2012 Annual Conference

Olivier, Genevieve

TIRR Memorial Hermann Neurologic Physical Therapy Residency Program in Collaboration with Texas Woman's University and the University of Texas Medical Branch at Galveston; Houston, TX

Impairment from stroke can affect walking function, resulting in a lack of independence and participation. An ankle foot orthosis (AFO) is often prescribed for people with hemiparesis to improve gait speed, kinematics, and decrease the risk of falls. The advanced ground reaction design ankle foot orthosis (GRAFO) is a novel type of AFO designed to increase stance stability by transferring the ground reaction force to the anterior tibia, creating a plantarflexion moment at the ankle and a knee extension moment during stance. The purpose of this case report was to prospectively assess the effect of a traditional AFO and an advanced GRAFO on walking function in a person with a chronic stroke.

The subject was a male, age 38, with right hemiparesis following a left-sided ischemic stroke 7.5 years ago. Prior to this study, the subject utilized an articulated ankle foot orthosis (AAFO) for 7.5 years. Functional limitations included impaired gait speed, endurance, and balance, along with knee hyperextension in stance phase of gait.

The subject was casted for the test orthosis, a DBS Balancer™ design GRAFO. This device uses a unique weight bearing casting method, very intimate fit, and rigid material to afford control in the coronal, transverse, and sagittal planes. An extended rigid toe ramp allows the brace to affect the knee through terminal stance. The subject’s current orthosis was an AAFO, traditional in design and made of polypropylene. It was much less rigid than the test orthosis, had a plantarflexion stop, and allowed unrestricted motion into dorsiflexion. The subject was assessed in 3 conditions: no AFO, traditional AAFO, and advanced GRAFO. Assessments included 6 Minute Walk (6MW), 10 Meter Walk (10mW), and Timed Up and Go (TUG). Follow-up testing was 4 weeks later in the GRAFO.

Compared to no brace, time to perform the TUG decreased by 13.94 (AAFO) and 15.31 (GRAFO) seconds. Self-selected walking speed (SSWS) increased by 0.34 (AAFO) and 0.45 (GRAFO) m/s, and fast walking speed (FWS) by 0.37 (AAFO) and 0.73 (GRAFO) m/s. Distance on the 6MW increased by 679.75 (AAFO) and 991.92 (GRAFO) feet. Four weeks later, follow-up testing was performed in the GRAFO and, compared to previous testing in the GRAFO, revealed a 195.25 foot increase on 6MW, a 0.12m/s increase in SSWS, a 0.18m/s increase in FWS, and a 0.99 second decrease in time to perform the TUG.

While performance was better in both braces than in no brace, this subject with a chronic stroke had the greatest improvement in all outcome measures immediately after donning the GRAFO, as compared to walking in his previous brace (AAFO). This difference in improvement between the GRAFO and the AAFO did exceed the Minimal Clinically Important Difference (MCID) for the 6MW and 10mW (both SSWS and FWS). Additionally, at follow-up testing after walking in the GRAFO for 4 weeks, the subject improved further, with changes from initial GRAFO testing to GRAFO follow-up testing exceeding the MCID in all outcome measures except the TUG.