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Ankle Foot Orthotic for CVA patient?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kahuna, Mar 30, 2009.

  1. Kahuna

    Kahuna Active Member

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    I have a 69 year old patient who suffered a CVA 18months ago. The result is a weak (L)side with (L) foot drop. Muscle testing shows weak foot flexion and her gait shows this too.

    She has been aware of this situation since the stroke, but during hospital rehab, she has never been offered an AFO.

    My question is this: :confused: is it now an indicated time to fit her with a (L) AFO? Is there any reason for example, why it would be contraindicated 18months on?

  2. efuller

    efuller MVP

    Re: Ankle Foot Orthotic?

    Hi Pete,

    We are all taught to treat a drop foot with an ankle joint dorsiflexion assist AFO. However, if the foot drop isn't much of a problem the patient might not want to deal with an AFO (looks, hassle of putting on etc.) There's not much point in giving someone a device if it is just going to sit in their closet. How bad is the drop foot? Is the patient stumbling, is their a huge steppage gait? Is the patient complaining about difficulty walking?

    An AFO can improve gait in a drop foot whenever it is used. There are some OTC AFO that would be inexpensive to try to see if the patient likes the amount of improvement that she could get.


  3. Kahuna

    Kahuna Active Member

    Re: Ankle Foot Orthotic?

    Hi Eric

    Thanks for the quick reply and confirming my thoughts.

    The foot drop is bad... patient stumbling, huge steppage in base of gait, obvious difficulty walking (is now using a walking stick).

    I just thought it odd that she has been to so many rehab therapists over the last 18months and no other speciality (including hospital podiatrists) have provided an AFO yet).

    Thanks again
  4. efuller

    efuller MVP

    Re: Ankle Foot Orthotic?

    The other thing I forgot to ask is whether or not there is a plantar flexion contracture. If there is, it will be a lot harder to make an AFO work.


  5. Admin2

    Admin2 Administrator Staff Member

    Related threads
    Other threads tagged woth AFO
  6. Kahuna

    Kahuna Active Member

    Re: Ankle Foot Orthotic?

    No Pl.Flexion contracture thankfully!
  7. rommel04

    rommel04 Member

    Apologies for delay in a response Pete, just managing to catch up with postings. Given the picture you describe you have to consider the AFO options regardless of time passed. I work across two sub specialities in Trauma and Neurology and its not unusual to have such a timelag between injury (either tauma or Neuro insult) and assessing for orthotic intervention. At any point the question i ask myself is what is the functional cost of orthotic intervention versus the functional cost of allowing this compromised gait pattern to continue.

    The minimum you should see is the reduction in all the parameters you have described. I guess one of the reasons why no one else in the chain has intervened is either a lack of knowledge regarding mechanical impact or a lack of confidence in device selection. OTC devices are good as a means of testing the water, but if the device needs to be bespoke (due to thin / wide legs or other practical issues) then this becomes an additional issue and may also demand looking at the role of footwear as a compliment to the AFO.

    Having worked with 2 excellent orthotists over the last few years the AFO has become a fantastic addition to the armoury and my outcomes have improved on the back of this. As a Podiatrist i do not see the role of AFO provison unique to any discipline, but it has been (and still is to some extent in gaining further knowledge and material selection / hinge options etc) an area which demands a real understanding in regard to mechanical function.

    Would be good to hear how your patient progresses.


  8. Peter

    Peter Well-Known Member

    Hello Pete

    I have worked with an orthotist for 5 years, and can vouch that the use of some dorsiflexion assistance can improve the quality of life of your pt.

    I would suspect that no-one to date has offered your pt some assistance with walking is either
    1. Couldn't be bothered, with the measurements/adjustments/casting etc
    2. hasn't seen your pt walking!

    You are now in a great position to sort this yourself, and put you ahead of the game with your peers.

    Just one other thing, if you pt has significant sensory deficit, consider a rizolli splint, very useful.
  9. Aqua61

    Aqua61 Welcome New Poster

    Hi All,
    Firstly, I am not a podiatrist or an orthotist nor do I have knowledge of the fantastic skills and knowledge you all have. However I am a Consultant Nurse in Emergency Nursing and have a father whom was diagnosed very recently with a "Parkinsonian type" disease in that only his lower limbs are affected and he does not have (nor will have) the all to familiar Parknisonian shakes. His issue is gait initiation and a small degree of neuropathy in his lower limbs and associated with some foot drop. His left leg is more affected and when he initiates a step it is very slow and he is dragging his left foot which looks (and feels) is sticking to the floor. My father went off on his own and had what sounds like a plantar(?) brace that sits inside his shoe and straps under his knee which he swears by, however I have yet to see that bit makes any difference and was wondering if this thread could advise me on what type of help we should seek; ie shoes, orthotics etc. and the type of assessment would be best for him? He currently walks with a four wheel frame but walks with it out in front of him whils leaning forward and looking down as his feet are always hitting the rear wheels...I guess due to his wide gait? Regards, Julie (Sydney Australia)
  10. efuller

