Accepted Manuscript Effects of an Anterior Ankle-Foot Orthosis on Walking Mobility in Stroke Patients: Get Up and Go and Stair Walking Chiung-Ling Chen, PhD, OT Ya-Ling Teng, MA, OTR Shu-Zon Lou, PhD Hsin-Yi Chang, MS, OT Fen-Fen Chen, PhD Kwok-Tak Yeung, MA, OTR PII:

S0003-9993(14)00936-8

DOI:

10.1016/j.apmr.2014.07.408

Reference:

YAPMR 55925

To appear in:

ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 3 May 2014 Revised Date:

27 June 2014

Accepted Date: 19 July 2014

Please cite this article as: Chen C-L, Teng Y-L, Lou S-Z, Chang H-Y, Chen F-F, Yeung K-T, Effects of an Anterior Ankle-Foot Orthosis on Walking Mobility in Stroke Patients: Get Up and Go and Stair Walking, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2014), doi: 10.1016/ j.apmr.2014.07.408. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Running head: Effects of Anterior Ankle-Foot Orthosis on Walking Mobility

Effects of an Anterior Ankle-Foot Orthosis on Walking Mobility in Stroke Patients: Get Up and Go and Stair Walking

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Chiung-Ling Chen1,2, PhD, OT, Ya-Ling Teng1,2, MA, OTR, Shu-Zon Lou1,2, PhD, Hsin-Yi Chang3, MS, OT, Fen-Fen Chen1,2, PhD, Kwok-Tak Yeung1,2*, MA, OTR School of Occupational Therapy, Chung Shan Medical University

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Occupational Therapy Room, Chung Shan Medical University Hospital

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Room of Occupational Therapy, Department of Rehabilitation, Cishan Hospital

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Acknowledgment

The authors would like to thank the patients who participated in the study.

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Conflict of interest statement

We certify that no party having a direct interest in the results of the

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research supporting this article has or will confer a benefit on us or on

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any organization with which we are associated.

*Corresponding author Kwok-Tak Yeung, School of Occupational Therapy, Chung Shan Medical University Occupational Therapy Room, Chung Shan Medical University Hospital

ACCEPTED MANUSCRIPT No. 110, Sec. 1, Jianguo N. Rd., Taichung City 40201, Taiwan. Cell phone number: +886-930765963

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Business telephone number: +886-4-24730022 ext 12354 Fax number: +886-4-23248181

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E-mail address: [email protected]

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Number of figure and table: One figure and one table

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Effects of an Anterior Ankle-Foot Orthosis on Walking Mobility in

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Stroke Patients: Get Up and Go and Stair Walking

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Abstract

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Objective: To examine the effects of an anterior ankle-foot orthosis (AAFO) on

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walking mobility in stroke patients.

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Design: Cross-sectional and repeated-measures study design.

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Setting: A university’s neurological rehabilitation department in Taiwan.

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Participants: Twenty one ambulant stroke patients.

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Interventions: Not applicable.

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Main Outcome Measures: Walking mobility was measured by the Timed Up and Go

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(TUG) test and the Timed Up and Down Stairs (TUDS) test. The paired t-test was

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used to determine the difference between the mobility performances measured with

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and without the AAFO.

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Results: There were significant differences between mobility performances with and

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without an AAFO in the TUG test (p = 0.038) and the TUDS test (p = 0.000).

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Conclusions: This study supports the effect of an AAFO on walking mobility in

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stroke patients. The findings demonstrate that the stroke patients wearing an AAFO

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may ambulate with greater speed and safety on level surfaces and stairs.

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Keywords

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Foot orthosis; Walking; Stroke

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List of abbreviations

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ACCEPTED MANUSCRIPT AAFO: anterior ankle-foot orthosis

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PAFOs: posterior ankle-foot orthoses

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TUG: timed up and go

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TUDS: timed up and down stairs

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BBS: Berg Balance Scale

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Mobility refers to the ability to independently and safely move from one place

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to another1. Walking mobility is defined as one

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incorporates many types of tasks. Walking mobility tasks include walking initiation,

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walking on smooth and rough surfaces, and walking up and down stairs. These tasks

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require both static and dynamic balance.2 Strokes often cause deficits in balance and

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mobility, including increases in static postural sway,3,4 diminished weight-bearing on

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the paretic limb while standing, asymmetrical weight-shifting ability between the two

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limbs,5 and overall reductions in the range of weight-shifting.6 At least 70% of stroke

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patients are able to regain walking ability, but they generally walk more slowly than

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s capacity for ambulation, which

healthy individuals.7 The gait characteristics of stroke patients include a lower

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cadence, shorter steps and stride length, a shorter stance phase and prolonged swing

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phase on the affected side, a prolonged double-support phase,8,9 inadequate propulsion,

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and an increase in the energy required for walking compared with healthy

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individuals.10 These changes in the gait of stroke patients increase their risk of falling.

