is essential to avoid muscle contracture development, which is the demonstration of the imbalanced muscle appeals on the joint to inhibit the following subluxation. The knee is the furthermost affected joint by the aforementioned problem due to the inherent lack of ligamentous and bony stability. Joint stiffness is the other possible unfavorable effect of lengthening. It happens because of extensive muscle contractures or may possibly be attributed to rigidity of the joint following the amplified pressure on the joint surface during the process of lengthening. Physiotherapy and occupational therapy including endurance and strength exercise as well as stretching play an important role during the rehabilitation periods for the prevention and also the treatment of muscle contracture and the following deformity and also joint stiffness. Likewise, the effect of mental and physical rehabilitation programs should not be overlooked.     

Physical therapy for spinal accessory nerve injury complicated by adhesive capsulitis

BACKGROUND AND PURPOSE: The authors found no literature describing adhesive capsulitis as a consequence of spinal accessory nerve injury and no exercise program or protocol for patients with spinal accessory nerve injury. The purpose of this case report is to describe the management of a patient with adhesive capsulitis and spinal accessory nerve injury following a carotid endarterectomy. CASE DESCRIPTION: The patient was a 67-year-old woman referred for physical therapy following manipulation of the left shoulder and a diagnosis of adhesive capsulitis by her orthopedist. Spinal accessory nerve injury was identified during the initial physical therapy examination, and a program of neuromuscular electrical stimulation was initiated. OUTCOMES: The patient had almost full restoration of the involved muscle function after 5 months of physical therapy. DISCUSSION: This case report illustrates the importance of accurate diagnosis and suggests physical therapy intervention to manage adhesive capsulitis as a consequence of spinal accessory nerve injury.