The more important question to answer is; What is the protocol to wean yourself off the AFO? If your doctor and therapists don't know that answer you need to fire them.
The sooner the better?!: Providing ankle-foot orthoses in the rehabilitation after stroke
Abstract
In stroke, the blood circulation in the brain is affected, being
either ischemic or hemorrhagic. Depending on the location of the lesion,
the effects can widely vary. Initial walking function is limited in
approximately two-third of the patients. A “drop-foot”, the inability to
dorsiflex the foot, is estimated to be present in 20-30% of the people
after stroke and causes foot-clearance problems during swing phase and
also affects initial contact at the start of the stance phase.
Insufficient foot-clearance is associated with high risks for stumbling
and falling. Ankle-foot orthoses (AFOs) are commonly used to correct
drop-foot after stroke and are reported to improve mobility and balance,
ankle kinematics, walking speed, self-confidence and fear of falling
after stroke. However, most studies reporting on AFOs after stroke
included chronic stroke patients who were already provided with AFOs in
daily life and were able to walk independently. The general aim of this
thesis was to increase the understanding of the effects of providing
AFOs early after stroke. The EVOLUTIONS-project was conducted, including
a randomized controlled trial in which the effects of AFO-provision on
two different time points in the rehabilitation after stroke were
studied. Subjects were included within six weeks after stroke and
randomized for AFO-provision at inclusion of the study (in week 1) or
eight weeks later (in week 9). The subjects were provided with one of
three commonly used types of off-the-shelf, non-articulated AFOs with
variability in stiffness. Subjects randomized for delayed provision did
not use an AFO in the first eight weeks of the study. Subjects were
studied up to 17 weeks with (bi)weekly intervals. Follow-up measurements
up to 26 and 52 weeks were included. Measurements included functional
outcomes related to balance, walking and activities of daily life.
Furthermore, gait kinematics of the affected lower limb, muscle
activation patterns of the tibialis anterior muscle, and falls and near
falls were studied. Results showed positive effects on functional
outcomes, both when AFOs were provided early or delayed. After 26 weeks
no differences in functional outcomes were found between both groups.
However, the results suggest that early provision results in better
outcomes in the first 11-13 weeks of the study. Ankle dorsiflexion
significantly improved directly after AFO-provision, changing the ankle
from a plantarflexion into a dorsiflexion angle at initial contact,
foot-off and during swing. These results were obtained regardless of
AFO-provision early or delayed after stroke. In general, knee, hip and
pelvis angles did not change directly after AFO-provision. After 26
weeks, no differences in kinematics in any of the joint angles were
found between the two groups. These kinematic results indicate that AFOs
improved drop-foot, but did not influence movement patterns around
pelvis and hip. Previous literature suggested that AFO-use might
increase muscle weakness, and thereby could impede recovery. Therefore,
the effects of AFO-provision on muscle activity of the tibialis anterior
were assessed. Results showed that AFO-use reduced muscle activity
during swing within a measurement session, compared to walking without
AFO. However, 26 weeks use of an AFO did not affect tibialis anterior
muscle activity during walking without AFO. Again, early or delayed
AFO-provision did not affect the results. These results indicate that
there is no need to fear negative consequences on tibialis anterior
activity because of long-term AFO-use (early) after stroke. In addition,
the effects on the occurrence and circumstances of (near) falls were
studied using diaries. In case of an incident, the location, performed
activity, possible injuries and whether the AFO was used. We found that
subjects in the early group, who had already been provided with AFOs,
fell significantly more often in the first eight weeks of the study,
compared to the delayed group who had not yet been provided with AFOs.
The majority of the falls in the early group in week 1-8 occurred
without wearing the AFO. Falls mainly occurred during transfers and
standing, during activities related to getting in/out bed, toileting and
showering. The majority of the subjects had not yet reached an
independent ambulation level at the time of the fall (Functional
Ambulation Categories ≤3) and had low balance levels (Berg Balance Scale
<45). This highlights the need for careful instructions from
clinicians and nursing staff to patients and their relatives, and to
emphasize the potential risks of performing activities without the
proper assistance, especially in situations without wearing the AFO and
without independent walking ability. Summarizing, the results of the
current thesis show that clinicians, together with the patient, can
decide what they value most in when making the decision on when to
commence with AFO-provision. AFOs were found to improve drop-foot
regardless of the timing of AFO-provision after stroke. Early AFO-use is
expected to result in higher functional levels earlier in the
rehabilitation. Despite potential functional gains in the first period
of rehabilitation, early AFO-provision does not lead to higher
functional levels after 26 weeks, compared to delayed provision. In
addition, early or delayed AFO-provision did not influence pelvis, hip
and knee kinematics on the short- or long-term. Therefore, AFOs should
be provided to correct the drop-foot, but there is no reason to assume
that early AFO-provision will influence the development of compensatory
movements around the pelvis and hip in the rehabilitation after stroke.
AFO-use reduced muscle activity of the tibialis anterior in swing
compared to walking without AFO, when effects were measured within one
measurement session. However, no negative effects over 26-weeks were
found. Therefore, based on the results of our study, fear of disuse
concerning the tibialis anterior does not seem to be a justifiable
reason to delay AFO-use in the rehabilitation after stroke. One should
be aware that higher numbers of falls were found in case that subjects
were provided with AFOs early after stroke. Special attention needs to
be made to the specific instructions given regarding AFO-use, since the
majority of the falls occurred without wearing the AFO and while
subjects were not allowed to ambulate independently.
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