Literature review on the effects of ankle-foot orthoses ... · AFO effects in drop foot after...
Transcript of Literature review on the effects of ankle-foot orthoses ... · AFO effects in drop foot after...
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Literature review on the effects of ankle-foot orthoses after stroke
Dr. Andreas Kannenberg
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Stroke
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destruction of brain tissue due to lack of local
perfusion
85% ischemic infarction
(blood clotting, thromboembolism)
15% hemorrhage
approx. 200,000 new stroke cases per year in
Germany (UK: 130,000 ; US: 750,000)
about 1 million stroke survivors in Germany with
disabilities and handicaps (US: 5 million)
most frequent cause of permanent disabilities
acquired in adult life
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Pareses after stroke
Depending on location and extend of the
infarction or hemorrhage the clinical symptoms
may vary from discreet pareses to hemiparesis or
hemiplegia.
Drop foot is a common sequela of stroke that
afftects about 40% of patients.
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Treatment of drop foot: Figure-8 elastic bandage
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Off-the-shelf ankle-foot orthoses (AFO)
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plastic AFO (Ottobock 28U9) Carbon fiber AFO
Ottobock Walk On (28U11)
spring element
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Custom AFOs
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Evidence on effects of AFOs
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Use of AFOs is controversial: Many professionals discourage the use
of orthoses as they believe them to prevent or delay recovery.
no consistent prescription or use in practice
only little evidence is available
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Review of the literature on AFO effects after stroke
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Literature search in Pubmed
Search terms: ankle-foot orthosis + stroke
Ankle-foot orthosis: 587 citations
Ankle-foot orthosis + stroke: 98 citations
After title and abstract review 14 studies with 342 patients remained for
further analysis.
All trials studied immediate or short-term effects only. High variability in patient mobility.
All studies were cross-over trials with randomization of order of testing
(with or without orthosis, different types of orthoses [off-the-shelf,
custom, plastic, metal, hinged, non-hinged]).
Patient numbers 8 to 61 with no drop outs.
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Results: Walking speed (m/s) Average improvement: 20.1%
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AFO No AFO
Study Mean SD Mean SD Difference p-value
Alvin et al. 1988 0.69 0.51 0.55 0.42 25.5% NR
Burdett et al. 1988 (1) 0.27 0.07 0.22 0.11 22.7% NR
Burdett et al. 1988 (2) 0.22 0.07 0.19 0.08 15.8% NR
Corcoran et al. 1970 (1) 0.84 0.19 0.74 0 13.5%
NR
Corcoran et al. 1970 (2) 0.83 0.2 0.74 0.21 12.2%
NR
de Wit et al. 2004 0.49 0.24 0.42 0.24 16.7% 0.02
Francheschini et al. 2003 0.36 0.12 0.26 0,12 38.5% <0.001
Gök et al. 2003 (1) 0.37 0.14 0.32 0.13 15.6% n.s.
Gök et al. 2003 (2) 0.41 0.16 0.32 0.13 28.1% <0.05
Hesse et al. 1996 0.43 0.21 0.33 0.17 30.3% 0.006
Hesse et al. 1999 0.33 0.15 0.32 0.17 3.1% n.s.
Simons et al. 2009 0.58 0.24 0.46 0.21 26.1% 0.05
Tyson et al. 2009 0.3 0.14 0.3 0.12 0.0% n.s.
Tyson et al. 2001 0.25 0.1 0.18 0.1 38.9% 0.000
Wang et al. 2005 (1) 0.71 0.34 0.61 0.27 16.4% 0.028
Wang et al. 2005 (2) 0.69 0.41 0.58 0.29 19.0% n.s.
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Results: Paretic side step or stride length (m) Average improvement: 10.3%
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AFO No AFO
Study Mean SD Mean SD Difference p-value
Alvin et al. 1988 0.74 0.39 0.64 0.35 15.6% NR
Burdett et al. 1988 (1) 0.34 0.09 0.31 0.09 9.7% NR
Burdett et al. 1988 (2) 0.33 0.1 0.3 0.11 10.0% NR
Gök et al. 2003 (1) 0.37 0.08 0.33 0.08 12.1% <0.05
Gök et al. 2003 (2) 0.37 0.08 0.33 0.08 12.1% <0.05
Hesse et al. 1996 0.69 0.18 0.58 0.19 19.0% 0.006
Hesse et al. 1999 0.65 0.18 0.62 0.17 4.8% n.s.
Tyson et al. 2009 0.53 0.16 0.53 0.15 0.0% n.s.
Tyson et al. 2001 0.24 0.12 0.22 0.09 9.1% 0.005
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Results: Overall mobility (Functional Ambulation Categories)
Average improvement: 43.6%
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AFO No AFO
Study Mean SD Mean SD Difference p-value
Simons et al. 2009 4.7 0.5 4 0.6 17.5%
<0.05
Tyson et al. 2009 1.56 0.59 1.1 0.31 41.8%
0.005
Tyson et al. 2001 3.84 0.7 2.24 1.01 71.4%
0.00
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Results: TUG and postural sway Average improvement: 16% / 11.8%
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Timed up and Go AFO No AFO
Study Mean SD Mean SD Difference p-value
de Wit et al. 2004 25.6 11.7 29.2 12.9 -12.3% 0.0000
Simons et al. 2009 23.4 9.7 29.1 12.9 -19.6% <0.05
Postural sway AFO No AFO
Study Mean SD Mean SD Difference p-value
Alvin et al. 1988 28.96 9.77 37.93 14.48 -23.6% NR
Chen et al. 1999 44.2 21.2 48.4 13.8 -8.7% n.s.
Pohl et al. 2006 12.5 5.2 15.7 6.7 -20.4% <0.05
Wang et al. 2005 (1) 0.31 0.24 0.31 0.25 0.0% n.s.
Wang et al. 2005 (2) 0.29 0.2 0.31 0.16 -6.5% n.s.
But: Other parameters representative of balance and stability showed
significant improvements.
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Results: Time to complete one flight of stairs Average improvement: 13.5%
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AFO No AFO
Study Mean SD Mean SD
Differenc
e p-value
Corcoran et al. 1970 (1) 16.1 4.4 19.7 6.87 -18.3%
NR
Corcoran et al. 1970 (2)
17.2 5.3 19.7 6.87 -12.7% NR
de Wit et al. 2004 73 37.8 80.61 44.4 -9.4% 0.004
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Results: Energy consumption Improvement: 35.5%
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AFO No AFO
Study Mean SD Mean SD Difference p-value
Francheschini et al. 2003 0.49 0.2 0.76 0.41 -35.5% <0.01
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Discussion
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Results are confirmed by a recently published systematic review of
AFO effects in drop foot after stroke:
Significant improvement in overall mobility / independent walking with
AFO: standardized mean difference (SMD) 1.34 FAC; p<.001
Significant improvement in walking speed: SMD .06 m/s; p<.0001
Significant improvement in step or stride length: SMD .28 m; p=.02
Trend to improve TUG: p=.09
Trend to improve time to negotiate stairs: p=.07
Balance: mixed results due to heterogeneity of study samples and
outcome measures
Tyson SF, Kent RM: Effects of an ankle-foot orthosis on balance and walking after stroke: A systematic review of the
literature. Arch Phys Med Rehabil 2013, e-pub ahead of print
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Conclusion
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Ankle-foot orthoses can improve walking, overall mobility,
walking efficiency and balance after stroke.
However, studies of long-term effects and comparative trials of the various
types of AFOs in different subgroups of stroke patients are needed to
guide distinguished orthosis prescription.
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Thank you for your attention
Dr. Andreas Kannenberg │