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Studies have reported that stroke patients with poor balance experience a high

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recurrence of falls.11 Self-confidence in performing tasks without falling was

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correlated significantly with observer-based balance and gait speed.12 Subsequent

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problems caused by falls are numerous, including physical injuries, immobility,

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psychosocial trauma, and increased costs of care.13 Therefore, improving balance and

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mobility to prevent falls is an important goal of post-stroke rehabilitation.

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Walking up and down stairs is similar to walking that involves reciprocal

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movements of the legs by alternating the stance and swing phases. When walking up

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stairs, the knee and ankle joints must produce concentric contractions for forward and

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upward progression. The greatest stability is demanded during the single-leg stance

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requires the generation of eccentric contractions of the hip, knee, and ankle extensors

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and control of the position of the body in response to the accelerating force of

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gravity.1 In addition, factors that affect performance in walking up and down stairs

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include ankle joint angles (such as the dorsiflexion flexibility of the ankle)14 and

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visual detection (such as ambient lighting and stair edge contrast).15,16 Thus, walking

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up or down stairs is more challenging than walking on a level surface.

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In Taiwan, occupational therapists often provide anterior ankle-foot-orthosis (AAFO) for stroke patients to improve their balance and mobility. The advantages of

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the AAFO are that it is fabricated quickly, easily and custom fit; provides excellent

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foot fixation, toe pickup and maximal medio-lateral stability; and allows normal heel

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contact on the ground and thus can be worn barefoot indoors as well as with shoes.17

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In addition, the AAFO is formed at an angle of dorsiflexion, approximately 5-10

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degrees. Clinically, a dorsiflexion of 5-10 degrees will facilitate the knee into an

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appropriate flexion that prevents a tendency toward recurvation during stance18 and

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creates satisfactory toe pickup during swing.

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Previous studies have investigated the effects of AAFO on the walking ability

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and gait pattern of stroke patients.19-21 Wong et al.21 first revealed that gait pattern did

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improve by using the AAFO, especially with respect to the foot pressure distribution.

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Chen et al.19 used a Computer Dyno Graphy system to examine the effects of AAFO

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on hemiplegic gait, and the authors concluded that wearing AAFO led to faster

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walking speed and increased cadence, but no significant difference in gait symmetry

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was found. Hung et al.20 examined chronic stroke patients who wore AAFO for at

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ACCEPTED MANUSCRIPT least five months and determined that the AAFO improved functional walking ability

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significantly. The authors also indicated that the use of AAFO was better suited for

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younger patients and those with diminished walking ability. Only one study reported

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the effect on functional ambulation using the Timed Up and Go (TUG)20; no one has

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examined the effects of AAFO on the stair walking ability of stroke patients.

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Therefore, the TUG and Timed Up and Down Stairs (TUDS) tests were used in this

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study to explore the effects of AAFOs on get up and go and stair walking mobility in

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stroke patients.

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Methods

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Participants

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Between June 2012 and September 2012, 254 stroke patients who were

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undergoing therapy at the university’s neurological rehabilitation department were

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selected to participate in this study. The criteria for selection were as follows:

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Unilateral hemiplegic stroke patients capable of following simple verbal

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instructions 2.

Ability to walk on a level surface and to walk up and down stairs independently

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or under supervision with or without assistive devices (handrail or cane) and

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without wearing an AAFO

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No systemic or local medical problems, other than stroke, that might affect walking mobility Four exclusion criteria were established: 1) clinically significant visual

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impairment; 2) unilateral neglect; 3) aphasia; and 4) the ability to voluntarily dorsiflex

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ankle against gravity. The Medical Research Council (MRC) scale for muscle strength

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grading was used as a screen test to exclude the patients whose affected ankle

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doesiflexor was MRC grade 3 or above on account of that the AAFO is indicated for

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weakness or paralysis of ankle dorsiflexor.

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Of these 254 stroke patients, 125 patients were found eligible for study

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enrollment. One hundred patients were excluded for having visual impairment,

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unilateral neglect, aphasia, or their affected ankle doesiflexors were MRC grade 3 or

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above. After an introduction and explanation of the study, potential participants were

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asked whether or not they wanted to participate. Two potential participants refused to

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participate in the study. During the TUDS test, 2 additional patients were excluded for

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safety concerns. A total of 21 patients participated in the study.