    efuller MVP

    I think your answer is that he likes it. You could measure effectiveness in number of falls, "times toes caught on floor" or something like that. Not all improvement will be visual. The brace could be helpful in reducing the need for muscle power. It sounds like the condition is limiting foot dorsiflexion power and an Ankle Foot Orthosis (AFO) provides some help there. There are different kinds of AFO with a trade off between weight and amount of dorsiflexion assist. For example a double upright (two metal bars with springed hinges) with dorsiflexion assist would provide the most foot lift, but we be heavier than a posterior leaf plastic AFO. It sounds like weight might be an issue.

    Good luck,

  11. Hey Pete.

    If the problem is flaccid drop foot I would suggest you start her with a foot up splint.


    You can get them from most good orthotic companies and some really bad ones as well. Its a fraction of the cost of an AFO and in my experiance can work as well and much better in some cases. Compliance tends to be better as well because there is no "hard plastic" so there is no :eek: as you present them with something which looks like you could club seals to death with it!

    I've been using these for a few years now in adults and children and I swear by them. Might be the comprimise between function and comfort which you are seeking.

  12. Kahuna

    Kahuna Active Member

    Thanks Robert - nice one!
  13. Nilsen

    Nilsen Active Member

    [Check4SPAM] RE: URL Attempt

    Hi Aqua61
    i realise i'm joining this thread a little late but thought my tuppenceworth might be useful?
    If the foot sticks on initiating a step, it may not be a siple drop foot problem, but a hip flexor weakness that stops him initiating gait. If he is stooped over a walking frame, the hip is already preflexed, compounding the problem. try heightening the frame so he doesn't need to stoop over it.
    the musmate harness www.musmate.co.uk can be useful in initiating stepping, but again works better when the person is upright.
    as for the foot-up, in my experience it only works if the patient has at least as 3 dorsiflexion power with no involvement higher up.
    it might be worth your dad having an assessment with your local orthotist.
  14. Mark Smith

    Mark Smith Member

    I will second what Robert has added with regards to the Foot-up device.

    I have been using these for a few years on patients with flaccid foot-drop.

    In comparrison to an old fashioned AFO they not only help to maintan 90 degrees at the ankle, but can be fitted in a slightly dorsiflexed position whilst still allowing active plantarflexion assuming this is not impaired.

    They also come with a shoeless addition allowing for a wider selection of shoe choice for the patient and as they have no rigid parts this adds to the patient concordance.:D
  15. RobinP

    RobinP Well-Known Member

    All of the suggestions are valid in terms of assisting with dorsiflexion of the ankle in swing phase and or providing stability in stance. There are just a couple of things worth mentioning.

    Is the limited ankle ankle dorsiflexion creating a problem with swing phase clearance? If so, then it is essential that you determine whether the swing phase clearance is an issue from the foot/ankle complex or somewhere else. For example, an extended contraction of the rectus femoris will accelerate hip flexion initially but due to the extended contraction, the resulting knee extension will create an effective leg lengthening which can cause swing phase clearance issues. Often, CVA patients can utilise tib anterior as a replacement for peroneal activity so they have good active dorsiflexion yet still have major swing phase clearance issues as a result of extended rectus contraction.

    Perform a duncan ely test quickly to see if the rectus femoris will show some neurological contractile activity. If knee flexion is limited to less than 90 degrees, this is fairly good indicator that swing phase clearance will be limited.

    Is the muscle weakness/muscle dominance causing stance phase instability? If causing excess pronatory moments due to muscle dominance, this can usually be dealt with via a foot up device and a corrective foot orthosis. If the muscle dominance creates excessive supinatory moments, this can be a little more tricky to deal with. Often a rigid or very full trimmed ankle foot orthosis.

    If the foot is mildly supinating and moving into equinous in swing phase with only a moderat amount of spastic activity, the dyna ankle brace from Otto Bock is particularly good. It is lightweight flexible but has a strapping mechanism that will resist a considerable amount of supination.

    Alternatively, with a CVA patient who has good cognitive function and 1 good hand, functional electrical stimulation may be an option


    These are surface electrodes adhered to the skin on the peroneal nerve area. As the heel lifts on the affected side, a current is sent from a battery pack to the electrodes which stimulates the peroneal nerve to initiate peroneal activity. It can also be attached to the popliteal nerve to improve knee flexion in swing if duncan ely test is positive.

    Sorry for such a lengthy posting but hope this helps some folks. PM me if you want more suggestions of products which can be used or adapted to trial effectiveness



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