Effects of ankle joint degree of freedom of knee–ankle–foot orthoses on loading patterns and triceps surae muscle activity on the paretic side in individuals with subacute severe hemiplegia: a retrospective study

 What are the protocols to get back to regular walking without the KAFO? If your doctor and therapists don't have any, you don't have a functioning stroke doctor, therapist or hospital! I don't know what it is but in my opinion it is not worth staying there for rehab!

I consider AFOs as preventing recovery of correct walking, they may get you mobile faster but do nothing for recovery!

I seriously believe that an AFO actually hinders recovery, you do no training of your dorsiflexion while wearing an AFO.  I went cold turkey on using one on a 21 day canoe trip in Canada and Alaska, 3 years after stroke. It forced me to immediately strengthen my ankle to keep it from rolling and get toe clearance. Didn't fall on that trip.  

Peter Levine does a much better explanation of prolonged AFO use;

AFO after stroke: Once its on there, its on there for life.

But you can't listen to anyone but your doctor. But does your doctor know anything EXACT about stroke recovery?

The latest here:

Effects of ankle joint degree of freedom of knee–ankle–foot orthoses on loading patterns and triceps surae muscle activity on the paretic side in individuals with subacute severe hemiplegia: a retrospective study

• Ayumu Ogura,
• Yuta Chujo,
• Naoto Mano,
• Kimihiko Mori,
• Takayuki Konishi,
• Takayuki kuwabara,
• Masanori Wakida &
• Kimitaka Hase 

Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 150 (2024) Cite this article

• Metrics details

Abstract

Background

Individuals with subacute severe hemiplegia often undergo alternate gait training to overcome challenges in achieving walking independence. However, the ankle joint setting in a knee–ankle–foot orthosis (KAFO) depends on trunk function or paralysis stage for alternate gait training with a KAFO. The optimal degree of ankle joint freedom in a KAFO and the specific ankle joint conditions for effective rehabilitation remain unclear. Therefore, this study aimed to investigate the effects of different degrees of freedom of the ankle joint on center-of-pressure (CoP) parameters and muscle activity on the paretic side using a KAFO and to investigate the recommended setting of ankle joint angle in a KAFO depending on physical function.

Methods

This study included 14 participants with subacute stroke (67.4 ± 13.3 years). The CoP parameters and muscle activity of the gastrocnemius lateralis (GCL) and soleus muscles were compared using a linear mixed model (LMM) under two ankle joint conditions in the KAFO: fixed at 0° and free ankle dorsiflexion. We confirmed the relationship between changes in CoP parameters or muscle activity under different conditions and physical functional characteristics such as the Fugl–Meyer Assessment of Lower Extremity Synergy Score (FMAs) and Trunk Impairment Scale (TIS) using LMM.

Results

Anterior–posterior displacement of CoP (AP_CoP) (p = 0.011) and muscle activity of the GCL (p = 0.043) increased in the free condition of ankle dorsiflexion compared with that in the fixed condition. The FMAs (p = 0.004) and TIS (p = 0.008) demonstrated a positive relationship with AP_CoP. A positive relationship was also found between TIS and the percentage of medial forefoot loading time in the CoP (p < 0.001).

Conclusions

For individuals with severe subacute hemiplegia, the ankle dorsiflexion induction in the KAFO, which did not impede the forward tilt of the shank, promotes anterior movement in the CoP and muscle activity of the GCL. This study suggests that adjusting the dorsiflexion mobility of the ankle joint in the KAFO according to improvement in physical function promotes loading of the CoP to the medial forefoot.

Background

Many individuals develop a gait disorder after a stroke. Despite recent advancements in rehabilitation science, 40% of individuals with hemiplegia who initially have difficulty in walking do not achieve walking independence, even 3 months after stroke onset [1]. Early and high-intensity gait training for individuals with subacute stroke has been reported to promote walking independence at 6 months after gait training [2]. Rehabilitation for individuals with hemiplegia aims to induce plastic changes in the central nervous system by inhibiting compensation from the nonparetic limb and increasing the frequency of using paretic limb. Orthotic treatment plays a vital role in facilitating repetitive movement of the paretic limb with a reduced degree of freedom. Currently, previous studies have reported the effectiveness of gait training on overground surfaces using a knee–ankle–foot orthosis (KAFO) for individuals with subacute severe hemiparesis [3, 4].