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Outcome measures

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The TUG test was used to evaluate basic mobility. Participants were asked to sit

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in a standard chair (seat height of approximately 46 cm; arm rest height of

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approximately 65 cm), get up and walk three meters, turn around, walk back to the

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chair, and sit down again. We recorded the number of seconds each participant

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required to complete this task. This test possesses a high degree of reliability and

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validity. 22 The TUDS test included walking up and down a staircase, which had a total

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of 12 steps, each with a height and depth of 16 cm and 26 cm, respectively. The

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ACCEPTED MANUSCRIPT participants could use the handrails or a cane and any method (e.g., step-over-step or

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step-by-step patterns) to complete the test. The time required by each participant to

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walk up and down the 12-step staircase was recorded, and the sum of all of the times

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was determined. To ensure that the patients did not become fatigued, each test was

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conducted only once.

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Before the experiment, all participants provided informed consent, and the protocol was approved by the Institutional Review Board. Information about clinical

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and demographic characteristics was obtained through interviews with the patients

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and from their medical charts, i.e., gender, age, when the stroke occurred, the type of

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stroke, and the duration of AAFO usage. Subsequently, the Brunnstrom motor

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recovery stage of lower extremity, inversor or plantar flexor spasticity (using the

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Modified Ashworth Scale), and the Berg Balance Scale (BBS) scores of each

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participant were evaluated. The BBS was used to evaluate the participants

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without wearing an AAFO. This scale includes 14 items on a 5-point scale (0-4

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points), with a maximum score of 56 points. Higher scores indicate better balance,

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and research results have indicated that the BBS has a high degree of reliability and

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validity.23,24

balance

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Participants who already had an AAFO made by a therapist were allowed to use the device for testing. If a participant did not have an AAFO, one was fabricated by

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the participant’s occupational therapist.

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The participants were requested to complete the TUG and TUDS tests. During the testing process, two individuals stood by the participants, one on either side, to

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prevent falls. The sequence of measuring the participants with and without AAFO was

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randomized. The participants were allowed an appropriate amount of rest, generally

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five to ten minutes, between each test, so the total testing time ranged from 30

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minutes to an hour.

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Descriptive statistics were used to describe the demographic information of each

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participant. A paired t test was used to examine the difference between the time

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required to complete the TUG and TUDS tests with and without an AAFO, with a

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level of significance of α = 0.05. SPSS statistical software, Version 16.0, was used for

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the analyses.

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Results

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The characteristics of participants are presented in Table 1. The mean age of the participants was 58.2±12.1 years (range, 39 to 80 years), the mean time post-onset

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was 25.3±27.7 months (range, 2 to 94 months), and the mean BBS score was 43.4±7.8

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(range, 27 to 54).

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The average time required for the TUG test with an AAFO was 40.2 ± 19.1 seconds, whereas the average time required without an AAFO was 49.1 ± 30.4

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seconds. Therefore, wearing AAFOs reduced the test completion time by 18%. The

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paired t-test indicated that AAFO usage significantly improved the walking mobility

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of the participants as they were undergoing the TUG test (p = 0.038) (Figure 1).

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The average time required for the TUDS test with an AAFO was 65.9 ± 34.1

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seconds, whereas the average time required without an AAFO use was 83.6 ± 45.4

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seconds. Therefore, wearing an AAFO reduced the test completion time by 21%. The

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paired t-test demonstrated that AAFO usage significantly improved the walking

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mobility of participants as they were undergoing the TUDS test (p = 0.000) (Figure

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Discussion

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The findings of this study were that wearing an AAFO significantly improved

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walking mobility as measured by the TUG and TUDS tests. Participants were required

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to complete the walking up-and-down stairs test, which requires a high level of

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balance. The lowest BBS score of the participants in this study was 27, and the

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average BBS score was 43.4. These results are consistent with the interpretation of

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BBS scores suggested by the previous study, which indicated that assisted walking

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requires at least a cutoff score of 21.25 In addition, the stroke patients with an average

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BBS score of 43.4 who participated in this study possessed relatively high balance.

4 The results of this study indicated that wearing an AAFO reduced the

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completion time in the TUG and TUDS tests by 18% and 21%, respectively. The

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beneficial effects of the AAFO on walking mobility may be due to the following three

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reasons.

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First, the motor tasks included in these two tests (e.g., standing up from sitting

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and stair walking) require relatively large amounts of ankle dorsiflexion while the

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majority of the participants exhibited drop foot or plantar flexor hypertonicity, which

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profoundly influences the participants’ performance. Because the AAFO fixes the

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ankle joint at approximately 5-10 degrees of dorsiflexion to provide joint stability and

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toe clearance, the adverse effects of drop foot or plantar flexor hypertonicity are

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avoided. Bonnyaud et al.26 also demonstrated that the strength of the ankle

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dorsiflexors were related to the TUDS test performance and suggested that using of an

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AFO to compensate for the weakness of ankle dorsiflexors.

