May 6, 2023
Orthotic and motor learning-based neurophysiological approaches play an important role in stroke rehabilitation. While orthotic applications were traditionally used in the subacute period, recent studies have shown that the use of orthotics in the acute period contributes more to the patient’s functionality.
Although the purpose of orthotic treatment differs between the acute and chronic periods, the general purpose of orthotics is to prevent possible complications and provide functional independence. The purpose of orthotics in stroke patients is to increase the effectiveness of neurophysiological treatment approaches, maintain the ankle in a neutral position, prevent contractures and limitations in muscle tone disorders, break the compensatory mechanisms of walking, provide correct sensory input with accurate positioning, and increase control by providing stabilization in the joints.
Considering the functional level of the stroke patient, the classification of purposeful orthotics is as follows:
Orthoses for Positioning:
These orthotics, which can be used early, help maintain the correct position during bed rest and maintain the proper position sense by supporting the patient’s lower extremity during ambulation.
Functional Orthoses:
These are the preferred orthotics for biomechanical support and maintenance of walking. Functional orthoses are designed by the principles of energy conservation in stroke patients, where fatigue is common. Examples include in-shoe supports, insoles, and shoe modifications. Common foot deformities in stroke patients include flexible and established deformities in the direction of inversion, flexion or extension patterns in the toes due to spasticity, and flexible or rigid equinus deformities.”
Lateral heel and sole wedges in flexible deformities in the inversion direction, medial wedges that provide positional adaptation in rigid inversion deformities, and in the presence of mediolateral instability in the ankle, the calcaneal cup is assisted by UCBL (the University of California Biomechanic Laboratory) or Air-Stirrup, Air-Cast orthoses can be used.
A. In-Shoe Supports, Insoles, Shoe Modifications:
Common foot deformities in stroke patients include flexible and established deformities in the direction of inversion, flexion, or extension patterns in the toes due to spasticity, and flexible or rigid equinus deformities.
B. Static ankle-foot orthosis (AFO):
Although these orthoses are the most commonly used orthoses in the clinic, their main function is keeping the foot in a neutral position and maintaining it while walking. Additionally, AFOs provide correct sensory input depending on the correct position of the foot, prevent synergistic patterns during walking, facilitate balance, and improve function by reducing energy consumption and fatigue.
People with stroke cannot keep their toes in contact with the ground due to decreased strength or increased tone in the swing phase of gait, and they perform a circumduction gait. It is known that the center of gravity moves in front of the knee joint in the mid-stance phase, and there is an increase in the knee joint in the direction of extension due to the imbalance between the flexor and extensor muscles in the affected hip. In addition, the stance phase is prolonged on the healthy side, shortened on the affected side, and the double support period is prolonged. These biomechanical changes decrease gait speed, but using AFOs can increase gait speed by inhibiting plantar flexion.”
C. Knee Orthoses:
The most common knee problem in stroke patients is genu recurvatum deformity, which can occur due to quadriceps weakness or spasticity of the knee, weakness or spasticity of the plantar flexors, dorsiflexor weakness, or Achilles contracture, especially in the stance phase of gait. Genu recurvatum develops due to uncontrolled plantar flexion during walking due to spasticity of the plantar flexors or weakness of the dorsiflexor. This deformity can be eliminated with the help of an appropriate AFO for the patient. However, if the recurvatum develops due to quadriceps weakness or spasticity, Supracondylar Recurvatum Orthosis or Swedish Knee Cage should be preferred. Although varus and valgus deformities of the knee are uncommon in stroke patients, they should be supported with a KAFO (a long walking orthosis that includes the knee) rather than a knee orthosis due to the possibility of accompanying ankle deformity.”
D. Walking Orthoses:
(KAFO, HKAFO): KAFO and HKAFO (hip and knee long walking orthoses) are commonly used in clinics for walking purposes. However, long-term use of KAFO is not preferred in stroke rehabilitation as it provides more support than necessary. Long-walking orthoses may be preferred for patients who cannot regain ambulation after recurrent cerebrovascular events (CVO) or long-term acute care, depending on their needs.
References
Padilla, M. Guerra, F. Molina Rueda, and IM Alguacil Diego. “Effect of ankle-foot orthosis on postural control after stroke: a systematic review.” Neurología (English Edition) 29.7 (2014): 423-432.
Ferreira, Luiz Alfredo Braun, et al. “Effect of ankle-foot orthosis on gait velocity and cadence of stroke patients: a systematic review.” Journal of physical therapy science 25.11 (2013): 1503-1508.
Aurore Thibaut, Camille Chatelle, Erik Ziegler, Marie-Aurélie Bruno, Steven Laureys & Olivia Gosseries (2013) Spasticity after stroke: Physiology, assessment and treatment, Brain Injury, 27:10, 1093-1105
Guerra Padilla M, Molina Rueda F, Alguacil Diego IM. Effect of ankle-foot orthosis on postural control after stroke: a systematic review. Neurologia. 2014 Sep;29(7):423-32.
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