Generating a gait rhythm with sensory input is important as a gait strategy for individuals with subacute severe hemiparesis and those having difficulty in achieving walking independence. The transition from stance to swing is controlled by muscle spindles in the hip flexor muscles and group Ib afferents from the Golgi tendon organs in the ankle extensor muscles [5]. Alternate gait training is provided to induce ankle dorsiflexion and hip extension in gait, which a KAFO assists. Abe et al. demonstrated that alternate gait training overground with a KAFO in the subacute phase led to earlier improvements in Functional Independence Measure gait scores [4], suggesting providing information on hip extension under load may induce increased muscle activity in the lower limbs on the paretic side. However, muscle activity in the lower limb on the paretic side during alternate gait training with a KAFO has not yet been confirmed.

Additionally, the center-of-pressure (CoP) on the paretic side is an important indicator of gait ability in hemiplegia. Choi et al. reported that greater anterior–posterior displacement of the CoP (AP_CoP) in the subacute phase improved walking independence in individuals with hemiplegia [6]. In addition, Echigoya et al. reported a positive relationship between Fugl–Meyer Assessment scores and walking speed [7]. Therefore, AP_CoP serves as a marker of functional impairment and activity limitation. Development of strategies to promote an increase in the AP_CoP may lead to the acquisition of independent walking ability in individuals with subacute stroke. However, few studies have focused on CoP during assisted gait using a KAFO in individuals with subacute stroke. A previous study reported that the CoP path moved from the heel to the medial forefoot and hallux in healthy participants [8]. Thus, we believe that medial forefoot loading is crucial for gait in individuals with stroke, as well as for increased AP_CoP.

Limiting the degree of freedom in the ankle joint with an ankle–foot orthosis for individuals with chronic hemiplegia has been shown to increase the ankle dorsiflexion angle during the stance phase [9] and to decrease braking forces during the initial double support, resulting in improved gait speed [10]. However, Mulroy et al. reported that, compared to the free ankle dorsiflexion condition, limitation of the ankle dorsiflexion angle results in decreased muscle activity of the soleus (SOL) during the stance phase in individuals with chronic stroke [11]. Therefore, adjusting the degree of freedom in the ankle joint according to the degree of functional recovery is crucial. In addition, improvements in gait ability in individuals with subacute stroke have been associated with physical function, which reduces limb motor function and trunk control [12, 13]. However, the specific ankle joint conditions for a KAFO according to physical function remain unclear.

First, this study aimed to examine the effects of different degrees of freedom in the ankle joint on CoP parameters and muscle activity on the paretic side using a KAFO for individuals with severe hemiplegia. Second, we aimed to determine the relationship between CoP parameters, muscle activity, and physical function according to different settings of ankle joint angles in a KAFO. We hypothesized that CoP parameters and muscle activity in the triceps surae would improve under ankle dorsiflexion induction in a KAFO, as it does not impede the forward tilt of the shank during terminal stance. Moreover, adjusting ankle joint function based on individual physical function may be necessary, as previous studies suggest that motor impairment and trunk control impairment after stroke are closely associated with poor mobility performance and gait instability [14, 15].

More at link.

3D Lower Limb Orthotic Therapy for Hemiplegic Stroke Patients Using an Adjustable Plastic Knee Ankle Foot Orthotic Device

With these great results you still have lots to do to complete your job.  

Write it up as a stroke protocol and distribute it to every stroke doctor and therapist in the world. OR, distribute the protocol to every one of the 10 million yearly stroke survivors  now and into the future forever. Your job is not done just by writing this paper.  Or get a great stroke association up and running and have them do the distribution.

 

3D Lower Limb Orthotic Therapy for Hemiplegic Stroke Patients Using an Adjustable Plastic Knee Ankle Foot Orthotic Device

脳卒中片麻痺患者に対する調節式プラスチック型 長下肢装具（Adjustable Plastic Knee Ankle Foot Orthosis）を用いた3D下肢装具療法.  Rigakuryoho Kagaku , Volume 34(2) , Pgs. 271-274.

NARIC Accession Number: I245445.  What's this?
Author(s): Taku KOBAYASHI; Nobuo MOROTOMI.
Publication Year: 2019.
Abstract: This paper reports two cases of 3D lower limb orthotic therapy for patients with post-stroke hemiplegia using an adjustable plastic knee ankle foot orthotic device, with a view to enhancing the recognition of this method as one of the orthotic therapy approaches. The hemiplegic stroke patients, one during the early stage of the recovery phase and the other during the maintenance phase, were assessed and treated with an adjustable plastic knee ankle foot orthotic device available at hospitals and a raising tool. The time needed for the patient during the early stage of the recovery phase to walk 10 m decreased from 40 to 7 seconds. He became able to walk outdoors independently within 16 weeks. The time needed for the other patient during the maintenance phase to walk 10 m remained unchanged, but the knee extension angle during the stance phase improved from −25 to 0° in 10 weeks. These results indicate that 3D lower limb orthotic therapy using an adjustable plastic knee ankle foot orthosis may provide a basis for selecting more appropriate orthotic devices.
Descriptor Terms: Hemiplegia, Lower extremities, Muscles, Orthotics, Stroke.
Language: Japanese
Geographic Location(s): Japan, East & Southeast Asia.