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Second, the ability to shift body weight onto the paretic limb while standing has

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been shown to be correlated with walking performance.27 Similar findings were

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obtained in the study by Bonnyaud et al., who found that the closer the percentage of

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the single-support phase of the affected leg is to normal values (meaning a greater

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degree of weight borne by the affected limb), the faster the subjects’ performance was

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on the TUDS test.26 Research has suggested that stroke patients exhibited an

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after weight-shifting while wearing an AAFO.28 In addition, as part of the research

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project, a previous study have also revealed that the stroke subjects wearing an AAFO

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could improve the maximal distance of weight shifting toward the affected side and

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increase the affected weight-bearing percentage after weight shifting.29 Therefore, in

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this study, the improvement in the performance of the participants on the TUG and

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TUDS test when they used AAFOs possibly could be attributed to the improved

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weight-shifting ability and weight-bearing capability of the affected side.

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Third, the subjective perception of patients while wearing an AAFO affects the

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speed at which they can walk up or down stairs. The postural threat condition may

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increase patients’ anxiety and the fear of falling or anxiety regarding the potential

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consequences of a possible fall can influence the construct of the central set or the

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preparation for a motor response. Anxiety-mediating modifications, which include

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reduced gait velocity and stabilization of the head, may be used to help prevent

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postural instability.30 During the testing process, most of the participants reported that

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AAFO usage improved their confidence about walking and reduced the fear of falling,

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which led to improved performance. Furthermore, four participants who typically did

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not wear an AAFO did so while outside their homes because they described that

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walking outside poses a greater challenge, such as walking on uneven surfaces.

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The results of this study are consistent with the findings of the previous studies

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that stroke patients exhibited improved walking ability in the TUG and stair test when

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they were wearing static31 or dynamic32 posterior ankle foot orthoses (PAFOs). The

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authors of those studies also proposed that the favorable results may be attributed to

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the patients felt more self-confident31 or a greater sense of postural security was

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resulted32 when wearing the PAFOs.

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In contrast to the beneficial effects of the AAFO, the AAFO restricts the ankle’s range of motion may negatively affect the performance of stair walking. Because

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healthy adults typically walk up and down stairs using the step-over-step pattern, the

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mean value for the maximum sagittal plane motion of the ankle was 27 degrees.33

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Although wearing a static AFO results in decreased ankle dorsiflexion angles,

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proximal compensations at the pelvis, hip, and knee occurred, which was not the case

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for the dynamic AFOs.34 Previous research indicated that, for children with spastic

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hemiplegia, the use of a solid AFO did not impair their ability to walk up and down

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stairs.35 Furthermore, the majority of stroke patients who were examined in this study

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completed the TUDS test using the step-by-step pattern. While walking up the stairs,

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the participant’s healthy leg was raised first due to poor control of the ankle joint in

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the affected leg, and when walking down stairs, the affected leg was lowered first,

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both of which required a small degree of ankle dorsiflexion. Therefore, the wearing an

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AAFO does not interfere with performance of stair walking and, in fact, improves the

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speed of doing so when walking up or down the stairs by placing both feet on each

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step of the staircase.

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Study limitation

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A limitation of this study was that each of the participants was tested only once

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we had been able to take the average of repeated tests. In a subsequent study, it is our

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intention to include the use of a motion analysis system to measure the kinematic

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changes when the AAFO is used for stair walking so that we can provide a more

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detailed explanation of the participants’ behavioral performance.

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Previous studies have demonstrated that there was no significant difference in walking speed and gait pattern in hemiplegic patients wearing AAFOs and those

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wearing PAFOs.21,36 However, Chen et al.37 demonstrated that there were different

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effects on the rear-foot kinematic change during gait between these two types of

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AFOs. In this study, we only compared the participants’ walking mobility with an

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AAFO versus no AAFO. Further studies should compare the performance between

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anterior and posterior AFO in stroke patients.

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Conclusions

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The results indicated that the use of an AAFO by stroke patients with affected

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ankle dorsiflexor weakness or paralysis significantly improved their performance on

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the TUG test and the TUDS test. The stroke patients may ambulate with greater speed

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and safety on level surfaces and stairs when wearing an AAFO.

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Figure Legends

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Figure 1. Comparisons of walking mobility performance with and without an AAFO.

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(*p

Effects of an anterior ankle-foot orthosis on walking mobility in stroke patients: get up and go and stair walking.

To examine the effects of an anterior ankle-foot orthosis (AAFO) on walking mobility in stroke patients...
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