Can this document be ordered through NARIC's document delivery service*?: Request Information.
Get this Document: https://www.jstage.jst.go.jp/article/rika/34/2/34_271/_pdf/-char/en.

Citation: Taku KOBAYASHI, Nobuo MOROTOMI. (2019). 3D Lower Limb Orthotic Therapy for Hemiplegic Stroke Patients Using an Adjustable Plastic Knee Ankle Foot Orthotic Device.  脳卒中片麻痺患者に対する調節式プラスチック型 長下肢装具（Adjustable Plastic Knee Ankle Foot Orthosis）を用いた3D下肢装具療法.  Rigakuryoho Kagaku , 34(2), Pgs. 271-274. Retrieved 8/20/2019, from REHABDATA database.
 

Treatment strategies for Genu recurvatum in adult patients with hemiparesis: a case series

No idea on Genu recurvatum, that is what your doctor and therapists are supposed to know more about than you.
http://www.pmrjournal.org/article/S1934-1482%2814%2901474-9/abstract

Malathy Appasamy, MD^∗

,

Michelle E. De Witt^∗2

,

Nisha Patel, MD^∗1

,

Nancy Yeh, MD^∗2

,

Ona Bloom, Ph.D³

,

Anthony Oreste, MD^∗2

^∗Address where study conducted: Department of Physical Medicine and Rehabilitation The Hofstra North Shore Long Island Jewish health system 1554 Northern Blvd, 4th Floor Manhasset, New York 11030 TEL: 516-627-8470 FAX: 516-365-8941

¹Current institutional affiliation: Adventist rehab hospital 9909 Medical center drive Rockville MD 20850

²Department of Physical Medicine and Rehabilitation The Hofstra North Shore Long Island Jewish health system 1554 Northern Blvd, 4th Floor Manhasset, New York 11030 TEL: 516-627-8470 FAX: 516-365-8941

³Assistant Investigator, The Feinstein Institute for Medical Research Assistant Professor, Dept. of Physical Medicine and Rehabilitation; Molecular Medicine The Hofstra North Shore-LIJ School of Medicine 350 Community Drive, Fl 2352 Manhasset, NY 11030 Tel: #516-562-3839

Received: December 18, 2012; Received in revised form: October 3, 2014; Accepted: October 12, 2014; Published Online: November 13, 2014

DOI: http://dx.doi.org/10.1016/j.pmrj.2014.10.015

Publication stage: In Press Accepted Manuscript

Abstract

Objective

To report our clinical experience and propose a biomechanical factor-based treatment strategy for improvement of genu recurvatum (GR), in order to reduce the need for knee-ankle-foot orthosis (KAFO) or surgical treatment.

Design

Case series.

Setting

Outpatient clinic of a Department of Physical Medicine and Rehabilitation in an academic medical center.

Subjects and interventions

Adult subjects (n=22) with hemiparesis and GR who received Botulinium injections alone or in combination with multiple types of orthotic interventions that included solid AFO ± heel lift, hinged AFO with an adjustable posterior stop (APS) ± heel lift, AFO with dual-channel ankle joint ± heel lift or a knee AFO (KAFO) with offset knee joint. Biomechanical factors reviewed included muscle strength, modified Ashworth score (MAS) for spasticity, presence of clonus, posterior capsule laxity, sensory deficits and proprioception.

Outcome Measurements

Outcome factors were improvement or elimination of GR based on subjective assessment before and after the interventions by the same experienced clinician.

Results

More than one biomechanical factor contributed to GR in all patients. Botulinium toxin A injection was used in patients who had significant plantar flexor spasticity and/or clonus. Four types of orthotic interventions were used based on the biomechanical factor : solid AFO in patients with severe ankle dorsiflexion and plantar flexion weakness or clonus; hinged ankle joint with APS with less severe ankle dorsiflexion weakness in the absence of clonus; AFO with a dual-channel ankle joint for quadriceps weakness or severe proprioceptive deficits; KAFO with offset knee joints in Achilles tendon contracture or severe proprioceptive deficits. Adjunctive options included addition of heel lifts and to toe plate modifications. Combinatorial interventions of Botulinium injection, modified AFOs, and heel lifts improved or eliminated GR and avoided need for cumbersome orthotics or surgical interventions.

Conclusions

GR in hemiparesis is multifactorial and can be successfully controlled by a using a conservative biomechanical factor-based approach and using combined medical and orthotic interventions. A algorithmic approach and a prospective study design is proposed to determine a combination of effective interventions to correct GR.